Select Literature Review-Clinical Usage and Application of Hypnotherapy

Running head: SELECTIVE LITERATURE REVIEW: HYPNOTHERAPY 1

Selective Literature Review:

Clinical Usage and Application of Hypnotherapy

Tammy Daniel Coles

Walden University

SELECTIVE LITERATURE REVIEW: HYPNOTHERAPY

Abstract

This literature review explores research conducted in the past 10 years related to the utilization

of hypnotherapy treatments for Acute Stress Disorder (ASD), Post-Traumatic Stress Disorder

(PTSD), and Major Depressive Disorder (MDD). The focus of this review is to investigate the

effectiveness of hypnotherapy in treating the symptoms of each DSM-IV disorder. Findings

indicate that the use of hypnotherapy methods in the treatment ASD and PTSD offer the most

consistently positive outcomes. Hypnosis treatments in relation to MDD are relatively

inconsistent.

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Clinical Usage and Application of Hypnotherapy

Over the past decade, there has been a great deal of discussion about the potential use of

hypnotherapy as a treatment method in clinical counseling. There is a significant lack of

empirical research to support the use of hypnosis in a clinical setting for most disorders. Much of

the available research discusses moderate effect sizes utilizing small samples that may not

accurately represent a multicultural population. That said most researchers support

hypnotherapeutic treatment applications as effective methodology in mental health counseling.

Current research is limited in scope and the study of hypnotherapy in individuals that meet the

diagnostic criteria for depression and post-traumatic stress disorder (PTSD) may require stronger

supportive data to be recognized as an established clinical counseling method. Hypnosis in

treating PTSD shows the greatest potential with the most supportive research.

Much of the research reviewed discusses hypnotherapy as being most effective when

utilized simultaneously with other treatment methodologies. The literature doesn’t seem to

support this theory consistently. Cognitive Behavioral Therapy (CBT) is the most commonly

cited as a complimentary treatment approach, but in data regarding the effectiveness of a CBT

only control group in comparison to a CBT with hypnotherapy treatment group for treating Acute

Stress Disorder (ASD), there was no statistical difference between groups (Bryant, Moulds,

Guthrie, & Nixon, 2005).

Findings in the current research literature regarding the effectiveness of hypnotherapy in

treating depression are inconsistent. The empirical support necessary for hypnosis to be

considered a viable treatment option for depression, just isn’t available. Although there are many

individual case studies that offer evidence of a single individual who significantly benefited

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from hypnosis in treating clinical depression, there are very few empirical studies that offer

supportive evidence.

Some debate also exists regarding the over-reporting of positive results in current

research and arguments that earlier studies utilized assessment instruments that don’t accurately

measure the hypothesis of the research. Researcher bias is a strong topic of debate. The lack of

independent auditing and lack of research bias statements also sacrifice the validity of the

strongest supportive research.

A combination of solid clinical studies, unbiased researchers, independent auditors and

empirically recognized research methodologies could offer the support that hypnotherapy

requires to be widely accepted a therapeutic mental health treatment strategy. Studies that have

been critically reviewed by peers on both sides of the debate prior to publication would add

further strength to the validity of current data. In case studies and convention speeches, it is

obvious that clinical practitioners are enthusiastic about the potential of adding hypnotherapeutic

methodologies to their practices. The need for solid research is a clear one that has and will

continue to consistently limit the incorporation of hypnosis into clinical psychological practice.

Strong and consistent PTSD treatment evidence offers the strongest support for hypnosis in

clinical settings. Utilizing hypnosis in treating PTSD and conducting more research that

scientifically/empirically supportable could help remove the “fad” stigma from hypnotherapy

and help the methodology gain needed professional support.

Research Inclusions and Exclusions

The literature included in this review was limited to research articles that studied the

effectiveness of hypnosis on symptoms that specifically related to ASD, PTSD, and Depressive

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Disorders. An article regarding the effectiveness of hypnotherapy on self-esteem was included

due to the research criteria including depression related to low self-esteem. Research that based

on a single case study or focused on ICD-10/medical diagnosis was excluded. Specific research

excluded included those articles related smoking-cessation, medical hypnotherapy for physical

ailments and pain management/anesthetic hypnosis applications. The research articles selected

were those that pertained to depression and trauma that were conducted in the past 10 years.

Utilizing Hypnotherapy In The Treatment of Depression

Depression is one of the most common mental conditions that leads individuals to seek

psychological counseling.t Most researchers in this review are supportive of the utilization of

hypnotherapy in the treatment of depression. Findings are not always consistent with this

support. There is approximately an equal amount of research available that supports the

effectiveness of hypnotherapy and research that denounces the effectiveness of hypnotherapy in

treating depression. There are many factors that may account for this inconsistency including

research methods or issues, types of hypnosis/hypnotherapy administered, sample demographics,

and staff training.

In a quantitative meta analysis study, Shih, Yang and Koo (2009) examined six (n=7)

randomized studies and found an effect size of 0.57 (p <. 0001), meaning that data

demonstrated a medium effect of hypnotherapy in the treatment of depression. A major issue

that Shih, Yang and Koo (2009) reporting in their findings was the inconsistency in results

within the six studies. The quantitative data in the studies reviewed found hypnosis to offer a

moderate beneficial effect on depression. Cultural difference with in the samples or locations if

the studies were not discussed but could be one possible explanation for the inconsistency. The

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use of hypnosis is more widely accepted in certain cultures, countries, and ethnicities than in

others.

In one of the most widely referenced studies regarding cognitive hypnotherapy (CH) for

Major Depressive Disorder (MDD), Alladin and Alibhai (2007) conducted a study to investigate

the effectiveness of CH in comparison with Cognitive Behavioral Therapy (CBT). Ninety-eight

individuals who met diagnostic criteria for chronic MDD were randomly assigned to a CH or

CBT group. Over the course of 16 weeks, using a baseline test, an assessment at the termination

of treatment and a follow up assessment conducted 12 months later, Alladin and Alibhai found

that CH produced an 8% greater reduction in hopelessness than CBT. The researchers also found

that CH offered the greatest long-term impact on anxiety and hopelessness at the 12 month

follow up. Alladin and Alibhai’s evidence suggest that CH may be an effective treatment option

for chronic depression.

In a feasibility study, Dobbin and Elton (2009) studied the effects of self-hypnosis

utilizing 58 individuals (n=58), aged 18-65 who were currently experiencing a diagnosed

episode of depression. In each case, the participant’s general practitioner intended to prescribe

antidepressants. Of those individuals, 50 participants chose to participate in the self-hypnosis

program in an effort to cope with depression. Depression scores were compared at the beginning

and end of the study. The study was benchmarked against 3 other studies. The researchers found

that 93% of participants preferred self-hypnosis to pharmacological treatment options. Dobbin

and Elton (2009) utilize this information as further evidence that self-hypnosis is a useful

addition to depression treatments administered by general practitioners.

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In a study of long-term depressed mood, Butler et al. (2008) created two treatment

groups for those with long-term low to moderate depression. The first group (n=17) consisted of

individuals that utilized meditation with hatha yoga and psychoeducation. The second group

(n=17) consisted of individuals who participated in group therapy with hypnosis and

psychoeducation. Both groups were compared with a psychoeducation only control group

(n=18). The randomized sample included 46 participants (n=46), 50% that had a clinical

diagnosis of dysthymia, 28% had a dual diagnosis of dysthymia and a major depressive episode,

15% had a diagnosis of a major depressive episode with partial remission, and 6.5% were

diagnosed with a chronic major depression lasting 2 or more years. Butler et al. (2008) report a

remission rate of 77% with the meditation group, 62% with the hypnosis group, and 36% in the

control group. Butler et al. cite Kocsis’s (2007) remission rate findings to be 73% for traditional

psychotherapy and antidepressant treatment. Given this data, the hypnosis group’s success rate is

still lower than current empirically recognized methodology.

In a more general study of mood and tiredness, Thompson, Steffert, Steed, and Gruzelier

(2011) conducted a randomized study of 35 individuals. The individuals were randomly placed

in a verbal imagery self-hypnosis group, a 3-d computer animated imagery hypnosis group, and

a relaxation group. A series of baseline assessments were conducted followed by mood

assessments administered immediately before and after each treatment session. None of the

methods achieved statistically significant results over the others. The researchers did discover

that visualization through self-hypnosis increased participant engagement in imagery for those

that traditionally have issues “picturing things in their minds” and that both self-hypnosis groups

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reported low levels of tiredness after each treatment session. Thompson et al. (2011) didn’t

report any evidence of improvements in mood.

Schreiber (2011) conducted an analysis of 5 case studies of hypnosis with clients that had

major depressive disorders. In looking at the case studies, Schreiber clients were referred in

each case by their family physician and had been formally diagnosed by a psychiatrist. Each

client underwent the same clinical assessments and each client was able to hypnotized quickly.

Schreiber found that all five case studies showed a reduction follow treatment in a test-retest

model. Schreiber’s findings based on the case studies appear to be inconsistent with those found

in empirical research models.

Acute Stress Disorder and Post-Traumatic Stress Disorder

In studying ASD, Bryant et al. (2005) identified 109 participant (n=109) who were at

highest risk of developing Post-Traumatic Stress Disorder (PTSD). Of those participants, 22

(n=22) declined treatment and the remaining 87 (53 women, 34 men) were placed in randomly

selected treatment groups. The 3 treatment groups either participated in CBT, CBT with

hypnotherapy, or supportive counseling (SC). All participants met DSM diagnostic criteria for

ASD. 69 (n=69) of the participants completed the program. The SC group had the lowest

dropout rates. Bryant et al. (2005) found that there were no significant differences in good end

of treatment functioning between participants in each group. The CBT/hypnosis group didn’t

have greater clinical gains than those in the CBT only group. Bryant et al. (2005) make the

argument that CBT groups that include hypnosis perform more effectively than groups that

participate in CBT alone. Bryant et al. suggest that the motivation of participants may increase

the effectiveness of treatment. The researchers note that this is one of the first controlled studies

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to evaluate the effectiveness of hypnotherapy in the treatment of ASD, the sample size is small,

the drop out rate was higher in the CBT and CBT/hypnosis group, and that the researchers failed

to use CAPS-2 at the initial assessment and were not able to index to what extend the assessors

were blind to the participants treatment groups. The study provides no empirical support of

hypnotherapy enhancing the effectiveness of CBT in the treatment of ASD.

In researching the effects of hypnosis in treating PTSD in children, Lesmana, Suryani,

Jensen and Tiliopoulos (2009) conducted a study of children ages 6-12 who met the criteria for

PTSD after witnessing the 2002 terrorist attacks in Bali. Lesmana et al. (2009) utilized spiritual-

hypnosis assisted therapy (SHAT) for treatment children. The research design was based on a

longitudinal, test-retest design. The study included 46 children (n=46) in the SHAT treatment

group and 178 children in an untreated control group. 77.1% of the children in the treatment

group showed improvement. There was an improvement of 24.2% in the control group. Lesmana

et al. (2009) point to spirituality that is consistent with the culture of their sample group

combined with children’s tendency to be more receptive than adults to hypnotic suggestions as a

possible explanation for the strongly statistically significant results.

In a study of 36 patients (n=36) with chronic PTSD, Abramowitz and Lichtenberg (2010)

researched the use of hypnotherapeutic olfactory conditioning (HOC) with combat soldiers with

symptoms that were not improved by other forms of treatment. In an uncontrolled open study,

clinical assessments were utilized at the baseline, 6-weeks (immediately following HOC

treatment), 6 months and 1 year. Abramowitz and Lichtenberg (2010) found an improvement of

symptoms that was maintained over the entire course of the study. The potential benefits of HOC

in the treatment of PTSD require further study.

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Barabasz and Barabasz (2012) conducted an open controlled study of 36 volunteers who

met the diagnostic criteria for the PTSD. The volunteers participated in a single 5.5- 6 hour

session of manualized ego state therapy emphasizing abreactive hypnosis. A Post Traumatic

Stress Checklist (PCL) was conducted as a baseline and at 1 month and 4 month follow-ups.

Barabasz and Barabasz (2012) found that the manualized therapy group showed significantly

lower PCL scores than the control group at 1-month and 4-month follow-up retests and a

significantly lower PCL scores at all post therapy testing periods than their pre-test scores.

Barabasz and Barabasz concluded that 1 session of abreactive hypnosis was enough to show an

improvement in symptoms.

In experimental research aimed at studying the effectiveness of Hypnosis, Neuro

Linguistic Programming and Time Line Therapy reducing the intensity of negative emotions

attached to memories of stressful events, Bin Ahmad (2011) that all three methods offered

significant reduction in negative emotions when compared with a null control group. The

research consisted of 32 treatment group subjects and 32 control group subjects. The participants

did not have to meet the diagnostic criteria for a trauma related disorder to meet the

requirements for participation in the study. Bin Ahmad (2011) assessed participants at the

baseline, during the procedure, and immediately after the procedure. He determined that there

was a significant improvement in negative emotions after each session. Bin Ahmad (2011)

specifically notes that hypnosis has been shown to be useful in helping people relax their minds

and body. He suggests that hypnosis simply provides a distraction or change of focus (with out

forgetting the event). It is important to note that Bin Ahmad utilized a combination of neuro

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linguistic programming, time line therapy, and hypnosis as complementary treatments in order to

achieve the significant results.

In a randomized controlled study, Abramowitz, Barak, Ben-Avi and Knobler (2008) gave

a group of 15 patients SSRI antidepressant in the control treatment group and a second treatment

group of 17 patients symptom-oriented hypnotherapy. Abramowitz et al. (2008) utilized a daily

morning questionnaire and a series of clinical assessments at the beginning, immediately after

the study and again 1 month after the study. At the end of treatment, the PTSD symptoms were

tested lower in the hypnotherapy group than in the SSRI group. There was also improvement in

insomnia and sleep disorder symptoms noted. Abramowitz et al. (2008) determined that

symptomatic hypnotherapy is an effective treatment in patients suffering from chronic PTSD.

In a program evaluation of cognitive behavioral group therapy for PTSD in Knapp

(2006) conducted a study of 10 young female offenders. Based upon research she cited from Van

Etten and Taylor (1998), Knapp theorized that behavior therapy and a form of hypnotherapy

known as Eye Movement Desensitization and Reprocessing (EMDR) would be more effective

than the CBT currently being utilized. The initial phase of her dissertation was to study the

effectiveness of the current program. Knapp (2006) found that statistical analyses could not be

performed because there were too few participants, poor retention, and considerable amounts of

data missing. Knapp suggests a more structured research methodology with increased

administrative and parental support. Knapp also notes that uncertified and untrained staff often

runs the current CBT programs. She suggests incorporating proper training with staff prior to

beginning the next study. Based on the lack of statistical analyses, Knapp is unable to make a

recommendation regarding hypnotherapy or other alternative methods.

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Self-Esteem and Self-Concept

In a randomized clinical trial, Scholze et al. (2011) found that there was no statistical

significance between the treatment group that participated in 4 weeks of hypnosis and the

Hawthorne method or Hawthorne method only control group. In terms of self-concept and self

esteem improvement, the student participants (n=35) showed the same results regardless of

randomized treatment group placement. There is no evidence to suggest that hypnosis improves

self esteem.

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Clinical Use

In her doctoral thesis, Pignotti (2009) investigated that usage of unsupported therapies in

clinical practice by licensed social workers. Pignotti utilized a research-specific exploratory

survey instrument that included demographics (specific to the research), open ended questions,

and different types of therapeutic approaches listed alphabetically. Participants indicated which

approaches they used in their practice, how often they used each approach, and how recently

they used each approach. The therapeutic approaches were categorized into 3 broad groups for

evaluation. Those categories were empirically supported therapies (EST), conventional therapies

that lacked empirical support (CUT) and novel unsupported therapies (NUT). The participants

were not aware of the categorization. Out of 193 respondents (n=193), 45 reported current use of

hypnosis in their practice. An additional 9 respondents reported using hypnosis in the past. The

high amount of reported hypnosis usage in practice without empirical or scientific support

demonstrates a disconnect between scientific support and practical application (Pignotti, 2009).

Evaluating Research

Looking at 444 studies of Flammer and Bongartz (2003) looked at the efficacy of

hypnosis in a meta-analysis study. The researchers only considered clinical, randomized studies

and that utilized one research group that was treated exclusively with hypnotherapy and another

group that received no treatment. The researchers worked with a group of 57 (n=57) that met the

research criterion. Two types of hypnosis were evaluated, classical (70%) and modern (19%).

The researchers couldn’t determined the type of hypnosis being used in approx.. 11% of the

studies.

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Flammer and Bongartz note that studies regarding affective disorders, obsessive

compulsive disorders and psychotic disorders are missing completely in the sample and that

somatoform and psychological disorders caused by substances are under represented in the

available studies. Flammer and Bongartz (2003) point to gap between clinical research and

therapeutic research as a major issue in evaluating the effectiveness of hypnotherapy. ICD-10

disorders are well represented in the research, which pain management being most commonly

represented hypnotherapeutic application. The prevalent lack of research in the area of

psychotherapy is a significant weakness in supporting hypnotherapy usage in clinical practice.

Flammer and Bongartz (2003) point to the high effect size in their findings as evidence to

support randomized clinical studies of psychological hypnosis applications.

In a separate meta analysis of the studies reviewed by Flammer and Bongartz, Moshagen

and Musch (2008) reevaluated the entirety of the 444 studies to assess for publication bias.

Moshagen and Musch theorized that Flammer and Bongartz may have overreported the mean

treatment effect of hypnosis by selecting publications with positive outcomes. Moshagen and

Musch (2008) did find evidence of publication bias, but still showed a significantly significant

treatment effect to suggest that the efficacy of hypnosis is substantial and can’t be attributed to

the selective reporting of positive outcomes.

Discussion of Findings

In conducting a literature review, many of the researchers consistently found that those

individuals who met the diagnostic criteria for PTSD were more susceptible to hypnosis

(Abramowitz et al., 2008). Findings in each of the PTSD studies support that hypnotherapy is

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often most successful when treating PTSD and trauma related disorders. The literature reviewed

did not support hypnotherapy as a successful treatment for depression.

In terms of the hypnotherapy/hypnosis in each study, there was a lack of consistency in

the types of hypnotherapy being utilized. Many of the studies include a type of hypnosis that is

specific to that individual study. There is also a lack of information regarding the hypnotherapy

provider in each case. In the absence of data regarding who administered the hypnotherapy, what

type of certification or licensure the hypnotherapist possessed, what specific experience or

training the practitioner possessed in the type of hypnosis administered, or in some cases if the

hypnotherapy was administered in-person…it is hard to determine if the treatment being

administered was the best available for the intended study.

Discussion of Cultural Impact

As with most types of treatments, there are cultural concerns that can greatly impact the

effectiveness of hypnosis. Some cultures and traditions are generally more accepting of hypnosis

than others. Capafons et al. (2008) used a sample of psychology students from Spain, the US,

Portugal and Romania to examine the effects of having personal experience and information

versus beliefs and attitudes about hypnosis. Capafons et al. used a large research sample

consisting of 1103 students in Spain, 1024 students in the US, 402 students in Romania, and 315

students in Portugal. The researchers utilized the Revised Valencia scale to develop 8 categories.

The researchers determined that accurate beliefs were correlated with positive attitudes and

inaccurate beliefs correlated with negative attitudes in regard to hypnosis. Capafons et al. (2008)

found evidence that cultural and personal experience with hypnosis translated to a more positive

attitude and accurate beliefs about hypnosis. In cultures where hypnosis is practiced more

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commonly, the more positively students studying psychology received the treatment. These

findings are supported by a randomized controlled research study conducted by Green. Green

(2003) t sampled 276 undergraduate students beliefs about hypnosis utilizing a control group and

a treatment group that was hypnotized. Utilizing a test-retest approach, Green theorized that

experience with hypnosis would change participant’s perceptions and attitudes about hypnosis.

Half of the students completed a hypnosis susceptibility questionnaire and the other students

completed an Opinions About Hypnosis Scale. The Opinions About Hypnosis scale was

organized into 4 broad categories with a total of 21 items measured. Green (2003) found that

experience being hypnotized altered beliefs and eliminated many misperceptions about hypnosis.

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