Brain Scan

Copyright © Donald Robertson, 2010.  All rights reserved.

It is sometimes claimed that that people in hypnotic trance produce a higher frequency of “alpha”, or sometimes “theta”, brain waves on electroencephalogram (EEG) brain scans. Michael Heap, one of the UK’s leading psychological researchers in this field warns,

Incidentally, ignore any statements in the popular hypnosis literature to the effect that hypnosis is an “alpha state” or “theta state” or that the right hemisphere is put into one of these states, or that the hypnotist directs suggestions to the unconscious mind in the right hemisphere by sitting on the subject’s left side, or that the hypnotist matches the frequency of his voice with that of the subject’s brainwaves, etc., etc. (Heap, 2006: 6)

Likewise, Steven Jay Lynn and Irving Kirsch, two of the most prolific contemporary researchers in the field of hypnosis, and leading critics of the notion that hypnotism works by inducing an altered state of consciousness or “trance”, write,

The idea that hypnosis involves a trance state may be the most pernicious of popular ideas about hypnosis.  Decades of research have failed to confirm the hypothesis that responses to suggestion are due to an altered state of consciousness, and a s result, this hypothesis has been abandoned by most researchers in the field.  Many knowledgeable scholars either reject the use of the term trance as misleading or use it in a sufficiently broad sense to include such commonplace experiences as being absorbed in an interesting move, conversation, or daydream.  (Lynn & Kirsch, 2006)

Indeed, referring to hypnosis as involving a “trance” actually appears to make people less hypnotisable.  It may foster anxiety about loss of control and encourage subjects to adopt an overly-passive “wait and see” attitude.  By contrast, researchers have generally found that subjects who actively imagine the things being suggested tend to respond better to hypnosis.  For example, Lynn and his colleagues found that when participants in an experimental study were told that it was necessary to enter “trance” to respond to hypnotic suggestions, they became less suggestible instead of more so. 

There are some brain imaging correlates of hypnotic responses but they tend to be more complex and “task-specific” than popular psychology books assume.  For example, after reviewing the literature on EEG scans during hypnosis, James E. Horton and Helen J. Crawford, two experts in this area, recently concluded,

Hypnosis is not a unitary state and therefore should show different patterns of EEG activity depending upon the task being experienced. In our evaluation of the literature, enhanced theta is observed during hypnosis when there is task performance or concentrative hypnosis, but not when the highly hypnotisable individuals are passively relaxed, somewhat sleepy and/or more diffuse in their attention. (Horton & Crawford, in Heap et al., 2004: 140)

Similar differences, they note, are well-known from research on meditation, where changes in brain wave activity depend on the kind of meditation being practiced, in particular whether it involves intense concentration or not. These changes are, therefore, probably merely a reflection of the concentration employed rather than anything which could be accurately referred to as a “trance” or “altered state of consciousness.”  Because the neurological and physiological correlates of hypnosis are task-specific, nobody has ever been able to produce a single unambiguous marker of hypnotic trance. In other words, it is currently impossible to point at two brain scans and say, “That one’s definitely in hypnotic trance and that one isn’t.” 

Some magazine articles that may be of interest,

This recent Scientific American magazine article by Scott Lilienfeld (2009) summarises research on hypnosis from a sceptical nonstate position.

Scientific American

This older TIME magazine article from the 1970s provides quotes from T.X. Barber outlining some of the key experimental observations which led to the “cognitive-behavioural” theory of hypnosis.

TIME Magazine

Applied Tension and Blood-Injection-Injury Type Phobia

Blood Phobia

Copyright © Donald Robertson, 2010. All rights reserved.

This article provides a brief overview of the main evidence-based treatment for blood phobia, and related problems. Acute anxiety about either blood, injections, or injuries, falls under the broad heading of “Blood-Injection-InjuryPhobia” according to DSM-IV-TR, the main system for classifying psychiatric problems. To meet a full diagnosis of Blood-Injection-Injury (BII) Phobia, the anxiety needs to be severe enough to impact seriously on someone’s quality of life and ability to function normally. This is one of the most common forms of full-blown phobia. The most serious impact is typically upon the individual’s ability to obtain appropriate medical treatment for other health problems, i.e., avoiding having necessary injections, blood tests, operations, etc. Lifetime prevalence is 3.5%, which means that if you get on a double-decker bus full of people (n=60) there should theoretically be at least two passengers onboard who have suffered from full-blown Blood-Injection-Injury phobia. However, many more people have somewhat milder (“subphobic”) fears of blood and related things, which can nevertheless be quite distressing at particular times. (For brevity, I’ll refer from now on to “blood phobia” though most of what I say should apply to related phobias of injury, injections, etc.) In fact, although we refer to phobias as involving anxiety and a strong urge to avoid the feared object, many blood phobics appear to experience little fear of blood but rather more feelings of nausea or disgust.

The psychiatric classification shouldn’t cause alarm, it just means that like other phobias it’s a psychological rather than physical problem. However, it’s a relatively “normal” reaction. Most researchers believe that many common phobias occur because people are genetically predisposed to develop them, to varying degrees. In human evolutionary history, for many thousands of years, being born with these deep-seated fears probably served to protect our ancestors from dangers in their primitive environment. For example, it’s possible that fainting at the sight of blood helped our ancestors to reduce blood loss and avoid further injury. When lying down, blood mainly flows horizontally rather than vertically, so the heart doesn’t have to pump as much against the pull of gravity. Lying down therefore reduces blood pressure, potentially decreasing blood lost as a result of injury, but it also increases the ease with which blood can circulate to the brain, carrying vital oxygen. Moreover, as a last resort “defence mechanism” when things were going badly, it may also have prevented further injury from animal attacks by forcing our primitive ancestors to “play dead.” (Animals that are surprised or defending their territory, rather than hunting prey, will often cease attacking under these circumstances as they no longer feel threatened when their “victim” lies prone and motionless.) In other words, blood phobia is based on a naturalbodily reaction that varies in strength between individuals, depending on a combination of genetic and developmental factors, etc. It may have served an important evolutionary purpose by actually helping our primitive ancestors survive, for most of human history, but frequently becomes unhelpful in our modern environment.

There is a broad consensus among researchers and experts in the field of psychotherapy that most phobias tend to respond quite reliably to a behaviour therapy technique termed “exposure”, in which the subject is asked to repeatedly face their fears in a controlled manner. This is usually done gradually over several sessions, starting with slightly “easier” fears, and it is usually done in the real world (“in vivo”) although sometimes it may be done in imagination (termed “imaginal exposure”). However, blood phobia differs in an important respect from other phobias. It tends to be accompanied by actual fainting or feelings of fainting, termed “emotional fainting” and caused by a physiological mechanism termed the “vasovagal response.” This is very significant because anxiety normally increases blood pressure and heart rate. Fainting, by contrast, is associated with a decrease in heart rate and blood pressure and a drop in cerebral blood flow, i.e., blood flowing to your brain reduces. (A similar experience, called “orthostatic hypotension” occurs when someone stands up too quickly and feels faint or dizzy.) Hence, anxiety normally prevents fainting, even when accompanied by feelings of faintness and disorientation. Blood phobia actually triggers a “biphasic” (aka “diphasic”) response, which begins with an initial rise in blood pressure and heart rate, as in normal anxiety. This may last a minute or more but is soon followed by a very rapid decrease in both heart rate (termed “bradycardia”) and blood pressure (“hypotension”) that may lead to reduced oxygen reaching the brain (“cerebral blood flow”) and cause fainting(“syncope”). Researchers have found that 75% of blood phobics report a history of actual fainting in response to their fear (Ayala, et al., 2009). Treatment for blood phobia is now modified to take account of the different type of physiological reaction that occurs compared to other forms of anxiety.

In clinical trials, treatment for blood phobia usually occurs weekly, takes an average of 5 one-hour sessions (though the range across studies is 1-10 sessions) and requires completion of homework between therapy sessions. Some research has been carried out on more intensive single session (2-hour) methods, although this appears somewhat less effective. Homework usually involves “exposure”, meaning that the client is asked to repeatedly face blood-phobic situations they previously avoided, e.g., handling a phial of blood, or watching a video of an operation. Exposure is usually done in gradual steps and stages, so that the client doesn’t feel overwhelmed. In the “Applied Tension” treatment, discussed below, a special “coping skill” is learned during sessions and used to cope with the feelings aroused during exposure to the feared objects and situations.

Applied Tension (AT)

Applied Tension (AT) is the name of the behaviour therapy approach developed by Öst, based on earlier work by Kozak & Montgomery (1981). The rationale for Applied Tension is that through gradual practice the client learns to spot the earliest signs of their blood pressure decreasing and to use special “coping skills”, involving tensing muscles, to counteract this by raising their blood pressure slightly, i.e., training their body to do the opposite of what normally happens until this becomes habitual. The tension coping skill therefore targets the second phase of the “biphasic” blood phobia response, i.e., the sense of fainting rather than the initial anxiety. This is combined with exposure to a range of feared blood-related situations, termed “exposure therapy”, which is a well-established form of behaviour therapy for phobia, and therefore targets the initial anxiety response that usually precedes the sense of feeling faint. In extreme cases where actual fainting seems likely, the subject may lie down on a couch during exposure as this normally prevents them losing consciousness. The steps of Applied Tension are as follows,

1. An assessment of the problem is carried out and the sequence of sensations is discussed, e.g., anxiety, dizziness, sweating, nausea, faintness, etc.
2. A simple tension “coping skill” is demonstrated by the therapist and then copied by the client.
3. Seated in a chair, the muscles of the arms, chest, and legs are tensed until a slight feeling of warmth develops in the face, which usually takes 10-20 seconds, and signals an increase in blood pressure.
4. The tension is released to return to a normal physical state, but no attempt is made to relax further than normal.
5. After a brief, 20-30 second, pause this is repeated, about five times in total during a session, and five sets of five repetitions are completed each day for homework.
6. At the second session, after a week of practice, the therapist begins systematically “exposing” the client to anxiety-provoking images of blood, etc.
7. When the client notices the first sensations of faintness they immediately employ the tension coping skill above to prevent their blood pressure from decreasing.
8. During subsequent sessions, and as homework, the client progressively faces more difficult situations, while using their tension coping skill.
9. After the fifth session, the client continues to make an effort to face specific feared situations for at least the next 6 months, to maintain their improvement.

Training in the tension coping skill seems to effectively increase blood pressure and heart rate with practice. Previous researchers had done something similar by using imagery to evoke feelings of anger and raise blood pressure to counter fainting (Marks, 1981). Öst reports that even if someone does faint, the amount of time required to recover is dramatically reduced, from 3-4 hours down to 5-10 minutes, by use of the tension coping skill. Tensing can cause headaches sometimes but this is easily avoided by doing it less often and not tensing the muscles as powerfully during the exercise.  The tension coping skill is practised alone for one week so that the client becomes skilled at controlling their blood pressure.  In the second and third sessions the therapist begins exposing the client to a wide range (n=32) of photographs of blood and injuries, etc., training them to spot the earliest sensations of their blood pressure dropping and to use the tension coping skill as quickly as possible in response to this cue.  Common preliminary sensations are cold sweat, dizziness, queasy stomach, nausea, etc.

In the fourth session, Öst’s method involves the therapist taking his client on a trip to the Blood Donor Centre where he first observes others having blood taken before giving a sample of his own, while using the tension coping skill to manage their anxiety and faintness. The client may be trained to relax the arm from which the sample is being taken while simultaneously tensing the other muscle groups, to use the coping skill during the procedure.  (An alternative coping skill is simply to clench the fist of the arm not being used as tightly as possible and focus intensely on this while internally repeating coping statements such as “I can do this…” until the procedure is actually finished, as a form of distraction, although this may constitute a “safety-seeking” behaviour in some cases.)

In the fifth session, they go together to the Dept. of Thoracic Surgery and observe open-heart or lung surgery happening.  Although these would normally be considered powerful tests of improvement and likely to lead to further reduction (“habituation”) of anxiety, they do not seem to be essential to the treatment.  In studies where these encounters were omitted completely, the results were virtually identical. That’s fortunate, because it can be difficult to arrange these sort of trips in other settings.  (Although you can buy animal hearts or livers, etc., from many butchers, handling which could be an alternative for some blood phobics, once they’re ready.)

After the treatment has finished, for six months, the client abides by a contract to stop avoiding exposure to the feared situations and to systematically expose themselves in a deliberate manner by viewing photographs of injuries, watching films of surgery, or visiting the blood donor centre, etc., to continue exposure therapy and the use of applied tension in the real world as a way of maintaining improvement.

Research

Research on treating blood phobia has almost exclusively been conducted by one group of researchers: Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden. Recently, a full systematic review was carried out, which identified five treatment outcome studies, all by Öst and his colleagues, and critically evaluated their findings from an independent perspective using careful statistical analysis (Ayala, Meuret & Ritz, 2009). Although the results make comparison rather complex, overall they concluded that both the tension coping skill and exposure to feared encounters with blood, etc., appeared to contribute to clinically significant improvement in 70-80% of blood phobics (Ayala et al., 2009). Where people have other anxieties, they may obtain more general benefit from the exposure part of the treatment (on standard fear surveys) as the tension coping skill only really benefits blood-injection-injury type phobias, although it does appear to do so regardless of whether fainting is a problem (Ayala at al., 2009). However, there has been some debate as to whether certain clients may use the tension coping skill in an unhelpful way (termed a “safety behaviour”). In some studies, clients have agree to follow an ongoing “maintenance programme” following treatment, involving an agreement not to avoid any subsequent exposure to blood-related situations and also to actively engage in regular deliberate exposure exercises. This ongoing homework, involving facing one’s fears, seems to make an important contribution to increased improvement over the longer term (Ayala, et al., 2009).

Öst has compared several variations of the treatment for blood phobia to try to determine which aspects are most important. Öst found that 20 out of 30 people (67%) in one group of blood phobics reported having actuallyfainted in response in a feared situation . However, “fainters” improved as much as “non-fainters” from the same treatment (Öst, Fellenius & Sterner, 1991). Measures of blood pressure have provided direct evidence that the tension coping skill described below does indeed lead to an increase in blood pressure, which improves with practice, in the face of situations feared by blood phobics and normally associated with faintness and a drop in blood pressure (Öst, Fellenius & Sterner, 1991). An surprising finding was that “tension only”, which involved training in the tension coping skill but did not require phobics to actually face their fears, was almost as effective as the full Applied Tension treatment, which added this requirement.

The table below shows the percentage of blood phobic individuals who met stringent research criteria for improvement following different types of treatment, in two different studies. These outcomes suggest that the tension coping skill is a very important component of any treatment for blood phobia.

References

Öst, Fellenius & Sterner (1991). ‘Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia’, Behav. Res. Ther., vol. 29, no. 6, pp. 561-574.

Öst, Sterner & Fellenius (1989). ‘Applied tension, appplied relaxation, and the combination in the treatment of blood phobia’, Behav. Res. Ther., 27, 109-121.

Öst & Sterner (1986). ‘A specific behavioral method for treatment of blood phobia’, Behav. Res. Ther., vol. 25, no. 1, pp. 25-29.

Ditto B.; France CR.; Holly C. (2010). ‘Applied tension may help retain donors who are ambivalent about needles’, Vox Sanguinis. 98(3 Pt 1):e225-30

Ayala ES.; Meuret AE.; Ritz T. (2009). ‘Treatments for blood-injury-injection phobia: a critical review of current evidence’, Journal of Psychiatric Research. 43(15):1235-42

Hypnotherapy and Rational Psychotherapy as Psychoprophylaxis

Copyright (c) Donald Robertson, 2010.  All rights reserved.

Following the large-scale use of Pavlovian hypnotherapy at the start of the 20th century, as a means of reducing pain and anxiety during childbirth and dealing with associated complications, Soviet clinicians began to employ rational psychotherapy in a group setting as a preventative (prophylactic) against pain during childbirth.  These techniques were generally influenced by Pavlovian conditioning theory.  Today we would probably refer to what the Soviet therapists called “psychoprophylaxis” as “psycho-education”.

In a collection of papers by experts in this field, Shugom provides a brief review of Soviet statistical data on the results of psychoprophylaxis of labour pain.  His first observation is that the duration of labour among women who have attended group rational psychotherapy seminars in preparation for childbirth is reduced by an average of two hours, compared to childbirth under anaesthetic, or 3-4 hours compared to labour without anaesthesia.  Shugom provides a table illustrating this conclusion by reference to data from fifteen studies by different authors.  Eight of these were studies specifically on psychoprophylaxis, which report average duration of labour to be between 5hrs 40 min. and 16hrs.  The seven other studies, on duration of labour without psychoprophylaxis, found labour duration to range from 11hrs to 24hrs.

Soviet Rational Psychotherapy for Prophylaxis of Pain during Childbirth

Shugom reports the following mean figures collated from many thousands of cases, measured on a standard five-point clinical scale,

Summing up the results of pain prevention by the psychoprophylactic method on the basis of the reports of 20 authors, including 9 foreign authors, using the materials of more than 15,000 childbirths, A. Nikolayev reported at the Tenth All-Union Congress of Obstetrics and Gynaecology the following data on the effectiveness of rendering childbirth painless by the psychoprophylactic method:

Complete effect of preparation (5): 45-50%
Considerable partial effect (4): 30%
Insignificant (3): 15%
No effect (2): 4-5%

In old studies of this kind, complete or significant partial improvement are often pooled to provide a success rate figure, which in this case would be 75-80%, based on Nikolayev’s data from 15,000 women undergoing childbirth following psychoprophylaxis by the Soviet method. 

Shugom also provides a table of data, summarised in the chart above, which (excluding one site where the number of participants was unknown) shows that among a total sample of 5,610 pregnant women at seven different sites in the Soviet Union, psychoprophylaxis resulted in complete or significant reduction of pain during 83% of childbirths, on average.  Comparison of the figures across sites shows that they are fairly consistent, lending some additional credibility to the finding.

In a direct comparison between the psychoprophylactic method and Pavlovian suggestion-based hypnotherapy for labour pain, another Soviet author, Velvovsky, reported data from exactly 1,000 childbirths.  In this study, the reported level of pain during labour of 641 women who had preventative rational psychotherapy (psychoprophylaxis) was compared directly against a sample of 113 women who received hypnotherapy.  See my article on Velvovsky’s comparison between psychoprophylaxis and hypnotherapy for a more detailed discussion.  The graph below places the data on psychoprophylaxis from Nikolayev’s study alongside the figures from Velvovsky’s direct comparison,

Combined data from Velvovsky and Nikolayev's Studies

These figures need to be treated with caution because little information is provided on the studies and any comparison the two sets of data can only be very tentative indeed.  However, they may provide some inspiration for further research in this area using modern research design methods.  There certainly seems to be an indication, from large numbers of women treated with these methods in the Soviet Union, that psychological methods can reduce the pain of labour to varying degrees, and that the inclusion of Pavlovian-style relaxation hypnosis may substantially improve the effect of psycho-education and suggestion, although non-hypnotic relaxation techniques may be found to have similar properties.

References
Velvovsky, I.; Platonov, K.; Ploticher, V.; Shugom, E.   (1960).  Painless Childbirth through Psychoprophylaxis.
Zdravomyslov, V.I.   (1956).  ‘The Significance of Psychotherapy in Obstetrics and Gynecology’ in Psychotherapy in the Soviet Union, Ralph B. Winn (ed.).  Grove Press: New York.

Copyright (c) Donald Robertson, 2010.  All rights reserved.

These data were reported by I.A. Zhukov in a paper presented at, apparently, the last conference on psychotherapy in the Soviet Union, held in 1956.  Although this is an old study, and doesn’t provide enough information to meet modern research design criteria, it has the benefit of a control group and the figures come from a reasonably large sample of 580 patients.  Participants were treated for different skin conditions in spa resorts at Sochi, Matsesta and the Caucausus, where hypnotherapy was combined with recuperation, sulphur mineral baths and sunbathing.  The patients were mainly (about 92%) women, apparently aged between 20-60, their skin conditions were of one to twenty-five years in duration, and Zhukov says their case histories contained “in all instances some psychological traumata.”  He provides separate data on those patients presenting with eczema, neuro-dermatitis, and psoriasis, which he says in most cases “was quite extensive and affected the head, the trunk, and the legs and feet.”

Comparison of Hypnotherapy and Spa Treatment

Half of the patients constituted a control group who received spa treatment as usual, whereas the other half, the experimental treatment group, received the same spa treatment plus hypnotherapy.  Treatment consisted of seventeen sessions of direct suggestion hypnotherapy based on a Pavlovian conditioning model.  This approach usually involved prolonged periods of deep hypnotic relaxation combined with suggestions of symptom remission and general well-being.  Zheltakov, who presented to the same conference, observed that many of these dermatological patients also suffered from neurotic anxiety and problems sleeping, which might now be described as more “stress-related” or psychosomatic cases.  Zhukov describes his technique as a form of Braidism,

All our hypnotic treatments were conducted by means of the so-called fascination technique (involving staring at some bright object), the spoken word conveying the required suggestion.  Evening hours were chosen for the hypnotic sessions, insofar as this time was most compatible with the resort regimen and permitted us to extend the patients’ sleep to ten or twelve hours.  the sessions were conducted in the patients’ own words.

On average, the control group, who received spa treatment only, reported marked or complete improvement in 23% of cases.  By contrast, those who received hypnotherapy in addition to treatment as usual were marked or completely improved in 63% of cases.  These figures were broadly similar for different conditions, although neuro-dermatitis patients exhibited most improvement with 70% of the hypnotherapy group showing at least marked improvement, compared to 27% of the treatment as usual control group.

There was a follow-up of this study of eczema, neuro-dermatitis, and psoriasis.  Practically all the patients of the experimental group and many patients of the control group were contacted by means of a questionnaire, and 229 answers were received [i.e., a 39% response rate].  The answers overwhelmingly testified to the permanent nature of the improvements.

According to these data, the vast majority of patients, 85% in the treatment as usual group and 98% in the hypnotherapy group, reported at least slight improvement.  However, whereas only 10% of patients in the spa treatment control group were classed as “completely recovered”, three times as many, 31% of the hypnotherapy patients met criteria for full recovery. 

References
Zheltakov, M.M.  (1961).  ‘The use of hypnosis and conditioned-reflex therapy in dermatology’, in Winn, Ralph B. (ed.), Psychotherapy in the Soviet Union.
Zhukov, I.A.  (1961).  ‘Hypnotherapy of dermatoses in resort treatment’, in Winn, Ralph B. (ed.), Psychotherapy in the Soviet Union.

Modes of Relaxation

Copyright (c) Donald Robertson, 2009.  All rights reserved.

Relaxation techniques constitute some of the simplest, most versatile, and most effective interventions in the therapeutic armamentarium.  Relaxation is particularly central to traditional hypnotherapy which, as practised by James Braid, originally aimed to induce various degrees of “nervous sleep” for therapeutic recuperation in many clients.  Relaxation is equally central to traditional behaviour therapy techniques such as Wolpe’s systematic desensitisation and is frequently employed in modern CBT.

However, therapists often fail to make elementary distinctions between different forms of relaxation which could be of considerable importance to the outcome of treatment.  The word “relaxation” was not in common use in its modern sense prior to the 20th century and it is used today to describe a multitude of different techniques, often on the assumption that they are somehow equivalent in their results.

Research on behaviour therapy led to the observation that anxiety and tension do not manifest in all aspects of psychological and physiological functioning equally.  Someone can have tense shoulders but very relaxed facial muscles, for example.  However, more significant differences can exist between different neurological response systems, e.g., cognition, behaviour, and physiology.  In our approach, we might a distinction, like the folk-psychology one between thoughts, actions, and feelings.  However, we use the terms cognition, behaviour and affect (including “feelings” in the sense both of emotions and autonomic sensations).

A. Affect and autonomic sensations including the feelings of anxiety and physiological responses such as heart rate, blood pressure, etc.

B. Behaviour including all tension in the musculature of the body and even slight movements, etc.

C. Cognitive arousal including racing thoughts, narrowing of attention, and fearful appraisals, etc.

To some extent, relaxation in one of these response systems may, sometimes after a delay, produce relaxation in the other systems, but this is not always the case.  The lack of correlation between them has been referred to as “desynchrony”.  Indeed, it’s very common to observe groups of people doing meditation or relaxation techniques who are clearly frowning, fidgeting, clenching their jaws, hunching their shoulders, or tensing other parts of the body while apparently feeling extremely mentally calm and serene.  Likewise, people who learn to relax their body, even if they succeed in reducing muscle tension and even lowering heart rate, will often report that their mind begins racing, especially in the early periods of practice.

As it happens, different relaxation techniques can be seen to focus differentially upon these response systems.  For example,

A. Breathing techniques arguably come closest to directly influencing heart rate and other physiological responses.

B. Tension-release techniques such as Jacobson’s influential progressive muscle relaxation (PMR) approach directly influence the level of muscular tension in the body.

C. Meditation techniques such as Herbert Benson’s “relaxation response” method, or other concentrative approaches, and mindfulness meditation techniques of a more contemplative nature, may be the most direct way of reducing cognitive arousal and slowing down thinking.

Understanding this simple distinction can help to better match the intervention to the needs of the individual client and the nature of their presenting problem.

Brief Introduction & FAQ

What is Cognitive-Behavioural Hypnotherapy?

The cognitive-behavioural approach to hypnotherapy is the main evidence-based approach to hypnotherapy, and draws heavily upon psychological research on hypnosis and suggestion.  It can best be understood as in terms of three features it typically adopts,

1. What’s traditionally termed the “cognitive-behavioural” theory of the nature of hypnosis, which basically rejects the notion of hypnotic “trance”.
2. Cognitive and behavioural therapy interventions, which partly derive from modern cognitive-behavioural therapy (CBT) and partly derive from traditional hypnotherapy pre-dating CBT.
3. A broadly cognitive-behavioural theory of people’s problems (psychopathology), which attempts to explain issues such as anxiety using specific evidence-base models.

You may encounter training courses or articles on the internet that suggest cognitive-behavioural hypnotherapy is just hypnotherapy combined with CBT techniques but this is incorrect.  The cognitive-behavioural approach to hypnosis is mainly characterised by the rejection of the notion of “hypnotic trance” and an emphasis on ordinary psychological factors such as suggestion, expectation, and imagination, instead.

Where can I find more detailed information?

There are several good books on the subject.  We especially recommend Essentials of Clinical Hypnosis: An Evidence-Based Approach (2006) by Steven Jay Lynn and Irving Kirsch, two of the leading researchers in this area.  There are many articles on our UKhypnosis.com blog and you may find the one below particularly helpful as a more detailed historical overview,

http://ukhypnosis.com/2009/06/21/cbt-cognitive-behavioural-theories-of-hypnosis/

What are the other approaches to hypnotherapy?

Cognitive-Behavioural Hypnotherapy (CBH) is a term used to describe one of three major approaches to hypnotherapy.  The others two are the Ericksonian and Regression (or “psychodynamic”) approaches, which originate with the work of Milton Erickson and Sigmund Freud, respectively.  Virtually all hypnotherapy falls into one of these three broad categories, although they adopt different assumptions, language and methods from each other. 

Is it a new thing?

No.  It’s recently grown in popularity, since the 1980s, because of the success of CBT.  However, the cognitive-behavioural approach to hypnosis can be traced all the way back to the founder of hypnotherapy, James Braid, who coined the term “hypnotism” around 1841.  His approach to hypnosis and that of other Victorian hypnotists was not “cognitive-behavioural” in the modern sense but definitely contains traces of theories that were to develop later under that heading.  From the 1950s onward, psychologists such as Ted Sarbin began to propose theories of the nature of hypnosis that rejected the notion of “hypnotic trance” and emphasised the role of ordinary cognitions (thoughts and beliefs) and behaviour in explaining apparently extraordinary responses such as hypnotic amnesia or painless surgery.  Following on from this early work, the psychologist Theodore Barber and his colleagues carried out a systematic programme of research on hypnosis.  This led to further refinements of Sarbin’s non-trance (called “non-state”) model which in one of the most influential books in the field of hypnosis, Hypnotism: Imagination and Human Potentialities (1974) by Barber, Spanos & Chaves, he eventually labelled the “cognitive-behavioural” approach to hypnosis.  Since the 1970s, it has become common to refer to various non-trance theories as the “cognitive-behavioural” tradition in hypnosis. 

Is it fairly common?

The non-trance (“non-state”) perspective was adopted by the most prolific researchers in the field, i.e., Sarbin, Barber, Spanos, Wagstaff, Kirsch, Lynne, etc.  However, most hypnotherapists have tended not to engage with the research literature in their field and still tend to use the older language of hypnotic “trance”, etc.  The modern emphasis on evidence-based practice means that hypnotherapists are increasingly under pressure to read and assimilate the scientific research in their field, however, and that tends to favour a “cognitive-behavioural” approach to hypnosis.  Hence, from the 1980s onward, cognitive-behavioural hypnotherapy has become increasingly popular.

Is it derived from CBT?

Not really.  The cognitive-behavioural theory of hypnosis has its roots in the original Victorian theories of hypnosis, began to develop properly in the 1950s and 1960s, and was labelled “cognitive-behavioural” in the mid-1970s.  Cognitive therapy, which later became known as “cognitive-behavioural therapy” or CBT, was just beginning to develop around this time and did not become well-established until the 1980s.  Cognitive-behavioural approaches to hypnosis therefore predate the development of modern CBT.  However, because of the overlap between them, modern cognitive-behavioural approaches to hypnotherapy inevitably draw on elements of CBT.  On the other hand, some of the ideas and methods found in CBT may derive from earlier hypnotherapy approaches and precursors of them can certainly be found in the literature of hypnosis before the 1970s.

Where can I find courses?

The UK College of Hypnosis & Hypnotherapy has always adopted a cognitive-behavioural approach to hypnosis and was one of the first (perhaps the first) training school in the UK to do so.  More recently other schools have switched from other (contradictory) orientations to teaching the cognitive-behavioural approach to hypnotherapy.  However, the UK College have a long-standing reputation for adopting an evidence-based and cognitive-behavioural approach.  See our main website below for information on our externally-accredited Diploma in Cognitive-Behavioural Hypnotherapy.  We also sometimes run “conversion” courses or short workshops for qualified hypnotherapists who wish to change from another orientation to adopt a more evidence-based or cognitive-behavioural approach to their work.

See our main website below for more information on these and other training courses.  You can call our office free on 0800 195 9809 or email us at admin@ukhypnosis.com for a prospectus or more information.

www.UKhypnosis.com

Advances in Cognitive Therapy

The Uncertainty of Things

Copyright (c) Donald Robertson, 2010.  All rights reserved.

Thus conscience does make cowards of us all;
And thus the native hue of resolution
Is sicklied o’er with the pale cast of thought;
And enterprises of great pith and moment,
With this regard, their currents turn awry,
And lose the name of action.  (Hamlet)

So said Hamlet, in Shakespeare’s play, whose quest for certain proof regarding his father’s murder drove him into depression, anguish, and interminable procrastination, until his hand was eventually forced by the ultimate “deadline” – he was poisoned and took decisive action just before he died.  Hamlet’s plight resembles that of the typical modern psychotherapy patient whose irrational (“neurotic”) demands were well-understood by Albert Ellis, the founder of Rational-Emotive Behaviour Therapy (REBT).  Ellis identified one of the most common dysfunctional beliefs as “There is invariably a right, precise, and perfect solution to human problems and it is catastrophic if this perfect solution is not found.” (Reason and Emotion in Psychotherapy, 1962). 

In recent decades, there has been increasing interest in the notion that “intolerance of uncertainty” may play an important causal role in the development of pathological worry.  Attitudes of intolerance to uncertainty have consistently been found to correlate with the presence of worry.  Worry is common to many forms of anxiety and depression, but particularly central to the diagnosis of Generalised Anxiety Disorder (GAD).  A number of studies have produced mounting evidence for the importance of intolerance of uncertainty as a trait linked to GAD and other problems.  For example, paradoxically, researchers have found that some chronic worriers actually prefer certainty about a negative outcome happening to uncertainty.  Perhaps once these individuals know something bad is going to happen they feel able to resign themselves to planning how to cope, whereas uncertainty keeps them on edge.  Moreover, there is some evidence of causation as intolerance of uncertainty has been found to chronologically precede the development of worry as well as correlating with it.

Traditional cognitive therapy for anxiety has struggled to treat these cases successfully.  Cognitive therapy for GAD originally emphasised re-evaluating the probability of a feared outcome, which chronic worriers tend to find difficult and unconvincing.  Whatever the estimated probability of danger the inescapable element of uncertainty will often be sufficient to maintain an ongoing process of worry because it continues to trigger “What if?” questions about hypothetical catastrophes, which may become distorted over time.  The psychologist Michel Dugas has been especially responsible for promoting this concept of “intolerance of uncertainty” within CBT, although it has now been assimilated by Aaron Beck into his cognitive model and treatment of GAD.  Treatment outcome studies have provided evidence that Dugas’ approach, based on acceptance of uncertainty, is more effective than traditional CBT for generalised anxiety, with 77% of chronic worriers being significantly better at the end of treatment.

Dugas’ basic “intolerance of uncertainty” model is as follows,

Uncertainty
   -> “What if?” questions
      -> Worry
         -> Anxiety
            -> Demoralisation / Exhaustion

A situation which is problematic and characterised by uncertainty triggers “What if?” questions, which lead to catastrophic predictions about uncertain future events, and evolve into a process of worry, focused on uncertain future threats, and cumulative anxiety.  Questions tend to maintain attention, sucking you in further, and “What if?” questions tend to involve negative predictions about the future, creating a state of prolonged mental absorption in different negative possibilities.  This tends to be linked together as abstract verbal thoughts in worry, almost like a kind of negative self-hypnosis.  The chain reaction begins with our response to uncertain threats, however, and it’s at this point, perhaps, that we can nip it in the bud before “What if?” thinking develops into pathological worry.  Otherwise, the “What if?” question mark is like a little fishing hook that keeps our attention snagged.

Dugas describes intolerance for uncertainty, metaphorically, as a kind of allergy.  Some people are just more “allergic” to uncertain situations than others and react with more worry and anxiety.  People who can’t tolerate uncertainty typically “lose the name of action”, like Shakespeare’s Hamlet, and tend to procrastinate and avoid attempting to solve their problems.  They hold out for certainty, conclusive evidence, and a “perfect solution” and are unwilling to adopt an experimental, trial and error, approach by testing out imperfect solutions until they find something that works.  Some things are simply unknowable and some uncertainty is inescapable in life.  Refusing to accept that fact keeps worry going pointlessly and fuels anxiety.

Reduction of Uncertainty

People who are intolerant of uncertainty, feel like they “must” overcome it, and tend to try compulsively to reduce uncertainty in their lives.  In particular they may seek reassurance from other people, think about things repeatedly, or try to find information from sources like the internet.  However, this quest for certainty seldom leads to satisfaction and people who suffer from chronic worry show a marked tendency to waste considerable time and energy in futile and repetitive attempts to find a “perfection solution” where none can be found.  The search for certainty also tends to lead to procrastination and avoidance because taking action might involve risk and uncertain outcomes, and intolerance of uncertainty is associated with being risk averse.  Increasing everyday exposure to “uncertainty”, or “uncertainty inoculation”, involves systematic “behavioural experiments”.  These experiments require decreasing or eliminating one’s attempts to reduce uncertainty, like reassurance-seeking, repeated checking, over-preparing, and excessive information searches.

Treatment

The alternative to compulsive certainty-seeking and intolerance of uncertainty is, of course, acceptance of uncertainty and a commitment to taking action, where necessary, in the face of uncertainty.  Dugas’ treatment protocol for GAD consists of five key components,

1. Worry awareness training involves keeping a daily record of worry topics in order to spot when they arise and what the main themes are
2. Coping with uncertainty by reducing attempts to reduce uncertainty and carrying out behavioural experiments where uncertainty is deliberately embraced during prescribed activities
3. Challenging positive beliefs about worry, e.g., that it’s positive character trait, aids in problem-solving, it’s motivating, protects you from negative feelings, or prevents negative events.
4. Problem-solving training, especially developing a positive and confident attitude toward problems, seeing them as challenges rather than threats, but also developing specific planning skills
5. Imaginal exposure to core fears, which reverses mental avoidance by asking the client to repeatedly visualise the feared catastrophic outcome and accept their feelings until they reduce

Traditional cognitive therapy is adapted to evaluate the evidence for and against beliefs that certainty can be achieved or a perfect solution found.  The client is asked to carefully reconsider their reasons for believing that uncertainty about specific problems can be reduced or eliminated, that living with uncertainty is intolerable, or that one has sufficient control over future events to achieve a perfect solution to certain problems.  According to psychologist Robert Leahy, author of The Worry Cure, challenging positive beliefs about worry may involve evaluating the pros and cons of worry about specific matters in detail to identify the difference between helpful and unhelpful instances of worry.  This will often lead to the realisation that some problems are hypothetical, distant, uncontrollable, or unlikely, and not worth worrying about.  Others are more imminent and concrete and may demand a solution, although worrying is usually less helpful than systematic problem-solving.

Problem-Solving / Imaginal Exposure

Hence, Dugas and his colleagues ask clients to distinguish between worries about current problems and those related to hypothetical situations, i.e., problems that are actually solvable in practice and ones that are not.  Solvable problems are tackled using a version of traditional problem-solving therapy (PST), which involves cultivating a positive and confident attitude or “orientation” toward problems, getting in the right mind-set to start working on solutions.  This is followed by the four typical steps,

1. Definition of problems and goals
2. Brainstorming alternative solutions
3. Evaluation of consequences
4. Action planning and solution implementation

Problem-solving, which goes beyond the “action planning” stage, to solution implementation, will inevitably require that worriers reverse their procrastination and avoidance, and usually entails accepting, and acting despite, some degree of uncertainty and risk.

Problems which are not suitable for practical problem-solving are addressed using a version of imaginal exposure therapy, in which the worst-case scenario is repeatedly visualised in concrete terms for prolonged periods, of around 30 minutes, until the anxiety naturally abates due to the process known as “classical extinction” or “habituation”.  This is a bit like saying that by facing your fears repeatedly, for long enough, without distractions, you will tend to grow bored with them and get used to the feelings until they wear off and diminish.  Accepting anxiety as harmless, temporary, and natural, seems to aid the process of extinction, whereas being ashamed of feeling anxious or trying to suppress your emotions and battle with them tends to maintain the problem and prevents the natural process of overcoming fears from following its normal course.

Suggested Reading

D’Zurilla, T. J., & Nezu, A. M. (2007). Problem-Solving Therapy: A Positive Approach to Clinical Intervention. New York: Springer Publishing.

Koerner, N., & Dugas, M. J. (2006). A Cognitive Model of Generalized Anxiety Disorder: The Role of Intolerance of Uncertainty. In G. C. Davey, & A. Wells (Eds.), Worry and its Disordres: Theory, Assessment and Treatment. Chichester: Wiley.

Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2007). Solving Life’s Problems: A 5-Step Guide to Enhanced Well-Being. New York: Springer.

Robichaud, M., & Dugas, M. J. (2006). A Cognitive-Behavioral Treatment Targeting Intolerance of Uncertainty. In G. C. Davey, & A. Wells (Eds.), Worry and its Disorders: Theory, Assessment and Treatment. Chichester: Wiley.

Data from Soviet Studies

Copyright (c) Donald Robertson, 2010 

The graph below shows data from exactly one thousand childbirths in the Soviet Union.  641 of the women had “prophylactic preparation” in the form of preventative psychological education suggestion, of whom 25% reported complete absence of pain in childbirth.  This sort of rational “psycho-education” took place in groups of 30-35 women over the space of up to six sessions.  A smaller group, 246 women, were given verbal reassurance and suggestion by a hypno-psychotherapist who was actually present at the birth, of this group 56% reported painless birth.  Only 113 women received full hypnotherapy, of whom an impressive 84% reported completely painless childbirth. 

These figures have very limited validity, for a number of reasons.  In particular, there is no indication of randomisation, so women may have been selected for different treatments in a way that could have prejudiced the results.  There’s also little information on the method used to measure the outcome, i.e., the way pain was measured and reported.  Nevertheless, during this period there was considerable support for hypnotherapy and suggestion used to alleviate the pain of childbirth in the Soviet Union on a very large scale, and these figures give some rough indication of the perceived benefits. 

Reference 

Zdravomyslov, V.I.   (1956).  ‘The Significance of Psychotherapy in Obstetrics and Gynecology’ in Psychotherapy in the Soviet Union, Ralph B. Winn (ed.).  Grove Press: New York. 

Data on Soviet Hypnotic Childbirth

Copyright © Donald Robertson, 2011.  All rights reserved.

This is an excerpt from our online course on problem-solving which deals with general-purpose strategies for approaching problems.  Begin by clearly defining your problem and goal first.  Then try considering each one of these general strategies in turn.  Make a note of specific tactics you could employ which correspond to the strategies that look most helpful…

Problem-Solving Strategies

Which of these might be relevant to your problem? How would you translate them into specific tactics?

Wait and See.
Maybe you’re trying to hard to change things. Perhaps patience would be a virtue. What happens if you just do nothing but just sit back and wait?

More of the Same.
Maybe you’re already doing the best you can under the circumstances. What happens if you just persevere and keep up what you’re already doing to deal with the problem? Perhaps what you’re doing is fine but you just need to do more of it or keep it up longer.

Keep it Simple.
Maybe you’re overcomplicating things. What’s the simplest solution? What would be the easiest thing to do? Maybe it’s better to try something simple first just to get started and then introduce a more complicate plan later, if it’s required.

Get Specific.
Maybe you’re being too vague. What would happen if you made your plans more specific and detailed? How could you approach the problem in a more concrete way?

Get a Move on.
Maybe you’re delaying things unnecessarily. What would happen if you acted quickly? What could you do right away, or as soon as possible, to start addressing the problem? A stitch in time saves nine. Strike while the iron is hot.

Pause for Thought.
Maybe you’re rushing things unnecessarily. What would happen if you took things more slowly? Would it be better to postpone action until a later date? Fools rush in where angel’s fear to tread. Act in haste, repent at leisure. Maybe this isn’t the right time. When would be?

Take a Risk.
Maybe you’re trying to get all the answers before taking a risk. Perhaps you can afford to take a gamble and try something out in practice that may or may not work. What have you got to lose by making an experiment? Perhaps you won’t be certain how to solve the problem until you’ve had a go and tested something out in practice.

Do the Opposite.
Maybe you’d be better off doing the complete opposite of what you usually do with problems like this. What would happen if you just tried something radically different and went in the opposite direction?

Divide and Conquer.
Maybe you’re biting off more than you can chew. What would happen if you divided this problem down into smaller chunks and tackled them one step at a time. Even a journey of a thousand miles begins with a single step. Perhaps you should focus on what the first few steps should be instead of trying to solve the whole problem.

Call for Reinforcements.
Maybe you’re not the best person to handle this problem. What would happen if you got someone else to help you or to tackle it for you? Maybe you can delegate part of the solution to someone else. Maybe you could ask others for advice.

Practice Makes Perfect.
Maybe you need to practice before you tackle the main problem. What would happen if you rehearsed things in role-play or in your imagination first? Perhaps there’s a smaller problem you can test your solution out on first?

Face your Fears.
Maybe you’re avoiding doing something unpleasant. What would happen if you just forced yourself to get it over with? Maybe you just need to knuckle-down and get on with it. Perhaps things will be easier than you think or maybe by facing your problem, you’ll become stronger as a result. Feel the fear and do it anyway. Bite the bullet.

Draw a Plan.
Maybe you need to spend more time developing a plan of action. What would happen if you drew a diagram or made a detailed list of the steps first? Perhaps by planning your action more systematically you stand a better chance of succeeding. Perhaps you could go back to the drawing board.

Learn from the Best.
Maybe you need to research what other people do to resolve similar problems. What would happen if you set aside time to talk to people, observe them, or read up on things? Make a list of tactics other people employ and observe exactly how they do it.

Use a Safety Net.
Maybe you need some security or a plan B. What would happen if you did something to protect yourself in case your plan doesn’t work? Sometimes it’s wise to have certain precautions in place.

Get Creative.
Maybe you should try something a bit different. What would happen if you came up with a really creative solution? Think outside the box. Think laterally and creatively. What’s the inspired solution? What have you never tried? What would be a clever or inventive solution?

101 Other Strategies.
There are countless other strategies that you may consider but hopefully this list will help spark some ideas of your own. Take this opportunity to think about what alternatives you haven’t considered so far.

Hypnotherapy as Empirically-Supported Treatment (EST)

Ratings using Chambless & Hollon (1998) criteria reviewed by David M. Wark (2008)

Copyright © Donald Robertson, 2009 Reprinted from The Hypnotherapy Journal Spring 2009

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I beg farther to remark, if my theory and pretensions, as to the nature, cause, and extent of the phenomena of [hypnotism] have none of the fascinations of the transcendental to captivate the lovers of the marvellous, the credulous and enthusiastic, which the pretensions and alleged occult agency of the mesmerists have, still I hope my views will not be the less acceptable to honest and sober-minded men, because they are all level to our comprehension, and reconcilable with well-known physiological and psychological principles. – James Braid, Hypnotic Therapeutics, 1853

One of the most useful articles to be published recently was arguably Wark’s review of those studies on hypnotherapy that were rated as meeting the Chambless & Hollon (1998) criteria for “empirically-supported treatments” in the field of psychology, known as ESTs for short. It may not surprise many NCH members to know that when the research literature on psychotherapy was previously reviewed by a task force of nineteen psychologists led by Prof. Dianne Chambless most of the psychological therapies identified as “empirically-supported” (formerly termed “empirically-validated”) tended to be specific forms of cognitive and/or behaviour therapy (CBT). Most forms of psychotherapy, ranging from the more controversial and pseudoscientific ones to some of the more “respectable” and mainstream approaches, do not meet these strict criteria for empirical support. However, one study was identified which demonstrated that cognitive-behavioural hypnotherapy (CBH) was “probably efficacious” for weight loss in obese clients. In this respect, hypnotherapy might (tentatively) be said to have garnered more compelling evidence for its efficacy than many other modalities of psychological therapy, apart from the cognitive and/or behavioural treatments and some brief psychodynamic approaches.

However, over the past decade, many additional studies of a high quality have been published which provide support for the efficacy of hypnotherapy, including meta-analyses and systematic reviews which collate data from multiple studies to form a more general picture of the research findings in this area. David Wark’s review entitled ‘What we can do with hypnosis: a brief note’ identifies over thirty additional studies on hypnotherapy which he rates using the revised Chambless & Hollon (1998) criteria for either “possible”, “probable”, or “specific” empirically-supported treatments, depending upon the nature of the evidence available (see the explanations below). I have compiled this information into a new table which you will find underneath. Of course, these are not all the possible applications of hypnotherapy, simply the ones which currently have the strongest empirical support, based on Wark’s rating using established criteria for research quality. More studies are published every year which potentially meet these criteria and might be included on a future list.

I think it might be observed that certain hypnotherapy treatments for certain types of pain, anxiety, and weight loss are supported by the strongest evidence at present, by this standard. In total, three studies (anxiety due to asthma, public speaking, and taking a test) provide good evidence for the efficacy of hypnotherapy as a treatment for anxiety. Assen Alladin’s recent study which provides support for the use of hypnosis in the treatment of depression is rated as meeting the “possibly” efficacious criteria. Most of the other studies provide evidence relating to the treatment of acute or chronic pain, and certain stress-related or psychosomatic medical conditions such as insomnia, migraine and IBS. Wark even finds one study on hypnotherapy for smoking cessation which meets the criteria for “possibly efficacious”, an area where well-designed research has previously been lacking.

This overview is consistent with a general trend in the literature, since the Victorian era, which tends to point toward hypnotherapy showing most promise in the treatment of anxiety, insomnia, pain management, and several stress-related medical conditions, with mixed findings in relation to its use for the treatment of habits and addictions such as over-eating, smoking, and alcohol abuse. For example, a committee of experts commissioned by the British Medical Association concluded in 1892 that,

The Committee are of opinion that as a therapeutic agent hypnotism is frequently effective in relieving pain, procuring sleep, and alleviating many functional [i.e., psycho-somatic] ailments.

However, we can now go beyond those early clinical observations and primitive experiments and provide an overview of the therapeutic usefulness of hypnotherapy based on modern research design meeting the highest standards of quality.

These ratings are derived from the review published by Wark (2008), in which the references and criteria are given in full. In brief, the main criteria for the ratings are those set by Chambless & Hollon (1998), which they define roughly as follows but see their article for a more specific and detailed account of the criteria.

Possible

A treatment is “possibly” empirically-supported if peer-reviewed studies meet the following minimum criteria. Studies should normally contain samples of at least 25 subjects who are randomly assigned to treatment and control groups, i.e., the study is a randomised control trial (RCT). There is a treatment manual or equivalent (such as a hypnosis script) so that the treatment can be replicated in other studies. Treatment must be conducted upon a specific condition which has been adequately assessed, and adequate outcome measures must be used which are subject to suitable statistical analysis. The outcome must essentially show the treatment to be significantly more effective than a placebo or no-treatment control group, or equivalent to another empirically-supported treatment.

Effective

A treatment is termed empirically-supported as being “effective” if statistically significant superiority to control group measures have been replicated with completely independent samples or by independent research teams, and data supporting the treatment in question must be shown to predominate if there are conflicting data from other studies.

Specific

A treatment can be considered empirically-supported as “specific” (i.e., better than “non-specific” treatment) if it has shown statistically significant superiority to a placebo (“sham”) therapy or another psychological therapy in at least two independent studies.

References

Bolocofsky, D.N., Spinler, D., & Coulthard-Morris, L. (1985). ‘Effectiveness of hypnosis as an adjunct to behavioral weight management’, Journal of Clinical Psychology, 41.

Chambless, D.L., & Hollon, S. ‘Defining empirically supported therapies’, Journal of Consulting and Clinical Psychology, 66.

Task Force on Promotion and Dissemination of Psychological Procedures. ‘Training in and dissemination of empirically validated psychologist treatments: report and recommendations.’ Clin Psychol 1995;48:3–23.

Chambless DL, Sanderson WC, Shoham V, Bennett Johnson S, Pope KS, Crits-Christoph P, et al. ‘An update on empirically validated therapies.’ Clin Psychol 1996;49:5–18.

Chambless DL, Baker MJ, Baucom DH, Beutler LE, Calhoun KS, Crits-Christoph P, et al. ‘Update on empirically validated therapies, II.’ Clin Psychol 1998;51:3–16.

Wark, David M. (2008). ‘What we can do with hypnosis: a brief note’, American Journal of Clinical Hypnosis, July 2008