March 2013
Catherine Fredette, Ghassan El-Baalbaki, Sylvain Neron and Veronique Palardy
1. Introduction
In psychotherapy outcome research, many empirical studies have shown that cognitive behavioural treatments are efficacious for many disorders [1]. In a recent systematic review of 27 studies, Hofmann and Smits [2] show that cognitive behavioural therapy (CBT) has proven to be an unquestionably efficacious treatment for adult anxiety disorder when compared to both pharmacological and psychological placebos. However, they conclude that there was considerable room for improvement. Moreover, the high complexity and co-morbidity that is often found with anxiety disorders sometimes requires the use of two or more treatment methods that are flexible and adjustable to one other [3]. According to Kirsch, Lynn, and Rue [4] and Schoenberger [5], hypnosis can be integrated easily into current cognitive and behavioural interventions in clinical practice.
Indeed, CBT and hypnosis share a number of aspects that render their combination natural; for example, imagery and relaxation, which are found in both techniques [6]. Hypnosis has been used effectively in a variety of medical settings (surgery, dentistry, chronic pain management, labour etc.) and several studies report its efficacy in the treatment of anxiety disorders [7-13].
A recent systematic review of randomized controlled trials concludes that current evidence is not sufficient to support the use of hypnosis as a sole treatment for anxiety [14]. However, in a meta-analysis, Kirsch, Montgomery, and Sapirstein [15] found that the addition of hypnosis to CBT substantially enhanced the treatment outcome for several problems (anxiety, obesity, pain, etc.).
The addition of hypnosis to CBT helps the patient in several aspects of therapy, such as the preparation for in-vivo exposure, imagery exposure, developing coping skills, and cognitive restructuring [6, 16-18]. Moreover, patients using hypnosis effectively develop a better sense of self-efficacy, which is known to enhance self-regulation and is linked to lower psychological distress and better quality of life. Hence, hypnosis is worth exploring as an additional tool to improve traditional CBT.
In this chapter, we offer a comprehensive review of the literature regarding the use of hypnosis in the treatment of anxiety disorders. We will present evidence that supports its use or not as an adjunct treatment to CBT, also known as cognitive-behavioral hypnotherapy (CBH).
We will also present evidence that does not justify its use as an independent treatment for anxiety disorders. Due to the amount of research on Post-Traumatic Stress Disorder (PTSD) and hypnosis, the reader will notice that a lot of the information will be related to PTSD. We will conclude by giving a simple guideline for practitioners interested in developing and using hypnosis as an adjunctive therapeutic tool in their practice.
2. Description and definition
Although under different names and applications, hypnosis has been depicted, described and documented in ancient civilizations (e.g. Egyptians, Greeks, Chinese, Indians, Sumerians, Persians and others) and was mostly used by healers. In his book Ash Shifa (Healing), Ibn Sina (Avecenna) wrote about the mind–body relationship and accepted the reality of hypnosis, naming it "al Wahm al-Amil" [19]. He differentiated it from sleep and described the impact of imagination on sensation and perception [20].
More recently, the British physician James Braid [1795-1960], who is recognized for conducting many research studies and experiments on hypnotic phenomena, coined the words neurypnology and neuro-hypnosis [21, 22]. In fact, he observed his patients while in trance and concluded that they were in a "nervous sleep." The Greek word for sleep is hypnos [21].
These terms were quickly transformed into the word hypnosis. Hypnosis lost its appeal with the rise of psychoanalysis during the first half of the 20th century [23]. Indeed, after a short interest in the practice of hypnosis, Freud abandoned and rejected the idea [21]. As a valid form of psychotherapy, hypnotherapy only regained its popularity with the advent of the First and Second World Wars [23]. During this time, psychiatrists were faced with a new disease, called shell shock or war fatigue, and used hypnosis as a way to relieve the symptoms [21].
Today, this disorder is known as PTSD. Subsequently, the modern study of hypnosis began to flourish. Throughout the years, hypnosis has been represented in various ways, whether good or bad, and many popular misconceptions around this phenomenon remain [22]. Indeed, people under hypnosis are sometimes viewed as robots who do things that they would not normally do [22]. Even though individuals under hypnosis are more prone to suggestions, they still remain in control of what they say and do [24].
In fact, despite the perception that experiences under hypnosis often contain automatic or involuntary actions, hypnotised patients ultimately act in congruity with their goals and in accordance with their points of view [25]. Another mistaken belief is that hypnosis is not real. However, recent scientific studies (e.g. brain imaging studies) go beyond these mainstream conceptions and expose the true nature of hypnosis and its possible uses [25].
Burrows, Stanley, and Bloom [26] describe hypnosis as a technique that induces, through relaxed and focused attention, an elevated state of suggestibility. During this state, reduction in critical thinking, reality testing and tolerance of reality distortion allow the person to experience different phenomena (vivid imagery, drug free anaesthesia, drug free analgesia, and so on) that might otherwise be hard to attain [26].
Contrary to common perceptions, hypnosis is a natural phenomenon which people experience in a lighter way several times a day [27]. Daydreaming, being so absorbed by a book or movie that you do not hear someone calling your name or absent-mindedly driving past an expressway exit are all examples of shallow hypnotic states [27]. According to the division 30 of the American Psychological Association (APA), a procedure becomes a hypnotic one when the following two components are present: an introduction in which a person is told that suggestions for imaginative experiences will come, and the first suggestion, which functions as the induction [22].
Examples of suggestions during the introduction include: "I am going to ask you to imagine some changes in the way you think and feel. Is that ok? Let's see what happens" [22]. The formulation of hypnotic suggestions is different from other types of suggestions (e.g. placebo, social influence), given the fact that it requests the patient to participate [22].The first suggestion might come directly after the introduction and is usually a suggestion to close the eyes, move the arm or hand or alter perception [22].
Given that there are many types of hypnotic suggestions, standardized scales of suggestibility can be applied before someone undergoes formal hypnotherapy to see how suggestible the person is to all kinds of hypnotic suggestions [28]. During ideomotor suggestions, a certain action, such as arm levitation occurs automatically without awareness of volitional effort by the person [28].
Challenge suggestions occur when the hypnotised person is unable to execute an act that is ordinarily under voluntary control such as bending an arm [28]. Cognitive suggestions also can be used to create various cognitive or visual distortions such as pain reduction, selective amnesia, and hallucinations [28]. These different types of suggestions were characterized by Hilgard [29] as the domain of hypnosis.
Hypnotic experiences take place in the realm of imagination of the person under hypnosis [30]. However, it is interesting to note that hypnotic mental imageries and ordinary ones do not have the same experiential qualities [30]. Indeed, the construction of a mental imagery is both intentionally and consciously created, whereas imaginary experiences under hypnosis are generally involuntary [30].
People are suggested or informed about an image and it naturally comes to them. This difference seems to be supported by the fact that neurocognitive activations differ from normal and hypnotic imaginary experiences [31]. Another characteristic of hypnotic experiences, including the ideomotor ones, is that they are cognitive in nature [30]. Indeed, participants simply experience alterations in cognitive processes such as perception and memory.
People differ in their abilities to experience hypnosis and it might be that some hypnotic responses require specific underlying abilities that are not shared by everyone, or that many individual components might be needed to experience a hypnotic phenomenon [32]. The ability to dissociate, cognitive flexibility, susceptibility to suggestions, fantasy proneness, and imaginative abilities were identified as possible traits that make an individual more amenable to experience hypnosis [33-36].
