Hypnotherapy – Glasgow Cognitive Behavioural Hypnotherapy
American Journal of Clinical Hypnosis
This article describes cognitive hypnotherapy (CH), a visionary model of adjunctive hypnotherapy that advances the role of clinical hypnosis to a recognized integrative model of psychotherapy. As hypnosis lacks a coherent theory of psychotherapy and behavior change, hypnotherapy has embodied a mixed bag of techniques and thus hindered from transfiguring into a mainstream school of psychotherapy. One way of promoting the therapeutic standing of hypnotherapy as an adjunctive therapy is to systematically integrate it with a well-established psychotherapy. By blending hypnotherapy with cognitive behavior therapy, CH offers a unified version of clinical practice that fits the assimilative model of integrated psychotherapy, which represents the best integrative psychotherapy approach for merging both theory and empirical findings.
As an adjunctive therapy, hypnotherapy has been traditionally combined with other psychotherapies. However, the assimilation has not always been driven by a coherent theory of integration. The blending of hypnotic techniques with other therapies has vacillated from being very systematic to idiosyncratic (Alladin & Amundson, 2011). In this article cognitive hypnotherapy (CH) is described as an assimilative model of integrative psychotherapy. The purpose of this article is not to discuss the cognitive-behavioral theories of hypnosis as explicated by, for example,Sarbin and Coe (1972) and recently revisited by Lynn and Green (2011). The present focus is on the assimilation of hypnotherapeutic techniques with other psychotherapies within the context of a coherent model of psychotherapy integration. It is thus fitting to briefly review the psychotherapy integration movement before providing an overview and clinical implications of CH.
Psychotherapy Integration Movement
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Due to xenophobic fear and reflexive dismissal, for decades the field of psychotherapy had been marked by deep division and segregation of theories and methods (Gold & Stricker, 2006). Fortunately, some clinicians and writers such as French (1933), Dollard and Miller (1950), and Watchel (1977, 1997) were able to step out of this furrow and incorporate forbidden schools of psychotherapy, namely behavior therapy and psychodynamic psychotherapy, in their clinical work. Their pioneering work sparked the psychotherapy integration movement, which culminated in the formation of the Society for the Exploration of Psychotherapy Integration, the founding of the Journal of Psychotherapy Integration in 1991, and the publication of two influential handbooks on psychotherapy integration (Norcross & Goldfried, 1992; Stricker & Gold, 1993) during the last decade of the 20th century. Psychotherapy integration can be defined as the “search for, and study of, the ways in which the various schools or models of psychotherapy can inform, enrich, and ultimately be combined” (Gold & Stricker, 2006, p. 8) to reduce distress and suffering. From the current psychotherapy integration literature, four models of integrations can be identified, including technical eclecticism, common factors approach, theoretical integration, and assimilative integration.
The assimilative model of psychotherapy is considered to be the most recent model of psychotherapy integration, drawing from both theoretical integration and technical eclecticism (Gold & Stricker, 2006). In this mode of psychotherapy integration the therapist maintains a central theoretical position but incorporates or assimilates techniques from other schools of psychotherapy. This approach to integration is well illustrated by the psychodynamically-based integrative therapy developed and described by Gold and Stricker (2001, 2006). Within this framework, “therapy proceeds according to standard psychodynamic guidelines, but methods from other therapies are used when called for, and they may indirectly advance certain psychodynamic goals as well as address the target concern effectively” (Gold & Stricker, 2006, p. 12). Lampropoulos (2001) and Messer (Lazarus & Messer, 1991;Messer, 1989, 1992) claim that when techniques from different theories are incorporated into one’s preferred theoretical orientation both the host theory and the imported technique interact with each other to produce a new assimilative model. Assimilative integration thus represents the best model for integrating both theory and empirical findings to achieve maximum flexibility and effectiveness under a guiding theoretical framework.
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Integration within the field of hypnotherapy had been somewhat cursory and arbitrary, and the approaches to assimilation had ranged from being idiosyncratic to very systematic, rather than driven by a coherent integrated theory. Moreover, the practice of hypnosis had traditionally embraced psychoanalytic framework and like other schools of therapy, “classical” hypnotherapists had been resistant to diluting hypnotherapy with other schools of therapy (e.g.,Nash, 2008). Nonetheless some clinicians went on to incorporate hypnosis with behavior therapy (e.g.,Clarke & Jackson, 1983; Lazarus, 1973, 1992, 1999, 2002; Kroger & Fezler, 1976; Wolpe & Lazarus, 1966) and with CBT (e.g., Alladin, 1994, 2006, 2007a; Alladin & Alibhai, 2007; Chapman, 2006; Ellis, 1986, 1993, 1996;Golden, 1986, 1994, 2006; Golden, Dowd, & Friedberg, 1987; Kirsch, 1993; Lynn & Kirsch, 2006;Tosi & Baisden, 1984; Yapko, 2001). However with the exception of Alladin (2007a, 2008;Alladin & Amundson, 2011), none of the writers endeavored to combine hypnosis with CBT within any of the four current psychotherapy integration models mentioned before. Moreover, Alladin (1992, 1994, 2006, 2007a;Alladin & Heap, 1991) developed a working model of nonendogenous depression, dubbed the cognitive dissociative model of depression, which provides the theoretical framework for combining cognitive and hypnotic techniques with depression.
More recently Alladin (2007a) revised the model and called it the circular feedback model of depression (CFMD), which accentuates the biopsychosocial nature of depression and underlines the role of multiple factors in the causation and maintenance of depressive affect. The model is not a new theory of depression or an attempt to explain the causes of depression. It is an extension of Beck’s (1967) circular feedback model of depression, which was later elaborated on by Schultz (1978, 1984, 2003) and expanded by Alladin (1994, 2007a). In combining the cognitive and hypnotic paradigms, the CFMD incorporates ideas and concepts from information processing, selective attention (negative rumination), brain functioning, adverse life experiences, and the neodissociation theory of hypnosis (Hilgard, 1977).
The initial model was referred to as the cognitive dissociative model of depression because it encompassed the dissociative theory of hypnosis and it proposed that nonendogenous depression is analogous to a form of dissociation produced by negative cognitive rumination, which can be regarded as a form of negative self-hypnosis (NSH). CFMD consists of 12 interrelated components (e.g., negative rumination, negative affect, dissociation, kindling, symbolic transformation, etc.) that form into a circular feedback loop that may influence the course and outcome of depression (see Alladin, 2007a). Any of these factors, for example, negative affect, can trigger, exacerbate, or maintain depressive symptoms. The conceptualization of the model underscores how hypnosis can be used as a useful construct to study and understand certain aspects of the depressive phenomenology.
Utilizing the hypnosis construct to study psychopathologies is not a new concept. Historically the observation of the parallels between hypnosis and hysteria had played an important role in the discovery of the unconscious mental processes, the development of psychogenic theories of psychopathology, and the rise of psychotherapy (Ellenberger, 1970). In regard to experimental studies, Kihlstrom (1979) proposed that hypnotic anesthesia and analgesia, amnesia, and posthypnotic suggestions may serve as laboratory models of dissociative phenomena seen in the clinical settings. He also suggested that hypnosis may be useful in the exploration of processes involved in emotional response and the formation of hallucinations and delusions.
The circular feedback model can be easily applied to other emotional disorders beyond depression. Alladin (2008) stated three pragmatic reasons for combining cognitive and hypnotic paradigms in the treatment and understanding of emotional disorders. First, since hypnosis can produce cognitive, somatic, perceptual, physiological, and kinesthetic changes under controlled conditions, the combination of the two paradigms serves a conceptual framework for studying the psychological processes by which cognitive distortions (negative rumination) produce concomitant psychobiological changes underlying various emotional disorders. Secondly, hypnosis offers insight into the phenomenology of emotional disorders (Yapko, 1992). Like hypnosis, emotional disorders are highly subjective experiences. Hypnosis allows remarkable insights into the subjective realm of human experience and thus provides a very useful paradigm for understanding how experience, normal or abnormal, is generated and structured. Thirdly, after reviewing the strengths and limitations of CBT and hypnotherapy with emotional disorders, Alladin (1989, 2007) found each treatment approach lacking in several ways. For example, CBT does not focus on unconscious cognitive restructuring; instead, it concentrates on cognitive restructuring via conscious reasoning and Socratic dialogue. Hypnotherapy, on the other hand, has traditionally been concerned with insight and unconscious reframing, with less focus on systematic conscious restructuring of dysfunctional cognitions.
Alladin (1989, 2007a) suggested the integration of the two treatment modalities to compensate for the shortcomings of each single treatment. Similarly, Schoenberger (2000)asserted that since many CBT procedures are easily conducted with hypnosis or simply relabelled as hypnosis, CBT-oriented clinicians with experience in hypnosis could easily establish a hypnotic context “as a simple, cost-effective means of enhancing treatment efficacy” (p. 244). Furthermore, Golden (2006) indicated that integration of the two approaches seems natural as CBT and hypnosis share a number of commonalities such as imagery and relaxation.
CH uses CBT as the base theory for integration as the latter provides a unifying theory of psychotherapy and psychopathology and it effectively integrates theory and clinical practice. Absence of a good theory can be problematic as it is likely to lack conceptual coherence (Bergin & Garfield, 1994). Another distinctive characteristic of CBT is that it is technically eclectic, that is, although most of the techniques utilized in CBT are “behavioral” or “cognitive,” they routinely combine techniques from various psychotherapies. Alford and Beck (1997) emphasized that “any clinical technique that is found to be useful in facilitating the empirical investigation of patients’ maladaptive interpretations and conclusions may be incorporated into the clinical practice of cognitive therapy” (p. 90). However, in CBT the techniques are not chosen haphazardly or arbitrarily. They are selected in the context of cognitive case formulation that is used to guide the practice of CBT for each individual case (Needleman, 2003; Persons, 1989;Persons & Davidson, 2001; Persons, Davidson, & Tompkins, 2001). Beutler, Clarkin, and Bongar (2000) have provided evidence that matching of treatment to particular patient characteristics increases outcome. As CBT adopts multiple approaches to case formulation and treatment, it offers an excellent framework for integrating hypnotic and cognitive strategies with a variety of syndromes. Alladin (2007a, 2008; Alladin & Amundson, 2011) conceptualized CH, a multimodal approach, mainly consisting of CBT and hypnotic techniques, for treating emotional disorders, as an assimilative model of psychotherapy. The CH approach to integration is similar to the psychodynamically-based integrative therapy developed and described by Gold and Stricker (2001, 2006). Gold and Stricker’s assimilative model of psychotherapy integrates standard psychodynamic methods with other therapies “when called for” in order to “address the target concern effectively” (Gold & Stricker, 2006, p. 12).
However, for a therapy to be designated as an assimilative integrative model of psychotherapy, it should meet the six criteria laid down by Lampropoulos (2001), which include (a) empirical validation of host theory; (b) evidence-based imported techniques; (c) empirically based assimilation; (d) sensitivity around assimilation; (e) coherent assimilation; and (f) empirical validation of assimilated therapy. CH meets all of the six criteria listed above (Alladin & Amundson, 2011) and as such it promotes the adjunctive role of hypnotherapy to a recognized integrative model of psychotherapy. As Alladin and Amundson (2011) had reviewed the six criteria proposed byLampropoulos (2001) in great detail elsewhere, they will not be covered here, except for a discussion about the empirical validation of CH as an assimilative model of psychotherapy.
Empirical Validation of CH
Without empirical validation it is not possible to establish whether the importation of hypnotic techniques into CBT positively impact therapy, especially when the techniques are decontextualized and placed in a new framework. It is only through empirical validation that ineffective and idiosyncratic assimilation can be avoided. Moreover, empirical validation is important for the reevaluation of the assimilative model itself. Some empirical evidence for combining hypnosis with CBT already exists. Clinical trials (Alladin & Alibhai, 2007; Bryant, Moulds, Gutherie, & Nixon, 2005;Dobbin, Maxwell, & Elton, 2009; Schoenberger, Kirsch, Gearan, Montgomery, & Pastyrnak, 1997), meta-analysis (Kirsch, Montgomery, & Sapirstein, 1995), and detailed reviews (Moore & Tasso, 2008; Schoenberger, 2000)have substantiated the additive value of hypnotic interventions when combined with CBT for various emotional disorders.
As CH is based on latest empirical evidence, the treatment protocol provides an additive design for studying the summative effect of hypnosis. An additive design involves a strategy in which the treatment to be tested is added to another treatment to determine whether the treatment added produces an incremental improvement over the first treatment (Allen, Woolfolk, Escobar, Gara, & Hamer, 2006). For example, Kirsch, Montgomery, and Sapirstein (1995), from their meta-analysis of 18 studies in which CBT was compared with the same therapy supplemented or facilitated by hypnosis, found that the addition of hypnosis substantially enhanced therapy outcome. The average patient receiving cognitive-behavioral hypnotherapy demonstrated greater improvement than at least 70% of patients who received nonhypnotic treatment. The effects seemed particularly pronounced in the treatment of obesity, especially at long-term follow-up. Unlike nonhypnotic treatment, when treatment was facilitated with hypnosis, patients continued to lose weight after treatment was concluded. The findings were considered particularly striking because there were so few procedural differences between hypnotic and nonhypnotic treatments. In the one study of anxiety there was a high effect size of 1.4 standard deviations, indicating that the addition of hypnosis significantly enhanced the efficacy of cognitive-behavioral therapy (Sullivan, Johnson, & Bratkovitch, 1974). In CH, in an effort to empirically validate the therapeutic techniques and examine the additive effect of the combined intervention, the treatment protocols are clearly delineated and described. Alladin (2007a, 2008) has described the application of CH with a range of emotional and medical disorders. His comprehensive description provides clear guidelines of how to incorporate various hypnotic techniques within the CBT context to amplify the therapeutic experience and enhance the treatment effect. Similarly this special issue offers several well-structured assimilative treatment protocols that can be easily validated.
Fortunately, several assimilative hypnotherapy protocols with such conditions as acute stress disorder (Bryant et al., 2005), depression (Alladin & Alibhai, 2007), pain (Elkins, Jensen, & Patterson, 2007;Elkins, Johnson, & Fisher, this issue), and somatoform disorder (Moene et al., 2003) have already been validated. However, these studies need to be replicated and subjected to second generation studies, which involve dismantling designs to evaluate the relative effectiveness of each imported technique to the base therapy (Alladin, 2008). For example, Alladin and Alibhai (2007) in their CH protocol for depression imported several hypnotic techniques into CBT, including hypnotic relaxation, ego-strengthening, expansion of awareness, positive mood induction, posthypnotic suggestions, and self-hypnosis. Without further studies (second generation studies), there is no way of knowing which techniques were effective and which were superfluous. The assimilative protocols that have not been subjected to empirical validation yet, are deemed suitable for first generation studies. First generation studies involve either assessing the additive effect of imported techniques via the additive design, or comparing a single-modality hypnotherapy with another well established therapy, for example, ego-strengthening can be compared with exposure therapy (evidence-based CBT technique) in the treatment of post-traumatic stress disorder.
Clinical and Research Implications
Although the conceptualization of CH as an assimilative model of psychotherapy may advance the adjunctive role of hypnotherapy from the fringes of therapeutic activities to a more prominent position in the realm of psychotherapy integration movement, much work remains to be done. Future progress will depend a great deal on what the hypnosis community chooses to do. The attempt to formally conceptualize CH as a recognized form of integrative psychotherapy is only the first step to hypnotherapy gaining greater recognition as an empirically valid clinical intervention. For the field of clinical hypnosis to flourish and achieve the empirically supported status of treatment enhancer with various disorders, clinical practitioners and researchers are encouraged to endorse, adopt, and validate the assimilative model of hypnotherapy. Alladin and Amundson (2011) suggest seven strategies for advancing the clinical and empirical status of hypnotherapy as an assimilative model of integrative psychotherapy.
|1.||Clinicians and researchers are encouraged to take greater interest in integrative approaches to therapy rather than firmly holding on to a sectarian version of psychotherapy that were created generations ago.|
|2.||Clinical assessment and treatment are based on a more assimilative model of hypnotherapy. Clinicians use other base theories, beside CBT, such as psychodynamic psychotherapy, Ericksonian psychotherapy (Lankton, 2008), or gestalt therapy, to develop new assimilative models of hypnotherapy. The CH model provides a template for developing new models of integrative therapy. However, when generating new assimilative models it will be advisable to develop them within the framework proposed by Lampropoulos (2001).|
|3.||A case formulation approach is used for clinical assessment.|
|4.||Treatment strategies are based on individual case formulation and evidence-based best clinical practice.|
|5.||Baseline and outcome measures are routinely used.|
|6.||Assimilative treatment protocols that have not been subjected to empirical validation are subjected to first generation studies (see below).|
|7.||Assimilative hypnotherapy protocols that have already been validated are replicated and subjected to second generation studies (see below).|
|8.||To these suggestions, publication can be added. CH clinicians and investigators are encouraged to publish their work in other journals, beside hypnosis journals, such as Journal of Integrative Psychotherapy, Psychological Review, etc.|
Limitations of the Assimilative Model
The CH model described in this article is not seen as a finished product, but an evolving process. Although it is important to empirically evaluate and validate assimilative, integrative therapies, it is important to bear in mind that creativity and clinical advances often occur in the consulting room of individual therapists that cannot be operationalized or subjected to large-scale research investigations. Gold and Stricker (2006) write:
Future progress in psychotherapy integration may be stalled or even be made impossible by overly strict demands for rigor and regularity in psychotherapy that emphasize conformity to manuals and guidelines at the expense of clinical experimentation and innovation. (p. 13)
Therefore clinicians should be encouraged to continue to experiment with new integrative ideas, but within a single-case design framework, and in parallel with innovative clinical practice, theoreticians and investigators should continue to explore psychotherapy integration in its complex and sophisticated form, moving beyond clinical derivations. Moreover, beyond techniques blending, clinicians should attempt to integrate patient’s insight and feedback into their assimilative therapies.
Although many writers and clinicians advocate that hypnotherapy is very effective in the treatment of a wide range of disorders, limited research exists to support this claim. The current empirical state and the future of hypnotherapy can be summarized by quoting Graci and Hardie’s (2007) observation in the context of the empirical status of insomnia:
There is a plethora of research suggesting that combining cognitive behavioral therapy with hypnosis is therapeutic for a variety of psychological, behavioral, and medical disorders. Yet, very little empirical research exists pertaining to the use of hypnotherapy as either a single or multi-treatment modality for the management of sleep disorders. The existing literature is limited to a very small subset of “non-biologic” sleep disorders, specifically the insomnia disorders … . There is an immediate need for more research evaluating the efficacy of hypnotherapy as both a single treatment and multi-treatment modality for managing sleep disturbance. Once this efficacy is established, it will increase the utilization of hypnotherapy and a demand for its services as a treatment of non-biologic sleep disorders. (p. 288)
Fortunately the empirical evidence for the effectiveness of hypnosis with other conditions is better than with insomnia, particularly when hypnosis is combined with CBT. For example, the adjunctive effectiveness of hypnosis has been empirically validated with chronic pain (Elkins et al., 2007, this issue;Montgomery, David, Winkel, Silverstain, & Bovbjerg, 2002; Montgomery, DuHamel, & Redd, 2000;Patterson & Jensen, 2003), chronic headache and migraine (Alladin, 2008; Hammond, 2007), irritable bowel syndrome (Tan & Hammond, 2005), dermatology (Alladin, 2008; Spanos, Williams, & Gwynn, 1990), psychosomatic disorders (Flammer & Alladin, 2007; Tausk & Whitemore, 1999), somatization disorders (Moene et al., 2003), acute stress disorder (Bryant et al., 2005), depression (Alladin & Alibhai, 2007), various emotional disorders (Kirsch, Montgomery, & Sapirstein, 1995), public speaking anxiety (Schoenberger et al., 1997), and a wide range of medical conditions (Pinnel & Covino, 2000). For the latest empirical status of clinical hypnosis with various medical and psychiatric disorders see Lynn, Kirsch, Barabasz, Cardeña, and Patterson (2000), Moore and Tasso (2008), and the special issues on evidence-based practice in clinical hypnosis in the International Journal of Clinical and Experimental Hypnosis (Alladin, 2007b, 2007c). Albeit these empirical advances, research in clinical hypnosis is in its infancy. Considering modern hypnosis has been around for over a quarter of a century, the relative empirical foundation of clinical hypnosis is not very solid and hypnotherapy is far from being recognized as mainstream psychotherapy. On the other hand, while it is easy to criticize the relative lack of empirical research in hypnotherapy, it is enlightening to learn that the scientific basis of the practice of other health care, for example, medicine, is not as evidence-based as one would like to think. In a major article in the Journal of the American Medical Association,Tricoci, Allen, Kramer, Califf, and Smith (2009) reported that only 11% of 2,711 cardiac medical treatment recommendations are based on multiple randomized controlled studies, and only 41% are based on evidence from a single randomized trial or non-randomized studies, while 48% are simply based on “expert opinion” or only on case studies. Nevertheless, the authors recommend that practice guidelines should be evidence-based and not based on “lower levels of evidence or expert opinion” (p. 831). Similarly, Graci and Hardie (2007) have indicated that in order to increase credibility and utilization of clinical hypnosis, the empirical basis of hypnotherapy needs to be widely established. The following contributions from the practice of CH may represent an attempt to solidify the empirical status and credibility of hypnotherapy:
|1.||The assimilative model of hypnotherapy describes, disseminates, and encourages evidence-based clinical practice and research in hypnotherapy.|
|2.||CH provides clinicians some guidance on how to assimilate hypnosis as an adjunct with CBT in the management of various emotional disorders.|
|3.||CH lays down a solid theoretical foundation for combining hypnosis with CBT in the management of various emotional disorders.|
|4.||The conceptualization of CH as an assimilative model of psychotherapy advances the adjunctive role of hypnotherapy to a more prominent position in the realm of psychotherapy integration movement. To keep this momentum going, CH research and findings should be published in other reputable journals besides those pertaining to hypnosis.|
|5.||CH provides a case formulation approach to clinical practice. Such a model of practice allows the assimilation of techniques based on empirical findings rather than using techniques haphazardly in a hit or miss fashion. This approach, apart from individualizing therapy, also allows innovation and creativity.|
|6.||CH offers detailed step-by-step treatment protocol, which facilitates replication and validation.|
|7.||CH provides a template for developing other integrative hypnotherapies.|
|8.||By virtue of being a multimodal treatment approach, CH acknowledges the complexity of psychological disorders, paying particular attention to recent progress in aetiology, existing empirical treatments, and comorbid disorders. This approach is more likely to be effective with complex disorders such as depression and somatoform disorders than single technique such as ego-strengthening, regression, or abreaction.|
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This article provided an overview of CH as an assimilative model of integrative psychotherapy. It is hoped that the application of the model with various clinical disorders will inform and guide clinicians how to select treatment strategies, not haphazardly, but based on case formulation of each individual case. It is also hoped that the further developments of CH will contribute to solidify the empirical status of hypnotherapy and increase the clinical credibility of the integrative approach. Although it is important to empirically evaluate and validate assimilative integrative therapies, it is important to bear in mind that creativity, originality, and many advances occur in the consulting room of individual therapists who cannot submit their work to large-scale research investigations. Therefore vis-à-vis the exploration of complex and sophisticated integrative hypnotherapies, creativity and innovations should be encouraged. Moreover, beyond techniques blending, clinicians should also attempt to integrate patient’s insight and feedback into their assimilative therapies.
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