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Monday, July 16, 2012

Health Applications of Hypnosis

Can Hypnosis Improve the Quality of Life for Individuals with Chronic Illnesses?

Hypnosis has been used as a psychological treatment for a variety of illnesses with apparent success. While it is unlikely that hypnotic suggestions are capable of curing physical disease, they can be used to enhance relaxation and alleviate pain and other physical discomforts, and therefore they may make a positive contribution to the overall quality of care and of life. For example, several controlled studies have shown that hypnotic suggestions administered to patients who suffer from asthma can reduce both bronchodilator use and attacks of "wheezing", as well as increase peak expiratory flow rates. Hypnosis has also been used effectively in the treatment of irritable bowel syndrome, hyperemesis gravidarum (persistent nausea and vomiting) in pregnant women, and anticipatory nausea experienced by cancer patients who receive chemotherapy. Hypnotic suggestions have been observed to stimulate and inhibit allergic responses, and may also speed the healing of burns and wounds, but these issues require further carefully controlled study.

Even though the use of hypnosis may be associated with positive therapeutic outcomes, it is not clear that hypnosis itself is responsible for the effects observed. The active ingredient in some treatments labeled "hypnosis" might be mere relaxation, or a kind of placebo effect attributable to the use of a hypnotic ritual. It is well known, for example, that the "relaxation response" meditation technique introduced by Benson can alter blood pressure, heart rate, oxygen consumption, and the levels of certain neurotransmitters. The relaxation response is not the same as hypnosis, but hypnotic techniques may achieve some of their effects by virtue of the high levels of relaxation commonly associated with them. In the case of asthma, however, hypnosis seems to have a specific effect over and above relaxation.

The professional and popular literature contains occasional reports of clinical improvements and even cures of cancer in patients who have been treated with hypnosis or related techniques, such a relaxation and imagery. However, these apparent successes are typically poorly documented, and in the final analysis it is difficult to distinguish such "miracle cures" from spontaneous remissions which sometimes occur in these conditions. The most appropriate use of hypnosis in cancer treatment is as a complement to traditional medical treatments, such as chemotherapy, with the goal of enhancing the patient's quality of life while treatment is in progress.

Can Hypnosis be used in Pain Reduction?

Hypnosis has been employed in the clinic for both medical and psychotherapeutic purposes. By far the most successful and best documented of these has been hypnotic analgesia for the relief of pain. Clinical studies indicate that hypnosis can effectively relieve pain in patients suffering pain from burns, cancer and leukemia (e.g., bone marrow aspirations), childbirth, and dental procedures. In such circumstances, as many as half of an unselected patient population can obtain significant, if not total, pain relief from hypnosis. Hypnosis may be especially useful in cases of chronic pain, where chemical analgesics such as morphine pose risks of tolerance and addiction. Hypnosis has also been used, somewhat heroically perhaps, as the sole analgesic agent in abdominal, breast, cardiac, and genitourinary surgery, and in orthopedic situations, although it seems unlikely that more than about 10% of patients can tolerate major medical procedures with hypnosis alone.

A comparative study of experimental pain found that, among hypnotizable people, hypnotic analgesia was superior to morphine, diazepam, aspirin, acupuncture, and biofeedback. Hypnotic analgesia relieves both sensory pain and suffering. It is not a matter of simple relaxation or self-distraction. It does not appear to be mediated by endorphins or other endogenous opiates. There is a placebo component to all active analgesic agents, and hypnosis is no exception; however, hypnotizable people receive benefits from hypnotic suggestion that outweigh those of plausible placebos.

Does Hypnosis Increase Physical Performance?

From the beginning of the modern era, a great deal of research effort has been devoted to claims that hypnotic suggestions enable individuals to transcend their normal voluntary capacities -- to be stronger, see better, learn faster, and remember more. However, research has largely failed to find evidence that hypnosis can enhance human performance. Many early studies, which seemed to yield positive results for hypnosis, possessed serious methodological flaws such as the failure to collect adequate baseline information. In general, it appears that hypnotic suggestions for increased muscular strength, endurance, sensory acuity, or learning do not exceed what can be accomplished by motivated individuals outside hypnosis.

Can Hypnosis Improve Recall

A special case of performance enhancement has to do with hypnotic suggestions for improvements in memory -- what is known as hypnotic hypermnesia. Hypermnesia suggestions are sometimes employed in forensic situations, with forgetful witnesses and victims, or in therapeutic situations, to help patients remember traumatic personal experiences or the events of early childhood. While field studies have sometimes claimed that hypnosis can powerfully enhance memory, these anecdotal reports have not been duplicated under laboratory conditions.

A 1994 report by the Committee on Techniques for the Enhancement of Human Performance, a unit of the U.S. National Research Council, concluded that gains in recall produced by hypnotic suggestion were rarely dramatic, and were matched by gains observed even when individuals are not hypnotized. In fact, there is some evidence that hypnotic suggestion can interfere with normal hypermnesic processes. To make things worse, any increases obtained in valid recollection are met or exceeded by increases in false recollections. Hypnotized individuals (especially those who are highly hypnotizable) may be especially vulnerable to distortions in memory produced by leadingquestions and other subtle, suggestive influences.

Hypnosis is sometimes used therapeutically to recover forgotten incidents, as for example in cases of child sexual abuse. Although the literature contains a number of dramatic reports of the successful use of this technique, most of these reports are anecdotal in nature and fail to obtain independent corroboration of the memories that emerge. Given what we know about the unreliability of hypnotic hypermnesia, and the risk of increased responsiveness to leading questions and other sources of bias and distortion, such clinical practices are not recommended. Similar considerations obtain in forensic situations. In fact, many legal jurisdictions severely limit the introduction of memories recovered through hypnosis, out of a concern that such evidence might be tainted. The Federal Bureau of Investigation has published a set of guidelines for those who wish to use hypnosis forensically, and similar precautions should be employed in the clinic.

Similar conclusions apply to hypnotic age regression, in which individuals receive suggestions that they are returning to a previous period in their lives (this is also a technique that is used clinically to foster the retrieval of forgotten memories of child abuse). Although age-regressed individuals may experience themselves as children, and may behave in a childlike manner, there is no evidence that they actually lose adult modes of mental functioning, or return to childlike modes of mental functioning. Nor do age-regressed individuals retrieve forgotten memories of childhood.

Does Hypnosis have an Effect on Psychosomatic Disorders?

Hypnotic suggestion can have psychosomatic effects, a matter that should be of some interest to psychophysiologists and psychoneuroimmunologists. A famous case study convincingly documented the positive effects of hypnotic suggestion on an intractable case of congenital ichthyosiform erythroderma, a particularly aggressive skin disorder. Carefully controlled studies have shown that hypnotic suggestions can have a specific effect on the remission of warts. However, the same effects can be achieved by suggestions administered nonhypnotically. The mechanisms by which these "psychosomatic" effects are produced are theoretically interesting, and possibly clinically significant, but it is not yet clear that they have anything to do with hypnosis.

Can Hypnosis be used in Psychotherapy?

Hypnosis has been used in psychotherapy—both in psychodynamic or cognitive-behavioral oriented therapy. In the former case, hypnosis is used to promote relaxation, enhance imagery, and generally loosen the flow of free associations (some psychodynamic theorists consider hypnosis to be a form of adaptive regression or regression in the service of the ego). However, there is little evidence from controlled outcome studies that hypnoanalysis or hypnotherapy are more effective than nonhypnotic forms of the same treatment. By contrast, a 1995 meta-analysis by Kirsch and colleagues showed a significant advantage when hypnosis is used to complement cognitive-behavioral therapy for a number of problems, including anxiety and hypertension. In an era of evidence-based mental health care, it will be increasingly important for practitioners who use hypnosis to document, quantitatively, the clinical benefits of doing so.

Can Hypnosis help with Weight Control?

In the Kirsch study (mentioned above in the Psychotherapy section), the prospects for hypnosis appeared to be especially favorable in the treatment of obesity, where individuals in the hypnosis group continued to lose weight even after formal treatment had ended. In one study, for example, women who received personally tailored hypnotic suggestions for specific food aversions, in the context of a traditional self-monitoring and goal-setting treatment, lost approximately twice as much weight as a comparison group. This comparison group received the behavioral treatment alone (no hypnotic suggestion). However, the actual weight lost by the hypnosis group was only about 14 lb. on average. Given that the patients were approximately 50% overweight at the outset, it is not clear that the treatment actually improved their clinical status. Studies that document the clinical efficacy of hypnosis should pay careful attention to the terms in which outcome is assessed. While hypnosis may seem to offer an advantage over some other treatments, it is not clear that the statistical significance or experimental results translates into meaningful clinical significance or real results for individuals.

Can Hypnosis Help People Stop Smoking?

There have been many attempts to use hypnosis for habit control, however, hypnosis has no coercive power. That is, one cannot be hypnotized against his or her will, and even deeply hypnotized individuals cannot be made, by virtue of hypnotic suggestions, to do things that run against their own or others' interests. You cannot cajole a smoker to the local hypnotist and expect him or her to stop smoking. However, where the patient is appropriately motivated, as in the obesity study described earlier, hypnosis may offer a boost to treatment.

One popular hypnotic treatment for smoking involves a single session in which patients are taught to repeat a simple persuasive message during self-hypnosis. In one large-scale study of this technique, about 50% of patients stopped smoking immediately after treatment; at follow-up one and two years later, however, this figure had dropped to about 25%. Although this study did not include a nonhypnotic control group, this is about the same success rate as achieved with other cognitive-behavioral interventions. However, these other treatments are typically more intensive, so that the single-session hypnotic treatment may have some advantage in terms of efficiency. Interestingly, long-term abstinence was not related to traditional measures of hypnotizability, suggesting that the success of the treatment may have had more to do with the persuasive message than with hypnosis per se.

Caveats for Health Practitioners in the Use Hypnosis with Patients

An important but unresolved issue is the role played by individual differences in the clinical effectiveness of hypnosis. As in the laboratory, so in the clinic: a genuine effect of hypnosis should be correlated with hypnotizability.

It is possible that many clinical benefits of hypnosis are mediated by placebo-like motivational and expectational processes -- that is, with the "ceremony" surrounding hypnosis, rather than hypnosis per se. An analogy is to hypnotic analgesia, which appears to have a placebo component available to insusceptible and hypnotizable individuals alike, and a dissociative component available only to those who are highly hypnotizable. Unfortunately, clinical practitioners are often reluctant to assess hypnotizability in their patients and clients, out of a concern that low scores might reduce motivation for treatment. This danger is probably exaggerated. On the contrary, assessment of hypnotizability by clinicians contemplating the therapeutic use of hypnosis would seem to be no different, in principle, than assessing allergic responses before prescribing an antibiotic. In both cases, the legitimate goal is to determine what treatment is appropriate for what patient.

It should be noted that clinicians sometimes use hypnosis in non-hypnotic ways -- practices which tend to support the hypothesis that whatever effects they achieve through hypnosis are related to its placebo component. There is nothing particularly "hypnotic", for example, about having a patient in a smoking-cessation treatment rehearse therapeutic injunctions not to smoke and other coping strategies while hypnotized. It is likely that more successful use of hypnosis as an adjunct to the cognitive-behavioral treatment of smoking, overweight, and similar habit disorders would be to use hypnotic suggestions in order to control the patient's awareness of cravings for nicotine, sweets, and the like. Given the ability of hypnotic suggestions to control conscious perception and memory, such strategies might well have therapeutic advantage -- but only, of course, for those patients who are hypnotizable enough to respond positively to such suggestions.

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