Circadian Vs. Ultradian Rhythms

Circadian, twenty-four hour, biological rhythms and their influence on organisms are the most studied biological cycle (Estgate & Groome, 2005).  They have been seen as connected to cellular rhythms, information processing in neurology, and mood.  In essence, they relate to the daily cycle of light and darkness, and can be seen the regulation of sleep and waking.  For example, melatonin, the hormone that plays a part in the regulation of sleep, is inhibited by light, and secreted in the evening (Estgate & Groome).  Research has also suggested that in humans, circadian rhythms are also coordinated by an area of the hypothalamus know as the suprachiasmatic nucleus (SNC) (Estgate & Groome).

By contrast, ultradian rhythms are smaller cycles of activity and rest in organisms (Lavie, 1992).  Nathan Kletmann, an psychologist whose career was spent studying biological cycles, is credited with the discovery of ultradian cycles.  Kleitmann stated that Rapid Eye Movement (REM) and Non-Rapid Eye Movement (NREM) activity in sleeping humans are only a small part of a larger twenty-four hour cycle (Rossi & Lippincott, 1992).  This is known as the Basic Rest to Activity Cycle (BRAC) that plays out through both waking and sleeping life of organisms, and is the pattern of the ultradian cycle (Rossi & Lippincott; Lavie; Rossi, 2002).  In humans, the basic phase of activity takes place over 90-120 minutes.  The rest phase, or low end of the cycle, lasts anywhere from 15-20 minutes (Rossi & Lippincott; Rossi).  The BRAC is a well-studied phenomenon.  Over fifty studies corroborate the BRAC involvement in regulating hormone secretion, reaction time, intensity of visual hallucinations and motor coordination (Orr, Lavie, Gopher & Lavie as cited in Lavie, 1992).

Ultradian Rhythms in Hypnosis

The rest phase of the BRAC is held to be involved in the phenomenon of the afternoon nap and daydreaming.  Jungian analyst and hypnotherapist, Ernest Rossi, theorizes that the BRAC is associated with normal dissociative phenomenon of the “common everyday trance” (Erickson, Rossi & Rossi, 1976; Rossi, 2002).  As opposed to a stable trait theory of hypnotizability, this theory states that all people are hypnotizable, but that one must find the proper point in time for when the patient is ready to enter trance (Erickson, Rossi & Rossi).   Suggestions are altered to fit the personality style of the subject, depending on whether they are amiable to direct or indirect suggestions (Erickson, Rossi & Rossi).  This is also known as the utilization process of hypnosis and psychotherapy, as all “resistance” that a subject displays is accepted and used in the process of induction and ratification of trance (Erickson, Rossi & Rossi).

Rossi discovered the influence of ultradian biological cycles in hypnosis by watching his mentor psychiatrist Milton H. Erickson work with patients. Erickson would usually hold therapy sessions from 90 minutes to two hours, sometimes more (Rossi, 2002).  During the sessions, Erickson would use conversational or, non-invasive/indirect suggestions to direct a patient to work on her issues (Rossi, 2002).  He would watch for subtle, physical cues from the patient: staring off into space, eye-closure, and swallow reflex, all phenomena associated with hypnotic trance (Rossi).  At such moments, Erickson would suggest for the patient to close her eyes and begin the hypnotic work (Rossi).

Rossi later realized that the temporal aspect of Erickson’s sessions matched Kleitmann’s ultradian BRAC (2002).  Somewhere within the 90-120 minutes of the session, the patient would slip into a rest or low phase of activity, and slip in and out of trance, approximately 15-20 minutes at a time (Rossi).  When asked why he chose to work with patients for this length of time, Erickson simply stated that it seemed the right length of time for him to get work done with patients (Rossi).

Current Body of Evidence

Rossi’s ultradian BRAC concept of hypnosis has so far, has only produced a small body of research.  A review of the literature produces five studies published to date related to Rossi’s chronobiological hypothesis of hypnosis.  Four of them give evidence of chronobiological rhythms involved in hypnosis.

Aldrich & Bernstein (1987) tested a total of 1103 subjects at the University of Illinois for correlations in circadian BRAC rhythms, body temperature and hypnotizability.  A tape was made of an initial session and used at later sessions for a standardized induction.  The Harvard Group Scale of Hypnotic Susceptibility: Form A (HGSHS: A) was administered before the induction, along with a questionnaire concerning activities, such as exercise and eating, that may effect current body temperature.  The inductions were carried out at hourly intervals.  Each participant was hypnotized only once.

Results suggested a positive correlation between times of day, body temperature and hypnotic suggestibility, suggesting that any trait related to hypnotizability is not constant.  The average times for heightened hypnotizability were 12:00 PM, with a cascading drop to a low period of hypnotizability at 2:00 PM, and another high plateau between 5:00 and 6:00 PM (p. 143, Aldrich & Bernstein, 1987) By this standard, the best time for treating a patient with hypnosis that would evoke deep trance phenomenon would be between the hours of 11:00 AM and 1PM, and between 3:00M and 6:00 PM, those being the best circadian points wherein to find ultradian rest cycles to initiate the process.

Sommers (1993) tested 32 subjects with the Barber-Wilson Creative-Imagination Scale (CIS).  These subjects participated in two, two-hour sessions.  In theory, naturalistic trance states would appear at some point within the two hours.  When a subject showed signs of eye fixation and catalepsy, Sommers initiated a non-invasive induction, and a general suggestion to resolve an inner issue via their unconscious minds.  The trance state was timed as starting with eye closure.  Sommers remained quiet during the interim and gave no further suggestions.  Testing for time distortion was accepted a measure of hypnotic depth.

Sommers reports the average mean time for the subjects was 18.06 minutes for the first session and 17.50 for the second, well within the hypothesized 12-20 minutes, and no significant deviation.  Sommers concludes that her statistical analysis of the data “supports the premise that subjects will remain in a natural trance for an average of 15-20 minutes regardless of hypnotizability scores, age, sex, or previous hypnosis experience” (p. 140, 1993).

Rossi & Lippincott (1993) performed two studies, similar in form.  Rossi culled thirty clients from his private practice for his study.  They were, as in Sommer’s study, tested for suggestibility with the CIS.  A typical therapeutic hour was replaced by a 90-120 minute session to give the client enough time to enter a naturalistic trance.  When the client displayed signs of eye fixation or catalepsy, Rossi performed an ideodynamic induction procedure.  Trance was considered to begin with eye closure and end with eye opening.  Depth of trance was determined by asking the patient what their experience was like.   The entire procedure was conducted twice over a two-week period with each subject to confer results.

Lippincott created a variation on the first study with 42 volunteers.  They were told they were taking part in an experiment in the clinical use of hypnosis.  The Spiegel Hypnotic Induction Profile (HIP) was used to test subject suggestibility. Lippincott attempted to reduce context variables from influencing the patients.  A taped induction was utilized to make the procedure standardized across the subjects, and the experimenter left to room to observe them from a partially draped window and recorded length of trance.  Only one session was given (Rossi & Lippincott, 1993).

In Rossi’s study, mean time for trance was 19.40 minutes the first session, and 20.23 the second session.  Lippincott’s remained in trance an average of 18.69 minutes.  Thus, both studies point to the 20 minute time-frame suggested by the BRAC.

Wallace (1994) and Mann & Sanders (1995) both studied correlations between Kleitman’s BRAC and hypnotizablity in subjects who reported being more active either at day or night.  Wallace’s study was a variation on Aldrich & Bernstein’s 1987 study.  Both the HGSHS: A and the Stanford Hypnotic Susceptibility Scale, Form C (SHSS: C) were applied to 60 individuals.  The use of the two scales was to account for both within-group and within-subject variability. The findings suggest a difference in day and night people.  The length of the study went past the original study’s 8:00 AM to 8:00 PM time period to 8:00 to 10:00 PM to encompass the different wake cycles of the two groups.  Wallace states that although the study shows variability in hypnotizability and time of day, members of the day group, or “larks” peaked in hypnotizability at 10:00 AM and 2:00 PM; “night owls” peaked at 1:00 PM and peaked and displayed a constant high level between 6:00 and 8:00 PM.  Within-subject testing showed little variability, and could therefore not account for ultradian rhythms.

Mann & Sanders, also seeking to test Aldrich and Bernstein’s findings, discovered a similar correlation of levels of hypnotizability in larks and night owl groups at earlier and later times of day.  This is consistent with Wallace’s study, yet the authors contend that the findings are inconsistent with Rossi’s hypothesis.  The authors also relate that subjects who experienced a 15 minute trance period reported greater depth of trance (1995).  Sommers (1993) and Rossi & Lippincott  (1993), however, note that high hypnotizables in their studies experienced less time in natural trance than lows, but experienced more classical hypnotic phenomena.  Mann & Sander’s study does not incorporate any of the data from the 1993 studies of Wallace, Sommers or Lippincott work, though it was published two years later (p. 43).

Conclusion

From this small body of research, one can see that there is some evidence indicating to validity of Rossi’s theory, that trance phenomenon is naturally occurring, varies slightly across times of the day.  The studies also appear to lend support for Kleitmann’s original premise.  Rossi has also theorized that the BRAC plays a major part in genetic expression and neural growth, and may have further implications for psychotherapy as a whole (Rossi, 2002).

Perhaps it may be worthwhile to study the effect ultradian cycles on rapport, insight and catharsis, across all therapeutic modalities.  Would extending therapeutic sessions to two hours have a positive correlation with outcome?  Would patients report more rapport and self-efficacy within this type of session format?  This is now merely speculation, but perhaps, with the growth in the study and practice of mind-body therapies,  biological rhythms will one day be seen as an important aspect of the healing processes of medicine and psychotherapy.

References

Aldrich, K.J. & Bernstein, D.A. (1987).  The effect of time of day on hypnotizability: A brief communication. The International Journal of Clinical and Experimental Hypnosis. 35 (3), 141-145.

Erickson, M. H., Rossi, E., Rossi, S. (1976).  Hypnotic realities. New York: Irvington Publishers

Estgate, A, & Groome, S. (2005).  Introduction to applied cognitive psychology. NewYork: Psychology Press.

Lavie, P. (1993).  Ultradian cycles in sleep propensity, or, kleitmann’s brac revisited. In Lloyd, D. & Rossi, E. (Eds.) Ultradian Rhythms in Life Processes:  A Fundamental Inquiry into Chronobiology and Psychobiology (pp. 284-302). New York: Springer-Verlag.

Mann, B.J. & Sanders, S. (1995). The effects f light, temperature, trance length, and time of day on hypnotic depth.  The American Journal of Clinical Hypnosis, 37(3), 43-53.

Rossi, E, & Lippincott, B. (1992).  The wave nature of consciousness and being: Ultradian rhythms in mind-body communication. In Lloyd, D. & Rossi, E. (Eds.) Ultradian Rhythms in Life Processes:  A Fundamental Inquiry into Chronobiology and Psychobiology (pp. 371-402. New York: Springer-Verlag.

Rossi, E. & Lippincott, B.M. (1993).  A clinical-experimental exploration of erickson’s naturalistic approach.  Hypnos, 20 (1), 10-20.

Rossi, E. (2002). The psychobiology of gene expression. New York:  W.W. Norton.

Sommers, C. (1993).  Ultradian rhythms in common everyday trance.  Hypno, 20(3), 135-144.

Wallace, B. (1993). Day persons, night persons, and variability in hypnotic susceptibility. Journal of Personality and Social Psychology, 64 (5), 827-833.

Develop Your Unique Voice

Roger Love in Sing Like the Stars has some great advice for learning to find your own voice as a singer. This advice can be easily applied to finding your own voice as a hypnotist. He suggests that you begin by closely studying great singers. Listen to CD’s of your favorite song. Try to imitate what you hear. If you stick to just one singer, the danger is that you will sound just like them. Instead, do the same thing with a variety of singers. Finally you have to forget everything that you learned and find your own voice. The same idea applies the finding your voice as a hypnotist. In the beginning, you will listen to hypnotists that you admire and try to imitate their style. After a period of time; however, it’s time to find your own way of doing hypnosis. You will have at your disposal all that you’ve learned, but you will use what you’ve learned to express the total being that you are.

Within Western music there is only a finite number of notes. The major scale, for example consists of only seven notes. Yet individual musicians and composers can express themselves in a completely unique manner all utilizing the same seven notes. As hypnotic performing artists, are job is take what we have learned, and use what we have learned as elements of a unique personal expression.

The key to developing your own hypnotic voice is to study a variety of hypnotists. Do your best to imitate a particular mentor, but do not stay stuck there. Instead, move on to another mentor, and then another. In this way you will synthesize what you have observed and learned with your own unique individuality.

And that is the point–an in the moment expression of your own individuality, talents and resources in contact with the client’s individuality, talents and resources operating inside the hypnotic context, utilizing but not bound to scientific knowledge and past learning. Something that emerges to meet the present situation with wisdom and enlightened care, so as to move the client from their current stuck perspective–to something new.

“

Heinz von Forester is often quoted as saying the following. “If you desire see, learn how to act.” To learn about the world we must first act. Over thinking and planning can prevent us from taking the action that will teach us what we need to know. Patricia Ryan Madson says something similar in a different way. “The essence of improvisation is action–doing it in real time. We act in order to discover what come next. Notice she doesn’t say think about every possibility that might occur. Or have a script that tells you what to do. She says we must act in order to discover what’s next. One thing we can always count on is that clients will respond. As Paul Watzlawick has noted, you cannot not communicate and you cannot not respond. If you suggest to a client that they will close their eyes and they remain wide open, this is a response. It is this response that will tell you what to do next. How can you utilize what the client offers you for therapeutic purposes? How can their response to your interventions show you what to do next.?

Norman O. Brown has stated, “Wisdom is in wit, most excellent fooling; in play, and not in heavy puritanical seriousness. In levity, not gravity. My yoke is easy, my burden is light.  As quoted in Gods and Games P.147.

Rather than commencing a session with a detailed plan in mind, notice what the client and situation offer, and utilize what is offered in concocting the therapeutic stew that you will offer to your client. In her book Improv Wisdom, Patricia Madson discusses the French idea of bricolage. “It’s the art of commandeering the materials at hand — what is most obvious — to solve the problem. This way of doing things turns limitations into assets. You start by carefully noticing what is available. It is a mindset — a deeply ecological approach. Improvising, we’re dealing artfully with what is already there, can be understood not only as a backup approach but also as a way of life.” In the same manner, as hypnotists we need to notice what is present in the therapeutic situation. What is the client’s background? What are their values? What metaphors do they use to describe their dilemma? When you utilize what is offered, and respond to the feedback your client gives you, your sessions will now be tailored for the specific individual that you are working with–and thus more powerful and appropriate. It is the difference between purchasing clothing off the rack, and buying something custom tailored, bespoke clothing, as they say in the UK. Which is going to be the better fit?

The unconscious mind does not need to be bossed around. Rather it longs to be inspired with metaphors, stories, and a vivid imagery. Since most problems that we deal with as hypnotists are imaginary in nature we can solve them through imaginary means. Hypnosis is nothing but an opportunity to let your and your client’s imagination run wild.

I was working one day with my wife who was ill. I induced trance and then used what occurred to me. The image that came to mind was a blanket of comfort. So that’s what I went with. I mentioned being covered with a blanket that brought complete comfort physically, mentally, and emotionally. And I had that comfort began to descend down into her muscles and bones and nerves and deep into her soul so that her entire being was infused with this deep and profound comfort. Prior to the induction I had no idea exactly where I was going to go. I had a general sense of inducing healing and comfort, but it was only once we both sunk deeply into a trance that the image of a blanket of comfort occurred to me.

Learning to access your ability to respond creatively to your clients is largely a matter of learning to access your own ability to respond. It works a lot like a water faucet. The more trust you have the more the faucet opens and the more water flows through the pipes. The less trust you have the more the faucet closes down, and you are left with a mere trickle of water.

The other piece of this is adequate preparation. In listening to the client, with a not-knowing attitude, you are preparing the soil of your own creative resources. Listen to the words that they use, the metaphors, which shape their experience, and the values that they express. All of these factors are ingredients that you can use to create a therapeutic stew.

Letting go

Once, while working with a fellow student in a training session, I asked her what she wanted from the session. She responded with two words, “letting go”.

Following the hypnotic induction, I let my mind drift on examples of “letting go”. I remembered a time when I was moving. This was when compact discs had just come out, and I still had my album collection in a number of crates. I decided that this would be a good time to sort through my music collection, and decide what to keep and what to get rid of. I shared with the hypnotic subject that this process took a long time, because each album cover took me back in time, so that I was no longer sorting through my records, but was also sorting through my memories; taking what was valuable from those memories, and letting the rest go. At the end of the session, there were tears flowing down her face. I asked how that was, and she responded, “perfect”. Would the same result have taken place if I had been reading from a script?

Giving Permission and Learning to Trust Your Creativity

After the former head of the hypnosis program at a professional school of psychology suddenly left, I was called on to continue with the program. Luckily for me, for the first group of students this was their first course in hypnosis, so they lacked any inhibitions to their creative impulse. The second course was interesting, because among the students were people who had trained with the original instructor. To my shock, they had trained by reading scripts. My approach had been just the opposite. I told my students that reading from scripts was not allowed. They were to begin with a basic idea in mind and from that basic idea they were to improvise and to create suggestions in the moment in relationship with what the client offered, utilizing whatever feedback was offered by the client.

It took my new students a little time to adjust. They had been trained not to trust themselves, not to trust their unconscious minds and not to trust the wisdom of the total situation in which therapy can best arise. Eventually, after much initial anxiety, they did get it and were able to learn to be excellent hypnotists.

The notion of trusting your unconscious is often portrayed as the opposite of learning technique. But as anyone knows who is a practicing musician, technique and improvisation are two sides of the same coin. One must be both technically proficient as well as have the ability to trust your unconscious abilities. The same is true in hypnosis: conscious practice builds a working vocabulary which is utilized to communicate to the client, in the same manner that a musician learns chords, rules of harmony, and scales.

During a seminar that I was giving on conversational hypnosis, I was asked a question regarding how I develop stories to tell clients. I responded by asking if they want to know how I do it or how they can learn to do it, because these are really very different questions. How I proceed is that I listen to what the client is offering until I find inspiration to respond. Sometimes an image comes to mind and then I simply go with that. This type of response is what psychologist George Pransky has called Pop up thinking (personal communication). This type of creative thinking is different than linear problem solving where the mind operates on a step-by-step basis. Linear thought works wonderfully when were balancing a checkbook or working on a simple math problem. Here thinking is a step-by-step process.

The Grateful Dead’s live performances epitomized the ecstatic wonder of spontaneous creation.  They did not abandon song structures all together; rather, they treated those structures as jumping off points for wild improvisational excursions. In their slyly oxymoronically titled album, Live/Dead, the band traverses its way through a diverse terrain of musical genres.  No matter the material, the music is alive with a vibrant energy.   This vibrancy of expression is the result of both the joy of spontaneous creation in the moment, as well as the fact that the Dead’s music was relational in nature. They were not simply communicating with their audience, but the audience was also communicating with them in a rock and roll feedback loop.

Bradford Keeney, in “The Creative Therapist: The Art of Awakening A Session, advocates the implementation of the same flexible, relational strategies which one finds in musical improvisation into the domain of psychotherapy, proposing “that creativity — rather than theory, method, technique, or research — is what awakens meaningful and transformative therapy.” He goes on to suggest that “rather than replicating or reproducing a template to be hammered out for every clinical situation, creative therapy custom builds a therapeutic encounter as the patient and occasion calls it forth.” How can we bring that creative spark that is exemplified by Keeney and the Dead into our hypnotic sessions? What if we contextualized hypnosis as a creative performance one, which is improvisational in nature? Such an approach would not be a license to do things arbitrarily, but would rather allow us to respond creatively to the total situation in which we find ourselves as hypnotists.

The notion of hypnosis as a creative performance is bound to come up against much well meaning resistance. Almost from its inception, hypnotism has been denounced as fraudulent. Mesmer’s theories were challenged in Paris by a committee made up of eminent scientists of the day including Benjamin Franklin. To make matters worse, there is the tradition of stage magicians who focus on making volunteers act in a silly manner, and advertisements for how to seduce women with the power of hypnosis. Hypnotists can feel a bit insecure and find themselves wishing for a big dose of credibility that they hope that science can provide. There has been a recent clamor for what is called evidence-based hypnosis. In many of these studies, the idea is to create standardized protocols, administer these protocols in a precise manner, and then measure the results. But what if good therapy is not the result of standardized protocols, but rather emanates from the creative and individualized interaction between client and hypnotist? How are we going to measure that? My fear is that this movement toward standardized protocols may lead us in the wrong direction – to lifeless and rigid practice rather than alive creative performance.

Last week, I watched the movie howl. I saw an advertisement for it, for on demand .  Same time as in theaters it said.  My wife was skeptical, why watch a movie about some depressed  beat poet. I however,  was excited. I’ve always been a big fan of the poem Howl. I knew this was the story of the poet Allen Ginsberg centered around his groundbreaking poem.

For those who for those who don’t know Howl, groundbreaking is probably too mild a word. It was an atomic bomb, in the cultural mindset of the 1950s. The courage of the Beats to express what it was that they expressed at that time in history  is a lesson for all of us in courage.

The  movie utilizes the poem as a way to explore Ginsberg’s life, as well as to show the trial that occurred. Though it’s hard to imagine today, Howl was considered obscene and without any socially redeeming value. The book was banned and the publisher, Lawrence Ferlinghetti of City Lights Bookstore was charged with a crime for selling the book.

The cool thing about the movie, is that interspersed with various readings of the poem are animations. One that was most powerful for me is the section of the poem where Ginsberg invokes Moloch.  Moloch is a God to whom people would offer sacrifices of their children. In one of the scenes Ginsburg is chanting Moloch! Moloch! Nightmare of Moloch! Moloch the loveless! Mental Moloch! Moloch the heavy judger of men! Etc. You see parents with their children and the children have frightened looks; they about to be sacrificed to this evil God . Then suddenly the children are grown up. Now they are soldiers marching off to war where again they will be sacrificed to Moloch.

This movie reminded me how powerful art can be. It communicated the plight of the homosexual Ginsburg in a conservative society, his struggles as well as the struggles of the poets and artists attempting to find meaning and self-expression in 1950s America. It was so much more powerful than any textbook on diversity that one could read. What might we as hypnotists learn from artists?

Summary

This article takes on several tasks; it reviews the theoretical and experimental basis of empirical studies, gives a history and background of evidence-based practice, delineates both process and content studies, reviews the latest evidence for efficacy of hypnosis with treatment of various presenting issues, and gives suggestions for further studies within the field.  The pros and cons of evidence-based therapies are given equal weight, with the importance of balancing the art of therapy and hypnosis with evidence for both efficacy and effectiveness.

The authors begin with a discussion of the movement from theory driven practice, which was at its height in the 1960s, toward an empirical basis in the 1990s. This trend has not been without controversy.  The main arguments against have been that practice of therapy is a messy procedure, and that the rigidness of manualized treatment can never be replicated in the real world.  Other factors, such as the impact of the clinician on the patient, the therapeutic relationship itself and the personal “intricacies of clinical judgment in the empirical evaluation of treatments” are also part of the debate (p. 118).  Yet the obvious support raised in some circles is that manualized treatments can assure consumers receive treatment has been found efficacious.

Evidence-based treatments of hypnosis for several disorders are cataloged, with mixed results found.  Content (efficacy) versus process (effectiveness) types of research are examined for furthering evidence-based practice in hypnosis.  The authors give further indications for the development of empirical research and practice for hypnotherapy.

Key Points

Alladin et al review research of hypnosis in six areas: clinical hypnosis with children, analgesia, hypnosis as an adjunct to CBT, hypnosis and medicine, smoking cessation, and PTSD.  Child and adolescent studies are abundant in case studies, but little in the way of randomized clinical trials.  A meta-analysis of 18 articles and 28 effect sizes for hypnotic analgesia yielded evidence that “hypnosis can be considered a well-established treatment for pain,” and assuring its place as primary method of treatment.  CBT and adjunctive hypnosis studies were positive, yet problematic in that they did not match the gold standards of the APA.  Medical interventions for such issues as dermatological disorders and irritable bowel syndrome, also have supporting evidence, but it has not been clearly determined whether hypnosis is the main effect involved.  Smoking cessation has mixed results, leading some to claim that hypnosis “as a ‘possibly efficacious treatment for smoking cessation,” with the need for improved research. PTSD treatment with hypnosis, as of this publication, lacked any strong, systematic studies.

The authors spend a great deal of the article covering the background of evidence-based practice.  Criticisms are aired over the APA’s establishment of empirical studies, Wampold, a major proponent of Rosenweig’s dodo bird effect, argued that the APA task force used an incorrect method of establishing it’s list.  According to the dodo bird verdict, all psychotherapies work equally well, with negligible differences between them.  Thus the task force would have better created the list of empirical studies by adding all bona fide treatments and removing those that did not meet empirical standards.  Other arguments include the fact that some therapies have more experimental support than others, and thus were chosen for the list (CBT and behavior therapies which are more conducive to studies by their nature), and statistical power differs between studies, making some therapies appear better suited for the APA list (p. 117).

Alladin et al note that the APA released a report on clinical expertise, adding eight elements of the individual therapist to the mix of evidence-based practice.  The authors liken this to a quote from Wittgenstein, wherein he “stated that it impressed him very little when a man states he owns a trapeze artist’s suit: he would wait to see how he puts it to use” (p. 124). That is to say just because a treatment meets APA gold standards, does not place it with the context of usefulness or adaptableness for practice, or with use by all practitioners.

The implications of evidence-based hypnotherapy practice are examined, particularly with regard to content versus process variables.  Content variables look at efficacy, and can assist hypnotherapists from falling into romantic delusions or theoretical bias regarding their practice.  Process variables are of great assistance for hypnosis practice and research as they can focus on rapport, and therapist and client variables involved in treatment (p.125). The authors conclude that evidence-based practice is important for hypnosis, and that that it will generally help to increase the validity of this treatment method.

Critique

Having been trained in, and used hypnosis with patients; I found this article extremely interesting.  It also shook some of my current biases, such as the use of hypnosis for smoking cessation, which is generally recognized as a well-established treatment for this area.  Further debate over this has continued, but hypnosis is still considered more efficacious than other treatments due to it short term, and slighter costs (Mendoza & Capafons, 2009).  The literature review was not as inclusive as it could have been. More current publications list a plethora of other medical, and anxiety and mood disorders for which hypnotherapy has been judged a worthy treatment (Mendoza & Capafons; Barabasz, Olness, Boland, Kahn, 2010).  I was also surprised that they did not include weight loss among the list, another standard area for hypnosis practice.  However, the authors attempted to cover evidence-based practice as a whole, while making suggestions for the future of hypnosis within APA standards of practice.  This was no small undertaking, and they largely succeed.

There are several areas within which a manger or supervisor may need to address when supervising hypnotherapists with APA gold standards in mind.  First, the article points out what can be problematic for many practitioners; the difference between theory driven and research drive practice.  Whether the APA likes I or not, the bulk of psychotherapist are trained, usually in three of the four hundred-plus, possible psychotherapy orientations–psychodynamic, humanistic and cognitive-behavioral.   Thus, they lead theoretically, and case-conceptualize in this manner, not based on evidence for efficacy or effectiveness, but on personal attraction to the orientation.  Reversion to “romantic notions” of psychotherapy, or a “my school is better than the other one” attitude is likely to be encountered in many therapists.  The problem for the therapist, and for a manager or supervisor would be to be able to integrate the manualized procedure into practice.  Where world the original practice end and the manualized treatment begin?  How would the integration change the treatment, and would it still be considered the same treatment after the integration?

The authors do not cover the individual differences in hypnotherapy practice, not to mention schools of hypnotherapy.  One must consider that there is not one operational definition of hypnosis.  What actually constitutes this elusive practice is still up for debate.  Thus, the manualized treatment must be specific to the hypnotherapeutic school and its definition and practice of hypnosis.  Mixing this with a practitioner with another orientation may confound results if viewed through the lens of process research.  It may give pause to consult with the therapist after reading the journal reviews of the manualized treatments.

To conclude, Alladin, et al cover a great deal of ground, and manage to create more room for debate within the field of evidence-based psychotherapy.  Light is shed on which hypnotherapy interventions to proceed with in practice, though the list is by no means complete.   However, since the article manages to place hypnosis squarely in the larger picture, I recommend it as a primer for any psychologist in a clinical supervisory position.

References

Barabasz, A. F., Olness, K., Boland, R., & Kahn, S. (2010).  Medical hypnosis primer: Clinical and research evidence. New York: Routledge.

Mendoza, M.E. & Capafons, A. (2009).  Efficacy of clinical hypnosis: a summary of its empirical evidence. Papeles del Psicologo, 30 (2), 98-116.