Alladin, A, Sabatini, L., & Amundson, J.K. (2007). What should we mean by empirical validation in hypnotherapy: Evidence-based practice in clinical hypnosis. International Journal of Clinical and Experimental Hypnosis, 55, (2), 115-130.
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.
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