EFPT Guidebook • EFPT Psychotherapy Guidebook

Gustavo França

Published on: Jul 07, 2019 EFPT Psychotherapy Guidebook • EFPT Psychotherapy Guidebook Hypnotherapy

Brief historic overview Described by some authorities as the "mother of psychotherapy", raises fair enough myths and misconceptions

Although the techniques of hypnosis could be appreciated in ancient civilisations, (1734- 1815) is regarded as the first modern westerner to be interested in this method. He advocated that a magnetic or an invisible fluid, given by a physician, could restore patient's fluid stability. Despite controversial, his theory of attracted interest in others.

In England, (1795-1860) (to whom has been attributed the origin of the term hypnosis) noticed that the could be induced by visual fixation. He rejected the fluidist theory and postulated the concept called monoideism, which means the fixation of on a single idea. Braid observed that the patients were particularly more suggestible in this state. In Paris, José Faria (1756-1819) stated a theory of somnambulism in which the characteristics of the subject, rather than the activity of the magnetizer, were responsible for the hypnotic trance. Later, Jean-Martin Charcot (1825-1893), an academic neurologist, considered hypnotism to be a pathological phenomenon, an artificial comparable to a hysterical phenomenon. Charcot was right when he analysed the hypnotic state as a neurophysiological phenomenon but wrong when he thought it was a clear sign of mental illness. Following Charcot, was initially an enthusiastic supporter of hypnosis and recognised the value of (a strong emotional reaction during hypnosis).

Milton Erickson (1901-1980) was the great advocate of hypnosis in the XX century. Erickson's approach was more permissive, accommodating, using indirect (presented without any imposing tone of command, but in a subtle, even amusing way).

Nowadays, several professionals use hypnosis in their work, including medical doctors, psychologists, nurses, and counsellors. More than a school of psychotherapy, hypnosis can be described as a technique. As Milton H. Erickson is considered to be the such, hypnosis dialogues with different schools, from father of modern hypnotherapy. (), to cognitive- (with the use of systematic desensitization while the patient is in trance), and existential therapies (hypnodrama and Ericksonian hypnosis) and transpersonal therapies. At a when there is a growing interest in , it is important to remark that although the pathway is different, in mindfulness one can also attain altered states of like those of hypnosis. This plurality makes hypnosis as desirable and challenging now as centuries ago.

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Description It is difficult to find a definition of hypnosis that pleases everyone. In 2015, a new American task force defined hypnosis as a “state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to ”; and hypnotherapy as “the use of hypnosis in the treatment of a medical or psychological disorder or concern”.

This discrete altered state of consciousness (the hypnotic trance) is associated with a relative reduction in external reality and ncreased inward absorption. In this state there is a provisional suspension of critical judgment, the imagery is richer, and the is modified, including sensations, perceptions and thoughts. This state can be activated by the individual himself (self-hypnosis) or by an operator (hetero-hypnosis). A sequence of a traditional hypnotic session may be as follows:

At the beginning of the interview, the therapist establishes a rapport and the procedure is explained (the desired outcome is defined, and eventual false expectations are corrected).

The is the first step of hypnosis. There are several techniques (the four-step induction, eye-fixation technique, among others), but nowadays the induction signal system is mostly verbal, relying on suggestions for and concentration. The usual sequence of suggestions is from simple to complex, from frequent to infrequent. The result is that the subject becomes increasingly aloof from all sources of stimulation other than therapist’s suggestions. To consolidate the quality of the trance, the therapist can match the cadence of his words with the breathing of the patient. In a deepen trance state the subject is more receptive to new suggestions which could be integrated into new patterns of thinking and behaviour.

Post-hypnotic suggestions are positive or negative reinforcements which help to achieve the desired behavior. They are, by definition, prospective - they should be formulated in the present and the future - and extensively - should always be used in the circumstances indicated. In the termination phase, there is a slow and gradual return to full consciousness.

Main uses (indications) American Psychiatry Association’s recent position statement on hypnosis (2015) stressed that “Hypnosis should be implemented in the context of a thorough medical and psychiatric evaluation, and its delivery

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should be consistent with the treatment plan for that patient “. In the medical setting, hypnotherapy could be used to alleviate the burden of symptoms (, for example) and in the psychotherapeutic setting, it could be used to restructure cognitive-affective patterns, which might later facilitate behaviour changes.

Currently, hypnotherapy is used in mental health in the treatment of various conditions, including depression, panic disorder, generalised anxiety disorder, , , , psychosomatic disorders) and functional neurological disorders, among others.

Efficacy Hypnosis has been shown consistently to decrease anxiety symptoms and avoidance behaviour in anxiety disorders, and through the mechanisms of muscle relaxation and cognitive dissociation to decrease sensitivity to pain across several medical disorders. Some studies have also shown that hypnosis may enhance , be effective in treating and could have benefit in , although there are conflicting results.

Despite the testimony and the enthusiasm of therapists and patients, the systematic analysis of available data is somehow disappointing. Cochrane Reviews showed that hypnotherapy appears to be well tolerated, without serious effects but fails to prove its superiority over or conventional treatment. Only in the Irritable Bowel Syndrome, the therapeutic effect of hypnotherapy was found to be superior to that of regular medical management. Overall, there is no substantial evidence of a more significant effect of hypnotherapy when compared to traditional psychotherapy.

The research is hampered by the difficulty in double-blinding hypnotic interventions and by the lack of agreement of dimensions on which patient and outcome variables should be measured. High- quality research with Randomized Controlled Trials comparing a hypnotic intervention with no treatment or standard treatment (using standardized assessment tools to evaluate depressive and anxious symptoms, for example) are needed.

Contraindications Hypnotizability is a trait that shows a mild correlation with attentional skills, absorption, dissociation and active imagination. The patient who would benefit less from hypnotherapy would be a person with a low capacity for concentration, a weak imagination and a low expectation regarding the outcome of hypnosis. However, the relationship between the degree of hypnotizability and clinical efficacy has not been clearly established.

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Patients with traumatic brain injury and cognitive deficits are bad candidates for hypnosis. The use of hypnosis is contraindicated in psychotic disorders following a potential risk of symptomatic exacerbation. It is also not advisable for patients with a borderline personality disorder (the risk of potential inappropriate relationships). As cooperation is essential for the whole procedure, non- cooperative patients often found in mental health settings are also bad candidates for hypnotherapy. Finally, it is noteworthy to state that a variety of negative symptoms have been reported followed hypnosis. One of the most important is the risk of inducing false memories, which might be a devastating experience for the patient.

Quote from a famous psychotherapist Milton Erickson (1901-1980): “Patients are patients because they are out of rapport with their own unconscious. Hypnotherapy patients are people who have had too much programming – so much outside programming that they have lost touch with their inner selves. People who are in rapport with their unconscious minds are also in control of their destiny”.

Comment from a trainee with experience “While there is general agreement that certain effects of hypnosis exist, there are differences of opinion within the research and clinical communities about how hypnosis works. Recent research supports the view that hypnotic communication and suggestions effectively change aspects of the persons physiological and neurological functions. “

João Perestrelo (Psychiatry trainee, Centro Hospitalar Vila Nova de Gaia).

Research possibilities Experimental hypnosis gained a new impetus due to the increasing interest in cognitive and clinical neurosciences. Hypnosis is still a promising tool in the study of consciousness and as a way of exploring mind-body interactions. In Europe, several research possibilities are available, including structured Master and PhD programs. In Francophone countries, the Confédération Francophone d’hypnose et thérapies brèves promotes research initiatives on hypnosis (https://www.cfhtb.org/). In the United Kingdom, several universities offer masters in hypnosis (Bournemouth University is one example. In Portugal, the BIAL Foundation promotes research in the field of hypnosis and altered states of consciousness through funding research.

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Country options Interested trainees are encouraged to explore some of the options below (please, note that the list is not exhaustive):

Austria - Mega: Milton Erickson Society for Clinical Hypnosis and Brief Therapy || www.hypno-mega.at

Belgium - VHYP: Vlaams Wetenschappelijke Hypnose Vereniging || www.vhyp.be

Bulgaria - BAHH : Bulgarian Association of Hypnosis and Hypnotherapy || www.bahh.org

Denmark - DSCH : Danish Society of Clinical Hypnosis || www.hypnoseselskabet.dk

Finland - THVH : Tieteellinen Hypnoosi ry, Vetenskaplig || www.hypnoosi.net

France - L’Eveil: Centre de formation a l’hypnose clinique et aux therapies breves. || www.eveil- formation.com

Germany - DGH: Deutsche Gesellschaft fur Hypnose || www.hypnose-dgh.de MEG: Milton Erickson Gesellschaft fur Klinische Hypnose || www.MEG-Hypnose.de

Hungary - HAH: Hungarian Association of Hypnosis || www.hipnozis-mhe.hu

Iceland - DI: Dáleiðslufélag Īslands || www.dfi.is

Ireland - CHPA: Clinical Hypnotherapy and Psychotherapy Association || www.chpa.ie

Italy - AMISI: Associazione Medica Italiana Studio Ipnosi || www.amisi.it CIICS: Instituto Franco Granone – Centro Italiano di Ipnosi Clinico || https://www.ciics.it

Luxembourg - IMHEL: Institut Milton H Erickson de Luxembourg a.s.b.l. || www.imhel.lu

Netherlands - Nvvh: Nederlandse vereniging voor hypnose || www.nvvh.com

Norway - NFKEH: Norwegian Society of Clinical Evidencebased Hypnosis || hypnoseforeningen.snappages.com

Poland - P-I-E: Polski Instytut Ericksonowski || http://www.p-i-e.pl

Portugal - SPHM: Sociedade Portuguesa de Hipnose e Motivação || www.sphm-hipnoterapia.org AHCP: Associação de Hipnose Clínica de Portugal || www.ahcp.com.pt

Russia - NSHRF: National Society of Hypnosis Russian Federation || www.rushypnosis.ru

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Spain - AEHE: Spanish Society for Ericksonian Hypnosis || www.aehe.com OrgHipnosis: Organización Professional de Hypnosis Clínica de España || www.hipnosis.org.es

Sweden - SSCH: Swedish Society of Clinical Hypnosis || www.hypnosforeningen.se

Switzerland - SMSH: Swiss Medical Society for Hypnosis || www.smsh.ch

United Kingdom - Royal Society of Medicine (Section of Hypnosis & Psychsomatic Medicine) || www.rsm.ac.uk/hypnosis UK College of Hypnosis and Hypnotherapy || www.ukhypnosis.com LCCH: London College of Clinical Hypnotherapy || www.lcchinternational.co.uk

Final Remarks Hypnosis is becoming more popular and socially acceptable; however, it still struggles to reach scientific respect in the medical community. Clinical hypnosis should be considered as an adjunct therapy and not as a substitute form of treatment to treat the untreatable (it is not a panacea). In psychiatry, it appears to offer a viable non-pharmacological intervention mainly for primary and secondary anxiety disorders. It remains to be elucidated how, in what intensity, and in what patients this intervention should be performed in an evidence-based manner. One should be mindful of formal contraindications. Ethical concerns shouldn’t be overlooked. Care must be taken to ensure that a collaborative therapeutic interpersonal process does not become a relationship of epistemological and even relational dependence on the subject, who could be constrained by the practitioner.

Books, manuals, articles Kaplan’s Comprehensive Textbook of Psychiatry (the “holy grail” of psychiatry!) has an entire chapter of more than 100 pages devoted to hypnosis. It is a rigorous and solemn introduction to any trainee interested in the subject. For Portuguese readers, we recommend two propaedeutic works from Mário Rui Santos and Joyce-Moniz.

Books: Kaplan’s Comprehensive Textbook of Psychiatry (Eds. Benjamim Sadock, Virgina Sadock and Pedro Ruiz), Tenth Edition. 2017. Wolters Kluwer. The Handbook of Clinical and Experimental Hypnosis (Ed. Jesse Gordon), First Edition, 1967. Collier Macmillan Ltd. Watkins JG. Advanced Hypnotherapy: Hypnodynamic Techniques. 2008. Routledge.

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The Handbook of Contemporary Clinical Hypnosis (Ed.Jacky Owens). 2015. Wiley-Blackwell. Mário Rui Santos. Hipnose nos nossos dias. 2010. Ariana Editora, 2ª Edição. L. Joyce- Moniz. Hipnose, meditação, relaxamento, dramatização. 2010. Porto Editora

Articles: Ardigo S, Herrmann FR, Moret V, Déramé L, Giannelli S, Gold G, et al. Hypnosis can reduce pain in hospitalized older patients: a randomized controlled study. BMC Geriatr. 2016 Jan 15;16:14. Elkins GR, Barabasz AF, Council JR, Spiegel D. Advancing research and practice: the revised APA Division 30 definition of hypnosis. Int J Clin Exp Hypn. 2015;63(1):1–9. Frischholz EJ. Hypnosis, hypnotizability, and placebo. Am J Clin Hypn. 2015;57(2):165–74. Gamus D, Kedar A, Kleinhauz M. Hypnosis in . Progress in Palliative Care. 2012 Nov 1;20(5):278–83. Grover MP, Jensen MP, Patterson DR, Gertz KJ, Day MA. The Association Between Mindfulness and Hypnotizability: Clinical and Theoretical Implications. Am J Clin Hypn. 2018 Jul;61(1):4–17. Jensen MP, Jamieson GA, Lutz A, Mazzoni G, McGeown WJ, Santarcangelo EL, et al. New directions in hypnosis research: strategies for advancing the cognitive and clinical neuroscience of hypnosis. Neurosci Conscious- 2017 Apr 12. Kaplan R, Manicavasagar V. Is there a syndrome? A review of three cases. Compr Psychiatry. 2001 Aug;42(4):342–8. Kihlstrom JF. Neuro-Hypnotism: Prospects for Hypnosis and Neuroscience. Cortex. 2013 Feb;49(2):365–74. Kraft, David & Kraft, Thomas. The place of hypnosis in psychiatry: Its applications in treating anxiety disorders and disturbances. Australian Journal of Clinical and Experimental Hypnosis. 2006, 34: 187-203. Lam T-H, Chung K-F, Yeung W-F, Yu BY-M, Yung K-P, Ng TH-Y (2015). Hypnotherapy for insomnia: A systematic review and meta-analysis of randomized controlled trials. Complementary Therapies in Medicine 2015, 23(5):719–32. McCann BS, Landes SJ. Hypnosis in the Treatment of Depression: Considerations in Research Design and Methods. Int J Clin Exp Hypn. 2010 Apr;58(2):147–64. Posner MI, Rothbart MK. Brain states and hypnosis research,. Conscious Cogn. 2011 Jun;20(2):325–7. Tan G, Rintala DH, Jensen MP, Fukui T, Smith D, Williams W. A randomized controlled trial of hypnosis compared with for adults with chronic low back pain. Eur J Pain. 2015 Feb;19(2):271–80. Winfried Hauser, Maria Hagl, Albrecth Schmierer, Emil Hansen. The Efficacy and Applications of Medical Hypnosis – a systematic review of meta-analyses. Dtsch Arztebl Int 2016; 113:289-96.

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Other Resources: Cochrane EBM Reviews which are available www.cochranelibrary.com

Jeffrey S Forrest (2017). Therapeutic Hypnosis, available online: emedicine.medscape.com/article/1948365

Affiliations Gustavo França is a medical doctor, last year psychiatry resident at Hospital de Magalhães Lemos in Porto.

Pedro Amadeu is a medical doctor, a third-year psychiatry resident at the same hospital.

They are both interested in psychotherapy. Gustavo has been trained in hypnotherapy (Sociedade Portuguesa de Hipnose e Motivação) and Pedro in psychoanalysis (Sociedade Portuguesa de Psicanálise). Dr. Hernâni Carqueja (MD) should be acknowledged for the constant effort and motivation that he places on young physicians to deepen the study and critical analysis regarding hypnosis and the cryptic area of altered states of consciousness.