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Running head: SELECTIVE LITERATURE REVIEW: HYPNOTHERAPY 1
Selective Literature Review:
Clinical Usage and Application of Hypnotherapy
Tammy Daniel Coles
Walden University
SELECTIVE LITERATURE REVIEW: HYPNOTHERAPY
Abstract
This literature review explores research conducted in the past 10 years related to the utilization
of hypnotherapy treatments for Acute Stress Disorder (ASD), Post-Traumatic Stress Disorder
(PTSD), and Major Depressive Disorder (MDD). The focus of this review is to investigate the
effectiveness of hypnotherapy in treating the symptoms of each DSM-IV disorder. Findings
indicate that the use of hypnotherapy methods in the treatment ASD and PTSD offer the most
consistently positive outcomes. Hypnosis treatments in relation to MDD are relatively
inconsistent.
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Clinical Usage and Application of Hypnotherapy
Over the past decade, there has been a great deal of discussion about the potential use of
hypnotherapy as a treatment method in clinical counseling. There is a significant lack of
empirical research to support the use of hypnosis in a clinical setting for most disorders. Much of
the available research discusses moderate effect sizes utilizing small samples that may not
accurately represent a multicultural population. That said most researchers support
hypnotherapeutic treatment applications as effective methodology in mental health counseling.
Current research is limited in scope and the study of hypnotherapy in individuals that meet the
diagnostic criteria for depression and post-traumatic stress disorder (PTSD) may require stronger
supportive data to be recognized as an established clinical counseling method. Hypnosis in
treating PTSD shows the greatest potential with the most supportive research.
Much of the research reviewed discusses hypnotherapy as being most effective when
utilized simultaneously with other treatment methodologies. The literature doesn’t seem to
support this theory consistently. Cognitive Behavioral Therapy (CBT) is the most commonly
cited as a complimentary treatment approach, but in data regarding the effectiveness of a CBT
only control group in comparison to a CBT with hypnotherapy treatment group for treating Acute
Stress Disorder (ASD), there was no statistical difference between groups (Bryant, Moulds,
Guthrie, & Nixon, 2005).
Findings in the current research literature regarding the effectiveness of hypnotherapy in
treating depression are inconsistent. The empirical support necessary for hypnosis to be
considered a viable treatment option for depression, just isn’t available. Although there are many
individual case studies that offer evidence of a single individual who significantly benefited
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from hypnosis in treating clinical depression, there are very few empirical studies that offer
supportive evidence.
Some debate also exists regarding the over-reporting of positive results in current
research and arguments that earlier studies utilized assessment instruments that don’t accurately
measure the hypothesis of the research. Researcher bias is a strong topic of debate. The lack of
independent auditing and lack of research bias statements also sacrifice the validity of the
strongest supportive research.
A combination of solid clinical studies, unbiased researchers, independent auditors and
empirically recognized research methodologies could offer the support that hypnotherapy
requires to be widely accepted a therapeutic mental health treatment strategy. Studies that have
been critically reviewed by peers on both sides of the debate prior to publication would add
further strength to the validity of current data. In case studies and convention speeches, it is
obvious that clinical practitioners are enthusiastic about the potential of adding hypnotherapeutic
methodologies to their practices. The need for solid research is a clear one that has and will
continue to consistently limit the incorporation of hypnosis into clinical psychological practice.
Strong and consistent PTSD treatment evidence offers the strongest support for hypnosis in
clinical settings. Utilizing hypnosis in treating PTSD and conducting more research that
scientifically/empirically supportable could help remove the “fad” stigma from hypnotherapy
and help the methodology gain needed professional support.
Research Inclusions and Exclusions
The literature included in this review was limited to research articles that studied the
effectiveness of hypnosis on symptoms that specifically related to ASD, PTSD, and Depressive
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Disorders. An article regarding the effectiveness of hypnotherapy on self-esteem was included
due to the research criteria including depression related to low self-esteem. Research that based
on a single case study or focused on ICD-10/medical diagnosis was excluded. Specific research
excluded included those articles related smoking-cessation, medical hypnotherapy for physical
ailments and pain management/anesthetic hypnosis applications. The research articles selected
were those that pertained to depression and trauma that were conducted in the past 10 years.
Utilizing Hypnotherapy In The Treatment of Depression
Depression is one of the most common mental conditions that leads individuals to seek
psychological counseling.t Most researchers in this review are supportive of the utilization of
hypnotherapy in the treatment of depression. Findings are not always consistent with this
support. There is approximately an equal amount of research available that supports the
effectiveness of hypnotherapy and research that denounces the effectiveness of hypnotherapy in
treating depression. There are many factors that may account for this inconsistency including
research methods or issues, types of hypnosis/hypnotherapy administered, sample demographics,
and staff training.
In a quantitative meta analysis study, Shih, Yang and Koo (2009) examined six (n=7)
randomized studies and found an effect size of 0.57 (p <. 0001), meaning that data
demonstrated a medium effect of hypnotherapy in the treatment of depression. A major issue
that Shih, Yang and Koo (2009) reporting in their findings was the inconsistency in results
within the six studies. The quantitative data in the studies reviewed found hypnosis to offer a
moderate beneficial effect on depression. Cultural difference with in the samples or locations if
the studies were not discussed but could be one possible explanation for the inconsistency. The
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use of hypnosis is more widely accepted in certain cultures, countries, and ethnicities than in
others.
In one of the most widely referenced studies regarding cognitive hypnotherapy (CH) for
Major Depressive Disorder (MDD), Alladin and Alibhai (2007) conducted a study to investigate
the effectiveness of CH in comparison with Cognitive Behavioral Therapy (CBT). Ninety-eight
individuals who met diagnostic criteria for chronic MDD were randomly assigned to a CH or
CBT group. Over the course of 16 weeks, using a baseline test, an assessment at the termination
of treatment and a follow up assessment conducted 12 months later, Alladin and Alibhai found
that CH produced an 8% greater reduction in hopelessness than CBT. The researchers also found
that CH offered the greatest long-term impact on anxiety and hopelessness at the 12 month
follow up. Alladin and Alibhai’s evidence suggest that CH may be an effective treatment option
for chronic depression.
In a feasibility study, Dobbin and Elton (2009) studied the effects of self-hypnosis
utilizing 58 individuals (n=58), aged 18-65 who were currently experiencing a diagnosed
episode of depression. In each case, the participant’s general practitioner intended to prescribe
antidepressants. Of those individuals, 50 participants chose to participate in the self-hypnosis
program in an effort to cope with depression. Depression scores were compared at the beginning
and end of the study. The study was benchmarked against 3 other studies. The researchers found
that 93% of participants preferred self-hypnosis to pharmacological treatment options. Dobbin
and Elton (2009) utilize this information as further evidence that self-hypnosis is a useful
addition to depression treatments administered by general practitioners.
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In a study of long-term depressed mood, Butler et al. (2008) created two treatment
groups for those with long-term low to moderate depression. The first group (n=17) consisted of
individuals that utilized meditation with hatha yoga and psychoeducation. The second group
(n=17) consisted of individuals who participated in group therapy with hypnosis and
psychoeducation. Both groups were compared with a psychoeducation only control group
(n=18). The randomized sample included 46 participants (n=46), 50% that had a clinical
diagnosis of dysthymia, 28% had a dual diagnosis of dysthymia and a major depressive episode,
15% had a diagnosis of a major depressive episode with partial remission, and 6.5% were
diagnosed with a chronic major depression lasting 2 or more years. Butler et al. (2008) report a
remission rate of 77% with the meditation group, 62% with the hypnosis group, and 36% in the
control group. Butler et al. cite Kocsis’s (2007) remission rate findings to be 73% for traditional
psychotherapy and antidepressant treatment. Given this data, the hypnosis group’s success rate is
still lower than current empirically recognized methodology.
In a more general study of mood and tiredness, Thompson, Steffert, Steed, and Gruzelier
(2011) conducted a randomized study of 35 individuals. The individuals were randomly placed
in a verbal imagery self-hypnosis group, a 3-d computer animated imagery hypnosis group, and
a relaxation group. A series of baseline assessments were conducted followed by mood
assessments administered immediately before and after each treatment session. None of the
methods achieved statistically significant results over the others. The researchers did discover
that visualization through self-hypnosis increased participant engagement in imagery for those
that traditionally have issues “picturing things in their minds” and that both self-hypnosis groups
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reported low levels of tiredness after each treatment session. Thompson et al. (2011) didn’t
report any evidence of improvements in mood.
Schreiber (2011) conducted an analysis of 5 case studies of hypnosis with clients that had
major depressive disorders. In looking at the case studies, Schreiber clients were referred in
each case by their family physician and had been formally diagnosed by a psychiatrist. Each
client underwent the same clinical assessments and each client was able to hypnotized quickly.
Schreiber found that all five case studies showed a reduction follow treatment in a test-retest
model. Schreiber’s findings based on the case studies appear to be inconsistent with those found
in empirical research models.
Acute Stress Disorder and Post-Traumatic Stress Disorder
In studying ASD, Bryant et al. (2005) identified 109 participant (n=109) who were at
highest risk of developing Post-Traumatic Stress Disorder (PTSD). Of those participants, 22
(n=22) declined treatment and the remaining 87 (53 women, 34 men) were placed in randomly
selected treatment groups. The 3 treatment groups either participated in CBT, CBT with
hypnotherapy, or supportive counseling (SC). All participants met DSM diagnostic criteria for
ASD. 69 (n=69) of the participants completed the program. The SC group had the lowest
dropout rates. Bryant et al. (2005) found that there were no significant differences in good end
of treatment functioning between participants in each group. The CBT/hypnosis group didn’t
have greater clinical gains than those in the CBT only group. Bryant et al. (2005) make the
argument that CBT groups that include hypnosis perform more effectively than groups that
participate in CBT alone. Bryant et al. suggest that the motivation of participants may increase
the effectiveness of treatment. The researchers note that this is one of the first controlled studies
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to evaluate the effectiveness of hypnotherapy in the treatment of ASD, the sample size is small,
the drop out rate was higher in the CBT and CBT/hypnosis group, and that the researchers failed
to use CAPS-2 at the initial assessment and were not able to index to what extend the assessors
were blind to the participants treatment groups. The study provides no empirical support of
hypnotherapy enhancing the effectiveness of CBT in the treatment of ASD.
In researching the effects of hypnosis in treating PTSD in children, Lesmana, Suryani,
Jensen and Tiliopoulos (2009) conducted a study of children ages 6-12 who met the criteria for
PTSD after witnessing the 2002 terrorist attacks in Bali. Lesmana et al. (2009) utilized spiritual-
hypnosis assisted therapy (SHAT) for treatment children. The research design was based on a
longitudinal, test-retest design. The study included 46 children (n=46) in the SHAT treatment
group and 178 children in an untreated control group. 77.1% of the children in the treatment
group showed improvement. There was an improvement of 24.2% in the control group. Lesmana
et al. (2009) point to spirituality that is consistent with the culture of their sample group
combined with children’s tendency to be more receptive than adults to hypnotic suggestions as a
possible explanation for the strongly statistically significant results.
In a study of 36 patients (n=36) with chronic PTSD, Abramowitz and Lichtenberg (2010)
researched the use of hypnotherapeutic olfactory conditioning (HOC) with combat soldiers with
symptoms that were not improved by other forms of treatment. In an uncontrolled open study,
clinical assessments were utilized at the baseline, 6-weeks (immediately following HOC
treatment), 6 months and 1 year. Abramowitz and Lichtenberg (2010) found an improvement of
symptoms that was maintained over the entire course of the study. The potential benefits of HOC
in the treatment of PTSD require further study.
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Barabasz and Barabasz (2012) conducted an open controlled study of 36 volunteers who
met the diagnostic criteria for the PTSD. The volunteers participated in a single 5.5- 6 hour
session of manualized ego state therapy emphasizing abreactive hypnosis. A Post Traumatic
Stress Checklist (PCL) was conducted as a baseline and at 1 month and 4 month follow-ups.
Barabasz and Barabasz (2012) found that the manualized therapy group showed significantly
lower PCL scores than the control group at 1-month and 4-month follow-up retests and a
significantly lower PCL scores at all post therapy testing periods than their pre-test scores.
Barabasz and Barabasz concluded that 1 session of abreactive hypnosis was enough to show an
improvement in symptoms.
In experimental research aimed at studying the effectiveness of Hypnosis, Neuro
Linguistic Programming and Time Line Therapy reducing the intensity of negative emotions
attached to memories of stressful events, Bin Ahmad (2011) that all three methods offered
significant reduction in negative emotions when compared with a null control group. The
research consisted of 32 treatment group subjects and 32 control group subjects. The participants
did not have to meet the diagnostic criteria for a trauma related disorder to meet the
requirements for participation in the study. Bin Ahmad (2011) assessed participants at the
baseline, during the procedure, and immediately after the procedure. He determined that there
was a significant improvement in negative emotions after each session. Bin Ahmad (2011)
specifically notes that hypnosis has been shown to be useful in helping people relax their minds
and body. He suggests that hypnosis simply provides a distraction or change of focus (with out
forgetting the event). It is important to note that Bin Ahmad utilized a combination of neuro
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linguistic programming, time line therapy, and hypnosis as complementary treatments in order to
achieve the significant results.
In a randomized controlled study, Abramowitz, Barak, Ben-Avi and Knobler (2008) gave
a group of 15 patients SSRI antidepressant in the control treatment group and a second treatment
group of 17 patients symptom-oriented hypnotherapy. Abramowitz et al. (2008) utilized a daily
morning questionnaire and a series of clinical assessments at the beginning, immediately after
the study and again 1 month after the study. At the end of treatment, the PTSD symptoms were
tested lower in the hypnotherapy group than in the SSRI group. There was also improvement in
insomnia and sleep disorder symptoms noted. Abramowitz et al. (2008) determined that
symptomatic hypnotherapy is an effective treatment in patients suffering from chronic PTSD.
In a program evaluation of cognitive behavioral group therapy for PTSD in Knapp
(2006) conducted a study of 10 young female offenders. Based upon research she cited from Van
Etten and Taylor (1998), Knapp theorized that behavior therapy and a form of hypnotherapy
known as Eye Movement Desensitization and Reprocessing (EMDR) would be more effective
than the CBT currently being utilized. The initial phase of her dissertation was to study the
effectiveness of the current program. Knapp (2006) found that statistical analyses could not be
performed because there were too few participants, poor retention, and considerable amounts of
data missing. Knapp suggests a more structured research methodology with increased
administrative and parental support. Knapp also notes that uncertified and untrained staff often
runs the current CBT programs. She suggests incorporating proper training with staff prior to
beginning the next study. Based on the lack of statistical analyses, Knapp is unable to make a
recommendation regarding hypnotherapy or other alternative methods.
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Self-Esteem and Self-Concept
In a randomized clinical trial, Scholze et al. (2011) found that there was no statistical
significance between the treatment group that participated in 4 weeks of hypnosis and the
Hawthorne method or Hawthorne method only control group. In terms of self-concept and self
esteem improvement, the student participants (n=35) showed the same results regardless of
randomized treatment group placement. There is no evidence to suggest that hypnosis improves
self esteem.
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Clinical Use
In her doctoral thesis, Pignotti (2009) investigated that usage of unsupported therapies in
clinical practice by licensed social workers. Pignotti utilized a research-specific exploratory
survey instrument that included demographics (specific to the research), open ended questions,
and different types of therapeutic approaches listed alphabetically. Participants indicated which
approaches they used in their practice, how often they used each approach, and how recently
they used each approach. The therapeutic approaches were categorized into 3 broad groups for
evaluation. Those categories were empirically supported therapies (EST), conventional therapies
that lacked empirical support (CUT) and novel unsupported therapies (NUT). The participants
were not aware of the categorization. Out of 193 respondents (n=193), 45 reported current use of
hypnosis in their practice. An additional 9 respondents reported using hypnosis in the past. The
high amount of reported hypnosis usage in practice without empirical or scientific support
demonstrates a disconnect between scientific support and practical application (Pignotti, 2009).
Evaluating Research
Looking at 444 studies of Flammer and Bongartz (2003) looked at the efficacy of
hypnosis in a meta-analysis study. The researchers only considered clinical, randomized studies
and that utilized one research group that was treated exclusively with hypnotherapy and another
group that received no treatment. The researchers worked with a group of 57 (n=57) that met the
research criterion. Two types of hypnosis were evaluated, classical (70%) and modern (19%).
The researchers couldn’t determined the type of hypnosis being used in approx.. 11% of the
studies.
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Flammer and Bongartz note that studies regarding affective disorders, obsessive
compulsive disorders and psychotic disorders are missing completely in the sample and that
somatoform and psychological disorders caused by substances are under represented in the
available studies. Flammer and Bongartz (2003) point to gap between clinical research and
therapeutic research as a major issue in evaluating the effectiveness of hypnotherapy. ICD-10
disorders are well represented in the research, which pain management being most commonly
represented hypnotherapeutic application. The prevalent lack of research in the area of
psychotherapy is a significant weakness in supporting hypnotherapy usage in clinical practice.
Flammer and Bongartz (2003) point to the high effect size in their findings as evidence to
support randomized clinical studies of psychological hypnosis applications.
In a separate meta analysis of the studies reviewed by Flammer and Bongartz, Moshagen
and Musch (2008) reevaluated the entirety of the 444 studies to assess for publication bias.
Moshagen and Musch theorized that Flammer and Bongartz may have overreported the mean
treatment effect of hypnosis by selecting publications with positive outcomes. Moshagen and
Musch (2008) did find evidence of publication bias, but still showed a significantly significant
treatment effect to suggest that the efficacy of hypnosis is substantial and can’t be attributed to
the selective reporting of positive outcomes.
Discussion of Findings
In conducting a literature review, many of the researchers consistently found that those
individuals who met the diagnostic criteria for PTSD were more susceptible to hypnosis
(Abramowitz et al., 2008). Findings in each of the PTSD studies support that hypnotherapy is
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often most successful when treating PTSD and trauma related disorders. The literature reviewed
did not support hypnotherapy as a successful treatment for depression.
In terms of the hypnotherapy/hypnosis in each study, there was a lack of consistency in
the types of hypnotherapy being utilized. Many of the studies include a type of hypnosis that is
specific to that individual study. There is also a lack of information regarding the hypnotherapy
provider in each case. In the absence of data regarding who administered the hypnotherapy, what
type of certification or licensure the hypnotherapist possessed, what specific experience or
training the practitioner possessed in the type of hypnosis administered, or in some cases if the
hypnotherapy was administered in-person…it is hard to determine if the treatment being
administered was the best available for the intended study.
Discussion of Cultural Impact
As with most types of treatments, there are cultural concerns that can greatly impact the
effectiveness of hypnosis. Some cultures and traditions are generally more accepting of hypnosis
than others. Capafons et al. (2008) used a sample of psychology students from Spain, the US,
Portugal and Romania to examine the effects of having personal experience and information
versus beliefs and attitudes about hypnosis. Capafons et al. used a large research sample
consisting of 1103 students in Spain, 1024 students in the US, 402 students in Romania, and 315
students in Portugal. The researchers utilized the Revised Valencia scale to develop 8 categories.
The researchers determined that accurate beliefs were correlated with positive attitudes and
inaccurate beliefs correlated with negative attitudes in regard to hypnosis. Capafons et al. (2008)
found evidence that cultural and personal experience with hypnosis translated to a more positive
attitude and accurate beliefs about hypnosis. In cultures where hypnosis is practiced more
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commonly, the more positively students studying psychology received the treatment. These
findings are supported by a randomized controlled research study conducted by Green. Green
(2003) t sampled 276 undergraduate students beliefs about hypnosis utilizing a control group and
a treatment group that was hypnotized. Utilizing a test-retest approach, Green theorized that
experience with hypnosis would change participant’s perceptions and attitudes about hypnosis.
Half of the students completed a hypnosis susceptibility questionnaire and the other students
completed an Opinions About Hypnosis Scale. The Opinions About Hypnosis scale was
organized into 4 broad categories with a total of 21 items measured. Green (2003) found that
experience being hypnotized altered beliefs and eliminated many misperceptions about hypnosis.
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