**5. Cognitive hypnotherapy (CH): treatments**

A meta-analysis was conducted by critically reviewing 18 studies where a cognitive-behavioural therapy was compared with the same therapy supplemented by hypnosis across a wide variety of targeted disorders. Evidence showed that the addition of hypnosis to CBT enhanced treatment outcome compared to CBT treatment alone. The mean scores of the patients receiving cognitive-behavioural hypnotherapy showed a substantial improvement compared with 70% of the patients receiving only CBT [52].

The use of CBT and hypnotic techniques to enhance treatment effects has occurred in various domains and several studies have demonstrated the effectiveness of the integration.

In the first controlled treatment study using hypnosis as an adjunct to CBT for acute stress, it was found that CBT + hypnosis resulted in a greater reduction in stress than CBT alone, which was still evident at a 6-month follow-up. However, the researchers reported that a limitation of the study was the lack of specific guidelines regarding the mechanisms that potentially mediate hypnosis in the context of CBT and this could have weakened the procedure as the guidelines were unclear [9].

Evidence for the added effect of combining hypnosis with CBT in the management of chronic depression was provided in a seminal investigation [29]. It was found that hypnosis enhanced the overall beneficial effect of the treatment and reduced the number of sessions needed in comparison with CBT treatment alone. This investigation using cognitive hypnotherapy met the criteria laid down by the American Association Task Force and provided validation (for patients' safety) of the integration of hypnosis with CBT in the management of depression [53]. Further information was supplied when evidence-based hypnotherapy was reviewed for the treatment of depression [8].

The potential benefits of hypnotherapy were investigated with 32 patients suffering from chronic combat-related post-traumatic stress disorder (PTSD) [54]. The patients were already being treated with anti-depressants and supportive psychotherapy and were randomised into two groups. Fifteen patients in the first group received Zolpidem 10 milligrams nightly for 14 nights, and 17 patients in the hypnotherapy group were treated by symptom-orientated hypnotherapy, two 1.5 hour sessions each week for 2 weeks. All patients completed the Stanford Hypnotic Susceptibility Scale, Beck Depression Inventory, Impact of Event Scale and Sleep Quality Questionnaire prior to and post-treatment. It was found that there was a significant main effect of condition in the hypnotherapy group on PTSD symptoms as measured on the Post-traumatic Disorder Scale, and this effect was maintained at a 1-month follow-up. No such effects were reported in the non-hypnotherapy group either during the main data collection period or at the 1-month monitoring. The hypnotherapy group experienced additional benefits: decreases in intrusion and avoidance reactions and improvement in all sleep variables assessed. This investigation

**111**

*Cognitive Hypnotherapy*

set up [22].

*DOI: http://dx.doi.org/10.5772/intechopen.91327*

with medication treatments [55].

therapy in the following domains:

recovery of this condition.

as an adjunct to therapy.

demonstrates the beneficial effect of hypnotherapy with positive results achieved in a 2-week period. The methodology is robust as it uses a number of different scales and incorporates a control group. To aid further research in this domain, guidelines and protocols for the integration of hypnosis with CBT in the treatment of PTSD was

An investigation into the treatment of headaches and migraines provided an update of the literature first reviewed in 1996 by the National Institute of Health Technology Assessment Panel on the Integration of Behavioural and Relaxation Approaches into the treatment of chronic pain and headaches. It concluded that hypnosis is very effective and virtually free of side effects and adverse reactions and it meets the clinical psychology research criteria for being a well-established treatment. The research further drew attention to the ongoing expense associated

The literature also gives evidence of the beneficial effects of cognitive hypno-

Hypnotic techniques have also been researched regarding common sleep disorders [58]. However, there appears to be little empirical 'sleep research' integrating CBT with hypnosis. Therefore, the goal of this research was to educate clinicians on how to incorporate hypnosis with CBT in the management of sleep disturbance.

Hypnosis as an adjunct to therapy has been investigated in the management of both Type 1 and Type 2 diabetes [59]. The authors report that hypnotherapy appears to be psychologically beneficial and warrants further investigations. The findings indicate promising results for the stabilisation of blood glucose and decreased peripheral vascular complications. However, it is not reported whether comparisons were made with a control group, where no treatment was given, which would be a limitation of this research. It has been argued as to what constitutes sound methodology [54]; the minimal threshold of 'soundness' suggested is a design that compares a treatment with some form of minimal or non-treatment condition. The above investigation into diabetes however adds to current knowledge and is important in highlighting the effects that psychological aspects exert on

Hypnotherapy studies have been conducted in the following domains: pain management in burn patients [60], pain relief during labour and childbirth [61] and mild hypertension [62]. The results of these studies indicate that the psychological treatment through hypnotherapy can be very beneficial; however, the studies

Investigations have also been conducted in performance anxiety using hypnosis

Performance anxiety and treatment outcome were investigated when CBT and CBT with hypnosis were tested for effective treatment of public speaking anxiety. It was found that although both treatments effectively reduced anxiety when performing, the addition of hypnosis to CBT generated expectancies for greater change among participants, which further enhanced treatment effects and produced a faster drop in anxiety levels post-treatment [63]. It was concluded in a review of the empirical status of the use of hypnosis in conjunction with CBT programmes [64]

CH was adopted as a therapy for investigations studying irritable-bowel syndrome-induced agoraphobia [56]. The research demonstrated the efficacy of CBT with the integration of hypnosis, and the effectiveness of this multi-modal treatment in aiding the accompanying agoraphobia. A further study into irritable bowel syndrome condition using hypnotic techniques was conducted with eight female patients [57]. This research supported the earlier findings and demonstrated

a significant improvement in the quality of life of the patients.

This will be of value both in this research field and to therapists.

appear not to have a control group, which weakens the research.

### *Cognitive Hypnotherapy DOI: http://dx.doi.org/10.5772/intechopen.91327*

*Hypnotherapy and Hypnosis*

guiding practice [49].

haphazard [29].

hypnotherapy treatments.

patients receiving only CBT [52].

reviewed for the treatment of depression [8].

ness of the integration.

**5. Cognitive hypnotherapy (CH): treatments**

• The integrative approach offers a much needed theoretical framework, thus

• Treatment based on individual case formulation is prescriptive and not

Having considered the rationale for integration of hypnosis with CBT, the next section provides a short overview of key findings from research of cognitive

A meta-analysis was conducted by critically reviewing 18 studies where a cognitive-behavioural therapy was compared with the same therapy supplemented by hypnosis across a wide variety of targeted disorders. Evidence showed that the addition of hypnosis to CBT enhanced treatment outcome compared to CBT treatment alone. The mean scores of the patients receiving cognitive-behavioural hypnotherapy showed a substantial improvement compared with 70% of the

The use of CBT and hypnotic techniques to enhance treatment effects has occurred in various domains and several studies have demonstrated the effective-

The potential benefits of hypnotherapy were investigated with 32 patients suffering from chronic combat-related post-traumatic stress disorder (PTSD) [54]. The patients were already being treated with anti-depressants and supportive psychotherapy and were randomised into two groups. Fifteen patients in the first group received Zolpidem 10 milligrams nightly for 14 nights, and 17 patients in the hypnotherapy group were treated by symptom-orientated hypnotherapy, two 1.5 hour sessions each week for 2 weeks. All patients completed the Stanford Hypnotic Susceptibility Scale, Beck Depression Inventory, Impact of Event Scale and Sleep Quality Questionnaire prior to and post-treatment. It was found that there was a significant main effect of condition in the hypnotherapy group on PTSD symptoms as measured on the Post-traumatic Disorder Scale, and this effect was maintained at a 1-month follow-up. No such effects were reported in the non-hypnotherapy group either during the main data collection period or at the 1-month monitoring. The hypnotherapy group experienced additional benefits: decreases in intrusion and avoidance reactions and improvement in all sleep variables assessed. This investigation

In the first controlled treatment study using hypnosis as an adjunct to CBT for acute stress, it was found that CBT + hypnosis resulted in a greater reduction in stress than CBT alone, which was still evident at a 6-month follow-up. However, the researchers reported that a limitation of the study was the lack of specific guidelines regarding the mechanisms that potentially mediate hypnosis in the context of CBT and this could have weakened the procedure as the guidelines were unclear [9]. Evidence for the added effect of combining hypnosis with CBT in the management of chronic depression was provided in a seminal investigation [29]. It was found that hypnosis enhanced the overall beneficial effect of the treatment and reduced the number of sessions needed in comparison with CBT treatment alone. This investigation using cognitive hypnotherapy met the criteria laid down by the American Association Task Force and provided validation (for patients' safety) of the integration of hypnosis with CBT in the management of depression [53]. Further information was supplied when evidence-based hypnotherapy was

**110**

demonstrates the beneficial effect of hypnotherapy with positive results achieved in a 2-week period. The methodology is robust as it uses a number of different scales and incorporates a control group. To aid further research in this domain, guidelines and protocols for the integration of hypnosis with CBT in the treatment of PTSD was set up [22].

An investigation into the treatment of headaches and migraines provided an update of the literature first reviewed in 1996 by the National Institute of Health Technology Assessment Panel on the Integration of Behavioural and Relaxation Approaches into the treatment of chronic pain and headaches. It concluded that hypnosis is very effective and virtually free of side effects and adverse reactions and it meets the clinical psychology research criteria for being a well-established treatment. The research further drew attention to the ongoing expense associated with medication treatments [55].

The literature also gives evidence of the beneficial effects of cognitive hypnotherapy in the following domains:

CH was adopted as a therapy for investigations studying irritable-bowel syndrome-induced agoraphobia [56]. The research demonstrated the efficacy of CBT with the integration of hypnosis, and the effectiveness of this multi-modal treatment in aiding the accompanying agoraphobia. A further study into irritable bowel syndrome condition using hypnotic techniques was conducted with eight female patients [57]. This research supported the earlier findings and demonstrated a significant improvement in the quality of life of the patients.

Hypnotic techniques have also been researched regarding common sleep disorders [58]. However, there appears to be little empirical 'sleep research' integrating CBT with hypnosis. Therefore, the goal of this research was to educate clinicians on how to incorporate hypnosis with CBT in the management of sleep disturbance. This will be of value both in this research field and to therapists.

Hypnosis as an adjunct to therapy has been investigated in the management of both Type 1 and Type 2 diabetes [59]. The authors report that hypnotherapy appears to be psychologically beneficial and warrants further investigations. The findings indicate promising results for the stabilisation of blood glucose and decreased peripheral vascular complications. However, it is not reported whether comparisons were made with a control group, where no treatment was given, which would be a limitation of this research. It has been argued as to what constitutes sound methodology [54]; the minimal threshold of 'soundness' suggested is a design that compares a treatment with some form of minimal or non-treatment condition. The above investigation into diabetes however adds to current knowledge and is important in highlighting the effects that psychological aspects exert on recovery of this condition.

Hypnotherapy studies have been conducted in the following domains: pain management in burn patients [60], pain relief during labour and childbirth [61] and mild hypertension [62]. The results of these studies indicate that the psychological treatment through hypnotherapy can be very beneficial; however, the studies appear not to have a control group, which weakens the research.

Investigations have also been conducted in performance anxiety using hypnosis as an adjunct to therapy.

Performance anxiety and treatment outcome were investigated when CBT and CBT with hypnosis were tested for effective treatment of public speaking anxiety. It was found that although both treatments effectively reduced anxiety when performing, the addition of hypnosis to CBT generated expectancies for greater change among participants, which further enhanced treatment effects and produced a faster drop in anxiety levels post-treatment [63]. It was concluded in a review of the empirical status of the use of hypnosis in conjunction with CBT programmes [64]

#### *Hypnotherapy and Hypnosis*

that existing studies demonstrate substantial benefits by the use of hypnosis as an adjunct to CBT, supporting the meta-analysis conducted in 1995 [52].

A large-scale study was conducted with pianists looking at the effect of hypnotherapy on music performance anxiety (MPA) [65]. Using two groups, it was found that the hypnotherapy group but not the control group showed a significant reduction in MPA post-intervention, which was still evident 6 months later. At that time, there were no definitive protocols and procedure for the adoption of CH as an intervention for MPA but these have now been recently documented, giving guidelines and clear directives for the process of integration in this domain [47].

Recent research was conducted into MPA with 46 advanced pianists where participants were randomly assigned to a cognitive hypnotherapy (CH), eye movement desensitisation and reprocessing (EMDR) or non-treatment group and given two sessions only of the allocated therapy. They were tested in two concert performances pre- and post-intervention. Significant decreases in performance anxiety (the cognitive, physiological and behavioural aspects of performance) were found in both the therapy groups but not in the control group [66]. This research was extended when trait levels of anxiety (an individual's general anxiety level) were tested at 4 months and 1 year post-intervention. Statistical evidence at both monitoring points demonstrated a significant reduction in trait anxiety levels below baseline, showing the effectiveness of both CH and EMDR over time [67].

Nine case studies documenting performance anxiety in different domains have recently been published (five in music, two in the sports arena and two in the workplace) where CH was one of the interventions adopted. The effects of CH were recorded immediately post-intervention and longitudinally, and shown to be beneficial in a short space of time for the reduction of negative, psychological perceptions in a performing situation [68].

The findings from the above studies indicate that the addition of hypnosis to CBT protocols for the treatment of a variety of disorders is an effective remedy. It brings positive change rapidly in cognitive perceptions and physiology which impacts on subjective behaviour. However, there appear to be few guidelines for an integrative procedure and the assimilation of hypnotic techniques for the treatment of diverse medical conditions, and this needs to be addressed in future research.

As hypnosis influences behavioural and psychological responses, it is difficult to assess whether a placebo effect is operative here and, if it is, the extent to which it plays a role. For a number of individuals, hypnosis may act as a placebo due to positive expectations. There is evidence that hypnotic trance inductions are beneficial for those patients who believe in their efficacy [13, 69] and there is further evidence that patients' attitudes and beliefs can have a profound therapeutic effect on both medical and psychological conditions [70]. This effect may be difficult or impossible to control but if it enhances suggestibility and positive therapeutic outcome, then it can be beneficial and add to the impact and strength of the therapy.
