Hypnotherapy and therapeutic suggestion: bridging the gap between evidence and utility

Summary

The use of hypnotherapy in psychiatry has been controversial. However, evidence presented by Chan and colleagues shows that it is beneficial to the promotion of good mental health and well-being, specifically being applicable in the management of mental disorders. But what does this mean for practice? This commentary looks at what we agree and disagree with, what we opine is missing from the article and what now needs to happen. Patients should be able to access hypnotherapy or hypnosis routinely on the National Health Service. Since it works, who may it work for and how may we make this available to those who could benefit from it?

Hypnotherapy, also known as hypnosis, involves the use of a formal induction procedure and targeted suggestions to address a particular symptom or group of symptoms. It is more likely to be used as a primary psychological treatment rather than as augmentation of existing treatment. A related though slightly different concept that may find wider use in healthcare is the use of targeted, positive suggestions on their own as therapeutic suggestion (Varga 2013). This technique does not require induction, nor does it need to be labelled as hypnosis. Therapeutic suggestion is more likely to be used as an ‘add-on’ rather than as distinct treatment. It can be incorporated as a technique to enhance existing therapies. Many patients and practitioners would feel more open to the use of therapeutic suggestion than a practice labelled ‘hypnotherapy’, which for many will still carry negative associations.

Chan et al's article (2022) presents a comprehensive review of the evidence for hypnotherapy where it exists. The strengths of the article are the timeliness of its presentation, its publication in mainstream mental health literature and its robust review of methodologies and outcomes. Although this evidence has been around for some time, hypnotherapy (hypnosis) continues to struggle with image problems, mislabelling and stigmatisation within psychiatry (Du Plessis 2021). The consequences of this are that patients are hampered from accessing its benefits (Krouwel 2017) and mental health professionals are discouraged from training in or delivering hypnosis. Health professionals often do not realise that a lot of research has gone into hypnotic interventions in recent years and, anecdotally, they often opine from points of view that are uninformed by evidence.

Definition of clinical hypnosis

The characterisation of clinical hypnosis as something that is done to patients over which they have no control – in effect, involuntary mind control – is controversial. This does not appear to be the view of contemporary practitioners of clinical hypnosis in Europe or America. The accepted definition of hypnosis has undergone various iterations over the years (Elkins 2015). This effort has ensured that its definition is recognisable and widely accepted. In 2014, the Society of Psychological Hypnosis (Division 30 of the American Psychological Association) defined hypnosis as ‘a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion’ (Society of Psychological Hypnosis 2022). These are the essential components of what is called the trance state. We agree with the Society's definition but must point out that resulting therapeutic effects are often experienced by patients as involuntary and realistic (Blakemore 2003), although it requires the active engagement and cooperation of patients with the procedure and imaginal content of suggestions.

The formal induction of a trance or hypnotic state (focused relaxation), which might be called neutral hypnosis (Cardeña 2013), is to be differentiated from the use of therapeutic suggestion (the making of positive suggestions to produce intended beneficial effects), for example in healthcare (Phillips 2022). The induction of neutral hypnosis plus the use of therapeutic suggestion together make up ‘hypnotherapy’, but an induction process and/or ‘hypnosis’ is not necessary for people to respond to positive suggestions (although neutral hypnosis does produce a small but significant increase in response) (Kirsch 2001). Therapeutic suggestion may be added to existing therapies, such as in chronic pain management, cognitive–behavioural therapy (Ramondo 2021) and mindfulness (Olendzki 2020), to increase effect sizes. Teaching patients self-hypnosis, which is advocated by hypnosis societies, helps them to take control of their own thought processes, emotions and behaviours. This increases their self-efficacy and participation in their own treatment (Wark 2002; Kohen 2010).

An omission from the article

What is missing from Chan et al's article is discussion of the most common uses of hypnosis and therapeutic suggestion in psychiatry. These include the management of medically unexplained symptoms (or functional disorders) and of comorbid physical and mental illnesses in adults and children (Phillips 2022). These problems are often encountered in liaison psychiatry. General hospitals bring added complexity and challenges to what mental health interventions can be quickly and easily delivered, and hypnosis and therapeutic suggestion have value in this setting (Holler 2021). This value extends to the cost-effectiveness of hypnotherapeutic interventions (Montgomery 2007; Maines 2021), improvements in patients’ experience of care (Arbour 2022) and quality of life. A systematic review and meta-analysis has found hypnosis and therapeutic suggestion to be effective in chronic pain management (Adachi 2014). In cancer care, hypnosis reduces pain, anxiety, depression, fatigue and insomnia associated with treatments (Remondes-Costa 2021; Hayat 2022). It has been approved by the National Institute for Health and Care Excellence (NICE) as a treatment for irritable bowel syndrome (NICE 2017: recommendation 1.2.3), although mental health professionals, even those in the UK, are often unaware of this. Irritable bowel syndrome can be conceptualised as a common functional disorder that has high comorbidity with common mental disorders. To participate fully in integrated care, psychiatrists would do well to understand these interventions and participate in their delivery. The curriculum for training in child and adolescent (consultation) liaison psychiatry in Australia, for example, lists hypnosis as one of the interventions that trainees could learn to deliver (Shaw 2019).

Education and training for healthcare professionals

Interventions that have been evidenced to improve healthcare professionals’ knowledge, attitudes and perceptions of hypnosis and therapeutic suggestion are limited in scope. The following have been evidenced: a short online video lecture (Montgomery 2019); longer, in-person, didactic educational/training sessions (Martín 2010; Carvello 2021; Arbour 2022); a training programme involving patients (Aramideh 2020) and their families (Ogez 2021); and comprehensive training with ongoing supervision and continuing education (McKernan 2020). Expanding awareness of hypnosis and therapeutic suggestion among healthcare professionals and their students would be of benefit to a wide range of patients. Although improved awareness may not necessarily translate into practice, it would be a good starting point.

Hypnosis practitioners and societies should focus on educating the wider healthcare community about the benefits of hypnosis and encourage its incorporation into clinical guidelines (Box 1). For too long, the evidence of the benefits of hypnosis continues to circulate mainly within highly specialised communities of practice, robbing other health professionals of this enlightenment. For mental health services, the question that needs consideration is: For whom are hypnosis and therapeutic suggestion effective and how can we make these interventions available to those patients who would benefit?

BOX 1 Sources of information

For professionals

• • British Society of Clinical and Academic Hypnosis – This is the professional body of health professionals in England, Wales and Northern Ireland who utilise hypnosis in healthcare. It promotes safe and responsible practice, aims to educate both professionals and the public about hypnosis and its use, and encourages research, audit and publication on the subject (www.bscah.com).

• • British Society of Medical and Dental Hypnosis (Scotland) – This organisation in Scotland aims to promote the safe and responsible use of hypnosis in medicine and dentistry. It aims to educate healthcare workers and the public about hypnosis and its uses and to advance scientific research, education and standards of practice in hypnosis (www.bsmdhscotland.com).

• • Hypnosis and Psychosomatic Section, the Royal Society of Medicine – Promotes knowledge and understanding of hypnosis and psychosomatic medicine, through continuous professional development activities (www.rsm.ac.uk/sections/hypnosis-and-psychosomatic-medicine-section).

For patients

• • Hypnosis and Hypnotherapy – Online leaflet from the Royal College of Psychiatrists (www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/hypnosis-and-hypnotherapy).