K. Hypnosis

OBJECTIVE

A therapeutic intervention that may be an effective adjunctive procedure in the treatment of PTSD.

BACKGROUND

Hypnosis is not a therapy per se, but an adjunct to psychodynamic, cognitive-behavioral, or other therapies, and has been shown to enhance significantly their efficacy for a variety of clinical conditions (Kirsch et al., 1998; Spiegel & Spiegel, 1987). In the specific context of posttraumatic symptomatology, hypnotic techniques have been used for the psychological treatment of shell shock, battle fatigue, traumatic neuroses, and more recently, PTSD, and dissociative symptomatology.

Hypnosis is defined by the APA as “a procedure during which a health professional or researcher suggests that a client, patient, or subject experience changes in sensations, perceptions, thought, or behavior. The hypnotic context is generally established by an induction procedure (Kirsch, 1994). An induction procedure typically entails instructions to disregard extraneous concerns and focus on the experiences and behaviors that the therapist suggests or that may arise spontaneously.

Hypnosis should only be used by redentialed health care professionals, who are properly trained in the clinical use of hypnosis and are working within the areas of their professional expertise.

DISCUSSION

Most of the case studies that reported that hypnosis was useful in treating posttrauma disturbances following a variety of traumas lack methodological rigor, and therefore strong conclusions about the efficacy of hypnosis to treat PTSD cannot be drawn (Rothbaum, 2001).

Brom and colleagues (1989), in a RCT, showed that hypnosis and desentization significantly decreased intrusion, whereas psychodynamic therapy was useful for reducing avoidance symptoms in patients with various types of posttraumatic symptomatology. A recent meta-analysis of controlled clinical trials (Sherman, 1998) compared the effects of the Brom et al. trial and those of other controlled studies and found that the major advantage of using hypnosis may come at follow-up rather than at the end of treatment; this is consistent with meta-analyses of hypnosis for conditions other than PTSD (Kirsch et al., 1999).

Various meta-analyses of studies on the treatment of anxiety, pain, and other conditions imply that hypnosis can substantially enhance the effectiveness of psychodynamic and CBTs (Kirsch, 1996; Kirsch et al., 1999; Smith et al., 1980). However, most of the literature on the use of hypnosis for PTSD is based on service and case studies.

Hypnotic techniques have been reported to be effective for symptoms often associated with PTSD such as pain (Daly & Wulff, 1987; Jiranek, 1993; Richmond et al., 1996), anxiety (Kirsch et al., 1995) and repetitive nightmares (Eichelman, 1985; Kingsbury, 1993).

There are a number of indications for using hypnosis in the treatment of PTSD (Foa et al., 2000):

1. Hypnotic techniques may be especially valuable for symptoms often associated with PTSD, such as dissociation and nightmares, for which they have been successfully used.
2. PTSD patients who manifest at least moderate hypnotizability may benefit from the addition of hypnotic techniques to their treatment.
3. Because confronting traumatic memories may be very difficult for some PTSD patients, hypnotic techniques may provide them with a means to modulate the emotional and cognitive distance from such memories as they are worked through therapeutically.

There are a number of contraindications for using traditional hypnotic techniques in the treatment of PTSD (Foa et al., 2000):

1. In the rare cases of individuals who are refractory or minimally responsive to suggestions, hypnotic techniques may not be the best choice, beause there is some evidence that hypnotizability is related to treatment outcome efficacy (Levitt, 1994; Spiegel et al., 1981 & 1993).
2. Some PTSD patients may be reluctant to undergo hypnosis, either because of religious belief or other reasons. If the resistance is not cleared after dispelling mistaken assumptions, other suggestive techniques can be tried, including emotional self-regulation therapy (ESRT), which is done with open eyes and uses sensory recall exercises rather than a hypnotic induction (Bayot et al., 1997; Kirsch et al., 1999).
3. For patients who have low blood pressure or are prone to fall asleep, hypnotic procedures such as “alert hand,” which emphasize alertness and acitivity rather than relaxation, may be substituted (Cardena et al., 1998).