All Ss were private patients referred for hypnotherapy; most were diagnosed clinically.
“…I found that there were sexual implications in 7 of the 16 miscellaneous warts in patients over 13, so I separated the cases into pre- and postpuberty to evaluate the results” (p. 4).
“An early success was with a medical student (Case 28) with whom I used suggestions of warmth, with the blood vessels dilating and bringing in antibodies, leukocytes, opsonins, etc. Changes were visible in 3 days. This biased me toward using ‘warm,’ but two of the children (Cases 6 and 9) got no result until I gave them a choice. Using ideomotor signals they chose cold. Only two healed with ‘warm,’ while five did with ‘cold.’ All of them had either had the warts cauterized or frozen previously and had a personal feeling about heat and cold. I’ve learned to give the patient a choice on the first visit” (p. 5).
“Three… were first treated using DSIH without result and later responded to hypnoanalysis. After obtaining an ideomotor signal that there was no more subconscious value to the warts, the suggestion was given that the body’s healing processes would take over without any more conscious attention by the patient. No self-hypnosis was prescribed” (pp 7-8).
Gildston, Phyllis; Gildston, Harold (1992). Hypnotherapeutic intervention for voice disorders related to recurring juvenile laryngeal papillomatosis. International Journal of Clinical and Experimental Hypnosis, 40 (2), 74-87.
Recurring juvenile laryngeal papillomatosis is resistant to cure, and thus usually requires multiple operations which may lead to the extensive proliferation of vocal fold scar tissue. Severe hoarseness, sharply lower pitch, and weak loudness levels are common sequelae. Adjunctive hypnotherapy can increase motivation for change, speed up the acquisition of vocal skills, and possibly even facilitate or sustain remission of growths in selected patients. An 8-year-old girl with severe active eruptions went into remission after 16 sessions, and a 12-year-old boy, already in remission at the beginning of the intervention period, remained free of neoplasms throughout the regimen. Whether or not hypnosis contributed significantly to the sanguine results, it is probable that, at the least, the hypnotic intervention facilitated the achievement of certain technical objectives in voice therapy.
1990
Spanos, Nicholas P.; Williams, Victoria; Gwynn, Maxwell I. (1990). Effects of hypnotic, placebo, and salicylic acid treatments on wart regression. Psychosomatic Medicine, 52, 109-114.
Subjects with warts on their hands and/or feet were randomly assigned to a hypnotic suggestion, topical salicylic acid, placebo, or no treatment control condition. Subjects in the three treated groups developed equivalent expectations of treatment success. Nevertheless, at the six-week follow-up interval only the hypnotic subjects had lost significantly more warts than the no treatment controls. Theoretical implications are discussed.
Study involved 15 females, 25 males (18-35 yrs old) with warts on at least one hand or foot, recruited through posters and newspaper ads; N = 10 in each condition. Hypnotic treatment consisted of 10 minute induction (modified from T. X. Barber’s 1969 book) and a suggestion for wart regression that was 2 minutes in duration (the skin around warts was ‘beginning to tingle and grow warm’; ‘vividly imagine the warts shrinking and dissolving away’; 30 second break; repeated the suggestions). For Ss with warts on more than one limb the complete suggestion procedure was repeated for each wart-infected limb.
Results indicate psychological factors can influence course of some virally produced disorders; that self-medicating with over-the-counter products doesn’t explain suggestion-induced wart regression; that expectation of treatment success is the most important variable in psychologically induced wart regression. “Hypnotic subjects attained significantly higher CURSS:S scores than did control subjects. Nevertheless, it is unlikely that between group differences in hypnotizability accounted for the group differences in wart regression. Two previous experiments (3) that used the CURSS found that hypnotizability failed to predict wart loss in either hypnotic suggestion, nonhypnotic suggestion, or placebo treatments, and even in the present study the hypnotic treatment failed to differ from either the real or placebo treatment on CURSS:S scores, and none of the treatments differed significantly on the CURSS:O scores. Our finding and earlier findings that hypnotic subjects reported more intense suggested sensations than placebo subjects is consistent with the hypothesis that vivid suggested imagery facilitates wart loss (7, 8) .
“An alternative hypothesis emphasizes that only our hypnotic suggestion treatment encouraged subjects to see themselves as developing cognitive control over their own wart regression. This hypothesis suggests that subjects’ subjective sense of cognitive involvement in and control over treatment outcome (as opposed to the vividness of their suggested imagery) may have been the important psychological factor in wart regression. It would be of interest in a future study to manipulate subjects’ sense of cognitive involvement in their treatment independently of suggested imagery in order to assess the relative contributions of these variables to wart regression” (pp. 113-114).
1989
Reid, S. (1989). Recalcitrant warts: Case report. British Journal of Experimental and Clinical Hypnosis, 6, 187-189.
NOTES
Recalcitrant warts which persisted for 5 years despite treatment cleared in 51 days with hypnotherapy. A cause/effect relationship between hypnotherapy and resolution was shown by at first excluding and then including the left hand from the suggestions given.
1988
Noll, Robert B. (1988). Hypnotherapy of a child with warts. Journal of Developmental and Behavioral Pediatrics, 9 (2), 89-91.
Child with 82 warts was treated using hypnosis; suggestions for removal from face only resulted in 8 of 16 facial warts disappearing after one treatment and two weeks. (Child had previous experience with hypnosis for pain and anxiety associated with lumbar punctures and bone marrow aspirates.)
Spanos, Nicholas P.; Stenstrom, Robert J.; Johnston, Joseph C. (1988). Hypnosis, placebo, and suggestion in the treatment of warts. Psychosomatic Medicine, 50, 245-260.
Two experiments assessed the effects of psychological variables on wart regression. In Experiment 1, subjects given hypnotic suggestion exhibited more wart regression than those given either a placebo treatment or no treatment. In Experiment 2, hypnotic and nonhypnotic subjects given the same suggestions were equally likely to exhibit wart regression and more likely to show this effect than no treatment controls. In both experiments, treated subjects who lost warts reported more vivid suggested imagery than treated subjects who did not lose warts. However, hypnotizability and attribute measures of imagery propensity were unrelated to wart loss. Subjects given the suggestion that they would lose warts on only one side of the body did not show evidence of a side-specific treatment effect.
1984
Gould, Sol S.; Tissler, Doreen M. (1984). The use of hypnosis in the treatment of herpes simplex II. American Journal of Clinical Hypnosis, 26, 171-174.
Hypnosis training was used to treat the painful lesions and emotional symptoms associated with Herpes Simplex II in two females, ages 32 and 26. Three weekly sessions of hypnosis and daily practice sessions were initiated in the first case. During this time, the patient experienced a decline in the subjective level of pain and severity of the lesions, as well as an elevation in mood level. On three-month followup, she reported no pain or skin eruptions and significantly less feelings of stress and anxiety. The second case utilized two sessions of hypnosis and daily practice sessions, and similar results were obtained. A traumatic event caused a relapse in the latter patient, but she was again able to use hypnosis to bring the virus back under control and to experience an elevation in mood level as well. A seven-month follow-up indicated no eruptions and an improvement in self-esteem.
In the first case the tape included ego-strengthening suggestions (Hartland, 1971); another tape used the patient’s fantasy of water and snow skiing. The patient felt that hypnosis helped her acquire a more positive attitude toward herself and relief of guilt and blame, as well as an improved ability to cope with the unpleasant sensations.
In treatment session, ego strengthening suggestions were followed by 2 minutes of quiet for integration of suggestions, then visualization used in cancer therapy (Simonton): suggestions of a strong cell structure, perfect skin, hormonal balance, cleanliness, and a cooling refreshed feeling in the area of the vagina and perineum; imagery of internally controlled friendly white sharks was used to “devour” the virus; of water and snow skiing, imagery of cool breezes, white refreshing snow, clean fresh water; visualized herself forgiving and releasing her previous boyfriend of guilt, thereby allowing her anger to abate.
For second patient it was similar, plus visualization of being bathed in white lights and traveling through concentric circles radiating peace and protection, being purified as she traveled through the circles until she emerged as flawless as a diamond, reflecting only clarity and light. Both patients scored 4 on Spiegel’s Hypnotic Induction Profile (HIP).
Witchcraft & Voodoo
1994
Mulhern, Sherrill (1994). Satanism, ritual abuse, and multiple personality disorder: A sociohistorical perspective. International Journal of Clinical and Experimental Hypnosis, 42 (4), 265-288.
During the past decade in North America, a growing number of mental health professionals have reported that between 25% and 50% of their patients in treatment for multiple personality disorder (MPD) have recovered early childhood traumatic memories of ritual torture, incestuous rape, sexual debauchery, sacrificial murder, infanticide, and cannibalism perpetrated by members of clandestine satanic cults. Although hundreds of local and federal police investigations have failed to corroborate patients’ therapeutically constructed accounts, because the satanic etiology of MPD is logically coherent with the neodissociative, traumatic theory of psychopathology, conspiracy theory has emerged as the nucleus of a consistent pattern of contemporary clinical interpretation. Resolutely logical and thoroughly operational, ultrascientific psychodemonology remains paradoxically oblivious to its own irrational premises. When the hermetic logic of conspiracy theory is stripped away by historical and socio/psychological analysis, however, the hypothetical perpetrators of satanic ritual abuse simply disappear, leaving in their wake the very real human suffering of all those who have been caught up in the social delusion.
Spanos, Nicholas P.; Burgess, Cheryl A.; Burgess, Melissa Faith (1994). Past-life identities, UFO abductions, and satanic ritual abuse: The social construction of memories. International Journal of Clinical and Experimental Hypnosis, 42 (4), 433-446.
People sometimes fantasize entire complex scenarios and later define these experiences as memories of actual events rather than as imaginings. This article examines research associated with three such phenomena: past-life experiences, UFO alien contact and abduction, and memory reports of childhood ritual satanic abuse. In each case, elicitation of the fantasy events is frequently associated with hypnotic procedures and structured interviews which provide strong and repeated demands for the requisite experiences, and which then legitimate the experiences as “real memories.” Research associated with these phenomena supports the hypothesis that recall is reconstructive and organized in terms of current expectations and beliefs.
1992
Morse, Donald R.; Martin, John; Moshonov, Joshua (1992). Stress induced sudden cardiac death: Can it be prevented?. Stress Medicine, 8, 35-46.
Previously, psychosomatically induced death relative to stress, hypnosis, mind control, and voodoo was discussed. In this article, emphasis is on one aspect of that – stress induced sudden cardiac death (SCD). A brief review is presented of the sympathetic aspects of the acute stress response and stress induced SCD. Findings from previous studies are presented to highlight sympathetic aspects of the acute stress response. This is followed by a presentation of various strategies to prevent of decrease the possibilities for stress induced SCD. These include long-term measures (e.g. diet control, smoking control, hypertension control, stress management strategies) and immediate measures (e.g. calm, controlled approach, elicitation of the relaxation response, selected use of drugs, and heart rate variability monitoring). Relative to prevention strategies, findings are presented both from previous studies and new investigations.
1991
Morse, Donald R.; Martin, John; Moshonov, Joshua (1991). Psychosomatically induced death: Relative to stress, hypnosis, mind control, and voodoo: Review and possible mechanisms. Stress Medicine, 7, 213-232.
A common denominator in psychosomatically induced death is stress. Death can occur slowly, as from the preponderance of chronic stressor, or it can come on suddenly, as from an acute stressor. Sudden death is more likely in an individual with preexistent serious medical conditions, which were outlined. Seven types of individuals more prone to sudden death were outlined. Most cases of sudden death are related to the presence of a severely stressful situation in which there appears to be no means of control or escape. With mind control, hypnosis, and voodoo curses, circumstances can be manipulated to achieve severe stress and uncontrollability.
1984
Suryani, L. K. (1984). Culture and mental disorder: The case of bebainan in Bali. In Culture, medicine and psychiatry. D. Reidel Publishing Company.
NOTES
Bebainan is a form of dissociation which is culturally associated with Bali. Thought to be caused by sorcery, a bebainan attack lasts up to an hour and is manifested by confusion, crying, screaming, and shouting, with inability to control one’s actions. However, it seems most victims maintain awareness of their own behavior and are not amnesic for it afterwards.
In this study, the author interviewed 27 people, mostly female, most of whom experienced their first attack between 16-30 years of age. The author concluded that the attacks permitted release of feelings of frustration and anger without stigma. Author concluded it is not a form of psychosis, is not organic, and is not a neurosis
1979
Spanos, Nicholas P.; Gottlieb, Jack (1979). Demonic possession, Mesmerism, and hysteria: A social psychological perspective on their historical interrelations. Journal of Abnormal Psychology, 88 (5), 527-546.
Provides a social psychological interpretation of the interrelations among demonic possession, mesmerism, and hysteria. It is argued that the reciprocal role relationship of mesmerist and magnetized S in the 18th and 19th centuries involved the secularization of the role relation that had existed between exorcist and demonically possessed. The commonalities between these 2 sets of social roles are delineated, some of the variables leading an individual to learn and enact the posessed role are outlined, and several lines of historical evidence pertaining to the influence of the exorcist-demoniac relationship on the mesmeric relationship are outlined. The influence of the possessed role in shaping the role of the hysterical patient is also discussed. The use of hysteria as a modern explanatory concept in histories of possession and mesmerism, however, is criticized. (198 ref).
1977
Brown, Daniel P.; Fromm, Erika (1977). Selected bibliography of readings in altered states of consciousness (ASC) in normal individuals. International Journal of Clinical and Experimental Hypnosis, 25, 388-391.
The bibliography is divided into the following sections:
I. General Works
II. Reference material on personality in relation to altered states
III. Social and cultural determinants of altered states
IV. Cognition, information-processing, and ego-functioning
V. Methodology in the study of altered states
VI. Differentiation of hyperaroused states
VII. Shamanistic states
VIII.Possession-trance
IX. Psychedelic states
X. The meditative states
XI. Personality differences and meditation
XII. Affective and cognitive change in meditation
XIII.Ordinary Buddhist meditation, concentration, and insight meditation
XIV. The variety of Buddhist meditation traditions
1966
Devereux, G. (1966). Cultural factors in hypnosis and suggestion: An examination of some primitive data. International Journal of Clinical and Experimental Hypnosis, 14, 273-291. (Abstracted in American Journal of Clinical Hypnosis, 1967, 4, 294)
SOCIOCULTURAL FACTORS, USUALLY RELATED TO SUPERNATURALISTIC ATTITUDES AND PRACTICES, GREATLY ENHANCE THE HYPNOTIZABILITY OF THE PRIMITIVE BY INCREASING THE PRESTIGE (“POWER”) OF THE HYPNOTIST, WHO IS USUALLY A MAGICIAN. AN ANALYSIS OF PRIMITIVE CULTURAL DATA MAY SHED NEW LIGHT UPON PSYCHOLOGICAL PHENOMENA IN OUR OWN SOCIETY. (SPANISH + FRENCH SUMMARIES) (27 REF.) (PsycINFO Database Record (c) 2002 APA, all rights reserved)
1961
Bowers, Margaretta K. (1961). Hypnotic aspects of Haitian voodoo. International Journal of Clinical and Experimental Hypnosis, 9, 269-282.
The voodoo ritual is analyzed within the framework of hypnosis and hypnotically induced secondary personalities. The author contends that “If the hypnotic nature of voodoo and similar religious rites were better understood the problem of discarding the evil and nurturing the good in the cultural life of people would be facilitated.” From Psyc Abstracts 36:04:4II69B. (PsycINFO Database Record (c) 2002 APA, all rights reserved).
41 THE STATUS OF HYPNOSIS AS AN EMPIRICALLY VALIDATED CLINICAL INTERVENTION: A Preamble to the Special Issue MICHAEL R. NASH Editor, The International Journal of Clinical and Experimental Hypnosis Abstract: In his introductory remarks to this Journal’s special issue on the status of hypnosis as an empirically supported clinical intervention, the editor briefly describes the dawn of clinical hypnosis research, the logic of the natural science model, the importance of an inspired but tough-minded clinical science, and the auspicious confluence of practice and research purpose in this enterprise. The progenitor of this effort was indeed the Report of the Royal Commission co-authored by Benjamin Franklin and Antoine Lavoisier, among others, more than 215 years ago-a report noted as one of the most important documents in the history of human reason. The ethos and logic of this special issue is grounded on the legacy of that document. Eschewing the conflicting mental health agendas of managed-care, government, patient rights, and professional guild interests, this special issue seeks to present a frank, even-handed, informed, and dispassionate assessment of what science knows and does not know about clinical hypnosis. More than 215 years ago, in a report cited as one of the key documents in the history of human reason (Could, 1991), Benjamin Franklin, Antoine Lavoisier, and others reviewed the claims of Mesmerism, described 18 experiments to test those claims, and crafted an assessment of whether patients actually benefited from such interventions (Franklin, Majault, Le Roy, Sallin, Bailly, D’Arcet, De Borie, Guillotin, & Lavoisier, 1785). Their report (usually referred to as the Report of the Royal Commission) is a masterpiece, not just because it anticipated the core methodologies of clinical science but because it challenged the tyranny of anecdote, which reigned supreme in 18th century culture. Today, the ethos of clinical science, indeed the guiding principle of the medical and psychological professions, is that our interventions and theories derive from systematic, inspired, and tough-minded observation (i.e., the evidence) about what does and does not work: when, for whom, and under what circumstances. There are those within medicine, psychology, and hypnosis who still dismiss the importance of research, relying instead on cherished beliefs, revered authority, or dramatic, unsubstantiated anecdotes. In neglecting to systematically test efficacy, they follow a path that at best leads to misunderstanding and at worst perpetuates human suffering. For if science does nothing else, it tells us what works. The logic is that the more we understand about what works, the better our patients are served, and the more likely it is that we might develop even more effective interventions in service of reducing human misery. Thankfully, for more than 100 years, there has been a robust and prolific recognition within the hypnosis community that our stem progenitors on the Royal Commission had gotten it right. That is, they had set the bar appropriately high: If it is to be said that hypnosis works, then this must be demonstrated with evidence that is replicable and seamlessly married to current understandings of medical and cognitive science. With research tools in hand, clinical investigators early on embarked on a process of discerning fact from exaggerated claim at a sometimes withering pace, especially in 42 the past 50 years. As a result, the study of hypnotic phenomena is now squarely in the domain of normal cognitive and clinical science, with empirical work published in such journals as Science, Procedures of the National Academy of Sciences, Lancet, and the Journal of the American Medical Association. Indeed, hypnosis may be one of the most thoroughly researched forms of psychotherapeutic intervention, with more than 7,000 publications since 1966, in more than 150 different general medicine, psychological, and interdisciplinary journals (Nash, Minton, & Baldridge, 1988). No contemporary therapeutic intervention has a longer history of empirical examination, and very few psychotherapy literatures can match the sheer bulk of research. This special issue seeks to harvest that literature. Two years ago, I commissioned Drs. Steven Lynn and Irving Kirsch to solicit and review a series of articles that would comprehensively, systematically, and frankly address the entire clinical efficacy literature on hypnotic intervention and to employ the very highest standards of design and inference. This was a formidable task, one that I know monopolized the senior editor’s professional life over the past two years. The product meets and exceeds my expectations. Six articles catalogue and critique the research literatures on clinical hypnosis with children, hypnotic analgesia, hypnosis as an adjunct to cognitive-behavioural therapy, hypnosis in medicine, hypnosis and smoking cessation, and hypnosis in the treatment of post-traumatic disorders. A seventh article, not originally planned and authored by Drs. Steven Lynn, Irving Kirsch, Arreed Barabasz, Etzel Cardena, and David Patterson, summarizes the findings across articles and sketches a blueprint for what research work is needed and how it might best be done. The articles’ authors operate from diverse theoretical perspectives (e.g., physiological, cognitive-behavioural psychoanalytic, and behavioural). However, all adhere to the notion that, in the final analysis, the field and our patients are best served by examining the evidence carefully, thoughtfully, and dispassionately. The yardstick chosen to assess efficacy was adopted from an influential set of guidelines developed by the American Psychological Association (Chambless & Hollon, 1998). These guidelines are described in each of the six content articles as well as in the summary article. The advantage of adopting these general guidelines for this report is that it enables us to compare hypnosis’ empirical record of efficacy with that of other therapeutic interventions. However, there are two disadvantages. First, because they are methodological guidelines for testing general therapeutic models (e.g., cognitive-behavioural therapy, short-term psychodynamic therapy), the Chambless and Hollon yardstick offers less guidance when clinical hypnosis researchers seek not to validate an all-encompassing therapeutic model but to determine if hypnosis adds benefit when incorporated into standard treatment protocols (i.e., when used adjunctly). This is not a problem when the researcher seeks to determine if a more-or-less pure form of hypnotic intervention is effective in symptom reduction (e.g., with warts or asthma), but it is a problem when the researcher seeks to test if hypnosis confers extra benefit when integrated with more general treatment approaches, such as cognitive-behavioural therapy or psychodynamic therapy. Second, the Chambless guidelines are not universally accepted nor are they the final word on judging merit. For instance, they were not employed by the National Institutes of Health when it reported hypnosis to be effective in managing pain and symptoms associated with some physiological disorders (National Institutes of Health technology assessment panel, 1996). Indeed, these guidelines are somewhat arbitrary, continuously evolving, and not well suited for some types of clinical inquiry. Still, imperfect as they are, there is wisdom 43 in their operational definitions of methodological merit. Though there are no longer Royal Commissions to assess efficacy, there are governmental, pharmacological, managed-care, and professional guild interests, which have a variety of axes to grind on matters pertaining to efficacy in mental health treatment. Nevertheless, this special issue strives to insulate itself from the partisan acrimony. We seek instead to craft a frank, even-handed, informed, and dispassionate assessment of what we know and what we do not know about clinical hypnosis. In so doing, the journal embraces the notion that it is scientifically grounded evidence that informs social policy decisions, not the other way around. Finally, in providing this comprehensive and authoritative assessment of clinical hypnosis, we bring together the two abiding traditions of the hypnosis community: research and practice. Though sometimes the relationship between these two traditions has been bumpy, this special issue is ample testimony to the fact that we do work productively together. Indeed, the summary article articulates an agenda for future work that clearly requires a closer marriage of clinical experience and thoughtful research design and outlines how fulltime practitioners can participate in this enterprise. Interestingly, 30 years ago, Ernest Hilgard predicted that, as knowledge about hypnosis became more widespread in the scientific community, there would be a process of domestication, with researchers using it more and more as a routine tool to study other topics of interest (e.g, hallucination, pain, memory). Thus grounded in normal science, clinical use of hypnosis for some patients with some problems will simply become a matter of routine. I believe that this special issue documents that, to a degree, Hilgard’s prediction has been realized. There is an array of hypnotic interventions for which there is substantial evidence of efficacy. Still, there are many applications of hypnosis that cannot at this time fully claim empirical support. This is not to say that these particular applications may not have important merits. Rather, it is to say that, at this point in time, these specific interventions should be offered as potentially useful applications that possess only limited and tentative support (Bryant, in press). However, it is clear now that the tyranny of anecdote has been superseded by systematic observation. I like to think that Ben Franklin and Antoine Lavoisier would smile approvingly at this outcome, which is so fully convergent with their notion of science as disciplined wonderment. REFERENCES Bryant. R. A. (in press). Review of “Clinical hypnosis and self-regulation: Cognitive-behavioural perspectives.” International Journal of Clinical and Experimental Hypnosis. Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of Consulting and Clinical Psychology, 66, 7-18. Could, S. J. (1991). Bully for brontosaurus: Reflections in natural history. New York: W. W Norton. Franklin, B., Majault, Le Roy, Sallin, Bailly, D’Arcet, De Borie, Guillotin, & Lavoisier, A. (1785). Report of Dr. Benjamin Franklin and the other commissioners charged by the King of France with the examination of the animal magnetism as now practiced at Paris (W. Godwin, Trans.). London: St. Paul’s Church Yard. Nash, M. R., Minton, A., & Baldridge, J. (1988). Twenty years of scientific hypnosis in dentistry, medicine, and psychology. International Journal of Clinical and Experimental Hypnosis, 36,198-205. National Institutes of Health technology assessment panel on integration of behavioural and relaxation approaches into the treatment of chronic pain and insomnia. (1996). Journal of the American Medical Association, 276, 313-318. 44 CLINICAL HYPNOSIS WITH CHILDREN: First Steps Toward Empirical Support’ LEONARD S, MILLING AND CHRISTINE A. COSTANTINO* University of Connecticut, Storrs The authors would like to express their gratitude to Sylvia Czyz for her instrumental assistance in the completion of this project. *Address correspondence to Leonard S. Milling, Ph.D., Department of Psychology (U1020), University of Connecticut, 406 Babbidge Road, Storrs, CT 06269-1020. In this paper, we use the generic terms children and youngsters interchangeably to represent child and adolescent age groups. The International Journal of Clinical and Experimental Hypnosis, Vol. 48, No. 2, April 2000 113-137 (c) 2000 The International Journal of Clinical and Experimental Hypnosis. Abstract: A review of controlled studies on the efficacy of clinical hypnosis with children reveals promising findings, particularly for reduction of acute pain, chemotherapy-related distress, and enuresis. However, no child hypnosis interventions currently qualify as “efficacious” according to criteria for empirically supported therapies (EST). A major limitation of the existing literature relative to EST guidelines is the lack of treatment specification via a manual or its equivalent. Is clinical hypnosis as effective in treating children and adolescents as it has been shown to be with adults? Consider that children are thought to be more hypnotically suggestible than adults are. Normative studies have found that suggestibility steadily increases from as early as the age of 3, peaks between the ages of 8 and 12, declines somewhat through the age of 16, and thereafter remains relatively fixed throughout much of adulthood (London, 1965; Morgan & Hilgard, 1978/1979). Indeed, on equivalent standardized measures of hypnotic suggestibility, children are more likely to pass almost every one of the same set of items than adults (London, 1962). In view of these striking developmental variations in suggestibility, an abundant empirical literature indicating the utility of hypnosis for a wide range of adult problems would seem to argue that clinical hypnosis should be equally, if not more, potent when used with children.* Certainly, interest in child hypnosis has grown over the past 40 years. For example, important edited volumes (e.g., Rhue, Lynn, & Kirsch, 1993) designed to provide an overview of major developments in the field of hypnosis have begun to address child hypnosis issues (e.g., Kohen & Olness, 1993). Also, a number of well-regarded books devoted solely to clinical applications of hypnosis with youngsters have Manuscript submitted September 5, 1999; final revision received September 7, 1999 appeared (e.g., Gardner & Olness, 1981; Hilgard & LeBaron, 1984; Olness & Kohen, 1996; Wester & O’Grady, 1991). Additionally, two standardized measures of children’s hypnotic responsiveness, the Children’s Hypnotic Susceptibility Scale (CHSS; London, 1963) and the Stanford Hypnotic Clinical Scale for Children (SHCS:C; Morgan & Hilgard, 1978/1979) have been published, along with a major revision of the latter instrument (Zeltzer & LeBaron, 1984). Finally, a wealth of published case material has provided anecdotal evidence suggesting that clinical hypnosis may be helpful for many sorts of psychological and medical problems encountered by youngsters (for an overview, see Olness & Kohen, 1996). However, the growing interest in child clinical hypnosis has not been accompanied 45 by many controlled studies of its efficacy. In a field such as child hypnosis that is in an early stage of development, uncontrolled outcome studies and case materials can play an important role in pointing towards useful avenues of investigation and methods of clinical practice. Ultimately, however, controlled outcome research is necessary to validate the utility of hypnosis with youngsters. The purpose of this paper is to describe and appraise existing controlled studies of the efficacy of clinical hypnosis with children. More specifically, one focus of our review is to summarize the findings of controlled outcome studies of child clinical hypnosis. A second focus is to assess the methodological strengths and weaknesses of this small literature. A third focus involves evaluating child clinical hypnosis outcome studies against criteria advanced by Chambless and Hollon (1998) for empirically supported therapies (ESTs). With regard to this third focus, the American Psychological Association (APA) Division 12 Task Force on Promotion and Dissemination of Psychological Procedures developed a framework for identifying psychological treatments that are efficacious for particular populations or problems (Chambless et al., 1996; Task Force, 1995) that was later refined by Chambless and Hollon (1998). According to the refined framework, studies of a specific psychological treatment presumed to be beneficial for a particular group of patients or clients are evaluated against rigorous methodological criteria with the goal of classifying the treatment as an EST. In short, for a treatment to be considered efficacious for a particular population, it must meet certain criteria. There must be at least two between-group design experiments conducted by at least two different investigative teams demonstrating that the intervention in question is superior to a no-treatment control condition, an alternative treatment, or a placebo; or that the treatment is equivalent to a previously established efficacious treatment. To be designated possibly efficacious for a particular population, there need be only one between-group design study of a treatment that meets these criteria. Finally, to be considered efficacious and specific, a treatment must be shown by two different teams to be superior to a placebo or to a treatment of previously established efficacy in studies that control for non-specific processes. (A series of single-ease design experiments can be substituted for between-group design studies.) To ensure valid treatment implementation, studies must utilize treatment manuals, except where the treatment is simple and adequately described in the journal article. Furthermore, studies must clearly define the characteristics of the client sample for which the treatment was provided. Finally, studies likely to succeed in the evaluation process are those that adhere to generally accepted methods of sound research, including random assignment to treatment condition, adequate statistical power and appropriate statistical analyses, as well as utilization of valid and relevant outcome measures. (See Chambless & Hollon, 1998, for a cogent discussion of these issues as they pertain to the evaluation process.) In our review, the literature on clinical hypnosis with children will be assessed from the vantage point of these criteria for designating treatments as possibly efficacious, efficacious, and efficacious and specific. To be included in our review, studies were required to utilize a between-subjects design in which a hypnotic intervention was compared against at least one alternative hypnotic or nonhypnotic intervention and/ or a placebo, attention, or no-treatment control condition. Furthermore, all participants were required to be no older than 18 years of age. An exhaustive computer search of the PsychLit database from 1974 to the present and the MEDLINE database from 1984 to the present as well as examination of related reviews in this area, produced 15 child clinical hypnosis outcome studies satisfying these criteria. Table 1 summarizes the 46 major characteristics of these studies, including presenting problems, age range of participants, types of interventions, and treatment outcomes. The studies can be grouped into five content areas: (a) learning problems, (b) basic physiological processes, (c) general medical problems, (d) nausea and emesis from chemotherapy, and (e) acute pain. Children’s Learning Problems Test anxiety. A relatively substantial literature has accumulated on treating test anxiety in children with cognitive-behavioral and behavioural procedures (cf. S. B. Johnson, 1979; Strumpf & Fodor, 1993). Stanton (1994) studied self-hypnosis as an intervention for this problem. Participants were 40 boys and girls, aged 12 to 15 and from a standard middleclass high school, who had scored in the upper third on a questionnaire measure of test anxiety. Pairs of subjects, matched for sex and test anxiety scores, were assigned either to self-hypnosis or education control conditions. A self-hypnosis group underwent two 50-minute training sessions in which breathing as well as imagery emphasizing relaxation, mastery, and self-efficacy were presented. An education control group participated in two 50- minute sessions in which ways of reducing test anxiety were discussed. Compared with controls, the selfhypnosis group achieved significantly greater reductions on the questionnaire measure of test anxiety at post-treatment and at a 6-month follow-up. No information regarding the effect of the training program on other indicators of test anxiety (e.g., behavioural observations) or actual test performance was available. The findings are intriguing in that they suggest that self-hypnosis may hold promise for treating children’s test anxiety. Further study of self-hypnosis for test anxiety would seem warranted, perhaps comparing it against established behavioural inter~ ventions for this problem. Learning disabilities. Clinicians have reported some success using hypnosis to enhance the academic performance of children suffering from learning disabilities (Crasilneck & Hall, 1985; Illovsky, 1963; Krippner, 1966). L. S. Johnson, Johnson, Olson, and Newman (1981) investigated the effect of group and self-hypnosis on the self-esteem and academic performance of learning-disabled children. Thirty-three learning-disabled boys and girls ranging in age from 7 to 13 years (plus their parents and teachers) served as subjects. Children in the treatment condition participated in three group-hypnosis training sessions where they listened to suggestions for imagery emphasizing improved academic performance and enhanced self-esteem. Instruction in self-hypnosis was introduced to enable youngsters to experience similar imagery on their own. Furthermore, parents and teachers took part in three sessions in which imagery for improvements in the child’s school performance and self-concept were presented. Youngsters in the control condition received standard learning disability instruction. Results indicated no significant differences between groups in gains on measures of academic achievement or self-esteem. However, it does not seem unreasonable to suspect that the motivational and affective components of learning might be facilitated through hypnosis. Thus, further controlled research on this topic would probably be of value. Basic Physiological Processes Temperature regulation. Thermal biofeedback involves the use of monitoring equipment to train subjects to warm a peripheral body part, typically the hands, which produces feelings of relaxation and calm. This type of biofeedback somehow enables subjects to learn to direct blood toward their skin by dilating the vessels in the skin of their hands. Warming biofeedback has been successfully employed to 47 treat a number of disorders, including migraine headache and Raynaud’s disease (Lehrer, Carr, Sargunaraj, & Woolfolk, 1994). Likewise, there is some evidence hypnosis can successfully treat these disorders in adults (Andreychuk & Skriver, 1975; Barabasz & Wright, 1975). To test the potential of these interventions for children, Dikel and Olness (1980) compared the temperature changes produced by biofeedback against those obtained through self-hypnosis and through a combination of self-hypnosis and biofeedback. Forty-eight boys and girls, aged 5 to 15, who had previously been trained to use self-hypnosis, were assigned to self-hypnosis-only and biofeedback plus self-hypnosis conditions. Children assigned to the biofeedback only group were randomly selected school children who had never been taught selfhypnosis. The experiment began with baseline recordings of finger temperature. Thereafter, subjects in the self-hypnosis and self-hypnosis plus biofeedback groups listened to a 10-minute relaxation tape containing pleasant imagery, such as the child’s favourite animals and activities. During post-treatment recordings of skin temperature, subjects in the hypnosis and hypnosis plus biofeedback conditions were asked to imagine that their hands were becoming warmer or cooler. Subjects in the hypnosis plus biofeedback and the biofeedback-only conditions were provided with audio feedback about changes in finger temperature. All three groups were able to produce significant changes in skin temperature, but there were no significant differences among the groups in amount of warming or cooling. These findings are interesting, because they raise the possibility that simple imagery for temperature change can produce an effect similar to that of biofeedback in children. Immune functioning. The field of psychoneuroimmunology is concerned with relationships between function of the immune system, changes in health status, and psychological variables. Studies have shown that stress can lead to weakening of the immune system (Jemmott et al., 1983; Jemmott & Magloire, 1988). Thus, interventions that reduce the effects of stress should contribute to more resilient immune functioning. A few investigations have found that hypnosis can affect immune functioning in adults (e.g., Barber, 1978). A logical extension of such research was undertaken by Olness, Culbert, and Uden (1980), who studied whether hypnosis could influence the immune systems of children. Fifty-seven healthy youngsters, aged 6 to 12, were assigned to one of three experimental conditions. A self-hypnosis group listened to an audiotape containing instructions for relaxation and pleasant imagery. A self-hypnosis and suggestion group heard a similar audiotape that also contained specific instructions to increase the number of immune proteins in the saliva. Children in an attention control group were engaged in conversation for the same amount of time that the treatment groups listened to audiotapes. Saliva samples were obtained on two occasions before and once after intervention and were assayed for concentrations of salivary immunoglobulins lgA and IgG. There were no significant pre- to post-intervention differences among the three experimental groups on IgG levels. On the other hand, the relaxation plus suggestion group (but not the other two groups) showed a significant increase from Time 2 to Time 3 for lgA levels. lgA is an antibody that protects the upper respiratory tract from infection and plays a role in fighting dental cavities. The authors interpreted their findings to mean that changes in salivary IgA concentrations may be affected by self-hypnosis with specific suggestions for increasing immune substances. The results are fascinating but do not necessarily mean that the specific suggestions directly caused an increase in lgA. Rather, children may have found the specific suggestions more involving in the context of this experiment, thereby causing more 48 Study Nature of Problem Age Treatment Conditions Dependent Variables Results Learning Problems Stanton (1994) Test Anxiety 12-15 SH – Self-Hypnosis C – Control (Discussion Session) Test anxiety questionnaire: At time of study 6 mo. later SH > C SH > C Johnson, Johnson, Olson & Newman (1981) Academic Performance & Self-Esteem of Learning Disabled Children 7-13 SH – Self-hypnosis + Hypnosis C – Control Achievement tests Self-Esteem: Parent Report Child Report SH = C SH = C SH = C Physiological Processes Dikel & Olness (1980) Peripheral Temperature Control 5-15 SH – Self-Hypnosis only SH&B – Self-hypnosis & Biofeedback B – Biofeedback only Skin temperature changes SH = SH&B = B Olness, Culbert, & Uden (1989) Self-control of Salivary Immunoglobulin 6-12 SH – Self-hypnosis SS – Self-hypnosis w/ Specific Suggestions AC – Attention Control Immuno. Concentrations: Salivary IgA Salivary IgG SS > SH = AC SS = SH = AC General Medical Problems Belsky & Khanna (1994) Cystic Fibrosis 7-18 SH – Self-hypnosis C – Control Lung Function Locus of Control Health Locus of Control Self-concept Trait Anxiety State Anxiety SH > C SH > C SH > C SH > C SH > C SH = C Edwards & van der Spuy (1985) Nocturnal Enuresis 8-13 TS – Trance with Suggestions Dry Nights per Week: at 6 wks. TS = S > T = C TABLE 1 : Characteristics of Studies of Clinical Hypnosis with Children 49 Study Nature of Problem Age Treatment Conditions Dependent Variables Results Banerjee, Srivastav, & Palan (1993) Nocturnal Enuresis 5-16 T – Trance alone S – Suggestions alone C – Control H – Hypnosis I – Imipramine At 6 mos. Dry Nights: At 3 mos. At 9 mos. TS = T = S > C H = I H > I Chemotherapy Distress Zeltzer, Dolgin, LeBaron, & LeBaron (1991) Nausea & Emesis 5-17 H – Hypnosis (Imagination Focus) D – Distraction / Relaxation AC – Attention Control Nausea Emesis H = D > AC H > AC Zeltzer, LeBaron & Zeltzer (1984) Nausea & Emesis 6-17 H – Hypnosis (Imagination Focus) D – Distraction Nausea Emesis H = D H = D Jacknow, Tschann, Link & Boyce (1994) Nausea & Emesis 6-18 H – Hypnosis with medication p.r.n. M – Antiemetic Medication only Amount of Medication Used: First Course on Chemo. Second Course of Chemo. H > M H > M Acute Pain Zeltzer, Fanurik & LeBaron (1989) Cold Pressor Pain 6-12 H – Hypnosis (Imagination Focus) C – Control Self-reported Pain H > C Katz, Kellerman, & Ellenberg (1987) Bone Marrow Aspiration 6-12 H – Hypnosis + Self- hypnosis AC – Attention Control Self-reported Pain Self-reported Fear Observer-reported Pain Observer-reported Fear H = AC H > AC H = AC H = AC 50 Study Nature of Problem Age Treatment Conditions Dependent Variables Results Acute Pain Kuttner, Bowman, & Teasdale (1988) Bone Marrow Aspiration & Lumbar Puncture 3-10 H – Hypnosis D – Distraction C – Standard Medical Practice (control) 3-6 yr.-olds: Observer-reported Pain Observer-reported Anxiety 7-10 yr.-olds: Observer-reported Pain Observer-reported Anxiety Self-reported Pain Self-reported Anxiety H = D = C H = D = C H = D > C H = D > C H > D H > D Zeltzer & LeBaron (1982) Bone Marrow Aspiration & Lumbar Puncture 6-17 H – Hypnosis (Imagination Focus) D – Deep Breathing & Distraction Self-reported Pain Self-reported Anxiety H > D H > D Smith, Barabasz, & Barabasz (1996) Venipuncture & Bone Marrow Aspiration 3-8 H – Hypnosis D – Distraction Pain: Self-reported Parent reported Anxiety: Self-reported Parent-reported Observer-reported Distress Hh > Hl, Dl. Dh* Hh > Hi, Dl, Dh Hh > Hl, Dl, Dh Hh = Hl = Dl = Dh Hh > Dl, Dh > Hl Note. *h = suggestible, l = low suggestible. 51 relaxation, and, in turn, producing higher lgA levels. Nonetheless, the findings suggest that hypnosis may potentially benefit immune functioning in children. General Medical Problems Cystic Fibrosis. Cystic fibrosis is a genetic disorder that causes dysfunction in the exocrine system. The disorder primarily affects the lungs, producing severe respiratory distress. Belsky and Khanna (1994) examined whether selfhypnosis could enhance the pulmonary function and psychological adjustment of cystic fibrosis patients. Twelve children, aged 7 to 18 years, contacted through a local cystic fibrosis clinic, were assigned to self-hypnosis and control conditions. The self-hypnosis group participated in three training sessions where they listened to a hypnotic induction followed by imagery designed to enhance relaxation. Additional suggestions were offered in which children were asked to imagine that their lungs were clear, enabling them to breathe comfortably and to feel healthy. This intervention was taped, and subjects were encouraged to listen to the tape once a day at home. All participants completed baseline self-report measures of locus of control, health locus of control, self-esteem, anxiety, as well as peak expiratory flow rate, a measure of lung function. Immediately after training, participants in the treatment group completed the outcome measures a second time. Participants in the control group returned 4 months after the baseline assessment to take part in the post-assessment. Results showed that, compared with the control group, the treatment group achieved significantly greater improvements in lung function, as well as self-esteem, state anxiety, and health and locus of control. Despite differences between experimental and control conditions in the interval between administrations of baseline and post-assessment measures, the results are intriguing, because they raise the possibility that selfhypnosis can produce improvements in the lung function and general adjustment of paediatric cystic fibrosis patients. Enuresis. Another medical problem that has been treated with hypnosis is nocturnal enuresis, defined as urination in bed beyond the age when children should be toilet-trained. Edwards and van der Spuy (1985) evaluated the effectiveness of hypnosis for treating 24 primary (i.e., never dry) and 24 secondary enuretic boys between the ages of 8 and 13. Following a baseline period in which the number of wet nights per week was tallied, children were assigned to one of four treatment conditions provided in six standardized weekly sessions. Treatments were based on a text available from the authors. Thus, this study is notable for its inclusion of the equivalent of a treatment manual. In an induction-plus-suggestion condition, participants listened to a hypnotic induction followed by suggestions for dry nights. Children in the suggestion-without-induction condition heard the same suggestions without entering hypnosis. The induction-only group listened to a hypnotic induction without hearing suggestions for dry nights. A notreatment control condition was offered treatment following the conclusion of the experiment. Findings showed that by the end of treatment the number of wet nights per week for the induction-plus-suggestion and suggestion-only groups had significantly decreased relative to the other conditions. Furthermore, across a six-month follow-up period, all three treatments produced significantly greater reductions in wet nights than the control condition. Overall, the findings of this study indicate that suggestions for dry nights, provided in or out of the context of hypnosis, may be a useful intervention for enuresis. 52 In another study of enuresis, Banerjee, Srivastay, and Palan (1993) treated 50 nocturnally enuretic children, ranging in age from 5 to 16, with either hypnosis or imipramine, the most common drug therapy for this problem. Children in the hypnosis condition attended three sessions in which they were taught the anatomy and physiology of the bladder. Thereafter, these youngsters listened to a hypnotic induction followed by suggestions for appropriate use of the toilet during the night. Furthermore, these children were encouraged to practice self-hypnosis before going to sleep. Children assigned to the imipramine condition received 25 mg every night for the first week of treatment. Doses were increased an additional 25 mg each week as necessary to produce dry nights. The imipramine and hypnosis interventions were discontinued after 3 months. Each week, parents were interviewed to assess children’s responses to the interventions. A reduction in frequency of wet nights was classified a “positive response,” whereas no change in frequency of urination was labelled “no response.” Across the 3-month treatment period, the proportion of positive responders did not differ between the two groups. However, at a 6-month follow-up (i.e., 6 months after treatments had been discontinued), there was a significant difference between the two treatments accounted for by the substantial number of youngsters in the medication group who had relapsed without the medication. Obviously, classifying responses as positive whether a child was dry one or seven additional nights per week obscures important individual differences among children. However, the results of this study are similar to those of other investigations of enuresis treated with imipramine; initially, the medication produces a positive response followed by a high relapse rate when it is withdrawn (Blackwell & Currah, 1973). In combination, the findings of Banerjee et al. (1993) and Edwards and van der Spuy (1985) argue that hypnosis maybe an effective intervention for nocturnal enuresis and would seem to be preferable to the most commonly used medication for this problem. Future studies might usefully compare hypnosis against the enuresis alarm, Dry Bed Training, and other behavioural interventions that have been proven effective for enuresis. (For a review of treatments for enuresis, see Walker, Kenning, & Faust, 1989.) Nausea and Emesis From Chemotherapy Almost all childhood cancers are treated with chemotherapy. Unfortunately, this indispensable treatment has many unpleasant side effects, including nausea and vomiting. So aversive is chemotherapy that many youngsters rate it as worse than the cancer it is intended to cure (Zeltzer, Kellerman, Ellenberg, Dash, & Rigler, 1980). These side effects are often the reason why children become noncompliant with their chemotherapy regimens. Rates of non-compliance have been reported as high as 59% in adolescent patients (S. D. Smith, Rosen, Trueworthy, & Lowman, 1979). Hilgard and LeBaron (1984) have developed an innovative, imagination-focused form of clinical hypnosis for problems associated with paediatric cancer. The approach is derived from Hilgard’s work on imaginative involvements (Hilgard, 1979). The premise behind imagination-focused hypnosis is that if children can be helped to become highly involved in imaginative activities, they will suffer less distress undergoing unpleasant medical interventions, like chemotherapy, or invasive procedures. Imaginative activities are thought to be especially helpful because they are said to be more involving and intrinsically interesting than simple 53 distraction techniques (e.g., deep breathing or diversion of attention to external objects). To implement imagination-focused hypnosis, the child is interviewed about his or her favourite activities, games, television programs, movies, and foods, as well as family members, friends, and pets. The therapist employs this material to help the child develop a story-like fantasy that he or she is encouraged to experience in the present moment. The therapist guides the child’s production of the fantasy, attempting to heighten multisensory aspects and introduce material gathered during the interview in novel and unexpected ways. Imagination-focused hypnosis was originally developed to help reduce the aversiveness of chemotherapy and painful medical procedures but can be adapted to other problems as well (e.g., anxiety, depression). Zeltzer, Dolgin, LeBaron, and LeBaron (1991) studied the effectiveness of imagination-focused hypnosis for relieving the distress of chemotherapy. Fifty-four children, aged 5 through 17 and reporting 54 significant chemotherapy-related nausea and vomiting, were assigned to one of three experimental conditions. In the hypnosis condition, a therapist trained children in the use of imagination-focused clinical hypnosis. Later, during the next administration of chemotherapy, the therapist helped the child become involved in the imaginative fantasy developed during training. Children in the distraction condition were trained by a therapist in the use of attention diversion techniques like counting objects in the room and deep breathing. During their next chemotherapy, children were helped by their therapist to utilize these distraction techniques. Children in the attention control group met with a therapist for an equivalent amount of training and intervention time that was spent in conversation. Following treatment, children reported a significantly shorter duration of nausea in both the hypnosis and distraction/ relaxation conditions than the control condition and a significantly shorter duration of vomiting in the hypnosis condition than the control condition. Overall, the results of this study suggest the greatest relief from the side effects of chemotherapy was achieved using imagination focused hypnosis. In a similar study, Zeltzer, LeBaron, and Zeltzer (1984) tested imagination-focused hypnosis against a distraction condition (labelled supportive counselling) to alleviate chemotherapy-related distress. Nineteen patients, aged 6 to 17 years who had reported distress resulting from chemotherapy for leukaemia, lymphomas, or bone tumours, were randomly assigned to a condition. After baseline assessment, patients in the hypnosis condition were trained in imagination-focused techniques, whereas patients in the distraction condition were taught to use attention diversion (e.g., telling jokes, taking deep breaths, focusing on objects in the room). During the next chemotherapy trial, the therapist was present to help the child use the techniques he or she had been taught. Both interventions were found to produce significant reductions in nausea and vomiting, but there was no difference between the two treatments in the amount of relief obtained. Considered together, the findings of Zeltzer et al. (1984) and Zeltzer et al. (1991) would seem to suggest that both imagination-focused hypnosis and distraction might be of substantial benefit to children experiencing distress from chemotherapy. Jacknow, Tschann, Link, and Boyce (1994) compared the effectiveness of hypnosis against standard medical treatment (i.e., antiemetic medications on a p.r.n. or as-needed basis) for chemotherapy distress. Participants, 20 children between the ages of 6 and 18, newly diagnosed with cancer, and who had no previous experience with chemotherapy, were assigned to one of two groups. Those in the hypnosis condition attended two or three sessions where they learned self-hypnosis emphasizing imagination techniques (e.g., favourite Place, favourite activity), progressive muscle relaxation, and direct suggestions for emesis control (e.g.,locating the brain’s vomiting control centre and turning it off). Subjects in the control condition spent an equivalent amount of time conversing with a therapist. Control patients received a base dosage of antiemetic medication plus additional medication as needed, whereas patients in the hypnosis group received medication solely on an as-needed basis. Following intervention, episodes of nausea and vomiting were equivalent between conditions, but controls used significantly more p.r.n. antiemetic medication than did youngsters in the hypnosis group. Moreover, at 1 to 2 months after diagnosis, patients in the hypnosis group experienced significantly less anticipatory nausea than did children in the control group. This study, along with the work of Zeltzer and her colleagues, would seem to argue that hypnosis, whether delivered in a more traditional format or an innovative, imagination-oriented mode, can be of substantial 55 value to paediatric oncology patients undergoing chemotherapy. Acute Pain Experimental pain. Hypnosis has repeatedly been shown to help adults experiencing pain both in the laboratory and in clinical settings. (For a review, see Holroyd, 1996.) Research on child hypnosis for laboratory induced pain has been limited to a single investigation. Zeltzer, Fanurik, and LeBaron (1989) examined the effectiveness of hypnosis with cold pressor pain in 37 children, aged 6 to 12 years. All subjects completed two baseline pain assessment trials in which they immersed their arms in ice cold water and made pain ratings every 10 seconds for a maximum of 40 seconds. Thereafter, subjects were assigned to either a hypnosis or control group. The hypnosis condition utilized imagination-focused hypnosis in which an experimenter helped the children become involved in fantasy imagery. After 30 to 90 seconds of coaching, the child underwent two post-assessment trials while continuing to be immersed in imaginative fantasies. In the control condition, subjects received no intervention and completed post-assessment trials in a manner similar to the baseline trials. Results indicated children in the hypnosis condition experienced significantly more pain reduction than controls, thereby suggesting the value of imagination-focused hypnosis for pain induced under highly controlled laboratory conditions. Invasive medical procedures. Most studies of child hypnosis for acute pain have examined the benefits of this intervention for distress caused by invasive medical procedures. These include bone marrow aspirations (where a large-gauge syringe is inserted into the child’s hipbone and marrow is suctioned out) and lumbar punctures (where a narrow-gauge needle is inserted into the spinal column and spinal fluid is withdrawn or medication is introduced). Children typically describe these procedures, especially bone marrow aspirations, as extraordinarily painful (jay, Ozolins, Elliott, & Caldwell, 1983). Katz, Kellerman, and Ellenberg (1987) studied the effects of hypnosis on distress caused by bone marrow aspirations (BMA). Participants were 36 leukaemia boys and girls, aged 6 to 11, recruited from the haematology-oncology service of a major children’s hospital. Baseline self-report and observer ratings of pain and fear were obtained during a BMA; thereafter, children were assigned to one of two experimental conditions. Those in the hypnosis group received training in hypnosis and self-hypnosis. Accordingly, these children underwent a hypnotic induction and were given suggestions for active imagery involving the child’s interests, as well as relaxation, distraction, positive affect, pain reduction, plus a posthypnotic suggestion for practicing self-hypnosis and re-entering hypnosis during the BMA. Children in the attention-control condition participated in nondirective play sessions designed to equate the amount of time and attention received from medical staff. Training was provided in two 30-minute sessions. During the next three BMAs, the children participated in a brief 20-minute preparation session and were accompanied by their therapist during the procedure. In the hypnosis condition, therapists provided a nonverbal cue to remind children of the posthypnotic suggestion. However, therapists did not actively intervene during the BMA (e.g., make suggestions for analgesia, guide the child in an imaginative fantasy, etc.). Results indicated self-reported pain (but not observer pain) significantly decreased in both conditions. However, there was no difference between hypnosis and the attention control condition in pain or fear reduction, thereby raising the possibility that improvements were due to non-specific factors like attention and support. 56 Kuttner, Bowman, and Teasdale (1988) compared the relief produced by hypnosis during BMAs against distraction and a control condition. Forty-eight boys and girls were divided into younger (3 to 6) and older (7 to 10) age groups and were then randomly assigned to one of three conditions. In the hypnosis condition, a variety of interventions were employed, including imaginative fantasy and direct suggestions for analgesia using a “pain-switch” metaphor in which the child is told that he or she can switch off pain messages to various parts of the body. The distraction condition emphasized breathing and directing attention to external stimuli. In the two treatment groups, a therapist provided 5 to 20 minutes of preparation before the procedure, followed by active intervention with the techniques during the BMA. The control group received standard medical care for bone marrow aspirations (i.e., medical staff offered information, support, and reassurance). Older children in the hypnosis and distraction conditions achieved significantly greater reductions in observer-rated pain and anxiety compared with their counterparts in the control condition. Among younger children, those in the hypnosis condition achieved significantly greater reductions in observer-rated distress than did those in the other conditions. Self-report measures of pain and anxiety suggested neither intervention was more successful than standard medical practice. Overall, the results are somewhat contradictory but tend to suggest that the hypnosis intervention yielded the greatest amount of relief across age ranges. Zeltzer and LeBaron (1982) compared the effectiveness of imagination-focused hypnosis against distraction for relieving the distress caused by BMAs and lumbar punctures (LPs). Thirty-three oncology patients, aged 6 to 17 and suffering from leukaemia, non-Hodgkin’s lymphoma, and neural tumours, were assigned to hypnosis or distraction interventions. In the hypnosis condition, children were helped to become involved in imaginative activities that were fun, novel, or highlighted their interests. In the distraction condition, subjects were coached to use deep breathing and diversion of attention to external stimuli. It does not appear that training sessions were provided in this experiment therapist involvement seems to have been provided only during the invasive procedures. Hypnosis was found to be significantly more effective than distraction in reducing pain and anxiety encountered during BMAs. Indeed, only hypnosis significantly reduced both pain and anxiety during LPs. Once again, results suggest the superiority of imagination-focused hypnosis over distraction in reducing the self reported distress of invasive medical procedures. J. T. Smith, Barabasz, and Barabasz (1996) compared hypnosis and distraction for reducing pain and anxiety resulting from venipuncture (where a syringe is inserted into a vein), BMAs, and other invasive procedures. Twenty-seven oncology patients, aged 3 to 8, and their parents were randomly assigned to one of two balanced sequences of treatment. In the hypnosis condition, parents were taught to help their children develop a fantasy about taking a journey together to the child’s favourite place. In the distraction condition, parents were taught how to engage their children in play with a pop-up toy. Each intervention involved training sessions for the parents and practice sessions for the children. After training and practice ended, parents used the intervention with their children during a subsequent invasive procedure and then crossed over to the alternative intervention during a third procedure. Child-report, parent-report, and observational measures of pain and anxiety were collected during baseline, hypnosis, and distraction phases. For self-reported pain and anxiety, highly suggestible children in the hypnosis treatment reported significantly less pain and anxiety following intervention than highs in the 57 distraction condition and low suggestibles in both conditions. Parent reports of pain reduction followed a similar pattern. Overall, these results indicate that hypnosis may be an especially effective intervention for highly suggestible children undergoing painful medical procedures. More generally, as a group, these studies of acute pain tend to suggest that hypnosis can provide significant relief to children when a therapist is available to provide active intervention during the procedure. Methodological Considerations and EST Criteria Conclusions drawn from this small literature regarding the efficacy of child clinical hypnosis must be tempered by the methodological status of these studies. Table 2 evaluates the 15 reviewed studies against four key methodological criteria: (a) random assignment to condition, (b) treatment specification via a manual or its equivalent, (c) hypnosis condition delivered in “hypnotic” context, and (d) specification of patient characteristics. Some of these criteria are explicitly contained in the EST guidelines for evaluating studies of therapies (e.g., treatment manual, specified sample), whereas other criteria are implied or are discussed elsewhere relative to the EST evaluation process (Chambless & Hollon, 1998). A study was rated as having satisfied a criterion if it was obvious to us from the article that the standard was likely to have been met (indicated by a “Yes” in Table 2). Otherwise, we allocated a rating of “No.” Generally, random assignment to an experimental condition is considered a prerequisite in most treatment outcome research. Non-random assignment increases the likelihood that obtained differences between conditions (or lack thereof) may have been due to factors other than the treatment itself, even when non-random groups can be matched on key pre-treatment scores. Random assignment provides protection against many (but not all) threats to internal validity (Cook & Campbell, 1979). Overall, random assignment to condition was one of the strengths of this literature. However, 3 of the 15 studies reviewed failed to randomly assign participants to condition (Dikel & Olness, 1980; L. S. Johnson et al., 1981; Belsky & Khanna, 1994). In addition to random assignment, the use of treatment manuals has become an imperative in sophisticated outcome research. Indeed, to establish a therapy as empirically supported, studies are required by the EST guidelines to utilize a treatment manual, except where the treatment is simple and adequately described in the journal article. A manual increases the likelihood that the intervention will be clearly operationalised, thereby enabling clinicians and other researchers to implement the treatment in a reliable and valid manner. Only 1 of the 15 studies appears to have used the equivalent of treatment manuals (Edwards & van der Spuy, 1985). An additional four studies were judged to have employed relatively simple interventions that were well described in the journal articles (Belsky & Khanna, 1994; Dikel & Olness, 1980; L. S. Johnson et al., 1981; Olness et al., 1989). Unfortunately, some impressive studies failed to satisfy the treatment manual criterion. Consider the very important work of LeBaron, Zeltzer, and colleagues. Imagination-focused hypnosis was shown to be more effective than distraction in reducing pain from invasive medical procedures (Zeltzer & LeBaron, 1982) and more effective than a control condition in reducing nausea and vomiting caused by chemotherapy (Zeltzer et al., 1991). Clearly, imagination-focused hypnosis holds much promise as a treatment for the difficulties encountered by children with cancer. 58 However, because it is an intervention that requires much skill and decision making on the part of the therapist, a treatment manual is necessary not only to satisfy EST criteria but also to enable other investigators to adequately replicate the intervention. More generally, a failure to utilize treatment manuals throughout the child hypnosis literature would seem to pose a serious obstacle to achieving EST status. TABLE 2 : Evaluation of Outcome Studies by Key Methodological Criteria A related treatment issue evident in this literature involves the context in which hypnosis interventions were presented to child participants. Specifically, from reading some studies, we question whether patients or subjects explicitly understood that the treatments in the hypnosis condition actually involved “hypnosis.” There is general agreement among hypnosis scholars that contextual variables play at least some role in determining hypnotic responses (Kirsch & Lynn, 1995). Indeed, a growing number of studies have found that simply re-labelling a cognitive-behavioural intervention as hypnosis significantly increases its effectiveness (see Kirsch, Montgomery, & Sapirstein, 1995 for a meta-analysis). Our understanding of this literature suggests that in no more than 5 of the 15 studies were participants in the hypnosis condition explicitly led to believe that they were experiencing “hypnosis” (Banerjee et al., 1993;Edwards & van der Spuy, 1985;Jacknow et al., 1994; Katz et al., 1987; J. T. Smith et al., 1996). Failing to establish a hypnotic context may have substantially reduced the impact of treatment provided as part of a hypnosis condition. Some clinicians who adhere to a special process orientation may argue that establishing context is irrelevant, particularly because children are believed to easily shuttle between reality and fantasy. However, until it is clearly demonstrated that establishing a hypnotic context has no impact on the effectiveness of child clinical hypnosis, it may be helpful for Study Specified Sample Random Assignment Treatment Manual Treatment in Hypnotic Context Learning Problems Stanton (1994) Johnson, Johnson, Olson & Newman (1981) Basic Physiological Processes Dikel & Olness (1980) Olness, Culbert & Uden (1989) General Medical Problems Belsky & Khanna (1994) Edwards & van der Spuy (1985) Banerjee, Srivastav, & Palan (1993) Chemotherapy-Related Distress Zeltzer, Dolgin, LeBaron, & LeBaron (1991) Zeltzer, LeBaron, & Zeltzer (1984) Jacknow, Tschann, Link & Boyce (1994) Acure Pain Zeltzer, Fanurik, & LeBaron (1989) Katz, Kellerman, & Ellenberg (1987) Kuttner, Bowman & Teasdale (1989) Zeltzer & LeBaron (1982) Smith, Barabasz, & Barabasz (1996) No No No No No No No Yes Yes No No Yes No Yes Yes Yes No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes No No No No No No No No No No No No No No Yes Yes No No Yes No Yes No No Yes 59 researchers to clearly communicate to child participants that the hypnosis treatment actually involves “hypnosis.” In addition to using a manual to specify treatments, another explicit EST criterion involves defining the population for whom the treatment is intended. Accordingly, the nature of samples utilized in supporting studies must be adequately specified. All 15 of the reviewed studies indicated the age range of their samples. This information is especially important given substantial developmental variations in suggestibility. However, few studies went beyond this very basic data in describing samples. We would consider sex, socioeconomic status (SES), and ethnicity to represent the bare minimum necessary to satisfy the EST requirement. Only 6 of the 15 studies contained information on SES or ethnicity. Statistical issues go hand in glove with methodological concerns in evaluating the adequacy of a research literature. We would like to briefly comment on some statistical practices that could hinder the development of the child clinical hypnosis literature. Generally, we were impressed by the statistical sophistication evident in this literature. However, on occasion, investigators utilized simple pre- to post-treatment change scores as their metric of change and thereafter performed multiple statistical tests (e.g., multiple ‘t’ tests) to determine whether there were significant differences between experimental conditions. There are at least two problems with this approach. First, simple pre to post change scores are subject to a regression to the mean phenomenon that distorts the true change attributable to treatments. Second, by performing multiple statistical tests, alpha increases beyond .05 by a multiple of the number of tests calculated. Both problems can be easily addressed by utilizing appropriate statistical tests such as repeated measures analysis of variance or analysis of covariance. When multiple statistical tests are necessary, alpha can be controlled using a Bonferroni correction. In addition to these concerns, only 7 of 15 studies presented post-treatment means and standard deviations by experimental condition. Inclusion of such data would facilitate meta-analytic techniques. Thus, journal editors may wish to consider requiring presentation of complete descriptive data by condition and appropriate statistical analyses for publishing child hypnosis outcome studies. Current Status and Future Directions of Research on Clinical Hypnosis With Children The findings of child clinical hypnosis outcome studies and the associated methodological limitations suggest several important conclusions about the status of this literature. First, child clinical hypnosis research appears to be in a very early stage of development. There have been very few controlled investigations of clinical hypnosis with children and even fewer studies satisfying basic research prerequisites, such as random assignment to experimental condition. Second, the focus of this literature has been directed toward the use of hypnosis to relieve the distress of chemotherapy and acute pain. More than half of existing investigations address these two problems. Remarkably, despite the explosion of sophisticated child clinical treatment outcome research over the past 20 years, we could not find a single controlled study of hypnosis for children’s emotional or behavioural problems. Third, the literature on clinical hypnosis with children has not evolved to the point 60 where any child hypnosis intervention can qualify as efficacious or efficacious and specific, based on EST criteria. The standards for designating a treatment as possibly efficacious are less stringent in that only a single study (utilizing a treatment manual, specified treatment population, and valid outcome measures) must demonstrate that an intervention is superior to a no-treatment control condition, placebo, or alternative treatment. Accordingly, clinical hypnosis for nocturnally enuretic children, aged 8 to 13, as described by Edwards and van der Spuy (1985), would seem to qualify as a possibly efficacious therapy. Clearly, replication of this study by a separate investigative team would seem to be in order. Fourth, although there are many encouraging reports suggesting the efficacy of clinical hypnosis with children, one major obstacle posed to many studies is a lack of a treatment manual or an equivalent to guide treatment implementation. Without such a manual, child hypnosis outcome studies are in double jeopardy relative to the EST process. That is, a treatment manual or its equivalent is a requirement for attaining EST status of any kind. Moreover, without adequate specification, treatments cannot be replicated by independent investigative teams, thereby preventing endorsement as an efficacious therapy. Because of the requirement for a treatment manual, several impressive studies did not meet EST guidelines. For example, had LeBaron, Zeltzer, and colleagues incorporated a treatment manual into their studies, it is likely that their very promising imagination-focused hypnosis would have qualified as a possibly efficacious therapy for children experiencing nausea and vomiting from chemotherapy (Zeltzer et al., 1991), as well as pain from bone marrow aspirations and lumbar punctures (Zeltzer & LeBaron, 1982). Similarly, hypnosis for highly suggestible young children (aged 3 to 8) undergoing venipuncture and bone marrow aspirations as described by J. T. Smith et al. (1996) would probably have satisfied the criteria for a possibly efficacious therapy had a treatment manual been in place. Continued investigation of these propitious interventions using treatment manuals would be a very important contribution to the literature on clinical hypnosis with children. Indeed, more research on child clinical hypnosis is clearly desirable in many different content areas. Especially wanting are studies of clinical hypnosis for child psychopathology. In a recent review of empirically supported child and adolescent treatments, Kazdin and Weisz (1998) described several promising examples of ESTs for child psychopathology. Specifically, these scholars point towards cognitive-behavioural therapy for child anxiety (emphasizing education and exposure) and coping skills training for child depression (emphasizing modification of depressogenic cognitive styles, interpersonal skills training, and development of mood-enhancing skills) as interventions that are well supported by the empirical literature. Conceivably, hypnosis could play a valuable role as an adjunctive therapy in treatments like these for child anxiety and depression similar to the way that adding hypnosis to cognitive-behavioural treatments for a range of adult problems has been shown to enhance effectiveness (cf. Kirsch et al., 1995). Regardless of content area, future research in child clinical hypnosis could profit from increased rigor, emphasizing random assignment to condition, clearly specified samples, well-documented treatments delivered in a reliable and valid manner, with multi-channel outcome measures. Additionally, it may be useful for child hypnosis researchers to present hypnosis treatments to child participants in a context that is clearly hypnotic in order to derive maximum benefit. Also, researchers may wish to 61 eschew the uniformity myth that all forms of child hypnosis are equivalent (Kiesler, 1966). Conceptually, traditional hypnosis utilizing an induction and direct suggestions for changes in experience may have a very different appeal and impact compared with, for instance, imagination-focused hypnosis. Likewise, children may respond very differently to self-hypnosis than to hypnosis delivered by a trusted adult therapist. As for patient uniformity myths, child hypnosis researchers may wish to attend to individual differences among youngsters that could influence outcome. Most obviously, suggestibility has been a neglected variable in child hypnosis research that may be a good predictor of treatment results. Almost no studies in the existing child hypnosis literature have examined relations between suggestibility and outcome in a systematic and meaningful manner. The notable exception is J. T. Smith et al. (1996), who reported that among children undergoing painful medical procedures, greater reductions in pain and anxiety were achieved by highly suggestible youngsters treated with hypnosis than low suggestibles undergoing hypnosis and both highs and lows treated with distraction. Without question, additional research examining the link between suggestibility and treatment outcome is needed. Relatedly, given well-known developmental variations in suggestibility (London, 1965; Morgan & Hilgard, 1978/1979), researchers may wish to confine studies to limited age ranges or to include sufficient numbers of children from various age groups to permit analyses of adequate statistical power within age categories. In sum, research on clinical hypnosis with children is in an early stage of development. The child hypnosis literature is predominantly composed of anecdotal case histories and uncontrolled research studies. However, the few controlled investigations of clinical hypnosis with children suggest much promise for treating certain problems, most notably enuresis, chemotherapy-related distress, and acute pain owing to invasive medical procedures, Additional research clearly specifying treatment and patient variables will be necessary to establish child hypnosis as an EST for these and other childhood problems. 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Unpublished scale. 64 Zeltzer, L. K, LeBaron, S, & Zeltzer, P. M. (1984). The effectiveness of behavioural intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy. Journal of Clinical Oncology, 2, 683-690. A META-ANALYSIS OF HYPNOTICALLY INDUCED ANALGESIA: How Effective Is Hypnosis? GUY H. MONTGOMERY, KATHERINE N. DuHAMEL, and WILLIAM H. REDID* Mount Sinai School of Medicine, New York, New York Manuscript submitted September 5, 1999; final revision received January 7, 2000. *Address correspondence to Guy H. Montgomery, Ph.D., Assistant Professor, Cancer Prevention and Control Program, Derald H. Ruttenberg Cancer Centre, Mount Sinai School of Medicine, Box 1130, One Gustave L. Levy Place, New York, NY 10029-6574 or guy.montgomery@mssm.edu. Abstract: Over the past two decades, hypnoanalgesia has been widely studied; however, no systematic attempts have been made to determine the average size of hypnoanalgesic effects or establish the generalizability of these effects from the laboratory to the clinic. This study examines the effectiveness of hypnosis in pain management, compares studies that evaluated hypnotic pain reduction in healthy volunteers vs. those using patient samples, compares hypnoanalgesic effects and participants, hypnotic suggestibility, and determines the effectiveness of hypnotic suggestion for pain relief relative to other nonhypnotic psychological interventions. Meta-analysis of 18 studies revealed a moderate to large hypnoanalgesic effect, supporting the efficacy of hypnotic techniques for pain management. The results also indicated that hypnotic suggestion was equally effective in reducing both clinical and experimental pain. The overall results suggest broader application of hypnoanalgesic techniques with pain patients. Hypnosis has been used as a psychological technique for treatment of abroad range of disorders and illnesses. For example, it has been used in treating phobias, depression, anorexia nervosa, dissociative identity disorder, psychotic disorders, post-traumatic stress disorders, obesity, smoking, and somatization disorders (see Rhue, Lynn, & Kirsch, 1993). Even given the breadth of treatment contexts, hypnosis is perhaps best known as a pain management technique. Indeed, this popularity maybe due to longstanding reports of pain relief with hypnosis during aversive medical procedures (e.g., Esdaile, 1957). Hypnosis has been demonstrated to relieve pain in patients with headache (Spinhoven, Linssen, Van Dyck, & Zitman, 1992; ter Kuile et al., 1994; Van Dyck, Zitman, Linssen, & Spinhoven, 1991), burn injury (Patterson, Everett, Burns, & Marvin, 1992; Patterson & Ptacek, 1997; Wakeman & Kaplan, 1978), heart disease (Weinstein & Au, 1991), arthritis (Haanen et al., 1991; Horton & Mitzdorf, 1994), cancer (Katz, Kellerman, & Ellenberg, 1987; D. Spiegel & Bloom, 1983; Syrjala, Cummings, & Donaldson, 1992; Wall & Womack, 1989), dental problems (Stam, McGrath, & Brooke, 1984), eczema (Hajek, Radil, & Jakoubek, 1991), and chronic back problems (MeIzack & Perry, 65 1975; Spinhoven & Linssen, 1989). Although there are a number of studies that examine the effects of hypnotic suggestion for clinical pain management (e.g., Barabasz & Barabasz, 1989), and there have been several review articles attempting to summarize these studies (e.g., Wadden & Anderton, 1982; and National Institutes of Health technology assessment panel on integration of behavioural and relaxation approaches into the treatment of chronic pain and insomnia, 1996), to our knowledge there have been no attempts to rigorously quantify the analgesic impact of hypnotic suggestion across studies. That is, it is unknown what proportion of people demonstrate pain relief following hypnotic interventions. This lack of quantification is surprising, given the managed health care industry’s emphasis on treatment efficacy and the general public’s rising interest in, and use of, unconventional therapies for the treatment of physical problems (Eisenberg et al., 1993). The purpose of this study is: (a) to determine the percentage of people who benefit from hypnoanalgesic suggestions, (b) to explore whether results based on empirical work in the laboratory generalize to medical settings and whether the effects of hypnosis are limited to a particular segment of the population (e.g., highly suggestible individuals), and (c) to explore whether the effects of hypnoanalgesic suggestions are less effective, equally effective, or more effective than other psychological interventions (e.g., relaxation training) in providing pain relief. Meta-analysis (Hunter & Schmidt, 1990; Smith, Glass, & Miller, 1980) provides an established methodology for evaluating the effectiveness of hypnosis for pain relief across study samples in the published literature. In summary, meta-analysis is the organization and integration of previously published data through calculation of effect sizes. An effect size is a standardized estimate of the magnitude of a study effect that permits direct comparisons of effects across studies. In addition, statistical analyses of effect sizes can provide a better understanding of cumulative research findings for an area, or subject, of research interest than traditional narrative review articles (Hunter & Schmidt, 1990). Although previous meta-analyses have supported the use of hypnosis as an effective adjunct to both cognitive-behavioural (Kirsch, Montgomery, & Sapirstein, 1995) and psychodynamic psychotherapies (Smith et al., 1980) for a variety of psychological disorders, the specific effects of hypnotic interventions for pain relief have not been addressed with this statistical technique. The primary aim of this study is to estimate the proportion of people who benefit from hypnotic suggestions for pain relief. To achieve this goal, we will use meta-analytic statistical techniques to estimate effect sizes for studies that compared hypnoanalgesic suggestion to notreatment or standard-treatment conditions. Secondary aims of this study are to explore potential differences in the magnitude of pain relief due to participant sample characteristics (i.e., clinical vs. experimental pain, level of suggestibility) and to compare the treatment efficacy of hypnotic interventions with that of nonhypnotic psychological interventions in providing pain relief. At this point in the development of the hypnosis literature, it is not clear whether patients enduring clinical pain demonstrate similar levels of hypnotically suggested pain relief as healthy volunteers experiencing experimental pain. It has been argued that clinical patients should demonstrate greater hypnotic pain reduction than healthy volunteers based on data showing that hypnosis has greater impact on pain suffering than on pain sensation (see Holroyd, 1996). Because pain patients are 66 likely to suffer to a much greater degree than healthy volunteers undergoing experimental pain procedures, pain patients may enjoy greater benefit from hypnotic interventions relative to experimental volunteers. We will use meta-analytic techniques to explore the possibility that pain patients demonstrate greater hypnoanalgesic effects. A second participant characteristic potentially linked to hypnoanalgesic effects is the participant’s level of suggestibility. Previous reports have indicated that hypnoanalgesic effects should be larger for more suggestible participants (Barabasz & Barabasz, 1989; Hilgard & Morgan, 1975; Miller & Bowers, 1986; H. Spiegel & Spiegel, 1978). Although this position is widely accepted (Holroyd, 1996), it is not certain that individuals high in suggestibility will demonstrate greater hypnotically induced pain reduction than those of moderate suggestibility, or whether those of moderate suggestibility will outperform participants of low suggestibility. Given that most people score in the middle range on tests of hypnotic suggestibility (Hilgard, Weitzenhoffer, Landes, & Moore, 1961), it is important to estimate the benefits of hypnosis (i.e., effect size) for people of moderate hypnotic suggestibility, because they make up the largest segment of the population. The American Psychological Association, through the Division of Clinical Psychology, has recommended that the effectiveness of psychological interventions should be emphasized to the public (Task force on promotion and dissemination of psychological procedures, 1995). Indeed, criteria for empirically validated psychological treatments have been proposed for ‘”Well-established treatments,” and “probably efficacious treatments” (Chambless et al., 1998; Task Force on Promotion and Dissemination of Psychological Procedures, 1995). If hypnosis is revealed as an effective method for reducing, pain, it is then important to estimate the effects of hypnosis relative to other frequently used psychological interventions for pain management. In the present study, meta-analyses will be used to compare the effectiveness of hypnosis to that of nonhypnotic psychological pain management strategies on the basis of their ability to provide pain relief. The finding that hypnotic suggestions for pain relief are at least as effective as other cognitive-behavioural interventions would empirically validate the use of hypnosis for pain management and support its use in situations where hypnosis is more efficient or specifically requested by patients suffering pain. As the primary focus of this paper is to statistically estimate the effectiveness of hypnotic procedures for pain relief, we limited this first sample of studies to those that directly compared hypnotherapy to notreatment, wait list, or standard-treatment control groups on measures of pain. For the comparison of hypnosis to other psychological pain management strategies, we changed the criteria and included studies that contained both hypnotic and nonhypnotic psychological treatment groups but not necessarily control groups as described above. METHOD Studies included in the present sample were identified from previous reviews of this literature (Chaves & Dworkin, 1997; Ellis & Spanos, 1994; Genuis, 1995; Holroyd, 1996; Spinhoven, 1988). We also conducted a computer search of the PsycLIT database from 1974 to 1997, using the search terms hypnosis and pain, hypnosis and analgesia, hypnotherapy and pain, and hypnotherapy and analgesia. The computer search algorithm was set to accept plurals (i.e., hypnotherapies, pains) and word variants (i.e., hypnotically, hypnotize, hypnotizability, painful, analgesic). Initial inclusion criteria were as follows: (a) a hypnotic intervention intended to 67 reduce pain was administered to at least one group of subjects; (b) the inclusion of a no-treatment or standard-treatment control group; and (c) sufficient data (including some form of pain measurement on a continuous scale) were reported to allow calculation of effect sizes (Hunter & Schmidt, 1990; Smith et al., 1980). For the comparison of hypnosis to cognitive-behavioural treatments, the inclusion of a cognitive-behavioural treatment was substituted for the inclusion of a no-treatment or standard treatment control group (point b above). In several papers with clinical pain samples, control groups were treated according to standard clinical practices (“treatment as usual”) (Lang, Joyce, Spiegel, Hamilton, & Lee, 1996; Patterson et al., 1992; Syrjala et al., 1992; Wakernan & Kaplan, 1978; Weinstein & Au, 1991). In these experimental studies, hypnosis was used as an adjunct to the prescription of a pain reliever. For example, in the study by Lang and colleagues (1996), radiology patients received analgesic medications throughout the study. However, the amounts and types of medications were controlled for within the study design (i.e., use of medication was a dependent variable). Medication use was similarly controlled for in studies of bum patients (Patterson et al., 1992; Wakernan & Kaplan, 1978). In each case, study procedures were identical for control groups and experimental groups with the exception that experimental group procedures included the addition of hypnotic suggestions for pain relief. Following these standardized methods, 41 effect sizes were initially calculated from 18 papers.’ Effect sizes were based on the pain reports of 933 participants, nearly all of who were randomly assigned to control or hypnotic intervention conditions. Exceptions to strict random assignment were as follows: participants were assigned to treatment conditions sequentially following referral while counterbalancing for order of group assignment between study therapists (Edelson & Fitzpatrick, 1989); participants were alternately placed in one of three treatment groups (Elton, Boggie-Cavallo, & Stanley, 1988); and group membership was determined by odd or even medical chart numbers (Weinstein & Au, 1991). In order to protect against the possibility that studies with greater numbers of dependent variables (pain measures) would have undue influence on the final estimate of hypnotically induced pain reduction (Hunter & Schmidt, 1990), effect sizes were averaged for treatments within studies. For example, if a single study contained two hypnotic treatments and four pain measures, then the four pain measures were averaged for each treatment condition, and the study was represented by these two effect sizes in subsequent analyses. In the present sample of studies, only three studies (Baker & Kirsch, 1993; Girodo & Wood, 1979; Spanos & Katsanis, 1989) contained more than a single treatment, and therefore the risks to statistical independence due to multiple treatments seemed small relative to the benefit of a larger sample of effect sizes for evaluation of participant characteristics. Three additional studies are represented by two (Spanos, Perlini, & Roberston, 1989; Wakeman & Kaplan, 1978), or even three (ter Kuile et al., 1994), effect sizes. However, in these cases, the multiple effect sizes are due to the findings of two separate experiments having been reported within a single paper (Spanos et al., 1989) and results having been independently described for separate and diverse sample groups (e.g., community members, patients, students) within papers (ter Kuile et al., 1994) *It should be noted that, when possible, we based the calculation of effect sizes on the standard deviation within the control groups. We took this approach because of the potential for inflated experimental group standard deviations due to interactions between the hypnotic interventions and participant levels of hypnotic suggestibility. Specifically, if level of suggestibility interacts with hypnoanalgesic effects (a study 68 question), then one would anticipate greater variance within experimental groups. Study data cautiously argue that such an interaction exists. ‘In the calculation of the effect size for Experiment 1 in the paper by Spanos, Perlini, and Robertson (1989), results were collapsed across orders of administration for the comparison of the hypnotherapy and control groups as the authors reported no significant effects due to order (p. 287). Wakeman & Kaplan, 1978). Therefore, the primary analysis of the effectiveness of hypnosis for pain reduction was performed on 27 effect sizes derived from 18 studies. Secondary analysis of differences between clinical and student study samples were based on a comparison of 10 and 17 effect sizes, respectively; nine additional effect sizes were recalculated to compare effect sizes according to reported levels of hypnotic suggestibility; and 27 additional effect sizes were calculated to compare hypnotic to nonhypnotic psychological pain management strategies. RESULTS Types of pain, sample sizes, and effect sizes are presented in Table 1. Two outliers from the Wakernan and Kaplan (1978) study were immediately apparent (d = 15.45, d = 17.42). In order to provide a more accurate estimate of the effects of hypnotherapy for pain reduction and control for the excessive influence of these extraordinary outliers (Abelson, 1995) on the overall mean effect size, we winsorized the data with g = 2 (Winer, 1971). All subsequent analyses are based on the winsorized data set unless otherwise noted. In addition, no differences were found between studies that included standard-treatment control groups versus true no-treatment control groups (p > .10). Results revealed a moderate to large effect size, d =.74 (Cohen, 1992). To control for possible bias in effect size due to study sample sizes and to take a conservative approach, we weighted effect sizes by the size of the samples from which they were derived and calculated the mean weighted effect size (D) according to procedures described by Hunter and Schmidt (1990). The calculation of variation of D was also weighted for study sample sizes. That is, the deviation of individual study effects sizes from the weighted mean effect size was adjusted for sample size.’ The results revealed a significant effect of hypnotic interventions in the treatment of pain (D =.67, VarD =.26; p .10). Therefore, the winsorized results were used for all remaining analyses. As seen in Table 2, participants experiencing both clinical and experimental pain significantly benefited from hypnotic interventions (p < .01), as indicated by the moderate effect sizes. Interestingly, the two pain groups did not statistically differ from each other in the degree to which they experienced pain relief (p > .10), suggesting that hypnotic suggestions for analgesia work equally as well in laboratory and medical settings. ‘Variation of D = Eni( di – D)2 / Eni where n is the study sample size, d is the raw effect size, and D is the mean weighted (by study sample size) effect size. 69 Table 1: Study Characteristics and Mean Effect Sizes by Publication Date In a between-groups analysis of variance, hypnotic analgesic effects were found to differ according to participants’ levels of suggestibility, F 5.26, p < .05. No other level of suggestibility between group comparisons were statistically significant (i.e., participants in the midrange did not differ from those in the high or low range of hypnotic suggestibility, p > .05). However, these between-group findings must be viewed with some caution due to the small sample sizes (high, n = 7; low, n = 4) and assignment of the majority of participants to the midrange of suggestibility. Types of nonhypnotic psychological treatment, sample sizes, and effect sizes for comparisons of hypnosis to nonhypnotic psychological interventions are presented in Table 4. Results of the comparison of hypnotically suggested analgesia with other nonhypnotic psychological pain management strategies found no differences in effectiveness between these treatment strategies, d = .12, D = .11, VarD = .62; p >.10. The results indicate that the average participant treated with hypnosis demonstrated equivalent analgesic responses to participants in alternate Study Participants Type of Pain n d Wakeman et al. (1978) Wakeman et al. (1978) Girodo & Wood (1979) Girodo & Wood (1979) Girodo & Wood (1979) Stam et al. (1980) Spanos et al. (1984) Spanos et al. (1985) Tripp & Marks (1986) Stam et al. (1987) Elton et al. (1989) Edelson et al. (1989) Spanos et al. (1989) Spanos et al. (1989) Zeltzer et al. (1989) Spanos & Katsanis (1989) Spanos & Katsanis (1989) Spanos et al. (1990 Weinstein & Au (1991) Syrjala et al. (1992) Patterson et al. (1992) Baker et al. (1993) Baker et al. (1993) ter Kuile et al. (1994) ter Kuile et al. (1994) ter Kuile et al. (1994) Lang et al. (1996) Patients Patients Students Students Students Students Students Students Students Students Students Patients Students Students Students Students Students Students Patients Patients Patients Students Students Community Patients Students Patients Burn Burn Cold pressor Cold pressor Cold pressor Cold pressor Cold pressor Cold pressor Cold pressor Ischemic Ischemic Chronic pain Focal pressure Focal pressure Cold pressor Focal pressure Focal pressure Focal pressure Coronary Cancer Burn Cold pressor Cold pressor Headache Headache Headache Radiological procedures 24 18 20 20 20 20 45 42 28 45 137 16 96 60 37 20 20 30 32 22 20 20 20 29 36 26 30 15.45 17.42 -0.01 1.50 -0.45 0.12 0.47 0.94 0.88 0.12 0.70 0.94 0.29 0.37 1.19 1.35 1.81 1.67 0.65 0.10 0.72 0.10 0.41 -0.43 0.34 0.62 1.01 70 psychological treatment groups. TABLE 2: Population effect sizes as a function of type of pain NOTE: Effect sizes for high and low levels of suggestibility significantly differ (p< .0001), the study has generated considerable interest in the past few years. It is quite clear that psychosocial interventions significantly affect survival rate in terminal breast cancer patients, yet it is unclear what worked. Was it the group support? Was it the fact that patients had a context to express feelings? Was it the self-hypnosis? Or was it something else? Research is currently being done to ascertain whether or not self-hypnosis contributed to the positive outcome. Chronic Illness Another growing area within behavioural medicine is the use of psychosocial interventions as an adjunct to the treatment of chronic illness (D. P. Brown & Fromm, 1987). Although hypnosis has not been used extensively in this area, a few interesting and promising exploratory studies have appeared in the past several years. Ratner, Gross, Casas, and Castells (1990) studied the effects of 166 hypnotherapy on compliance with regular insulin injections among adolescent insulin-dependent diabetics. A small sample size was used-only seven patients, each serving as his or her own control. A 6-month documented history of noncompliance with diet, insulin injections, and blood/urine testing served as the baseline measure of non-compliance. Blood haemoglobin and fasting blood sugar levels were used as indices of control over hyperglycaemia. Hypnotic suggestion emphasized self-regulation of the disease. Patients also visualized and reinforced treatment goals during self-hypnosis twice daily. A significant drop in fasting blood sugar and haemoglobin levels occurred over three hypnotic sessions as compared to the pre-treatment levels. Despite the small sample size, the results suggest that hypnosis and self-hypnosis hold some promise in improving compliance with medical regimens in the treatment of certain chronic illnesses such as diabetes. In another study, Swirsky-Sacchetti and Margolis (1986) studied the effects of self-hypnosis on haemophilia. A total of 30 haemophiliacs were randomly assigned to self-hypnotic treatment or to a waiting-list control group. The self-hypnosis group received a 6-week training program in self-hypnosis. Subjects learned about the relationship between stress and bleeding. Self-hypnosis was used for relaxation training and ego strengthening suggestions that the patients could give to themselves. Direct hypnotic suggestions regarding decreasing bleeding were included in the instructions. Over the 18-week post-treatment follow-up, the selfhypnosis group significantly reduced the amount of clotting factor used to control bleeding as compared to the no-treatment group. Subjects in the self-hypnosis group also had significantly reduced overall subjective distress, as measured by a symptom checklist. Hypnotisability was not significantly correlated with the positive treatment effect. Whereas the two studies described above have addressed the behavioural dimension of chronic illness, several pilot studies have raised the possibility that hypnosis can directly alter disease course in certain organic conditions. Radil, Snydrova, Hacik, Pfeiffer, and Votava (1988) investigated the effects of hypnosis on the degree of foot drop in hemiparetic patients. Direct hypnotic suggestions were associated with improved movement during and immediately after the hypnosis. The promising results merit a more carefully designed study. Thompson, Hall, and Sison (1986) used a multiple-baseline design to study three patients with Broca's aphasia. Each patient was given hypnotic suggestions to develop vivid visual images of randomly presented experimental picture stimuli. Following hypnosis, two of the patients significantly improved in their ability to name the picture stimuli, although verbal labels were never introduced during hypnotic training. The third subject's naming ability improved after visual and verbal labels were both suggested in hypnosis. AN subjects performed poorly on a hypnotisability scale. Since the hypnotisability of aphasics is unknown, it was not possible to assess the relative contribution of hypnotisability to the positive treatment outcome. Overall, these studies offer promise that hypnotherapy may be useful as an adjunct to the treatment of a variety of chronic illnesses; let us hope that they will serve as an invitation for much more research on hypnosis in this area of behavioural medicine. Medicine and Surgery 167 Surgery The use of hypnosis with medical-surgical patients has a long history. Before chemoanesthesia was known, hypnosis was used as the sole anaesthesia (see E. R. Hilgard & Hilgard, 1983). More recently, hypnosis has also been used to facilitate recovery from surgical operations. In recent years two well-designed clinical studies have appeared (Bonke, Schmitz, Verhage, & Zwaveling, 1986; C. Evans & Richardson, 1998), along with an excellent review of 18 clinical studies over more than two decades on the use of hypnosis to ease the discomfort of operations (Blankfield, 1991). In the study by Bonke et al. (1986), a total of 91 patients undergoing biliary tract surgery were randomly assigned to a treatment group or to one of two control groups. All subjects listened to a tape recording in a manner that blocked out all other sound. Neither the patients nor the operating staff could tell which tape played during the surgery. The treatment group listened to a hypnosis tape consisting of ego-strengthening suggestions for relaxation, enhanced wellbeing, decreased discomfort, and rapid recovery. The placebo control groups listened to a recording of either white noise or typical operating room sounds. No significant differences were found between groups in duration of postoperative hospital stay, subjective well-being, subjective experience of pain, or the use of pain medications. The objective ratings of postoperative recovery by nursing staff also failed to yield significant differences between the groups. When the results were analyzed, taking age into account as a variable, a significant difference emerged with respect to duration of postoperative hospital stay: Older people (above 55 years of age) had a significantly shorter stay, but only in the hypnosis group. Another well-designed study, that by C. Evans and Richardson (1988), yielded somewhat more positive findings. They conducted a double-blind placebo control study of 39 women undergoing abdominal hysterectomy. Subjects were randomly assigned to a treatment group (n = 19) or a placebo control condition (n = 20), and were played either a pre-recorded audiotape of hypnosis or a blank tape during the operation. Operating room staff were unaware of which tapes subjects heard during the surgery. Hypnosis consisted of 12 minutes of continuous suggestions describing typical operative and postoperative experiences, along with ego strengthening suggestions focused on enhanced ability to cope with the experience of the operation. Patients in the hypnosis group had a significantly shorter stay in the hospital than the controls, significantly less pyrexia, and fewer gastrointestinal problems. Also, nurses rated the hypnosis patients as significantly more mobile than those in the control group during their postoperative recovery. There were no significant differences between the groups in the use of medication, report of mood state, anxiety, pain report, or occurrence of symptoms such as nausea and vomiting. Noxious Medical Procedures Hypnosis has also been used to alleviate the distress associated with noxious medical procedures. L. C. Walker, Dawson, Pollet, Ratcliffe, and Hamilton (1988) conducted an uncontrolled outcome study with 14 patients, all of whom had severe side effects from chemotherapy as part of their cancer treatment. Two to six 30-minute sessions of hypnotherapy were used as an adjunct to the typical course of chemotherapy. Improvements in both nausea and vomiting were reported in the 168 majority of patients. Hockenberry-Eaton and Cotanch (1989) studied the effects of hypnotherapy on perceived self-confidence in children undergoing chemotherapy for the treatment of cancer. Twenty-two children were randomly assigned to a self-hypnosis treatment group and a group receiving standard medical care. Self-hypnosis practice emphasized increased control and mastery. Relative to the control children, the children in the self-hypnosis group had significant increases in five of six dimensions of perceived self-confidence. Both groups showed increases in social and academic confidence after treatment. Wall and Womack (1989) studied the effects of hypnosis on distress associated with bone marrow aspiration and lumbar puncture in paediatric oncology patients. A total of 20 subjects were randomly assigned to an hypnotic treatment condition or a cognitive strategy condition. Subjects in both groups received instructions in coping strategies designed to distance the children psychologically from uncomfortable medical procedures. Subjects in the hypnosis group were also given a hypnotic induction. Both groups showed significant decreases in pain but not anxiety. Hypnotisability did not correlate with pain reduction. It appears from these studies that hypnotic interventions hold some promise m reducing subjective distress, enhancing psychological well~ being, increasing recovery rate, and decreasing associated symptoms in patients undergoing uncomfortable medical and surgical procedures. However, much more work needs to be done with carefully controlled, randomized, blind clinical trials designed to discriminate among the differential effects of hypnotisability, hypnotic induction, situational demands, and type of hypnotic suggestions before definitive conclusions can be drawn as to the relative efficacy of hypnotic interventions as an adjunct to such procedures. A few studies have also appeared in which hypnosis has been used with obstetrical and gynaecological patients. Omer, Friedlander, and Palti (1986) and Omer (1987) investigated the effects of hypnotic relaxation as an adjunct to pharmacotherapy with 39 pregnant women hospitalized for premature labour contractions. Another 74 women in the control group received pharmacological treatment alone. Hypnotic suggestions focused on relaxation, increased control over bodily processes (including uterine contractions), and future time orientation to completion of the pregnancy at full term. Patients in the hypnosis group were also given audiotapes for daily self-hypnosis practice. The rate of pregnancy prolongation and mean weight of the infants were both significantly higher in the hypnosis group than in the medication control group. This study suffers from a number of methodological flaws-for example, non-random assignments to conditions, unmatched demographic and medical variables across groups, greater treatment time and therapist contact in the treatment group, and failure to assess hypnotisability. Thus, it is impossible to say whether hypnosis contributed to the significant treatment effects. The preliminary findings are important enough, however, to merit carefully designed controlled clinical trials on the effects of hypnosis in delaying premature labour. In another study, Venn (1986) compared the efficacy of hypnosis to the Lamaze method for childbirth. A total of 122 women self-selected for one of three treatment groups: Lamaze classes alone (n = 8), hypnosis alone (n = 17), or Lamaze plus hypnosis (n = 25). Subjects who volunteered were given the Stanford Hypnotic Clinical Scale (Morgan & Hilgard, 1978-1979a) (only a small portion of the subjects in the groups volunteered to take the hypnotisability test). Group hypnosis training 169 included suggestions for pain control, age progression through the birth experience, and posthypnotic suggestions to re-enter hypnosis at the appropriate time during labour and delivery. There were no significant differences between treatment groups in self-ratings or nurses' ratings of pain experience or well-being during labour, use of medication, or duration of labour. Hypnotisability was moderately correlated with subjective reports of less pain and discomfort during delivery, but only in the Lamaze group in which sufficient subjects took the hypnotisability scale. Although Venn concludes that there may be "functional similarities between hypnosis and Larnaze" (1986, p. 79), the failure to assign women randomly to the treatment conditions makes it difficult to distinguish between self-selection and treatment effects. Health-Risk and Addictive Behaviours Traditionally, clinical studies on hypnosis and smoking have been poorly designed. Moreover, the wide variety of hypnotic treatment strategies utilized has led to marked variations in treatment outcomes, which make it difficult to draw conclusions (D. P. Brown & Fromm, 1987). In an authoritative review of the literature, Wadden and Anderton (1982) concluded that hypnosis is not a uniquely effective strategy for smoking cessation or weight reduction. In response to this quite negative conclusion, we (D. P. Brown & Fromm, 1987) stated that the largely inconsistent and often poor maintenance rate at long-term follow-up intervals is more a problem with often ill-conceived hypnotic strategies to stop smoking or lose weight than with hypnosis per se. Within the field of behavioural medicine, there has been a distinct shift toward multimodal or broad-spectrum treatment approaches and also toward maintenance or relapse prevention strategies for weight loss and smoking cessation in particular, as well as for addictive behaviours in general (D. P. Brown & Fromm, 1987; Marlatt & Gordon, 1985). Nevertheless, by the time of the publication of Hypnosis and Behavioural Medicine (D. P. Brown & Fromm, 1987), few controlled clinical trials using primarily mulitmodal or relapse prevention approaches to hypnosis and weight reduction or smoking cessation had appeared in the literature. Multimodal strategies include interventions designed to address a number of dimensions of complex addictive behaviours: increasing motivation; facilitating coping; encouraging self management of the habit per se; providing alternatives to the manner in which the. habit is used in the service of affect regulation; altering negative cognitions and self-images that reinforce the addiction; decreasing negative social influences; and attenuating withdrawal states and risk situations for relapse. The research literature on hypnosis and smoking and weight loss in the last several years can be grouped into three categories: (1) comparative efficacy studies; (2) multimodal hypnotic interventions; and (3) single session hypnotic interventions. Consistent with our earlier conclusions (D. P. Brown & Fromm, 1987), results of the multimodal studies merit serious consideration. The comparative efficacy studies have generally failed to show an advantage of hypnotic interventions over other methods. Hyman, Stanley. Burrows, and Horne (1986) compared hypnosis to focused smoking and to attention placebo and waiting list control conditions in 60 subjects. Smoking rates were not significantly different at the 3- and 6-month follow-ups. Frank, Umlauf, Wonderlich, and Ashkanazi (1986) compared different types of hypnotic treatments: two hypnotic sessions, four hypnotic sessions plus a booster; or two hypnotic sessions plus two behavioural 170 sessions with a booster. A group hypnotic treatment protocol was used to enhance motivation and to facilitate coping strategies to quit smoking. There were no significant differences across treatments in the number of cigarettes smoked. A total of 31% of all subjects were abstinent at the end of treatment, and 20% at the 6-month follow-up. Success was negatively correlated with scores on the Creative Imagination Scale. Considering that most smoking interventions show recidivism to a baseline maintenance of about 20% by the second year after treatment, the results of these comparative efficacy studies are not impressive. The results of multimodal interventions, in which hypnosis is integrated into a broad-spectrum treatment protocol, are more promising. T. B. Jeffrey, Jeffrey, Greuling, and Gentry (1985) developed a five-session treatment protocol, which included behavioural management of the habit, cognitive interventions, hypnotic relaxation, hypnotic reinforcement of the commitment to stop smoking, suggestions for smoking cessation, ego strengthening, and hypnotic control of craving to smoke. A total of 35 subjects in the group treatment sessions were compared to 30 waiting-list control subjects. Significantly more subjects in the multimodal hypnosis treatment group were abstinent than in the control group. A total of 63% in the hypnosis group were abstinent at the end of the treatment, and 31% maintained abstinence at a 3-month follow-up. In a subsequent study, L. K. Jeffrey and Jeffrey (1988) added another dimension to this treatment; they called it "exclusion therapy." All smokers were required to maintain abstinence for 48 hours just prior to the treatment. A total of 120 subjects were randomly assigned to the hypnotic treatment condition, half of them with and half of them without a pre-treatment abstinence condition. There were no significant differences between the treatment conditions. The abstinence rate in both groups was 59% at the end of treatment and 37% at the 3-month follow-up point. Unfortunately, the 1988 study lacked a control group, and no measures of hypnotisability were used in the earlier study. Nevertheless, compared to the predicted baseline recividism rate of 20%, multimodal hypnotic protocols may offer a distinct advantage to smoking cessation; still, a 3-month follow-up is too short to permit conclusions to be drawn about the efficacy of multimodal treatment. The efficacy of multimodal hypnotherapy for weight loss has also been investigated (Cochrane & Friesen, 1986). A total of 60 obese women (>20% overweight) were randomly assigned to one of three conditions: group hypnosis; group hypnosis plus self-hypnosis; and a control group. Hypnosis in both treatment conditions included a group hypnotic induction, group suggestions to enhance motivation, ego strengthening, and facilitation of patients’ decision making about weight treatment goals. Individualized hypnotic suggestions helped each patient identify unconscious factors related to weight loss. Patients in the treatment groups attended two weekly 3-hour sessions over a month. Whereas patients in the control group did not lose weight, patients in both treatments groups had a significant mean weight loss of 7-8 pounds at the end of the treatment and of about 17 pounds at a 6-month follow-up. Various measures of patient characteristics were included in the study. These included measures of suggestibility, imagery absorption, self-concept, family-of-origin conflict, age of onset of obesity, educational level, and socioeconomic status. None of these variables were significantly related to weight loss. Cochrane and Friesen concluded that hypnotherapy is a useful treatment for weight reduction. The addition of self-hypnosis did not add anything to the positive treatment outcome. The mean weight loss of 17 pounds at the 6-month follow-up is consistent with the expected weight loss from behaviourally oriented interventions 171 (D. P. Brown & Fromm, 1987), although at least a 2-year follow-up interval is usually required in the weight loss field before clear conclusions can be reached (Stunkard, 1977). The other popular approach to smoking and hypnosis entails a single session treatment. Neufeld and Lynn (1988) reported their findings on a 2-hour single-session multimodal hypnotic protocol. The treatment manual included hypnotic suggestions to increase motivation, to induce relaxation, to alter self-image by visualizing the self as a non-smoker, to identify risk situations and enhance coping strategies to prevent relapse, and to enhance the health benefits from smoking cessation. Abstinence rates were 26% at a 3-month follow-up and 19% at a 6-month follow-up. A study with more promising results was conducted by Williams and Hall (1988). A total of 60 subjects were assigned to a single-session hypnotic treatment, a placebo condition, or a non-treatment control condition. Subjects in the hypnotic condition received primarily hypnotic cognitive therapy, adapted from H. Spiegel (1970) and Stanton (1978). Subjects in the treatment group were significantly more abstinent (60%) than the controls (40%) following treatment. About 45% of the subjects maintained their abstinence at a 48-month follow-up. A. F. Barabasz, Baer, Sheehan, and Barabasz (1986) studied a variety of treatment variables in 307 patients who utilized group hypnotic treatment for smoking cessation. The primary intervention was a single-session hypnotic approach. A number of subgroups were used, each of which varied the length of the session, the use of additional sessions, the use of post-treatment booster sessions, and the use of adjunctive sessions with REST. Some subgroups were led by interns and some by experienced psychologists. The primary hypnotic intervention employed H. Spiegel’s (1970) approach to maintaining commitment to health. Abstinence rates at various follow-up points varied considerably, from 4% to 47%. The highest abstinence rates were found when experienced clinicians were used, when patients were given more treatment contact, and when REST (see Barabasz & Barabasz, Chapter 7, this volume) was used as an adjunct to hypnotherapy (the 47% abstinence rate was achieved at a 20-month follow-up in the hypnosis plus REST condition). In contrast to the previous negative conclusions of Wadden and Anderton (1982), hypnotisability was correlated significantly with the treatment outcome of this study. The studies. discussed above suggest that single-session treatment is worth considering as a brief cost-effective approach to smoking cessation. To the extent that tentative conclusions can be drawn, despite the various methodological weaknesses in the studies, it appears that unidimensional treatment emphasizing primarily hypnocognitive interventions (H. Spiegel, 1970; Stanton, 1978) yield better results than multimodal approaches (Neufeld & Lynn, 1988) in single-session hypnotic treatment. It may be that multimodal protocols are too complex for patients to grasp in a single session. Moreover, positive treatment outcomes may depend more on hypnotisability in single-session treatment than is the case over a number of sessions, where a variety of nonhypnotic variables may effect treatment outcome. At any rate, the A. F. Barabasz et al. (1986) paper is valuable in helping us to appreciate the complex number of variables that must be addressed if significant progress is to be made in the use of hypnosis for weight reduction and smoking cessation. 172 Psychiatric Conditions Very few controlled clinical trials of hypnotherapy for psychiatric conditions have appeared in recent years. Several studies are worth noting, although each suffers from methodological limitations. Der and Lewington (1990) used a single-subject design to study the effects of hypnotherapy on panic attacks. After a 2-week baseline period, the subject was treated with hypnotherapy for 13 weeks. The hypnotic method was largely cognitive an integration of hypnotically enhanced self-control strategies and rational-emotive therapy. According to the subject’s reports and responses to objective symptom inventories, there was a reduction in anxiety-related symptoms. Although this study provides more data than an anecdotal case report, it is hard to make treatment generalizations from a single case. Clarke and Reynolds (1991) conducted an outcome study on hypnotherapy and bruxism with eight patients. Hypnotic suggestions emphasized enhanced awareness of and control over masseter muscle activity. Nightly electromyographic (EMC) measurements of masseter activity served as the outcome measure, along with subjective ratings of pain. Relative to baseline measurements taken before treatment began, the bruxers showed a significant decrease in EMC activity and subjective reports of pain. Treatment gains were maintained up to 36 months. Griffiths (1989) investigated the outcome of hypnobehavioral therapy with 12 bulimia nervosa patients. Treatment consisted of 4 weeks of behavioural therapy followed by 4 weeks of hypnotherapy. Hypnotic suggestions emphasized enhanced selfcontrol and mastery. Significant reductions in bingeing and vomiting were observed after treatment and at a 9-month follow-up. However, the lack of control groups or a crossover design between the behavioural and hypnotherapy treatment makes it difficult to assess the relative contribution of hypnosis to the positive treatment outcome. One very important large-scale controlled outcome study was conducted on patients in The Netherlands with a diagnosis of post-traumatic stress disorder (Brom, Kleber, & Defares, 1989). The study included 112 patients who had been victims of violent crimes, had lost someone close to murder or suicide, or had suffered a serious traffic accident. Patients typically scored very high on the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979), which measures intrusion and avoidance symptoms in response to traumatisation. All patients were randomly assigned to one of four conditions: (1) desensitization therapy, in which subjects were presented with traumatic scenes from a hierarchy while in a relaxed state; (2) hypnobehavioral therapy, in which patients learned to cope better with traumatic imagery while in trance; (3) brief psychodynamic therapy, emphasizing resolution of conflicts triggered by the traumatic experience; and (4) a waiting-list control. All treatment was conducted by therapists who had at least 10 years of experience with the respective treatment approach. The average treatment lasted from 15 to 18 sessions. Relative to the waiting-list controls, who changed very little, subjects in all three treatment groups showed a significant reduction in post-traumatic symptoms as well as in a host of other symptoms. Subjects in all three treatment groups also reported significantly less distress and improved self-esteem. About 60% of all treated patients improved, in comparison to 26% in the control group. There were few remarkable differences across treatment groups, except that subjects in the desensitization and hypno-behavioural groups showed a greater initial reduction in 173 intrusive re-experiencing of symptoms than did the psychotherapy group. This finding is not surprising, because in both of the former groups the treatment directly emphasized active coping with intrusive post-traumatic symptoms. Since no measure of hypnotisability was included, it is impossible to say whether or not hypnotisability contributed anything unique to the positive treatment effect. Nevertheless, this ground-breaking study is the first to clearly demonstrate the effectiveness of hypnotherapy in the treatment of post-traumatic stress disorder. The 60% improvement rate at the 6-month follow-up is impressive for brief treatment of this condition. A limitation of the study is that the hypno-behavioural approach used was limited to what others have called the “stabilization phase” of posttraumatic recovery (D. P. Brown & Fromm, 1986). It is conceivable that additional hypnodynamic treatment designed to help traumatized patients uncover and integrate the memories and feelings associated with traumatisation may elevate the overall treatment effect. The Clinical Relevance of Hypnotisability Wadden and Anderton (1982) concluded in their review that hypnotisability is significantly correlated to treatment outcome for pain, asthma, and warts, but not for self-initiated disorders such as smoking, weight problems, and alcoholism. Although a number of additional studies on hypnotisability have appeared in the literature in the last several years, the conclusions we might draw at present are not essentially very different from those drawn by Wadden and Anderton a decade ago. A number of studies have found a significant relationship between hypnotisability and the reduction of chronic pain (A. F. Barabasz & Barabasz, 1989), chronic facial pain (Stam, McGrath, Brooke, & Cosier, 1986), and headache (van Dyck et al., 1991). However, insignificant results have also been reported with paediatric patients suffering from headaches (M. S. Smith, Womack, & Chena, 1989) or undergoing painful medical procedures (Wall & Womack, 1989). The recent studies on asthma (Ewer & Stewart, 1986; Murphy et al., 1989), like the earlier studies, have consistently reported a significant relationship between hypnotisability and treatment outcome. Wadden and Anderton’s (1982) comments about skin disorders were limited to warts. More recent studies suggest that at least the subjective effects associated with certain other skin conditions are significantly related to hypnotisability-for example, the severity of itching accompanying chronic urticaria (Shertzer & Lookingbill, 1987) and the pain associated with atopic eczema (H’ajek et al., 1990). With respect to behavioural conditions, the evidence is inconsistent. A. F. Barabasz et al. (1986) found that hypnotisability was significantly related to smoking cessation, but Frank et al. (1986) did not find such a relationship. Hypnotisability has also been found to be significantly related to weight reduction (Andersen, 1985) and not significantly related to it (Cochrane & Friesen, 1986). With regard to other clinical populations, no significant relationship was found between hypnotisability and treatment outcome in delayed immunosensitivity (Locke et al., 1987) or with hemophiliacs (Swirsky-Sacchetti & Margolis, 1986). Although no definite conclusions can be drawn, some patterns do emerge. One reasonably consistent finding is that hypnotisability does appear to be significantly related to treatment outcome in adults with pain, asthma, and certain skin conditions. Hypnotisability does not appear to be significantly related to treatment outcome with respect to certain psychobiological conditions such as immune 174 response and blood clotting. The relationship between hypnotisability and behavioural disorders such as smoking and weight problems is so exceedingly complex that, so far, no consistent findings have emerged. Overall, Wadden and Anderton’s (1982) conclusions are still relevant, except that the recent findings regarding health-risk behaviours are less consistently negative than those reported by Wadden and Anderton. Hypnotisability may be related to the development or at least to the maintenance of certain clinical conditions. Since the pioneering work of Frankel (1976) on phobias, clinical researchers have come to appreciate the role of hypnotisability and associated dissociative mechanisms in the etiology of diseases. The early studies documented a significant treatment correlation between hypnotisability and anxiety/ phobic disorders. Although more recent studies have not always found a significant correlation (Owens, Bliss, Koester, & Jeppsen, 1989) the view that hypnotisability may contribute to the formation and maintenance of certain symptoms has persisted. For example, patients suffering from post-traumatic stress disorder (D. Spiegel, Hunt, & Dondershine, 1988) and multiple personality disorder (Bliss, 1986) are generally more hypnotizable than normals. Severe abuse may cause children to draw upon normal dissociative capacities in the service of defence; if this is done repeatedly, it may lead to the development of dissociative disorders (Braun & Sachs, 1985; F. W. Putnam, 1989). Hypnotisability has also been found to correlate positively with nightmare occurrence (Belicki & Belicki, 1986), severity of itching in patients with chronic urticaria (Shertzer & Lookingbill, 1987), and proneness to nausea and vomiting during pregnancy (Apfel, Kelley, & Frankel, 1986). Although it is tempting to speculate about some underlying mechanism by which normal hypnotic ability is transmuted into psychopathology, notably psychophysiological and dissociative disorders, some caution is necessary. Most of these studies in question simply demonstrate a correlation between hypnotisability and psychopathology, and a correlation does not imply a causal relationship. Current and Future Trends An examination of the clinical research on hypnotherapy in the past several years makes it clear that the preponderance (if controlled clinical research during that period was done in the domains of behavioural medicine in particular and medicine in general. Hypnosis and Behavioural Medicine (D. P. Brown & Fromm, 1987) was written with the intent of inviting a greater integration of the respective fields of hypnotherapy and behavioural medicine. It is encouraging to see the increased application of hypnosis in the field of behavioural medicine, and even more encouraging to see the number of clinical research studies appearing the literature that document the efficacy of hypnosis in the treatment (or adjunctive treatment) of psychophysiological and medical illnesses. Data are accumulating that enable us to carefully evaluate the efficacy of hypnosis in treating pain, headache, asthma, gastrointestinal disorders, skin disorders, immune diseases, and insomnia, as well as in facilitating adjustment to noxious medical procedures and chronic illnesses. The main contributions of hypnosis to clinical outcome, lie in positive subjective effects (decreased distress and increased well-being) and in behavioural changes (symptom reduction, a decrease in the use of medication and the frequency of medical visits). Whether or not hypnosis can alter the underlying pathophysiology of psychophysiological disorders and chronic illnesses remains largely untested, though there are interesting suggestive findings with respect to asthma, hemiparesis, premature labour, and metastatic breast cancer. 175 With respect to habit disorders, the efficacy of hypnosis is not firmly established. The percentages of hypnotized patients who stop smoking or lose weight, and who maintain the treatment gains for reasonable follow-up intervals of 1 to 2 years, vary considerably across clinical research reports; as a result, it is impossible to say whether or not hypnosis consistently adds anything unique to the treatment outcome. Instead of attempting to demonstrate the efficacy of hypnosis in the treatment of health-risk behaviours, a more promising research strategy in recent years has been to identify the numerous complex variables relevant to treatment outcome. These include patient and therapist characteristics, the nature of the therapeutic interaction, and the context of the treatment and the intervention used (which in this case includes the nature of the hypnotic induction and the specific hypnotic suggestions given). A. F. Barabasz et al.’s (1986) follow-up study on smoking cessation and Cochrane and Friesen’s (1986) study on weight control at least move in the direction of identifying a range of relevant variables, in addition to investigating the relative efficacy of hypnotherapy with health risk behaviours. Certainly much more work needs to be done in this area. The main surprise in reviewing hypnotherapy research since 1986 is the absence of controlled clinical trials of hypnotherapy with psychiatric disorders. The one important exception is the study by Brom et al. (1989) on posttraumatic stress disorder. Then again, judging from the rapid proliferation of clinical literature on post-traumatic stress disorder in the past decade, it is just as surprising that only one reasonably well-designed controlled clinical outcome study has appeared in the literature. Several anecdotal reports have appeared regarding multiple personality disorder patients who were successfully treated with hypnosis (Coons, 1986; Kluft, 1985; Ross, Norton, & Fraser, 1989; Ross, Norton, & Wozney, 1989). However, controlled clinical trials using hypnosis as the primary intervention with such patients have not yet appeared. In contrast, about 40 clinical reports (mostly anecdotal) on hypnosis and dissociative disorders have appeared in the hypnosis journals or in the journal Dissociation since 1986. Although there appears to be tremendous interest in the use of hypnosis in the treatment of post-traumatic stress and dissociative disorders, the field simply has not evolved enough to generate a foundation of solid clinical outcome studies. Yet the paper by Brom et al. (1989) is indeed a very promising beginning. It is all the more puzzling, then, that controlled studies of hypnotherapy in more established areas of psychiatric treatment (e.g., anxiety, phobias, conversion disorders, grief reactions, and habit disorders) have been virtually nonexistent in recent years. Neglected Areas This reflection on the areas of hypnotherapy research that have developed in the past several years makes it easier to see the blind spots in such research. First, considering the enormous amount of research conducted on drug efficacy in this country, it is amazing that there has been virtually no research on the interaction of hypnosis and drug-induced states. It is likely that many patients treated with hypnosis take medication for their main complaint and/or other conditions. But we know virtually nothing about how various medications affect hypnotic responsiveness, or how hypnosis may potentiate or attenuate drug effects. It is well established that set and setting greatly affect drug experiences (Tart, 1969). Likewise, the types of cognitive tasks carried out in hypnosis and situational variables significantly affect hypnotic responsiveness. Therefore, research on the 176 interaction of drug effects, hypnotic suggestions, expectation effects, and contextual variables would be quite useful. With respect to psychiatric conditions, there has been far too little work on hypnosis with affective disorders. Since cognitive therapy has made significant contributions to the treatment of depression (Burns, 1980), it is surprising to see so few studies on hypnocognitive therapy and depression. It would be useful to see research on the applications of Hartland’s (1965) ego-strengthening suggestions or Stanton’s (1989b) rational-emotive hypnotherapy in controlled clinical studies with depressive patients. Moreover, the use of hypnosis with bipolar patients is controversial. There are arguments for (Feinstein & Morgan, 1986) and against (D. P. Brown & Fromm, 1986) its use. These clinical arguments need to be backed up by research. Another rapidly developing area of clinical hypnosis is the hypnoanalytic treatment of severely disturbed patients-that is, schizophrenic, borderline, and narcissistic patients. A number of important clinical papers and books on the theory and practice of hypnoanalysis with such patients have appeared in the literature (E. L. Baker, 1981, 1987, 1990; Fromm, 1984; D. P. Brown, 1985; D. P. Brown & Fromm, 1986; Copeland 1986; Sands, 1986; Hodge, 1988). Although claims have been made about the efficacy of hypnosis in the treatment of certain severely disturbed patients, virtually no clinical research studies have examined these claims. Priority should be given to outcome studies for potentially useful treatments with the chronically mentally ill. Another “hot” clinical area is the treatment of alcoholism and other substance abuse. Since our (D. P. Brown & Fromm, 1987) review of the hypnotherapy literature in this area, only a few anecdotal case reports have been published (Orman, 1991; Stanton, 1987); no controlled outcome studies on hypnotherapy with substance abuse have appeared. If this field is to address current social and clinical problems, much more work is needed in this area. Finally, it is quite rare to find a reference in the clinical hypnosis literature to the use of hypnosis with patients from ethnic minority groups. Since 1986, one clinical article has described the use of hypnosis with Hispanic burn patients (Dobkin de Rios & Friedman, 1987). In another article, Richeport (1988) argues that it is important to understand cultural differences in framing hypnotic treatment. With the exception of these two articles, no other references to the concerns of ethnic minorities could be found in the clinical hypnosis literature surveyed, and certainly no controlled clinical studies have been conducted on hypnotherapy with ethnic minority populations. A Shift toward Integrative Hypnotherapy In the past several years, a number of authors have clearly articulated the theoretical foundations that guide their use of hypnosis in psychotherapy. Some (D. P. Brown & Fromm, 1986; Lavoie, 1990; Watkins, 1986) have presented consistent theoretical explanations of the psychodynamic theories underlying their approaches to hypnotherapy and hypnoanalysis. Others (D. P. Brown & Fromm, 1987; E. L. Baker, 1990; Copeland, (1986) have detailed the essential features of a structural/ developmental psychoanalytic theory as it applies to the hypnoanalytic treatment of the severely disturbed psychiatric patient. Several clinicians have articulated the essential features of their behavioural (D. P. Brown & Fromm, 1987; Spinhoven, 1987) and cognitive-behavioural (Stanton, 1989a,b; Okhowat, 1985) approaches to 177 hypnotherapy. Still other clinicians have attempted to integrate family systems theory and hypnotherapy (Brink, 1986-1987; Lind, 1989; Somer, 1990). In my opinion, the best clinicians mature beyond identification with a particular theoretical position and are able to move flexibly across diverse theoretical perspectives to select the theory and related treatment approach, or combination of approaches, that best matches a given patient’s needs. When the data of the individual case are used to guide the selection of a treatment from among diverse possibilities, the selection process is by no means haphazard or eclectic, but systematic and integrative. As I see it, integrative psychotherapy is probably the wave of the future as we come to understand which treatments are best matched to which conditions. In anticipation of this trend, more studies are necessary in which the outcome of hypnotherapy conducted from diverse theoretical perspectives is compared with respect to selected patient populations. For example, this chapter has reported a number of positive outcome studies in which hypnocognitive therapy was matched to specific patient populations whose illnesses had a high cognitive load (notably patients with IBS and insomnia). In an ideal sense, criteria may be developed to guide clinical treatment planning, so that we know which particular approach to hypnotherapy is best suited to a particular syndrome or personality type. Design Strategy There are four types of clinical research designs, intended to meet different goals. Clinical efficacy studies are designed to answer these questions: Does a particular treatment work? Is it effective? Comparative efficacy studies are designed to compare the relative efficacy of two or more treatment approaches: For example, is hypnotherapy more effective than progressive muscle relaxation or a cognitivebehavioral approach to the treatment of insomnia? Multimodal studies compare the relative contribution of a number of combined treatment strategies to the overall variance of the clinical outcome. A sample question here is as follows: How much do motivational enhancement, hypnotic relaxation, behavioural habit management, hypnocognitive therapy, and relapse prevention strategies each contribute to the overall treatment outcome, when these combined strategies are used for smoking cessation? Finally, individualized designs allow the individual patient to select and/or tailor hypnotic imagery and suggestions within the overall treatment frame. The question here is this: Are individual treatment protocols more or less effective than standardized treatment protocols? In the field of behavioural medicine, the majority of the studies have been comparative efficacy studies, with a more recent shift toward more sophisticated multimodal and individualized designs (D. P. Brown & Fromm, 1987). In the area of psychotherapy research in general, a number of internally consistent treatment manuals are appearing; the components of these treatments can be added or subtracted as a means of assessing the relative contribution of each component to the overall outcome (Beutler & Clarkin, 1991). The hypnotherapy studies reviewed here follow the same trend as do other studies of behavioural medicine and psychotherapy outcome. Newer research areas (e.g., treatment of eczema or duodenal ulcer) are primarily represented by clinical efficacy studies. A number of comparative efficacy studies have emerged, in which hypnosis and (typically) behavioural or cognitive-behavioural treatments have been compared. There are, however, still very few multimodal and individualized treatment designs represented in the studies reviewed. Because a trend toward 178 integrative psychotherapy, along with the development of dearly articulated treatment manuals, is anticipated, more multimodal and individualized designs are warranted. The Standard of Research Design In reflecting on the clinical hypnosis research over the past several years, I find it encouraging to see an increase both in the number of clinical studies and in the number of well-designed controlled clinical studies, in contrast to poorly designed post hoc comparisons of nonrandomized groups (Beutler, Crago, & Machado, 1991). The standard of hypnotic research has been raised somewhat by the well-designed studies that have appeared, By “well-designed,” I mean studies that use appropriately matched control groups along with experimental groups; that randomise assignment into these groups; that conduct the treatment in a blind way, wherever possible; and that also control for situational demands (e.g., through the use of placebo controls, simulator controls, counter demand suggestions, etc.). Such ideal designs, although easy to carry out in experimental settings with normal subjects, are much harder to implement with clinic patients. The fact that a number of the studies reviewed here move in the direction of meeting most of these criteria is encouraging and suggests that a clear standard of hypnotherapy research is evolving. Nevertheless, even the best of these studies fall far short of the ideal. The evolving standard of psychotherapy outcome research addresses the complex interaction of different important variables: (1) specific treatment; (2) therapist qualities; (3) patient characteristics; (4) specific problem area; and (5) nature of the setting (Beutler & Clarkin, 1991). Psychotherapy process research has also emphasized the importance of understanding the therapist/patient relationship (Beutler et al., 1991). Within the wider context of psychotherapy research, it is too simple to ask the hypnotherapy outcome question, “Does hypnosis work in treating certain symptoms?” (D. P. Brown & Fromm, 1987, p. 57). Clinical outcome studies of hypnotherapy must control for at least six specific types of variables: (1) treatment variables (the approach to hypnosis, the style of hypnosis used, the nature and wording of suggestions given); (2) hypnotherapist variables (the level of experience of the hypnotherapist, the characteristics of the hypnotherapist); (3) the characteristics of the given patient population; (4) the nature of the presenting problem; (5) the nature of the setting (the context of the treatment, and the expectation and situational demands inherent in that context); and (6) the quality of the hypnotherapeutic relationship. If there is one major flaw in most of these outcome studies, I believe that it is the recurrent failure to control for the type of hypnotic suggestions utilized in each type of clinical trial. Unfortunately, it is still quite rare to see a research report that includes the entire wording of the hypnotic protocol used in the treatment. This curious omission merits some explanation. In part, it can be attributed to the greater emphasis on studying hypnotherapy outcome than on hypnotherapy process. Within the wider context of psychotherapy research, the evolving standard is likely to be a integration of process and outcome research (Beutler et al., 1991). Thus, I anticipate that more emphasis will be given to the hypnotherapy process in the future by investigators studying hypnotherapy outcome. Since there is much we do not know about the process of hypnotherapy, it may be advisable to follow the general recommendation of L. Horwitz and his associates for psychotherapy process 179 research-namely, that future research engage in hypothesis finding about therapy process as much as in hypothesis testing about therapy outcome (L. Horwitz, Allen, Colson, Frieswyk, Gabbard, Coyne, & Newsom, 1991). Hypnotisability versus a Specificity Theory of Hypnotic Responsiveness Clinical research on hypnosis has often included some standardized measure of hypnotisability and/or has controlled for some kind of specified formal hypnotic induction. The underlying assumptions of this research strategy were as follows: (1) The hypnotic state is a unitary phenomenon that is or is not induced; and (2) the induction of this so-called hypnotic state or trance may contribute to treatment outcome. Another perspective on hypnotic responsiveness currently gaining popularity might be called a “specificity theory of hypnotic responsiveness.” Specificity theory does not assume that the hypnotic responsiveness is a unitary response, but rather that a number of very different behavioural responses and/or experiential dimensions may be tapped by specifically worded suggestions. Both views originate in E. R. Hilgard’s pioneering research on hypnotisability, as described in his classic text Hypnotic Susceptibility (E. R. Hilgard, 1965a). Hilgard concluded that there is a general factor of hypnotisability, and also described a number of representative hypnotic behaviours for (e.g., ideomotor phenomena, posthypnotic effects, hypermnesia, age regression, and hallucinatory phenomena). These specific phenomena might be considered special abilities of sub talents within the overall domain of hypnotic responsiveness. In other words, a given hypnotic subject may show more or less talent in each of these specific areas. just as two individuals can be equally talented as musicians, one with wind instruments and one with percussion instruments, two people can be equally hypnotizable, but one can manifest hypnotic talent primarily in terms of hypnotic imagery and another in terms of persistent effects. Since 1986, more attention has been paid to the specificity of hypnotic behaviours. Spanos and his associates have conceptualized hypnosis in terms of very specific cognitive tasks. Specific cognitive tasks suggested in hypnosis may lead to different hypnotic effects—for example, in pain control (Spanos, Horton, & Chaves, 1975). In the last decade, a view has been emerging that the differences between subjects high and low in hypnotisability can be explained in terms of differences in the type of cognitive strategies typically used by subjects during hypnosis. It has become clear that whereas both high and low hypnotizable subjects depend on absorption strategies in making a positive response to hypnotic suggestions, high but not low hypnotizable subjects also rely on dissociative strategies, which buffer them against an otherwise expected deterioration in hypnotic performance if the hypnotic suggestions are ambiguous, inconsistent, or conflictual (Bartis & Zamansky, 1990). it has also become clear that high and low hypnotizable subjects utilize very different cognitive strategies in response to reduction of muscle tension. In one study, high hypnotisables were able to reduce muscle tension significantly better than low hypnotisable with hypnotic relaxation strategies but not with EMC biofeedback, whereas low hypnotisable showed significant reduction in muscle tension only when EMG biofeedback was used (L. S. Miller & Cross, 1985). The authors concluded that high and low hypnotizable subjects use different cognitive strategies to relax, and that it is advantageous to match different treatment methods to these respective populations. This increased appreciation of the a priori 180 differences between high and low hypnotizable subjects in terms of cognitive skills has led to the idea that low hypnotizable subjects might successfully be taught the cognitive strategies typically employed by high hypnotizable subjects, as a way to enhance their hypnotisability (Spanos, Cross, Menary, & Smith, 1988; Spanos & Flynn, 1989a). Moreover, increased attention is being paid to the range of different cognitive strategies used by high hypnotizable subjects. These include focused attention, enhanced imagery processing, absorption, and dissociation (Crawford, 1990a). According to this line of reasoning, each of the different cognitive strategies utilized in hypnosis is predicted to have very specific effects. Crawford (1990a), for example, has demonstrated that successful identification of discrete physiological correlates to hypnosis depends on the type of cognitive task(s) required of the hypnotized subject as much as on the nature of the physiological measurement. The view emerging from such studies is that after the induction of a hypnotic state, hypnosis can be understood in terms of a variety of highly specific task demands that produce a variety of differential hypnotic behaviours. Shor’s (1962) pioneering work on dimensions of hypnotic experience is an example of a specificity theory of hypnotic experience. In the past several years, more attention has been paid to mapping out phenomenological dimensions of hypnotic experience (Fromm & Kahn, 1990; Kumar & Pekala, 1988, 1989; Pekala & Nagler, 1989; Pekala & Kumar, 1989; Kihlstrom, Register, Hoyt, Albright, Gregorian, Hendel, & Morrison, 1989). Again, in terms of hypnotic experience there are marked differences between high and low hypnotizable subjects, and specific hypnotic suggestions lead to differential effects among the high hypnotizable subjects. Future research directions on hypnotherapy should include a greater emphasis on specificity of hypnotic responsiveness. I would expect that such future research would be concerned not only with hypnotisability, but also with the specifics of hypnotic behaviours and experiences. My hope is that a typical research report in the future will clearly articulate which hypnotic strategy or which experiential dimensions of hypnosis have been emphasized (by means of specifically worded hypnotic. suggestions) in order to achieve the best treatment outcome, when hypnosis is used with a specific clinical condition. This is not to say that the construct of hypnotisability, or the use of formal measures of hypnotisability, will be less important. 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Page 1 Clinical Hypnosis Research since 1986 DANIEL P. BROWN In Hypnotherapy and Hypnoanalysis (D. P. Brown & Fromm, 1986) and Hypnosis and Behavioural Medicine (D. P. Brown & Fromm, 1987), Erika Fromm and I discussed the clinical literature on the use of hypnosis in psychodynamic treatment and behavioural medicine before 1986. This chapter reviews the developments and findings on clinical hypnosis research in the years since then, as a way to update our understanding of new developments in the application of clinical hypnosis. Behavioural Medicine Pain It is generally accepted that hypnosis offers an advantage in the treatment of pain and that successful outcome of pain control is related to hypnotisability (D. P. Brown & Fromm, 1987; Wadden & Anderton, 1982). This favourable view of hypnosis for pain control was derived primarily from experimental rather than clinical studies of pain control. There have been few well-designed clinical trials demonstrating the effects of hypnosis in the treatment of clinical pain syndromes. The clinical studies on pain control in the past several years have yielded inconsistent results. Freeman, MacCaulay, Eve, Chamberlain, and Bhat (1986) conducted a clinical trial comparing self-hypnosis to a control procedure for reducing pain associated with labour in childbirth. A total of 65 subjects were randomly assigned either to a hypnotic or a nonhypnotic condition. All subjects attended weekly prenatal classes after the 32nd week of gestation. In addition to the prenatal classes, hypnotic subjects were given suggestions for relaxation and transfer of analgesia from one hand to the abdominal area. There were no significant differences in the amount of pain relief, but women in the hypnotic condition reported greater satisfaction with the labour experience. Spinhoven and Linssen (1989) reported changes in 45 patients with low back pain who participated in a group program consisting of a psychoeducational approach to their pain, and who also received training in self-hypnosis. Patients reported significant favourable post-treatment changes: reduction in the use of pain medication and increased activity level. There was no reported change in pain intensity. The relative contribution of the psychoeducational approach and hypnosis was unclear. Since no external control group was used, it was difficult to know whether hypnosis contributed anything unique to the results, or whether the positive changes were due to non-specific treatment effects. Like the Freeman et al. (1986) study, this study failed to demonstrate a unique contribution of hypnosis to pain relief, although a number of other favourable subjective changes were reported. In a third study, Edelson and Fitzpatrick (1989) compared the relative efficacy of cognitive-behavioural and hypnotic treatment of chronic pain. A total of 20 chronic pain subjects were assigned (non-randomly) to one of three treatment conditions: hypnotherapy or cognitive-behavioural treatment, and a control condition (in which patients talked about their pain experience). The cognitive-behavioural treatment consisted of modifying negative self-statements regarding pain experience, and reinterpretation of pain as numbness. Hypnotic treatment consisted of the same Page 2 treatment as the cognitive-behavioural treatment, following a standard hypnotic induction. Each group received four 1-hour treatment sessions over a 2-week period. Both treatment groups showed significant changes, whereas there were none in the control group. Subjects in the cognitive-behavioural group had reduced pain ratings on the McGill Pain Questionnaire and increased levels of daily activity as reported in the Fordyce Activity Log. Subjects in the hypnosis group showed reduction in pain ratings, but no change in activity level. Because the cognitive-behavioural and hypnotic induction group showed similar pain reduction ratings, the hypnotic induction failed to offer any therapeutic advantage. In addition, it failed to increase significantly the likelihood that patients would normalize daily activity in the face of pain. Taken as a unit, these studies imply that hypnosis may be useful in altering a variety of subjective experiences associated with acute and chronic clinical pain, but not necessarily in altering the pain experience per se. However, failure to demonstrate a positive treatment effect on pain experience could be attributable to various methodological weaknesses of each study or to a narrow approach to hypnotic pain control. Some evidence exists that effective pain control is contingent on the type of pain coping strategy utilized, and especially on matching the specific hypnotically suggested coping strategy to the coping resources of the individual pain patient (D. P. Brown & Fromm, 1987). None of the three studies discussed above attempted to control for the type of hypnotic pain coping strategy used. Furthermore, none of the studies adequately addressed the issue of hypnotisability and its association with outcome; nor did they control for a variety of non-specific factors that could have explained the outcome. More convincing findings come from the programmatic work of A. F. Barabasz and M. Barabasz in well-designed studies on restricted environmental stimulation therapy (REST) and its enhancing effects on hypnotisability and pain control. The Barabasz’s had demonstrated in their previous work (Barabasz & Barabasz, 1989) that the use of REST temporarily enhanced hypnotisability in experimental subjects. A. F. Barabasz (1982) further documented that use of the REST methodology enhanced hypnotisability, and in turn offered an opportunity to teach low hypnotizable subjects more effective strategies for pain control. The 1989 investigation tested whether this effect might also obtain for chronic pain patients. A total of 20 subjects were assigned to either a treatment or a control condition. Subjects in the treatment condition received 6 hours of REST; those in the control group did not. Subjects in the REST condition were also divided into two groups: one with a high situational demand, favouring increase of hypnotisability following the experience; and another with a low situational demand, in which the experimental hypotheses were intentionally disguised. The Stanford Hypnotic Susceptibility Scale, Form C (Weitzenhoffer & Hilgard, 1962), an ischemic pain test, and a posthypnotic suggestion for pain relief .were given before and after the REST. A significant increase in hypnotisability was found in the experimental but not in the control condition. Significant decreases in pain scores were also found in the experimental but not control condition. There were no differences in the high and low demand groups, which suggests that the results were more a function of hypnotisability than of task motivation. Although this study clearly shows the relative contribution of hypnotisability to pain control in a clinical population of pain patients, it must be remembered that patients reported a decrease in response to ischemic pain (an experimental measure). Measures of chronic pain were not the focus of the study. The study also suffers from a lack of follow-up. Nevertheless, the study is valuable in that it attempts to differentiate between non-specific treatment effects Page 3 and hypnotic effects in the control of pain in the clinical population. Overall, it is clear that better-designed studies controlling for hypnotisability, situational demands, and type of pain coping strategy utilized are needed, if we are to be able to draw more definitive conclusions about the efficacy of hypnosis with clinical pain populations. Research on hypnotherapy for headaches since 1986 has not significantly advanced our previous understanding of the clinical efficacy of hypnosis with headaches. According to a previous review (D. P. Brown & Fromm, 1987), the effectiveness of behavioural medicine interventions with headaches ranges from 40% to 90%, and that of hypnotic interventions ranges from 35% to 65%. Comparative studies of hypnotherapy and other behavioural medicine techniques have yielded equivocal results. We stated (D. P. Brown & Fromm, 1987) that the failure to achieve better outcomes is largely attributable to the fact that most studies have favoured unidimensional over multidimensional treatment protocols. P. Davidson (1987) reported a 70% improvement in 10 migraine patients with H. Spiegel and D. Spiegel’s unidimensional hypnotherapy approach. The patients showed a significant decrease in the severity and frequency of their headaches after four treatment sessions. No control group was used, and no follow-up data were given. In a better-designed clinical trial, van Dyck, Zitman, Linssen, and Spinhoven (1991) randomly assigned 55 tension headache patients to autogenic training or future oriented hypnotic imagery, combined with suggestions to enhance coping, and to decrease headache pain and frequency over time. Patients in both groups received a total of four treatment sessions. No external control group was used. The results of both treatment groups were equivocal, and the data of all treatment groups were pooled for analysis. Significant pre-post differences were then found: Ratings of headache intensity, medication use, and associated depressive and anxiety symptoms decreased. Pain reduction was correlated significantly with hypnotisability across groups, as measured by the Stanford Hypnotic Clinical Scale (Morgan & Hilgard, 1978-1979a), and also with a subjective rating of depth of relaxation and involvement in imagery. In this study, the positive treatment outcome seemed to be related more to hypnotisability than to the type of treatment. In a well-designed study, Olness, MacDonald, and Uden (1987) compared the relative efficacy of self-hypnosis to the use of propranolol and to placebo treatment in children from ages 6 to 12 suffering from classic migraines. A total of 28 patients were randomly assigned to one of three treatment conditions in a 3-month by 3-month crossover design: propranolol in one group and placebo in another for 3 months, and then vice versa for 3 months, after a 1-month baseline period prior to either. After the initial 7 months, all children were taught self-hypnosis for 3 months. Self-hypnosis included suggestions for relaxation, pleasant imagery, and pain control. Self-hypnosis emphasized self-regulation. A significant reduction in the frequency of headaches was found only after self-hypnosis treatment. No changes were reported in the subjective ratings of headache severity or in objective ratings of headache duration. Self-hypnosis was superior to the pharmacological intervention. Unfortunately, the relationship of treatment outcome to hypnotisability was not studied. Although it is clear that hypnosis and self-hypnosis offer some advantage, a definitive clinical study remains to be done. It is unclear why headache frequency and not severity was affected in one study (Olness et al., 1987) and headache Page 4 severity in another (van Dyck et al., 1991). More careful attention needs to be paid to the type of suggestions given, in the context of multimodal treatment that includes relaxation and suggestions for pain control as well as for muscular and vascular control. Moreover, whether a formal hypnotic induction adds to the overall treatment gain has not yet been firmly established. Asthma The prevailing view is that hypnosis is generally effective in the treatment of asthma (D. P. Brown & Fromm, 1987; Wadden & Anderton, 1982). Early controlled clinical studies comparing hypnosis to various control conditions (Maher-Loughnan, McDonald, Mason, & Fry, 1962) described positive treatment effects primarily in terms of subjective effects (e.g., decreased wheezing) and behavioural indices (e.g., decreased use of bronchial dilators). Clinical trials that utilized objective measures of pulmonary functioning reported largely negative results (Edwards, 1960). Thus, although hypnosis may offer some advantage in the treatment of asthma, it remains to be established whether or not hypnotic interventions can alter the physiological basis of the illness-namely, bronchial spasm and tissue inflammation. Two recent studies have attempted to determine the impact on hypnosis on objective measures of airways flow, in addition to the subjective and behavioural outcome measures. Morrison (1988) studied 16 asthmatic patients over a 1-year course of hypnotherapy. Hypnotic relaxation, direct suggestions to alter breathing rate, and ego-strengthening suggestions were given. Each patient also practiced self-hypnosis daily for 5 to 15 minutes. Subjects served as their own controls. After 1 year, a number of objective changes were noted: The number of admissions to the hospital and the duration of stay in the hospital had diminished. and a reduction or total cessation in steroid use had occurred in 14 to 16 patients. Although improvements in peak flow after hypnotherapy were reported for most subjects, these changes in airways flow were highly variable and not always reproducible. The hypnotic suggestions, however, were shown to directly affect the rate and volume of breathing. Morrison alludes to the fact that the inconsistency in the peak flow results may have been related to compliance. The lack of a comparison control group, and the fact that all patients shared the same physician, make it hard to conclude whether the beneficial effects were results of hypnotherapy, transference, or other non-specific treatment factors. A randomized controlled clinical trial conducted by Ewer and Stewart (1986) allows us to draw more definitive conclusions about the efficacy of hypnosis with asthmatics. Hypnotisability was assessed with the Stanford Hypnotic Clinical Scale (Morgan & Hilgard, 1978-1979a). A total of 39 patients were divided into high and low hypnotizable groups and then randomly assigned to either a treatment or a control condition. Hypnotic interventions included suggestions for relaxation, ego strengthening, guided imagery, self-hypnosis, and symptom challenge. Dependent measures included subjective measures of symptom evaluation; behavioural measures of medication use; and subjective sensitivity ratings and objective measures of peak flow and airways response after a methacholine challenge. High hypnotizable subjects in the treatment group showed significant changes in pulmonary functioning (forced vital capacity and peak expiratory flow), as well as objective decreases in bronchial hyperactivity as measured by the methacholine challenge test. Low hypnotizable subjects in the treatment group and high hypnotizable subjects in the control group showed decreased subjective but not Page 5 objective sensitivity during the methacholine challenge test. High hypnotizable subjects in the treatment group also had significant reductions in the subjective evaluation of symptoms, such as wheezing, inhibition of activity, and use of medication, relative to low hypnotizable and nontreatment control subjects. This well-designed study clearly demonstrates that hypnosis affects more than a patient’s subjective evaluation of his or her asthmatic condition. Hypnotic intervention directly affects physiological processes; it reduces the hyperresponsiveness of the airways and improves airways flow in highly hypnotizable patients. Thus, this study lends further strong support to the conclusion reached earlier by Wadden and Anderton (1982) that hypnotisability is positively related to the outcome with asthmatics when hypnotherapy is used. A more recent study of nonhypnotic relaxation therapy with asthma (Murphy, Lehrer, Karlin, Swartzman, Hochron, & McCann, 1989) reached similar conclusions: When a nonhypnotic behavioural intervention was used, a significant change in the response to the methacholine challenge test was correlated with hypnotisability. Gastrointestinal Disorders In Hypnosis and Behavioural Medicine, we (D. P. Brown & Fromm, 1987) wrote that “the treatment of gastro-intestinal disorders with hypnosis has not yet evolved substantially compared with, say, hypnotic treatment of pain and other physiological disorders. Few detailed and proven treatment protocols are available” (p. 117). Whorwell, Prior, and Faragher (1984) undertook the first controlled study comparing the effectiveness of hypnosis, psychotherapy, and placebo treatment for irritable bowel syndrome (IBS). Only the hypnotherapeutic treatment proved effective. More recent research from this clinical research group has convincingly demonstrated the advantage of hypnosis in the treatment of gastrointestinal disorders, such as IBS and duodenal ulcer. In the original study, IBS patients were randomly assigned to one of three treatment conditions: hypnosis, supportive psychotherapy, and placebo treatment. Hypnotic interventions, called “gut-directed hypnotherapy,” focused on direct suggestions for relaxation and ego strengthening. Only the patients in the hypnotic group showed significant treatment gains at a 3-month follow-up. The weakness of the study was that it lacked an extended follow-up. A subsequent study, designed to correct these limitations, reported follow-up data on the 15 original IBS patients previously reported to be successfully treated with hypnosis (Whorwell, Prior, & Colgan, 1987). The later study also contributed another 35 IBS patients treated with hypnosis to the overall data pool. Only 2 patients out of the total sample of 50 patients experienced a single relapse episode of the IBS at the 18-month follow-up. Some attempt was made to identify patient characteristics that predicted the outcome. The success rate with classical cases of IBS (meeting all diagnostic criteria) was 95%, whereas the success rate of atypical cases associated with a wide spectrum of associated symptoms of psychopathology was between 40% and 60%. Age was a factor, in that the success rate was 100% in IBS patients under 50 and only 25% in patients over 50 years of age. Further evidence for the efficacy of hypnosis of IBS has been given by Harvey, Hinton, Gunary, and Barry (1989). A total of 33 patients with refractory IBS were treated with hypnosis in four 40-minute sessions over a 7-week interval. Twenty of the patients showed improvement at a 3-month follow-up. Although this study lacks Page 6 the rigor of an adequate experimental design, the results are entirely consistent with the positive results of the original Whorwell et al. (1984) well-designed study. A major finding in the Harvey et al. (1989) study was that group hypnotic treatment (with up to eight patients) was as effective as individual hypnotherapy. In more recent work, Prior, Colgan, and Whorwell (1990) have focused on psychological mechanisms by which hypnosis works with IBS. Physiological studies were conducted on patients treated with hypnotherapy, who were compared with a no-treatment control group. Thirteen of the 15 hypnotherapy patients, but no control patients, showed significant decreases in symptoms such as abdominal pain, distension. and disturbance in bowel habit. A significant decrease in rectal sensitivity, but not in rectal motor activity as measured by anorectal manometry techniques, was found in diarrhoea-predominant IBS patients. The authors concluded that one mechanism by which gut-directed hypnotherapy works is to desensitize IBS patients to the discomforting visceral sensations associated with IBS. Since the pioneering study by Whorwell et al. (1984) on IBS, other studies have investigated essentially the same treatment strategy with duodenal ulcers. Tosi, Judah, and Murphy (1989) reported on a 3 X 4 multifactorial repeated measures design consisting of pre-treatment, post-treatment, and follow-up testing of 25 patients in one of four conditions: rational stage-directed hypnotherapy, cognitive restructuring, hypnosis only, and a non-treatment control. Hypnosis, consisting of cognitive restructuring of self-defeating beliefs and associated behaviours, contributed to a significant decrease in symptoms and associated beliefs. Colgan, Faragher, and Whorwell (1988) also conducted a trial with 30 patients with rapidly relapsing duodenal ulcers, who were matched and randomly assigned to a hypnotherapy or a control condition. After successful treatment of the duodenal ulcers with ranitidine, the drug was discontinued for 10 weeks. During this interval, the patients in the hypnotherapy group received seven hypnotherapy sessions and were given an audiotape for daily self-hypnosis. The control group was seen by clinicians for the same amount of time but did not receive hypnotherapy. One year after discontinuance of ranitidine, 100% of the control patients, but only 53% of the hypnotherapy patients, had relapsed. Taken as a whole, this group of studies suggests that hypnotherapy can be effective in the treatment of certain types of gastrointestinal disorders. The effectiveness, in my opinion, is dependent on the type of hypnotherapy utilized. The hypnotic interventions used in most of these studies primarily involve ego-strengthening suggestions, a type of hypnotic cognitive therapy. It is well established that there is a strong association between negative cognitions, notably worry, and IBS symptoms (Latimer, 1983). Direct hypnotic suggestions to increase psychological well-being or to restructure cognitions may be particularly well matched to this patient population’s unique characteristics. In addition to altering visceral sensitivity, gut-directed hypnotherapy may serve as a hypnotic cognitive therapy that alleviates negative cognitions, which otherwise serve to exacerbate (and may even predispose patients to) IBS symptoms. Skin Disorders Although it is generally believed that hypnosis is effective in the treatment of a wide variety of skin diseases (D. P. Brown & Fromm, 1987, Scott, 1960), there have been Page 7 relatively few controlled clinical trials using hypnosis in the treatment of skin disorders. However, numerous clinical cases have been reported anecdotally in the literature. The research study most often cited is based on only six subjects. Sinclair-Gieben and Chalmers (1959) treated six patients with bilateral warts. Direct hypnotic suggestions and graded posthypnotic suggestions were given that the warts would disappear, but only on one side of the body; they did. Surman, Gottlieb, Hackett, and Silverberg (1973) replicated this study with 17 patients. Their findings were more modest: A little more than half the patients with bilateral warts improved in the hypnosis group, compared with none in an untreated control group. Wart improvement was not specific to one side of the body. However, no measure of hypnotisability was used. R. F. Q. Johnson and Barber (1978) compared the use of direct suggestions for wart removal in subjects with and without a formal hypnotic induction. The results suggested that wart relief may depend more on task motivation than on the characteristics of hypnosis per se. A few new studies have emerged in recent years. Spanos, Stenstrom, and Johnson (1988) compared hypnotherapy of warts to placebo treatment and a no-treatment control. Only subjects in the hypnotic condition showed significant regression in their warts. In a second experiment reported in the same paper, these authors compared imagery suggestions given with and without a formal hypnotic induction for wart removal; both were equally effective. Since subjects in the respective treatment groups might have had different efficacy expectations, Spanos and his associates conducted another study in which they attempted to differentiate between hypnotic and expectation effects (Spanos, Williams, & Gwynn, 1990). A total of 40 subjects were randomly assigned to one of four conditions: hypnosis; the use of an over-the-counter medication for wart treatment (given the name “Wart-Killing Compound”); a neutral or placebo substance (also called “Wart-Killing Compound”); and a no-treatment control. Subjects in the three treatment groups all developed equivalent expectations regarding treatment effectiveness, as measured by responses to a questionnaire assessing treatment expectations. Hypnosis consisted of a hypnotic induction and direct suggestions for wart disappearance. Only subjects in hypnotic induction showed significant reduction in the number of warts after treatment-an effect that persisted at a 6-month follow-up. Thus, a hypnotic induction, in addition to suggestions for wart disappearance, does seem to contribute significantly to the overall variance of the treatment effect. Although the clinical experimental studies on hypnosis and skin conditions continue to focus primarily on warts, a few reports have appeared regarding other skin conditions. Shertzer and Lookingbill (1987) investigated the effects of hypnotherapy on 1-5 patients with chronic urticaria. A within-subject crossover design was used: Half of the subjects received hypnosis first and then projective psychological testing; the other half received projective testing first and then hypnosis. Both were done on the same day over a 5 hour session. All subjects also were given the Barber Creative Imagination Scale (T. X. Barber & Wilson, 1978) as a measure of hypnotisability, Hypnotic suggestions were used for deep relaxation. Direct suggestions for decreased itching and disappearance of hives were also included. Significant decreases in the severity of itching were reported during and up to 2 hours after hypnotherapy. No differences were found in the number of wheals immediately following hypnotherapy. Hypnotisability did not contribute significantly to the outcome. However, hypnotisability was significantly correlated with itch severity, in that high hypnotizable subjects reported greater itching during control testing. Moreover, these subjects were more likely than less hypnotizable subjects to attribute their urticaria to stress. Thus, hypnotisability may contribute more to the Page 8 development and maintenance of the condition than to its cure. Upon follow-up over the next 14 months, 6 of the 15 subjects were clear of all hives, and 7 showed some improvement. Unfortunately, no data were available on the relationship between the long-term treatment gains and hypnotisability. H’ajek, Jakoubek, and Radil (1990) studied the effects of hypnosis on coetaneous pain threshold in normal subjects and patients with atopic eczema. Coetaneous pain threshold was measured in terms of time taken to measure the subject’s pain threshold following the onset of a standard heat source applied to the skin. Hypnotic suggestions for interrupting pain perception and imagining immune cells destroying damaged skin cells were given in a series of ten 1-hour hypnotherapy sessions in 24 normal and 13 eczemic patients. All hypnotic subjects demonstrated a gradual increase in pain threshold compared to the control subjects in the study, an effect that was significantly correlated with hypnotisability. Overall, these studies suggest that at least subjective effects, such as itching and pain perception, are readily influenced by hypnotic suggestion; the effects of hypnotic suggestion on objective measures of tissue change have yet to be established. Insomnia Although there is a substantial literature on treatment of insomnia (see reviews by Borkovec, 1982; Knapp, Downs, & Alperson, 1976; Turner & DiTomasso, 1980; Montgomery, Perkins, & Wise, 1975), there are fewer clinical research studies on the hypnotherapeutic treatment of insomnia. When relaxation was compared to hypnotic relaxation, relaxation was found to be the superior treatment. Both treatment conditions resulted in subjective reports in sleep improvement, but only nonhypnotic relaxation led to objective changes in decreased frequency of nights of insomnia (Graham, Wright, Toman, & Mark, 1975). When hypnotic relaxation was compared to progressive muscle relaxation and a no-treatment control condition in a well-designed randomized study, both relaxation conditions resulted in significant decreases in the latency of sleep onset relative to the no-treatment control (Borkovec & Fowles, 1973). Unfortunately, the latter study failed to include a measure of hypnotisability, and no controls for non-specific treatment effects were included. An important study that has appeared in recent years on insomnia is that of Stanton (1989a). He conducted a controlled clinical study with 45 subjects matched on their baseline sleep onset latency, and then randomly assigned them to one of three treatment conditions: hypnotherapy, stimulus control, and placebo treatment. The placebo control entailed imagining neutral presleep images. Each group was given four weekly 30-minute treatment sessions. Hypnosis consisted of hypnotic imagery to go to a special place and ego-strengthening suggestions for subjects to let go of their problems. Demand characteristics were controlled by using counter demand instructions in which subjects were told that improvement in their sleep condition would not occur until their fourth treatment session. Sleep onset latency at the end of the third treatment session was used as the primary outcome measure for the counter demand condition, and sleep onset latency at the end of the fourth session was used for the demand condition. A significant reduction of sleep onset latency was found only in the hypnotherapy group: Subjects in this treatment group were able to reduce their baseline sleep onset latency by over 50% by the end of the second treatment session. Since no differences were observed between the counter demand and the demand conditions, Stanton concluded that the positive treatment Page 9 effect was attributable to hypnosis, and not to demand characteristics or other nonspecific treatment factors. The Stanton (1989a) study adds further evidence to the view that hypnosis offers a unique advantage to the short-term treatment of insomnia, at least when nightly sleep onset latency is taken as an outcome measure. Since the Stanton study, unlike the Borkovec and Fowles (1973) study, demonstrated the superiority of hypnosis over behavioural treatment, one possible interpretation of the difference is that the two studies entailed different types of hypnotic suggestion. In addition to suggestions of hypnotic relaxation, Stanton’s subjects were given ego-strengthening suggestions to “let go of their problems.” Once again, this hypnocognitive approach may be particularly well matched to insomniacs, who suffer from a condition of “cognitive hyperactivity” (Borkovec, 1982). Psychoneuroimmunology A rapidly growing area in behavioural medicine is Psychoneuroimmunology (D. P. Brown & Fromm, 1987). Unfortunately, controlled clinical studies of hypnotherapy with patients with immune-related illnesses have lagged behind studies of nonhypnotic interventions. Following the pioneering work of Black and his associates (Black, 1963; Black, Humphrey, & Niven, 1963) on the effects of direct hypnotic suggestions on allergic response, several studies have appeared since 1986 on hypnosis and immediate and delayed immunosensitivity. Locke, Ransil, Covino, Toczydlowski, Lohse, Dvorak, Arndt, and Frankel (1987) failed to demonstrate a significant effect of direct hypnotic suggestions on delayed immunosensitivity in 12 highly hypnotizable subjects as compared to 30 low-hypnotisability controls. Suggestions to either enhance or suppress the size of the allergic skin response or the degree of cellular infiltration failed to produce any significant treatment effect. Zachariae, Bjerring, and Arendt-Nielsen (1989) did find a significant effect on both immediate and delayed immunosensitivity, using direct hypnotic suggestions and guided imagery. Direct hypnotic suggestions were effective in reducing the flair but not the wheal reaction to immediate immunosensitivity to a histamine prick test. Hypnotic guided imagery was effective in significantly modifying the size of the flair and induration in response to delayed immunosensitivity to tuberculin antigen (Mantoux test). Laser doppler flowmetry and ultrasonic measures of skin thickness were used to demonstrate significant changes in regional blood flow and cellular infiltration following hypnosis. The discrepancies between the two studies with respect to the effects of hypnosis on delayed immunosensitivity may have resulted from the different types of hypnotic suggestions given. Another important clinical study has recently appeared. Haanen, Hoenderdos, Romunde, Hop, Mallee, Terwiel, and Hekster (1991) studied the effects of hypnotherapy on patients with refractory fibromyalgia. A total of 40 patients were randomly assigned to 12 weeks of either hypnotherapy or physical therapy. Hypnotherapy consisted of hypnotic relaxation, suggestions to alter sensory perceptions (especially pain perception), and ego strengthening suggestions. Patients were also given a 30-minute audiotape to use for daily self-hypnosis. Patients in the physical therapy group practiced progressive muscle relaxation and received massage therapy. Patients in the hypnotherapy group had significantly less pain, fatigue upon awakening, and sleep disturbance than those in the physical Page 10 therapy group. They also reported significantly less overall discomfort, fewer symptoms, and less use of medications. These effects were still observable at a 3-month follow-up. Objective measures were taken of the number of tender points within the musculature; they were not significantly reduced after either treatment. The authors conclude that hypnotherapy may be useful in alleviating the subjective distress associated with fibromyalgia, but does not necessarily lead to a biological effect. The lack of an external control group, a comparison of treatments with and without hypnotic induction, a comparison of demand and non-demand treatment suggestions, or a measure of hypnotisability makes it impossible to ascertain whether hypnosis per se contributed significantly to the reported positive treatment factor. The most interesting and potentially important study on hypnosis and Psychoneuroimmunology to appear recently is a long-term prospective study of survival rate in women with breast cancer (D. Spiegel, Bloom, Kraemer, & Gottheil, 1989). A total of 86 women with metastasized breast cancer were randomly assigned to either a treatment or a control group. The control group received routine oncological care. In addition, the treatment group received 11/2 hours of weekly supportive group therapy and self-hypnosis for pain control. Follow-up was done every 4 months for the first year. No differences in survival rate were apparent 1 year after treatment. At a 10-year follow-up, only three patients were alive; however, the survival rate for those patients in the group therapy/self-hypnosis group (X = 36.6 months) was double that in the control group (X = 18.9 months). This is one of the few prospective studies available. Since the difference in survival rate was highly significant (p < .0001), the study has generated considerable interest in the past few years. It is quite clear that psychosocial interventions significantly affect survival rate in terminal breast cancer patients, yet it is unclear what worked. Was it the group support? Was it the fact that patients had a context to express feelings? Was it the self-hypnosis? Or was it something else? Research is currently being done to ascertain whether or not self-hypnosis contributed to the positive outcome. Chronic Illness Another growing area within behavioural medicine is the use of psychosocial interventions as an adjunct to the treatment of chronic illness (D. P. Brown & Fromm, 1987). Although hypnosis has not been used extensively in this area, a few interesting and promising exploratory studies have appeared in the past several years. Ratner, Gross, Casas, and Castells (1990) studied the effects of hypnotherapy on compliance with regular insulin injections among adolescent insulin-dependent diabetics. A small sample size was used-only seven patients, each serving as his or her own control. A 6-month documented history of noncompliance with diet, insulin injections, and blood/urine testing served as the baseline measure of non-compliance. Blood haemoglobin and fasting blood sugar levels were used as indices of control over hyperglycaemia. Hypnotic suggestion emphasized self-regulation of the disease. Patients also visualized and reinforced treatment goals during self-hypnosis twice daily. A significant drop in fasting blood sugar and haemoglobin levels occurred over three hypnotic sessions as compared to the pre-treatment levels. Despite the small sample size, the results suggest that hypnosis and self-hypnosis hold some promise in improving compliance with medical regimens in the treatment of certain chronic illnesses such as diabetes. Page 11 In another study, Swirsky-Sacchetti and Margolis (1986) studied the effects of self-hypnosis on haemophilia. A total of 30 haemophiliacs were randomly assigned to self-hypnotic treatment or to a waiting-list control group. The self-hypnosis group received a 6-week training program in self-hypnosis. Subjects learned about the relationship between stress and bleeding. Self-hypnosis was used for relaxation training and ego strengthening suggestions that the patients could give to themselves. Direct hypnotic suggestions regarding decreasing bleeding were included in the instructions. Over the 18-week post-treatment follow-up, the selfhypnosis group significantly reduced the amount of clotting factor used to control bleeding as compared to the no-treatment group. Subjects in the self-hypnosis group also had significantly reduced overall subjective distress, as measured by a symptom checklist. Hypnotisability was not significantly correlated with the positive treatment effect. Whereas the two studies described above have addressed the behavioural dimension of chronic illness, several pilot studies have raised the possibility that hypnosis can directly alter disease course in certain organic conditions. Radil, Snydrova, Hacik, Pfeiffer, and Votava (1988) investigated the effects of hypnosis on the degree of foot drop in hemiparetic patients. Direct hypnotic suggestions were associated with improved movement during and immediately after the hypnosis. The promising results merit a more carefully designed study. Thompson, Hall, and Sison (1986) used a multiple-baseline design to study three patients with Broca's aphasia. Each patient was given hypnotic suggestions to develop vivid visual images of randomly presented experimental picture stimuli. Following hypnosis, two of the patients significantly improved in their ability to name the picture stimuli, although verbal labels were never introduced during hypnotic training. The third subject's naming ability improved after visual and verbal labels were both suggested in hypnosis. AN subjects performed poorly on a hypnotisability scale. Since the hypnotisability of aphasics is unknown, it was not possible to assess the relative contribution of hypnotisability to the positive treatment outcome. Overall, these studies offer promise that hypnotherapy may be useful as an adjunct to the treatment of a variety of chronic illnesses; let us hope that they will serve as an invitation for much more research on hypnosis in this area of behavioural medicine. Medicine and Surgery Surgery The use of hypnosis with medical-surgical patients has a long history. Before chemoanesthesia was known, hypnosis was used as the sole anaesthesia (see E. R. Hilgard & Hilgard, 1983). More recently, hypnosis has also been used to facilitate recovery from surgical operations. In recent years two well-designed clinical studies have appeared (Bonke, Schmitz, Verhage, & Zwaveling, 1986; C. Evans & Richardson, 1998), along with an excellent review of 18 clinical studies over more than two decades on the use of hypnosis to ease the discomfort of operations (Blankfield, 1991). In the study by Bonke et al. (1986), a total of 91 patients undergoing biliary tract surgery were randomly assigned to a treatment group or to one of two control Page 12 groups. All subjects listened to a tape recording in a manner that blocked out all other sound. Neither the patients nor the operating staff could tell which tape played during the surgery. The treatment group listened to a hypnosis tape consisting of ego-strengthening suggestions for relaxation, enhanced wellbeing, decreased discomfort, and rapid recovery. The placebo control groups listened to a recording of either white noise or typical operating room sounds. No significant differences were found between groups in duration of postoperative hospital stay, subjective well-being, subjective experience of pain, or the use of pain medications. The objective ratings of postoperative recovery by nursing staff also failed to yield significant differences between the groups. When the results were analyzed, taking age into account as a variable, a significant difference emerged with respect to duration of postoperative hospital stay: Older people (above 55 years of age) had a significantly shorter stay, but only in the hypnosis group. Another well-designed study, that by C. Evans and Richardson (1988), yielded somewhat more positive findings. They conducted a double-blind placebo control study of 39 women undergoing abdominal hysterectomy. Subjects were randomly assigned to a treatment group (n = 19) or a placebo control condition (n = 20), and were played either a pre-recorded audiotape of hypnosis or a blank tape during the operation. Operating room staff were unaware of which tapes subjects heard during the surgery. Hypnosis consisted of 12 minutes of continuous suggestions describing typical operative and postoperative experiences, along with ego strengthening suggestions focused on enhanced ability to cope with the experience of the operation. Patients in the hypnosis group had a significantly shorter stay in the hospital than the controls, significantly less pyrexia, and fewer gastrointestinal problems. Also, nurses rated the hypnosis patients as significantly more mobile than those in the control group during their postoperative recovery. There were no significant differences between the groups in the use of medication, report of mood state, anxiety, pain report, or occurrence of symptoms such as nausea and vomiting. Noxious Medical Procedures Hypnosis has also been used to alleviate the distress associated with noxious medical procedures. L. C. Walker, Dawson, Pollet, Ratcliffe, and Hamilton (1988) conducted an uncontrolled outcome study with 14 patients, all of whom had severe side effects from chemotherapy as part of their cancer treatment. Two to six 30-minute sessions of hypnotherapy were used as an adjunct to the typical course of chemotherapy. Improvements in both nausea and vomiting were reported in the majority of patients. Hockenberry-Eaton and Cotanch (1989) studied the effects of hypnotherapy on perceived self-confidence in children undergoing chemotherapy for the treatment of cancer. Twenty-two children were randomly assigned to a self-hypnosis treatment group and a group receiving standard medical care. Self-hypnosis practice emphasized increased control and mastery. Relative to the control children, the children in the self-hypnosis group had significant increases in five of six dimensions of perceived self-confidence. Both groups showed increases in social and academic confidence after treatment. Wall and Womack (1989) studied the effects of hypnosis on distress associated with bone marrow aspiration and lumbar puncture in paediatric oncology patients. A total Page 13 of 20 subjects were randomly assigned to an hypnotic treatment condition or a cognitive strategy condition. Subjects in both groups received instructions in coping strategies designed to distance the children psychologically from uncomfortable medical procedures. Subjects in the hypnosis group were also given a hypnotic induction. Both groups showed significant decreases in pain but not anxiety. Hypnotisability did not correlate with pain reduction. It appears from these studies that hypnotic interventions hold some promise m reducing subjective distress, enhancing psychological well~ being, increasing recovery rate, and decreasing associated symptoms in patients undergoing uncomfortable medical and surgical procedures. However, much more work needs to be done with carefully controlled, randomized, blind clinical trials designed to discriminate among the differential effects of hypnotisability, hypnotic induction, situational demands, and type of hypnotic suggestions before definitive conclusions can be drawn as to the relative efficacy of hypnotic interventions as an adjunct to such procedures. A few studies have also appeared in which hypnosis has been used with obstetrical and gynaecological patients. Omer, Friedlander, and Palti (1986) and Omer (1987) investigated the effects of hypnotic relaxation as an adjunct to pharmacotherapy with 39 pregnant women hospitalized for premature labour contractions. Another 74 women in the control group received pharmacological treatment alone. Hypnotic suggestions focused on relaxation, increased control over bodily processes (including uterine contractions), and future time orientation to completion of the pregnancy at full term. Patients in the hypnosis group were also given audiotapes for daily self-hypnosis practice. The rate of pregnancy prolongation and mean weight of the infants were both significantly higher in the hypnosis group than in the medication control group. This study suffers from a number of methodological flaws-for example, non-random assignments to conditions, unmatched demographic and medical variables across groups, greater treatment time and therapist contact in the treatment group, and failure to assess hypnotisability. Thus, it is impossible to say whether hypnosis contributed to the significant treatment effects. The preliminary findings are important enough, however, to merit carefully designed controlled clinical trials on the effects of hypnosis in delaying premature labour. In another study, Venn (1986) compared the efficacy of hypnosis to the Lamaze method for childbirth. A total of 122 women self-selected for one of three treatment groups: Lamaze classes alone (n = 8), hypnosis alone (n = 17), or Lamaze plus hypnosis (n = 25). Subjects who volunteered were given the Stanford Hypnotic Clinical Scale (Morgan & Hilgard, 1978-1979a) (only a small portion of the subjects in the groups volunteered to take the hypnotisability test). Group hypnosis training included suggestions for pain control, age progression through the birth experience, and posthypnotic suggestions to re-enter hypnosis at the appropriate time during labour and delivery. There were no significant differences between treatment groups in self-ratings or nurses' ratings of pain experience or well-being during labour, use of medication, or duration of labour. Hypnotisability was moderately correlated with subjective reports of less pain and discomfort during delivery, but only in the Lamaze group in which sufficient subjects took the hypnotisability scale. Although Venn concludes that there may be "functional similarities between hypnosis and Larnaze" (1986, p. 79), the failure to assign women randomly to the treatment conditions makes it difficult to distinguish between self-selection and treatment effects. Page 14 Health-Risk and Addictive Behaviours Traditionally, clinical studies on hypnosis and smoking have been poorly designed. Moreover, the wide variety of hypnotic treatment strategies utilized has led to marked variations in treatment outcomes, which make it difficult to draw conclusions (D. P. Brown & Fromm, 1987). In an authoritative review of the literature, Wadden and Anderton (1982) concluded that hypnosis is not a uniquely effective strategy for smoking cessation or weight reduction. In response to this quite negative conclusion, we (D. P. Brown & Fromm, 1987) stated that the largely inconsistent and often poor maintenance rate at long-term follow-up intervals is more a problem with often ill-conceived hypnotic strategies to stop smoking or lose weight than with hypnosis per se. Within the field of behavioural medicine, there has been a distinct shift toward multimodal or broad-spectrum treatment approaches and also toward maintenance or relapse prevention strategies for weight loss and smoking cessation in particular, as well as for addictive behaviours in general (D. P. Brown & Fromm, 1987; Marlatt & Gordon, 1985). Nevertheless, by the time of the publication of Hypnosis and Behavioural Medicine (D. P. Brown & Fromm, 1987), few controlled clinical trials using primarily mulitmodal or relapse prevention approaches to hypnosis and weight reduction or smoking cessation had appeared in the literature. Multimodal strategies include interventions designed to address a number of dimensions of complex addictive behaviours: increasing motivation; facilitating coping; encouraging self management of the habit per se; providing alternatives to the manner in which the. habit is used in the service of affect regulation; altering negative cognitions and self-images that reinforce the addiction; decreasing negative social influences; and attenuating withdrawal states and risk situations for relapse. The research literature on hypnosis and smoking and weight loss in the last several years can be grouped into three categories: (1) comparative efficacy studies; (2) multimodal hypnotic interventions; and (3) single session hypnotic interventions. Consistent with our earlier conclusions (D. P. Brown & Fromm, 1987), results of the multimodal studies merit serious consideration. The comparative efficacy studies have generally failed to show an advantage of hypnotic interventions over other methods. Hyman, Stanley. Burrows, and Horne (1986) compared hypnosis to focused smoking and to attention placebo and waiting list control conditions in 60 subjects. Smoking rates were not significantly different at the 3- and 6-month follow-ups. Frank, Umlauf, Wonderlich, and Ashkanazi (1986) compared different types of hypnotic treatments: two hypnotic sessions, four hypnotic sessions plus a booster; or two hypnotic sessions plus two behavioural sessions with a booster. A group hypnotic treatment protocol was used to enhance motivation and to facilitate coping strategies to quit smoking. There were no significant differences across treatments in the number of cigarettes smoked. A total of 31% of all subjects were abstinent at the end of treatment, and 20% at the 6-month follow-up. Success was negatively correlated with scores on the Creative Imagination Scale. Considering that most smoking interventions show recidivism to a baseline maintenance of about 20% by the second year after treatment, the results of these comparative efficacy studies are not impressive. The results of multimodal interventions, in which hypnosis is integrated into a broad-spectrum treatment protocol, are more promising. T. B. Jeffrey, Jeffrey, Greuling, and Gentry (1985) developed a five-session treatment protocol, which included behavioural management of the habit, cognitive interventions, hypnotic Page 15 relaxation, hypnotic reinforcement of the commitment to stop smoking, suggestions for smoking cessation, ego strengthening, and hypnotic control of craving to smoke. A total of 35 subjects in the group treatment sessions were compared to 30 waiting-list control subjects. Significantly more subjects in the multimodal hypnosis treatment group were abstinent than in the control group. A total of 63% in the hypnosis group were abstinent at the end of the treatment, and 31% maintained abstinence at a 3-month follow-up. In a subsequent study, L. K. Jeffrey and Jeffrey (1988) added another dimension to this treatment; they called it "exclusion therapy." All smokers were required to maintain abstinence for 48 hours just prior to the treatment. A total of 120 subjects were randomly assigned to the hypnotic treatment condition, half of them with and half of them without a pre-treatment abstinence condition. There were no significant differences between the treatment conditions. The abstinence rate in both groups was 59% at the end of treatment and 37% at the 3-month follow-up point. Unfortunately, the 1988 study lacked a control group, and no measures of hypnotisability were used in the earlier study. Nevertheless, compared to the predicted baseline recividism rate of 20%, multimodal hypnotic protocols may offer a distinct advantage to smoking cessation; still, a 3-month follow-up is too short to permit conclusions to be drawn about the efficacy of multimodal treatment. The efficacy of multimodal hypnotherapy for weight loss has also been investigated (Cochrane & Friesen, 1986). A total of 60 obese women (>20% overweight) were randomly assigned to one of three conditions: group hypnosis; group hypnosis plus self-hypnosis; and a control group. Hypnosis in both treatment conditions included a group hypnotic induction, group suggestions to enhance motivation, ego strengthening, and facilitation of patients’ decision making about weight treatment goals. Individualized hypnotic suggestions helped each patient identify unconscious factors related to weight loss. Patients in the treatment groups attended two weekly 3-hour sessions over a month. Whereas patients in the control group did not lose weight, patients in both treatments groups had a significant mean weight loss of 7-8 pounds at the end of the treatment and of about 17 pounds at a 6-month follow-up. Various measures of patient characteristics were included in the study. These included measures of suggestibility, imagery absorption, self-concept, family-of-origin conflict, age of onset of obesity, educational level, and socioeconomic status. None of these variables were significantly related to weight loss. Cochrane and Friesen concluded that hypnotherapy is a useful treatment for weight reduction. The addition of self-hypnosis did not add anything to the positive treatment outcome. The mean weight loss of 17 pounds at the 6-month follow-up is consistent with the expected weight loss from behaviourally oriented interventions (D. P. Brown & Fromm, 1987), although at least a 2-year follow-up interval is usually required in the weight loss field before clear conclusions can be reached (Stunkard, 1977). The other popular approach to smoking and hypnosis entails a single session treatment. Neufeld and Lynn (1988) reported their findings on a 2-hour single-session multimodal hypnotic protocol. The treatment manual included hypnotic suggestions to increase motivation, to induce relaxation, to alter self-image by visualizing the self as a non-smoker, to identify risk situations and enhance coping strategies to prevent relapse, and to enhance the health benefits from smoking cessation. Abstinence rates were 26% at a 3-month follow-up and 19% at a 6-month follow-up. A study with more promising results was conducted by Williams and Hall (1988). A total of 60 subjects were assigned to a single-session hypnotic Page 16 treatment, a placebo condition, or a non-treatment control condition. Subjects in the hypnotic condition received primarily hypnotic cognitive therapy, adapted from H. Spiegel (1970) and Stanton (1978). Subjects in the treatment group were significantly more abstinent (60%) than the controls (40%) following treatment. About 45% of the subjects maintained their abstinence at a 48-month follow-up. A. F. Barabasz, Baer, Sheehan, and Barabasz (1986) studied a variety of treatment variables in 307 patients who utilized group hypnotic treatment for smoking cessation. The primary intervention was a single-session hypnotic approach. A number of subgroups were used, each of which varied the length of the session, the use of additional sessions, the use of post-treatment booster sessions, and the use of adjunctive sessions with REST. Some subgroups were led by interns and some by experienced psychologists. The primary hypnotic intervention employed H. Spiegel’s (1970) approach to maintaining commitment to health. Abstinence rates at various follow-up points varied considerably, from 4% to 47%. The highest abstinence rates were found when experienced clinicians were used, when patients were given more treatment contact, and when REST (see Barabasz & Barabasz, Chapter 7, this volume) was used as an adjunct to hypnotherapy (the 47% abstinence rate was achieved at a 20-month follow-up in the hypnosis plus REST condition). In contrast to the previous negative conclusions of Wadden and Anderton (1982), hypnotisability was correlated significantly with the treatment outcome of this study. The studies. discussed above suggest that single-session treatment is worth considering as a brief cost-effective approach to smoking cessation. To the extent that tentative conclusions can be drawn, despite the various methodological weaknesses in the studies, it appears that unidimensional treatment emphasizing primarily hypnocognitive interventions (H. Spiegel, 1970; Stanton, 1978) yield better results than multimodal approaches (Neufeld & Lynn, 1988) in single-session hypnotic treatment. It may be that multimodal protocols are too complex for patients to grasp in a single session. Moreover, positive treatment outcomes may depend more on hypnotisability in single-session treatment than is the case over a number of sessions, where a variety of nonhypnotic variables may effect treatment outcome. At any rate, the A. F. Barabasz et al. (1986) paper is valuable in helping us to appreciate the complex number of variables that must be addressed if significant progress is to be made in the use of hypnosis for weight reduction and smoking cessation. Psychiatric Conditions Very few controlled clinical trials of hypnotherapy for psychiatric conditions have appeared in recent years. Several studies are worth noting, although each suffers from methodological limitations. Der and Lewington (1990) used a single-subject design to study the effects of hypnotherapy on panic attacks. After a 2-week baseline period, the subject was treated with hypnotherapy for 13 weeks. The hypnotic method was largely cognitive an integration of hypnotically enhanced self-control strategies and rational-emotive therapy. According to the subject’s reports and responses to objective symptom inventories, there was a reduction in anxiety-related symptoms. Although this study provides more data than an anecdotal case report, it is hard to make treatment generalizations from a single case. Page 17 Clarke and Reynolds (1991) conducted an outcome study on hypnotherapy and bruxism with eight patients. Hypnotic suggestions emphasized enhanced awareness of and control over masseter muscle activity. Nightly electromyographic (EMC) measurements of masseter activity served as the outcome measure, along with subjective ratings of pain. Relative to baseline measurements taken before treatment began, the bruxers showed a significant decrease in EMC activity and subjective reports of pain. Treatment gains were maintained up to 36 months. Griffiths (1989) investigated the outcome of hypnobehavioral therapy with 12 bulimia nervosa patients. Treatment consisted of 4 weeks of behavioural therapy followed by 4 weeks of hypnotherapy. Hypnotic suggestions emphasized enhanced selfcontrol and mastery. Significant reductions in bingeing and vomiting were observed after treatment and at a 9-month follow-up. However, the lack of control groups or a crossover design between the behavioural and hypnotherapy treatment makes it difficult to assess the relative contribution of hypnosis to the positive treatment outcome. One very important large-scale controlled outcome study was conducted on patients in The Netherlands with a diagnosis of post-traumatic stress disorder (Brom, Kleber, & Defares, 1989). The study included 112 patients who had been victims of violent crimes, had lost someone close to murder or suicide, or had suffered a serious traffic accident. Patients typically scored very high on the Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979), which measures intrusion and avoidance symptoms in response to traumatisation. All patients were randomly assigned to one of four conditions: (1) desensitization therapy, in which subjects were presented with traumatic scenes from a hierarchy while in a relaxed state; (2) hypnobehavioral therapy, in which patients learned to cope better with traumatic imagery while in trance; (3) brief psychodynamic therapy, emphasizing resolution of conflicts triggered by the traumatic experience; and (4) a waiting-list control. All treatment was conducted by therapists who had at least 10 years of experience with the respective treatment approach. The average treatment lasted from 15 to 18 sessions. Relative to the waiting-list controls, who changed very little, subjects in all three treatment groups showed a significant reduction in post-traumatic symptoms as well as in a host of other symptoms. Subjects in all three treatment groups also reported significantly less distress and improved self-esteem. About 60% of all treated patients improved, in comparison to 26% in the control group. There were few remarkable differences across treatment groups, except that subjects in the desensitization and hypno-behavioural groups showed a greater initial reduction in intrusive re-experiencing of symptoms than did the psychotherapy group. This finding is not surprising, because in both of the former groups the treatment directly emphasized active coping with intrusive post-traumatic symptoms. Since no measure of hypnotisability was included, it is impossible to say whether or not hypnotisability contributed anything unique to the positive treatment effect. Nevertheless, this ground-breaking study is the first to clearly demonstrate the effectiveness of hypnotherapy in the treatment of post-traumatic stress disorder. The 60% improvement rate at the 6-month follow-up is impressive for brief treatment of this condition. A limitation of the study is that the hypno-behavioural approach used was limited to what others have called the “stabilization phase” of posttraumatic recovery (D. P. Brown & Fromm, 1986). It is conceivable that additional hypnodynamic treatment designed to help traumatized patients uncover and integrate the memories and feelings associated with traumatisation may elevate the Page 18 overall treatment effect. The Clinical Relevance of Hypnotisability Wadden and Anderton (1982) concluded in their review that hypnotisability is significantly correlated to treatment outcome for pain, asthma, and warts, but not for self-initiated disorders such as smoking, weight problems, and alcoholism. Although a number of additional studies on hypnotisability have appeared in the literature in the last several years, the conclusions we might draw at present are not essentially very different from those drawn by Wadden and Anderton a decade ago. A number of studies have found a significant relationship between hypnotisability and the reduction of chronic pain (A. F. Barabasz & Barabasz, 1989), chronic facial pain (Stam, McGrath, Brooke, & Cosier, 1986), and headache (van Dyck et al., 1991). However, insignificant results have also been reported with paediatric patients suffering from headaches (M. S. Smith, Womack, & Chena, 1989) or undergoing painful medical procedures (Wall & Womack, 1989). The recent studies on asthma (Ewer & Stewart, 1986; Murphy et al., 1989), like the earlier studies, have consistently reported a significant relationship between hypnotisability and treatment outcome. Wadden and Anderton’s (1982) comments about skin disorders were limited to warts. More recent studies suggest that at least the subjective effects associated with certain other skin conditions are significantly related to hypnotisability-for example, the severity of itching accompanying chronic urticaria (Shertzer & Lookingbill, 1987) and the pain associated with atopic eczema (H’ajek et al., 1990). With respect to behavioural conditions, the evidence is inconsistent. A. F. Barabasz et al. (1986) found that hypnotisability was significantly related to smoking cessation, but Frank et al. (1986) did not find such a relationship. Hypnotisability has also been found to be significantly related to weight reduction (Andersen, 1985) and not significantly related to it (Cochrane & Friesen, 1986). With regard to other clinical populations, no significant relationship was found between hypnotisability and treatment outcome in delayed immunosensitivity (Locke et al., 1987) or with hemophiliacs (Swirsky-Sacchetti & Margolis, 1986). Although no definite conclusions can be drawn, some patterns do emerge. One reasonably consistent finding is that hypnotisability does appear to be significantly related to treatment outcome in adults with pain, asthma, and certain skin conditions. Hypnotisability does not appear to be significantly related to treatment outcome with respect to certain psychobiological conditions such as immune response and blood clotting. The relationship between hypnotisability and behavioural disorders such as smoking and weight problems is so exceedingly complex that, so far, no consistent findings have emerged. Overall, Wadden and Anderton’s (1982) conclusions are still relevant, except that the recent findings regarding health-risk behaviours are less consistently negative than those reported by Wadden and Anderton. Hypnotisability may be related to the development or at least to the maintenance of certain clinical conditions. Since the pioneering work of Frankel (1976) on phobias, clinical researchers have come to appreciate the role of hypnotisability and associated dissociative mechanisms in the etiology of diseases. The early studies documented a significant treatment correlation between hypnotisability and anxiety/ phobic disorders. Although more recent studies have not always found a significant correlation (Owens, Bliss, Koester, & Jeppsen, 1989) the view that hypnotisability Page 19 may contribute to the formation and maintenance of certain symptoms has persisted. For example, patients suffering from post-traumatic stress disorder (D. Spiegel, Hunt, & Dondershine, 1988) and multiple personality disorder (Bliss, 1986) are generally more hypnotizable than normals. Severe abuse may cause children to draw upon normal dissociative capacities in the service of defence; if this is done repeatedly, it may lead to the development of dissociative disorders (Braun & Sachs, 1985; F. W. Putnam, 1989). Hypnotisability has also been found to correlate positively with nightmare occurrence (Belicki & Belicki, 1986), severity of itching in patients with chronic urticaria (Shertzer & Lookingbill, 1987), and proneness to nausea and vomiting during pregnancy (Apfel, Kelley, & Frankel, 1986). Although it is tempting to speculate about some underlying mechanism by which normal hypnotic ability is transmuted into psychopathology, notably psychophysiological and dissociative disorders, some caution is necessary. Most of these studies in question simply demonstrate a correlation between hypnotisability and psychopathology, and a correlation does not imply a causal relationship. Current and Future Trends An examination of the clinical research on hypnotherapy in the past several years makes it clear that the preponderance (if controlled clinical research during that period was done in the domains of behavioural medicine in particular and medicine in general. Hypnosis and Behavioural Medicine (D. P. Brown & Fromm, 1987) was written with the intent of inviting a greater integration of the respective fields of hypnotherapy and behavioural medicine. It is encouraging to see the increased application of hypnosis in the field of behavioural medicine, and even more encouraging to see the number of clinical research studies appearing the literature that document the efficacy of hypnosis in the treatment (or adjunctive treatment) of psychophysiological and medical illnesses. Data are accumulating that enable us to carefully evaluate the efficacy of hypnosis in treating pain, headache, asthma, gastrointestinal disorders, skin disorders, immune diseases, and insomnia, as well as in facilitating adjustment to noxious medical procedures and chronic illnesses. The main contributions of hypnosis to clinical outcome, lie in positive subjective effects (decreased distress and increased well-being) and in behavioural changes (symptom reduction, a decrease in the use of medication and the frequency of medical visits). Whether or not hypnosis can alter the underlying pathophysiology of psychophysiological disorders and chronic illnesses remains largely untested, though there are interesting suggestive findings with respect to asthma, hemiparesis, premature labour, and metastatic breast cancer. With respect to habit disorders, the efficacy of hypnosis is not firmly established. The percentages of hypnotized patients who stop smoking or lose weight, and who maintain the treatment gains for reasonable follow-up intervals of 1 to 2 years, vary considerably across clinical research reports; as a result, it is impossible to say whether or not hypnosis consistently adds anything unique to the treatment outcome. Instead of attempting to demonstrate the efficacy of hypnosis in the treatment of health-risk behaviours, a more promising research strategy in recent years has been to identify the numerous complex variables relevant to treatment outcome. These include patient and therapist characteristics, the nature of the therapeutic interaction, and the context of the treatment and the intervention used (which in this case includes the nature of the hypnotic induction and the specific hypnotic suggestions given). A. F. Barabasz et al.’s (1986) follow-up study on smoking cessation and Cochrane and Friesen’s (1986) study on weight control at Page 20 least move in the direction of identifying a range of relevant variables, in addition to investigating the relative efficacy of hypnotherapy with health risk behaviours. Certainly much more work needs to be done in this area. The main surprise in reviewing hypnotherapy research since 1986 is the absence of controlled clinical trials of hypnotherapy with psychiatric disorders. The one important exception is the study by Brom et al. (1989) on posttraumatic stress disorder. Then again, judging from the rapid proliferation of clinical literature on post-traumatic stress disorder in the past decade, it is just as surprising that only one reasonably well-designed controlled clinical outcome study has appeared in the literature. Several anecdotal reports have appeared regarding multiple personality disorder patients who were successfully treated with hypnosis (Coons, 1986; Kluft, 1985; Ross, Norton, & Fraser, 1989; Ross, Norton, & Wozney, 1989). However, controlled clinical trials using hypnosis as the primary intervention with such patients have not yet appeared. In contrast, about 40 clinical reports (mostly anecdotal) on hypnosis and dissociative disorders have appeared in the hypnosis journals or in the journal Dissociation since 1986. Although there appears to be tremendous interest in the use of hypnosis in the treatment of post-traumatic stress and dissociative disorders, the field simply has not evolved enough to generate a foundation of solid clinical outcome studies. Yet the paper by Brom et al. (1989) is indeed a very promising beginning. It is all the more puzzling, then, that controlled studies of hypnotherapy in more established areas of psychiatric treatment (e.g., anxiety, phobias, conversion disorders, grief reactions, and habit disorders) have been virtually nonexistent in recent years. Neglected Areas This reflection on the areas of hypnotherapy research that have developed in the past several years makes it easier to see the blind spots in such research. First, considering the enormous amount of research conducted on drug efficacy in this country, it is amazing that there has been virtually no research on the interaction of hypnosis and drug-induced states. It is likely that many patients treated with hypnosis take medication for their main complaint and/or other conditions. But we know virtually nothing about how various medications affect hypnotic responsiveness, or how hypnosis may potentiate or attenuate drug effects. It is well established that set and setting greatly affect drug experiences (Tart, 1969). Likewise, the types of cognitive tasks carried out in hypnosis and situational variables significantly affect hypnotic responsiveness. Therefore, research on the interaction of drug effects, hypnotic suggestions, expectation effects, and contextual variables would be quite useful. With respect to psychiatric conditions, there has been far too little work on hypnosis with affective disorders. Since cognitive therapy has made significant contributions to the treatment of depression (Burns, 1980), it is surprising to see so few studies on hypnocognitive therapy and depression. It would be useful to see research on the applications of Hartland’s (1965) ego-strengthening suggestions or Stanton’s (1989b) rational-emotive hypnotherapy in controlled clinical studies with depressive patients. Moreover, the use of hypnosis with bipolar patients is controversial. There are arguments for (Feinstein & Morgan, 1986) and against (D. P. Brown & Fromm, 1986) its use. These clinical arguments need to be backed up by research. Another rapidly developing area of clinical hypnosis is the hypnoanalytic treatment Page 21 of severely disturbed patients-that is, schizophrenic, borderline, and narcissistic patients. A number of important clinical papers and books on the theory and practice of hypnoanalysis with such patients have appeared in the literature (E. L. Baker, 1981, 1987, 1990; Fromm, 1984; D. P. Brown, 1985; D. P. Brown & Fromm, 1986; Copeland 1986; Sands, 1986; Hodge, 1988). Although claims have been made about the efficacy of hypnosis in the treatment of certain severely disturbed patients, virtually no clinical research studies have examined these claims. Priority should be given to outcome studies for potentially useful treatments with the chronically mentally ill. Another “hot” clinical area is the treatment of alcoholism and other substance abuse. Since our (D. P. Brown & Fromm, 1987) review of the hypnotherapy literature in this area, only a few anecdotal case reports have been published (Orman, 1991; Stanton, 1987); no controlled outcome studies on hypnotherapy with substance abuse have appeared. If this field is to address current social and clinical problems, much more work is needed in this area. Finally, it is quite rare to find a reference in the clinical hypnosis literature to the use of hypnosis with patients from ethnic minority groups. Since 1986, one clinical article has described the use of hypnosis with Hispanic burn patients (Dobkin de Rios & Friedman, 1987). In another article, Richeport (1988) argues that it is important to understand cultural differences in framing hypnotic treatment. With the exception of these two articles, no other references to the concerns of ethnic minorities could be found in the clinical hypnosis literature surveyed, and certainly no controlled clinical studies have been conducted on hypnotherapy with ethnic minority populations. A Shift toward Integrative Hypnotherapy In the past several years, a number of authors have clearly articulated the theoretical foundations that guide their use of hypnosis in psychotherapy. Some (D. P. Brown & Fromm, 1986; Lavoie, 1990; Watkins, 1986) have presented consistent theoretical explanations of the psychodynamic theories underlying their approaches to hypnotherapy and hypnoanalysis. Others (D. P. Brown & Fromm, 1987; E. L. Baker, 1990; Copeland, (1986) have detailed the essential features of a structural/ developmental psychoanalytic theory as it applies to the hypnoanalytic treatment of the severely disturbed psychiatric patient. Several clinicians have articulated the essential features of their behavioural (D. P. Brown & Fromm, 1987; Spinhoven, 1987) and cognitive-behavioural (Stanton, 1989a,b; Okhowat, 1985) approaches to hypnotherapy. Still other clinicians have attempted to integrate family systems theory and hypnotherapy (Brink, 1986-1987; Lind, 1989; Somer, 1990). In my opinion, the best clinicians mature beyond identification with a particular theoretical position and are able to move flexibly across diverse theoretical perspectives to select the theory and related treatment approach, or combination of approaches, that best matches a given patient’s needs. When the data of the individual case are used to guide the selection of a treatment from among diverse possibilities, the selection process is by no means haphazard or eclectic, but systematic and integrative. As I see it, integrative psychotherapy is probably the wave of the future as we come to understand which treatments are best matched to which conditions. In anticipation of this trend, more studies are necessary in which the outcome of hypnotherapy conducted from diverse theoretical perspectives is compared with respect to selected patient populations. For example, this chapter Page 22 has reported a number of positive outcome studies in which hypnocognitive therapy was matched to specific patient populations whose illnesses had a high cognitive load (notably patients with IBS and insomnia). In an ideal sense, criteria may be developed to guide clinical treatment planning, so that we know which particular approach to hypnotherapy is best suited to a particular syndrome or personality type. Design Strategy There are four types of clinical research designs, intended to meet different goals. Clinical efficacy studies are designed to answer these questions: Does a particular treatment work? Is it effective? Comparative efficacy studies are designed to compare the relative efficacy of two or more treatment approaches: For example, is hypnotherapy more effective than progressive muscle relaxation or a cognitivebehavioral approach to the treatment of insomnia? Multimodal studies compare the relative contribution of a number of combined treatment strategies to the overall variance of the clinical outcome. A sample question here is as follows: How much do motivational enhancement, hypnotic relaxation, behavioural habit management, hypnocognitive therapy, and relapse prevention strategies each contribute to the overall treatment outcome, when these combined strategies are used for smoking cessation? Finally, individualized designs allow the individual patient to select and/or tailor hypnotic imagery and suggestions within the overall treatment frame. The question here is this: Are individual treatment protocols more or less effective than standardized treatment protocols? In the field of behavioural medicine, the majority of the studies have been comparative efficacy studies, with a more recent shift toward more sophisticated multimodal and individualized designs (D. P. Brown & Fromm, 1987). In the area of psychotherapy research in general, a number of internally consistent treatment manuals are appearing; the components of these treatments can be added or subtracted as a means of assessing the relative contribution of each component to the overall outcome (Beutler & Clarkin, 1991). The hypnotherapy studies reviewed here follow the same trend as do other studies of behavioural medicine and psychotherapy outcome. Newer research areas (e.g., treatment of eczema or duodenal ulcer) are primarily represented by clinical efficacy studies. A number of comparative efficacy studies have emerged, in which hypnosis and (typically) behavioural or cognitive-behavioural treatments have been compared. There are, however, still very few multimodal and individualized treatment designs represented in the studies reviewed. Because a trend toward integrative psychotherapy, along with the development of dearly articulated treatment manuals, is anticipated, more multimodal and individualized designs are warranted. The Standard of Research Design In reflecting on the clinical hypnosis research over the past several years, I find it encouraging to see an increase both in the number of clinical studies and in the number of well-designed controlled clinical studies, in contrast to poorly designed post hoc comparisons of nonrandomized groups (Beutler, Crago, & Machado, 1991). The standard of hypnotic research has been raised somewhat by the well-designed studies that have appeared, By “well-designed,” I mean studies that use appropriately matched control groups along with experimental groups; that Page 23 randomise assignment into these groups; that conduct the treatment in a blind way, wherever possible; and that also control for situational demands (e.g., through the use of placebo controls, simulator controls, counter demand suggestions, etc.). Such ideal designs, although easy to carry out in experimental settings with normal subjects, are much harder to implement with clinic patients. The fact that a number of the studies reviewed here move in the direction of meeting most of these criteria is encouraging and suggests that a clear standard of hypnotherapy research is evolving. Nevertheless, even the best of these studies fall far short of the ideal. The evolving standard of psychotherapy outcome research addresses the complex interaction of different important variables: (1) specific treatment; (2) therapist qualities; (3) patient characteristics; (4) specific problem area; and (5) nature of the setting (Beutler & Clarkin, 1991). Psychotherapy process research has also emphasized the importance of understanding the therapist/patient relationship (Beutler et al., 1991). Within the wider context of psychotherapy research, it is too simple to ask the hypnotherapy outcome question, “Does hypnosis work in treating certain symptoms?” (D. P. Brown & Fromm, 1987, p. 57). Clinical outcome studies of hypnotherapy must control for at least six specific types of variables: (1) treatment variables (the approach to hypnosis, the style of hypnosis used, the nature and wording of suggestions given); (2) hypnotherapist variables (the level of experience of the hypnotherapist, the characteristics of the hypnotherapist); (3) the characteristics of the given patient population; (4) the nature of the presenting problem; (5) the nature of the setting (the context of the treatment, and the expectation and situational demands inherent in that context); and (6) the quality of the hypnotherapeutic relationship. If there is one major flaw in most of these outcome studies, I believe that it is the recurrent failure to control for the type of hypnotic suggestions utilized in each type of clinical trial. Unfortunately, it is still quite rare to see a research report that includes the entire wording of the hypnotic protocol used in the treatment. This curious omission merits some explanation. In part, it can be attributed to the greater emphasis on studying hypnotherapy outcome than on hypnotherapy process. Within the wider context of psychotherapy research, the evolving standard is likely to be a integration of process and outcome research (Beutler et al., 1991). Thus, I anticipate that more emphasis will be given to the hypnotherapy process in the future by investigators studying hypnotherapy outcome. Since there is much we do not know about the process of hypnotherapy, it may be advisable to follow the general recommendation of L. Horwitz and his associates for psychotherapy process research-namely, that future research engage in hypothesis finding about therapy process as much as in hypothesis testing about therapy outcome (L. Horwitz, Allen, Colson, Frieswyk, Gabbard, Coyne, & Newsom, 1991). Hypnotisability versus a Specificity Theory of Hypnotic Responsiveness Clinical research on hypnosis has often included some standardized measure of hypnotisability and/or has controlled for some kind of specified formal hypnotic induction. The underlying assumptions of this research strategy were as follows: (1) The hypnotic state is a unitary phenomenon that is or is not induced; and (2) the induction of this so-called hypnotic state or trance may contribute to treatment outcome. Another perspective on hypnotic responsiveness currently gaining Page 24 popularity might be called a “specificity theory of hypnotic responsiveness.” Specificity theory does not assume that the hypnotic responsiveness is a unitary response, but rather that a number of very different behavioural responses and/or experiential dimensions may be tapped by specifically worded suggestions. Both views originate in E. R. Hilgard’s pioneering research on hypnotisability, as described in his classic text Hypnotic Susceptibility (E. R. Hilgard, 1965a). Hilgard concluded that there is a general factor of hypnotisability, and also described a number of representative hypnotic behaviours for (e.g., ideomotor phenomena, posthypnotic effects, hypermnesia, age regression, and hallucinatory phenomena). These specific phenomena might be considered special abilities of sub talents within the overall domain of hypnotic responsiveness. In other words, a given hypnotic subject may show more or less talent in each of these specific areas. just as two individuals can be equally talented as musicians, one with wind instruments and one with percussion instruments, two people can be equally hypnotizable, but one can manifest hypnotic talent primarily in terms of hypnotic imagery and another in terms of persistent effects. Since 1986, more attention has been paid to the specificity of hypnotic behaviours. Spanos and his associates have conceptualized hypnosis in terms of very specific cognitive tasks. Specific cognitive tasks suggested in hypnosis may lead to different hypnotic effects—for example, in pain control (Spanos, Horton, & Chaves, 1975). In the last decade, a view has been emerging that the differences between subjects high and low in hypnotisability can be explained in terms of differences in the type of cognitive strategies typically used by subjects during hypnosis. It has become clear that whereas both high and low hypnotizable subjects depend on absorption strategies in making a positive response to hypnotic suggestions, high but not low hypnotizable subjects also rely on dissociative strategies, which buffer them against an otherwise expected deterioration in hypnotic performance if the hypnotic suggestions are ambiguous, inconsistent, or conflictual (Bartis & Zamansky, 1990). it has also become clear that high and low hypnotizable subjects utilize very different cognitive strategies in response to reduction of muscle tension. In one study, high hypnotisables were able to reduce muscle tension significantly better than low hypnotisable with hypnotic relaxation strategies but not with EMC biofeedback, whereas low hypnotisable showed significant reduction in muscle tension only when EMG biofeedback was used (L. S. Miller & Cross, 1985). The authors concluded that high and low hypnotizable subjects use different cognitive strategies to relax, and that it is advantageous to match different treatment methods to these respective populations. This increased appreciation of the a priori differences between high and low hypnotizable subjects in terms of cognitive skills has led to the idea that low hypnotizable subjects might successfully be taught the cognitive strategies typically employed by high hypnotizable subjects, as a way to enhance their hypnotisability (Spanos, Cross, Menary, & Smith, 1988; Spanos & Flynn, 1989a). Moreover, increased attention is being paid to the range of different cognitive strategies used by high hypnotizable subjects. These include focused attention, enhanced imagery processing, absorption, and dissociation (Crawford, 1990a). According to this line of reasoning, each of the different cognitive strategies utilized in hypnosis is predicted to have very specific effects. Crawford (1990a), for example, has demonstrated that successful identification of discrete physiological correlates to hypnosis depends on the type of cognitive task(s) required of the hypnotized subject as much as on the nature of the physiological measurement. The Page 25 view emerging from such studies is that after the induction of a hypnotic state, hypnosis can be understood in terms of a variety of highly specific task demands that produce a variety of differential hypnotic behaviours. Shor’s (1962) pioneering work on dimensions of hypnotic experience is an example of a specificity theory of hypnotic experience. In the past several years, more attention has been paid to mapping out phenomenological dimensions of hypnotic experience (Fromm & Kahn, 1990; Kumar & Pekala, 1988, 1989; Pekala & Nagler, 1989; Pekala & Kumar, 1989; Kihlstrom, Register, Hoyt, Albright, Gregorian, Hendel, & Morrison, 1989). Again, in terms of hypnotic experience there are marked differences between high and low hypnotizable subjects, and specific hypnotic suggestions lead to differential effects among the high hypnotizable subjects. Future research directions on hypnotherapy should include a greater emphasis on specificity of hypnotic responsiveness. I would expect that such future research would be concerned not only with hypnotisability, but also with the specifics of hypnotic behaviours and experiences. My hope is that a typical research report in the future will clearly articulate which hypnotic strategy or which experiential dimensions of hypnosis have been emphasized (by means of specifically worded hypnotic. suggestions) in order to achieve the best treatment outcome, when hypnosis is used with a specific clinical condition. This is not to say that the construct of hypnotisability, or the use of formal measures of hypnotisability, will be less important. Both the patient’s hypnotisability and the therapist’s skilful use of language and individualized strategy are of the utmost importance in the process and for the outcome of hypnotherapy. Future hypnotherapy research should strive to integrate process and outcome perspectives, as is already the trend in other psychotherapy research. Through utilizing both the construct of hypnotisability and the specificity theory of hypnotic responsivity in clinical hypnotherapy research, we may strengthen the scientific base on which the art of clinical hypnosis is built.
Hypnosis Research Saving Money With Hypnosis – San Francisco (Reuters Health) – Using hypnosis in the operating room could cut costs of some medical procedures in half, Harvard researchers reported Monday at the annual meeting of the American Psychological Association. “Doing hypnosis on the operating room table certainly makes sense, but unless it saves money, you will not be doing it,” said study author Dr. Elvira V. Lang, associate professor of radiology and medicine at Beth Israel Deaconess Medical Center in Boston, Massachusetts. The National Institutes of Health National Center funded the research for Complementary and Alternative Medicine. The study followed 241 patients undergoing various medical procedures such as clearing blocked arteries. **All the patients were given standard medical care, including the option of self-medicating drugs for pain. **One-third was also given empathic attention from a health professional in addition to standard care. **Another third were given self-hypnotic relaxation techniques in addition to standard care as part of preparation for the procedure. Lang reported that the hypnotized group reported significantly less pain during the procedure. The hypnotized group also took significantly less time to complete their procedures and used half as much pain medication. Based on these and other findings, Lang calculated that the average cost for a procedure using standard care was $638, while the cost for a procedure using adjunct hypnosis would cost $300, cutting the cost by more than half. Even if hypnosis added nearly an hour to the preparation time, it would still save money, she said. “Hypnosis in the operating room is feasible, it is effective and very resource-sensitive,” Lang concluded. Hypnosis Subjects See What They Believe: Scientists are admitting hypnosis makes people literally see what they believe by affecting the way their brains function. Volunteers who had their brains scanned while under hypnosis showed they were not merely doing what they were told. The scans revealed that when they were asked to see non-existent colours, they really saw them. In the tests by the University of California a burst of activity was seen in the part of their brain responsible for perceiving colour. The scientists carrying out the study believe it has important implications and a spokesman said: “There has been a whole argument that hypnosis is just an exaggerated form of social compliance – in other words, people just telling you what you want to hear.” The research team is now looking at how hypnosis can prevent pain. One trial currently under way involves a group of children aged six to 12 with a suspected kidney disorder. It can only be investigated by inserting a catheter probe into the bladder without anaesthetic. Under hypnosis, the children imagine they are enjoying a trip to Disneyland. “There is less crying, less pain as they are inserting the catheter, and the procedure takes 20 minutes less, which for a kid is a big difference,” said the spokesman. See this story on Ananova: http://www.ananova.com/go/523059 Scientific American Feature Article: July, 2001 The Truth and the Hype of Hypnosis – By Michael R. Nash Though often denigrated as fakery or wishful thinking, hypnosis has been shown to be a real phenomenon with a variety of therapeutic uses — especially in controlling pain… Read it at: http://www.sciam.com/2001/0701issue/0701nash.html Hypnosis & Bone Fracture: The Harvard Medical School conducted research on the use of hypnosis to enhance physical healing. Twelve people with a recent bone fracture were divided into two groups. One group received hypnosis and the other group served as control. Both groups received standard orthopedic treatment. The hypnosis group had individual hypnotic sessions and listened to audio tapes designed to increase bone healing. Xray and orthopedic evaluations were made during the 12 weeks of the experiment. The results showed a faster healing for the hypnosis group at week 9 of the experiment. Xrays revealed a notable difference at the edge of the fracture at week 6 of the experiment. The hypnosis group also had better mobility and used less pain killers. The researchers conclude by saying that “despite a small sample size…. these data suggest that hypnosis may be capable of enhancing both anatomical and functional fracture healing, and that further investigation of hypnosis to accelerate healing is warranted.” The article was “Using hypnosis to accelerate the healing of bone fractures: a randomized controlled pilot study”, by Ginandes, CS, Rosenthal, DI. Alternative Therapy Health Medicine, 1999, March, 5(2), pp.67-75. Experts Urge the Inclusion of Hypnosis and Biofeedback in the Medical Treatment of Chronic Pain and Insomnia: An expert panel assembled by the National Institutes of Health has announced their finding that the use of hypnosis, biofeedback, meditation, and other behavioral therapies should be used more widely for the treatment of chronic pain and insomnia. Further, the panel said those therapies should be reimbursed bv health insurance along with standard medical care. Read more. Hypno-Birthing Research: The benefits of hypnotic analgesia as an adjunct to childbirth education were studied in 60 nulliparous women. Subjects were divided into high and low hypnotic susceptibility groups before receiving 6 sessions of childbirth education and skill mastery using an ischemic pain task. Half of the Subjects in each group received a hypnotic induction at the beginning of each session; the remaining control Subjects received relaxation and breathing exercises typically used in childbirth education. Both hypnotic Subjects and highly susceptible Subjects reported reduced pain. Hypnotically prepared births had shorter Stage 1 labors, less medication, higher Apgar scores, and more frequent spontaneous deliveries than control Subjects’ births. Highly susceptible, hypnotically treated women had lower depression scores after birth than women in the other three groups. We propose that repeated skill mastery facilitated the effectiveness of hypnosis in the study. Weight Loss A study from the University of Connecticut, Storrs, suggests that long term results are better when hypnosis is part of the therapy package particularly if the patient is a believer in hypnosis. Researchers analyzed 18 studies comparing a cognitive behavioral therapy, such as relaxation training, guided imagery, self monitoring or goal setting with the same therapy supplemented by hypnosis. Those who received the hypnosis lost more weight than 90 percent of the non hypnosis, and maintained the weight loss two years after treatment ended. The placebo effect may account for some of hypnosis’s success, says Irving Kirsch, PhD professor of psychology. Although therapeutic suggestion and relaxation training were used in both hypnotic and non hypnotic sessions, they worked much better when they were referred to as “hypnosis” techniques, he notes. Hypnotic Visual Illusion Alters Color Processing in the Brain Stephen M. Kosslyn, Ph.D., William L. Thompson, B.A., Maria F. Costantini-Ferrando, Ph.D., Nathaniel M. Alpert, Ph.D. and David Spiegel, M.D. Am J Psychiatry 2000 157: 1279-1284. The journal is online (but requires a subscription) at: http://ajp.psychiatryonline.org/ OBJECTIVE: This study was designed to determine whether hypnosis can modulate color perception. Such evidence would provide insight into the nature of hypnosis and its underlying mechanisms. METHOD: Eight highly hypnotizable subjects were asked to see a color pattern in color, a similar gray-scale pattern in color, the color pattern as gray scale, and the gray-scale pattern as gray scale during positron emission tomography scanning by means of [15O]CO2. The classic color area in the fusiform or lingual region of the brain was first identified by analyzing the results when subjects were asked to perceive color as color versus when they were asked to perceive gray scale as gray scale. RESULTS: When subjects were hypnotized, color areas of the left and right hemispheres were activated when they were asked to perceive color, whether they were actually shown the color or the gray-scale stimulus. These brain regions had decreased activation when subjects were told to see gray scale, whether they were actually shown the color or gray-scale stimuli. These results were obtained only during hypnosis in the left hemisphere, whereas blood flow changes reflected instructions to perceive color versus gray scale in the right hemisphere, whether or not subjects had been hypnotized. CONCLUSIONS: Among highly hypnotizable subjects, observed changes in subjective experience achieved during hypnosis were reflected by changes in brain function similar to those that occur in perception. These findings support the claim that hypnosis is a psychological state with distinct neural correlates and is not just the result of adopting a role. [Editorial Note: This “just adopting a role,” or “role playing to please the audience” theory is no longer held by most researchers for talented and motivated subjects/clients and hasn’t been for a number of years. The role taking theory of Sarbin for example is effectively a psychological state theory in most ways because it views hypnotic phenomena as mediated by “organismic involvement” in the role (basically what most practitioners call depth). This study is very useful because it shows things going on specifically in hypnosis vs. “just imagining,” and so is a start in identifying the neurological differences between someone experiencing something in a hypnotic way and experiencing in a more casual way. Given a way to establish the ‘reality’ of a hypnotic hallucination, this potentially also provides a way to distinguish between what is going on with “low” vs. “high” hypnotizable people. The people involved in this particular study were all pre-selected as “highs,” a common technique in research of this sort to maximize the effects seen. – Todd Stark] Irritable Bowel Syndrome A British study of 18 adults with IBS published in The Lancet found that hypnosis “strikingly” reduced colonic motility, thus decreasing diarrhea and cramping (July 11, 1992). Erectile Dysfunction In a controlled study of 79 men with impotence from no known organic cause, only hypnosis proved more effective than a placebo, boosting sexual function by 80 percent (British Journal of Urology, February 1996). Preparing for Surgery A controlled study of 32 coronary bypass patients showed that those taught self-hypnosis preoperatively were more relaxed after surgery and had less need for pain medication (Journal of Cardiovascular Surgery, February 1997). Pain. A review panel appointed by the National Institutes of Health found “strong evidence” for the use of hypnosis in alleviating pain associated with cancer (Journal of the American Medical Association, July 24-31, 1996). Self-Hypnosis Can Cut Stress and Boost Your Immune System A number of studies have suggested stress can hinder the body’s immune system defenses. Now researchers say people may be able to fight back with the stress-relieving techniques of self-hypnosis. In a study of medical students under exam-time stress, investigators found that those who received “hypnoticrelaxation training” did not show the same reduction in key immune system components that their untrained counterparts did. The researchers looked at 33 medical and dental students during relatively low-stress periods and around the time of the first major exam of the term. Half of the students attended sessions where they learned to relax through selfhypnosis. The investigators found that during exam time, the self-hypnosis students launched stronger immune responses compared with students who did not learn the technique. And the more often students practiced the relaxation strategy, the stronger their immune response. In previous studies, the researchers found that stressful times may impair the body’s wound-healing process and response to vaccination. They and other researchers have also found that relaxation techniques may combat these effects by relieving stress and boosting the immune system. The data from this study provide encouraging evidence that interventions may reduce the immunological dysregulation associated with acute stressors. Journal of Consulting and Clinical Psychology 2001;69 Relax and live longer by Emma Young Patients with Hodgkin’s disease or non-Hodgkin’s lymphoma live longer if they receive relaxation and hypnotherapy treatment along with standard chemotherapy. Similar approaches has resulted in mixed results for other cancers.Leslie Walker of Hull University studied 63 patients with newly diagnosed cancers, all of whom were receiving chemotherapy and standard anti-nausea drugs. The patients were split into three groups. One group was given relaxation tapes, another received the tapes plus hypnotherapy to reinforce their effect. The third received neither. Walker followed up the patients 13 years after diagnosis. “We found that the patients who had received relaxation or relaxation and hypnotherapy lived significantly longer,” he says. New lease of life On average, patients in the relaxation and hypnotherapy group lived an average of 10.7 years after diagnosis, patients who used only the tapes lived 8.7 years and patients with neither lived 7.8 years. But Walker stresses that the patients differed in age and the stage of disease when treatment started. So although the differences are significant, translating hypnotherapy plus relaxation into three extra years of life is not possible, he says. How the relaxation and hypnotherapy may increase survival is not clear. Other studies of cancer patients have found that similar treatments can boost levels of killer T cells. But researchers have not been able to link this rise with increased survival.”Chemotherapy and radiotherapy tend to suppress immune system functioning, so small interventions may help patients be more resistant to these effects,” Walker says. This research was presented at the British Psychological Society’s Centenary Conference in Glasgow, UK. Submitted by Todd I. Stark, toddstark@aol.com, http://ToddStark.com/ Hypnosis Trials 1976 – 1998 Agras WS. Horne M. Taylor CB. Expectation and the blood-pressure lowering effects of relaxation. Psychosomatic Med. 1982; 44(4):389-95 In a study of the blood-pressure-lowering effects of relaxation training in patients with essential hypertension, instructions concerning the relaxation procedure were varied so that one group was told to expect delayed blood-pressure-lowering and the other group immediate lowering. The systolic blood pressure decrease during the training period in the immediate lowering group was 17.0 mm Hg, compared with 2.4 mm Hg for the delayed group (p = 0.001). Diastolic blood pressure changes were not significantly different. Measures of therapy credibility and perceived relaxation failed to differentiate the groups. The implications of these findings for future research and for clinical practice are considered. Aikins Murphy P. Alternative therapies for nausea and vomiting of pregnancy. Obstetrics & Gynecology 1998;91(1):149-55 OBJECTIVE: To review available evidence about the effectiveness of alternative therapies for nausea and vomiting of pregnancy. DATA SOURCES: MEDLINE and 13 additional US and international data bases were searched in 1996-1997 for papers that described use of alternative medicine in the treatment of pregnancy and pregnancy complications, specifically those addressing nausea, vomiting, and hyperemesis. Bibliographies of retrieved papers were reviewed to identify additional sources. METHODS OF STUDY SELECTION: All relevant English language clinical research papers were reviewed. Randomized clinical trials addressing specifically the use of nonpharmaceutical and nondietary interventions were chosen for detailed review. TABULATION, INTEGRATION, AND RESULTS: Ten randomized trials studying the effects of acupressure, ginger, and pyridoxine on nausea and vomiting of pregnancy were reviewed. Evidence of beneficial effects was found for these three interventions, although the data on acupressure are equivocal. Insufficient evidence was found for the benefits of hypnosis. Other interventions have not been studied. CONCLUSION: There is a dearth of research to support or to refute the efficacy of a number of common remedies for nausea and vomiting of pregnancy. The best-studied alternative remedy is acupressure, which may afford relief to many women; ginger and vitamin B6 also may be beneficial. [References: 36] Allison DB. Faith MS. Hypnosis as an adjunct to cognitive-behavioral psychotherapy for obesity: a meta-analytic reappraisal. Journal of Consulting & Clinical Psychology 1996;64(3):513-6 I. Kirsch, G. Montgomery, and G. Sapirstein (1995) meta-analyzed 6 weight-loss studies comparing the efficacy of cognitive-behavior therapy (CBT) alone to CBT plus hypnotherapy and concluded that “the addition of hypnosis substantially enhanced treatment outcome” (p.214). Kirsch reported a mean effect size (expressed as d) of 1.96. After correcting several transcription and computational inaccuracies in the original meta-analysis, these 6 studies yield a smaller mean effect size (.26). Moreover, if 1 questionable study is removed from the analysis, the effect sizes become more homogeneous and the mean (.21) is no longer statistically significant. It is concluded that the addition of hypnosis to CBT for weight loss results in, at most, a small enhancement of treatment outcome. Amigo I, Cuesta V, Fernandez A, Gonzalez A The effect of verbal instructions on blood pressure measurement. Journal of Hypertension 1993 Mar;11(3):293-6 AIM: To determine whether orally delivered instructions can modify the intensity and direction of blood pressure and heart rate fluctuation. METHODS: The blood pressure of 120 subjects, 60 hypertensive and 60 normotensive, was measured before and after oral instructions. The normotensive subjects were selected from a sample of university students and the hypertensive patients were selected at a routine medical screening. Each sample of 60 subjects was randomly divided into four groups of 15. Each subject was left seated alone in a room for 5 min. The researcher then measured the subjects’ blood pressure and heart rate. Following this, each group of normotensives and hypertensives was told that their blood pressure would diminish, or that it would not change or that it would increase. The control group was given no instructions. After 5 min the blood pressure and heart were measured again. RESULTS: In the normotensive and hypertensive groups who were told that their blood pressure would increase, systolic blood pressure increased by 4.3 and 2.5 mmHg, respectively. In the groups who were told that their blood pressure would decrease, systolic pressure fell by 7.8 and 7.4 mmHg, respectively. Those who were told that no change would occur showed a systolic pressure decrease of 3.5 and 1.8 mmHg, respectively. In the control groups systolic blood pressure decreased by 5.6 and 4.2 mmHg, respectively. CONCLUSIONS: These results show that oral instructions are a source of variation in the assessment of blood pressure and emphasize the need for 24-h blood pressure monitoring to eliminate this type of variation. Anderson JA, Basker MA, Dalton R Migraine and hypnotherapy International Journal of Clinical & Experimental Hypnosis 1975;23(1):48-58 Compared the treatment of migraine by hypnosis and autohypnosis with the treatment of migraine by the drug prochlorperazine (Stemetil). Random allocation of 47 patients was made to one or other prophylactic measure, followed by monthly assessments and independent evaluation of 1 yr of continuous care. Criteria of improvement were the number of attacks/month, number who had Grade 4 attacks, and complete remission. Results show that the number of attacks and the number who suffered blinding attacks were significantly lower for the group receiving hypnotherapy than for the group receiving prochlorperazine. For the group on hypnotherapy, these 2 measures were significantly lower when on hypnotherapy than when on previous treatment. Prochlorperazine seemed about as effective as previous treatment. 10 out of 23 patients on hypnotherapy achieved complete remission during the last 3 mo of the trial, compared to only 3 out of 24 on prochlorperazine. It is concluded that further trials of hypnotherapy are justified against some other treatment not solely associated with the ingestion of tablets. (German, French, & Spanish summaries) Anderson JA. Dalton ER. Basker MA. Insomnia and hypnotherapy. Journal of the Royal Society of Medicine 1979;72(10):734-9 Andreychuk T, Scriver C Hypnosis and biofeedback in the treatment of migraine headache Int J Clin Exp Hypn 1975; 23: 172-3 Anonymous. Hypnosis for asthma–a controlled trial. A report to the Research Committee of the British Tuberculosis Association. BMJ 1968;4(623):71-6 Investigated the use of hypnosis in the treatment of asthma in patients, 10-60 yr. old with paroxysmal attacks of wheezing or tight chest capable of relief by bronchodilators. 1 group was given hypnosis monthly and used autohypnosis daily for 1 yr. Comparisons were made with a control group prescribed a specially devised set of breathing exercises aimed at progressive relaxation. Treatment was randomly allocated and Subjects were treated by physicians in 9 centers. Results were assessed by daily diary recordings of wheezing and the use of bronchodilators, and by monthly recordings of forced expiratory volume (FEV) and vital capacity (VC). Independent clinical assessments were made by physicians unaware of Subjects’ treatment. 176 out of 252 patients completed the program. Both treatment groups showed some improvement. Among men the assessments of wheezing score and use of bronchodilators showed similar improvement in the 2 groups; among women, however, those treated by hypnosis showed improvement similar to that observed in the men, but those given breathing exercises made much less progress, the difference between the 2 groups reaching statistical significance. Changes in FEV and VC between the control and hypnosis groups were closely similar. Independent clinical assessors considered the asthma to be better in 59% of the hypnosis group and in 43% of the controls, the difference being significant. There was little difference between the sexes. Physicians with previous experience of hypnosis obtained significantly better results than did those without such experience. Ashton C Jr. Whitworth GC. Seldomridge JA. Shapiro PA. Weinberg AD.Michler RE. Smith CR. Rose EA. Fisher S. Oz MC. Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial. Journal of Cardiovascular Surgery 1997;38(1):69-75 OBJECTIVE: The role of complementary medicine techniques has generated increasing interest in today’s society. The purpose of our study was to evaluate the effects of one technique, self-hypnosis, and its role in coronary artery bypass surgery. We hypotesize that self-hypnosis relaxation techniques will have a positive effect on the patient’s mental and physical condition following coronary artery bypass surgery. EXPERIMENTAL DESIGN: A prospective, randomized trial was conducted. Patients were followed beginning one day prior to surgery until the time of discharge from the hospital. SETTING: The study was conducted at Columbia Presbyterian Medical Center, a large tertiary care teaching institution. PATIENTS: All patients undergoing first-time elective coronary artery bypass surgery were eligible. A total of 32 patients were randomized into two groups. INTERVENTIONS: The study group was taught self-hypnosis relaxation techniques preoperatively, with no therapy in the control group. MEASURES: Outcome variables studied included anesthetic requirements, operative parameters, postoperative pain medication requirements, quality of life, hospital stay, major morbidity and mortality. RESULTS: Patients who were taught self-hypnosis relaxation techniques were significantly more relaxed postoperatively compared to the control group (p=0.032). Pain medication requirements were also significantly less in patients practising the self-hypnosis relaxation techniques that those who were noncompliant (p=0.046). No differences were noted in intraoperative parameters, morbidity or mortality. CONCLUSION: This study demonstrates the beneficial effects self-hypnosis relaxation techniques on patients undergoing coronary artery bypass surgery. It also provides a framework to study complementary techniques and the limitations encountered. Ashton RC Jr. Whitworth GC. Seldomridge JA. Shapiro PA. Michler RE.Smith CR. Rose EA. Fisher S. Oz MC. The effects of self-hypnosis on quality of life following coronary artery bypass surgery: preliminary results of a prospective, randomized trial. Journal of Alternative & Complementary Medicine 1995;1(3):285-90 The effects of complementary techniques and alternative medicine on allopathic therapies is generating much interest and research. To properly evaluate these techniques, well controlled studies are needed to corroborate the findings espoused by individuals practicing complementary medicine therapies. To this end, we evaluated the role of one of these therapies, self-hypnosis relaxation techniques, in a prospective, randomized trial to study its effects on quality of life after coronary artery bypass surgery. Subjects were randomized to a control group or a study group. Study group patients were taught self-hypnosis relaxation techniques the night prior to surgery. The control group received no such treatment. Patients then underwent routine cardiac management and care. The main endpoint of our study was quality of life, assessed by the Profile of Moods Scale. Results demonstrated that patients undergoing self-hypnosis the night prior to coronary artery bypass surgery were significantly more relaxed than the control group (p = 0.0317). Trends toward improvement were also noted in depression, anger, and fatigue. This study demonstrates the beneficial effects of self-hypnosis relaxation techniques on coronary surgery. This study also identifies endpoints and a study design that can be used to assess complementary medicine therapies. Results of this preliminary investigation are encouraging and demonstrate a need for further well-controlled studies. Attias J, Shemesh Z, Sohmer H, Gold S, Shoham C, Faraggi D Comparison between self-hypnosis, masking and attentiveness for alleviation of chronic tinnitus. Audiology 1993;32(3):205-12 The efficacy of self-hypnosis (SH), masking (MA) and attentiveness to the patient’s complaints (AT) in the alleviation of tinnitus was evaluated. Fortyfive male patients close in age with chronic tinnitus related to acoustic trauma were assigned to three matched subgroups: SH, AT or MA. The therapeutic stimuli in the SH and MA sessions, recorded on audio cassettes, were given to the patients for use when needed. SH significantly reduced the tinnitus severity; AT partially relieved the tinnitus; MA did not have any significant effect. Aydin S. Ercan M. Caskurlu T. Tasci AI. Karaman I. Odabas O. Yilmaz Y. Agargun MY. Kara H. Sevin G. Acupuncture and hypnotic suggestions in the treatment of non-organic male sexual dysfunction. Scandinavian Journal of Urology & Nephrology 1997;31(3):271-4 We have examined the effects of acupuncture and hypnotic suggestions, and compared them with placebo in the treatment of male sexual dysfunction with no detectable organic cause. The study comprised 15 men (mean age 36.7 +/- 10.43 years) who received acupuncture treatment, 16 men (mean age 38.4 +/- 10.75 years) who underwent hypnosis (mean age 35.3 +/- 11.52 years) and 29 men (mean age 36.2 +/- 11.38 years) who served as controls. They were interviewed periodically; the patients’ reports were verified by interviewing their partners. Men who received placebo had a 43-47% improvement in sexual function, while the rates of improvement in the treated groups were higher, but not significantly so. The success rates of acupuncture and hypnotic suggestions were 60% and 75% respectively. Although the improvement was not statistically significant, treatment with acupuncture could be used as an adjuvant therapy in non-organic male sexual dysfunction. The only treatment superior to placebo seemed to be hypnosis. A more effective treatment may be obtained by combining these therapeutic modalities, but this needs further study. Aydin S. Odabas O. Ercan M. Kara H. Agargun MY. Efficacy of testosterone, trazodone and hypnotic suggestion in the treatment of non-organic male sexual dysfunction. British Journal of Urology. 1996;77(2):256-60 OBJECTIVE: To examine the effects of hypnotic suggestions or the administration of testosterone or trazodone to impotent men with no detectable organic cause for the impotence. PATIENTS AND METHODS: The study comprised 79 men in whom clinical and laboratory examinations revealed no organic cause for their impotence: 20 men (mean age 38.7 +/- 11.47 years) received testosterone, 21 men (mean age 39.5 +/- 10.73 years) received trazodone, 20 men (mean age 34.2 +/- 11.69 years) underwent hypnosis and 18 men (mean age 39.1 +/- 11.46 years) served as controls. They were assessed by interview 4, 6 and 8 weeks after starting treatment: the patient’s reports were verified by interviewing their partners. RESULTS: Men who received a placebo had a 39% improvement in sexual function, while the rates of improvement in the treated groups were higher, but not significantly so. The success rates of testosterone and trazodone treatment and hypnotic suggestions were 60%, 67% and 80%, respectively. CONCLUSION: Although the improvement was not statistically significant, treatment with testosterone and trazodone could be used as an adjuvant therapy in nonorganic male sexual dysfunction. The only treatment superior to placebo seemed to be hypnosis. A more effective treatment may be obtained by combining these therapeutic modalities, but this needs further study. Baltar Lopez E La autorrelajacion como medio para reducir la algestesia en pruebas diagnosticas dolorosas Natura Medicatrix 1995;41:12-8 It taked place a study of painful perception and psycho-emotional component in two groups of patients in a random selection. It was made bone marrow biopsy and iliac crest myelogram in the patients. In the control group received a session of hypnosis of forty minutes; in this session were trained in autohypnosis technique to be applied in the moment of the painful tests. The comparison of outcomes shows a significant reduction of algesthesia and unpleasant emotions in the experimental group. The application of this technique was workable, effective and inexpensive. Banerjee S. Srivastav A. Palan BM. Hypnosis and self-hypnosis in the management of nocturnal enuresis: a comparative study with imipramine therapy. American Journal of Clinical Hypnosis 1993;36(2):113-9 Various therapeutic modalities have been used for treating enuresis due to the lack of a single identifiable cause. We carried out a comparative study of imipramine and direct hypnotic suggestions with imagery used for the management of functional nocturnal enuresis. Enuretic children, ranging in age from 5 to 16 years, underwent 3 months of therapy with imipramine (N = 25) or hypnosis (N = 25). After termination of the active treatment, the hypnosis group continued practicing self-hypnosis daily during the follow-up period of another 6 months. Of the patients treated with imipramine, 76% had a positive response (all dry beds); for patients treated with hypnotic strategies, 72% responded positively. At the 9-month follow-up, 68% of patients in the hypnosis group maintained a positive response, whereas only 24% of the imipramine group did. Hypnosis and self-hypnosis strategies were found to be less effective in younger children (5-7 years old) compared to imipramine treatment. The treatment response was not related to the hypnotic responsivity of the patient in either group. Barabasz AF. Treatment of insomnia in depressed patients by hypnosis and cerebral electrotherapy. American Journal of Clinical Hypnosis 1976;19(2):120-2 Investigated the influence of suggestion on recovery in the treatment of sleep disturbances by cerebral electrotherapy (CET). 60 adult psychiatric outpatients (diagnostic classification– mild depressive neurosis) were randomly assigned to 4 groups. Group A received CET only; Group B received a CET placebo; Group C received CET with hypnosis; and Group D received a CET placebo with hypnosis. Group A reported a significantly higher recovery than Group B, Group C a significantly higher recovery than Group A, and Group D a significantly higher recovery than Group B. No significant differences were found between Group C and Group D or between Group A and Group D. Findings support suggestion via passive hypnosis with CET as a powerful variable in the treatment of sleep disturbances with depressed patients. Barber TX. Wilson SC. Hypnosis, suggestions, and altered states of consciousness: experimental evaluation of the new cognitive-behavioral theory and the traditional trance-state theory of “hypnosis”. Annals of the New York Academy of Sciences 1977; 296:34-47 Sixty-six subjects were tested on a new scale for evaluating “hypnotic-like” experiences (The Creative Imagination Scale), which includes ten standardized test-suggestions (e.g. suggestions for arm heaviness, finger anesthesia, time distortion, and age regression). The subjects were randomly assigned to one of three treatment groups (Think- With Instructions, trance induction, and Control), with 22 subjects to each group. The new Cognitive-Behavioral Theory predicted that subjects exposed to preliminary instructions designed to demonstrate how to think and imagine along with the suggested themes (Think-With Instructions) would be more responsive to test-suggestions for anesthesia, time distortion, age regression, and so on, than subjects exposed to a trance- induction procedure. On the other hand, the traditional Trance State Theory predicted that a trance induction would be more effective than Think-With Instructions in enhancing responses to such suggestions. Subjects exposed to the Think-With Instructions obtained significantly higher scores on the test-suggestions than those exposed either to the traditional trance-induction procedure or to the control treatment. Scores of subjects who received the tranceinduction procedure were not significantly different from those of the subjects who received the control treatment. The results thus supported the new Cognitive- Behavioral Theory and contradicted the traditional Trance State Theory of hypnosis. Two recent experiments, by De Stefano and by Katz, confirmed the above experimental results and offered further support for the Cognitive-Behavioral Theory. In both recent experiments, subjects randomly assigned to a “Think-With Instructions” treatment were more responsive to test-suggestions than those randomly assigned to a traditional trance-induction treatment. Barkley RA. Hastings JE. Jackson TL. The effects of rapid smoking and hypnosis in the treatment of smoking behavior. International Journal of Clinical & Experimental Hypnosis 1977;25(1):7-17. 29 young adult volunteers were assigned to one of 3 treatment conditions and treated for their cigarette smoking over a 2-wk period. These conditions were group rapid smoking, group hypnosis, and an attention-placebo control group. All treatments produced significant reductions in average daily smoking rates during the treatment phase, but all Subjects returned to near baseline levels of smoking by the 6-wk follow-up. The rapid smoking and hypnosis groups did not differ from the control group in smoking rates at treatment termination or at the 6-wk follow-up. They also did not differ from the control group in the number of Subjects abstaining from smoking by treatment termination but did differ at follow-up. Eventually, at the 9-mo follow-up, only Subjects from the rapid smoking condition had significantly more abstainers than the control group. Results suggest that rapid smoking can work as effectively in group procedures as previous individualized approaches had demonstrated. Group hypnosis, while less effective than some previous individualized approaches had indicated, was only marginally less effective than the rapid smoking procedure. The use of abstinence rates as opposed to average rates of smoking is strongly recommended as the best measure of treament effectiveness for future research in this area. (German, French & Spanish summaries) Beaugerie L. Burger AJ. Cadranel JF. Lamy P. Gendre JP. Le QuintrecY. Modulation of orocaecal transit time by hypnosis. Gut 1991;32(4):393-4 The ability of hypnosis to modulate the orocaecal transit time of 10 g lactulose was tested in six healthy volunteers. Orocaecal transit time was measured by the hydrogen breath test during three periods in random order. During the control period the subjects remained throughout the test in a semirecumbent position without moving. During the hypnotic relaxation period subjects were hypnotised before lactulose ingestion and were instructed to experience relaxation till the orocaecal transit time had elapsed. During the acceleration suggestion period subjects were hypnotised before lactulose ingestion and were repeatedly instructed to imagine the acceleration of lactulose through the intestine until transit time had elapsed. The mean orocaecal transit time was significantly longer during the hypnotic relaxation period (mean (SEM) 133 (8) min) than during the control period (93 (13) min). The mean orocaecal transit time during the acceleration suggestion period was 105 (26) minutes and was not significantly different from the mean transit time during the control period. The individual values during the acceleration suggestion period were scattered. We conclude that lactulose orocaecal transit time is delayed during hypnotic relaxation. Bennett HL. Davis HS. Giannini JA. Non-verbal response to intraoperative conversation. British Journal of Anaesthesia 1985;57(2):174-9 In a double-blind study, 33 patients (herniorraphy, cholecystectomy and orthopaedic) were randomly assigned to either suggestion or control groups. Under known clinical levels of nitrous oxide and enflurane or halothane anaesthesia, suggestion patients were exposed to statements of the importance of touching their ear during a postoperative interview. Compared with controls, suggestion patients did touch their ear (tetrachoric correlation 0.61, P less than 0.001) and they did so more frequently (Mann-Whitney U test, P less than 0.02). All suggestion patients were completely amnesic for the intraoperative spoken suggestion, despite inquiries which included hypnotic regression to the operation. Benson H. Frankel FH. Apfel R. Daniels MD. Schniewind HE. Nemiah JC. Sifneos PE. Crassweller KD. Greenwood MM. Kotch JB. Arns PA. Rosner B. Treatment of anxiety: a comparison of the usefulness of selfhypnosis and a meditational relaxation technique. An overview. Psychotherapy & Psychosomatics. 1978;30(3- 4):229-42 We have investigated prospectively the efficacy of two nonpharmacologic relaxation techniques in the therapy of anxiety. A simple, meditational relaxation technique (MT) that elicits the changes of decreased sympathetic nervous system activity was compared to a self- hypnosis technique (HT) in which relaxation, with or without altered perceptions, was suggested. 32 patients with anxiety neurosis were divided into 2 groups on the basis of their responsivity to hypnosis: moderate-high and low responsivity. The MT or HT was then randomly assigned separately to each member of the two responsivity groups. Thus, 4 treatment groups were studied: moderate-high responsivity MT; low responsivity MT; moderate-high responsivity HT; and low responsivity HT. The low responsivity HT group, by definition largely incapable of achieving the altered perceptions essential to hypnosis, was designed as the control group. Patients were instructed to practice the assigned technique daily for 8 weeks. Change in anxiety was determined by three types of evaluation: psychiatric assessment; physiologic testing; and self-assessment. There was essentially no difference between the two techniques in therapeutic efficacy according to these evaluations. Psychiatric assessment revealed overall improvement in 34% of the patients and the self-rating assessment indicated improvement in 63% of the population. Patients who had moderate-high hypnotic responsivity, independent of the technique used, significantly improved on psychiatric assessment (p = 0.05) and decreased average systolic blood pressure from 126.1 to 122.5 mm Hg over the 8-week period (p = 0.048). The responsivity scores at the higher end of the hypnotic responsivity spectrum were proportionately correlated to greater decreases in systolic blood pressure (p = 0.075) and to improvement by psychiatric assessment (p = 0.003). There was, however, no consistent relation between hypnotic responsivity and the other assessments made, such as diastolic blood pressure, oxygen consumption, heart rate and the self-rating questionnaires. The meditational and selfhypnosis techniques employed in this investigation are simple to use and effective in the therapy of anxiety. Blankfield RP. Zyzanski SJ. Flocke SA. Alemagno S. Scheurman K. Taped therapeutic suggestions and taped music as adjuncts in the care of coronary-artery-bypass patients. American Journal of Clinical Hypnosis. 1995;37(3):32-42 A randomized, single-blinded, placebo-controlled trial examined the benefits of taped therapeutic suggestions and taped music in coronary-artery-bypass patients. Sixty-six patients listened to either suggestion tapes or music tapes, intraoperatively and postoperatively; 29 patients listened to blank tapes intraoperatively and listened to no tapes postoperatively. Half the patients who listened to a tape found it helpful. There were no significant differences between groups in length of SICU or postoperative hospital stay, narcotic usage, nurse ratings of anxiety and progress, depression, activities of daily living, or cardiac symptoms. There were no significant differences in these same outcomes between the patients who were helped by the tapes and the patients not helped. These results suggest that if taped therapeutic suggestions have a measurable effect upon cardiac surgery patients, demonstrating this effect will require more detailed patient evaluations to identify subgroups of patients responsive to this type of intervention. Block RI. Ghoneim MM. Sum Ping ST. Ali MA. Efficacy of therapeutic suggestions for improved postoperative recovery presented during general anesthesia. Anesthesiology 1991;75(5):746-55 There have been claims that the postoperative course of patients may be improved by presentation during general anesthesia of therapeutic suggestions which predict a rapid and comfortable postoperative recovery. This study evaluated the effectiveness of such therapeutic suggestions under double-blind and randomized conditions. A tape recording predicting a smooth recovery during a short postoperative stay without pain, nausea, or vomiting was played during anesthesia to about half the patients (N = 109), while the remaining, control patients were played a blank tape instead (N = 100). The patients were primarily undergoing operations on the fallopian tubes, total abdominal hysterectomy, vertical banding gastroplasty, cholecystectomy, and ovarian cystectomy or myomectomy. The anesthesia methods consisted of either isoflurane with 70% nitrous oxide in oxygen to produce end-tidal concentrations of 1.0, 1.3, or 1.5 MAC; or 70% nitrous oxide in oxygen combined with high or low doses of opioids. Assessments of the efficacy of the therapeutic suggestions in the recovery room and throughout the postoperative hospital stay included: the frequency of administration of analgesic and antiemetic drugs; opioid doses; the incidence of fever; nausea, retching, and vomiting; other gastrointestinal and urinary symptoms; ratings of pain; ratings of anxiety; global ratings of the patients’ physical and psychological recoveries by the patients and their nurses; and length of postoperative hospital stay. There were no meaningful, significant differences in postoperative recovery of patients receiving therapeutic suggestions and controls. These negative results were not likely to be due to insensitivity of the assessments of recovery, as they showed meaningful interrelations among themselves and numerous differences in recovery following different types of surgery. Widespread utilization of therapeutic suggestions as a routine operating room procedure seems premature in the absence of adequate replication of previously published positive studies. Boeke S. Bonke B. Bouwhuis-Hoogerwerf ML. Bovill JG. Zwaveling A. Effects of sounds presented during general anaesthesia on postoperative course. British Journal of Anaesthesia 1988;60(6):697-702 In a double-blind, randomized study, patients undergoing cholecystectomy were administered one of four different sounds during general anaesthesia: positive suggestions, nonsense suggestions, seaside sounds or sounds from the operating theatre. The effect of these sounds on the postoperative course was examined to assess intraoperative auditory registration. No differences were found between the four groups in postoperative variables. Bonke B, Schmitz PI, Verhage F, Zwaveling A Clinical study of so-called unconscious perception during general anaesthesia British Journal of Anaesthesia 1986;58(9):957-64 Ninety-one patients undergoing biliary tract surgery were randomly assigned to one of three treatment groups in which different sounds were administered, by means of earphones, in a double-blind design. The effects of the administration of positive suggestions, noise or operating theatre sounds on the postoperative course were studied. Results showed that exposure to positive suggestions during general anaesthesia, as compared with noise or operating theatre sounds, protected patients older than 55 yr against prolonged postoperative stay in hospital. Bonke B. Van Dam ME. Van Kleff JW. Slijper FM. Implicit memory tested in children during inhalation anaesthesia. Anaesthesia 1992;47(9):747-9 Memory for stimuli presented during inhalation anaesthesia was tested in 80 children undergoing eye surgery. Two groups were exposed, in a random double-blind study, to repeated neutral phrases including either the colour orange or green. A postoperative colouring task was used as a test of implicit memory to detect any preference for the colour named under anaesthesia. No colour preference attributable to implicit memory could be demonstrated. One patient had a distinct preference for the named colour. No patient remembered any intra-operative events. Bornstein PH. Devine DA. Covert modeling-hypnosis in the treatment of obesity. Psychotherapy: Theory, Research Practice 1980;17(3):272-276. Investigated the efficacy of a covert modeling/hypnosis treatment package in the control of obesity. 48 overweight female volunteers (who had been administered the Harvard Group Scale of Hypnotic Susceptibility, Eating Patterns Questionnaire, and Rotter’s Internal-External Locus of Control Scale) were randomly assigned to 1 of the following groups: (a) covert modeling/hypnosis, (b) covert modeling, (c) no-model scene control, and (d) minimal treatment (where Subjects received a shortened version of the covert modeling/hypnosis procedure following an 8-wk no-treatment period). Results indicate a significant effect for weight loss from pretreatment to follow-up across all groups combined. Proportion weight loss measures indicated significantly greater weight loss only for the covert modeling/hypnosis group as compared to the no-model controls. Implications for combining behavior therapy and hypnotic techniques are discussed. Boutin GE. Tosi DJ. Modification of irrational ideas and test anxiety through rational stage directed hypnotherapy RSDH. Journal of Clinical Psychology 1983;39(3):382-91 Examined the effects of four treatment conditions on the modification of Irrational Ideas and test anxiety in female nursing students. The treatments were Rational Stage Directed Hypnotherapy, a cognitive behavioral approach that utilized hypnosis and vivid-emotive-imagery, a hypnosis-only treatment, a placebo condition, and a no-treatment control. The 48 Ss were assigned randomly to one of these treatment groups, which met for 1 hour per week for 6 consecutive weeks with in-vivo homework assignments also utilized. Statistically significant treatment effects on cognitive, affective, behavioral, and physiological measures were noted for both the RSDH and hypnosis group at the posttest and at a 2-month followup. Post-hoc analyses revealed the RSDH treatment group to be significantly more effective than the hypnosis only group on both the post- and follow-up tests. The placebo and control groups showed no significant effects either at post-treatment or at follow-up. Bregman NJ. McAllister HA. Role of suggestions in digital skin temperature: implications for temperature biofeedback research. International Journal of Neuroscience 1985;27(1-2):115-20 The purpose of the present experiment was to explore the role suggestions and assessment procedures play in affecting digital skin temperature. Four different types of suggestions were given subjects (warm, cool, pseudo (electronic terms), and no suggestions). Twenty-five subjects were randomly assigned to the four experimental conditions. The data were analyzed by three popular assessment procedures typically found in the literature. As predicted, subjects displayed significant decreases in skin temperature each day regardless of the training condition they were in. The assessment procedures produced differential results. Brodeur JB, Kurtz RM, Strube MJ Hypnotic susceptibility order effects in walking analgesia Int J Clin Exp Hypn 1998 Jul;46(3):240-9 This study reexamined Spanos, Hodgins, Stam, and Gwynn’s (1984) contention that susceptibility testing order effects generated a relationship between walking analgesia pain reduction and level of hypnotic responsiveness. Undergraduate volunteers with no previous hypnosis experience were randomly assigned to 2 groups. Group 1 (n = 69) first received a cold pressor pain protocol, and then was administered the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C). Group 2 (n = 69) was administered the SHSS:C prior to the cold pressor pain protocol. Our findings do not support Spanos, Hodgins et al.’s contention that sucsceptibility testing order effects generate the often reported relationship between walking analgesia and level of hypnotic responsiveness. We found significant partial correlation coefficients between the SHSS:C and nonhypnotic pain reduction regardless of order of susceptibility testing. Implications regarding the adequacy of design-generated expectancies to explain hypnotic analgesia phenomena were examined. Bruck M. Ceci SJ. Francoeur E. Barr R. “I hardly cried when I got my shot:” Influencing children’s reports about a visit to their pediatrician. Child Development 1995;66(1):193-208 We examined, in 2 phases, the influence of postevent suggestions on children’s reports of their visits to a pediatrician. Phase 1 examined the effect of giving one of 3 types of feedback to 5-year-old children immediately following their Diphtheria Pertussis Tetanus (DPT) inoculation. Children were given pain-affirming feedback (the shot hurt), pain-denying feedback (the shot did not hurt), or neutral feedback (the shot is over). 1 week later, they did not differ in their reports concerning how much the shot hurt or how much they cried. In Phase 2, the same children were visited approximately 1 year after their inoculation. During 3 separate visits, they were either given additional pain-denying or neutral feedback. They were also given misleading or nonmisleading information about the actions of the pediatrician and the assistant. Children given pain-denying feedback reported that they cried less and that the shot hurt less than did children given neutral feedback. Those who were given misleading information about the actions of the assistant and the pediatrician made more false allegations about their actions than did children who were not given this information. These results challenge the view that suggestibility effects are confined to peripheral, nonaction events; in this study children’s reports about salient actions involving their own bodies in stressful conditions were influenced. Buchser E. Burnand B. Sprunger AL. Clemence A. Lepage C. Martin Y.Chedel D. Guex P. Sloutskis D. Rumley R. Hypnosis and self-hypnosis, administered and taught by nurses, for the reduction of chronic pain: a controlled clinical trial. Schweizerische Medizinische Wochenschrift – Supplementum 1994;62:77-81 Hypnosis is a technique whereby an individual can reach a particular state, quite unrelated to sleep, characterized by aroused, attentive and focused concentration. Although there are numerous clinical applications of hypnosis, there are virtually no controlled clinical trials to support its effectiveness. We propose a controlled randomized clinical trial comparing a “control” group of chronic pain patients treated by a programme including conventional oral medication combined with various nerve blocks and/or spinal administration of drugs, with a “treatment” group having a similar treatment programme plus hypnosis carried out by nurses. Outcome measurements include mainly the variation of pain intensity, the amount of analgesic drug consumption, spontaneous physical activity, and the change in health-related quality of life. The assessment of the outcome variable is done at the initial workup, weekly for the first 3 weeks, and at 6 and 12 weeks. A follow-up survey is conducted at 6 months. Campbell DF. Dixon JK. Sanderford LD. Denicola MA. Relaxation: its effect on the nutritional status and performance status of clients with cancer. Journal of the American Dietetic Association 1984;84(2):201-4 Relaxation was used to promote normal food consumption patterns among persons with cancer. As part of a larger study, 22 persons with cancer were randomly assigned to receive instruction and reinforcement in a relaxation technique to be used preprandially. The relaxation procedure included four components: (a) deep abdominal breathing, (b) tensing and relaxing of various body parts, (c) relaxation by autosuggestion, and (d) voluntary image control. Twelve clients complied with relaxation instructions in part, and 10 did not. Among compliers, 75% experienced desirable weight change over a six-week period. Performance status, measured by the Karnofsky scale, improved for 33% and worsened for 17% over eight weeks. Research has shown relaxation to be an effective measure in relation to pain, hypertension, and other conditions. These preliminary results now suggest that relaxation may also be effective in treating the eating problems of the person with cancer, leading to improvement in weight and performance status. Cochrane G. Friesen J. Hypnotherapy in weight loss treatment. Journal of Consulting & Clinical Psychology 1986;54(4):489-92 Investigated the effects of hypnosis as a treatment for weight loss among women. The sample consisted of 60 women (aged 20-65 yrs) who were at least 20% overweight and were not in any other treatment program. Six client variables (suggestibility, self-concept, quality of family origin, age of obesity onset, education level, and socioeconomic status (SES)) and 1 process variable (multimodal imagery) were analyzed in relation to the dependent variable (weight loss). Two experimental groups, hypnosis plus audiotapes and hypnosis without audiotapes, and the control group were investigated for weight loss immediately after treatment and again after a 6- mo follow-up. The primary hypothesis that hypnosis is an effective treatment for weight loss was confirmed, but the 7 concomitant variables and the use of audiotapes were not significant contributors to weight loss. Colgan SM, Faragher EB, Whorwell PJ Controlled trial of hypnotherapy in relapse prevention of duodenal ulceration Lancet 1988;1(8598):1299-300 30 patients with rapidly relapsing duodenal ulceration were studied to assess the possible benefit of hypnotherapy in relapse prevention. After the ulcer had healed on treatment with ranitidine, the drug was continued for a further 10 weeks during which time patients received either hypnotherapy or no hypnotherapy. The two randomly selected groups were comparable in terms of age, sex, smoking habits, and alcohol consumption. Follow-up of both groups of patients was continued for 12 months after the cessation of ranitidine. After 1 year, 8(53%) of the hypnotherapy patients and 15(100%) of the control subjects had relapsed. The results of this study suggest that hypnotherapy may be a useful therapeutic adjunct for some patients with chronic recurrent duodenal ulceration. Council JR. Kirsch I. Vickery AR. Carlson D. “Trance” versus “skill” hypnotic inductions: the effects of credibility, expectancy, and experimenter modeling. Journal of Consulting & Clinical Psychology 1983;51(3):432-40 A hypnotic induction procedure based on social learning principles (skill induction) was compared with a traditional eye-fixation/relaxation trance induction, a highly credible placebo induction, and a no induction base rate control. The trance induction surpassed the skill induction only on the Field Inventory, a measure of hypnotic depth that contains items corresponding to suggestions contained in the trance induction. Experimenter modeling was not found to enhance the effectiveness of the skill induction. Skill and trance inductions elicited slightly higher behavioral scores on the Stanford Hypnotic Susceptibility Scale: Form C than did the placebo induction. However, this difference was not obtained on other measures of hypnotic responsivity and depth. Significant correlations were found between expectancy, absorption, and responsiveness on all dependent measures. Multiple regression analyses indicated that the relationship between absorption and responsivity was mediated by expectancy. The results are interpreted as supporting the hypotheses that hypnotic responses are elicited by the expectancy for their occurrence and that induction procedures are a means of increasing subjects’ expectancies for hypnotic responses. Crawford HJ. Allen SN. Paired-associate learning and recall of high and low imagery words: moderating effects of hypnosis, hypnotic susceptibility level, and visualization abilities. American Journal of Psychology. 1996;109(3):353-72 Relationships between recall of low and high imagery paired-associate (P-A) words and hypnotic susceptibility, and the influence of hypnosis on recall as moderated by hypnotic level were examined. Subjects were assessed on 2 hypnotic susceptibility scales [Harvard Group Scale of Hypnotic Susceptibility; Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C)]. Forty-one low (0-4 SHSS:C) and 41 highly (9-12 SHSS:C) hypnotizable college students were assigned to 1 of 4 experimental groups: waking-hypnosis, hypnosiswaking, waking-waking, or hypnosis-hypnosis. Recall was significantly better for high than low imagery words. In the more sensitive within-subjects design, high hypnotizables recalled more P-A words during hypnosis than waking, and lows did not differ. In the between-subjects design, hypnotic level was not a moderator of performance during hypnosis. Low hypnotizables recalled more words in the within-subjects design. Visualization ability was a poor moderator of imagery-mediated learning. High imagery recall correlated significantly with Marks’s (1973) Vividness of Visual Imagery Questionnaire (.25) and Paivio and Harshman’s (1983) Individual Differences Questionnaire (IDQ) Verbal scale (.29 1973;), but not with the IDQ Imagery scale, the Mental Rotations Test (Vandenberg & Kuse Crawford HJ. Harrison DW. Kapelis L. Visual field asymmetry in facial affect perception: moderating effects of hypnosis, hypnotic susceptibility level, absorption, and sustained attentional abilities. International Journal of Neuroscience. 1995;82(1-2):11-23 Effects of hypnotic level, affect valence and cerebral asymmetry on reaction time (RT) in the discrimination of Ekman and Friesen’s (1978) stimuli of angry and happy faces were studied in counterbalanced conditions of waking and hypnosis. Assessed previously on two hypnotic susceptibility scales [Harvard Group Scale of Hypnotic Susceptibility; Stanford Hypnotic Susceptibility Scale, Form C (SHSSC)], nondepressed subjects were 16 low (0-4 SHSSC) and 17 highly (10-12 SHSSC) hypnotizable, right-handed college students. Subjects were required to identify affects of faces, presented tachistoscopically to left (LVF) or right (RVF) visual fields, by using a forced-choice RT paradigm. Highs were significantly faster than lows in angry and happy affect recognition. Hypnosis had no significant effects. For highs only, angry emotional valence was identified faster when presented to the right hemisphere (LVF), but there were no significant hemispheric effects for happy emotional valence. For lows there were no hemispheric differences. Gender was a nonsignificant factor. Significant correlations showed that faster reaction times to angry and happy stimuli, in both LVF and RVF in waking and hypnosis, were obtained by subjects who reported more deeply absorbed and extremely focused and sustained attention on the Tellegen (1982) Absorption Scale and a subscale of the Differential Attentional Processes Inventory (Grumbles & Crawford, 1981). Vividness of Visual Imagery Questionnaire (Marks, 1973) and Affect Intensity Measure (Larsen, 1985), in general, did not correlate with RTs. The potential role of the fronto-limbic attentional system in the recognition of external visual sensory affect is discussed. Crawford HJ. Macdonald H. Hilgard ER. Hypnotic deafness: a psychophysical study of responses to tone intensity as modified by hypnosis. American Journal of Psychology 1979;92(2):193-214 Hypnotic deafness was suggested for 1000 Hz tones presented in random orders at seven intensities between 17 and 70 db. Subjects were 70 college students stratified into four levels of hypnotic susceptibility, ranging from low to high. Four conditions were presented within a single session. Two conditions tested normal hearing, one in waking and one in hypnosis; two tested reported loudness of the tones as reduced by hypnotic suggestion. The method of magnitude estimation was employed. Hearing reduction was found to correlate .59 with hypnotic susceptibility in the total sample. Few high hypnotizables reduced their hearing to zero; their mean residual hearing during the deafness conditions was 55% of normal. Power functions for the relationship between tone intensity and magnitude estimates for conditions of normal hearing and deafness were found to be relatively parallel and orderly, differing primarily in intercept value. Order effect anomalies are discussed. The “hidden observer” method showed that for 4 of the 70 subjects the covert hearing was found to be at least 20% greater than that reported overtly within hypnotic deafness and approached normal hearing. As in our previous hypnotic analgesia research, not all subjects who reduced their hearing significantly gave subsequent covert reports which differed from reported overt hearing. Discussion is given for evidence of two levels of information processing during hypnotically suggested perceptual distortions. Crowther JH. Stress management training and relaxation imagery in the treatment of essential hypertension. Journal of Behavioral Medicine 1983;6(2):169-87 The present study compared the effectiveness of three procedures in the treatment of 34 individuals with essential hypertension: (1) stress management training plus relaxation imagery, which consisted of an adaptation of existing stress management techniques in conjunction with extensive relaxation training using relaxation imagery; (2) relaxation imagery alone; and (3) weekly blood pressure checks. The relaxation imagery technique involved visualization of a relaxing image along with concentration on suggestions of relaxation, heaviness, and warmth. Treatment was individualized and lasted 8 weeks. Results indicated stress management plus relaxation imagery and relaxation imagery alone were significantly more effective than blood pressure checks in reducing systolic and diastolic blood pressures during treatment and in maintaining diastolic blood pressure reductions during follow-up. However, no significant differences were found between the two treatment procedures. Clinical implications of these findings are discussed. Cruise CJ. Chung F. Yogendran S. Little D. Music increases satisfaction in elderly outpatients undergoing cataract surgery. Canadian Journal of Anaesthesia 1997;44(1):43-8 PURPOSE: Music has long been known to reduce anxiety, minimize the need for sedatives, and make patients feel more at ease. The purpose of the study was to evaluate the effect of music in elderly outpatients undergoing elective cataract surgery with retrobulbar block and monitored anaesthetic care using fentanyl or alfentanil and midazolam. METHODS: One hundred and twenty one patients were prospectively and randomly assigned to hear: relaxing suggestions, white noise, operating room noise or relaxing music via audio-cassette headphones. Vital signs were documented before and after retrobulbar block and every 15 min thereafter. Anxiety was assessed using the State-Trait Anxiety Inventory (STAI) before and after surgery. Visual analogue scales (VAS) were used to assess anxiety and patient satisfaction postoperatively with a standardized questionnaire. Between group comparisons were made using Chi-Square, or ANOVA, where appropriate. RESULTS: There were no differences between groups in STAI or anxiety VAS scores at any time. Differences were noted in systolic blood pressure, but not in other vital signs. Patients’ ratings of the whole operative experience, satisfaction with the tape played, general level of relaxation and preference for the chosen tape for subsequent surgery were different (music > relaxing suggestions > white noise and OR noise, P < 0.05). CONCLUSIONS: Elderly patients undergoing cataract surgery under retrobulbar block were more satisfied with their experience if they heard relaxing music, rather than relaxing suggestions or white noise or OR noise. The type of auditory stimuli to which the patients were exposed did not influence the level of anxiety. Dahlgren LA. Kurtz RM. Strube MJ. Malone MD. Differential effects of hypnotic suggestion on multiple dimensions of pain. Journal of Pain & Symptom Management. 1995;10(6):464-70 Within the framework of multidimensional pain assessment, this study extended an earlier finding that hypnotic analgesia and relaxation suggestions have differential effects on pain reduction by evaluating these strategies in subjects undergoing a cold pressor protocol. Thirty-two highly susceptible subjects were randomly assigned to an analgesia or a relaxation suggestion treatment group. Six pain reports were taken at 10-sec intervals for each experimental condition. The baseline measures served as covariates. A 2 x 2 x 2 x 6 repeated-measures analysis of covariance (ANCOVA) revealed a significant group (analgesia, relaxation) by pain dimension (intensity, unpleasantness), by condition (suggestion alone, hypnotic induction plus suggestion) interaction. Analysis of the simple-simple main effects, holding both group and condition constant, revealed that application of hypnotic analgesia reduced report of pain intensity significantly more than report of pain unpleasantness. Conversely, hypnotic relaxation reduced pain unpleasantness more than intensity. The clinical implications of the study are discussed. De Pascalis V. Caddia F. Effect of suggestion on perception: replication of Gheorghiu and Reyher's study. Perceptual & Motor Skills 1985;61(1):123-30 Gheorghiu and Reyher in 1982 described a Scale of Sensory Suggestibility consisting of an indirect-direct method of assessing suggestibility. In this study a further sample of 81 women was tested on Gheorghiu and Reyher's scale. The scale has tactual, auditory, and visual items. Each item was administered to the left and right sides of the body in random sequence and the method of presentation was varied. The scale is indirect in that the announced stimuli are never presented to participants, contrary to their expectations; it is direct because the subjects are cautioned that a stimulus might not actually be presented. The scale showed acceptable internal consistency. There were no right-left side differences. The methods of presentation were not equally successful. Progressive Intensification and Progressive Decrease in Intensification of stimulation were the most successful, whereas Expectation of series without objective stimuli was the least successful, contrary to Georghiu and Reyher's results. Finally, item analysis showed that all the items had high reliability coefficients, except two auditory and one visual items. Implications for clinical practice were discussed. DeBenedittis G. Cigada M. Bianchi A. Signorini MG. Cerutti S. Autonomic changes during hypnosis: a heart rate variability power spectrum analysis as a marker of sympatho-vagal balance. International Journal of Clinical & Experimental Hypnosis 1994;42(2):140-52 Spectral analysis of beat-to-beat variability in electrocardiography is a simple, noninvasive method to analyze sympatho-vagal interaction. The electrocardiogram is analyzed by means of an automatic, autoregressive modeling algorithm that provides a quantitative estimate of R-R interval variability by the computation of power spectral density. Two major peaks are recognizable in this specter: a low-frequency peak (LF, -0.1 Hz), related to the overall autonomic activity (ortho+parasympathetic) and a high-frequency peak (HF, - 0.25 Hz), representative of the vagal activity. The LF/HF ratio is an index of the sympatho-vagal interaction. This technique was applied, using a computer-assisted electrocardiograph, to 10 healthy volunteers (6 high and 4 low hypnotizable subjects as determined by the Stanford Hypnotic Susceptibility Scale, Form C) in randomized awake and neutral hypnosis conditions. Preliminary results indicated that hypnosis affects heart rate variability, shifting the balance of the sympatho-vagal interaction toward an enhanced parasympathetic activity, concomitant with a reduction of the sympathetic tone. A positive correlation between hypnotic susceptibility and autonomic responsiveness during hypnosis was also found, with high hypnotizable subjects showing a trend toward a greater increase of vagal efferent activity than did low hypnotizables. Dikel W. Olness K. Self-hypnosis, biofeedback, and voluntary peripheral temperature control in children. Pediatrics 1980;66(3):335-40 Forty-eight children, aged 5 to 15 years, were tested for their ability to raise and lower their index finger temperature with self-hypnosis and/or biofeedback. Group A (self-hypnosis only) and group B (selfhypnosis with biofeedback) were children who had previous successful experience with self-hypnosis (eg, for the treatment of enuresis, pain, asthma, or obesity). Group C (biofeedback only) were children with no experience with hypnosis. All three groups showed significant success with warming and cooling. The range of warming for the three groups was 0 to 3.7 F, and for cooling, 0 to 7.3 F or 0 to 8.8 F for attempts exceeding the ten-minute trial period. No significant difference in ability to warm or cool was noted when the children were compared by group, age, or sex. Some of the children in group A who had little or no success with hypnosis only were very successful with the addition of biofeedback monitoring, suggesting a synergistic effect between biofeedback and hypnosis. A significant temperature rise was also noted in groups A and B accompanying a neutral hypnotic induction relaxation-imagery exercise in which no mention of temperature change was made. This rise varied from 0 to 6 F, averaging 1.7 F. Possible therapeutic implications include the treatment of migraine headaches, Raynaud's syndrome, sickle cell anemia, and the use of temperature monitoring as a diagnostic and therapeutic adjunct to clinical hypnosis. Disbrow EA. Bennett HL. Owings JT. Effect of preoperative suggestion on postoperative gastrointestinal motility Western Journal of Medicine. 1993;158(5):488-92 Autonomic behavior is subject to direct suggestion. We found that patients undergoing major operations benefit more from instruction than from information and reassurance. We compared the return of intestinal function after intra-abdominal operations in 2 groups of patients: the suggestion group received specific instructions for the early return of gastrointestinal motility, and the control group received an equal-length interview offering reassurance and nonspecific instructions. The suggestion group had a significantly shorter average time to the return of intestinal motility, 2.6 versus 4.1 days. Time to discharge was 6.5 versus 8.1 days. Covariates including duration of operation, amount of intraoperative bowel manipulation, and amount of postoperative narcotics were also examined using the statistical model analysis of covariance. An average savings of $1,200 per patient resulted from this simple 5-minute intervention. In summary, the use of specific physiologically active suggestions given preoperatively in a beleivable manner can reduce the morbidity associated with an intraabdominal operation by reducing the duration of ileus. Donk LJ. Vingoe FJ. Hall RA. Doty R. The comparison of three suggestion techniques for increasing reading efficiency utilizing a counterbalanced research paradigm. International Journal of Clinical & Experimental Hypnosis 1970;18(2):126-133. Reports an experiment in which both Barber-type and alert-trance procedures significantly increased reading speed while maintaining comprehension when compared to a control group; a traditional hypnotic procedure followed by the specific suggestions failed to obtain these results. 32 volunteer undergraduates were randomly assigned to 4 groups in terms of a counterbalanced design. 2 groups were administered trance inductions (traditional and alert) followed by specific suggestions, a 3rd simply the suggestions, while the 4th served as control. Reading suggestions were to eliminate specific problems, increase speed, and increase or maintain comprehension. (Spanish & German summaries) Dubreuil DL. Spanos NP. Bertrand LD. Does hypnotic amnesia dissipate with time? Imagination, Cognition Personality 1982;832(2):103-113. Investigated, in 2 experiments, the hypothesis that hypnotic amnesia dissipates "spontaneously" over time. Subjects were 94 undergraduates (mean age 19 yrs) who obtained scores of 2 or above on the Objective dimension of a responsiveness to suggestion scale. Subjects were assigned at random to 4 groups. Subjects in the Remember More, Remember Less, and Retest control groups showed partial amnesia on the 1st of their 2 challenge trials. After the administration of a hypnotic amnesia suggestion for a previously learned word list, Retest Subjects in Exp I received 2 successive recall challenges before cancellation of the suggestion. Delay Subjects received only 1 challenge. It occurred at the same time that Retest Subjects received the 2nd challenge. No differences in amount of amnesia were found between the Delay trial and either of the Retest trials, thereby failing to provide support for the dissipation hypothesis. Exp II manipulated Subjects' expectations concerning the amount of amnesia typically shown on a 2nd challenge. Subjects in the Remember More or Remember Less conditions were led to believe that they would recall either more or less critical material on the 2nd amnesia challenge. Both Retest (no expectancy) and Remember More Subjects recalled significantly more words on the 2nd challenge than on the 1st one. However, a significantly greater proportion of Remember More Subjects than Retest Subjects showed recall increments on the 2nd challenge. Results do not support the dissipation hypothesis of hypnotic amnesia. Eberhart LH. Doring HJ. Holzrichter P. Roscher R. Seeling W. Therapeutic suggestions given during neuroleptanaesthesia decrease post-operative nausea and vomiting. European Journal of Anaesthesiology 1998;15(4):446-52 A double-blind randomized study was performed in 100 patients undergoing thyroidectomy to evaluate the effect of positive therapeutic suggestions made during neurolept-anaesthesia. The classic droperidol-fentanyl-N2O technique was used as these drugs preserve the neurophysiological functions required to process the information in the therapeutic suggestions given during general anaesthesia. Patients in the suggestion group heard positive nonaffirmative suggestions during the whole operation. An autoreverse tape player was used. The control group listened to an empty tape. Both groups were comparable with respect to demographic variables, anaesthetic technique, drug dosage, duration of anaesthesia and surgery. Patients in the suggestion group suffered significantly less from post- operative nausea or vomiting (suggestion: 47.2% vs. control: 85.7%) and required less anti-emetic treatment (suggestion: 30.6% vs. control: 68.6%). We conclude that therapeutic suggestions heard during neuroleptanaesthesia are processed and decrease post-operative nausea and vomiting in patients after thyroidectomy. Echterling LG. Whalen J. Stage hypnosis and public lecture effects on attitudes and beliefs regarding hypnosis. American Journal of Clinical Hypnosis. 1995;38(1):13-21 Stage hypnosis shows, designed to entertain and amaze, and public lectures, designed to explain and educate, provide dramatically different introductions to hypnosis. This study examined how audience members' attitudes and beliefs regarding hypnosis are affected by these two different experiences. Two hundred and five college students completed pretest measures before either watching a stage hypnosis show, or attending a lecture on hypnosis, or participating in a control group. Subjects completed posttest measures between one to three weeks later. Both the stage hypnosis show and the lecture increased attendees' motivation to use hypnosis in treatment and decreased their belief that hypnotizability reflects lower intelligence. Moreover, the lecture also increased beliefs that hypnotizability reflects creativity and inner strength. Finally, while the lecture reduced the belief that a hypnotized person is robotlike and automatically acts on all suggestions, the stage hypnosis show increased this attitude among its audience members. Enqvist B. Bjorklund C. Engman M. Jakobsson J. Preoperative hypnosis reduces postoperative vomiting after surgery of the breasts. A prospective, randomized and blinded study. Acta Anaesthesiologica Scandinavica 1997;41(8):1028-32 BACKGROUND: Postoperative nausea and vomiting (PONV) after general anesthesia and surgery may have an incidence as high as 70% irrespective of antiemetic drug therapy. The use of preoperative hypnosis and mental preparation by means of an audio tape was investigated in the prophylaxis of nausea and vomiting before elective breast reduction surgery. Similar interventions have not been found in the literature. METHODS: Fifty women were randomized to a control group or a hypnosis group; the latter listened to an audio tape daily 4-6 days prior to surgery. A hypnotic induction was followed by suggestions as to how to relax and experience states incompatible with nausea and vomiting postoperatively (e.g. thirst and hunger). There was a training part on the tape where the patients were asked to rehearse their own model for stress reduction. Premedication and anesthetic procedures were standardized. RESULTS: Patients in the hypnosis group had significantly less vomiting, 39% compared to 68% in the control group, less nausea and less need of analgesics postoperatively. CONCLUSIONS: Preoperative relaxation and/or hypnotic techniques in breast surgery contribute to a reduction of both PONV and postoperative analgesic requirements. Enqvist B. Fischer K. Preoperative hypnotic techniques reduce consumption of analgesics after surgical removal of third mandibular molars: a brief communication. International Journal of Clinical & Experimental Hypnosis 1997;45(2):102-8 The effects of hypnosis in connection with surgery have been described in many clinical publications, but few controlled studies have been published. The aim of the present study was to evaluate the effects of preoperative hypnotic techniques used by patients planned for surgical removal of third mandibular molars. The patients were randomly assigned to an experimental (hypnotic techniques) or a control (no hypnotic techniques) group. During the week before the surgery, the experimental group listened to an audiotape containing a hypnotic relaxation induction. Posthypnotic suggestions of healing and recovery were given on the tape together with advice regarding ways to achieve control over stress and pain. The control group received no hypnotic intervention. Only one surgeon who was not aware of patient group assignments performed all the operations. Thirty-six patients in the control group were compared to 33 patients in the experimental group. Anxiety before the operation increased significantly in the control group but remained at baseline level in the experimental group. Postoperative consumption of analgesics was significantly reduced in the experimental group compared to the control group. Enqvist B. von Konow L. Bystedt H. Pre- and perioperative suggestion in maxillofacial surgery: effects on blood loss and recovery. International Journal of Clinical & Experimental Hypnosis 1995;43(3):284-94 The basic assumption underlying the present study was that emotional factors may influence not only recovery but also blood loss and blood pressure in maxillofacial surgery patients, where the surgery was performed under general anesthesia. Eighteen patients were administered a hypnosis tape containing preoperative therapeutic suggestions, 18 patients were administered hypnosis tapes containing pre- and perioperative suggestions, and 24 patients were administered a hypnosis tape containing perioperative suggestions only. The patients who received taped suggestions were compared to a group of matched control patients. The patients who received preoperative suggestions exhibited a 30% reduction in blood loss. A 26% reduction in blood loss was shown in the group of patients receiving pre- and perioperative suggestions, and the group of patients receiving perioperative suggestions only showed a 9% reduction in blood loss. Lower blood pressure was found in the groups that received pre- and perioperative and perioperative suggestions only. Rehabilitation was facilitated in the group of patients receiving perioperative suggestions only. Ernst E. Rand JI. Stevinson C. Complementary therapies for depression: an overview. Archives of General Psychiatry 1998;55(11):1026-32 Depression is one of the most common reasons for using complementary and alternative therapies. The aim of this article is to provide an overview of the evidence available on the treatment of depression with complementary therapies. Systematic literature searches were performed using several databases, reference list searching, and inquiry to colleagues. Data extraction followed a predefined protocol. The amount of rigorous scientific data to support the efficacy of complementary therapies in the treatment of depression is extremely limited. The areas with the most evidence for beneficial effects are exercise, herbal therapy (Hypericum perforatum), and, to a lesser extent, acupuncture and relaxation therapies. There is a need for further research involving randomized controlled trials into the efficacy of complementary and alternative therapies in the treatment of depression. [References: 95] Evans C, Richardson PH Therapeutic suggestions during general anesthesia Advances 1988;5(4):6-11 Tested the hypothesis that the quality and duration of recovery from surgery would be improved by therapeutic suggestions made while patients were under general anesthesia, in a double-blind randomized controlled study of 39 adult hospital patients who were admitted for an abdominal hysterectomy. Results support the hypothesis. Evans C. Richardson PH. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet. 1988 Aug 27;2(8609):491-3. The clinical value of therapeutic suggestions during general anaesthesia was assessed in a double-blind randomised placebo-controlled study. 39 unselected patients were allocated to suggestion (n = 19) or control (n = 20) groups who were played either recorded therapeutic suggestions or a blank tape, respectively, during hysterectomy. The patients in the suggestion group spent significantly less time in hospital after surgery, suffered from a significantly shorter period of pyrexia, and were generally rated by nurses as having made a better than expected recovery. Patients in the suggestion group, unlike those in the control group, guessed accurately that they had been played an instruction tape. Everett JJ. Patterson DR. Burns GL. Montgomery B. Heimbach D. Adjunctive interventions for burn pain control: comparison of hypnosis and ativan: the 1993 Clinical Research Award. Journal of Burn Care & Rehabilitation. 1993;14(6):676-83 Thirty-two patients hospitalized for the care of major burns were randomly assigned to groups that received hypnosis, lorazepam, hypnosis with lorazepam, or placebo controls as adjuncts to opioids for the control of pain during dressing changes. Analysis of scores on the Visual Analogue Scale indicated that although pain during dressing changes decreased over consecutive days, assignment to the various treatment groups did not have a differential effect. This finding was in contrast to those of earlier studies and is likely attributable to the low baseline pain scores of subjects who participated. A larger number of subjects with low baseline pain ratings will likely be necessary to replicate earlier findings. The results are argued to support the analgesic advantages of early, aggressive opioid use via PCA or through careful staff monitoring and titration of pain drugs. Ewer TC, Stewart DE Improvement in bronchial hyper-responsiveness in patients with moderate asthma after treatment with a hypnotic technique: a randomised controlled trial BMJ Clinical Research Edition. 1986;293(6555):1129-32 A prospective, randomised, single blind, and controlled trial of a hypnotic technique was undertaken in 39 adults with mild to moderate asthma graded for low and high susceptibility to hypnosis. After a six week course of hypnotherapy 12 patients with a high susceptibility score showed a 74.9% improvement (p less than 0.01) in the degree of bronchial hyper-responsiveness to a standardised methacholine challenge test. Daily home recordings of symptoms improved by 41% (p less than 0.01), peak expiratory flow rates improved by 5.5% ( p less than 0.01), and use of bronchodilators decreased by 26.2% (p less than 0.05). The improvement in bronchial hyperreactivity occurred without a change in subjective appreciation of the degree of bronchoconstriction. A control group of 17 patients and 10 patients undergoing treatment with low susceptibility to hypnosis had no change in either bronchial hyper-responsiveness or any of the symptoms recorded at home. This study shows the efficacy of a hypnotic technique in adult asthmatics who are moderately to highly susceptible to hypnosis. Faymonville ME. Mambourg PH. Joris J. Vrijens B. Fissette J. Albert A. Lamy M. Psychological approaches during conscious sedation. Hypnosis versus stress reducing strategies: a prospective randomized study. Pain 1997;73(3):361-7 Stress reducing strategies are useful in patients undergoing surgery. Hypnosis is also known to alleviate acute and chronic pain. We therefore compared the effectiveness of these two psychological approaches for reducing perioperative discomfort during conscious sedation for plastic surgery. Sixty patients scheduled for elective plastic surgery under local anesthesia and intravenous sedation (midazolam and alfentanil upon request) were included in the study after providing informed consent. They were randomly allocated to either stress reducing strategies (control: CONT) or hypnosis (HYP) during the entire surgical procedure. Both techniques were performed by the same anesthesiologist (MEF). Patient behavior was noted during surgery by a psychologist, the patient noted anxiety, pain, perceived control before, during and after surgery, and postoperative nausea and vomiting (PONV). Patient satisfaction and surgical conditions were also recorded. Peri- and postoperative anxiety and pain were significantly lower in the HYP group. This reduction in anxiety and pain were achieved despite a significant reduction in intraoperative requirements for midazolam and alfentanil in the HYP group (alfentanil: 8.7 +/- 0.9 microg kg(-1)/h(-1) vs. 19.4 +/- 2 microg kg(-1)/h(-1), P < 0.001; midazolam: 0.04 +/- 0.003 mg kg(-1)/h(-1) vs. 0.09 +/- 0.01 mg kg(-1)/h(-1), P < 0.001). Patients in the HYP group reported an impression of more intraoperative control than those in the CONT group (P < 0.01). PONV were significantly reduced in the HYP group (6.5% vs. 30.8%, P < 0.001). Surgical conditions were better in the HYP group. Less signs of patient discomfort and pain were observed by the psychologist in the HYP group (P < 0.001). Vital signs were significantly more stable in the HYP group. Patient satisfaction score was significantly higher in the HYP group (P < 0.004). This study suggests that hypnosis provides better perioperative pain and anxiety relief, allows for significant reductions in alfentanil and midazolam requirements, and improves patient satisfaction and surgical conditions as compared with conventional stress reducing strategies support in patients receiving conscious sedation for plastic surgery. Fellows BJ. Creamer M. An investigation of the role of 'hypnosis', hypnotic susceptibility and hypnotic induction in the production of age regression. British Journal of Social & Clinical Psychology 1978;17(2):165-71 In response to criticisms of the methodology of Barber's(1969)experiments, a 2x2 factorial design, varying hypnotic susceptibility and hypnotic treatment, was used to study the role of 'hypnosis' in the production of age regression by suggestion. Twenty subjects of high hypnotic susceptibility and 20 subjects of low hypnotic susceptibility were randomly allocated to one of two treatment conditions:hypnotic induction procedure or motivational instructions. Both treatments were followed by suggestions to regress to the age of seven years. Two measures of age regression were taken:the Draw-A-Man-Test and a subjective rating of the reality of the experience. The results showed significant effects of both variables, with high suceptibility and induction treatment producing better regression on both measures than low susceptibility and motivation treatment. Hypnotic susceptibility was the stronger of the two variables. The ranking of the four conditions corresponded with predictions of hypnotic depth from the state theory of hypnosis, but the findings were not inconsistent with the non-state theory. The drawings of all regressed groups were more mature than the norms for the age of seven and the drawings of a group of seven year old children. Freeman RM. Macaulay AJ. Eve L. Chamberlain GV. Bhat AV. Randomised trial of self hypnosis for analgesia in labour. BMJ Clinical Research Edition. 1986;292(6521):657-8 We undertook a randomised trial to evaluate the effect of selfhypnosis on pain relief, satisfaction, and analgesic requirements for women in their first labour. Fry L, Mason AA, Pearson RS Effect of hypnosis on allergic skin responses in asthma and hayfever BMJ 1964; i: 1145-8 Gearan P. Kirsch I. Response expectancy as a mediator of hypnotizability modification: a brief communication. International Journal of Clinical & Experimental Hypnosis. 1993;41(2):84-91 The role of response expectancy in bringing about increases in hypnotic susceptibility by use of the Carleton Skill Training Program (CSTP) was assessed with 27 subjects selected for their low hypnotizability scores. Subjects were randomly assigned to one of two conditions: 13 received the CSTP to increase their hypnotic susceptibility, and 14 received no training. In addition to assessing hypnotizability, hypnotic response expectancies were assessed before and after training. With pretreatment hypnotizability controlled, subjects in the training group scored significantly higher than control subjects on all self-report measures of hypnotizability but not on a measure of observed behavioral response. Changes in response expectancy were found to be highly correlated with changes in hypnotizability. With changes in expectancy controlled, no significant differences between the trained and control groups were found. Gearan P. Schoenberger NE. Kirsch I. Modifying hypnotizability: a new component analysis. International Journal of Clinical & Experimental Hypnosis 1995;43(1):70-89 The effects of the Carleton Skills Training Program (CSTP) on hypnotizability were compared to those of a modified training program in which instructions for physical enactment of the response were omitted. After training, subjects in the original CSTP reported an increase in the extent to which they intentionally enacted suggested behaviors. In contrast, subjects in the modified training program reported increased fantasy without voluntary physical enactment. Nevertheless, both training programs increased behavioral and subjective responsiveness to suggestion, and there were no significant differences in response enhancement between the two programs. Across conditions, increases in behavioral and subjective responses to suggestion were correlated with increased use of fantasy. In contrast, increases in enactment were correlated only with compliance. The modified training program is recommended as a means of enhancing suggestibility with less likelihood than the original CSTP of engendering compliance. Godeby J. Erdt G. Canavan T. Revenstorf D. Experimental hypermnesia: Effects of hypnosis on learning and memory processes Experimentelle und Klinische Hypnose 1993;9(2):71-95. Studied the effects of hypnosis on learning and memory to test the hypothesis that hypnotic trance facilitates learning and memory processes by changing the form and depth of verbal processing. Subjects included 36 normal male and female German adults (aged 21-45 yrs) (university students). Subjects were randomly assigned to 1 of 4 experimental groups. Group 1 learned a list of 48 neutral words in a waking state and had to recall it later under hypnosis. Group 2 learned the list under hypnosis and was tested during a waking state. Group 3 learned and recalled the list under hypnosis, and Group 4 learned and recalled the list in a waking state. Intergroup differences in recall performances were analyzed. (English abstract) Goldmann L. Ogg TW. Levey AB. Hypnosis and daycase anaesthesia. A study to reduce pre-operative anxiety and intra-operative anaesthetic requirements. Anaesthesia 1988;43(6):466-9 Fifty-two female patients who underwent gynaecological operations as day cases received either a short pre-operative hypnotic induction or a brief discussion of equal duration. Hypnotized patients who underwent vaginal termination of pregnancy required significantly less methohexitone for induction of anaesthesia. They were also significantly more relaxed as judged by their visual analogue scores for anxiety. Less than half of the patients were satisfied with their knowledge about the operative procedure even after discussions with the surgeon and anaesthetist. A significant correlation was found between anxiety and perceived knowledge of procedures. The results suggest that pre-operative hypnosis can provide a quick and effective way to reduce pre-operative patient anxiety and anaesthetic requirements for gynaecological daycase surgery. Greenberg RP. Land JM. Influence of some hypnotist and subject variables on hypnotic susceptibility. Journal of Consulting & Clinical Psychology 1971;37(1):111-5 Randomly assigned 48 21-56 yr. Old females to 1 of 4 groups given different information with regard to a hypnotist's warmth and experience. The 6 male graduate student hypnotists had previously been judged on their objective warmth and competent appearance. Following structuring, all ss underwent individual hypnotic induction. As predicted, ss run by the objectively warmer, more competent appearing es obtained significantly higher susceptibility scores. Structured warmth produced significant differences only in ss run by the objectively less warm es. Both structured warmth and experience affected ss' subjective impressions of whether they thought they had been hypnotized. The complex relationship between antecedent variables and the various objective and subjective dependent indicators of hypnotic phenomena are discussed. Greenleaf M. Fisher S. Miaskowski C. DuHamel K. Hypnotizability and recovery from cardiac surgery. American Journal of Clinical Hypnosis 1992;35(2):119-28 We studied 32 coronary bypass patients to examine the effect of hypnosis on recovery from surgery. The patients were assessed for hypnotizability with the Hypnotic Induction Profile (HIP) and assigned to experimental groups with a random stratification procedure to equate for differences in hypnotizability, age, and severity of illness. We taught patients in groups one and two formal hypnosis with different treatment strategies; patients in group three were not taught formal hypnosis or a treatment strategy. Scores on the HIP were significant predictors of recovery, independent of experimental treatment with formal hypnosis. Patients who scored "Midrange" stabilized more quickly in the intensive care unit (ICU) than those who scored "High" or "Low" (p = < .05). Patients who scored "High" had more labile blood pressure in the ICU compared to the "Midrange" and "Lows" (p = < .05). Measured hypnotizability was associated with the recovery sequence from surgery. Gregory J. Diamond MJ. Increasing hypnotic susceptibility by means of positive expectancies and written instructions. Journal of Abnormal Psychology 1973;82(2):363-7 Investigated the extent to which hypnotic susceptibility could be modified by means of induced positive expectancies and written instructions that were designed to correct misconceptions concerning hypnosis as well as to provide concrete methods for experiencing hypnosis. 40 undergraduates were given a baseline test of hypnotic susceptibility and then randomly assigned to 1 of 4 conditions. Subjects receiving the positive expectancy were given false personality test feedback that they were good hypnotic Subjects prior to a criterion hypnotic scale. Subjects receiving the written instructions were given 10 min to read the information prior to the hypnotic test. Other Subjects browsed through magazines prior to testing in hypnosis. Both positive expectancies and written instructions were significantly effective in increasing susceptibility in comparison with practice only. Theoretical explanations are advanced and the implications of these findings are considered. Griffiths RA, Channon-Little L The hypnotizability of patients with bulimia nervosa and partial syndromes participating in a controlled treatment outcome study Contemporary Hypnosis 1993;10(2):81-7 This is a report of the hypnotizability of a large sample of bulimia nervosa and partial syndromes (n = 113) who participated in a controlled treatment outcome study. Data from the HGSHS:A (Harvard Group Scale of Hypnotic Susceptibility, Fom A) confirmed previous findings of high hypnotizability in these patients compared with normal populations. Furthermore, there was evidence that the responses of bulimia nervosa and partial syndrome patients differed significantly to the responses of the normal population on seven of the 12 items of the HGSHS:A. Griffiths RA, Hadzi Pavlovic D, Channon Little L A controlled evaluation of hypnobehavioural treatment for bulimia nervosa: Immediate pre post treatment effects Eur Eating Disord Rev. 1994;2(4):202-220 The study reports the pre post findings from a controlled comparative evaluation of treatments for bulimia nervosa. These pre post results allow comparison of the hypnobehevioural and cognitive behavioural treatments with a waiting list control group and a comparison of the immediate effects of the two modalities. One hundred and thirty subjects were screened to enter the study. Seventy eight subjects entered the investigation after being randomly allocated to either a waiting list control group, or to hypnobehavioural or cognitive behavioural groups. The treatments were delivered individually and matched in duration (8 weeks) and the number of sessions. Pre to posttreatment outcome indicated significant differences between the control group and the two treatments in reductions in bulimic behaviours and related eating pathology. The immediate effects of both treatments were equal. There were no differences at posttreatment between the treatments in abstinence from either bingeing or purging. The treatment effects were also similar to the immediate effects obtained by longer therapeutic approaches. Grond M. Pawlik G. Walter H. Lesch OM. Heiss WD. Hypnotic catalepsy-induced changes of regional cerebral glucose metabolism. Psychiatry Research. 1995;61(3):173-9 In an attempt to elucidate the physiological basis of hypnosis, we investigated the changes of whole-brain and regional cerebral glucose metabolism, from a state of resting wakefulness to a hypnotized state with whole-body catalepsy, using positron emission tomography and the 2[18F]fluorodeoxyglucose method in 15 highly hypnotizable adults. Neither the random order of study conditions nor any of the other experimental factors had a measurable effect, and there was no statistically significant global activation or metabolic depression. However, repeated measures analysis of variance revealed a statistically significant heterogeneity of symmetric regional responses: Mainly the occipital areas, including visual and paravisual cortex, became relatively deactivated, while some metabolic recruitment was found in structures involved in sensorimotor functions. The observed pattern of changes of regional cerebral activity corresponds with the shift of attention away from normal sensory input that hypnosis is known to produce. Groth-Marnat G. Mitchell K. Responsiveness to direct versus indirect hypnotic procedures: the role of resistance as a predictor variable. International Journal of Clinical & Experimental Hypnosis 1998;46(4):324-33 Empirical research attempting to demonstrate that indirectly phrased hypnotic suggestions result in greater responsiveness than do direct approaches generally has not shown any differences on formal hypnotizability scales. However, empirical research in related areas along with clinical observation suggests that client resistance might be a crucial moderating variable. Specifically, participants with greater resistance would be expected to be more responsive to indirect approaches, whereas those with low levels of resistance would be more responsive to direct hypnotic procedures. To test this hypothesis, participants were given either a standardized test of hypnotic responsiveness that used direct suggestions (Harvard Group Scale of Hypnotizability) or a comparable indirect scale (Alman Wexler Indirect Hypnotic Susceptibility Scale) followed by administration of a measure of resistance (Therapeutic Reactance Scale). The hypothesis was not confirmed, in that those with higher (or lower) reactance/resistance did not score differently than those on either the indirect or direct hypnotizability measures. Grunberger J. Linzmayer L. Walter H. Hofer C. Gutierrez-Lobos K.Stohr H. Assessment of experimentally-induced pain effects and their elimination by hypnosis using pupillometry studies. Wiener Medizinische Wochenschrift 1995;145(23):646-50 Hypnotherapeutical technique were often used for control of pain. However, an objective examination of this phenomenon was seldom carried out. The aim of the study was the psychophysiological objectivation of the effect of experimental induced pain and the elimination of pain by means of hypnosis. 22 healthy volunteers (11 female and 11 male) aged between 22 and 35 years participated in the study. In the 1st phase of the experiment static pupillometry was carried out before randomized presentation of a light stimulus (143 lux, 0.3 sec) and of a pain stimulus (coldness-spray, -50 degrees C, 0.5 sec) respectively. Afterwards the dynamic pupillary measurement was done. Additionally the Fourier analyses of pupillary oscillations reflecting central nervous activation during the static measurement (25,6 sec) was calculated. In the 2nd phase the subjects were investigated by means of the same techniques during hypnosis with specific suggestions for elimination of pain. Under light condition as well as after induction of pain an autonomic deactivation could be observed during hypnosis. Furthermore under pain condition a central deactivation could also be found, reflecting the depth of the hypnosis and the reduced perception of pain. Haanen HC. Hoenderdos HT. van Romunde LK. Hop WC. Mallee C. Terwiel JP. Hekster GB. Controlled trial of hypnotherapy in the treatment of refractory fibromyalgia. Journal of Rheumatology 1991;18(1):72-5 In a controlled study, 40 patients with refractory fibromyalgia were randomly allocated to treatment with either hypnotherapy or physical therapy for 12 weeks with followup at 24 weeks. Compared with the patients in the physical therapy group, the patients in the hypnotherapy group showed a significantly better outcome with respect to their pain experience, fatigue on awakening, sleep pattern and global assessment at 12 and 24 weeks, but this was not reflected in an improvement of the total myalgic score measured by a dolorimeter. At baseline most patients in both groups had strong feelings of somatic and psychic discomfort as measured by the Hopkins Symptom Checklist. These feelings showed a significant decrease in patients treated by hypnotherapy compared with physical therapy, but they remained abnormally strong in many cases. We conclude hypnotherapy may be useful in relieving symptoms in patients with refractory fibromyalgia. Haddock CK. Rowan AB. Andrasik F. Wilson PG. Talcott GW. Stein RJ. Home-based behavioral treatments for chronic benign headache: a meta-analysis of controlled trials. Cephalalgia 1997;17(2):113-8 Controlled clinical trials have consistently demonstrated that behavioral treatments for chronic benign headache produce clinically beneficial outcomes both post-treatment and at follow-up. Given these results there is interest in cost-reduction and redesign of these treatments to improve their accessibility. One promising approach in this regard is home-based headache treatment. These treatments seek to provide the same amount of treatment as clinic-based treatments; however, some of the material typically presented to the patient by a clinician is presented through home-study materials (e.g., manuals, audiotapes). To date, the published literature contains 20 controlled clinical trials which have examined the outcomes produced by home-based treatments. This article presents the first comprehensive meta-analysis of these clinical outcome studies. Results of the quantitative analyses suggest that home-based treatments produce comparable, or with certain outcome measures, superior results to clinic-based treatments. Moreover, costeffectiveness scores of home-based treatments were found to be more than five times larger than those of clinic-based therapies. Methodological analyses are also presented along with suggestions for future research. Hammarstrand G. Berggren U. Hakeberg M. Psychophysiological therapy vs. hypnotherapy in the treatment of patients with dental phobia. European Journal of Oral Sciences 1995;103(6):399-404 The aim of this study was to compare two different modes of behaviorally-oriented therapies for dental fear. The subjects were chosen consecutively from the waiting-list of a Dental Fears Research and Treatment Clinic. In addition, a control group was selected from patients treated under general anesthesia to compare levels of dental and general fear with the experimental groups. Twenty-two women, with a mean age of 31.8 yr, were included and randomly assigned to two groups. The median time of avoidance of dental care was 9.5 yr. One group received hypnotherapy (HT) and one group a behavioral treatment based on psychophysiological principles (PP). Both therapies included eight sessions followed by standardized conventional dental test treatments. Pre- and posttreatment measures were dental fear, general fear, mood, and patient behavior. Nine patients were not able to conclude the treatment sessions (6 HT and 3 PP); these patients did not differ significantly from the remaining patients before treatment. The PP group reported a statistically significant decrease in dental fear as well as a rise in mood during dental situations, as opposed to the HT group. General fear levels decreased but not significantly. Eleven patients completed conventional dental treatment according to a dentist's behavioral rating scale, indicating that they were relaxed, and no problems occurred during the treatments. These patients were referred to general practitioners within the community dental service. In conclusion, this small size study showed that a majority of the patients, who accomplished the behavioral therapy and the dental test treatments, became less fearful of dental care and were able to manage conventional dental care, including changing dentist. Hammond DC. Haskins-Bartsch C. Grant CW= Jr. McGhee M. Comparison of self-directed and tape-assisted selfhypnosis. American Journal of Clinical Hypnosis 1988;31(2):129-37 48 inexperienced adult volunteers were hypnotized and taught self-hypnosis by posthypnotic suggestion and immediate practice in the office. Subjects were randomly assigned to 1 of 2 experimental orders to practice self-directed and tape-assisted self-hypnosis. No differences were found between heterohypnosis or either type of self-hypnosis in response to behavioral suggestions. Experiential ratings, however, consistently favored heterohypnosis over either type of self-hypnosis. Tape-assisted self-hypnosis was consistently evaluated as superior to self-directed practice by newly trained Subjects. Harmon TM. Hynan MT. Tyre TE. Improved obstetric outcomes using hypnotic analgesia and skill mastery combined with childbirth education. Journal of Consulting & Clinical Psychology 1990;58(5):525-30 The benefits of hypnotic analgesia as an adjunct to childbirth education were studied in 60 nulliparous women. Subjects were divided into high and low hypnotic susceptibility groups before receiving 6 sessions of childbirth education and skill mastery using an ischemic pain task. Half of the Ss in each group received a hypnotic induction at the beginning of each session; the remaining control Ss received relaxation and breathing exercises typically used in childbirth education. Both hypnotic Ss and highly susceptible Ss reported reduced pain. Hypnotically prepared births had shorter Stage 1 labors, less medication, higher Apgar scores, and more frequent spontaneous deliveries than control Ss' births. Highly susceptible, hypnotically treated women had lower depression scores after birth than women in the other 3 groups. We propose that repeated skill mastery facilitated the effectiveness of hypnosis in our study. Hartman BJ. Hypnotizability as Affected by Attitudinal and Motivational Variables. International Journal of Clinical & Experimental Hypnosis 1967;15(2):86-91 Attempted to discover whether task-motivated subjects would be more hypnotizable than those not given task-motivation instructions, and whether the attitude of the E would affect subjects' hypnotizability. The Barber suggestibility scale was employed for measuring susceptibility to hypnosis. Subjects were divided randomly into 6 groups of 10: task-motivated, E neutral; non-task-motivated, E neutral; taskmotivated, E friendly; task-motivated, E harsh; non-task-motivated, E friendly; and non-task-motivated, E harsh. Analyses of variance, both for objective and subjective scores, did not yield significant results for the taskmotivation variable but did yield significant results (p = .01) for the variable dealing with E attitude. Harvey RF. Hinton RA. Gunary RM. Barry RE. Individual and group hypnotherapy in treatment of refractory irritable bowel syndrome. Lancet 1989;1(8635):424-5 33 patients with refractory irritable bowel syndrome were treated with four 40-minute sessions of hypnotherapy over 7 weeks. 20 improved, 11 of whom lost almost all their symptoms. Short-term improvement was maintained for 3 months without further formal treatment. Hypnotherapy in groups of up to 8 patients was as effective as individual therapy. Hendler CS, Redd WH Fear of hypnosis: The role of labeling in patients' acceptance of behavioral interventions Behav Ther. 1986;17(1):2-13 One hundred and five outpatient cancer chemotherapy patients were interviewed to assess their attitudes toward hypnosis and relaxation as well as to determine their beliefs in and willingness to try a behavioral procedure. Patients were randomly assigned to groups receiving identical descriptions labeled 'hypnosis', 'relaxation', or 'passive relaxation with guided imagery'. The description stressed the behavioral components of hypnosis and relaxation rather than the nonbehavioral techniques often associated with hypnosis such as age regression and posthypnotic suggestion. Patients believed hypnosis to be a powerful process that involved loss of control and altered states of consciousness. When compared with a group of college students, patients held significantly more fearful, conservative views about hypnosis. Patients who received a description of an intervention labeled 'hypnosis' were significantly less likely to believe the procedure would effectively control their nausea and vomiting and were significantly less likely to state they would try the procedure than patients in the other two label conditions. This reaction to the label occurred independently of patients' degree of nausea, vomiting, and pain due to their chemotherapy treatments. Hockenberry-Eaton MJ. Cotanch PH. Evaluation of a child's perceived self-competence during treatment for cancer. Journal of Pediatric Oncology Nursing 1989;6(3):55-62 The purpose of this study was to evaluate the effect of self- hypnosis on the perceived self-competence of children undergoing treatment for cancer and to determine longitudinal differences in perception of self-competence over time. Twenty-two children were randomized into an experimental group (taught self-hypnosis) and a control group (given standard care). Data were collected using the Harter Perceived Self-Competence Profile (HPSCP) during four courses of chemotherapy. A decrease in mean scores for the control group was found compared with the hypnosis group, which showed an increase in mean scores in five of six domains. Both groups showed a statistically significant increase in the scholastic cognitive domain and social acceptance domain from the time of diagnosis compared with the second test period. Ten children had a visible physical disability. These children were found to have significant decreases in the domains of athletic competence, social acceptance, and global self-worth. Decreases remained significant throughout all test periods in the athletic competence domain for the children with a visible physical disability. This study is unique in that the researchers evaluated children's perception of self-competence over time. These findings support previous studies and identify the need for nurses to become actively involved in helping children develop effective coping skills during chemotherapy for cancer. Houle M. McGrath PA. Moran G. Garrett OJ. The efficacy of hypnosis- and relaxation-induced analgesia on two dimensions of pain for cold pressor and electrical tooth pulp stimulation. Pain 1988;33(2):241-51 This study evaluated the efficacy of hypnosis- and relaxation-induced suggestions for analgesia for reducing the strength and unpleasantness dimensions of pain evoked by noxious tooth pulp stimulation and by cold pressor stimulation. The Tellegen Absorption Questionnaire was used to assess hypnotic susceptibility for 28 subjects in order to match treatment groups according to sex and susceptibility scores. Tooth pulp stimulation consisted of a 1 sec train of 1 msec pulses at a frequency of 100 Hz, applied at 20 sec intervals to the central incisor. Six stimuli, selected between subject's pain and tolerance thresholds, were presented 3 times each in random order. Cold pressor stimulation consisted of forearm immersion in a circulating water bath maintained at 0-1 degrees C. Subjects made threshold determinations of pain and tolerance and used Visual Analogue Scales to rate the strength and the unpleasantness of both noxious stimuli before and after receiving either hypnosis- or relaxation-induced analgesia. There were no significant differences in pain reductions between hypnosis- and relaxation-induced interventions. However, the percent reduction in both strength and unpleasantness varied significantly as a function of the type of pain. Both hypnosis and relaxation significantly reduced the strength and the unpleasantness of tooth pulp stimulation, but only the unpleasantness dimension of cold pressor pain. The pain reductions were not correlated with subjects' hypnotic susceptibility levels. The results indicate that the extent and the quality of the analgesia produced by these cognitivebased therapies vary not only according to subjects' characteristics and the efficacy of the intervention, but also according to the nature of the noxious stimuli. Tooth pulp and cold pressor stimulation represent qualitatively different stimuli with respect to both the type of nerves activated and the mode of stimulus application. Discrete, randomly presented levels of noxious electrical stimulation to the teeth activate predominantly small fibers and produce brief pain sensations that vary unpredictably in intensity. In contrast, continuous cold stimulation to the forearm activates a variety of nociceptive and non-nociceptive fibers and produces progressive cold and pain sensations with a predictable increase in intensity from cold sensations to paresthesia and severe pain. Howard WL. Reardon JP. Changes in the self concept and athletic performance of weight lifters through a cognitivehypnotic approach: an empirical study. American Journal of Clinical Hypnosis 1986;28(4):248-57 Examined the effects of a cognitive-hypnotic-imagery approach (CHI), cognitive restructuring, and hypnosis only treatments on neuromuscular performance, muscular growth, reduction of anxiety, and enhancement of self-concept in 32 male weightlifters (mean age 22.5 yrs). Subjects were randomly assigned to 4 treatment conditions conducted over a 4-wk period. The CHI group showed significant treatment effects over the other groups on 6 dependent variables from pretest to posttest 1. From posttest 1 to posttest 2, a 1-mo period in which no treatment was conducted, self-concept and muscular growth measures for CHI Subjects showed significance. The CHI group was superior to the other conditions. Neuromuscular performance and muscular growth were positively modified by CHI. Data suggest that combining hypnotic relaxation and imagery with cognitive restructuring enhances both the immediate and longrange effects of treatment. Hughes JA. Sanders LD. Dunne JA. Tarpey J. Vickers MD. Reducing smoking. The effect of suggestion during general anaesthesia on postoperative smoking habits. Anaesthesia. 1994;49(2):126-8 In a double-blind randomised trial, 122 female smokers undergoing elective surgery were allocated to receive one of two prerecorded messages while fully anaesthetised. The active message was designed to encourage them to give up smoking whilst the control message was the same voice counting numbers. No patient could recall hearing the tape. Patients were asked about their postoperative smoking behaviour one month later. Significantly more of those who had received the active tape had stopped or reduced their smoking (p < 0.01). This would suggest a level of preconscious processing of information. Hurley AE. The effects of self-esteem and source credibility on self-denying prophecies. Journal of Psychology 1997;131(6):581-94 Self-fulfilling prophecies are a well-studied phenomenon. The study of self-denying prophecies, however, is rare. Self-denying prophecies shift people's behavior in the direction opposite to the prophecy. The existence of self-denying prophecies was investigated in 222 students. The effects of self-esteem and the source of the prophecy were also investigated. The results suggest that self-denying prophecies exist and that self-esteem is an important moderator of self-denying prophecies. If managers and industrial/organizational psychologists had an understanding of self-denying prophecies, they might be better able to structure negative performance reviews in a way that could lead to improved employee performance. Hurley JD. Differential effects of hypnosis, biofeedback training, and trophotropic responses on anxiety, ego strength, and locus of control. Journal of Clinical Psychology 1980;36(2):503-7 Pretested 60 college students on three scales: The IPAT Anxiety Scale, the Barron Ego-strength scale, and the Rotter I-E scale. The Ss then were assigned randomly to one of four treatment groups designated: Hypnotic treatment, biofeedback treatment, trophotropic treatment, and control. Three of these groups met separetely for 60 minutes once a week for 8 weeks. The control group did not meet during this time. During the sessions, each group was trained in a different technique for self-regulation. At the end of the 8-week period the scales were readministered to all groups. A series of covariance analyses indicated that hypnosis was a more effective self-regulatory technique for lowering anxiety levels when compared to biofeedback or trophotropic response procedures. With regard to increasing ego strength, both the hypnotic training group and the biofeedback training group proved to be significant. No significant difference was found between the experimental and control gorups on the I-E scores. Hyman GJ. Stanley RO. Burrows GD. Horne DJ. Treatment effectiveness of hypnosis and behaviour therapy in smoking cessation: a methodological refinement. Addictive Behaviors 1986;11(4):355-65 Studies in smoking cessation have generally failed to adequately control for active treatment effects and have assumed that measures of smoking behaviour (i.e., estimated smoking rate, self-monitoring and chemical analysis) are equally reliable measures. Sixty smokers were randomly assigned to one of four different smoking cessation treatment groups: hypnosis, focussed smoking, attention placebo and a waiting list control. Subjects were asked to estimate and monitor their own smoking behaviour. Blood samples were also taken for thiocyanate analysis before treatment. Smoking rates were similarly measured directly, at 3 months and 6 months after treatment. The results indicate that the three measures of smoking behaviour were all highly correlated. No significant differences were found between treatments, directly after treatment or at the 3- and 6-month follow-ups. These results suggest that active treatment effects may not be responsible for behavioural change in a smoking cessation program. The implications of these findings are discussed. Jacknow DS. Tschann JM. Link MP. Boyce WT. Hypnosis in the prevention of chemotherapy-related nausea and vomiting in children: a prospective study. Journal of Developmental & Behavioral Pediatrics 1994;15(4):258-64 To study the effectiveness of hypnosis for decreasing antiemetic medication usage and treatment of chemotherapyrelated nausea and vomiting in children with cancer, we conducted a prospective, randomized, and controlled singleblind trial in 20 patients receiving chemotherapy for treatment of cancer. Patients were randomized to either hypnosis or standard treatment. The hypnosis group used hypnosis as primary treatment for nausea and vomiting, using antiemetic medication on a supplemental (p.r.n.) basis only, whereas the control group received a standardized antiemetic medication regimen. Nausea, vomiting, and p.r.n. antiemetic medication usage were measured during the first two courses of chemotherapy. Anticipatory nausea and vomiting were assessed at 1 to 2 and 4 to 6 months postdiagnosis. Patients in the hypnosis group used less p.r.n antiemetic medication than control subjects during both the first (p < .04) and second course of chemotherapy (p < .02). The two groups did not differ in severity of nausea and vomiting. The hypnosis group experienced less anticipatory nausea than the control group at 1 to 2 months postdiagnosis (p < .02). Results suggest self-hypnosis is effective for decreasing antiemetic medication usage and for reducing anticipatory nausea during chemotherapy. Jacobs AL, Kurtz RM, Strube MJ Hypnotic analgesia, expectancy effects, and choice of design: a reexamination. Int J Clin Exp Hypn 1995 Jan;43(1):55-69 Previous research by Stam and Spanos suggests that if waking analgesia is followed by hypnotic analgesia, subjects refrain from maximally responding during the waking trial so they report less pain under hypnosis (i.e., a holdback effect). This hypothesis was re-examined using more stringent controls. Thirty-six highly susceptible subjects chosen by a combination of the Harvard Group Scale of Hypnotic Susceptibility, Form A and the Stanford Hypnotic Susceptibility Scale, Form C were randomly assigned to one of three treatment groups (waking analgesia followed by hypnotic analgesia, waking analgesia followed by waking analgesia, or hypnotic analgesia followed by waking analgesia). Each group received three 60-second immersions of cold pressor pain stimulation (baseline, Immersion 1, Immersion 2) and rated pain using a magnitude estimation and a category rating scale. The obtained results failed to support the hypotheses of a holdback effect or a reverse-order holdback effect. Properties of within-subjects and between-subjectsdesigns were considered in explaining the superiority of hypnotic analgesia over waking analgesia typically found in within-subjects models. Jansen CK. Bonke B. Klein J. van Dasselaar N. Hop WC. Failure to demonstrate unconscious perception during balanced anaesthesia by postoperative motor response. Acta Anaesthesiologica Scandinavica 1991;35(5):407-10 Eighty patients undergoing a standardized balanced anaesthesia were randomly assigned to either a suggestion group (N = 38) or a control group (N = 42), in a double-blind design. Anaesthesia was maintained with nitrous oxide, enflurane and fentanyl. Patients in the suggestion group were played seaside sounds, interrupted by statements of the importance of touching the ear during a postoperative visit, by means of a prerecorded audiotape and headphones. Tapes containing these suggestions were played from 30 min after the first incision, for a duration of 15 min. Patients in the control group were only played seaside sounds. There were no significant differences between the groups in either the number of patients touching their ears postoperatively or the number and duration of ear touches. Jasiukaitis P. Nouriani B. Spiegel D. Left hemisphere superiority for event-related potential effects of hypnotic obstruction. Neuropsychologia. 1996;34(7):661-8 Twenty-two highly hypnotizable subjects were run in a visual target detection task which compared hypnotic obstruction of the left and right visual fields over separate blocks. The visual event-related potentials (ERPs) to non-target stimuli revealed that hypnotic obstruction reduced the P200 component to stimuli in the right hemifield, but did not affect P200 for stimulation in the left hemifield. The earlier P100 and N100 were also reduced to hypnotic obstruction but not as preferentially for either hemifield, while the P300 was not significantly changed. Right visual field left hemisphere P200 reduction predicted suppression of behavioral response (button press) to hypnotically obstructed targets in both hemifields. The results are discussed in terms of Farah's model of a left hemisphere mechanism for image generation, and how highly hypnotizable subjects might use this mechanism to comply successfully with the suggestion of a hallucinated visually opaque barrier. Javel AF. One-session hypnotherapy for smoking: a controlled study. Psychological Reports 1980;46(3 Pt 1):895-9 Not randomised Jeffrey LK. Jeffrey TB. Exclusion therapy in smoking cessation: a brief communication. International Journal of Clinical & Experimental Hypnosis 1988;36(2):70-4 Investigated the effect of exclusion therapy on the outcome of a 5-session treatment protocol for smoking cessation. 120 adult Subjects were randomly assigned to a group hypnotic and behavioral program that required 48 hrs of pretreatment abstinence from use of tobacco products, or to an identical treatment that encouraged, but did not include, this pretreatment stipulation. Results indicate no significant differences between groups in dropout rates or number of Subjects abstinent from smoking. For all Subjects, including dropouts, the abstinence rate was 59.2% upon completion of treatment. It was 45.5% and 36.7% at 1- and 3-mo follow-up, respectively. Johnson LS. Johnson DL. Olson MR. Newman JP. The uses of hypnotherapy with learning disabled children. J Clinical Psychology. 1981; 37(2):291-9 Three hypnotic training sessions and instructions for 6 weeks of daily selfhypnotic practice that contained suggestions for imagery related to improvement in these areas were given to 15 children (12 males and 3 females, ages from 7 to 13), their reading teacher, and both their parents, and their responses were compared to a similar but untreated control group of 18. No overall differences were observed between groups. A multiple regression analysis revealed important predictors of self-esteem improvement for the experimental group. The child's hypnotic susceptibility score and self-hypnotic practice by children and parents were the most relevant. These LD children were at least as hypnotically susceptible as a normative sample. Hypnotherapy is seen as feasible in group administration by persons only moderately trained in hypnosis and of potential benefit to self-esteem improvement in LD children, depending on individual difference factors. Johnson PR. Thorn BE. Cognitive behavioral treatment of chronic headache: group versus individual treatment format. Headache 1989;29(6):358-65 Two hypotheses were tested in this study: (1) that a short course of cognitive behavioral therapy (CBT) is effective in the treatment of chronic headache; and (2) that group CT is as effective as individually administered CBT. Twenty-two chronic headache sufferers were randomly assigned to one of three treatment conditions: group administered CBT, individually administered CBT, or no treatment (wait list) control. Wait list subjects ultimately received treatment identical to that offered to subjects in the group treatment condition. Treatment outcome measures included the Brief Symptom Inventory, the McGill Pain Questionnaire, and several measures calculated from self-monitoring data. Tentative support was found for the hypothesis that CBT as provided in this study is effective in the treatment of chronic headache. There was no evidence that group versus individually treated subjects differed significantly on any of the measures used, although the small N and large variance among subjects limit us to preliminary conclusions for our findings. Clinical implications and suggestions for future research are discussed. Johnson RL. Johnson HC. Effects of anxiety-reducing hypnotic training on learning and reading-comprehension tasks. Journal of the National Medical Association 1984;76(3):233-235. 15 college students who reported having test-taking anxiety were randomly assigned to an experimental or a control group. The experimental group received hypnotic training to reduce anxiety prior to taking a learning and reading-comprehension test. No significant difference was found between the experimental and the control group on the simple-recall task. However, on the reading-comprehension test the experimental group scored significantly higher than the control group. Further examination of the total score revealed that the experimental group difference was due to superior performance on the inference items. There was no difference between groups on items that required the recall of information from the passage. Findings support the notion that hypnotic training may be useful to reduce anxiety and improve test performance. Johnson VC, Walker LG, Heys SD, Whiting PH, Eremin O Can relaxation training and hypnotherapy modify the immune response to stress, and is hypnotizability relevant? Contemporary Hypnosis 1996;13(2):100-8 A study was carried out with the following aims: (1) to evaluate the psychological and immunological effects of 3 weeks' relaxation practice; (2) to investigate the effects of relaxation training and hypnosis on the modulation of the immune response to an experimental stressor, and (3) to relate changes to hypnotic susceptibility. Twenty-four healthy volunteers were assigned, according to a stratified, permuted blocks, random allocation procedure, to relaxation training with hypnosis or to a control condition. Subjects attended of three occasions: day 1, day 21 and day 22 or 23. Various psychological tests were carried out on each of the occasions and, in addition, samples of urine and blood were collected for immunological and biochemical analysis. Two samples of blood were taken at the second visit, one before exposure to an experimental stressor on day 21 and one immediately thereafter. Relaxation had several effects including improvement on a number of measures of mental state and a reduction in lymphocyte responsiveness and IL-1 secretion. However, on exposure to the stressor, previous relaxation training and pre-exposure hypnotic suggestion led to increased lymphocyte responsiveness and IL-1 secretion. The extent to which IgA increased as a result of relaxation therapy for 3 weeks was positively correlated with Creative Imagination Scale (CIS) scores (changes in the control group during the same period were not correlated with CIS scores). Moreover, immediate changes in IL-1 following exposure to the stressor were positively correlated with CIS scores in the experimental groups and negatively in the control group. Hypnotizability, as assessed by the CIS, may be an important moderator of the psychneuroimmunological response to relaxation training and exposure to acute stress. Johnston M, Vogele C Benefits of psychological preparation for surgery: A meta analysis Ann Behav Med. 1993;15(4):245-256 There is now substantial agreement that psychological preparation for surgery is beneficial to patients. It is important, however, to establish which benefits can be achieved by psychological preparation and if all forms of preparation are equally effective. The results of randomized controlled trials of psychological methods of preparing adult patients for surgery were analyzed in terms of eight outputs (negative affect, pain, pain medication, length of stay, behavioral and clinical indices of recovery, physiological indices, and satisfaction). In order to reduce publication bias, published as well as unpublished studies were included in the meta analysis. It was concluded that significant benefits can be obtained on all of the major outcome variables that have been explored. Procedural information and behavioral instructions show the most ubiquitous effects in improving measures of post-operative recovery. The results have implications for the improvement of patient care in surgical units. Kaplan GM, Barabasz AF Enhancing hypnotizability: differential effects of flotation restricted environmental stimulation technique and progressive muscle relaxation Australian Journal of Clinical & Experimental Hypnosis 1988 May;16(1):39-51 Investigated the effectiveness of flotation restricted environmental stimulation technique (REST) for enhancing hypnotizability. 30 Subjects were randomly assigned to flotation REST, progressive muscle relaxation (PMR), or no-treatment control conditions. Subjects were tested with the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C), and readministered the SHSS:C after treatment and at follow-up. Results show that PMR enhanced hypnotizability more than no-treatment control. Flotation REST was not found to enhance hypnotizability more than PMR. Both REST and PMR Subjects significantly increased hypnotizability over time while control Subjects did not. The role of relaxation in hypnosis is discussed. Katcher A. Segal H. Beck A. Comparison of contemplation and hypnosis for the reduction of anxiety and discomfort during dental surgery. American Journal of Clinical Hypnosis 1984;27(1):14-21 Used complex moving visual stimuli to induce states of relaxation, hypnosis, and revery in 42 dental patients (aged 21-60 yrs). To test the efficacy of using aquarium contemplation to induce relaxation, Subjects were randomly assigned to 1 of 5 treatments prior to elective oral surgery: contemplation of an aquarium, contemplation of a poster, poster contemplation with hypnotic induction, aquarium contemplation with hypnosis, and a nonintervention control. Subjects were administered 5 tests of susceptibility adapted from the Stanford Hypnotic Susceptibility Scale; blood pressure, heart rate, and subjective and objective measures of anxiety were also taken. It was found that pretreatment with aquarium contemplation and hypnosis, either alone or in combination, produced significantly greater degrees of relaxation during surgery than poster contemplation or the control procedure. Two-way ANOVA demonstrated that a formal hypnotic induction did not augment the relaxation produced by aquarium contemplation. Findings suggest that aquarium contemplation can alter patients' subjective experiences and overt behavior during oral surgery. Other clinical applications of the contemplation procedure are discussed. Katz ER. Kellerman J. Ellenberg L. Hypnosis in the reduction of acute pain and distress in children with cancer. Journal of Pediatric Psychology 1987;12(3):379-94 12 female and 24 male 6-11 yr olds with acute lymphoblastic leukemia who were undergoing repeated bone marrow aspirations (BMAs) were randomized to hypnosis or play comparison groups. Subjects were selected on their behavioral performance on baseline procedures and received interventions prior to their next 3 BMA procedures. Major results indicate an improvement in self-reported distress with both interventions. Girls exhibited more distress behavior than boys on 3 of 4 dependent measures. Suggestions of an interaction effect between sex and treatment groups were noted. The role of rapport between patient and therapist in therapeutic outcome is discussed. Katz NW. Hypnotic inductions as training in cognitive self-control. Cognitive Therapy Research 1978;2(4):365-369. Compared the efficacy of the traditional trance induction, the author's cognitive training induction, and a combination of cognitive training and active-alert instructions. In the context of a guest lecture on hypnosis, volunteer undergraduates were randomly assigned to 1 of 3 groups. The Harvard Group Scale of Hypnotic Susceptibility and a measure of attitudes toward hypnosis and conceptions of the hypnotic process were used. Results show the following: (a) The 2 inductions containing training procedures were significantly more effective than the trance induction in enhancing suggestibility but did not differ from each other. (b) Subjects exposed to the combined training and fantasy inductions saw themselves as more hypnotizable in the future than Subjects exposed to training alone. Kaufert JM. Rabkin SW. Syrotuik J. Boyko E. Shane F. Health beliefs as predictors of success of alternate modalities of smoking cessation: results of a controlled trial. Journal of Behavioral Medicine 1986;9(5):475-89 The primary objective of this study was to determine whether health beliefs influenced the outcome of the three alternate modalities of reducing cigarette consumption. The study randomized volunteers either to a control group or to one of three cessation programs, using behavior modification, health education, or hypnosis. A questionnaire was used to document health beliefs, demographic characteristics, and smoking history. Blood samples were taken before and after the completion of intervention programs to measure changes in serum thiocyanate. A follow-up questionnaire was used to assess smoking behavior after 6 months. Statistically significant decreases in serum thiocyanate levels followed participation in each of the three programs. Factor analysis and reliability tests were used to identify four scales reflecting major variable dimensions in the health belief model. Significant correlations between change in serum thiocyanate and two of the scales (general health concern and perceived vulnerability) were found only for the group randomly assigned to the health education intervention program. Kirsch I. Hypnotic enhancement of cognitive-behavioral weight loss treatments--another meta-reanalysis Journal of Consulting & Clinical Psychology 1996;64(3):517-9 In a 3rd meta-analysis of the effect of adding hypnosis to cognitive-behavioral treatments for weight reduction, additional data were obtained from authors of 2 studies, and computational inaccuracies in both previous meta-analyses were corrected. Averaged across posttreatment and follow-up assessment periods, the mean weight loss was 6.00 lbs. (2.72 kg) without hypnosis and 11.83 lbs. (5.37 kg) with hypnosis. The mean effect size of this difference was 0.66 SD. At the last assessment period, the mean weight loss was 6.03 lbs. (2.74 kg) without hypnosis and 14.88 lbs. (6.75 kg) with hypnosis. The effect size for this difference was 0.98 SD. Correlational analyses indicated that the benefits of hypnosis increased substantially over time (r = .74). Kirsch I. Montgomery G. Sapirstein G. Hypnosis as an adjunct to cognitive-behavioral psychotherapy: a metaanalysis. Journal of Consulting & Clinical Psychology 1995;63(2):214-20 A meta-analysis was performed on 18 studies in which a cognitive-behavioral therapy was compared with the same therapy supplemented by hypnosis. The results indicated that the addition of hypnosis substantially enhanced treatment outcome, so that the average client receiving cognitive-behavioral hypnotherapy showed greater improvement than at least 70% of clients receiving nonhypnotic treatment. Effects seemed particularly pronounced for treatments of obesity, especially at long-term follow-up, indicating that unlike those in nonhypnotic treatment, clients to whom hypnotic inductions had been administered continued to lose weight after treatment ended. These results were particularly striking because of the few procedural differences between the hypnotic and nonhypnotic treatments. Klein KB. Spiegel D. Modulation of gastric acid secretion by hypnosis. Gastroenterology 1989;96(6):1383-7 The ability of hypnosis to both stimulate and inhibit gastric acid secretion in highly hypnotizable healthy volunteers was examined in two studies. In the first, after basal acid secretion was measured, subjects were hypnotized and instructed to imagine all aspects of eating a series of delicious meals. Acid output rose from a basal mean of 3.60 +/- 0.48 to a mean of 6.80 +/- 0.02 mmol H+/h with hypnosis, an increase of 89% (p = 0.0007). In a second study, subjects underwent two sessions of gastric analysis in random order, once with no hypnosis and once under a hypnotic instruction to experience deep relaxation and remove their thoughts from hunger. When compared to the no-hypnosis session, with hypnosis there was a 39% reduction in basal acid output (4.29 +/- 0.93 vs. 2.60 +/- 0.44 mmol H+/h, p less than 0.05) and an 11% reduction in pentagastrin-stimulated peak acid output (28.69 +/- 2.34 vs. 25.43 +/- 2.98 mmol H+/h, p less than 0.05). We have shown that different cognitive states induced by hypnosis can promote or inhibit gastric acid production, processes clearly controlled by the central nervous system. Hypnosis offers promise as a safe and simple method for studying the mechanisms of such central control. Kohen DP Relaxation-mental imagery (self-hypnosis) for childhood asthma: behavioral outcomes in a prospective, controlled study Hypnos 1995 Sep;22(3):132-44 Twenty-eight (28) 7-12 yr old children entered a controlled study of the effects of self-hypnosis on asthma. Asthma belief and behavioural inventories were collected before, and at one and two yrs after intervention. Asthma diaries were kept daily and mailed monthly. Subjects were randomly assigned to (1) Experimental (self-hypnosis), (2) Waking suggestion (no Hypnosis), (3) attention placebo (no hypnosis or asthma discussion), or (4) traditional control groups. Twenty four (24) completed 1 month follow-up, 16 completed 6 months, and 13 completed 2 yrs. Results included fewer Emergency Room visits in the experimental group (p greater than 0.05); (2) less school missed in the experimental group compared to the traditional controlled group (p greater than 0.001) and to the waking suggestion group (p greater than 0.005); (3) no differences in psychological evaluations between groups, and (4) surprising findings regarding hypnotic and hypnotic-like experiences among subjects. Kohen DP Relaxation/mental imagery (self-hypnosis) for childhood asthma: behavioural outcomes in a prospective, controlled study Australian Journal of Clinical & Experimental Hypnosis 1996 May;24(1):12-28 Twenty-eight 7-12- year-old children entered a controlled study of the effects of self-hypnosis on asthma. Asthma belief and behavioural inventories were collected before, and at one and two years after intervention. Asthma diaries were kept daily and mailed monthly. Subjects were randomly assigned to (a) experimental (self-hypnosis), (b) waking suggestion (no hypnosis), (c) attention placebo (no hypnosis or asthma discussion) or (d) traditional control groups. Twenty-four completed one-month follow-up, 16 completed six months, and 13 completed two years. Results included: (a) fewer emergency room visits in the experimental group; (b) less school missed in the experimental group compared to the traditional control group and to the waking suggestion group; (c) no difference in psychological evaluations between groups; and (d) surprising findings regarding hypnotic and hypnotic-like experiences among subjects. Kurtz RM. Strube MJ. Multiple susceptibility testing: is it helpful?. American Journal of Clinical Hypnosis. 1996;38(3):172-84 This study explored whether or not the use of combined group and individually administered susceptibility tests improve the predictive power over the use of a singly administered test. Two hundred and eighty undergraduates were assigned to one of five groups: Group 1 received the HGSHS: A and then the SHSS:C; Group 2 the CIS and SHSS:C; Group 3 the HGSHS: A and the SHCS:A; Group 4 received the CIS and the SHCS:A; and Group 5 was tested on the SHSS:C alone. After the susceptibility screening the subjects were hypnotized and tested on four types of target hypnotic behaviors. From the RSPSHS:I&II the following four factors were chosen (1) cognitive distortion, (2) positive hallucination, (3) negative hallucination, (4) dreams and regression. The items were matched on difficulty level. The data were subjected to a series of stepwise multiple regression and logistic regression analyses. The results confirmed previous research; i.e., (1) The SHSS:C is the best single measure, (2) the SHCS:A is a poor substitute for the SHSS:C; (3) the HGSHS:A is not adequate substitute for SHSS:C; (4) the CIS is weak in predictive power compared to the HGSHS:A; (5) Only for a weak measure such as SHCS:A does combined testing produce an advantage; (6) There appear to be no warm-up effects for SHSS:C when preceded by HGSHS:A. Kuttner L. Bowman M. Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. Journal of Developmental & Behavioral Pediatrics 1988;9(6):374-81 The study compared the efficacy of hypnotic "imaginative involvement," behavioral distraction and standard medical practice for the reduction of pain, distress and anxiety in children with leukemia, during bone marrow aspirations. Two age groups of children, 3 to 6, and 7 to 10 years, were randomized to the three treatment groups. Two intervention sessions were given. At first intervention, observational ratings of distress indicated significant reductions for the younger group in the hypnotic treatment, whereas the older group achieved significant reductions in both treatment conditions for observer-rated pain and anxiety. At second intervention, all groups showed reductions and the control group appeared to be contaminated. The hypnotic method with its internal focus had an all-or-none effect, whereas distraction appeared to require that coping skills be learned over one session or more. Lambe R. Osier C. Franks P. A randomized controlled trial of hypnotherapy for smoking cessation. Journal of Family Practice 1986;22(1):61-5 A randomized controlled study in a family practice setting was conducted on the use of hypnosis in helping people quit smoking. In the hypnosis group 21 percent of patients quit smoking by the three month follow-up compared with 6 percent in the control group. By six months there were no significant differences between the two groups, and at one year 22 percent in the hypnosis group and 20 percent in the control group had quit. The only significant predictor of success with quitting was having a college education. Lambert SA. The effects of hypnosis/guided imagery on the postoperative course of children. Journal of Developmental & Behavioral Pediatrics. 1996;17(5):307-10 Hypnosis, guided imagery, and relaxation have been shown to improve the postoperative course of adult surgical patients. Children have successfully used hypnosis/guided imagery to significantly reduce the pain associated with invasive procedures and to improve selected medical conditions. The purpose of this study was to examine the effect of hypnosis/guided imagery on the postoperative course of pediatric surgical patients. Fifty-two children (matched for sex, age, and diagnosis) were randomly assigned to an experimental or control group. The experimental group was taught guided imagery by the investigator. Practice of the imagery technique included suggestions for a favorable postoperative course. Significantly lower postoperative pain ratings and shorter hospital stays occurred for children in the experimental group. State anxiety was decreased for the guided imagery group and increased postoperatively for the control group. This study demonstrates the positive effects of hypnosis/guided imagery for the pediatric surgical patient. Lang EV. Joyce JS. Spiegel D. Hamilton D. Lee KK. Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use. International Journal of Clinical & Experimental Hypnosis 1996;44(2):106-19 The authors evaluated whether self-hypnotic relaxation can reduce the need for intravenous conscious sedation during interventional radiological procedures. Sixteen patients were randomized to a test group, and 14 patients were randomized to a control group. All had patient-controlled analgesia. Test patients additionally had self-hypnotic relaxation and underwent a Hypnotic Induction Profile test. Compared to controls, test patients used less drugs (0.28 vs. 2.01 drug units; p < .01) and reported less pain (median pain rating 2 vs. 5 on a 0-10 scale; p < .01). Significantly more control patients exhibited oxygen desaturation and/or needed interruptions of their procedures for hemodynamic instability. Benefit did not correlate with hypnotizability. Self-hypnotic relaxation can reduce drug use and improve procedural safety. Larison G. Exploring an experimental method for producing the spontaneous repressions of impulses. Proceedings of the 81st Annual Convention of the American Psychological Association, Montreal Canada 1973;8:1097-1098. Attempted to identify the necessary and sufficient conditions for producing psychopathology upon the posthypnotic motivation of anger in a study with 16 female Subjects. Subject's feelings and amnesia for the paramnesia serving as a matrix for the anger were assessed. A paramnesia which previously had not produced psychopathology was used in a 2 * 2 randomized design. Mild symptoms of psychopathology were elicited, but neither of the variables was significant. However, the amnesia condition was associated with significantly greater repression of the posthypnotically activated anger and significantly less GSRs. The success in producing psychopathology is discussed in the light of earlier failures with this paramnesia. Lee DY. Barak A. Uhlemann MR. Patsula P. Effects of preinterview suggestion on counselor memory, clinical impression, and confidence in judgments. Journal of Clinical Psychology 1995;51(5):666-75 This study examined the effects of schematic preinterview suggestion on counselors' (a) recognition memory of the information presented by the client; (b) clinical impression rating of the client; and (c) confidence in rating clinical impression. Fifty-two Master's-level counselor-trainees were assigned randomly to two conditions of preinterview suggestion about the status of the client (i.e., depression and no depression). After subjects had received appropriate preinterview information (i.e., depression or no-depression content) and had viewed a videotaped counseling interview, information was gathered from them. The results indicated that the preinterview suggestion (a) did not affect counselor-trainees' clinical impression rating of the client; (b) did not affect confidence of rating; and (c) yielded a weak, but significant, confirmatory memory. Implications for the interview setting are discussed. Lieberman J. Lavoie G. Brisson A. Suggested amnesia and order of recall as a function of hypnotic susceptibility and learning conditions in chronic schizophrenic patients. International Journal of Clinical & Experimental Hypnosis 1978;26(4):268-280. Investigated the influence on suggested amnesia of hypnotic susceptibility and active vs passive learning. 36 chronic schizophrenic patients, 18 low in hypnotic susceptibility and 18 medium or high in hypnotic susceptibility, were randomly assigned to active or passive learning conditions. Subjects were first tested in a hypnosis condition (Day 1) and were retested in a nonhypnosis condition (Day 2) with the presence of waking suggestion. Results for the hypnosis condition indicate that (a) there were no differences between low and mediumhigh susceptible Subjects on recall amnesia and reversibility, (b) recall amnesia and reversibility were significantly higher in passive than active learning conditions, and (c) in all conditions recall was consistently ordered. Results for the nonhypnosis condition were similar, except that reversibility was not significantly higher in passive than active learning conditions. A secondary analysis, which partitioned high susceptible from medium susceptible Subjects, revealed that reversibility was significantly higher in the high than in the low susceptible Subjects; medium susceptible Subjects did not differ from either high or low susceptible Subjects. The data suggest that the chronic schizophrenics' failure to recall hypnotic events may involve different mechanisms from those that account for posthypnotic amnesia in normal Subjects. (German, French & Spanish summaries) Lieberman LR. Fisher JR. Thomas R. King W. Use of tape recorded suggestions as an aid to probationary students. American Journal of Clinical Hypnosis 1968;11(1):35-41. A controlled study of the effectiveness of tape recorded hypnotic-like techniques on probationary students was performed. 35 pairs of probationary students, matched in curriculum predicted grade, sex, marital status, and age, were randomly assigned to control and experimental conditions. Both groups were tested for intelligence and hypnotic susceptibility; no differences were found. Results showed no significant difference in final grades for the 2 groups; however, there were significantly more experimental Subjects (14 to 8) removed from probation at the end of the quarter. Linton CP, Sheehan PW The relationship between interrogative suggestibility and susceptibility to hypnosis Australian Journal of Clinical & Experimental Hypnosis 1994 May;22(1):53-64 Using the Gudjonsson Suggestibility Scale (GSS; Gudjonsson, 1984) and Harvard Group Scale of Hypnotic Susceptibility (HGSHS:A, Shor and Orne, 1962) as measures of interrogative suggestibility and hypnotic susceptibility, 117 subjects were tested to examine the hypothesis that a relationship exists between these two measures of suggestibility. Subjects were assigned randomly to conditions within a 2 (susceptibility: high, low) x 2 (state instruction: hypnosis, waking) x 2 (feedback on the GSS: neutral, negative) design. The data suggest that the two types of suggestibility are, in fact, associated. Analyses indicated that suggestibility scores on the GSS differed appreciably for high versus low susceptible subjects, and the HGSHS:A was significantly correlated with yield scores on the interrogative suggestibility scale. Results challenge previous claims that the two types of suggestibility are independent of one another and have forensic implications that may be usefully explored. Liu WH. Standen PJ. Aitkenhead AR. Therapeutic suggestions during general anaesthesia in patients undergoing hysterectomy. British Journal of Anaesthesia 1992;68(3):277-81 In a double-blind, randomized study, we have examined the influence of positive therapeutic suggestions, presented to anaesthetized patients undergoing total abdominal hysterectomy, on postoperative morbidity and duration of hospital stay. Seventy-five patients were allocated randomly to be exposed to one of three tapes containing positive therapeutic suggestions, a modified history of the Queen's Medical Centre, or no message. We found that neither therapeutic suggestions nor the presence of a voice during anaesthesia improved postoperative outcome or reduced duration of hospital stay after total abdominal hysterectomy. Llaneza-Ramos ML. Hypnotherapy in the treatment of chronic headaches. Philippine Journal of Psychology 1989;22:17-25. 35 chronic headache patients were assessed on frequency, duration, intensity, amount of medication, and number of difficulties associated with headaches. 25 Subjects were randomly assigned to 2 psychotherapists who administered Ericksonian hypnotherapy; 10 Subjects became the comparison group. Prior to treatment, all 25 Subjects were nonsignificantly different on their baseline measures. Posttreatment measures showed all Subjects with complete relief from headaches. Two months later, 20 Subjects experienced complete recovery while 5 had a single attack of headache. For the 2 experimental groups, there were no significant differences in symptomatic manifestations before and after treatment. At the delayed posttreatment period, post hoc test analysis evidenced a shared pattern of significant differences between each of the 2 treatment groups and the comparison group. Locke SE. Ransil BJ. Zachariae R. Molay F. Tollins K. Covino NA. Danforth D. Effect of hypnotic suggestion on the delayed-type hypersensitivity response. JAMA. 1994;272(1):47-52 OBJECTIVE--To determine whether individuals selected for good general health, high hypnotizability, and the ability to alter skin temperature under hypnotic suggestion can influence the delayed-type hypersensitivity (DTH) response to varicella-zoster (VZ) antigen under hypnotic suggestion. DESIGN--A blinded clinical trial using a repeated measures design with subjects serving as their own controls. Subjects were randomly assigned to undergo a predetermined sequence of four different experimental conditions, occurring at weekly intervals, with each condition including VZ skin testing: (1) hypnosis with suggestions to enhance the DTH response to VZ antigen; (2) hypnosis with suggestions to suppress the DTH response; (3) hypnosis with suggestions for relaxation only; and (4) skin testing without hypnosis. SETTING--A National Institutes of Health-supported clinical research center in a teaching hospital. SUBJECTS--A stratified sample of 24 ambulatory, healthy, highly hypnotizable, volunteer college students selected for their above-average ability to alter skin temperature after hypnotic suggestions and their positive baseline responses to VZ antigen. There were 11 males and 13 females with a mean +/- SD age of 22 +/- 6 years. The mean +/- SD hypnotizability score (Harvard Group Scale of Hypnotic Susceptibility) was 11 +/- 1. INTERVENTIONS--Intradermal skin testing with VZ antigen (Mantoux method) and hypnotic suggestion. MAIN OUTCOME MEASURES--Areas of induration of the DTH response measured at 24 and 48 hours after injection of antigen. RESULTS--The area of the DTH response was not affected by the experimental interventions. The area of erythema was likewise unaffected. CONCLUSIONS--Our subjects were unable to alter their DTH responses using hypnotic suggestion. Long N. Labeling relaxation procedures: impact on adolescent's self-report of effectiveness. Journal of Adolescent Health 1992;13(8):686-92 Adolescents are being taught relaxation techniques by health-care professionals with increased frequency. The present study examined the effect, on self-reported relaxation, of labeling passive relaxation techniques as "hypnotic relaxation" or as "relaxation training." Subjects were 64 adolescent college students who scored above the 50th percentile, from a subject pool of 189 potential subjects, on the Spielberger Trait Anxiety Inventory. A two by two by two factorial design was utilized with sex, label (hypnotic relaxation versus relaxation training) and relaxation technique (hypnotic induction versus autogenic training) as the independent variables. Under the guise of an investigation of the physiologic correlates of relaxation, subjects were assigned at random to one of four groups. Manipulations of label and relaxation technique were presented on tape via an intercom system. The dependent variable, perceived degree of relaxation, was obtained using a form presented as a "double check" of the accuracy of the physiologic monitoring equipment to which subjects seemingly were attached. Results indicate that the label attached to relaxation techniques can have a significant effect on an individual's subjective report of relaxation depending on the subject's sex. MacHovec FJ. Man SC. Acupuncture and hypnosis compared: fifty-eight cases. American Journal of Clinical Hypnosis 1978;21(1):45-7 Fifty-eight volunteers seeking to eliminate cigarette smoking were treated in a general hospital "smoking clinic" by being divided into five groups: placebo-site acupuncture; correct-site acupuncture; group hypnosis; individual hypnosis; untreated control. Six months after treatment, correct-site acupuncture and individual hypnosis proved to be the most effective treatment. Differing rates of improvement suggest these interventions are separate and distinct rather than involving suggestion or reinforcement of already existing motivation. (Referenced in ter Riet et al. A meta-analysis of studies into the effect of acupuncture on addiction. Br J Gen Pract 1990;40:379-82 Scored 43 point, positive result) Maher-Loughnan GP, McDonald M, Mason AA, Fry L Controlled trial of hypnosis in the symptomatic treatment of asthma BMJ 1962; ii: 371-6 Manganiello AJ. A comparative study of hypnotherapy and psychotherapy in the treatment of methadone addicts. American Journal of Clinical Hypnosis 1984;26(4):273-9 This study sought to examine the effects of hypnotherapy on the ability of methadone maintained patients to reduce and/or eliminate their drug taking behavior. Seventy adult volunteers at a methadone maintenance program were randomly assigned to experimental and control groups. The experimental group received hypnotherapy for six months in addition to the psychotherapy offered as standard clinic treatment. The control group received only psychotherapy. After treatment, a six month follow up was conducted by interviews. Groups were compared to determine significant differences in the number of successful withdrawals, the mean change in methadone dose level, incidence of illicit drug use, and degree of discomfort. Significant differences were found on all measures. The experimental group had significantly less discomfort and illicit drug use, and a significantly greater number of withdrawals. At six month follow up, 94% of the subjects in the experimental group who had achieved withdrawal remained narcotic free. Mann BJ. Sanders S. The effects of light, temperature, trance length, and time of day on hypnotic depth. American Journal of Clinical Hypnosis. 1995;37(3):43-53 We evaluated predictions derived from the ultradian theory of hypnosis regarding the effects of temperature, light, trance length, and time of day on reported trance depth in 95 college undergraduates. Temperature and light showed no relation to trance depth. However, as predicted by ultradian theory, subjects who were kept in trance for 15 minutes reported greater trance depth than those who experienced a 5-minute trance. Time of day interacted with subjects' self-reported time of peak alertness in the following way: Subjects who reported greatest alertness in the morning achieved greater trance depth in the morning than in the evening, whereas those subjects who reported greater evening alertness reported deeper trance in the evening than in the morning. This latter finding was inconsistent with ultradian theory and prior research. Alternative explanations for this finding are discussed. Overall, the results from the present study do not provide strong support for Rossi's ultradian theory of hypnosis. Marks NJ. Karl H. Onisiphorou C. A controlled trial of hypnotherapy in tinnitus. Clinical Otolaryngology 1985;10(1):43-6 A group of 14 patients with unilateral tinnitus were selected because of the constant nature of their tinnitus, and its resistance to all other forms of therapy. They were subjected to hypnosis in three forms in random order. The induction of a trance state alone formed the control arm of the trial. Compared to this were the effects of 'ego boosting' and active suppression of tinnitus whilst in a trance state. One of the 14 patients showed a highly significant response to the latter treatment as judged by visual analogue scales. Five of the 14 patients (36%) found the induction of a hypnotic state of value. This seemed to help them tolerate their tinnitus better, although its loudness and quality were unaltered. Maroof M. Ahmed SM. Khan RM. Bano SJ. Haque AW. Intra-operative suggestions reduce incidence of post hysterectomy emesis. JPMA - Journal of the Pakistan Medical Association 1997;47(8):202-4 The influence of therapeutic intraoperative auditory suggestions on the incidence and severity of emetic episodes was investigated in 50 adults ASA I and II patients undergoing elective abdominal hysterectomy. The patients were randomly divided into two groups, each consisting of 25 patients. In group I, a blank tape was played and in group II, positive suggestion was played via headphones throughout the anaesthetic period. It was observed that there was statistically significant difference (P < 0.05) between the incidence of vomiting in group I (60%) and group II (36%). The number of vomiting episodes per patient in group I was 3.1 +/- 1.2 as compared to 1.7 +/- 0.6 in group II. This difference was statistically significant. The patients requiring rescue antiemetic was significantly higher (P < 0.05) in group I (66.6%) as compared to group II (22.2%). It is concluded that positive therapeutic suggestion may be considered as an alternative to antiemetic therapy. Mason JD. Rogerson DR. Butler JD. Client centred hypnotherapy in the management of tinnitus--is it better than counselling?. Journal of Laryngology & Otology. 1996;110(2):117-20 The aim of this study was to assess whether client centred hypnotherapy (CCH) which required three sessions with a trained therapist was superior to a single counselling session in reducing the impact of tinnitus. Patients were randomly allocated to receive either counselling (n = 42) or CCH (n = 44). The outcome measures were: tinnitus loudness match, subjective tinnitus symptom severity score, trend of linear analogue scale, request for further therapy and whether the patient had an impression of improvement in their tinnitus after treatment. CCH was no better than counselling in reducing the impact of tinnitus using the three quantative measures of tinnitus, and requests for further follow up. The only significant difference between the two therapies was that 20 (45.5 per cent) of the CCH group reported a general sense of improvement compared to six (14.3 per cent) in the counselling group, this is significant p < 0.01. The study did not demonstrate whether this was a genuine hypnotic effect or simply a response to the additional attention from the therapist. McCabe MP. et . al. The role of sex of therapist and group vs. individual therapy in treatment outcome using hypnosis with obese female patients: A research note. Australian Journal of Clinical & Experimental Hypnosis 1983;11(2):10-109. 44 18-66 yr old obese females were randomly assigned to either a male or female therapist and either to group (with 5 Subjects in each group) or individual therapy. The treatment program involved 10 therapy sessions with interspersed measurement sessions. There were 2 components of clinical sessions: (1) counseling focused on modification of current maladaptive behaviors related to obesity, and (2) a standardized hypnotic session using the Macquarie Hypnotic Script C (W. L. Walker et al (see PA, Vol 70:10892)). The hypnotic session covered the areas of general motivating suggestions; acquisition of new habits and attitudes related to eating, diet, and exercise; and the promotion of coping skills and an increased sense of inner locus of control. ANOVA revealed no differences in Subjects' weight loss due to therapist gender or type of therapy. McCauley JD. Thelen MH. Frank RG. Willard RR. Callen KE. Hypnosis compared to relaxation in the outpatient management of chronic low back pain. Arch Phys Med Rehab 1983;64(11):548-52 Chronic low back pain (CLBP) presents a problem of massive dimensions. While inpatient approaches have been evaluated, outpatient treatment programs have received relatively little examination. Hypnosis and relaxation are two powerful techniques amenable to outpatient use. Seventeen outpatient subjects suffering from CLBP were assigned to either Self-Hypnosis (n = 9) or Relaxation (n = 8) treatments. Following pretreatment assessment, all subjects attended a single placebo session in which they received minimal EMG feedback. One week later the subjects began eight individual weekly treatment sessions. Subjects were assessed on a number of dependent variables at pretreatment, following the placebo phase, one week after the completion of treatment, and three months after treatment ended. Subjects in both groups showed significant decrements in such measures as average pain rating, pain as measured by derivations from the McGill Pain Questionnaire, level of depression, and length of pain analog line. Self-Hypnosis subjects reported less time to sleep onset, and physicians rated their use of medication as less problematic after treatment. While both treatments were effective, neither proved superior to the other. The placebo treatment produced nonsignificant improvement. McGarry J Mesmerism vs hypnosis: a comparison of relaxation responses and evaluation of mental and psychophysiological outcomes Aust J Clin Hypnother Hypn 1987 Nov;8(1):7-36 Examined the concept put forward by L. Pulos (see PA, Vol 66:5078) that a distinction may be made between hypnotic and mesmeric phenomena. To test for psychophysiological differences in these 2 states, 45 undergraduates were randomly allocated to 1 of 3 groups that received a hypnotic induction, a hypnotic induction with mesmeric passes, or no induction and no passes. It was found that the mesmerism group showed a relaxation response similar to the hypnosis group in terms of muscle tension. However, heart rate readings for the groups were divergent, and both groups differed from the control group on both measures. Subjective reports also indicated a difference between mesmerism and hypnosis. Findings demonstrate that hypnosis alone does not produce the same physiological measures as hypnosis and mesmerism combined. McKelvie SJ. Pullara M. Effects of hypnosis and level of processing on repeated recall of line drawings. Journal of General Psychology 1988;115(3):315-29 Moderately susceptible subjects (N = 30) initially judged 30 line drawings of objects for pleasantness (deep processing) and 30 line drawings for visual complexity (shallow processing), after which they were given two immediate recall tests. Following a 48-hr delay, subjects were allocated randomly to hypnosis, simulation, or neutral control conditions and were tested four more times. Subjects produced more correct and incorrect responses over the six trials and gave a higher number of correct responses for deep items than for shallow items. Over the last four trials, hypnosis had no general facilitative effect relative to the other two treatments, but the effect of depth was strongest for hypnotized subjects, who recalled more deep items than did the controls. Finally, both hypnotized and simulating subjects rated their recall as more involuntary and their experimental treatment as more helpful than did the controls. Caution is urged in the forensic use of hypnosis as a retrieval device. McLintock TT. Aitken H. Downie CF. Kenny GN. Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. BMJ 1990;301(6755):788-90 OBJECTIVE--To establish whether positive suggestions given to a patient under general anaesthesia reduce postoperative pain and analgesic requirements. DESIGN--Prospective double blind randomised study. SETTING--Operating theatre and gynaecology ward of a teaching hospital. PATIENTS--63 Woman undergoing elective abdominal hysterectomy were randomised to be played either a tape of positive suggestions or a blank tape during the operation through a personal stereo system. INTERVENTIONS--Three women were withdrawn from the study. Anaesthesia was standardised for all of the women. Postoperative analgesia was provided through a patient controlled analgesia system for the first 24 hours. Pain scores were recorded every six hours. MAIN OUTCOME MEASURES--Morphine consumption over the first 24 hours after the operation; pain scores. RESULTS--Mean morphine requirements were 51.0 mg (95% confidence interval 42.1 to 60.0 mg in the women played positive suggestions; and 65.7 mg (55.6 to 75.7 mg) in those played a blank tape. The point estimate (95% confidence interval) for the difference of means was 14.6 mg (22.4%) (1.9 (2.9%) to 27.3 mg (41.6%] (p = 0.028). Pain scores were similar in the two groups. CONCLUSION--Positive intraoperative suggestions seem to have a significant effect in reducing patients' morphine requirements in the early postoperative period. McWilliams JL. Using hypnotic suggestions to reduce postoperative nausea and pain following lumbar laminectomies Unpublished: MISSISSIPPI STATE UNIVERSITY 1990 PH.D. The purpose of this study was to predict the effectiveness of general anesthesia and hypnotic suggestions in reducing pain and nausea in the postoperative period for patients having lumbar laminectomy surgery. The 60 subjects were patients at the Mississippi Baptist Medical Center in Jackson, Mississippi. The subjects were randomly assigned to treatment in the order that they were scheduled for surgery. The 30 experimental subjects listened to prerecorded hypnotic suggestions and environmental sounds, under general anesthesia, via a tape player equipped with ear phones. The instructions given to the experimental group included suggestions regarding reduction of nausea and pain following lumbar laminectomy surgery while the 30 subjects in the control group listened only to environmental sounds during anesthesia. For the purpose of statistical analysis, a multivariate analysis of variance was used. The multivariate Fvalue (F(6,49) = 4.03, p < 0.001). Hypnotic anesthesia blocked sensation without interrupting the initiation of the early component of the MIP, but did suppress its late component. In the second experiment, 8 subjects were tested for the perceived intensity of 5 levels of electrical tooth pulp stimulation under hypnotic anesthesia and placebo. Sensory intensity was measured by the visual analog scale (VAS). Hypnotic anesthesia was significantly more effective than placebo (P < 0.001) in reducing sensation. The differential effect of hypnotic anesthesia on the early and late component of the MIP lends further support to the hypothesis that hypnotic anesthesia operates primarily at suprasegmental, higher levels in the brain. Simon MJ, Salzberg HC The effect of manipulated expectancies on posthypnotic amnesia Int J Clin Exp Hypn. 1985;33(1):40-51 The effects of manipulated S expectancy and direct suggestions for amnesia on posthypnotic amnesia were assessed. 120 undergraduate students were randomly assigned to 6 groups: negative expectancy (for amnesia)/suggestions (for amnesia); no expectancy/suggestions; negative expectancy/no suggestions; no expectancy/no suggestions; and 2 control groups. The results indicated that the expectancy manipulation had no effect on the occurrence of posthypnotic amnesia measured by the Stanford Hypnotic Susceptibility Scale, Form A (Weitzenhoffer & Hilgard, 1959), whereas suggestions for amnesia were found to have a significant effect. Hypnotized suggestion and no suggestion Ss remembered significantly less than Ss in the nonhypnotized control groups. The implications of the findings were discussed. Sokel B, Kent CA, Lansdown R, Atherton D, Glover M, Knibbs J A comparison of hypnotherapy and biofeedback in the treatment of childhood atopic eczema Contemporary Hypnosis 1993;10(3):145-54 44 children (aged 5-15 yrs) with atopic eczema took part in a controlled trial in which they were treated with hypnotherapy or encouraged to use a biofeedback device based on galvanic skin resistance (as relaxation techniques) to control their symptoms. A 3rd group discussed the problems of having eczema without being given specific suggestions to help reduce the symptoms. Complete data were available for 31 Subjects. The total amount of body surface affected by eczema was not altered in any of the groups. 20 wks after entry to the trial, Subjects in the 2 relaxation groups showed a significant reduction in the severity of surface damage and lichenification compared with the control group. Girls in the hypnotherapy group showed greater improvement than the girls in other groups and showed greater improvement than the boys in the hypnotherapy group. Spanos NP. De Groh M. Structure of communication and reports of involuntariness by hypnotic and nonhypnotic subjects. Perceptual & Motor Skills 1983;57(3 Pt 2):1179-86 We hypothesized that phrasing a communication to move the arm as either a suggestion, a directive, or an instruction would differentially affect subjects' interpretations of the movement. 45 hypnotic and 45 nonhypnotic subjects who responded positively to a suggestion tended to describe the movement as involuntary both on open-ended questionnaires and later on an explicit involuntariness scale. Subjects given a directive to move the arm, or an instruction to reach for a pencil, rarely described their experience as involuntary on the open-ended questionnaires but sometimes rated it as involuntary on the scale. The ratings of involuntariness by subjects given suggestions seem likely to reflect interpretations made concurrently with the movement suggested. However, such ratings by subjects given directives or instructions are likely to reflect retrospective interpretations cued by the instrument used to assess subjects' experiences. Spanos NP, de Groot HP, Tiller DK Trance logic duality and hidden observer responding in hypnotic-imagination control, and simulating subjects: a social psychological analysis Journal of Abnormal Psychology 1985;94(4):611- 23 Tested the hypothesis that a tolerance for logical incongruity characterizes hypnotic responding and is related to reports of duality experiences during age regression and hidden-observer responding during suggested analgesia. 30 undergraduates (the "reals") with high scores on a responsiveness-to-suggestion scale were randomly assigned to hypnotic or imagination control treatments, while 15 undergraduates with low scores were assigned to a simulation treatment in which they were instructed to fake hypnosis. Subjects were assessed on 6 indicators of logical incongruity, given age-regression suggestions and perception tasks, administered a suggestion for analgesia and hidden observer instructions, and interviewed. Results do not support the hypothesis. The differences in responding that did emerge between reals and simulators were accounted for by the different task demands to which Subjects were exposed. These behavioral differences, which have been previously interpreted in terms of intrinsic characteristics of hypnosis, may instead reflect a combination of between-treatments differences in demands and between-Subjects differences in the interpretation of those demands and in the ability to fulfill them. Spanos NP. Gottlieb J. Rivers SM. The effects of short-term meditation practice on hypnotic responsivity. Psychological Record 1980;30(3):343-8. 81 male undergraduates were pretested on absorption and 3 measures of hypnotic responsiveness and were then randomly assigned to 1 of 3 conditions: meditation for 8 sessions, attendance at lectures on hypnosis for 8 sessions, and no treatment. Subjects were posttested on absorption, hypnotic responsivity, and Harvard Group Scale of Hypnotic Susceptibility, Form A, measures. Degree of meditating remained stable across sessions, and meditating Subjects were much more likely than those who listened to lectures to report intrusions into their attending. Neither the meditation nor the listening treatments enhanced hypnotic responsivity or absorption. Spanos NP. McNeil C. Gwynn MI. Stam HJ. Effects of suggestion and distraction on reported pain in subjects high and low on hypnotic susceptibility. Journal of Abnormal Psychology 1984;93(3):277-84 84 18-30 yr old undergraduates high or low in hypnotic susceptibility (the Carleton University Responsiveness to Suggestion Scale) immersed an arm in ice water on 2 separate trials. Within susceptibility levels, Subjects were randomly assigned to 3 groups, with an equal number in each group. Between trials, Subjects in 1 group were administered a suggestion to imagine their hand as numb and insensitive, those in a 2nd group practiced a distraction task to be used during the 2nd trial (shadowing words), and those in a 3rd group (controls) received no special instructions. The suggestion significantly lowered rated pain in high but not in low susceptibles. Contrary to dissociation accounts of hypnotic susceptibility and suggested analgesia, low-susceptible shadowers showed as much reduction in rated pain as high susceptibles given suggestion. The social psychology of the experimental pain assessment situation is discussed. Spanos NP, Mondoux TJ, Burgess CA Comparison of multi-component hypnotic and non-hypnotic treatments for smoking Contemporary Hypnosis 1995;12(1):12-9 Cigarette smokers who volunteered to participate in a free smoking session programme were administered a two session multi-component hypnotic or non-hypnotic treatment, a two session psychologocal placebo treatment, or no treatment. All subjects monitored the number of cigarettes they smoked during the three month period. The hypnotic and non-hypnotic treatment produced a significant, but temporary reduction in smoking. Placebo and control subjects did not report significant changes in smoking. Spanos NP. Saad CL. Prism Adaptation in hypnotically limb-anesthetized subjects: more disconfirming data. Perceptual & Motor Skills 1984;59(2):379-86 Two experiments assessed the effect of hypnotically suggested arm anesthesia on adaptation to displacing prisms. In Study 1, 30 highly susceptible subjects adapted to prisms by pointing at a visual target for 2 min. with their hypnotically anesthetized dominant arm. Suggestion and hypnosis were then "lifted," and subjects were randomly assigned to three groups: subjects in one group were asked to move the hand slowly during the posttest (slow motion); those in a second group were told that hypnotic anesthesia would enable them to overcome displacement aftereffects (hypothesis informed); the remaining subjects (controls) were given no special instructions. During posttesting, all groups showed a significant displacement aftereffect, with no differences occurring between groups. Study 2 followed the same procedure except that during adaptation the usual target was removed and subjects pointed towards a homogeneous backboard. 20 highly susceptible subjects were assigned to an hypothesis-informed or control group immediately before posttesting. All subjects showed a significant displacement aftereffect. Both studies provide further evidence that hypnotic suggestions do not influence automatic perceptual processes. The results of Exp. 2 contradict the suggestion that hypnotic limb anesthesia eliminates the displacement aftereffect when the target is removed during adaptation trials. Spanos NP. Williams V. Gwynn MI. Effects of hypnotic, placebo, and salicylic acid treatments on wart regression. Psychosomatic Medicine 1990;52(1):109-14 Subjects with warts on their hands and/or feet were randomly assigned to a hypnotic suggestion, topical salicylic acid, placebo, or no treatment control condition. Subjects in the three treated groups developed equivalent expectations of treatment success. Nevertheless, at the six-week follow-up interval only the hypnotic subjects had lost significantly more warts than the no treatment controls. Theoretical implications are discussed. Spiegel D. Albert LH. Naloxone fails to reverse hypnotic alleviation of chronic pain. Psychopharmacology 1983;81(2):140-3 The hypothesis that the alleviation of chronic pain with hypnosis is mediated by endorphins was tested. Six patients with chronic pain secondary to peripheral nerve irritation were taught to control the pain utilizing self-hypnosis. Each subject was tested at 5-min intervals during four 1-h sessions for the amount of reduction of pain sensation and suffering associated with hypnosis while being given, in a random double-blind crossover fashion, an IV injection of either 10 mg naloxone or a saline placebo through an indwelling catheter. The patients demonstrated significant alleviation of the pain with hypnosis, but this effect was not significantly diminished in the naloxone condition. These findings contradict the hypothesis that endorphins are involved in hypnotic analgesia. Spiegel D. Bloom JR. Group therapy and hypnosis reduce metastatic breast carcinoma pain. Psychosomatic Medicine 1983;45(4):333-9 The pain and mood disturbance of 54 women with metastatic carcinoma of the breast were studied over the course of one year. A random sample was offered weekly group therapy during the year, with or without self-hypnosis training directed toward enhancing their competence at mastering pain and stress related to cancer. Both treatment groups demonstrated significantly less self-rated pain sensation (t = 2.5 p less than 0.02) and suffering (t = 2.17, p less than 0.03) than the control sample. Those who were offered the self-hypnosis training as well as group therapy fared best in controlling the pain sensation (F = 3.1, p less than 0.05). Pain frequency and duration were not affected. Changes in pain measures were significantly correlated with changes in self-rated total mood disturbance on the Profile of Mood States and with its anxiety, depression, and fatigue subscales. Possible mechanisms for the effectiveness of these interventions are discussed. Spiegel D. Bloom JR. Kraemer HC. Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2(8668):888-91 The effect of psychosocial intervention on time of survival of 86 patients with metastatic breast cancer was studied prospectively. The 1 year intervention consisted of weekly supportive group therapy with self-hypnosis for pain. Both the treatment (n = 50) and control groups (n = 36) had routine oncological care. At 10 year follow-up, only 3 of the patients were alive, and death records were obtained for the other 83. Survival from time of randomisation and onset of intervention was a mean 36.6 (SD 37.6) months in the intervention group compared with 18.9 (10.8) months in the control group, a significant difference. Survival plots indicated that divergence in survival began at 20 months after entry, or 8 months after intervention ended. Spinhoven P. Linssen AC. Education and self-hypnosis in the management of low back pain: a component analysis. British Journal of Clinical Psychology 1989;28 ( Pt 2):145-53 The aim of this study was to conduct a component analysis of a group programme for chronic low back pain patients. Forty-five patients participated in the pain control course, consisting of education about pain and a training in self-hypnosis. A pain diary was used as a measure of pain intensity, up-time and use of pain medication. Psychoneuroticism and depression were assessed using the Symptom Checklist-90 (SCL-90). No evidence was found for a differential efficacy of education or self-hypnosis on pain diary and SCL-90 scores. On completion of the total treatment package, patients manifested statistically significant changes on all measures except reported pain intensity. It is suggested that the pain control course is a non-invasive, inexpensive means of treatment which could be of some value in teaching even more severely disabled low back pain patients to cope more adequately with their pain problem. For this group of patients, a better adjustment to continuing pain may prove to be a more realistic therapy goal than pain reduction. Staats P. Hekmat H. Staats A. Suggestion/placebo effects on pain: negative as well as positive. Journal of Pain & Symptom Management 1998;15(4):235-43 This study explores the effect of positive and negative placebo suggestions on pain induced by hand exposures to ice water. Thirty-six participants were randomly assigned to one of the following interventions: (a) positive placebo suggestion, (b) negative placebo suggestion, and (c) control. The positive placebo-suggestion participants were given favorable messages about the beneficial effects of ice-water hand immersion. The negative placebo-suggestion group was given messages depicting the negative effects of exposure to ice water. The control groups were given neutral messages about exposure to ice water. Participants rehearsed the messages and focused on them during their second hand exposures. Results indicate that both the positive and negative placebo-suggestion interventions significantly altered participants' pain threshold, pain tolerance, and pain endurance. Participants exposed to a positive placebo condition tolerated pain better than a neutral condition. Participants exposed to a negative placebo did not tolerate pain as well as participants with a neutral condition. Stam HJ. McGrath PA. Brooke RI. The effects of a cognitive-behavioral treatment program on temporo-mandibular pain and dysfunction syndrome. Psychosomatic Medicine 1984;46(6):534-45 Sixty-one patients clearly diagnosed as suffering from Temporo-Mandibular Pain and Dysfunction Syndrome (TMPDS) were randomly assigned to one of three groups, 1) hypnosis and cognitive coping skills, 2) relaxation and cognitive coping skills, or 3) a no-treatment control group. All patients were evaluated with a standard hypnotic susceptibility scale before treatment. The two treatment groups received four weekly sessions of their respective treatments. Patients in the hypnosis and relaxation groups reported equivalent decrements in pain, abnormal sounds in the temporomandibular joint, and limitations of jaw mobility. Hypnotic susceptibility was significantly correlated with reductions in reported pain for the treatment groups. Patients' age and the duration of pain before treatment were not related to treatment outcome. Patients who dropped out of treatment had fewer limitations in jaw movement but did not differ in any other variable from patients who remained in treatment. These findings are discussed in relation to the hypothesis that TemporoMandibular Pain and Dysfunction Syndrome is stress-related muscular pain and dysfunction. Stanton HE A comparison of the effects of an hypnotic procedure and music on anxiety level Australian Journal of Clinical & Experimental Hypnosis 1984 Nov;12(2):127-32 A hypnotic procedure involving a relaxing induction, positive suggestion, and mental imagery was compared with music as a means of reducing anxiety level defined in terms of scores on the Willoughby Questionnaire. Sixty adults seeking help in handling their anxiety were divided, at random, into three groups, one experiencing three weekly half hour sessions of the hypnotic procedure, another listening to music for the same amount of time, and the third serving as a non treatment control. Results indicated that both experimental treatments reduced anxiety level with the hypnotic procedure being significantly more effective. A 6 months follow up confirmed this superiority. Stanton HE Overcoming fear of public speaking with the diagnostic trance Australian Journal of Clinical & Experimental Hypnosis 1991 May;19(1):41-7 24 male executives (aged 34-53 yrs) were matched on their fear of public speaking thermometer scores and allocated at random to either an experimental or a control group. Controls read articles describing how performance anxiety might be overcome, while the experimental Subjects had 2 treatment sessions learning a diagnostic trance procedure. After the 1st stage of the study had been completed, controls experienced the same 2 treatment sessions as had the experimental group. Subjects in both the experimental group of the 1st stage and the control group of the 2nd stage were able to reduce their fear of public speaking level significantly through use of the diagnostic trance procedure. Three months later, this improvement had been maintained. Stanton HE Self-hypnosis: one path to reduced test anxiety Contemporary Hypnosis 1994;11(1):14-8 Examined the efficacy of a 5-step self-hypnosis technique in reducing test anxiety among 40 high school students (aged 12-15 yrs). Subjects were paired on the basis of sex and scores on the Test Anxiety Scale for Children (TASC), and were randomly allocated to experimental and control groups. Subjects in the experimental group learned the self-hypnosis technique in 2 50-min sessions, spaced 1 wk apart. The TASC was administered following the intervention period and once again 6 mo later. Results indicate a significant reduction of TASC scores in the experimental group, maintained over a 6-mo period, which was not matched by the control group. Stanton HE. Is hypnotic induction really necessary?: A study of ego-enhancing suggestions and their effects. Psychotherapy Psychosomatics 1975;26(6):330-336. 60 university students in an experiment involving ego enhancement through the use of positive suggestion were randomly allocated to 3 groups. Group A experienced a hypnotic induction before hearing a series of ego-enhancing suggestions, Group B simply closed their eyes and listened, and the control group had no exposure to suggestions. All Subjects completed the Willoughby Questionnaire, the Assertiveness Scale (A. A. Lazarus, 1971), and 2 social interaction scales before and after the experiment which involved 4 20-min sessions over a period of 2 wks. Subjects of the 2 experimental groups experienced significant gains, as operationalized by inventory scores. Differences between these groups were apparent only on the social interaction scales, where Group A showed significantly greater improvement. Reasons for this are discussed, and implications for hypnotherapy outlined. Stanton HE. Reduction of performance anxiety in music students. Australian Psychologist 1994;29(2):124-127. Investigated the use of hypnotherapy for music students with stage fright. 40 2nd- and 3rd-yr students at a music conservatory were paired by their scores on the Performance Anxiety Inventory (PAI) by J. Nagle et al (1981). One member of each pair was randomly assigned to the experimental group (EG), and the other was placed in the control group (CG). The EG Subjects received 2 50-min treatment sessions (TSs) of hypnotic relaxation suggestions, 1 wk apart. The TSs included breathing induction, visual imagery (clouds and a lake), and verbal suggestions linking the images to increased mental control. The CG met for 2 50-min discussion sessions. The PAI was administered before and after the TSs and 6 mo later. A significant improvement in the EG PAI scores was noted after the TSs, but not in the CG scores. Follow-up scores showed a modest improvement by the CG and continued improvement by the EG. Stanton HE. Hypnosis and rational-emotive therapy--a de-stressing combination: a brief communication. International Journal of Clinical & Experimental Hypnosis 1989;37(2):95-9 It has been suggested that teacher stress might be reduced through cognitive restructuring which is aimed at improving the rationality of their thinking. To test this hypothesis, 40 high school teachers were paired on their level of reasonable thinking, operationalized in terms of scores on the Teacher Idea Inventory (Bernard, Joyce, & Rosewarne, 1983), and allocated at random to one of 2 groups. They also completed the Face Valid Stress Test. The experimental group participated in 4 weekly treatment sessions involving a hypnotic induction and suggestions derived from key elements of Rational-Emotive Therapy. These focused on the reduction of what Ellis (Ellis & Grieger, 1977), the originator of this treatment, calls "irrational thinking." The control group spent the same amount of time discussing stress reduction methods. Both the Face Valid Stress Test and the Teacher Idea Inventory were re-administered at the end of this period and again 12 months after conclusion of the experiment. Results indicated that both the experimental and control groups significantly reduced their levels of irrational thinking and stress, although the former's improvement was more marked, particularly at the 12-month follow-up. Stanton HE. Hypnotic relaxation and the reduction of sleep onset insomnia. International Journal of Psychosomatics 1989;36(1-4):64-8 In the present study, a hypnotic relaxation technique was compared to stimulus control and placebo conditions as a means of reducing sleep onset latency (SOL). Forty-five subjects (Ss) were matched on their baseline SOL as measured through sleep diaries. They were randomly assigned to one of three groups: hypnotic relaxation; stimulus control; and placebo. These groups experienced four weekly sessions of 30-minutes duration with demand effects being controlled through the use of counter-demand instructions. Data generated by the study suggested that the particular hypnotic relaxation treatment used was effective in helping Ss go to sleep more quickly. Neither stimulus control nor placebo groups recorded similar improvement. Stanton HE. Gurdjieff and ego-enhancement: a powerful alliance. American Journal of Clinical Hypnosis 1997;40(1):376-84 24 housewives wishing to take more control over their lives were matched on their Control of Life Thermometer scores, one member of each pair being randomly allocated to either an Experimental or a Control group. While this latter group read material on how they might achieve the increased control they desired, the Experimental group had two 50-minute sessions during which they learned how to embed suggestions derived from the work of Gurdjieff into a framework designed to maximize their acceptance. The Control of Life Thermometer was administered on two further occasions, one immediately after completion of the second training session and one as a follow-up six months later. After completion of this first stage of the study, Control group housewives experienced the same two treatment sessions as had the Experimental group. Results indicated that control of life, as operationally defined by the Thermometer, was significantly greater both immediately after treatment and at the six month follow-up. Stern GS. Miller CR. Ewy HW. Grant PS. Perceived control: bogus pulse rate feedback and reported symptom reduction for individuals with accumulated stressful life events. Biofeedback & Self Regulation 1980;5(1):37-49 The present investigation tested the hypothesis that perceived control reduces reported symptom incidence for individuals with stressful life events. Subjects (undergraduate psychology students from an urban university) were divided into two groups, high and low in stress, based on their life change unit scores as measured by the Schedule of Recent Events (Holmes & Rahe, 1967). Subjects participated in a study in which they attempted to reduce pulse rate (PR) and were informed of their successes (i.e., PR reductions) through bogus feedback. High and low stress subjects were assigned randomly to one of the following conditions: bogus ascending success feedback (AS), wherein successes were concentrated more in the later stage of a PR reduction period; bogus equally distributed success feedback (EDS), wherein successes were equally distributed in the early and later stages of a PR reduction period; or no feedback (NF). The study consisted of three sessions held on 3 consecutive days. Each session consisted of a 3-minute baseline (nonfeedback) period followed by a 10-minute PR reduction period. Self-reports on 13 symptom items were measured 2 weeks before the study (pretest), after the final session of the study (posttest), and 3 weeks after the study (follow-up). Results indicated that on 5 of the 13 symptom items, the AS condition produced a significant reduction in reported symptom incidence for high-stress subjects only, and this effect was maintained for 3 weeks after the experiment. Results are discussed in terms of the effect perceived control may have on perceptions of physical health. Suggestions are made regarding the use of biofeedback treatment as a method by which perceptions of symptom distress may be reduced for individuals exposed to cumulative stressful experiences. Stradling J. Roberts D. Wilson A. Lovelock F. Controlled trial of hypnotherapy for weight loss in patients with obstructive sleep apnoea. International Journal of Obesity & Related Metabolic Disorders 1998;22(3):278-81 OBJECTIVE: To assess if hypnotherapy assists attempts at weight loss. DESIGN: Randomised, controlled, parallel study of two forms of hypnotherapy (directed at stress reduction or energy intake reduction), vs dietary advice alone in 60 obese patients with obstructive sleep apnoea on nasal continuous positive airway pressure treatment. SETTING: National Health Service hospital in the UK. MEASURES: Weight lost at 1, 3, 6, 9, 12, 15 and 18 months after dietary advice and hypnotherapy, as a percentage of original body weight. RESULTS: All three groups lost 2- 3% of their body weight at three months. At 18 months only the hypnotherapy group (with stress reduction) still showed a significant (P < 0.02), but small (3.8 kg), mean weight loss compared to baseline. Analysed over the whole time period the hypnotherapy group with stress reduction achieved significantly more weight loss than the other two treatment arms (P < 0.003), which were not significantly different from each other. CONCLUSIONS: This controlled trial on the use of hypnotherapy, as an adjunct to dietary advice in producing weight loss, has produced a statistically significant result in favour of hypnotherapy. However, the benefits were small and clinically insignificant. More intensive hypnotherapy might of course have been more successful, and perhaps the results of the trial are sufficiently encouraging to pursue this approach further. Sullivan DS. Johnson A. Bratkovitch J. Reduction of behavioral deficit in organic brain damage by use of hypnosis. Journal of Clinical Psychology 1974;30(1):96-8 Assessed the effects of "catastrophic anxiety" on the functioning of organically brain-damaged 15-35 yr olds. Subjects were randomly assigned to either a control group, a relaxation group, or a hypnosis group. All Subjects were pre- and posttested on the Bender-Gestalt Test and the WAIS Picture Completion subtest. On the WAIS, the hypnosis group performed significantly better than the other 2 groups. On the Bender-Gestalt, there were similar differences between groups when those Subjects who were less susceptible to hypnosis were not included in the analysis. There was a highly significant correlation between hypnotic susceptibility and improvement on the dependent measures. Surman OS. Hackett TP. Silverberg EL. Behrendt DM. Usefulness of psychiatric intervention in patients undergoing cardiac surgery. Archives of General Psychiatry 1974;30(6):830-5 Syrjala KL, Cummings C, Donaldson GW Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial Pain 1992; 48(2): 137-46 Few controlled clinical trials have tested the efficacy of psychological techniques for reducing cancer pain or post-chemotherapy nausea and emesis. In this study, 67 bone marrow transplant patients with hematological malignancies were randomly assigned to one of four groups prior to beginning transplantation conditioning: (1) hypnosis training (HYP); (2) cognitive behavioral coping skills training (CB); (3) therapist contact control (TC); or (4) treatment as usual (TAU; no treatment control). Patients completed measures of physical functioning (Sickness Impact Profile; SIP) and psychological functioning (Brief Symptom Inventory; BSI), which were used as covariates in the analyses. Biodemographic variables included gender, age and a risk variable based on diagnosis and number of remissions or relapses. Patients in the HYP, CB and TC groups met with a clinical psychologist for two pre-transplant training sessions and ten in-hospital "booster" sessions during the course of transplantation. Forty-five patients completed the study and provided all covariate data, and 80% of the time series outcome data. Analyses of the principal study variables indicated that hypnosis was effective in reducing reported oral pain for patients undergoing marrow transplantation. Risk, SIP, and BSI pre-transplant were found to be effective predictors of inpatient physical symptoms. Nausea, emesis and opioid use did not differ significantly between the treatment groups. The cognitive behavioral intervention, as applied in this study, was not effective in reducing the symptoms measured. Talone JM. Diamond MJ. Steadman C. Modifying hypnotic performance by means of brief sensory experiences. International Journal of Clinical & Experimental Hypnosis 1975;23(3):190-199. Examined the extent to which hypnotic performance could be modified by means of 2 types of prehypnosis sensory experiences: (a) auditory stimulation in the form of recorded music and (b) a variant of sensory restriction in the form of a short period of silence with eyes closed. 39 university students were administered the Harvard Group Scale of Hypnotic Susceptibility, Form A, as a baseline test of susceptibility and were then randomly assigned to 1 of 3 conditions. Subjects in the music and silence groups were exposed to 10 min of either recorded music or silence prior to completing an adaptation of the tape recorded posttest version of the Stanford Scale of Hypnotic Susceptibility, Form C. Control-group Subjects were exposed only to the hypnotic test scale. All Subjects reported their experienced hypnotic sensations. Music- and silence-group Subjects completed a self-report scale assessing the role played by relaxation and receptive perception in the manipulation. Although the results were not consistent, both music and silence were significantly effective in increasing responsivity in comparison with practice only. Findings are discussed with reference to possible mediating mechanisms, and implications of these findings with regard to modifying hypnotic ability, along with the need for replication studies, are considered. Tamalons AM, Mitchell J An empirical comparison of Ericksonian and traditional hypnotic procedures Aust J Clin Hypnother Hypn 1997 Mar;18(1):5-16 Researchers have investigated the effect of direct and indirect hypnotic procedures upon performance of various tasks. None, however, had used thoroughly stringet controls nor examined the effect of these procedures upon improving memory of visual stimuli. This study compares these procedures with a memory task using 80 high to low susceptible female subjects randomly assigned to 4 experimental groups. Taped traditional hypnosis (TH); taped Ericksonian hypnosis (EH); Ericksonian hypnosis presented by an experimenter (LEH) and contro group (CG). The visual data recalled was significantly greater in the EH and LEH than that of the TH and CG groups. These results are discussed in terms of how a conversational induction with an indirect suggestion phase which accessed prior unconsciousness associations contributes to the power of the Ericksonian technique. Directions for further research and implications for more effective hypnosis are discussed. Taylor DN. Effects of a behavioral stress-management program on anxiety, mood, self-esteem, and T-cell count in HIV positive men. Psychological Reports. 1995;76(2):451-7 This study evaluated the effects of a behavioral stressmanagement program on anxiety, mood, self-esteem, and T-cell count in a group of HIV-positive men who were asymptomatic except for T-cell counts below 400. The program consisted of 20 biweekly sessions of progressive muscle relaxation and electromyograph biofeedback-assisted relaxation training, meditation, and hypnosis. Ten subjects were randomly assigned to either a treatment group of a no-treatment control group, and the 2 groups were compared on pre- to posttreatment changes in the dependent measures. Analysis showed that, compared with the notreatment group, the treatment group showed significant improvement on all the dependent measures, which was maintained at a 1-mo. follow-up. Since stress is known to compromise the immune system, these results suggest that stress management to reduce arousal of the nervous system and anxiety would be an appropriate component of a treatment regimen for HIV infection. Tebecis AK. Provins KA. Further studies of physiological concomitants of hypnosis: skin temperature, heart rate and skin resistance. Biological Psychology 1976;4(4):249-58 Forehead skin temperature, heart rate and palmar skin resistance were recorded during passive hypnosis and compared with corresponding data obtained during the resting awake condition in a group of highly hypnotizable subjects experienced in self-hypnosis. Similar physiological measures were also monitored during experimental periods when subjects were experiencing suggested environmental conditions of cold and heat in hypnosis as compared with imagining the stress conditions. The data from these subjects were also compared with those obtained from a randomly selected group of people who were low in waking suggestibility and had never been hypnotized. The results indicate that the differences in mean physiological parameters were greatest between the two subject groups, although some noteable differences were also apparent between hypnosis and the awake condition within the experimental group. ter Kuile MM. Spinhoven P. Linssen AC. van Houwelingen HC. Cognitive coping and appraisal processes in the treatment of chronic headaches. Pain 1996;64(2):257-64 The purpose of the present study was to investigate the active cognitive ingredients of change in psychological treatments for long-term chronic headache complaints. The primary questions this study addressed were: (1) Is a cognitive self-hypnosis training which explicitly attempts to change appraisal and cognitive coping processes more effective in producing these changes than a relaxation procedure, and (2) are changes in pain appraisal and cognitive coping related to changes in pain and adjustment in the short and long term? A total of 144 patients were assigned at random to a cognitive self-hypnosis (CSH) treatment or autogenic training (AT) with a duration of 7 weeks. Measures used were: Headache Index (HI), Symptom Checklist-90 (SCL-90), Coping Strategy Questionnaire (CSQ), Multidimensional Locus of Pain Control Questionnaire (MLPC) and treatment expectations. The results indicated that patients successfully changed their use of coping strategies and pain appraisals. Cognitive therapy was more effective than relaxation training in changing the use of cognitive coping strategies which were the direct targets of treatment. However, treatment effects were only related with changes in the use of coping strategies and appraisal processes to a limited extent and the mediational role of cognitive processes in pain reduction and better adjustment was inconclusive. ter Kuile MM. Spinhoven P. Linssen AC. Zitman FG. Van Dyck R. Rooijmans HG. Autogenic training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups. Pain. 1994;58(3):331-40 The aims of this study were to (a) investigate the efficacy of autogenic training (AT) and cognitive self-hypnosis training (CSH) for the treatment of chronic headaches in comparison with a waiting-list control (WLC) condition, (b) investigate the influence of subject recruitment on treatment outcome and (c) explore whether the level of hypnotizability is related to therapy outcome. Three different subjects groups (group 1, patients (n = 58) who were referred by a neurological outpatient clinic; group 2, members (n = 48) of the community who responded to an advertisement in a newspaper; and group 3, students (n = 40) who responded to an advertisement in a university newspaper) were allocated at random to a therapy or WLC condition. During treatment, there was a significant reduction in the Headache Index scores of the subjects in contrast with the controls. At post-treatment and follow-up almost no significant differences were observed between the 2 treatment conditions or the 3 referral sources regarding the Headache Index, psychological distress (SCL-90) scores and medication use. Follow-up measurements indicated that therapeutic improvement was maintained. In both treatment conditions, the highhypnotizable subjects achieved a greater reduction in headache pain at post-treatment and follow-up than did the low-hypnotizable subjects. It is concluded that a relatively simple and highly structured relaxation technique for the treatment of chronic headache subjects may be preferable to more complex cognitive hypnotherapeutic procedures, irrespective of the source of recruitment. The level of hypnotic susceptibility seems to be a subject characteristic which is associated with a more favourable outcome in subjects treated with AT or CSH. Thorne DE. Amnesia and hypnosis. International Journal of Clinical & Experimental Hypnosis 1969;17(4):225-241. Explored the relative effects of 2 factors on short-term memory for a paired-associate learning task. 36 undergraduate and graduate paid volunteers were stratified, according to their Harvard Group Scale of Hypnotic Susceptibility, Form A scores, into 3 groups of 12 Subjects each. The Subjects within each of the 3 groups were then evenly but randomly assigned to 3 treatment conditions, which differed in terms of the kind of motivational procedure in which suggestions of amnesia for a recently learned paired-associate task were given. Results did not directly support or were sometimes contrary to predictions derived from popular hypnosis theories, which assert that posthypnotic amnesia is a reliable behavioral criterion for the "hypnotic state." (Spanish & German summaries) Thorne DE. Is the hypnotic trance necessary for performance of hypnotic phenomena?. Journal of Abnormal Psychology 1967;72(3):233-9 The performance of 2 so-called hypnotic phenomena (selective awareness and auditory hallucinations) were compared between highly susceptible subjects in the waking or hypnotic states. 40 subjects (from an original 148 paid, volunteer, university students) were trained in deep hypnosis and subsequently assigned randomly to 4 groups of 10 subjects each. Each group was tested on its performance of the 2 "hypnotic phenomena" while experiencing 1 of 4 combinations of 2 variables, namely, the waking or hypnotized state of each subject, and the suggestion to hallucinate during or after exposure to a paired-associate word list given audibly to each s. Quantitative and qualitative changes in subject responses to 2 separate administrations of a word-association test were used as an index of each subject's level of awareness to the paired-associate word list, and his objective and subjective effectiveness in auditory hallucinations. Results indicate no differences attributable to state, but significant differences attributable to the suggested time of hallucinating. Thorne DE. Hall HV. Hypnotic amnesia revisited. International Journal of Clinical & Experimental Hypnosis 1974;22(2):7-178. Randomly assigned 60 high- and 60 low-susceptible undergraduates (12 groups of 10 Subjects each) to 6 experimental procedures which differed in terms of the type of amnesia suggestions given (i.e., permissively or authoritatively worded amnesia suggestions) and the kind of motivation accompanying the amnesia suggestions (i.e., hypnotic motivation, waking motivation, and waking nonmotivation). High susceptible Subjects performed more effectively in the direction of the amnesia suggestions, but these suggestions were not totally effective for any of the 12 groups. There were no differences in response either to permissively or authoritatively worded amnesia suggestions or to hypnotic or waking procedures, but there were differences in response to taskmotivating and non-task-motivating procedures (task-motivated Subjects were ostensibly more amnesic). (German, French, & Spanish summaries) Timm HW. Effect of posthypnotic suggestions on the accuracy of preemployment polygraph testing. Journal of Forensic Sciences 1991;36(5):1521-1535. Examined the efficacy of both a posthypnotic (PTH) polygraph countermeasure suggestion and a PTH ideomotor lie detection suggestion within an analog preemployment screening context. 45 Subjects (aged 18-37 yrs) were randomly assigned to 1 of 3 equal-sized groups, controlling for their performance on the Harvard Group Scale of Hypnotic Susceptibility, Form A. Subjects assigned to one of the groups received the PTH suggestion that the Subject's index finger would rise whenever he or she lied during the polygraph test; Subjects in another group were given a PTH countermeasure designed to help them appear innocent whenever they lied; and those in the 3rd group were not given either hypnotic intervention. None of the Subjects given the ideomotor suggestion raised his or her finger when he or she lied during the polygraph test. The countermeasure suggestion also was ineffective, as was demonstrated by its failure to produce significantly more false negative responses. Trussell JE. Kurtz RM. Strube MJ. Durability of posthypnotic suggestions: type of suggestion and difficulty level. American Journal of Clinical Hypnosis. 1996;39(1):37-47 This study investigated the impact of Difficulty Level and Type of Suggestion upon the durability of posthypnotic suggestion over an 8-week period. Seventy-eight highly susceptible subjects selected by both the Harvard Group Scale of Hypnotic Susceptibility: Form A (HGSHS:A) and Stanford Hypnotic Scale of Susceptibility: Form C (SHSS:C) were assigned to six groups (two levels of Difficulty x three Types of Suggestion). S's were tested for posthypnotic suggestion at 1, 3, 6, and 8 weeks. A 2 x 3 x 4 (Difficulty x Suggestion x Time) factorial ANOVA was conducted, with Time treated as a repeated-measure. The outcome variable at each time was either pass or fail for relevant suggestion. We found a significant Time effect, a significant Difficulty effect, and a significant Time x Difficulty interaction. Fewer subjects passed the difficult suggestions than passed the easy suggestions; fewer passed suggestions at a latter time; and the decay in pass rate was more pronounced for the easy suggestion condition, due largely to the higher initial pass rate. Type of Suggestion was not significant, nor were any of the other interactions. Clinical implications were discussed. Turtz JS The effects of stress management training on stress level, death anxiety for persons with type II diabetes mellitus Dissertation Abstracts International, 1986;47(3):1289, University of Southern California This study examined the effects of stress management training on stress level, general anxiety, diabetic control, mental health, and death anxiety for persons with Type II diabetes. This study also sought to determine the relationships among the dependent variables. The 21 subjects who completed the study were female Type II diabetics ranging in age from 51.94 years to 77.50 years. All were volunteers, and all were obtained from a physician's private practice in the Century City area of Los Angeles. The subjects were randomly assigned to either the experimental group (n+10) or the waiting list control group (n=11). The treatment given to the members of the experimental group consisted of an 8-week stress management course that included instruction in diaphragmatic breathing, progressive muscle relaxation, a Hatha Yoga technique, Autogenics, and self-hypnosis. Level of stress was measured by the Hassles Scale; general anxiety was measured by the State-Trait Anxiety Inventory; diabetic control was measured by the glycosylated hemoglobin test, a test of long-term blood sugar control; mental health was measured by the Mental Health Inventory; death anxiety was measured by the Templer-McMordie Scale. All subjects were pretested before the treatment and posttested after the treatment. The ANCOVA procedure was used to test for the treatment effects on the dependent variables. Pearson Product-Moment Correlation Coefficients were used test for the relationships among the dependent variables at the time of pretesting. The level of significance for all statistical analyses was set at p = less than 0.05. The findings indicated that the only dependent variable that was significantly affected by the treatment was state anxiety. Although no significant increase in diabetic control was found, a trend toward lowered glycosylated hemoglobin values in the experimental group was observed. Significant correlations among the dependent variables at the time of pretesting occurred between stress level and general anxiety, stress level and diabetic control, state anxiety and diabetic control, frequency of hassles and mental health, and general anxiety and mental health. Valbo A. Eide T. Smoking cessation in pregnancy: the effect of hypnosis in a randomized study. Addictive Behaviors. 1996;21(1):29-35 At Buskerud Central Hospital in Norway, a county hospital with 2000 deliveries per year, an intervention study, using hypnosis, aimed at smoking cessation and reduction among pregnant women still smoking around 18th week of pregnancy was carried out during the period 1992-1993. Two sessions (each lasting 45 minutes) using conventional induction into a superficial nonsomnabulistic stage of trance were performed. A tape was played, encouraging the pregnant woman's wish to quit smoking and her capacity to do so. Relaxation techniques together with self-hypnotic methods were introduced to combat craving. Changes in smoking pattern were investigated at delivery time. No significant effect on smoking cessation or smoking reduction was obtained (p > 0.05). We recorded a 10% quit rate in both intervention group and control group, and 42% and 31% reduced their smoking in the intervention group and control group, respectively. van der Laan WH. van Leeuwen BL. Sebel PS. Winograd E. Baumann P. Bonke B. Therapeutic suggestion has no effect on postoperative morphine requirements. Anesthesia & Analgesia. 1996;82(1):148-52 This study was designed to confirm the effect of therapeutic intraoperative auditory suggestion on recovery from anesthesia, to establish the effect of preoperative suggestion, and to assess implicit memory for intraoperative information using an indirect memory task. Sixty consenting unpremedicated patients scheduled for elective gynecologic surgery were randomly divided into three equal groups: Group 1 received a tape of therapeutic suggestions preoperatively, and the story of Robinson Crusoe intraoperatively; Group 2 heard the story of Peter Pan preoperatively and therapeutic suggestions intraoperatively; Group 3 heard the Crusoe story preoperatively and the Peter Pan story intraoperatively. A standardized anesthetic technique was used with fentanyl, propofol, isoflurane, and nitrous oxide. After surgery, all patients received patient-controlled analgesia (PCA) with a standardized regimen. In the 24 h postsurgery, morphine use was recorded every 6 h and at 24 h an indirect memory test (free association) was used to test for memory of the stories. Anxiety scores were measured before surgery and at 6 and 24 h postsurgery. There were no significant differences between groups for postoperative morphine use, pain or nausea scores, anxiety scores, or days spent in hospital after surgery. Seven of 20 patients who heard the Pan story intraoperative gave a positive association with the word “Hook,” whereas 2 of 20 who did not hear the story gave such an association. Indirect memory for the Pan story was established using confidence interval (CI) analysis. (The 95% CI for difference in proportion did not include zero). No indirect memory for the Crusoe story could be demonstrated. This study did not confirm previous work which suggested that positive therapeutic auditory suggestions, played intraoperatively, reduced PCA morphine requirements. In contrast, a positive implicit memory effect was found for a story presented intraoperatively. Van Dyck R. Spinhoven P. Depersonalization and derealization during panic and hypnosis in low and highly hypnotizable agoraphobics. International Journal of Clinical & Experimental Hypnosis. 1997;45(1):41-54 The primary aim of the present study was to investigate the association between spontaneous experiences of depersonalization or derealization (D-D) during panic states and hypnosis in low and highly hypnotizable phobic individuals. Secondarily, the association among level of hypnotizability, capacity for imaginative involvement, and severity of phobic complaints was also assessed. S 1987;ixty-four patients with panic disorder with agoraphobia according to the DSM-III-R (American Psychiatric Association, Proneness to experience D-D during hypnosis was positively related to hypnotizability, but only for agoraphobic patients who had already experienced these perceptual distortions during panic episodes. Correlations of level of hypnotizability and capacity for imaginative involvement with severity of agoraphobic complaints were not significant. These findings suggest that hypnotizability may be a mediating variable between two different, although phenotypically similar, perceptual distortions experienced during panic states and hypnosis. Implications for both theory and clinical practice are discussed. Van Dyck R. Spinhoven P. Does preference for type of treatment matter? A study of exposure in vivo with or without hypnosis in the treatment of panic disorder with agoraphobia. Behavior Modification 1997;21(2):172-86 There is evidence that preference for a given therapy may influence results. Literature also suggests that hypnotizability may be elevated in agoraphobic patients, making hypnosis a potentially powerful method for treatment. Agoraphobic patients (N = 64) were treated with either exposure in vivo or exposure combined with hypnosis in a crossover design. Half of the patients started with the treatment they preferred and the other half received the other treatment first. Although patients’ preference clearly shifted in favor of the combined therapy in the course of the study, no effect of preference on outcome was evident. Although hypnotizability clearly correlated to outcome in the combined therapy, no difference in effect between the two therapies was found on behavioral, self-report, and observer measures. No additional effect of hypnosis could be shown and preference was not found to be a powerful mediator of effect. VanDyck R. Zitman FG. Linssen AC. Spinhoven P. Autogenic training and future oriented hypnotic imagery in the treatment of tension headache: outcome and process. International Journal of Clinical & Experimental Hypnosis 1991;39(1):6-23 The aim of the present study was (a) to investigate the relative efficacy of autogenic training and future oriented hypnotic imagery in the treatment of tension headache and (b) to explore the extent to which therapy factors such as relaxation, imagery skills, and hypnotizability mediate therapy outcome. Patients were randomly assigned to the 2 therapy conditions and therapists. 55 patients (28 in the autogenic therapy condition and 27 in the future oriented hypnotic imagery condition) completed the 4 therapy sessions and 2 assessment sessions. No significant main effect or interaction effects for treatment condition or therapist was revealed. A significant effect for time in analyzing scores for headache pain, pain medication usage, depression, and state anxiety was found. In the self-hypnosis condition, pain reduction proved to be associated with depth of relaxation during home practice (as assessed with diaries) and capacity to involve in imagery (as assessed with the Dutch version [van der Velden & Spinhoven, 1984] of the Creative Imagination Scale [Barber & Wilson, 1978/79; Wilson & Barber, 1978]). After statistically controlling for relaxation and imagery, hypnotizability scores (as assessed with the Dutch version [Oyen & Spinhoven, 1983] of the Stanford Hypnotic Clinical Scale [Morgan & J.R. Hilgard, 1975, 1978/79]) were significantly correlated with ratings of pain reduction. Results are discussed in the context of the neo-dissociation and social-cognitive model of hypnoanalgesia. The clinical relevance and the methodological shortcomings of the present study are also critically assessed. Velten E= Jr. A laboratory task for induction of mood states. Behaviour Research & Therapy 1968;6(4):473-82 Administered to 100 female college students the Harvard Group Scale of Hypnotic Susceptibility, Form A, to provide a measure of primary suggestibility. In a 2nd hr., each Subject was randomly assigned to 1 of 5 individual treatments of 20 Subjects each. 1 group read and concentrated upon 60 self-referent statements intended to be elating; a 2nd group read 60 statements intended to be depressing. A 3rd group read 60 statements which were neither self-referent nor pertaining to mood. This group controlled for the effects of reading and experimental participation per se. 4th and 5th groups received demand characteristics control treatments designed to produce simulated elation and simulated depression, respectively. 2 measures of pretreatment mood level were obtained from each Subject at the beginning of her individual treatment. Following treatment, as criteria for elation and depression, seven behavioral task measures were obtained. 4 of these distinguished significantly among the treatment groups. The comparative performance of Subjects in the 3 control groups indicated that the obtained mood changes could not be attributed to artifactual effects. Moreover, postexperimental questionnaire data strongly supported the conclusion that Elation and Depression treatments had indeed respectively induced elation and depresssion. Vingoe FJ, Hobro N, Milner-Whitaker I Response to a modified hypnosis experience questionnaire (HEQ-44) following alert and relaxation hypnotic procedures Contemporary Hypnosis 1993;10(3):159-65 40 patients were randomly assigned in a counterbalanced design to 2 recorded hypnotic inductions (alert-relaxation or relaxationalert). Following each induction, Subjects were required to complete a modified version of the Hypnosis Experience Questionnaire, which included an Alert subscale. Subjects also rated which procedure was best for them in terms of focusing on pleasant experience. Differences were found only on the Relaxation subscale in favor of the relaxation procedure. While no difference between procedures was found on the Alert subscale, because 13 of 40 Subjects selected the alert procedure as being best for them as a component of treatment, further research with alerting procedures is suggested. Voss H. Meyer H. Relationships between trait and state measures of anxiety and curiosity under conditions of selfappraised risk Psychologische Beitrage 1981;23(1):97-114. 96 college students (50% males) were randomly assigned to 1 of 4 conditions (control, hypnosis, shock, or drug). State and trait measures of curiosity and anxiety were administered. Results showed medium negative correlations between both state and trait measures. Measures of both curiosity and anxiety were positively intercorrelated, whereas correlation coefficients between the 2 types of measures were low. Results are seen as a partial confirmation that increasing stress over situations is related to increasing anxiety state (linear trend) and to an increase followed by a decrease or to a decrease in state curiosity. The modulating effects of cognitive processes, leading to reappraisal of the given situation and therefore mediating between states and overt behavior, are discussed. (French abstract) Wagstaff GF, Mercer K Does hypnosis facilitate memory for deep processed stimuli Contemporary Hypnosis 1993;10(2):59-66 Evidence previously presented by I. W. Shields and V. J. Knox (see PA, Vol 74:12488) suggests that hypnosis can facilitate recall and recognition memory for target words deep processed in terms of the levels of processing theory of F. I. Craik and R. S. Lockhart (1972). No facilitation effect is indicated, however, for shallow processed words. The present study attempted to replicate this finding, using 20 undergraduates in the hypnotic condition and 2 nonhypnotic control groups (10 undergraduates each) who were unaware they were participating in a hypnosis experiment. The findings of the present study failed to confirm those of Shields and Knox. The untreated control group recalled fewer shallow processed words than the other hypnotic and waking conditions and produced fewer intrusions than the relaxed/motivated waking group. It is concluded that Shields and Knox’s findings may have resulted from underperformance by their waking control groups. Wagstaff GF, Royce C Hypnosis and the treatment of nail biting: a preliminary trial Contemporary Hypnosis 1994;11(1):9-13 Examined the efficacy of hypnotherapeutic suggestions alone or preceded by hypnotic induction in the treatment of nail biting. The influences of motivation to improve, belief in effectiveness of treatment, and level of imaginative involvement were also examined. Subjects were 17 undergraduates (aged 19-22 yrs). Results indicate that only suggestions preceded by hypnotic induction resulted in symptom improvement. Belief in efficacy predicted treatment success better than motivation, hypnotic induction, or scores on the Creative Imagination Scale. Within the group receiving hypnotic induction, hypnotic depth scores significantly correlated with treatment success. Wall VJ. Womack W. Hypnotic versus active cognitive strategies for alleviation of procedural distress in pediatric oncology patients. American Journal of Clinical Hypnosis 1989;31(3):181-91 This study provided a differential comparison of the efficacy of standardized instruction in hypnosis or active cognitive strategy for provision of relief from procedurally induced pain and anxiety. Subjects were instructed to self-direct in the use of strategies during medical procedures. Twenty pediatric oncology patients participated in the study. They were not informed that hypnosis was one of the strategies. Subjects were screened for hypnotizability and randomly assigned to treatments. Demographic data were collected. Pre-strategy training observations were made during a Bone Marrow Aspiration or Lumbar Puncture (BMA/LP) using visual analog scales, the McGill Pain Questionnaire, State-Trait Anxiety Inventory, pulse and temperature readings, and interview. Following strategy training, data were collected during a second BMA/LP using the same measures as employed pre-intervention. Results indicated that both strategies were effective in providing pain reduction. Neither technique provided for anxiety reduction. Hypnotizability scale scores failed to correlate with degree of pain reduction. Weaver DB Hypnotherapy audiotapes for the treatment of chronic insomnia Alternative Therapies in Health and Medicine 1996;2(4):94-5 Whitehouse WG. Dinges DF. Orne EC. Keller SE. Bates BL. Bauer NK. Morahan P. Haupt BA. Carlin MM. Bloom PB. Zaugg L. Orne MT. Psychosocial and immune effects of self-hypnosis training for stress management throughout the first semester of medical school. Psychosomatic Medicine. 1996;58(3):249-63 This study was a 19- week prospective conducted to determine the effectiveness of a self-hypnosis/relaxation intervention to relieve symptoms of psychological distress and moderate immune system reactivity to examination stress in 35 first-year medical students. Twenty-one subjects were randomly selected for training in the use of self-hypnosis as a coping skill and were encouraged to practice regularly and to maintain daily diary records related to mood, sleep, physical symptoms, and frequency of relaxation practice. An additional 14 subjects received no explicit training in stressreduction strategies, but completed similar daily diaries. Self-report psychosocial and symptom measures, as well as blood draws, were obtained at four time points: orientation, late semester, examination period, and postsemester recovery. It was found that significant increases in stress and fatigue occurred during the examination period, paralleled by increases in counts of B lymphocytes and activated T lymphocytes, PHA-induced and PWM-induced blastogenesis, and natural killer cell (NK) cytotoxicity. No immune decreases were observed. Subjects in the selfhypnosis condition reported significantly less distress and anxiety than their nonintervention counterparts, but the two groups did not differ with respect to immune function. Nevertheless, within the self-hypnosis group, the quality of the exercises (ie, relaxation ratings) predicted both the number of NK cells and NK activity. It was concluded that stress associated with academic demands affects immune function, but immune suppression is not inevitable. Practice of self-hypnosis reduces distress, without differential immune effects. However, individual responses to the self-hypnosis intervention appear to predict immune outcomes. Whitehouse WG. Dinges DF. Orne EC. Orne MT. Hypnotic hypermnesia: enhanced memory accessibility or report bias?. Journal of Abnormal Psychology 1988;97(3):289-95 Laboratory studies of hypnotic hypermnesia have yielded inconsistent evidence of memory enhancement, and the process responsible for the occasional positive findings have eluded identification. The present experiment assessed delayed recall for filmed material under conditions in which subjects were required to answer all questions, by guessing if necessary. They also rated confidence in the accuracy of each response. After an initial wake-baseline forced-recall test, subjects were randomly assigned to hypnosis or waking conditions for a second forced-recall test. Both groups of subjects recalled additional correct details on the second test, but the magnitude of this hypermnesia was no greater for subjects exposed to the hypnosis treatment. Hypnotized subjects did, however, exhibit a significantly greater increase in confidence for responses designated as “guesses” on the prior waking test–a finding consistent with the view that hypnosis engenders a shift in the subjective criterion for what constitutes a “memory.” Implications of these findings for the use of hypnosis in forensic situations are discussed. Whorwell PJ. Houghton LA. Taylor EE. Maxton DG. Physiological effects of emotion: assessment via hypnosis. Lancet 1992;340(8811):69-72 Assessment of the physiological effects of physical and emotional stress has been hampered by a lack of suitable laboratory techniques. Since hypnosis can be used safely to induce specific emotional states of considerable intensity, we studied the effect on distal colonic motility of three hypnotically induced emotions (excitement, anger, and happiness) in 18 patients aged 20-48 years with irritable bowel syndrome. Colonic motility index was reduced by hypnosis on its own (mean change 19.1; 95% CI 0.8, 37.3; p less than 0.05) and this change was accompanied by decreases in both pulse (12; 8, 15) and respiration (6; 4, 8) rates (p less than 0.001 for both). Anger and excitement increased the colonic motility index (50.8; 29.4, 72.2; and 30.4; 8.9, 51.9, respectively; p less than 0.01 for both), pulse rate (26; 22, 30; and 28; 24, 32; p less than 0.001 for both), and respiration rate (14; 12, 16; and 12; 10, 14; p less than 0.001 for both). Happiness further reduced colonic motility although not significantly from that observed during hypnosis alone. Changes in motility were mainly due to alterations in rate than in amplitude of contractions. Our results indicate that hypnosis may help in the investigation of the effects of emotion on physiological functions; this approach could be useful outside the gastrointestinal system. Our observation that hypnosis strikingly reduces fasting colonic motility may partly explain the beneficial effects of this form of therapy in functional bowel disorders. Whorwell PJ. Prior A. Colgan SM. Hypnotherapy in severe irritable bowel syndrome: further experience. Gut 1987;28(4):423-5 Fifteen patients with severe intractable irritable bowel syndrome previously reported as successfully treated with hypnotherapy, have now been followed up for a mean duration of 18 months. All patients remain in remission although two have experienced a single relapse overcome by an additional session of hypnotherapy. Experience with a further 35 patients is reported giving a total group of 50. This group was divided into classical cases, atypical cases and cases exhibiting significant psychopathology. The response rates were 95%, 43%, and 60% respectively. Patients over the age of 50 years responded very poorly (25%) whereas those below the age of 50 with classical irritable bowel syndrome exhibited a 100% response rate. This study confirms the successful effect of hypnotherapy in a larger series of patients with irritable bowel syndrome and defines some subgroup variations. Whorwell PJ. Prior A. Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritablebowel syndrome. Lancet 1984;2(8414):1232-4 30 patients with severe refractory irritable-bowel syndrome were randomly allocated to treatment with either hypnotherapy or psychotherapy and placebo. The psychotherapy patients showed a small but significant improvement in abdominal pain, abdominal distension, and general well-being but not in bowel habit. The hypnotherapy patients showed a dramatic improvement in all features, the difference between the two groups being highly significant. In the hypnotherapy group no relapses were recorded during the 3- month follow-up period, and no substitution symptoms were observed. Wickramasekera I. Effects of sensory restriction on susceptibility to hypnosis: a hypothesis and more preliminary data. Journal of Abnormal Psychology 1970;76(1):69-75 Randomly assigned 45 young adult white male prisoners to 1 of 3 groups of equal size. Experimental Subjects (Groups 2 and 3) were exposed to 1 hr. of sensory restriction. Subjects in Group 2 were given a set of neutral instructions prior to sensory restriction, and Subjects in Group 3 were given a set of nonneutral instructions. Controls (Group 1) were exposed to conditions similar to experimentals, but without sensory restriction per se. All Subjects were tested before and after the above procedures with the Stanford Hypnotic Susceptibility Scale. On posttesting, experimental Subjects appeared to have increased in hypnotizability. Wigal JK. Stout C. Kotses H. Creer TL. Fogle K. Gayhart L. Hatala J. Experimenter expectancy in resistance to respiratory air flow. Psychosomatic Medicine 1997;59(3):318-22 OBJECTIVE: The effect of experimenter expectancy was investigated on the resistance to respiratory air flow, measured as total respiratory resistance (Rt) in healthy individuals. METHOD: Each of three naive experimental assistants collected air flow resistance responses from 30 subjects who they had been told were either likely or unlikely to respond to the suggestion of breathing difficulty. RESULTS: The subjects were assigned to the two conditions at random. The subjects who were described to the experimenters as being likely to respond exhibited greater Rt increases to bronchoconstriction suggestion than did the subjects who were described as unlikely to respond. CONCLUSIONS: These findings confirmed the presence of a source of variance that has not been considered previously in suggestion studies. Williams AR. Hind M. Sweeney BP. Fisher R. The incidence and severity of postoperative nausea and vomiting in patients exposed to positive intra-operative suggestions. Anaesthesia. 1994;49(4):340-2 In a double-blind study, the effects of positive intra-operative suggestions on the incidence and severity of postoperative nausea and vomiting were studied in 60 patients randomly selected to undergo routine major gynaecological surgery. Patients who received positive suggestions suffered significantly less nausea and vomiting in the 24 h after surgery. Williams JM. Hall DW. Use of single session hypnosis for smoking cessation. Addictive Behaviors 1988;13(2):205- 8 Twenty of sixty volunteers for smoking cessation were assigned to single-session hypnosis, 20 to a placebo control condition, and 20 to a no-treatment control condition. The single-session hypnosis group smoked significantly less cigarettes and were significantly more abstinent than a placebo control group and a no treatment control group at posttest, and 4-week, 12-week, 24-week and 48-week follow-ups. Wojcikiewicz A, Orlick T The effects of post-hypnotic suggestion and relaxation with suggestion on competitive fencing anxiety and performance Int J Sport Psychol 1987;18(4):303-13 Investigated the relative effectiveness of (1) post-hypnotic suggestion and (2) relaxation with suggestion, induced on site preceding a national competition. 33 fencers were randomly assigned to 1 of 3 groups: experimental hypnotic, experimental relaxation, and control. Subjects were tested and retested during 2 consecutive competitions on perceived anxiety, perception of task difficulty, and competition performance. Significant differences were found between the hypnotic group and the control group for perceived level of competition anxiety. On the estimated level of task difficulty, significant differences were found for both the hypnotic and the relaxation groups when compared with the control group. No significant differences were found on fencing performance measures. (French, Spanish, German & Italian abstracts) Wolff BB. Horland AA. Effect of suggestion upon experimental pain: a validation study. Journal of Abnormal Psychology 1967;72(5):402-7 INVESTIGATED GELFAND’S HYPOTHESIS THAT PAIN THRESHOLD AND TOLERANCE HAVE DIFFERENT LOADINGS OF PHYSIOLOGICAL AND PSYCHOLOGICAL COMPONENTS. IT WAS POSTULATED THAT NONPERMISSIVE INSTRUCTIONS (SUGGESTION) SHOULD SIGNIFICANTLY INCREASE PAIN TOLERANCE COMPARED TO PERMISSIVE INSTRUCTIONS (NO SUGGESTION), BUT THAT THERE SHOULD BE NO SIGNIFICANT CHANGES IN PAIN THRESHOLD. 34 HEALTHY SUBJECTS WERE DIVIDED RANDOMLY INTO 2 EQUAL GROUPS. 1 STARTED WITH PERMISSIVE AND THE OTHER WITH NONPERMISSIVE INSTRUCTIONS USING ELECTRICAL STIMULATION, AND AFTER 5 TRIALS INSTRUCTIONS WERE REVERSED IN BOTH GROUPS. THE RESULTS SUPPORTED THE HYPOTHESIS FOR ASCENDING PAIN THRESHOLD AND PAIN TOLERANCE, BUT NOT FOR DESCENDING PAIN THRESHOLD. THE LATTER WAS EXPLAINED BY SUGGESTING THAT PAIN RELIEF IS AN EMOTIONAL STATE INTERFERING WITH SENSORY DISCRIMINATION. Zachariae R. Bjerring P. Laser-induced pain-related brain potentials and sensory pain ratings in high and low hypnotizable subjects during hypnotic suggestions of relaxation, dissociated imagery, focused analgesia, and placebo. International Journal of Clinical & Experimental Hypnosis. 1994; 42(1):56-80 Pain reports and amplitudes of painful argon laser-induced brain potentials were obtained for 10 high and 10 low hypnotizable volunteers following placebo and a randomized sequence of four hypnotically induced conditions of (a) neutral hypnosis, (b) deep relaxation, (c) pleasant dissociated “out of body” imagery, and (d) focused analgesia of the hand. Both high and low hypnotizable subjects exhibited significant reductions of reported pain during conditions of neutral hypnosis, relaxation, dissociated imagery, and focused analgesia. High hypnotizable subjects displayed significantly greater reductions than low hypnotizables in all conditions except placebo. Both high and low hypnotizables exhibited significant reductions of reported pain in all five conditions as well as in the posthypnotic condition, when amplitudes of evoked potentials were compared to the prehypnotic baseline. Only the high hypnotizable group showed significant reductions in amplitudes when the data were recalculated to reflect relative changes compared to the average amplitude of the pre- and postconditions to compensate for a possible habituation effect indicated by the significantly lowered amplitudes in the posthypnotic condition. The results are discussed in light of a number of hypotheses concerning mechanisms of hypnotic analgesia. Zachariae R. Bjerring P. Arendt-Nielsen L. Nielsen T. Gotliebsen K. The effect of hypnotically induced emotional states on brain potentials evoked by painful argon laser stimulation. Clinical Journal of Pain 1991;7(2):130-8 The relationship between pain perception and emotional states is well known. However, the nature of this relationship and how different emotional states affect sensory and cognitive dimensions of pain remains uncertain. Results from experimental investigations are often contradictory, which may be due to methodological difficulties in inducing pain and monitoring physiological responses. In addition, most studies have focused on a single emotion, and data on the relative effects of different emotional states are lacking. In the present study we attempted to eliminate some of these methodological problems. Laser evoked potentials were used as a quantitative correlate to pain perception and were measured in 12 highly hypnotically susceptible subjects during seven conditions: (a) a prehypnotic baseline condition; (b) a neutral hypnotic control condition; (c-e) hypnotically recalled anger, fear, and depression in randomized order; (f) a hypnotically recalled happy condition, and (g) a posthypnotic awake control condition. The pain evoked potentials were significantly decreased in the angry condition and significantly increased in the depressed condition compared with baseline. No differences could be detected for either the happy or the fearrelated condition compared with the baseline or neutral hypnotic condition. A significant positive correlation between the subjective intensity of depression and the increase in evoked potentials was found, but none for the other three emotions. The results support earlier findings that clinical depression is related to increased pain perception, and findings that the expression of anger can inhibit the experience of pain.(ABSTRACT TRUNCATED AT 250 WORDS) Zachariae R. Hansen JB. Andersen M. Jinquan T. Petersen KS. Simonsen C. Zachariae C. Thestrup-Pedersen K. Changes in cellular immune function after immune specific guided imagery and relaxation in high and low hypnotizable healthy subjects. Psychotherapy & Psychosomatics 1994;61(1-2):74-92 This article presents the results of two investigations, each measuring cellular immune function on 3 investigation days 1 week apart in 15 high and 15 low hypnotizable healthy subjects randomly selected for three groups: (1) a guided imagery group receiving instructions to enhance cellular immune function: (2) a relaxation group which did not receive instructions regarding the immune system, and (3) a control group. Study 1 investigated changes in monocyte chemotaxis (MC) and lymphocyte proliferative response (LPR) to three mitogens, while natural killer cell activity (NKCA) was measured in study 2. The results show similar patterns of brief decreases in LPR and NKCA immediately after intervention on all investigation days in both the imagery and relaxation groups. Increases in MC were found in both intervention groups on day 1. On a follow-up investigation day in study 2, a brief stress task yielded a slight increase in NKCA. In study 2, the control group showed decreases in NKCA similar to those observed in the two intervention groups. In general there were no significant changes in preintervention immune function throughout the investigation period. When comparing the effects in high and low hypnotizable subjects, we found that high hypnotizables showed greater decreases in LPR and NKCA than low hypnotizables. There are several inconsistencies between the results of the limited number of investigations studying the effects of guided imagery and relaxation on immune function. These differences may in part be explained by differences in methodology, time intervals between blood sampling, and subject characteristics such as age, health status and hypnotizability. The inconsistent results make it premature to make inferences about possible benefits of the application of these techniques in the treatment of immune related diseases, and further investigations are needed. Zachariae R. Oster H. Bjerring P. Effects of hypnotic suggestions on ultraviolet B radiation-induced erythema and skin blood flow. Photodermatology, Photoimmunology & Photomedicine 1994;10(4):154-60 Results from both animal and human studies have indicated that inflammatory skin reactions such as the flare response to histamine prick test involve a neurogenic regulatory component. It is still unknown to which degree inflammation induced by ultraviolet (UV) radiation may be mediated by the central nervous system. To investigate this, the effect of hypnotic suggestions to increase and decrease the response to UVB radiation on erythema and cutaneous blood flow was investigated in 10 highly hypnotizable subjects. The results showed a significant effect of hypnotic suggestions on cutaneous blood flow compared with the responses of a control group. For erythema no conclusive evidence was found. The results indicate the possibility of separate regulatory mechanisms behind central nervous system influence on UVB-induced erythema and skin blood flow respectively, and further investigations are needed. Zachariae R. Oster H. Bjerring P. Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. Journal of the American Academy of Dermatology. 1996;34(6):1008-15, BACKGROUND: Case reports have indicated that psychologic treatments may have a beneficial effect on psoriasis activity. OBJECTIVE: Our purpose was to further investigate the hypothesis that psychologic intervention has a beneficial effect on psoriasis activity in a blinded, controlled manner. METHODS: Fifty-one patients with psoriasis vulgaris were randomly assigned to a treatment or a control group. Patients in the treatment group participated in seven individual psychotherapy sessions in 12 weeks. Intervention techniques included stress management, guided imagery, and relaxation. The Psoriasis Area Severity Index (PASI), Total Sign Score (TSS), and Laser Doppler Skin Blood Flow (LDBF) of a selected reference plaque was measured in a blinded fashion at baseline (week 0), week 4, week 8, and after treatment (week 12). RESULTS: Slight, but significant, changes in TSS and LDBF were found in the treatment group but not in the control group. When analyses were performed for both groups separately, the treatment group displayed significant reductions for all three psoriasis activity measures, whereas no changes were seen in the control group. CONCLUSION: Our preliminary results suggest that psychologic intervention may have a moderate beneficial effect on psoriasis activity. Zachariae R. Oster H. Bjerring P. Kragballe K. Effects of psychologic intervention on psoriasis: a preliminary report. Journal of the American Academy of Dermatology 1996;34(6):1008-15 BACKGROUND: Case reports have indicated that psychologic treatments may have a beneficial effect on psoriasis activity. OBJECTIVE: Our purpose was to further investigate the hypothesis that psychologic intervention has a beneficial effect on psoriasis activity in a blinded, controlled manner. METHODS: Fifty-one patients with psoriasis vulgaris were randomly assigned to a treatment or a control group. Patients in the treatment group participated in seven individual psychotherapy sessions in 12 weeks. Intervention techniques included stress management, guided imagery, and relaxation. The Psoriasis Area Severity Index (PASI), Total Sign Score (TSS), and Laser Doppler Skin Blood Flow (LDBF) of a selected reference plaque was measured in a blinded fashion at baseline (week 0), week 4, week 8, and after treatment (week 12). RESULTS: Slight, but significant, changes in TSS and LDBF were found in the treatment group but not in the control group. When analyses were performed for both groups separately, the treatment group displayed significant reductions for all three psoriasis activity measures, whereas no changes were seen in the control group. CONCLUSION: Our preliminary results suggest that psychologic intervention may have a moderate beneficial effect on psoriasis activity. Zeltzer L. LeBaron S. Hypnosis and nonhypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. Journal of Pediatrics 1982;101(6):1032-5 Hypnosis was compared with nonhypnotic behavioral techniques for efficacy in reducing pain and anxiety in 27 children and adolescents during bone marrow aspiration and in 22 children and adolescents during lumbar puncture. The patients and independent observers each rated (scale of 1 to 5) pain and anxiety during one to three procedures prior to intervention and one to three procedures with intervention. Prior to intervention for both groups, pain during bone marrow aspiration was rated as more severe (P less than 0.01) than pain during lumbar puncture. During bone marrow aspiration pain was reduced to a large extent by hypnosis (P less than 0.001) and to a smaller but significant extent by nonhypnotic techniques (P less than 0.01), and anxiety was significantly reduced by hypnosis alone (P less than 0.001). During lumbar puncture only hypnosis significantly reduced pain (P less than 0.001); anxiety was reduced to a large degree by hypnosis (P less than 0.001) and to a smaller degree by nonhypnotic techniques (P less than 0.05). Thus hypnosis was shown to be more effective than nonhypnotic techniques for reducing procedural distress in children and adolescents with cancer. Zeltzer L. LeBaron S. Zeltzer PM. The effectiveness of behavioral intervention for reduction of nausea and vomiting in children and adolescents receiving chemotherapy. Journal of Clinical Oncology 1984;2(6):683-90 Fifty-one children 6-17 years of age rated the severity of nausea, vomiting, and the extent to which chemotherapy bothered them during each course of chemotherapy. Sixteen patients had no symptoms and the doses administered to 16 others were not constant so that matched courses could not be assessed. After baseline measurement of two matched courses, the remaining 19 patients were randomized to receive hypnosis or supportive counseling during two more matched courses. An additional course with no intervention was assessed in half of the patients. No significant reduction of symptoms was demonstrated prior to intervention. However, intervention with both hypnosis and supportive counseling was associated with significant reductions in nausea, vomiting, and the extent to which these symptoms bothered patients (all p less than 0.001). Also, after termination of intervention, symptom ratings remained significantly lower than baseline. The data indicate that chemotherapy-related nausea and emesis in children can be reduced with behavioral intervention and that reductions are maintained after intervention has been discontinued. Zeltzer LK. Dolgin MJ. LeBaron S. LeBaron C. A randomized, controlled study of behavioral intervention for chemotherapy distress in children with cancer. Pediatrics 1991;88(1):34-42 Fifty-four pediatric cancer patients were studied to determine the relative efficacy of two forms of behavioral intervention for reducing chemotherapy-related distress. Following baseline assessment, subjects were randomly assigned to receive either hypnosis, non-hypnotic distraction/relaxation, or attention placebo (control) during the subsequent identical chemotherapy course. Observational and interview measures of anticipatory and postchemotherapy nausea, vomiting, distress, and functional disruption served as outcome data. Results indicated that treatment condition was the single best predictor of change from baseline to intervention, with children in the hypnosis group reporting the greatest reduction of both anticipatory and postchemotherapy symptoms. The cognitive distraction/relaxation intervention appeared to have a maintenance effect in which symptoms did not get much worse or much better, while children in the control group had symptoms that consistently became worse over time. Emetic potential of the chemotherapy and the prophylactic use of antiemetics each appeared to contribute to the overall severity of symptoms. While the efficacy of hypnosis in the management of chemotherapy distress is supported, the complexities of interacting biologic and psychologic factors are highlighted. Zeltzer LK. Fanurik D. LeBaron S. The cold pressor pain paradigm in children: feasibility of an intervention model (Part II). Pain 1989;37(3):305-13 The purpose of this study was to examine the feasibility of testing a psychological approach (hypnosis) to pain reduction in children using the cold pressor paradigm. Children’s pain ratings at 10 sec intervals and duration of arm immersion (40 sec maximum) in 15 degrees C (n = 37) and 12 degrees C water (n = 29) were assessed in 6-12-year-old children during 2 baseline trials (alternating arms), followed by 2 more trials after randomization to a control or hypnosis treatment condition. Hypnosis was found to reduce pain significantly more than the control condition in both 15 degrees C and 12 degrees C water. Hypnotic susceptibility was not strongly related to hypnotic pain reduction. However, age was significant, with younger children showing higher pain ratings and early arm withdrawal rates and less response to hypnosis than older children. In 15 degrees C water, females had higher pain ratings and early withdrawal rates than males, but this sex discrepancy disappeared in 12 degrees C water. This study demonstrated the feasibility of the cold pressor paradigm for testing intervention strategies and its potential for enhancing our understanding of pain in children. Zitman FG. van Dyck R. Spinhoven P. Linssen AC. Hypnosis and autogenic training in the treatment of tension headaches: a two-phase constructive design study with follow-up. Journal of Psychosomatic Research 1992;36(3):219-28 Tension headaches can form a chronic (very long duration) condition. EMG biofeedback, relaxation training and analgesia by hypnotic suggestion can reduce the pain. So far, no differences have been demonstrated between the effects of various psychological treatments. In a constructively designed study, we firstly compared an abbreviated form of autogenic training to a form of hypnotherapy (future oriented hypnotic imagery) which was not presented as hypnosis and secondly we compared both treatments to the same future oriented hypnotic imagery, but this time explicitly presented as hypnosis. The three treatments were equally effective at posttreatment, but after a 6-month follow-up period, the future oriented hypnotic imagery which had been explicitly presented as hypnosis was superior to autogenic training. Contrary to common belief, it could be demonstrated that the therapists were as effective with the treatment modality they preferred as with the treatment modality they felt to be less remedial.