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International Journal of Clinical and Experimental Hypnosis


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Hypnosis and behavior therapy: A review


Philip Spinhoven
a a

University of Leiden, Leiden, Netherlands Version of record first published: 31 Jan 2008.

To cite this article: Philip Spinhoven (1987): Hypnosis and behavior therapy: A review, International Journal of Clinical and Experimental Hypnosis, 35:1, 8-31 To link to this article: http://dx.doi.org/10.1080/00207148708416033

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The International journal of Clinical and Experimental Hypnosis 1987,Vol. XXXV, No. 1, 8-31

HYPNOSIS AND BEHAVIOR THERAPY: A REVIEW


PHILIP SPINHOVEN.
University of Leiden, Leiden, Netherlands

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Abstract: Hypnosis is widely used as an adjunct to behavior therapy. Hypnosis can be defined both as an antecedent variable (the hypnotic context and suggestions given) and as a subject variable (the capacity to experience profound subjective changes). A factor common to hypnosis and imagination-based behavior therapies is the use of relaxation and imagination processes. Empirical studies of hypnosis and behavior therapy are reviewed. It is concluded that hypnosis as an adjunct primarily influences common therapy factors such as expectancy of success and treatment credibility. A more specific effect of hypnosis in behavior therapy still needs to be demonstrated. It is suggested that a fruitful combination of hypnosis and behavior therapy requires a therapeutic approach in which voluntary control is less prominent and suggestions for involuntary hypnotic experiences are given. One finds many clinical studies in the literature which report the successful application of a combination of hypnotherapy and behavioral techniques. In this context, hypnosis is described as a valuable adjunct to certain behavior therapy procedures. This article presents an analysis of some concepts and empirical findings in this field of research. The concept of hypnosis and hypnotherapy are briefly discussed, and the role of principles of learning in diverse imagination-based behavioral procedures is critically reviewed. Commonalities and differences between hypnotherapy and cognitive behavior therapy are analyzed at a process level. This is followed by a review of available controlled outcome studies of hypnotherapy and behavior therapy. Finally, some general issues concerning the use of hypnosis in a behavior therapy context are raised. Hypnosis and Hypnotherapy The term hypnotherapy signifies such a wide array of theoretical formulations and practical techniques that the word has almost lost its descriptive value (Katz, 1980; Wadden & Anderton, 1982). Experimentally, hypnosis can be defined in two different ways: as an antecedent variable and as a subject variable. When hypnosis is an antecedent variable, the therapy situation is defined by the therapist as one involving hypnosis. The therapist induces hypnosis in a traditional or nonauthoriManuscript submitted May 16, 1984; final revision received July 22, 1985. The author gratefully acknowledges the critical remarks and very valuable and stimulating suggestions of Richard Van Dyck, M.D. and the four anonymous reviewers of the Znternuf tional Journal o Clinical and Experimental Hypnosis. Reprint requests should be addressed to drs. Philip Spinhoven, Jelgersrnapolikliniek, Rhijngeesterstraatweg 13, 2342 AN Oegstgeest, The Netherlands. 8

HYPNOSIS AND BEHAVIOR THERAPY: A REVIEW

tarian way, and suggestions for hypnotic phenomena are given. Central to this antecedent definition is everything the therapist does or says to convince the patient (and himherself) that hypnosis is applied. It goes without saying, however, that a hypnotic context is no proof that hypnotic phenomena are actually involved. Conceptually distinct from this first definition-but not easy to separate in practice-is the definition of hypnosis as a subject variable. There are important individual differences in hypnotic ability (i.e., the ability actually to experience the given hypnotic suggestions, Hilgard, 1965). In fact, when a subject has a high hypnotic capacity, even an experimental instruction can be experienced as a hypnotic suggestion (Weitzenhoffer, 1974). A subject can tap hisher hypnotic abilities even when the situation is not defined as hypnosis (Andreychuk & Skriver, 1975; Benson, Frankel, Apfel, Daniels, Schniewind, Nemiah, Sifneos, Crassweller, Greenwood, Kotch, Ams, & Rosner, 1978; Knox & Shum, 1977)and no hypnotic induction is given (Barber & Hahn, 1962; Spanos, Radtke-Bodorik, Ferguson, & Jones, 1979). What is the relevance of this experimental definition of hypnosis to the elucidation of the concept of hypnotherapy? In one respect, hypnotherapy does not exist because it is not a special method of treatment; it is more accurate to regard hypnosis as a facilitator of a number of different treatment methods (Mott, 1982). Consequently, it is no wonder that differences between hypnotic and nonhypnotic therapies are difFicult to determine and that the common factors among different techniques identified as hypnosis are similarly elusive (Brown, 1982). In the present article, hypnotherapy will be defined both as a contextual and a subject variable. Although this definition will not capture the essence of hypnotherapy from the perspective of the clinician, for research purposes, this definition helps to disentangle nonhypnotic and specific hypnotic variables influencing the outcome of hypnotherapy. When therapists label their therapy as hypnosis and administer a hypnotic induction, patients are not necessarily hypnotized. Improvement can be associated with relaxation in the absence of hypnosis and, in most instances, will also be related to the faith the patient has in the hypnotherapist and the procedure. The definition of hypnotherapy as a subject variable is more essential for hypnosis per se. Treatment outcome can be said to be achieved hypnotically only when it is positively correlated with hypnotic ability. Individuals with hypnotic ability are more likely to experience involuntary perceptual and memory alterations that cannot be accounted for by nonhypnotic events such as relaxation or placebo effects (Hilgard, 1977, 1979; Orne, 1977). Principles of Learning in Imagination-Based Behavioral Procedures The experimental and clinical literature on hypnosis as an adjunct to behavior therapy refers almost exclusively to behavior therapy techniques that make use of relaxation and imaginative processes as the pivot for change. The present article limits itself to the use of hypnosis as an adjunct

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PHILIP SPINHOVEN

to relaxation and imagination procedures in behavior therapy. Behavior modification procedures which do not focus on relaxation and imagination will not be discussed. Wilson (1978) delineated three major models which have been and continue to be influential in behavior therapy: applied behavioral analysis, the neo-behavioristic mediational stimulus-response (S-R) model, and the social learning model. In addition, behavior therapy is said to have undergone a cognitive revolution during the past decade, and many different cognitive therapies have emerged. Some imagination-based behavioral procedures will be described with reference to the particular learning model from which they were developed. It will be argued that traditional classical and operant learning theories are inadequate to explain the results of imagination-based procedures in behavior therapy. Cognitive processes such as the meanings which subjects attach to their situation and their expectations will be stressed as being of primary importance in mediating therapeutic results. Applied behavioral analysis model. This model focuses primarily on changing overt behavior by principles of operant conditioning. In this model, it is assumed that behavior is directly increased or decreased by its immediate consequences. Responses that result in unrewarding or punishing effects tend to be discarded, whereas those that produce rewarding outcomes are retained. Cautela (1970a, b) and Cautela and McCullough (1978) developed different covert operant imagination procedures by applying operant conditioning principles on a covert basis. For example, in covert positive reinforcement, the individual is trained to generate imagery of a pleasant activity (e.g., eating a favorite food or attaining social approval). The individual is asked to imagine performing some desired response (e.g., asserting oneself) and then to shift to a reinforcing image. Further, patients are trained to practice the technique on their own. The efficacy of many of the covert operant techniques is as yet undemonstrated (Mahoney & Arnkoff, 1978). Moreover, it is highly questionable that covert behaviors (imaginalevents) follow the same principles as overt behaviors (Mahoney, 1974). According to Cautela (1975), it is more scientific to use covert conditioning procedures without hypnosis in the absence of data pointing to a facilitative effect of a hypnotic induction. Although Cautela discourages the ancillary use of hypnosis, techniques introduced by him such as covert positive reinforcement and covert sensitization have, in fact, been used for decades by hypnotherapists in their practice in one form or another. Neo-behavioristic mediatiowl stimulus-response (SR) model. This model relies heavily on principles of classical conditioning and concerns itself primarily with anxiety-based disorders. In this model, it is assumed that a conditioned stimulus (e.g., dog) can come to elicit an emotional response (e.g., anxiety), because in the past it has occurred together with an unconditioned stimulus (e.g., being bitten by a dog). Treatment methods such as flooding (Stampfl, 1967) and systematic desensitization (Wolpe, 1958) rely on both verbal and imaginal processes.

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It is intriguing that systematic desensitization is not based on overt behavior rehearsal but on the capacity of patients to relax and concentrate on visual images (Singer & Pope, 1978). In systematic desensitization, the therapist establishes a hierarchy of frightening situations. Patients are taught relaxation and asked to visualize each of the perhaps 20 steps in the hierarchy. As soon as they come to a point on the hierarchy where they experience any anxiety, they are encouraged to relax more, until they feel comfortable and can tolerate the images that constitute the particular step in the hierarchy without discomfort. The procedure thus serves to gradually desensitize the fear of the phobic object, and it is assumed that this reduction will generalize to real life situations. It is worth mentioning that most of the controlled experiments and case studies on hypnosis as an adjunct to behavior therapy relate to relaxation and desensitization procedures. Wolpe and Lazarus (1966) used hypnosis in one-third of their systematic desensitization patients, but Wolpe (1969) reduced this to 10%. Despite the rather frequent use of hypnosis, for Wolpe this variable played no role in the explanation of the efficacy of systematic desensitization which was accounted for in terms of reciprocal inhibition (i.e., the inhibition of the sympathetic nervous activity associated with anxiety by relaxation which is thought to be predominantly a parasympathetic reaction). Several authors state, however, that nonspecific factors such as treatment credibility and expectancy of success are essential ingredients of systematic desensitization (Emmelkamp, 1982; Van Dyck, 1982; Woody, 1973). After reviewing the experimental literature, Lick and Bootzin (1975) as well as Kazdin and Wilcoxon (1976) concluded that it still needs to be demonstrated more conclusively that systematic desensitization is more effective than a placebo therapy which generates expectations of therapeutic improvement comparable to those elicited by systematic desensitization. Rosen (1976), in his review of the comparative effectiveness of systematic desensitization under experimental versus therapeutic conditions, also states that the results of systematic desensitization are strongly determined by expectancy factors. Social learning model. This model is more comprehensive in that it acknowledges the role of both classical and operant processes, while it emphasizes the importance of cognitive mediational processes. It is assumed that most human behavior is learned observationally through modeling: from observing others, one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action. The response information can be conveyed by physical demonstration, but also by verbal description and pictorial imaginal representation. Kazdin (1974, 1975) has demonstrated that the imaginal rehearsal of appropriate behavior (covert modeiing) is more effective than control conditions in reducing avoidance behavior and in increasing assertive responses. Covert modeling, however, has been shown to be less effective than in uiuo participant modeling phase & Moss, 1976). During the last

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PHILIP SPINHOVEN

few years, hypnosis has, on several occasions, been described as an adjunct to covert modeling procedures (Devine & Bornstein, 1980; Deyoub & Wilkie, 1980; Wadden & Flaxman, 1981). During the last decade, cognitively based therapies have proliferated, many of them explicitly drawing on treatment components used in behavior therapy (Latimer & Sweet, 1984). As Rachman and Wilson (1980) have pointed out, the fundamental assumptions on which all cognitive behavior therapy methods are based are that emotional disorders are a function of maladaptive thought patterns and that the major task of treatment is to restructure these faulty cognitions [p. 1951. Patients nave to become aware of what they are thinking. They need to recognize what thoughts are dysfunctional, and they have to substitute accurate for inaccurate judgments. Finally, they need feedback on the correctness of their cognitive changes. Notwithstanding these shared fundamental assumptions, several cognitive behavior therapies exist, and the three most influential are Ellis (1975) rational-emotive therapy; Becks (1970) cognitive therapy; and Meichenbaums (1977) self-instructional training. Most cognitive therapists make use of imagination procedures, for example, rational-emotive imagination (Ellis, 1975); coping imaginations (Meichenbaum, 1977); and spontaneous imagination (Beck, 1970). Typically, patients are asked to imagine the desired behavioral and emotional responses while thinking the rational thoughts discussed during therapy. There are few controlled studies which compare cognitive imagination procedures with other therapy procedures or with an attentiodplacebo group. Cognitive therapies - including imagination as just one of the procedural components-appear to be just as effective as other forms of psychotherapy (Miller & Berman, 1983). Furthermore, the cognitive theory underlying these procedures has not received sufficient empirical support and scarcely has been addressed in studies of cognitive therapies. In a few reports, the hypnotic utilization of suggestions derived from rational-emotive therapy has been described (Boutin, 1976; Stanton, 1977). In summary, better controlled research on the efficacy of covert operant procedures and various cognitive imagination procedures is needed. Available evidence supports the claim that the established efficacy of systematic desensitization and covert modeling is mediated through cognitive processes, which are altered by experiences of mastery arising from successful in vitro performance. Patients expectations of therapeutic improvement and altered expectations of personal efficacy are assumed to regulate behavior in the social learning model (Bandura, 1977). This model offers a more comprehensive explanation of the results of various (imagination) procedures than traditional classical or operant learning theories, which assume that individuals automatically respond to stimuli and that behavior is directly affected by its immediate consequences.
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Common Processes in Hypnotherapy and Imagination-Based Therapies


The conceptualizations of hypnotherapy and imagination-based behavioral therapy discussed above ask for an analysis of the commonalities and differences between the two phenomena. An analysis of common and different process variables may help in the understanding of the results of treatment studies reviewed in the next section of the present paper. At first glance, the fact that relaxation and imagination are essential ingredients of both approaches gives the impression of a fundamental similarity. Indeed, some authors try to reduce hypnotherapy to imaginationbased behavior therapy and vice versa, because it is hypothesized that identical processes are involved. Murray (1963)and Litvak (1970)state that imagination procedures used in behavior therapy (e.g., systematic desensitization, implosive therapy, flooding) inadvertently induce a hypnotic state, which facilitates therapeutic gain. Litvak (1970)explicitly hypothesized that hypnosis is effective in systematic desensitization, even when a formal hypnotic induction has not been employed. Although no empirical data were provided, this possibility can be tested by research. The inadvertent use of hypnosis by behavior therapists using relaxation and imagery can be studied by measuring hypnotic responsiveness and analyzing the correlation between the level of hypnotizability and the effect of behavior therapy. When a significant positive correlation is found, it suggests that hypnosis as a subject variable is tapped by and is effective in behavior therapy. (The empirical evidence for this position will be reviewed on p. 22 of the present paper.) Cautela is a behavior therapist who proposes an opposite view. In his first article on systematic desensitization and hypnosis, Cautela (1966b) concluded, on the basis of a logical and empirical analysis, that the efficacy of systematic desensitization cannot be explained in terms of hypnosis. On the contrary, in a subsequent article (Cautela, 1966a), he concluded that therapeutic gains obtained by hypnotherapists in the treatment of phobic complaints are the result of an unsystematic use of desensitization principles (behavior therapy) rather than of an altered state of consciousness (hypnosis). With reference to his covert operant techniques, Cautela (1975) also states that hypnotherapists use procedures which are similar to covert conditioning on an intuitive and unsystematic basis. In his covert conditioning model, however, Cautela makes several implicit assumptions about human behavior (Mahoney, 1974). Two of the most significant are the continuity and the automaticity assumptions. The continuity assumption contends that covert behaviors follow the same principles of learning as overt behavior. The automaticity assumption contends that human learning is automatically produced by stimulusresponse contiguities. Both of these assumptions are questionable, because there is little empirical evidence for conditioning of covert events (Mahoney, 1974; Mahoney & Arnkoff, 1978). More likely, vicarious symbolic and self-regulatory processes play a decisive role in human learning (Bandura, 1977).

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Weitzenhoffer (1972), Dengrove (1973, 1976), Kroger (1980), and Kroger and Fezler (1976) conceptualize hypnosis and behavior therapy as two different entities. They argue that a wide range of behavior therapy methods are effective without employing any hypnotic techniques, but that hypnosis can be an extremely useful adjunct. Hypnosis can make treatment easier, especially by facilitating relaxation, heightening the vividness of imagery, and increasing the level of suggestibility. Claims of hypnotherapists for the efficacy of hypnosis at this process level, however, contradict research findings. After critically reviewing the experimental literature, Edmonston (1981) concluded that hypnotic and nonhypnotic relaxation methods are equally effective and have similar physiological effects. In some experimental studies, hypnotic relaxation was compared with progressive muscle relaxation, which is a method widely used in behavior therapy. Paul (1969a) discovered that relaxation training in fact produced significantly more physiological relaxation (as indicated by heart rate and tonic muscle tension) and did so more rapidly than did the hypnotic technique. Paul and Trimble (1970)found in a study of these same methods presented on tape that only the hypnotic technique was significantly more effective than a self-relaxation control group. Paul (1969b) also found that progressive muscle relaxation and hypnotic relaxation were equally eflfective and both significantly superior to a control group in reducing physiological responses evoked by anxiety-inducing imagery. In their review of the experimental literature, both Sheehan (1979) and Coe, St. Jean, and Burger (1980) conclude that there are conflicting data on the enhancement of imagery during hypnosis. In studies where imagery seems to be enhanced, it is not clear (a)whether this enhancement is the result of either a hypnotic induction or positive expectations, or (b) whether this effect is confined to highly hypnotizable subjects. Existing clinical research also gives some evidence that hypnosis per se is not really influential in deepening relaxation or enhancing vividness of imagery (Devine & Bornstein, 1980; Lazarus, 1973; Wadden & Flaxman, 1981). Besides, it is questionable whether deeper levels of relaxation and more vivid imagination are process variables which are essential for a more positive outcome (Kazdin, 1978; McLemore, 1972; Spanos, de Moor, & Barber, 1973; Wilkins, 1971). It is possible that existing research has overstated the clinical importance of these processes which are thought to be of central importance in the traditional learning model of classical conditioning (Wolpe, 1958). Several authors have drawn attention to the fact that there are differences but also several important common factors in a hypnotherapy and behavior therapy situation which make use of the subjects imagination (de Moor, 1978; Spanos & Barber, 1976; Spanos et al., 1973; Turk, Meichenbaum, & Genest, 1983; Wickramasekera, 1976). Spanos et al. (1973) argued that the behavioral and experiential changes occurring in hypnosis and behavior therapy can, in part, be accounted for in terms of

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four sets of common variables: (a)positive motivation toward the therapy situation and instructions or suggestions given; (b) positive attitude and expectancy concerning the procedure; (c) wording of suggestions and instructions which provide information concerning the overt behavior and cognitive activity expected; and (d) involved imaginings, which are consistent with the theme suggested. This position reflects the growing consensus that hypnosis involves imaginative processes. Terms such as believed-in imaginings (Sarbin & Coe, 1972), imaginative involvement (J. Hilgard, 1970), involvement in suggestion related imaginings (Spanos & Barber, 1972) all point to similar imaginative characteristics of hypnosis. This consensus concerning imagination as an essential component of hypnosis, however, does not preclude theoretical controversy. In a social learning model of hypnosis, patients are assumed to be actively involved in adopting and maintaining the definition of the situation contained in the suggestions when they try to become absorbed in imaginary situations. In contrast, in more traditional models it is hypothesized that, special psychological processes such as trance or dissociation produce automatic hypnotic responding. In this view, motivation, positive attitudes, and suggestions merely set the stage for the occurrence of involuntary and dissociative imaginative experiences characteristic of hypnosis per se. When deliberately enacted imaginative processes play a decisive role both in hypnosis and in imagination-based behavior therapies, it is difficult to understand how and to what extent hypnosis can have a special facilitative effect on behavior therapy. At the process level, a most relevant research topic is whether the results of imagination-based behavior therapy and hypnotic imagery are brought about by the same cognitive processes. Studies which validate the occurrence of more involuntary and dissociative imaginative experiences during hypnosis andlor in highly hypnotizable subjects can help to differentiate behavior therapy from hypnosis per se. Until now, clinical research along these lines does not exist. Controlled Outcome Studies of Hypnotherapy and Behavior Therapy A search of the literature resulted in 21 analogue and clinical studies in which a hypnotherapeutic technique was compared with a behavioral therapeutic technique. These studies are listed in Table 1, and their salient features charted. Apart from methodological weaknesses and differences in population and therapeutic technique, hypnotherapy was more effective in 5 studies, behavior therapy in 7 studies, and in 9 studies both methods yielded a comparable therapeutic result. At first sight, chance seems to offer the most plausible explanation for this distribution of results. In view of the difficulties of a global comparison between hypnotherapy and behavior therapy, a closer review of the controlled research based on the following questions can be more informative: (a) Are hypnotic relaxation and symptom-reduction techniques more effective than progressive muscle relaxation, used in behavior therapy? (b) Does a

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PHILIP SPINHOVEN TABLE 1 CHARA~RISTICS OF CONTROLLED OUTCOME STUDIES OF HYPNOTHERAPY BEHAVIOR AND THERAPY
~~

Study

Population.

Sessions

nenpy

Dependent Hypnotizahility Follow-up Posttreatment Measurer' Scale Results'

Hmnotic h.luation) techniques and progressive muscle relaxation Maher-Loughnau (1970) asthma
252p

12

1. hypnmir and self-hypnosis: direct suggestions 2. m i v e relaxation + breathing exercises 1. hypnosis: direct suggestions Z. pmgressive relaxation 3 waling control .

OAT

no

no

1=2

McAmmond e d. phobia t (1~1) Borkovec et al. (1973) insomnia

27P

0,s
S

no

5mor.

1=2=3

37V

1 hypnosis: relaxation . 2 progressive relaxation 3. self-relaxation 4. waiting-list control


1. hypnosis: relaxation 2. progressive relaxation 3. no-treatment control

no

no

1=2>3=4

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Deahler et d . (1973) Sullivan et al. (1974)

hypertension ZIP

no

no

1>2>3

behavioral deficit in brain &age muscle contraction headache

24P

1. hypnosis: direct suggestions 2. progressive relaxation 3. no-treatment control


1. hypnosis: analgesia 2. EMC

SHSS:A

no

1>2>3

Schlutter et d. (1980)

48P

P, s

"0

10-14
wkr.

i=2=3

3 progressive relaxation . EMC

Behavior therapy in a hypnotic context

Lazarus (1973)
Schubot (1967)

outpatients phobia

26P

?
?

1. "hypnosis"received 2. "hypnosis" refused 1. systematicdesensitization hypnotic induction 2. systematic desensitization

no SHSS:C

no

1=2=3 1=2

3 V O

+ 0,s
+
0.S

fang (1969)
Deyoub et d . (1980)

phobia

27V

1. systematicdexnsitization hypnotic induction


2. systematic desensitization

snss:m
BSS

1=2

obesity

72V

1. covert modeling induction


2. covert modeling

+ hypnotic
+ task

2mos.

2>1=3

motivation 3 no-treatment m n t d . Devine et al. obesity

48V

(1980)

1. covert modeling hypnotic induction 2. covert modeling 3 no-model control . 4. minimal treatment m n t d

0,s

HGSHSA

3mos.

1>3; 2=3

Wadden et al. (1981)

obesity

33V

1. covert modeling hypnotrc induction + parthypnotic suggestions 2. covert modeling 3. relaxatiodattention control
1. behaviormodification + hypnotic induction + trance ratification 2. behavior modification + hypnotic induction 3. behavior modification

0,s

BSS

1+4
mos.

1=2=3

Goldstein (I9w

obesity

6OP

no

5mos.

1>2=3

O'Brien et al. (1W

phobia

18V

9 or 4

1. systematic desensitization hypnotic induction + posthypnotic suggestion 2. systematic desensitization

0,s

"0

no

1>2

(TABLE 1 cont. p. 17)

HYPNOSIS AND BEHAVIOR THERAPY: A REVIEW

17

TABLE 1 (Continued) CHARAIXERISTICSCONTROLLED OF OUTCOME STUDIES OF HYPNOTHERAPYBEHAVIORTHERAPY AND


Study Population

Sessions

nernpy Procedure
1. hypnosis: pseudotherapy
2. systematic desensitization 3. no treatment control

Lkpendent Hypnotizability Follow~upPosttreatment Measuresb Scale ResultsC


0.S

Hypnotherapeutic and behavior therapeutic methods

Lang et al.
(1965)

phobia

44V

16

no

no

221=3

Mmre
(1965)

prthma

12P

1. hypnosis: direct suggestions 2. relaxation systematic

0,s

no

no

2>1=3

desensitization 3. relaxation

o w
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Marks et al.

phobia phobia

2AP

12
5 or 3

Gibbons et al.

2 N

1. hypnosis direct suggestions 2. systematic desensitization 1. hypnosis: directed experience 2. systematic desensitization 3. no treatment control 1. hypnosis: directed experience 2. systematic desensitizntion 3. contact no treatment control 4. no contact control
I n v i m and in uitro methods

ST .
S

no

land4
yrs.

2>1

no

lyr.

1=2>3

Melnick et al. (1976)

phobia

36V

0.s

no

no

2>1=3= 4

WR)

Barkley et al.

smoking

29V

1. hypnosis: cognitive restructuring + selfhyqnosis 2. rapid smoking 3. attention-placebo control restructuring + selfhypnosis 2. rapid smoking
1. hypnoskwgnitive

no

6and 12wks.
9 mos.

221=3

Perry et al. (1979)

smoking

46V

HGSHS:A

3mos.

221

*P = ptientr; V = volunteerr. bO = physiological or objective change associated with symptom removal; S = self-report of symptom removal; T = therapists or investigators impression of symptom removal. Numbers refer to numbered items in column 5 (Therapy Procedure) on same line.

hypnotic context enhance the effectiveness of behavior therapy? (c) Are behavior therapy in uitro techniques more effective than forms of hyp.notherapy in which behavior therapy techniques are not explicitly used? ( )Is the level of hypnotizability related to the effectiveness of hypnod therapy andlor behavior therapy? (e) Are hypnotherapy in vitro techniques more effective than behavior therapy in uiuo techniques? Hypnotherapy and progressiue muscle relaxation. In six studies, a hypnotherapeutic technique was compared with Jacobsons (1929) progressive muscle relaxation. Recently, behavior therapists (see Rachman & Wilson, 1980) have used this training procedure as a therapeutic technique in its own right as originally proposed by Jacobson. A comparison between hypnotherapy techniques and relaxation per se is also interesting, in view of the position of some authors that hypnosis can be equated to relaxation, because both have very similar physiological effects characterized by decreased blood pressure, heart rate, respiration, etc. (Edmonston, 1981).

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PHILIP SPINHOVEN

In two of these studies, the hypnotic procedure consisted of hypnotic relaxation only. Borkovec and Fowles (1973) compared a hypnotic relaxation procedure, a progressive muscle relaxation procedure, self-relaxation, and a no-treatment condition for the treatment of insomnia in college students. There were no significant differences between the hypnosis group and the progressive muscle relaxation group. In a study by Deabler, Fidel, Dillenkoffer, and Elder (1973), hypertension was treated with progressive relaxation and further lowered to a normal level by hypnotic relaxation. The apparent superiority of hypnosis may have been caused by an order effect, because all patients received hypnosis directly after the relaxation. In the other four studies, hypnotherapy included a hypnotic induction followed by direct suggestions to diminish or eliminate symptoms such as asthma (Maher-Loughnan, 1970); pain and anxiety in a dental situation (McAmmond, Davidson, & Kovitz, 1971); tension headache (Schlutter, Golden, & Blume, 1980);and anxiety in patients with organic brain damage (Sullivan, Johnson, & Bratkovitch, 1974). In the study by MaherLoughnan (1970), both asthma treatment groups showed some improvement. There were marked differences in response according to sex; women treated with hypnosis showed significantly greater improvement than women treated with relaxation and breathing exercises. McAmmond et al. (1971) measured self-reported anxiety, skin conductance, and pain tolerance of frightened patients in a dental situation. In general, there were no clear-cut differences between hypnosis, relaxation, and control subjects at posttreatment. At follow-up, however, significantly more subjects from the hypnosis group than from the relaxation group were willing to seek and again undergo dental treatment. Sullivan et al. (1974) found that hypnosis improved intellectual functioning of brain damaged persons by reducing catastrophic anxiety significantly more than relaxation or control conditions. No follow-up data were reported, however, and the possibility of experimenter bias could not be excluded. Finally, Schlutter et al. (1980) in a study of the control of muscle contraction headache observed a comparable effect of hypnotic analgesia, EMG feedback, and EMG feedback combined with progressive relaxation. On the basis of six studies with various shortcomings in methodology, each involving the treatment of a difFerent disorder, no firm conclusions on the relative efficacy of hypnosis and progressive muscle relaxation training can be drawn. A clear superiority of hypnosis over progressive muscle relaxation was not found. More clinical research is needed to investigate different hypnotic and relaxation techniques at a physiological level and at the level of treatment outcome. The study by Benson et al. (1978)is a very good example of research along these lines. These authors found that there was no essential difference between a meditational technique and a self-hypnotic relaxation technique in the treatment of 32 patients with anxiety neurosis. Independent of the technique used, patients who had moderately high hypnotic responsiveness, however, sig-

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nificantly improved on psychiatric assessment and decreased average systolic blood pressure over the 8-week training period. Behavior therapy in a hypnotic context. With respect to the issue of an enhanced effectiveness of behavior therapy in a hypnotic context, the following questions can be posed: (u) Does the definition of the therapeutic situation as one involving hypnosis enhance the effectiveness of a behavior therapy procedure? (b) Does the induction of hypnosis enhance the effectiveness of a behavior therapy procedure? (c) Do suggestions for specific hypnotic phenomena increase the effectiveness of behavior therapy procedures? In a study of an outpatient population whose symptoms were not described, Lazarus (1973) compared a treatment labeled hypnosis with behavior therapy. The only difference between the hypnotic and nonhypnotic treatment was that relaxation was called hypnotic relaxation or hypnosis in the hypnosis condition and was called relaxation in the relaxation condition. Patients who specifically requested hypnosis and received hypnosisimproved more than patients who requested hypnosis and received relaxationor patients who were indifferent to hypnosis and received relaxation,although the differences between treatments were not statistically significant (p C .lo). Clinical outcome was judged globally by the author who was also the therapist in the study; hence, a potential for experimenter bias was present. On the grounds of this clinical trial, Lazarus concluded that expectancy fulfillment is the most plausible explanation for the differences found between the three groups. In four studies not only was the situation defined as hypnosis, but a behavior therapy procedure was also preceded by a hypnotic induction. In two studies (Lang, 1969; Schubot, 1967), the effectiveness of systematic desensitization in the treatment of snake phobics was investigated in a hypnotic and a nonhypnotic condition. In both studies no differences in outcome between the two groups were found. Both systematic desensitization with and without a hypnotic induction resulted in a significant reduction in phobic anxiety. The two other studies dealt with a comparison of covert modeIing with and without hypnotic induction in the treatment of obesity. Deyoub and Wilkie (1980) found that only covert modeling without a hypnotic induction was significantly effective compared to a no-treatment control group. The authors interpret their findings by pointing out that patients in the hypnosis condition were less relaxed and concentrated and more anxious and defensive. Uncertainty about a sufficient level of hypnotic capacity may have interfered with a positive outcome. Devine and Bornstein (1980) investigated the efficacy of covert modelinghypnosis and covert modeling alone in the control of obesity. Measurement of proportional weight loss indicated a significantly greater weight loss only in covert modeling hypnosis subjects as compared to the nomodel controls. Credibility may be crucial in this respect, because patients rated the hypnotic treatment as more credible than covert modeling without hypnosis.

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In three studies not only was the situation defined as hypnosis and a hypnotic induction used, but the behavior therapy procedure was also supplemented with specific hypnotic suggestions. In the treatment of obesity with covert modeling, Wadden and Flaxman (1981) gave direct suggestions for weight reduction and suggestions that the induction of a hypnotic trance and the power of the unconscious would facilitate the loss of weight. At posttreatment and follow-up, there were no significant differences between the covert modeling with and without hypnosis group and a relaxation-attention control group. Goldstein (1981)investigated the effectiveness of a treatment for obesity under the following three conditions: (a)behavior modification following the program of Stuart and Davis (1972); (b)same as (a) and including a definition of the situation as hypnosis, a hypnotic induction, and posthypnotic suggestions for a changing eating pattern; (c)same as (b)and including verbal and nonverbal suggestions for hand levitation. Treatment time between subjects was variable. A t posttreatment and follow-up, there was a significant difference in weight reduction between the hypnosis with hand levitation group and the other two groups. Goldsteins conclusion that hand levitation as a form of trance ratification influences the credibility and hence the effectiveness of the treatment procedure does not seem warranted, because his study contains a major confounding variable in terms of length of treatment for each of the subjects. In the treatment of snake phobics, OBrien, Cooley, Ciotti, and Henninger (1981) compared systematic desensitization alone with systematic desensitizatioh complemented with posthypnotic suggestions for positive nocturnal dreams about the anxiety-provoking situation. At posttreatment, more students belonging to the hypnosis group were able to touch a snake than those belonging to the nonhypnosis group. The two subjects from the hypnosis group who were unable to touch the snake reported dreams in which a snake was absent or threatening. The results of this study are diacult to interpret in view of the following methodological problems: (a) subjects from the hypnosis group were highly hypnotizable -hypnotizability in the nonhypnosis group was not assessed; (b) subjects in the hypnosis group received nine therapy sessions, while those in the nonhypnosis group received four; and (c) one therapist conducted the measurements and both sets of treatment. In summary, research into the facilitation of behavior therapy by a hypnotic context is scarce and shows varying degrees of methodological rigor. Hypnosis as an adjunct can influence the effectiveness of behavior therapy in two different ways. Dependent on the therapy expectations of patients, a hypnotic context enhances or reduces the credibility and hence the effectiveness of a behavior therapy method. A hypnotic context has the nonspecific value of a ritual. That suggestions for hypnotic phenomena (such as posthypnotic dream suggestions) also have a more specific effect still needs to be demonstrated more definitely.. Hypnotherapy and behavior therapy imagination procedures. In five studies, systematic desensitization has been compared with a hypno-

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therapy method, which was not an explicit application of a procedure known in behavior therapy. Lang, Lazovik, and Reynolds (1965) tried to prove that the results of systematic desensitization are not related to suggestibility. They compared systematic desensitization with no-treatment and pseudotherapy, a condition which is described in later articles as a form of hypnosis (cp. Marks, Gelder, & Edwards, 1968). Systematic desensitization proved to be significantlymore effective than no-treatment and pseudotherapy. But it is misleading to interpret these results as an indication that systematic desensitization is superior to hypnosis. For one thing, 18 of the 33 college students in the systematic desensitization condition received a hypnotic induction, as mentioned casually in a footnote. Furthermore, students in the pseudotherapy condition were encouraged to discuss topics totally unrelated to their phobic complaints. Marks (1971) and Marks et al. (1968) treated phobic patients with systematic desensitization and hypnosis in a crossover design. In the hypnotic condition a forceful suggestion was made to the patients that their phobias would gradually disappear. Only a general suggestion was given. No imagery was presented and no suggestionswere made that they should enter particular situations [Marks et al., 1968, p. 12651. As rated by the therapist and an independent observer, phobic problems were reduced in both conditions. According to the self-ratings of patients, however, systematic desensitization resulted in a significantly greater reduction of anxiety than hypnosis. Moore (1965) treated asthma patients in a balanced incomplete block design with relaxation, relaxation with suggestion (hypnosislhypnoidal state), and systematicdesensitization. In the suggestion condition, strong reiterated suggestions were given while the patient was relaxed, that he would be a little improved in various specific ways during the coming week and that he would be a more relaxed person [p. 2591. All three conditions showed a significant subjective improvement, but only in the systematic desensitization group was a significant objective improvement reached. Gibbons (1971) and Gibbons, Kilbourne, Saunders, and Castles (1970) assessed the comparative effectiveness of systematic desensitization and a directed experience hypnotic technique in reducing test anxiety. In the hypnosis condition, suggestions were given that the subject was taking a test and that some serious decision concerning his future depended upon the results of this test. Selected items of existing tests were presented to the subject in a context of ease and automatic control. Compared to a notreatment control group, both groups improved significantly. The results of this study are dificult to interpret, however, because (a)subjects were permitted to choose their own treatment, (b) time in treatment was not equal across treatment groups, and (c) no objective measures were included. Melnick and Russell (1976)replicated the study of Gibbons et al. (1970), while controlling for the methodological shortcomings mentioned above. In this particular study, only systematic desensitization yielded a significant subjective reduction in anxiety compared to two control groups. For

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either treatment condition, however, there was no significant improvement observed in academic performance. Only the no-treatment control group showed a positive improvement on the final exam. An outstanding feature of the studies reviewed above is the almost caricatural way in which behavior therapists such as Lang, Marks, and Moore operationalize hypnotherapy as a form of pseudotherapy or as an authoritarian dismissal of symptoms. The apparent superiority of behavior therapy compared to hypnosis in these studies must be interpreted in this perspective. Studies which assess the therapeutic value of a more complex hypnotherapeutic approach, however, show many methodological flaws (Gibbons et al., 1970). The comparative research into hypnotherapeutic and behavioral methods is especially illustrative of the mutual prejudices of proponents of either approach. Hypnotizability, behavior therapy, hypnotherapy. The relationship between the level of hypnotizability and the outcome of hypnotherapy was assessed in 7 of the 21 studies. Three of the 4 studies in which a significant positive correlation was found were related to the treatment of anxiety disorders (Lang, 1969; Schubot, 1967; Sullivan et al., 1974). In 3 studies of the treatment of obesity and smoking, no relationship was demonstrated (Devine & Bornstein, 1980; Perry, Gelfand, & Marcovitch, 1979; Wadden & Flaxman, 1981). Only Deyoub and Wilkie (1980) reported a significant positive correlation between hypnotizability and weight reduction in hypnotherapy. These findings further validate the hypothesis that in hypnotherapy, hypnotizability is especially relevant in the treatment of psychosomatic and anxiety disorders as opposed to habit disorders which have a more voluntary component (Spinhoven, 1982; Wadden & Anderton, 1982). In none of the six behavior therapy studies in which the relationship between hypnotizability and outcome was measured did significant correlations emerge. The fact that in behavior therapy irrespective of the nature of the disorder no relationship between hypnotic capacity and outcome was found, sheds a critical light on the position of Murray (1963) and Litvak (1970), who hold that imagination procedures used in behavior therapy inadvertently induce a hypnotic state. In five of these six studies, an imagination procedure was investigated and, in contrast to, the hypnotic condition, hypnotizability was not therapeutically relevant. The finding that behavior therapy procedures with a high ingredient of relaxation and imagination do not tap the hypnotic capacities of patients possibly can be explained by the issue of control. Behavior therapists typically emphasize a rational and explicit use of scientifically based procedures. This emphasis on voluntary control may prevent the occurrence of more involuntary and dissociative experiences characteristic of hypnosis per se. In vivo and in uitro methods. In only two studies (Barkley, Hastings, & Jackson, 1977; Perry et al., 1979) has the question of the comparative effectiveness of hypnotic (in uitro) and behavioral (in viuo) techniques been addressed. Perry et aI. (1979) compared Spiegels (1970) singletreatment method utilizing ancillary (self) hypnosis with rapid smoking.

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This technique requires patients to smoke cigarettes rapidly while concentrating on the accompanying feelings of discomfort. Barkley et al. (1977) assessed the effectiveness of group rapid smoking with group hypnosis. The hypnotic suggestions were the same as those reported by Hall and Crasilneck (1970). In both studies, a significantly greater number of abstainers was found in the aversive conditioning group which is in agreement with results of research on the relative effectiveness of in uiuo versus in vitro techniques (Rachman & Wilson, 1980). This field of research points to the conclusion that overt behavioral rehearsal results in a more profound behavioral change than covert techniques, and that techniques which are based on the use of imagination should be applied in combination with overt techniques.

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DISCUSSION
This review has confirmed the speculation of many clinicians that hypnosis can be a valuable adjunct to some behavioral procedures to a certain extent. This effectiveness, however, is not attributable to the enhancement of factors critical for conditioning processes such as a deeper relaxation or more vivid imagery. Hypnosis primarily influences common therapy factors such as expectancy of success and treatment credibility. That hypnosis as an adjunct to behavior therapy also has a genuine hypnotic effect still needs to be demonstrated more definitively. Moreover, no evidence was found that imagination-based behavior therapies inadvertently tap the hypnotic capacities of patients. Further controlled clinical outcome research is necessary in light of the relatively small number of studies conducted to date and the methodological problems associated with these studies. Among the improvements needed are longer follow-up, the use of multiple outcome measures, the use of patients instead of volunteers, random assignment of subjects to experimental conditions, and standardized measurement of hypnotizability. Above all, future research should address procedures and techniques that are more representative of cIinical hypnosis as it is currently practiced. The image of hypnotherapy which arises from the studies in the present review is that of hypnosis in a sloppy, ready-made behavioral suit or hypnosis as an authoritarian dismissal of symptoms. In almost all studies, hypnosis merely involved a hypnotic induction followed by a behavior therapy procedure or a standardized relaxation procedure with direct hypnotic suggestions of symptom amelioration. Perhaps hypnotherapists who use less rigid approaches think that individualized hypnotherapy is inconsistent with methodologically sound research. That outcome research does not necessarily restrict the intuition and flexibility of the therapist is, however, well illustrated by Holroyds (1980) review of hypnosis and cigarette smoking. This review gives a reasonably strong indication that therapeutic effectiveness is associated with more individualized approaches to hypnotherapy. The most fruithl line of research involving hypnosis and behavior therapy is to study the conditions under which clinical hypnosis can be

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used to facilitate behavior therapy. It is unlikely that behavior therapy researchers will address this issue of the effectiveness of a more flexible and individualized approach to hypnosis as an adjunct to behavior therapy. References to hypnosis or hypnotic phenomena in the behavior therapy literature have lessened over the past several years. There appear to be several reasons for this trend. Some time ago, behavior therapists loosely defined hypnosis as a controI condition for the specific conditioning components of behavior therapy. Times have changed and more sophisticated placebo control conditions are used in the research strategies of behavior therapists (Kazdin & Wilson, 1980). Secondly, in the 196Os, behavior therapy still had to establish its position as a respectable form of psychotherapy. Smith, Glass, and Miller (1980) concluded that at this stage these data are simply not in. Behavior therapy researchers are mainly interested in studying the comparative efficacy of variants of behavior therapy instead of the comparative efficacy of different forms of psychotherapy. Moreover, one of the forces at work has been the move away from imaginal systematic desensitization to other methods, including in uiuo exposure methods with phobic disorders. It is noteworthy that about two-thirds of the studies in the present review involved relaxation and imaginal desensitization. Perhaps the most influential factor is that behavior therapists, and lately cognitive behavior therapists, use strategies and interventions which are almost identical to hypnotic strategies and interventions without being bothered by the common factors between the two therapy situations. As Weitzenhoffer noted as early as 1972 with regard to certain therapy methods used by behavior therapists (i.e., aversive conditioning), it is not the procedure itself which is new, but the explanation of the efficacy of the procedure in terms of 1earningTheory. Illustrative in this respect is the cognitive treatment of pain in which a variety of imagination procedures are used, procedurally similar to hypnotic interventions but otherwise labeled. Authors in this field who mention hypnosis (Turk et al., 1983; Turner & Chapman, 1982) equate hypnosis with a form of cognitive behavioral treatment. The question arises whether and how behavior therapy can be improved by considering hypnosis. The answer to this question must be based on a more carefully considered conceptualization of what hypnosis is and how it works; this has not been the basis of the majority of the studies mentioned in this review. The most common hypotheses about hypnosis as an adjunct to behavior therapy are concerned with characteristics of hypnosis per se. An example is the hypothesis that imagination procedures used in behavior therapy inadvertently induce a hypnotic state, which mediates therapeutic change. In the light of current evidence, it is not likely that even behavioral procedures, in which one of the main ingredients is imagination, always tap the hypnotic abilities of a volunteer subject or patient. In the six studies in which the relationship between outcome of behavior therapy and level of hypnotizability was assessed in the behavior therapy condition, no relationship was demonstrated in contrast to the hypnotic condition.

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The hypothesis that hypnotic induction adds leverage to a behavior therapy procedure by inducing a hypnotic state andlor by enhancing factors critical for (classical) conditioning, such as the level of bodily relaxation and the vividness of imagery, also has to be reassessed. On the contrary, the studies reviewed above suggest that the therapeutic effects of defining the therapy situation as hypnosis and using a hypnotic induction are mainly effective by influencing the credibility of the therapy procedure and inducing expectations of therapeutic success. This finding fits neatly into the changed theoretical perspective on the efficacy of imagination-based behavior therapy discussed above. Traditional learning theories are thought to be inadequate to interpret the results of such procedures in terms of cognitive processes. Contemporary social learning approaches, however, which emphasize the roIe played by subjects expectations and meanings in mediating therapeutic effects offer a conceptual framework in which the results of behavior therapy and behavior therapy in a hypnotic context can be more meaningfully interpreted. Studies along these lines of the nonspecific role of hypnosis in the process of change seem more promising than existing studies which have tried to elucidate the specific ways in which hypnosis facilitates especially classical conditioning processes. The possibility of influencing credibility and expectancy by a hypnotic context has now been reasonably documented. The way in which hypnosis potentiates or depotentiates other common therapy factors (such as the facilitation of the therapeutic relationship) deserves further clarification and validation. A fundamental objection to this position would be the contention that similarities between hypnosis and behavior therapy must not obscure relevant distinctions. It can be argued that hypnosis as a subject variable involves a capacity to experience profound changes in perception, memory, and cognition (Orne, 1977)not accountable in terms of social-learning theory. The studies in the present review have been so designed that this question, which is more fundamental for hypnosis per se, is scarcely broached. It can hardly be expected that hypnotic capacity will facilitate a more successful outcome of behavior therapy of which the only hypnotic component is a hypnotic induction added to a standard behavior therapy procedure. The behaviorists emphasis on control -deliberately doing something to change ones thoughts, emotions, behavior, or circumstances -is excessively organized around rational and willful efforts to produce significant change (Bowers, 1982). In hypnotherapy it is realized to a greater extent that sometimes it can be more beneficial to circumvent the patients willful, active efforts to control his subjective experiences, and instead, to engender a psychologicalstate, which facilitates the occurrence of automatic and dissociative responses. A fruitful combination of hypnosis and behavior therapy requires a therapeutic approach in which voluntary control is less prominent and suggestions for involuntary hypnotic experiences are given. The very few studies in the present review which addressed just this issue, however, were methodologically weak (Goldstein, 1981; OBrien et al., 1981).

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Wadden and Anderton (1982) suggest that the preferred design for better controlled research is to assign individuals of low and high hypnotizability to induction and non-induction conditions; the individuals otherwise receive the same treatment. It is suggested, here, that the therapeutic value of hypnosis for behavior therapy must be approached by comparing in high and low hypnotizables a behavioral treatment of known efficacy to the same treatment plus a hypnotic induction and specific hypnotic suggestions relevant for the disorder under treatment. In such a constructive therapy research strategy, treatment components are added to study the resulting enhancement of therapeutic effects (Kazdin & Wilson, 1980). If the hypnotic suggestions address problems and capacities which are overlooked by the behavioral treatment, then the combination treatment should yield superior results, especially in the high hypnotizable-hypnosis condition. A nonspecific effect of hypnosis could be assessed by comparing the low hypnotizable-hypnosis condition with the low-hypnotizable-waking state condition. The influence of hypnotic responsiveness on outcome can be more pronounced in the treatment of pain, anxiety, and vegetative complaints than in the treatment of addictive disorders such as smoking, obesity, and alcoholism (Bowers, 1982; Perry et al., 1979; Spinhoven, 1982; Wadden & Anderton, 1982). Employing the above design in the treatment of different disorders can help to elucidate further the conditions for using hypnosis as an adjunct in behavior therapy. This kind of research can help to answer the important clinical questions of why and how to use or not use hypnosis in behavior therapy. In conclusion, the nonspecific and specific effects of hypnosis as an adjunct to behavior therapy have not been convincingly demonstrated by controlled outcome studies. As Wadden & Anderton (1982) note, It is time for the field to abandon its Muse, Hypnos, and to awaken to the need for experimental rigor in the pursuit of improved clinical service [p. 2381. To this can be added that for clinical researchers interested in and sympathetic to both hypnosis and behavior therapy, it is time to delineate the conditions in terms of context, type of disorder, patient characteristics, and hypnotic interventions under which hypnosis can be a valuable adjunct to behavior therapy. In the absence of confirming data, the most parsimonious position is to state that hypnotherapy is procedurally similar to certain (cognitive) behavior therapy procedures but that it is labeled otherwise. If proponents of hypnosis advocate that this equation is false, they need to demonstrate either that hypnosis has an additional nonspecific effect or that for certain patients it yields a far more favorable therapeutic outcome.

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Hypnose und Verhaltenstherapie: Ein Uberblick Philip Spinhoven Abstrakt: Hypnose wird in weitem Ma6e als ein Zusatz zur Verhaltenstherapie benutzt. Hypnose kann als eine vorhergehende Variable (Hypnosekontext und gegebene Suggestionen) wie auch als eine Subjektvariable (die Fihigkeit, profunde, subjektive Verinderungen durchzumachen) definiert werden. Ein Faktor, den Hypnose mit e i n e r auf Vorstellungskraft basierten Verhaltenstherapie gemeinsam hat, ist der Gebrauch von Entspannungs- und Imaginationsprozessen. Empirische Hypnosestudien und Verhaltenstherapie werden hier rividiert. Man kam zu dem BeschluB, da6 Hypnose als ein Zusatz in erster Linie gewohnliche Therapiefaktoren, wie Erwarten des Erfolgs und Vertrauen zur Behandlung, beeinflu6t. Ein mehr spezifischer Effekt der Hypnose in der Verhaltenstherapie mu6 immer noch demonstriert werden. Es wird daher vorgeschlagen, daB eine fruchtbare Kombination von Hypnose und Verhaltenstherapie ein therapeutisches Vorgehen verlangt, in dem eine spontane Kontrolle weniger prominent ist und Suggestionen fiir unwillkurliche Hypnoseerlebnisse gegeben werden. Hypnose et therapie behaviorale: une revue Philip Spinhoven Resume: L'hypnose est largement utilisee comme compkment A la th6rapie behaviorale. L'hypnose peut &tredefinie autant comme une variable situationnelle (contexte hypnotique et suggestions donn6es) que comme une variable individuelle (la capacitb dexpkrimenter des changements subjectifs profonds). L'utilisation de la relaxation e t des processus imaginatifs semble 6tre le facteur commun 5 l'hypnose e t aux therapies behaviorales bas6es sur I'imagination. Une revue des etudes empiriques de I'hypnose et des therapies behaviorales est presentee. 1 est conclut que I'hypnose mmme complement a la th6rapie behav1 iorale influence premibrement des facteurs communs aux therapies e n g6n6ral comme par exemple les attentes de s u d s et la credibilitb du traitement. Un effet plus specifique de l'hypnose dans les therapies behaviorales reste encore a demontrer. L'auteur sdggbre qu'une mmbinaison fructueuse dhypnose et de th6rapie behaviorale exige une approche thkrapeutique ax6e plus sur la suggestion d'expkriences hypnotiques involontaires que sur le mntr6le volontaire comme tel. Una revisi6n sobre hipnosis y terapia comportamental Philip Spinhoven Resumen: Se ha generalizado el us0 de la hipnosis como complementaria a las terapias comportamentales. La hipnosis puede ser definida ya sea como una variable antecedente (el context0 hipn6tico y las sugestiones dadas) o como una variable del sujeto (la capacidad para experimentar cambios subjetivos profundos). Un factor comirn a la hipnosis y a las terapias comportamentales basadas en la imagineria, es el us0 de relajaci6n y de procesos imaginativos. Se lleva a cab0 una revisi6n d e estudios empiricos sobre hipnosis y terapia comportamental. Se concluye que la hipnosis utilizada mmo complemento, influencia, en primer lugar, factores tales como expectativa de Bxito y credibilidad del tratamiento. Todavia necesitaria ser demostrado otro efecto mis especifico d e la hipnosis sobre la terapia comportamental. Se sugiere que una combinaci6n fructifera de hipnosis y terapia comportamental, requiere de un enfoque terapeutico, e n el cual el control voluntario sea menos importante y se den, en camhio, sugestiones para experiencias hipn6ticas involuntarias.

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