Hypnotherapy, also known as hypnosis, involves the use of a formal induction procedure and targeted suggestions to address a particular symptom or group of symptoms. It is more likely to be used as a primary psychological treatment rather than as augmentation of existing treatment. A related though slightly different concept that may find wider use in healthcare is the use of targeted, positive suggestions on their own as therapeutic suggestion (Varga Reference Varga2013). This technique does not require induction, nor does it need to be labelled as hypnosis. Therapeutic suggestion is more likely to be used as an ‘add-on’ rather than as distinct treatment. It can be incorporated as a technique to enhance existing therapies. Many patients and practitioners would feel more open to the use of therapeutic suggestion than a practice labelled ‘hypnotherapy’, which for many will still carry negative associations.
Chan et al's article (Reference Chan, Zhang and Yin2022) presents a comprehensive review of the evidence for hypnotherapy where it exists. The strengths of the article are the timeliness of its presentation, its publication in mainstream mental health literature and its robust review of methodologies and outcomes. Although this evidence has been around for some time, hypnotherapy (hypnosis) continues to struggle with image problems, mislabelling and stigmatisation within psychiatry (Du Plessis Reference Du Plessis, Nel and Taylor2021). The consequences of this are that patients are hampered from accessing its benefits (Krouwel Reference Krouwel, Jolly and Greenfield2017) and mental health professionals are discouraged from training in or delivering hypnosis. Health professionals often do not realise that a lot of research has gone into hypnotic interventions in recent years and, anecdotally, they often opine from points of view that are uninformed by evidence.
Definition of clinical hypnosis
The characterisation of clinical hypnosis as something that is done to patients over which they have no control – in effect, involuntary mind control – is controversial. This does not appear to be the view of contemporary practitioners of clinical hypnosis in Europe or America. The accepted definition of hypnosis has undergone various iterations over the years (Elkins Reference Elkins, Barabasz and Council2015). This effort has ensured that its definition is recognisable and widely accepted. In 2014, the Society of Psychological Hypnosis (Division 30 of the American Psychological Association) defined hypnosis as ‘a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion’ (Society of Psychological Hypnosis 2022). These are the essential components of what is called the trance state. We agree with the Society's definition but must point out that resulting therapeutic effects are often experienced by patients as involuntary and realistic (Blakemore Reference Blakemore, Oakley and Frith2003), although it requires the active engagement and cooperation of patients with the procedure and imaginal content of suggestions.
The formal induction of a trance or hypnotic state (focused relaxation), which might be called neutral hypnosis (Cardeña Reference Cardeña, Jönsson and Terhune2013), is to be differentiated from the use of therapeutic suggestion (the making of positive suggestions to produce intended beneficial effects), for example in healthcare (Phillips Reference Phillips, Price and Molyneux2022). The induction of neutral hypnosis plus the use of therapeutic suggestion together make up ‘hypnotherapy’, but an induction process and/or ‘hypnosis’ is not necessary for people to respond to positive suggestions (although neutral hypnosis does produce a small but significant increase in response) (Kirsch Reference Kirsch and Braffman2001). Therapeutic suggestion may be added to existing therapies, such as in chronic pain management, cognitive–behavioural therapy (Ramondo Reference Ramondo, Gignac and Pestell2021) and mindfulness (Olendzki Reference Olendzki, Elkins and Slonena2020), to increase effect sizes. Teaching patients self-hypnosis, which is advocated by hypnosis societies, helps them to take control of their own thought processes, emotions and behaviours. This increases their self-efficacy and participation in their own treatment (Wark Reference Wark and Kohen2002; Kohen Reference Kohen2010).
An omission from the article
What is missing from Chan et al's article is discussion of the most common uses of hypnosis and therapeutic suggestion in psychiatry. These include the management of medically unexplained symptoms (or functional disorders) and of comorbid physical and mental illnesses in adults and children (Phillips Reference Phillips, Price and Molyneux2022). These problems are often encountered in liaison psychiatry. General hospitals bring added complexity and challenges to what mental health interventions can be quickly and easily delivered, and hypnosis and therapeutic suggestion have value in this setting (Holler Reference Holler, Koranyi and Strauss2021). This value extends to the cost-effectiveness of hypnotherapeutic interventions (Montgomery Reference Montgomery, Bovbjerg and Schnur2007; Maines Reference Maines, Peruzza and Angheben2021), improvements in patients’ experience of care (Arbour Reference Arbour, Tremblay and Ogez2022) and quality of life. A systematic review and meta-analysis has found hypnosis and therapeutic suggestion to be effective in chronic pain management (Adachi Reference Adachi, Fujino and Nakae2014). In cancer care, hypnosis reduces pain, anxiety, depression, fatigue and insomnia associated with treatments (Remondes-Costa Reference Remondes-Costa, Magalhães and Martins2021; Hayat Reference Hayat, Abderrahmane and Karim2022). It has been approved by the National Institute for Health and Care Excellence (NICE) as a treatment for irritable bowel syndrome (NICE 2017: recommendation 1.2.3), although mental health professionals, even those in the UK, are often unaware of this. Irritable bowel syndrome can be conceptualised as a common functional disorder that has high comorbidity with common mental disorders. To participate fully in integrated care, psychiatrists would do well to understand these interventions and participate in their delivery. The curriculum for training in child and adolescent (consultation) liaison psychiatry in Australia, for example, lists hypnosis as one of the interventions that trainees could learn to deliver (Shaw Reference Shaw, Rackley and Walker2019).
Education and training for healthcare professionals
Interventions that have been evidenced to improve healthcare professionals’ knowledge, attitudes and perceptions of hypnosis and therapeutic suggestion are limited in scope. The following have been evidenced: a short online video lecture (Montgomery Reference Montgomery, Force and Dillon2019); longer, in-person, didactic educational/training sessions (Martín Reference Martín, Capafons and Espejo2010; Carvello Reference Carvello, Lupo and Muro2021; Arbour Reference Arbour, Tremblay and Ogez2022); a training programme involving patients (Aramideh Reference Aramideh, Ogez and Mizrahi2020) and their families (Ogez Reference Ogez, Aramideh and Mizrahi2021); and comprehensive training with ongoing supervision and continuing education (McKernan Reference McKernan, Finn and Patterson2020). Expanding awareness of hypnosis and therapeutic suggestion among healthcare professionals and their students would be of benefit to a wide range of patients. Although improved awareness may not necessarily translate into practice, it would be a good starting point.
Hypnosis practitioners and societies should focus on educating the wider healthcare community about the benefits of hypnosis and encourage its incorporation into clinical guidelines (Box 1). For too long, the evidence of the benefits of hypnosis continues to circulate mainly within highly specialised communities of practice, robbing other health professionals of this enlightenment. For mental health services, the question that needs consideration is: For whom are hypnosis and therapeutic suggestion effective and how can we make these interventions available to those patients who would benefit?
Sources of information
For professionals
• British Society of Clinical and Academic Hypnosis – This is the professional body of health professionals in England, Wales and Northern Ireland who utilise hypnosis in healthcare. It promotes safe and responsible practice, aims to educate both professionals and the public about hypnosis and its use, and encourages research, audit and publication on the subject (www.bscah.com).
• British Society of Medical and Dental Hypnosis (Scotland) – This organisation in Scotland aims to promote the safe and responsible use of hypnosis in medicine and dentistry. It aims to educate healthcare workers and the public about hypnosis and its uses and to advance scientific research, education and standards of practice in hypnosis (www.bsmdhscotland.com).
• Hypnosis and Psychosomatic Section, the Royal Society of Medicine – Promotes knowledge and understanding of hypnosis and psychosomatic medicine, through continuous professional development activities (www.rsm.ac.uk/sections/hypnosis-and-psychosomatic-medicine-section).
For patients
• Hypnosis and Hypnotherapy – Online leaflet from the Royal College of Psychiatrists (www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/hypnosis-and-hypnotherapy).
Acknowledgements
We thank Dr Carol McDaniel (consultant psychiatrist) and the RCPsych International Peer Group: Drs Shangobiyi (UK), Njoku (UK), Awani (Canada), Datubo (UK) and Odeyale (UK) for their initial comments on this commentary. We are grateful to the University of Western Ontario Library for access to papers used in forming our opinions.
Author contributions
Both authors contributed to the conception and design of this work and to its drafting, and gave final approval of the version published. They agree to be accountable for all aspects of the work.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
I.U. is a member of the BJPsych Advances editorial board and did not take part in the review or decision-making process of this paper. I.U. is a member of the British Society of Clinical and Academic Hypnosis (BSCAH). Views expressed are not necessarily those of the BSCAH.
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