Efficacy of Hypnosis

in the Treatment of Anxiety Disorders:

A Ten-year Review
Specializations Thesis in Clinical Adult Psychology
By

Hussein M. Ali

Copyright 2009 Hussein M. Ali

All Rights Reserved

Abstract
The aim of the present paper is to look at the current state of the evidence concerning the
efficacy of hypnosis in the treatment of anxiety disorders in adults. The English literatures
that have been published in the last ten years on the use of hypnosis in the treatment of
anxiety disorders in adults were reviewed and thoroughly investigated. Based on this review
and judged against the guidelines of Chambless and Hollon, the efficacy of hypnosis as an
adjunct procedure in the treatment of anxiety disorders in adults is yet to be established.
However, this conclusion is not to be understood to mean that hypnosis is ineffective in the
treatment of anxiety disorders. In fact there are several single-case studies and clinical reports
that demonstrating the benefit of hypnosis as an adjunct procedure in the treatment of anxiety
disorders in adults. But these clinical cases, due to their methodological shortcomings, are not
sufficient to establish a scientific basis for the efficacy of hypnosis. Although Efficacyfocused research is important, the establishment of the efficacious status of a particular model
or technique in psychotherapy and the implementation of such technique is not in itself a
guarantee for delivering an effective treatment.

Introduction
According to the recent definition by the American Psychological Association (APA; Green et
al., 2005), hypnosis typically involves an introduction to the procedure during which the
subject is told that suggestions for imaginative experiences will be presented. The hypnotic
induction is an extended initial suggestion for using ones imagination, and may contain
further elaborations of the introduction. In hypnosis, the subject/client is guided by the
hypnotist to suggestions for changes in subjective experience, alterations in perception,
sensation, emotion, thought, or behavior. Persons can also learn self-hypnosis, which is the
act of administering hypnotic procedures on ones own. Details of hypnotic procedures and
suggestions will differ depending on the goals of the practitioner and the purposes of clinical
or research endeavor. Procedures traditionally involve suggestions to relax, though relaxation
is not necessary for hypnosis and a wide variety of suggestions can be used including those to
become more alert. Suggestions that permit the extent of hypnosis to be assessed by
comparing responses to standardized scales can be used in both clinical and research settings.
While the majority of individuals are responsive to at least some suggestions, scores on
standardized scales range from high to negligible. Traditionally, scores are grouped into low,
medium, and high categories.
A century ago, hypnotherapy often consisted of hypnotic induction, followed by the
administration of suggestions for symptom removal. However, suggestions for symptom relief
play a relatively minor role in contemporary hypnotherapy. Instead, hypnotherapy generally
consists of the addition of hypnosis to some recognized form of treatment (e.g.,
psychodynamic therapy, behavior therapy, or cognitive-behavior therapy) (Rhue et al., 1993;
Kirsch et al., 1995). Hypnosis in itself is not a method of psychotherapy. The clinical areas
treated with psychotherapy plus hypnosis, should also respond to treatment without hypnosis.
The healthcare worker should never use hypnosis without being theoretically and clinically
trained also to deal with the particular pathology without hypnosis (Godoy, 1999).
Beside anxiety disorders, hypnosis has been implicated in the treatment of several psychiatric
disorders and medical conditions including, among others, eating disorders (Capafons &
Amig, 1995), sleep disorders (Nielson, 1990; Scholtz & Ott, 2000), substance addiction

2
(Guena, 1992; Spiegel et al., 1993), sexual dysfunction (Carrese & Araoz, 1998), and chronic
pain (Edelson & Fitzpatrick, 1989).
The aim of the present paper is to look at the current state of the evidence concerning the
efficacy of using hypnosis as an adjunct procedure in the treatment of anxiety disorders in
adults. The English literatures that have been published in the last 10 years on the use of
hypnosis in the treatment of anxiety disorders in adults will be reviewed and thoroughly
investigated.

Review of the Literatures

Literatures were obtained from a computer search of three databases (PsycINFO, EMBASE,
and MEDLINE) from January, 1999 to December, 2008, using the search terms, Hypnosis OR
Self-hypnosis OR Hypnotherapy in conjunction with Anxiety OR Anxiety Disorders OR
Performance Anxiety OR Generalized Anxiety Disorder OR GAD OR Phobic Anxiety
Disorders OR Phobias OR Agoraphobia OR Panic Disorder OR Social Phobias OR Specific
Phobias OR Obsessive-Compulsive Disorder OR OCD OR Posttraumatic Stress Disorder
OR Post-traumatic Stress Disorder, OR PTSD, with the restriction of English language.
Reviews together with studies dealing with children and studies dealing with subclinical
anxiety or ambiguous/unclear diagnosis were excluded.
In addition, the studies and case reports included in the review satisfy the following inclusion
criteria: (a) the therapist/researcher explicitly refers to the use of Hypnosis, Self-hypnosis or
Hypnotherapy in the treatment, and (b) the diagnosis falls in one of the following categories
of anxiety disorders:

Agoraphobia
Panic Disorder
Specific Phobias
Social phobias (including Performance Anxiety)
Generalized Anxiety Disorder (GAD)
Obsessive-Compulsive Disorder (OCD)
Posttraumatic Stress Disorder (PTSD)

The total number of studies and case reports satisfying the above criteria were 28. These are
reviewed below together with further elaboration of the above categories of anxiety disorders.
Agoraphobia and Panic Disorder
The term agoraphobia literally means fears of open spaces, but as described in the 10th
revision of the International Classification of Diseases (ICD-10; WHO, 1992) it includes
fears not only of open spaces but also of related aspects such as the presence of crowds and
the difficulty of immediate easy escape to a safe place. The term therefore refers to an
interrelated and often overlapping cluster of phobias embracing fear of entering shops,
crowds, and public places, or of travelling alone in trains, buses, or planes. This is the most
incapacitating of the phobic disorders and some sufferers become completely housebound;
many are terrified by the thought of collapsing and being left helpless in public. Most
sufferers are women and the onset is usually early in adult life.

3
The essential features of panic disorder are recurrent attacks of severe anxiety which are not
restricted to any particular situation or set of circumstances, and which are therefore
unpredictable (ICD-10). Sudden onset of palpitations, chest pain, choking sensation,
dizziness, and feelings of unreality (depersonalization or derealization) are common. There is
also, almost invariably, a secondary fear of dying, losing control, or going mad. A panic
attack is often followed by a persistent fear of having another attack. Panic disorder can be
present with agoraphobia.
There were three clinical case reports in which hypnosis was used as an adjunct to other forms
of therapy in treating agoraphobia and panic disorder (one case of panic disorder and
agoraphobia and to cases of panic disorder alone):
Schoenberger (2000) described the use of hypnosis and self-hypnosis in conjunction with
Cognitive-Behavior Therapy in the treatment of panic disorder and agoraphobia in a 62-yearold woman. The patients first episode of panic attack occurred when she was in her late
forties, and subsequent panic attacks led her to avoid more and more situations, eventually
causing her to stop working. When the patient sought treatment, she did not leave her home
unaccompanied; refused to shop in crowded stores, even with someone else; and would not
ride the bus, train, subway, or elevators. Despite severe symptoms at the onset of treatment,
the patient was able to make substantial progress. She made enough changes in her thinking
and anxiety reactions to engage in many fulfilling activities that had not been possible for her
for many years.
Singh & Banerjee (2002) used hypnosis in combination with Rational Emotive therapeutic
approach in the treatment of panic disorder in a man of his early forties. They reported that
there was only one panic attack after six sessions but subsequently the panic attacks ceased
completely after 16 sessions. Treatment showed an increased sense of control, improved selfconfidence and elimination of pathological psycho-physiological symptoms. The patient did
not report recurrence of the attacks even after three years.
Iglesias & Iglesias (2005) utilized a form of awake-alert hypnosis together with visualization
and ego-strengthening techniques in the treatment of panic disorder in a 72-year-old woman.
Her panic episodes were characterized by an accelerated heart rate, shortness of breath, chest
pain, fears of losing control and being detected, and sweating. She was tried on several SSRIs
and a benzodiazepine but the medications had to be discontinued because they irritated her
intestinal lining and exacerbated the patients diverticulitis. After twelve 30-minute sessions
in a period of four weeks, they reported no change in the frequency of the episodes (three
episodes a week), but the intensity level of the episodes was markedly suppressed.
Social Phobias and Performance Anxiety
Social phobias centered around a fear of scrutiny by other people in comparatively small
groups (as opposed to crowds), usually leading to avoidance of social situations. Unlike most
other phobias, social phobias are equally common in men and women. They may be discrete
(e.g. eating in public, encounters with the opposite sex) or diffuse, involving almost all social
situations outside the family circle. Social phobias are usually associated with low self-esteem
and fear of criticism (ICD-10). Avoidance is often marked, and in extreme cases may result in
almost complete social isolation.

4
Performance anxiety is a subgroup of social phobias in which patients have a marked and
persistent fear of one or more social or performance situations; this often occurs when
patients are exposed to unfamiliar people, or when they are subjected to scrutiny by others
Kraft & Kraft (2006). The most common form of performance anxiety is public speaking,
however, there are many other areas, these include actors who are frightened that they might
forget their lines, musicians who are afraid of making mistakes, and others who worry about
being beaten in contests (Lazarus & Abramovitz, 2004). Exam anxiety can also be considered
as a type of performance anxiety because it involves the evaluation of the persons
performance by others.
Three clinical case studies were found that involved the use of hypnosis together with other
forms of therapy in the treatment of performance anxiety:
Pearce (1999) studied a case of a 27-year-old woman account clerk who was trying to pass
her final Account exam to become a Certified Practicing Accountant. She had attempted the
exam on two previous occasions without succeeding, due to her exam anxiety. He employed
hypnosis in conjunction with relaxation and visualization techniques. After only three
sessions the woman reported substantial improvement and was able to pass the exam and get
her certificate.
Livnay (2004) developed a nine stage approach to treat different forms of performance
anxieties, including exam anxiety, stage fright, music performance, acting, and interview.
These stages are: Loosening the certainty of failure; Reframing of past concepts of selfhypnosis to include phobic behavior; Future Progression to a point in time following success;
Creation of a positive anchor (resources/setting which fosters success); Creation of negative
anchor (arousal of the anxiety response, and channeling it out); Rehearsals of positive
performance; Treatment of examiners and judges; Visual and auditory effects in the
treatment of the audience; and finally bringing together all of the previous components into
a running through of the dress rehearsal before an actual performance or examination. The
author gave a detailed description of the application of his approach on patients suffering
from exam anxiety and other forms of performance anxieties based on his clinical practice
with successful results.
Yu (2006) utilized hypnosis as an adjunct to cognitive-behavioral therapy in managing
examination anxiety and facilitating performance of three Chinese undergraduate participants
(one male and two females). The treatment protocol was principally derived from the
undergraduate stress management program by the Hypnosis Unit of the University College
London. He employed a Subjective Units of Discomfort Scale (SUDS) to measure the general
anxiety level about examinations, together with the Achievement Anxiety Test (AAT) and
stress symptoms checklist. The treatment comprised four sessions in a period of two weeks.
The result indicated mild improvement for two participants on AAT, while one participant
(female) showed no significant difference in pre- and post-AAT. SUDS indicated a decline of
general examination anxiety throughout the sessions. All psychological, behavioral and
physical signs were likewise rated lower in the stress symptoms checklist administered in the
intermittent follow-ups for a month. Compared with their previous experience, all participants
had done their best during the examinations without any memory retrieval problems that they
expected before.

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Specific Phobias
These are phobias restricted to highly specific situations such as proximity to particular
animals, heights, thunder, darkness, flying, closed spaces, dentistry, the sight of blood or
injury, and the fear of exposure to specific diseases. Specific phobias usually arise in
childhood or early adult life and can persist for decades if they remain untreated. The
seriousness of the resulting handicap depends on how easy it is for the sufferer to avoid the
phobic situation (ICD-10).
In total there were 10 clinical case studies/reports in which hypnosis was employed in
conjunction of other forms of therapy in the treatment of specific phobias. The specific
phobias included dental and needle phobias (3 studies), driving phobia (4 studies), flying
phobia (2 studies), and phobia of medical procedures (one study):
Dental and Needle phobias:
Gow (2002) used hypnosis and desensitization techniques together with topical anesthetic in
the treatment of a dental needle phobia in a 48-year-old woman. After six treatment sessions,
the patient score on the Modified Corah Dental Anxiety Scale has significantly decreased.
There was also a significant decrease in her anticipated pain level.
Morgan (2004) described the use of hypnosis in conjunction with some cognitive-behavioral
and visualization techniques in the treatment of a 26-year-old pregnant woman who was
having a phobia of needles and other invasive medical procedures that were associated with a
high level of anticipatory pain. The treatment was carried out through two sessions. A follow
up after several weeks revealed that the treatment was effective in reducing the patients
anxiety during the birth process.
Gow (2006) reported a case of successful treatment of a 31-year-old woman who was
suffering of a dental phobia that prevented a necessary extraction procedure of a tooth. The
three sessions long treatment included desensitization technique and hypnosis in conjunction
with topical anesthetic. Her dental anxiety was measured before and after the treatment using
Modified Corah Dental Anxiety Scale. Pain experience and the anticipation of pain were also
measured before and after the treatment using the Visual Analogue Scales (VAS).
Hypnotizability was also assessed using the Creative Imaginative Scale (CIS) and Spiegel Eye
roll scale. These measures indicated a high level of anxiety, high level of anticipated pain, and
high hypnotizability. The result indicated a significant reduction in her dental anxiety and
anticipated pain.
Driving Phobia:
Morgan (2001) studied a case of a 47-year-old woman who had developed a phobia for
driving and being a passenger of a motor vehicle after involving in a three accidents. The
treatment consisted of 9 sessions that involved hypnosis and gradual desensitization within a
structured cognitive-behavioral approach. The author reported a considerable improvement.
McNeal (2001) studied a case of a 33-year-old woman who specifically wanted treatment
with Eye Movement Desensitization and Reprocessing (EMDR) for her phobias of driving on
the freeway and driving over bridges. She had been in psychotherapy with another therapist
for twelve years with little change, and felt she wanted to try something different. The woman
was involved in a motor vehicle accident as a child, where her sister was badly injured. He
utilized EMDR and hypnosis, and reported a positive treatment outcome.

6
Kraft and Kraft (2004) studied a case of a 55-year-old woman who had a severe driving
phobia with a concomitant reduction in her mobility. The woman was previously involved in
one accident on the motor way and in another recent incident of a near collision. The
treatment consisted of a systematic desensitization of driving scenarios in hypnosis. After
sixteen treatment sessions, the patient made a complete recovery and was able to drive on all
public roads. In hypnosis, the patient was able to create a world of vivid imagery using all
sensory modalities that contributed significantly to her complete recovery.
Hill and Bannon-Ryder (2005) described a case of a 37-year-old woman who was working as
a community psychiatric nurse. The woman was involved in a number of accidents that
resulted in anxiety and avoidance behavior. After four treatment sessions that involved
hypnosis and a behavioral driving program, the patient was able to make a long distance
driving trip that she has been avoiding for a number of years, but with some residual anxiety.
A follow up a year later revealed that anxiety had diminished and that progress had continued.
Flying phobia:
Schreiber (2004) used hypnosis and visualization techniques to treat two women (28 and 68years-old) and one man (59-years-old) who manifested a strong fear of flying. The clients
personality traits with regard to commercial flying were studied two years prior to the
treatment and for two years after the treatment. Each client participated in five sessions of
treatment. The author reported a reduction between 50 and 75% in fear of flying for each
client. All clients were also free of panic attacks as a result of the treatment.
Golden (2006) reported a case of a 45-year-old woman who was having two phobias, a fear of
going to the dentist and her fear of flying. However, she only wanted to work on her fear of
flying. The treatment plan included cognitive, behavioral, and hypnotic interventions.
Specific treatment interventions included eye-fixation hypnotic induction techniques,
relaxation techniques, together with the use of rational statements as hypnotic suggestions and
imagery and in vivo desensitization. The treatment lasted for four sessions, and as a result the
woman was able to take her airplane trips without any fear. The author reported that the
patient returned again after 9 years for the treatment of her dental phobia. She gained
improvement after two sessions of hypnosis and desensitization techniques.
Phobia of medical procedures:
Pearce (2004) presented a case study of the use of hypnosis and a specific visualization
technique called Stepping into Time Technique in treating a specific phobia of medical
procedures. The client was a 37-year-old male who had been having panic attacks, anxiety
and phobic reactions in response to almost anything medical, whether it be medical
procedures, such as an eye examination, visiting a doctor, watching a medical procedure on
television or even at times driving past a hospital. The client sought hypnosis to control his
phobic reactions to anything medical, as he wanted to be present with his partner at the birth
of their first child. After several sessions, the patient was able to attend the birth of his first
child without anxiety. A follow up after two years revealed that the patient was able to attend
the birth of his second child without the need for any further therapeutic suggestions.
Generalized Anxiety Disorder (GAD)
The essential feature is anxiety, which is generalized and persistent but not restricted to, or
even strongly predominating in any particular environmental circumstances. Complaints of
continuous feelings of nervousness, trembling, muscular tension, sweating, lightheadedness,

7
palpitations, dizziness, and epigastric discomfort are common. Fears that the sufferer or a
relative will shortly become ill or have an accident are often expressed, together with a variety
of other worries and forebodings. This disorder is more common in women, and often related
to chronic environmental stress (ICD-10).
There was only one clinical case report that involved the use of hypnosis together with
cognitive-behavioral therapy in the treatment of generalized anxiety disorder:
Golden (2006) employed hypnosis in the treatment of generalized anxiety disorder in a 50year-old woman. The patient was referred to the therapist by another cognitive-behavior
therapist to receive hypnosis and stress management. The previous therapist mainly used
cognitive interventions, which had not been effective in reducing her anxiety. The treatment,
which extended over 10 sessions, included cognitive, behavioral, and hypnotic interventions.
Specific treatment interventions included a relaxation hypnotic induction technique, cognitive
restructuring, imagery rehearsal, and assertiveness training. After treatment the patients freefloating anxiety was greatly reduced in frequency, duration, and intensity and her sleeping
improved dramatically.
Obsessive-Compulsive Disorder (OCD)
As described in ICD-10, the essential feature of this disorder is recurrent obsessional thoughts
or compulsive acts. Obsessional thoughts are ideas, images or impulses that enter the
individuals mind again and again in a stereotyped form. They are almost invariably
distressing and the sufferer often tries, unsuccessfully, to resist them. They are, however,
recognized as the individuals own thoughts, even though they are involuntary and often
repugnant. Patients are often obsessively anxious about dirt, contamination, flooding, germs,
or a fear of real or imagined traumas.
Compulsive acts or rituals are stereotyped behaviors that are repeated again and again. The
individual often views them as preventing some objectively unlikely event, often involving
harm to or caused by himself/herself. Compulsive acts may include continuous hand washing,
checking of locks, gas taps, water taps and plugs.
One case report was found in which self-hypnosis was employed as an interventional
technique together with other forms of therapy in the treatment of OCD:
Frederick (2007) provided a case report of a 30-year-old dentist with obsessive-compulsive
disorder. Due to his extreme fear of contamination while performing procedures, the dentist
was using triple face masks and multiple layers of gloves. He also had checking practices and
excessive rumination about doing certain procedures. He had to years of cognitive-behavior
therapy combined with Clomipramine without any improvement. After a year of weekly
therapy, that involved the use of self-hypnosis, hypnotic ego-strengthening, and cognitivebehavioral interventions, together with Flouxetine, the patients symptoms reduced, he
became more assertive, and he was able to relax and enjoy both work and recreation. During
the second year of his treatment, his symptoms gradually vanished, and he became completely
free of ruminations and compulsive behaviors.

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Posttraumatic Stress Disorder (PTSD)
According to ICD-10, PTSD arises as a delayed and/or protracted response to a stressful
event or situation of an exceptionally threatening or catastrophic nature, which is likely to
cause pervasive distress in almost anyone (e.g., natural or man-made disaster, combat, serious
accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape,
or other crime).
Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories
(flashbacks) or dreams, occurring against the persisting background of a sense of
numbness and emotional blunting, detachment from other people, unresponsiveness to
surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma.
There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle
reaction, and insomnia. Anxiety and depression are commonly associated with the above
symptoms and signs, and suicidal ideation is not infrequent (ICD-10).
In total there were 10 clinical case studies/reports that involved the use of hypnosis in
conjunction with other forms of psychotherapy in the treatment of PTSD:
Lumsden (1999) used hypnosis as an adjunct to cognitive-behavior therapy in the treatment of
posttraumatic stress disorder in a 48-year-old woman. The patient had experienced a lifethreatening home invasion in which she was held at knife point and the intruder told her
several times that he would kill her. In order to assess her hypnotizability, the Stanford
Hypnotic Clinical Scale was administered, on which she scored 4 of 5. She was having a
positive attitude toward the use of hypnosis and there were no contraindications such as
depression, psychosis, or personality disorder. The treatment consisted of eight weekly
sessions. The therapist reported positive outcomes of the treatment, although some of the
patients avoidance behavior was unaffected. The patient reported that she was feeling
emotionally stronger and her anxiety had reduced.
Moore (2001) reported on the application of hypnosis in the treatment of 24-year-old woman
posttraumatic stress disorder resulting from the patients exposure to an armed hold-up at
work. Before starting hypnotherapy, the patient was treated by a psychologist trained in
dealing with work-stress issues. The treatment lasted for three months and involved the use of
graduated exposure without any progress. To assess her hypnotic ability, she was asked to
describe and elaborate upon a positive experience. She chose to describe her wedding day
and displayed great capacity for affective involvement. She was also able to describe the
warmth and smells of the day, as well as visualizing the event. The therapist used the theatre
of the Mind Technique where the patient was asked to view the events from a distance, and
not feel so vulnerable and emotionally involved. The therapist also suggested that she would
be able to play the situation backwards and forwards, at different speeds and black-and-white
or color. After seven sessions, the patient was able to achieve her goals of abolishing the
distressing flashbacks, feeling of not being safe, and sleep disturbance which she had been
experiencing. She was also able to re-frame her experience from a negative to a more positive
one, and to resume work.
Degun-Mather (2001) described a successful treatment of a 61-year-old British veteran who
had chronic posttraumatic tress disorder of 40 years duration. He had also developed
dissociative fugues during this time. The patient was finally admitted to a psychiatric hospital
with severe depression and PTSD. After discharge he was treated by three-phase oriented

9
treatment: Stabilization with psycho-education and a cognitive-behavioral approach with
hypnosis, re-processing of traumatic material by use of a safe-remembering hypnotic method
with cognitive re-evaluation of traumatic events to resolve the negative feelings, and further
memory integration and rehabilitation. This was aided by dream elaboration, both with and
without hypnosis. At the end of therapy, the patient was symptom-free and was able to regain
emotional and social contact with his family and friends.
Barnard (2002) described the use of hypnosis together with cognitive restructuring and
visualization techniques in the treatment of a 41-year-old man who was displaying symptoms
of PTSD resulting from a history of verbal, physical, and sexual abuse that happened over
several years during his stay as a child in two institutions. After 21 sessions, there was some
improvement, and the author concluded that hypnosis proved to be an invaluable tool in this
therapy case, although the therapy was still continuing.
Salerno (2005) reported on a therapeutic program, conducted in a correctional center, which
included the use of hypnosis with women who had been diagnosed with PTSD. The
participants in the program consisted of a sample of six women who had served more than six
months of a custodial sentence. The sample ranged in age from 20 to 64. The program
consisted of two-hour sessions, conducted once per week for 10 weeks. Hypnosis was used
initially for tension reduction with post-hypnotic suggestion for relaxation. In subsequent
sessions, hypnotic regression was used to recall and revivify the traumatic incident and
gradually reintegrate the experience with improved coping skills. Beside hypnosis and
coping-skills training, the program also included the use of Cognitive-Behavioral Therapy
(CBT) and Dialectical Behavior Therapy (DBT.) The Posttraumatic Stress Diagnostic Scale
(PDS) was chosen as a screening and pre- and post-test for the PTSD group. An attempt to
conduct both quantitative and qualitative evaluation was made. But because of the small
number of participants completing both pre- and post-tests, the significance levels cannot be
reported. Qualitatively, group cohesion was quickly established and solidified by midway
through the program, a useful indicator of an effective group suggesting that more intensive
therapeutic programs are beneficial in facilitating disclosure and developing insight.
Participants also provided positive feedback overall and emphasized the meaningfulness of
this particular program, in that it differed from standard prison-based core programs. But it
was difficult to separate the efficacious component of the provision of hypnotic techniques.
Pantesco (2005) utilized hypnosis in the treatment of a 31-year-old woman who was suffering
of PTSD as a result of sexual abuse. The woman had been in traditional insight-oriented
therapy for approximately five years without substantial results. Hypnosis was used as a
means of accessing the traumatic memories that were registered in the physical and emotional
systems of the patient. These memories are not accessible by traditional verbal narration
methods. The treatment consisted of 25 sessions in period of one year with successful
results. A three-year follow-up showed maintenance of these results.
Carter (2005) applied hypnosis in the treatment of a 50-year-old woman with posttraumatic
stress disorder resulting from her experience of having large glass doors collapse and shatter
on top of her at work on two separate occasions. To assess her hypnotic ability, the Creative
Imagination Scale was administered. She scored 25, which placed her in the medium high
category. The treatment consisted of 7 sessions and involved the use of controlled breathing
techniques and Cognitive-behavioral strategies beside hypnosis. At the end of the treatment
the patients symptoms from the workplace incidents were significantly reduced and she felt
that she was much better equipped to deal with any distressing events in the future.

10
Lynn & Kirsch (2006) used self-hypnosis, age regression, and video-monitor viewing
techniques to treat a woman who was suffering from PTSD. The woman was sexually
molested by her grandfather at the age of 8. She was having flashbacks that disrupted her
sexual relation with her husband. During self-hypnosis, the patient was asked to create a
realistic image of her parental grandfather. She was reluctant to do this, so she was asked to
watch herself on a mental video monitor as an 8-year-old child, small and vulnerable in the
soothing presence of her mother. Then she was asked to observe her mother, who somehow
learned what had happened, confront her grandfather, make him stop molesting her, and
reassure her that it was over and she would be safe. This imagery helped the patient to relax.
Then she was asked to turn the video monitor off and create an image of her grandfather and
make it dimmer and smaller. She was able to make increasing modifications in the image,
eventually to the point where it was invisible. The procedure was repeated the next session,
and she reported a SUD (Subjective Unit of Distress) level of only 2 when she tried to
imagine her grandfather. Finally, she was invited to create this image the next time she had
sexual encounter with her husband and to turn it on and off at will. This helped her to
overcome her problems that resulted from the traumatic experience and have a satisfactory
sexual relation to her husband. At 1-year follow-up, she reported she was flashback free.
Kwan (2006) described the application of hypnosis in the treatment of a 35-year-old Chineseborn Indonesian woman, who ha posttraumatic stress disorder resulting from her long history
of being maltreated by her father and witnessing his acts of violence when she was in
Indonesia. In the assessment phase of the treatment, the Impact of Event Scale (IES) was
administered and the results indicated the traumatic experiences had moderate impact on her
(IES = 49). Beside that, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI)
were administered and the results indicated she had mild depression (BDI = 18) and moderate
anxiety (BAI = 19). The patient was found to be a good hypnotic subject according to her
scores (25) on the Creative Imagination Scale. The results of the BDI (mild depression and no
suicidal ideation) also indicated there should be no contradiction to apply hypnosis on her.
Hypnosis was used together with cognitive restructuring techniques, age regression, Visual
Hallucination Screen Technique, and ego-strengthening techniques. The treatment consisted
of 11 weekly sessions. The psychological inventories (IES, BDI, and BAI) were readministered, and she scored 0 on all of these inventories, which indicted that her symptoms
had been eliminated. Beside that, her self-efficacy was enhanced and her relationship with her
husband and children improved. A follow-up after six months revealed that the improvement
was maintained.
Poon (2007) reported on the use of hypnosis with a battered 35-year-old Chinese woman who
had posttraumatic stress disorder after being abused by her spouse for about eight years. The
treatment consisted of three phases: Stabilization by reducing stress and building up personal
resources, re-exposing the patient to the trauma by graded approximation, and consolidation
of the therapeutic gains. Data obtained by the patients verbal reports, the therapists
observations, and objective measures (Beck Anxiety Scale, BAI and the Impact of Event
Scale, IES) at one month and three month post-treatment follow-ups provided evidence of
maintenance and continued improvement in symptoms. The patients hypnotizability was
assessed by using the Stanford Hypnotic Clinical Scale for Adults. She scored 3.5 out of 5,
demonstrating good response in imagery and fantasy. The treatment consisted of 19 sessions.
At the end of therapy, the patients score on the IES dropped from 64 to 20. At the one month
follow-up, her score had further dropped to 15. At the three month follow-up, she scored 14
on the IES, implying that she had maintained the therapeutic gain. She scored 14 on the BAI,
implying a mild level of anxiety.

11

Discussion
Only two out of the 28 works on hypnosis that have been reviewed in this paper dealt with
more than a single participant. One study involved the treatment of flying phobia in three
patients (Schreiber, 2004) and the other study dealt with a therapeutic program, conducted in
a correction center, which included the use of hypnosis with 6 women who had been
diagnosed with PTSD (Salerno, 2005). In the flying phobia study, the author reported a
reduction between 50 and 75% in fear of flying for each client. And all clients were also free
of panic attacks as a result of the treatment. But there were no objective measures of these
outcomes, no adequate sample size, and no control group. In the PTSD study, the author
could not report significant results because of the small number of participants completing
both pre- and post-tests.
The remaining works consisted of single-case studies or clinical reports in which hypnosis
was used as an adjunct of other forms of psychotherapy. Most of these forms involved
cognitive and behavioral techniques that in many cases overlap with hypnotic interventions,
for example, relaxation and visualization. In most of these cases, the therapist relied on
subjective reports, rather than objective measures of outcomes. And finally, and most
important of all, there is no way to tell whether the reported outcomes were due to hypnosis or
to other forms of interventions that have been employed together with hypnosis in the
treatments.
The American psychological Association (APA) has developed specific guidelines for
evaluating the efficacy of a given form of treatment in psychology (Chambless & Hollon,
1998). The authors argue that to meet the least stringent criteria of a possibly efficacious
treatment, it is required that at least one study show that the treatment is superior to a notreatment control, placebo group, or alternate treatment, or that the treatment in question
matches the effectiveness of an alternative treatment of established efficacy (Lynn et al.,
2000).
In order to meet the criteria of an efficacious treatment, the above criteria must be fulfilled
with the additional stipulation that two studies, rather than one, must be demonstrably
effective in two independent research settings, with no well-controlled research providing
contradictory evidence. And finally to fulfill the most stringent criteria of efficacious and
specific, the treatment must be shown to be superior to pill or psychological placebo or an
alternative established treatment in at least two independent research settings (Lynn et al.,
2000).
Chambless and Hollon (1998) have also recommended a number of methodological criteria
including the use of a randomized controlled trial, an adequate description of the treatment
procedures or the use of a treatment manual, the employment of a valid and reliable outcome
measures, and the specification of patient inclusion criteria in a reliable, valid manner. They
recommended a sample size of 25 to 30 per condition in controlled (nonsingle-case) studies to
measure adequate statistical power. Single-case experiments or equivalent time-series design
are also acceptable with as few as three participants (Lynn et al., 2000).
None of the reviewed studies can satisfy the methodological criteria that have been
recommended by Chambless and Hollon. Based on this review and judged against the above
guidelines, the efficacy of hypnosis as an adjunct procedure in the treatment of anxiety

12
disorders in adults cannot be established. Even the least stringent criteria of a possibly
efficacious treatment cannot be fulfilled.
Several researchers in clinical psychology have expressed their concerns and were unsatisfied
with these guidelines since they have been adopted by APA in 1998. Alladin et al. (2007) has
outlined several criticisms that have been raised by different researcher toward these
guidelines. The first criticism concerning the APA definition of empirically validated
treatments. Validated treatments may imply a greater degree of precision and authority that is
not supported by current research. As a result of this criticism, APA adopted the term
empirically supported treatments (EST) as opposed to empirically validated treatments. The
other main criticism was around the methodology of psychotherapy research. The research
methods used to understand and determine the efficacy of therapeutic techniques in
psychology have typically followed in the medical model of clinical trials and statistical
significance based on differences using control group comparisons (Alladin et al., 2007).
Subjects in randomized clinical trials do not represent real clinical clients or patients.
Moreover, the experimental settings, usually universities, may be very different from real
clinical settings and the experimenters may not represent typical clinical therapists. Another
related concern revolves around the issue of the nature of therapeutic relationship and the
characteristics of the clinicians. These seemed to have been neglected by the APA guidelines.
Several criticisms were launched against the use of manuals in clinical practice. These
include: adherence to a manual, which may not reflect clinical competence; since manuals
often provide general principles of a treatment approach, they cannot provide guidance to
treatment delivery; and manuals may restrict clinical flexibility (Alladin et al., 2007).
As a result of these concerns, the APA Presidential Task Force on Evidenced-Based Practice
in Psychology (EBPP; APA, 2006) recently revised and expanded the criteria for evidencedbased treatments. This Task Force considers empirical support for a particular approach to a
particular problem as only one element in any effective treatment (Alladin et al., 2007).
According to this Task Force efficacious treatment is embedded in not less than eight
additional research-based and research-supported dynamics. They refer to these activities as
the constituent aspects of clinical expertise. These activities are: (1) Assessment, diagnostic
judgment, systematic case formulation, and treatment planning; (2) Clinical decision making,
treatment implementation, and monitoring of patient progress; (3) Interpersonal expertise;
(4) Continual self-reflection and acquisition of skills; (5) Evaluation and use of research
evidence; (6) Understanding the influence of individual, cultural, and contextual differences
on treatment; (7) Seeking available resources as needed; and (8) A cogent rationale for
clinical strategies (APA, 2006). As stated in these recent guidelines, it is important not to
assume that interventions that have not yet been studied in controlled trials are ineffective.
Amundson et al. (2003) discussed the differences between efficacy-focused research and
effectiveness-focused research in psychotherapy. They argue that effectiveness-focused
research is of equal if not greater relevance than simple efficacy-focused gatekeeping.
Efficacy-focused research arises from the medical model and seeks to evaluate specific
models and specific therapeutic protocols with the criteria or goal of achieving empirically
supported therapy status (Nash, 2000). Effectiveness-focused research attempts to understand
not only the ways therapy is practiced in the real world but also to identify those factors and
dynamics that influence therapy (Beutler, 1998; Alladin et al., 2007). The focus here is on the
process of psychotherapy, and investigation is directed at discovering and explaining what
might make any treatment work. While efficacy-based methodology places greater emphasis

13
on internal validity and how consumer benefit or gain is achieved, effectiveness-focused
research emphasizes external validity and is driven by real-world factors (Alladin et al.,
2007). Amundson et al. (2003) argue that the concept of clinical effectiveness as a researchbased methodology may have a greater significance for the field of clinical hypnosis.
Empirical research points to the fact that perhaps as little as 8% of outcome is attributed to a
model or technique, 70% accounted for by general features common in all good therapies, and
22% of the outcome in therapy unexplained (Walmpold, 2001 ). This emphasizes the
importance of effectiveness-focused research in psychotherapy in general and in clinical
hypnosis in particular.

Conclusion
Based on this review and judged against the guidelines of Chambless and Hollon (1998), the
efficacy of hypnosis as an adjunct procedure in the treatment of anxiety disorders in adults is
yet to be established. However, this conclusion is not to be understood to mean that hypnosis
is ineffective in the treatment of anxiety disorders. In fact there are several single-case studies
and clinical reports that demonstrating the benefit of hypnosis as an adjunct procedure in the
treatment of anxiety disorders in adults, particularly in specific phobias, performance anxiety,
and PTSD. But these clinical cases, due to their methodological shortcomings, are not
sufficient to establish a scientific basis for the efficacy of hypnosis. Although Efficacyfocused research is important, the establishment of the efficacious status of a particular model
or technique in psychotherapy and the implementation of such technique is not in itself a
guarantee for delivering an effective treatment.

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