This article was downloaded by:[McMaster University Library]

[McMaster University Library]

On: 10 May 2007
Access Details: [subscription number 769426004]
Publisher: Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

International Journal of Clinical and

Experimental Hypnosis

Publication details, including instructions for authors and subscription information:

http://www.informaworld.com/smpp/title~content=t713657963

What Should We Mean by Empirical Validation in

Hypnotherapy: Evidence-Based Practice in Clinical
Hypnosis

To cite this Article: , 'What Should We Mean by Empirical Validation in

Hypnotherapy: Evidence-Based Practice in Clinical Hypnosis', International Journal
of Clinical and Experimental Hypnosis, 55:2, 115 - 130
To link to this article: DOI: 10.1080/00207140601177871
URL: http://dx.doi.org/10.1080/00207140601177871

PLEASE SCROLL DOWN FOR ARTICLE

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction,
re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly
forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents will be
complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be
independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or
arising out of the use of this material.
Taylor and Francis 2007

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

Intl. Journal of Clinical and Experimental Hypnosis, 55(2): 115130, 2007

Copyright International Journal of Clinical and Experimental Hypnosis
ISSN: 0020-7144 print / 1744-5183 online
DOI: 10.1080/00207140601177871

WHAT SHOULD WE MEAN BY EMPIRICAL

VALIDATION IN HYPNOTHERAPY:
Evidence-Based Practice in Clinical Hypnosis
1744-5183
0020-7144
NHYP
Intl.
Journal of Clinical and Experimental Hypnosis
Hypnosis, Vol. 55, No. 2, January 2007: pp. 130

Empirical
ASSEN
ALLADIN
Validation
ETinAL.
Hypnotherapy

ASSEN ALLADIN1
University of Calgary, Calgary, Alberta, Canada

LINDA SABATINI
Calgary, Alberta, Canada

JON K. AMUNDSON
Private Practice, Calgary, Alberta, Canada

Abstract: This paper briefly surveys the trend of and controversy surrounding empirical validation in psychotherapy. Empirical validation of hypnotherapy has paralleled the practice of validation in
psychotherapy and the professionalization of clinical psychology, in
general. This evolution in determining what counts as evidence for
bona fide clinical practice has gone from theory-driven clinical
approaches in the 1960s and 1970s through critical attempts at categorization of empirically supported therapies in the 1990s on to the
concept of evidence-based practice in 2006. Implications of this progression in professional psychology are discussed in the light of
hypnosiss current quest for validation and empirical accreditation.

THE DEVELOPMENT OF PROFESSIONAL PSYCHOLOGY AS

CONTEXT FOR CONSIDERATION OF EVIDENCE-BASED
HYPNOTHERAPY
Informing clinical practice through empirical methods and a
research base has a 60-year history that reached critical threshold over
the past 10 years (American Psychological Association [APA], 1995;
Thorne, 1947). Fundamentally, this evolution, if not revolution, in
mental health practice has involved attempts to determine what valid
and reliable methods of treatment exist and ought to be promulgated
(Chambless, Baker, et al., 1998; Chambless, Sanderson, et al., 1996). The
Manuscript submitted February 14, 2006; final revision accepted August 26, 2006.
1
Address correspondence to Assen Alladin, Ph.D., R.Psych., Department of Psychology,
Foothills Medical Centre, 1403 29th Street NW, Calgary, AB T2N 2T9, Canada.
E-mail: assen.alladin@calgaryhealthregion.ca
115

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

116

ASSEN ALLADIN ET AL.

pursuit of guidelines or templates (APA, 1995, 2002) for clinical practice attempt to not only determine criteria by which to judge clinical
validity but the methods to evaluate a given practice (Chambless &
Hollon, 1998).
This movement away from theory or model-based treatment to
more critical science and random clinical trial (RCT) thresholds to
determine the parameters of professional practice has been both enlivening to the profession and controversial. While the pursuit of
accountability, respectability, and efficacy was in all ways laudable,
determining what did and didnt count as basis for clinical practice
was not without debate. As criteria for bona fide or acceptable treatment emerged and became increasingly linked to health care or insurance policy, concern for broader effectiveness or clinical utility criteria
emerged and was advanced and debated in journals ranging from the
American Psychologist, the Journal of Consulting and Clinical Psychology,
and Canadian Psychology through Psychotherapy, Cognitive and Behavioral
Practice and Clinical Psychology: Science and Practice.
Simply stated, this debate on clinical validation contrasted the
cleanliness of RCT-based treatment protocols and the listing of
empirically supported therapies (EST) with the untidiness of realworld demands (Beutler, 1998, 2000; Beutler, Williams, & Enthwhistle,
1995; Borkovec & Castonguay, 1998; Clarke, 1995; Garfield, 1996;
Hubble, Duncan, & Miller, 1999; Jacobson & Christensen, 1996;
Persons & Silberschatz, 1998; Wampold, 2001). The issues of empirical
definition/standard, transfer, generalizability, feasibility, patient
accessibility, and cost/benefit made the all-encompassing benefits of
treatment manuals less promising than might have been initially
thought (Stricker, Abrahamson, Bologna, Hollon, Robinson, & Reed,
1999). Four main criticisms emerged as counterbalance to a simplistic
completion of protocols associated with efficacious treatment. These
criticisms related to: (a) definition of terminology; (b) research methodology; (c) limitations inherent in compiling/listing empirically supported therapies; and, (d) manual-based treatment.
Definition of Terminology
The main controversy here revolves around the APA Division 12
Task Force definitions of validated, well-established, probably
efficacious, and experimental treatments. Although clear guidelines are available for these designations in various published reports
(e.g., Chambless et al., 1996, 1998; Chambless & Hollon, 1998), the
opponents of EST are not fully satisfied. For example, Garfield (1996)
expressed concern that validated treatments may imply a greater
degree of precision and authority than is supported by current
research. The Task Force acknowledged the legitimacy of this concern
and indicated that validation will never be complete; relative to the

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

117

ongoing process that prevails in science. Hence, the Task Force

adopted the term empirically supported treatments as opposed to empirically validated treatments. Hunsley, Dobson, Johnston, and Mikail
(1999) argued that even if one accepts this stance, there may be problems in the actual determination as to whether a treatment meets the
validated criteria. Garfield (1996) noted that the Task Force was inconsistent in the application of its own criteria when several of the studies
employing very small samples were cited as supporting the validity of
certain treatments. One might infer that this term empirically supported
includes a realm of defining reference terms and criteria, in an attempt
to accommodate both the rigorous adherence to the recommended
criteria (based on the medical model involving clinical trials) and other
relevant scholarly investigations (involving naturalistic approaches).
Borkovec and Castonguay (1998) argued for the more inclusive
definition.
Methodology of Psychotherapy Research
The research methods used to understand and to 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. Wampold (1997)
expressed concern for the strategy used by the Task Force to determine
whether a delineated treatment meets the established criteria. He
noted that the Task Force started with an empty set of EST to which
were added treatments that met the established criteria. This strategy,
he argues, may be inconsistent with the state of psychotherapy
research, which indicates that most bona fide treatments are equally
effective. This dodo bird verdict states that there is no difference
between bona fide treatments, and, even if a difference exists, it is usually very small and confined to one or two outcome measures.
Wampold puts forward the suggestion that the Task Force should
have included all bona fide treatments in the list of EST and then
removed those that proved to be inferior to others on a preponderance
of measures. Kazdin and Bass (1989) point out that the reason for lack
of large differences between the bona fide treatments may be due to
lack of statistical power. Ollendick (1999) states that whatever criteria
are used some treatments are likely to have more experimental support than others.
Another argument is whether it is possible to export the findings of
laboratory-based RCTs to the world of clinical practice. Subjects in
RCTs 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. These are very realistic concerns and there is
an urgent need to build a strong bridge between science and practice.

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

118

ASSEN ALLADIN ET AL.

The Task Force does not provide any blueprints on how to build a
bridge between research therapy and clinic therapy. Nonetheless, the
Task Force has provided the impetus for studying treatment effects
regarding both the external and the internal validity.
Another related concern revolves around the issue of therapeutic
relationship. Several writers (Garfield, 1996; Henry, 1998; Wampold,
1997) have accused the Task Force of neglecting the characteristics of
the clinicians, the nature of the therapeutic relationship, and the intricacies of clinical judgment in the empirical evaluation of treatments.
Efficacy research has primarily focused on detecting differences
between various treatment approaches. The treatments and clinicians
have been homogenized, which dilutes some of the most important
ingredients of successful psychotherapy. So, although it seems some
treatments may be more efficacious than others, factors related to overall effectiveness variability require consideration.
The Impact of Compiling a List of ESTs
The Task force initiative has prompted the creation of a list of ESTs.
There is always the risk of not including a treatment on the list that
may be efficacious as well as the challenge of compiling an up-to-date,
complete listing of ESTs (Garfield, 1996). Further, if a listing of treatments is to be useful in routine clinical practice, attention should be
paid to the clinical setting and nature of services delivered. Such an
approach would help to ensure that all forms of treatments related to a
clinical setting are included in the list. However, again, transtheoretical
and patient variables may be overriding factors that influence outcome
beyond the simple efficacy of a given treatment.
Use of Manuals
Although treatment manuals have been used in psychotherapy for a
long time, the Task Forces insistence that ESTs must be manual based
has been a bone of contention. Ollendick (1999) defined a treatment
manual as a set of guidelines that instruct or inform the user as how to
carry out a certain treatment. He went on to state that a
. . . manual provides an operational definition of the treatment to be
implemented, providing instruction in how to conduct the treatment in a
relatively standard manner. Assuming the treatment was implemented
in a fairly standard way, manuals could also allow for potential replication of efforts across therapists and settings. (p. 2)

Luborsky and DeRubeis (1984) wrote about the potential benefits of

using treatment manuals in psychotherapy. Beck and colleagues treatment manual for depression (Beck, Rush, Shaw, & Emery, 1979) has
been extensively used and studied. The Task Force has simply
endorsed this movement. Those who oppose the usage of manuals

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

119

consider them to be cookbooks (Silverman, 1996) and more a

straightjacket than a set of guidelines (Goldfried & Wolfe, 1996).
Hence they are wary about the manualization of treatments. Proponents seem puzzled that one would argue against the specification of
what constitutes a certain type of therapy or how it should be implemented for a designated set of clients. Irrespective of the debate, the
National Institute of Mental Health has officially adopted the recommendation of the Task Force and will only fund psychotherapy efficacy research studies that use manuals. Although this practice upholds
standards for research activities, it limits our understanding and application of the findings along with the potential efficacy and outcomes
for our clients.
Another related concern to manualization is the standardization of
treatment delivery. One of the main criteria for a treatment to be listed
on the Task Force list of ESTs is the use of a manual. In this context,
several criticisms have been leveled against the usage of manuals in
clinical practice. These include (a) adherence to a manual, which may
not reflect clinical competence; (b) treatment manuals may not be
appropriate for some forms of psychotherapy; (c) since manuals often
provide general principles of a treatment approach, they cannot provide guidance to treatment delivery; and (d) manuals may restrict clinical flexibility. Supporters of manuals argue that treatment manuals
facilitate the dissemination of a treatment and they provide optimal
intervention strategies in routine practice.
As a result of concerns of this sort, the APA Presidential Task Force
on Evidenced-Based Practice in Psychology (EBPP; APA, 2006)
recently revised and expanded the criteria for evidence-based treatments. This Task Force considers empirical support for a particular
approach to a particular problem as only one element in any effective
treatment. Before discussing EBPP and its relevance to hypnotherapy,
well review the empirical status of hypnotherapy.

EMPIRICALLY SUPPORTED HYPNOTHERAPY

The pursuit of empirical support in hypnotherapy has been no less
an issue and controversy. However, the movement toward empirical
validation of clinical hypnosis is still in its infancy and, therefore,
wider acceptance of hypnotic intervention under evidentiary standards remains contingent on further empirical research. A special
issue of the International Journal of Clinical and Experimental Hypnosis
(2000) assessed the status of hypnosis as an empirically supported clinical intervention. The guidelines developed by APA (Chambless &
Hollon, 1998) were the chosen yardsticks to assess the clinical efficacy
of hypnotherapy. The editor of the special issue (Nash, 2000) stated
that the advantage of adopting these general guidelines for this report

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

120

ASSEN ALLADIN ET AL.

is that it enables us to compare hypnosis empirical record of efficacy

with that of other therapeutic interventions (p.109). Six papers catalogued and critiqued the research literature in the areas of clinical hypnosis with children (Milling & Costantino, 2000), hypnotic analgesia
(Montgomery, DuHamel, & Redd, 2000), hypnosis as an adjunct to
cognitive-behavioral therapy (Schoenberger, 2000), hypnosis in medicine (Pinnell & Covino, 2000), hypnosis and smoking cessation (Green
& Lynn, 2000), and hypnosis in the treatment of posttraumatic stress
disorder (Cardea, 2000). A seventh paper by Lynn, Kirsch, Barabasz,
Cardea, and Patterson (2000) summarized the findings across the articles and made recommendations for future research.
The evidence drawn from this literature review continues to be relevant in the present climate of competition for health care dollars and
the existence of various effective cognitive-behavioral psychotherapies. It was considered essential to conduct controlled-outcome
research in order to validate the utility of clinical hypnosis, particularly
with children and adolescents. Because efficacy was considered to be
the gold standard, it is only through clinical validation that hypnosis
might be considered efficacious for a particular disorder or particular
group of clients. For example, a wealth of published case material has
provided anecdotal evidence suggesting that clinical hypnosis may be
helpful for many sorts of child psychological and medical problems.
Milling and Costantino (2000) believe the field of child hypnosis is in
an early stage of development and hence uncontrolled outcome studies and case observations can play an important role in pointing
toward useful avenues for investigation and methods of clinical practice (p. 114). So, too, can theoretical papers and case studies. However,
gold standard validation regarding children and hypnosis has yet to be
achieved.
In contrast to the paucity of controlled studies in child hypnosis,
hypnoanalgesia has been investigated empirically. Montgomery et al.
(2000) conducted a meta-analytic review of 18 articles and 27 effect
sizes to determine the effectiveness of hypnotic suggestions for pain
relief relative to other nonhypnotic psychological interventions. In
light of the positive findings, Montgomery and his colleagues recommended broadening the application of hypnotic procedures with pain
patients. Lynn and colleagues (2000) concluded that the fact that hypnosis can be considered a well-established treatment for pain should
go a long way to ensure that hypnotic interventions move into the
mainstream of first-line interventions for pain-related disorders and
conditions (p. 242).
An important consideration, however, in studying hypnosis from
an RCT/EST perspective relative to pain and other areas is that it is not
usually used as a stand-alone treatment. Currently, it is largely used as
an adjunctive technique that can be easily integrated with cognitive,

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

121

behavioral, or psychodynamic techniques. Although such integration

is feasible, it is questionable whether the inclusion of the hypnotic
modality increases the treatment effect of a particular combined therapy. Kirsch, Montgomery, and Sapirstein (1995) carried out a metaanalysis of 18 studies (1974 to 1993) comparing cognitive-behavioral
treatments (CBT) with the same treatments supplemented by hypnosis
to examine this issue. Their review found the mean effect size for the
CBT treatment supplemented by hypnosis to be significantly larger
than CBT alone. Similarly, Schoenberger (2000), in a more detailed
review, substantiated the additive value of hypnotic interventions
when combined with CBT. However, Schoenberger pointed out that
no hypnotically augmented CBT has as yet met the criteria for wellestablished treatment, although promising treatment gains have been
observed in relation to obesity, anxiety disorders, and pain management. She went on to say that since many CBT procedures are easily
conducted with hypnosis or simply relabeled as hypnosis, CBToriented clinicians with experience in hypnosis may easily establish a
hypnotic context as a simple, cost-effective means of enhancing treatment efficacy (p. 244). The challenge, however, even in the face of
some empirical validation, remains in distinguishing the characteristic
differences among hypnotic techniques, CBT, and other therapeutic
techniques. The study by Alladin and Alibhai (2007; in this issue)
addresses some of these issues.
Although hypnosis has been used in medicine from antiquity to the
present time, the review by Pinnell and Covino (2000) indicated that
currently there was only moderate support for integrating hypnotic
techniques into the treatment of medical problems. The reviewers indicate that wider acceptance of hypnotic intervention in medicine will be
contingent on further empirical research. Nonetheless, there is empirical evidence to support the effectiveness of psychological treatments
that include hypnotic interventions with preoperative preparation of
surgical patients, a subgroup of asthmatic patients (see Brown, 2007; in
this issue), certain dermatological disorders, irritable bowel syndrome,
postchemotherapy nausea and emesis, and with obstetrical patients.
However, it is unclear whether hypnosis adds anything to treatment
effectiveness above and beyond information, relaxation training, or
suggestions provided without a hypnotic induction (Pinnell &
Covino). In other words, the role of hypnosis and hypnotizability has
not been efficaciously determined. Pinnell and Covino argue that even
if in the future researchers are able to determine the additive effect of
hypnotherapy, it will be also important to determine the mechanisms
through which psychological and hypnotic interventions effect physiological changes. Although many hypotheses, including changes in
immune functioning, autonomic control of blood supply, and an
increased subjective sense of cognitive involvement and control, are

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

122

ASSEN ALLADIN ET AL.

advanced, the mechanisms are not understood. Cardeas (2000)

reference to The Hunting of the Snark reflects what we know about
hypnotherapy:
In The Hunting of the Snark, Lewis Carroll whimsically stated that any
statement becomes a fact if it is repeated three times. Much of what
passes for clinical lore is really just a set of statements that, repeated
over generations by mentors and authors, have become facts.
(p. 233)

The empirical status of hypnosis in the area of smoking cessation is

also fraught with methodological issues. From their review of 59 studies of hypnosis and smoking cessation, Green and Lynn (2000) concluded that hypnosis cannot, as yet, be regarded as a well-established
treatment for smoking cessation (p. 195). Although hypnotic procedures generally yield higher rates of abstinence relative to waiting-list
and no-treatment controls, the effects of hypnotic interventions are
generally comparable to a variety of nonhypnotic treatment. Moreover, the evidence for whether hypnosis yields outcomes superior to
placebos is mixed. Further, in many cases, it is impossible to determine
whether the treatment gains associated with hypnosis are related to
the hypnotic procedure or to cognitive, behavioral, or educational procedures. Nevertheless, Green and Lynn contend that, in the light of the
evidence available, it is justified to classify hypnosis as a possibly
efficacious treatment for smoking cessation. (p. 195). They recommend various methodological procedures for improving future
research and believe that future research will more firmly establish
hypnosis as an empirically supported treatment for smoking cessation and elucidate ways in which hypnosis can be combined with
other interventions to contribute to the health and well-being of our
society (p. 219).
Although hypnosis has been widely used with posttraumatic conditions, such as posttraumatic stress disorder (PTSD), and survivors of
sexual assaults and accidents, there have been almost no systematic
studies on the efficacy of hypnosis with posttraumatic disorders
(Cardea, 2000, p. 225). Cardea, after reviewing the literature on hypnosis and trauma, remarked that this
. . . state of affairs is especially disappointing considering that hypnosis
can be easily integrated into therapies that are commonly used with
traumatized clients; a number of PTSD individuals have shown high
hypnotizability in various studies; hypnosis can be used for symptoms
associated with PTSD; and hypnosis may help modulate and integrate
memories of trauma. (p. 225)

Cardenas observation does not suggest hypnosis is not effective

with posttraumatic conditions, he is indicating that the effectiveness of

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

123

a hypnotic treatment should be systematically established before it can

be declared as effective, under the criteria associated with purely
empirically supported status. Since this publication, further progress
has been made in the application of hypnotherapy with PTSD (see
Lynn & Cardea, 2007; in this issue).
Empirical Status Seeking
As reflected above, parallel to pursuit of empirically supported
status in psychology generally, hypnosis has subjected itself in particular to the rack of RCTs and the APA guidelines (Chambless &
Hollon, 1998). This effort, as reviewed above, has been less than successful. However, Amundson, Alladin, and Gill in 2003 argued that
perhaps limiting therapy in general and hypnosis in particular to
these narrow criteria may miss other equally compelling empirical
considerations.
In their argument, the authors identify effectiveness-focused research
as being 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). The emphasis here is upon the content of a
particular treatment. Replication is highly desired and hence guidelines, manuals, and standards of practice are emphasized. Effectiveness-focus 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; Cone, 2001; Luborsky,
McClellan, Diguer, Woody, & Seligman, 1997; Seligman, 1996). 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 on internal validity and how consumer benefit or gain is achieved,
effectiveness-focused research emphasizes external validity and is
driven by real-world factors. Amundson, Alladin, and Gill (2003)
argue that the concept of clinical effectiveness as a research-based
methodology may have a greater significance for the field of clinical
hypnosis. In fact, the authors caution that if EST and efficacy-focused
research becomes the exclusive fulcrum for treatment judgment, it is
possible that hypnosis could be at risk as a clinical practice (p. 13).
This argument is today reflected in contemporary APA science and
practice integration where effective practice is defined as application
and integration of the best available research with clinical expertise,
in the context of patient characteristics culture and preference (APA,
2006, p. 273). Frederick (2007; in this issue) has integrated some of
these issues in her treatment protocol for Obsessive-Compulsive
Disorder.

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

124

ASSEN ALLADIN ET AL.

EVIDENCE-BASED PRACTICE IN
PSYCHOLOGY/HYPNOTHERAPY
The APA Presidential Task Force on Evidenced-Based Practice in
Psychology-EBPP (APA, 2006) recently released its report on the
refinement of clinical practice. The Task Force and report arose from a
realization that empirical support for a particular approach to a particular problem (EST criteria and list-focused research) may be only one
element in any effective treatment. Efficacious treatment, it is their
finding, 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 (p. 275).
Clinical expertise has a rich history of empirical investigation. This
research based on what makes efficacious treatments effective involves
therapist activities related to:
Assessment, diagnostic judgment, systematic case formulation, and
treatment planning
Clinical decision making, treatment implementation, and monitoring of
patient progress
Interpersonal expertise
Continual self-reflection and acquisition of skills
Evaluation and use of research evidence
Understanding the influence of individual, cultural, and contextual differences on treatment
Seeking available resources as needed (e.g., consultation, adjunctive, or
alternative services)
A cogent rationale for clinical strategies (APA, 2006, p. 276278)

Clinical expertisethe ability to adequately execute the role/function of a therapistinvolves multiple complex skills that are associated with effective treatment. A model or approach per se is situated
within or serves as vehicle for acquirable skills, established through
research, which potentiate or make more effective a given empirically
supported treatment. Wittgenstein, the philosopher, once stated that it
impressed him very little when a man states he owns a trapeze artists
suit: he would wait to see to what use he puts it. So too might we state
that it impresses us less that a particular treatment approach has
attained EST status as we await its usefulness in the context of a particular patient.

IMPLICATIONS FOR CLINICAL HYPNOSIS

Evidence-Based Hypnotherapy Practice
Clarke (1995) suggested that a merging of the best treatment science
we have is likely to provide the most useful information about generic

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

125

change process. This proposition is also inherent in the Amundson,

Alladin, and Gill article from 2003. What this means for hypnosis can
be clearly stated. Empirical methods, research-informed practice, and
evidence-based treatment, if they are to be central to the practice of
clinical hypnosis, ought to be applied to both the content and process
of treatment.
Content empiricism involves determining efficacy: what are the simplest, most likely treatments to address a particular sort of difficulty in
a valid and reliable fashion. This position in hypnosis is reflected in the
proposition by Lynn et al. (2000) that it is timely for hypnosis to adopt
the initial APA Task Force criteria in evaluating and showcasing specific hypnotherapeutic treatments. The procrustean bed of RCT and
statistical evaluation has a place in clinical practice when debates
regarding mode, approach, or technique emerge. Secondarily, RCTs
guard hypnosis from unduly embracing bold and speculative theory
that is as yet unsubstantiated by treatment protocols. As stated in the
APA Presidential Task Force (2006):
It is important not to assume that interventions that have not yet been
studied in controlled trials are ineffective. . . . Nonetheless, good practice
and science call for timely testing of psychological practices [read: specific
hypnotherapeutic treatments] in ways that adequately operationalize them
using appropriate scientific methodology. (p. 274)

On yet another level, embracing standards associated with EST

links content empiricism (critical evaluation of claims for a specific
method) to process empiricism (critical attention to the ways treatment
of whatever sortis made more effective.
Process-related variables hold great promise for hypnosis. In
essence, process-focused research emphasizes domains associated with
clinical expertise: how to engage, to conceptualize, to strategize influence, to increase receptivity, to account for patient status, to promote
active participation, to formulate, to reflect, to evaluate, etc., in ways
associated with research on better outcome (Amundson & Gill, 2001).
Implications of Evidence-Based Hypnotherapy Practice for Research,
Training, and Practice
There are then very specific implications for clinical hypnosis in the
light of efficacy and effectiveness considerations and the current task
force position on EBPP. These professional considerations impact
training and professional education, research, clinical practice, and
hypnosiss responsibility to the public.
Regarding training and professional education in hypnotherapy,
there are specific ramifications regarding EBPP. If hypnosis is to
become a more legitimate component of professional training, it will
be important for trainers, teachers, students, or interns to:

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

126

ASSEN ALLADIN ET AL.

Appreciate the importance of empirically supported treatment protocols

in effective treatment
Appreciate the use of critical evaluation in limiting self or patient deception through theory-based or purely speculative models of treatment
Utilize empirical perspectives to treatment proper so that each case may
be considered an N of 1 in service to process and outcome effectiveness
Understand process researchappreciation of the skills associated with
better outcome generallyand see the relevance of such research to
advancing hypnotherapy
Learn to situate and to rationalize ones practice generally through content and/or process research
Continually review the literature and/or state of the art regarding
research of a critical nature
Neither succumb to undue romanticism (i.e., too much emphasis upon
the art and indeterminate aspects of treatment) nor scientism (i.e., too
narrow or limiting criteria related solely to efficacy)

Regarding research more generally, there are similar admonitions

for the field of clinical hypnosis. It would be axiomatic that: (a) as
definitively as possible, demonstrate replicability through controlled
studies and development of protocols for the use of hypnosis for particular disorders; however, (b) research ought to focus as well upon the
supraordinate areas of clinical expertise; (c) in the light of health care
concerns and cost-benefit emphasis, integration of both treatment
approaches proper and broader considerations about ways to make
treatment more effective, converge; (d) radical or unusual treatment
approaches or claimsan endemic aspect it seems of hypnotherapy
(Yapko, 1994)be explicated regarding not only ability to stand up to
RCTs but to appreciate what might make a nonefficacious treatment
(an approach that does not meet criteria for EST inclusion) effective
(able to achieve outcome in clinical observations or case studies).
For clinical practice, an evidence-based hypnotherapy would incorporate the principles associated with education and training in the light of:
Aspirations to ground all clinical activities in a research base, arising
from treatment specific empirical content and the principles associated
with processes related to clinical expertise
More pragmatic application of treatment in the light of research on outcome generally and case to case specifically
Promotion of hypnosis to the extent it serves patients best interests relative to outcome and economy

Finally, in regard to responsibility to society, empirical methods and

our research base ought to be brought to bear in order to:
Promote a prudent, even conservative, view of hypnosis regarding its
role in particular treatments

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

127

Counter or address representations of hypnosis that have yet to be

shown to be valid or reliable or that misrepresent what is known about
hypnosis

CONCLUSION
As with the initial empirical wave in psychology in general, so too
with hypnosis there is, at second glance, more than has met the eye. In
pursuit of inclusion of hypnosis within bona fide standards of
evidence-based practice there are both the particular empirical content
of given treatments and the process of effective treatment. Hypnosis has a
rich and both romantic and scientific past. It is our belief, in light of the
above consideration, that it can have a useful and beneficial future.
The current and next issue of this journal is devoted to evidence-based
hypnotherapy practice to illustrate that practitioners of hypnotherapy
take their field seriously and are not divorced from the trends and controversies surrounding psychotherapy.
REFERENCES
Alladin, A., & Alibhai, A. (2007). Cognitive hypnotherapy for depression: An empirical
investigation. International Journal of Clinical and Experimental Hypnosis (in this issue).
American Psychological Association (1995). Template for developing guidelines: Interventions for mental disorders and psychological aspects of physical disorders. Washington, DC:
Author.
American Psychological Association. (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57, 10521059.
American Psychological Association (2006). Evidence-Based Practice in Psychology.
American Psychologist, 61, 271285.
Amundson, J., Alladin, A., & Gill, E. (2003). Efficacy vs. effectiveness research in psychotherapy: Implications for clinical hypnosis. American Journal of Clinical Hypnosis, 46, 1129.
Amundson, J., & Gill, E. (2001). Psychotherapy as an N of 1. Psymposium, 11, 1315.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.
New York: Guilford.
Beutler, L. (1998). Identifying empirically supported treatments: What if we didnt.
Journal of Consulting and Clinical Psychology, 66, 113120.
Beutler, L. (2000). David and Goliath: When empirical and clinical standards of practice
meet. American Psychologist, 55, 9971007.
Beutler, L., Williams, R., & Enthwhistle, S. (1995). Bridging scientist and practitioner
perspectives in clinical psychology. American Psychologist, 50, 984994.
Borkovec, T. D., & Castonguay, L. G. (1998). What is the scientific meaning of empirically
supported therapy? Journal of Consulting and Clinical Psychology, 66, 136142.
Brown, D. (2007). Evidence-based hypnotherapy for asthma: A critical review. International Journal of Clinical and Experimental Hypnosis (in this issue).
Cardea, E. (2000). Hypnosis in the treatment of trauma: A promising, but not fully
supported, efficacious intervention. International Journal of Clinical and Experimental
Hypnosis, 48, 225238.
Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L., Calhoun, K. S., CritsChristoph, P., et al. (1998). Update on empirically validated therapies, II. Clinical
Psychologist, 51, 316.

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

128

ASSEN ALLADIN ET AL.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies.

Journal of Consulting and Clinical Psychology, 66, 718.
Chambless, D. L., Sanderson, W. C., Shoham, V., Bennett Johnson, S., Pope, K. S., CritsChristoph, P., et al. (1996). An update on empirically validated therapies. Clinical Psychologist, 49, 518.
Clarke, G. N. (1995). Improving the transition from basic efficacy research to effectiveness studies: Methodological issues and procedures. Journal of Consulting and Clinical
Psychology, 63, 718725.
Cone, J. D. (2001). Evaluating outcome: Empirical tools for effective practice. Washington, DC:
American Psychological Association.
Frederick, C. (2007). Hypnotically facilitated treatment for Obsessive-Compulsive Disorder: Can it be evidence-based? International Journal of Clinical and Experimental Hypnosis (in this issue).
Garfield, L. (1996). Some problems associated with validated forms of psychotherapy.
Clinical Psychology: Science and Practice, 3, 218229.
Goldfried, M. R., & Wolfe, B. E. (1996). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66, 143150.
Green, J. P., & Lynn, S. J. (2000). Hypnosis and suggestion-based approaches to smoking
cessation: An examination of the evidence. International Journal of Clinical and Experimental Hypnosis, 48, 195224.
Henry, W. P. (1998). Science, politics, and the politics of science: The use and misuse of
empirically validated treatment research. Psychotherapy Research, 8, 126140.
Hubble, M., Duncan, B., & Miller, S. (1999). The heart and soul of psychotherapy: What works
in psychotherapy? Washington, DC: American Psychological Association.
Hunsley, J., Dobson, K. S., Johnston, C., & Mikail, S. F. (1999). Empirically supported
treatments in psychology: Implications for Canadian professional psychology.
Canadian Psychology, 40, 289302.
Jacobson, N. S., & Christensen, A. (1996). Studying the effectiveness of psychotherapy:
How well can clinical trials do the job? American Psychologist, 51, 10311039.
Kazdin, A. E., & Bass, D. (1989). Power to detect differences between alternative treatments in comparative psychotherapy outcome research. Journal of Consulting and
Clinical Psychology, 57, 138147.
Kirsch, I., Montgomery, G., & Sapirstein, G. (1995). Hypnosis as an adjunct to cognitivebehavioral psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 214220.
Luborsky, L., & DeRubeis, R. J. (1984). The use of psychotherapy treatment manuals: A
small revolution in psychotherapy research style. Clinical Psychology Review, 4, 514.
Luborsky, L., McClellan, A. T., Diguer, L., Woody, G., & Seligman, D. A. (1997). The psychotherapists matters: Comparisons of outcomes across twenty-two therapists and
seven patient samples. Clinical Psychology: Research and Practice, 4, 5356.
Lynn, S. J., & Cardea, E. (2007). Hypnosis and the treatment of posttraumatic conditions: An evidence-based approach. International Journal of Clinical and Experimental
Hypnosis (in this issue).
Lynn, S. J., Kirsch, I., Barabasz, A., Cardea, E., & Patterson, D. (2000). Hypnosis as an
empirically supported clinical intervention: The state of the evidence and a look to
the future. International Journal of Clinical and Experimental Hypnosis, 48, 239258.
Milling, L. S., & Costantino, C. A. (2000). Clinical hypnosis with children: First steps toward
empirical support. International Journal of Clinical and Experimental Hypnosis, 48, 113137.
Montgomery, G. H., DuHamel, K. N., & Redd, W. H. (2000). A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and
Experimental Hypnosis, 48, 138152.
Nash, M. R. (2000). The status of hypnosis as an empirically validated clinical intervention: A preamble to the special issue. International Journal of Clinical and Experimental
Hypnosis, 48, 107112.

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

EMPIRICAL VALIDATION IN HYPNOTHERAPY

129

Ollendick, T. H. (1999). Empirically supported treatments: Promises and pitfalls. Clinical

Psychologist, 52, 13.
Persons, J. B., & Silberschatz, G. (1998). Are results of randomized controlled trials useful
to psychotherapists? Journal of Consulting and Clinical Psychology, 66, 126135.
Pinnell, C. M., & Covino, N. A. (2000). Empirical findings on the use of hypnosis in medicine: A critical review. International Journal of Clinical and Experimental Hypnosis, 48,
170194.
Schoenberger, N. E. (2000). Research on hypnosis as an adjunct to cognitive-behavioral
psychotherapy. International Journal of Clinical and Experimental Hypnosis, 48, 154169.
Seligman, M. E. P. (1996). Science as an ally of practice. American Psychologist, 51,
10721079.
Silverman, W. H. (1996). Cookbooks, manuals, and paint-by-numbers: Psychotherapy in
the 90s. Psychotherapy, 33, 207215.
Stricker, G., Abrahamson, D. J., Bologna, N. C., Hollon, S. D., Robinson, E. A., & Reed,
G. M. (1999). Treatment guidelines: The good, the bad, and the ugly. Psychotherapy,
36, 6979.
Thorne, F. C. (1947). The clinical method in science. American Psychologist, 2, 159166.
Wampold, B. E. (1997). Methodological problems in identifying efficacious psychotherapies. Psychotherapy Research, 7, 2143.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings.
Mahway, NJ: Erlbaum.
Yapko, M. (1994). Suggestibility and repressed memories of abuse: A survey of psychotherapists beliefs. American Journal of Clinical Hypnosis, 36, 163171.

Was wir unter empirischer Validierung in der Hypnosetherapie verstehen

sollten: Evidenzbasierte Praxis in Klinischer Hypnose
Assen Alladin, Linda Sabatini und Jon K. Amundson
Zusammenfassung: Diesel Artikel gibt einen berblick ber die
Entwicklung und die Kontroverse um empirische Validierung in der
Psychotherapie. Die empirische Validierung der Hypnosetherapie verlief
parallel zur Validierungspraxis im Bereich der Psychotherapie und zur
Professionalisierung der klinischen Psychologie im Allgemeinen. Diese
Entwicklung der Ausarbeitung von Kriterien fr gute klinische Praxis verlief
ausgehend von den theoriegeleiteten klinischen Anstzen in den 60er und 70er
Jahren ber die kritischen Anstze zur Kategorisierung von empirisch
gesttzten Therapien in den 90er Jahren hin zum Konzept der Evidenzbasierten
Praxis im Jahr 2006. Die Implikationen dieses Verlaufs in der professionellen
Psychologie werden im Hinblick auf die gegenwrtigen Bestrebungen nach
Validierung und empirischer Akkreditierung der Hypnose besprochen.
RALF SCHMAELZLE
University of Konstanz, Konstanz, Germany
Ce que devrait signifier validation empirique en hypnothrapie:
Pratiques fondes sur lexprience en hypnose clinique
Assen Alladin, Linda Sabatini et Jon K. Amundson
Rsum: Cet article examine brivement la tendance avoir recours la
validation empirique en psychothrapie et la controverse suscite par cette
mthode. La validation empirique de lhypnothrapie a volu, en parallle

Downloaded By: [McMaster University Library] At: 18:10 10 May 2007

130

ASSEN ALLADIN ET AL.

avec la pratique de la validation en psychothrapie et avec la

professionnalisation de la psychologie clinique en gnral. La
dtermination de ce qui constitue une exprience concluante de pratique
clinique srieuse a beaucoup volu depuis les dernires dcennies, allant
des approches cliniques fondes sur la thorie qui avaient cours dans les
annes 1960 et 1970, des tentatives cruciales de catgorisation de thrapies
concrtes durant les annes 1990, jusquau concept de pratique fonde sur
lexprience clinique, en 2006. Les implications de cette progression du
domaine de la psychologie professionnelle sont discutes la lumire du
besoin actuel de validation et de reconnaissance empirique de lhypnose.
JOHANNE REYNAULT
C. Tr. (STIBC)
Cmo debemos interpretar la validacin emprica en la hipnoterapia?
La prctica basada en la evidencia en la hipnosis clnica
Assen Alladin, Linda Sabatini, y Jon K. Amundson
Resumen: Este artculo describe brevemente la tendencia y controversias
que rodean a la validacin emprica en la psicoterapia. La validacin
emprica en la hipnoterapia ha sido paralela a la prctica de validacin en la
psicoterapia y la professionalizacin de la psicologa clnica en general. Esta
evolucin para determinar qu cuenta como evidencia en la buena prctica
clnica ha pasado de enfoques clnicos basados en la teora en el decenio de
los 60s y 70s a intentos crticos de categorizacin de terapias con bases
empricas en los 90s al concepto de prctica basada en la evidencia en el
2006. Discutimos las implicaciones de esta progresin en la psicologa
profesional desde la perspectiva del movimiento actual de la hipnosis para
su validacin y acreditacin empricas.
ETZEL CARDEA
University of Lund, Lund, Sweden