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european journal oi ciinical hypnosis - volume five - issue three

Clinical Articles

THE USE OF HYPNOSIS IN BOOSTING THE EFFECT OF COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF CHRONIC FATIGUE
Author: Jeff Wailes

This study looks at the possible increase in the efficacy of Cognitive Behavioural Therapy (CBT) in the amelioration of the symptoms of Chronic Fatigue Syndrome (CFS) by the inclusion of hypnosis. Undertaken by a practising psychotherapist, the study Vi/as carried out in a clinic environment. The study took the form of quasi-experimental, pre-test/post-test design with two groups undergoing therapy and a third "control" group providing reports but not undergoing therapy. Of those undergoing therapy one of the two groups experienced hypnosis within the duration of the therapy. The study extended over twelve weeks. In addition all participants completed two Lifestyle Questionnaires. One completed prior to the onset of therapy and the other at the end of the twelve-week period. Comparison of qualitative and quantitative data gathered, during the study, suggests possible theories as to the links between fatigue and stress. The effects of stress on the potential exhaustion of physical resources essential to the efficient working of the endocrine and nervous systems leads on to an analysis of material from previous studies relating to the possible connection between dysfunction in the interplay between the Hypothalamus, Pituitary and Adrenal glands (the HPA axis) and CFS. The resulting data illustrates that those participating in therapy reported increased energy levels following treatment. Those within the control group showed little or no improvement. However, there was only marginal difference in increased energy level between those receiving hypnosis within their therapy and those that did not.

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european journal ot clinical hypnosis - volume five - issue three

BACKGROUND
The National Task Force on Chronic Fatigue Syndrome (1994) states that fatigue is, now, recognised by the medical authorities as one of the major health issues of our time, yet there is little known of its cause or effective treatment. The debate as to whether Chronic Fatigue Syndrome is purely physical, purely psychological or psychophysiological in nature will no doubt rage for years. In the meantime sufferers find little real help in minimising the effects of this illness. This study looks at some of the theories regarding fatigue and describes a qualitative research programme assessing the effectiveness of a Hypno/ Cognitive Therapy. It should be noted that this research programme is seen as a developmental process and. therefore, ongoing It was always thought, therefore, that it was likely that any number of additional questions could be raised as the study unfolded. As important as the answer to the main question is an underlying need to continually improve knowledge and information that may guide the practitioner to improved levels of effectiveness. Over a period of three years, commencing in 1996, a number of clients at Tyringham Naturopathic Clinic suffering chronic fatigue were referred for psychotherapy. The majority had been diagnosed by their GP as suffering from CFS others described themselves as having absolutely no energy. The therapy offered usually consisted of 2 one-hour sessions of Cognitive Behavioural Therapy and Hypnosis. Initial results from the treatment sessions suggested that these sessions offered at least some short-term relief. Even more encouraging were reports from clients that long-term improvements in mood and energy seemed to be taking place. There are many questions raised by the reported successes. Firstly, we have to acknowledge that the clients went through a variety of therapies whilst at Tyringham. In addition to the psychotherapy, other therapies offered to clients would include a detoxification diet regime, relaxation through visualisation techniques, osteopathy and graded exercise. There are claims from a variety of sources that some of these techniques may have a positive effect in the treatment of fatigue. For instance relaxation and graded exercise are both cited as being helpful for CFS sufferers (Fulcher, 1997). We are. therefore, left with a number of questions regarding the Tyringham experience. Was it the combination of the various therapies experienced by

patients that was at the root of the improvements? What value can be attached to the contribution of the psychotherapy toward the overall health improvement of these clients? The influence of hypnosis in a variety of psychophysiological disorders is well documented, especially those linked to stress and depression (Yapko, 2001). The question posed in this study was, therefore, designed to expand on the existing research into the effectiveness of CBT by introducing the potentially beneficial effects of hypnosis. When one considers the difficulties in presenting CBT to severely fatigued individuals with limited attention span, delivering such therapy in a deep relaxation mode might be seen as a logical step in helping those suffering with CFS.

AETIOLOGY
The cause of CFS is still a mystery, indeed there are concerns that the CFS umbrella is far too large in definition to be useful. New diagnosis criteria were set down in what is now termed the Oxford Criteria (Sharpe et al, 1996). These new criteria attempt to separate CFS and Post Viral Fatigue Syndrome the latter having a recognised causality link to earlier viral infection such as glandular fever. The symptoms of CFS are many and overlap with other illnesses including depression, chronic stress, hormone dysfunction to name but a few. The National Task Force on CFS (1994) suggested the following criteria in diagnosing CFS: Persistent (excess of 6 months) debilitating fatigue not resolved with bed rest. The fatigue must be severe enough to impair daily activity to below 50% of the patient's pre-illness level. The National CFS Task Force produced a report detailing many aspects of CFS research (NTF report, 1994) and included the following statement:"Chronic fatigue appears not to fit neatly into the conventional view that disease is either physical or psychological. Instead, the holistic concept of disease as a disorder of the whole person, body, mind and spirit, provides a better model for the chronic fatigue syndromes." The report goes on to suggest that the boundaries of physical and psychological disease are becoming blurred as understanding of the interplay between endocrine and neurological systems become apparent. The physical effects of depression and chronic stress are prime examples of the interplay

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between mind and body (Rossi, 1993). Indeed the correlation between chronic stress leading to HPA dysfunction and the onset of chronic fatigue is becoming a major focus for research (Demitrack, 1991) (Kavelaars et al, 1998). It seems also possible that stress caused by unhelpful thinking may be alleviated by cognitive therapy, relaxation through visualisation and exercise (McNammara,1997). From these concepts it seems appropriate to consider realignment of thinking and core beliefs through the use of CBT as potentially beneficial to those with CFS. Previous research (Sharpe 1996) points to the effectiveness of CBT in treating CFS. Adding hypnosis to the treatment regime may be beneficial in increasing the learning taken from such CBT sessions. For the purposes of this study the state of hypnosis is one in which the individual experiences deep relaxation and an altered state of consciousness. The induction of the hypnotic state initiated through the use of imagination and visualisation, suggested as effective in unlocking the power of the mind (Hilgard, 1977). As hypnosis utilizes the client's own imagination it may be suggested that this may increase the effectiveness of the treatment, an important concept utilised in Eriksonian hypnosis (Erickson 1964). There is a body of research suggesting a strong link between changes in behaviour, thinking style and suggestion delivered within a state of hypnosis (Hilgard, 1977). Full explanation of the therapy content is given in the text of the full research report.

ability to cope with daily activities before, during and after the therapy sessions; in this way giving a guide to their fatigue status throughout the study. To monitor any changes in self-esteem and ongoing stress levels all participants completed the Lifestyle Questionnaire on two separate occasions, on commencement of the study and at the end of week twelve. The objective of this was to identify changes in the participants' feelings of self-worth and susceptibility to stress. Kreger (1995) suggests links between stress, perception of control of life's events and levels of self worth. It was therefore felt important that these issues be monitored. Participants were randomly allocated to three separate groups: "A" receiving CBT and hypnosis, which we shall call Hypno-Cognitive Therapy. 'B' received CBT only. "C" purely completed the documentation. CBT consisted of three, sixty-minute sessions. Qbjectives of the sessions were the progressive reduction of the overall psychological stress and developing a rational acceptance of the prognosis of the illness. Underlying, unhelpful belief patterns (Yankora & Dryden, 1990) identified prior to or during therapy were also addressed during the sessions. Homework in the classic CBT tradition (Dryden, 1996) was given and self-help exercises provided as necessary. In the hypno-cognitive sessions 30 minutes were confined to the delivery of suggestion under hypnosis.The classical hypnosis method, fully described in Hartland's Medical and Dental Hypnosis (Waxman, 1998), was used throughout.

METHODOLOGY
A randomised, pre/post therapy energy level Results questionnaire approach was the chosen research Percentage change in mean energy levels within strategy. This was supplemented with Lifestyle groups: Questionnaires taken before commencement of and at the end of the study. In addition to these, research Group n Lowest Highest Range Mean tools data was gathered in the form of notes taken A 42.380 5 8.870 33.51 22.696 during the therapy sessions. The duration of the B 5 40.330 39.610 22.404 0.720 study was twelve weeks. This allowed three weeks of C 4 4.710 6.570 1.610 -1.860 data collected prior to the intervention leaving six weeks available for data collection post therapy. The figures shown represent the mean of the energy levels
reported in each group collected from the participant's diary

The study took place in the natural environment of each of the participants and within each therapy session with the therapist. Participants reported their energy levels on a twice daily basis, using a proforma provided. The energy diaries provided an indication of the participants'

sheets.

The numerical data shows only marginal difference in percentage energy improvement between group 'B' (22.404%) and group 'A' (22.696%). The change in energy levels within the control group was negligible at 1.610%.

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european journal ot clinical hypnosis - volume five - Issue three

It is interesting to note a strong correlation ( 0.725) between stress index and self-worth index. This would tend to bear out previous work undertaken by Seligman (1984). During the course of the study a great deal of qualitative data was also collected. Included in this was a range of core belief statements used by participants. The frequency of use is shown below:
SCALE BANDS Statement Relaxing is difficult Achieving is important Self critical Control is important Nervous in company Others opinions are important Inferior to others 1 can never do enough Unable to meet demands of others 1 question own judgement Being top is paramount Embarrassed when praised Deleqation is difficult Keep feelinqs to self Defer to others wishes Hide emotions 1 0 3 2 4 2 3 3 10 low=not like me 1-3 2 3 0 0 2 0 4 0 0 4-7 3 3 1 2 1 2 0 1 0 8-10 9 8 14 12 11 12 10 13 14

There may of course be particular reasons for this result. One such cause is the so called Placebo effect. Surveys into the use of placebos (the replacement of medication with something of similar appearance but medicinally inert) have been repeated many times. Figures reported in Rossi (1993) show that studies undertaken in 1959 (Beecher) and again in 1985 (Evans) indicate that 36yo of patients reported pain relief following the use of placebos. Rossi (1993) goes on to say that the placebo effect, having been demonstrated across a wide range of medical problems, may be a general ingredient of many clinical situations and also contributes to improvements in medical condition. "The consistent placebo response suggests there is a common, underlying mechanism that accounts for mind-body healing, regardless of the problem" (Rossi,1993). We should be aware of the fact that in many forms of psychotherapy the use of suggestion is a part of that therapy. Indeed, in the case of hypnosis we are dealing almost exclusively with suggestion. This last point might well raise an interesting question. What Rossi proposes is that there is always some form of placebo effect in clinical situations. Placebo is formed by suggestion, as is hypnosis and this might, therefore, explain why there was little difference between the two groups. The placebo effect may have effectively minimized the benefit of hypnosis. It would appear that there seems to be a fairly strong case for taking placebo effect seriously. Just how this could be controlled in any future research needs careful consideration. Just how much these findings can be extended to the wider population is a matter to be considered by each practitioner that may be tempted to adopt a similar approach to their own clients experiencing CFS. It would seem that the suggestibility of the individual should be considered before discussing the possible effectiveness of hypnosis. However, those knowledgeable in CBT might wish to consider looking into how they may help those with CFS. As to the possibility of further research in this area, it might appear that more questions have been raised than answers found. In some respects this could be seen as a very positive result. As we continue to ask the questions then hopefully we continue to learn more of the issues raised and therefore become more effective in bringing help to those most in need.

2
4 4 2 5 1

12 7
8 8 7 10

The figures show the frequency of occurrence of that phrase within the Lifestyle questionnaire. Please note that the

maximum occurrence has to be 14 as this was the number of participants.

The most frequently occurring self-descriptive phrases fall into high achievers, high stress type individuals as described within Seyles GAD principles (1978). Phrases implying low self-worth also seem to be high in frequency. DISCUSSION The data from the study leads us to a conclusion that there was little difference in improvement of energy levels between those receiving purely CBT and those whose therapy included hypnosis. It would be apparent therefore that although the results support the adoption of CBT in the treatment of CFS the inclusion of hypnosis is of little help. Yet it should be noted that a member of group 'A' and therefore receiving therapy under hypnosis showed the biggest single improvement, a 42.38 percent increase over the pre-therapy mean value.

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REFERENCES Demitrack, M. (1991): Evidence of Impaired hypothalamic. pituitary, adrenal axis in CFS, J Clin Endocrinol IVletab, USA. Dryden, W, (1996): Handbook of Individual Therapy- London: Sage, Dryden W, Palmer S, (1995): Counselling for Stress Problems. London Sage, Erickson, M, (1964): Confusion Technique of Hypnosis, American Journal of Hypnosis 6, 183-207 Fulcher. (1997): Randomised trial of graded exercise In patients with CFS, British Medical Journal Hilgard, E,R, (1977): Divided Consciousness Multiple Controls in Human Thought and Action. New York: Wiley & Sons. Kavelaars, A, Kuis, W, Knook, L. Sinnema. G. Hejjnen ,C J, (1998): HPA Dysfunction. University Medical Centre Utrecht, The Netherlands Kreger D.W, (1995): Self-esteem, stress, and depression among graduate students, reported in American CFS Association Journal. New Jersey, NTF. (1994): Report on Chronic Fatigue Syndrome, Westcare Dept of Health, London,

Rogers, C,R, (1951): Client Centred Therapy 51-56. London: Constable. Rossi, E L , (1993) The Psychobiology of Mind-Body Healing. New York: Norton, Seligman M,, (1984): Attributional Style and Depression. American Journal of Abnormal Psychology, Selye, H, (1978): The Stress of Life. New York: Me Gow-Hill. Sharpe, M, et al, (1996): Cognitive Behavioral Therapy for CFS. a Randomised controlled trial, BMJ 312:22-6 Weitzenhoffer, A,M, (1989): The Practice of Hypnotism. New York: Wiley and Son, Yankora J. Dryden W, (1990): Doing RET Albert Ellis in Action, New York: Springer, Yapko, M.D, (2001): Treating Depression with Hypnosis. Philadelphia: Routledge. Background information National CFS Association, notes from lectures on causality and therapy. Research and Methods in Social Relations Judd C M , , Harcourt, NY Real World Research, Robson C, Blackwell, Oxford,

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