Where Is The Evidence Base For Evidence Based Hypnotherapy?
Posted on November 26, 2009 in Hypnosis, Hypnotherapy Training | 4 Comments
Todays blog post is not really for anyone other than hypnotherapists, therapists, trainers in these fields or related fields… I need to get something off mychest…
Those of us in the hypnotherapy field, especially us hypnotherapy trainers have noticed a shifting trend in our field recently… There is muchmore demand for advancing a scientific basis for hypnosis and hypnotherapy.
Recent articles in Newsweek and recently the Washington Post in the US have filtered there way over here and have advised therapy consumers that their therapist better be using techniques that have been “scientifically proven” to be effective. If not, the therapist may be behind the times, misinformed, or worst of all unethical.
I wanted to have a reality check for a moment today… I am in favour in putting the field of hypnotherapy under the microscope, don’t get me wrong and heck, just last week I wrote up a long list of hypnotherapy and hypnosis studies that gave this field a huge amount of credence and credibility…
Let’s look at the reality of things though… What the proponents of evidenced based treatment are talking about is randomised placebo controlled studies of treatment modalities. For example, take a population of patients with a simple phobia. Randomly assign them to three treatment categories: a placebo, a drug treatment or exposure therapy. See which group does best, and there’s your science, your evidenced based treatment. Let’s imagine, hypothetically but not improbably, that the results of the well run, placebo controlled, randomised study show that exposure therapy is most effective for the most people suffering from a simple phobia.
Keep in mind that in this hypothetical population, there is a minority for whom exposure therapy, at least in the conditions of the study, is not effective.
So now a imagine a client comes along – let’s say a 30 year old man- to see their GP, the hypnotherapist, psychologist, psychiatrist, or even a psychoanalyst (god forbid). He has a simple phobia. He also has some obsessive compulsive disorder, low self-esteem, and even some low level depression within the mix, and just went through a messy divorce. He describes his work life as deeply dissatisfying. He feels, in some vague way, that he is different from other men of a similar age to him… This is not hugely untypical of the clients I see in my consulting rooms.
What does the clinician who does not live in the cleanly dichotomous world of health policy and enthusiasts for evidence based randomised control studies do now?
Surely you treat the client, not a symptom or a set of disorders, no? Ideally, I believe, with a mix of approaches that fluidly adapts itself to the needs and capacities of the client at any given moment. I am a hypnotherapist and an NLP practitioner among other things, and I know that gradual exposure is one of the best ways to treat a phobia.
I would consider myself quite ridiculous if I decided to do some anchoring for that (though I have heard some people doing such)…. Now on the other hand, I also know that problems related to low self-esteem, whatever that may mean to an individual client, can be complex, subtle, pervasive and potentially crippling in life… And that going through divorce may affect ones belief in their own ability to have successful relationships and I might indeed recommend something different to this client…
Once again, I find myself wanting to plead, can’t we live with complexity and layers and multiple possibilities and nuance in mental health care, and avoid the dangers and false comforts of simple-simplistic-dichotomies. Like the tempting but false dichotomy, there is evidience or there is not evidence. Are things quite as black and white as that?
I understand and appreciate the scientific method, and value the data obtained by systemic, well designed studies with appropriate controls. But of necessity, these studies can generally test one element of a real person in real life, and their results must be used appropriately, in the context of a larger and more complex picture.
And by the way, can someone point me to the evidence basis that underlies the propositions that evidenced based studies are the best way to reach policy and clinical decisions that help people the most? What’s the control group? ;-)
Absolutely agree. I’ve had 3 clients come in on the same day who booked for the same reason but the sessions I did with them were all different because they were 3 different people who had 3 different life experiences, beliefs and ways of processing information. If I’d done the same thing with all 3 then it wouldn’t have worked for 2 of them.
Posted by Sharon Stiles on 29th November, 2009 at 12:16 am.
Thank you Sharon – really good hearing from you :-)
Posted by Adam Eason on 30th November, 2009 at 9:02 am.
I think you have misunderstood evidence-based practice Adam. Evidence-based practice blends the best clinical research evidence, WITH the therapist’s own clinical experience AND the wishes and preferences of the client. That provides lots of space for individual, creative and experimental approaches – and keeps responsibility with the clinician.
However surely we have a requirement as therapists (and especially as trainers) to be up to date with clinical AND experimental research.
Also there is distinction between efficacy and effectiveness. Efficacy relates to measurements of improvement in ideal conditions. Effectiveness relates to measurements of improvement in real world conditions.
That goes some way to answering you question in the last paragraph – but with regard to whether studies showing real world effectiveness are a good basis for making policy and clinical decisions for a population – we can only talk about probabilities. However what is the alternative? Letting any doctor or therapist just do want they “feel” is right? With taxpayers money?
A therapist who uses only their own experience as evidence puts their clients at a disadvantage to one who blends their own experience with clinical effectiveness results in randomised control trials. There’s an amazing study which showed that experienced psychotherapists are no more effective that novice psychotherapists. To me that is a SHOCKER which we should all burn into our brains. There is a huge capacity to delude ourselves that we are getting better as therapists when all we are doing is distorting and sifting the evidence to fit our practice and chosen treatments.
I’m against completely heavily manualised treatments (for x do y) but even more against therapists being ignorant of best practice and ignoring the research. That’s one of the reasons the hypnotherapy profession is so fragmented and unprofessional.
To Sharon I’d have to ask the question: how do you know if you’d have used the same protocol that the results wouldn’t have been equally successful? You might say that is based on your experience – i.e. your evidence of clinical effectiveness. So it is a sort of evidence-based approach.
(Also even a heavily manualised CBT approach aims to map out the individual dysfunctional beliefs and appraisals).
Blending clinical experience with latest research results is an ongoing challenge that keeps a therapist constantly questioning their whole theoretical and pragmatic approach. They realise they may have learned theories and practice that just don’t hold up… and they have to change. That’s a good thing. Clients expect us to know what works – not just in our experience – but in the broader world of practice.
Great blog BTW!
Posted by Mark Davis on 19th December, 2009 at 7:34 pm.
Hello Mark,
Thank you for your contribution here, it is very much appreciated.
Firstly, let me say that I consider myself to be a heavy proponent of evidence-based practice and I have worked as an evidence based practitioner for years. I agree with what you have said here.
We have a legal duty of care, I work closely with informed consent principles and employ modern research findings inherently throughout my work – much of the printed research from the IJECH makes its way to this blog and to my students via my members area and I am very particlar to include such principles as those you have mentioned here in my own trainings.
I actually think you have misunderstood the ethos behind my post here. I was asking some questions about the notion of evidence based practice, and discussing it. Not just taking it as given, my belief is that it is incredibly important to do (rather than always taking for granted everything we do and how we are in therapy as right, correct and without flaws). I think often in therapeutic circles, people just tend to take on board the entire set of fundamental beliefs and strategies that their trainer offers up and they believe in much the same without question.
I teach many principles of NLP, yet I find it incredibly important to point out where research has found techniques and strategies from the field of NLP to be flawed or wrong assumptions made, for example.
Though whilst we champion the notion of being evidence based in our work, as is a large trend on the therapy community of the last 10-15 years or so (thank goodness) – I was (albeit rather ironically) questioning the rationale for evidence based therapy… And (albeit even more ironically) questioning if there was any evidence to suggest that evidence based therapy had more efficacy than non-evidence based therapy.
A large number of psychotherapy techniques nowadays are characterised by their fans as “evidence-based.” This sounds good, and most people have heard it enough to recognise that “evidence-based” must be something better than “not evidence-based”. Evidence is something you have to have for success in court, and none of us would want to be such fools that we believed everything without any evidence at all. But exactly what does evidence have to do with psychotherapy?
During the last 15 years or so, a movement in the medical world began to emphasise the need for appropriate research to show that treatments were effective– that they actually accomplished what they were intended to do. The thrust of this movement for evidence-based medicine was that treatment for disease or injury should focus on the methods with the best indications of past success, not on anyone’s personal preference, tradition, or old habits. From the medical world, the idea of using methods supported by good research evidence came into psychology as well. Evidence-based practice has become a goal in many fields.
But there are very few treatments such that we could say, “this one has perfect evidence supporting it; that one has no evidence at all. The first one is evidence-based, the second one is not.” This is because there are many kinds of evidence that we could bring into a discussion about the effectiveness of a treatment. Even the much-maligned testimonial is evidence of a sort, although not a very convincing sort. In fact, we need to think not just about the amount of evidence for a treatment, but for the kind of evidence: what is called the “level” of evidence, as we rank different kinds of evidence from the very powerful to the very weak.
Professionals working in medicine, psychology, public health, and a number of other fields have generated a number of ideas about the factors that make for a high or a low level of evidence. Generally, authors agree that research evidence involving randomised controlled trials is the most compelling of all, because randomisation ( the assignment of people to treatments on the basis of numbers alone, not because of their individual characteristics) does all we can do to exclude the confusion of confounding variables, that might make us think a treatment was effective when it was not. Under the many circumstances that make randomisation impossible, the best approach might be clinical controlled trials, where individual wishes or circumstances place people in one or another of the treatment groups— but these arrangements can make it difficult to know whether a treatment that worked for the kind of person who chooses it would also work for other people.
I have been part of lengthy discussions recently where it was suggested that treatments supported by randomised controlled trials should be designated “evidence-based”, and those supported by clinical controlled trials termed “evidence-supported”. Both of these are high levels of evidence, and with respect to psychotherapy, we need to remember that randomisation can be very difficult to do. It was also suggested that a classification for treatments that were supported only by case studies or by other studies with various weaknesses: these would be called “evidence-informed”. They even created a fourth category, “belief-based”, for methods that were based on a theory or assumption but which had no usable research evidence to support them. Finally, they added the category “Potentially harmful interventions” for those that had shown evidence of injury or worsening of symptoms to persons receiving treatment, or that had manuals or other materials suggesting the possibility of harm, though there would be lots of heated discussion, wouldn’t there? I mean, lots of people would consider we have a duty of care and in line with informed consent principles should be advising clients of false memory syndrome issues related to regression therapies or purposely inducing abreaction, yet others use this as their main modailty on therapy.
These basic characteristics of different levels of evidence are not the only things required before a treatment can be called “evidence-based” or categorised in another way, according to may. For the higher levels, the research supporting the treatment would have to be replicated independently– that is, by researchers who did not have the personal interest that the initial investigators usually have. There would need to be a manual for the intervention, or some other way of assuring intervention fidelity (that the treatment is carried out in the same way each time). Evaluation would need to be done “blind”, with testers who are ignorant of the treatment an individual is receiving, so their assessments are not affected by their expectations. Statistical analyses would have to follow the rules agreed upon by researchers. In other words, the research and the reports of its results would all have to be done correctly before they were considered to be helpful in deciding whether a treatment was “evidence-based” or should be categorised differently.
Mark, when it comes to evidence based therapy or treatment, I think I understand what it is… None the less, I like to question these things on a regular basis… Not just the factual evidence itself, but the stance of it and the underlying philosophy that evidence-based notions are the way forward.
I certainly do not advocate experience-only as a way forward and of course there must be balance and a combination, but I also think it healthy to question assumptions that inherently exist within how we work and what we believe about our work.
Thanks again, A.
Posted by Adam Eason on 21st December, 2009 at 7:43 am.