The Use of Hypnosis in Boosting the Effect of Cognitive Behavioural Therapy in the Treatment of Chronic Fatigue

8/2/2019 The Use of Hypnosis in Boosting the Effect of Cognitive Behavioural Therapy in the Treatment of Chronic Fatigue

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european journal oi ciinical hypnosis - volume five - issue three Q

Clinical Articles

THE USE OF HYPNOSIS INBOOSTING THE EFFECT OFCOGNITIVE BEHAVIOURAL

THERAPY IN THE TREATMENTOF CHRONIC FATIGUE

Author:Jeff Wailes

This study looks at the possible increase in the efficacy of Cogni t ive Behavioura l Therapy (CBT) in thameliorat ion of the symptoms of Chronic Fatigue Syndrome (CFS) by the inclusion of hypnosis. Undertakenby a practising psychotherapist, the study Vi/as carried out in aclinic environment.The study took the form of quasi-experimental, pre-test/post-test design with two groups undergoing therapyand a third "control" group providing reports but not undergoing therapy. Of those undergoing therapy one ofthe two groups experienced hypnosis within thedurat ion of the therapy. The study extended over twelvewe eks. In addition al l part ic ipants co mpleted tw o Lifestyle Que stionnaires. On e com pleted prior to the onset oftherapy and the other at the end of the twelve-week period.Comparison of quali tat ive and quanti tat ive data gathered, during the study, suggests possible theories as tothe links between fatigue and stress. The effects of stress on the potential exhaustion of physical resourcesessential to the efficient working of the endocrine and nervous systems leads on to an analysis of material fromprevious stud ies re la t ing to the possib le connect ion between dysfunct ion in the in terp lay between theHypothalamus, Pituitary and Adrenal glands (the HPA axis) and CFS.The resulting data il lustrates that those participating in therapy reported increased energy levels followingtreatment. Tho se within the control group show ed l i t tle orno improvement. However, there was only margina


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10 european journal ot clinical hypnosis - volume five - issue three

BACKGROUNDThe Nat ional Task Force on Chronic Fat igueSyndrome (1994) s ta tes that fa t igue is , now,recognised by the medical authorities as one of themajor health issues of our t ime, yet there is l i t t leknown of its cause or effective treatment. The debateas to whether Chronic Fatigue Syndrome is purelyphysical, purely psychological or psychophysiologicalin nature wil l no doubt rage for years. In themeantime sufferers find litt le real help in minimisingthe effects of this il lness.This study looks at some of the theories regardingfat igue and descr ibes a qual i ta t ive researchprogramme assessing the effect iveness of a Hypno/Cognit ive Therapy. I t should be noted that thisresearch programme is seen as a developmenta lprocess and . therefore , ongoing It was a lwaysthought, therefore, that it was likely that any numberof additional questions could be raised as the studyunfolded. As important as the answer to the mainquestion is an underlying need to continually improveknowledge and in format ion that may gu ide thepractit ioner to improved levels of effectiveness.Over a period of three years, com men cing in 1996, anumber of cl ients at Tyringham Naturopathic Clinicsuffering chronic fat igue were referred forpsychotherapy. The majori ty had been diagnosed bythe ir GP as suf fer ing f rom CFS others descr ibedthemselves as having absolutely no energy.The therapy offered usually consisted of 2 one-hoursessions of Cogni t ive Behavioura l Therapy andHypnosis. Initial results from the treatment sessionssuggested that these sessions offered at least someshort - term re l ie f . Even more encouraging werereports from clients that long-term improvements inmood and energy seemed to be taking place. Thereare many quest ions ra ised by the reportedsuccesses. Firstly, we have to acknowledge that theclients went through a variety of therapies whilst atTyr ingham.In addi t ion to the psychotherapy, o ther therapiesoffered to clients would include a detoxification dietregime, relaxat ion through visual isat ion techniques,osteopathy and graded exercise. There are claimsfrom a variety of sources that some of thesetechniques may have a posit ive effect in thetreatment o f fa t igue. For instance re laxat ion andgraded exercise are both cited as being helpful for

patients that was at the root of the improvements?What value can be attached to the contribution of thepsychotherapy toward the overa l l heal thimprovement of these cl ients?The in f luence of hypnosis in a var ie ty o f psycho-physio log ica l d isorders is wel l documented,especia l ly those l inked to s t ress and depress ion(Yapko, 2001).The quest ion posed in th is s tudy was, therefore,designed to expand on the existing research into theeffect iveness of CBT by introducing the potential lybeneficial effects of hypnosis. When one considersthe diff iculties in presenting CBT to severely fatiguedindividuals with limited attention span, delivering suchtherapy in a deep relaxation mode might be seen asa logical step in helping those suffering with CFS.A E T I O L O G YThe cause of CFS is stil l a mystery, indeed there areconcerns that the CFS umbrel la is far too large indefinition to be useful. New diagnosis criteria wereset down in what is now termed the Oxford Criteria(Sharpe et al, 1996). These new criteria attempt toseparate CFS and Post Viral Fat igue Syndrome thelatter having a recognised causality link to earlier viralinfection such as glandular fever.The symptoms of CFS are many and over lap wi thother i l lnesses including depression, chronic stress,hormon e dysfunct ion to nam e but a few. The NationalTask Force on CFS (1994) suggested the fol lowingcri teria in diagnosing C FS :Persistent (excess of 6 months) debi l i tat ing fat iguenot resolved with bed rest. The fat igue must besevere enough to impair daily activity to below 50% ofthe patient's pre-il lness level.The Nat ional CFS Task Force produced a reportdetai l ing many aspects of CFS research (NTF report,1994) and included the following statement:-"Chro nic fatigue app ears not to fit nea tly into theconventional view that disease is either physical orpsycho logical. Instead, the holistic conce pt ofdisease as a disorder of the whole person, body,mind and spirit, provides a better mode l for thechronic fatigue syndromes."The report goes on to suggest that the boundaries of


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european journal of clinical hypnosis - volume five - issue three 11

between mind and body (Rossi, 1993). Indeed thecorrelat ion between chronic stress leading to HPAdysfunct ion and the onse t of chronic fa t igue isbecoming a major focus for research (Demi t rack ,1991) (Kavelaars et al, 1998). It seems also possiblethat s t ress caused by unhelpfu l th ink ing may bealleviated bycogni t ive therapy, re laxat ion throughvisual isat ion and exercise (McNammara,1997).From these concepts it seems appropr ia te tocons ider rea l ignment of th inking and core bel iefsthrough the use of CBT aspotentially beneficial tothose with CFS. Previous research (Sharpe 1996)points to the effect iveness of CBT in t reat ing CFS.Add ing hypnos is to the t reatment reg ime may bebeneficial in increasing the learning taken from suchCBT sessions.For the purposes of this study the state of hypnosis iso ne in which the ind iv idual experiences deeprelaxation and an altered state of consciousness. Theinduction of the hypnotic state initiated through theuse of imaginat ion and visual isat ion, suggested aseffective in unlocking the power of the mind (Hilgard,1977). As hypnosis ut i l izes the cl ient 's ownimag ina t ion it may be suggested that th is mayincrease the ef fect iveness of the t rea tment , animportant concept ut i l ised in Eriksonian hypnosis(Erickson 1964).There is a body of research suggesting a strong linkbe tween changes in behaviour, thinking style andsuggest ion de l ivered wi th in a state of hypnos is(Hilgard, 1977).Full explanation of the therapy content is given in thetext of the full research report.M E T H O D O L O G YA randomised, pre/post therapy energy leve lquest ionnaire approach was the chosen researchstrategy. This was supplemented wi th L i festy leQuestionnaires taken before commencement ofandat the end of the study. In addition to these, researchtools data was gathered in the form of notes takenduring the therapy sess ions. The durat ion of thestudy was twelve weeks . This al lowed three weeks ofdata col lected prior to the intervention leaving sixweeks available for data collection post therapy.The study took place in the natural environment ofeach of the part ic ipants and wi th in each therapy

ability to cope with daily activit ies before, during andafter the therapy sessions; in this way giving a guideto their fat igue status throughout the study. Tomonitor any changes in sel f -esteem and ongoingstress levels all participants completed the LifestyleQues t ionna i re on two separate occasions, oncommencement of the study and at the end of weektwelve. The objective of this was to identify changesin the part ic ipants' feel ings of sel f -worth andsusceptibil ity to stress. Kreger (1995) suggests linksbetween stress, perception ofcontrol of l i fe's eventsand levels of self worth. It was therefore felt importantthat these issues be monitored.Part ic ipants were randomly al located to th reeseparate groups:"A" receiving C BT and hypnosis, which we shal l callHypno-Cognit ive Therapy.'B ' received CBT only."C" purely completed the documentat ion.CBT consis ted of three, s ix ty-minute sess ions.Qbject ives of the sess ions were the progress ivereduct ion of the overa l l psycholog ica l s t ress anddeveloping a rat ional acceptance of the prognosis ofthe i l lness. Underly ing, unhelpfu l be l ie f pat terns(Yankora & Dryden, 1990) identif ied prior to or duringtherapy were also addressed during the sessions.Ho me wo rk in the c lass ic CBT t rad i t ion (Dryden,1996) was given and self-help exercises provided asnecessary.In thehypno-cogni t ive sess ions 30minutes wereconf ined to the delivery of suggest ion underhypnosis .The c lass ica l hypnosis method, fu l lydescribed in Hartland's Medical and Dental Hypnosis(Waxman, 1998), was used throughout.ResultsPercen tage change in mean energy leve ls wi th ingroups:

GroupABC

n554

Lowest8.8700.720-1.860

Highest42.38040.3304.710

Range33.5139.6106.570

Mean22.69622.4041.610

The figures shown represent the mean of the energy levelsreported in each group collected from the participant's diarysheets.


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It is interesting to note a strong correlation ( 0.725)between st ress index andself-worth index. Thiswould tend tobear out previous work undertaken bySeligman (1984).During the course of the study a great deal ofqualitative data was also collected. Included in thisw a s a range of core be l ie f s ta tements used byparticipants. The frequency of use is shown below:

SCALE BANDSStatementRelaxing is difficultAchieving is importantSelf criticalControl is importantNervous in companyOthers opinions areimportantInferior to others1 can never do enoughUnable to meet demandsof others1 question own judgementBeing top is paramountEmbarrassed when praisedDeleqation is difficultKeep feelinqs to selfDefer to others wishesHide emotions

low=not like me

1- 32300204001032423

4 - 73312120103244251

8-1098

141 2111 21 01 31 41 0127887

1 0

The figures show the frequency of occurrence of that phrasewithin the Lifestyle questionnaire. Please note that themaximum occurrence has to be 14 as this was the number ofparticipants.

The most f requent ly occurr ing se l f -descr ip t ivephrases fal l into high achievers, high stress typeind iv iduals as descr ibed wi th in Seyles GADprinciples (1978). Phrases implying low self-worthalso seem to be high in frequency.DISCUSSIONThe data from the study leads us to aconclusion thatthere was litt le difference in improvement of energylevels between those receiving purely CBT and thosewhose therapy inc luded hypnosis . It wou ld beapparent therefore that although the results supportthe adopt ion of C BT in the t rea tment of CFS theinclusion ofhypnosis is of little help. Yet it should be

There may of course be part icular reasons for thisresu l t . One such cause is the so cal led Placeboeffect. Surveys into the use of p lacebos (thereplacement of medicat ion with something of similaappearance but medic ina l ly inert ) have beenrepeated many t imes. Figures reported in Ross(1993) show that s tud ies undertaken in 1959(Beecher) and again in 1985 (Evans) indicate tha36yo of patients reported pain relief following the useof placebos. Rossi (1993) goes on to say that theplacebo effect, having been demonstrated across awide range of medical problems, may be a generaingredient of many cl in ical si tuat ions and alsocontributes to improve men ts in medical condit ion."The consistent placebo response suggests there isa comm on, un derlying m echanism that accounts fomind-body healing, regardless of the problem"(Rossi,1993).We should be aware of the fact that in many forms opsychotherapy the use ofsuggestion is a part of thatherapy. Indeed, in the case of hypnosis we ardealing almost exclusively with suggestion. This laspoint might well raise an interest ing question. WhaRossi proposes is that there isalways some form oplacebo effect in clinical situations. Placebo is formedby sugges t ion , as is hypnosis and th is mighttherefore, exp la in why there was l i t t le dif ferencebe tween the two groups. The p lacebo ef fect mahave effectively minimized the benefit ofhypnosis. Iwould appear that there seems to be a fairly strongcase for taking placebo effect seriously. Just how thiscould becontro l led in any fu ture research needscareful considerat ion.Just how m uch these f indings can be extended to thewider population is a matter to be considered by eachpractit ioner that may be tempted to adopt a similaapproach to their own cl ients experiencing CFS. Iwould seem that the suggestibi l i ty of the individuashould be considered before discussing the possibleef fect iveness of hypnosis . However, thoseknowledge able in CBT might wish to consider lookinginto how they m ay help those with CF S.As to the possibility of further research in this area, imight appear that more questions have been raisedthan answers found. Insome respects this could beseen as a very positive result. As we continue to askthe questions then hopeful ly we cont inue to learnmore of the issues ra ised and therefore become


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european journal of clinical hypnosis - volume five - issue three 13

REFERENCESDemitrack, M. (1991): Evidence of Impaired hypothalamic.pituitary, adrenal axis in CFS, JClin 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, AmericanJournal of Hypnosis 6, 183-207Fulcher. (1997): Randomised trial of graded exercise In patientswith CFS, British Medical JournalHilgard, E,R, (1977): Divided Consciousness Multiple Controls inHuman 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, TheNetherlandsKreger D.W, (1995): Self-esteem, stress, and depression amonggraduate students, reported in American CFS Associat ion Journal.New Jersey,NTF. (1994): Report on Chronic Fatigue Syndrome, WestcareDept of Health, London,

Rogers, C,R, (1951): Client Centred Therapy 51-56. London:Constable.Rossi , EL, (1993) The Psychobiology of Mind-Body Healing.New York: Norton,Sel igman M,, (1984): Attributional Style and Depres sion. Amer icanJournal of Abnormal Psychology,Selye, H, (1978): The Stress of Life. New York: Me Gow-Hill.Sharpe, M, et al, (1996): Cognitive B ehavioral Therapy for CFS. aRandom ised control led trial, BMJ 312:22-6Weitzenhoffer, 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 informationNational CFS Association, notes from lectures on causality andtherapy.Research and Methods in Social Relat ions Judd C M ,, H arcourt,NY Real World Resea rch, Robson C, Blackwel l , Oxford,

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The Use of Hypnosis in Boosting the Effect of Cognitive Behavioural Therapy in the Treatment of Chronic Fatigue