INTRODUCTION

Hypnotherapy is increasingly recognized as a standalone therapy, or as a useful adjunct to other conventional and integrated therapeutic modalities. Like all forms of therapy, hypnotherapy has the capacity to bring about benefits, but also the capacity to cause harm. Most risks in practice are predictable, and are minimized if hypnotherapy is provided by suitably trained, regulated practitioners in safe practice settings.

A practitioner’s responsibilities fall into three broad areas relating to: respecting autonomy, benefiting patients and not harming them, and demonstrating respect for principles of justice. Specific issues explored will include consent, confidentiality and its limits, working within limits of competence, avoidance of harm, working as part of a multidisciplinary team, and safety and clinical governance issues.

Public misperceptions around hypnotherapy arise, in no small part, because of the association with stage hypnosis, and the inducing of trance for the purpose of entertainment. The confusion between hypnosis and hypnotherapy gives rise to concern that hypnotherapists are able to make people submit to their will while ‘under their spell’. This perception is not representative of hypnotherapy used as a therapeutic technique, which the UK House of Lords’ Science and Technology Select Committee defined as: ‘the use of hypnosis in treating behavioural disease and dysfunction, principally mental disorders.’ In this context, hypnotherapy is employed solely for the benefit of patients. Nonetheless, the fears conjured by lack of understanding about the remit of hypnotherapy need to be addressed, because they go to the heart of issues of control, power in the therapeutic relationship, best interests and therapeutic intent. As with all therapeutic endeavours, the focus of treatment should be in the best interests of the patient. Patients themselves must decide whether they wish to undergo, receive or participate in any given therapy, and the giving of information is a key responsibility of practitioners, reflected in the law through the duty to obtain consent.

WHY ETHICS AND LAW ARE AN ESSENTIAL PART OF PROFESSIONAL PRACTICE

Healthcare relationships are based on trust. Patients rely on practitioners to act in their interests at all times. The power imbalance inherent in all healthcare professional relationships requires hypnotherapists to be sensitive to the ethical implications of the therapeutic encounter. Patients are often, but not always, anxious or vulnerable, and assume that therapists know what they are doing, and working within the scope of their competence. The patient’s beliefs are shaped by the environment in which treatment is offered, the white coat (if worn), and the use of technical language, which frame the professional encounter. Professionalism implies ‘service to others’. This reflects the fiduciary nature of the relationship between any therapist and patient. The offer to heal is extremely potent, and it is vital that hypnotherapists do not abuse their patient’s trust, overstate their own capabilities, or make unrealistic claims about what treatment can offer. Critically, the foundation of the professional relationship is based on the best interests of the patient, and not the convenience or financial advantage of the practitioner.

There are obvious reasons why practitioners should work within the law. The main reason is that healthcare laws, relating e.g. to consent and confidentiality, are in place to protect the rights of the patient. Additionally, working within the law, including keeping good records of what has been said and done, acts as a protection for practitioners in the event of any dispute arising out of treatment, which may result in a complaint to employers or a professional disciplinary tribunal. The key ethical and legal issues for hypnotherapists are set out in Box 3.1.

Benefiting and not Harming

The main ethical issue in any given modality is the need to benefit patients and not cause harm. This reflects the key principles of beneficence and non-maleficence, cornerstones of professional ethics. For any treatment to be offered, its benefits should outweigh its risks, and treatment should, so far as is possible, be evidence-based. Benefits of hypnotherapy may be specific (e.g. a reduction in symptoms) or broader (e.g. an enhanced sense of well-being or optimism). Arguments exist around who should determine what constitutes a benefit, and conventional medicine has tended to look for measurable benefits to provide some objective, verifiable evidence as to effect. Risks may also be specific, e.g. exacerbation of symptoms (or causing side-effects) and non-specific, e.g. loss of confidence in health professionals, and contributing to patients not seeking other forms of treatment from which they might benefit.

Risks and Benefits of Hypnotherapy

As stated, the risks and benefits relate both to therapies and individual practitioners, and each needs to be considered separately. As regards the therapy itself, patients may not be aware of what the purported benefits of hypnotherapy are, so practitioners who use hypnotherapy, either on its own, or as part of other treatment pathways, should be in a position to articulate what the anticipated benefits of this therapy are. Information leaflets can be a helpful way of setting out the main benefits of treatment and any anticipated side-effects. This can provide a basic level of information, allowing patients to then ask more specific questions. Information giving is also important to ensure that a patient is in a position to give their consent, which will be considered later in this chapter.

Working Within Limits of Competence

Generally speaking, benefits of therapy will be achieved when hypnotherapy is delivered by well-trained therapists, working within the limits of their competence. Risks are most likely to occur when a therapist works outside his or her level of competence and provides treatment which is contraindicated and/or fails to spot conditions which require referral to another more suitable practitioner. An appropriate referral might be to another hypnotherapist who has higher-level skills (e.g. specific experience of working with children or adults who have been sexually abused), or a referral to a different specialist might be required (e.g. referral to a physician or psychiatrist). Hypnotherapists should avoid giving patients a medical diagnosis unless they are qualified to do so.

The skill of an individual practitioner will be determined by various factors. Some of these are intrinsic to the individual, such as good character, trustworthiness, and genuine warmth and empathy, whereas other skills, such as effective communication, are acquired as part of an appropriate training. One of the major ethical concerns within hypnotherapy is the variability of training and what is required to produce a competent hypnotherapist. Courses in hypnotherapy vary from short study courses over a period of weeks, to courses over a period of years. There is no agreed core curriculum, and no occupational standards which determine the competencies that a pre-registration hypnotherapist needs to be taught. This is a concern not only for therapists who work exclusively with hypnotherapy, but also for conventional practitioners, including doctors and dentists who use hypnotherapy as an adjuvant technique, e.g. for relaxation purposes. Any practitioner using hypnotherapy techniques should be appropriately trained. The failure on the part of the hypnotherapy profession to agree core competences and a standard curriculum have thwarted attempts, to date, to regulate the profession under a single professional body.

Box 3.2 gives an example of a case where a hypnotherapist should consider a referral to a psychiatrist as a matter of urgency, as the patient not only has suicidal ideation, but has formulated an action plan. In this situation, every attempt should be made to discuss with the patient why it is felt that a referral would be helpful and any referral should be made, if at all possible, with the patient’s consent, in order to maintain the patient’s trust. In very rare situations where it is not possible to secure the patient’s agreement, the therapist would be justified in breaching confidentiality in order to protect the patient from harm.

Box 3.2 Case study

A patient who has been coming for hypnotherapy treatment discloses that she has been feeling suicidal following the break-up of her marriage and talks about how she might put her plan into action.

Avoiding harm involves working within limits of competence, and also refraining from specific techniques which are likely to cause harm. One hypnotherapy register specifically prohibits hypnotherapists from using past-life regression and exorcism or spirit-releasing techniques. Because of the concerns that hypnotherapists might abuse their position of trust when patients are in a trance (and potentially more suggestible), it is vital that a therapist using hypnotherapy techniques sets clear and firm professional boundaries. This will be discussed later in this chapter.

Continuous Professional Development

Hypnotherapists have an ethical responsibility to keep their knowledge and skills up-to-date and to undertake continuous professional development. Many professional associations now provide CPD programmes, and undertaking CPD may, in future, be a condition of registration and revalidation. CPD courses provide practitioners with useful opportunities to ensure that they have skills in areas which may not have been taught in any great detail on their course, including ethics, law, audit and research and IT skills.

SUPERVISION

Supervision provides a useful safeguard for practitioners and patients and should be seen as integral to competent, safe practice. Supervision involves the supervisee and a supervisor meeting at regular intervals to discuss matters that may arise during the supervisee’s work with clients (Mackereth & Carter 2006). A range of issues may be discussed in relation to the supervisee’s client work, with matters discussed treated as confidential and the anonymity of clients preserved. Supervision is one method of ensuring that high standards of ethical practice are maintained by therapists. Hypnotherapists who are registered counsellors and psychotherapists may already access supervision, but supervision can be helpful for all hypnotherapists. Unethical practice is rarely deliberate. Poor practice is more likely to originate from inadequate training, reinforced by working in isolation from peers over a period of time. Constructive supervision may provide a necessary outlet for therapists in which technical and ethical difficulties can be discussed openly, and in a supportive and non-judgemental environment.