4 Research and hypnotherapy interventions
EVIDENCE-BASED PRACTICE
The ethos of evidence-based practice is a simple one; it involves the application of best practice and the best use of resources. From its rise in the UK in the early 1990s, it has spread to become a global phenomenon and is now the foundation of UK health policy (Reynolds 2000). It has led to the creation of the National Institute for Health and Clinical Excellence (NICE), an independent body responsible for providing guidance on the promotion of good health and the treatment of ill health. This guidance aims to achieve consistency across health services, ensuring they are up-to-date and that they provide good value to health consumers. Sometimes politically sensitive, the sad matter of fact is that the publicly funded health services do not have endless reserves to draw upon and so resources must be used as best as possible, based on the evidence available. This is why, if CAM interventions like hypnotherapy are to be further integrated into the NHS, the need for high-quality research evidence must be met.
The House of Lords Science and Technology Report (2000) identified the lack of high-quality CAM research available and recommended that work be done to ensure that such practices be exposed to the same level of scientific rigour as conventional medicine. The report classified different therapies into three groups and placed hypnotherapy in Group 2 alongside practices like massage, aromatherapy and meditation. While satisfied that therapies in this category provide comfort and can help to complement medical treatments, the report nonetheless acknowledges the lack of a scientific basis from where they are practiced. It further recommends that structures for regulation and education are strengthened and that the evidence base is developed to underpin practice.
REASONS FOR ENGAGING IN RESEARCH
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A therapist’s belief that hypnotherapy works may come from observing changes in their clients, this may be a sufficient basis for their ongoing individual practice. Equally, consumers of hypnotherapy may experience the benefits and not require that it be proven scientifically to them. Anecdotal evidence can provide interesting ‘cases’ to reflect upon. Indeed, further understanding of the application and effects of hypnotherapy can be gained by analysing the processes and outcomes for one individual. Standing alone, however, these case reports are not enough to widen the scope of practice for hypnotherapy. Ozturk (2006) reported on the case of a woman undergoing a cholecystectomy, the removal of her gall bladder. The surgery was conducted with the patient being inducted into trance but without the use of any medication. Remaining pain-free, she was conscious during the operation and was eventually discharged earlier than the accepted norm. While a case like this fires the imagination, it does not provide enough evidence to justify replacing general anaesthesia with hypnosis in similar cases. Science demands that studies are easily replicated and it may be difficult to reproduce the conditions that were in place in the previous example. The next patient may have low hypnotic susceptibility or may experience a spontaneous emergence from trance. In either case, the resulting effects may be dramatic and potentially devastating.
The aforementioned case study cited by Ozturk (2006) illustrates the need to identify variables involved in treatment, to measure them, control them and to ascertain the effects that they have on the treatment as a whole. Until quantified, the effect of variables on treatment outcomes is unknown. Examples of such variables include hypnotic susceptibility, the rapport between therapist and client, length of treatment, suggestions used and the context in which hypnotherapy is employed.
AREAS FOR RESEARCH
It is easy to see that no one study can possibly answer all the questions posed. An enthusiastic hypnotherapist or potential researcher may want to ‘prove’ that hypnotherapy works in one fell swoop; not only is that impractical but it is impossible. Not only is hypnotherapy a complex intervention, but the demographic differences (diagnosis, reasons for attending, expectations, etc.) among the patients who use it will also vary widely. The budding researcher needs to identify potential areas of interest (Box 4.1), to refine the question that they want to answer, to plan the most appropriate way they can answer it and, most importantly, to ensure that their question has not been answered satisfactorily by someone else. It would be a waste of time, effort and money to conduct a study if there already existed one of sufficient quality that showed significant effects. However, if a previous study had been conducted and the question posed had not been answered definitively, then a follow-up study would be feasible.
HIERARCHY OF EVIDENCE
QUALITATIVE STUDIES
Box 4.2 outlines the accepted hierarchy of evidence within the medical sciences, adapted from Sackett et al (2000), which forms a component of NHS research and development policy. It is easy to see that quantitative methodologies dominate the classification of acceptable evidence and thus the research priorities to affect change in service provision. Historically, clinicians have been interested in whether or not a treatment works and whether the effect can be measured. And so there exists a potential conflict as hypnotherapists may be more interested in how their clients feel about the treatment and how it has affected the way they live their lives. Such questions naturally draw themselves toward a qualitative design and although results may be compelling, parts of the medical establishment may well consider them substandard when compared with the results of a well-designed RCT.