Contrary to the popular misconception that hypnosis can control a person's mind and free will, this alternative form of therapy actually teaches patients how to master their own states of awareness to affect physiological and psychological responses (Saichek 2000). Hypnotherapy typically uses relaxation-imagery exercises to induce deep relaxation and an altered state of consciousness, also known as trance (Vickers and Zollman 1999). Many people routinely experience a trance-like state in instances such as watching television or sitting at a red light. This highly focused condition is unusually responsive to an idea or image that facilitates healing or achieves a specified goal (Kohen et al. 1984). Such trance states have been used throughout history by shamans and ancient peoples as part of ritualistic activities to divine the future (Saichek 2000).

Franz Anton Mesmer (1734-1815), whose hypnotic techniques led to the term mesmerize, is regarded as the first hypnotist (Saichek 2000). The medical community considered his methods unscientific and accused him of fraud, which led to a mixed reputation for the practice. Despite this setback, hypnotism was used for a variety of disorders during the mid-eighteenth, nineteenth, and early twentieth centuries (Hackman et al. 2000). Although Sigmund Freud (1856-1939) used hypnotism in the early stages of his psychoanalytical practice, he eventually abandoned the technique. Given his prominence at the time, his decision not to use hypnosis in his practice damaged its credibility in the medical community (Saichek 2000).

Milton H. Erickson (1901-1980) renewed the medical application and practice of hypnotherapy. In 1958 the therapy was recognized by both the American Medical Association (AMA) and the American Psychological Association (APA) as a valid medical procedure (Saichek 2000). Since 1995, the National Institutes of Health (NIH) has advocated hypnotherapy as a treatment for chronic pain and recommends insurance reimbursement for this clinical indication, which has lent credibility to the modality (Hackman et al. 2000).

A new or continuous event causes the ascending reticular activating system (RAS) to alert the hypothalamus and limbic system. Activation of these brain centers leads to the release of hormones and neurotransmitters that affect memory and learning. When information is stored in the memory, it is encoded with its original, corresponding biochemistry. The information is then inseparable from the state in which it was first acquired and becomes a dysfunctional replication of the original event. When the brain perceives a similar situation, usually with distorted perception formed by previous associations, the corresponding physiological state emerges, creating a dysfunctional reaction. Hypnotherapy allows the patient to remember the defining event that led to the stress reaction, reconstruct the situation, and dissociate the memory and learned behavior from the encoded abnormal biochemical reaction. Hypnotherapy then implants "new" associations with the original event, this time triggering the hypothalamus and limbic system to release a different biochemical configuration that seems to promote a more adaptive functioning of the autonomic, endocrine, immune, and neuropeptide systems (Saichek 2000).

Scientists believe that hypnotherapy promotes access to the unconscious so that dysfunctional beliefs and attitudes can be reprogrammed without interference by the analytical, conscious mind (Saichek 2000). The hypnotherapeutic process involves a series of stages: reframing the problem, trance induction, intensification, therapeutic suggestion, return to usual awareness, and reflection on the experience (Sugarman 1996). The state of highly focused concentration experienced under hypnotherapy makes the patient more responsive to therapeutic suggestions from the practitioner to change physical and psychological reactions. For example, the practitioner may suggest to patients who wish to quit smoking that they will no longer find smoking pleasurable or necessary. Hypnotherapy can also teach patients self-regulation skills to use on their own; for instance, practitioners may suggest to patients with arthritis that they can turn down their pain like the volume on a radio (Vickers and Zollman 1999).

Practitioners consult with patients in half-hour or hour-long hypnotherapy sessions. After evaluating the presenting complaint, practitioners induce hypnosis and give patients a post-hypnotic suggestion, intended to change behaviors and alleviate symptoms. For instance, patients suffering from panic attacks may be given the post-hypnotic suggestion that, in the future, they will be able to relax at will. Practitioners also tend to teach patients how to induce self-hypnosis in order to be able to recreate the feelings experienced during the session and reinforce the learning. Hypnotherapy may also be taught to groups as part of a treatment program (Vickers and Zollman 1999).

Hypnotherapy has many applications in hospital settings. A prospective, randomized clinical trial, for example, indicates that hypnosis may improve hemodynamic stability during surgery. Hypnotherapy may also decrease pain and anxiety associated with invasive or uncomfortable medical procedures; this may allow for reduced use of medication(s) in stressful settings, as was seen in a group of subjects undergoing interventional radiological procedures (Lang et al. 2000). Hypnotherapy can also improve recovery time, enhance intra-operative patient comfort by reducing anxiety and pain, and may help create optimal surgical conditions (Faymonville et al. 1998). In addition, clinical trials performed at intensive burn care units suggest that hypnotherapy decreases pain, accelerates healing, and provides a viable alternative when opioid medications are contraindicated or ineffective (Ohrbach et al. 1998). Furthermore, a prospective, randomized, controlled, surgeon-blinded study suggests that patients undergoing coronary artery bypass surgery who are taught self-hypnosis techniques may experience greater postoperative relaxation and decreased use of pain medication (Ashton et al. 1997).

A prospective, randomized, single-blind, controlled study suggests that hypnotherapy may improve the quality of life for those with asthma (Hackman et al. 2000). Another study shows promise in using hypnotherapy to reduce symptoms caused by refractory fibromyalgia (Leventhal 1999). In addition, a study of 23 patients with irritable bowel syndrome who received gut-focused hypnotherapy suggests that such treatment may help normalize rectal hypersensitivity (Houghton et al. 1999). A randomized controlled pilot study of 11 healthy adults with fractures used radiographic data to demonstrate that hypnotherapy may accelerate the healing of fractures and improve mobility and function (Ginandes and Rosenthal 1999). Critical literature reviews of randomized, controlled trials also reveal that hypnotherapy can be helpful for pain management in cancer patients (Sellick and Zaza 1998).

Applications of hypnotherapy in dentistry have been described in the literature including anesthesia, analgesia, anxiety management, and control of both gagging and bleeding during procedures; hypnotherapy has also been applied for treatment of bruxism and periodontal disease (Wood and Zadeh 1999).

Certain factors, such as age and susceptibility, affect the efficacy of hypnotherapy; responsiveness is greatest in children aged 9 through 12 (Hackman et al. 2000). Clinical trials conducted at emergency treatment centers show that it decreases anxiety, fear, and discomfort, and increases cooperation, self-control, and mastery in acute or chronically ill children (Olness 1989). In another study, 83 percent of children with enuresis, asthma, problematic habits (sleep walking, thumb sucking, nail biting), obesity, encopresis, anxiety, and pain showed significant to complete improvement (Kohen et al. 1984). Other applications for children include stress, chronic disease, behavioral problems, psychosomatic symptoms (Sugarman 1996), and juvenile migraine (Olness 1989).

As with all adjunct treatment methods, patients need to be correctly assessed and diagnosed before undergoing hypnotherapy (Olness 1989). The greatest risk is that without adequate and appropriate assessment, hypnotherapy can actually exacerbate an underlying psychological condition or even trigger latent psychosis. Available evidence for such exacerbation is inconclusive, however (Vickers and Zollman 1999). Hypnotherapy may also induce false memories fabricated by the unconscious, known as confabulation (Saichek 2000).

Contraindications to hypnotherapy include personality disorders, psychosis (Vickers and Zollman 1999), and paranoia (Saichek 2000).

In addition to the above conditions, hypnotherapy may be useful for panic disorder, insomnia, phobias, obesity, nausea, and vomiting (Vickers and Zollman 1999). Certain experts also believe it to be effective for cardiac arrhythmias, hypertension, chronic fatigue syndrome, Ménière's disease, Raynaud's disease, periodic/restless leg movement syndromes, narcolepsy, tinnitus, torticollis, paruresis, childbirth and postpartum care, vaginismus, dysmenorrhea, emotional amenorrhea, menopause, menstrual cramps, premenstrual syndrome, dyspareunia, neurodermatitis, dental phobias, constipation, chronic diarrhea, GERD, gastritis, gastric ulcers, systemic lupus erythematosus, hemolytic anemia, Graves' disease, arthritis, myasthenia gravis, allergies, gout, AIDS, hyperreflexic bladder, addictions, and warts. It may be a valuable adjunctive therapy for diabetes mellitus (Saichek 2000). Hypnotherapy is also thought to be useful in the treatment of cystic fibrosis (Belsky and Khanna 1994), eating disorders such as anorexia nervosa and bulimia (Torem 1992), and in the management of habit disorders such as tics (Kohen et al. 1984). Since most illnesses have an emotional or psychologic component, it is not surprising that a technique that trains the mind can be so pervasively effective.

Hypnotherapy has not gained wide acceptance to date in the Western community. Some suggest that this may be due to misconceptions on the part of physicians as well as the general public. One reason that it may be difficult to study the efficacy of hypnotherapy is because symptoms are frequently subjective. Specific areas of clinical application that show promise but require further research include adjunctive application of hypnotherapy for coronary artery bypass surgery (Ashton et al. 1997) and for asthma. Similarly, given that hypnotherapy has demonstrated promise for teaching mastery and coping skills to children with chronic diseases (see Clinical Applications section), research is needed to determine the best way to apply these techniques in appropriate clinical settings (Hackman et al. 2000). In general, it seems that in order for hypnotherapy to gain more recognition and become mainstream, additional research and education are necessary.

There is currently no standardized training, as hypnotherapy courses differ greatly in their scope of education, nor is there consensus on the amount of training necessary to become a qualified hypnotherapist. There is also no standardized examination in the field of hypnotherapy. Credentialing is controlled by individual states (Saichek 2000). The American Society of Clinical Hypnosis (ASCH) and its affiliate, the ASCH Education and Research Foundation, jointly sponsor basic, intermediate, and advanced level instruction (for contact information, see section entitled Resources). Regional ASCH workshops are held four to six times a year around the country, and are accredited for Continuing Educational Units (CEUs). In addition, the American Psychotherapy and Medical Hypnosis Association provides certification for licensed medical and mental health professionals who complete a six- to eight-week course.

For information on training and credentialing, contact the American Association of Professional Hypnotherapists in Palo Alto, CA at 650-323-3224 or on the web at www.aaph.org; the American Psychotherapy and Medical Hypnosis Association (APMHA) in Reno, NV at 775-786-5650 or on the web at http://members.xoom.com/Hypnosis; or the International Society of Hypnosis (an umbrella organization to which many other organizations belong) on the web at www.ish.unimelb.edu.au. In addition, the American Society of Clinical Hypnosis (ASCH) in Roselle, IL 60610, fosters education and research and maintains referral information; contact the society at 630-980-4740 or on the Web at www.asch.net.

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