Thérapie cognitivo-comportementale brève (TCC) et #hypnothérapie
Cette étude illustre l'efficacité de deux méthodes de traitement intégrées pour faire un meilleur pronostic dans le traitement d'une ménagère pakistanaise déprimée âgée de 25 ans, qui souffrait depuis un an.
Les séances comprenaient l'induction hypnotique, l'enseignement de l'#autohypnose avec des #suggestions positives, la surveillance de l'#humeur, l'utilisation d'images et de techniques de #relaxation ainsi que des stratégies spécifiques de brève TCC. La caractéristique dominante de sa présentation clinique était la #croyance d'être mal aimée et les pensées négatives d'être dévaluées par le mari.
L'hypnothérapie a contribué à réaliser des progrès thérapeutiques remarquables en un temps relativement court. Lors de la présentation initiale, les symptômes dépressifs étaient extrêmement élevés, comme l'ont démontré les tests d'évaluation psychologique et le Beck Depression Inventory (BDI).
Les résultats des tests ultérieurs ont indiqué qu'elle était revenue à un niveau de fonctionnement normal (81-90) tel qu'évalué par le Global Assessment of Functioning Scale (GAFS). Au moment de signaler le cas, elle était en phase de suivi. Le cas met en évidence la valeur de l'hypnose en tant qu'outil d'autonomisation particulièrement important pour réduire la dépression lorsqu'il est utilisé en complément d'une thérapie cognitivo-comportementale.
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Cognitive Behaviour Therapy (CBT) is a form of therapy used to treat a wide range of psychological problems. It is based on the assumption that thoughts, feelings, emotions and behaviour are parts of a unified system, and that change in any part can bring about change in the entire system. Hypnotherapy is a combination of hypnosis and therapeutic intervention. The therapist leads the patient to positive change while the patient is deeply relaxed in a state of heightened suggestibility called trance. The degree to which a technique influences the other is known as integration of therapy techniques. When combined with psychotherapy, hypnosis becomes hypnotherapy. Therefore, it is said that hypnosis actually contributes to the effectiveness of CBT. Similarly, CBT is a therapy lacking the power to bring accelerated human changes in the form of belief, perception and behaviour. However, this is achieved when CBT is used in integration with hypnosis.1
Hypnosis can stop playing of automatic negative thoughts in the unconscious through positive suggestions. Hypnosis adds flexibility in perception and behaviour, enabling the client to think in a more adaptive manner. It also helps by detaching the clients from their own thoughts and feelings allowing them to observe their thoughts and feelings as a third person. Instead of making changes at conscious level, which is a very time-consuming process before becoming automatic, hypnosis can be used to bring about changes directly at the unconscious level.2
Hypnosis is most commonly integrated with CBT if the therapist wants the clients to focus on their cognitive distortions (thinking errors). Hypnosis might be used through which correction in thinking pattern can be made in more natural way and the process is actually automatic. Aron. T. Beck, the founder of cognitive therapy, did not deal with the unconscious, but dealt with automatic negative thoughts in the therapy that are embedded in the unconscious. Through hypnosis, these automatic negative thoughts can be eradicated and positive thoughts can be instilled into the subconscious mind.3
Literature suggests that hypnosis works to catalyse different interventions, including CBT. Hypnosis through positive suggestions alleviates symptoms of psychological disorder, including depression, and holds a creative and practical addition to the therapist's practising skills while providing intervention.4 Literature suggests cognitive hypnotherapy as an adjunctive to psychotherapy that enhances the role of hypnosis. As hypnosis lacks empirical evidence regarding therapeutic and behavioural change, it is used as an adjunctive therapy with other psychotherapies to promote its standing therapeutically. It is systematically integrated with a well-established CBT which represents the best integrated psychotherapeutic approach for merging empirical findings.5 The American Psychological Association in 19996 acknowledged hypnosis as an effective adjunct to CBT. Literature clearly suggests the effectiveness of hypnosis for many conditions. Currently, the challenge is to empirically explore the limitation and further the possibilities for hypnotherapy as an effective treatment modality.7 Literature further suggests that hypnotherapy is a beneficial part of some treatment regimes.8 According to a study, hypnotic intervention showed promising results for treating low to moderate level depression,9 and found it to be a successful non-pharmacological treatment to address symptoms of depression.10 Kirsch et al. compared the efficacy of cognitive behaviour hypnotherapy with CBT alone through meta-analysis and concluded that CBT was more effective when integrated with hypnosis compared to CBT alone.11
A housewife aged 25 years came to seek therapy who had done her graduation in 2016 and had got married in June, 2017. She had a daughter aged 3 months, and lived in a nuclear family setup in Gujranwala in the Punjab province of Pakistan. She was accompanied by her mother to Transformation Wellness clinics in Lahore throughout the therapy sessions. Her mother reported to be worried for her daughter as her son in law had sent her back, saying he would take her home only after she was mentally stable. At first sight, the client appeared to be sad, was talking in a low tone, and appeared resistant in interacting with the therapist.
She reported experiencing low mood throughout the day with crying spells, changes in her appetite, insomnia, lack of energy, loss of interest in routine activities, negative thoughts, poor concentration, and feelings of worthlessness, hopelessness and indecisiveness. Her symptoms had started a year back and had exacerbated in the preceding 6 months. She said she has been disappointed with her husband as he did not give her proper time and attention, and she had a feeling that he did not love her. She expressed her emptiness and hopelessness with her future life. She was having frequent disputes with her husband over her demand to shift his family business to Lahore. She reported to have never liked the environment of the city she was residing in and wanted to come back to her birthplace. She felt suffocated and devastated by her in-laws, her husband's gathering and was having adjustment issues. She demanded a lot of time and attention from her husband which he was unable to provide because of his work routine and socialisation with his friends. She reported having a train of automatic negative thoughts throughout the day, feeling low and hopeless. She had difficulty in falling asleep and usually woke up in the middle of her sleep. She also complained of her weight-gain because of over-eating under stress. She was also having indecisiveness regarding undergoing treatment, staying with her mother or going back to her husband. She believed that if she stayed with her mother, her husband would have no choice to shift his business to Lahore.
Assessment for Diagnosis
For the diagnosis of client's symptomatic presentation, psychological assessment was carried out through Human Figure Drawing, Thematic Apperception Test (TAT), Rorschach Inkblot Test and Beck Depression Inventory (BDI)12. Her baseline level of functioning was assessed through Global Assessment of Functioning Scale (GAFS).
Assessment of Suitability for CBT and Hypnotherapy
An initial CBT assessment was carried out to check her appropriateness for the therapy and to decide whether to continue with the brief version of CBT or to switch to some other therapy.
It included strong motivation to change with knowledge of benefits associated with treatment; clear goals for treatment; willingness to devote the time needed for the weekly sessions; commitment for out-of-session homework; family's support; adequate cognitive functioning and educational level; and mild level of psychopathology.
In order to assess her hypnotisability and level of suggestibility to carry out acceptable primary suggestions, her level of concentration and imagination were tested. In addition, to allay her fears and anxieties, misconceptions about hypnosis and to establish rapport with her, four of the primary suggestibility tests were carried out that included Chevreul's Pendulum Experiment, a permissive test of concentration; Arms Rising and Falling Test, a permissive test of imagination;
a) Hand Clasp Test, an authoritative test of imagination; and the Progressive Muscle Relaxation Test, a permissive test of relaxation.
These tests provided the therapist an opportunity to evaluate her likeliness to be a successful client for clinical hypnosis. The tests also preconditioned her for hypnosis by allaying her fears and provided clues to the therapist in selecting appropriate induction methods based on her response to the tests.
On the basis of evaluation, it was decided to provide her 2 sessions (45 minutes each) in a week. Brief CBT was completed in the period of a month excluding the follow-up sessions. The treatment was carried out in December, 2017, and continued till the end of follow-up sessions in June, 2018. Client's verbal and written consent was taken before using her case for the current study. Throughout the process of assessment, therapy and while reporting her case, confidentiality was maintained at all times.
A 45-minutes session, during which the client was given CBT orientation, including a description of how her problems can be conceptualised and treated. She was psycho-educated about the structure, format and expectations of the therapy, her concerns were assessed and initial treatment goals were set that included awareness of her thoughts before thought-challenging through psycho-education, learning of two cognitive and two behavioural strategies to cope with stress, to learn and use thought testing to manage depression, plan and perform one pleasant activity per week, a check on symptoms, and completion of homework assignments. Finally, she was educated about her disorder with an instillation of hope and sense of empowerment. Keeping in mind her stubbornness, indirect conversational hypnosis techniques were used to inculcate positive suggestions in her subconscious and challenge her negative thought in a non-threatening manner.
In the first 5 minutes, client's mood was reviewed and with the help of the therapist, she elicited her automatic negative thoughts associated with the shift in her emotions. It was then decided to focus on those automatic thoughts that bring about most of the mood changes. Before initiating specific CBT techniques, hypnotic inductions were used to facilitate the process of change with hypnotic and post-hypnotic suggestions used as ego strengtheners. She underwent first hypnotic induction with positive suggestions specific to her case. Her negative thoughts, beliefs and associated negative feelings were rated on a scale of 0-100 and the strongest ones were considered first. The client practised thought record form in an attempt to change her maladaptive thoughts and beliefs to more adaptive ones by recording the situation in which the negative thought occurred, the negative thought itself, associated negative emotion and mood, evidences that does and does not support the negative thought. The client was then asked to generate an alternative positive thought and rate her mood in response to the thought. After the activity, a list of cognitive distortions with examples was discussed with her, giving her insight into what thinking errors she was usually engaging herself in. As a homework assignment, she was given thought record form and was asked to complete the first three sections, create a list of assumptions, evidence for and against those assumptions, and to keep a list of automatic thoughts she had during the day.
Client's mood was briefly reviewed in 5 minutes and discussion from the previous session was bridged with the current session and agenda items for the current session were set. In 5 minutes, her homework assignment was reviewed. Her maladaptive thoughts and beliefs were than challenged through Socratic questioning and she was guided for developing a more balanced thinking by taking evidences against her negative thoughts. Once evidence was generated, a more balanced thought was formed. She rated the believability of the alternative thought from 0-100. If the thought was above 50 it was accepted otherwise more work was done on it. Once an alternative thought was formed, her mood and emotions associated to the automatic thoughts were re-rated and she was given the insight that a more adaptive emotion had been generated by modifying the thought. This method was followed for each of her strong negative thought. She was than given second hypnotic induction with a deep breathing exercise and backward counting as a deepener. In this induction all the therapeutic skills learned were incorporated in positive suggestions to be used in future life when needed to strengthen the therapy process and an ego-strengthening script was used to fulfil the purpose. By the end of the session, she was given homework assignment of listing the advantages and disadvantages of keeping a thought record and to complete the 7 columns of thought record form by herself at home.
The client's mood was briefly reviewed in 5 minutes and discussion from the previous session was bridged with the current session and agenda items for the current session were set. In 5 minutes, her homework assignment was reviewed. She was taught suggestion management to help her achieve the desired goals, keep her mood positive, hypnotise herself and cope with her own problems. The suggestions were taught on the basis of 6 rules to be followed when used under self-hypnosis: simple in phrase, positive in tone, should be in the present tense, measureable, believable, and rewarding in nature. As homework assignment she was given practice exercise on positive hypnotic suggestions.
Client's mood was briefly reviewed in 5 minutes and discussion from the previous session was bridged with the current session and agenda items for the current session were set. In 5 minutes, her homework assignment was reviewed. The therapist then started teaching her behavioural activation strategies, including introduction of new pleasant activities and learning of active coping skills to alleviate her stressors. She was taught the 'SOLVED' technique for effective problem-solving where S = selecting a problem, O = opening mind to all solutions, L = listing the pros and cons of each solution, V = verifying the best solution, E = enacting the plan and D = deciding if the plan worked. At the end of the session, she was given homework assignment to list the activities needed to improve her situation and to create a schedule of new activities to be performed. Integration of hypnosis with this technique was done through muscle relaxation and deep breathing techniques along with quick-trance techniques with positive suggestions.
After a 5-minute review of her mood in the preceding week, discussion from her previous session was bridged with the current session. The agenda items for current session were set and she was taught the 3-step self-hypnosis to become her own therapist. The first step was pre-sleep technique where she was taught a suggestion "every day in every way, I am getting better and better" which she had to repeat to herself for the following 7 days at night after going to bed just before falling asleep. In order not to fall asleep before giving suggestion to self, it was suggested to press each finger while giving suggestion and imagine herself getting better until she completed the suggestion 10 times. The second step was induction which required the pre-sleep technique to be continued along with it for another 7 days. In this step she was taught to hypnotise herself twice a day, staying in hypnosis for 2-3 minutes and then waking up. This was to be achieved by sitting in a chair comfortably with her back supported, focussing all attention effortlessly on a spot slightly above eye level. Three deep breaths were to be taken while staying in hypnosis for 2-3 minutes and counting down slowly from 10 to 1 and then waking up by counting 1-3. The third step to be done was of programmed suggestions in the third week along with the pre-sleep technique. Step 2 was not needed and was to be replaced with step 3 for which a 3x5 card was needed on which suggestion prepared for self was to be written. Again, a spot was to be chosen slightly above the eye level, holding the card in front of the spot and reading the suggestion 3 times before dropping the card, closing the eyes and taking 3 deep breaths counting backward from 3 to 1. The suggestion was to be allowed to repeat in the subconscious over and over again while imagining it. After 2-3 minutes, she was to open the eyes after count from 1 to 3.
In this session she was guided towards effective use of imagery for relaxation and pleasant feeling. At first, imagery was introduced to her explaining how pleasant images can actually change physical and emotional state. Secondly, she identified the desired outcome to decrease sadness, increase attention and concentration. Third, she was asked to develop an image or scene. She was asked to select a powerful image as it is critical to the success of this technique.
Fourth, to increase vividness of the image, she was asked to explore as many senses as possible, increasing the details of her experiences. As step five, she was asked if she noticed any changes after the imagery exercise and it was repeated until she reported skill understanding and benefit. In step six, she was asked to identify the situations where imagery might be appropriate. Finally, she was asked to continue the practice outside the session. She was given homework assignment that encouraged application of imagery to situations where she might feel stress or feel that the imagery might be beneficial.
The last session of brief CBT was spent recalling and reviewing all the different cognitive and behavioural skills learnt in the preceding sessions. As it was the end of the treatment, she anticipated possible stressors, relapse symptoms and further plan which included the tools she might use for particular stressor or symptom, situations where she might need to consult the therapist again, and a functional assessment to identify future problematic situations. She vocalised and problem-solved concerns about functioning outside the treatment. The discussions reduced her anxiety and allayed fears she had about ending a therapeutic relationship.
At the time of reporting this case study, the client was in the follow-up phase where she was being assessed to determine her current level of functioning through GAFS. Results indicated that she was back to her level of functioning prior to depression. After only 3-4 sessions, she was better able to control her negative thoughts and had started generating alternative positive thoughts. Within this short period of time, she rated her depression to decrease to 40% from 90% initially, and from 'extremely high' to 'normal' by the end of the 7th session as assessed by BDI. She reported improved attention and concentration, was feeling more energetic and had started taking interest in daily routine activities again. Her sleeping pattern had returned to normal and she had started socialising as well. Through her discussion of the daily routine and events, it was evident that she was now more flexible, had more options and psychological tools to handle perceived difficult solutions. She also indicated that self-hypnosis had helped her in achieving her goals and staying relaxed most of the time.
In follow-up sessions, the therapist continued seeing her twice a month to continue working on any difficulty occurring in routine life. Although she was in total remission, some minor anxieties and insecurities still prevailed which were being handled in her follow-up sessions through specific interventions.
Being a suggestible, intelligent, open and compliant client, she had been receptive to positive hypnotic suggestions and optimistic towards therapy which contributed to a successful treatment. Moreover, due to her compliance she readily altered her negative beliefs and incorporated more adaptive beliefs which alleviated her self-concept and self-esteem. The techniques taught during the sessions were successful in learning new useful life skills. Hypnosis had particularly been successful as treatment because of positive post-hypnotic suggestions provided during the trance which operated even after the induction of hypnosis. Suggestions made in hypnosis can be effective in the waking state after hypnosis has ended, and these are called post-hypnotic suggestions. They can be very important in linking what has been learned, incorporated, or experienced in hypnosis back to the subject's world of external reality.
She proved to be highly motivated towards the therapy, was receptive to employing goals, and was committed to practising it between the sessions, doing all her homework assignments. Her faith in therapy was achieved even more after a few sessions when she started experiencing remission of her symptoms. Her confidence level increased and she successfully mastered how to remit some of her difficult feelings. Cognitive behaviour hypnotherapy was an effective intervention for developing problem-solving skills, enabling her to return to her prior normal level of functioning.
J Pak Med Assoc. 2020 Apr;70(4):719-723. doi: 10.5455/JPMA.23735.
Integration of hypnotherapy with brief cognitive behaviour therapy (CBT) for treatment of depression.