The following article appeared in the July, 2004 issue of the American Journal of Clinical Hypnosis. Dr. Sward was a close associate of Dr. Potter and he also uses hypnosis at times in the treatment of Substance Abuse.
Utilizing Hypnosis in the Treatment of Substance Abuse Disorders
Hypnosis was once a viable treatment approach for addictions. Then, due to hypnosis being used for entertainment purposes many professionals lost confidence in it. However, it has now started to make a comeback in the treatment of substance abuse. The approach described here, using hypnosis for treatment, borrowed from studies effectively treating alcoholism by using intensive daily sessions. Combining the more intense treatment of 20 daily sessions with hypnosis is a successful method to treat addictions. The treatment has been used with 18 clients over the last seven years and has shown a 77 percent success rate for at least a one-year follow-up.
Intensive Treatment Program:
Recently, the use of hypnosis in the treatment of addictions has been primarily limited to cigarette smoking (Spiegel, Frishholz, Fleiss, & Spiegel, 1993; Capafons & Amiga 1995; Apostolides & Yunker, 1996; Ahijevych & Yerardi, 2000; Green & Lynn, 2000; Barber, 2001).
According to Martensen (1997) in the 19th century hypnosis and alcoholism medically converged, and the results were very good. There were as high as 80 percent success rates with samples up to 700 patients reported. Then by 1910, because of its growing prevalence as entertainment, ethical professionals were using hypnosis less for treatment of any medical or psychological disorder. By 1920 hypnosis was rarely used in the treatment of alcoholism.
However, hypnosis has begun making a comeback as a viable treatment for alcoholism and other addictions. Wolberg (1948) treated alcoholism by using hypnosis to enhance dream imagery. Lemere (1959) using a conditioned reflex treatment reported a 57% success rate on a one-year follow up. Success was based on the abstinence of alcohol. Feamster and Brown (1963) successfully used an aversive treatment through hypnosis to control excessive drinking.
Orman (1991) reported a single case study of the treatment of alcoholism using 17 sessions. Orman combined hypnosis with psychotherapy and the patient also increased Alcoholics Anonymous meetings from three times per week to six or seven times per week. The patient reported continued abstinence at six months and one-year follow-up. Allan (1995) found hypnosis helpful because of its efficacy in reducing tension. Avantis and Margolin (1995) used hypnosis to enhance imagery techniques in the treatment of addictions.
Tiffany and Conklin (2000) discussed the possibility of a reward center deep within the brain. They reported emotional-laden memories of past positive drinking experiences become associated with cues. Then exposure to these cues can activate the reward center, potentially leading to craving during abstinence. They can change these experiences to experiences that promote abstinence and reduce craving by using suggestion, reframes, metaphors and positive imaging in hypnosis.
Walsh (2003) presented three case studies using a brief one-session approach called “The Utilization Sobriety Model.” This model uses an ideomotor finger signal to identify the absolute best high from using the drug of choice. After they identified the high, the therapist suggested that the patient touch two fingers together and anchored a post hypnotic suggestion to the best high. The patient was then instructed to use the two fingers together to recall the high when urges for the drug came up. Walsh reported successful abstinence in client number one and two in one year follow-ups. Client number three had a cocaine addiction and struggled with relapses, but has stayed clean for the last year and a half prior to the writing of the manuscript. Page and Handley (1993) also wrote about the use of hypnosis to treat a cocaine addiction.
Addiction contains spiritual, mental, social and biological components. Hypnosis is a treatment modality that addresses all of these issues.
Gorski and Miller (1986) name six symptoms of Post Acute Withdrawal (PAW) that can occur following acute withdrawal from an addictive drug. These symptoms can recur for years after a person has successfully withdrawn from a chemical dependency. The six symptoms are: (1) inability to think clearly, (2) memory problems, (3) emotional overreactions or numbness, (4) sleep disturbances, (5) physical coordination problems, and (6) stress sensitivity. There have been numerous reports of using hypnosis to treat each of these PAW symptoms including Whitehouse, et al (1996) in a nineteen-week study that showed hypnosis to produce lower stress levels. Yet the use of hypnosis with chemical dependency continues to be thought of as an alternative therapy when it is, possibly, one of the better choices available.
Hypnosis has traditionally been looked at as a quick fix and if it does not work quickly, confidence in it is lost. Hypnosis does, sometimes produce very rapid changes. However, when used over a longer period of time in a systematic process the results are much longer lasting.
Traditionally, treatment methods for addictions include intense daily sessions. Combining the intensive treatment of daily sessions with hypnosis appears to strengthen treatment for many people who are suffering from addictions. Among the advantages of using hypnosis is that it allows the client to better imprint, modulate and integrate new patterns of behavior. Also, the deep relaxation naturally addresses the recovering person’s need to manage stress and handle cravings.
The following describes a 20-session intensive treatment program. Over the last seven years 18 clients have started treatment using the full 20-session approach outlined below.
There were 16 men and two women. The age range was 18 to 63, and the mean age was thirty-seven. There was one African American, and the rest were Caucasian. Of the 18 clients, 15 were being seen for alcoholism or alcohol abuse, 2 clients for cocaine addiction and 1 client had a marijuana addiction. The 18 participants were clients who voluntarily sought treatment at a private practice facility.
No hypnosis was used for the first two sessions. The first session consists of an assessment and involves a detailed history. As in any form of therapy, the assessment of the client is where the decisions are made of how to proceed with treatment. It is important to assess the client for any dual diagnosis and other stressors. Any testing instruments used should have a purpose and be comfortable to the therapist.
The determination of whether a medical detox is necessary is made during the personal intake interview by asking very direct, pointed questions about the clients’ unique involvement with the drug or drugs in question. The key items are: (1) How many drugs are being used and to what extent? (2) The date and time of last use. (3) How long was the longest time the client went without using the drug and when was it? (4) The motivation of the client to use the drug, and then the motivation to stop using the drug. (5) Does the client feel confident and appear capable of staying abstinent from the drug while working on an outpatient basis?
A formal hypnotic susceptibility measure is not used. The first hypnotic session, however, lends itself nicely to using two measures from the Stanford Hypnotic Susceptibility Scale (Weitzenhoffer and Hilgard, 1959). The measures I use are eye closure and arm rigidity. These measures do not tell me exactly the amount of hypnotic talent the client has, but passing these two challenges gives me confidence that the client has enough hypnotic talent for our purposes.
Between the first and second sessions a detailed treatment plan is developed. The second session is used to review the treatment plan with the client and our signatures on the plan create the therapeutic alliance, which is an important part of all therapy work. Therefore, including the assessment and review of the treatment plan, a 20-session intensive treatment program is actually 22 sessions.
The program consists of 50 to 60 minute sessions, five days a week, in which five to ten minutes are typically used to assess progress and understand the next step. The next 35 to 45 minutes are used in trance. I generally use a 20 to 30 minute trance induction and deepening processes. Clients seem to enjoy this daily relaxing. The relaxation also appears to be a treatment benefit for stress reduction and handling cravings for the drug in question. This induction process creates a healthy environment for the therapeutic work to be done. The actual trance utilization and treatment phase of the program is about 15 to 35 minutes per session, depending on whether a deepening technique is used. The client is seen once a day, five days a week for four weeks. This schedule allows 20 trance inductions.
The content of the treatment phase of the hypnotic sessions are individualized based upon the needs of the client, and should be determined by the therapist. As in all treatment using hypnosis, the therapist should be able to treat the individual not using hypnosis. Therefore, it is important for the therapist to be knowledgeable in the treatment of addictions before accepting the client for treatment.
Sobriety starts as soon as the client is not drinking or using the drug, and the treatment is built around a healthy recovery process. The first hypnotic session is a good time to begin developing a self-image as a sober person. When the client comes to the conclusion that the drug cannot safely be used, it is helpful to begin developing a self-image away from the addiction. Clients are asked to think about their ideal self-image. They often come up with terms like healthy, sober, energetic, responsible, honest, respected, drug free, etc. These words are then put into suggestion form. In the first session, then, direct suggestion is used to begin a process of imprinting the positive characteristics into the client’s self-image. These impressions can be reinforced in subsequent sessions as much as the therapist deems necessary based upon the individual needs of the client.
Also, during the first session an anchor is usually employed to create a post hypnotic suggestion of “no, I don’t want that, I’m free.” This suggestion is anchored, by firmly touching the client on the left shoulder (Citrenbaum, King, & Cohen, 1985), to the feelings of “peace, strong and control.” Then, when there are any cravings or thoughts of using the drug, the client repeats, no I don’t want that, I’m free to bring about the suggested feelings of peace, strong and control. Anchors are more fully described in the “Treatment Tools” section of this paper.
In addition to building a non-using self-image, it is helpful to employ self-strengthening techniques. Self-strengthening is an important part of the recovery process that can assist the client to address the PAW symptoms (Gorski & Miller, 1986), and is typically used in more than one session.
Treatment follows a relapse prevention process, which is built around a healthy recovery. This process involves the effective handling of stress, monitoring and treating the PAW symptoms (Gorski & Miller, 1986) and a focus on healthy living.
When working with substance abuse or addiction, I ask the client to read the book Staying Sober by Gorski and Miller (1986). This book focuses on relapse prevention techniques and is a valuable resource. The reading of the Staying Sober book is not negotiable because it provides the education of the recovery process that cannot be covered during hypnosis.
Following the initial treatment, there is an aftercare program that ranges from no planned visits to planned weekly visits. Following the clinical perspective of the program the aftercare sessions are also individualized to fit the needs of the client. The aftercare sessions provide a nice forum for more complete coverage of the Staying Sober book and making sure the client is aware of the recovery process.
The hypnotic sessions can include anything that the client needs to focus on in therapy. The following is a description of treatment tools that I have found to be effective. The specific tools used are a decision of the therapist.
As in most therapeutic paradigms, direct suggestion is a valuable tool for working with addictions. Direct suggestion can be used for creating a positive expectancy. The therapist can also use direct suggestion to inspire confidence, commitment, motivation, and perseverance in the client to achieve the stated goals, as well as encourage the proper behavioral changes.
Citrenbaum et al. (1985) point out several unique ways to use anchors when treating addictions. Bandler and Grinder (1975) also wrote about anchoring. In hypnosis, anchoring happens when a post hypnotic suggestion is paired to a feeling state. Therefore, when an individual has a craving for the drug, the post hypnotic suggestion is used to bring about the anchored feelings. I commonly use anchors to help clients handle cravings, as discussed earlier.
Barker (1985) suggests that metaphor is an essential feature of human communication. A metaphor used in therapy usually consists of a story that has a short metaphor embedded within. The whole story is not metaphoric, but captures the client’s attention so the metaphoric message can be subconsciously embedded. The therapeutic idea that later emerges, materializes like the individual’s own idea. For example, a 45-year-old male client attended four sessions of hypnosis to stop smoking and a metaphor was used in one of the sessions. He decided to terminate treatment while still smoking, although he had considerably reduced his smoking. I saw him about two months later and he informed me that he stopped smoking on his own. I congratulated him on a job well done. He never mentioned nor did he give any credit to the hypnotic sessions he attended. Although a therapist could never prove the hypnotic sessions were ultimately the reason he stopped, there is a good chance that the hypnotic metaphor helped him formulate a way to “stop on his own.” In clinical practice therapists have to be willing to help induce change without the need to take the credit. I have found many metaphors useful for working with addictions, including Wallas (1985) “The Boy Who Lost his Way.” All metaphors are altered, paraphrased and structured to fit the individual’s situation in order to make a therapeutic impact. For example, for female clients “the boy” in the metaphor becomes a girl.
There may be many issues that arise while working with addictions that could be reframed. For example; the way a person views New Year’s Eve; or what it means to go fishing or boating. Any situation that the client generally drunk alcohol or used the drug of choice, can be reframed to exclude the drug.
The affect bridge, Watkins (1971), is used with clients who have particular emotions associated with the use of drugs. By following the emotion through the affect bridge to the first time the client felt that particular emotion before using the drug, the client can become more aware of and break the connection with that emotion and the drug.
Watkins and Watkins (1997) describe parts of the individual client who are intellectually, emotionally, and behaviorally vested in conflicting goals. Hypnosis is a nice tool to create a safe environment for the client to access and get to know various parts. When using ego-state therapy with addictions, the therapist can help the client understand the needs of his or her part that wants the drug, and help that part achieve it’s goal without using the drug. The part’s goal may be a benefit like comfort, relaxation, control, independence, excitement, etc. Ego-state therapy has been shown to be quite effective with some clients.
Self-hypnosis is routinely taught to all clients. It is left up to the clients as to how they use it. I recommend using self-hypnosis without the assistance of tape recorders. This avoids anchoring the client to the recorder so he or she can be free to use the skill anywhere.
Since August of 1996, 18 clients have started the intensive treatment program of five sessions per week. The length of the intensive treatment program is four weeks. Two of those clients did not complete the full 20 sessions. One of those two, a man in his early thirties, left treatment after 19 sessions and at last contact, 16 months after terminating treatment was still abstinent from alcohol. The second one of those clients terminating early was a man in his late twenties who attended 15 sessions, terminated his program and returned to drinking.
Twelve clients continued treatment following the 20-session program for after-care counseling. Four clients terminated treatment following the 20 sessions. The most sessions (including after-care) attended for this program was 64 sessions. This client was a 39-year-old white male in treatment for a cocaine addiction, and went through two relapses before achieving a complete year without a relapse. Those 64 sessions were over a three-year time frame. At last contact he had been drug free for three years.
Of the 18 clients who started the 20-session program and most attending aftercare sessions, 12 remained drug free. Two clients returned to moderate drinking, and appear to be doing well. Two clients relapsed to abusive drinking, and one of those clients was charged with a third DUI. There are two clients, whom I have lost contact with and don’t know their status. Therefore, 14 out of 18 people have successfully maintained their goal for at least one-year. The program has produced a 77 percent success rate, for at least a one-year follow-up. However, as Powell (1995) points out, when the goal is not achieved there is always something new to learn. So, maybe there are no successes and no failures–only results followed by the next step.
In light of the continued struggle to find efficacious treatment modalities for addictions, hypnosis appears to be a viable treatment approach. However, for hypnosis to be effective the treatment plan must be individualized. Although hypnosis should never be presented as a quick fix, not all of your addictions clients are going to agree to or be in need of a 20-session program. Hypnosis can also be utilized as a part of a broadband approach that may include AA or NA meetings, and other forms of talk therapy.
My particular experience has been mostly with men. It would be interesting to see similar approaches conducted with more women participants. It is my belief, however, that gender would not be a deciding factor of whether hypnosis was used. If a client is depressed or has another dual diagnosis, a decision must be made on how to incorporate the other diagnosis in the treatment process. This sometimes contraindicates the use of hypnosis, until the person has effectively dealt with the other diagnosis.
Limitations of this study included: no random sample; no control group; no formal measure of hypnotizability; no two treatment plans are the same; and varying numbers of sessions. However, perhaps it can add to the literature and encourage more intensive study of the effectiveness of utilizing hypnosis as a core treatment for addictions.
There is a vast need in our society today for viable addiction treatment methods. Therapists who understand addictions and are skilled in the use of hypnosis appear to have a viable tool to help this population.
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