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International Journal of Clinical and Experimental Hypnosis

What Should We Mean by Empirical Validation in Hypnotherapy: Evidence-Based Practice in Clinical Hypnosis

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To cite this Article: , 'What Should We Mean by Empirical Validation in Hypnotherapy: Evidence-Based Practice in Clinical Hypnosis', International Journal of Clinical and Experimental Hypnosis, 55:2, 115 - 130 To link to this article: DOI: 10.1080/00207140601177871 URL: http://dx.doi.org/10.1080/00207140601177871

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Intl. Journal of Clinical and Experimental Hypnosis, 55(2): 115130, 2007 Copyright International Journal of Clinical and Experimental Hypnosis ISSN: 0020-7144 print / 1744-5183 online DOI: 10.1080/00207140601177871

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WHAT SHOULD WE MEAN BY EMPIRICAL VALIDATION IN HYPNOTHERAPY: Evidence-Based Practice in Clinical Hypnosis
1744-5183 0020-7144 NHYP Intl. Journal of Clinical and Experimental Hypnosis Hypnosis, Vol. 55, No. 2, January 2007: pp. 130 Empirical ASSEN ALLADIN Validation ET in AL. Hypnotherapy

ASSEN ALLADIN1
University of Calgary, Calgary, Alberta, Canada

LINDA SABATINI
Calgary, Alberta, Canada

JON K. AMUNDSON
Private Practice, Calgary, Alberta, Canada

Abstract: This paper briefly surveys the trend of and controversy surrounding empirical validation in psychotherapy. Empirical validation of hypnotherapy has paralleled the practice of validation in psychotherapy and the professionalization of clinical psychology, in general. This evolution in determining what counts as evidence for bona fide clinical practice has gone from theory-driven clinical approaches in the 1960s and 1970s through critical attempts at categorization of empirically supported therapies in the 1990s on to the concept of evidence-based practice in 2006. Implications of this progression in professional psychology are discussed in the light of hypnosiss current quest for validation and empirical accreditation.

THE DEVELOPMENT OF PROFESSIONAL PSYCHOLOGY AS CONTEXT FOR CONSIDERATION OF EVIDENCE-BASED HYPNOTHERAPY

Informing clinical practice through empirical methods and a research base has a 60-year history that reached critical threshold over the past 10 years (American Psychological Association [APA], 1995; Thorne, 1947). Fundamentally, this evolution, if not revolution, in mental health practice has involved attempts to determine what valid and reliable methods of treatment exist and ought to be promulgated (Chambless, Baker, et al., 1998; Chambless, Sanderson, et al., 1996). The
Manuscript submitted February 14, 2006; final revision accepted August 26, 2006. 1 Address correspondence to Assen Alladin, Ph.D., R.Psych., Department of Psychology, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB T2N 2T9, Canada. E-mail: assen.alladin@calgaryhealthregion.ca 115

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pursuit of guidelines or templates (APA, 1995, 2002) for clinical practice attempt to not only determine criteria by which to judge clinical validity but the methods to evaluate a given practice (Chambless & Hollon, 1998). This movement away from theory or model-based treatment to more critical science and random clinical trial (RCT) thresholds to determine the parameters of professional practice has been both enlivening to the profession and controversial. While the pursuit of accountability, respectability, and efficacy was in all ways laudable, determining what did and didnt count as basis for clinical practice was not without debate. As criteria for bona fide or acceptable treatment emerged and became increasingly linked to health care or insurance policy, concern for broader effectiveness or clinical utility criteria emerged and was advanced and debated in journals ranging from the American Psychologist, the Journal of Consulting and Clinical Psychology, and Canadian Psychology through Psychotherapy, Cognitive and Behavioral Practice and Clinical Psychology: Science and Practice. Simply stated, this debate on clinical validation contrasted the cleanliness of RCT-based treatment protocols and the listing of empirically supported therapies (EST) with the untidiness of realworld demands (Beutler, 1998, 2000; Beutler, Williams, & Enthwhistle, 1995; Borkovec & Castonguay, 1998; Clarke, 1995; Garfield, 1996; Hubble, Duncan, & Miller, 1999; Jacobson & Christensen, 1996; Persons & Silberschatz, 1998; Wampold, 2001). The issues of empirical definition/standard, transfer, generalizability, feasibility, patient accessibility, and cost/benefit made the all-encompassing benefits of treatment manuals less promising than might have been initially thought (Stricker, Abrahamson, Bologna, Hollon, Robinson, & Reed, 1999). Four main criticisms emerged as counterbalance to a simplistic completion of protocols associated with efficacious treatment. These criticisms related to: (a) definition of terminology; (b) research methodology; (c) limitations inherent in compiling/listing empirically supported therapies; and, (d) manual-based treatment. Definition of Terminology The main controversy here revolves around the APA Division 12 Task Force definitions of validated, well-established, probably efficacious, and experimental treatments. Although clear guidelines are available for these designations in various published reports (e.g., Chambless et al., 1996, 1998; Chambless & Hollon, 1998), the opponents of EST are not fully satisfied. For example, Garfield (1996) expressed concern that validated treatments may imply a greater degree of precision and authority than is supported by current research. The Task Force acknowledged the legitimacy of this concern and indicated that validation will never be complete; relative to the

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ongoing process that prevails in science. Hence, the Task Force adopted the term empirically supported treatments as opposed to empirically validated treatments. Hunsley, Dobson, Johnston, and Mikail (1999) argued that even if one accepts this stance, there may be problems in the actual determination as to whether a treatment meets the validated criteria. Garfield (1996) noted that the Task Force was inconsistent in the application of its own criteria when several of the studies employing very small samples were cited as supporting the validity of certain treatments. One might infer that this term empirically supported includes a realm of defining reference terms and criteria, in an attempt to accommodate both the rigorous adherence to the recommended criteria (based on the medical model involving clinical trials) and other relevant scholarly investigations (involving naturalistic approaches). Borkovec and Castonguay (1998) argued for the more inclusive definition. Methodology of Psychotherapy Research The research methods used to understand and to determine the efficacy of therapeutic techniques in psychology have typically followed in the medical model of clinical trials and statistical significance based on differences using control group comparisons. Wampold (1997) expressed concern for the strategy used by the Task Force to determine whether a delineated treatment meets the established criteria. He noted that the Task Force started with an empty set of EST to which were added treatments that met the established criteria. This strategy, he argues, may be inconsistent with the state of psychotherapy research, which indicates that most bona fide treatments are equally effective. This dodo bird verdict states that there is no difference between bona fide treatments, and, even if a difference exists, it is usually very small and confined to one or two outcome measures. Wampold puts forward the suggestion that the Task Force should have included all bona fide treatments in the list of EST and then removed those that proved to be inferior to others on a preponderance of measures. Kazdin and Bass (1989) point out that the reason for lack of large differences between the bona fide treatments may be due to lack of statistical power. Ollendick (1999) states that whatever criteria are used some treatments are likely to have more experimental support than others. Another argument is whether it is possible to export the findings of laboratory-based RCTs to the world of clinical practice. Subjects in RCTs do not represent real clinical clients or patients. Moreover, the experimental settings, usually universities, may be very different from real clinical settings and the experimenters may not represent typical clinical therapists. These are very realistic concerns and there is an urgent need to build a strong bridge between science and practice.

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The Task Force does not provide any blueprints on how to build a bridge between research therapy and clinic therapy. Nonetheless, the Task Force has provided the impetus for studying treatment effects regarding both the external and the internal validity. Another related concern revolves around the issue of therapeutic relationship. Several writers (Garfield, 1996; Henry, 1998; Wampold, 1997) have accused the Task Force of neglecting the characteristics of the clinicians, the nature of the therapeutic relationship, and the intricacies of clinical judgment in the empirical evaluation of treatments. Efficacy research has primarily focused on detecting differences between various treatment approaches. The treatments and clinicians have been homogenized, which dilutes some of the most important ingredients of successful psychotherapy. So, although it seems some treatments may be more efficacious than others, factors related to overall effectiveness variability require consideration. The Impact of Compiling a List of ESTs The Task force initiative has prompted the creation of a list of ESTs. There is always the risk of not including a treatment on the list that may be efficacious as well as the challenge of compiling an up-to-date, complete listing of ESTs (Garfield, 1996). Further, if a listing of treatments is to be useful in routine clinical practice, attention should be paid to the clinical setting and nature of services delivered. Such an approach would help to ensure that all forms of treatments related to a clinical setting are included in the list. However, again, transtheoretical and patient variables may be overriding factors that influence outcome beyond the simple efficacy of a given treatment. Use of Manuals Although treatment manuals have been used in psychotherapy for a long time, the Task Forces insistence that ESTs must be manual based has been a bone of contention. Ollendick (1999) defined a treatment manual as a set of guidelines that instruct or inform the user as how to carry out a certain treatment. He went on to state that a
. . . manual provides an operational definition of the treatment to be implemented, providing instruction in how to conduct the treatment in a relatively standard manner. Assuming the treatment was implemented in a fairly standard way, manuals could also allow for potential replication of efforts across therapists and settings. (p. 2)

Luborsky and DeRubeis (1984) wrote about the potential benefits of using treatment manuals in psychotherapy. Beck and colleagues treatment manual for depression (Beck, Rush, Shaw, & Emery, 1979) has been extensively used and studied. The Task Force has simply endorsed this movement. Those who oppose the usage of manuals

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consider them to be cookbooks (Silverman, 1996) and more a straightjacket than a set of guidelines (Goldfried & Wolfe, 1996). Hence they are wary about the manualization of treatments. Proponents seem puzzled that one would argue against the specification of what constitutes a certain type of therapy or how it should be implemented for a designated set of clients. Irrespective of the debate, the National Institute of Mental Health has officially adopted the recommendation of the Task Force and will only fund psychotherapy efficacy research studies that use manuals. Although this practice upholds standards for research activities, it limits our understanding and application of the findings along with the potential efficacy and outcomes for our clients. Another related concern to manualization is the standardization of treatment delivery. One of the main criteria for a treatment to be listed on the Task Force list of ESTs is the use of a manual. In this context, several criticisms have been leveled against the usage of manuals in clinical practice. These include (a) adherence to a manual, which may not reflect clinical competence; (b) treatment manuals may not be appropriate for some forms of psychotherapy; (c) since manuals often provide general principles of a treatment approach, they cannot provide guidance to treatment delivery; and (d) manuals may restrict clinical flexibility. Supporters of manuals argue that treatment manuals facilitate the dissemination of a treatment and they provide optimal intervention strategies in routine practice. As a result of concerns of this sort, the APA Presidential Task Force on Evidenced-Based Practice in Psychology (EBPP; APA, 2006) recently revised and expanded the criteria for evidence-based treatments. This Task Force considers empirical support for a particular approach to a particular problem as only one element in any effective treatment. Before discussing EBPP and its relevance to hypnotherapy, well review the empirical status of hypnotherapy.

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EMPIRICALLY SUPPORTED HYPNOTHERAPY

The pursuit of empirical support in hypnotherapy has been no less an issue and controversy. However, the movement toward empirical validation of clinical hypnosis is still in its infancy and, therefore, wider acceptance of hypnotic intervention under evidentiary standards remains contingent on further empirical research. A special issue of the International Journal of Clinical and Experimental Hypnosis (2000) assessed the status of hypnosis as an empirically supported clinical intervention. The guidelines developed by APA (Chambless & Hollon, 1998) were the chosen yardsticks to assess the clinical efficacy of hypnotherapy. The editor of the special issue (Nash, 2000) stated that the advantage of adopting these general guidelines for this report

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is that it enables us to compare hypnosis empirical record of efficacy with that of other therapeutic interventions (p.109). Six papers catalogued and critiqued the research literature in the areas of clinical hypnosis with children (Milling & Costantino, 2000), hypnotic analgesia (Montgomery, DuHamel, & Redd, 2000), hypnosis as an adjunct to cognitive-behavioral therapy (Schoenberger, 2000), hypnosis in medicine (Pinnell & Covino, 2000), hypnosis and smoking cessation (Green & Lynn, 2000), and hypnosis in the treatment of posttraumatic stress disorder (Cardea, 2000). A seventh paper by Lynn, Kirsch, Barabasz, Cardea, and Patterson (2000) summarized the findings across the articles and made recommendations for future research. The evidence drawn from this literature review continues to be relevant in the present climate of competition for health care dollars and the existence of various effective cognitive-behavioral psychotherapies. It was considered essential to conduct controlled-outcome research in order to validate the utility of clinical hypnosis, particularly with children and adolescents. Because efficacy was considered to be the gold standard, it is only through clinical validation that hypnosis might be considered efficacious for a particular disorder or particular group of clients. For example, a wealth of published case material has provided anecdotal evidence suggesting that clinical hypnosis may be helpful for many sorts of child psychological and medical problems. Milling and Costantino (2000) believe the field of child hypnosis is in an early stage of development and hence uncontrolled outcome studies and case observations can play an important role in pointing toward useful avenues for investigation and methods of clinical practice (p. 114). So, too, can theoretical papers and case studies. However, gold standard validation regarding children and hypnosis has yet to be achieved. In contrast to the paucity of controlled studies in child hypnosis, hypnoanalgesia has been investigated empirically. Montgomery et al. (2000) conducted a meta-analytic review of 18 articles and 27 effect sizes to determine the effectiveness of hypnotic suggestions for pain relief relative to other nonhypnotic psychological interventions. In light of the positive findings, Montgomery and his colleagues recommended broadening the application of hypnotic procedures with pain patients. Lynn and colleagues (2000) concluded that the fact that hypnosis can be considered a well-established treatment for pain should go a long way to ensure that hypnotic interventions move into the mainstream of first-line interventions for pain-related disorders and conditions (p. 242). An important consideration, however, in studying hypnosis from an RCT/EST perspective relative to pain and other areas is that it is not usually used as a stand-alone treatment. Currently, it is largely used as an adjunctive technique that can be easily integrated with cognitive,

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behavioral, or psychodynamic techniques. Although such integration is feasible, it is questionable whether the inclusion of the hypnotic modality increases the treatment effect of a particular combined therapy. Kirsch, Montgomery, and Sapirstein (1995) carried out a metaanalysis of 18 studies (1974 to 1993) comparing cognitive-behavioral treatments (CBT) with the same treatments supplemented by hypnosis to examine this issue. Their review found the mean effect size for the CBT treatment supplemented by hypnosis to be significantly larger than CBT alone. Similarly, Schoenberger (2000), in a more detailed review, substantiated the additive value of hypnotic interventions when combined with CBT. However, Schoenberger pointed out that no hypnotically augmented CBT has as yet met the criteria for wellestablished treatment, although promising treatment gains have been observed in relation to obesity, anxiety disorders, and pain management. She went on to say that since many CBT procedures are easily conducted with hypnosis or simply relabeled as hypnosis, CBToriented clinicians with experience in hypnosis may easily establish a hypnotic context as a simple, cost-effective means of enhancing treatment efficacy (p. 244). The challenge, however, even in the face of some empirical validation, remains in distinguishing the characteristic differences among hypnotic techniques, CBT, and other therapeutic techniques. The study by Alladin and Alibhai (2007; in this issue) addresses some of these issues. Although hypnosis has been used in medicine from antiquity to the present time, the review by Pinnell and Covino (2000) indicated that currently there was only moderate support for integrating hypnotic techniques into the treatment of medical problems. The reviewers indicate that wider acceptance of hypnotic intervention in medicine will be contingent on further empirical research. Nonetheless, there is empirical evidence to support the effectiveness of psychological treatments that include hypnotic interventions with preoperative preparation of surgical patients, a subgroup of asthmatic patients (see Brown, 2007; in this issue), certain dermatological disorders, irritable bowel syndrome, postchemotherapy nausea and emesis, and with obstetrical patients. However, it is unclear whether hypnosis adds anything to treatment effectiveness above and beyond information, relaxation training, or suggestions provided without a hypnotic induction (Pinnell & Covino). In other words, the role of hypnosis and hypnotizability has not been efficaciously determined. Pinnell and Covino argue that even if in the future researchers are able to determine the additive effect of hypnotherapy, it will be also important to determine the mechanisms through which psychological and hypnotic interventions effect physiological changes. Although many hypotheses, including changes in immune functioning, autonomic control of blood supply, and an increased subjective sense of cognitive involvement and control, are

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advanced, the mechanisms are not understood. Cardeas (2000) reference to The Hunting of the Snark reflects what we know about hypnotherapy:
In The Hunting of the Snark, Lewis Carroll whimsically stated that any statement becomes a fact if it is repeated three times. Much of what passes for clinical lore is really just a set of statements that, repeated over generations by mentors and authors, have become facts. (p. 233)

The empirical status of hypnosis in the area of smoking cessation is also fraught with methodological issues. From their review of 59 studies of hypnosis and smoking cessation, Green and Lynn (2000) concluded that hypnosis cannot, as yet, be regarded as a well-established treatment for smoking cessation (p. 195). Although hypnotic procedures generally yield higher rates of abstinence relative to waiting-list and no-treatment controls, the effects of hypnotic interventions are generally comparable to a variety of nonhypnotic treatment. Moreover, the evidence for whether hypnosis yields outcomes superior to placebos is mixed. Further, in many cases, it is impossible to determine whether the treatment gains associated with hypnosis are related to the hypnotic procedure or to cognitive, behavioral, or educational procedures. Nevertheless, Green and Lynn contend that, in the light of the evidence available, it is justified to classify hypnosis as a possibly efficacious treatment for smoking cessation. (p. 195). They recommend various methodological procedures for improving future research and believe that future research will more firmly establish hypnosis as an empirically supported treatment for smoking cessation and elucidate ways in which hypnosis can be combined with other interventions to contribute to the health and well-being of our society (p. 219). Although hypnosis has been widely used with posttraumatic conditions, such as posttraumatic stress disorder (PTSD), and survivors of sexual assaults and accidents, there have been almost no systematic studies on the efficacy of hypnosis with posttraumatic disorders (Cardea, 2000, p. 225). Cardea, after reviewing the literature on hypnosis and trauma, remarked that this
. . . state of affairs is especially disappointing considering that hypnosis can be easily integrated into therapies that are commonly used with traumatized clients; a number of PTSD individuals have shown high hypnotizability in various studies; hypnosis can be used for symptoms associated with PTSD; and hypnosis may help modulate and integrate memories of trauma. (p. 225)

Cardenas observation does not suggest hypnosis is not effective with posttraumatic conditions, he is indicating that the effectiveness of

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a hypnotic treatment should be systematically established before it can be declared as effective, under the criteria associated with purely empirically supported status. Since this publication, further progress has been made in the application of hypnotherapy with PTSD (see Lynn & Cardea, 2007; in this issue). Empirical Status Seeking As reflected above, parallel to pursuit of empirically supported status in psychology generally, hypnosis has subjected itself in particular to the rack of RCTs and the APA guidelines (Chambless & Hollon, 1998). This effort, as reviewed above, has been less than successful. However, Amundson, Alladin, and Gill in 2003 argued that perhaps limiting therapy in general and hypnosis in particular to these narrow criteria may miss other equally compelling empirical considerations. In their argument, the authors identify effectiveness-focused research as being of equal if not greater relevance than simple efficacy-focused gatekeeping. Efficacy-focused research arises from the medical model and seeks to evaluate specific models and specific therapeutic protocols with the criteria or goal of achieving empirically supported therapy status (Nash, 2000). The emphasis here is upon the content of a particular treatment. Replication is highly desired and hence guidelines, manuals, and standards of practice are emphasized. Effectiveness-focus research attempts to understand not only the ways therapy is practiced in the real world but also to identify those factors and dynamics that influence therapy (Beutler, 1998; Cone, 2001; Luborsky, McClellan, Diguer, Woody, & Seligman, 1997; Seligman, 1996). The focus here is on the process of psychotherapy, and investigation is directed at discovering and explaining what might make any treatment work. While efficacy-based methodology places greater emphasis on internal validity and how consumer benefit or gain is achieved, effectiveness-focused research emphasizes external validity and is driven by real-world factors. Amundson, Alladin, and Gill (2003) argue that the concept of clinical effectiveness as a research-based methodology may have a greater significance for the field of clinical hypnosis. In fact, the authors caution that if EST and efficacy-focused research becomes the exclusive fulcrum for treatment judgment, it is possible that hypnosis could be at risk as a clinical practice (p. 13). This argument is today reflected in contemporary APA science and practice integration where effective practice is defined as application and integration of the best available research with clinical expertise, in the context of patient characteristics culture and preference (APA, 2006, p. 273). Frederick (2007; in this issue) has integrated some of these issues in her treatment protocol for Obsessive-Compulsive Disorder.

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EVIDENCE-BASED PRACTICE IN PSYCHOLOGY/HYPNOTHERAPY

The APA Presidential Task Force on Evidenced-Based Practice in Psychology-EBPP (APA, 2006) recently released its report on the refinement of clinical practice. The Task Force and report arose from a realization that empirical support for a particular approach to a particular problem (EST criteria and list-focused research) may be only one element in any effective treatment. Efficacious treatment, it is their finding, is embedded in not less than eight additional research-based and research-supported dynamics. They refer to these activities as the constituent aspects of clinical expertise (p. 275). Clinical expertise has a rich history of empirical investigation. This research based on what makes efficacious treatments effective involves therapist activities related to:
Assessment, diagnostic judgment, systematic case formulation, and treatment planning Clinical decision making, treatment implementation, and monitoring of patient progress Interpersonal expertise Continual self-reflection and acquisition of skills Evaluation and use of research evidence Understanding the influence of individual, cultural, and contextual differences on treatment Seeking available resources as needed (e.g., consultation, adjunctive, or alternative services) A cogent rationale for clinical strategies (APA, 2006, p. 276278)

Clinical expertisethe ability to adequately execute the role/function of a therapistinvolves multiple complex skills that are associated with effective treatment. A model or approach per se is situated within or serves as vehicle for acquirable skills, established through research, which potentiate or make more effective a given empirically supported treatment. Wittgenstein, the philosopher, once stated that it impressed him very little when a man states he owns a trapeze artists suit: he would wait to see to what use he puts it. So too might we state that it impresses us less that a particular treatment approach has attained EST status as we await its usefulness in the context of a particular patient.

IMPLICATIONS FOR CLINICAL HYPNOSIS

Evidence-Based Hypnotherapy Practice Clarke (1995) suggested that a merging of the best treatment science we have is likely to provide the most useful information about generic

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change process. This proposition is also inherent in the Amundson, Alladin, and Gill article from 2003. What this means for hypnosis can be clearly stated. Empirical methods, research-informed practice, and evidence-based treatment, if they are to be central to the practice of clinical hypnosis, ought to be applied to both the content and process of treatment. Content empiricism involves determining efficacy: what are the simplest, most likely treatments to address a particular sort of difficulty in a valid and reliable fashion. This position in hypnosis is reflected in the proposition by Lynn et al. (2000) that it is timely for hypnosis to adopt the initial APA Task Force criteria in evaluating and showcasing specific hypnotherapeutic treatments. The procrustean bed of RCT and statistical evaluation has a place in clinical practice when debates regarding mode, approach, or technique emerge. Secondarily, RCTs guard hypnosis from unduly embracing bold and speculative theory that is as yet unsubstantiated by treatment protocols. As stated in the APA Presidential Task Force (2006):
It is important not to assume that interventions that have not yet been studied in controlled trials are ineffective. . . . Nonetheless, good practice and science call for timely testing of psychological practices [read: specific hypnotherapeutic treatments] in ways that adequately operationalize them using appropriate scientific methodology. (p. 274)

On yet another level, embracing standards associated with EST links content empiricism (critical evaluation of claims for a specific method) to process empiricism (critical attention to the ways treatment of whatever sortis made more effective. Process-related variables hold great promise for hypnosis. In essence, process-focused research emphasizes domains associated with clinical expertise: how to engage, to conceptualize, to strategize influence, to increase receptivity, to account for patient status, to promote active participation, to formulate, to reflect, to evaluate, etc., in ways associated with research on better outcome (Amundson & Gill, 2001). Implications of Evidence-Based Hypnotherapy Practice for Research, Training, and Practice There are then very specific implications for clinical hypnosis in the light of efficacy and effectiveness considerations and the current task force position on EBPP. These professional considerations impact training and professional education, research, clinical practice, and hypnosiss responsibility to the public. Regarding training and professional education in hypnotherapy, there are specific ramifications regarding EBPP. If hypnosis is to become a more legitimate component of professional training, it will be important for trainers, teachers, students, or interns to:

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Appreciate the importance of empirically supported treatment protocols in effective treatment Appreciate the use of critical evaluation in limiting self or patient deception through theory-based or purely speculative models of treatment Utilize empirical perspectives to treatment proper so that each case may be considered an N of 1 in service to process and outcome effectiveness Understand process researchappreciation of the skills associated with better outcome generallyand see the relevance of such research to advancing hypnotherapy Learn to situate and to rationalize ones practice generally through content and/or process research Continually review the literature and/or state of the art regarding research of a critical nature Neither succumb to undue romanticism (i.e., too much emphasis upon the art and indeterminate aspects of treatment) nor scientism (i.e., too narrow or limiting criteria related solely to efficacy)

Regarding research more generally, there are similar admonitions for the field of clinical hypnosis. It would be axiomatic that: (a) as definitively as possible, demonstrate replicability through controlled studies and development of protocols for the use of hypnosis for particular disorders; however, (b) research ought to focus as well upon the supraordinate areas of clinical expertise; (c) in the light of health care concerns and cost-benefit emphasis, integration of both treatment approaches proper and broader considerations about ways to make treatment more effective, converge; (d) radical or unusual treatment approaches or claimsan endemic aspect it seems of hypnotherapy (Yapko, 1994)be explicated regarding not only ability to stand up to RCTs but to appreciate what might make a nonefficacious treatment (an approach that does not meet criteria for EST inclusion) effective (able to achieve outcome in clinical observations or case studies). For clinical practice, an evidence-based hypnotherapy would incorporate the principles associated with education and training in the light of:
Aspirations to ground all clinical activities in a research base, arising from treatment specific empirical content and the principles associated with processes related to clinical expertise More pragmatic application of treatment in the light of research on outcome generally and case to case specifically Promotion of hypnosis to the extent it serves patients best interests relative to outcome and economy

Finally, in regard to responsibility to society, empirical methods and our research base ought to be brought to bear in order to:
Promote a prudent, even conservative, view of hypnosis regarding its role in particular treatments

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Counter or address representations of hypnosis that have yet to be shown to be valid or reliable or that misrepresent what is known about hypnosis

CONCLUSION
As with the initial empirical wave in psychology in general, so too with hypnosis there is, at second glance, more than has met the eye. In pursuit of inclusion of hypnosis within bona fide standards of evidence-based practice there are both the particular empirical content of given treatments and the process of effective treatment. Hypnosis has a rich and both romantic and scientific past. It is our belief, in light of the above consideration, that it can have a useful and beneficial future. The current and next issue of this journal is devoted to evidence-based hypnotherapy practice to illustrate that practitioners of hypnotherapy take their field seriously and are not divorced from the trends and controversies surrounding psychotherapy.
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Was wir unter empirischer Validierung in der Hypnosetherapie verstehen sollten: Evidenzbasierte Praxis in Klinischer Hypnose Assen Alladin, Linda Sabatini und Jon K. Amundson Zusammenfassung: Diesel Artikel gibt einen berblick ber die Entwicklung und die Kontroverse um empirische Validierung in der Psychotherapie. Die empirische Validierung der Hypnosetherapie verlief parallel zur Validierungspraxis im Bereich der Psychotherapie und zur Professionalisierung der klinischen Psychologie im Allgemeinen. Diese Entwicklung der Ausarbeitung von Kriterien fr gute klinische Praxis verlief ausgehend von den theoriegeleiteten klinischen Anstzen in den 60er und 70er Jahren ber die kritischen Anstze zur Kategorisierung von empirisch gesttzten Therapien in den 90er Jahren hin zum Konzept der Evidenzbasierten Praxis im Jahr 2006. Die Implikationen dieses Verlaufs in der professionellen Psychologie werden im Hinblick auf die gegenwrtigen Bestrebungen nach Validierung und empirischer Akkreditierung der Hypnose besprochen. RALF SCHMAELZLE University of Konstanz, Konstanz, Germany Ce que devrait signifier validation empirique en hypnothrapie: Pratiques fondes sur lexprience en hypnose clinique Assen Alladin, Linda Sabatini et Jon K. Amundson Rsum: Cet article examine brivement la tendance avoir recours la validation empirique en psychothrapie et la controverse suscite par cette mthode. La validation empirique de lhypnothrapie a volu, en parallle

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avec la pratique de la validation en psychothrapie et avec la professionnalisation de la psychologie clinique en gnral. La dtermination de ce qui constitue une exprience concluante de pratique clinique srieuse a beaucoup volu depuis les dernires dcennies, allant des approches cliniques fondes sur la thorie qui avaient cours dans les annes 1960 et 1970, des tentatives cruciales de catgorisation de thrapies concrtes durant les annes 1990, jusquau concept de pratique fonde sur lexprience clinique, en 2006. Les implications de cette progression du domaine de la psychologie professionnelle sont discutes la lumire du besoin actuel de validation et de reconnaissance empirique de lhypnose. JOHANNE REYNAULT C. Tr. (STIBC) Cmo debemos interpretar la validacin emprica en la hipnoterapia? La prctica basada en la evidencia en la hipnosis clnica Assen Alladin, Linda Sabatini, y Jon K. Amundson Resumen: Este artculo describe brevemente la tendencia y controversias que rodean a la validacin emprica en la psicoterapia. La validacin emprica en la hipnoterapia ha sido paralela a la prctica de validacin en la psicoterapia y la professionalizacin de la psicologa clnica en general. Esta evolucin para determinar qu cuenta como evidencia en la buena prctica clnica ha pasado de enfoques clnicos basados en la teora en el decenio de los 60s y 70s a intentos crticos de categorizacin de terapias con bases empricas en los 90s al concepto de prctica basada en la evidencia en el 2006. Discutimos las implicaciones de esta progresin en la psicologa profesional desde la perspectiva del movimiento actual de la hipnosis para su validacin y acreditacin empricas. ETZEL CARDEA University of Lund, Lund, Sweden