Clinical review

Hypnosis and relaxation therapies

Andrew Vickers,  Catherine Zollman. 

A wide variety of complementary therapies claim to improve health by producing relaxation. Some use the relaxed state as a means of promoting psychological change. Others incorporate movement, stretches, and breathing exercises. Relaxation and "stress management" are found to a certain extent within conventional medicine. They are included here because they are generally not well taught in conventional medical curriculums and because of the overlap with other, more clearly complementary, therapies.

Franz Mesmer, 1734-1815, was responsible for the rise in popularity, and notoriety, of hypnosis ("mesmerism") in the 18th century

	Techniques

Top Techniques What happens during a... Therapeutic scope Safety Practice

Hypnosis
Hypnosis is the induction of a deeply relaxed state, with increased suggestibility and suspension of critical faculties. Once in this state, sometimes called a hypnotic trance, patients are given therapeutic suggestions to encourage changes in behaviour or relief of symptoms. For example, in a treatment to stop smoking a hypnosis practitioner might suggest that the patient will no longer find smoking pleasurable or necessary. Hypnosis for a patient with arthritis might include a suggestion that the pain can be turned down like the volume of a radio.

Relaxation and meditation techniques
One well known example of a relaxation technique is known variously as sequential muscle relaxation (SMR), progressive relaxation, and Jacobson relaxation. The subject sits comfortably in a dark, quiet room. He or she then tenses a group of muscles, such as those in the right arm, holds the contraction for 15 seconds, and then releases it while breathing out. After a short rest, this sequence is repeated with another set of muscles. Gradually, different sets of muscle are combined.

Many relaxation techniques aim to increase awareness of areas of chronic unconscious muscle tension. They often involve a conscious attempt to release and relax during exhalation

In China many people practise tai chi for health promotion on a daily basis

	What happens during a treatment?

Top Techniques What happens during a... Therapeutic scope Safety Practice

Hypnosis
In hypnosis, patients normally see practitioners by themselves for a course of hourly or half hourly treatments. Some general practitioners and other medical specialists use hypnosis as part of their regular clinical work and follow a longer initial consultation with standard 10-15 minute appointments. Patients can be given a post-hypnotic suggestion that enables them to induce self hypnosis after the treatment course is completed. Some practitioners undertake group hypnosis, treating up to a dozen patients at a timefor example, teaching self hypnosis to antenatal groups as preparation for labour.

Self hypnosis can be taught to pregnant women as preparation for labour

Relaxation and meditation techniques
Most relaxation techniques need to be practised daily. Typically, patients learn a relaxation technique over the course of eight weekly classes, each lasting an hour or so. Between classes, they practise by themselves for 15 to 30 minutes a day. After the course is over, patients are encouraged to continue on their own, though they may take further classes to learn advanced techniques or to maintain group support. Methods such as sequential muscle relaxation are learnt relatively readily: yoga, tai chi, and meditation can take years to master completely.

Relaxation classes can play a social function in addition to having therapeutic benefits

	Therapeutic scope

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The primary uses of hypnosis and relaxation techniques are in anxiety, in disorders with a strong psychological component (such as asthma and irritable bowel syndrome), and in conditions that can be modulated by levels of arousal (such as pain). They are also commonly used in programmes for stress management.

Research evidence
There is good evidence from randomised controlled trials that both hypnosis and relaxation techniques can reduce anxiety, particularly that related to stressful situations such as receiving chemotherapy. They are also effective for panic disorders and insomnia, particularly when integrated into a package of cognitive therapy (including, for example, sleep hygiene). A systematic review has found that hypnosis enhances the effects of cognitive behavioural therapy for conditions such as phobia, obesity, and anxiety.

	Safety

Top Techniques What happens during a... Therapeutic scope Safety Practice

Adverse events resulting from relaxation techniques seem to be extremely uncommon. Though rare, there have been reports of basilar or vertebral artery occlusion after yoga postures that put particular strain on the neck Sequential muscle relaxation should be avoided by people with poorly controlled cardiovascular disease as abdominal tensing can cause the Valsalva response. In patients with a history of psychosis or epilepsy there have been reports of further acute episodes after deep and prolonged meditation.

Though rare, cases of basilar or vertebral artery occlusion have been reported after certain yoga positions that put stress on the neck

Hypnosis or deep relaxation can sometimes exacerbate psychological problemsfor example, by retraumatising those with post-traumatic disorders or by inducing "false memories" in psychologically vulnerable individuals. Concerns have also been raised that it can bring on a latent psychosis, although the evidence is inconclusive. Hypnosis should be undertaken only by appropriately trained, experienced, and regulated practitioners. It should be avoided in established or borderline psychosis and personality disorders, and hypnotherapists should be competent at recognising and referring patients in these states.

	Practice

Top Techniques What happens during a... Therapeutic scope Safety Practice

Relaxation techniques are often integrated into other healthcare practices. For example, they may be included in programmes of cognitive behavioural therapy in pain clinics or occupational therapy in psychiatric units. Many different complementary therapists, such as osteopaths and massage therapists, may include some relaxation techniques in their work. Some nurses use relaxation techniques in the acute setting, such as in preparation for surgery. A small number of general practices offer regular classes in relaxation, yoga, or tai chi.

Regulation
The practice of many relaxation techniques is poorly regulated, and standards of practice and training are variable. This situation is unsatisfactory, but, given the relatively benign nature of many relaxation techniques, this variation in standards presents usually more of a problem of ensuring effective treatment and good professional conduct rather than one of avoiding adverse effects.

Training
The British Society of Medical and Dental Hypnosis runs basic, intermediate, and advanced courses for doctors and dentists and holds regular scientific meetings. There is no standard training in hypnosis for practitioners without a conventional healthcare background.

	Acknowledgments

The picture of Mesmer is reproduced with permission of UT Medical Branch Library. The pictures of relaxation techniques are reproduced with permission of BMJ/Ulrike Preuss. The picture of tai chi exercise is reproduced with permission of Hutchison Library/Felix Greene. The picture of a pregnant woman is reproduced with permission of Mother and Baby Picture Library. The picture of yoga is reproduced with permission of Collections/Sandra Lousada.

	Footnotes

The ABC of complementary medicine is edited and written by Catherine Zollman and Andrew Vickers. Catherine Zollman is a general practitioner in Bristol, and Andrew Vickers will shortly take up a post at Memorial Sloan-Kettering Cancer Center, New York. At the time of writing, both worked for the Research Council for Complementary Medicine, London. The series will be published as a book in Spring 2000.