How practitioners (and others) can make scientifically viable contributions to clinical-outcome research using the single-case time-series design

Review article: the effectiveness of group and self-help hypnotherapy for irritable bowel syndrome and the implications for improving patients' choice and access to treatment

BACKGROUND

Individual hypnotherapy (IH) is a recognised treatment for irritable bowel syndrome (IBS). However, it is not widely available to patients due to its resource-intensive nature, lack of adequately trained therapists, and scepticism about hypnosis. Non-individualised hypnotherapy approaches, such as group and self-help hypnotherapy, could maximise existing therapist resources by treating more patients at the same time, thus widening patient access to treatment without incurring additional expenditure.

AIMS

To investigate the research literature for non-individualised approaches to hypnotherapy for IBS and to determine their effectiveness for reducing symptom severity and/or providing adequate relief.

METHODS

A literature review of published peer-reviewed studies was conducted. Quantitative research was selected to determine the effectiveness of the interventions.

RESULTS

Ten studies were eligible for inclusion. Three delivered group hypnotherapy, three integrated hypnosis within a group concept, and four utilised a self-help home hypnotherapy treatment using audio recordings. Both group hypnotherapy for adults and the self-help home hypnotherapy treatment for children were effective interventions that may be non-inferior to IH for patients with mild-to-moderate symptoms. Treatment benefits were long-lasting. The evidence for the integrative group concept and home treatment for adults was less compelling.

CONCLUSIONS

Group hypnotherapy for adults, and self-help hypnotherapy for children, may be cost-effective treatments that can widen access for patients with milder IBS in primary care settings. Further research is needed to determine the effectiveness of group hypnotherapy for patients with severe, refractory IBS.

Hypnosis for refractory severe neuropathic pain: A case study

Chronic pain not only has the greatest negative effect on quality of life compared with other chronic health problems but also contributes to the greatest disability worldwide. Management of chronic neuropathic pain is particularly challenging given its association with other pain processes, the fact that less than half of patients respond to a single pain medication, and the lack of evidence regarding combination therapy (i.e. a treatment regimen that combines several scheduled pain medications) safety and efficacy. Given these challenges, there is a growing interest in the application of complementary and alternative medicine (CAM) therapies such as yoga, acupuncture, and hypnosis. We present the case of a 67-year-old male with severe diabetic neuropathy refractory to first, second, and third-line treatments. His disabling pain precipitated premature retirement, contributing to severe depression with suicidality requiring hospitalization. Ultimately, he experienced relief through an integrative health regimen, and he identified hypnosis as the most effective therapy for his pain. Through individual and group sessions, recordings, and daily self-hypnosis, he improved both his chronic pain symptomatology and quality of life, simultaneously decreasing opioid use. Simulation modeling analysis of his pain ratings over time showed that they reliably decreased after engaging in hypnosis, r = -.33, p =.001. A growing body of research suggests that hypnosis is beneficial as part of an integrative treatment approach to chronic pain and enhances the efficacy of other therapies. Our medically challenging case study supports that hypnosis may serve as a viable and durable treatment for chronic neuropathic pain.

A randomized trial to examine the mechanisms of cognitive, behavioral and mindfulness-based psychosocial treatments for chronic pain: Study protocol

This randomized trial will evaluate the mechanisms of three chronic pain treatments: cognitive therapy (CT), mindfulness meditation (MM), and activation skills (AS). We will determine the extent to which late-treatment improvement in primary outcome (pain interference) is predicted by early-treatment changes in cognitive content, cognitive process, and/or activity level. The shared versus specific role of these mechanisms across the three treatments will be evaluated during treatment (Primary Aim), and immediately post-treatment to examine relapse mechanisms (Secondary Aim). We will enroll 300 individuals with chronic pain (with low back pain as a primary or secondary condition), with 240 projected to complete the study. Participants will be randomly assigned to eight, 1.5 h telehealth group sessions of CT, MM, or AS. Mechanisms and outcomes will be assessed twice daily during 2-week baseline, 4-week treatment period, and 4-week post-treatment epoch via random cue-elicited ecological momentary assessment (EMA); activity level will be monitored during these time epochs via daily monitoring with ActiGraph technology. The primary outcome will be measured by the PROMIS 5-item Pain Interference scale. Structural equation modeling (SEM) will be used to test the primary aims. This study is pre-registered on clinicaltrials.gov (Identifier: NCT03687762). This study will determine the temporal sequence of lagged mediation effects to evaluate rates of change in outcome as a function of change in mediators. The findings will provide an empirical basis for enhancing and streamlining psychosocial chronic pain interventions. Further, results will guide future efforts towards optimizing maintenance of gains to effectively reduce relapse risk.

Psychodynamic Psychotherapy With Adjunctive Hypnosis for Anxiety Management and Smoking Cessation

The present study examines the therapy of an individual diagnosed with generalized anxiety disorder, two situation type specific phobias, and nicotine dependence. Treatment consisted of psychodynamic psychotherapy with adjunctive hypnosis. Client’s symptoms were tracked using daily, self-report measures over the 6-month treatment period. The simulation modeling approach for time-series was used to assess the phase change from baseline to treatment. Tracked symptoms included generalized anxiety, worry associated with specific phobias, phobic avoidance, number of cigarettes smoked daily, and nicotine craving intensity. All symptoms decreased significantly over the course of treatment. Utility of an ideographic and also quantified research methodology for treatment outcome studies are discussed.

An unanticipated allergic reaction to a hypnotic suggestion for anesthesia: a brief communication and commentary

During a demonstration of hypnotically induced anesthesia and following a suggestion for a Novocain-like numbness, a totally unanticipated and dramatic swelling of 1 cheek appeared. The participant had forgotten to inform the psychologist that she had experienced the identical reaction to Novocain when she received an injection a few weeks earlier. The swelling was quickly removed by a countersuggestion based upon a simulated injection of the antidote previously administered by the dentist. This case report is relevant to current research and theorizing on the interaction of hypnosis with the immune system. The fact that it was retrospectively recognized as a single-case time-series B-A-B design significantly enhances its scientific value beyond that afforded by the traditional case report.

Expanding the single-case study: a proposed psychoanalytic research program

This paper offers a proposed program of research using single-case time-series methods that can be used by practicing clinicians. The paper is written for psychodynamically oriented clinicians who want to get involved in psychotherapy research and make contributions to the scientific literature. How to measure treatment outcomes and psychodynamic constructs are discussed. With few exceptions, conducting single-case time-series research using psychodynamic psychotherapy has far more advantages than disadvantages.

Psychodynamic Psychotherapy With Adjunctive Hypnosis for Social and Performance Anxiety in Emerging Adulthood

This is a single case study of a college aged woman with generalized anxiety disorder. Treatment consisted of psychodynamic psychotherapy, with an emphasis on facilitating separation and individuation, using hypnosis as a supportive, self-regulation skill for anxiety management. The patient’s symptoms were tracked using daily subjective, self-report measures over the 13-month treatment period. The simulation modeling approach for time-series (SMATS) was used to assess the phase change from baseline to treatment. Symptoms tracked included anxiety peaks, preoccupation with time, interpersonal closeness, and self-sacrificing of self for others. The patient’s worries about time decreased significantly over the course of treatment. There was also a trend of both less interference of anxiety in the patient’s daily tasks and less self-sacrificing behaviors in her interpersonal relationships. Utility of an idiographic and also quantified research methodology for treatment outcome studies is discussed.

Routine assessment of patient-reported outcomes in behavioral health: room for improvement

Outcomes assessment has become an important tool in assessing the quality of health care. To date, most quality initiatives have focused on adverse events, clinical processes, and/or cost variables. Considerably less attention has been paid to indices of clinical improvement, especially from a patient's perspective and in behavioral health settings. The relative inattention given to clinical improvement is attributable to a number of reasons, including (but not limited to) a lack of consensus regarding measures of improvement, few simple methods for data collection and analysis, and an inability to provide timely feedback. In this article, the authors describe a Web-based system designed to routinely collect quality-of-life ratings from patients in outpatient behavioral health clinics, allowing for real-time feedback at the patient levels regarding clinical improvement. The system also allows for administrative evaluation of overall clinic performance. The costs and benefits of this system are discussed.

Neurophysiological attributes of the hypnotic state and the utility of hypnosis in pediatric medicine and burn care

Three articles of special interest to the hypnosis community recently appeared in the general scientific and medical literatures. The first paper is a thoughtful review of the clinical applications of hypnosis in pediatric settings. The second article reports the findings of a randomized, controlled trial of hypnosis for burn-wound care, carried out at the University of Washington Medical School. The third article describes an innovative EEG laboratory case study tracking the cortex functional connectivity of a highly hypnotizable subject across various baseline and experimental conditions. These three articles are sturdy examples of how hypnosis illuminates (and is illuminated by) medical and psychological science.

Clinical outcomes assessment in behavioral healthcare: searching for practical solutions

Most quality management initiatives in behavioral healthcare have focused on adverse events, clinical processes, or cost variables. Considerably less attention has been paid to indices of clinical improvement, likely because of a lack of agreed-upon measures of improvement, a lack of availability of simple methods for data collection and analysis, and an inability to provide timely feedback regarding clinical improvement, among other reasons. A computerized system was designed to collect relevant psychiatric symptom ratings in a manner that allows for real-time feedback at the patient and clinician Levels regarding clinical improvement and for higher-level, administrative evaluation of overall clinic performance. The costs and benefits of this system are discussed.

Enhancing patient safety in psychiatric settings

OBJECTIVE

There is growing national consensus that use of institutional measures of control, such as seclusion, restraint, enforced medications, and hand-cuffed transport, within psychiatric hospitals is all too common and is potentially counter-therapeutic. Unfortunately, little is known about how to reduce such measures of last resort. This article reviews the available literature and describes a proposed research agenda involving a behavioral effort, the Engagement Model, for reducing seclusion and restraint procedures and enhancing patient safety in psychiatric settings.

METHODS

Using Medline and PsychInfo, we reviewed studies that specifically evaluated efforts to reduce seclusion and restraint on psychiatric units. Key search terms included seclusion, restraint, reduc*, psychiatric patient safety, psychiatric safety, psychiatric sanctuary, and quality of care psychiatry.

RESULTS

Only very limited data are available on reducing measures of last resort and improving the safety of psychiatric settings, and virtually no controlled data are available concerning the effectiveness of specific behavioral efforts on subsequent reduction of seclusion and restraint events. In light of the paucity of data, we describe efforts to incorporate and evaluate such a model in a large academic psychiatric hospital using a multiple baseline times-series design and review principles for and obstacles to implementing this model.

CONCLUSIONS

It is hoped this discussion will stimulate research on this understudied topic and provide a framework for improving patient safety in psychiatric settings.

Evaluating Initiatives to Reduce Seclusion and Restraint

The use of institutional measures of control such as seclusion and restraint within psychiatric hospitals is common and arguably countertherapeutic; however, little is known about how best to reduce the use of these measures. The development and implementation of new institutional strategies to reduce the use of seclusion and restraint are important. Although traditional performance improvement (PI) project methodology might seem well-suited to helping managers and administrators identify effective hospital-wide interventions to decrease seclusion and restraint rates, the Logic of the standard PI model precludes managers from making valid inferences about which interventions actually cause change. This article presents a model (derivative of the multiple baseline time-series design with randomization) for testing individual elements of a Large-scale PI project to reduce the use of seclusion and restraint in a behavioral healthcare organization. The proposed model is flexible, accommodates overlapping organizational initiatives, and simultaneously allows for meaningful inferences to be made about the active components of the interventions. The ability to make meaningful inferences is important because, if the initiatives to reduce seclusion and restraint rates work, other healthcare organizations would benefit from knowing Key Words which specific interventions actually Lead engagement model to change and which interventions have multiple baseline design Little impact on secLusion and restraint performance improvement rates. Early experiences with this model psychiatry from a hospital manager's perspective sanctuary trauma are discussed, along with the costs and benefits of using it.

Efficacy of hypnotherapy in the treatment of eating disorders

Research on the efficacy of hypnosis in the treatment of eating disorders has produced mixed findings. This is due in part to the interplay between the characteristics of people with eating disorders and the phenomena of hypnosis. In addition, several authors have noted that methodological limitations in hypnosis research often make evaluation of treatment efficacy difficult. Many of the studies extant provide insufficient information regarding the specifics of the hypnotic intervention(s) to facilitate replication and clinical implementation. Therefore, this paper only reviews literature with replicable methodological descriptions. It focuses on the three primary disorders of interest to clinicians: bulimia nervosa, anorexia nervosa, and obesity. The implications for evaluating treatment efficacy are discussed.

Hypnotically facilitated treatment of obsessive-compulsive disorder: can it be evidence-based?

There are extensive evidence-based guidelines for the treatment of Obsessive-Compulsive Disorder (OCD) with medication, behavior therapy, and cognitive therapy. Nevertheless, there remain a significant percentage of patients whose symptoms are more or less refractory to standardized treatments. This situation could be rooted in the phenotypic heterogeneity of the disorder as well as in its high rates of comorbid psychopathology. Studies have also found OCD to be associated with higher levels of dissociation. This paper examines what may be needed to establish evidence-based hypnotically facilitated therapies for treatment-resistant OCD. It provides an introduction to the complexity of the treatment issues surrounding OCD and considers both possibilities for and obstacles to setting up an evidence-base for using hypnotically facilitated psychotherapies for its treatment.

How unusual are the "unusual events" detected by control chart techniques in healthcare settings?

Statistical process control (SPC) charts have become widely implemented tools for quality monitoring and assurance in healthcare settings across the United States. SPC methods have been successfully used in industrial settings to track the quality of products manufactured by machines and to detect deviations from acceptable Levels of product quality. However, problems may arise when SPC methods are used to evaluate human behavior. Specifically, when human behavior is tracked over time, the data stream generated usually exhibits periodicity and gradualism with respect to behavioral changes over time. These tendencies can be quantified and are recognized in the statistical field as autocorrelation. When autocorrelation is present, conventional SPC methods too often identify events as "unusuaL" when they really should be understood as products of random fluctuation. This article discusses the concept of autocorrelation and demonstrates the negative impact of autocorrelation on traditional SPC methods, with a specific focus on the use of SPC charts to detect unusual events.

Charting a course for health services research at the National Institute on Drug Abuse

Through research, we continue to develop and refine an array of safe and efficacious interventions to prevent and treat drug abuse; however, these interventions have not led to widespread improvements in prevention and treatment services in nonresearch settings. In addition, investigator-initiated research rarely examine or refine interventions that practitioners have found relevant and that are widely practiced. To address these problems, the National Institute on Drug Abuse convened a blue ribbon task force to examine its health services research program. The report served as a catalyst for the institute to promote a vigorous program of research that seeks to examine prevention and treatment intervention delivery systems and policies that facilitate provision of effective care in a range of real world settings. Findings from this research should help address the translational bottleneck of bringing evidence-based interventions into the community.