NICE recognition for hypnotherapy … neither complementary nor alternative

Whether the following proves to be good or bad news for hypnotherapy in the UK is currently unclear.

But what is now clear is that hypnotherapy is not classified as a Complementary Therapy by either the National Institute for Health and Clinical Excellence (NICE) or, at least in some circumstances, by the Department of Health.

It is a development which will doubtless leave most of the country totally unshaken but one which hypnotherapists themselves might do well to take on board.

The fact hypnotherapy is now described as “a psychological intervention” by NICE and DoH has been confirmed in email replies from both organisations.

That classification was made more than two years ago, in February 2008 when NICE published a 554-page clinical practice guideline on “Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care.”

Commissioned by NICE and prepared by the National Collaborating Centre for Nursing and Supportive Care, the guidelines have already been reported as recommending that hypnotherapy be considered for refractory IBS, i.e., continuing for more than a year.

What was less noticed was the guideline's inclusion of a 17-page chapter on hypnotherapy for IBS followed by a five-page section on indirect comparisons of psychological interventions plus two pages of evidence on the inquiry’s recommendations for psychotherapy, CBT and hypnotherapy.

The inquiry team considered psychological interventions for IBS, recognising several different disciplines, including “psychotherapy, biofeedback, cognitive behavioural therapy, family therapy, hypnotherapy, interpersonal therapy and psychodynamic therapy.”

Evidence included the findings from a 2006 study showing hypnotherapy resulted in a “significant reduction in the use of prescriptions in the one year following intervention.”

The report therefore recommend that IBS patients who fail to respond to pharmacological treatments after more than 12 months, should then be considered for psychological interventions.

The inquiry developed two models of treatment to try to estimate the cost-effectiveness of different types of IBS interventions. First – long-term maintenance with pharmacological interventions. Second – a “one-off” intervention model for behavioural interventions (CBT, psychotherapy and hypnotherapy) over a defined period with the expectation that benefit continued beyond the intervention period.

Examining whether hypnotherapy had a role in managing IBS symptoms the guidelines stated: “More complex psychological interventions include biofeedback, cognitive behavioural therapy, dynamic psychotherapy and hypnotherapy are usually initiated for people with moderate or severe symptoms who have not responded to other management programmes.”

It then adds: “These therapies are effective, but time consuming to provide, require specialist input and currently availability varies widely across the UK.”

We have to plough on all the way to page 375 before the guidelines attempts to explain what hypnotherapy is and how it works. Helpfully it describes gut-directed hypnotherapy as “a specific form of hypnotherapy developed for the management of gastrointestinal disorders.”

It also quoted Professor Peter Whorwell’s conclusion that: “IBS is ideal for treatment with hypnosis, as there is no structural damage to the body. During hypnotherapy people learn how to influence and gain control of their gut function and then seem to be able to change the way the brain modulates their gut activity.”

Details on past studies of hypnotherapy for IBS; comparisons with different treatments, its efficacy with pain controls, bloating and other symptoms were also provided.

Which then led to a look at the economic issues; pointing to the total lack of any analyses of the cost-effectiveness of hypnotherapy for IBS or any NHS reference cost, even though hypnotherapy is funded in some regions of the NHS.

But – and this for UK hypnotherapy is a big, important but – it crucially considered just where hypnotherapists might fall within NHS pay scales.

The NICE-commissioned inquiry decided the salary of a typical hypnotherapist should fall within the Agenda for Change band 6 – the same scale as counsellors. Which meant the cost, based on seven sessions at £41.55 each, would be £291 per patient.

The report explained: “We have assumed that hypnotherapists have a similar working pattern to counsellors undertaking psychotherapy in terms of the proportion of their time that is spent on direct client contact and the proportion that is spent on research, administration, education and other activities.”

What is important here is that the study team clearly believed hypnotherapy should and would be provided by hypnotherapists rather than clinicians, psychologists or psychotherapists.

As mentioned earlier, all this probably seems far from exciting to the world at large, but to UK hypnotherapists it is a decision of potentially immense importance and long-term significance.

And it only came to light with a written Commons question from the chairman of the Commons Science and Technology Select Committee, Liberal Democrat MP Phil Willis.

He wanted to know which complementary or alternative treatments, medicines or therapies (CAMs) NICE had either considered or approved for use by NHS clinicians.

Health Minister Gillian Merron listed reflexology, acupressure, massage, Tai Chi, the Alexander Technique, Aromatherapy and others … but not a mention of hypnotherapy.

Her reply seemed puzzling since NICE had specifically included hypnotherapy as appropriate for refractory irritable bowel syndrome.

Why on earth was hypnotherapy not on the list? The answer – because as far as NICE is concerned hypnotherapy is not a CAM.

Validation of this came during a chat with NICE’s External Communication Manager, Laura Gibson along with an email stating: “Following your enquiry about whether NICE classes hypnotherapy as a psychological intervention or a complimentary/alternative therapy, I can confirm that it is classed as a psychological intervention.”

So was this view shared by the Department of Health? Yes it was for the Department’s press office explained that the written parliamentary reply to Willis was based on NICE's guidance.

It’s email added: “In the context of the clinical guideline on Irritable Bowel Syndrome published in 2008, NICE's independent Guideline Development Group considered hypnotherapy as a psychological intervention and not as a complementary therapy. NICE's guidance was subject to extensive consultation with stakeholders throughout its development."