Ethical Guidelines For Hypnotherapy
The study of ethics concerns moral choices, generally in the areas of relationships, agreements between parties, intentions, and possible outcomes. In practice this starts as the observation of the moral choices people make and the reasons given for these choices. Ethical thinking is then responsible for producing theories about what is, or should be, the basis for moral choice. In the case of a practicing hypno-psychotherapist the main place for ethical consideration concerns questions of what expectations clients can have - basically the laws which govern the therapist, and the rights of the client.
During the following discussion of the ethical guidelines which are key for an ethical hypno-psychotherapeutic practice we must assume that the laws of the county take precedence. However, it is important that professional bodies take responsibility for their members and provide them with boundaries within which they can legally and safely practice and which ensure the safety, physically and psychologically, of their clients.
Broadly speaking the key ethical guidelines involved in the practice of hypno-psychotherapy can be divided into two areas, one, how the therapist should conduct their practice, and two, how the therapist should behave toward the client. This classification holds when considering a variety of professional bodies including the NCHP (the "College"), The International Society of Professional Hypnosis (ISPH), The National Guild of Hypnotists' Code of Ethics and Standards (NGH), and The National Board of Professional and Ethical Standards - Hypnosis Education and Certification (NBPES). We will concentrate on the guidelines outlined by the NCHP primarily, but where other bodies have additional guidelines these will be mentioned, particularly in the second part of the paper.
The NCHP's code of ethics consists of 17 points and two clauses which outline the consequences of breaking the ethical code. The consequences of not keeping to the ethical guidelines are not important for discussing the ethical issue and so will not be considered further.
The spirit of all of this material is contained within the College's statement as follows;
"All therapists are expected to approach their work with the specific aims of alleviating suffering and promoting the well-being of their clients. Therapists should, therefore, endeavour to use those abilities and skills commensurate with their trained competence, to the clients' best advantage, without prejudice and with due recognition of the value and dignity of every human being." (NCHP, 2001).
Clearly then the intention of the guidelines is primarily to assist the client, however, it is also clear that therapists are being protected by the insistence that they work within their area(s) of competence.
Rather than reproduce verbatim the College's guidelines, using the aforementioned categories (practice/client) an outline of these guidelines will be presented. It should be borne in mind that the boundary between the two categories is not always clear and that this is a distinction of convenience.
The rights of the client are protected in points 2, 5, 6, 7, 9, 10, and 11. They require that therapists only use treatments that they are familiar with, they maintain confidentiality, contact third parties as necessary and with the client's permission, maintain appropriate personal boundaries (in all spheres), and ensure that clients are consulted if they are to be involved in research and if so, their anonymity is maintained. In none of these is there a specific requirement for not causing harm to the client in the process of alleviating suffering.
The NGH specifically state that, "Frightening, shocking, obscene, sexually suggestive, degrading or humiliating suggestions shall never be used with a hypnotized client", and the ISPH state, "Suggestions shall be avoided, whether given post-hypnotically or otherwise, which are of a degrading or embarrassing nature." This is a potentially interesting area of difference because in essence it would allow a therapist working within the College's guidelines to use "harmful" interventions if they fell within the therapist's area of competence and if they ultimately led to the client's well being and lack of suffering. Other than this final point, the College guidelines appear to guarantee the client, as far as is reasonably possible, protection from unwanted, overt outcomes that could come about once hypno-psychotherapy has been consented to.
Two areas of potential concern, where it might be argued there are loop-holes, are in points 5 and 10. Point 5 is concerned with confidentiality and disclosure and specifically states, "It should be borne in mind that therapists have a responsibility to the community at large, as well as to individual clients." Where does the boundary lie which separates responsibility for the client and responsibility for the community? If in regression a client reveals they have been a victim of a serious crime and that they can identify the perpetrator should the therapist try to convince the client to contact the police? If the client reveals that s/he was the perpetrator of a serious crime should the therapist contact the police? Should the therapist inform the client in either of these cases if it appears that the client has completely repressed the information?
These concerns may influence a therapist's decisions regarding what their own limits of confidentiality are and in turn this may alter their ability to practice.
Point 10 concerns the maintenance of clients' anonymity and welfare when material based on cases is going to be published. In principle anonymity can be maintained by substituting the individual's name. However some of the details of a case might be enough for the person's identity to be guessed at (recent media cases involving accusations of rape against John Leslie, and certain premiership footballers, and the case of Dr. David Kelly are evidence of this). This means that some of the interesting areas of the case might have to remain unpublished as they would too closely identify the individual client. The dilemma then is how we can guarantee that the quality of published work is maintained without accidentally identifying the clients involved.
The ethical practice of the hypno-psychotherapy is outlined by the College in points 1, 3, 4, 8, 12, 13, 14, 15, 16, and 17. They cover the professionalism of the therapist, disclosure of their qualifications, and terms, conditions, and methods of practice, the necessity for continued professional development, constraints on advertising and using hypnosis as entertainment, and guidelines on requirements concerned with complaints against the therapist or a colleague.
Basically they are concerned with ensuring that therapists are suitably qualified to engage in work, that they will maintain their skills and that their business is carried out in a manner which will not bring disrepute upon the therapist, the College or the practice of hypno-psychotherapy. One interesting difference between the College and the ISPH is that the ISPH would refer to most therapists trained by the College as "Hypnotechnicians", that is they are not trained medical doctors, psychiatrists or clinical psychologists. Why this is important is that according to ISPH guidelines hypnotechnicians are not permitted to perform all therapeutic interventions;
"Age regression is not to be undertaken by the 'hypnotechnician'. The society regards age regression as a tool of the psychotherapist and not the hypnotechnician because of the possibility of arousing traumatic past experiences which the technician is not competent to handle. Age regression by a hypnotechnician may only be undertaken at the direction of and in the actual, physical presence of an MD, psychiatrist clinical or psychologist." (ISPH, 2003).
Apart from this difference the College and the other bodies mentioned earlier are in agreement about the ethical issues concerned with the practice of hypno-psychotherapy.
The previous outline of the ethical requirements has highlighted some areas where there is the possibility of some concern regarding these issues and the following discussion will focus on two. First, concerning the discomfort of a client whilst in the process of change and second concerning the ethics of the practice of regression.
As stated in the College's guidelines, therapists are explicitly expected to "alleviate suffering" and promote "the well-being of their clients". At the first glance this might seem to suggest that the process of hypno-psychotherapy should be without suffering or loss of well-being, although by the very nature of abreaction this is not going to be possible in all cases.
In some ways we may think of abreaction as an unfortunate consequence of alleviating suffering, in that the therapist is not always seeking to cause it, although it might be necessary for successful treatment. Of more concern is where it might be necessary to purposefully produce suffering and loss of well-being in a client in order to achieve a beneficial outcome, one that the client requests.
For example, a well known technique used with sex offenders, based on behaviourist principles, is aversion therapy (Marshall, Anderson, & Fernandez, 1999). This requires that the offender imagines a scene in which they are about to offend, and then they are either asked to imagine an aversive outcome (for example, whilst about to approach a child outside a school, a paedophile would be asked to imagine feeling a hand on their shoulder and turning to see a policeman) or are presented with an aversive stimulus (an electric shock, aversive smell etc.). The idea being that these aversive outcomes become paired with the offending behaviour and so that behaviour is reduced. Similarly, humiliation has been used to change the behaviour of exhibitionists.
In principle these same approaches could be used in hypnosis, with post-hypnotic suggestions etc. The ultimate goal is to alleviate the suffering which inappropriate thoughts and fantasies might be causing the client and thus reduce the risk to the community. The College does not specifically address this issue although we can assume that they do not intend clients to have to suffer, but other bodies do address it. The NGH specifically state that, "Frightening, shocking, obscene, sexually suggestive, degrading or humiliating suggestions shall never be used with a hypnotized client."
Conversely they also state, "Members shall use hypnosis with clients to motivate them to eliminate negative or unwanted habits, facilitate the learning process etc." (NGH, 2002). Thus, in certain areas where hypnosis might prove useful it appears that there is a contradiction - it is the therapist's role to motivate the client to change unwanted habits (or more generally, behaviours), yet the tools which have proved useful in order to do this are not available because of the discomfort they might cause the client. The ethical issue revolves around two points, firstly, the relationship with the client and secondly the relationship with society. Should the rights of the individual outweigh the potential benefits of the many? That is, should our concern for the client be greater than our concern for potential victims? The dilemma occurs because we have to make a choice between two conflicting demands and results.
This was recognised by the ethical principle of Intuitionism (Moore, 1903) where an action can be defined as 'right' if it leads to a 'good' outcome; the problem being then which outcome is more 'good'. Indeed, it is more complex because such work could not be performed without the client's consent, so what is the therapist's position if the client demands that s/he receives treatment which might be "frightening, shocking, obscene, sexually suggestive, degrading or humiliating"? Should they agree to this, and if so, what if another client were to make other demands, such as demanding that their lack of self-esteem would be alleviated if the therapist were to engage in sexual activity with them? (See note 1).
To resolve this issue would require a far lengthier consideration than is possible here, however one approach might be to restrict the interpretability of ethical guidelines (e.g., "a therapist may not under any circumstances engage in sexual activity with a client, present or past"), and, where necessary, make them case specific. For example, the above issue concerning treatment of sexual offenders could be dealt with if the use of negative material were permitted in specific cases. This is in line with Aristotle's ideas of "efficient cause" and "final cause".
Understanding the final cause, or outcome, will guide us in knowing how to achieve it (via the efficient cause) and it is the meaning and purpose of the final cause which determines if it is ethically 'good'. Where it has been proven to have ultimately positive outcomes, and where the client consents, such interventions could be argued as being appropriate and there are likely to be few other areas of intervention where such imagery might be useful and appropriate. A statement such as, "Negative imagery may be used by a therapist trained in treating sexual offenders, where is can be clearly shown to be the best form of treatment and with the written consent of the client, the client either suffering from, or having acted upon inappropriate sexual fantasies" might be a useful first draft. Naturally, before this was adopted it would have to be shown that such interventions do indeed produce the desired results.
The second area where they may be some concern is in the use of regression. The concerns about the effects of regression requiring a competent therapist have been mentioned, but there are two other areas of interest.
Firstly, the ethics of regression itself and secondly the assumption that the effects will be short lived, that they will occur during therapy.
As described above, therapists are ethically required to engage in practices which do not cause harm to the client, although it has been argued that in certain situations, if the outcome warrants it, this restriction may be lifted. The ethical problem with regression (See note 2) is that neither the therapist nor the client knows what might be awaiting the client when s/he is regressing. The latter issue is important because it leads to a problem with informed consent.
How can the client reasonably be expected consent to something when they do not know what the outcome might be? Of concern to the harm issue is that the therapist does not know if the client's past will be traumatic (and potentially frightening, humiliating, sexually suggestive etc.), does not know how being exposed to this might influence the client's later decisions and actions and finally, whether the retrieved information will be something which the therapist is qualified to deal with.
Although it is always possible to refer a client to a more qualified therapist this does not remove the ethical responsibilities of the original therapist. The dilemma is similar in this case as it was in the previous one, the important difference being that in the former the decision to use negative imagery is informed by empirical evidence, knowledge of the client, and used with consent, whereas here the occurrence of negative memories (and their nature and quality) cannot be predicted, and true informed consent cannot be given.
Of secondary importance is what the therapist should do if the retrieved memories are of an illegal nature, whether the client is the victim or the perpetrator, but this could be addressed to some extent in the therapists description of their code of conduct for confidentiality. The problem with this particular set of ethical issues is that it is not possible to produce appropriate guidelines. It is meaningless to demand that therapists do not uncover negative and potentially harmful memories in clients because there is no way in which this can be achieved. All that can be done is that therapists can be suitably trained to ensure that they can manage these occurrences.
However, there are circumstances where this might not be possible. For example, feelings of humiliation, anger, sadness etc. can be reasonably dealt with in the therapeutic session, but longer term emotional consequences cannot necessarily be so easily handled. If a client has retrieved a painful memory of having mistreated someone this can alter the way they behave toward this person, or their feeling about themselves as an individual.
In severe cases this might lead to suicidal ideation and attempts at suicide. Where a client recovers a memory of having been mistreated by an individual they may decide to exact revenge, something which will be out of the therapists hands. If the client does not share these particular aspects of their thinking with the therapist, either because they do not wish to, or because they occur when the session has finished, or if s/he does share them but the therapist does not have suitable experience, it is clear that the therapist no longer has control of these unintended consequences of regression.
These secondary, or unintended effects, have been discussed by some philosophers. For example, St. Thomas Aquinas (trans. 1964) argued that everything is governed by a "natural law", where everything has its proper end. By this argument one is only responsible for the immediate consequences of one's actions, not unintended effects, and this is known as the Law of Double Effect. Unfortunately this argument does not really help with the ethical responsibilities of a therapist working through regression and certainly is not a suitable resolution to the dilemma. Simply washing our hands of later consequences is probably not the intention of any of the governing bodies of hypno-psychotherapy.
So how can we resolve this dilemma? Logical positivism suggests that moral statements are meaningless because they are neither tautologies nor are they empirical statements of fact. They are thus expressions of preference and emotion (Thompson, 2003). In this situation it may be the best that we can hope for, providing statements of preference, based on emotion.
It is not possible to cover every eventuality, but it is possible to provide preferred guidelines which also outline courses of action should the outcome of regression prove negative for the client. Careful training of therapists, ensuring that each therapist has a support network, including contact with the body experts at the therapist's training college can go some way in preparing therapists for worst case scenarios. We must also have some understanding of where the therapist's ethical responsibility ends. Should therapists be responsible (whether ethically, emotionally or legally) for their client's behaviour a week, a month, or a year after therapy has ended? Hypno-psychotherapists may have to consult with other professional bodies (the British Medical Association, the British Psychological Society, the Law Society etc.) in order to inform decisions relating to this matter.
This brief outline of ethical guidelines and ethical issues in hypno-psychotherapy demonstrates the difficulty in trying to produce legislation for interventions which affect other individuals. It is not restricted to the practice of hypno-psychotherapy, but occurs in medicine and mental health amongst others. In some case it might be possible to produce guidelines which allow for the ethical treatment of clients, and which provide safety for the therapists, in some, as in the second case discussed, it may not be possible. Either way we must consider ethical guidelines as a template for the practice of hypno-psychotherapy and never forget that counter examples and exceptions will arise, at which point it is the therapists responsibility to discuss the matter with their supervisor and other qualified therapists.
(The NGH states as one of its general principles, "The rights and desires of the client shall always be respected" but therapists are warned against "moral impropriety or sexual misconduct with a client" and the College warns "therapists are required to maintain appropriate boundaries with their clients and to take care not to exploit their clients, current or past?", thus the therapist is required to consider issues of vulnerability and morality rather than the ethical guidelines being absolute in this case.)
Throughout this paper the assumption is being made that recovered memories are true representations of past events. The debate concerning recovered memories raises another set of important ethical issues which require a separate discussion.
St Thomas Aquinas general editor: Thomas Gilby Summa Theologiae - Latin and English (1964). London: Blackfriars in conjunction with Eyre & Spottiswoode.
Aristotle translated and edited by Roger Crisp. Nicomachean ethics. (2000). Cambridge: Cambridge University Press.
Marshall, W.L., Anderson, D. & Fernandez, Y (1999). Cognitive Behavioural Treatment of Sexual Offenders. Chichester: John Wiley & Sons, Ltd.
Moore, G.E. (1903). Principia Ethica. Cambridge: Cambridge University Press.
National College of Hypnosis and Psychotherapy (NCHP) (2001). Code of Ethics and Practice. http://www.hypnotherapyuk.net/ethics.htm
The International Society of Professional Hypnosis (ISPH) (1978) Code of ethics and standards. http://www.iit.edu/departments/csep/PublicWWW/codes/coe/
The National Guild of Hypnotists (NGH) (2004) Code of Ethics and Standards http://www.hypnosisunlimited.com/Hypnosis-How.html
The National Board of Professional and Ethical Standards -
Hypnosis Education and Certification (NBPES) (2004). The National Board of Professional and Ethical Standards - Code Of Ethical Standards. http://hypnosiseducation.com/
Thompson, M. (2003). Ethics. London: Hodder Headline Inc.
Simon Diff - Hypnotherapist