PsycCRITIQUES - Contemporary Psychology: APA Review of Books
New Tools for Treatment, But More Than Placebos
A review of
Biofeedback, Behavior Therapy and Hypnosis: Potentiating the Verbal Control of Behavior for Clinicians.
Ian Wickramasekera (Ed.)
Chicago: Nelson-Hall, 1976. Pp. xv + 591. $18.95.

Reviewed by

In this book, Ian Wickramasekera has assembled 48 papers dealing largely with the use of biofeedback, behavioral, and hypnotic techniques in the clinical practice of psychotherapy. Of these, 36 have already appeared in professional or popular journals, all but one since 1970. The editor has included 24 of his own papers, 10 of which have not been previously published. The individual articles are grouped topically, and are united chiefly by Wickramasekera's prefatory remarks, commentary introducing each major section, and a major essay at the end.

The emphasis in the first two sections is on practical applications of biofeedback and behavior therapy. In the section on biofeedback, a great deal of attention is devoted to various methods for treating pain and anxiety. The material on behavior therapy includes papers on anxiety, depression, phobias, and difficulties in the sexual sphere. The papers in the third section on hypnosis, however, lie largely outside the realm of the clinic, and deal mostly with laboratory studies of the modification of hypnotic susceptibility and of the use of hypnotic suggestions to influence behavior and experience. Some of the most prominent investigators in the several fields are represented here, and the papers have been well selected to provide stimulating reading.

This is not simply another book of readings, however, for Wickramasekera employs the individual articles to communicate some important points about the successful use of biofeedback, behavioral, and hypnotic techniques in the clinic. Reading the papers underscores the feeling that, while these techniques are potentially very powerful, practitioners must ground themselves thoroughly in the body of knowledge that constitutes scientific psychology, and take care to keep that knowledge up to date, if the techniques are to be maximally effective. Thus, biofeedback appears to require fairly sophisticated understanding of physiological systems and psychophysiological relationships. In pain control, for example, EMG feedback helps relieve tension headache but skin-temperature feedback aids migraine, for reasons that seem to have to do with the different mechanisms underlying pain in the two syndromes. With regard to other clinical syndromes, it now appears that feedback for specific patterns of psychophysiological responses, involving multiple systems rather than only a single index, may be most beneficial.

Behavior therapy has clearly gone beyond its origins in S–R learning theory, and potential users must now consider biological constraints on learning that limit the extent to which aversion procedures can be effectively employed, as well as cognitive factors such as expectancies of reinforcement and the perception of control. Finally, anyone who uses hypnosis will have to be aware of the limitations of hypnotic effects on behavior and experience, and the implications for therapy of current theoretical accounts of hypnotic phenomena.

Another point that comes up often is the matter of individual differences in response to treatments. Such differences are well known in hypnosis, and it is important for the clinician to bear in mind that many of the most dramatic hypnotic phenomena demonstrated in the laboratory—analgesia, positive and negative hallucinations, age-regression and other personality changes, amnesia and hypermnesia—are obtained only in that minority of the population that is most deeply hypnotizable. The general thrust of research in this area is that hypnotizability consists of both stable aptitude and modifiable attitude components, with the former being the more important of the two. In the study of human learning, individual differences on such dimensions as emotional stability-neuroticism, introversion-extraversion, and internal-external locus of control are known to affect the degree to which people respond to environmental contingencies. Despite the situationist world-view which has dominated the field since its beginnings, then, behavior therapists must begin to consider seriously the impact of personality and cognitive predispositions on the course and outcome of treatment. Finally, those who work in the area of biofeedback are now beginning to recognize that some people go through feedback training much more quickly than others, while some are not successful at all. Whether this variability reflects the usual kinds of "personality" differences or individual differences in flexibility of the response system being trained is a subject for future research, but it is clear now that the matter is of some practical importance.

Again with respect to the matter of individual differences in response to biofeedback, behavioral, and hypnotic procedures, Wickramasekera is constantly concerned with the development of methods by which response to these methods of treatment can be enhanced. Sometimes he advocates using one technique in the service of another, as in his own studies which suggest that EMG training can enhance hypnotic susceptibility. He also emphasizes the importance of explicitly structuring the therapeutic situation so that the patient knows what is going on, why, and what he or she is expected to do. This is accomplished by means of "homework" reading assignments from the popular press, pep talks, modelling, and a carefully planned, progressive routine that conveys maximal information feedback and provides optimal reinforcement. It is Wickramasekera's belief that elements of biofeedback, behavior therapy, and hypnosis, and lessons drawn from their respective areas of research, can be combined to create a very powerful treatment package.

What do biofeedback, behavior therapy, and hypnosis have in common? Wickramasekera gives the answer away with his subtitle. He argues that the largely verbal, insight-oriented methods which psychotherapists typically employ to help their patients are not always enough. Biofeedback, behavioral procedures, and hypnosis give the therapist and patient added leverage, increasing the power of words by providing new sources of information about private events and a battery of powerful techniques for the manipulation of cognition and affect. In his concluding essay, Wickramasekera goes on to articulate nine specific features shared by the three types of treatment. Some of these features are perfectly straightforward—the acknowledgement, for example, that all three have their roots deeply planted in laboratory work in experimental psychology. Other commonalities that Wickramasekera sees are somewhat more strained, such as the proposition that all three techniques are explicitly psychophysiological in approach. The final one, however, is going to be downright controversial: Wickramasekera contends that biofeedback, behavior therapy, and hypnosis all achieve their effects by strengthening the placebo response in psychotherapy. From his point of view, the scientific image associated with these procedures and those who employ them, and the careful arrangement of situational factors that have maximal cue value in communicating expectations and delivering reinforcement, both serve to maximize the placebo effect.

Now, placebos can be very powerful indeed, and while they can be harmful when purveyed by charlatans, under appropriate conditions they can also be very important therapeutic tools. Almost all therapeutic procedures have placebo components, and the skilled clinician makes every effort to maximize them in order to insure the successful outcome of treatment. But I think it is a mistake to argue that all psychological effects in treatment can be reduced to placebo effects. Beecher defined the placebo as a nonspecific procedure that mimics the effects of an active therapeutic agent: for example, a sugar pill that relieves pain. In order to make his argument stick, Wickramasekera must redefine the placebo effect to subsume virtually all psychological treatments, a shift that blurs some essential distinctions. I think that biofeedback, behavior therapy, and hypnosis are more than merely plausible, and do more than systematically manipulate situational demands. Surely, what sets them apart from the traditional "talking" psychotherapies is not merely the fact that they are cloaked in a scientific-technological guise or that the therapist communicates explicit expectations to the patient, but rather the fact that they apply specific procedures derived from empirical research to achieve specific effects determined by a careful consideration of the requirements of the individual case. This factor, and not an enhanced placebo effect alone, probably accounts for whatever superiority they may have over other types of treatment. As an empirical matter, there is by now an extensive literature showing that many forms of biofeedback, behavioral, and hypnotic treatments yield results superior to those obtained with plausible placebo treatments. Wickramasekera undoubtedly knows this literature—he even reprints some of it in this volume—but he fails to deal with it in any systematic way.

It is important to point out that Wickramasekera does not seem to believe that biofeedback, behavioral procedures, and hypnosis are "nothing but" placebo treatments, although his terms make it hard to draw the distinction precisely. Through the papers that make up this volume, and his editorial commentary, it is clear that he has a healthy respect for the power of these new forms of psychological treatment. The book is filled with "how to do it" advice, and well-chosen examples illustrate the major points. For this reason, the book will serve well as a reader for the practicing clinician or student who wishes to become acquainted with the clinical applications of biofeedback, behavior theory, and hypnosis. The experienced researcher will find statements of a number of important problems that require more systematic research. And those who wish to grapple with the problem of the relationships among the various forms of psychological treatment will want to consider Wickramasekefa's unique and provocative point of view.

Ian Wickramasekera (Wickram) is Assistant Professor of Psychiatry at Peoria School of Medicine (University of Illinois College of Medicine) and in private practice. A PhD of Illinois, he was previously Research Assistant at the Children's Research Center there, and Staff Psychologist at the Peoria Mental Health Clinic and the East Moline Street Hospital. Wickramasekera is President of the Illinois Biofeedback Society and an ABPH Diplomate in Experimental Hypnosis. He contributed a chapter to E. Dengrove's Behavior Therapy and Hypnosis and to T. Blass's Contemporary Social Psychology.

John F. Kihlstrom is Assistant Professor in the Department of Psychology and Social Relations at Harvard University. A University of Pennsylvania PhD, he conducted research as a graduate student at the Unit for Experimental Psychiatry of The Institute of Pennsylvania Hospital. Kihlstrom is coeditor with F. J. Evans of the forthcoming Functional Disorders of Memory.

Previously published in Contemporary Psychology: A Journal of Reviews, August 1977, Vol. 22, No. 8, 573–575
© 1977, American Psychological Association