The Clinical Effectiveness of Neurolinguistic Programming

A Critical Appraisal

Lisa Wake, Richard Gray, Frank Bourke, Lisa Wake, Richard Gray, Frank Bourke

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136186639
• Edition: 1
• Topic: Filología
• Subtopic: Psicolingüística

Despite widespread use, Neurolinguistic Programming (NLP) is a topic of much debate, often receiving criticism from academic and professional sectors. In this book international academics, researchers and therapists are brought together to examine the current evidence of the clinical efficacy of NLP techniques, considering how NLP can be effective in facilitating change, enrichment and symptom relief.

Lisa Wake and her colleagues provide a critical appraisal of evidence-based research in the area to indicate the benefits of the approach and identify the need for an increase in randomized well-controlled clinical trials. Contributors also explore how NLP has been used to treat various disorders including:

• 
  
  

• post-traumatic stress disorder
• phobias
• addictions
• anxiety disorders
• mild depression.

Illustrated throughout with clinical examples and case studies, this book is key reading for practitioners and researchers interested in NLP, as well as postgraduate students.

Part I

Clinical and practitioner evidence

1Phobias

Richard M. Gray, Richard Bolstad

Phobias and their treatment

Clinically, a phobia (from the Greek φóβoς, or “fear”) is a persistent fear of a situation or object, due to which the person invests disproportionate energy into avoiding or coping with that stimulus object or situation, compared to the minimal danger involved in it. The DSM-V (proposed), in its listing of anxiety disorders, refers to three very different types of situations using this same term: specific phobias, social phobias, and agoraphobias. Social phobia refers to fear of being with and being observed by others, and Agoraphobia involves a fear of leaving the person’s familiar safe area, often with additional social phobia and fear of the possibility of panic attacks in unsafe places. These latter two diagnoses have a more complex structure than simple phobias, and treatment by all methods has yielded less convincing research results (Roth et al., 2005).

Specific phobias have seven diagnostic criteria (APA, 2010) which can be summarised as:

AFear cued by the presence or anticipation of the stimulus.

BExposure consistently provokes fear or anxiety.

CThe object or situation is actively avoided or its presence is endured with intense fear or anxiety.

DThe fear or anxiety is out of proportion to the actual threat posed.

EDuration at least six months.

FAvoidance interferes with functioning in major life contexts.

ENot a result of another condition.

Phobias represent classically conditioned fear responses to objects or situations (Öhman and Mineka, 2001; Schweckendiek et al., 2011). They are disproportionate to the actual threat presented by the phobic stimulus, sometimes represent incidents of one trial conditioning (Öhman et al., 1975; Öhman and Mineka, 2001; Seligman, 1971), are often associated with what may be evolutionarily prepotent stimuli (Domjian, 2005; Gerdes et al., 2009; Öhman and Mineka, 2001; Öhman et al., 1975; Ohman et al., 1976) which are more resistant to extinction than truly neutral stimuli (Öhman and Mineka, 2001; Öhman et al., 1975; Ohman et al., 1976).

The United States’ National Institute of Mental Health notes that phobias are the most common mental illness among women in all age groups and the second most common illness among men older than 25 (the first being depression, see Kessler et al., 2005a, b). Successful and efficient treatments for phobias are of considerable importance. There is good evidence that any short-term benefits of pharmacotherapy with anxiolytics is quickly lost and that their use may even increase later anxiety responses. Exposure to the phobic stimulus under certain conditions may reduce phobic response. Wilhelm and Roth (1997) randomised 28 clients with flight phobias to receive either the anxiolytic drug alprazolam or a placebo while undertaking a first flight. They found that in a second flight, those who had received the active medication had much higher levels of anxiety than those who received the placebo, indicating that those who had the placebo may have benefitted from the exposure in the first flight and reduced their fear. Thom et al. (2000) conducted a randomized study of clients with a phobia of dentistry, who received either benzodiazepines (anti-anxiety drugs), a stress-management package (relaxation training, exposure to the dentistry situation, and cognitive therapy), or no intervention. Both treated groups initially reported a reduction in anxiety, but only 20 percent of drug treatment clients actually completed their dentistry, as compared to 70 percent of those receiving the stress management package.

NLP has identified several procedures for the treatment of phobias. The best known and most well attested is the NLP Fast Phobia Cure, otherwise known as the Visual Kinesthetic Dissociation Protocol (V/KD). Two other techniques predate the V/KD protocol and are used less frequently. The first is a counter-conditioning protocol called collapsing anchors, and the second is the six-part reframe. The six-part reframe has, for many, fallen from use and will not be discussed here. The two NLP procedures reviewed here can be considered imaginal exposure techniques (Wolitzky-Taylor et al., 2008).

Classical models and approaches

Two specific types of intervention have been the focus of the most successful psychological research: systematic desensitization and exposure. Systematic desensitization generally involves a prolonged, gradual introduction of the feared stimulus, done over a large number of sessions and using a base of training in relaxation. Therapist-controlled exposure has proven more successful, and clinically significant improvement in one or a few intensive sessions tends to be as good as improvement over a prolonged series of short sessions, and to average 70–85 percent reductions in symptoms. Exposure results in what researchers have called extinction of the fear response. There is evidence to suggest that, although in-vivo experience provides immediate improvements relative to imaginal exposure, follow-up studies have shown that initial differences disappear over time (Wolitzky-Taylor et al., 2008).

Extinction is one of the basic phenomena in classical conditioning. It describes the case in which, after multiple unreinforced exposures, the previously conditioned response attenuates or disappears. Extinction, however, is not permanent but is subject to various kinds of response recovery (Bouton, 1994; Bouton and Moody, 2004; Pavlov, 1927; Rescorla, 1988).

When the memory linkage between a conditioned stimulus (CS) and a fear evoking event (UCS) is extinguished, a new memory is created that communicates the absence of the feared object and blocks access to the original memory that signaled the onset of the feared event. These new memories tend to be context sensitive and somewhat more fragile than the original memories. Extinction, therefore, in the classical learning paradigm, refers to the learning of new information about the changed learning context as it is now provided by the CS. It does not refer to the elimination, forgetting, or modification of the memory. Extinction is characterized by four specific effects through which the behavior may be re-established or through which relapse occurs. As they appear in the post-treatment or relapse behavior of phobic patients, they may be viewed as a clear indication of the fact that extinction is the specific mechanism underlying the treatment. These effects are spontaneous recovery, contextual renewal, reinstatement, and rapid reacquisition (Bouton, 2004; Bouton and Moody, 2004; Dillon and Pizzagalli, 2007; Hartley and Phelps, 2009; Massad and Hulsey, 2006; Quirk and Mueller, 2007; Rescorla, 1988; Vervliet, 2008).

Spontaneous recovery refers to the re-occurrence of the extinguished or unreinforced fear response after the passage of time. It was first observed by Pavlov (1927) and is one of the first evidences that extinction does not remove the memory. As noted, extinction involves the creation of a new contextual association signifying that in this context, the CS does not predict the UCS and, therefore, the fearful response is irrelevant. That new memory of the new contingencies, if unreinforced, is subject to a time-based delay. It is forgotten over time and the fear re-emerges (Bouton, 2004; Bouton and Moody, 2004; Dillon and Pizzagalli, 2007; Massad and Hulsey, 2006; Rescorla, 1988; Vervliet, 2008).

Contextual renewal refers to the re-emergence of the conditioned response in a new circumstance where the extinction memory was not created. If the patient is subjected to unreinforced (extinction) trials in one context, so that the CS fails to evoke the feared response in that context, a subsequent test of that same CS in another context may show little or no reduction in expression. Even though the original fear response may generalize to multiple contexts, extinction phenomena are much more context dependent. Contextual renewal is contextually bound; the response is only renewed in the contexts where the UCS has again appeared (Bouton, 2004; Bouton and Moody, 2004; Dillon and Pizzagalli, 2007; Massad and Hulsey, 2006; Rescorla, 1988; Vervliet, 2008).

Reinstatement occurs when the fearful stimulus, the UCS, is presented without the CS. In that context where the original UCS is presented, despite the fact that the fearful response had been fully extinguished, the CS will be restored. It will not, however, reappear in other contexts where the UCS has not been presented (Bouton, 2004; Bouton and Moody, 2004; Dillon and Pizzagalli, 2007; Massad and Hulsey, 2006; Rescorla, 1988; Vervliet, 2008).

Rapid reacquisition, as the name suggests, describes the reacquisition of the fear memory after it has been successfully extinguished. In this case there is a net savings in the number of trials needed to reacquire the memory. If, for example, the original fear association took ten trials to install, during post-extinction training, it may take only three (Bouton, 2004; Bouton and Moody, 2004; Dillon and Pizzagalli, 2007; Massad and Hulsey, 2006; Rescorla, 1988; Vervliet, 2008).

Extinction, as exposure to the fear-evoking stimulus, has traditionally been held to be one of the tools of choice for the treatment of phobias and post-traumatic stress disorder (PTSD). Foa and her colleagues have indicated that in its various forms, from desensitization through imaginal and in-vivo exposure, inter alia, it is the most well-researched and most highly regarded of treatments and represents the scientific treatment of choice (Foa et al., 2000; Foa and Meadows, 1997; Rothbaum and Davis, 2003; Wessa and Flor, 2007; Wolitzky-Taylor et al., 2008).

The other most commonly encountered tool for dealing with phobias is systematic desensitization, itself a variant of an exposure/extinction paradigm.

Systematic desensitization was the theoretical brainchild of Wolpe (1958). Basing his ideas on the work of Pavlov, Watson, and their followers, Wolpe held that if an anxiety-reducing stimulus were presented in the presence of an anxiety-evoking stimulus so that the anxiety was either reduced or eliminated, the conditioned association between the anxiety-producing stimulus and the anxiety would be weakened. This was based on the principle that two competing or antagonistic responses (sympathetic and parasympathetic) could not exist simultaneously in an individual’s neurology and that one could be manipulated to overpower the other (Rachman, 1967; Schaeffer and Martin, 1969; Wolpe, 1958).

Using conditioned place learning, Wolpe began by training cats to become neurotically anxious in a specific experimental circumstance. After installing the neuroses, he began feeding the cats in neutral contexts that bore no resemblance to the original neurosis evoking context. Gradually, in measured increments, he began to introduce more and more elements from the original context into the feeding context. At last, the cats were able to feed in the context where the anxious response had been learned without any sign of the previous anxiety (Rachman, 1967).

In transferring the pattern to humans, Wolpe understood that feeding was not an optimal counter-conditioning stimulus and decided to use Jacobson’s progressive muscle relaxation as the positive stimulus. Wolpe believed that this procedure could be used with human subjects to successfully compete with anxiety. Originally beginning with physical objects and photographs of the aversive stimulus, he soon switched to imaginal presentations of the problem stimuli (Rachman, 1967; Schaeffer and Martin, 1969; Wolpe, 1958).

The pre-treatment procedure consisted of the creation of a ranked list of progressively more powerful anxiety-producing stimuli and the training of the subject in Jacobson’s technique. Treatment proceeds through several sessions in which the patient, beginning with the least anxiety-producing stimulus, is instructed to relax and, while relaxing, imagine the stimulus. While still remembering the stimulus he is to reinstate the relaxed state. From within the relaxed state he is then instructed to relax further. Finally, in the absence of the anxiety-producing stimulus, the patient is instructed to relax again. This procedure continues over multiple sessions with successively more intense stimuli from the previously created hierarchy until the patient experiences no anxiety—even in the presence of what had been the most potent of the anxiety-producing stimuli. An abbreviated version of the technique often limits the procedure to the least significantly disturbing versions of the phobic stimulus and is executed in the course of one session (Rachman, 1967; Richardson and Suinn, 1974; Schaeffer and Martin, 1969; Wolitzky-Taylor et al., 2008; Wolpe, 1958).

In an early study of the effectiveness of desensitization in the treatment of snake phobias reported by Rachman (1967), 24 college students with demonstrated snake phobias were subjected to 11 sessions of systematic desensitization preceded by five training sessions. Lang and Lazovik (1963) reported that experimental subjects showed a marked reduction in symptoms and that the symptom reduction was tied to the level of the subjects’ progress through the hierarchy. However, it is noted that several of the subjects did not complete the entire hierarchy. This suggests that the complete absence of the phobic response is not always the criterion of success.

In his extensive review of the experimental data to date, Rachman (1967) reported that the standard result for systematic desensitization is a significant reduction in the anxiety, not elimination of the response. He also indicated that he and other researchers had reported a consistent relapse rate of 50 percent. More recent studies place the effectiveness of desensitization at about 80 percent reduction in symptoms.

Visual Kinesthetic Dissociation or the NLP Fast Phobia Treatment

Procedure

The V/KD procedure first appeared in Bandler’s Use Your Brain for a Change (1985). An expanded version of the pro...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures and tables
• List of contributors
• Foreword
• Introduction
• Part I Clinical and practitioner evidence
• Part II Neurolinguistic programming contemporary research
• Part III Towards the future
• References
• Index