Contextual Model on Clinical Hypnotherapy
for a Client with Chronic Schizophrenia in Hong Kong
Occupational Therapy Department,
Wong Chuk Hang Complex for the Elderly,
2 Wong Chuk Hang Path, Wong Chuk Hang, Hong Kong
Mind Liberté Training Center
Citation:Lau H & Chu M (2019) Contextual Model on Clinical Hypnotherapy for a Client with Chronic
Schizophrenia in Hong Kong
. International Journal of Psychosocial Rehabilitation. Vol 22 (2) 3-10
Evidence of clinical studies affirmed the impact of hypnotherapy by reducing
pain and anxiety, and enhancing relaxation. The efficacy of hypnotherapy in
stress reduction and pain control for persons with mental illness was evaluated
through a conceptual framework of Contextual Model.
The subject recruited from the community was invited to participate in five
treatment sessions in a consecutive of three months. Each session lasted for
60-90 minutes. Pre-talk, hypnotic induction, deepening, post-hypnotic
suggestion and debriefing would be carried out as systematized intervention.
Client’s level of hope, mental well-being and intensity of pain would be
assessed by standardized assessment tools.
Results indicated improvement in Chinese Hope Scale with total score increased
from 44 to 56; the score of Chinese Short Warwick-Edinburg Mental Well-being
Scale rose from 20 to 28; the pain score recorded from the initial interview
was 6/10, and thereafter decreased to 1/10 upon completion of session three.
Hypnotherapy enhances psychological well-being with positive effects of stress
reduction and pain relief.
is one of the commonly used approaches in mind-body medicine. International
Medical and Dental Hypnotherapy Association (2019) defines hypnosis as a
communication process to a person's mind that allows his or her conscious and
subconscious mind to receive the same message. The process produces an altered
state of consciousness through physical and mental relaxation. Once the
conscious critical faculty of mind is by-passed, the person’s subconsciousness would
be enabled to openly receive the suggestion. At this stage, the person’s senses
are in a state of heightened awareness, and the mind will only accept messages
which are consistent with the established morals and ethics. The person in a
hypnotic state will respond only to suggestions which he or she agrees. Desire,
belief and expectancy are necessary for this altered state to have effect on
the extrinsic behavior of the individual.
In this case study, the Contextual Model was
adopted to examine the process and efficacy of hypnotherapy. In the definition
of context, Baars (1989) stated three distinguishing properties as follows: (a)
Contexts constitute a set of information-processing systems, (b) contexts shape
conscious experience of an individual, and (c) contexts function at the
unconscious level. Contexts mediate human learning, perception, emotion,
memory, judgment and information comprehension. Besides, contexts are also
connected to “meaning”. Without a context, words and actions are meaningless.
This study explains the process of hypnotherapy by using five major
propositions of contextual theory. First, contexts facilitate comprehension of
information. In hypnosis, the application of metaphors, examples, and analogies
offer useful contexts which will facilitate the client to increase understanding
and respond to hypnotic suggestions appropriately (Erickson and Rossi, 1979).
Second, contexts alter perceived meaning of events. According to Otani (1991),
contexts presumably provide the ground against which the figure stands.
Therefore, alternation of context can shift perceived meaning of an event. In
hypnosis, reframing is a relevant example that illustrates this principle for
therapeutic purposes. Third, context can prime cognitive responses. Sherman
(1988) stated that “Priming”, a cognitive psychological phenomenon, referred to
the activation or change in accessibility of a concept by an earlier
presentation of the same or closely related concept. In the process of
hypnosis, “yes-set” is a vigorous context that secures a functional fixedness
on trance behaviour. Due to this property, a trance-induction sequence would be
primed in hypnotic response. Fourth, competing contexts can create confusion. During
hypnosis, when confusion occurs, it creates ambiguity and the client would pay
more attention to figure out the logic hence develop a deeper focus. Lastly,
contextual predominance of consciousness results in a state of absorbed mental
states. In this absorption state, the individual’s attention and awareness are
narrowly and exclusively focused on the engaging tasks. Baars (1989) wrote that
the absorbed mental state closely resembles the trance state in hypnosis.
This thesis reviews and further examines the
efficacy of hypnosis for person with chronic mental illness. In current
literature, there is strong evidence that hypnosis could be beneficial to
people with pain and anxiety disorders. First, Montgomery et al. (2000) stated that hypnotically suggested analgesia could
bring about significant reduction of awareness in both clinical and
experimental pain. According to the well-known study by Derbyshire et al. (2004), a pain experience was
created using hypnotic suggestion. As shown in Derbyshire’s study, in the
absence of any real stimulus, significant changes were recorded in the brain
images using functional magnetic resonance imaging (fMRI). Such findings from
fMRI images compared well with the activation pattern of real pain sensation
from nociceptive sources to cortical regions. Based on such findings, it was
hypothesized that the real pain sensation could be altered by hypnosis by
creating a different sense such as numbness, and consequently reducing a
subject’s perceived pain sensation. Moreover, Ahmadi et al. (2018) suggested that hypnosis had significant effect in
reducing both tension headache and migraine headache. Second, Gonsalkorale et al. (2002) indicated that hypnosis
demonstrated its effectiveness in the treatment of irritable bowel syndrome
with reduction of anxiety. Patients also reported a decrease in consultation
rates and medication use following the completion of hypnotherapy. Third,
Austin (2015) depicted that a deep trance brought profound relaxation so it
could be very healing with great therapeutic value for stress reduction.
Hypnosis allows body to relieve tension during trance state. Effective hypnotic
suggestion enables the body to reduce muscle tension, and brings about
relaxation effect to the whole body hence potentially promoting mood status.
The abovementioned studies provide support to the clinical application of hypnosis.
Ethical issue and approval
the assessments and interviews were conducted solely for treatment purpose. The
data and information has been kept confidential. Informed consent was obtained
from client before intervention started.
client was recruited from the community with regular consultations with
psychiatrists. A total of five sessions, comprising of one session of initial
interview, three sessions of hypnotherapy and one session of evaluation, were
conducted between March 2017 and June 2017. The sessions were run by a
certified hypnotherapist. Each session lasted for 60-90 minutes. Pre- and post-
assessments were administered for outcome measures.
(I) Chinese Hope Scale. Chinese Hope Scale is a self-reported
measure designed to assess the level of hope comprising agency (will-power) and pathways
(way-power) to reach goals. It consists of 12 items. The higher the score, the
higher level of hope indicated. According to Snyder et al. (1996), the Hope Scale illustrated acceptable internal
consistency and test–retest reliability.
(II) Chinese Version of the Short
Warwick-Edinburgh Mental Well-Being Scale (C-SWEMWBS). Chinese Version of the Short
Warwick-Edinburgh Mental Well-Being Scale is an assessment scale consists of seven
items. The respondent rates on a 5-point Likert scale ranging from “none of the
time” (scored 1) to “all of the time” (scored 5). The total score ranges from 5
to 35. Higher score reveals a higher level of mental well-being. C-SWEMWBS demonstrated
good internal reliability coefficient with Cronbach’s alpha 0.89, and good
test-retest reliability (r=0.677; p=0.0001) (Ng et al., 2013).
(III) Pain Scale. 0-10 Numeric Pain Rating Scale was applied
in this case study ranging from “no pain at all” (scored 0) to “unbearable
pain” (scored 10).
(I) Initial Interview. An initial interview and assessment were
conducted before the commencement of treatment sessions. Mr. A was 53 years
old. He was diagnosed with Schizophrenia in the 1980s. Despite that he remains
to have residual symptoms of auditory hallucination, he has been coping well
with activities of daily living. He started working as a part-time cashier in a
kiosk since 2014. Mr. A began to have left knee pain after going camping for two
days and one night in December 2016. He received physiotherapy treatment for
around 6-8 sessions between January 2017 and March 2017. He took painkiller
prescribed by medical officer whenever necessary, and the pain score in the most
severe condition was 6/10. After the onset of knee pain, he suspended work for two
an initial interview with Mr. A, some possible factors were identified in the
case formulation. For predisposing factor, he felt stressed at workplace if he
knew the cashier balance was incorrect. He would immediately think if he had
made mistakes in calculation. The precipitating factor was that he may want to
take a break from cashier duties. The perpetuating factor could be adopting a
sick role and not working in the kiosk anymore. The goals of hypnosis sessions
were stress reduction and alleviation of knee pain.
(II) Hypnosis sessions. After the initial interview, three hypnosis
sessions were conducted on Mr. A. Before the commencement of each session,
mental state was examined to ensure that Mr. A felt comfortable to continue for
A. Pre-talk. Pre-talk facilitates the establishment of rapport
between the client and the therapist. Through pre-talk, the therapist could
gain more information about the client’s current condition, and observe any
micro-movements or somatic complaints of the client. These are important for
the consideration of induction methods and suggestions to be delivered by the
therapist. In addition, pre-talk illustrated the first proposition of
Contextual Model in facilitating comprehension of information when examples and
analogies were used. For the pre-talk session with Mr. A, he was given more
practical information about hypnosis such as the myths of hypnosis and the clinical
application of hypnosis. For instance, hypnosis was one of the methods to
practise relaxation and manage stress. Then he was invited to share his current
stress coping methods. In the next session, Mr. A was invited to talk about his
experience in swimming to assess for the suitability of using “healing water”
as a main theme of the hypnosis session. He commented that he felt good in
water and he enjoyed swimming. Further explanation was given to Mr. A on the
nature of water. For example, Mr. A was told that, with buoyancy, the joints
and muscle could have better support. Moreover, suggestibility test may also be
included in the pre-induction phase. Client’s responses provide information for
the proper induction methods. An example of suggestibility test applied in this
case was “Raising and Falling Arm”. Mr. A was told to imagine that a small
helium balloon was tied to his left hand, which would naturally pull his hand
upwards. On the other hand, he was told to envisage that there was a dictionary
placed on his right palm. During the process, Mr. A was more responsive to
“Rising Arm” as he felt more relaxed and light. In contrary, he said that he
could not hold the “dictionary” for a long time and he needed to place his right
forearm on the armrest for support.
B. Induction. According to Yapko (2012), induction
provides concrete stimulus that clients can focus their attention. It serves as
a bridge between the normal waking state and the focused experience of
hypnosis. Induction exhibited another concept in the Contextual Model about
priming: The activation in accessibility of a concept by an earlier
presentation of the same or closely related concept. With more understanding
through pre-talk, the client began to engage better on the flow of a session, and
had more agreement on the exercise or suggestion introduced by the therapist.
Thus, a “yes-set” was gradually created. Otani (1991) suggested that a hypnotic
yes-set is a vigorous context that secures a functional fixedness on trance
behavior. As a result of this mechanism, hypnotic response would be primed in a
trance-induction sequence. After the pre-talk, different induction methods were
applied to Mr. A in each session. The first one was pacing in breathing. Mr. A
was guided to have breathing exercise: “Start with exhalation, then breath in
deeply, withhold for a moment, and exhale.” The exercise was repeated for three
times. The other induction method was eye fixation. Mr. A was told to look at a
spot on a paper located slightly above the eye level. While he was fixing his
gaze on the spot, he was encouraged to relax his eyes. He could even close his
eyes if he felt comfortable.
C. Deepening. Deepening technique was often used
immediately after induction to intensify an individual’s hypnosis experience.
Both induction and deepening could manifest the absorption state concept as
described in the Contextual Model. In an absorption state, an individual’s
awareness to the peripheral environment would decrease, and his or her
attention would be remarkably drawn to focus on the engaging activities
instead. For deepening in each session to Mr. A, deep breathing was used: “For
every breath you take, it brings you to a more profound state of relaxation.”
On the other hand, guided imagery on a bathtub was used in session two. Mr. A
was asked if he would like to stay in a pool of water with the temperature just
right to him, where he could feel relaxed and comfortable. Thereafter, he said
that he wished to stay in the healing water for a short period of time every
day to relax and be away from daily hassle. Moreover, positive suggestions were
also added into the session. With reference to St John (2018), positive
suggestions paint images in our minds of how good things can be if we were to
change our behaviors. These images become our subconscious motivation and they
can possibly open up our inner strength and internal resources. The following
examples were positive suggestions introduced to Mr. A: “You become more
energized for every breath you take. You notice the exhaustion would go away when
you breathe out.” “You can have a soothing feeling from the current of healing
water around your limbs. You would notice the support to your joints and muscle
from the buoyancy of water. You would feel how good it is to relax deeply.”
D. Post-hypnotic suggestion. Yapko (2015) suggested that post-hypnotic
suggestions were those given to the client while he or she was in hypnosis
which encouraged particular thoughts, behaviors and feelings that he or she
could subsequently have in other desired context of living. By such means, the
learning acquired by the client during hypnosis would not be limited to the
session itself. In post-hypnotic suggestion for Mr. A, the following was
delivered: “In the future, when you find yourself anxious or stressed, you can
close your eyes for a moment, and take a deep breath. For every breath you take,
you gain more strength and become more energetic. When you breathe out, the
anxiety and stress would just go away with the exhaled breath. You can enjoy
the relaxed moment whenever you desire.”
E. Waking procedure and orientation. The trance state was ended by counting slowly
from one to five by the therapist. Mr. A was told to return calmly to his full
awareness. Moreover, he was told to stretch his limbs and neck gently. He felt
relaxed and refreshed in every aspect afterwards.
(III) Debriefing. Debriefing was carried out upon completion
of each session. Reframing was often exercised within a session or in the
debriefing. Yapko (2015) pointed out that reframing meant changing the meaning
of some events by changing the context that defines the way the event was
perceived. Rosen (1991) concluded that when the client held an alternative
viewpoint or interpretation to a conventional situation, it involved a reframe.
As mentioned in the introduction at the beginning of this article, reframing
also portrays the second characteristic of Contextual Model being that context
can alter perceived meaning of events. In a cognitive information processing
paradigm, contexts presumably bring forth the ground against which the figure stands.
This distinctive feature attributes to the change of a context can shift
perceived meaning of an event (Wapner, 1986; Tversky and Kahneman, 1981). For
the case of Mr. A, knee pain was reframed as a bodily message telling him to
rest. The inaccurate till balance was not solely about having made mathematical
errors. Taking a short break would allow his body to “recharge” physically and
mentally. After the sessions, Mr. A realized that he did not have a long
vacation except public holiday since nine months ago, and he wanted to make a
the baseline score of Chinese Hope Scale for pathway and agency were
both 22. Significant improvement was shown in the result of
re-assessment with pathway score increased to 24 and the agency score
increased to 32. Secondly,
Chinese Version of the Short Warwick-Edinburgh Mental Well-Being Scale
a distinguished rise from 20/35 in the pre-test to 28/35 in the
conducted after three months. Last but not least, the pain score
the initial interview was 6/10, which then decreased to 2/10 after
1/10 after session two, and 1/10 upon completion of session three.
treatment outcome for Mr. A was satisfactory. Improvement of two outcome
assessments and subjective pain scale were demonstrated in post-assessment. There
are two major factors which may account for the success of hypnosis sessions.
The first one was contributed by the detailed initial assessment and the
ongoing assessment in each pre-talk. These are important elements not only for
enhancing client-therapist relationship, but also reduce the potential
resistance or undesirable reaction from the client. The information from the
pre-talk assisted the therapist in identifying suitable resources for induction
and deepening, and rendering appropriate suggestions for the client. For
example, Mr. A was more suggestible to the feeling of “light”.
Therefore, the metaphor
related to cotton, feather or dandelion might be used instead of dictionary or
heavy iron. Another example was that if the client did not know how to swim, or
even had bad experience such as drowning, “healing water” would unlikely be selected
as the theme during the process. Although Mr. A has been diagnosed with
schizophrenia, he did not have marked cognitive impairment, which allowed him
to go through the process of induction to visualize images during hypnotherapy.
The second factor was contributed by the building of response (yes-set)
gradually. Yes-set encouraged Mr. A to promote focus of attention and become
increasingly responsive to suggestions. Therefore he was facilitated to
experience beneficial effects as the session progressed. The beneficial effects
included the relaxation experience when practising breathing exercise, the
soothing feeling around muscles and joints when exercising guided imagery on
“healing water”, the reduction of knee pain upon completion of each session,
and the idea of reframing in making a holiday plan.
Three limitations were identified in this
case study. The first one is related to the integration of Contextual Model and
clinical hypnotherapy. The process of hypnotherapy was examined systematically with
the features of Contextual Model except confusion technique was not applied in
the case of Mr. A who revealed ample readiness for trance state since he was
responsive to induction especially for the part of “Raising and Falling Arm”. Confusion
technique would be useful for those who have difficulty to go into hypnotic
trance with normal induction. Thus, whether a specific technique would be
practised depends on the need and response of each subject. The second
limitation of this case study was the application of numeric pain scale
which could not reflect the results quantitatively. Moreover, the
measurement of pain level could be controversial as the soft tissue might have gradually
healed with time. Lastly, clients diagnosed with schizophrenia with active
psychotic symptoms, suicidal risk and dual diagnosis might be less effective
for hypnotherapy due to more unpredictable variables in the course of
counter the controversy of pain measurement, the study design in the future
would be improved by including self-hypnosis and technology of neuroscience. For
the case of Mr. A, the hypnosis session could be recorded for him to listen again
at home. Self hypnosis could serve as a home program to encourage self reliance
and independence, and also become one of Mr. A’s stress coping strategies. Client
can also note down any changes in mood and/or somatic feeling so as to supply
more information for later analysis. Besides, a standardized treatment protocol
and hypnotherapy scripts could be prepared in the future study for
standardization and treatment consistency if hypnotherapy would be applied to
more subjects. In addidion, with the advancement of brain-scanning technique, in
a study done by Jensen (2015) indicated that using scalp Electroencephalography
(EEG) has already shown positive evidence in detecting frequency changes, theta
wave in particular, during hypnosis. Theta activity may also reflect new connections
and new learning, such as an increased ability to respond to post-hypnotic suggestions
or suggestions for new ideas and perspective of a problem. According to
previous studies (Williams & Gruzelier, 2001; Al-Fahoum & Al-Fraihat,
2014), the prefrontal cortex and anterior cingulate cortex are the most
significant regions on the scalp in detecting brain waves during hypnotherapy
process. It is hypothesized that the person who received hypnotherapy would experience
an increase in theta activity and enhancement of psychological wellbeing (Bryant
et al., 2006). For that reason, the reflection of brain state by EEG could
provide more scientific evidence on the hypnosis process.
Hypnosis alone is a phenomenon only. What make
hypnosis therapeutic are the client-therapist interaction during the hypnotic
state which can enhance and facilitate the treatment (Spiegel and Spiegal,
2004), and the post-hypnotic suggestions which are essential for the client to
enact alternatives or new possibilities into future experience (Yapko, 2012). In
addition, Clarke and Jackson (1983) suggested that post-hypnotic suggestion was
regarded as a form of higher-order conditioning, which functions as positive
reinforcement to increase desired behavior or negative reinforcement to
decrease probability of undesirable behavior. It is believed that the
aforementioned therapeutic constituents of hypnosis could contribute positively
to the client’s functional status, thus promote his or her physical and
psychological well-being. Clinicians are encouraged to systematize the
procedures of hypnosis with the application of neuroscience techniques as
evidence-based measurement so that hypnosis could become a standardized
non-pharmacological treatment and self-management option for clients with
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