The International Journal of Psychosocial Rehabilitation
 

Contextual Model on Clinical Hypnotherapy
for a Client with Chronic Schizophrenia in Hong Kong

LAU, Hiu-ying
Occupational Therapy Department,
Wong Chuk Hang Complex for the Elderly,
2 Wong Chuk Hang Path, Wong Chuk Hang, Hong Kong
blythe.lau@tungwah.org.hk

CHU, Man-keung
Mind Liberté Training Center
mindliberte@on-nets.com


 




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



Abstract
Background
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.
Method
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
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.
Conclusion
Hypnotherapy enhances psychological well-being with positive effects of stress reduction and pain relief.



 


Introduction:
Hypnotherapy 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
All 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.

Methodology
Participant
The 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.

Measure
(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).
 
Procedure
(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 months.

After 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 session.

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 holiday plan.

Results
Firstly, 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 indicated a distinguished rise from 20/35 in the pre-test to 28/35 in the post-test conducted after three months. Last but not least, the pain score recorded from the initial interview was 6/10, which then decreased to 2/10 after session one, 1/10 after session two, and 1/10 upon completion of session three.
 
Discussion
The 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 treatment.

To 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.

Conclusion

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 mental illness. 


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