A project to change the attitudes, beliefs and practices of health professionals concerning hypnosis
This study describes an educational project designed to change the beliefs, attitudes and practices of health care professionals concerning hypnosis and hypnotherapy. The purpose of the study was to investigate whether an educational offering that dispelled myths and misconceptions of hypnosis, offered a historical perspective, discussed how hypnosis works therapeutically, and elucidated the many medical uses of hypnosis, could change the attitudes, practices and beliefs of health care providers. Workshops were given to health care professionals at a variety of venues. Three questionnaires were used to collect data from study subjects before, immediately after and three months following the educational intervention. The results indicated that it is possible with a 90 to 180 minute lecture on hypnosis to create changes in beliefs, attitudes and practices. When health professionals have accurate information on hypnosis that is substantiated by scientific research, they are more likely to believe that hypnosis has a place in traditional mainstream medicine and to suggest self-regulatory strategies and hypnosis to their patients. An educational presentation on hypnosis can encourage health care professionals to learn more about this modality and to seek training in hypnosis.
Keywords: Attitudes, change, education,hypnosis, lectures, misconceptions, myths
Hypnosis is a beneficial therapeutic adjunct that is frequently misunderstood, poorly accepted, and greatly underutilized. Most health care professionals have little accurate information about hypnosis, and their attitudes and beliefs are often based on misinformation. Consequently, many health care providers have probably not used hypnosis, referred patients for hypnosis, or even considered that hypnosis has a place in mainstream medicine. It was the purpose of this study to determine whether an educational presentation on hypnosis could change the attitudes, practices and beliefs of medical health care professionals about hypnosis.
There is very little research on the possibility that receiving educational information on hypnosis or attending an informative and accurate lecture on hypnosis might have a potential for positive effects in those receiving it. When Hawkins and Bartsch (2000) studied the effects of an educational lecture on hypnosis, they found that the lecture-exposed subjects had more positive attitudes towards hypnosis and fewer stereotypic negative beliefs.
It is noteworthy that health providers frequently have little experience with the therapeutic benefits of hypnosis and its therapeutic applications. Not unlike the general public they have widespread misperceptions of hypnosis (Pratt, Wood & Alman, 1988; Crasilneck, 1985; Marcuse, 1964; Kroeger, 1963; Wallace 1979). Attitudes concerning hypnosis are often shaped by the media and stage hypnotists (Pratt et al. 1988; Wallace, 1979; Marcuse, 1964). Studies have shown that subjects who viewed a stage hypnosis performance or had seen one on television had not been given any accurate information about hypnosis and were left with negative attitudes toward hypnosis (Echterling & Emmerling, 1987; Meeker & Barber, 1971; Large & James, 1991).
On the other hand, research has shown that subjects will be less likely to subscribe to the “myths” surrounding hypnosis when they have been given accurate information about hypnosis and will have a corresponding willingness to respond to hypnotic suggestions (Echterling & Whalen, 1995; Saavedra & Miller, 1983). In a study by Large and James (1991), subjects who had expressed negative attitudes toward hypnosis felt more positive about hypnosis after receiving accurate information and were more receptive to the possibility of trying hypnosis for pain relief.
Johnson and Hauck (1999) looked at the beliefs and opinions of the lay public concerning hypnosis and the sources of their beliefs. The group that had the greatest willingness to experience hypnosis, had beliefs and opinions which were most influenced by medical/psychological clinicians rather than the media or stage hypnotists. However, when Sohn and Loveland-Cook (2002) examined clinicians who recommended hypnosis and other complementary and alternative therapies, they determined their knowledge of these modalities was minimal and their primary source of information on the subject was through personal experience and the lay literature. Of the nurse practitioners surveyed 11.2% had previously referred patients for hypnosis. When asked to rate their knowledge concerning hypnotherapy on a Likert scale (Lowry, 2000) with one representing no knowledge and five, extensive knowledge, the mean score was 2.2. In this study 5.1 % indicated that the source of their knowledge was from their graduate nurse practitioner education; 7.4% indicated that it was outside their nurse practitioner education. The percent of nurse practitioners surveyed who expressed interest in further education in hypnosis was 14.5%.
In a study done by Hall and Giles-Corti (2000) which explored the knowledge, attitudes and referral patterns of general practitioners in Australia concerning complementary and alternative therapies including hypnosis, 90% had been approached by patients for advice on complementary therapies; 75% had referred patients for complementary therapies which included hypnosis among the most common. Less than half of those physicians surveyed had ever studied about even one complementary therapy and 60% wished further training. Pirotta et al. (2000) found that general practitioners underestimate their patients’ use of complementary therapies. Although 80% had referred patients for acupuncture, hypnosis and meditation, only 20% had any training in hypnosis. Another study in Australia (Newell & Sanson-Fisher, 2000) assessed radiation and medical oncologists’ attitudes and knowledge about complementary therapies. This group considered meditation, hypnosis and acupuncture to be the most likely to be helpful and reported self-identified gaps in knowledge about non-traditional therapies.
Borkan, Neher, Anson and Smoker (1994) looked at the referral patterns of allopathic physicians for complementary-alternative therapies. They found no relationship between the rate of referral and physicians’ knowledge, beliefs and familiarity with the effects of alternative therapies. In a study of American pediatricians, Sikard and Laken (1998) determined that 13.8% had referred patients for hypnosis. More than half, 54.1 %, were interested in continuing medical education courses in complementary and alternative therapies. Elkins and Wall (1996) assessed the attitudes, experience, training levels, and interest in future education regarding the use of hypnosis among physicians and residents. They found that 79% of physicians and 67% of residents were interested in pursuing training regarding hypnosis.
The present state of hypnosis training and the attitudes of program chairs toward including hypnosis training in doctoral programs was examined by Walling, Baker and Dott (1998). Forty-four out of 170 programs surveyed reported that they offered course work in hypnosis. Of the nurse practitioner programs investigated by Rauckhorst (1997), 37% included formal education in complementary and alternative therapies in their curricula.
Professional standards dictate that treatment and referrals must be grounded in a knowledge base of past experience and practice with solid roots in scientific knowledge. When professionals attempt to fill the void in their education and provide guidance to patients about hypnosis based on personal experience and lay literature, they risk losing credibility and may jeopardize patient care by referring patients to unlicensed, uncertified or inadequately trained providers. According to Sohn and Loveland-Cook (2002), nine out of 10 providers recommended complementary and alternative therapies, yet their source of information was not derived from professional education. Given the high rate of referrals and the absence of any apparent internal logic or solid base of knowledge for such recommendations, guidelines and expanded educational opportunities are advisable. Integrated medicine that combines alternative and traditional treatment approaches is the future of health care. As the public demand for and use of complementary and alternative therapies including hypnosis increases, the content of complementary and alternative modalities in formal academic programs, professional conferences and in-service educational opportunities must increase. The purpose of this study was to determine if providing medical health care professionals with accurate information about hypnosis in the form of a lecture would change their attitudes, practices and beliefs concerning hypnosis and hypnotherapy.
The research methodology utilized was experimental in nature and descriptive by design. It involved the collection and analysis of new data from study subjects before and after an educational intervention about hypnosis.
The presentation on hypnosis was given to approximately 300 health care professionals in seven separate venues. These continuing educational offerings were given at national nurse practitioner conferences, grand rounds at a hospital, and a medical center, as well as over interactive television to nurse practitioner students at a university graduate program in nursing. Seventy percent of the study sample are nurse practitioners. Nurse practitioners are advanced practice registered nurses who are Master’s degree prepared and nationally certified. The remainder of the participants are nurses, physicians, nurse practitioner students, and their faculty. Completing the questionnaire was not an attendance requirement at the continuing education offering. There were 196 participants who completed the pre-test. Several participants arrived several minutes late and filled in the post-test without having done the pre-test. There were 202 post-tests in the study. A remarkable 64% or 126 returned the follow-up questionnaire three months following the intervention. Participation in the study was completely voluntary. Study subjects received no remuneration for their participation.
Data collection in this study was accomplished with the use of three questionnaires: pre-intervention, post-intervention and a three-month follow up questionnaire. Each questionnaire consisted of six questions concerned with the attitudes, practices or beliefs of the subjects regarding hypnosis and its place in mainstream medicine, hypnotherapeutic techniques, relaxation, self-regulatory strategies and interest in pursuing training in hypnosis. A Likert type scale (Lowrey, 2000) was used for questions 1 through 5 since beliefs, attitudes and practices vary along a continuum and can be measured by a scale that employs summated ratings based upon weighting the multiple response categories in a predetermined direction. A copy of each questionnaire is in the Appendix.
The study subjects attended a 90 to 180 minute educational offering presented by the author. The lecture included a historical perspective of the evolution of hypnosis, and a discussion of the myths and misconceptions concerning hypnosis and characteristics of hypnotizability. The presentation provided an overview of how hypnosis works therapeutically. This included a discussion of the relaxation response, distraction, the power of positive thinking, and the placebo response. The powerful therapeutic uses of language, post-hypnotic suggestions, and metaphors were presented along with the components of hypnosis and hypnotic phenomenon. Psychoneuroimmunology and cyberphysiology were also introduced. Criteria for success were discussed as well. One of the objectives of the educational intervention was that the participants develop an appreciation and understanding of the various uses of hypnosis in clinical practice and learn how to integrate hypnotherapeutic techniques and self-regulatory strategies into traditional practice. Information was also given concerning how to receive training in hypnosis.
The educational intervention included a didactic lecture supplemented by slides, videotapes, and handouts and was followed by a question and answer period. There was a variety of videotapes used during the educational intervention. One of the tapes shown demonstrated how hypnotherapeutic techniques could be used to engage a child’s cooperation during a physical examination, injections, and blood draws. Other videos showed a teenage girl having a gynecological procedure done while in a hypnotic trance; in another a patient gave a first-person account of how she had utilized hypnosis to help her help herself with enuresis. Following the lecture those participants who so chose could participate in a hypnotic trance for the purpose of relaxation.
The data was collected by indirect means utilizing paper and pencil techniques. The study subjects completed questionnaires before and immediately after the educational intervention. The follow-up questionnaires were mailed to the study subjects three months after the workshop along with a stamped, addressed return envelope.
The raw data collected in this study was converted to an orderly body of knowledge through statistical computation and analysis. The Friedman Test (Lowry, 2000) a non-parametric test of one-sample repeated measures was performed to determine significant differences between the variables.
The data was collated from each of the three questionnaires: pre-test, post– test, and follow-up. The Likert type scale (Lowry, 2000) used on the questionnaires for questions 1 through 5 was analyzed using a weighted scoring program. Numerical weights from 1 to 5 were pre-assigned to each question. A response of 1 or 2 to any question on the questionnaires indicated an unfavorable or negative attitude toward hypnosis or a behavior that would never or was very unlikely to ever occur. A response of 4 or 5 to any question indicated strong agreement or a behavior which would definitely or very probably take place. A response of 3 represented uncertainty. Responses to the questions on the pre-test were compared with the responses on the post-test and followup questionnaires.
Mean scores were tabulated and the Friedman test (Lowry, 2000) was utilized to determine if a significant difference existed between the subjects’ responses on the pretest and those on the post-test which followed the educational intervention for each individual question. Likewise, the Friedman test (Lowry, 2000) was used to compare the responses on the pre-test with those on the follow-up questionnaire to determine if changes held up over time (Table 1).
There was a highly significant difference between the beliefs of health care professionals concerning the place hypnosis has in traditional mainstream medicine before and following an educational intervention both immediately (p = 0.000) and three months later (p = 0.012). Before the educational intervention, 77% believed hypnosis has a place in traditional mainstream medicine as compared with 96% immediately following the lecture and 91% three months later.
There was a significant difference between the health care professionals’ current use of hypnotherapeutic techniques and their plans for using them in the future (p = 0.00). Their actual use of hypnotherapeutic techniques in the three months following the educational session increased; this was statistically significant at the 95% confidence interval (p = 0.050).
There was a highly significant difference between the health care professionals’ practice of suggesting relaxation techniques to patients before the educational intervention and their plans for suggesting relaxation techniques in the future (p = 0.000). Seventy percent of health care professionals were already suggesting relaxation techniques to their patients before the educational intervention. Immediately following the educational intervention there was a highly statistically significant increase in the number of study subjects who planned to suggest relaxation to their patients. However, at the three-month follow-up the responses were virtually identical to those on the pre– test with 70% recommending relaxation. The educational intervention had made no change in the behavior of health care professionals concerning their use of relaxation strategies with patients (p = 0.492). The majority had already been using these techniques and were continuing to use them.
There was a highly significant difference between health care professionals’ practice of suggesting self-regulatory strategies to patients before the educational intervention and their plans for suggesting self-regulatory strategies in the future (p = 0.000). Their actual practice of suggesting self-regulatory strategies during the 3 month period following the educational program was not significantly different than before the intervention (p = 0.075).
There is a highly significant difference between health care professionals’ practice of suggesting hypnosis with a trained practitioner to patients before the educational intervention and their plans for suggesting hypnosis to their patients in the future (p = 0.000). There was also a highly statistically significant change in the practice of suggesting hypnosis as a valuable therapeutic adjunct to patients between the pre-test and the three-month follow-up (p = 0.00).
During the educational intervention it was emphasized that hypnosis is a skill that could be added to professionals’ armamentaria. However, like any clinical skill it requires education, training, and practice. Information was given to the participants as to where they could receive training in hypnosis. Before the lecture 30% had no interest in pursuing training in hypnosis; following the lecture that percentage dropped to 4%. After the intervention a large majority of the respondents (78%) were interested in pursuing training in hypnosis. There was a highly statistically significant difference in the respondents’ interest in pursuing training in hypnosis before and after the educational intervention (p = 0.000). The three-month follow-up questionnaire revealed that 83% planned to pursue training in hypnosis. Twenty-four percent had already done something to further their knowledge of hypnosis after attending the lecture. Due to a flaw in the testing instrument, the statistical significance of this could not be assessed in the same manner as the other questions.
On the basis of this study it is possible to conclude that there was a significant difference between the attitudes of health care professionals concerning hypnosis and hypnotherapy before and immediately following their attendance at an educational intervention and this difference persists over time. The change in the attitudes of the study subjects concerning hypnosis directly following the educational intervention would support the results obtained by Large and James (1991) which showed that after subjects were given accurate information about hypnosis, subjects were more positive about hypnosis in general and the possibility of trying hypnosis in the future.
Many health care professionals, not unlike the population as a whole, view hypnosis skeptically and would not consider it a part of traditional allopathic medicine. Providing the subjects with factual, scientifically based research that showed the effectiveness of hypnosis was pivotal in changing their beliefs concerning the place hypnosis should have in traditional mainstream medicine. Learning about the possibilities of integrating hypnotherapeutic techniques into traditional clinical practice may also have contributed to change their perception of hypnosis.
The health care providers learned from the educational intervention that many of the successful techniques they currently used with patients were hypnotherapeutic, such as guided imagery, distraction, diaphragmatic breathing, reframing, leading, and pacing. The recognition of that fact and their enthusiasm after viewing videotaped examples (such as a child blowing away the pain of an injection by blowing a pinwheel) were reflected in their answers on the post-test. The number of study participants who by self-report continued to incorporate hypnotherapeutic techniques into their clinical practice following the lecture on hypnosis increased, and was statistically significant at the 5% significance level. These practitioners had not received formal training in hypnosis, but rather had learned about hypnosis and the effectiveness of techniques that are hypnotic in nature but do not require a formal induction and trance state.
I found a large majority of health care professionals currently use and will continue to use relaxation techniques with their patients. These percentages were not affected by the lecture. The term self-regulatory strategies was intentionally not defined to the participants in the study. The educational intervention elucidated varying self– regulatory strategies. For some participants, the recognition that they were already utilizing some self-regulatory strategies with patients may be reflected in the large statistically significant increase in the participants who indicated on the post-test that they planned on suggesting self-regulatory strategies to patients in the future. This change, however, was not statistically significant at the three-month follow-up. Most health care professionals rely on pharmacology, technology, and surgery to heal their patients. Hopefully, the lecture broadened their awareness and acceptance of other healing modalities.
Techniques related to hypnosis that involve the careful use of therapeutic language such as suggestion, reframing, distraction, leading, pacing, and imagery, can be integrated into a clinical practice by a skilled clinician without extensive training in hypnosis. Hypnosis, however, should only be used by trained health care or mental health professionals. Before the educational intervention most of the study subjects had never considered suggesting hypnosis to a patient. The presentation was very successful in raising the consciousness of the attendees to a powerful healing modality. The post-test revealed that 83% of the health care professionals planned to suggest hypnosis to their patients in the future as compared to 29% before the intervention, and only 1% said they did not plan to suggest hypnosis to patients. By the time of the follow-up (three months after attending the lecture) 56% had already suggested hypnosis with a qualified provider as a possible therapeutic option to patients. The analysis of the responses of the study subjects to this question clearly illustrates the value of a presentation on hypnosis to health care professionals to dispel myths and misconceptions and to educate them to the wide range of medical uses of hypnosis, substantiated by research.
As part of the educational intervention in this study, subjects were given an experiential opportunity. Those who wished could experience a hypnotic trance led by the author for the purpose of relaxation. At all venues the participants (with the exception of only one or two individuals) remained for the experiential portion. Previous research has shown that subjects who have previously experienced hypnosis are not as fearful and have a more accurate concept of hypnosis (Hawkins & Bartsch, 2000). When subjects are provided accurate information and have the opportunity to experience a hypnotic trance, positive attitudes and more realistic beliefs about hypnosis result.
The generalizability of this study is limited by the fact that the attendees at the educational intervention chose to attend because the subject was of interest to them. In addition, participation in the study was completely voluntary and only two-thirds of the attendees chose to participate. Therefore, only those who were motivated or interested enough completed the questionnaires. This limitation is particularly relevant in analyzing the follow-up data. The 64% of the study group who contributed follow-up data may not have been representative of the entire group. The 36% who did not complete the follow-up questionnaire may have been much less enthusiastic about the topic.
The findings from this study provide evidence for the position that when subjects have accurate information on hypnosis that is supported by scientific research, they will be more likely to incorporate hypnotherapeutic techniques into their clinical practices and suggest hypnosis with qualified providers to their patients. Their use of self-regulatory strategies and relaxation techniques with patients may also increase. This project found that when health care providers are educated about hypnosis, learn the therapeutic benefits for a variety of conditions and obtain more information about how to integrate hypnotherapeutic techniques into their clinical practices, they are more likely to have an interest in pursuing training in hypnosis. The findings of this research also showed that health care professionals who are not knowledgeable about hypnosis or convinced of its validity could be educated and informed by attending a presentation on hypnosis.
Myths and misconceptions concerning the legitimacy of hypnotherapy abound, not only among the lay public, but also among health care professionals as well. Its recognized legitimacy and use among medical health care professionals lags far behind its potential effectiveness. An educational presentation, which confronts the myths about hypnosis, can be very effective in dispelling misconceptions. Offering a historical perspective and discussing how hypnosis can be integrated into clinical practice can stimulate interest in healthcare professionals. Substantiating the therapeutic usefulness of hypnosis with solid research can alter opinions.
The study subjects in this research project viewed videotapes of patient encounters, and also heard case vignettes and taped first-person accounts from patients who had utilized hypnosis to help themselves with physical or psychological problems. Having the participants experience a hypnotic trance for the purpose of relaxation at the end of the intervention was very powerful. There is no substitute for experience. It is evident from the analysis of the data that the educational intervention made a positive impact on the attitudes, beliefs and practices of health care professionals concerning hypnosis and hypnotherapy.
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University of Vermont
Acknowledgement: The author gratefully acknowledges the help of Dr. John Newbauer in the statistical analysis of the data and the encouragement and support of Dr. Claire Frederick. Request reprints from:
Linda Thomson, MSN, CPNP
131 Thomson Dr.
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