Four session hypnosis intervention for smoking cessation: Treatment outcome evidence from Pakistan.
Keywords: Hypnosis, Smoking cessation, Pakistan, Self hypnosis, Outcome of treatment.
Hypnosis is usually defined as an altered state of consciousness where an individual is able to evade certain aspects that are related to reality, tolerate rational discrepancies, experience perceptual and memory distortions as reality and feel a compulsion to follow instructions of the hypnotherapist in an uncritical fashion.1 Hypnotic suggestions are influenced by a subject's trance capability, motivation and relationship with the hypnotist. Use of suggestions is an important element in hypnosis with concentration and focused attention.2 Most of the smokers come to hypnotherapist with an idea that hypnosis will eliminate their desire to smoke and hope that it will happen in a single visit. Hypnosis encourages smokers to concentrate on (a) smoking is poison for the body (b) the body needs to live (c) you owe the body respect and protection. Patients are encouraged to repeat these ideas any time they experienced an urge to smoke.
Motivation to quit smoking is considered to be a significant variable in smoking cessation.3 There is constant debate regarding the hypnotizability of a patient with smoking addiction. It is said that the patients who are treated with hypnosis produce 25% chances of success; however, most of the controlled studies have found that hypnotic interventions were no equal to all other interventions. Moreover, only those patients failed to respond to hypnosis who were not motivated to quit smoking.4 For smoking cessation through hypnotic interventions success rate of 94% based on the evaluation of clinical case reports was reported by Johnston and Donoghue in 1971.5 However, Holroyd in 19806 examined 17 reports of clients and reached to a conclusion that more sessions on smoking cessation are healthier than few sessions. A Meta analysis was performed by Viswesvaran and Schmidt in 19927 where they examined 48 clients under hypnosis.
Results indicate that hypnosis achieved 36% success rate than any other treatment. It is therefore, difficult to ignore the role of hypnosis in high cessation rates of smoking being reported, and the clinical significance of the results that have been obtained.8 Evaluation of studies on the impact of hypnotic intervention on smoking cessation are not available in Pakistan. As this field is new and still emerging, people of Pakistan do not usually opt for hypnosis as a treatment method. However, currently due to media efforts and interviews of hypnotists and hypnotherapists, people have started gaining insight into hypnotic interventions with other traditional interventions for treatment. Hypnotherapists from University in Montreal, Canada have said that alternate treatment options still stand for smokers who are determined to break their habit of tobacco dependency.
There are plenty of questions raised in our country regarding the effectiveness of hypnotic interventions as an alternative therapy against conventional methods to quit smoking. It is said that smokers should initially try the traditional approaches including nicotine-replacement therapy, medications and behavioral counseling. But some of our people are not interested in taking medication and therefore, traditional methods do not work on them. Such clients are than recommended acupuncture and hypnosis as treatment choices.9 A Pakistani psychiatrist at (Markaz-e-Nafsiat) is using hypnotherapy for smoking cessation in Karachi. According to her the clients cannot stop smoking unless they are motivated to quit.10 Present study was carried out with the main objective to find out effectiveness of clinical hypnosis as an intervention for smoking cessation.
Four criteria were kept in mind while treating clients with tobacco dependency (a) more than one session should be carried out, (b) individualized hypnotic suggestions should be used, (c) follow-up sessions within the period of one year would be carried out (d) there should be treatment outcome evidence available from Pakistan. The effectiveness of clinical hypnotic intervention was examined by the end of the treatment at 3, 6 and 12 months through follow up sessions post to the treatment. Furthermore, this study also examined the level of patient's satisfaction with this treatment.
Method and Results
Ethical review statement
The Code of Ethics and standards of practice of the National Guild of HypnotistsTM was followed while conducting the study. Participants' confidentiality was maintained and outcome of treatment published with their signed written consent. They gave consent for their information relating to the subject matter "Treatment of Smoking Cessation through Hypnotic Intervention" to appear in a journal article, or to be used for the purpose of presentation. They gave consent that the Information will be published without their name attached and every attempt will be made to ensure complete anonymity. The Information may be published in a journal which is read worldwide or an online journal. Journals are aimed mainly at health care professionals but may be seen by many non-doctors, including journalists. The Information may be placed on a website.
They can withdraw their consent at any time before online publication, but once the Information has been committed to publication it will not be possible to withdraw the consent. Three smokers self approached the hypnotherapist through Transformation International Society website. Consultation was done at Transformation Wellness Clinic, Lahore, Pakistan for smoking cessation. The study was carried out within the duration of two years from January 2015 to December 2017. Three male clients with ages 30, 35 and 18 were included in the study. Two of the clients were married and one was single. The average years of smoking were 5 years and average number cigarettes smoked per day were 20. All clients reported failure in previous self assisted attempts with strong motivation to quit smoking. The clinical hypnotic intervention protocol included four sessions. The first session was based on consultation, behavioural assessment, rapport building and pre-sleep technique of self hypnosis.
Sessions 2 and 3 were completely based on hypnotic induction, individualized hypnotic suggestions with remaining steps of self hypnosis and strong post hypnotic sessions were given in 4th session. The clients were seen once a week for treatment and the Intervention protocol was based on the teachings of National Guild of Hypnotists, Inc.
The first session with each of the clients was a double session of 1 and half hours. Initial 45 minutes of the session were used to establish rapport and initial consultation was completed with a detailed assessment process beginning with initial interview/intake covering every aspect of clients' problem and life. The session also included discussion on factors that triggered their desire to smoke and relationship between stress and cigarette smoking and what they were expecting to achieve from hypnosis. After a detailed discussion behavioral assessment was performed through BASIC assessment technique where clients were asked questions regarding behaviour, affect, sensations, imagery and cognitions. The hypnotherapist obtained a comprehensive understanding of the total context in which the smoking behaviour occurred. Hypnosis was that explained to the clients in 5 minutes including and misconceptions related to hypnosis were clarified.
Stop Smoking Agreement was discussed with them with a date decided for quitting cigarette. During the next 45 minutes Arms Rising and Falling (Permissive), Handclasp (Authoritative) suggestibility tests and a 20 minutes progressive relaxation induction were done. During the last 10 - 15 minutes the contract was reviewed and first step of self hypnosis (pre-sleep) was taught as homework assignment with positive suggestions. They were asked to keep a daily record of smoking for next session.
The second session was of 45 minutes where during initial 15 minutes the action plan of first session was reviewed and client's behaviour and smoking record during the week was discussed. During the next 30 minutes clients participated in a hypnotic session with suggestions. The steps of hypnotic induction were:
a) Dr. Flower Induction:11 This method involves counting to cause fatigue to the eyes because in between every count the client opens and closes his eyes causing the eye muscles to get tired and they no longer feel the need to keep their eyes open.
b) Hypnotize the Client: This is the state where the client's focus and concentration are heightened and they can focus on a thought or memory without distraction showing increased response to suggestions. This state is induced by a procedure known as a hypnotic induction.
c) Deepen Hypnosis: It is the process of making the hypnotic state more profound and creating a somnambulistic state which means a mindset which is accepting more suggestions.
d) Imagery Related To the Problem/Goal: Imagination produces the same effects as if it is happening right in front of you or you are in the event. Having an idea of an action results in that action. Therefore, imagery related to the problem/goal is created in this process.
e) Commitment for Smoking Cessation: Through positive imagery and suggestions clients see themselves to be quitting smoking.
f) Post Hypnotic Suggestions: When a hypnotized person is given suggestions for a specific action to be performed after awakening from hypnosis often in response to a cue.
g) Self Hypnosis: Is a process also called autohypnosis which is a self-induced method of hypnosis, where positive suggestions are given to on self.
In order to reinforce the action plan ego strengthening script was used by adding customized suggestions for the presenting problem/goal for each client. Clients were than emerged from hypnosis. As the client emerged Second step of hypnosis was taught and was also given as homework assignment after practice to be continued for a week till the next session. Use of self-hypnosis was also discussed. Further, it was discussed how self hypnosis is going to help them feel more in total control of any craving for the bad habit again.
The third session was also of 45 minutes where steps one and two of self hypnosis were repeated for the client. Clients were taught steps for making suggestions and the concept of working with suggestions. They were then asked to formulate an action suggestion for their immediate problem. Then third step in self-hypnosis was taught to them which enabled them to work with the suggestion in step two. They were told to practice it in a day. Quick trance techniques with positive suggestions were applied and homework assignment and action plan was reviewed.
Another 45 minutes session included discussion with client regarding changes in his behaviour and record of their smoking. After that prior week's activities were reviewed. Clients were hypnotized by deepening hypnosis, imagery associated with problem or situation was created, post hypnotic suggestions were given, positive imagery for future was created, ego strengthening suggestions were delivered with direct suggestions dealing with the client's situation after which they were emerged. Three step self hypnosis and its practice was discussed. Clients were encouraged to use self hypnosis in future and termination of therapy after follow up sessions was discussed with them.
Follow Up Sessions and Analysis of Outcome of Treatment
The frequency and termination of treatment was already discussed with the clients in the fourth session. They came for follow up sessions initially once every month and then once after every 6 months for a year. In follow up sessions hypnotherapist discussed if they had stopped smoking or not and whether there was any craving or not. Clients were also asked whether they had stopped smoking with or without relapse for 3, 6 and 12 months. All of the three clients reported that they did not smoke any cigarette post treatment and did not experience relapse. They reported that they were consistently practicing self hypnosis and other relaxation techniques taught along with positive suggestions. No inconsistencies were noted between the clients verbatim and the observation of family members who usually accompanied them.
This study was carried out with the primary objective to find out effectiveness of clinical hypnosis as an intervention for smoking cessation. A four session hypnosis intervention for smoking cessation based on the teachings of National Guild of Hypnotists Inc has been discussed in detail. The inclusion of four sessions was based on hypnotic inductions, individualized hypnotic suggestions, self hypnosis, and development of trustworthy interpersonal relationship with clients and self hypnosis. All three clients reported full recovery after a year with 95 - 100% satisfaction level with the practice of self hypnosis and auto suggestions post treatment. Analysis of treatment outcome was based on self reports of clients in follow up sessions after 3, 6 and 12 months post treatment. Clients came to visit the hypnotherapist for follow up sessions where they were asked whether they had stopped smoking or not and for how long after treatment.
Stop Smoking Follow-Up Questionnaire was used to obtain self reports of clients including questions a) were they still an ex-smoker or not (b) what was the date they quit smoking on (c) If they haven't stopped smoking how many cigarettes per day were they smoking (d) how many cigarettes per day were you smoking at the start of sessions (e) How often did they practice their autosuggestion at least once a day (f) it was also suggested to practice self-hypnosis exercise after they stopped smoking. They were asked how often they practiced self-hypnosis in a week and were told that their responses will be kept strictly confidential even while publishing the results. No inconsistencies were noted for the clients who attended the sessions. They were also asked about their satisfaction with the treatment they have received. None of the clients started smoking till the time treatment ended.
The primary outcome was based on the verbatim of clients who reported having stopped smoking, for how long, after treatment and the patient's reported level of satisfaction with the treatment. Great deal of attention should have been paid to the efficacy of hypnotic interventions for smoking cessation in a developing country like Pakistan. However, there is no evidence of treatment outcome using hypnosis for smoking cessation techniques. This study will be beneficial for Pakistani smokers to motivate them to undertake cessation effort thorough hypnotic interventions. This study also indicates that despite of small sample size and methodological weaknesses, there is still hope for future research on treatment outcome. As our people mostly use traditional interventions for smoking cessation, hypnosis should also be given consideration as a treatment choice.
Conclusion and Recommendation
These results are only preliminary and may be of clinical interest. Further studies should be carried out considering the findings of this study. First, the treatment outcome and satisfaction level of clients were based on self-reports. This study did not use any biochemical measures of abstinence. Secondly, as the study was clinical in nature it did not include a treatment and control group which is necessary to determine the effectiveness of hypnosis versus the effect of other variables. Lastly, sample size is too low and it might be possible that all three of the clients were highly responsive to hypnosis and attained superior benefits through it. Therefore, additional research is needed to further evaluate this clinical hypnosis intervention for smoking cessation in Pakistan incorporating all the mentioned elements.
Disclaimer: The abstract has not been presented or published in any conference, or published in any abstract book.
Conflict of Interest: "None to declare"
Funding Disclosure: "None to declare".
1. Orne MT. The nature of hypnosis: artifact and essence. J Abnorm Soc Psychol. 1959; 58: 277-99.
2. Frankel FH. Hypnosis. In: Frankel FH, eds. Trance as a Coping Mechanism. New York: Plenum Medical Books, 1976.
3. Covino NA, Bottari M. Hypnosis, Behavioral Theory, and Smoking Cessation. J Dent Educ. 2001; 65:340-7.
4. Barkley RA, Hasting JE, Jackson TL. The effects of rapid smoking and hypnosis in the treatment of smoking behavior. Int J Clin Exp Hypn.1977; 25:7-17.
5. Johnston E, Donoghue J. Hypnosis and smoking: A review of the literature. Am J Clin Hypn.1971; 13:265-72.
6. Holroyd J. Hypnosis treatment for smoking: An evaluative review. Int J Clin Exp Hypn.1980; 28:341-57.
7. Viswesvaran C, Schmidt F. A meta-analytic comparison of the effectiveness of smoking cessation methods. J Appl Psychol.1992; 77:554-61.
8. Green JP, Lynn SJ. Hypnosis and suggestion-based approaches to smoking cessation: An examination of the evidence. Int J Clin Exp Hypn.2000; 48: 195-224.
9. Want to quit smoking? Try acupuncture or hypnosis. The Express Tribune. [Online] [Cited 2012 May 07]. Available from: URL: https://tribune.com.pk/story/375217/want-to-quit-smoking-try-acupuncture-or-hypnosis/
10. Ahmad AH. The Express Tribune. E-cigarette: Put this in your pipe and smoke it. [Online] [Cited 2013 Jan 02]. Available from: URL: https://tribune.com.pk/story/539877/put-this-in-your-pipe-and-smoke-it.
11. Flowers SD. Dr. Flower's Hypnotic Induction Technique. Student Manual. New Hampshire: Professional Development Division - National Guild of Hypnotists. Inc, 2014; pp 31-32.
|Printer friendly Cite/link Email Feedback|
|Publication:||Journal of Pakistan Medical Association|
|Date:||May 31, 2019|
|Previous Article:||A case of an absent gall bladder presenting as biliary colic in a tertiary care hospital in Karachi.|
|Next Article:||Frequency of human papilloma virus in patients with oesophageal squamous cell carcinoma in Khyber Pakhtunkhwa.|