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The Uncertain Relationship Between Hypnotizability and Smoking Treatment Outcome Jean Holroyd
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Neuropsychiatric Institute University of California , Los Angeles Published online: 31 Jan 2008.
To cite this article: Jean Holroyd (1991) The Uncertain Relationship Between Hypnotizability and Smoking Treatment Outcome, International Journal of Clinical and Experimental Hypnosis, 39:2, 93-102, DOI: 10.1080/00207149108409623 To link to this article: http://dx.doi.org/10.1080/00207149108409623
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THE UNCERTAIN RELATIONSHIP BETWEEN HYPNOTIZABILITY AND SMOKING TREATMENT OUTCOME JEAN HOLROYD’.’ Downloaded by [University of Toronto Libraries] at 02:14 02 February 2015
Neuropsychiotric Institute, Uniuersity of Cdifornio at Los Angeles
Abstract: Literature on the relationship between hypnotizability and smoking treatment outcome was reviewed. 91 private patients treated for smoking with hypnotherapy participated in an investigation designed to correct problems in some of the earlier research. 43% quit smoking by the end of treatment but only 16% abstained at least 6 months. Neither immediate quitting nor continued abstinence correlated with hypnotizability. Other variables hypothesized to predict smoking cessation also were not correlated with outcome: number of treatment sessions, need to smoke, motivation to quit, and gender. The low abstention rate may have impeded verification of a relationship between hypnotizability and treatment outcome.
More than one-fourth of American adults remain addicted to nicotine despite national policies discouraging smoking (U. S. Department of Health and Human Services, 1988). Hypnotherapy has proven to be a useful intervention (Holroyd, 1980; Schwartz, 1979), though it is not clear how much hypnosis adds to such nonspecific factors as expectancy, therapist attention, ad hoc patient education, and implicit behavior therapy. If hypnosis aids treatment, then outcome should be related to hypnotizability (Bowers & Kelly, 1979). A review of the literature on hypnotizability and treatment outcome yielded mixed results. Six investigations found a positive relationship between hypnotizability and outcome, based on self-reports. H. Spiegel and D. Spiegel (1978) reported 10-day success rates that ranged from 47% to 18% for extremes of hypnotizability. Mott (1979) indicated that 100% of high, 44% of medium, and 17% of low hypnotizable patients quit, though the differences were reduced on long-term (not defined) follow-u (2096,22%, and 0%, respectively). DePiano, Cash,and Sandford (1982) reported that 55% of
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Manuscript submitted July 21, 1989; final revision received June 26, 1990. ‘The author would like to thank Michael J. Diamond and Andrew W. Sills for their very helpful suggestions in the preparation of this manuscript. ‘Reprint requests should be addressed to Jean Holroyd, Ph.D., Department of Psychiatry and Biobehavioral Sciences, Neuropsychiatric Institute, UCLA; 760 Westwood Boulevard, Los Angeles, CA 90024. 3DePiano. F.A., Sandford, I., Cash, J., & Rush, C. Hypnosis and smoking: A comparison of individualized versus “packaged” suggestions with and without self-hypnosis. Unpublished manuscript, 1982. Available from Frank A. DePiano. Ph.D.. School of Psychology, Nova University, College Avenue, Fort Lauderdale, FL 33314.
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those in the high hypnotizability group stopped as compared to only 26% in the low hypnotizability group; 41% and 5%, respectively, remained abstinent after 4 months. Basker (1985) reported 64% of high, 45% of medium, and 25% of low hypnotizable patients were abstinent after 6 months. Re-analysis of data from another study (A. E Barabasz, Baer, Sheehan, & M. Barabasz, 1986)indicates 79% of high, 18%of medium, and 4% of low hypnotizable patients were abstinent at an average of 17 months follow-up. Baer, Carey, and Meminger (1986) plotted relapse curves for the 80% of their treatment group which could be located at follow-up. Low hypnotizable patients had abstinence rates of only 20% 1week after treatment and reached 0% in 6 months; whereas medium to high hypnotizable patients had 1-week rates of 60-705 and long-term rates of 20-305 after 1 year. Seven studies did not find an association between hypnotizability and outcome. Phelps (1986b)4found that 6- and 12-month outcome did not relate to hypnotizability as measured by an unpublished scale. Perry and Mullen (1975) observed no relationship at 3 months follow-up, though their 13%abstention rate would artificially limit correlation possibilities due to a restricted range. Stanton (1985)observed no association between abstinence and hypnotizability, as measured by a single-item scale, for those of his sample located 12 months after treatment. Powell (1980) detected no relationship between trance intensity and outcome at an unspecified follow-up date, whiIe noting that most of his Ss were rated at the low end of Crasilneck and Hall's (1975) 4-point hypnotizability scale. Sheehan and Surman (1982) found no difference in subjective trance level between abstainers and nonabstainers in 15-month retrospective estimates. Frank, Umlauf, Wonderlich, and Ashkanazi (1986) reported that people who scored below the median on the Creative Imagination Scale (Barber & Wilson, 1978179) were more likely to be abstinent at 6 months follow-up. Perhaps the most widely cited negative result is that of Perry, Gelfand, and Marcovitch (1979), who used a single hypnosis session and/or a rapidsmoking treatment. At 3 months, 29% of high, 15%of medium, and 31% of low hypnotizables were abstinent. Questionnaires measuring desire to quit, current need for cigarettes, and reasons for smoking successfully predicted outcome with multiple regression (r = .42), leading those authors to suggest that motivation is more important than hypnotizability for outcome. This study (Perry et al., 1979) is unique in the hypnosis treatment literature in that the immediate quit rate (13%)was lower than long-term abstinence rate (21%). One cannot assume that negative findings countervail the positive ones because in this case positive replication contributes to validity generaliza'Phelps, L. A. Clinical hypnosis for the smoking habit: A study. Unpublished manuscript. 1986. Available from Lynn A. Phelps. M.D.,310 North Pinckney Street, Madison, WI 53703.
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tion (Rosnow & Rosenthal, 1989), while negative findinqmay be attributed to research design. Five of the negative studies have such low abstinence figures that it would have been difficult to establish a relationship due to restricted range. (Four negative studies used a single-session intervention, which historically has been associated with lower success rates [ Holroyd, 19801.) Four negative studies used nontraditional measures of hypnotizability. A fifth study used retrospective estimates of trance depth after 15 months, which could have been unreliable. One study did not report the actual hypnotizability data; one did not report the number of Ss lost at follow-up; and one combined hypnosis and rapid smoking groups. Finally, five of the seven studies did not use enough Ss, thereby increasing the odds of a Type I1 inferential error of “conservatism or blindness” over a Type I inferential error of “gullibility or overeagerness” (Rosnow & Rosenthal, 1989). Despite these shortcomings, the impression of no association between hypnotizability and smoking treatment outcome has crept into the review literature (e.g., Baker, 1987; Brown & Fromm, 1987; Wadden & Anderton, 1982). The present author undertook the present study to examine the relationship between hypnotizability and treatment outcome using multiple treatment sessions, a standard hypnotizability scale, and a large sample. Recommendations for improved treatment conditions (Holroyd, 1980) were followed as closely as possible in a private practice setting, with hopes of obtaining sufficiently high abstinence rates to permit the expected association to emerge. Motivational measures were included to replicate the findings of Perry et al. (1979).
METHOD Procedii res
Treatment. Ninety-six private patients who telephoned requesting hypnosis for smoking were treated by the present author, but 4 were excluded from the data analysis because severe psychopathology prevented adherence to the treatment protocol, and a fifth case was omitted because hypnotizability was not measured. The remaining 91 patients (45 females and 46 males) were charged $250 each for treatment. The protocol was changed twice during 7 years, resulting in three sequential treatment groups. Each patient was interviewed to provide the basis for an individually tailored intervention based on smoking history, attempts to quit, previous hypnosis experience, and reasons the patient was quitting. Patients completed a questionnaire comprised of three previously effective predictors of abstinence (Perry et a]., 1979)- desire to quit smoking, current need for cigarettes, and reasons for smoking - plus an item assessing realistic versus magical expectations regarding hypnosis. A personalized relaxation induction was used to prepare the patient for maximal responsivity, followed by the Stanford Hypnotic Clinical Scale (SHCS) of Morgan and
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J. R. Hilgard (1975, 1978/79),which was introduced as an opportunity to have a broader hypnosis experience. When, on occasion, patients said they felt relaxed but not hypnotized, they were assured that some of the best results came from a therapist who used only a "relaxation" procedure (Watkins, 1976). The third induction during Session 1 was individually tailored, based on feedback from the first two hypnosis experiences, and was followed by suggestions related to the smoking problem. Session 1 took approximately 90 minutes to complete. Croup 1patients (N = 23) were offered four sessions and given suggestions tailored to their needs and motivations. Sessions 1and 2 were usually spaced 2-3 days apart, with later sessions scheduled days apart if the patient had not quit, or a week or two apart if the patient had quit. If patients did not quit after Session 1, therapy explored what dimculties were being experienced and employed counseling as well as hypnosis. Patients who quit smoking were asked to telephone daily and then weekly and monthly. Group 2 (N = 29) procedures were the same as for Croup 1, modified to reduce premature termination of treatment. Patients signed a foursession contract costing $250 whether or not they stopped smoking. Croup 3 (N = 39) was like Croup 2, except that patients were requested to stop smoking 24 hours before their appointment. Though most patients drastically reduced their smoking during this 24-hour period, only 9 stopped completely. In Session 1, instead of personalized suggestions, a script was used that had been very successful with patients who abstained 48 hours before treatment (T. B. Jeffrey'; T. B. Jeffrey, L. K. Jeffrey, Creuling, & Gentry, 1985).'The 10-minutescript derived from Crasilneck and Hall (1975), H. Spiegel (1970), and Stanton (1978). (This script also was used for 9 patients in Group 2.) Subsequent sessions were more individualized, as in Croups 1and 2. Posttreatment. Patients were considered to have quit if they reported that they had stopped prior to the last session. After quitting, they were requested to telephone the therapist daily and then weekly, depending on their need for support.' A letter requestkg follow-up information was mailed at least 6 months after treatment (X = 9 months, S.D. = 3.8). Patients were considered abstinent if they reported not smoking on the follow-up questionnaire.' Patients who did not respond at follow-up were
"r. B. Jeffrey, personal communication,January 6, 1984. 'Subsequent work did not replicate the potent effect of &hour abstention (L. K. Jeffrey & T. B. J e h y , lQ88).
'Consistent posttreatment telephone contact was very difficult to maintain. Frequently patients did not telephone followingcessation, and they could not be reached by telephone. b e letter stated, "You came for hypnosis to stop smoking a few months ago. . . Did you stop smoking? For how long?" Only responses indicating continuous, uninterrupted abstinence were counted as abstaining. The one person who achieved abstinence at a later date was counted as a failure.
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considered to be treatment failures. Biochemical confirmation of patient report was not used nor was there an attempt to corroborate patient reports with a third party.
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RESULTS
The three groups were examined for differences that might influence abstinence.' They did not differ significantly on level of hypnotizability, number of reasons for smoking, the desire to quit, or hypnosis expectancy, but did differ on current need for cigarettes (F = 3.20, df = 79,2; p < .05)." Croup 2 reported more Need than Group 3 (X = 3.28 and 2.98, respectively, t 2.62, a!! = 57, p < .02, two-tailed test,) but not more than Group 1 (X = 3.17). The difference between Croups 1 and 3 also was not significant. The three groups also differed on number of treatment sessions completed: Croup 1 = 2.5, Croup 2 = 3.3, and Group 3 = 3.4 (F = 6.90, clf = 2,88; p < .002).The overall difference was due to Group 1completing significantly fewer sessions than Group 2 (t = -2.48, df = 50, p < .02) and significantly fewer than Group 3 (t = -3.92, df = 60, p < .001, two-tailed tests). Thus, signing a written contract for four sessions at full fee had the predictable effect of keeping patients in treatment. Considering all 91 patients, an average of 3.2 sessions were completed; 36% stopped treatment prematurely (i.e., before they quit smoking and before they completed Four sessions). Quit rates for Groups 1, 2, and 3 (39% 4596, and 4496, respectively) did not differ significantly, despite the fact that Croup 1 patients completed fewer treatment sessions and Croup 2 patients reported a higher current need for cigarettes. Since the quit rate was the same for all three groups, and since the groups did not differ on most pretreatment variables, the groups were combined to analyze the relationships between hypnotizability, motivation, and treatment outcome. Mean hypnotizability was 2.7 for all patients, which approximates the mean in published SHCS norms (2.75, Morgan & J. R. Hilgard, 1978179). Quitting Of the total sample, 43% quit smoking by the last treatment session, with no difference between male and female patients. People who quit were not distinguished from nonquitters on current need for cigarettes, desire to quit, number of reasons for smoking, hypnosis expectancy, or &rests of significance were bidirectional in all cases, except where a relationship had been predicted between hypnotizability and outcome or between motivational measures and outcome, in which cases they were unidirectional one-tailed tests. 10 Some patients did not complete all the items on the questionnaire, resulting in fewer cases for such comparisons.
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hypnotizability.‘I Those who stopped by the last session, however, completed more sessions than nonquitters (3.6 versus 2.8; F = 14.27. df = 90,l; p c .001) resulting in a positive correlation (r = 3 7 , df = 89, p < .001).
Abstaining Forty-nine patients (54%)responded to a single follow-up letter. ” Hypnotizability for these individuals was 2.7, the same as for the total group. Counting people who did not respond to the letter as nonabstainers, only 16% were abstaining, with no difference between male and female patients. Abstainers were compared with nonabstainers on all relevant variables. Abstainers were not distinguished by gender, current need for cigarettes, desire to quit, number of reasons for smoking, number of treatment sessions, or hypnotizability. With respect to the hypnosis expectancy question, abstainers responded more in the direction of “Hypnosis will work automatically, without any effort on my part,” than in the direction of “Hypnosis will have a facilitative, supportive effect on my efforts to stop smoking” (r = - .25, d ?= 82, p < .02). Multiple correlations using the three motivational tests (current need, number of reasons, and desire to quit) did not demonstrate a relationship to abstaining (r = .12, n.s.). Multiple regression using a host of variables (SHCS, treatment group, number of sessions, the three motivational measures, and hypnosis expectancy)to predict abstinence did not improve upon prediction from hypnosis expectancy alone. l3 DISCUSSION The 43%initial quit rate and 16% Bmonth abstention rate found in the present study are comparable to rates reported by other investigators (Holroyd, 1980; Schwartz, 1979). (Median 6-month abstinence rates are “In the total sample of 91 patients, the percentages of low (0-1). medium (2-3) and high (4-5) hypnotizables (on SHCS) that initially quit smoking were 29, 47, and 47, respectively (N = 91. X‘ = 2.28. df = 2, p = .32).When medium and high hypnotizable groups are combined to contrast with the low hypnotizable group (47% versus 29%). the difference appears similar to positive reports in the literature, but it does not quite reach significance (Fisher’s Exact Test, p = .lo,one-tailed test). ‘?he three groups differed in months until follow-up (6.6,10.3.and 9.8for Croups 1, 2. and 3, respectively; F = 8.6, df = 2.88; p < .Ol),but were combined for follow-up. 13 Post hoc analyses suggested there may be complex interactions between number of required treatment sessions, hypnotizability, and outcome, and that hypnotizability may be a more significant factor for patients receiving a brief number of sessions. These analyses may be obtained from the National Auxiliary Publications Service (NAPS). For 6 pages order document No. 04828 from ASIS-NAPS, d o Microfiche Publications, P.0.Box 3513,Grand Central Station, New York. NY 101633513. Remit’in advance, in U.S. funds only, $7.75 for photocopies or $4.00for microfiche and make checks payable to Microfiche Publications NAPS. Outside the United States and Canada, add postage of 54.50 for a photocwpy and $1.50for a fiche. There is a $15.00invoicing fee for orders not prepaid.
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4 . 9 7 4 % for people who try to quit by themselves [Cohen, Lichtenstein, Prochaska, Rossi, Gritz, Carr, Orleans, Schoenbach, Biener, Abrams, DiClemente, Curry, Marlatt, Cummings, Emont, Giovino, & OssipKlein, 19891.) Unfortunately, a low abstention rate works against finding the relationships predicted by the present author. Restricted range on the hypnotizability measure (only six points) also works against finding a relationship between hypnotizability and outcome. The unexpected appearance of a correlation between abstinence and attitude toward hypnosis, if replicated, might suggest that the more faith one has in the power of hypnosis the better the outcome, but at any rate the relationship is weak. Several problems were noted that may have detracted from the validity of the present results. Knowledge of patients’ hypnotizability might have caused the therapist to be more pessimistic and less involved with the low hypnotizable patients, or conversely to invest more energy in the treatment to compensate for the low hypnotizability. Introspection and the fact that the protocol was modified twice in an attempt to increase overall success suggests the latter is more true. Secondly, the present research design in effect tested the potency of hypnosis (hypnotizable patients) against nonhypnotic treatment (nonhypnotizable control patients) in a research design recommended by Orne (1977). Intensive nonhypnotic involvement with the nonhypnotizable individuals over several sessions may have worked against finding differences between low and high hypnotizables. Patients generally did not complete the recommended four sessions (also noted by L. K. Jeffrey & T. B. Jeffrey, 1988), and they generally were non-adherent to recommended follow-up telephone contact. The observed relationship between initial quitting and number of treatment sessions may exist because people who are responding to treatment stay in treatment longer, or because more treatment sessions provide a more potent intervention, or both. With respect to any influence that the weak follow-up procedures may have had, the reviews by Glasgow and Lichtenstein (1987) and Pechacek (1979) indicate that follow-up support actually has not been proven to be very beneficial. The present study did not replicate Perry et al.’s (1979) finding that motivational measures of need and desire to quit were better predictors of outcome than hypnotizability, or the frequent observation that a higher percentage of males are successful. It is possible that the surge in the net quit rate in the late 1970’s left the 1980’s population of smokers with many “hard core” smokers (Oster, Colditz, & Kelly, 1984; Stoto, 1986), with restricted range lessening the likelihood of finding a relationship between Perry et al.’s (1979) predictors and cessation. Also, it is possible that gender differences in treatment outcome are disappearing as the incidence of smoking-related cancer increases for women.
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In conclusion, the present results could be interpreted as saying that long-term effects of hypnosis-assisted treatment for smoking are dimcult to predict from any of the variables that wereexamined: hypnotizability, number of treatment sessions, desire to quit, number of reasons for smoking, need for cigarettes, and gender. Treatment contracts between patients and therapist increased the number of sessions that patients completed but did not increase their abstinence rate. The often-reported finding that two-thirds of patients who stop smoking as a result of a treatment program return to smoking again within months was replicated.
REFERENCES BAER,L.. CAREY,R. J., Q MEMINCER.S. R. Hypnosis for smoking cessation: A clinical follow-up. Int. 1.P.rcJchosotn..1986, 33. 13-16. BAKER, E. L.The state of the art of clinird hypnosis. lnt.]. din. exp. Hypnosis. 1987,3.5. 203-214. BAHABASZ, A. F.. BAER. L.. SHEEHAN. D. V.. Q BAHABASZ. M. A three-year follow-up of hypnosis and restricted environmental stimulation therapy for smoking. Int. ]. din. exp. Hypnosis. 1986,34. 169-181. BAIwEH, x.. & WILSON,S. C. The Burlwr Suggestibility Scde and the Creative Imagination Scde. Atner.]. d i n . Hc~jino.ris.197W9.21. 84-loll. BASKEH, A. M. Hypnosis in the alleviation of the smoking habit. In D. Wuinan. P. C. Misra. bl. Gibson. t M. A. Bilsker (Eds.). M o d e m trench in hypnosis. New York: Plenum, 1985.Pp. 269-275. BOWERS, K. S., d( KELLY, P. Stress, diseuse, psychotherapy, and hypnosis. ]. ahnortn. PscJchuf.. 1979,88..190505. BROWN, D. P., t FROMM,E. Hc~jinu.riuand behaliiord tncdicine. Hillsdale. NJ: Erlhum. 1987. COHEN.S.. LICHTENSTEIN.E., PRWHASKA,J. 0.. ROW. J. S.. C x i n , E. R., CARH, C. R., ORLEANS, C. T., SCHOENBACH, V. j.. BIENEH.L., ABRAMS, D.. DICLEMENTE, K. M.. E M O . ~ S. , L.. GIOVINO.C., C.. CURRY,S., MARLAIT, G. A., CUMMINCS, OSSIP-KLEIN,D. Dehunking myths alxiut self-quitting. Atner. Psychologist, 1989.44. 1355-1365.
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Die ungewisse Baiehung Rvischen Hypnotisierbarkeit und dem Ergebnis einer Raucherbehandlung
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Jean Holroyd Abstrakt: Es wurde die Literatur iiberpriift, die sich mit der Bedehung mischen Hypnotisierbarkeit und dem Ergebnis einer Raucherbehandlung befa5t. 91 Privetpatienten, die mit Hypnotherapie fiir ihr Rauchen behandelt wurden, nahmen an der Untersuchung teil, die so angelegt war, Probleme in einiger der friiheren Forschung zu korrigieren. 43% harten mit dem Rauchen am Ende der Behandlung auf, jedoch enthielten sich nur 16% fiir zumindest 6 Monate. Weder dps sofortige AuChbren noch anhaltende Abstinenz waren mit Hypnotisierbarkeit verkniipft. Andere Variablen, von denen die Hypothese gestellt worden war, dad3 sie das A u M r e n des Rauchens vorhenagen wiirden, waren auch nicht mit dem Resultat verkniipft: Anzahl der Behandlungssihungen, Bediirfnis zu rauchen, Motivierung zum Aufh6ren und Ceschlecht. Die niedrige Enthaltungsrnte mag die Verifikation einer Beziehung mischen Hypnotisierbarkeit und Behandlungsresultat behindert haben.
L'hypnotisabilitb et resultats dun traitement de cessation de fumer: prbsence ou absence de relation Jean Holroyd Resume: Un relevd de litterature sur In relation entre llypnotisabilite et I'effet du traitement pour cesser de fumer a bt6 fait. Quatre-vingt-onze patients traiter avec hypnothbrnpie unt particip6 h une btude effectube duns le but de corriger certains problbmes des etudes prbcbdenter. Quarante-trois pour cent des patients ne fumaient plus in la fin du traitement. mais seulement 16% Ctaient encore abstinents aprbs 6 mois. Ni l a cessation immediate de fumer ni Ihbstinence uprhs 6 mois ne sont en corrblation significative avec I'hypnotisabilitb. D'autres facteurs pressentis comme prbdicteurs de la cessation de fumer n'ont egalement pas dbmontrb de corrblation nvec la rbussite du traitemenk nombre de sessions de traitement, besoin de fumer. motivation A cesser et sexe. Ce faihle taux &abstinence peut avoir nui h la verification de la relation entre I'hypnotisabilitk et la rbussite du traitement.
La incierta relacion entre sugestibilidad hipnotica y el resultado del tratamiento del tabaquismo Jean Holroyd Resumen: Se revis6 la literatura existente sobre la rehci6n entre sugestibilidad hipn6tica y 10s resultados del tratamiento del tabaquismo. Se h e 6 6 una nueva investigaci6n para corregir algunos problemas encontrados en 1anteriores. De la misma participaron 91 pacientes privador tratados con hipnoterapia. Un 43% de lor pacientes abandon6 el c i p r r i l l o hacia el fin del tratamiento. per0 s610 ua 16% se mantuvo en abstinencia por lo menos 6 meses. Ni el abandono inmedinto, ni In abstinencia re correhcionaron con la sugestibilidad. Tampoco se wrrehcionemn con 10s resultados otras variables que hipotbticamente predecfan el abandono del tabam nlmero de sesiones de tratamiento, necesidad de fumnr, motivaci6n para dejar de h m a r y gbnero. La baja tasa de abstenci6n puede haber impedido la verificaci6n de la relaci6n entre sugestibilidad hipn6tica y el resultado del tratamiento.
International Journal of Clinical and Experimental Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/nhyp20
The Uncertain Relationship Between Hypnotizability and Smoking Treatment Outcome Jean Holroyd
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Neuropsychiatric Institute University of California , Los Angeles Published online: 31 Jan 2008.
To cite this article: Jean Holroyd (1991) The Uncertain Relationship Between Hypnotizability and Smoking Treatment Outcome, International Journal of Clinical and Experimental Hypnosis, 39:2, 93-102, DOI: 10.1080/00207149108409623 To link to this article: http://dx.doi.org/10.1080/00207149108409623
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THE UNCERTAIN RELATIONSHIP BETWEEN HYPNOTIZABILITY AND SMOKING TREATMENT OUTCOME JEAN HOLROYD’.’ Downloaded by [University of Toronto Libraries] at 02:14 02 February 2015
Neuropsychiotric Institute, Uniuersity of Cdifornio at Los Angeles
Abstract: Literature on the relationship between hypnotizability and smoking treatment outcome was reviewed. 91 private patients treated for smoking with hypnotherapy participated in an investigation designed to correct problems in some of the earlier research. 43% quit smoking by the end of treatment but only 16% abstained at least 6 months. Neither immediate quitting nor continued abstinence correlated with hypnotizability. Other variables hypothesized to predict smoking cessation also were not correlated with outcome: number of treatment sessions, need to smoke, motivation to quit, and gender. The low abstention rate may have impeded verification of a relationship between hypnotizability and treatment outcome.
More than one-fourth of American adults remain addicted to nicotine despite national policies discouraging smoking (U. S. Department of Health and Human Services, 1988). Hypnotherapy has proven to be a useful intervention (Holroyd, 1980; Schwartz, 1979), though it is not clear how much hypnosis adds to such nonspecific factors as expectancy, therapist attention, ad hoc patient education, and implicit behavior therapy. If hypnosis aids treatment, then outcome should be related to hypnotizability (Bowers & Kelly, 1979). A review of the literature on hypnotizability and treatment outcome yielded mixed results. Six investigations found a positive relationship between hypnotizability and outcome, based on self-reports. H. Spiegel and D. Spiegel (1978) reported 10-day success rates that ranged from 47% to 18% for extremes of hypnotizability. Mott (1979) indicated that 100% of high, 44% of medium, and 17% of low hypnotizable patients quit, though the differences were reduced on long-term (not defined) follow-u (2096,22%, and 0%, respectively). DePiano, Cash,and Sandford (1982) reported that 55% of
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Manuscript submitted July 21, 1989; final revision received June 26, 1990. ‘The author would like to thank Michael J. Diamond and Andrew W. Sills for their very helpful suggestions in the preparation of this manuscript. ‘Reprint requests should be addressed to Jean Holroyd, Ph.D., Department of Psychiatry and Biobehavioral Sciences, Neuropsychiatric Institute, UCLA; 760 Westwood Boulevard, Los Angeles, CA 90024. 3DePiano. F.A., Sandford, I., Cash, J., & Rush, C. Hypnosis and smoking: A comparison of individualized versus “packaged” suggestions with and without self-hypnosis. Unpublished manuscript, 1982. Available from Frank A. DePiano. Ph.D.. School of Psychology, Nova University, College Avenue, Fort Lauderdale, FL 33314.
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those in the high hypnotizability group stopped as compared to only 26% in the low hypnotizability group; 41% and 5%, respectively, remained abstinent after 4 months. Basker (1985) reported 64% of high, 45% of medium, and 25% of low hypnotizable patients were abstinent after 6 months. Re-analysis of data from another study (A. E Barabasz, Baer, Sheehan, & M. Barabasz, 1986)indicates 79% of high, 18%of medium, and 4% of low hypnotizable patients were abstinent at an average of 17 months follow-up. Baer, Carey, and Meminger (1986) plotted relapse curves for the 80% of their treatment group which could be located at follow-up. Low hypnotizable patients had abstinence rates of only 20% 1week after treatment and reached 0% in 6 months; whereas medium to high hypnotizable patients had 1-week rates of 60-705 and long-term rates of 20-305 after 1 year. Seven studies did not find an association between hypnotizability and outcome. Phelps (1986b)4found that 6- and 12-month outcome did not relate to hypnotizability as measured by an unpublished scale. Perry and Mullen (1975) observed no relationship at 3 months follow-up, though their 13%abstention rate would artificially limit correlation possibilities due to a restricted range. Stanton (1985)observed no association between abstinence and hypnotizability, as measured by a single-item scale, for those of his sample located 12 months after treatment. Powell (1980) detected no relationship between trance intensity and outcome at an unspecified follow-up date, whiIe noting that most of his Ss were rated at the low end of Crasilneck and Hall's (1975) 4-point hypnotizability scale. Sheehan and Surman (1982) found no difference in subjective trance level between abstainers and nonabstainers in 15-month retrospective estimates. Frank, Umlauf, Wonderlich, and Ashkanazi (1986) reported that people who scored below the median on the Creative Imagination Scale (Barber & Wilson, 1978179) were more likely to be abstinent at 6 months follow-up. Perhaps the most widely cited negative result is that of Perry, Gelfand, and Marcovitch (1979), who used a single hypnosis session and/or a rapidsmoking treatment. At 3 months, 29% of high, 15%of medium, and 31% of low hypnotizables were abstinent. Questionnaires measuring desire to quit, current need for cigarettes, and reasons for smoking successfully predicted outcome with multiple regression (r = .42), leading those authors to suggest that motivation is more important than hypnotizability for outcome. This study (Perry et al., 1979) is unique in the hypnosis treatment literature in that the immediate quit rate (13%)was lower than long-term abstinence rate (21%). One cannot assume that negative findings countervail the positive ones because in this case positive replication contributes to validity generaliza'Phelps, L. A. Clinical hypnosis for the smoking habit: A study. Unpublished manuscript. 1986. Available from Lynn A. Phelps. M.D.,310 North Pinckney Street, Madison, WI 53703.
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tion (Rosnow & Rosenthal, 1989), while negative findinqmay be attributed to research design. Five of the negative studies have such low abstinence figures that it would have been difficult to establish a relationship due to restricted range. (Four negative studies used a single-session intervention, which historically has been associated with lower success rates [ Holroyd, 19801.) Four negative studies used nontraditional measures of hypnotizability. A fifth study used retrospective estimates of trance depth after 15 months, which could have been unreliable. One study did not report the actual hypnotizability data; one did not report the number of Ss lost at follow-up; and one combined hypnosis and rapid smoking groups. Finally, five of the seven studies did not use enough Ss, thereby increasing the odds of a Type I1 inferential error of “conservatism or blindness” over a Type I inferential error of “gullibility or overeagerness” (Rosnow & Rosenthal, 1989). Despite these shortcomings, the impression of no association between hypnotizability and smoking treatment outcome has crept into the review literature (e.g., Baker, 1987; Brown & Fromm, 1987; Wadden & Anderton, 1982). The present author undertook the present study to examine the relationship between hypnotizability and treatment outcome using multiple treatment sessions, a standard hypnotizability scale, and a large sample. Recommendations for improved treatment conditions (Holroyd, 1980) were followed as closely as possible in a private practice setting, with hopes of obtaining sufficiently high abstinence rates to permit the expected association to emerge. Motivational measures were included to replicate the findings of Perry et al. (1979).
METHOD Procedii res
Treatment. Ninety-six private patients who telephoned requesting hypnosis for smoking were treated by the present author, but 4 were excluded from the data analysis because severe psychopathology prevented adherence to the treatment protocol, and a fifth case was omitted because hypnotizability was not measured. The remaining 91 patients (45 females and 46 males) were charged $250 each for treatment. The protocol was changed twice during 7 years, resulting in three sequential treatment groups. Each patient was interviewed to provide the basis for an individually tailored intervention based on smoking history, attempts to quit, previous hypnosis experience, and reasons the patient was quitting. Patients completed a questionnaire comprised of three previously effective predictors of abstinence (Perry et a]., 1979)- desire to quit smoking, current need for cigarettes, and reasons for smoking - plus an item assessing realistic versus magical expectations regarding hypnosis. A personalized relaxation induction was used to prepare the patient for maximal responsivity, followed by the Stanford Hypnotic Clinical Scale (SHCS) of Morgan and
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J. R. Hilgard (1975, 1978/79),which was introduced as an opportunity to have a broader hypnosis experience. When, on occasion, patients said they felt relaxed but not hypnotized, they were assured that some of the best results came from a therapist who used only a "relaxation" procedure (Watkins, 1976). The third induction during Session 1 was individually tailored, based on feedback from the first two hypnosis experiences, and was followed by suggestions related to the smoking problem. Session 1 took approximately 90 minutes to complete. Croup 1patients (N = 23) were offered four sessions and given suggestions tailored to their needs and motivations. Sessions 1and 2 were usually spaced 2-3 days apart, with later sessions scheduled days apart if the patient had not quit, or a week or two apart if the patient had quit. If patients did not quit after Session 1, therapy explored what dimculties were being experienced and employed counseling as well as hypnosis. Patients who quit smoking were asked to telephone daily and then weekly and monthly. Group 2 (N = 29) procedures were the same as for Croup 1, modified to reduce premature termination of treatment. Patients signed a foursession contract costing $250 whether or not they stopped smoking. Croup 3 (N = 39) was like Croup 2, except that patients were requested to stop smoking 24 hours before their appointment. Though most patients drastically reduced their smoking during this 24-hour period, only 9 stopped completely. In Session 1, instead of personalized suggestions, a script was used that had been very successful with patients who abstained 48 hours before treatment (T. B. Jeffrey'; T. B. Jeffrey, L. K. Jeffrey, Creuling, & Gentry, 1985).'The 10-minutescript derived from Crasilneck and Hall (1975), H. Spiegel (1970), and Stanton (1978). (This script also was used for 9 patients in Group 2.) Subsequent sessions were more individualized, as in Croups 1and 2. Posttreatment. Patients were considered to have quit if they reported that they had stopped prior to the last session. After quitting, they were requested to telephone the therapist daily and then weekly, depending on their need for support.' A letter requestkg follow-up information was mailed at least 6 months after treatment (X = 9 months, S.D. = 3.8). Patients were considered abstinent if they reported not smoking on the follow-up questionnaire.' Patients who did not respond at follow-up were
"r. B. Jeffrey, personal communication,January 6, 1984. 'Subsequent work did not replicate the potent effect of &hour abstention (L. K. Jeffrey & T. B. J e h y , lQ88).
'Consistent posttreatment telephone contact was very difficult to maintain. Frequently patients did not telephone followingcessation, and they could not be reached by telephone. b e letter stated, "You came for hypnosis to stop smoking a few months ago. . . Did you stop smoking? For how long?" Only responses indicating continuous, uninterrupted abstinence were counted as abstaining. The one person who achieved abstinence at a later date was counted as a failure.
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considered to be treatment failures. Biochemical confirmation of patient report was not used nor was there an attempt to corroborate patient reports with a third party.
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RESULTS
The three groups were examined for differences that might influence abstinence.' They did not differ significantly on level of hypnotizability, number of reasons for smoking, the desire to quit, or hypnosis expectancy, but did differ on current need for cigarettes (F = 3.20, df = 79,2; p < .05)." Croup 2 reported more Need than Group 3 (X = 3.28 and 2.98, respectively, t 2.62, a!! = 57, p < .02, two-tailed test,) but not more than Group 1 (X = 3.17). The difference between Croups 1 and 3 also was not significant. The three groups also differed on number of treatment sessions completed: Croup 1 = 2.5, Croup 2 = 3.3, and Group 3 = 3.4 (F = 6.90, clf = 2,88; p < .002).The overall difference was due to Group 1completing significantly fewer sessions than Group 2 (t = -2.48, df = 50, p < .02) and significantly fewer than Group 3 (t = -3.92, df = 60, p < .001, two-tailed tests). Thus, signing a written contract for four sessions at full fee had the predictable effect of keeping patients in treatment. Considering all 91 patients, an average of 3.2 sessions were completed; 36% stopped treatment prematurely (i.e., before they quit smoking and before they completed Four sessions). Quit rates for Groups 1, 2, and 3 (39% 4596, and 4496, respectively) did not differ significantly, despite the fact that Croup 1 patients completed fewer treatment sessions and Croup 2 patients reported a higher current need for cigarettes. Since the quit rate was the same for all three groups, and since the groups did not differ on most pretreatment variables, the groups were combined to analyze the relationships between hypnotizability, motivation, and treatment outcome. Mean hypnotizability was 2.7 for all patients, which approximates the mean in published SHCS norms (2.75, Morgan & J. R. Hilgard, 1978179). Quitting Of the total sample, 43% quit smoking by the last treatment session, with no difference between male and female patients. People who quit were not distinguished from nonquitters on current need for cigarettes, desire to quit, number of reasons for smoking, hypnosis expectancy, or &rests of significance were bidirectional in all cases, except where a relationship had been predicted between hypnotizability and outcome or between motivational measures and outcome, in which cases they were unidirectional one-tailed tests. 10 Some patients did not complete all the items on the questionnaire, resulting in fewer cases for such comparisons.
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hypnotizability.‘I Those who stopped by the last session, however, completed more sessions than nonquitters (3.6 versus 2.8; F = 14.27. df = 90,l; p c .001) resulting in a positive correlation (r = 3 7 , df = 89, p < .001).
Abstaining Forty-nine patients (54%)responded to a single follow-up letter. ” Hypnotizability for these individuals was 2.7, the same as for the total group. Counting people who did not respond to the letter as nonabstainers, only 16% were abstaining, with no difference between male and female patients. Abstainers were compared with nonabstainers on all relevant variables. Abstainers were not distinguished by gender, current need for cigarettes, desire to quit, number of reasons for smoking, number of treatment sessions, or hypnotizability. With respect to the hypnosis expectancy question, abstainers responded more in the direction of “Hypnosis will work automatically, without any effort on my part,” than in the direction of “Hypnosis will have a facilitative, supportive effect on my efforts to stop smoking” (r = - .25, d ?= 82, p < .02). Multiple correlations using the three motivational tests (current need, number of reasons, and desire to quit) did not demonstrate a relationship to abstaining (r = .12, n.s.). Multiple regression using a host of variables (SHCS, treatment group, number of sessions, the three motivational measures, and hypnosis expectancy)to predict abstinence did not improve upon prediction from hypnosis expectancy alone. l3 DISCUSSION The 43%initial quit rate and 16% Bmonth abstention rate found in the present study are comparable to rates reported by other investigators (Holroyd, 1980; Schwartz, 1979). (Median 6-month abstinence rates are “In the total sample of 91 patients, the percentages of low (0-1). medium (2-3) and high (4-5) hypnotizables (on SHCS) that initially quit smoking were 29, 47, and 47, respectively (N = 91. X‘ = 2.28. df = 2, p = .32).When medium and high hypnotizable groups are combined to contrast with the low hypnotizable group (47% versus 29%). the difference appears similar to positive reports in the literature, but it does not quite reach significance (Fisher’s Exact Test, p = .lo,one-tailed test). ‘?he three groups differed in months until follow-up (6.6,10.3.and 9.8for Croups 1, 2. and 3, respectively; F = 8.6, df = 2.88; p < .Ol),but were combined for follow-up. 13 Post hoc analyses suggested there may be complex interactions between number of required treatment sessions, hypnotizability, and outcome, and that hypnotizability may be a more significant factor for patients receiving a brief number of sessions. These analyses may be obtained from the National Auxiliary Publications Service (NAPS). For 6 pages order document No. 04828 from ASIS-NAPS, d o Microfiche Publications, P.0.Box 3513,Grand Central Station, New York. NY 101633513. Remit’in advance, in U.S. funds only, $7.75 for photocopies or $4.00for microfiche and make checks payable to Microfiche Publications NAPS. Outside the United States and Canada, add postage of 54.50 for a photocwpy and $1.50for a fiche. There is a $15.00invoicing fee for orders not prepaid.
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4 . 9 7 4 % for people who try to quit by themselves [Cohen, Lichtenstein, Prochaska, Rossi, Gritz, Carr, Orleans, Schoenbach, Biener, Abrams, DiClemente, Curry, Marlatt, Cummings, Emont, Giovino, & OssipKlein, 19891.) Unfortunately, a low abstention rate works against finding the relationships predicted by the present author. Restricted range on the hypnotizability measure (only six points) also works against finding a relationship between hypnotizability and outcome. The unexpected appearance of a correlation between abstinence and attitude toward hypnosis, if replicated, might suggest that the more faith one has in the power of hypnosis the better the outcome, but at any rate the relationship is weak. Several problems were noted that may have detracted from the validity of the present results. Knowledge of patients’ hypnotizability might have caused the therapist to be more pessimistic and less involved with the low hypnotizable patients, or conversely to invest more energy in the treatment to compensate for the low hypnotizability. Introspection and the fact that the protocol was modified twice in an attempt to increase overall success suggests the latter is more true. Secondly, the present research design in effect tested the potency of hypnosis (hypnotizable patients) against nonhypnotic treatment (nonhypnotizable control patients) in a research design recommended by Orne (1977). Intensive nonhypnotic involvement with the nonhypnotizable individuals over several sessions may have worked against finding differences between low and high hypnotizables. Patients generally did not complete the recommended four sessions (also noted by L. K. Jeffrey & T. B. Jeffrey, 1988), and they generally were non-adherent to recommended follow-up telephone contact. The observed relationship between initial quitting and number of treatment sessions may exist because people who are responding to treatment stay in treatment longer, or because more treatment sessions provide a more potent intervention, or both. With respect to any influence that the weak follow-up procedures may have had, the reviews by Glasgow and Lichtenstein (1987) and Pechacek (1979) indicate that follow-up support actually has not been proven to be very beneficial. The present study did not replicate Perry et al.’s (1979) finding that motivational measures of need and desire to quit were better predictors of outcome than hypnotizability, or the frequent observation that a higher percentage of males are successful. It is possible that the surge in the net quit rate in the late 1970’s left the 1980’s population of smokers with many “hard core” smokers (Oster, Colditz, & Kelly, 1984; Stoto, 1986), with restricted range lessening the likelihood of finding a relationship between Perry et al.’s (1979) predictors and cessation. Also, it is possible that gender differences in treatment outcome are disappearing as the incidence of smoking-related cancer increases for women.
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In conclusion, the present results could be interpreted as saying that long-term effects of hypnosis-assisted treatment for smoking are dimcult to predict from any of the variables that wereexamined: hypnotizability, number of treatment sessions, desire to quit, number of reasons for smoking, need for cigarettes, and gender. Treatment contracts between patients and therapist increased the number of sessions that patients completed but did not increase their abstinence rate. The often-reported finding that two-thirds of patients who stop smoking as a result of a treatment program return to smoking again within months was replicated.
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CRASILNECK, H. 6.. Q HALL, J. A. Clinical hypnosia: Principb and applicatiuns. New York: Grune Q Stratton, 1975. DEPIANO,F. A.. CASH, J., t SANDFORD.J. Hypnosis and smoking: A comparison of individualized versus “packaged” suggestions with and without self-hypnosis. Paper presented at the 34th annual meeting of the Society for Clinical and Experimental Hypnosis, Indianapolis, Indiana. October 1982. FRANK,R. G . , UMLAUF, R. L.. ~ O N U E R L I C HS. , A., h hHKANAZI. G . S. Hypnosis and behavioral treatment in il worksite smoking cessation program. Addict. Behao., 1986. 11,5%62. CLASCOW, R. E.. Q LICHTENSTEIN, E. Long-term effects of behavioral smoking cessation interventions. Behcro. Ther.. 1987,18.297-324. HOLROYD,J. Hypnosis treatment for smoking: An evaluative review. Int. 1. d i n . exp. Hypnosis,1980.28,341-357. JEFFREY.T. B.. JEFFREY,L. K., GREULINC.J. W., & GENTRY.W. R. Evaluation of a brief p u p hypnotic treatment puckage including hypnotic induction for maintenance of smoking cessation: A brief communication. Inr.1. clin. exp. Hypnosis, 1985.23,95-98. JEFFREY, L. K.,Q JEFFREY. T. B. Exclusion therapy in sinokingcessation: A brief mmmunic-ation. I n t . ] . din. exp. Hypnosis. 1988, 36. 70-74.
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JEAN HOLROYD
Die ungewisse Baiehung Rvischen Hypnotisierbarkeit und dem Ergebnis einer Raucherbehandlung
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Jean Holroyd Abstrakt: Es wurde die Literatur iiberpriift, die sich mit der Bedehung mischen Hypnotisierbarkeit und dem Ergebnis einer Raucherbehandlung befa5t. 91 Privetpatienten, die mit Hypnotherapie fiir ihr Rauchen behandelt wurden, nahmen an der Untersuchung teil, die so angelegt war, Probleme in einiger der friiheren Forschung zu korrigieren. 43% harten mit dem Rauchen am Ende der Behandlung auf, jedoch enthielten sich nur 16% fiir zumindest 6 Monate. Weder dps sofortige AuChbren noch anhaltende Abstinenz waren mit Hypnotisierbarkeit verkniipft. Andere Variablen, von denen die Hypothese gestellt worden war, dad3 sie das A u M r e n des Rauchens vorhenagen wiirden, waren auch nicht mit dem Resultat verkniipft: Anzahl der Behandlungssihungen, Bediirfnis zu rauchen, Motivierung zum Aufh6ren und Ceschlecht. Die niedrige Enthaltungsrnte mag die Verifikation einer Beziehung mischen Hypnotisierbarkeit und Behandlungsresultat behindert haben.
L'hypnotisabilitb et resultats dun traitement de cessation de fumer: prbsence ou absence de relation Jean Holroyd Resume: Un relevd de litterature sur In relation entre llypnotisabilite et I'effet du traitement pour cesser de fumer a bt6 fait. Quatre-vingt-onze patients traiter avec hypnothbrnpie unt particip6 h une btude effectube duns le but de corriger certains problbmes des etudes prbcbdenter. Quarante-trois pour cent des patients ne fumaient plus in la fin du traitement. mais seulement 16% Ctaient encore abstinents aprbs 6 mois. Ni l a cessation immediate de fumer ni Ihbstinence uprhs 6 mois ne sont en corrblation significative avec I'hypnotisabilitb. D'autres facteurs pressentis comme prbdicteurs de la cessation de fumer n'ont egalement pas dbmontrb de corrblation nvec la rbussite du traitemenk nombre de sessions de traitement, besoin de fumer. motivation A cesser et sexe. Ce faihle taux &abstinence peut avoir nui h la verification de la relation entre I'hypnotisabilitk et la rbussite du traitement.
La incierta relacion entre sugestibilidad hipnotica y el resultado del tratamiento del tabaquismo Jean Holroyd Resumen: Se revis6 la literatura existente sobre la rehci6n entre sugestibilidad hipn6tica y 10s resultados del tratamiento del tabaquismo. Se h e 6 6 una nueva investigaci6n para corregir algunos problemas encontrados en 1anteriores. De la misma participaron 91 pacientes privador tratados con hipnoterapia. Un 43% de lor pacientes abandon6 el c i p r r i l l o hacia el fin del tratamiento. per0 s610 ua 16% se mantuvo en abstinencia por lo menos 6 meses. Ni el abandono inmedinto, ni In abstinencia re correhcionaron con la sugestibilidad. Tampoco se wrrehcionemn con 10s resultados otras variables que hipotbticamente predecfan el abandono del tabam nlmero de sesiones de tratamiento, necesidad de fumnr, motivaci6n para dejar de h m a r y gbnero. La baja tasa de abstenci6n puede haber impedido la verificaci6n de la relaci6n entre sugestibilidad hipn6tica y el resultado del tratamiento.
