The Hypnotherapist’s 6 FAQ’s!

Q 1: Will I cluck like a chicken?

 

A: Yes if you want to!

The subconscious brain (the one responsible for automatic action) will only accept suggestions that are acceptable to the individual. Therefore, if you are up for a laugh, a bit of and exhibitionist, have had the nerve to get up on stage, then, yes you are quite likely to accept the suggestion when the hypnotherapist clicks her fingers.

The person least likely to accept the suggestion is sitting in the shadows, avoiding eye contact with the hypnotherapist, trying to blend in with the wallpaper. Alternatively they are at home alone, enjoying their own company, snuggled up with a good book.

Q 2: What if I cannot go in to trance?

A: You can.

You do this every day. Just as you are drifting off to sleep – hypnogogic state and just as you are waking up – hypnopompic state. It’s just a form of altered perception an inward focus, as in day dreaming; driving from A to B without realising how you got there; staring at the traffic lights when they are on green yet not acknowledging they have changed until the car behind blasts you back in to reality!

Q 3: What if I don’t come back?

A: You will, no one has ever been left in trance.

It’s like asking, ‘what if I don’t come back from my day dream’ or ‘what if my my hair doesn’t dry if I wash it’ or ‘ what if I get lost in this book’!

Children are in a kind of trance, a make believe world full of adventure and fantasy, unfortunately reality does begin to creep in at around the age of 5 or 6. Children over this age do find it easier than adults to slip in and out of trance due to their vivid imagination in their wold of play.

Q 4: What if I drool when I’m asleep?

 

A: You are not asleep!

In fact you are 30% more aware when in trance. Aware of the sounds around and the environment, it’s just the focus of attention is altered. Although you are aware of the environment around it fades into insignificance as your thoughts are focused elsewhere – deep inside your imagination.

You will always be in complete control and aware of where you are in the room and what’s happening around you.

It’s just unfortunate that the term hypnosis originates from the Greek word for sleep – hypnos!

Q 5: How does it work

A: It’s like giving a twig a push when it gets stuck down the stream. The stick doesn’t need me to analyse why it is stuck, it just needs a shove! 

Once in trance/ altered state/ deep relaxation the subconscious brain is more open to beneficial suggestions for positive change. A good hypnotherapist will take a detailed history first and really get to know how that person ticks. They will then facilitate the client to reach a really relaxed state, this is hypnosis. Then the hypnotherapy begins, with the use of metaphor and positive suggestion relevant to the individual, the client will be encouraged to ditch the old way of thinking for a new beneficial one – in a nutshell! It’s a bit like a computer updating.

Q 6: What if the hypnotherapist dies whilst I’m in trance?

A: Eventually you will realise it’s gone quiet, come round and dispose of the body accordingly!

 

Critical Realism – Discuss!

This week at school we are still feeling very philosophical about ontology, epistemology and methodology. We are looking at Critical realism as a post positive philosophical approach to reality and knowledge. I’m not sure why it is called post-positivist as it also looks post constructionist too, I think.

I am requested to:

Read through the paper by Clark (2007). (http://elearnwithnca.co.uk/elearn/assets/Integrative-Collaborative_Medicine_Session_2/downloadables/Integ-Collab_S2_Clark_et_al_2007_CR_and_health.pdf)

Spend no more than 30 minutes making some notes about the following:

  • How does critical realism help the authors approach this problem?

The authors are able to recognise the complexities of the health intervention and take it beyond a positivist view of attendance and effectiveness. Utilising mixed methods they can obtain a deeper understanding of the mechanisms at play that affect attendance and effectiveness of interventions. This then a useful research project in that they can make recommendations for future interventions in given populations and situations.

  • What problems or weaknesses can you see with this approach?

I see that this was a very large and complex research project, not in the grasp of the sole researcher.

Also, I think there were assumptions on the part of the researchers dictating which mechanisms they chose to observe and which questions they chose to ask. This would be due to the researcher’s generative mechanisms at play in their contexts and  situations. The subject was so complex, I suppose they had to start somewhere and in light of new knowledge, since knowledge is fallible, then they could possibly ask new questions.

Just a thought
If reality is dependent on concepts we might not be able to see but have effect on us, then is this not relativism? The affects being relative to the mechanisms at play.

  • Looking back to the earlier slide on ‘Applying critical realism’, does critical realism fit into the area of research you’d like to develop further? Why/why not?

CR appears a useful and realistic (!) approach to large scale research where there is adequate funding and resources. For a small scale sole researcher it appears impractical unless there is already the empirical quantitative research there which can be expanded on by looking at the contextual and situational generative mechanisms that may have influenced the empirical results.

My research will not have large numbers of participants as hypnoacupuncture is not widely practiced. There are no RCT’s to suggest efficacy. I suppose, from a CR position, the RCT measuring tool is not an appropriate fit for the nature of the therapy anyway, ‘closed system’ questions being asked in an ‘open’ system.

So if I haven’t measured efficacy how can I go on to see how generative mechanisms are at play in my client’s decisions to attend and their perceived outcomes? Maybe I can use MYMOP as measuring tool but the numbers will be still small and I will inevitably affect the outcome as they are my own clients. Could the way I practice and consult then be a generative mechanism or are they larger more universal concepts? CR would at east give some ‘outcome’ results rather just clients perceptions, making it a more useful , explanatory and pragmatic undertaking.

I like the CR view, it does make sense in that not only does it explain outcomes it then goes on to make practical recommendations. It takes account of both agency and structure, midway between positivism and constructionist. This has implications for future funding and commissioning of services. The approach is useful in large institutions with lots of resources, at the moment I can see that the sole researcher could plan their research with a CR philosophy and aim to maybe capture a small part of the bigger picture, with a view to keep chipping away!

Tutor’s reply to above: –

Hi Carolyn,

These are great first ramblings, especially given that these concepts are so new. You sound like you have a good grasp of the key concepts so well done!

Good question re difference between relativism and CR. Relativists hold that there is no external reality that can be studied because in their view, all knowledge is subjective due to cultural beliefs and so forth. Critical realism accepts that there are layers of reality – the external reality operating within the closed systems at one end of the scale, and the subjective reality operating within the open systems at the other end (and with many other realities in between!). Just going back to your comment about the RCT not necessarily being an appropriate tool for an open system – whilst this is accepted in some CR circles, some critical realists do see RCTs as being valid as part of their CR evaluations. This is because they accept that there is value in obtaining a measurable ‘hard’ outcome within an RCT – the difference between the positivist and the critical realist approach to such an RCT however would be in how they use or interpret the information within the RCT. So a positivist take on the results could be ‘this RCT showed that this intervention produced this specific effect on individuals with this condition’ (power ascribed to the intervention as described in Table 2 in the Clark paper p520). A critical realist analysis of the same RCT would take into account various factors such as the RCT setting, the care given by research staff and personal health behaviours in producing the outcomes described – the power to influence health outcomes here is ascribed to a complex mix of agency and structural factors and to exploring the question ‘what works, for whom and under what circumstances’ that is central in CR.

It’s great that you’re starting to think about the generative mechanisms that could be at play in your research and also in recognising that CR tends to be outcomes-focused, rather than looking soley at perspectives as relativists do. To add to your comment on whether the way you practice and consult could be examples of generative mechanisms, I would consider these factors to be ‘context’ as opposed to ‘mechanisms’ when referring to the ‘context-mechanisms-observation’ (C-M-O) configuration that was introduced in the Connelly paper (p116). Contexts can be thought of as existing institutional or social conditions which have the power to facilitate or hinder people’s choices. Mechanisms on the other hand are the resources (or absence of resources) that allow for these choices to be made. In the Connelly paper, the example in column two (p116) is given whereby ‘laying on free and reliable transport’ (Mechanism) might be expected to enable certain single parents who are motivated and have marketable skills (Context) to find employment and move out of poverty (Outcome/Observation). In your suggestion of using MYMOP and the notion that you will still be affecting the outcome as they are your own clients – in CR there isn’t a need to ‘separate’ these effects unlike in positivist research. Instead in CR these factors are recognised for what they are and the contribution they may or may not make towards the outcome of your research. This means that the use of MYMOP (to record the outcome – O) and the recognition that you may be affecting the outcome through the consultation or other practitioner factors (context – C) remain compatible in CR. You have identified a possible ‘C’ and a possible ‘O’ now – you may now want to think of some mechanisms (M) from this example that you think could be especially relevant :)

My reply:-

Thank you Lily, this is really making sense now. So the ‘m’ part of the research would be to identify the un-observable mechanisms at play and their effect on ‘o’ and maybe ‘c’. These mechanisms are stratified or layered, in that they work at an individual, a structural and cultural level, in other words far more complicated than the positivist view. So then could I be looking at what mechanisms are at play which render the outcome favourable and compare that to an unfavourable outcome to examine the difference, this would be at the individual level. But then the individual is born into a certain structure and culture which will affect their outcome. To take it even further then, what mechanisms are at play when an individual decides to access CAM therapy? Some individuals are denied access to CAM therapy due to the mechanisms which constrain them – cultural beliefs, the dominant medical model, financial constraints for example. It’s getting wider and wider and in so doing getting more and more interesting. It’s making me think of all the people who are denied access to CAM and how we can identify these mechanisms and make it more accessible. Turn it totally on it’s head and look at the people who do not access our services and find out why by examining the mechanisms and how they affect individual decisions?

Next question

Which of these statements are true about critical realism?

A: Uses an ideological framework

    B: Prefers to adopt qualitative methods
        C: Is ontologically

pragmatic

    D: Can be used for exploratory, hypothesis-seeking research

A: Uses an ideological framework
I tended to think an ideological framework was about power and dominant groups in a society having the ability to indoctrinate the less dominant groups in to believing that what they postulate was the ‘truth’. Sorry, this is not very well articulated but I know what I mean! I relate ideology as being the terminology of the Marxist movement in the stance against capitalism. Cruickshank does mention this in his discussion about CR and that advocates of CR see this philosophy as emancipatory and empowering to the less dominant groups. So CR is a philosophical underpinning which determines the questions being asked and ultimately the methodology used to answer the questions. If an ideological framework is viewed as a set of beliefs which unite individuals
rather than from a structural and cultural angle of the assertions of nations or political groups and organisations, then yes, CR does use an ideological framework intended to explain how causal mechanisms affect who, why and where with a view to social change.

B: Prefers to adopt qualitative methods.
No, CR will use whatever methods and analytical tools are suitable for answering the question

C: Is ontologically pragmatic
Yes, there is a reality, it’s just fallible, the aim of CR research is to not only explain reality in a given context but to change that reality in a positive way. Seeks the information then acts on it.

D: Can be used for exploratory, hypothesis-seeking research
I think CR is described as an explanatory philosophy, but I suppose yes, the aim is to both explore the reality and the mechanisms at play and then explain and aim to change them or recommend change. The hypotheses would not be singular but complex embedded in the layers identified by CR, they would also be open to change and be fluid in the light of new evidence over time.

The video conference was very interesting this week, I felt more comfortable when speaking out. I will look forward to next week now, this is proving very interesting.

Integrative/collaborative Medicine – Philosophical Underpinnings

So I did it again, signed up for the next module with the Northern College of Acupuncture on my journey to earning an MSc in Advanced Complimentary Medicine.

For this module I think I will use this blog to reflect on my learning so that when it comes to ‘reflective diary time’ all my work will already be done.

It looks like this module is building on the last. The first reflection they are asking me to make is: –

  1. What is my research topic?
  2. How might I go about researching this?
  3. What is my choice of paradigm and methodology?
  4. How would I approach this research topic with a different paradigm?

My research topic is related to how clients perceive the intervention of hypnotherapy and acupuncture used concomitantly, how they perceive their problem and the outcome. I want to know about their lived experience of the problem and the intervention.

It follows on then that my world view is constructivist, interpretative, I’m a relativist. Ontologically there is no reality apart from the reality perceived from an individual view point. Therefore, epistemogically then, how can we obtain knowledge about it if it doesn’t exist, let alone – methodologically measure it?  I have to say I sway towards the critical realist stance that this cannot be taken out of the context of society. It depends on the culture we are born into as to our world view. I recognise that there is a power factor here too, we are not all equal, some models/societies/ disciplines/research approaches/genders dominate over others.

To get back to my research interests, I will go about finding out about my clients’ experience from a qualitative angle, research-in-action, practitioner as researcher. I will inevitably affect the outcome, all experience is subjective, we cannot measure it out of the context of society, so I don’t need to control for that. My clinic will be my case study, I will be my case study, field notes, observation and unstructured interviews will be my methods of data collection.

If I was approaching this from a positivist angle I would need to control for everything, my question would be based on efficacy – is hypnoacupuncture more effective than usual treatment for headache for example. I would need a large number of participants and the control group would need to be matched to the intervention group. I would need to remove all possible variables which might confound the outcome, remove the person from society, maybe get robots to do the treatment to control for the therapeutic relationship, I’m getting sarcastic now!

Maybe my approach will change over the course of this module, watch this space for learning outcome one – I need to refine and focus my research question even further in light of new knowledge.

Next up on the e-learning is to read Howick (2013) paper on Placebo Use in the United Kingdom and then make the following notes:-

  1. Is this coming from a positivist or interpretivist approach? Positivist. A survey of GP’s in the UK regarding placebo usage, utilising statistical analysis to interpret the data.
  2. What assumptions do the authors appear to have made in terms of the nature of the knowledge they wish to gain? Assumptions are made about what constitutes a placebo. Can a placebo be so easily defined, if it works then is it really a placebo since it has had a therapeutic outcome. For example, if positive suggestion is a placebo most practitioners use this in all consultations, it is taught as basic communication skills. If positive suggestion is purely placebo then so is hypnotherapy. Practitioners are asked to categorise their complex consultations in a tick box exercise with no room for the complexities of individual consultations. Assumptions are made that the GP’s can remember all their consultations, some doing over 100 in a week – impossible.

What is gained or lost from the picture based on the approach and methodology taken? The patient perspective is missing, this is all about the GP and their practice. How does the patient feel about being given a placebo, what does the patient perceive as a placebo. Given antibiotics for a sore throat may be a welcome gesture when nothing else has worked.

I’m not sure how useful an exercise this was and what it contributes to future practice, the outcome in terms of improving practice was not discussed. Also the GP perspective is lost, there is no room for discussion, one box must be ticked and it might not quite fit!

 

Next mandatory guided activity: –

Slide 19

 

Look at the words in the blue boxes. Spend about 20 minutes thinking and making notes about how EBM and patient-centred medicine might approach them. Take into consideration the following:

  • What differences and similarities are apparent?
  • Why do you think these differences exist?
  • How does either approach affect the patient?
  • What parallels can you see with these approaches when looking at your discipline?

I need to pick one or two words and discuss them on the forum.

I can’t help thinking that there is a word missing ‘NURSE’

The nurse bridges the gap between EBM and PCM. The nurse treats the whole person, the individual in front of them, equipped with the knowledge of current guidelines in the area of concern. The nurse involves and educates the patient so that they can achieve an effective and informed decision about their care. The nurse in the ‘bridge’.

The distinction between EBM and PCM is power. There is a power struggle between the two approaches EBM is the dominant medical, illness/doctor orientated approach, PCM is the ‘soft’, may I say feminine, approach, with lower status due t this, like the distinction between quantitative an qualitative research. PCM represents the patient, how they feel and experience the illness. The nurse bridges the gap.

Some patients want to be told what to do and trust the medical practitioner implicitly to put their best interests at heart, they hand over power to the practitioner. If this person is asked their opinion and give treatment options to consider they are at risk of thinking the practitioner is not sure what to do. To use the other extreme as an example, the other patient may want to know all the options and be treated as an equal in the decision making, they respect the practitioner’s skill and knowledge but also have a voice of their own which  they know how to use!

There is a conceptual  bridge too and it is not difficult to see, it is called informed consent. It is a negotiation between practitioner and  individual patient utilising knowledge of current best practice with the aim of positive outcome for the patient. If litigation is a worrying aspect to patient choice of treatment, as long as it is documented (and signed) that the patient has had all options available explained and offered and has chosen to opt out then the clinician is covered.

My two words I choose are NHS and litigation. Practitioners in the NHS have to be guided by the evidence for fear of litigation. It is when the patient chooses to diverge from the NHS when treatment has failed that they receive truly patient centred care. They choose to pay for ‘care’ on sometimes anecdotal evidence since the so called, dominant, positivist approach to EBM has failed them. Sometimes it is ‘care’ that they require, not medicine. If this is classed as placebo but it works for the patient is it ethically wrong?

My practice is evidence based but patient centred, without the patient there is no practice!

On to the next quest:-

Spend 30 – 60 minutes reading and collecting your thoughts on the Anderson (1999) paper A Case Study in Integrative Medicine: Alternative Theories and the Language of Biomedicine.

Ths is case study about  patient with back pain that did not respond to conventional approach to treatment. 6 alternative practitioners examined, diagnosed and offered a management plan from their philosophical stance on the problem.

Consider the following:

  • What challenges does this paper highlight in a collaborative setting? 

The main problem is language and discourse and power. Each discipline has a different philosophical approach to the illness/patient. This particular case study did not appear to be patient centred at all, they all seemed to adopt the dominant medical model discourse to describe and label the problem.

  • How is language used here to express or share power in this example?

It appears the practitioners naturally used the dominant medical language and approach without conscious thought. Showing how powerful the culture of medicine can be. There was definitely a hierarchy with the patient at the bottom, having treatment prescribed without dialogue with the patient on her views and understanding of the problem and treatment options.

  • How do you think this impacts the patient?

This seriously impacts on the patient as she was treated as an inanimate, unthinking subject to be discussed and not involved at all in her treatment plan. There was no social context discussed, how was the illness impacting on her life, were there any psychological reasons for her hanging on to the pain, maybe there were advantages to be had from this – no-one discussed or considered that aspect it was viewed from the  narrow medical angle alone.

So far so good, now I have to go on the forum and discuss my thoughts, not too confident at sticking my neck out just yet!
Attended the video conference and it was fine, I did have to think and speak out as there were only 2 students and 3 tutors – private tuition, brilliant. Great module so far, lets hope it continues.