Kenan Tastan  ( Department of Family Medicine, Ataturk University; Erzurum, Turkey )
Halime Pinar Demiroz  ( Department of Family Medicine, Ataturk University; Erzurum, Turkey )
Coskun Oztekin  ( Department of Family Medicine, Ataturk University; Erzurum, Turkey. )
Suat Sincan  ( Department of Family Medicine, Ataturk University; Erzurum, Turkey )

Objective: To construct a scale for testing hypnotic suggestibility for Turkish-speaking adults that may be quick and convenient, and to test its reliability and validity.
Methods: The study was conducted at the hypnotherapy outpatient clinics of Atatürk University Acupuncture and Complementary Medicine Application and Research Centre. Erzurum, Turkey, from June to August 2017, and comprised aged 18-60 years. As the first step in the preparation of the scale, a panel of 15 experts was founded. The draft was pilot-tested. Incomprehensible suggestion templates in the pilot study were abolished, and the templates were reduced to four which were put to test as the Tastan Suggestibility Scale. Stanford Hypnotic Clinic Scale was also used on the same subjects, and the results were analysed using SPSS.

Results: Of the 61 subjects, 38(62.3%) were females and 23(37.7%) were males. The overall mean age was 34.21±9.9 years. Cronbach alpha internal reliability coefficient of the scale was calculated to be 0.53. Correlation between the Tastan Suggestibility Scale and Stanford Hypnotic Clinic Scale total scores was high (p<0.001). Mean duration of the application of the scale was 5.0±1.2 minutes.

Conclusion: Tastan Suggestibility Scale was found to be a new, reliable, and rapidly applicable scale.

Keywords: Hypnotherapy, Suggestibility, Psychometrics. (JPMA 69: 1325; 2019)

Introduction

Hypnosis is a state of human consciousness involving focussed attention and reduced peripheral awareness and an enhanced capacity for response to suggestion. It is a mental state while the subjects are having full control of their mind, done approvingly without any condition of unawareness.¹ Hypnosis has been known for centuries and is one of the spreading complementary and alternative treatment methods used to aid some disease conditions. ^2-4 Hypnosis can be used in the treatment of hyperemesis gravidarum, pain control, obesity, depression, anxiety disorders, eating disorders, smoking cessation, and sleep disorders . ^5-11 When the psychological disorders began to be treated by therapeutic trance, professionals needed to ascertain whether their patients were suitable for hypnosis or not. The Stanford Hypnotic Clinic Scale (SHCS) was introduced in 1959 as a suggestibility scale that measures the proclivity for hypnosis. The suggestibility of patients can be measured by this scale, and therapeutic hypnosis can be used more efficiently. ¹² The original SHCC had two different forms named A and B, and both included 12 items. Application of these scales took one hour. Because of the application duration, utilisation of these scales decreased. Later, the same researchers prepared a new scale and named it the Stanford Hypnotic Clinic Scale Form C (SHCS-C). ¹³ But it was still difficult to apply the form, and the time required for the application could not be shortened . These difficulties forced researchers to look for new methods of testing suggestibility. H. Spiegel¹⁴ was the first researcher who developed an alternative, calling it the Hypnotic Induction Profile (HIP). Some scales such as the Barber Suggestibility Scale (BSS), ¹⁵ the Ghildren's Hypnotic Susceptibility Scale (GHSS), ¹⁶ SHCS for Adults, SHCS for Children, ¹⁷ the Alman-Wexler Indirect Hypnotic Susceptibility Scale, ¹⁸ and the Waterloo-Stanford Group C Scale¹⁹ were developed later. Utilization of suggestibility scales increases the overall effectiveness of hypnotic treatment. ²⁰ The current study was planned to develop Tastan Suggestibility Scale (TSS), a new scale for Turkish-speaking adults, that may be quick and convenient, and to test its reliability and validity.

Subjects and Methods

The study was conducted at the hypnotherapy outpatient clinics of Atatürk University Acupuncture and Complementary Medicine Application and Research Centre, Erzurum, Turkey, from June to August 2017, and comprised consecutive patients aged 18-60 years who signed informed consent to participate. Patients with mental retardation, having any psychotic disorder, hearing loss, or being illiterate were excluded and were those who refused participation. The study was completed in 3 steps. First, a panel of 15 experts took part in the development of TSS. Communication was maintained through telephone contacts or e-mails. Items suggested by the experts with explanations were collected. There were 41 recommended items which were revised in concordance with literature^10,12,14-21s and items similar in nature were combined. Seeking advice from the experts in the second phase, time-consuming items and items challenging to apply were excluded. In the final phase, TSS was refined to include 11 elements. The scale was pilot-tested on 38 consecutive patients aged 18-60 in the same clinic. Items that were found to be difficult to comprehend for the subjects were removed, leaving the final scale with four elements. TSS scale consists of 4 items (Appendix 1):



swaying body, eyelids catalepsy, symptom formation, and hand rising. The scale starts with an explanation after which suggestions in the scale are applied, and according tothe reactions observed, 0, 1, or 2 points are given to each item. Scoring is done according to the TSS scorecard which means that the maximum total TSS score is eight (Appendix 2).



According to the SHCC guide, a subject who passes 4-5 items is highly hypnotisable, 2-3 average degree of hypnotisability, and 0-1 lowly hypnotisable.20 TSS categorised 0-2 points = low suggestibility, 3-5 points = med ium sugges ti bil ity, and 6 -8 points = h ig h suggestibility. Face validity of the instrument was done during the pilot study that had 38 university students, academicians and family practice residents as volunteers. Their opinions were taken qualitatively y requesting them to answer certain questions (Table 1).



Participants defined their view related to TSS Explanation part as "simple, comprehensible." They expressed their view related to TSS Suggestion part, and their general view was that TSS was "simple, practical and applicable". Any item recommended to be rephrased was reorganized accordingly. Participants considered TSS language "comprehensible, plain and simple". Participants did not indicate any incoherent suggestion. According to the participants' opinions, spelling errors and inverted sentences were corrected. Factor analysis was done after the application of the final scale to the larger sample. Principal component extraction using varimax rotation was done which revealed two components with high factor loadings(Table 2).



Symptom formation and Swaying body were grouped under Factor 1, while Eyelids catalepsy and Hand raising were under Factor 2. The Turkish version of the Stanford suggestibility scale20was applied to the same number if subjects. Concurrent validity with the SHCC was checked using Pearson correlation analysis. There was a strong significant correlation between TSS and SHCC scores (p<0.001 (Figure).



Cronbach alpha internal reliability coefficient was calculated to be 0.536.

 

Results

Of the 70 individuals approached, 61(87.14%) responded. Among them, 38(62.3%) were females and 23(37.7%) were males. Overall mean age was 34.21±9.9 years. In terms of education, 4(6.6%) were graduates of primary school, 29(47.5%) high school, and 28(45.9%) university. The overall mean TSS score was 4.64±1.76 (Table 3).



Compared with women, the mean TSS score was significantly higher for men (5.22±1.59 vs. 4.29±1.78; t=2.047; p=0.045) (Table 3). Using the SHCC as the gold-standard, the TSS showed high sensitivity and specificity values in categorising the participants as low, medium or high hypnotisable



(Table 4). Application of TSS was easy and the mean time for completing the induction step was 5.0±1.2 minutes.

Discussion

Findings suggested that TSS is a valid, reliable and consistent scale to evaluate hypnotic suggestibility of Turkish-speaking adults. Hypnosis, including susceptibility to suggestion, compliance with instructions, and adherence to directives, has steadily harnessed scientific attention over the past century. ²² Although hypnosis has been used for centuries, it has only been relatively recent that research has provided empirical evidence showing how hypnosis can help in gaining control over deeply-ingrained psychological processes. ²³ Internal reliability of the TSS was calculated as 0.53. The Cronbach alpha internal reliability coefficient of the SHCC has been estimated as 0.66. ²² However, given that TSS has only four items, the obtained value is satisfactory. Their liability of the suggestibility scales is one of the essential points for hypnotists. Evaluation of the applicant for suggestibility is significant both from the perspective of applying safe hypnosis as well as choosing the correct induction method. To determine the correlation between being a good candidate for hypnosis and psychopathology will be useful for providing right, powerful and professional use of hypnosis. It also results in reducing malpractices and wastage of time and money. ²⁰ Although several scales for assessing hypnotisability exist ^24,25 most researchers rely on the SHCS-C. ¹³ However, the developers themselves ²⁶ expressed concerns regarding the confusion between suggestions and instructions, as well as the clinical impracticality (50-90  minutes) of the SHCS-C. Correlation of the TSS scores with the SHCS demonstrated a high consistency of the scale. Additionally, the high sensitivity and specificity values suggested that the TSS is comparable with the SHCS. The application time for TSS was only 5 minutes. This is relatively short compared to the 50-90 minutes neededto apply SHCS.20 One of the most important things for hypnotherapists is the efficient use of time. The shorter time required for prac tice during TSS is more advantageous for hypnotherapists. Another critical  rationale for developing a scale for the Turkish populationwas the interference of cultural factors. Particular cultural ac tivities may induce specific altered states of consciousness, such as the use of psychoactive plants, fasting, thirsting, self-mutilation, sweat lodges, sleeplessness, incessant dancing, bleeding, walking on hot coals, meditation, chanting, or drumming. ²⁷ Suitability of comparative measurements follows by grounding transcultural studies in the local context. ²⁸ Items of the TSS were developed with the input of experienced hypnotists from Turkey who had long years of contact with the members of the community. Since TSS can be performed quickly and easily, it is also more useful in terms of patient compliance. We recommend health professionals who are competent for hypnotherapy to use the TSS in daily practice.

Conclusion

The relatively short time of application, ease of use and scoring, as well as a strong correlation with the SHCS makes TSS a good alternative for evaluating suggestibility in office conditions. TSS has essential validity and reliability for practices and academic studies.

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

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