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A case study of the use of hypnosis for school refusal 1988

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A CASE STUDY OF THE USE OF HYPNOSIS FOR SCHOOL REFUSAL By C a r o l e S o l b e r g A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (Department o f C o u n s e l l i n g P s y c h o l o g y ) We a c c e p t t h i s T h e s i s as c o n f o r m i n g to t h e r e q u i r e d s t a n d a r d . THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1988 c Carole Solberg, 1988 In p r e s e n t i n g this thesis in part ia l f u l f i lmen t o f t h e requ i remen ts fo r an a d v a n c e d d e g r e e at t h e Univers i ty o f Bri t ish C o l u m b i a , I agree that t h e Library shall m a k e it f reely avai lable fo r re ference and s tudy . I f u r the r agree that permiss ion fo r ex tens ive c o p y i n g o f th is thesis fo r scholar ly p u r p o s e s may be g r a n t e d by the h e a d o f m y d e p a r t m e n t o r b y his o r her representa t ives . It is u n d e r s t o o d that c o p y i n g o r pub l i ca t i on o f th is thesis f o r f inanc ia l gain shall n o t b e a l l o w e d w i t h o u t m y w r i t t e n pe rm iss ion . D e p a r t m e n t T h e Univers i ty o f Brit ish C o l u m b i a 1956 M a i n M a l l Vancouver , Canada V 6 T 1Y3 DE-6(3 /81) Abstract The intent of this research is to demonstrate the effectiveness of hypnosis as a treatment for school refusal. The research design is a single-case study employing an A-B Follow-up format. The 10 year old male subject completed measures of personality (The Children's Personality Questionnaire), self-concept (The Piers-Harris Children's Self-concept Scale), identified stressors, and anxiety. The baseline period was two weeks and therapy lasted four weeks. Follow-up data was collected on the same measures ten months later. A l l post-therapy results indicate change in a more adaptive direction. The subject showed increased self-concept, lessened anxiety, greater ability to cope and he returned to school with l i t t l e or no of the previous psychosomatic complaints evident. The follow-up results show that the subject has maintained his gains. Hypnosis is seen as an effective, fast method of treatment for.school refusal, a syndrome which needs to be dealt with quickly since consequences can be severe for • the child. (ii) Table of Contents Page. Abstract i List of Tables v i List of Figures '. v i i Ackrotfledgements v i i i Chapter 1 rira^rxrcTTON TO THE PROBLEM 1 School Refusal 1 Evolution of the term "School Refusal" 2 Consequences of School Refusal 3 PURPOSE OF THE STUDY 4 Hypotheses Tested 5 Rationale 6 Limitations of the Study 7 2 ITTERATURE REVIEW 8 SCHOOL REFUSAL - Terminology 8 INCIDENCE 9 CHARACTERISTTCS ASSOCIATED WITH SCHOOL REFUSAL 11 Age 11 Gender 12 Socic^-economic Status 13 Familial Patterns 14 Intelligence and Academic Achievement 15 Extensiveness of Disturbance 16 Precipitating Factors 18 ( i i i ) Cnapter Page 2 PERSONALITY AND SCHOOL REFUSAL 19 Anxiety and School Refusal 20 Self-Concept and School Refusers 21 TREATMENT 21 Major Theories Associated with Treatment 21 Hypnosis - Theories and Definitions 23 Hypnosis and Children 24 3 METHOD 25 Introduction 25 The Subject 25 Pre-Therapy Procedure 27 Dependent Measures 28 Therapeutic Procedures 31 4 RESULTS 35 First Hypothesis 35 Second Hypothesis 35 Third Hypothesis 36 Fourth Hypothesis 42 iv Chapter 5 DISCUSSION 47 INIRDDUCTICW 47 THE MAIN HYJOTHESIS 47 SELF-CONCEPT 48 ANXTETY 49 SOMATIC VARIABLES 50 CONCLUSION 51 REFERENCES 53 Appendix A 62 Appendix B 63 Appendix C 64 Appendix D 68 v List of Tables: Table Page 1 Summary of Scores from the Piers-Harris Self- Concept Scale 36 2 Summary of CPQ Scores 37 3 Summary of Second Order Factors (CPQ) 38 v i List of Figures: Figure Page 1 Anxiety Acceptance 39 2 Problem Severity 40 3 Coping Effectiveness 41 4 School Related Complaints 43 5 Social Complaints 44 6 Complaints About Everything 45 7 Somatic Complaints 46 Cvli) Ackncwledqements: I would like t o thank John Hoddinott f o r h i s . contribution of time and technical advice as well as emotional support. I doubt that I would have completed this without his assistance. I am grateful to Dr. Du-Fay Der, ray long distance supervisor, whose talent as a therapist made this entire study possible. Sincere thanks goes to Dr. J. Paredes and Dr. L. QDchran, who as members of my committee, contributed an invaluable service by providing me with helpful suggestions and insightful recommendations. The County of Strathcona is thankfully acknowledged because their grant of Sabbatical Leave enabled me to undertake this venture. ( v i i i ) 1 CHAPTER 1 INTRODUCTION TO THE PROBLEM School Refusal F i f t y - s i x years ago, Broadwin (1932) i d e n t i f i e d a "neurotic" form of school nonattendance that could be di f f e r e n t i a t e d from truancy and parentally-enforced absenteeism. Increasingly the term "school r e f u s a l " i s used t o describe t h i s syndrome since school refusal i s not a unitary construct (Granell de Aldoz, Vivas, Gelfand, & Feldman, 1984; Hersov, 1985; Hsia, 1984) and there i s a "lack of agreement as t o the fundamental nature of the disorder" (Atkinson, Quarrington, & Cyr, 1985, p. 3). The disorder manifests i t s e l f when child r e n begin t o stay home from school usually because they say they are i l l . The ref u s a l aspect i s r a r e l y apparent because t h i s behaviour i s masked by one or more somatic complaints, f o r example, headaches, stomach aches, insomnia, and many various ailments - si n g l y or i n combination. The appearance of these complaints usually occurs j u s t p r i o r t o departure f o r school. Medical examination reveals no physical etiology and subsequently a psychi a t r i c or psychological r e f e r r a l i s made. School re f u s a l has been c a l l e d the "Masquerade Syndrome" (Waller & Eisenberg, 1980, p. 212) and hypothesized causes have resulted i n the terms "school phobia" or "separation anxiety" being used as descriptors f o r t h i s avoidance behaviour. 2 Evolution of the Term "School Refusal" This r e f u s a l behaviour was f i r s t c a l l e d "school phobia" by Johnson, F a l s t e i n , Szurek & Svendsen (1941). In a follow-up study t o the 1941 paper, Estes, Haylett & Johnson (1956) coined the term " separation anxiety" i n "an attempt t o provide a diagnostic l a b e l that more accurately r e f l e c t e d the true locus of pathology" (Waller & Eisenberg, 1980, p. 211) because of the u n r e a l i s t i c worries expressed about harmful things that might happen t o parents or the c h i l d during the time the c h i l d attended school. Separation, rather than fear of school, was seen as the issue i n the refusal behaviour (Barker, 1983; Bowlby, 1973; Gittelman-Klein & KLein, 1980; Lawlor, 1976; Prazer & Friedman, 1985). S t i l l others posited fear of f a i l u r e due t o u n r e a l i s t i c self-concept l e v e l s (Leventhal & S i l l s , 1964; Leventhal, Weinberger, Stander & Stearns, 1967) or fear of school (Lazarus, Davidson, & Polefka, 1965; Nichols & Berg, 1970) as the reason. Same think that i t i s important t o draw a d i s t i n c t i o n between fear of separation and fear of school f o r treatment purposes (Eysenck & Rachman, 1965; Ross, 1980) yet evidence has not been forthcxsming t o prove t h i s assertion. Ultimately "school r e f u s a l " has become the term of choice (Atkinson et a l , 1985; Beeghly, 1986; Hersov, 1985; Kahn, Nursten & C a r r o l l , 1981; Munoz, 1986) although there are dissenters (Berecz, 1969, Reber, 1985). The term does not correspond t o a single p s y c h i a t r i c category, yet as a descriptor i t has the advantages of emphasizing the ess e n t i a l observable c h a r a c t e r i s t i c of the disorder and hi g h l i g h t i n g the psychosocial 3 aspect (Kahn et a l . , 1981). School refusal i s not a single c l i n i c a l entity and i t may be part of other neurotic disorders (Snaith, 1981). The point i s that school refusal can be the result of school phobia which i s an irrational fear of school; separation anxiety, which i s fear of loss of attachment to a security figure; or intrahuman variables such as a grandiose view of s e l f or lack of coping s k i l l s when anxious and self-preoccupied. I t may be impossible to pinpoint cause with certainty yet exploration of subject variables related to the behaviour may be a paradigm to describe effective treatment. We know that school refusal i s the observable behaviour of this syndrome (Hersov, 1985) and precipitating factors can be anything that represents a threat to the individual. Under conditions of threat, anxieties and fears are common (Beck & Emery, 1985) and absentee students realize that their distress i s almost immediately reduced when they withdraw from the circumstances around which i t i s generated. Consequences of School Refusal The consequences for children who refuse to attend school and who receive no treatment are grim as school refusal's pattern i s sporadic absences leading to total absence from school (Hersov, 1985) resulting i n disruption and fragmentation of academic instruction. There i s some evidence that educational and psychological growth are interdependent since academic achievement and self-concept have been positively correlated (Kawash & Clewes, 1986). Other, not so obvious, negative effects 4 are that successful school r e f u s a l may lead t o avoidance behaviour i n other situations such as going t o a friend's house or p a r t i c i p a t i n g i n (Community or recreational a c t i v i t i e s (Brulle, Mclntyre & M i l l s , 1985) although t h i s does not always happen. What i s a consistent consequence i s that maturation does not solve the problem as children do not outgrow patterns of behaviour involved i n school refusal and the e f f e c t s are more d e b i l i t a t i n g with increasing maturational demands and s o c i a l pressure i f children are not helped t o cope with the increasing stress of the s i t u a t i o n . Social demands carry the weight of law since school attendance i s compulsory i n most countries. There i s also the implication that school r e f u s a l behaviour i s self-destructive (Kahn et a l , 1981) and that adult e f f o r t s t o intervene are i n e f f e c t i v e . Children refuse t o attend school although parents may persuade, entreat or punish them (Bryce & Baird, 1986). PURPOSE OF THE STUDY The effectiveness of hypnosis as a treatment f o r school r e f u s a l was documented by quantitative measures i n t h i s single case study. The subject was a 10-year o l d male f i f t h grader who had not attended school f o r three weeks when he was referred t o a c l i n i c a l psychologist f o r treatment. P r i o r attendance d i f f i c u l t i e s had been evident before t h i s full-blown r e f u s a l f o r at l e a s t s i x months. Reported studies of hypnosis as a treatment f o r school r e f u s a l , as i s the case with much research i n hypnosis outcome 5 effectiveness, has been la r g e l y anecdotal and outcome assessment has been neglected and i l l - d e f i n e d (Lambert, 1982). This study assessed change over a number of measurable variables t o provide d i r e c t evidence that during the period of treatment there was a quantifiable move toward more p o s i t i v e adjustment as regards school attendance, anxiety, and self-concept leading t o more e f f e c t i v e coping behaviour. Both criterion-referenced and normative data were collected t o document and estimate the degree of change. Hypotheses Tested Stated i n the N u l l form, the hypotheses t h i s case study investigated were: 1) Hypnosis w i l l have no e f f e c t on school r e f u s a l behaviour as measured by school attendance and parent reports. 2) There w i l l be no change i n self-concept as measured by The Piers-Harris Children's S e l f Concept Scale. 3) There w i l l be no change i n anxiety as measured by the Children's Personality Questionnaire (CPQ), The Piers-Harris Children's S e l f Concept Scale, and The Anxiety Acceptance Scale, The Coping Effectiveness Scale and Personal Stress Level. 4) There w i l l be no change i n somatic complaints as measured by Personal Stress Level and parent reports. 6 Rationale Few studies have been conducted where school refusal was treated by hypnosis. These reports are largely anecdotal accounts which do l i t t l e to isolate essential variables for change. This study used a single system design i n an attempt "to monitor problems continuously to determine whether or not the problem actually changes" (Nugent, 1985, p. 192) as well as to t r y to determine i f causitive relationships existed between the intervention and observed change. A single case design was chosen to evaluate hypnosis as a •treatment for school refusal because repeated measures i n t h i s framework can help establish a knowledge base about individual responses over time and allow for the analysis of individual v a r i a b i l i t y . I t also provided information about the need for treatment adjustment and refinement (Kratcchwill, Mott, & Dodson, 1984). "The A - B design, with s t a b i l i t y information... seemed particularly well suited for use with hypnotic interventions" (Nugent, 1985) and a single case design with repeated measures increased the v a l i d i t y of causal inference (Kazdin, 1982). Standardized pre and posttests of personality and self-concept are measures used to provide psychometric evidence of change i n c r i t i c a l variables associated with school refusal. Since these were collected at the three crucial points of entering treatment, leaving treatment and after a 10 month follow-up period, they indicated change s t a b i l i t y which i s an important factor i n assessing treatment effectiveness. 7 T . I irritations of the Study Results from single case studies are not generalizable because more than one subject i s needed t o get an estimate of inter-subject v a r i a b i l i t y within the population. Furthermore measurement i s always i n error and a l l instruments are l e s s than perfect, therefore cautious interpretation of the r e s u l t s i s es s e n t i a l and must also be made i n context of the known information about the instruments used. In t h i s study, only part one of each CPQ form was administered at each session. Therefore, the r e s u l t s were interpreted as d i r e c t i o n a l markers rather than attainment l e v e l s . Another consideration was that observations i n a s i n g l e case study are not s t r i c t l y independent and t h i s l i m i t s the s t a t i s t i c a l choices f o r the researcher. In t h i s study, s i g n i f i c a n t c l i n i c a l outcomes precluded the generation of s u f f i c i e n t data points to do a time-series analysis which i s a design strategy that would have increased s t a t i s t i c a l i n f e r e n t i a l capacity. An A - B Follow-up format was used with a 2 week baseline due t o the severity of the problem and the urgency f o r treatment as outlined by the parents. B a s i c a l l y t h i s study confirmed the e f f e c t s but i t could not delineate the mechanisms of treatment. I t demonstrated that target variables had been modified but could not specify which aspect of the treatment was c r u c i a l so the therapeutic procedure was accepted as a whole. The general impact l e v e l of t h i s intervention would j u s t i f y the case study despite the above considerations. 8 CHAPTER 2 IJTERATURE REVIEW SCHOOL REFUSAL - Terrninoloay In the early 1930's, Broadwin (1932) recognized a neurotic form of school absence which d i f f e r e d from truancy. For t h i s group of children, much anxiety was attached t o school attendance. Johnson et a l (1941) coined the terra "school phobia" t o describe an anxiety reaction i n children that resulted i n t h e i r persistent absence from school. These e a r l i e r studies focused on the t h e o r e t i c a l etiology with the consequence that t h i s condition, which had the same presenting problem, was described i n various d i f f e r e n t ways. The most common were "school phobia", "separation anxiety" or "grandiosity". Waller & Eisehberg (1980) proposed the behavioural descriptor "inappropriate homebound school absence" (p. 210). In other words, these children presented a varied c l i n i c a l picture and often the l a b e l depended upon the therapist's t r a i n i n g and orientation. School r e f u s a l has been viewed as a s i n g l e syndrome that presents with a v a r i e t y of symptoms (Frick, 1964) and "as a v a r i e t y of syndromes with a common presenting symptom" (Atkinson et a l . , 1984, p. 83). One author has dealt with the problem of terminology by conceptualizing school non-attendance "as a continuum with progression from *• involuntary' symptoms on one end t o *• w i l l f u l ' r e f u s a l on the other end as time elapses" (Hsia, 1984,p. 361). She envisioned the early stages as school phobia and the l a t e r stages as school r e f u s a l . 9 I f one attempted t o use the Diagnostic and S t a t i s t i c a l Manual's diagnostic system - DSM-111-R, (American Psyc h i a t r i c Association, 1987), the best f i t may be between over anxious disorder and separation anxiety. Individuals may f i t i n t o d i f f e r e n t categories and yet have the common problem of school ref u s a l (Snaith, 1981). There are further cxmpounding problems because i n most countries, unless there are v a l i d medical reasons, school attendance i s mandated by law (Kahn e t a l . , 1981), thus inaking t h i s a psychosocial problem (Skynner, 1974). In researching t h i s subject, i t was necessary t o include the l i t e r a t u r e on school phobia and separation anxiety as these e a r l i e r terms have wide acceptance. School re f u s a l i s "a more in c l u s i v e term since i t covers a l l cases where there i s a psychosocial component" (Kahn et a l . , 1981,p. 3). The term "school r e f u s a l " has further merit i n that i t does not force one to adhere t o a p a r t i c u l a r t h e o r e t i c a l orientation yet i t allows f o r consideration of the whole c h i l d i n a context where the impact of both home and school can be weighed (Hersov, 1985). In t h i s paper, the term "school r e f u s a l " was used except where s p e c i f i c references used school phobia or separation anxiety. INCIDENCE There have been no d i r e c t investigations of the prevalence of school re f u s a l (Trueman, 1984b). Different figures have been c i t e d i n a r t i c l e s ; the most common of which i s 17 per 1000 c l i n i c a l cases (Kennedy, 1965). This claim i s unsubstantiated and the basis f o r i t was unreported but as Trueman (1984b) 10 pointed out t h i s figure would mean that "one of approximately every 59 children i s school phobic" (p. 193). A study, which attempted to investigate t h i s t o p i c i n a more systematic manner, used these c r i t e r i a : the c h i l d was absent from school more than one standard deviation above the school norm and parent, teacher and self-reports agreed that the c h i l d was highly f e a r f u l . The range was .4 ( t o t a l agreement) to 1.5 (agreement of c h i l d or parent report) i n t h i s sample of 1034 Venezuelan children from 3 to 14 years of age (Granell de Aldaz et a l . , 1984). In t h e i r analysis of ten cross-cultural studies, they concluded that prevalence rates varied with "population c h a r a c t e r i s t i c s , the methodology applied and c r i t e r i a selected (p.723). Ranges from 1% t o 8% have been reported from various c h i l d guidance c l i n i c s (Beeghley, 1986). The true extent of school refusal may never be exactly assessed because not only do many d i f f e r e n t r e f e r r a l agencies deal with these children but the problem i s further cxsmpounded because those children, who ex h i b i t mild symptoms, may be e f f e c t i v e l y treated within the school s i t u a t i o n by the school counsellor and never become a s t a t i s t i c from a mental health c l i n i c or a hosp i t a l (Sugar & Schrank, 1979). Another d i f f i c u l t y i n accurately assessing numbers stems from the f a c t that somatic complaints are often the reason a physician's diagnosis i s sought. I f the adult makes no reference t o the c h i l d ' s nonattendance at school, the school r e f u s a l behaviour may go unnoticed (Waller & Eisenberg, 1980). Despite the d i f f i c u l t y of obtaining precise figures, i t i s reported t o be a common problem 11 which poses s i g n i f i c a n t therpeutic management problems (Trueman, 1984a). Indeed, acute school r e f u s a l i s seen as a true c h i l d p s y c h i a t r i c emergency (Derogatis,1986; Prazer & Friedman, 1985). CHARACTERISTICS ASSOCIATED WITH SCHOOL REFUSAL Much has been written about school r e f u s a l . Age, gender, socio-economic l e v e l s , f a m i l i a l patterns, school achievement, extensiveness of disturbance, p r e c i p i t a t i n g factors, and personality c h a r a c t e r i s t i c s are some of the variables that various authors have hypothesized as useful i n understanding school r e f u s a l (Atkinson et a l . , 1985; Trueman, 1984b). Acre Age of onset i s d i s t r i b u t e d bi-modally with the greatest incidence a t age eleven (Baker & W i l l s , 1978; Marks, 1978) and again, at school entrance, usually between the ages of f i v e and s i x . Age of onset and extent of pathology are often li n k e d since l a t e r onset i s equated with greater pathology (Kennedy, 1965; Hersov, 1960a; Coolidge, Hahn, & Peck, 1957). However, there i s no experimental evidence f o r such a dichotomy and many authors believe that the difference i s more a matter of degree than of kind i n that school refusal i s seen as a continuum (Atkinson et al.,1985; Hersov, 1985; Trueman 1984b). To account f o r the f a c t that there are older school refusers who have attended school successfully f o r several years, i t has been proposed that increased stress may be the most l i k e l y p r e c i p i t a t i n g factor (Baker & W i l l s , 1978). Although the capacity t o cope with stress 12 var i e s with age, preadolescents and adolescents have a great many stressors - developmentally, s o c i a l l y and academically. I f t h i s syndrome i s a continuum, t h i s may be the point where ce r t a i n children may be unable t o maintain successful attendance. "Very often, school refusal i s one i n d i c a t i o n of the young adolescent's general i n a b i l i t y t o cope with the increased demands f o r an independent existence outside the family and entry i n t o normal peer group relationships" (Hersov, 1985, p. 384). School refusal i n adolescents i s also seen as panic i n facing development (Coolidge, W i l i e r , Tessman & Waldfogel,1960). Gender Gender issues are often noted i n studies of school r e f u s a l and i t i s d i f f i c u l t t o draw any r e a l conclusions as there have been "no systematic assessments of the proportions of boys and g i r l s with school phobias" (Trueman, 1984b, p. 194). There have not been any meaningful attempts t o delineate sex differences i n personality, attitudes towards school or other relevant variables i n the school refusal population. Several investigators had more boys i n t h e i r samples (Baker & W i l l s , 1978; Berg, Butler & Pritchard, 1974; Hersov, 1960a; Rodriguez, Rodriguez & Eisenberg, 1959). Other studies had a greater proportion of g i r l s (Gittelman-KLein & K l e i n , 1973; Nichols & Berg, 1970; Berg, Nichols & Pritchard, 1969). However, Hersov (1985), i n a thorough review, concluded the ciccurence of school r e f u s a l i s "equal f o r both sexes" (p. 384). This was also the conclusion of the Venezuelan study (Granell de Aldaz e t a l . , 13 1984). Atkinson et a l . (1985), i n t h e i r review of the l i t e r a t u r e , reported differences i n boy's and g i r l ' s attitudes, amount of a n t i s o c i a l behaviours displayed and family i n t e r a c t i o n patterns. There was l i t t l e experimental evidence t o support these conclusions and when there was, confounding variables and t e s t r e s u l t s which were not s i g n i f i c a n t d i d l i t t l e t o c l e a r up questions as t o how gender relates t o school r e f u s a l . Socio-economic Status Socio-economic status (SES) was mentioned i n an ear l y study by Talbot (1957) when i t was pointed out that t h i s study had a high proportion of upper t o middle class subjects which was accounted f o r by the location of the c l i n i c . Since then, i t has been a p r e v a i l i n g notion that "school phobia was more endemic t o higher socio-economic groups" (Trueman, 1984b,p. 194). This has not been borne out i n subsequent examinations. One study used s o c i a l c l a s s t o c l a s s i f y school refusers and found no s i g n i f i c a n t differences between the upper and lower groups but a higher SES trend was noted (Baker & W i l l s , 1978). In a study, which used a control group, the school re f u s a l group had a lower SES but the s t a t i s t i c a l significance was not reported (Nichols and Berg, 1970). School refusal rates were found t o be s i g n i f i c a n t l y higher f o r children "attending pu b l i c and lower SES schools" i n Venezuela (Granell de Aldaz et a l . , 1984, p. 728). With such fragmentary and contradictory evidence, i t i s impossible t o say that there i s a relationship between SES and school r e f u s a l . 14 F a m i l i a l Patterns Family patterns and dynamics of school refusers have been discussed and examined by various researchers. In reporting on acute school refusers, i t was found that they were l i k e l y t o be the youngest c h i l d i n a small family (two or fewer s i b l i n g s ) , t h e i r mothers tended t o be older and the age of onset was l a t e r (Baker & W i l l s , 1978). Bowlby (1973) noted four main family patterns i n school refusers: 1) The mother and, sometimes the father, s u f f e r from chronic anxiety regarding t h e i r own parents and want the c h i l d t o be home f o r companionship; 2) the c h i l d i s a f r a i d something w i l l happen t o ei t h e r parent and stays home t o prevent t h i s ; 3) the c h i l d i s scared that he may get hurt and stays home where i t i s safe; 4) ei t h e r parent may be f e a r f u l that some harm w i l l came to the c h i l d and they wish him t o stay home. Bowlby (1973) found the f i r s t pattern t o be the most common one i n school r e f u s a l . Families of school refusers have been described as neurotic (Harris, 1980; Talbot, 1957); with a disproportinate balance of power (Hsia, 1984; Coolidge et a l . , 1960) and as ei t h e r over involved or under involved (Hersov, 1960b). Hersov (1960b) saw three main types of parent-child relationships - a) an overindulgent mother and passive father with a w i l l f u l demanding c h i l d while at home yet f e a r f u l and tim i d outside; b) a severe, c o n t r o l l i n g , demanding mother and a passive husband with a passive, obedient c h i l d a t home who became f e a r f u l and tim i d when outside the home; c) a firm, c o n t r o l l i n g father and an over-indulgent mother. She i s close t o 15 her c h i l d who i s w i l l f u l , stubborn and demanding at home yet who may be f r i e n d l y and outgoing away from home. In a follow-up study of previously hospitalized school refusers, former school refusers saw t h e i r mothers as overprotective or they had unresolved attachments t o t h e i r mothers (Weiss & Burke, 1970). From a family systems point of view, school r e f u s a l can have both a protective and s t a b i l i z i n g function w i t h i n a pathological family system (Hsia, 1984). Intelligence and Academic Achievement Early studies usually stated that school refusing children are average t o above-average i n i n t e l l i g e n c e but t h i s was based mainly on c l i n i c a l impressions rather than on c o l l e c t e d data (Trueman, 1984b).There seems to be a general impression that people with p s y c h i a t r i c disorders have a lower IQ than the r e s t of the population but evidence f o r t h i s i s inconclusive (Beitchman, Patterson, Gelf and & Minty, 1982). Case studies have reported evidence of learning d i s a b i l i t i e s i n school refusers (Suttonfield, 1954) and low achievement despite average i n t e l l i g e n c e ( M i l l e r , 1972). A study of children i n r e s i d e n t i a l treatment found that school achievement was the best area of h o s p i t a l adjustment (Weiss & Cain, 1964).There have been no s i g n i f i c a n t differences reported i n the scores of acute versus chronic school refusers (Baker & W i l l s , 1978; Berg, Nichols & Pritchard, 1970; Nichols & Berg, 1970) but school refusers i n general were overachievers of at l e a s t average i n t e l l i g e n c e (Hersov, 1985). In a follow-up study, school achievement was 16 found t o be high but s o c i a l adjustment was low. Involvement with school work was often used as the rationale f o r having few or no friends (Weiss & Burke, 1970). In one systematic study of the IQ scores of school refusing children, the mean F u l l Scale IQ score on the Wechsler Intelligence Scale f o r Children was 98.9; the mean Verbal score was 96.7 and the mean Performance score was 101.6 in d i c a t i n g that t h i s group of fifty-seven children scored i n the average range f o r t h i s t e s t . IQ equivalent scores were lower on an achievement measure (Wide Range Achievement Test) leading the authors t o conclude that these children were not performing t o t h e i r p o t e n t i a l (Hampe, M i l l e r , Barrett & Noble, 1973). Evidence i s mixed and does not support the notion that school refusers are homogeneous as f a r as i n t e l l i g e n c e and school achievement are concerned. Extensiveness of Disturbance Most writers now acknowledge that school r e f u s a l i s a condition associated with a range of behaviours, that i s , i t i s not a sin g l e c l i n i c a l e n t i t y (Hersov, 1985). Extensiveness of disturbance was correlated with age of onset, so early researchers t r i e d t o dichotomize school refusers i n t o discrete categories since there are two d i s t i n c t groups - those whose school attendance ceased abruptly and those whose school r e f u s a l developed slowly over time (Kahn et a l . , 1981). One attempt used the labels "neurotic" and "characterological". The former group had an abrupt onset usually a f t e r several trouble-free years of 17 school attendance. With the onset of school r e f u s a l , behaviour at both home and school had changed but despite t h i s , t h e i r s o c i a l and i n t e l l e c t u a l functioning was unimpaired. This group had a better prognosis than d i d the characterological type who were more disturbed and more generally f e a r f u l (Coolidge et a l . , 1957). Later these groups were r e l a b e l l e d Type 1 and Type 2 school refusers and ten c r i t e r i a were suggested f o r use i n d i s o r i i n i r a t i n g between them (Kennedy, 1965). The process used t o devise these was not explained and a very small sample of Type 2 (characterological) school refusers was used (Atkinson e t a l . , 1985). Other studies show that the characterological, or the more deeply disturbed group, can be further divided on the basis of family dynamics (Weiss & Cain, 1964; Hersov, 1960b). Hersov's f i r s t two family descriptions, as described e a r l i e r i n t h i s paper, are associated with t h i s group f o r wham school r e f u s a l i s only one signal that the c h i l d i s more deeply disturbed. I t would appear that school refusal sometimes indicates a syrrirome wherein the c h i l d i s temporarily affected and h i s basic personality remains i n t a c t , and f o r others i t denotes a more all-pervasive condition of greater pathology. In working with 63 f i l e cases of highly anxious school refusers, Smith (1970) distinguished three groups. They were: 1) young children who manifested fears at an early age, who tended t o encounter these d i f f i c u l t i e s repeatedly, and were seen as suff e r i n g from separation anxiety; 2) older children who had not had previous school d i f f i c u l t y . These were seen as "school phobic" and were also generally seen as phobic outside of 18 school. Not a l l these children could i d e n t i f y a feared school s i t u a t i o n rather they were described as generally f e a r f u l and t i m i d ; 3) older children who appeared depressed or who showed signs of fear of f a i l u r e or r e j e c t i o n . These children were also perf e c t i o n i s t i c . None of the syndromes was believed t o be mutually exclusive. Precipitating: Factors As might be expected, examinations of events which lead t o school r e f u s a l also revealed mixed and sometimes contradictory findings. There would appear t o be a myriad of events which activates avoidance behaviour i n connection with school. A study of sixteen school refusers revealed that two-thirds had a di s c e r n i b l e p r e c i p i t a t i n g event such as a move t o a new school, entrance t o junior high school, h o s p i t a l i z a t i o n of the c h i l d , i l l n e s s of the mother or c h i l d or a death i n the family. For the remaining one-third there was no apparent reason (Weiss & Cain, 1964). Others have mentioned "overwhelming threats t o the c h i l d ' s security" (Hsia, 1984, p. 361); separation anxiety (McDonald & Sheperd, 1976; Bowlby, 1973); and anxiety avoidance (Eisenberg, 1958). One study, stated that a " s i g n i f i c a n t l y larger number of acute cases had known p r e c i p i t a t i n g factors" (Baker & W i l l s , 1978, p. 495) whereas chronic school refusers usually d i d not. Despite the f a c t that two of the three t h e o r e t i c a l models used t o explain t h i s phenomenon place great importance on p r e c i p i t a t i n g events, there has been very l i t t l e research done i n t h i s area. There have been no studies which 19 assessed the school s i t u a t i o n (Trueman, 1984b). Hersov (1960b) studied 50 f i l e cases and abstracted the explanations given by the children f o r t h e i r refusal t o attend school. The responses f e l l i n t o three groups: 1) fear of harm craning t o mother; 2) fear of the teacher or other p u p i l s ; and 3) fear of academic f a i l u r e . PERSONALITY AND SCHOOL REFUSAL In i t s e a r l i e s t inception, school r e f u s a l was viewed as a symptom of a personality problem described as "a neurotic character of an obsessional type 1 1 (Hersov, 1985, p. 382). Since then, various personality dimensions have been observed i n t h i s group of children. Besides being described as anxious and neurotic, these children were also seen as dependent (Blanco, 1982; Trueman, 1982b). Results of an experiment designed t o uncover more about school refusers and dependency reported that the chronic subgroup showed greater dependency c h a r a c t e r i s t i c s than the acute subgroup (Berg et a l . , 1969). "Acute" meant at lea s t three trouble-free years of continuous attendance. Another strand of personality descriptors which runs through the l i t e r a t u r e depicts these children as w i l l f u l , manipulative and grandiose at home yet shy and f e a r f u l a t school (Leventhal & S i l l s , 1964; Leventhal et a l . , 1967). These children were high achievers who had an i n f l a t e d sense of s e l f . When they could no longer "maintain t h e i r n a r c i s s i s t i c s e l f image" (Leventhal & S i l l s , 1964, p. 686) because the r e a l i t y demands of school deflated i t , they avoided 20 school. Studies have not provided support f o r t h i s hypothesis (Berg & C o l l i n s , 1974; Berg et a l . , 1969). Anxiety and School Refusal Anxiety i s a defining c h a r a c t e r i s t i c of school r e f u s a l behaviour (Barker, 1983; Beeghly, 1986; Blanco, 1982; Coolidge e t a l . , 1960; Gittelman-KLein & K l e i n , 1971; K l e i n , 1980; Smith, 1970) and school refusal has been c a l l e d "the most frequent form of anxiety i n children" (Crasilneck & H a l l , 1985, p. 241). However, pharmacological reduction of anxiety i n school refusing children d i d not lead t o an automatic return t o school (Gittelman-KLein & K l e i n , 1971 & 1973). Other studies reported that anxiety impairs cognition (Crowne, 1979; Sarason, Davidson, L i g h t h a l l , Waite & Ruebush, 1960); interferes with concentration (Decker, 1987); i s involved with self-esteem expression (Kawash & Clewes, 1986); and may be "that something that mediates avoidance behaviour" (Ross, 1980, p. 146). P h i l l i p s (1978) suggested that anxiety caused children t o undergo basic personality changes which l e d to two d e b i l i t a t i n g behaviours - 1) s e l f preoccupation and 2) avoidance behaviours. Experimental evidence showed that anxious children regress t o a p r i m i t i v e l e v e l of perceptual functioning when presented with contradictory sensory experiences which are beyond t h e i r l e v e l of cognitive maturity (Smith & Danielsson, 1982) and one implication of these studies i s that overly anxious children operate more comfortably i n a regressed state than one commensurate with t h e i r developmental l e v e l . 21 Self-Concept and School Refusers Rutter (1984) envisioned personality development occurring i n a s o c i a l context and " s o c i a l cognitions provide an important part of personality functioning" (p. 316). D i f f i c u l t i e s with peer relationships often t y p i f y the school refuser's s o c i a l orientation (Hersov, 1985; Weiss & Burke, 1970; Weiss & Cain, 1964) though t h i s i s not always true (Davidson, 1960). Normal patterns of s o c i a l i z a t i o n are disrupted and, because of t h i s , dependent behaviours may be reinforced. I t was hypothesized (Dielman & Barton, 1983) that dependence leads t o f r u s t r a t i o n which leads t o aggression toward s e l f which i n turn leads t o low self-concept. Low self-concept has been reported i n school refusing children (Hersov, 1985; Hsia, 1984). Healthy relationships and p o s i t i v e reinforcement f o r learning help determine self-esteem - the evaluative component of self-concept (Sniderman, 1983). Unhealthy relationships both f a m i l i a l l y and with peers seem t o be the case with children who refuse t o attend school (Berg, Butler, & H a l l , 1976; Bowlby, 1973; Hersov, 1985 & 1960b; Kahn & Nursten, 1962; Talbot, 1957). TREATMENT Manor Theories Associated with Treatment Studies have described treatment procedures based on various t h e o r e t i c a l formulations mainly psychoanalytic, psychcdynamic and learning theory (Atkinson et a l . , 1985). The psychoanalysts use the concepts of f i x a t i o n and regression when 22 they describe the school refuser's strong attachment t o the nourishing figure and t h e i r desire t o return t o an e a r l i e r state of dependency where they were so nurtured. Often i t i s the mother t o whom the strong bond i s formed. Adaptational and s o c i a l pressures push f o r d i f f e r e n t i a t i o n and s t r i v i n g toward independent actions. The c h i l d ' s struggle with these opposing forces may be threatening f o r e i t h e r or both mother and c h i l d . Thus psychoanalysts favour separation anxiety as an explanation f o r school refusal (Bowlby, 1973). Psychodynamic theo r i s t s refute t h i s because of the l a t e r age of peak prevalence of school r e f u s a l and they focus p r i m a r i l y on the aspect of the c h i l d ' s over i n f l a t e d self-image which lessens ego strength preventing the c h i l d from coping with the r e a l i t y demands of school. Fear of f a i l u r e may be the overriding emotion i n t h i s conceptualization (Leventhal & S i l l s , 1964). Learning t h e o r i s t s see phobias as learned responses and fear-inducing s t i m u l i must be i d e n t i f i e d as part of the treatment. Therefore i t i s considered important t o discuss whether the fear i s of the school environment or of leaving home (Eysenck & Rachman, 1965). Behavioural techniques that are commonly used are relaxation and systematic desensitization. These views are not necessarily discrepant as they "may involve differences of focus rather than substance" (Atkinson et a l . , 1985, p. 86). Whatever the t h e o r e t i c a l underpinnings, i t has been recognized that school refusal i s "often a d i f f i c u l t and taxing problem t o t r e a t " (Bryce & Baird, 1986, p. 199). 23 Recently, there has been renewed in t e r e s t i n b i o l o g i c a l aspects of t h i s syrdrome. There have been reports of unusual sleep and wakefulness cycles i n school refusers (Jackson, 1964; Talbot, 1957). One case study (Fukuda & Hozxmd, 1987), found that d i r e c t manipulation of the circadian system reduced the l e v e l of f i l i a l violence i n a male school refuser. Hypnosis - Theories and Definitions Hypnosis i s s t i l l a controversial subject "despite more than 200 years of use" (Wadden & Anderton, 1982, p. 215). In attempts t o define t h i s phenomenon, hypnosis has been described as corimunication with the unconscious (Barnett, 1981), mental p a s s i v i t y (Bowers, 1982), an altered state of consciousness (Grinder & Bandler, 1981), and a "natural learning process which i s psychologically complex" (Kahn, 1984, p. 4). Some writers describe hypnosis as an antecedent condition and focus on what the therapist does t o convince the c l i e n t and him/herself that hypnosis i s being used. The important behaviours here are using a formal induction and l a b e l l i n g the treatment as hypnosis. Others define i t i n terms of c l i e n t behaviours such as hypnotic s u s c e p t i b i l i t y . Described t h i s way, hypnosis i s a dependent var i a b l e (Wadden & Anderton, 1982). In the f i r s t case, hypnosis i s not seen as a treatment method but as a technique t o help motivate the c l i e n t and increase the effectiveness of the therapeutic intervention (Kohn, 1984). In the l a t t e r scenario, hypnosis i s viewed as a state wherein there i s a narrowing of attention, anxiety a l l e v i a t i o n , reduction of normal planning 24 f a c i l i t i e s as the passive c l i e n t t r i e s t o please the hypnotist, e x h i b i t s enhanced a b i l i t y t o express repressed or dissociated material, and has the a b i l i t y t o control involuntary physiological responses (Kohn, 1984; Reber, 1985). There i s some tentative evidence that hypnosis i s more e f f e c t i v e when i t i s ind i v i d u a l i z e d t o s u i t the c l i e n t (Clarke & Jackson, 1983; Hammond, 1985; Holroyd, 1980). Hypnosis and Children Research on the hyp n o t i z a b i l i t y of children suggests that hypnosis i s a very e f f e c t i v e technique when used with children - esp e c i a l l y between the ages of 7 t o 14 (Ambrose & Newbold, 1980, Cooper & London, 1979; Gardner, 1974; London, 1962; London & Cooper, 1969; Morgan & Hilgard, 1979). I t has even been suggested that hypnosis i s more e f f e c t i v e with children than with adults (Johnson, Johnson, Olson & Newman, 1981). Medical and s u r g i c a l problems, emotional and behaviour disorders, and learning and school-related disorders are three areas where hypnosis with children has had extensive research i n d i c a t i n g the effectiveness of the technique (Gardner, 1974). Very few studies, however, describe treatment f o r school r e f u s a l with hypnosis. Three case studies using a hypnotic intervention with "school phobic" children were reported by lawlor (1976). Hypnosis was used t o achieve "meaningful cxranunications and t o bring fears t o consciousness so that they could be discussed and faced" (lawlor, 1976, p. 75). 25 CHAPTER 3 METHOD Introduction Treatment f o r the 10-year o l d school male refuser was hypnosis. The therapist had been i n practice since 1974 and had extensive experience working with children. The techniques used are described i n d e t a i l so that r e p l i c a t i o n i s possible. One reason why hypnosis may be useful i s that i t reduces anxiety (Kohn, 1984) and renders other therapeutic techniques more fo r c e f u l (Gaunitz, Unestalh, & Berglund, 1975; Matheson, 1979). Treatment variables controlled by the therapist were: 1) the therapist's language; 2) the s e t t i n g ; and 3) data c o l l e c t i o n . The Subject The subject was a 10-year o l d Caucasian male i n Grade 5, the youngest of two male s i b l i n g s . He had not attended school f o r three weeks when he was referred f o r treatment t o a c l i n i c a l psychologist. For s i x months p r i o r , the subject had gone through a period of complaints of headaches, stomach aches, insomnia and increasing school absence. Typically, he would have d i f f i c u l t y f a l l i n g asleep and would wake up two t o three hours before the alarm clock rang. He would wake h i s mother who would t a l k t o him and, u n t i l h i s ultimate r e f u s a l , could get him t o go t o school with much persuasion. He blamed h i s health, h i s lack of friends, h i s classroom s i t u a t i o n (he was i n a combined Grade 5/6 class) and h i s i n a b i l i t y t o cope with math and reading comprehension when asked why he could not go t o school. He was examined by the 26 family p e d i a t r i c i a n who could f i n d no physical cause f o r the various complaints. Father i s a company executive and mother i s a homemaker. Their socioeconomic status i s upper middle-class. The subject has one brother who i s two years older and who excels i n academics and sports. A l l nuclear family members are avid athletes and strong competitors. The subject was the top-ranking track and f i e l d contestant f o r h i s age i n h i s school d i v i s i o n the previous spring. He i s well-formed and a t t r a c t i v e i n appearance. His report card marks are usually i n the high average range (B to B+ on a 5-point scale A, B, C, D, F where C i s average) despite h i s view of having d i f f i c u l t y i n s p e c i f i c school subjects. There was no h i s t o r y of school r e f u s a l but h i s mother reported that he was t i m i d i n approaching most new situations and somatic complaints had previously i n t e r f erred with school attendance. To place the subject within the conceptual framework provided by the l i t e r a t u r e on school r e f u s a l , various aspects are cl e a r . He would be i d e n t i f i e d as being classed as "acute" near the most frequent age of onset. His previous length of regular attendance as w e l l as being the youngest i n a small family, which are defining c h a r a c t e r i s t i c s of t h i s grouping, would q u a l i f y him f o r the l a b e l . Though described as l e s s serious as f a r as development i s concerned, acute school r e f u s a l r a r e l y disappears without intervention (Hersov, 1985) and the prognosis i s l e s s favourable as time goes on. The reason f o r the school refusal was unclear. His 27 reports of p r e c i p i t a t i n g factors center around school. His fear of academic f a i l u r e coupled with anxiety about being i n a combined grade class make i t appear t o be a phobic reaction. On the other hand, he stayed close to h i s mother and appeared calmer when she was present. From t h i s behaviour, one could i n f e r that separation also plays a r o l e i n h i s unwillingness t o go t o school. Pre-Therapy Procedures In t h i s phase of treatment, rapport was established as w e l l as the i d e n t i f i c a t i o n of problematic thoughts and areas of worry f o r the subject, that i s , where the subject defined the personal meaning of thoughts about himself and events (Beck, 1976). Rapport, "a comfortable, relaxed, unconstained, mutually accepting interaction between persons" (Reber, 1985, p. 609), was established by providing an accepting environment, pacing, empathic r e f l e c t i o n , explaining therapeutic procedures and obtaining the subject's verbal consent t o undergo therapy. Acceptance was shown by believing the c h i l d and seeking h i s permission. Pacing i s noticing behaviours, breathing, rate of speaking and matching them to b u i l d an "unconscious biofeedback loop" (Grinder & Bandler, 1981, p. 14). Empathic r e f l e c t i o n i s paraphrasing the content and a f f e c t i n a subject's statements t o l e t him know that he i s being heard and understood. The subject was t o l d that together he and the therapist would t a l k about what worried the c h i l d and they would write h i s worries down so they could be used t o assess change. Other measures would be 28 taken at the beginning and at the end of treatment as w e l l as at a l a t e r date. The subject was asked i f he could do t h i s and i f he consented t o do i t . The reply was i n the affirmative. He was also asked i f he wanted h i s mother t o be present during therapy. The subject r e p l i e d that he did. Since changing the manner i n which an i n d i v i d u a l conceptualizes h i s world l i e s at the heart of the therapeutic procedure and the aim was to extend, modify, and relearn behavioural patterns to f a c i l i t a t e coping i n anxiety-producing s i t u a t i o n s , e s p e c i a l l y school, the subject's day-to-day stressors were i d e n t i f i e d and scaled. The subject's l e v e l of anxiety acceptance, view of problem severity and a b i l i t y t o cope were also measured. Assessments of self-concept and personality, both of which included anxiety scales, were adnunistered during t h i s two week period and are pre-treatment measures. The . self- r e p o r t data constituted the baseline phase. Though desirable, i t was not i n the subject's i n t e r e s t t o extend the baseline phase because of the imperative f o r an early return t o school. Dependent Measures The design generated two kinds of data. One type was criterion-referenced wherein the subject was not compared t o a representative group but compared to c r i t e r i a related t o himself. These were self-report measures developed between the therapist and the subject. From the i n i t i a l interview, a se l f - r e p o r t scale, c a l l e d Personal Stress Level, was constructed 29 to measure subject-identified complaints. The areas were somatic complaints, academic and s o c i a l issues plus a statement about general anxiety. Each was rated on a L i k e r t Scale and t h i s 1 t o 5 scale was used t o a i d the subject t o recognize change (Appendix A). Three other scales administered were anxiety acceptance, problem severity and coping effectiveness. These were adopted with p a i r s of b i p o l a r adjectives or a d j e c t i v a l phrases (Ishiyama, 1986). Each had seven empty spaces i n between and were scored from 1 t o 7 i n the appropriate d i r e c t i o n with the t o t a l score being used f o r each scale (Osgood, Suci, & Tannenbaum, 1957) (Appendix B). This i s a form of the Semantic D i f f e r e n t i a l Technique. Two standardized, norm-referenced measures were administered pre and posttreatment and a f t e r a 10 month follow-up period. One measure was the Piers-Harris Children's S e l f Concept scale - "The Way I Feel About Myself" (1984) which comprises s i x item-clusters: behaviour, i n t e l l e c t u a l and school status, physical appearance and a t t r i b u t e s , anxiety, popularity,and s a t i s f a c t i o n . The r e l i a b i l i t y of these scales has been questioned (Platten & Williams, 1979) but recent r e l i a b i l i t y studies have placed i n t e r n a l consistency from .88 t o .93 (Kuder-Richardson 20) on the t o t a l scale (Jeske, 1985). When res u l t s are integrated with other data regarding the i n d i v i d u a l , i t i s seen as the "best children's self-concept scale currently available" (Jeske, 1985, p. 1169). Scores between the 31st and 70th percentiles are considered average. The manual notes that 30 "high scores may r e f l e c t p o s i t i v e self-evaluation or a healthy desire t o look good i n front of others, and may not be a cover f o r underlying problems" (Cosden, 1984, p. 516; Pier s , 1984). This t e s t gives information on the s o c i a l and a f f e c t i v e states of children i n Grades 4 t o 12. As w e l l as the s i x c l u s t e r scores, there i s a t o t a l self-concept score which i s based on the assumption that a unitary score can represent how one fe e l s about oneself i n r e l a t i o n t o peers i n a global way. The mean f o r the t o t a l t e s t i s 51.84 and the standard deviation i s 13.87 (Piers, 1984). The other standardized measure used was the Children's Personality Questionnaire (CPQ) "What You Do and What You Think" by B. Porter and R.B. C a t t e l l (1975 e d i t i o n ) . This i s a personality inventory f o r children between the ages of 8 and 12 along 14 dimensions of personality which were derived through factor analysis and found to be f a c t o r i a l l y independent. Each scale has a technical name as wel l as an alphabetic reference symbol. " S p e c i f i c a l l y , the t e s t has been used i n c l i n i c a l c h i l d psychology t o i d e n t i f y and understand anxiety, neuroticism, and delinquency" (Drummond, 1984, p. 196). Raw scores are transformed t o Stens which are a special case of standard scores. These scores use a standard ten scale and are derived from a l i n e a r transformation of the z-scale. The range i s 1 t o 10, the mean i s 5.5 with a standard deviation of two (Porter & C a t t e l l , 1975). There has been same c r i t i c i s m that there i s a lack of equivalence among forms and also that factor homogeneity and s t a b i l i t y are lower than might be expected so the 31 r e l i a b i l i t y of t h i s t e s t on an ind i v i d u a l basis may be affected (Drummond, 1984). Therapeutic Procedure Treatment was scheduled f o r 60 minutes once each week i n the psychologist's o f f i c e . A f t e r the two week baseline data c o l l e c t i o n phase and f i r s t treatment session, a l l other data was col l e c t e d p r i o r t o trance induction so that post-hypnotic e f f e c t s would not account f o r measured changes. The four treatment sessions followed the same format. For about 20 minutes, discussion centered around sub j e c t - i d e n t i f i e d stressors, coping a b i l i t y , and problem severity. Then r a t i n g took place. The hypnotic intervention occupied the following 20 minutes. F i n a l l y , there was discussion and feedback about the session. The subject was reminded t o play the audio tape a t bedtime. The subject sat i n a comfortable r e c l i n i n g chair opposite the therapist. Mood music played i n the background and the room was dim. His mother sat behind and about two metres from the subject. The subject was t o l d he could close h i s eyes or leave them open and t o focus attention on h i s breathing as w e l l as other physical sensations (Appendix C). A trance was induced by means of pacing, systematic relaxation, and using sensory-based non-specific language (Grinder & Bandler, 1981). The subject was t o l d that he could respond i n a normal voice t o questions while under hypnosis. He was t o l d t o imagine himself going t o t o the 32 therapist's other o f f i c e where the subject would f i n d what he needed t o make changes f o r himself. The subject was asked t o construct exactly what he saw i n the o f f i c e , how i t was furnished, decorated and what i t contained. The therapist t o l d him there was also special equipment such as a t a l k i n g computer and a beam of white l i g h t which had healing powers. The subject was t o l d that as he l a y i n the chair i n the imaginary o f f i c e the beam of l i g h t would pass over him and work with h i s own bodily processes t o provide healing so that h i s headaches and stomach aches would disappear and that h i s n i g h t l y sleep would be uninterrupted. The l i g h t would work as n a t u r a l l y as h i s breathing or h i s heart beating, thus anchoring a f e e l i n g of well-being with naturally occurring bodily processes which become conscious from time t o time. "Anchoring refers t o the tendency f o r any one element of an experience t o bring back the e n t i r e experience" (Grinder & Bandler, 1981, p. 61). Posthypnotic amnesia was introduced because the subject was t o l d he d i d not have t o remember everything, only the feelings of health and well-being when he became aware of h i s breathing or h i s heart beating. The t a l k i n g computer was used i n conjunction with the procedure c a l l e d " The New Behaviour Generator" (Grinder & Bandler, 1981, pp. 178 - 200). The behaviour selected f o r change was going t o school. Instructions t o the subject directed him t o see himself going to school on the computer and t o l i s t e n t o what he was t e l l i n g himself. When he could watch t h i s dissociated image comfortably, he t o l d the therapist by g i v i n g a 33 prearranged "yes" signal. The next step directed the subject to choose preferred behaviour i n this situation. When the subject indicated that he knew what behaviour response he would make, he was instructed to watch and l i s t e n to himself making the new response of going successfully to school on the talking computer. The therapist checked to see i f the subject was completely sati s f i e d with t h i s image. A "no" answer led to having the subject make refinements i n the dissociated image u n t i l he was sure he f e l t happy with i t . Once these adjustments were i n place, the therapist instructed the subject to put himself inside the computer image and carry out the behaviours i n the situation as i f he were actually doing them. This was rehearsed u n t i l the subject could signal "yes" he could satisfactorily accomplish this behaviour and that he f e l t good doing i t . To be sure that this changed behaviour transferred automatically to real l i f e , future-pacing or bridging was used. In t h i s technique, the unconscious mind was asked i f i t would take responsibility for having this new behavior actually take place and get the subject successfully to school. The subject was asked to see, hear, and feel specifically what would occur on the way to school. Then he was asked to signal "yes" when he could make th i s behaviour occur and his unconscious mind would vouch for his being able to do this i n real l i f e . Covert positive reinforcement (Cautela, 1979) was established through imagery conditioning, and the desired adaptive responses to the school situation were reinforced by 34 associating them with an imagined pleasurable stimulus. In t h i s phase, upon induction of hypnosis, the subject was t o imagine a time and a place where he f e l t i n control, confident and capable. He chose running. Then he was t o l d t o imagine a l l the pleasurable bodily and thought sensations he could associate with running and to combine them in t o an o v e r a l l f e e l i n g . When the subject s a i d he could do t h i s , he was t o transfer himself i n imagery t o the school and, as he progressed t o h i s classroom, at various stages he rewarded himself with h i s confident capable feelings. When he could do t h i s i n d i f f e r e n t settings such as i n the school yard, going through the door, going t o h i s classroom, s i t t i n g i n h i s desk, etc., then he rewarded himself i n imagined meetings with friends as w e l l as i n successfully completing math and reading comprehension a c t i v i t i e s . An audio-tape was made of the hypnotic content of the session and the subject was instructed t o l i s t e n t o i t at bedtime. 35 CHAPTER 4 RESuTJS F i r s t Hypothesis As treatment came t o i t s conclusion, the subject attended school regularly and continued t h i s behaviour f o r the l a s t two months of h i s grade 5 school year. Subsequently, as the new term commenced, he was able t o go t o school on a continuing basis with no reoccurrence of the school r e f u s a l behaviour. Parent reports and school attendance records v e r i f i e d t h i s change. The f i r s t hypothesis was rejected as stated i n the N u l l form. Second Hypothesis Pre-txeatment assessment on the Piers-Harris S e l f Concept Scale resulted i n a score at the 17th percentile. At treatment conclusion, the score was at the 99th percentile where i t remained as shown by the 10 month follow-up assessment scores. Results generated from the S i g n i f i c a n t Change Formula (Christensen & Mendoza, 1986) (Appendix D) showed a s i g n i f i c a n t difference between the pre and posttest scores at the 0.05 l e v e l on a one-tailed t e s t . This indicated that the subject had moved from the dysfunctional t o the functional range of behaviour. Table 1 i s a summary of the subject's r e s u l t s . Convergent evidence f o r a p o s i t i v e increase i n self-concept was obtained when the subject's score changed 5 STEN points on Factor 0 on the CPQ (Table 2) because both Piers-Harris and CPQ Factor O scores have been shown t o be highly correlated (Karnes & Wherry, 1982). 36 These r e s u l t s l e d t o a re j e c t i o n of the hypothesis as stated i n the N u l l form. Self-concept had changed as measured by t h i s scale. Table 1 Summary of Scores from Piers-Harris Self-concept Scale Administration Total Scores Period Raw Score Percentile Stanine T-score Pre-treatment 38 17 3 39 r^t-treatment 79 99 9 79 Follow-up 76 99 9 75 Third Hypothesis Anxiety on the CPQ i s i d e n t i f i e d as a second order factor. The contributing factors are C, H, 0, and Q4. There was a change of two or more STEN scores on Factors C,H, and 0 (Table 2). 37 Table 2 Summary of CPQ Scores Dimension STANDARD TEN SCORES (STEN) Dimension STEN Scores Pre Post Follow-up A. Reserved 1 3 3 Outgoing B. Concrete thinking 4 5 4 Abstract thinking C. Ego-^weakness 1 4 4 Ego strength D. Phlegmatic 1 2 4 Excitable E.Obedient 1 2 1 Assertive F. Sober 1 5 5 Happy-go-lucky G.Expedient 4 2 3 Conscientious H.Shy 1 4 4 Venturesome I.Tough minded 6 1 1 Tender minded J . Vigorous 4 1 4 Doubting N.Forthright 4 3 3 Schrewd 0.Placid 6 1 1 Apprehensive Q3.Casual 1 3 1 Controlled Q4.Relaxed 5 3 4 Tense Note. The mean of a STEN score i s 5.5 and the standard deviation i s 2. Pre-treatment and follow-up data i s from CPQ, Form A, Part 1. Post-treatment data i s from CPQ, Form B, Part 1. 38 Overall, the l e v e l of anxiety proneness remained much the same throughout the assessment and follow-up period (Table 3). Table 3 Summary of Second Order Factors (CPQ) Extraversion Anxiety Tough Poise Independence Pre 3 6 6 2 Post 4 5 7 2 Follow-up 7 6 5 4 The anxiety score on the Piers-Harris was at the f i r s t p ercentile f o r the pretest. By the posttest session, the anxiety l e v e l was at the 99th percentile. The subject responded with more "no" responses t o the items which loaded on the anxiety factor during the l a t e r data c o l l e c t i o n periods. Results showed that the subject's acceptance of anxiety on the Semantic D i f f e r e n t i a l measure changed from a baseline with a mean score of 1 t o a mean score of 4.9 as treatment proceeded. Individual scores ranged between 4 and 6. At follow-up, the score was 7 (Figure 1). Other continuous measures of anxiety based on the Semantic D i f f e r e n t i a l revealed s i m i l a r r e s u l t s . Problem severity (Figure 2) and Coping effectiveness (Figure 3) showed immediate reduction with the onset of treatment. 39 B A S E L I N E T R E A T M E N T — • — ^ • • — — • I I I I 1 2 3 4 5 6 / T R E A T M E N T ( W E E K S ) R E- T E S T Wo Figure 1. Anxiety Acceptance as measured by the Semantic D i f f e r e n t i a l Technique. 4 0 8 (f) L U rr: O O oo B A S E L I N E T R E A T M E N T • • — — 1 1 i i i i R E - T E S T y/i. 1 2 3 4 5 6 ' ' 4 0 T R E A T M E N T ( W E E K S ) Figure 2. Problem Severity as measured by the Semantic D i f f e r e n t i a l Technique. 41 B A S E L I N E L L T R E A T M E N T J I I L R E- T E S T y/i. 1 2 3 4 5 6 ' f 4 0 T R E A T M E N T ( W E E K S ) Figure 3. Coping Effectiveness as measured by the Semantic Differential Technique. 42 In the former assessment, the baseline was a mean score of 1 and the treatment was a mean score of 5.1. The l a t t e r was a baseline mean of 1.2 and a treatment mean of 4.9. In each case the follow-up score was 7. The data from subject i d e n t i f i e d stressors c a l l e d Personal Stress Level are graphed i n Figures 4, 5, and 6. The subject rated h i s anxiety about school, s o c i a l concerns and anxiety i n general (everything). In each case, change cccurred immediately and v i s u a l analysis showed the lessening of reported concern. Each follow-up score was less or equal t o the score at the posttreatment session. There were the changes on anxiety measures which l e d t o a re j e c t i o n of the hypothesis. Fourth Hypothesis Somatic complaints lessened according t o parent report and the subject's r a t i n g on the sections of The Personal Stress Level that pertain t o the somatic complaints of sleep disturbance, headaches and stomach aches (Figure 7). The hypothesis that there would be no change i n somatic complaints was rejected. 43 8 B A S E L I N E 4 1 T R E A T M E N T R E - T E S T 1 1 1 2 3 4 5 T R E A T M E N T ( W E E K S ) Figure 4. Anxiety About School from the Personal Stress Level Self-Report Measure. 44 B A S E L I N E 1 T R E A T M E N T R E - T E S T 1 i 1 2 3 4 5 T R E A T M E N T ( W E E K S ) Figure 5. Soc i a l Concern from the Personal Stress Level Self-Report Measure. V 45 8 B A S E L I N E 6 h 4\- 2 h T R E A T M E N T 1 1 1 2 3 4 5 T R E A T M E N T ( W E E K S ) R E- T E S T Figure 6. Anxiety About Everything from the Personal Stress Level Self-Report Measure. 46 8 B A S E L I N E 1 T R E A T M E N T R E- T E S T 1 1 1 2 3 4 5 T R E A T M E N T ( W E E K S ) W o Figure 7. Somatic Complaints from the Personal Stress Level Self-Report Measure. 47 CHAPTER 5 DISCUSSION INTRODUCTION The general purpose of t h i s case study was t o provide evidence f o r the e f f i c a c y of hypnosis as a therapeutic intervention f o r school r e f u s a l . Hypotheses, wr i t t e n i n the N u l l form, made statements of no change i n school r e f u s a l behaviour, self-concept, anxiety, and somatic complaints. Specified continuous s e l f report as w e l l as pre, post, and follow-up assessment scores provided the c r i t e r i a f o r change. Both s t a t i s t i c a l and v i s u a l analyses were used t o assess impact and each hypothesis was rejected. THE MAIN HYPOTHESIS Hypnosis appears to be an e f f e c t i v e treatment f o r t h i s subject's school refusing behaviour. Success of treatment can be evaluated, i n part, by how w e l l the c h i l d learns to behave i n ways appropriate t o his/her chronological age (Roberts & Nelson, 1984). The subject returned t o school, remained i n school f o r the l a s t two months of the school year and returned t o school i n Grade 6 i n September. During the summer, he was confident enough to enter and win a tennis tournament at h i s l o c a l club. Observations and data of t h i s kind indicate the general impact l e v e l of the treatment (Kendall & Braswell, 1982) which answers the question, "Does treatment have a conspicuous impact?" (p. 21). In t h i s case, the answer has t o be "yes" because without the intervention, i t i s u n l i k e l y that the subject would have 48 returned t o school (Hersov & Berg, 1980). Specifying l e v e l s of assessment are also important because t h i s i s how we can determine exactly what d i d and d i d not change. In t h i s study, indices of the subject's reported stressors and h i s subjective evaluations of school-related anxieties charted the progressive change as treatment was pursued. Parent report substantiated the disappearance of the school r e f u s a l behaviour. SELF-CDNCEPT Si g n i f i c a n t changes i n self-concept as measured by The Piers-Harris S e l f Concept Scale were reported. The changes were unimpaired by time because follow-up r e s u l t s remained at the same l e v e l as the post-treatment scores. Scores between the 31st and 70th percentile are considered average however higher scores have been interpreted t o r e f l e c t a p o s i t i v e self-evaluation or a healthy desire t o look good i n front of others (Piers, 1984). The changes f o r the subject were pervasive across the s i x areas of evaluation, one of which i s i n t e l l e c t u a l and school status. School no longer was a threat t o a p o s i t i v e self-concept. Self-esteem and self-concept are also asserted t o be personality c h a r a c t e r i s t i c s which determine how children handle perceived threats i n the school s i t u a t i o n because i t has been reported that persons with high self-esteem think they can cope with s t r e s s f u l and anxiety provoking events (Hobfall & Walfisch, 1984) and they are l e s s l i k e l y t o react with avoidance and anxiety t o threatening situations. The subject reported 49 increased a b i l i t y t o cope with school as treatment progressed. As w e l l as s i g n i f i c a n t changes on the Piers-Harris scores, there was a corresponding change on Factor 0 on the CPQ. There i s evidence that these measure the same construct (Karnes & Wherry, 1982) and t h i s lends c r e d i b i l i t y t o the assertion that there has been a change i n s e l f concept. Indications are that s e l f concept i s related t o whether situations are perceived t o be s t r e s s f u l or not (Hobfoll & Walfisch, 1984) and when the subject was p o s i t i v e about himself i n school, he was not so l i k e l y t o engage i n avoidance behaviour. ANXIETY The r e s u l t s indicate that there was a strong change i n scores on the anxiety component i n The Piers-Harris Children's S e l f Concept Scale. However, the STEN scores of the second-order factor c a l l e d "anxiety" on the CPQ were r e l a t i v e l y stable. Possibly, t h i s can be explained by examining the equation which was used t o compute t h i s second-order anxiety factor because the subject had areas of great change and areas of s t a b i l i t y or l i t t l e change, and interactions among these may have cancelled or masked ef f e c t s , or the measures may tap into d i f f e r e n t factors both l a b e l l e d "anxiety". I t also could mean that anxiety, the t r a i t , was stable f o r t h i s subject and that i t would be more meaningful t o examine the subject's ratings of h i s perceived coping a b i l i t y and stress l e v e l s at school. Much empirical research on s e l f concept i s based on the assumption that a p o s i t i v e appraisal of one's competence i s related t o how 50 the person deals with anxiety producing situations (Nicholls, Jagacinski & M i l l e r , 1980). The subject's self-reports on anxiety showed s i g n i f i c a n t changes as d i d h i s reports of h i s acceptance of anxiety and h i s a b i l i t y t o cope. Since anxiety i s "a general and l a s t i n g emotional state that r e f l e c t s one's feelings of weakness, ineptitude, and helplessness, anxiety i s tantamount t o the l o s s of s e l f esteem" (Wolman, 1984, p. 143). The hypnotic intervention stressed the feelings of w e l l being the subject could experience i n the school s i t u a t i o n as w e l l as providing t r a i n i n g i n relaxation techniques, and both of these behaviours are incompatible with stress or anxiety reactions. SOMATIC VARIABLES Somatic complaints such as headaches and stomach aches were reduced d r a s t i c a l l y while disrupted sleep patterns and early morning awakening were v i r t u a l l y eliminated. Reports from the l i t e r a t u r e indicate that psyche and soma are i n t e r r e l a t e d . Physical i l l n e s s may cause psych i a t r i c symptoms and v i c e versa (Guidano & L i o t t i , 1983). School r e f u s a l i s almost always accompanied by somatic complaints which often cover up the syndrome (Waller & Eisenberg, 1980). In t h i s study, a se l f - r e p o r t measure on s t r e s s f u l thoughts about sleep, headaches and stomach aches was c o l l e c t e d during the baseline, treatment, and follow-up phases. Progressive ratings showed a p o s i t i v e change i n a l l these areas and parent reports confirmed the actual changes d i d occur. 51 CPNCJTJJSION Although personality, anxiety, and self-concept were treated as separate topics i n t h i s paper, they were not viewed as discrete e n t i t i e s but as interactions. Conclusions reached about each as regards hypothesis statements must be understood i n t h i s l i g h t . Results of t h i s research indicated that the outcome of hypnosis f o r the treatment of school r e f u s a l was a functional change f o r adaptive behaviour. This was supported by p o s i t i v e changes i n self-concept, a lessening of psychosomatic complaints, a return t o regular school attendance, and greater a b i l i t y t o cope with anxiety. Both criterion-referenced and normative standards provided confirmation. One other plausible explanation f o r the change besides treatment e f f e c t i s that the interaction between the therapist and the subject made the difference. This variable i n therapeutic relationships i s d i f f i c u l t t o delineate i n therapeutic studies ( S t i l e s , Shapiro, & E l l i o t t , 1986). Hypnosis i s no exception and one view i s that "hypnosis i s a xdual phenomenon' occurring within the context of an intense interpersonal relationship" (Diamond, 1984, p. 3). In other words, the subject and the hypnotist can be viewed as a u n i t (Diamond, 1987). Nonspecific factors, such as perceived therapy c r e d i b i l i t y and therapist attention and support, are seen as ef f e c t i v e but not s u f f i c i e n t as an explanation f o r the change which occurred (Spirihoven, 1988, p. 190). More process research i s needed t o explicate the mechanisms of therapist involvement 52 as a c a u s i t i v e agent f o r change. What may be an important concept i n the exploration of c r i t i c a l factors i n the school refusing personality p r o f i l e i s the relationship to and the e f f e c t of anxiety on self-concept. In t h i s case study, as the subject rated h i s a b i l i t y t o cope higher, problem severity decreased and anxiety acceptance increased. Treatment content, under hypnosis, dealt d i r e c t l y with being confident and coping i n the school s i t u a t i o n . Implications from t h i s research would suggest that i t may be worthwhile t o investigate the e f f e c t of t h i s type of hypnotic intervention on self-concept i n other types of anxiety disorders i n children. 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Appendix A 62 PERSONAL STRESS LEVEL Least Most St r e s s f u l S t r e s s f u l 1.Sleep 1 2 3 4 5 2. Going t o sleep 1 2 3 4 5 3. Upset stomach 1 2 3 4 5 4. Gas pains 1 2 3 4 5 5. Going t o school 1 2 3 4 5 6. Being i n classroom 1 2 3 4 5 7. Doing math i n c l a s s 1 2 3 4 5 8. Doing reading comprehension i n class 1 2 3 4 5 9. Taking a t e s t 1 2 3 4 5 10. Feeling accepted i n class 1 2 3 4 5 11. Feeling inadequate and unsure i n c l a s s 1 2 3 4 5 12. Playing with close friends 1 2 3 4 5 13. Playing with other students 1 2 3 4 5 14. Doing homework 1 2 3 4 5 15. Worry about everything 1 2 3 4 5 (Nothing specific) 63 Appendix B 1. Anxiety Acceptance Scale ("My anxious nature...") a) Acceptable b) Useful c) Desireable Unacceptable Useless Undesireable 2. Problem Severity Scale ("My anxiety problem i s . . . " ) a) Manageable Unmanageable b) Easy t o solve Hard t o solve c) Bearable Unbearable Coping Effectiveness Scale ("I f e e l . . . i n dealing with the problem.") a) Competent b) Hopeful , c) Patient : d) Self-accepting e) Objective f) Clear minded g) S e l f confident h) Relaxed Incompetent Hopeless Impatient S e l f - c r i t i c a l Emotional Confused Unsure Tense (Ishiyama, 1986) 64 Appendix C Trance Induction (This induction can take from 10 t o 15 minutes.) "Make yourself as comfortable as you can...allow your muscles t o relax...close your your eyes i f you want t o . . . f e e l the sensations, warm and relaxing.. .allow them t o d r i f t down and down...allow the music and my voice and any surrounding sounds t o become part of your comfort and relaxation.. .take a deep breath and gradually release a l l the tension and stress from your body system.. .take i n the oxygen so that every body c e l l w i l l be r e v i t a l i z e d , energized.. .each time you exhale, l e t a l l the tension and stress leave your body.. .and l e t the music make you f e e l more and more relaxed.. . d r i f t i n g . . . d r i f t i n g . . .you may f e e l c e r t a i n sensations.. .allow them t o become more comfortable, more relaxed...as a l l parts of your body can become more r e s t f u l , more limp.. .with each breath you may notice your body i s beginning t o f e e l more and more relaxed, more and more calm. ..allow yourself t o f e e l the sensations of relaxation i n your muscles, i n your chest, i n your arms, i n any part of your body.. .consciously you don't need t o pay attention t o a l l the things I'm saying t o you because consciously you may be thinking of other things or fantasizing about something else ... your unconscious mind w i l l understand and remember the things I'm going t o t a l k about and your unconscious mind w i l l u t i l i z e the things I'm going t o be t a l k i n g about, f o r your own benefit ... I ' l l count from f i v e backwards t o one and you can d r i f t deeper 65 and deeper, more and more relaxed ..5.. inhaling ... exhaling ..4.. d r i f t i n g down ..3...2.. allow yourself t o d r i f t a l i t t l e deeper ... breathing very regularly ... heart rate i s normal ... a l l the i n t e r n a l functions are normalized ..1.. and relax. Pleasant Scene (The subject was asked t o think of a pleasant scene or a c t i v i t y before the trance induction. The therapist should use the words and adjectives supplied by the subject t o describe the scene or a c t i v i t y t o help him v i s u a l i z e and experience i t more f u l l y . ) "Imagine you're at a beautiful place ... fresh a i r ... nice breeze ... birds i n the distance enjoy the sensations of comfort ... breathe i n the fresh a i r and l e t i t r e v i t a l i z e and energize your whole body system ... l e t your body absorb a l l the energy ... enjoy your quiet, peaceful surroundings ... f e e l the warm sun on your face and your shoulders ... l e t those feelings wi t h i n you of peace and confidence and calmness f i l l your body ... allow them t o reenergize those p o s i t i v e feelings w i t h i n you ... you may not hear a l l the things I'm saying ... you may be l i s t e n i n g t o the waves r o l l i n g onto the beach ... or you may be thinking of something else ... your unconscious mind w i l l remember ... now spend a few minutes enjoying your b e a u t i f u l surroundings ... I w i l l be quiet f o r a few moments so you can enjoy your safe, peaceful, relaxing place ... (Therapist remains s i l e n t f o r 2-4 minutes). 66 Cognitive Restruc±urim "Now i t s time t o leave t h i s pleasant scene but remember as you go that t h i s i s your place and you can return here any time you wish ... so l e t s return t o the o f f i c e ... s t i l l enjoying the sense of relaxation and peacefulness ... comfortable, confident feelings ... look around the o f f i c e u n t i l you see the TV screen ... t e l l me what you see on TV ... I want you t o v i s u a l i z e on that screen a s i t u a t i o n which caused you discomfort or anxiety ... picture yourself i n that s i t u a t i o n ... and how are you fe e l i n g ... how does your body f e e l at that moment ... what are you doing i n that s i t u a t i o n ... t e l l me as soon as you have completed watching and l i s t e n i n g , with comfort and security, t o t h i s behaviour that you want t o change ... (wait u n t i l you get a "yes" response) ... do you know what new behaviour you would prefer t o make i n t h i s s i t u a t i o n ? good, now watch and l i s t e n t o yourself as you make the new response i n the s i t u a t i o n that used t o be a problem f o r you ... give me a "yes" response when you're done ... t h i s time I want you t o watch yourself on the computer ... put yourself on the screen and f e e l what i t i s l i k e t o carry out those new behaviours i n school ... does i t s t i l l f e e l good ? ... give a "yes" response when i t f e e l s completely comfortable and l i k e you ... w i l l you, h i s unconscious mind, take r e s p o n s i b i l i t y f o r having t h i s new behaviour a c t u a l l y occur i n the context where the o l d behaviour used t o occur ? ... now give me a "yes" response as scon as you, h i s unconscious mind, have discovered what s p e c i f i c a l l y y o u ' l l see, hear, or f e e l , that w i l l indicate that t h i s i s a context 67 where you are going t o make t h i s new behaviour occur ... a l r i g h t , now I want you t o return t o your pleasant scene, and a l l the feelings of comfort and relaxation and calmness you f e e l there ... f e e l the sun and the l i g h t breeze ... allow the fresh a i r t o refresh and r e v i t a l i z e you.. .allow yourself a few moments t o f e e l a l l the p o s i t i v e sensations there ... 11 Much of the t e x t i n t h i s section i s taken from Grinder & Bandler, 1981,pp. 178-182. (The therapist works through one or more sit u a t i o n s with the c l i e n t . As therapy progresses, the subject may volunteer more information, requiring fewer questions from the therapist. I t i s important t o obtain "yes" and "no" answers because the feedback must be unambiguous). Termination of Formalized Trance "Now I'm going t o count from one t o f i v e and as I do so you w i l l begin t o slowly wake up and as I'm counting you don't have t o l i s t e n t o me consciously because your unconscious w i l l remember to forget what i t wants t o forget and remember as much as your conscious mind wants you t o ..1.. y o u ' l l f e e l comfortable and relaxed ..2.. as I count you can begin t o open your eyes ..3.. s t i l l f e l l i n g relaxed and p o s i t i v e ..4...5.. when you're ready, you can open your eyes ... f e e l i n g refreshed and relaxed." (Following trance, the subject may wish t o review the events which took place and discuss the s i t u a t i o n or s i t u a t i o n s ) . 68 Appertdix D S i g n i f i c a n t change can be assessed i n a sin g l e subject by assessing the difference between pretest and posttest (obtained) score. The formula developed t o do t h i s i s as follows: SC = X2 - XI S d i f f where SC = s i g n i f i c a n t change XI = pretest score X2 = posttest score S d i f f = standard error of difference between two t e s t scores. (Christensen & Mendoza, 1986, p. 306)

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