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Hypnotic susceptibility and the Lamaze childbirth experience
and the Lamaze childbirth
Hypnotic susceptibility experience MICHAEL
R.
LAWRENCE San Antonio,
SAMKO,
M.S.*
S. SCHOENFELD,
Px.D
Texas
This study explored the relationship between childbirth training and hypnotic susceptibility. A multiple linear regression analysis was performed on the various medical and attitudinal variables related to the subjects’ Lamaze childbirth experience and these were tested against hypnotic susceptibility. The results of the analysis indicate that hypnotic susceptibility is not significantly related to Lamaze training, nor is it significantly related to the type of childbirth experience that a Lamare-trained woman has.
T H E c o N C E P T of psychological analgesia and its application toward childbirth continues to be a controversial issue. Although many writerslm4 have pointed out the important role played by hypnotic factors in producing psychological analgesia, many proponents of childbirth training argue against hypnosis. Many parallel relationships that appear to exist between hypnosis and the psychoprophylactic technique and so it appears that the two techniques are closely related. An overview of the literature implies that suggestibility, relaxation, focal attention, and concentration are just some of the factors that seem essential in hypnosis and that someone who is adept in these qualities should be more hypnotically susceptible than someone who is not very suggestible and who is easily distracted. Since these same factors appear to be important in the Lamaze method and From Trinity University Psychiatry, University
since aspects of the Lamaze method, such as relaxation, have been noted to produce a mild hypnotic state, it is theorized that hypnotic susceptibility should serve as a valid and predictive tool in assessing the relative degree of ease or difficulty that a woman might have using the Lamaze technique. It is therefore hypothesized that women who are more hypnoticahy susceptible are relatively more successful using the Lamaze method of childbirth than women who are less hypnotically susceptible and, therefore: ( 1) are more awake, alert, and aware during their labor and delivery as a result of requiring less medication; (2) have a generally more positive attitude toward their child delivery experience; (3) are considered successful in their use of the Lamaze technique by their physicians.
Method Subjects. A list of approximately
200 names of women who had received Lamaze training within the last 2 years and had delivered only one child was obtained from a childbirth training association. Of these 200 women there were 111 women who had delivered within the last year and a half. These 111 women were contacted individually by telephone and were asked to participate. Of these 111 women there were 26 who could not be reached, 13 who refused, nine who could not be used due to having had cesarean section, and eight who volunteered but did not show up at the testing site and could not be rescheduled. A total of 55
and the Department of of Texas Health Science
Center. Received Revised Accepted
for publication July
April
10, 1974.
29, 1974.
August
7,1974.
Reprint requests: Dr. Lawrence S. Schoenfeld, Department of Psychiatry, University of Texas Health Science Center of San Antonio. 7703 Floyd Curl Drive, San A’ntonio, Texas’78284. *This paper is based on a clinical research project presented to the faculty of the graduate school of Trinity University, San Antonio, Texas.
631
632
Samko
and
Table I. Variable
identification
Variable No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
March 1, 1975 Am. J. Obstet. Gynecol.
Schoenfeld
Variable
name
Hypnotic susceptibility Husband’s age Subject’s age Husband’s education Subject’s education Prior pregnancy Number of medical interventions Physical condition Conscious during labor and delivery Estimated length of labor Weight of baby Number of Lamaze classes attended by subject Number of Lamaze classes attended by husband Husband present during delivery Subject practiced Lamaze exercises regularly Lamaze techniques practiced with husband Subject’s self-rating of awake, alert, and aware Subject’s individual attitudes (Appendix C) : Successful Confident Relaxed-labor Relaxeddelivery Pleasant or satisfying Control Expectation Cooperative Usefulness of husband Value of Lamaze Contributed to stronger relationship with husband Better able to cope with everyday problems Awake, alert, and aware How unpleasant How painful Total attitude score Physician’s rating of subject’s level of awake, alert, and aware Physician’s rating of subject’s success Physician’s rating of how helpful the mother’s use of the Lamaze technique was to her delivery
subjects participated in the experiment. The sample is, therefore, relatively small and selected on the basis of willingness to participate.
Instruments used. Hypnotic Zn.duction Profile (eye-roll levitation method). The Hypnotic Induction Profile was developed by Spiegel and Bridger.5 The Hypnotic Induction Profile is a test of the person’s ability to concentrate in an attentive, receptive manner to signals from the operator (hypnotizability) and is designed to measure such hypnotic indicators as eye-roll and arm levitation. Testing time for administration of the Hypnotic Induction Profile averaged between 5 and 10 minutes per person.
The Hypnotic Induction Profile consists of four main procedures, referred to as “anchor” scores, and six subprocedures which evaluate various sensations commonly attributed to hypnosis. In this study, the four anchor scores were added to the six subprocedure scores to obtain a final score reflecting the degree of hypnotic susceptibility. Demographic and medical information questionnaire. This questionnaire was developed in order to obtain demographic data on the subjects and to obtain medical information essential in evaluating the subject’s childbirth experiences. In addition to the demographic and medical information, the questionnaire was also designed to gather information pertaining to the degree to which husband and wife participated in Lamaze preparation and the degree to which the subject was awake, alert, and aware during the active labor. Attitude questionnaire. This questionnaire assesses the subject’s attitudes toward her childbirth experience. It consists of 15 questions, each rated on a scale of 1 to 5 (a score of 5 indicating an extremely positive attitude). This questionnaire was designed not only to assess the subject’s individual attitudes but also to obtain a measure of her general attitude toward her childbirth experience. This measure is compiled by simply adding together the scores of the individual attitudes. Physician questionnaire. This brief questionnaire consisted of three questions. The physician was asked to rate the degree to which the subject was awake, alert, and aware relative to the amount of medication she received during her labor and delivery. He was also asked to indicate the degree to which he felt the subject successfully used the Lamaze technique and the extent to which he felt the subject’s use of the technique was helpful to the delivery. Procedure. Each subject was seen individually. The subject was presented a consent form and was informed that she would be asked to complete several questionnaires pertaining to her childbirth experience and that she would be asked to participate in a brief test of hypnotic susceptibility which would essentially be a concentration-relaxation exercise. After completing the questionnaire, the subject was seated in a comfortable chair, was provided with a footstool, and, after she had had a few moments in which to relax, the Hypnotic Induction Profile was administered. The entire testing procedure lasted approximately 30 to 45 minutes per subject. At the completion of the
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testing the nature of the study was explained to the subject in more detail and any questions were answered. A release of information form was obtained from each subject and it was sent with the physician questionnaire to the subject’s obstetrician. Results Although 55 subjects participated in the experiment, 13 questionnaires were not returned by the physicians, leaving a total of 42 subjects whose data were used in this study. The data in this study were analyzed by two different procedures: multiple linear regression analysis and discriminant analysis. Multiple linear regression analysis. The 36 variables that were analyzed in this study are presented in condensed form in Table I. An intercorrelational matrix was also generated. For purposes of the regression analysis, variable 1 (hypnotic susceptibility) was the criterion variable and the other 35 variables served as predictors and were analyzed in terms of the following four general categories: Category I-demographic (variables 2 to 16); Category II-awake, alert, and aware (variables 17 and 34) ; Category III-attitude: ( 1) Individual (variables 19 to 32) and (2) composite (variable 33) ; Category IV-physician’s rating (variables 35 and 36). The accuracy of these categories of variables as predictors of the criteria was tested individually and in various combinations according to the experimental hypothesis. Multiple discriminant analysis. For purposes of discriminant analysis the subjects were divided into two groups: those who were awake, alert, and aware during their labor and delivery vs. those who were not awake, alert, and aware. The degree to which the subjects were awake, alert, and aware was indicated by four levels: A-not awake, alert, or aware; B-alert and aware but anesthetized against common delivery pain; C-alert, awake, and aware but given small doses of medication and/or anesthesia for episiotomy; D-fuily alert, awake, and aware with no anesthesia, analgesia, tranquilizers, or sedatives. Because of the small numbers of subjects that were found in levels A and D, levels A and B were combined as Group I, indicating not awake, alert, or aware; levels C and D were combined as Group II, indicating those subjects who were awake, alert, and aware. A discriminant analysis was done not only on the two awake, alert, and aware groups as based on the subjects’ self-ratings but also com-
Hypnotic
susceptibility
and Lamaze
childbirth
633
Table II. Types of drugs administered to relieve discomfort
during
to subjects labor and delivery Subjects type
Type
of drug
General anesthetic Strong analgesic, e.g., twilight Mild analgesic, e.g., Demerol Tranquilizers and sedatives Regional block anesthetic Local anesthetic *Per received
cent does not total more than one type
sleep
100 because of medication.
receiving of drug
No.
%*
3 3 23 20 3 37
7 7 54 47 7 88
some
subjects
paring the two groups as rated by their physicians. The 42 subjects who were analyzed in this study had a mean age of 26 years and had completed approximately 2 years of formal schooling beyond high school. The mean age of their husbands was 27 and their educational level averaged between 4 and 5 years of formal schooling beyond high school. Over all, the sample used in this study was probably of above average intelligence and in the middle income bracket. The Lamaze mothers had a labor that was approximately 9 hours long and the average weight of their babies was 7 pounds 5 ounces. The types of medications that were administered to the subjects are shown in Table II. All 42 subjects had their husbands present with them during labor and no one reported having received any formal training in self-hypnosis nor was anyone unwillingly prevented from using the Lamaze technique. The multiple linear regression analysis was used to test the hypothesis. Although the subject’s self-rating and the physician’s rating of the degree to which the subject was awake, alert, and aware were significantly correlated with each other (r = 0.70, df =41, p < 0.05), the two ratings were viewed independently. A Pearson Product Moment Correlation showed that the subject’s self-rating of the degree to which she was awake, alert, and aware was not significantly related to the degree of hypnotic susceptibility (r = 0.24, p > 0.05) and that the physician’s evaluation of the degree to which the subject was awake, alert, and aware was also not significantly correlated with hypnotic susceptibility (r = 0.02, p > 0.05). An F test of the Category II variables (awake, alert, and aware-variables 17 and 34) tested against the zero model (discrimination based on chance) indicated that taken alone, Category II variables are
634
Samko
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March 1, 1975 Am. J. Obstet. Gynecol.
Schoenfeld
not significant predictors of the criterion (F (2, 39) = 2.80, p > 0.05). A statistical test of Category II as a significant contributor for the total set in hypnotic susceptibility also produced nonsignificant results (F (2, 7) = 3.37, p > 0.05). A Pearson Product Moment Correlation testing the predictability of the subject’s composite attitude score toward hypnotic susceptibility showed a nonsignificant correlation (r = 0.18, p > 0.05). An F test assessing the criteria using the composite attitude score as a predictor also provided nonsignificance (F (1, 40) = 1.31, p > 0.05). Finally, an appraisal of each of the 15 attitudes using the F test reflected their general weakness in predicting hypnotic susceptibility (F (2, 39) = 0.643, p >
0.05). The correlations between hypnotic susceptibility and the physician’s rating of how successful he felt the subject’s use of the Lamaze technique (r = 0.12) and the physician’s rating of how helpful he found the mother’s use of the Lamaze technique was to the delivery (r = 0.17) were both nonsignificant. Comparing these two variables (Category IV) against the zero model also provided nonsignificant results (F (2, 39) = 0.643, p > 0.05). Although both these variables taken alone and together are nonsignificant, their mean values (3.88, 3.76) appear fairly large considering the range of numbers. However, since the standard deviations of these variables are also large (S.D. of variable 35 = 1.199, S.D. of variable 36 = 1.305)) the scores would be skewed to the left indicating that for a few of these subjects their use of the Lamaze technique was neither successful nor helpful above a chance level. An F test was performed on the predictability power of the four categories (all variables) taken collectively versus the zero model. The result (F (37, 7) = 2.83, p > 0.05) indicated that even with a knowledge of all the 35 variables tested one could not significantly predict the degree of hypnotic susceptibility. Although over all the results indicate no significant relationship between hypnosis and Lamaze childbirth, some mention should be given to those variables that were most strongly related to hypnotic susceptibility. For example, variable 30 (attitude rating-awake, alert, and aware), variable 3 (subject’s age), variable 27 (attitude rating-value 15 (subject practiced of Lamaze) , and variable exercises regularly) taken together accounted for
49 per cent of the variability existing between all the variables tested against hypnotic susceptibility. Of these four variables, however, only variable 30 was significantly related to hypnotic susceptibility (r = 0.41) and it accounted for only 17 per cent of the variability. Finally, discriminant analysis was performed so that the data could be studied from a slightly different perspective. The two awake, alert, and aware groups, as based on the subject’s self-rating, were analyzed for all variables* along the discriminant axis; there were nine subjects in Group I (not awake, alert, or aware) and 33 subjects in Group II (awake, alert, and aware). A multivariate F test indicated that there was no significant difference between the two groups (F (34, 7) = 2.935, p > 0.05). A discriminant analysis was also done based on the physician’s rating of the degree to which the subject was awake, alert, and aware.? The result also showed no significant difference between the two groups of subjects (F (33, 8) = 2.73, p > 0.05). Comment The results of this study do not support the hypothesis that women who are more hypnotically susceptible (as measured under conditions not necessarily comparable to the actual experience at labor) are relatively more successful using the Lamaze method of childbirth than those women who are less hypnotically susceptible and, therefore, indicate that hypnotic susceptibility is not significantly related to the general child delivery experience of a Lamazetrained woman. Hypnotic susceptibility was not significantly related to the type of medication that the Lamaze mother received, i.e., the degree to which she was awake, alert, and aware, and it was not significantly related to the mother’s attitude toward her over-all Lamaze experience. Those women who were rated by their physicians as being relatively successful in using Lamaze were also not significantly more hypnotizable than those women who were not regarded as successful. The null results are consistent with Lamaze’s assumption that “the practice of hypnosis differs markedly from that of psychoprophylaxis.” Lamaze’ *Variable
30 was
dropped
due
to probable
contamina-
tion effect. tk’ariables contamination
35 and effect.
36 were
dropped
due
to probable
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contended that his training simply involved conditioning and the formation of a reflex arc. Since hypnosis itself is considered by some to simply be classical conditioning,7s * it might be argued that its effects may have been disguised. However, this contention would be difficult to maintain. Barber,” for example, noted that practice facilitates hypnotic susceptibility, particularly when subjects are exposed to a variety of different suggestions. Assuming for the moment that Barber was correct, then if Lamaze training does involve hypnosis, it should have resulted in an increased level of hypnotic susceptibility. If hypnosis and the Lamaze method are indeed separate entities, how then can one account for at least the superficial resemblance that exists between the Lamaze technique and the hypnotic technique? Perhaps Chertok” was correct in assuming that although the hypnotic suggestive method differs from the psychoprophylactic method, this difference is simply based on the fact that in hypnosis the verbal and direct pain-preventing effect is “massive” whereas in psychoprophylaxis the verbal and direct effect is not “massive” but is diluted in a network of relationships and exercises. Perhaps it is this difference that accounted for the null results obtained in this study. The discriminant analysis performed on the data of those women who were awake, alert, and aware vs. those who were not showed that these two groups of women cannot be significantly differentiated from each other on the basis of the variables used in this study. Since the degree to which the subjects were awake, alert, and aware was judged on the basis of the type of medication each received, the results seem to indicate that Lamaze-trained women generally have a similar frame of mind toward their labor and delivery experience regardless of the amount of medication they required. This finding is in line with the Lamaze philosophy: during Lamaze classes it is emphasized that use of Lamaze does not contraindicate use of medication or obstetric techniques when required. This basically positive position most likely had some influence on how the subjects responded to the questionnaire. Over all, although the subjects in this study did not find that the Lamaze training helped them feel somewhat more relaxed and better able to cope with tense situations and everyday problems, they did feel successful in using the Lamaze technique in
Hypnotic
susceptibility
and
Lamaze
childbirth
635
their labor and delivery and expressed that they felt confident, relaxed, and well in control during labor and delivery. The Lamaze mothers also found the delivery experience to be pleasant and satisfying and were noted by their physicians to have been successful in using the Lamaze technique. The subjects noted that they found the support of their husbands to have been particularly helpful during labor and delivery and they stressed belief in the value of the Lamaze method. Although the number of Lamaze classes attended and whether or not the subjects themselves practiced Lamaze exercises regularly did not seem to be particularly important variables in the Lamaze experience, whether or not the subjects practiced the Lamaze exercises with their husbands did appear to be a notable factor. Regarding the issue of pain, on the average, the subjects did not report painless deliveries. Ewy and Ewy”’ noted that, although Lamaze training tends to alleviate the pain factor, the aim of the training is not to make childbirth painless but to make it a controllable, positive experience. Although the Lamaze mother’s over-all childbirth experiences did not significantly differ from one another, based on the types of medication they received, 70 per cent of the subjects received only a mild drug such as a local anesthetic for episiotomy and were, therefore, awake, alert, and aware. Of the 42 Lamaze women included in this study, only seven per cent required general anesthesia and only seven per cent required a strong analgesic. It is, therefore, speculated that Lamaze training does have some substantial effect in terms of what type of medication the pre‘gnant woman might require during labor and delivery. Summary
A review of literature on childbirth training and psychological analgesia implicated the close relationship that appears to exist between childbirth training and hypnosis. It was concluded that hypnotic susceptibility should serve as an important tool in predicting the relative degree of success that a woman might have using the Lamaze technique of childbirth training. On this basis it was hypothesized that women who are more hypnotically susceptible are relatively more successful using the Lamaze method of childbirth than women who are less hypnotically susceptible. Relative degree of success was established by evaluating the degree to which subjects were awake, alert, and aware based
636
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March 1, 1975 Am. J. Obstet. Gynecol.
Schoenfeld
on type of medication, assessing attitudes, and considering the obstetricians’ ratings of their patients’ success in using Lamaze. This study was conducted post partum with 42 women who had completed Lamaze training and had delivered only one child as subjects. A measure of each subject’s hypnotic susceptibility was obtained with the Hypnotic Induction Profile developed by Spiegel. A multiple linear regression analysis was performed on the various medical and attitudinal variables related to the subject’s Lamaze childbirth experience and these were tested against hypnotic susceptibility.
The results of the analysis indicated that hypnotic susceptibility is not significantly related to Lamaze training nor is it significantly related to the type of childbirth experience that a Lamaze-trained woman has. A discriminant analysis was performed on the data to determine whether those subjects who received less medication and were, therefore, more awake, alert, and aware differed significantly from those subjects who were not very awake, alert, and aware. The results showed that, based on the 35 discriminating variables used in this study, the two groups of subjects were not significantly different.
REFERENCES
1. 2. 3. 4. 5. 6.
Chertok, L.: Am. J. Psychiatry 119: 1152, 1963. Spiegel, H.: Acta Psychother. 11: 412, 1963. Bartlett, E.: Am. J. Clin. Hypnosis 13: 273, 1971. Kroger, W. S.: Br. J. Med. Hypnotism 5: 1, 1953. Spiegel, H., and Bridger, A. A.: Manual for Hypnotic Induction Profile, New York, 1970, Soni Medica. Lamaze, F.: Painless Childbirth, New York, 1972, Pocket Books.
7. 8. 9. 10.
Pavlov, I. P.: Br. Med. J. 1: 256, 1923. Barber, T. X., Ascher, L. A., and Mavroides, M.: Am. J. Clin. Hypnosis 14: 48, 1971. Chertok, L.: Motherhood and Personality, London, 1969, Tavistok. Ewy, D., and Ewy, R.: Preparation for Childbirth; a Lamaze Guide, New York, 1972, Signet.
Hypnotic susceptibility experience MICHAEL
R.
LAWRENCE San Antonio,
SAMKO,
M.S.*
S. SCHOENFELD,
Px.D
Texas
This study explored the relationship between childbirth training and hypnotic susceptibility. A multiple linear regression analysis was performed on the various medical and attitudinal variables related to the subjects’ Lamaze childbirth experience and these were tested against hypnotic susceptibility. The results of the analysis indicate that hypnotic susceptibility is not significantly related to Lamaze training, nor is it significantly related to the type of childbirth experience that a Lamare-trained woman has.
T H E c o N C E P T of psychological analgesia and its application toward childbirth continues to be a controversial issue. Although many writerslm4 have pointed out the important role played by hypnotic factors in producing psychological analgesia, many proponents of childbirth training argue against hypnosis. Many parallel relationships that appear to exist between hypnosis and the psychoprophylactic technique and so it appears that the two techniques are closely related. An overview of the literature implies that suggestibility, relaxation, focal attention, and concentration are just some of the factors that seem essential in hypnosis and that someone who is adept in these qualities should be more hypnotically susceptible than someone who is not very suggestible and who is easily distracted. Since these same factors appear to be important in the Lamaze method and From Trinity University Psychiatry, University
since aspects of the Lamaze method, such as relaxation, have been noted to produce a mild hypnotic state, it is theorized that hypnotic susceptibility should serve as a valid and predictive tool in assessing the relative degree of ease or difficulty that a woman might have using the Lamaze technique. It is therefore hypothesized that women who are more hypnoticahy susceptible are relatively more successful using the Lamaze method of childbirth than women who are less hypnotically susceptible and, therefore: ( 1) are more awake, alert, and aware during their labor and delivery as a result of requiring less medication; (2) have a generally more positive attitude toward their child delivery experience; (3) are considered successful in their use of the Lamaze technique by their physicians.
Method Subjects. A list of approximately
200 names of women who had received Lamaze training within the last 2 years and had delivered only one child was obtained from a childbirth training association. Of these 200 women there were 111 women who had delivered within the last year and a half. These 111 women were contacted individually by telephone and were asked to participate. Of these 111 women there were 26 who could not be reached, 13 who refused, nine who could not be used due to having had cesarean section, and eight who volunteered but did not show up at the testing site and could not be rescheduled. A total of 55
and the Department of of Texas Health Science
Center. Received Revised Accepted
for publication July
April
10, 1974.
29, 1974.
August
7,1974.
Reprint requests: Dr. Lawrence S. Schoenfeld, Department of Psychiatry, University of Texas Health Science Center of San Antonio. 7703 Floyd Curl Drive, San A’ntonio, Texas’78284. *This paper is based on a clinical research project presented to the faculty of the graduate school of Trinity University, San Antonio, Texas.
631
632
Samko
and
Table I. Variable
identification
Variable No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
March 1, 1975 Am. J. Obstet. Gynecol.
Schoenfeld
Variable
name
Hypnotic susceptibility Husband’s age Subject’s age Husband’s education Subject’s education Prior pregnancy Number of medical interventions Physical condition Conscious during labor and delivery Estimated length of labor Weight of baby Number of Lamaze classes attended by subject Number of Lamaze classes attended by husband Husband present during delivery Subject practiced Lamaze exercises regularly Lamaze techniques practiced with husband Subject’s self-rating of awake, alert, and aware Subject’s individual attitudes (Appendix C) : Successful Confident Relaxed-labor Relaxeddelivery Pleasant or satisfying Control Expectation Cooperative Usefulness of husband Value of Lamaze Contributed to stronger relationship with husband Better able to cope with everyday problems Awake, alert, and aware How unpleasant How painful Total attitude score Physician’s rating of subject’s level of awake, alert, and aware Physician’s rating of subject’s success Physician’s rating of how helpful the mother’s use of the Lamaze technique was to her delivery
subjects participated in the experiment. The sample is, therefore, relatively small and selected on the basis of willingness to participate.
Instruments used. Hypnotic Zn.duction Profile (eye-roll levitation method). The Hypnotic Induction Profile was developed by Spiegel and Bridger.5 The Hypnotic Induction Profile is a test of the person’s ability to concentrate in an attentive, receptive manner to signals from the operator (hypnotizability) and is designed to measure such hypnotic indicators as eye-roll and arm levitation. Testing time for administration of the Hypnotic Induction Profile averaged between 5 and 10 minutes per person.
The Hypnotic Induction Profile consists of four main procedures, referred to as “anchor” scores, and six subprocedures which evaluate various sensations commonly attributed to hypnosis. In this study, the four anchor scores were added to the six subprocedure scores to obtain a final score reflecting the degree of hypnotic susceptibility. Demographic and medical information questionnaire. This questionnaire was developed in order to obtain demographic data on the subjects and to obtain medical information essential in evaluating the subject’s childbirth experiences. In addition to the demographic and medical information, the questionnaire was also designed to gather information pertaining to the degree to which husband and wife participated in Lamaze preparation and the degree to which the subject was awake, alert, and aware during the active labor. Attitude questionnaire. This questionnaire assesses the subject’s attitudes toward her childbirth experience. It consists of 15 questions, each rated on a scale of 1 to 5 (a score of 5 indicating an extremely positive attitude). This questionnaire was designed not only to assess the subject’s individual attitudes but also to obtain a measure of her general attitude toward her childbirth experience. This measure is compiled by simply adding together the scores of the individual attitudes. Physician questionnaire. This brief questionnaire consisted of three questions. The physician was asked to rate the degree to which the subject was awake, alert, and aware relative to the amount of medication she received during her labor and delivery. He was also asked to indicate the degree to which he felt the subject successfully used the Lamaze technique and the extent to which he felt the subject’s use of the technique was helpful to the delivery. Procedure. Each subject was seen individually. The subject was presented a consent form and was informed that she would be asked to complete several questionnaires pertaining to her childbirth experience and that she would be asked to participate in a brief test of hypnotic susceptibility which would essentially be a concentration-relaxation exercise. After completing the questionnaire, the subject was seated in a comfortable chair, was provided with a footstool, and, after she had had a few moments in which to relax, the Hypnotic Induction Profile was administered. The entire testing procedure lasted approximately 30 to 45 minutes per subject. At the completion of the
Volume Number
121 5
testing the nature of the study was explained to the subject in more detail and any questions were answered. A release of information form was obtained from each subject and it was sent with the physician questionnaire to the subject’s obstetrician. Results Although 55 subjects participated in the experiment, 13 questionnaires were not returned by the physicians, leaving a total of 42 subjects whose data were used in this study. The data in this study were analyzed by two different procedures: multiple linear regression analysis and discriminant analysis. Multiple linear regression analysis. The 36 variables that were analyzed in this study are presented in condensed form in Table I. An intercorrelational matrix was also generated. For purposes of the regression analysis, variable 1 (hypnotic susceptibility) was the criterion variable and the other 35 variables served as predictors and were analyzed in terms of the following four general categories: Category I-demographic (variables 2 to 16); Category II-awake, alert, and aware (variables 17 and 34) ; Category III-attitude: ( 1) Individual (variables 19 to 32) and (2) composite (variable 33) ; Category IV-physician’s rating (variables 35 and 36). The accuracy of these categories of variables as predictors of the criteria was tested individually and in various combinations according to the experimental hypothesis. Multiple discriminant analysis. For purposes of discriminant analysis the subjects were divided into two groups: those who were awake, alert, and aware during their labor and delivery vs. those who were not awake, alert, and aware. The degree to which the subjects were awake, alert, and aware was indicated by four levels: A-not awake, alert, or aware; B-alert and aware but anesthetized against common delivery pain; C-alert, awake, and aware but given small doses of medication and/or anesthesia for episiotomy; D-fuily alert, awake, and aware with no anesthesia, analgesia, tranquilizers, or sedatives. Because of the small numbers of subjects that were found in levels A and D, levels A and B were combined as Group I, indicating not awake, alert, or aware; levels C and D were combined as Group II, indicating those subjects who were awake, alert, and aware. A discriminant analysis was done not only on the two awake, alert, and aware groups as based on the subjects’ self-ratings but also com-
Hypnotic
susceptibility
and Lamaze
childbirth
633
Table II. Types of drugs administered to relieve discomfort
during
to subjects labor and delivery Subjects type
Type
of drug
General anesthetic Strong analgesic, e.g., twilight Mild analgesic, e.g., Demerol Tranquilizers and sedatives Regional block anesthetic Local anesthetic *Per received
cent does not total more than one type
sleep
100 because of medication.
receiving of drug
No.
%*
3 3 23 20 3 37
7 7 54 47 7 88
some
subjects
paring the two groups as rated by their physicians. The 42 subjects who were analyzed in this study had a mean age of 26 years and had completed approximately 2 years of formal schooling beyond high school. The mean age of their husbands was 27 and their educational level averaged between 4 and 5 years of formal schooling beyond high school. Over all, the sample used in this study was probably of above average intelligence and in the middle income bracket. The Lamaze mothers had a labor that was approximately 9 hours long and the average weight of their babies was 7 pounds 5 ounces. The types of medications that were administered to the subjects are shown in Table II. All 42 subjects had their husbands present with them during labor and no one reported having received any formal training in self-hypnosis nor was anyone unwillingly prevented from using the Lamaze technique. The multiple linear regression analysis was used to test the hypothesis. Although the subject’s self-rating and the physician’s rating of the degree to which the subject was awake, alert, and aware were significantly correlated with each other (r = 0.70, df =41, p < 0.05), the two ratings were viewed independently. A Pearson Product Moment Correlation showed that the subject’s self-rating of the degree to which she was awake, alert, and aware was not significantly related to the degree of hypnotic susceptibility (r = 0.24, p > 0.05) and that the physician’s evaluation of the degree to which the subject was awake, alert, and aware was also not significantly correlated with hypnotic susceptibility (r = 0.02, p > 0.05). An F test of the Category II variables (awake, alert, and aware-variables 17 and 34) tested against the zero model (discrimination based on chance) indicated that taken alone, Category II variables are
634
Samko
and
March 1, 1975 Am. J. Obstet. Gynecol.
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not significant predictors of the criterion (F (2, 39) = 2.80, p > 0.05). A statistical test of Category II as a significant contributor for the total set in hypnotic susceptibility also produced nonsignificant results (F (2, 7) = 3.37, p > 0.05). A Pearson Product Moment Correlation testing the predictability of the subject’s composite attitude score toward hypnotic susceptibility showed a nonsignificant correlation (r = 0.18, p > 0.05). An F test assessing the criteria using the composite attitude score as a predictor also provided nonsignificance (F (1, 40) = 1.31, p > 0.05). Finally, an appraisal of each of the 15 attitudes using the F test reflected their general weakness in predicting hypnotic susceptibility (F (2, 39) = 0.643, p >
0.05). The correlations between hypnotic susceptibility and the physician’s rating of how successful he felt the subject’s use of the Lamaze technique (r = 0.12) and the physician’s rating of how helpful he found the mother’s use of the Lamaze technique was to the delivery (r = 0.17) were both nonsignificant. Comparing these two variables (Category IV) against the zero model also provided nonsignificant results (F (2, 39) = 0.643, p > 0.05). Although both these variables taken alone and together are nonsignificant, their mean values (3.88, 3.76) appear fairly large considering the range of numbers. However, since the standard deviations of these variables are also large (S.D. of variable 35 = 1.199, S.D. of variable 36 = 1.305)) the scores would be skewed to the left indicating that for a few of these subjects their use of the Lamaze technique was neither successful nor helpful above a chance level. An F test was performed on the predictability power of the four categories (all variables) taken collectively versus the zero model. The result (F (37, 7) = 2.83, p > 0.05) indicated that even with a knowledge of all the 35 variables tested one could not significantly predict the degree of hypnotic susceptibility. Although over all the results indicate no significant relationship between hypnosis and Lamaze childbirth, some mention should be given to those variables that were most strongly related to hypnotic susceptibility. For example, variable 30 (attitude rating-awake, alert, and aware), variable 3 (subject’s age), variable 27 (attitude rating-value 15 (subject practiced of Lamaze) , and variable exercises regularly) taken together accounted for
49 per cent of the variability existing between all the variables tested against hypnotic susceptibility. Of these four variables, however, only variable 30 was significantly related to hypnotic susceptibility (r = 0.41) and it accounted for only 17 per cent of the variability. Finally, discriminant analysis was performed so that the data could be studied from a slightly different perspective. The two awake, alert, and aware groups, as based on the subject’s self-rating, were analyzed for all variables* along the discriminant axis; there were nine subjects in Group I (not awake, alert, or aware) and 33 subjects in Group II (awake, alert, and aware). A multivariate F test indicated that there was no significant difference between the two groups (F (34, 7) = 2.935, p > 0.05). A discriminant analysis was also done based on the physician’s rating of the degree to which the subject was awake, alert, and aware.? The result also showed no significant difference between the two groups of subjects (F (33, 8) = 2.73, p > 0.05). Comment The results of this study do not support the hypothesis that women who are more hypnotically susceptible (as measured under conditions not necessarily comparable to the actual experience at labor) are relatively more successful using the Lamaze method of childbirth than those women who are less hypnotically susceptible and, therefore, indicate that hypnotic susceptibility is not significantly related to the general child delivery experience of a Lamazetrained woman. Hypnotic susceptibility was not significantly related to the type of medication that the Lamaze mother received, i.e., the degree to which she was awake, alert, and aware, and it was not significantly related to the mother’s attitude toward her over-all Lamaze experience. Those women who were rated by their physicians as being relatively successful in using Lamaze were also not significantly more hypnotizable than those women who were not regarded as successful. The null results are consistent with Lamaze’s assumption that “the practice of hypnosis differs markedly from that of psychoprophylaxis.” Lamaze’ *Variable
30 was
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tion effect. tk’ariables contamination
35 and effect.
36 were
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to probable
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contended that his training simply involved conditioning and the formation of a reflex arc. Since hypnosis itself is considered by some to simply be classical conditioning,7s * it might be argued that its effects may have been disguised. However, this contention would be difficult to maintain. Barber,” for example, noted that practice facilitates hypnotic susceptibility, particularly when subjects are exposed to a variety of different suggestions. Assuming for the moment that Barber was correct, then if Lamaze training does involve hypnosis, it should have resulted in an increased level of hypnotic susceptibility. If hypnosis and the Lamaze method are indeed separate entities, how then can one account for at least the superficial resemblance that exists between the Lamaze technique and the hypnotic technique? Perhaps Chertok” was correct in assuming that although the hypnotic suggestive method differs from the psychoprophylactic method, this difference is simply based on the fact that in hypnosis the verbal and direct pain-preventing effect is “massive” whereas in psychoprophylaxis the verbal and direct effect is not “massive” but is diluted in a network of relationships and exercises. Perhaps it is this difference that accounted for the null results obtained in this study. The discriminant analysis performed on the data of those women who were awake, alert, and aware vs. those who were not showed that these two groups of women cannot be significantly differentiated from each other on the basis of the variables used in this study. Since the degree to which the subjects were awake, alert, and aware was judged on the basis of the type of medication each received, the results seem to indicate that Lamaze-trained women generally have a similar frame of mind toward their labor and delivery experience regardless of the amount of medication they required. This finding is in line with the Lamaze philosophy: during Lamaze classes it is emphasized that use of Lamaze does not contraindicate use of medication or obstetric techniques when required. This basically positive position most likely had some influence on how the subjects responded to the questionnaire. Over all, although the subjects in this study did not find that the Lamaze training helped them feel somewhat more relaxed and better able to cope with tense situations and everyday problems, they did feel successful in using the Lamaze technique in
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their labor and delivery and expressed that they felt confident, relaxed, and well in control during labor and delivery. The Lamaze mothers also found the delivery experience to be pleasant and satisfying and were noted by their physicians to have been successful in using the Lamaze technique. The subjects noted that they found the support of their husbands to have been particularly helpful during labor and delivery and they stressed belief in the value of the Lamaze method. Although the number of Lamaze classes attended and whether or not the subjects themselves practiced Lamaze exercises regularly did not seem to be particularly important variables in the Lamaze experience, whether or not the subjects practiced the Lamaze exercises with their husbands did appear to be a notable factor. Regarding the issue of pain, on the average, the subjects did not report painless deliveries. Ewy and Ewy”’ noted that, although Lamaze training tends to alleviate the pain factor, the aim of the training is not to make childbirth painless but to make it a controllable, positive experience. Although the Lamaze mother’s over-all childbirth experiences did not significantly differ from one another, based on the types of medication they received, 70 per cent of the subjects received only a mild drug such as a local anesthetic for episiotomy and were, therefore, awake, alert, and aware. Of the 42 Lamaze women included in this study, only seven per cent required general anesthesia and only seven per cent required a strong analgesic. It is, therefore, speculated that Lamaze training does have some substantial effect in terms of what type of medication the pre‘gnant woman might require during labor and delivery. Summary
A review of literature on childbirth training and psychological analgesia implicated the close relationship that appears to exist between childbirth training and hypnosis. It was concluded that hypnotic susceptibility should serve as an important tool in predicting the relative degree of success that a woman might have using the Lamaze technique of childbirth training. On this basis it was hypothesized that women who are more hypnotically susceptible are relatively more successful using the Lamaze method of childbirth than women who are less hypnotically susceptible. Relative degree of success was established by evaluating the degree to which subjects were awake, alert, and aware based
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on type of medication, assessing attitudes, and considering the obstetricians’ ratings of their patients’ success in using Lamaze. This study was conducted post partum with 42 women who had completed Lamaze training and had delivered only one child as subjects. A measure of each subject’s hypnotic susceptibility was obtained with the Hypnotic Induction Profile developed by Spiegel. A multiple linear regression analysis was performed on the various medical and attitudinal variables related to the subject’s Lamaze childbirth experience and these were tested against hypnotic susceptibility.
The results of the analysis indicated that hypnotic susceptibility is not significantly related to Lamaze training nor is it significantly related to the type of childbirth experience that a Lamaze-trained woman has. A discriminant analysis was performed on the data to determine whether those subjects who received less medication and were, therefore, more awake, alert, and aware differed significantly from those subjects who were not very awake, alert, and aware. The results showed that, based on the 35 discriminating variables used in this study, the two groups of subjects were not significantly different.
REFERENCES
1. 2. 3. 4. 5. 6.
Chertok, L.: Am. J. Psychiatry 119: 1152, 1963. Spiegel, H.: Acta Psychother. 11: 412, 1963. Bartlett, E.: Am. J. Clin. Hypnosis 13: 273, 1971. Kroger, W. S.: Br. J. Med. Hypnotism 5: 1, 1953. Spiegel, H., and Bridger, A. A.: Manual for Hypnotic Induction Profile, New York, 1970, Soni Medica. Lamaze, F.: Painless Childbirth, New York, 1972, Pocket Books.
7. 8. 9. 10.
Pavlov, I. P.: Br. Med. J. 1: 256, 1923. Barber, T. X., Ascher, L. A., and Mavroides, M.: Am. J. Clin. Hypnosis 14: 48, 1971. Chertok, L.: Motherhood and Personality, London, 1969, Tavistok. Ewy, D., and Ewy, R.: Preparation for Childbirth; a Lamaze Guide, New York, 1972, Signet.