Abstract
Objective:
This survey study aimed to investigate the willingness and accessibility of a hypnosis intervention for anxiety among low socioeconomic status patients in a primary care setting.
Methods:
Participants were asked to complete a one-page survey during a scheduled office visit with their primary care provider. Survey questions included participants' interest in hypnosis as a treatment for anxiety, how many sessions they would be willing/able to attend, how they would prefer access to a recorded hypnosis intervention, and items relating to anxiety, including the Generalized Anxiety Disorder-7 measure.
Results:
Two hundred participants (71.5% female) completed the survey with a mean age of 43.16 (standard deviation = 15.78). Over half (54.6%) of the survey participants reported that they experience anxiety, and 74% of the participants indicated that they would be interested in hypnosis if it were recommended by their provider for anxiety.
Discussion:
Given the high prevalence of anxiety among survey participants, there exists a clear need for effective and accessible treatment options. These results demonstrate the willingness of individuals to use hypnosis for anxiety and to engage in remote hypnosis interventions.
Introduction
Hypnosis is an effective treatment for mild to moderate anxiety compared with control conditions as indicated by a recent meta-analysis by Valentine and colleagues 1 reporting that hypnosis was more effective in reducing anxiety when utilized as a supplemental treatment to other psychological interventions. Hypnosis is defined as “a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion.” 2 A survey study of undergraduate college students and community participants by Robin and colleagues 3 found that participants were most likely to seek hypnosis for anxiety as a complementary treatment to standard medical practices. Participants also reported that the referral source they would find most influential would be their primary care physician. 3
A recent nationwide demographically balanced internet survey to assess views and experiences of clinical hypnosis in the United States found that most participants held a positive (38.6%) or neutral (48.4%) view of clinical hypnosis, with only 12.8% expressing a negative view. 4 Furthermore, hypnosis was perceived to be “moderately or very useful” by approximately 50% of participants. Overall, these results indicate that U.S. adults hold positive beliefs about hypnosis, believe it can be helpful, and are willing to participate in it, if needed. Unfortunately, African American and Hispanic minority participation in the survey was lower than the national population ratios of these groups; thus, these results may or may not generalize to racial and ethnic minority groups. 4
The self-administered nature of many hypnosis interventions, through the use of standardized audio recordings, makes it an attractive stand-alone or supplemental treatment. Evidence indicates that the use of hypnosis audio recordings, used outside of sessions, are as effective as in-person sessions for the treatment of anxiety symptoms and sleep disturbances. 1,5 This increased accessibility allows for individuals to tailor their treatment experience, accessing the treatment in any location and at any time that works best for the individual. While treatment duration using hypnosis for anxiety varies, studies have shown the combination of two to five 45- to 60-min sessions with daily home practice using audio recordings over a span of 2–5 weeks has significant positive effects. 6,7
Estimates indicate that the percentage of primary care patients experiencing anxiety, including Generalized Anxiety Disorder (GAD), can range from 2.4% to 31.2%. 8 –12 Symptom severity can range from mild to severe; however, patients in primary care are most likely to experience mild to moderate anxiety that may not meet diagnostic criteria for GAD. 13 Research has yet to examine the willingness and acceptability of hypnosis for anxiety among low socioeconomic status patients in a primary care setting.
Rationale
To provide services to reduce anxiety symptoms among primary care patients, it is important to first determine the willingness and accessibility of such a treatment for the specified treatment population. The primary aim of this study was to examine and assess the interest and ability to engage in a hypnosis intervention for anxiety among low socioeconomic status patients at a community health center, with the secondary aim of identifying an optimal intervention delivery method (number of sessions and recording delivery method) to which patients would likely adhere.
Institutional Review Board status
Upon submission to the university's Institutional Review Board (IRB), this study was granted exempted status.
Materials and Methods
Participants
Participants were English-speaking individuals, age 18 years or older, who were primary care patients of the Heart of Texas Community Health Center, Inc. (DBA McClennan County Family Health Center) and present at the health center for a scheduled health visit at the time of the survey. All participants were active patients of a variety of primary care providers at the Heart of Texas Community Health Center, Inc., which is a Federally Qualified Health Center (FQHC). Approximately 58,000 patients were served in the year of data collection with demographics representing a diverse population, with 45.8% identifying as Hispanic/Latino, 29.28% as non-Hispanic White, and 24.95% as Black/African American. 14
Data obtained from the Health Resources and Services Administration 14 indicate that approximately 96% of patients served in the year of data collection were at or below the 200% poverty level (i.e., a maximum income of double the Federal Poverty Level for 2017) with 30.71% of patients uninsured, 40.92% on Medicaid/Children's Health Insurance Program, and 12.69% on Medicare.
Measures
Participants completed a brief demographics questionnaire including questions regarding age, gender, and race.
Hypnosis perceptions/accessibility survey
Before the survey questions, a description of hypnosis was provided to the participants. Participants then completed eight questions assessing their interest in hypnosis as a treatment for anxiety, preferences for accessing a recorded hypnosis intervention, access to technology (e.g., smartphone and internet), how many sessions the patient would be willing/able to attend to meet with a research therapist, and for what conditions they would be willing to use hypnosis. The ninth question of the survey inquired about the self-report presence of anxiety for the participant, then participants were asked to complete the GAD-7, which was the final item of the survey.
Generalized Anxiety Disorder-7
The GAD-7 is a brief self-report measure for assessing GAD. Items are rated on a 4-point Likert scale, ranging from 0 indicating “not at all” to 3 indicating “nearly every day.” The participant answered the items referencing how often he/she experienced the symptoms during the previous 2 weeks. Scores range from 0 to 21, with higher scores indicating more severe symptoms. The measure has good reliability and good criterion, construct, factorial, and procedural validity, and thus is considered a valid screening tool for GAD in a primary care setting. 15
Procedure
A convenience sampling method, with permission from the health center, was used to recruit participants who were patients already present at the pharmacy waiting room at the health center after a scheduled appointment with their primary care provider. Potential participants were approached by a trained researcher to determine eligibility and to obtain participant consent. Eligibility criteria stated that individuals must be over 18 years of age, a primary care patient at the Heart of Texas Community Health Center, and English-speaking.
Once eligibility was determined, using a predetermined script, verbal consent was acquired to complete the demographics questionnaire and survey questions. The survey took approximately 15 min to complete and was anonymous with no identifiable information collected. The researcher was available to assist, if needed, during the time each participant completed the survey. Participants did not receive financial compensation for completion of study materials. Data were collected over approximately a 2-week timeframe in Spring 2017.
Statistical analysis
Data were analyzed using SPSS v 21.0. 16 Since this is an exploratory survey study, data were analyzed by inspection of frequencies. No formal statistical hypothesis testing was performed on the data. The sample size was determined based on the capacity of the research staff and the availability of access to the patients.
Results
The final sample population comprised 200 participants (71.5% female) with a mean age of 43.16 (standard deviation = 15.78). Table 1 provides the frequencies and percentages associated with race and ethnicity.
Demographics of Study Participants
Anxiety
Results demonstrate a high percentage of self-reported anxiety, with 54.6% (n = 107) of individuals responding affirmatively to item number nine on the survey, which asks for a “Yes” or “No” response to the question “Do you have anxiety?” GAD-7 results support this finding with 55.7% (n = 102) meeting criteria for the presence of mild to severe levels of anxiety. According to identified cutoffs, 15 25.7% (n = 47) exhibit mild symptom severity, 15.8% (n = 29) moderate symptom severity, and 14.2% (n = 26) severe symptom severity.
Willingness
Results for survey item number one indicate 74% (n = 148) of individuals would be interested in hypnosis for anxiety if it were recommended by their physician. Of those interested, 74.6% stated that they would be willing to attend three in-person sessions, 11.3% were willing to attend five in-person sessions, and 14.1% were willing to attend eight in-person sessions. In addition, results for survey item number six indicate that 65.2% (n = 129) of individuals would be willing to download and utilize a hypnosis relaxation recording onto their mobile phone.
Accessibility
Accessibility was investigated specifically pertaining to the possession of applicable technology and ability to use downloadable hypnosis relaxation recordings. Eighty-one percent of individuals (n = 160) owned a smartphone, and 83.8% (n = 166) had access to the internet on their mobile phone. Regarding the method of downloading a hypnosis recording, 62% (n = 96) preferred to download the recording themselves, while the remaining individuals preferred for a staff member to perform the download on their behalf.
Limitations
Limitations include the utilization of a self-report survey at a single site. The total number of individuals approached and, therefore, the number of individuals who declined to complete the survey was not collected. Due to the nature of the study, no hypothesis testing was executed, and reliability was not able to be assessed. In addition, no identifiable information was obtained for follow-up. However, given these limitations, the results still provide useful information and insight for designing a hypnosis intervention for anxiety in a low socioeconomic status population.
Discussion
As mentioned earlier, up to 31.2% of primary care patients experience mild to moderate anxiety. 8 –12 Furthermore, the survey sample of this study reported a higher prevalence of anxiety at 54.6%, which indicates an even larger prevalence among low socioeconomic status primary care patients than previously considered by the literature. Previous hypnosis literature has not appropriately addressed the treatment of anxiety among this population, and thus this survey provides the first step in understanding the use of hypnosis to treat mild to moderate anxiety for low socioeconomic primary care patients.
Using hypnosis as a treatment for anxiety, specifically among a low socioeconomic population, is important given the limitations and concerns of traditional treatments, such as medications and cognitive behavioral therapy (CBT). The use of anxiolytics can reduce anxiety symptoms, although this class of medications is contraindicated for long-term use due to risk of dependency and addiction. 17 CBT can also aid in the reduction of anxiety 17 but is time-consuming and may not be accessible or too costly for many patients, such as low-income or minority primary care patients.
Previous studies have demonstrated that hypnosis interventions can be delivered remotely (e.g., through audio recordings) and in as few as three to five sessions, 5,7 and this study similarly found that the majority (74.6%) of individuals would be willing to engage in a remotely delivered hypnosis intervention for three sessions. With this base of knowledge about this population's willingness and accessibility of the intervention type, future research is needed to determine both the feasibility and efficacy of a hypnosis intervention for anxiety among low socioeconomic status primary care patients.
Conclusions
To develop meaningful treatments for anxiety, it is important to examine the factors that influence a patient's willingness and accessibility for treatment. The sample of this survey study self-reported a high prevalence of general anxiety, as assessed by the GAD-7. Additional survey items support the overall interest and willingness of a diverse population for a hypnosis intervention for anxiety. This study supports the accessibility of such an intervention utilizing the patient's personal mobile device.
The results of this survey successfully examined and assessed the need, willingness, and accessibility of a hypnosis intervention for anxiety among a low socioeconomic status adult population. There is a need for integrated or alternative treatments for anxiety, and the results of this study indicate that individuals from various demographic backgrounds would be willing and able to participate in a novel treatment format. Future studies should consider the practicality of such interventions, including length, cost, and specific procedures of treatment experience.
In addition, the sample in this survey study was representative of the overall racial/ethnic diversity of the patient population at Heart of Texas Community Health Center, Inc. (DBA McClennan County Family Health Center), and future research should investigate how barriers specific to racial/ethnic minority patients, such as lack of health care coverage as found by Bazargan and colleagues, 18 may influence access and engagement with the intervention. There is also a need to assess attitudes toward willingness and accessibility of hypnosis interventions among non-English speaking populations, specifically Spanish-speaking, as these results may differ. Results from a future study such as this may indicate the need for translation of the hypnosis interventions into non-English languages.
Moderating factors influencing the aspects of a hypnosis intervention may include the influence of primary care provider's referral on overall treatment adherence, the role of demographic characteristics (e.g., participant sex), and finally the potential role of hypnotizability in the number of sessions needed for effective treatment.
Research, including this study, indicates that hypnosis is a highly accessible intervention that can be utilized remotely to address anxiety among low socioeconomic status primary care patients. Results indicate that individuals in this population have access to the technology needed to engage in a remote hypnosis intervention and would be willing to do so. This is important considering the high prevalence of anxiety among this population, the vast need for novel anxiety treatment options, and the growing prevalence of telehealth interventions as a result of the COVID-19 pandemic. Hypnosis, in this format, is a promising telehealth treatment for anxiety as it has the potential to ameliorate the suffering of many individuals in a highly accessible low-cost time-limited manner.
Footnotes
Authors' Contributions
J.R.R., M.L.B., and G.R.E. interpreted the results and prepared the article for publication. R.L.R. analyzed the data as data coordinator. J.G. is currently the chief executive officer of Waco Family Medicine (formally known as McClennan County Family Health Center) and served as a collaborator to help facilitate data collection.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.