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Contextual Roles in Clinical Hypnosis and Hypnotherapy: Theory and Applications Akira Otani

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University of Maryland Counseling Center , USA Published online: 21 Sep 2011.

To cite this article: Akira Otani (1991) Contextual Roles in Clinical Hypnosis and Hypnotherapy: Theory and Applications, American Journal of Clinical Hypnosis, 34:2, 111-121, DOI: 10.1080/00029157.1991.10402970 To link to this article: http://dx.doi.org/10.1080/00029157.1991.10402970

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AMERICAN JOURNAL OF CLINICAL HYPNOSIS VOLUME

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Contextual Roles in Clinical Hypnosis and Hypnotherapy: Theory and Applications

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Akira Otani! University of Maryland Counseling Center Context is a cognitive psychological term that has relevance to hypnosis and hypnotherapy. This paper has three purposes: (a) to review five major characteristics of contexts in light of contemporary experimental cognitive psychological findings, (b) to examine the role of contexts in hypnosis theories, and (c) to discuss applications of contexts in clinical situations. As a heuristic concept, the contextual theory can offer new insights into the understanding of various hypnotherapeutic techniques. Clinicians are encouraged to understand and apply contextual functions to their practice of hypnotherapy.

Clinical applications of hypnosis and hypnotic phenomena have regenerated interest among health professionals in recent years. In addition to medical and dental uses of hypnosis, clinicians have used hypnotherapy successfully in such diversified areas as behavioral medicine (Brown & Fromm, 1987), forensic evaluation (Scheflin & Shapiro, 1989), and terminal illness management (Jevne & Levitan, 1989). Despite this growing in-

For reprints write to Akira Otani, Counseling Center, Shoemaker Hall, University of Maryland, College Park, MD 207428111. Received February 27, 1991; revised May 20, 1991; accepted for publication May 24, 1991. "The author is indebted to the works of B. J. Baars for contemporary views 'of contexts. The author alone, however, is responsible for any inaccuracies of their description in this article.

terest in clinical application, the fundamental nature of hypnosis remains relatively little understood. Competing theories have been proposed (Weitzenhoffer, 1989), but they are "no more than hypotheses that have yet to be tested" (p. 20). To advance knowledge of hypnosis and its clinical applicability, we need more rigorous conceptualization and empirical inquiry. An emerging framework that holds promise for dynamic understanding of various psychological phenomena, including hypnosis and hypnotherapy, is cognitive psychology. In particular, recent advances in cognitive psychology emphasize the role of contexts in conscious and unconscious information processing (see Baars, 1989; Bransford, 1979; Wapner, 1986). As discussed in this article, context is a unifying term that can help to explain the nature of psychotherapy and hypnosis. Indeed, some authors 111

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(Erickson & Rossi, 1976; Mott, 1982) noted the roles of contexts in hypnotherapy but did not elaborate on them. The purpose of this paper is threefold: (a) to summarize the nature and properties of context from a contemporary cognitive psychology perspective, (b) to delineate the prospective roles of contexts in contemporary hypnosis theories, and (c) to describe clinical applications of contexts in therapeutic practice. Readers will recognize that the contextual theory is founded on both sound conceptual models and rich empirical data that are beneficial to the study of hypnosis and hypnotherapy. Moreover, the theory is heuristic enough to augment existing theories of hypnosis.

Johnson, 1972) and neuropsychology (Kubie & Ranck, 1984) suggests convincingly that contexts mediate human learning, perception, emotion, memory, judgment, and information comprehension (see the summary below). In view of this definition, a good example of contextual impact is hypnotic time distortion (Cooper & Erickson, 1959). A given length of time can be perceived either as long or short, depending upon the context in which it is experienced. As a rule, the individual who senses the passage of time does not recognize the particular context (e.g., a pleasurable vs. aversive frame of reference) as it affects the perceived duration. Properties of Context

Contemporary Views of Contexts in Cognitive Psychology Definition

Although the role of context has been well documented in human perception studies (e.g., Gestalt psychology), it has received more systematic attention recently in cognitive psychology, most notably in the global workspace theory (Baars, 1988, 1989). In light of this theory, a context is defined as a set of information-processing structures that define conscious experience without themselves being consciously recognized (Baars, 1988). Note that this definition expressly states three distinct properties of contexts. To be precise, contexts (a) constitute a set of information-processing systems, (b) shape conscious experience of an individual, and (c) function at the unconscious level. The term resembles other familiar concepts in clinical psychology, such as frame of reference, mental set, expectation, cognitive schema, and the equivalents (Baars, 1989). Evidence in cognitive science (Bransford, 1979; Bransford &

As unconscious knowledge structures, contexts shape conscious experience in several specific ways. I have summarized five unique characteristics of contexts in this section. Contexts facilitate comprehension of information, In their elegant experiments Bransford and Johnson (1972, 1973) demonstrated that even the simplest information (e.g., laundry instructions) cannot be understood easily without a proper context. Watkins (1990) similarly noted that contexts could influence individuals' ability to recognize faces. These results suggest that contextual identification and access are critical in the comprehension of verbal and nonverbal information. In hypnosis, use of examples, analogies, and metaphors provide useful contexts that will help the subject to understand and respond to hypnotic suggestion appropriately. Behavioral compliance increases when these components are integrated as part of tranceinduction sequence or hypnotic therapy (Erickson & Rossi, 1979).

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Contexts alter perceived meaning of events. In a cognitive informationprocessing paradigm, contexts presumably provide the ground against which the figure stands. Because of this property, change in a context can shift perceived meaning of an event (Tversky & Kahneman, 1981; Wapner, 1986). Reframing is a primary example that uses this principle for therapeutic purposes (Watzlawick, Weakland, & Fisch, 1974). The technique refers to "the conceptual and/or emotional setting or viewpoint in relation to which a situation is experienced and to place it in another frame which ... changes its meaning" (Watzlawick et aI., 1974, p. 95). In a hypnotic framework, contextual shifting of the figure-ground relationship may occur as the hypnotist deals with the subject's resistance in trance induction. For example, in response to the subject's "noncompliance" to a directive for hand levitation, the hypnotist may encourage an increase in the noncompliant behavior. This paradoxical encouragement of resistance can often change the meaning of noncompliance and, as a result, transforms the situation into "compliance" (Haley, 1973). This example illuminates the figure-ground reversal effect of contextual manipulation in hypnotic resistance management. Contexts can prime responses. Priming is a cognitive psychological phenomenon that refers to "the activation or change in accessibility of a concept by an earlier presentation of the same or a closely related concept" (Sherman, 1988, p. 65). Simply stated, once a context is provided, it will shape the responses that follow. To corroborate this assertion, Motley and Baars (1979) demonstrated experimentally that the subjects who were primed by a phrase "salary scale" tended to mis-

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pronounce a nonsensical word-pairing "rage weight" as "wage rate." The authors speculated that the subjects' subsequent response resulted from the contextual priming caused by the stimulus phrase. When priming effect becomes exclusive, functional fixedness (Duncker, 1945) has occurred. It is a condition under which only context-proper behavior appears. In light of this conceptual model, a hypnotic "yes set" is a vigorous context that secures a functional fixedness on trance behavior. As a result of this mechanism, hypnotic response will be primed in a trance-induction sequence.

Competing contexts can create confusion. Recent studies (Carpenter & Just, 1989; Just & Carpenter, 1980) suggest that using multimeaning words and polysyntactic (grammatically complex) structures in a sentence make comprehension difficult. Erickson's use of synonyms, homonyms, and antonyms in the confusion technique demonstrates this principle (Otani, 1989). Availability of competitive contexts obviously generates confusion. Confusion also occurs when contexts are ambiguous or when their assumptions are violated (Baars, 1989; Clark & Carlson, 1981). "Inspecting officers can be intimidating" is a confusing sentence because of its contextual ambiguity ("officers who inspect" vs. "to inspect officers"). Likewise, a statement, "John behaved well today; he assaulted three people," is confusing." The sentence makes little sense in that the context of "behaving well" is inconsistent with that of "assaulting three people." In this case the violation of the first context by the second renders confusion. Contextual predominance of consciousness results in a state of "absorp-

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tion. " Studies (Broadbent, 1958; Cherry, 1953) indicate that cognitively demanding tasks or exciting activities can produce powerful contexts that may overwhelm and dominate ordinary conscious function. Formation of such contexts compels the individual to be "absorbed" in them. In this absorption state, the individual's attention and awareness are narrowly and exclusively focused on the demanding tasks or engaging activities (e.g., writing a paper, watching a movie). Based on this and other empirical evidence in visual information processing (e.g., Oswald, 1960) and hypnotic susceptibility (e.g., Tellegen & Atkinson, 1974), Baars (1989) concluded that the absorbed mental state closely resembles the trance state. It is important that further studies assess the rate of contextual dominance and its influence on conscious states. In summary, contexts have significant influence on human cognition and conscious experience. The five characteristics of contexts, (a) facilitation of information comprehension, (b) meaning alteration, (c) priming, (d) confusion, and (e) creation of absorbed mental states, are highly relevant and useful properties that can shed light on the nature of hypnotherapeutic techniques. Before analyzing hypnotherapeutic techniques according to these contextual attributes, however, I will examine briefly the proposed roles of contexts in hypnosis theories. Role of Contexts in Hypnosis and in Hypnotherapy As a heuristic concept, contexts have been well adapted to clinical and therapeutic theories. For example, more than 30 years ago Bateson and his colleagues (Bateson, Jackson, Haley, & Weakland, 1956; Ruesch & Bateson, 1968) con-

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tended on the basis of their interactional communication hypotheses that pathological family interactions could harm human behavior once they form double-bind contexts. Summarizing his lifelong studies in ethnology, anthropology, and psychiatry, Bateson (1979) concluded the role of context in human communication as follows: And "context" is linked to another undefined notion called "meaning." Without context, words and actions have no meaning at all. This is true not only of human communication in words but also of all communication whatsoever, of all mental process, of all mind . . .. It is the context that fixes the meaning. (p. 15, emphasis original)

This quote suggests that Bateson recognized the pivotal role of contexts in human communication and therapy. Similarly, recent efforts to elucidate "convergence" and "divergence" in various psychotherapeutic approaches (Goldfried, 1980, 1982; Wachtel, 1977) indicate an active search for both common and unique contexts in which behavior change occurs. These authorsdelineated specific contextual assumptions in psychoanalytic, behavioral, and humanistic therapies. With regard to hypnotic paradigms, many theories incorporate contextual roles in their models. For instance, the roleenactment theory (Sarbin, 1950; Sarbin & Coe, 1972) claims that trance behavior results from the individual's compliance with assigned hypnotic roles. Similarly, the real-simulating theory (Orne, 1959) postulates that demand characteristics can successfully influence both hypnotized subjects and trance simulators. Both of these concepts share the functional properties of a context, namely: (a) they are not recognized explicitly by the individual, but (b) they can influence the indi-

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vidual's behavioral response to sugges- dependent memory and learning. Drawing extensively on recent empirical evitions in experimental situations. dence in cognitive neuroscience (e.g., From the social psychological perspective of hypnosis, so-called "trance" be- Blum 1967; McGaugh, 1983; Overton, havior presumably occurs as a result of 1973; Swanson & Kinsbourne, 1979), the interpersonal-influence and cogni- Rossi (1986) contends that "therapeutic tive-mediation processes (Barber, 1969; hypnosis is a process of accessing stateSpanos, 1986). More than any other the- bound information and utilizing it for orists, social psychological proponents problem solving" (p. 204; emphasis explicitly argued that these two psycho- original). According to this formulalogical processes would form dominant tion, the trance state is viewed as a bycontexts that define the nature and the product of accessing contextually orgaextent of a given hypnotic response. This nized memory. Indeed, this position is view parallels the interactional formu- rooted in Erickson's conceptualization lation of hypnosis proposed by Kihls- of hypnosis. Examine the following trom (1985). According to his model, quotations from Erickson: Consciousness does not have available the hypnotist-patient dyad relationship all the knowledge that is in the unconitself becomes a context that elicits hypscious, which actually governs our percepnotic behavior without the patient's tions and behavior (Erickson & Rossi, 1979, awareness of the behavior. This descripp. 367; emphasis added). tion matches the functional definition of Hypnosis is a technique of communicacontexts. tion whereby you make available the vast In contrast to these nonstate views of store of learnings that have been acquired, hypnosis, the neodissociation model of the usefulness of which lies primarily in the hypnosis (Hilgard, 1985, 1987) is less way of automatic response. In hypnosis we articulate about the role of contexts in make a direct call on these learnings that trance induction and behavior. One may have been dropped into the area of autonote, however, that the concept of mulmatically available learnings (Erickson & Rossi, 1981, p. 100; emphasis original). tiple control systems may have the properties of contexts. Like contexts, these As expressed clearly in these quotations, systems supposedly influence both overt Erickson regarded the individual's collecand covert human behaviors while op- tive learning set as a knowledge base that erating at the unconscious level (Hil- is stored and processed in the uncongard, 1985). Given that contextual scious. As such, past learnings form a predominance can yield a state of ab- cognitive frame of reference, a systemsorption, multiple control systems may atically organized context that influences possess similar mechanisms, especially conscious perception and behavior. For in the creation of dissociative states. This this reason, according to Erickson, effechypothesis warrants further theoretical tive hypnotic therapy must access, reand empirical investigation. trieve, utilize, and restructure the From an Ericksonian tradition, Rossi individual's unconscious learning. This (1986, 1988) postulated a psychobio- conceptual model is consistent with conlogical model of hypnosis that accounts temporary cognitive psychology of confor the role of contexts by way of state- texts (Otani, 1990).

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Clinical Applications of Contexts in Hypnotherapy It is evident from the preceding discussion that contexts play central roles in the induction and regulation of trance behavior. Because human conscious experience is closely modulated by various contextual functions, it is no surprise that most contemporary theories of hypnosis account for contextual roles in their explanation of trance phenomena. From a clinical perspective, the cognitive-contextual theory seems to offer conceptually useful schemata to account for a wide range of hypnotherapeutic techniques. On the basis of this theory, the following recommendations are offered to hypnotherapists.

Phrase Suggestions to Fonn and Develop Relevant Therapeutic Contexts for the Patient Since contexts are indispensable for comprehension of information, effective hypnotherapy should incorporate appropriate contexts to assist the patient's quick, accurate understanding of suggestion. While well-organized contexts can facilitate hypnotherapeutic process and outcome, their absence likely elicits "resistance" to hypnotic directives by the patient. In this latter condition, the patient's compliance to suggestion is diminished as a result of insufficient or faulty comprehension of hypnotic messages. To guard against this oppositional behavior and to augment the patient's hypnotic response, hypnotic suggestions should be worded in such ways as to create lucid contexts for specific results. Consider, for example, a standard direct suggestion for dental anesthesia: "Your lower left jaw will go numb shortly." Although acceptable, this directive may be ineffectual for

patients who exhibit high dental anxiety or those who have never experienced hypnoanesthesia. To ameliorate this suggestion, an analogical statement may be added to the suggestion to create a context for anesthesia: "Your lower left jaw will go numb shortly as if it received a nice shot of Novocain," Provided that the patient has had success with this chemoanesthesia, the underlined phrase creates an easy-to-understand context relevant to numbness for the patient. Once available, this context can readily evoke a topical anesthetic response and consequently enhances the patient's compliance to the suggestion. Similarly, clinicians should create a hypnotic 'yes set" to maximize the effects of suggestion. As reviewed earlier in this article, a "yes set" can produce powerful contexts that will prime hypnotic responses, thereby expediting the process of trance induction. In clinical practice, the hypnotist can build a "yes set'" easily by the use of truisms. Because truisms communicate unrefutable, apparent truths, tacit agreement to these statements by the patient likely raises his or her receptivity to subsequent hypnotic suggestions. Once established, a "yes set" will facilitate the process of trance induction and hypnotherapeutic outcome.

Transform Dysfunctional Contexts to Gain Positive Hypnotherapeutic Results As described in the Properties of Contexts section above, cognitive psychology abounds in empirical findings, showing that contextual shifting changes meanings of events or behavior. This evidence signifies that manipulation of contexts can mediate maladaptive behavior. Given that a context is an information-processing structure that influences various mental functions, the contextual mechanism of

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change resembles that of cognitive therapy (e.g., Beck, 1976; Guidano & Liotti, 1983). Both approaches regard proper internal reconstruction of external reality as essential for behavior change and, consequently, promote such process in therapy. Unlike cognitive therapy, however, the contextual approach does not attempt modification of the patient's "faulty thinking style" or "irrational beliefs" directly. Instead, it transforms anomalous contexts to promote therapeutic problem solving. As a result of this systemic transition in contexts, desired behavior change is expected to occur "spontaneously." Two exemplary hypnotic techniques applicable to context transformations are reframing and therapeutic paradox. Recent studies (Conoley & Garber, 1985; Kraft, Claiborn, & Dowd, 1985) demonstrated that positive reframing (i.e., positive reinterpretation of negative events or attributes) was particularly effective for a wide range of problems, including depression, low self-esteem, and nonassertiveness. Paradoxical strategies have been found to be especially useful for disorders that require attitudinal alteration for problem resolution (Weeks & L' Abate, 1982). They include marital discord, sexual dysfunctions, insomnia, and obsessive-compulsive disorder (Ascher, 1989). To use paradox clinically, the therapist should encourage the patient (a) to repeat distressing habits, obsessions, or compulsions deliberately or (b) to try inducing depressive moods or panic attacks in expectation of imminent melancholia or anxiety. These paradoxical instructions are intended to reverse the patients' self-defeating posture toward their problems, thereby turning avoidance to acceptance. With this contextual shifting, perceived problems may become no longer problematic and lead to eventual symptom res-

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olution. These observations suggest that the contextual theory provides a parsimonious conceptual framework for the change mechanism underlying therapeutic paradox.

Use Existing Contexts of the Patient to Generate Therapeutic Benefits Contexts are, by definition, unconscious structures that govern a range of cognitive functions. As such, there are numerous internal and external factors that create contexts, including, for instance, the environment, life history, personality, occupation, social and economic status, and education of the patient. Some of these inputs are situational or transient (e.g., the environment), while others may be more permanent and stable (e.g., personality). In the clinical practice of hypnotherapy, it has been recommended that a hypnotherapist access and model prominent contexts that characterize the patient. This protocol corresponds to Erickson's (1959) utilization approach in which the patient's symptoms and resistances are applied as part of hypnotherapy. Research in cognitive science demonstratedthat such intentional modeling of contexts can produce contextual dominance, which may heighten the patient's trance experience as well as the effects of hypnotherapy. Erickson (1973) reported an excellent example of contextual utilization with a patient who suffered from chronic premature ejaculation. In this case, Erickson conceptualized the patient's sexual dysfunction in relation to a larger context, namely, the obsessive character pathology. Following this assessment, Erickson adapted the patient's obsessive style, such as persistent doubts and preoccupationover time, to correct the ejaculatory problem. Furthermore, to ensure therapeutic success, Erickson modeled the patient's ob-

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sessive style by phrasing the suggestions in a detailed, repetitious fashion. As a result of this hypnotherapeutic intervention, the patient quickly developed a new obsession about failing to ejaculate within the "proper" time. As this obsessive ideation grew stronger, the premature ejaculation ceased without behavioral intervention (e.g., the squeeze technique; Masters & Johnson, 1970). Unfortunately, no detailed follow-up information is available to evaluate the long-term outcome of this therapy. As "Ericksonian brief therapy" gains popularity among hypnotherapists, future research must submit the utilization approach to a rigorous, empirical test to examine its efficacy in light of the contemporarycognitivecontextual paradigm. Readers interested in various clinical cases of contextual utilization techniques are referred to Erickson (1965).

"Decontextualize" Dysfunctional Contexts to Initiate Therapeutic Change Clinicians frequently encounter individuals who exhibit consistent resistance to trance induction or patients who present recurring symptoms that are seemingly unresponsive to hypnotherapeutic interventions. These individuals are usually considered "difficult" because of the challenge they pose to the hypnotist. In the conceptual framework of contextual theory, these problems may be viewed as responses that are primed by negative contexts. That is, the patient's persistent noncompliance and symptoms may be the results of countertherapeutic contexts that are incompatible with desired hypnotic goals. As these contexts grow solid during hypnotic therapy, the patient's responses may become "functionally fixed" and the observed resistance and symptoms may worsen. Consequently, the pa-

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tient's difficulties will continue, and may even exacerbate, so long as the underlying contexts remain intact. In light of this analysis, a plausible contextual approach to perpetual resistance and symptoms is (a) to eliminate the dysfunctional contexts causing the difficulties and (b) to substitute more pertinent contexts for them. This strategy parallels the principle of decontextualization in cognitive psychology (Baars, 1989), and its appropriate application to clinical situations can dispel the ill effects of priming and functional fixedness, including chronic resistance and symptoms. For example, take a patient who claims to be "unhypnotizable" on the basis of the past failure experience with hypnotic induction. Besides the empirical validity of this self-assertion, the patient's disbelief in his or her own hypnotizability itself creates a powerful context against successful trance induction. Such context alone can further undermine future hypnotic work with the patient. How, then, can and should the hypnotist manage this patient clinically? According to the contextual perspective, the hypnotist needs to abolish the unfavorable context and to introduce an alternative, more productive context. In this hypothetical case, the hypnotist may discontinue the trance induction attempt entirely and instead recommend "relaxation training" to the patient. This strategy allows removal of the banal context of "hypnotic induction" and replaces it with one for "relaxation training." With this new context in place, the patient's compliance should increase for successful trance work. This contextual "bait-andswitch" technique has been implemented successfully for trance induction with resistant patients (Erickson, Haley, & Weakland, 1959; Erickson & Rossi, 1976). Similarly, the decontextualization princi-

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pIe has been extended to clinical hypnotherapy for symptom management. Psychological shock approach (Rossi, 1973) and ordeal therapy (Haley, 1984) are two such examples. Both of these techniques achieve therapeutic goals by undoing the patient's symptom-causing contexts through calculated application of mental shocks, surprises, and onerous tasks. In summary, contextual development, transformation, utilization, and decontextualization provide valuable heuristic guidelines for clinical hypnotherapy. Some of the contextual strategies have already achieved popularity among hypnotherapists, most notably metaphors, reframing, and therapeutic paradoxes. Other contextual strategies exist, however, and I encourage readers to study and master these techniques. Concluding Remarks Context is one of the key concepts in contemporary cognitive psychology. Its role in conscious and unconscious information processing has been theoretically and empirically investigated over the past 25 years. Many of these findings offer important implications for hypnotic research and therapy. The current paper summarized major properties of contexts, their relevance to hypnosis theories, and their clinical applications to hypnotic therapy. I hope that future advances in contextual research will provide further information on the nature of hypnosis and hypnotherapy. References Ascher, L. M. (Ed.). (1989). Therapeutic paradox. New York: Guilford. Baars, B. J. (1988). Momentary forgetting as a "resetting" of a conscious global workspace due to competition between incom-

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CONTEXTUAL ROLES IN HYPNOSIS

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Contextual roles in clinical hypnosis and hypnotherapy: theory and applications.

Context is a cognitive psychological term that has relevance to hypnosis and hypnotherapy. This paper has three purposes: (a) to review five major cha...
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