clinsa Clínica y Salud Clínica y Salud 1130-5274 2174-0550 Colegio Oficial de Psicólogos de Madrid 00005 10.1016/j.clysa.2016.11.001 Articles Effectiveness of hypnosis therapy and Gestalt therapy as depression treatments Eficacia de la terapia de hipnosis y de la terapia gestáltica como tratamientos de la depresión González-Ramírez Elizabeth Carrillo-Montoya Teresita García-Vega María L. Hart Catherine E. Zavala-Norzagaray Alan A. Ley-Quiñónez César P. * Autonomous University of Sinaloa, Mexico Universidad Autónoma de Sinaloa Autonomous University of Sinaloa Mexico Instituto Politecnico Nacional, CIIDIR - SINALOA, Guasave, Sinaloa, Mexico Instituto Politécnico Nacional Instituto Politecnico Nacional CIIDIR - SINALOA Guasave Sinaloa Mexico Centro Universitario de la Costa, Universidad de Guadalajara, Jalisco, México Universidad de Guadalajara Centro Universitario de la Costa Universidad de Guadalajara Jalisco Mexico Instituto Politecnico Nacional, CIIDIR - SINALOA, Guasave, Sinaloa, Mexico Instituto Politécnico Nacional Instituto Politecnico Nacional CIIDIR - SINALOA Guasave Sinaloa Mexico cleyq@ipn.mx Corresponding author. Instituto Politecnico Nacional, CIIDIR - SINALOA, Guasave. Sinaloa, Mexico. PO 81101. E-mail address: cleyq@ipn.mx (C.P. Ley-Quiñónez).

The authors of this article declare no conflict of interest.

 03 2017 28 1 33 37 01 11 2015 30 11 2016 This is an open-access article distributed under the terms of the Creative Commons Attribution License Abstract

We analyzed the effectiveness of two psychological therapies to treat depression in the Culiacan population, Mexico. According to criteria of MINI (international Neuropsychiatric interview), 30 individuals from a total of 300 were selected and diagnosed with some kind of depression. Patients were divided in three groups: 1) treatment with hypnosis therapy, 2) treatment with Gestalt-hypnosis therapy, and 3) control group. Before and after the treatments the Beck Anxiety Inventory (BAI) was applied to know the depression level of the analyzed groups. The results show that the three groups were presenting a moderated level of depression. The groups under hypnosis therapy and Gestalt-hypnosis therapy show statistical differences between pre-test and post-test. The hypnosis therapy shows significant statistic differences to treat depression with respect to the other two groups. In conclusion, the therapeutic hypnosis is an effective treatment and has relevance to treat depression, while other therapeutic treatments tend to be slow and with minor result. This study is the first of this kind carried out in Culiacan in Sinaloa, Mexico.

 Resumen

En este estudio se analiza la eficacia de dos terapias psicológicas para tratar la depresión en la población de Culiacán, México. Según los criterios de la MINI (entrevista neuropsiquiátrica internacional) se seleccionó a 30 sujetos de un total de 300 y se les diagnosticó de algún tipo de depresión. Se dividió a los pacientes en tres grupos: 1) tratamiento con terapia hipnosis, 2) tratamiento con terapia gestalt-hipnosis y 3) grupo control. Antes y después de los tratamientos se aplicó el Inventario de Ansiedad de Beck (BAI) para conocer el grado de depresión de los grupos analizados. Los resultados muestran que los tres grupos presentaban un grado moderado de depresión. Los grupos de hipnosis y gestalt-hipnosis muestran diferencias estadísticas entre el pretest y el postest. La terapia de hipnosis muestra diferencias estadísticamente significativas para tratar la depresión con respecto a los otros dos grupos. En conclusión, la hipnosis terapéutica es un tratamiento eficaz y es relevante para tratar la depresión, mientras que otros tratamientos terapéuticos tienden a ser más lentos y tener peores resultados. Se trata del primer estudio de este tipo llevado a cabo en Culiacán, Sinaloa, México.

 Keywords Depression Psychological treatments Hypnosis Gestalt therapy Palabras clave Depresión Tratamientos psicológicos Hipnosis Terapia gestáltica

Depression is considered one of the most frequent psychological disorders in the world (McCann & Landes, 2010). It is estimated that depression affects 350 million people, and can turn into a serious public health problem (Barton & Hirsch, 2015; Shenoy, Lee, & Trieu, 2015; Vaughn, Drake, & Haydock, 2016), especially when it lasts a long time and is from moderate to severe intensity (Becker, 2015; Vanhaudenhuyse & Faymonville, 2015); it can also cause a great suffering and disturb work activities, school, and family (American Psychiatric Association, 2013). In the worst cases depression can lead to suicide; no wonder this mental disorder causes 804,000 deaths each year (OMS, 2012).

Although there are effective treatments for depression, fewer than half of those affected in the world receive such treatments (Baena, Sandoval, Urbina, Jarez, & Villaseñor, 2005). Barriers to effective care include lack of both resources and trained health care providers, and social stigma associated with mental disorders. Another barrier to effective care is inaccurate assessment. Even in some high-income countries, people who are depressed are not always correctly diagnosed, and others who do not suffer the disorder are occasionally misdiagnosed and prescribed antidepressants (OMS, 2012).

The psychological therapy, one of the key components of cognitive behavior therapy for anxiety disorders, suggests that attention may play an important role in the extinction of fear and anxiety (Barry, Vervliet, & Hermans, 2015); however, the exact cause of depression is unknown and grows rapidly. Nowadays there is a great variety of therapeutic alternatives, like cognitive behavioral therapy (Spiegel & Spiegel, 2004). The effectiveness of these therapies or psychological interventions for depression is high, and there are no significant differences between them (Bados López, García Grau, & Fusté Escolano, 2002; Chambless & Ollendick, 2001; DeRubeis, Siegles, & Hollon, 2008).

Within the current existentialist-humanistic and phenomenological paradigms, Gestalt therapy emphasizes an individual's capacity to develop his/her potential. Along these lines, the change produced in a person takes place through the experience, since it is awareness, in this process, what gives meaning to discovery. In Gestalt psychotherapy, what is considered is the person in his totality, a combination of sensorial, affective, intellectual, social, and spiritual dimensions (Brownell, 2010). Some studies show that the patients treated with Gestalt therapy demonstrated fewer depressive symptoms following the intervention (Cook, 1999). However, there has not been a great deal of research evaluating the effectiveness of Gestalt therapy (Hender, 2001).

As for Hypnosis therapy, it was defined in 1993 by the psychological hypnosis division of the American Psychological Association (APA) as a procedure through which a health care professional suggests a person to experiment sensations changes, perceptions, thoughts, or behaviors (Ludwig et al., 2015; Mahler, 2015; Palsson & van Tilburg, 2015). The use of hypnosis therapy in the treatment of various psychiatric disorders, including depressive disorders, has been recognized (Schoenberger, 2000). This effectiveness is found in all the clinical variables that have been studied: anxiety, depressive neurosis, major depression, and mugging (Besterio-González & García-Cueto, 2000). Previously, studies mentioned that effectiveness of Cognitive-Behavioral Therapy (CBT) under hypnosis conditions was obtained for all clinical variables studied, such as anxiety, depressive neurosis, and major depression (Besterio-González & García-Cueto, 2000). Patients who received CBT with hypnosis fared better than 75% of patients who received therapy without hypnosis (Kirsch, Montgomery, & Sapirstein, 1995).

The first psychiatric national survey (ENEP is the Spanish acronym) conducted in Mexico revealed that between 15% and 20% of residents were in risk of depression (Medina et al., 2003), a reason why improvements in mental health care of Mexican citizens are urgently needed (Borges, Benjet, Medina-Mmora, Orozco, & Wang, 2008).

This study aims to recognize the effectiveness of two different therapeutic treatments in patients with some kind of depression diagnostic, following MINI (International Neuropsychiatric Interview) criteria, with the purpose of knowing which treatments are more effective for patients with depression diagnosis in Culiacan, Sinaloa, Mexico.

Method

This study was developed in the Autonomous University of Sinaloa (UAS, for its acronym in Spanish) Culiacan, Sinaloa, Mexico.

Participants

To select the sample size group, was applied the auto-evaluation scale International Neuropsychiatric Interview 5.0.0 (MINI) (Amorim, Lecrubier, Weiller, Hergueta, & Sheehan, 1998; Pinninti, Madison, Musser, & Rissmiller, 2003; Sheehan et al., 1998; Sheehan et al., 1997), according with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA, 2000). The MINI is a rapidly administered diagnostic interview; it is acceptable to patients and should improve diagnostic accuracy (Pinninti et al., 2003). MINI was applied to 300 individuals and identified patients with some kind of depression. All individuals are working-class.

 Procedure

Once the participants were selected, the Beck Anxiety Inventory (BAI) was applied as a pre-test to assign the participants in an equal way to each group. BAI is a self-administered survey of 21 items, 15 items make reference to psychological-cognitive symptoms, and 6 more to vegetative somatic symptoms. It systematizes 4 alternative answers to each item and evaluates symptom severity/intensity and they are ordered from highest to lowest severity (Beck, Steer, & Carbin, 1988; Becker, 2015). The total score in each item is from 0 to 3. The total score in the BAI test is from 0 to 63 points. The points usually accepted to graduate the intensity/severity are: no depression (0-9 points), slight depression (10-18 points), moderated depression (19-29 points), and serious depression (30-63 points) (Beck et al., 1988; Wardenaar, Monden, Conradi, & de Jonge, 2015). A quantitative quasi-experimental method was used, with two experimental groups and a control group, with a pre-post-test design. One experimental group was intervened with therapeutic hypnosis (HT) (McCann & Landes, 2010), while the other experimental group was intervened with a combination of the Gestalt-Hypnosis Therapy (GHT) and Cognitive-Behavioral Therapy (CBT). The latter is more effective when it is combined with the former than when is used in an isolated way (Besterio-González & García-Cueto, 2000). Finally, a control group was used like passive listening, i.e., it only heard passively with no type of intervention or feedback during the different sessions in the study.

 Inclusion/Exclusion Criteria

Patients were included if they had a diagnosis of slight depression or moderated depression, a score among 10-29 on the BAI.

Once that the participants were alternately assigned to each group, the participants worked individually, in a weekly session lasting approximately an hour, the day and time being decided with respect to participant availability. We requested permission to videotape each session following the ethics of privacy and trust which are paramount psychotherapeutic practice.

Subsequently the experimental groups were provided with objective information in order to reduce prejudice about hypnosis, what hypnosis is, its nature, its procedure (description of the hypnotic process as an engramic formation) and the causes of depression. This was followed by the application of sensory suggestibility and psychomotor tests which included “the handshake” and the “pendulum” tests in order to inform the hypnotherapist and convince the patient about their hypnotizability and suggestibility. At the end of this first session, patients were provided with a book entitled “Hypnosis Therapy” which included answers to common questions about hypnosis.

In the first session the session focus was shown to the participants:

Individual session with one week session, with about an hour duration, and the day and time to administer the therapy was established according to the time needs.

Each participant was informed of the kind of therapy they will take, characteristics and procedures, videotaping each session, informing of the ethical nature of privacy and the reliability that is required in psychotherapy practice, and a consent letter was signed.

The treatment consisted of six sessions with each participant, with a duration of 40minutes per session in the HT group and 60minutes in the GHT and control groups.

The control group received six sessions using the passive listening technique. The patient was allowed to speak freely about what they felt the need to communicate was. The patient was also told that they were free to remain silent at any time as this was also part of the process. The patient received no direction or intervention by the therapist, who only had to listen without interrupting the patient.

At the end, a post-test was applied according to the BAI.

 Data analysis

Arithmetic means and standard deviations were calculated. We used Kolmogorov Smirnov test (KS) to determine data distribution and all data were normal. We used one-way analysis of variance to test for differences between pre-test and post-test by analysis groups and between the analysis groups. Tukey test was used for multiple comparisons in the event of a significant difference. We performed all statistical analyses using Minitab® 17.1.0 (Minitab Inc., State College, Pennsylvania, USA).

 Results

Thirty participants aged 23 to 35 years old were selected, 9 males and 21 females, all of them diagnosed with some kind of depression. Ten participants were included by group.

Table 1 shows the statistical comparison of pre-test and post-test in the three analysis groups according to BAI. Data shows a normal statistical distribution (KS, p = .150).

Comparison Statistics of Pre-test and Post-test by Analysis Groups
BAI Control group HT group GHT group
Pre-test 20.10 ± 4.82 20.40 ± 4.84(A) 22.90 ± 4.82(A)
Post-test 20.10 ± 5.22 13.10 ± 4.51(B) 15.10 ± 3.96(B)
Statistical analysis F (1, 18) = 0.00, p = 1.00 F (1, 18) = 12.19, p = .003 F (1, 18) = 15.65, p = .001

Note. BAI: Beck Anxiety Inventory, HT: Hypnosis Therapy, GHT: Gestalt-Hypnosis Therapy. The statistical test used was the analysis of variance (ANOVA), statistical data in mean ± SD followed by Tuckey Test in parenthesis if presented statistical difference.

The results show that the three groups presented a level of moderate depression according to BAI. At the end of treatments, the control group showed no statistical differences between pre-test and post-test (F (1, 18) = 0.00, p = 1.00), while the other groups treated with HT and GHT showed statistical differences between pre-test and post-test (HT: F (1, 18) = 12.19, p = .003; GHT: F (1, 18) = 15.65, p = .001), showing a decrease in the depression degree (see Table 1 and Figure 1).

Statistical Comparison between Pre-test and Post-test in the Different Analysis Groups according with Beck Anxiety Inventory

In the pre-test, the between group analysis showed no statistical differences among its means (F (2, 27) = 1.02, p = .376) (Table 2). The post-test showed statistical differences in the group treated with HT vis-à-vis the other two groups, and no statistical differences between GHT and control group (F (2, 27) = 11.82, p < .000) (Table 2, Figure 2). HT had more effectiveness as a treatment in attention to patients that some level of depression. These results are consistent with results observed in previous studies, where after treating the patients with hypnosis treatment they showed lower scores in different tests used to measure their level of mental disorder (Besterio-González & García-Cueto, 2000; Brown, 1998; Capafons, 1998). Besterio-González and García-Cueto (2000) mentioned that possibly the patients with some mental disorder tended to be highly suggestible, allowing us to observe better results in treatment, while other treatments like relaxation and cognitive behavioral therapy tended to be slower and with worst results (Genuis, 1995; Griffiths, 1995; Schoenberger, 2000; Willshire, 1996). Some clinicians and researchers who use hypnosis mention that even few interventions can contribute to rapid early responses or sudden treatment gains (Dobbin, Maxwell, & Elton, 2009) whereas other authors suggest that even the cognitive behavioral treatment is more effective when used in combination with hypnosis than in an isolated way or with relaxation techniques (Connors, 2015; Kleinbub et al., 2015; Riehl & Keefer, 2015).

Comparison Statistics of Pre-test and Post-test among Analysis Groups
BAI Control group HT group GHT group Statistical analysis
Pre-test 20.10 ± 4.82 20.40 ± 4.84 22.90 ± 4.82 F (2, 27) = 1.02, p = .376
Post-test 20.10 ± 5.22(1) 13.10 ± 4.51(2) 15.10 ± 3.96(3) F(2,27) = 11.82, p = .000

Note. BAI: Beck Anxiety Inventory, HT: Hypnosis Therapy, GHT: Gestalt-Hypnosis Therapy. The statistical test used was the analysis of variance (ANOVA), statistical data in mean ± SD followed by Tuckey test in parenthesis if presented statistical difference.

Statistical Comparison between Different Analysis Groups according with Beck Anxiety Inventory

McCann and Landes (2010) mentioned that we have much to learn about depression and how to treat it. Fortunately, a wide range of methodologies can be deployed. Clinicians and researchers who use hypnosis are in a unique position to be able to test some of the underlying assumptions about how depression leads to dysfunction, and how brief or even single-session interventions can contribute to rapid early responses or sudden treatment gains. In this study, we can observe that the use of two treatments in conjunction (Gestalt-hypnosis) showed not to be an effective therapy in comparison whit the hypnosis therapy, that showed to be more effective to treat depression disorders. Probably the treatment time in Gestalt Hypnosis psychotherapy could influence the results obtained. GHT required longer time in each of the seasons, because of treatment characteristics, though more studies are needed for better conclusions.

 Discussion

Depression is a disorder that not only affects an individual's mood state, but also their behavior, the way they look at themselves, their relationship with people around them and their physical and organic function. A depressed person should follow an adequate treatment. As results show, therapeutic hypnosis is an effective treatment (McCann & Landes, 2010). Hypnosis therapy is relevant as a depression treatment, helping to build a positive expectation regarding treatment, addressing numerous depressive symptoms and modifying patterns of self-organization that contribute to depressed thinking and mood (Yapko, 2006). However, studies following up long-term patients who have been treated with different validated therapies have concluded that one of the main causes of high depression prevalence in the world is new depression episodes in people who had experimented a previous episode (Segal, Williams, & Teasdale, 2012), recommending a follow up of patients treated with different therapeutic interventions.

It is necessary to consider future research about the level of effectiveness of treatments, applied in separate ways and in an effective time for significant results.

 Acknowledgments

We would like to thank each participant for their help in doing this research, carried out in the Faculty of Psychology, UAS, Mexico.

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