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Hypnotic Susceptibility, Achievement Motivation, And The Treatment Of Obesity

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Hypnotic Susceptibility, Achievement Motivation, And The Treatment Of Obesity

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Xerox University Microfilms 300 North Zoob Road Ann Arbor, Michigan 40100 74-28*456 HILLER, Jeffrey Earl, 1948- HYPNOTIC SUSCEPTIBILITY, ACHIEVEMENT MOTIVATION, AND THE TREATMENT OF OBESITY. University of Southern California, Ph.D., 1974 Psychology* clinical University Microfilms, A X E R O X Company, Ann Arbor, Michigan HYPNOTIC SUSCEPTIBILITY, ACHIEVEMENT MOTIVATION, AND THE TREATMENT OF OBESITY by Jeffrey Earl Miller A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Psychology) August 1974 UNIVERSITY O F SOUTHERN CALIFORNIA THE GRADUATE 8CHOOL UNIVERSITY PARK LOS ANQEUH. CALIFORNIA 8 0 0 0 7 This dissertation, written by ................. under the direction of h.in,.. Dissertation Com m ittee, and approved by all its members, has been presented to and accepted by The Graduate School, in partial fulfillm ent of requirements of the degree of D O C T O R OF P H IL O S O P H Y \J Dtta Date...^M<x^..l.?/.j..J.5.Z3!.. DISSERTATION COMMITTEE iE R X ^IO N COMMIT! ACKNOWLEDGMENTS The writer wishes to express appreciation to the members of his committee, Dr. Norman Tiber, Dr. Edward Conolley, Dr. A. Steven Frankel, and Dr. Constance Lovell, for their critical comments. Special thanks are due to Steven Kibrick, a friend and colleague, Dr. Leslie Cooper, and Dr. Albert Marston, for their invaluable assistance and suggestions. Most important, of course, were the contributions of Dr. Perry London. The writer is deeply grateful for his constant guidance, insight, and support. The editing of the various drafts of this disserta tion, as well as encouragement and understanding, are the contributions of my wife, Kathy. ii TABLE OF CONTENTS Page ACKNOWLEDGMENTS ii LIST OF TABLES V ABSTRACT Vi Chapter I INTRODUCTION 1 II LONDON'S THEORY 6 Need for Susceptibility Model High and Low Susceptibles High and Low Need Achievers Clinical Application of London's Theory III OBESITY...................................... 17 Definition and Measurement Etiology IV TREATMENT.................................... 21 Hypnotherapy Non-Induction Hypnotherapy Task-Oriented Therapy Diet and Exercise Summary of Hypotheses V METHOD........................................ 48 Subjects Assessment Instruments Procedure Treatment Hypnotherapy Group Non-Induction Hypnotherapy Group Task-Orianted Group Drop-Outs Follow-up Session iii Chapter VI RESULTS Page 78 Data Drop-Outs Overview Intercorrelational Analyses Treatment Versus Follow-Up Regression Analyses Control Group VII DISCUSSION....................................... 103 BIBLIOGRAPHY .......................................... 113 APPENDIX................................................ 123 A BIOGRAPHICAL QUESTIONNAIRE B DIET AND EXERCISE FORM C FEEDBACK QUESTIONNAIRE D MEDICAL RELEASE FORM E ACCEPTANCE LETTER iv LIST OF TABLES Table Page 1. NUMBER AND RATE OF DROP-OUTS ....................80 2. INTERCORRELATIONS AMONG VARIABLES ACROSS ALL GROUPS.............................. 83 3. INTERCORRELATIONS AMONG VARIABLES FOR THE HYPNOTHERAPY GROUP ....................85 4. INTERCORRELATIONS AMONG VARIABLES FOR THE NON-INDUCTION HYPNOTHERAPY G ROUP........................................... 87 5. INTERCORRELATIONS AMONG VARIABLES FOR THE TASK-ORIENTED GROUP.................... 89 6. REGRESSION ANALYSES WITH TOTAL WEIGHT LOSS AS THE DEPENDENT VARIABLE .......................................97 7. ONE-WAY ANALYSIS OF VARIANCE ON TOTAL WEIGHT L O S S ............................. 100 8. WEIGHT LOSS OF ALL TREATMENT GROUPS COMBINED COMPARED TO CONTROL GROUPS IN OTHER STUDIES ............................. 102 v ABSTRACT HYPNOTIC SUSCEPTIBILITY, ACHIEVEMENT MOTIVATION, AND THE TREATMENT OF OBESITY Jeffrey Earl Miller University of Southern California, August, 1974 Perry London, Ph.D., Chairman The purpose of this research was two-fold: l)to further test a recent theory proposed by London (Grenzge- biete Per Wissenschaft, 1971, 3, 97-113) that hypnotic susceptibility is inversely related to achievement motiva-* tion, and 2)to investigate the clinical application of this theory to the treatment of obesity. The subjects in this study were 60 (after attri tion) female volunteers selected from 2500 volunteers re questing help with weight reduction. All subjects were 20-40% overweight, according to insurance tables; and half were high and half low in hypnotic susceptibility, ac cording to the Harvard Group Scale of Hypnotic Suscepti bility. A Biographical Questionnaire and the Mehrabian Female Scale of the Tendency to Achieve were also adminis tered during selection. Once selection had been made, 15 high and 15 low susceptible subjects were randomly assigned to each of vi four groups: Hypnotherapy (with treatment focused on the modification of specific eating behaviors through hypnotic suggestions), Non-induction Hypnotherapy (the same proce dure as the Hypnotherapy group but without the instructions for trance induction), Task-oriented Therapy (with treat ment focused on practicing in vivo the eating behaviors which the other groups practiced covertly) , and a Minimal Treatment Control group (which later had to be eliminated from the analyses because of resistances on the part of the subjects to the establishment of a self-help program). Treatment consisted of seven one-hour sessions, ex tending over a seven week period, plus a follow-up session one month after the final treatment session. In addition to the special conditions (e.g., hypnosis) all subjects were instructed to follow a basic diet and exercise pro gram. Routine measures at each session included: body weight, Diet and Exercise Record Forms, and a Feedback Questionnaire. It was hypothesized, following from London's theory, that hypnotic susceptibility scores would correlate inversely with scores on achievement motivation. This hypothesis was not confirmed. With the Hypnotherapy and Non-induction Hypnotherapy groups it was found that, con trary to the hypotheses, susceptibility did not correlate positively, and achievement motivation did not correlate vii inversely, with weight loss. In the Task-oriented group, however, susceptibility correlated inversely with weight loss as per hypothesis. Serendipitous findings included significant positive correlations between weight loss (for all three groups separately and combined) and three other variables: number of Diet and Exercise Record Forms com pleted, number of daily weighings, and amount of time set aside for daily exercise. Also, weight loss correlated inversely with the number of absences from the sessions. Although the Minimal Treatment Control group was elimina ted from the analyses, the effectiveness of the treatment groups was suggested by a comparison between weight loss for subjects in the three treatment groups combined and weight loss of subjects in control groups in other studies in the literature. The results suggest that future obesity research attend not only to the subject variables related to the use of particular treatment techniques, but also to the subject variables which reflect efforts to modify and attend to daily eating habits. viii CHAPTER I INTRODUCTION This study reports an experiment relating hypnotic susceptibility and achievement motivation to weight reduc tion. It examined three approaches to the treatment of obesityf but the comparison of these treatments was not its goal. Research on hypnotic susceptibility indicates that it is a reliably measured and relatively stable phenomenon. In spite of this, attempts to relate susceptibility to other aspects of personality have been largely unsuccessful. Consequently, there has been a need for a comprehensive model that would relate susceptibility to cognitive and social behavior patterns instead of specific personality traits. Perry London (1971) has recently proposed such a model, which involves the personality pattern denoted by McClelland and his associates (1953) aB the achievement motive or need to achieve.! This model developed largely *The terms "achievement motivation," "need to achieve," "achievement motive," and "need achievement" all refer to the same personality construct and will be used interchangeably throughout this paper. 1 2 out of the results of a series of studleB by London and his associates which Indicate that subjects low In hypnotic susceptibility are generally more highly motivated, per sistent, and competitive at task-oriented activities than those high in susceptibility. These findings tie-in re markably well with the research literature on the need to achieve, defined by McClelland and his associates (1953) as a "concern over competition with a standard of excellence" (p. 181). Subjects high in achievement motivation, like low susceptibles, tend to be more persistent and motivated to perform at various tasks than those low in achievement motivation, who resemble high susceptibles. The results of these studies on susceptibility and achievement motiva tion led London (1971) to hypothesize that hypnotic sus ceptibility is inversely related to the achievement motive dimension— that is, high susceptibles are lower in the need to achieve than low susceptibles. This theory has been supported by Miller (1973) who found a significant inverse correlation between scores on susceptibility and achieve ment motivation in a group of adult males. The purpose of the present study was two-fold: l)to further test London's theory by investigating the re lationship between these two variables in a group of adult, female subjects; and 2)to investigate the practical appli cation of London's theory to the treatment of obesity. 3 The latter goal was achieved by testing specific hypotheses concerning the interrelationships among the two subject variables— hypnotic susceptibility and achievement motiva tion— and three approaches to the treatment of obesity— Hypnotherapy, Non-induction Hypnotherapy, and Task-oriented Therapy. Obesity was selected as an area of treatment for testing the proposed hypotheses because it is a highly prevalent, yet easily and objectively measured, disorder. The treatment of obesity, therefore, was not the focus of this study, but rather it was a convenient means of testing the proposed hypotheses. The particular treatments used here were selected and developed because of their logical relevance to the two subject variables. Hypnotherapy was the most logical treatment in this connection because of its wide-spread use in the clinical treatment of obesity and because of its obvious relation ship to hypnotic susceptibility. Susceptibility scores are based on antecedant behaviors similar to those involved in hypnotherapy, i.e., responding to hypnotic and post-hypno tic suggestions. It was predicted in this study that hyp notic susceptibility would correlate positively with post treatment weight loss of subjects in the hypnotherapy group: high susceptibles would lose more weight than low susceptibles. Based on London's theory, it was also pre- 4 dieted that low need achievers in this group would lose more weight than high's. While the trance induction procedure is commonly thought of as a necessary and integral part of hypnother apy, there is research evidence to suggest that the induc tion procedure may not be indispensable to the hypnothera- peutic procedures, though it may heighten responsivity to suggestions under certain conditions. To test this possi bility, a Non-induction Hypnotherapy condition was included which paralleled the hypnotherapy condition in every re spect except that no instructions for trance induction were included in the treatment procedures, and no mention was made of it being a "hypnotic" therapy in the presence of any subjects. The predictions for this treatment condition were the same as for the hypnotherapy group; high suscepti bles in this group would lose more weight than low sus ceptibles and low achievers would lose more weight than high's. The third treatment condition, Task-oriented Therapy, was designed to focus on tasks which would modify eating behaviors and thereby promote weight loss. These tasks included various behavior therapy techniques such as slowing down the pace of eating, throwing away left-overs, and exercising vigorously before eating in order to curb the appetite. The content and goals of the Task-oriented group paralleled the content and goals of the Hypnotherapy and Non-induction Hypnotherapy conditions, but subjects in the Task-oriented group actually engaged in the behaviors which subjects in the other two groups only imagined doing, e.g., eating more slowly. It was hypothesized that for the Task-oriented group achievement motive scores would corre late positively with weight loss, but hypnotic susceptibil ity would correlate inversely with weight loss because dif ferences in both of these dimensions have been reflected in differences in performance on task-oriented activities. In addition to the various treatment procedures, all of the subjects in this study were instructed to follow a basic diet and exercise program developed by Stuart and Davis (1972). This program is widely known and involves a standard instructional manual, given to individual sub jects, and Btandard record keeping forms. This program provided structure for regulating the subjects' eating and exercising activities. It also negated the belief that techniques used in the sessions are "magical" and can some how produce weight loss "automatically" without any real effort on the part of each subject. CHAPTER II LONDON'S THEORY Need For Susceptibility Model It has been recognized, at least since the time of Braid (1843) (cf. Hilgard, 1967), that some individuals can be easily hypnotized and respond readily to hypnotic sug gestions while others cannot be hypnotized even after sever al hypnotic induction trials. The first well-standardized instrument for measur ing susceptibility was developed by Davis and Husband (1931), and it.,was subjected to a major revision by Fried- lander and Sarbin (1938). In 1959 the first of the Stan ford Hypnotic Susceptibility Scales was published by Weitzenhoffer and Hilgard. Since that time research on differences in susceptibility, largely using the Stanford scales, indicates that it is a reliably measured and rela tively stable phenomenon. On the Stanford Hypnotic Susceptibility Scale (SHSS), developed by Weitzenhoffer and Hilgard (1959), sus ceptibility is operationally defined as "the number of times the subject acts like a hypnotized person when hypnosis is induced by a standard procedure, and when the opportunities to react are presented in a standard manner." (p. 5). The scale essentially consists of a standard procedure for in ducing a hypnotic trance, followed by a "work sample" of the effectiveness of the procedure. This "work sample" consists of 12 challenge items which are scored one or zero depending upon whether or not the subject complies behav- iorally With the hypnotic suggestion given. The SHSS has been standardized on college students and has retest reli abilities ranging from .78 to .87 (Weitzenhoffer and Hil gard, 1959). The Harvard Group Scale of Hypnotic Susceptibility (HGS), developed by Shor and Orne (1962), is an adaptation of the SHSS, constructed for standardized group administra tion and scoring by self-report. As with the SHSS, the HGS consists of a verbatim hypnotic induction procedure and 12 challenge items. The HGS has a test-retest reliability on the order of .74 (Hilgard, 1967). Research based on the use of these various scales suggests that hypnotic susceptibility remains stable and basically unchanged over long periods of time (Hilgard, 1967). In addition, it is relatively impervious to most efforts to manipulate it and, in particular, to increase it (Cooper et al., 1967; Sachs and Anderson, 1967). Despite the reliability in measurement and its stability, attempts to relate susceptibility to various 8 personality traits and dimensions have proven largely un successful. Studies relating susceptibility to sex differ ences (Weitzenhoffer and Weitzenhoffer, 1958) , intelligence (Hilgard, 1967), persuasibility (Moore, 1964), and other variables have yielded either insignificant or only low correlations. A few studies, however, have demonstrated signifi cant correlations between susceptibility and role-involve- ment (Lee-Teng, 1965), motoric interests (Hilgard, 1965), and field dependency (Roberts, 1964). Josephine Hilgard (1970), summarizing these more significant findings, de scribes the hypnotizable person as one who has "rich sub jective experiences in which he can become deeply involved; ...one who reaches out for new experiences and is thus friendly to hypnosis; .. .one who is interested in the life of the mind, rather than being a competitive activist." (pp. 36-37). While these results provide important insights into susceptibility, there is a need for a more comprehensive model. If susceptibility is more than a situational re sponse and is, as many experimental findings suggest, a structural trait, then it should be related to a more gen eral personality profile instead of only a few isolated traits. As London (1971) has stated, 9 Having a measurable phenomenon which is at once as stable as hypnotic susceptibility, as dramatically visible in hypnotic inductions, and as isolated from any satisfactory empirical correlates or the oretical accounts relating it to other things, is the scientific equivalent of having an 'answer' to which the 'questions' are unknown, (pp. 15-16) London (1971) has recently proposed such a model, one that relates susceptibility to achievement motivation and electrophyBiological (EEG) correlates. The present study focused only upon the relationship between hypnotic susceptibility and achievement motivation. The derivation of this component of the model is based on the convergence of two lines of inquiry: 1) differences in task perfor mance between high and low susceptibles, and 2) differences in task performance between high and low need achievers. High and Low Susceptibles The historical development of this model began as a serendipitus finding arising out of a study by London and Fuhrer (1961). As a control over positively motivating effects of the hypnotic induction procedures, subjects were divided according to their hypnotic susceptibility. It was expected that high and low susceptibles would perform equally well on base rate measures of strength, endurance, and motor stability. Contrary to this expectation, low susceptibles did significantly better than high's on these 10 base rate measures. Furthermore, these differences occur red across independent subject blocks run by each of four experimenters, none of whom compared notes with the others during the experiment. Since then, the results of a series of studies by London and his associates have confirmed these differences between high and low susceptibles across experimental con ditions and across various learning and performance tasks. While the results of these studies are not entirely self- consistent, taken together they support the conclusion that low susceptibles out-perform high's on most maximum effort tasks. London and Fuhrer (1961), Rosenhan and London (1963a), Slotnick and London (1965), London and Rochman (1967), and Schaefler and London (1969) have found that low susceptibles perform significantly better than high's on base rate measures of strength, endurance, and motor sta bility as measured by the dynamometer, weight-holding, rotary pursuit, and other psychomotor coordination tasks. These differences also hold under experimental conditions of severe environmental stress (London and McDevitt, 1970; London, Ogle, and Unikel, 1968) and under conditions where the subjects have no knowledge of the true purpose of the experiment or of their hypnotic susceptibility (Rosenhan and London, 1963a). 11 Low susceptibles are also superior to high's on rote verbal learning tasks (London and Rochman, 1967). Rosenhan and London (1963b) and London, Conant, and David son (1966) found that low's were able to learn more non sense syllables presented on a memory drum than high's. Furthermore, these performance differences cannot, by and large, be accounted for by such variables as method of solicitation, volunteering, being paid or not, sex of subjects, kind of tasks, scale used to assess susceptibil ity, or experimenter differences. More importantly, these performance differences apparently reflect more general behavioral disposition characteristics of high and low sus ceptibles. Low susceptibles seem to be more highly moti vated, persistent, responsible, punctual, and competitive them high's, in and out of the experimental setting. Evi dence of this comes from observations that very highly susceptible subjects in some studies tended not to return to the laboratory for experiments, while low susceptibles were more reliable and punctual (Orne, 1963), or that low's volunteered to tolerate higher intensity levels of shock in an experiment than did high's (Shor, 1959). Schaefler and London (1969) also found evidence that low's have a strong er sense of responsibility and are less readily satisfied with themselves. In their study in which subjects were asked to quit unless they could promise to perform better 12 on the next round, only some of the subjects— mostly low's-- dropped out. Later, these same subjects agreed to resuihe, and their endurance scores rose proportionately higher than any of the other subjects. These differences do not necessarily Imply that high susceptibles are typically unmotivated or that low's are desperate to excel, but the results of these studies do suggest a general composite portrait of low's. London (1971), summarizing these findings, states that low sus ceptibles are: positively motivated, even striving...with a strong sense of responsibility, alert rather than easy go ing in relations with others,...not taking commit ments lightly, attentive to new situations, and responsive to instructions. (p. 20) This description i B remarkably similar to that reported by Josephine Hilgard. Summarizing the results of interviews with students, she concludes that high involvement in com petitive athletics, or in achievement- or work-oriented recreation, is negatively related to susceptibility. Also, pride in one's skill, attentiveness, stress on disciplined activity, persistence against odds, capacity for decision and control, vigilance and accuracy in perceiving and handling stimuli in the environment are all characteristic of low susceptibles (J. R. Hilgard, 1965). These findings on the differences between high and 13 low susceptibles tie-in remarkably well with the research findings on the construct of achievement motivation. High and Low Need Achievers Weinstein (1969) defines and summarizes the con struct of achievement motivation stating, The theory of achievement motivation...attempts to account for the determinants of the direction, mag nitude, and persistence of human behavior in ac tivities in which the individual believes his per formance will be evaluated (by himself or others) against some standard of excellence and where the outcome is clearly one of success or failure, (p. 153) As a motivational trait, the need to achieve should not be misconstrued as a state of motivation to excel in every task. Rather, the need to achieve depends upon the interaction of many different factors in any given person- environment relationship. Competitive conditions, for ex ample, tend to arouse and promote achievement motivation. The most commonly employed measure of achievement motivation has been the Thematic Apperception Test (TAT). Research on the TAT, however, indicates that it does not have satisfactory test-retest reliability (e.g. Krumboltz and Farquhar, 1957), and the scoring of it requires con siderable training and is time-consuming. Recently, mea sures of achievement motivation which are more reliable and 14 easier to score have appeared in the literature. Mehrabian (1968), for instance, has developed Male and Female Scales of the Tendency to Achieve, which have high test-retest re liability (r « .76, p < .05) and which are easily and ob jectively scored. Considerable research has been done on differences between high and low achievers. The evidence from these studies suggests that high achievers, like low susceptibles, tend to be more persistent and tend to perform better on various tasks them low achievers, who resemble high sus ceptibles. In fact, persistence on performance tasks has been found to be a primary attribute of high achievers. Feather (1962) and others report that low need achievers, when faced with a difficult task, abandon their efforts toward a solution sooner than high need achievers. It has been found that high achievers out-perform low's on tasks requiring language ability or skills, such as anagrams (McClelland et al., 1953), scramble word tests (Lowell, 1952), and composition of stories from given sen tences (French, 1955) . They also perform better on tasks requiring perception, such as maze learning (Johnston, 1955); learning of nonsense syllables and pursuit rotor (Heckhausen, 1967); and speed tests and arithmetic problems (Reitman, 1960). Comparing the general composite descrip tion of low susceptibles with that of high need achievers, 15 as well as high susceptibles with low need achievers, the similarities are remarkable and strongly suggest that these two traits may be closely related. Based on this research evidence on susceptibility and achievement motivation, London (1971) has hypothesized that these two dimensions are inversely related to one another, i.e. high susceptibles are lower in achievement motivation than low susceptibles. This theory has recently been tested by Miller (1973) who assessed base rate measures of hypnotic suscep tibility (using the HGS) and achievement motivation (using the Mehrabian Male Scale of the Tendency to Achieve), in a group of sixty adult males. While difficulties in the as sessment of the susceptibility dimension obscured the sig nificance of the results, a strong inverse correlation (r = -.49, p < .01) was found between scores on the Harvard Group Scale and scores on the Mehrabian Scale. While this evidence tentatively supports London's theory, one of the primary purposes of the present study was to obtain additional evidence by testing the inverse relationship between these two variables in a group of adult females, using the same test instruments employed by Miller (1973). 16 Clinical Application of London's Theory Apart from the theoretical speculation and inquiry which such a theory engenders, it may have practical, clin ical relevance as well. Specifically, it may be possible to use London's theory to match subject and treatment vari ables so that the outcome of certain therapeutic techniques can be predicted from pre-treatment scores on hypnotic sus ceptibility and achievement motivation. While many behavioral disorders other than obesity (e.g. phobias) could have been selected as a basis for testing the application of London's theory, obesity has several advantages: 1) it's a highly prevalent disorder; Stuart and Davis (1972) estimate that there are currently 40 to 80 million obese Americans, and 2) body weight, as an index of obesity, can be easily and objectively measured by standard balance scales. Since hypnosis has been used extensively in the treatment of obesity and since hypnotic susceptibility is a relatively stable phenomenon, it seemed logical to ex plore the relevance of hypnotic susceptibility to the treatment of obesity, to discover whether there is an in teraction between subject and treatment variables. CHAPTER III OBESITY Definition and Measurement While obesity has commonly been defined as "an excessive proportion of fat or adipose tissue in the body mass" (Stuart and Davis, 1972, p. 3), the translation of this definition into operational terms has generated much controversy due to difficulties in the determination and actual measurement of excess fat. A number of different techniques have been devised to determine the presence of excess adipose tissue. The two moBt commonly used measures have been reference to height/weight tables and measure ment of skinfold thickness. The simplest and most widely used method is the comparison of the height, weight, and build of an individual to standard tables of ideal or desirable weight, such as those published by the Metropolitan Life Insurance Company (1969). According to this procedure, an individual is con sidered obese if his weight is 15% to 20% or more in excess of the desirable weight as listed in the tables. In con trast, skinfold measurements are taken with the use of ex ternal, constant calipers. Skinfold densities greater than 17 18 one standard deviation above the mean are indicative of obesity (Seltzer and Mayer, 1965). While skinfold thickness measurement is generally regarded as a more accurate index of obesity than compari son to height/weight tables (Stuart and Davis, 1972), most researchers involved in the treatment of obesity choose the height/weight definition over that of skinfold thickness. Craddock (1969) states in this regard, "Where the weight is 10 percent above the desirable weight as shown by the Metropolitan Life Insurance Tables, the clinical diagnosis of obesity is rarely in doubt." Etiology There are numerous theories concerning the possible relationship of certain factors to the development of obesity. Most of these theories can be grouped into one of three categories: 1)genetic, 2)metabolic, or 3)psycho logical . Research into the role of genetic factors indicates that inheritance plays a predispositional role in the path ogenesis of obesity (Newman et al., 1937; and Wither, 1964). Thr current findings, however, are inadequate to answer important questions regarding the exact nature of these genetic factors and their size. Although there are numerous metabolic dysfunctions 19 and diseases which can cause obesity (e.g., Frolich's Syndrome, hypothalamic dysfunctions, and hypothyroidism), the actual number of obese patients with these disorders is relatively small. Bigsby and Muniz (1962) estimate that only about 3% of obesity cases have an organic or en docrine basis, which means that the great majority of cases are related to psychological factors which influence eating habits and physical activity. Earlier studies dealing with the psychological factors of obesity, concentrated upon demonstrating that obesity is a consequence of various neurotic disorders and that obeBe persons are more neurotic in some measurable way than the non-obese. More recent studies have discon- firmed many of these earlier findings, and at present there are no significant differences between the obese and non- obese in terms of psychopathology (Moore, 1962; McCance, 1961; and Shipman and Plesset, 1963) . Current research has largely abandoned the pursuit of neurotic disorders as a cause of obesity and have instead focussed upon the inter action of physiological and psychological factors and the circumstances affecting eating habits. Perhaps the only conclusions that can be derived from these three areas of research are that genetic fac tors may be predispositional but are apparently not causal, metabolic factors can be causal but occur infrequently, and psychological factors related to psychopathology are probably unrelated. Until the exact cause and effect re lationships of these various factors are known and their implications for treatment agreed upon, therapists must somehow conceptualize the relationship between the obese and food and pursue a course of treatment. If obesity is viewed simply as the result of a caloric imbalance, where the caloric intake exceeds output, then the indicated treatment would be a reversal of this imbalance, i.e., a caloric output exceeding the input. The most direct method of correcting this imbalance is to change the obese indi vidual's eating and exercising habits. ThiB model was used as a basis for the treatment techniques employed in this study. CHAPTER IV TREATMENT Hypnothe rapy Hypnotherapy has been widely used in the treatment of obesity, but there appears to be little consensus as to which form of hypnotherapy is most effective, and no ex perimental studies have yet compared the various approaches. In fact, there are few studies which adequately describe the hypnotherapeutic procedure employed. Perhaps the best description of how obesity can be treated using hypnosis in conjunction with behavior modifi cation techniques, is the one provided by Hanley (1967), who developed a weight reduction program for groups of obese females. Hanley describes the theoretical premise and goals of this procedure as follows: Regardless of etiology, any individual patient, with his specific genetic, metabolic, and emotion al make up, gains weight because, in the last analysis, he is taking in more food than he actually needs for energy and maintenance. For the obese, overeating is not simply an occasional practice but has become a habit, a learned pat tern of behavior involving long-standing atti tudes to food and eating. Added to this are self- dislike generated by the disfigurement and and discouragement due to the frequent failure to re verse the process of weight gain or even to con trol it adequately by dieting... The basic prob- 21 22 lent with obesity is to help the patient to learn new, more satisfactory eating habits and to have these become so firmly implanted that they will last indefinitely. (p. 549) According to Hanley, the treatment hour begins with a group discussion in which the patients are encouraged to express their feelings of guilt, discouragement, and hostil ity associated with eating and obesity. These discussions are intended to provide mutual support and an interchange of helpful ideas among the members. Following the discussion, the remainder of the hour is spent on group hypnosis. When everyone is in a satis factory trance.state, suggestions are given concerning the pleasure which can be derived from eating. They are told that they will enjoy even more the taste of food and the satisfaction of chewing it and that when they swallow the first mouthful they will begin to feel satisfied and full. It is suggested that by the time they have eaten a very small portion of food they will feel so satisfied and full that they will have no desire to eat anything more until the time of the next meal. Increased feelings of confi dence and self-esteem are also suggested. They are asked to visualize themselves at the size and weight they would like to be, doing the things they cannot do now, wearing the clothes they would like to wear, enjoying additional energy, and so on. Following these general suggestions, 23 special suggestions are offered to individual patients in the group by referring to them by name and by telling other patients that they may disregard these remarks. Each member of the group is permitted to lose weight at her own individual rate. Hanley estimates the average weight Iobs to be 2 or 3 pounds a week. The great est weight loss has been 70 pounds in 6 months. The general hypnotic suggestions formulated by Hanley (1967) are similar to those developed by other hyno- therapists such as Brodie (1964) and Hartman (1969) in that the suggestions are directed towards altering specific eating habits and towardB improving the patient's self- evaluation . It has been the observation of Brodie (1964) and others that the obese tend to eat rapidly without attending to the taste and smell of food. By giving hypnotic sugges tions concerning the importance of eating more slowly and of deriving greater pleasure from gustation, it causes the obese to attend more carefully to the taste and texture of food. If these suggestions produce the desired results, the patient will begin to experience a satiation of the taste buds and a diminution in appetite after consuming a minimal amount of food. Brodie (1964), in his hypnotherapeutic procedure, also emphasizes the importance of getting patients to 24 attend more carefully to how they eat, e.g., which teeth are used, which side of the mouth, and so forth. The goal is to make them: aware of how they eat and of how they feel while eating, to make them aware of what they have been doing unconsciously and, in this way, the food be comes an item of experience to be enjoyed and con trolled. (p. 213) The hypnotherapy condition employed in the present study included an induction procedure patterned after the one employed in the Harvard Group Scale, followed by a com bination of techniques and hypnotic suggestions developed by Hanley (1967) and Brodie (1964), as well as new tech niques not previously reported in the literature. Non-Induction Hypnotherapy While it is generally accepted that the induction procedure is useful in eliciting hypnotic behaviors, the extent of its utility is less certain. Empirical evidence concerning this issue is clear on one point, however; induction is not indispensable to the elicitation of many of the behaviors commonly associated with hypnosis. It has been demonstrated through a series of studies by Theodore Barber and his associates that most behaviors which occur in the hypnotic trance can also be elicited through direct instructions in the waking state. Barber 25 and Hahn (1964) found that waking-imagined analgesia and hypnotically-suggested analgesia had a similar effect in producing a reduction in subjective pain experiences. Barber and Calverly (1964a) made a similar discovery with hypnotic deafness: subjective reports of alterations in auditory perception were elicited with and without prior administration of a hypnotic induction. In a different study, Barber and Calverly (1964b) found that hypnotic time distortion (i.e., subjective testimony that a brief period seemed to be a very long period of time) can be produced by suggestions given to subjects under waking conditions. Finally, physiological effects produced under hypnosis have also occurred under waking conditions. These effects include elevation of gastric acidity (Luckhardt and Johnston, 1924), heart acceleration (Favill and White, 1917,), and reduction of warts (Ullman and Dudek, 1960). While this evidence suggests that hypnotic induc tion is not indispensable to the elicitation of many be haviors identified with hypnosis, it has been argued by London (1967) that induction is not totally irrelevant. Research studies suggest that the induction procedure may improve verbal productivity ( N o b s and Stachowiak, 1963), tolerance for anxiety-producing situations (Nayyar and Brady, 1962), vividness of reported imagery (Rossi et al., 1963), and a number of other behaviors (Barber and Glass, 26 1962; Weitzenhoffer and Sjoberg, 1961). London (1967), summarizing the research literature on the role of the induction procedure in the elicitation of hypnotic behaviors, states: It is not at all clear, however, that blanket statements about induction effects can be made... Some behaviors, it seems, are more likely to happen with induction than without and some not; and either effect is more likely in Borne people than in others, and in some situations or experiments more than in others. And any of the effectB are sometimes replicated and sometimes not. In brief, it all depends— but it is not clear on what. (p. 48) The issue of the relevancy of induction in elicit ing particular behaviors leads to speculation about its role in hypnotherapeutic procedures as well. That is to ■ay, how would the outcome of hypnotherapy be affected by the elimination of the induction from the therapeutic pro cedure? While no studies have yet attempted to answer this question with regard to the treatment of obesity, studies related to this issue have reported on the effectiveness of desensitization therapy with and without hypnotic in duction . On the assumption that hypnotic induction might en hance visualization and thus facilitate treatment, Lang (1969) used desensitization therapy with and without hypno sis in the treatment of snake phobic subjects. The re sults indicate that the mean difference between the two 27 conditions was not significant, suggesting that hypnotic induction is not a significant aspect of the desensitiza tion process. The importance of hypnotic induction to desensiti zation therapy has also been assessed indirectly through studies of the relationship between hypnotic susceptibil ity and therapy change. Lang, Lazovik and Reynolds (1965) used the Stanford Hypnotic Susceptibility Scale as a mea sure of responsiveness to imagery in desensitization ther apy with snake-phobic subjects and found no significant re lationship between the susceptibility scoreB and any mea sure of fear change. Larsen (1966), however, reports a positive correlation between post-test, but not pre-test, measures of hypnotic susceptibility and snake-approach be havior. He suggests that this finding indicates a rela tionship between hypnotizability and improvement in ther apy. Schubot (1966) studied the desensitization of snake phobics and also examined the relationship between the SHSS and approach behavior. He found very high posi tive correlations between change in approach behavior and the SHSS for subjects who were desensitized using a hypno- tic-relaxation procedure, but essentially no relationship for subjects who were desensitized without using hypnosis. While the results of these studies are too con 28 fusing and conflicting to arrive at any definite conclu sions regarding the utility of induction, most of these studies suggest that the hypnotic induction is not indis pensable, though it may be relevant to heightening re- sponsivity to suggestions under certain circumstances. This issue was further explored in the present study by including a second treatment condition. This treatment. Non-induction Hypnotherapy, paralleled the Hyp notherapy condition in every respect, with two exceptions: 1)there was no hypnotic induction employed, and 2)it was not referred to as a "hypnotic" therapy group by the ther apists to the subjects. The purpose of this second modi fication was to circumvent any of the expectancies or re sponse biases which have been found to be associated with the term "hypnosis." As Barber (1967) states: Defining the situation as 'hypnosis' may be suf ficient to arouse the subject's curiosity, to enhance his interest in the experiment, and to motivate him to perform well on the criterion tasks, irrespective of whether the subject enters 'trance'... By defining the situation as 'hypno sis' additional factors are introduced that could bias the results. (p. 467) It was hypothesized that if, as previously predic ted, hypnotic susceptibility is positively related to treatment outcome of hypnotherapy, and if induction is not indispensible to the elicitation of hypnotic behaviors, then hypnotic susceptibility should also correlate with 29 the outcome of the Non-induction Hypnotherapy group. As with the Hypnotherapy group, if London's theory is valid, low achievers would be more successful at weight reduction than high's in this group. Task-Oriented Therapy In the Hypnotherapy and Non-induction Hypnotherapy conditions, the Bubject and treatment variables were match ed such that high susceptibles and low need achievers would logically lose more weight than low susceptibles and high achievers. Xn contrast to theBe other treatments, a third treatment condition— Task-oriented therapy— was in cluded which was designed such that low susceptibles and high achievers would conceivably lose more weight than high susceptibles and low achievers. This third treatment condition provided a means of further investigating the ap plicability of London's theory. The development of this third condition followed logically from the results of studies on hypnotic sus ceptibility and achievement motivation. As previously dis cussed, low susceptibles and high achievers out-per form high susceptibles and low achievers on specific, goal- oriented tasks such as pursuit rotor, memorization of nonsense syllables, and unscrambling of anagrams (Heck- hausen, 1967) . Furthermore, they also demonstrate greater 30 persistence at these tasks (Feather, 1962). Based on these findings, it would be predicted that in order to adequately match subject and treatment variables, this treatment procedure would primarily involve specific, goal- oriented tasks which require persistence on the subject's part in accomplishing the desired goals. Recently, be havior therapy techniques directed towards contingency management have been developed which meet these require ments . Contingency Management Techniques The basic goal of this approach to treatment is to teach subjects how to use behavior modification techniques to gain control over the stimuli which promote eating as well as their own responses to these stimuli. Ferster, Nurnberger, and Levitt (1962) were the first to report on the development of a contingency management program. The goal of their program was primarily to make the aversive consequences of overeating more immediate to the subjects. Towards this goal, they had subjects review the unpleasant consequences of their obesity (e.g., illness and loss of loved ones), record their food consumption, schedule eating to occur at given intervals, increase the frequency and duration of activities which would be incompatible with eating, and, in general, gain stimulus control over their 31 eating. Stuart (1967) treated eight female patients using a program silimar to the one developed by Ferster et al., (1962) but with some modifications. Stuart's program con sisted of a six-step curriculum. Subjects were first trained in the analysis of their own eating behavior and of the variables which maintain it. Following this, they were instructed in methods by which they could control and modify this behavior. These methods included: taking smaller bites, replacing utensils on the table between bites, and engaging in alternative behaviors at times when between-meal eating would normally occur. In a subsequent report, Stuart and Davis (1972) expanded this program to include dietary planning and increased energy expenditure, both of which will be discussed more fully in the section on diet and exercise. Harris (1969) investigated the effectiveness of using covert sensitization procedures in addition to a program emphasizing contingency management techniques. In her study, 24 subjects were assigned to either of two ex perimental sections or to a control group. For the first part of the program both experimental sections were of fered the same treatment which was comprised of three techniques: training subjects to reinforce themselves for appropriate eating behavior, reducing the number of stimu- 32 li eliciting eating, and lengthening the chain of responses involved in eating by training subjects to eat slower and take short breaks during meals. After ten weeks, one half of the experimental subjects were placed in an aversive conditioning program using covert sensitization while the other half continued with the same treatment procedure as before. The results indicated that subjects in the ex perimental conditions lost significantly more weight than those in the control group, but there was no difference between the two experimental groups which did and did not receive covert sensitization. Wollersheim (1970) compared the effectiveness of a focal-treatment procedure to that of a nonspecific treat ment, a positive expectation-social pressure procedure, and a no-treatment control. Subjects in the focal-treat- ment group were first taught deep muscle relaxation to be used in situations where tension would typically result in eating. Following this, the content of the sessions focus sed on developing stimulus control over eating behaviors, self-reinforcement for control of eating, and establishing alternative behaviors incompatible with eating. In con trast, the non-specific treatment group focussed on the development of insight into problematic eating, and the positive-social pressure procedure used social pressure to induce weight loss (analogous to the TOPS program) . Sub- 33 jects in all three treatment groups lost significantly more than controls but the focal-treatment group lost signifi cantly more weight than either of the other two groups. Penick, Filion, Fox, and Stunkard (1971) conducted a study in which the effectiveness of a group behavioral treatment procedure was compared with traditional group therapy. The behavioral group, which used techniques simi lar to those employed by Stuart (1967), focussed upon nar rowing the scope of stimulus cues for eating to a minimum. This group lost significantly more weight than the tradi tional group at the time of the follow-up (from three to six months after termination of the program). While the evidence is not entirely consistent, the results of these studies taken together suggest that con tingency management techniques produce greater weight loss in subjects and that this loss is maintained over a longer period of time in comparison to the more traditional ap proaches to treatment. Although these various contingency management, or self-control, techniques differ in terms of the various be haviors they involve, they are also similar to one another in at least two respects. First, all of these techniques involve well-defined, goal-oriented activities. The techniques of taking smaller bites and taking short breaks during meals, for instance, are specific behaviors directed 34 towards the goal of slowing down the pace of eating. Secondly, in order for subjects to become proficient at using any of these techniques, they must have sufficient motivation and persistence to practice the relevant be haviors on a daily basis. Since high need achievers (low susceptibles) are characteristically more highly motivated and persistent at goal-oriented activities, it would be predicted that they would acquire these techniques more readily and thereby lose weight at a faster rate than their low achieving (high susceptible) counterparts. To test this prediction, the Task-oriented condi tion in this study included many of the techniques used in previous studies, as well as new techniques never used be fore. This treatment condition, however, differed from these other studies in one important respect: instead of instructing subjects in techniques to be implemented and practiced outside of the sessions in their natural en vironment, subjects in this program practiced the desired behaviors during the sessions as well as outside of them. The theoretical rationale for this approach was basically two-fold: l)it assured that all of the subjects in the group understood how these techniques were to be implement ed and practiced, and 2) it increased the likelihood that these behaviors would generalize to situations outside of the sessions. 35 As mentioned previously, the content of the Task- oriented condition paralleled the content of the Hypno therapy and Non-induction Hypnotherapy groups, but sub jects in this condition actually engaged in the behaviors which the subjects in the other groups only imagined doing, e.g. eating slowly and taking small bites. This made the treatment groups roughly comparable in terms of content while permitting intra-group variance in response to the particular techniques used to present this content. Diet and Exercise It has become a common practice in research studies on the treatment of obesity to compare and investigate various behavioral techniques by using them in isolation, rather than in combination with a basic diet and exercise program. Several studies have reported the use of tech niques such as hyponosis (Hanley, 1967; Brodie, 1964), covert sensitization (Manno and Marston, 1972), and avoi dance conditioning (Kennedy and Foreyt, 1968) during the treatment sessions, but subjects were not provided with, or encouraged to follow, a diet and exercise program be tween sessions. While such a procedure avoids the con founding of variables and may therefore be desirable from that point of view, it runs the hazard of encouraging the belief that these techniques are "magical" or that they can 36 cause weight loss "automatically" without any real effort on the subjects' part between the weekly sessions. Also, the use of behavioral techniques in isolation leaves the subjects to their own devices as to exactly how they regu late their eating habits to lose weight. For some indi viduals this may not pose any problems. Other individuals, such as those in the study by Mann (1972), however, may resort to extreme measures such as taking laxatives or diuretics in order to promote rapid weight loss between sessions. Still others may elect to follow a diet program which promises rapid weight loss but which can be hazardous to their health.2 In this study these problems were circumvented by using a diet and exercise program, developed by Richard Stuart and Barbara DaviB (1972), in combination with all three experimental procedures. The theoretical basis for this was that the techniques would aid subjects in their efforts to adhere to the diet and exercise program. A discussion of the relevant literature, as well as the rationale for the selection of the Stuart and Davis pro gram, is presented below. 2as an example of this, The Medical Letter (1973) reported that the diet promoted in the best seller, Dr. Atkin's Diet Revolution, is "unbalanced, unsound, ancPun- sale7w------------------ 37 Diets Most diet programs seek to create a caloric deficit by altering the proportions of three main dietary compo nents— carbohydrates# fats# and protein. Diet programs such as the "Airforce Diet#” "Calories Don't Count Diet#" "Inches-Off Diet#" and "Quick Weight-loss Diet" produce weight loss by promoting high-protein# low-carbohydrate foods. Other diet programs emphasize the complete removal of carbohydrates from the diet (Bloom and Clark# 1964)# the promotion of grapefruit and eggs as the basic regimen ("Mayo Clinic Diet")# ingestion of bulk or indigestible materials to curb the appetite# and various dietary pro ducts such as Metrecal. At present# however# there is only limited re search evidence to support any of these diet programs as an effective# palatable# nutritious# and lasting means of losing weight. As pointed out by Stuart and Davis (1972), nearly all of these diets suffer from two major drawbacks: First, while radical changes may have a temporary psychological appeal, experience has shown that extreme alterations in existing food practices cannot be tolerated for long periods of time. Such diets therefore are not conducive to the long-term regimens necessary for reconditioning of eating habits and maintenance of weight reduc tion. Second# bizarre regimens may fail to pro vide satisfactory levels of essential nutrients. (p. 137) 38 The current research findings, based on studies by Mayer (1968), Martsook and Hershberger (1963), and Griffith and Dyer (1967) , seem to favor the by-now familiar pre scription: eat a balanced diet but reduce the over-all intake of food. Stuart and Davis (1972) have translated this into more specific terms: the diet should promote a reasonable balance of carbohydrates, fats, and protein; should restrict calories moderately but provide a generous supply of all other essential nutrients; and should consid er cultural and individual food preferences. In keeping with these basic guidelines Stuart and Davis (1972) have developed a dietary management plan based upon a division of the main food groups into lists, each containing a variety of foods which are approximately equal in food value. Dieters are allowed a selection of food from each list, the type and number being determined by nutritional value and the caloric limitation of the choBen food plan. Foods in each of the lists are referred to as "exchanges" since they may be freely exchanged for other foods in the same list. There are four basic steps in implementing this program. They can be summarized as follows: 1. The first step is choosing a caloric level which will maintain a loss of an average of one pound of body fat per week through dietary restriction. To calculate the amount of dally caloric Intake neces sary for such a weight loss, an individual must first determiner by reference to a table of caloric allowancer his estimated daily caloric requirement. Since one pound of body fat can be lost in a week by creating a caloric deficit of 500 calories per day, the dieter must subtract 500 calories from this requirement in order to arrive at his final dietary goal. For example, a man at age 25 must limit his caloric intake to 2,300 calories per day in order to lose one pound per week. As an individual loses weight the caloric deficit must be adjusted accordingly. As each 25 pounds is lost, it is necessary to decrease daily intake by an additional 100 calories because less energy is required to move a lighter body mass. The second step of the program is choosing a food plan to provide approximately this number of calories. Stuart and Davis have devised basic food plans which are both nutritious and well- balanced. Within the basic framework of these food plans, the dieter has a great deal of latitude in terms of the specific food items that he is per mitted to have. Once a suitable food plan has been chosen, the 40 next step is the actual monitoring of food intake by keeping a daily record of the amount of food eaten and the time at which the eating occurs. This daily record is designed to provide feedback as to how much more can be eaten during that day and cues for the selection of appropriate foods. Exercise The relationship between physical activity and obesity has been well established by research evidence: obese individuals are generally less active during the day than are non-obese individuals. Studies by Bullen, Reed, and Mayer (1964), using time motion pictures of obese and non-obese girls, revealed that the obese girls expended less energy than the normal-weight subjects even though both groups were involved in the same scheduled activity. A study by Stefanik, Heald, and Mayer (1959) assessed 14 obese boys and 14 normal controls at school and during summer camp and found that the obese boys preferred the less active exercises. Exercises involving running, for instance, were preferred by three obese boys but by eight of the controls. Similar findings have been made with normal and obese adults. Doris and Stunkard (1957), for instance, studied the amount of walking undertaken by 15 obese 41 women and compared it with that of 15 normal controls. During one week the obese women walked an average of 2.1 miles daily while the non-obese women walked 4.9 miles daily. Whether the lower activity levels of the obese are a cause or a result of their overweight condition is dif ficult to determine with the existing evidence. Inactiv ity , in any caBe, undoubtedly perpetuates their condition and would therefore, appear to be an important factor in weight control programs. Traditionally, though, the im portance of physical activity has been minimized in weight control programs because of several misconceptions. A popular belief perpetuated by some researchers has been that physical exercise is not an effective or realistic means of weight reduction because it requires extreme physical exertion to work off even a couple of pounds. As Bigsby and Muniz (1962) point out; It takes a 10-mile walk to use up the calories in one chocolate sundae,...one must walk 36 miles to lose a pound, and...a person must saw wood for at least an hour to offset a piece of apple pie. (p. 107) Such statements are enough to dampen the enthusiasm of even the most ardent exercisers. The difficulties with this viewpoint are two-fold. First, physical exercise need not be exhausting and pro 42 longed to be beneficial. Short but regular periods of exercise can produce the same results and can be a useful and enjoyable adjunct to weight-reduction regimens. As pointed out by Stuart and Davis (1972): Carefully controlled studies on small groups of people have demonstrated that when diet and exercise are combined, regular exercise increases the rate of weight loss. Furthermore, it is well known that the obese individual will burn more calories per minute than his lean counterpart when carrying out the same task. Thus, while dietary restriction has the most dramatic effect on weight reduction, regular exercise can in the long run make a contribution. (pp. 173-174) Secondly, studies by Kleiber (1961), Herxheimer et al. (1926), Edwards et al. (1935), and Kang et al. (1963) suggest that the increase in metabolic rate result ing from exercise may continue on long after the cessation of physical activity and is not limited to the time period of the actual exercising as perviously thought. Miller (1969) , commenting on the significance of the results of these studies, states: These observations are of importance in the treat ment of obesity by exercise because they suggest that the metabolic rate is raised not only during the period of the task. We may calculate that the extra energy cost to a business man who plays a game of golf is relatively small but if the exer cise stimulates his metabolism long enough, it could make a significant difference to energy bal ance. (pp. 66-67) 43 Another misconception has been that increased ac tivity levels will always increase appetite, which in turn leads to an increase in food intake. Thus, the benefit of additional energy expenditure through exercise would be cancelled out by the stimulation of appetite. According to Stuart and Davis (1972), the intri cate physiological mechanisms which act to regulate appe tite and to balance food intake with energy expenditure only work adequately within normal ranges of physical activity. When the energy expenditure is at a sedentary level, below the normal range of activity, these physio logical mechanisms fail to work properly and the rate of food intake may exceed energy expenditure. However, when the activity patterns increase from a sedentary to a normal level, the mechanisms which regulate appetite become operable. Stuart and Davis (1972) conclude in this regard: As well as allowing normal functioning of appetite- control mechanisms, exercise may affect food intake in other respects. Strenuous exercise before a meal frequently acts to decrease appetite for that meal. In addition, by adding periods of some form of regu lar, enjoyable exertion to the daily routine the ten sion and boredom that frequently stimulate eating may be alleviated. (p. 171) While even a moderate level of exercise seems to be of value in weight reduction, a major obstacle in promoting increased activity among the obese is that a daily regimen 44 of exercise or calisthenics can quickly become aversive and will be abandoned if it is too strenuous, inconvenient, or monotonous. One method of circumventing these obstacles is to make exercise a part of daily or recreational activ ities. Stuart and Davis (1972) have developed such an exercise program, one that integrates increased energy ex penditure into the natural course of daily activities. In this program they emphasize the importance of not using many of the modern conveniences in the course of our daily living but instead choosing more energetic options, e.g., taking the stairs instead of the elevator, standing instead of sitting, and parking at the farthest end of the lot. Regularly scheduled recreational activities such as tennis or golf can also provide significant increases in energy expenditure with a minimal amount of discomfort. In order to provide more immediate feedback and re inforcement for increases in daily and recreational activi ties, they have also devised a useful guide for quick cal culations of energy expenditure. It is suggested that in dividuals first gather baseline information regarding their present levels of activities. Once baseline infor mation has been derived, it is recommended that individuals then concentrate on increasing this amount by 250 calories per day. Such an increase should result in a weekly weight 45 loss of about one-half pound. If this exercise program Is used In conjunction with the diet program previously discussed, the potential for weight loss is significant but not overly impressive. Stuart and Davis (1972) estimate that an individual can lose 1% pounds a week if he diligently follows both the diet and exercise programs. Summary of Hypotheses The hypotheses tested in the present study are summarized as follows: Hypothesis 1. London's theory: hypnotic suscepti bility will correlate inversely with achievement motiva tion across all groups. Hypothesis 2. Pre-treatment scores on hypnotic susceptibility will correlate positively with post-treat- ment weight loss of subjects in the hypnotherapy3 group, i.e., high susceptibles will lose more weight than low susceptibles. Hypothesis 3. Pre-treatment scores on achievement motivation will correlate inversely with post-treatment 3A11 therapy and control conditions were used in combination with a diet and exercise program which included contact and support, dietary information and discussion, weekly weigh-ins, and recording of daily caloric intake and expenditure. 46 weight loss of subjects in the Hypnotherapy group, i.e., low achievers will lose more weight than high achievers. Hypothesis 4. Pre-treatment scores on hypnotic susceptibility will correlate positively with post-treat- ment weight loss of subjects in the Non-induction Hypno therapy group. Hypothesis 5. Pre-treatment scoreB on achievement motivation will correlate inversely with post-treatment weight loss of subjects in the Non-induction Hypnotherapy group. Hypothesis 6. Pre-treatment scores on hypnotic susceptibility will correlate inversely with post-treatment weight loss of subjects in the Task-oriented Therapy group, i.e., low susceptibles will lose more weight than high susceptibles. Hypothesis 7. Pre-treatment scoreB on achievement motivation will correlate positively with post-treatment weight loss of subjects in the Task-oriented Therapy group, i.e., high achievers will lose more weight than low achievers. Hypothesis 8. Subjects in the Hypnotherapy group will lose significantly more weight than subjects in the Minimal Treatment Control groupt Hypothesis 9. Subjects in the Non-induction Hyp notherapy group will lose significantly more weight than 47 subjects in the Minimal Treatment Control group. Hypothesis 10. Subjects in the Task-oriented Therapy group will lose significantly more weight than the Minimal Treatment group. CHAPTER V METHOD Subjects The subjects in this study were all females be tween the ages of 25 and 45 who were from 20% to 40% over weight, according to standard height-weight tables (see Davidson et al., 1959). In addition, they were women who reported themselves to be in generally good health and who believed that overeating was the cause of their over weight condition. Subjects were recruited through a news release to local newspapers and radio stations, as well as television appearances by Dr. Perry London, Professor of Psychology and Psychiatry at the University of Southern California. Approximately 2500 women from the Los Angeles area volun teered for the program by submitting letters containing information as to their height, weight, age, and brief history of their weight problem. Subjects who reported in their letters having diseases such as hypoglycemia or diabetes, physical disabilities which would prevent them from engaging in moderate exercise, or any other serious medical or psychological problem, were excluded from the 48 49 initial subject pool. Out of the remaining group of volun teers, the first 300 subjects who met the basic require ments listed above were selected to participate in the pre treatment screening sessions. Assessment Instruments The measures employed in this study were weight, > Biographical Questionnaire, Harvard Group Scale of Hypnotic Susceptibility, the Mehrabian Female Scale of the Tendency to Achieve, Diet and Exercise Record Form, and the Feed back Questionnaire. Weight All subjects were weighed at the beginning of every session, including the pre-treatment and follow-up sessions. Weights were determined on a standard physician's balance scale to the nearest half-pound. The measures of interest were the pre-post-treatment weight differences, the post- follow-up weight difference, and the .total weight differen ces between pre-treatment and follow-up for all participa ting subjects. Biographical Questionnaire This 36 item questionnaire (see Appendix A) re- 50 quested information as to their current state of health, history of their weight problem, current eating habits, previous attempts at treatment of their weight problem, and schedule of availability to attend the sessions of the program. This questionnaire was used for screening purposes and for obtaining the normative data included in the statistical analyses. Harvard Group Scale of Hypnotic Susceptibility This scale, developed by Shor and Orne (1962) , is an adaptation of Form A of the Stanford Hypnotic Sus ceptibility Scale, constructed for standardized group ad ministration and scoring by self-report. It consists of a tape recorded verbatim hypnotic induction procedure and self-report booklets which are scored by the subject ac cording to how similar the subject's responses are to the responses of good hypnotic subjects. Scores range from 0 (least susceptible) to 12 (most susceptible) and cor respond to the number of items passed on the 12 item scale. The test-retest reliability is on the order of .74 and correlations between self-scoring and observer-scoring are on the order of .85 (Hilgard, 1967). 51 Mehrabian Female Scale of the Tendency to Achieve This scale, developed by Mehrabian (1968), con sists of twenty-three statements, e.g., "My strongest feelings are aroused more by fear of failure than by hope of success." Subjects respond to each item on a 7 point scale, ranging from +3 or "very strong agreement" to -3 or "very strong disagreement.” The items are designed to measure independence; choice of achievement-related activi ty; feelings relating to success and failure; preference of moderate versus high or low risk situations; and pre ference for activity of, or persistence at, demanding tasks. A high score on this test indicates a high level of achievement motivation. The test-retest reliability is .72 and it correlates .28 with the TAT (p < .01) {Mehra bian, 1968) . Diet and Exercise Record Form This form was patterned after the one designed by Stuart and Davis (1972) (see Appendix B). The form pro vided space for the recording of all calories expended daily through exercise, total number of calories consumed, and body weight measured daily. The total number of daily records completed during the program was used as an indi cator of the subject's adherence to the diet and exercise 52 regimen. Feedback Questionnaire This 11 item questionnaire (see Appendix C) is a self-report measure of changes in dieting and exercising habits during the four week follow-up period between the last treatment session and the follow-up session. It also provided information as to calls made and received among the subjects of each group. Procedure The group of 300 subjects selected to participate in the pre-treatment screening sessions, were sent a post card notifying them that in order to determine whether or not they could be accepted into the weight-control program, it would be necessary for them to attend a pre-treatment session during which they would complete some preliminary tests and questionnaires. They were also notified as to the time, date, and place of this session. Pre-Treatment Screening Session For this session, subjects were run in six groups, ranging in size from 30 to 60 subjects. As subjects ar- rived for the session they were weighed and their height was measured. After all of the subjects had arrived, the experimenter introduced himself and gave them an introduc tion to the general nature and structure of the program, as well as the purpose of this pre-treatment session. Sub jects were informed that this weight-reduction program was a research project sponsored by a grant from the National Institute of Mental Health and was designed to "find new and better ways of helping people to lose weight." It was explained that there would be three treatment groups. One would use hypnosis; another, covert sensitization (which was actually the Non-induction Hypnotherapy group); and the third group would use a new approach to diet and exercise (which was actually the Task-oriented group). The false labels for these treatments were used as a means of further disguising the true intent of these two groups. Also, sub jects were not informed as to the existence of the fourth group at this time because originally the control group was to consist of subjects on a waiting list. Only later was it decided to replace the No-treatment control group with a Minimal-treatment group. Since a few subjects had requested a particular treatment group, they were told that it would be impossi ble to assign participants to groups on the basis of indi vidual preferences. They were urged instead to trust the 54 judgment and decisions of the staff in this regard. They were told that the sessions of the program would be scheduled for one hour per week for seven con- sectutive weeks, with a follow-up session four weeks after the seventh treatment session. While there was no cost involved, all participants would be required to make a fifteen-dollar deposit which would be refunded only if they attended all of the sessions, including the follow-up. This deposit was intended to sustain their commitment to the research project. They were informed that the purpose of this pre treatment session was to obtain more information about them by having them complete a questionnaire concerning their health and medical history, and by assessing their responsiveness to hypnosis. They were told (contrary to fact) that their score on the hypnotic susceptibility scale would have no bearing on their acceptance into the pro gram. Since not everyone attending the pre-treatment sessions could be accepted into the program, final selec tion of participants would be based upon height/weight ratio, availability to attend the sessions, and informa tion obtained from the questionnaire. ' They were told that they would be notified by mail within two weeks re garding their acceptance or rejection. Following this introduction, subjects were given 55 the Biographical Questionnaire. After completing this, each subject was next given a pencil and a copy of the self-scoring booklet of the Harvard Group Scale of Hypnotic Susceptibility. They were told that this scale would be administered by tape recording and they were asked to lis ten carefully and follow all of the instructions on the tape. They were also reminded that their score on the scale would have no bearing on their acceptance into the program. Following the administration of the scale and sub sequent completion of the susceptibility scale forms, sub jects were dismissed with the thanks of the experimenter. Assignment to Groups After completion of the pre-treatment sessions, the additional information obtained was reviewed and sub jects not meeting the basic height, weight, age, and health requirements were eliminated as prospective subjects. Of the remaining group, 120 subjects were selected on the basis of two criteria: l)they had to be available to at tend all of the sessions of at least one of the treatment groups, and 2) they had to have a score between 0 or 6 be tween 8 and 12 inclusive on the Harvard Group Scale. Sub jects scoring between 0 and 6 were designated low sus ceptibles (low's) and subjects scoring between 8 and 12 56 were designated high susceptibles (high's). The 120 sub jects were selected such that 60 of them were high's and 60 were low's. An equal number of high's and low's were randomly assigned to the four groups, so that there were 15 high's and 15 low's In each group. A few subjects were transferred from their original assignments to other groups in order to overcome scheduling difficulties. The purpose of selecting subjects and assigning them to groups in this manner was to increase the strength of the correla tion values between susceptibility and other variables, as per hypothesized. Subjects who were accepted into the program were notified by mail and were given information as to the date, time, and place of the first treatment session. A medical release form (see Appendix D) accompanied the acceptance letter (see Appendix B) and they were asked to have their physician sign and return this form prior to the first session. Furthermore, they were asked to contact the Project Coordinator immediately by phone if, for any rea son, they were no longer interested in participating in the program. The subjects who were not accepted into the program were also notified by mail and were given an opportunity to be placed on a waiting list for participation in future weight-reduction studies. 57 Therapists Five male therapists, including the investigator, participated in the program. Therapists I, II, and III were all Professors of Clinical Psychology with extensive experience in both the clinical and research aspects of hypnotherapy and behavior therapy. Therapists IV and V were Ph.d. Candidates in Clinical Psychology who had at least two years of supervised experience in psychotherapy (both individual and group) and who had experience in ad ministering scales of hypnotic susceptibility to a minimum of 60 adults each. The therapist variable was controlled by counter balancing therapists and treatment sesBionB in the follow ing manner: Therapist I conducted sessions 1 and 7 for all four groups; Therapist II conducted sessions 6 and the follow-up; Therapist III, session 4; Therapist IV, sessions 3 and 5; and Therapist V (the investigator and Project Coordinator) conducted session 2 and served as an assistant to the other therapists during all of the other sessions. Although all of the therapists involved were aware of the basic design of the experiment and the hypotheses to be tested, their awarenesB was not a research issue since the hypotheses concerned the subject differences within each group rather than differences between groups, and all of the therapists, including the investigator, 58 were blind to the susceptibility and achievement scores of the individual subjects. Setting All of the treatment sessions were conducted in a large lecture room in the Psychological Research and Ser vice Center at the University of Southern California. Subjects were seated in wooden chairs with a side-arm writing surface, facing the therapist. The over-head flourescent lighting could be adjusted to dim the lights during the trance-induction procedure of the hypnotherapy sessions. Treatment The treatment phase of the program, which covered a seven week period, began the second week in May and was concluded the third week in June. These sessions, which were once weekly, were of one hour duration, except for the last session at which time there was a lengthy dis cussion and evaluation of the program. The four groups always met on consecutive days of the week such that the Hypnotherapy group met on Mondays, the Non-induction Hyp notherapy group on Tuesdays, Task-oriented group on Wednesdays, and the Minimal Treatment Control group on Thursdays. 59 Session 1 (Orientation) For this session, all subjects in all of the groups were run through the same procedure which was designed to provide a general orientation to the program. At the be ginning of this session, all subjects were weighed, their fifteen-dollar deposit was collected, and they were given a packet of materials which included the following: 1) Mehrabian Female Scale of the Tendency to Achieve, 2)the condensed version of Slim Chance in a Fat World: Behavior Control of Obesity by Stuart and Davis (1972), and 3)seven Diet and Exercise forms (one for each week of the program). After introducing himself, the therapist informed the group that this first session was an orientation meet ing to explain the basic diet and exercise program, which all participants would be following, regardless of the particular treatment group they were assigned to. They were also told that the staff had not yet decided which group would get which treatment, but that this information would be given them at the beginning of the next session. The purpose of taking this approach was to get the sub jects thoroughly involved in the basic diet and exercise program before they were introduced to particular treat ment techniques. 60 By way of introduction to the basic program, they were urged to view this as a weight-reduction program for life, rather than a temporary or "fad" diet. The initial steps of the Stuart and Davis program, as presented in their book, were then explained and discussed, In partic ular, the food exchange lists, recording system of calories taken in and expended, and the calorie food plans were ex plained in some detail, in order to insure that subjects understood the basics of the program. They were also urged to carefully read and re-read the Stuart and Davis book given to them. As part of the basic program, all subjects were instructed to use the Diet and Exercise forms to record all calories consumed and expended each day, and their daily weight. These forms would be collected at the be ginning of each session. Finally, they were told that while the members of the staff would be willing to answer any questions they might have about the Stuart and Davis program, subsequent sessions would focus on material other than the basic diet and exercise program. Specifically, it was explained that future sessions would concentrate on * helping them to adhere to the following guidelines with regard to eating and exercising: 1. They were urged to think about their diet 61 as much as possible, so as to promote the learning of all phases of the program. 2. They were urged to tell their family members and friends about the program and to elicit their sup port and cooperation. 3. They were told to take small bites of food, chew each bite very slowly, and throw away the remain ing food as soon as they began to feel full. 4. They were told to "eat with concentration," i.e., attend to the taste, smell, and sight of each bite of food. 5. They were urged to exercise as much as possible because exercising is beneficial in at least two ways: l)it increases the rate of weight loss when used in combination with a diet program, and 2) it curbs the appetite when it occurs just prior to eating. Following the discussion of these guidelines, it was explained that during the remaining sessions special techniques would be used to focus upon changing their be havior in the direction pf these guidelines. The precise nature of these techniques, however, would depend upon the group they were assigned to. They were cautioned, though, not to rely solely upon the techniques used in the sessions to bring about the desired weight loss, but were urged to 62 concentrate their efforts upon following the Stuart and Davis program. Finally, they were asked to complete the questionnaires given to them and return them at the be- ginning of the following session. Hypnotherapy Group The first fifteen minutes of these sessions were set aside for weighing, handing-in of the Diet and Exercise forms for the previous week, and discussion of difficulties and successes with regard to dieting and exercising. Introduction. At the beginning of the second ses sion, subjects were informed that they had been assigned to the "Hypnotherapy" group on a random basis without re gard to their scores on the hypnotic susceptibility scale. Since a few low susceptible subjects were disgruntled about being assigned to this group, it was explained that research evidence and past experience indicates that low susceptible subjects respond as well as high susceptibles to hypnotherapy. They were told that "anyone can use their imagination to become involved in the hypnotic suggestions, even though they may not feel themselves to be hypnotized." Induction. The induction of the hypnotic trance, for all of the hypnotherapy sessions, was achieved through a procedure patterned after the one used in the adminis- 63 tration of the Harvard Group Scale. After the lightB had been dimmed, subjects were told to fix their eyeB on a spot on their hand and were given suggestions to relax. Towards the end of the induction instructions, subjects who had not yet closed their eyes were asked to do so and additional trance-deepening suggestions were given. Content. Following the induction period, subjects were asked to imagine themselves in a variety of situa tions related to eating and exercising. The imagery for these sessions focussed on the following topics: eating more Blowly; taking smaller bites of food; concentrating on the appearance, smell, and taste of food; eating low- calorie foods in preference to high-calorie foods; being more aware of feelings related to satiation; feeling nauseous when eating excessive amounts of high-calorie foods; feeling proud of their physical appearance once they have attained their desired weight goal; experiencing the benefits of daily exercise; resisting social pressure to eat when not hungry; distinguishing feelings related to true hunger from other emotions such as loneliness, anxiety or depression; and resisting the temptation to buy high- calorie foods when grocery shopping. PoBt^Hypnotic Suggestion. The following post hypnotic suggestion, related to the transfer of their ex periences during the session to their everyday activities, 64 was given at the end of every session, just prior to in structions for bringing them out of the hypnotic trance: When you wake up, you do not have to remember all of the experiences that I have described to you to night, but you will remember most of these experiences on a conscious or unconscious level. Whenever you eat anything you will remember to eat slowly and savor every bite. Even when you are not eating you will recall the experiences you had tonight. These images will even pervade your dreams and you will think of them often. You will want to change your eating habits so as to get the greatest pleasure from food. The slow er you eat the more you will enjoy it. Discussion Period. After subjects were brought out of the trance, they were allowed ten minutes at the end of the session to vent their feelings and to ask questions re lated to their experiences while hypnotized. A notable exception to thiB procedure occurred at the end of the fourth session, when each subject was given a pair of bamboo chop-sticks and instructed in their use. They were told that the chop-sticks were another tech nique for getting them to eat slower and to take smaller bites. They were urged to eat at least one meal each day, during the following week, using the chop-stickB in place of utensils. Session 7 The last treatment session was devoted to estab- 65 llshing a program which would help them to maintain the diet and exercise regimen on their own and to obtaining post-treatment feedback as to their perceptions of the program. Maintenance. In order to provide subjects with the moral support necessary for maintaining the program on their own, a self-help communication system was created. Each subject was given a list of the names and phone num bers of all the members of their group. They were then urged to call one another over the next four weeks, when ever they were having difficulties staying on their diet and exercise plan. But, in any case, they were told to call another member of the group at least twice a week. They were also asked to keep a record of the number of calls made and received and to bring this record with them to the follow-up session. In order to facilitate the formation of this self-help system, subjects were instruc ted to form groups of 3 or 4 during the session, and to make a definite appointment to call one of the members of their sub-group during the following week. About ten minutes were permitted for this social interaction. Subjects were then given three, 8 x 12 inch signs. One said, "Eat Slow, Eat Often, Eat With Concentration"; another said, "Is your stomach hungry— Or only your Heart?" and the third said, "Don't conserve energy— Ex- ercisel” They were asked to put these Bigns up in their home, wherever they felt that they would do the most good, e.g., on the kitchen cabinets and bedroom walls. They were also encouraged to make up similar signs of their own. In this same vein, they were asked to tape their weekly Diet and Exercise forms to their refrigerator door. Four additional forms were given them for this purpose. Finally, subjects were given instructions in self- hypnosis which they could use at home on their own. As during the previous sessions, they were instructed to stare at a spot on their hand while concentrating on relaxing all of the muscles in their body. As they count from one to twenty, they were told that they would go deeper and deeper into the hypnotic trance. Once hypnotizedt they could then imagine eating slower, taking smaller bites, resisting the temptation to eat when not hungry, and so forth. To bring themselves out of the trance they were told to count backward from 20 to 1 and as they did this they would gradually awaken until they were again in their normal state of wakefulness. The subjects were then al lowed to practice hypnotizing themselves and bringing them selves out of the trance state. 67 Non-Induction Hypnotherapy Group Sessions 2 - 6 As in the Hypnotherapy Group, the first fifteen minutes of these sessions were set aside for weighing, handing-in of the Diet and Exercise forms for the previous week, and discussion of difficulties and successes with regard to dieting and exercising. Sessions 2 - 6 Introduction. At the beginning of the second session, subjects were informed that they had been as signed on a random basis to the "Covert Sensitization" group. Subjects were given the following description of this approach to treatment: There are many different techniques that psychol ogists hhve developed, and this is a relatively new one. What it involves is being able to imagine different kinds of situations and differ ent kinds of foods and being able to imagine them so vividly that you can build up your will power. The best way for me to explain to you, or show you, what it's about is to go ahead with the ses sion, and then by the end of it you will have a pretty good idea of what it involves. The title and description of this procedure were deliberately obscure and vague in order to avoid the de mand characteristics associated with the words "hypnosis" 68 or "hypnotherapy.” Content. In place of the hypnotic induction pro cedure, subjects were asked to get comfortable in their chairs, close their eyes, and relax. The therapist then read to them a verbatim transcript of the imagery sugges tions which followed the trance induction instructions in the Hypnotherapy group. The same post-hypnotic suggestion was also given to this group, following presentation of the imagery. After the imagery and post-hypnotic suggestions were given, subjects were asked to open their eyes. As in the hypnotherapy group, at the end of each session a ten- minute period was devoted to answering questions and dis cussing their experiences. As in the other group, the end of the fourth ses sion was devoted to giving subjects chop-sticks and the same instructions for their use during the subsequent week. Session 7 Maintenance. The same instructions regarding the self-help communication system and the use of signs, pre sented to the Hypnotherapy group, were also given to this group. Unlike the hypnotherapy group, however, this group was instructed in a procedure whereby they could use 69 imagery as a means of maintaining the program on their own. To demonstrate this, subjects were asked to close their eyes and relax. They were then told to imagine some of the scenes which had been described to them during the previous sessions. Task-Oriented Group As in the other two groups, the first fifteen min utes of the sessions were set aside for weighing, handing- in of the Diet and Exercise forms for the previous week, and discussion of difficulties and successes with regard to dieting and exercising. Introduction. At the beginning of the second ses sion subjects were informed that they had been assigned, on a random basis, to the "Overt Sensitization" group. The subjects were given the following information as to the nature of this group: You all know that eating is a habit, a learned pattern of behavior which takes the particular form it has in our individual lives according to the patterns we have learned in childhood and preserved into our adult lives. Most of us have learned to eat in a thoughtless, auto matic way. As a result of this, some of the patterns we have developed interfere with our adult needs and desires— to be healthy, comfor table, and physically attractive to ourselves and others. 70 Some of the things you are going to learn here are to eat thoughtfully, to savor your food, and to appreciate it to the fullest using all your sen ses. We are going to teach you these skills and have you rehearse in the sessions what you have learned. This will make it easier for you to apply these skills to your daily eating experience. Content. SubjectB were given instructions for carrying out the following exercises during these sessions: 1. Subjects were given half of an apple and told to eat it very slowly, savoring every bite. The re sulting physiological changes, feelings, and ex periences related to masticatory and digestive pro cesses were brought to their attention as they ate the fruit. 2. Subjects were given a Hostess Cupcake on a paper plate. They were then instructed to place their hand on top of the cupcake and gradually smash it into the plate. As they did this, they were told to notice the smell and texture of it and the re sulting feelings of repugnance and nausea. Final ly, they were told to throw it away and to feel relieved as they did so. 3. Subjects brought fruit of their choice from home. They were instructed to eat the fruit slowly, taking small bites.and chewing each bite thirty times before swallowing it. They were also in- 71 structed to put the remaining fruit back on the plate between bites. After eating only ten bites they were told to dispose of what was left. 4. Subjects brought pieces of pastry of their choice from home. They were instructed to break the pastries in half and then eat them in the same manner as the fruit. As they were eating, they were told to become aware of the gradual sensations of fullness in their stomachs. After eating only ten bites, they again were told to dispose of the remaining pastry. 5. Subjects were instructed not to eat lunch or dinner on the day of the session and were asked to wear clothes suitable for physical exercising. They were told to bring to the session a Bandwich and an eight-ounce beverage. At the beginning of the session, the therapist led the group in three ex ercises: body bends, arm rotations, and running- in-place. Each exercise was conducted for two minutes with a two-minute rest period between ex ercises. During the resting periods, subjects were aBked to notice all of their bodily sensations, e.g., increased heartbeat, pleasant feelings of relaxation and exertion of muscles, increased blood flow to the brain, and a diminution of the feelings 72 of hunger. Folloiwng the exercises, subjects ate the sandwiches and drank the beverages they had brought. Again, the eating and drinking was done Blowly, concentrating on the taBte of each bite or sip. 6. As with the other groups, subjects were given a pair of chop-sticks and instructions for their use during the subsequent week. 7. Subjects were instructed to bring to the session the package or container of the food which they have had difficulty in resisting the temptation to eat. At the beginning of the session, subjects were given the abridged edition of Brand-*Name Calorie Counter by Netzer (1969). They were in structed to calculate the caloric value of the food in the entire package that they had brought and the number of minutes of their favorite ex ercise that it would take to burn up this number of calories. They then repeated these calculations for only one bite of this same food, instead of the entire package, in order to compare the effects of eating a lot of the high-calorie food with eating only a small portion of this same food. Finally, they were asked to think of their favorite low-calorie food and to calculate the amount of 73 this food that it would take to equal in caloric value the package of the high-calorie food. 8. Subjects were given various suggestions for re sisting the social pressure to eat when not hungry at home and at parties# For example# instead of eating meals with the family they could eat after wards# or they could refuse a hostess's offer of high-calorie foods by telling her that they weren't feeling well. 9. In order to get subjects to experience more fully the taste and texture of food# the following ex ercises# adapted from The Psychologist's Eat Every thing Piet by Pearson and Pearson (1973)# were conducted: licking the low-calorie seasoning from a barbecued potato chip and then throwing away the high-calorie chip; carefully chewing a slice of pickle while noting its texture and seasonings; and taking a piece of chocolate and rubbing it over the teeth with the tongue while it melts. Session 7 Maintenance. The instructions regarding the self- help communication system and the use of signs were also given to this group. Unlike the other groups# subjects in 74 this group were instructed to carry out at home exercises similar to those in Pearson's book— using different foods. Minimal Treatment Control Group It was originally planned to have a Minimal Treat ment control group where subjects would rely upon one an other for support instead of on the therapist or on par ticular treatment techniques. The plans for achieving this goal were to create a self-help communication system during the second session and then to devote the remaining sessions to lectures on dieting and exercising, with a minimal amount of interpersonal contact between the thera pists and subjects. As will be explained, however, this goal was not realized because the control group evolved into a treatment group and had to be eliminated from the analyses. Sessions 2 - 7 At the beginning of the second session, subjects were informed that they had been assigned on a random basis to the "Diet and Exercise" group. The self-help communication system was then introduced by explaining that in order to facilitate the learning of the basic diet and exercise program subjects had been paired up randomly 75 to form teams or a "buddy system." Each member of each pair would then help the other to stay on the diet by cal ling her during the week and working with her in the ses sions. The name and phone number listing of all the pairs was distributed, and the subjects were instructed to call their buddy at least once a day to discuss any diet pro blems they were having and offer moral support. Further more, they were asked to write a one-paragraph joint re port of their conversations during the week and to turn it in at the beginning of the next session. At the beginning of the next session, only four of the fourteen pairs of subjects turned in the required paragraph or indicated that they had made any attempt to call one another. Consequently, the therapist decided to change the original format of this session to discuss the apparent resistance to the establishment of the self-help program. When queried as to why they had not called each other, subjects gave a variety of reasons. Many subjects reported that it was "difficult to call a stranger and discuss personal problems." Others reported that they worked during the day and didn't have time to call during the evenings. Still others stated that they didn't feel a need for that kind of support, insisting that it was up to them alone to stay on the diet. After allowing sub jects to ventilate their feelings, the therapist reiterated 76 the benefits of the self-help program and asked them to try once more to call one another during the following week. At the next session, only five pairs of subjects turned in the requested paragraphs or indicated that they had made any attempt to call one another, suggesting that the resistances encountered during the previous session had not been resolved. It was at this point that the staff decided to exclude the Minimal Treatment Group from the experiment. In order to meet the ethical obligations to the subjects, the remaining four sessions of the pro gram were conducted as promised but modified in form. The format was changed from the self-help program to an in- sight-therapy approach, which included some of the tech niques used in the other groups, e.g., hypnosis and imagery suggestions. Drop-Outs During the week following the last treatment ses sion of the program, every effort was made to contact all of the subjects who were absent for the final treatment session, and to set up individual appointments for a final weighing. Unfortunately, not all of these subjects could be recalled. Some refused to return, others repeatedly missed their scheduled appointments, and still others were 77 unreachable by mail or phone. Subjects who missed two or more sessions, one of which was the final session, and who could not be recalled, were designated drop-outs. Follow-Up Session Four weeks after completion of the treatment ses sions, the subjects returned for the follow-up session. The procedure for this session was the same for all groups. After completing the usual procedural activities of weigh- ing-in and collecting the Diet and Exercise forms, sub jects were asked to fill out the Follow-up Questionnaire. After completing this, the remainder of the session waB spent discussing their problems and successes in maintain ing the diet and exercise program on their own. Their deposit was then returned to them and they were dismissed with the thanks of the staff. CHAPTER VI RESULTS Data The data collected in this study was fairly large and consisted of what was considered primary and secondary variables. Primary variables were those from which the hypotheses could be directly tested. These variables are: 1. Hypnotic Susceptibility 2. Achievement Motivation 3. Weight Loss between Sessions 1 and 7 4. Weight Loss between Session 7 and the Follow-up 5. Total Weight loss between Sessions 1 and the Fol low-up The secondary variables were those which would pro vide only inferential information about the hypotheses. They are: 1. Age (in years) 2. Height (in inches) 3. Education (in years) 4. Weight at Session 1 5. Number of Diet and Exercise Forms completed between 78 79 Sessions 1 and 7 6. Number of Diet: and Exercise Forms completed between Sessions 7 and the Follow-up 7. Number of Absences during the seven sessions of the program 8. Number of Daily Weighings reported between Sessions 1 and 7 9. Number of Daily Weighings Reported between Sessions 7 and the Follow-up 10. Number of telephone calls made and reoeived between Sessions 7 and the Follow-up 11. The amount of time (in minutes) reportedly set- aside for exercising each day Drop-outs Subjects who missed two or more treatment sessions, one of which was the final session, and who could not be recalled, were excluded from the data analyses. Table 1 shows the total number of drop-outs and the drop-out rates for each group separately and for all groups combined. All of the non-drop-outs attended the follow-up session. Overview The hypotheses were tested using Pearson product- TABLE 1 NUMBER AND RATE OP DROP-OUTS Hypnotherapy Non-induction Hypnotherapy Task-oriented Therapy Total N at Session 1 30 30 30 90 # of Drop-outs 8 9 13 30 N at Session 7 22 21 17 60 Drop-out Rate 27% 30% 43% 33% o o o 81 moment Intercorrelational analyses on the variables for each group separately as well as all groups combined, for all of the sessions of the program including the follow-up, and for the treatment versus the follow-up segments of the program. In addition, regression analysis, analysis of variance, and t-tests were performed as required, to clari fy the results. The results indicate that only Hypothesis 6 was confirmed; namely that hypnotic susceptibility correlated inversely with weight loss of the Task-oriented condition. Hypotheses 1 through 5 were not supported. These hypo theses concerned the relationship of hypnotic susceptibil ity and achievement motivation to weight loss of the Hypno therapy and Non-induction Hypnotherapy groups. The rela tionship between achievement motivation and weight loss of the Task-oriented group (Hypothesis 7) was similarly not confirmed. Hypotheses 8, 9, and 10, regarding the effec tiveness of the treatment conditions in comparison to a control group, could not be tested directly because of the elimination of the Minimal Treatment Control group. The effectiveness of the treatment procedures, however, was supported indirectly by a statistical comparison of these treatment groups with control groups in other studies re ported in the literature. There were also important seren dipitous findings involving some of the secondary variables. 82 Intercorrelational Analyses Results of the Pearson product-moment intercorrela- tlonal analyses and the means and standard deviations for the variables for each group separately, as well as all three groups combined, are presented in Tables 2 through 5. All Subjects Combined Analysis of the Susceptibility and Achievement Motive scores of subjects in all three groups combined re*- veals that the main theory— Hypothesis 1— was not confirmed. Contrary to London's theory, the correlation between Hypno tic Susceptibility and Achievement Motivation failed to achieve significance at the .05 level (r = .00). While no hypotheses were made regarding the rela tionship between the secondary and primary variables, some of the secondary variables correlated quite significantly with Total Weight Loss, as indicated in Table 2. Total Weight Loss correlates with; 1. Number of Diet and Exercise Forms for Sessions 1-7 (r = .49, p < .01) 2. Number of Diet and Exercise Forms for Sessions 7- Follow-up (r = .28, p < .01) 3. Number of Absences (r » -.39, p < .01) TABLE 2 INTERCORRELATIONS AMONG VARIABLES ACROSS ALL GROUPS (N = 60) Variable 2 3 4 5 6 7 8 9 M SD 1) Hypn. Suscept. .00 .04 i • * » . 1 • O to -.20** .09 -.10 .18** 7.8 3.2 2) Ach. Motiv. .07 -.05 .04 -.02 -.12 .19** -.03 -5.5 20.7 3} Wt. Loss 1-7 .27* .91* -.18** .20* .08 -.02 6.7 5.7 4) Wt. Loss 7-F.U. .69* -.02 .08 -.03 -.16 0.6 3.5 5) Total Wt. Loss -.15 .19** .05 -.09 7.2 7.1 6) Age -.06 -.12 -.15 33.7 6.5 7) Height -.11 .42* 64.8 2.5 8) Education -.08 13.6 2.0 9) Wt. Pre-treat. 181.4 22.2 10) D. & E. 1-7 23.9 17.4 11) D. & E. 7-F.U. , 16.2 12.1 12) Absences 1.4 2.0 13) Weighings 1-7 20.2 17.6 14) Weighings 7-F.U. « 14.2 12.4 15) Calls 1.4 2.0 16) Time for Exercise 40.7 26.4 *p < .01 **p < .05 QO u» TABLE 2 INTERCORRELATIONS AMONG VARIABLES ACROSS ALL GROUPS (N = 60) (Continued) Variable 10 11 12 13 14 15 16 1) Hypn. Suscept. .09 -.28* -.13 .05 -.19** .03 -.10 2) Ach. Notiv. -.05 -.02 .01 -.04 -.03 -.07 -.25** 3) Wt. Loss 1-7 .46* .21** -.43* .45* .20** .30* .22** 4) Wt. Loss 7-F.U. .31* .26** -.08 .23** .23** .03 .18 5) Total Wt. Loss .49 .28 -.39* .46* .26** .24** .25** 6) Age -.04 .09 .05 -.05 .13 -.16 -.12 7) Height -.01 -.05 -.04 .01 -.01 -.04 .02 8) Education .05 -.03 -.07 .09 -.17 .05 .05 9) Wt. Pre-treat. -.20** -.22** .07 -.15 -.17 .04 -.16 10) D. & E. 1-7 .62* .70* .88* .53* .12 .25** 11) D. & E. 7-F.U. -.28* .65* .84* -.04 .15 12) Absences -.62* -.20** -.13 -.13 13) Weighings 1-7 .66* .21** . K* 00 p 14) Weighings 7-F.U. .07 .01 15) Calls * * - • 00 16) Time for Exercise *p < .01 **p < .05 * TABLE 3 INTERCORRELATIONS AMONG VARIABLES FOR THE HYPNOTHERAPY GROUP (N = 22) Variable 2 3 4 5 6 7 8 9 MSD 1) Hypn. Suscept. -.23 -.26 -.23 -.31 -.11 .09 -.15 .30 7.8 3.0 2) Ach. Motiv. .18 .17 .21 .05 -.24 .25 -.16 -10.8 21.8 3) Wt. Loss 1-7 .11 .89** .15 -.28 .42* -.15 6.5 4.9 4) Wt. Loss 7-F.U. .71** -.22 -.06 .12 -.32 1.4 3.3 5) Total Wt. Loss .07 -.29 .40* -.28 7.5 6.0 6) Age -.12 -.01 .07 36.1 5.6 7) Height -.12 .50** 64.8 2.7 8) Education -.20 13.3 1.9 9) Wt. Pre-treat. 181.4 21.0 10) D. & E. 1-7 22.8 16.0 11) D. & E. 7-F.U. 17.3 13.0 12) Absences 1.2 2.0 13) Weighings 1-7 16.4 17.3 14) Weighings 7-F.U. 15.3 13.6 15) Calls 0.8 1.1 16) Time for Exercise 39.7 26.8 *p<.05 **p<.01 oo U) TABLE 3 INTERCORRELATIONS AMONG VARIABLES FOR THE HYPNOTHERAPY GROUP (N = 22) (Continued) Variables 10 11 12 13 14 15 16 1) Hypn. Suscept. -.25 -.61** -.01 . to in -.37 .06 -.11 2) Ach. Motiv. -.03 .23 .03 .11 .21 -.04 -.20 3) Wt. Loss 1-7 .54** .45** -.55** .47** .31 -.14 -.40* 4) Wt. Loss 7-F.U. .09 -.03 .03 .11 .02 .11 -.01 5) Total Wt. Loss .52** .31 -.52 .48** .25 -.03 -.24 6) Age -.06 -.03 -.01 .00 -.01 -.13 .21 7) Height -.50** -.02 .47** -.30 -.07 -.45** .00 8) Education .17 .12 -.44* .18 -.01 .06 -.23 9) Wt. Pre-treat. -.35 -.12 .44* -.22 .03 -.30 -.42* 10) D. & E. 1-7 .80** -.65** .80** .71** .23 -.07 11) D. & E. 7-F.U. -.19 .75** .87** .17 H O • 1 12) Absences -.49** -.11 .35 .08 13) Weighings 1-7 .92** .32 -.19 14) Weighings 7-F.U. .30 -.19 15) Calls .04 L6) Time for Exercise *p .05 **p .01 GO Ol TABLE 4 INTERCORRELATIONS AMONG VARIABLES FOR THE NON-INDUCTION HYPNOTHERAPY GROUP (N = 21) Variable 2 3 4 5 6 7 8 9 M SD 1) Hypn. Suscept. .19 .25 .18 .26 -.50** .07 .26 .42* 7.6 3.1 2) Ach. Motiv. -.02 -.24 -.09 .04 -.21 .30 .14 -6.4 21.9 3) Wt. Loss 1-7 .42* .94** -.36* .14 -.12 -.13 6.1 6.3 4) Wt. Loss 7-F.U. .73** -.20 -.08 -.24 -.11 0.7 8.1 5) Total Wt. Loss -.36* .08 -.17 -.14 6.7 5.3 6) Age -.20 -.04 -.36* 33.4 2.3 7) Height .01 .01 64.8 24.4 8) Education -.05 13.7 14.3 9) Wt. Pre-treat. 184.9 24.4 10) D. & E. 1-7 29.9 14.3 11) D. & E. 7-F.U. 18.5 11.4 12) Absences 0.9 1.5 13) Weighings 1-7 27.4 16.0 14) Weighings 7-F.U. 15.6 12.0 15) Calls 1.5 2.0 16) Time for Exercise 41.7 22.3 *p < .05 **p < .01 oo *sl TABLE 4 INTERCORRELATIONS AMONG VARIABLES FOR THE NON-INDUCTION HYPNOTHERAPY GROUP (N = 21) {Continued) Variable 10 11 12 13 14 15 16 1) Hypn. Suscept. .19 -.22 -.16 .05 -.27 .17 .35 2) Ach. Motiv. .05 -.01 -.09 .03 -.09 -.39* -.43* 3) Wt. Los 1-7 .53** -.01 -.54** .58** .06 .58** .34 4) Wt. Loss 7-F.U. .12 .22 -.09 .16 .25 .40* .20 5) Total Wt. Loss .46** .08 -.46** ,52** .15 .61** .34 6) Age -.16 .04 .26 -.19 .16 -.13 -.35 7) Height .08 -.03 -.15 .16 .24 .28 .32 8) Education .10 .21 -.02 .13 -.23 .10 .18 9) Wt. Pre-treat. -.12 -.18 .03 -.06 -.14 -.09 .25 10) D. & E. 1-7 .49** -.91** .88** .35 .09 .15 11) D. & E. 7-F.U. -.49** .59** .70** -.21 -.34 12) Absences -.83** -.34 -.17 -.08 13) Weighings 1-7 .44* .14 .16 14) Weighings 7-F.U. -.04 -.35 15) Calls .31 16) Time for Exercise *p .05 **p .01 oo C O TABLE 5 INTERCORRELATIONS AMONG VARIABLES FOR THE TASK-ORIENTED GROUP (N = 17} Variable 2 3 4 5 6 7 8 9 M SD 1) Hypn. Suscept. . 0 VO 1 • to CD -.50** -.37* -.07 -.05 -.51** -.01 8.0 3.2 2) Ach. Motiv. -.14 -.21 -.16 -.05 -.18 -.57** -.21 0.1 18.6 3) Wt. Loss 1-7 .37 .93** -.31 .44* .08 .02 7.4 5.6 4} Wt. Loss 7-F.U. .74 .00 .32 .04 -.13 0.6 3.2 5) Total Wt. Loss -.25 .48** .07 -.03 7.8 7.0 6) Age -.10 . .31 -.22 34.9 4.7 7) Height -.20 .57** 65.2 2.2 8) Education .01 13.2 1.6 9) Wt. Pre-treat. 180.1 23.6 10) D. & E. 1-7 24.6 19.6 11) D. & E. 7-F.U. 17.1 11.0 L2) Absences 2.0 2.4 L3) Weighings 1-7. 20.1 19.6 14) Weighings 7-F.U. 15.2 11.8 15) Calls 1.5 1.7 16) Time 38.7 32.9 *p < .05 **p < .01 CD VO TABLE 5 INTERCORRELATIONS AMONG VARIABLES FOR THE TASK-ORIENTED GROUP (N = 17) (Continued) Variable 10 11 12 13 14 15 16 1) Hypn. Sucept. .21 -.20 -.32* . .21 -.02 -.17 -.19 2) Ach. Motiv. .15 -.34* .05 -.23 -.37* -.36* -.32* 3) Wt. Loss 1-7 .50** .66** -.40* .54** .55** .52** .74** 4) Wt. Loss 7-F.U. .15 .29 .16 .03 .14 .04 .22 5) Total Ht. Loss .47* .62** -.34 .47* .47* .40 .64** 6) Age -.14 -.26 .17 -.05 -.06 -.02 -.25 7) Height .31 -.16 -.44* .25 -.23 .48* .04 8) Education .17 -.10 .23 -.10 -.12 .08 -.13 9) Wt. Pre-treat. .22 -.56** .00 -.18 -.54* .43* .17 10) D. & E. 1-7 .74** -.80** .89** .62** .20 .62** 11) D. & E. 7-E.U. -.25 .73** .89** .05 .57** 12) Absences -.70** -.15 -.39* -.56* 13) Weighings 1-7 .80** .37* .59** 14) Weighings 7-F.U. .08 .40* 15) Calls .55* 16) Time for Exercise *p < .05 **p < .01 vo o 91 4. Number of Daily Weighings for Sessions 1-7 (r = .46, p < .01) 5. Number of Daily Weighings for Sessions 7-Follow-up (r a .26, p < .05) 6. Number of Telephone Calls (r = .24, p < .05) 7. Time set-aside for exercising (r = .25, p < .05) These findings suggest that, across all groups, subjects who tended to lose more weight were those who completed more Diet and Exercise Forms, missed fewer sessions, weighed themselves more often, made more phone calls during the follow-up period, and set-aside more time for exercis ing. As will become evident, these findings hold up in the correlational analyses within each of the groups as well. Hypnotherapy As indicated in Table 3, Hypotheses 2 and 3 were not supported. Scores on the Harvard Group Scale of Hypno tic Susceptibility and on the Mehrabian Female Scale of the Tendency to Achieve, failed to correlate significantly with any of the weight loss variables. Furthermore, the signs of the correlation values were the opposite of what was predicted: Hypnotic Susceptibility tended to correlate inversely with Total Weight Loss (r - -.31, p > .05), and Achievement Motivation tended to correlate positively with 92 Total Weight Loss (r = .21, p > .05). As in the analyses o£ all subjects combined, Total Weight Loss correlated in this group with the secondary variables of: 1. Number of Diet and Exercise Forms for Sessions 1-7 (r = .52, p < .01) 2. Number of Absences (r =-.52, p < .01) 3. Number of Daily Weighings for Sessions 1-7 (r = .4EV p < .01) 4. Education (r = .40, p < .05) This suggests that subjects who tended to lose more weight were those who completed more Diet and Exercise Forms, missed fewer sessions, weighed themselves more often, and had more years of formal education. Non-Induction Hypnotherapy As in the Hypnotherapy group, Hypnotic Susceptibil ity and Achievement Motivation failed to correlate signifi cantly with Total Weight Loss of subjects in this group (see Table 4). These findings disconfirm Hypotheses 4 and 5. The signs of these correlational values, however, were in the predicted directions. Hypnotic susceptibility tend ed to correlate positively with Total Weight Loss (r = .26, p > .05) and Achievement Motivation tended to correlate inversely with Weight Loss {r = -.09, p > .05). Total Weight Loss, however, did correlate with the secondary variables of: 1. Number of Diet and Exercise Forms for Sessions 1-7 (r = .46, p < .01) 2. Number of Absences (r = -.46, p < .01) 3. Number of Daily Weighings for Sessions 1-7 (r ** .52, p < .01) 4. Number of Telephone Calls (r *= .61, p < .01) These findings suggest that the subjects in this group who tended to lose more weight were those who completed more Diet and Exercise Forms, missed fewer sessions, weighed themselves more often, and made more calls during the follow-up period. Task-Oriented Group As predicted in Hypothesis 6, Hypnotic Susceptibil ity correlated inversely with Total Weight Loss of subjects in this group (r » -.37, p < .05) (see Table 5). This sug gests that low susceptibles tend to lose more weight than high susceptibles when the treatment procedures involve task-oriented activities. Contrary to Hypothesis 7, how ever, Achievement Motivation failed to correlate signifi cantly with Total Weight Loss (r ® ..16, p > .05). 94 As in the other two groups, Total Weight Loss of subjects in this group correlated significantly with: 1. Number of Diet~and Exercise Forms for Sessions 1-7 (r = .47, p < .01) 2. Number of Diet and Exercise Forms for Sessions 7- Follow-up (r = .62, p < .01) 3. Number of Daily Weighings for Sessions 1-7 (r = .47, p < .05) 4. Number of Daily Weighings for Sessions 7-Follow-up (r - .47, p < .05) 5. Time set-aside for exercising (r = .64, p < .01) According to these findings, subjects who tended to lose more weight were lower in Hypnotic Susceptibility, complet ed more Diet and Exercise Forms, weighed themselves more often, and set-aside more time for exercising. Treatment Versus Follow-up The results of the intercorrelational analyses for the total study from session 1 through follow-up, can be broken down into two parts s the treatment segment (ses sions 1-7) and the follow-up segment (sessions 7-follow-up). A comparison of these two result segments reveals that while each follows the overall trend, differences between the two segments do exist. 95 Across all groups, the relationships between weight loss and the secondary variables are essentially the same for both segments of the study. Weight Loss 1-7 and Weight Loss 7-follow-up correlate respectively with Number of Diet and Exercise Forms 1-7 and 7-follow-up, and with Daily Weighings 1-7 and 7-follow-up. When the results are fur ther broken down by treatment group within each segment, however, the follow-up segments have fewer significant cor relations between weight loss and the secondary variables, than do the treatment segments. Within each of the three treatment groups, Weight Loss 1-7 correlates significantly with the variables of 1) Diet and Exercise Forms 1-7, 2) Daily Weighings 1-7, and 3) Time for exercise. In compari son, Weight Loss 7-follow-up correlates only with Calls (r = .40, p< .05) in the Non-induction Hypnotherapy grpup, and with Hypnotic Susceptibility (r = -.50, p < .01) in the Task-oriented group. These differences between the two segments of the program suggest that the trend in the results for the total study and for the treatment segment also holds for the follow-up segment but to a lesser degree. Regression Analyses In order to clarify the results obtained from the 96 correlational analyses and to determine the relative con- tribution of each variable to the main dependent variable of Total Weight Loss, a multiple regression analysis was performed on the data. The regular (B) and the normalized (Beta) regression coefficients for each variable are listed in Table 6. As indicated by the size and ranking of the % Beta coefficients, the secondary variables o£ Diet and Exercise Forms completed, Daily Weighings, and Time Set- aside for Exercising contributed more to the variance of Total Weight Loss, than the primary variables of Hypnotic Susceptibility and Achievement Motivation. These results suggest that, contrary to the original hypotheses, Hypnotic Susceptibility and Achievement Motivation are among the least predictive variables of post-treatment weight loss for all groups combined, relative to the secondary vari ables. Control Group The elimination of the Minimal Treatment Control group from the statistical analyses poses a problem with regard to interpreting the results. Without a control group the effectiveness of the three treatment conditions cannot be adequately determined, which leads to speculation regarding the testing of the hypotheses. That is, did the 97 TABLE 6 REGRESSION ANALYSES WITH TOTAL WEIGHT LOSS AS THE DEPENDENT VARIABLE Variable B Beta 1) Calls 1.159 0.301 2) D. & E. 1-7 0.137 0.248 3) Height 0.430 0*154 4) Time for Exercise 0.004 0.014 5) D. & E. 7-F.U. -0.003 -0.004 6) Weighings 1-7 -0.004 -0.010 7) Weighings 7-F.U. -0.015 -0.025 8) Ach. Motiv. -0.011 -0.033 9) Age -0.094 -0.075 10) Absences -1.193 -0.112 11) Education -0.517 -0.130 12) Hypn. Suscept. -0.362 -0.161 13) Wt. Pre-treat. -0.056 -0.197 98 predicted correlations fail to achieve significance because the relevant variables were not in fact related to one another, or because the treatment procedures were ineffec tual? While there is no completely adequate method for resolving this dilemma, some indication of the effective ness of the treatment conditions can be obtained by compar ing the Total Weight Loss of subjects in the treatment groups in the present study to the weight loss of subjects in the control groups in other studies reported in the literature. Three separate studies by Hall et al. (1973), Meynen (1970), and Harris (1969) were selected for this comparison. In the study by Hall et al. (1973), two self-manage- ment treatment groups were compared to Non-specific treat ment and No-treatment control groups. Subjects in this study were males and females with a mean age of 34 years. The Non-specific control group met for 75 minutes each ses sion, one session per week for ten weeks. The treatment for this group consisted of instructing subjects in tech niques of deep muscle relaxation which were used in con junction with the imagining of tension producing situations which often lead to overeating. Subjects were also in structed to limit their caloric intake and were given home work assignments related to the desensitization procedure. 99 In contrast, subjects in the No-treatment control group of this same study were weighed at the pre-treatment session and were encouraged to lose weight on their own. They re turned ten weeks later for a post-treatment weighing. Meynen (1970) compared three treatment groups to a No-treatment Control group. Subjects in her study were all females between the ages of 18 and 45. The No-treatment Control group, after filling out rating scales and being weighed at the pre-treatment session, were told that treat ment was not available at the time. At the end of the pro gram, eight weeks later, this group returned, as instructed, for a post-treatment weighing. Harris (1969) compared two treatment groups to a No-treatment control group. The male and female members of the control group, after being weighed at the beginning of the program, were asked to lose weight on their own, using a calorie chart given to them. This group was re weighed at the end of the experiment, four months later. Analysis of Variance Before comparing the effectiveness of the treatment groups in the present study to the control groups in these other studies, it is necessary to determine whether or not the three treatment groups in this study differ signifi cantly from each other in terms of total weight loss and, therefore, whether these groups should be compared sep arately or combined. To make this determination, a one-way analysis of variance was performed on the data, with Total Weight Loss as the dependent variable. The results of this analysis are presented in Table 7. As can be seen, the overall F value was not significant, indicating that the Total Weight Loss scores did not differ significantly among the three treatment groups, and therefore the weight loss data from the three groups will be combined in the subse quent analyses. TABLE 7 ONE-WAY ANALYSES OF VARIANCE ON TOTAL WEIGHT LOSS Source df MS F Treatment 2 0.09 0.85 Error 57 0.32 p > .05 t Tests The means and standard deviations of weight loss of the combined treatment groups in the present study and of weight loss of the four control groups are presented in Table 8. As indicated in the table, the results of one 101 tailed t-tests comparing the present study with each of the control groups are all significant at the .05 or .01 level. This suggests that in terras of weight loss, the treatment conditions in the present study were more effec tive than the non-specific or no-treatment control groups in other, comparable studies. TABLE 8 WEIGHT LOSS OF ALL TREATMENT GROUPS COMBINED COMPARED WITH CONTROL GROUPS IN OTHER STUDIES Study M SD t Values Bodyweight Loss In lbs. % Bodyweight Loss Bodyweight Loss In lbs. % Bodyweight Loss Present (N = 60) -7.20 -5.00 7.10 10.00 Hall et al. (1973) Non-specific (N = 18) No-treatment (N = 20) -0.47 +0.92 — — 2.60 4.33 1.92, p<.05 2.59, p<.01 Meynen (1970) No-treatment (N =9) +3.50 6.53 4.29, p<.01 Harris (1969) No-treatment (N * 4) +5.62 4.06 H o s> 3.55, p<.01 CHAPTER VII DISCUSSION Contrary to expectation, London's theory was not supported by the results, neither on a theoretical basis nor in terms of its applicability to the treatment of obe sity. On a theoretical basis, one of the main purposes of this study was to replicate and extend an earlier finding by Miller (1973) of an inverse relationship between hyp notic susceptibility and achievement motivation. This finding, however, was not replicated in the present study even though the same test instruments were used in the same experimental setting. The discrepancy between the results of these studies may be attributed to either sex differ ences between the subject populations and/or a sampling bias regarding body weight. Miller (1973) used adult male volunteers not selected on basis of body weight, whereas the present study used obese, adult female volunteers. This leads to speculation that, for whatever unknown rea sons, London's theory may apply only to normal weight adult males and not obese females. Since the body weight and sex variables are confounded, further research needs to be done to clarify which variables are primarily responsible 103 104 for this failure to replicate the earlier finding. In terms of the application of London's theory to the treatment of obesity, the results are surprising. Of all the predicted relationships among the primary variables of hypnotic susceptibility, achievement motivation, and weight loss, only one hypothesis was confirmed: high sus ceptibles lose more weight than lows when the treatment procedure involves task-oriented activities. While this finding is consistent with London's theory, it must be re garded somewhat skeptically. The fact that this relation ship held between susceptibility and total weight loss but not between susceptibility and weight loss between sessions 1 and 7, and the fact that this was the only hypothesis to be confirmed, suggests that this findings may be a spurious artifact of the analyses. A replication of this finding is needed to rule out this possibility. It is particularly surprising that the main vari able of hypnotic susceptibility failed to correlate sig nificantly with weight loss of the Hypnotherapy group with and without the induction procedure. It had been reasoned that hypnotherapy was the most logical treatment procedure to be associated with hypnotic susceptibility because sus ceptibility scores are based on antecedant behaviors simi lar to those involved in hypnotherapy. The results of this study, however, would suggest that hypnotic susceptibility 105 scores derived from the administration of standard scales, may not be predictive of responsivity to hypnotherapy. This lends credence to the unconfirmed belief among prac- i ticing hypnotherapists that a patient need not be suscepti ble to hypnotic suggestions in order to benefit from hypno therapy . The failure of hypnotic susceptibility to correlate with outcome of hypnotherapy leads to speculation about other variables that may be more predictive of therapy out come. In the present study, the variables which were as sumed to be of secondary importance to the prediction of post-treatment weight loss were, in fact, the most predic tive, and the variables assumed to be of primary importance turned out to be less predictive. In order to gain insight into these confusing findings, it is necessary to examine more carefully the assumptions underlying the selection of relevant subject variables. In selecting the variables of hypnotic susceptibili ty and achievement motivation and matching them to treatment procedures, it was assumed that variance in weight loss for a particular group would correspond mostly to individual differences in responsiveness to the particular techniques employed during the treatment sessions. In the hypnotherapy group, for instance, it was assumed that high susceptibles would lose more weight than lows^ because hypnosis was the 106 primary therapeutic technique used during the sessions, and high susceptibles, by definition, are more responsive to hypnotic suggestions than lows. In retrospect, this assumption seems unrealistic considering the intractability of eating behavior. Since eating is a highly repetitive behavior, which is practiced several times a day for the duration of our lives, it seems unrealistic to expect that giving hypnotic and post-hypnot ic suggestions, or practicing the desired eating behaviors for one hour a week, would be sufficient per se to produce lasting changes in eating behavior, or that the variables of hypnotic susceptibility and achievement motivation would relate significantly to weight loss. It seems more logical and rational to expect that a permanent reduction in the level of caloric intake would occur in response to consci entious efforts to practice the prescribed behaviors on a daily basis. In the present study this was, in fact, what the subjects were told at the start of the treatment program. They were specifically asked not to rely solely on the techniques used during the treatment sessions to bring about the desired weight loss but were urged instead to follow the basic diet and exercise program on their own be tween sessions. The secondary variables of: 1) Number of Diet and 107 Exercise Forms, 2) Number of Daily Weighings, and 3) Time Set-aside for Exercising, reflect the degree to which sub jects in all of the treatment groups attended to their be havior, monitored it, and, in essence, did what they were asked in terms of following the Stuart and Davis program. Viewed from this perspective, the primary variables reflect changes in behavior during the treatment sessions (e.g. responsiveness to hypnotic suggestions), whereas the secondary variables reflected changes in behavior outside of the sessions (e.g. efforts to exercise daily). This leads to speculation that the secondary variables corre lated significantly with weight loss but the primary vari ables didn't because these changes in daily behavior, as reflected by the secondary variables, are more predictive of weight loss than changes in intra-session behavior. Unfortunately, due to the elimination of the Mini mal Treatment Control group and the confounding of the pri mary and secondary variables, other explanations for the same results cannot be ruled out. Without the control group, the contribution of the intra-session techniques cannot be adequately portioned out from the contribution of the basic diet and exercise program and self-monitoring to the total weight loss. As a result, an alternative expla nation would be that changes in intra-session behaviors, resulting from the use of particular techniques such as 108 hypnosis, actually contribute more to weight loss than any changes in extra-session behaviors achieved through the diet and exercise program, but the variables of hypnotic susceptibility and achievement motivation do not adequately reflect the contribution of the intra-session techniques. Regardless of which explanation is actually cor rect, the implications of these results for future research are that rather than focusing only on subject variables relevant to the use of particular techniques employed dur ing the treatment sessions, as many studies have done, it may be more fruitful to examine subject variables which reflect efforts to modify and attend to daily eating hab its. It may be discovered that carefully monitoring of one's eating and exercising behaviors may lead to as much, or more, weight loss than the use of particular techniques such as hypnosis. A somewhat different, yet related, issue for future research is the nature of the control groups included in the experimental design. Most studies to date have includ ed a no-treatment control group where subjects are left to their own devices in losing weight, and/or a minimal treat ment group where subjects are trained in relaxation or other non-specific techniques and encouraged to count calo ries as a means of weight reduction (e.g. Hall, 1973; Mey- nen, 1970). These control procedures, however, are inade- 109 quate to resolve the basic Issue of whether particular treatment techniques employed during the sessions are more effective than self-administering, self-monitoring methods of weight loss. What is needed is a minimal-treatment con trol group, similar to the one designed for the present study, which includes a well-balanced, self-management diet and a structured exercise program (e.g. Stuart and Davis, 1972) used in conjunction with a self-help program. Such a group would demonstrate more clearly which techniques, if any, are superior to methods by which subjects can lose weight on their own without the aid of a professional ther apist or special techniques. The present study further indicates that resis tances may be encountered in the establishment of self-help programs. Even though a minimal degree of interpersonal contact was required of subjects in the control group, the feedback from the subjects indicates that this contact aroused anxiety concerning the formation of interpersonal relationships and about the discussion of weight problems. Perhaps a longer period of interaction and socializing among subjects is necessary to developing a espirit de corps which would more naturally lead to a desire to trust and help one another. This study indicates that force in teraction is not a short cut to this goal and that a more gradual development of the self-help program may be required 110 in order for it to be successful. Although the main purpose of this study was not a comparison of the effectiveness of different treatment pro cedures, it is of interest that there were no significant differences in terms of total weight loss among the three treatment groups. It is of particular interest that there was no difference in weight loss between the Hypnotherapy with induction group and the Hypnotherapy without induc tion. This would suggest that the induction procedure is irrelevant to hypnotherapy outcome in the treatment of obe sity. In summary, the results do not support London's theory on a theoretical basis or in its application to the treatment of obesity. The hypothesis has been offered that London's theory may be valid but only for a certain subset of the population, i.e. males but not obese females. The negative findings regarding the primary variables of hyp notic susceptibility and achievement motivation, but the significant relationship between the secondary variables and weight loss, suggest that changes in behavior which oc cur during the sessions in response to particular tech niques, may not contribute as much to weight loss as change- es which occur on a daily basis outside of the sessions. As a result of the elimination of the Minimal treatment group from this study, however, other hypotheses cannot be Ill ruled out. The most significant findings related to the hypno therapy groups were that the variables of hypnotic suscep tibility and the induction procedure, had no significant relationship to weight loss of these groups. This suggests that the outcome of hypnotherapy does not depend upon the susceptibility of the patient or whether the presentation of hypnotic suggestions is preceeded by a formal induction process. The most important finding related to the Task- oriented group was that low susceptibles lost more weight than high's as per hypothesized. This findings, however, must be regarded skeptically for reasons that have been discussed. It is recommended that future research attend not only to the subject variables related to the use of partic ular treatment techniques during the sessions but also to the subject variables which reflect efforts to modify and attend to daily eating habits. It has also been recommend ed that future research include control groups which com bine a well-balanced, self-management diet and a structured exercise program with a self-help program. The resistances encountered from subjects in the control group of this study, suggest that in the initial phases of establishing a self-help program, subjects should be given an ample amount 112 of time to socialize and interact before any formal thera peutic interaction is encouraged. B I B L I O G R A P H Y 113 BIBLIOGRAPHY Baird, Barber, Barber, Barber, Barber, Barber, Bigsby, Bloom, Braid, Brodie, I. M. and Howard, A. N. Obesity: Medical and scientific aspects. Edinburg and London: e7 and S. Livingston LTD., 1969. T. X. "Hypnotic" phenomena: A critique of experi mental methods. In J. E. Gordon (Ed.) Handbook of clinical and experimental hypnosis. New York: MacMillan Co., 1967. T. X. and Calverly, D. S. 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The American Journal of Clinical Hypnosis, 1964, 6, 211-215. 114 115 Bullen, B. A., Read, R. B. and Mayer, J. Physical activity of obese and non-obese adolescent girls appraised by motion picture sampling. American Journal of Clinical Nutrition, 1964, 14, 2li. Cooper, L., Banford, S., Schubot, E. and Tart, C. A fur ther attempt to modify hypnotic susceptibility through repeated individualized experience. Inter national Journal of Clinical and Experimental Hypnosis^ 1 $6 * 1, 15, 118. Craddock, D. Obesity and its management. Baltimore* Williams and Wilkins Co., ld<>9. Davidson, S., Meiklejohn, A. P. and Passmore, R. Human nutrition and dietetics. Baltimore: Williams and Wilkins, 1959. Davis, L. W. and Husband, R. W. A study of hypnotic sus ceptibility in relation to personality traits. Journal of Abnormal and Social Psychology, 1931, 26, 175-182. Doris, P. J. and Stunkard, A. J. Physiological activity, performance and attitudes of a group of obese women. American Journal of Mediaal Science, 1957, 233, 622*1 Edwards, H. T., Thorndike, A. and Dill, D. B. New England Journal of Medicine, 1935, 213, 532. Favill, J. and White, P. D. Voluntary acceleration of the rate of the heart beat. Heart, 1917, 6, 175-188. Feather, N. T. The study of persistence. Psychological Bulletin, 1963, 59, 94-115. Ferster, C. B., Nurenberger, J. I. and Levitt, E. B. The control of eating. Journal of Mathematics, 1962, 1, 87-109. French, E. G. Some characteristics of achievement motiva tion. Journal of Experimental Psychology, 1955, 50, 232-236. Friedlander, J. W. and Sarbin, T. R. The depth of hypnosis. Journal of Abnormal and Social Psychology, 1938, ■J5Y 453-475.------- --------- ---- 116 Galton, D. J. An enzyme defection in a group of obese patients. British Medical Journal/ 1966, 2, 1948. Griffith, W. H. and Dyer, H. M. Present knowledge of spe cific dynamic action. In Present knowledge in nutrition. New Yorks The Nutrition Foundation, jsrr.-- Hall, S. M., Hall, R. G., Hanson, R. W. and Bordon, B. L. Permanence of two self-managed treatments of over weight in university and community populations. Unpublished article, University of Wisconsin, 1973. Hanley, F. W. The treatment of obesity by individual and group hypnosis. Canadian Psychiatric Association Journal, 1967, 12, 54$-i>!>i. Harris, Mary B. Self-directed program for weight control: A pilot study. Journal of Abnormal Psychology, 1969, 74, 262-270. Hartman, B. J. Group hypnotherapy in a university counsel ing center. The American Journal of Clinical Hyp nosis, 1969, 12, 16-19. Hartsook, E. W. and Hershberger, T. V. Influence of low, intermediate, and high levels of dietary protein on heat production of rats. Journal of Nutrition, 1963, 81, 209-217. Heckhausen, H. The anatomy of achievement motivation. New York! Academic Press, 19<>7. Herxheimer, H., Wissing, E. and Wolff, E. Spatwirkungen erschopfender muskelarbeit aufden sauerstoffver- bauch. Zietschrift fur Die Gesamte Experimentelle Medizin, 1926, 51, 916. Hilgard, E. R. Hypnotic susceptibility. New York: Har- court, Brace and World, 1965. Hilgard,. E. R. Individual differences in hypnotizability. In J. E. Gordon (Ed.) Handbook of clinical and experimental hypnosis. New York: MacMillan Co., Hilgard, Josephine R. Personality and hypnosis. Chicago: University of Chicago Press, 1970. I 117 Johnston, R. A. The effects of achievement imagery on maze-learning performance. Journal of Personality, 1955, 24, 145-152. Kang, B. S., Song, S., Suh, C. S. and Hong, S. K. Changes in body temperature and basal metabolic rate of the ama. Journal of Applied Physiology, 1963, 18, 483. Kennedy, W. A. and Foreyt, J. P. Control of eating behav ior in an obese patient by avoidance conditioning. Psychological Report, 1968, 22, 571-576. Kleiber, M. The fire of life; An introduction to animal energetics. New York: Wiley, 1961. Kroger, W. S. Comprehensive management of obesity. The American Journal of Clinical Hypnosis, 1970, 12, 165-176. Krumboltz, J. P. and Farguhar, W. W. Reliability and val idity of the n-Achievement test. Journal of Con sulting Psychology, 1957, 21, 226-228. Lang, P. J. The mechanics of desensitization and the lab oratory study of human fear. In C. Franks (Ed.) Behavior therapy: Appraisal and status. San Fran cisco: McGraw-Hill Book Co., 1969. Lang, P. J., Lazovik, A. D. and Reynolds, D. J. Desensi*- tization, suggestibility, and pseudotherapy. Journal of Abnormal Psychology, 1965, 70, 395-402. Larsen, S. Strategies of reducing phobic behavior. Dis sertation Abstracts, 1966, 26, 6850. Lee-Teng, E. Trance-susceptibility, induction suscepti bility, and acquiescence as factors in hypnotic performance. Journal of Abnormal Psychology, 1965, 70, 383-389. London, P. The induction of hypnosis. In J. E. Gordon (Ed.) Handbook of clinical an sis. New York: MacMillan Co (Ed.) Handbook of clinical and experimental hypno- London, P. Verhaltenstherapie and Hypnose. Grenzgebiete Per Wissenschaft, 1971, 3, 97-113. London, P., Consult, M. and Davison, G. More hypnosis in the unhypnotizable: Effects of hypnosis and ex- 118 h o r t a t i o n o n r o t e l e a r n i n g . J o u r n a l o f P e r s o n a l i t y , 1966, 32, 132-152. L o n d o n , P . a n d P u h r e r , M. H y p n o s is , m o t i v a t i o n a n d p e r f o r m a n c e . J o u r n a l o f P e r s o n a l i t y , 1961, 29, 321-333. London, P. and McDevitt, R. A. Effects of hypnotic sus ceptibility and training on responses to stress. Journal of Abnormal Psychology, 1970, 76, 336-348. L o n d o n , P . , O g le , M. a n d U n i k e l , I . E f f e c t s o f h y p n o s is a n d m o t i v a t i o n o n r e s i s t a n c e t o h e a t s t r e s s . Journal of Abnormal Psychology, 1968, 73, 532-541. London, P. and Rochman, G. The relation of induced tension to hypnotic susceptibility. Unpublished manuscript, University of Southern California, 1967. Lowell, E. L. The effect of need for achievement of learn ing and speed of performance. Journal of Psychol ogy, 1952, 33, 31-40. Luckhardt, A. B. and Johnston, R. L. Studies in gastric secretions: I. The psychic secretion of gastric juice under hypnosis. American Journal of Physiol ogy, 1924, 70, 174-182. Mann, R. A. The behavior-therapeutic use of contingency contracting to control an adult behavior problem: Weight control. Journal of Applied Behavior Anal ysis, 1972, 5, 99-109. ' Manno, B. S. and Marston, A. Weight reduction as a func tion of negative covert reinforcement (sensitiza tion) versus positive covert reinforcement. Be- havior, Research and Therapy, 1972, 10, 201-2^7. Mayer, J. Overweight: Causes, coBt and control. Englewood Dliffs, New Jersey: Prentice-Hall, 1968. McCance, C. Psychiatric factors in obesity. Dissertation for Diploma in Psychological Medicine. University of Lone Ion, 1961. McClelland, D. C., Atkinson, J. W., Clark, R. A. and Lowell, E. L. The achievement motive. New York: Appletonr Century-Crofts, Inc., 1953. 119 Mehrabian, A. Male and female scales of the tendency to achieve. Educational and Psychological Measure ment# 1968, 28, 493-502. Metropolitan Life Insurance Company, New York, New weight standards for men and women. Statistical Bulletin, 1969. Meynen, G. E. A comparative study of three treatment ap proaches with the obese: Relaxation, covert sen sitization and modified systematic desensitization. Dissertation Abstracts International, 1970, 31, 2998. Miller, D. S. Energy metabolism. In I. M. Baird and A. N. Howard (Eds.) Obesity: Medical and scientific as pects. Edinburgh and London: E. and S. Livingston LTD., 1969. Miller, J. E. Relationships between hypnotic susceptibil ity, achievement motivation, and brain waves. Un published Master's Thesis, University of Southern California, 1973. Moore, M. E., Stunkard, A. J. and Sroll, L. Obesity, social class, and mental illness. Journal of American Medical Association, 1962, 181, 962. Moore, R. K. Susceptibility to hypnosis and susceptibility to social influence. Journal of Abnormal and Social Psychology, 1964, 68, 282-294. Moss, C. S. and Stachowiak, J. G. The ability of hypnotic subjects to interpret symbols. Journal of Projec tive Techniques, 1963, 27, 92-97. Nayyar, S. N. and Brady, J. P. Elevation of depressed skull fracture and frontal topectomy under hypnotic anesthesia. Journal of the American Medical Asso ciation, 1962, 181, 790-792. : Netzer, C. T. Brand-name calorie counter (Abridged) New York: Dell Publishing Co., 1969. Newman, H. H., Freeman, F. N. and Hollzinger, K. J. Twinst A study of heredity and environment. Chicago: University of Chicago Press, 1937. 120 Orne, M. T. The nature of hypnosis: Artifact and essence. Journal of Abnormal and Social Psychology, 1959, 58, 277-299. Orne, M. T. On the social psychology of the psychological experiment with particular reference to demand characteristics and their implications. American Psychologist, 1962, 17, 776-783. Orne, M. T. The nature of the hypnotic phenomenon: Recent empirical studies. APA Symposium, The New "Hard- Nosed" Approach in Hypnosis Research. Philadelphia, 1963. Pearson, L., Pearson, Lillian and Saekel, K. The Psycholo gist's eat-anything diet. New York: Peter H. Wyden, Inc., 1973. Penick, S. B., Filion, R., Fox, S. and Stunkard, A. J. Behavior modification treatment of obesity. Psy chosomatic Medicine, 1971, 33, 49-55. Reitman, W. R. Motivational induction and the behavior correlates of achievement and affiliation motives. Journal of Abnormal and Social Psychology, 1960, go/ 8-it: -------- -------- ---- Roberts, M. R. Attention and related abilities of affect ing hypnotic susceptibility. Dissertation Abstracts, 1964, 25, 4261. Rosenhan, D. and London, P. Hypnosis: Expectation, sus*i ceptibility, and performance. Journal of Abnormal and Social Psychology, 1963a, 66, 77-80. Rosenhan, D. and London P. Hypnosis in the unhypnotizable: A study in rote learning. Journal of Experimental Psychology, 1963b, 65, 30-34. Rossi, A. M., Sturrock, J. B. and Solomon, P. Suggested effects on reported imagery in sensory deprivation. Perceptual and Motor Skills, 1963, 16, 39-45. Sachs, L. and Anderson, W. L. Modification of hypnotic Susceptibility. International Journal of Clinical and Experimental Hypnosis, 19<>7, 15, 1?2. Schaefler, K. and London, P. Differential effects of hyp notic susceptibility and instruction sets on cogni tive and motor performance. Proceedings of the 121 77th Annual Convention of the American Psychologi cal Association, 1969, 909-910. Schubot, E. D. The influence of hypnotic and muscular re laxation in systematic desensitization of phobias. Unpublished doctoral dissertation, Stanford Univer sity, 1966. Seltzer, C. C. and Hayer, J. A. Simple criterion of obesi ty. Postgraduate Medicine, 1965, 38, A101-A107. Shipman, W. G. and Plesset, M. Anxiety and depression in obese dieters. Archives of General Psychiatry, 1963, 8, 530-535. Shor, R. E. Hypnosis and the concept of the generalized reality-orientation. American Journal of Psycho therapy, 1959, 13, 582-602. Shor, R. E. and Orne, Emily C. Harvard group scale of hypnotic susceptibility, Form A. Palo Alto: Consulting Psychologists Press, 1962. Silverstone, J. T. Psychological factors in obesity. In I. M. Baird and A. N. Howard (Ed.) Obesity: Medi cal and scientific aspects. London! E. and S. Livingstone LTD., 1969. Slotnick, R. and London, P. Influence of instructions on hypnotic performance. Journal of Abnormal Psychol- ogy, 1965, 70, 38-46. Stefanik, P. A., Heald, F. F. and Hayer, J. Caloric intake in relation to energy output of obese and non-obese adolescent boys. American Journal of Clinical Nutrition, 1959, 7, 55. Stuart, R. B. Behavior control of overeating. Behavior Research and Therapy, 1967, 5, 357-365. Stuart, R. B. and Davis, B. Slim chance in a fat world. Champaign, Illinois: Research Press Co., 1972. Stunkard, A. J. and McLaren-Hume, H. The results of treat ment for obesity (a review of the literature and a report on a series). American Medical Association Archives of Internal Medicine, 1959', 103, 79-85. 122 Ullman, M. and Dudek, S. On the psyche and warts: IX Hypnotic suggestion and warts. Psychosomatic Medicine, 1960, 22, 68-76. Weinstein, M. A. Achievement motivation and risk prefer ence. Journal of Personality and Social Psychol ogy, 1969, 13, 153-1^2. Weitzenhoffer, A. M. and Hilgard, E. R. Stanford hypnotic susceptibility scale, forms A and B. Palo Alto, Calif.: Consulting Psychologists Press, 1959. Weitzenhof fer, A. M. and Sjoberg, B. M., Jr. Suggestibil ity without induction of hypnosis. Journal of Nervous and Mental Disorders, 1961, 132, 204-220. Weitzenhoffer, A. M. and Weitzenhoffer, G. B. Sex trans ference, and susceptibility to hypnosis. American Journal of Clinical Hypnosis, 1958, 1, 15-24. Withers, R. F. J. Problems in genetics of human obesity. Eugenics Review, 1964, 56, 81. Wollersheim, J. P. Effectiveness of group therapy based upon learning principles in the treatment of over weight women. Journal of Abnormal Psychology, 1970, 76, 462-474. AP PENDICES r 123 APPENDIX A BIOGRAPHICAL QUESTIONNAIRE Name_________________________________________________________________ ( l a s t ) ( f i r s t ) (m id d le ) A d d re s s _________________ __________ ^ _________ (num ber a n d s t r e e t ) ( c i t y ) ( z ip c o d e) P h o n e N um ber H e ig h t f t . i n . W e ig h t Age_ M a r i t a l S t a t u s : S i n g l e M a r r ie d D iv o rc e d ( c i r c l e one) O c c u p a tio n _____________________________________________________________ E d u c a ti o n : W h a t's t h e h i g h e s t g r a d e y o u h a v e c o m p le te d ? ___ 1) Check if you have had any of the following: Ulcers_____ Gallbladder disease Bleeding Chest Pain__Heart Murmer Shortness of Breath Pneumonia Asthma__TB Kidney Disease Urinary Infections Seizures Severe Head- aches Dizziness Excessive Nervousness High Blood Pressure___ (circle one) 2) Do you have pains in the heart or chest? YES NO 3) Are you often bothered by thumping of the heart? YES NO 4) Does your heart often race like mad? YES NO 5) Do you often have difficulty in breathing? YES NO 6) Do you get out of breath long before anyone else? YES NO 7) Do you get out of breath just sitting still? YES NO 8) Are your ankles often swollen? YES NO 124 125 9) Do cold hands or feet trouble you even In hot weather? YES NO 10) Has a doctor ever said you had heart trouble? YES NO 11) Does heart trouble run In your family? YES NO 12) Does your face often get badly flushed? - YES NO 13) Do you take any prescribed drugs or medication? YES NO If yes, what kind and how often? (be specific) 14) Do you suffer from any chronic disease? If yes, please describe it. YES NO 15) Did you ever have a serious operation? YES NO 16) About how many cups of coffee or tea do you drink in a day? 17) How many alcoholic drinks do you usually have a day? 18) Do sudden noises make you jump or shake badly?YES NO 19) Are you often awakened out of your sleep by frightening dreams? YES NO 20) Do you often become scared for no good reason? YES NO 21) Do you often break out in a cold sweat? YES NO 22) Did a doctor ever suggest that you should go on a diet? YES NO 23) What is the most you have ever weighed? 24) What is the least you have ever weighed within the last three years? 126 25) What do you consider to be an ideal weight for you? 26) Have you ever been hypnotized before? YES NO If yes, please explain the circumstances.___________ 27) On a scale of 1 to 10 how would you rate your current Btate of health? Poor ____ ^ ^ ______________ Good {check the appropriate space) 28) What do you see as the cause of your weight problem? 29) Do you think you overeat? YES NO 30) Do you eat more when you're upset? YES NO 31) Do you have a tendency to snack? YES NO When do you usually snack?______________________________ What kinds of food do you usually snack on?___________ What kinds of sweets, if any, do you snack on?_ 32) At what age did your weight problem first become evident? Did you associate it with any event in your life? YES NO If yes, please explain 33) Has a physician ever prescribed diet pills or injec tions for your weight problem? YES NO If yes, are you taking them now? YES NO 34) When did you last have a physical examination? 127 (date) What if any physical illnesses or disabilities were discovered at that time? 35) Are you currently under treatment by a doctor for any reason? YES NO If yes, please explain 36) Please put a check mark next to the times listed below when you would be available to attend the treatment sessions. Thurs Fri - Sun Wed Mon Tues 10 a.m 11 a.m 12 1 p.m 2 p.m 3 p.m. 4 p.m. 5 p.m 6 p.m 7 p.m 9 p.m. 10 p.m. APPENDIX B DIET AND EXERCISE FORM M«ae__________________________________ D a te EXERCISE PLAN EXERCISE PUN L i g h t T u esd ay L ig h t Eac:h box > 5 m in, x 2 0 - > 2 0 c a l o r l a a E ach b o x - 5 m in x 2 0 - . ■ 20 c a l o r i e s M oderate M oderate Bach BO X " 5 n l n . ■ 3 5 c a l o r i o a x 3 5 - E ach b o x “ 5 B x3 i n 5 - • —35 c a l o r i e s Heavy Hoavy I Each box ■ 5 m in . > » c a l o r i o a x 5 0 - Bach box > 5 m in . “ 50 c a l o r i o a x50> DAILY TOTAL DAILY TO TA L 1 L ig h t >% « •0 m 0 1 L ig h t Bach ta x - 5 n l n x 2 0 - a ■ 26 c a l o r i e s E ach BOX “ 5 m in . ■ 20 c a l o r i o a x20> M oderate M oderate . 1 ♦ Bach box * 5 u in « - 3 5 c a l o r i e * X 35- E a c h .b o x > 5 m in . > 3 5 c a l o r i x35> .e s H eavy ‘ H eavy B ach OOlt - 5 n l n . - 5 0 c a l o r i e s x 5 0 - E ach BOX - 5 p iin . > x50> 50 c a l o r i.08 DAILY TOTAL! DAILY TO TA L 128 Friday T h u rsd a y 129 Nana EXERCISE PUN Eight B a< h box - s w in . - 20 c a l o r i e s x 2 0 - Moderate uauiwlIC Each box « 5 m in . - IS c a l o r i e s x35« Heavy E x ercise Each box “ 5 n l n . - x50« SO c a l o r i e s DAILY TO TA L ! C I S E PLAN L ig h t Each box - s m in. ■ x20« 20 c a lo rlo s 4o d era te Bach box - 5 m in. - i s c a lo r ie s x35- Heavy Bacti box » s m in. * x50« 50 c a lo r ie s DAILY TOTA > . M I C O Each box - win.- 20 calorlos x20- Each box »S min X35- ♦ * 15 calorlos Each box *5 min. - x50- 50 calories DAILY TO TA L Sunday 130 1500— CALORIE FOOD P U N 1500— CALORIE FOOD PU N EXCHANGES 7 S 2 3 3 5 EXCHANGES 7 S 2 3 5 5 N e a t C e r e a l M ilk V eg F r u i t M la c M e a t C e r e a l M ilk V eg F r u i t M lac □ □ □ □ 3 □ □ 1 □ □ □ □ □ 1 2 □ □ ' □ □ □ □ C □ 1 □ □ □ I 1 1 □ ii □ ro o d E x t r a s P la n T o ta l T o t a l C a lo r io a S ’ n □ □ d id 3 □ d a 8 1 _ _ 1 1 _ _ 1 1 _ _ 1 U L 5 2 □ □ □ C Z □ □ □ □ □ □ □ □ □ I □ □ □ 1 1 n b • P la Food E x t r a s n T o t a l T o t a l C a l o r l o s EXCHANGES 7 5 2 3 5 5 H e a t C e r e a l M ilk V eg F r u i t M lae EXCHANGES 7 5 2 3 5 5 M e a t C e r e a l M ilk V eg F r u i t M lac o > a 2 □ □ I~1 □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ Food P la n T o t a l E x t r a s B l □ □ i — H Z 3 1 1 d □ □ □ □ d I □ □ d id 2 — t a a □ □ □ □ □ □ 3 I □ did] □ □ ii n £ □ H . W o t . l T o t a l C a l o r i e s F r id a y n T h u rsd a y 131 1500 — CALORIE FOOD PLAN EXCHANGES 7 5 2 3 5 . 5 M oat C e r e a l M ilk V eg F r u i t K ia e Name DAILY WEIGHT □ □ □ □ CZ □ □ □ □ □ □ □ □ □□ □ □ □ □ □ □ □ □ □ □ □ F o o d H a n T o t a l E x t r a s T o t a l C a l o r i e s S u n d a y M onday T u e s d a y W ed n esd ay T h u rs d a y F r i d a y ___ S a t u r d a y - 1500— CALORIE FOOD PLAN KCIIANGES 7 5 2 3 5 S EXCHANGE 7 5 2 3 5 S H e a t C e r e a l M ilk V eg F r u i t M is c M oat C e r e a l M ilk V eg F r u i t M ia c I Q t t u □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ czicziacz □ □ □ □ □ □ F o o d | E x t r a s j T o t a l c a l o r i e s P la n T o t a l w a. CZ1 □ □ □CZ) □ □ □ □ □ □ CZJ □ □ □ □ □ □ □ □ □ □ □□ □ □ □ 'o o d P la n T o t a l E x t r a s T o t a l C a l o r i e i APPENDIX C NAME DATE FEEDBACK QUESTIONNAIRE Please fill out this questionnaire very carefullyi 1. Did you miss not having the sessions during the last month? If yes, in what ways?__________________________________ 2. Do you feel that your friends or relatives acted dif ferently towards you, in any way, since you stopped attending the sessions? ____________________________ If yes, in what ways?____ 3. How many times did you call someone in your group over the past month? How many times did you receive calls from members of the group? What did you usually talk about?___________________________________ 4. How frequently did you exercise? (circle one) Daily Every other day Twice a week Once a week or less 132 133 If you exercised lesB during the past month than you did while attending the sessions, what problems led you to cut down on exercising?______________________ 5. Did you put up any of the signs that we gave you? If yes, where did you put them?__________________ 6. Did you make up any signs of your own? If yes, what did they say?____________ 7. Did you stop keeping records of you dieting and ex ercising?_____ If yes, why?________________________________________ 8. Before, while you were still attending the sessions, how often did you: (circle one) a. Eat in only one room of your house? seldom half-the-time often b. Engage in other activities while eating? seldom half-the-time often c. Make a grocery list before going shopping? seldom half-the-time often d. Make a conscious effort to eat slowly and take small bites? seldom half-the-time often e. Weigh yourself daily? seldom half-the-time often 9. Over the past four weeks, since you stopped attending the sessions, how often did you: (circle one) 134 10. a. Eat in only one room of your house? seldom half-the-time often b. Engage in other activities while eating? seldom half-the-time often c. Make a grocery list before shopping? seldom half-the-time often d. Make a conscious effort to eat slowly and take small bites? seldom half-the-time often e. Weigh yourBelf daily? seldom half-the-time often Did you go off your diet plan at anytime over the past month?_____ If yes, how often did you have each of the following eating problems? a. Snacking b . Eating more at meals c. Eating high-calorie foods d. Drinking alcoholic drinks e. Social pressure at home f. Social pressure away from home g. Eating when sad or lonely h. Eating when frighten ed or anxious i. Eating without really being aware of the taste of the food (circle one) seldom sometimes often seldom sometimes often seldom sometimes often seldom sometimes often seldom sometimes often s e l d o m B o r n e t i m e s o f t e n seldom sometimes often seldom sometimes often seldom sometimes often 135 11. Are there any ways in which you feel we could have better prepared you to follow the program on your own? APPENDIX D M e d ic a l R e le a s e Form T o: E x a m in in g P h y s i c i a n __________ has volunteered to participate in our experimental weight reduction program at the University of Southern California. The program employs the diet and exercise regimen developed by Dr. Richard Stuart and Barbara Davis and presented in their book Slim Chance in a Fat World. The balanced diet involved, which is both flexi- ETe and nutritious, restricts caloric intake to 1,500 calor ies per day for women between the ages of 22 and 35 and to 1,350 calories per day for women 36 to 55^. The exercise part of the regimen encourages and increased caloric out put of 250 calories per day above the participant's present level of expenditure. Our preliminary requirements for participation in the pro gram are that volunteers must consult their physician for examination and for his approval that they can participate without adverse effects. We are not accepting volunteers with diverticulitis, diabetes, gout, tuberculosis, Addi son' b disease, pregnancy, ulcerative colitis, regional ileitis, hypoglycemia, any heart disease, or any other con dition which, in your professional opinion, might make it ill advised to participate in a standard weight reducing diet program or engage in additional physical exercise. We also cannot accept participants using prescription medica tion to help them lose weight for the duration of the pro gram and request that you disqualify patients who, in your judgment, should be on such regimens during the three month period involved. If your examination indicates that the patient meets the qualifications of this study, please sign the form below. With thanks for your cooperaiton, I am Yours singerely, 136 137 I have examined _________ on this date and have discovered no disease, disorder, or other condition which would disqualify her as a participant in your weight reduction program. Date:________________ ________________ ____ Signature of Examining Physician Address of Physician APPENDIX E A c c e p ta n c e L e t t e r Dear We are pleased to inform you that you have been accepted into our weight-reduction program. The first session will be on May__________ , at__________ o'clock P.M. at this ad dress . As we told you, the success of this experimental program depends on your commitment to staying in it and attending all of the treatment sessions. There is no charge for the complete program, but we require all participants to de posit $15.00 with us at the first session. It will be re funded to everyone who completes all seven of the treatment sessions plus the one-month follow-up session. Also, please have your doctor sign the enclosed medical re lease form and bring it with you to the first or second session. If you decide, for any reason, not to participate in the program, please call us immediately. Otherwise, we look forward to seeing you at your sessions. Sincerely, 138

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Asset Metadata

Creator Miller, Jeffrey Earl (author)

Core Title Hypnotic Susceptibility, Achievement Motivation, And The Treatment Of Obesity

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor London, Perry (committee chair), Conolley, Edward S. (committee member), Tiber, Norman (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-734082

Unique identifier UC11356507

Identifier 7428456.pdf (filename),usctheses-c18-734082 (legacy record id)

Legacy Identifier 7428456.pdf

Dmrecord 734082

Document Type Dissertation

Rights Miller, Jeffrey Earl

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA