Can I use parametric analyses for my Likert scales? A brief reading guide to the evidence-based answer.

Whether to use parametric or non-parametric analyses for questionnaires is a very common question from students. It is also an excellent question since there seem to be strong opinions on both sides and that should make you search for deeper answers. It is the difference between modeling your data using parametric statistics (means and linear relationships, e.g., ANOVA, t-test, Pearson correlation, regression) or non-parametric statistics (medians and ranks, e.g., Friedman/Mann-Whitney/Wilcoxon/Spearman).

Consider this 5-item response. What do you think better represents this respondent’s underlying attitude? The parametric mean (SD) or the non-parametric median?

 

Here, we will leave armchair-dogma and textbook-arguments aside and look to the extensive empirical literature for answers. I dived into a great deal of papers to compose an answer to my students:

Be aware that this is a debate between the ordinalists (saying that you should use non-parametric) and the intervalists (arguing for parametric) which is still ongoing. So any answer would be somewhat controversial. That said, I judge that, for common analyses, the intervalist position is much better justified. The literature is big, but most of the conclusions are well presented by Harpe (2015). In brief, I recommend the following:

You would often draw similar conclusions from parametric and non-parametric analyses, at least in the context of Likert scales. For presenting data and effect sizes, always take a descriptive look at your data and see what best represents it. As it turns out, (parametric) means are usually fine for Likert scales, i.e., the mean of multiple Likert items. But (non-parametric) counts are often the correct level of analysis for Likert items, though this can be further reduced to the median if you have enough effective response options (i.e., 7 or more points which your respondens actually use). Due to measurement inaccuracy, interpreting single Likert items is often unallowably fragile, and no statistical tricks can undo that. So you should operationalize your hypotheses using scales rather than items as indeed all standardized questionnaires do. As you see from the above, this, in turn, means that your important statistical tests can be parametric. Because parametric inferences are much easier to interpret and allows for a wider range of analyses, it is not only an option but really a recommendation to use parametric statistics for Likert scales.

I would personally add to this that you should not dismiss the ordinalist-intervalist debate since its exactly the lines of thought that we ought to have when we chose our statistical model, namely to what extent the numbers represent the mental phenomena we are investigating. Others (e.g., the censor) may be ordinalists, so make sure (as always) to justify your choice using empirical literature. This makes your conclusions accessible to the widest audience possible. I provide here a short reading guide to help you make those justifications.

Reading guide

Students and newcomers are recommended to read the papers in the stated order to get a soft introduction. Readers more familiar with the topic can jump straight to Harpe (2015). I would say that Sullivan & Artino (2013) and Carifo & Perla (2008) gets you 75% of the way and Harpe (2015) gets you 95% of the way. Norman (2010) is included for its impact on the debate and because it presents the arguments slightly more statistically, but content-wise it adds little over and above Harpe (2015).

Note that this is an extensive literature, including some papers leaning ordinalist. However, I have failed to find ordinalist-leaning papers that did not commit the error of either (1) a conflation of Likert items and Likert scales without empirical justification for doing so, or (2) extrapolating from analysis of single items to analysis of scales – again without empirical justification that this is reasonable. If I learn about a paper which empirically uncovered that parametric analyses of Likert scales are unforgivingly inaccurate, I would not hesitate to include it. However, I feel like all major arguments are represented and addressed in this list.

  • (15 minutes) Sullivan, G. M., & Artino, A. R. (2013). Analyzing and Interpreting Data From Likert-Type Scales. Journal of Graduate Medical Education, 5(4), 541–542. https://doi.org/10.4300/JGME-5-4-18
    A light read for novices which could serve as an introduction to Likert-scales understood statistically and the idea of using parametric analyses on Likert data. However, it is too superficial to constitute a justification for doing so.
  • (15 minutes) Carifio, J., & Perla, R. (2008). Resolving the 50-year debate around using and misusing Likert scales. Medical Education, 42(12), 1150–1152. https://doi.org/10.1111/j.1365-2923.2008.03172.x
    A very concise list of arguments on the statistical side of the intervalist-ordinalist debate, heavily favoring the intervalist side for most situations. As a side note, this is a continuation and summary of Carifio & Perla (2007), but while the fundamental arguments of that paper are strong, it is so poorly written that I do not include it in this reading guide. Maybe this is why they needed this 2008 paper.
  • (60 minutes) Harpe, S. E. (2015). How to analyze Likert and other rating scale data. Currents in Pharmacy Teaching and Learning, 7(6), 836–850. https://doi.org/10.1016/j.cptl.2015.08.001
    This paper introduces both the history, rating scale methodology, and empirically-based review of inferring ratio parameters (like means) from ordinal data (like Likert-items). Here too, the conclusion is that parametric analyses are appropriate for most situations. Most importantly, Harpe presents practical recommendations and nuanced discussion of when it is appropriate to deviate from those recommendations. Also, it has one of the most extensive reference lists, pointing the reader to relevant sources of evidence. As a reading guide, you may skip straight to the title “statistical analysis issues” on page 839 while studying Figure 1 on your way. Even though this paper is very fluently written, do take note of the details too because the phrasing is quite accurate.
  • (40 minutes) Norman, G. (2010). Likert scales, levels of measurement and the “laws” of statistics. Advances in Health Sciences Education, 15(5), 625–632. https://doi.org/10.1007/s10459-010-9222-y
    This is the most cited paper on the topic, so I feel like I need to comment on it here since you are likely to encounter it. Recommendation-wise, it adds little new that Harpe (2015) did not cover. Some advantages of the paper are that it brings you to the nuts and bolts of the consequences of going parametric instead of non-parametric, e.g., by presenting some simulations and actual analyses. The paper is fun to read because Norman is clearly angry, but unfortunately, it also reads largely as a one-sided argument, so retain a bit of skepticism. For example, Norman simulates correlations on approximately linearly related variables and concludes that Spearman and Pearson correlations yield similar results. While this is a good approximation to many real-world phenomena, the correlation coefficients can differ around 0.1 when the variables are not linearly related (Pearson inaccurate) but still monotonically increasing/decreasing (Spearman accurate). This can change the label from “small” to “medium” cf. Cohen’s (1992) criteria which are (too) conventionally used.

Additional comments

Many “non-parametric” analyses are actually parametric. If the paper used the mean Likert rating of multiple items, they are largely parametric, no matter if they do non-parametric tests of this mean. This is because taking the mean embodies the parametric assumption that the response options are equidistant, e.g., that the mean of “strongly disagree” and “neutral” is “disagree.” Similarly, if the paper used Cronbach’s alpha to assess reliability or unidimensionality, they are parametric since it’s a generalized Pearson correlation, i.e., modeling a continuous linear relationship between Likert items. The vast majority of the academic literature does this, including every single standardized questionnaire. A practical consensus is not a convincing defense of going parametric on Likert data, but it does indicate that it requires little to get to the level of current publication practices.

Prediction of responses to single responses must be ordinal. Predictions of responses should only yield actual response options. E.g., not 2.5 or 6 on a 5-point Likert scale. For scales or predictions across subjects (i.e., the mean of items) the parametric estimate will often be good enough. I have not found literature which has tried to predict responses on individual items by individual subjects, but if you were to do so, you would have to do some transformation of the inferred parametric estimates back into predicted discrete ordinal responses (e.g., probit transformation).

Multilevel models are superior. Always beware when “manually” computing differences, means, analyzing subsets of data, etc. since you usually through away valuable data. Similarly in the context of Likert scales where you compute a mean. It is self-evident that the mean of 100 items would much better approximate the true underlying attitude of your respondent than the mean of 4 items. Yet, Mann-Whitney U or other analyses would not “know” this difference in certainty. Multilevel models would much better represent the data, seeing the response to particular items as samples of a more general attitude of the respondent (with a mean and a standard deviation) rather than pure measures. However, I have not presented or discussed multilevel solutions above, since the learning curve can be steep and the classical scales-as-means approach is accurate enough for most purposes.

Let’s rename “fixed” to “Population-level” and “Random” to “Varying”

I was reading this interesting preprint on ordinal regression by Paul Bürkner and Matt Vuorre. Now see this footnote about their vocabulary:

Hallelujah and Eureka!! I think that these terms may help solve (some of) the long-standing confusion about the difference between “fixed” and “random” effects.

TL;DR: To shrink or not to shrink – that is the question

The mathematical distinction is that Varying (“random”) parameters have an associated variance while Population-level (“fixed”) parameters do not. Population-level effects model a single mean in the population. Varying effects model a mean and a variance term in the population, i.e., two rather than one parameters. The major practical implication is that Varying parameters have shrinkage in a regression towards the mean-like way whereas the Population-level parameters do not.

The figure below shows this shrinkage in action for the following three models:

The figure shows five illustrative participants (panels), each tested four times. A model with varying subject-intercept (red lines) shrinks subjects closer to the group mean (black line) than the model with the population-level subject-intercept (blue lines). The green lines are actual scores. Furthermore, the shrinkage is stronger the further away the data is from the overall mean. See the accompanying R notebook for all details and all participants.

So shrinkage is the only practical difference. This is true for both frequentist and Bayesian inference. Understanding when to model real-world phenomena using shrinkage, however, is not self-evident. So let me try to unpack why I think that the terms “Population-Level” and “Varying” convey this understanding pretty well.

Population-level parameters

General definition:

Values of Population-level parameters are modeled as identical for all units.

Example:

Everybody in the population of individuals who could ever be treated with X would get an underlying improvement of exactly 4.2 points more than had they been in the control group. Mark my words: Every. Single. Individual! The fact that observed changes deviate from this true underlying effect is due to other sources of noise not accounted for by the model.

The example above could be a 2×2 RM-ANOVA model of RCT data ( outcome ~ treatment * time + (1|id)) with treatment-specific improvement (the  treatment:time interaction) as the population-level parameter of interest. Populations could be all people in the history of the universe, all stocks in the history of the German stock market, etc. Again, the estimated parameters are modeled as if they were exactly the same for everyone. The only thing separating you from seeing that all-present value is a single residual term of the model, reflecting unaccounted-for noise. The residual is an error term so it is not the model itself. As seen from the model, everybody is identical and the residual is simply an error term (which is not part of the model) indicating how far this view of the world deviates from observations.

I think that modeling anything as a Population-level parameter is an incredibly bold generalization of the sort that we hope to discover using the scientific method: the simplest model with the greatest predictive accuracy.

Now, it’s easy to see why this would be called “fixed” when you have a good understanding of what it is, but as a newcomer,  the term “fixed” may lead you astray thinking that either (1) it is not estimated, (2) that it is fixed to something, or that its semantically self-contradictory to call a variable fixed! Andrew Gellman calls them non-varying parameters, and I think this term suffers a bit from the same possible confusions. Population-level goes a long way here. The only ambiguity left is whether parameters that apply to the population also apply to individuals, but I can’t think of a better term. “Universal”, “Global”, or “Omnipresent” are close competitors but they seem to generalize beyond a specific population so let’s stick with Population-level.

Varying parameters

General definition:

Values of Varying parameters are modeled as drawn from a distribution.

Example for (1|id) :

Patient-specific baseline scores vary with SD = 14.7.

Example for (0 + treatment:time | id) :

The patient-specific responses to the treatment effect vary with SD = 3.2 points.

This requires a bit of background explaining so bear with me: Most statistics assume that the residuals are independent. Independence is a fancy way of saying that if you know any one residual point, you would not be able to guess above chance about any other residuals. Thus, the independence assumption is violated if you have multiple measurements from the same unit, e.g., multiple outcomes from each participant since knowing one residual from an extraordinary well-performing participant would lead you to predict above-chance that other residuals from that participants would also be positive.

You could attempt to solve this by modeling a Population-level intercept for each participant ( outcome ~ treatment * time + id), effectively subtracting that source of dependence in the model’s overall residual. However, which of these participant-specific means would you apply to an out-of-sample participant? Answer: none of them; you are stuck (or fixed?). Varying parameters to the rescue! Dropping the ambition to say that all units (people) exhibit the same effect, you could estimate the recipe on how to generate those intercepts for each participant which helped you get rid of the dependence of the residuals (or more precisely: model it as a covariance matrix). This is a generative model in the form of the parameter(s) of a distribution and in GLM this would be the standard deviation of a normal distribution with mean zero.

One way to represent this clustering of variation to units is a hierarchical model where outcomes are sampled from individuals which are themselves sampled from the nested Population-level parameter structure:

Two-level multilevel model in r. By Kristoffer Magnusson
Figure by Kristoffer Magnusson. Click to see the source which includes R code to fit this model and many more.

 

For this reason, I think that we could also call Varying parameters sampled parameters. This is true whether those sampled parameters are intercepts, slopes, or interaction terms. Crossed Varying effects are just parameters sampled from the joint distribution of two non-nested populations (e.g., subject and questionnaire item). Simple as that!

Again, it’s easy to see why one would call this a “random” effect. However, as with “fixed effects,” it is just easy to confuse this for (1) the random-residual term in the whole model, or (2) the totally unrelated difference between frequentist and Bayesian inference as to whether data or parameters are fixed or random. Varying seems to capture the what it’s all about – that units can vary in a way that we can model. With variation comes regression towards the mean so it follows naturally.

Two derived properties of Varying

Firstly, it models regression towards the mean for the varying parameters: Extreme units are shrunk towards the mean of the varying parameter since those units are unlikely to reflect a true underlying value. For example, if you observe an exceptionally large treatment effect for a particular participant, he or she is likely to have experienced a lesser underlying improvement, but unaccounted-for factors exaggerated this by chance. Similarly, when you observe exceptionally small observed treatment effects, it is likely to reflect a larger underlying effect masked by chance noise.

Secondly, it requires enough levels (“samples”) of the Varying factor to estimate its variance. You just can’t make a very relevant estimate of variance using two or three levels (e.g. ethnicity). Similarly, sex would definitely make no sense as Varying since there is basically just two levels. Participant number, institution, or vendor would be good for analyses where there are many different of those. For frequentist models like lme4::lmer, a rule of thumb is more than 5-6 levels. For Bayesian models, you could have even one level (because Bayes rocks!) but the influence of the prior and the width of the posterior would be (unforgivably?) big.

Some potential misunderstandings

I hope that I conveyed the impression that the distinction between Population-level and Varying modeling is actually quite simple. However, the Fixed/Random confusion has caused people to exaggerate their difference for illustrative purposes, giving the impression that they do have distinct “magical properties”. I think they are more similar:

Both random and fixed can de-correlate residuals: It is sometimes said that you model effects as “fixed” to model effects of theoretical interest and other effects as “random” to account for correlated residuals, thus respecting the independence assumption (e.g., repeated measures). However, both “fixed” and “random” effects de-correlate residuals with respect to that effect. No magic!

Both random and fixed can account for nuisance effects: It is often said that random effects are for nuisance effects and fixed effects model effects of theoretical importance. However, as with the point above about de-correlating residuals, they can both do this. Say you want to model some time-effect (e.g., due to practice or fatigue) of repeated testing to get rid of this potential systematic disturbance if your theory-heavy parameters. You could model time as a fixed effect and just ignore its estimate or you could model it as random. The decision should not be theory vs. nuisance but rather whether the effect of time is modeled as identical for everyone or as Varying between units. No magic!

Both Varying and Population-level are model population-wide parameters. The word “population-level” effect may sound like it is the only parameter that says something about the population or that it is easier to generalize. In fact, I highlighted above that for “sampled” parameters, it was easier to see how Varying effects would generalize. Is this self-contradictory? No. Population-level effects are the postulate that there is a single mean in the population. Varying effects are the postulate that there is a mean and a variance term in the population.

 

Helpful sources

A few sources that helped me arrive at this understanding was:

  1. Here are some nice visualizations of “fixed” vs. “random” effects in the context of meta-analyses. The distinction is the same. Instead of “study”, just think “participant”, “country”, or whatever.
  2. Writing mixed models in BUGS helped me to de-mysticise most of linear models, including fixed/random and what interactions are. I started in JAGS. Here’s a nice example.
  3. This answer on Cross-Validated which made me realize that shrinkage is the only practical difference between modeling parameters as “fixed” or “random.”
  4. The explanation in the FAQ to R mailing list on GLMM, primarily written by the developers of the lme4 package.
  5. Brauer & Curtin (2017) with plain-language recommendations for mixed models.
  6. Hodges & Clayton (2011) makes a distinction between “old-style” random effects (draws from a population), which I have mentioned here, and “new-style” random effects where the variance term is used more for mathematical convenience, e.g. when there is no population, the observed units exhaust the population, or when no new draws are possible. It is my impression that “new-style” is seldom used in psychology and human clinical trials.

 

TO DO

  • IMPORTANT: Rename terms? Varying is just two population-level parameters instead of one. How about: “
  • Mention that population-level has superior fit to data.
  • Fix plot annotations
  • Varying as uncertainty around fixed and residual as errors from model!
  • Use intro model in the quotes below
  • Fixed vs. random well-known in MA
  • Add legend to figure

New tutorial on computing Bayes factors in R

I just published a practical guide on computing Bayes factors using various packages in R. Head over to RPubs and check out How to compute Bayes factors using lm, lmer, BayesFactor, brms, and JAGS/stan/pymc3.

My first goal is to present solutions to things that I found difficult in the respective packages and which are relatively undocumented. A second goal was to show a side-by-side comparison on whether the packages converge on the same Bayes factor estimates.

I hope to keep the document updated. In particular, I’m keeping an eye on the development of, BASand I need to learn how to specify a full JZS prior in brms.

Personally, this is a lot of firsts for me and took way too much time: my first R notebook (including Markdown), first tutorial in many years, and first use of brms and  BAS.

Software for graphical models

I’m currently writing a paper on a new Bayesian method for scoring Complex Span tasks. I needed some software to represent it using plate notation of a directed acyclic graph (DAG). Many people have pointed to the Tikz/pgf drawing library for latex, but I did not want to install latex for this simple task. Here I briefly review yEd, Daft, and Libreoffice Draw.

yEd

I ended up using yEd and produced this graph which contains plates, estimated nodes, deterministic nodes (double-lined), observed nodes (shaded), and categorical nodes (rectangles).yEd is purely graphical editing which is fast to work with and great for tweaking small details. A very handy yEd feature is its intelligent snapping to alignments and equal distances when positioning objects. Actually, I don’t understand why yEd almost never makes it to the “top 10 diagram/flowchart programs” lists.

A few things I learned: To make subscripts, you have to use HTML code. For example, the \(R_{trial_{i,j}}\) node is

However, it is not possible to do double-subscripts. Also, the double-edges node is made completely manually by placing an empty ellipse above another. I did not manage to align the \(WMC_i\) label a bit lower in the node. A final limitation is that arrowhead sizes cannot be changed. You can, however, zoom. Therefore, your very first decision has to be the arrowhead size. Zoom so that it is appropriate and make your graphical model. I didn’t think about this so the arrows are too large for me in the graph above.

I’m pretty pleased with the result. For the final paper I may try and redo this in Libreoffice Draw to see if I can fix the final details.

Libreoffice Draw

In retrospect, I think that Draw could have done better than yEd. First, you can scale arrowheads to your liking! Furthermore, you can write math in LibreOffice Math, so double-subscripting is no problem. However, you have to group a math object with an ellipse rather than entering it as “content”, which is a bit convoluted. Speaking of math, LibreOffice Math was great for entering the model specifications for the graphical model:

One small annoyance is that you have to choose between left-aligning everything including the denominators in fractions (which of course should be centered), or center-align everything. I would have liked a center-aligned denominator while left-aligning everything lines.

The above was created using the following code. The matrix was used to align the terms.

I have to say that there’s something to the lacking snap-to-alignment and the general interface in Draw that makes it feel less nice than yEd, even though it is probably more versatile for the present purpose. I may update this blog post with a Draw model when I get around doing it.

Daft

Daft is a python module for rendering graphical models. The syntax is quite nice, but I quickly learned that you have to choose between shaded or double-edged nodes as indicators of observed variables. You cannot have both. You can draw an empty smaller node on top to make it double-edged, but using the \(scale\) argument makes it non-aligned with the outer line. I raised this as a GitHub issue, but Daft has not been maintained for years, so I don’t expect this to be fixed. Also, you have to install an old fork to draw rectangular nodes. This is as far as I got:

Here’s the code to do it, very much inspired (/ripped off) by this example.

Some notes

  • Rob Zinkov posted an interesting argument on how generative stories can be used instead of plate notation.
  • For those used to R, the ggdag package seems like a really convenient way to draw quick DAGs from formulas.

Five divided by forty-nine

At a family dinner, my brother told me that he had stumbled upon a curious number. Divide five by forty-nine and take a look at the digits:

$$5 / 49 = 0.10204081632653061…$$

Do you see a pattern in the digits? Yes! It’s powers of two: (0.)1, 02, 04, 08, 16, 32, 65, … Huh, 65? Yes! The next number, 128, is a three-digit number and so the first digit “overlaps” the last digit of 64, making it 65. And this continues for the first digits of 256 (28 + 2 = 30), 512, the first two digits of 1024, etc. Then floating point errors kicked in, and we stopped there.

I immediately googled it, but no one seems to have noticed this pattern in the digits before. It began to dawn on us that we may just be looking at a hitherto undiscovered “interesting number” such as pi, e, the golden ratio, etc. But the social norms of family meetings do not allow for simulations and mathematical derivations, so we put it aside.

Simulations

The number kept lingering in the back of my head. A few weeks later, I had several pressing deadlines, and as usual, procrastination kicked in full force. I needed to see how far this sequence continued. I fired up Python and wrote a small script which generates the power sequence first, then calculates the number 5/49, and finally identifies at what decimal place the two diverge:

The print-function in the first for-loop visualizes the adding of the power sequence:

and the other print functions compare the “ideal” number to the fraction:

Ok, wow, so it goes on for quite a while. Setting max_power = 10.000 and…

Now I’m convinced that this is an infinite pattern. But it gets even better: the sequence starts over every 42 digits. I repeat: Every. 42!!! Digits. Here are the first 168 decimals:

Is the key to the universe hidden in there somewhere!!?? I was exploding with excitement when I ran and presented this to my wife late in the evening.

The math

My wife is a mathematician. She was not impressed. “Jonas, do you know how to divide five by forty-nine by hand?”. No, I must admit that I never properly learned to do long division (even though I later enjoyed doing long polynomial division). And sure enough: the remainder of the first operation is 50-49 = 1. The remainder of the second operation is two decimal places further to the right where 1 is 100, and the equation becomes 100 – 98 = 2. Then two further to the right and doubling again: 200 – 196 = 4. Then 400 – 392 = 8, etc.

Every 21 such operations the division again hits the operation 50/49, and it repeats. This is extremely common for integer fractions in general. In fact, all rational numbers either have repeating decimals (like 5/49) or terminate (like 1/4 = 0.250000…), so one should not be surprised. Also, this particular 42-decimal period is shared by the division of 42 different integers by 49, albeit starting at different locations in the sequence, e.g., 1/49=0.02040816… and 3/49=0.06122448….

My wife went to bed. For a few seconds, I felt bad. My intellectual love affair crashed hard upon realizing that 5/49 was in many respects just a normal number. But as with human relationships, so with numbers: I’ve learned a great deal about rational numbers through this journey and that’s a comfort.

Conclusion

I do still think that 5/49 stands out. A 42-decimal period with powers of two is an intriguing property only shared by x/49 fractions. Furthermore, 5/49 is the only one of these fractions to start at 20=1 – the true beginning of the power sequence.

The long-division property can be exploited to generate numbers with custom power-sequences in the decimals. So without further ado, I give you:

$$10/(10^n-x)$$

… where x ∈ R≥0 is the root of the exponential and n ∈ N≥2 is the number of decimal places between each number. Let’s try this for a few numbers:

For two decimal places between powers of two, we get

$$10/(10^2 – 2) = 10/98 = 5/49$$

I hope that this number will henceforth be known as Lindeløv’s number. At least it’s on Google now.

I do not recommend hypnosis for brain injury (yet)

I have been overwhelmed with requests following our article about the effect of hypnotic suggestion on working memory performance following acquired brain injury. I present frequent questions and very short answers below. My answers to the questions all originate in the same point: there is insufficient evidence right now to establish whether to use or not to use hypnosis for the treatment of cognitive problems following acquired brain injury. I predict that we should be able to give a recommendation (or refusal) regarding hypnosis following acquired brain injury in 2020.

Frequent questions from patients and relatives:

Question: I have a brain injury. Where can I get hypnosis?
Answer: I won’t give any recommendations. I am a researcher and there is not a firm research-based basis for such a recommendation. If you choose to find a hypnotist, make sure to avoid hypnotists who offer regression to past lives, healing of aura, contact with dead relatives, etc. They have demonstrated an inability to learn from science.

Question: Can I be a test subject in an experiment?
Answer: Unfortunately, not by asking me. If we had experiments with open recruitment, we would recruit through other sources to avoid the strong selection bias.

Question: My daughter is diagnosed with ADHD/Schizophrenia/chronic pain/other – can hypnosis help her?
Answer: The results from our experiment should not be uncritically transferred to other conditions. I do not know enough about the effectiveness of hypnosis for the condition you mentioned here.

Frequent questions from rehabilitation professionals and hypnotists:

Question: Can you send me the manuscript?
Answer: No, the manuscripts will be made freely available if (and only if) there is sufficient evidence to decide if it can be recommended as a generalized treatment. We expect to have that evidence in 2020. Here is a list of all public information about the our experiment, which is more than for most scientific articles. This includes some excerpts from the manuscript in the supplementary materials.

Question: Can you help us get started using this intervention for our clients?
Answer: I’m eager to work with you to set up a research project if you are an institution working professionally with brain-injured patients. That means that you can offer the treatment but you will have less control over to whom and how the treatment is administered while the research is ongoing. These projects are needed to accumulate the evidence to decide if hypnosis can be recommended as a treatment for cognitive problems following acquired brain injury.

Background to the answers

Although our study is very convincing in and of itself, it is just one study and one should remember to factor in prior skepticism and that skepticism should be quite high in this case. The results are surprising exactly because they seem unlikely given prior evidence. One also should consider the fact that the results from scientific studies on humans and animals often fail to replicate. I know of several widely used “treatments” in neurorehabilitation that was introduced because of positive early studies but they are still lingering on even though the collective evidence points to small or no effects. If our results should fail to replicate, its better that hypnosis was never brought to use in neurorehabilitation than spending everybody’s precious time on something ineffective.

I am personally optimistic because I have more (less scientific) sources of evidence than what has been published, but I am also a strong believer in science as the right way to make clinical recommendations. With the ongoing and planned studies, I expect that we have sufficient evidence to make a recommendation (whether for or against) in 2020. We keep the final details about the intervention to research projects until then.

I may come across as dismissive. I really am both personally moved by individual stories and intellectually baffled by the scale of the problem on a world scale. I believe that the solution above will, on average, be the best. One potential advantage of it is that it increases the probability that the treatment, if effective, will be implemented in standard treatment instead of on the all-too-grey market of private hypnotists.

See also my post on what our experiment did not show.

 

Jeg anbefaler ikke hypnose efter erhvervet hjerneskade (endnu)

Jeg får mange henvendelser omkring vores artikel om effekten af hypnotiske suggestioner på arbejdshukommelsen efter erhvervet hjerneskade. Nedenfor giver jeg korte svar på ofte stillede spørgsmål.All svarene bunder i den samme pointe: der er endnu ikke tilstrækkelig evidens til at afgøre, om hypnose kan.- eller ikke kan anbefales som behandling af kognitive problemer efter erhvervet hjerneskade. Jeg forventer, at vi kan anbefale (eller afvise) hypnose efter erhvervet hjerneskade omkring år 2020.

Ofte stillede spørgsmål af patienter og pårørende:

Spørgsmål: Jeg har en hjerneskade. Hvor kan jeg få hypnose?
Svar: Jeg vil ikke anbefale nogen. Jeg arbejder med forskning og der er ikke et stærkt nok forskningsbaseret grundlag for at give en anbefaling. Hvis du vælger at opsøge en hypnotisør, så undgå alle der tilbyder regression til tidligere liv, healing af aura, kontakt med døde pårørende osv. De har dermed vist, at de ikke arbejder videnskabeligt.

Spørgsmål: Can jeg være med i et eksperiment?
Svar: Desværre ikke ved at spørge mig. Hvis vi havde eksperimenter der manglede deltagere ville vi rekruttere igennem andre kilder (fx hjerneskadeforeningen og hjernesagen) for at mindske selektionsbias.

Spørgsmål: Min datter er diagnosticeret med ADHD/Skizofreni/kronisk smerte/andet – kan hypnose hjælpe hende?
Svar: Resultaterne fra vores eksperiment kan næppe overføres så direkte til andre patientgrupper. Jeg kender ikke nok til hvor effektiv hypnose er på den problematik du nævner til at give et svar.

Ofte stillede spørgsmål af professionelle indenfor rehabilitering og hypnose:

Spørgsmål: Kan du sende mig manuskriptet?
Svar: Nej, manuskripterne gøres frit tilgængelige, hvis (og kun hvis) der er tilstrækkelig med forskning der viser, at det kan anbefales som en generel behandling. Her er en oversigt over al offentlig information omkring vores eksperiment, hvilket er mere end for det meste forskning. Dette inkluderer nogle uddrag fra manuskriptet, som du finder i supplementary materials.

Spørgsmål: kan du hjælpe os i gang med at bruge denne intervention til vores klienter?
Svar: Jeg vil meget gerne samarbejde med jer om at starte et forskningsprojekt hvis I er en institution som arbejder professionelt med borgere med erhvervet hjerneskade. Det betyder, at I får muligheden for at tilbyde det til borgerne, men også at I får mindre kontrol over hvordan det udbydes, mens forskningen pågår. Denne slags forskningsprojekter er nødvendige for at afgøre, om hypnose kan abefales som en behandoling af kognitive problematikker efter erhvervet hjerneskade.

Baggrund for svarene

Selvom vores resultater i ovenstående artikel er meget overbevisende isoleret set, er det stadig kun et enkelt eksperiment. Man skal huske at medregne den skepsis man ville have overfor resultaterne, da de bryder med en del veletableret forskning. Man skal også huske, at resultaterne fra videnskabelige studier på dyr og mennesker ofte ikke kan gentages. Jeg er bekendt med flere udbredte “behandlinger” i neurorehabilitering, som netop blev taget på grund af nogle positive resultater, og som stadig er i brug selvom den samlede evidens nu viser at effekten er meget lille eller helt fraværende. Hvis vores resultater ikke kan gentages, er det bedre at hypnose aldrig blev taget i brug i neurorehabilitering, end at alle bruger deres kostbare tid på noget ineffektivt.

Personligt er jeg optimistisk fordi jeg kender til flere (mindre videnskabelige) resultater end det der er blevet publiceret. Men jeg står også fast på, at videnskab må være det rigtige grundlag for kliniske anbefalinger. Med de igangværende og planlagte studier forventer jeg at vi har nok resultater til at give en egentlig anbefalinger (hvad end den er for eller imod) i år 2020. Indtil da holder vi visse detaljer om metoden lukket til forskningsprojekter.

Jeg kan måske give indtryk af at være afvisende. Jeg er personligt rørt over historierne fra alle de personer med hjerneskade jeg har mødt. Jeg er også intellektuelt oprørt over størrelsen af problemet på verdensplan. Jeg tror at ovenstående strategi vil give det bedste udfald i gennemsnit. En mulig fordel er fx at det øger sandsynligheden for, at behandlingen (hvis den er effektiv) bliver implementeret som en del af den offentlige behandling i stedet for at blive overladt til det grå marked af privatpraktiserende hypnotisører.

Se også min post om hvad vores eksperimnet ikke viser.

Decimals of PI with consistent colors

I was invited to do a fun task by my office colleague, Hazel Anderson. She researches synesthesia, and she wanted to induce grapheme-color synesthesia by having participants learn pi using digit-color mapping as one available strategy. So she needed something that could a Word document with pi with an arbitrary number of decimal places. Approximately 40 minutes of the pure joy of structured procrastination and:

 

 

Here’s the python script to generate this beauty:

 

Scientific papers on hypnosis and brain injury

This is an attempt to make a complete up-to-date list of all literature pertaining to hypnosis and brain injury. I now consider the literature so big and dispersed that I feel quite confident that my list won’t be complete, but hopefully, it can get close. In each section, the most informative paper(s) are highlighted in green font.

This list contains many case-studies so there is likely a strong positive bias. I would advise reading the cases purely for methodological inspiration and look to the more systematic and comprehensive studies for an actual assessment of treatment effects.

I recommend reading the review by Appel (2003) as a start. It is a review on hypnosis for rehabilitation in general (not only brain injury) and is by far the most comprehensive review available so far, citing around half of the papers below.

As a side note, I was completely unaware of the scale of the literature when I undertook this search. The first version of this post contained around 10 papers and I considered it complete. One notable surprise is that the list of researchers now includes Milton Erickson and Aaron T. Beck in addition to John Kihlstrom.

Cognitive rehabilitation

Status (April 2018): Completed.

Summary of the literature: There are (large) positive effects of hypnosis on cognition following acquired brain injury.

  • Cui-ping, L. I. (2011). Influence of hypnosis therapy on recovery of hemorrhagic stroke. Journal of Taishan Medical College, 1, 025. http://en.cnki.com.cn/Article_en/CJFDTOTAL-TSYX201101025.htm (see my English translation and comments)
    An RCT showing large effects (SMD = 1.0 to 1.7) on Barthel, anxiety, and depression in stroke patients given ten sessions of hypnosis between one and twelve weeks after the injury onset. The study is relatively large with 120 treatment-as-usual patients of which 49 had additional adjunctive hypnosis. It was published in Chinese in a Chinese journal with impact factor 0.1, and it is unclear whether it was peer-reviewed. In general, there are many reasons to be skeptical of the quality of this paper. Nonetheless, everything else being equal, it does increase the probability that hypnosis can improve cognition following acquired brain injury. With the help of Chinese friends, I got hold of the paper and helped reading it. I’ve added a link to my translation in the reference above, containing comments to clarify particular unclear sections and dubious statistics.
  • Lindeløv, J. K., Overgaard, R., & Overgaard, M. (2017). Improving working memory performance in brain-injured patients using hypnotic suggestion. Brain, 140(4), 1100–1106. https://doi.org/10.1093/brain/awx001.
    Our study, showing a large specific effect on working memory performance of hypnotic suggestions involving the return to pre-injury (or normal) functioning. It’s an RCT with a total of 68 patients stratified to targeted hypnosis, an active control, and a passive control. The effect of four and eight treatment sessions is assessed with long-term follow-up.
  • Milos, R. (1975). Hypnotic exploration of amnesia after cerebral injuries. International Journal of Clinical and Experimental Hypnosis, 23(2), 103–110. https://doi.org/10.1080/00207147508415934
    This paper is not really on cognitive rehabilitation but it does manage to (temporarily) cancel retrograde or anterograde amnesia during hypnosis in 7 out of 20 cases of severe injury.
  • Sullivan, D. S., Johnson, A., & Bratkovitch, J. (1974). Reduction of behavioral deficit in organic brain damage by use of hypnosis. Journal of Clinical Psychology, 30(1), 96–98. https://doi.org/10.1002/1097-4679(197401)30:1<96::AID-JCLP2270300133>3.0.CO;2-A.
    Later we discovered this similar study had been carried out by Sullivan et al. (1974). The Sullivan study, however, had an intervention consisting of just seven sentences repeated twice – probably less than two minutes! They obtained a small positive effect on the Picture Completion task from the WAIS battery but not on the Binder-Gestalt test. They had a quite small sample, and the two-page article leaves many details unreported.
  • Vanhaudenhuyse, A., Laureys, S., & Faymonville, M.-E. (2015). The use of hypnosis in severe brain injury rehabilitation: a case report. Acta Neurologica Belgica, 115(4), 771–772. https://doi.org/10.1007/s13760-015-0459-3
    A brief report on a 50-year case with cerebral hemorrhage, who underwent hypnosis when he was deemed chronic with severe symptoms. Hypnosis sparked further improvement. As a side note, the authors write that “To the best of our knowledge, this is the first study reporting on the integration of hypnosis as part of rehabilitation treatment of severe brain injury patients.” Well… 🙂

Motor rehabilitation

Status (April, 2018): Approximately 70% completed. Needs a search for post-2000 literature, references, and citations

With the notable exception of Spankus & Freeman (1962) and Irawan et al. (2018), this literature consists largely of single-case studies, making it very vulnerable to publication bias. Confirming this, most studies report positive findings while Spankus & Freeman (1962) only report positive outcomes for four out of nineteen patients with cerebral palsy. Although somewhat disconcerting, this observation may not generalize to all of the literature given the large variability in the patient characteristics and treatment protocols between papers.

  • Appel, P. R. (1990). Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports. American Journal of Clinical Hypnosis, 33(2), 85–93. https://doi.org/10.1080/00029157.1990.10402909
    See case number two.
  • Chappell, D. T. (1961a). A Psychological Approach to Traumatic Paraplegia: Use of Hypnosis. The Journal of Nervous and Mental Disease, 132(5), 432.
  • Chappell, D. T. (1961b). The Reduction of Spasticity in Paraplegia with Hypnosis. American Journal of Clinical Hypnosis, 3(4), 213–225. https://doi.org/10.1080/00029157.1961.10401844
  • Chappell, D. T. (1964). Hypnosis and Spasticity in Paraplegia. American Journal of Clinical Hypnosis, 7(1), 33–36. https://doi.org/10.1080/00029157.1964.10402388
  • Crasilneck, H. B., & Hall, J. A. (1970). The use of hypnosis in the rehabilitation of complicate vascular and post-traumatic neurological patients. International Journal of Clinical and Experimental Hypnosis, 18(3), 145–159.
  • Diamond, S. G., Davis, O. C., Schaechter, J. D., & Howe, R. D. (2006). Hypnosis for rehabilitation after stroke: six case studies. Contemporary Hypnosis, 23(4), 173–180. https://doi.org/10.1002/ch.319
  • Holroyd, J., & Hill, A. (1989). Pushing the limits of recovery: Hypnotherapy with a stroke patient. International Journal of Clinical and Experimental Hypnosis, 37(2), 120–128. https://doi.org/10.1080/00207148908410541
  • Irawan, C., Mardiyono, M., Suharto, S., & Santjaka, A. (2018). COMBINATION OF HYPNOSIS THERAPY AND RANGE OF MOTION EXERCISE ON UPPER-EXTREMITY MUSCLE STRENGTH IN PATIENTS WITH NON-HEMORRAGHIC STROKE. Belitung Nursing Journal4(1), 104-111.
    This is an RCT on 2 x 16 stroke patients. Although the descriptive statistics seem convincing, there are some red flags. For example, the journal seems a bit dubious, there are spelling/grammatical mistakes, and half of the citations are non-English. More content-related, the statistics are relatively poor, lacking the test of the crucial 2 (pre/post) x 2 (treatment/control) interaction term, which would be identical to the independent t-test on the change scores in each group. It does look like such a test would come out significant with a test would come out positive given the large improvement in the treatment group (d = 1) as compared to the control group (d = 0.1).
  • Manganiello, A. J. (1986). Hypnotherapy in the rehabilitation of a stroke victim: a case study. The American Journal of Clinical Hypnosis, 29(1), 64–68. https://doi.org/10.1080/00029157.1986.10402680
  • Martin, J. (1983). Hypnosis also useful in rehabilitation therapy. JAMA, 249(12), 1536–1536. https://doi.org/10.1001/jama.1983.03330360006002
  • Radil, T., Snýdrová, I., Háĉik, L., Pfeiffer, J., & Votava, J. (1988). Attempts to influence movement disorders in hemiparetics. Scandinavian journal of rehabilitation medicine. Supplement17, 157-161.
  • Seder, I. I., & Gelberd, M. B. (1964). Hypnosis as a Relaxant for the Cerebral Palsied Patient. American Journal of Clinical Hypnosis, 6(4), 364–365. https://doi.org/10.1080/00029157.1964.10402378
  • Slater, R. C., & Flores, L. S. (1963). Hypnosis in organic symptom removal: A temporary removal of an organic paralysis by hypnosis. American Journal of Clinical Hypnosis5(4), 248-255.
  • Spankus, W. H., & Freeman, L. G. (1962). Hypnosis in cerebral palsy. International Journal of Clinical and Experimental Hypnosis, 10(3), 135–139. https://doi.org/10.1080/00207146208415875
  • Vodovnik, L., Roskar, E., Pajntar, M., & Gros, N. (1979). Modeling the voluntary hypnosis-induced motor performance of hemiparetic patients. IEEE Trans. on Systems, Man, and Cybernetics, SMC-9 (12).
  • Yensen, R. (1963). Hypnosis and Movement Re-Education in Partially Paralysed Subjects. Perceptual and Motor Skills, 17(1), 211–222. https://doi.org/10.2466/pms.1963.17.1.211

Citations without available abstract or full text below. Notice that the list includes papers on neuromuscular illnesses, even though these typically relate to the peripheral nerve system. But due to my inability to scan these papers, I keep them on the list in case they include cases of brain injury.

  • Baer, R. F. (1962). Hypnosis in the treatment of neuromuscular sequelae of injuries. Industrial medicine & surgery, 31, 315.
  • Kroger, W.S. (1970) Hypnosis therapy in neuromuscular disorders. Osteopathic Physician (1970), pp. 69-70, September.
  • Martin (1983, see above) cites a paper by Korn which I cannot find, saying: “At least Errol R. Korn, MD, can point to definite rehabilitative gains made by “dozens of patients” with stroke and spinal cord injuries in relearning the swallowing reflex, regaining muscle and balance control, and healing decubitus ulcers.”
  • E. Roskar, M. Pajntar, L. Vodovnik, and N. Gros (1977) Improvements of motor response in hemiplegic patients by means of hypnosis, in Proc. I st. Mediterranean Conf. on Med. and Biol. Engng., Sorrento, Italy, pp. 1-85-I-88.
  • E. Roskar, M. Pajntar, L. Vodovnik, and N. Gros (1978.) Improved neuromuscular activity of hemiparetic extremity due to hypnosis, Advances in External Control of Human Extremities, Yugoslav Committee for Electronics and Automation, Belgrade, pp. 257-268
  • Shires EB, Peters JJ, Krout RM (1954) Hypnosis in neuromuscular re-education. U.S. Armed Forces Medical Journal 5: 1519–23.

Aphasia rehabilitation

Status (April 2018): Completed.

  • Kirkner, F. J., Dorcus, R. M., & Seacat, G. (1953). Hypnotic motivation of vocalization in an organic motor aphasic case. Journal of Clinical and Experimental Hypnosis, 1(3), 47–49. https://doi.org/10.1080/00207145308411081
  • Laures, J. S., & Shisler, R. J. (2004). Complementary and alternative medical approaches to treating adult neurogenic communication disorders: a review. Disability and Rehabilitation, 26(6), 315–325. https://doi.org/10.1080/0963828032000174106
    Contains a very short section (page 317-318) reviewing Thompson et al. (1986) and Manganielly (1986) (see this list). Finds the results promising but insufficient due to weaknesses from inconsistency in the former and lack of objective outcome measures in the latter.
  • Macfarlane, F. K., & Duckworth, M. (1990). The use of hypnosis in speech therapy: a questionnaire study. British Journal of Disorders of Communication25(2), 227-246.
    This is just a survey on usage frequencies without an assessment of effectiveness. Also covers non-neurological speech problems.
  • Mason, C. F. (1961). Hypnotic motivation of aphasics. International Journal of Clinical and Experimental Hypnosis, 9, 297–301. https://doi.org/10.1080/00207146108409683
  • McKeever, W. F., Larrabee, G. J., Sullivan, K. F., Johnson, H. J., Furguson, S., & Rayport, M. (1981). Unimanual tactile anomia consequent to corpus callosotomy: Reduction of anomic deficit under hypnosis. Neuropsychologia, 19(2), 179–190. https://doi.org/10.1016/0028-3932(81)90103-2
  • Moss, C. S. (1972). Recovery with aphasia: The aftermath of my stroke. Oxford, England: U. Illinois Press.
    This is a self-report (i.e., not a scientific paper) of a clinical neuropsychologist who suffered from aphasia following a cerebral vascular incident. Moss recovered well and reports, among other things, on hypnotherapy in the process.
 Citations without available abstract or full text:
  • GILDSTON, H., & GILDSTON, P. (1986, January). HYPNOTHERAPY IN ADULT APHASIA REHABILITATION. In FOLIA PHONIATRICA (Vol. 38, No. 5-6, pp. 301-301). ALLSCHWILERSTRASSE 10, CH-4009 BASEL, SWITZERLAND: KARGER.
  • Glazer, M. J. (1964). A comparison of performance of predominantly expressive aphasic patients before, during and after hypnosis: a thesis (Doctoral dissertation, Tulane University).
  • HONEYGOSKY, R. (1976, January). APPLICATION OF RELAXATION THERAPY, AUTOGENIC THERAPY, BIOFEEDBACK, AND HYPNOSIS IN REHABILITATION OF CERTAIN FORMS OF APHASIA. In FOLIA PHONIATRICA(Vol. 28, No. 4-5, pp. 243-243). ALLSCHWILERSTRASSE 10, CH-4009 BASEL, SWITZERLAND: KARGER

Dementias

Status (April, 2018):Approximately 50% completed. Needs a systematic search, reference search, and citation search.

  • Eisenberg, M. G., & Jansen, M. A. (1983). Rehabilitation psychology: State of the art. Annual review of rehabilitation.
    This review contains a quite extensive section on hypnosis for dementias. Though this is superseded by Appel the (2003) review.

Not properly vetted for this list yet (copy-pasted from Appel (2003)):

  • H.J. Wain, D. Amen, B. Jabbari The effects of hypnosis on a Parkinsonian tremor: Case report with polygraph/EEG recordings.
    Am J Clin Hypn, 33 (1990), pp. 94-98
  • E.E. Stambaugh Hypnotic treatment of depression in the Parkinsonian patient: A case study
    Am J Clin Hypn, 19 (1977), pp. 185-186
  • F.A. Buell, J.P. Biehl The influence of hypnosis on the tremor of Parkinson’s disease
    Journal of Disorders of the Nervous System, 10 (1949), pp. 20-23
  • H.W. Bird Varying hypnotizability in a case of Parkinsonism
    Bull Menninger Clin, 12 (1948), pp. 210-217
  • M. Witz, S. Kahn Hypnosis and the treatment of Huntington’s Disease
    Am J Clin Hypn, 34 (1991), pp. 79-90
  • R. Moldawsky Hypnosis as an adjunctive treatment in Huntington’s disease
    Am J Clin Hypn, 26 (1984), pp. 229-231
  • V. Stein Hypnotherapy of involuntary movements in an 82-year-old man
    Am J Clin Hypn, 23 (1980), pp. 128-131
  • D. Vann Successful hypnotherapy for anxiety neuroses in Huntingtonı́s chorea
    Med J Aust, 2 (1971), p. 166
  • G. Ambrose Multiple sclerosis and treatment by hypnotherapy
    Am J Clin Hypn, 3 (1955), pp. 203-209
  • R.F. Baer Hypnosis, An adjunct in the treatment of neuromuscular disease
    Arch Phys Med Rehabil, 41 (1960), pp. 514-515
  • J.T. Brunn Hypnosis and neurological disease: A case report
    Am J Clin Hypn, 8 (1966), pp. 312-313 (Link)
  • J.R. Dane Hypnosis for pain and neuromuscular rehabilitation with multiple sclerosis: Case summary, literature review, and analysis of outcomes
    Int J Clin Exp Hypn, 44 (1996), pp. 208-231
  • H. McCord Hypnotically hallucinated physical therapy with a multiple sclerosis patient
    Am J Clin Hypn, 5 (1963), p. 168
  • H. McCord Hypnosis and multiple sclerosis: A brief case report
    Am J Clin Hypn, 8 (1966), pp. 313-314
  • D.Y. Medd The use of hypnosis in multiple sclerosis: Four case studies
    Contemp Hypn, 9 (1) (1992), pp. 62-66
  • B. Strauss, S. Billie Hypnosis with cerebral palsy patients, and how may it be applied
    ASCH Newsletter, 26 (6) (1985), p. 2
  • R.F. Baer Hypnosis applied to bowel and bladder control in multiple sclerosis, syringomelia and traumatic transverse myelitis
    Am J Clin Hypn, 4 (1961), pp. 22-23

Pain, vertigo, anxiety (in progress)

Status (April, 2018): Approximately 40% completed. Needs a systematic search, reference search, and citation search.

This is a catch-all category for directly unpleasant sequelae following acquired brain injury. Sullivan et al. (1974) hypothesized that they relieved anxiety. But they never directly assessed anxiety, so I presented it on the list for cognitive rehabilitation. Fromm (1964) and Gruenewald & Fromm (1967) tried to induce catastrophic anxiety in healthy subjects.

  • Cedercreutz, C., Lähteenmäki, R., & Tulikoura, J. (1976). Hypnotic treatment of headache and vertigo in skull injured patients. International Journal of Clinical and Experimental Hypnosis, 24(3–4), 195–201. https://doi.org/10.1080/00207147608416201
    This paper summarizes clinical results of 155 patients with pain and/or vertigo sequelae. So this is a large portion of evidence as compared to the rest of this list. As with the other case studies, it may be prone to experimenter bias. The reported effects are quite impressive in a median of three-to-four sessions to achieve complete symptom relief in more than half of the patients.
  • Laclave, L. J., & Blix, S. (1989). Hypnosis in the management of symptoms in a young girl with malignant astrocytoma: A challenge to the therapist. International journal of clinical and experimental hypnosis37(1), 6-14.
    A single-case study on a 6½-year old girl predominantly focused on nausea following chemotherapy. I still include it on this list because of the neurogenic nature of the disease.
  • Sapp, M. (1992). Relaxation and hypnosis in reducing anxiety and stress. Australian Journal of Clinical Hypnotherapy and Hypnosis, 13(2), 39-55.
  • Bertoni, F., Bonardi, A., Magno, L., Mandracchia, S., Martinelli, L., Terraneo, F., & Tonoli, S. (1999). Hypnosis instead of general anaesthesia in paediatric radiotherapy: report of three cases. Radiotherapy and oncology52(2), 185-190.
    Two cases of child patients with resected cerebellar tumors undergoing hypnotically induced general anesthesia.
  • Nolan, M. (2008). Hypnosis to enhance time limited cognitive-behaviour therapy for anxiety. Australian Journal of Clinical and Experimental Hypnosis36(1), 30-40.
    I was in doubt whether to include this on the list. It is the case of hypnosis with a client who self-reports transient ischemic attacks and fears a full-blown stroke, but there no direct evidence is reported for either. She did have high blood pressure and was subjected to bypass and other treatments.

Suggestibility

Status (April 2018): Completed.

Take-home: Brain injured patients are as suggestible/hypnotizable as the general population

  • Laidlaw, T. M. (1993). Hypnosis and Attention Deficits After Closed Head Injury. International Journal of Clinical and Experimental Hypnosis, 41(2), 97–111. https://doi.org/10.1080/00207149308414541
    No difference in suggestibility on the HGSHS:A for young concussion patients relative to healthy controls.
  • Lindeløv, J. K., Overgaard, R., & Overgaard, M. (2017). Improving working memory performance in brain-injured patients using hypnotic suggestion. Brain, 140(4), 1100–1106. https://doi.org/10.1093/brain/awx001
    Our study tested 49 brain-injured patients on SHSS:C but did not compare them directly to healthy controls. However, looking at SHSS:C norms from other countries, the suggestibility of the patients seemed normal.
  • Kihlstrom, J. F., Glisky, M. L., McGovern, S., Rapcsak, S. Z., & Mennemeier, M. S. (2013). Hypnosis in the right hemisphere. Cortex, 49(2), 393–399. https://doi.org/10.1016/j.cortex.2012.04.018
    No difference in suggestibility between middle-aged stroke patients relative to young controls on AMSH.

General reviews

Status (April 2018): Completed.

  • Appel, P. R. (2003). Clinical hypnosis in rehabilitation. Seminars in Integrative Medicine, 1(2), 90–105. https://doi.org/10.1016/S1543-1150(03)00010-3
    This is an impressive review of the field. For brain injury and neurological conditions, pages 96-97 are particularly relevant.
  • Appel, P. R. (2003) Clinical Hypnosis. In S. Wainapel, & A. Fast (Eds.) Alternative Medicine and Rehabilitation: A guide for practitioners. NY: Demos
    This is basically a shortened version of the excellent other Appel (2003) review. Pages 224-227 are especially relevant for neurological cases.

 

Citations without available abstract or full texts:

  • Wright, M. E. (1960) Hypnosis and rehabilitation. Rehabilit. Lia, 21(1), 2-12.
  • LaScolla, R. (1975). Hypnosis in stroke rehabilitation. In Scientific Proceedings of the 22nd Annual Meeting of the Am Society of Clinical Hypnosis.
  • Feher, T.L. (1987) Hypnosis in clinical neurology. In W. Wester (Ed.), Clinical Hypnosis: A Case Management Approach, Behavioral Science Center Inc. Publications, Cincinnati, OH
  • Celinski, M.J. (1992) Hypnosis in neurological rehabilitation. In W. Bongartz (Ed.), Hypnosis: 175 years after Mesmer-Recent developments in theory and application, Universitaetsverlag, Konstanz, Germany, pp. 357-362
  • Halama, P. (1993). Hypnotherapy for stroke patients. Hypnos20(3), 154-162.
  • Spellacy, F. (1992). Hypnotherapy following traumatic brain injuries. Hypnos19(1), 34-39.

Papers not fitting into the above categories

  • Gravitz, M. A. (1981). Non-verbal hypnotic techniques in a centrally deaf brain-damaged patient. International Journal of Clinical and Experimental Hypnosis29(2), 110-116.
  • Erickson, M. H. (1963). Hypnotically Oriented Psychotherapy in Organic Brain Damage. American Journal of Clinical Hypnosis, 6(2), 92–112. https://doi.org/10.1080/00029157.1963.10402329
    A case of hemiparesis, aphasia, and hyperalgesia following some vascular anomalities. This is Milton Erickson!
  • Beck, A. T., & Guthrie, T. (1956). Psychological Significance of Visual Auras: Study of Three Cases with Brain Damage and Seizures. Psychosomatic Medicine, 18(2), 133–142. (link to PDF)
    Yes, Aaron T. Beck, the father of cognitive behavioral therapy (CBT) did a study on hypnosis and acquired brain injury!

Induction of “brain injury” in non-injured subjects

Status (April 2018): Probably completed. But needs systematic search, reference search, citation search.

Take-home: healthy subjects can be hypnotized to play the role of brain-injured patients, but they are probably not realistic brain-injury models.

  • Fromm, E., Sawyer, J., & Rosenthal, V. (1964). Hypnotic simulation of organic brain damage. The Journal of Abnormal and Social Psychology, 69(5), 482. http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1965-08145-001
    Hypnotized subjects (n=9) to believed that they had sustained an organic brain injury. After “hypnotic brain injury,” the subjects who experienced being in deep hypnosis were judged to be more “organic” by blinded neuropsychologists than under “hysterical” and no-hypnosis conditions, in which they were judged to be non-injured. The results from this study failed to replicate in a methodologically superior follow-up in Gruenwald & Fromm (1967).
  • Gruenewald, D., & Fromm, E. (1967). Hypnosis, simulation, and brain damage. Journal of Abnormal Psychology, 72(2), 191–192. https://doi.org/10.1037/h0024452 
    Replication of Fromm et al. (1964) with an improved method, controlling for more potential confounders. There were no difference between the hypnosis and control group judgment, actual score, or subjective experience.
  • Wagstaff, M., Parkes, M., & Hanley, J. R. (2001). A comparison of posthypnotic amnesia and the simulation of amnesia through brain injury. International Journal of Psychology and Psychological Therapy, 1(1), 67–78. http://www.ijpsy.com/volumen1/num1/5.html
    Like Fromm (1964), but adds malingering-detection tests to the test battery, showing that “hypnotically brain injured” healthy subjects indeed do act as malingerers, not as real brain-injured patients.

Search strategy and current status of this list

Google Scholar was searched using the term “hypnosis OR “hypnotic suggestion” brain-injury OR brain-damage OR stroke OR hemiplegia OR paraplegia OR “traumatic brain” OR “diffuse axonal” OR hemorrhage”. The reference list of all hits for which I had access to full texts were scanned. For some papers, the list of papers citing that paper were scanned too, using Google Scholar.

Next steps (my to do):

  • Read Appel (2003) thoroughly again for more keywords to search on.
  • Make a histogram of publication years relative to general science publication volume.

Identified papers that I need to screen/comment:

  • Look into https://www.amazon.com/Clinical-Experimental-Hypnosis-Dentistry-Psychology-ebook/dp/B01MXFB423. Apparently contains something on hypnosis and brain injury
  • https://www.frontiersin.org/articles/10.3389/fpsyg.2012.00465/full

Hypnosis and brain injury: where to find stuff

This post is a continually updated list of important communications on our paper in Brain entitled “Improving working memory performance in brain-injured patients using hypnotic suggestion.” and my comments to each of them.

Reports

Data and materials

  • Supplementary materials: Supports the main article with a more detailed presentation of data, methods, and stats. It took a long time to write the supplementary (15 pages), so I really hope that you read it!
  • Data and analysis at OSF: Contains all the data and analyses used in the Brain article and it’s supplementary materials. We encourage you to scrutinize this, suggest improvements, as well as carry out alternative analyses.
  • We plan to make the hypnosis scripts available to everybody eventually. On the other hand, we want to avoid putting it “out in the wild” if it somehow turns out to be a fluke. So for now, we pursue a strategy where we only make non-published details about the intervention and the hypnosis scripts available to institutions/companies who can and will evaluate the effectiveness of the scripts systematically. If you’re such an institution, we’d be eager to set up a collaboration. For example, Tryg Foundation just funded an RCT at Jobkompagniet Silkeborg which will include 120 patients during the next 2-4 years. The design and outcome measures simultaneously satisfy research purposes and Jobkompagniet’s core mission. We expect to stick to this institution-and-evaluation-only strategy for 2-4 years until enough evidence has accumulated that we feel confident about the clinical effectiveness of hypnosis following acquired brain injury. If you’re a private therapist, if you have suffered an acquired brain injury, or if you’re a relative, we will ask you to wait until we have this evidence. Also see FAQ and answers above.

Press

  • Spot on Danish national television, including a case with a 19-year old man who had sustained a traumatic brain injury in a high-speed car crash two years before enrollment in the experiment. The spot is accompanied by two articles and a radio spot (also Danish). Our impression is that this case is in the top 30% on real-life improvement, i.e. not too unrepresentative.

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