THE group, with decrease of the means of





Abstract. We investigated the effect of self-hypnosis (SH) training on depression and insomnia reduction in a sample of Mutah University students.
The sample consisted of 84 students suffering from depression and insomnia.
Participants were randomly assigned to two groups: the experimental group (n = 42) and the control group (n = 42). The
experimental group was trained on SH, whereas the control
group received no training. The training period lasted on average eight sessions
for each student. Depression and insomnia scales were administered as pre- and posttest
to all participants. MANCOVA revealed a significant training effect for the
experimental compared to the control group, with decrease of the means of
depression and insomnia in the posttest.


Key words: Depression, insomnia, self-hypnosis




Insomnia is a
subjective experience of inadequate sleep and is one of the most frequently
reported health complaints. ?t is defined as habitual sleeplessness or the inability to sleep. It
has high prevalence in the population (2-4%) (Roth & Drake 2004; Lalive, Rudolph, Luscher, & Tan, 2011). People who
suffer from insomnia have more somatic and mental disorders (Novak, Mucsi,
Shapiro, Rethelyi, & Kopp, 2004) compared to people who sleep sufficiently.
Epidemiological, cross-sectional,
and prospective studies suggest that insomnia, chronic pain,
and depression frequently co-occur and are mutually interacting
conditions. Specifically, several studies have found a relationship
between insomnia and depression and/or anxiety (American Psychiatric
Association, 2000; Breslau, Roth, Rosenthal, & Andreski 1996; Ford &
Kamerow, 1989; Johna, Meyera, Rumpfb, & Hapke, 2005; Popa & Cuza, 2013; Riemann & Voderholzer, 2003; Soldatos,
1994). Specifically, sleep is physiologically abnormal in
persons at risk for depression. For example, shortened REM sleep latency is
present not only during clinical episodes of depression, but also before the
clinical episode in individuals at risk for depression. Although insomnia
usually disappears as depression is treated, it may persist, indicating
heightened vulnerability to depressive relapse or recurrence (Lustberg & Reynolds, 2000). In addition, research suggests that common mechanisms underlie
insomnia and depression (Benca & Peterson, 2008; Finan & Smith, 2013; Staner, 2010). However,
the exact neurobiological and psychological mechanisms that link them remain largely unknown (Benca & Peterson, 2008).


Since research has demonstrated that insomnia increases the risk of
new-onset depression or recurrence of depression, optimal treatment of insomnia
associated with depression becomes an important clinical goal. Various
treatment options have been suggested for patients presenting insomnia and
depression symptoms, including single agents, combination strategies and
behavioral interventions (Jindal & Thase, 2004; Lam, 2017). Insomnia is
most often treated with pharmacotherapy, which can be effective in the
short-term (Fiorentino & Ancoli-Israel, 2007; Holbrook, Crowther, Lotter, Cheng,
& King, 2000; Krystal, 2009; National Institutes of Health, 2005), but
fails to treat the underlying condition, Psychological treatments for insomnia
include cognitive behavioral therapies along with pharmacological therapies
gives the best results in overcoming insomnia symptoms (Glaze, 2004; Savard
& Morin, 2001; Silber, 2005).

In general, there are five main psychological
strategies for treating insomnia. Three of them emerged from mainstream
behavioral therapy: relaxation, cognitive therapy, and stimulus control. Two
others originated from empirical investigations of sleep disorders: bedtime
restriction and sleep hygiene (Nowell, Mazumdar, & Buysse, 1997). Another way
to group behavioral interventions for the treatment of insomnia is the degree
to which they emphasize internal vs. external (environmental) factors. In
relaxation and cognitive therapy, the emphasis is on internal change. In
stimulus control, bedtime restriction and sleep hygiene, the emphasis is on
changing external aspects of sleep (Carmack, 1988).

Self-hypnosis is one of the most common cognitive behavioral
therapies used to overcome insomnia and consists of two main stages: 1) the
induction stage, designed to produce a change in the state of consciousness,
and 2) the suggestions application stage (Mazzoni et al., 2009). Suggestions
may act at the level of cognition, perception, affect, or behavior, and
depending on the problem may include suggestions for anesthesia, relaxation, increased
self-efficacy, stress reduction or sleep induction (Batty, Bonnington, Tang,
Hawken, & Gruzelier, 2006). The suggestions formulated for treatment of insomnia
are usually associated with notions related to sleep (e.g., bedroom,
sleepiness, eye closing, falling asleep and deep sleep) (Assen, 2007). In this
way, hypnosis can be used as both a method of sleep inductions (e.g., self-induction),
as well as a way of accessing problems that may induce insomnia, such as
depression and anxiety, beyond mere symptomatic treatments used in other types
of hypnotherapy (Popa & Cuza, 2013).

Most of the early published research on the use of SH as a cognitive
therapy for insomnia has involved depressive and anxious adults. For example, instruction
of SH in two sessions aiming to induce relaxation to 18 participants aged 29 to
60 years was shown to be more effective in improving insomnia than use of the
pharmaceutical Nitrazepam or a placebo (Anderson, Dalton, & Basker, 1979).
Stanton (1989) and Becker (1993) found that SH is more effective than placebo
or reinforcement treatment in dealing with insomnia. In addition, the treatment
of depression through hypnosis significantly contributes to overcome the
negative thoughts related to the difficulty of going to sleep, and helps break
the cycles of thinking about the concerns of the future and the suffering of
the past (Alladin, 2006; Alladin & Alibhai, 2007).

Kohen and Murray (2006) explored the treating of depression in
children and adolescents primarily from the standpoint of clinical
intervention. Result found that SH treatment can be applied to help reduce
depressive symptoms, and encourage young people to apply these skills to help
themselves. Furthermore, Alladin (2009, 2010) described cognitive hypnotherapy
(CH) as an evidence-based multimodal treatment for depression, which can be
applied to a wide range of patients with depression. Specifically, cognitive
hypnotherapy is combined with cognitive behavior therapy, and the two have
substantial positive effects. Finally, Farrell-Carnahan et al. (2010) investigated
the feasibility and preliminary efficacy of SH recordings in cancer survivors.
Overall, adjusted effect sizes showed small SH treatment effects in the case of
sleep, fatigue, mood, and quality of life.

Overall, there is evidence supporting the effectiveness of SH training
to reduce depressive symptoms and
help getting smooth sleep and overcoming insomnia. The present study aimed to further explore whether training on SH can reduce depression and insomnia symptoms. The
hypothesis was that the SH training group, compared to a control group that
received treatment after the completion of the intervention to the experimental
group, will have lower depression and insomnia scores at the posttest compared
to the pretest.





Eighty-four students
of the Mutah University participated in the present study. They were selected randomly
from seven courses of Science College, that were taught at the same day and
time. Forty-two were assigned to the experimental group (EG) and 42 to the control
group (CG). There were no psychology students in the two groups. The students who
met the conditions of the study were limited to 84 students (out of 432), 45.14
% males (38), 54.76 % females (46). The mean age of the entire sample was 20
years (ranging from 18 to 21 years, SD=3.25). The sample of students suffering
from insomnia and depression were chosen based on the cut-off points of the
Athens Insomnia Scale and the Beck Depression Inventory-II (see Instruments).




Insomnia Scale

The Athens Insomnia Scale (AIS) (Soldatos,
Dikeos, & Paparrigopoulos, 2000) aims
to measure sleep induction, awakenings during the night, final awakening, total
sleep duration, general sleep quality, the consequences of insomnia during the
following day ?specifically, well-being, functional capacity (both physical and
mental) and sleepiness.  It comprises of
eight items. Participants were asked to respond to each item in a Likert-type
scale ranging from 0 = no problem at all
to 3 = very serious problem. They also
reported whether they had experienced any difficulty sleeping at least three
times a week during the last month. The total score of the AIS ranges from zero
to 24. A cut-off score of ?6 on the AIS was used to
establish the diagnosis of insomnia and select the study sample. This kind of insomnia is called adjustment insomnia or short-term
insomnia, disturbs one’s sleep and usually is due to stress. The sleep problem
ends when the source of stress is gone or when you adapt to the stressful
situation. The stress does not always come from a negative experience.
Something positive can make one too excited to sleep well (Benca & Peterson, 2008; Soldatos,
Dikeos, & Paparrigopoulos, 2002).

Seven bilingual
(English and Arabic) translators from different universities in Jordan and Oman
translated the English version of the AIS into Arabic. The translators were instructed
to retain both the formal aspects of language and the meaning of the items of
the original as closely as possible, but to give priority to meaning
equivalence. When the Arabic translation was finalized, the AIS was then
back-translated (from Arabic to English) by other seven bilingual professors The
back-translated items were then evaluated by a group of eight
faculty members to ensure that the item meanings were
equivalent between the original English version and the back-translated
version. The differences found between items, were re-entered into the forward
and back-translation process, until the evaluators were satisfied with substantial
meaning equivalence.

validity for the AIS was established by asking twelve expert raters to evaluate
candidate items on quality (clarity, lack of bias, and lack of offensiveness),
and goodness-of-fit with the intended AIS. On a scale ranging from 1 = poor to 4
= excellent the average quality rating was 3.69, and the average goodness-of-fit
rating was 3.78. Unanimously, 100 % of the expert reviewers agreed on all eight
items. The internal consistency of the instrument was determined using a group
of the same participants as a pilot study (N=217). The calculated coefficient
alpha reliability for the (AIS) was (0.90). Finally, test-retest reliability
was applied and accounted on a sample of study participants, (n=52 students). The
AIS demonstrated good test-retest reliability (r = .91 for the total score). Depending
on these psychometric properties of AIS we can considered the AIS to be an effective
tool in insomnia diagnosis, as well as it was validated in various countries by
testing it on local samples. 


Beck Depression
Inventory-second edition (BDI-II)


The 21 items of
the BDI-II (Beck, Epstein, Brown, & Steer, 1988; Beck, Steer, & Garbin,
1993) are designed to assess the severity of the affective, cognitive,
motivational, psychomotor and vegetative components of depression. BDI-II items
are rated on a 4-point scale ranging from 0 (I do not feel sad) to 3 (I am so
sad or unhappy that I can’t stand it) based on severity of the symptom depicted
in the item. The maximum total score is 63. Higher total scores indicate more
severe depressive symptoms. The standardized cutoffs used differ from the
original: 0–13: minimal depression, 14–19: mild depression, 20–28: moderate
depression, 29–63: severe depression. Eleven was the cut point between normal
and depressed. (Aldahadha, 2008; Beck, Steer, Ball & Ranieri, 1996). For
the purposes of this study, the degree 20 and above was adopted to be among the
members of the study.

 Alpha reliability coefficients of the BDI-II
have been found to exceed .90 in a range of populations. The 21 items of the BDI-II
can be separated into two subscales: 1) a cognitive-affective subscale (the sum
of the first 13 items), and 2) a somatic-performance subscale. These subscales,
as well as the total score of the BDI-II were used in the analyses of the
current study. Finally, in accordance with guidelines stipulated by Beck, Steer,
and Garbin (1993), the cut-offs for assessing different levels of depression
were as follows:

To achieve the
accredited standards of psychometric properties, content validity for the
BDI-II was established by asking twelve expert raters to evaluate candidate
items on quality unanimously, 100 % of the expert reviewers agreed on all scale
items. For further confirmation of the validity, the scale was tested by
construct validity. The correlation coefficients between the items and the
total score of the questioner ranged from 78 and 91. For the purpose of this study,
the cut point of 50 correlation coefficient score and above was adopted to
accept the construct validity. Reliability measures for the depressed cases
revealed a coefficient alpha of .94 (p < .001) and a split-half coefficient of .91 (p < .001). The internal consistency of the instrument was determined using a group of the same participants as a pilot study (N=189). The calculated coefficient alpha reliability for the BDI-II was (0.93), (subscale alpha coefficients from .89 to .92). This also included the accepted average of reliability and validity beck depression inventory.   Procedures The study sample was obtained from Mutah University students for the period 2015-2016. Insomnia was defined as difficulty sleeping for more than 30 minutes when going to sleep and at least once a week for eight weeks. These symptoms are associated with some symptoms of depression. Students who said they had nightmares, sleepwalking or inability to wake up were excluded from the study sample. In addition, all students were diagnosed with mild or moderate depression, as well as adjustment insomnia and no one declared at the beginning of answering the scale that he was suffering from psychosis or other kind of insomnia. All respondents reported that they did not receive any kind of medical treatment to facilitate entry in sleep, all students agreed to participate according to a special model prepared for it, as has been referred to the ethics of scientific research due to the Helsinki declaration of Ethical Principles for Medical Research Involving Human Subjects, World Medical Association (WMA, 2017). Intervention The experimental group was trained on SH exercises during the first and second sessions for 45 minutes. The first session consisted of a general description of SH. The second session focused on hypnosis techniques and the third session was to choose a favorite place to imagine and help develop the ability to relax through listening to the instructions of SH. Finally, it was the fourth session on developing the ability to imagine overcoming insomnia, the researcher urge the students to exercise these techniques every day and before going to sleep almost half an hour. The control group did not receive any form of treatment or training, but in accordance with the ethics of scientific research have been invited to practice all techniques of SH after taking the post-testing measurements and the completion of the study. For the purpose of this study the following steps and procedures where implemented in chronological order: 1) at the beginning of the fall semester 2016/2017 the researcher began preparing and accrediting the instruments and training program. 2) the cut-off point of AIS and BDI-II were applied to exclude students where including others in the study sample. 3) The study members were distributed randomly into two groups while the scales were applied on both groups as a pre-test measurement. 4) The experimental group (EG) was taught and trained on (SH) while the control group (CG) received no training. 5) for the purpose of this study, the researchers benefit from the full-text training that refer to Aldahadha (2010) where the sketch was recoded as a digital audio file and then downloaded as SH training and procedures for the trainees on their mobiles. 6) At the end of the semester, post- test was applied on the both groups. 7) AIS and BDI II were the dependent variables of the study and the two independent variables of this study was the group (experimental group and control group). Finally, 8) after the termination of training and scoring the post-test, CG subjects were advised to contact the student counseling center to get material of SH as well as the digital recording of SH. The preliminary checks were conducted using T-test to ensure that there were no violation of variances, at the pre-testing of AIS and BDI-II. Results of T-test revealed that no significant differences between the two groups at the pre-testing scores of AIS, T=.626 (623), p<.05. Additionally, there were no significant differences due to the BDI-II, T=.479 (634), p<.05. RESULTS To test the study hypotheses, the means and standards deviations were calculated on the pre-testing and post-testing of AIS and BDI-II for each of the two groups as shown in Table 1. Table 1. Means, Standards Deviations on the AIS and BDI-II for each of two groups group Pre -AIS Post- AIS Pre - BDI-II Post - BDI-II EG M 16.26 9.9744 23.07 12.75 N 42 39 42 41 SD 4.617 6.433 7.756 9.38 CG M 15.59 16.35 23.83 23.00 N 42 42 42 41 SD 5.17 4.42 6.80 8.06 Total M 15.92 13.28 23.45 17.87 N 84 81 84 82 SD 4.88 6.32 7.26 10.11 Note. EG= experimental group; CG=control group; Pre= pre-test; post= post-test; AIS = Athens Insomnia Scale; BDI-II = Beck Depression Inventory – 2nd Edition; M= Means; N= number; SD= Standard deviation; Pre= Pre testing; Post= Post testing.             Results shown in table 1 reveal that there were apparent differences between the means of the two groups at post- test means values. This result shows that there is a primary improvement of AIS and BDI-II among the EG. To examine the significance of these differences, the MANCOVA test was administered to respond to the hypothesis of whether there is a significant effect of training on SH between the EG and the CG, at the pre- and post- test stages. The results are shown in Table 2. Table 2. Results of MANCOVA between the (EG) and (CG) groups at the pre- and post- testing measurement in the means of AIS and BDI-II scores       AIS Source Type III Sum of Squares df Mean Square F Sig. Partial Eta Squared Group 804.121 1 804.121 26.530 .000 .254 Error 2364.195 78 30.310       Total 17492.000 81         BDI-II Group 2070.265 1 2070.265 27.702 .000 .260 Error 5903.872 79 74.733       Total 34490.000 82         Note. ** p < .001. AIS = Athens Insomnia Scale; BDI-II = Beck Depression Inventory – 2nd Edition . Results reveal in table 2 that there was a significant effect for the group, in reducing the level of AIS in favor of experimental group F (26.530) = .000, p<.001, with a large effect size (eta squared=.254) (Cohen, 1988). On the other hand, the results revealed a significant effect for the group in reducing the level of BDI-II in favor of experimental group. F (27.702) = .000, p<.001, with a large effect size (eta squared=.260).            DISCUSSION We investigated the effect of SH training on depression and insomnia reduction in a sample of Mutah University students. Results of the study and testing of  hypothesis indicate that the EG, after completing a SH training program, showed a more substantial increase in overcoming insomnia through learning the SH while they also appeared to benefit more from the SH directions, which reflect the effectiveness of the group guidance program on the AIS at the post- test measurement. Again, results showed that the EG experienced a more substantial increase in overcoming depression through learning SH after completion of the training program, reflecting the effectiveness of the group program on the BDI-II at the post- test measurement. In describing previous literature, we mentioned that the idea of hypnosis not only improves sleep practices but also helps tackle the underlying problems that are reducing sleep quality and fueling depression. This would be key to support hypnosis is as effective as CBT (Alladin, 2009; Alladin, 2010). SH allows trainees to experience their thoughts and images as real. SH has been clinically effective with symptoms of insomnia as like as overcoming depression and mood disorders. The results obtained are consistent with previous studies of Kohen and Murray (2006) found that hypnosis might be applied in treatment to teach specific skills, help reduce depressive symptoms, and encourage young people to apply these skills in the service of self-help. The results also consistent with the study conducted by Novak et al. (2004), who used a Hungarian version of the AIS in their survey of healthcare services use by insomniacs. The scores obtained by Alladin (2009) were slightly higher than in the present psychiatric sample and more in accordance with those reported by Soldatos (1994); this could be explained by the fact that the former used a population with a principal diagnosis of a major depressive disorder and that the AIS scores for the latter were obtained after defining the individuals as insomniacs.            Hypnosis can be especially helpful because of its demonstrated ability to suppress the areas of the brain that interpret pain signals and attach meaning to them. Studies show that hypnotic suggestions can change allergic and inflammatory reactions, eliminate warts, control seizures, reduce inflammation and pain from burns, help asthma patients cut back on—or eliminate the need for—inhalers and enable hemophiliacs to control excessive bleeding by promoting relaxation, reducing physical pain and stress. Significance and benefits aside, this study has several limitations. First, the results should be interpreted with caution in view of missing information on the AIS and BDI-II. In addition, considering that this study was exclusively focused on two courses of Mutah University students, the results cannot be generalized to all students. The results of this study were also determined by the effectiveness of the SH-training program prepared for this purpose. Follow-up and duration of treatment was not administered due to the end of the semester. Therefore, we cannot recollect the students to apply the follow-up testing. Finally, the present study was limited to the fall semester of the academic year 2016/2017. In spite of these limitations and several difficulties encountered during the sessions of training period, such as applying the training in the classroom and recruiting the subjects, it was apparent that participants enjoyed the SH and felt that it was extremely helpful to talk to other individuals who had similar problems and they felt satisfaction, relaxation and peaceful. This study offers insights for healthcare practitioners as it demonstrates that instruction in SH and the understandings derived from its use appear to facilitate efficient therapy for insomnia in college students. Future research is needed to determine whether this self-treatment option is efficacious for deadly diseases, panic attack, anxiety and other sleeping disorders with insomnia.

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