So, you’re doing a hypnotherapy session, and it all seems to be going well, but how can the therapist (or the client) actually measure their progress? Is there a way to recognise tangible changes and increments of improvement? Yes! Scaling the issue at the start of the change process, then during and at the end of the process is a sure-fire way to help track and quantify the extent of change.
Even if you expect positive changes to happen, measuring the significance of the issue gives the client and therapist a clear starting point. Imagine you have a client called ‘Toby’ who is seeking help with chronic pain. He comes to see you and says his pain is ‘pretty bad’. You work together during the session and make some positive changes. He comes back for another session and he might then say his pain was still pretty bad, and that the hypnotherapy hadn’t worked. However, as we naturally forget how much pain we were in, just like forgetting how bad a case of the flu was, months after it went away), in reality his pain may have reduced massively, yet he doesn’t remember exactly what it was like before. Instead, imagine you scaled Toby’s pain at the first session and he said perhaps it was 8 out 10 overall, and 7 out of 10 for how much it disturbed his sleep and 9 out of 10 for how it limits his daily activities… At the next session these are clear scores that he can measure his present pain experience against, likely showing definitive progress!
There are many different ways of scaling a problem. You might use a simple numerical scale, such 0-10 or 0-100. However, some clients find it hard to assign a number, so a verbal scale may be easier, such as asking them to choose from ‘very painful, moderately painful, a little painful, not painful’. Alternatively, you might like to use a ‘Likert scale’. These have been in use since the 1930’s and offer commonly a five- or seven-point scale, where the client can indicate how much they agree or disagree with a specific statement. For example, “I have at least twelve hours of pain-free comfort every day” with the choices “strongly agree”, “agree” “neither agree/disagree”, “disagree” and “strongly disagree”. These types of scales can be useful if you are asking a lot of questions as you can create a simple chart. Here are some more examples:
Another type of scaling is using pictorial representations. These are commonly used with children and with individuals with communication differences (e.g. a non-English speaking person in an English-speaking country). These commonly show a series of simple faces ranging from very sad to very happy.
When using a numerical scale, to help clients better scale their experience, you may prefer to offer a guide of what each number on the scale may relate to. For example, with someone who is scared of returning to work after a long period away, you may suggest a 0 – 10 scale:
0 = Peaceful
1 = Not particularly bothered
2 = A little bothered, only aware of feelings when focus on them
3 = Mildly distressed, am aware of feeling worried
4 = Feeling distressed, don’t feel good, but can handle feelings
5 = Moderately distressed, just about manageable with effort
6 = Bad feelings, enough to do something to address them
7 = Bad feelings, struggling to maintain control
8 = Freaking out
9 = Feeling desperate
10 = Unbearably bad
Your descriptors may change according to the issue. For example, if you are working with a client to alleviate intrusive thoughts, you might describe the intensity and frequency of the thoughts.
A popular form of scaling used by talking therapists is a ‘SUD scale’. SUD is an acronym for ‘subjective units of disturbance’ (the terms ‘distress’ and ‘discomfort’ are commonly used as alternatives to ‘disturbance’). A SUD scale measures how bothered someone is by an event, measuring it (or components of it) in a hierarchy from least disturbing through to most. First discussed in literature by Joseph Wolpe in 1969, he suggested the SUD scale is an effective tool to measure the intensity of disturbance experienced by a negative emotion associated with a specific (‘target’) event. When using a SUD scale, to ensure a client feels listened to, and to comprehensively address each point on the SUD hierarchy, it can also be useful to note any feelings, thoughts or physical sensations they have when they state their number e.g. clammy hands, tight throat. Whilst generally a 0-10 scale will be fine for most scaling applications, it is common to use a 0-100 scale for fears and phobias. Although you may still only complete the SUD hierarchy at 10-point intervals (10, 20, 30, etc.) there are opportunities to use different increments, such as 10, 25, 32, etc.
Unlike standard scaling, with one score chosen from a scale, with SUDS scaling you are looking to score multiple elements across a single scale. This type of scaling enables the therapist and client to gain insight into the different components of the issue and to work on progressively achieving resolution. For example, ‘Jim’ has a fear of flying, so her SUDS scale may look something like this:
0 = Not thinking about flying
10 = Seeing a picture of a plane
30 = Hearing someone talk about turbulence on a flight
60 = Going to an airport
70 = Seeing a plane crash in a movie
80 = Getting on a plane
90 = Taking off
95 = Landing
100 = Experiencing turbulence during a flight
As you can see, you are looking for a progression of disturbance and a measurement of these events. Once you have this information, you can utilise systematic desensitisation approaches, and tailor the client’s therapy goals in increments they are comfortable with. This is great for clients that need a more gradual change process, where a single session might be too much for them to cope with.
There are many other ways in which you can use scaling as part of the therapy process, including as part of a solution-focused questioning approach. For example, someone might say that they are 80% committed to stopping smoking. You could ask them what would need to happen for them to move to 90% and to 100%. Or, if someone reported feeling stressed at a scale of 7 out of 10, you could ask what prevents them from being at a 5 out of 10. You can also build progression into scaling. For example, using a metaphorical ladder of success, you could ask a client to describe what would need to happen for them to climb each rung of the ladder. Wherever possible, guide the client towards a personal action (within their scope of control), rather than relying on someone else to act (outside of their scope of control). This also boosts engagement and emotional responsibility.
Does scaling just have to measure problems? Not at all. Scaling works really well for improvements as well. For example, ‘Jenny’ comes to see you to work on her sleep and says she has 2 nights a week where she sleeps with only mild disturbances, the rest of the nights she tosses and turns through the night. You may work on improving her sleep hygiene and habits, and the following week she reports better sleep for 5 out of 7 nights. Measuring success works really well for children as well. If you are working with moving beyond bed-wetting, then working towards increasing the number of ‘dry nights’ has a more positive direction than reducing ‘wet nights’.
So, as you can see, measuring your success as a hypnotherapist with scaling is an integral part of the hypnotherapy process. If you’d like to learn more about becoming an effective hypnotherapist, check out our popular Hypnotherapy 101 online course. We hope you’ve enjoyed this blog, and if you have any more questions about this topic, or anything else for that matter, do please get in touch, because we’re always happy to help!
– written by Dr Kate Beaven-Marks