Hypnosis interventions for reducing test anxiety among students: A systematic review

Abstract

Test anxiety is a distinct fear of exams that is highly upsetting and can seriously impair academic performance and generate negative behavioural, physiological, and emotional responses. Numerous methods are available for managing and reducing test anxiety. This review examined the effectiveness of hypnosis in reducing test anxiety among students. Five databases were searched for articles published between 2000 and 2021: Web of Science, Scopus, PubMed, EBSCOhost, and SAGE. The electronic search identified 445 studies, of which 12 studies with 515 students met the eligibility requirements. The reviewed hypnosis intervention studies were highly diverse. Overall, the findings show that hypnosis helps decrease test anxiety among students. Further rigorous research with extended follow-up periods is required to fully understand the potential of hypnosis. Importantly, hypnosis interventions can be used to address students’ specific test anxiety conditions in schools and universities.

Keywords:

• test anxiety
• hypnosis
• self-hypnosis
• systematic review
• effectiveness

1. Introduction

Globally, students are vulnerable to test anxiety (Klug et al., 2021; Nyroos, 2015). Its debilitating physiological and psychological effects can influence their academic and general well-being (Scott et al., 2018). Studies show that 10–40% of students exhibit some degree of test anxiety (Thomas et al., 2018). A recent review by Howard (2020) found that the prevalence of high-level test anxiety among children was ranged between 12–18%. Importantly, many studies find that test anxiety is linked to lower academic performance (McDonald, 2001; Segool et al., 2013; von der Embse et al., 2018). According to a recent meta-analysis, test-nervous students have poorer mental health and are more likely to have other mental health disorders, such as depression and social anxiety. Test anxiety is also regularly identified as one of the primary reasons why students seek mental health treatment (Huntley et al., 2019).

Interventions for test anxiety mostly use cognitive, behavioural, study skill training, and combination approaches that alter thoughts, emotional responses, and behaviour (Howard, 2020). An alternative method to reduce test anxiety among students is hypnosis, as two separate meta-analyses have shown that hypnosis is an effective tool for managing general anxiety (Valentine et al., 2019) and more specifically, test anxiety (Baker et al., 2009).

The definition of hypnosis and its related terms has evolved because of a lack of agreement among researchers stemming from the varying theoretical lenses used to define the term (Wagstaff, 2014). For instance, Kirsch (1993) defined hypnosis as a procedure “during which a trained professional or researcher suggests that a client, patient, or subject experience changes in sensations, perceptions, thoughts, or behaviour”. Kirsch (1993) adapted the term from Kihlstrom’s (1985) definition of hypnosis as a “process in which one person, designated the hypnotist, offers suggestions to another person, designated the subject, for imaginative experiences entailing alterations in perception, memory, and action” (Kirsch, 1993; Kihlstrom, 1985; as cited in Lynn et al., 2015).

Based on the American Psychiatric Association [APA] division 30, hypnosis is defined as a state of consciousness involving focused attention and reduced peripheral awareness characterised by an enhanced capacity for responding to suggestions (Elkins et al., 2015, p. 6). Moreover, most studies defined hypnosis as an induced state characterised by increased suggestibility in which patients are susceptible to suggestions that change perceptions, feelings, thoughts, and behaviour by concentrating on ideas and images uttered by the therapist (Heap, 2005). Table 1 lists the definitions of terms used in hypnosis given by APA Division 30.

Table 1. Definition of terms in hypnosis treatment

Term	Definition
Hypnosis	A state of consciousness involving focused attention and reduced peripheral awareness characterised by an enhanced capacity for response to suggestions.
Hypnotic induction	A procedure designed to induce hypnosis (Eye roll induction, Hartland’s Progressive Muscle Relaxation induction, etc)
Hypnotisability	An individual’s ability to experience suggested alterations in physiology, sensations, emotions, thoughts, or behaviour during hypnosis
Hypnotherapy	The use of hypnosis in the treatment of a medical or psychological disorder or concern

Hence, the fundamental principles of hypnosis are suggestions in the form of thoughts, feelings, and visuals, which can influence mind-body correlations and bring about positive changes throughout the hypnosis intervention (Lynn et al., 2019). Since the definition of hypnosis is constantly changing, the underlying theories are also affected. No single theory has been proven or approved by hypnosis researchers or psychotherapists (Jensen et al., 2015). In fact, Heap (2005) asserted that, “It depends what you mean by hypnosis”.

During hypnosis (hetero-hypnosis), the hypnotist gives suggestions to the subject, whereas during self-hypnosis, the individual learns the skill and performs their own suggestions (Yapko, 2012). According to Martínez-Tendero et al. (2001), self-hypnosis is as old as hetero-hypnosis. Research indicates that hetero-hypnosis is more positively received, followed by tape-assisted hypnosis than self-hypnosis. However, some studies find self-hypnosis to be as effective (Martínez-Tendero et al., 2001).

Bibby et al. (2001) studied self- and hetero-hypnosis and found that the differences depend on the type of induction experienced by the individual. Moreover, the students in their study revealed that the subjective experience of hetero-hypnosis is more natural and involuntary than self-hypnosis, where the latter requires more active thoughts. Although studies have shown that self-hypnosis is fast, efficient, and affordable, additional research is required to support its effectiveness, because hetero-hypnosis has been the focus of the majority of investigations (Eason & Parris, 2019; Hammond, 2010). According to Neill and Stork (2011), all hypnoses are self-hypnoses; if an individual allows changes and is determined to change, the outcome will be positive.

According to Hammond (2010, p. 433), hypnosis can help students who are experiencing test and general anxieties to perform better academically. Hypnosis training, particularly self-hypnosis training, can equip students with self-management skills. Research using hypnosis has shown promising and effective results in reducing test anxiety among university (Boutin & Tosi, 1983; Graham et al., 2010; Gruzelier et al., 2001; Naito et al., 2003; Sapp, 1991; Whitehouse et al., 1996) and secondary school students (Hart & Hart, 1996; Stanton, 1993). Dogan et al. (2018) found that self-hypnosis significantly reduced test anxiety and stress among university students.

Two previous meta-analyses have been conducted to evaluate the effectiveness of hypnosis in reducing test anxiety (Baker et al., 2009) and anxiety (Valentine et al., 2019). Baker et al. (2009) conducted a meta-analysis of five randomised controlled trials (RCTs) and found that hypnosis was helpful in lowering test anxiety. In their study, the initial screening generated 176 articles, but only five met all inclusion criteria based on the consolidated standards of reporting trials (CONSORT) quality; further, the participants were primarily undergraduates. Notably, the empirical evidence for the success rate of hypnosis treatment for test anxiety were not very encouraging and minimal as it was conducted vastly in clinical settings; the effect size of the five RCTs was 0.39 and statistically significant at the 0.05 level. In a second meta-analysis by Valentine et al. (2019), hypnosis therapies were found to be highly successful in lowering anxiety related to dental work, surgery, medical procedures, testing, performance, and other types of anxiety. Specifically, hypnosis substantially reduced test- and performance-related anxiety. Overall, these studies highlight the beneficial effects of hypnosis in reducing test anxiety among students.

In terms of the theoretical framework, explanations of test anxiety have changed from using behavioural to cognitive theories. The most recent theory incorporates social factors, as explained by Lowe et al. (2008) biopsychosocial model. Meanwhile, Hypnosis has various applicability to postmodern approaches, and can be utilised across many theoretical approaches under social constructionism and multicultural psychology theories (Sapp, 2016). Sapp (1991) proposed that test anxiety and hypnosis are linked. For instance, Sapp (1991) asserted that hypnosis is cognitive in nature, as the process typically involves visualisation, imagination, and relaxation components and can thus be implemented to address psychological issues faced by students, particularly test anxiety.

Hypnosis consists of cognitive and behavioural elements that can help alleviate test anxiety. The cognitive element involves visualisation and imagination, while the relaxation component is a behavioural element that can be used to reduce test anxiety. Hence, by providing suggestions, ego-strengthening, and relaxation or progressive relaxation during hypnosis, students can be assisted in managing their test anxiety problems.

To the best of our knowledge, only a few studies and one meta-analysis on test anxiety among undergraduates have been conducted (Baker et al., 2009). Recently, another meta-analysis was conducted by Valentine et al. (2019) but on the efficacy of hypnosis in reducing general and medical anxiety. Seven studies from this meta-analysis examined test anxiety and performance anxiety. In addition, no systematic evaluation has been conducted on the usefulness of hypnosis in lowering test anxiety among elementary and high school students. This systematic review aims to update the current evidence base and extend our understanding of the effectiveness of hypnosis in reducing test anxiety among students. We focus on studies conducted in the period between 2000 and 2021, and ask the following research question: Is hypnosis an effective intervention for reducing test anxiety among students?

2. Methods

This systematic review was conducted according to the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) statement (Moher et al., 2016). This review was registered with PROSPERO (CRD42021279942) and used five databases: Web of Science, Scopus, PubMed, EBSCOhost, and Sage. Search terms representing “hypnosis” (or “hypnotherapy” or “self-hypnosis”) AND “Test anxiety” (or “test stress” or “examination anxiety” or “examination stress”) were adapted to fit the specific databases requirement. Finally, an online search for articles published between 2000 and 2021 was conducted in December 2021. The search terms used and the search formula with limits are shown in Appendix A.

2.1. Search outcome

The search strategy for the use of hypnosis in reducing test anxiety was based on a qualitative, quantitative, or mixed-methods research design, and the language was set to English. The inclusion criteria were as follows: (i) published in English, (ii) journal articles published during 2000–2021, (iii) qualitative and quantitative studies, (iv) pilot and feasibility studies, (v) other systematic reviews/literature reviews/meta-analyses on test anxiety and hypnosis, (vi) mixed methods, (vii) good empirical evidence or findings, and (vii) should report the relationship between test anxiety and hypnosis. The exclusion criteria were as follows: (i) dissertations/theses, (ii) conference papers/reports/letters, (iii) essays/commentaries/calls for action, and (iv) book chapters.

The lead author (SP) conducted the initial search and assessed the articles for eligibility, following which all authors reviewed the findings. The qualities of the individual studies were checked using the standardised checklist (see Appendix B) comprised of three stages: (i) assessing the relevance, (ii) data extraction, and (iii) scoring for methodological rigour (Hawker et al., 2002). If there were any uncertainties or disagreements in the data extraction, the authors held a discussion and resolved them by consensus (see Appendix B for decision-making criteria). In total, 438 articles were identified through the database search, and seven additional studies were manually searched. Of these 445 articles, 40 duplicates were removed, and the remaining 405 were screened based on the title and abstract. Next, 386 articles were excluded after screening because they were not related to test anxiety and hypnosis interventions. Next, the full text of the remaining 19 articles was assessed for eligibility, of which seven were excluded as they did not meet the inclusion criteria. Finally, 12 articles were included in the final review. This process is summarised in the PRISMA-P flowchart (Figure 1).

Figure 1. PRISMA flow chart.

The PRISMA guidelines include a flowchart outlining the criteria for the identification, selection, eligibility, and inclusion of articles covered by the review. Finally, 12 studies were considered in this review.

3. Results and data analysis

In total, 12 studies published between 2000 and 2021 were included in this systematic literature review. Their characteristics are shown in Table 2. Participants ranged from university to school students, whereby 395 students were from university, 110 from high schools, and 10 from a lower secondary school (Mathur & Khan, 2011), resulting in 515 students. Most were female students. The majority of studies were quantitative studies, of which five were randomised control trials and four were non-randomised studies. Finally, two studies were mixed-methods case studies, and only one was a qualitative study.

Table 2. Summary of key characteristics of all included articles

Author or Year	Study Settings/ Sample size	Study Design	Type of group	Instrument/ HS	Hypnosis technique/Duration	Hypnosis/SH Intervention	Theory	Data Analysis	Challenges/ issues	Findings/strength
Ainsworth et al. (2010)	24 first-year nursing students Avg: 26 years UK 22 F 2 M	Quan: Randomised Pre and Post-Test	H: 12 C: 12 NT	SSTEAS	Hypnosis NOSW: 1 NOW: 3 TNOS: 3 NOMPS: 60 -90 minutes 5 in a group	Prior to Numeracy test Relaxation suggestions CD 3 hypnotherapists	NA	DS/T-test	Not wanting to be hypnotised Choosing the right type of exam No follow up	Hypnosis is useful and helpful
Dadashi et al. (2018)	60 high school students 17–19 years Iran All F	Quan: Randomised Pre and Post-Test	R: 20 H: 20 C: 20; NT	TAQ HS: Eye roll Test	Hypnosis NOSW: 2 NOW: 2 TNOS: 4 NOMPS: 40 minutes	Anxiety management/ PS	Briefly on test anxiety and hypnosis	DS/T-test ANCOVA/	Busy school/lack of facilities/ No follow up	Hypnosis intervention decreases test anxiety and is the most significant treatment compared to the Relaxation technique
Dogan et al. (2018)	33 nursing students 20–24 years Turkey 32 F 1 M	Quan: Non-randomised Pre and Post-Test	Single group SH:33 C: NA	VAS BAQ HS: NA (Prior to exam)	Self-hypnosis NOSW: 5 NOW: 1 TNOS: 5 NOMPS: 40 minutes	5 days before the exam Relaxation suggestions mp3	NA	DS	No control Group, No follow up	Self-hypnosis decreases anxiety and stress before the exam
Dundas et al. (2009)	36 university students 19–46 years Norway 27 F 9 M	Qual: Interview	CB: 18 CB and SH:18 C: NA	NA HS: NA	CBH/Self-hypnosis NOS: 3 1^st session; CB, 3 hours 2^nd and 3^rd session: CBH 2 hours TNOHS: 2 POT: 1 year	CBH/SH training Relaxation/ Positive self-suggestions	NA	Interview NVivo	Theme: “Making exam a manageable task” cannot be linked to SH training (limited analysis). Could not be generalised, No follow up	Students have their own individual way of making exams manageable. Mixed results Detailed interview analysis may describe a clinical tool for test anxious students
Dundas et al. (2013)	73 university students 18–46 years Norway 81% F	Quan: Randomised Pre and Post-Test	CB 39 CB and SH: 34 C: 85; NT	RTA STAI SDQ GSE (Prior to exam) HS: HGSHSA	Self-hypnosis NOS: 3 1^st session; 3 hours 2^nd and 3^rd session: CBH; 2 hours TNOHS: 2 POT: 3.5 years	CBH/SH training Relaxation/ positive self-suggestions	NA	DS/T-test /ANOVA/ANCOVA/	Lack of random assignment to the control group/2 hypnosis sessions/No follow up	Self-hypnosis training may not add to the effectiveness of CB intervention.
Gruzelier et al. (2001)	28 volunteer pre-clinical medical students, mean age 20.1 London 17 M 11 F	Quan: Randomised Pre and Post-Test	SH:12 HS.8, LS, 8 C: 16; NT	HS: HGSHSA SAS LV FCA (Prior to exam)	Self-hypnosis HT: 1 NOSW: 3 NOW: 3 (Tape recorded) TNOS: 9 + 1;10	Relaxation, immune imagery, suggestions	NA	DS/T-test /ANOVA/ correlations	The self-hypnosis practice is questionable No follow up	Self-hypnosis training proved to be effective in buffering the immune compromise, which accompanied the distress of examinations in medical students. The use of HGSHSA Hypnotic relaxation may help in boosting immune disorders and for promoting health
Hammer et al. (2021)	104 medical students 17–27 years Germany F:69.2% M: 30.8%	Quan: Non-randomised Pre and Post-Test	H: 52 C: 52; NT	PAF (Prior to oral test) HS: NA	Hypnosis TNOS: 2 NOMPS: 1 hour	Individually chosen induction/ resources/ audio file	NA	DS/T-test /ANOVA/ANCOVA/	Whether students listen to audio-recording of their hypnosis session is questionable/ No treatment for the control group/ No follow up	Hypnosis helped in reducing test anxiety in all dimensions. (emotionality, worry, interference, lack of confidence) Individualised hypnosis sessions for every student
Hammer et al. (2020)	46 Medical students 22 years F:78.3% M:21.7%/ Germany	Quan: Non-randomised Pre and Post-Test	H: 23 C: 23; NT	PAF (Prior to oral test)	Hypnosis TNOS: 2 NOMPS: 1 hour	Individual hypnosis session/audio file	NA	DS/T-test	Whether students listen to audio-recording of their hypnosis session is questionable/ No treatment for the control group/ No follow up	The global test anxiety and lack of confidence scores were reduced significantly over time in the group that underwent clinical hypnosis but not in the control group. Direct comparisons of hypnosis vs control group yielded no statistically significant differences in the test anxiety scores. Small sample size and limited time Individualised hypnosis sessions for every student
Laidlaw et al. (2003).	48 university students 19–23 years London 22 M 26 F	Quan: Randomised Pre and Post-Test	SH:16 J; 16 C; R: 15	POMS STAI PEI PSS TAS (Prior to exam) HS: HGSHSA	Self-hypnosis NOSW: 2 NOW: 4 TNOS: 8	Relaxation/immune imagery, tape recording given & SH 3 times a day	NA	DS/T-test /ANOVA/	a 3-weeks and a 3-month post hoc data	Self-hypnosis helps in reducing test anxiety, depression and tension Relaxation training for the control group
Mathur and Khan (2011)	10 school children 13–14 years India 5F 5 M	Quan and Qual Case study One group pre and Post-test	Single group H: 10 C: NA	TAQ AP (Prior to exam) HS: NA	Hypnosis NOSW: 2 NOW: 4 TNOS: 8	Relaxation/ Positive self-suggestions	NA	DS	No control Group, No Follow up	Hypnosis is effective in reducing exam anxiety and improving academic performance
Pourhamidi et al. (2019)	50 High school students Iran 100% M	Quan: Randomised Pre and Post-Test	H: 25 C: 25; NT	FTAS HS: NA	Hypnosis NOSW: 1 NOW: 9 TNOS: 9 NOMPS: 1.5 hours	Concentration/dissociation and suggestibility	Briefly on test anxiety and hypnosis	DS/T-test /ANOVA/	a 3-month post hoc data Only Male students	CBH reduced students’ test anxiety scores in three dimensions: social humiliation, cognitive error and stress The link between TA and HY explained Discussion of validity and reliability of the scales
Yu (2006)	3 university students Age: NA Hong Kong/London 1 M 2F	Quan and Qual Case study Pre and Post-Test	Single group CBH/SH	SUDS AAT (Prior to exam) HS: NA	Self-Hypnosis NOW: 2 TNOS: 4	Progressive Relaxation/Special place Positive self-suggestions/rapid hypnosis	NA	DS: mean score Interview transcript discussion	No control Group, No follow up Four sessions were finished within two weeks Near to examination The self-hypnosis practice is questionable	Improvement in managing test anxiety and academic performance Detailed hypnosis intervention procedure

F: Female; M: Male; Quan: Quantitative; Qual: Qualitative; H: Hypnosis; C: Control; CB: Cognitive behaviour; SH: Self-hypnosis; CBH cognitive-behavioural-based hypnotic treatment; R: Relaxation; NOW: Number of weeks; NOSW: Number of sessions in a week; TNOS: Total number of sessions; TNOHS: Total number of hypnosis sessions; NOMPS: Number of minutes per session; POT: Period of time; SUDS: Subjective units of discomfort scale; AAT: Achievement Anxiety Test; NA: not available; TAQ: Test Anxiety Questionnaire; VAS: Visual Analogue Scale; BAQ: Beck Anxiety Inventory; RTA: Revised Test Anxiety scale; SSTEAS: Spielberger State-Trait Exam Anxiety Scale; STAI: State Trait Anxiety Inventory; SDQ: Self-Description Questionnaire; GSE: General Self Efficacy scale; TAS: Friedben Test Anxiety Scale; HGSHSA: Harvard Group Scale of Hypnotic Susceptibility; HS: Hypnotic Susceptibility; PAF: “Prüfungsangstfragebogen” or German for “test anxiety questionnaire”; AP: Academic performance; NT: No Treatment; DS: Descriptive statistics, PS: Positive suggestion.

Based on Table 2 and critical appraisal (Appendix B), most reviewed studies had at least moderate methodological quality. For example, the sample size was less than 100 in all studies, except for one quantitative study (Hammer et al., 2021). Some quantitative studies even have fewer students than qualitative studies. For example, Dundas et al. (2009) qualitative study had a sample of 36 university students, whereas Gruzelier et al. (2001) quantitative study only had 28 students. Yu (2006) used both quantitative and qualitative methods with only three participating students.

Next, Figure 2 compares the hypnosis and self-hypnosis studies, which were six each.

Figure 2. Comparison between hypnosis and self-hypnosis studies’.

The chart shows that six studies used hypnosis and six studies used self-hypnosis interventions to reduce Test anxiety. The grouping was based on the study’s findings.

The studies written in bold and italics are randomised trials. Notably, almost all reviewed hypnosis studies helped students reduce their test anxiety, whereas only one study (Dundas et al., 2013) showed that self-hypnosis combined with cognitive-behavioural (CB) intervention did not help reduce test anxiety.

The data for this study are presented descriptively by explaining whether hypnosis had a positive or negative effect on reducing test anxiety. Statistical effect sizes and pooling were not tabulated because of the lack of essential data in the review of quantitative articles, and as some studies involved qualitative and mixed methods.

4. Discussion

4.1. The mode of hypnosis intervention

This section presents a detailed analysis of the type of intervention, duration of the intervention, number of sessions, measurement of test anxiety and follow-up, hypnotisability, and hypnosis in schools. Note that the included studies had different designs and qualities, and varied in how the intervention was implemented, leading to bias. Therefore, the findings should be interpreted with caution.

First, Table 1 shows that the number of sessions and how the hypnosis intervention was delivered differed in most studies unless they involved the same authors. For example, the number of total hypnosis sessions varied from two to ten. The highest frequency was for two hypnosis sessions, which were conducted by four studies (Dundas et al., 2009, 2013; Hammer et al., 2020, 2021). Of these, studies conducted by Hammer et al. sent audio recordings to students to practice at home, while Dundas et al. neglected homework sessions. Only one study (Gruzelier et al., 2001) reported ten hypnosis sessions; however, only one session was face-to-face, with the remaining nine conducted through tape recording. Importantly, note that the researchers contacted the students to ensure that they practiced self-hypnosis and recorded the same. Notably, only one study conducted nine sessions of CB hypnosis, with one session of one and a half hours each week for nine weeks (Pourhamidi et al., 2019). However, no audio recordings were provided to students to practice at home.

This shows that there were no set number of sessions for hypnosis interventions, with some researchers assigning audio recordings as homework (Ainsworth et al., 2010; Dogan et al., 2018; Gruzelier et al., 2001; Hammer et al., 2020, 2021; Laidlaw et al., 2003) while others did not (Dadashi et al., 2018; Dundas et al., 2009, 2013; Mathur & Khan, 2011; Pourhamidi et al., 2019; Yu, 2006). Similar findings were reported in a previous meta-analysis on test anxiety, whereby the studies differed in terms of intervention period (Baker et al., 2009). Therefore, the duration of intervention is vital for schools and universities to plan a robust and cost-effective course that can yield positive results. Furthermore, as both hypnosis and self-hypnosis are discussed here, teaching hypnosis first can be more effective, after which students can learn and practice self-hypnosis. Interventions can also be offered multimodally in this digital age, especially self-hypnosis ones.

The second factor reviewed was the test anxiety instruments and number of times they were measured. The measurement and understanding of test anxiety evolved rapidly, consistent with theory and the demands in the educational environment (von der Embse et al., 2018). Several instruments were used to measure test anxiety. Most studies measured test anxiety in general, with only three measuring the constructs of test anxiety, such as social, cognitive, tenseness, and lack of confidence (Hammer et al., 2020, 2021; Pourhamidi et al., 2019). According to Sapp (1991), hypnosis comprises both cognitive and behavioural constructs that can be used to reduce the worry and tenseness constructs of test anxiety, and these variables can be empirically verified. Unfortunately, there was an absence of theory in all studies, except for Dadashi et al. (2018) and Pourhamidi et al. (2019). Hence, there is ample room for more robust theorising. The number of times test anxiety was measured was almost the same in all studies, whereby pre- and post-tests were performed; however, only two studies did follow-ups (Pourhamidi et al., 2019: 3-month follow-up; Laidlaw et al., 2003: 3-week and 3-month follow-up).

Besides the test anxiety instruments, one study measured students’ total white blood cell and lymphocyte counts to determine their immunity, and measured students’ lifestyle questionnaires and mood changes. The findings revealed that self-hypnosis minimises test anxiety in medical students and is helpful in buffering the immunological impairment that precedes exam stress (Gruzelier et al., 2001). A similar study showed that self-hypnosis can help boost students’ immune systems during stressful examination periods (Naito et al., 2003).

The third factor reviewed was hypnotisability. Hypnotisability is defined as “an individual’s ability to experience suggested alterations in physiology, sensations, emotions, thoughts, or behaviour during hypnosis” (Elkins et al., 2015, p. 6). Simply, individual differences in the ability to experience suggestions during hypnosis are referred to as hypnotisability, which is the same as hypnotic suggestibility or hypnotic susceptibility. Earlier, Kirsch (1997) concluded that suggestibility and hypnotisability ought to be distinguished. He made a distinction between (I) suggestibility, which is the capacity to respond to suggestions regardless of hypnosis, (II) hypnotic suggestibility, which is the capacity to respond to suggestions while under the influence of hypnosis, and (III) hypnotisability, which is the increase in suggestibility as a result of inducing hypnosis. Additionally, Acunzo and Terhune (2021) asserted in their review that the term hypnotic suggestibility is more appropriate because it is the most theory-neutral descriptive phrase for what hypnosis scales measure, namely, the responsiveness to direct verbal suggestions or suggestibility after an induction. Hence, there are two specific definitions: operational and theoretical (Kirsch, 1997; Zahedi & Sommer, 2022).

In some studies, hypnotisability is measured using scales, such as the Hypnotic Induction Profile (HIP), Harvard Group Scale of Hypnotic Susceptibility Form A (HGSHSA), Stanford Hypnotic Susceptibility Scales, or Stanford Hypnotic Clinical Scale for Adults (SHCS). The scores are divided into low, medium, and high suggestible individuals (Elkins, 2021). Notably, only three reviewed studies used a hypnotisability scale (Dundas et al., 2013; Gruzelier et al., 2001; Laidlaw et al., 2003).

A previous systematic review of test anxiety by Baker et al. (2009) suggested that hypnotic susceptibility should be measured because hypnosis is likely to be more beneficial among susceptible students than among non-susceptible students. In contrast, some argue that hypnotisability may be considered a natural human ability that can occur without the induction of hypnosis (Dell, 2021). Unlike Dell (2021), Acunzo and Terhune (2021) articulated that hypnotic suggestibility measurement has significantly affected both the experimental and therapeutic use of hypnosis and is almost unanimously acknowledged to be necessary. The scales of hypnotic suggestibility do, however, have some drawbacks that significantly lower their effectiveness. Hence, a more refined and accurate scale can improve the measurement of hypnotic suggestibility.

However, mixed results were observed on the effectiveness of hypnosis in reducing test anxiety where a susceptibility scale was used; two studies (Gruzelier et al., 2001; Laidlaw et al., 2003) showed that the hypnosis intervention reduced test anxiety, while one study showed no effect (Dundas et al., 2013). In Gruzelier et al. (2001), the researchers placed moderately susceptible students in the control group, while the hypnosis group was further divided into high- and low-susceptibility groups. The findings showed no differences due to hypnotic susceptibility. In Laidlaw et al. (2003), the researchers mentioned the use of the HGSHSA, but did not discuss the effect of the susceptibility scale used. Finally, Dundas et al. (2013) findings were similar to those of Gruzelier et al. (2001), wherein the results of the intervention groups did not differ significantly due to hypnotic susceptibility. Thus, whether the assessment of hypnotic suggestibility is a requisite for hypnosis research is questionable and more empirical research is needed to support the claim. In addition, researchers may have unintentionally discouraged some less-susceptible students from trying and accepting the positive gain of hypnosis (Dundas et al., 2013).

According to Davis (2015), during hypnosis immediate suggestions are made while a person is hypnotised., post-hypnotic suggestions, however, are offered to participants to help them after the hypnosis session. The following is an illustration of a post-hypnotic suggestion: “Starting now, whenever you feel these anxious feelings in your stomach, you will immediately take a deep breath in, and as you breathe out, your whole body will relax.” Unfortunately, in this review, only two studies (Dundas et al., 2013; Yu, 2006) have mentioned the used of post-hypnotic suggestions, which are very important for a lasting effect of post-hypnosis.

Regarding the use of hypnosis in schools (Mathur & Khan, 2011) and with high school students (Dadashi et al., 2018; Pourhamidi et al., 2019), the results showed a significant effect of cognitive behaviour hypnotherapy (CBH) in reducing test anxiety among high school students. Furthermore, the hypnosis technique is beneficial for lowering test anxiety and boosting school children’s academic performance (Mathur & Khan, 2011). In addition, there is increasing evidence of hypnosis in treating challenges in school-aged children, and research shows that children respond strongly to hypnosis (Perfect et al., 2013). Specifically, children are more hypnotically susceptible than adults. This inclination can be used as a successful tool to assist children help themselves (Thomson, 2013). However, further studies involving school-aged children are warranted.

4.2. The effectiveness of hypnosis intervention

In general, the reviewed studies have a definite inclination to consider hypnosis as an effective technique for reducing test anxiety, except for Dundas et al. (2013). The latter found that self-hypnosis training does not increase the effectiveness of the CB intervention. In fact, CB is more beneficial without self-hypnosis, suggesting that self-hypnosis can be designated for students who do not respond to CB and prefer self-hypnosis. Meanwhile, a case study involving three university students (Yu, 2006) found that although CBH does not affect achievement anxiety, it improves anxiety control and exam performance, as well as allows students to have a defined learning goal. Furthermore, students were enthusiastic and confident regarding their examinations.

Two recent studies involving high school students showed that CB hypnosis reduces students’ test anxiety (Dadashi et al., 2018; Pourhamidi et al., 2019). Pourhamidi et al. (2019) measured students’ test anxiety in detail using the Friedben Test Anxiety Scale (FTAS) (Friedman & Bendas-Jacob, 1997). FTAS measures the constructs of test anxiety comprising social humiliation, cognitive errors, and stress. This experimental study involved a CBH intervention, and the test anxiety survey was conducted thrice: pre-test, post-test, and at a 3-month follow-up. The findings showed that CBH reduced students’ test anxiety scores in all the three constructs of test anxiety (i.e., social humiliation, cognitive errors, and stress) as well as at the post-test and 3-month follow-up.

Similarly, Laidlaw et al. (2003) compared self-hypnosis, Johrei (Japanese method), and control (relaxation) groups in helping students deal with examination stress. Students’ mood scales, EEG, and immune system parameters were measured. The findings showed that self-hypnosis and Johrei training performed better than the control group in decreasing students’ anxiety, depression, and tension levels. Note that the four studies discussed above combined hypnosis with other therapies (CB or Johrei), whereas the other eight studies used only hypnosis/self-hypnosis interventions.

However, older studies fail to consider the multidimensional aspects of test anxiety, with only recent studies exploring these aspects empirically (Hammer et al., 2020, 2021; Pourhamidi et al., 2019). Hammer et al. (2021) measured the emotionality, worry, interference, and lack of confidence constructs of the Test Anxiety Inventory, and the scores within each subscale are added to produce a single test anxiety value for each construct, allowing for a more detailed examination of how test anxiety manifests in one’s life. Following the intervention, the Test Anxiety Inventory was assessed three times. The scores for overall Test Anxiety Inventory and lack of self-confidence within the hypnosis group decreased dramatically with time, but not in the control group. However, no significant differences were observed in the overall test anxiety scores between the hypnosis group and control group. Notably, the individual hypnosis sessions had a more significant impact because the hypnotherapist could build a better relationship, and identify the positive experiences and resources of the individual students. Further, the researchers helped students by giving them individual hypnosis audio recordings that they could listen to at home. This is a major strength of this study, although only one hypnosis session was conducted.

Baker et al. (2009) meta-analysis notes that hypnosis is a highly effective test anxiety treatment which is even more successful when combined with other psychological treatments and therapeutic applications. Similarly, our review shows that hypnosis can be an intervention to reduce test anxiety independently or in combination with other treatments. Our review shows that hypnosis interventions can be enhanced by exploring the aim of the intervention, type of psychological problem, duration and number of sessions, researcher’s training, rapport-building skills, standardised procedures, and scripts. Overall, this review indicates the promise and probable effectiveness of hypnosis in reducing test anxiety among students.

5. Implications and recommendations

According to Howard (2020), CB psychology describes how thoughts, feelings, and behaviours are interrelated. Hence, by modifying a person’s thoughts, their emotional responses and feelings can also be changed. This is the framework followed by many test anxiety interventions. Overall, our systematic review suggests that hypnosis interventions, which include both cognitive and behavioural components, may be effective in reducing test anxiety among students. However, most reviewed studies involved undergraduate students. Indeed, studies have stated that the literature on test anxiety intervention is limited, focused more on the factors and prevalence of test anxiety, and revolves around undergraduates (Putwain & Pescod, 2018). Therefore, more studies should be conducted in schools on interventions that equip children with the knowledge and skills which help reduce the effect of test anxiety early on. Moreover, children are typically more receptive to hypnosis than adults because they are in their cognitive development stage (Perfect et al., 2013; Thomson, 2013).

Hypnosis myths and misconceptions have long been a problem, and many of these falsehoods have been spread by stage and television artists. Television and stage shows commonly propagate myths and misconceptions about hypnosis, making it seem beyond understanding and probably dangerous (Perfect et al., 2013; Yapko, 2012). Hence, researchers may face difficulties, as some studies have reported that students were not interested in participating and withdrew from the studies (Ainsworth et al., 2010). Hence, dispelling the myths and misconceptions is crucial, such as by explaining and supporting them with empirical data, and using a sound and solid scientific approach when conducting research (Yapko, 2012). As a result, a strong support network of educators, teachers, parents, and educational department authorities, particularly in schools, is necessary for the effective use of this technique.

Moreover, when conducting hypnosis studies, researchers should consider the heterogeneity of hypnosis. The therapist’s hypnosis approach has a few major elements structured to ensure that students experience relaxation and focus on the suggestions given. A verbatim script covering inductions, deepening, suggestions, ego-strengthening, post-hypnotic suggestions, and awakening is crucial for students and parents to know (Jensen et al., 2017). Specific suggestions and ego-strengthening for test anxiety can be used as standard scripts. However, the reviewed studies lacked a detailed explanation of the hypnosis technique used but mentioned key terms such as relaxation, deep breathing, suggestions, and progressive muscle relaxation. Hence, a precise script can be shared, which will help future researchers determine its effectiveness and modify the script for better results. This has been suggested as a key recommendation for developing hypnosis research (Jensen et al., 2017; Valentine et al., 2019). Some of the popular books that can assist researchers in finding types of inductions and scripts for hypnosis are by Hammond (1990) and Jensen (2017).

Further, students who have been instructed to perform self-hypnosis should be supervised by submitting a weekly checklist (see Appendix C) to the researchers. A checklist is a form for the student to report their audio hypnosis listening and self-hypnosis practice daily. Researchers must also encourage and remind students to engage in everyday practice (Gruzelier et al., 2001). An appropriate time to do this is before sleep, as it is the best time to practice it and can lead to a night of good sleep. This technique can be studied in the future (Yu, 2006). Regarding the self-hypnosis technique, Davis (2015) stated that students can learn and experience hypnosis under the supervision of the hypnotherapist for the first two to three sessions before practicing on their own using audio recordings.

Finally, in the research setting, researchers must ensure that the study has obtained ethics clearance and that all relevant information regarding the research is provided to research participants. This can help them understand and decide whether to participate. An informed consent form is a valuable source of information for participants, families, and friends (Coleman et al., 2021). The reviewed studies typically addressed ethical considerations, either by obtaining verbal consent (Dogan et al., 2018) or by consent letters. However, three studies did not (Laidlaw et al., 2003; Mathur & Khan, 2011; Yu, 2006), or perhaps did not state the same. Moreover, Dogan et al. (2018) neither justified nor documented the use of verbal consent. Before signing the form, participants can read and comprehend the anticipated benefits and potential risks attributable to the consent letter. Future hypnosis research must adhere to the criteria of the research ethics committee because it involves humans.

6. Limitations

Overall, the reviewed studies substantially differed in terms of population, type of hypnosis intervention, number of hypnosis sessions, and research design. This makes it difficult to reach definitive conclusions regarding the effectiveness of hypnosis in reducing test anxiety. In addition, only a few English-language articles were found. The reviewed studies focused on different age groups; as such, students may have had different physical and mental capacities. Therefore, the comparability of all results is questionable.

Furthermore, because of the high level of heterogeneity across studies, establishing clear conclusions on outcome modifiers was difficult, such as the optimum dose of hypnosis, whether hypnosis or self-hypnosis is effective, or the sustainability of the intervention outcomes. Baker et al. (2009) addressed some of these problems in their meta-analysis. Future research should be based on rigorous RCTs that can offer a new perspective and better understanding of how hypnosis is used to help students who are anxious about tests.

7. Conclusion

Test anxiety is a widespread issue that can be advantageous to some students but can also be detrimental to other students, even negatively impacting their health and academic performance. Therefore, a mind-body intervention programme should be implemented to improve students’ overall health and well-being (Hamzah et al., 2018). As hypnosis is a mind-body intervention technique used to manage stress for various psychological and physical issues (Elkins et al., 2018), it has the potential for greater use among school children and students. Given the numerous professional organisations worldwide, teachers and counsellors may be able to easily learn this technique via workshops organised by the respective country’s education department. Some of the organisations that provide professional training for hypnosis are the American Society of Clinical Hypnosis, the International Society of Hypnosis, the National Pediatric Hypnosis Training Institute, and the Society of Clinical and Experimental Hypnosis.

Overall, this systematic review showed that hypnosis may help decrease specific constructs of test anxiety or anxiety in general. Policymakers can consider hypnosis as a viable approach that can be integrated into the educational curriculum. For instance, instructional design models can be developed for students to learn hypnosis to alleviate test anxiety. Counsellors and educators can modify it to improve academic performance, confidence, and motivation, and assist students in focusing on their studies. This can open a new area of hypnosis research and its application in education.

Disclosure statement

The authors report there are no competing interests to declare.No potential conflict of interest was reported by the author(s).

Data availability statement

The authors confirm that the data supporting the findings of this study are available in the article and its supplementary materials (Appendices A, B and C).

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/23311908.2023.2281745.

Additional information

Funding

The authors received no financial support for the research of this article.