GUIDED IMAGERY ASSISTED BY HYPNOSIS -
A FORM OF MENTAL TRAINING WHICH IMPROVES AN ATHLETE'S PERFORMANCE IN SPORTS

BY
FRANK BECKERS ID 252751
SUBMITTED TO THE DEPARTMENT OF PSYCHOLOGY
UNIVERSITY OF MAASTRICHT
DIRECTION: COGNITIVE PSYCHOLOGY
SUPERVISOR: Dr. HUGO ALBERTS

Abstract

Mental training in sports life is getting increasingly popular. One special form of mental training is visualization or (guided) imagery, which is the process of creating internal mental images like for example seeing oneself serving with an ace in a tennis match. According to Liggett (2000), visualization assisted by hypnosis is even more effective than visualization on its own. To explore this hypothesis we raised the following questions: Are guided imagery and hypnosis both apart effective methods to improve athletic performance in sports? And could they be even more effective if combined? Referring to the current literature we investigated within this thesis, we can affirm all three hypotheses. The reason why the combination of imagery and hypnosis is even more effective than each of both apart seems to be that hypnosis substantially enhances the intensity and effectiveness of imagery. Furthermore, it is discussed why this effective combination will have a fruitful future and why it has not been used more often until today as a performance enhancement for athletes in sports life.

"See your future - Be your future"
(Joe Namath, Football Quarterback)
Introduction

In today's sports life, athletes try almost everything to increase their chances of winning a competition. From taking proteins to using illegal doping medicaments and special rituals previous to a game; there are innumerable ways to improve an athlete's ability to compete in the professional sports market. Especially mental training in sports life is getting increasingly popular. It was the famous tennis player Boris Becker, the youngest Wimbledon winner at the age of seventeen, who said that a match is won "between the ears”. But also many other trainers of diverse sport disciplines started to add mental training and sport psychology to their physical exercise agendas. Obviously, mental training in sports becomes more popular from day to day. One form of mental training on which I will focus in this paper is visualization. Visualization within psychology is the process of creating internal mental images also known as imagination or (guided) imagery. When I use the terms imagery and visualization in this paper, I refer to the process of creating mental images. An example of a mental image could be a special exercise or a goal an athlete wants to achieve, like serving with an ace in a tennis match or winning the gold medal in olympic canooing.
Many rumours and fairy tales about visualization which fascinate the listeners are spread. For example, the story of the golfer who sits in jail for many years and only practiced mentally by visualizing the golf courts. Only one month after his discharge he played and won the championships. This story, of course, sounds extremely fascinating like almost every high goal reached at minimal costs, but at the same time it is also quite absurd. Nevertheless, can there be any truth in that story? Is it possible to increase an athlete's performance in sports by visualization?
According to Liggett (2000), visualization assisted by hypnosis is even more effective than visualization on its own. This hypothesis raises several questions, such as:
Are guided imagery and hypnosis both apart effective methods to improve athletic performance in sports? And could they be even more effective if combined?
Thus, the aim of this thesis is to answer these questions and to find out whether the hypotheses stated above are valid or not. Therefore, I will first of all summarize the current literature on imagery and hypnosis in sports separately. The next step will then be to investigate the literature on the efficiency of the combination of imagery and hypnosis as a form of mental training in sports life.

1. Visualization and guided imagery in sports

With the following excerpts of the current literature on imagery and sports performance a short overview of the topic is given. Within the literature the act of visualizing is investigated by a method called guided imagery. As this term will be used several times in the present paper it is necessary to briefly give an explanation and an example of it. Guided imagery means that the visualization is guided by another person who appoints what should be visualized by the subject. An example would be a sport psychologist or a trainer who provides an athlete with suggestions as in the following excerpt from the script Martial Arts of Andy Gallacher, clinical Hypnotherapist, 4th dan black belt in Karate and teacher of the current ladies World Heavyweight Taekwondo Champion:

"And now - I'd like you to imagine - that you are walking through the doors at the venue for the competition… - you are feeling calm - your breathing even and effortless… - and now you pick up your sports bag, leave the changing rooms and head towards the competition area - you open the door to the arena and stand just inside… - you look around noticing the spectators - you find an area to begin your warm up… warming up in the same way that you have done many times before… you begin to do some light shadow sparring - you feel so loose… your punches crisp and smooth - you feel really in the zone - all the hard work now showing in the effortlessness of your movements - everything flowing together…your mind focused and alert - and now you are ready - you hear your name being announced and you step on to the competition area… your breathing easy and controlled - you are feeling so alert and relaxed as the referee signals the start of the fight - you move smoothly and easily - your punch and kick combinations coming together so easily - you're able to score almost at will - you are aware of the techniques your opponent favors and are able to block and slip them without effort…you begin to work your jump and jump spinning kicks now…your opponent unable to answer your speed and accuracy…everything you've worked on in practice now coming together… and then the fight is at an end… your breathing still almost normal… and the referee is holding up your hand… as the crowd go wild… you enjoy the applause…as you collect the winner's trophy…”

Many athletes from different sport disciplines believe that imagery improves their performance. Suinn (1993) for example mentions the skier Jean-Claude Killy, the golfer Jack Nicklaus, the tennis pro Chris Evert, the high jumper Dwight Stones and the defensive end Bill Glass who all benefit from imagery skills in their individual sport disciplines. The considered two reviews of Weinberg (1981) and one of Feltz and Landers (1983) were also generally supportive of imagery as performance enhancement in a variety of different sports. Furthermore, the literature shows that "[…] the research on the effects of mental imagery on competitive performance has been supportive of its value” (Feltz & Landers, 1983; Greenspan & Feltz, 1989). Lee (1990) examined the effects the content of the image could have on performance. She gave a control group a sit-up task and was able to show that relevant imagery improved the performance significantly. She thus proved that the content is highly important and concluded that the appropriate imagery definitely prepared the performer for action. Howe (1991) writes about research on the imagery perspective of subjects. He mentions that there are positive differences for those who use an internal perspective rather than an external perspective. An internal perspective means imagining from within the body and experiencing the action in a multi-sensory way, whereas an external perspective would be imagining the action from an ‘outer' perspective, like a video presentation. Martens (1982) lists a number of situations in which imagery can be of use, such as developing and practicing motor skills and strategies, setting goals and motivating achievements, learning to control emotions, focussing or concentrating energy and attention and increasing self-confidence and self-awareness for instance.
Apart from this very direct influence of imagery, there may also be other advantageous influences, or rather side effects, on the athlete. Howe (1991), for example, claims a rise in self-efficacy achieved by imagery. Pajares (2002) defines self-efficacy as the belief that one has the capabilities to execute the courses of actions required to manage prospective situations. It is important here to understand the distinction between self-esteem and self-efficacy. Self-esteem refers to a person's sense of self-worth, whereas self-efficacy refers to a person's perception of their ability to reach a goal. To illustrate, take a group beginning mountaineers. They would likely have a low self efficacy in regard to rock climbing, but this would not necessarily effect their self-esteem; most people do not invest much of their self-esteem in this activity (Pajares, 2002).
An interesting aspect how imagery and self-efficacy could be linked is the factor of modelling. Baron (2003) writes that modelling is one of the four sources which cause self-efficacy. Modelling is a comparison between a person and another person. If in this comparison the person compared with turns out to have favourable traits or qualities, the other person gradually changes and adapts these features. This means that in a situation where a person sees someone succeeding at something, his or her self-efficacy will increase. People then often think "If they can do it, I can do it as well.” With the help of imagery people have the opportunity to see themselves in the situation they want to model. Moreover, by internal imagery they even perceive all the other sensory information happening inside. Due to imagery they prepare themselves for the action, because they have already experienced it in their mind. The athlete's feeling to be able to control the situation is improved. Accordingly, three different steps can be detected in this process: first of all, the person models the idol, then the practice follows in the imagery where the person sees him- or herself reaching the goal and finally the person also succeeds in reality.
When the imagery is guided, the trainer should try to use the athlete's own words to create a better basis of understanding of what the athlete is going to visualize. The athlete's own words are something he is used to imagine and therefore it is easier for him to transform these words into mental images. Furthermore, Howe (1991) mentions other advantages of imagery like the use of pre-performance imagery to improve control and avoid distraction as well as to improve persistence in competition and training. Other potentially mediating variables might be positively influenced by the use of imagery including the belief in the process, locus of control and expectation. Additionally, imagery can be helpful for focusing and arousal management prior to performance. For instance in a study by Woolfolk, Parrish and Murphy (1985) the effect of imagery instructions on a simple motor skill accuracy task (putting a golf ball) was investigated. College students were randomly assigned to one of the three following experimental conditions: a) positive imagery, b) negative imagery, and c) control group. Imagery conditions a) and b) got the same instructions for imagining the backswing and putting stroke. In the positive imagery group, the students imagined the ball going into the cup, while the negative imagery group visualized the ball missing the cup. The subjects in the control group putted without any instruction. A 10-putt trial was conducted for each subject on each of 6 consecutive days. Woolfolk, Parrish and Murphy (1985) found a significant main effect on performance improvement for the experimental manipulation. The positive imagery group produced the most improvement, the control condition produced less improvement and the negative imagery group resulted in performance deterioration.

1.1 Short report on my own experiences with imagery in sports

With the following section I would like to add my own experiences in relation to imagination and sports. Although these experiences were not scientifically tested, they illustrate how imagination in sports can be beneficial. From the age of 6 I practiced table tennis and after a few years I began to play in a team and participate in competitions. Because I trained a lot and developed enthusiasm while I was playing, I had a very positive win-loss balance at the end of the season. But there was one player I could not beat. In the past years I had lost all five matches against him. His name is Christoph Keimes and he definitely was my most feared opponent. However, the important day came and our team played the league match for the advancement into the next higher class. This most influential last match would decide which of our teams would be promoted into the next league. And, of course, there I had to face my adversary. I had never beaten him before but at this day everything worked out very well. Although I lost the first set, the situation changed in the second set. Suddenly ball after ball and each of my hits succeeded. In the concentration phase, shortly before the serve, I saw how I could make the next point and only a few moments later it happened exactly the same way I had imagined it. First, I thought it would just be luck, but point after point succeeded. Thus, I realized that I was able to do what I wanted to, a state which Unestahl (1986) describes as "Ideal Performance State”. I was so highly concentrated and fascinated that I did not perceive what was going on around me. Finally I won the match in three sets.
My father, who was with me at the game, told me afterwards how the spectators cheered during the match. Only in this very moment I came to realize that I could not remember anything the spectators did. The only thing I could remember, and of which the imprints of my forefinger could give evidence, was that I held my right fist in front of my mouth and bit myself lightly in the forefinger during the concentration phase. From this point onwards, I repeated this gesture in every important situation of another match and remembered and imagined this superb past league match. This gesture has become very important to me, because until today, I use it when high concentration is needed. It was interesting to see how I could use this mental technique also for my other sport Judo. From this time onwards the right fist in front of my mouth was my anchor to trigger a phase of high concentration, which is the basis for effective imagery for me. This kind of mental technique was also the reason why I was listed in the table-tennis ranking list as one of the 5 best youth-players of the federal state North Rhine-Westphalia. For me this was a great success. I experienced how this mental training of visualization triggered by an anchored situation began to improve my own performance in sports. Something very similar to this personal experience was described by Unestahl (1986) as he quotes one of his athletes:

"Suddenly everything worked. I did not wonder any longer what to do or how to do it-everything was automatic. I just looked on. … I had no thoughts of doing it correctly, no thoughts of failure, no thoughts of fatigue. I felt an inner security and confidence that was tremendous. It was completely natural that I should succeed” (Unestahl, 1986).

The athlete is intensely focused on a limited number of task-relevant stimuli, almost like being in a tunnel. After a good Ideal Performance State the athlete may have little recall of the event … (Liggett, 2000). As I read these lines I felt that my experience from the past was exactly the same Unestahl (1986) and Liggett (2000) describe. The perception of the athlete changes during this ‘Ideal Performance State'. The action seems to happen in slow motion, pain does not exist, enjoyment is intense and everything seems effortless. This state can be reached by actions which become automatic. Exercise is needed and many athletes need years of practice to reach it. In my example imagery during the concentration phase shortly before the serve was the trigger which brought me into the Ideal Performance State. Being in the Ideal Performance State, I did not recognize what was happening around me. My physical perception changed in a way that my concentration was focussed only on the imagery of the next ball. The following example will show how imagery can alter physical perception. Read the following text slowly and try to create a clear mental image of what you are reading. Try to use all your senses and you will recognize that your body seems to react as if your imagination is reality.
Now just think of a lemon in great detail. The lemon is lying in front of you on the table. There is also a knife on this table and you cut the lemon into four parts like you do with an apple. Then you take one part and take it to your mouth. You recognize the fresh and sour smell; you see the yellow colour and the lemon's juicy flesh. There is also a bit of juice dropping from the lemon. And now imagine yourself taking a bite of this lemon. Feel how the juice squirts into your mouth. Taste the sour lemon juice with all your taste buds. Imagine it in full detail. Many people automatically salivate when they do this. And in the moment they bite into the lemon they pull a face. The exercise demonstrates how your body can respond to what you are imagining. And athletes use imagery, because they want to influence these body responses. They apply imagery as a remedy for effective goal setting, to develop and practice motor skills, to focus their energy, to increase self-confidence, to rise self-efficacy and to reach their ideal performance state. Imagery evidently becomes more and more popular. As a matter of fact, it is not only used in sport psychology, but in many other fields as well. Still, there is yet another point to consider, namely hypnosis, which also is an important method to increase the athlete's efficiency. Thus, imagery is often assisted by hypnosis. What exactly hypnosis is and how it can assist imagery, is explained in the next section.

2. Hypnosis

First of all, the question arises: What is hypnosis? To begin with, hypnosis is not what many people think it is. Against all prejudice, hypnosis is not a state of unconsciousness in which the subject is totally dependent on the hypnotist. In fact, it is a state of heightened focal attention. This heightened focal attention during hypnosis results in significant effects on a variety of other cognitive functions including memory, physiological sensitivity, and perception (Barber, 1979; Diamond, 1977; Diamond, 1987; Gill & Brenman, 1959; Sheehan & McConkey, 1982). When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced (APA, Div.30, 2006).
Hypnosis is neither a treatment nor an intervention (Frischholz & Spiegel, 1983). It can rather be regarded as a vehicle, which helps to implement therapeutic or motivational suggestions. Kosslyn et al. (2000) consider hypnosis as a psychological state with distinct neurological correlates rather than the result of simply adopting a role. Moreover a commonly held belief is that people under hypnosis lose their consciousness and control. This is again another major prejudice. Individuals always possess volition and control over their actions (Taylor, Horevitz & Balague, 1993). While some evidence of successful clinical manipulation of people's behaviour exists, there is no empirical evidence for hypnotically-derived anti-social behaviour (Conn, 1972; Laurence & Perry, 1988). Hypnosis as a state of heightened focal attention is very similar to other states of extreme concentration, where a person is lost in thought and forgets his or her environment. Most of us have experienced this while driving the car, when we suddenly find ourselves much further down the road without any memory of driving the intervening distance. Playing an instrument is another example. People perform an often played song, but they do not do this consciously. They play their instrument, but they do not think about which tune to play next. They just do it. In this state of heightened focal attention we become oblivious to what happens around us. We forget about doubts, negative intentions, embarrassment and prejudices. To forget about this and to concentrate solely on solution oriented thoughts is an important goal of using hypnosis in therapy.
The question to be asked should be whether hypnosis enhances the effectiveness of a treatment and not if it works better than other therapies. Hypnosis should be seen as a vehicle which for instance should increase the vividness of imagery. Furthermore hypnosis can be used as an adjunct to other therapies. Most of the procedures in hypnotherapy are the same as the procedures in nonhypnotic psychotherapy. The only difference is the state of heightened focal attention which is induced by a hypnotherapist. The state of heightened focal attention is often also referred to as trance state or hypnotic state. It is established by an induction procedure which usually contains instructions for relaxation. But how can this relaxed state of heightened focal attention be of use for athletes in sports?

2.1 Hypnosis in sports

Jacobs and Gotthelf (1986) concluded that "hypnosis aimed at increasing relaxation and alleviating psychological anxiety may have positive and enhancing effects on the performance of athletes". Research by Orlick and Partington (1988) involves a study of Canadian Olympic athletes, which demonstrates the importance of reducing distractions. They report that the ability to control distractions was closely associated with superior performance at the Olympics. In particular, athletes who best resisted the environmental stimulation and who were less awed by being at the ‘Games', were able to stay focused on their own goals and game plan. Accordingly, they performed optimally (Orlick and Partington, 1988). Furthermore, hypnosis and cognitive behaviour therapy could also be used to treat pre-competitive anxiety.
An example of an indirect suggestion under hypnosis could run as follows: "And if you enter the football ground, you may notice that a feeling of self-esteem and strength will appear as you allow it to appear.” You can go back to a point of time, where you were in your optimal shape and where you reached the "Ideal Performing State” … (Unestahl, 1986). Then this ideal performing state can be practiced under hypnosis. Here the expertise and experience of the trainers is important. Professionals, who use hypnosis, should maintain a respect for its potency to influence human behaviour both within and outside the athletic area. Self-Hypnosis is also a kind of mental training and is often used as alternative to guided imagery and hypnosis. Actually every hypnosis is a self-hypnosis, because it is the subject who determines if she or he goes into trance or not. The crucial difference between self-hypnosis and hypnosis is that with self-hypnosis the person hypnotizes her- or himself, whereas hypnosis means that one person hypnotizes another.
Morton (2003) reports how self-hypnosis is used for physical healing and to enhance motivation with regard to climbing. She describes the successful use of self-hypnotic techniques in acute stress situations or when people suffer from post-traumatic symptoms. Furthermore, Morton illustrates the use of hypnotic ego-strengthening, mental rehearsal, age progression, and "Inner Strength” as well as active alert trance states. Alpine mountaineering is said to be a very complex and strenuous sport, but Morton (2003) reports that the trickiest moves at any climb are the mental ones. She writes that self-hypnosis could be a powerful tool in all phases of a climbing expedition: training, climbing, and recovering from injury. Indirect support is given by Howard and Reardon (1986) who examined the effects of a cognitive-hypnotic-imagery approach on the athletic performance of weight lifters. Thirty-two voluntary male weightlifters served as subjects and were randomly assigned to the treatment conditions: cognitive-hypnotic-imagery (CHI), hypnosis only (HO), cognitive restructuring (CR) and a control condition. Dependant variables for this study were the pre- and post- measures on: 1) the supine bench press, 2) Tennessee Self Concept Scale (TSCS), 3) State-Trait Anxiety Inventory (STAI), and 4) anthropometric measurement of chest and dominant arm. The cognitive-hypnotic-imagery (CHI) group showed a statistically significant improvement on the dependant measures representing enhanced self-concept, reduced anxiety, increased muscular growth, and improved neuro muscular performance from pre-test to post-test. The other treatment groups (hypnosis only, cognitive restructuring and the control group) had no statistically significant effect on the dependent measures. The cognitive-hypnotic imagery approach utilizes hypnotic relaxation and imagery techniques to develop and reinforce cognitive restructuring skills. The study emphasized the use of vivid hypnotic imagery to facilitate the control of physiological processes (increased blood flow to specific muscle groups to increase muscular growth), and to facilitate performance on the behavioural criterion measure (supine barbell press). The hypnotic induction included the following four steps: a. The individual was asked to make himself comfortable in his chair, close his eyes, and focus on deep breathing. b. Next, the individual was directed through progressive cognitive muscle relaxation from the forehead to the toes. c. After muscle relaxation, counting was used as a deepening technique. d. Finally the individual was asked to visualize a pleasant scene. Visualizing was extended and intensified until a hypnotic trance was induced.
The hypnotic state was next utilized to enhance physiological processes associated with increased performance via rich hypnotic imagery. The subjects were directed to imagine themselves performing the behavioural criterion measure (supine barbell press) while hypnotized. The subjects were directed to practice several dimensions via hypnotic imagery: 1) psychological - elimination of negative ideation, increased focusing, elimination of distractions, 2) physiological - attaining proper levels of arousal, 3) behavioural - successful performance of the supine barbell press (facilitation of correct neural pathways). Furthermore, the subjects were directed to see themselves on a special point of time in the future with increases in muscular size in the chest and arms. The subjects should visualize themselves feeling proud and happy about the increases they had achieved, and to see others recognizing their muscular gains. All subjects were encouraged to practice the imagery techniques during the week. The neuro-muscular performance (supine barbell press mean increase of +23 pounds) and muscular growth (arm and chest measurement mean increase of .5 inch) were dramatically and positively modified by, the above described, cognitive-hypnotic imagery approach. Interesting in this study is that the combination of hypnosis and imagery seem to be much more efficient than both of them individually.
In the next section I am going to examine the viewpoint that imagery is even more efficient if assisted by hypnosis than imagery on its own. Here, susceptibility tests are a good way to distinguish ‘normal' imagery from hypnotic trance. These tests show the extent to which a person is in trance. Two of the first and most popular susceptibility tests were the Harvard Test of Susceptibility (Shor & Orne, 1962) and the Stanford Hypnotic Susceptibility Scale (Weitzenhofer & Hilgard, 1959). To explain the way they work would go beyond the scope of this thesis. Important is that they were designed to test the level of susceptibility, hypnotisability and imagination ability. Apart from the athletic arena, hypnosis is also often used in medicine and psychotherapy. Therefore, the next part will briefly deal with imagery in medicine and psychotherapy.

3. Combination of Hypnosis and Imagery in medicine and psychotherapy

One field of interest where imagery and hypnosis have been successfully implemented is in the medical field, namely in the rehabilitation from illness and injury. Kirsch, Montgomery and Sapirstein (1995) established a meta-analysis of 18 studies in which a cognitive-behavioural therapy was compared with the same therapy supplemented by hypnosis. The comparisons involved 577 participants. The topics of the 18 studies were insomnia, hypertension, pain, anxiety, obesity, snake phobia, self concept and athletic performance, chronic pain, duodenal ulcer and public speaking anxiety. The meta-analysis compared the outcomes across the studies by the calculation of the effect sizes, the standardized mean difference between the experimental group (hypnosis + cognitive-behaviour therapy) and the control group (cognitive-behaviour therapy). The average client who received cognitive-behaviour therapy assisted by hypnosis showed greater improvement than at least 70% of the clients who received only cognitive behaviour therapy. The results of this meta-analysis indicated that the addition of hypnosis substantially enhanced treatment outcome. According to Kirsch, Montgomery and Sapirstein (1995), the results were particularly striking because of the few procedural differences between the hypnotic and non-hypnotic treatments. For instance, one of the studies in the meta-analysis, a study by Bolocofsky et al. (1985), examined the effect of adding hypnosis to a behavioural weight-management program on short- and long-term weight change. In a 9 week program 109 subjects, between the age of 17 and 67, completed a behavioural treatment either with or without the treatment of hypnosis. At the end of the 9 week program, both interventions showed a significant weight reduction. However, at the 8 month and 2 year follow-ups, the hypnosis clients showed significant additional weight loss, while those in the behavioural treatment exhibited little further change. More of the hypnosis condition subjects also achieved and maintained their personal weight goals.
As can be seen from the literature, hypnosis seems to be an effective supplement to cognitive behavioural therapy. A closely related subject is hypnosis and imagery in pain relief. Montgomery, DuHamel and Redd (2000) established a meta-analysis of 18 studies to find out how effective hypnosis is for pain management. This study compares studies that evaluated hypnotic pain reduction in healthy volunteers versus those using patient samples. Furthermore the hypnoanalgesic effects and participants' suggestibility were compared. The study determines the effectiveness of hypnotic suggestion for pain relief relative to other nonhypnotic psychological interventions. They discovered a moderate to large hypnoanalgesic effect, which supports the efficacy of hypnotic techniques for pain management. Moreover, their results also indicated that hypnotic suggestion was equally effective in reducing clinical as well as experimental pain. The overall results show that these hypnoanalgesic techniques with pain patients should be applied to more people (Montgomery, DuHamel and Redd, 2000). Two additional benefits of pain treatment via hypnosis are that hypnosis is a relatively inexpensive therapy and that there are only minimal side effects.
Furthermore, Ginandes and Rosenthal (1999) conducted a study on using hypnosis to accelerate the healing of bone fractures. Ginandes and Rosenthal (1999) suggest that hypnosis may be capable of enhancing both anatomical and functional fracture healing. They also report a trend towards a faster healing process. Here it is important to mention that this study has a limited sample size and consequently has a restricted statistical power. Still, the accelerated healing of bone fractures with the help of hypnosis could be an interesting aspect for sport injuries. On the whole, it can be said that the literature shows evidence for the beneficial use of hypnosis in medicine and psychotherapy. To give an example of how imagery and hypnosis can be beneficial, the following section reports my own experience with the combination of imagery and hypnosis.

3.1 Short report on my own experiences with imagery assisted by hypnosis in medicine and psychotherapy

Apart from the theory and the analyses stated earlier, I would like to provide the reader with a day-to-day experience of how hypnosis can assist imagery to reach a medical aim, e.g. recovering from an illness. This is what exactly happened to me. With the following short report I would like to give the reader a clue why I chose this topic and why I personally think that imagery assisted by hypnosis has a very fruitful future as well in the medical as in the sports field. At the age of 16 I had severe health problems in form of strong and painful migraine attacks which sometimes even lead to the loss of consciousness. One to three times a week I could not do my daily routines, because I had to stay in bed with pain. I had tried a lot of therapies and medicaments in Germany and the Netherlands before, but nothing really helped. Then one doctor proposed to help me with hypnotherapy and he wanted me to learn self-hypnosis to cope with the pain and to operate prophylactic. Together we produced an individual audio CD with psychological suggestions on migraine and my personal situation. I was supposed to listen to this CD every evening before I went to bed. With the help of this CD I learned for example how to visualize during such an acute migraine attack that my widened vessels in the head went back to their normal shape so that they would no longer produce the terrible pain stimulus. The doctor's advice and the self-hypnosis technique I learned with the CD were the reasons why I soon had the ability to control the migraine attacks and that today I can say that I have not had any migraine attack for many years.
Also Gysin (1999) writes that hypnosis/self-hypnosis appeared to be superior to behavioural therapy, not only in terms of frequency and intensity of headaches, but also with regard to the patients' ability to keep their headaches under control. My own positive experiences with imagery and hypnosis were the reason to browse the current literature and find out what imagery assisted by hypnosis can be used for. Sports and medicine are the two fields in relation to imagery and hypnosis where much literature can be found. After this brief survey of the current literature, which states that the combination of imagery and hypnosis seems to be effective in medicine and psychotherapy, I would like to come back to the hypothesis of Liggett (2000). He maintains that visualization assisted by hypnosis is even more effective than visualization on its own.

3.2 Combination of imagery and hypnosis in sports

Taylor, Horevitz and Balague (1993) suggest that hypnotically-enhanced imagery can increase self-confidence by generating success imagery, improve body awareness and deal with performance blocks. Howard and Reardon (1986) found that adding hypnosis to cognitive restructuring enhanced both performance and muscle growth of weight lifters. Research has also shown that vividness of imagery is related to hypnotizability (Hilgard, 1979; Perry, 1973). This correlation appears to be heteroscedastic, that is, individuals with good imagery ability may or may not be susceptible, but poor imagery skills are strongly related to low hypnotizability (Hilgard, 1979). Taylor and Gerson (1992) examined whether hypnosis combined with mental imagery was more effective in enhancing tennis performance than mental imagery alone. Their findings indicated that hypnotically-induced mental imagery resulted in significant improvement of self-efficacy, technical form and performance - and was significantly better than mental imagery alone in enhancing self-efficacy. In a study conducted by Liggett (2000) athletes imagined specific situations of their own sport. The study used Martens' Sport Imagery Questionnaire. Subjects should imagine four different situations, namely practicing alone, practicing in front of others, watching a team mate and competing. The subjects were asked to report their subjective impression of vividness on four dimensions: visual, auditory, kinaesthetic and affective. Subjects imagined each of the situations with and without hypnosis. The participants reported that the imagery under hypnosis was more intense for each dimension and more intense for each situation. Liggett (2000) suggests that hypnosis substantially enhances imagery intensity and effectiveness. Hypnosis improves the vividness of imagery, because it focuses the attention and diminishes the surrounding noise. It reduces the distractibility. Athletes must stay focussed on their own goals and plans to reach high performance. With the help of hypnosis, the athlete is so much concentrated on the particular goal as if the athlete is in a tunnel and only sees the goal at the end of it. The noise around him is perceived but not consciously recognized. With the help of hypnosis the athlete reaches a shape of highly focussed attention which helps to create the optimum level of concentration.
Furthermore, Liggett and Hamada (1993) write about the use of imagery under hypnosis to help gymnasts to perfect their tricks. There was one case in which a gymnast perfected a double back flip with a full twist in a trance, first by visualizing the flip in a slow motion, then imagining the flip with an increased timing. After a while he could imagine the flip at full speed. Prior to the hypnotic imagery he could rarely stick a landing. After the trance he could do it five consecutive times and he was able to include this flip in his floor routine. Another case about a gymnast is reported by Liggett (2000). He worked with a gymnast who had been injured on a dismount six months earlier. On a purely rational plane the gymnast knew that he could do the dismount because he had done it several times before, but when it actually came to the point of performance, something stopped him from doing it. In a trance the gymnast was taken back to the point in time the injury occurred. He there was asked to imagine himself doing the trick successfully several times. He then should imagine the dismount at his home gym and at an upcoming important competition. After this one session he was able to perform the dismount for the first time in six months. While non-hypnotic imagery had not helped, the much more vivid (his subjective evaluation) hypnotic imagery effected an emotional change which enabled him to overcome the block (Liggett, 2000).

4. Possible explanations for the effectiveness of hypnosis and visualization in sports

One possible explanation for the effectiveness of hypnosis and visualization in sports could be priming. Let us just imagine a tennis player who visualizes under hypnosis how Andre Agassi serves with an ace. The tennis player then goes mentally through the movement step by step. The next exercise of the tennis player is to see himself in the situation of Andre Aggassi. This technique was earlier described in this thesis under the name "modelling”. Through mentally switching between the roles of Andre Agassi and the role of himself, the tennis player could have primed himself with the traits of Andre Agassi, who stands for a perfect technique, a hard serve, high self confidence and an absolute will to win. Dijksterhuis and van Knippenberg (1998) examined a very similar situation. They tested and confirmed the hypothesis that priming a stereotype or a trait leads to complex overt behaviour in line with the activated stereotype or trait. They measured if participants' performance on a general knowledge scale was influenced by priming participants on the one hand with the stereotype professor and the trait intelligent and on the other hand with the stereotype soccer hooligans and the trait stupid. As from the authors hypothesized, the stereotype professor and the trait intelligent enhanced participants' performance and the stereotype soccer hooligan and the trait stupid reduced participants' performance on a general knowledge scale. Dijksterhuis and van Knippenberg (1998) explain their results by claiming that perception has a direct and pervasive impact on overt behaviour. They report that when stereotypes are associated with traits, the priming of a stereotype would activate the related trait constructs. To transform these results to our given example, priming a tennis player with Andre Agassi and the traits, hard serve, perfect technique, high self confidence and absolute will to win could be the reason for an improved serve in tennis and more aces during a match. Furthermore Dijksterhuis and van Knippenberg (1998) mention that it seems that the activation of a mental representation of a specific movement resulted in the tendency to actually make this movement. The mental activation of a trait may also elicit a number of behavioural representations characteristic of this trait. For example, priming participants with a stereotype of elderly made participants walk more slowly than participants who were not primed (Bargh, Chen, & Burrows, 1996).
After visualizing inspiring pictures, athletes may have an altered feeling of their ability which may result in a different use of their own knowledge and their ability like e.g. an enhanced feeling of confidence. Interesting in this context is that Bargh et al. (2001) came to the conclusion that goals can be put into motion without requiring conscious choice and instigation. They believe that goals can be activated outside of awareness and then operate nonconsciously to guide self-regulation effectively. No conscious intervention, act of will or guidance should be needed for this form of goal pursuit. So it could be that while imagining the serve of Andre Agassi in hypnosis, the athlete forms the nonconscious goal to serve like Andre Agassi. Within hypnosis the athlete's attention is absolutely focussed on the serve of Andre Agassi. No blockades, doubts or thoughts like ‘I will never reach that level' will hinder him during this state. During consciously visualizing, the mentioned doubts could prevent the athlete from improving his serve. Bargh (1990) argues that goals can be triggered outside of awareness and then run to completion, attaining desired outcome. If we consider Bargh's theory this could mean that during imagery in hypnosis a goal is activated nonconsciously. This goal will further operate after the hypnosis either by conscious or nonconscious means, to guide a person's goal relevant cognition and behaviour. This phenomenon is known as automatic goal pursuit. An interesting possible avenue for future research may be the relation between automatic goal pursuit and hypnosis. In addition to automatic goal pursuit, priming athletes during imagery could be one reason for the success of imagery and hypnosis in sports. It would be very interesting to see if there are strong parallels between hypnotic and priming phenomena. In this context, the following question could be of interest: Do people who are more suggestible and more easily deeply hypnotized also show stronger priming effects?
Another reason why hypnosis is effective as a form of performance enhancement in sports could be that it focuses the attention of an athlete in such a way that he does not recognize the mental blockades, fears and the nervousness during or before a match. Woody and Bowers (1994) argue that hypnosis may alter the self-perception and the control of one's behaviour. The self perception and the actual control of one's behaviour are, for an athlete, crucial characteristics which can decide about winning or losing a match. The self perception of an athlete can be the all-dominant item which decides about his motivation and his achievement e.g. in a tennis match. This leads us to another technique which could partake in the explanation for the effectiveness of hypnosis and imagery in sports. Gollwitzer and Brandstätter (1997) came up with the implementation intention technique for better goal attainment. An implementation intention can be a part of a plan somebody creates e.g. ("I intend to perform goal directed behaviour Y when I encounter situation Z”). The planning in advance when, where and how somebody will complete a self assigned goal will help to fulfil this goal. Important here is that the goal directed behaviour is connected to a specific situation. Each time this specific situation is faced, the goal directed behaviour should be performed. An implementation intention can help to facilitate difficult processes by making the processes automatic over time. Therefore, implementation intentions can also be used as technique to fight against bad habits. A smoker who is used to smoke after lunch in the lunch break could now say: "Every day after taking my lunch I walk ten minutes outside instead of smoking and take some deep breaths to get new power for the rest of the day.” With this implementation intention he has connected the situation ‘after lunch' with the goal directed behaviour ‘walking and breathing fresh air'. This goal directed behaviour can be applied as self regularity-tool to reach one's goals. After some time, walking outside after lunch can become a ritual which feels as if it would be automatically performed. The consequence of having formed this implementation intention is that the one who carries out the goal directed behaviour feels a commitment to achieve the end state. As I read about the implementation hypothesis of Gollwitzer & Brandstätter (1997), I recognized that while visualizing in hypnosis similar operations as in implementation intention theory occur. At the beginning of this thesis we used an excerpt from the script Martial Arts of Andy Gallacher, clinical Hypnotherapist, 4th dan black belt in Karate and teacher of the current ladies World Heavyweight Taekwondo Champion. In this session parts of the implementation theory are used through connecting goal directed actions to specific situations.

"… - and now you are ready - you hear your name being announced and you step on to the competition area… your breathing easy and controlled - you are feeling so alert and relaxed as the referee signals the start of the fight - you move smoothly and easily - your punch and kick combinations coming together so easily - you're able to score almost at will - you are aware of the techniques your opponent favors and are able to block and slip them without effort…you begin to work your jump and jump spinning kicks now … "

If we consider the situation shortly before the taekwondo match, when the referee calls the name of the athlete, both are recurring situations which can be mentally practiced through visualizing in hypnosis. The situation is the stimuli which should elicit the goal directed behaviour. By frequent performing of the same behaviour in the same situation strong links between cues and actions are created. In the case of implementation intentions, strong links are thought to originate from a single mental act (Gollwitzer & Brandstätter, 1997). In the above stated hypnosis excerpt, we have the single mental act of will and the mentally rehearsal through visualizing the situation. A single mental act of will ("I will execute behaviour Y whenever I encounter situation Z.”) suffices to elicit goal directed behaviour as soon as the situation occurs. Interesting is also that by forming implementation intentions, people can deliberately switch from conscious and effortful action to automated control of their goal-directed actions. The automated control has the advantage that e.g. an athlete can make complex motion sequences effortless and automatically. And this leads us to another possible reason why visualization under hypnosis is an effective method to improve an athlete's performance in sports. Through mentally practicing and visualizing a specific motion sequence, this specific motion sequence becomes faster automatic and is carried out unconsciously and without effort. Gollwitzer & Brandstätter (1997) indicate that implementation intentions differ from other internal memory techniques in that it does not require repeated rehearsal.
As we can see is the success which often is allocated solely to hypnosis and visualization, probably a combination of a great deal of different psychological theories and mental techniques, all combined during visualizing in hypnosis. In the present paper, some of these potential processes were highlighted. These processes include priming, implementation intention, automatic goal pursuit, focus, modelling, self efficacy, goal setting theories, self control and motivation.
Interesting is also that a trend can be recognized that cognitive behaviour therapy is used more and more in combination with hypnosis and visualization. Important to emphasize is that the effect of hypnosis and visualization in sports is a collective achievement of all the psychological theories and mental techniques used during visualization in hypnosis. In how far which theory contributes to the effect is an open question to be answered by future research.

Discussion

At the beginning of this essay I implied that imagery and hypnosis both apart are effective methods of mental training to improve an athlete's performance in sports. According to Liggett (2000) imagery assisted by hypnosis is even more effective than imagery on his own. These were the hypotheses set up at the beginning of writing this thesis. First I started to examine the current literature on (guided) imagery and visualization in the context of sports. I found that imagery has been used successfully in many different kinds of sports as a form of mental training. Suinn (1993) for example mentions the skier Jean-Claude Killy, the golfer Jack Nicklaus, the tennis pro Chris Evert, the high jumper Dwight Stones and the defensive end Bill Glass who all benefit from imagery skills in their individual sport disciplines. Something similar has been written by Weinberg (1981) and Fels and Landers (1983) who were also generally supportive of imagery as performance enhancement in a variety of different sports. Lee (1990) proved that the content of imagery is highly important and concluded that the appropriate imagery definitely prepared the performer to action. Martens (1982) lists a number of other situations in which imagery can be of use, such as developing and practicing motor skills and strategies, setting goals and motivating achievements, learning to control emotions, focussing or concentrating energy and attention and increasing self-confidence and self-awareness. Howe (1991) also adds the rise in self-efficacy, focussing skills and arousal management achieved by imagery.
From my own experience, I can only confirm what was mentioned above. Before an important match took place, imagery helped me to focus my concentration and improved my motivation. It gave me the self-confidence to visualize my goals in detail and helped me to physically perform exactly what I had visualized before. I continued to use imagery in sport from the moment I recognized how effectively it improved my performance. Furthermore, I remembered previous games in imagery where I performed excellently and made use of them to reach the ideal performance state (Unestahl, 1986). Even today, imagining previous games helps me to create an optimal basis position to start a game. It brings me in the right mood and in an optimal physical shape.
My second hypothesis was that hypnosis can be an effective method of performance enhancement in sports. Reviewing the literature, I found that Orlick and Partington, 1988, Jacobs and Gotthelf (1986) and Liggett 2000 support this statement. Furthermore, Morton writes that self-hypnosis could be a powerful tool in all phases of a climbing expedition: training, climbing, and recovering from injury. And Taylor, Horevitz & Balague (1993) report that hypnosis may be an effective tool in the rehabilitation of sports-related injury. It is difficult to discriminate between hypnosis and imagery as a form of mental training in sports. In most cases of hypnosis, imagery is used as well, because hypnosis enables the subject to imagine more intensively. Research has shown that vividness of imagery is related to hypnotisability (Hilgard, 1979; Perry, 1973). The reason why the combination of imagery and hypnosis is even more effective than each of both apart seems to be that hypnosis substantially enhances the intensity and effectiveness of imagery.
Hypnosis in sports can be seen as a remedy, which assists imagery to reach the athlete's individual goal. Especially in the medical field hypnosis is also often used as a remedy in combination with cognitive behaviour therapy. Kirsch, Montgomery and Sapirstein (1995) established a meta-analysis of 18 studies in which a cognitive-behavioural therapy was compared with the same therapy supplemented by hypnosis. The results of this meta-analysis indicated that the addition of hypnosis substantially enhanced treatment outcome. But can guided imagery in combination with hypnosis be even more effective as a form of mental training to improve an athlete's performance in sports? Taylor (1993) examined whether hypnosis combined with mental imagery was more effective in enhancing tennis performance than mental imagery alone. Their findings indicated that hypnotically-induced mental imagery resulted in significant improvement of self-efficacy, technical form and performance - and was significantly better than mental imagery alone in enhancing self-efficacy. Liggett (2000) also supports the hypothesis and mentions that his participants reported that the imagery under hypnosis was more intense for each dimension and more intense for each situation. According to him the findings suggest that hypnosis substantially enhances imagery intensity and effectiveness. There are psychological processes occurring during hypnosis, which could be jointly responsible for the effect of hypnosis and visualization in sports. To these psychological processes or mental techniques which could contribute to the effect of hypnosis and imagery belong: priming, implementation intention, automatic goal pursuit, focus, modelling, self efficacy, goal setting theories, self control, motivation and surely a lot more. In how far which theory contributes to the effect is an open question to be answered by future research.
But despite the positive study results for imagery and hypnosis in sports there are also points of criticism. First of all, the results of the respective studies indicate only information over the effects in the kind of sport examined in each case. Whether and to what extend the results can be transferred to other kinds of sport cannot be determined. Sport disciplines which demand an explosive force like for example sprint performance or hammer throwing are unlikely to benefit from a deep relaxed shape shortly before the action. In these cases imagery and hypnosis may have a negative impact on performance. However, they still could use imagery and hypnosis to enhance their technique through mental training the night before the tournament. Once the athlete has the ability to train mentally through imagery and (self) hypnosis he or she is very flexible in time and can use it whenever it is necessary. He or she is not dependent on the schedule of a therapist or a trainer when once it is known how to handle it.
Another point of criticism is that not all athletes are hypnotizable and that therefore not every athlete can make use of it. Reasons for this could be a lack of imagination, a low intelligence quotient or a psychological disorder. About 10 % of the subjects have a low hypnotizability. For these persons imagery and hypnosis are not applicable. Furthermore, it is difficult to learn self-hypnosis and imagery on your own without a trainer who shows the way how to do it. Motivation and perseverance are important abilities needed to learn self-hypnosis and imagery. The way to learn it is difficult, but the benefits people gain through it are impressive. More and more psychologists, doctors and trainers educate people in (self) hypnosis and imagery. This increasing amount of trainers will make hypnosis and imagery more popular and future studies will give more insight into the development and its efficiency. Still a big disadvantage of hypnosis is its "mystical” connotation. Show hypnotists and magicians who claim their tricks are based upon hypnosis, are responsible for the negative prejudice hypnosis and hypnotherapy has to cope with. Due to the fact that this kind of illusion reaches high viewer levels in the media, only the sensational, "supernatural” view of hypnosis is mostly known. This unserious connotation is the reason why many trainers and therapists do not even try to work with hypnosis. Something what is absolutely needed is the awareness that hypnosis is an effective method to help in a variety of categories.
Based on the current literature and on my own positive and for me outmost convincing experiences with imagery and hypnosis, I think that the advantages outweigh the disadvantages. Imagery and hypnosis and even more their combination are effective methods of mental training to enhance an athlete's performance in sports. Moreover, it is legal, inexpensive and in the studied literature there was nothing mentioned about any adverse effects. Even in case of that hypnosis and imagery once should not work for a sportsman; the resulting consequences would be inconsiderably. So if there is nothing to lose why should a trainer not try out a promising new way? To arouse interest in the topic, to awaken the public opinion and to reduce the prejudices of hypnosis and imagery is a major challenge for future studies. In the USA, many athletes already recognized the benefit of imagery and hypnosis and make use of it in training as in competition. Therefore, I think it is only a question of time and awareness training until imagery and hypnosis become as popular in Europe as it already is in the USA. Imagery and hypnosis face a fruitful future in sports and also in medicine. I committed myself to this topic and hope that my interest will carry over onto the reader. I would have widely exceeded my goal if I could inspire the one or other scientist to start research in this interesting field. If we could manage to find out how our thoughts can alter our physical actions, like for example the fact that we can consciously alter our blood pressure through imagery in hypnosis (Hautkappe et al., 2001), wouldn't this break totally new ground in sports as well in medicine?

References

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Division 30, American Psycholog