Suggestions for Natural Childbirth (Role Theory)

Defining the Role of the Parturient Woman

Copyright © Donald Robertson, 2010.  All rights reserved.

One of the most influential cognitive-behavioural models of hypnosis is known as “role-taking” theory, and was introduced by “Mr. Role Theory”, psychologist Ted Sarbin, in the 1950s.  Role theory interprets hypnosis itself as a socially-constructed role (the “socio-cognitive” theory).  What was once called “depth of trance” is viewed as simply depth of identification with the role, or the degree of what Sarbin now calls “believed-in imagining.”  Instead of “depth of hypnotic trance” it might be better and more accurate to speak of hypnosis as an imaginative activity rather than an altered state the woman’s depth of absorption in her imagination, or depth of belief in the things imagined, during childbirth.  Sarbin’s work on hypnosis was inspired by a seminal article written by the personality theorist Robert White, which famously redefined hypnosis in social psychological terms as follows,

Hypnotic behaviour is meaningful, goal-directed striving, its most general goal being to behave like a hypnotised person as this is continuously defined by the operator [i.e., hypnotist] and understood by the client.

Sometimes this is expressed as saying that hypnosis is a verb rather than a noun, that it is about (actively) doing self-hypnosis rather than being in a (passive) stateof hypnosis, or that “all hypnosis is self-hypnosis.”  This is based on an analogy with acting and is therefore called the “dramaturgical” model.  It leads to more careful consideration of factors which determine the depth of the person's immersion or involvement in a specific role, such as,

1. Role definition (or “role expectations”), the comprehensiveness and detail with which a role is understood, which can be based on an explicit account like a detailed “job description”, or an actor’s script
2. Self-role congruence, the extent to which the woman is comfortable adopting the role outlined and wants to genuinely immerse herself in it
3. Situational cues, the extent to which other people (the “audience”) and the environment are conducive to and support (“reinforce”) the specific role being adopted, i.e., the “demands” of the situation with regard to the woman's behaviour
4. Role-taking skill, the extent of the individual woman’s psychological (cognitive) and physical (behavioural) ability to become absorbed in her imagination or play different roles
5. Role rehearsal, the amount of practice and preparation the woman has had in self-hypnosis, i.e., progressively absorbing herself in enacting her role through speech and action

Self-confidence in her ability to successfully adopt the role defined for her (“self-efficacy”) will also determine the extent to which a woman succeeds in using the technique of hypnosis effectively, i.e., using her focused imagination to her own satisfaction.  The level of her role expectations, or response (outcome) expectancies will define what consequences follow from her actions, i.e., different women will vary in the degree to which they actually expect to relax, reduce pain, or overcome anxiety as a result of using hypnosis, imagination, and suggestion, etc.  Just as an actor’s performance may be aided by an acting coach or theatrical director, the woman may be prepared by the hypnotist.  Moreover, much as actors are rewarded or punished by the applause of the audience or feedback of critics, the hypnotic subject is either reinforced and encouraged by the gentle praise and sensitive support of those around her, or undermined by their negative reactions, lack of support, etc.  Some research studies have found that certain types of actors (e.g., “method” actors) have a slight advantage in terms of their ability to be hypnotised and other, more recent, studies have consistently found that the trait of being “fantasy-prone” or the ability to become absorbed in imagination is slightly correlated with the ability to be hypnotised.

One of the best-known concepts in the field of psychotherapy is the “working alliance” between therapist and client, defined in a seminal article by the psychoanalyst Bordin as consisting of three main ingredients,

1. A bond of “basic trust” between both parties, i.e., rapport
2. Agreement upon the goals of therapy, i.e., upon the specific goals of hypnotherapy for childbirth (“What do you want to achieve?”)
3. Agreement upon the tasks of therapy, i.e., the specific strategies and coping techniques used by the woman, such as breathing and visualisation, etc. (“How are you going to achieve it?”)

A very large volume of research in the field of psychotherapy has consistently shown the strength of the working alliance to correlate with the outcome of treatment.  For our purposes, these can be seen in relation to the “role-taking” theory of hypnosis.  If the woman has sufficient faith in her coach or hypnotist, who may be the husband, to collaborate with them deeply, and agrees profoundly upon the specific goals and tasks that define her role as hypnotic subject, then she will be able to enter deeply into imaginative (hypnotic) role-identification, or what used to be called “hypnotic trance”.  People often confuse the working alliance with mere trust or rapport but if you don’t have agreement upon goals and tasks, and the treatment rationale that links them, then you don’t have a working therapeutic relationship.  It’s agreement upon the tasks (techniques) and goals that defines the role of the woman in hypnosis and determines her responses during the experience of childbirth.

Just as an actor’s role may be defined by a script, the “suggestion scripts” used in hypnosis can be seen as a way of defining the role of the hypnotic subject, i.e., their overall mind-set or attitude.  The hypnotic scripts used to prepare women for childbirth can be seen as stories or “narratives” defining her role and expectations.  Of course, now the role of the hypnotic subject is defined by the client, the pregnant woman, or by the client and therapist working together collaboratively.  A quick review of some of the literature of hypnosis reveals many underlying common factors in the scripted definition of the woman’s role.  The following ideas are typically employed in hypnotic suggestions used to define the goals and rehearse the tasks of the woman during childbirth, although they should, of course, be phrased according to individual preferences.  (NB: These are just the ideas used, they're not phrased as hypnotic suggestions below.)

• You feel excited and look forward to the birth of your child, being able to hold the baby, etc.
• Focus on the knowledge that labour is a very natural and common experience and normally completely safe for mother and baby.
• Each contraction (“surge”, etc.) passes quickly, within about a minute, and is experienced positively, as a step closer toward the goal of the baby being born.
• Contractions are natural and normal, they're similar to other muscles of the body contracting and releasing.
• Pay attention only to the voice of the person speaking to you, to the goal of giving birth to a child, or to the specific tasks of coping (“hypnotic rapport” or selective attention).
• Focus on feeling emotionally calm, physically relaxed, and mentally confident throughout.
• The likely scenario is that you will have a normal birth and a healthy child.
• Interpret each contraction as a signal (cue) to go deeper into hypnosis or to focus attention more on the expectation of relaxing and giving birth naturally, etc.
• Light massage or touch (self-massage or from a partner) is a cue or signal that can soothe the body and increase comfort, or numb the area touched, etc.
• You can have medication if you want it, it’s your choice, but you will probably be able to cope without it.
• You can trust the wisdom of your body to take care of things and your intuition to guide you, just like millions of women throughout human history.
• Childbirth is a completely normal and natural process, just like breathing, eating, or sleeping, etc., and your body is very well-prepared to cope with it.
• You’re the boss; you’re in charge of things and you have a perfect right to decide what sort of birth experience you want.
• It doesn’t matter what other people say or do, you remain confident, optimistic, and positive.
• You trust the people helping you, doctors, midwives, etc., and feel comfortable and accepting of their presence, and you feel you're all working together for your own benefit and for the baby.
• You’re doing your best for yourself and for your baby and can be proud of yourself for the attitude you're adopting and the efforts you're making to have a natural and positive birth experience.
• Time can pass quickly; you are relaxed, aware, and have plenty of energy; your courage and confidence grow as labour progresses.
• You enjoy giving birth and you will always remember the best parts of the experience in the future.
• You believe in yourself and you tell yourself, “I can do this…”, and whatever you need to say to feel calm, relaxed, and self-confident.

I would particularly emphasise these factors, based on cognitive models of anxiety, etc.,

• Focus on the most-likely scenario, that things will happen naturally and you will have a wonderful, healthy baby, etc.
• Accept any feelings of pain, anxiety, or discomfort as normal, harmless, and transient rather than trying to suppress or avoid them (unless they are particularly strong).
• Focus on the genuine signs (or evidence) of safety that you have around you, e.g., the support from others, and the signs that things are proceeding as normal.
• Focus on your ability to cope using the techniques you have learned and adopt a self-confident and optimistic attitude throughout.

These should be treated simply as examples of things other people have recommended, and used as an aid to reflection.  It also strikes me that although we speak of the woman giving birth, it might be helpful to consider looking at birth as a collaboration or “team effort” between the mother and child, who is normally trying to be born, and actively contributing to the process, etc.  Ideally, the woman will write her own script and define her own role, as she sees fit.  The role of the hypnotic subject can also be thought of according to a “tripartite” (ABC) model, defined in terms of three main factors,

A.  Affect, i.e., the emotions and bodily sensations that should be evoked, experienced, and focused upon, etc.

B.  Behaviour, i.e., things the woman says and does, and the way she does them

C.  Cognition, i.e., the things the woman imagines, thinks, or believes, etc., including autosuggestions she says to herself and attitudes toward the situation

I call this the “painting by numbers” approach because it provides a framework to be “coloured-in” with your own specific details.  Researchers in the field of psychotherapy, particularly in relation to research on anxiety, have generally found an unreliable correlation between changes in thoughts, actions, and feelings.  Sarbin's role theory defines hypnosis not merely in terms of superficial acting “as if” or mere pretence or faking but rather he equates “depth of hypnotic trance” what he calls “organismic involvement” in the role.  By “organismic involvement” he means the extent to which the whole “organism” of the woman, the whole of her being, is involved in the role she's chosen to adopt at any given time., i.e., thinking, acting, and feeling like a calm, relaxed, and confident person during childbirth, etc.  You don't need to be in an “altered state of consciousness” or “hypnotic trance” to do this.  In fact few modern researchers believe that “hypnotic trance” exists, but rather, following Sarbin, that hypnosis works by means of ordinary psycholgoical abilities such as imagination and expectation, etc.

The thrust of our argument has been in the direction of removing hypnosis from the realm of special states [i.e., “hypnotic trance”] and examining hypnotic events from a general perspective, that is, social psychology. […] In examining the work of hypnotherapists, it would be instructive to ask, for example, whether the hypnotic induction is no more than an entrance ritual, parallel to entrance rituals in other interpersonal or therapeutic relations.  The effectiveness of hypnotism as a therapeutic procedure or as a means of relieving suffering is not at issue.  One consequence of our efforts to clarify the events traditionally labelled hypnotism would be an increase in therapeutic effectiveness following from more precise knowledge.  (Sarbin & Coe, 1972, p. 247)

When someone is immersed in thinking, acting, and feeling “as if” they are calm, relaxed, and confident, believes deeply in what they are imagining, and identifies completely with that role, then psychological and physiological changes are experienced that may be outside the sphere of normal voluntary control, such as reductions in the perception of pain, reduction of nervous arousal, and certain physiological changes, etc.  This is the role theory explanation of hypnotic suggestion, that the combined effect of imagination and expectation constitute hypnosis to the extent that one is immersed in the imaginative role enacted and believes in what one imagines and the beneficial (therapeutic) responses expected to occur as a consequence.

For these reasons, it makes sense to use hypnosis to rehearse changes across all three dimensions simultaneously, i.e., to use hypnosis to rehearse thinking, acting, and feeling “as if” you are the person you want to become.  Sometimes this has been referred to as the “as if” technique.  Research on cognitive-behavioural therapy suggests that it may also be beneficial to genuinely praise yourself in your mind (“self-reinforcement”) and offer yourself words of encouragement, to reward yourself for your efforts, periodically throughout the process of preparation and during childbirth.  It's also important to emphasise flexibilityas integral to the role of the parturient woman.  Setbacks, problems, unplanned interventions, and other unexpected events may parise which are outside of the woman's direct control and her role will probably also consist of adapting to these changes.  Central to this resilience in the face of potential difficulties will be a flexible and adaptive attitude and mind-set.  Albert Ellis, the founder of Rational-Emotive Behaviour Therapy (REBT), defined this adaptive attitude as the difference between rigid demands (“I must…”, “You must…”) and flexible preferences, e.g., “I would really prefer this to happen but if it doesn't that's not the end of the world.”

These role-rehearsal scripts, which describe how you want to think, act, and feel during childbirth, can be written first as brief, simple, rough drafts.  It’s a good idea to make a commitment to yourself to read the script to yourself carefully three times every few days, and make a few additions or modifications.  Eventually, you may wish to record your script so that you can listen to it on the train, in bed, or at quiet times during the day.  (Recordings can be made easily on most computers and turned into MP3 files or CDs.)  Scripts are usually about 15-25 minutes in length.  If you have a very short script, though, that’s okay – you might want to listen to it “on a loop”, i.e., on repeat.

Adopt an “experimental” or “trial-and-error” approach, whereby you practise your script and improve it at the same time, in gradual steps and stages.  No matter how rough or simplistic your first draft, you will be surprised how quickly, with patient practice, you arrive at a rounded and satisfactory version, a final draft.  As you get more used to your script, you can begin trying to imagine yourself experiencing the thoughts, actions, and feelings, you’re describing, i.e., identifying yourself more and more deeply with the role, like an actor immersing himself in a character.  Make use of evocative language that is designed to stimulate the imagination.  However, hypnosis is not magic and writing scripts is not like casting spells.  Your goals must be primarily psychological goals, within your sphere of control to achieve, i.e., they should be realistic things for you to achieve.  Fortunately, childbirth is inherently natural and normally safe, and it should be within every woman’s power, more or less, to adopt, through patient practice, what she considers the most healthy and desirable attitude toward the experience, e.g., an attitude of calm, relaxed confidence, etc.  I hope that the observations and comments above will be found helpful in doing so.

About the author | Donald Robertson

Donald is a writer and trainer, with over twenty years’ experience. He’s a specialist in teaching evidence-based psychological skills, and known as an expert on the relationship between modern cognitive-behavioural therapy (CBT) and and classical Greek and Roman philosophy. Donald is the original founder of The UK College of Hypnosis & Hypnotherapy, setting up in 2003 under the name Hypnosynthesis. Donald developed the evidence-based hypnotherapy approach taught in the College. He also has been instrumental in the further integration of hypnosis with CBT – both via the training courses of the College and his publication: The Practice of Cognitive Behavioural Hypnotherapy. He passed the College along to Mark Davis in 2013. He now lives in Canada

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