Cognitive-Behavioural Hypnotherapy:
Rubin’s Hypnotic Reciprocal Inhibition

Copyright (c) Donald Robertson 2007-2009

Joseph Wolpe developed the first major behaviour therapy approach, systematic desensitisation, in the 1950s.  Wolpe employed a hypnotic induction (arm levitation) with many clients and originally referred to his approach as “hypnotic desensitisation”, a term borrowed from the hypnotist Lewis Wolberg’s Medical Hypnosis (1948).  Subsequent behaviour therapists and hypnotists who combined hypnotic suggestion with techniques like systematic desensitisation inevitably embraced a more “cognitive” approach insofar as verbal suggestions of improvement, etc., entailed changes to client’s attitudes and beliefs.

In 1972, for example, the behaviour therapist Morton Rubin published an article entitled “Verbally Suggested Responses for Reciprocal Inhibition of Anxiety” (q.v., Dengrove, 1976).  Rubin proposed an alternative to systematic desensitisation which employed hypnosis and a variety of direct suggestions instead of muscle relaxation.  Wolpe had previously considered the use of hypnotic suggestions for relaxation and concluded this was no more effective than other techniques of muscle relaxation.  He had also rejected the crude technique of direct post-hypnotic suggestions that the anxiety was gone. 

            However, Rubin proposed a more sophisticated use of hypnosis in which direct suggestion was used to control exposure to the anxiety stimulus in hypnotic visualisation in a number of different ways.  In particular, hypnotic suggestions were designed specifically to evoke reciprocal inhibition.  He makes no mention of Wolberg but his technique is obviously even more like Wolberg’s original “hypnotic desensitisation” than conventional systematic desensitisation.  Moreover, Wolpe himself endorsed Rubin’s technique which he describes as follows, 

This technique brings the hypnotists repertoire to the service of behaviour therapy.  Instead of the classical ineffective practice of suggesting away symptoms or reactions, it brings suggested responses into opposition with anxiety responses.  (Wolpe, 1990: 201)

In other words, Wolpe criticises traditional hypnosis for attempting to cure anxiety by means of direct post-hypnotic suggestions such as “You will no longer be afraid of cats”, but endorses the use of behavioural hypnotherapy which asks clients to visualise themselves in the presence of cats while giving suggestions of relaxation, etc.  It seems likely that he underestimates the extent to which this practice was already found within the field of hypnotherapy though.

            Wolpe states that he used hypnotic suggestion for reciprocal inhibition himself in a few cases and proceeds to supply a case study in which behavioural hypnotherapy for fear of flying resulted in a “miracle cure” after just one session (Wolpe, 1990: 202).  Wolpe’s approach involved encouraging the client to focus on the pleasant aspects of flying and to practice this imagery at home.  This way of combining hypnosis with behaviour therapy also resembles Lazarus’ use of emotive imagery in some respects. 

Evidence for Hypnotic Reciprocal Inhibition

Rubin claims that his method proved “unusually effective” compared to traditional SD.  After developing the technique over five years, he cited records of his clinical outcomes with forty psychiatric patients based on follow-up assessments.  Based this retrospective analysis of his case studies, Rubin reported average treatment duration of only 7.5 sessions.  However, some clients were complex and severe psychiatric cases who required longer-duration therapy, the most common length of treatment, among more typical clients, was only four sessions.  

            Conditions treated by Rubin, just as in Wolpe’s practice, were mainly simple phobias, social phobia, and sexual dysfunction.  In total, 95% of his patients exhibited some improvement, with 77% exhibiting “marked” or “complete” improvement – the usual criterion of “success.”  This is a similar outcome rate to that reported by Lazarus and Wolpe’s other colleagues using SD.  The crucial difference was that it was achieved in less than half the number of sessions required even for most abbreviated versions of conventional SD.  

Rubin’s Hypnotic Suggestion Method

Rubin’s abstract summarises the technique as follows, 

A new and rapid technique for effecting change on the reciprocal inhibition principle is described.  The patient after a detailed explanation of the learned character of his unadaptive anxiety habit, is forcefully told that through being juxtaposed with a different response, the stimuli concerned will come to evoke the latter in place of the anxiety.  The counter-anxiety response is then induced in the patient by direct suggestion.  Next, anxiety-evoking stimuli are presented in imagination while the counter-anxiety response is verbally sustained.  The anxiety-evoking stimuli are not presented in hierarchical order, but a weaker scene will be used if the chosen one is found to evoke more anxiety than the suggested response can inhibit.  The manner of introducing scenes departs from [Wolpe’s] standard practice in that the patient is told not to imagine the scene while it is being described, but only at the presentation of a signal to be given shortly thereafter.  (Rubin, in Dengrove, 1976: 208)

Rubin’s technique was much bolder and more directive than Wolpe’s, beginning with simple explanation of the nature of the problem and mechanism of cure.  He also provided a firm assurance from the therapist that the treatment should work. 

            It should be clarified that Rubin’s method clearly does not depend solely upon reciprocal inhibition, and probably resembles exposure therapy more than traditional SD.  He writes himself,

If we isolate the factors involved in the technique, we find it includes relaxation, manipulation of imagery, role enactment, directly suggested changes in affect, and changes in attention or inattention.  (Rubin, in Dengrove, 1976: 215)

The enthusiastic encouragement of the therapist is also clearly meant as a form of shaping by positive reinforcement.  Indeed, the stages in Rubin’s method can easily be identified and reconstructed as follows, using the terminology of modern CBT, 

Reciprocal Inhibition by Direct (Hypnotic) Suggestion

1. Identify Target.  No hierarchy is constructed.  Exposure begins with the most feared aspect of the problem, if possible.
2. Stimulus-Response Analysis.  A detailed “behavioural analysis” is carried out to identify the various anxiety responses and external and internal cues in the scene.  This is used to design the suggestions and imagery employed.
3. Identify Adaptive Behaviour.  An equally detailed account of alternate, adaptive responses is established; it is emphasised that these responses will inhibit the anxiety.  (Rubin actually drew detailed diagrams to illustrate the conclusions of both steps to the client.)
4. Role-Enactment.  Having defined the adaptive role in detail, Rubin directly instructs the client to imagine things “in the manner of a calm, relaxed person.”
5. Identify Positive Reinforcement.  Possible pleasant aspects of the phobic scenes are identified in detail, presumably for both reciprocal inhibition and positive reinforcement.
6. Induce Hypnotic Relaxation.  The subject is hypnotised and asked to relax as deeply as possible.
7. Preparatory Instructions.  While in hypnosis, the subject is told in advance what to expect.  The imagery they are about to employ is described before they proceed.  Rubin believed that doing this helped to further reduce their anxiety.
8. Imaginal Exposure.  The client is told to begin picturing the scene on the count of three and to raise their finger when they are satisfied they have the image in mind.
9. Reciprocal Inhibition.  The feared situation is visualised while direct verbal suggestions are given to the client that they will continue to feel increasingly relaxed in the scene. 
10. Coping Imagery.  At the same time, direct suggestions are given that the client can imagine responding in adaptive ways to the scene, i.e., exhibiting coping behaviour and become more focused upon the positive and pleasurable aspects of doing so.
11. Positive Reinforcement.  When the client has finished picturing the scene, they lower their finger as a signal.  The therapist then enthusiastically congratulates the client on managing to picture the scene while remaining calm, in order to positively reinforce his achievement.
12. Repeat Graded Exposure.  Where the client successfully remains relaxed the process can be repeated for more challenging scenes.
13. Homework Assignment.  Before emerging from hypnosis the client is given instructions to repeatedly rehearse the situation in the same way, using self-hypnosis, between sessions.

Rubin describes the “central therapeutic procedure”, following the hypnotic induction, as follows,

He is told that he will be expected to imagine a scene incorporating a stated anxiety-provoking stimulus at the count of three.  Thereupon, the previously identified counter-anxiety responses are very strongly suggested, usually together with further suggestions of calm and relaxation. […]

                Having ascertained that the patient comprehends what is required, the count of three is given to signal the start of visualisation.  The patient is directed to indicate by a finger signal when visualisation takes place.  Then suggestions are continued that he feel relaxed and respond in pleasurable ways to the scene.  If the patient visualises the scene without anxiety, he is rewarded by the enthusiastic approval of the therapist.  Before being brought out of the hypnotic state he is told to practice the scenes at home, relaxing and eliciting the alternative mode of responding now available to him.  If anxiety, should ever develop, either during a practice session or during a real life exposure to a stimulus to neurotic anxiety, he is to make every effort to evoke the alternative responses.  (Rubin, in Dengrove, 1976: 210-211)

The description of the scene must emphasise direct suggestions for emotional calm, adaptive role enactment behaviour, physiological relaxation, and direction of attention to the more positive and pleasant parts of the scene and away from the negative aspects.  Notice that these are virtually identical to the processes employed by Wolberg over two decades earlier, although Rubin does describe the protocol for the technique in much more detail.

            Rubin provides the case study of a woman who developed anxiety and neck pains when sitting down to apply make-up or eating a meal.  His report contains an actual transcript of the third treatment session, in which he begins by summarising the client’s problem in behavioural terms and reassuring her that the anxiety is basically a learned habit response.  Rubin continues, 

Your problem will be solved when you are able to relax, to feel calm and unafraid even when you are sitting down with discomfort in the back of your head or neck, doing such things as applying cosmetics.  And so we will rehearse these activities in the manner of a calm, relaxed person.  When you are able to rehearse and experience these events in this manner, which I will describe to you, you will find that these responses transfer to the real life situation.  I want you to understand and accept this completely with no doubt in your mind whatever.

                Now I am going to describe a series of scenes to you.  Please listen carefully while I describe a scene, but do not attempt to visualise it until I have given you the signal by counting to three.  Then visualise the scene as I have described it.  Indicate that visualisation is taking place by raising your index finder and drop it only when the visualisation has ended.  It is important that you visualise each scene exactly as I describe it, but free of any fear or anxiety and in a calm, relaxed state.

                First I would like you to visualise that you are sitting down to eat in your own kitchen.  You have prepared a delicious-looking filet mignon and you are quite hungry.  As you sit eating the meat, you feel quite comfortable and relaxed, and it is such a wonderful feeling to enjoy the food and feel relaxed.  You are really not worried or concerned.  You do have a feeling of some pain and discomfort at the back of your head and neck, but in spite of this you feel good.  It is such a wonderful feeling to sit there feeling relaxed and enjoying the food.  When I count to three, you may begin to visualise the scene and indicate this to me by raising the index finger of your left hand and keep it elevated until visualisation is completed…  One, two, three.  (Rubin, in Dengrove, 1976: 213-214)

Rubin continues to add suggestions while the client is picturing the scene, providing more detail and instruction on remaining calm and relaxed.  Other, related scenes are gradually added to extend the range of anxiety stimuli which can be coped with.  After four sessions, this lady, who had suffered from acute anxiety accompanied by depression for the preceding two years, had improved sufficiently to resume work.  A follow-up at nine months confirmed the lasting success of the treatment.