NEW: Introductory Certificate in Cognitive-Behavioural Therapy (CBT)

Get Started using CBT in your Therapy Practice

If you’re interested in expanding your therapy skills, this is your perfect opportunity to begin training in cognitive-behavioural therapy (CBT). There’s a growing demand for evidence-based psychological therapists using methods such as CBT. This introductory certificate course has been specifically designed for peopler who already work with therapy clients but want to learn more about CBT. The course is delivered by three experienced trainers who specialise in CBT: Dr. Mia Debidin, Henry Whitfield, and Dr. Steve Harris. The content of this course is based upon standard core textbooks and contemporary evidence-based practice in CBT. It is mapped against the new National Occupational Standards for CBT, and includes practical classroom training and licensed video material from leading CBT experts such as Lazarus, Meichenbaum, etc. Call now on freephone 0800 1985 9809 to reserve your place.

Special Offer: Save £100

Reserve your place before Friday 19th March 2010 and save £100 off the total course fees.
(Normally, £646.25 inc. VAT, discounted price, £546.25 inc. VAT.)

Who should attend?

This course is designed for therapists and mental health professionals including psychologists, GPs, psychiatrists, psychotherapists, counsellors, hypnotherapists, social workers, occupational therapists, nurses, counselling and psychology students, etc. You should already be qualified to work with clients before taking this course or be in the process of completing a professional qualification.

This is an introductory course aimed at those seeking basic training in CBT theory and practice. It may be used for CPD purposes by qualified therapists.

Course Dates

Monday 19th – Friday 23rd April 2010

Course Venue

Jurys Inn Hotel, Central Croydon, South London. 15 minutes by train from Central London.

Course Fees

£646.25 (£550 + VAT)

Course Structure

Practical skills training is emphasised in each class and interwoven with group discussion of CBT theory and concepts. Throughout the course, you will be encouraged to develop your CBT skills through experiential learning and clinical case presentations. Therapeutic demonstrations are also given live and by video. You will also be asked to role-play examples of CBT interventions to develop your core practical skills.

Assessment

After attending the classroom training, students will complete a an online assessment from home. A certificate of attendance will be issued by the college on successful completion of the classroom training and assessment.

Course Content

Day One: Henry Whitfield

The basic theory and rationale of CBT
Semi-structured assessment in CBT
Introducing CBT conceptualisation
Risk assessment in therapy
Evidence-based relaxation skills training (tension-release/breathing/applied relaxation)
Basic evidence-based mindfulness exercises

Day Two: Mia Debidin

Motivational interviewing and engaging the client
Evaluating and developing the working alliance, and dealing with ruptures
Defining problems, setting goals, and developing graded hierarchies
Psychopathology and treatment of depression
Validated outcome measurement for depression

Day Three: Henry Whitfield

The CBT toolbox of techniques: Behavioural interventions
Desensitisation, graded exposure (in reality and in imagination)
Cognitive-behavioural modelling
Habit reversal techniques in CBT
Assigning homework to CBT clients
Monitoring and evaluating client progress

Day Four: Mia Debidin

The CBT toolbox of techniques: Cognitive interventions
Socratic questioning
Thought forms
Cognitive rehearsal imagery, time projection, double standards, role-play disputation
Psychopathology and treatment of anxiety
Validated outcome measurement for anxiety

Day Five: Steve Harris

Case conceptualisation
Treatment planning
Setting the session agenda and delivering structured treatment sessions
Putting what you have learned into practice
Relapse prevention and concluding treatment

Course Tutors

Dr Steven Harris MSc MB BCh

Steven is a medical doctor who has been working as a General Practitioner in North London for the last ten years. Dr Harris has a special interest in mental health and was one of the first to introduce CBT into General Practice in the UK. He developed a brief form of CBT which proved to be highly effective in Primary Care. Dr Harris completed his Masters Degree in Rational Emotive and Cognitive Behaviour Therapy at the University of London in 2006 and is now the lead General Practitioner for Mental Health in West Haringey and the head of IAPT which helps patients gain access to CBT on the National Health System.

Recent Publications
Harris S, Davies M, Dryden W, An experimental test of a core REBT hypothesis: evidence that irrational beliefs lead to physiological as well as psychological arousal, 2006 June: 101-111
Harris S, Body Dysmorphic Disorder, Aesthetic Medicine, 2007 February: 20-22

Dr Mia Debidin PhD C.Psych

Mia is a forensic psychologist with experience in clinical psychology. Dr Debidin worked in the development, delivery and evaluation of CBT treatment programmes for offenders for 15 years, and implemented a structured programme for anger mangement across the Prison Service in England and Wales. She completed the Masters Degree in Rational Emotive and Cognitive Behaviour Therapy at the University of London in 2006. At present she works within two NHS Trusts providing psychological services, including assessment and treatment of adults and older adults, using CBT.

Recent Publications
A systematic review of the literature on the use of Rational Emotive Behaviour Therapy in criminal justice work to reduce re-offending. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 2011, 29(2). Accepted September 2008.

Henry Whitfield MSc (CBT/REBT) MBACP

Henry has research interests in the theoretical and practical integration of mindfulness with cognitive behavioural theories, Acceptance and Commitment Therapy and in case-formulated applications of mindfulness. After 4 years as a trauma specialist for Victim Support Lambeth, Henry now works in private practice and is currently doing empirical research to compare second and third-wave CBT approaches with MIND in City and Hackney. He has been training therapists on a regular basis since 2003.

Recent Publications
Whitfield, H., Towards case-specific applications of mindfulness-based cognitive-behavioural therapies: A Mindfulness-Based Rational Emotive Behaviour Therapy – Counselling Psychology Quarterly June; Vol 19(2): 205-217. Routledge (2006) .
Whitfield, H., Traumatic Incident Reduction: Operationalising Rogerian theory in Brief therapy practice. Chapter 4 in Tudor, K. Brief Person-Centred Therapies. Sage (2008).
Whitfield, H., Bringing Mindfulness into the therapeutic relationship. Healthcare Counselling and Psychotherapy Journal. BACP, (in press).

Being AWARE in Cognitive Therapy & Hypnotherapy

The short handout below is based on the AWARE acronym used by Aaron Beck and his colleagues in their cognitive therapy for anxiety and phobias. For more information see Beck, Emery, & Greenberg, Anxiety Disorders & Phobias: A Cognitive Perspective (2005). This self-help advice to clients can precede typical cognitive therapy to modify negative automatic thoughts. Similar acceptance and self-awareness strategies have been used in hypnotherapy and humanistic psychotherapies for many decades, especially in Gestalt psychotherapy.

Your First Job: Being AWARE

At the beginning of therapy it helps to start learning a whole new attitude toward your anxiety, which has been summed up in the acronym “AWARE” to help you memorise the instructions. You can think of this as defining your initial “role” in therapy, or as a kind of job description. Paradoxically, learning to accept anxiety tends to help overcome it. People sometimes describe this as stopping “battling against” or “fighting with” their symptoms, taking the pressure off themselves, being non-judgemental, or forgiving themselves for feeling anxious.

Accept that your anxious thoughts and feelings are natural. Allow yourself to feel anxious without becoming annoyed or frustrated with yourself. Say “hello” to the thoughts and feelings, think of them as being fairly normal, acknowledge the fact that they exist, and adopt a patient attitude toward change.
Watch your anxiety from a distance. Observe your thoughts and feelings non-judgementally, without making strong value judgements about them being bad, or about yourself for having them. Just imagine you’re observing your thoughts and feelings from a detached perspective, from a distance, without placing too much importance on them. You are not your thoughts or your feelings; rather you’re the person observing them. Observe your thoughts and feelings as if they’re transient things, like clouds passing across the sky, instead of becoming absorbed in them.
Act despite your anxiety. Act as if you’ve overcome your fears, act as if you’re in control or you’ve already achieved your goal of getting better. Reverse your avoidance behaviour and face your fears in steps and stages, dropping any unnecessary signs of anxiety such as gripping objects for safety or averting your gaze from people.
Repeat as much as possible. Keep accepting your anxiety, watching it from a detached perspective, and acting as if you’re better until it becomes second nature and your feelings change.
Expect realistic improvement. Be hopeful and confident but don’t rush things. Be realistic and expect possible setbacks but see them as temporary, surmountable, and opportunities to improve your coping skills. Expect that anxiety may return, because it’s human nature, but also expect that you can learn to cope and make more and more progress if you persevere.

In other words, begin by accepting things, watching the symptoms of anxiety without worrying about them, and acting as if you were feeling better already. To begin with, adopting this mind-set might take some effort and you’ll need to keep reminding yourself to do it, but it soon becomes easier and easier until it has evolved into a habit and something you’ll find yourself doing automatically. It takes a lot of fuel to get a steam engine to start moving but a lot less fuel to keep it going once it’s started rolling. It sometimes takes a lot of motivation to begin learning new thinking habits but it takes less and less effort with each attempt – the main thing is to take the first step and get the process started. So why don’t you begin right now and see what happens if you put the AWARE strategy into practice as often as possible over the next few days or weeks?

Pavlov & Hypnotic Sleep Therapy

The Nobel prize-winning Russian physiologist and psychologist, Ivan P. Pavlov, developed an influential theory of hypnosis based upon his experiments in animal conditioning. Pavlov’s collection of lectures entitled Conditioned Reflexes (1927) culminates in ‘The experimental results obtained with animals in their application to man’ which summarises two conclusions of his research in relation to hypnotherapy,

That the state of relaxation induced in human hypnosis resembles the physiological phenomenon of “animal hypnosis” and results from intense fatigue or inhibition of specific cells in the cerebral cortex (“cortical inhibition”) irradiating to other parts of the brain.
That hypnotic suggestions function by using words as stimuli to evoke conditioned responses which are intensified in nature because the general inhibition of the cortex leaves individual “rapport zones”, i.e., residual centres of attention and excitation in which conditioned reflex responses to words become greatly enhanced.

In contrast to much of the subsequent literature concerning his theories, Pavlov opens his own discussion of conditioning and hypnotherapy in terms which appeal to common sense observations from daily life.

It is obvious that the different kinds of habits based on training, education and discipline of any sort are nothing but a long chain of conditioned reflexes. We all know how associations, once established and acquired between definite stimuli and our responses, are persistently and, so to speak, automatically reproduced, sometimes even although we fight against them. For instance, in the case of games and various acts of skill, it is as difficult to abolish all sorts of superfluous movements as to acquire the necessary movements and it is equally difficult to overcome established negative reflexes, i.e., inhibitions. Again, experience has taught us that a difficult task should be approached by gradual stages. We know also how different extra stimuli inhibit and discoordinate a well-established routine of activity, and how a change in a pre-established order dislocates and renders difficult our movements, activities and the whole routine of life. Again, we know how weak and monotonous stimuli render us languid and drowsy, and very often lead to sleep. We are also well acquainted with different cases of partial alertness in the case of normal sleep, for example a sleeping mother next to her sick child. All these [human] phenomena are analogous to those constantly met with in our animals and described in the preceding lectures […] (Pavlov, 1927, Lecture 23).

Regarding the method of inducing hypnosis employed and its relation to conditioning theory, Pavlov observed that a monotonous and weak stimulus, such as the sound of a metronome, or gentle stroking, could progressively induce relaxation and sleep in animals.

The method of inducing hypnosis in man involves conditions entirely analogous to those which produced it in our dogs. The classical method consisted in the performance of so-called [Mesmeric] “passes” – weak, monotonously repeated tactile and visual stimuli, just as in our experiments upon animals. At present the more usual method consist in the repetition of some form of words, describing sleep, articulated in a flat and monotonous tone of voice [i.e., direct verbal suggestions of relaxation and sleep]. Such words are, of course, conditioned stimuli which have become associated with the state of sleep. In this manner any stimulus which has coincided several times with the development of sleep can now by itself initiate sleep or a hypnotic state. […] Most of the procedures producing hypnosis become more and more effective the more frequently they are repeated. (Pavlov, 1927, Lecture 23)

Braid had emphasised the “law of sympathy and imitation” whereby hypnotic subjects seem to show an enhanced ability to imitate the behaviour of others. Pavlov pre-empts later social theories of learning by acknowledging the role of this mechanism in hypnotherapy.

Obviously we deal with a certain degree of inhibition of some parts of the cortex – a state in which the more complicated forms of normal activity are excluded and replaced by responsiveness to immediate stimuli. This partial inhibition allows of or even favours the establishment and reinforcement of the physiological connections between certain stimuli and certain activities, e.g., movements. In this manner, in hypnosis all activities based on “imitation” are accentuated and we see revealed the long-submerged reflex which in all of us in childhood forms and develops the complicated individual and social behaviour. (Pavlov, 1927, Lecture 23)

Pavlov conceived of hypnotic suggestion as a complex example of a conditioned reflex, fundamental to human nature,

Among the various aspects of the hypnotic state in man attention may be drawn to “suggestion” so-called and its physiological interpretation. Obviously for man speech provides conditioned stimuli which are just as real as any other stimuli. At the same time speech provides stimuli which exceed in richness and many-sidedness any of the others, allowing comparison neither qualitatively nor quantitatively with any conditioned stimuli which are possible in animals. Speech, on account of the whole preceding life of the adult, is connected up with all the internal and external stimuli which can reach the cortex, signalling all of them and replacing all of them, and therefore it can call forth all those reactions of the organism which are normally determined by the actual stimuli themselves. We can, therefore, regard “suggestion” as the most simple form of a typical conditioned reflex in man. The command of the hypnotist, in correspondence with the general law, concentrates the excitation in the cortex of the subject (which is in a condition of partial inhibition) in some definite narrow region, at the same time intensifying (by negative induction) the inhibition in the rest of the cortex and so abolishing all competing effects of contemporary stimuli and of traces left by previously received ones. This accounts for the large and practically insurmountable influence of suggestion as a stimulus during hypnosis as well as shortly after it. The command retains its effect after the termination of hypnosis, remaining independent of other stimuli, being impermeable to them, since at the time of primary introduction of the stimulus into the cortex it was prevented from establishing any connection with the rest of the cortex. The great number of stimuli which speech can replace explains the fact that we can suggest to a hypnotized subject so many different activities, and influence and direct the activities of his brain. (Pavlov, 1927, Lecture 23)

Pavlov considers the question as to why hypnotic suggestions should be more effective stimuli than the imagery experienced in dreaming, a point which could be made in comparing hypnosis with ordinary daydreaming or reverie as well.

It could be questioned why does suggestion carry in itself such a commanding influence as compared with dreams, which are usually forgotten and only have a very small vital significance? But dreams are due to traces, generally of very old stimuli, while suggestion is a powerful and immediate stimulus. Moreover, hypnosis depends upon a smaller intensity of inhibition than sleep. Suggestion, therefore, is doubly effective. Still further, suggestion as a stimulus is brief, isolated and complete, and therefore vigorous, while dreams are generally linked up into chains of various, sometimes inconsistent or antagonistic, traces of stimuli. (Pavlov, 1927, Lecture 23)

Soviet Hypnotherapy (Platonov)

Following Pavlov’s seminal physiological research, which concluded that hypnosis was a form of artificial (conditioned) sleep, Platonov and other Soviet researchers began employing hypnotherapy on a massive scale. They developed a form of hypnotherapy which employed extended periods of “suggested sleep” in a manner resembling Victorian Mesmerism but based on laboratory research on conditioning. Indeed, Platonov subtitled his book on hypnotherapy “The Theory and Practice of Psychotherapy according to I.P. Pavlov.” (1959).

In the Soviet approach, subjects were left to sleep for around an hour following a hypnotic induction without any further suggestions, i.e., in total silence so that they could rest without any disturbance whatsoever.

We have always used long-continued suggested sleep as an auxiliary therapeutic method. It is usually employed in more or less grave conditions as a concluding method after a course of psychotherapy and serves the purpose of restoring the function of the cortical cells and consolidating the therapeutic effect obtained.

Even short suggested sleep not infrequently exerts a positive influence on the patient’s nervous system. This is indicated by very numerous observations of many authors, as well as our own and those of our associates. In a number of cases even a state of light suggested sleep produces a certain therapeutic effect of itself, without any special suggestions. Thus, upon awakening from the very first suggested sleep some of our patients frequently report the disappearance of pain or unpleasant sensations. (Platonov, 1959: 234)

Platonov found physiological evidence that the recuperative function of hypnosis was significantly deepened when explicit suggestions of a “state of absolute rest”, e.g., were used instead of the normal procedure, merely suggesting that the subject was “sleeping deeper”, etc. (Platonov, 1959: 77-78).

These studies have led us to the recognition of the extraordinarily great importance of a special physiological state of deep rest specially created by verbal suggestion.

It must be especially emphasised that natural sleep does not always put all the organs and systems of man into a state of complete rest. […] It is precisely for this reason that it is necessary to exert special influence on the subject’s cerebral cortex by a verbal suggestion that his organism “is in a state of complete rest” during which “all of the experienced emotions have been fully eliminated,” while his brain and all organs and tissues are rapidly regaining their functions. Thus the first step in the verbal suggestion [“sleep”, “sleep deeper”, etc.] puts the person from his usual waking state into a state of suggested sleep, while the second step in the suggestion [“rest completely”] creates special conditions for deep rest during this suggested sleep. (Platonov, 1959: 78).

He goes so far as to claim that this special method succeeds by inducing “a maximal activation of the restorative function of the cerebral cortex.” (1959: 235, his italics).

In the vast majority of cases, Platonov’s clinic employed short sessions of direct hypnotic suggestion, followed by around an hour of deep hypnotic rest in silence, for about 5-6 sessions. This approach would be considered unusual today. However, deep rest of this kind clearly has considerable therapeutic potential.

Experience has shown that one hour of this state, in most cases, provided maximum rest for the entire organism. This prolonged state of suggested deep rest is extraordinarily beneficial not only to the cortical dynamics and the entire higher nervous activity as a whole, but also to the functional state of all tissues and organs and the entire vegetative and endocrine system. (Platonov, 1959: 79).

Platonov seemed to believe that any suggestions given during this state might disturb the state of rest, a fact consistent with a number of empirical observations, e.g., Clark L. Hull’s (1933) findings on the phenomenon of initial negative reaction in response to direct suggestion. He also argued that continued rapport with the hypnotist required the retention of a certain level of awareness, and therefore stimulation of the cerebral cortex. Whereas, in these periods of silent relaxation, with no disturbing suggestions from outside or need for continued attention, the subject was free to enter an even more profound level of relaxation. After a while, the subjects receiving “suggested sleep” appear to become unresponsive to suggestion. Indeed, the subject becomes progressively detached from their whole environment for a while, including the hypnotist as the following report from one of Platonov’s patients illustrates.

“When I am in a state of hypnosis,” writes a woman patient, “I experience different sensations at each session. Thus during the first session I continued to feel my entire body but was unable to move a single member and though I clearly heard the voice of the hypnotist and was conscious of everything my thoughts were in a sort of muddle. This was what I should call bodily sleep. At each successive session my body grew increasingly heavier, I no longer felt it, though I continued to hear all that was going on and it seemed to me it was all happening somewhere far away, I was not quite conscious of it, and it was all absolutely immaterial to me.

“During the last, fifth, session I no longer felt my body at all, as if I had none. Nor could I think of anything. I had no thoughts at all. I heard various external sounds which did not concern me in the least. During suggestions I heard everything clearly, but my mind failed to work, and the words of suggestion relating to my former experiences in no way affected me.

“At the words of awakening, I begin to awaken at first from the head, as it were: thoughts rise in my mind, I begin to think about how to move, to get up; I understand everything that takes place around me, but begin to feel my body somewhat later; as my consciousness clear up, I begin to feel a heaviness throughout my body, which subsequently dissipates upon complete awakening.” (Platonov, 1959: 73)

This approach is obviously impractical for modern clinical practice. Clients may resent paying for a session in which they are merely left to relax in silence. However, a similar technique might be used in different settings, e.g., during group workshops or between sessions with the aid of a self-hypnosis CD.

Hypnotic Sleep Therapy: Some Basic Instructions

This is an excerpt from the Coping with Noise self-help workbook from the chapter on improving sleep…

It helps if you can try different methods that other people have found helpful and pick the one that appeals to you, or seems to work best. Try using the techniques you’ve already learned first of all, or the methods below, if they appeal to you. Many different relaxation techniques are known to be effective, but you have to practice most of them regularly to get the most benefit. The most important thing, therefore, is probably that you pick a simple technique that you feel comfortable using, and are willing to use every day for a few weeks or more.

James Braid’s Method of “Sleep at Will”

The physiologist and physician Dr. Edmund Jacobson concluded after many decades of research, conducted at leading universities in the USA, that relaxation of the facial muscles, eyes and voice were particularly conducive to sleep and relaxation. It’s certainly true that people tend to find this kind of technique useful, and similar approaches have been used for over 150 years. James Braid, the Scottish surgeon who invented hypnotism, wrote in 1843 of a method for inducing “sleep at will.” Braid observed quite simply that by relaxing, focusing on the idea of falling asleep and fixing one’s attention on an unexciting image or sound, sleep tended to be induced. He recommends a number of ways of doing this, but a modern account might read as follows,

Focus your gaze. Stare at a point on the ceiling and keep your eyes glued to the spot. Make them feel tired and sleepy, without straining them too much. Close them slowly when they begin to feel tired. This shouldn’t take more than a few minutes, if you really imagine your eyes feeling tired. Alternatively, close your eyes and imagine you’re staring up at an image, like a star in the sky.
Relax your breathing. All the while, act relaxed, lie still, and let your breathing become shallow and steady, as relaxed as possible. Make your body comfortable, and try to feel as pleasantly relaxed as you can throughout the whole process.
Focus your mind on sleep. All the while, keep your attention fixed upon on the idea of falling asleep. Don’t try to force yourself to sleep, that won’t work. There’s a knack to focusing on an idea in a relaxed, pleasant and passive way. Forget about absolutely everything else for a while. Have faith, believe you can do it easily and expect to drift off to sleep.
Rest and repeat. When your eyes close, continue to relax for a few more minutes. If you’re still not falling asleep then fix your gaze again and repeat the process as many times as is necessary and you will fall asleep eventually. It’s unusual to have to repeat it more than 3-4 times, though.

As Braid observed, this kind of technique tends to become much easier with practice, as you get the knack of doing it and your body starts to respond out of habit.

Conscious Autosuggestion

Braid also recommends repeating a monotonous phrase, like a lullaby. This technique was popularised in the 1920s by the French pharmacist Emile Coué, renowned as the father of modern self-help. Coué developed a technique which he called “conscious autosuggestion.” These are his instructions for insomniacs,

Having settled themselves comfortably in bed they will repeat (not gabble) “I am going to sleep, I am going to sleep,” in a quiet, placid, even voice, avoiding of course, the slightest mental effort to obtain the desired result. The soporific [sleep-inducing] result of this droning repetition of the suggestion soon makes itself felt; whereas, if one actually tries to sleep, the spirit of wakefulness is kept alive by the negative idea, according to the law of converted effort. Insomnia indeed affords a striking demonstration of the disastrous effect of the exertion of the will, the result of which is just the contrary of the one desired. (Coué, 1923: 31-32)

Coué’s law of “converted effort” or “reversed effect” is also known as the principle of “paradoxical” effect. It refers to the fact that in many ordinary situations, the more effort we make to do something, the more we may achieve the opposite. One notorious example of this is sleep. The more we try to force ourselves to fall asleep, the more we tend to become tense and alert, and to keep ourselves awake. It’s well-known that when people who suffer from insomnia are asked to try to stay awake as long as possible, paradoxically, they tend to fall asleep more quickly.

In the 1970s, Herbert Benson, another scientist who became a well-known authority on relaxation techniques, developed a similar method called the “Benson method” for inducing what he termed the “relaxation response.” Benson compared many popular relaxation and meditation techniques, and found that although most worked, and produced measurable physiological signs of relaxation, there was little difference between them. They all seemed equally effective, although some were more complicated than others, so he tried to develop a simplified approach that worked as well as the existing ones, but was much easier to learn. Benson’s method simply requires that you sit still with your eyes closed and repeat any word or short phrase over and over for about 20 minutes. Benson found that the most important aspect of the technique was the client’s attitude toward distraction. People who try too hard to relax, or worry about their mind wandering, etc., tend to remain tense, but people who say “So what?”, shrug off distractions, and patiently return to the monotonous exercise, tend to relax more easily and more deeply. Benson’s method is used both to overcome stress and to help people fall asleep. It’s really just a modern variation of the old method introduced by Braid and popularised long ago by Coué.

Evidence Against the Doctrine of “Symptom Substitution”

One traditional criticism levelled at hypnotherapy by psychoanalytic therapists was that its benefits must be temporary unless it attempted (as in regression) to “get to the root” of the problem by analysing its remote childhood causes. This theory was first propounded by Freud, on the basis of a tiny handful of cases,

[Hypnosis] could be employed in certain cases only and not others; with some much could be achieved by it, and with others very little, one never knew why. But worse than its capricious nature was the lack of permanence in the results; after a time, if one heard from the patient again, the old malady reappeared or had been replaced by another. (Freud, 1920: 157)

Indeed, Freud and his followers tended to argue that any therapy which attempted to directly remove symptoms without analysing their unconscious root cause, in the so-called “Oedipus Complex”, would lead to temporary improvement while leaving the client vulnerable to relapse and deterioration. As all symptoms, on the original psychoanalytic model, were viewed as disguised representations of unconscious complexes, new symptoms were expected to occur which would symbolise repressed material in different ways a “return of the repressed.”

In fact, this was merely a supposition made by Freud, an objection based on theory rather than observed facts. However, it was not until the introduction of behaviour therapy that hypnotherapy found its first major ally in disputing this hypothesis. However, as Marks rightly points out, it seems absurd that this presupposition is confined to psychotherapy which is symptom-focused whereas nobody seems to “fear the dragon of symptom substitution” when prescribing common psychiatric medication, such as tranquilisers (Marks, 1981, p. 237). In cases where medication is used to remove symptoms, there is clearly no evidence of new substitute symptoms erupting from the unconscious mind in symbolic form, contrary to the prediction made by psychoanalytic theory. Hence, in the opening salvos of the “psychotherapy wars”, Eysenck announced that contrary to the assumptions of Freud, symptom substitution was essentially a myth.

How about the return of symptoms? I have made a thorough search of the literature dealing with behaviour therapy with this particular point in view. Many psychoanalytically trained therapists using these methods have been specially on the outlook for the return of symptoms, or the emergence of alternative ones; yet neither they nor any of the other practitioners have found anything of this kind to happen except in the most rare and unusual cases. […] relapses occur, as indeed one would expect in terms of learning theory under certain circumstances, but they quickly yield to repeat treatment. […] Nor would it be true that alternative symptoms emerge; quite the contrary happens. The disappearance of the very annoying symptom promotes peace in the home, allays anxieties, and leads to an all-round improvement in character and behaviour. […] Once the symptom is removed, the patient is cured; when there are multiple symptoms, as there usually are, removal of one symptom facilitates removal of the others, and removal of all the symptoms completes the cure. (Eysenck, 1960: 12-13)

Even when psychoanalysts turned to the empirical evaluation of this theory, their own results were negative,

Mowrer, having accepted, as we have seen, Freud’s conclusion with regard to the meaning and function of symptoms, was considerably embarrassed by his own empirical finding that “symptomatic” treatment of enuresis was not only 100 percent successful with regard to the symptoms, but was not followed by symptom substitution in a single case! (Yates, 1958, in Eysenck, 1960: 22)

Likewise, when Azrin and Nunn carried out direct habit reversal treatment with over 300 subjects, they reported remarkable success in breaking habits such as nail-biting, hair-pulling, stammering and tics, of the kind traditionally treated by Freudian psychoanalysis. However, despite changing the habit symptoms directly, without attempting to interpret their “unconscious root”, they found no evidence whatsoever of symptom substitution (1977: 32). Freud himself forwarded no evidence whatsoever for this theory other than anecdotes based on his own limited clinical experience with a small sample of clients. It is inconsistent with the clinical experience of most modern therapists. However, it has seeped into popular culture and you will find many clients who have internalised this view in the form of a superstition or a “myth” about therapy.

Behaviour therapists passionately argued that symptom substitution was a superstition and only likely to occur if the client had been led to expect it to happen. Of course, in some cases clients may solve one problem while neglecting another, but it is rare that this would lead to new symptoms. Lazarus carried out a detailed follow-up study of 112 clients who were treated by him using behaviour therapy. He could find indications of symptom substitution in only five or six cases (5%) and even these were classed as “tenuous.” Similarly, Kroger & Fezler confidently assert that there is “no evidence” that psychodynamic symptom substitution exists (1976: 79). Even Weitzman, a psychoanalytic therapist, in an article openly critical of behaviour therapy, accepts,

It has been pointed out, from both camps, that analytic theory requires that symptom substitution or recurrence must attend a symptomatic treatment which, by definition, does not affect the dynamic sources of the symptoms. The evidence is rather impressive that neither substitution nor recurrence typically follows treatment by systematic desensitization. When occasional recurrences are reported, they are described as being of low intensity and, apparently, never catastrophic. (Weitzman, 1967: 301)

Drawing on evidence from reviews by behavioural researchers including Bandura, Lazarus, Paul and Wolpe, Rimm & Masters conclude,

Reviews of empirical findings (including case histories and controlled experiments) indicate that the evidence is overwhelmingly against symptom substitution. (Rimm & Masters, 1974, p. 10)

Evidence from behaviour therapy unequivocally demonstrated that this psychoanalytic theory was false, and that people did improve as a result of direct symptom removal, without analysis of their past. Indeed, the results of behaviour therapy were often much quicker and more reliable than anything that could be hoped for from psychoanalytic approaches. As one behavioural hypnotherapist, explains,

Once these changes start to occur, they will become self-perpetuating. You will realise you can cope with what once seemed formidable problems, and so you will approach other situations with far greater expectations of success. The therapeutic effects of hypnosis and self-hypnosis are undoubtedly ongoing and permanent. (Jackson, 1990: 30)

Indeed, as Freud himself had originally stated (1895), when any symptom is removed clients will generally develop more ego-strength, growing in confidence in a way that tends to make them improve across the board in other areas of their life. For example, when people successfully quit smoking, it is rare (though not impossible) for them to substitute some other negative behaviour. Most people feel more empowered and tend to improve in other areas of their life as well, creating a kind of positive “domino effect.”

The notion of “symptom substitution” is a particularly insidious one as it discourages clients from making practical changes that are well within their sphere of control. This is most notable in depressed clients who typically suffer from a lack of initiative and motivation and are further de-motivated by the excuse that the myth of symptom substation offers. They may complain that there is “no point” fixing one problem until they have solved their “underlying” character problem. In most cases, this is not a realistic goal, however, and it is many small changes which improve the quality of life for most people. Notably, psychoanalysis has been blamed for worsening the condition of some depressed clients. Likewise, after reviewing relevant outcome data from a wide range of independent studies, Bandura was tempted to speculate that the predictions of “dire consequences” resulting from symptom substitution were little more than scare-mongering by psychoanalytic therapists, attempting to stifle innovations in symptom-focused treatment (Bandura, 1969, p. 48).

The distorted “grain of truth” in the theory of symptom substitution, as Eysenck (1960: 13) notes, is that where the client suffers from an (autonomic) emotional reaction and their (psychomotor) behaviour is reconditioned without addressing their underlying mood, they may relapse or seek another behaviour to alleviate their inner distress. For example, someone who bites their nails to cope with stress may relapse or begin grinding their teeth instead if this habit is suppressed directly, unless they are also alleviated of the emotional arousal associated with stress, e.g., by desensitisation therapy.

Thus, there is no axiom of behaviourism which precludes the substitution of one maladaptive behaviour for another. But from a practical point of view, it is a phenomenon only rarely observed. (Rimm & Masters, 1974, p. 10)

This is a far cry, moreover, from the Freudian notion of “symptom substitution” due to unconscious dynamics, and only a seriously incompetent therapist would attempt to remove a self-comforting habit without also addressing the associated emotions. It isn’t a question of removing the symptom and its cause, but rather one of removing all of the symptoms from a mutually inter-dependant and self-maintaining cluster.

Strategies & Applications of CBH

What is Cognitive-Behavioural Hypnotherapy?

Cognitive-behavioural hypnotherapy (CBH) is a core modality of modern hypnotherapy and hypno-psychotherapy. It is a branch of hypnotherapy, not a branch of cognitive-behavioural therapy (CBT). It combines traditional concepts and techniques from Victorian hypnosis, of a cognitive or behavioural nature, with modern cognitive-behavioural theories of hypnosis, and certain elements of CBT. Cognitive and behavioural techniques have always been implicit in hypnotherapy since the original writings of Braid and Bernheim in the Victorian era. However, modern cognitive-behavioural hypnotherapy became more explicitly formulated in a number of research articles and books published the 1980s.

Cognitive-behavioural therapy (CBT) evolved primarily out of Joseph Wolpe’s behaviour therapy, introduced in the 1950s, which it gradually combined with elements of Aaron Beck’s Cognitive Therapy (CT), Albert Ellis’ Rational-Emotive Behaviour Therapy (REBT), and a number of other influences from the “cognitive” approaches to psychotherapy which appeared in the 1950s and 1960s.

Hypno-CBT^® (HCBT) is a proprietary model of cognitive-behavioural hypnotherapy, developed by Donald Robertson. It integrates elements of CBT with hypnotherapy in the same way that hypno-analysis traditionally combines elements of psychoanalysis with hypnotherapy.

Cognitive Mediation

The cognitive therapies are so-called because they share an emphasis upon the role of cognition in psychopathology and in psychotherapy. The word “cognition” comes from the Latin cognitus meaning “to know.” Cognitions are thoughts, spoken or otherwise, which express a statement of belief. For instance, the thought “The cat is on the mat”, is a cognition; the thought “Ouch!” is not. Cognitions, crucially, can be true or false and are therefore susceptible to rational and evidence-based disputation. Cognitions, of course, can be helpful or harmful, rational or irrational, good or bad, healthy or unhealthy, negative or positive, etc.

Emphasis upon the way that our beliefs shape our experiences is central to all forms of cognitive therapy. In their Handbook of Cognitive Behavioural Therapy, Dobson and Dozois offer a formal definition of CBT in terms of the following characteristic, shared assumptions,

Cognitive activity affects behaviour.
Cognitive activity may be monitored and altered.
Desired behaviour change may be affected through cognitive change. (Dobson & Dozois, in Dobson, 2001: 4)

They add, in elaboration,

A number of current approaches to therapy fall within the scope of cognitive-behavioural therapy as it is defined above. These approaches all share a theoretical perspective assuming that internal covert processes called “thinking” or “cognition” occur, and that cognitive events may mediate behaviour change. (Ibid.: 6)

It should be noted that this definition is broad enough in scope to encompass many traditional forms of hypnotherapy.

Hypnotherapy as Cognitive-Behavioural Therapy

Even James Braid’s later “ideo-dynamic” model of hypnotherapy, from the mid-Victorian era, could be interpreted as cognitive-behavioural in this sense. Braid believed that negative “fixed ideas” were responsible for many problems. He introduced the technique of using hypnosis to “break down the pre-existing, involuntary fixed, dominant idea in the patient’s mind, and its consequences.” (James Braid, Hypnotic Therapeutics, 1853). This was done by replacing negative fixed ideas with positive, therapeutic suggestions.

The Nancy School of Liébault and Bernheim, the most influential school of Victorian psychotherapy, developed this notion even further. Bernheim argued that most psychopathology was due to negative autosuggestion and could be rectified either by rational persuasion, aimed at disputing these fixed ideas, or by direct positive suggestions of a counter-acting nature. In the 1920s, Coué made this very explicit in his system of self-help through “conscious autosuggestion”,

From our birth to our death we are all the slaves of suggestion. Our destinies are decided by suggestion. It is an all-powerful tyrant of which, unless we take heed, we are the blind instruments. Now, it is in our power to turn the tables and to discipline suggestion, and direct it in the way we ourselves wish; then it becomes auto-suggestion: we have taken the reigns into our own hands, and we have become masters of the most marvellous instrument conceivable. (Emile Coué, My Method, 1923: 6)

More recently, in the 1980s, Daniel Araoz introduced the term “negative self-hypnosis” to describe the role of harmful suggestions in psychopathology. The notion of negative autosuggestion or self-hypnosis in traditional hypnotherapy clearly pre-empts the parallel concept of “negative automatic thoughts” in modern cognitive-behavioural therapy.

Moreover, hypnotherapy since the time of Braid has also evoked physical responses such as aversion and relaxation to directly counter-act states such as craving or anxiety with which they are mutually exclusive. This fundamentally pre-empts the concept of “reciprocal inhibition” which forms the basis of modern behaviour therapy as introduced by Wolpe in the late 1950s.

The Cognitive-Behavioural Theory of Hypnosis

The central theoretical debate in the history of hypnotism is known as the “state versus nonstate” argument. Proponents of the nonstate position have tended to argue that rather than requiring a special theory which posits a unique, altered state of consciousness or “trance” state, hypnosis can be better explained by established psychological theories which draw upon familiar concepts. Because they tend to explain hypnosis in terms of cognitive, behavioural, and social psychology, the theories of influential hypnotic researchers like Sarbin, Barber, Kirsch, et al., are termed “cognitive-behavioural” or “sociocognitive.”

Since the 1960s, cognitive-behavioural theories of hypnosis have tended to dominate, and state theories have been revised to the extent that they are now virtually assimilated within the nonstate models. For instance, the idea of a special altered state of consciousness or “trance” has been reduced largely to the theory that some hypnotic subjects respond to suggestion partly because of increased absorption in their imagination. This is “trance” in such a watered-down and “naturalistic” sense that it is easily accepted by the cognitive-behavioural theorists as part of ordinary psychological functioning.

Although the cognitive-behavioural theory of hypnosis and cognitive-behavioural therapy are two fundamentally different things, it is important to see the connection between them. Both share a similar terminology and set of concepts. However, cognitive-behavioural theories of hypnosis have been discussed in the research literature for many decades prior to the development of modern cognitive or behavioural therapy.

Hypnotic Skills Training

Many hypnotherapists dismiss the state versus nonstate as irrelevant to practice. This is wrong, and betrays a basic misunderstanding of the issues at stake. In fact, the cognitive-behavioural theory of hypnosis has led to the gradual development, mainly in the 1980s, of hypnotic skills training programmes designed to increase the hypnotic responsiveness of subjects as measured by validated psychometric scales. One of the earliest expressions of the social psychology position is found in the personality psychologist Robert White’s ‘A preface to the theory of hypnotism’ published in 1941. White writes,

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 and understood by the client. (White, 1941)

In other words, the hypnotic subject is not a passive recipient of hypnosis but has a specific role to fulfil, which they may do well or badly. As White puts it, good hypnotic subjects generally make substantial “spontaneous additions” to the hypnotic process by the way they behave, the things they tell themselves, and what they imagine, as the hypnotists speaks to them. In reality, there are two hypnotic processes occurring in parallel, the suggestions coming from the hypnotist (hetero-hypnosis) and the internal dialogue and stream of consciousness of the subject (self-hypnosis). The role of the subject is to develop an internal state that complements the suggestions of the hypnotists, but this state will vary depending upon the goals of suggestions and is mediated by a range of different “subjective strategies.” Skills training can help the subject both to understand and fulfil this role.

It is now firmly established, that special programmes of cognitive-behavioural skills training can successful enhance hypnotic responses. The most important approach is known as the Carleton Skills Training Programme (CSTP) and its effects have been independently confirmed by many different psychology departments at leading universities.

Cognitive Disputation & Restructuring

Contrary to popular misconception, psychotherapists have made use of “rational” methods of therapeutic “persuasion” and “Socratic” disputation, since the late Victorian era. For instance, the Swiss psychotherapist Paul DuBois (1848-1918) was world-renowned for his persuasive psychotherapeutics, which attempted to identify harmful patterns of thinking and correct them. DuBois’ school of psychotherapy, which rivalled that of Freudian psychoanalysis, had considerable influence upon early 20^th century hypnotherapy.

Modern cognitive therapy, following Ellis and Beck, focuses upon the use of structured techniques to identify negative cognitions and systematically dispute them. This process is known as “cognitive restructuring.” A variety of techniques, such as self-monitoring of thoughts, are used to help identify negative cognitions. Most simply, a client is often asked “What were you telling yourself when you experienced those negative feelings?”

CBT has specifically catalogued common “thinking errors” or “cognitive distortions” which are used to help clients identify flaws in their thinking patterns. These range from “over-generalisation” to “jumping to conclusions”, etc. Therapists also help clients to challenge their negative beliefs by asking “Socratic questions”, designed to help the client re-evaluate things. There are many examples, the simplest and most common being “What evidence do you have for that belief?”

These specific techniques are central to CBT, though perhaps not essential. They are also important to cognitive-behavioural hypnotherapy. However, hypnotherapy session time is limited and rational disputation is not particularly well-suited to being done in hypnosis itself. Hence, direct verbal disputation is often more abbreviated in cognitive-behavioural hypnotherapy and may take place at the start of the session. However, modern cognitive therapy, especially the work of Aaron Beck’s daughter Judith, also makes considerable use of special mental imagery techniques, designed to encourage cognitive restructuring, which are particularly well-suited to use in hypnosis.

Self-Efficacy Beliefs (Bandura)

In the 1970s, Albert Bandura introduced the influential theory that therapeutic outcomes are primarily determined by client’s “self-efficacy” beliefs, their belief in their own ability to control their environment, similar to the older behavioural notion of a “sense of mastery.”

To some extent, the role of cognition in mediating responses, especially in relation to anxiety disorders, may be simplified as being the result of relevant self-efficacy beliefs. Fundamentally, if a client believes that they can cope successfully with the situation that they face they are unlikely to continue to feel anxious. Many problems can be helped by focusing on the use of autosuggestions based upon this theme, i.e., “I can do it”, “I can deal with this”, etc. As the Roman poet Virgil famously wrote, “They can because they believe they can.”

The generic value of suggestions of self-efficacy recalls the method of “ego-strengthening” popular in traditional hypnotherapy. Earlier, in 1960, the medical hypnotist John Hartland had published an influential article claiming that by ego-strengthening suggestions alone he was able to help 70% of his clients recover from a wide range of different problems. Ego-strengthening and self-efficacy suggestions may therefore be seen as playing a central part in most cognitive-behavioural hypnotherapy.

Ellis’ ABC Model (REBT)

Albert Ellis developed a simplified description of the cognitive mediation model which is popular in modern CBT, mainly because it is meant to be easy to explain to clients. Ellis has produced more complex versions, however, his basic ABC model is as follows,

A: Activating Event

E.g., someone shouts at me at work.

Some situation or event triggers a reaction in the client.

B: Beliefs (Rational or Irrational)

E.g., “They think I’m a complete nobody.”

The client’s beliefs combine with the activating event to create their experience, transforming the meaning of things.

C: Consequences (Emotional, behavioural, cognitive and physiological)

E.g., feelings of rage and depression.

The combination of events and the client’s beliefs about them brings about an emotional response, and also changes in behaviour, cognition and physiological reaction.

As Ellis puts it, most clients feel as though events cause their suffering (as if “A causes C”). The primary task of the therapist is to help the client to perceive how their own thinking intervenes to influence their reactions (thus “A plus B causes C”). This can be seen as basically a modified version of the behavioural “stimulus-response” model, which introduces the intervening variable of cognition, i.e., stimulus-cognition-response.

The Hypno-CBT^® model rejects the causal assumptions implicit in Ellis’ ABC model but does accept that it can serve as a simplified explanation for clients. For instance, it might be argued that in many instances cognitions constitute part of the emotional responses in question rather than causing them to happen. The practical implications of this distinction are beyond the scope of this article, however.

Hypnotic Desensitisation

Wolpe’s technique of systematic desensitisation was the central method of behaviour therapy. More research has been conducted on systematic desensitisation than any other psychotherapy method and it has consistently been supported as one of the most efficacious therapies for phobias, and a range of other anxiety-related disorders.

However, many hypnotherapists may be unaware that Wolpe and his colleagues originally referred to “hypnotic desensitisation” in the 1950s because their method used Lewis Wolberg’s well-known arm-levitation induction as a means of relaxing the client. Wolpe himself gradually abandoned the use of hypnotic inductions but many other researchers continued to modify his approach and incorporate changes such as self-talk and mental imagery which are even more compatible with traditional hypnotherapy. Other researchers, such as Rubin, therefore found that a more sophisticated combination of systematic desensitisation and hypnotherapy could produce even more rapid and effective improvements than the orthodox behaviour therapy approach advocated by Wolpe.

Multimodal Therapy (ABC)

Arnold Lazarus, Wolpe’s research assistant, broke away from orthodox behaviour therapy in the 1960s and began to develop what has now been termed Multimodal Therapy (MMT). Lazarus helped pave the way for modern CBT by integrating elements of Ellis’ rational therapy with Wolpe’s approach and incorporating more elements of hypnosis and mental imagery. Lazarus based his approach on a philosophy of “technical eclecticism” which held that techniques should be chosen primarily on the basis of research evidence supporting their efficacy, rather than on the basis of theoretical assumptions.

We have modified Lazarus’ multimodal approach to form the basis of our own three-dimensional (ABC) model of cognitive-behavioural hypnotherapy. Clients are assessed in terms of three primary dimensions which are addressed in treatment. This model can be easily adapted to a wide range of situations. Most notably, the combination of this multi-modal approach and hypnotic desensitisation leads to a form of mental rehearsal (or “imaginal exposure”) treatment which combines elements of hypnotherapy, behaviour therapy, and cognitive restructuring as follows,

A: Affect

Client’s physical and emotional responses to a problem.

E.g., anxiety which may be addressed by rehearsing physical relaxation and emotional calm during hypnotic desensitisation.

B: Behaviour

Client’s body language, speech and behaviour associated with the problem.

E.g., avoidance or aggression, addressed by rehearsing positive and assertive behaviour during hypnotic visualisation of coping skills.

C: Cognition

Client’s pattern of thinking and beliefs linked to the problem.

E.g., negative self-talk, cognitive distortions, false assumptions, etc., addressed by rehearsing positive autosuggestions during hypnosis.

Different presenting problems naturally require that different emphasis is given to each dimension, or that they are tackled in a different sequence. However, this generic framework provides a model for treating any problem using any intervention in cognitive-behavioural hypnotherapy.

Cognitive Mood Induction

One of the simplest techniques of cognitive-behavioural hypnotherapy helps to illustrate its basic concepts very well. The technique of “mood induction” asks the client to deliberately experiment with negative and positive cognitions to experience their effect upon mood. For example, once a negative autosuggestion has been identified such as “Nobody will ever love me”, the client is asked to close their eyes and try repeating this a few times while imagining that they believe it 100%, at an emotional level. This is always followed by positive mood induction, where the client is asked to do the same with a positive autosuggestion chosen by them to counteract the effect, e.g., “I love myself for who I am, whatever others think.”

This can be used during the preparation of the client for formal hypnotherapy work or self-hypnosis training. It should form the basis for discussion of how suggestions work, and the specific autosuggestions which help or harm the client most.

This is similar to Ellis’ main visual imagery technique from REBT, known as “rational-emotive imagery” (REI). Many variations of REI exist, but it is common for a client to be asked to close their eyes, picture themselves in a situation (Activating Event) and make themselves feel their negative response (Consequence) in order to identify the internal cues (irrational Beliefs) which cause the problem. After discussing this with the therapist, the client is then asked to practice changing the negative response into a positive one, and afterwards to discuss with the therapist what things (e.g., rational Beliefs) helped them to achieve this improvement. This is a tremendous aid in identifying suggestions and images which can be used more systematically in hypnotherapy or structured self-hypnosis.

Insofar as these approaches involve repeatedly evoking negative responses they resemble the method of “negative practice” developed in the 1930s by the psychologist Knight Dunlap. Variations of Dunlap’s method constitute part of the armamentarium of CBH. Likewise, similar techniques can be used to raise self-awareness in a way that resembles the awareness experiments of Gestalt psychotherapy or the techniques of modern Mindfulness-based CBT, both of which are influences on our Hypno-CBT^® approach.

Concluding Remarks

This brief overview of cognitive-behavioural hypnotherapy has attempted to introduce the reader to its historical rationale and relationship with CBT, and to illustrate some characteristic therapy techniques. I strongly recommend the reader to explore the subject in more detail by reference to the discussions of cognitive-behavioural hypnotherapy found in modern research journals and in such introductory textbooks as Golden, Dowd & Friedberg’s Hypnotherapy: A Modern Approach (1987).

Cognitive-Behavioural Hypnotherapy:
Rubin’s Hypnotic Reciprocal Inhibition

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

Identify Target. No hierarchy is constructed. Exposure begins with the most feared aspect of the problem, if possible.
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.
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.)
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.”
Identify Positive Reinforcement. Possible pleasant aspects of the phobic scenes are identified in detail, presumably for both reciprocal inhibition and positive reinforcement.
Induce Hypnotic Relaxation. The subject is hypnotised and asked to relax as deeply as possible.
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.
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.
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.
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.
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.
Repeat Graded Exposure. Where the client successfully remains relaxed the process can be repeated for more challenging scenes.
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.

Notes on Pavlov & Hypnotic Sleep Therapy

That the state of relaxation induced in human hypnosis resembles the physiological phenomenon of “animal hypnosis” and results from intense fatigue or inhibition of specific cells in the cerebral cortex (“cortical inhibition”) irradiating to other parts of the brain.
That hypnotic suggestions function by using words as stimuli to evoke conditioned responses which are intensified in nature because the general inhibition of the cortex leaves individual “rapport zones”, i.e., residual centres of attention and excitation in which conditioned reflex responses to words become greatly enhanced.

In refreshing contrast to the subsequent technical debate stemming from such theories, Pavlov himself opens his discussion of conditioning and hypnotherapy in terms which appeal to common sense observations from daily life.

It is obvious that the different kinds of habits based on training, education and discipline of any sort are nothing but a long chain of conditioned reflexes. We all know how associations, once established and acquired between definite stimuli and our responses, are persistently and, so to speak, automatically reproduced, sometimes even although we fight against them. For instance, in the case of games and various acts of skill, it is as difficult to abolish all sorts of superfluous movements as to acquire the necessary movements and it is equally difficult to overcome established negative reflexes, i.e., inhibitions. Again, experience has taught us that a difficult task should be approached by gradual stages. We know also how different extra stimuli inhibit and discoordinate a well-established routine of activity, and how a change in a pre-established order dislocates and renders difficult our movements, activities and the whole routine of life. Again, we know how weak and monotonous stimuli render us languid and drowsy, and very often lead to sleep. We are also well acquainted with different cases of partial alertness in the case of normal sleep, for example a sleeping mother next to her sick child. All these [human] phenomena are analogous to those constantly met with in our animals and described in the preceding lectures […] (Pavlov, 1927, Lecture 23).

The method of inducing hypnosis in man involves conditions entirely analogous to those which produced it in our dogs. The classical method consisted in the performance of so-called [Mesmeric] “passes” – weak, monotonously repeated tactile and visual stimuli, just as in our experiments upon animals. At present the more usual method consist in the repetition of some form of words, describing sleep, articulated in a flat and monotonous tone of voice [i.e., direct verbal suggestions of relaxation and sleep]. Such words are, of course, conditioned stimuli which have become associated with the state of sleep. In this manner any stimulus which has coincided several times with the development of sleep can now by itself initiate sleep or a hypnotic state. […] Most of the procedures producing hypnosis become more and more effective the more frequently they are repeated. (Pavlov, 1927, Lecture 23)

Obviously we deal with a certain degree of inhibition of some parts of the cortex – a state in which the more complicated forms of normal activity are excluded and replaced by responsiveness to immediate stimuli. This partial inhibition allows of or even favours the establishment and reinforcement of the physiological connections between certain stimuli and certain activities, e.g., movements. In this manner, in hypnosis all activities based on “imitation” are accentuated and we see revealed the long-submerged reflex which in all of us in childhood forms and develops the complicated individual and social behaviour. (Pavlov, 1927, Lecture 23)

Pavlov conceived of hypnotic suggestion as a complex example of a conditioned reflex, fundamental to human nature,

Among the various aspects of the hypnotic state in man attention may be drawn to “suggestion” so-called and its physiological interpretation. Obviously for man speech provides conditioned stimuli which are just as real as any other stimuli. At the same time speech provides stimuli which exceed in richness and many-sidedness any of the others, allowing comparison neither qualitatively nor quantitatively with any conditioned stimuli which are possible in animals. Speech, on account of the whole preceding life of the adult, is connected up with all the internal and external stimuli which can reach the cortex, signalling all of them and replacing all of them, and therefore it can call forth all those reactions of the organism which are normally determined by the actual stimuli themselves. We can, therefore, regard “suggestion” as the most simple form of a typical conditioned reflex in man. The command of the hypnotist, in correspondence with the general law, concentrates the excitation in the cortex of the subject (which is in a condition of partial inhibition) in some definite narrow region, at the same time intensifying (by negative induction) the inhibition in the rest of the cortex and so abolishing all competing effects of contemporary stimuli and of traces left by previously received ones. This accounts for the large and practically insurmountable influence of suggestion as a stimulus during hypnosis as well as shortly after it. The command retains its effect after the termination of hypnosis, remaining independent of other stimuli, being impermeable to them, since at the time of primary introduction of the stimulus into the cortex it was prevented from establishing any connection with the rest of the cortex. The great number of stimuli which speech can replace explains the fact that we can suggest to a hypnotized subject so many different activities, and influence and direct the activities of his brain. (Pavlov, 1927, Lecture 23)

It could be questioned why does suggestion carry in itself such a commanding influence as compared with dreams, which are usually forgotten and only have a very small vital significance? But dreams are due to traces, generally of very old stimuli, while suggestion is a powerful and immediate stimulus. Moreover, hypnosis depends upon a smaller intensity of inhibition than sleep. Suggestion, therefore, is doubly effective. Still further, suggestion as a stimulus is brief, isolated and complete, and therefore vigorous, while dreams are generally linked up into chains of various, sometimes inconsistent or antagonistic, traces of stimuli. (Pavlov, 1927, Lecture 23)

Soviet Hypnotherapy (Platonov)

We have always used long-continued suggested sleep as an auxiliary therapeutic method. It is usually employed in more or less grave conditions as a concluding method after a course of psychotherapy and serves the purpose of restoring the function of the cortical cells and consolidating the therapeutic effect obtained.

Even short suggested sleep not infrequently exerts a positive influence on the patient’s nervous system. This is indicated by very numerous observations of many authors, as well as our own and those of our associates. In a number of cases even a state of light suggested sleep produces a certain therapeutic effect of itself, without any special suggestions. Thus, upon awakening from the very first suggested sleep some of our patients frequently report the disappearance of pain or unpleasant sensations. (Platonov, 1959: 234)

Sleep induced by suggestion often seems considerably more restful and recuperative than normal, nocturnal sleep. Platonov cites research by Petrova, one of Pavlov’s research team, supporting this observation experimentally (Platonov, 1959: 234). Platonov applied this method to the prevention of hypertension, treatment of ulcers, and other physical conditions, but also in the treatment of neuroses. However, Platonov also found physiological evidence that the recuperative function of hypnosis was significantly deepened when explicit suggestions of a “state of absolute rest”, e.g., were used instead of the normal procedure, merely suggesting that the subject was “sleeping deeper”, etc. (Platonov, 1959: 77-78).

These studies have led us to the recognition of the extraordinarily great importance of a special physiological state of deep rest specially created by verbal suggestion.

It must be especially emphasised that natural sleep does not always put all the organs and systems of man into a state of complete rest. […] It is precisely for this reason that it is necessary to exert special influence on the subject’s cerebral cortex by a verbal suggestion that his organism “is in a state of complete rest” during which “all of the experienced emotions have been fully eliminated,” while his brain and all organs and tissues are rapidly regaining their functions. Thus the first step in the verbal suggestion [“sleep”, “sleep deeper”, etc.] puts the person from his usual waking state into a state of suggested sleep, while the second step in the suggestion [“rest completely”] creates special conditions for deep rest during this suggested sleep. (Platonov, 1959: 78).

He goes so far as to claim that this special method succeeds by inducing “a maximal activation of the restorative function of the cerebral cortex.” (1959: 235, his italics).

Experience has shown that one hour of this state, in most cases, provided maximum rest for the entire organism. This prolonged state of suggested deep rest is extraordinarily beneficial not only to the cortical dynamics and the entire higher nervous activity as a whole, but also to the functional state of all tissues and organs and the entire vegetative and endocrine system. (Platonov, 1959: 79).

“When I am in a state of hypnosis,” writes a woman patient, “I experience different sensations at each session. Thus during the first session I continued to feel my entire body but was unable to move a single member and though I clearly heard the voice of the hypnotist and was conscious of everything my thoughts were in a sort of muddle. This was what I should call bodily sleep. At each successive session my body grew increasingly heavier, I no longer felt it, though I continued to hear all that was going on and it seemed to me it was all happening somewhere far away, I was not quite conscious of it, and it was all absolutely immaterial to me.

“During the last, fifth, session I no longer felt my body at all, as if I had none. Nor could I think of anything. I had no thoughts at all. I heard various external sounds which did not concern me in the least. During suggestions I heard everything clearly, but my mind failed to work, and the words of suggestion relating to my former experiences in no way affected me.

“At the words of awakening, I begin to awaken at first from the head, as it were: thoughts rise in my mind, I begin to think about how to move, to get up; I understand everything that takes place around me, but begin to feel my body somewhat later; as my consciousness clear up, I begin to feel a heaviness throughout my body, which subsequently dissipates upon complete awakening.” (Platonov, 1959: 73)

At a time when psychoanalysis was struggling to achieve success with roughly two-thirds of patients despite taking many hundreds of sessions, Platonov and his colleagues reported 78% success rates in just 5-6 sessions by using Pavlovian hypnotherapy with tens of thousands of patients presenting with a variety of psychiatric and general medical conditions in Soviet polyclinics and hospitals.

The Conditioning & Inhibition Theory of Hypnosis

As the psychologist Kurt Lewin famously remarked: “Nothing is as practical as a good theory.” That phrase came to mind when reading Alfred Barrios’ recent series of articles which concisely and systematically outline a relatively simple “conditioning and inhibition” theory of hypnosis (Barrios, 2001), which recently led to an exchange with Steven Jay Lynn relating to the similarities and differences between Barrios’ theory and the influential “socio-cognitive” theory of hypnosis.

Barrios’ theory ultimately derives, I think, from the “cortical inhibition” theory of hypnosis which crowned Pavlov’s physiological research on animals at the turn of last century – a theory further developed by Platonov and other Soviet hypnotherapists. Anyway, Barrios does an admirable job of carefully spelling out his modern variation, with intermittent references to supporting research data. In a nutshell, Barrios draws on a revised form of conditioning theory to describe hypnosis as a method for reinforcing the subject’s tendency to progressively fade out (“inhibit”) intrusive thoughts and sensations in a way that heightens their sensitivity to learned associations between words, such as hypnotic suggestions, and physiological responses such as emotions. From this point of view, words, such as verbal suggestions, function as stimuli which in turn evoke “cognitive stimuli” (ideas and images) in a way that triggers hypnotic responses. Barrios’ use of behavioural learning theory obviously has the potential to highlight certain overlaps between the theory and practice of hypnosis and behaviour therapy.

Barrios’ theory consists of the following seven hypotheses, divided into three groups,

A. Hypnotic induction

1. “Hypnotic induction is a conditioning process.”

2. “The response conditioned during hypnotic induction is an inhibitory set, a set which tends to inhibit stimuli incompatible with the response suggested by the hypnotist.”

3. “A positive response to a suggestion will induce within the responding person a more or less generalised increase in the normally existent tendency to respond to succeeding suggestions.”

B. Explanation of hypnotic phenomena

4. “A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that process.”

5. “The inhibitory set facilitates the suggested response by inhibiting stimuli competing with the cognitive stimulus.”

C. Post-hypnotic suggestion

6. “Suggestion leads to behaviour change by a form of higher-order conditioning called C-C [cognitive-cognitive] conditioning.”

7. “Hypnosis facilitates the C-C conditioning produced by suggestion.”

Barrios published two subsequent articles, the first of which explores the relationship between his “conditioning and inhibition” theory and four other modern theories of hypnosis: sociocognitive theory (Spanos/Lynn), Neo-dissociation (Hilgard), response expectancy (Kirsch), and Milton Erickson’s approach (Barrios, 2007). The second reviews the possible benefits and applications of the theory to understanding phenomena such as the placebo effect, improving the effectiveness of hypnotic induction, improving post-hypnotic suggestions, and the development of Barrios’ therapeutic technique called Self-Programmed Control (Barrios, 2007b).

Comparison Between Theories

In the current edition of Contemporary Hypnosis, Steven Jay Lynn and Sean O’Hagen have responded in some detail to Barrios’ comparison between the conditioning and inhibition and sociocognitive theories of hypnosis.

Sociocognitive theories reject the traditional view that hypnotic experiences require the presence of an altered state of consciousness. Rather, the same social and cognitive variables that determine mundane complex social behaviours are said to determine hypnotic responses and experiences. (Lynn & O’Hagan, 2009)

They praise Barrios for providing a systematic and comprehensive account of his theory and its practical implications. Indeed, contrary to Barrios’, they conclude that his theory is itself one of several falling under the broad “sociocognitive” umbrella term. However, while endorsing some of his points, they disagree with others, citing several research studies in support of their own position. In particular,

Barrios emphasises the power of hypnotist prestige but sociocognitive researchers have generally found the qualities of the hypnotist to be of less importance than the qualities of the subject, e.g., their level of motivation, expectations, and imaginative capacity.
Following Spanos, Barrios emphasises the power of “goal directed fantasies”, or mental imagery, in evoking hypnotic responses but, according to Lynn, research has failed to show that imagery alone can account for hypnotic responses without the aid of factors such as motivation and expectation.
Barrios, like many hypnotists, naturally assumes that hypnotic suggestions are more effective when presented in order of difficulty, giving the subject an increasing confidence in their ability to respond. However, Lynn cites evidence from experimental studies showing that this is not the case and subjects respond just as well when suggestions are given in descending order of difficulty.
They do, however, find support for Barrios’ contention that subjects increase in responsiveness to genuine suggestion tests after first being duped into believing they are hypnotised, e.g., by surreptitiously playing quiet music in the background while suggesting that they will hallucinate the sound of music, etc.
They raise doubts over Barrios’ claim that some induction techniques induce hypnosis more “deeply” than others. Research has consistently failed to demonstrate much difference between different induction techniques.
Moreover, the increase in suggestibility following hypnotic induction techniques is around 20% on average, which seems to show that the presence of a hypnotic state (“trance”), even if such a thing did exist, would be far less important to hypnotism than other factors such as the personality of the subject, their attitudes, and the type of suggestions given.

It’s truly fascinating to observe these debates between researchers from different theoretical traditions because they highlight the pros and cons of their respective points of view. This is research in action; the competition between contrasting hypotheses, appealing to their respective supporting evidence. It’s through this kind of dialogue that genuine progress is achieved in hypnotic research and we work our way gradually closer to an accurate and comprehensive theory of hypnosis and hypnotherapy.

Bibliography

Barrios, A. A. (2001). A Theory of Hypnosis based on Principles of Conditioning & Inhibition. Contemporary Hypnosis , 18 (4), 163-203.

Barrios, A. A. (2007). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part I: Contrasts with Other Perspectives & Supporting Evidence. Contemporary Hypnosis , 24 (3), 109-122.

Barrios, A. A. (2007b). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part II: Benefits of the Theory. Contemporary Hypnosis , 24 (3), 123-138.

Lynn, S. J., & O’Hagan, S. (2009). The Sociocognitive and Conditioning and Inhibition Theories of Hypnosis. Contemporary Hypnosis , 26 (2), 121-125.

Persuasion & Re-education Hypnotherapy (Wolberg)

In his Medical Hypnosis (1948), Lewis Wolberg, one of the most influential psychotherapists of his day, discussed three main categories of psychotherapy: symptom removal, re-education, and psychoanalysis. Wolberg refers to re-education under the broad heading of “psychobiologic” therapy, meaning “mind-body” therapy (or what Braid termed “psycho-physiology”). Wolberg defines this approach as follows.

Psychobiologic therapy is the name given to a variety of technics, chief among which are guidance, reassurance, persuasion, desensitisation, re-education and reconditioning. […] Psychobiologic therapy is a far more rational form of treatment than simple symptom removal by prestige [authoritarian] suggestion. (Wolberg, 1948b: 135)

The re-educational approach attempts to identify the client’s individual character traits, his strengths and weaknesses, and to organise his philosophy of life to take account of them. Wolberg refers to this as an “education in living” consisting in teaching the client “practical ways of overcoming his personality liabilities and of enhancing his assets.” (Wolberg, 1948b: 138).

Hypnosis is remarkably effective as a catalyst to the various technics used in psychobiologic therapy. Guidance, reassurance, persuasion, desensitisation, re-education and reconditioning gain reinforcement with its use. […] An increased faith in the therapist caused the patient to respond more forcefully to persuasive and re-educational influences. In addition, the hypnotic experience has the unique quality of convincing the patient that something definite and important is being done for him immediately. (Wolberg, 1948b: 142)

The components of Wolberg’s psychobiologic therapy therefore consist of the following methods,

Guidance consists in giving the client direct advice on how to manage their life. Wolberg notes that this approach is more relevant to more disturbed clients. Guidance can take the form of recommending hobbies to the client as a means of encouraging social and extraverted activities.
Reassurance consists in removing client’s fears, common examples being the fear of insanity or illness, and sexual fears that may be simply unfounded. Verbal reassurance therefore often includes the correction of basic misconceptions.
Persuasion consists in directly motivating the client to adopt a more healthy and rational philosophy of living.
Desensitisation, in Wolberg’s terminology, consists in releasing negative emotions from unconscious conflicts by venting or catharsis.
Re-education resembles persuasion but places greater emphasis upon acquiring a rational understanding of one’s own personality dynamics.
Reconditioning employs behavioural learning theory to condition new habitual feelings and behaviours, and includes the use of techniques pre-emptive of Wolpe’s behaviour therapy.

Although Wolberg’s “reconditioning” approach was based on behavioural psychology and pre-empted Wolpe’s systematic desensitisation in many respects, his own use of the term “desensitisation” often referred to venting or abreaction of repressed emotions under hypnosis. I have discussed Wolberg’s use of behavioural psychology and hypnotic desensitisation in more detail elsewhere. We will turn instead to a consideration of his “persuasion” and “re-education” methods which prefigure modern cognitive therapy in a number of respects.

The “Persuasion” Approach in Hypnotherapy

Wolberg describes “persuasion” in hypnotherapy as a general “orientation” of the client to rational living.

Persuasion is based upon the belief that the patient has within himself the power to modify his pathologic emotional processes by force of sheer will, or by utilisation of common sense. In persuasive therapy, appeals are made to the patient’s reason and intelligence, in order to convince him to abandon neurotic aims and symptoms, and to help him gain self-respect. He is enlightened as to the false nature of his own concept regarding his illness, as well as the bad mental habits he has formed, and by presenting him with all the facts in his case, he is shown that there is no reason for him to be ill. He is urged to ignore his symptoms by adopting a stoical attitude, by cultivating a new philosophy of life aimed at facing his weaknesses, and by adopting an attitude of self tolerance. An attempt is made to bring the individual into harmony with his environment, and to get him to think of the welfare of others as well as himself. (Wolberg, 1948b: 172)

He attributes this approach to Paul Dubois,

The use of persuasion was first advocated by Paul DuBois of Switzerland who held conversations with his patients and taught them a philosophy of life whereby they substituted in their minds thoughts of health for their customary preoccupations with disease and suffering. Much of the success that DuBois achieved by his persuasive methods was due to his own vigorous personality which exuded confidence and cheer. (Wolberg, 1948b: 173)

Wolberg emphasises the importance of a good rapport between client and therapist, therefore.

DuBois recommended prolonged discussions during which it was necessary to convince the patient of his errors in reasoning. He had to be shown that his symptoms were the product of emotional stress. Though annoying, they were not serious in themselves. The less one concentrated on symptoms, the less disturbing these would become. If the heart palpitated, let it pound; if the intestines were active, let them grumble. If one had insomnia, he had best say: “If I sleep, all the better; if I don’t sleep, no matter.” Undue attention aggravated the difficulty. The best way to overcome symptoms was to stop thinking about them. Fatigue, tension and fear were all exaggerated by attention. (Wolberg, 1948b : 174)

Clients are encouraged in this approach to stop dwelling on their symptoms and focus instead on the idea of improvement, to seek out evidence of their progress and monitor it closely.

One of the most important elements in therapy was to question the patient about his conceptions of life and his philosophy. False views were to be criticised, and those viewpoints that were logical and helpful were to be encouraged. The physician had to make an effort also to discover in the patient qualities of superiority that would elevate him in his opinion [i.e., positive qualities and strengths that would raise his self-esteem]. It might even be necessary to teach him to make an optimistic inventory of his good qualities. (Wolberg, 1948b: 175)

Wolberg claims that in the late 1940s “persuasive” psychotherapy methods in general still drew heavily on the earlier work of DuBois and his successor Dejerine. All these approaches motivate clients to adopt a consistently more healthy and rational philosophy of life, and to face up to their practical problems, or learn to accept those (such as certain illnesses) that they cannot physically change (1948b: 176). As Wolberg notes, of course, the therapist cannot force the client to adopt a philosophy of life which clashes too much with their existing traits, so care must be taken to tailor persuasion to the client’s personality type.

Wolberg further sub-divides persuasion psychotherapy methods into the following categories which include re-appraisal of one’s goals in life, psycho-education about the stress response, problem-solving training, thought-substitution, relaxation training, and training in acceptance of one’s situation, similar to the Serenity Prayer.

1. Redirection of goals.

The client is encouraged to consider his goals in life and whether he is pursuing materialistic goals (wealth), egotistic goals (fame), or a more philosophical ideal of personal happiness and well-being. Many people benefit from a re-evaluation of their fundamental goals in life and improvement often consists in sacrificing some more superficial goals for the sake of investing more time and energy in the pursuit of genuine serenity or happiness.

One can attain happiness and health by learning to live life as it should be lived, by taking the good with the bad, the moments of joy with the episodes of pain. One must expect hard knocks from life and learn to steel himself against them. It is always best to avoid foreboding and anticipations of what might happen in the future. Rather one should aim for a freer, more spontaneous life in the present. He should take advantage of the experiences of the moment, and live for every bit of joy he can get out of each day. The place to enjoy life is here; the time is now. By being happy oneself, one can also make others happy. (Wolberg, 1948b: 178)

It is particularly important to challenge feelings of hopelessness which prevent constructive action from being taken to pursue legitimate goals in life.

Wolberg doesn’t mention this, but it makes sense in this regard to ask clients to calculate how much time they actually dedicate toward their highest priorities in life each week, and how much is spent on more trivial activities or diversions. An action plan can be drawn up for the pursuit of primary goals and steps taken to ensure that the client makes progress in this area. The therapist may also wish to help the client evaluate their goals by thinking through the consequences of adopting different priorities in life.

2. Overcoming physical suffering and disease.

The client should be educated to understand the powerful effect that the mind has over the body and physical health.

The patient, if he is suffering from ailments of a physical nature, may be told that physical symptoms are very frequently caused by emotional distress. Studies have shown that painful thoughts can affect the entire body through the autonomic nervous system. For instance, if we observe an individual’s intestines by means of a fluoroscope, we can see that when the person thinks of fearful or painful thoughts, the stomach and intestines contract, interfering with digestion. On the other hand, peaceful happy thoughts produce a relaxation of the intestines and a restoration of peristaltic movements, thus facilitating digestion. The same holds true for other organs. Understanding the powerful effect that mind has over body is important, for it lends scientific proof to the fact that physical suffering can be mastered by a change in attitudes. (Wolberg, 1948b: 179)

Many illnesses are caused by bad habits of thinking and negative emotions. The true cause of physical illness must be identified and addressed. Where the client suffers from a genuine organic illness, they must learn to accept the limitations of their situation as peacefully as possible, without adding additional worry or distress. Where the illness is due to worry or tension, this should be emphasised and corrected. The patient is persuaded not to dwell morbidly on their bodily problems, but to engage in positive activities and hobbies which divert their attention from themselves in a healthy manner.

3. Overcoming the “worry habit.” (Problem-solving)

Clients are taught to see worry as a futile expense of energy, the opposite of constructive planning behaviour.

Patients who are obsessed with worrying about themselves may be urged to remember that worry is a state of tension in which energy is spent ruminating about one’s problems and fears, instead of doing something positive about their solution. Worry tends to magnify the importance of petty difficulties, and usually paralyses initiative. The worrier’s thoughts are constantly preoccupied with ideas of fear, dread and morbid unpleasantness. These thought shave a disastrous effect on the motor system, the glands and the organs. (Wolberg, 198b: 181)

Instead, Wolberg asked clients to clearly formulate their chief problem, setting aside morbid feelings while evaluating it from a more rational perspective. The client is persuaded to think things through carefully, logically and objectively. In a manner very reminiscent of problem-solving approaches in CBT, Wolberg instructs clients first to adopt this calm, rational orientation to the problem, before taking the following steps.

It is necessary to review all possible solutions for the problem at hand. Next, the best solution is chosen even though this may seem inadequate in coping with all aspects of the problem. A plan of action must then be decided on. It is then necessary to proceed with this plan of action immediately, and to abandon all worry until the plan is carried out as completely as possible. Above all the person must stick to his plan of action, even if he finds it distasteful.

If the person himself cannot formulate a plan, the physician may help him to do so. The patient should be told that it is better to concern himself with a constructive plan than to get tangled up in the hopelessness of an apparently insoluble problem. Until he can work out something better, it is best to adjust himself to the present situation, striving always to externalise his energy in a constructive way. (Wolberg, 1948b: 182)

While working on his plan, the client should make a deliberate effort to exclude worrying thoughts and to avoid unnecessary discussion of distressing subjects with others, i.e., to minimise “moaning”, “complaining”, “whinging”, and other morbid patterns of speech and behaviour. He is motivated to focus all of his energy away from worry and on to the solution he is testing out in practice.

4. “Thought control” and “emotion control.”

Through dedicated practice, clients can learn to reduce worrying thoughts and replace them with thoughts of health and confidence.

Emancipation from tension and fear can come by training one’s mind to think joyous and peaceful thoughts. But new thought habits do not come immediately. One must show persistence and be steadfast in his application. One must never permit himself to be discouraged. He must practice, more and more. Only through persistent practice can perfection be obtained, so that the mind shuts out painful thoughts automatically. (Wolberg, 1948b: 184)

However, as Wolberg emphasises, mere “willpower” is not the answer, as negative thoughts must be counter-acted by habitually cultivating contrary positive thoughts and images. Wolberg, like Assen Alladin, recommends frequently thinking of happy memories in order to make these more habitual, and thereby counter-act negative thoughts.

It is not necessary to force oneself to stop worrying or to force oneself to stop feeling pain, or anxiety, or tension. Will power used this way will not crowd out the painful emotions. One must substitute different thoughts or appropriate actions. If he starts feeling unhappy or depressed, he should immediately raise his head and determine to rise above this emotion. He should talk cheerfully to others, try to do someone a good turn or he may lie down for a short while, relax his body and then practice thinking about something peaceful and pleasant. As soon as this occurs, unhappy thought swill be crowded out, and the entire body will respond. A good practice is to think of a period in one’s life when one was happiest. This may be in the immediate past or during childhood. One may think of people he knew, the pleasant times he had with them. This substation of pleasant for unpleasant thoughts may take several weeks before a new thinking habit results. (Wolberg, 1948b: 184-185)

This process seems to perhaps be influenced by James Alexander’s earlier method of “thought control” although Wolberg does not reference any particular source.

5. Correcting tension and fear.

Wolberg emphasises that clients should come to see tension and anxiety as originating from their own disposition rather than from external events. Adopting a more detached attitude or learning to laugh at one’s fears can be a powerful remedy. However, Wolberg also recommends specific relaxation skills training methods.

Practising relaxation may be very helpful. Each day a person may lie on his back, on the floor, or on a hard surface for twenty minutes, consciously loosening up every muscle from his forehead to his feet, even his fingers and toes. He may then start breathing deeply, with slow, deep exhalations through pursed lips. At the same time he may think of a peaceful scene at the mountains or seashore. Mental and muscular relaxation are of tremendous aid in overcoming states of tension. In spite of his fears, he should continue his work and not yield to his irrational emotions. (Wolberg, 1948b: 186)

6. Facing adversity.

Wolberg means by this that clients should be counselled in adopting an accepting attitude, an attitude of resignation, toward unavoidable problems. Clients should be discouraged from exaggerating their difficulties by comparing their situation in life rationally, with others who cope well despite more hardship. Again, Wolberg’s advice here very much resembles Stoic philosophy, “The sign of character is to change those conditions that can be remedied and to accept those that cannot be changed.” (Wolberg, 1948b: 188).

There are always, of course, situations one must accept. Facts must be faced. If one cannot change things as they are, he can change his own attitude so that he will not overreact to his difficulties. As soon as a person has decided to make the best of things, his condition will improve immediately. Progress will be made in changing oneself. One must accept some difficulties that life imposes on him without struggling or rebelling. (Wolberg, 1948b: 188)

Wolberg recommends the use of a list drawn up between sessions, again a strategy resembling cognitive therapy,

Keeping two lists, on one side the things that have troubled him, on the other side the things that have gone in his favour, will often convince the person, after a while, that the balance is on the positive side. (Wolberg, 1948b: 188-189)

Wolberg, it has to be said, felt that persuasive psychotherapy was very limited unless supplemented by psychodynamic techniques which identify and resolve unconscious emotional conflicts. However, the place of these methods might be taken by more experiential methods used in modern CBT and hypnotherapy. He does, however, claim that he has found rational persuasion more effective than other methods in the treatment of obsessive compulsive personalities. Persuasion methods were also supplemented, however, by “desensitisation” and “re-education” in psychobiologic hypnotherapy.

The “Re-education” Approach in Hypnotherapy

Re-education is a more rational extension of persuasive psychotherapy, according to Wolberg, insofar as it recognises the client’s personality traits and their role in his problems. In a manner resembling the schema psychology of modern cognitive therapy, Wolberg attempts to identify these traits and teach the client how to deal with them better.

Reaction patterns are always elaborated to preserve the integrity of the individual, to insure his security and self-esteem. As a result of disturbing early experiences and conditionings, the person may become excessively dependent, perfectionistic, or power-driven, or he may develop the notion that he cannot depend upon anyone except himself. He may harbour bloated ambitions, and expectations of himself may become inordinate and out of proportion to his intelligence, capacities, or available opportunities. He may belief that others must fulfil his demands and consequently show little spontaneity and initiative. He may detach himself from people and attempt to function without ties to others. He may be resentful and fail to establish any form of satisfying relationship with another person. Countless other attitudes and impulses may develop on the bedrock of unfortunate early experiences, and these are incorporated in the adult character structure. (Wolberg, 1948b: 199-200)

As Wolberg observes, merely gaining insight into the existence of these character drives within oneself seldom changes them. People often know they are being overly-perfectionistic, but continue to find themselves habitually acting in the same way. However, fully recognising the nature of one’s character drives is an important first step in treatment.

The process of changing character responses is difficult and prolonged. It consists of bringing to the conscious attention of the person his maladaptive attitudes, demonstrating to him what difficulties are consequent to their exploitation. The person is shown the reasons for their development in his past life and for their persistence in the present. Finally, he is helped to adjust with new, healthful, adaptive patterns. (Wolberg, 1948b: 201)

However, in the psychobiologic approach, the emphasis is not on uncovering the childhood roots of a problem but on the retraining new patterns of thinking and behaviour. In particular, Wolberg refers to the re-educational system of Dr. Austen Fox Riggs in his books Just Nerves (1922) and Intelligent Living (1929).

Wolberg observed that although re-education should ideally be tailored to the client’s personality, that some clients could be helped by prescribing reading about general personality problems, such as Riggs’ books provide. When the therapist has an opportunity to do so, he may interpret the client’s problems in terms of personality traits which can be addressed. Wolberg recommends having clients draw up lists of their personal strengths and weaknesses, another method that is found in modern cognitive therapy. Martin Seligman’s positive psychology approach, in Authentic Happiness (2002), also helps individuals to identify their personal strengths and focus attention upon making better use of them.

The physician teaches the patient to regard his symptoms as the product of emotions and distorted goals in life. He outlines for the patient the disturbed attitudes and strivings which get him into difficulties with people. Next he helps the patient apply the knowledge about himself to immediate life situations. An evaluation is made of the patient’s assets and these are compared with his liabilities. From this the patient often learns that he has concentrated upon his liabilities more than on his assets. He may come to the realisation that he has been so provoked by his failures that he has minimised any good qualities that he possesses. Indeed when his assets are brought to his attention, he may be surprised that he has accepted them without realising their proper value. He may gradually become cognisant of how exclusively he has focused his attention on his bad features, blotting from his mind his good points. Redirecting his attention on the latter gives him new goals toward which to strive. This may break up a vicious chain of frustration and despair. An investigation of the patient’s objectives may disclose ambitions that he is unqualified to fulfil which have contributed to his sense of defeat. An attempt is made to modify these ambitions within the range of the patient’s capacities, energies and environmental opportunities. (Wolberg, 1948b: 203)

This approach may resemble the giving of guidance mentioned above, but is more “non-directive” insofar as the client is encouraged to assess his own strengths and weaknesses and set new goals for himself in the light of these traits.

Re-education may take the form of teaching the patient to think unemotionally, to face facts bravely, to adjust to painful memories and impulses without panic, to meet stresses of life with courage, and to forsake fantasy in thinking. Each trait that the patient exhibits may be taken up in detail, discussing its origin, purpose, value to the individual, and the ways it interferes with his happiness and adjustment. More adaptive substitutive patterns may then be instituted. (Wolberg, 1948b: 204)

Focusing on specific strengths and weaknesses allows the client to be clearer about his goals, and to explore what specific changes he will need to make in his daily routine, or in concrete situations, in order to gradually shift closer toward a more adaptive philosophy of life.

Psychobiologic Hypnotherapy Suggestions

Wolberg gives the following transcript of re-educational suggestions given in group hypnosis sessions, probably based on Riggs’ group re-education approach, which combine some of the elements described above.

You have acquired faulty emotional habits that need correction. Such habits are the result of the wrong kind of thinking. You can be happy, free from worry and tension, by establishing the right habits of thinking and acting. You must tell yourself, “I will correct those difficulties that can be remedied. I will face those that cannot be remedied. I may be unable to change the world, but I can change myself so that I will not get emotional about things. I will abolish worrying and thinking too much about myself. If anything comes up that needs solution, I will immediately review all possible courses of action and choose the one that seems to be best. Once I have made up my mind, I shall follow the plan I have evolved. I shall stop thinking and talking too much about my troubles. I shall be pleasant in my relationships with people, and shall not permit myself to be upset. I shall direct my thoughts to pleasant things, and keep in mind the kind of person I would like to be. I must think I am well, and then I will get better. If worrisome ideas keep coming up in my mind, I shall control my thoughts by picturing in my mind a time in my life when I was really happy.” (Wolberg, 1948a: 183-184)

This is an early example of direct suggestion being used to reinforce prior cognitive re-education. Although crude, it clearly pre-empts subsequent cognitive-behavioural approaches to hypnotherapy in many respects.