Advertising Smoking Cessation Hypnotherapy

Sole copyright © Donald Robertson, 2007

[The text of this article was checked and approved by Donna Mitchell of the ASA Communications Team (31/1/07) before publication by the NCH journal and GHR newsletter.]

What advertising claims can you make about hypnotherapy to quit smoking?  There are three main restrictions which bind UK hypnotherapists, 

1. The UK law insofar as it restricts certain forms of advertising.
2. Having made an agreement to abide by their (NCH) code of ethics, they are bound to abide by any restrictions imposed by their professional body, failure to do so might be construed as a breach of contract.
3. The Advertising Standards Authority (ASA) administer self-regulatory codes of practice for the advertising sector.  Written advertisements are regulated by the CAP Code (the British Code of Advertising, Sales Promotion and Direct Marketing – www.asa.org.uk or www.cap.org.uk)

The ASA have the power to investigate complaints about specific advertisements and to impose sanctions on advertisers who break their codes.  They publish a very useful database of adjudications online.

            I should mention in passing that, unfortunately, the ASA database shows that a number of therapists, including hypnotherapists, have made advertising claims in the past which they have been unable to substantiate when evidence was requested by the ASA Council.  The adjudications make very interesting reading. 

            All hypnotherapists should be aware that the Committee of Advertising Practice (CAP), which is responsible for writing the CAP Code that is administered by the ASA, publishes a number of very valuable articles in their AdviceOnline database available from their main website.  In particular, hypnotherapists should be familiar with, 

1. Ailments, Treatments and Therapies: General

2. Ailments, Treatments and Therapies: Hypnotherapy

3. Smoking, Stopping

CAP also provide a very useful service through the CAP Copy Advice team who will inspect your proposed advertising copy and make recommendations on wording to help ensure it complies with the codes.  Several of our students have found this service very helpful.  In fact, the Copy Advice team have not only helped us avoid transgressions but actually, on a more positive note, came up with some good ideas for new advertising headlines!

            One important requirement of the CAP Code is that specific claims should be supported by appropriate evidence.  We spotted that an adjudication relating to Nicotine Replacement Therapy (NRT) had made use of the important meta-analysis by Viswesvaran and Schmidt (1992) of the University of Iowa.  This study compares many different pieces of individual research to compare the efficacy of different methods of stopping smoking.  The evidence shows that NRT is more effective than willpower alone.  (A finding, incidentally, which many researchers now consider a research artefact due to the dubious research design used with NRT.)  However, we were aware from our own research that this study also authoritatively shows hypnotherapy to be more effective than NRT for smoking cessation.

            I believe that there are strong grounds for concluding that meta-analysis tends to substantially underestimate the efficacy of treatments like hypnotherapy which can evolve significantly in response to research findings, unlike chemical therapies including NRT and Zyban, which are pretty fixed in their nature and therefore do not improve much over time.  If you take the statistical average of old studies using clumsy hypnotherapy methods and new ones using sophisticated multi-component cognitive-behavioural hypnotherapy strategies you necessarily negate the benefits of progress that has been made over time.  Nevertheless, even in these unfavourable conditions, research consistently shows hypnotherapy to be more effective than NRT and other treatments.  It is therefore something of a scandal that anti-smoking charities and the NHS continue to recommend NRT as the treatment of choice for smoking and resist calls to endorse hypnotherapy.  Most therapists suspect that this has something to do with the David versus Goliath problem, the voice of the hypnotherapy profession is inherently feeble, indeed virtually non-existent, compared to the “Big Pharm” lobby who have the ears of the decision makers and media.

            It is my personal belief, based on the research, that NRT will be conclusively shown to be of negligible efficacy within the next ten years or so.  It’s not much better than placebos, i.e., dummy patches.  As my students know, I believe that the key to smoking cessation lies in evidence-based client selection procedures derived from other research studies.  We provide training in our own approach on our “Smoking Cessation Masterclass” available in central London.  Most private hypnotherapists will not undertake treatment with clients who they feel are unmotivated or only coming for treatment because someone else wants them to stop smoking.  That’s just common sense.  There are much more sophisticated and empirically-based ways of assessing clients’ suitability for treatment, though.

            We attempted to take a proactive stance on advertising smoking cessation by submitting our own advertising copy to the copy advice team for approval, and supporting specific claims by reference to independent research.  The copy advice team exchanged several emails with us during which we carefully revised our wording until we arrived at agreement upon the following wording,

Obviously, this is a template and individual advertisers would need to add their details and modify the wording to suit their requirements.  However, we would recommend that any changes to wording which might change the meaning or even connotation should be cleared with the CAP Copy Advice team on an individual basis.  In particular, the Copy Advice team were insistent that the wording make it clear that the evidence relates to hypnotherapy in general and not the outcome rates for the specific practice being advertised.  We eventually agreed that the wording above satisfied this requirement. 

* Clarification.  Since publication of this article, several professional organisations have emphasised that they think the guarantee should be time-limited.  This wording was only meant to demonstrate the kind of claims that could be acceptable, we never intended hypnotherapists to use it as it stands without further elaboration.  As you can see from our manual, we have ourselves always recommended that satisfaction guarantees are time-limited.

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,

1. Cognitive activity affects behaviour.
2. Cognitive activity may be monitored and altered.
3. 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).

Typical Subjective Experiences in Hypnosis

Theodore X. Barber in Hypnosis: A Scientific Approach (1969) provides the following table of data on the percentage of participants, from a group of 55, who experienced commonly-cited subjective experiences in hypnosis, following a traditional induction.  In brackets are the percentage of a control group (n=50) who just sat with their eyes shut for the same amount of time.

51%  Alterations in (felt) size of body or body parts.  (36%)

20%  “Disappearance” of body or body parts.  (4%)

85%  Changes in equilibrium.  (66%)

69%  Feelings of unreality.  (26%)

36%  Changes in experienced temperature (feeling very hot or very cold).  (34%)

71%  Hypnotist’s voice seemed either very close or very far.  (34%)

Hypno-CBT® (HCBT)

Evidence-Based & Cognitive-Behavioural Approaches to Hypnotherapy

Copyright © Donald Robertson 2008.  All rights reserved. 
An extended version of this article was previously published in The Hypnotherapy Journal.

 

…the real origin and essence of the hypnotic condition, is the induction of a habit of abstraction or mental concentration, in which, as in reverie or spontaneous abstraction, the powers of the mind are so much engrossed with a single idea or train of thought, as, for the nonce, to render the individual unconscious of, or indifferently conscious to, all other ideas, impressions, or trains of thought. 

–James Braid, 1852.

 

What is Hypno-CBT® (HCBT)?

Hypno-CBT^® (HCBT) is one among several extant systems of cognitive-behavioural hypnotherapy.  It is not simply “hypnotherapy plus CBT”, however.  As opposed to “theoretical eclecticism”, HCBT is a tight integration of social, cognitive and behavioural psychology with traditional hypnotism.  It is based upon various established models of theory and practice which pre-date the development of modern cognitive-behavioural therapy (CBT).  Nevertheless, HCBT employs the modern principle of evidence-based “technical eclecticism” (Lazarus) which encourages clinicians to seek proven methods from different disciplines and attempt to incorporate them within a consistent theoretical model.

            In this article, I will outline the nature of cognitive-behavioural hypnotherapy (CBH) and briefly indicate some of the evidence that shows CBH to be older than CBT, and to have influenced the development of modern cognitive and behavioural therapies.  I will also outline the BASIC model of assessment and triple-response (ABC) model of treatment employed in HCBT, as these help to illustrate the key features of this approach in a way that has proven popular with our students and other clinicians.

 

Evidence-Based Practice in Hypnotherapy

Modern research on hypnotherapy is increasingly focused upon the integration of hypnotherapy and CBT since the publication in a mainstream peer-reviewed psychology journal of an influential meta-analysis carried out in 1995 by Irvine Kirsch et al.  Kirsch’s research team pooled data from 18 separate controlled studies, including 577 participants, comparing the efficacy of cognitive-behavioural hypnotherapy to CBT alone.  They proved that for between 70-90% of clients, cognitive and behavioural therapies were more effective when integrated with hypnosis, i.e., that for the vast majority of clients cognitive-behavioural hypnotherapy is superior to CBT alone.

 

A meta-analysis was performed on 18 studies in which a cognitive-behavioural therapy was compared with the same therapy supplemented by hypnosis.  The results indicated that the addition of hypnosis substantially enhanced treatment outcome, so that the average client receiving cognitive-behavioural hypnotherapy showed greater improvement than at least 70% of clients receiving nonhypnotic treatment. […] These results were particularly striking because of the few procedural differences between the hypnotic and nonhypnotic treatments.  (Kirsch et al., 1996) 

 

This finding led to the inclusion of cognitive-behavioural hypnotherapy for obesity on the list of empirically supported treatments (ESTs) compiled by the American Psychological Association.  The only other therapies to have proven their efficacy sufficiently to meet these stringent research criteria are almost exclusively cognitive-behavioural. 

However, throughout the history of CBT, since the 1960s, expert clinicians’ reports and individual studies have converged on a similar conclusion, viz.,

 

We believe on the basis of our clinical experience that when behaviour therapy and hypnosis are used together, a synergistic effect results.  (Kroger & Fezler, 1976: 74).

 

There has long been a consensus among certain clinicians that hypnosis enhances cognitive and behavioural interventions, specifically, by raising “response expectancy”, facilitating autonomic relaxation, and improving the client’s degree of “imaginal absorption”, etc.

 

What is Hypnotherapy?

Although many people believe that psychotherapy only began with Freud, at the start of the Twentieth century, Freud himself studied hypnotic psychotherapy at the French “Nancy School” of psychotherapy founded by Bernheim.  Indeed, it was largely Bernheim, and his followers who popularised the use of the word “psychotherapy” to describe the hypnotic method.  The original model of hypnotherapy, from which their approach derived, was developed in the 1840s and 1850s by James Braid, and was already implicitly cognitive and behavioural in orientation.  Braid, a Scottish surgeon, derived his theory of hypnotism from two main sources,

1. Philosophical Psychology (Stewart).  From his earliest writings, and throughout his career, Braid repeatedly cites the conventional principles of “suggestion”, “expectation”, “imitation”, “sympathy”, “attention”, “imagination”, “association”, and “habit”, explicitly derived from 19^th Century philosophical psychology, as the basis for his theory of hypnotism.  In particular, he derived his model from the agenda for a “rational” alternative to Mesmerism set forth during the Scottish Enlightenment period by philosophers of the dominant “Common Sense” school of philosophical psychology.  The influential Glasgow professor Dugald Stewart urged Scottish physicians to salvage a “common sense” account of the effects of Mesmerism by trying ‘to ascertain how far it is possible to fortify and exalt the imagination, and by what means this may most effectually be done.’ (Stewart, 1827).  Braid had argued that fixation of the gaze upon a single point led to fixation of attention upon a single idea or train of thought, and induced nervous fatigue to varying degrees, but also heightened responsiveness to the “dominant idea” consciously focused upon.  This simple neurological and psychological observation is relatively uncontroversial when correctly understood, even today, and found immediate support in various empirical studies carried out by Braid and other Victorian scientists.

2. Victorian Neurology (Carpenter).  As his own reputation as an influential sceptic grew, Braid found an important friend and ally in the eminent Victorian neurologist, William B. Carpenter, who coined the term “ideo-motor response” to describe the observation that minute, unconscious, muscular responses could be observed in response to conscious attention upon a “dominant idea” (by which the Victorians often meant a memory, sensation, sound, or visual image).  Braid, Carpenter, and their colleagues used this concept to systematically debunk pendulum dowsing, “table-turning”, and other alleged Victorian spiritualist phenomena.  They extended the idea to encompass the observation that other bodily systems, such as sensation and the secretion of hormones, could be similarly affected by dominant ideas.  Braid supplemented this concept with practical observation that focused attention and other methods could be deliberately used to amplify the ideo-dynamic reflex and this became the basis of his mature theory of hypnotism.  He expressed concern over the misunderstanding caused his earlier use of the word “hypnotism” (sleep) and suggested “mono-ideo-dynamics” instead, i.e., the methodology of concentrating attention upon a dominant idea in order to amplify its causal effect on the body’s physiology. 

Before the term “placebo” was even in widespread use, these cognitive and neurological observations led to early placebo-controlled experiments in which Braid, Carpenter, and their supporters, set about debunking Victorian “quack” or “nostrum” remedies.  Most of these pseudoscientific therapies were, however, the predecessors of modern complementary therapies like magnet therapy, homoeopathy, crystal healing, “energy therapies”, etc. 

However, the potent combination of philosophical psychology and Carpenter’s neurological theory of ideo-dynamic reflexes seemed to offer an alternative, rational and “common sense”, explanation of how these prototypical “complementary therapies” achieved their alleged results.  Braid and his followers therefore thoroughly rejected the “occult” and pseudoscientific theories of Mesmerism which he dedicated his mature career to systematically debunking.  It is thus ironic that modern hypnotherapy is seen as a form of complementary therapy itself, when its founder was perhaps one of the most influential Victorian critics of such therapies, whose perceived effects he repeatedly demonstrated to be reproducible by means of simple expectation, suggestion, focused attention, physical manipulation, and other “well-established laws of physiology and psychology”, as he put it.

The original hypnotism was, therefore, grounded in a philosophical and neurological model which pre-empts modern cognitive-behavioural models of therapy.  Contrary to popular misconception, its original orientation was explicitly “common sense”, “realist”, “rational”, “neurological”, “empirical”, and “sceptical.”  Even today, concepts from hypnotism are used by critics of complementary therapies to explain the role of suggestion, etc., in their alleged effects.  To a large extent, the popular confusion of hypnotism with complementary therapies and other pseudo-scientific methods can be blamed upon the influence of stage hypnosis and “New Age” books on hypnotism which perpetuate the myth that hypnotism is the same thing as Mesmerism.

 

The modern father of hypnosis was an Austrian physician, Franz Mesmer (1734-1815), from whose name the word ‘mesmerism’ is derived.  Though much maligned by the medical world of his day, Mesmer was nevertheless a brilliant man.  He developed the theory of ‘animal magnetism’ –the idea that diseases are the result of blockages in the flow of magnetic forces in the body.  He believed he could store his animal magnetism in baths of iron filings and transfer it to patients with rods or by ‘mesmeric passes.’  (Paul McKenna, The Hypnotic World of Paul McKenna, 1993)

 

In fact, this has nothing whatsoever to do with hypnotism.  The two traditions were opposites and bitter opponents, hypnotism being developed specifically to disprove the pseudo-scientific theory of “animal magnetism” and offer a rational and empirical alternative to Mesmerism’s primitive “energy” theory and supernatural claims.  It has always been in the interests of showmen and comedy “stage hypnotists”, however, to obscure the differences between hypnotism and Mesmerism in order to add an element of drama and mystique to their performances, and to misdirect the attention of their audiences.

 

Socio-Cognitive & Behavioural Hypnotherapy

Cognitive-behavioural theories of hypnosis began to explicitly develop when mainstream social psychology was used to interpret hypnotic phenomena as far back as the 1940s, forming the basis of what soon became known as the “socio-cognitive” or “cognitive-behavioural” theory of hypnosis.  For example, in 1941 Robert White published the seminal article ‘A preface to the theory of hypnotism’, interpreting hypnosis in terms of early social psychology, as a form of role-enactment behaviour,

 

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)

 

Role-enactment does not simply mean “faking”, though, as identification with the role ascribed to the hypnotic subject can lead to genuine psychological and physiological changes.  Braid himself had already compared the enhanced “ideo-dynamic” ability of the hypnotic subject to the ability of an actor to shed real tears in role, by means of deliberate imagination.  In the context of therapy, however, Braid was more interested in how focused imagination could be used to induce physiological changes such as altered heart rate, circulation, muscular function, and nervous arousal, in opposition to the patient’s prevailing symptoms.  On this model of treatment, for instance, a phobic client might be induced to systematically focus upon the idea of profound sleep or relaxation in order to induce measurable reduction in heart rate and other bodily responses.  Braid’s “psycho-physiological” approach to hypnotherapy clearly pre-empts the concept of “reciprocal inhibition” central to modern behaviour therapy.

White’s work was followed by a series of social psychologists and cognitive-behavioural theorists –such as Sarbin, Barber, Spanos and Kirsch– who abandoned the Freudian psychodynamic model of the unconscious mind as model of hypnotism and, in their extensive writings, systematically re-interpreted hypnotic phenomena within the framework of mainstream psychology.  From the 1950s onward, these researchers increasingly emphasised the role of conscious variables such as favourable “expectation, attitude, and motivation” (the “positive cognitive set”), “imaginal absorption”, and the use of specific “subjective strategies.”  A growing body of experimental data led to criticism of the “special state” theory of hypnosis, which posited the existence of a unique “trance” or altered state of consciousness.  Instead, “nonstate” theorists, especially influenced by Sarbin and Barber, proposed that hypnosis was best understood as a special application of ordinary social, cognitive, and behavioural processes, such as role-taking, expectation, and focused attention. 

In doing so, ironically, their work marks a return to the original philosophical and neurological concepts employed by Braid, who had no concept of an “unconscious mind” and instead emphasised the role of conscious attention upon dominant ideas in his definition of hypnotism.  Braid repeatedly and vigorously emphasised throughout his career that he viewed hypnosis as the result of ordinary psychological and physical processes,

 

I beg farther to remark, if my theory and pretensions, as to the nature, cause, and extent of the phenomena of nervous sleep [i.e., hypnotism] have none of the fascinations of the transcendental to captivate the lovers of the marvellous, the credulous and enthusiastic, which the pretensions and alleged occult agency of the mesmerists have, still I hope my views will not be the less acceptable to honest and sober-minded men, because they are all level to our comprehension, and reconcilable with well-known physiological and psychological principles.  (Braid, Hypnotic Therapeutics, 1853)

 

Not only was hypnotism implicitly cognitive-behavioural from its very inception, but in the first half of the Twentieth Century it became integrated within the emerging framework of social, cognitive and behavioural psychology, several decades before the appearance of modern cognitive therapy (Beck, Ellis, et al.), or even its precursor behaviour therapy (Wolpe et al.), in the late 1950s and early 1960s.  Indeed, as Weitzenhoffer and others have shown, hypnotherapy can be seen, in many ways, as the roots and trunk of a historical tree from which cognitive-behavioural therapy, and other modalities, sprouted forth as branches. 

 

Examination of the hypnotherapy literature leaves little doubt that many hypnotherapists apply a variety of [behavioural] learning principles in conjunction with their hypnotic techniques.  In many cases, they use procedures similar enough to those employed by behaviour therapists to identify their approach as “behaviour therapeutically oriented hypnotherapies,” or, more simply, “behaviouristic hypnotherapies” [….].  (Weitzenhoffer, 1972: 304).

 

He notes that ‘Much relevant literature in hypnotherapy was published long before “behaviour therapy” became a recognised branch of psychotherapy.”  Indeed, from the start of the Twentieth Century onwards, other prototypical cognitive and behavioural approaches to psychotherapy came and went, dwarfed by the dominance of the Freudian Empire.  The origins of the modern-day cognitive-behavioural tradition are therefore usually traced to the late 1950s when Joseph Wolpe’s work established the beginning of a coherent system of behavioural therapy, in opposition to psychoanalysis.

Wolpe’s method of systematic desensitisation, e.g., the archetypal technique of modern behaviour therapy, was visibly derived from established hypnotherapy methods.  In order to induce relaxation during desensitisation, Wolpe himself had initially employed a hypnotic induction derived from Lewis Wolberg’s Medical Hypnosis (1948), one of the best-known hypnotherapy textbooks of the period.  Wolpe therefore referred to his technique as hypnotic “desensitisation.”  As several sharp-eyed researchers quickly pointed out, however, Medical Hypnosis also contained a whole chapter explicitly dedicated to behavioural hypnotherapy, entitled ‘Hypnosis in Reconditioning’, in which the technique of hypnotic “desensitisation” is already described as a treatment for specific phobia and social anxiety. 

 

Another means of treating phobias is by desensitisation.  Under hypnosis the patient is given suggestions to expose himself gradually to the terrifying situation.  The aim in desensitisation is to get the patient to master his fears by actually facing them.  It is essential for the individual to force himself again and again into the phobic situation, in order that he may finally learn to control it. […] The hope is that the conquering of graduated doses of his fear will desensitise him to its influence.  (Wolberg, Medical Hypnosis, 1948: 235, my italics)

 

Wolberg describes how a patient with social anxiety is taught to relax by means of a ‘peaceful isolated scene on the seashore.’  He was then asked in hypnosis to visualise progressively more anxiety-provoking social situations while remaining relaxed and emotionally calm.  By “reconditioning” him to associate relaxation and pleasure with social situations, Wolberg reported that he was able to do so in reality, overcoming his social phobia.  It would seem therefore that the same hypnotherapy textbook from which Wolpe acknowledged deriving his hypnotic induction also contained several descriptions of the behavioural “desensitisation” treatment, unacknowledged by him, which he claimed to have invented.  As Weitzenhoffer diplomatically puts it, these and other examples of “desensitisation” in behavioural hypnotherapy “clearly antedate” the founding text of behaviour therapy, Wolpe’s Psychotherapy by Reciprocal Inhibition (1958).

Similar observations can be made regarding the unacknowledged influence of hypnotherapy over the development of many other CBT interventions, too diverse to cover in this short article, with the following exception from the cognitive tradition.  Albert Ellis the first modern cognitively-oriented therapist reported that he originally studied the “New Nancy School” approach to hypnotism, in the writings of Coué, as a teenager.  The seminal notion of “negative cognition” in CBT is described in Ellis’ early writings as a form of “negative autosuggestion.”  Speaking of his bemusement over the power of hypnotic suggestion, Ellis wrote,

 

The answer to this riddle, in the light of the theory of rational-emotive psychotherapy, is simply that suggestion and autosuggestion are effective in removing neurotic and psychotic symptoms because they are the very instruments which caused or helped produce these symptoms in the first place.  Virtually all complex and sustained adult human emotions are caused by ideas or attitudes; and these ideas or attitudes are, first, suggested by persons and things outside the individual (especially by his parents, teachers, books, etc.); and they are, second, continually autosuggested by himself.  (Ellis, 1962: 277)

 

However, this notion of pre-existing negative autosuggestion was already present in the writings of James Braid from the 1850s, and rose to prominence in the New Nancy School of the 1920s. 

 

By knowing how to practise it [autosuggestion] consciously it is possible in the first place to avoid provoking in others bad autosuggestions which may have disastrous consequences, and secondly, consciously to provoke good ones instead, thus bringing physical health to the sick, and moral health to the neurotic and the erring, the unconscious victims of anterior autosuggestions, and to guide into the right path those who had a tendency to take the wrong one.  (Coué, 1922: 5)

 

The very concept of cognitive mediation, and negative cognition, so central to modern cognitively-oriented therapy, is arguably a necessary concomitant of any theory of hypnotic suggestion.  The “dominant ideas” which Braid and Carpenter blamed hysterical illness upon, or the “autosuggestions” of Coué, can be seen as prototypical “cognitive” theories of psychopathology.  Even Braid, the founder of hypnotherapy, speaks of employing hypnotism ‘so as to break down the pre-existing, involuntary fixed, dominant idea in the patient’s mind, and its consequences.’ (Braid, 1853).  The Freudian transposition of such cognitions to a hypothetical “unconscious mind” obscured the fact that Braid and other hypnotists had, from the outset, recognised the role of conscious, but unintentional, attention and conscious dominant ideas in determining hysterical illness, i.e., neurosis and psycho-somatic complaints.

 

Hypno-CBT® (HCBT)

Hypno-CBT^® is a proprietary system of cognitive-behavioural hypnotherapy which, at a conceptual level, integrates the original hypnotic theory of Braid with modern social, cognitive and behavioural psychology.  At a practical level, it also integrates hypnotic techniques and strategies with those derived from modern cognitive and behavioural therapies.  Hypno-CBT^® is based on a cognitive-behavioural “skills training” model of hypnotic responsiveness derived from the seminal “role-taking” model introduced by White in the early 1940s and developed by subsequent socio-cognitive researchers.  The theory and practice of HCBT have already been extensively developed, and constitute an accredited training based upon highly-detailed training manuals.  However, one of the distinguishing features of this approach is the use of a specific multi-modal and social-cognitive-behavioural model of assessment and treatment, ultimately derived from the Multimodal Therapy (MMT) of Arnold Lazarus and the triple-response model of clinical anxiety issuing from the research of Lang and Rachman. 

We reject the outdated and reductionist psychodynamic model of psychopathology, taken for granted in hypnotic regression therapy, in which a hypothetical “unconscious idea” is assumed to produce multifarious conscious and overt symptoms.  We likewise reject the potentially counter-productive, and long disproven, theory of “symptom substitution” which claims that unless this hidden emotion, drive, idea or memory is uncovered the client is doomed to relapse or to the formation of new symptoms.  This kind of “symptom substitution” is not observed in following-up non-psychodynamic therapy, such as CBT, or when ordinary people quit habits or overcome fears, in daily life, without the aid of any therapy whatsoever.  The recovery or interpretation of unconscious memories is now seen as a dangerously pseudoscientific practice by mainstream researchers, following advances in the neuro-psychological understanding of memory in the wake of the “recovered memory” scandals of the 1980s and 1990s.  It seems increasingly likely that “recovered” memories are largely “recreated” memories, and may or may not be true depending upon the degree to which the client’s inflated confidence in their memory, heightened expectations, the leading influence of the therapist, and numerous other factors, impossible to measure or control, may distort the process of reconstruction and turn an educated guess into a partial or total “false memory.” 

Symptoms are inter-active and overlapping, they are not conceptually distinct.  Removal of symptoms in all dimensions constitutes complete cure; removal of symptoms in some dimensions, while remaining in others, is incomplete and leaves clients vulnerable to relapse.  For example, removing the drinking behaviour (B) of a socially anxious alcoholic, through aversion therapy, without treating their feelings of anxiety (A), through desensitisation, may leave them vulnerable to relapse in the future or encourage them to seek alternate forms of self-medication, e.g., drug abuse.  However, improvement in one dimension may often have a direct effect upon other dimensions, e.g., the same alcoholic may find that he experiences increased self-confidence from stopping drinking which, in itself, spontaneously reduces his social anxiety over time, leading to total cure.  Therapists are optimally effective when they help clients to identify all dimensions which contribute to or are affected by their presenting problem.  Clients are optimally able to fulfil their role in treatment when they are able to understand all modalities of their own problem and the relationships between different dimensions.  Some problems predominantly relate to one or more modalities, and are less relevant to others, though, as should be obvious. 

            Consequently, Hypno-CBT^®, like conventional hypnotherapy, focuses directly upon the three modalities of Affect (A), Behaviour (B), and Cognition (C), and only indirectly, as a result of personal psychological change, upon the client’s health (S) and inter-personal environment (I).  Hypnotherapy is primarily a cognitive therapy, though, because it explicitly focuses on the use of verbal autosuggestion and suggestion, and other “cognitive strategies” (Spanos), in order to facilitate emotional and behavioural changes.

            In treatment, moreover, the therapist is optimally effective when he carefully identifies specific situations or events which the client currently responds badly to, i.e., the client has a phobia of dogs which specifically causes them distress when they attempt to walk across their local park on the way to work each morning and they see people walking past them with dogs, especially large ones.  Ideally, specific situations or events which the client will face, or may choose to face, within the next 7 days are identified.  This allows the therapist to combine imaginal therapy (in vitro) with real world (in vivo) graded exposure.  For example, the client may choose to walk through the park tomorrow morning in order to test their response following treatment.  Of course, real world exposure requires careful management to avoid unnecessary distress and is therefore combined with coping skills training and the collaborative setting of a graded hierarchy of manageable goals, where appropriate.

            A similar approach can be modified for the treatment of memories, abstract thoughts, etc.  However, the simplest and most common treatment protocol takes the following form.  The client is hypnotised, following preliminary assessment, education and skills training, etc., and repeatedly imagines the target situation while mentally rehearsing more healthy and adaptive responses, with the assistance of the therapist.  This is done in accord with established cognitive-behavioural methods based on clinical research.  However, we employ the following triple-response or “three dimensional” template for mental rehearsal which accords with modern “desynchrony” models of anxiety treatment, developing out of clinical research in the 1970s,

 

It is helpful to think of fear as comprising three main components: the subjective experience of dread, associated physiological changes, and behavioural attempts to avoid or escape from the threatening situation.  The three components of fear do not always correspond.  Some people experience subjective fear but remain outwardly calm and show none of the expected physiological correlates of fear, such as trembling, palpitations, or perspiring; others report subjective fear but make no attempt to escape from or avoid the supposedly threatening situation.  The existence of these three components of fear, and the fact that they do not always correspond, makes it helpful to specify which component of the fear one is describing.  (Rachman, 2004: 8-9)

The therapist will, most typically, employ this as a framework for mental rehearsal, or imaginal exposure.  Often one modality is addressed at a time, over 3-4 sessions of treatment, or as required.  However, the choice of which order to address modalities in will also depend upon the preference and personality of the client and the nature of their problem. 

            As Salter (1949) said, the “cardinal technique of psychotherapy” is simply that the stimulus be presented, while the response is prevented.  On a triple-response model of treatment this means that during mental rehearsal, and subsequently during real-world exposure, clients rehearse facing their fears (or other challenging issues) in a controlled manner, with focused attention, and while employing certain evidence-based “cognitive-behavioural strategies”, derived from the technical eclectic armamentarium or chosen by the client themselves, to prevent negative feelings (A), and actions (B), and thoughts (C) and replace them with more adaptive ones.

These three modalities of assessment (ABC) correspond, very neatly, to three established modalities of treatment intervention used in mental rehearsal, the central component of Hypno-CBT^®.  In its simplest and most typical form, e.g., mental rehearsal consists of facing one’s fears repeatedly in imagination while responding with relaxed physiology and calm emotions (Affect), visualising “acting as if cured” (Behaviour), and repeating positive, congruent, and realistic autosuggestions (Cognition).

Put very simplistically, our dog phobic may, at this stage, be hypnotised and asked to picture walking through the park, several times.  To begin with he may be trained in relaxation skills and asked to focus on inducing muscular and autonomic relaxation while facing his fears in this way, following a standard hypnotic desensitisation protocol, influenced by Wolpe.  When he reports, by using a SUD (Subjective Units of Disturbance) scale or similar measure, that he is ready, he will proceed to incorporate behavioural and cognitive components to his mental rehearsal. 

He may choose next to relax and picture walking in the park while imagining now that he walks confidently and even approaches dogs in a calm friendly manner, gradually building up a more detailed and congruent image of success in graded steps, following a standard “coping to mastery” imagery protocol.  At first it helps to picture minor setbacks, like a slight sense of panic, and to see himself recovering from it, for the purposes of relapse prevention.  Finally, however, he pictures himself “acting as if cured”, as we put it. 

When he is satisfied, he may now address the cognitive dimension.  This can be done at any stage through simple autosuggestion, i.e., telling himself congruently that “I can do it”, using a self-efficacy statement (Bandura), being the most generic method.  However, in the latter stages of treatment negative cognitions should be actively identified and the client helped to counteract and dispute them systematically.  For instance, the client may fear that his improvement is temporary and he should be encouraged to monitor the effects of this thought and to seek a more rational and helpful alternative, e.g., “If I keep practising and think positively, I can make relaxation more automatic and lasting in this situation, until it becomes permanent.” 

Statements like this can then be rehearsed systematically in hypnosis and measured by means of a self-efficacy scale (“How confident do you feel about handling that situation, from 0-10?”) or a validity of cognition scale (“How true does that positive statement feel, at an emotional level, as a percentage?”).  Affective, Behavioural, and Cognitive components of rehearsal can be practised separately in sessions, or combined together.  They may be tackled in a different order than ABC, though this is the most common sequence.  Clients may employ similar interventions as homework between sessions, often facilitated by means of a specially-tailored recording.

Conclusion

In this short article, I have outlined in cursory fashion, the historical basis for Hypno-CBT^® and demonstrated the fact that it can claim historical precedence over modern CBT.  As Kirsch et al. (1995) observe, in published research, cognitive-behavioural hypnotherapy (CBH) and CBT are often indistinguishable in terms of the techniques and protocols used.  However, most of the techniques employed can be found in hypnotherapy literature prior to the development of modern CBT, and the inclusion of socio-cognitive and cognitive-behavioural theories and concepts within the framework of mainstream hypnotherapy research began as far back as the early 1940s.  Traces of similar techniques and concepts, and an explicitly evidence-based and rational-empirical orientation, visibly dominate the writings of James Braid, who introduced the concept of hypnotism in the early 1840s.

I have not had space to describe the huge armamentarium, or “toolbox”, of therapeutic interventions which are employed in HCBT within a cognitive-behavioural model, derived from Lazarus’ philosophy of evidence-based technical eclecticism.  However, I hope to have clarified the multi-modal nature of HCBT assessment and treatment planning and to have provided clinicians with a basic understanding of the ABC or triple-response approach to mental rehearsal which constitutes the central intervention employed within HCBT.

 The Story of Hypnotic Psychotherapy

(c) Copyright Donald Robertson, 2008

Daniel Hack Tuke, an early English advocate of hypnotherapy and great-grandson of the Quaker who founded the famous York Retreat, had made some initial use of the term “psychotherapy” in his writings.  However, it was effectively introduced to widespread use in the fields of medicine and psychology by Hippolyte Bernheim and the followers of his “Nancy school” of therapy, at the end of the late nineteenth century.  Bernheim used the term specifically to describe hypnotherapy, and wrote, e.g., ‘to provoke this special psychic state by hypnotism and to exploit it with the aim of cure or of relief […] this is the role of the hypnotic psycho-therapeutic.’ (1886: 218). 

            Historians believe that the very first use of the word “psychotherapy” in a book title came a few years later in the English hypnotist Charles Lloyd Tuckey’s Psycho-therapeutics, or Treatment by Hypnotism & Suggestion (1889).  Tuckey popularised the use of the word “psychotherapy” as a synonym for the hypnotherapy of the Nancy school.  In his “history and bibliography of psycho-therapeutics”, he writes, 

To James Braid, the Manchester surgeon, is due the credit of having seen the germs of truth which lay hidden and obscured in the writings of Mesmer and the animal magnetisers. […] Although he publicly demonstrated his system of healing – which he practised with much success – and wrote several works upon the subject, it appears to have died with him, and it remained for Dr. Liébault to arrive at the truth of psycho-therapeutics.  (Lloyd Tuckey, 1889: xi)

This specific issue was recently investigated on behalf of the The Wellcome Trust Centre for the History of Medicine by the researcher Sonu Shamdassani whose conclusions are published in ‘Psychotherapy: The invention of a word’ in History of the Human Sciences, 2005 (vol. 18, no. 1).  Shamdassani states,

The making of psycho-therapeutics synonymous with hypnosis and suggestion [by Bernheim] meant that the word became widely disseminated.  ‘Psycho-therapeutics’ rode on the back of the burgeoning hypnotic movement. (Loc cit.)

He adds,

For Bernheim and his followers, as psychotherapy was identified with hypnotic and suggestive therapies, the history of psychotherapy was identical with that of the latter. (Loc. cit.)

The meaning of “psychotherapy” was gradually widened to encompass the rational “persuasion” methods of Paul Dubois and his followers and the psychoanalytic methods of Freud’s disciples.  Gradually it became more and more generic in meaning, covering an incredibly diverse range of concepts and techniques.  In recent decades, it has been estimated that there are over 300 distinct models of psychotherapy.

            As various branches of psychotherapy diverged from their roots in hypnotherapy they quickly evolved into a myriad of autonomous schools of thought.  However, over the decades what became split off was often re-assimilated back into clinical hypnotherapy, as hypnotists learned from other branches of psychotherapy.  Hence,

A century ago, hypnotherapy often consisted of a hypnotic induction, followed by suggestions of symptom removal.  Consequently, hypnotherapy has been viewed by some writers as a mode of therapy that might be compared with psychodynamic, cognitive-behavioural, or other therapeutic approaches.  However, suggestions for symptom relief play a relatively minor role in contemporary hypnotherapy.  Instead, hypnotherapy generally consists of the addition of hypnosis to some recognised form of psychotherapy.  (Kirsch et al., 1995: 214)

Consequently, hypnotherapy was apparently the first major school of psychotherapy, gave birth to most other branches of psychotherapy, and has evolved alongside its cousins into an increasingly sophisticated and integrative discipline.  It is nevertheless common nowadays to distinguish between “hypnotherapy”, which mainly uses direct suggestion and other simple interventions, and “hypno-psychotherapy” which has assimilated more theory and technique from other branches of psychotherapy, although it is often very difficult to distinguish the two things in practice.

This is the American Psychological Association’s definition of hypnosis.  This short document really outlines a scientific account of hypnosis which tries to avoid theoretical disagreements.

The Division 30 Definition and Description of Hypnosis

Hypnosis typically involves an introduction to the procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for using one’s imagination, and may contain further elaborations of the introduction. A hypnotic procedure is used to encourage and evaluate responses to suggestions. When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior. Persons can also learn self-hypnosis, which is the act of administering hypnotic procedures on one’s own. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced. Many believe that hypnotic responses and experiences are characteristic of a hypnotic state. While some think that it is not necessary to use the word “hypnosis” as part of the hypnotic induction, others view it as essential.

Details of hypnotic procedures and suggestions will differ depending on the goals of the practitioner and the purposes of the clinical or research endeavor. Procedures traditionally involve suggestions to relax, though relaxation is not necessary for hypnosis and a wide variety of suggestions can be used including those to become more alert. Suggestions that permit the extent of hypnosis to be assessed by comparing responses to standardized scales can be used in both clinical and research settings. While the majority of individuals are responsive to at least some suggestions, scores on standardized scales range from high to negligible. Traditionally, scores are grouped into low, medium, and high categories. As is the case with other positively-scaled measures of psychological constructs such as attention and awareness, the salience of evidence for having achieved hypnosis increases with the individual’s score.

(This definition and description of hypnosis was prepared by the Executive Committee of the American Psychological Association, Division of Psychological Hypnosis. Permission to reproduce this document is freely granted.)

http://www.apa.org/divisions/div30/define_hypnosis.html

[youtube=http://www.youtube.com/watch?v=wbYAd7Okmls]

This is part of a longer video interview that I did recently on Stoicism and psychotherapy.

“Where do I find research on hypnosis and xyz?”, is the most common question I get asked as NCH research director, and in my job as a trainer. See my news item in the current NCH journal for more information on searching for studies online, and also the table of Empirically-Validated Treatments in hypnotherapy for additional references to well-designed research studies.

There are several research journals in the field of hypnosis. The most important is the International Journal for Clinical & Experimental Hypnosis (IJCEH). The good news is that the publishers of IJCEH provide a superb “advanced” search facility, free of charge, on their website. It contains the abstracts from every single article published since the launch of the journal in 1953. Full copies of the articles can also be purchased online (this is not cheap). The abstracts will usually contain a brief report of the results of the study, though. See the link below. If you’re looking for research on hypnosis and diabetes just type “diabetes” in the search box under the picture of the journal cover (4 hits),

Search IJCEH for hypnosis research online

The American Journal of Clinical Hypnosis (AJCH) is perhaps the second most influential research journal in the field of hypnosis. Many of its articles are available via the website below,

Search AJCH for hypnosis research online

You can also search PubMed, the public medical resesarch database of US Government’s National Library of Medicine, which contains citations for most of the studies published on hypnotherapy. This database also contains many links to full PDF copies of articles available online, and its archive goes back to 1948. Just type in “Hypnotherapy diabetes” to find research, for example, on hypnosis and diabetes (31 hits).

Search PubMed for hypnosis research online

There are many other journals and search engines available online, including the excellent Google Scholar, where you can easily find references to most of the published articles about hypnosis.

Google Scholar Search Online

Donald Robertson
NCH Research Director

Hypnotic Suggestion & Non-deceptive (“Non-blind”) Placebo Research

Copyright (c) Donald Robertson, 2008

 

In a sense, the history of hypnosis is all about the discovery of the placebo effect and its relation to verbal suggestion.  The Mesmerists believed that they were placing people in a “trance” and influencing them by means of an invisible energy known as “animal magnetism.”  Physicians and scientists of the day were naturally sceptical.  Mesmerism was, therefore, one of the first major objects, and victims, of early medical placebo research.  The overall conclusion of the early scientific committees studying Mesmerism was that its effects were often real but due to “belief” and “imagination” rather than anything resembling animal magnetism. 

        Ironically, it took several decades before someone, in response to these criticisms, could popularise an alternate system explicitly based upon the assumption that belief and imagination were effective as a technique in their own right.  In the early 1840s, James Braid, introduced the term “neuro-hypnotism”, or “hypnotism” for short, to describe a special state of physical relaxation and nervous fatigue.  Although Braid did not fully recognise the role of belief and imagination, i.e., suggestion, until later in his career, he did categorically reject the theory of invisible energy proposed by Mesmer.

        Some of the areas where research has most strongly established the placebo effect, such as in pain management and the treatment of neurotic disorders, are also areas where hypnosis is proven to be particularly effective.  Indeed, until the introduction of chemical anaesthetics around 1845 the dominant use of Mesmerism was in the treatment of pain, hypnotic anaesthesia, and subsequently its primary use became the treatment of “hysteria” or neurotic and psychosomatic symptoms.

 

In the 1960s, two researchers called Park and Covi published a groundbreaking article entitled simply ‘Nonblind placebo trial: An exploration of neurotic patients’ responses to placebo when its inert content is disclosed’ in The Archives of General Psychiatry (April 1965, vol. 12).  They selected 15 neurotic patients from the outpatient dept. of a psychiatric clinic, with a variety of mental and physical ailments.  Each patient was seen individually for two sessions only, once for a one-hour assessment and again for a 15-30 minute prescription session.  They were each given a bottle of placebo pills, without any active ingredients, to be taken three times per day.  Patients were each read the following script at the second appointment,

 

“Mr. Doe, at the intake conference we discussed your problems and it was decided to consider further the possibility and the need of treatment for you before we make a final recommendation next week.  Meanwhile, we have a week between now and our next appointment, and we would like to do something to give you some relief from your symptoms.  Many different kinds of tranquilisers and similar pills have been used for conditions such as yours, and many of them have helped.  Many people with your kind of condition have also been helped by what are sometimes called “sugar pills,” and we feel that a so-called sugar pill may help you, too.  Do you know what a sugar pill is?  A sugar pill is a pill with no medicine in it at all.  I think this pill will help you as it has helped so many others.  Are you willing to try this pill?”  (Park & Covi, 1965)

 

Only one patient expressed reluctance to take part in the experiment.  Of the remaining 14 patients, 13 showed signs of significant improvement across a battery of self-report and psychiatrist administered measures.  Overall there was a ‘highly significant’ 41% decrease in symptoms reported, on average for each subject, across different measures.  The researchers note that this was greater than the improvement found in previous studies of real drugs, using the same measures.  Four patients reported, indeed, that the placebo medication did them more good than anything they’d previously been prescribed.  By contrast, the one patient who dropped out was subsequently assessed and found to have increased on the same measures of symptom severity.

            Some patients were convinced they were receiving placebos, others convinced themselves that the script was a ruse and assumed the “sugar pill” must contain some active ingredient.  Notably, however, one patient actually compared the non-blind placebo experiment to a kind of hypnosis,

 

The patient indicated that she was quite suggestible, and she thought the treatment had been effective through a form of ‘hypnosis’ because she had been told so many times she would improve.  (Park & Covi, 1965)

 

Perhaps she was right; at least her interpretation of the proceedings would accord with Kirsch’s model of hypnosis as a “non-deceptive mega-placebo”, and perhaps even with James Braid’s original perspective on the relationship between hypnotic suggestion and placebo therapy.  Indeed, like Braid, the researchers conclude that the use of non-deceptive placebos could have “psychotherapeutic implications”, by using suggestion to heighten expectation in combination with factors which the researchers term “support and autonomy”,

 

The present placebo treatment could be viewed as having some affinity to psychotherapy not only in a manner similar to the “non-specific form of psychotherapy” which Rosenthal and Frank describe as “produced by the patient’s faith in the efficacy of the therapist and his technique.”  Two major characteristics of accepted psychotherapeutic techniques were present: on the one hand, support and reassurance were given, while, on the other hand, the responsibility for improvement was thrown back to the patient by means of the paradoxical statement that he need treatment but that he could improve with a capsule containing no drug.  (Park & Covi, 1965)

 

It is clear to see how this can be related to the role of suggestion and other “non-specific” factors in modern hypnotherapy.  The deliberate attempt to construct a psychotherapy approach based upon an understanding of the placebo effect has been undertaken by a number of authors, e.g., Jefferson M. Fish in his Placebo Therapy: A Practical Guide to Social Influence (1973).