The Practice of Cognitive-Behavioural Hypnotherapy: A Manual for Evidence-Based Clinical Hypnosis

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This is a comprehensive evidence-based clinical manual for practitioners of cognitive-behavioural hypnotherapy.Cognitive-behavioural hypnotherapy is increasingly becoming the dominant approach to clinical hypnosis. At a theoretical level, it adopts a research-based cognitive-behavioural model of hypnosis. At a practical level, it closely integrates traditional hypnotherapy and cognitive-behavioural therapy techniques. This is the first major treatment manual to describe a fully integrated cognitive-behavioural approach to hypnotherapy, based on current evidence and best practice in the fields of hypnotism and CBT. It is the product of years of work by the author, Donald Robertson, a cognitive-behavioural therapist and specialist in clinical hypnosis, with over fifteen years' experience in the therapy field. This book should be essential reading for anyone interested in modern evidence-based approaches to clinical hypnosis. It's also an important resource for cognitive-behavioural therapists interested in the psychology of suggestion and the use of mental imagery techniques.

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CHAPTER ONE. Introduction to cognitive-behavioural hypnotherapy

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What do we mean by “cognitive-behavioural hypnotherapy” (CBH)? This term is sometimes used to refer to the integration of hypnosis with cognitive-behavioural therapy (CBT). However, as we shall see, it may also denote the adoption of a cognitive-behavioural reconceptualisation of hypnosis, which replaces the notion of “hypnotic trance” with an explanation based upon more ordinary psychological processes. In a sense, though, the practice of cognitive-behavioural hypnotherapy actually predates modern cognitive-behavioural therapy, although they are intimately connected. As we shall see in later chapters, the founder of hypnotism, James Braid, adopted an approach based on the Victorian philosophical psychology known as Scottish “common sense” realism, which arguably contains concepts that prefigure those of later cognitive-behavioural theorists. Hypnotism was discovered by Braid in 1841, and entailed a more common sense psychological explanation of the apparent effects of Mesmerism. Braid defined hypnotism as focused attention upon an expectant dominant idea or image (Braid, 2009). Later, Hippolyte Bernheim, perhaps the second most important figure in the history of hypnotism, said that there was no such thing as “hypnosis” other than heightened suggestibility, and named his approach “suggestive therapeutics” (Bernheim, 1887). Indeed, hypnotism is essentially the art and science of suggestion, and not that of inducing “trances” or altered states of consciousness. Hypnotherapy is therefore the therapy of “imaginative suggestion”, of words that are used to stimulate the conscious imagination profoundly enough to bring about genuine therapeutic change.

 

CHAPTER TWO. James Braid and the original hypnotherapy

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To understand modern hypnotherapy it’s essential to have a basic grasp of the history of hypnotism. Unfortunately, that’s an area which is surrounded by confusion. Hence, we must first consider how hypnotism originated, in opposition to Mesmerism, and how its essential nature was subsequently obscured by the tendency to confuse it with Mesmerism and the frequent use of certain misleading pieces of terminology. When key misconceptions are cleared away, the nature of the relationship between traditional hypnotism and modern cognitive-behavioural therapy (CBT) inevitably becomes more apparent.

James Braid (1795–1860) coined the English term “hypnotism”, around 1841–1842, and is widely-considered to be the founder of both hypnotism and hypnotherapy. For example, Lynn and Kirsch, two of the leading cognitive-behavioural researchers in the field, open their recent textbook on evidence-based clinical hypnosis, by remarking: “Our use of the term hypnosis has its origin in the work of the nineteenth-century British physician James Braid” (Lynn & Kirsch, 2006, p. 6). A little-known fact is that Braid introduced “hypnotism” as an abbreviation for the longer-term “neuro-hypnotism”, meaning sleep of the nervous system. This was the original expression coined by him to describe his discovery. Throughout his writings, Braid progressively developed a more specific psycho-physiological conceptualisation of hypnotism, eventually labelled the “monoideo-dynamic” model. This term literally denotes the seemingly automatic or reflex-like (“dynamic”) power of focused attention on a single (“mono”) train of thought or dominant cognition (“idea”) to influence a wide range of behavioural and physiological responses (Braid, 1855, p. 81). He elsewhere refers to the monoideo-dynamic theory simply in terms of the “power of the mind over the body”, for which he also coined the term “psycho-physiology”. Braid’s original theory and practice of hypnotism are sometimes referred to as “Braidism”. As noted earlier, for convenience, we can perhaps refer to their reprisal in relation to modern psychological therapy as “Neobraidism” or as a “return to Braid.”

 

CHAPTER THREE. Cognitive-behavioural theories of hypnosis

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Since its origin, hypnotism has been subject to a considerable amount of research, and revisions and improvements have been made to our understanding of it, particularly its therapeutic applications. Sometimes it has evolved as the result of fads, sometimes in the light of genuine scientific progress. In particular, we will examine the influence of psychological research derived from socio-cognitive and cognitive-behavioural theories of hypnosis. Doing so may serve to illustrate the extent to which Braid’s original approach to hypnotism was on the right track and anticipated many modern concepts. In part, when we speak of “cognitive-behavioural” theories of hypnosis, this implies an emphasis on ordinary psychological processes rather than abnormal ones, such as an “altered state of consciousness” or “hypnotic trance”. Braid’s alignment with Scottish Common Sense realist philosophy of mind led him to approach the subject in a similarly down-to-earth manner.

Nevertheless, a long history of research and publications has led to the development of psychological theories of hypnosis which share certain concepts and postulates with those found in modern psychotherapy, especially cognitive-behavioural therapy (CBT). It is important to emphasise that what became known as the “cognitive-behavioural” theory of hypnosis must be distinguished from cognitive-behavioural therapy (CBT) techniques, although the latter are increasingly used in hypnotherapy. Indeed, although cognitive-behavioural theory and therapy are two different things, they naturally fit together and we shall attempt to explore the potential synthesis of traditional hypnotism, as practised by Braid, with cognitive-behavioural theories of hypnosis and CBT techniques. Although there is sometimes an inevitable ambiguity over what is and is not “hypnotism”, it seems incontestable that the work of Braid at least has sufficient historical priority to be considered bona fide hypnotism. Indeed, we shall see that modern theories and practices were often foreshadowed, at least in part, by the original ideas of Braid and other Victorian hypnotists.

 

CHAPTER FOUR. Assessment in cognitive-behavioural hypnotherapy

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This chapter, and the one following, provide a basic, generic overview of assessment and case formulation in cognitive-behavioural hypnotherapy. The inclusion of hypnosis only entails slight modifications to common CBT approaches, which are well-documented elsewhere (Grant, Townend, Mills & Cockx, 2008; Persons, 2008). However, some counsellors and therapists who use hypnosis will be less familiar with structured approaches to assessment and cognitive-behavioural case conceptualisation. As this area is not well described in many books on hypnotherapy, and because there are some minor adjustments worth including, I have chosen to include a chapter discussing assessment and conceptualisation sufficiently to provide a very basic introduction. However, I would suggest that readers consult the texts referenced for more detailed information and guidance.

Many practitioners using hypnotherapy assess clients primarily in the initial session, which typically lasts around fifty minutes. Other practitioners employ longer sessions, or more of them, to complete the initial assessment and conceptualisation process (Westbrook, Kennerley & Kirk, 2007, p. 54). For example, Chapman provides an example of clinical hypnosis in CBT where two sessions are dedicated to preparation for treatment (Chapman, 2006, p. 76). This is bound to vary depending on the therapist and their circumstances, for example, whether the client has already been thoroughly assessed commencing treatment. Although hypnotherapists will probably tend toward simpler and more concise approaches to both assessment and conceptualisation, and briefer treatment plans, things should not be abbreviated at the expense of “essentials” such as the assessment of risk factors and contra-indications, etc.

 

CHAPTER FIVE. Case formulation in cognitive-behavioural hypnotherapy

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Case conceptualisation or “clinical formulation”, as it is sometimes known, is central to modern psychotherapy although fewer references are made to it in the literature of hypnosis. Conceptualisation is the centrepiece of modern psychotherapy, especially CBT, and has been described as the “bridge from assessment to treatment” (Dobson & Dobson, 2009, p. 32). The effects of psychotherapeutic intervention differ fundamentally from those of taking medication, for example, insofar as it depends to a greater extent upon the rationale given for the treatment and the language used to formulate the conceptualisation (Alford & Beck, 1997, p. 96). Some attempts have previously been made to combine cognitive-behavioural case formulation with the use of clinical hypnosis and Chapman has argued that this provides the best way to integrate hypnosis fully within a CBT approach (Chapman, 2006).

As either an alternative or adjunct to formal diagnosis, case formulation attempts to provide a theoretically-derived explanation of the client’s presenting problems and possibly other underlying factors. It forms a progressively refined “map” or “picture” of the client’s problems by offering a “working hypothesis”, usually developed collaboratively, regarding the cause and nature of her symptoms. The working hypothesis, which forms the heart of the conceptualisation, is normally derived from theory-based models of different types of problem. The conceptualisation is tested out by adopting a fundamentally experimental attitude toward implementation of the treatment plan, which is modified in the light of therapeutic progress and other emerging information. In other words, testing of the working hypothesis takes place in an atmosphere of “collaborative empiricism”, broadly emulating basic scientific method.

 

CHAPTER SIX. Socialisation and hypnotic skills training

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If we reconceptualise hypnosis in terms of a particular, favourable cognitive set, or “hypnotic mind-set”, rather than the concept of “hypnotic trance”, an altered state of consciousness, certain practical consequences follow. Cognitive factors such as expectation and focused attention on appropriate ideas and strategies can be developed through education and skills training. The traditional “hypnotic induction” takes on a new meaning and is seen more as a opportunity for adoption of the relevant set of attitudes rather than a mechanical way of inducing an “altered state” or “trance”. Understanding the role of the hypnotic induction better also allows us to be more flexible about the technique used and focus instead upon the underlying processes, which can be utilised in a variety of different ways.

Following the initial assessment, the next step is usually to progressively educate the client about the method of cognitive-behavioural hypnotherapy and to socialise her to the role of “hypnotic subject”, as reconceptualised within this approach. This typically involves some discussion, correction of misconceptions, fostering a suitably favourable attitude, and the use of various initial “suggestion experiments” to begin helping the client develop a practical understanding of hypnosis from her own experience. This naturally leads into the process of training in self-hypnosis, which provides an introductory homework assignment that tends to be an important initial part of the overall treatment plan in hypnotherapy.

 

CHAPTER SEVEN. Applied self-hypnosis and coping skills

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Following on from socialisation of the client to cognitive-behavioural hypnotherapy, and initial hypnotic skills training, the therapist can easily progress to teaching self-hypnosis as a coping skill, tailored to suit the client’s needs and preferences. What we shall call “Applied Self-Hypnosis” (ASH) or the “coping skills” approach to self-hypnosis is probably the simplest cognitive-behavioural framework for hypnotherapy. Indeed, earlier texts on cognitive-behavioural hypnotherapy have explicitly presented self-hypnosis as a versatile coping skill that can be applied by clients across a wide range of situations (Golden, Dowd & Freidberg, 1987, p. xi). The approach adopted here attempts to build upon the established research on hypnotic skills training and coping skills methodologies in CBT (Gorassini & Spanos, 1999; Meichenbaum, 2007). Self-hypnosis is widely taught in hypnotherapy as a generic coping skill and it is logical to do so early in treatment as a way of further socialising the client to her role. A simple but comprehensive cognitive-behavioural framework for doing so is presented below, modelled upon established treatments for mild to moderate stress and various subclini-cal issues. However, this initial approach can easily be expanded to treat more serious clinical problems, which the following chapters attempt to do by adding more rigorous exposure therapy, problem-solving, and cognitive restructuring strategies for anxiety.

 

CHAPTER EIGHT. Affect: hypnotic exposure therapy

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Everyone knows what it means to be “exposed to danger”. In behaviour therapy and CBT the term “exposure” is used to refer to the presentation of situations or events, which the client unrealistically and mistakenly perceives as significantly threatening or experiences as unnecessarily anxiety-provoking.

In its simplest form, exposure treatment consists merely of advice to sufferers to expose themselves every day to a situation they find rather difficult and to record their daily actions in a diary which the therapist reviews at the next visit. As they gain confidence, they can set themselves fresh targets to achieve from one week to the next. (Marks I. M., 2005, p. 144)

As conceived within modern cognitive therapy for anxiety, exposure has been defined as follows:

[Exposure is] systematic, repeated, and prolonged presentation of external objects, situations, or stimuli, or internally generated thoughts, images, or memories, that are avoided because they provoke anxiety. (Clark & Beck, 2012, p. 129)

 

CHAPTER NINE. Behaviour: Problem-Solving Hypnotherapy (PSH)

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The important thing is not so much to know how to solve a problem as to know how to look for a solution.

(Skinner, 1971)

Problem-solving therapy (PST) originated in the 1970s as a form of cognitive-behavioural therapy (CBT) that focused on helping individuals to improve their general confidence and skill when it comes to solving their own problems (Goldfried & D’Zurilla, 1971). It is often referred to as “Social Problem-Solving”, although the term “social” merely denotes problem-solving in the real (social) world, rather than specifically social or interpersonal problems. (However, PST does excel as an adjunct to assertiveness or social skills training.) It draws on psychological research on problem-solving abilities in experimental settings and combines elements of behavioural self-management and coping skills training, which fundamentally emphasise the client taking over the role of the therapist and co-ordinating her own therapeutic strategies. It is a relatively brief, simple, action-oriented, and pragmatic approach to therapy that has been used for a very wide variety of client groups and issues and seems to hold promise as quite a general-purpose therapeutic strategy. It is also particularly useful in managing crises, building resilience, and relapse prevention. PST provides a generic framework for the planned implementation of specific coping strategies and can therefore flexibly assimilate strategies from cognitive therapy, hypnotherapy, and many other approaches. Meichenbaum distinguished between “coping skills” approaches to CBT, such as his stress inoculation training, that emphasise training in adaptive responses to stressful situations, and problem-solving approaches that emphasise “standing back” from stressful situations and more systematically analysing the problem to evaluate possible solutions (Meichenbaum, 1977, p. 195). However, he noted that these two styles of CBT overlap insofar as problem-solving in anticipation of stressful situations is naturally followed, in many cases, by more systematic training in coping skills to be applied during confrontation of the stressor.

 

CHAPTER TEN.Cognition: cognitive hypnotherapy

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How can standard cognitive therapy interventions be integrated with clinical hypnosis? Hypnotherapy historically shared more in common with early behaviour therapy than with the subsequent cognitive approaches of Ellis and Beck. However, modern cognitive therapy and hypnotherapy can easily be combined and a number of authors have already done so, by drawing on elements of Ellis’ REBT or Beck’s cognitive therapy (Alladin, 2008; Clarke & Jackson, 1983; Dowd, 2000; Golden, Dowd & Freidberg, 1987). Perhaps the main obstacle to integrating these approaches is the fact that direct verbal disputation of cognitions is usually better done outside of hypnosis. Nevertheless purely cognitive interventions can be enhanced by hypnosis in a number of ways, such as through the use of mental imagery techniques or coping statements combined with autosuggestion, etc. Moreover, the strategy of “distancing” from automatic negative thoughts in cognitive therapy (Beck A. T., 1976), which has been developed more extensively in recent mindfulness and acceptance-based approaches to CBT (Hayes, Follette & Linehan, 2004), can be conceptualised as a form of “dehypnosis”, as we have seen.

 

CHAPTER ELEVEN.Conclusion and summary

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This work has attempted to provide a detailed account of cognitive-behavioural hypnotherapy that integrates “nonstate” or “cognitive-behavioural” theories of hypnosis with techniques assimilated from hypnotherapy and CBT. The aim has been to do so in a more rigorous manner than previous books on the subject, and to draw on more contemporary research and clinical literature in the fields of hypnosis and CBT. A cornerstone of this integrative approach is the historical link between the parallel concepts of automatic negative thoughts in cognitive therapy and of morbid autosuggestion, or negative self-hypnosis (NSH), in hypnotherapy.

Based on the hypnosis research of Barber and others in the cognitive-behavioural tradition, a “problem-orientation” model of hypnosis has been proposed that identifies five elements of the hypnotic mind-set. This draws on the notion of the hypnotic subject as an active agent and a problem-solver, who selects strategies to help her enact hypnotic responses with a degree of perceived automaticity. To recap, the “hypnotic mind-set”, or favourable cognitive set, has been defined in terms of the following beliefs and attitudes derived from cognitive-behavioural theories of problem-solving:

 

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