CBT & Cognitive-Behavioural Theories of Hypnosis

Cognitive-behavioural theories of hypnosis and their use in CBT

Copyright (c) Donald Robertson, 2009.  All rights reserved. 
www.UKcognitive.com

This article aims to evaluate the relevance of cognitive-behavioural theory in the field of hypnosis for the practice of cognitive-behavioural therapy (CBT).  It begins with a brief historical overview of the theorists and concepts in question and definition of key terms[1].  It proceeds to discuss the relationship between theories of psychopathologyin hypnotherapy and CBT, and finally to consider the relationship between clinical interventions employed in cognitive-behavioural hypnotherapy and their practicalrelevance to CBT.

The Cognitive-Behavioural Theories of Hypnosis

Modern research on hypnotherapy has increasingly focused upon integrating hypnotherapy and CBT since the publication of Kirsch et al.’s influential meta-analysis which pooled data from 18 separate controlled studies (577 participants) comparing the efficacy of “cognitive-behavioural hypnotherapy” to CBT alone.  They concluded that for 70-90%[2]of clients CBT was more effectivewhen integrated with hypnosis, i.e., that for the vast majority of clients cognitive-behavioural hypnotherapy is superior to CBT alone (1995, p. 214).

            However, hypnotism has a long and complex historical relationship with cognitive/behavioural psychological theories and therapies.  Hypnotherapy originated in 1841 when James Braid, its founder, developed his “psycho-physiological” model in oppositionto the “animal magnetism” of the Mesmerists[3].  Braid’s hypnotism assimilated the “ideo-motor reflex”[4]theory of his ally Prof. William B. Carpenter to provide an early neuro-psychological theory of suggestion.  This association between psychological research and clinical practice continued and in the 20th century, hypnotism was studied extensively by key social and behavioural psychologists leading to the development of influential theories of hypnosis and suggestion. 

            The “behavioural” theories of hypnosis can be traced to Pavlov’s physiological research in the late 19thcentury and his recommendations for the development of a hypno-psychotherapy based on “cortical inhibition” and conditioned verbal reflexes (Platonov, 1959).[5]  In the 1920s, the eminent behavioural psychologist Clark L. Hull commenced his influential programme of behavioural research on hypnosis published as Hypnosis & Suggestibility: An Experimental Approach (1933).  Hull concluded that he could find no essential features of the “hypnotic state” except an increase in “prestige” suggestibility.  Hull’s failure to demarcate “hypnotic trance” from normal suggestibility led early social psychologists to re-conceptualise hypnosis as an inter-personal construct comprising ordinary cognitive and behavioural factors. 

            Hence, Robert White’s aptly-named 1941 article ‘A preface to the theory of hypnotism’ is usually cited as the origin of the social psychological and cognitive-behavioural tradition in hypnosis which progressively undermined the popular concept of “hypnotic trance” .  White argued that research suggested hypnotic responses were primarily due to the conscious attitudesand voluntary efforts of the subject.  In an oft-quoted passage, he rejected the mechanical connotations of traditional descriptions and radically re-defined hypnosis as follows, 

Hypnotic behaviour is meaningful, goal-directed striving, its most general goal being to behave like a hypnotised person as this is continuously defined by the operator and understood by the client. (White, 1941) 

From White’s perspective “hypnosis” becomes essentially a verb rather than a noun, a skillrather than a passive state, something the subject actively “does” rather than something that automatically “happens” to her as a result of “mechanical” induction rituals and suggestions.

            White thereby set the agenda that hypnosis should “take its place as a chapter in social psychology”.  This was fulfilled in the 1950s through a programme of research led by the social “role-taking” theorist Theodore Sarbin who explicitly rejected “hypnotic trance” in favour of what he subsequently called a “cognitive model of action”, i.e., behaviour (Sarbin & Coe, 1972, p. 66).  Sarbin proposed that behavioural responses were mediated by cognitive factors, primarily identification with social roles, not unlike Beck’s “core beliefs” and “schemas”.  Hence, Sarbin replaced the Victorian concept of “trance depth” with degrees of imaginative “role-involvement” and was the first researcher to combine cognitive factors from social psychology with behaviourism and formulate a fully-elaborated “nonstate” theory of hypnosis.  As Nicholas Spanos, following Sarbin, later spelled out,

Social psychological accounts of hypnotic responding are not alternatives to cognitive accounts; they are cognitive accounts.  More specifically, social psychological accounts construe hypnotic subjects as continuously modifying their cognitive activities and behaviour in terms of the changing social context that constitutes the ongoing hypnotic situation. (Spanos, 1982, p. 258)

In 1974, Hypnotism: Imagination & Human Potentialities, which became one of the most widely-referenced texts in the history of hypnosis research was published by Theodore Barber, Nicholas Spanos, and John Chaves.  Their detailed review of experimental research on hypnosis led them to follow Sarbin in rejecting the concept of “hypnotic trance”. 

An alternative point of view, which is elaborated in the present text, might be labelled the cognitive-behavioural viewpoint.  This approach proceeds to account for so-called “hypnotic” experiences and behaviours without postulating that the subjects are in a special state of “hypnotic trance”. […] From the cognitive-behavioural viewpoint, subjects carry out so-called “hypnotic” behaviours when they have positive attitudes, motivations, and expectations toward the test situation which lead to a willingness to think and imagine with the themes that are suggested. (1974, p. 5)

Barber’s research team produced a wealth of empirical evidence supporting what they christened the “cognitive-behavioural” theory of hypnosis.  They also compared the processes involved in hypnotherapy and behaviour therapy, i.e., Wolpe’s “systematic desensitisation”, and concluded that, once the concept of “hypnotic trance” was rejected, research on mediating factors suggested considerable overlap between the two approaches (1974, p. 141).

            Sarbin and Barber were followed by other well-known researchers who developed different aspects of what is variously known as the “nonstate”, “sceptical”, “socio-cognitive” or “cognitive-behavioural” approach to hypnosis.  As Andre Weitzenhoffer, a well-known critic of this approach, put it,

Most members of these groups directly and indirectly credit Robert W. White for giving impetus to this school of thought.  However, it was Theodore Sarbin, first, and later Theodore X. Barber (and from then on their students and collaborators) who were most responsible for the development of the cognitive-behavioural position. (Weitzenhoffer, 1972, p. 112)

A concise up-to-date summary of “cognitive-behavioural” models was given by Lynn and O’Hagan in which several groups of hypnosis researchers are distinguished, who emphasise the following factors, 

(a) enactment of the social role of a hypnotised person (William Coe, Theodore Sarbin);
(b) attitudes and beliefs about hypnosis, fantasy involvements and motivated engagement with imaginative suggestions (T.X. Barber);
(c) cognitive strategies, goal-directed activities and interpretation of suggestions (John Chaves, Nicholas Spanos, Graham Wagstaff); and
(d) expectancies, response sets and automatic responses in everyday actions (Irving Kirsch, Steven Jay Lynn). (Lynn & O’Hagan, 2009) 

When the “cognitive-behavioural viewpoint” and terminology are adopted, innate similarities between hypnotherapy and CBT become more and more apparent.            

Moreover, similarities between cognitive and hypnotherapeutic theories of psychopathology have been noted by both Beck and Ellis, the two most influential pioneeres of modern “cognitive” therapy.  Essentially, cognitive models emphasise the central role of factors such as rigid demands (Ellis) or schemas and automatic thoughts (Beck) in the aetiology of the neuroses, etc.  Braid repeatedly emphasised the role of negative automatic thoughts (“involuntary dominant ideas”) in various psychological problems especially so-called “conversion hysteria”, employing hypnotherapy to “break down the pre-existing, involuntary fixed, dominant idea in the patient’s mind, and its consequences.” (Braid, Hypnotic Therapeutics, 1853).  

The most striking cases of all, however, for illustrating the value of the hypnotic mode of treatment, are cases of hysterical paralysis, in which, without organic lesion, the patient may have remained for a considerable length of time perfectly powerless of a part, or of a whole body, from a dominant idea which has paralysed or misdirected his volition. (Braid, 1853)

Braid proceeded to describe how hypnotherapy opposes negative ideas with counter-acting suggestions. 

In such cases, by altering the state of the circulation, and breaking down the previous [negative] idea, and substituting a [positive] salutary idea of vigour and self-confidence in its place (which can be done by audible suggestions addressed to the patient, in a confident tone of voice, as to what must and shall be realised by the process he has been subjected to) on being aroused a few minutes afterwards, with such [positive] dominant idea in their minds, to the astonishment of themselves as well as of others, the patients are found to have acquired vigour and voluntary power over their hitherto paralysed limbs […]. (Braid, Hypnotic Therapeutics, 1853)

Indeed, this concept of suggestion as both causeand cure of “hysteria” was central to Victorian hypnotherapy especially Bernheim’s Nancy School[6] whose members, e.g., attributed stuttering, blushing, and agoraphobia to irrational autosuggestion (Moll, 1889, p. 58).  Hence, the attribution of various problems to involuntary “autosuggestion” was also taken over by the New Nancy School of Emile Coué (1923). 

            The founder of REBT, Albert Ellis, studied the writings of Coué as a young man (Ellis, The Road to Tolerance: The Philosophy of Rational Emotive Behavior Therapy, 2004, p. 19) and negative cognition is repeatedly described in Ellis’ early writings as a form of “negative autosuggestion.”  Musing over the therapeutic power of hypnotic suggestion, e.g., he 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 auto-suggested by himself. (Ellis, 1962, p. 277) 

Ellis’ early study of Couéism and autosuggestion seems therefore to have inspired the REBT theory of irrational beliefs.

            Likewise, in one of his earliest books on Cognitive Therapy, Beck compares his cognitive theory of psychopathology to the Victorian hypnotists’ theory of “hysterical” autosuggestion which he dubs “the illustration par excellence of the phenomenon of cognitive distortion in psychiatric disorders.”  Beck draws direct analogies between the mechanism underlying hypnotherapy and his own approach, concluding that the Victorian hypnotherapists’ autosuggestion theory is more consistent with Cognitive Therapy than Freud’s psychoanalytic theory (Beck A. T., 1976, pp. 207-208).

 

Cognitive-Behavioural Hypnotherapy & CBT

So how do hypnotism and CBT relate therapeutically?  Dobson prefaces his Handbook of Cognitive-Behavioural Therapiesby emphasising the lack of a consensual definition.  He tentatively concludes that, broadly speaking, “for a treatment to be accurately labelled a cognitive-behavioural therapy, it must be based on the mediational model.” (2001, p. xii).  On this view, CBT is a relativelybroad church which encompasses Ellis’ REBT and Beck’s Cognitive Therapy but also Meichenbaum’s self-instruction training, and various other methods.  Some of these approaches are more indebted to behaviourism than others although all recognise the central role of cognition in some shape or form. 

            However, hypnotherapy also evolved through inter-action with behavioural psychology and inspired many behaviour therapy interventions, particularly desensitisationand aversion.  Weitzenhoffer’s  literature review showed that for many decades hypnotherapists had employed behavioural psychology concepts, derived from Hull and Pavlov, and used techniques overlapping behaviour therapy, justifying the label “behaviouristic hypnotherapy” (Weitzenhoffer, 1972).  Moreover, behavioural hypnotherapy would arguably meet Dobson’s definition of CBT as it necessarily emphasises the mediating role of cognition, not least insofar as verbal suggestion and autosuggestion are essentially cognitivefactors (Kroger & Fezler, Hypnosis & Behavior Modificaiton: Imagery Conditioning, 1976, p. 13).

            There are therefore a growing number of clinical texts which attempt to integrate techniques from hypnotherapy with CBT and vice versa.[7]  However, theory and practice are not totally correlated and some hypnotherapists employ CBT-related techniques without embracing the cognitive-behavioural theory of hypnosis.  Alladin’s recent book Cognitive Hypnotherapy, e.g., employs Hilgard’s “neo-dissociationist” theory in which hypnotic trance, rather than ordinarycognition, mediates behaviour (2008, p. 37).  By contrast, explicitly “cognitive-behavioural” (nonstate) theoriesof hypnosis are, of course, especially well-suited to integration with CBT techniques.  

Hypnosis and cognitive-behavioural psychotherapy are well suited to each other because of the historical connection between them and their procedural similarities.  The use of hypnosis in cognitive-behavioural therapy is as old as behaviour therapy itself. […] Cognitive and behavioural therapies are especially compatible with the cognitive-behavioural approach to hypnosis. (Kirsch, Capafons, Cardeña-Buelna, & Amigó, Clinical Hypnosis & Self-Regulation: Cognitive-Behavioural Perspectives, 1999, pp. 4-5)

Undoubtedly, there is negligible reference to “Socratic disputation” in the history of hypnotherapy[8] and therefore limited overlap with Beck and Ellis’ approaches.  However, “covert” behaviour therapy techniques like desensitisation, behaviour rehearsal, exposure, modelling, reinforcement, and sensitisation, and cognitive rehearsal techniques like Meichenbaum’s “self-instruction training” (1977) bear considerable resemblance to hypnotherapy techniques. 

            Moreover, following the work of Sarbin and Barber, a variety of “skills training” methodologies influenced by social learning theorists such as Bandura evolved in the 1970s (Diamond, 1989), followed by an extensive programme of research led by Nicholas Spanos at Carleton University which culminated in the Carleton Skill Training Programme (CSTP), the most empirically-supported methodology for enhancing hypnotic responses.  According to Gorassini & Spanos, “the client is provided with instruction in tactics for successful responding and given a chance to observe models demonstrating appropriate behavioural and cognitive responses.” (1999, p. 151).

            In recent decades, skills training methods have led to the development of a specific clinicalapproach called “emotional self-regulation therapy” (ESRT) (Kirsch, Capafons, Cardeña-Buelna, & Amigó, Clinical Hypnosis & Self-Regulation: Cognitive-Behavioural Perspectives, 1999) which trains clients to use autosuggestion for therapeutic purposes in a manner harking back to the New Nancy School of Emile Coué.  This cognitive-behavioural derivative of hypnotherapy also greatly overlaps with methods such as Meichenbaum’s self-instruction training, itself influenced by Couéism (Meichenbaum, 1977, p. 160).  Salvador Amigó, one of the developers of ESRT, writes, 

The fundamental component of ESRT is sensory recall.  ESRT is a synthesis of suggestive procedures derived from cognitive-behavioural studies of hypnosis (e.g., motivational instructions, instructions to think with suggestions, and procedures to teach people how to increase their responsiveness to suggestions). (1999, p. 313)

 ESRT is basically divided into three broad phases, 

  1. The treatment rationale is presented and clients are taught to trigger sensory and muscular responses while using a physical aid, e.g., feelings of heaviness and arm-lowering while holding a heavy book.
  2. The physical cues are gradually “faded” and the client rehearses using cognitive and behavioural strategies to evoke the feeling purely by means of sensory recall, e.g., using cues, autosuggestions, mental imagery, etc.
  3. Generalisation of the skills is rehearsed by using similar strategies to evoke responses to suggestions which have not been previously rehearsed, e.g., including therapeutic autosuggestions. (1999, pp. 313-314)

However, the originalhypnotic therapy can be seen as anticipating cognitive-behavioural skills training methods.  Braid coined the term “psychophysiology” to refer to the inter-action between mind and body and therefore made a distinction between two complementary forms of suggestion. 

  1. Dominant ideas, which influence bodily responses by means of the “ideo-dynamic reflex”.
  2. Muscular suggestion, which reverses the normal causal sequence between mind and body and evokes subjective states through changes in body posture, facial expression and gestures.

 “Dominant ideas” later become known, following the Nancy School, as “autosuggestions”; Braid’ theory of “muscular suggestion”, though less well-known, was equally central to hypnotherapy.  

In this way, we influence the muscles of physiognomy [facial expression] and it is possible for us to arouse any passion or sentiment whatsoever; the contraction of the interconnected muscles, constituting “the anatomy of expression”, evokes in the brain of the hypnotised person certain impressions just as these, in the waking state, determine the whole facial expression.  It is thus merely a reversal of the usual order [of causation] between the emotions and their physical expressions. (Braid, “On Hypnotism” (1860) De L’Hypnotisme, 2009)

Braid’s theory of “muscular suggestion” therefore prefigures the influential James-Lange theory of emotion, utilised in later behaviour therapy (James, 1884). 

            In the parlance of modern skills training approaches (CSTP, ESRT) Braid’s hypnotherapy model might be expressed as follows, 

  1. Cognitive strategies, i.e., the “ideo-dynamic reflex” identified by Braid, although hypnosis researchers now add attentional, dissociative, and other high-level responses.
  2. Behavioural strategies, i.e., the “muscular suggestion” identified by Braid and therefore the James-Lange method and related role-taking (acting “as if”) techniques in CBT.

Indeed, the rationale for Braid’s original hypnotic “eye-fixation” method becomes apparent when this reciprocalcognitive and behavioural theory of suggestion is borne in mind.  Subjects were instructed to employ several behavioural strategies, i.e., to voluntarily act “as if” they are falling asleep by stilling their body, relaxing their breathing, and closing their fatigued eyelids lethargically.  Braid must assume that these “muscular suggestions” would evoke subjective feelings of sleepiness by what he terms the “law of association”.  Simultaneously, clients were asked to focus conscious attention upon the idea of sleep thereby evoking the ideo-dynamic reflex response, i.e., a simple cognitive strategytermed “sensory recall” by behaviourists (Kroger & Fezler, 1976).[9]

Conclusion

I have tried to outline the historical role of early social and behavioural psychology in shaping what finally became the “cognitive-behavioural” theory of hypnosis in the 1970s and to show how similarities in the “cognitive” and “suggestion” models of psychopathology lead to potential overlaps in the theory and practice of modern hypnotherapy and CBT.  The influence of nonstate theories on skills training methodology (CSTP) and self-regulation therapy (ESRT) has been discussed, which brings us full-circle to consideration of their precursors in the original “ideo-motor” hypnotherapy of James Braid.

            In short, the tangled historical web of theory and practice which binds hypnotherapy and CBT together both conceals and reveals.  It highlights useful parallels when we employ a shared terminology, and abandon pseudoscientific concepts like “hypnotic trance”, but fads in terminology have also served to obscure the relevance of previous therapeutic literature.  However, periodically returning to our roots can be an opportunity to unearth aspects of psychological therapy, such as Braid’s concept of reciprocal cognitive and behavioural suggestion strategies, which potentially contribute to modern psychotherapy.

Bibliography & Works Cited

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Barber, T. X., Spanos, N. P., & Chaves, J. F. (1974). Hypnotism, Imagination, & Human Potentialities.New York: Pergamon Press.

Beck, A. T. (1976). Cognitive Therapy & Emotional Disorders. New York: International University Press.

Beck, J. S. (1995). Cognitive Therapy: Basics & Beyond.New York: Guilford Press.

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Diamond, M. J. (1989). The Cognitive Skills Model: An Emerging Paradigm for Investigating Hypnotic Phenomena. In N. P. Spanos, & J. F. Chaves (Eds.), Hypnosis: The Cognitive-Behavioural Perspective (pp. 380-399). New York: Prometheus.

Dobson, K. S. (Ed.). (2001). Handbook of Cognitive-Behavioural Therapies (Second Edition).New York: Guilford Press.

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Ellis, A. (2004). The Road to Tolerance: The Philosophy of Rational Emotive Behavior Therapy. New York: Prometheus Books.

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Footnotes

[1] This is too complex a subject to treat comprehensively in a short article so I’ll confine myself to an outline which must necessarily leave certain key concepts and debates untouched.

[2] Depending on whether a possible statistical “outlier” is excluded.

[3] I’ve explored Braid’s development of hypnotism in detail in my edition of his collected writings The Discovery of Hypnosis (2009).

[4] It’s perhaps worth noting in passing that, prima facie, “ideo-motor” might mean exactly the same thing as “cognitive-behavioural”.

[5]Pavlov’s model of hypnotism subsequently became the basis for very large-scale implementation of Soviet hypno-psychotherapy programmes as documented by Platonov (1959).

[6] The most influential Victorian school of hypnotic psychotherapy.

[7] There are too many to fully reference here but a selection is shown in the bibliography.

[8] Although some early 20thcentury hypnotists like Morton Prince and Platonov did assimilate Paul Dubois’ “rational persuasion” method into hypnotherapy, which is a primitive cognitive disputation approach, this faded into obscurity.

[9] Braid nowhere claims that this technique induces a hypnotic “trance” but rather that hypnotic therapy is reducible to these “well-established” psycho-physiological laws of association.

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