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Strategies & Applications of CBH
What is Cognitive-Behavioural Hypnotherapy? (Hypno-CBT®)
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 originally by Donald Robertson. It integrates elements of CBT with hypnotherapy in the same way that hypno-analysis traditionally combines elements of psychoanalysis with hypnotherapy.
The cognitive therapies are so-called because they share an emphasis upon the role of cognition in psychopathology and in psychotherapy. The word “cognition” comes from the Latin cognitus meaning “to know.” Cognitions are thoughts, spoken or otherwise, which express a statement of belief. For instance, the thought “The cat is on the mat”, is a cognition; the thought “Ouch!” is not. Cognitions, crucially, can be true or false and are therefore susceptible to rational and evidence-based disputation. Cognitions, of course, can be helpful or harmful, rational or irrational, good or bad, healthy or unhealthy, negative or positive, etc.
Emphasis upon the way that our beliefs shape our experiences is central to all forms of cognitive therapy. In their Handbook of Cognitive Behavioural Therapy, Dobson and Dozois offer a formal definition of CBT in terms of the following characteristic, shared assumptions,
- Cognitive activity affects behaviour.
- Cognitive activity may be monitored and altered.
- Desired behaviour change may be affected through cognitive change. (Dobson & Dozois, in Dobson, 2001: 4)
They add, in elaboration,
A number of current approaches to therapy fall within the scope of cognitive-behavioural therapy as it is defined above. These approaches all share a theoretical perspective assuming that internal covert processes called “thinking” or “cognition” occur, and that cognitive events may mediate behaviour change. (Ibid.: 6)
It should be noted that this definition is broad enough in scope to encompass many traditional forms of hypnotherapy.
Hypnotherapy as Cognitive-Behavioural Therapy
Even James Braid’s later “ideo-dynamic” model of hypnotherapy, from the mid-Victorian era, could be interpreted as cognitive-behavioural in this sense. Braid believed that negative “fixed ideas” were responsible for many problems. He introduced the technique of using hypnosis to “break down the pre-existing, involuntary fixed, dominant idea in the patient's mind, and its consequences.” (James Braid, Hypnotic Therapeutics, 1853). This was done by replacing negative fixed ideas with positive, therapeutic suggestions.
The Nancy School of Liébault and Bernheim, the most influential school of Victorian psychotherapy, developed this notion even further. Bernheim argued that most psychopathology was due to negative autosuggestion and could be rectified either by rational persuasion, aimed at disputing these fixed ideas, or by direct positive suggestions of a counter-acting nature. In the 1920s, Coué made this very explicit in his system of self-help through “conscious autosuggestion”,
From our birth to our death we are all the slaves of suggestion. Our destinies are decided by suggestion. It is an all-powerful tyrant of which, unless we take heed, we are the blind instruments. Now, it is in our power to turn the tables and to discipline suggestion, and direct it in the way we ourselves wish; then it becomes auto-suggestion: we have taken the reigns into our own hands, and we have become masters of the most marvellous instrument conceivable. (Emile Coué, My Method, 1923: 6)
More recently, in the 1980s, Daniel Araoz introduced the term “negative self-hypnosis” to describe the role of harmful suggestions in psychopathology. The notion of negative autosuggestion or self-hypnosis in traditional hypnotherapy clearly pre-empts the parallel concept of “negative automatic thoughts” in modern cognitive-behavioural therapy.
Moreover, hypnotherapy since the time of Braid has also evoked physical responses such as aversion and relaxation to directly counter-act states such as craving or anxiety with which they are mutually exclusive. This fundamentally pre-empts the concept of “reciprocal inhibition” which forms the basis of modern behaviour therapy as introduced by Wolpe in the late 1950s.
The Cognitive-Behavioural Theory of Hypnosis
The central theoretical debate in the history of hypnotism is known as the “state versus nonstate” argument. Proponents of the nonstate position have tended to argue that rather than requiring a special theory which posits a unique, altered state of consciousness or “trance” state, hypnosis can be better explained by established psychological theories which draw upon familiar concepts. Because they tend to explain hypnosis in terms of cognitive, behavioural, and social psychology, the theories of influential hypnotic researchers like Sarbin, Barber, Kirsch, et al., are termed “cognitive-behavioural” or “sociocognitive.”
Since the 1960s, cognitive-behavioural theories of hypnosis have tended to dominate, and state theories have been revised to the extent that they are now virtually assimilated within the nonstate models. For instance, the idea of a special altered state of consciousness or “trance” has been reduced largely to the theory that some hypnotic subjects respond to suggestion partly because of increased absorption in their imagination. This is “trance” in such a watered-down and “naturalistic” sense that it is easily accepted by the cognitive-behavioural theorists as part of ordinary psychological functioning.
Although the cognitive-behavioural theory of hypnosis and cognitive-behavioural therapy are two fundamentally different things, it is important to see the connection between them. Both share a similar terminology and set of concepts. However, cognitive-behavioural theories of hypnosis have been discussed in the research literature for many decades prior to the development of modern cognitive or behavioural therapy.
Hypnotic Skills Training
Many hypnotherapists dismiss the state versus nonstate as irrelevant to practice. This is wrong, and betrays a basic misunderstanding of the issues at stake. In fact, the cognitive-behavioural theory of hypnosis has led to the gradual development, mainly in the 1980s, of hypnotic skills training programmes designed to increase the hypnotic responsiveness of subjects as measured by validated psychometric scales. One of the earliest expressions of the social psychology position is found in the personality psychologist Robert White’s ‘A preface to the theory of hypnotism’ published in 1941. White writes,
Hypnotic behaviour is meaningful, goal-directed striving, its most general goal being to behave like a hypnotised person as this is continuously defined by the operator and understood by the client. (White, 1941)
In other words, the hypnotic subject is not a passive recipient of hypnosis but has a specific role to fulfil, which they may do well or badly. As White puts it, good hypnotic subjects generally make substantial “spontaneous additions” to the hypnotic process by the way they behave, the things they tell themselves, and what they imagine, as the hypnotists speaks to them. In reality, there are two hypnotic processes occurring in parallel, the suggestions coming from the hypnotist (hetero-hypnosis) and the internal dialogue and stream of consciousness of the subject (self-hypnosis). The role of the subject is to develop an internal state that complements the suggestions of the hypnotists, but this state will vary depending upon the goals of suggestions and is mediated by a range of different “subjective strategies.” Skills training can help the subject both to understand and fulfil this role.
It is now firmly established, that special programmes of cognitive-behavioural skills training can successful enhance hypnotic responses. The most important approach is known as the Carleton Skills Training Programme (CSTP) and its effects have been independently confirmed by many different psychology departments at leading universities.
Cognitive Disputation & Restructuring
Contrary to popular misconception, psychotherapists have made use of “rational” methods of therapeutic “persuasion” and “Socratic” disputation, since the late Victorian era. For instance, the Swiss psychotherapist Paul DuBois (1848-1918) was world-renowned for his persuasive psychotherapeutics, which attempted to identify harmful patterns of thinking and correct them. DuBois’ school of psychotherapy, which rivalled that of Freudian psychoanalysis, had considerable influence upon early 20th 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.
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,
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.
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.
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.
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).