On Ericksonian Hypnotherapy from The Practice of Cognitive-Behavioural Hypnotherapy (2012)

On Ericksonian Hypnotherapy

[This is the section on Ericksonian Hypnotherapy, reviewing some key summaries of clinical and experimental research, from The Practice of Cognitive-Behavioural Hypnotherapy (2012) by Donald Robertson.  It takes a critical stance, because cognitive-behavioural hypnotherapy, the subject of this book, is based on different conclusions about the nature of hypnotherapy from Erickson’s approach, and cites the scientific evidence supporting the CBH perspective and conflicting with the Ericksonian approach, as well as comments on the differences from several key cognitive-behavioural authors.]

Practice-of-CBH-Cover-3It is important to spell out the fact that these principles conflict with certain key aspects of one of the most popular approaches to hypnotherapy, the so-called “Ericksonian” approach, derived from the work of the late Dr. Milton Erickson. Erickson’s approach is best-known for its emphasis on “indirect” forms of suggestion. However, these constitute a radical departure from traditional forms of hypnosis, which emphasise more direct methods. This has led to some disagreement over the extent to which Erickson’s approach can be compared to previous forms of hypnotism, or even whether it might be better called something else, other than “hypnotism”, to avoid confusion. One of the key difficulties here is that indirect suggestions appear to function by means of a fundamentally different mechanism from traditional hypnotic suggestion, meaning that conclusions derived from research on hypnosis do not necessarily relate to what Erickson’s followers actually do under that name. For example, Lynn et al. define hypnotic suggestion as follows:

Unlike placebos, misleading questions and other forms of indirect suggestion, hypnotic suggestions are requests for imaginative experiences, and for that reason they can also be termed imaginative suggestions. (Lynn, Kirsch, & Hallquist, 2008, p. 112)

By that definition, much of “Ericksonian hypnotherapy” is clearly not employing hypnosis at all and would perhaps be better labelled “indirect suggestion therapy”, which may or may not turn out to be a useful therapy approach in its own right but cannot claim to do so on the back of research on traditional direct-suggestion hypnotherapy. For example, in the meta-analytic study mentioned above, out of 57 randomised controlled trials reviewed, only 19% were found to have employed predominantly indirect techniques (Flammer & Bongartz, 2003). Overall conclusions about the efficacy of hypnotherapy therefore relate mainly to the use of more traditional-style techniques.

Moreover, although it is often claimed by people promoting commercial workshops on “Ericksonian hypnosis” that the indirect approach is dramatically more effective than direct suggestion, especially with “resistant” clients, this appears to be little more than marketing hype. Indeed, a review of twenty-nine independent studies comparing direct and indirect suggestion styles was conducted by Lynn and his colleagues, which found both styles broadly equivalent in terms of their effectiveness (Lynn, Neufeld, & Maré, 1993). They found no evidence across these studies that indirect suggestions improved responses to test items on hypnotic susceptibility scales, as Ericksonians had predicted, or that they somehow bypassed the subject’s resistance.

We believe it is fair to conclude that the best controlled studies provide no support for the superiority of indirect suggestions, and there are indications that direct suggestions are superior to indirect suggestions in terms of modifying subjects’ experience of hypnosis. (Lynn, Neufeld, & Maré, 1993, pp. 138-139)

Unfortunately, the Ericksonian approach also has the disadvantage of being more complex, time-consuming, and less consistent with general principles of evidence-based psychotherapy. Moreover, Lynn and Kirsch observe that many popular workshops that teach indirect hypnosis, loosely based on the Ericksonian approach, make absurdly extravagant claims for their methods.

However, research indicates that many of these specialised techniques provide no benefit whatsoever, and some may even decrease the effectiveness of a hypnotic intervention. In general people who receive traditional authoritative and direct suggestions pass as many suggestions as do people who receive more permissive and indirect suggestions. Although direct or authoritative suggestions may engender feelings of suggestion-related involuntariness more so than would indirect or permissively worded suggestions, these differences are small in magnitude. (Lynn & Kirsch, 2006, p. 42)

It has also been the author’s experience that many popular books and workshops tend to confuse students and to mislead them about the nature of hypnosis and its role in psychological therapy, often making claims that are completely inconsistent with research in the field of hypnotism.

Moreover, Erickson’s approach emphasised the notion that the therapist should try to circumvent clients’ “resistance” by influencing them outside of their awareness, using indirect means. This “pulling the wool over their eyes” approach to suggestion, which typically emphasises the need to deceive the client about the content of suggestions supposedly given, fundamentally clashes with some of the basic professional values of modern therapy, which emphasise “informed consent”, collaboration, and education, etc. Likewise, Erickson is associated with the deceptive use of “paradoxical” therapy techniques, which run counter to the expectations of the client rather than being based upon a shared treatment rationale. Hence, regarding the cognitive therapy of anxiety, Beck and his colleagues write:

Although some techniques may appear paradoxical (for example, if someone is afraid of anxiety, he is asked to experience it), cognitive therapy avoids paradoxical techniques in the usual [e.g., Ericksonian] sense. The therapist does not prescribe symptoms or use restraint-from-change procedures unless in a straightforward way with the rationale clearly spelled out. We have, for example, had patients purposefully try to make themselves more anxious as a way to counteract their anxiety. This is presented as a coping technique that the patient can choose to use, and is not a strategy the therapist is covertly [i.e., indirectly and surreptitiously] using to combat the patient’s anxiety. (Beck, Emery, & Greenberg, 2005, p. 176)

Likewise, Curwen, Palmer, and Ruddell, although including a chapter dedicated to hypnosis in their book on brief CBT, make a point of specifying that the Ericksonian “indirect suggestion” approach potentially conflicts with the basic collaborative stance in CBT.

Because in cognitive behaviour therapy an open, collaborative approach is used in which the theory and practice of each intervention are explained to the client, direct suggestion explicitly focusing on the particular problem concerned is employed in the hypnosis script and indirect suggestion is avoided. (Curwen, Palmer, & Ruddell, 2000, p. 132)

Arguably, therefore, the “indirect” approach characteristic of the followers of Erickson, insofar as it involves an element of deception, is inherently antagonistic to the basic CBT principle of collaboration. However, traditional hypnosis, which employs direct (conscious) suggestions to which the client gives her attention and her voluntary consent, is a different matter entirely, and completely consistent with CBT and the principle of collaborative therapy. Direct suggestions are sometimes termed “imaginative suggestions” to highlight the fact that they are intended as explicit invitations for the client to actively imagine the things being described and are therefore addressed primarily to her conscious mind, to put it crudely. As we shall see, Braid’s original definition of hypnotism was in terms of focused (conscious) attention on a particular idea or mental image accompanied by the (conscious) expectation that some response would happen as a result. Only later, did certain authors seek to portray hypnotism, in more obfuscating and mystifying terms, as something to do with “talking to the unconscious mind” of the client.

Consequently, sometimes CBT practitioners are quite concerned that hypnotists encourage “magical thinking” or surround themselves with mystique. This is true of some approaches to hypnotherapy but not others. It was, in particular, a criticism levelled against Erickson by Barber. In a symposium discussion of one of Erickson’s papers summarising some aspects of hypnosis research, Barber said:

It seemed to me that half of Dr. Erickson’s presentation was from the position of a natural scientist, psychologist, and psychiatrist trying to understand what hypnosis is; the other half of the time the presentation seemed to be from the position of someone of many years ago who really thought hypnosis was a mysterious, magical thing. […] the subject goes into a trance, and when he is in a trance, magiclike things happen. It is implied that a kind of mysterious thing happens because of trance. (Erickson, 1980, pp. 333-334)

This quotation is important because it highlights very clearly the fundamental difference in outlook between the Ericksonian tradition in hypnotism and the cognitive-behavioural approach, represented by Barber. The more “common sense” and skeptical cognitive-behavioural perspective is fairly dominant in the current research literature, although many hypnotherapists are still drawn to the Ericksonian approach despite the lack of evidence supporting it.