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Vol. 8 No. 2 September 1987
The Theory and Practice of Cognitive Behavioural Hypnosis
Alfred D. Kornfeld, Ph.D.
Psychology Department
Eastern Connecticut State University

ABSTRACT
An outline of some recent developments in the field of therapeutic hypnosis is presented with a focus on treatment of the individual adult. A question is raised regarding the work of some authors, i.e. Ericksonian techniques, and the validity of its relationship to hypnosis as such. It is noted that there is a low level of research sophistication associated with reported clinical studies.

INTRODUCTION
There has been a recent proliferation of cognitive behavioural techniques in the field of therapeutic hypnosis (Kornfeld, 1985). This paper attempts to outline some of the more recent developments in the area. My goal is not to develop a unique approach, but rather to bring together a number of interrelated concepts to further theory and clinical practice. In addition, the focus will be upon the treatment of the individual adult.

Many of the concepts presented here have long been known to hypnotic clinicians, and it can be argued that we may have an “old wine in new bottles” situation. For example, much of the early 20th century clinical hypnosis literature deals with symptomatic problems (migraine, alcoholism, drug dependency, and smoking) in a manner that is reminiscent of behaviour therapy (Freedberg, 1973). The theory of cognition and hypnosis itself has its roots in late nineteenth century psychotherapy. While the role that hypnosis has played in the development of Psychoanalysis is well documented (Gravitz & Gerton, 1984), Freud’s early and more cognitive interpretation of hypnosis is less familiar.

In discussing a successful hypnotic treatment of a young woman, Freud (1968) proposed that there is a category of ideas that deal with expectations and which has two members: First intentions which refer to self-initiated, self-directed activity. Secondly, expectations proper which refer to things being done or happening to the individual. The amount of negative emotion attached to intentions and expectations is determined by additional cognitive factors, specifically the degree of importance of the event and the belief that the outcome will be a negative one. The resulting negative belief, is labelled by Freud a counter expectation or “distressing antithetic idea”. In the case of intentions, the associated cognition is “I will not succeed in carrying out my intentions because this or that is too difficult for me”. The corresponding cognition for expectations involves enumerating all of negative things that could occur. Hypnosis is successful when it modifies negative intentions or expectations proper. Of course, this sounds very much like the theorizing of a contemporary cognitive behaviour therapist.

COGNITIVE BEHAVIOUR THERAPY (CBT) PRINCIPLES
In spite of the aforementioned historical antecedents, one can not deny the impact that the so-called “Cognitive Revolution” has had on all forms of psychological treatment, including hypnosis. Cognitive Behaviour Therapy (CBT) is a term that applies to a wide variety of therapeutic techniques. CBT’s common features include: (1) an active, time-limited and structured approach to therapy; and (2) the assumption that how a person feels and behaves is determined by how that individual construes the world.
Some of the key therapeutic elements of CBT include:
1. Entering the patient’s perspective. Treatment compliance is believed optimal when the “fit” between the patient’s expectations and the therapist’s approach is maximized (Turk et. Al., 1983).
2. Changing the patient’s perspective or “reconceptualization of the problem”. This includes: (a) education: reframing the patient’s expectations and assumptions through a dialogue. The goal here is both a redefinition of the problem and an increase in patient morale and expectation that there is some reason for hope. The overall emphasis is on a collaborative relationship; and (b) collecting data, i.e., experiences, behaviours, images, etc.
3. Encourage the patient to engage in actual high probability behaviours in situations where they are most likely to attribute the behaviour to their own capability rather than to an outside force.
4. Consolidation of the changes, promoting generalization, and laying a foundation for the maintenance of change.
5. Dealing with relapse: Prepare patient for the possibility of relapse. Relapses should be a signal for new coping efforts rather than reinforcing beliefs involving failure.

COGNITIVE BEHAVIORAL HYPNOSIS
Cognitive Behavioural Hypnosis (CBH) may be defined as the amalgamation of cognitive-behavioural and hypnotic techniques in the clinical setting. A cognitive behavioural approach recognizes the cognitive, affective, and situational elements that influence hypnosis (Turk et. al., 1983).

Gilandas (1985) argues that hypnosis has broadened the definition of behaviour therapy to include imaginal-cognitive components. Common therapeutic foci shared by hypnosis and behaviour therapy include motivational variables, expectance and attitudinal variables, specific direction / instruction and goal-directed imagining. Perhaps of greatest import for the cognitive behavioural therapist are the roles played in hypnosis by individual differences and suggestibility (Bowers, 1983).

At a more precise level of theoretical analysis, Smyth (1981) has proposed a theory of hypnotic suggestibility based upon social learning theory. In this model, attentional, symbolic, rehearsal, reproductive, modelling, and motivational factors combine to form a comprehensive structure. Smyth generates a number of practical techniques from his model. These include: (1) reinforcing subjects for closely attending to the words of the hypnotist; (2) graded training in dissociative skills; (3) training in goal-directed fantasy; and (4) presenting hypnosis in a favourable light. Smyth depicts the good hypnotic subject as having the ability to ignore contradictory and irrelevant stimuli.

At this point, I would like to turn my attention to some of the connections between Cognitive Behaviour Therapy and Hypnosis. First, both approaches emphasize an S-O-R rather than a pure S-R approach to understanding and controlling behaviour. Most hypnotic practitioners have long been aware of the importance of such organismic variables as belief, expectation, and image. In contrast, the efforts of such workers as Pavlov (1927), Hull (1968), and Salter (1961) to create a strictly S-R approach for hypnosis have been accepted only by a minority of hypnotic practitioners.

Secondly, both cognitive behaviour therapy and hypnosis focus on the relationship between changes in covert behaviour (images, thoughts) that accompany changes in overt behaviour.

Thirdly, both approaches are conceptually broad enough to allow for a diversity of theories and therapeutic techniques.

In a recent comprehensive and critical review of the literature, Spinhoven (1987) observes that hypnotic and imagination-based behaviour therapies share the common factors of relaxation-induction and imagination. It remains, however, to be demonstrated that a specific therapeutic factor (other than expectancy and credibility) is associated with hypnosis. The common assertion that hypnosis increases imagination and responsiveness to behavioural instructions is not supported by research findings. Cautela’s “covert conditioning” model (1975) illustrates how one may integrate operant conditioning and cognitive-imagery techniques without using hypnosis. Some clinicians and clients, however, maintain the belief that hypnosis does have a synergistic effect when added to other techniques. And, it seems to be good clinical practice to meet patient expectations when the latter are appropriate. In contrast, many behaviourally-oriented psychologists seem to set up hypnosis as a straw man to be demolished. Spinhoven cogently identifies the conflict as being between the behaviour therapist’s emphasis on rational, wilful, and deliberate control, and the hypnotic therapist’s interest in change effected through dissociative processes that are experienced as automatic or involuntary.

SOME GENERAL APPROACHES TO COGNITIVE BEHAVIOURAL HYPNOSIS
Some of the principles that are derived from cognitive behaviour therapy include:
1. Client expectations: Patient expectations play a significant role in cognitive approaches to hypnosis. Does the client desire or expect hypnosis? Has the client initiated the request for hypnosis? Lazarus (1973) has demonstrated that the withholding of hypnosis from clients who expect to receive it may result in negative therapeutic outcome. Referred patients may have a less positive view. What is the patient’s concept of hypnosis? How can this concept be utilized to insure maximum benefit?
2. The presence of negative and positive attitudes and previous experience with hypnosis. Again, can any of this be utilized and / or modified so as to insure greater compliance with hypnotic-suggestions? For example, Erickson employed the strategy of having recalcitrant subjects observing successful subjects.
3. Dealing with potential failures during hypnosis. More often than not, “failures” during hypnosis actually are improper matches between patient’s belief systems about hypnosis and their monitoring of their actual behaviour. Admittedly, it can sometimes be extremely difficult to modify a particular patient’s belief system. In many instances, however, this can be achieved.
4. Cognitively restructure failures during hypnosis so that they seem to be positive experiences. (Again the work of Erickson provides a number of useful ideas indicating how apparent “failures” may be reinterpreted as compliance with hypnotic directives).
5. A specific technique CBH technique that may be employed to increase patient compliance and minimize post-hypnotic failure involves first establishing through interviewing the nature of the client’s high probability failure situations. The client then may be instructed to visualize the failure situation, which exploit paradoxical intention.

The failure situation can then be transformed through suggestions to become a “discriminative” stimulus that is associated with behaviours that will lead to success. The behavioural literature provides two inspirations for this approach. First, Pavlov’s experiments using aversive stimuli as CS’s followed by positive reinforcement. Second, Goldfried’s (1977) approach which instructs subjects to remain with imaginal scenes when tension is experienced, rather than leaving them as is prescribed by systematic desensitization. Goldfried interprets standard relaxation training as resulting in an active coping skill rather than literally serving to counter-condition anxiety as hypothesized by Systematic Desensitization. Similarly, CBH views hypnosis as an active cognitive process that has significant coping power.

Consolidation of the changes, promoting generalization and laying a foundation for the maintenance of change are the penultimate concern of the therapist.

The final task is preparing patients for relapse. This is a concern of all types of psychotherapy. Depression, anxiety, pain, and habits are especially likely to return in some form. In the CBH approach, potential relapses are routinely redefined to the client as a signal for new coping efforts rather than reinforcing beliefs involving failure.

THE PATIENT’S COGNITIVE ACTIVITY
Earlier views of the patient by behavioural and hypnotic therapies were both simplistic and authoritarian. Patients were largely defined as passively responding in an entirely predictable manner to either stimulus input or suggestions.

However, recent research contradicts this simplistic model of human behaviour and calls attention to the complexity of cognitive operations present in behavioural and hypnotic therapies.

Smith (1986) observes that the cognitive-behavioural model of relaxation actually includes three components: focusing, passivity, and receptivity. He defines focusing as “the ability to attend to a restricted stimulus for an extended time”. Passivity is the ability to put aside goal directed and analytic activity. Receptivity is the willingness to accept the relaxed state in spite of experiences that are unfamiliar and uncertain. Smith ranks hypnosis as an intermediate in its demands for focusing, passivity and receptivity.

Smith also proposes that progressive relaxation and breathing exercises might be appropriate for beginners who lack experience with hypnosis or meditative techniques.

Sheehan and McConkey (1982) have proposed three modes of cognitive responses in hypnotic tasks. First a concentrative mode characterized by focusing on the communications of the hypnotist and thinking in literal terms. Second, an independent mode where the subject interprets the hypnotist’s communications in terms of personal meanings. Third, a constructive mode where subjects use a “scheme” to organize the information contained in the hypnotist’s communications. This latter mode minimizes contradictions in the hypnotist’s communications while maximizing consistency in the subject’s behaviour. The resulting subject/patient behaviour may be at variance with the hypnotist’s suggestions.

CLINICAL ILLUSTRATION
A 35 year old woman suffering from a severe form of “hormonal” migraine was being taught pain control. The patient had high hypnotic capacity, and quickly learned to block the pain which was on the right side of her head and behind her eye. While I had given her a number of possible substitutions for pain (numbness, tingling, benign focusing on some other part of her body), she independently chose a feeling of lightness on the right side of her face and behind her eye. It was my intention to then teach her self-hypnosis. As a preliminary, I suggested that just enough of the pain could return to allow for conscious awareness. To my surprise, there was an initial resistance to this suggestion, with the complete anaesthesia maintained by the patient. In a subsequent discussion, it soon became apparent that in no way was she going to give up her newly discovered ability to deal with pain and the resulting sense of relief and hope. It was only in a later session, when the pain control ability was secure, that this patient would allow herself to experience pain.

This model of active, spontaneous cognitive processing found in patients experiencing imaginal therapies is not new. In a classic study, Weitzman (1967) observed that systematic desensitization requires both internal observation and the ability to imagine a stimulus. In interviewing 200 clients following systematic desensitization he found a universal report of a “flow of visual imagery”. The original scene suggested by the therapist was actively transformed by the client resulting in spontaneous, autonomous, and affective fantasy productions that Weitzman likened to Jungian “guided imagery”.

There are examples from the experimental literature which also attest to the complex and active processing of information that takes place during hypnosis. For example, Spanos and Barber (1968) suggest that high hypnotic susceptibility subjects show a high level of sustained inattention when asked to forget material. Interestingly, the experimental subjects’ interpreted their experiences as effortless. In other words, the subjects were responding to the “demand characteristics” (Orne) of an experimental situation involving hypnosis and labelling their experiences accordingly.

SOME SPECIFIC APPLICATIONS
There are a number of cognitive-behavioural techniques that are relevant to hypnosis. However, these techniques can be grouped into three major categories: changing cognitions, modifying images, and correcting self-statements.

For example, Cognitive anxiety is mediated through self-statements, belief systems and expectations (Clarke and Jackson, 1983). Hypnosis may be applied to the direct modification of negative self-statements, as well as being employed as an adjunct to stress-inoculation and assertiveness training through the manipulation of images.

Howard & Reardon (1986) found a Cognitive-Hypnotic approach to be superior to both a cognitive restructuring and standard hypnotic procedure in self-concept, anxiety reduction, and weight-lifting performance.

The Cognitive-Hypnotic-Imagery approach utilized intense imagery, cognitive control and restructuring of negative beliefs and self-concepts. The authors argue for a synergistic effect when hypnosis and cognitive approaches are combined.

From a CBH viewpoint, symptoms and problems in living may be conceptualized as the result of “conditional spontaneous auto-suggestion”, a term borrowed from the Coue French school of autosuggestion. This describes a type of rapid, classical conditioned learning. The resulting expectations (Cs’s) are sufficient to elicit the original negative emotions. A similar concept is Negative Self Hypnosis (NSH) (Araoz, 1982), which is defined as non-conscious negative beliefs and defeatist negative images that are paradoxically maintained and / or strengthened by the individual, and in conflict with their conscious desires to positively change. Araoz observes that NSH is related to A. Ellis’ irrational beliefs, and he believes that NSH involves negative post-hypnotic suggestions that are akin to self-fulfilling prophecies. He recommends that NSH first be made conscious before any attempts at encouraging positive self-talk and behaviour.

Blumenthal (1984) employed a hypnotic approach to RET and argued that suggestions be phrased in such a manner as to maximize the likelihood that they will find a number of potential positive outlets or situations resulting in genuine positive changes.

“Rational Stage Directed Hypnotherapy” (Gwynne et. al. 1978) is another integration of RET and hypnosis. RET treatment is here presented in six stages, with cognitive restructuring implemented and reinforced through hypnosis. The time dimension is also manipulated via hypnosis, and thus patients may cognitively restructure events in the past, present, and future.

Powell (1980) combined a flooding technique with hypnotic desensitization for the treatment of habitual smokers. This study employed a variant of interesting combinations of cognitive and hypnotic techniques. The creation of a state of cognitive dissonance was manipulated through contrasting a heightened awareness of the need to smoke that conflicted with suggestions of a non-smoker identity.

Araoz (1985) has recently attempted to comprehensively integrate the findings of cognitive-behavioural, humanistic, and hypnotic therapies under the rubric of “The New Hypnosis”. He further claims that The New Hypnosis has its roots in the teaching of the “New Nancy School” and the experimental work of T. Barber.

Araoz emphasizes the concept of “suggestion” and frequently makes analogies to right hemispheric functioning when discussing hypnotic suggestion. He de-emphasizes rational functioning while he stresses the experiential aspects of hypnosis. He argues that the “New Hypnosis” is more natural than older authoritarian approaches to hypnosis and he sees the “New Hypnosis” as being consistent with democratic ideology.

Rituals are de-emphasized, with a corresponding emphasis placed upon experience and process / skills. “Hypnotizability” is irrelevant, rather Araoz states the importance of his TEAM concept (trust, expectation, attitude and motivation).

SOME CAVEATS AND THOUGHTS
1. There may be a “problem specific” component to hypnotic treatment: Less effective for habit or maladaptive behaviours (like smoking), but more successful for vegetative-autonomic functions (i.e., pain, migraine). This situation results in a lower correlation between hypnotisability and treatment outcome in smoking studies where motivation is more important in determining treatment outcome. The clinician needs to assess the match of the patient and their presenting problem as far as hypnosis is concerned.
2. Never assume that the patient’s inner experience and cognitive activity automatically mirrors therapist expectation. This caution is particularly applicable when one is employing standardized images such as the type outlined by Kroger and Fezier (1976). While such images may be useful for a number of clients, the practicing clinician will inevitably encounter patients who have a difficulty in creating and / or sustaining a particular image whether because of cognitive or affective factors.
3. The boundary between hypnosis and imaginal techniques is being blurred. Are non-hypnotic techniques being called “hypnosis?” as in the work of Erickson and Araoz? Are we guilty of assuming that therapist behaviour (e.g., induction rituals) automatically produces hypnosis without any independent assessment of the client (Wadden and Anderson, 1981)?
4. The overall level of theoretical sophistication of the clinical cognitive-behavioural hypnosis is low when compared to the general-experimental cognitive literature. This in part seems to reflect the generally pragmatic orientation of clinical hypnotists. In particular, there are few research models that take into account the hierarchical nature of cognition that is represented by Freud’s primary versus secondary process thinking, Erickson’s conscious versus unconscious understandings, and Hilgard’s “hidden observer”. However, some recent changes are evident. For example Beck (1985) has proposed that the “automatic thoughts” that he postulates as preceding psychopathology are related to levels of cognitive functioning. He hypothesizes that more primitive cognitive structures are activated following stress. This results in an extreme, egocentric, and absolutistic judgement. The result is a relative impairment in rational thinking and a loss of the normal limits of emotional expression.
5. All too frequently, there is a low level of research sophistication associated with reported clinical hypnosis studies. Clinical hypnosis has historically been isolated from the mainstream of academic based psychotherapy research in North America (Bowers, 1982). As is the case with theory, there does appear to be some recent movement toward methodologically more sophisticated studies. (For example, see Stam et. al. 1986).
6. A potentially useful concept in understanding subject behaviour is that of attributional disposition. According to attribution theory, individuals usually attribute their behaviours to the environment while observers attribute actions to persons. Positive behaviours, however, are attributed to self, while negative behaviours to the environment. Hypnotic psychotherapies may have to take into account differences in attributional styles.
7. Finally, it is my hope and expectation that future work in this area will see a greater employment of cognitive restructuring, RET-type approaches, imaginal-based therapies, and above all a greater integration of experimental findings and clinical sophistication.

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