Research – National Council for Hypnotherapy Hypnotherapy - With You In Mind Wed, 07 Mar 2018 13:29:20 +0000 en-US hourly 1 Hypnosis & Applied Relaxation (AR) – January Research Snippet Sun, 16 Jan 2011 22:49:17 +0000 The January Research Snippet, for a change, provides a complete outline of an evidence-based protocol for modern behaviour therapy for anxiety (Öst's Applied Relaxation). It's suggested that this method could be easily adapted for use as a cognitive-behavioural hypnotherapy treatment for anxiety, and that its standardised and simple nature (and the comparison with established methods) make it well-suited for use in treatment outcome studies on hypnotherapy for anxiety. Continue reading

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Hypnosis & Applied Relaxation (AR)

January Research Snippet by Donald Robertson, NCH Research Director

(Some of the material for this post is derived from the forthcoming book The Practice of Cognitive-Behavioural HypnotherapyCopyright (c) Donald Robertson, 2011.  All rights reserved.)

This month’s snippet is a bit of a change again: a slightly longer article providing the whole outline of a modern evidence-based behaviour therapy for anxiety, which is well-suited to be assimilated into hypnotherapy.  People often ask “Why isn’t there more research on hypnosis?”  In fact, the people who ask this, in my experience, never seem to have read (or even heard of) the main research journals in the field of hypnosis (IJCEH, AJCH, and Contemporary Hypnosis) and are unaware that there’s actually an awful lot of research on hypnosis, arguably more than on any other psychological therapy, apart from cognitive-behavioural therapy (CBT).  However, one of the problems facing hypnosis researchers is that methods of hypnotherapy are too messy, eclectic and complex to be well-suited to good research design.  It helps build an evidence base if a treatment is “manualised” and can be described in a guide so that other researchers can replicate it in independent studies.  Hypnotherapists tend to do lots of strange things with clients, making it difficult to isolate which “bits” are effective and which bits are redundant.  Modern research on psychological therapies is constantly evolving and improving in quality.  Protocols for therapies tend to have become simpler in order to facilitate the process of research. 

A well-known example is the “Applied Relaxation” protocol developed in Sweden by the psychologist Lars-Goran Öst, currently a professor at the University of Stockholm, and his colleagues (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  It developed out of Edmund Jacobson’s Progressive Muscle Relaxation, Wolpe’s Systematic Desensitisation, and a variety of “coping skills” approaches to anxiety management that evolved in the 1970s.  The following account is based on Öst’s original protocol and the self-help version published by Davis et al. (Davis, et al., 1995 pp. 65-74; Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  Although essentially a form of modern behaviour therapy, Applied Relaxation has also been used in combination with cognitive restructuring as part of a cognitive-behavioural therapy (CBT) approach.

Applied Relaxation is of interest to hypnotherapists because it consists of a very simple treatment protocol employing relaxation coping skills, which has been adapted for use with a range of problems, and supported by a number of well-designed research studies.  It has met critical appraisal criteria for being classed as an Empirically-Supported Treatment (EST) for panic disorder and research has also supported its efficacy in the treatment of generalised anxiety disorder (GAD) and, to some extent, for specific phobias, headache, pain, epilepsy, tinnitus, and other conditions.  It’s also been recommended for general management of worry and stress, i.e., for subclinical problems.

I think this protocol would be of interest to hypnotherapists because the method closely resembles “hypnotic desensitisation” (Wolberg, 1948; Wolpe, 1958) and it provides a good example of how a simplified hypnotherapy treatment protocol could be developed for use in treatment outcome research.  When reading the description below, just consider replacing the Jacobson tension-release relaxation method with self-hypnosis training in suggested relaxation and (I hope) it should be easy for hypnotherapists to see how this coping skills framework can be directly modified and transformed into a simple behavioural hypnotherapy method for anxiety.

Overview of the Applied Relaxation (AR) Protocol

The full text of a journal original article by Prof. Öst describing the method in detail is currently available online at this link.

Components of Applied Relaxation

Components of Applied Relaxation

In brief, Applied Relaxation begins with training in Progressive Muscle Relaxation, which is gradually developed into a cue-controlled relaxation coping skill, and systematically applied during in vivo exposure to feared situations.  The original protocol takes about 10-12 sessions, following assessment, and the specific stages of treatment are as follows,

  1. Assessment, formulation, and self-monitoring, which Öst seems to imply takes 2-3 sessions prior to training
  2. Progressive Muscle Relaxation, lasting 2-3 weeks/sessions
  3. Release-only relaxation, lasting 1-2 weeks/sessions
  4. Cue-controlled relaxation, lasting 1-2 weeks/sessions
  5. Differential relaxation, lasting 1-2 weeks/sessions
  6. Rapid relaxation, lasting 1-2 weeks/sessions
  7. Applied relaxation (application training), lasting 2-3 weeks/sessions
  8. Maintenance

1. Assessment & Formulation Phase

The full protocol begins with behavioural analysis and self-monitoring, usually carried out over three weeks.  Clients are asked to begin during the first week by recording their experiences on a very simple self-monitoring form that contains the following three headings: Date, Situation, and Intensity (rated 0-10).  In the second week, a column is added headed “Reaction (What did you feel?)”, and finally, in the third week, a column is included headed “Action (What did you do?”).  The final self-monitoring form, therefore contains headings as follows,

Tension Self-Monitoring Record




(What did you feel? 

Focus on the earliest signs.)




(What did you do?)


Öst introduces clients to a three-system conceptualisation model of anxiety (or stress) that distinguishes between physiological sensations, behaviour, and cognitive (subjective) responses.  The emphasis of assessment and conceptualisation is on helping the client spot the signs of stress, especially the earliest stages of the response developing.  This tends to particularly involve identifying common physiological sensations, such as muscles tensing or heart rate increasing, and environmental antecedents such as typical events or situations that are associated with elevated stress.  Öst recommends presenting the treatment rationale to clients as follows,

One good way of breaking this development [of anxiety] is to focus on the physiological reactions and learn not to react so strongly.  The method we are going to use to achieve this is called applied relaxation.  The aim of this technique is to learn a skill of relaxation, which can be applied very rapidly and in practically any situation. This skill can be compared to any other skill, e.g. learning to swim, ride a bike, or drive a car, in that it takes time and practice to learn, but once you have mastered it you can use it anywhere.  You are not restricted to the calm and non-stressful situation in my office or your own home.  The goal is to be able to relax in 20-30 sec and to use this skill to counteract, and eventually get rid of, the physiological reactions you usually experience in phobic situations.  To achieve this we are going through a gradual process starting with tensing and relaxing different muscle groups.  This takes about 15 min, and you are to practice it twice a day.  Then we start to reduce it by taking the tension part away, just relaxing, which takes 5-7 min.  The next step teaches you to connect the self-instruction “Relax” to the bodily state of relaxation.  Then we teach you to do different things while still being relaxed in the rest of your body, and also relaxing while standing and walking.  After that it is time for the rapid relaxation, which you practice many times a day in non-stressful situations.  Finally, you reach the stage of applying the skill in phobic situations, and I will take you to different anxiety arousing situations coaching you how to apply the relaxation at the first signs of anxiety in these situations.  Applied relaxation is thus a skill that most people can acquire with the right instructions and a lot of practice.  It is a “portable” skill that can be used in almost any situation and is not restricted to phobias, but can be used in other situations, e.g. when having problems in falling asleep. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987)

2. Coping Skills Training Phase

2.1 Progressive Muscle Relaxation

The first phase of actual Applied Relaxation training consists of Jacobson’s Progressive Muscle Relaxation technique, which Öst derives directly from the abbreviated approach introduced by Wolpe and Lazarus as part of Systematic Desensitisation (Wolpe, et al., 1966; Jacobson, 1938).  This training is divided across the first 2-3 sessions, the first of which focuses on relaxing the head and arms (hands, arms, face, neck, and shoulders), to which are added, in the second session, relaxation of the torso and lower body (back, chest, stomach, breathing, hips, legs, and feet).  In Öst’s version, each muscle group is tensed for only five seconds, much abbreviated from Jacobson’s original method, followed by 10-15 seconds of relaxation.  In Jacobson’s original approach, the aim is to learn to keep relaxing the rest of the body while tensing individual muscle groups, i.e., to only tense the muscles you’re deliberately using, which helps create a bridge to the “differential relaxation” stage (Jacobson, 1938).  At the end of the procedure, the client rates their level of tension on scale (0-100%), similar to a traditional SUD scale, where zero means absolute relaxation and 100% means maximum tension – the same self-rating scale used during homework.  Although people do normally find it easier to relax when lying down, training begins in a seated upright position, as the purpose is to develop a coping skill that will generalise to situations where the client is physically active.  The same relaxation routine is to be practised twice daily for homework, sessions typically lasting about 15-20 minutes, with each recorded on a homework form for review during sessions.

Relaxation Homework Record
Date/Time Component(Technique) Tension Before(0-100%) Tension After(0-100%) Duration(Minutes) Comments(Any difficulties?)

2.2 Release-only Relaxation

The next phase of Applied Relaxation, like the original Progressive Muscle Relaxation approach, focuses on “release-only relaxation” training for an additional 1-2 weeks.  In this phase, the initial tensing of muscles is omitted, some basic skill having been acquired in closely studying the contrasting sensations of tension and relaxation.  This also means a reduction in the time taken to induce relaxation from 15-20 minutes to 5-7 minutes.  The therapist verbally prompts the client to “Breathe with calm, regular breaths and feel how you relax more and more for every breath… Just let go… Relax your forehead… eyebrows… eyelids… jaws… tongue and throat… lips… your entire face…”, etc. (Applied Relaxation: Description of a Coping Technique and Review of Controlled Studies, 1987).  The client then scans their body for any remaining tension and tries to relax completely.  However, if the client does find tension creeping back into a muscle group during release-only relaxation they are to revert to the original tension-release technique, for that part of the body alone.            

2.3 Cue-controlled Relaxation

The next phase, cue-controlled relaxation, involves training in a “verbal cue” or “self-instruction” to induce relaxation more quickly, usually in around 2-3 minutes, by using the word “RELAX”, which is practised for another 1-2 weeks.  This is apparently conceptualised by Öst as a process of conditioning the relaxation response to the verbal stimulus (“RELAX”).  During the session the client relaxes as deeply as possible using the release-only approach, signalling when they have done so by raising a finger.  The client then focuses on their breathing, while the therapist repeatedly says the words “INHALE”, just before each inhalation, and “EXHALE”, before each exhalation, five times in a row.  The therapist then fades this verbal prompt and the client takes over using her own self-instruction by saying “INHALE” and “RELAX” internally (covertly), in a similar manner.  After about a minute, the therapist begins repeating the words again, about five times, and the client takes over again, repeating the process above, and once more after a break of about fifteen minutes.  The therapist should ask the client to estimate how long it took them to relax completely, and feedback the correct answer, because, as Öst points out, clients typically over-estimate the duration.  This routine should also be practised about twice per day, to help condition an association between the verbal cue “RELAX” and rapid release-only relaxation.           

2.4 Differential Relaxation

The next phase involves “differential relaxation, again derived from Jacobson’s approach, which consists of learning to relax while using some muscles.  The client is asked to induce cue-controlled relaxation while seated in a hard chair or standing, and to remain relaxed while moving their head or arms, or legs, etc., and finally while walking.  Emphasis is placed on further reducing the time taken to induce relaxation, which typically comes down to 60-90 seconds, according to Öst.           

2.5. Rapid Relaxation

This is followed by a “rapid relaxation” training phase, which aims to help the client relax in vivo, in naturally stressful situations, while further reducing the time taken for relaxation to 20-30 seconds.  The client is asked to relax 15-20 times each day for homework.  Obviously, this means the technique is used very frequently throughout the day, and so cues are identified to act as reminders, such as each time the client checks the time on a watch or clock, or opens a door, etc.  Sticky notes or other reminders can be used in the work or home environment to act as additional reminders.  The rapid form of cue-controlled relaxation consists in taking three deep breaths, saying “RELAX” internally after each one, before exhaling slowly.  The body is then scanned for any remaining tension, and the client tries to maintain maximum relaxation in the real-world situation.           

3. Application & Maintanence Phase

3.1 Application

The “application” phase usually begins after roughly 8-10 sessions of preceding training, and involves brief exposure to a wide variety of anxiety-provoking stimuli and situations.  The client is encouraged to use their cue-controlled relaxation coping skill immediately prior to exposure, and to continue to use the technique during exposure, in response to any initial signs of escalating tension.  Exposure using Applied Relaxation typically takes 10-15 minutes, much briefer than normal prolonged exposure sessions, which can last 1-2 hours.  However, the aim is not to extinguish anxiety completely but rather to learn to cope with it by using cue-controlled relaxation as a coping strategy.  The client may be exposed in vivo to feared objects or events, or through interoceptive exposure to panic sensations, or using imaginal exposure, especially for feared catastrophes in worry and GAD.          

3.2 Maintanence

Training is followed by a “maintenance” programme to help ensure that the coping skill further generalises to different situations in the future and is not simply forgotten.  To help maintain the skill, clients are asked to scan their body at least once each day and use their rapid relaxation method to dispel any tension identified, and to practice either differential or rapid relaxation at least twice per week.  The client may also keep the therapist updated by posting them records of their progress, e.g., for a period of six months after treatment.

Hypnosis & Applied Relaxation

Very little in Öst’s original protocol needs to be changed in order, I think, to legitimately transform it into a hypnotherapy technique.  As cognitive-behavioural approaches to hypnotherapy typically conceptualise hypnosis mainly as a form of self-hypnosis, and emphasise specific evidence-based skills training procedures (such as Nicholas Spanos‘ CSTP), cognitive-behavioural hypnotherapy in particular lends itself well to a “coping skills” approach, like Öst’s Applied Relaxation.  There’s not much reason to believe that the tension-release (Jacobson) method has significant advantages in relation to treating common problems over suggestive methods like Autogenic Training, which can easily be used instead as part of a hypnotic version of Applied Relaxation.

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Christmas Research Snippet: Hypnotism & Babies Fri, 03 Dec 2010 16:35:44 +0000 Christmas research snippet about a recent review of evidence-based practice in relation to hypnosis for childbirth and related issues, focusing on pain management in childbirth, etc. Continue reading

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Christmas Research Snippet: Hypnotism & Babies

Donald Robertson, NCH Research Director

For personal reasons, I’ve been delving into the research relating to hypnotism and childbirth recently, an area that, I confess, I’ve largely overlooked before.  Throughout its entire history, hypnotherapy has been used in relation to childbirth.  Even James Braid, the founder of hypnotherapy, reports a case where hypnotic suggestion was used to induce childbirth early for medical reasons.  However, the largest and most systematic use of hypnosis for issues relating to childbirth occurred in the Soviet Union at the start of the 20th century, based on the Pavlovian approach to hypnosis and psychotherapy.  Tens of thousands of women received hypnosis and a surprising amount of data was collected on its use.  In order to make it accessible to  a wider audience, by being conducted in a group setting, the hypnotic method was replaced by a psycho-educational method termed “psychoprophylaxis”, meaning “psychological prevention” of pain and anxiety during childbirth.  The French obstetrician Dr. Fernand Lamaze visited Moscow in the 1940s to study the Pavlovian psychoprophylactic method from which he developed the well-known Lamaze method of natural childbirth that continues in popularity today.  The Pavlovian hypnotic approach, psychoprophylaxis and the Lamaze methods competed with Dr. Grantly Dick-Read’s “Childbirth without Fear” approach, and all of these co-existed alongside numerous other uses of hypnosis in obstetrics, e.g., in the work of William S. Kroger, one of the best-known authors in clinical hypnosis, who wrote Psychosomatic Gynecology (1951) and the self-help book Childbirth with Hypnosis (1961).

Perhaps the most important recent review in this area was published by Donald C. Brown and D. Corydon Hammond in 2007 in a Special Issue of The International Journal for Clinical & Experimental Hypnosis dedicated to reviewing evidence-based practice in clinical hypnosis.  Professor Hammond is a clinical psychologist at the University of Utah School of Medicine and former president of the American Society of Clinical Hypnosis.  He’s well-known in the field of hypnosis for his many publications and as the editor of The Handbook of Hypnotic Suggestions & Metaphors (1990), a resource most experienced hypnotherapists possess and will be familiar with.

Brown & Hammond reviewed the evidence concerning the benefits of hypnosis in obstetrics, labor, and delivery, in relation to a range of issues, including,

  1. Reduction in use of analgesics and anaesthetics, i.e., reducing pain in labor
  2. Increasing enjoyment of labor
  3. Reducing the duration of labor
  4. Preventing preterm labor (PTL)

The review is quite wide-ranging and takes in many other benefits and applications of hypnosis, with reference to studies of varying age and quality.

The authors begin by reporting a previous review by Hoffman & Kipenhaur (1969) that found studies reported that hypnosis eliminated or substantially reduced the pain of childbirth for 50% (median) of women, with individual studies reporting success rates ranging from 35% to 90% of cases.  That suggests that the chances of having a painless childbirth with hypnosis varies enormously, depending upon the specific characteristics of the study, i.e., the way hypnotherapy is conducted and the characteristics of the women participating, including their level of motivation, expectations, etc.  Roughly half the women typically experienced substantial freedom from pain in these old studies.  There’s no mention of control comparisons, so it’s impossible to tell what percentage of these women would have reported painless childbirth without the use of hypnosis, i.e., their attitude and motivation to give birth naturally may explain their success to some extent. 

This ambiguity is addressed to some extent by a recent meta-analysis, identified by Brown and Hammond as the most comprehensive study to date on hypnosis for analgesia in childbirth.  The meta-analysis identified three randomised controlled trials (RCTs) where hypnotised and non-hypnotised women were compared (Cyana et al., 2004).  Across three studies, involving 142 women in total, they found that the hypnotised group were about half as likely to require pharmaceutical pain relief (analgesia) during childbirth compared to women giving birth without hypnosis.  More specifically, 62% of hypnotised women (mean) did not require analgesia compared to only 26% of non-hypnotised women (see chart).  This suggests, again, that more than half the women having hypnosis had relatively painless childbirths, although a large part of their success must be attributed to non-hypnotic factors.  (This is not a surprising finding and broadly consistent with research on other uses of hypnotherapy, and indeed psychological therapies in general.)

Although use of chemical analgesics, etc., is a more objective measurement, it does not necessarily reflect an accurate picture of the amount of subjective pain reported.  This has seldom been adequately reported in the literature, however, Brown and Hammond report a study by Mairs (1995) in which 28 hypnotised women subjectively rated their pain and anxiety levels, before (expected level) and after childbirth (actual level) , which were compared to ratings from 27 women in a non-hypnotised (control) group.  No differences were found between the hypnotised and non-hypnotised women in their anticipated levels of pain or anxiety before childbirth, however, after the birth the hypnotised women rated their pain as 5.41 on average compared to 7.58 in the non-hypnotised group, excluding those (n=7) who required caesarean sections.  By my calculations, that suggests that the women giving birth without hypnosis reported their feelings of pain as being about 40% higher during labour, on average, than the hypnotised group did.

In addition to these data, Brown & Hammond focus at length on the limited evidence regarding the potential of hypnosis in the prevention of preterm labour.  I’d suggest that anyone interested in the whole area of evidence-based practice in relation to hypnosis for obstetrics and childbirth, etc., consult this article for the wealth of information and useful references it contains.  Indeed, over fifty books and articles specifically relating to the use of hypnosis in childbirth were referenced by the authors.

Graph of Childbirth without Chemical Analgesia

Graph of Childbirth without Chemical Analgesia



Brown, DC; Hammond, DC    (2007).  ‘Evidence-based clinical hypnosis for obstetrics, labor and delivery, and preterm labour’, IJCEH, 55(3), pp. 355-371

Cyna, A.M.;McAuliffe, G.L.;Andrew, M.I.  (2004).  ‘Hypnosis for pain relief in labour and childbirth’, British Journal of Anaesthesia, 93(4), 505-511.

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Blood & Tension: November Research Snippet Sat, 23 Oct 2010 17:14:21 +0000 The November research snippet reviews some research on the treatment of blood phobia using muscular tension (Applied Tension) as opposed to relaxation techniques of the kind traditionally favoured by hypnotherapists. Continue reading

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Blood & Tension

Applied Tension in Treating Blood Phobia

Donald Robertson, NCH Research Director

This month’s research snippet deviates once again from the usual format.  This is an issue I’ve been talking to some hypnotherapists about recently and it’s of interest because it highlights the possible limitations of relaxation-based therapies in treating certain common anxieties. 

Virtually all contemporary researchers have rejected the idea that hypnosis can be equated with any form of relaxation, or that relaxation is a necessary component of hypnotherapy.  However, the notion that hypnosis involves mental or physical relaxation is still very popular, even among many hypnotherapists.  It is also widely-assumed that relaxation serves well as a method of managing anxiety, including in most phobias.  However, the value of relaxation in treating certain forms of anxiety has been questioned over recent decades for a number of reasons.

In particular, the treatment of choice for blood-injection-injury (BII) type phobias is currently the “Applied Tension” method developed by Lars-Göran Öst and his colleagues at the University of Uppsala in Sweden.  Basically, Öst has produced a series of research studies which provide evidence that training in a special tension “coping skill” combined with exposure to feared situations or events appears to be more effective than exposure alone or accompanied by relaxation training (termed “Applied Relaxation”).  The rationale for Applied Tension is that BII phobia, unlike most other forms of anxiety, is often accompanied by actual fainting or feelings of faintness caused by the vasovagal response.  The response to blood among phobics has been found to be unusual in that it consists of a “biphasic” reaction during which blood pressure and heart rate first rise (as in normal anxiety) and then rapidly drop, leading to fainting.  

The tension coping skill learned in Applied Tension involves tensing one’s arms, chest, and legs until a feeling of warmth occurs in the face, usually taking about 10-20 seconds.  This is repeated five times in a row, with 20-30 second pauses between.  Relaxation more than normal is deliberately avoided.  Doing so has been found to increase blood pressure and, in particular, cerebral blood flow, and to do so sufficiently to prevent the drop in blood pressure associated with fainting and the associated sensations of faintness.  This coping skill is then repeated for sessions of five repetitions, five times per day, over the space of five weeks.  It is combined with systematic exposure to the feared situations, which in the research conducted by Öst, includes a visit to the blood donor clinic, where the phobic provides a blood sample, and ultimately to an operating theatre to observe thoracic surgery taking place in person.  90% of blood phobics have been found to have improved to a clinically-significant degree following this brief intensive treatment, compared to only 60% of those trained in relaxation methods.

Most of the (highly-regarded) research on Applied Tension for blood phobia comes from the same research group and has, unfortunately, tended to employ relatively small sample sizes.  Recently, the findings have been questioned somewhat by one team of reviewers (Ayala, Meuret & Ritz, 2009).  On the other hand, a recent large-scale study of 614 blood donors found that those who expressed fears of fainting were more likely to continue donating blood if trained in Applied Tension (Ditto, France & Holly, 2010).

So if tension may be more beneficial than relaxation in the treatment of blood phobia, how can this be incorporated into hypnotherapy?  Well hypnotherapy certainly doesn’t seem to require relaxation and so “active alert” approaches to hypnotic induction might be better indicated for this client group.  James Braid, the founder of hypnotherapy, definitely used to induce either tense (“cataleptic”) or relaxed states depending on the individual needs of his clients.  Modern active-alert hypnotic procedures can be combined with suggestions for confidence-building (or ego-strength) which seems important with this client group, and used in conjunction with Applied Tension training.  Let us know what you think, though, by posting your comments below.


Öst, Fellenius & Sterner   (1991).  ‘Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia’, Behav. Res. Ther., vol. 29, no. 6, pp. 561-574.

Öst, Sterner & Fellenius  (1989).  ‘Applied tension, appplied relaxation, and the combination in the treatment of blood phobia’, Behav. Res. Ther., 27, 109-121.

Öst & Sterner (1986).  ‘A specific behavioral method for treatment of blood phobia’, Behav. Res. Ther., vol. 25, no. 1, pp. 25-29.

Ditto B.;  France CR.;  Holly C. (2010).  ‘Applied tension may help retain donors who are ambivalent about needles’, Vox Sanguinis.  98(3 Pt 1):e225-30

Ayala ES.;  Meuret AE.;  Ritz T.  (2009).  ‘Treatments for blood-injury-injection phobia: a critical review of current evidence’, Journal of Psychiatric Research.  43(15):1235-42

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Mindfulness, Metacognition and Hypnosis: August Research Snippet Mon, 26 Jul 2010 23:20:10 +0000 The August Research Snippet reviews arguably the most important recent journal articles reviewing the cognitive psychology of mindfulness meditation and its relevance for hypnotherapy. Continue reading

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Mindfulness, Metacognition and Hypnosis

August Research Snippet

Donald Robertson, NCH Research Director

Apologies for the absence of a July Snippet but here’s August’s a bit early as compensation.  Following our previous snippets on meta-analyses, finding research online, and treatment outcome studies, etc., we’ve recently looked at attempts to combine mindfulness research and hypnosis in the treatment of depression.  This is a popular area so I thought I’d continue in the same theme by looking at, arguably, the most important recent article on this subject.  In 2006, Steven Jay Lynn collaborated with the Buddhist teacher Lama Surya Das, and two other researchers, in an attempt to explore the possibility of combining elements of Buddhist mindfulness meditation practice, cognitive therapy, and hypnosis, drawing on recent research in cognitive psychology.

Mindfulness versus Thought Suppression

Over the past couple of decades, enthusiasm for mindfulness meditation techniques derived from Buddhism has flourished among cognitive-behavioural therapists, inspired by the early success of Jon Kabat-Zinn’s meditation programme for stress management.  Meditation and acceptance strategies have been used to counteract the tendency of many clients to try to suppress, control, or “fight” distressing thoughts.  Lynn et al. refer to the recent study by Wegner and his colleagues, which found that when people tried to deliberately suppress a thought there was evidence of a “rebound effect” in which they subsequently experienced more intrusions of the thought than a control group who were simply asked to think freely about the same thing.  Other studies have found evidence that emotional suppression can inhibit memory and problem-solving and increase physiological signs of nervous arousal.  Lynn and his colleagues report that of nearly a hundred subjects who were asked to keep their minds blank while listening to hypnotic suggestions, only one reported any success. 

Where thought-control strategies backfire, mindfulness and acceptance have been seen as offering an alternative way of responding to distressing experiences.  Lynn et al. follow other contemporary cognitive-behavioural therapists in contrasting non-judgemental mindfulness and acceptance with the unhealthy suppression of thoughts and feelings.  (However, they fail to mention that experimental studies on this “rebound” effect in thought suppression have produced some mixed results – q.v. Clark & Beck, 2010, for a more detailed review.)  Lynn et al. also cite a 2003 meta-analysis of mindfulness-based cognitive therapy and stress reduction approaches by Baer, which found a mean effect size of 0.59 (a medium-sized treatment effect) for this approach across various emotional problems and medical conditions.  In other words, it probably works, but the effects are comparable to those of other therapies and not dramatically superior to them.

Mindfulness & Metacognition

Lynn et al. appeal to a cognitive model combining elements of Adrian Wells’ influential metacognitive theory and Lynn and Kirsch’s own “response set” theory to explain the mechanism underlying mindfulness meditation and its relationship with hypnosis.  Contrary to Beck’s earlier cognitive therapy model, Wells introduced a focus on the notion of “metacognition”, thinking about thinking, or beliefs about beliefs.  According to this model, negative automatic thoughts aren’t particularly unhealthy in themselves, but rather they become so because of our attitude toward them.  In plain English, whereas Beck’s original cognitive therapy assumed that negative thoughts play a central role in the development of emotional disturbance, Wells points to the fact that many people experience lots of negative thoughts without becoming upset by them, whereas patients with severe emotional disorders appear to be unusually disturbed by individual negative thoughts and worries.  Mindfulness meditation, likewise, can be seen as an attempt to adopt a more detached attitude toward our stream of consciousness, and thereby to modify our thinking about thinking, i.e., to see automatic (spontaneous) thoughts as relatively transient and harmless, rather than important and dangerous.  Indeed, Beck has recently assimilated many aspects of Wells’ metacognitive approach into his revised cognitive therapy for anxiety (Clark & Beck, 2010).

Curiously, Lynn et al. don’t mention the fact that Wells’ metacognitive model raises serious problems for hypnotherapy because it suggests that the assumptions often made by hypnotherapists about the “power of thought” risk reinforcing maladaptive (metacognitive) assumptions held by many clients, i.e., the assumption that thoughts (including suggestions) are inherently powerful, whereas Wells teaches his clients that ideas are only as powerful as we believe them to be and we can learn to dismiss them as “mere thoughts”, lacking any real power or significance.  Likewise, Lynn et al. cite the recent research by Twohig (2004), which found that by repeating a negative thought to oneself one hundred times, like a mantra or autosuggestion, subjects made it seem less believable rather than more so, as some hypnotists might assume.  To borrow Wells’ terminology, hypnotism itself can be seen as a set of metacognitive beliefs rather than an altered state of consciousness or “hypnotic trance”.  The belief that autosuggestions are powerful when phrased in certain ways and the strategy of attending to their meaning for a prolonged period, to the exclusion of distractions, are ways of “thinking about thinking” (metacognition), which it’s the aim of most “hypnotic inductions” to instantiate.  In a sense, mindfulness meditation can be seen as a kind of “de-hypnosis” or “counter-hypnosis”, which aims to develop a metacognitive mind-set that weakens the hold of certain thoughts or suggestions, e.g., “Imagine that you are transparent, and disturbing thoughts and emotions cannot penetrate you or have any power to control your actions” (Lynn et al.), which contrasts sharply with typical preliminary hypnotic suggestions to experience certain ideas (suggestions) as powerful, controlling, and deeply penetrating into the mind, etc. 

Combining Hypnosis & Meditation

Lynn et al. summarise the relevance of hypnosis to mindfulness training as follows,

  1. Suggestions can be used to motivate clients to persevere with meditation practice on a regular basis.
  2. Suggestions can be used to generate a patient mind-set, so that when the attention naturally wanders this is seen as normal and accepted.
  3. Suggestions can be given about acceptance of things that cannot be changed.
  4. Hypnosis can be used to help people avoid identification with thoughts and feelings.
  5. Hypnosis can help clients to become more tolerant of unpleasant feelings.
  6. Clients can be hypnotised to perceive negative thoughts as transient and unimportant.

They specifically recommend the use of the following hypnotherapy techniques in conjunction with mindfulness meditation, which generally involves exposure to aversive feelings and events in CBT,

  1. Mental (“covert behavioural”) rehearsal of previously avoided situations.
  2. Cue-controlled relaxation to help facilitate exposure to feared situations.
  3. The use of hypnotic desensitisation to facilitate mental (“imaginal”) exposure .
  4. The use of hypnotic regression or reliving as a form of imaginal exposure to traumatic memories (as in PTSD treatment).
  5. The use of suggestion to help clients tolerate the discomfort and repetition of exposure therapy.

They add that the most basic use of hypnosis in combination with mindfulness-based CBT would be in the use of suggestion to directly develop an ongoing state of mindfulness.  As Lynn et al. emphasise, virtually all modern researchers now take it for granted (following several well-known studies) that hypnosis does not necessarily entail any form of relaxation, although it is frequently accompanied by it.  The same applies to meditation and Lynn et al. refer to a recent EEG brain imaging study in which subjects trained in relaxation showed markedly different brain activity from those trained in mindfulness meditation.

Negative Reactions

As an aside, Lynn et al. also note that a considerable body of research demonstrates the existence of transient, relatively superficial, negative reactions following standard hypnosis, i.e., things like headaches, feelings of nausea, anxiety, etc., in up to 29% of subjects.  This is comparable to the rates of negative responses reported by control groups who are simply asked to sit with their eyes shut, without being hypnotised, for the same amount of time.  However, similar negative reactions are also reported following meditation training, and may even be more frequent, being reported in up to 63% of subjects.  Hence, we might say that although negative reactions can occur following hypnosis it may be as harmless (generally speaking) as common meditation or relaxation techniques.



Lynn, Steven Jay; Das, Lama Surya; Hallquist, Michael N.; Williams John C.             (2006).  Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives.  IJCEH, 54(2), 143-166.

Clark, David A.; Beck, Aaron T.    (2010).  Cognitive Therapy of Anxiety Disorders: Science and Practice.

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Hypnosis, Meditation, Problem-Solving, Depression (June Research Snippet) Sun, 13 Jun 2010 17:43:56 +0000 Reflections on the recent special issue of IJCEH dealing with hypnotherapy for clinical depression, and attempts to create hybrid hypnotherapy approaches combined with modern evidence-based psychotherapies for depression. Continue reading

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June’s Enhanced Research Snippet

Hypnosis, Meditation, Problem-Solving, & Depression

Donald Robertson, NCH Research Director

For a bit of a change, this snippet is about a proposed protocol for treatment of clinical depression, based on existing evidence-based interventions.  I reckoned the subject needed a bit of background explanation so apologies if it’s a bit longer than usual!  It’s difficult to avoid jargon when talking about state-of-the-art stuff but I’ve tried to explain briefly what some of it means.  Email me with any questions, though.

There’s been growing interest recently in the relationship between cutting-edge, “third wave”, approaches to cognitive-behavioural therapy (CBT) and hypnotism.  Some of these new approaches place particular emphasis on cultivating particular states or attitudes of mind, such as acceptance or mindfulness, rather than the disputation emphasised in early cognitive therapy.  There’s also increasing emphasis on the role of attention in psychopathology and psychotherapy.  These are both, obviously, factors which can be related to hypnotherapy, which specialises in inducing particular states of mind and shifting the allocation of attention.

A June 2010 special edition of the International Journal for Clinical and Experimental Hypnosis (IJCEH) was dedicated to the subject of clinical depression, edited by Michael Yapko, who is well-known as a specialist in this particular area.  This follows on the success of Assen Alladin’s recent randomised controlled trial (RCT), which provided evidence that cognitive hypnotherapy could compete with standard cognitive therapy in the treatment of depression, and may be superior on some measures.  (The treatment of clinical depression by ordinary hypnotherapists is considered inappropriate by many experts but this research can probably be applied, to some extent, to the treatment of subclinical symptoms of depression of the sort more commonly encountered in hypnotherapy.)  The article by Lynn et al. (see below) was of particular interest because it outlined proposals for a third-wave cognitive-behavioural approach to hypnotherapy for depression, with scripted examples. 

Lynn et al. focus in particular on the central role now ascribed to morbid “rumination” in the maintenance of depressive symptoms.  They provide proposals for combining thee specialised treatments with modern hypnotherapy.

  1. Rumination-Focused Cognitive-Behavioural Therapy (RFCBT)
  2. Cognitive Control Training (CCT)
  3. Mindfulness-Based Cognitive Therapy (MBCT)

Full details of the hybrid protocol can be found in the article referenced below.  However, to illustrate their approach, I’d like to elaborate briefly on one small aspect of this multi-component treatment approach.

Lynn et al. refer briefly to the use of problem-solving methods which are near-universal in CBT.  However, they could have also mentioned the fact that Problem-Solving Therapy (PST), an approach originating in the 1970s, has received growing support recently from treatment outcome studies as a stand-alone intervention for clinical depression.  (This is an area of special interest to me at present.)  Now, as far back as the 1940s, Lewis Wolberg had discussed the use of problem-solving methods within hypnotherapy, from a cognitive-behavioural perspective.  Wolberg, an eclectic psychotherapist, combined elements of behavioural psychology with rational persuasion psychotherapy, an early precursor of cognitive therapy, in his Medical Hypnotism, one of the best-known clinical hypnosis textbooks of the period. 

Problem-Solving Therapy (PST), in its modern form, has the merit of being a very brief and simple approach, with a well-rounded evidence-base.  It’s simple enough to combine well with hypnotherapy to form a brief hybrid treatment.  Lynn et al. go for a more complex mixture, as mentioned above, but their modified problem-solving plus hypnosis, might be viable as another stand-alone intervention.  I’d strongly recommend that you check out the third edition of the core text, Problem-Solving Therapy: A Positive Approach to Clinical Intervention, by D’Zurilla and Nezu, for a thorough description of PST methodology.  Problem-Solving methodology is derived from experimental studies on problem-solving, decision-making, and related skills, and focuses on helping clients to become more skilled and confident at identifying and solving their own problems of living, of whatever kind.  It’s based on the observation that clients, especially depressed clients, tend to complain of feeling overwhelmed by various problems of living and helpeless to start tackling them.  Essentially, the method is divided into five basic components,

  1. Problem Orientation.  The client is trained to adopt and maintain a positive attitude toward solving their problems, and the key components of this mind-set are explored with them.
  2. Problem Definition.  The client is trained to identify relevant problems and define them objectively with reference to appropriate goals and key obstacles.
  3. Brainstorming Alternatives.  Osborn’s principles of brainstorming are employed to systematically develop a wide variety of alternative solutions.
  4. Decision Making.  Cost-benefit analysis and other methods are used to evaluate proposed solutions and rank them in order of suitability.
  5. Solution Implementation.  An action plan is developed and tested out in practice, followed by systematic reflection on the observed consequences, and possibly re-iteration of the process above.

That’s it in a nutshell, but read the manual above for a proper description.  PST seems to benefit a wide range of clients but it’s been especially linked to the treatment of clinical depression where there is clear evidence of a correlation between depression and problem-solving deficits, in the first place, and evidence from treatment outcome studies that PST can be broadly equivalent to standard cognitive therapy or antidepressants, although delivered in a very brief format, over about six 30-minute sessions. 

Anyway, Lynn et al., propose the following ways in which problem-solving can be facilitated by hypnosis, and I would suggest that these can be integrated with standard problem-solving methodology to form brief hypno-PST for depression, or related issues,

  1. Age regression is used to regress subjects to times in the past when problem-solving was done better and prevented morbid rumination happening.
  2. Suggestions can be given for increased perception of the key features of problems to be solved.
  3. Imaginal rehearsal in hypnosis can be used to test out different proposed solutions and evaluate their consequences.
  4. Imaginal rehearsal can also be used to develop skill and confidence in implementing the chosen solution.
  5. Self-talk (autosuggestions such as “I can do this!”) can be rehearsed during hypnosis, to enhance coping skills in relation to solution implementation.
  6. Hypnotic age progression can be used to have clients envision a future time when they have already solved their problems and to retrospectively identify steps they might have taken to do so.

They also mention that brooding can be overcome by use of direct suggestions (which could be recorded on a CD) to develop a positive problem-orientation or problem-solving mind-set.  I would observe that there’s some reason to believe that problem-orientation is the most important part of the whole methodology and that hypnotic suggestion could serve well as a simple way of helping clients to feel more positive and confident about tackling their problems of living, and to see them more objectively, from a realistic perspective, rather than being threatened or overwhelmed by problems.

Lynn et al., as I have done, are merely commenting on existing evidence-based methods and speculating about protocols which could combine them within a hypnotherapy framework but we can probably look forward to other treatment outcome studies, like Assen Alladin’s, which attempt to provide direct evidence for the efficacy of such multi-component hypnotic approaches. 


Lynn, S., Barnes, S., Deming, A. & Accardi, M. (2010). Hypnosis, Rumination, and Depression: Catalyzing Attention and Mindfulness-Based Treatments. International Journal of Clinical and Experimental Hypnosis, 58(2), 202-221.

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Review of Evidence-Based Hypnotherapy: May 2010 Mega-Research-Snippet Mon, 26 Apr 2010 20:46:30 +0000 This article summarises the research studies on hypnotherapy identified in a recent review as meeting the criteria for empirically-supported treatments (ESTs). Continue reading

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Which Forms of Hypnotherapy are Evidence-Based?

Hypnotherapy as Empirically-Supported Treatment (EST)

Ratings using Chambless & Hollon (1998) criteria reviewed by David M. Wark (2008)

Copyright © Donald Robertson, 2009  Reprinted from The Hypnotherapy Journal Spring 2009

I beg farther to remark, if my theory and pretensions, as to the nature, cause, and extent of the phenomena of [hypnotism] have none of the fascinations of the transcendental to captivate the lovers of the marvellous, the credulous and enthusiastic, which the pretensions and alleged occult agency of the mesmerists have, still I hope my views will not be the less acceptable to honest and sober-minded men, because they are all level to our comprehension, and reconcilable with well-known physiological and psychological principles.  – James Braid, Hypnotic Therapeutics, 1853

One of the most useful articles to be published recently was arguably Wark’s review of those studies on hypnotherapy that were rated as meeting the Chambless & Hollon (1998) criteria for “empirically-supported treatments” in the field of psychology, known as ESTs for short.  It may not surprise many NCH members to know that when the research literature on psychotherapy was previously reviewed by a task force of nineteen psychologists led by Prof. Dianne Chambless most of the psychological therapies identified as “empirically-supported” (formerly termed “empirically-validated”) tended to be specific forms of cognitive and/or behaviour therapy (CBT).  Most forms of psychotherapy, ranging from the more controversial and pseudoscientific ones to some of the more “respectable” and mainstream approaches, do not meet these strict criteria for empirical support.  However, one study was identified which demonstrated that cognitive-behavioural hypnotherapy (CBH) was “probably efficacious” for weight loss in obese clients.  In this respect, hypnotherapy might (tentatively) be said to have garnered more compelling evidence for its efficacy than many other modalities of psychological therapy, apart from the cognitive and/or behavioural treatments and some brief psychodynamic approaches. 

            However, over the past decade, many additional studies of a high quality have been published which provide support for the efficacy of hypnotherapy, including meta-analyses and systematic reviews which collate data from multiple studies to form a more general picture of the research findings in this area.  David Wark’s review entitled ‘What we can do with hypnosis: a brief note’ identifies  over thirty additional studies on hypnotherapy which he rates using the revised Chambless & Hollon (1998) criteria for either “possible”, “probable”, or “specific” empirically-supported treatments, depending upon the nature of the evidence available (see the explanations below).  I have compiled this information into a new table which you will find underneath.  Of course, these are not all the possible applications of hypnotherapy, simply the ones which currently have the strongest empirical support, based on Wark’s rating using established criteria for research quality.  More studies are published every year which potentially meet these criteria and might be included on a future list.

            I think it might be observed that certain hypnotherapy treatments for certain types of pain, anxiety, and weight loss are supported by the strongest evidence at present, by this standard.  In total, three studies (anxiety due to asthma, public speaking, and taking a test) provide good evidence for the efficacy of hypnotherapy as a treatment for anxiety.  Assen Alladin’s recent study which provides support for the use of hypnosis in the treatment of depression is rated as meeting the “possibly” efficacious criteria.  Most of the other studies provide evidence relating to the treatment of acute or chronic pain, and certain stress-related or psychosomatic medical conditions such as insomnia, migraine and IBS.  Wark even finds one study on hypnotherapy for smoking cessation which meets the criteria for “possibly efficacious”, an area where well-designed research has previously been lacking. 

            This overview is consistent with a general trend in the literature, since the Victorian era, which tends to point toward hypnotherapy showing most promise in the treatment of anxiety, insomnia, pain management, and several stress-related medical conditions, with mixed findings in relation to its use for the treatment of habits and addictions such as over-eating, smoking, and alcohol abuse.  For example, a committee of experts commissioned by the British Medical Association concluded in 1892 that,

The Committee are of opinion that as a therapeutic agent hypnotism is frequently effective in relieving pain, procuring sleep, and alleviating many functional [i.e., psycho-somatic] ailments.

However, we can now go beyond those early clinical observations and primitive experiments and provide an overview of the therapeutic usefulness of hypnotherapy based on modern research design meeting the highest standards of quality. 

 “Specific” empirically supported treatments
1. Anxiety about asthma attack   Brown, 2007
2. Headaches and migraine Relaxation + image modification > wait list control Hammond, 2007
“Effective” empirically-supported treatments
3. Cancer pain   Syrjala et al., 1992
4. Distress during surgery Hypnosis reduces distress and pain > controls Lang et al., 2006
5. Surgery pain (adult) Self-hypnosis reduces drug use > attention control Lang et al., 1996
6. Surgery pain (child) Hypnosis reduces pain + hospital time > control Lambert, 1996
7. Weight reduction Hypnosis + CBT > CBT, differences increase over time Kirsch, 1996
“Possible” empirically-supported treatments
8. Acute pain (adult)   Patterson & Jensen, 2003
9. Acute pain (children) Hypnosis > distraction for bone marrow aspiration Zeltzer & LaBaron, 1982
10. Anorexia Staged treatment with hypnosis > same without hypnosis Baker & Nash, 1987
11. Anxiety about public speaking Hypnosis > CBT Schoenberger et al., 1997
12. Anxiety about taking a test Self-hypnosis>discussion control Stanton, 1994
13. Asthma Hypnosis>attention control Ewer & Stewart, 1986
14. Bed wetting Suggestion with or without hypnosis > wait list control Edwards & Van der Spuy, 1986
15. Bulimia Hypnosis = CBT > wait list Griffiths et al., 1996
16. Chemotherapy distress Hypnosis>conversation + antiemetic medication Jacknow et al., 1994
17. Cystic fibrosis Self-hypnosis>wait list control Belsky & Khanna, 1994
18. Depression Hypnosis enhances CBT Alladin & Alibhai, 2007
19. Duodenal ulcer relapse Hypnosis + medication > medication only Colgan et al., 1988
20. Fibromyalgia Hypnosis > physical therapy for subjective symptoms Haanen et al., 1991
21. Haemorrhage Preoperative suggestion reduces blood flow Enqvist et al., 1995
22. High blood-pressure Hypnosis > wait list in reducing BP long-term Gay, 2007
23. Hip or knee osteoarthritis pain Hypnosis = relaxation > wait list control Gay et al., 2002
24. Insomnia (primary) Hypnosis + CBT > medication long-term Graci & Hardie, 2007
25. Irritable bowel syndrome (IBS) Hypnosis > psychotherapy Whorwell et al., 1984
26. Nausea & hyperemesis Hypnotic-like relaxation > control Lyles et al., 1982
27. Obstetrics Apgar score Hypnosis associated with higher Apgar score Harmon et al., 1990
28. Obstetrics pain Hypnosis shortens labour and reduces analgesic use Jenkins & Prichard, 1983
29. Smoking cessation Hypnosis or relaxation > wait list controls for good subjects Schubert, 1983
30. Trauma recovery Desensitisation = hypnosis = psychodynamic therapy > control Brom et al., 1989
31. Wart removal Suggestion with or without hypnosis > control or medication Spanos et al., 1990

These ratings are derived from the review published by Wark (2008), in which the references and criteria are given in full.  In brief, the main criteria for the ratings are those set by Chambless & Hollon (1998), which they define roughly as follows but see their article for a more specific and detailed account of the criteria.


A treatment is “possibly” empirically-supported if peer-reviewed studies meet the following minimum criteria.  Studies should normally contain samples of at least 25 subjects who are randomly assigned to treatment and control groups, i.e., the study is a randomised control trial (RCT).  There is a treatment manual or equivalent (such as a hypnosis script) so that the treatment can be replicated in other studies.  Treatment must be conducted upon a specific condition which has been adequately assessed, and adequate outcome measures must be used which are subject to suitable statistical analysis.  The outcome must essentially show the treatment to be significantly more effective than a placebo or no-treatment control group, or equivalent to another empirically-supported treatment.


A treatment is termed empirically-supported as being “effective” if statistically significant superiority to control group measures have been replicated with completely independent samples or by independent research teams, and data supporting the treatment in question must be shown to predominate if there are conflicting data from other studies.


A treatment can be considered empirically-supported as “specific” (i.e., better than “non-specific” treatment) if it has shown statistically significant superiority to a placebo (“sham”) therapy or another psychological therapy in at least two independent studies.


Bolocofsky, D.N., Spinler, D., & Coulthard-Morris, L. (1985).  ‘Effectiveness of hypnosis as an adjunct to behavioral weight management’,  Journal of Clinical Psychology, 41.

Chambless, D.L., & Hollon, S.  ‘Defining empirically supported therapies’, Journal of Consulting and Clinical Psychology, 66.

Task Force on Promotion and Dissemination of Psychological Procedures. ‘Training in and dissemination of empirically validated psychologist treatments: report and recommendations.’ Clin Psychol 1995;48:3–23.

Chambless DL, Sanderson WC, Shoham V, Bennett Johnson S, Pope KS, Crits-Christoph P, et al. ‘An update on empirically validated therapies.’ Clin Psychol 1996;49:5–18.

Chambless DL, Baker MJ, Baucom DH, Beutler LE, Calhoun KS, Crits-Christoph P, et al. ‘Update on empirically validated therapies, II.’ Clin Psychol 1998;51:3–16.

Wark, David M.  (2008). ‘What we can do with hypnosis: a brief note’, American Journal of Clinical Hypnosis, July 2008

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August Research Snippet: Hypnosis, Pain, Expectation & Placebo Tue, 18 Aug 2009 17:29:15 +0000 This snippet discusses a recent experimental study which attempted to quantify (as a percentage) the extent to which expectation contributed to the pain-reducing effects of hypnosis, imagination, and a placebo medication. Strong evidence was derived from statistical analysis suggesting that the effect of hypnotism is "partially-mediated" by expectation, albeit to a lesser degree than the placebo effect. Continue reading

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The Role of Expectation in Hypnosis:
Hypnosis, Imagination & Placebo Pain Relief

James Braid defined hypnotism as focused attention upon an “expectant dominant idea”, to the temporary exclusion (“abstraction”) of other thoughts.  Since that time, researchers have pondered the role of expectation in hypnotic responses.  Most therapists, and even more so stage hypnotists, probably share the common impression that the expectations of clients/subjects are an important factor, shaping how they respond to hypnotic suggestions.  However, human beings have a notable tendency toward “reductionism” and so debates like this tend to involve back-and-forth between all-or-nothing viewpoints, e.g., “hypnotism is all just expectation” versus “expectation doesn’t matter.”  An alternative, middle-way, would be the position that hypnotism is partially determined (“mediated”) by expectation, but not 100% so.  As one of the most prolific researchers in our field Professor Irving Kirsch has famously pointed out in his “response expectancy” theory of hypnosis, this would suggest that hypnotism is fundamentally related to the mechanism underlying the placebo effect, i.e., that hypnosis is a “non-deceptive mega-placebo”.  Again, that is very different from the notion that hypnotism is “just” a placebo, or the naive view that placebo effects are somehow “not real”.  People experience measurable physiological change and symptom remission after being given placebos and the process can be compared to the (anachronistic) concept of “waking suggestion” in the field of hypnotherapy.  Indeed, Braid introduced the concept of “hypnotism” (as opposed to Mesmerism) precisely on the basis of his observations of Victorian quack (“nostrum”) remedies, which modern researchers would consider examples of deceptive placebo remedies.  In other words, Braid saw people physically responding to treatments, such as animal magnetism or wearing “galvanic rings”, whose effects he and other sceptics attributed to expectation and suggestion, and subsequently developed hypnotism as a means of more honestly employing suggestion as an explicit technique in medicine.

In an important new experimental study ‘Response Expectancies: A Psychological Mechanism of Suggested and Placebo Analgesia”, Leonard S. Milling has carried out a very thorough and careful statistical analysis of the extent to which expectation appears to mediate the effect of hypnosis, imagination, and placebo, in the reduction of experimentally-induced pain among a sample of 172 college students (Contemporary Hypnosis, 26(2): 93-110, 2009).  All three interventions reduced pain substantially.  Traditional hypnotism and instructions to “imagine” were nearly equivalent, and both were almost twice as effective as the placebo.  This, and Milling’s other findings, lend additional support to the view that instructions to imagine may often be substituted for a traditional hypnotic induction, a central premise of Barber’s nonstate (“cognitive-behavioural”) theory of hypnosis.

Milling also found strong evidence supporting the role of expectation in mediating pain reduction.  However, the importance of expectation varied depending upon the techniques employed, calculated as follows,

  • Traditional hypnotic induction plus suggestion.  25%
  • Instructions to “imagine” plus suggestion.  29%
  • Placebo (an inert topical lotion).  41%

As Milling concludes, this appears to show that about 25% of the effectiveness of traditional pain-reduction hypnotherapy is due to expectation.  Expectation is an important factor but there may be one or two other factors involved which contribute more to the response, e.g., attention, motivation, imagination, or a trait of hypnotisability, etc.  By comparison, expectation contributed more substantially to the placebo effect, but still less than fifty percent, supporting the view that a cluster of factors contribute to the placebo response and it is not simply reducible to expectation alone, although this may turn out to be the single most important manageable factor involved.  Motivation, role-perception, attention, and other factors may be involved in the placebo response as well and Milling also points to the Pavlovian theory of classical conditioning which has been cited as providing another mechanism by which placebos (and hypnotism) may function.  For instance, a person who has previously received a real medication and experienced its effects may be more likely to respond to a similar-looking placebo because it acts as a reminder (conditioned stimulus) for the associated sense of pain relief (a conditioned response) – independently of the effect of expectation.  So previous experience of a real drug combined with high levels of expectation would probably produce a strong placebo response.  Likewise, tapping into remembered sensations (“sensory recall”) may combine well with expectation in eliciting certain hypnotic responses.

As expectation is a “cognitive” factor, these findings can be interpreted as supporting the view that the effect of hypnotherapy for pain reduction is “cognitively-mediated” in a manner overlapping with CBT interventions, which also stress the role of cognition in shaping the perception of pain.  In other words, although superficially different, hypnotherapy and CBT probably work, to some extent, in a similar manner, at least to some extent. 

As Milling points out, the usual cautions apply insofar as this was experimental pain induced with college students, etc., and therefore only provides an analogy (indirect evidence) for the mechanisms underlying pain relief among genuine therapy clients with genuine medical problems.  (Although, I think most researchers would consider it likely similar factors operate in the clinical setting as well.)

“In sum, this study substantiates that response expectancies are an important mechanism of hypnotic, imaginative and placebo analgesia.  The findings corroborated the view that the effect of hypnosis on pain is partially mediated by response expectancies.  The results also showed that the effect of a placebo on pain was largely, but not completely, mediated by response expectancies.  […] Thus, although the results of this study do not suggest that response expectancies are the final common pathway [as Kirsch has suggested] to pain relief, they do indicate that response expectancies are one of the major psychological mechanisms of suggested and placebo analgesia.”

So, as other studies have shown, the traditional hypnotic induction is probably not essential to hypnotic pain reduction, and client expectation is probably one of the most important factors which we should make use of.  Moreover, Barber, Spanos, Kirsch, and other cognitive-behavioural researchers have already discussed in some detail the possible means by which factors such as expectation may be systematically enhanced in hypnotherapy through methods tested in experimental settings such as role-modelling, manipulation of activating sensations, task-motivational instructions, etc.

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July Research Snippet: Competing Theories of Hypnosis Wed, 08 Jul 2009 22:43:19 +0000 A recent series of articles compared the influential "sociocognitive" and "response expectancy" theories of hypnosis with Alfred Barrios' "conditioning and inhibition" theory, which reprises elements of Pavlov's theory of hypnotic suggestion. This snippet outlines the opposing theories and research findings cited in favour of the sociocognitive position. Continue reading

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The Conditioning & Inhibition Theory of Hypnosis

In previous snippets, we’ve looked at factors in the typology of suggestion, some clinical outcome studies, etc., this month I’d like to draw attention to some research attempting to support a comprehensive theory of hypnosis.  As the psychologist Kurt Lewin famously remarked: “Nothing is as practical as a good theory.”  That phrase came to mind when reading Alfred Barrios’ recent series of articles which concisely and systematically outline a relatively simple “conditioning and inhibition” theory of hypnosis (Barrios, 2001), which recently led to an exchange with Steven Jay Lynn relating to the similarities and differences between Barrios’ theory and the influential “socio-cognitive” theory of hypnosis. 

            Barrios’ theory ultimately derives, I think, from the “cortical inhibition” theory of hypnosis which crowned Pavlov’s physiological research on animals at the turn of last century – a theory further developed by Platonov and other Soviet hypnotherapists.  Anyway, Barrios does an admirable job of carefully spelling out his modern variation, with intermittent references to supporting research data.  In a nutshell, Barrios draws on a revised form of conditioning theory to describe hypnosis as a method for reinforcing the subject’s tendency to progressively fade out (“inhibit”) intrusive thoughts and sensations in a way that heightens their sensitivity to learned associations between words, such as hypnotic suggestions, and physiological responses such as emotions.  From this point of view, words, such as verbal suggestions, function as stimuli which in turn evoke “cognitive stimuli” (ideas and images) in a way that triggers hypnotic responses.  Barrios’ use of behavioural learning theory obviously has the potential to highlight certain overlaps between the theory and practice of hypnosis and behaviour therapy. 

Barrios’ theory consists of the following seven hypotheses, divided into three groups,

A. Hypnotic induction

1. “Hypnotic induction is a conditioning process.”

2. “The response conditioned during hypnotic induction is an inhibitory set, a set which tends to inhibit stimuli incompatible with the response suggested by the hypnotist.”

3. “A positive response to a suggestion will induce within the responding person a more or less generalised increase in the normally existent tendency to respond to succeeding suggestions.”

B. Explanation of hypnotic phenomena

4. “A suggestion produces the desired response by first evoking a cognitive stimulus which is associated with that process.”

5. “The inhibitory set facilitates the suggested response by inhibiting stimuli competing with the cognitive stimulus.”

C. Post-hypnotic suggestion

6. “Suggestion leads to behaviour change by a form of higher-order conditioning called C-C [cognitive-cognitive] conditioning.”

7. “Hypnosis facilitates the C-C conditioning produced by suggestion.”

Barrios published two subsequent articles, the first of which explores the relationship between his “conditioning and inhibition” theory and four other modern theories of hypnosis: sociocognitive theory (Spanos/Lynn), Neo-dissociation (Hilgard), response expectancy (Kirsch), and Milton Erickson’s approach (Barrios, 2007).  The second reviews the possible benefits and applications of the theory to understanding phenomena such as the placebo effect, improving the effectiveness of hypnotic induction, improving post-hypnotic suggestions, and the development of Barrios’ therapeutic technique called Self-Programmed Control (Barrios, 2007b).

Comparison Between Theories

In the current edition of Contemporary Hypnosis, Steven Jay Lynn and Sean O’Hagen have responded in some detail to Barrios’ comparison between the conditioning and inhibition and sociocognitive theories of hypnosis.  

Sociocognitive theories reject the traditional view that hypnotic experiences require the presence of an altered state of consciousness.  Rather, the same social and cognitive variables that determine mundane complex social behaviours are said to determine hypnotic responses and experiences. (Lynn & O’Hagan, 2009)

They praise Barrios for providing a systematic and comprehensive account of his theory and its practical implications.  Indeed, contrary to Barrios’, they conclude that his theory is itself one of several falling under the broad “sociocognitive” umbrella term.  However, while endorsing some of his points, they disagree with others, citing several research studies in support of their own position.  In particular,

  1. Barrios emphasises the power of hypnotist prestige but sociocognitive researchers have generally found the qualities of the hypnotist to be of less importance than the qualities of the subject, e.g., their level of motivation, expectations, and imaginative capacity.
  2. Following Spanos, Barrios emphasises the power of “goal directed fantasies”, or mental imagery, in evoking hypnotic responses but, according to Lynn, research has failed to show that imagery alone can account for hypnotic responses without the aid of factors such as motivation and expectation.
  3. Barrios, like many hypnotherapists, naturally assumes that hypnotic suggestions are more effective when presented in order of difficulty, giving the subject an increasing confidence in their ability to respond. However, Lynn cites evidence from experimental studies showing that this is not the case and subjects respond just as well when suggestions are given in descending order of difficulty.
  4. They do, however, find support for Barrios’ contention that subjects increase in responsiveness to genuine suggestion tests after first being duped into believing they are hypnotised, e.g., by surreptitiously playing quiet music in the background while suggesting that they will hallucinate the sound of music, etc.
  5. They raise doubts over Barrios’ claim that some induction techniques induce hypnosis more “deeply” than others. Research has consistently failed to demonstrate much difference between different induction techniques.
  6. Moreover, the increase in suggestibility following hypnotic induction techniques is around 20% on average, which seems to show that the presence of a hypnotic state (“trance”), even if such a thing did exist, would be far less important to hypnotism than other factors such as the personality of the subject, their attitudes, and the type of suggestions given.

It’s truly fascinating to observe these debates between researchers from different theoretical traditions because they highlight the pros and cons of their respective points of view.  This is research in action; the competition between contrasting hypotheses, appealing to their respective supporting evidence.  It’s through this kind of dialogue that genuine progress is achieved in hypnotic research and we work our way gradually closer to an accurate and comprehensive theory of hypnosis and hypnotherapy. 


Barrios, A. A. (2001). A Theory of Hypnosis based on Principles of Conditioning & Inhibition. Contemporary Hypnosis , 18 (4), 163-203.

Barrios, A. A. (2007). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part I: Contrasts with Other Perspectives & Supporting Evidence. Contemporary Hypnosis , 24 (3), 109-122.

Barrios, A. A. (2007b). Commentary on a Theory of Hypnosis based on Principles of Conditioning & Inhibition, Part II: Benefits of the Theory. Contemporary Hypnosis , 24 (3), 123-138.

Lynn, S. J., & O’Hagan, S. (2009). The Sociocognitive and Conditioning and Inhibition Theories of Hypnosis. Contemporary Hypnosis , 26 (2), 121-125.

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June Research Snippet: Eysenck’s Typology of Hypnotic Suggestion Wed, 03 Jun 2009 16:02:31 +0000 What's the relationship between indirect suggestion and traditional hypnotism? This article gives a plain English review of Hans Eysenck's seminal research on the factors in hypnotic suggestibility. Continue reading

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Okay, research snippet time and it’s back into the past again for a look at an important historical piece of research. Many of you will be familiar with the name of Hans Eysenck (1916-1997). He was allegedly the most widely-referenced psychologist in scientific literature at one point during his lifetime and a pioneer of behaviour therapy. Well, hypnotherapists may not know that Eysenck also carried out some seminal research on the different factors in suggestion and the relationship between hypnosis and personality traits. His original research on hypnosis was published in a well-known journal article and reviewed in his book Dimensions of Personality (1947) which contains a whole chapter on hypnosis and suggestion.

Basically, Eysenck’s research is important for two reasons,

1. He provided data which contradicted the traditional assumption that “hysterical” patients were particularly hyper-suggestibile, i.e., that hypnosis itself is a form of “artificial hysteria.”
2. He was one of the first people to provide evidence which suggested a distinction between different species of suggestion and suggestibility.

Eysenck carried out a series of studies, and reviewed other research. He collated data from over a thousand military personnel and psychiatric patients. Essentially, he found that so-called “hysterics” were no more hypnotisable than other emotionally disturbed patients. However, he did find data pointing to a link between trait neuroticism and hypnotic suggestibility. In the preface to the 1998 edition of the book, presumably written just before his death, he neatly sums up his findings on suggestion,

I was trying to extend my experimental approach to psychiatric concepts, and chose certain specific statements from psychiatric textbooks for testing. It had been almost universally claimed that hysterics are suggestible, but there was no experimental evidence. I applied a number of standard tests of suggestibility to groups of hysteria and anxiety states, as well as non-neurotic controls, and found that there were at least two kinds of suggestibility which I called “primary” and “secondary”. Hysterics did not differ from anxiety states, but neurotics as a group differed profoundly from normals, being much more suggestible. When I showed the results to Sir Aubrey Lewis, my boss, he immediately summoned all the patients I had tested to make sure the hysteria had been correctly diagnosed – he agreed that they had.

Eysenck’s factor analysis of the data from hypnotic suggestion tests seemed to show that indirect (“secondary”) suggestion functioned by means of a fundamentally different mechanism from direct (“primary”) suggestion. Indeed, Eysenck concluded that indirect suggestibility was probably not a single trait and probably not directly related to hypnotism as traditionally understood. He was not alone in this conclusion as earlier researchers such as Binet and Hull had produced similar findings.

In two factorial studies of altogether 16 different tests of suggestibility, it was shown that these tests define two entirely different and separate types of suggestibility: (1) Primary suggestibility, characterised by dependence on ideo-motor action, and (2) Secondary suggestibility, characterised by dependence on indirection. Primary suggestibility was shown to be closely related to hypnosis; secondary suggestibility showed no such relation. (Eysenck, 1947: 201)

If Eysenck’s interpretation of the data is correct then, to put it in plain English, the concept of “indirect hypnosis” becomes a bit of a problem because what we know about traditional hypnotism probably can’t be applied to the use of indirect suggestion. For instance, there’s good evidence that direct (“primary”) suggestibility tends to increase (albeit by a modest amount on average) following a standard hypnotic eye-fixation induction. It wouldn’t follow from this, though, that indirect suggestions would become stronger following the same induction. Moreover, Hull and others had found evidence that direct (primary) suggestion responses tend to increase with practice whereas responses to indirect (secondary) suggestion do not seem to do so, and may even weaken with repetition.

Of course, questions have been raised in the past over the relatioship between Milton Erickson’s indirect approach and traditional hypnotherapy. Eysenck’s analysis is part of the backdrop to that riddle and his intelligent discussion of the research evidence provides some interesting facts and figures to chew over.

You can read a more detailed discussion of this research on my blog article below,

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May Research Snippet: Multiple Sclerosis Sun, 03 May 2009 17:24:05 +0000 May Research Snippet. Some updates on research news and a short discussion of a recent study comparing self-hypnosis and progressive muscle relaxation in the treatment of chronic pain in multiple sclerosis. The role of expectation and hypnotic susceptibillity are examined. Continue reading

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Apologies for the delay, but here we are again… Research snippets… but first some news…

Stephanie Kirke’s research on hypnotic pain management, sponsored by NCH, is nearing publication and that will probably be summarised in the NCH Journal.

Incidentally, the NCH page on Facebook now has over 300 members and we’re posting research snippets there on a regular basis. There are now ways to subscribe to various RSS news feeds online whereby you can receive updates on research news and journal articles as they’re published, updated in real time. Scientific American even have a news feed that links to 60 second audio podcasts summarising news snippets about psychology, much of which would be of interest to hypnotherapists. You can beam psychology factoids directly into your brain via your ipod while you’re playing sardines on the underground. Technology races ahead of us!

I should also give a plug for my own research into cognitive-behavioural hypnotherapy for noise-related stress, and my historical article in this month’s IJCEH, which presents a backward translated version of James Braid’s last article On Hypnotism (1860), also published in the new NCH book The Discovery of Hypnosis: The Complete Writings of James Braid, the Father of Hypnotherapy. You can now order the book online at Amazon UK. In the same edition of IJCEH as Braid’s “lost manuscript” we find an intersting outcome study by a team of ten (!) researchers, let’s call them Jensen, Barber, Romano, et al., entitled ‘A comparison of self-hypnosis versus progressive muscle relaxation in patients with multiple sclerosis and chronic pain’ (IJCEH, 57(2): 198-221).

Twenty-two participants were recruited for this study (which is just short of the 25 required for an empirically-supported treatment). Self-hypnosis was compared head-to-head against progressive muscle relaxation (PMR) for its ability to help management of pain in multiple sclerosis and, basically, those receiving self-hypnosis reported significantly greater pain reduction during sessions, and following treatment, than those using PMR., this was maintained at 3-month follow-up. (The use of an established relaxation technique as an active treatment control group serves here as a valid alternative to a placebo control group.)

Two predictor variables were measured: hypnotic susceptibility and the Treatment Expectancy Scale (TES). The TES is a common measure of expectancy which I think might have some useful applications in clinical practice. It basically asks the client to rate their response to four questions (0-10),

1. How logical does this type of treatment seem to you?
2. How confident are you that this treatment will be succesful in eliminating your symptoms?
3. How succesful do you feel that this treatment will be in reducing your symptoms?
4. How confident would you be in recommending this treatment to a friend who is suffering badly from the same symptoms?

Despite having similar outcome expectations, however, in both relaxation and self-hypnosis groups, the hypnotic subjects experienced more improvement. In other words, their improvement probably exceeded the effect of expectation alone. However, overall there was a moderate correlation between expectation and outcome across both groups (r=.40). In other words, expectation probably contributed substantially but does not account for all of the effects of self-hypnosis. Hypnotic susceptibility, by contrast, was not found to correlate with outcome. (Both findings which have been reported in other studies.)

Analysis of the levels of clinically significant reduction in pain showed that at 3-month follow-up, 47% of self-hypnosis subjects reported clinically meaningful pain reduction compared to only 29% of the relaxation group. (Although below 50%, this is a reasonably good outcome for a clinical trial of this kind.)

This study provides some support for the view that relatively simple self-hypnosis techniques can be effective in managing pain associated with multiple sclerosis, and is substantially superior to relaxation training, and probably therefore superior to placebo. It adds further to the body of evidence showing that treatment outcome expectations are an important factor in determining the outcome of therapy, but far from being the only factor. And it also adds to those studies which question the value of hypnotic susceptibility scales in predicting treatment outcome. Either these scales are flawed, perhaps because they measure the wrong type of responses, or being highly hypnotisable isn’t more helpful than being moderately hypnotisable when it comes to the kind of suggestions used in therapy.

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