COGNITIVE—DEVELOPMENTAL

HYPNOTHERAPY
E. THOMAS DOWD

Cognitive therapy has, in its relatively short life, undergone a signif-

icant metamorphosis. It was originally developed by Aaron T. Beck, Albert
Ellis, and Donald Melchenbaum as a way of modifying distorted thought
patterns that were presumed to underlie emotional disorders. Beck ( 1976)
emphasized the role of dysfunctional automatic thoughts and maladaptive
rules in the development of psychological problems. He noted that these
automatic thoughts were idiosyncratic to the person, even to tho5e with
the same disoTder. Ellis ( 1977) , on the other hand, stressed the role of
irrational beliefs in the development of emotional problems and
developed a list of typical irrational beliefs engaged in by disturbed
individuals. Mei- chenbaum ( 1977) emphasized the role of the internal
dialogue, or negative self-statements, in the development of psychological
problems. Indeed, Meichenbaum's negative self-statements seem to function
as negative verbal conditioning.
These three systems of cognitive therapy share four underlying as-
sumptions. First, it is assumed that emotional disorders have in common a
set of negative cognitions regarding one's abilities, worth, or activities.
Although it is incorrect to say that these negative cognitions directly cause

http://dx.doi.org/10.1037/10274-010
Handbook of Clinical Hypnosis, edited by J. W. Rhue, S. J. Lynn, and I. Kirsch
Copyright © 1993 American Psychological Association. All rights reserved.
 psychological disorders, they do appear to interact with environmental
events, which results in dysfunctional behavioral and emotional patterns.
Thus, a history of negative cognitions may predispose the individual, under
stressful conditions, to develop emotional problems. However, without the
existence of a stress-inducing situation, these individuals may function
adequately. Second, these negative cognitions tend to be ahistorical in
nature (i.e. , it is what the individuals tell themselves now that really mat-
ters). Thus, there is an assumption that if current dysfunctional thinking
can be corrected, the emotional problems will diminish. Therefore, there
is a third similarity among these systems of cognitive therapy: the
emphasis on directly disputing (Ellis), presenting evidence against (Beck), or
coun- teracting by coping strategies (Meichenbaum) the negative cognitions
ex- isting in the present. Replacing these with more adaptive cognitions is
assumed to result in less emotional distress. Fourth, there seems to be a
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tacit assumption that these negative cognitions are more or less accessible
to consciousness. Therefore, it is the task of the therapist to help the client
to identify them so that they can be disputed and corrected.
There is a recent development within cognitive therapy, however,
that deviates from some of these assumptions. l refer to the cognitive—
developmental approach. In some ways, this approach represents a signif-
icant departure from previous cognitive therapy models.
In the cognitive—developmental approach, above all, cognitive activ-
ity is seen as being developmental in nature; that is, over time the cognitive
organizational structure is progressively elaborated and differentiated by
interaction with the environment, especially the environment of other
people (Guidano fi Liotti, 1983). These environmental interactions result
in a set of cognitive assumptions or rules that guide the individual's further
interactions with the environment. In particular, individuals acquire knowl-
edge about themselves (self-knowledge or self-concept) through
interactions with other people. Thus, cognitive assumptir›ns both cause and
are the result of the individual's interaction with the environment.
The cognitive—developmental model also distinguishes between tacit
and explicit knowledge, including self-knowledge (Guidano fi Liotti,
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1983). Tacit knowledge, by its nature, is developed prior to the

acquisition of formal language structures and, as a result, it is largely
nonaccessible verbally. Rather, it tends to be accessed thTOtlgh images and
feelings (Gui- dano, 1987). From a cognitive science perspective, Tataryn,
Nadel, and Jacobs ( 1989) made the same point when they referred to
nonconscious mental processing. Explicit knowledge, on the other hand,
is that which is acquired by means of language processes and is therefore
much more accessible verbally. lt is also much more amenable to change
via verbal psychotherapy. Tacit knowledge, precisely because it is
nonaccessible ver- bally, is also much more difficult to modify by
traditional verbal psycho-

216 E. THOMA3DJWD
 therapy. These two types of knowing processes should not be seen as two
polarities, however, but as two processes in constant interaction (Guidano,
1987). Thus, tacit knowledge, as well as explicit knowledge, is constantly
being elaborated and differentiated over the individual's life span.
One important implication of the cognitive—developmental model
for psychotherapy is that resistance to change is not necessarily an
annoying by-product of human cussedness but a natural and necessary self-
protective mechanism (Mahoney, 1988). Sudden and massive changes in core
cogs nitive constructs that are part of tacit knowledge are deeply unsettling
and frightening because they threaten the individual's personal meaning struc-
ture and therefore implicate personal identity (Dowd fi Seibel, 1990;
Liotti, 1987). Precisely because these core constructs are embedded within
the tacit knowledge system and are not verbally accessible, they are therefore
highly resistant to change via verbal psychotherapy. Cognitive constructs
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contained within the explicit knowledge system, however, should be con-

siderably easier to change using language.
lt follows from the aforementioned that verbal psychotherapy, as tra-
ditionally practiced, should be much more useful in changing cognitive
constructs that are part of the explicit knowledge system than those that
are contained withir the tacit knowledge system. Indeed, that has been
the clinical intuition of generations of practicing psychologists, Peripheral
attitudes and behaviors are often readily modifiable, whereas core constructs
involving issues of personal identity and self-concept change only slowly
over time. In addition, one implication of the previous discussion is that
verbal interaction may be of limited help in changing tacit cognitive con-
structs at all because it relies primarily on the use of language. Rather, tacit
constructs may be5t be changed by recourse to interventions involving
images and emotions. This, too, has been part of clinical lore. Interventions
that engage the “head” only, without emotional involvement, do not appear
to have the same power to cause “deep” change. This, indeed, was the
basis of the “corrective emotional experience” (Alexander, 1963), wherein
psychological change was predicated on emotional reinvolvement with a
previously problematical situation. Tataryn et al. ( 1989) likewise have
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stated that maladaptive behavior is governed largely by tacit schemata.

CHARACTERISTICS OF HYPNOSIS

There have been a number of different definitions of hypnosis, with

several aspects appearing common to most. First, hypnosis is characterized
by a heightened suggestibility and receptivity to suggestions. Second, the
individual's perceptual and cognitive focus is both narrowed and intensified.
Indeed, one form of hypnosis has been called “alert hypnosis” (Golden,

COGNITfVE—DEVELOPMENTAL HYPNOTHERAPY
 Dowd, fi Friedberg, 1987). Third, the hypnotic trance state tends tti rely
more on imagery and intuitive cognitive processes than on the formal use
of language. In this regard, certain descriptions of hypnot c phenomena
consider them to be dissociative in nature (Kihlstrom, 1984). Fourth, the
Ericksonian hypnotherapists in particular (Erickson fi Rossi, 1979, 1981)
argue that their indirect hypnotic techniques are particularly useful in by-
pass ng, discharging, or displacing resistance.
lt is important to assess the hypnotic ability of the individual. Al-
though almost anyone can enter at least a light trance, people vary greatly
in their ability to achieve a moderate or deep trance. Indeed, Bowers ( 1984)
went so far as to state that “the effects of a treatment intervention are not
due to suggestion unless treatment outcome is correlated with hypnotic
ability” (p. 444). Hypnotic ability seems to be distributed among the pop-
ulation on a normal curve and is highly stable over time (Bowers, 1976;
Udolf, 1981). Therefore, the ability to enter a trance readily and to benefit
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frs m hypnosis differs considerably among individuals. Hypnotic ability can

be assessed in a number of ways. Preinduction hypnotic ability tests, such
as arm levitation, hand clasping, and the postural sway, are discussed ir a
variety of sources (e. g. , Crasilneck fi Hall, 1985; Udolf, 1981). However,
Crasilneck and Hall (1985) considered them to be of little use in the clinical
situation and even to involve some risk (p, 58). Standardized tests, such
as the Stamford Hypnotic Susceptibility Scale or the Harvard Group Scale
of Hypnotic Susceptibility, can also be used. However, these instruments
are laborious to administer in a clinical situation and are used primarily for
research. Perhaps, as Crasilneck and Hall ( 1985) stated, “There is, after
all, no better test for susceptibility to hypnosis than a trial induction of
hypnosis itself” (p. 58). Several signs can be observed that indicate mod-
erate to good hypnotic ability. These include eyelid buttering, spontaneous
eye closure, deep relaxation and flaccid facial muscles, deep and slow breath-
ing, and changes in the swallow reflex (Crasilneck fi Hall, 1985; Udolf,
1981).
Given this, one can see how hypnosis can be useful in modifying the
disordered tacit schemata that underlie emotional disorders from a cogni-
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tive—developmental viewpoint. The resistance that is aroused naturally by

the threat to existing core cognitive schemata may be reduced by indirect
hypnotic suggestions. The concentrated perceptual and cognitive focus and
tncreased receptivity to influence and suggestions from the hypnotherapist
likewise may increase the probability of psychological change of any kind,
particularly core cognitive change that is tacit in nature. The reliance of
hypnosis on imagery and intuitive cognitive processing also may provide
the type of intervention that is most helpful in facilitating changes in tacit
cognitive schemata. Thus, hypnosis may be an especially useful intervention
both in accessing and modifying tacit knowledge.

zis E. THOMAS DOWD

 CLINICAL APPLICATIONS

There is probably no psychological disorder that someone, somewhere,

stimetime has not attempted to cure using hypnosis. Although almost any
hypnotherapeutic intervention can succeed on occasion, often for reasons
unrelated to hypnosis, certain kinds of di5orders in general seem more
amenable to change via hypnosis than others. Wadden and Anderton
(1982), in a comprehensive review of the experimental literature, concluded
that hypnosis is more effective with nonvoluntary disorders (e. g. , pain,
warts, asthma) than with self-initiated behavior (e.g. , obesity, smoking,
alcoholism). They speculated that one reason for that situation is that the
latter problems are rewarding, at least in the short run, whereas the former
are not. My own experience has led me tti similar conclusions. In addition
to the clinical problem5 discussed by Wadden and Anderton, I have found
hypnosis to be useful in treating depression, anxiety, and stress-related
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disorders. It can also be useful in overcoming client resistance (Golden et

at. , 1987). However, I have been approached by numerous individuals
who wanted me to hypnotize them to “get me to stop smoking” or “to make
me lose 5 or 10 lb.” I have rarely found that hypnosis is particularly useful
with these problems in that context. The issue seems to be lack of
motivation. These individuals appear to view hypnosis as a quasi-magical
technique that will remove their problem without any effort on their part.
When I encounter such a person, I ask, “do you want to eliminate your
problem or do you want to want to?” When put like that, they generally
admit sheepishly that it is the latter.
A major point of this chapter, however, is that hypnosis can also be
useful in cognitive restructuring, especially the restructuring of tacit cog-
nitive schemata. Cognitive restructuring has been extensively described by
Marvin Goldfried (Goldfried, Decenteceo, fi Weinberg, 19?4), but it un-
derlies other cognitive therapies, such as those of Beck ( 1976), Ellis ( 1977),
and Meichenbaum ( 1977), As a hypnotherapeutic technique, it has been
described by Golden et al. ( 1987) and Spiegel and Spiegel ( 1978).
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Cognitive Restructuring,

Originally, this technique referred to the Teplacement of negative self-

statements by more adaptive or positive self-statements. These statements,
such as “I must be perfect in everything I do” or “everyone must approve
of me,” could be readily accessed, either directly by the individual or with
the help of a therapist. Golden et al. ( 1987) provided several examples of
cognitive restructuring of specific and accessible statements and their re-
placement by more adaptive self-statements within a hypnotherapeutic
framework. For example, the negative thought “I’m hopeless, I'll never

COGNITIVE—DEVELOPMENTAL HYPNOTHERAPY 219

 change, I don't do anything right” can be replaced by “I used to do many
things well before I became depressed and l can do so again.” These more
adaptive statements can be said to the client while in a trance by the
therapist and eventually by the client. Self-statements pertaining to a wide
variety of psychological problems can thus be corrected while the client is
in a hypnotic trance. Cognitions such as these have been described by
Meichenbaum and Gilmore ( 1984) as cognitive events.
It has been increasingly noticed, however, that some cognitions are
not directly accessible to the client, even with the assistance of a therapist,
and are not necessarily in the form of self-statements. Rather, they are in
the form of tacit assumptions, schemata, or implicit rules for living that
form the bedrock of human cognition. These schemata are laid down
early in life by the interaction of the individual with the environment.
Because they are formed at a preverbal developmental 5tage, they are highly
resistant to subsequent modification. Once formed, however, these schemata
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act as templates to filter and channel future environmental stimuli, so that

they also constrain the ability of the individual to modify these schemata
or the basis of new information. Thus, the structure of the existing cognitive
framework tends to be preserved. Meichenbaum and Gilmore ( 1984) re-
ferred to these schemata as “cognitive structures.”
A particularly important cognitive structure is the self-schema (Mar-
kus, 1977), which refers to cognitive generalizations about the self that are
based on the individual's past social experience. New information that is
congruent with one's self-schema tends to be processed easily, whereas
information that is discrepant tends to be processed more slowly, if at all.
This may be the source of much therapeutic resistance and the finding that
low-interpretation discrepancy in the therapeutic situation tends to be more
effective than high-interpretation discrepancy in causing immediate client
attitudinal or behavioral change (e. g. , Claiborn fi Dowd, 1985). fnferpre-
motion di5Ct€bancy refers to the difference between the therapist's
interpre- tation of an event or a behavior and the client's interpretation. In a
similar vein, Mahoney ( 1988) argued that core cognitive structures are
appropri- ately resistant to massive change in order to protect the self-
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identity. ln many instances, however, it is precisely the Self-schema that is

appropriately the target of change. If so, hypnotherapy can be useful both in
modifying these self-schemata and in bypassing the resistance that generally
accom- panies attempts to change these schemata.

Hypnothernbextic Cognitive Restructuring

Because of the resistance that can be aroused by direct change attempts

on core cognitive schemata, the indirect approach used by Ericksonian
hypnotherapists can be useful. Golden et al. ( 1987) described two ways
that the indirect techniques of Milton Erickson can be used to bypass

220 E. THOMAS DOWD

 resistance. First, Erickson used therapeutic binds, or the “illusion of alter-
natives” (p. 112), wherein the therapist offer5 only alternatives that will
help to overcome the problem. Second, he used implications or implied
directives, wherein the therapist implies a particular change without directly
suggesting it. These techniques tend to discharge client resistance because
they do not directly challenge an existing client attitude or belief.
There are two types of hypnotherapeutic cognitive restructuring: re-
structuring cognitive events and restructuring core cognitive structures.

Restructuring Cognitive Events

Initially, it is important to understand the negative self-statements
that underlie the individual's presenting problem. Because these are cog-
nitive events, they are generally accessible to the client with the help o1
the therapist. The first task is to identify these negative self-statements, to
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test the reality of these negative assumptions, and to develop alternative

adaptive self-statements. The cognitive psychotherapy techniques of Beck
( 1976) and Ellis ( 1977), as well as other more recent writings, provide
numerous examples. Especially valuable is the two-column technique
(Golden et al. , 1987), in which negative self-statements are written down
one vertical column and corresponding adaptive self-statements are written
down the other.
The second task is to assist the client in entering a hypnotic trance.
For those with moderate to good hypnotic ability, standard inductions
available in most textbooks (e. g. , Udolf, 1981) should suffice. For clients
with little hypnotic ability, repeated inductions may be necessary. Fortu-
nately, most hypnotic cognitive restructuring of cognitive events can be
accomplished with a light trance. Moderate or deep trances are not needed.
The third task is to replace the negat ve self-statements with more
adaptive coping statements while the individual is in the trance. It is helpful
if the therapist first says the negative sell-statement to the client, then
replaces it with the adaptive statement. After repeated practice with this,
the client is asked to state aloud the negative and adaptive statements.
After more practice, the client can do the exercise silently and outside of
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the therapeutic situation. It is important that the therapist monitor the

activity to ensure that it is practiced diligently.

Restructuring Core Cognitive Structures

Because these are not accessible to the client and only by inference
to the therapist, they are much more diff cult to change. The
Ericksonian indirect hypnotherapeutic methods have been claimed to be
especially useful here because they do not tend to arouse the client's
resistance and may implicitly suggest new perceptions and new ways of
looking at problematic situations, often without the client being aware
that these are being sug-

COGNITIVE—DEVELOPMENTAL HYPNOTHERAPY 22 I
 gested. However, this position has been challenged. Bowers (1990) dis-
cussed laboratory studies indicating that subtle and indirect hypnotic sug-
gestions were not more effective than direct suggestion in reducing pain
and causing positive hallucinations and that they might have actually
aroused more resistance, The dependent measures used in these studies,
however, have consisted of relatively straightforward phenomena, in which
the subjects presumably had little hedonic investment. Tacit cognitive
schemata, on the other hand, are much less accessible to conscious aware-
ness and much more central to an individual's sense of identity. lt is there-
fore likely that changes in these cognitive structures would be much less
amenable to direct suggestion. Therefore, in accordance with past clinical
practice, indirect suggestions were used in these cases.
There are several tasks that the hypnotherapist must complete in
attempting to restructure core cognitive structures. The first task is to
identify the major themes and assumptions that underlie the client's core
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cognitive structure. Effective therapists of all persuasions often do this as

part of the therapeutic work, although it generally extends over several
sesstons and often continues intermittently throughout the course of ther-
apy. Indeed, the explicit identification of these themes to the client forms
the basis of interpretation and is at the heart of psychodynamic psycho-
therapy. However, client resistance is often aroused and therefore inter-
pretations, especially of core assumptions, are often challenged or not pro-
cessed by the client. Indirect suggestion can facilitate the acceptance of
these challenges to core assumption5.
The second task, as in the previous description of restructuring cog-
nitive events, is to assist the client in entering a hypnotic trance. Often,
more indirect methods are used, such as a conversational induction (Er-
ickson fi Rossi, 1979). Although Ericksonian hypnotherapists downplay
the importance of good hypnotic ability, I think that it is important for
the ultimate therapeutic outcome even in Ericksonian hypnotherapy. How-
ever, even individuals who can achieve only a light trance can benefit
somewhat from hypnotherapeutic intervention5. In addition, hypnotic abil-
ity can often be increased to some extent as the individual becomes more
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comfortable with the hypnotist and the situation.

The third task is the creation and use of an indirect hypnotic routine
designed to address the client's core cognitive assumptions. Examples of
such routines are available in many books on Ericksonian hypnotherapy.
However, the construction of these routines is not as easy as it appears,
and the nascent hypnotherapist is well advised to enroll in skill-building
workshtips sponsored by the Erickson Foundation or other hypnosis socie-
ties. As I illustrate shortly, indirect hypnotherapeutic routines make use of
techniques such as embedded suggestions, multiple levels of meaning, and
implicit reframing of meaning to address the core cognitive assumptions

222 E THOMAS DOWD

 and facilitate new learning, as well as open-ended sugge.stions, truisms, and
the “yes set” to bypass resistance.
In attempting to restructure either cognitive events or cognitive struc-
tures, it is important that the hypnotherapist rely on repetition of con-
structed routines. Using a hypnotic routine once or twice is, except in rare
instances, not likely to result in permanent change. This is especially true
in attempting to change core assumptions. Unfortunately, some of the
clinical anecdotes have fostered the image of hypnosis as a quick and
mysterious cure.

CASE MATERIAL

Detailed examples of the clinical application of hypnosis abound in

the literature (e. g. , Dowd fi Healy, 1986). In order to illustrate the
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specific applications of hypnosis to cognitive restructuring, 1 provide

excerpts of ca5es. It is important to emphasize that the hypnotherapist be
creative in devising hypnotic inductions and routines and not rely on a
“cookbook approach.” These cases should therefore be used for their
heuristic potential.

Restructuring Cognitive Events: The Case of John

“John” sought assistance in order to cope with anxiety regarding

being successful in his new job. Initially, the therapist helped ]ohn to
identify the negative self-statements that he had concerning his job
performance. This was accomplished partly by skilled therapist
questioning and partly by asking John to self-monitor his cognitions
during times of self-doubt. The following negative self-statements were
uncovered:
1. I will never be able to succeed at this job!
2. I got this job only because l was able to hide my incompetence.
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3. If I lose this job, l'll never get another!

4. My wife will leave me if l lose this job.
The therapist then helped ]ohn generate adaptive coping statements to
match the negative statements. The following were generated:
1. There is no reason to think I won't succeed at this job, since
I've succeeded at every other I've held.
2. I got this job because I had demonstrated competence on
previous jobs.
3. Even if l lost this job, 1 have more than enough skills to get
another.
4. My wife has stuck with me through worse than job losses
before, and I'm sure she will again.

COGNITIVE—DEVELOPMENTALHYPNOTHERAPY zys
 The therapist's next step was to assist John in entering a trance. As
initial trance induction, using eye fixation and muscle relaxation,
indicated that John may have moderate hypntitic ability. However, he was
highly anxious about “doing a good job” and was able to enter into a light
trance only after two practice sessions. While he was in a trance, the
therapist then used the following hypnotic routine.
Ytiu have constantly been hypnotizing yoursel with negative
thoughts. Now, I'd like to help you hypnotize yourself with positive
thoughts. As I explained, all hypnosis is really self-hypnosis, so that
you can learn to do what I teach you ....Now, say to yourself, “I've
succeeded at every job I've ever had, so there's no reason to think 1
won't succeed at this one.” That's right .... Now, say to yourself,
“I've shown competence on every other job, which is why I got this
one!” That's right, very good .... Now, say to yourself, “Even ’it I
lose a Job, I have the skills to get another one.” Very good! ... Now,
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say to your- self, “My wife has shown her loyalty to me many times
and has stuck with me, and I'm sure she'll do it again.” That's
right...................................................................................................................... Now,
notice how good you feel after having said those things. Notice how
warm, peaceful, and comfortable you feel................And you can recapture
this feeling anytime you want, just by entering a trance and saying
the same things to yourself, letting those thoughts gently roll around
in your mind.
The therapist practiced this kind of hypnotic routine (expanded) with
John for parts of several sessions and then asked him to practice it at
home. The therapist then discussed the result5 Of the home practice with
John and suggested modifications. After several sessions, John reported that
his job anxiety had diminished and that he was able to function better at
work.
lt is important to remember that this example is only a guide. Hypnotic
routines should be constructed only after some information about the client
has been collected, although preliminary trance inductions can be done
almost immediately.
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fiestructtirirtg Cognitive Strttcttires: the Case of Joan

“Joan” entered therapy because of an intense fear of the dark. She

had been in therapy previously for a number of issues, which had been
generally resolved to her satisfaction. However, her fear of the dark was
proving inconvenient because she experienced intense anxiety when home
alone at night and when walking alone in the evening. She felt that easy
mobility was restricted to daylight hours.
After two sessions, the therapist suspected that Joan had an unusually
strong need to be in control of herself and situations that involved her.
This need extended to control o1 the therapy sessions, which hampered
the development of the therapeutic alliance and led her to resist therapist

E. THOMAS DOWD
 interventions. Such an expectation of, and need for, control has been
hypothesized to be a core cognitive assumption for many people, especially
in the individualistic North American and Western European cultures
(Dowd, 1989). The therapist likewise suspected that this core assumption
of the desirability of a high level of control was an exacerbating factor in
her earlier problems and therefore decided to intervene hypnotically at the
tacit level.
An initial hypnotic induction, including eye closure and a
subsequent arm levitation, indicated that Joan had good hypnotic ability.
She reported that her arm had appeared to rise nonvolitionally, and the
therapist observed that it dropped abruptly into her lap after it touched her
forehead. This level of hypnotic ability made it more likely that a hypnotic
intervention would be successful. After Joan had entered a trance, the
therapist used the following hypnotic routine. This routine had been
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developed in outline form earlier and was fleshed out in detail on the
basis of Joan's responses while in the trance. Commentary on the routine
appears in brackets.
You have learned many things recently (referring to previous sessions]
about yourself and your relations to others. Now you can, if you wish,
learn more about your Year of the dark and other things [open-ended
invitation to relax and absorb suggestions, with an implication to
search cognitively]. It has been important to remain in control, hasn't it,
in many ways [introduction of tacit assumption and facilitation of yes set]
? It is important to be right now [multiple levels of meaning; “right” is
used simultaneously in two senses]. And this control has been good in
many ways, hasn't it [reframing and yes set] / But perhaps you have
learned that control may not always be good [a truism; few things are!].
Perhaps you have longed to relax, to relinquish control (implicitly tying
together two concepts] . . to find peace and relaxation. And perhaps
you have discovered an important thing [raises client's interest level,
focuses attention] that only those people who ore truly in control
cm oJord to give tip control temporarily (words in italic boldface
indicate that they were vocally emphasized]! So, the more control you
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really have, the more comfortable you can feel giving it up tempo-
rarily ... knowing that you can take it back whenever you want [par-
adoxical reframing]. And, you can practice being truly in control at a
deeper, more profound level by relinquishing control briefly, for as long
as you feel comfortable, knowing that you can take the control back
whenever you want [future paradoxical prescription]. It's just like rlght
now, isn’t it! You can comfortably allow yourself to be relaxed here
[note earlier pairing with relaxation and relinquishing control], know-
ing that you could leave the trance any time von wanted [I had earlier
mentioned that all hypnosis is sell-hypnosis]. But you really don't want
to right now, do you [yes set] / You feel so relaxed and comfortable just
being ln a trance. And you can have this feeling anytime you want by
relaxing and letttng go, feeling increasingly comfortable in relax lng and
letting go, finding peace and happiness in so doing. And the more you

COGNITIVE—DEVELOPMENTAL HYPNOTHERAPY
 practice relaxing, letting go, you, Joan, can begin to find increasing
relaxation and less control bthe underlined words identify an embedded
suggestion], the more you can feel truly in control ... and the more
you feel truly in control, the more you can allow yourself to
relinquish control longer [setting up an adaptive spiral], and you can
allow yourself to learn many new things about yourself [open-ended
future invitation].
This routine, with variations, was repeated during each session for several
more sessions. The vocally emphasized sentence was used repeatedly because
this was a key area for this client, The following hypnotic routine was then
used as the client entered a trance:
Now imagine yourself walking alone at night but in a lighted area. As
you begin to feel anxious, allow yourself to let go and to relax all
over .... That's right! ... Now imagine yourself at home alone at
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night. As you begin to feel anxious, just allow yourself to let go and
to relax all over .... That's right! And you can let go, relax, and
relinquish control whenever you feel anxious, knowing that You do not
have to be in control at all times to have ultimate control, that you
can achieve control by relaxing because then you have control of
your reactions [introducing by implication the concept of personal
control as being distinct from environmental control] .... So that
the more you relax, the more you can achieve personal control. You
don't even have to do anything (introducing the concept of obtaining
control by not trying to]. And every time you feel anxious in the dark,
you can find increasing personal control by relaxing and letting go.
In order to further test Joan's level of hypnotic ability, 1 asked her
not to remember all or most of what I had said (posthypnotic amnesia).
After awakening from the trance, she did indeed remember little,
thereby further validating her high level of hypnotic ability. We discussed
relaxation exercises she could practice when anxious, and her fear of the
dark had diminished markedly within a few weeks.
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RESEARCH AND APPRAISAL

The therapeutic effectiveness of cognitive restructuring, compared

with control conditions and other treatments, has been investigated for
some time. Studies have almost universally shown that cognitive restruc-
turing is more effective than a no-treatment control. However, research
has not clearly shown the superiority of cognitive restructuring to alternative
treatments or in conjunction with other treatment5 for a variety of psy-
chological disorders. Biran and Wilson ( 1981) found that guided exposure
was superior to cognitive restructuring on most measures in the treatment
of phobic disorders. Baucom, Sayers, and Sher ( 1990) found that the ad-
dition of cognitive restructuring or emotional expressiveness training did

E. THOMAS DOED
 not increase the effectiveness of behavioral marital training with maritally
distressed couples. However, Mattick and Peters (1988) found that cog-
nitive restructuring and guided exposure were more effective than guided
exposure alone in treating social phobia. Pecsok and Fremouw (1988) found
that cognitive restructuring was more effective than self-monitoring in ov-
ercoming binge eating. However, Franklin ( 1989) found that cognitive
restructuring was less effective than respiratory retraining but more effective
than a placebo in treating agoraphobia. De Jong, Trieber, and Henrich
( 1985) found that cognitive restructuring alone was as effective as a com-
bination of activity scheduling, social competence training, and cognitive
restructuring in the treatment of severe and chronic depression; both treat-
ments were more effective than a waiting-list control condition. Patsiokas
and Clum (1985) found that cognitive restructuring was equally as effective
as problem-solving training and a nondirective control condition in reduc-
ing feelings of hopelessness among suicide attempters, although problem-
Copyright American Psychological Association. Not for further

solving training was significantly more effective than the nondirective con-
dition.
These mixed and inconclusive results are characteristic of the litera-
ture. Cognitive restructuring sometimes adds significantly to a treatment
package, but it is not generally more effective thar alternative treatments.
That these results may be attributable to individual diferences was suggested
by Frank and Noble (1984), who found that field-independent individuals
were more efficient in their use of cognitive restructuring skills than were
field-dependent individuals.
There have been a few studies on the effectiveness of cognitive re-
structuring with hypnosis. Tosi, Judah, and Murphy (1989) found that a
combination of hypnosis and cognitive restructuring (called rational stage-
diTected hypnotheraQy [RSDH]) was generally more effective than cognitive
restructuring arid hypnosis alone in the treatment of psychological factors
(e.g. , locus of control, irrational beliefs, personality coping styles) associated
with duodenal ulcers. Boutin and Tosi ( 1983) compared RSDH with hyp-
nosis only, a placebo condition, and a no-treatment control condition on
the modification of irrational ideas and test anxiety in nursing students.
distribution.

They found that RSDH and hypnosis were both effective in ameliorating
these problems but that RSDH was significantly more effective than hyp-
nosis alone. Howard and Reardon ( 1986) found that a cognitive hypnotic
imagery approach was more effective than cognitive restructuring or hyp-
nosis alone in the immediate and long-term reduction of anxiety and en-
hancement of self-concept in male weight lifters. Edelson and Fitzpatrick
( 1989) compared hypnosis, cognitive—behavioral, and attention-control in-
terventitins in the treatment of chronic pain. They found that both pro-
cedures reduced pain intensity (as measured by the McGill Pain Question-
naire) but that only the cognitive—behavioral treatment led to a significant
increase in the overt motor behavior element of chronic pain. Wall and

COGNITIVE—DEVELOPMENTAL HYPNOTHERAPY
 Womack ( 1989) compared standard hypnotic instructions with an active
cognitive coping strategy in the treatment of procedurally induced pain and
anxiety. Both interventions proved equally effective in reducing pain, but
neither was effective in reducing anxiety. No studies were found regarding
the effectiveness of cognitive—developmental hypnotherapy, as described
and illustrated in this chapter.
Thus, there is tentative evidence that hypnosis may add to the efficacy
of cognitive restructuring in the treatment of a variety of cognitively based
phenomena. However, to my knowledge, no study appears to have inves-
tigated the utility of hypnosis in the modification of tacit cognitive sche-
mata. It is there that future research should be directed.

CONCLUSION
Copyright American Psychological Association. Not for further

CognitiveHevelopmental hypnotherapy is in its infancy. Although the

theoretical and conceptual oundations for its practice are being laid down,
and interventions are being developed, there has been no research
evidence directly bearing on its effectiveness. Indirectly, however, it ten-
tatively appears that hypnotherapeutic cognitive restructuring tnay be ef-
fective beyond that demonstrated by cognitive restructuring alone. Theo-
retically, cognitive—developmental hypnotherapy derives from the
developmental and constructivistic movements within cognitive therapy and
epistemologically from the distinction between tacit and explicit know- ing
systems. The interventions have been developed in part from the writ- ings
and practice of Milton Erickson and his successors, who seem to operate at the
level of tacit knowledge. In this chapter I have outlined the theo- retical
structure underlying cognitive—developmental hypnotherapy and il-
lustrated how its principles may be applied to actual case examples. Al-
though it has not been demonstrated fully, it is my contention that tacit
cognitive restructuring can best be used with individuals who have good
hypnotic ability.
distribution.

REFERENCES

Alexander, F. ( 1963). Fttndamenrals o{ p5ychoanniysts. New York: Norton.

Baucom, D H. , Sayers, S. L. , fi Sher, T. G. ( 1990). Supplementing behavioral
marital therapy with cognitive restructuring and emotional expressiveness
traintng: An outcome investigation. JoxTnai of Consulting anet PltRtCOl Psy-
chology, 50, 636-645.
Beck, A. T. ( 1976). Cognitive theTap y and the emotional dtSordeTs. Madison, CT:
International Universities Press.