Integrating Mindfulness Practice in Cognitive Behavioral Hypnotic Psychotherapy
Bnai-Zion Medical Center, Haifa, Israel, Yezreel Valley College, Israel
Academic Editor: Joseph Meyerson
Special Issue: Hypnotic and Strategic Psychotherapy
Received: January 28, 2022 | Accepted: April 25, 2022 | Published: May 06, 2022
OBM Integrative and Complementary Medicine 2022, Volume 7, Issue 2, doi:10.21926/obm.icm.2202021
Recommended citation: Arnon Z. Integrating Mindfulness Practice in Cognitive Behavioral Hypnotic Psychotherapy. OBM Integrative and Complementary Medicine 2022; 7(2): 021; doi:10.21926/obm.icm.2202021.
© 2022 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.
After the emergence of Mindfulness in the Western world, many studies proved its mental and physical benefits. However, implementing Mindfulness in psychotherapy has several challenges: therapists are not formal Mindfulness instructors; the Mindfulness course is a continuous eight-week course, which many patients do not attend during therapy, while others attend and drop out. Thus, Hypnosis was applied to shorten and strengthen the desired changes. The article describes the logic behind this integration, demonstrates it using a case study, and details the ideas, philosophy, and hypnotic scripts in the appendix.
Mindfulness emerged in the western culture in the 1970s when John Kabat-Zinn initiated a project to implement Buddhist Meditation in a public hospital (MBSR: Mindfulness-Based Stress Reduction) . His exposure to meditation led him to build a stress reduction course based on Buddhist meditation. The course was so successful that the approach was appreciated throughout the Western world. Since then, many studies have been published annually on the physical, mental, psychological, and medical effectiveness of Mindfulness .
Although there are many possible definitions of Mindfulness , Mindfulness could be defined as a mental training method aimed at one’s awareness to be at the present moment, solely and non-judgmentally.
Mindfulness is the basic human ability to be fully present and aware of where we are and what we’re doing and not overly reactive or overwhelmed by the surrounding situation . We all naturally possess Mindfulness. Whenever we are aware of what we’re directly experiencing via our senses or are aware of the state of mind via our thoughts and emotions, we are mindful. Some studies have shown that when someone trains their brain to be mindful, they re-model the physical structure of their brain (https://www.restorativeconversations.ca/workshop/mindful-journey-spring-2019).
Mindfulness practice is associated with numerous benefits, including improved working memory, increased metacognitive awareness, lower levels of anxiety, reduced emotional reactivity, enhanced visual attention processing, reduced stress, and better management of physical pain .
The classical Mindfulness course (https://www.mindfulleader.org) consists of eight meetings, and each includes a lecture and training. The trainees receive a prerecorded workout for practicing at home during the week until the next session. After the sixth or seventh meeting, an entire day is dedicated to a guided meditation (retreat).
2. Hypnosis and Mindfulness
Several studies have compared hypnosis with Mindfulness. For example, in a study, Lin et al.  stated, “We contend that hypnosis and Mindfulness inhabit a common, albeit broad, domain of suggestive approaches. However, we also argue that meaningful differences exist that are particularly salient and consequential in the forensic arena.”
Yapko, in his comprehensive book , investigated the similarities and differences between hypnosis and Mindfulness. He explained that Mindfulness is prevalent because it works, and this is supported by many empirical studies. He argued that Mindfulness applied in psychotherapy and medical psychology is different regarding direction and technique compared to its spiritual origin in Buddhism. Western Mindfulness is neither spiritual nor spiritual oriented.
According to Yapko , Mindfulness is not a single approach but a collection of approaches and techniques aimed at increasing focus on the present moment instead of the past and the future. In Yapko’s view, hypnosis deals with focus, like Mindfulness, but they are different. There are differences in philosophy, intention, and purpose. However, there are similar aspects like the intention to be good, the relationship with the therapist, and the changes that are recognized in the functioning of the brain.
Mindfulness contributes to a change in the understanding of treatment instead of focusing on pathology and seeking to correct it. Mindfulness focuses on accepting the world as it is and allows the natural healing power to work. Mindfulness is closely associated with cognitive therapy and a positive psychological approach, and thus, might be implemented in psychotherapy.
3. Mindfulness and Psychotherapy
The concept of Mindfulness has been applied to various therapeutic interventions—for example, mindfulness-based cognitive behavior therapy, mindfulness-based stress reduction, and mindfulness meditation—to help people avoid destructive or automatic habits and responses by learning to observe their thoughts, emotions, and other experiences in the present moment without judging or reacting to them .
According to my personal experience, meditation in general and mindfulness, in particular, can make positive cognitive and emotional changes. Thus, I referred patients to courses of Mindfulness so that they would gradually change according to the classical course structure. I found that the course helped patients with low self-esteem, anxiety, self-criticism, OCD, and reactive depression. Most patients might benefit from ego strengthening and improving self-esteem.
Ego strengthening was defined by John Hartland as a set of “generalized positive suggestions, aimed to increase the patient’s confidence and belief in him or herself, enhance general coping abilities, and minimize anxiety and worry” . It is similar to the concept proposed by Bandura and others regarding self-efficacy (which does not include hypnosis), which states “the expectation and confidence of being able to cope successfully with various situations” .
Those patients who completed the course and continued psychotherapy showed significant changes in cognitive and emotional processes. The treatment was significantly shortened, and they reached stabilization of the desired changes more quickly.
However, many patients did not complete the course for various reasons. Some claimed that the course was very slow and boring, and although they understood and accepted the ideas, they did not have the patience to complete the course. Some did not practice at home according to the instructions, so the changes were not internalized and remained at the level of cognitive understanding only. However, a significant proportion of the patients did not complete the eight-week course and hence, did not undergo the possible change. These dropout cases were rarely studied and were analyzed mainly for comparing the results between MBSR and dropout groups or referring to comorbid pathologies [9,10,11].
Implementing hypnosis in psychotherapy created a reinforcement of cognitive therapy, and the change is faster and more resilient after combining the two. This is not surprising as hypnosis can intensify and strengthen changes that occur in other ways, such as in psychotherapy, since the suggestions do amplify changes.
A question was framed regarding psychological therapy based on the difficulty people have while completing a course on Mindfulness and drawing benefits from it and the ability of hypnosis to intensify the desired changes: Is it possible to use hypnosis to achieve the desired targets of Mindfulness during psychological therapy, without taking the formal course on Mindfulness for eight weeks?
4. Hypnotic Mindfulness
Based on the information mentioned, a three-session program was built, which used hypnosis to enhance the process and change on the one hand and the content and ideas of Mindfulness and Buddhism on the other. Hypnosis is used when a cognitive explanation fails to change unconscious resistance, which leads to the necessity to bypass it by implementing hypnosis. Each session includes a part of “psychoeducation”, which consists of cognitive explanation and practice. The patient receives a prerecorded Mindful-Hypnotic script and is encouraged to practice it daily.
The intervals between sessions are determined by the pace of practice and the changes generated. Thus, weekly meetings, biweekly sessions, or even monthly meetings can be conducted.
The first session starts with psychoeducation (see details in appendix 1). In the session, the psychological foundations of Buddhism are explained, the importance of positive non-judgmental thinking is emphasized, and Alfred Adler’s EIERC is presented.
4.1 In Vivo Practice: Mindfulness Meditation
Sit and relax the shoulders, neck, and eyes.
Take three long and deep breaths, and then let the breath determine its rhythm.
Focus on breathing, experiencing the sensations of breathing:
Cool air enters in nostrils, and warm air exits the nostrils.
Focus on exhaling; discover that the body inhales on its own.
Focus on the gap between exhalation and inhalation.
Expand our awareness from breathing to all physical sensations:
From the top of the head and the face, the neck, down to the legs.
Do not imagine the physical sensation, but recognize and identify them: heat, cold, heaviness, stress, movement, tingling, itching, etc.
Identify numb areas.
Identify areas with unnamed sensation and identification.
Identify moments when there is an urge to do something, think about something, remember something, let it go, and get back to the body.
Pay attention to the surrounding: sound, light and color, smell, flavor, etc.
At the end of the session, prerecorded audio is given to the patients, encouraging them to practice it daily (Appendix 1: Mindfulness meditation - body scanning).
The second session starts with debriefing the previous session and practicing between sessions. The title of this session is: accepting what is.
Psychoeducation (see details in appendix 2):
After explaining the source of human suffering according to Buddhism, a possible solution is presented.
4.2 In Vivo Practice
Relying on inner unconscious resources
At the end of the session, prerecorded audio is given to the patients, encouraging them to practice it daily (Appendix 2: Mindfulness self-acceptance and ego strengthening).
The third session starts with debriefing the previous session and practicing between sessions. The title of this session is positive psychology and hypnosis.
Here proceed from non-judgmental to positive thinking, using daily examples, and enhancing gratitude.
4.4 In Vivo Practice
Love kindness and think of a time when you wanted to wish someone good. Focus on that emotion, and wish all living things well by repeating the following sentences over and over again. For example: may all living things (beings) be healthy, feel good, feel calm, and feel safe.
At the end of the session, prescribe homework:
Write letters of gratitude.
Write about things that you are thankful for because they exist in your life, and maybe maintain a daily diary.
Remember moments of kindness, both receiving and giving
Initiate thank you visits to the people you want to thank
Practice self-talk of gratitude
At the end of the session, prerecorded audio is played to the patients, encouraging them to practice the tasks daily (Appendix 3: Metta meditation: loving kindness).
Patients completing these three sessions report feeling less anxious, lower self-criticism, and higher self-esteem.
5. An Example
A 50-year-old woman, married and a mother of four children, was referred by a psychiatrist to undergo CBT treatment for reactive depression and anxiety. During the first meeting, she described herself and her family as anxious. She was on the verge of OCD, had a hospitalized bipolar father, and previously dynamic-oriented treatments over the years did not show significant improvement. She asked for help with the aid of hypnosis. She was suffering from depression, decreased appetite and weight, and OCD.
In the first session, hypnosis was explained to her, and she practiced breathing-based relaxation.
In the second session, relaxation was used as an induction. After putting her in a hypnotic state, I suggested that she separate the conscious and the unconscious. The ego was strengthened based on this separation, i.e., believing and trusting the unconscious, which is a guide in life and decision making (https://www.erickson-foundation.org/dr-ericksons-perspective-on-mind-body-interconnections/). As she described herself as a pleaser, we ended the session with a future progression of freedom from others’ expectations. The session was recorded for home practicing.
In hypnosis debriefing, she said that she did not feel completely free, maintained alertness and control, and remarked that she should practice the recorded session at home.
Since she went abroad for three weeks, we scheduled the next session a month later.
In the second session, she described a chest tightness that felt like steel chains. While she was in the hypnotic state, we used metaphoric scissors to cut them and then used a magnet to remove them. After that, she began to feel physical and mental ease and relaxed.
After the hypnotic part of the therapeutic session, I realized that the desired changes were not sufficient, so I decided to introduce the idea of mindfulness and suggested that she should take the three sessions.
In the third meeting, we started the first “Hypnotic Mindfulness”. After hypnosis, she explained that there were still doubts and resistance and rationalization; nevertheless, she began to apply the ideas in her daily life.
In the fourth meeting, we started the second “Hypnotic Mindfulness”, and although she could feel an improvement, she continued to resist and express doubts.
In the fifth meeting, she stopped resisting the ideas and the process, recognized changes in her thinking style toward less judgmental thoughts and better feelings, and felt that she internalized things and accepted them. We conducted the third “Hypnotic Mindfulness”, after which she asked for a break from therapy to let things seep in.
The fifth meeting was our last one, and in these three years, she has not required therapy. After 30 months, the patient reported feeling good in a follow-up session over the telephone. She practiced meditation which was different from the meditation style taught during therapy.
Integration of mindfulness into psychotherapy using hypnosis helps to induce positive desired therapeutic changes more quickly, overcoming one of the disadvantages of the MBSR course, i.e., a long duration (eight weeks). Hypnosis can help patients to adopt positive thinking and self-acceptance without the requirement of the therapist to be a Mindfulness instructor. There is no need to formally adopt the Buddhist philosophy to undergo this method of therapy.
The author did all the research work of this study.
The author has declared that no competing interests exist.
The following additional materials are uploaded at the page of this paper.
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