Newsletter Signup

Please register to the site before you can sign for a list.
No account yet? Register

My Account Menu

Newsletter Signup

Please register to the site before you can sign for a list.
No account yet? Register

Brief Cognitive Hypnosis: A Comprehensive Review

by Bruce N. Eimer, Ph.D, ABPP.

12 Credit Hours - $120
Last revised: 06/29/2017

Course content © Copyright 2011 - 2020 by Bruce N. Eimer, Ph.D, ABPP. All rights reserved.


This test is only active if you are successfully logged in.


Course Outline


Author Disclaimer

Learning Objectives

The Brief Cognitive Hypnosis (BCH) Model

The Theoretical Foundation of BCH

Matching Patient and Methodology

The Initial Intake and Evaluation

Establishing the Therapeutic Relationship

Formulating a Treatment Plan

The Waking State Reframing Model

Change Language: General, Waking State, Trance State, and Post–Trance Waking State Reframing

The Clinician’s “Invisible Language”

Trance Induction: Design, Choice, and Administration

Self-Hypnosis for Continued Problem Resolution

Common Factors in Dysfunctional Behavior and the Creation of Double Binds

Rituals: Dysfunctional and Therapeutic

Summary and Conclusions






This course is intended for the experienced mental health clinician who may or may not be familiar with hypnosis.  Whether you have experience with hypnosis or you are looking to add it to your practice, this course will provide you with introductory and engaging material.  The goal of this course is to provide you with a rewarding experience.  Dr. Eimer is a licensed clinical psychologist in Philadelphia with more than twenty years of experience treating people using cognitive behavioral and hypnosis strategies. He is Board Certified by the American Board of Professional Psychology in the specialty of Cognitive-Behavioral Psychology, a Fellow of the American Society of Clinical Hypnosis, and an Approved Consultant in Clinical Hypnosis.  More information about his credentials can be found on the Authors Page


Portions of this course content draw on the author’s work found in the following resources (and work done since then).  More detailed information can be found there. Some of these books are also excellent to be used as patient resources.   


Eimer, B.N. (2008). Hypnotize yourself out of pain now (Second Edition). Carmarthen, Wales, UK: Crown House Publishing (CD also available).


Eimer, B.N. and Freeman, A. (1998). Pain management psychotherapy: A Practical Guide. New York: John Wiley and Sons.


Eimer, B. and Torem, M.S. (2002). Coping with uncertainty.  Oakland: New Harbinger Publications.


Ewin, D.M. and Eimer, B.N. (2006). Ideomotor signals for rapid hypnoanalysis: A how-to manual.  Springfield, IL: CC Thomas.


Zarren, J. and Eimer, B. (2002). Brief cognitive hypnosis: Facilitating the change of dysfunctional behavior.  New York: Springer Publishing.


The goal of this course to introduce the clinician to the idea of a simpler way of thinking about patient dysfunction, ways to assess quickly and accurately the target problem requiring immediate attention, a conceptual framework for planning the treatment process, and ways to utilize therapeutic language and hypnotic procedures effectively. In this course, the clinician will learn an overview of Brief Cognitive Hypnosis (BCH) and be presented with the following: specific therapeutic procedures and techniques, their rationale and means of flexible application, and guidelines for fitting them into your already established ways of working.


You may decide that some of this new learning can be directly incorporated into your already established way of working; however, it is recommended that further training be undertaken to master all aside from the most basic techniques.  For those who utilize these methods immediately, it is assumed that you will have a modicum of comfort and experience in the use of clinical hypnosis within the context of your own professional discipline.      


The model termed “Brief Cognitive Hypnosis” incorporates a unique cognitive perspective and a simple way of using "change language" in brief psychotherapy.  It also addresses the relationship between the patient and the clinician, and the continuing interaction and learning that occurs during the therapeutic process. 


Author Disclaimer


The clinical evaluation and treatment methods described in this course are not intended as substitutes for competent and thorough medical, psychiatric, or psychological evaluation and care, nor are they intended to replace the medical or professional recommendations of physicians or other health‑care providers who are familiar with a given case.  This course is intended to offer usable information that can enhance the effectiveness of the reader/clinician in helping his or her patients alleviate or gain control over their symptoms and change their dysfunctional behaviors.



  • Discuss hypnotic trance, hypnotic state, and waking state
  • Describe the theoretical foundations of BCH
  • List the basic steps in treatment planning
  • Explain the clinician’s use of “invisible language”
  • Contrast dysfunctional and therapeutic rituals


The Brief Cognitive Hypnosis Model


The Brief Cognitive Hypnosis (BCH) model suggests that most behaviors that are difficult for the patient to control or change are the result of cognitive dissonance and conflict occurring between the conscious and unconscious parts of the mind.  The conscious mind can be conceptualized as that part of the mind that the individual has control over from moment to moment.  A conscious thought can initiate an immediate accompanying action, behavior or general response.  A person can usually change that response by a direct thought to do so.


The unconscious mind is that part of the mind that controls an individual’s automatic behaviors.  This includes all of the actions of the autonomic nervous system and an individual's habitual patterns of thinking and behavior.  The unconscious mind controls the person’s built-in survival mechanisms through the functions of the immune system and "fight-flight response" as part of the "general adaptation syndrome" (GAS; Selye, 1974, 1976).  It utilizes inherited gene imprinting, learned environmental and social imprinting in constructing its own unique interpretation of the individual's internal and external world.  Through a highly developed sensory system, the unconscious mind interprets the world by selectively filtering informational input from both internal and external sources.  The unconscious mind is also influenced by the selective interpretation of language.  It is particularly responsive to extreme emotional imprinting, repetition, and suggestion through language directed to its strongest sensory representational system.


The concept of the "unconscious" and the evolution of this concept have played a pivotal role in the emergence of hypnosis as a tool in psychotherapy (Ellenberger, 1970; Gauld, 1992).  The practice of hypnosis in psychotherapy has evolved from its common roots with the emergence and evolution of dynamic psychotherapy and psychiatry with their focus on the unconscious (Bromberg, 1959; Ellenberger, 1970; Fine, 1990).  The reality of unconscious cognition is now solidly established in empirical research (Greenwald, 1992; Kihlstrom, Barnhardt, & Tataryn, 1992; Lynn, Kirsch, & Rhue, 2010).


A View of Hypnosis for this Course


Although there are many definitions and conceptualizations about “what hypnosis is” in the research literature and other writings, it is useful to have a standard understanding for this course (See Kallio and Revonsuo, 2003).


Hypnosis as an altered state.  Hypnosis is an altered state of focused attention and heightened suggestibility that may or may not include a formal trance induction. Hypnotic trance is an altered state that is produced by a formal hypnotic induction ritual or ceremony that serves as the focusing method.  In contrast to hypnotic trances that are formally induced for therapeutic purposes, there are informal trances that occur spontaneously without any formal hypnotic induction ceremony (Bowers, 1976; Erickson & Rossi, 1979, 1981; Spiegel & Spiegel, 1978, 1987).


For the purposes of this course, hypnosis will be viewed as an alteration in internal perception, an altered state that is initiated at the start of a unique process of communication.  The communication in and of itself is not hypnosis.  The altered state that is labeled hypnosis results from the communication process (Eimer & Freeman, 1998; Zarren, 1996a; Zarren & Eimer, 1999).  In fact, natural everyday altered states might be labeled as hypnoidal states and therapeutic altered states as hypnosis states.


In the clinical setting, a hypnosis state (as differentiated from the trance state) can be induced without a formal trance induction.  This occurs when the clinician communicates with the patient in a language and form that is acceptable to the patient's conscious and unconscious minds.  This has been termed a form of communication: Waking State Reframing.  In the current conceptualization, the subsequent formal induction of hypnotic trance serves to fix the information communicated further in place in the patient's unconscious.


Hypnotic trance can be formally induced or informal suggestions for entering into trance can be given to the patient who is already in hypnosis and ready to go "deeper" (Specific examples of how to do this will be provided subsequently).  This then moves the process erickson_imagealong so that suggestions can be given while the patient is in a trance state and "Trance State Reframing" can occur.  This serves to “fix” the information (that was communicated earlier in the Waking State) in the patient's unconscious.


Milton Erickson (1961) and David Cheek (1994) both believed that people "enter hypnosis as they mentally review sequential events" (Cheek, 1994, p. 1).  Cheek (1994) wrote, "A hypnoidal state is entered when [remembering sequential events such as:] recalling a tune, remembering the visual images of waves breaking on a beach, the movements of a candle flame, and the words of a poem" (p. 1).  Thus, a basic mechanism for inducing a hypnotic altered state is the review or processing of a sequence of sensory impressions or memories.


The special communication experience that initiates a hypnosis state can start as the result of an externally evoked stimulus that alerts the unconscious to pay attention.  In the clinical or therapeutic treatment setting, the initiating stimulus is often the clinician's words; for example, the lulling sound of the therapist's voice in conjunction with the quietness, peacefulness, separateness from the outside world, and feelings of safety engendered by the office environment. 


Whether or not a patient enters a therapeutic altered state (i.e., therapeutic hypnosis or a hypnosis state) is influenced by the words the clinician chooses to use and whether or not they match the patient's primary sensory representational system.  It is also influenced by the extent to which the clinician communicates the right (correct) information for that individual patient in a form that the patient can accept. The patient must also be a willing participant in the treatment process.



Table 1. Summary of Important Concepts



Conscious mind. The conscious mind can be conceptualized as that part of the mind that the individual has moment to moment control over.  A conscious thought can initiate an immediate accompanying action, behavior or general response.  A person can usually change that response by a direct thought to do so.


Unconscious mind. The unconscious mind is that part of the mind that controls an individual’s automatic behaviors.  Through a highly developed sensory system, the unconscious mind interprets the world by selectively filtering informational input from both internal and external sources.  It is influenced by the selective interpretation of language and is particularly responsive to extreme emotional imprinting, repetition, and suggestion through language directed to its strongest sensory representational system.


Hypnosis. Hypnosis is an altered state of focused attention and heightened suggestibility that may or may not include a formal trance induction. 


Hypnotic trance is an altered state that is produced by a formal hypnotic induction ritual or ceremony that serves as the focusing method.  In contrast to hypnotic trances that are formally induced for therapeutic purposes, there are informal trances that occur spontaneously without any formal hypnotic induction ceremony.


Hypnosis state is the review or processing of a sequence of sensory impressions or memories. The special communication experience that initiates a hypnosis state can start as the result of an externally evoked stimulus that alerts the unconscious to pay attention. 


Language.  Language is inherent to how we learn.  We automatically and unconsciously interpret the representational code of language to understand and apply meaning to our world.  Therefore, certain language forms can affect how we feel and behave.  Our sensory representational systems give guidance to these interpretations and have direct access to the learning centers of the conscious and unconscious parts of the mind.    


Therapeutic application of hypnosis.  The therapeutic use of the focused altered state we call hypnosis is seen during the delivery of waking and trance state suggestions.  Clinical hypnosis is viewed as the intentional induction and utilization of altered states for therapeutic purposes in the clinical setting (Eimer & Freeman, 1998; Zarren, 1996a; Zarren & Eimer, 1999).


Waking state hypnotic communication.  Waking state communication is directed at the conscious and unconscious mind.  Waking state hypnotic communication includes the state of alteration in internal perception that occurs without a formal trance induction or ceremony.  The importance of the waking state to the change process will be presented in detail later in the course.


Reframing.   The term reframing refers to the purposeful verbal intervention of the clinician to assist the patient in changing the meaning of his or her beliefs that continue to propagate dysfunctional behavior.  This does not change the substance of the problem, but does change the way the patient thinks about his or her self in relation to the problem. 



The Hypnotic Trance State


The hypnotic trance state is an intensified (more highly focused) altered state that is formally induced through some form of ritual or ceremony, which is labeled the hypnotic trance induction. During the trance state, the altered ways of thinking and feeling that were accepted by the patient during the waking state (e.g. Waking State Reframing) are integrated and fixed in place by the patient's unconscious.  This is what BCH terms Trance State Imprinting. Trance state imprinting is further enhanced by the delivery of additional suggestions that are more specific to the unique change needs of the individual patient.  One can think of this as a "fixative process" or catalyst.  A useful metaphor is to think of it is as if the clinician were repairing an object and applied epoxy. If the catalyst for the epoxy is not applied, it will not be effective (it may hold for awhile but will end up with a sticky mess).  Adding the catalyst causes the epoxy to harden resulting in a permanent repair.



Table 2. Twenty Basic Characteristics of Hypnotic Trance



Humphreys (2000) details 20 non-mutually exclusive basic characteristics of hypnotic trance as an "altered state of consciousness".  These include:


narrowed focus of attention


increased absorption and reduced distractibility


inattention to or disinterest in environmental stimuli other than the therapist


increased concentration on a particular aspect of experience (e.g., sensations, emotions, ideation)


increased suggestibility


reduction of critical evaluation and screening


reduction of voluntary activity (mental and/or physical)


passive responsiveness or non-volitional activity


relative effortlessness


reduction in internal dialogue or self-talk


alteration of cognitive functions


facilitation of atypical modes of thinking such as "trance logic"


heightened rapport with the therapist


some degree of physical relaxation or comfort


altered sense of one's body


increased imaginal processing


time distortion


alteration of memory processing


relative dominance of the parasympathetic branch of the autonomic nervous system accompanied by a dampening or reduction in sympathetic nervous system activity, along with attendant calming, relaxing, and restorative psychophysiological phenomena (Humphreys & Eagan, 1999)


relative dominance of right hemispheric cerebral functioning (also see Watzlawick, 1978).



The concept of imprinting.  We learn from repetition and from emotionally powerful experiences. When a thought, feeling, or behavior is repeated, the unconscious part of the mind is more able to accept that which is repeated as appropriate and valid.  That is how we learn and establish habits. In BCH, this learning is imprinting. The unconscious does not always discriminate between good and bad repetition (unless the behaviors and experiences are perceived as life threatening).  As such, we may learn bad habits or less functional ways of behaving along with good habits or more functional ways of behaving.


Most of our learning and imprinting takes place in the Waking State.  That is, we are conscious and aware of that consciousness. We are not asleep or in an altered state (e.g. trance).  However, imprinting also occurs during highly emotionally charged experiences, such as shock, trauma, loss, illness, etc.  These emotionally charged experiences are also altered states. The imprints they create are often negative, uncomfortable, intrusive, and dysfunctional.  The strategic utilization of therapeutic altered states (i.e., therapeutic trance) may be one of the best ways to restructure or reframe these negative sequelae.


During the process of Waking State Reframing BCH utilizes special change language that is referred to as "Reframes".  This begins the task of neutralizing negative imprinting that has become dysfunctional and that has been experienced as a problem by the patient.    


Self-hypnosis.  Self-hypnosis, among other things, is a way of communicating with one's unconscious or “inner mind.”  Most individuals do not consciously know how to appropriately communicate with their own unconscious mind.  Therefore, to be effective, self-hypnosis has to be taught by someone who understands these communication factors and who also is experienced in practicing self-hypnosis. 


Hypnosis as a "Therapeutic Tool".  The effective use of hypnosis as an adjunctive therapeutic tool utilized by the experienced clinician requires that it be used within a frame of reference that contains its own well structured system of learning and therapeutic design.  It is a tool, in the hands of an experience clinician, for shortening the length of time required for changing and healing the patient.  Hypnosis also is useful in helping the patient accomplish change that is more permanent. It is an adjunctive method that can improve the results of treatment and assist the patient in dealing positively with the treatment experience and the outcomes of treatment.


The many models of psychotherapy that are used by the experienced practitioner are the foundation upon which the tool of hypnosis is added.  Because the psychotherapeutic process is essentially an interpersonal communication process, attention to sensory learning and language meaning is of paramount importance.


"Brief" Rather Than "Short -Term"


The model discussed in this course, and elsewhere, is termed “Brief Cognitive Hypnosis” because


it takes much less time to bring about change

it uses a logical cognitive frame of reference

it increases the effectiveness of the tool called clinical hypnosis      


Short-term psychotherapy is often the label placed on therapy that takes a year or less, as compared to dynamic or psychoanalytic psychotherapy that may go on for much longer.  Short-term psychotherapy is usually task- rather than insight-directed.  Most models for short-term psychotherapy are precise and sometimes almost ritualistic designs that are taught as specific formulas to deal with specific diagnostic labels.  They can become cumbersome in their detail and thus are often very complicated or not flexible enough.  Other models of short-term psychotherapy attempt to individualize, but are frequently very non-directive, assuming the patient’s unconscious already has all or most of the information it needs to solve the problem. 


BCH is very brief and often accomplished in one to five sessions.  Verbal therapy contracts are established in five session units when it is decided that multiple or complex problems need to be addressed.  This model is simplified and can be more generally applied to a wide range of behaviors while allowing for the needs and goals of each individual patient.  It does this by logically grouping behaviors that, though expressed and experienced differently, are initiated through a common behavioral mechanism.


Initial Coping and Evolving Complexity


Common underlying mechanisms of different dysfunctional behaviors. One premise of this course is that there are particular cognitive, behavioral, and affective mechanisms that different dysfunctional behaviors have in common as underlying factors.  As an example, by addressing anxiety as the common underlying affective and behavioral mechanism of a number of different dysfunctional behaviors, one can often simplify the start of treatment.  Instead of viewing phobias and obsessive compulsive behaviors as separate and different problems, they are approached fundamentally as starting with the same basic mechanism (anxiety).  From this viewpoint, maladaptive behaviors are viewed as different negative ways of coping that have become exaggerated and have evolved in an attempt to reduce anxiety. 


The choice of different sets of criteria for symptoms and behaviors has been used to establish different specific diagnostic labels (DSM-IV; American Psychiatric Association, 1994).  In contrast, one can conceptualize dysfunctional behavior by determining the initial emotional and physiological response mechanism that took place as the patient attempted to cope with a stimulus that was interpreted as threatening.  This conceptual approach often allows one to start at the beginning, and change the initial response that subsequent and more debilitating negative symptoms were built upon.  Thus, the treatment is often more focused and goal directed. It allows the patient, and the practitioner, to uncomplicate the problem into workable components. This often brings some recognizable feeling of partial relief from the intensity of the presenting symptoms very quickly.  By reframing the patient’s belief that he or she is trapped, the clinician establishes the possibility for new choices and change.  This "untraps" the trapped feelings and fears.        


By recognizing common dysfunctional behaviors that cut across a number of supposedly different diagnostic categories, the experienced clinician can start the change process at the very beginning by addressing the core behaviors that have evolved and have become more complex over time, by repetition.


The Theoretical Foundation of Brief Cognitive Hypnosis


Clinical hypnosis.  The theoretical foundation of the BCH model views clinical hypnosis as a two-faceted system:


(1) A relationship-based process of communication that occurs from the very first contact with the patient when communication takes place with the patient’s conscious and unconscious minds simultaneously.  This process is termed "Waking State Reframing".  This creates an altered state that can be viewed as an "anticipatory trance like state". 


(2) The formal hypnotic trance state that allows positive imprinting to occur in the unconscious mind, “fixes” the communications and learning in place so they can be automatically applied to create continuing appropriate changes in thinking and behavior.


"Challenge" not "Confrontation".  BCH reframes the concept of confrontation and re-labels it as a challenge.  That is, BCH challenges the patient’s established belief systems so that the possibility of change can occur. 


All patients enter into the therapeutic relationship with a number of established beliefs that tend to be expressed as absolutes.  Often, the events they describe are verbalized as “always” happening. Patients then become trapped in particular negative behaviors because of those beliefs.  The beliefs are usually not true and are invalid.  That is why the patient is in trouble.


The therapist has the responsibility to assist the patient in changing from believing in the absolutism of always being trapped and always feeling helpless, to recognizing and believing that change is possible.  Challenging these beliefs is the basis of the change and reframing process.  Reframing starts to occur during the initial interview, when information is given to the patient and when the patient's questions are answered.  It also occurs when the clinician starts asking the patient questions to clarify the patient's beliefs.


This is all part of the process that BCH has termed "Waking State Reframing".  All of this occurs prior to any formal trance induction.  The "change language" that is the language of hypnosis is used throughout this process.


"Coping Behavior" not "Defense Mechanisms".  BCH does not talk about "defense mechanisms"; rather, all behaviors are viewed as coping behaviors.  Some are more effective and appropriate than are others. In the view of BCH, during childhood, or adolescence, or early adulthood, something may have taken place that was interpreted as a threat to the continued safety or existence of the person.  A minor or major "Fight-Flight Response" (Selye, 1974, 1976) may have then occurred.  At that time, the first attempt to cope with the event that was interpreted as threatening or traumatic may have been a behavior that created a feeling of less anxiety and greater comfort.  It may have helped at the time it was first used, and thus became imprinted as the "coping behavior of choice".  It was then repeated when memories or feelings from that event or similar events reoccurred.  Thus, it was further fixed in place by repetition.  This may even happen when the chosen coping behavior is uncomfortable, painful or embarrassing, and dysfunctional.  It is predictable and, therefore, acceptable to the unconscious.


The original event is in the past.  It is no longer taking place.  The continuation of the initial dysfunctional coping behavior is no longer valid. It is no longer serving its original purpose.  Yet, it continues by repetition, as a habit.  In fact, the longer it is repeated, the more it tends to feed on itself, and the more it evolves.  It becomes more complicated and dysfunctional, and often more generalized.


Symptoms.  The clinician needs to identify these invalid negative coping behaviors as such.  Invalid negative coping methods are leftover dysfunctional behaviors that are labeled symptoms.  They started as a way of coping with some stressful situation, but continued because of repetitious imprinting and habit formation.  They are no longer needed and are behavioral remnants from the past.  In the view of BCH, if the patient has not responded to the more traditional approaches to treatment that have been used, this should not be interpreted as resistance, and should not be explained to the patient as a defense mechanism.  It should be explained, during the Waking State Reframing process, as a continuing attempt to cope with an old emotional wound in a manner that is no longer needed.  The cooperative and collaborative responsibilities of the patient and therapist are to appropriately re-interpret the need for the presenting dysfunctional behavior.  This can then lead to replacing it with a more appropriate functional behavior, or helping the patient accept that the behavior can be modified or eliminated without the necessity of replacing it.


Differences Require Flexibility


BCH does not acknowledge resistance as a mechanism that prevents the patient from participating in the process of change.  The use of the label “resistance” when talking to a patient may imply that the patient is somehow responsible for the inability to do what he or she is expected to do by the clinician.  When the patient expresses such phrases as “can’t” or is “unable to”, or similar expressions of frustration, the therapist can use the phrases "because people are different from each other…” or “different methods often work for different people…." One might say for example, "That approach (or choice, or method, or technique, or skill, or strategy) wasn’t very effective for you, so let’s choose another approach.”  It is not useful to say, “try harder”.  This approach of flexibility allows for other choices and for the patient to be relieved of feelings of guilt. 


Patients often take responsibility for previous therapeutic procedures that may not have been helpful.  They may label their inability to change as "failure" when in fact they might have been able to change if other therapeutic procedures had been tried.  Patients may feel guilty and this can further strengthen their belief that they are trapped and helpless.  Being relieved of these negative feelings of failure, guilt, and self-blame can help in finding an approach that can be more effective. However, this does not negate the need for the patient to take responsibility to participate in the change process.


Therapeutic and Hypnotic Relationship Begins With the First Contact


All behaviors are expressions of a form of communication.  Communication on a conscious and unconscious level is expressed through our verbal and non-verbal language, our behavior, our choice of coping mechanisms, and even our symptoms.  The clinician needs to be conscious of his or her own way of communicating and the patient’s way of communicating.  This is essential to the establishing of any relationship.  A positive relationship between the clinician and the patient is necessary to bring about a positive therapeutic result.  The patient must have faith and trust in the clinician for any treatment to be effective (with or without hypnosis).  From the very first contact with the patient, everything the clinician says and does makes an important impact on the relationship and the outcome of treatment. 


Initial telephone contact with the patient.  In most cases, a clinician makes the initial appointment directly with the patient, on the telephone.  During the initial telephone contact the following might occur:


a very brief intake to determine the purpose of the request for an appointment

why the patient chose to contact us

specifically what the patient's goals are

previous treatment contacts for this problem


Costs and payment options are explained and questions are answered which usually takes 5 to 10 minutes (e.g. whether the first visit is to be an evaluation only or will include some treatment components).  Over the telephone, and face to face, it is important for the therapist to be precise in the questions asked, how the questions are worded, and in the way information is given to the patient.  The goal is to communicate to the patient that details matter.  Hypnotic processes are meant to serve as agents of effective therapeutic communication and change.  What the clinician says and does, beginning from initial telephone contact to the Intake Evaluation will affect the patient’s expectations about the skill of the clinician, the therapeutic process, and the use of hypnosis as an appropriate intervention.


Conscious Use of Self


An important concept in BCH is the clinician's conscious use of self.  The clinician is the "agent of change".  Even experienced clinicians can fall into the pattern of reflexively and mechanically dealing with some of their patients in automatic ways.  This may include categorizing the patient based upon past experience and personal prejudices.  There may be an unconscious reaction on the part of the clinician, who may then go into an automatic judgment and treatment mode.  Patients, like everyone else including the clinician, learn by repetition.  Individuals often develop habits out of their conscious awareness. When this occurs, the clinician will often stop listening to the patient and paying conscious attention to his or her communication with the patient.


Listening to the patient.  Conscious use of self also includes paying conscious attention to the ways the patient uses his or her self.  How the patient communicates through choice of language, choice of labels, non-verbal behavior, body language, expression of strengths and weaknesses, and choice of symptoms, are but a few of the important messages the patient communicates.  The clinician must consciously attend to all of these details. 


As an experienced clinician, you already know how to establish a relationship with a patient.  Most of what you do has probably been part of the way you have practiced for many years and may be somewhat “automatic” or unconscious.  It is likely that it works very well. However, sometimes it may work slowly, or the patient may be identified as someone with whom you can’t or don’t want to work.  This is usually because something just doesn’t "click" between you and the patient.  By learning how to consciously use yourself, you may be able to figure out why things "don't seem to be clicking" and improve the process and outcome.


Listening to the patient's sensory representational language.  Listening to the sensory representational language that the patient uses to describe what he or she is experiencing, and how the patient answers your questions, provides essential information.  The clinician needs to determine the primary types of predicates and descriptive adjectives that are being used. Some examples are illustrated in Table 3:



Table 3. Examples of Representational Language Verbalizations






When I look at myself I see someone who is in trouble.





When I feel everyone's against me, I get knotted up inside.





I keep listening to myself and hearing myself sound stupid.




I smell something going on and it smells fishy.






This tastes sour to me. He's left me with a sour taste.


Matching predicates and descriptive language to build rapport.  Once you identify the patient's primary linguistic predicates and descriptive adjectives, and the sensory representational systems to which they are attached, you will be aware of what primary sensory systems the patient uses most often to process information and learning.  It is also important to pay close attention to the language that you use most often, and to identify it with one or more of the five sensory representational systems.  If these are different from the ones that the patient uses, you should focus on changing your predicates and descriptive language to more often match those of the patient (Cameron-Bandler, 1978; Grinder & Bandler, 1976, 1981; Lankton, 1980; Lewis & Pucelik, 1982).


This process is a very important first step in establishing rapport with a patient. You may be talking the same language (i.e., English), but be processing the information quite differently.  If the clinician’s sensory language is primarily kinesthetic and the patient’s is primarily visual, there may be a problem of understanding and relationship. For example, the patient may ask, “Can you see what I mean? and the clinician may answer, “What you told me doesn’t feel right.”  This discrepancy can create discordance that needs to be corrected by the clinician consciously switching to the sensory representational language of the patient.  So, the clinician ought to respond instead with a comment like, “Now that you have described it to me, I can certainly see it.”


Unfortunately however, it is not usually quite that simple because most people also use sensory language other than their primary one in representing how they think and feel.  For example, a patient may say,


“When he comes near (kinesthetic) me, he looks (visual) as if he is about to do something fishy (olfactory) and that makes me feel (kinesthetic) sour (gustatory).” 


Of course, this is an exaggeration and is used only to emphasize the use of overlapping language relating to sensory systems.  If the clinician recognizes that there is significant overlapping in the use of sensory language, more attention should be paid to non-verbal cues as a way of identifying the more favored processing system.


Asking questions: Finding exceptions to the presenting problem.  It is important to ask questions to get more detail about the presenting problem and what has been done previously.  The patient usually does not tell you verbally what he or she is not consciously aware of.  The patient does tell you about his or her beliefs, and these beliefs may or may not be valid or true.  For example, the patient may be describing a problem as if it is always happening. This is an absolute. You, the clinician, know it is not always happening.  So, how can you help the patient recognize that there are many times when it is not happening?  You can do this by asking more questions about possible times when it is not occurring.  For example, “Does it happen when you are asleep? Does it happen when you are busy at work?  How about when you are having a good time or when you are making love, etc.?”


If you ask enough questions about other times when the problem does not happen, some of these questions will have to be answered with “It does not happen then.”  When we find exceptions to the problem, we no longer have an absolute.  Now the patient can be helped to recognize that he or she is not trapped.  For example, "So, there are times when it is not happening!  Now we can help you establish a conscious and unconscious memory of those times when it is not happening and stretch that memory so it doesn’t have to happen as often, or not at all.”


This is related to the reframe, “We only pay attention to events.  We don't pay attention to non-events.  When something is happening, we pay attention to it.  If something is not happening, naturally, we are not aware of it.” 


Matching of Patient and Methodology


There are a number of indicators that clinicians can use to determine whether their treatment approaches will help their patients.  Patients arrive from another health care professional’s referral, a referral by a former patient or family member, the friend of a former patient, or through advertisements (e.g. Yellow Pages, Internet, Web based referral service, MPN, etc.).  It is important to recognize that not every patient or problem is going to respond to the BCH approach, or any brief therapy approach for that matter.  Patients should be screened for their appropriateness for the BCH or any other approach. 


If you adopt and market a hypnosis treatment approach you will get patients who call or come in expecting “magic”.  They are generally not good candidates for positive treatment outcomes.  These are usually individuals who are not interested in being told that they must be active participants in the change process.  They generally want to be "zapped" for instant change. They want hypnosis to be an instant cure for any and all of their ailments.  Often, they insist when they make an appointment, that they receive hypnosis treatment during the first session, even before the clinician knows what the real problem is!  If a prospective patient is not willing to accept that formal treatment will only take place after the clinician determines what is needed, and what approach is appropriate, than an appointment is not made.


The Initiation of "Waking State Reframing"


The patient may express an unrealistic attitude during the initial session; that of consciously changing maladaptive thoughts.  If this occurs, the clinician should embark on an informed consent procedure.  When this occurs, something like the narrative in Table 4 can be used.   



Table 4. Reframing Narrative



“No change can occur without the active agreement and participation of the patient.  The therapeutic procedures to be used are Brief Cognitive Hypnosis and Psychotherapy (or whatever your professional discipline is).  All hypnosis is not the same.  Hypnosis is a tool in the hands of a clinician already skilled in his or her profession.  That tool called hypnosis can help shorten the length of time it takes to help people change and can often help that change occur more easily and last much longer.  But, we first need to get as much information as we can before we decide if we will be using hypnosis, and how, and I need to explain to you what it is all about.”



Patients, who are seeing you because they are being pressured by someone else to seek help, may demonstrate little or no motivation to change or resolve their problem.  They may be willing to “pay for failure” so that they can say to the pressuring person “See, I tried and it didn’t work, so get off my back.”  As you become aware of this possibility, it is often time to stop the intake procedure and challenge the patient as to his or her motivation for change.  Here, Waking State Reframing will be designed to deal with the crucial issue of clarifying why the patient wants to continue to suffer the consequences of the stated problem as opposed to wanting to be more comfortable and "in charge".  Often, this testing of the patient's reasoning can expose the patient's secondary gains, such as having a great deal of control over others in the family by maintaining the somewhat debilitating symptoms.



Case Example. The Whispering Boy



A young pre-adolescent boy was referred because he was not able to talk above a whisper.  A complete medical examination discovered no medical or physical reason for this kind of problem.  The boy was seen alone.  Early during the intake and evaluation process, it was determined that the whispering behavior was a very powerful way for him to control his relationships with others and what was asked of him.  Others had to come to him (and listen carefully) to hear what he was saying.  Teachers had to come close to hear his answers.  He wasn’t asked to speak before the whole class, etc.  This insight by the therapist was not revealed to the patient.


The patient was asked if he wanted to control the whisper and speak normally.  We discussed the various pluses and minuses of the whispering problem and it was further determined that the patient did want to stop whispering, but couldn’t do so without “losing face.”  The patient did not verbalize this and it was not explained to the patient.  He was trapped in his own controlling behavior.  On the one hand, the whispering served a purpose: He could control other people and ensure that they were listening to him.  One the other hand the “cost” to him was a significant disability.  He said he absolutely had no control over it but that he would like it to stop. 


This young man enjoyed playing pinball, little league baseball, as well as other individual and team sports.  He was a curious and otherwise normal appearing young man.  He was asked if he would like to play a pinball game in his head while he was hypnotized.  He said he would, but that he was not sure what being hypnotized meant.  It was explained that this was "like imagining some fun thing while your eyes are closed and you are very relaxed".


The patient was told that while a person is relaxed, some of the things imagined, almost feel real. He agreed, and we reached an agreement that every time he got a ball in the hole he would be able to verbally express pleasure without having to whisper.  He said that would be great.


We did an induction (that will be discussed in another section) and proceeded to play the game.  It was suggested that if he got a "great score", which he could set, he would not have to whisper any longer.  He was able to loudly express pleasure each time he got a ball in a hole, but was not able to reach the score he had set as winning.  When he was awakened, he continued to talk in a whisper.  Additional attempts to win the game during hypnosis brought the same results.  He rejected suggestions that he lower the score for winning.  However, he did acknowledge that he no longer had to speak in a whisper all the time, because he knew now that there were times when he could in fact speak normally.  He said he didn’t know why he could not do it during the waking state. 


It was determined that this was progress, but that we had not yet dealt with the face-saving problem.  He was eventually helped to give up his whispering comfortably, and save face with another strategy involving ancillary assistance that will be explained later in another part of this book.  The point to this case description is that the therapist needs to determine what is possible and what is not in order to do the best therapy possible.



In this case, as in most, motivation is very important, but the patient was trapped in the dysfunctional behavior.  Because what the patient has done in the past has not worked (although it served an unconscious purpose), we do not want to repeat what has not worked.  We do something different.  This is explained to the patient, and often is received with an expression of relief and more openness to participating in other approaches with greater intrinsic personal motivation.  So, we need to know what has been tried before that has not worked.  This is part of the information that is obtained during the intake process.


To further help us in patient selection, we know that because we are dealing with cognitive function that does require reasoning and the ability to sustain concentration, severe mental impairment, organic or psychogenic (such as dementia or psychosis), would suggest that the patient is not appropriate for this treatment approach.


The Intake Evaluation   


A clinician may become frustrated that their intervention (BHC) either does not work or the results are short-lived.  In many cases this is due to the fact that the practitioner did not have important information about the patient.  One of the most common problems is not knowing how to listen to the patient’s clues and hints that required more exploration.


The intake evaluation format (template) is structured but flexible within the context of what the patient presents.  Also, there is certainly no need to get the evaluation done by the conclusion of the first session.  Depending on the case, the evaluation might be viewed as a process, going on for several sessions.  The following is a list in outline form of the minimum we ask for during the Initial Intake.  It will also include a checklist.  This checklist is a learning tool and is not to be used in front of the patient.  It is not a test, but just a way to help the clinician to be as aware as possible of what needs to be asked.



Table 5. Example Intake Evaluation Outline



Identifying Information -- Patient's full name; Address; Telephone numbers; home, work, mobile; age; marital status; email; etc.


The Patient’s Household Constellation -- Ages; gender; relationship to patient; living and sleeping arrangements; significant interactional or health problems; emotional or substance abuse problems; anything else of importance to the patient regarding this area of inquiry.


The Patient’s Employment -- Status; general schedule; job satisfaction; responsibilities; relationships; worries.


The Patient’s Habits -- Smoking: what brand, how much, around children and family; Coffee intake: regular or decaffeinated, how much per day (mugs or cups) and when, sugar or sweetener, how much; Tea: hot or cold, caffeinated or decaffeinated, how much and when, sugar or sweetener; Soda intake, with similar details; Alcohol use: types of alcoholic beverages, how much, when consumed, more or less in the past, at night, on weekends, where, more when under stress, is it considered a problem, details about alcohol use by others in the home; Prescription drugs: which ones, what for, doses and number of times per day, for how long, do they help, prescribed by; Non-prescription drugs (include alternative herbs, etc.): how much and what for, do they help; Substance abuse: past and current prescription and non-prescription; when, where, how much, for how long, why, attempts to stop, success in stopping, desire to stop.


The Patient’s Health and Medical History -- Glasses; Hearing (aides); Sleeping problems: what kind, frequency, longevity, treatments, success; Headaches: severity, kind, frequency, longevity, treatment; Mouth or jaw pain, TMJ, Bruxism: severity, treatment, etc.; Shoulder, neck, or low back pain: severity, treatment, etc.; Bothersome coughing; Sinus problems; Allergies; Breathing problems; Pressure in the chest area; Frequent heartburn or indigestion: severity, treatment, etc.; Stomach cramps or aches; Problems with bowel movements or diarrhea or constipation; Problems with urination; Cramping in legs or feet; Major illnesses, surgeries, or hospitalizations in the past five years; Mood swings; Impulse control problems; Mild or extreme anxiety; Depression; Emotional problems: Current or past treatment by a psychiatrist, psychologist or other mental health professional.  If so, get more details.


The Patient’s Family Health History -- Obtain as much detail as you think is necessary.  This is especially important if it appears stressful for the patient or if there has been any long-term problem, or inter-generational pattern of occurrence.


How the Patient Got to You -- Professional referral (get details), family member, friend, yellow pages, other.  If it is a professional or person to person referral, ask what that person specifically said when suggesting that you be seen.


The Patient’s Current Expectations -- Details on the stated problem (description, onset, level of dysfunction); Previous experiences in addressing the stated problem; Previous treatment experiences for other psychological, emotional or behavioral problems; Professional fields of the clinicians who have treated the patient; Understanding, beliefs, and previous experience regarding: psychotherapy (if appropriate), hypnosis, and other treatment modalities.



Paying Attention to How the Patient Communicates


As suggested previously when discussing establishing a relationship with the patient, the clinician needs to be very aware of his or her own way of asking for information and how it is personally processed.  In BHC this process is called "conscious use of self".  Each individual has his or her own biological and psychological patterns of thinking, communicating and learning.


When we first encounter people in whose presence we feel uncomfortable, and to whom we seem to immediately respond with suspicion, distrust, or even subtle or open hostility, we may think, “I don’t like this person”.  In social situations, we can choose to avoid them or limit our contact.  However, in our professional relationships with patients or colleagues, this is usually not as easy. This is why we need to develop greater awareness of our own ways of communicating and processing information, as well as those of the patient. 


When our sensory processing choices clash with those of another person, we usually feel uncomfortable.  We may feel dislike or distrust, or confused by the way the other person communicates to us, and seems to so easily misunderstand what we are trying to communicate. This interferes with the easy establishment of rapport and can be an obstacle to communicating effectively with others, particularly with our patients. 


We receive and process information through our sensory system.  We see, hear, smell, taste and feel.  It appears that most people process information visually.  That is, they picture in their minds, that which needs to be understood and learned, because this is their primary way of internalizing information.  Secondarily, we feel that many people experience their information intake as a kinesthetic process.  They internalize their thinking to experience how that which is being communicated feels to them.  Visual and kinesthetic processing seem to be the two most common and universal sensory processing systems. A smaller number of people, often those who have perfect pitch or have musical talent, listen very carefully to what is being said and hear tonal cues that allow them to process information through their auditory system more effectively.


The senses of taste and smell are less often used as primary sensory processing systems.  Both however, are very important for the ability to access memory.  The sensation of taste is triggered by a suitable stimulus applied to the gustatory nerve endings in the tongue. These sensations are imprinted early when the newborn is first drawn to the taste of the mother’s milk and the pleasure and security that sucking evokes.  Smells, which are perceived by means of the olfactory apparatus, are rich in the ability to almost instantly bring back detailed memories of the past (both positive and negative in nature).


Paying attention to the patient's sensory language.  We can most easily identify patients' primary systems by paying attention to the language they use in describing their experiences, as referred to earlier.  As part of the intake, the clinician may want to write down the words the patient uses.  There are explicit words that indicate sensory clues to the patient's way of processing and communicating information.  Table 6 presents some representative words for each of the sensory systems.  Note that some words fit into several categories. 



Table 6. Representative Words For Each of the Sensory Systems



Visual System – visualize, see, look, imagine, picture, pretty, ugly, envision, view, observe, perspective, witness, scan, scene, dim, light, lighten, brighten, vista, etc.


Kinesthetic System – feel, sense, touch, endure, resonate, vibrations (“vibes”), suffer, rough, hard, soft, strong, experience, anesthetize, numb, nauseous, volume, stomach, hurt, pain, sharp, sting, itch, ouch, gut, heavy, light, lighten, low, load, etc.


Auditory System – hear, listen, sound, volume, report, rumor, voice, loud, lower, tone, roar, echo, etc.


Gustatory System – taste, snack, savor, digest, flavor, sip, hungry, appetite, bitter, sharp, sweet, sour, tasteful, strong, delicious, nauseous, tasty, tasteless, etc.


Olfactory System – smell, nose, odor, scent, strong, pungent, whiff, rancid, stinks, aroma, sharp, stench, etc.



The clinician's choice of words.  It is important for you, as the clinician, to search your own language use to determine your own primary or lead system.  If your patient uses visual predicates, and you respond in kinesthetic predicates (although you both may be talking the English language), you may not be communicating with each other effectively. As suggested, one or both of you may in fact feel uncomfortable and confused about what was said, and even feel unhappy about the interaction.  It is easier for the clinician to be aware and consciously change the predicates to match those of the patient.  This will greatly improve the chance for rapidly establishing rapport (Cameron-Bandler, 1978; Grinder & Bandler, 1976, 1981; Lankton, 1980; Lewis & Pucelik, 1982).


Carefully observing the way your patient stands, walks, sits, and moves can also give clues in this regard.  A person with a hearing problem is going to move their head in a distinctive way to make sure that you are heard.  You may want to change your office seating arrangement to be able to talk into the best hearing ear.  An eye fixation induction for someone who is not very visual will probably not be helpful in bringing about a trance state.     


Formulating a Treatment Plan


Agreeing on "The Problem" and "The Goals".  At this point, the clinician can begin to share the assessment of the problem (initial hypothesis).  If it differs from the patient's presenting problem, this needs to be discussed and clarified.  There may be a need to further refine the problem into smaller workable units that will allow for less lofty goals to start.  The loftier the goal and the more complicated the treatment plan, the less observable and immediately positive the results will be.  


So, the clinician establishes the patient's goals based on a valid intake assessment.  This usually requires some discussion that involves clarifying what the patient means by some of the things the patient says.  This is all part of the process of Waking State Reframing.  At this stage, the therapeutic objective is to agree upon a reasonable (realistic and attainable) goal or set of goals.  The clinician will also want to clarify what can be accomplished through the addition of hypnosis to the usual treatment approach and what might not be accomplishable.  Once goals are established, a therapeutic strategy for achieving them must be established.



Case Example. Weight Problem



A sixty year old woman was referred by a psychologist from another State for a presenting problem of a thirty pound weight increase that had occurred a few years previously.  The patient felt as if the added weight caused her to appear disfigured because it settled in the upper part of her body and made her look “top heavy.”


While growing up, her mother had tried to force her to eat healthy foods, but the patient found ways of eating only what she wanted and fooling her mother into believing otherwise.  She started putting on weight at age 14, and at age 16, she started taking diet pills.


The patient's mother and other close family members had an alcohol problem.  Her mother also used to give her frequent mixed messages about how good she looked and how much more she could do to look better.  Her mother was an expert at creating double binds.  Eventually, the patient also became a heavy drinker while taking diet pills.  However, she did stop drinking and taking pills at age 32 after seeing a psychologist and attending AA meetings.  Nevertheless, she substituted compulsive behaviors, and became a compulsive spender.


At the time she presented for treatment, she was married to her third husband. There were problems of body image, compulsive eating and purging.  The patient stated that she never felt hungry or full, but that she thought about food from the moment she got up in the morning to the moment she went to sleep at night. She stated that she loved food, and that she found eating “very comforting”.


This patient had an extreme fear of heights and cats, exhibited a continual low level of anxiety, had impulse control problems, and a need for immediate gratification.  It was apparent that her presenting goal of losing thirty pounds through the use of hypnosis was not a realistic goal as the extra weight in and of itself was not the "real problem".  Any attempt to satisfy the patient's initial request would have most likely failed and created more problems.


This formulation was shared with the patient and her husband.  It was explained that the problem was deeper and more complicated than the patient had been prepared to acknowledge.  She was offered an opportunity for a more extended therapy program, and it was suggested that the patient and her husband take some time to think about and discuss my recommendations, and then get back to me.

The patient and her husband were returning to their home in the North for the Summer.  They told me that they would contact me some time after their return to Florida in the Fall so that the patient could start her treatment program.



Formulating a therapeutic strategy.  Hypnosis is not a strategy or therapy by itself.  In the hands of a skilled clinician, it is a "treatment tool" that facilitates the implementation of a therapeutic strategy and shortens therapy.  In this course, “Brief Cognitive Treatment” is defined as a way to help individuals change the way they think about themselves; their world; their present, past and future; their behavior, relationships, and personal situation; so that CHANGE can take place.  Beliefs and behavior can change making it possible for a person's circumstances to also change.


Change is only recognized in retrospect.  As part of the treatment process, it is important to assist the patient in recognizing that change is occurring.  Usually, change is only recognized in retrospect.  This means that as each small goal is realized, the patient has to be helped to be aware of it.  For example: “Have you noticed that you are no longer coming into the office all tensed up?  Remember what it was like three weeks ago when you first came in to see me?  Notice how different, how much more comfortable you look and feel today.”


The clinician’s diagnosis, evaluation of the problem's severity and estimated time frame to solve the problem, all influence the treatment plan design and the verbal contract that is established with the patient.  Some patients will be seeing you with an understanding that they require only one visit, (e.g. as for smoking cessation) or one or two visits (e.g. as for other simple habits).  Other patients, with more complex problems, will need help in understanding that more visits will be required.  While you should establish agreement with the patient about the treatment plan in advance of initiating treatment, all verbal contracts should be subject to re-evaluation, modification, and change as is necessary.


Basic Steps in Treatment Planning


The following examples are meant to guide the clinician in establishing a treatment plan.  The steps outlined in each of the following two examples are not designed to be shared with the patient.  The practitioner may explain to the patient what to expect, but the actual treatment plan from a clinical perspective is not shared.  Treatment planning is for the benefit of the clinician to establish guidelines. 


Treatment plans for problems that can be managed in only one or two sessions have very short, specific goals.  They include Waking State Reframing, but typically do not include teaching the patient self-hypnosis or self-relaxation.  Treatment plans for problems that are likely to require more than one or two sessions typically require more extensive Waking State Reframing and usually include teaching the patient self-hypnosis or self-relaxation.



Table 7. Example Treatment Plans



Treatment Pain – Simple Problem



Do Waking State Reframing to change the patient’s belief system about the problem from complex to simple.  This typically involves reframing the patient’s absolute beliefs about the problem behavior, to help the patient recognize that it occurs sometimes, but not always, that the problem is changeable and not permanent, that it is understandable and not mysterious, and that the patient is not to blame.


Explain the functions of the conscious and the unconscious parts of the mind, and how they are involved in controlling voluntary and involuntary behavior.


Discuss the nature of the hypnosis trance experience, and what the patient can expect to experience during trance, and after the trance is concluded.


Determine the most appropriate induction procedure and describe it to the patient.


Formulate the change language and specific suggestions to be used during the patient’s   trance experience. 


Decide whether to include trance in this initial session, or schedule another session for the trance work.


Implement the induction of trance.


After inducing trance, administer pertinent therapeutic suggestions, with appropriate change language and reframes, including appropriate post-trance imprinting suggestions.


Re-alert (awaken) the patient from trance, conduct a post-trance evaluation, and administer further appropriate post-trance suggestions.  If asked about self-hypnosis by the patient, we explain why it is NOT necessary for this particular problem. 



Treatment Plan – More Complex Problem



Identify the negative coping behavior or symptom that is most amenable to change so that the patient can almost immediately feel some relief. 


Determine what has been done previously to change the current evolved behavior or symptom, so as not to repeat what has not worked before.


Reframe the patient’s absolute beliefs about the problem behavior, to help the patient recognize that it occurs sometimes, but not always, that the problem is changeable and not permanent, that it is understandable and not mysterious, and that the patient is not to blame.


Do a deep relaxation induction to imprint a strong memory of how it feels to be relaxed.


Include in this induction and trance experience instructions on how the patient can do self-relaxation to reinforce and re-charge this memory of how it feels to be deeply relaxed.


After awakening, if the patient has been taught self-relaxation during this session, have the patient immediately relax his or her self again without the help of the clinician.  This brings an even deeper level of relaxation, and affirms the patient’s ability to do it without help.


Instruct the patient to do NO self-talk during his or her own practice of self-relaxation.  Suggest that this self-practice will automatically reinforce and refresh what the clinician said while teaching it to the patient.  This prevents self-talk distortion that might be counter-productive.


Attach, through suggestion, during the trance experience, a belief that the feeling of relaxation being experienced by the patient will be repeatable, and will allow the patient to feel progressively better, and exhibit fewer and milder experiences of the negative coping behavior, if at all.


Re-alert (awaken) the patient from trance, conduct a post-trance evaluation, and administer further appropriate post-trance suggestions. Review the steps the patient will take in practicing self-relaxation or self-hypnosis, and discuss how this one to two times daily ten-minute practice can be inserted into the patient's daily schedule.



The following case examples illustrate some of the concepts that have been discussed.



Case Example. Patient Not Treated For the Presenting Problem



A woman presented for a single session smoking cessation program.  After conducting the intake evaluation, it was determined that smoking cessation could not be accomplished in a single visit because there was a deeper problem that had to be addressed first.  The deeper problem was a pattern of serious impulse control deficits.  The patient was immediately informed that her problem was more serious than just smoking cigarettes.  She was told that it would be inappropriate to address the smoking and probably not succeed, because there was a bigger problem that had to be addressed first. 


The concept of "impulse control" was explained to the patient using examples of other kinds of control difficulties she had described.  It was explained that a more extensive therapy program requiring five or more visits was indicated.  Until the patient was taught greater control over her impulses, she would not be inclined to stop smoking.  The patient decided that she did not want to make that commitment at this time.  She was told that she could return in the future if she reconsidered her decision.  It was also suggested that she might consult with her family physician regarding referral to a psychiatrist who might be able to prescribe helpful medication.




Case Example. Patient Treated with a Carefully Tailored Procedure



In another case, an appointment was made for smoking cessation, and it was discovered during the intake, that the patient was on full medical disability from the Army.  He was in outpatient treatment at the local VA Hospital with a diagnosis of Paranoid Schizophrenia.  There were some delusional beliefs about his skills as an inventor of a very complex mechanism that he claimed to have designed for the government. 


The patient was taking an antipsychotic three times a day and exhibited some cognitive impairment.  He was, however, very clear about his desire to stop smoking, and talked about health as the reason he wanted to stop.  This man knew little about hypnosis, but he believed it would not be something that would have undue negative influence on him.  He believed that hypnosis might help him stop smoking without uncomfortable withdrawal. 


The patient lived in an assisted care facility in his own apartment, and took good care of himself.  He was neat and clean, and he could get around by taxicab or public transportation.


Having had experience using hypnosis with psychotic patients in the past, it was decided that I could possibly help this patient to stop smoking without exacerbating his psychological and medical problems.  I explained hypnosis as relaxation, and that he would feel relaxed, and always be aware of what I was saying to him.  Furthermore, I told him that he would be able to open his eyes any time he wanted to, if he wanted to.  I explained that while he was relaxed and had his eyes closed, I would be talking to the part of him that controlled the smoking habit to give it information that would allow him to stop smoking.


Because of my judgment that there was some cognitive impairment, I skipped the extensive Waking State Reframing regarding smoking.  After the short explanation described above, I performed the "Rising and Falling Arms Induction".  Then, I verbalized the trance language material that is a regular part of our smoking cessation protocol.


After exiting from trance, the patient stated that he felt very relaxed and heard everything. He enjoyed being hypnotized.  In a subsequent telephone follow-up six months later, he indicated that he had not touched a cigarette since our session.




Case Example. Patient Treated with Ancillary Help



Remember the young boy who couldn’t speak above a whisper?  He loved to play baseball.  A few weeks earlier, he had injured his right wrist while sliding into base.  He was told he needed surgery to correct the problem so he would be able to play baseball again.  I (JIZ) asked permission from his parents to talk to his surgeon, who I knew, about helping me help their son to speak in a normal voice. 


In my meeting with the surgeon, I described what his problem was, including the need to "save face", in order to be comfortable speaking normally.  I asked the surgeon if he would be willing to give certain suggestions to the youngster during the induction of general anesthesia.  I explained that this state was similar to that which occurs during the hypnotic trance state.  I also explained to the surgeon that suggestions from a trusted authority figure could be very powerful in establishing communication with the young man's Unconscious Mind, to produce change.  I told him that during my next session with our mutual patient, I would set up during hypnosis, the surgeon's suggestions as acceptable and effective.


I wrote out what I wanted the surgeon to say, and how to say it, and I instructed the surgeon to repeat it from time to time during the surgery.  These suggestions were: "When the patient is just beginning to relax during the administration of the anesthesia, say to him, 'You can rest comfortably because we are going to be able to fix EVERYTHING that has been bothering you, while we repair your wrist.'  Repeat these suggestions four or five times as he is going under, and then every once in awhile as the surgery progresses.  Also, as you proceed with the repair, comment to the patient, 'This is going great and will fix everything'."


During the next session with the boy, prior to his surgery, we talked about how he can relax himself and feel comfortable during the surgery.  I taught him how to pay attention to his breathing with his eyes closed to help him feel relaxed before the surgery.  I repeated this during his trance experience, and I talked about what a great Doctor he had for a surgeon, and how his Doctor was "going to fix everything". 


Upon awakening from the surgery, which went very well, the boy spoke in a normal voice, and he has done so since.  Neither the medical staff, nor his family, as they had been instructed, made any specific reference about this to the patient.  He was congratulated on how good he had been before, during, and after his surgery, and how well the healing was going. 


This strategy worked because the surgeon, during general anesthesia and surgery, spoke to the patient’s Unconscious and suggested that he, the surgeon, and the surgery, would fix everything that needed fixing.  This allowed the patient to psychologically "save face", if necessary, by identifying his whispering problem as "medical", and one that would be cured by medical means.  The patient had been primed to accept this during the trance experience in the therapist’s office. 



The Waking State Reframing concept


The BCH model emphasizes the importance of how beliefs are established and how those beliefs create behavioral responses that can be positive or negative.  Earlier, hypnosis was referred to as "an alteration in internal perception, a focused altered state that is initiated at the start of a unique process of communication".  This happens in the “waking state” as well as in the “trance state”.  This suggests that carefully constructed verbal communication from the clinician to the patient during the normal exchange of information can be very powerful in bringing about therapeutic change.  Psychotherapy is "talk therapy".  Brief cognitive talk therapy, utilizing the language of hypnosis, when carefully and consciously crafted, can bring about positive change relatively quickly and permanently (See Capafons and Mendoza, 2010). 


"Waking State Reframing" takes place during the intake evaluation process and during the preparation for the trance experience.  Most of the work in the brief therapy model actually takes place during the waking state.  The clinician talks to the patient’s conscious and unconscious minds at the same time.  This overlapping process of communication is identified as "Waking State Reframing".


The Meaning of Reframing


The term “Reframing” refers to "the intentional intervention by the clinician to assist the patient in changing the meaning of beliefs, rituals, patterns, labels, feelings and behaviors, to open the way for emotional and behavioral change" (Zarren, 1996a).  When initiated by the clinician, this is a conscious cognitive procedure that affects the cognitive, emotional and behavioral systems of the patient.  The reframe itself does not produce change; rather, it changes the patient's way of thinking and belief systems in such a manner to provide the possibility of change.  To reframe something is "to change the way that one thinks about that something without changing that something".


The way someone thinks about something may be changed even though the facts remain the same. The original situation may in fact remain unchanged, but it can be perceived from a new point of view.  How this occurs may not be immediately obvious because even though there is a change in the point of view, the situation itself initially may remain unchanged.  What is changed, as a result of the reframing, is the meaning attributed to the situation and thus, its consequences.  The concrete fact may not have changed at all. 



Case Example. Noise at the Window



A classic example of “reframing” from cognitive behavioral therapy is the following:  It is very late at night and you are awakened by a noise at the window.  Earlier that evening, you listened to a news report of a prowler in the neighborhood.  Your first thought is that someone is trying to break into the house.  Based on this belief, the expected physiological and behavioral reactions occur.  Your heart races, your muscles tense, your breathing becomes rapid, etc.  Behaviorally, you might grab a flashlight and baseball bat while calling the police.  On the other, let’s say you pause and realize that the wind is blowing and a tree grows near the window.  You wonder whether the noise may have been a tree branch hitting against the window due to the wind.  You check it out and are proven correct.  The wind continues to blow, the branches continue to bang against the window, but you return to bed and sleep soundly.  In this example, the “facts” have not changed; rather, the meaning attached to the situation has changed.  



Reframing operates on a different level of reality, almost like “trance logic”. Change can take place even if the objective circumstances appear to suggest that they are beyond one’s control.  When looking at a half of a glass of water, one may perceive it as half empty at one time and half full at another point in time.  There is still only a half a glass of water, but instead of thinking of it as half empty, it is thought of as half full.  The change in perception then changes the way the individual responds to the situation, which may or may not change the situation. 


Changing Labels Changes Beliefs


The ability of the mind to change subjective and objective realities by changing labels offers the opportunity to utilize therapeutic interventions that is called “reframing.”  There is no single reality. All reality is our interpretation of the world and its contents based on the way we process information and what we choose to identify as our unique reality.  When we feel trapped in a feeling or behavior, we believe that we have no choices.  We are caught in a dilemma.  We feel we are damned if we do, and damned if we don’t.  So we may freeze and do nothing. Successful reframing requires taking into account the views, expectations, reasons, premises, and entire conceptual framework of the patient whose beliefs and views are to be challenged. It is essential to pay attention to everything the patient is bringing to you.


Reframing requires that the clinician learn what the patient believes by questioning, listening and looking.  It is very easy to make the assumption that the clinician and patient have the same frame of reference when describing something.  For example, as part of a therapeutic exercise, you both may be thinking about “relaxing” on a beach beside a body of water.  However, you may be imagining relaxing by the ocean and your patient may be thinking about trying to relax on a beach near a lake.  To make matters more challenging, your patient may be trying to relax using this imagery you have suggested but can only focus on her last outing to the beach: getting lost on the trip, the wind blowing, sand getting into the lunch meal, bugs everywhere, the kids getting burned, and the overall aversiveness of the outing – Not a very relaxing image.  


An even more powerful word (label) change involves reframing words like "addiction" and many others that the patient uses to identify behaviors that have so far been difficult to change.  Many of these emotionally charged negative labels have been imposed on the patient by societal convention. This satisfies our societal need to generalize some of the most difficult dysfunctional behaviors into the category "disease".  Then, these problems may no longer be considered the patient’s fault or within the patient's power to change. 


These extreme labels may be accurate for some severe medical or psychological problems. Unfortunately, they often are applied to many other behaviors that are frustratingly difficult to treat, even though there may be little actual evidence to identify those behaviors in this extreme way.  For example, the label "addiction" has been applied to many dysfunctional habit behaviors that may be emotionally difficult to change.  They are labeled as "addictions" only because they are difficult to change and not because they substantially change the biochemical structure of the brain.  The label "addiction" has been generalized to include some psychologically compulsive behaviors such as gambling, excessive sexual desire, compulsive shopping, and others.


Choices Lead to Change    


The following reframe can be shared with patients: “We are only trapped as long as we believe we have no choices.  Once we recognize that we have other choices, and we make a choice, then we are no longer trapped.” This reframe (i.e., change in thinking) can open the trap and allow for change. Similarly, we are taught from early childhood that “if at first we don’t succeed, try, try again.”  Continuing to try again that which doesn’t work will not make it work any better.  However, by recognizing that there are choices, and deliberately choosing to do something different, we open up the possibility of success.



Case Example. A Metaphor for Change



"Imagine yourself walking down a beautiful country path through the woods.  The path leads to a beautiful lake further on where you very much want to go and relax.  Suddenly, you come upon a very high stone wall that cuts right across the path and into the woods on both sides of the path.  You are completely blocked from proceeding further unless you can somehow get over or through that solid stone wall.  You try climbing it, but you can’t.  You try pushing against it, but it doesn’t budge.  As your frustration grows, your attempts become more frantic, and you may even bloody your hands in the process of trying so hard.  How can you get to the other side of the wall?  More of the same is certainly not the answer.  And yet, all too often, we do more of the same even though it is not effective, hoping that increasing the effort will work.  But, it doesn’t."



It is important to recognize, and help the patient to recognize, that there are other choices and other options that can be applied to solving the problem.  Pushing against an immovable stone wall harder and harder will still not move the wall.  However, backing off and rethinking possible solutions to the problem may produce better results.



Case Example. A Metaphor for Change



"We can calmly look to the right and left of the path, near the wall, for a pathway we can follow that may take us to a door, or to the end of the wall.  This makes more sense.  We do so, and we notice a small clearing and path on our right near the wall.  We follow it and are joyfully relieved to see an unlocked gate through the wall to the other side.  There, we see a lovely flower covered meadow leading to a serene lake on the other side.  The solution to the problem was not to push so hard doing the same thing that didn’t work, but to recognize that we have choices, and to make a different choice."



Reframing is Not "Insight"


When we talk about reframing we are not talking about "insight".  Insight doesn’t change behavior (Bloom, 1994).  Pursuing insight is often interesting because most of us have little conscious understanding why we think and behave as we do. Most people want to know why.  This desire to know the cause of our problem behavior contributed to the development of long-term, exploratory, "insight-oriented" psychotherapies (Bromberg, 1959; Ellenberger, 1970; Fine, 1990). 


Generally, brief therapies are not so much interested in why something happened.  The past is not explored to help the patient develop insight.  When the past is explored, it is to elicit enough information to understand not so much what happened, but rather what the patient did to deal with what happened.  Exploring the past helps to answer questions such as: What was the outcome of what happened?  What was the choice of behavior that immediately felt good and by repetition evolved into dysfunctional behavior?  This information helps in the reframing process and in the treatment plan.  By itself, this information does not change the behavior.  In the BCH model, there is no attempt to determine meaning or decipher obscure symbolism for the purpose of developing insight.


"Need to Know Why"


Often, patients express a strong need to know "why", "what", and "when" something occurred that was the cause of the presenting problem. In the BCH model, these patients are offered two choices. In Choice One, it is explained that this is not a treatment approach requiring long-term therapy that spends years looking for meaning (and costs a lot of money).  If this is what the patient wants, explaining the approach of BCH satisfies informed consent and the offer is made to make an appropriate referral. 


Choice Two is to instruct the patient to go home, block out some time, and in as much detail as possible make up a reason (the why, what, when, etc.) for the presenting problem.  This can be written, typed on a computer or dictated. Instruct the patient to be sure to spend as much time as may be needed to be as complete and logical as possible.  The homework is to have the patient detail all of the things that can be imagined that led up to the start of the problem. This might include writing down what the precipitator was, how long ago it happened, where it happened, who was present, etc.  When the patient is satisfied that the written narrative is complete, he or she should go over it again very slowly and make sure nothing needs to be added or changed.  This written or printed material is to be brought to the clinician to be reviewed at their next meeting. 


In the process of reviewing this information written by the patient, he or she is helped to believe, if only for a moment, that this is the "true cause" of the behavior.  This usually eliminates any future need to explore further.  The patient is helped to believe that this is the real cause in two ways.  During waking discussion, the patient is asked if the material that he or she came up with is an acceptable explanation.  If the patient agrees that it is, no further discussion is required.  If the patient says that it might be, or is not sure, permission is requested to proceed with doing a hypnotic trance induction.  During the trance experience, encourage the patient to accept this explanation as sufficiently valid and satisfying the “need to know”. This exercise usually satisfies the patient’s need to know and is an effective way to use reframing.


Labels Dictate Behavior


“The labels we place on the behaviors often dictate future behavior. What we call something (or label it) leads to what we do about it.  If we call something a failure, then we continue to repeat the behavior as if we have failed.  If we call it a mistake, we realize that mistakes can be corrected, so we haven’t failed.  We have only made a mistake.  So we can back off and start over again and correct the mistake.”


This reframe opens up the possibility of correcting the behavior.  This is a very valuable reframe that can be used when a patient has re-experienced a behavior that had been changed.  Sometimes this re-experience of the behavior is called a "relapse" such as when a smoking patient stops smoking and, in a moment of stress, smokes one or more cigarettes. This reframe is used during the waking state and is also one of the suggestions given during trance to correct the mistake.


Anticipation or Expectation?


When many patients talk about the future, they commonly use the word "anticipate".  Patients often choose this verb to describe a negative future outcome.  A synonym of "anticipate" is "expect".  When a patient is offered the choice of using the word expect instead of the word anticipate, the general response is that the former word feels better.  When encouraged to explain why, the usual answer is that their previous use of the word "anticipate" always led to negative feelings that were a continuation of their feelings of anxiety, pain, etc.  When they verbalize the word "expect" they are allowed to think about the future as possibly being more positive. 


Although there may be little literal differences between the words (expect, anticipate) many people experience a different connotation and emotional response to each of these words.  The simple choice of having a different word available to describe the future may assist the patient to interrupt the past experience of mentally creating a negative self-fulfilling prophesy.


Behavior is an Attempt to Cope


Most dysfunctional behaviors are the exhibited symptoms of the problem.  Symptoms are a way of coping with a deeper problem.  Initially, the symptoms of unconscious choice relieve some anxiety and the patient feels better.  Then, as the symptoms become more frequent and intense, they become dysfunctional and the patient feels worse.  Repetition of the symptoms imprints them, leading to further repetition and deeper imprinting. 


Often, the symptoms are no longer needed but they continue as a habit.  The repetitions of symptoms, which are negative coping behaviors, are then maintained as habits.  A symptom is a coping mechanism with a negative outcome.  A habit is a behavior, positive or negative, imprinted by repetition. Though habits are difficult to change consciously, they respond very quickly to change with reframing and an appropriate trance experience.      


Waking Hypnosis and the Waking State Reframing Process


The “Waking State Reframing” process.  During the Waking State Reframing process, the patient is helped to rethink or reframe beliefs, feelings, and behaviors.  This takes place during the Initial Intake Evaluation and during the exchange of information between the clinician and the patient.  The patient's labels, belief systems, and dysfunctional coping mechanisms (i.e., symptoms) are challenged and reframed during the waking state utilizing cognitive restructuring, suggestion, and appropriate representational language (termed "change language" or the "language of hypnosis").


During the Waking State Reframing process, the patient is being prepared consciously for a hypnosis induction and trance experience.  The patient, in effect, anticipates or expects that he or she will be helped to experience an hypnotic trance during the session and waits for this to happen.


The patient's Waking State Reframing experience may enhance the patient's acceptance of suggestions for change because it is an altered state.  This altered state might be labeled an anticipatory trance state or an expectation of trance state.  If the clinician carefully observes the patient during the waking state, as this process is being directed by the clinician, many of the physiological indicators that are observed during trance are already present before formal trance is induced.  The clinician can effectively utilize the changes that are taking place in expectation of entering trance to later assist the patient to enter formal trance more easily and comfortably. In the BCH model, most of the change that the patient experiences occur during the Waking State Reframing.  The "trance state" is when the change is "fixed in place".  A brief, carefully chosen induction is used and then the "fixative suggestions" are given to the patient.


This method allows a relatively seamless integration of hypnotic communication from the time the patient is in a waking state to that of the trance state.  This is a process of "priming" the patient's suggestibility (receptivity to appropriate therapeutic suggestions).  This enhances the chances of achieving favorable therapeutic outcomes.



Case Example: Chronic Back Pain



A patient was referred for help in coping with his chronic back pain possibly utilizing clinical hypnosis.  He had seen numerous specialists and considered none of these contacts to have been helpful.  After doing a thorough intake evaluation, it was suggested to the patient that perhaps he had not really heard what one of the physicians he had visited (known to be a "great doctor"), had been telling him.  It was suggested that, as an "experiment", he try two of the things that this doctor had recommended.  These were recommendations that could not possibly hurt the patient; they would either help or not help. 


The doctor's recommendations were (1) for the patient to replace his desk chair with a more ergonomic one that better supported his posture; and (2) that the patient become more aware of good versus bad posture for his back and neck.  The value of these recommendations was reinforced in the waking state and then in trance.  The patient agreed to come back in two weeks so that treatment could proceed.  


The patient canceled his next appointment because he had not been able to get a new chair until just a few days before his next scheduled appointment.  He wanted to give it a week or two to test the strategy out.  The patient did call back a week later to reschedule a follow-up.  At that next session, he reported that his back and neck didn't hurt as much after he spent several hours in his new desk chair and that he was "minding his posture". 


In this case, the patient tried something different after it was pointed out to him that perhaps he had missed something important in his earlier contact with one of the physicians he had seen.  This opened up the possibility of reframing his absolute belief that none of his previous physician contacts had been helpful.  It was suggested that “perhaps his visit with that one doctor could turn out to be helpful if we carefully reviewed the information that the doctor had given to him”.  He was willing to do this.  This led to his modifying several behaviors, which provided him with different feedback, and the new feedback was discordant with his old point of view that nothing was helpful.  This created cognitive dissonance (Festinger, 1957), which led to his modifying or reframing his old point of view.  The possibility was then opened to his re-examining several other previously fixed beliefs that "might not have been very helpful".


The patient continued to work with the hypnotic trance state and utilizing self-hypnosis, to help him develop greater control over his pain experience.



The Value of Waking State Reframing 


Waking State Reframing is the time when intensive work is performed.  The relationship is built, positive rapport and trust are established, expectations and readiness for positive change are induced, choices are pointed out and recognized, and what had previously been felt to be a trap becomes an open door to freedom and wellness. Most patients come for help after they have exhausted many other treatment options.  During their previous attempts to find relief from their particular and unique suffering, their repeated lack of success may have powerfully imprinted a belief that they are forever trapped. They may verbalize that you are their last resort, but not really believe that you will do any better than others have tried and failed to do before you.  Their previous clinicians may not have seemed to listen to their messages of fear, anger, depression, and desperation.  These previous health professionals may have hardly asked any questions or given any satisfactory answers.  For example, an important part of treating the "emotional overlay" associated with the persistent suffering of many chronic pain patients is to address their need for some "satisfactory answers" (Eimer & Freeman, 1998; Patterson, 2010).  It may have seemed to your patient that these professionals' eyes were shut, ears were covered, and minds were closed. 


The clinician, therefore, needs to really look at the patient, make adequate eye contact, and be aware of minimal cues.  You need to listen carefully to the patient’s language, to what the patient is really saying and hear the hidden messages being expressed.  You need to "resonate" with the patient (Watkins, 1978) so that you can feel with the patient the import of his or her emotional state and sense of helplessness (similar to the Rogerian concept of empathetic listening).  Most importantly, you need to communicate that:


you can be trusted;

there is an opportunity for change;

there are still choices previously not realized; and,

that the responsibility for change will be shared between you and the patient.  


Informing Your Patient about What to Expect


One of the responsibilities of the clinician is to explore the patient's understanding and beliefs regarding hypnosis and the experience of it.  Those patients who enter into this experience for the first time may have trepidation about what it will be like.  Those with previous hypnosis experiences that happened in the distant past (especially if unsuccessful) might be ambivalent or concerned that you will do the same things that didn’t work before.  The patient may even have information about hypnosis from others who did not have a positive experience.


It is important to help the patient understand that all hypnosis is not the same.  Hypnosis is a tool and, like any other tool, differs in its effectiveness depending upon the skilled professional.  You, the clinician, do not know the credentials, background or training of the past purveyors of hypnosis with whom the patient has treated; therefore, you cannot judge their skill or competence. 



Case Example: Explaining Hypnosis



Let me explain to you how I think about hypnosis and what it is and what it is not.  For our purposes, the mind is made up of two parts.  One part we call the Conscious Mind.  You have control over your Conscious Mind.  You can look at this pen and make the conscious decision to pick it up or put it down. 


The other part of the mind we call the Unconscious or the Subconscious Mind.  Both names mean the same thing.  The Unconscious controls all of your automatic behaviors.  It controls your breathing, heartbeat, pulse rate, blood flow, all of the things that go on inside of your body that keep you alive that you pay little or no attention to.  They are automatically controlled by the Unconscious Mind.


The Unconscious also controls all of the other things that you do that you feel like you have little or no control of.  It controls your habits, your patterns of behavior, even such things as which side of the bed you sleep on every night, and which shoe you put on first when you get dressed in the morning.  These are all controlled by the Unconscious Mind.


One of the problems is that we assume that if we know something consciously, we automatically know it unconsciously.  The fact is we may not.  The reason we may not is because the unconscious part of the mind is not the memory system, though it has memory components, and it is not easily communicated with.  Let me explain. 


One of the ways of communicating with the Unconscious is by repetition.  We do something over and over and over again.  The Unconscious gets the idea that we want to do it.  The Unconscious takes charge of it, and makes a habit out of it.  Once it is a habit, we have little or no control over it.  But, the Unconscious hasn’t asked if this is good for us or bad for us.  So, we can form a bad habit as well as a good habit.  The reason the Unconscious hasn’t asked is because it doesn’t have enough information to make that judgment.  If it did, we probably wouldn’t be doing it.


Another way of communicating with the Unconscious is if there is a trauma, a major conflict, a death in the family, a serious illness, or some other significant negative event.  This can imprint into the Unconscious a feeling of fear or anxiety or depression, or whatever emotional response is appropriate for the particular traumatic experience.


A third way of communicating with the Unconscious is the way we will be using here in the office today.  That is when a person is in a deep state of relaxation, and for the moment I use the words relaxation and hypnosis interchangeably.  I will talk more about that in a moment.  During this relaxation, the doorway to the Unconscious opens, and with your permission, I can talk to the Unconscious, and give it information it needs, in a language and form it will accept, to change the behavior that you want to change.  That is why I asked you the questions that I did, to establish the language and form specifically for you.  Once the Unconscious accepts this information, it can’t ignore it.  It has to act on it and begin to change the behavior you want to change.


But, it is not quite that simple.  And the reason it is not that simple is because there are two parts of the mind, the Conscious and the Unconscious.  The Conscious Mind wants to change the behavior.  The Unconscious Mind doesn’t yet know it needs to change the behavior.  This causes a conflict between the conscious wish to change and the unconscious control of the behavior.  This conflict produces stress and discomfort.  This stress is what makes it so difficult to change. 


When the Conscious and Unconscious join together, in cooperation with each other, like my two hands folding together, without conflict or pressure or stress, the behavior changes easily and comfortably, and by repetition, becomes a new and positive behavior.  This cooperation between the Conscious and Unconscious is very important.  I can't make you do something that you don’t want to do.  I can help you change something that you do want to change.


The reason I talk about hypnosis and relaxation in the same breath, is because I am not talking about "ZAP" you are under my power.  I’m talking about helping you into the kind of relaxation that you experience just before you go to sleep at night, and just before you are fully awake in the morning.  You are lying there, loose and comfortable and relaxed.  Your mind is active.  Sounds are off in the background.  You know you could move if you had to, but you just don’t feel like doing it.  You know the feeling.  We all have that experience.


That pre-sleep post-sleep relaxed feeling is technically called the "hypnogogic state".  The reason it is called that is because it is very similar in brain wave function to what happens when a person is in hypnosis.  You hear everything that I say.  Sounds are off in the background.  If your mind wanders, it doesn’t make any difference because your Unconscious will hear everything that I am saying. This is when the doorway to the Unconscious opens, and with your permission, I can give information to the Unconscious that it can use to help you change the behavior that you want to change.  Do you have any questions?


This simple explanation about hypnosis and what to expect usually cover most of the questions a patient might consider asking.  If there are other questions, they are answered in the same comfortable easygoing manner. 





Conscious use of language.  The patient’s responses to the clinician are influenced to a large extent by the language the clinician chooses to use.  Therefore, it is a necessity that the clinician be consciously aware of how his or her choice of language and delivery affects certain responses by the patient.  This involves two issues that one should always be aware of:


First, this involves standardizing the language that is used.  It is necessary to be conscious and aware of our language used with patients.  For instance, specific verbalization scripts to present particular reframes might be used to explain certain concepts to the patient, such the concept of the conscious and unconscious parts of the mind (See previous example).


Second, the clinician will individualize the specific language used with each patient based on the evaluation of the patient's unique needs and perceptual processing and learning style.  For example, visual or kinesthetic words might be used if those seem to be the patient's primary sensory representational systems.  Alternatively, with another patient, one might emphasize auditory language.


Because the effects of communications are also amplified by the nature of the ongoing and unfolding interaction, it is important to listen carefully and observe the patient's responses.  The clinician’s responses should be modified consciously to "pace" and "match" those of the patient (Cameron-Bandler,  1978; Grinder & Bandler, 1981; Lankton, 1980; Lankton & Lankton, 1983).


Change Language


In BHC, the concept of “Change Language” refers to maintaining conscious awareness of how certain language affects, produces, and evokes certain responses in the patient and clinician. The clinician should be aware of the meanings that patients attribute to both their own language and our use of language (Fourie, 1995).  In addition, the concept also refers to our physiological and biochemical responses to language and the mind and body’s ability to respond to appropriate suggestions.  Language and its interpretation evoke emotion (Beier, 1966; Cheek, 1994; Ewin, 1984, 1992a; Vetter, 1969; Watzlawick, 1978).  Emotion evokes biochemical and physiological responses (Rossi, 1993; Selye, 1974, 1976; See Oakley and Halligan, 2010).   These concepts present the clinician with at least the following challenges:


How does the clinician know what language to use? 

How does the clinician know what information to give? 

How does the clinician know what labels need reframing? 


Part of the answer involves assessing one’s own level of knowledge and recognition of how language affects us personally, emotionally and professionally.  Another part of the answer involves assessing carefully how the patient employs language, represents and constructs meaning out of experience, and construes the problems that have led the patient to the clinician.  This requires careful questioning in order to achieve the following, after which the clinician can make a conscious effort to become an agent of change:


a)   clarify the meaning of the patient’s wording and expressions

b)   narrow down and establish the appropriate focus of what needs to be done to help the patient

c)   make note of the labels the patient uses to identify his or her functional and dysfunctional world. 


"Change language" is "hypnotic language".  From a definitional perspective, “change language" is "hypnotic language".  However, this does not mean it automatically induces a formal hypnotic trance.  As discussed earlier, hypnosis encompasses more than just the Trance State.  When the clinician is using appropriate "change language", he or she is talking to the patient’s conscious mind on one level and the unconscious mind on another level, without necessarily inducing a formal trance state.  Consequently, the patient is likely to be more accepting of what the clinician is saying because information is being communicated in a form that is acceptable to all parts of the patient’s mind.  This makes it easier to change the meaning of the patient’s beliefs and experiences, and ultimately bring about positive change in the patient’s state.


The Effect of Language on Therapeutic Change


There are four very important issues that relate to the effect that language has on the whole process of therapeutic change.


Sensory representational systems.  The clinician should attend to the language form favored by the patient (visual, auditory, kinesthetic, olfactory, and gustatory sensory modalities). This can be very important for the immediate establishment of rapport.  The choice of sensory language tells the clinician how the patient processes information.  In some cases, there can be so much crossover of sensory language, that it is difficult to immediately discern the patient's primary system of sensory processing.  Attention must also be paid to eye movements and the subtle use of language to assist in making clinical judgments. 


The patient's labels.  The labels used by the patient to describe his or her beliefs and dysfunctional behaviors further imprint the continuation of those beliefs and dysfunctional behaviors.  One aspect that needs to be noted is the recognition of labels that imply the requirement for action versus those that do not.  Consider these two examples:


The label “urge” (a verb defined as exerting a force that impels to action) implies that some action to satisfy that urge needs to take place. 


The label “memory” (a noun that refers to the ability to revive in the mind past thoughts, images, feelings, ideas, etc).  It does not imply that some immediate action is required. 


By reframing for the patient the label "urge" to the label "memory", the clinician can help change the patient’s beliefs and expectancies about the patient's future behavior.  The clinician can do this by helping the patient redefine or re-label what the patient refers to as an "urge" as a "memory" instead.  Such re-labeling changes the patient's ongoing experience.  For instance, to label a behavior as an "urge" (e.g., to smoke, to eat, to have sex) compels some sort of action to satisfy the urge.  Alternatively, if the experience is labeled as a recalled "memory", no such action is required. Memories can be interrupted, changed, or recalled at another time.


Some labels imply that no action or movement is possible.  These labels typically represent dysfunctional absolutes.  For example, a patient may describe certain behaviors as “always” happening.  The clinician can respond therapeutically by helping the patient to recognize and accept that the behavior does not always happen.  This is accomplished by further questioning and also by helping the patient to recognize the many times when this singular behavior is not exhibited. There are exceptions to this “absolute”.


The clinician's use of sensory and other language forms.  The sensory and other language forms used by the clinician can help or hurt the relationship with the patient and the therapeutic effectiveness of the treatment process.  Therefore, it is important that the clinician remain aware of whether his or her own choice language form is complimentary, or at odds with. those used by the patient. This is essential to forming a good relationship and rapport with the patient and a successful treatment. 


Iatrogenic imprinting.  Another factor that should be assessed is the effects that the language of other clinicians may have had in imprinting dysfunctional beliefs and behaviors on the patient.  This effect can be termed negative iatrogenic imprinting when it inadvertently occurs as a result of what previous clinicians have said, or as a result of the negative outcomes and experiences brought about by past treatment choices and procedures that were not successful. 


Unless iatrogenically-induced imprints are recognized and reframed, the current treatment can be stalled.  Dabney Ewin (1986, 1992a) discuss at some length an important example of the iatrogenic imprint that doctors often inadvertently create when they tell patients with persistent pain that (a) "they will always have the pain" and (b) "they must learn to live with the pain".  The patient's unconscious, which is very literal, interprets this to mean that (a) the patient will always be in pain, and (b) the patient would DIE if he or she were to be rid of the pain!  So, the patient's unconscious is naturally unwilling to let the pain go.


One aspect of “change language” is maintaining conscious awareness of the underlying meaning or deeper content of what the patient is saying and of what the clinician is saying.  Though you may both be speaking English, the intent and deeper meaning of the words that are used may be interpreted differently by each of you.  This divergence in interpretations can affect the therapeutic working relationship, your diagnostic judgment, and the whole treatment process.  This point is especially important to consider prominently when the patient’s primary language is not English, even when the patient is fluent in English, and the clinician’s primary language is English. 


Words often have more than one meaning when they have to be processed and translated from one language to another.  They may also have different connotative meanings if they are expressing emotional, psychological, or culturally relative content.  Therefore, careful questioning is required in order to clarify continuously the real meaning of the patient’s words and expressions.  In addition, the meaning of the patient's words is affected by the degree of emotionality associated with them (termed "emotional overlay") and their centrality and commonality to the patient’s habitual way of thinking.


The Patient's Beliefs


The patient's expectations and agenda.  The patient comes to the treatment setting with an agenda and belief system that can be unrealistic or misinformed.  This can prevent or delay a successful outcome of the treatment.  It is very easy to assume that you and the patient understand each other’s statements, environments, and emotional, physical, and visual worlds in exactly the same way; when in reality, each of you may not.


The patient may have an understanding about hypnosis treatment, and his or her problem symptoms, that are not factual or realistic.  To complicate matters, motivations to change may be based on outside influences, such as family or friends, as opposed to a personal interest in changing. The patient’s previous attempts to change may have established a particular mind-set that can influence the outcome of treatment.  How the patient got to you may affect the treatment process. What the referral source said may have negatively affected the possible outcome of treatment because of "iatrogenic imprinting". 


Repetition facilitates unconscious learning.  You will notice that various proscriptions and prescriptions in this course are repeated often in slightly different words.  Though their meaning and purpose may be the same, the slight variations in wording are purposefully designed to fit the information smoothly into a slightly different context.  The useful kind of repetition often increases conscious and unconscious learning (Greenwald, 1992; Kihlstrom, Barnhardt, & Tataryn, 1992). Relative to a clinical setting, the practitioner's words and form of language need to be individualized to the patient's specific language, learning needs, and information processing style. This tenet also holds true for a course on hypnosis. To cite the master, Milton Erickson, in the context of using hypnosis to treat patients with terminal illness,


"Hypnotherapeutic benefits, especially in such cases as reported here, are markedly contingent upon a varied and repetitious presentation of ideas and understandings to insure an adequate acceptance and responsiveness by the patient.  Also the very nature of the situation precludes a determination of [exactly] what elements in the therapeutic procedure are effective in the individual case." (Erickson, 1980b, p. 261). 


In the clinician's office, this slight variation in the language used to suggest change is another important conscious use of "slightly different" language during Waking State Reframing and Trance State Reframing.  Most trance state change language is a combination of reframing and direct suggestions for change, along with encouraging the patient to allow permission to change.  Because of the hypnotic phenomenon known as "trance logic", direct suggestions may contain illogical content.  However, the unconscious may accept them because the suggestions meet the needs of the patient and are phrased in a form that the patient can accept.


Post-trance state imprinting.  In the post-trance state, immediately after “awakening”, the patient is still very receptive to suggestion.  This is a time when change language is used to further imprint the positive experience of relaxation by the patient, and the comfortable feelings experienced during trance.  At this point in the session, it is important to encourage the patient to verbalize and recognize that the good experience and pleasant way of feeling now, compared to how the patient felt when first coming into the office, are a result of trance.  All of this assumes that the patient has been found to be a good candidate for hypnosis. 


It is important to be aware of the fact that “we” (the term here is used in the universal sense, not just specifically to patients) initially recognize change in retrospect.  We rarely recognize it while it is happening.  So, assisting the patient to examine how the patient feels after awakening from the trance state, as compared to before entering trance, can promote and imprint this recognition.  Once acknowledged by the patient, the experience of change can be further imprinted by suggesting continued awareness of the recently experienced change, and suggesting that there will be a progressive continuation of change as the therapy process continues.  This examination of the positive results and changes that continue to occur as treatment progresses is an important part of the beginning of each future therapeutic contact (this includes office sessions and all telephone calls).  It establishes the future expectation of continued positive change. 



Case Example: Undoing Previous Inadvertent Iatrogenic Imprinting



Brief reference was made earlier to a physician's referral to help a patient relax that presented a problem because of the doctor’s inadvertent iatrogenic suggestion that it was "impossible" for the patient to relax!  Even following a thorough intake evaluation, the clinician’s attempts were unsuccessful in helping the patient to experience this state called "relaxation".  So, the process was stopped.  The clinician “regrouped” and asked the patient, "What were the exact words that Dr. Jones used when he suggested that you come to see me?” The patient responded, “Dr. Jones said, ‘It is impossible for you to relax so I am going to send you to see someone to help you relax.” 


Dr. Jones was a very competent physician who was highly respected by the patient.  Dr. Jones’s powerful iatrogenic statement “it is impossible for you to relax” was a strong negative suggestion that was immediately and uncritically accepted by the patient’s unconscious as an absolute and thus, it was imprinted.  This made it a very difficult to accomplish relaxation unless that negative imprint was recognized by the clinician and the patient was helped to change this fixed belief. 


As part of the ongoing Waking State Reframing process, Dr. Jones’s instruction to the patient was discussed.  The patient was helped to recognize that this statement, as interpreted by the patient, was not Dr. Jones’s actual intent.  He would not have referred the patient if he didn’t mean for her to learn how to relax.  As the patient began to process this new interpretation of what Dr. Jones had said (and had really meant), she could be observed to loosen up.  She began to permit herself to accept that relaxation might be possible. 


An appropriate hypnotic induction was chosen and she was helped to experience a thoroughly relaxed state in the office.  The induction included a self-hypnosis technique that she was to practice once or twice every day for about ten minutes, and she did so with great success.  Dr. Jones was then able to successfully continue to treat her for the medical problems that had been exacerbated by her constant tension and inability to experience relaxation (which had previously created an "emotional overlay"). 


In this case, there is a discussion about reframing the patient’s imprinted unconscious belief, transitioning from one of it “it is impossible to relax” to a belief that “it is possible to relax.”  Reframes are an important part of the concept of "change language".



The Clinician’s "Invisible Language"


Correcting bad clinical habits.  Given that we are all human, like our patients, we clinicians develop habits also.  We repeat things with our patients until what we say becomes almost automatic and unconscious.  As a result, we can develop bad therapeutic habits as well as good ones.  One of the most effective ways of becoming aware of those bad therapeutic habits is by recording sessions (with the patient’s permission, of course) and having them transcribed.  Just listening to the tape of the session is not enough; listening to the tape while reading the transcript is much more effective.  The mistakes will jump out of the page!  When you recognize a pattern, start to underline (or circle) the repetitive unproductive language that is being given to the patient. This will make you very conscious of the language you are using and allow you to change it to further the patient’s opportunity for change and independence.


Observing body language: the patient's BMIR. In addition to becoming more aware of your language and the patient’s verbal language, it is also important to “listen” to the patient's non-verbal language and observe the patient's facial and body language.  They often provide additional important clues to their emotional state and how they access, process, and learn new information. The patient's non-verbal language (including facial and body language) is referred to as Behavioral Manifestations of Internal Responses (using the abbreviation: BMIR).  The patient's non-verbal (subtle and not so subtle) and overt gestural responses provide clues about the internal responses and experience. 


These clues, or "minimal cues", should be noted through careful listening and observation of the patient.  It takes significant practice and experience (often supervised) to develop the skill of recognizing these BMIRs and making therapeutic use of theme.  They should never be interpreted as indicating absolutely that the patient is experiencing a certain reaction or response without verification from additional sources of data (e.g., the patient's verbal report, consistencies and inconsistencies in patterns of responding, intensity of the patient's behavioral and emotional responses, etc.).  They should be used as data for forming hypotheses.  There are several sources of such data.


Non-verbal language and "Voice Stress Analysis".  When a person is anxious, angry, depressed, or otherwise stressed, that individual may:


  • raise or lower the volume of verbalizations
  • change the pitch and tonality of his or her voice
  • talk faster or slower
  • hesitate, stutter, stammer, or speak in a pressured manner,
  • show a flat, affectless manner
  • consciously or unconsciously stress particular syllables or words for emphasis. 


It is important for the clinician to be continuously running an informal "voice stress analysis" while listening to the patient (again, developed with clinician skill and experience). Additionally, emotional reactions and cognitive accessing processes are often manifested by non-verbal expressions, vocalizations, and utterances.  For example, chronic pain patients often exhibit signs of their pain and suffering through such "pain behaviors" as groaning, moaning, grunting, whimpering, sighing, grimacing, glaring, contorting, and jaw clenching (Eimer, 1988; Eimer & Freeman, 1998).  As another example, someone who is perplexed, or trying to remember their train of thought, might repetitively make such utterances as "geez", "hmmm", "so, so . . .", etc., while they are trying to re-access the lost material.


Breathing patterns.  When a patient is aroused, anxious, or experiencing a "fight-flight" response, the breathing tends to be more uneven, quicker, and located higher in the chest.  Alternatively, the patient may begin to breathe more deeply as if to take in more air; breathe more shallowly; or hold his or her breath more frequently.  The patient may also begin to yawn or sigh indicating the release of tension and stress. Conversely, when the patient begins to enter a relaxed state, the breathing tends to become more even, rhythmic, regular, and the respiration rate slows.  Eventually, the breathing may become shallower although initially the patient may take in deeper breaths.  Again, as the patient begins to settle back and relax, yawning or sighing may occur, indicating the release of tension.


Skin color and tone.  If a patient is embarrassed or enraged, he or she may appear flushed as blood rushes to the face and head.  However, fear may produce the opposite physiological response, making the patient appear paler.  In most states of arousal, the lips may thin and tighten.  As the patient begins to enter a relaxed state, skin pallor may also increase.  Conversely, the lips may become more full and pink or red. Aside from a condition like Reynaud’s or something similar, the patient’s extremities (e.g. hands and handshake) may also become quite cold due to vasoconstriction (related to stress).


Muscle tone.  As a patient begins to enter a state of relaxation, muscles begin to let go and relax. The muscles in the forehead and around the eyes may appear to flatten. The fluttering of the eyelids, if the patient's eyes are closed, may either increase or decrease.  The jaw muscles may relax and consequently the patient's lips may part and the jaw may begin to hang down or open.  Usually, there will be less movement and the relaxed patient will appear more still.  Periodically, one may notice involuntary muscle twitching or fasciculation as tension is released.  The patient may also swallow more frequently. If the patient is anxious or angry, the facial muscles may tense up.  The forehead muscles may crinkle and a frown may be evidenced.  Facial tics may also be observed.  The patient is likely to appear restless and the large muscles of the upper body (neck, shoulders, chest) may tense up.  The arms and hands may also tense and the patient may make fists, tense the fingers and hands, or be unable to keep his or her hands and arms still.  The patient may also be unable to settle back and may appear "on the edge of his or her seat".


Ideomotor responses.  The unconscious mind communicates its feelings constantly through spontaneous and involuntary movements of the skeletal muscles.  This expression or conversion of ideas, emotional reactions, and feelings into automatic, largely unconscious, motor responses is termed “ideomotor responding.”  For example, we may automatically and unknowingly nod our head or smile when something feels good or okay (also, when saying “yes"). Or, we may automatically shake our head "no", or frown, or tense up, when something does not feel okay or positive (interestingly, you may also notice an individual verbally agreeing while at the same time shaking his or her head from side to side).  These observable ideomotor responses are "minimal cues" to the patient's internal emotional reactions and states.  It is very important to watch for the occurrence of these "minimal cues" in our patients.


Physiological and visceral responses.  The unconscious mind also communicates its feelings through automatic changes in our Autonomic Nervous System (ANS).  Our ANS controls all of the physiological functions that keep us alive.  These functions include our heart rate, blood pressure, breathing, digestion, bowel and bladder functions, and hormonal responses.


When a person experiences some form of the "fight-flight response" (becomes anxious, scared, angry, enraged, or otherwise aroused), heart rate, respiration rate, and blood pressure usually increase.  Breathing may become centered mostly in the upper chest, the bladder and/or bowels may become stimulated, with a consequent increased need to visit the bathroom.  The individual may also experience stomach pain or nausea if the stomach is relatively full of food and the digestive process is not stimulated.  As the hypothalamic-pituitary-adrenal axis (HPA) is activated, the body's physiological stress response system is also activated and certain hormones and neurotransmitters are produced in larger quantities as compared to when the mind-body system is unaroused.  These hormones and neurotransmitters, such as norepinephrine, adrenaline, and cortisol set the body's instinctive "fight-flight reaction" in motion. This response has a significant survival purpose (“I see a tiger and I need to run or die”), the complex details of which are beyond the scope of this course.  The interested reader is referred elsewhere (Why zebras don’t get ulcers is an entertaining book related to these issues).


When an individual enters a relaxed state, certain opposing autonomic and visceral responses to those mentioned above (e.g. the fight or flight) may occur.  The individual's heart rate, respiration rate, and blood pressure usually decrease.  Breathing may become more centered in the middle chest area and the abdomen.  The bladder and bowels tend to relax.  Stomach contractions or spasms may also increase if the hunger response or digestive process is stimulated and stomach acids are secreted.  When the brain sends a message that all is safe to the HPA system, the body's physiological stress response system is deactivated and the production of the above stress hormones and neurotransmitters is turned off.     


Observing eye movements.  It has often been said that "the eyes are the windows to the soul".  A patient's physiological ophthalmic responses (e.g. dilations of the pupils, tearing, blinking, eye opening versus closure, etc.), eye movements and eye scanning patterns may also serve as a BMIR. The eyes can often convey clues to a person's emotional state and cognitive processes.


When people are thinking and talking, they tend to move their eyes in regular repeated patterns as they scan their memory.  These eye movements are the accompanying physical expression of their attempt to gain access to internally stored information.  The attentive clinician can observe these BMIRs, especially if a patient is not very verbal, to further ascertain the patient’s method of processing.  These eye movement patterns often provide clues to the patient's primary or dominant sensory representational systems for accessing and processing information (Bandler & Grinder, 1979; Cameron-Bandler, 1978; Lankton, 1980; Lewis & Pucelik, 1982).  It is useful to carefully observe the patient's eye movements when he or she is answering your questions that require memory recall. 


It is important that the clinician not rely on just one source of sensory data for drawing conclusions about the patient's dominant processing systems.  The validity of the clinician's hypotheses is always bolstered when consistency is obtained between several sources of data (e.g., the patient's language forms, eye scanning patterns, physiological responses, etc.). In research, this is convergent validity.


Eye scanning patterns.  Eye scanning patterns are perhaps the most easily recognized BMIRs and clues to the patient's cognitive and emotional accessing and processing behaviors (Bandler & Grinder, 1979; Cameron-Bandler, 1978; Lankton, 1980; Lewis & Pucelik, 1982).  However, like all of the other BMIRs described above, the data they provide should not be taken as conclusive without additional sources of confirmatory data.  This includes talking with the patient, listening carefully to the patient's language, and noting and observing all of the patient's behaviors (overt and covert, gross and subtle).


Most people are right-handed, so patterns that are usually (but not always) shown by right-handed people, most of who are left hemisphere dominant, will be discussed.  The patterns are reversed for some, but not all, left-handed individuals, some of whom may be right hemisphere dominant, or of mixed cerebral dominance.  Some individuals may also be ambidextrous or do some things with one hand and other things with the other hand.  Often, a left-handed individual whose inherited hand dominance was changed from writing with the left hand to writing with the right hand in his or her early school years, will have developed superior fine-motor skills with the learned dominant right hand, and superior gross-motor physical skills with the once dominant left hand.  Such a person may play gross motor sports and activities as a "lefty", but fine motor activities as a "righty”. These persons may have well-developed multiple accessing systems and may not fit the generalizations to follow.  Therefore, this is important information to obtain in the Intake.


The word “looking” in the following descriptions refers to the eye movements of the person in the direction indicated.  “Left” means toward the person’s left and “right” means toward the person's right. 


Looking up and to the right: "constructed visual images".  This eye movement pattern is understood to reveal that visual images, or pictures are being created by the individual.  These images may be made up partly of previously experienced and remembered visual input as well as newly created visual representations.  They can also be created images that are responses to other sensory stimuli or the clinician’s questions.  Because these are transitory images, they are usually without depth or vivid color.  From a neuropsychological perspective, this accessing pattern is thought to involve left hemisphere occipital, parietal, and temporal cerebral activity.


Looking up and to the left: "eidetic images".  This eye movement pattern is understood to reveal the accessing of stored or remembered visual images of past events and other previously experienced visual stimuli.  They may also include dreams, fantasies, and other constructed memories that have been imprinted by emotion or repetition.  They may have depth, color and even motion.  From a neuropsychological perspective, this accessing pattern is thought to involve right hemisphere temporal-parietal and occipital cerebral activity.


Staring straight ahead: Visualizing "constructed" and "remembered" images.  This eye position is understood to reveal the simultaneous accessing of both remembered images and constructed images, or the combination of remembered images in a new way.  For example, it might reveal that the perceiver is imagining what a person he or she knows (visually remembered) would look like (and perhaps even "feel like") dressed in a manner uncharacteristic for that person.  Neuropsychologically speaking, this accessing pattern is thought to involve bilateral occipital and more whole brain cerebral processing.


Looking level and to the right: "constructed speech".  This eye movement pattern relates to the process of creating spoken language.  The person is putting into words what he or she wants to say next.  This eye movement pattern is often used extensively by individuals who have a different first language than English.  They often have to continually translate from their own native language into English as a second language.  This accessing pattern is thought to involve left hemisphere temporal cerebral activity.


Looking level and to the left: "remembered sound".  This eye movement pattern includes jingles, melodies, the words of songs, the childhood “alphabet song”, slang and swearing.  It also includes accessing of sounds and auditory messages that are short, repeated, rote reminders of tasks to be done, like “stop at the store on the way home”, that have been repeated and then dropped from conscious awareness.  It is thought to involve right hemisphere temporal-parietal-occipital cerebral activity.


Looking down and to the right: "feelings".  This eye movement pattern allows a person to access emotions and store kinesthetic memories.  Depressed persons, who are "very into their feelings” of sorrow and despair, and "down right depressed", often are viewed with head down, shoulders rounded, and their body drawn in.  This emotional state accessing pattern is thought to involve left hemisphere frontal-temporal and parietal cerebral activity.


Looking down and to the left: "internal dialogue".  When a person is in deep thought, they may access the words and sounds that are invoked internally during this state.  Often, when a person is mumbling something, not even aware that it is being expressed out loud, that individual is accessing "internal dialogue".  This is referred to by traditional Cognitive Therapists as "self-talk" and "automatic thoughts" (J. Beck, 1995; Dobson, 2002; Eimer & Freeman, 1998; Ellis, 1996; Meichenbaum, 1977).  Usually, "internal dialogue" is a running commentary on current experience.  This eye movement accessing pattern is associated with "internal dialogue" and is thought to involve right frontal and temporal cerebral processing.        


Other ways that the patient accesses and processes information may be expressed through shallow breathing when the patient is constructing or remembering visual images and head cocking at an angle to “hear” what you are saying better.  This head positioning may also suggest a hearing problem that may need to be investigated further and assessed.  This could require changing the seating positions of the patient and clinician. These non-verbal accessing cues are offered as additional ways of learning the patient’s cognitive-perceptual processing patterns.  They may, or may not, be readily apparent.  As with many other treatment models, BCH considers these behaviors ancillary and complimentary to the verbal cues and clues discussed earlier.


Important Note to the Reader. In reading all of these factors that the clinician might take into account during evaluation and treatment, it might seem somewhat overwhelming.  It is important to remember that this course is an overview of most of the issues related to the BCH treatment model.  It is not necessary to do all of things “perfectly” to obtain a successful result.  They are simply presented as issues that the clinician can be cognizant of as the clinical experience progresses.  After awhile, the clinician is paying attention to all of these subtle cues at an unconscious level that still impacts the intervention.  The treatment becomes a fluid process influenced by many factors, many of which are out of awareness of the clinician.   



Table 8. Change Language: Summary of Concepts




Conscious use of language

Change language

Change language is a hypnotic language


The Effect of Change Language on Therapeutic Change

Sensory representation systems

The patient’ labels

The clinician’s use of sensory and other language forms

Iatrogenic imprinting


The Patient’s Beliefs

The patient’s expectations and agenda

Post-trance state imprinting


The Clinician’s Invisible Language

Correcting bad clinical habits

Observing body language: BMIR

Non-verbal language and voice stress analysis

Breathing patterns

Skin color and tone

Muscle tone

Ideomotor responses

Physiological and visceral responses

Observing eye movements



General Reframes


Labels reframe.  The labels we place on the behaviors dictate future behavior. Recurring behavior tends to establish its continuity, frequency, and duration.  For example, if we call a reoccurrence or temporary relapse of a previously changed negative behavior a “failure” then we may tend to repeat that behavior again because we have invoked implicitly the belief that we are "trapped" in that behavior (we give the behavior control).   


Alternatively, if we call it a “mistake” then that verbal label suggests that it can be corrected and we can then proceed to correct it.  So, the reframing of a belief that expresses failure to the recognition and belief that it was only a mistake can allow an individual to further believe that the behavior does not have to continue because mistakes are errors which can be corrected. Clinically, the correction can take place during Waking State Reframing, or during a subsequent trance experience through trance state reframing. 


As an interesting side bar, many software programs allow a “do-over” if a problem occurs (e.g., loss of data, accidental delete, cyber-attack, program installation, etc). These programs allows for resetting the software to an earlier date before the problem occurred.  These programs allow the user to correct the mistake.  Memory of the functional system contents is retained long enough to be accessed, if done immediately, to allow the computer to return to full normal function.


Events / non-events reframe.  This is an ideal lead-in to the reframe that "We only pay attention to “events”.  We don’t pay attention to “non-events.”  That is, we pay attention to things that are happening, or have happened.  When something is happening, or has happened, it is an event.  On the other hand, we don't pay attention when something is not happening.  After all, how can we be aware of something if it is not happening?  So, when something is not happening, there is no event.


The "Absolute" reframe.  The patient who comes into to your office talking about “always” feeling afraid or anxious needs to be helped to recognize that “always” is an absolute. Using another general reframe can help to refute this belief.  That reframe is the fact that, 


“The only ABSOLUTE is that there are NO ABSOLUTES”


Further questioning the patient about times when the patient is not afraid, such as when sleeping, with family or friends, or during other pleasant secure times, can do this.  The only agreement needed from the patient is that there has been at least one time when the patient was not, or is not, afraid.  The acknowledgment of this exception can allow the patient to change the label from “always” to “sometimes”.  This change in belief can open up the possibility that less frequent repetition and eventual elimination of the fear, the fearful thoughts, and the fear-based behavior are possible. 


"Post-hypnotic suggestions" versus "post-trance imprinting".  "Post-hypnotic suggestions" usually have a short life-span or "psychological half-life".  Therefore, they usually have to be reinforced by the clinician and/or the patient to maintain a continued effectiveness. 


As discussed, one of major ways of communicating with the unconscious part of the mind is repetition.  When we repeat something over and over again, that behavior or thought tends to become automatic and unconscious.  Post-hypnotic suggestions are suggestions delivered in the trance state for certain behaviors, thoughts, or feelings to occur after the trance state is terminated. These occur in the presence of specific cues or stimuli, but are outside of the patient's conscious control and awareness (unconscious).  In order for these types of unconscious associations to last, they have to be repeated over and over again without the patient feeling that the post-hypnotically suggested behavior or feelings are being deliberately or consciously invoked.


Post-trance imprinting is instructions given to the patient during trance and rehearsed in the trance state.  This requires consciously evoked actions by the patient.  Self-relaxation or self-hypnosis practice, for example, are post-trance imprinting behaviors.  The actual behavior is evoked by a conscious decision.  The experience of the consciously evoked behavior further communicates to the unconscious change and control.  By repeatedly consciously accessing "Instant Relaxation" it becomes automatic by repetition.


Trance Induction: Design, Choice, and Administration


BCH is generally in agreement with the American Psychological Association (APA) Division of Hypnosis (Division 30) theoretically neutral definition and description of hypnosis. However, BHC views hypnosis as an alteration in internal perception, an altered state that is initiated at the start of a unique process of communication evoked by an external stimulus that alerts the unconscious mind to pay attention.  Definitions of hypnosis used by two leading organizations are provided in Table 9   



Table 9. Definitions of Hypnosis



American Psychological Association (Division 30)


Hypnosis typically involves an introduction to the procedure during which the subject is told that suggestions for imaginative experiences will be presented. The hypnotic induction is an extended initial suggestion for using one’s imagination, and may contain further elaborations of the introduction. A hypnotic procedure is used to encourage and evaluate responses to suggestions. When using hypnosis, one person (the subject) is guided by another (the hypnotist) to respond to suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought or behavior. Persons can also learn self-hypnosis, which is the act of administering hypnotic procedures on one’s own. If the subject responds to hypnotic suggestions, it is generally inferred that hypnosis has been induced. Many believe that hypnotic responses and experiences are characteristic of a hypnotic state. While some think that it is not necessary to use the word “hypnosis” as part of the hypnotic induction, others view it as essential.


Details of hypnotic procedures and suggestions will differ depending on the goals of the practitioner and the purposes of the clinical or research endeavor. Procedures traditionally involve suggestions to relax, though relaxation is not necessary for hypnosis and a wide variety of suggestions can be used including those to become more alert. Suggestions that permit the extent of hypnosis to be assessed by comparing responses to standardized scales can be used in both clinical and research settings. While the majority of individuals are responsive to at least some suggestions, scores on standardized scales range from high to negligible. Traditionally, scores are grouped into low, medium, and high categories. As is the case with other positively-scaled measures of psychological constructs such as attention and awareness, the salience of evidence for having achieved hypnosis increases with the individual’s score.


American Society of Clinical Hypnosis (ASCH)


Hypnosis is a state of inner absorption, concentration and focused attention. It is like using a magnifying glass to focus the rays of the sun and make them more powerful. Similarly, when our minds are concentrated and focused, we are able to use our minds more powerfully. Because hypnosis allows people to use more of their potential, learning self-hypnosis is the ultimate act of self-control. While there is general agreement that certain effects of hypnosis exist, there are differences of opinion within the research and clinical communities about how hypnosis works. Some researchers believe that hypnosis can be used by individuals to the degree they possess a hypnotic trait, much as they have traits associated with height, body size, hair color, etc. Other professionals who study and use hypnosis believe there are strong cognitive and interpersonal components that affect an individual's response to hypnotic environments and suggestions. Recent research supports the view that hypnotic communication and suggestions effectively changes aspects of the person’s physiological and neurological functions.



The "trance state".  The trance state is a further intensification and focusing of this alteration in internal perception.  It can occur spontaneously, be purposely induced by the clinician, or induced by the patient (self-hypnosis).  Earlier, twenty non-mutually exclusive basic characteristics of hypnotic trance as an "altered state of consciousness" were listed (which have been delineated by Humphreys, 2000). 


Deep relaxation, involuntariness and automaticity. In BCH, therapeutic trance also involves a component of deep relaxation fostered by parasympathetic activation or dominance in the continuing homeostatic balance between the parasympathetic and sympathetic branches of the autonomic nervous system (Benson, Arns, & Hoffman, 1981; Edmonston, 1981; Eimer & Freeman, 1998; Humphreys, 2000).  There is also an element of what is termed involuntariness or unconsciously mediated automaticity involved.  Thus, the experience of hypnotic phenomena is felt to be effortless as opposed to effortful and consciously willed (Eastwood, Gaskowski, & Bowers, 1998; Holroyd, 1996; Spiegel & Spiegel, 1978, 1987).   


Facilitating communication and therapeutic learning.  During treatment in which hypnosis is used as an adjunctive tool, the above characteristics of the trance state may allow important therapeutic learning to take place much more quickly on cognitive, emotional, and physiological levels.   Drawing on Milton Erickson's work, the patient in trance can access inner resources for healing (Erickson and Rossi, 1979, 1981; Rossi, 1993; Rossi and Cheek, 1988). The concept of “Inner Strength” was developed from the standpoint of ego state psychology (Frederick & McNeal, 1999;Watkins & Watkins, 1997).  They defined "Inner Strength" as a helpful "ego state" (i.e., aspect of the patient's personality) that can be accessed in trance to help the patient get in touch with inner resources and strengthen the patient's ego (i.e., the patient's self-confidence and self-efficacy).


Hypnosis facilitates communication and development of a relationship with one's own unconscious.  In a state of deep relaxation, a "doorway" into the patient's unconscious is somehow opened.  With the patient's cooperation and permission, therapeutic information can then be provided in a language and form that is acceptable to the individual (Eimer, 2000a, 2000b; Zarren, 1996a; Zarren & Eimer, 1999). In treatment, the clinician skilled in the use of hypnosis facilitates the re-direction and narrowing of the patient's attention towards a therapeutic goal.  This hypnotic communication process takes place during the waking state ("Waking State Reframing") and during formal hypnotic trance work.  It is grounded in a positive therapeutic relationship based on trust, faith, necessity, and positive expectancy.  It promotes the patient's comfort, cooperation, suggestibility, and ease of compliance with the treatment procedures. 


BCH first goes through the process of “Waking State Reframing” (communication with the patient's conscious and unconscious minds simultaneously to start the change process).  However, the “change” is not yet “fixed” in place. The therapeutic trance state is then purposely induced, and the “doorway to the Unconscious Mind opens”.  The Unconscious is then given further information in a form and language it will accept to fix in place the desired change. When the trance induction procedure is used as part of the ongoing therapeutic process, the clinician is further changing the patient’s belief system.  Because one of the unique phenomena of the hypnotic trance is a suspension of some critical judgment (termed "trance logic"), the patient can more readily accept suggestions of change without having to examine these suggestions critically as to their logic or difficulty. 


Hypnotic Inductions


Inductions are the beginning of, or entrance to, the trance experience.  The body of the trance experience follows the induction procedure. This is a continuous flow experience.   The practitioner may only spend a few minutes for the induction and many more minutes verbalizing the suggestions for change during the extended Trance State. There are many methods for inductions (See Gibbons and Lynn, 2010; and other resources).   


This issue requires much attention since most hypnosis training emphasizes the teaching of induction procedures.  There is usually little discussion about what we do with the Trance State once it is induced.  It is beyond the scope of this course to provide the reader with all the skills necessary to completely address this issue.  What to do after a patient is placed in a Trance State is learned from education, supervision, and clinical experience.


During the induction and the trance state, the language used by the clinician is critical in helping the patient's unconscious mind to accept specific or even general suggestions.  The clinician is further imprinting or fixing change in place during the trance experience.  The trance functions as a "catalyst" and a "fixative" but it does not initiate the change.  The change is initiated in the waking state. The trance experience, however, can create general change by creating an experience and memory of deep relaxation.  The deep relaxation may feel new and different to the patient because it reduces or temporarily eliminates most of the physical tension associated with the dysfunctional behavior or symptoms.


Choice of Induction


Several considerations affect the choice of an induction procedure.  One consideration is the patient’s way of processing information.  The clinician needs to consider the patient’s needs, personality style, learning systems, as well as the problems being addressed.  For example, long inductions may not be suitable for most pain patients.  These patients need to begin to experience a reduction in tension and increase in relaxation very quickly during induction to distract their attention away from the area of concentrated discomfort (Eimer & Freeman, 1998). 


Internal vs. external focus of attention.  Some patient complaints require induction methods that are externally focused because of extreme somatic (i.e., internal) symptoms.   In such cases, the patient's focus of attention may need to be re-directed away from the experienced internal locus of his or her symptoms and discomfort.  Inductions that utilize an eye fixation or holding on to an object such as a marble would be appropriate.  Others require an internal focus because of strong emotional feelings the patient is experiencing that may be exacerbating the patient's physical discomfort.  In this case, attention to breathing or awareness of arm rigidity might be utilized. 


Brief versus long induction procedures.  In the practice of BCH, relatively short and direct induction procedures are favored.  Long and drawn out relaxation, metaphoric, or confusion inductions tend to get in the way of the BCH paradigm and therapeutic agenda.  Thus, whatever induction procedures the clinician prefers are generally acceptable as long as they are quick and direct; they should also be chosen based on the patient’s individual needs and the nature of the problem being treated.  In the remainder of this section, both original and modified traditional inductions will be reviewed as they meet the goals of the BCH model.


The assessment of "hypnotizability".  In the BCH mode, routine testing for "hypnotizability" is not done.  Though some clinicians always test for hypnotizability as a regular part of the intake process (Council, 1999; Spiegel & Spiegel, 1978, 1987), the BCH model does not do so for two main reasons:


(1) If a patient tests with low hypnotizability, this often leads the clinician to work with that patient with the preconception that hypnosis and trance work will not be effective.  This can become a self-fulfilling prophecy, as clinicians' expectations influence patients' expectations, which can influence treatment outcomes (Coe, 1993; Kirsch, 2000; Shutty, DeGood, & Tuttle, 1990).  In such cases, patients are often deprived of the benefits of hypnosis as a tool for making treatment more pleasant, quick, and efficient, and therapeutic results may be compromised.


(2) Experimental and laboratory research on hypnotizability do not necessarily or specifically translate into clinical practice (Barber, 1996; Eimer, 2000a, 2000b; Woody, Bowers, & Oakman, 1992).  Experimental research requires standardized, fixed, inflexible, and replicable procedures.  On the other hand, clinical work requires flexible, adjustable, and adaptable procedures based on individual differences among patients such as personality, dissociation potential, cognitive style, and flexible control of cognitive processes (Bates, 1993; Evans, 1991; Spiegel & Spiegel, 1978, 1987). Early in the development of BCH, testing for hypnotizability was done.  It was found that even those patients testing as "low hypnotizables" could benefit from BCH when it was carefully tailored to meet their individual needs and when appropriate reframes were put in place during the Waking State Reframing process. 


The issue of trance "depth".  The BCH model does not focus on the depth of the trance experience; although, the term “deep” is used it is in reference to the quality of the trance experience.  The term "deepening procedures" is used to discuss with patients the “depth” (as assessed by their subjective report) of how comfortable he or she feels.  Patients experience different levels of subjective relaxation throughout the trance experience. That is, patients typically feel very relaxed and less relaxed at different times during their trance experience. 


The Trance Induction Scripts that follow in this section are generalized scripts. They do not present the language that may be added during the Trance State to meet the varying needs of individual patients.  They also do not include reframes or suggestions specific to the particular dysfunctional complaints of patients.  However, the sample trance induction scripts may use some specific suggestions and reframes as examples. 


Induction Categories


In BCH induction procedures are divided into three main categories:


  1. Instant spontaneous inductions that flow from the patient’s readiness to enter into trance
  2. Inductions that include the teaching of self-hypnosis
  3. Inductions that do not include the teaching of self-hypnosis


Instant Spontaneous Inductions


There are some patients who exhibit trance-like behavior during the Waking State Reframing process.  For instance, the clinician may notice that the patient is exhibiting the following


their eyes are blinking very fast and frequently. 

they are having difficulty keeping their eyes open. 

body posture and breathing that suggests that they are already very relaxed.

the color of their facial complexion has deepened. 

their eyes may be fixed on some object in front of them or look "glazed over". 


Instant spontaneous induction trance script.  When you are aware of these "behavioral manifestations of internal responses" (BMIRs), you can simply say,


"You are already feeling very relaxed, so why don’t you just close your eyes and allow yourself to relax even more?"  Usually, the patient does just that.  That is, the patient closes his or her eyes and formally enters trance.  Then, you might say, “This is what it feels like to be in hypnosis.  You can enjoy it even more by paying attention to your breathing without trying to change your breathing.  If your mind wanders, the moment you realize that you are thinking of something else, bring yourself back to concentrating on your breathing and feel yourself going even deeper into relaxation and hypnosis. Deeper with each normal breath that you take, and deeper with each word that I say, regardless of the meaning of my words.  As you go deeper and deeper into relaxation and hypnosis with each breath and each word, the doorway to your Unconscious opens.  With your permission, I have the opportunity to talk to your Unconscious and give it information it needs to have to help you change the behavior that you want to change.”


A therapeutic double bind.  If you, the clinician, need to test your own judgment as to the patient’s readiness to enter into Instant Trance at this point during the session, a very simple choice is available to you.  You have already made it!  Usually, if the patient complies with the suggestion of eye closure, that is enough.  If the patient does not close his or her eyes when initially suggested, you can say, “That’s fine.  You can close your eyes whenever you are ready to feel more relaxed.  When you do, you will know what it feels like to be in hypnosis.  Meanwhile, just pay attention to your breathing, and enjoy how it feels to be relaxing more and more.”


This is a suggestion that can be interpreted as a "therapeutic double bind" because whatever choice the patient makes is acceptable to the clinician.  The patient usually will close his or her eyes shortly if you remain silent.  When that happens, you may pick up on giving suggestions with the phrase, “Now that your eyes are closed, continue paying attention to your breathing without trying to change your breathing, etc.”


Adding therapeutic suggestions after instant trance is induced.  At this point, you may proceed to add appropriate suggestions and slightly altered reframes to further imprint and fix in place the desired beliefs and therapeutic changes.  If you planned on teaching the patient self-hypnosis, you should not do it during a session when an Instant Trance occurred.  This is because you were not able to induce the trance using the trance induction procedure that you want the patient to use on his or her own.  You would suggest to the patient, while in trance, the value of this deep relaxation experience that will “build a memory of what it feels like to be deeply relaxed" that can be used next time to teach the patient self-hypnosis. 


The process of awakening the patient, and post-hypnotic or post-trance imprinting, will be discussed shortly.  BHC differentiates between "post-hypnotic suggestion" and "post-trance imprinting".  Teaching self-hypnosis combines elements of both.  Self-hypnosis is taught during trance, so it includes unconscious post-hypnotic responses to suggestions to fix the experience in place for future use.  Also, by consciously practicing self-hypnosis repetitively, it is further imprinted outside of the initial trance experience.  It becomes something the patient consciously does to feel better.  By regular repetition, it becomes a part of daily ritual, and is done almost automatically.


Inductions That Include Teaching Self-Hypnosis


“Eye fixation with attention to breathing induction" trance script.  The following induction (See Table 10) fits the BCH paradigm in that it is brief, direct, and conducive to teaching the patient self-hypnosis:



Table 10. Eye Fixation and Breathing Script



Sit comfortably in the chair, with your feet flat on the floor, and your arms comfortably on the arms of the chair or in your lap, and look at some small object in front of you.  Here in the office you can look at the hands of the Buddha in the picture on the wall, or the crystal ball in the stand on the window sill in front of you.  As your eyes continue to look at the object you have chosen, also pay attention to your breathing without trying to change your breathing.  Just let yourself breathe normally while you pay attention to your breathing.  Let your breathing become the center of your thoughts and attention while your eyes stay focused on the object you chose in front of you.  If your mind wanders, and it may, the moment you realize that you are thinking of something else, bring your mind back to concentrating on your breathing. 


As you do this, you will notice, that your eyelids begin to blink more frequently than usual, and that they may feel heavier.  This more frequent blinking, and the way your eyelids feel are a part of the hypnosis experience.  Shortly you will find your eyes closing.  When they do, just leave them closed until I ask you to open them.  Do not squeeze them tight.  Just leave them closed lightly and comfortably.  You may notice a fluttering of your eyelids.  That is also part of the hypnosis experience.  After a while, you will pay no attention to them.  Meanwhile, your breathing has begun to change, as you become more relaxed.  Notice how comfortable your breathing feels, and how much more relaxed you have become.  Allow your more comfortable breathing to take you deeper and deeper into relaxation and hypnosis.  As you continue to go deeper with each breath that you take, and with each word that I say, regardless of the meaning of those words, the doorway to your Unconscious opens, and with your permission, I have the opportunity to talk directly to your Unconscious, and give it the information it needs to have to help you change the behavior that you want to change."


Here you might add appropriate suggestions and re-phrased reframes to complete the imprinting process and fix the desired changes in place, if you have decided that teaching self-hypnosis is not essential to accomplishing the therapy goals that you have established.  However, if you have decided that teaching self-hypnosis is essential, then you can go on to verbalize the following:   


“Today, you are learning what it feels like to be comfortably relaxed.  You are building a memory of deep relaxation that you can borrow back to relax yourself.  When you are relaxed you can’t be angry or upset, anxious or afraid, frustrated or stressed, because relaxation is the physical and emotional opposite of those feelings. 


When you want to practice your own self-relaxation, your own self-hypnosis, you will do what we did here in the office today, by yourself.  Ideally, that would be first thing in the morning before breakfast, and again, late in the afternoon or some time before dinner.  Find a comfortable chair to sit in, off by yourself, look at some object not too far away to fix your gaze, and pay attention to your breathing.  Don't try to change your breathing.  Shortly, your eyelids will begin to feel heavier, you will notice that they are blinking more frequently than usual, and you will gently and comfortably close your eyes without squeezing them tight.  Continue to pay attention to your breathing without trying to change your breathing.  Your breathing will change all by itself.  If you find your mind wandering, the moment you realize it is wandering, bring your attention back to your breathing, and allow yourself to relax even more. 


After awhile, when you choose to awaken yourself, as we will be doing shortly here in the office today, you will feel very good, very relaxed and very comfortable, and yet wide awake at the same time.  You will feel better for some time after you awaken yourself from your own self-relaxation. You will do that by counting up slowly from one to five.  With the number five, open your eyes, and be wide awake and yet still feel a great deal of relaxation.  But, don’t do that yet.  I will help you do that today, shortly.”


If you have decided that it is appropriate to teach the patient a coping skill for instantly managing stress, then you can go on to verbalize the following:


Now, I am going to teach you a whole new way to relax yourself instantly to deal with stressful situations whenever you need to, wherever you are, in seconds, without closing your eyes, and without anyone knowing you are doing it. 


When someone begins to feels stressed, it is usually experienced as a pressure or feeling in the chest, the shoulders or in the back of the neck.  When this first begins to happen to you, and you may be more aware of it more quickly, just look at something, not too far away to focus your attention.  Then take two or three very slow deep breaths.  Breathing in relaxation through your nose and letting out the tension slowly through your mouth, all the way down to your stomach.  Immediately, you will bring back a part of this feeling of relaxation.  Enough to melt away, dissolve away, any feelings of pressure, or tension, or stress.


Now, you are sitting here in the chair already very relaxed.  Take a few very slow deep  breaths.  Breathing relaxation slowly in through your nose, and breathing out the tension slowly through your mouth, all the way down to your stomach.  Very good.  Now take another slow deep breath, but, slow it down even more.  Excellent.  Now let yourself breathe normally.  That's great.  That helped you to feel even more relaxed, didn't it?  If it did, just nod your head for me.  Thank you.


Now, when you are ready to awaken yourself, count slowly and silently to yourself from one up to five.  With each number you count, you will feel more and more alert while still feeling relaxed.  With the number five, open your eyes and be wide awake.  How do you feel?  How was that?  You did feel more relaxed from the deep breaths, didn’t you?  That’s great.”



While discussing this in a workshop, someone once asked, “Why don’t you just automatically teach self-hypnosis to every patient?”  There are some behaviors that are referred to as simple habits, (e.g. smoking cessation) that can be treated as single session procedures.  Once the behavior has been extinguished, the patient is not instructed to do anything that would become a ritual that is necessary to continue to prevent the behavior from returning. That would be like trying not to think of a pink elephant.  The harder you try not to do something, the more difficult it becomes, and the more obsessed you become with what you are trying not to do.  This is what often happens when people try to stop smoking "cold turkey".  It creates a stress reaction that can increase thoughts of smoking and that can make the desire to smoke even stronger.  Therefore, we do not usually teach self-hypnosis for single session procedures.  Sometimes, however, we do teach “Instant Relaxation”, such as the deep breaths, for general stress control. 


Inductions That Do Not Include Teaching Self-Hypnosis 


All of the inductions above can be utilized without teaching self-hypnosis when the clinician is doing a single session change procedure.  However, a common method is described below.


"Rising and falling arms induction" trance script.  This induction is a combined adaptation of arm levitation and reverse arm levitation, and contains a self-ratification of the trance experience. This induction is often used when doing single sessions (e.g., smoking cessation program).  It is fast, re-directs the patient's attention to his or her arms and creates an immediate feeling that something uniquely different is happening (as the rigidity and changes in arm position occur).



Table 11. Rising and Falling Arms Induction



In a moment, I am going to ask you to close your eyes, but not yet.  When I do, leave them closed until I ask you to open them, and don’t squeeze them tight.  Just let them close comfortably and easily.  Meanwhile, lift your two arms up like this.  (Demonstrate by raising and extending your two arms straight out and rigid, palms down, parallel to the floor, and about chest high.)


Turn one hand over, palm up.  That’s good.  Now, when you close your eyes, but not yet, I am going to attach a string to this wrist (Lightly touch the wrist with the palm facing down.) attached to a large make believe helium filled balloon.  (Slowly move the finger touching the wrist up and then in a circle simulating the outline of a large round balloon.)  If I really did attach a helium filled balloon to this wrist, this arm would move slowly up, wouldn’t it?  I am also going to place a make believe small book in the palm of this hand.  (Lightly touch the palm of the hand facing up.)  If I really did that, this arm would get heavier and move down, wouldn’t it?  But, don’t move your arms on purpose.  Let them move all by themselves.


Now, gently and comfortably close your eyes.  I am tying the string attached to the helium balloon to this wrist (lightly touch the wrist), and this arm will get lighter and lighter and slowly rise.  I am placing the small book in the palm of this hand  (lightly touch the palm of the hand facing up), and this arm will get heavier and slowly move down.  One arm is slowly rising, and the other arm is slowly moving down.  But, something else is also happening.  Both arms have become stiff and rigid.  I am going to lightly press a finger on each wrist. (Lightly press down on each wrist with your fingertips simultaneously.)  As I press lightly down on your wrists, notice that both arms tend to bounce.  That is not usual.  It only happens when someone is going into hypnosis.  So it tells us that you are in going into hypnosis. 


Keep this arm floating in the air.  (Lightly tap the wrist of the hand facing down.) (Lightly turn over the hand facing up as you say the following:)  Now, with your permission, I am going to turn this hand over, and slowly lower it down to the arm of the chair (or, if the chair is without armrests, say: to your lap), without your help, while you go even deeper into relaxation and hypnosis.  Very good. Now I am going to put a small hole in the helium filled balloon tied to this wrist, and slowly guide this arm down to the other arm of the chair (or lap) as you go even still deeper into relaxation and hypnosis.  Very good.  The eyelid fluttering that you are experiencing is a part of the hypnosis experience.  After awhile you will pay no attention to it.


Now, as you are sitting in the chair, already relaxed, and breathing normally, and listening to the sound of my voice, you will find yourself going even deeper into relaxation and hypnosis. Deeper with each breath that you take, and deeper with each word that I say, regardless of the meaning of those words.  As you go deeper with each breath, and deeper with each word, the doorway to your Unconscious opens.  With your permission, I have the opportunity to talk directly to your Unconscious and give it information it needs to have to help you change the behavior that you want to change.  (Name the behavior, such as: "Namely, to be a non-smoker".)”



This brief induction actually takes longer to describe than it does to carry out.  The clinician can often attach, toward the end of this trance experience, the instant, eyes-open relaxation using three deep breaths, as a skill that can be used by the patient as a "stress interrupter" without anyone knowing that it is being done. Refer to the Eye Fixation Attention to Breathing Induction described earlier. 


Trance Deepening Methods 


There are a number of very comfortable trance deepening procedures, some of which have already been discussed. This is usually not necessary when doing a single session behavior change procedure.  However, when helping a patient to learn self-hypnosis as part of ongoing treatment, these methods are certainly useful.  These are some specific situations when it may be appropriate.


If during the first trance experience, the patient comments that he or she did not feel very relaxed, or not much different than usual, a deepening procedure is appropriate.  Consider the following method to address this problem:  The clinician can use a simple, slow countdown from 20 to 1, after the hypnotic induction procedure is completed, and the patient is into the body of the trance experience.  One might say,


“Now that the doorway to your unconscious is open, I am going to help you to go even deeper into relaxation and hypnosis by my counting slowly down from 20 to 1.  With each number that I count, you will find yourself going deeper and deeper into relaxation and hypnosis.  So, just listen to the numbers, let yourself go, and enjoy the experience of going deeper into relaxation and hypnosis.  As you go deeper, you will feel better with each number that I count. 20---19---18---17---16---ongoing to 1.


Because of its simple application, this deepening procedure is the preferable one to also use prior to the application of direct suggestions for change and learning.  When you have successfully taught the patient self-hypnosis have him/her go into a trance (as s/he has been practicing at home). Then, ask the patient to signal you with a head nod or hand or finger lift when he or she is ready to be "taken deeper".  Do the countdown with the dialogue above and suggest that the patient also countdown silently when he or she does his or her own self-hypnosis.  The goal is to further deepen the experience of relaxation and hypnosis.


It is important to note that the clinician does not have the patient verbalize self-suggestions during the early learning of self-hypnosis.  The patient is instructed as follows: “When you regularly practice your own self-relaxation or self-hypnosis, do not talk to yourself.  Just enjoy the deepening feeling of relaxation.  As you do this, the things that I say to you when we are working together here in the office will automatically be reinforced during your own self-hypnosis.”


Fractionation.  After an induction and deepening procedure, the patient can be “awakened” and then helped to go back into trance a second time.  If the patient has been taught self-relaxation or self-hypnosis, the patient can be asked to put his or her self back into hypnosis without the clinician's help.  This immediate re-induction of the Trance State is called "fractionation".  It is a very powerful deepening procedure, and helps the patient to recognize that, in fact, the patient can accomplish self-hypnosis on his or her own.


Choosing the Right Induction to Meet the Needs of the Patient


Anyone who practices hypnosis has their favorite inductions.  Choosing the induction best suited to the patient’s needs is important because it often prevents what is frequently described as "resistance".  The following general guidelines of "do's and don'ts" apply to induction choices consistent with BCH.



Table 12. Induction Choice Guidelines



  1. Choose short inductions. 


  1. Don’t teach self-hypnosis for single-session procedures.  If a behavior can be successfully changed in one or two visits, why do anything that may suggest otherwise?  Possible exceptions include such things as stress control skills such as "taking a few deep breaths" or other methods to induce Instant Relaxation.


  1. Avoid using an induction procedure that is full of requests for visualization for someone whose primary sensory processing system is not visual.


  1. If you visual images make sure that what you are suggesting the patient visualize is in fact what the patient is seeing.  Just imagine the myriad of possibilities when requesting a patient visualize a mountain! (or similar)


  1. Although the concept of visualization usually emphasizes “seeing” in the context of trance, it actually includes all of the sensory systems.  When suggesting such things as: "feeling the texture", smelling the rose", "hearing the rushing water" or "tasting the apple", the clinician is descriptively tapping into other primary sensory systems. 


  1. Choose an induction and trance experience that helps the patient to externalize thinking when dealing with pain or other physical, somatic, and medical problems. 


  1. When dealing with anxiety-related problems, or patients who have difficulty appropriately identifying or interpreting bodily messages, choose an induction that encourages the patient to focus inward.  The patient's difficulty in appropriately recognizing and interpreting the meanings of normal bodily messages may require extensive reframing in and out of the trance state.  Appropriate inductions may include concentrating on the breathing, an arm extension, or the fluttering of the eyelids.  An eye roll with the eyes closed may also be an excellent initial trance induction or trance deepening technique (Ewin, 1984, 1998).


  1. If one induction does not seem to be working, don’t keep pushing; choose another one and tell the patient: "Everyone is different.  All hypnosis is not the same.  Some approaches work better with some people, and other approaches work better with others."  The patient should feel comfortable with the induction being used.  If there seems to be a problem, give the patient permission to tell you what is going on.  For example, if the patient has physical limitations, such as a sore neck or shoulder, an arm extension induction would not be an appropriate one because of possible strain on the affected area. 


  1. Avoid asking the patient to do it for you, the clinician (e.g., "I want you to . . ."). 



Guidelines for Effective Trance State Suggestions--Basic Do's and Don'ts


During the Trance Induction and the Trance State, the language used by the clinician is critical in helping the patient's Unconscious Mind accept specific or even general suggestions.  The clinician further imprints or fixes desired changes in place during the trance experience.  In the practice of BCH, a number of basic principles or guidelines are followed in the verbal delivery of suggestions to the patient in trance.


Linking ideas.  Trance State suggestions are meant to reinforce positive behaviors and promote positive expectations for continued positive change.  The practitioner accomplishes this by linking positive changes already accomplished to the expectation of continuing positive change.  One thing that has already been accomplished is suggested as the basis for accomplishing something else that is related, but not yet accomplished.  For example, you might suggest:


"You did very well. You succeeded in staying calm when you were riled, which is proof of your progress in taking charge of how you feel and how you behave.  Now that you know that you can do this, you can continue to gain greater control from now on.  As we continue to work together, [Or, As you continue to experience progress,] you will continue to experience more and more control over your feelings and behaviors."


Verbalizing confidence and positive motivation.  When suggestions for behavior change are given, they are linked to the patient's key motivations for changing to facilitate their acceptance by the unconscious.  There is also verbalization of confidence that the desired changes will take place. Some examples:


"When you stop smoking today, as you will, your body immediately begins to heal itself and repair itself.  So, you find that you feel better and enjoy your life more with your improved state of health." 


"When you’re in deep relaxation, self-hypnosis, using the marble as the focus of your attention, what you’re doing is you’re enhancing your body’s ability to do what needs to be done, to send the necessary signals and messages and biochemistry to the areas that need to be helped to heal within your body, your mind and system.”  


Appropriate amount of repetition.  Suggestions are repeated several times, at different points during the trance state, with and without slight modification, to facilitate their imprinting into the patient's Unconscious. 


Positive phrasing.  Suggestions are phrased in positive as opposed to negative terms.  Patients are told what will happen, or what is happening, as opposed to being told what they do not or will not experience.  For example,


It is therapeutically effective to suggest: "Every day, as your body continues to heal, you will notice that you are feeling better and better and more and more comfortable." 


It would probably be less effective to suggest: "You will not feel as much pain."  The latter suggestion might be interpreted by the patient's Unconscious as "I will feel pain", minus the "not".


Time frames.  It is usually useful to place a time frame on suggestions, especially when you want to suggest the lessening or end of a behavior or experience.  So, for example, it might be therapeutically effective to suggest: "You no longer need to clench your teeth to release tension.  You now have other more effective ways of releasing tension."  On the other hand, to suggest "You don't need to clench your teeth to release tension", could be interpreted by the patient's unconscious as "I do need to clench my teeth to release tension" (minus the "not") because the dysfunctional coping mechanism of clenching had been imprinted in the Unconscious. 


Expectant time markers.  It is also useful to use time markers to prime, or prepare, the patient's Unconscious for the next suggestion, to build expectation, as in saying, "In a moment, but not just yet, I will ask you to allow your eyes to close". 


Present and future tenses.  Also, related to the issue of time frames, it is useful to make suggestions in the present tense and to link these with suggestions of what will happen, as long as these suggested changes are believable and desirable, hence, acceptable.  For example, "You are feeling more enthusiastic about exercising your new skills, and you have more energy as you do your job.  You will enjoy your job more and more as you exercise those new skills."


Precision.  It is helpful to be as precise as possible in delivering suggestions. This makes them easier to follow. In trance, the patient does not think critically or analytically.  The patient's unconscious processes not just the words themselves, but the entire flow and the feelings created by the suggestions.  Therefore, be selective about your choice of words.  This is what is meant by the concept of the "conscious use of self".


Keep it simple and concise.  Related to this last point, in the trance state, the clinician should give direct suggestions that repeat waking state suggestions in a simpler and more concise form. Suggestions should be limited in their scope.  Do not try to tackle too many problems at once.  Do not introduce entirely new areas for suggested changes during the trance state.  The patient's attention is narrowed.  Trance is a focusing mechanism.  Too much at once tends to unfocus and bring the patient "up" out of trance.


Don't try - Do it!  This brings up the issue of the use of the word "try".  "Try" is not a good word to use in either Waking State or Trance State Suggestion.  To "try" implies effort and strain.  One of the advantages of hypnosis and "trance work" is that it can bypass conscious effortful processing. So, to draw the patient's attention to "trying" sort of defeats this built in advantage of using the hypnosis tool!  Trying also implies "to attempt" and "to test".  Thus it implies the possibility of failure.  The practitioner does not want to direct the patient's attention to the possibility of failure on either a conscious or an unconscious level.  So, one should suggest “doing it” rather than “trying". 


Remove unwanted suggestions.  It is important to pay attention to remove unwanted suggestions. Make sure to suggest that when the trance state is ended, and the patient is "awakened" or "re-alerted", that the patient's normal state of “pre-hypnosis” conscious state will be restored.  Sensory or motor suggestion changes that had been used for trance ratification or deepening need to be removed.  A patient should not be leaving your office with an arm that feels "stiff as a board", "light as a feather", "buoyant like a balloon", or "totally numb"!  Don't neglect restoring your patient's pre-trance sensory motor status; however, this does not include removing desirable, changes in the patient's experience and behavior that are intended to continue after the trance state is terminated.  This refers to both "post-hypnotic suggestions" and "post-trance imprints".  You can suggest that the patient will continue to experience some comfortable relaxation for some period of time, while still active and alert.


Self-Hypnosis for Continued Problem Resolution


james_braid_200What is Self-Hypnosis?


Self-hypnosis is defined as the process by which a person intentionally self-initiates a hypnotic trance state.  Clinicians, and researchers, may label the experience the patient initiates as self-relaxation, self-hypnosis, or both.  The simple practice of “self-relaxation” may be considered self-hypnosis. The clinician usually teaches the patient self-hypnosis during a formal trance state experience.  As mentioned earlier, some procedures (inductions) are better suited for teaching self-hypnosis than others.  The choice of induction not only depends on the patient’s ways of processing information, but also on the goals established for the use of self-administered hypnosis.


James Braid, an eighteenth century Scottish Surgeon (1795-1860), who coined the term "hypnosis" as a replacement for the name "Mesmerism".  Braid wrote that “patients can throw themselves into the nervous sleep (hypnosis) and manifest all the usual phenomena of Mesmerism through their own unaided efforts” (Braid, 1843).  In fact, it has even been reported that Franz Anton Mesmer, the eighteenth century Austrian physician who is considered to have been the "father of hypnosis", and who was the inventor of the concept of "animal magnetism", even "mesmerized" himself to treat his own ailments (Gravitz, 1994).



Table 13. The Father of Modern Self-Hypnosis



The father of modern self-hypnosis is considered to be Emile Coue, a late nineteenth emile_coueand early twentieth century French pharmacist (1857-1926), who taught patients "Self Mastery Through Conscious Autosuggestion" (Coue, 1922).  Coue established some basic laws of autosuggestion including the "Law of Reversed Effect" defined above.  Coue further wrote: “Every idea which enters the Conscious mind, if accepted by the Unconscious, is transformed by it into a reality and forms henceforth a permanent element in our life.”  He conceptualized the process of "Autosuggestion" as consisting of two steps: (1) the acceptance of an idea and (2) it’s transformation into a reality.  He believed that this could happen through the process of repetition.


Coue specifically called his approach to self-suggestion "Conscious Autosuggestion".  That means that the Conscious Mind, during the waking state, is giving suggestions repetitively so that the Unconscious Mind will accept them and make them a part of the Unconscious.  He further believed that "all suggestion is autosuggestion".  Thus, the clinician can give the patient suggestions for change but, in order for that change to occur, the patient must take possession of the suggestions and make the suggestions his or her own.  Therefore, all suggestions that are accepted become autosuggestions.  This may not require the patient to frequently repeat these suggestions through self-talk, but only to accept the suggestions as the patient's own. Coue was the originator of the much quoted phrase, “Every day in every respect, I am getting better and better.”  It is often rephrased as “Every day, in every way, I am feeling better and better.”


The acceptance of an idea and that idea's transformation into reality, according to Coue, were accomplished by the Unconscious.  He wrote that whether or not an idea originated in the mind of the patient, or was presented by an external event, or another person (Waking State Reframing or Trance State?), made no difference.  In both cases, the idea is submitted to the Unconscious and either accepted or rejected.  Thus, the distinction between "Autosuggestion" and "Heterosuggestion", or therapist-given suggestion, was seen to be arbitrary and superficial.  More than just a few modern hypnosis clinicians, researchers, and scholars have maintained that all hypnosis is essentially self-hypnosis--that is, self-induced (Cheek, 1994; Erickson, 1948; Kroger, 1977; Sanders, 1991; Teitelbaum, 1965). 


Whether or not the hypnosis state, induced in the communication process between the clinician and patient, is essentially self-hypnosis, depends on whether or not the ideas submitted to the patient are accepted by the patient's Unconscious.  For this to be so, the clinician must use language in a form that can be accepted by the patient's Unconscious.  When the clinician uses the right language, it makes the hypnotic communication process much more effective.



When is self-hypnosis taught?  Self-hypnosis is not taught to the patient who is being seen for a single visit.  It is usually taught to the patient who is to be seen for a minimum of three or more visits.  The major purposes of teaching self-hypnosis are,


1.   to give the patient self-control that can be continued through self-administration, and thus, reduce the patient’s dependence on the clinician,

2.   to help the patient experience a greater sense of personal power over something that the patient has felt powerless about, and

3.   to reduce the cost of treatment by assisting the patient to continue self-treatment.


Some Important Considerations


There are four progressive processes and considerations that relate to the patient’s initial learning and immediate and ongoing utilization of self-hypnosis.  They are:


1.   The choice of trance induction. 

2.   Helping the patient experience and build a memory of simple relaxation. 

3.   The types of suggestions the clinician should administer during the initial teaching and patient learning of self-hypnosis. 

4.   How the patient can later use self-suggestions once he or she is comfortable with self-initiating and deepening the self-hypnotic trance state.


Choosing the "Right" Trance Induction


It is preferable to choose simple procedures for the induction and teaching of self-hypnosis.  They should be short and easy to learn without complicated instructions.  They should induce a trance experience that the patient will be able to repeat during his or her own self-hypnosis. 


The procedure should be practiced in a sitting up position with the patient's head supported if needed.  Patients should not be encouraged to practice self-hypnosis lying down and, generally, doing hypnosis work in the office with the patient in a lying down position is avoided. Rather, a comfortable arm chair is preferable (you can place a pillow to allow the patient to put his or her head back if that is most comfortable).  The patient sits back without slouching, with the feet flat on the floor.  The patient is encouraged to use a similar chair at home for practicing.  This helps the patient to be able to do self-hypnosis almost anywhere, without a special chair (generalization of the skill).  Lying down, on the other hand, usually leads to sleep and the use of a bed, sofa or recliner for self-hypnosis sessions is discouraged. If a recliner is used, it is suggested that it be in an upright position.


Not surprisingly, there are exceptions to the above and the clinician must keep an open mind. Some patients are more comfortable in other positions. Consider the following examples:


A patient with a bad back requested that she be allowed to lie on the floor and look up at the ceiling while experiencing hypnosis.  The hard carpeted floor was more comfortable for her.  In this case, an eye-fixation induction with added specific suggestions that “Your Unconscious Mind will know if you are about to fall asleep.  If that happens, your Unconscious will move your body slightly to alert you enough to maintain the trance state and not fall asleep.”  This is usually enough to prevent a sleep state from occurring.  This same suggestion can be used if the patient is sitting up during trance, and the clinician or the patient is concerned that the patient will fall asleep.


A patient diagnosed with fibromyalgia had a difficult time finding a comfortable position for the trance experience.  She asked if she could hug a pillow and curl up on the small couch in the office, with her head against the back of the couch.  This felt more protective to her, and she could move as much as she wanted.  She also tended to be very restless, and she would often feel the need to get up and walk around during waking state therapy.  She was pleasantly surprised that she could stay still so long while she was in trance. 


Often, patients who tend to be restless or "hyper" or may need to get up and move around often during talk therapy, are quite pleased with the hypnotic trance process, when they find that they are able to stay seated for longer than expected.


The above case examples illustrate that continued flexibility remains a very important ingredient in the practice of BCH.  Regardless of the preferred method(s), one must always be ready to adjust the approach based on the patient's ongoing feedback.  The above examples provide illustrations of how to be flexible in the design and choice of trance induction procedures whether in the office and/or teaching self-hypnosis.


Simple Relaxation


Simple relaxation is important for:


1.   the immediate effect it has on the patient and

2.   its experiential reframe allowing the patient to feel different and better 


This initial experience of physical and emotional relief is often the first good feeling, in a long time, with which the patient can identify.  Patients often verbalize that they have not felt “so relaxed” for many years, or even ever.  Because of this, the simple experience of relaxation may appear exaggerated.  However, this allows for the fixing in place in the patient's Unconscious of a powerful memory imprint that opens up further possibilities for change and symptom relief.  Simple relaxation is the first and primary goal; and, sometimes may be the only goal in teaching self-hypnosis to the patient.  When self-hypnosis is initially taught, it is usually labeled as "self-relaxation".  It may be described to the patient as the beginning way to:


1.   Reduce the emotional overlay that has made the patient’s problem worse.

2.   Imprint a memory of relaxation that can be repeated for continuing progressive relief. 

3.   Establish workable skills for evoking instant relaxation whenever the patient feels the need. 

4.   Interrupt the belief that the patient is "trapped" in dysfunctional feelings and behavior.

5.   Choose one or two 10 to 15-minute periods during the day when the patient can enjoy treating his or her self to a comfortable quiet time.


The values of "self-relaxation" are discussed with the patient during the waking state as part of the Waking State Reframing process.  It is also explained that the patient is to do no self-talk and not give self-suggestions during this learning and practice of self-relaxation.  The only immediate goal is to learn how to relax.  Being able to imprint and increase the feeling of relaxation establishes a foundation for future change.  When the patient is very relaxed, he or she cannot be tense, upset, uncomfortable, anxious, afraid, stressed or angry, since these are the antithesis of relaxation. 


Clinician Administered Suggestions


In BCH, after the initial simple relaxation period of learning, the patient may be instructed not to attempt to give self-suggestions when continuing to practice what is labeled as "self-hypnosis".  The rationale for this is to avoid a situation where the patient unknowingly distorts the clinician's suggestions when the patient self-administers them during self-hypnosis.  Furthermore, the effort involved in remembering what to say while in self-hypnosis, can often be counter-productive. It is explained that now that the patient has successfully learned to relax, and now that this experience of relaxation has been helpful, we are ready to enter into the "suggestions for change" part of the program. This is discussed with the patient in terms of suggestions that will be given by the clinician while the patient is in trance in the clinician’s office.  At this point, the patient doesn’t have to consciously listen to the suggestions or try to repeat them during the daily practice of self-hypnosis.  


The patient will often be told, "Your Unconscious will hear everything that I am saying without your having to listen".  "The very nature of your relaxation experience automatically reinforces those things that I say to you when you and I are working together".  Note the phrase "when you and I are working together".  This implies, in and out of trance.  These suggestions can be very powerful and liberating, and can often prevent any distortion of the suggestions given by the clinician.  They give the patient permission to stop worrying about making mistakes or unknowingly saying the wrong things.  They also help the patient who is somewhat obsessive to avoid obsessing about the language used to bring about change.


A very powerful reframing suggestion is also given during the trance state that reduces or eliminates the patient’s concerns that "because previous attempts to change may not have worked, why should this approach work?"  When the patient is in a satisfactory trance state, and the clinician is starting to give suggestions for change, the following may be said first:


“This deep and comfortable level of relaxation that you are experiencing now is called the NEUTRAL STATE or the HEALING STATE.  This is when the doorway to the Unconscious opens and the Unconscious can accept suggestions for change.  But, we can’t go directly from negative to positive.  That is too much of a leap.  That is why you may not have been as successful before.  In order to make the transition we need to go from negative to neutral. When in neutral, everything is in balance.  There is no wasted energy on stress or distress. All of the energy of mind and body is in balance, and available to the mind-body system to be used as an energy resource, for change, and to build a memory of deep relaxation that you can borrow back every time you do your own relaxation, your own self-hypnosis.  This allows the movement from negative, to neutral, and then to positive.”


This approach fosters a collaborative team effort between the clinician and patient.  While the patient is learning self-hypnosis skills, the clinician initially takes the role of "director of change" and "administrator of suggestions".  This approach allows the patient to focus on a single achievable goal.  The patient's growing skill in "shifting into neutral" also adds to a growing self-confidence that encourages the continued practicing of self-hypnosis and learning more skills for change.  This has strong ego building and "ego strengthening" characteristics (Frederick & McNeal, 1999; Hartland, 1965, 1971).


Patient Administered Suggestions


By the time the patient becomes proficient and comfortable practicing self-hypnosis without self-talk, many of the presenting complaints, dysfunctional feelings and behaviors will have been reduced in intensity or eliminated entirely.  This may be the result of several interacting factors. 


Marked alterations in the relative balance between sympathetic and parasympathetic nervous system activation and dominance appear to be associated with specific physical and psychological symptoms of pathology (Humphreys & Eagan, 1999), including the perpetuation of anxiety, depressive, and chronic pain disorders (Eimer, 1988, 1989; Eimer & Freeman, 1998; Melzack, 1999; Turk & Flor, 1999).  Proficiency in practicing self-relaxation and self-hypnosis apparently leads to increased control over the autonomic nervous system and decreased sympathetic dysregulation and hyper-arousal (Benson, Arns, & Hoffman, 1981; De Pascalis, 1999; Edmonston, 1981; Humphreys & Eagan, 1999; Oakley & Halligan, 2010). 


Relaxation is the opposite of stress, pain, anxiety, rage, and depressive states.  A person cannot be relaxed and feel distressed at the same time.  Learning self-relaxation and self-hypnosis is associated with increased thoughts and feelings of self-efficacy, self-control and the feeling of being "in charge" of oneself.  "Self-efficacy" has been shown to account for a significant portion of the main treatment effects variance in psychophysiological treatment studies (Bandura et al., 1987; Blanchard et al., 1993; Eimer & Freeman, 1998; Gatchel & Blanchard, 1993).


The experience of symptom exacerbation as a consequence of "emotional overlay", which is partly associated with autonomic imbalance and dysregulation, is a real one to which clinicians should pay close attention. By doing so, the negative elements left are much easier to deal with.  In the same way that positive suggestions sequentially attached to real experiences imply the reality of those suggestions, multiple negative symptoms attached to each other suggest that negatives are the only feelings and behaviors to expect.  As the negatives are reduced or eliminated, this previous belief system is easily changed to positive expectations.  The next natural step is the patient self-administering these positive suggestions.


There are specific positive suggestions for specific disorders and these are beyond the scope of this course (See Resources).  However, it is important to frequently evaluate the patient’s progress and re-establish treatment goals.  This will lead to giving the patient specific suggestions to be verbalized prior to his or her self-hypnosis sessions.  These suggestions should be verbalized as positive rather than negative.  They should be worded to suggest positive outcomes rather than be worded to suggest not doing or not experiencing something. As an example, the clinician might avoid having the patient self-administer the suggestion “I will not feel pain in my shoulder.”  It would be more effective and better to have the patient say “I will enjoy feeling more comfort in my shoulder.”  One should avoid suggesting to the patient to not do something.  This is because the harder we try not to do something, the more difficult it becomes not to do it!  Remember Coue's (1922) "Law of Reversed Effect".  For instance, try not to think of a pink elephant.  Or, try not to notice, or try not to scratch that itch on your nose, or, try not to blink your eyes as you read this!


Self-suggestions before entering self-hypnosis.  When patients are ready to give themselves self-suggestions during their practice of self-hypnosis, they are instructed to do so before they self-induce the hypnotic trance state.  One method is to help the patient write down specific suggestions that relate to the realization of specific change goals, or to a specific dimension of the patient's experience that the patient wants to modify.  The patient is then instructed to read these suggestions before entering self-hypnosis.  For example, before self-inducing hypnosis, the patient could read from an index card, "I control my anger [or, "I will (or can) control my anger"] and stay calm and in charge when my wife criticizes me" or "My shoulder feels really comfortable when I rest it, and when I move it".


By reading pertinent, goal-oriented suggestions three or four times before entering self-hypnosis, as opposed to doing self-talk during self-hypnosis, the patient's Unconscious is freed to "do its work" during and after the practice of self-hypnosis.  This uncomplicates the utilization of self-hypnosis for change purposes.  It provides a simpler way for the patient to communicate with his or her own unconscious mind.


General Guidelines


The experienced clinician may have his or her own favorite trance induction methods.  That is not a problem as long as the general guidelines that were established for the practice of BCH.  In summary they are:



Table 14. General Guidelines for Trance Induction in BCH



Use short uncomplicated induction procedures.


Do not teach self-hypnosis for single-session procedures such as smoking cessation, or simple habit extinction.


Utilize the initial learning of self-hypnosis for relaxation only.


Initially, do not add any self-talk or self-suggestion to the self-relaxation/self-hypnosis procedure. In some cases, the clinician may decide that self-suggestions are not necessary.


Pay attention to, match, and utilize the patient's unique and individual language and sensory systems.


Choose a hypnotic induction procedure that is either internally directed or externally directed based on your assessment of the patient's presenting problem and needs.


Make sure that the patient can give you feedback about the comfort of the chosen induction procedure and experience.


Encourage patients to practice self-hypnosis regularly (usually 10 to 15 minutes twice a day; e.g., once in the morning before breakfast and once in the late afternoon or early evening before dinner). It is better to practice self-hypnosis on an empty stomach.  If the patient regularly exercises at a fixed time during the day, it is better to do a self-relaxation before exercising rather than after.  After exercise, the process of adrenaline pumping is still going on, and this makes self-relaxation more difficult to achieve.



The Use of Tapes or Recordings   


In the following discussion the use of the terms “tapes” or “tape recording is used”.  Of course, tapes are rapidly becoming a thing of the past with digital records, etc.  The term “tape” or “recording” will be used for simplicity and this may take any form (even audiovisual).


Many clinicians who teach and utilize self-hypnosis with their patients make tapes or recordings of sessions that they give to the patient to use at home.  They may feel that this is a valid vehicle for the patient to use to enter into hypnosis.  Those who use tapes often describe that their value lies in having the patient listen to the clinician's voice giving the specific suggestions for change that were given during the office session.  The clinician may even make new tapes during subsequent sessions that are then given to the patient to replace the previous ones, or as part of a history (or record) of each progressive session.  However, this may be giving too much information to the patient that may cause too much obsessing and intellectual evaluation of the process of treatment, and not allow the Unconscious to do its work. 


Other clinicians encourage the use of selected commercial tapes (digital downloads to the patient’s smartphone or maybe an “app”) that are geared primarily for relaxation and that have some special sounds or music in the background.  They are usually selected to meet the unconscious needs of the clinician, especially when there is a musical background that the clinician finds relaxing.  Most clinicians have their personal favorite music and sounds.  There probably are as many different individual favorites as there are clinicians!  The patient may not have the same favorites.


Suggestions for the Use of Recording


In BCH, recordings are rarely used. "Rarely" means sometimes, but not often. When they are used, they do not include music.  Music may or may not help with relaxation, depending on the patient’s own musical tastes and auditory propensities.  Also, music is not always available when it is important for the patient to practice self-hypnosis in a setting other than their quiet home.  Some reasons for rarely using recordings are:


Patients change, tapes do not.  Each time the patient initiates self-relaxation or self-hypnosis, some subtle or significant change takes place.  Suggestions, which may have been valid when given in the office by the clinician, may no longer be valid the next day.  Continued use of a tape containing suggestions given during the first induction and self-hypnosis training session in the office may prevent change by regressing the patient back, during each subsequent use of the tape, to when the patient was in trouble.  This can produce a cycle of progress -– regress.  This is also why we often start with no self-talk during the patient's self-relaxation/self-hypnosis practice.


Tapes require special equipment and supplies and special settings.  If the patient uses tapes, the patient does not learn to do self-hypnosis as a self-contained, self-initiated independent process, but becomes dependent on the clinician's voice and the equipment to transmit it.  This means that the patient’s own power of imagination is limited to the words of the clinician on the tape, and this establishes further dependency on the clinician. 


Commercial recording are not individualized.  Generic commercial tapes are intended to be all things to all people. They are not individualized to meet the unique needs of the patient in terms of sensory system learning and change language that will be easily accepted by the patient's unconscious mind.  Furthermore, they are often too long and too repetitive causing the message to become redundant after more than a few minutes.  Such redundancy can paradoxically negate the acceptance of the suggestions by the patient's Unconscious!


Special Circumstances 


Tapes or recording may be used for special circumstances.  For example, if an anxious patient has an impending trip, and must travel before complete anxiety control training is complete, the patient may be given a specialized relaxation tape (or digital recording on the phone, etc) that is custom made for the patient; however, it is not recorded during a therapy session.  This recording can be used with earphones while flying or traveling in some other commercial means of transportation about which the patient is anxious.  This would certainly go unnoticed in this day of smartphones, MP3 players and Ipods.  If the patient is taking a difficult examination away from home, or participating in an anxiety-producing work situation away from home, a special recording for use before the examination or meeting might be made.  This could be used the evening before and/or shortly before the event. 


In BCH, recordings are produced specifically for a limited group of individual patients and are for a specific time-limited purpose.  They are individualized.  Even so, suggestions that allow the patient to change are contained on the recording to be reinterpreted based on unconscious changes. To achieve this, we add certain suggestion phrases at the end of the tape.  The following is one example:


"As you continue to grow and change, the meaning of my words and suggestions that you hear on this tape will also change.  Though the words may be the same, the meaning of those words will be different.  They will continuously change, and be interpreted by your Unconscious to meet your changing needs."


Common Factors in Dysfunctional Behavior


Most patients who present for psychotherapy and hypnosis feel significant loss of control. Consciously, the patient may be aware that a particular behavior or symptom is dysfunctional, self-defeating, distressing, or harmful, but the patient feels helpless, or powerless to change it.  The dysfunctional behavior or feeling may have originally been imprinted in the Unconscious as the result of some traumatic experience, and through repetition, further imprinted.  The Unconscious continues to repeat the dysfunctional behavior or feeling, and it becomes a habit, because the Unconscious does not have enough information to judge the behavior as no longer necessary, or as invalid.


If the patient consciously knows that the behavior or symptom is undesirable (i.e., "ego-dystonic"), but the patient's Unconscious does not have the data or information to invalidate it, then this results in an incongruity between the Conscious Mind and the Unconscious Mind that controls the behavior or symptom.  The Conscious Mind "knows" that the behavior or symptom is undesirable, but the Unconscious Mind does not know this. 


Such an incongruity can produce a “pathological double bind” that manifests as psychological conflict, and causes further dysfunctional thoughts, feelings, and behavior.  Then, the patient becomes "frozen" in the dysfunctional way of thinking, feeling and acting because of a conviction of being trapped.  The underlying belief is that there are no choices, so "I am dammed if I do, and dammed if I don’t".  Here the proverbial saying, "being caught between a rock and a hard place" also applies.


In a "pathological double bind", the uncomfortable, debilitating, symptom behavior continues because the patient is trapped into believing that this behavior, which is a negative coping mechanism, is unchangeable.  However, it is the only choice the patient has because of the patient's belief that there are no other choices.


From the perspective of BCH, all "bad", dangerous, or self-destructive behaviors, most psychosomatic symptoms, and all dysfunctional behaviors are precipitated and maintained by pathological double binds.  These double binds are essentially internal miscommunication systems.


The Conscious Mind is aware that something is wrong, but can’t help it.  The Unconscious Mind is unaware that something is wrong, so continues to perpetuate it.  In fact, the Unconscious Mind may be maintaining the problem feelings and behaviors in the belief that the dysfunctional behavior is an appropriate coping behavior.  Remember that all behaviors are both a form of communication as well as a way of coping. 


At first, the coping behavior choice may have been temporarily appropriate.  However, as it was repeated for its palliative value, it changed and evolved by repetition into a less palliative dysfunctional coping behavior.  The original precipitating cause of this choice of coping behavior is no longer occurring, but the behavior has taken on a life of its own.  It has now become imprinted as the behavior of choice because the Unconscious Mind is unable to re-evaluate it and thus discard it.  The dysfunctional behavior has been transformed into a habit.  Habits are created by repetition. The unconscious does not judge whether they are good or bad, or their appropriateness, except if they are life threatening.


The Original "Double Bind" Theory


The "Double Bind" Theory was originally introduced by Bateson et al. (1956) to describe the paradox established by certain unresolvable sequences of experiences confronting an individual in that individual's family interactions or primary interpersonal context (Sluzki & Ransom, 1976; Walrond-Skinner, 1986).  The concept was further elaborated by Watzlawick, Beavin, & Jackson (1967).  These clinical researchers proposed that these situations were "schizophrenogenic" because they placed the individual in a "no-win" situation in which whatever that individual did in response to the authority figure's communications and injunctions was defined as "bad".  As Laing (1965) stated, the individual, which he described as a "divided self", was "mystified" and this "mystification" led the conflicted individual to develop unconventional communication habits that were appropriate or adaptive in that "crazy-making" context. 


In this model, schizophrenia was not seen as an intrapsychic disturbance primarily caused by a biochemical imbalance or genetic factors.  It was seen to be interpersonally induced primarily through a dysfunctional socialization process in which a person was bombarded by continuous, manipulative, and mixed communication messages by family authority figures.  The schizotypal behavior was posited to develop as an appropriate coping response for dealing with the conflict generated by ongoing, incongruent communications.  Such a paradoxical assault on the developing individual's psyche could only be handled if the individual constructed a separate reality.  This "separate reality" then gives rise to accompanying coping behaviors which, in that original "impossibly" conflicted context, were life saving for the recipient of the discordant and "crazy-making" manipulations.


Beyond Schizophrenia


Modern research on schizophrenia has discovered many biological influences (etiologies) to the disorder and these will not be reviewed here. Even so, the idea of the Double Bind is useful “beyond schizophrenia”. 


BCH recognizes that this concept can be extended to understand the origins of most dysfunctional, fixed behaviors and beliefs.  The experience of being trapped in dysfunctional feelings and behaviors is associated with the belief that there are no other viable choices.  This belief structure perpetuates those feelings and behaviors.  It also creates a closed feedback system of internal miscommunications that fixes in place rigid beliefs that give rise to the patient's distorted world view and internal reality.


In his seminal work on "Personal Construct Psychology", George Kelly (1955) posited that all behavior represents a test of the validity of a person's personal construct system.  According to Kelly, a person's personal constructs (what might be called concepts or beliefs) are the "lenses" or "dimensions" or "channels" through which the individual sees or understands "reality", and anticipates and makes predictions about events.  This conceptualization was further extended in the theoretical work of Powers (1973) who proposed a cybernetic feedback model in which behavior serves to control perception (and personal beliefs).


According to these models, and others, particular beliefs lead to specific behaviors that are unconsciously chosen to confirm those beliefs.  In turn, a person's perceptions and feelings are seen to be determined by his or her beliefs and experiences in the world acting on those beliefs.  When the predicted outcomes of particular behaviors do not occur, the discrepancy between the construing person's beliefs and predictions and the actual outcomes can create cognitive dissonance (Festinger, 1957).  People are intrinsically motivated to resolve or avoid such dissonance because it is unsettling and uncomfortable.  One way that it is often avoided is by reinterpreting the outcomes to fit the original beliefs and predictions.  It is usually harder to change the beliefs themselves.  However, it is often necessary, and hence adaptive to do so, when "reality" does not turn out as "anticipated" or predicted.  This is why the technique of reframing is so useful and important.


In the view of BCH, most of the choices people make are not conscious choices, but unconscious ones.  These unconscious choices either lead to coping well and feeling relatively good or to coping poorly and feeling bad.  In BCH, all behavior and symptoms are an expression of the attempt to cope. 


Beliefs, feelings, and coping behaviors, dysfunctional or otherwise, are imprinted in the unconscious through the processes of repetition or trauma.  Dysfunctional beliefs, feelings, and behaviors (symptoms) can be changed through the appropriate application of Waking State Reframing and these therapeutic changes can be fixed in place through hypnotic trance work. 


The Illusion of Alternatives


Beliefs can be changed and that is the purpose of reframing.  Reframing involves changing beliefs that are discordant thinking processes. In addition to reframing, pathological double binds can be changed by establishing "therapeutic double binds", which are also reframes.  Therapeutic double binds maneuver the patient into a situation and new belief system in which the patient cannot lose. Instead of feeling "damned if you do, and damned if you don’t”, the patient is helped to experience “I win no matter which choice I make”.  In a "therapeutic double bind", the patient is “changed if he or she does what the clinician suggests or directs and changed if he or she does not”.  This is called the "illusion of alternatives" and was an integral part of the therapeutic approach of Milton Erickson (Haley, 1986).  The "illusion of alternatives" was a part of many of Erickson's hypnotic trance inductions (Erickson, 1980a; Erickson, Rossi, & Rossi, 1976; Havens, 1992).  For example, he often gave patients the choice of "going into trance now or going into trance later".


Rules for Constructing Therapeutic Double Binds


Some basic rules apply to the construction and use of therapeutic double binds. They have to do with:


the choice of appropriate language and trance induction methods


the effective utilization of the "illusion of alternatives" to limit the patient's number of choices to a few therapeutic ones


the appropriate use of the reframe, “You are only trapped if you believe that you have no choices"


the appropriate use of the reframe, “We only pay attention to events.  We don't pay attention to non-events"


the appropriate reframing of the "illusion of absolutes"


Choice of language and methods of induction.  Most trance induction language contains the makings of a series of small double binds that nudge the patient into the trance-state. Each suggestion contains double level requests that tell the patient not to do something, while at the same time, implying that something will happen even while the patient tries not to make it happen. For example, the patient is asked to voluntarily look at an object, and involuntarily experience eyelid fluttering and heaviness.  The patient is asked to "pay attention to your breathing, but try not to change your breathing" and the breathing changes involuntarily.  Then, the patient is asked to be aware of the changed breathing that occurred automatically.  This attention to a change in behavior that was not supposed to be consciously willed by the patient, ratifies that the altered state labeled "trance" actually exists and is occurring.


The practitioner might say to the patient “I am not doing this to you.  You are doing this to yourself.  I’m just a guide, teaching you how.”  So, the patient is being told not to try to relax and that the patient, not the clinician, is bringing about the relaxation.  This paradoxical statement "don’t try, but you will do it anyway" is a therapeutic double bind that is a part of all hypnotic trance induction procedures and well-constructed trance language suggestions.


Remember the example, "Try not to think of a pink elephant".  The harder you try not to do so, the more you become preoccupied with thinking of a pink elephant.  So, if a patient is being instructed to relax, and there appears to be eye fluttering, but no eye closure, an appropriate request might be, "That’s very good.  Now, try not to close your eyes, let them close all by themselves". 


Limit the choices (The "Illusion of Alternatives").  In parenting, if often works best to limit a children’s choices when offering suggestions for learning or providing direction (e.g., telling them what they should do).  The more choices a person has, the more difficult it is to make a decision. For example, when a child is encouraged to go to bed, and doesn’t want to go to bed, the parent may say, “Okay, then I am going to let you decide.  You can go to bed now, but you don’t have to go to sleep right away or you can go to bed in fifteen minutes, and go right to sleep.  You choose.” Or the parent may say, "Do you want to go to bed at a quarter to eight or eight o’clock?"  Usually, the child makes a choice.  Either choice is acceptable to the parent, but the child believes that he or she made the decision.  In fact, the child did make the choice, but because the choices were limited to only two alternatives, and they were both acceptable, this was a win-win situation for both the parent and the child.  Of course, the command “you are going to bed now and you will go to sleep.  If you do not, you will be punished” does not generally work out well.


Appropriate us of reframe: "You are only trapped as long as you believe you have no choices.”  Many of us were brought up believing that determination and will-power can solve most if not all problems.  Many of us were taught that if we are determined to solve a problem, or accomplish a goal, that we should keep at it, and eventually we would succeed.  Thus, goes the old adage, “If at first you don’t succeed, try, try again”.  However, if something isn’t working, continuing to repeat what isn’t working, to try and try again, isn’t going to make it work any better. Therefore, it would have been better if we were taught that “If at first you don’t succeed, try something different”. This principle requires the recognition that there are choices.  By making a new choice, we are no longer trapped.


Patients usually come to the clinician feeling trapped.  Their prior choices that didn’t work helped maintain and strengthen their trap.  The therapeutic choices that didn’t work further fixed the trapped feelings and beliefs in place (previous “failed” counseling, etc.).  Often you, the current clinician, may be the patient's latest and last therapeutic choice.  Therefore, it is very important for you to have as much information as possible about what the patient's previous unsuccessful choices were, and what actions were taken that did not work. 


It is your job to help the patient realize that it is time to try something different.  You do this by helping the patient understand that the patient's previous choices didn't work as well as the patient would have liked.  Now, the patient has made another choice--to see you.  You need to help the patient realize that the patient still has the power of choice, and that you will help the patient to be aware of other choices, and to make new choices, and by doing so, to find a way out of the trap.


Appropriate us of reframe: “We only pay attention to events.  We don’t pay attention to “non-events.” We usually only pay attention to something when it is happening.  For example, we pay attention to things like when we are smoking, biting our nails, pulling our hair, getting angry, experiencing pain, etc.  We usually pay no attention when these and other negative habits, or dysfunctional feelings and behaviors, are not occurring.  This normal process of "selective attention" can be adaptive, but it also gives rise to "selective memory".  That is, if we have a problem, such as with handling anger constructively, selective attention can lead us to focus solely on and remember only when we have blow-ups or experienced temper tantrums, and not notice or remember those occasions when we did not.  So, we are deprived of the positive reinforcement and validation that comes from "catching ourselves being good".


To address this issue therapeutically, another type of therapeutic double bind can be established which has been termed a "Perceptual Contrast".  In BCH, the patient is helped to become aware of the fact that he or she has been paying attention to the problem or symptom when it has been happening, and not when it has not been happening.  Often, it is not happening more often than it is happening!  For example, most smokers spend more time each day not smoking than they do smoking.


Similarly, many chronic pain patients present with the absolute belief that their persistent pain is constant (Ewin, 1992).  However, in most chronic pain states, the nature and quality of the pain frequently changes (Eimer, 2000a; Eimer & Freeman, 1998).  It either comes and goes, or goes up and down in intensity.  Understandably, most chronic pain patients mainly pay attention to their pain when it is present and strong.  Therefore, as one part of the therapeutic process of helping them manage their pain better, BCH draws their attention to the less painful intervals in between the more painful intervals, utilizing Waking State Reframing and Trance State Imprinting. 


Using BCH, the suggestion that the patient's less painful or more comfortable times will be extended, and that the painful episodes will shrink or diminish in duration and/or intensity, can be imprinted (Hypnotic time distortion and sensory alteration: Brown & Fromm, 1987; Eimer, 2000a; Erickson, 1980b; Hilgard & Hilgard, 1994).  These hypnotic strategies represent the imprinting of a "Perceptual Contrast" in the patient's Unconscious. 


Redirecting the patient’s attention to such perceptual contrasts can create a paradoxical message that can be a very powerful reframe.  After all, the patient doesn’t always do or experience these dysfunctional feelings and behaviors.  By only being aware of when they are happening, and not being aware of when they are not happening, an “Illusion of Absolutes” is created, which needs to be changed in order for positive change to take place and continue.


The "Illusion of Absolutes”.  Often, patients verbalize to the clinician things like:


“I always feel pain”

“I never get any sleep”

“I’m always feeling hungry”

“We are always fighting”

“I’m never happy”

 “I can never relax”

“I always have a cigarette in my mouth”

“This has been going on forever” 


Notice the use of unconditional absolutes in each of the above statements.  They are the words that are underlined, words like "always", "never", and "forever".  This concept is not unique to BCH but is always a core principle for cognitive behavioral therapy, rational emotive therapy, etc.


The "illusion of absolutes" is the ultimate pathological double bind.  Yet, “the only absolute is that there are no absolutes!”  This is a very powerful reframe that, when combined with the reframe that "we only pay attention to events", is an excellent "double wammy" that can impact positively on the patient’s belief system about being trapped.



Case Example. The Nail Biter



A patient was referred to a clinician by his physician to “help him stop his long-standing behavior of nail biting”.  This was a 53-year-old male who had retired early from his work and moved to Arkansas with sufficient money to live very comfortably.  During the intake evaluation, it was discovered that his mother and his younger brother also bit their nails.  He said that "I've bit my nails for as long as I can remember”.  When asked, "Can you remember if there was ever a time when you did not bite your nails?" (Questions contain embedded suggestions), he suddenly remembered that 15 years ago he had gone to see a therapist for hypnosis to stop smoking and that he hadn’t smoked since.  However, he had not remembered until just that moment in the interview that he had also stopped biting his nails for a whole year, even though he did not remember the therapist making specific reference to his nail-biting behavior.


This positive recovered memory opened the door for the two reframes, that "there are no absolutes" and that "we only pay attention to events, we do not pay attention to non-events".  The clinician commented, “Can you remember other times when you are not biting your nails?”  [Note the you are not present tense that was used as an embedded suggestion.]  The reframe, "we only pay attention to events and don't pay attention to non-events" was delivered to the patient by asking questions such as, “Do you bite your nails while you are asleep?”, “Do you bite your nails while you are taking a shower?”, “Do you bite your nails while you are cooking dinner?” (He liked to cook), etc.  The patient answered with either “I don’t think so” or “No.”  This further reframed the "illusion of absolutes" to an agreement that he bit his nails often but not always.


It was then explained to the patient that, without realizing it, the patient had expressed that he had a memory in place, that was working and operational, that indicated that "there are times throughout the day and night when I do not bite my nails”.  It was then explained that his nail biting was an "empty habit" that was only continuing by habit, and not because of need.  So, the patient was told that it would be easy to remove without having to replace it with something else.


The details of the induction procedure and the change language employed during trance will not be reviewed here.  However, the patient did not continue to bite his nails after the conclusion of the trance experience.  The Waking State Reframing process that took place prior to the trance induction and trance experience was essential to helping the patient recognize that he no longer had to be trapped in his pathological double bind.  There were other choices, and making a choice worked for him.



Patient Trust


Why should the patient believe that choosing you and your therapeutic approach will work any better than what the patient has done before? Helping the patient to believe that the choices for change that you offer are different from the previous ones that didn’t work is an ongoing process that starts during your first contact with the patient (and is very important if the patient is to schedule a second appointment).  As discussed, the intake process involves utilizing the patient's primary representational and sensory systems of learning, the language of choice, and the process of Waking State Reframing.  Different trance induction methods, and how to choose the best one to use in a given situation, has also been reviewed.  When and how to teach self-hypnosis, and when not to, has also been explained. It has been suggested that the simple and new experience of relaxation is often powerful enough to establish a belief that change is really possible, this time. 


In every step along the way, the patient is offered suggestions and demonstrations that progressively reframe beliefs and experiences, and provide credibility that this clinician’s approach makes sense and offers hope.  Under these conditions, a positive patient-clinician relationship is established.  This relationship is the foundation for the development of trust, and trust is a key ingredient in efficient brief therapy.


Every interaction and communication between the patient and the clinician must be recognized consciously by the clinician as being therapeutic.  Everything said is important.  There is no such thing as casual conversation.  This is what we mean by the clinician's "conscious use of self".  Every question that is asked of the clinician, even if it seems innocuous, has meaning and significance in the patient’s conscious and unconscious search for solutions and trust.  Likewise, every question asked by the clinician has meaning and significance to the patient.


Earlier case example.  Earlier, the case of the patient of Dr. Jones who had been referred "to learn how to relax" was discussed.  At first, she did not respond to the procedures offered by the therapist. She was unable to allow herself to experience a relaxed state.  When questioned further as to what Dr. Jones said when making the referral, she explained that Dr. Jones told her that it was "impossible" for her to relax so he was sending her to this therapist "to learn how to relax".  That iatrogenic, physician induced, powerful suggestion was a paradoxical communication that forced the patient into a double bind.  She couldn’t relax because Dr. Jones said it was impossible for her to do so.  At the same time, she was told that she would relax by visiting the BCH practitioner. This contradiction, in effect, “froze” her in place.  However, once Dr. Jones's true intent was examined, and after the patient accepted the reinterpretation (reframing), she now had a new choice.  She was no longer trapped by the pathological double bind: Relaxation was now seen to be both acceptable and possible.  The ensuing process of hypnotic trance induction, deep relaxation, and learning of self-hypnosis, validated her new belief and trust in the practitioner and exposed the real intent of Dr. Jones, her referring physician.


The Power of "Dysfunctional Labels"


Another equally important common factor in dysfunctional behavior has to do with the need that many mental health professionals have to label each dysfunctional behavior as unique and different. While this does allow the establishment of formal diagnostic categories, as compiled in the American Psychiatric Association's DSM-IV (APA, 1994), and it often legitimizes insurance coverage of psychotherapy, it also has its downsides.  It leads clinicians to employ diagnostic labels that can become dysfunctional.


Dysfunctional behaviors are often labeled and categorized as distinct “mental illnesses” having specific characteristics, along with sub-categories (more labels).  In the view of BCH, this often unnecessarily complicates and obfuscates the diagnostic and treatment planning process.  This can happen in several ways. The clinician or therapist feels that it is necessary to place a diagnostic label on the patient and this may not be therapeutic, or even anti-therapeutic.  Many of these labels (e.g. Borderline and Narcissistic Personality Disorders, Addictive Disorders, Dissociative Disorders) are associated with the expectation that the patient cannot be helped to change; or, that for change to occur, extensive personality restructuring is required that can only be accomplished with expensive long-term psychotherapy. 


Such diagnostic labels often have negative or pejorative connotations that can lead a patient to develop rationalizations for not changing (e.g. he or she has or is a “Borderline”or "Addictive” personality).  Such labels are often a source of demoralization for patients and therapists. After all, why bother working at changing if one cannot?  Why bother with expensive therapy that will make little difference in the end? Patients who accept such labels may develop excuses for not changing and maintaining the status quo.  Therapists who treat patients who are labeled as such often become "burned out", since their expectations are that therapy will be long, complicated, difficult, and in the end, likely ineffective.


This type of dysfunctional diagnostic labeling sets up the need to require specific, ritualized, mechanistic treatment protocols for each major diagnostic category of dysfunctional behavior.  For example, phobias require ritualized systematic desensitization procedures (for examples, see Wolpe, 1982; and Hope & Heimberg, 1993).  Borderline Personality Disorders require long-term, intensive, insight-oriented, dynamic psychotherapy incorporating ritualized treatment procedures (e.g. see Clarkin, Yeomans, & Kernberg, 1999), or long-term, intensive, cognitive-behavioral psychotherapy incorporating complicated treatment protocols (e.g., see Linehan, 1993). In addition, many dysfunctional ritualized behaviors are treated by setting up and substituting other ritualized behaviors.  In some cases, these mechanistic treatment protocols are as complex, or more complex, than the labeled and categorized dysfunctional behaviors.  For example, Obsessive-Compulsive Disorders might require more intense rituals for controlling thinking and actions (e.g. thought stopping, exposure, flooding, and response prevention protocols; see Kozak & Foa, 1999 and Steketee, 1996).


Evolved Negative Coping Mechanisms


One of the main theoretical constructs of BCH is that many complex dysfunctional behaviors involving compulsivity and avoidance are basically negative coping behaviors that have evolved over an extended period of time from simpler less complex attempts to cope.  This evolution into increasingly complex and more debilitating symptoms may have been driven by frequency of repetition, generalization, emotional intensification, and developmental maturation. In many cases, these evolved, complex, matured complaints may have been further exaggerated by futile attempts to apply complex, ritualized, mechanistic treatment protocols to change them.  The reframe, "the harder you try, the more difficult it becomes", might therefore be re-phrased as "the more complex the treatment, the less likely the outcome will be successful".


Hans Selye’s Concept of the "Fight-Flight Mechanism"


selye_imageThe Austrian-born research endocrinologist, Hans Selye (1907-1982) offered the "Fight-Flight" model to explain the automatic survival mechanism that is a programmed part of all of us.  According to Selye (1974, 1976), our nervous systems are biologically "hard-wired" to respond to anything perceived as a danger or threat, with an automatic response that prepares us to either fight to protect ourselves, or flee to escape from the source of the perceived threat.  This physical-chemical-mental response to a stressor is called the "Fight-Flight Mechanism".  The biochemical infusion of adrenaline following an interpreted signal of danger, creates an anxiety-driven reaction that mobilizes the organism to either fight or escape (flee), to protect the organism.  Thus, a response of anger to a perceived stressor can be interpreted as the "fight" part of the "Fight-Flight Mechanism" and a response of fear-based avoidance can be interpreted as the "flight" part.


Selye also developed the concept of the "General Adaptation Syndrome" or "GAS".  This theoretical model described the stages of any living creature's adjustive responses to a stressor.  According to Selye, the GAS consists of three stages:


(1) The initial "alarm reaction"

(2) the intermediate "stage of resistance"

(3) the final "stage of exhaustion"


The "Alarm Stage".  The initial "alarm reaction" is a call to mobilize the body’s defenses (i.e., the Autonomic Nervous System and Immune System).  It is automatically triggered when an organism first encounters a stimulus strong enough to demand adaptation and change.  This is what is meant by a "stressor".  For example, when a person goes out into a blisteringly cold, snowy day, the first reaction to the biting cold, which is a stressor, is an "alarm reaction".  Other examples of stressors would be when a person is yelled at, or verbally or physically assaulted or threatened.


The "Resistance Stage".  Gradually, the human body adjusts to the cold stressor and produces its own heat to bring about adaptation, maintain homeostasis and comfort.  This is the "stage of resistance".  If the individual does not stay in motion, or move out of the cold, by donning a warm coat, building a fire, or going inside where it is warmer, then the body cannot continue to produce enough heat to offset the loss to the cold air.  If the person has to continue to "resist" the cold, as would be the case if the person were stranded in the wilderness without sufficient resources,  he or she would eventually succumb to the cold stressor and freeze to death.  However, before this happened, the body and the mind would eventually reach the "stage of exhaustion". 


The "Stage of Exhaustion".  The person's body could continue automatically to try and produce the necessary amount of body heat for survival by shivering--but eventually, the mind and body would exhaust their available supply of energy. In the muscles, the wastes from each cell would begin to accumulate; resulting in tiredness and aching, and then numbness, and then the body would eventually start to shut down.  This is the third stage, the "stage of exhaustion".  Taking this example to its unfortunate inevitable conclusion, the person would eventually freeze to death.


Similarly, the stressors of being repeatedly or continually verbally assaulted, yelled at, harshly reprimanded, or criticized, would initially mobilize a person's bodily defenses (i.e., the Sympathetic branch of the Autonomic Nervous System), and "alarm reaction".  The assailed person may repeatedly attempt to fend off the aggressor or hostile opponent.  However, if the person is not successful, a prolonged "stage of resistance" occur and results in the "stage of exhaustion".  The repeated mobilization of the "fight-flight reaction" will, in all likelihood, take its toll physically and mentally.  This too may then lead into the third "stage of exhaustion".


It should be noted that the stressor inducing the Alarm Reaction does not have to be a physical threat.  It may be a mental threat and, in our modern society, not even based in reality.  Most time-limited physical and mental stressors only lead to changes of the first and second stage type. We may initially become upset about feeling alarmed and the need to adjust, but we eventually accept the stressful stimuli, adapt to them by changing our responses in some way, and then they become less stressful.  This adaptation, when repeated often enough, over an extended period of time, becomes learned behavior.  It is imprinted in the Unconscious as the individual's own unique stress reaction or way of responding to and coping with stress.


Almost any stimulus that is interpreted as threatening, whether mild or extreme, evokes some level of anxious feelings.  Even when these anxious feelings are interpreted as not life-threatening on a conscious level, this anxiousness still evokes an automatic response to escape from the perceived threat and seek relief from the fear.  This is a natural adaptive response mechanism that leads the organism to select a coping behavior that temporarily reduces the anxiety.  This could be as simple as thumb-sucking or as complex as Agoraphobia.  This selection of a way of coping is largely an unconscious process.  It is influenced by various factors such as, unconscious role modeling and observational learning (Bandura, 1976), selective positive and negative reinforcement contingencies (Bower & Hilgard, 1981), innate temperament (Chess & Alexander, 1996), developmental maturation and learning, and cognitive adaptational processes of assimilation and accommodation (Piaget & Inhelder, 2000).


Anxiety-Based Behaviors


In BCH, anxiety-based coping responses have been categorized into six progressively more complex systems of behavioral response as follow: 


Mild or low level feelings of anxiousness.  When mild or low level feelings of anxiousness are spontaneously evoked during childhood, they can lead to the unconscious choice of a coping behavior, such as nail chewing or thumb sucking, that is further imprinted by repetition. Eventually, the "behavior of unconscious choice" may become a "simple" or "empty habit". In adolescence and adulthood, when continued unabated low level anxiety is experienced, and no temporarily effective anxiety ameliorating coping behavior is initiated, the individual may experience a continuing anxious feeling whose cause is unknown.  This may further lead to a generalized feeling of uneasiness, diffuse emotional and/or physical discomfort, mild depression, and feelings of impending negative expectations.


Generalized anxiety.  Mild or low level feelings of anxiousness can lead to obsessive worrying as the coping behavior of unconscious choice. This results in more intense and longer duration feelings of anxiety (e.g., Generalized Anxiety Disorder). The anxiety is associated with the misinterpretation of a wide range of situations and circumstances as potentially threatening and dangerous along with repeated predictions of future harm.  This creates a vicious, unending cycle of worrying, negative predictions, apprehension, feelings of impending doom, helplessness, and perceived vulnerability to many perceived threats. The end result is a distressing and uncomfortable state of hypervigilance and sustained physiological arousal.


Phobic behavior.  This is the anxiety behavior that BHC identifies as evoking actions such as running away or taking extreme measures to avoid stimuli or settings that have been identified as dangerous or threatening.  If not treated, phobic avoidance behavior can generalize into aoraphobia, which is a phobic reaction to everything outside of one's "zone of comfort".  Ultimately, one's "comfort zone" progressively becomes more narrowed and confining.  In extreme cases, the increasingly distressed individual refuses to leave the confines and illusory safety of his or her own home.


Panic attacks.  A "panic attack" is a highly distressing and severely negative emotional response to an extremely negative or catastrophic interpretation of the bodily sensations of the "flight-fight mechanism".  For example, the afflicted individual develops the fear and conviction that he or she is dying of a heart attack or is completely losing control.  This is often accompanied by difficulty breathing, accelerated heart rate (tachycardia), pressure in the chest, stomach pain, weakness or wobbliness in the legs, fear of passing out, sweating, dizziness, tremulousness, shaking, and other physical symptoms.  Emergency room physicians are very familiar with the presentation of a possible heart attack that is actually a panic attack.   


In a panic attack, the body's "flight-fight mechanism" is triggered unconsciously.  Panic attacks often occur spontaneously (or that is the perception of the individual) in any setting.  The person then become sensitize to whatever situation or setting in which the panic occurred (classical conditioning).  This may then lead to future avoidance of that situation or setting.  Subsequently, the fear typically generalizes to other settings and stimuli, and the person may remain unaware of what sets the panic off. 


Most individuals attribute their panic attacks to there being something wrong with them physically. This leads to repeated visits to hospital emergency rooms, family doctors, general practitioners, and cardiologists that usually reveal that there is nothing physically wrong.  However, the condition is perpetuated by a negative feedback loop in which the individual maintains a continued belief that there really is something physically wrong, and that he or she really is going to die or lose control.  Medical reassurance is rarely successful.  Consequently, overwhelming flight-fight reactions are triggered repeatedly and unexpectedly; and, they are repeatedly misinterpreted as evidence confirming the sufferer's worst predictions.  The repetition of this extremely dysfunctional cyclical process imprints it into the Unconscious.


Obsessive thinking.  This category of anxiety-evoked thought behavior can be experienced on a continuum from mild to extreme.  It can be as common as having difficulty getting a song out of one’s head or as disruptive as having to repeat certain verbal phrases over and over again.  It can also be as intrusive and anxiety-provoking as having repeated thoughts of doom and gloom about individuals or situations that have already occurred or may possibly occur.  Once again, by repetition, these thought patterns are imprinted in the Unconscious and become habits. 


Obsessive-compulsive behavior and obsessive compulsive disorder (OCD).  This category covers extreme, repeated behavior that may be singular: repeated hand washing, counting, avoiding cracks in the sidewalk or more complex: making sure that everything is shut off multiple time before leaving the house and even returning to “make sure”, checking that all the doors are locked, etc. The repetitions to reduce anxiety can range from just a few to many.   Through this process of repetition, the thoughts, and behavioral responses aimed at reducing the anxiety associated with the thoughts, are imprinted in the Unconscious.  This reinforces the dysfunctional habit patterns and strengthens their compulsive aspects.


Each of the above examples include as their core component the experience of anxiety which is interpreted in different ways and attributed to differing degrees of danger by the individual.  As mentioned previously, the more extreme anxiety-related behaviors typically evolve from the less extreme anxiety-evoked behaviors.


The BCH approach is to initially avoid treating the mature, evolved, extreme forms of the dysfunctional behavior.  To begin, and to simplify treatment, the first step is to go back and treat the original (or originating behavior; termed the "foundation behavior”). In BCH, the foundation behavior is simple anxiety, which is much easier to address effectively than its more evolved manifestations.  BCH begins to address the foundational behavior during Waking State Reframing, when the patient is told that something may have happened a long time ago that produced discomfort or anxiety. However, the patient is also told that whatever happened then, is no longer happening now (if this is true, which we determine in the intake evaluation). 


The process is almost like doing a therapeutic waking state regression without formally regressing the patient.  In the BCH model, even though it is not labeled as such, it is believed that regression actually does take place during this reframing process as the patient remembers past sequences of events and spontaneously enters a hypnotic like state (Cheek, 1994; Erickson, 1961, 1985; Grinder & Bandler, 1981). 


Dysfunctional and Therapeutic Rituals




The word ritual is derived from the Latin word "ritus" meaning "rite".  The term refers to a "formal pattern of behavior, culturally prescribed for use in certain specific circumstances.  The term includes the social, religious and cultural practices which symbolically convey meaning about an event and those who are participating in it (Walrond-Skinner, 1986, p. 300-301; e.g. "rites of passage").  In BCH, rituals are conceptualized as a series of sequential acts or behaviors or procedures that are part of a prescription that must be followed, without interruption, to accomplish a set result.  Individuals, families, social groups, business organizations, religions, ethnic groups, political organizations, government organizations, societies, and countries all establish “normal” ritual systems to maintain order and organizational integrity.  Knowing what the structure is and knowing the appropriate procedures to follow make for a smoother and more orderly system. 

The first introduction to ritual behavior that we experience is within the family system.  The family constellation establishes the rules of behavior that may include rigid time frames to establish order and harmony with each family member assigned a role.  Roles and rituals evolve as the family constellation changes.  Most of us are taught from infancy that ritual and order are necessary and good.  Dramatic and powerful rituals are seen in organized societal ceremonies, "rites of passage". Most often these organized social order rituals are positive and contribute to enriching the lives of individuals and families. 


The Origin of Dysfunctional Rituals


Unfortunately, we all encounter crises at times: individually, as a family, within our greater extended family, and in our general environment. For instance, in Florida normal rituals may be interrupted by the threats of hurricanes and in California, the threat of earthquakes.  These crisis situations force us to interrupt normal everyday patterns of behavior.  This disruption causes us to change predictable future activities and requires more or less drastic adjustments to deal with the crisis.  At the same time, a crisis imprints a powerful emotional response in the Unconscious and evokes some type of emergency behavior.  A dysfunctional crisis ritual may then be established as a way of coping with the extraordinarily stressful occurrence, even though that ritual may not appear dysfunctional at the time the crisis is occurring. 


The coping ritual established to deal with the crisis might be appropriate at the time and in the situation in which it is required.  Eventually, however, the crisis usually passes and a more normal daily ritual is needed to attain stability.  If the individual and family are generally well-adjusted, this transition back to a more normal pattern of activity will be relatively comfortable and occur without leaving much negative residue in the wake of the crisis situation.  However, if there are other dysfunctional forces at work prior to the incident, the crisis response may be fixed in place and continued long after it is needed.  Thus, it may become a dysfunctional ritual.  As with most negative behavior that is repetitious, this too can evolve into more complex and disruptive behavior patterns.


Dysfunctional rituals may initially seem appropriate but later become uncomfortable because they no longer satisfy the original purpose (decreasing anxiety). Although the dysfunctional ritual may be uncomfortable for the patient, it may still meet a fundamental need.  One might hear a patient say something like, "I know that this behavior is bad, but at least I know what to expect.  If I get rid of it, what might happen next?  Things could be worse!"  Many smokers are afraid to give up their smoking ritual for fear of the possible discomfort of “withdrawal” behavior, weight gain, irritability, etc.  This fear of the problem getting worse, combined with fear of the unknown and intolerance for uncertainty, may help maintain the dysfunctional ritualistic behavior.  The behavior is also strengthened and maintained by repetition.  Trauma initially imprints a coping behavior and repetition further imprints the behavior.  Imprinted behavior that is repeated often and long enough can then generalize and evolve.


Visible rituals.  Many patients seek help from clinicians for such dysfunctional behaviors as obsessive compulsiveness and extreme phobias.  These are the kinds of dysfunctional ritualistic behaviors that are often seen in clinical settings since they have become extreme enough to force some search for help.  They are very visible both to the patient and to others.  For example, the hand-washing ritual is a cleansing ceremony and is very visible.  As discussed previously, in BCH, "we only pay attention to events" - visible ritual behavior is "event behavior".


Invisible and covert rituals.  There are many unrecognized ritual behaviors that go on for years, and permeate almost all of the other frequent problems that present to clinicians.  Some of these “invisible” rituals are treatment or health-focused.  They evolve in order to help the individual cope with a problem that may or may not be ongoing.  Other rituals are associated with the enactment of certain social roles in particular contexts and occur without much notice in certain situations.  For example, many dating and sexual behaviors are ritualistic.  Other examples have to do with eating behaviors, social etiquette, role expectations at social events, when eating out, participation in worship services, etc. Many of these "invisible rituals" may actually be visible, but they may remain unrecognized or covert because they have become "the norm".  They continue to exist as a part of the expectations attached to many everyday experiences.  Their establishment as "normal rituals" may become "non-events" which makes them invisible. 


Medical rituals.  There are also many medical rituals that, by definition, are the behavioral manifestations of certain medical treatment protocols.  Each disease or illness has prescribed its own treatment ritual.  The administration of medication, radiation, chemotherapy, surgery, physical therapy, spinal manipulation and alternative therapies all establish their own rituals designed to help the patient feel better.  Some rituals can be identified as very powerful placebos and that extensive research will not be reviewed here.


The Use of Rituals for Therapeutic Purposes


Rituals are widely used for various therapeutic purposes in varied psychological treatment settings (Van Der Hart, 1982; Haley, 1984; Imber-Black, Roberts, & Whiting, 1989).  They can lend structure and order to the therapeutic encounter and set the context for the treatment (Frank, 1974; Langs, 1995).  Therapeutic rituals can also confirm both the treatment provider's and the patient's expectations about what will take place and this reduces uncertainty and anxiety.  It also socializes the patient to the therapy (Eimer & Freeman, 1998; Freeman et al., 1990) and can facilitate patient compliance (Meichenbaum & Turk, 1987).  Rituals in psychotherapy can also assist in creating new corrective emotional experiences, as has been discussed by psychoanalytically oriented psychotherapists such as Alexander and French (1946). 


"Exchanging new rituals for old, dysfunctional ones forms a major therapeutic ingredient of social skills training, problem solving interventions and coping skills learning, and new rituals for engaging in more productive interpersonal relationships are consciously taught in sex therapy, marital therapy, and family therapy" (Walrond-Skinner, 1986, p. 301).


Palazzoli et al. (1978, 1995) describe the use of rituals in the context of changing severely dysfunctional family systems of interaction.  They define a therapeutic ritual as "an action or series of actions usually accompanied by verbal formulae or expressions which are to be carried out by all members of the family" (as quoted by Walrond-Skinner, 1986, p. 301).  They are sometimes referred to as “homework assignments”.


Hypnotic inductions as "rituals".  The hypnotic induction process has also been aptly described by some experts as a formal "ceremony" or ritual (Spiegel & Spiegel, 1978, 1987).  Drs. Spiegel and Spiegel state that "trance phenomena may occur spontaneously, or in response to a myriad of ceremonies of induction…" (p. 35).  They define a ceremony as "an action usually performed with some formality but lacking in deep significance.  If the subject interprets the cues properly and conforms to what is expected, the trance ensues." (p. 35).  Their major thesis is that hypnotizability is the capacity to experience trance that manifests as a stable trait and should be measured by a standardized "formal ceremony".  One example they give is their "Spiegel Hypnotic Induction Profile" (HIP).  They also make the point that for highly hypnotizable individuals, a myriad of induction rituals or ceremonies can serve to induce hypnotic trance. 


The Spiegel’s redefine deepening techniques as procedures for "clarifying the context" and "clarifying the patient's motivation or the relevance of hypnosis in the first place; correcting misunderstandings or aesthetic preferences of the patient; altering expectations of the patient, the therapist or both." (p. 36).  Their HIP procedure is "regarded as another ceremony" and also as "a measurement of hypnotizability in which a systematized sequence of instructions, responses, and observations are recorded with a uniform momentum in a standardized way, as the subject shifts into trance to the extent of his ability, maintains it, and exits in a prescribed manner." (p. 36).


Thus, hypnotic trance induction ceremonies can be seen as fitting the definition of a ritual in that they are a series of sequential acts or behaviors or procedures [a "formal pattern of behavior"] that are part of a prescription that must be followed [in certain specific clinical circumstances] without interruption, to accomplish a set result [i.e., the induction or evocation of the hypnotic trance state]. 


Other ways to use rituals therapeutically.  The use of rituals for therapeutic purposes does not necessarily involve the prescription of new rituals designed to be therapeutic.  Often, in the practice of BCH, therapeutic elements are added to existing normal rituals.  In this way, the treatment can take advantage of normal, everyday, healthy coping behaviors by adding additional therapeutic behaviors.  One such example is incorporating the practice of self-hypnosis into daily ritual activities.


Replacing Dysfunctional Rituals with Therapeutic Rituals


When considering the concept of therapeutic rituals, there are two separate processes.  Both of these processes are important and often integral to the success of the treatment.


Visible rituals.  One process involves the removal of dysfunctional rituals and the establishment of therapeutic rituals to replace them.  This initially requires an examination of the visible rituals that constitute the presenting problems.  These should be uncovered, understood, demystified, and reframed during the Waking State Reframing process.  This is when BCH establishes the concept that the presenting problem and its accompanying rituals are an evolved exaggeration of an original attempt to cope with an earlier event that was once interpreted as threatening.  That earlier event is no longer happening.  Therefore, the original attempt to cope and the current exaggerated behavior are no longer needed.


Invisible rituals.  The second process involves the invisible rituals associated with previous unsuccessful attempts by the patient to cope or that are associated with previous treatment failures. These too need to be uncovered, understood, and reframed.  This will help in the reframing process, when the patient wants to know why previous attempts to cope with, or get relief from, symptoms did not work.  Uncovering these invisible rituals may also assist the clinician to avoid repeating things that did not work before and in establishing a treatment plan that is likely to work now. 


Problem interruption, not ritual substitution.  When deciding on a treatment plan, the clinician needs to be aware of how ritualized the plan is.  The clinician then should simplify the treatment ritual so that it is not interpreted by the patient as a substitution for the undesirable and problematic presenting ritual.  BCH does not suggest to patients that they are going to be given a better, more functional ritual as a replacement.  As discussed, BCH suggests that the current symptom is an exaggerated evolved outcome of a coping response. By suggesting a substitute ritual, the patient could postulate consciously and unconsciously that the new ritual could negatively evolve also (and this is not a treatment goal). In BCH, the description of the treatment, such as learning relaxation, is presented as a way to interrupt the dysfunctional ritual by treating the original pre-evolved attempt to cope.  For example, the practitioner might say to patients whose presenting problems involve anxiety, "You can’t be anxious when you are relaxed.  They are physically and emotionally opposites of each other."


Single therapeutic prescriptions are not considered rituals.  However, they can become ritualistic when they are repeated and attached to other repeated behaviors.  For example, teaching a patient self-relaxation and then suggesting that the patient practice self-relaxation or self-hypnosis, is a process of "post-trance imprinting".  The suggestions are consciously evoked by the patient and visible.  Then, other therapeutic behaviors can gradually be attached to the practice of daily relaxation:  such as feelings of energy following the relaxation, and then exercise because of the increased feelings of revitalization and energy.  When these additional therapeutic behaviors are added to the regular daily schedule of the patient, they become incorporated into the patient’s daily rituals.


All treatment programs and protocols are of course assumed to be therapeutic and very often also ritualistic.  One caveat, the more regimented they are, the more rigid they tend to become; and, the more rigid they become, the less therapeutic they tend to be. Complex therapeutic rituals are designed to give order to the therapeutic work of the patient and to enhance compliance.  However, one can always “go overboard” with assignment of ritualistic behavior to the point of creating more stress and furthering the patient's feelings of confusion, being trapped, and being preoccupied with the problem.  The intended purpose of ritual behaviors is to increase the patient’s sense of control (present and future).  It is only valuable if it can be experienced as comfortable and eventually become invisible and unconscious. 


For this reason, it is preferable to attach therapeutic prescriptions to existing, normal, and comfortable everyday rituals.  If those daily rituals include dysfunctional aspects, the clinician should help the patient to remove those parts of the rituals that are uncomfortable.  This might be done by adjusting the order of the activities, changing the time frame of the activities, or slightly altering or adding to the activities.  Suggesting other choices and new ways of thinking about what is being experienced can also be effective.  As an example, let us examine the ritual of eating that caused a patient to seek help because of weight gain and preoccupation with food.



Case Example. Weight Loss



Session One.  A 52 year-old, divorced, successful, professional woman, was referred to by her physician because she complained of being preoccupied with thoughts of food and could not lose 20 pounds that she had gained in the past year.  Her height was 5 feet-3 inches and her weight was 143 pounds.  She worked as a financial planner and experienced a great deal of job stress.


During the intake evaluation, she reported that she had breakfast between 8:00 and 8:30 AM which generally consisted of a half a cup of juice with vitamins and either: boiled egg, plain oatmeal with boiling water, or cottage cheese and fruit.  Sometimes, she had cheese sticks between breakfast and lunch.  Lunch was eaten at about Noon, and she usually had a lunch salad with dressing or meatballs without pasta with a house salad and part of a roll.  Her liquid intake with her lunch consisted of a glass of water with a wedge of lemon.  Between lunch and dinner, she had some nutrition bars.  Dinner was taken between 6:00 and 8:00 PM and was usually made up of leftovers such as salads, soup, a barley drink, or water with lemon.  She ate at home most evenings.  She said that she did not snack in the evening and went to bed between 12 midnight and 1:00 AM.  What was reported so far appeared very positive.


When asked, she answered that she did eat fast.  She stated that she would become so hungry that it would make her feel weak.  She had also just started a “Sugar Busters” diet that involved eating no sugar, if at all possible.


When questioned further about feeling so hungry, she said that she felt a pressure in her stomach and heard stomach noises that told her that she was hungry.  She had been on hormone replacement pills, but had stopped them because she gained weight while on them.  When asked at what times of the day she felt most hungry, she answered that it was usually late in the afternoon. Her office always had cakes, cookies, and candy available, so she ate what was there.  This led to her commenting that she had a "sweet tooth". [Note the new negative feeling and eating behavior that was elicited by further questioning.]


For the clinician, something just "didn’t add up".  She was questioned further regarding how often she thought she was hungry because of stomach pressure and noise, and how often she thought about food and eating.  She admitted that she felt “hungry” much of the time and that she thought of food most of the time.  She stated that her “strong will” kept her from eating more often.  Then she said that maybe she snacked more than she admitted to, even to herself.  In terms of exercise, she rollerbladed for forty minutes every morning before she went to work and walked for an hour or more on the sand at the beach near her home after work.  This, of course, was considered positive and healthy.


On initial examination, it seemed that she basically ate right and exercised regularly.  She appeared to have control.  However, she did have a problem properly interpreting the messages of her body (some snacking behavior had been invisible to her). She was preoccupied with the fight over food and she was exaggerating her weight problem.


Further examination of the data suggested that many of her "visible" eating rituals were in fact healthy.  But, there were some "invisible rituals" that were not healthy.  She had a problem with her kinesthetic awareness of her body’s messages.  In her case, as in many cases of "weight problems" that present to clinicians who use hypnosis, fluid retention may have been more of a problem when she was on hormone therapy, than body fat.  She ate too fast.  She also had a problem with sugar and it was hypothesized that she might have been hypoglycemic as indicated by her late afternoon hunger which is often caused by a drop in blood sugar level.  She also carried an unrecognized low level of anxiety related to the pressure of her work and her limited social life. So, she ate when stressed.


The issues that needed to be addressed were: (1) her low level of continual anxiety; (2) her stress eating; (3) her habit of eating too fast; (4) her misinterpretations of body messages; (5) her fluid retention; (6) her "sweet tooth"; and (7) her possible hypoglycemia.  These were discussed with her during the Waking State Reframing portion of the first visit.  In summary, she was told: 


"There are a number of patterns and feelings that need to be dealt with in order to help you feel better and look better.  My approach will not be to help you lose weight, so you are not to weigh yourself while we are working together.  I will help you change your behavior, and you will notice that your clothes fit more comfortably.  You will be aware that you are loosing inches.  You will be taught a form of self-relaxation to remove the anxiety feelings.  Those anxiety feelings, that you may not have even been aware of, are your reaction to the many things that you identify as stressful.  You said that you eat when you feel stressed.  By practicing relaxation for about ten minutes once or twice a day, you will no longer feel stressed, so you will no longer feel like eating.  When you are relaxed, you can’t feel stressed because they are physical and emotional opposites of each other.


You will be helped to eat very slowly.  The stomach fills up on a time frame, not a volume frame.  So, the slower you eat, the less volume you will consume when your own individual ‘full time’ is reached. 


You will be helped to ignore body messages that you thought meant that you were hungry, and to better recognize the true messages of your body. 


You will be helped to reduce your fluid retention that makes you feel heavy, by drinking more of the water with lemon that you already enjoy doing.


You will be able to avoid sweet sugary foods easily and reduce any hypoglycemic reaction, which occurs in the late afternoon, which makes you snack then.  You will also be aware that sweet foods no longer taste as good as they did.  This will make it easy for you to start your ‘Sugar Busters’ program.  By the way, it is better to call it a 'program' and not a 'diet'.  This will make it easier to follow.


All of this will happen as you add daily relaxation exercises to your normal daily routine.  We will need up to five sessions after this evaluation session.  If we can accomplish your goals in less than five, fine.  How does that sound to you?  Good.  Then, let’s set up an appointment for you.  During the next session, I will explain about the two parts of the mind that control your behavior, and teach you self-relaxation to start the change process."



Session Two.  The second session included the Waking State Reframing material about the Conscious and Unconscious Mind, and the explanation about hypnosis and relaxation.  The patient stated that she was already eating better after the last session (not uncommon give expectancy effects) and that she looked forward to learning self-relaxation. 


She was taught to enter trance (relaxation) using an Eye Fixation with Attention to Breathing Induction procedure.  This was chosen because she would be taught "instant relaxation" using three slow deep breaths during the second session.  This induction also helped in reframing her body's messages.  Redirecting her attention to her breathing helped to make the sounds and other feelings she interpreted as hunger invisible. 


During trance, she was asked to be aware of how good this relaxation experience felt and that she could experience it on her own by doing at home what we did in the office, without my help. Before the induction, we had agreed that the best time for her to practice was in the morning (before her exercise activity) and in the afternoon (right after she got home from work and before her walk on the beach).  It is better to practice self-hypnosis before as opposed to after physical exercise. The following suggestions were also given during this trance experience in the office:


"You will be eating very slowly and filling up very quickly in a comfortable way, and eating less and enjoying it more. When you think you are feeling hungry, pay attention to your breathing without trying, to change your breathing, and the feelings that brought the thoughts of hunger will disappear.  You will drink your water with lemon between breakfast and lunch and in the afternoon and evening, in addition to with your meals.  This will help you eliminate more of your body fluid retention and your feeling of bloating.


Do not give these suggestions to yourself.  You are to do no self-talk while doing your own self-relaxation.  Every time you do your own relaxation, you will automatically reinforce the things that I say to you when we work together."



Session Three.  A week later at the third session, the patient reported a five-pound weight loss and that her clothes were fitting better.  I asked her how she knew that she lost five pounds.  She said that she had "cheated" and had weighed herself this morning, the day of her appointment, but not before.  I told her that it was okay now, to weigh herself once a week on the day she was to come in to see me.  She further reported that she was feeling much more relaxed, thinking about food hardly at all, and drinking more water instead of snacking.  She enjoyed the relaxation time and said it gave her more energy for her exercise times. 


She was surprised that she did not feel hungry.  I asked her if she found herself occasionally paying attention to her breathing.  She answered yes, but hadn’t remembered until I asked if she had been doing so.  It had become invisible and unconscious as it became comfortable. 


We are usually only aware of invisible change in retrospect.  In order to know about changes that have been suggested, but that are not described by the patient, we ask the patient if they are aware of such changes.  That is because changes that become invisible become "non-events".  They become a part of "normal" behavior.


I asked the patient to put herself into relaxation the way she was doing at home and to signal me by lifting one of her hands to let me know when she was ready to have me take her deeper.  The hand lifting is not an "ideomotor signal".  It is a simple acknowledgment in answer to my request to be informed when she was ready.  I could have, as I often do, just as easily asked her to nod her head. Our approach is to keep things as simple as possible.  I then explained the following:


"I am going to take you deeper into relaxation by my counting slowly from twenty down to one.  I use the word 'deeper' because I don’t have a better one.  I am really talking about improving the quality of your relaxation experience rather than the distance traveled.  With each number that I count, you will find yourself feeling more and more comfortable, and more and more relaxed.  So, just listen to the numbers and let yourself go, and enjoy the feeling of going deeper into relaxation.”


When I reached the number one, my observation of the patient’s posture, breathing, facial coloring and eyelid flutter indicated to me that she was much more relaxed than when she had signaled me earlier.  I then said:


"That’s very good.  You are much more relaxed after my countdown from twenty to one.  From now on, when you do your own relaxation, when you are about as relaxed as when you signaled me, start your own silent countdown to yourself from twenty to one.  By the time you reach the number one, you will be much more relaxed.  That deeper feeling of relaxation is the deeper level of relaxation that you will be able to reach every time you do your own self-relaxation.  That is the level of relaxation that allows all of the changes you have made and all of the changes that you will make to be imprinted in your Unconscious Mind.  They become new memories of success and change that are repeatable and enjoyable.  So, all of your successes now become a part of your normal everyday life, continued and improved as each day goes by."



Session Four.  We scheduled a fourth session for a week later to make sure that the routine was established and that the changes were in place.  The patient reported further weight loss, feelings of greater confidence, less stress, and being very much in charge.  We did another session with the patient relaxing herself.  I reinforced her personal success and decided that this could be her last regular session with me.  She was told that I was as close as the telephone.  She could call me if she had a question, or if there was some additional help that she thought she could benefit from.  I congratulated her on her success and told her that I very much enjoyed working with her. 


"Normal" is "Invisible". A colleague once told us that calling this kind of process a "therapeutic ritual" was "a stretch".  BCH posits that in order for any change behavior to become effective, it had to become normal behavior and almost invisible.  Behavior modification and progressive relaxation rituals were not long lasting because they could not be incorporated into normal everyday activity.  They stood out as attempts to change behavior rather than becoming a part of normal everyday behavior.  That is why the BCH approach prefers the label rituals that are therapeutic rather than therapeutic rituals.


Review, Summary and Conclusions


According to BCH, most dysfunctional behaviors are anxiety-based.  These dysfunctional behaviors are coping behaviors that were originally invoked to reduce anxiety. They were imprinted in the Unconscious initially by some form of marked hurt or trauma and then further imprinted by repetition.  They became labeled as dysfunctional and negative when they become consciously recognized as a problem.  Although the original initiating hurt or trauma may no longer be present, and no longer even be identifiable, the continuation of the negative coping behavior, now labeled dysfunctional, has become a habit by repetition.


Because the initiating cause is no longer present, the negative coping behavior may no longer be needed and may be labeled as an "empty habit", or as a "simple negative behavior".  "Empty habits" can be removed without the need for substitution.  This has been called "symptom removal". It was used sparingly in the past because of the concern for possible "symptom substitution".  However, it has been found that "empty habits" or "simple negative behaviors" can often be removed in a single therapeutic session without symptom substitution.  Their treatment usually does not require the teaching of self-hypnosis.


When dysfunctional behaviors continue because the original stressors (or new stressors) are present, the current "dysfunctional behavior" may be an exaggeration of the original coping behavior.  According to BCH, the original behavior arose as an attempt to cope with anxiety. The presence of stressors, and the strong coping behaviors, causes the original coping behavior to be repeated and eventually to evolve into a more complex behavior pattern.  Anxiety produces avoidance behavior which often becomes generalized and more complex if left untreated.


BCH identifies these dysfunctional behaviors as "complex habits" or "complex negative behaviors".  They require more than a single session to treat and usually necessitate teaching the patient self-hypnosis.  These evolved, more complex anxiety-based behaviors may include dysfunctional behaviors such as overeating, agoraphobia, obsessive compulsive rituals, alcohol and drug abuse, depression, anger problems, exacerbation of pain syndromes, and other medical problems.


The Basic Principles of Brief Cognitive Hypnosis    


The intake evaluation.  A brief but thorough intake evaluation establishes the basis for doing BCH.  It is required to understand the patient and the patient's presenting problem.  The intake evaluation gathers pertinent information about the patient and the patient’s current and past family and social constellations.  Most experienced clinicians have developed their own intake evaluation format.  This is easily modified for those patients appropriate for the BCH intervention.  The BCH intake evaluation places emphasis on the patient’s belief systems, patterns of behavior, personal labels, habits, rituals, sensory processing systems, language use, goals, motivation, choice of coping behaviors, and functionality.  This list includes the patient's previous attempts to deal with the presenting problem as well as with other related or implied problems.  Often, during an intake evaluation, in addition to talking about the "presenting problem", the patient demonstrates other problems.


The conscious and unconscious parts of the mind. BCH conceptualizes that the mind is made up of two functional parts: Conscious and Unconscious.  The Conscious Mind is essentially under the active control of the individual.  The Unconscious Mind is that part of the mind that controls all automatic behaviors over which the individual has little or no active control.


Hypnosis as an "Altered State".  BCH views hypnosis as an alteration in internal perception which is initiated at the start of a unique process of communication that can be verbal or non-verbal.  Natural everyday altered states are labeled as "Hypnoidal States" and therapeutic altered states are viewed as "Hypnosis States" or "Trance States".  In the clinical setting, an informal Hypnosis State is differentiated from a formal Trance State which is induced by performing a Trance Induction Procedure.  The former may occur without a formal trance during the intake and evaluation process.  It is a Waking State, but it has trance-like qualities that arise from the early experience of relaxation which naturally develops during the patient's comfortable interaction with the clinician.  This comfort, the patient's growing sense of trust in the clinician, and the patient's expectation of eventually entering a formal trance, all help create the experience of relaxation which leads to the informal Hypnosis State.


Waking State Reframing.  The communication process that takes place during this Waking State is designed to start the process of change that is later further fixed in place during the Trance State. The term "Reframing" used in this context refers to the purposeful verbal intervention by the clinician to assist the patient in changing the meaning of beliefs and labels that propagate dysfunctional behavior. During Waking State Reframing, the patient begins to change beliefs, labels, and misconceptions.  The belief of being trapped is changed to the possibility of changing. The expression of Absolutes becomes "sometimes" rather than "always" and erroneous and iatrogenic beliefs are corrected and changed.  This is the time when most of the change work actually takes place, in preparation for the trance experience, which acts as a sort of "fixative".


The Waking State Reframing procedure consists of redefining problems, clarifying real versus imagined causes, and challenging and changing the patient’s beliefs.  Through the careful use of reframing, the provision of new corrective information and the changing of negative labels is completed.  This is all accomplished while communicating with the patient’s Conscious and Unconscious simultaneously during the waking state.  This is when most of the change work occurs in preparation for the use of the Trance State as a "fixative".  The Waking State Reframing experience is an altered state during which the patient is more receptive to suggestions.  It may also be described as an "Anticipatory Trance State" or "Expectant Trance State" in that it sets up the desired expectancies.  It starts with a simple explanation of the Conscious and Unconscious Minds. It then continues as hypnosis is explained to the patient and it is experienced.  The process then moves into reframing beliefs and labels that have been used by the patient in maintaining the dysfunctional behavior. Many of the physiological markers of Formal Trance are often noticed during this "pre-trance experience".  The patient is expecting trance to occur and is already entering into an altered state in preparation for trance.


The role of language.  Language is inherent in how we learn.  We automatically and unconsciously interpret the representational code of language to understand and apply meaning to our world.  So, the choice of language forms used by the patient and clinician are important to the furtherance of the change process. In BCH, the clinician pays close attention to sensory-based language.  Language that is visual, kinesthetic, auditory, olfactory, and gustatory are carefully noted and then utilized for improving rapport and facilitating change.


The concept of "Imprinting".  We learn from repetition and from emotionally powerful experiences.  When a thought, feeling, or behavior is often repeated, the Unconscious is more able to accept that which is repeated as appropriate and valid, even if the behavior has a possible negative outcome.  This is how we learn and establish habits, whether they are good or bad.  This is called "Imprinting".  We also learn from shock, trauma, extreme emotionality, serious illness and loss. These traumatic imprints initiate behaviors and emotions designed to reduce the trauma’s effect on the individual.  Such responses may include anxiety, fear, depression, and other emotional and psychological disorders.    

Symptoms are seen as attempts to cope. In BCH, those presenting problems that are labeled as "symptoms" as unconsciously initiated attempts to cope with imprints that are negative in nature.  As they are repeated, these coping attempts become further imprinted and interpreted as dysfunctional. 


Selye’s "Fight-Flight Response". BCH postulates that most attempts to cope are initiated as a result of experienced anxiety due to the initiation of a "Fight–Flight Response".  The patient either reacts with an angry externalized coping behavior or, if unable to externalize or run away, the reaction is internalized and may be expressed in some other dysfunctional way.  The chosen coping behavior is an attempt to alleviate the anxiety.  Repeated similar stressors repeat the anxiety and the chosen coping behavior.  Repetition imprints the behavior and experience so they continue and are eventually perceived as dysfunctional.                  


Evolving symptoms create more complex dysfunction.  As negative anxiety-coping attempts are repeated without resolution, they often become more generalized and more complex, and dysfunctional.  Anxiety that initially produced discomfort can evolve into avoidance when it becomes situational or object-oriented.  Eventually, with continued repetition of the anxiety experience in different situations, the avoidance behaviors can further generalize and evolve into agoraphobia.  Anxiety that initially produced fear of future calamity may evolve into other extreme problems (e.g., obsessive or ritual behavior).


Treating the initial anxiety rather than the evolved complex dysfunction.  The choice of different sets of criteria for classifying symptoms and dysfunctional behaviors has been used to establish different diagnostic labels for specific psychological disorders.  These systematic efforts have led to the creation of different treatment protocols.  In BCH, dysfunctional behavior is instead conceptualized by determining the emotional and physiological response mechanism that operated originally as the patient first attempted to cope with a stimulus that was interpreted as threatening. This is in contrast to identifying the extended phobic or ritualistic behavior that evolved and became the later presenting problem that needed to be addressed. With this recognition, the BCH intervention is able to start at the beginning and change the initial response that later and more debilitating symptoms (i.e., "dysfunctional coping behaviors") were built upon.


"Simple Empty Habits".  If the original circumstances that initiated the initial negative coping response are no longer present, and if the initial coping response has not evolved to an extreme level, treatment may be simplified and shortened.  The problem can be treated as a "Simple" or "Empty Habit" that no longer serves a purpose.  Therefore, it can be given up without substituting other dysfunctional behavior.  This may often be accomplished in a single visit.


"Complex Habits".  When dysfunctional behaviors continue to generalize and evolve because the original stressors are still present, or because the intensification of the emotional response occurs, exaggerated coping mechanisms are labeled as Complex Habits or Behaviors.  These more complex habits (behaviors) take more than a single visit to address.  Complex habits may include such dysfunctional behaviors as overeating, agoraphobia, obsessive-compulsive rituals, alcohol and drug abuse, exacerbation of pain syndromes, and aggravation of existing medical problems, among others.


Choice of induction.  The ritual of the Induction Procedure that produces, or induces, the Hypnotic Trance State is viewed as separate from the Trance State itself.  It is a state of transition from the Waking State (which may already have some trance-like characteristics) into a more dissociated state.  That dissociated state, the Trance State, is characterized by a form of logic (called "trance logic") that is less critical and judgmental than the form of logic associated with the Waking State.  Thus, in trance, the individual is more open to suggestion and change than when in the Waking State.


The choice of the induction procedure should be based on the needs of the patient and the particular problem to be resolved.  In most cases, it should be short and uncomplicated.  BCH avoids long, complicated, elegant, inductions because as often uneconomical time-wise and more often chosen to meet the needs of the clinician as opposed to those of the patient. Also, it can be argued that the quicker the patient experiences relaxation and reduces the experience of anxiety, the more effective the treatment will be.  There are a great number of inductions available in various texts, on the Internet, and elsewhere that can be added to the practitioner’s repertoire. The choice of the trance induction is very important because it should be tailored to meet the particular needs of the patient.  In addition to being short and uncomplicated, inductions in the practice of BCH are direct and self-ratifying.  They have built-in deepening mechanisms and access the sensory processing system of the patient. 


The induction process involves re-directing the patient's focus of attention.  As such, some induction procedures are designed to internalize the patient's focus of attention, some are designed to externalize it, and some induction procedures do both.  If a change in mind and body function is what is called for, then an "internalizing induction" is typically indicated.  If a release of emotional overlay is mostly indicated, then an "externalizing induction" is typically indicated.  If both goals are indicated, then the induction will typically be designed to both internalize and externalize.  BCH usually utilizes inductions that are designed to add self-hypnosis or instant relaxation if appropriate. This decreases or eliminates reliance on the therapist as soon as appropriate and gives the patient a sense of long-term self-control (self-efficacy).  


The importance of the relaxation experience. BCH assumes the position that the experience of clinician-induced and self-induced relaxation within the hypnotic construct is a very important beginning to the change process.  The reduction of emotional overlay and the building of a memory of physical and emotional comfort are important in helping the patient change from a negative mind set to one of positive expectancy.  This allows for the establishment of a new memory that is a great relief from thoughts and feelings of suffering that the patient brought to the treatment setting. This new memory will be accessed continuously during the treatment process and strengthened until it automatically becomes the unconscious and automatic memory of choice.


The "Trance State".  Because BCH includes the assumption that most of the work of change takes place during the Waking State Reframing process, the Trance State is viewed as a critical process in which logic is set aside and suggestions, acceptable to the patient and appropriately presented, become fixed in place.  Therefore, often the state of Trance can be relatively short, compared to the longer time involved for the Waking State Reframing.  Trance is the "fixative" and the "imprinter" of change.


Self-Hypnosis. In BCH many "Simple" or "Empty Habits" (and single problem symptoms) can be changed in a single visit, without the teaching of self-hypnosis.  For more complex problems, the teaching of self-hypnosis is essential.  Even so, there are some occasions when the patient cannot or chooses not to practice self-hypnosis.  When this situation arises, if the experience of deep relaxation occurs during clinician-initiated trance, self-hypnosis can be put aside. Instead, more direct suggestions for change may be just as effective with many patients.


"Instant Relaxation" as an immediately available coping skill.  The learning of instant relaxation skills (e.g. Three Deep Breaths, Attention to Breathing, etc.) can be an important adjunct to helping the patient deal with future situations that may be stressful.  The use of these skills can also avert the fear of the return to old behavior.  This is different from Post-hypnotic cues or suggestions that are often given to automatically feel relaxed.  Most Post-hypnotic suggestions may have a limited life span or "half-life" unless they are frequently reinforced.        




·             The American Society of Clinical Hypnosis (ASCH)


·             American Psychological Association, Division of Hypnosis


·             The International Journal of Clinical and Experimental Hypnosis (IJCEH)


·             The International Society of Hypnosis (ISH)


·             The International Society for the Study of Dissociation (ISSD)


·             The Milton H. Erickson Foundation


·             Hypnosis News & Discussion Group on


·             The Society for Clinical and Experimental Hypnosis (SCEH)





Alexander, F., & French, T. (1946).  Psychoanalytic therapy: Principles and applications. New York: Ronald Press.


Bandler, R., & Grinder, J. (1979).  Frogs into princes: Neurolinguistic programming. Moab, UT: Real People Press.


Bandura, A. (1976).  Social learning theory.  New York: Prentice Hall.


Bandura, A., O'Leary, A., Taylor, C.B., Gauthier, J., & Gossard, D. (1987).  Perceived self-efficacy and  pain control:  Opioid and nonopioid mechanisms. Journal of Personality and Social Psychology, 53, 563-571.


Barber, J. (1996).  Hypnosis and suggestion in the treatment of pain.  New York: W.W. Norton.


Barnier, A.J. and Council, J.R. (2010). Hypnotizability matters: The what, hwy and how of measurement (pp. 47-78). In S.J. Lynn, J.W. Rhue, & I. Kirsch (Eds.). Handbook of clinical hypnosis, Second Edition. Washington DC: APA Books.


Bates, B.L. (1993).  Individual differences in response to hypnosis.  In J.W. Rhue, S.J. Lynn & I. Kirsch (Eds.), Handbook of clinical hypnosis (pp. 23-54). Washington, DC: APA.


Bateson, G., Jackson, D.D., Haley, J., & Weakland, J.H. (1956).  Toward a theory of schizophrenia. Behavioral Science, Vol. 1, 251-264.


Beck, J.S. (1995).  Cognitive therapy: Basics and beyond.  New York:  The Guilford Press.


Beier, E.G. (1966).  The silent language of psychotherapy: Social reinforcement of unconscious processes.  Chicago: Aldine Publishing Company.


Benson, H., Arns, P.A., & Hoffman, J.W. (1981).  The relaxation response and hypnosis. International Journal of Clinical and Experimental hypnosis, Vol. XXIX, No. 3, 259-270.


Blanchard, E.B., Kim, M., Hermann, C., & Steffek, B.D. (1993).  Preliminary results of the effects on headache relief of perception of success among tension headache patients receiving relaxation. Headache Quarterly, 4, 249-253.


Bloom, P.B. (1994).  Is insight necessary for successful treatment? Discussion of suggestibility and Repressed Memories of Abuse.  American Journal of Clinical Hypnosis, Vol. 36, No. 3, 172-174.


Bower, G.H., & Hilgard, E.R. (1981).  Theories of learning.  New York: Prentice Hall.


Bowers, K.S. (1976).  Hypnosis for the seriously curious.  New York: W.W. Norton.


Braid, J. (1843).  Neurypnology, or the rationale of nervous sleep considered in relation with animal magnetism.  London: Churchill.


Bromberg, W. (1959).  The mind of man: A history of psychotherapy and psychoanalysis. New York: Harper & Brothers, Publishers.


Brown, D.P. & Fromm, E. (1987).  Hypnosis and behavioral medicine.  Hillsdale, NJ: Lawrence Erlbaum.


Cameron-Bandler, L. (1978).  They lived happily ever after: A book about achieving happy endings in coupling.  Cupertino, CA: Meta Publications.


Cheek, D.B. (1994).  Hypnosis: The application of ideomotor procedures.  Boston: Allyn & Bacon.


Chess, S., & Alexander, T. (1996).  Temperament: Theory and practice.  New York: Brunner/Mazel.


Clarkin, J.F., Yeomans, F.E., & Kernberg, O.F. (1999).  Psychotherapy for borderline personality.New York: John Wiley & Sons, Inc.


Coe, W.C. (1993).  Expectations and hypnotherapy.  In J.W. Rhue, S.J. Lynn & I. Kirsch (Eds.), Handbook of clinical hypnosis, (pp. 73-94).  Washington, DC: APA.


Coue, E. (1922).  Self-mastery through conscious autosuggestion.  New York: American Library Service.


Council, J.R. (1999).  Measures of hypnotic responding.  In I. Kirsch, A. Capafons, E. Cardena, & S. Amigo (Eds.), Clinical hypnosis and self-regulation: Cognitive-behavioral perspectives (pp. 119-140).  Washington, D.C.: American Psychological Association.


De Pascalis, V. (1999).  Psychophysiological correlates of hypnosis and hypnotic susceptibility.         International Journal of Clinical and Experimental hypnosis, Vol. 47, No. 2, 117-142.


Eastwood, J.D., Gaskowski, P., & Bowers, K.S. (1998).  The folly of effort: Ironic effects in the mental control of pain.  International Journal of Clinical and Experimental hypnosis, Vol. XLVI, 1, 77-91.


Edmonston, W.E. (1981).  Hypnosis and relaxation: Modern verification of an old equation. New York: John Wiley and Sons.


Eimer, B.N. (1988).  The chronic pain patient: Multimodal assessment & psychotherapy.  International Journal of Medical Psychotherapy, 1, 23-40.


Eimer, B.N. (1989).  Psychotherapy for chronic pain: A cognitive approach.  In A. Freeman, K.M. Simon,  L. Beutler, & H. Arkowitz, (Eds.), Comprehensive handbook of cognitive therapy (pp. 449-465).    New York: Plenum Press.


Eimer, B.N. (2000a).  Clinical applications of hypnosis for brief and efficient pain management psychotherapy.  American Journal of Clinical Hypnosis, Vol. 43, No. 1, 17-40.


Eimer, B.N. (2000b, Summer).  Hypnosis for the relief of pain: What's possible and what's not. Psychological Hypnosis, Vol. 9, No. 2.


Eimer, B.N., & Freeman, A. (1998).  Pain management psychotherapy: A practical guide. New York: John Wiley and Sons.


Eimer, B.N., & Hornyak, L. (2001, Spring).  Forensic considerations when using hypnosis with post-accident personal injury patients: 10 essential guidelines. Psychological Hypnosis, Vol. 10, No. 1.


Ellenberger, H.F. (1970).  The discovery of the unconscious: The history and evolution of dynamic psychiatry.  New York: Basic Books.


Ellis, A. (1996).  Better, deeper and more enduring brief therapy: The rational emotive behavior therapy approach.  New York: Brunner/Mazel Publishers.


Erickson, M.H. (1948).  Hypnotic psychotherapy.  In The medical clinics of North America (pp. 571-583). New York: W.B. Saunders.


Erickson, M.H. (1961).  Historical note on the hand levitation and other ideomotor techniques.         American Journal of Clinical Hypnosis, 3, 196-199.


Erickson, M.H. (1980a).  An hypnotic technique for resistant patients: the patient, the technique, and its rationale and field experiments.  In E.L. Rossi (Ed.), The nature of hypnosis and suggestion: The collected papers of Milton H. Erickson on hypnosis.  Vol. I (p. 306).New York: Irvington Publishers, Inc.


Erickson, M.H. (1980b).  Hypnosis in painful terminal illness.  In E.L. Rossi (Ed.), Innovative         hypnotherapy: The collected papers of Milton H. Erickson on hypnosis.  Vol. IV. New York: Irvington Publishers, Inc.


Erickson, M.H. (1985).  Life reframing in hypnosis.  E.L. Rossi, & M.O. Ryan (Eds.), The seminars, workshops and lectures of Milton H. Erickson (Vol. II).  New York: Irvington Publishers.


Erickson, M.H., & Rossi, E.L. (1979).  Hypnotherapy: An exploratory casebook. New York: Irvington Publishers, Inc.


Erickson, M.H., & Rossi, E.L. (1981).  Experiencing hypnosis: Therapeutic approaches to altered states. New York: Irvington Publishers, Inc.


Erickson, M.H., Rossi, E.L., & Rossi, S.I. (1976).  Hypnotic realities: The induction of clinical hypnosis    and forms of indirect suggestion.  New York: Irvington Publishers, Inc.


Evans, F.J. (1991).  Hypnotizability: Individual differences in dissociation and the flexible control of cognitive processes. In S.J. Lynn & J.W. Rhue (Eds.), Theories of hypnosis.  New York: Guilford.


Ewin, D.M. (1984).  Hypnosis in surgery and anesthesia.  In W.C. Wester, II, & A.H. Smith (Eds.), Clinical hypnosis: A multidisciplinary approach (pp. 210-235).  Philadelphia: J.B. Lippincott Company.


Ewin, D.M. (1986).  Hypnosis and pain management.  In B. Zilbergeld, M.G.


Edelstien, & D.L. Araoz        (Eds.), Hypnosis: Questions & Answers (pp. 282-288). New York: W.W. Norton & Company. 


Ewin, D.M. (1992a).  Constant pain syndrome: Its psychological meaning and cure using hypnoanalysis.   Hypnosis, XIX (1), 57-62.


Festinger, L. (1957).  A theory of cognitive dissonance.  Stanford, CA: Stanford University Press.


Fine, R. (1990).  History of psychoanalysis.  Northvale, New Jersey: Jason Aronson Publishers.


Fourie, D.P. (1995).  Attribution of meaning: An ecosystemic perspective on hypnotherapy. American Journal of Clinical Hypnosis, Vol. 37, No. 4, 300-315.


Frank, J.D. (1974).  Persuasion and healing: A comparative study of psychotherapy. New York: Schocken Books.


Fredericks, L.E. (2001).  The use of hypnosis in surgery and anesthesiology: Psychological preparation of the surgical patient.  Springfield, IL: Charles C. Thomas.


Freeman, A., Pretzer, J., Fleming, B., & Simon, K.M. (1990).  Clinical applications of cognitive therapy.  New York:  Plenum Press.


Gatchel, R.J., & Blanchard, E.B. (Eds.). (1993).  Psychophysiological disorders: Research and clinical applications.  Washington, DC:  American Psychological Association.


Gauld, A. (1992).  A history of hypnotism.  Cambridge, UK: Cambridge University Press.


Gibbons, D.E. and Lynn, S.J. (2010). Hypnotic Inductions: A Primer.  In SJ Lynn, JW Rhue, & I Kirsch (Eds), Handbook of Clinical Hypnosis.  Washington DC: APA Books.


Gravitz, M.A. (1994).  The first use of self-hypnosis: Mesmer mesmerizes Mesmer. American Journal of Clincal Hypnosis, Vol. 37, No. 1, 49-52.


Greenwald, A.G. (1992).  New look 3: Unconscious cognition reclaimed.  American Psychologist,       47, 766-779.


Grinder, J., & Bandler, R. (1976).  The structure of magic II: A book about communication & change. Palo Alto, CA: Science and Behavior Books, Inc.


Grinder, J., & Bandler, R. (1981).  Trance-formations: Neuro-linguistic programming and the structure of hypnosis.  Moab, UT: Real People Press.


Haley, J. (1986).  Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D. New York: W.W. Norton & Company.


Hartland, J. (1965).  The value of ego-strengthening procedures prior to direct symptom-removal under hypnosis.  American Journal of Clinical Hypnosis, 8, 89-93.


Hartland, J. (1971).  Further observations on the use of ego-strengthening techniques. American Journal of Clinical Hypnosis, 14, 1-8.


Havens, R.A. (Ed.). (1992). The wisdom of Milton H. Erickson: Hypnosis & hypnotherapy (Vol I). New York: Irvington Publishers.


Hilgard, E.R., & Hilgard, J.R. (1994).  Hypnosis in the relief of pain (Rev. ed.). New York: Brunner/Mazel.


Holroyd, J. (1996).  Hypnosis treatment of clinical pain: Understanding why hypnosis is useful. International Journal of Clinical and Experimental hypnosis, Vol. XLIV, No. 1, 33-51.


Hope, D.A., & Heimberg, R.G. (1993).  Social phobia and social anxiety.  In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (Second ed.) (pp. 99-136).  New York: Guilford Press.


Humphreys, R.B. (2000).  The neurobiology of hypnosis.  Advanced workshop presented at the annual meeting of the American Society of Clinical Hypnosis, Baltimore, MD.


Hunter, M.E. (1996).  Making peace with chronic pain: A whole-life strategy.  New York: Brunner/Mazel.


Imber-Black, E., Roberts, J., & Whiting, R. (Eds.). (1989). Rituals in families and family therapy. New York: W.W. Norton & Company.


Kelly, G.A. (1955).  The psychology of personal constructs (Vols. 1 and 2).  New York: W.W. Norton.


Kihlstrom, J.F., Barnhardt, T.M., & Tataryn, D.J. (1992).  The psychological unconscious.  American Psychologist, 47, 788-791.


Kirsch, I. (2000).  The response set theory of hypnosis. American Journal of Clinical Hypnosis, Vol. 42, Nos. 3, 4, 274-292.


Kozak, M.J., & Foa, E.B. (1999).  Mastery of Obsessive Compulsive Disorder therapist guide. New York: Therapyworks Series, Academic Press.


Kroger, W.S. (1977).  Clinical and experimental hypnosis (2nd ed.).  Philadelphia: J.B. Lippincott.


Laing, R.D. (1965).  Mystification, confusion, and conflict.  In I. Boszormenyi-Nagy & J. Framo (Eds.), Intensive family therapy.  New York: Harper & Row.


Langs, R.J. (1995).  The therapeutic interaction: Synthesis of the multiple components of therapy.  Northvale, New Jersey: Jason Aronson.


Lankton, S.R. (1980).  Practical magic: A translation of basic neuro-linguistic programming into clinical psychotherapy.  Cupertino, CA: Meta Publications.


Lankton, S.R., & Lankton, C.H. (1983).  The answer within: A clinical framework of Ericksonian hypnotherapy.  New York: Brunner/Mazel Publishers.


Lewis, B.A., & Pucelik, F. (1982).  Magic demystified: A pragmatic guide to communication and change. Lake Oswego, OR: Metamorphous Press.


Linehan, M.M. (1993).  Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press.


Lynn, SJ, Kirsch, I, and Rhue, JW. (2010). An introduction to clinical hypnosis (p.3-18). In S.J. Lynn, J.W. Rhue, & I. Kirsch (Eds.). Handbook of clinical hypnosis, Second Edition. Washington DC: APA Books.


Meichenbaum, D. (1977).  Cognitive-behavior modification: An integrative approach.  New York: Plenum.


Meichenbaum, D., & Turk, D.C. (1987). Facilitating treatment adherence: A practitioner's guidebook. New York: Plenum Press.


Melzack, R. (1999).  Pain and stress: A new perspective.  In R.J. Gatchel, & D.C. Turk (Eds.),         Psychosocial factors in pain: Critical perspectives (pp. 89-106).  New York: Guilford Press.


Oakley, D.A. and Halligan, P.W. (2010). Psychophysiological foundations of hypsnosis and suggestion. (p. 79-118). In S.J. Lynn, J.W. Rhue, & I. Kirsch (Eds.). Handbook of clinical hypnosis, Second Edition. Washington DC: APA Books.


Palazzoli, M.S., Boscolo, L, Cecchin, G, & Prata, G. (Eds.). (1978;1995).  Paradox and counter paradox: A new model in the therapy of the family in schizophrenic transaction.  Northvale, New Jersey: Jason Aronson.


Piaget, J., & Inhelder, B. (2000).  The psychology of the child (Revised ed.).  New York: Basic Books.


Powers, W.T. (1973).  Behavior: The control of perception.  Chicago: Aldine Publishing Company.


Rossi, E.L. (1993).  The psychobiology of mind-body healing: New concepts in therapeutic hypnosis.New York: W.W. Norton & Company.


Rossi, E.L., & Cheek, D.B. (1988).  Mind-body therapy: Methods of ideodynamic healing with hypnosis.New York: W.W. Norton and Company.


Sanders, S. (1991).  Clinical self-hypnosis: The power of words and images. New York: The Guilford Press.


Selye, H. (1974).  Stress without distress.  New York: Harper & Row Publishers.


Selye, H. (1976).  The stress of life.  New York: McGraw-Hill Book Company.


Shutty, M.S., DeGood, D.E., & Tuttle, D.H. (1990).  Chronic pain patients' beliefs about their pain and treatment outcomes.  Archives of Physical Medicine and Rehabilitation, 71, 128-132.


Simonton, D.C., Matthews-Simonton, S., & Creighton, L.J. (1978).  Getting well again. Los Angeles: Tarcher-St. Martins.


Sluzki, C.E., & Ransom, D.C. (Eds.). (1976).  Double binds: The foundation of the communicational approach to the family.  New York: Grune & Stratton.


Sobell, M.B. (1978).  Behavioral treatment of alcohol problems: Individualized therapy and controlled drinking.  New York: Plenum.


Spiegel, H., & Spiegel, D. (1978/1987).  Trance and treatment: Clinical uses of hypnosis. Washington, DC: American Psychiatric Press, Inc.


Steketee, G.S. (1996).  Treatment of obsessive-compulsive disorder.  New York: The Guilford Press.


Teitelbaum, M. (1965).  Hypnosis induction technics.  Springfield, IL: Charles C. Thomas.


Turk, D.C., & Flor, H. (1999).  Chronic pain: A biobehavioral perspective.  In R.J. Gatchel, & D.C. Turk (Eds.), Psychosocial factors in pain: Critical perspectives (pp. 18-34).  New York: Guilford Press.


Van Der Hart, O. (1982).  Rituals in psychotherapy: Transition and continuity. New York: Irvington Publishers.


Vetter, H.J. (1969).  Language, behavior, and psychopathology.  Chicago: Rand McNally.


Walrond-Skinner, S. (1986).  Double bind.  In Dictionary of psychotherapy (pp. 102-103). London: Routledge & Kegan Paul.


Watkins, J.G. (1978).  The therapeutic self.  New York: Human Sciences Press.


Watkins, J.G., & Watkins, H.H. (1997).  Ego states: Theory and therapy.  New York: W.W. Norton.


Watzlawick, P., Beavin, J.H., & Jackson, D.D. (1967).  Pragmatics of human communication.New York: W.W. Norton and Company.


Watzlawick, P. (1978).  The language of change: Elements of therapeutic communication. New York: W.W. Norton.


Wolpe, J. (1982).  The practice of behavior therapy (Third ed.).  New York: Pergamon Press, Inc.


Woody, E.Z., Bowers, K.S., & Oakman, J.M. (1992).  A conceptual analysis of hypnotic responsiveness: Experience, individual differences, and context.  In E. Fromm & M.R. Nash (Eds.), Contemporary hypnosis research (pp. 3-33).  New York: The Guilford Press.


Zarren, J.I. (1996a).  Cognitive hypnosis for behavior change.  Unpublished manuscript.


Zarren, J.I. & Eimer, B.N. (1999).  Brief cognitive hypnosis.  Advanced workshop presented at the annual meeting of the American Society of Clinical Hypnosis, Atlanta, GA.



This test is only active if you are successfully logged in.

Additional information