Why are CBT Outcomes Greatly Improved by Hypnosis?

CBT techniques can be a part of treatment, and sometimes a really important part. But we are all thinking, feeling, and imaginative beings and psychotherapy needs to address all these different, natural parts of human experience.

My client Rebecca looked pained. “I know not everyone can like me. But I feel that everyone should. I’m terrified of rejection!”

As with so many clients, the divide between Rebecca’s thoughts and feelings was stark. I needed to change not just her troublesome thinking but also her self-harming feelings.

One of the original premises of cognitive behavioral therapy – CBT – is that the best way to change feelings is to challenge thoughts. But that’s not always so easy. If you use clinical hypnosis in your work then you might not be surprised to know that CBT can be more effective when used in combination with hypnosis. And the effect is not small.

A large meta-analysis of 18 studies has shown that cognitive behavioral therapy is a whopping 70% more effective when used in combination with hypnosis than when used alone.¹

If you’ve treated even a few clients using hypnosis, this should come as little surprise. Here I want to show why hypnosis makes such a difference to positive treatment outcomes and therefore why all CBT practitioners should be well versed in clinical hypnosis.

How thoughts blend with feelings

CBT is the style of therapy that seeks to challenge and change thoughts in order to change feelings, as well as help the client make positive behavioral changes.

Thoughts and feelings do track together. For example, the more depressed or frightened someone is, the more black-or-white their thinking tends to be.² By examining our thoughts, we can decide whether they are valid or not. In this way, CBT can and does help people.

But if it’s as simple as just logging and changing thoughts, or suggesting new behaviours (many CBTers would claim it’s not that simple, but that is the basic premise), then why the huge increase in success when hypnotic treatment is added to CBT?

Could it be that powerful feelings drive our thinking, and not the other way around? That strong feelings are beyond reason and that calming the feelings is a better and easier way to change thoughts than the other way about?

This would make sense for a startlingly simple reason.

The brain needs you to survive

When we look at the structure of the brain, we see the history of the brain.³ Like a house in which new parts have been added on top of older parts, the structure of the brain shows us how it has evolved over time. The newest roof extension (the cerebral cortex, which is responsible for higher processing) sits on top of the older parts (the ‘reptilian’ brainstem and limbic system, which deal in emotion).

We were emotional before we were cognitive, and these parts of us can still dominate. What’s more, there are more neuronal connections leading from the limbic system to the cortex than the other way about, giving the emotional brain enormous influence on how we think as well as feel.⁴

Yes, we can think our way out of emotionality to a certain extent, but this can be really hard when we are strongly emotional. Powerful emotion means we can react emotionally before any thought happens at all! An instigating trigger, such as seeing a snake, will be fast-tracked to your fight-or-flight centre, the amygdala, and drive you to run, fight, or feel terrified before you have time to form thoughts.⁵ This happens because our emotions are critical to our survival. They need to occur before thought.

When we react unthinkingly, we are experiencing a pattern match,which always occurs in the absence of thought. A pattern match is simply the brain instinctively responding to an environmental trigger. These matches can be innate, such as when a baby naturally matches the instinct to suck when presented with a teat; or they can be learned, such as when a person comes to match the instinct to run when they see a spider.

Simply trying to analyze what you might have been thinking before you became fearful, or what your assumptions were, may do little good when in fact the brain is simply doing an emotional pattern match. Trying to douse an inferno of feeling with a few cupfuls of cognition may be worse than useless if those cognitive approaches aren’t used alongside techniques that help the client change at the instinctive level of automatic pattern matching.

When we use hypnosis in therapy we can work with the client to directly change the way they respond to life’s events on an emotional level.

Why else might hypnosis be so amazingly effective at increasing the outcomes of CBT therapy?

Hypnosis helps us make changes at the level of the problem

Many emotional problems are not due to faulty thinking or ‘thought disorders’, but rather unconscious and initially non-cognitiveemotional conditioning which is then reflected in the way the person thinks.

Negative, simplistic, or extremist thinking, which we find in those who suffer anxiety and depression (as well as jealousy and anger) tend to be produced by the emotion, but then in turn produce more of the emotion.

So calming the emotions down first, then examining and challenging the disordered thoughts seems to be the easiest route to better mental health. Hypnosis helps us help a person on the level of the unconscious so that they can start to feel better without even necessarily knowing why they feel better.

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It’s not the conscious mind that knows how to create a dream, or release insulin from the pancreas, or heal scarred skin. And it’s not the conscious mind that knows how to blush when we feel embarrassed, or produce a flashback or phobic response.

We can’t consciously stop any of this, or not easily anyway.

It’s within the unconscious mind that real change happens, and the best way to connect with someone’s unconscious processes is through hypnosis. This is why it may be harder to treat, say, physical pain through CBT than through hypnosis – because the onset of pain may have little to do with what someone thinks or doesn’t think.⁶

Hypnosis can greatly augment CBT for yet another reason. Hypnosis is a powerhouse for creating unconscious positive expectancy.

Creating powerful expectation with hypnosis

Placebo, the power of positive expectancy, is immensely powerful. As is, unfortunately, its evil twin nocebo, in which we expect the worst. Some expectations reside in our conscious minds, as when you expect (or not) to have a great time at your friend’s upcoming wedding. But expectations aren’t just about forming cognitive assumptions about the future. Many – in fact, most – expectations reside at the unconscious level.

You may have had the experience of trying to consciously recall some famous person’s name. The more you try to bring their name to mind, the further it goes from you. Hours later you’ve long since consciously forgotten about this celebrity’s name, but your unconscious mind has been working on the problem all the while. Now that it has an expectation that you need to recall that actor’s name, hey presto, it pops into your mind when you’re consciously thinking about something else entirely!

So what has this got to do with hypnosis greatly improving CBT results? Well, there’s an interesting thing about the use of CBT to treat depression.

Through a meta-analysis of 70 studies between 1977 and 2014, psychological researchers Tom Johnsen and Oddgeir Friborg drew a strange conclusion: CBT is now around half as effective in treating depression as it used to be.⁷ Why on Earth would that be?

It may have to do with expectations, and that is exactly the conclusion the researchers drew. In the early days of CBT, depression sufferers would have likely had high hopes for its effectiveness. But as the novelty of CBT has worn off and reports have emerged questioning its effectiveness, such positive expectation (the placebo effect) may have worn off a bit.

Half of CBT’s initial effectiveness in the treatment of depression may have been purely due to the sense of hope it generated in those being treated. But when you add hypnosis to CBT, you are using a clinical tool that inherently utilises the power of expectancy.

So it makes sense that CBT could be 70% more effective when used with hypnotic therapy in that positive expectations can be instilled as part of the therapy when we use hypnosis.

Okay, but what about the behaviour part of cognitive behaviour therapy?

Helping people behave differently as well as think differently can be a vital part of effective therapy. But we need to help our clients actually become motivated to behave in new ways.

Hypnosis can help here too.

How hypnosis can improve the B of CBT

Exercise⁸, acting more assertively, and tending towards actively solving problems rather than simply dwelling on them are all behaviours that help clients thrive. But simply telling clients they should try this or that new behaviour may have us coming up against a wall of reluctance.

Research has found that hypnotically rehearsing new behaviours, especially when we inwardly experience seeing ourselves engage in them, makes us much more likely to actually engage in these new behaviours.⁹

Other research has found that expecting success was much more predictive of actual success than simply fantasizing about success.¹⁰ Presumably this is because those who expect success are more focused on the actual steps to success.

I have found that hypnotically rehearsing the steps towards the goal rather than just fantasizing about the end result makes working towards that goal much more compelling. This creates an expectation that you will take those steps, just as your efforts to recall a famous person’s name create an unconscious compulsion to remember it. Hypnotic rehearsal of the steps makes the steps themselves more compelling and adds a sense of confidence that, actually, you can do this.

Without the engine of hypnosis, CBT starts to look less effective.

But there’s one more huge advantage to augmenting CBT therapy with hypnosis – an advantage that is rather obvious but may be easily overlooked.

The enormous benefits of calm and peace

Emotional problems ride on the back of acute and chronic stress in the mind and body. The old expression “a depressed brain is a stressed brain”is absolutely right.¹¹ Stress drives panic disorders and many forms of depression, and is acute, of course, during phobic responses and post-traumatic stress disorder. So any tool that can profoundly lower stress will help therapy along.

Hypnosis is one of the most relaxing experiences people can have. During hypnotic therapy we can make suggestions that difficult parts of a client’s life can become much calmer, but we can also help the client feel more generally relaxed in their life and therefore better able to meet their emotional needs.

The antidote to stress is calm, peace, and relaxation, and it’s during times of such comfort that many beneficial unconscious changes can occur within the client.

So hypnosis is a great boon to CBT, and in fact may make all the difference, because:

1. Many really powerful emotional responses occur before any thought at all. Therefore an approach like hypnosis, which deals directly with lived experience, may be more effective.
2. The pattern of the emotional problem lies within the unconscious rather than conscious mind, and we use hypnosis to make unconscious changes.
3. We are all a bundle of expectations, and the quality of our expectations is related to our mental health and wellbeing. Hypnosis is highly effective in helping clients develop positive expectations and also sometimes suspend expectations so they can better tolerate uncertainty.
4. We can, through hypnotic rehearsal, help our clients feel truly motivated to act in ways that will help them.
5. We can help our clients find deep peace and calm through the application of clinical hypnosis in therapy.

So CBT techniques can be a part of treatment, and sometimes a really important part. It can be a great way to help clients see what they have been doing and understand common cognitive distortions. But the fact that CBT is so greatly improved by adding hypnotic work into the mix is really telling I think.

We are all thinking, feeling, and, yes, hypnotic beings – and therapy needs to address all these different, natural parts of human experience.

How to Add Hypnosis to Your Therapeutic Toolkit

As therapists, we need to use every tool available to us to help our clients as quickly as possible. Hypnosis is the human mind’s most powerful capability and can effect change rapidly and deeply. Learn how to use clinical hypnosis with our online course Uncommon Hypnotherapy.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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