Cognitive-behavioural hypnotherapy

1. Introduction

Version followed: Donald J. Robertson, The Practice of Cognitive-Behavioural Hypnotherapy: A Manual for Evidence-Based Clinical Hypnosis (Karnac 2012/2013; Routledge reissue), used for the overall structure (assessment, case formulation, socialisation and hypnotic-skills training, then coping skills, affect, behaviour and cognition modules). The mindfulness-based variant follows Lynn et al.'s mindfulness-hypnosis suggestions and Elkins & Olendzki's Mindful Hypnotherapy (Springer 2019). Only the publishers' tables of contents and descriptions of these books are drawn on, not their full text. Step-level detail is therefore labelled [synthesis] unless another cited source supports it. [uncertain]

What it is. Cognitive-behavioural hypnotherapy (CBH) is an integrated psychological therapy that combines clinical hypnosis with cognitive-behavioural therapy (CBT). It is a framework for combining the two, not a single fixed protocol. Robertson presents it as using a research-based cognitive-behavioural model of hypnosis, combined in practice with traditional hypnotherapy and CBT techniques. [source: Routledge book page; Wikipedia, Hypnotherapy]

Lineage of the names (as far as the sources allow).

Theodore X. Barber and colleagues (Barber, Spanos & Chaves, 1974, Hypnosis, Imagination and Human Potentialities) argued that hypnosis reflects ordinary psychological variables rather than a special state. These variables are active imagination, expectation, attitudes and motivation. Barber introduced the term "cognitive-behavioral" for this nonstate view and discussed its use in behaviour therapy. [source: Wikipedia, Hypnotherapy; Chaves 2006]
Irving Kirsch co-authored the 1995 meta-analysis of hypnosis as an adjunct to cognitive-behavioural psychotherapy (Kirsch, Montgomery & Sapirstein). With Lynn and Rhue he co-edited clinical handbooks of evidence-based hypnosis. His response-expectancy theory is commonly linked to CBH, but the theory is not described here. [uncertain] [source: Chaves 2006; Wikipedia]
Donald Robertson is a UK CBT therapist and principal of the UK College of Hypnosis & Hypnotherapy. He wrote the treatment manual followed here and edited James Braid's writings (The Discovery of Hypnosis). [source: Karnac product page]
Related but distinct: Assen Alladin's cognitive hypnotherapy (Wiley 2008; LWW 2007 depression handbook) combines CBT with hypnosis using his own case formulation and the "Circular Feedback Model of Depression". It is a parallel integrative approach, not Robertson's manual. [source: Wiley e-bookshelf page; Ovid page]

Mindfulness-based cognitive-behavioural hypnotherapy. This exact name is not attested as a distinct, separately developed therapy. [uncertain] Two named strands combine mindfulness with hypnosis:

Steven Jay Lynn and colleagues are cognitive-behavioural and sociocognitive hypnosis researchers. They describe giving hypnotic inductions with mindfulness and attention-training suggestions, with examples for depression and PTSD. This places mindfulness inside a cognitive-behavioural hypnosis frame. [source: Lynn et al., J Mind–Body Regulation]
Gary Elkins and Nicholas Olendzki at Baylor University developed Mindful Hypnotherapy, also called Mindfulness-Based Hypnotherapy (MBH). It is manualised in Elkins & Olendzki (2019) as eight weekly one-hour sessions that use hypnotic induction and suggestion to build mindfulness. [source: Padilla, ISH Encyclopedia; Olendzki 2016]

In this guide, "mindfulness-based CBH" means CBH (Robertson's frame) plus a mindfulness module drawn from these two strands. Treat it as an application of those approaches, not as a separate school. [synthesis]

Core idea of change. On the cognitive-behavioural view, hypnotic responding is a skill built on imagination, expectancy, attitudes and motivation. Inductions and suggestions work by guiding the client to imagine and mentally simulate desired experiences. They also raise positive expectancy and help the client rehearse coping responses. Once the client has learned these skills, they serve as vehicles for CBT change processes: coping-skills acquisition, exposure, problem-solving and cognitive restructuring. [source: Wikipedia; Zahedi, Lynn & Sommer 2024 (imagery/simulation and expectancy); Routledge TOC] In the mindfulness variant, the same hypnotic vehicle is used to build present-moment, nonjudgmental awareness and decentring from thoughts. [source: Lynn et al.; Padilla]

2. Framework

CBH is modular. Robertson's manual is organised as follows. [source: Routledge TOC]

Phase	Manual heading	Goal
A. Assessment	Assessment in CBH	Define problems, goals, suitability and risk
B. Formulation	Case formulation in CBH	Build a shared cognitive-behavioural model of the problem
C. Socialisation and skills	Socialisation and hypnotic skills training	Correct misconceptions; teach hypnosis as a learnable skill of imagination and expectancy
D. Coping skills	Applied self-hypnosis and coping skills	Self-hypnosis used as a portable coping skill
E. Affect module	Hypnotic exposure therapy	Reduce fear and anxiety through exposure in imagination
F. Behaviour module	Problem-Solving Hypnotherapy (PSH)	Generate and mentally rehearse solutions
G. Cognition module	Cognitive hypnotherapy	Modify unhelpful beliefs and thoughts while hypnotised
H. Optional mindfulness module	(Lynn et al.; Elkins & Olendzki)	Present-moment, decentred, self-compassionate awareness

Format. Individual sessions, typically weekly. Hypnosis forms part of a CBT-structured session: agenda, homework review, in-session hypnosis, debrief and new homework. Audio recordings or self-hypnosis practice go between sessions. [synthesis] Lynn et al. note that attention exercises can be delivered by recording, and that the hypnosis arm of a depression pilot learned self-hypnosis. [source: Lynn et al.]

Session count. The sources give no session count for Robertson's manual. [uncertain] Mindful Hypnotherapy is eight weekly one-hour sessions. [source: Padilla; Olendzki 2016] An example from a related hypnotherapy-versus-CBT depression trial (Tübingen) used 20 individual sessions per arm. [source: NCT02375308] Plan about 6–20 sessions, depending on the modules used and the problem. [synthesis]

Sequencing and criteria for moving on. [synthesis, derived from the module order]

A→B: problem list, goals and risk screen done; no contraindication present (see 5).
B→C: client agrees with the formulation and with the rationale for adding hypnosis.
C→D: misconceptions are corrected, and the client shows at least some response to simple imaginative suggestions. Low responders can still continue, because Lynn et al. note that mindfulness-type suggestions are easy to pass, so high responsiveness is not required.
D→E/F/G: client can use self-hypnosis to settle arousal, and practises it between sessions.
Choose modules by formulation: anxiety or avoidance → E; skills deficit or indecision → F; dominant negative beliefs or rumination → G and/or H.
Ending: goals met, client self-applies skills, relapse-prevention rehearsal done.

3. Guiding principles

The source of each principle is tagged on its line.

Hypnosis is a learnable cognitive-behavioural skill, not a trance imposed by the therapist. In practice, teach it collaboratively, attribute success to the client's own imagining, and train it like any other CBT skill. [source: Wikipedia on Barber; Routledge TOC "hypnotic skills training"]
Expectancy matters. Present hypnosis credibly and positively, and avoid framing that predicts failure. Expectations told to participants change how they respond to suggestions. [source: Zahedi et al. 2024]
Imagination and simulation are the active ingredients. Write suggestions as vivid, multisensory things to imagine, not as commands. [source: Zahedi et al. 2024; Barber per Wikipedia]
Hypnosis is an adjunct inside CBT, not a replacement for it. Keep formulation, measurement and homework; use hypnosis to deliver or intensify CBT methods. [source: Routledge description; Kirsch et al. 1995 as cited]
Integrate cognition, affect and behaviour. Choose the module by the formulation, not by habit. [source: Routledge TOC]
Base suggestions on the client's own description of the problem. Use the client's words and images; Chaves notes Hamburg did this. [source: Chaves 2006]
Goal-directed fantasy. Have clients imagine scenarios consistent with the desired outcome, a technique Chaves links to Spanos. [source: Chaves 2006]
Watch for ambivalence. Explore mixed feelings about change before suggesting it, because ambivalence about a positive outcome can undermine success. [source: Chaves 2006]
Self-hypnosis builds self-efficacy. Every in-session procedure should end up as something the client practises alone. [source: Routledge TOC; Padilla (self-efficacy in self-hypnosis as an MBH theme)]
Responsiveness is not a gatekeeper. Offer hypnosis to moderate and low responders too, especially with mindfulness-type suggestions. [source: Lynn et al.]
Acceptance plus change (mindfulness variant). Hypnosis carries a change emphasis and mindfulness an acceptance emphasis; the combination uses both. Elkins is reported to frame the method as "not a form of mind control". [source: Baptist News report; Padilla]
Memory caution. Never use hypnosis to retrieve or verify memories. Labelling a procedure as hypnosis can increase recalled material, including inaccurate material, and raise confidence in it. [source: Lynn et al.]
Consent and transparency. Describe exactly what will happen; the client can stop at any time; no covert or indirect inductions without consent. [synthesis]
Work within competence. Use hypnosis only for problems you are trained to treat without it. For medical uses, act only as an adjunct after medical assessment. [synthesis]

4. Intervention inventory

How to read this section. The intervention names and their order follow Robertson's chapter structure and the other sources. The manual's step-by-step text is not drawn on, so the steps below are standard CBT and clinical-hypnosis practice written by me, tagged [synthesis] unless a source is tagged. All example language is illustrative and is not the authors' scripts.

Standard hypnosis session frame. Use this frame for every in-session hypnosis procedure. [synthesis]

Check in, review homework and set an agenda.
Get specific consent for today's procedure.
Agree a stop signal, for example raising a hand.
Induction.
Optional deepening.
Therapeutic suggestion or imagery.
Post-hypnotic suggestion to cue self-hypnosis.
Re-alerting.
Debrief: what was experienced, any unwanted effects, link back to the formulation.
Set self-hypnosis or audio homework.

4.1 Assessment and suitability screening

Purpose / when: At the start of therapy. Defines problems, goals, risk and suitability for hypnosis. [source: Routledge TOC (assessment chapter); content synthesis]
Steps:
1. Run a standard CBT assessment: problem list, onset, maintaining factors, measurable goals and baseline symptom measures.
2. Screen for contraindications and cautions (see 5.1): psychosis, bipolar disorder, severe dissociation, acute suicide risk, severe cognitive impairment, active substance intoxication, and unprocessed trauma where imagery might trigger it. Two related depression trials excluded bipolar disorder, psychotic symptoms, acute suicide risk and severe cognitive impairment. [source: NCT02375308 (trial exclusions, not CBH-specific guidance)]
3. For somatic complaints, confirm that a medical assessment has been done before treating hypnotically as an adjunct.
4. Ask about previous hypnosis or meditation experiences, both good and bad, and about expectations.
5. Optional: a standardised hypnotisability measure. The Elkins Hypnotizability Scale was used in MBH research. Use it under licence and do not reproduce items. [source: Olendzki 2016]
Example language (illustrative): "Before we decide whether hypnosis fits, I'd like to understand the problem and check a few health questions. Some conditions need a different approach."
Watch for: Hopes of uncovering hidden memories (redirect, see 5.6). Expectations of a magic cure or fear of losing control (address in 4.3). Medical symptoms that have not been assessed.

4.2 Cognitive-behavioural case formulation

Purpose / when: After assessment. A shared model that drives module choice. [source: Routledge TOC; Alladin's books also have a case-formulation chapter (Wiley page)]
Steps:
1. Map triggers, thoughts or images, emotions, physical sensations and behaviours, including avoidance and safety behaviours.
2. Identify which of these the client imagines vividly; these mark entry points for hypnotic imagery.
3. Note any negative self-hypnosis, such as rumination, catastrophic imagery or worry, that can be treated as an unhelpful trance-like habit to be redirected. This is a common CBH framing but its exact source was not verified. [uncertain]
4. Agree which module or modules to use (see Framework).
Example language (illustrative): "When you picture the presentation going wrong, your body reacts as if it's happening now. Hypnosis can use that same imagination to rehearse coping instead."
Watch for: Disagreement with the model. Revise it together before you start hypnosis.

4.3 Socialisation: rationale and correcting misconceptions

Purpose / when: Before the first induction. Builds accurate, positive expectancy and informed consent. [source: Routledge TOC ("socialisation"); Zahedi et al. (expectancy shapes responding); Barber's nonstate view per Wikipedia]
Steps:
1. Ask what the client believes hypnosis is.
2. Explain the cognitive-behavioural view: hypnosis is focused imagination plus positive expectation and willing cooperation. The client stays aware, can refuse any suggestion and can stop at will.
3. Contrast this with stage shows and films.
4. Explain what the client will be asked to do, which is to actively imagine along with the suggestions.
5. Get verbal consent and record it.
Example language (illustrative): "Think of hypnosis as guided, absorbed imagining. You'll hear everything, you can open your eyes at any time, and the effects come from how fully you let yourself imagine, not from anything I do to you."
Watch for: Lingering fear of losing control (spend more time here). Over-attribution of power to the therapist (re-attribute to the client's skill).

4.4 Hypnotic skills training

Purpose / when: Early sessions, after socialisation. Teaches the client how to respond to suggestions: imagining actively, "going along" with the experience, and treating responses as things they let happen. [source: Routledge TOC ("hypnotic skills training"); sociocognitive tradition per Chaves and Wikipedia] The specific skills-training programmes in that tradition are not reproduced here. [uncertain]
Steps:
1. Start with simple imaginative suggestions, such as arm heaviness or lightness, or hands moving together.
2. Before each one, coach the strategy: picture something that would produce the effect.
3. Debrief: what did you imagine, and what helped?
4. Refine the strategy and repeat.
5. Gradually move to suggestions linked to the client's goals.
Example language (illustrative): "As I suggest your arm becoming light, imagine a cluster of helium balloons tied to your wrist, tugging gently upward, and let the arm respond if it wants to." (Balloon imagery for hand levitation is the example given in Zahedi et al.)
Watch for: The client trying to make the movement happen through effort, or waiting passively for something to happen. Coach toward active imagining while allowing the response. Improved subjective vividness and some response mean it is working.

4.5 Induction

Purpose / when: Each hypnosis session. Marks the shift into focused, absorbed imagining. [source: Zahedi et al. 2024: relaxation suggestions are the most common inductions, and how much the induction adds to the effect of verbal suggestions is not well established]
Steps (relaxation or eye-fixation type): [synthesis]
1. The client sits comfortably.
2. Fixate the eyes on a point.
3. Give suggestions that the eyelids are tiring, then that the eyes close.
4. Slow the breathing.
5. Relax progressively from head to feet.
6. Narrow attention to the therapist's voice and the client's inner imagery. Allow 3–10 minutes. An alert, eyes-open, focused-attention induction is an option for clients who dislike relaxation.
Example language (illustrative): "Let your eyes rest on that spot… notice the lids getting heavier… whenever they want to close, let them… and with each out-breath let your shoulders soften a little more."
Watch for: Anxiety caused by relaxation (relaxation-induced anxiety). If it appears, switch to an alert induction. Slowed breathing, stillness and reported absorption are signs it is working.

4.6 Deepening

Purpose / when: Optional, after induction, for clients who find it helps absorption. [synthesis]
Steps:
1. Count down from 10 to 1 paired with imagery of descending, such as a staircase or path, or with a deepening breath.
2. Ask for a finger signal at the end of the count.
Example language (illustrative): "As I count from ten down to one, imagine walking down a gentle path, a little more absorbed with each step."
Watch for: Imagery the client dislikes, such as stairs or water for someone with phobias. Ask about preferences beforehand.

4.7 Re-alerting and debrief

Purpose / when: Close every hypnosis segment. [synthesis]
Steps:
1. Remove any suggestions that were meant only for the session, such as heaviness.
2. Count up from 1 to 5 with suggestions of alertness and normal sensation.
3. Ask the client to stretch and orient to the room.
4. Debrief: experience, vividness, any distress, and what to practise.
5. Check the client is fit to drive.
Example language (illustrative): "Coming back now… one… feeling returning to your arms and legs… five, eyes open, clear-headed and alert."
Watch for: Grogginess, headache, unexpected emotion or spontaneous memories. Re-orient fully and document.

4.8 Applied self-hypnosis and coping skills

Purpose / when: Phase D, and the base for every module. Provides a portable skill for managing arousal and self-suggestion. [source: Routledge TOC; Lim 2016 abstract (basic self-hypnosis with classic "dial" imagery as part of hypnotically enhanced CBT)]
Steps:
1. Teach a brief self-induction, such as three slow breaths with eye closure.
2. Give a post-hypnotic cue linking a cue word to this state.
3. Teach a control image, for example a dial the client turns down from their current tension rating to a lower one.
4. Have the client practise in session while you coach, then alone.
5. Homework: daily practice, plus applying it in mildly stressful situations with ratings before and after.
Example language (illustrative): "Picture a dial showing your tension now, say seven. As you breathe out, imagine turning it down a notch at a time and notice what changes in your body."
Watch for: Using it only as avoidance or escape (see 5.8). No practice (see 5.4). Falling distress ratings and spontaneous use outside sessions mean it is working.

4.9 Coping imagery, mental rehearsal and goal-directed fantasy

Purpose / when: Preparing for feared or difficult situations; building confidence. [source: Chaves 2006 (goal-directed fantasy, Spanos); Zahedi et al. ("learning through simulation": mentally rehearsing new strategies)]
Steps:
1. In hypnosis, the client imagines the situation step by step.
2. At the planned difficulty point, the client imagines noticing early signs of distress and then using coping skills: breathing, the self-hypnosis cue, coping self-statements.
3. The client imagines coping well enough, not perfectly.
4. Repeat 2–3 times.
5. Finish with a post-hypnotic suggestion linking the real situation to the coping response.
Example language (illustrative): "You're walking into the meeting… you notice the familiar flutter… and you let it be a cue to breathe out slowly and remind yourself you've prepared."
Watch for: The client imagining an unrealistic perfect performance. Coping-model imagery, which includes some difficulty, is generally preferred in CBT. [synthesis] Rising self-efficacy ratings mean it is working.

4.10 Ego-strengthening and generalised change suggestions

Purpose / when: After the basics are in place, to build confidence and expectation of change. [source: Lim 2016 abstract (ego-strengthening interventions within hypnotically enhanced CBT); Chaves 2006 (Hamburg combined generalised suggestions about the possibility of rapid change with client-specific suggestions)]
Steps:
1. Draw specific strengths and past successes from assessment.
2. In hypnosis, suggest that the client reconnects with these, in their own terms.
3. Add one or two client-specific suggestions tied to current goals.
4. Keep suggestions believable.
Example language (illustrative): "You've already shown you can learn new things under pressure, like when you… and that same capacity is here now, ready to use this week."
Watch for: Generic praise the client rejects. Use the client's real evidence instead.

4.11 Hypnotic exposure therapy (affect module)

Purpose / when: Fear, phobias and anxiety-driven avoidance. Exposure in imagination is delivered in hypnosis, usually as a bridge to real-life exposure. [source: Routledge TOC ("Affect: hypnotic exposure therapy"); Chaves 2006 (hypnosis augmenting desensitisation for fear of dying)] Robertson's exact protocol is not drawn on here. [uncertain]
Contraindications and consent: Get explicit consent for exposure that deliberately provokes anxiety. Screen as in 4.1. For trauma memories, use only after stabilisation and readiness (see 5.6), or refer to a trauma-focused protocol. Medical clearance is needed where strong arousal is risky, such as cardiac conditions. [synthesis]
Steps: [synthesis]
1. Build a graded hierarchy with distress ratings (0–100).
2. Induce hypnosis and establish a calm baseline.
3. Present the lowest item vividly.
4. Hold the image while distress rises and then falls, rather than escaping. In graded-desensitisation style, pair the image with self-hypnotic calming; in prolonged-exposure style, stay with it until distress falls by about half.
5. Repeat until the item is low.
6. Move up the hierarchy across sessions.
7. End with calming and re-alerting.
8. Assign matching real-life exposure.
Example language (illustrative): "Let the scene come in clearly… notice your number… stay with it, breathing slowly… tell me the number again when you're ready."
Watch for: Using hypnotic relaxation to avoid the anxiety (neutralising). Dissociation (see 5.3). Distress falling within and across sessions and avoidance dropping in real life mean it is working.

4.12 Problem-Solving Hypnotherapy, with age progression (behaviour module)

Purpose / when: Indecision, skills deficits, life problems and low self-efficacy. Problem-solving steps are carried out and rehearsed in hypnosis. [source: Routledge TOC ("Behaviour: Problem-Solving Hypnotherapy (PSH)"); Lim 2016 abstract (clinician-guided "age progression" used to support mental rehearsal of problem-solving skills)] Robertson's PSH step order is not drawn on here. The steps below follow generic CBT problem-solving. [synthesis] [uncertain]
Steps:
1. Out of hypnosis, define the problem concretely and set a realistic goal.
2. Brainstorm options without judging them, then weigh pros and cons and choose one.
3. In hypnosis, the client imagines carrying out the chosen solution step by step, including handling obstacles.
4. Optional age progression: the client imagines a future self, for example in six months, who has worked the problem through, and describes from that vantage point what they did and how it feels.
5. Re-alert. Turn the plan into a real-life action with a date.
6. Review the outcome next session.
Example language (illustrative): "Imagine moving forward in time to a point a few months from now when you've handled this… look back and notice the first small step you took."
Watch for: Future imagery that is vague or wishful. Ask for concrete, observable steps. Implementation in real life is the measure of success.

4.13 Cognitive hypnotherapy (cognition module)

Purpose / when: Unhelpful automatic thoughts, beliefs and catastrophic imagery. Cognitive restructuring is prepared out of hypnosis and then rehearsed and consolidated in hypnosis. [source: Routledge TOC ("Cognition: cognitive hypnotherapy"); Alladin's cognitive hypnotherapy is a parallel approach (Wiley/Ovid pages)] The detailed protocol is not drawn on here. [uncertain]
Steps: [synthesis]
1. Identify and examine the target thought with standard CBT methods: evidence, alternatives, and testing it against experience.
2. Write a balanced alternative in the client's own words.
3. In hypnosis, the client re-experiences a trigger scenario, notices the old thought, then brings in the alternative and imagines acting and feeling in line with it.
4. Strengthen with a post-hypnotic cue.
5. Assign a behavioural experiment to test the new belief.
Example language (illustrative): "As the old thought 'I'll be humiliated' appears, notice it, and then let the statement you wrote come to mind: 'I can be nervous and still get my point across.' Imagine speaking from that."
Watch for: Hypnotic suggestion replacing real evaluation of the evidence, which gives "positive thinking" without belief change. Belief ratings shifting and experiments being carried out mean it is working.

4.14 Post-hypnotic suggestions and cue-controlled responses

Purpose / when: To transfer in-session gains into daily life. [source: Zahedi et al. 2024 (cite post-hypnotic suggestions that improved executive function and shifted food preferences toward healthy options)]
Steps: [synthesis]
1. Choose a specific everyday cue, such as touching the thumb and finger together, or the moment of entering the office.
2. Choose a specific response, such as the self-hypnosis breath and the coping thought.
3. Link the two during hypnosis and rehearse them in imagination.
4. Re-alert and test the link in the room.
5. Log its real-world use.
Example language (illustrative): "Whenever you press thumb and finger together and breathe out, you can bring back some of this steadiness."
Watch for: Cues that are too vague. Strengthen the link through repetition.

4.15 Mindfulness module (mindfulness-based CBH)

This module takes the attention, acceptance and decentring exercises described by Lynn et al. and delivers them after a hypnotic induction. The themes of Elkins & Olendzki's eight-session Mindful Hypnotherapy are present-moment awareness, nonjudgmental awareness of thoughts, emotions and sensations, self-efficacy in self-hypnosis, self-compassion, and values awareness. [source: Lynn et al.; Padilla] The order of themes across MBH sessions is not given in the sources. [uncertain]

4.15a Hypnotic attention training

Purpose / when: Rumination and worry; strengthens flexible control of attention. Lynn et al. base it on Wells' Attention Training Technique.
Steps:
1. After induction, the client notices separate sounds near and far.
2. Switch attention between named sounds on request.
3. Widen attention to take in all sounds at once.
4. Return to the breath. [source: Lynn et al.]
Example language (illustrative): "Notice the sound of the clock… now the traffic outside… now move back and forth between them… now let your attention open to hold every sound at once."
Watch for: Self-criticism when attention wanders. Frame wandering and returning as the exercise itself.

4.15b Hypnotic body scan and tension-spot release

Purpose / when: Body awareness, relaxation and decentring from sensations.
Steps:
1. After induction, move attention part by part from the top of the head downward.
2. Note any "tension spots" and let attention release from them.
3. Return to the breath. [source: Lynn et al.]
Example language (illustrative): "Let your attention rest at the crown of your head… then slowly drift down… where you find tightness, simply notice it, and let your attention move on."
Watch for: Pain or trauma-related body memories. Offer to scan only neutral areas, or to keep the eyes open.

4.15c Concentration task

Purpose / when: Anchoring attention.
Steps:
1. Count backward by sevens between breaths.
2. When attention drifts, gently restart. [source: Lynn et al.]
Watch for: Performance anxiety. Make it explicit that mistakes don't matter.

4.15d Labelling and decentring from thoughts

Purpose / when: Negative thoughts and feelings; fusion with thoughts.
Steps:
1. In hypnosis, the client silently labels each passing thought or feeling as "just a thought" or "just a feeling".
2. Observe without judgement, and let it pass.
3. Optional decentring images: thoughts carried away in bubbles, or urges rising and falling like ocean waves. Lynn et al. cite these images from Wallace and Marlatt. [source: Lynn et al.]
Example language (illustrative): "When a worry appears, quietly note 'just a thought'… picture it inside a bubble… and watch it drift up and away at its own pace."
Watch for: The client using labelling to push thoughts away (suppression). Emphasise allowing them.

4.15e Bare attention ("eye spy")

Purpose / when: Practising nonjudgmental description; easy to generalise.
Steps:
1. Eyes open, the client describes an object in the room with no evaluative words.
2. The therapist gently points out any judgements.
3. Practise regularly between sessions. [source: Lynn et al.]
Example language (illustrative): "Describe the mug only by what you see: colour, shape, light on its surface, without 'nice' or 'ugly'."

4.15f Self-compassion and values suggestions

Purpose / when: Shame, self-criticism and lack of direction. These are MBH suggestion themes. [source: Padilla]
Steps: [synthesis]
1. After induction, invite a kind, accepting stance toward the client's own difficulty, for example imagining how they would speak to a friend.
2. Invite the client to notice what matters most to them and one small value-guided action.
3. Add a post-hypnotic cue.
Example language (illustrative): "Notice the part of you that's struggling, and see if you can offer it the same warmth you'd offer someone you care about."
Watch for: Self-compassion feeling threatening, as can happen with high shame. Go slowly and normalise.

4.15g Mindful self-hypnosis practice

Purpose / when: Between sessions; builds self-efficacy in self-hypnosis, which is an MBH theme. [source: Padilla; Lynn et al. (exercises can be given by recording)]
Steps: [synthesis]
1. Record a 10–20-minute session for the client.
2. The client practises daily and logs practice and stress ratings.
3. Over the weeks, fade the recording toward self-guided practice.

4.16 Medical-adjunct applications

Tension headache in a hypnotically enhanced CBT case report [source: Lim 2016], and stress, sleep and somatic complaints, are all handled as adjuncts within medical care, after medical assessment, never as a replacement for medical treatment. No method here treats cancer or any other physical disease. [synthesis per brief]

4.17 Relapse prevention and ending

Steps: [synthesis]
1. Review which techniques helped.
2. Write a personal plan: early warning signs and which self-hypnosis or coping routine to use for each.
3. Rehearse a future setback in hypnosis using coping imagery (see 4.9).
4. Space out the final sessions.
Example language (illustrative): "Let's imagine a rough week a few months from now and rehearse exactly how you'd use what you've learned."

5. Handling problems

The sources say little about handling problems. Unless a line is tagged with a source, the guidance below is my own synthesis drawn from general CBT and clinical-hypnosis practice. [synthesis]

5.1 Screening and contraindications

From the sources:
- Related depression trials excluded bipolar disorder, psychotic symptoms, acute suicide risk, severe cognitive impairment and severe substance use disorder. These are trial criteria, not CBH guidance. [source: NCT02375308]
- Avoid using hypnosis to enhance memory. Hypnotic labelling can increase both inaccurate recall and confidence in it. [source: Lynn et al.]
Added [synthesis]:
- Active psychosis or mania: do not use hypnosis.
- Severe dissociative disorder: use only within specialist trauma treatment, after stabilisation.
- Unprocessed trauma: no regression or abreaction work.
- Epilepsy, or where strong arousal is risky: medical input before exposure.
- Pending legal testimony: avoid hypnosis on any memory relevant to the case.
- Under the influence of alcohol or drugs: postpone.
- Somatic complaints: medical clearance first.

5.2 "Nothing happened" or low responsiveness

Normalise this, and frame responding as a skill that improves with practice (see 4.4).
Check whether the client was trying too hard or waiting passively. Coach active imagining, and use suggestions the client is likely to pass first.
Switch to mindfulness-type suggestions, which are easy to pass, so high responsiveness is not required. [source: Lynn et al.]
Drop the hypnosis label if it causes performance pressure. Lynn et al. note that some clients prefer one framing over the other. [source: Lynn et al.]

5.3 Overwhelm, abreaction or dissociation during hypnosis

Stop the suggestion. Ask the client to open their eyes, feel their feet on the floor, name objects in the room and slow the out-breath.
Speak in a normal, conversational voice and re-alert fully.
Debrief: what came up, and what the client needs now.
Do not explore or interpret any emerging "memory" content. Treat it as current experience.
Next time, lower the intensity: shorter exposure, keep the eyes open, or more stabilisation first.
For trauma memory work: readiness means stable safety, the ability to self-regulate (4.8), and no current dissociative crisis. Dose the exposure in session with distress ratings and planned closure, using the standard session frame. If the client is not ready, refer to a trauma-focused protocol.

5.4 No self-hypnosis practice

Explore the obstacles: time, doubts, or not knowing what to do.
Shorten the practice to 2–3 minutes, tie it to an existing routine, and provide a recording.
Use ratings to show the link between practice and change. Reframe practice as the active ingredient, not optional extra.

5.5 Ambivalence and resistance to change suggestions

Explore the pros and cons of change before giving suggestions. Ambivalence about a positive outcome can undermine success. [source: Chaves 2006]
Use permissive, choice-based wording.
Never press suggestions the client rejects. Go back to formulation and goals.

5.6 Requests for regression or memory recovery

Decline to use hypnosis to uncover or check memories. Explain that hypnosis can create confident but inaccurate recall. [source: Lynn et al.]
Offer present-focused CBH work, or refer to trauma-focused therapy.

5.7 Fear of losing control, or stage-hypnosis beliefs

Return to socialisation (4.3).
Show control in action: the client opens their eyes at will, rejects a trivial suggestion, or uses an alert induction.

5.8 Hypnosis used as avoidance

Signs: relaxing away every anxiety, or using self-hypnosis to escape exposure.
Response: reframe self-hypnosis as a tool for approaching difficult situations, use it after exposure tasks rather than instead of them, and drop safety-behaviour uses.

5.9 Ruptures and over-attribution to the therapist

If the client feels "done to", or credits the therapist instead of themselves: attribute change to the client's own skill, move to self-hypnosis and recordings in the client's voice, and invite feedback on the method.
After a session that went badly, acknowledge it, repair, and adjust the next session together with the client.

5.10 Unwanted after-effects

Headache, drowsiness, lingering heaviness or low mood: re-induce briefly, cancel the earlier suggestions explicitly, re-alert again, and check fitness to drive.
Document the after-effect and adjust future sessions.

5.11 Suicide risk

If risk emerges, pause hypnosis. Carry out a standard risk assessment and make a safety plan. This includes means-safety counselling about storing or removing means, with no method detail.
Resume hypnosis only once the client is stable.

Sources

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