Cognitive Hypnotherapy

Once the depressed patient becomes familiar with cognitive behavior therapy (CBT) and hypnotherapy, the next few sessions attempt to integrate cognitive and hypnotic strategies in the treatment. Specifically these sessions focus on (a) cognitive restructuring under hypnosis and (b) symbolic imagery techniques for dealing with a variety of emotional problems such as guilt, anger, fears, doubts, and anxieties. Before describing unconscious cognitive restructuring, the CBT methods of uncovering and restructuring core beliefs are first described.

Restructuring Core Beliefs

As reviewed in Chapter 2 Beck (1976) proposed that each diagnostic condition is characterized by certain schemas or habitual patterns of thinking that represent vulnerability. Depressive schemas seem to reflect concerns about loss, failure, rejection, and depletion (Leahy, 2003). This approach to therapy focuses on assisting the patient to identify and modify his schema or core beliefs. Patients are coached to differentiate between surface or automatic cognitive distortions (“I can’t do this”) and deeper or enduring (“I’m a failure”) negative cognitive structures (self-schemas). The therapist uses different strategies to restructure the deeper self-schemas. As discussed in Chapter 2 the term schema refers to enduring, deep cognitive structures or “templates” that are particularly important in structuring perceptions and building up “rule-giving” behaviors (Sanders & Wills, 2005). According to Sanders and Wills, schemas are:

Unconditional
Not immediately available to consciousness
Latent, activated by triggering events
Can be functional or dysfunctional, depending on the patient’s life experience and cherished goals
Compelling or noncompelling, depending on their influence on the patient’s life
Pervasive or narrow in the extent to which they influence the patient’s life

A depressed person spirals down from surface thinking to dysfunctional assumption to core beliefs, all grounded in an early maladaptive schema (adapted from Sanders & Wills, 2005):

Negative automatic thought: “They don’t care for me” (a high school teacher referring to her colleagues at a staff meeting). The thought states that the teachers at this specific meeting do not care for her. Despite the upset of this specific situation,
however, it is possible that other teachers in many other situations do care for her.
Dysfunctional assumption: “If I take my work seriously and try to be a good teacher, it may be possible for other teachers to care for me.”
Core belief: “No one cares for me. No matter what I do, however hard I try to be a good teacher, no matter how much effort I put into pleasing my students and my colleagues, I don’t seem to get anywhere, no one seems to care.”
Early maladaptive schema: This patient’s parents divorced when she was 9 years old. Although both parents had custody, she had to live with her grandparents because her father worked overseas and her mother was at school. She felt rejected, uncared for, and unloved by her parents. At school, she was teased and bullied for being overweight. She developed a profound sense of worthlessness, resulting in the deep belief that no one cares for her because she is unworthy.

Although interest is growing in the role of schemas as risk factors in depression, CBT usually adopts the principle of parsimony; that is, initially the work begins at the symptom level, particularly with automatic thoughts. Beck, et al. (1979) stress that “insight” work is not recommended during severe depression, because the patient is incapacitated by feeling of hopelessness and difficulty with concentration. Similarly, “working through” the depressive symptoms using cognitive techniques alone may also be counterproductive and may worsen negative feelings. Cognitive work becomes productive only after some of the most severe symptoms have lifted. Blackburn and Davidson (1995) estimate that approximately 75% of standard CBT for depression is directed at the symptom level, particularly working with behavioral responses to passivity and countering negative automatic thoughts. Only 25% of CBT is concerned with underlying issues and preventative work. Schema work or schema-focused therapy becomes a major focus of CBT when case conceptualization demands address underlying issues (e.g., in a complex case, or when the depression is comorbid with personality disorder) or when it is predicted that a depressed patient is at risk of relapse due to unaddressed underlying negative self-schemas.

The development of schema-focused therapy has undoubtedly expanded our understanding and treatment of depression. On the other hand, such a development raises some concerns, as echoed by Sanders and Wills (2005, p. 151):

We have observed that therapists from other disciplines are more likely to believe that core beliefs and early experience are where the action is. They tend to want to dive into these areas early on in therapy, neglecting to fully explore maintenance cycles and day-to-day aspects of the client’s problems, perhaps feeling that they are not doing “real therapy” without bringing up the past.

Depressed patients can be extremely vulnerable when exposing and examining their core beliefs. Although the downward arrow method (described later) is a very simple CBT technique for uncovering core beliefs, it can lead to strong emotional consequences as a patient unmasks a strongly held, although such a belief has
been unconscious. Sanders and Wills (2005, p. 152) caution that: “Unpacking a seemingly straightforward negative thought can lead to uncovering difficult and sensitive meanings, and if this is done too early in therapy, before the person is able to cope with the consequences, then he or she may end up feeling much worse.” James (2001) and James and Barton (2004) therefore recommend that therapists think through the possible emotional reactions and consequences of accessing core beliefs. They suggest that hypotheses about core beliefs are brought on gradually and sensitively into the course of therapy rather than suddenly or confrontationally. It should also be noted that beliefs can be mood dependent. A person may consider herself useless and worthless when depressed, but when not depressed such core beliefs vanish. James, Southam, and Blackburn (2004) believe it may be “counterproductive” and “aversive” to dig for core beliefs when a person is not depressed. Moreover, they believe therapists must have sufficient skill and expertise, therapy time, and supervision to do this kind of work. For this reason, the circular feedback model of depression (CFMD) described in Chapter 4 places “symbolic transformation” further up in the cycle, although it has the potential to trigger the depressive cycle on its own. This position emphasizes that digging into core beliefs should come later in the course of therapy. Moreover, CH case formulation, which adopts the “stepped care” model (Davidson, 2000), provides a useful approach in deciding when and where to start working at a deeper level. The stepped care approach advocates delivering services in the most parsimonious way. The simplest intervention is adopted initially. More intensive and expensive forms of therapy are only used where there is clear evidence for their effectiveness and where they are likely to serve the patient’s best interests. Sanders and Wills (2005) recommend avoidance of core-belief work with mild depression and single-episode problems. They believe core-belief work is most appropriate in the following situations:

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