by Andrew Homer. Email: ghostbuster@blueyonder.co.uk
Behaviourist psychology and clinical hypnotherapy shares many parallels with learning theory. Learning theory as taught in teacher training makes a clear distinction between behaviourist (or connectionist) approaches and cognitive psychology. The discussion here will centre only on behaviourist theories as opposed to the more cognitive approaches typified by Freud’s psychoanalytical theories. Cognitive approaches are more concerned with the inner workings of the mind, with perception, memory, personality, motivations and other internal structures and processes. However, we are only really concerned here with learned behaviour. My approach will be very much that there is little or no difference between learned behaviour as in the acquisition of a skill such as driving and learned behaviour in the form of unwanted or inappropriate habits, phobias or anxieties resulting in stress. Whilst the process of acquisition may be similar, the difference is clearly one of wanted or unwanted behaviour patterns.
The discussion will describe how unwanted or detrimental behaviour patterns may be modified, reduced or eliminated entirely (extinction). Where it seems appropriate I would like to draw on actual experiences in addition to the wealth of published material on the subject.
At its very basic level, behaviourist psychology is concerned mainly with stimulus (S) and response (R) connections. Hence, the alternative term of connectionists to describe behaviourist psychologists. Such S-R connections can be manipulated and observed in both animal and human behaviours.
The development of behaviourist psychology is well documented and can be broadly traced back to the seventeenth century philosopher, Hobbs (Harris, 1968). He made the basic assumption that human beings were essentially machines functioning on the basis of input and output operating to a defined set of laws. It is interesting to note that this essentially computer based model (as we would view it today) requires none of the cognitive processes of say, psychoanalysis, on which to base theories of learning and behaviour. The computer analogy I think is a fair one as however sophisticated and intuitive (eg expert systems) computer software may appear to be it is only as sophisticated as the code behind it. Furthermore, this code has to comply with the ‘rules’ of programming or things soon start to go wrong. There is a computer term called GIGO which stands for garbage in, garbage out. It is perhaps an oversimplification to apply this idea to human behaviour but nevertheless from a behaviourist psychology point of view I feel it is applicable.
Having outlined the human condition as machine philosophical basis of behaviourist psychology we can more clearly see how this approach was developed by the main players. This discussion is too brief to attempt to describe the development of behaviourist psychology through the key players. However, J B Watson (1878 – 1958), E L Thorndyke (1874 – 1949) and I P Pavlov (1849 – 1936) at the turn of 20th century all directed their attention to how animals and humans behaved in given controlled situations. B F Skinner took the concepts of stimulus response connections a stage further to demonstrate how an organism could act on its own environment to produce a reward or reinforcement thus creating a learned behaviour.
Of particular significance to clinical hypnotherapy is the work of Wolpe who is perhaps best known for his theories of systematic desensitisation to gradually eliminate unwanted fears and phobias. This theme will be explored more thoroughly later on in a discussion of techniques and hypnobehavioural approaches to clinical hypnotherapy.
Behaviourist Techniques
It is important to note that the experiments performed by the early behaviourists were all in vivo. That is, that is, they were using actual situations to develop the techniques. Generally (though not always) in hypnotherapy we are dealing with in vitro techniques whereby the patient is effectively asked to imagine the situations. Hypnosis can be used to enhance the rapidity of behaviour changes, hence the term hypnobehavioural.
Systematic Desensitisation
Systematic desensitisation involves gradually exposing an individual to an anxiety provoking situation in conjunction with a response which is incompatible with fear (Carlson and Buskist, 1997). The four basic states which are considered to be incompatible are relaxation, sexual arousal, hunger and thirst. Wolpe’s earlier in vivo experiments with cats involved the use of food but from an in vitro and hypnobehavioural point of view the easiest state to work with is relaxation. Thus relaxation is used as a reciprocal inhibition to the anxiety response.
The technique requires the construction of a hierarchy which runs from a state the patient can cope with right up to the situation which causes maximum fear or anxiety. These days relaxation tends to be commonly used as the incompatible response. This technique can, and is, used as an in vivo process whereby a patient can be successively desensitised to a given anxiety producing stimulus. A typical technique for inducing the relaxed state is Jacobson’s progressive relaxation. This technique basically involves focussing on relaxing muscles throughout the body. The skill of the therapist in using systematic desensitisation lies in creating appropriate steps for the patient to eventually reach their goal.
For example. in treating a fear of flying a person may start by simply visiting an airport and then gradually build up to entering a plane and eventually taking a short flight. This is an example of an in vivo application of the technique. However, the same technique could very easily be used in vitro by getting the patient to imagine the progressive anxiety producing situations. As a hypnobehavioural technique the whole sequence can be very effectively carried out under hypnosis. In addition, the relaxed state can very quickly and effectively installed in the hypnotic state. An additional advantage of the hypnotic state is that the patient can imagine an aeroplane which is exactly the right type of aeroplane for them.
Flooding
Flooding involves exposing the patient to the fear producing situation but without the benefit of any kind of relaxation or even escape (Kroger, 1977). The absence of any real dire consequences of being in the fear provoking situation eventually leads to extinction of the anxiety. The patient is unable to reinforce the anxiety by applying their usual escape or avoidance tactics. This can be viewed in terms of Thorndyke’s Law of Exercise which states that bonds are strengthened where the same stimulus – response repeatedly occurs (Child, 2004). Similarly, a reduction in the response can eventually lead to extinction of the bond. In the case of flooding the response is suppressed so theoretically extinction eventually occurs.
An example of in vivo application of flooding is where a patient is actually placed in a fear producing situation and prevented from escaping. This is clearly a drastic technique and has the potential to do more harm than good.
In vitro applications involve the patient in imagining the anxiety producing situation until extinction occurs. Under hypnosis the fear provoking situation can be created and the anxiety heightened. For example, someone with a fear of spiders could be given a vivid imaginary image of being covered by spiders in a room with no escape. Clearly not a technique to use with anyone who has a heart problem! However, it is worth making the point here that hypnosis is not automatically relaxing. Indeed, any emotion, including anxiety can be enhanced in the hypnotic state.
Massed Practice
Massed practice involves continuous repetition of either the stimulus trigger or the habit itself until the response is extinguished (Kroger, 1977). Pavlov showed that extinction of a stimulus – response bond would occur if the conditioned stimulus was repeatedly presented without reinforcement.
In vivo applications of massed practice need to treated with care. For example it would be a very poor technique to use with Bruxism as severe physical damage could occur. In vitro applications and the use of hypnobehavioural techniques also need care as imagined behaviours can sometimes be realised in vivo.
Aversion
Aversion therapy is based on getting the patient to dislike a stimulus that is currently liked (Carlson and Buskist, 1997). The undesirable behaviour is paired with an extremely unpleasant or even painful stimulus. For example, an in vivo technique would be to paint a vile tasting liquid onto fingernails which are being bitten. The theory is that the unwanted behaviour or emotion is inhibited by a strong aversive stimulus. We are dealing here with mainly physiological responses to a stimulus which is an aspect of Pavlov’s classical conditioning.
As with the other techniques described here, in vitro where the patient is asked to imagine the unwanted behaviour and the aversive stimulus, is enhanced by the use of hypnosis as direct communication with the subconscious mind is possible. Thus the required images can be created more quickly and effectively in the hypnotic state.
Assertiveness training
Wolpe is also associated with assertiveness training (Hockenbury and Hockenbury, 2000). Wolpe and Lazarus (Davis et al, 2000) redefined assertiveness as expressing personal rights and feelings. They found that nearly everyone could be assertive in some situations yet be ineffectual in other situations. Assertiveness training attempts to increase the number and variety of situations in which assertive behaviour is possible and decrease occasions of passivity or anger.
A core idea of assertiveness is the bill of rights. There are a number of variations but basically the bill of rights asserts the rights of an individual to express their feelings, needs and wants clearly. Assertiveness recognises three basic types of behaviour, passive, aggressive and assertive. Passive behaviour can engender feelings of aggression, irritation and superiority in others as the person behaving passively is not standing up for themselves or making their own decisions. Aggressive behaviour can result in others feeling threatened, anxious, hurt or resentful and ultimately alienates people. Assertive behaviour helps others to feel positive, respectful and co-operative and makes people feel more confident.
Aspects of assertiveness training can be seen in terms of Skinner’s operant conditioning (Carlson and Buskist, 1997). The individual acts on his or her own environment in order to learn. By introducing changes to the way the individual behaves in terms of body language, communication, voice and language patterns more assertive behaviour can be established.
Hypnotherapy is particularly useful here as passive behaviour may be the result of underlying anxieties tensions and stress which can effectively be dealt with. Similarly, relaxation and anger management techniques could be effective with aggressive people.
Hypnobehavioural techniques are particularly helpful here as situations which would normally produce passive or aggressive behaviour can be practised in trance in vitro but then transferred to real life situations in vivo.
The principle of reciprocal inhibition also comes into play here. It is simply not possible to be relaxed and angry at the same time. Neither is it possible to be relaxed and stressed at the same time.
Hypnobehavioural approaches
Phobias
The definition of a phobia is that it is a fear invoked by an object or a situation which is out of proportion to the situation, is out of voluntary control, leads to avoidance and cannot be explained away.
Hypnodesensitisation is a useful technique for dealing with phobias (Kroger,1977).
A typical protocol for hypnodesensitisation is as follows. Firstly, an anxiety hierarchy is established based on detailed information from the patient. Using a 0 to 100 Subjective Unit of Disturbance scale (SUD) the most stress provoking situation imaginable for the patient is placed at 100. At 0 a situation where the patient feels absolutely calm is placed. In between these two extremes the patient rates different situations in which the anxiety appears based on detailed interview, patient’s history, questionnaires, therapists intuition etc.
I have actually tried this myself as I have had a long standing fear of water. My 0 was a walk along a beach and 100 for me was falling into deep water. It was quite an interesting experience for me to rate various water based activities on the SUD scale.
After inducing and deepening the trance it is necessary to install Yes and No IMRs. I think it is also sensible to have a safe place for the patient to go to if necessary. Starting at the lowest point on the hierarchy the situation is presented and the patient asked to indicate if they are calm with it. If the patient indicates Yes then the next highest situation can be presented. If the patient is not happy at any level feelings of calm, relaxation, safety and control can be suggested and the scene presented again. It may be that the scene needs to be broken down into more manageable parts if a sticking point is reached. Breaking a situation down into more manageable parts is evident in Skinner’s theories of learning (eg programmed learning). The procedure carries on over one or more sessions until the patient reaches a level they are satisfied with. Ego strengthening is also given and it is very useful for the patient to be able to apply self hypnosis in order to reinforce the relaxation response.
I managed to remain calm through two or three of the levels and from personal experience I feel this is a technique which would work if and when I choose to follow it through to an appropriate conclusion for myself.
From a personal point of view I do not feel that either flooding would help with my water phobia (no pun intended!). In fact, I think that flooding particularly, even if done as a hypnobehavioural technique, could well make the phobia worse for me! From a hypnobehavioural point of view if flooding is used it is important not to include any relaxation as part of the process. However, I feel that flooding could be a dangerous technique for some people particularly if there is any history of heart disease etc. Flooding can lead to a stronger phobic response if not properly handled (Kroger, 1977).
Anxiety
As with phobias, systematic desensitisation could be used for situations which create anxiety and stress. The approach would be very much as described above using the situations where anxiety is experienced. Hypnosis is particularly useful for quickly installing relaxation responses and by teaching self hypnosis the patient can trigger the relaxation when needed. For example, a cue can be used which can trigger the relaxation response. For example, ‘as soon as you step on stage all unnecessary nervous tension will disappear ‘. This is fairly straightforward stimulus – response bonding and the situations can easily be rehearsed under hypnosis.
For people suffering from anxiety and stress, assertiveness training may also be a useful part of the treatment process. Whether or not to use assertiveness training should become apparent from the case study, discussion with the patient and visual clues from his or her behaviour (eg passive or aggressive). Again, from a hypnobehavioural point of view the hypnotic state can be used as a safe place to practice assertive behaviour in imagination (Kroger, 1977). Whilst in the hypnotic state situations can be rehearsed and more appropriate language patterns and body language can be introduced.
Habit breaking
Massed practice is a technique which can be used to break habits. However, it should be used with care as it is possible for a behaviour being practised under hypnosis in vitro to become an overt behaviour in vivo. For this reason it would not be a good technique for use with Bruxism as it could result in even more teeth grinding (Kroger, 1977). Common sense also says that it would be unwise to do this with anyone who has an alcohol problem, smokers or people suffering from some obsessive compulsive disorders.
A hypnobehavioural technique for using massed practice is as follows. After inducing and deepening the trance an IMR is installed. When the patient is experiencing the unwanted behaviour the IMR finger is lifted. The finger remains lifted until the behaviour can no longer be experienced.
Aversion therapy is another technique which can be used for breaking habits (Kroger, 1977). However, I would consider it to be something of a last resort! Informed consent from the patient must be obtained and they must be made fully aware of what is involved. In vitro aversion therapy is more effective when carried out under hypnosis as a hypnobehavioural technique. Through the case study the stimulus prior to the unwanted behaviour should be identified.
The aversion stimulus must be something that the patient personally finds repulsive and is not necessarily something that others would find repulsive. In my case, the most repulsive thing I can think of is Parmesan cheese! Under hypnosis the aversive stimulus is linked with the unwanted behaviour.
Conclusion
Behavioural techniques are interesting in that they can be used as a therapy in their own right but also lend themselves to hypnotherapeutic work. There are clear advantages in using a hypnobehavioural approach. Firstly, hypnosis is an extremely effective method of producing a relaxed state. Therefore with techniques such as systematic desensitisation which typically use relaxation, hypnosis is an ideal means of accomplishing this. The patient can also be taught self hypnosis for use outside of the consulting rooms. Cues can be put in place hypnotically to trigger relaxation responses when the patient is faced with stress producing situations.
Another advantage of the hypnobehavioural approach is that the therapist is communicating directly with the patient’s subconscious mind where both wanted and unwanted behaviours are stored. By short circuiting the conscious mind suggestions and behaviour changes can be communicated directly into the subconscious.
In terms of resources there are advantages in using the hypnobehavioural approach. It is possible to recreate any desired situation in the patient’s mind without having to have access to the physical resources. In addition, because the situation is created in the patient’s own mind it can be absolutely the right situation for them. For example, if the patient has a fear of dogs he or she can visualise exactly the right type of dog which elicits the maximum response.
Finally, hypnobehavioural techniques are generally quicker to take effect than the purely behavioural approaches. The sessions themselves can be shorter and fewer sessions required to achieve the desired results.
References
Carlson, N and Buskist, W. Psychology, The Science of Behaviour (Fifth Edition). Boston: Allyn and Bacon, 1997.
Child, D. Psychology and the Teacher (Seventh Edition). London: Continuum, 2004.
Davis, M., McKay, M., Eshelman, E., The Relaxation & Stress Reduction Workbook (5th edition). California: New Harbinger Publications, 2000.
Harris, R.W. Reason and Nature in 18th Century Thought. London: Blandford Press, 1968.
Hockenbury, S and Hockenbury, D. Psychology (Second Edition). New York: Worth, 2000.
Kroger, W.S. Clinical and Experimental Hypnosis (Second Edition). Philadelphia: J. B. Lippincott, 1977.