Mindfulness, Metacognition and Hypnosis

August Research Snippet

Donald Robertson, NCH Research Director

Apologies for the absence of a July Snippet but here’s August’s a bit early as compensation.  Following our previous snippets on meta-analyses, finding research online, and treatment outcome studies, etc., we’ve recently looked at attempts to combine mindfulness research and hypnosis in the treatment of depression.  This is a popular area so I thought I’d continue in the same theme by looking at, arguably, the most important recent article on this subject.  In 2006, Steven Jay Lynn collaborated with the Buddhist teacher Lama Surya Das, and two other researchers, in an attempt to explore the possibility of combining elements of Buddhist mindfulness meditation practice, cognitive therapy, and hypnosis, drawing on recent research in cognitive psychology.

Mindfulness versus Thought Suppression

Over the past couple of decades, enthusiasm for mindfulness meditation techniques derived from Buddhism has flourished among cognitive-behavioural therapists, inspired by the early success of Jon Kabat-Zinn’s meditation programme for stress management.  Meditation and acceptance strategies have been used to counteract the tendency of many clients to try to suppress, control, or “fight” distressing thoughts.  Lynn et al. refer to the recent study by Wegner and his colleagues, which found that when people tried to deliberately suppress a thought there was evidence of a “rebound effect” in which they subsequently experienced more intrusions of the thought than a control group who were simply asked to think freely about the same thing.  Other studies have found evidence that emotional suppression can inhibit memory and problem-solving and increase physiological signs of nervous arousal.  Lynn and his colleagues report that of nearly a hundred subjects who were asked to keep their minds blank while listening to hypnotic suggestions, only one reported any success. 

Where thought-control strategies backfire, mindfulness and acceptance have been seen as offering an alternative way of responding to distressing experiences.  Lynn et al. follow other contemporary cognitive-behavioural therapists in contrasting non-judgemental mindfulness and acceptance with the unhealthy suppression of thoughts and feelings.  (However, they fail to mention that experimental studies on this “rebound” effect in thought suppression have produced some mixed results – q.v. Clark & Beck, 2010, for a more detailed review.)  Lynn et al. also cite a 2003 meta-analysis of mindfulness-based cognitive therapy and stress reduction approaches by Baer, which found a mean effect size of 0.59 (a medium-sized treatment effect) for this approach across various emotional problems and medical conditions.  In other words, it probably works, but the effects are comparable to those of other therapies and not dramatically superior to them.

Mindfulness & Metacognition

Lynn et al. appeal to a cognitive model combining elements of Adrian Wells’ influential metacognitive theory and Lynn and Kirsch’s own “response set” theory to explain the mechanism underlying mindfulness meditation and its relationship with hypnosis.  Contrary to Beck’s earlier cognitive therapy model, Wells introduced a focus on the notion of “metacognition”, thinking about thinking, or beliefs about beliefs.  According to this model, negative automatic thoughts aren’t particularly unhealthy in themselves, but rather they become so because of our attitude toward them.  In plain English, whereas Beck’s original cognitive therapy assumed that negative thoughts play a central role in the development of emotional disturbance, Wells points to the fact that many people experience lots of negative thoughts without becoming upset by them, whereas patients with severe emotional disorders appear to be unusually disturbed by individual negative thoughts and worries.  Mindfulness meditation, likewise, can be seen as an attempt to adopt a more detached attitude toward our stream of consciousness, and thereby to modify our thinking about thinking, i.e., to see automatic (spontaneous) thoughts as relatively transient and harmless, rather than important and dangerous.  Indeed, Beck has recently assimilated many aspects of Wells’ metacognitive approach into his revised cognitive therapy for anxiety (Clark & Beck, 2010).

Curiously, Lynn et al. don’t mention the fact that Wells’ metacognitive model raises serious problems for hypnotherapy because it suggests that the assumptions often made by hypnotherapists about the “power of thought” risk reinforcing maladaptive (metacognitive) assumptions held by many clients, i.e., the assumption that thoughts (including suggestions) are inherently powerful, whereas Wells teaches his clients that ideas are only as powerful as we believe them to be and we can learn to dismiss them as “mere thoughts”, lacking any real power or significance.  Likewise, Lynn et al. cite the recent research by Twohig (2004), which found that by repeating a negative thought to oneself one hundred times, like a mantra or autosuggestion, subjects made it seem less believable rather than more so, as some hypnotists might assume.  To borrow Wells’ terminology, hypnotism itself can be seen as a set of metacognitive beliefs rather than an altered state of consciousness or “hypnotic trance”.  The belief that autosuggestions are powerful when phrased in certain ways and the strategy of attending to their meaning for a prolonged period, to the exclusion of distractions, are ways of “thinking about thinking” (metacognition), which it’s the aim of most “hypnotic inductions” to instantiate.  In a sense, mindfulness meditation can be seen as a kind of “de-hypnosis” or “counter-hypnosis”, which aims to develop a metacognitive mind-set that weakens the hold of certain thoughts or suggestions, e.g., “Imagine that you are transparent, and disturbing thoughts and emotions cannot penetrate you or have any power to control your actions” (Lynn et al.), which contrasts sharply with typical preliminary hypnotic suggestions to experience certain ideas (suggestions) as powerful, controlling, and deeply penetrating into the mind, etc. 

Combining Hypnosis & Meditation

Lynn et al. summarise the relevance of hypnosis to mindfulness training as follows,

1. Suggestions can be used to motivate clients to persevere with meditation practice on a regular basis.
2. Suggestions can be used to generate a patient mind-set, so that when the attention naturally wanders this is seen as normal and accepted.
3. Suggestions can be given about acceptance of things that cannot be changed.
4. Hypnosis can be used to help people avoid identification with thoughts and feelings.
5. Hypnosis can help clients to become more tolerant of unpleasant feelings.
6. Clients can be hypnotised to perceive negative thoughts as transient and unimportant.

They specifically recommend the use of the following hypnotherapy techniques in conjunction with mindfulness meditation, which generally involves exposure to aversive feelings and events in CBT,

1. Mental (“covert behavioural”) rehearsal of previously avoided situations.
2. Cue-controlled relaxation to help facilitate exposure to feared situations.
3. The use of hypnotic desensitisation to facilitate mental (“imaginal”) exposure .
4. The use of hypnotic regression or reliving as a form of imaginal exposure to traumatic memories (as in PTSD treatment).
5. The use of suggestion to help clients tolerate the discomfort and repetition of exposure therapy.

They add that the most basic use of hypnosis in combination with mindfulness-based CBT would be in the use of suggestion to directly develop an ongoing state of mindfulness.  As Lynn et al. emphasise, virtually all modern researchers now take it for granted (following several well-known studies) that hypnosis does not necessarily entail any form of relaxation, although it is frequently accompanied by it.  The same applies to meditation and Lynn et al. refer to a recent EEG brain imaging study in which subjects trained in relaxation showed markedly different brain activity from those trained in mindfulness meditation.

Negative Reactions

As an aside, Lynn et al. also note that a considerable body of research demonstrates the existence of transient, relatively superficial, negative reactions following standard hypnosis, i.e., things like headaches, feelings of nausea, anxiety, etc., in up to 29% of subjects.  This is comparable to the rates of negative responses reported by control groups who are simply asked to sit with their eyes shut, without being hypnotised, for the same amount of time.  However, similar negative reactions are also reported following meditation training, and may even be more frequent, being reported in up to 63% of subjects.  Hence, we might say that although negative reactions can occur following hypnosis it may be as harmless (generally speaking) as common meditation or relaxation techniques.

References

Lynn, Steven Jay; Das, Lama Surya; Hallquist, Michael N.; Williams John C.             (2006).  Mindfulness, acceptance and hypnosis: cognitive and clinical perspectives.  IJCEH, 54(2), 143-166.

Clark, David A.; Beck, Aaron T.    (2010).  Cognitive Therapy of Anxiety Disorders: Science and Practice.