A range of possibilities exists for the integration of hypnosis with cognitive-behavioural techniques. These include
1 A thorough assessment of depression, including records of activities, cognitions and formal rating scales (such as the Hamilton Depression Rating Scale, the Beck Depression Inventory and the Beck Hopelessness Scale), is required so that an individualized treatment approach can be developed. It is highly likely that the severity of depression will be a significant factor in deciding the focus of treatment.
2 Hopelessness may need to be addressed before an individual experiencing major depression is able to engage in any other aspect of therapy. An understanding of hopelessness is a significant feature of cognitive-behavioural approaches to depression. The learned helplessness model of depression (Abramson, Seligman & Teasdale, 1978) emphasizes 'depressive' attributional style whilst Beck's (1979) theory of depression included a negative view of the future as one aspect of his depressive triad. Yapko (1992) describes several strategies to address hopelessness. Appendix A contains a description of a possible approach to the modification of hopelessness using a hypnotic process.
3 Ego strengthening techniques hold considerable promise for the modification of depression on theoretical grounds. A negative view of the self is one of the primary components of Beck's (1979) cognitive triad. Hartland (1971) popularized the concept of 'ego-strengthening' and utilized it in much of his therapy to reinforce self-reliance and a positive self-image. (see Hammond, 1990, for a useful discussion and a range of hypnotic approaches to ego-strengthening).
4 The process of cognitive restructuring may be facilitated by the use of hypnotic techniques. Alladin (1994) describes a process of cognitive restructuring under hypnosis. Trance is established and the client imagines a situation that normally causes distress. The client is then instructed to focus on the dysfunctional cognitions and associated emotions, physiological, and behavioural responses. Encouragement is given to identify or 'freeze' (frame by frame, like a movie) the faulty cognitions in terms of thoughts, beliefs, images, fantasies, and daydreams. Once a particular set of faulty cognitions is frozen, the patient is helped to replace it by more appropriate thinking or imagination and then to attend to the resulting (desirable) 'syncretic' responses. This process is repeated until the patient can confidently restructure a set of faulty cognitions related to a specific situation. (p.283).
5 Hypnosis may be used to facilitate imagery and cognitive rehearsal strategies to deal with depressive thoughts and behaviours. Clarke & Jackson's (1983) method for the use of visualization and rehearsal strategies with hypnosis for assertive problems (p. 256) may serve as a useful starting point for the use of similar strategies for depression.
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