A she was looking for something ‘stronger’. Given that

A Critical Evaluation Of A Clinical
Hypnotherapy Treatment For
Chronic Health Anxiety

This essay will critically evaluate a hypnotherapeutic treatment of a 52 year old woman with health
anxiety following the death from cancer of a number of relatives. The patient (who will now be
referred to as Mary) presented with compulsive thoughts about cancer, vivid memory recall and the
need to self-examine on a regular basis.

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Anxiety affects large numbers of people in the UK, with 8.2 million cases reported in 2013 alone
(Fineberg et al 2013). The American Psychological Association (APA) defines anxiety as “an
emotion characterized by feelings of tension, worried thoughts and physical changes like increased
blood pressure.” Anxiety is more likely to affect certain demographic groups with women nearly
twice as likely to be diagnosed as men (Martin-Merino et al 2009).

Health anxiety (hypochondriasis) is a specific anxiety related to developing or presently having an
undiagnosed health condition or illness. It frequently occurs in patients who have been exposed to
health trauma (either themselves or a person close to them) however there are co-morbid factors
to consider. According to Fallon et al (2012) approximately 40% of those suffering with
hypochondriasis have a personality disorder comorbidity. A decision to treat Mary was made on
the following basis: Mary had been seen frequently by her own GP, private consultants and NHS
specialists. She was never prescribed anxiolytic or anti-depressants. She was never diagnosed
with any form of psychosis or even anxiety disorder.

Available treatment for health anxiety includes pharmacological approaches such as anti-
depressants and anxiolytic drugs, cognitive behavioural therapy and traditional talk/
psychotherapies. Mary was reluctant to explore pharmacological solutions due to the long-term
nature of these medications. As Wilson and Later state (2015) there is also little good quality
guidance about managing the withdrawal process from medications such as antidepressant and in
particular second-generation antidepressants. In any case therapy would be complete long before
any course of antidepressants or other prescribed medications was ended. Cognitive behavioural
therapy had already proved ineffective for Mary and consequently she informed the author that she
was looking for something ‘stronger’. Given that Mary was experiencing vivid and associated
memory recall in addition to the need to self-examine and negative self-talk it was decided that a
cognitive approach targeting the specific sensitising events would be appropriate. A combination of
hypnotherapy and neuro-linguistic programming was selected.

At the time treatment started Mary had been experiencing high levels of anxiety about developing
cancer for 2 years. She had no other concerns about her health, however even the mention of the
word ‘Cancer’ was highly distressing to her. She was self-examining for several hours per day and
frequently asking her teenage daughter to verify that there were no lumps in her breasts. She
experienced vivid and automatic recall of a number of highly emotional and potentially traumatising
incidents around the cancer related death of her mother and sister many times per day.
Notwithstanding the intensity of Mary’s anxiety it was decided that, since Mary had never been
diagnosed with a psychological condition and there was no physical basis for her health anxiety
(ascertained from her frequent visits to her GP) that no GP referral would be required to work with
this patient. It was further decided that since Mary was otherwise fairly stable in her life (with the
exception of the health anxiety) that there was no contraindication to using hypnotherapy.

Certainly she did not present with any symptoms of psychosis or personality disorder that might
constitute a contraindication.

Treatment started with a detailed case history where it was discovered that Mary had lost both her
mother and sister to cancer in the last 5 years. Both deaths had been unexpected and had left
Mary suffering frequent recall of sensitive memories. Her mother and sister had both been health-
conscious and careful to regularly self-examine for cancer. Failings in the NHS led to the discovery
of the cancer of both mother and sister after the time when treatment would be viable.
Consequently Mary had developed the belief that a normal or healthy amount of self-examination
is not adequate to detect tumours in time for treatment. It was established after the case history
that, given the highly emotional nature of the sensitising events, a gradual approach would be
taken over a longer timeframe. The patient was initially informed that a minimum of 6 sessions
would be needed to get a meaningful outcome and a therapeutic contract was established to make
expectations clear to both parties. Ultimately the treatment lasted 8 sessions. The contract
included a commitment to practice self-hypnosis from Mary and a commitment to maintain
confidentiality from the author. (Proctor & Keys 2013).

Secondary gain was considered due to the semi-somatised nature of Mary’s condition. It seemed
to Mary that there were physical lumps in her breasts (hence the need for external validation)
however these lumps were not physically manifested. Secondary morbid gain was therefore ruled
out. Secondary gain of a purely psychological nature was, however, more complex to determine.
Feinstein (2011) states that Secondary gain is the external benefits that a patient may derive from
having symptoms. The patient may, for example suddenly experience paresis (primary gain) thus
causing their spouse to remain in a relationship which may otherwise have failed (secondary gain).
On this definition secondary gain could well be ruled out due to the damaging effect of the health
anxiety on Mary’s relationship with the only close relative in her life, her daughter. However
Connors (1985) argues that some patients may claim the sick role to be exempt from being sick
and thereby, through assuming the role or patient they may exchange their role as caregiver for
that of one who receives care instead. It was decided to focus initially on the immediate primary
gain: the protection form cancer that the self-examination provided. Secondary gain would be
investigated if the symptoms could not be brought under control through direct suggestion and
interruption of the self-examination behaviour.

Goal setting was subsequently incorporated into the contract to ensure that Mary had a reasonable
appreciation of progress being made. It was agreed that specific goals would be set for each
session including items such as “number of self-exams per day”, “number of times external
validation is required from daughter per week”. Specific and challenging goals were chosen
(Strecher et al 1995). Given that Mary had sought out therapy for herself, her motivation for
change was considered to be high. As Overholser (2005) states, there are many factors which
might be involved for patients who tend to place responsibility for their problems external to
themselves. This may include the emphasis of society on biological interpretations of mental
illness, the continuing reliance of medication to treat non medical (i.e. psychological) conditions
and a desire to overemphasise the role that society may play in creating psychological conditions.
By seeking out therapy the author concluded that Mary was not externalising responsibility for her
condition. Mary was also accepting the idea that her anxiety was of psychological rather than
medical origin. Mary’s level of motivation was monitored throughout therapy, specifically with
regard to her resistance to change. As Ryan et al state (2011) resistance can result from an
attempt to defend or keep in place earlier forms of functioning. Demotivating ideas were
investigated but did not appear to be present leading the author to conclude that the prospect of
successful therapy was good. (Buckner & Schmidt 2008).

Helping Mary to make sense of her behaviour was an integral part of the therapeutic process.
According to Donker et al 2009 even though many professionals believe that psychoeducation
interventions are not effective, certain brief psychoeducational interventions can reduce symptoms
of psychological distress and depression, particularly when such interventions are passive in
nature. Psychoeducation was therefore appropriate for Mary and included explaining how the
memory recalls are triggered by seemingly unrelated events and how compulsive behaviours
(such as the need to self-examine) can be reduced through mindfulness based approaches.
Furthermore Mary reported that she had been researching health anxiety for many months prior to
her first appointment yet she had little understanding of how the condition could be overcome.
Treatment protocols that she had discovered online had only served to reinforce the idea that her
condition was extremely complex and difficult to treat; they had left her with little practical advice.
The need for positive self talk was also emphasised.

After all of the above considerations, the author chose to begin treatment with hypnotherapy. Mary
was clearly very anxious at the outset of the session so care was taken to ensure that a hypnotic
trance could be achieved in a graduated and subtle manner. Despite her condition, Mary was not
depressed, experienced many areas in her life where she did not feel anxious and was not
concerned about her weight. There were, therefore no contraindications to Hartland’s progressive
relaxation which was selected due to it’s gradual nature. Hartland’s is also a relatively
authoritarian induction which can be beneficial in the early stages of therapy (James 2010).
Ambient noise was utilised to deepen the trance and enhance the rapport with the therapist
(Bandler & Grinder 1975). An Ericksonian approach to hypnotherapy was already intended for
later sessions due to it’s permissive characteristics and natural compatibility with neuro-linguistic
programming. A voice tonality that matched the nature of the suggestions was used in contrast to
a monotone as favoured by some hypnotherapists. It is this author’s opinion that whilst both
approaches reliably induce trance when appropriately used, the monotone is, by it’s very nature,
less flexible (Garfield 1995). Upon the elicitation of an adequate trance state, as calibrated by
breathing, postural and skin tone (Pekala and Kumar 2000), Mary was then guided to a safe place
of relaxation (a beach). Establishment of the safe place was necessitated by future work on the
initial sensitising events (using NLP) however it is also beneficial as a simple relaxation therapy
(Vickers et al 2001). The safe place also formed part of the self-hypnosis homework that Mary
committed to as part of the therapeutic contract. Specific suggestions were given to be more
mindful of behaviour at times when she felt the need to self examine. The initial trance was then
brought to a close with ego-strengthening suggestion about feeling calmer, stronger and more
confident each and every day. Upon delivering the count up to officially conclude the trance the
patient was directed to reintegrate any and all parts and sensations. Self hypnosis homework was
set for Mary and the importance of completing homework tasks emphasised (Mausbach et al
2010).

After the initial session Mary reported that she had experienced more mindfulness of her condition,
but the need to self-examine was unchanged. Her memory recalls had also continued. It was
noted that episodes of health anxiety often followed these recalls and they had a very disturbing
effect even when they did not trigger the need to self examine. The decision was therefore made
to treat the recall episodes. Mary was initially reluctant to work on these episodes because she
feared that bringing them to mind would only strengthen their intensity. The author reassured
Mary that treating these episodes would only reduce the intensity and that she would not have to

‘relive’ them. It is a common concern among anxious and phobic patients that exposure is a
necessary component of therapy therefore setting accurate expectations is imperative to full
patient cooperation (Spira 1991). Due to it’s highly dissociative nature, the rewind technique
(originally developed under the name “Fast Phobia Cure”) was selected to perform the treatment of
the recalled episodes (Bandler & Grinder 1979). Dissociation provides a significantly less volatile
framework for treating sensitive and traumatic memories than might be expected from non-
dissociative re-exposure. Furthermore, according to Jamieson et al (2017) dissociation creates
parallel streams of neurological control via a split in the unity of control at a high level of
abstraction. This split may be considered a split in awareness whereby each stream of control has
only limited access to the internal states, outputs and inputs of the other. It is, therefore, valuable
for the patient to experience such highly emotional events without the anticipated and previously
attendant kinaesthetic outputs.

A simple eye-closure induction and countdown from 10 to 1 deepener was selected (there are no
contraindications to these techniques.). It was determined that this would provide a sufficient level
of trance given that further deepening would occur through creating the dissociations. The rewind
technique is a form of stage dissociation whereby a patient re-experiences a sensitising (or
traumatising) memory as though watching it from a movie theatre. As the memory runs forward in
black and white the patient is viewing themselves watching the movie from the projection booth,
creating a double dissociation. The patient then experiences the movie from an associated
perspective, in reverse and at high speed. This process is repeated a number of times. Great
care was taken to give instructions with the appropriate linguistic predicates (Bandler & Grinder
1975), ensuring that the kinaesthetic component of the safe place was added to the visual
component of the movie theatre resulting in a Visual internal / Kinaesthetic internal-meta (Vi/Kim)
synesthesia (Bandler & Grinder 1976). The technique has several properties that make it an ideal
choice for working with unresourceful or challenging memories. Firstly it has the effect of adding
impossible and even ludicrous content to memories, meaning it is far less likely to be
spontaneously recalled. For example, more recent iterations of the technique even include adding
clown music (Bandler 2008) as the memory plays backwards (which may be suitable for dealing
with simple phobias however it was decided to omit this from the technique performed with Mary
due to the extremely sensitive and personal nature of the sensitising memory she was processing).
Other forms of impossible content, as included in the original presentation of the technique, include
seeing it in black and white or watching it backwards. If impossible (or highly implausible) content
is found in a memory then it is unlikely to be presented to consciousness because no external
situation would occur to trigger it. There is also an increased likelihood that such a memory could
simply be dismissed as dream material for which humans appear to have a much greater ability for
total amnesia. Another powerful effect of the rewind technique is that it dismantles the V/K
synesthesia (Bandler 1985) which generally accompanies sensitising events (the rewind technique
is only appropriate where there is both a kinaesthetic and a visual component to the sensitising
memory in question thus we can assume synesthesia is always present wherever the technique is
appropriately applied). Given the highly anxious state of the patient this was a highly desirable
effect, enhanced by bringing the feelings of the safe place into the movie theatre.

On Mary’s subsequent visit she reported that the memory had not troubled her in the intervening
week and that it had only occurred once or twice. On those occasions the recall had been
‘scrambled’ and ‘further off’ suggesting that a permanent change had been affected to the recall of
that sensitising memory. Mary’s health anxiety was still high and she was still self-examining
regularly however she reported being increasingly aware of what she was doing and able to ‘get
out of it quicker’. In particular, Mary reported that she could now see herself doing the self-
examining and that helped her to stop it faster and feel more in control of it. Given that Mary had a
significant number of highly sensitising memories it was agreed that, on this visit we would
continue desensitisation using the rewind technique. 2 further memories were desensitised on this
visit, both with the effect of ‘scrambling’ the memory. On this occasion, the author decided that
rapport was adequate to include the circus noise as the memory was being rewound – adding an
additional sensory channel to the process. This was welcomed with a smile by Mary.

On Mary’s next visit she reported an improvement in her levels of anxiety, a reduced need to self-
examine, and fewer recalls (with all treated memories coming back ‘scrambled’). Given the
excellent progress it was decided to apply dissociation to the behaviour of self-examining. Mary
had previously reported that seeing herself doing the behaviour helped her to stop it quicker
therefore dissociation was already a factor in her recovery. The rewind technique was again
selected due to it’s efficacy in previous sessions. It is also noteworthy that the technique was
originally created by modelling individuals who had spontaneously ‘cured themselves’ of a phobia.
According to Bandler (1979), all these individuals reported ‘Taking a long hard look at myself. The
rewind technique was, therefore perfectly suited to Mary’s situation. The session concluded with
more direct hypnotherapeutic suggestions to remain calm and in control, with law of the reverse
effect suggestion similar to: “Mary, the more you feel the need to self-examine, the more see
exactly what you are doing to yourself”. This suggestion has the effect of challenging the ongoing
experience and creating spontaneous dissociation. In subsequent sessions the author continued
exploring dissociation and employed the rewind technique to more sensitising memories. All were
subsequently desensitised and Mary reported gradual improvement with each session.

Several assumptions were made at the outset which may have impacted the efficacy of treatment.
Firstly, it was assumed that Mary does not have a personality disorder underlying the health
anxiety. Given that the treatment was effective it appears that this assumption was somewhat
correct. It is, in any case not the position of this author to diagnose, however the decision not to
refer this patient to a psychiatrist or psychotherapist appears to have been the right one. Secondly
it was assumed that the health anxiety was created via recall of historical sensitising memories,
however recovery was slower than the author anticipated therefore it is likely that other factors
were involved. A more appropriate diagnosis (from a qualified professional) might be that this
patient was in fact suffering carcinophobia, rather than hypochondriasis. Health anxiety
(hypochondriasis) was the patient’s own term. This view might be further supported by the fact
that the patient was unconcerned with other illnesses, it was only cancer that Mary worried about.

Thirdly it was assumed that treating the sensitising memories would resolve the emotional and
behavioural issues. In retrospect it seems that there may be deeper, underlying issues. For
example, Mary became increasingly aware of her feelings of guilt toward her mother and sister as
treatment progressed (Popiel 2013). As such the initial ruling-out of secondary gain may be
erroneous as the gain is toward the mother and sister.

In conclusion, this patient may well have benefitted from a longer, more detailed intake process
however in the context of a brief therapy such as hypnosis this is not often practicable.
Furthermore, without the capacity to diagnose conditions, a case such as Mary’s needs to be
handled with great care to ensure that a referral is made at the relevant point, should complications
that fall outside the scope of hypnotherapy arise. Notwithstanding these considerations Mary did
make progress during the sessions and now experiences significantly more self control when the
perceived need to self-examine arises. Mary is also reports that she no longer goes to great
lengths to avoid the subject of cancer and can now hear it in a conversation without re-
experiencing her sensitising memories. This constitutes a major improvement to Mary’s overall
psychological wellbeing and therefore the therapy has been largely successful.

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