Intl.

Journal of Clinical and Experimental Hypnosis, 54(2): 143166,

2006 Copyright International Journal of Clinical and Experimental
Hypnosis ISSN: 0020-7144 print / 1744-5183 online
DOI: 10.1080/00207140500528240

MINDFULNESS, ACCEPTANCE,
AND HYPNOSIS:
Cognitive and Clinical Perspectives
1,2

STEVEN JAY LYNN

State University of New York at Binghamton, Binghamton, New York, USA

LAMA SURYA DAS

Dzogchen Foundation, Austin, Texas, USA

MICHAEL N. HALLQUIST AND JOHN C. WILLIAMS

State University of New York at Binghamton, Binghamton, New York, USA

Abstract: The authors propose that hypnosis and mindfulness-based

approaches can be used in tandem to create adaptive response sets
and to deautomatize maladaptive response sets. They summarize
recent research on the effectiveness of mindfulness-based approaches
in clinical and nonclinical contexts and propose that the cognitive
underpinnings of mindfulness approaches can be conceptualized in
terms of the metacognitive basis of mindful attention, Toneattos elucidation of the Buddhist perspective on cognition, and Kirsch and
Lynns response-set theory. They also suggest that mindfulness can
serve as a template for generating an array of suggestions that provides cognitive strategies to contend with problems in living and to
ameliorate stress and negative affect more generally. Many of the
ideas the authors advance are speculative and are intended to spur
additional research and clinical work.

More than 2000 years ago, the Buddha attributed human suffering to
the tendency to cling to thoughts, feelings, and ingrained perceptions
of reality and habitual ways of acting in the world. Afraid of remaining
in direct, open, and unguarded contact with the totality of subjective
expe- rience, many people engage in experiential avoidance, habitually
striv- ing to avoid what is unpleasant and experience only what is
pleasant. Ironically, not only does what is avoided tend to occur (Hayes
& Wilson,
Manuscript submitted August 20, 2004; final revision received November 1, 2004.
This article is based on a paper presented to the Annual Meeting of the Society for
Clinical and Experimental Hypnosis, November, 2002, Boston, MA. We thank Albrecht
Inhoff for his helpful comments regarding an earlier version of this manuscript.
1

Address correspondence to Steven Jay Lynn, Ph.D., Psychology Department, State

University of New York at Binghamton, Binghamton, NY 13905, USA. E-mail: slynn@
binghamton.edu
143

14
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STEVEN JAY LYNN ET AL.

2003), but recent research findings suggest that the propensity to inhibit
unsettling thoughts, feelings, and memories contributes to a variety of
clinical disorders and conditions including depression (see MacLeod,
Bjork, & Bjork, 2003) and anxiety (Amir, Coles, Brigidi, & Foa, 2001).
The Buddha proposed that mindfulnessthe radical and
unmitigated attention to pleasant as well as unpleasant experiences
is a means of counteracting experiential avoidance and alleviating
human suffering. Kabat-Zinn (2003) has defined mindfulness as
purposeful, nonjudgmen- tal attention to the unfolding of experience
on a moment-to-moment basis. According to Lama Surya Das (1997),
pure mindfulness is relaxed, open, lucid, moment to moment present
awareness. It is like a bright mir- ror: nonclinging, nongrasping,
nonaversive, nonreactive, undistorting (p. 300). Or put yet another
way by Zen master Dogen more than 700 years ago (in Mitchell,
1991, p. 100), Many thoughts will crowd into your mind. . . . Let
[them] come and go, without getting involved in them or trying to
suppress them. Traditional Buddhist meditation manuals describe
mindfulness as paying attention to what we experience, not to what
we would like to experience. According to this perspective, it is
through mindfulness and alert awareness that meditators and yogis
traverse the path of insight and self-realization, inner peace and
freedom, awakened heart and mind, and ultimate enlightenment.
The challenge of confronting what is actively and routinely avoided
is illustrated by the ancient Tibetan practice of Chod. As described by
Lama Surya Das (2003), the Chod practitioner travels to a physical or
mental place where his or her fears will be pushed to the limit. The
goal is to summon and master fears that are difficult to contemplate,
much less confront. Often this practice is done in the dead of night in a
charnal ground or burial site such as a cemetery. The practitioner visualizes the most terrifying demons, ghosts, and ghouls that can be
imag- ined, creating a sense of unadulterated terror. When the fears
seem to be overwhelming, rather than retreat and escape, the
practitioner invites the experience of terror by symbolically offering
the body as food to the demons and visualizes the body being
chopped up and all of the blood pouring into a cauldron made of the
upturned skull of the practitioners own head. The practitioner then
imagines that the gory stew is blessed, mystically transformed,
sanctified, and ritualistically offered up to repay karmic debts and
satisfy the demons hunger. Tibetan meditation masters contend that
this technique cultivates fear- lessness and the ability to regard
adversity and suffering as means of promoting personal growth and
acceptance.
Relatedly, in the West, monks have had similar practices for centuries, and the yoga tradition is replete with methods of confronting what
is usually avoided. For example, one meditation instructs practitioners
to exhale completely and then vigorously pump the navel point in and
out without inhaling. This action quickly engenders sensations of

suffocation. Practitioners are encouraged to remain in this state as long

as possible and thereby symbolically confront their fear of death.
The necessity of mindful attention and confronting what is feared is
consistent with emerging trends in contemporary psychology that recognize the importance of exposure to what is feared, mindfulness of
subjective experiences, and unconditional acceptance of thoughts, feelings, and actionsan acceptance that does not preclude choice, preferences, plans, or sincere efforts to change things for the better. A
growing number of modern clinical psychologists contend that rather
than trying to fix things and searching for more elaborate strategies
to do so, an attitude of acceptance can serve as a platform for change.
From humanistic-existentialist approaches (Greenberg, 1994) to rational emotive therapy (Ellis, 1994), solution-focused therapy (Fish, 1996),
behavior therapy (Koerner & Jacobson, 1994), and acceptance and
commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), acceptance seems to be an idea whose time has come. Therapies that incorporate one or more techniques designed to promote acceptance and
mindfulness include: Linehans dialectical behavior therapy (1993) for
borderline personality disorder; Teasdale, Segal, and Williams depression relapse program (e.g., Segal, Williams, & Teasdale, 2002; Teasdale
et al., 2000); Borkovecs treatments for generalized anxiety disorder
(GAD) (Borkovec, Alcaine, & Behar, in press); Marlatts alcohol relapse
prevention program (Marlatt, 2002; Marlatt & Kristeller, 1999); and
Kabat-Zinns (Kabat-Zinn, Lipworth, & Burney, 1985) treatment of
pain and functional somatic syndromes.
In this paper, we suggest that hypnosis and mindfulness-based
approaches can be used in tandem to create adaptive response sets and
ameliorate maladaptive response sets. At the outset, it is important to
acknowledge that hypnosis and mindfulness differ from one another
in important respects. The most obvious difference is that the success
of hypnosis relies largely on participants ability to experience suggestions for changes in thoughts, emotions, perceptions, sensations, and
memories. Hypnotic suggestions can be given to achieve detachment,
to mindfully attend, and to separate a particular stimulus from intense
affect (see Lynn & Kirsch, in press). However, suggestion is not central
to mindfulness-based approaches. In fact, if there is a fundamental
rule of mindfulness, it is to not give special importance to any given
con- tent of the mind at any given moment. Nor is there an
imperative to change anything in mindfulness, as is the case in
administering thera- peutic suggestions to achieve a clear-cut
treatment objective such as pain relief.
These differences aside, both hypnosis (Kirsch, Capafons, CardeaBulena, & Amigo, 1999) and mindfulness (Roemer & Orsillo, 2003) are
multifaceted self-regulation techniques that can be used to promote
cognitive and behavioral change, problem solving, and acceptance of a

wide array of emotions and thoughts (Baer, 2003; Teasdale, Segal, &
Williams, 2003). We suggest that a mindfulness approach can serve as
a template or springboard for generating an array of suggestions that
provide cognitive strategies to contend with a variety of problems in
living and to ameliorate stress and negative affect more generally.
In the discussion that follows, we will proceed by: (a) summarizing
recent research on acceptance and mindfulness-based approaches,
(b) proposing a framework for understanding mindfulness based on a
synthesis of Buddhist and modern cognitive and clinical psychology,
(c) delineating ways in which hypnosis and mindfulness-based
approaches can be combined, and (d) highlighting a number of parallels between hypnosis and mindfulness-based approaches. Many of
the ideas we present are speculative and intended to spur additional
research and clinical work, rather than to summarize what has been
well established by rigorous research.

A BRIEF REVIEW OF THE EVIDENCE

Evidence from the following sources provides a rationale for the
practice of mindfulness in clinical and nonclinical contexts. In general,
the attempt to suppress a particular thought or action tends to increase
the propensity to engage in the thought or action (Polivy & Herman,
1987; Strauss, Doyle, & Kreipe, 1994; Wegner, Schneider, Carter, &
White, 1987). In a recent study (Wegner, Wenzlaff, & Kozak, 2004),
thoughts about a person that were intentionally suppressed 5 minutes
before sleep were more likely to lead to increased dreaming about the
person than merely thinking about the person or writing freely after
the person was mentioned. When emotions are suppressed or concealed, rather than fully experienced and expressed, memory (pleasant
and unpleasant slides, Bonanno, Papa, Lalande, Westphal, & Coifman,
2004; recall of what was said in a social interaction, Richards, Butler, &
Gross, 2003) and problem solving (anagram problem-solving task,
Baumeister, Bratslavsky, Muraven, & Tice, 1998) are compromised.
Moreover, physiological markers of stress increase (e.g., electrical conductivity of the skin, constriction of blood vessels; Richards & Gross,
1999; Study 2) in the face of emotional suppression.
In contrast to the finding that relatively poor clinical outcomes
accompany avoidance or suppression of negative emotions or
thoughts (Amir et al., 2001; Hayes et al., 1999; Teasdale, Segal, &
Williams, 1995), a high level of acceptance and experiencing of
emotions is associated with positive psychotherapeutic outcomes (e.g.,
Greenberg & Safran, 1987). Recently, Bach and Hayes (2002) demonstrated that rehospitalization rate decreased among psychotic patients
who were taught to accept unavoidable events such as auditory hallucinations. Finally, therapies that promote exposure to negative as well

as positive feelings, and directly confront experiential avoidance, have

an important role in the treatment of anxiety and posttraumatic stress
disorders (see Mellinger & Lynn, 2003).
There also are indications that mindfulness can play a salutary role
in nonclinical populations. Easterlin and Cardea (19981999)
reported preliminary evidence that mindfulness meditation, as a spiritual practice, has psychological benefits. That is, compared to beginning meditators, advanced Vipassana meditators exhibited greater
resistance to the negative effects of stress on mood and self-acceptance.
Also, Davidson and colleagues (2003) recently found that a group of
coworkers trained in mindfulness-based stress reduction (MBSR;
Kabat-Zinn, Massion, Kristeller, & Peterson, 1992) exhibited increased
influenza-vaccine-antibody titer levels and changes in frontal cerebral
asymmetry indicative of increased positive mood, compared to
coworkers not trained in MBSR.
Meta-analyses (Baer, 2003) and qualitative research reviews
(Hayes, Jacobson, Follette, & Dougher, 1994; S. L. Shapiro & Walsh,
2003) have documented the promise of mindfulness techniques
across multiple indices of psychological functioning. Baer (2003)
examined studies that compared groups of participants trained in
mindfulness with control participants who did not receive mindfulness training, or participants assessed before and after they completed mindfulness training. Baer concluded that mindfulness-based
interventions, many of them grounded in Kabat-Zinns approach
(1994), and mindfulness training combined with cognitive-behavioral
interventions significantly improved a variety of problems and medical conditions. These include chronic pain; anxiety; depression; binge
eating; fibromyalgia; psoriasis; stress and mood disturbance in cancer patients; and a variety of symptoms of obsessive-compulsive disorder and narcissistic and borderline personality disorders. Baer
reported an effect size range at posttreatment of .15 to 1.65 and a
medium mean effect size at follow-up of .59.
Baer (2003) was careful to acknowledge that it is difficult to draw
strong conclusions about the effects of these treatments, because
many of the studies have significant methodological weaknesses.
These weaknesses include poor control groups, small sample sizes,
inadequate evaluation of treatment integrity, and a lack of attention
to clinical significance. We heartily endorse Baers caveats regarding
the status of research on mindfulness. However, Baer also concluded
that mindfulness-based stress reduction may meet (and mindfulnessbased cognitive therapy may approach) the criteria for probably
efficacious treatments set forth by the Division 12 Task Force on
Promotion and Dissemination of Psychological Procedures, but further studies are required before either treatment can be considered
well-established.

MINDFULNESS

AND

COGNITION

The cognitive underpinnings of mindfulness training and the

poten- tial value of the technique can be brought into relief by
considering the metacognitive (Wells, 2000) basis of mindful
attention, Toneattos (2002) elucidation of the Buddhist perspective on
cognition, and Kirsch and Lynns (1998) response set theory. Wells
has defined metacogni- tion as cognitive processes that are engaged
in the appraisal, monitor- ing, or control of other cognitions. He
further distinguished between three varieties of metacognition,
which we will discuss in turn: meta- cognitive knowledge,
metacognitive experiences, and metacognitive control strategies.
Metacognitive Knowledge
Metacognitive knowledge refers to beliefs about ones own cognitions and can be divided into two categories: explicit (i.e., conscious
and verbally expressed) and implicit (i.e., normally not conscious or
verbally expressed). Adopting the definition of mindfulness as nonjudgmental attention, explicit metacognitive knowledge refers to an
appreciation of the notion that cognitions are nothing more than mental events. According to Toneatto (2002), a fundamental tenet of Buddhist thought is that the objects of awareness do not necessarily mirror
accurate or true reality. Valid perceptions are inextricably linked
with attitudes, beliefs, assumptions, and feelings about perceptions.
Catastrophizingthe tendency to greatly exaggerate the frequency,
danger, or unpleasantness of a negative feeling or aspect of the environment one dislikesis an important component of anxiety and
depression (see Beck & Emery, 1985; Mellinger & Lynn, 2003). Indeed,
the very expectation of negative events or their continuing without
relief can have quite serious consequences. For example, Abramson,
Alloy, and Hogan (1997) have identified a subtype of depression they
term hopelessness depression in which patients believe that desired outcomes are unlikely to occur or that aversive outcomes are inevitable.
However, the tendency to catastrophize or worry is by no means
equivalent to a real or mortal danger in the world. Rather, such
unproductive mental activities can be thought of as absorption in
unsettling thoughts or physical sensations that deviates from
moment- to-moment awareness of the constantly changing field of
experience.
A fixation on negative thoughts can result in a pervasive negative
mood because of spreading activation (Norman, 1968). That is, when a
concept is perceived or imagined, the concept, which is embedded in a
memory network, is activated and spreads its connections to associated concepts and activates those conceptsin the case of worrisome
thoughts, negative ideas and predictions about the self. The tactic of
merely observing the flow of experience without the imperative to act

on a given impulse or feeling (e.g., anger) can disrupt constellations of

thoughts, impulses, and actions that accompany feelings.
Baer (2003) suggests that during the practice of mindfulness,
extended exposure to emotions, cognitions, and sensations that are
habitually avoided reduces the frequency and aversiveness of such
experiences. For example, encouraging individuals with chronic pain
to remain still during meditation and to adopt a nonjudgmental,
accepting attitude toward any painful sensations and catastrophic cognitions that arise can result in the alleviation of pain sensations via
desensitization and extinction (Kabat-Zinn, 1982). Similarly, borderline
personality disorder patients, who routinely experience intense negative emotions, may benefit from prolonged exposure to and observation of their emotions and thoughts (Linehan, 1993).
Hayes and Wilson (2003) suggest that mindfulness allows individuals to observe their thoughts without having to assign value
judgments to each thought. They argue that language is inherently
evaluative. The considerable utility of categorizing and organizing
experiences using language breaks down when these skills are used
to evaluate oneself and ones cognitions because the ability to
evaluate various subjective experiences is accompanied by a tendency
to prefer positive over negative outcomes. Accordingly, a mental
dialogue ensues in which negative experiences are avoided and
positive experiences are valued and sought after, a state of affairs that
can become increasingly maladaptive and demoralizing when
desired outcomes are not achieved. Hayes and Wilson contend that
mindfulness and acceptance approaches fundamentally alter the way
in which psychologists con- ceptualize problematic behavior: rather
than a particular thought or behavior indicating psychopathology,
maladaptive patterns of behav- ior can be thought of as the product
of intransigent verbal rules that limit behavioral options and
flexibility.
Metacognitive Experiences
Closely related to metacognitive knowledge, metacognitive experiences are conscious, moment-to-moment interpretations of cognition,
including appraisals and feelings about cognitions and the status of
cognition (Wells, 2000). An example of a mindful appraisal of cognition is the perception of paying attention in the moment and consciously labeling the contents of consciousness as they unfold.
However, at any given moment, it is easy to identify with cognitions
(i.e., Because I think I am worthless, I am worthless) or with cognition itself (i.e., I am nothing more than my worries), or to conflate
momentary thoughts or impressions with a more permanent reality.
In Lama Surya Dass (1997) terms, We are not what we think. . . . We
create our thoughts and we are responsible for our thoughts, but we
are not limited by them or enslaved by the thinking process (p. 310).

15
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STEVEN JAY LYNN ET AL.

A Buddhist perspective on cognition holds that negative thought patterns have no inherent potency (Toneatto, 2002): Merely because a particular thought that arises on an evanescent basis is pleasant or
unpleasant does not, of necessity, lead to the assumption that unpleasant thoughts are dangerous or harmful or that pleasant thoughts are
harmless and helpful. Mindfulness teaches individuals to relate to
thoughts and feelings in the context of a wider, decentered or disidentified perspectiveas mental events that arise unceasingly in many
and varied permutations (Teasdale et al., 2000).
Enhanced awareness of maladaptive thought patterns and attachments to habitual ways of thinking may afford awareness of early indicators of maladaptive responses (Baer, 2003; Linehan, 1993; Marlatt,
1994) and tendencies to relapse from disorders such as depression
(Teasdale et al., 1995), thereby establishing an early warning system.
Indeed, the practice of mindful awareness may also serve to dilute or
nullify the malign influence of maladaptive cognitions. That is, by
appraising troubling thoughts as they arise as nothing more than a
chain or cascade of mental events, and by detaching, decentering, or
disidentifying from such thoughts (e.g., just because I think I will die
if I do not wash my hands, does not mean I actually will die), and
thus changing the context or perceived relationship between the self
and mental activity, it is possible to achieve a degree of freedom
from habitual or conditioned reactions. Hayes and his colleagues
(Hayes et al., 1999; Hayes & Wilson, 2003) have suggested that one
way this outcome can be achieved is by means of the technique of
cognitive defusion. One approach to defusion involves saying a
particular nega- tive thought aloud or to oneself 100 times.
Masuda, Hayes, Sackett, and Twohig (2004) recently demonstrated
that this technique was more effective in reducing the believability
of self-relevant negative thoughts than distraction and thoughtcontrol tasks.
Metacognitive Strategies. Metacognitive control strategies are cognitive strategies that are specifically employed to control cognitions.
Pekala (1987) described meditation as a process that allows practitioners to develop attentional control of the processes and contents of
consciousness. Metacognitive strategies include thought suppression
and worrying to avert anticipated catastrophes (Borkovec, HazlettStevens, & Diaz, 1999). However, as noted earlier, tactics geared to
evade unpleasant experiences are generally not productive. Hayes and
Wilson (2003) suggest that suppressing a particular thought requires
one to instantiate an explicit, verbal rule that specifies the thought to
avoid. However, the rule itself contains the thought to be avoided and
thus is ineffective at stopping the thought. These authors conclude that
such a verbal ruleindeed language itselftends to be inflexible and
restrictive and that mindfulness provides individuals with an
opportunity

to observe their internal dialogue in a nonevaluative way, thereby promoting behavioral flexibility.
Another strategy to control a mental activity such as rumination is
to direct attention to what is transpiring in the environment. However,
mindful awareness does not aim to control cognitions as much as
observe them, insofar as the goal is to remain disidentified from cognitions and related emotions as they arise. In mindful awareness, it is
more productive to appraise thoughts in terms of categories, such as
memories or worries, than to label thoughts as good or bad,
which is contrary to the goal of nonjudgmental awareness. Of
course, one may also employ the strategy of redirecting ones
attention to the intention to be mindful in the present. Advanced
practitioners of mindfulness may adopt a strategy along the lines of
the Zen concept of no mind, cultivating thought-free or
nonconceptual awareness, which is not merely mindlessness or
stupor but actually a lucid and vivid presence of mind.
Toneatto (2002) has observed that the Buddhist perspective holds
that cognitive events are impermanent, ephemeral, and constantly
changing, as exemplified by the metaphor of a stream of consciousness. Regardless of the positive or negative valence of a mood, it is
likely that a different mood will occur on its heels. By using paradoxical approaches and inviting depressed persons to focus on their negative thoughts, for example, positive thoughts often emerge to
command attention (Lynn & Hallquist, 2004). Relatedly, behavior therapists request that anxious individuals set up worry periods in which
they are mindful of their current concerns and notice that worries are
merely thoughts that pass and morph into different thoughts in time
(see Mellinger & Lynn, 2003). Depressed persons trained in meditation
and cognitive-behavioral relapse-prevention techniques have the
opportunity to learn that their depressed moods often shift over relatively short intervals and thus can be tolerated. By accepting depressed
feelings yet soldiering on with the business of life, depressed persons
can discover that their moods lift as they are distracted, regain a sense
of accomplishment and find renewed pleasure in daily activities (Segal
et al., 2002).
Mindfulness-based cognitive therapy (Segal et al., 2002; Teasdale
et al., 1995) is based on the idea that recurrent depressive episodes
result from persistent depressive thinking that is often a learned and
reinforced remnant of previous depressive episodes. Mindfulnessbased cognitive therapy encourages individuals to realize that their
thoughts not only come and go but, as noted above, that thoughts do
not necessarily reflect who they truly are or their personal worth. This
clinical intervention has proved successful in preventing rumination
associated with persistent negative thoughts. Baer (2003) suggests that
the construal of thoughts as impermanent events is an important

outcome of mindfulness practice. Linehan (1993) uses the metaphor of

waves in the sea to describe the rising and falling of mental events,
which are always changing.
In addition to their ephemeral nature, cognitive events often arise
and cease with little or no conscious involvement. Thoughts are rarely
initiated in a deliberate fashion but typically seem to be automatic,
autonomous, and difficult to suppress. Of the 99 subjects we tested in
our laboratory who were asked to keep their minds blank in the face
of hypnotic suggestions, only one claimed to be able to do so with
much success (Lynn & Jacquith, 2001). Mindfulness-based
approaches clearly acknowledge the automaticity of cognition and
address nega- tive automatic thoughts by encouraging acceptance
and discouraging self-deprecating judgments.

RESPONSE SET THEORY

Kirsch and Lynns response set theory (1997, 1998) is consistent
with the Buddhist perspective on cognition, as described by Toneatto
(2002). Kirsch and Lynns theory highlights the automaticity of everyday actions (see also Wegner, 2002) and the role of response sets in
hypnosis and a wide variety of clinical conditions (e.g., anxiety,
depression). Response sets are conditioned patterns of associations
composed of expectancies, intentions, and cognitive-representations or
constructions of the self. Expectancies and intentions are temporary
states of readiness to respond in particular ways to particular stimuli
(e.g., hypnotic suggestions), under particular conditions. For example,
self-schemas have been described as cognitive overgeneralizations
about the self derived from past experience that organize and guide
the processing of self-related information contained in the individuals
social experiences (Markus, 1977, p. 64). Response sets prepare cognitive and behavioral schemas (i.e., knowledge structures) or scripts for
efficient activation and can be triggered or automatically activated by
environmental and internal stimuli, such as physical sensations and
moods. A sizable literature indicates that response sets have an instrumental role in many vexing conditions including anxiety, depression,
and eating disorders, in which self-worth is inextricably linked to
weight and shape; and in sexual dysfunctions, in which poor sexual
performance is closely tied to expectations of poor performance (see
Kirsch & Lynn, 1999, for a review).
Closer to our discussion, mindfulness approaches have been
advanced as promising means of deautomatizing habitual response
sets. Tart (1986, 1995) described everyday living as a consensus
trancethe automatic and mindless activities that comprise typical
daily routines that are shared among individuals (e.g., driving a car
or checking out at the grocery store). Tart stated that repetition of

common daily activities promotes an automaticity of behavior that is

antithetical to a mindful, aware state. He conceived of mindfulness
meditation, particularly as influenced by Gurdjieff training, as a vehicle to transition from mindless, automatic living to a mindful, aware
existencea process he calls waking up.
The following examples suggest that deautomatizing response sets
can be valuable in a variety of contexts:
Marlatt (2002): Meditation helps clients with addictive behavior
problems to monitor urges and cravings without overidentifying
with them and reacting in an automatic, habitual manner.
Groves and Farmer (1994): Mindfulness might mean becoming
aware of triggers for alcohol, smoking, depression, and choosing to do
something elseweakening the habitual response.
Kristeller and Hallet (1999): Mindfulness skills can lead to an
increased ability to observe urges to binge without yielding to them.
Teasdale, Segal, and Williams (2003): Mindfulness trains individuals to switch out of habitual, relatively automatic, patterns of reaction
into more intentional, considered choice of response (p. 159).
Lama Surya Das (1997): Mindful awareness in structured meditation sessions is the practice of freedom. It intentionally reconditions
and eventually deconditions the mind, liberating it from unfulfilling
reaction patterns and inculcating broader present awareness conducive to creative proactivity rather than habitual reactivity.
These ideas are consistent with the notion that mindful attention
can play a pivotal role in modifying response sets, a goal that is of paramount importance to virtually all psychotherapeutic endeavors
(Lynn & Hallquist, 2004).

HYPNOSIS, ACCEPTANCE,

AND

MINDFULNESS

Hypnosis and Response Sets

Hypnosis and mindfulness approaches are complementary in key
respects. Our discussion implies that mindfulness can deautomatize
response sets and create the mental workspace for the formation of
new ones. Hypnosis is also a viable method for creating positive
response sets as well as deautomatizing dysfunctional response sets.
Erickson, Rossi, and Rossi (1976) defined therapeutic hypnosis as
occurring when the limitations of ones usual conscious sets and
belief systems are temporarily altered so that one can be receptive to
an experience of other patterns of association and modes of mental
functioning . . . that are usually experienced as involuntary by the
patient (p. 20). According to these authors,
Most people do not know that most mental processes are autonomous. . . .
Hypnotic suggestions come into play when the therapists directives

have a significant effect on facilitating the expression of that flow (of

associations) in one direction or another. . . . Much initial effort in every
trance induction is to evoke a set or framework of associations that will
facilitate the work that is to be accomplished. (p. 58)

In addition, Erickson claimed that the most effective aspect of any

suggestion is that which stirs the listeners own associations and mental processes into automatic action. We are in essential agreement with
Michael Yapkos (2003) statement: . . . if you were to ask me what single stage of the interaction most influences the overall success of the
hypnosis session, Id say its the stage of deliberately building a
response set (p. 283).
The starting place for much of the work of clinical hypnosis, and
the creation of new response sets, is acceptance. Erickson pioneered
the utilization approach in hypnosis and psychotherapythe radical
acceptance of the clients current reality and responses, as a foundation
on which to build new response sets by way of the following strategies: using permissive and indirect suggestions, subtle priming of
therapeutic responses, accepting/utilizing client resistance as a springboard for change, noticing and capitalizing on small changes in the
client, gently guiding the clients associations and stream of awareness
to influence the outcomes they think about, and using paradoxical
interventions and reframing to turn a clients deficits into assets (see
Lynn & Hallquist, 2004). Each of these tactics implies a profound
respect for clients individuality and acceptance of their moment- tomoment experience. The use of many of these techniques is now
widespread in the hypnosis field and reflected in a number of mindfulness-based approaches, including ACT (Hayes et al., 1999).
Hypnosis as a Catalyst of Mindfulness-Based Approaches
Even though practice in meditation does not appear to enhance
hypnotic suggestibility, and the facility in meditation does not seem to
be related to suggestibility (Murphy, Donovan, & Taylor, 1997; Rivers &
Spanos, 1981; Spanos, Gottlieb, & Rivers, 1980; Spanos, Stam, Rivers, &
Radtke, 1980; Spanos, Steggles, Radtke-Bodorik, & Rivers, 1979),
Holroyd (2003) has proposed that mindfulness training can facilitate
the phenomenological investigation of hypnotic experiences. In the
case of very highly responsive participants, there seem to be interesting parallels (e.g., a sense of being in contact with everything) to
what some individuals report during meditation (see Cardea, 2005).
We suggest that it may be worthwhile to use hypnosis to catalyze
mindfulness-based approaches. Meta-analyses and qualitative reviews
have shown that hypnosis enhances the effectiveness of both psychodynamic and cognitive-behavioral psychotherapies (Kirsch, 1990;
Kirsch, Montgomery, & Sapirstein, 1995; Lynn, Kirsch, Barabasz,
Cardea, & Patterson, 2000). In fact, the mean effect for adding
hypnosis

to cognitive-behavioral therapy (.48) rivals the effect size of psychotherapy itself (.52; Lipsey & Wilson, 1993). Accordingly, there is reason
to believe hypnosis will enhance the effectiveness of mindfulness
training as well. After all, basic instructions to practice mindfulness
can be thought of as suggestions that, like other imaginative or attention-altering suggestions, can be augmented by means of hypnosis.
The following suggested images and approaches, designed to facilitate
mindfulness, can be presented in a hypnotic context.
Imagine that your thoughts are written on signs carried by
parading soldiers (Hayes, 1987), or thoughts continually dissolve like
a parade of characters marching across a stage (Rinpoche, 1981, p. 53).
Observe the parade of thoughts without becoming absorbed in any of
them.
Imagine that the mind is a conveyor belt. Thoughts, feelings that
come down the belt are observed, labeled, and categorized (Linehan,
1993; Tart, 1986).
The mind is the sky, and thoughts, feelings, and sensations are
clouds that pass by, just watch them (Linehan, 1993).
Imagine that each thought is a ripple on water or light on leaves.
They naturally dissolve (Rinpoche, 1981, p. 44). Relatedly,
Think of each of your thoughts as a wave on the ocean of awareness. No
matter how large or outlandish your waves, the boundless ocean retains
its essential quality. The ocean of awareness never leaves its bed, no matter what kind of waves are moving along the surface. . . . In meditation,
as thought waves ripple on the surface, we keep returning to the deeper
ocean . . . (Lama Surya Das, 1997, p. 310).

Imagine that urges to smoke or drink are ocean waves that grow
gradually until they crest and subside. Imagine riding the wave, surfing it, without giving in to the urge. Learn that the urge will pass
(Marlatt, 2002).
Imagine that you are transparent, and disturbing thoughts and
emotions can not penetrate you or have any power to control your
actions.
Verbalize any thought, sensation, or perception on an ongoing
basis.
Transcendent Self-Suggestions
The following suggestions, adapted from Hayes, Strosahl, and Wilson
(1999), can be used to promote acceptance and mindfulness by fostering a sense of disidentification and reducing experiential avoidance.
You have been you your whole life. Whether you think of something
that happened last year or last minute, it was always you who was noticing, you who were aware, you who are aware today. And everywhere
youve been, youve been there noticing. Notice now how you are constantly changing. Your awareness is changing constantly. Your body is

constantly changing. Perhaps you are aware of sounds in the room that
you did not notice a few minutes ago. Perhaps some of your muscles are
more relaxed than they were when I started speaking to you. Sometimes
your body is sick, and sometimes it is well. Sometimes your heart beats
fast, and sometimes it is so slow you would not think to notice it. Your
body may be strong; it may be weak. It may be tired or rested. Are you
rested now and comfortable, a bit tired, or are you alert and attentive?
You were once a tiny baby, but your body grew. Your cells have died
and literally almost every cell in your body was not there as a teenager
or even last summer. You cannot remember today things that were so
important to you years ago, or even last week, perhaps. Your moods
come and they go, your thoughts are constantly changing. Even as I have
spoken, things have changed, most of which you are not aware of, but
some of which you may be aware of now, like the gradual slowing down
of your breathing, or has it sped up ever so slightly? I dont know, but
you can notice this. Yes, things change, inside and outside of youyour
blood pressure, for example, or your body temperature, if ever so
slightly. Are you aware of these changes? Probably not. But there are
some changes you may be aware of now, like the gradual slowing down
of your breathing, or has it sped up ever so slightly? And maybe sometimes you are listening to me more carefully than others.
And as you notice shiftssubtle though they may bein your
thoughts, sensations, perceptions, feelingsyou notice that you are the
one noticing, witnessing. You are more than your body, more than your
roles, your emotions, your thoughts. These things are the content of your
life, while you are the arena . . . the space in which they unfold. You will
always be there. You have been through it all . . . what you think at any
given moment is not the measure of who you are or your life. Just notice
the experiences in all aspects of your life, notice how they come, they go.
As your breathing rises and falls, be aware of so many things, stay in
contact with whatever arises, and if there is anything that comes up that
frightens you, let it pass, or go to your safe place, and know who you are
will remain secure there, even if thoughts pass through your mind, or
feelings pass through you body that you are not entirely comfortable
with in the moment. Let them come, and let them go in this safe place.
Move your awareness there any time you wish, any time you want. But
at some point, perhaps, you will realize that this safe place is consciousness itself, perhaps you will discover that you dont have to go anywhere, so to speak, it is safe to be inside your skin, to feel your different
feelings, think your thoughts, knowing that you dont have to act on
them, unless you want to, unless you need to.

Hypnotic and posthypnotic suggestions can also be used to encourage individuals to: (a) practice mindfulness on a regular basis; (b) not
become discouraged when attention inevitably wanders; (c) learn
ways to accept what can not be changed; (d) not personally identify
with feelings as they arise; (e) be tolerant of specific troublesome feelings (e.g., anger at a child), using whatever comes up to trigger adaptive action, if appropriate; and (f) appreciate the fact that even

disquieting feelings are impermanent and that they will eventually be

replaced with different feelings.
Similarities
Promoting acceptance, minimizing experiential avoidance. Before closing, we highlight a number of similarities between hypnosis and mindfulness-based approaches. Buddhist visualization practices taught
during guided meditation, especially with eyes closed during instruction, veer close to what many modern psychologists would term hypnosis or consider to be hypnotic-like. Mindfulness-based techniques,
like hypnotic suggestions, can be used to promote acceptance and mitigate behavioral avoidance. Hypnotic approaches that can be used for
this purpose include: (a) behavioral rehearsal (e.g., imagining future
events and coping with them during visualization); (b) cue-controlled
relaxation (e.g., saying a key word associated with relaxation, employing a physical gesture such as touching two fingers to trigger relaxation) to facilitate encountering a feared situation; (c) hypnotically
controlled desensitization; (d) imagining or reliving past painful
occurrences; and (e) assisting clients in tolerating exposure therapy
(see Lynn & Kirsch, in press, for a description of these techniques). At
the most basic level, simple suggestions for mindfulness (see KabatZinn, 1994) can be given to clients during hypnosis.
Relaxation and subjective experiences. In all likelihood, mindfulness
meditation and hypnosis are intimately associated with attentional
processes and utilize attentional resources to establish an internal
focus or locus of attention in the service of achieving positive therapeutic outcomes. Specifically, during hypnosis, participants are invited
to listen receptively and nonjudgmentally to suggestions and to let
themselves become deeply absorbed in their internal experiences. Similarly, mindfulness practitioners are instructed to observe their flow of
thoughts and emotions in an accepting, nonevaluative manner.
Both procedures typically involve eye closure and sitting still, so it
is not surprising that relaxation often accompanies both hypnosis and
meditation. However, neither intervention can be reduced to relaxation. The preponderance of hypnotized subjects indicates that they
feel relaxed following a standardized induction procedure (Lynn,
Brentar, Carlson, Kurzhals, & Green, 1992). However, relaxation is not
essential to responding to hypnotic suggestions insofar as responsivity
to suggestions is not diminished while exercising on a bicycle (see Bnyai, 1991). It is well documented that meditation often induces relaxation (Benson, 1975; Morse, Martin, Furst, & Dubin, 1977), although
the purpose of mindfulness training is not to relax. Nevertheless,
mindfulness training and hypnosis may afford an opportunity to
reduce anxiety and autonomic arousal, thereby promoting physical
comfort and mental quiescence (Goldenberg et al., 1994; Miller,

Fletcher, & Kabat-Zinn, 1995). A recent study compared EEGs of individuals trained in relaxation, concentrative meditation, and mindfulness meditation and found statistically reliable differences in EEG
patterns, with mindfulness meditation associated with less slow wave
activity and more fast wave activity than relaxation (Dunn, Hartigan, &
Mikulas, 1999).
Although workers in the field have drawn attention to similarities
in subjective experiences across different types of meditation and hypnosis (Cardea, 2005; Holroyd, 2003; Otani, 2003; Pekala, 1987), there
may also be notable differences. For example, D. P. Brown, Forte, Rich,
and Epstein (19821983) found that whereas self-hypnosis involves
self-referential thinking, intense emotions, and memory changes, experience in meditation was associated with greater awareness of bodily
processes, changes in time perception, and the sense that bodily processes slow down. Participants attention (e.g., focused versus free
floating) and subjective response to hypnosis and meditation will
likely depend, at least in part, on specific suggestions and the instructional set adopted (e.g., mindfulness vs. concentration meditation,
such as focus on a single thought, object, sound; self vs. hetero-hypnosis, Kahn & Fromm, 1990), as well as participants willingness and ability to respond to perceived task demands.
Untoward reactions. It warrants mention that meditation and hypnosis can be accompanied by unsettling emotions and untoward reactions.
As many as 29% of hyponotized individuals report at least one (generally temporary) negative experience following hypnosis (Crawford,
Hilgard, & McDonald, 1982). Rates of negative reactions (e.g., relaxation-induced anxiety, boredom, pain, feeling spaced out) as high as
62.9% (D. H. Shapiro, 1992) have been documented in relation to the
practice of meditation. However, controlled studies of negative experiences during and after hypnosis have indicated that untoward reactions are no more common than in situations in which individuals sit
still with eyes closed for comparable periods of time or merely focus
on body parts in a nonhypnotic context that parallels the focus of
suggestions administered in a hypnotic context (see Brentar, Lynn,
Carlson, & Kurzhals, 1992; Lynn, Martin, & Frauman, 1996, for a
review). Also, when prehypnotic experiences (e.g., headaches, anxiety)
are taken into account, no differences between hypnotic and nonhypnotic conditions are apparent (Sivec & Lynn, 1996). It may well be the
case that similar findings will be obtained in studies of meditation.
However, therapists should be alert to possible negative effects that
may arise in the context of both hypnosis and the practice of
meditation.
Positive expectations. Hypnosis and mindfulness procedures are generally presented in a positive expectational context as a means of promoting personal growth. Historically, mindfulness has been integral to

a spiritual path grounded in a clear formulation of human suffering

(Teasdale et al., 2003). Although mindfulness may have beneficial
effects because it targets processes (e.g., exposure) that span a range
of disor- ders, when employed in psychotherapy, mindfulness is
embedded in a coherent rationale that encompasses the expectation
that treatment gains will ensue with regular practice. In specific
therapies, mindfulness is practiced in the context of an explicit
analysis of the processes involved in creating the problem targeted,
such as depressive relapse.
Although hypnosis is not embedded in a 2,500-year-old belief system, it has long been associated with the ability to transform personal
experiences and perceptions of reality. After all, if a person can radically alter his or her thoughts, feelings, and actions during hypnosis, if
only briefly, it can be done in other situations and on a more enduring
basis as well. A fundamental premise of much hypnotic work is that
psychopathology is the direct result of automatic thoughts and negative self-suggestions and that it is possible to replace negative with
positive self-suggestions (Barber, 1985). In short, both hypnosis and
mindfulness-based approaches have the potential to instill the belief
that significant changes in cognition, emotion, and behavior can be
achieved. In all likelihood, expectation has an important role in shaping the outcome of mindfulness interventions as well as hypnosis.
Portability. The learnable skills of self-hypnosis and mindfulness are
portable. Hypnotic suggestions can be constructed to build positive
response sets that can be automatically activated in everyday life
when maladaptive, habitual patterns might otherwise prevail.
Mindfulness training fosters awareness and acceptance of
maladaptive response sets, along with a sense of detachment from
problematic ways of think- ing and feeling and, in so doing, has the
potential to abet the discovery of more adaptive options in the
moment.
Self-hypnosis can be used in many situations outside the clinicians
office (see Lynn & Kirsch, in press). Mindfulness meditation can be
practiced and developed with eyes open while doing tasks, walking,
standing, gardening, and so forth. This is classically known as meditation in action. Consider the resemblance between relaxation instructions administered in the context of self-hypnosis and Lama Surya
Dass suggestions for meditating in a car:
Start with three breaths. Take a deep breath. Inhale, exhale. Pay attention. It pays off. Inhale again, and let it go. Relax a little, release the tension, the unnecessary hurrying and scurrying. Sit in your own car seat,
fully. Are your hands gripping the wheel? That wont get you there any
faster. Is your back tense? Shoulders bunched up? How about your
neck? Stomach clenched perhaps? Breath constricted, chest constricted?
Breathe, relax, smile. You might as well enjoy the ride. Settle back into
your seat. Breathe and relax. Fully inhabit your present experience. Here
and now at home and at ease. One with all.

16
0

STEVEN JAY LYNN ET AL.

Individual differences. Prominent individual differences are apparent

with respect to hypnotic suggestibility and mindfulness. Reliable and
valid scales have long been available to assess hypnotic responsiveness
(Weitzenhoffer & Hilgard, 1962). In the past few years, scales that measure mindfulness have been developed to assess the construct. In order
to examine empirical links between mindfulness and well-being, K. W.
Brown and Ryan (2003) developed the Mindful Attention Awareness
Scale (MAAS). This 15-item scale assesses individual differences in the
frequency of mindful states over time. Brown and Ryans research
indicated that the MAAS is a reliable and valid instrument that can be
used with both student and adult populations. Moreover, the scale
was able to discriminate between groups that are expected to differ in
degree of mindfulness; specifically, Zen practitioners and untrained
control participants. Importantly, mindfulness correlated positively
with indices of wellbeing including self-esteem, optimism, positive
affect, life satisfaction, vitality, self-actualization, autonomy, competence, and relatedness. In contrast, and as might be expected, mindfulness correlated negatively with neuroticism, anxiety, hostility,
depression, self-consciousness, impulsiveness, vulnerability, negative
affect, unpleasant affect, somatization, and frequent medical visits.
Research that compares hypnotic responsiveness and mindfulness,
and evaluates a measure of acceptance that we developed, is underway in our laboratory.

CONCLUSIONS
Our review indicates that hypnosis and mindfulness-based
approaches have promise in the treatment of a variety of disorders and
conditions. Nevertheless, both interventions require basic research to:
(a) delineate active ingredients and mechanisms and (b) tease apart
the specific effects of mindfulness and hypnosis from nonspecific
effects such as motivation, expectations, relationship with the
therapist or teacher, and so forth (Roemer & Orsillo, 2003). Indeed, at
this point in time, we can do no more than hypothesize that hypnosis
will augment the effects of mindfulness training in advance of
rigorous studies that document the fruitfulness of combining these
approaches or indicate that each is best practiced independently.
Hayes and Wilson (2003) noted that, . . . mindfulness is treated
sometimes as a technique, sometimes as a more general method or collection of techniques, sometimes as a psychological process that
can produce outcomes, and sometimes as an outcome in and of itself
(p. 161). This statement would be equally valid if we replaced the word
mindfulness with the word hypnosis. As Hayes and Wilson observed, an
important task is to specify the actual principles that unite all of these
levels. We agree. In the process of addressing Hayes and Wilsons

concerns, researchers will hopefully examine many fascinating questions fundamental to understanding human consciousness: How do
thoughts and states of consciousness arise? Where do they come from,
and where do they return to? How are thoughts and emotions connected? Why are some thoughts more influential than others? Why
do some thoughts form response sets while others do not? What is
the relationship between acceptance and change or transformation?
And, finally, how can we strive for goals while focusing on present
experience?

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Achtsamkeit, Akzeptanz und Hypnose: Kognitive und klinische

Perspektiven
Steven Jay Lynn, Lama Surya Das, Michael N. Hallquist und
John C. Willliams
Zusammenfassung: Die Autoren schlagen den kombinierten Einsatz von
hypnose- und achsamkeitsbasierten Anstzen vor, um adaptive Antwortsets
zu generieren und maladaptive Antwortsets zu deautomatisieren. Sie geben
einen berblick ber aktuelle Forschungsergebnisse zur Effektivitt von
achtsamkeitsbasierten Anstzen im klinischen wie auch im nichtklinischen
Kontext und schlagen vor, dass die kognitiven Grundlagen der
Achtsamkeitsanstze in den Begriffen der meta-kognitiven Basis achtsamer
Aufmerksamkeit (Toneattos Erluterungen zur buddhistischen Sichtweise des
Denkens) wie auch in der Antwort-Set-Theorie von Kirsch und Lynn
konzeptualisiert werden knnen. Auerdem legen sie nahe, dass Achtsamkeit
als Vorlage zur Erzeugung einer Reihe von Suggestionen dienen kann, welche
kognitive Strategien zum Umgang mit Problemen, zur Stressreduktion und
der Reduktion negativen Affekts im allgemeinen beinhalten. Viele der Ideen,
die von den Autoren vorgebracht werden, sind bislang noch spekulativ und
sollen zustzliche Forschung und klinische Arbeit in Gang setzen.
RALF SCHMAELZLE
University of Konstanz, Konstanz, Germany

Attention, acceptation et hypnose: perspectives cliniques et cognitives

Steven Jay Lynn, Lama Surya Das, Michael N. Hallquist, et John C.
Willliams
Rsum: les auteurs suggrent que lhypnose et les approches bases sur
lattention peuvent tre utilises en tandem pour crer des rponses adaptes
et dsactiver les rponses automatiques mal adaptes. Ils rsument leurs
recherches rcentes sur lefficacit des approches bases sur lattention dans
des contextes cliniques et non-cliniques et suggrent que la cognition,
fondement mme des approches bases sur lattention, peut tre
conceptualise en terme de base mta-cognitive base sur lattention.
Lexplication de Toneatto sur la perspective boudhiste de la cognition et la
thorie de Kirsch et Lynn sur les rponses. Ils suggrent aussi que
lattention peut servir de modle pour gnrer une panoplie de
suggestions qui fournissent des stratgies cognitives leur permettant
daffronter les problmes du quotidien et de vaincre les effets stressants
et ngatifs en gnral. La plupart des ides avances par les auteurs sont
purement spculatives et ont pour but dinciter de plus amples recherches
et travaux cliniques.
VICTOR SIMON
Psychosomatic Medicine & Clinical Hypnosis
Institute, Lille, France
Consciencia reflexiva, aceptacin, e hipnosis: Las perspectivas clnica y
cognitiva
Steven Jay Lynn, Lama Surya Das, Michael N. Hallquist, y John C. Willliams
Resumen: Los autores proponen que la hipnosis y los enfoques basados en
la consciencia reflexiva (mindfulness) pueden usarse conjuntamente para
crear patrones de respuesta adaptativos y desautomatizar patrones
desadaptativos.. Sumarizamos investigacin reciente sobre la eficacia de los
enfoques basados en la consciencia reflexiva en contextos clnicos y no
clnicos y proponemos que los substratos cognitivos de los enfoques de la
consciencia reflexiva pueden ser conceptualizados desde el punto de vista
de la base meta-cognitiva de la atencin reflexiva, la elucidacin de Toneatto
de la perspectiva Budista sobre la cognicin, y la teora de Kirsch y Lynn de
patrones de respuesta (response set). Los autores tambin sugieren que la
consciencia reflexiva puede servir como un modelo para generar varias
sugestiones para proveer estrategias cognitivas para lidiar con problemas en
la vida y en general disminuir la tensin y emociones negativas. Muchas de
las ideas de los autores son especulativas y tienen el objetivo de fomentar
investigacin y trabajo clnico adicionales.
ETZEL CARDEA
University of Texas, Pan American,
Edinburg, Texas, USA