American Journal of Clinical Hypnosis

ISSN: 0002-9157 (Print) 2160-0562 (Online) Journal homepage: http://www.tandfonline.com/loi/ujhy20

Hypnosis and Mindfulness: The Twain Finally Meet

Akira Otani

To cite this article: Akira Otani (2016) Hypnosis and Mindfulness: The Twain Finally Meet,
American Journal of Clinical Hypnosis, 58:4, 383-398, DOI: 10.1080/00029157.2015.1085364

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 American Journal of Clinical Hypnosis, 58: 383–398, 2016
Copyright © American Society of Clinical Hypnosis
ISSN: 0002-9157 print / 2160-0562 online
DOI: 10.1080/00029157.2015.1085364

Hypnosis and Mindfulness: The Twain Finally Meet

Akira Otani
Spectrum Behavioral Health, Arnold, Maryland, USA

Mindfulness meditation (or simply mindfulness) is an ancient method of attention training. Arguably,
developed originally by the Buddha, it has been practiced by Buddhists over 2,500 years as part of
American Journal of Clinical Hypnosis 2016.58:383-398.

their spiritual training. The popularity in mindfulness has soared recently following its adaptation as
Mindfulness-Based Stress Management by Jon Kabat-Zinn (1995). Mindfulness is often compared to
hypnosis but not all assertions are accurate. This article, as a primer, delineates similarities and
dissimilarities between mindfulness and hypnosis in terms of 12 specific facets, including putative
neuroscientific findings. It also provides a case example that illustrates clinical integration of the two
methods.
Keywords: Buddhist meditation, hypnosis, mindfulness, neuroscience

Interest in mindfulness meditation (hereafter meditation or mindfulness to be used inter-

changeably) has soared in recent years. Thanks in particular to the introduction and
subsequent popularity of “the third-wave” cognitive behavioral therapies (CBT), including
the Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1995), Mindfulness-Based
Cognitive Therapy (MBCT) (Teasdale et al., 2000), Dialectical Behavior Therapy (DBT)
(Linehan, 1993) and Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, &
Wilson, 2003), Time magazine recently hailed mindfulness with a headline, “A
Mindfulness Revolution” (February 3, 2014). Similarly, Huffington Post declared 2014
as “the year of mindful living” (January 2, 2014). Paralleling this “pop” phenomenon,
scientific studies are amassing to explicate putative neurophysiology (e.g., Farb, Segal, &
Anderson, 2012; Hölzel, Lazar, et al., 2011; Taylor et al., 2011), clinical efficacy (Baer,
2003; Lykins & Baer, 2009; Zeidan, Johnson, Diamond, David, & Goolkasian, 2010), and
general impact (Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008; Giluk, 2009; Kemeny
et al., 2012) of this technique. In short, mindfulness has established itself in a short period
both as a cultural phenomenon and novel clinical paradigm (Wilson, 2014).
It deserves mention that hypnosis has been compared to meditation (Holroyd, 2003;
Lynn, Das, Halloquist, & Williams, 2006; Otani, 2003). Attempts have been made to
synthesize clinical hypnosis with mindfulness by hypnotic researchers and practitioners
alike (e.g., Alladin, 2008; Yapko, 2011). The Journal of Mind-Body Regulation devoted

Address correspondence to Akira Otani, Spectrum Behavioral Health, 1509 Ritchie Highway, Arnold, MD 21012,
USA. E-mail: relax227@gmail.com
 384 OTANI

an entire issue to the examination of the two modalities in terms of respective conceptual
and empirical foundations (Lifshitz, Cusumano, & Raz, 2014). In their introduction to this
special issue, Lifshitz and Raz (2012) wrote:
[Hypnosis and mindfulness] seem to overlap in phenomenology, and perhaps also in terms of
cognitive mechanisms, neural substrates, and potential therapeutic merits…. Considering hypnosis
and meditation together may force us to take a more critical glance at how we construe these
practices, and could potentially highlight mechanisms that researchers have largely overlooked to
date. (pp. 3–4)

Their point is well-taken in light of the contemporary effort to identify common

therapeutic principles among different therapeutic modalities (Forman, 2012).
In this article, I will discuss three main topics: (1) a definition and the roots of
mindfulness, (2) major similarities and differences between hypnosis and mindfulness,
American Journal of Clinical Hypnosis 2016.58:383-398.

and (3) a clinical application of mindful decentering with a case illustration. Although
far from comprehensive, this article is intended to serve as a primer to a better under-
standing and appreciation of hypnosis and mindfulness.

A Definition of Mindfulness

The current popularity notwithstanding, no consensus currently exists as to what

“mindfulness” means operationally (Bishop et al., 2004). Reminiscent of the similar
state of consternation in hypnosis (Wagstaff, 2014), the definitional ambiguity of
mindfulness is due to the proliferation of unique methods and practices advocated by
different lineages of existing Buddhism (e.g., Theravada, Mahayana, and Vajrayana
among others; Analayo, 2009). Nevertheless, the overarching goal of the practice
remains identical: the cultivation of capacity to see things as they are (Nyanaponika,
1965).
The absence of a unified definition has forced clinicians to describe mindfulness
according to its purported qualitative characteristics. The most widely accepted descrip-
tion to date is “paying attention in a particular way; on purpose, in the present moment,
nonjudgmentally” by Kabat-Zinn (1995, p. 4). Subsequent investigators added open
awareness and acceptance of the “here-and-now” phenomena as common mindfulness
characteristics. Note that these descriptors resemble hypnotic ego receptivity, a corner-
stone concept describing trance and suggestibility (Fromm, 1976), indicating conceptual
similarities between mindfulness and hypnosis.

The Roots of Mindfulness

The Buddha’s original instructions for mindfulness meditation are concise and
succinct. Appearing in two main Buddhist scriptures (i.e., Anapanasati-sutta and
Satipatthana-sutta), they both describe the systematic methods of cultivating
 HYPNOSIS AND MINDFULNESS 385

awareness with a particular focus on paying close attention to in- and out-breaths.
The first four stanzas of Anapanasati-sutta, for example, state as follows:
[1] Breathing out long, he knows, “I am breathing out long.”
Breathing in long, he knows, “I am breathing in long.”
[2] Breathing out short, he knows, “I am breathing out short.”
Breathing in short, he knows, “I am breathing in short.”
[3] Experiencing the whole body (or breath), “I shall breathe out,” thus he trains himself.
Experiencing the whole body (or breath), “I shall breathe in,” thus he trains himself.
[4] Calming the bodily-formation, “I shall breathe out,” thus he trains himself.
Calming the bodily-formation, “I shall breathe in,” thus he trains himself.
(Buddhadasa, 1976, p. 103)

These verses reveal that the Buddha viewed the breath as both (1) an object of
American Journal of Clinical Hypnosis 2016.58:383-398.

awareness (“[1] Breathing out long, he knows, ‘I am breathing out long’”) and (2) the
means by which to facilitate attention (“[3] Experiencing the whole body (or breath), ‘I
shall breathe out,’ thus he trains himself”). The practitioner therefore not only pays
continuous attention to breath, but also utilizes this process to cultivate awareness on
various aspects of self as part of mental training. The subsequent stanzas in the scripture
delineate the mindful awareness of feeling and perception ([5] to [8]), thinking and
volition ([9] to [12]), and impermanence of phenomena ([13] to [16]).
From the Buddhist standpoint, there are two forms of mindfulness: concentration-
based samatha and open-monitoring vipassana (Shaw, 2006). Samatha is said to create
“calm abiding,” characterized by mental focus and altered states of consciousness
(ASC). In contrast, vipassana is practiced to achieve the fundamental insight into
nature, i.e., impermanence, suffering, and non-self. While some secular meditation
experts equate mindfulness exclusively with the vipassana meditation, most Buddhist
scholars contend that both systems are employed in the traditional training (Kuan,
2012). In the case of renowned Thai meditation master, Ajahn Chah, who is known
to have trained many senior American meditation teachers, including Jack Kornfield,
has rejected any distinction between the two forms of mindfulness (Chah, 2011).
Whichever method is used, the practitioner pays on-going attention to the breath
while monitoring simultaneously thoughts and sensations openly, without censorship
or judgment.
Easy as it may sound, this practice proves to be quite challenging to beginners. Many
practitioners complain initially about distraction, or “mind wandering” during focused
breath awareness (Schooler et al., 2014). So common is this counterproductive phe-
nomenon that it is referred to humorously as “the monkey mind,” comparing it to a wild
monkey jumping incessantly from one branch of a tree to another. Another inadvertent,
but contrary, phenomenon is known as “the donkey mind,” where the meditator is
fixated on a single idea, feeling or sensation (e.g., a recurrent thought, an itch on the
nose) like a donkey tied to a stake unable to gain freedom. This is what Tibetan
Buddhists call shenpa (Chödrön, 2006).
 386 OTANI

One method to ameliorate these difficulties is guided mindfulness in which the instructor
(or the therapist) facilitates the process. Since no mention is made in Buddhist scriptures
about it, this method is obviously a Western invention and has quickly gained popularity
among secular meditators. As Lynn, Malaktaris, Maxwell, Mellinger, and van der Kloet
(2012) postulated, this form of mindfulness resembles clinical hypnosis. As such, it fits the
clinical hypnosis practice and may be easily incorporated in hypnotherapy.

Similarities and Dissimilarities Between Hypnosis and Mindfulness

Having described the definition and roots of mindfulness, I will now examine simila-
rities and dissimilarities between hypnosis and mindfulness. Table 1 is a summary
American Journal of Clinical Hypnosis 2016.58:383-398.

comparison between the two modalities in terms of 12 categories. Due to within-

group methodological as well as theoretical diversity in each discipline per se, some
categories remain speculative (e.g., conscious states). Nevertheless, the table should
shed light on how mindfulness resembles, and differs from, hypnosis. For further
details, the interested reader is referred to the references in this article, especially the
special 2012 issue of The Journal of Mind-Body Regulation.

Goals

The primary goals of mindfulness are twofold: (1) a daily practice of meditative lifestyle
(i.e., open, nonjudgmental, “hear-and-now” awareness of reality) and (2) clinical behavior

TABLE 1
Comparison of Mindfulness and Hypnosis

Mindfulness Hypnosis

Goal Open, detached observation of “here-and- Use of trance to achieve behavior change
now” experience / Possible use for and health promotion
behavior change and health promotion
Attention Focused/selective / Open/inclusive Focused/selective
Putative Conscious States Ordinary Altered (depends upon methods) Altered Ordinary (depends upon theory)
GRO1 Heightened Faded
Imagery Increase Increase
Therapeutic Paradigm Self-regulation Utilization of trance phenomena
Treatment Method Detached observation Therapeutic suggestion
Mechanism of Change Decentering Dissociation, regression, expectancy, etc.
Manner of Practice Self-directed Guided Heterohypnosis Autohypnosis
Indications Life style As needed As needed
Neuroplasticity Confirmed Yet to be confirmed
PFC2 connectivity with Connected Decoupled
ACC3

Note. 1GRO = Generalized Reality Orientation; 2PFC = Pre-Frontal Cortex; 3ACC =Anterior Cingulate Cortex
 HYPNOSIS AND MINDFULNESS 387

change and health promotion of individuals by its application. The first goal characterizes
the Buddhist lifestyle and may be called “pure mindfulness” (Otani, 2014). The second is
secular and therapeutic in nature, a paradigm that has come to be known as “clinical
mindfulness” (Germer, 2005). MBSR and MBCT of the third-wave CBT belong in this
latter category as do ACT and DBT. In these models, mindfulness is applied to achieve
targeted therapeutic goals and gains, including emotion regulation, pain management,
depression and anxiety treatment, and addiction relapse prevention among others (see
Chambers, Gullone, & Allen, 2009; Gardner-Nix & Costin-Hall, 2009; Germer, Siegel, &
Fulton, 2013).
It is ironic that the two mindfulness paradigms prove to be conceptually at odds with
each other. Buddhist teaching emphasizes impermanence of phenomena (anicca) and
non-attachment to the concept of “self” (anatta) as they cause suffering (dukkha) (Chah,
American Journal of Clinical Hypnosis 2016.58:383-398.

1994). Pure mindfulness therefore repudiates any form of physical and mental attach-
ment, including health enhancement that is the essential goal of clinical mindfulness.
Some Buddhism scholars for this reason rebuke clinical mindfulness, claiming it to be
problematic, even antithetical, to the Buddhist teachings and ethos (Wilson, 2014).
The premise of clinical hypnosis, in contrast, remains exclusively therapeutic. Unlike
mindfulness, it is never considered a lifestyle. If hypnosis is practiced on a daily basis at
all, i.e., self-hypnosis, it is intended purely for therapeutic benefits (e.g., pain control).
Clinical hypnosis may be used singularly or may be added to existing treatment
modalities (e.g., psychodynamic approach, CBT) to augment clinical efficacy (Kirsch,
Montgomery, & Sapirstein, 1995). In short, this bifurcation reflects pure versus clinical
mindfulness.

Attention, Generalized Reality Orientation (GRO), and Putative Conscious

States

Attention is an essential factor in both hypnosis and mindfulness. The underlying

distinction, however, becomes obvious when the role of attention is examined from
the GRO perspective (Shor, 1959). GRO fades while attention becomes more selective
and focused in hypnosis. This occurrence, together with hypnotic role taking and
archaic involvement, is considered a hallmark of deep hypnotic trance (Shor, 1962).
Neodissociation theorists (e.g., Hilgard, 1991) consider this phenomenon a major sign
of hypnotically induced ASC, while socio-cognitive proponents (e.g., Kirsch & Lynn,
1998) reject this notion even though recent neurophysiological evidence seems to
suggest changes in conscious functioning in hypnosis (Kihlstrom, 2013). Regardless
of the controversy about the nature of ASC and trance, GRO is a well-established
concept in clinical hypnosis.
In mindfulness, diminished GRO is discussed with exclusive reference to the
samatha method. In this practice, like deep hypnosis, attention is selective and focused
in order to create mental absorption (i.e., calm abiding) known as jhana. This is not the
 388 OTANI

case with the vipassana method (see “The Roots of Mindfulness” section). Buddhist
texts explicate the jhana states in eight consecutive stages, ranging from blissful
absorption (stage 1) to nothingness (stage 7) and finally “neither-perception-nor-
nonperception” (stage 8; see Bucknell, 1993, for details). Jhana is viewed as the
precursor to samadhi, the highest form of meditative concentration. The phenomenolo-
gical descriptions of jhana have yet to be examined in specific comparison to hypnotic
trance. They are a rich and valuable source of information that may shed light on the
nature of deep hypnosis and its cognitive characteristics.
It is worth mentioning that the goal of vipassana meditation, unlike its counterpart
samatha, is the observation of reality in the “here and now” by way of open and
inclusive attention. GRO does not occur in this form of mindfulness meditation.
Berkovich-Ohana, Glicksohn, and Goldstein (2012) demonstrated in an important
American Journal of Clinical Hypnosis 2016.58:383-398.

study that vipassana meditators showed an increase in high-frequency gamma electro-

encephalogram in the right temporal and parieto-occipital regions. This finding suggests
“an increase in attentional skills and heightened awareness to internal and external
sensory stimuli” (p. 708). Therefore, conscious states associated with mindfulness
depend on the type of practice (samatha versus vipassana).

Capacity and Imagery

Can all meditators experience the jhana states in samatha or continuously open, non-
judgmentally heightened attentional states in vipassana through mindfulness? This ques-
tion parallels the impact of hypnotizability on hypnotic experience. Unfortunately, no
Buddhist scriptures address this issue nor do available empirical literature present norma-
tive data as to who can experience what type of mindfulness phenomena (see Quagila,
Brown, Lindsay, Creswell, & Goodman, 2015, for a review).
In the domain of hypnosis, hypnotic responsiveness has been well studied using
different suggestibility and imaginative scales over half a centruy (e.g., Hilgard &
Hilgard, 1968; Wilson & Barber, 1978). The methodologies established in hypnotizability
studies may contribute to future research in mindfulness responsivity.
One principal commonality between mindfulness and clinical hypnosis is the use of
imagery. Buddhist meditators are instructed to concentrate on a wide array of images
while following the breath. Examples abound in the classic Theravadin Buddhist medita-
tion text, Visuddhimagga (“The Path of Purification”) (Ñāṇamoli, 2010), including visua-
lizations of particular scenes, colors, and various abstract images and concepts (e.g., the
Buddha, emptiness, etc.). The text even elucidates vivid, systematic imagination of
“foulness” with a detailed list of 10 progressive states of a decaying corpse to raise
consciousness about death. This practice resembles prolonged exposure in CBT even
though the intended goal of Buddhist meditation concerns the understanding of
impermanence.
 HYPNOSIS AND MINDFULNESS 389

In hypnosis, both pleasant and aversive images are included in suggestions to attain
specific therapeutic goals. Image production may be achieved through direct suggestion
as well as indirect techniques, e.g., metaphors, analogies, and “goal-directed fantasy”
(Lankton & Lankton, 1989; Spanos, 1971; Spanos & McPeake, 1977).

Therapeutic Paradigm and Treatment Method

Clinical mindfulness predicates its efficacy on the self-regulation paradigm. It is an

active practice of “development and successful maintenance of health promotive habits”
(Bandura, 2005, p. 246) in which mindfulness is optimally utilized. It was already
mentioned (see “Goals” section) that this application of mindfulness contradicts the
American Journal of Clinical Hypnosis 2016.58:383-398.

traditional Buddhist pure mindfulness paradigm.

The main treatment paradigm underlying clinical hypnosis concerns elicitation of trance
phenomena and their utilization for specific behavior change. This includes cognitive,
affective, behavioral, physiological, and even interpersonal responses (Erickson, 1966;
Heap & Aravind, 2002). Treatment methods are diverse and tailored according to different
theoretical orientations (e.g., psychodynamic, cognitive-behavioral, solution-focused, etc.)

Mechanisms of Change

What are the plausible mechanisms of change underlying mindfulness and hypnosis?
Clinical mindfulness authorities (Bishop et al., 2004; Sauer & Baer, 2010) contend
decentering to be the primary therapeutic principle associated with mindfulness
meditation. Decentering refers to “observe one’s thoughts and feelings as transitory
events in the mind that do not necessarily reflect reality, truth or self-worth,… and do
not require particular behaviors in response” (Sauer & Baer, 2010, p. 35). It is in
essence conscious observation and distancing from maladaptive cognitions and
affects.
Hypnosis, in comparison, postulates various theoretically-derived concepts, such as
dissociation, regression, expectancy, to name a few, as primary mechanisms of change.
Hence, multiple interpretations are possible for a given successful outcome (e.g.,
dissociation of pain versus expectation of pain attenuation). It is important to note
that hypnotic dissociation is an unconscious process (Hilgard, 1991), while mindfulness
decentering is a conscious mechanism (see “Neuroplasticity and Functional
Connectivity” below for more discussion on this issue).

Manner of Practice

Mindfulness in the traditional Buddhist context is entirely self-directed. The meditator

sits alone and observes the stream of consciousness quietly with no external assistance.
 390 OTANI

This description stands in contrast to the currently favored guided-mindfulness in which

the meditator follows the therapist’s directives.
Therapeutic hypnosis, like mindfulness, may be practiced alone as autohypnosis or
with the aid of a hypnotist as heterohypnosis. Whether all hypnosis is autohypnosis or
not remains a controversy (see Fromm & Kahn, 1990), there is no disagreement that
both self-directed and guided forms of practice are effective in mindfulness and
hypnosis.

Indications

As previously mentioned, mindfulness may be practiced either as a lifestyle (i.e., pure

American Journal of Clinical Hypnosis 2016.58:383-398.

mindfulness) or as a therapeutic tool (i.e., clinical mindfulness). As a clinical tool,

mindfulness seems to be effective with a wide range of disorders, including chronic
pain, depression, anxiety, and borderline personality disorder (see Khoury et al., 2013,
for a comprehensive meta-analytic review).
In regard to clinical hypnosis, despite the relatively small number of randomized
controlled studies, a meta-analysis (Flammer & Bongartz, 2003) indicates favorable
outcome of hypnotherapy in the treatment of somatic complaints, smoking cessation,
assistance in medical procedures, and cancer treatment support. The average effect size
of hypnotic treatment (Cohen’s d = .59) is roughly equivalent to that of overall clinical
mindfulness (Hedge’s g = .55) (Khoury et al., 2013).

Neuroplasticity and Functional Connectivity

Finally, a brief mention is warranted regarding the plausible functional and structural
neural changes, or neuroplasticity, related to mindfulness and hypnosis. Because of the
complexity of the topic, the interested reader is referred to other reliable literature (e.g.,
Hölzel, Carmody, et al., 2011; Zeidan, 2015). Suffice it to say that sustained mind-
fulness practice has been reliably associated with neuroplastic effects. The evidence
includes: increased capacity to focus, better affect regulation, heightened bodily (inter-
oceptive) awareness, and alteration in self-concept (Hölzel, Lazar, et al., 2011).
Plausible brain areas responsible for these effects include: the anterior cingulate cortex
(ACC), the prefrontal cortex (PFC), the insula, the hippocampus, and the precuneous
(see Ivanovski & Malhi, 2007, for a review).
Hypnotic potential for neuroplasticity has not been well established at this point.
However, the involvement of ACC in various hypnotic phenomena has been well
documented (see Jamieson, 2007, for a review of neuroscientific aspects of
hypnosis).
What is interesting is that mindfulness and hypnosis seem to exhibit an opposite
pattern in regard to functional connectivity in the brain. While noting possible
 HYPNOSIS AND MINDFULNESS 391

confounding effects due to hypnotic suggestion and social demand, Lynn et al. (2012)
cautiously asserted:
[I]n hypnosis, there may be a decoupling between brain regions associated with monitoring and
cognitive control … whereas in meditation experiences, there appears to be a stronger coupling of
self-monitoring and cognitive control. (emphasis added, p. 17)

The “brain regions associated with monitoring and cognitive control” in the quote
refer to the ACC and PFC. Hence, mindfulness, particularly the non-concentrative
vipassana type, and hypnosis operate on different neural mechanisms, suggesting
disparate functional connectivity processes.
In summation, mindfulness and hypnosis comprise separate phenomena and practices
that share some common domains. Needless to say, comparisons are difficult because of
American Journal of Clinical Hypnosis 2016.58:383-398.

the within-group variations in each discipline in regard to unique theoretical, procedural,

and neuroscientific postulates. Broad and general statements such as, “mindfulness is a
form of trance,” “hypnotic suggestion is the key to mindfulness,” are thus erroneous and
must be avoided.

Clinical Integration of Mindfulness and Hypnosis

In light of the preceding discussion, how can the hypnotically-minded practitioner

incorporate mindfulness in clinical work? I will below describe two easy-to-adopt
mindfulness strategies: (1) guided mindfulness for emotion regulation and (2) decenter-
ing of affect and cognition. A case example integrating these approaches will follow to
conclude the article.

Guided Mindfulness for Emotion Regulation

As mentioned earlier, imagery is a shared component in both mindfulness (i.e., samatha)

and hypnosis. Imagery-based guided-mindfulness and hypnotic metaphor resemble so
closely that it is sometimes difficult to differentiate them. To illustrate, read the following
mindfulness script designed for emotion regulation:
Just become aware of whatever you notice at this moment. You may close your eyes or keep them
open, or half-closed. It doesn’t really matter. You may notice sounds from outside, sensations in your
body, thoughts and feelings in your mind. You may experience more than one thing at the same time
as well. Whatever you become aware, simply notice your breath. Do not change the way you
breathe. This is not relaxation. Just pay attention to the air that continues going in and out of your
nose. If your attention wanders away from the breath, that’s fine. Notice that and gently go back to
the breath. No matter where your mind goes, you simply go back to the breath. Your mind is like the
big sky. Thoughts, sensations, feelings, the stuff you notice outside or whatever comes to your mind,
are like clouds rolling in and out of the sky. The big sky is always there for you. When bad weather
comes over, you can simply watch it from a distance, knowing the blue sky will appear as soon as it
is over. All you do meanwhile is return to the breath again and again with a touch of gentleness and
 392 OTANI

compassion to yourself. Continue doing this for a few more breaths and when it feels ready to stop,
you may do so.
While making clear that relaxation is not a goal (“this is not relaxation”), continuous
observation of breath generally leads to profound mental calm, likely due to an activation
of the ACC (Hölzel, Lazar, et al., 2011). When attention is disrupted from the breath
focus (“mind wandering”), the client is instructed to acknowledge it openly, then to gently
go back to the breath again. The image of watching clouds rolling in and out of the sky
from a distance, a metaphor, is designed for detached observation of disturbing emotions
and cognitions. This is mindful decentering (see the next section). From the hypnotic
perspective, this text may be viewed as therapeutic metaphor for emotion regulation.
Can guided-mindfulness be applied to trance induction? Although imaging studies
reveal opposite functional connectivity patterns between mindfulness and hypnosis (i.e.,
American Journal of Clinical Hypnosis 2016.58:383-398.

coupling versus decoupling of ACC with PFC; see “Neuroplasticity and Functional
Connectivity” section), distraction from breath focus generates a state of mental absorp-
tion in an temporal imagery (Hölzel & Ott, 2006). Capitalizing on this feature, the
clinician may encourage the client to go along with the imagery instead of continuously
monitoring the breath. This procedure can result in a hypnotic trance. The therapist may
say: “Whatever you become aware, just be curious about them. It may help you even
imagine other things and you can really enjoy them.” This verbalization may be
followed by subsequent directives for trance deepening. It is unclear at present if the
attentional shifting from breath monitoring to temporal imagery alters the functional
connectivity between the PFC, the ACC, and other associated brain regions (Berkovich-
Ohana et al., 2012; Farb, Segal, & Anderson, 2013; Lynn et al., 2012).

Decentering of Affect and Cognition

Decentering, or a detached, nonreactive monitoring of changing internal states during

mindfulness, has diverse clinical applications (Sauer & Baer, 2010). It is a deliberate
cognitive process and differs from hypnotic dissociation (see “Mechanisms of Change”
section). In practice, nonetheless, there is similarity between the two. Consider the
following hypnotic suggestion for pain control (Wright, 1987/1990, p. 60):
No matter how intense the pain may become … you will be able to manage it…. Observe what
images are in your mind as the pain begins…. Tell me what you are thinking of … what you are
feeling … [Pain intensification is suggested:] Let this pain become stronger and more intense…. Feel
it in all typical ways … Let the part of that is with me in the here and now describe it [sic], while the
part that is going through the pain episode feels it in all its usual intensity. (emphasis added)
Here, following the direct suggestion for pain management, the actual pain experi-
ence is dissociated by way of the client’s verbalization about it (e.g., “Observe what
images are in your mind as the pain begins” “Let the part of that is with me in the here
and now describe it”). Hypnotic literature is replete with examples like this one in which
the client observes pain, anxiety, fear, traumatic memory, and ruminating ideation in a
 HYPNOSIS AND MINDFULNESS 393

dispassionate and neutral manner. Hypnotic dissociative strategy after all may be
considered decentering with trance.
Given this understanding, the author frequently integrates mindful decentering with
hypnotic dissociation in clinical work. As seen in the sample verbalizations for emotion
regulation in the previous section, the client begins with mindfulness, either by self-
directed or guided manner. If mindfulness is easily maintained, the client is encouraged
to continue monitoring thoughts or feelings while focusing on the breath. If not, the
client switches to imagery involvement and exploration. Alternatively, these two
approaches may be combined in an alternating fashion, i.e., beginning with mind-
fulness, then hypnosis, back again mindfulness, and so forth. The client through this
process generates safe distance and detaches self from problematic thoughts and/or
feelings either by conscious observation (decentering) or by imagery absorption (dis-
American Journal of Clinical Hypnosis 2016.58:383-398.

sociation). As long as the termination is made unequivocal in the end, no difficulties

will result.

A Case Illustration

To conclude this article, perhaps a case illustration may help elucidate the use of guided-
mindfulness for emotion regulation and decentering. The client, a successful lawyer in
his mid-1950s, sought the author’s help, following a physical examination by a general
practitioner (GP). The primary symptoms of concern were panic attacks, general
anxiety, and acute hypertension (i.e., > 145/100+). On the basis of the client’s medical
and lifestyle information, the client and the physician agreed that the symptoms were
caused by “recent stressful occupational and family events.” The client was
psychologically-minded, believed in the “mind–body” connection, and expressed strong
interest in “learning mindfulness meditation” to maintain health. He was also curious
about hypnosis after reading the author’s portrait webpage. A good therapeutic rapport
was established quickly. There were no known secondary gains associated with the
desired therapeutic goal. The author explained the nature of guided-mindfulness to the
client and proceeded. Hypnotizability was not assessed.
The first practice, as common in most cases, lasted no more than a few minutes.
Upon completion, the client reported “a sense of calm and relaxation” while acknowl-
edging “difficulty staying with the breath because of irrelevant thoughts.” He was
reassured that such distraction (i.e., “the monkey mind”) was common among begin-
ners. Prior to the second practice, he was permitted to go with the images, if so desired,
as he listened to the author’s instructions. This paradoxical intervention is consistent
with Erickson’s (1959) utilization principle. Because the client was an avid fisherman, a
metaphor of a “fish resting comfortably in calm, deep water whenever turbulence occurs
on the water surface” was interspersed among breath monitoring directives. The client
liked this approach very much, as anticipated, and produced deep mental and physical
 394 OTANI

relaxation. This second practice session was recorded on his smartphone. He was eager
to listen to it at home daily and, if necessary, at work as well.
Within 2 weeks, the client reported a marked reduction in anxiety and complete
disappearance of panic attacks. His blood pressure normalized as well (i.e., average 102/
80). He was “very pleased” even though his GP was “somewhat skeptical of ‘the new
wave approach.’” The client indicated that between breath focus and imagery absorption
he preferred the latter. As such, he was encouraged to enjoy images even though he
could still focus on the breath. Bi-weekly sessions followed for 2 more months before
terminating the therapy completely. At the 6-month follow up, the therapeutic results
were maintained solidly. Approximately 18 months after the initial visit, the client
experienced a relapse when his aging parents came down with serious illness. He
complained about the fatigue and distress over frequent long-distance driving to New
American Journal of Clinical Hypnosis 2016.58:383-398.

England. No panics attacks or hypertension recurred fortunately. He had begun listening

to the old recording but requested “preventive” sessions and making new recordings to
cope with the emerging stress. The author gladly complied with this request. The client
continues doing well at present.
It is impossible to discern from this anecdote what components of, or even if, the
mindfulness-based guided imagery resulted in the client’s successful stress management
and improved health. Yet, the reduction in anxiety and in blood pressure, lasting over
a year and a half, suggests efficaciousness of the intervention. He is pleased with the
result and told the author, with a smile, that he had been “raving about this approach
with his colleagues.”

Conclusion

Mindfulness and hypnosis are two distinct approaches each with its own theoretical,
historical, and possible neurological facets, that share certain common domains.
Although much remains unknown, some mindfulness approaches may be easily incor-
porated into hypnosis to enhance overall clinical effectiveness. In particular, guided
imagery and decentering are most relevant to clinical hypnosis practitioners.

Acknowledgments

The author gratefully acknowledges Dr. Marion P. Kostka for his thorough review of an
earlier version of this article. The author alone is responsible for the content of this
work.
 HYPNOSIS AND MINDFULNESS 395

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