The following paper is a pre-publication version of the article published in Contemporary Hypnosis & Integrative Therapy. This paper is based on a Lecture given by David Kraft to the Section of Hypnosis and Psychosomatic Medicine at the Royal Society of Medicine on 6th of June, 2011

Abstract

The following case study reports the successful treatment of a heavy smoker (age=33) in a one hour session using a multi-modal approach. Before treatment, the therapist made a verbal contract with the client who confirmed that he was ready to give up smoking and that the proposed approach would be a complete abstinence programme. Having agreed to this, the patient then agreed to throw out all smoking paraphernalia. In the first session, having identified times of the day when smoking occurred, the therapist gave conditioning trials (Cautela, 1967, 1968; Kraft & Kraft, 2005) for each time of the day, pairing the thought of smoking with an aversion. The therapist utilized the client?s personal motivations to encourage smoking cessation; used split screen imagery (Taylor, 1985), ego strengthening and gave suggestions that any cravings would be significantly reduced or absent. Further, he was encouraged to enjoy the sensations of being a non smoker during hypnosis. The client, who had not smoked that day, remained smoke free and maintained this abstinence at one year follow up. This case study demonstrates that hypnosis is a cost effective form of treatment (Barber, 2001) for smoking cessation.

Key words: Smoking cessation, aversion (covert sensitization), non smoker walk, split screen imagery

Introduction

Smoking has a deleterious effect on nearly every organ in the body, and is responsible for many life threatening diseases, thus reducing quality of life and life expectancy (Mikhailidis et al, 1998; Department of Health, 2007; Balbi et al, 2010; Ash, 2011). In the UK, figures for 2011 show that approximately 21% of the population reported that they smoked?generally more men (22%) smoke than women (21%). During the period 2009/10, 67% of smokers reported that they wanted to stop and 75% had tried various approaches to give up in the past (ICHSC, 2010). Indeed, 40% try to give up each year, but only 6% actually manage to achieve this and maintain abstinence (Hughes, 2000; Hughes, 2003). Epidemiological research indicates that approximately two thirds of ?self quitters? relapse within 2 days (Hughes et al, 1992): thus Hughes (2003) recommends that the main focus of intervention should cover the first few days. During the period 2008/9, it was estimated that approximately 463,000 of hospital admissions (aged between 35 and over) had been related or directly attributable to smoking and an estimated 81,400 deaths were also due to smoking, accounting for 18% of all deaths in this age group (NHS, 2010). Most individuals die from one of three main diseases?lung cancer, coronary heart disease or chronic obstructive pulmonary disease (COPD, bronchitis and emphysema) (Ash, 2011; McBride, 1992). Approximately 86% of people having died from lung cancer were smokers (Cancer Research UK, 2011). In addition, smoking can also cause cancer in the following areas?the larynx and oesophagus; stomach; pancreas; bladder; kidneys; cervix; ovaries; oral and nasal cavities; pharynx, liver; and bowels (Haxby, 1995; Secretan et al, 2009; Cancer Research UK, 2011). It can also cause ulcers in the stomach or duodenum, chronic obstructive pulmonary disease, pneumonia and be responsible for circulatory disorders including ischaemic heart disease, other arterial diseases, cerebrovascular disease, aortic aneurysm, atherosclerosis and other heart diseases (Ash, 2011; WHO, 2008).

Various pharmacological treatments have been employed in order gradually to reduce smoking behaviour. Nicotine replacement products (such as Nicorette) have been used with mixed results, and these come in the form of a nasal spray, chewing gum and patches. The benefit of these products is that it provides smokers with nicotine without inhaling lethal toxins (West et al, 2000; Shiffman et al 2003). The additional use of anxiolytics and antidepressant medication has also been helpful during this weaning off process (Hughes et al, 2000; Sela, 2001;); however, the latter study (Hughes et al, 2000) concluded that there was no evidence to show that anxiolytics aided smoking cessation and that, although bupropion and nortriptyline compared favourably to placebo, it was not clear whether the effects were specific for each individual drug or were a result of a class effect. There have also been a huge number of self help books that have been used over the years and are still available on the market (for example, McFarland & Folkenberg, 1964; Carr, 2004). But the advantage of using hypnosis is that it gives patients greater control of their behaviour, and the therapist can draw attention to the motivational factors for giving up smoking and utilize this powerful force during treatment.

Evidence from reviews, meta-analyses and randomized control trials has gone some way in showing that hypnosis is efficacious in the treatment of smoking behaviour although with varying results. For example, Carmody and colleagues (2008) compared hypnotherapy with behavioural counselling in which both groups were also given nicotine patches. Participants in both conditions received 2 hour length sessions of either hypnosis or behavioural counselling (n=286). At the 6 month follow up, 29% of those who received hypnosis reported 7 day point prevalence abstinence compared to 23 % in the counselling group. Further, at 6 month follow up, 26% of individuals in the hypnosis group were abstinent compared with to 18% in the counselling group; and, at the year follow up 24% of the hypnosis group were abstinent compared to 16% in the counselling group.

Viswesvaran and Schmidt (1992), in a meta-analysis of therapies for smoking cessation, revealed that, in the 48 studies that used hypnosis, this approach was found to be more effective than most of the other treatments including chewing gum, aversion, nicotine chewing gum and 5 day cognitive cessation plans. Green and Lynn (2000) examined 59 cessation studies and reported that hypnosis was a ?possibly efficacious? treatment. However, in many of these studies, it is difficult to ascertain whether the effectiveness was due to the therapy (for example CBT, behavioural techniques, counselling or psychodynamic psychotherapy), the educational support or the hypnosis (Lynn & Kirsch, 2006), and absence of a significant difference might well be interpreted as evidence of equivalence (Barnes et al, 2010).

Encouraging results have nevertheless been reported using a combination of approaches. Alexander (1996) combined hypnosis with cognitive and behavioural approaches, and he reported a cessation rate of 31% at the 3 month follow up. There are also a number of studies?both clinical and case studies?that have shown clearly that the use of hypnosis as an adjunctive technique is effective in one session (Kline, 1970; Spiegel, 1970; Stanton, 1978; Javel, 1980; Neufeld & Lynn, 1988; Williams & Hall, 1988; Marriott & Brice, 1990; Spiegel et al, 1993; Feldman et al, 2002). However, although some researchers claim that, due to a high relapse rate in clinical practice, reinforcement over further sessions is needed (Kroger & Fezler, 1976; Golden et al; Elkins & Rajab, 2004), or a three session programme is required (Elkins & Rajab, 2004). Others point out that, if the patient is not going to give up after the first session, it is unlikely that he will give up after further appointments (Stanton, 1978; Hughes, 2003).

The number of successful results reported in a single session, both in the clinical trials and in the form of case studies implies that, if hypnosis is used expertly, using an individualized treatment strategy (Villano & White, 2004), it can have an immediate effect on heavy smokers and that the success of the treatment can be maintained. For example, Spiegel (1970) treated 615 smokers using psychotherapy, reinforced by hypnosis in a single session lasting 45 minutes. At the 6 month follow up, of the 271 patients (44%) who had returned the questionnaire, 121 (20%) had remained non smokers and a further 120 (20%) had reduced their smoking. Spiegel concluded that motivation was the driving force of this approach and he utilized this along with a three point affirmation in which the patients made a commitment to ?respect and protect? his or her own body. Indeed, motivation has been shown to be an extremely important factor in successful treatment (Perry et al, 1979; Neufeld & Lynn, 1988; Green & Lynn, 2000).

Neufeld and Lynn (1988) assessed the efficacy of a manual-based single session intervention where patients used self hypnosis in a group setting (n=27?male=14; female=13). At the 3 month follow up, 29.92% reported total abstinence and, at the 6 month follow up, 18.52% were free from smoking. Social support and, again, motivation were associated with successful outcome. A study using a restructuring technique with self hypnosis in a single session reported by Spiegel and colleagues (Spiegel et al,1993), found that 52% achieved total abstinence after 1 week and 23% maintained this abstinence at the 2 year follow up. They concluded that high hypnotisability and living with a significant other were important moderators of long term treatment outcome. This supports the view that social support is an important component in the treatment of smokers (Coppotelli & Orleans, 1985; Neufeld & Lynn, 1988; Westmaas et al, 2010).

Javel (1980) compared 3 groups who received a formal induction with suggestions (group 1), suggestions alone (group 2) or no treatment (control; group 3) and found that 60% (6/10) of individuals who received a formal induction were abstinent from smoking at the 3 month follow up?this compared favourably to the suggestion alone group (40% or 4/10) and the no treatment group (0% or 0/10). The results showed that induction plus suggestion and suggestion alone were significantly better that no treatment (X²= 8.57, p < .01; X²=5.00, p < .05 respectively). Feldman et al (2002) also reported favourable results in a single session using hypnosis. Out of the 35 patients that replied to the postal questionnaires, 27/35 (77%) were abstinent at the one month follow up and 23/35 (66%) were abstinent at the 3 month follow up.

The following case study reports the successful treatment of a heavy smoker who, after a one hour session, remained abstinent at the one year follow up. It demonstrates that the combination of approaches used by the therapist?the careful preparation (throwing out of all tobacco and smoking paraphernalia), building of expectation, utilization of motivational factors, use of covert sensitization and split screen imagery?can be employed successfully in helping patients to give up in one session and maintain this at follow up.

Case Study

The following case study has been divided into 3 sections?the initial booking of the appointment on the telephone (1), the hypnosis session (2), and the follow up, including the structured interview (3).

Initial booking of session

The client, referred to here as Philip, phoned the author for an appointment in January 2010. Philip was a professional man who came across as being highly intelligent. He reported that he had been a smoker from the age of 13 until the present day?he was 33 at the time of the first appointment. He stated that he was a heavy smoker and, for the most part, he had been smoking 25 cigarettes each day. During the last 20 years, he had attempted to give up smoking on many occasions and had tried nicotine patches, chewing gum, audio CDs and had even read self help books (for example, Carr, 2004). However, after each attempt, he went back to smoking. The author asked Philip whether he was ready to give up smoking on this occasion, and he confirmed that it was now the time to give up once and for all. It was pointed out to him that the treatment was a complete abstinence programme, and that once he had had the first session, he must not ever smoke one cigarette again. He confirmed that this was a positive goal and said that he understood this.

Following this, Philip asked the therapist when he should have the last cigarette. We decided together that we would not make a big thing of this event. We agreed that it was probably not a good idea to smoke just before the session but that he should smoke his last cigarette the previous day. It was then pointed out to him that it was important to get rid of all the smoking paraphernalia and we made a list of items that should be removed from the house?all cigarettes, tobacco, spare tobacco, ash trays, lighters and cigarette cases. He agreed to do this and we arranged for an appointment for the following week. Philip then asked how long the therapy would last and how successful it was. It was confirmed to him that the approach, which largely consisted of covert sensitization (aversion therapy) (Cautela, 1966; Cautela, 1967; Kraft & Kraft, 2005), and ego strengthening, was highly effective and that, in some cases, clients were able completely to eliminate their unwanted behaviour in one hour, although some others required a ?booster session?. Finally, the author explained the rationale behind aversion therapy and how this would be employed in the consulting room.

Hypnotherapy session

When Philip arrived for the appointment, he said that he felt confident about the proposed treatment and commented that this felt like the ?real thing?. He also confirmed that he had got rid of all smoking paraphernalia and that, to some extent, he was already feeling like a ?non smoker?. Philip then talked about his motivations for treatment and what he hoped to achieve as a non smoker. Philip said that he wanted to feel healthier and that he didn?t want to put his life at risk. His partner was also expecting a baby girl and he felt very strongly that he didn?t want to smoke in front of her. The author told him that his lungs would recover very quickly and that he would feel the immediate effects of being a non smoker in a matter of days.

Using a simple eye fatigue induction, Philip focussed on his breathing, gradually letting all the muscles in his body relax: he was then encouraged to experience his special place which consisted of him relaxing in the comfort of his home. In the special place, he was given suggestions that he was completely relaxed and confident, but that, here, he would also be aware of his abilities and that these abilities could be utilized any time he wished. The ego strengthening was repeated using poetic repetition which maximized his potential (Callow, 1998; Callow, 2003) and implicit suggestions were given that he was already able to give up smoking and that he just needed to utilize this inherent ability (Calvert, 2007). This proceeded along the following lines:

As you continue to relax, I wonder how soon it will be before you begin to notice how confident you feel in your special place…confident and relax…perhaps more confident than you have been for a long time…and as your confidence builds more and more, so, too, does your ability to think clearly about what you want to do..what you want to become..as you realize that you are becoming the BEST YOU…whose abilities grow stronger and stronger…And isn?t it interesting to know that, in this special place…as you become more and more confident…you begin to realize the immense strength that you have inside of you..and this strength and will power becomes stronger and stronger with every day that passes…and from moment to moment and from minute to minute…you begin to embrace those abilities?the abilities that you always and already have.

At this point the therapist said authoritively, ?Are you ready to be a Non Smoker?? Philip confirmed that he was ready. Having confirmed that he was motivated and willing, he was then asked him what time he usually got up in the morning and when he usually felt like having a cigarette. He confirmed that it was normally with his first cup of coffee. Philip described his special place and was encouraged to enjoy the sensations of being comfortable and relaxed at home?then, using ego strengthening, it was explained to him that, in this special place, not only was he calm and relaxed, but he was also in control of his thoughts and behaviour and that he would become increasingly aware of his immense abilities. The ego strengthening consisted of the encouragement of his active involvement (Callow,1998, 2003), chaining suggestions (Yapko, 2003), and the building of the expectation of his success (Kroger, 2008). An example of this is shown below:

Isn?t it interesting to know that in this special place not only do you feel comfortable and relaxed but you become more confident too?because this is your special place?a place of anywhere and ?anywhen??and in this place?you immediately become aware of your abilities that you always and already have?and the stronger you feel inside?the more confident you become?and the more confident you become?the more will power you seem to have?and as this strength and confidence builds inside of you…you notice that you begin to take care of yourself?more and more?and you are already tasting success?knowing that you will be able to do what you want to do…to become the person who you want to be?the person who you always and already are?and this strength and feelings of healthiness will grow inside of you on its own?as you become aware of the success of your thinking…you become aware of the success of your life as a non smoker…

It was then stressed that, whenever he thought about having a cigarette, before he put a cigarette in his mouth, he would feel ghastly and nauseous, and would also feel disgusted with himself for letting himself down. Philip was given time and space to feel the physical sensations of being nauseous, although it was confirmed to him that he would not in fact be physically sick. The author then asked him the direct question, ?Are you going to take that cigarette??. He replied, in a resounding and defying voice, ?No?. He was then asked when he would next be likely to want to have a cigarette and Philip said that it was at the first break at work. At this point, using the same approach as before, we focussed on the fact that he would feel ghastly before he took a cigarette, because if he were to put a cigarette in his mouth he would, in most cases, begin to smoke (Kraft & Kraft, 2005). Once more, he was asked the question, ?Are you going to take that cigarette??, and, again, Philip said that he would not. He was then given conditioning trials (Cautela, 1968; Reiss, 1980; Kraft and Kraft, 2005) for the mid morning, after lunch, early afternoon, arriving home, after supper, late evening and the last thing before bed-time. The author asked him about other occasions when he might want a cigarette, and he said, ?any gaps in the day when he had some time to himself?. We went through each trial together, and, on each occasion, he confirmed that he was not going to take a cigarette.

Following this, it was suggested to him that he imagine a typical day and that, whenever he felt like having a cigarette, he would feel ghastly and that he would not smoke. The author guided him through the first two trials; each time, he was asked whether he would smoke, and he answered with a resounding ?no?. On each occasion that he did not take a cigarette, he was congratulated: as a result, the unwanted behaviour (smoking) was paired, and therefore associated with, an unpleasant stimulus, and the wanted behaviour (being smoke free) was paired with pleasurable sensations. This was combined with more ego-strengthening which involved two or three truisms, in a ?yes set?, in which the client silently agreed with each one (Erickson et al, 1976), and chaining suggestions together using an implied causative (Yapko, 2003)?i.e., ?as you experience this, you will begin to experience that? (Yapko, 2003; Bandler & Grindler, 1975). He was then given the opportunity to do this on his own in imagination and in silence, and, when he was ready to move on, he gave an ideomotor signal. He was also encouraged to use an imaginary fast-forward button and that he should cover all the times of the day when he might feel that he wanted a cigarette. This was set this up as follows:

I now wonder whether you are ready to explore all the times in the day when you might want to take a cigarette…and, if you are, please let me know {wait for ideomotor or verbal response}…Well, now that you are ready…just take some time to explore a typical day..and every time you feel like taking a cigarette…allow yourself to feel ghastly and disgusted with yourself…and each time…are you going to take that cigarette? {wait for the answer, No}…Good. And, on each occasion, you don?t take that cigarette, you feel good about yourself…and you congratulate yourself…and this makes you feel more confident inside…and the more confident you feel, the more will power you seem to have…And some people surprise themselves with regard to how much ability they have at these times…as the cravings, even if they do arise, just fade away…and isn?t it interesting that some people don?t seem to have cravings at all…and, even if they do, these will just wash away…just allow them to fade away and let them go…And no matter how strange it seems, you can imagine that day on your own with me by your side…and, after you have finished exploring this day, raise your finger on your right hand or tell me that you are ready to continue, and then my voice will come back to you.

Philip spent between five and ten minutes on his own exploring a typical day in imagination after which he was asked whether he took a cigarette, and he confirmed that he had not. He was then given the opportunity, using the fast forward button, to imagine hundreds of scenarios like quick flash images in the near and distant future when he would think about having a cigarette, but that on each occasion he would not take one. Once more, Philip indicated that he had not smoked one cigarette and that he felt good inside. The author congratulated him on this achievement and gave him the direct suggestion that he was now a non smoker. This proceeded as follows:

Congratulations on becoming a non smoker…Can you remember a time when you were a smoker?…At that time you were unhealthy..but now, you are a non smoker, you are taking care of yourself…and you see yourself as a non smoker…When you were a smoker you spent a lot of money on cigarettes and the smoke did not smell very good…Think of all those reasons to give up {leave a break for contemplation}…But now you are a non smoker just allow yourself in your own time to enjoy the sensations of feeling healthy and good about yourself…And if you feel that it is helpful, repeat to yourself again and again…?I AM A NON SMOKER?.

At this point, it was important here to refer to him as a smoker in the past tense. Following this, using future orientation in time, Philip was transported to a time in the near future and was encouraged to go on a ?non smoker walk? in which he observed all the smokers in the world and enjoyed not being one of them.

And as you continue to walk down the road as a non smoker…breathing deeply and slowly…in a relaxed and confident way…you begin to notice all those people around you who are still smoking…I wonder how that makes you feel {leave time for reflection}…Does it make you feel strong inside…you see yourself in social situations…you are in control but all these people are not in control because they are breathing in smoke…But you are in control…you are always and already healthy…and proud of yourself…you are rewarding yourself and that makes you feel good inside…just allow yourself to enjoy walking down this road, observing others and feeling good inside…in your own unique way…and when you have finished enjoying this process, just let me know{leave time for the client to experience these pleasurable sensations in private}.

Philip enjoyed this process for about three or four minutes, after which, using split screen imagery (Taylor, 1985; Spiegel & Spiegel, 1987; Kraft & Kraft, 2006; Poon, 2007), he was asked to imagine a screen in which there were two pairs of lungs. On the left was a healthy pairs of lungs?they were described as having a soft and spongy texture, pink in colour and working efficiently. On the right hand side there was a pair of lungs which was described as being black in colour, polluted with tar, with blocked bronchial tubes, constricted cells, and working inefficiently. Philip was given further ego strengthening, and was asked the direct question to confirm that he was motivated to be healthy. He confirmed that he was ready. He was then invited him to take the pair of lungs that he wanted to put inside his body, and he confirmed that he wanted the healthy pair of lungs. He stretched out his hands and drew them closer to his body finally touching his hands on his chest. He was then given further ego strengthening and suggestions that he would have no cravings at all as well as indirect suggestions that, as each day passed, he would gradually become less aware of smoking in general.

Back in the present time now…As you hands touch your chest you feel warm inside, and that warmth becomes stronger inside of you..and as that warmth continues to grow you become more and more confident and healthy, too…relaxed and ready to lead your life as a non smoker…and isn?t it interesting that you don?t even want to take a cigarette…you don?t want to take a cigarette..and you have absolutely no desire to take a cigarette…Just think of all the things you will be able to do instead..and this adaptive behaviour will make you feel happy inside and proud of yourself…a sense of feeling worthwhile…feeling confident…and your thoughts about having a cigarette will become less and less…And as each day passes…you will think about it less and less…and I wonder if you will think about more important things instead….as all your senses…which have become suddenly alive and free…will work together to help you always and already to be, and become, the person of your dreams…to do what you want to do and what you want to become..because…YOU ARE NOW A NON SMOKER.

Following the disengagement, Philip said that he felt like an entirely ?new person? and that he would phone next week to see if he needed a further session. It was stressed to him that it was important to tell as many people as possible that he was now not smoking and that he should ask for support from close members of his family. He said that they were already supporting him that he was ready to talk about his success with close friends. The following week came and Philip said that he had not had one cigarette that week and that, strangely, he had had no cravings whatsoever. He confirmed that he was now a non smoker and that he was very grateful indeed.

Follow up and some comments on the problems in using measures for verification

It is desirable to use measures for verification in order to make sure that it is not just the opinion of the author which shows that the treatment has been a success but that there is also empirical evidence to support this claim. This is a difficult task when treating smokers, particularly as many individuals under-play the number of cigarettes they smoke, or deny smoking altogether. There are, however biochemical tests that can be used to detect the amount of nicotine present?for example, the ?Cotinine Test? which is a rapid urine screening test which has been used by insurance companies, teachers and health care professionals. Cotinine tests vary, but a well known retailer of nicotine testing (Transmetron Drug Test, 2011) states that, ?the window of detection for Cotinine in urine at a cut off level of 200 ng/mL is expected to be up to 2-3 days after nitotine use?. Thus, if cotinine typically remains in the body for between 2-4 days after the last cigarette, this cannot be used to show that an individual has abstained from smoking for long periods of time. Therefore, the author has decided to use a short structured interview in order to ascertain the success of the therapy, the result of which will show the comments of the clients about the success of the treatment and why it was successful. This was done at the one year follow-up.

Structured Interview

Question 1: Can you tell me about your experience of having hypnosis and using covert sensitization, and tell me about any benefits that have arisen from being a non smoker? Philip said that the treatment was a complete success. He pointed out that, he had no cravings to smoke and that this was at the heart of what made it different this time. He felt inside that his lungs were working more efficiently, and felt better generally. In direct contrast to the past, when he was a smoker, he was now able to run freely and much further distances. He also commented that he had saved about £2,500 a year from not buying cigarettes and he felt that there were huge long-term benefits to his health. Further, he said that he was pleased that he had given up because he didn?t want to smoke in front of his daughter.

Question 2: Can you tell me a little bit about what you thought worked best in the sessions? Why was the hypnosis successful? Philip pointed out that he saw the whole thing as ?a challenge?. He said that he felt in control of his actions but that he needed an ?internal trigger mechanism? to help him to give up smoking, and that this was provided during treatment. He pinpointed out that two techniques were particularly helpful?namely, (1) the conditioning trials throughout the day and (2) being given the chance on his own to work through all the times in the day when he might conceivably have a cigarette. He felt that this was helpful because they ?covered all the bases?. Further, he said that he felt physically sick for the first two days and for almost two weeks he felt negatively about cigarettes in general.

Question 3: Is there anything else that you feel that is important to mention about the therapy and its efficacy? Philip said that what was strange was that he had no cravings and that this was of paramount importance. He pointed out that, this time, it was, ?not a battle?, and he ?didn?t feel deprived??in short, the process this time was different. He volunteered the point that not smoking was not about denial but it was about, ?positive change?, and that this effect was long lasting. Philip concluded that he was now a ?non smoker? and he would never go back to smoking again.

Discussion

The approach used in this study relies on a number of important techniques as well as the careful preparation. It is important, when the patient initially books the appointment on the phone, first to establish a level of belief and expectation that (s)he will be successful in giving up smoking (Bednar, 1970; Stanton, 1978). Secondly, it is stressed that the medical model of hypnosis (Barber, 1985) is that all hypnosis is self hypnosis and that the clients? active cooperation is required throughout the process (Barabasz et al, 2009). In the session, this point is followed up by saying that the client is welcome to resist treatment and to deliberately smoke after the session but that the only person who will lose out will be the patient, who will continue to damage his body, and pay for cigarettes. Thirdly, it is always pointed out to clients that, in many instances, individuals have stopped in one session and that, although ?booster sessions? are available, they are not always necessary. The authoritative question, ?Are you ready to be a non-smoker?? is useful as it acts like a telephone contract and this can then be repeated before hypnosis is used in the consulting room.

The aversion used in this study is a powerful one and it is important to use it with care. Using words and phrases such as ?ghastly?, ?You will feel nauseous and sick in the pit of your stomach? and, ?You will feel disappointed in yourself? can, if used in isolation, cause some distress. But this technique is very effective and is designed to empower the client; it is important, however, that this is followed up with the question, ?Do you take that cigarette??, and, on answering ?no?, it is recommended that this should be combined with congratulations (Stanton, 1978), ego strengthening (Hartland, 1973), suggestions of healthy eating behaviour (Solloway et al, 2006) and/or increased physical activity (Barber, 2001). Further, although direct and indirect suggestions can be used in order to eliminate or significantly reduce cravings, it is nevertheless important to acknowledge that they can occur, and if they do, that they should be accepted (Barber, 2001). Clinicains are advised to uses phrases such as, ?Just allow these cravings to wash away?, ?fade away? and that one should ?let them go? (Marlatt, 2002; Lynn & Kirsch, 2006;). Lynn and Kirsch (2006) also pointed out that even if, in the worst scenario, they take a cigarette, all is not lost and that, ?a lapse does not mean a relapse?. These aversions should be used at every point during the day when the patient might think that he might want a cigarette (Kraft & Kraft, 2005). It is essential to cover all the times of the day and to identify high risk, trigger situations when the patient is most likely to want to smoke: indeed, the patient, Philip, commented that this was an important strand to the success of the therapy. The first few trials were therefore done with the therapist; he was then given the chance to explore on his own, using the play and fast forward buttons, all the times of the day when he might want to smoke. On each occasion that he did not take a cigarette, he was encouraged to feel all the pleasurable sensations of achieving. This was an important component to the treatment because, by giving him the opportunity to explore these scenarios in imagination, with minimal content from the therapist?a process often referred to as ?content free therapy? (Emerson, 2007; Hamill, 2007)?he was able to exercise a huge amount of control over his behaviour.

The split screen imagery, used at the end of the hypnotherapy, provided Philip with the opportunity to choose the healthy pair of lungs, to reject the unhealthy choice, and to be in control of that decision. Having established that he had become a non smoker, Philip was then invited to experience the ?non smoker walk?, enjoying all the health benefits that this offers. At the end of the session, after disengagement, the author, using an Ericksonian approach (cited in Bonshtein et al, 2005), gave the clear message that he was now a ?non smoker?, and that he should see himself as a ?non smoker? (Tobin et al, 1986). In addition, the author stressed the importance of asking clients to tell as many friends as possible that they have given up smoking in order to make sure that they receive social support; indeed, this is an important component in this process of maintaining abstinence.

This report has shown that a multimodal approach to hypnosis is highly effective in treating a heavy smoker and it is hoped that this study will be helpful for therapists in clinical practice.

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Correspondence to David Kraft PhD, 10 Harley Street, London, W1G 9PF, UK
E-Mail: David Kraft
Phone: 0207 467 8564