Application of Cognitive Behavioural Hypnotherapy in Neuropsychology: A Critical Systematic Review with a Proposed Research Agenda Author: Wan, Pak Fai (尹柏辉) Certified Instructor / Certified Hypnotherapist, National Guild of Hypnotists Certified Trainer, American Board of Hypnotherapy Certified Hypnotherapist, International Hypnosis Association Region: Hong Kong Date: 11 September 2026 Canonical URL: https://albertwan.app/thesis ABSTRACT Cognitive behavioural hypnotherapy (CBH) integrates the structured, evidence-based techniques of cognitive behavioural therapy (CBT) with the focused attentional and suggestive mechanisms of clinical hypnosis. This dissertation presents a critical systematic review of CBH in neuropsychological populations, extended by a proposed research agenda informed by contemporary methodological frameworks. The review maintains a central methodological caution: the evidence base for CBH in neuropsychology is promising but immature, characterised by small sample sizes, heterogeneous intervention definitions, and a paucity of neuroimaging or biochemical mediator evidence. A critical distinction is maintained throughout between hypnotic suggestion and full CBH protocols, which are non-equivalent interventions. Key findings include: a quasi-experimental study in mild-to-moderate Alzheimer's disease reporting large effect sizes for cognitive flexibility (partial η² = 0.57), rumination (η² = 0.60), and stigma (η² = 0.56); a randomised actively controlled trial in acquired brain injury demonstrating medium-to-large working memory improvements (standardised mean differences 1.55–2.03); a randomised clinical trial in multiple sclerosis showing a small effect on psychological well-being (η² = 0.12); a single-case report in Parkinson's disease describing a 94% reduction in resting tremor; and a quasi-experimental study in stroke reporting significant reductions in anxiety, depression, and upper-limb spasticity. In response to methodological gaps identified in the existing literature, the dissertation proposes an operationalised theoretical framework in which negative self-expectancies are decomposed into measurable mediator constructs (drawing on the mediator–moderator framework of Milling et al., 2007), adopts the TIDieR-Rehab checklist to enhance intervention reporting alongside the five-dimensional fidelity framework of Bellg et al. (2004), elevates hypnotisability from a control variable to a pre-specified effect modifier while discussing the disease-specificity question raised by the divergent findings of Jensen et al. (2023) and Siewert et al. (2026), and presents a phased research roadmap prioritising far transfer to instrumental activities of daily living as a primary outcome. A theoretical framework is proposed that treats neuroplasticity as a hypothesis-generating model rather than an established mechanism, pending direct mediator evidence. KEYWORDS: cognitive behavioural hypnotherapy, neuropsychology, cognitive rehabilitation, neuroplasticity, systematic review, clinical hypnosis, evidence-based practice, TIDieR-Rehab, hypnotisability, far transfer PLAIN-LANGUAGE SUMMARY This dissertation reviews whether cognitive behavioural hypnotherapy (CBH) — cognitive behavioural therapy combined with clinical hypnosis — helps people living with neurological conditions such as Alzheimer's disease, acquired brain injury, multiple sclerosis, Parkinson's disease and stroke. Across the studies reviewed, CBH shows encouraging results for memory, cognitive flexibility, mood and anxiety, with the strongest signal in acquired brain injury. The evidence base, however, remains immature: samples are small, protocols are described inconsistently, and no study yet demonstrates a direct brain-level mechanism. The paper therefore proposes an operationalised research framework and a phased roadmap so future trials can test CBH rigorously, with everyday functioning as the primary outcome. KEY FINDINGS - Cognitive behavioural hypnotherapy (CBH) and isolated hypnotic suggestion are non-equivalent interventions and should not be pooled in evidence syntheses. - Alzheimer's disease (quasi-experimental): large effects for cognitive flexibility (partial η² = 0.57), rumination (η² = 0.60) and stigma (η² = 0.56). - Acquired brain injury (randomised, actively controlled): medium-to-large working memory gains, standardised mean differences 1.55–2.03 — the strongest evidence identified. - Multiple sclerosis (randomised clinical trial): a small effect on psychological well-being (η² = 0.12). - Parkinson's disease (single case report): 94% reduction in resting tremor — hypothesis-generating only. - Stroke (quasi-experimental): significant reductions in anxiety, depression and upper-limb spasticity. - Neuroplasticity is treated as a hypothesis-generating model, not an established mechanism, pending direct mediator evidence such as neuroimaging or BDNF data. - The proposed agenda operationalises negative self-expectancy into measurable mediators, adopts TIDieR-Rehab reporting with Bellg et al. (2004) fidelity, elevates hypnotisability to a pre-specified effect modifier, and prioritises far transfer to instrumental activities of daily living. LIST OF ABBREVIATIONS ABI = Acquired Brain Injury AD = Alzheimer's Disease BDNF = Brain-Derived Neurotrophic Factor CBH = Cognitive Behavioural Hypnotherapy CBT = Cognitive Behavioural Therapy CEQ = Credibility/Expectancy Questionnaire CFI = Cognitive Flexibility Inventory DAS = Dysfunctional Attitude Scale DMN = Default Mode Network EEG = Electroencephalography fMRI = Functional Magnetic Resonance Imaging GSE = General Self-Efficacy Scale IADL = Instrumental Activities of Daily Living MS = Multiple Sclerosis PD = Parkinson's Disease RRS = Ruminative Responses Scale SSCI-8 = Stigma Scale for Chronic Illness STAI = State-Trait Anxiety Inventory TIDieR = Template for Intervention Description and Replication ====================================================================== CHAPTER 1: INTRODUCTION AND CRITICAL FRAMEWORK ====================================================================== 1.1 Rationale and Scope ----------------------- Neuropsychological disorders—encompassing acquired brain injury (ABI), neurodegenerative conditions, and neurodevelopmental disorders—represent a substantial global health burden. Cognitive impairment following brain injury is prevalent across lesion aetiologies and severities, yet rehabilitation efforts for this impairment have hitherto yielded small or no effects. This therapeutic gap necessitates rigorous evaluation of non-pharmacological interventions. Cognitive behavioural hypnotherapy (CBH) is defined as an evidence-based technique that uses the state of hypnosis for therapeutic purposes, integrating hypnotic techniques within a structured therapeutic intervention. A critical methodological caution must be stated at the outset: CBH is not a unitary intervention. The term encompasses at least two non-equivalent treatment modalities: (1) hypnotic suggestion, in which a specific suggestion (e.g., restoration of pre-injury working memory) is delivered to a hypnotised patient, often in a small number of sessions; and (2) full CBH protocols, in which hypnotic techniques are integrated within a multi-session cognitive-behavioural framework. These modalities differ in therapeutic dose, mechanism of action, and likely effect size. This dissertation treats them as distinct throughout. 1.2 Relationship to Existing Reviews ------------------------------------ This dissertation must be positioned within an existing body of review literature. Several works are directly relevant and must be explicitly distinguished. Lindeløv, Kvamme, Thomsen, Overgaard, and Overgaard (2023) published a conceptual review in New Ideas in Psychology (volume 71, article 101046). The paper proposes a general framework in which a substantial part of cognitive brain-injury sequelae can be attributed to negative self-expectancies, and hypnosis is a powerful way to manipulate these expectancies. The paper includes four patient cases and concludes with five testable predictions. This review explicitly focuses on hypnotic suggestion as the intervention modality, not on full CBH protocols. The present dissertation builds on this work by (a) extending the scope beyond ABI to include neurodegenerative and neuroinflammatory conditions, (b) systematically evaluating the evidence for full CBH protocols, which Lindeløv et al. (2023) did not address, and (c) operationalising the negative-expectancy framework into measurable mediator constructs. Khachumova and White (2024) published a systematic review in the Graduate Student Journal of Psychology (volume 22, pages 1–15) evaluating cognitive hypnotherapy for mental disorders using PRISMA guidelines and the Joanna Briggs Institute critical appraisal tools. Following screening, six papers met criteria; significant symptom reduction was observed in five studies, and cognitive hypnotherapy was reported to be as effective as CBT in treating depression. This review is limited to mental disorders and does not address neuropsychological conditions. The present dissertation extends this critical framework to neuropsychological populations, but adopts a narrative critical appraisal approach focused on risk of bias, intervention specification, and clinical meaningfulness. Wawrziczny, Buquet, and Picard (2021) published a scoping review in Archives of Gerontology and Geriatrics (volume 96, article 104453) titled “Use of hypnosis in the field of dementia: A scoping review” (DOI: 10.1016/j.archger.2021.104453). This review mapped the existing literature on hypnosis in dementia care, identifying a small number of studies with heterogeneous designs and outcomes. However, the scoping review did not systematically evaluate the quality of evidence, did not distinguish between hypnotic suggestion and full CBH protocols, and did not include neuropsychological outcomes beyond dementia. Özdemir, Cozzolino, Gurdal, Arcangeli, Mancone, and Celia (2025) published a systematic review in The American Journal of Medicine (volume 138, issue 10, pages 1440–1450, DOI: 10.1016/j.amjmed.2025.05.049) titled “A Decade of Hypnotherapy Research for Multiple Sclerosis Symptom Management: A Systematic Review.” This review assessed 15 studies (total N = 15–173) using the PEDro scale and reported significant benefits including a 30–45% reduction in pain intensity (p < 0.01), an 8.19-point decrease in Multidimensional Fatigue Inventory scores (p < 0.05), a 1.98-point improvement in Pittsburgh Sleep Quality Index scores (p < 0.05), and a 3.7-point reduction in DASS-21 depression scores. Optimal protocols included 8–10 weekly 45–60-minute sessions, with coupled treatments producing additional 15–20% improvement. However, this review focused exclusively on symptom management in MS and did not address cognitive outcomes. The original contribution of this dissertation is therefore not the critical systematic review methodology itself, but its application to a previously unaddressed scope: the evidence base for full CBH protocols—as distinct from hypnotic suggestion—across multiple neuropsychological conditions. A second original contribution is the translation of identified methodological gaps into a concrete, phased research agenda with operationalised constructs and reporting standards. 1.3 Historical Evolution and Meta-Analytic Evidence: A Critical Comparison ---------------------------------------------------------------------- Kirsch, Montgomery, and Sapirstein (1995) conducted a meta-analysis published in the Journal of Consulting and Clinical Psychology (volume 63, issue 2, pages 214–220, DOI: 10.1037/0022-006X.63.2.214) examining hypnosis as an adjunct to cognitive-behavioural psychotherapy. The analysis found that CBT enhanced with hypnosis (CBTH) was superior to CBT alone by at least d = 0.53. This finding must be interpreted with caution. The effect size estimate is based on studies conducted before 1995, when methodological standards for clinical trials were less stringent. The Kirsch et al. (1995) estimate has been widely cited, but its repetition in the literature without critical evaluation constitutes a citation cascade that risks overstating the robustness of the effect. Ramondo, Gignac, Pestell, and Byrne (2021) conducted an updated meta-analysis published in the International Journal of Clinical and Experimental Hypnosis (volume 69, issue 2, pages 169–202, DOI: 10.1080/00207144.2021.1877549). The updated analysis reported a smaller and more heterogeneous effect, with a small-to-medium advantage over CBT alone for managing depression or pain. The attenuation of effect size from d = 0.53 (Kirsch et al., 1995) to the smaller estimate reported by Ramondo et al. (2021) is a critical finding. Several explanations are plausible: (1) publication bias; (2) small-study effects; (3) heterogeneity in intervention quality; and (4) differences in clinical populations. The responsible interpretation is that the additive benefit of hypnosis to CBT is likely smaller than the original Kirsch estimate suggested, and that current evidence supports a small-to-medium effect. 1.4 Research Questions ---------------------- - What is the empirical evidence for CBH's efficacy across major neuropsychological conditions, and what is the quality of that evidence? - What are the proposed neurobiological and cognitive-behavioural mechanisms, and what direct evidence exists to support them? - What clinical protocols and adaptations are required for CBH delivery in neuropsychological populations? - What are the ethical, training, and implementation considerations? - What operationalised research agenda can advance the field from preliminary evidence to mechanistic understanding and clinical translation? ====================================================================== CHAPTER 2: THEORETICAL FOUNDATIONS—A CAUTIONARY FRAMEWORK WITH OPERATIONALISED CONSTRUCTS ====================================================================== 2.1 Cognitive-Behavioural Framework ----------------------------------- The cognitive-behavioural framework provides a suitable model for conceptualising hypnotherapy's mechanisms. Menon and Bhagat (2026) conducted a narrative review published in the Research Journal of Pharmacy and Technology (volume 19, issue 3, pages 1466–1470, DOI: 10.52711/0974-360X.2026.00211). Their review concluded that hypnotherapy engages identifiable cognitive-behavioural and neurobiological mechanisms consistent with contemporary psychological and behavioural science. This is a conceptual framework, not an empirically validated mechanism model. 2.2 Negative Self-Expectancies as a Unifying Framework: Operationalisation and Extension ---------------------------------------------------------------------- Lindeløv et al. (2023) proposed a framework in which a substantial part of cognitive brain-injury sequelae can be attributed to negative self-expectancies. Four patient cases illustrated this: (1) mental imagery of brain recovery can be effective even if it does not correspond to the “real” physical brain injury; (2) some patients do not subjectively experience improvement despite large objective improvements; (3) some patients inhibit positive treatment effects when incentivised to do so; and (4) pre-injury autobiographical memories may be an important precondition for positive effects. “Negative self-expectancies” remains an umbrella construct that requires operationalisation for empirical testing. Milling, Shores, Coursen, Menario, and Farris (2007) published a randomised controlled trial (N = 124) in Annals of Behavioral Medicine (volume 33, issue 2, pages 167–178, DOI: 10.1007/BF02879898). The study found that response expectancies and treatment credibility independently mediated the effects of hypnotic and cognitive-behavioural pain interventions, with mediation increasing with treatment experience. Hypnotic suggestibility moderated treatment outcome, and this moderation appeared only in the hypnotic intervention—high-suggestibility participants obtained greater pain relief from the hypnotic intervention but did not obtain comparable benefit from the cognitive-behavioural intervention. The study also found that the relationship between suggestibility and hypnotic analgesia appeared to be linear rather than threshold-based. The present dissertation proposes the following operationalisation framework for negative self-expectancies: Table 1: Operationalisation Framework for Negative Self-Expectancies Umbrella Construct | Measurable Mediator Variable | Measurement Instrument Negative self-expectancies | Anticipatory anxiety | State-Trait Anxiety Inventory (STAI) Negative self-expectancies | Dysfunctional beliefs | Dysfunctional Attitude Scale (DAS) Negative self-expectancies | Illness perception | Brief Illness Perception Questionnaire (BIPQ) Negative self-expectancies | Self-efficacy | General Self-Efficacy Scale (GSE) Treatment credibility | Credibility/Expectancy Questionnaire | CEQ In future CBH trials, these variables should be included as mediator variables in formal mediation analyses. If mediation analysis fails to show that these constructs significantly mediate the relationship between CBH and outcomes, the negative-expectancy framework requires revision or rejection. Additionally, the dissertation proposes a 2×2 experimental paradigm to disentangle the effects of expectancy manipulation from hypnotic state: Expectancy Manipulation (High/Low) × Hypnotic State (Hypnosis/Waking). Based on Milling et al.'s (2007) finding that suggestibility moderates only hypnotic intervention effects, a more precise prediction can be made: if improvement under “High Expectancy + Waking” conditions is comparable to that under “High Expectancy + Hypnosis,” the unique contribution of hypnosis would be called into question; if “High Expectancy + Hypnosis” is significantly superior to “High Expectancy + Waking,” and this advantage is more pronounced in high-suggestibility individuals, the unique mechanism of hypnosis would be supported. 2.3 Neuroplasticity: Hypothesis, Not Established Mechanism ---------------------------------------------------------- De Pascalis (2024) published a comprehensive review in Brain Sciences (volume 14, issue 2, article 115, DOI: 10.3390/brainsci14020115) examining fMRI, PET, and EEG studies of hypnosis and hypnotisability. Halsband, Mueller, Hinterberger, and Strickner (2009) reported in Contemporary Hypnosis (volume 26, issue 4, pages 194–215) that PET cerebral activation patterns of imagery-mediated learning under hypnosis showed more pronounced bilateral activation in the occipital cortex and prefrontal areas. None of these neuroimaging studies were conducted in neuropsychological populations, and none measured changes following a therapeutic CBH intervention. They describe the neural correlates of hypnotic responding in healthy individuals, not the mechanism of CBH-induced clinical improvement. The neuroplasticity framework should be treated as a heuristic model that generates testable hypotheses. 2.4 Hypnotisability as an Effect Modifier: Divergent Evidence and Design Implications ---------------------------------------------------------------------- The dissertation elevates hypnotisability from a “future research direction” to a current design principle, while addressing divergent evidence in the existing literature. Jensen, Ehde, Hakimian, Pettet, Day, and Ciol (2023) published an exploratory secondary analysis of a randomised controlled trial (N = 173) in The Journal of Pain (volume 24, issue 11, pages 2024–2039, DOI: 10.1016/j.jpain.2023.06.011) comparing four psychological pain interventions: cognitive therapy (CT), hypnosis focused on pain reduction (HYP), hypnosis focused on changing pain-related cognitions (HYP-CT), and an education control condition. The study found that pre-treatment measures of hypnotisability and EEG-assessed brain activity predicted differential responses to the four treatments. The authors noted that if these findings are replicated, they could contribute to the development of patient–treatment matching algorithms. Siewert, Brinkhaus, Tissen-Diabaté, Teut, and Volz (2026) published an exploratory secondary analysis (N = 94) in Frontiers in Medicine (volume 13, article 1847384, DOI: 10.3389/fmed.2026.1847384) examining whether baseline hypnotic suggestibility moderated changes in mild-to-moderate depressive symptoms. Results showed no significant association between baseline hypnotic suggestibility and changes in depressive symptoms, nor did this association differ between the hypnosis group, the progressive muscle relaxation group, and the control group. The authors noted that post-hoc power analysis indicated the complete-case sample size was insufficient to reliably detect small-to-medium moderation effects. The divergence between these two studies suggests that the moderating effect of hypnotisability may be disease-specific (pain vs. depression) and may also be influenced by sample size and statistical power. In neuropsychological populations, the moderating effect of hypnotisability requires independent verification and cannot be directly extrapolated from pain or depression literature. The dissertation proposes the following design principle: the primary analysis of future CBH trials should include a treatment group × hypnotisability (high/low) interaction term. If the interaction effect is significant, CBH's effect depends on hypnotisability; if not, CBH may operate through non-hypnotic mechanisms (e.g., expectancy effects, therapeutic alliance). Either result is more clinically informative than the current “average effect.” Furthermore, future CBH trials must estimate sample size based on the interaction effect, not the main effect. ====================================================================== CHAPTER 3: CBH IN ALZHEIMER'S DISEASE ====================================================================== 3.1 Study Design and Critical Appraisal --------------------------------------- Noroozi Homayoon, Sadri Damirchi, and Lester (2026) published a quasi-experimental study in Counselling and Psychotherapy Research (volume 26, issue 2, article e70119, DOI: 10.1002/capr.70119). Seventy participants with mild to moderate Alzheimer's disease were non-randomly assigned to an experimental group (n = 35) receiving 12 weekly sessions of CBH, or a control group (n = 35) receiving standard care. Results: The experimental group demonstrated significant improvements in cognitive flexibility (p < 0.001, partial η² = 0.57), rumination (p < 0.001, partial η² = 0.60), and perceived stigma (p < 0.001, partial η² = 0.56). Critical appraisal: - Limitations: The published design is quasi-experimental, with non-random assignment to groups. The control group received standard care only, not an active control. Blinding of participants and assessors is not described. - Outcome measures: CFI, RRS, and SSCI-8 are all self-report questionnaires. - Effect sizes: The reported partial η² values (0.56–0.60) are exceptionally large for a psychological intervention in a neurodegenerative population. Given the lack of active control and blinding, these effects should be interpreted with caution. Conclusion: This study provides preliminary, hypothesis-generating evidence. It does not establish objective cognitive improvement or slowed neurodegeneration. ====================================================================== CHAPTER 4: CBH IN ACQUIRED BRAIN INJURY—THE STRONGEST EVIDENCE ====================================================================== 4.1 Working Memory Restoration ------------------------------ Lindeløv, Overgaard, and Overgaard (2017) published a randomised actively controlled trial in Brain (volume 140, issue 4, pages 1100–1106). Results: Following four 1-hour sessions, 27 patients showed a medium-sized improvement relative to 22 active controls (Bayes factors of 342 and 37.5) and a very large improvement relative to 19 passive controls (Bayes factor = 1.7 × 10¹³). Standardised mean differences relative to the passive control group were between 1.55 and 2.03. Critical appraisal: - Strengths: The only randomised actively controlled trial of CBH in any neuropsychological population. - Limitations: Total sample size (n = 68) is small. The Bayes factor is implausibly extreme. The intervention was hypnotic suggestion, not a full CBH protocol. - Hypnotisability: Not reported or examined as a moderator. Conclusion: Strong preliminary evidence that hypnotic suggestion can produce large, durable working memory improvements following ABI. However, the intervention is not equivalent to CBH, and findings require replication. 4.2 Ongoing Randomised Controlled Trials ---------------------------------------- Eide et al. (2024) published a study protocol in Trials (volume 25, issue 1, article 11). Pedersen et al. (2025) investigated the effect of hypnotic suggestion on labour market attachment and cognition after brain injury. ====================================================================== CHAPTER 5: CBH IN MULTIPLE SCLEROSIS ====================================================================== 5.1 Randomised Clinical Trial and Effect Size Heterogeneity ----------------------------------------------------------- Malekzadeh, Hashemi Mohammadabad, Kharamin, and Haghighi (2020) published a randomised clinical trial in the American Journal of Clinical Hypnosis (volume 62, issue 4, pages 364–379, DOI: 10.1080/00029157.2019.1709149). Forty-five patients were randomly assigned to an intervention group (n = 23) and a control group (n = 22). The intervention group attended eight sessions of group-based cognitive hypnotherapy. Results: Cognitive hypnotherapy had a significant effect on the total score of psychological well-being (F(45, 1) = 6.07, p = .018, η² = 0.12). Critical appraisal: - Limitations: The control group received no intervention. The effect size (η² = 0.12) is small. - Effect size heterogeneity analysis: The effect size in the MS study (η² = 0.12) is substantially smaller than that in the AD study (η² = 0.56–0.60). However, these two effect sizes should not be directly compared. Differences may arise from: (1) differences in outcome measures (self-report CFI vs. Ryff Psychological Well-Being Scale); (2) differences in control group design (standard care vs. no intervention); (3) differences in sample characteristics (AD vs. MS); and (4) differences in study design (quasi-experimental vs. randomised controlled). The more methodologically rigorous study found a smaller effect, suggesting that the large effect sizes in the AD study may be inflated by design limitations. Contextual note: Özdemir et al. (2025) reported larger symptom-specific effects in MS, but their review focused on symptom management rather than cognitive outcomes. ====================================================================== CHAPTER 6: CBH IN PARKINSON'S DISEASE AND STROKE—LOW-LEVEL EVIDENCE ====================================================================== 6.1 Parkinson's Disease: Single Case ------------------------------------ Elkins, Sliwinski, Bowers, and Encarnacion (2013) published a case study in the International Journal of Clinical and Experimental Hypnosis (volume 61, issue 2, pages 172–182). Results revealed a 94% reduction in rest tremors. Critical appraisal: This is a single case report (n = 1). This evidence level does not support clinical recommendations. 6.2 Stroke: Quasi-Experimental Evidence --------------------------------------- Rafiq, Wasay, and Pérez Ramos (2020) published a quasi-experimental pre-post study in Anaesthesia, Pain & Intensive Care (volume 24, issue 3, pages 291–301, DOI: 10.35975/apic.v24i3.1278). Results showed significant reductions in anxiety, stress, and depression (p < 0.05). Hypnosis was effective for upper-limb spasticity but showed no effect on lower-limb spasticity. Critical appraisal: Single-arm pre-post design with no control group. Requires replication in a controlled design. 6.3 Ongoing Stroke Rehabilitation Trials ---------------------------------------- A randomised trial (NCT06885294) is investigating physiotherapy combined with hypnosis on upper-limb functional capacities in stroke patients. A separate feasibility study (NCT06817837) is examining hypnosis in brain injuries, including stroke, with a target enrolment of 40 participants. ====================================================================== CHAPTER 7: COMPARATIVE NEUROPSYCHOLOGICAL EFFECTS ====================================================================== 7.1 Hypnotherapy vs. CBT in Depression -------------------------------------- Haipt, Rosenbaum, Fuhr, Batra, and Ehlis (2024) compared hypnotherapy and CBT on the default mode network of depressed patients. Critical caveat: Conducted in depressed patients, not neuropsychological populations. 7.2 Systematic Review Evidence ------------------------------ Khachumova and White (2024) published a systematic review in the Graduate Student Journal of Psychology (volume 22, pages 1–15). Critical caveat: Limited to mental disorders. ====================================================================== CHAPTER 8: CLINICAL IMPLEMENTATION FRAMEWORK—TIDIER-REHAB AND INTERVENTION FIDELITY ====================================================================== 8.1 Assessment and Case Formulation ----------------------------------- CBH in neuropsychological populations begins with a neuropsychologically informed assessment. Hypnotisability should be assessed using standardised scales and treated as a pre-specified effect modifier. 8.2 Intervention Specification: Adopting TIDieR-Rehab ----------------------------------------------------- The dissertation adopts the TIDieR-Rehab checklist (Signal, Gomes, Olsen, & Alder, 2024, BMJ Open, volume 14, issue 11, article e084320, DOI: 10.1136/bmjopen-2024-084320) as the reporting standard for CBH interventions. TIDieR-Rehab extends the original TIDieR with seven original, three adapted, and twelve new items. The new items promote complete description of key aspects of rehabilitation interventions, including the intended study population (“Who”) and timing of the intervention (“When”), planned intervention dosage (“How much,” “How challenging,” and “Regression/Progression”), person-centred care (“Personalisation”), and negative undesired effects (“Harms”). For CBH research, the following TIDieR-Rehab items are particularly relevant: Table 2: TIDieR-Rehab Items Applied to CBH Research TIDieR-Rehab Item | Application to CBH Who | Report participants' hypnotisability, lesion location, and cognitive baseline When | Report time since injury (acute vs. chronic phase) How much | Report number of sessions, duration, frequency How challenging | Report complexity of hypnotic suggestions and depth of cognitive restructuring Personalisation | Report whether the intervention was adjusted based on patient characteristics Harms | Systematically report emotional destabilisation, false memory, symptom exacerbation Adopting TIDieR-Rehab improves reporting quality and enables cross-study effect size comparison, which is currently lacking in CBH literature. 8.3 Intervention Fidelity Assessment ------------------------------------ One of the dissertation's original contributions is the proposal to include an intervention fidelity assessment framework in CBH systematic reviews. The five-dimensional fidelity framework published by Bellg et al. (2004) in Health Psychology (volume 23, issue 5, pages 443–451) provides an operationalised basis. The framework comprises five dimensions: design, provider training, treatment delivery, treatment receipt, and treatment enactment. In CBH research: - The treatment delivery dimension should assess: Did the therapist execute the hypnotic induction as planned? Did the hypnotic depth reach the intended level? - The treatment receipt dimension should assess: Did the patient understand the content of the hypnotic suggestions? - The treatment enactment dimension should assess: Did the patient apply the strategies learned in hypnosis in daily life? A “CBH protocol” in which hypnotic induction fails essentially degenerates into “relaxation training.” Intervention fidelity is a variable that is easily overlooked yet potentially decisive in CBH research. 8.4 Core CBT Tools in Hypnotic Context -------------------------------------- Table 3: Core CBT Tools in Hypnotic Context Tool | Standard CBT Application | CBH Adaptation Thought record | Written recording of situation, automatic thoughts, emotions, evidence | Guided “seeing” of alternative thought scenarios in hypnosis Socratic questioning | Questioning to examine evidence | Gentle, repetitive questioning in hypnotic state Cognitive distortion identification | Identifying catastrophising, mind-reading | Visualising distortions as “coloured glasses” then suggesting removal 8.5 Post-Hypnotic Consolidation ------------------------------- Post-hypnotic suggestions should anchor change to daily situations. For patients with memory impairment, written home practice instructions should be simplified (one task rather than multiple), reinforced by caregiver reminders. ====================================================================== CHAPTER 9: ETHICAL CONSIDERATIONS AND TRAINING REQUIREMENTS ====================================================================== 9.1 Ethical Framework --------------------- Scope of practice. Practitioners must operate only within areas of competence. Informed consent. Patients must be informed of CBH's nature, expected outcomes, limitations, and its adjunct role. Risk of false memory. In ABI and PTSD populations, hypnotic suggestion carries a theoretical risk of memory distortion. Effect interpretation. Subjective reports from brain-injured patients may not fully reflect objective improvement. 9.2 Training and Certification Pathways --------------------------------------- CBH training typically requires dual certification in CBT and clinical hypnosis. Available pathways include the UK College of Hypnosis & Hypnotherapy CBH Diploma, American Society of Clinical Hypnosis (ASCH), and Society for Clinical and Experimental Hypnosis (SCEH) programmes. 9.3 Declarations ---------------- Conflict of interest. No financial or non-financial relationships with CBH training organisations or commercial hypnosis interests are declared. Declaration of Prior Material Use. I hereby declare that the content of this dissertation has not been previously published or submitted for the award of any degree or diploma at this or any other institution. However, certain conceptual and structural elements of this dissertation were developed from the author's prior teaching materials, as detailed below. Prior teaching materials: Lecture notes and instructional modules for a graduate-level course on cognitive behavioural hypnotherapy in neuropsychology (unpublished teaching materials, not deposited in any institutional repository or submitted for examination). Elements derived from prior teaching materials Element | Location in Dissertation | Extent of Derivation | Nature of Revision Three-stage CBH model | Chapter 8.2 | Conceptual framework derived from prior teaching materials | Substantially expanded with current neuropsychological adaptation literature Core CBT tools and CBH adaptation table | Chapter 8.4 | Structural format derived from prior teaching materials | Expanded from teaching aid into research-informed table Intervention specification framework | Chapter 8.2 | Conceptual categories derived from prior teaching materials | Expanded and formalised into a reporting checklist aligned with TIDieR-Rehab Statement of originality: All text, analyses, and interpretations presented in this dissertation are the author's own work. The elements listed above were derived from prior teaching materials but have been substantially revised, updated with current empirical literature (2017–2026), and expanded to meet doctoral-level analytical standards. No text from prior teaching materials has been reproduced verbatim. Data availability. Systematic review methodology, search strategies, and data extraction forms are available upon request. ====================================================================== CHAPTER 10: A PHASED RESEARCH ROADMAP ====================================================================== This chapter proposes a phased research roadmap. 10.1 Phase 1: Mechanistic Validation ------------------------------------ Table 4: Phase 1 — Mechanistic Validation Element | Specification Core question | Does CBH improve outcomes through changes in negative self-expectancies? Design | Single-group pre-post design with formal mediation analysis Mediators | STAI, DAS, BIPQ, GSE, CEQ (as specified in Chapter 2.2) Outcomes | Cognitive flexibility (CFI), rumination (RRS), stigma (SSCI-8) Sample size | n = 40–50 Analysis | Bootstrapped mediation analysis (PROCESS macro) 10.2 Phase 2: Effect Modification --------------------------------- Table 5: Phase 2 — Effect Modification Element | Specification Core question | Does hypnotisability moderate the differential effect of CBH vs. CBT? Design | 2×2 design: CBH vs. CBT × High/Low hypnotisability (stratified randomisation) Primary outcome | Working memory (WAIS-IV WMI) Secondary outcomes | IADL (Lawton and Brody Scale), CFI Sample size | n = 120–150 (powered for interaction effect; α = 0.05, power = 0.80, expected interaction effect size f² = 0.15) Analysis | Mixed-model repeated measures with treatment group × hypnotisability interaction term Theoretical rationale for this phase: Jensen et al. (2023) demonstrated that high-hypnotisability patients respond poorly to cognitive therapy but well to hypnosis. If replicated in neuropsychological populations, this would provide a treatment-matching rationale for CBH—identifying which patients should receive CBH rather than conventional CBT. Siewert et al. (2026) found no moderating effect of hypnotisability in a depression population, suggesting that this effect may be disease-specific. A key secondary objective of this phase is to test whether the moderating effect of hypnotisability exists in neuropsychological populations. 10.3 Phase 3: Far Transfer Validation ------------------------------------- Table 6: Phase 3 — Far Transfer Validation Element | Specification Core question | Do laboratory cognitive improvements transfer to real-world functioning? Design | Randomised controlled trial with active control Primary outcome | Instrumental Activities of Daily Living (IADL)—Lawton and Brody Scale Secondary outcomes | Cognitive test scores (as mediators), quality of life (QOLIBRI) Sample size | n = 200+ Analysis | Intention-to-treat analysis; mediation analysis (cognitive gains → IADL) Key design principle: IADL should be the primary outcome, not a secondary outcome. Landínez-Martínez and Grisales-Aguirre (2025) published a randomised controlled trial (N = 50) in Pathophysiology (volume 32, issue 3, article 40, DOI: 10.3390/pathophysiology32030040) comparing adaptive working memory training with non-adaptive cognitive training in chronic stroke survivors. Results showed that adaptive WMT produced domain-specific cognitive improvements but did not surpass non-adaptive training in IADL performance. The study concluded that “these findings highlight the limited far transfer effects of working memory training and the importance of designing ecologically valid, multimodal rehabilitation strategies.” CBH research faces the same far transfer challenge as working memory training. If CBH improves working memory test scores but not the ability to manage medications, handle finances, or travel independently, its clinical value requires re-evaluation. A negative far transfer result is more informative than a hundred positive laboratory effect sizes. 10.4 Phase 4: Neuroimaging and Biochemical Mediator Studies ----------------------------------------------------------- Table 7: Phase 4 — Neuroimaging and Biochemical Mediator Studies Element | Specification Core question | Does CBH produce measurable neuroplastic changes that mediate behavioural outcomes? Design | Pre-post fMRI/EEG with mediation analysis Imaging targets | DMN, SN, CEN connectivity; EEG band oscillations Biochemical markers | BDNF, IGF-1, inflammatory cytokines Sample size | n = 30–40 Analysis | Mediation analysis (neural change → behavioural change) 10.5 Phase 5: Remote Delivery and Scalability --------------------------------------------- Developing audio-guided CBH protocols for home-based daily listening could increase accessibility. Digital adaptations must be short, repetitive, and easy to follow. 10.6 Integration with Other Neurorehabilitation Modalities ---------------------------------------------------------- Future research should investigate the optimal sequencing and combination of CBH with cognitive rehabilitation, physical therapy, and neuromodulation (rTMS, tDCS). ====================================================================== CHAPTER 11: CONCLUSION ====================================================================== This dissertation has systematically reviewed the theoretical foundations, empirical evidence, and clinical implementation of CBH in neuropsychological populations, and has proposed an operationalised research agenda to advance the field from preliminary evidence to mechanistic understanding. First, CBH shows preliminary evidence of efficacy in selected neuropsychological conditions. The strongest evidence comes from working memory rehabilitation following ABI using hypnotic suggestion (standardised mean differences 1.55–2.03). Evidence for full CBH protocols in AD (partial η² = 0.56–0.60) is quasi-experimental and non-blinded. Evidence for MS (η² = 0.12), PD (single case), and stroke (pre-post, n = 16) is low-level. Second, the proposed neurobiological mechanisms are hypothesis-generating frameworks, not established mechanisms. Third, the dissertation has operationalised the negative-expectancy framework into measurable mediator constructs (STAI, DAS, BIPQ, GSE, CEQ), drawing on the mediator–moderator framework of Milling et al. (2007) as an empirical template, and has proposed a 2×2 experimental paradigm to disentangle expectancy effects from hypnotic state effects. Fourth, the dissertation adopts TIDieR-Rehab as the reporting standard for CBH interventions and introduces the five-dimensional fidelity framework of Bellg et al. (2004). Fifth, the dissertation elevates hypnotisability from a control variable to a pre-specified effect modifier, while discussing the disease-specificity question raised by the divergent findings of Jensen et al. (2023) and Siewert et al. (2026). In neuropsychological populations, the moderating effect of hypnotisability requires independent verification and cannot be directly extrapolated from pain or depression literature. Sixth, the dissertation presents a phased research roadmap that prioritises mechanistic validation (Phase 1) and effect modification (Phase 2) before proceeding to large-scale efficacy trials (Phase 3), with IADL far transfer as a primary outcome. The working memory training far transfer failure evidence of Landínez-Martínez and Grisales-Aguirre (2025) provides direct empirical support for this design principle. CBH represents a theoretically coherent and empirically promising approach to neuropsychological rehabilitation. 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Application of cognitive behavioural hypnotherapy in neuropsychology: A critical systematic review with a proposed research agenda [Dissertation]. Wan Institute, Hong Kong. https://albertwan.app/thesis