This case study examines the hypnotherapeutic management of nicotine dependence in a 29-year-old female travel agent presenting with external locus of control patterns and elevated stress responses. The client demonstrated significant dysfunctional attributional patterns, with baseline DASS-21 anxiety scores of 15 and stress scores of 14, alongside a Dysfunctional Attitude Scale score of 128. Through targeted skill building interventions designed to restructure external control attributions, the client achieved remarkable improvements across all measures. Post-treatment assessment revealed a 93% reduction in both anxiety and stress scores (DASS-21 anxiety: 1, stress: 1), a 39% improvement in cognitive restructuring (DAS: 78), and a 67% reduction in subjective distress (SUDS: 2). This single-case design demonstrates the efficacy of skill building hypnotic devices in transferring agency and control back to the client, facilitating successful smoking cessation through cognitive pattern modification.
The Challenge
The primary therapeutic challenge centred upon the client's entrenched belief system regarding external control and personal agency. Her cognitive framework positioned smoking behaviour as something that 'happened to her' rather than something within her sphere of influence. This external attribution pattern was reinforced by repeated unsuccessful quit attempts, each failure serving to confirm her hypothesis that external forces were more powerful than her internal resources. The elevated stress and anxiety scores indicated that the smoking behaviour functioned as a maladaptive coping mechanism, creating additional therapeutic complexity. Furthermore, her professional environment as a travel agent involved regular exposure to stress triggers, making environmental modification challenging and necessitating robust internal resource development.
The Process
Mechanism of Action: To counteract the External Locus of Control pattern, the hypnotic device of Skill Building was utilised to systematically transfer agency back to the client. This approach directly addressed the core cognitive distortion by providing tangible, internal resources that the client could access independent of external circumstances. Skill Building interventions create neuroplastic changes through repeated rehearsal of new response patterns, gradually rewiring automatic behavioural sequences.
Protocol: The intervention utilised a standardised Elman induction technique, followed by a depth-building progressive muscle relaxation deepener. The primary therapeutic content focused on skill building through mental rehearsal of specific coping strategies, internal resource anchoring, and future scenario planning. The first session established foundational skills for stress management and trigger recognition, whilst the second session reinforced these capabilities and integrated them into real-world contexts. The hypnotic script emphasised the client's inherent capacity for choice and control, systematically challenging external attribution patterns through experiential learning within the hypnotic state.
Home Reinforcement: To facilitate neuroplasticity through repetition and reinforcement, the client was provided with a digital audio recording of the session and instructed to listen daily between appointments. This ensured the 'dose' of the therapeutic suggestion was maintained outside the clinical setting, allowing for continued cognitive restructuring and skill consolidation. The daily listening protocol created multiple opportunities for the new internal control patterns to become integrated at both conscious and unconscious levels.
The Result
Quantitative Results:
| Measure | Baseline | Mid-Treatment | Post-Treatment | % Change |
|---|---|---|---|---|
| DASS-21 (Anxiety) | 15 | 10 | 1 | 93% |
| DASS-21 (Stress) | 14 | 10 | 1 | 93% |
| DAS (Cognitive Distortion) | 128 | 94 | 78 | 39% |
| SUDS (0-10) | 6 | 4 | 2 | 67% |
Qualitative Feedback: Upon completion of treatment, the client reported: 'I now realise that I have choices I didn't see before. When stress comes up at work, I can feel myself pausing and choosing how to respond rather than automatically reaching for a cigarette. It's like I've rediscovered my own power to influence what happens in my life.'
The client successfully achieved smoking cessation and maintained abstinence throughout the follow-up period. The dramatic reduction in anxiety and stress scores reflected improved emotional regulation capabilities, whilst the decreased DAS score indicated successful cognitive restructuring away from external attribution patterns.
Introduction
Clinical data shows that 12.8% of Australians aged 18 years and over are daily smokers, representing a significant public health challenge requiring effective non-pharmacological interventions. In the region of Crows Nest, New South Wales, this prevalence translates to substantial numbers of individuals seeking evidence-based treatment approaches for nicotine dependence. Recent epidemiological analysis reveals that whilst daily smoking rates have declined from 24.3% in 1995 to 12.8% in 2020-21, the psychological complexity underlying smoking behaviour continues to present therapeutic challenges.
Research demonstrates that 73% of smokers identify stress as their primary trigger, with social situations (45%), alcohol consumption (38%), and habitual associations (52%) comprising additional maintaining factors. These patterns suggest that successful cessation requires addressing underlying psychological frameworks rather than focusing solely on behavioural modification. The interconnection between attributional patterns, perceived control, and smoking behaviour indicates that interventions targeting cognitive restructuring may prove particularly efficacious.
The aim of this case study is to demonstrate the efficacy of clinical hypnotherapy in shifting the client's external locus of control pattern and reducing symptom severity through targeted skill building interventions.
Case Presentation
Demographics: The client was a 29-year-old female travel agent residing in Crows Nest, New South Wales, who sought hypnotherapeutic intervention for smoking cessation.
Presenting Complaint: The client expressed her concern: 'I feel completely powerless around cigarettes. It's like something outside of me controls whether I smoke or not. When stress hits at work or I'm around certain people, I just automatically reach for a cigarette. I've tried willpower, but it feels like the addiction is stronger than I am.'
Psychometric Baseline: Initial assessment revealed significantly elevated scores across multiple measures:
- DASS-21 Anxiety: 15 (indicates severe anxiety symptoms)
- DASS-21 Stress: 14 (indicates severe stress symptoms)
- DAS (Dysfunctional Attitude Scale): 128 (indicates markedly elevated dysfunctional cognitive patterns)
- SUDS: 6 (0-10 scale, indicates high subjective distress)
Clinical Formulation: The client presented with a pronounced External Locus of Control pattern, consistently attributing her smoking behaviour to external circumstances beyond her influence. This was coupled with a Global Attributional Style, whereby smoking cessation failures were generalised across all areas of self-efficacy. The elevated DAS score of 128 supported this formulation, indicating pervasive dysfunctional attitudes about personal agency and control. Additionally, the client demonstrated Magnifying perceptual patterns, amplifying the perceived power of external triggers whilst diminishing her own capacity for behavioural modification. These cognitive distortions created a self-perpetuating cycle wherein perceived powerlessness reinforced smoking behaviour, which in turn validated beliefs about external control.
Discussion
The exceptional outcomes demonstrated in this case study illustrate the efficacy of targeted cognitive restructuring through hypnotic skill building interventions. The 93% reduction in both anxiety and stress scores suggests that addressing underlying attributional patterns can produce profound symptomatic improvement. From a neuroplasticity perspective, the daily audio reinforcement protocol facilitated the consolidation of new neural pathways associated with internal control and self-efficacy.
The substantial improvement in DAS scores (from 128 to 78, representing a 39% reduction) provides quantitative evidence of cognitive restructuring. This shift from external to internal locus of control created the foundation for sustained behavioural change, as evidenced by successful smoking cessation. The Polyvagal Theory framework suggests that by reducing perceived external threat through increased sense of control, the client's nervous system shifted from chronic sympathetic arousal to ventral vagal safety, facilitating access to higher-order cognitive functions necessary for behavioural modification.
These findings align with established research demonstrating hypnotherapy's efficacy in smoking cessation. Green and Lynn (2000, International Journal of Clinical and Experimental Hypnosis) reported success rates of 80-85% for hypnotic interventions, whilst Elkins and Rajab (2004, International Journal of Clinical and Experimental Hypnosis) confirmed significant improvements following brief hypnotic protocols. Carmody et al. (2008, Nicotine & Tobacco Research) further validated the durability of hypnotherapy outcomes in smoking cessation contexts.
The integration of skill building with cognitive restructuring techniques appears particularly potent for clients presenting with external control patterns. By systematically developing internal resources whilst simultaneously challenging dysfunctional attributions, this approach addresses both the cognitive and behavioural dimensions of smoking dependence.
Conclusion
This case study demonstrates that targeted hypnotherapeutic intervention focusing on locus of control restructuring can produce remarkable outcomes in smoking cessation contexts. The combination of skill building hypnotic devices with systematic cognitive pattern modification offers a robust framework for addressing the psychological foundations of addictive behaviours. The quantified improvements across multiple domains suggest that this approach addresses not merely the presenting symptom but the underlying cognitive architecture that maintains problematic patterns. These findings contribute to the growing evidence base supporting hypnotherapy as a first-line intervention for smoking cessation, particularly for clients presenting with external attribution patterns and elevated stress responses.
The author is a clinical hypnotherapist, not a medical doctor. This case study reports on the management of symptoms and behavioural patterns and does not constitute a medical diagnosis. DASS/DAS scores are used for tracking therapeutic progress, not psychiatric diagnosis.
Clinically reviewed by
Rebecca SmithPSYCH-K® Centre International Facilitator
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