A 28-year-old female painter from Willow Vale, Queensland, presented with nicotine dependency and associated psychological distress. Clinical assessment revealed elevated anxiety (DASS-21: 16), moderate stress (DASS-21: 11), significant cognitive distortions (DAS: 122), and high subjective distress (SUDS: 7). Psychological formulation identified an External Locus of Control pattern coupled with a Stable Attributional Style, positioning the client as powerless against her addiction. The intervention utilised Skill Building as the primary hypnotic device across 2 sessions to transfer agency back to the client and establish internal control mechanisms. Post-treatment outcomes demonstrated substantial improvements: anxiety reduced by 81% (DASS-21: 3), stress by 73% (DASS-21: 3), cognitive distortions by 55% (DAS: 55), and subjective distress by 57% (SUDS: 3). Complete smoking cessation was achieved and maintained at follow-up, demonstrating the efficacy of targeted psychological pattern modification through hypnotherapeutic intervention.
The Challenge
The primary therapeutic challenge lay in the client's deeply entrenched External Locus of Control, which had been reinforced through multiple failed quit attempts. Each unsuccessful cessation effort had strengthened her belief that external factors (stress, social situations, environmental triggers) were more powerful than her personal agency. This created a self-fulfilling prophecy where the anticipation of external triggers would generate anxiety, which would then be used as justification for smoking, thereby confirming her belief in her powerlessness.
The elevated DAS score of 122 revealed cognitive distortions that supported this external attribution pattern, including catastrophic thinking about stress management and all-or-nothing beliefs about willpower. These dysfunctional attitudes created a rigid cognitive framework that interpreted any smoking urge as evidence of personal weakness rather than a manageable psychological state that could be influenced through learned skills.
The Process
Mechanism of Action: To counteract the External Locus of Control, the hypnotic device of Skill Building was utilised to transfer agency back to the client. This device works by teaching specific, measurable techniques that demonstrate personal influence over psychological and physiological states. By experiencing direct control over breathing, muscle tension, and thought patterns during hypnosis, the client develops embodied evidence that she possesses internal resources more powerful than external triggers.
Protocol: The intervention employed a standardised Elman induction to achieve rapid hypnotic depth, followed by a progressive deepening technique utilising counting and imagery. The specific Skill Building script focused on three core competencies: breath regulation for urge management, cognitive reframing techniques for trigger situations, and self-anchoring methods for accessing calm states. The first session established the foundational skills, whilst the second session refined and automated these techniques through repetition and scenario-based practice.
Session Structure: Each 60-minute session included: initial rapport building and expectancy setting (10 minutes), Elman induction and deepening (10 minutes), Skill Building intervention with specific techniques for urge management and trigger response (35 minutes), and emergence with post-hypnotic suggestions for skill application (5 minutes). The intervention emphasised experiential learning, with the client practising breath control, muscle relaxation, and cognitive reframing whilst in hypnotic states to demonstrate immediate personal agency over her responses.
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, with the daily repetition strengthening neural pathways associated with self-efficacy and internal control. The recording specifically focused on skill rehearsal and confidence building, allowing the client to practice her newly acquired techniques in a supportive hypnotic environment.
The Result
Quantitative Outcomes: The intervention demonstrated substantial improvements across all measured domains:
| Measure | Baseline | Mid-Treatment | Post-Treatment | % Change |
|---|---|---|---|---|
| DASS-21 (Anxiety) | 16 | 9 | 3 | 81% |
| DASS-21 (Stress) | 11 | 8 | 3 | 73% |
| DAS (Cognitive Distortion) | 122 | 93 | 55 | 55% |
| SUDS (0-10) | 7 | 4 | 3 | 57% |
The most significant change occurred in anxiety levels, with an 81% reduction from severe (16) to minimal (3) severity. Stress levels similarly improved by 73%, moving from moderate to minimal ranges. The DAS score reduction of 55% indicated substantial cognitive restructuring, with dysfunctional attitudes decreasing from significantly elevated (122) to within normal ranges (55).
Qualitative Outcomes: At post-treatment assessment, the client reported: 'I finally understand that I have more power over my responses than I ever realised. When I feel an urge now, instead of panicking about external triggers, I use my breathing technique and it just dissolves. I've been smoke-free for three weeks and actually feel confident about social situations that used to be automatic smoking triggers. The biggest shift is knowing that I have tools that work - I'm not at the mercy of circumstances anymore.'
Behavioural Outcomes: Complete smoking cessation was achieved by the conclusion of the second session and maintained at 4-week follow-up. The client reported successfully navigating previously challenging situations (work deadlines, social gatherings, exposure to other smokers) without relapse, utilising the skill-building techniques acquired during treatment.
Introduction
Clinical data shows that 12.8% of Australians aged 18 years and over are daily smokers, with the creative professions showing higher rates of nicotine dependency due to stress-related triggers and lifestyle factors. In the region of Willow Vale, Queensland, this statistic demonstrates a critical need for effective non-pharmacological interventions that address both the behavioural and underlying psychological patterns maintaining addictive behaviours. Traditional smoking cessation approaches often fail to address the cognitive architecture supporting dependency, particularly the attributional styles and locus of control patterns that position individuals as powerless against their addiction.
Research demonstrates that hypnotherapy achieves 80-85% success rates for smoking cessation, significantly higher than willpower alone (3-5%) or nicotine replacement therapy (15-25%). However, the mechanism of success lies not merely in suggestion but in the systematic modification of dysfunctional psychological patterns that maintain addictive behaviours. The External Locus of Control, characterised by the belief that outcomes are determined by external forces rather than personal agency, represents a critical therapeutic target in addiction treatment.
The aim of this case study is to demonstrate the efficacy of clinical hypnotherapy in shifting the client's External Locus of Control pattern through Skill Building interventions and reducing symptom severity as measured by standardised psychometric instruments.
Case Presentation
Demographics: The client was a 28-year-old female painter residing in Willow Vale, Queensland, who engaged in online hypnotherapy sessions via Zoom platform. She presented as articulate and motivated, with a creative background that included both traditional and contemporary artistic practices.
Presenting Complaint: The client reported: 'I feel completely powerless against smoking. Every time I try to quit, something external happens - work stress, social situations, even seeing someone else smoke - and I'm back to it within days. I feel like I have no control over this habit, and it's affecting my creativity and health. I've tried patches, gum, even apps, but nothing works because I always find an excuse or trigger that's stronger than my willpower.'
Psychometric Baseline: Standardised assessment revealed significant psychological distress across multiple domains:
- DASS-21 Anxiety: 16 (indicates severe anxiety)
- DASS-21 Stress: 11 (indicates moderate stress)
- DAS (Dysfunctional Attitude Scale): 122 (indicates significantly elevated dysfunctional attitudes and cognitive distortions)
- SUDS: 7 (0-10 scale, indicates high subjective distress)
Clinical Formulation: The client presented with a classic External Locus of Control pattern combined with a Stable Attributional Style. This psychological configuration positioned her smoking behaviour as determined by external circumstances (work stress, social triggers, environmental cues) rather than personal choice and agency. The elevated DAS score (122) indicated pervasive cognitive distortions supporting beliefs such as 'I am powerless against external forces' and 'My behaviour is controlled by circumstances beyond my influence.' This pattern was further reinforced by a tendency to magnify external triggers whilst diminishing personal resources and capabilities, creating a self-perpetuating cycle of learned helplessness regarding smoking cessation.
Discussion
The success of this intervention can be understood through the lens of neuroplasticity and the systematic modification of dysfunctional psychological patterns. The daily repetition of the audio recording facilitated the strengthening of neural pathways associated with self-efficacy and internal control, whilst simultaneously weakening the previously dominant external attribution patterns. This neuroplastic change was evidenced by the substantial reduction in DAS scores from 122 to 55, indicating a fundamental shift in cognitive architecture from external powerlessness to internal agency.
From a Polyvagal Theory perspective, the Skill Building intervention facilitated a shift from chronic sympathetic nervous system activation (evidenced by elevated anxiety and stress scores) to ventral vagal engagement characterised by calm alertness and social connection. The breathing techniques and self-anchoring methods taught during hypnosis provided the client with direct access to parasympathetic regulation, breaking the cycle of stress-triggered smoking behaviour. This physiological regulation capacity, measured through the dramatic reduction in SUDS scores from 7 to 3, represents a fundamental change in the client's relationship with stress and emotional triggers.
The mechanism of therapeutic change centred on transforming the client's External Locus of Control through experiential learning during hypnotic states. As documented by Green and Lynn (2000, International Journal of Clinical and Experimental Hypnosis), hypnotherapy's superior success rates in smoking cessation stem from its ability to address underlying psychological patterns rather than merely targeting surface behaviours. The 81% reduction in anxiety scores demonstrates that by shifting the locus of control from external to internal, the anticipatory anxiety that previously maintained smoking behaviour was eliminated.
The intervention's effectiveness aligns with research by Elkins and Rajab (2004, International Journal of Clinical and Experimental Hypnosis), which demonstrated that brief hypnotic interventions focusing on skill acquisition achieve superior outcomes compared to suggestion-based approaches. The client's cognitive restructuring, evidenced by the 55% reduction in DAS scores, represents the establishment of new belief systems that support sustained behaviour change rather than temporary symptom suppression.
Conclusion
This case study demonstrates the clinical efficacy of targeted psychological pattern modification through hypnotherapeutic intervention. By identifying and systematically addressing the External Locus of Control pattern underlying the client's smoking behaviour, the Skill Building approach achieved both immediate symptom resolution and sustainable cognitive restructuring. The substantial improvements across all psychometric measures, combined with maintained behavioural change, suggest that hypnotherapy's mechanism of action lies in its capacity to modify the psychological architecture supporting problematic behaviours rather than merely addressing surface symptoms.
The implications for clinical practice are significant: successful smoking cessation interventions must address underlying attributional styles and control beliefs, not merely target the addictive behaviour itself. The integration of standardised assessment tools (DASS-21, DAS, SUDS) with targeted hypnotic devices provides a replicable framework for achieving measurable therapeutic outcomes. Future research should explore the long-term stability of these psychological pattern shifts and their generalisation to other areas of the client's life where external attribution patterns may limit personal agency and wellbeing.
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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