Hypnosis
Jeanne Hernandez
History of Hypnosis in Pain and Symptom Control
Hypnosis is a word derived from the Greek word meaning “sleep.” The fairly ancient practice was used by the Druids, the Celts, and by the Egyptians who frequented “sleeping temples” for relaxation and healing. In the 1770s, the Austrian physician Franz Friedrich Anton Mesmer (1734-1815) was interested in the effect of physical energy and magnetism on the body and spirit. He placed his patients in a tub of iron filings and with wide sweeps of his arm made “passes” up and down the patients’ bodies. The success of the practice, termed mesmerism, was attributed to animal magnetism, whereas the benefits were probably due to the hypnotic effect of his arm-waving ritual. In the 1830s, practical uses of mesmerism were discussed by Oliver in the United States and by the French Academy of Medicine. James Braid (1795-1860) in Scotland termed the word hypnosis in 1843, thinking it to be a stage of sleep that influenced the nervous system and distinguishing it from the state of mental concentration. Braid concluded that the relaxing suggestions diverted the patients away from critical thinking and led them into trance. Pavlov in the early 1900s also viewed hypnosis as an incomplete sleep state that allowed patients to mentally separate off from what was going on around them.
John Esdaile (1808-1859)1 began using trance inductions with surgery patients in 1845 in India, where there were not anesthetics available; he found the hypnotized patients to have increased resistance to infection, greater comfort, and quicker recovery times. In Europe, the School of Hypnotic Study was being formed in Nancy, France, where the view was that suggestion led to hypnotic trance states that were quite normal phenomena. Neurologist Jean-Martin Charcot (1825-1893) also noted that hysteria was effectively treated with hypnotism; although he brought hypnotism into favorable light, he viewed it as a part of the hysteria process and not a normal healthy phenomena. However, there does appear to be a high proportion of patients with hysteria-related psychopathology who are highly hypnotizable.2
Pierre Janet (1849-1947) saw hypnosis as dissociation or a split away from cognitive consciousness, which was sometimes normal and healthy and other times related to dissociative states or multiple personalities. Freud in the late 1800s became interested in accessing repressed memories through hypnosis, recognizing it as a pathway to the unconscious mind. However, he was not a good hypnotist and therefore abandoned it; in doing so, he led others away as well. However, he did continue his interest in the hypnotic properties of dreams and free associations.
In the mid-1840s, the introduction of chloroform and ether into surgical practice was another reason for the apparent hiatus in the use and study of hypnosis in medicine. In the 1950s, its use in understanding the workings of the mind and its application to psychotherapy began to pick back up. In the United States, psychologist Clark Hull3 documented its use for anesthesia, posthypnotic amnesia, and pain relief. Milton Erickson conducted many of these experiments and went on to study the mechanisms of trance practices brought to him by Jay Haley and Margaret Meade. Erickson had an exquisite understanding of the mechanisms of the unconscious mind, and his personal understanding of its effectiveness for reducing physical pain, through his personal use of self-hypnosis, left him well-poised to research, practice, and teach hypnosis for symptom control and pain management. The American Society of Clinical Hypnosis (ASCH) was founded in 1957 as a spinoff from the Society for Clinical and Experimental Hypnosis (SCEH), founded in 1949. Hypnosis was endorsed by both the American Psychological Association (APA) and the American Medical Association (AMA) in the late 1950s. The British Medical Association in 1958 endorsed its use as an anesthetic in certain surgical situations.
In a way, there is a great difference between the linear and precise thinking of modern medicine and the spiritual and imagination-rich mosaic thinking of the hypnotherapist; yet, in this chapter, they come together in the discussion of pain as a psychological event and of the role of expectancy and hope in pain management and general wellness. The early researchers and practitioners identified that the spiritual and magical element of hypnosis were somehow related to positive expectation as noted in the early practices of Mesmer with his magnets, Freud with his dream work, and Erickson with his positive mind-set of hope and respect for the patients. These men all identified the role of the unconscious mind in psychosomatic symptom formation and, in doing so, let down the Cartesian wall between the mind and the body. They also recognized that the highly hypnotizable person may be more likely to develop psychosomatic symptoms but also may be more likely to benefit from hypnotic treatment. Upcoming sections in this chapter discuss pain as a psychological event that is moderately plastic and open to suggestion. Research shows that the triggered memory of pain and the expectation of future pain can be as painful as injury-induced pain. In 1970s, there began to be an interest and upsurge in multidisciplinary pain management. Fordyce,4 Bonica, and many others were at the forefront of the physicians, scholars, and researchers who moved the field forward in the 1980s. Although the ideal was for patients to be holistically treated by all disciplines together, psychological management is still usually done separate from medical treatment. Turk5 reviewed outcome data for patients receiving care from interdisciplinary chronic pain and rehabilitation programs (ICPRPs) compared with other care. He found that pain reduction and activity level of patients in ICPRPs was as good as or better than patients receiving standard medical treatment, and that iatrogenic complications, medication use, and health care utilization was less, with more patients returning to work. Other studies demonstrate that the outcomes of psychological treatment for chronic pain compare favorably to more invasive measures and to narcotic use. A systematic Cochrane review concluded that cognitive interventions combined with exercise are recommended for chronic low back pain,6 and this is discussed in detail in Chapter 73. There is also strong evidence that intensive multidisciplinary biopsychosocial rehabilitation improves function when compared with inpatient or outpatient nonmultidisciplinary treatments as summarized in Chapter 90.7 A study reconfirms the cost-effectiveness of perioperative hypnosis when used for patients in their hospitals.8 Given the evidence, we may expect that less invasive and less costly treatments may become the preferred options of patients, their providers, and insurance companies. An extensive review of the research9 found hypnosis to meet the APA’s criteria as an effective pain treatment for pain and superior to medication.
In the remainder of this chapter, I will explain hypnotic trance as a state of mind and describe its use in behavioral medicine in general. I will then discuss current understanding of how hypnosis works at the unconscious level in general and for pain relief, citing literature on brain mechanisms of pain. I will outline research suggesting hypnosis application to specific types and locations of pain and some commonly used hypnotic techniques to treat them. Even though some studies discuss symptom relief (tension, twitches, allergies, anxiety, rashes) as separate from pain itself, usually symptom relief leads to pain relief down the road. This chapter describes both traditional and newer practices of pain hypnosis and provides information on certification and training. I conclude with a discussion on chronic pain, where the emotional suffering related to pain, is a notable dynamic.
Hypnosis by Definition
Hypnosis is a process of bypassing the critical thinking cognitive mind to access unconscious processes. Without the critical thinking filters, the hypnotized person may be more suggestible and more easily influenced by the hypnotist. During hypnotic trance, a person can focus intently on just one aspect of an experience or dissociate from the experience to the point of losing track of his body and his whereabouts. Succinctly, hypnosis is simply a programmed entrance into “trance,” which is itself a perfectly normal state that we engage in whenever we are totally absorbed in a task or experience and are not reviewing the characteristics of our experience. Formally, hypnosis is “a social interaction in which one person, designated the subject, responds to suggestions offered by another person, designated the hypnotist, for experiences involving alterations in perception, memory, and voluntary action,”10 hopefully for the sake of some change the patient desires. Professionals should be thoroughly trained in hypnosis before practicing it and should work only in the areas of their professional expertise. ASCH and SCEH train and certify professionals in medical hypnosis; certification requires a professional degree in health or mental health and specific training that includes the ethical uses of hypnosis.
CONSCIOUS, UNCONSCIOUS, AND CONTENT OF CONSCIOUSNESS
A brief review of the conscious and unconscious minds will serve as the groundwork for discussing the mechanisms of hypnosis itself as well as the psychosomatic process of interpreting and feeling an emotional experience as physical pain.
Consciousness: what you are oriented toward in the present
Content of consciousness (i.e., perceptions and specific thoughts): what is on your mind and in your thoughts, including what is “on the back burner”
Selective consciousness: what you choose to have in the front rather than in the back or periphery of your mind
Unconscious
Long-term memory: which you may or may not access when necessary
Short-term memory: which has happened recently
Automatic functioning that usually but not always bypasses your conscious mind. This is sometimes called the primary process or body language that demonstrates when you are angry, happy, or frightened. It also includes behavior such as scratching an itch or catching yourself before you fall.
Programmed physiology that you have little or no access to in normal thinking state, such as your heart beating, breathing, allergic responses, healing rate, etc.
Deeper processes such as the essential self, (the “essence” of you or your sense of who you are at the core). Other parts of the self are the immune system and the neurologic map or the body.
We might say that the conscious mind includes awareness and cognition, and the unconscious mind includes everything else, including your physical self. Cognition is a tool to help with survival and with the expression of your sense of yourself; it is a small part of the whole self-constellation in a somewhat figure-ground relationship. The unconscious mind is adaptive and capable of profound change, potentially with both positive and negative outcomes.
When you are “associated” to a situation, you see it through your own eyes, and you are fully present to it; an example of this is the child who is involved in a task but is not monitoring himself and who needs an adult to oversee his behavior. In reflective thinking, you are in both the conscious and unconscious minds and processes at once, contemplating an idea or situation by looking into your unconscious mind to find new perspectives for viewing or approaching it. The conscious and unconscious processes can operate autonomous of one another, in the condition of dissociation (dis-“associated”), occurring when ideas are split off from the normal (associated) experience and when, to some extent, you are not paying attention. When dissociated, you may take a global experience of the situation and break it down into parts, amplifying one part while diminishing concentration on the other part—when, for instance, you notice one aspect of the situation and no longer notice others. You may see the situation and also see yourself in the situation, or you may see the situation differently. This can occur during trauma or during hypnosis; for instance, during surgery, you can dissociate from pain by imagining yourself at the beach and seeing the beach at the same time or dissociate from a body part during surgery and believe it to be having surgery or recuperating across the room. In an internally directed trance state, the patient may shut off pain and influence healing, immune functions, heart rate, blood flow, and autoimmune responses not commonly accessed in normal consciousness. Again, hypnosis is merely the programmed entrance into trance or dissociation at some level, and hypnotherapy is the programmed entrance into trance for therapeutic purposes.
Actually, the hypnotist or hypnotherapist is merely guiding the patient to self-hypnosis. Unless the state is induced with hypnotic medications or other psychoactive substances, the patient is the one to suspend vigilance, and his ability to do so is likely to depend on (1) the relationship that he has with the hypnotist, (2) the skill of the hypnotist inducing the trance, (3) the safety of the situation and environment, (4) the patient’s level of hypnotizability, (5) the patient’s expectancy that he will receive benefit and relief, (6) the patient’s need for the trance—pain itself can be a trance state to tap into, and (7) the patient’s past experience with trance states —ranging from dissociative disorders leading from experienced trauma to meditation and past hypnosis training.
Complementarity, the quantum physics concept of relativity, helps explain the use of hypnosis for pain control. Basically, it is impossible to be wholly in one state (fully present and focused in one perspective, such as the dissociative state) and keep another state (e.g., being in pain) fully in mind at the same time; the difference is being in the moment versus thinking about the moment. When you are fully locked into pain, you cannot get perspective to solve the pain problem; you need to dissociate from the pain somewhat to get a better perspective on it. Once you dissociate from it, you can no longer feel it. The hypnotherapist facilitates the process. Other examples of split consciousness or going back and forth between the conscious and the unconscious minds are the rewriting the endings of dreams (lucid dreaming), remembering that the stove is on while watching television (split concentration), and accessing memories—all of which are normal functioning but also, in a way, related to hypnosis. These principles of trance and hypnotic states are important to understanding hypnotic pain management. The more access to the unconscious mind
one can gain by self or guided hypnosis, to imagine or create another way of being or feeling, the more control of pain and physiologic symptoms one may have.
one can gain by self or guided hypnosis, to imagine or create another way of being or feeling, the more control of pain and physiologic symptoms one may have.
Central Mechanisms
CENTRAL MECHANISMS OF HYPNOSIS
Hypnosis has been viewed as magical, energy related, sleep related (Braid and Pavlov), psychosomatic, pathologic (Charcot), dissociative,11,12,13 and the consequence of normal suggestibility14—all of which are partly true. Recent brain research using functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) scans shed more light on the process. In general, the studies show that there are many brain areas involved in the hypnotic process, including simultaneous increased activities in some areas and selective shutting down of others. We can conclude that high- and low-hypnotizable people show different brain response patterns to hypnotic analgesic suggestions. However, there is no specific area of the brain that controls pain.15 Some studies look at performance on certain tasks (learning, verbal, auditory) and in certain situations (pain, for example) before and during hypnosis, whereas others compare high- and low-hypnotizable patients or subjects.
Clinicians as far back as Freud have known that some people are more suggestible or susceptible to hypnosis than others. About 15% of people are highly suggestible, 65% are moderately, and 20% are not very suggestible.12 Although hypnotizability is a fairly stable trait and not related to intelligence, people can learn or improve on their ability to develop or maintain trances, use self-hypnosis, and relax vigilance. Furthermore, hypnotizability is somewhat variable within individuals depending on factors such as the situation, the hypnotist’s skill, the patient’s motivation level and expectancies, the relevance of the induction and trance to the patient, and patient’s physical and psychological state. Experienced hypnotists help patients lower their vigilance by addressing all of the aforementioned factors and, even more important, by sensing and identifying the way their patients unconsciously process information in order to help them be maximally at ease (see Haley16 and Bandler and Grinder17 or an introductory manual on hypnosis for examples of hypnotic inductions).
HIGH AND LOW HYPNOTIZABILITY
Over the last two decades, Gruzelier18 has been involved in numerous experiments studying high- and low-hypnotizable patient’s brain responses to experimental tasks during pain episodes and other situations. His studies seemed to show that in a hypnotic state, subjects can selectively ignore what is in their perceptual field while still knowing what is there. This is important regarding pain, in that often the patient’s focus is as much on misery and helplessness as it is on his physiology; the clinician may not be able to change the physical condition, but he may help the patient selectively disregard the pain and the suffering. Gruzelier18 found that in general, highly hypnotizable subjects exhibit more neurophysiologic and cognitive flexibility (see also Evans19), which include “superior abilities in absorption, creativity, dissociation, attention, and vividness of imagery; these are all well-known correlates of hypnotizability.” Regarding hemisphere involvement, highly hypnotizable persons (highs) under hypnosis demonstrate more right hemispheric frontolimbic influence. Furthermore, there is more neuronal flexibility going from the right to left and from the left to right hemispheres, and, according to Gruzelier,18 “in stimulus repetitions, highs showed a shift from an initial right-sided preference, in line with the right hemisphere’s role in global orienting, to a left hemisphere preference, in line with the leftsided involvement in the local orienting process,” indicating absorption. One study found greater informational exchange in the prefrontal areas of highs during hypnosis.20 Highs were better able to inhibit pain from their conscious awareness. fMRIs showed them to have a significantly larger rostrum area, the corpus callosum area involved in transferring problemsolving information between the left and the right hemispheres. Gruzelier emphasized another difference between “highs” and persons with low hypnotizability (lows) during an auditory attention task: Prehypnosis, highs increased event-related potential (ERP) N100 activity (engaging frontal attentional circuits), whereas lows had little activity, indicating distraction; under hypnosis, highs had little activity, indicating disengagement of the frontal process or distraction, whereas lows’ activity progressively increased.21
Other studies involving mental tasks showed increased activity in the anterior cingulate under hypnosis in highs more than in lows (indicating that they were monitoring the task) and a decrease in the inferior frontal gyrus activity (indicating that they were disengaging from executive functioning).18 In other words, highs under hypnosis are relatively better at actively not paying attention to what they still know is in the field; they seem to let go of attending it. This seems to represent frontolimbic inhibition on the left side and a shift to the right brain, engaging the patients’ ability to feel or imagine things different than they were before. Hypnosis involves activation of the hippocampus and inhibition of the amygdala activity at the same time.22 A fractal analysis of electroencephalography (EEG) in patients under hypnosis showed dissociation of centralized activity and a loss of the normal patterns of integrated physiologic responses, which results in a trance state.23
CENTRAL MECHANISMS OF HYPNOTIC ANALGESIA
Price et al.24 provided a statistical path analysis to show four necessary elements of hypnotic analgesia—relaxation; absorption; disorientation from time, space, or sense of self; and automaticity—and their relationship order. Automaticity is the condition in which the suggestion bypasses cognition and leads directly to the sensation or experience, such that the suggestion of sinking into a warm bathtub will allow you to relax your back muscles and smile, without having to think about it or consciously relax or lower your shoulders. Studies show that imagining heat actually increases blood flow that relaxes muscles, thereby validating automaticity. The principle is similar to direct suggestion and to suggestion through expectancy and placebo. As well, those who exhibit more θ brain waves, which would lead to easier visualization and creativity and relaxation, prior to introduction of hypnotic analgesia, get better pain relief.25
Some suggest that hypnotic analgesia works by activating endogenous pain inhibitory systems that descend to the spinal cord, where it prevents transmission to the brain of pain coming from nociception. One study evoked experimental pain in subjects by stimulating the sural nerve, causing the nociceptive flexion reflex (NFR).26 Hypnotic suggestion could both increase and decrease the NFR, leading the researchers to conclude that their hypnotic suggestion actually controlled the response at the spinal level by activating descending antinociceptive mechanisms. However, this does not appear to stem from the opioid system alone,27,28 in that the administration of naloxone, an opioid antagonist, does not reverse hypnotic analgesia. It would seem, then, that there are nonopiate cortical fugal or brain-to-spinal-cord descending control mechanisms.
The relationship between pain and hypnotic or dissociative faculties of the brain is made clearer in recent studies of complex regional pain syndrome (CRPS), which begins with excruciating pain and can progress to include dramatic physiologic changes and neglect or dissociation from the painful limb. According to studies, within moments of an injury or absence of sensory input, there is a reorganization of the somatosensory cortex representation of the injured limb that leads the patient to behaviorally isolate or “favor” the limb. fMRI studies show
that the degree of change in the somatosensory cortex is directly related to the degree of perceived pain.29,30 Even when there is painless stimulation in the CRPS patient’s uninjured counterpart limb, there is pain-related activation all through the brain, including cerebral, motor, parietal, bilateral S2, and frontal lobe and the anterior and posterior potion of the cingulate cortex (aACC and pACC).31 When the CRPS pain lessens, however, both the cortical reorganization and impaired tactile sensation return to normal.32,33 Wobst34 summarizes the PET, fMRI, and evoked potential studies on pain, concluding that the ACC, insular, frontal cortices, amygdala, S1 and S2, and the lateral thalamus are all involved in pain and how the body processes the pain in regard to location and duration. The studies show that the affective (cognitive and evaluative) components of pain are processed in the medial thalamus and progress back to the ACC (also see Derbyshire et al.,35 Vogt et al.,36 Vogt et al.,37 and Peyron et al.38).
that the degree of change in the somatosensory cortex is directly related to the degree of perceived pain.29,30 Even when there is painless stimulation in the CRPS patient’s uninjured counterpart limb, there is pain-related activation all through the brain, including cerebral, motor, parietal, bilateral S2, and frontal lobe and the anterior and posterior potion of the cingulate cortex (aACC and pACC).31 When the CRPS pain lessens, however, both the cortical reorganization and impaired tactile sensation return to normal.32,33 Wobst34 summarizes the PET, fMRI, and evoked potential studies on pain, concluding that the ACC, insular, frontal cortices, amygdala, S1 and S2, and the lateral thalamus are all involved in pain and how the body processes the pain in regard to location and duration. The studies show that the affective (cognitive and evaluative) components of pain are processed in the medial thalamus and progress back to the ACC (also see Derbyshire et al.,35 Vogt et al.,36 Vogt et al.,37 and Peyron et al.38).
At the same time, other areas of the brain work to calm and heal. Following awareness of physical or emotional pain, the right ventral prefrontal cortex is involved with soothing responses that are triggered by hypnotic therapeutic suggestions and messages of comfort or healing, which proceed to help the right parietal lobe to reorganize and to perceive the body intact and comfortable (see section on CRPS and phantom limb pain).
In a hypnosis study of experimentally induced pain, highand low-hypnotizable patients responded differently.39 Under hypnosis, with the low-hypnotizable patients, as the pain ratings increased, so did frontal γ oscillations; however, with high-hypnotizable patients, as the pain ratings increased, the γ oscillations did not increase. The γ frequencies were noted primarily in the bilateral anterior cingulum (within the limbic system), which supports the understanding of pain being tied in with a complex of emotional responses. The midcingulate cortex may modulate and influence sensory, affective, cognitive, and behavioral aspects of nociception at least in the hypnotic state.40 Raij et al.41 used fMRI to compare brain mechanistic responses to noxious stimulation perceptions versus hypnotically hallucinated pain; they found that both real and imagined pain produced similar brain responses, although perception of hallucinated pain was less than the actual induced pain. In both cases, there was activity in the rostral and perigenual ACC and in the pericingulate regions of the medial prefrontal cortex. They conclude that the medial prefrontal cortex is involved in monitoring real and hallucinated pain, which then influences how noxious stimuli are experienced and processed. A study exposed subjects to pain (1) in the waking state, (2) with hypnotic relaxation, or (3) with hypnosis suggesting depersonalization (out of body experiences).42 All the subjects showed somatosensory, insular, and cerebral activation with pain; however, the depersonalization group showed less activation in the contralateral somatosensory, parietal, and prefrontal cortex; putamen; and ipsilateral amygdala. De Pascalis et al.43 have shown somatosensory event-related increase during pain, followed by a reduction when subjects were administered hypnotic analgesia. De Pascalis44 found that highs experiencing hypnotic analgesia showed smaller total, δ and β amplitudes in the right hemisphere; they experienced more θ activity in the left hemisphere during pain and more in the right hemisphere with hypnotic analgesia, decreasing both the sympathetic activity and the overall experience of pain. Meier et al.45 showed that hypnotic hypalgesia decreased subjects’ experimental pain; when suggestions about increasing pain were made, somatosensory evoked potentials, auditory evoked potentials, and EEGs remained unchanged from the hypalgesic state, indicating that the physical response to pain and its affective component can indeed be separated. Thus, hypnotizability level certainly appears to impact on the ultimate outcome of hypnosis in general as well as for pain management.
Pain as a Plastic Experience
Why is hypnosis particularly appropriate for acute and chronic pain management? How can it be that Jensen and Barber46 showed hypnotic analgesia to be more effective than other analgesics, including morphine, for reducing pain? We can begin to answer this by viewing pain as a perception or conclusion derived from a complex interweaving of a real physiologic signal and psychological responses based on expectations and memories of similar past experiences; the perception itself generates feedback to the body. Physical injury and disease cannot fully predict the amount of perceived pain a patient experiences; other determining factors are anxiety and trauma, context of the injury, depression, expectation, social support, and numerous other personality factors and cognitive styles. Interestingly, as is discussed elsewhere in this chapter, those who are highly hypnotizable are often the most likely to experience psychosomatic symptoms of the overlap of psychological interpretation with nociception, but they are also most likely to benefit by hypnosis and other well-applied psychological treatment.
Chapman47 describes nociception as an unconscious messaging about tissue damage through the nervous system, not to be equated with pain, which is the conscious awareness of that nociception. He defines pain as “a complex, compelling unpleasant bodily awareness normally associated with tissue trauma.” One purpose of pain is to engage the cognitive problem solving part of the brain in a plan to resolve the tissue damage. Biologically, pain is a cascade of neurotransmitter and biochemical responses to nociception, involving the hypothalamo-pituitaryadrenocortical (HPA) axis and the limbic system, and causing changes in blood pressure and blood sugar, serotonin and norepinephrine levels, effecting concentration, mood, behavior, healing, and sleep. Pain can interfere with psychological and physical well-being. When the nociception is not medically treated and stopped, the body’s unconscious responses to it can continue to cause permanent change and damage in other physiologic and psychological systems. At the same time, psychological stress and suffering can lead to the same cascade of physiologic stress responses and even lead to the construction of the sense of pain where no damage exists, which helps to explain why some events, physical or otherwise, cause pain to some people more than others.47
Hypnotherapy for pain aims to disengage pain from suffering and soothe both the physical and emotional stress. In the case of acute pain during surgery or procedures and after injury, the patient’s focus can be directed away from the experience, or the experience can be reframed as a beneficial and healing, and one not to be feared. Directing the patient’s focus away from the pain and back into himself is also a way to alleviate suffering, in that the pain would then be differentiated from the patient’s sense of self. Whereas pain is stressful, hypnotherapy is a relaxing and comforting experience that induces brain waves and levels of autonomic functioning that soothe the sympathetic nervous system and enhance healing and resistance to disease (see Gruzelier as mentioned in Liossi48) by changing the cognitive mind’s and body’s responses to nociception. Patients may simultaneously alleviate pain, promote healing, and learn to manage future pain better, all within the same cost-effective applications. For a detailed review of techniques according to medical problem, see Brown and Fromm49 and Hammond.50
Testing Hypnotizability
Hypnotizability level does appear to influence hypnotic pain management and the outcome of hypnosis in general, although there are ways for the experienced hypnotist to work with it successfully. Researchers may be more likely than clinicians
to use hypnotizability scales before engaging in subject or patient interactions. Some say that testing for hypnotizability may actually interfere with the research because testing itself is hypnotic training and subjects become more hypnotizable with practice.51 Nonetheless, when hypnotizability is very important, such as before attempting intraoperative hypnotic analgesia, it may be wise to use the Stanford Hypnotic Susceptibility Scale (SHSS), Form C,52 which is a fairly long (over an hour) and stringent test with a broad sampling of hypnotic suggestions. The Stanford Hypnotic Clinical Scale (SHCS)53 is a shorter version that gives scores for adults in 25 minutes; there are also versions for children. The Hypnotic Induction Profile (HIP)54 gives scores for adults and children in 5 to 15 minutes; it is based on a simple procedure (the eye roll) that goes beyond suggestibility to autonomic function. The Harvard Group Scale of Hypnotic Susceptibility55 may be read or administered by tape recording and should be used when there is a need to maintain a pool of subjects of varying suggestibility. The Waterloo-Stanford Group C (WSGC) scale of hypnotic susceptibility56 is a group version of the SHSS, Form C that may be best used for measuring suggestibility. The Hypnotic State Assessment Questionnaire (HSAQ)57 assesses patients’ hypnotic state at one point in time and may be used during clinical or experimental sessions. The Elkins Hypnotizability Scale58 takes 25.8 minutes, identifies four factors, and has good clinical and research correlation with the Stanford Hypnotic Susceptibility scale. Weitzenhoffer59 points out that suggestibility and hypnotizability are different and that some research has failed because subjects were not really hypnotized but rather merely followed suggestions. To be sure of hypnotizability, he recommends administering the Stanford Profile Scales of Hypnotic Susceptibility, Forms I and II,52 or at least one of them, and the next best assurance that the patient is in a hypnotic state would be to use a score of 10 as a cutoff on SHSS, Form C.
to use hypnotizability scales before engaging in subject or patient interactions. Some say that testing for hypnotizability may actually interfere with the research because testing itself is hypnotic training and subjects become more hypnotizable with practice.51 Nonetheless, when hypnotizability is very important, such as before attempting intraoperative hypnotic analgesia, it may be wise to use the Stanford Hypnotic Susceptibility Scale (SHSS), Form C,52 which is a fairly long (over an hour) and stringent test with a broad sampling of hypnotic suggestions. The Stanford Hypnotic Clinical Scale (SHCS)53 is a shorter version that gives scores for adults in 25 minutes; there are also versions for children. The Hypnotic Induction Profile (HIP)54 gives scores for adults and children in 5 to 15 minutes; it is based on a simple procedure (the eye roll) that goes beyond suggestibility to autonomic function. The Harvard Group Scale of Hypnotic Susceptibility55 may be read or administered by tape recording and should be used when there is a need to maintain a pool of subjects of varying suggestibility. The Waterloo-Stanford Group C (WSGC) scale of hypnotic susceptibility56 is a group version of the SHSS, Form C that may be best used for measuring suggestibility. The Hypnotic State Assessment Questionnaire (HSAQ)57 assesses patients’ hypnotic state at one point in time and may be used during clinical or experimental sessions. The Elkins Hypnotizability Scale58 takes 25.8 minutes, identifies four factors, and has good clinical and research correlation with the Stanford Hypnotic Susceptibility scale. Weitzenhoffer59 points out that suggestibility and hypnotizability are different and that some research has failed because subjects were not really hypnotized but rather merely followed suggestions. To be sure of hypnotizability, he recommends administering the Stanford Profile Scales of Hypnotic Susceptibility, Forms I and II,52 or at least one of them, and the next best assurance that the patient is in a hypnotic state would be to use a score of 10 as a cutoff on SHSS, Form C.
Lynn et al.60 outline various hypnotherapists’ views on assessing hypnotizability levels. Many (see Yapko51) object to the use of such tests, stating that they are obtrusive, undermine the therapeutic relationship, and do not adequately measure hypnotic capacity or take into consideration change in hypnotizability over time. Other options to using tests are to assess the patient’s success with the first induction61 or to use a conversational assessment of hypnotizability.62 A series of questions can give the clinician a good idea of how easy it will be to get a patient into a hypnotic state (i.e., questions about past hypnotic states or trauma, dissociative tendencies in various realms of life, and right/left brain characteristics).
A scale that may be informative to a psychologist treating pain patients is the Tellegen Absorption Scale,63 a 34-item true-false test that correlates well with hypnotic susceptibility. Wickramasekera64 found that patients scoring high on absorption scales or tests of hypnotic susceptibility and also scoring high on neuroticism as measure by the Marlowe-Crowne Social Desirability Scale65 were more likely to develop psychosomatic pain or symptoms, by dissociating traumatic or undesirable experiences and converting them into somatic symptoms or pain, creating what Damasio termed “psychological markers.” Wickramasekera developed a 25-item scale to be used to identify patients who were more likely to somatize. He points to the neural flexibility and “ideational fluency” that Gruzeleir18 suggested was related to a propensity to dissociate that can leave one vulnerable to schizotypy, affective distress, mood disorders, and somatic markers or memories that stay beyond conscious awareness. In simpler terms, highly hypnotizable patients are more likely to create a somatic marker for a psychological event and are more likely to trigger a memory of previous pain when they experience a new pain (see Chapman47). A meta-analysis66 shows classic, modern, and mixed forms of hypnosis to be effective for treating psychosomatic disorders (those which meet the criteria for somatoform disorder), which would include both hypersensitivity to pain, hyperawareness of symptoms and to body processes in general, and the transduction or conversion of emotions and memories into somatic markers. This is remarkable given the range of disorders and symptoms included: tinnitus, duodenal ulcers, asthma, irritable bowel syndrome (IBS), osteoarthritis, chronic pain, and dyspepsia. Also, DuHamel et al.67 found that their high-hypnotizable burned patients had significantly more intrusive avoidance and arousal symptoms with their injury-related trauma. Roelofs et al.68 showed that they could use hypnosis to induce catalepsy and altered perception of the cataleptic limb in high-hypnotizable subjects, suggesting the formation of conversion disorders or psychosomatic illness. Younger et al.69 show a linear correlation between hypnotizability and somatic complaints commonly assumed to be of a psychosomatic nature.
Current Research and Applications of Medical Hypnosis for Pain
The applications of hypnosis to medicine are numerous and go beyond the scope of this chapter because not all involve pain; Table 86.1 outlines common applications of hypnosis in medicine in general. Information on the effect of hypnosis on emotional pain and on physical pain, related or not to medical conditions, is undoubtedly not best found in the medical research but rather in books, articles, and trainings offered by the clinicians who regularly use it but who are not researchers. This is in part because every effective hypnotherapy session is, in research terms, an N of 1. However, research in hypnosis and its clinical use in medicine are increasing due to the recent surge in brain research and the increased understanding of what pain is and due to increased attention to the number of the people in chronic pain and in health care utilization and costs. Hypnosis research is important, for without published results, it is difficult for hospitals and insurance companies to justify reimbursing and endorsing its use in medicine.
Earlier research on psychological treatment of medical conditions often compares such treatment to standard care practices with and without the addition of cognitive-behavioral therapy (CBT). CBT often consists of a standardized program that is more applicable to research than hypnosis. CBT differs from hypnosis in that the therapist intends to speak directly to the patient’s cognitive conscious mind, without deliberately sending any direct or indirect messages to his or her unconscious mind. A hypnosis session may likely include behavioral
suggestions in and out of trance and messages to the conscious and the unconscious mind at the same time. Both may include homework. Kirsch et al.61 looked at 18 studies of CBT with and without additional hypnosis. The addition of hypnosis to CBT substantially enhanced treatment outcome, such that the patients who received additional hypnosis did better than 70% of those with just CBT treatment. In most cases, the authors mean CBT administered in the medium of hypnosis.
suggestions in and out of trance and messages to the conscious and the unconscious mind at the same time. Both may include homework. Kirsch et al.61 looked at 18 studies of CBT with and without additional hypnosis. The addition of hypnosis to CBT substantially enhanced treatment outcome, such that the patients who received additional hypnosis did better than 70% of those with just CBT treatment. In most cases, the authors mean CBT administered in the medium of hypnosis.
TABLE 86.1 Common Applications of Hypnosis in Medicine | ||||
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As we go on to discuss the research on medical hypnosis, there are some points to bear in mind. First, we expect there to be quite a difference between the methods and benefits of hypnosis in clinical practice and the process of studying it in research. We must assume that a clinician in his or her office would not exactly follow a research protocol and that he or she would modify even a hypnotic script to fit his or her patient’s situation. Also, pain hypnosis is used primarily for chronic pain, less often for procedural and least for surgical pain, where hypnosis is usually used as an adjunct to medicine. Under strict standards, for hypnosis to be considered the dependent variable in research, it must deliver suggestions that could not be just as well delivered to the patient cognitive behaviorally (as in telling the patient what to do). However, some highly hypnotizable or well-trained patients have ready access to the unconscious mind and absorb even a CBT message quite deeply or literally; a good example of this is the patient who testifies that he always gets all the side effects mentioned on the inserts of his medications. Finally, most patients in severe pain or in traumatic conditions are already in a trance and in a manner of speaking hypnotized, so that the comparison between CBT and hypnosis is muddy at best. A recent study found that multiple sclerosis (MS) patients who tried hypnosis for pain relief had more success than did those who tried opioids, benzodiazepines, or nerve blocks.70 But in general and in effect, the strict standards of the research may dilute the power of hypnosis. Fortunately, clinical success with hypnosis does not depend wholly on the results of research studies.
EFFICACY AND EFFECTIVENESS
To move the practice of hypnosis in medicine along, research on effectiveness—how hypnosis works in the real world, in quasiexperimental design—should be as methodical as the research on efficacy—how a technique works within the controlled research situation (see Wild and Espie,71 Nash,72 Chaves and Dworkin,73 and Gay et al.74). A 1982 article75 reported skepticism about the effect of hypnosis on pain due to the lack of controlled studies comparing hypnosis with credible placebos or other treatment methods. Hawkins76 updated that article with a review of research articles up to the year 2000 and was able to conclude that hypnosis is effective for pain related to cancer, burns, gastrointestinal problems, and for invasive medical procedures. He also noted that poor-quality reviews were not more likely to produce positive conclusions about efficacy and that there was a paucity of good studies in the areas of obstetrics, headache, and chronic pain. Montgomery et al.9 did a meta-analysis of pain analgesia studies using healthy subjects and patient samples and taking into consideration hypnotizability levels; they concluded hypnosis to be effective in both areas for 75% of their population. Hypnotic analgesia compared favorably in effect to standard care and to attention.77 Hypnosis has compared favorably to empathic attention78 and to autogenic training (AT) for psychosomatic and medical disorders.79 Yapko,51 however, suggests that AT is in itself a hypnotic induction and that the comparison of the two treatments presents a problem.
The research process itself raises some concerns. One is that research studies focus on the precise content of the intervention, not how it can be flexibly adapted to the real-life patient situation. Another concern is the outcome measure itself: We intend for patients to be noticing pain less, but then we ask them to tune into it and rate it at the end of the study. Also, many studies do not account for hypnotizability, which would color research results and which in clinical practice that therapist could address. Another issue is expectancy—the patient’s expectation that hypnosis will resolve his pain, which seems to predict pain relief. Jensen and Patterson80 suggest that most of hypnosis studies lack adequate controls for expectancy and placebo effects, even though the studies find that hypnotic analgesia is effective in treating chronic pain. Clearly, raising the patient’s expectancy is a good thing, as are raising his levels of self-efficacy and curiosity about finding new ways to cope and encouraging the placebo effect. A study looking at changes in various psychological responses to pain postoperatively and after 3 months found hypnosis to be effective. The positive effect was not significantly related to hypnotic ability, concentration of treatment (e.g., daily vs. up to weekly), or initial response pattern to treatment, but it was moderately related to the participants’ expectancy ratings of treatment after the first session.81
All of this being said, Amundson et al.82 point out that research probably underestimates the effectiveness of clinical hypnosis. Many are concerned about the randomized controlled trial (RCT) approach to hypnosis research that is so distinct from the patient-centered and cooperative relationship-based nature of clinical hypnotherapy.83,84 Clinical one-on-one hypnotic sessions take patient’s unique issues and personal variables into consideration, and scripted or standardized protocols cannot address the psychological and emotional issues intertwined with the pain. Spiegel and Kahn85 discuss the difficulties inherent in using an outside hypnotherapist as the interventionist in research or therapy, which lacks the all-important therapeutic relationship; they also point out that the relationship between the hypnotherapist and the treating physician is important. It would seem that hypnotic protocols would be most effective when designed for each patient by a therapist who is interactively responsive to the patient, for according to one extensive study, 30% of therapy outcome is based on the therapeutic relationship, even when the treatment is medication; another 15% is due to expectancy.86 Nonetheless, research showing the effectiveness of hypnosis must be stringent if it is to be widely available in medicine and adequately reimbursed by insurance companies. In fact, when comparing the delivery of hypnotic analgesia by sessions with the hypnotist present, manualized protocols, standardized audiotapes, or individualized audiotapes (as would be prepared for patients in clinical practice), a meta-analysis indicates that any delivery is better than none87; however, since clinicians understand the importance of being fully present and flexible in a hypnotic session, more research in this area is needed. Interesting delivery formats are now on the horizon. Patterson et al.88 have attempted to improve absorption that may be missing with audiotapes by creating virtual reality (VR) computer-based presentations that immerse patients in a three dimensional computer-generated environment to absorb the patients’ attention and divert it away from the pain experience. VR induces and sustains a hypnotic state without a therapist. Questions arise as to whether this intervention satisfies the research definitions for hypnosis and whether the same effect could be accomplished by naturalistic absorption or with audiotapes alone.
Here is an example of a clinical application of hypnosis that is distinct from research protocol. A female patient in her 30s had been extensively evaluated for her deep, sharp right-side pelvic pain that came on for 15 to 20 minutes as often as every hour, even during the night. She rarely has pain when she was on birth control pills, other than after sexual intercourse. There was a small area of endometriosis, successfully removed, and one cyst that ruptured, but otherwise, no diagnoses explained
the pain. She and her husband were anxious to be off birth control pills in order to conceive. She also exhibited generalized high vigilance. She asked a hypnotherapist to help find any unconscious motivations for the pain. She was highly hypnotic and motivated, with high expectancy. The therapist worked interactively with her on a wide range of techniques to find what worked uniquely for her in managing and accepting the nerve pain, which she practiced self-hypnotically at home. Hypnosis helped with vigilance, and therapy helped other issues about trust. The therapeutic relationship supported the work with hypervigilance and trust, and specific fears that related to pregnancy.
the pain. She and her husband were anxious to be off birth control pills in order to conceive. She also exhibited generalized high vigilance. She asked a hypnotherapist to help find any unconscious motivations for the pain. She was highly hypnotic and motivated, with high expectancy. The therapist worked interactively with her on a wide range of techniques to find what worked uniquely for her in managing and accepting the nerve pain, which she practiced self-hypnotically at home. Hypnosis helped with vigilance, and therapy helped other issues about trust. The therapeutic relationship supported the work with hypervigilance and trust, and specific fears that related to pregnancy.
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