Hypnosis and imagery in pain management

Hypnosis and imagery are similar but slightly different states that can be experienced and used in pain management. Although many people are slightly anxious about hypnosis because of connotations of stage hypnosis, some religious concerns, and the many myths about the practice, it is probably an experience that most of us have had at some point.

Hypnosis as a term was first used in 1820 by Etienne Felix d’Henin de Cuvillers, although the practice had been brought to the attention of the medical fraternity much earlier by Franz Mesmer (1743 – 1815). Its use in surgical procedures is documented from the 1830’s, it was probably only the discovery of anaesthetic chemicals in 1846 that prevented its more widespread use in surgery today.

What is it? Hypnosis is an “a subjective state in which alterations of perception or memory can be elicited by suggestion.” (Orne, 1977). The experience is of being in a focused state of attention, while at the same time being very relaxed – much like the ‘automatic’ state experienced while driving a familiar road, or the detached feeling while being absorbed in an interesting book.

How does it work? Although it is unclear exactly how hypnosis works, in the case of pain modulation, recent studies demonstrate there are changes that can be observed under fMRI (Schulz-Stubner, Krings, Meister et al., 2004). The areas influenced suggest that it is affective pain perception (the emotional meaning of pain) that is influenced under hypnosis, while other cortical areas that identify where the pain is located in the body remain unaffected.

Has it been used in clinical pain management? The short answer is yes, but it is relatively difficult to find high quality scientific studies. Quoting from a very extensive review article on surgical use of hypnosis by Wobst (2007), who says “Many clinical studies investigating the use of hypnosis involve small patient populations and often lack controls and statistical evaluations. Because active involvement of the study subjects in the hypnosis interventions is required, a double-blind study is impossible, and even a single-blinded study would be a challenge. Interpretation of results from different studies is also complicated by the lack of standard techniques and procedures.”

In chronic pain management it is less common to use therapist-directed hypnosis, patients are usually taught to develop skills in self-hypnosis. An exception to this may be where imagery and suggestion are used under hypnosis as part of a graded activity programme, as in the case of complex regional pain syndrome, phantom limb or during a graded exposure programme for pain-related anxiety and avoidance.

How do I achieve a hypnotic state? There are many myths about how hypnosis can be induced including the ‘you are getting sleepy’ monotone with the swinging pendulum or watch. While this can and does work, it would probably induce the giggles in many!

The format often followed is to:

• suggest to the person that they are becoming relaxed, often starting with slowing the breathing rate, closing the eyes, reducing awareness to the voice of the therapist
  
• once relaxed a ‘deepening’ induction is used, often counting down from a number to one or an image of descending as if on a stairway or elevator, or even walking down a path towards a peaceful place. This procedure may be modified depending on the depth of ‘trance’ observed and phrases such as ‘you are feeling more and more relaxed, getting deeper and deeper’ encourage deeper trance. The main gist of any patter is to encourage the person to relax, focus on the voice of the therapist, become less aware of outside noises, and allow themselves to drift into a focused but relaxed state.
• Once a deeply relaxed state is achieved, the therapeutic suggestions are made including post-hypnotic suggestions. These are suggestions that the person will become more aware of after the hypnotic session such as post-hypnotic analgesia, changes to gait pattern, reduced anxiety when engaging in a feared task, and even a reminder to use hypnosis at certain points during the day.

Hypnosis is used to help develop a sense of detachment from pain, calmness or serenity, ‘the pain doesn’t bother you so much’ rather than ‘your foot is numb’. It can be used quite playfully, with imagery such as pouring warm, scented oil over a painful foot allowing it to move more freely, or images of the person being able to walk gracefully without a limp, when in reality the person finds it difficult to put weight through the foot at all. In the latter sense, this is similar to using imagined movements in sports, where the person mentally rehearses successful movements prior to carrying them out in reality (ever rehearsed a golf swing?!).

As I mentioned above, therapists often teach patients how to use self-hypnosis. This allows the person to use hypnosis without a therapist present – throughout the day, to relax efficiently while maintaining an activity, or to focus the attention on something more ‘interesting’ than their pain intensity. The induction process is similar to that used by a therapist, although often a physical trigger or cue such as squeezing finger and thumb together is also learned so that it can be recalled easily in real life.

Who uses hypnosis? Most countries in the world have a clinical hypnosis society with training programme for therapists, although it is not necessary in New Zealand to register to use hypnosis. Although it is mostly psychologists who conduct hypnosis for pain management, it can also be carried out as an adjuctive therapy by occupational therapists, physiotherapists, nurses and social workers in the context of their usual pain management therapies.

The internet provides a huge range of hypnosis sites – some of them are less than humble about their claims! There are a huge number of hypnotic scripts freely available – the Diviniti website has some especially useful free ones that I have adapted for use in pain management.

For an interesting podcast on hypnosis, this one is very good, and I there are a number of good articles in the journal also.

Orne MT. The construct of hypnosis: implications of the definition for research and practice. Ann N Y Acad Sci 1977;296:14 –33.

Schulz-Stubner S, Krings T, Meister IG, et al. Clinical hypnosis modulates functional magnetic resonance imaging signal intensities and pain perception in a thermal stimulation paradigm. Reg Anesth Pain Med 2004;29:549 –56.

Speigel, D. The mind prepared. Journal National Cancer Institute. 2007; 99(17):1280 – 1281

Date last modified: 1 March 2008