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

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27 comments

  1. Hi, I’ve noticed you mention that not a few online selfhypnosis program resources often make claims they can’t fulfill. I’m currently using this hypnosis and hypnotherapy training and I just want to know what an expert’s view about this particular program is. Is it good enough? Or should I try looking for new ones? Thanks!

  2. Any self-hypnosis programme is only as good as:
    – the extent to which you follow it
    – the extent to which you believe the claims
    – your own alignment to the values or changes that the hypnotic script is making (you can’t be ‘made’ to change or do something that you really don’t want to do)
    – the degree to which you are ‘hypnotisable’ – which means really how much you’re OK with being very relaxed and/or focused

    I don’t make any claims for or against any specific products or services, so I’m not prepared to comment on the product you’re using. If it’s working for you – go ahead!

  3. I’m glad you enjoyed it Johnathon – I think hypnosis is a tool that many of us can use and one that is, once you’ve learned it, free, readily adapted for many uses, and very easy to do in many different settings.

  4. Thanks for visiting – I do use hypnosis often, but the main purpose is to help people learn the technique for themselves. Although I see people with chronic pain (via a public hospital), I really don’t want them to remain dependent upon me or my input – I hope they have lives to live!
    regards
    adiemus

  5. Well done article. Self-hypnosis is very effective in pain control. I really do hope for some clinical studies, with larger sample sizes, to show just how effective hypnosis can be in pain control. They have been many successful studies but all with smal sample sizes.

  6. I would be curious to know if there was a difference in effectiveness between people that practive self-hypnosis for pain relief versus people that go to a professional for hypnotherapy.

    1. What a good question. To be honest, I always aim for people to do self hypnosis, so that I encourage self management rather than relying on attending someone – but I haven’t read any literature suggesting that seeing a professional is more or less effective than doing it independently. I’ll do some searching and see what I can find out. Thanks for stopping by!
      cheers
      Bronnie

  7. Hello, I just now come across this blog whilst searching on online as I am researching some info on hypnotherapy and smoking. It’s an interesting site so I bookmarked your site and intend to revisit you tomorrow to give it a more detailed read when I can give it more time.

  8. A well researched article – thank you! I used to have misconceptions about hypnosis as the only evidence I had ever seen of it was a corny stage show back in 1995. I was amazed when my doctor offered it to me in 2001 as part of my bereavement council therapy and I have practised it ever since.
    I think people confuse the ‘sleepy state’ of hypnosis for the fact that we achieve a greater state of relaxation with our eyes closed.

  9. Great article and full of useful information. I believe that relaxation is the key to anything. If one is tense and stressed, it is more difficult to apply anything. My personal experience is that when relaxed especially when using the self hypnosis method, it is more successful. Relaxing music helps me to unwind and then it is much easier to adapt the therapy to my individual needs.

  10. For the last 30 years I have been teaching Certified Registered Nurse Anesthetist how to use hypnosis and imagery to manage pain. The seminar also includes cognitive restructuring, anxiety management, and sleep management. It really works.

    1. I agree with you! Hypnosis is a tool that individuals can use to great effect. Maybe one of the ways it works is through nonjudgemental awareness of what is present (aka mindfulness), but it’s true that it also draws on the brain’s great imagery repertoire too.

  11. Very informative post! I believe that everyone should do their research to make sure they know what they are getting themselves into. It’s great to see that people are taking a more natural approach to healing and handling pain. Thanks for sharing!

    1. My pleasure Annie. Hypnosis has some usefulness, although not everyone can use it, and not everyone has a significant effect – but for those who do, it has no adverse effects on the whole, it can empower people and it can support other analgesic effects. Thanks for taking the time to comment.

    1. Hi there, I think the distinctions are around the level of alertness. Hypnosis represents an altered level of awareness, a focus if you will, whereas it’s entirely possible to imagine/daydream/use imagery while not being in any particular state of alertness. It may be relatively academic, anyway, because in practice I think we probably move fairly fluidly between the various states.

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