Clinical indications for hypnosis

Who might benefit from learning hypnosis – and when might you suggest it?

I’m a person who doesn’t really try changing my own pain intensity very often, and most of the people I’ve worked with in therapy are also in the stage of wanting to learn how to live alongside their pain. However, there are some times when modulating pain intensity can be a really helpful part of even this phase of learning to live well with pain.

I haven’t found any clinical guidelines suggesting when it might be good to introduce hypnosis, so this is my own clinical reasoning. Remember I work with a particular group of people, and I have my unique approach and practice in pain management, so this reasoning may not resonate with you!

Hypnosis, for those who respond well, offers effective pain reduction (up to 40% for some, and on average, around 27 – 30% reduction), but it also offers effects other than reduced pain. Depending on the suggestions made during hypnosis, a person might feel pain as less distressing or intrusive, so that while pain is still intense it doesn’t bother them as much (see Jensen, 2011).

In my experience, hypnosis is great for pain reduction if the pain is likely to be short-term, or if the pain reduction from hypnosis doesn’t need to be long-lasting. The pragmatic reason for these suggestions is that hypnosis does take some effort both to learn, and to sustain. When thinking about reducing distress and the intrusive qualities of pain, I suspect these might be more about attention and interpretation and so I think developing a longer period of practice using hypnosis as a regular part of life is a good approach.

What does this mean?

Well, if someone has neuropathic pain with the nasty electric shock jolts from the blue, and the weird burning, tingling background pain, I like to teach self-hypnosis with an emphasis on feeling distant from the electric shock pains. My aim is to help the person experience less intrusion of these random intermittent pains, so they don’t get as caught up in the physiological arousal/sympathetic nervous system wind-up, and can calm their nervous system down quickly. This helps reduce the time these electric shock pains take up in a person’s day, and helps reduce the background nervous system irritability that in turn, seems to provoke and create the conditions for them to escalate.

The words and phrases I use will differ depending on the individual, but I suggest things like ‘you might notice a random electric shock feeling but it’s like it’s playing in the distance, maybe happening to someone else, or like in a dream and through mist.’ I add phrases like ‘you might notice a shock and each time you do, your body automatically remembers to breathe out and feel the contact of your feet on the ground, or your body on the chair, and you can quickly return to what really matters, what you were doing…’

Short-term use

If the person experiences period pains, then hypnosis to reduce pain intensity can be very helpful – it’s usually short-term, over a day or two, and hypnosis is easier to use through this time. In these cases, hypnosis that aims to reduce pain intensity and replace it with a more comfortable sensation can be good. For example, I might suggest ‘when you notice that deep gripping pain, you can also notice your lower back contacting the surface of the chair or bed, like a warm supporting hug, allowing that hard hot pain to melt into the gentle warmth of the hug as you feel the support of the chair or bed.’

Daily life use

Physical cues can be great for helping people access their hypnotic experience quickly. One of my favourites is simply holding finger and thumb together in a pinch. I introduce this during a hypnosis session, usually towards the end of the session before returning to everyday life. I invite the person to hold their finger and thumb in a pinch, and breathe in, hold it for a moment, then breathe out and let their finger and thumb relax. As we practice this several times, I suggest that the more firmly they press their finger and thumb together, the more they experience the peace and comfort of their hypnosis session, and the breath out will bring this relaxed experience into the present moment. I leave them with a post-hypnotic suggestion that every time they notice they’re feeling pain, or tension, they will press their finger and thumb together, take a breath in and hold it for a moment, then breathe out and relax and they’ll feel this wonderful sense of calm and comfort.

How can hypnosis be self-management?

Well, because hypnosis is a state, an experience, and not something done TO a person, I believe it’s something each person can learn for themselves. I work hard to teach people how to achieve self-hypnosis so they can implement it whenever and wherever they like. At the same time, I also often use recordings (people get given a recording of the session we did together so they can practice at home), and I personally used a recorded session for myself years ago when having trouble with sleep.

Want to try some hypnosis yourself?

deep-hypnotic-relaxation-with-cueDownload

Grab a phone and record yourself using this free and fairly standard hypnosis script (click). You’ll notice there are four main sections: the Induction, Deepening, Subject, and Awakening.

The induction guides you towards focusing your attention only on your voice, and also adds some ideas about deeply relaxing, still being able to attend to important things, but essentially becoming calm and comfortable.

Deepening brings your attention even more into the ‘trance’ state, or the point where you’re more open to suggestions.

The subject is all about what you want to achieve during this session – perhaps it’s sleep, perhaps it’s an efficient way to restore your energy, maybe it’s having pain not feeling as disruptive. It’s the time you can either rest in the calm of a trance, or add suggestions to help you experience what it is you want.

The awakening is the part where you bring yourself back to everyday life, becoming more aware of what’s going on around you, and yet also bringing back with you the sense of calm and comfort you experienced during your session.

Make sure your environment is quiet. Slow your voice down a bit. Give yourself lots of time between phrases. As you bring yourself back to everyday life, you might want to put some energy into your voice and quicken the pace a bit.

This script should take around 20 minutes to do. Enjoy!

Bicego, A., Rousseaux, F., Faymonville, M. E., Nyssen, A. S., & Vanhaudenhuyse, A. (2022). Neurophysiology of hypnosis in chronic pain: A review of recent literature. American Journal of Clinical Hypnosis, 64(1), 62-80. https://doi.org/10.1080/00029157.2020.1869517

Jensen, M. P. (2011). Hypnosis for Chronic Pain Management: Therapist Guide. https://doi.org/10.1093/med:psych/9780199772377.001.0001

Langlois, P., Perrochon, A., David, R., Rainville, P., Wood, C., Vanhaudenhuyse, A., Pageaux, B., Ounajim, A., Lavalliere, M., Debarnot, U., Luque-Moreno, C., Roulaud, M., Simoneau, M., Goudman, L., Moens, M., Rigoard, P., & Billot, M. (2022). Hypnosis to manage musculoskeletal and neuropathic chronic pain: A systematic review and meta-analysis. Neurosci Biobehav Rev, 135, 104591. https://doi.org/10.1016/j.neubiorev.2022.104591

The power of being present

I’ve been listening to Prof Kevin Vowles recently, as he presents his approach to pain using ACT. He made an important point about mindfulness that resonated with me: it’s that when learning to be fully present, it’s not how long we stray from our point of focus, nor even how many times we come back, the learning is that we can come back. Again and again and again.

There are arguments about what mindfulness is, and I’m certain these will continue, but for the purposes of this post and for people just learning mindfulness, I’m defining it as the deliberate practice of attending to a focus (this could be a single point of focus, or it could be broader – the practice is about being deliberate and self-regulating where attention is being placed), and ‘orienting’ towards sensory experiences in the moment with curiosity, openness and willingness to accept what shows up. This is a definition broadly adopted from Bishop et al., (2004).

A review by Leca and Tavares (2022) looked at mindfulness for people living with fibromyalgia and found, albeit with reservations brought about by study design, that mindfulness does have promise for this pain problem. They used fairly stringent criteria for selecting the studies included in their analysis, resulting in only seven eligible studies, from an initial 160 results.

What they found was that mindfulness helped participants experience better quality of life, and this was influenced by better sleep, less distress, and improved functioning. Not enormous effect sizes, but this is common for chronic pain outcomes of any kind. They also found flaws in the methods used to study mindfulness, including that participants’ experience with mindfulness prior to the research was often omitted, there was limited reporting on the teachers’ experiences or training, and there were a lot of drop-outs, programmes were quite onerous and brief and follow-ups were short. Again, not uncommon in chronic pain research.

Mindfulness is intriguing to study. From the outside there is nothing to see – a person usually sitting quietly, breathing. BUT there is converging evidence that those regularly using mindfulness show some interesting effects on how the brain functions. De Benedittis (2021) compared mindfulness and hypnosis and the brain networks thought to be at play, and found that while both share similar activity in the neural networks, they activate quite differently. Both hypnosis and mindfulness engage the frontal cortex (click here for an update on your neuroanatomy of the frontal cortex) but activate areas differently. De Benedittis found that the anterior cingulate cortex is a key area, the dorsolateral prefrontal cortex is activated in response to hypnotic suggestion in hypnosis, while in meditation, the same area is activated as the person gets more proficient.

So what?

I first started using hypnosis in the mid-1990s, as I needed help with my sleep. I regularly used a hypnotic induction to reduce the time it took me to fall asleep. I have a very active mind that starts to chat to me at night, possibly because I don’t slow down enough through the day for it to get a word in edgeways! Since childhood it’s always taken me at least 45 minutes to settle into bed and eventually fall asleep – and the delay in falling asleep gets worse if I’m tussling over a situation or a problem that I can’t readily find a solution for. There have been times in my life when I haven’t slept until the very wee hours – 4.ooam…. and I still wake (often) for short periods during the night.

Hypnosis helped me retrain my falling asleep practice to where now I can fall asleep most night in about 15 minutes.

As I became more drawn to ACT, I found myself turning to mindfulness rather than hypnosis. With hypnosis I have an outcome in mind: deep relaxation, achieving a trance state that makes it easy to let go and fall asleep. With mindfulness I have no particular destination. I’m willing to be present with whatever sensations and thoughts turn up.

With mindfulness I gently and consistently turn my attention to whatever the target is for that mindfulness practice. It could be my breath (because it’s boring, it’s always there, it’s a rhythm, and there’s a lot to notice!). It could be the contact of my body on the bed (similar reasons to breathing!).

My attention is taken away by thoughts. By weird and fleeting sensations – sharp pin-like stabs in my calves, a feeling like my toes are encased in a gently prickly sock, that my shoulder is being gripped by a large hand and squeezed, that aching in my lower back….

The practice of finding out that my attention has gone there and not my breath and then bringing my attention back to my breath: that is a key part of my mindfulness practice. And doing this without getting irritated by how often this happens!

When I’m particularly sore my mindfulness practice is such a gift. It doesn’t reduce my pain, let me be clear about that. It doesn’t change pain intensity or qualities, at least not for me. What mindfulness gives me is curiosity. My pain is never just one sensation. The more I explore an area where I’m sore, the more complex is my pain. There are areas of hot pain. Areas of no pain. Areas that pulse. Areas that are almost absent – I can’t ‘feel’ them in my mind. Areas that are tingling, and areas that are like tiny needles. And the weirdest thing of all is as I go to explore them in my mind, they slide away and change and metamorphose into another sensation. Pain is a slippery sucker!

Curiosity is, as I’ve written before, associated with willingness to not know. Curiosity is part of openness to experience (Silvia & Christensen, 2020), it’s essential for human growth because it leads to exploring our world and developing an understanding of what is currently unknown. My mindfulness practice unleashes my curiosity – what am I experiencing in my body at this moment? Curiosity has a tiny frisson of anxiety – I don’t know what I will find out – but tempered with a kind of calm knowledge that whatever I notice will likely change. That particular pain won’t last forever, even if my overall pain continues to be present. I would never have known this if I hadn’t explored, in minute detail, areas where I’m sore.

Mindfulness has given me the ability to manage that anxiety, and we need this kind of self-regulation when we live with pains that are negatively valenced – and all pain, by definition, is ‘unpleasant’ and ‘sensory’ and ’emotional’.

As a clinician, mindfulness has given me the skills to be present as I listen to distressing stories from people who haven’t had the kind of healthcare experience they deserve. Mindfulness means I can check in with what is happening here and now, rather than letting my mind head off in the direction of ‘how long will this take?’ or ‘let’s just cut to the chase: what’s wrong’ or ‘what a tragic tale, how dare this happen.’ Even brief dips in and out of mindfulness can give me a chance to notice that I’m not listening fully. And gives me a chance to come back to who I am here for. Mindfulness removes me from my mindiness, and steps me towards curiosity.

You see, while extended mindfulness meditation is part of my life, these brief moments of mindfulness are my mainstay as I go about my everyday living.

I invite you, whether you live with pain, or you’re a clinician – or both – to stop right now and pay attention to the contact of your body on whatever support you’re on. The chair. My feet on my footstool. The weight of my forearms on my computer keyboard. The pressure of my clothing on my legs, the cool areas where the air is circulating, the warmth where my legs touch the chair.

Notice that you can bring your attention back again and again and again.

You can’t do it wrong. Just bring your attention back to what is being sensed now.

And see how often you can do this throughout today.

And notice how it feels.

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., et al. (2004). Mindfulness: a proposed operational definition. Clinical Psychology Science & Practice, 11, 230–241.

De Benedittis, G. (2021). Neural Mechanisms of Hypnosis and Meditation-Induced Analgesia: A Narrative Review. International Journal of Clinical & Experimental Hypnosis, 69(3), 363-382. https://doi.org/10.1080/00207144.2021.1917294

Kashdan, T. B., Stiksma, M. C., Disabato, D. J., McKnight, P. E., Bekier, J., Kaji, J., & Lazarus, R. (2018). The five-dimensional curiosity scale: Capturing the bandwidth of curiosity and identifying four unique subgroups of curious people. Journal of Research in Personality, 73, 130-149. https://doi.org/10.1016/j.jrp.2017.11.011

Leca, S., & Tavares, I. (2022). Research in Mindfulness Interventions for Patients With Fibromyalgia: A Critical Review. Frontiers in Integrative Neuroscience, 16, 920271. https://doi.org/10.3389/fnint.2022.920271

Silvia, P. J., & Christensen, A. P. (2020). Looking up at the curious personality: individual differences in curiosity and openness to experience. Current Opinion in Behavioral Sciences, 35, 1-6. https://doi.org/10.1016/j.cobeha.2020.05.013

Online CALM – Resources for calming the mind and increasing emotional resilience

I found this website today CALM – it’s put together by three lecturers at the University of Auckland, and has a whole series of downloadable MP3’s on methods that will help develop resilience and positivity for dealing with life’s ups and downs. Actually, the whole website can be downloaded and played from a computer off-line, which is great if you’re wanting to access this for your personal use.
The areas covered are Mental Resilience; Managing Stress, Anxiety and Depression; Healthy Relationships; and Finding Meaning in Life.

While each area is dealt with quite briefly, there are loads of worksheets and MP3’s in each area. It’s that part that excites me! The MP3’s cover topics like ‘self hypnosis’ (by Dr Bob Large, Psychiatrist and Pain Specialist from The Auckland Regional Pain Service); Progressive muscle relaxation; Mindful breathing; Developing a coping plan; two on relationships; a whole bunch on religion and meaning in life including Catholic, Anglican, Bhuddist, Hindu; and meaning in life.

This site isn’t developed specifically for pain management – it’s for general life! Well worth a visit on a wet Sunday afternoon.

How does it work? Pick your theory

I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up.

We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; help him develop some self regulatory skills particularly to downregulate his very sensitive sympathetic drive; and to start the process of him being mindful of his hand rather than ignoring it or focusing on it.

I’m using a combination of approaches – Socratic questioning and guided discovery to help him develop a better understanding of his pain – particularly focusing on helping him recognise that trying to control his pain through either avoiding the use of his hand, or using distraction is counter-productive.  When he avoids using his hand, he’s either limiting the activities he can get through during the day and gets bored, frustrated and is probably contributing to the pain because his neuromatrix isn’t receiving normal movement patterns.  When he uses distraction, he can almost completely ignore the pain while pushing himself to ‘do everything’ – but then he gets an overwhelming increase in pain when he stops, which is distressing.

We’ve spent quite a while discussing the nature of control – is it pain we’re trying to control? Is it his activities we’re controlling? Is it is thoughts and emotions that we’re controlling?  I’ve been using mindfulness and some of the concepts from ACT and suggesting that try as hard as we might, pain is not something to control, and neither are thoughts or emotions.  In fact it seems the harder we try to control any of these things, the more they dominate and control us!

As a result, much of what I’m working on is helping this guy to non-judgementally regard his body sensations as simply sensations, allowing his attention to go to his hand without trying to ignore it (you can’t!) or to over-attend to it, but simply to notice it.

Taking this a little further, we’ve been working on breathing and mindfully attending to breathing as one way of introducing self regulation. This involves gently guiding his attention to his breath, and just as gently, noticing when his attention drifts away and bringing it back to his breathing.  Not as easy as you’d think!

I’ve been using biofeedback as part of this process because this guy is a practical man.  He’s not one to just accept doing something without having some feedback about what is actually going on.  I’ve used skin conductance, surface EMG, heart rate, respiration rate and skin temperature to monitor his overall arousal level.  He’s aware now that he can influence usually unconscious processes just by breathing or even thinking differently!

Yesterday I took it a little further.  I asked him to look at his painful hand, and simply describe the sensations without judging them.  What this means is he told me about the tingly, burning sensation over his palm, the throbbing aching in his fingers, he noticed where the pain started and stopped on his hand and fingers, the sensation of heat where his fingers touched each other, the sensation of pressure on his forearm where it rested against the arm of the chair, the sensation where the fabric of his T-shirt touched his skin – and so on.

It was interesting for him to notice that the painful area isn’t as big as he’d imagined.  When he really started to notice the quality of his pain, it wasn’t nauseating or particularly intense, it varied in sensation.  What I noticed was that initially his readings on biofeedback jumped – but they gradually settled down as he looked at his hand and really noticed it.

We then did some deep relaxation, really a kind of hypnosis.  In this we used an imagery device I’d discussed with him before the session.  I guided him in to using his attention to become aware of his hand and in particular, its position in space and the sensations over his whole hand and forearm.  I then guided him through an imagery process where he imagined holding his hand in warm water, allowing his hand to ‘thaw’ and open.  We then spent some time imagining his hand feeling normal, moving normally and imagined opening and closing his hand to lift a cup, pour milk, and flex and extend his wrist.  Throughout I was monitoring his biofeedback readings, and using words like ‘relax’ and ‘warm’ and ‘comfortable’ whenever the readings suggested he was becoming ‘stressed’.

When we completed the session, he had achieved sustained attention to his hand for about 35 minutes, completed a guided imagery of his hand doing normal activities, and had remained calm throughout.  He reported some increased discomfort around his wrist particularly after imagining wrist extension and flexion, but what really excited me was that he’d been able to increase the skin temperature on the finger of his right hand.

So, lots of choices in terms of theory to explain what I’d been doing.

1. Graded motor imagery and sustained attention gives the neuromatrix normalised input, while not activating what Lorimer Moseley and David Butler call ‘neurotags’ or emotionally-laden pathways in the brain.
2. Graded exposure using visual imagery as described by Johan Vlaeyen and following the exposure paradigm used in phobia reduction.
3. Using a behavioural model, biofeedback providing immediate feedback on progress and arousal levels, influencing both my behaviour (guided imagery) and the clients responses
4. Hypnosis allowing the ‘judgemental’ aspects of the mind to be quietened, thus allowing the client to experience sensations without distress
5. Mindfulness where sensations are experienced but judgements are stilled.

Take your pick!  I’m not entirely sure myself, but whatever the mechanism, I’ll be continuing with this approach to the point where this client can carry the same process out with eyes open, then when actually moving.  Oh, and at the same time, the rest of the team will be working (along with me) on helping him set and achieve goals, manage difficult emotions and maintain a regulated activity pattern, as well as work on his relationship, look to the future of work, and help him communicate effectively with his case manager.  This is why pain is often not the main focus in pain management!

A recording or the real thing?

I’m musing about an article I read while browsing the internet looking for information on hypnosis. It’s from the BBC – you can read it here – where it is announced that a recording of guided imagery is useful for kids with abdominal pain, saying ‘they can imagine themselves in scenarios like floating on a cloud’ and experience improvements in their pain.

I think this is a great piece of news with a sting in the tail. Like most news articles it fails to deliver the detail, and as you know, the devil is in the details! Let me say firstly that I haven’t read the original article which is found in the journal Pediatrics, and apparently follows on from similar studies showing that hypnosis for kids has some good effect – apparently because kids have ‘fertile imaginations’. We could add also that kids develop very strong expectancies when powerful and important people in their lives tell them that a treatment has a certain effect.

Back to the story – firstly, the study is a small study of only 30 children. The ages of the children ranged from 6 – 15, and the BBC article gives no details of the duration of the pain, the average of the kid, whether they’d had psychological input before, whether their parents supported the treatment etc etc – all quite important factors in determining the efficacy of treatment in the ‘real world’.

It seems that the kids were divided into two groups – one got normal management, the other received CD’s and were asked to use them daily for eight weeks. No mention in the BBC article about whether the CD group also got ‘other’ management!

The results – the CD group ‘73.3% reported that their abdominal pain was reduced by half or more by the end of the treatment course compared with 26.7% in the standard care group.’ … and apparently this was maintained to a certain extent in 2/3 of the kids six months later.

Why am I critical of this article? Well the first thing is that it is skimpy on details of the study. Not unexpected, this is a news article not a scientific paper! BUT it is inclined to lead parents who read this to jump to conclusions that simply by buying a CD they may be able to help little Johnny or Mary with their tummy pain. I suppose at least it won’t do harm – except if the parents delay getting their kids seen by a medical professional.

But I think it suggests rather unfairly a couple of things: firstly the article says ‘a lack of therapists led them to the idea of using a CD to deliver the sessions’ I can imagine some hospital managers rubbing their hands with glee thinking ‘ahah! we can reduce the number of occupational therapists, psychologists and social workers in paediatrics with a recording!’

Perhaps that’s a little unkind, but that’s the sort of simplistic thinking that I’ve seen before – therapist leaves, referrals for assessment have dipped a little so let’s not replace the therapist and we can save some money (haven’t you heard of natural referral fluctuations? and what is that waiting list for treatment?)

It also suggests that a simple intervention can solve what is a complex and challenging problem. In my experience, kids with abdominal pain are within family and school systems that need input. While helping a kid get off to sleep or reduce their abdominal pain is one part of the solution, there is almost always much more. And usually it involves helping parents understand their role, and the role of siblings, teachers, friends and even family doctors, in the maintenance of the child’s disability and illness role. A CD is not going to do this.

Some parents find it exceptionally difficult to accept that no clear medical ‘diagnosis’ (and therefore cure) can be found – one parent said to me ‘You can’t consign my child to a lifetime of pain’ even when my job was to help the child cope with the pain while the team worked to identify contributing factors. She’d had her pain for four years, had spent two years off school, and had seen many specialists before being referred to the chronic pain team. BTW no medical diagnosis was made for this girl apart from ‘chronic abdominal pain’, and her father removed her from our team and continued to seek further invasive diagnostic procedures. I understand she remains off school another 18 months later having had several procedures but still finding no evidence of diagnosable pathology. Maybe she really does have ‘chronic pain’ in the tummy. If a parent doesn’t support the approach, a recording isn’t going to cut it, even if it’s an effective recording for relaxation.

My final thoughts on this article: if you’ve ever tried using a relaxation or imagery recording, you’ll probably know that some ‘fit’ you and some don’t. I personally get irritated with strong accents, pan pipes, and water trickling. I also really don’t enjoy imagery of beaches.

One size of imagery does not fit all – which is one reason I prefer to do at least one session where I talk before I start an imagery relaxation or hypnosis. That way I can identify the specific triggers, words, images or sounds that work well for the individual. I can make a recording that is tailored to the needs of the individual.

I don’t know whether there is an evidence-base to suggest that this is more effective than a mass-produced recording, but I do remember when I was a kid having nightmares about fairy stories that were supposed to happy and nice. I’d rather not assume that what I give a person is right for them without having an opportunity to talk to them about it, and adjust the recording if necessary. Let’s hope the managers reading that particular article don’t assume that a recording is as good as the real thing.

Hypnosis: Response expectancies?

Let’s explore the proposed mechanisms in hypnosis as I wander through the subject this week.
According to some researchers, response expectancies, or ‘the expectation of one’s own non-volitional reactions to situational cues’ are thought to play a major part in both hypnosis and placebo responding. Let’s translate that: a person’s belief that they will respond to something may lead to them actually responding. Possibly the original ‘mind over matter’!

Both hypnosis and placebo (or meaning response – see Dan Moerman for more details on this!) are complex effects that are not yet really understood, except to confound most RCT’s and to provide food for thought for philosophers and psychologists and lay people alike. In this paper, response expectancies were experimentally examined to see whether they have a mediating effect on the effect of ‘suggested’ or placebo analgesia. The methodology is a wonderful design developed by Barron & Kenny, where separate sets of mediator analyses are performed in which the no-treatment control condition is contrasted in turn with each of the treatments. Performing the analyses in this way isolates the mediator function of response expectancies in each treatment. Three regression equations were estimated, to in turn, identify the strength of the relationship between each variable. For more of the maths, go to this paper!

What did they do?
A group of students were recruited to take part in a study examining the effectivenes of ‘an experimental topical anaesthetic’. They were not informed initially that hypnosis was part of the study, to minimise the chance that they would inadvertently over-report their levels of pain to ‘give room’ to pain reduction with hypnosis.

Pain intensity was measured using an 11 point graphical scale 0 = no pain, 10 = pain as intense as one can imagine, and taken every 20 seconds while their finger was put in a pain stimulator for one minute (cruel people these psychology professors!).

Pain expectancy was measured using the same 11 point scale and the score was taken immediately after the baseline pain rating and indicated the level of pain the participants expected to be like if they put their finger in the device without any intervention.  During the experiment, participants were asked to use this rating immediately after they had experienced a pain control intervention (but without putting a finger in the stimulator) indicating what participants expected the pain would be like while using the pain intervention they had just experienced.

The Carleton University Responsiveness to Suggestion Scale (CURSS) was used to establish how how much each participant responded to suggestions contained in the scale. This is a measure of three types of suggestability: ‘Objective suggestibility’ : what participants think an observer would have seen them do in response to each suggestion.
‘Subjective suggestibility’ : indicates participants’ internal experience of each suggestion.
‘Involuntariness’: assesses the extent to which participants experienced each suggestion as occurring automatically and without a feeling of effort.

The torture instrument? This was A Forgione-Barber Strain Gauge Pain Stimulator. Details shall remain secret, suffice to say that it squashes the fingertip so that it hurts (ouch! remind me not to be a psychology student).

There were two phases to the experiment: the preparation phase, during which participants were given information about pain management, and offered the chance to try a pain intervention without actually submitting to the finger device. They were then asked to rate what they thought the pain would have been like had they actually had the device applied to their finger while using that coping strategy.

During the intervention phase, participants were administered the intervention while actually submitting to the pain device, and making intensity ratings.

The interventions

Hypnotic analgesia – in the preparation phase, the participants listened to a tape recording presenting information about hypnosis (correcting myths), using the actual hypnotic induction from the CURSS, information about hypnotic analgesia, and an opportunity to experience a short ‘glove anaesthesia’.  In the intervention phase, participants had the same glove anaesthesia hypnosis, but actually got the pain.

In the ‘imaginative analgesia’ condition, participants experienced the same glove analgesia suggestion used in the hypnotic analgesia condition, but without the hypnotic induction or information designed to correct misconceptions about hypnosis. The glove anaesthesia was represented as a ‘guided imagery’. In the preparation phase, participants were asked to ‘use your imagination’ to experience the glove analgesia, while in the intervention phase, the induction was given ‘live’, and you guessed it, the pain was live too.

The placebo condition involved an inert solution presented as an experimental, local, topical anaesthetic, but was actually oil of thyme, and iodine, presented in a brown bottle and labelled ‘Trivaricaine: Approved for Research Purposes Only’. During the preparation phase, participants were told about the effects of analgesia, with a lot of showmanship to demonstrate how ‘powerful’ the liquid was. During the intervention phase, participants had this liquid applied, received the pain, and rated their pain.

The final group were given a ‘no treatment’ condition – They waited the same length of time between the initial rating of pain expectancy as the other three groups, then received the same pain, and asked to re-rate their pain.

I won’t detail the rest of the methodology, but it followed a random assignment format to the four conditions, with equal numbers of males and females to each condition. Strategies were undertaken to minimise the potential for demand bias, ‘hold-back’ effect, and of course, participants were free to withdraw if they chose to.

Results
As usual, I’m not going to go through all the statistical detail – it’s well-documented in the paper, and you should read it if you want to really scrutinise the quality of this study.

As hoped, there was an effect from giving people pain, and the scores differed depending on the pain interventions given – scores did change, with the no-treatment group reporting more intense pain than those in the placebo group, and those in either of the hypnotic groups.

The object of this experiment, however, wasn’t to establish whether hypnosis had an effect – it was to examine the effect of expectancy on pain intensity, and to look at suggestibility.

First up, suggestibility – ‘subjective and involuntariness dimensions of hypnotic suggestibility moderated the effect of the hypnotic analgesia treatment’ – what this means is that aspects of suggestibility do influence how effective hypnotic analgesia can be.

Then expectancies: ‘the effect of each of the three treatment conditions on pain intensity was partially mediated by response expectancies. The extent of mediation by response expectancies appeared to be greater in the placebo condition than in the hypnotic and imaginative analgesia conditions.’

What does this mean? The expectation that pain will be reduced influenced each of the treatment implemented – and more so on the placebo treatment.

Now that’s interesting!
Something about the beliefs that people place on not just the ‘active ingredients’ but the showmanship, ritual, and ‘hype’ involved in a treatment has an effect on how much pain relief a person achieves. Doesn’t that make you think about advertising for pharmaceuticals, the interpersonal skills involved in treatment – and how careful we need to be when discussing treatment options. However well-intentioned, I don’t think we can realistically offer impartial advice on different treatment options because we’re human – so how can a patient not be influenced by our (inadvertent) enthusiasm?

Milling, L. (2009). Response expectancies: a psychological mechanism of suggested and placebo analgesia Contemporary Hypnosis, 26 (2), 93-110 DOI: 10.1002/ch.379

It was a piece of cake! Hypnosis for sleep and tummy pain

After briefly looking at hypnosis yesterday, I found this lovely case study written by Leora Kuttner of an 11 year old girl with problems going off to sleep, including tummy pain and anxiety.

The girl had been through CBT, and introduced to the idea that she had a ‘worry bug’, and that the way to rid herself of the ‘worry bug’ was to ‘climb the fear ladder’. The ‘fear ladder’ being a graded hierarchy where her mother would gradually ease away from her side when going off to sleep. The problem being that this little girl kept waking as her mother left the room – and would start to panic. At 11 years old, this wasn’t exactly the best thing for her, given that girls like to go to sleep-overs!

Apparently this young girl had always been slow to get off to sleep, somewhat sickly, and quite fearful of being sick. Her mother had spent a lot of time helping to settle her at night, rubbing her tummy and often getting into bed with her to help her get off to sleep. You can see how easy it would be for this to reinforce the daughter’s anxiety about getting off to sleep! And the CBT approach is certainly one way of going about helping her to become more able to cope by herself – but it seemed that the process was taking a long time, and progress had halted because of the girl’s waking when her mother left the room.

Leora Kuttner is a very experienced psychologist, with a fun and playful approach with children, engaging with their imaginations – and that’s a big part of what hypnosis is all about. Hypnosis offers an opportunity for the ‘critical mind’ to switch off, and the playful imagination to be in front. It’s easy to see how children would be readily engaged in this process, especially an anxious child! After all, anxiety is the ability to imagine ‘as if’ it was happening now.

The intervention started with a hypnosis tape to help the child fall asleep – the usual breath regulation approach, with suggestions of ‘sweet sleep seeping in’ and the child finding it ‘easy and comfy’ to go off to sleep. This was used the first week – but once again, the girl heard her mother leaving the room and woke herself up feeling anxious and calling her for her mother. Now this is where I think creativity and playfulness came in!

Leora identified that the girl needed to feel competent, and to find a way for her to challenge her own anxiety about getting off to sleep. To do this, she asked the girl what her favourite home activity was – baking! So the pair carefully described the mixing and preparation of a cake – but as the girl described putting the cake carefully in the oven, Leora said ‘No you don’t! You drop it SPLAT!’. This puzzled the girl – she said ‘No I didn’t, I put it in the oven’. Leora then used a fantastic image straight from the girl’s own world to help challenge her sense of incompetence at sleep:

If you put the cake in the oven then there’d be no problem, and it would settle into the warmth easily, sleep the whole night through, and rise when done. But . . . you don’t let that happen, . . . you stop it . . . drop it . . . and all your good work goes splat on the floor! What a waste and what a mess − and surprisingly you’re actually a very neat kid, who doesn’t like messes!

The story goes on – ‘she was stunned, still and highly receptive. In that moment I sensed that she had got it. There was little more to say except to bring Mom into the picture, but in a very different role − one of supporting her daughter’s competence, instead of providing security for sleep’

Needless to say, it worked.

What was so hypnotic about this? Well – as the girl was caught up in the moment of describing her activity as if it were happening, she was in a trance – the perfect time for a suggestion to be made. The suggestion was that she was interrupting her own sense of competence by ‘dropping the cake’ just when it was ready to be baked.

I wonder if this is something we could use more often in therapy – helping someone change their own story by asking them to describe something they’re already competent at, then inserting a suggestion that challenges the way they’re managing their pain. A bit like suggesting that they’re fighting against themselves, scoring an own goal, driving the wrong way up a one way street, planting weeds instead of flowers or veges.

I think you need to choose the patient, and be comfortable yourself in your own sense of imagination – but what a powerful way to indirectly challenge an underlying unhelpful thought.

Kuttner, L. (2009). CBT and hypnosis: the worry-bug versus the cake Contemporary Hypnosis, 26 (1), 60-64 DOI: 10.1002/ch.375

Hypnosis for chronic pain management: How it works maybe?

There are plenty of people who look at me as if I’m stepping right into woowoo when I start to talk about hypnosis for managing chronic pain. I’m happy to say that science has provided some good evidence that not only does hypnosis have a neurophysiological basis, but it also has some good effect.

What exactly is hypnosis? Well, contrary to popular belief, it is NOT about a ‘hypnotist’ doing something to someone else – and most especially NOT about making people do things that they wouldn’t ordinarily consent to. This is the misconception that stage hypnotists perpetuate in an attempt to keep their mystique.

Hypnosis is ‘an induction followed by a suggestion (or set of suggestions)’ – now that has a lot of mystique, doesn’t it?! ‘The suggestions that follow the induction usually include ‘‘. . .suggestions for changes in subjective experience, alterations in perception, sensation, emotion, thought, or behavior” (Green JP, Barabasz AF, Barrett D, Montgomery GH. Forging ahead: the 2003 APA Division 30 definition of hypnosis. Int J Clin Exp Hypn 2005;53:259–64., cited in Jensen, in press).

I didn’t know it, but hypnosis has been used at least since the 1840’s (first documented evidence), but probably much, much earlier than this if we are to believe that trance and suggestion performed by various healers the world over are actually hypnosis.

Jensen’s paper suggests there are three reasons for the resurgence in popularity of hypnosis for pain management:

1. confirmation that chronic pain is influenced by the activity of supraspinal neurophysiological processes
2. similar evidence that neurophysiological processes associated with pain are influenced by hypnosis
3. empirical confirmation that hypnotic analgesia is effective for chronic pain management

In the first part of this paper, he reviews the evidence for chronic pain being influenced by supraspinal neurophysiological processes. To translate, this means activity above the level of the spinal cord (both descending and ascending) is implicated.  As Jensen puts it ‘the experience of pain is directly associated with multiple integrative and interlocking neurophysiological mechanisms and sites, with supraspinal sites playing a key role.’

It’s not enough to look only at the peripheral nervous system to understand how humans perceive pain – we need to look above and beyond!  The specific areas thought to be involved are the thalamus, the insula, the primary (S1) and secondary (S2) sensory cortices, the anterior cingulate cortex (ACC), and the prefrontal cortex.  This means that treatments can be based on altering activity in many of these sites, including hypnosis which affects the cortex
.

Incidentally, that site is a very good one if you’re interested in the science behind hypnosis (Hypnosis and Suggestion)

Jensen then briefly looks at imaging evidence that hypnosis has a direct effect on activity in many of the CNS sites associated with pain perception.  Studies have shown that when people are taken through a hypnotic induction, and asked to ‘imagine pain’, the cortical activity is quite different from those who are asked to simply ‘imagine pain’ without an induction.  He goes on to say ‘Presumably, if hypnotic suggestions can produce pain and increases in pain-related cortical activity, they might also be able to produce pain relief and decreases in activity in these same brain areas.’ – and he goes on to cite a further study where exactly this effect was obtained.  In that study, participants with chronic pain were asked to imagine their pain ‘low’, ‘medium’ and ‘high’ – one group under hypnosis, and the other simply asked to imagine.  While both groups achieved changes in perceived pain, along with concurrent imaging results, those who had been using a hypnotic induction had a greater response.

What is interesting is that hypnotic suggestion was able to target different areas of the brain – in one study, participants were asked to ‘imagine themselves distant from the pain’, leading to a change in activity in the ACC (a part of the limbic system that is associated with emotional responding), without concurrent change to the S1 and S2 cortices, which process sensation but not necessarily the emotional response to sensation.  The reverse activity was achieved when participants were asked to ‘imagine changes in pain intensity‘.

Clinical trials have also been held to study the effect of hypnosis on clinical chronic pain. Four new studies have been carried out since 2006, giving a total of 17 RCT’s for hypnosis – these recent studies demonstrate that ‘hypnosis was either as effective or more effective than other active treatments, and more effective than no treatment or standard care.’

Jensen identifies an interesting finding from these studies – although over 2/3 of participants continued to use self-hypnosis, only around 22 – 40% of participants experienced ‘clinically meaningful pain reduction’ which is 30% reduction in pain. Now why would people carry on doing something that doesn’t reduce their pain? Maybe it is, as Jensen points out, that this is a skill that can be carried out to produce even a small reduction in pain for some people, and it’s available at any time, so it may simply increase a sense of control and reduce the feeling of being overwhelmed.

The final section of this paper looks at ways to enhance the hypnotic effect – perhaps through virtual reality (already used for some painful procedures), combining hypnosis with neuralbiofeedback, and perhaps teaching self hypnosis early in the ‘life’ of a chronic pain problem. Jensen remarks that ‘it is also possible that this treatment could buffer some of the negative long-term effects of pain on the CNS.’ when endorsing the idea of early commencement of hypnosis for chronic pain – he then describes how hypnosis is currently being used in the military, on the battlefield, to help with war injuries.

Caution now: hypnosis doesn’t work for everyone. Not everyone who can be hypnotised will feel effects of hypnotic analgesia, and many will only feel effects short-term. Despite this, it seems a promising area for people who have chronic pain. Some real benefits ensue: it’s something a person can do for him or herself, it’s free, it has no side effects once learned, and most importantly, it has no calories!

Jensen, M. (2009). Hypnosis for chronic pain management: A new hope Pain DOI: 10.1016/j.pain.2009.06.027

Curious about hypnosis?

This week’s series of posts will probably be a bit random – bits and pieces of trivia that I find scattered about the interweb!

Like today’s post, which links to a site I stumbled across by chance, a New Zealand hypnotherapy site!

What I like about this site is the use of scientific references rather than opinion or testimony, and the list of myths that I think most people who teach hypnosis, and probably most people who try hypnosis, have encountered!

Some of the pages are not working, sadly – I’ve emailed the author Mike Reeves-McMillan from Titirangi in Auckland, so hopefully they’ll come back up sooner rather than later.  As you know I don’t endorse any specific therapist (or therapy) nor any products, but I do think the information on this site is worth a look.

If you’re interested in hypnosis – and fibromyalgia – this article, just published in European Journal of Pain and written by Stuart Derbyshire, Matthew Whalley and David Oakley, describes an fMRI analysis of Fibromyalgial pain and its modulation by hypnotic and non-hypnotic suggestion.

Recent studies from a range of discplines have been looking at the neuropsychology of ‘central sensitisation disorders’ such as fibromyalgia, irritable bowel syndrome, dysmennorhea, chronic fatigue syndrome and others (see Yunus, 2008).  This study uses fMRI to examine the changes that occur with suggestions regarding the pain experience of fibromyalgia with and without hypnotic induction.

The basic design was quite simple: suggestions following a hypnotic induction and the same suggestions without a hypnotic induction were used during functional MRI imaging to increase and decrease the subjective experience of fibromyalgia pain.

What happened? Suggestion in both conditions resulted in changes in reported pain intensity – but patients reported more control and greater pain reduction when they had been hypnotised.

What happened in the brain? Activation of the midbrain, cerebellum, thalamus and midcingulate, primary and secondary sensory, inferior parietal, insual and prefrontal cortices correlated wth reported changes.  The changes were of greater magnititue when suggestions followed a hypnotic induction in certain specific areas in the brain.

What does this tell us? It seems that in people who can be hypnotised, suggestions that fibromyalgia pain can be reduced (using an image of a dial which could be turned up or down) worked better in people who had a hypnotic induction.  The second interesting finding was that this indicates direct involvement of a network of areas widely associated with the pain ‘neuromatrix’ in the pain experience of people with fibromyalgia.

The study numbers were small, and typical of most experimental work, the selection criteria was quite strict – but for people who want to use hypnosis as a therapeutic strategy it is encouraging to see areas of the brain respond to the induction and suggestion.  Perhaps this is a strategy that is somewhat under-used in pain management – although I would probably call the method they used ‘imagery’ because it’s easier to describe and less likely to be misinterpreted by patients.

Derbeyshire SWG. et al., Fibromyalgia pain and its modulation by hypnotic and non-hypnotic suggestion: An fMRI analysis.  European Journal of Pain (2008), doi: 10.1016/j.ejpain.2008.06.010

YUNUS, M. (2008). Central Sensitivity Syndromes: A New Paradigm and Group Nosology for Fibromyalgia and Overlapping Conditions, and the Related Issue of Disease versus Illness. Seminars in Arthritis and Rheumatism, 37(6), 339-352. DOI: 10.1016/j.semarthrit.2007.09.003
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News for people interested in hypnosis and imagery

Hypnosis and the analgesic effect of suggestions has been the subject of much study over the years. Only recently, however, have the specific effects of suggested analgesia vs deeper hypnotic induction been studied, and equally, it’s only been possible recently to study the mechanisms through which this phenomenon occurs.

In the January edition of Pain (Pain. 2008 Jan;134(1-2):1-2. Epub 2007 Nov 26.), Pierre Rainville comments in an editorial about the additive effects of an analgesic suggestion to a hypnotic ‘deepening’ induction. He concludes from a study published in the same edition, that ‘both hypnotic induction and suggestions have analgesic effects but … that the effects of suggestions may be increased by hypnosis.’ The study he refers to is by Vilfredo De Pascalis, Immacolata Cacacea and Francesca Massicollea, from the University of Rome “La sapienza”, Department of Psychology, in which they study somatosensory event-related potentials (spikes in EEG readings) of people with high hypnotizability and low hypnotizability when subjected to painful electric stimuli under waking, hypnosis, and a cued eyes-open posthypnotic condition. The study, ‘Focused analgesia in waking and hypnosis: Effects on pain, memory, and somatosensory event-related potentials’ also published in the January 2008 edition of Pain, identified that hypnotic analgesia does affect both earlier and later stages of stimulation processing, and influences reported pain intensity, physiological markers, and memory for pain.

This is important basic science because until now, some clinicians have scoffed at the thought that something as ‘woolly’ and ‘psychological’ can have a fundamental physiological basis. In fact, some clinicians firmly believe that it is impossible to directly influence physiological responses to, for example, visceral pain.

If studies like this are conducted, using careful experimental methodology and as a result demonstrate that cortical processes actively influence processing of stimuli, I can see that eventually hypnotic induction and analgesia will be applied in many situations. It not only reinforces the notion that pain does not become pain until the cortex interprets a neural input, it suggests that these skills can be developed and actively recruited by people undergoing painful procedures, or while experiencing, for example, acute appendicitis!

Perhaps this is one clinical skill that should be routinely developed in all allied health programmes?

Rainville, P. (2008). Hypnosis and the analgesic effect of suggestions. Pain 134:1-2, pp 1-2

De Pascalis, Cacacea & Massicollea (2008). Focused analgesia in waking and hypnosis: Effects on pain, memory, and somatosensory event-related potentials. Pain 134:1-2, pp 197-208

While you’re reading those two, take a look at this article by Roy, Peretz, & Rainville (2008). The paper, Emotional valence contributes to music-induced analgesia, Pain. 2008 Jan;134(1-2):140-7. Epub 2007 May 25, examines the possibility that the modulatory effect of music on pain is mediated by the valence (pleasant-unpleasant dimension) of the emotions induced. Those results support the hypothesis that positive emotional valence contributes to music-induced analgesia, while negative emotional valence had little or no effect. Moral of this tale? Even though I’m no fan of my children’s hiphop, I can’t tell them it make my headache worse, I can just put my own, soothing, Natacha Atlas middle eastern fusion on and feel much, much better.