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The Use of Hypnosis in Pain Management
A Review of the Current State of Knowledge:
Hypnosis has long been understood to produce varied effects in subjects. Although the public at large tends to associate hypnosis with stage performances and bad sit-com episodes, the medical community has approached the topic in a different vein. Originally viewed as a magical cure-all, hypnosis has undergone tremendous amounts of scientific testing in modern times. When used in an appropriate manner, hypnosis has proven itself to be an effective tool in the management of pain and pain perception.
In this paper, I will initially address hypnosis from an historical perspective to give the reader a decent background in which to view current trends in research in the field. I will then explain how and when hypnosis has been shown to be effective in pain management, and illustrate some problems which have arisen in response to such research. Last, I intend to follow this discussion with a description of the current body of knowledge regarding the mechanisms, both psychological and physiological, behind which hypnosis lessens pain.
Hypnosis was discovered by a Viennese physician, Friederich Anton Mesmer, in the late 1700's. Mesmer began with a theory about animal magnetism, involving the distribution of magnetic fluid within an organism's body. He used hypnosis, then called Mesmerism, to produce a more harmonious distribution of this magnetic fluid in the body. Mesmer immediately understood the implications of his work, as he immediately claimed mesmerism as a superior form in which to hinder the development of disease without exposing the patient to the more hazardous techniques of the time period. In 1784, Louis XVI formed a commission to investigate Mesmer's findings. The commission was, incidentally, headed by none other than Benjamin Franklin. Although Mesmer's findings on hypnosis were undisputed by the commission, the commission played down the effects of an unfounded "magnetic fluid" in the human body and attributed Mesmerism's effects to a placebo effect. Because of the commission's findings regarding magnetism, Mesmerism fell from popularity (Hall, 1986)
In England around 1843, the surgeon James Braid revisited the phenomenon of Mesmerism and renamed it hypnosis, after the Greek god of sleep, Hypnos. He was the first person to attribute the phenomenon to psychological rather than physical variables. His findings renewed interest in the subject, especially in France, where hypnosis gained popularity again as a form of pain reduction during surgery. Eventually, Braid's technique was found to be unsatisfactory, and hypnosis drifted out of favor once again (Hall, 1986).
In the late 1800's, Bernheim and Liebeault came upon hypnosis as a treatment for physical and functional diseases, after one of Berheim's patients attributed her effective sciatica cure to hypnotic imagery. Bernheim and Liebeault began the most comprehensive study of hypnosis at the time, attempting to determine when and how hypnosis could be successfully applied. Once again, hypnosis lost favor to the effective new technological and medical advances of the period. Stronger emphasis was placed upon physical treatments for effective outcomes rather than psychological treatments (which was not an organized science at the time). This attitude continues today, although in the past several decades hypnosis has seen a revival of interest (Hall, 1986).
Once the scientific method has been applied to hypnosis, it has been shown to be increasingly effective in a wider variety of maladies than anyone had ever thought possible. At this point, the mechanisms for its effectiveness are not known, and many physicians continue to ignore its well-documented abilities. I propose that the medical community wants a definite, physical, and mechanistically sound approach the to treatment of any affliction. Because of this, the medical community tends to be neglectful of any treatment which ignores this "temperature-taking, shot-giving" mentality. Acupuncture has been scientifically supported as a viable alternative to invasive and costly treatments which are the norm, yet is not regularly addressed as an option for patients. Hypnosis falls under the same category. Until a mechanism can be described and proven, the medical community will probably continue to ignore a relatively easy and effective form of pain management, although hypnosis proponents are growing in numbers.
The body of literature which has investigated whether hypnosis can reduce pain sensitivity has been overwhelmingly supportive. An example of the many instances in which hypnosis has reduced pain sensitivity is in the Hajek, et al study of cutaneous pain threshold (1990). In the study, eczemic subjects under hypnosis reported a higher amount of applied pressure before pain was experienced than non-hypnotized subjects. In fact, hypnosis was shown to cure the patients quicker than those without! (Hajek et al, 1990)
In 1990, Evans investigated the possible ways in which hypnosis effectiveness varies according to different types of pain (Evans, 1990). He determined that the style of hypnosis was more important than the type of pain. For acute pain, he suggested hypnotic suggestions focusing on anxiety-reduction and emphasis on minimizing the importance of the pain. For chronic pain, Evans suggested directly confronting the pain under hypnosis, dealing with both the pain's physical and psychological effects on the patient (Evans, 1990).
In investigations of what types of pain hypnosis is effective and which types are not, most seem to indicate that hypnosis is universally successful in pain management. Hypnosis has been shown effective in management of many varied types of pain, including pain associated with childbirth (Weishaar, 1986), angioplasty (Weinstein & Au, 1991), leukemia (Silva, 1990), and even headaches (VanDyck, et al, 1991).
I wish to clarify an important point before continuing. There is a sizable amount of controversy involving the discrepancy between a curative approach to hypnosis and an analgesic approach. Although an analgesic approach may be the main focus of hypnosis literature, one must realize that if hypnosis provides an effective cure it would be considered an even more powerful treatment. For example, a patient with a severe tumor may find that hypnosis helps him/her to live comfortably. However, the tumor may continue to grow normally and eventually claim the life of the patient. Hypnosis, in this case, would simply be an analgesic. If the hypnosis actually were shown to make the tumor go into remission, then it would be applied in a curative approach.
Hall recognized this discrepancy by stating that "Far less attention has been focused on...the healing process" (Hall, 1986). Hawkins, however, argues with the necessity for a curative approach. Hawkins believes that clinics should focus their attentions on utilizing hypnosis to improve the patients' quality of life via a rehabilitation (or analgesic) methodology (Hawkins, 1988). He claims that frequent use of hypnosis as a cure are reliant upon outdated hypothesis that hypnosis is capable of curing a patient's source of pain rather than dealing with the pain itself. Hawkins, however, appears to be ignoring research which has addressed the curative powers of hypnosis. In a particularly intriguing case study, a patient was instructed in the use of hypnosis as a cure for warts (verrucae vulgaris). After a young girl attempted to use liquid nitrogen, curettage, and electrodessication to remove the warts on her hands, she used a hypnotic technique involving visualization of a wart-free hand. Within three months, the warts on her hand were completely eliminated, and continued to be gone for up to four months following her last treatment (Morris, 1985). This surprising case illustrates how hypnosis can, in fact, be used as a curative technique. Therefore, Hawkin's theory that hypnosis may be better used as an analgesic may be a bit nearsighted.
Another important point in this debate is that a curative process can also be considered an analgesic process. In fact, curing a malady is inarguably the best possible way to eliminate pain associated with it! If a treatment shortens the duration of a disorder, then it is certainly an analgesic, as it is also lessening the amount of suffering experienced by the patient. But because it also is eliminating the source of the pain, a curative treatment may be superior to an analgesic (assuming that the cure also reduces the pain felt by the patient).
Now that I have established the ways in which hypnosis can be effectively utilized to both lessen and cure pain, I wish to point out some problems which have been shown with this methodology.
A main difficulty in the widespread use of hypnosis involves the problem of hypnotizability ratings in patients. Frequently, hypnotizability has been positively correlated to effectiveness of the treatment. In a study of 55 headache sufferers, the deeper and more encompassing the hypnotic relaxation, the more in which patients self-reported pain reduction (VanDyck, et al, 1991). Unfortunately, this means that hypnotic treatments cannot be universally applied with the same degree of effectiveness. However, this should be considered par-for-the-course, as no treatment, either chemical, physical, or psychological, has ever been proven to be effective 100% of the time. If a treatment can help a sizable number of patients, it is then considered effective. Because hypnosis has been shown to be effective in pain management in many different studies in many different situations, it should not be ruled ineffective due to individual variations in hypnotizability.
Another interesting side-effect of hypnosis is that imagery presented to the patient highly influences the outcome. Patients under hypnosis are notorious for a literal interpretation of instructions, as in the case of subjects who are told they can only speak French, yet understand English when spoken to! This tends to not be a significant problem, but appropriate imagery must be used to achieve the desired outcomes. Adkins described a situation where a back patient's pain actually increased after receiving "heavy" imagery while under hypnosis (1986). Adkins suggests that the use of imagery involving lightness is much more effective than imagery which suggests body heaviness (1986). Obviously, the script which a physician uses to cure a patient's pain should be set according to some pain reduction standard. Unfortunately, such a standard does not currently exist, nor am I aware of any set of guidelines currently under development for maximal effectiveness of pain management.
Although it is fairly uncommon, there are cases in which hypnosis has simply been shown to not be terribly beneficial. In a study in which hypnotic management of labor pain was compared to a Lamaze method, neither hypnosis, Lamaze, nor a combination of the two were shown to be effective means for pain management (Venn, 1987). In contrast, Weishaar determined that hypnosis was a better method than Lamaze in regards to labor (1986). According to her, hypnosis requires a lower amount of effort, and helped the childbirth by making the mother more cooperative towards the doctors delivering the child. Incidentally, Weishaar was the subject of her own study! She compared the outcomes of her first and second children's' births in the article. Because of the discrepancies mentioned, no conclusion on this point can currently be drawn. More evidence supporting hypnosis as being a practical and effective use for labor pain management is needed before its effectiveness can be accurately assessed.
Regardless of the problems mentioned, hypnosis has been shown to be a useful tool for pain management in many situations. Most of the problems presented are surmountable, provided that the physician is careful to avoid the pitfalls of incorrect imagery and low hypnotizability in patients. In fact, some articles suggest that hypnosis is one of the great misunderstood treatments of our time! Egbert stated that it is his belief that all anesthetists should learn hypnosis techniques as part of their certification requirements (1985). Although it has not been well characterized in terms of its mechanisms of dealing with pain, hypnosis has been shown to be a relatively effective, safe, and inexpensive way in which patients can deal with their pain.
Now that I have explained how and why hypnosis is being used for pain management, I want to illustrate how hypnosis works. Unfortunately, there is no one on Earth who can conclusively explain the mechanisms by which hypnosis works! There is, however, scattered literature which attempts to describe the mechanism for hypnosis's effectiveness. I would like to issue a caveat to the reader at this point - this is a neophyte science at best, and the psychological and physiological mechanisms by which hypnosis operates are not well characterized nor understood. I therefore present what I have found to be available on the subject, as future research is required before any definite conclusions can be drawn.
The most common psychological explanation for how hypnosis works is based upon a dissociation model. This model has been seen in patients with multiple personality disorder. Dissociation eliminates pain by placing it in a sort of psychological storage area, away from the primary consciousness of the patient. This model of dissociation is commonly referred to as the "hidden observer" model of cognition.
Watkins and Watkins (1990) suggested that the dissociation which occurs in multiple personality patients can be analogously induced in normal hypnosis patients. They referred to the dissociation as the use of an "ego state", and that in a normal person this state is malleable, as seen in varying mood states. In some moods, we are susceptible to do things which in other moods we are not. It is when this ego state is faulty that it breaks off into the "hidden observer" model. But hypnosis can induce placement of pain into a "covert" ego state which is hidden away. Because of this model, it is noted that the pain is still there, it is simply tucked away so that it is not dealt with The pain, however may resurface later in an undesirable form, such as a nervous habit or fear. So far, no support to this resurfacing theory has been shown (Watkins & Watkins, 1990).
Unfortunately, this model of hypnosis mechanism is not very satisfying. Although it may explain where the pain goes to, it does not provide a definite road map for explaining the effectiveness of hypnosis. Why can't an awake patient simply "bury" the pain into a covert ego state? Why is hypnosis necessary to access such an ego state? Watkins and Watkins acknowledge these limitations, and claim that further research is required, especially in regards to their resurfacing theory.
Another interesting study compared the use of biofeedback with hypnosis to reduce test anxiety. Because both groups scored similarly, there may be a similar underlying mechanism responsible for their effectiveness. These results were compared to uses of desensitization and relaxation training, and were all found to be similar. Because all of those methods involve a form of a relaxation technique, that may be the underlying key to understanding hypnosis's effectiveness (Spies, 1979). Comprehension of relaxation may lead to a better understanding of all these techniques, including hypnosis. Once hypnosis is understood in regards to relaxation, it may yield the clues needed to explain its pain management capabilities. Once again, further research is required.
The physiological explanations for the mechanism by which hypnosis controls pain management are even less understood than the psychological models. This avenue of study has not been pursued by many researchers, and almost nothing is known in this area.
Weinstein and Au noticed that norepinephrine levels were significantly higher during angioplasty of hypnotized patients in comparison to non-hypnotized controls (Weinstein & Au, 1991). Consistent with that result is the knowledge that noradrenergic antagonists have inhibitory effects on REM sleep (Carlson, 1991). Because norepinephrine has an effect on sleep states, it is therefore possible that hypnosis increases these levels due to its similarity to an REM state of sleep. Unfortunately, endorphins are the neurotransmitter most frequently recognized as pain blockers. Research involving injection of a noradrenergic antagonist in hypnotized patients could lead to a more conclusive theory involving norepinephrine's role in hypnosis pain management.
Spiegel, et al, found a very conclusive physiological effect of hypnosis on pain management (1989). They determined that the neurophysiological amplitude of hypnotized subjects who were given pain-blocking imagery were significantly reduced in comparison to non-hypnotized subjects. They use this phenomenon to propose that there is, in fact, a definable neurophysiological basis for pain blockage via hypnosis. This would imply that hypnosis provides a measurable chemical inhibitory effect on pain conduction. Once again, further research is required to better characterize this inhibitory effect.
In conclusion, the field of hypnotic management of pain is in a strange position. Although hypnosis has been shown to be quite effective in many cases of pain, it tends to be somewhat of an undesirable method to lessen the pain. Hypnosis is an easy-to-administer procedure which has no deep or long-lasting side effects, yet most doctors ignore its effectiveness in lieu of more traditional methods. Even though its exact mechanisms of action are unknown, it still has merit. Fortunately, the body of knowledge regarding hypnosis continues to grow, and hopefully will one day address these issues. The trend will hopefully lead to an examination of the neurochemical basis for hypnosis pain management. Understanding of this mechanism can also lead to advances in comprehension of other relaxation and dissociative states. Obviously, the use of pain management via hypnosis should be rigorously examined, so that it can be available to patients and physicians as a useful and safe alternative to medication.
- Adkins, G. H. (1986). Hypnotic induction for the atypical patient. Journal of the American Academy of Medical Hypnoanalysts, 1(1), 34-37.
- Carlson, N. R. (1991). Physiology of behavior (4th ed.). Needham Heights, MA: Simon & Schuster.
- Egbert, L.D. (1985). The research, teaching, and use of psychologic factors are definitely not a major concern among surgeons and anesthetists. Advances, 2(4), 56-59.
- Evans, F. J. (1990). Hypnosis and pain control. Australian Journal of Clinical and Experimental Hypnosis, 33(1), 1-10.
- Hajek, P., Radil, T., & Jakoubek, B. (1991). Hypnotic skin analgesy in healthy individuals and patients with atopic eczema. Homeostasis in Health and Disease, 33(3), 156-157.
- Hall, H. (1986). Hypnosis, suggestion, and the psychology of healing : A historical perspective. Advances, 3(3), 29-37.
- Hawkins, R. (1988). The role of hypnotherapy in the pain clinic. Australian Journal of Clinical and Experimental Hypnosis, 16(1), 23-30.
- Morris, B. A. (1985). Hypnotherapy of warts using the Simonton visualization technique. American Journal of Clinical Hypnosis, 27(4), 237-240.
- Silva, M. N. (1990). "May the force be with you" hypnotherapy with a leukemic child. Psychotherapy in Private Practice, 8(3), 49-54.
- Spiegel, D., Bierre, P., & Rootenberg, J. (1989). Hypnotic alteration of somatosensory perception. American Journal of Psychiatry, 146(6), 749-754.
- Spies, G. (1979). Desensitization of test anxiety: hypnosis compared with biofeedback. The American Journal of Clinical Hypnosis, 22(2), 108-111.
- VanDyck, R., Zitman, F. G., Linssen, A. C., & Spinhoven, P. (1991). Autogenic training and future oriented hypnotic imagery in the treatment of tension headaches. International Journal of Clinical and Experimental Hypnosis, 39(1), 6-23.
- Venn, J. (1987). Hypnosis and Lamaze method. International Journal of Clinical and Experimental Hypnosis, 35(2), 79-82.
- Watkins, J. G., & Watkins, H. H. (1990). Dissociation and displacement : where goes the ouch? American Journal of Clinical Hypnosis, 33(1), 1-10.
- Weinstein, E. J., & Au, P. K. (1991). Use of hypnosis during angioplasty. American Journal of Clinical Hypnosis, 34(1), 29-37.
- Weishaar, B. B. (1986). A comparison of Lamaze and hypnosis in the management of labor. American Journal of Clinical Hypnosis, 28(4), 214-217.
University of California, Los Angeles
June 7, 1993
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