Hypnotic Techniques for Chronic Pain Management: Favorite Methods for Master Clinicians: Voices of Experience, #2

CHAPTER 1

INTRODUCTION

Mark P. Jensen

Chronic pain, usually defined as pain that persists for three months or more following initial onset, is a common and costly problem worldwide. As many as 37% of individuals in developed countries and 41% of individuals in developing countries report having had chronic pain in the previous 12 months (Tsang et al., 2008). Chronic pain is also a common comorbid problem associated with many health conditions, such as cancer, diabetes, multiple sclerosis, and spinal cord injury.

Chronic pain can, and for many people does, contribute to depression, sleep problems, relationship difficulties, vocational dysfunction, and inactivity. Through various biological and behavioral mechanisms, these negative effects of pain can themselves then result in more pain. This can create a vicious cycle of pain leading to depression, sleep problems, and disability, then increased pain, with subsequent worsening depression, sleep problems and disability (Bunzli et al., 2017; Tanik et al., 2016). In this way, and over time, pain and its associated negative effects can become self-perpetuating, long after the original injury associated with pain onset has healed.

By the time the pain problem is diagnosed as a chronic condition, many patients have received numerous biomedical treatments, including analgesic medications, surgeries, and medical procedures (e.g., nerve blocks). However, these biomedical treatments often target mechanisms that are no longer causing or maintaining the pain problem. Hence, while they might produce some temporary relief for some patients, biomedical interventions rarely have sustained benefits (Novy et al., 1995). Moreover, many of the biomedical treatments that are commonly provided to relieve chronic pain can cause adverse events and physical changes that contribute to more pain over time, making the problem worse rather than better (Annemans, 2011; Davis et al., 2017; Machado et al., 2017).

Over the past two decades, a growing body of research has demonstrated the beneficial effects of hypnosis and training in self-hypnosis for reducing pain and pain-related disability in individuals with chronic pain (Adachi et al., 2014; Jensen, 2009; Patterson & Jensen, 2003). The reason hypnosis is helpful for so many people is that it does, in fact, effectively target the central nervous system mechanisms that are maintaining the pain (Jensen et al., 2015). The purpose of this book is to provide clinicians working with patients who have been given the diagnosis of chronic pain specific examples of hypnotic techniques and approaches that master clinicians have found in their extensive clinical experience to be most effective.

In the first of these chapters (Chapter 2 of this book), David R. Patterson emphasizes the multifactorial biopsychosocial nature of pain. He makes the important point that patients who carry a diagnosis of chronic pain should be assessed from a biopsychosocial perspective, in order to identify the most important treatment goals. He notes that for some patients the most important treatment goal might not be pain reduction. He then describes a treatment approach based on both biopsychosocial and Ericksonian perspectives, incorporating many classic Ericksonian strategies. This includes use of a nonlinear induction, and suggestions that make use of confusion, truisms, indirect suggestions, metaphors, and patient choice. The specific example he provides illustrates this approach beautifully.

In Chapter 3, Alan O. Szmelskyj also notes the complexity of chronic pain—in this case, chronic back pain—and the importance of a thorough assessment that identifies the factors that are contributing to the patient’s pain. He points out that among the most common contributors to the perpetuation of pain are negative beliefs about the pain, low levels of activity, fear of pain, depression, and a history of traumatic life events. For back pain especially, fear of movement and inactivity are often key. To address these issues, he provides an example of an induction and suggestions that use imagery, age regression and age progression to increase comfort associated with increases in activity and movement.

In the Chapter 4, Giuseppe De Benedittis provides a thorough state-of-the-science review of the pathogenesis of fibromyalgia syndrome (FMS). He notes that while there is not yet consensus among experts regarding the best treatments for FMS, multimodal and multidisciplinary treatments—especially those that include cognitive behavioral therapy—are commonly recommended. At the same time, there is a growing body of research supporting hypnosis as a promising treatment for FMS. Professor De Benedittis provides two examples of scripts that he has found to be effective in his clinical work. One example includes an induction followed by suggestions that utilize imagery for achieving comfort, well-being, energy, and a positive body image. The second uses age regression to recover and nurture inner resources and suggestions to instill expectations for a positive future life.

Chronic pain is also a common comorbidity of gastrointestinal (GI) conditions. In chapter 5, Olafur S. Palsson cites the extensive evidence supporting the efficacy of hypnosis in the treatment of GI pain. He presents a model of hypnotic treatment that includes: (1) maximizing the patient’s receptive state, (2) presenting suggestions that target the four components of GI-related pain, and (3) linking the suggestions for improvements to imagery. The script he presents clearly demonstrates these principals.

In Chapter 6, Stella C. Nkenke describes how hypnosis can benefit patients with complex regional pain syndrome (CRPS). Having had a history of CRPS herself gives her a unique perspective on this complex and challenging condition. Because treating CRPS soon after it develops can make recovery easier, it is extremely important for clinicians to recognize this condition. Hence, Dr. Nkenke’s description of the clinical presentation and diagnostic criteria for CRPS is a critical component of the chapter. Treatment of CRPS is complicated, and no single treatment has been found to be universally effective. Dr. Nkenke points out that successful outcomes with CRPS treatment require that the patient do regular home practice of the skills they have been taught. The example treatment that Dr. Nkenke describes includes suggestions for an integration of the affected body part (with CRPS, this is most often the arm or leg) and nurturing associations between the CRPS diagnostic label and positive emotions and goals.

In Chapter 7, I discuss three facts about chronic pain that have important implications for the clinical use of hypnosis in providing comfort to patients: (1) pain is the end result of a complex interaction of activity in different parts of the brain and body; (2) pain is an experience created by the brain, not a sensation perceived by the brain; and (3) there are five clear strategies that clinicians can incorporate into their hypnosis sessions that will enhance outcomes. After reviewing these, I describe and provide examples of six evidence-based approaches, each designed to help patients who have chronic pain experience greater comfort.

In chapter 8, Shigeru Matsuki emphasizes the critical importance of tailoring treatment to each patient’s goals and needs. He presents the case of a patient with chronic pain who did not respond to a number of standardized hypnotic treatments (i.e., hypnotic approaches with demonstrated efficacy, on average), and who required a unique approach to address his chronic pain problem. In this case study, Professor Matsuki also shows how it is possible to listen carefully for the meaning underlying the many verbal and non-verbal communications provided by patients, and to incorporate this understanding into treatment. His case study illustrates the point that, given their experience with refractory cases, master clinicians are in an excellent position to discover and contribute new treatments that optimize efficacy. These treatments then have the potential to prompt further research into the factors contributing to therapeutic success.

In Chapter 9, Burkhard Peter describes two hypnotic techniques that he has found especially useful for helping patients with chronic pain. The first involves helping patients create an internal representation of pain that they can then change from a physical/kinesthetic experience to an alternative (visual, auditory, or tactile) sensory experience. He has found this technique to be particularly effective when the pain problem is focal and when the pain is not playing an important functional (e.g., social) role for the patient. The second technique is more effective for patients with more diffuse pain and/or with those for whom psychosocial factors may be playing a larger role. It involves inviting the patient to create in his or her imagination both a symptom carrier and an anti-symptom carrier who, respectively, do and do not have the same symptoms as the patient. Imagined interactions between the patient and these two individuals then allows the patient to gain important insight into his or her own pain problem.

Milton H. Erickson is well known for his use of hypnosis to assist individuals presenting with many problems and conditions, including chronic pain. In Chapter 10, Roxanna Erickson-Klein describes the various strategies that Milton Erickson used for treating chronic pain, and then provides detailed scripts and descriptions from his writings as examples of these strategies. She complements this information with a case study of a patient with a history of a back injury, treated in an integrated way using the Ericksonian techniques and approaches she describes.

In Chapter 11, Miyuki Mizutani summarizes the hypnotic approach she has developed for use in the context of a multidisciplinary pain treatment program. She has found it useful to think of hypnosis treatment as involving two distinct phases. The initial phase lasts until the patient first experiences a clinically meaningful—but not necessarily (yet) durable—decrease in pain during a session. During the second phase, the patient learns to use hypnosis to maintain the comfort achieved and can then experience this comfort outside of the session and in his or her daily life. Dr. Mizutani notes the importance of avoiding negative ideas and suggestions during treatment (i.e., to avoid referring to the patient’s pain as chronic, which implies that it will not change). She presents two transcripts of sessions that illustrate her approach, including a number of suggestions for helping patients to experience changes in their pain.

In Chapter 12, Hansjörg Ebell emphasizes the importance of the patient-clinician relationship in developing a treatment plan. The patient has expertise with respect to his or her experience and available resources, and the clinician has expert knowledge about the biological, psychological, and social factors that can contribute to pain and dysfunction, as well as the treatments that can influence these. Together, the patient and clinician can use their respective areas of expertise to help the patient change focus. Central to this change is the identification of the appropriate (hypnotic) suggestions that will help a patient make a shift from viewing pain as something to be fought against or removed (i.e., the biomedical find and fix it approach to pain management), towards a focus on nurturing the patient’s resources and identifying solutions for achieving well-being. Dr. Ebell presents a case study that illustrates how this process can be successfully applied in a patient with complex regional pain syndrome.

Leora Kuttner notes in Chapter 13 that patients often receive messages from health care providers that can be both inaccurate and disheartening. Being told that, There is nothing we can do about your pain can leave patients feeling helpless. Thus, a critical component of pain treatment is to provide patients with accurate, state-of-the-science information about pain. A key message is that the patient’s pain is only chronic until it changes, then it’s not. She describes and then provides an example of a specific favorite hypnotic technique—the Pain Switch—that on the surface targets pain reduction but also facilitates the development of self-efficacy and self-management skills.

Finally, in Chapter 14, Daniel P. Kohen emphasizes the importance of rapport in effective use of hypnosis and how clinicians can facilitate this. In his work, he is extremely attentive to his and the patient’s language, and he gently interrupts any negative words. The example transcript he offers of a session with a 12-year-old boy presenting with frequent migraine headaches shows how he uses hypnotic language to develop rapport, re-frame the presenting symptoms, identify patient resources, and increase outcome expectations and motivation. He then demonstrates how he integrates this all into a formal hypnotic experience.

Universal Issues

There are some consistent threads that run through all or nearly all of the chapters. These threads of consistency likely represent universal ideas that may be particularly important in the hypnotic treatment of chronic pain in all contexts. They include the ideas that: (1) pain is a complex biopsychosocial phenomenon; (2) because each patient is unique, with different biological, psychological, and social factors contributing to his or her pain problem, treatment must be tailored to each particular patient; (3) because pain impacts many quality of life domains, and these domains can then impact pain, treatment often needs to target other outcomes in addition to (and sometimes instead of) pain intensity; and (4) a key underlying principal in chronic pain treatment is patient empowerment.

Pain is a Complex Biopsychosocial Phenomenon

Virtually every author discussed the fact that pain is complex, and most noted that biological, psychological, and social factors contribute to the severity of pain and its impact on a patient’s life. This point was central to Patterson’s chapter (as indicated by the use of the term biopsychosocial in his chapter title, see Chapter 2), but was also mentioned by the majority of the master clinicians who wrote chapters for this book. These discussions emphasize a critical point made by Melzack and Wall over 50 years ago: pain is not only the result of the amount of damage done to tissue (Melzack & Wall, 1965).

In fact, for many individuals who might carry the diagnosis of chronic pain, the amount of tissue damage present plays little to no role in the amount of pain the brain creates. Instead, pain is created by the brain automatically (i.e., without conscious control or influence) in order to protect the individual from potential harm in response to multiple physiological, psychological, and social cues (cf. Moseley & Butler, 2015). It is likely that the automatic and non-conscious nature of pain’s creation is one of the reasons that hypnosis and hypnotic treatments are so effective for chronic pain management, given hypnosis’ ability to impact these processes.

Hypnotic Treatment Should be Tailored to Each Patient

Given the complexity of pain and the many factors that contribute to and influence its creation, it is extremely unlikely that the same factors are contributing to the pain of any two or more patients. Two patients may report an average pain intensity level of 7 on a 0-10 scale, but the biological, psychological, and social factors that contribute to this level 7 are almost always, if not always, different for each patient. This means that it is imperative for clinicians to perform a thorough biological, psychological, and social assessment of each patient. If the clinician does not have expertise in any one of these domains, then it is ethically important to ensure that the patient has received a thorough evaluation by the appropriate experts. For example, psychologists should not begin treating patients with a history of chronic pain until they know that the patient has had a thorough medical evaluation by an appropriately trained health care professional, and the psychologist has access to the results of that evaluation. Once an understanding has been reached of the patient’s circumstances in each of the three domains, treatment goals and approaches should be developed with this understanding in mind.

Moreover, even when one domain (e.g., psychological) plays a more important role to a particular patient’s pain problem than other domains (e.g., biological or social), within that domain, the contributing factors are going to differ from one patient to another. For example, within the psychological domain, for some a critical issue might be fear of movement. For others, it might be a focus on the search for a biomedical cure and a lack of self-efficacy regarding pain management. For still others, the most important issue might be a preponderance of negative (catastrophizing) self-talk that inhibits positive change.

Thus, it is important for clinicians to (1) be aware of the different factors within a particular domain that could potentially be contributing to the patient’s pain experience, (2) identify the factors that are playing the most important roles in any particular patient’s problem, and (3) develop a treatment plan that addresses each factor, as appropriate. The good news is that hypnosis can be used to facilitate the treatment of many of these factors, as illustrated in the chapters presented in this book.

Hypnosis Can (and Should) be Used to Facilitate Change in a Variety of Pain Outcomes

Although many patients with pain seek treatment with an initial primary goal of experiencing a reduction in the intensity of their usual pain, many of the authors in this volume noted that pain intensity need not be the only—or necessarily the primary—treatment target. Individuals with a history of ongoing pain can, and often do, report disruption in their sleep, mood, relationships, ability to work outside the home, and ability to engage in physical activities. As discussed previously, disruption in any of these areas can contribute to increased pain.

Thus, and paradoxically for many patients, if treatment focuses only on pain reduction without also targeting improvements in sleep quality, mood, and tolerance for activity, overall improvements in pain intensity may be limited. Readers may consider paying particular attention to the chapters that include discussion and hypnotic approaches which offer suggestions for improving these other critical outcomes. For example:

• You see yourself moving fluidly, comfortably… just loving life. And that feeling fills your entire body. … And maybe you will be curious about how you fall into a deep, profound, restful sleep when your head hits the pillow… (Patterson, Chapter 2).

• You may want to allow yourself now, and in the future, to walk just a little bit more, a little bit more than you used to… (Szmelskyj, Chapter 3).

• You are becoming happy, confident, energetic, and are progressing toward making yourself the best you that you can be… [an] incredible experience of well-being, full of energy… (De Benedittis, Chapter 4).

• …perhaps you are stronger… perhaps more fit… you have made important steps towards goals that are most meaningful to you… and succeeded. You can see how wonderful you feel. … Seeing your future self very vividly now… perhaps there is a smile on your face… the way you move… (Jensen, Chapter 6).

• Respect the need to balance rest with the productivity of work… (Erickson-Klein, Chapter 10).

Treatment Should Include a Focus on Patient Empowerment

Almost all of the authors discuss how the techniques they use are helpful for increasing patient self-efficacy for managing pain. Even as they emphasize the importance of automaticity of the treatment benefits—that benefits can and often do occur without any perceived effort on the part of the patient—these master clinicians teach patients how to use self-hypnosis to help maintain and expand these benefits.

These clinicians emphasize self-efficacy, self-control, and patient confidence in large part because they recognize that ongoing pain can undermine a patient’s sense of self-efficacy and control over their lives, and control over the activities that they find most meaningful and valuable. Thus, careful readers will recognize both the implicit and explicit focus on patient empowerment and self-efficacy in the hypnotic scripts offered. For example:

• … allow yourself to see your body and your back move gently side to side; all the while, feeling in control… the great pleasure and fun you feel as under your own control. … And enjoy how much better and more confident and comfortable you’ve become at doing what you want to do, and need to do… (Szmelskyj, Chapter 3).

• …continuing to move onward... you are in full control… (De Benedittis, Chapter 4).

• Would you be willing to learn a technique that draws on what you’ve learned today… one that empowers you to be the boss of your own body? ... and gives you back some control over your sensations, so that you can start feeling better? (Kuttner, Chapter 13).

Research evidence and clinical experience demonstrate that hypnosis and hypnotic strategies are effective for helping individuals who have been given a diagnosis of chronic pain. The authors who have contributed chapters to this volume represent the most experienced and knowledgeable clinicians working in this field throughout the world today. By learning and then using the strategies and techniques described here, clinicians will acquire additional tools to effectively help their patients improve comfort and achieve their most valued goals.

References

Adachi, T., Fujino, H., Nakae, A., Mashimo, T., & Sasaki, J. (2014). A meta-analysis of hypnosis for chronic pain problems: A comparison between hypnosis, standard care, and other psychological interventions. International Journal of Clinical and Experimental Hypnosis, 62, 1-28.

Annemans, L. (2011). Pharmacoeconomic impact of adverse events of long-term opioid treatment for the management of persistent pain. Clinical Drug Investigation, 31, 73-86.

Bunzli, S., Smith, A., Schutze, R., Lin, I., & O’Sullivan, P. (2017). Making sense of low back pain and pain-related fear. Journal of Orthopaedic & Sports Physical Therapy, 47, 628-636.

Davis, M. P., Behm, B., & Balachandran, D. (2017). Looking both ways before crossing the street: Assessing the benefits and risk of opioids in treating patients at risk of sleep-disordered breathing for pain and dyspnea. Journal of Opioid Management, 13, 183-196.

Jensen, M. P. (2009). Hypnosis for chronic pain management: A new hope. Pain, 146, 235-237.

Jensen, M. P., Adachi, T., Tomé-Pires, C., Lee, J., Osman, Z. J., & Miró, J. (2015). Mechanisms of hypnosis: Towards the development of a biopsychosocial model. International Journal of Clinical and Experimental Hypnosis, 63, 34-75.

Machado, G. C., Maher, C. G., Ferreira, P. H., Harris, I. A., Deyo, R. A., McKay, D., … Ferreira, M. L. (2017). Trends, complications, and costs for hospital admission and surgery for lumbar spinal stenosis. Spine, 42, 1737-1743.

Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.

Moseley, G. L., & Butler, D. S. (2015). Fifteen years of explaining pain: The past, present, and future. Journal of Pain, 16, 807-813.

Novy, D. M., Nelson, D. V., Francis, D. J., & Turk, D. C. (1995). Perspectives of chronic pain: An evaluative comparison of restrictive and comprehensive models. Psychological Bulletin, 118, 238-247.

Patterson, D. R., & Jensen, M. P. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129, 495-521.

Tanik, N., Sarp, U., Ucar, M., Celikbilek, A., Balbaloglu, O., Ak, H., … Inan, L. E. (2016). Pain, depression and sleep disorders in patients with diabetic and nondiabetic carpal tunnel syndrome: A vicious cycle. Arquivos de Neuro-Psiquiatria, 74, 207-211.

Tsang, A., Von Korff, M., Lee, S., Alonso, J., Karam, E., Angermeyer, M. C., … Watanabe, M. (2008). Common chronic pain conditions in developed and developing countries: Gender and age differences and comorbidity with depression-anxiety disorders. Journal of Pain, 9, 883-891.

CHAPTER 2

A MULTILAYERED, BIOPSYCHOSOCIAL APPROACH TO CHRONIC PAIN

David R. Patterson

David R. Patterson is a Professor of Psychology in the Departments of Rehabilitation Medicine, Surgery, and Psychology at the University of Washington School of Medicine, located in Seattle, Washington, USA. He is internationally recognized for his work in the area of hypnosis for pain control, as well as the psychology of burn and trauma injuries. Dr. Patterson is the author of Clinical Hypnosis for Pain Control, published by APA in 2010 (Patterson, 2010), as well as over 150 articles and book chapters. He has been funded by the National Institutes of Health for his work using hypnosis and virtual reality since 1989, and one of his grants with this agency continues to this date. He has received numerous awards for his work in hypnosis.

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Chronic pain is an inordinately complex issue to treat by any means. In a sense, we are often chasing a phantom when attempting to manage chronic pain. As Bill Fordyce taught us decades ago, when treating chronic pain, we are really addressing suffering rather than pain (Fordyce, 1976).

What patients view as pain