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Hypnotherapy For Pain and Other Conditions

Hypnotherapy is the use of hypnosis as a medical intervention, usually for the treatment of pain and other subjective symptoms. It remains controversial, primarily because the evidence for its efficacy is not yet compelling, but also because it is poorly understood. This situation is not helped by the fact that it is often characterized as an “alternative” therapy, a label that can “ghettoize” an otherwise legitimate treatment modality.

What Is Hypnosis?

Any meaningful discussion of hypnosis, or any other phenomenon, needs to start with a specific, and hopefully operational, definition.  If we cannot define hypnosis then it becomes impossible to meaningfully discuss it. The problem of definition plagues the science dealing with many so-called alternative therapies, such as acupuncture.  Good science requires controlling for specific variables, so that we can determine which variables are having what effects. If we don’t know which variables are part of the operational definition of a specific therapy, then we cannot conduct proper studies or interpret their results.

For example, with acupuncture, in my opinion the only meaningful definition of this procedure is the placing of thin needles into specific acupuncture points in order to elicit a specific response. Research has shown, however, that acupuncture points do not exist, that placing needles at specific points is not associated with a specific outcome, and even that sticking needles through the skin (as opposed to just poking the skin superficially) does not correlate with outcome. When these variables are isolated they do not appear to contribute anything to efficacy, therefore one might conclude that acupuncture does not work. Research into acupuncture, however, often does not adequately isolate these variables from the therapeutic ritual that surrounds acupuncture, or even mixes in other modalities, such as electrical stimulation.

Psychologically-based therapies all suffer from this potential failing as well. It is difficult to separate the variables that are specific to a treatment from the non-specific elements of the therapeutic interaction.

What, then, are the variables specific to hypnosis that make it an identifiable intervention? This is not clear, but we can start with a definition of hypnosis based upon our current understanding. Hypnosis, first of all, is not what happens on stage for the purpose of entertainment. It is not about making people act like a chicken. It is also not a deep sleep or trance-like state. Hypnosis, however, is believed to be a specific state of consciousness. We experience different states of consciousness all the time, defined by differences in alertness and focus of attention. Hypnosis, rather than being a sleep-like state, is actually a state of heightened alertness. Attention, however, is focused (usually on the hypnotist or something they are using as a focus of attention). In this state subjects are more responsive to social cues and suggestion.

The above description of hypnosis is fairly superficial, and is still a matter of ongoing debate. There are conflicts between the conceptual definition of hypnosis (what we think is going on in the brain) and the operational definition (how we define it experimentally). Some researchers suggest that the operational definition is simply increased suggestibility following a hypnotic induction procedure. Even this stripped down definition has problems as it is not clear if hypnosis depth scales are just measuring baseline suggestibility, rather than a hypnosis effect.

My understanding of the current state of the research is that the hypnotic induction procedure may place subjects in a state in which they are focusing their conscious attention and are more receptive to unconscious processing of information (suggestibility). Beyond this there are many theories as to what is going on in the brain, but at present we simply do not really know and much more research is needed. There is no consensus as to the theoretical model of hypnosis. This makes clinical research into hypnosis difficult.

Hypnosis as Therapy

Regardless of the conceptual definition of hypnosis, if we have a standardized operational definition then we can study its effects. Systematic reviews of hypnosis for specific indications, however, generally observe heterogeneity of operational definition of hypnosis across trials. In other words — there often is no consistent operational definition of hypnosis and this makes it difficult to interpret study results. This is another way of saying that clinical research often does not adequately control for variables that allow us to isolate something that can meaningfully be called “hypnosis.”

This is all another way of saying that effects seen from hypnosis may all be either placebo effects or non-specific effects from the therapeutic interaction, rather than a specific response to hypnosis itself.

A systematic review of hypnosis for fibromyalgia pain, for example, found that:

The significant effect on pain at final treatment was associated with low methodological and low treatment quality.

CONCLUSION: Further studies with better treatment quality and adequate methodological quality assessing all key domains of FMS are necessary to clarify the efficacy of H/GI in FMS.

Studies used variable definitions of hypnosis and control of what exactly was being delivered, and poor study quality correlated with positive outcome — a trend that always calls into question whether or not there is a real effect present.

Other systematic reviews of hypnosis for pain control generally find positive effects, but they do not always carefully assess for methodological quality (such as for cancer pain). A systematic review of hypnosis for labor pain also found positive effects, but also cited methodological limitations in the research.

The major limitation of much of this research is that it does not adequately control for the effects of relaxation, cognitive therapy, expectation, or the introduction of a novel therapeutic intervention — all phenomena that may “come along for the ride” with hypnotherapy but not be specific to hypnotherapy. In other words — is hypnotherapy a necessary component of a positive therapeutic effect or is it an unnecessary ritual by which other non-specific elements have an effect? Some researchers are trying to tease apart these variables, but that constitutes a minority of the clinical research on hypnotherapy.

Conclusion

My personal current summary of the clinical research is that there is a suggestion of a positive effect from the specific operational elements of hypnosis (specifically increased suggestibility) for the treatment of subjective symptoms, like pain and nausea, that are amenable to suggestibility. However, the research has not yet adequately isolated this variable and therefore more research of better methodological quality is necessary to definitively answer this question. Until then hypnotherapy will remain controversial.

The more basic question as to what hypnosis is also is in an early stage of research, although there do seem to be some promising conceptual theories. The use of fMRI and other techniques may help define hypnosis from a neuroanatomical perspective, and this may further aid in understanding what hypnosis actually is.

Meanwhile, I find it counterproductive to lump hypnosis in with the broad and poorly defined category of “alternative” therapies. A recent article on hypnotherapy, for example, contained this quote from a practitioner:

“You can think of it in the same general healing family as acupuncture, massage [or] Chinese herbs,” he said. “All of these are kind of nonmainstream or alternative or holistic treatments. But they are gaining much more respect and popularity every year in our country. These are things they’ve been doing in China or India for thousands of years.”

You can see how this approach causes only confusion. Hypnotherapy has not been used in China or India for thousands of years, and has absolutely nothing conceptually in common with any of the modalities mentioned. The only possible connection among these various treatments that would put them into a common “alternative” group is the lack of scientific support or the confusion of placebo effects for specific effects. This is exactly what I meant by the “ghettoizing” of hypnotherapy.

It would be unfortunate for this to happen. I would rather see hard scientific research to better define hypnosis and its therapeutic potential.

Posted in: Neuroscience/Mental Health

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21 thoughts on “Hypnotherapy For Pain and Other Conditions

  1. windriven says:

    A question that often dogs me in conversations about new or unusual or alternative therapies is: how is the proposed therapy better than exiting therapies?

    Many of the studies (of, for instance, sCAMs) discussed in these pages suggest that some slight therapeutic effect might be teased out of the background noise – and this is usually ascribed to placebo effects. But let’s imagine for a moment that the effects are real, not placebo, and exist at the levels shown by the research. In almost every case that still leaves one asking: so what?

    The armamentarium already offers a cornucopia of therapies and modalities for pain and for nausea; treatments that produce substantial effects. Why then even propose interventions of barely arguable merit as therapies to be used in current practice?

    Stated differently, to be a serious contender for clinical use, a proposed therapy should fill an important gap in a benefit/side-effect map of available treatments.

  2. WilliamLawrenceUtridge says:

    I wonder if you could use hypnotizability scales to differentiate groups within acupuncture and homeopathy trials to control for suggestibility?

    Science!

  3. Jan Willem Nienhuys says:

    Hypnosis was only invented in the wake of Mesmer, in the 19th century. One of the problems is that as far as I know most hypnotized subjects come from a culture that has some kind of idea about what hypnotized people are supposed to do. Of course the hypnotiser him- or herself also knows and instructs the client. So in a way it is a kind of theatre play where the client is supposed to play a very special kind of role. In experiments it is nearly or completely impossible to distinguish persons that have been instructed to acts as if
    they were hypnotized and ‘really’ hypnotiozed people.

    Of course, there may be hardly any difference. In the one case the ‘patient’ complies with the leader of the experiment who instructs him to play act hypnosis, in the other case the patient complies with the implicit suggestion of the hypnotiser to conform to the suggestions of the hypnotiser. In both cases the client or patient voluntarily shuts out critical faculties and goes into total obedience mode.

  4. mousethatroared says:

    Interesting article! I actually had assumed that hypnosis was a complete scam. Interesting to see that there is a possibility of some benefit.

    @Windriven, I don’t know much about hypnosis, but a couple/friends of mine took hypnosis classes before the birth of their first child. If it was something that could be used (reasonablly effectively) as a self therapy (rather than needing a professional to preform the hypnosis) the benefit could be having some sort of pain control accessible when one can’t take OTC pain medication, for conditions with chronic low grade pain or discomfort, or in the trip to the hospital and waiting for pain control, etc.

    Of course that is just speculation, looks like more research is needed before making any conclusions about hypnosis.

  5. cervantes says:

    Well, aside from symptom relief, what could be clinically useful about hypnosis is not short-term behavioral manipulation — act like a chicken — but long-term behavior change — stop smoking or lose weight, etc. People also use hypnosis for this purpose, although Dr. Novella didn’t mention it. This is a situation where it almost isn’t meaningful to talk about a placebo effect. If the person stops smoking, they stop smoking. If suggestibility and expectation and the therapeutic relationship bring about that result, fabulous. Let’s figure out how to maximize those variables.

    I don’t know that there is any evidence that hypnosis actually works for this purpose, but we do know that a big factor in behavior change is self-efficacy — believing that you can do it. If being hypnotized tricks you into that belief, then the belief is a self-fulfilling prophecy, and the trick becomes reality.

  6. Harriet Hall says:

    They taught us in medical school that hypnosis was not any kind of a special trance nor anything mysterious: it is simply a SASI state: selective attention, selective inattention. It’s a way of focussing the mind, perhaps somewhat analogous to what happens in meditation.

  7. Augh, I want to know! Hurry up, hypnosis researchers! I’ve been curious about this since I was about 12 years old. It really seems like something we should have a firmer understanding of by now!

  8. MOI says:

    Well, I do credit the ‘hypnobirthing’ with a huge decrease in discomfort while in labor compared with my previous two labors. I simply read their literature (there are at least two different companies who sell their ‘program’, a generous friend of mine sent me her’s to use) and listened to about 2 hours of a softly spoken woman, saying wonderful things about the birthing process and how relaxed I would be. During labor I just closed my eyes, rocked back and forth and visualized the contractions as “pressure waves”. I was cool as a cucumber. When I couldn’t stay cool anymore, I pushed out my daughter (seriously). For ME, self-hypnosis was nothing more than focusing and relaxing. I don’t believe the program promised any more than that (relaxation). The difference I felt between the last two labors was amazing. But when it comes to labor pain, you are dealing with expectations and subsequent labors can at least have somewhat learned expectations about pain.

  9. elmer says:

    I read “They Call It Hypnosis” on Dr. Hall’s suggestion. I’ll just note 1st of all that it’s kind of an odd book in that, according to what I’ve read, a lot of it is plagiarized, and it seems that a lot of the plagiarized bits seem to come from writers whose opinion of hypnosis is a lot more positive than the ostensible author’s, so the changes in tone can be sort of jarring.

    Anyway, his basic thesis is that the term refers to a lot of different phenomena, depending on the situation, none of which is a distinctive state, and all of which are explainable by normal psychology, and that therefore the word should be discarded. On the other hand, he does seem to think that it is useful for psychologists to study the various techniques used by hypnotists, including stage hypnotists.

    It seems reasonable to me that how one makes a suggestion can make a difference in its effectiveness, so even techniques for getting people to act like chickens would be worth studying.

  10. elmer says:

    …or she mentioned the book anyway.

  11. Dile E. Tante says:

    Hypnosis has been studied extensively by psychologists. Perhaps the best known experimental psychologist was Nicholas Spanos. Of course not all psychologists agree with his conclusions based on his research, but the Wikipedia page for Spanos says:

    “Nicholas (Nick) Spanos hypothesized that the behaviors and experiences associated with hypnosis are acted out in accordance with the social context and expectations of the hypnotist and the setting by the person undergoing hypnosis even though they may be sometimes experienced as involuntary. He argued persistently and demonstrated in over 250 experimental studies that hypnotic acts are strongly influenced by the definition of the contexts in which they occur as well as by the cognitive interpretation of the person hypnotized. Spanos argued against Hilgard’s (and others’) belief that hypnosis is an altered state of consciousness or a ‘special’ or dissociated state of consciousness.”

    While it’s a bit old and probably out of date, the article Kirsch, I., & Lynn, S. J. (1995). The Altered State of Hypnosis – Changes in the Theoretical Landscape. American Psychologist, 50(10), 846-858 says the following:

    “…it is now known that (a) the ability to experience hypnotic phenomena does not indicate gullibility or weakness: (b) hypnosis is not related to sleep; (c) hypnotic responsiveness depends more on the efforts and abilities of the person hypnotized than on the skill of the hypnotist; (d) participants retain the ability to control their behavior during hypnosis, and they are aware of their surroundings and can monitor events outside of the framework of suggestions during hypnosis; (e) spontaneous posthypnotic amnesia is relatively rare; (f) suggestions can be responded to with or without hypnosis, and the function of an hypnotic induction is merely to increase suggestibility to a minor degree; (g) hypnosis is not a dangerous procedure when practiced by qualified clinicians and researchers; (h) most hypnotized persons are neither faking nor merely complying with suggestions; (I) hypnosis does not increase the accuracy of memory; and (j) hypnosis does not foster a literal re-experiencing of childhood events…”

    It’s my very personal, very humble opinion that hypnosis should be thrown on the trash-heap of history.

  12. elmer says:

    Another thought occurred to me regarding Dr. Novella’s contrasting of hypnosis with acupuncture. He’s made three kinds of arguments against hypnosis: based on evidence, scientific plausibility and history (i.e. its basis in “pre-scientific” ideas). Personally I only find the evidence-based argument really convincing, but… sorry, I’m blanking; just imagine a slick segue here…

    Anyway, the idea of hypnosis, according to that book, originated with the deliberate trickery used by stage hypnotists, and was later applied to sincere attempts at therapy. Personally, I became interested in it because of the respectful way it’s treated in beginning psychology textbooks, which typically note (with no attempt at debunking) that a major inspiration for the earliest attempts at “scientific” psychology was the observation by people like Freud of stage hypnosis demonstrations.

  13. elmer says:

    sorry, I meant “three kinds of arguments against acupuncture”

  14. DugganSC says:

    Arguably, hypnosis has been in use for millennia in the same way that ingested medicine has, performed by individuals in an unscientific manner and generally operating by trial and error in terms of figuring out how to induce a particular effect, often accomplishing by accident effects that they later try to figure out how to invoke intentionally. *wry grin* Heck, look at the elements of a lot of religions and you’ll see primitive hypnosis at work, everything from sparkling surfaces to intoxicating incense to low intonations. And some no doubt used that to heal those with troubled souls, to bring them peace.

    The whole definition of what hypnosis is amuses me because it’s kind of like psychology… does it really work or is it all in your head? Personally, I feel the evidence seems to support that hypnosis is nothing more than a particular form of focusing your thoughts. There’s nothing done there that you couldn’t do outside of a hypnotic trance, but some things may be easier to do from there, kind of like how there’s very few activities you can’t accomplish at a dead run with practice, but it’s easier to start by learning to field-strip your weapon while standing still.

    As for why one might pursue an alternate modality which is “less effective” than the primary one, well, it all comes down to circumstances. Hypnosis avoids adverse drug reactions. It’s free if performed by yourself. It requires no outside implements. One had might as well ask why anyone would warm themselves by a fire when there are electric space heaters. Personally, I keep a space heater in my room, but there isn’t always a place to plug it into, and I’ve been through winters where the electricity goes, so I like to have a place that also has somewhere to build a fire.

  15. chaos4zap says:

    I just finished reading “Servants of the Supernatural”, which covers the whole mesmerism topic in detail. It seems to me that most of it back then was closer related to the stage hypnotists of today. The hope then, was that it would be a cure for psychological disorders (can we say, trans-oribtal Lobotomy?) which didn’t exactly pan out. I’m surprised to hear Steve talk about it as a separate state, in the past….he seemed to always make it a point to say that we are not really sure yet. With the difficulties in designing meaningful experimental protocol, we will probably have to wait for the brain imaging technology to move a little forward before we can get much further than we are today. The question I’ve always had with hypnosis is regarding the suggestibility. I don’t think there is any doubt that some people are easier to hypnotize than others and some cannot at all. I often wonder how ones susceptibility to suggestion under the context of hypnosis, translates to their suggestibility overall, in other situations in life. Are those that are easily hypnotized easier to deceive and more gullible overall?

  16. nybgrus says:

    @elmer:

    All three lines of inquiry are useful. You’ve correctly identified that direct empirical evidence is the most robust, but plausibility is also very important. History its indeed the least important.

    In fact, the big part of what differentiates EBM from SBM is prior plausibility – the bayesian.

    History its primarily important from our perspective when it it is useful to demonstrate that modalities have been invented wholesale or derived from other modalities that are demonstrably false (i.e. When it tires in to the bayesian).

    In the case of acupuncture it was both invented wholesale i’m its current form roughly 100 years ago and has its earliest beginnings in blood letting technique, both of which decrease the bayesian as well as nicely refute the already false arguments in its favor.

  17. elmer says:

    Well, I’m not going to argue that vigorously because of the evidence, but I don’t really find it implausible, and I think some of the history he’s written is questionable.

  18. leonet says:

    On a rhetorical level, I think it’s important to prevent hypnotherapy for being claimed by the “alternative” crowd because it actually goes a long way towards debunking anecdotes in which alternative modalities that can’t possibly have physiological effects appear to “work” for some individuals. If the same (or better) level of pain relief that acupuncture allegedly delivers can be obtained by merely talking to a patient, that’s pretty strong evidence that the appeals to Qi/mystical energy/spirits etc are superfluous.

    I’m fairly optimistic that neuroscience will eventually tease out the process by which the strong belief in something (a suggestion, a pill, a needle etc) can compel the brain to “go along with it” and ignore, to a degree, pain and other stimuli.

  19. I have followed hypnosis procedures with clients that have significant chronic pain. Since I have read a bunch of the theory and practice, and some eidence studies, and because I have seen it work very well on occasion, I believe it works for some, who happen to be suggestible, and when a good therapist-client match happens.

    It is very sad to see the only-temporary relief when it does work.

    Ideally, a practitioner would want to train the client to do self-hypnosis. This can happen, I believe, but I believe it is very rare.

    We all recognize that pain has some dependency on attention/inattention. Some of us have had the onset of serious pain after excitement, such as intense sports or traumatic events.

    If you simply do not believe in hypnosis, go to see a hypnosis comedy act at a comedy club. Those skilled practitioners diagnose suggestibility, then work with it.

    Go with a crowd. If things work out, a person you know will be swayed by the hypnotist-comedian, and you can afterward ask your friend what their recollection was.

    You will believe in hypnotism from that point forward. If it is you, you will not quite realize what happened from an observer point of view.

    These shows are on youtube, but simply not as convincing as in person. I have been to a comedy club twice – both times because someone dropped their business card in one of those win-tickets goldfish bowls, and they invited me to go – the deal is there is a two-drink minimum. Not bad. Not free, but not bad.

  20. Windriven sez:
    “The armamentarium already offers a cornucopia of therapies and modalities for pain and for nausea; treatments that produce substantial effects. Why then even propose interventions of barely arguable merit as therapies to be used in current practice?”

    Working with patients who have chronic pain will convince anyone that state of the art is not vevry good. Pain surgical interventions are worthwhile about 50% of the time, and the opiates have significant side effects.

    Lifestyle management, exercise, stretching, massage, and other behavioral strategies help decrease the burden and impact on quality of life to a valuable, worthwhile degree, but rarely get people down to the no-longer-a-big-deal level.

    I don’t do chronic pain work regularly – it is very taxing and discouraging, plus sad/guilty for me to know there is great need and I have chosen to do other things.

  21. leonet says:

    RE: Why would we pursue a less effective modality like hypnotherapy; among common ‘CAM’ modalities which are all effectively placebos, hypnotherapy may be one of the few ethical ways of invoking a placebo effect*, provided that it’s not used incompetently to pressure patients into ignoring symptoms of a real physiological problem. It may not be the ideal approach, but it’s definitely more ethical than telling a patient that some homeopathic sugar pill will help them (i.e. lying).

    *More precisely, the component of the placebo effect arising from patients’ beliefs. There are, of course, other potential contributions to the improvement of placebo groups in clinical trials.

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