OUTLINE OF HYPNOTIC STRATEGIES AND TECHNIQUES FOR MANAGING PAIN

In this chapter you will find a large number of hypnotic techniques discussed and modeled for you. You may find the following conceptualization of major hypnotic pain control strategies and the techniques that fall under these strategies to be useful in understanding these methods.

I. Unconscious Exploration to Enhance Insight or Resolve Conflict A. Ideomotor Signaling

B. The Inner Adviser Technique C. Guided Imagery

D. Hypnoprojective Techniques II. Creating Anesthesia or Analgesia

A. Direct or Indirect Suggestion B. Imagery and Imagery Modification C. Ideomotor Turn-off of Pain

D. Gradual Diminution of Pain

E. Interspersal Technique and Use of Metaphors F. The Clenched Fist Technique

D. Replacement or Substitution of Sensations E. Reinterpretation of Sensations

F. Unconscious Exploration of Function or Meaning of Pain G. Amnesia

K. The Inner Adviser Technique (to explore meaning and triggers of pain) IV. Decreasing Awareness of Pain (Distraction Techniques)

A. Time Dissociation

B. Imagining Pleasant Scenes and Fantasies C. Absorption in Thoughts

D. External Distraction Through Enhanced Awareness of the Environment E. Eliciting Mystical Experiences

STRATEGY AND TECHNIQUE SELECTION How does one select which one of the strategies to use? My personal preference is to first determine with a technique from strategy I (e.g., ideomotor exploration) that an unconscious dynamic or past event is not a part of the problem. This can generally be assessed in one part of a single session, although if factors are uncovered they may require an interview or two to resolve. One problem with conventional pain assessment strategies (e.g., Karoly & Jensen, 1987) is that they neglect the possible role of unconscious variables as a potential cause of a pain problem. There are occasions when a pain problem, or part of a pain problem, may be associated with past trauma (e.g., incest) or serve unconscious purposes (e.g., for self-punishment). We may hypothesize that this may particularly be the case when the cause of the pain is unknown and cannot be causally related to any pathophysiologic process, where the pain seems more intense than would ordinarily be anticipated, and/or when pain lasts longer than is appropriate.

Hypnotherapy for pain should include a brief routine check (e.g., with ideomotor signaling) to determine if unconscious factors contribute to the problem (Hammond & Cheek, 1988; Rossi & Cheek, 1988).

When it has been determined that psychological and unconscious factors do not play a role in the problem, suggestive hypnosis may then be introduced. Thus it is next recommended that you determine whether strategy II techniques (e.g., suggestions for anesthesia, ideomotor turn-off of pain, imagery modification) are successful in alleviating or managing the distress. When these more straightforward techniques are not entirely effective, we may then experiment with the more complex techniques that fall under strategies III and IV. These techniques will be particularly beneficial when pain is chronic and where several pain sites are identified. Certain techniques (e.g., time dissociation, imagining pleasant scenes) are primarily useful with patients who can be inactive, at least for segments of the day. For instance, if a patient is imagining a future or past time when they were not in pain, this inward absorption precludes simultaneous interaction with people or the performance of vocational tasks. When working with more difficult, chronic pain patients who have several sites or types of pain, you may also find it helpful to begin by working with their least difficult or intense problem first. Begin with the problem where you anticipate the highest probability of success. Successful management of one pain area or problem will enhance patient self-efficacy and helpful initially to demonstrate pain control techniques to manage acute pain that is therapist-induced; for example, begin by creating glove anesthesia to block pain that is induced through the use of a hemostat or nail file.

There are a variety of suggestive hypnotic strategies for pain management that will be reviewed in the first part of this chapter. In successfully controlling organic pain, however, it is extremely important to have frequent reinforcement sessions early in treatment. In particular, it has been recommended (Crasilneck & Hall, 1985) that we should reinforce pain control as quickly as possible after the patient becomes aware of the return of pain. Thus, in the first 24-hour period it may be necessary to see the patient several times (e.g., every four hours) and self-hypnosis should be learned as rapidly as possible.

We should also not neglect the role of ego-strengthening as part of hypnotic work with chronic pain patients. Patients with chronic pain customarily also develop feelings of low self-esteem and self-worth that may be responsive to hypnotic suggestion. Furthermore, self-hypnosis provides such patients with an active self-management strategy that can return some sense of control and mastery to their lives.

Most of our patients are not capable of creating a complete anesthesia and removing all of their pain through hypnosis. However, even for those patients who are this hypnotically talented, we should only remove all pain in a small number of conditions: (1) dental anesthesia; (2) childbirth; (3) terminal illness (e.g., cancer pain); (4) when hypnosis is being used for surgical anesthesia; (5) phantom limb pain; and (6) possibly for treating shingles or arthritis attacks (Crasilneck & Hall, 1985). In other cases, we must remain cautious to leave some “signal” pain so that the patient will not injure himself and so that pain from the development of new symptoms or a worsening of the patient’s condition will be perceived and reported.

Very importantly, as clinicians treating pain we must assume a realistic posture concerning the role of hypnosis. Hypnosis is like any other medical or psychological technique: it is not effective with every patient. Some patients obtain tremendous pain relief with hypnosis; others find it clearly helpful but are in need of still other methods of relief; some find that it reduces the affective components of pain (Price & Barber, 1987), making the sensory pain more tolerable; and some patients receive no benefit from hypnosis. Consequently we must also be familiar with nonhypnotic treatment options such as medications, nerve blocks and trigger point injections, physical therapy, transcutaneous electrical nerve stimulation (TENS), and biofeedback. When it comes to the treatment of pain, the hypnotherapist should not work in a vacuum. A multidisciplinary team is ideal, and interdisciplinary cooperation is vitally important.