Applications of Hypnosis: Pain Management

Linda Thomson, APRN, ABMHHypnovations III - Intermediate Workshop

Burlington, VTApril 2010

•Identify two hypnotic strategies that can be used in both acute and chronic pain

•Restate the precautions for using hypnotic pain relief

Objectives

Pain is an experience in the soul of the patient

Plato

•Pain . . . “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

• Merskey, Bugduk, 1994

•Pain is private and personal. It is subjectively experienced and includes both mental and emotional suffering and distressing physical sensations.

• Kuttner

•Von Frey – Specificity Theory

•Goldscheider – Pattern Theory

•Melzack and Wall – Gate Control

• Theory

Pain Theories

•Mechanical, thermal or chemical energy impinging on specialized nerve endings

•Signals the CNS about the occurrence of an aversive event

•Pain is the sensation that arises from nociception

PainNociception

•Nociceptive

•Inflammatory

•Neuropathic

•Functional

Types of Pain

•Sensory Pain – actual way the individual feels the pain

•Suffering – amount of unpleasantness that occurs as a result of sensory pain

Components of Pain

• Pain

• Sensation that can arise from nociception

• Suffering

• Affective response to pain

• Disruptions in work, relationships, activities, QOL

• Pain Behavior

• Actions that communicate suffering

• Independent of nociception

Pain, Suffering, Pain Behavior

•Sensory Pain

•Suffering

•Mental Anguish – the global feeling of sadness, frustration and dependency which results

Legal Definition – A Triad of Distress

•75 Million Severe Pain

•50 Million Chronic

•25 Million Acute Injury

•45% Pop. Seek Care

• 4 Billion Work Days Lost

•79 Billion Dollars in Lost Wages

•Most Common Complaint to Health Providers

Pain FactsNUPRIN Pain Report, Sternbach (1986)

•Hypnotic interventions for pain control began when the first mother kissed her child’s booboo and made it all better.

• Franz Baumann

•Humans have limited amount of conscious attention available

•When involved in a hypnotic trance experience there are less cognitive resources available to devote to evaluation of nociceptive pain

•There is an interplay of thoughts, beliefs, emotions and attitudes with the sensations occurring in the body that create the sensation of pain

•This same interaction of mind and body enables us to increase or decrease pain

David SpiegelJAMA, 1999

It is not simply mind over matter, but it is

clear that mind matters.

•The Hypnotic Experience

•Rapport

•Language

•Responsivity

•Heightened psychophysiologic control

•Positive Expectancy is an essential ingredient

Each component of pain can be modified

by

•Age and developmental stage

•Previous experience with pain

•Context of symptom, emotional significance of pain

•Physical and emotional state

•Culture

•Gender and individual differences

•Candy Erickson

Factors affecting pain perception

•Age and developmental stage

•Previous experience with pain

•Previous experience with hypnosis

•Context of symptom, emotional significance of pain

•Physical and emotional state

•Culture

•Gender and individual differences

Factors Affecting Efficacy of Hypnosis

•Coping style – attender or avoider

•Acceptability of hypnosis

•Medication

•Hypnotic susceptibility

Factors Affecting Efficacy of Hypnosis

•Attitude of family toward symptom and hypnosis

•Attitude of medical staff toward symptom and hypnosis

•Therapist’s attitude toward symptom, belief in hypnosis, and skill

Other Factors Affecting Efficacy of Hypnosis

Physiologic markers of pain appear to persist even when a person feels

no pain or decreased pain after hypnotic suggestion

Perhaps pain is not being

processed by cognitive processes

during hypnosis

•Poorly understood

•Pain activates the anterior cingulate cortex

•Anger activates the anterior cingulate cortex

•Hypnosis activates the anterior cingulate cortex

•The same structure may both respond to pain and participate in pain control

Mechanism of Hypnotic Analgesia

•“The evidence supporting the effectiveness of hypnosis in alleviating chronic pain is strong. In addition, hypnosis is effective for chronic pain in other conditions such as IBS and tension headache.”

•• NIH Technology Assessment

Conference

• JAMA 276:313 1996

•1994 – IASP includes hypnosis in its curriculum for pain

•1996 – NIH acknowledges hypnosis as a viable and effective intervention for alleviating pain from cancer and other chronic pain

Hypnosis for Pain Control

• Sympathetic Nervous System Reduction

• Reduced activity in somatosensory & limbic areas

• (Hofbauer et al., 2001; Rainville et al., 1997; Price & Barrell, 2000

• Inhibition of spinal cord fibers

• Analgesia suggestions (r) spinal R-III reflex

• (Kiernan et al., 1995; Danziger et al., 1998)

• Affective and Sensory reductions have been found with hypnosis and wording matters!

• (Price et al., 1987; Rainville et al., 1999)

Physiology and Hypnosis

Acute Pain

•Commands attention

•patient is already in a heightened state of awareness / intensely focused

•Shocks you into being protective

•Causes anxiety

•Drains energy

•Highly motivated to decrease pain

Acute Pain

•Keep voice soothing and re-assuring

•Talk to the patient even if he seems unconscious

•Explain what is happening

•Remind patient that the body knows what to do

•Explain any puzzling sights or sounds

•Minimize other sights and sounds

•Wrap-up in a positive manner

•Reframe

Emergency Room

•REFRAME

• Bright red, healthy blood

• Beautiful tears

• Strong lungs

• Captures attention because it is unexpected

• Offers positive suggestion about situation and outcome

• Separate pain from hurt

• Connect to the comforter

Modify the patient’s experience

•PARADIGM SHIFT

•From ‘out of control’ to ‘controlled’

•From ‘scary’ to ‘safe’

•From ‘sick’ to ‘mostly well’

Modify the patient’s experience

•PACE AND LEAD

•Join with the patient

•Convey understanding of the situation

•Recognize fixed attention

•Capture attention

Modify the patient’s

experience

•Decreasing anxiety will decrease pain perception

•Direct hands on

•Quick induction

•Suggestions guided by dissociative finger signals

Acute Pain

•Brutaine

•restraint by physical force

•Narcotics

•changes pain sensation

•Sedatives

•alters perception

•Hypnosis

•alters patient’s attention to and interpretation of pain

Procedural Therapies

•Safe

•Rapid Onset

•Predictability

•Ease of administration

•Creates analgesia and amnesia

Perfect Rx for Procedures

•Safe

•Ease of administration

•Creates analgesia and amnesia

•Gives patient skills instead of pills

•Promotes self-mastery, self-efficacy and self-esteem

Hypnosis for Procedures

•How you talk is as important as what you say

•Acknowledge and ask about pain

•“You are in a lot of pain right now and we are going to help you become alot more comfortable”

•Having the patient describe the discomfort helps to compartmentalize it

•Don’t underestimate the power of listening

• Kohen

The Language of Healing

•As much as possible allow the patient to set the pace

•Frame the patient’s discomfort with hope, not doom

•Note the parts of the body that aren’t in pain

•Avoid words that conjure up fear

•Kohen

The Language of Healing

•Reframe the patient’s distress

•Replace pain loaded words

•Pain - - discomfort - - bothered

•Attack - - episode - - event

•Use language that implies positive change

•You may be surprised how fast you start feeling better

•Kohen

The Language of Healing

I know you want to scream because you

can scream as loud as you want till you are all

done and don’t need the scream any more and it doesn’t bother

you

•Use words of encouragement and reassurance

•“You are doing this very well”

•When possible let patient know that what they are experiencing is normal, not life-threatening or the result of some terrible disease

•Remind patient that pain will come to an end

•Kohen

The Language of Healing

•Pain is usually predictable

•Anxiety is enhanced by environmental cues

•Identify threat

•Determine environmental cues

Procedural Hypnosis

•Induction with deep relaxation

•Anchor suggestions to threatening cues with post-hypnotic suggestion

•When you feel _____, then ________

Procedural Hypnosis

Chronic Pain

•Persists beyond its initial useful or protective function

•lasts more than 3 - 6 months

•More disabling

•Negative expectancy

•Possibility of secondary gain

Chronic Pain

Antecedent Operant Reinforcer

Tissue Damage

Sighing Attention

Workplace Complaints Less Work

Doctor/Lawyer Crying Compensation

Grimace/ Limp Drugs

Conditioning and Chronic Pain

•Anxiety and despair magnify perception of pain

•psychological distress in absence of nocioceptive pain

•Somatic Preoccupation - becomes part of person’s life

•Illness Conviction - hope is replaced by despair and thoughts that it will never

go away

Chronic Pain

•Negative expectancy

•when pain starts - it worsens; when it leaves - it returns

•Illness Behavior is reinforced

•Deactivation - guarding and pacing

Chronic Pain

• HeadacheHeadache -- migraine, cluster, tension-type

• Orofacial PainOrofacial Pain -- trigeminal neuralgia, pulpitis, dental pain, atypical facial pain

• Anatomic Locational PainAnatomic Locational Pain -- neck, shoulder, elbow, chest wall, knee, abdomen

• Back PainBack Pain

• Chronic pelvic painChronic pelvic pain

• Interstitial CystitisInterstitial Cystitis

• ArthritisArthritis -- OA and RA

• FibromyalgiaFibromyalgia

• Myofascial PainMyofascial Pain

• Neuropathic PainNeuropathic Pain

• Postherpetic NeuralgiaPostherpetic Neuralgia

• AIDS-related PainAIDS-related Pain

Some Types of Chronic (non-malignant) Pain

•Baggage must be identified

•Baggage must be disentangled

•Baggage must be dismantled

•Joint effort: clinician, patient and family

Pain takes on baggage as it gains strength

•Change in lifestyle

•Psychological Therapy

•Physical Therapy

•Medication

•Must include the family

•Kuttner

Pain Management Program

•Pain is the enemy. In the battle against pain, rely on extrinsic pain relief

•No pain, No gain

•Taking medication means that you are weak

Media Myths

•Meds can:

•break the cycle

•provide relief

•chance to sleep

•use available energy to heal

MEDICATION

•Purely physiological explanations cannot account for the impact of pain in a patient’s life.

•Exclusive reliance upon medical interventions may not result in relief.

•The quality, intensity, and duration of pain are influenced by psychological and social factors.

•The experience of chronic pain ultimately comes to be the product of conflict between a sensory stimulus and the whole person.

•Covino

The Need for a Multidisciplinary Approach to Treating Chronic Pain

•Chronic pain will always require some level of adaptation and adjustment and can, in many case, interfere with one’s work and livelihood, recreational pursuits, relationships with family and friends, and sexual intimacy.

•Through the introduction of associated psychosocial stressors and more enduring affective changes, it can also influence one’s self-esteem, and the ways in which one views oneself as a man or woman, husband or wife, father or mother, friend, member of society, and spiritual being.

• Covino

The Need for a Multidisciplinary Approach to Treating Chronic Pain

Reduction of pain is often a secondary goal or side effect

•Too much fuss

•gives pain too much power in the family

•may give patient the idea that the pain is life-threatening

•Responding with irritation

•deal directly with pain without emotional overlay

•Ignoring individual’s pain

•may escalate symptom to gain attention

•Kuttner

Unhelpful Responses to Patient in Pain

• Sexual bias

•Telling the patient he is faking it

•patient will lose trust they he will receive help

•Catastrophizing

•too much sympathy and not enough guidance or encouragement may escalate individual’s absorption in pain

•Kuttner

Unhelpful Responses to Patient

in Pain

•Acknowledge pain, don’t minimize or deny it

•otherwise patient feels discounted and unrespected

•Be present

•pain isolates and isolation is frightening

•Appropriate physical contact

•provides both physical and psychological relief

•Explain what is happening and what is being done to help

•Kuttner

Helpful Responses to Patient in Pain

•Provide hope that pain will change and get better

•Offer techniques to help the patient help himself

•moves patient beyond helplessness

•Support patient’s coping skills

•Manage your own anxiety

•Kuttner

Helpful Responses to Patient in Pain

•Decrease CNS arousal

•Help patient to learn to cope and function normally

•Help patient’s body heal

•Help patient develop a sense of optimism

•Help patient develop a sense of humor

Goals

•Medical History

•Physical examination

•Diagnostic studies

•Assess factors which affect the patient’s pain perception

•Assess factors which may affect efficacy of hypnosis

•Establish rapport –get to know the patient

Thorough understanding of the situation begins

with -

•Developmental level

•Coping Style: attender - avoider

•role of family

•Patient’s understanding of and attitudes about pain and hypnosis

•Fears

•Interests

Get to Know the Patient

•Sensory

•Behavioral

•Affective

• Interpersonal

•Environmental

•Cognitive components of the pain experience

Multi-Dimensional Assessment

•What would you like most to do if you didn’t have this pain?

•How would your life be different without pain?

•What would you be able to do that you can’t do now?

•What do you already do now to make it better?

QUESTIONS

•I wonder which part of the pain you would like to change first?

•Is there anything about the pain that you will miss when it is gone?

•Ask patient to draw a picture of their pain; then draw a picture of when it is gone, a picture of comfort. How did you get from pain to comfort?

Questions

•Methods which

•Achieve neurophysiologic alterations

•Change or reorganize the cognitive-emotional understanding

•Improve behavioral patterns

•Promote new useful perceptions of time and space

Hypnotic Pain Coping Strategies

•Teach the patient to go into trance (self-hypnosis) and encourage practice

•Emphasize patient’s control and mastery

•Teach pain control techniques

•Relaxation and general imagery AND specific imagery for pain control

•Utilize patient’s imagery and language

•Visualize future success

•Address anxiety as well as pain

•Generalization of technique to other situations

• a warning signal; it is neither good nor bad; but it is important.

•“Once everything that can be done and should be done has been done, there is no reason for it to continue.”

• Kay Thompson

Pain is . . .

•Skill # 1

•Belly Breathing

•relaxes muscles

•calms nerves

•releases endorphins

Be the Boss of Your Pain

•Skill # 2

• Imagine That - Re-program the Brain’s Computer

• TV - you are in charge of the remote CONTROL, change the channel

• Imagine something Fun - sports, games, amusement park

• Change the image

• change the color, shape or texture

• Switches in a control room

• Jettison technique - throwing it away

•Skill # 3

• You’re the Coach

•Positive Attitude - replace negative thought with a helpful one

Be the Boss of Your Pain

•Skill # 4

•Aromatherapy

•use smells to help you feel better

•imagine healing scent traveling through body sending out healing messages

•Skill # 5

• Acupressure

•releases endorphins to relieve symptoms

Be the Boss of Your Pain

•Distancing from Pain

•Taking a vacation and leaving pain behind

•Staying put and floating pain away

•Distraction and Redirection

•Involvement in pleasurable fantasy/memory

•Internal - mental work

•External - shift to external focus

•Selectively attend

•information has already been received

•Ignore the alarm

Pain Management Techniques

•Directing Attention to Pain itself

•Pain switches, dials, scales

•Give pain a shape and color and then change it

•Displacement to some other less bothersome body part

• Symptom Substitution

•less noxious than presenting pain

Pain Management Techniques

•Hypnotic Dissociation

• Body Disorientation - patients induced to experience themselves apart from their bodies

•Time Distortion

•reorient patient to a time earlier in illness when pain was less

•shorten duration of pain

•lengthen interval between pain

Pain Management Techniques

•Hypnotic Dissociation

•Glove anesthesia

•Analgesia

•Trade sensations and emotions

•Burning - Warm

•Pounding - tapping

•Stabbing - pressure

Pain Management Techniques

•Reframing and Reflecting

•Separate pain from hurt

•Connect to the Comforter

•Uncovering - explore the meaning of the pain

•Free association

•Age regression

•Affect bridge

•Hypnoprojective

Pain Management Techniques

•Reframing and Reflecting

•Release and Rework

•Anger

•Anxiety

•Grief

•Self-esteem

Pain Management Techniques

•C - conflict

•O - organ language

•M - motivation

•P - past experience

•I - identification

•S - self-punishment

•S - suggestion

Psychodynamic Exploration for Somatic Symptoms

Cheek’s 7 keys

•Emphasize patient’s control and mastery

•Use language of hope, courage, and possibilities

•Convey message that pain will get better

General Principles of Pain Management

•Reinforce whatever happens

•Get feedback from the subject

•Let patient determine what method will work best

General Principles of Pain Management

•If at first you don’t succeed - change techniques

•Address anxiety as well as pain

•Use other cognitive, behavioral strategies as well

General Principles of Pain Management

•Chronic/recurrent pain may be a symptom of PTSD, sexual or physical abuse or depression

•Physical pain may protect the individual from severe psychological pain

•If pain is protective, then hypnosis may be ineffective and contraindicated without psychotherapeutic intervention

Caveat

• Instill a new paradigm regarding reasons for the pain – reframe

• Increase the patient’s effectiveness of his or her own natural pain control system

• Reduce focus on self so that the patient can be open to possibilities of altered sensations, emotions and beliefs

• Enhance perceptions of controllability of pain by facilitating feelings of control and the belief that physical changes are possible

• Facilitate increased functionality

Goals for hypnotic intervention for pain