The typical chronic pain patient will be taking several medications, and will have been treated unsuccessfully by several specialists before considering hypnosis. These may have included neurologists and (neuro)surgeons ('when in doubt, cut it out'), manipulative procedures by orthopedic and chiropractic specialists ('when in doubt, pound it out'), physical therapists ('when in doubt, walk it out'), mental health professionals ('when in doubt, talk it out'), and extensive pharmacological intervention ('when in doubt, medicate'). For these patients, the demand, 'hypnotize me and get rid of my pain', is often an invitation to failure. When the burden of cure is abrogated to the implicit magic of the technique, any initial attempt to use hypnosis at best would be unsuccessful, and at worst, would precipitate an early termination of the therapeutic encounter. Most pain patients have been unable to accept their current reduced functionality, and angrily demand to be helped 'return to the way I used to be'. The typical chronic pain patient is angry, depressed, past-oriented, feels abused by the medico-legal system and insists that he/she has lost control of life. These are all relevant therapeutic issues. It is critical that the therapist accepts the pain as 'real', and not merely in the patient's head.
The importance of the initial therapeutic contact must be emphasized when hypnosis is to be used with the chronic pain patient. A direct approach is required to evaluate secondary gain and masked depression: it will be these issues that will determine the focus of the treatment plan. Four direct questions are usually helpful (Evans, 1989, 2001). The first two help evaluate secondary gain, while the second two are primarily therapeutic contractual questions.
1. 'What difference would it make to your life if suddenly you had no pain'? The patient will often hedge an answer with anger, which will reveal hints about the psychic utility of the pain as a reinforcing event. For example, one patient replied: 'My poor, poor, husband. Why, he looks after me so well. He could stop cooking and cleaning for me. He hates cleaning. He would rather be out with his friends.' Her response gives clear insight into the psychic economy of the pain which will need to be addressed before any hypnotic or other intervention will be useful in reducing her pain.
2. 'Do you want to get better'? Many chronic pain patients react with anger to this question. 'What do you mean? Of course I want to get better'! Even after repeating the question three times, failure to obtain an unequivocal 'yes' is common, and indicates the patient may not be ready to relinquish the pain.
3. 'Would you be satisfied if your pain could be reduced by about half'? Acquiescence is necessary to help evaluate whether the patient has realistic expectations, although it is stressed that the goal of treatment is to maximize pain relief.
4. 'Are you willing to work hard to get better'? This question is useful to ascertain that the patient does not have unrealistic expectations about a magical cure with hypnosis, and helps establish a contract that the patient must be responsible for his/her own progress.
Although it is uncommon, positive answers to each of these questions usually indicate that secondary gain is not an issue in the patient's pain behavior. Direct use of hypnotic techniques may be successful quite rapidly.
Some additional useful questions set the stage for later hypnotic interventions. When the chronic pain patient is asked to describe: 'What do you like about yourself'?, there is usually a long silence, with little response. In contrast is the verbal torrent usually accompanying the question: 'What do you dislike about yourself'? Both answers will provide a framework for later hypnotic ego-strengthening techniques, as well as indicate the major areas of dysfunction associated with the pain.
The manner in which the patient is asked to describe the pain may be useful for the selection of appropriate imagery and cognitive strategies when it is time to use hypnotic interventions. Because of the depression and years of feeling misunderstood, many patients find it difficult to describe pain verbally, but can write about it. Techniques such as asking about the 'color' and 'shape' of the pain, drawing the pain, and exploring conditions under which it is more or less intense (heat, cold, sitting, etc.), may be relevant to later hypnotic strategies. By asking the patient to give his/her pain a name ('Mr Sonofabitch' seems to be a popular choice), a letter can be written to 'Dear Mr Sonofabitch'. By encouraging a stream of consciousness approach (ignore punctuation, spelling, etc.) the patient is easily introduced to experiencing dissociation, and the letter may give clues about relevant psychodynamics.
While it is assumed that the chronic pain patient is depressed until proven otherwise, the masked depression cannot be dealt with initially.3 For example, the patient involved in compensation or litigation cannot give up the pain easily until the legal proceedings are resolved. Initially, hypnosis may not be very successful. However, when gradually introduced with supportive psychotherapy, hypnosis may be the adjunctive treatment of choice. Similarly, the chronic pain patient who is masking depression will not easily relinquish his/her pain with hypnotic (or any other) intervention. Where there is the possibility of unmasking depression due to too rapid removal of the pain symptom, complications, including suicide risk, must be carefully considered. Fortunately, those patients usually have their symptoms too well integrated to allow such a possibility. The symptom is usually too important to relinquish with direct hypnotic interventions.
Several techniques (Evans, 1989, 2001) are useful to help the patient 'discover' that he/she is capable of controlling bodily sensations, especially pain. Suggested glove analgesia can be induced in all except a few resistant patients. Done with care, the patient gradually begins to believe that he/she can control a physiological experience in a part of his/her body. With repeated experience glove analgesia can be transferred to the pain-afflicted area, but this should be done cautiously. Imagery, relaxation and self-hypnotic methods are usually introduced. Use of the Chevreul pendulum will help circumvent resistance (almost all patients respond unless deliberately resisting). The use of ideomotor suggestion (Evans, 1967, 2001) is an elegant way to introduce the mind-body connection, which usually plays such an important role in later hypnotic interventions. Several techniques borrowed from sports medicine applications (Unesthal, 1979) are helpful. For example, visual mental rehearsal of getting out ofbed for 30-60 seconds before arising will stimulate action potentials that will help the patient quickly overcome the stiffness often experienced when inactive for a period of time (see Evans, 2001, for sample transcripts).
In the subsequent hypnosis sessions a delicate balance is required between the initial, authoritarian, direct approach by the hypnotist to teach the patient mind-body control, and the later non-directive cognitive discovery of success and mastery of physical and bodily control in unrelated areas which will gradually be insightfully discovered by the patient as relevant to subsequent pain control. At the same time, this progress must be sufficiently slow so that the patient can be drawn into the therapeutic alliance to handle the psychological issues that are more relevant than the pain experience (e.g., 'What if I don't win the compensation case'? 'How do I handle my spouse's sexual advances and the children's behavior'?).
It is the melody rather than the lyrics that are important in hypnotic techniques. The hypnotic procedures used need to be a comfortable mix of the patient's abilities and the therapist's style. Many good examples of hypnotic pain reduction suggestions have been outlined by Hammond (1990, pp. 45-49) and Evans (2001). The emphasis of these hypnotic interventions is on the learning of mastery experiences and self-control. However, it is especially important that the patient has permission not to use these mastery techniques in all situations. For example, in a litigation case a contract can be established (usually while under hypnosis) that the pain can be controlled using hypnosis, but the patient should feel comfortable about deciding when to use these mastery techniques. The tactic of allowing the patient complete choice as to when to control pain is an important way to handle the problems associated with the exposure to psychological threat, and the removal of the pain as a defensive reaction. The thrust of the hypnotic intervention is simply to teach the patient that he/she is capable of controlling pain and the related psychological issues, but not to become involved in the ethical and moral issues as to when the patient should use these techniques. Such contracts allow the patient to manipulate pain when it is psychologically appropriate, progress at his/her own pace, provide time to develop a therapeutic alliance, and to treat the depression either with antidepressant medication or psychotherapeutic techniques.
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