Hypnotherapy Applications in Pain Management Frank McDonald Consultation-Liaison Psychologist The Townsville Hospital .

HypnotherapyHypnotherapyApplications in Pain Applications in Pain

ManagementManagement

Frank McDonaldFrank McDonaldConsultation-Liaison PsychologistConsultation-Liaison Psychologist

The Townsville HospitalThe Townsville Hospital

www.fmcdonald.com www.fmcdonald.com

IntroductionIntroduction

Most popular application in medical Most popular application in medical settings is for settings is for anxietyanxiety (e.g. distress (e.g. distress during medical procedures like needles, during medical procedures like needles, chemotherapy, adrenal vein sampling) chemotherapy, adrenal vein sampling) & & pain controlpain control (focus of this session) (focus of this session)

Session briefly describes recent pain Session briefly describes recent pain cases in general hospital setting, after cases in general hospital setting, after outlining nature of hypnotherapy, its outlining nature of hypnotherapy, its contra/indications & steps involvedcontra/indications & steps involved

OverviewOverview

1.1. Video clip of hypno-analgesia followed by hypno-Video clip of hypno-analgesia followed by hypno-anaesthesiaanaesthesia

2.2. Nature of hypnosis – What is it? How does it work? Nature of hypnosis – What is it? How does it work? Common ideas/misconceptions vs. evidenceCommon ideas/misconceptions vs. evidence

3.3. Who’s more & less likely to benefit from Who’s more & less likely to benefit from hypnotherapy? hypnotherapy?

4.4. ContraindicationsContraindications5.5. Procedural stagesProcedural stages6.6. Pain mx cases – chronic cervico-genic headaches, Pain mx cases – chronic cervico-genic headaches,

pain of burns-bath rx, chronic hyperemesis pain of burns-bath rx, chronic hyperemesis (severe nausea, stomach pain & vomiting)(severe nausea, stomach pain & vomiting)

7.7. ResourcesResources

Video clipVideo clip

Dr. Graham Wicks demonstrates hypno- Dr. Graham Wicks demonstrates hypno- analgesia followed by surgery under analgesia followed by surgery under hypnosis without anaesthetichypnosis without anaesthetic

Pre-view video at Pre-view video at http://www.abc.net.au/catalyst/stories/s14http://www.abc.net.au/catalyst/stories/s1440855.htm40855.htm Dr. Wicks starts around 19 minute mark Dr. Wicks starts around 19 minute mark

Presenter discusses neural mechanisms of Presenter discusses neural mechanisms of pain control as suggested by recent fMRI pain control as suggested by recent fMRI studiesstudies

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

Hypnosis - oldest (cognitive) psychological Hypnosis - oldest (cognitive) psychological strategy – predates written history – Egyptian strategy – predates written history – Egyptian records go back 4 000 years. Aboriginal records go back 4 000 years. Aboriginal Australians & Africans amongst earliest users Australians & Africans amongst earliest users

A phenomenon of attention in which brain A phenomenon of attention in which brain suspends authentication of raw sensory input. suspends authentication of raw sensory input. (Focus is on internal representation of input. (Focus is on internal representation of input. Working with that to change pt’s experience.) Working with that to change pt’s experience.)

Results in heightened suggestibility (a Results in heightened suggestibility (a cognitive flexibility resulting in reduced critical cognitive flexibility resulting in reduced critical analysis), or at least allows suggestibility to analysis), or at least allows suggestibility to come to the fore come to the fore

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

In turn, allows access to therapeutically-In turn, allows access to therapeutically-useful psychological & physical abilities useful psychological & physical abilities e.g. e.g. – dissociation dissociation – anaesthesia/analgesia anaesthesia/analgesia – involuntary movement involuntary movement – time distortion time distortion – involuntary nervous system functions (blood involuntary nervous system functions (blood

flow, coagulation time, blood pressure, flow, coagulation time, blood pressure, peristalsis of digestive tract, heart rate etc )peristalsis of digestive tract, heart rate etc )

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

‘‘Hypnosis’ a form of highly focused attention - Hypnosis’ a form of highly focused attention - like meditation. In meditation you concentrate like meditation. In meditation you concentrate on nothing in particular (e.g. “the space on nothing in particular (e.g. “the space between thoughts”); in hypnosis on something between thoughts”); in hypnosis on something (usually therapeutic suggestions)(usually therapeutic suggestions)

‘‘Hypnotherapy’ refers to use of strategies & Hypnotherapy’ refers to use of strategies & harnessing hypnotic phenomena (e.g. harnessing hypnotic phenomena (e.g. narrowed attention, heightened suggestibilty) narrowed attention, heightened suggestibilty) in the service of therapeutic goalsin the service of therapeutic goals

Hypnosis is regarded as an adjunct to therapy Hypnosis is regarded as an adjunct to therapy – not a therapy in its own right. A state of – not a therapy in its own right. A state of “resting arousal”, unlike sleep or relaxation“resting arousal”, unlike sleep or relaxation

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

How it works is not clear – absence of a How it works is not clear – absence of a scientific explanation has limited its scientific explanation has limited its acceptance. Age-old debates e.g. Charcot acceptance. Age-old debates e.g. Charcot (below) vs. Bernheim & the current ‘special (below) vs. Bernheim & the current ‘special state’ v. ‘role-play’ have made it controversialstate’ v. ‘role-play’ have made it controversial

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

How? = point of departure/division into How? = point of departure/division into two academic camps (& there’s two academic camps (& there’s heterogeneity within thoseheterogeneity within those))

Some say hypnotic behaviour reflects Some say hypnotic behaviour reflects changes in brain function changes in brain function

Others say social-psychological & ordinary Others say social-psychological & ordinary cognitive-behavioural factors, like placebo cognitive-behavioural factors, like placebo (albeit hypnosis more effective than sham (albeit hypnosis more effective than sham pills)pills)

Whilst polarising, debate helps us Whilst polarising, debate helps us appreciate its dual natureappreciate its dual nature

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

Assuaging an effect of controversies Assuaging an effect of controversies somewhat, PET scan & fMRI studies somewhat, PET scan & fMRI studies showing modulations of activity in showing modulations of activity in specific & relevant areas are starting specific & relevant areas are starting to allay prejudices to its application to allay prejudices to its application in certain fields, such as pain mx in certain fields, such as pain mx

The images differ from those of well-The images differ from those of well-instructed, well-motivated role-instructed, well-motivated role-playersplayers

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

So, not just “imagination”, “faking”, So, not just “imagination”, “faking”, “play-acting”, “stage-show “play-acting”, “stage-show gimmickery”. For high & moderate gimmickery”. For high & moderate hypnotisables (roughly 2 in 3 hypnotisables (roughly 2 in 3 people), hypnosis can bring benefits people), hypnosis can bring benefits beyond those of imagination or beyond those of imagination or willingwilling

Nature of Hypnosis:Nature of Hypnosis:What is it & how does it work?What is it & how does it work?

Even sceptics (who don’t believe in ‘trances’) Even sceptics (who don’t believe in ‘trances’) believe it can relieve conditions like insomnia, believe it can relieve conditions like insomnia, obesity, hypertension & improve behaviour obesity, hypertension & improve behaviour therapies, counselling & coping strategiestherapies, counselling & coping strategies

Whilst accepting imaging studies, they believe Whilst accepting imaging studies, they believe though that hypnosis is not tapping into though that hypnosis is not tapping into anything beyond a continuum of everyday anything beyond a continuum of everyday abilities that are distributed across the abilities that are distributed across the population in a pattern detected by population in a pattern detected by hypnotisability scaleshypnotisability scales

They say it’s just that hypnosis is one of the best They say it’s just that hypnosis is one of the best ways to tap into these commonplace capacitiesways to tap into these commonplace capacities

Nature of Hypnosis:Nature of Hypnosis:Common ideas vs evidence Common ideas vs evidence

What do you know about hypnosis?What do you know about hypnosis? (Nash,2001)(Nash,2001)

Who benefits more?Who benefits more?1. People who score high (26%) and moderately (36%) on 1. People who score high (26%) and moderately (36%) on

scales of hypnotisability. 29% are mildly hypnotisable. scales of hypnotisability. 29% are mildly hypnotisable. (9% unhypnotisable) (Hilgard, 1961)(9% unhypnotisable) (Hilgard, 1961)

2. Children (peaks age 9 - 12)2. Children (peaks age 9 - 12)3. People who ask for hypnotherapy/who are motivated3. People who ask for hypnotherapy/who are motivated4. People who have an imaginative ability e.g. artistic 4. People who have an imaginative ability e.g. artistic typestypes5. People who have a capacity for emotional involvement5. People who have a capacity for emotional involvement6. People who can take things on faith or trust as 6. People who can take things on faith or trust as

opposed to sceptical, analytical typesopposed to sceptical, analytical types7. People from certain cultures e.g. Latinos vs. Germans7. People from certain cultures e.g. Latinos vs. Germans8. Rights handers vs. left handers8. Rights handers vs. left handers

Who benefits less?Who benefits less?

1. People with abnormally low IQ's (attention and 1. People with abnormally low IQ's (attention and response-time factors)response-time factors)

2. Dementia patients (these patients cannot be 2. Dementia patients (these patients cannot be hypnotised due to problems in prefrontal areas hypnotised due to problems in prefrontal areas necessary to process induction signals)necessary to process induction signals)

3. People who score low (9%) on scales of 3. People who score low (9%) on scales of hypnotisabilityhypnotisability

4. People for whom condition brings secondary gains 4. People for whom condition brings secondary gains (conscious or unconscious pay-offs)(conscious or unconscious pay-offs)

5. People in psychotic states. (Can uncover too much 5. People in psychotic states. (Can uncover too much material and therapist can be drawn in to any material and therapist can be drawn in to any delusional beliefs)delusional beliefs)

6. People in hypermanic states6. People in hypermanic states

ContraindicationsContraindications There are few absolute contraindications to the use of There are few absolute contraindications to the use of

hypnosis. It is usually a very safe procedure. But there are hypnosis. It is usually a very safe procedure. But there are number of situations in which you should be cautiousnumber of situations in which you should be cautious

Hypnosis is usually contraindicated if you are dealing with:Hypnosis is usually contraindicated if you are dealing with:

1. Any condition which would be better treated another way1. Any condition which would be better treated another way 2. Any condition outside your specialty and area of 2. Any condition outside your specialty and area of

expertiseexpertise 3. Depression with a risk of suicide. Be on the qui-vive for 3. Depression with a risk of suicide. Be on the qui-vive for

"masked depression" e.g. depression masked by low back "masked depression" e.g. depression masked by low back pain or a habit disorder. The tranquillising effects of hypnosis pain or a habit disorder. The tranquillising effects of hypnosis may energise a lethargic depressive sufficiently to allow may energise a lethargic depressive sufficiently to allow suicidesuicide

4. Thought disorders such as Schizophrenia and Delusional 4. Thought disorders such as Schizophrenia and Delusional Disorder except if you have experience with these. While Disorder except if you have experience with these. While hypnosis cannot precipitate a psychosis, you may be hypnosis cannot precipitate a psychosis, you may be incorporated into the person's thought disorder more readilyincorporated into the person's thought disorder more readily

Phenomena & strategies Phenomena & strategies facilitated & intensified by facilitated & intensified by

hypnosishypnosis PhenomenaPhenomena Increased temporary and post-hypnotic suggestibilty = Increased temporary and post-hypnotic suggestibilty =

less critical, evaluative thinking less critical, evaluative thinking Reduced awareness that improves classical Reduced awareness that improves classical

conditioning. Easier to establish & more difficult to conditioning. Easier to establish & more difficult to extinguishextinguish

Hallucinations that are more real and absorbing than Hallucinations that are more real and absorbing than ordinary imaginationordinary imagination

Regression and revivificationRegression and revivification Time distortion e.g. time contraction in medical Time distortion e.g. time contraction in medical

proceduresprocedures Analgesia and anaesthesiaAnalgesia and anaesthesia Dissociation (split self off from current reality)Dissociation (split self off from current reality) A.N.S. control e.g. changing blood flowA.N.S. control e.g. changing blood flow Arousal modulation (within limits) for the demoralised Arousal modulation (within limits) for the demoralised

or the distressed to focus therapy attentionor the distressed to focus therapy attention

Phenomena & strategies Phenomena & strategies facilitated & intensified by facilitated & intensified by

hypnosishypnosisStrategiesStrategies Imaginal conditioningImaginal conditioning Revivification and (cognitive) restructuringRevivification and (cognitive) restructuring Exposure therapy/ extinction/ abreactionExposure therapy/ extinction/ abreaction Imaginal rehearsalImaginal rehearsal Relaxation / arousal reductionRelaxation / arousal reduction Suggestion: e.g. for ego-strengthening Suggestion: e.g. for ego-strengthening

and altering pain sensation, enhancing and altering pain sensation, enhancing performanceperformance

Simple encouragement and support Simple encouragement and support

Areas of applicationAreas of application

MedicalMedical AsthmaAsthma Burns Burns EnuresisEnuresis Hypertension Hypertension ChildbirthChildbirth MigraineMigraine

Minor Surgical Minor Surgical Procedures Procedures

Obesity Obesity Pain ControlPain Control Gastro-intestinal Gastro-intestinal

DisordersDisorders WartsWarts

Areas of applicationAreas of application

Psychological Practice Psychological Practice & Psychiatry& Psychiatry

Anxieties Anxieties Apathy and lack of Apathy and lack of

Motivation Motivation Confidence ProblemsConfidence Problems Eating DisordersEating Disorders DepressionDepression Nail-biting Nail-biting Fears and Phobias Fears and Phobias

Psychosomatic Psychosomatic Syndromes Syndromes

Panic Attacks Panic Attacks Sleep Disorders Sleep Disorders Sexual Dysfunction Sexual Dysfunction Thumb-sucking Thumb-sucking StutteringStuttering

Areas of applicationAreas of application

DentistryDentistry Anaesthesia Anaesthesia Anxiety / Anxiety /

ApprehensionApprehension Bleeding Control Bleeding Control Bruxism Bruxism Dental Phobia Dental Phobia Denture ProblemsDenture Problems

GaggingGagging Nausea Nausea Pain-control Pain-control Restlessness Restlessness Salivation-control Salivation-control Tempro-mandibular Tempro-mandibular

Joint DysfunctionJoint Dysfunction

Areas of applicationAreas of application

EducationEducation Concentration and Concentration and

Attention problems Attention problems Exam Fears/Phobias Exam Fears/Phobias Motivation training Motivation training Memory Training Memory Training Study habit problemsStudy habit problems

SportsSports Attitude Change Attitude Change Confidence Building Confidence Building Co-ordinate Mind & Co-ordinate Mind &

Body Body Fear of Success Fear of Success Fear of Failure Fear of Failure Maximise Potential Maximise Potential Improve Concentration Improve Concentration Performance Anxiety Performance Anxiety Motivation Training Motivation Training

controlcontrol

Procedural Stages of Procedural Stages of HypnotherapyHypnotherapy

1. Preparation (e.g. removing misconceptions, 1. Preparation (e.g. removing misconceptions, assess interests that may be incorporated in assess interests that may be incorporated in procedure)procedure)

2. Assessment of hypnotisability (capacity for 2. Assessment of hypnotisability (capacity for concentration and imagery, suggestibility)concentration and imagery, suggestibility)

3. Induction procedure3. Induction procedure4. Deepening stage4. Deepening stage5. Trance ratification5. Trance ratification6. Utilisation of trance for therapeutic purposes6. Utilisation of trance for therapeutic purposes7. Post-hypnotic suggestions including self- 7. Post-hypnotic suggestions including self- hypnosis instructionshypnosis instructions8. Termination of the trance8. Termination of the trance9. Discussion of the experience. Problems?9. Discussion of the experience. Problems?

Pain-related Case Pain-related Case DiscussionsDiscussions

Cervico-genic headaches in 37 yr old Cervico-genic headaches in 37 yr old female from m.v.a. at age 17female from m.v.a. at age 17

Mx of pain of burns bath treatment in Mx of pain of burns bath treatment in 10 yr old male10 yr old male

Mx of chronic (2yrs +) hyperemesis Mx of chronic (2yrs +) hyperemesis in 33 yr old femalein 33 yr old female

Resources + Pre-/post- session Resources + Pre-/post- session readingreading

http://www.abc.net.au/catalyst/stories/s144085http://www.abc.net.au/catalyst/stories/s1440855.htm5.htm Vision and transcript. Hypnosis for pain at 19 Vision and transcript. Hypnosis for pain at 19 minute markminute mark

Australian Society of HypnosisAustralian Society of Hypnosis

http://www.ozhypnosis.com.au/Default.htmhttp://www.ozhypnosis.com.au/Default.htm Hypnosis.com – the FAQ section is excellent Hypnosis.com – the FAQ section is excellent

http://hypnosis.com/faq/http://hypnosis.com/faq/ This presentation This presentation www.fmcdonald.comwww.fmcdonald.com Extra reading presented via JCU networkExtra reading presented via JCU network