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

Introduction Most popular application in medical settings is for anxiety (e.g. distress during medical procedures like needles, chemotherapy, adrenal vein sampling) & pain control (focus of this session) Session briefly describes recent pain cases in general hospital setting, after outlining nature of hypnotherapy, its contra/indications & steps involved

Overview Video clip of hypno-analgesia followed by hypno-anaesthesia Nature of hypnosis – What is it? How does it work? Common ideas/misconceptions vs. evidence Who’s more & less likely to benefit from hypnotherapy? Contraindications Procedural stages Pain mx cases – chronic cervico-genic headaches, pain of burns-bath rx, chronic hyperemesis (severe nausea, stomach pain & vomiting) Resources

Video clip Dr. Graham Wicks demonstrates hypno- analgesia followed by surgery under hypnosis without anaesthetic Pre-view video at http://www.abc.net.au/catalyst/stories/s1440855.htm Dr. Wicks starts around 19 minute mark Presenter discusses neural mechanisms of pain control as suggested by recent fMRI studies

Nature of Hypnosis: What is it & how does it work? Hypnosis - oldest (cognitive) psychological strategy – predates written history – Egyptian records go back 4 000 years. Aboriginal Australians & Africans amongst earliest users A phenomenon of attention in which brain suspends authentication of raw sensory input. (Focus is on internal representation of input. Working with that to change pt’s experience.) Results in heightened suggestibility (a cognitive flexibility resulting in reduced critical analysis), or at least allows suggestibility to come to the fore

Nature of Hypnosis: What is it & how does it work? In turn, allows access to therapeutically-useful psychological & physical abilities e.g. dissociation anaesthesia/analgesia involuntary movement time distortion involuntary nervous system functions (blood flow, coagulation time, blood pressure, peristalsis of digestive tract, heart rate etc )

Nature of Hypnosis: What is it & how does it work? ‘Hypnosis’ a form of highly focused attention - like meditation. In meditation you concentrate on nothing in particular (e.g. “the space between thoughts”); in hypnosis on something (usually therapeutic suggestions) ‘Hypnotherapy’ refers to use of strategies & harnessing hypnotic phenomena (e.g. narrowed attention, heightened suggestibilty) in the service of therapeutic goals Hypnosis is regarded as an adjunct to therapy – not a therapy in its own right. A state of “resting arousal”, unlike sleep or relaxation

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

Nature of Hypnosis: What is it & how does it work? How? = point of departure/division into two academic camps (& there’s heterogeneity within those) Some say hypnotic behaviour reflects changes in brain function Others say social-psychological & ordinary cognitive-behavioural factors, like placebo (albeit hypnosis more effective than sham pills) Whilst polarising, debate helps us appreciate its dual nature

Nature of Hypnosis: What is it & how does it work? Assuaging an effect of controversies somewhat, PET scan & fMRI studies showing modulations of activity in specific & relevant areas are starting to allay prejudices to its application in certain fields, such as pain mx The images differ from those of well-instructed, well-motivated role-players

Nature of Hypnosis: What is it & how does it work? So, not just “imagination”, “faking”, “play-acting”, “stage-show gimmickery”. For high & moderate hypnotisables (roughly 2 in 3 people), hypnosis can bring benefits beyond those of imagination or willing

Nature of Hypnosis: What is it & how does it work? Even sceptics (who don’t believe in ‘trances’) believe it can relieve conditions like insomnia, obesity, hypertension & improve behaviour therapies, counselling & coping strategies Whilst accepting imaging studies, they believe though that hypnosis is not tapping into anything beyond a continuum of everyday abilities that are distributed across the population in a pattern detected by hypnotisability scales They say it’s just that hypnosis is one of the best ways to tap into these commonplace capacities

Nature of Hypnosis: Common ideas vs evidence What do you know about hypnosis? (Nash,2001)

Who benefits more? 1. People who score high (26%) and moderately (36%) on scales of hypnotisability. 29% are mildly hypnotisable. (9% unhypnotisable) (Hilgard, 1961) 2. Children (peaks age 9 - 12) 3. People who ask for hypnotherapy/who are motivated 4. People who have an imaginative ability e.g. artistic types 5. People who have a capacity for emotional involvement 6. People who can take things on faith or trust as opposed to sceptical, analytical types 7. People from certain cultures e.g. Latinos vs. Germans 8. Rights handers vs. left handers

Who benefits less? 1. People with abnormally low IQ's (attention and response-time factors) 2. Dementia patients (these patients cannot be hypnotised due to problems in prefrontal areas necessary to process induction signals) 3. People who score low (9%) on scales of hypnotisability 4. People for whom condition brings secondary gains (conscious or unconscious pay-offs) 5. People in psychotic states. (Can uncover too much material and therapist can be drawn in to any delusional beliefs) 6. People in hypermanic states

Contraindications There are few absolute contraindications to the use of hypnosis. It is usually a very safe procedure. But there are number of situations in which you should be cautious Hypnosis is usually contraindicated if you are dealing with: 1. Any condition which would be better treated another way 2. Any condition outside your specialty and area of expertise 3. Depression with a risk of suicide. Be on the qui-vive for "masked depression" e.g. depression masked by low back pain or a habit disorder. The tranquillising effects of hypnosis may energise a lethargic depressive sufficiently to allow suicide 4. Thought disorders such as Schizophrenia and Delusional Disorder except if you have experience with these. While hypnosis cannot precipitate a psychosis, you may be incorporated into the person's thought disorder more readily

Phenomena & strategies facilitated & intensified by hypnosis Increased temporary and post-hypnotic suggestibilty = less critical, evaluative thinking Reduced awareness that improves classical conditioning. Easier to establish & more difficult to extinguish Hallucinations that are more real and absorbing than ordinary imagination Regression and revivification Time distortion e.g. time contraction in medical procedures Analgesia and anaesthesia Dissociation (split self off from current reality) A.N.S. control e.g. changing blood flow Arousal modulation (within limits) for the demoralised or the distressed to focus therapy attention

Phenomena & strategies facilitated & intensified by hypnosis Imaginal conditioning Revivification and (cognitive) restructuring Exposure therapy/ extinction/ abreaction Imaginal rehearsal Relaxation / arousal reduction Suggestion: e.g. for ego-strengthening and altering pain sensation, enhancing performance Simple encouragement and support

Areas of application Medical Asthma Burns Minor Surgical Procedures Enuresis Hypertension Childbirth Migraine Minor Surgical Procedures Obesity Pain Control Gastro-intestinal Disorders Warts

Areas of application Psychological Practice & Psychiatry Anxieties Apathy and lack of Motivation Confidence Problems Eating Disorders Depression Nail-biting Fears and Phobias Psychosomatic Syndromes Panic Attacks Sleep Disorders Sexual Dysfunction Thumb-sucking Stuttering

Areas of application Dentistry Anaesthesia Anxiety / Apprehension Bleeding Control Bruxism Dental Phobia Denture Problems Gagging Nausea Pain-control Restlessness Salivation-control Tempro-mandibular Joint Dysfunction

Areas of application Education Concentration and Attention problems Exam Fears/Phobias Motivation training Memory Training Study habit problems Sports Attitude Change Confidence Building Co-ordinate Mind & Body Fear of Success Fear of Failure Maximise Potential Improve Concentration Performance Anxiety Motivation Training control

Procedural Stages of Hypnotherapy 1. Preparation (e.g. removing misconceptions, assess interests that may be incorporated in procedure) 2. Assessment of hypnotisability (capacity for concentration and imagery, suggestibility) 3. Induction procedure 4. Deepening stage 5. Trance ratification 6. Utilisation of trance for therapeutic purposes 7. Post-hypnotic suggestions including self- hypnosis instructions 8. Termination of the trance 9. Discussion of the experience. Problems?

Pain-related Case Discussions Cervico-genic headaches in 37 yr old female from m.v.a. at age 17 Mx of pain of burns bath treatment in 10 yr old male Mx of chronic (2yrs +) hyperemesis in 33 yr old female

Resources + Pre-/post- session reading http://www.abc.net.au/catalyst/stories/s1440855.htm Vision and transcript. Hypnosis for pain at 19 minute mark Australian Society of Hypnosis http://www.ozhypnosis.com.au/Default.htm Hypnosis.com – the FAQ section is excellent http://hypnosis.com/faq/ This presentation www.fmcdonald.com Extra reading presented via JCU network