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Hypnotic Approaches for Chronic Pain Management
Clinical Implications of Recent Research Findings
Mark P. Jensen and David R. Patterson
University of Washington
The empirical support for hypnosis for chronic pain man- differences in expert opinion regarding which of these
agement has flourished over the past two decades. Clinical elements represents the core component(s) of hypnosis,
trials show that hypnosis is effective for reducing chronic making it difficult to determine if a specific treatment
broadly. pain, although outcomes vary between individuals. The should be classified as hypnosis or not. Despite the lack of
findings from these clinical trials also show that hypnotic consensus, we think it is important for clinicians and re-
publishers. treatments have a number of positive effects beyond pain searchers to specify the definition they use in their work.
control. Neurophysiological studies reveal that hypnotic Our preferred definition has been that proposed by Kihl-
allieddisseminatedanalgesia has clear effects on brain and spinal-cord func- strom (1985, p. 385): “a social interaction in which one
its be tioning that differ as a function of the specific hypnotic person, designated the subject, responds to suggestions
of to suggestions made, providing further evidence for the spe- offered by another person, designated the hypnotist, for
one not cific effects of hypnosis. The research results have impor- experiences involving alterations in perception, memory,
or is tant implications for how clinicians can help their clients and voluntary action.” (For further discussion regarding
and experience maximumbenefitsfromhypnosisandtreatments different definitions of hypnosis that have been proposed,
that include hypnotic components. and the theoretical models underlying them, see Barnier &
user Nash, 2008.)
Association Keywords: hypnosis, chronic pain, hypnotic analgesia Hypnosis has been used to treat every type of pain
hronic pain remains a significant burden for both condition imaginable over centuries and across cultures
individual individuals and society. Standard medical treat- (Pintar & Lynn, 2008). What is new about hypnotic anal-
the Cmentforchronic pain is often inadequate (Turk, gesia is the compelling empirical evidence that has
Psychologicalof emerged in the last two decades regarding its efficacy and
use Wilson, & Cahana, 2011), and it is common for frustrated mechanistic underpinnings. Much of the earlier research
patients to seek costly treatments from multiple health care studying hypnotic analgesia focused on acute pain induced
American professionals without significant relief. Although a number in laboratory settings or pain associated with medical pro-
the personal of psychological approaches to the treatment of chronic cedures (Chaves, 1994; Ewin, 1986). This work continues,
by the pain have demonstrated important success over the last few
for decades (see Jensen & Turk, 2014, this issue), there is a
need for additional and robust treatment options that could Editor’s note. This article is one of nine in the February–March 2014
solely benefit individuals with chronic pain. American Psychologist “Chronic Pain and Psychology” special issue.
copyrighted Growing awareness of the limitations of currently Mark P. Jensen was the scholarly lead for the special issue.
is available pain treatments make training patients in self-
intended hypnosis an attractive component of pain treatment. For Authors’ note. Mark P. Jensen and David R. Patterson, Department of
is example, there are increasing concerns about the overreli- Rehabilitation Medicine, University of Washington.
document ance on analgesic medications, which can have negative Mark P. Jensen is the author of two books (2011, Oxford University
article side effects, have limited evidence for long-term efficacy, Press) related to the topic of this article (Hypnosis for Chronic Pain
This and can result in significant problems associated with ad- Management: Therapist Guide and Hypnosis for Chronic Pain Manage-
This ment: Workbook), and David R. Patterson is the author of one book (2010,
diction or diversion (i.e., nonprescription use) (Manchi- American Psychological Association) related to the topic of this article
kanti & Singh, 2008; Maxwell, 2011). There is a corre- (Clinical Hypnosis for Pain Control). They receive royalties for the sale
sponding need for effective pain treatments that have of these books.
minimalnegative side effects; we are not aware of any pain This research was supported by the National Institutes of Health, the
National Institute of Child Health and Human Development, National
treatment option with fewer adverse effects than hypnosis Center for Medical Rehabilitation Research Grant R01 HDD070973, and
(Jensen et al., 2006). National Institute of Arthritis and Musculoskeletal and Skin Diseases
In spite of the promise of this treatment, however, Grant R01 AR054115. The views presented here are not necessarily those
general acceptance of and research on hypnosis continues of the National Institutes of Health.
We would like to express our appreciation to Lisa C. Murphy and
to be limited. This may be due in part to the lack of a Jenny Nash for their valuable comments and feedback on an earlier
widely accepted definition of hypnosis (Barnier & Nash, version of this article.
2008). Hypnosis incorporates a number of components, Correspondence concerning this article should be addressed to Mark
such as relaxation, focused attention, imagery, interper- P. Jensen, Department of Rehabilitation Medicine, University of Wash-
ington, Box 359612, Harborview Medical Center, 325 Ninth Avenue,
sonal processing, and suggestion. There continue to be Seattle, WA 98104. E-mail: mjensen@uw.edu
February–March 2014 ● American Psychologist 167
©2014 American Psychological Association 0003-066X/14/$12.00
Vol. 69, No. 2, 167–177 DOI: 10.1037/a0035644
between patients who receive treatment and patients in a
control condition (e.g., relaxation training, standard care,
attention). However, it is unwise to draw conclusions re-
garding the efficacy of any treatment based only on the
statistical significance of averaged results. Statistically sig-
nificant group differences can emerge even when there are
very small (i.e., essentially meaningless) improvements in
outcome in all or nearly all study participants. More im-
portant, perhaps, nonsignificant results can emerge for
treatments that have large and meaningful effects in many
study participants if the study sample is too small or if the
treatment is highly effective for a small subset of patients.
In short, average group differences tell us little about the
variability of treatment response among the individuals
broadly. who receive the treatment.
Responder analyses have been recommended as an
publishers. alternative strategy for determining the meaningfulness of
treatment effects in pain clinical trials once a significant
allieddisseminated treatment effect has been established (Dworkin et al.,
itsbe 2008). In a responder analysis, the investigator identifies
ofto MarkP. the amount of improvement in the outcome variable needed
onenot Jensen to determine that an improvement is clinically meaningful
oris and then reports the proportion of “responders” in the
and and there have also been a number of recent innovative different treatment conditions. For example, one early clin-
ical trial of hypnosis for migraine headache (Anderson,
user applications of this modality to treat acute procedural pain Basker, & Dalton, 1975) used “complete remission” as a
Association(e.g., Patterson, Wiechman, Jensen, & Sharar, 2006). Other criterion indicating a meaningful treatment response. More
recent advances in understanding have come from imaging recent studies use a 30% reduction in average daily pain
individualstudies examining the brain functions associated with hyp- intensity to represent a clinically meaningful improvement
the nosis and hypnotic analgesia (Barabasz & Barabasz, 2008; in chronic pain conditions (Dworkin et al., 2005).
PsychologicalofOakley, 2008; Oakley & Halligan, 2010; D. Spiegel, We were able to identify four hypnosis studies that
use Bierre, & Rootenberg, 1989). In addition, there has been a reported the results of responder analyses in addition to
recent and dramatic increase in research on the efficacy of group average results. In the first of these (Anderson et al.,
American hypnosis for chronic pain conditions (Montgomery, Du- 1975), 47 patients with migraine headache were randomly
thepersonalHamel, & Redd, 2000; Stoelb, Molton, Jensen, & Patter- assigned to receive 12 months of either (a) six or more
bythe son, 2009; Tomé-Pires & Miró, 2012). sessions of hypnosis (with instructions to practice self-
for Clinical outcome studies on acute and chronic pain as hypnosis daily) or (b) medication management (adminis-
well as neurophysiological studies in the laboratory have tration of the prophylactic drug Stemetil 5 mg four times
solely demonstrated that hypnosis is effective over and above per day for the first month and two times per day for the
copyrightedplacebo treatments and that it has measurable effects on remaining 11 months of the trial). A responder analysis
is activity in brain areas known to be involved in processing indicated that “complete remission” of headaches during
intendedpain. Equally important, recent clinical trials provide sig- the last three months of treatment was achieved by 44% of
is nificant findings useful to the clinical application of hyp- the participants in the hypnosis condition and 13% of the
document nosis for the management of chronic pain. The ensuing participants in the medication-management condition.
Thisarticlereview and discussion highlight the clinical relevance of In an early uncontrolled case series and two follow-up
This these findings to the use of hypnosis for chronic pain and controlled trials, we examined response to 10 sessions of
present the issues that we believe should be considered in self-hypnosis training in a combined total of 82 individuals
future clinical and theoretical work. with various diagnoses associated with physical disability
Findings From Hypnosis Clinical Trials who also had chronic pain (Jensen, Barber, Romano, Han-
ley, et al., 2009; Jensen, Barber, Romano, Molton, et al.,
Two general findings from hypnosis trials have particular 2009; Jensen et al., 2005). A 30% or more reduction in
clinical and theoretical relevance: (a) There is a high degree average pain identified treatment responders, and analyses
of variability in response to hypnotic analgesia, and (b) the showed treatment-response rates varied from a low of 22%
benefits of hypnosis treatment go beyond pain relief. for individuals with spinal cord injury to 60% for persons
Response to Hypnosis Treatment Is Highly with acquired amputation. Moreover, in one of these stud-
Variable ies, a significant Time Treatment Condition Pain Type
(neuropathic vs. nonneuropathic) interaction also emerged,
In hypnosis/pain clinical trials, the standard primary anal- explained by the fact that all of the participants who re-
ysis compares group average differences in pain reduction ported a clinically meaningful decrease in pain intensity
168 February–March 2014 ● American Psychologist
and the fact that the majority of patients show at least some
benefits of hypnotic treatment (Montgomery et al., 2000)
partially account for the fact that hypnotizability screenings
are seldom used in clinical approaches to hypnotic pain
control.
Hypnosis Treatment Has Significant Benefits
Beyond Pain Relief
Clinicians in our hypnosis clinical trials anecdotally noted
that the overwhelming majority of participants reported
high levels of treatment satisfaction whether or not they
experienced clinically meaningful pain relief. Moreover,
we also found that a large proportion of patients—includ-
ing many who did not report clinically meaningful de-
broadly. creases in average or characteristic pain with treatment—
reported at follow-up that they continued to practice the
publishers. self-hypnosis skills taught (Jensen, Barber, Romano, Han-
ley, et al., 2009; Jensen, Barber, Romano, Molton, et al.,
allieddisseminated 2009). To help understand what appeared to be an anom-
itsbe alous finding, we contacted a cohort of patients who re-
ofto David R. ceived self-hypnosis training to determine their reasons for
onenot Patterson continued use of self-hypnosis skills despite an apparent
oris lack of benefit on average daily pain intensity. Consistent
and with what the study clinicians reported, almost all of the
study participants reported high levels of treatment satis-
user had neuropathic pain, but none of the participants with faction (Jensen et al., 2006). In addition, the great majority
Associationnonneuropathic pain reported a meaningful pain reduction of those who continued to practice self-hypnosis reported
following hypnosis treatment (Jensen, Barber, Romano, that they experienced temporary pain relief when they
individualMolton, et al., 2009). listened to audio recordings of the treatment sessions or
the When discussing variability in response to hypnosis practiced self-hypnosis on their own without the record-
Psychologicaloftreatment, it is important to consider the issue of hypnotiz-ings.
use ability. Hypnotizability reflects a person’s tendency (or, as In short, we have found that hypnosis treatment has
some investigators in the field view it, a trait, talent, or two potential effects on chronic pain. First, as described
American ability) to respond positively to a variety of different sug- above, the treatment can result in substantial reductions in
thepersonalgestions following a hypnotic induction. A number of average pain intensity that is maintained for up to 12
bythe standardized measures of hypnotizability exist (e.g., the months in some—but not all—patients. We interpret this
for Hypnotic Induction Profile, H. Spiegel & Spiegel, 2004; finding as support for the hypothesis that hypnosis treat-
the Stanford Hypnotic Susceptibility Scale, Weitzenhoffer ment can result in sustained changes in how the brain
solely & Hilgard, 1962; the Harvard Group Scale of Hypnotic processes sensory information in subgroups of patients
copyrightedSusceptibility, Shor & Ome, 1962; and the Stanford Hyp- (larger or smaller subsets, depending on the specific pain
is notic Clinical Scale, Morgan & Hilgard, 1978–1979). Each condition studied). However, for greater numbers of pa-
intendedof these measures consists of a standardized hypnotic in- tients, hypnosis treatment teaches self-management skills
is duction followed by a series of suggestions (for changes in that patients can (and most do) continue to use regularly
document sensory experiences, amnesia, etc.), and the subject’s hyp- and that can result in temporary pain relief.
Thisarticlenotizability score is the simple sum of positive responses to Wealsoaskedoursampletodescribe the positive and
This the suggestions. negative effects of hypnosis, and of the 40 different effects
One of the most consistent research findings is that elicited, only three were negative (Jensen et al., 2006).
hypnotizability scores are very stable, even across decades Moreover, and to our surprise, only nine (23%) of the
(Morgan, Johnson, & Hilgard, 1974). Another consistent positive descriptions of hypnosis were pain-related. Non-
finding is that general hypnotizability (i.e., response to pain-related beneficial treatment effects included improved
suggestions not involving analgesia) predicts response to positive affect, relaxation, and increased energy. These
hypnotic analgesia in the laboratory setting (Hilgard & non-pain-related benefits were reported despite the fact that
Hilgard, 1975). This has led to speculations that hypnotiz- the hypnotic intervention was script driven and focused
ability might explain the variability in response to hypnotic exclusively on pain management.
treatments of chronic pain. However, a growing body of Theseresults are consistent with qualitative comments
evidence indicates that general hypnotizability demon- in the literature regarding the beneficial “side effects” of
strates weak and inconsistent associations with hypnotic hypnosis (Crawford et al., 1998; Stewart, 2005). They also
treatment of chronic pain in the clinical setting (Patterson reflect another important finding in the pain literature:
&Jensen, 2003). The weak associations with clinical pain People who report positive changes and satisfaction with
February–March 2014 ● American Psychologist 169
treatment do not always report substantial reductions in nosis can also include suggestions for improving activity
pain intensity (Turk, Okifuji, Sinclair, & Starz, 1998). As levels, adaptive coping responses, adaptive pain-related
we discuss in greater detail below, the use of hypnosis to cognitions, and sleep quality (Jensen, 2011). Thus, clini-
improve quality of life in people with chronic pain often cians should take full advantage of all potential hypnotic
involves focusing on outcome variables other than just pain effects to help patients achieve a number of treatment
relief. goals; suggestions should rarely, if ever, focus exclusively
on pain reduction.
Clinical Implications of Findings From Good practice involves giving patients
Hypnosis Clinical Trials withchronicpainrealistichope. Itisclear,based
The key findings from the hypnosis clinical trials reviewed on research findings, that not all patients with chronic pain
above have three important implications for maximizing are going to experience pain relief with hypnosis. This
the benefits of hypnotic pain treatment. Specifically, they brings up the question of how expectations for treatment
indicate that clinicians should (a) include suggestions for can be enhanced, given that outcome expectancy is an
both immediate and long-term pain relief, (b) include sug- important factor that can enhance any clinical intervention.
broadly.gestions for benefits in addition to pain reduction, and (c) Because of our finding that the great majority of the par-
use the knowledge about the multiple benefits of hypnosis ticipants in our clinical trials report some benefits through
publishers.to enhance treatment outcome expectancies. learning hypnosis, even when those benefits do not neces-
Immediate and long-term pain relief with sarily include pain relief, we now tell patients something
allieddisseminatedself-hypnosis. Given the evidence that hypnotic an- along the lines of the following to enhance outcome ex-
itsbe algesia treatment can result in both (a) long-term pain relief pectancies without giving unrealistic expectations:
of to and (b) learning skills that produce immediate but shorter
one Manypatients find that they experience meaningful reductions in
or not lasting (i.e., a matter of hours) relief, clinicians providing their pain that maintain for a year or more after treatment. Others
is hypnosis treatment should ensure that they take full advan- report that they use the skills they learn to experience pain relief
and tage of both of these outcomes. Specifically, they should for a few hours at a time when they use self-hypnosis for just a
user include hypnotic suggestions for “automatic” and long- minute or two. Even when the treatment does not result in
Associationterm reductions in pain and related distress. They should significant pain relief, almost everyone reports some benefit, such
also provide suggestions, such as the following, that can as improved sleep, an increased sense of overall calmness and
facilitate the regular use and practice of self-hypnosis: well-being, or reduced stress. I don’t know at this point which of
individual these benefits you would experience if you choose to learn self-
the And when you practice self-hypnosis, your mind can easily enter hypnosis . . . want to find out?
Psychologicalofthis state of comfort, and the comfort will stay with you for The Effects of Hypnotic Analgesia on
use minutes and hours . . . the more you practice, the easier and more Pain-Related Brain Activity
automatic this will be . . . and the longer the beneficial effects will
American last. To date, the primary imaging techniques used to study the
thepersonal Addressing issues beyond pain reduction. neurophysiological effects of hypnosis include positron
by the Given the established beneficial effects of hypnosis on emission tomography (PET; cortical metabolic activity),
for other outcome domains, hypnotic suggestions for address- functional magnetic resonance imaging (fMRI; changes in
ing additional pain-related issues should also be included in blood flowinthebrainandspinalcord),andelectroenceph-
solely the hypnotic treatment (Jensen, 2011; Patterson, 2010). In alography (EEG; cortical electrical activity). PET and
copyrightedchronic pain, there are almost always associated symptoms fMRI are most useful for identifying locations of brain
is that deserve attention. For example, between 50% and 88% activity, and EEG is most useful for assessing brain states.
intendedof patients with chronic pain report problems with sleep Rather than repeating what has been reported in a number
is (Smith & Haythornthwaite, 2004). For such patients, hyp- of reviews on cortical responses to hypnotic analgesia
document notic suggestions can be provided for an increased ability (Barabasz & Barabasz, 2008; Oakley, 2008; Oakley &
Thisarticleto fall asleep, to return to sleep if they awaken, and to feel Halligan, 2010; D. Spiegel et al., 1989), we discuss four
This rested in the morning (Jensen, 2011). key findings from this body of research that have important
Effective chronic pain treatments also often target clinical implications for applying hypnosis to chronic pain
increased activity and adaptive coping responses. Patients management.
whoare involved in physical therapy or who are maintain- Hypnotic Analgesia Influences Pain
ing a regular exercise program can be given suggestions Processing at Multiple Sites
that they will feel confident in their ability to engage in and
maintain exercise. Those who experience fatigue might be Oneofthemostimportant findings from recent neurophys-
given suggestions such as being able to draw on an inner iological studies of pain is that there is no single “pain
strength and experience reserves of energy when needed center” in the brain that is responsible for the processing of
and appropriate (Jensen, 2011). pain. We now know that pain is associated with activity in
It is also important to remember that people with and interaction between a number of different areas of the
chronic pain often suffer from clinically significant depres- peripheral and central nervous systems, each of which
sion and anxiety (Patterson, 2010), and mood states can be contributes to the overall experience of pain (Apkarian,
addressed by hypnosis (Alladin, 2010; Yapko, 2001). Hyp- Hashmi, & Baliki, 2011). The cortical areas most often
170 February–March 2014 ● American Psychologist
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