Course content © Copyright 2011 - 2026 by Bruce N. Eimer, Ph.D, ABPP. All rights reserved.

Course Outline

A Message from the Author

Learning Objectives

Author Disclaimer

Introduction

Scope of the Problem

Overview of the Course

A Definition of Pain

Chronic Pain and Suffering

The Physiology of Pain

Old Theories

New Ideas: The Gate Control Theory

When Acute Pain become Chronic

Evaluation of the Pain and Coping

Pain Evaluation Questionnaire

The Pain Description Questionnaire

Evaluating Coping

The “A” of Pain Coping

The Six “D”s of Pain Coping

Understanding What Hypnosis Is and Isn’t

What Hypnosis Is Not

What Hypnosis Is

Official Definitions

Hypnotic Analgesia

Hypnotic Suggestion

Sensory Memory Systems and Active Sensory Imagination

Practicing Inducing Hypnosis and Self-Hypnosis

An Initial Goal

Self-Hypnosis Methods

Learning to Use Self-Hypnosis to Cope with Pain

Choosing the Technique

The Six D’s of Hypnotic Coping

Deep Relaxation

Decatastrophizing

Direction

Twelve Behavioral Coaching Principles

Distraction

Distortion

Dissociation

Changing the Pain Experience

Constructing Effective Self-Suggestions

Seven Simple Rules

Post-hypnotic Suggestion

Resources

Reference

A Message from the Author

This course is intended for the experienced mental health clinician who may or may not be familiar with hypnosis and the application of this treatment method to chronic pain.  Whether you have experience with hypnosis or you are looking to add it to your practice, this course will provide you an overview of using it for chronic pain management. The goal of this course is to provide you with a rewarding experience.  Dr. Eimer is a licensed clinical psychologist in Philadelphia with more than twenty years of experience treating people using cognitive behavioral and hypnosis strategies.  He also suffers from chronic pain and has used hypnosis successfully to help with this problem. He is Board Certified by the American Board of Professional Psychology in the specialty of Cognitive-Behavioral Psychology, a Fellow of the American Society of Clinical Hypnosis, and an Approved Consultant in Clinical Hypnosis.  More information about his credentials can be found on the Authors’ Page.

Portions of this course content draw on the author’s work found in the following resources (and work done since then).  More detailed information can be found there. Some of these books are also excellent to be used as patient resources.   

Eimer, B.N. (2008). Hypnotize yourself out of pain now (Second Edition). Carmarthen, Wales, UK: Crown House Publishing (CD also available).

Eimer, B.N. and Freeman, A. (1998). Pain management psychotherapy: A Practical Guide. New York: John Wiley and Sons.

Eimer, B. and Torem, M.S. (2002). Coping with uncertainty.  Oakland: New Harbinger Publications.

Ewin, D.M. and Eimer, B.N. (2006). Ideomotor signals for rapid hypnoanalysis: A how-to manual.  Springfield, IL: CC Thomas.

Zarren, J. and Eimer, B. (2002). Brief cognitive hypnosis: Facilitating the change of dysfunctional behavior.  New York: Springer Publishing.

The course presents a philosophy of pain management along with practical strategies for building pain tolerance and inoculating the patient against unnecessary pain, stress, and suffering. I have endeavored to provide plenty of realistic and useful advice for practitioners who are working with patients who have tried everything else with little prior success. As a clinical psychologist who has treated hundreds of people with various chronic-pain syndromes over the years, I’m familiar with being considered a “court of last resort.” Being that I am also a person with chronic pain due to a permanent injury, physical impairment, and a progressive disease, I myself have been through the gamut of treatments. I have experienced the frustrations of going from one health-care professional to the next with the hope of finding pain relief, only to be disappointed in the end. One of the things that I have discovered as a result of my personal and professional experiences is that every person must ultimately take responsibility for his or her own behavior, feelings, thoughts, and experience. Pain is a behavior, a feeling, a thought, and an experience. Taking responsibility for how one copes with pain constitutes a conscious choice. It is the person’s choice—it’s up to the patient how to handle it. Nobody but you (your patient) can cope with the pain.  As will be discussed, for treatment to be successful and the results long-lasting, this personal responsibility issue is an important concept and philosophy for the patient to accept. This is an important issue to discuss with the patient at the beginning of treatment and throughout, as appropriate.

No risk with hypnosis. One of the benefits of using hypnosis to control pain is that there is no risk of negative side effects. Self-hypnosis is not like a pharmaceutical drug, which is an external agent that is ingested or injected and modifies biochemical and physiological processes. Self-hypnosis is an internal or inner method for communicating with the unconscious or subconscious mind, which is the part of the mind that controls all of the biochemical and physiological processes that keep us alive. Because self-hypnosis is an inner method of self-communication, it is safe; the unconscious mind will simply not accept suggestions that are consciously or subconsciously deemed harmful or unacceptable to the patient. There is only a potential upside and no downside to using self-hypnosis to control and relieve persistent pain and discomfort.  As can be seen in the figure, the use of narcotics is increasing, likely as a “quick fix” to pain.  As we all know, this causes its own myriad of problems. Hypnosis can be a great alternative to be used instead of, or adjunctive to, pain medication (with proper coordination of treatment with the physician).

Figure: Pain Medication Use

Taking personal responsibility and accountability. I learned that keeping my pain under control necessitated keeping an open mind, maintaining balance in my life by adopting a balanced philosophy, and using the tool of self-hypnosis regularly.  This is important to teach our patients.  Different parties involved in one’s chronic pain have different agendas. Unfortunately, people with chronic pain are often caught between the conflicting agendas of various people and institutions.  Just some of the conflicts facing the patient might include the following.  All of these factors “work against” successful coping with chronic pain.

The patient’s own need to escape from pain

The insurance companies’ desire to get the patient off disability and back to work

The patient’s family members’ need to have the “old you” back

The patient’s attorney wanting the greatest settlement possible which, unfortunately, is often based on one’s degree of disability (in the legal system, one is not “rewarded” for trying to get better)

The defense attorney who is trying to absolve his or her client of responsibility

The doctors who want to have a compliant patient who responds positively to the particular treatment provided

Conflict (such as that due to the above) creates stress which is experienced both consciously and subconsciously. Stress makes coping with persistent pain more difficult. One of the jobs of the “pain therapist” is to help the patient review, reframe and resolve conscious and unconscious conflicts. A relatively conflict-free person with persistent pain is more empowered to cope with the pain and more likely to get out of pain. The unconscious (or subconscious) part of the mind is aware of conflicts that the individual may be unaware of on a conscious level. The unconscious controls all of your automatic habits and all of the functions that keep you alive (such as blood pressure, heart rate, breathing, digestion, sleep-wake cycles, etc.), including pain. You need to be able to communicate with your unconscious mind to help alleviate persistent pain. Hypnosis is the most effective, nondrug tool we have for communicating with our unconscious mind.

This course presents my understanding and philosophy about pain coping, using the tools of hypnosis and self-hypnosis.  The goal of the course is to teach practitioners how to teach their patients to apply the appropriate counter and competing stimulation to subdue the pain. This involves learning how to refocus attention and mental energies to become absorbed and engaged in comforting and pleasurable mental activities. It involves mentally shifting from a state of discomfort to a state of comfort. The approach presented in this course will help your patients regain greater control over their pain, symptoms, and life experience.

learning objectives

·         Explain old and new theories of pain

·         Describe the initial evaluation of the pain patient for hypnosis

·         List and explain the six D’s of coping

·         Contrast what hypnosis “Is and Isn’t”

·         Describe the “Rules for Self-Suggestion”

Author Disclaimer

The clinical evaluation and treatment methods described in this course are not intended as substitutes for competent and thorough medical, psychiatric, or psychological evaluation and care, nor are they intended to replace the medical or professional recommendations of physicians or other health‑care providers who are familiar with a given case.  This course is intended to offer usable information that can enhance the effectiveness of the reader/clinician in helping his or her patients alleviate or gain control over their symptoms and change their dysfunctional behaviors.  All patients with pain should be evaluated by a physician.  In fact, it is recommended that patient’s not be accepted for pain management treatment if they have not been evaluated by a physician and, in most cases, are being “co-managed”.  If the nature or quality of the pain changes in any notable way, the patient should see his or her physician. (See Risk Management Course)

Introduction

Hypnosis for pain management is not a newly invented therapy or clinical application, but in fact has been employed with great success for more than two centuries (Gravitz 1994; Hilgard and Hilgard 1994; Patterson, Jensen and Montgomery, 2010). The use of hypnosis as a tool for relieving pain is not experimental—it is in fact supported by innumerable empirical studies. This course will teach the practitioner methods that can be taught to patients to help them become their own healer.  It will review specific exercises in self-hypnosis to help relieve pain. The philosophy is to teach the patient to become his or her own hypnosis practitioner.

The methods in this course make it possible for people in pain to gain effective results in pain reduction through self-hypnosis.  It reviews methods that you can teach your patients including evaluating his or her pain, coping strategies, and hypnotic responsiveness. A number of methods for inducing self-hypnosis (meaning entering and enjoying the hypnotic trance state) are also presented. This allows the clinician to help the patient choose the self-hypnosis method(s) that are most effective. It is an adjunctive tool that can be added to almost any pain management interventions.  Once the patient masters these methods, he or she will feel less helpless, and more confident, relevant to coping with pain.

When a patient has been in pain that hasn’t responded to treatment for a long time, it’s natural to become disillusioned and expect nothing to work. The self-hypnosis method of pain control can provide a fresh look at the problem of managing persistent pain.  This course assumes no prior training in hypnosis.

The Scope of the Problem

Almost 80 million people in the United States today have some form of chronic pain. For many, the pain is persistent and severe enough to cause significant disability. In fact, chronic pain is the leading cause of disability in this country, more than diabetes, heart disease, stroke, and cancer (See the US Department of Health and Human Services CDC Health Trends Report with special feature on pain, 2006; See also summary by the American Academy of Pain Medicine). When pain resulting from injury, disease, or physical impairment causes significant disability, it often brings untold suffering. The total annual cost of chronic pain in the United States is estimated to be 100 billion (yes, that’s a “B”). As we get older, the prevalence of chronic pain increases (See Figure)

Figure: Pain Duration by Age

The following statistics and Figure will help the practitioner get an idea of what type of pain problems he or she might be faced with treating.  These results are primarily from NIH and CDC:

When asked about four common types of pain, respondents of a National Institute of Health Statistics survey indicated that low back pain was the most common (27%), followed by severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%).

Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of 20-64 experience frequent back pain.

Adults with low back pain are often in worse physical and mental health than people who do not have low back pain: 28% of adults with low back pain report limited activity due to a chronic condition, as compared to 10% of adults who do not have low back pain.

Adults reporting low back pain were three times as likely to be in fair or poor health and more than four times as likely to experience serious psychological distress as people without low back pain.

Figure. Prevalence of Pain Problems

Overview of the Course

“Pain” refers to the physical sensations of discomfort. “Suffering” refers to the experience of emotional distress and may include feelings of anxiety, fear, depression, grief, and anger. Suffering makes physical pain worse. Suffering is one’s pain, plus the emotional response to the pain.  While pain may be an unavoidable consequence of injury, disease, or physical impairment, suffering is not necessary. Pain may be mandatory, but suffering is optional.

This course is a very practical guide to effective self-help techniques that can be taught to patients for hypnotizing oneself out of pain and suffering. It includes methods to briefly evaluate and assess the pain and use a variety of cognitive and self-hypnotic coping strategies to relieve it. More details about theories of pain, cognitive behavioral treatment of pain, etc., can be found in other courses.  This course will review self-hypnotic techniques to help patients:

“Reframing" and “decatastrophizing” problems

Distracting oneself from unnecessary pain

Taking control of one’s life and directing behavior

Using deep relaxation as a coping tool

Positively transforming pain sensations so that they are less uncomfortable and bothersome

Dissociating and disconnecting from the pain

This course is intended to inform, educate and provide your patients with new choices for coping more comfortably and effectively with chronic pain. Some of the techniques described may also serve as adjunctive methods to complement your ongoing treatment (including medical care). In my own personal process of managing a chronic pain problem, I have learned to follow the Ten Commandments for Coping with Chronic Pain (Bassman and Wester, 1997). The first letters of these commandments spell the acronym NO MORE PAIN and serve as a nice overview of the treatment approach:

Noticing where I am relatively comfortable;

Optimizing the control I do have;

Motivating myself to engage in positive activities;

Opening my mind to new possibilities and choices (being flexible as much as possible);

Relaxing in some regular way (i.e., using self-hypnosis regularly);

Evaluating my time and priorities (recall that managing chronic pain can be a full-time job);

Practicing self-hypnosis to gain some control over my pain and other symptoms;

Avoiding stressful and conflictual situations as much as possible;

Individualizing my schedule and not being afraid to make “downtime” when the pain flares up;

Negotiating support from others.

A Definition of Pain

Often, a first step in being able to control something as puzzling as pain that won’t go away is to be able to define it (or at least describe it in terms that make sense). Therefore, I think that we should start by defining pain. The definition that I use is one that accommodates the possibility of alleviating it using the psychological tool of self-hypnosis. This definition is an adaptation of the one provided by the International Association for the Study of Pain (IASP; 1994).

This definition acknowledges that pain contains several elements or components:

a bodily sensation with qualities like those experienced during or after tissue-damaging stimulation,

an experienced threat or interference with one’s functionality associated with this sensation, and

an emotional feeling of unpleasantness or other negative emotions based on this experienced threat or interference.

Pain contains sensory, cognitive and emotional components that are intertwined in its experience. One of the keys to relieving pain is to disentangle these components; to separate the sensory or physical from the emotional and mental components of the experience. Such a definition of pain allows for a balanced view. It does not overemphasize the importance of medical-physical factors at the expense of psychological ones. On the other hand, it does not compromise the importance of medical-physical factors and overemphasize psychological factors. Pain is neither all in one’s head, nor all in one’s body—it is contained and experienced in both places. The mind and the body both play an equally important role in initiating and perpetuating the experience of pain. This is a great advantage because it opens the door to the employment of psychological methods of intervention such as hypnosis for the alleviation and management of pain.

Types of Pain

All pain is not the same. First of all, an important distinction that needs to be made is between acute and chronic pain. Acute pain is pain that is of recent origin. For example, the immediate pain you feel when you stub your toe or burn yourself is acute. The new pain from a recent injury is also considered acute. With appropriate medical care and treatment, acute pain is supposed to eventually subside. However, as anyone with persistent pain knows firsthand, pain doesn’t always go away even when appropriate medical treatment is provided. When pain lasts beyond the point where it should have subsided or gone away (tissue healing), it may be considered chronic.

Acute pain. Acute pain fulfills a necessary function—it keeps us from destroying ourselves. It serves as a highly useful signal that the body is in danger or under siege. It signals current or imminent harm to the tissues of the body. Without the capacity to feel pain, the world would be a much more dangerous place. For instance, you could burn yourself irreparably without even knowing it. You might not know that your collar was too tight, the zipper on your garment was pinching your skin, that your finger was caught in the door, or that you were walking on a broken bone. Obviously this is not a healthy way to go through life (see the introduction to pain course for more information on this condition).

Chronic pain. Chronic pain is another story. Chronic pain is persistent pain that often has outlived its usefulness. It’s pain that has long since passed the time when it is necessary as a signal to alert you that there was something physically wrong in your body that needed to be addressed. It is pain that has not responded to appropriate medical or dental care and treatment. Some health professionals and pain scientists consider pain to be chronic if it lasts for three to six months or more without getting significantly better. However, these time requirements are somewhat artificial standards that can become misleading and counterproductive (e.g. neuropathic pain can take much longer to “heal”). Current conceptualizations include defining chronic pain as persisting beyond tissue healing and has not responded to appropriate and competent treatments.

Types of chronic pain. All chronic pain is not the same. In contrast to acute pain, chronic pain is usually less indicative of tissue damage and generally does not serve a protective function for the body. There are at least three types of chronic pain problems:

(1) chronic pain that is due to a clearly identifiable cause or process,

(2) chronic pain that is “non-specific” and there is no clearly identifiable pain generator that explains the pain, and

(3) chronic pain that is due to some type of nerve damage or abnormal nervous system reaction.

Chronic pain associated with a progressive disease. In chronic pain associated with a progressive disease, there is an ongoing disease process that is causing the pain. This might include such conditions as cancer, COPD, muscle spasm in multiple sclerosis, arthritis, etc. These conditions are often actually categorized by disease state (e.g., cancer pain) and this dictates special evaluation and treatment approaches.

Chronic non-cancer pain. Several terms have been developed for chronic pain in which a specific disease process or pain generator cannot be identified or does not account for the level of pain and suffering being reported by the patient. These include chronic pain, chronic benign pain, chronic non-cancer pain, and chronic non-specific pain. For the purposes of this discussion, we will simply use the term “chronic pain”. In this type of chronic pain, the problem may have started with an acute injury or trauma (e.g., back injury, etc) and developed into a chronic pain problem of more than 6 months duration such as chronic non-specific low back pain, fibromyalgia, etc.

It appears that pain can set up a pathway in the nervous system and, in some cases this becomes the problem in and of itself. In this type of chronic pain the nervous system may be sending a pain signal even though there is no ongoing tissue damage, or the tissue injury (e.g., pain generator; also termed nociception) is less than what would be expected given the patient’s pain experience. The nervous system itself misfires and creates the pain. As shall be discussed, the pain signal from the peripheral nervous system is enhanced by higher level central nervous system processes. In such cases, the pain is the disease rather than a symptom of an injury.

Chronic neuropathic pain. Neuropathic pain has only been investigated relatively recently and seems to involve some type of direct injury to the nerves. In most types of neuropathic pain, all signs of the original injury are usually gone and the pain that one feels is unrelated to an observable injury or condition. With this type of pain, certain nerves (that have been injured or irritated) continue to send pain messages to the brain even after the initial tissue damage has healed. Neuropathic pain (also called nerve pain or neuropathy), is very different from pain caused by an underlying injury. While it is not completely understood, it is thought that injury to the sensory or motor nerves in the peripheral nervous system can potentially cause neuropathy. Neuropathic pain is placed in the chronic pain category but it has a different feel then chronic pain of a musculoskeletal nature.

Neuropathic pain feels different than musculoskeletal pain and is often described with the following terms: severe, sharp, lancinating, lightning-like, stabbing, burning, cold, and/or ongoing numbness, tingling or weakness. It may be felt traveling along the nerve path from the spine down to the arms/hands or legs/feet. Different types of neuropathic pain conditions include reflex sympathetic dystrophy (or Complex Regional Pain Syndrome), trigeminal neuralgia, postherpetic neuralgia, radiculopathy, etc.

Chronic Pain and Suffering

As discussed by Morris (2003), the term “suffering” is often used as a synonym for “pain” even though they are theoretically and conceptually distinct.  As Morris (2003) discusses, a broken bone may cause pain without suffering or a great level of suffering.  When faced with the same level of nociceptive input, understanding why one individual will demonstrate a great level suffering while another will show minimal suffering is critical to the evaluation and treatment of chronic pain.  Unfortunately, the theoretical and conceptual distinction between pain and suffering is often neglected in clinical practice, which can negatively impact the evaluation and treatment of the patient’s condition.  In practice it can be useful to explicitly tell the chronic pain patient that the intervention will actually be focused on decreasing his or her level of suffering rather than the pain.  Frequently, the patient shows relief and optimism in response to this formulation since they have already had many failure experiences relative to treatments targeting the pain.  Also explaining that decreasing the level of suffering and improving the quality of life will, in turn, help diminish the perception of pain.

Suffering is very closely tied to the emotional aspect of pain. In general it is triggered by aversive events, such as loss of a loved one, fear, or a threat to one's well-being. Suffering very often occurs in anticipation of a possible perceived threat even though the threat may or may not actually exist. A very good example of this last scenario is similar to what was presented in the last section. A patient with severe headaches was firmly convinced she had a brain tumor. Her husband had recently died of a brain tumor that had started with simple headaches. Her suffering was very high, since she was anticipating that her headaches were a sign of a very serious condition that could lead to death. After the MRI confirmed that she did not have a tumor and that her headaches were likely due to muscle tension, her suffering decreased significantly, as did her pain. This illustrates extreme suffering in response to a threat that never actually existed. It also illustrates how a patient’s level of suffering can change even when the nociceptive input and pain sensation do not.

“Pain May Be Mandatory, but Suffering Is Optional”

This is a crucial statement and it is emphasized because of the essential idea that it represents. That is, if we can find a way to help the patient subtract the emotional suffering element from the chronic pain, what would be left would not likely hurt as much! Pure pain as a sensation by itself (nociception) is not as persistently wrathful, punishing, or extremely bothersome as is pain plus emotional suffering. 

The Puzzle of Pain

Pain is both a puzzle and a study in contrasts. It can be both our greatest friend and ally or our greatest antagonist. As a “friend” acute pain, and even to some degree chronic pain, helps us survive. Acute pain is a signal or warning of current, potential or imminent harm to the body. But chronic pain, untamed and uncontrolled, can become a fierce enemy that makes life feel unbearable. However, chronic pain can also function as a friend. That is because, when there is underlying physical disease or injury, chronic pain can remind us of our limits. When heeded, it can warn us not to overdo it, to pace ourselves, and let us know what activities are unsuitable for us. If we ignore this warning, we can stretch too far and too fast past our limits and cause further injury to occur. The key point is that chronic pain can perform this signaling function without having to cause undue suffering (the patient must understand that maximum discomfort is not necessary). The pain may be able to provide a signal and serve its protective function without having to be that intense.  Pain, whether acute or chronic, must be tamed and managed to remain our friend and ally. I shall be using the concepts and tools of hypnosis to illustrate how to “tame” pain enough to again make it a “friend.” These concepts and tools will be explained in enough detail so that your patient will be able to try them out and determine their usefulness.

As I shall explain later, hypnosis is probably the most powerful nonnarcotic tool we have to help people move from a state of discomfort to a neutral state or state of comfort. Comfort has a way of spreading and generalizing, similar to discomfort and pain on the other end of the spectrum. Once you get the “comfort ball” rolling, so to speak, it builds momentum and keeps rolling. Self-hypnosis can serve as a very useful tool to ease chronic pain and manage and cope with it better. However, given all of the misconceptions and myths about hypnosis that abound, it is an underutilized tool.

The Physiology and Neurology of Pain

This section will summarize the physiology and neurology of pain. Gaining this understanding will help you to appreciate the key role that psychological methods such as hypnosis can play in helping control and diminish chronic pain and suffering. It is important to explain these concepts to the patient since it forms a solid rationale for the hypnosis treatment.

Old Ideas: The Specificity Theory of Pain

Rene Descartes proposed one of the original theories of pain in 1664. His theory proposed that a specific pain system carried messages directly from pain receptors in the skin to a pain center in the brain. He suggested that it is like a bell-ringing mechanism in a church such that a man pulls the rope at the bottom of the tower and the bell rings at the top. In this model there is a one-to-one relationship between tissue injury and the amount of pain a person experiences. For instance, if you stick your finger with the needle you would experience minimal pain; whereas, if you cut your hand with a knife you would experience much more pain. Thus, the specificity theory proposes that the intensity of pain is directly related to the amount of tissue injury. The specificity theory underwent modifications throughout the 19th and early 20th centuries but its basic assumptions were unchanged (See Melzack and Wall, 1973, for a discussion of other pain theories including Muller’s doctrine of specific nerve energies, 1842; Von Frey’s theory, 1894; pattern theories, various theorists from 1894 through the mid-1950’s; Livingston’s central summation theory, 1943; and, Noordenbos’ sensory interaction theory, 1959).

The specificity theory is generally accurate for acute pain, but it does not explain many types of chronic pain. Unfortunately, variations on the specificity theory are still taught (or at least emphasized) in many medical schools and a majority of doctors still ascribe to it in practice. The theory assumes that if surgery or medication can eliminate the alleged “cause” of the pain, then the pain will disappear. In chronic pain cases, this is very often not true. If a doctor continues to apply the specificity theory to a chronic pain problem the patient is at risk for getting surgeries, medicines and procedures that will not work as the search for the “source of the pain” presses on. Ultimately, the validity of the patient’s pain complaints will be challenged if reasons cannot be found and the “treatments” do not work.

Problems with the Specificity Theory

Several research findings and clinical observations have proven the specificity theory to be inadequate and these can be summarized as follows (See Wall and Melzack, 1973; Turk and Gatchel, 2002, for a more detailed discussion):

The meaning of the situation influences pain. Dr. Henry Beecher worked with severely wounded soldiers during World War II. To his surprise, Dr. Beecher observed that only one out of three soldiers carried into a combat hospital complained of enough pain to require morphine. Most of the soldiers either denied having pain from their significant injuries or had so little pain that they declined medication. These soldiers were not in a state of shock nor were they unable to feel pain since they complained when the IV lines were placed.

When Dr. Beecher returned to his practice in the United States after the war he noticed that trauma patients with wounds similar to the soldiers he had treated required morphine to control their pain at a much higher rate. In fact, four out of five patients required morphine for pain from wounds similar to those he had seen in the combat soldiers. Dr. Beecher concluded that this evidence demonstrated there was not a direct relationship between the wound and the amount of pain experienced. He believed the meaning attached to the injuries in the two groups explained the different levels of pain. To the soldier, the wound meant thankfulness to escape alive from the battlefield and to be going home. Alternatively, the injury to a civilian often meant major surgery, loss of income, loss of activities, and many other negative consequences.

Pain after healing of an injury. Another finding that discounted the specificity theory was that of phantom limb pain. Many times patients who undergo the amputation of a limb continue to report sensations that seem to come from the limb that has been amputated. This might include feeling that the limb is still there, or it may be a sensation of pain. Of course, the sensations cannot be actually coming from the limb since it has been removed from the person’s body. The specificity theory cannot account for these findings since there is no ongoing tissue injury in the amputated limb.

Injury without pain and pain without injury. Injury without pain can occur in a variety of situations including individuals who are born without the ability to feel pain. These patients must learn to avoid damaging themselves severely since there is no “protective function” from pain. The following is just such a case as reported on CNN.com Health (November 1, 2004):

Another fairly common situation is a person being distracted when injured such that pain is not felt. In this case, it is not uncommon to hear stories of accident victims presenting to the emergency room stating they were injured (including major lacerations of the skin and fractured bones) but did not experience pain until minutes or hours afterwards.

Pain without injury or after the point of complete tissue healing can occur in a number of medical conditions such as central neuropathic pain after a stroke, reflex sympathetic dystrophy (complex regional pain syndrome), phantom limb pain, and post-herpetic neuralgia.

Hypnosis for anesthesia. The specificity theory cannot explain how hypnosis can be used for anesthesia during surgery. Certain people under hypnosis can withstand high levels of pain that would normally cause them to cry out. Surgery has been done on almost every part of the body using only hypnosis for anesthesia. Obviously, significant tissue damage is occurring during the surgery but the patient under hypnosis is not experiencing any pain. This finding dealt the specificity theory its final blow!

NEW IDEAS: THE GATE-CONTROL THEORY OF PAIN

Due to the findings listed previously a new theory of pain was developed in the early 1960’s that could explain these results. It is called the gate control theory of pain and it was developed originally by Melzack and Wall (1965). The gate control theory changed the way in which pain perception was viewed. The original theory is very complex and a detailed discussion is beyond the scope of this presentation. However, it will be valuable to present an overview of the theory in language that can be used with patients. Explaining the basics of this theory to patients can help establish the credibility of psychological pain management interventions. It will also demonstrate to the patient that the psychological intervention can actually change (decrease) the experience of pain on a physiological level.

The gate control theory attempts to explain the experience of pain (including psychological factors) on a physiological level. Based upon subsequent challenges and findings, the original gate control theory has undergone some reformulation and revision but the basic tenets hold true. It has been able to explain a variety of pain phenomena and has had enormous heuristic value in stimulating further research (Turk and Flor, 1999).

In the gate control theory, pain is divided into two components which are processed by the body separately. These are:

the peripheral nervous system which is outside of the brain and spinal cord, and

the central nervous system which includes the spinal cord and the brain.

Pain messages flow along the peripheral nerves to the spinal cord and proceed to the brain. In the spinal cord there are “nerve gates” (in the dorsal horn substantia gelatinosa) that can inhibit (close) or facilitate (open) nerve impulses going from the body to the brain. These nerve gates are influenced by a number of factors including the diameter of the active peripheral fibers converging in the dorsal horns as well as “instructions” coming down from the brain.

The relative excitatory activity in the afferent large-diameter (myelinated) and small-diameter (unmyelinated nociceptor) fibers is thought to influence the spinal gates. The activity in the A-beta (large diameter) is thought to primarily inhibit transmission (close the gates) whereas the A-delta and C (small diameter) activity are thought to primarily facilitate transmission (open the gate). When the gates are more open, a person experiences more pain since the messages flow freely. When the gates close, the pain is decreased or may not be experienced at all. The specifics of each part of the pain system are discussed in the following paragraphs. These are important concepts because they explain why various treatments are effective.

The Peripheral Nervous System

This will be a brief review of your graduate course in psychophysiology. Sensory nerves bring information to the spinal cord from various parts of the body. These nerves are specialized to detect: pain, heat, cold, vibration, and touch. At least two types of small diameter nerve fibers are thought to carry the majority of pain messages to the spinal cord:

A-delta nerve fibers carry electrical messages to the spinal cord at approximately 4 to 44 meters per second (“first” or “fast” pain).

C-fibers carry electrical messages at approximately .5 to 1 meter per second to the spinal cord (“slow” or “continuous pain”).

As discussed previously, the activity of the A-delta and C fibers tend to facilitate transmission of the nerve impulse (“open” the spinal nerve gates). In addition, they result in a different pain sensation. A good example of how these different nerve fibers work is when you strike your “funny bone” in your elbow (actually the ulnar nerve). You may notice that the first sensation is a sharp, tingling pain followed by a second sensation of achiness. The first sensation is the activation of the A-delta nerve fibers followed by the activation of the slower C-fibers. The activation of different nerve fibers can produce different qualities of pain sensation.

Also, you may have noticed that when you strike your elbow or hit your head, rubbing the area seems to provide some relief. This is because you are activating other sensory nerve fibers. These nerve fibers carry pressure and touch messages to the spinal cord:

These fibers are called “A-beta fibers” and they send their message at approximately 93 to 103 meters per second.

These speeding messages can reach the spinal cord and brain to override some of the pain messages carried by the A-delta and C-fibers. When this overriding occurs, the pain messages are decreased and you experience less pain. The action of these differing nerve fibers can explain why many treatments for pain are effective. Treatments such as massage, heat, cold, TNS (transcutaneous nerve stimulation), or acupuncture can change a pain message due to some of these differences in nerve fibers.

The Spinal Cord

The pain message travels along the peripheral nervous system until it reaches the spinal cord. At this point, an extremely complex system can:

·         Send the message directly to the brain

·         Change the message being sent to the brain

·         Stop the message from reaching the brain

As discussed previously, the gate control theory proposes that there are gates on the bundle of nerve fibers in the spinal cord between the peripheral nerves and the brain. These spinal nerve gates can either open to allow pain impulses to move freely from the peripheral nerves to the brain, or they can close to stop the pain signals from reaching the brain. Many factors determine how the spinal nerve gates will manage the pain signal including:

·         The intensity of the pain message

·         The competition from other incoming nerve messages (such as touch, vibration, heat, etc)

·         Signals from the brain telling the spinal cord to increase or decrease the priority of certain pain messages.

The Brain

Once the pain signal reaches the brain, a number of different things can happen. Certain parts of the brain stem can inhibit or muffle incoming pain signals by the production of endorphins, which are naturally occurring morphine-like substances. Stress, excitement, and vigorous exercise are among the things that may stimulate the production of endorphins. This is why athletes may not notice the pain of a fairly serious injury until the “big” game is over. This is also why regular aerobic exercise can be an excellent method to help control chronic pain.

In addition, pain messages may be directed along different pathways in the brain. For instance, a fast pain message is relayed by the spinal cord to specific locations in the brain: the thalamus and cortex. A fast pain message reaches the cortex quickly and prompts the individual to take action to reduce the pain or threat of injury.

In contrast, chronic pain tends to move along a “slow pain” pathway. As discussed above, slow pain tends to be perceived as dull, aching, burning, and cramping. Initially, the slow pain messages travel along the same pathways as the fast pain signals through the spinal cord. Once they reach the brain, the slow pain messages take a pathway to a different portion of the brain, the hypothalamus and the limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body. The limbic system is the brain area where emotions are processed. As shall be discussed later, this is one reason why chronic pain is often associated with stress, depression, and anxiety. The slow pain signals are actually passing through brain areas that control these experiences and emotions.

As discussed previously, the brain also controls pain messages by attaching meaning to the situation in which the pain is experienced. This occurs in the cortex, which is a higher level of the brain where thinking takes place. As reviewed previously, soldiers who were wounded in combat displayed much less pain then similarly wounded civilians who had been involved in a trauma such as a car accident. The meaning that the brain attached to the situation seemed to be the important difference. The brain also gives meaning to the pain signal and this occurs in the cortex. Depending on how the messages are received and other factors related to the situation, the brain may pay close attention to the pain signal, or choose to ignore it altogether.

DOWN THE PAIN PATHWAYS

So far we have primarily focused on factors that influence the pain signal as it travels from the periphery to central structures (afferent input). In addition to these influences, the pain signal can be influenced by efferent neural impulses that descend from the brain. In other words, the brain can send signals down the spinal cord to open and close the nerve gates. At times of anxiety or stress, the descending messages from the brain may actually amplify the pain signal at the nerve gate as it moves up the spinal cord. On the other hand, the descending message from the brain can “close” the nerve gate in the spinal cord and the message will be stopped at the closed nerve gate (no pain experienced by the brain). This can occur in situations such as being in battle, playing competitive sports, being under hypnosis, being distracted, etc.

Opening and Closing the Pain Gates

In working with chronic pain patients it is important to carefully explain the gate control theory of pain along with providing examples as previously discussed. This provides an excellent foundation to discuss what factors can open and close the spinal nerve gates. The following presentation can be helpful for patients:

Let's look at a number of other things that can open or close the pain gates as messages move up and down the spinal cord. These can be divided into sensory, cognitive, or emotional areas:

Sensory factors include things that are related to your actual physical being and activities.

Cognitive factors are those things that are related to your thoughts. This might include your memories, your interpretation of a current situation, or your predictions about the future.

Emotional factors are those things related to your emotions or feelings. Emotions are being happy, sad, mad, or glad.

Some examples of sensory, cognitive, and emotional factors that influence pain perception can be seen in the following table.

WHEN ACUTE PAIN BECOMES CHRONIC

Not all pain that persists will turn into chronic pain. Pain is experienced very differently for different people. Likewise, the effectiveness of a particular treatment will often differ from person to person. For example, a particular medication or injection for a herniated disc may provide effective pain relief for some people but not for others.

Not all patients with similar conditions develop chronic pain, and it is not understood why some people will develop chronic pain and others will not. Also, a condition that appears relatively minor can lead to severe pain, and a serious condition can be barely painful at all.

As pain moves from the acute phase to the chronic stage, influences of factors other than tissue damage and injury come more into play. Also, influences other than tissue input become more important as the pain becomes more chronic. These include such things as ongoing “pain” signals in the nervous system even though there is no tissue damage, as well as thoughts and emotions, as discussed previously. This can be a difficult concept for chronic pain patients to accept. A common retort is, “but my pain is real”. Remember, as we discussed at the beginning of this section, all pain is real and physically experienced. But, the gate control theory establishes that pain can be affected by a variety of factors other than tissue input. After a discussion of the gate control theory and some of these examples, patients are often more open to accepting the idea of psychological pain management treatment, including hypnosis.

Solving the Puzzle of Pain

While we do not understand everything about the mechanisms of chronic pain, we do know about factors that can increase it and reduce it. We know that “the strain of pain” is influenced by the brain. We know that hypnosis reduces the strain of pain by inhibiting the ascent of pain messages to the brain, or changing the way they are interpreted. However, before you can use hypnosis effectively with a patient to reduce the pain, it is important to evaluate and understand the particular type of pain, and the person’s responses to it.

EvaluatION of pain and Coping

The first step in hypnosis for pain control is patient evaluation. This will provide you and the patient with a basis for deciding what needs to be changed and what can be changed for a successful outcome. As I explained previously, pain has sensory, motivational-emotional, and cognitive-evaluative components. The patient must understand these three separate but related components of the pain experience to help determine a successful course of treatment.  Anyone with chronic pain must remember that pain may be inevitable, but suffering is avoidable. Suffering is one part of the emotional component of the pain experience, and it can be avoided, averted, escaped, diminished, and alleviated.

Chronic Pain: A Tough Adversary

No one has to tell the patient (the chronic pain sufferer) that chronic pain is a very tough adversary. Part of its toughness lies in its complexity. As time goes on, persistent pain tends to weave itself into the very fabric of a person’s life, finding its way into all kinds of places where it’s not welcome. Part of the struggle of coping with chronic pain is preventing the pain from taking over the person’s life, or taking back control if it already has.

Pain is a very subjective experience. The same identical injury can produce a vast range of pain responses in different individuals. Just as no two people experience pain in exactly the same way, no one can possibly “know” the patient’s chronic pain experience. Pain is much more than an unpleasant physical sensation that an individual experiences solely in the present moment. Pain is a total physical and psychological experience. Everyone describes pain in their own unique way. Pain is a very subjective experience that is colored by a complex of factors in addition to the nature of the bodily injury and tissue damage. These factors include the current situation, the implications of the pain for one’s life (personal, vocational, financial), other people’s reactions to the condition, the individual’s personality and coping style, personal history, memories of the past, and plans and expectations for the future. Also included are the individual’s ideas about the meaning of the pain, and his or her attitudes about it.

Evaluate the Pain to Start the Process of Change

Before starting the process of change, and before learning or being taught self-hypnosis, evaluation of pertinent factors is critical. Self-evaluation, often guided by a therapist, is the first phase of self-change. Once these issues are identified, self-hypnosis can be an excellent tool for further exploring these factors and modifying them in a helpful way. Self-hypnosis, as I shall also explain, can enable the patient to start and continue the process of change in the desired direction. The first step is valid evaluation of the pain and its effects on the patient’s life. Assessment and evaluation also constitute the first phase of treatment. You and the patient establish a baseline against which progress can be evaluated (See Table 3).

A more comprehensive patient exercise can be completed next (See Table 4).  This involves a more objective questionnaire that will help to guide the treatment, including hypnosis.  There are several ways to utilize this type of questionnaire including: as a semi-structured interview; as a self-report measure; as a patient questionnaire sent prior to the first visit, etc.

The Pain Description Questionnaire (PDQ)

The Pain Description Questionnaire (PDQ) below is an adaptation of the well-known and widely used McGill Pain Questionnaire authored by Ronald Melzack (Melzack 1975; adaptation below used with permission). The following modified questionnaire will help the patient describe the pain in plain language. It will enable him or her to pinpoint what the pain actually feels like by identifying its precise qualities. The questionnaire will provide words to describe how, and how much, it hurts. This information is used later in developing hypnotic and waking suggestions for pain relief based on opposing qualities that spell comfort. These opposing qualities will give the patient specific goals for pain management geared to the person’s individual needs.

Interpreting and Using the Responses

To help in interpreting the results, please note the following.  This can be explained to the patient after the questionnaire is completed:

Descriptor groups 1 through 17 refer to pain’s sensory qualities. These words may describe the physical character of the pain itself.

Descriptor groups 18, 19, and 20 refer to the temporal qualities of pain; that is, how continual, persistent, and predictable the pain is.

Descriptor groups 21 through 27 refer to your possible emotional reactions; that is, what the pain does to you. For example, “tiring, fatiguing, exhausting.”

Descriptor groups 28, 29, and 30 refer to the degree of suffering the pain may cause; that is, how you evaluate the pain.

The patient’s ratings for the emotional and evaluative descriptors will help to get a sense of the degree of emotional upset associated with the pain (suffering). Table 6 suggests a guide for reviewing the PDQ with the patient.

The next step, which will complete the initial evaluation process, is to evaluate how the patient copes.

Evaluating Coping

To “cope” means to “handle,” “endure,” “deal with,” “contend with,” “manage,” and/or “control.” Chronic, persistent pain certainly is something to cope with, and when one is coping well, pain is less of an energy drain and the person feels more comfortable. Therefore, the goal of the practitioner is to help the patient improve pain coping skills.

The famous physician Dr. William Osler professed that it is much more important to know what sort of a patient has a disease than what sort of disease a patient has. Understanding the patient’s coping strategies, what coping strategies are available, and what strategies might be favored by the patient, will yield valuable insights about the individual.  You will find these insights and this information useful later when you help the patient choose the right self-hypnosis method(s) and coping strategies.

Coping Strategies

Psychologists have come up with different schemes for classifying people’s coping strategies and this has helped us better understand the commonalities and differences among them. It also has enabled us to isolate certain key ingredients that appear to be associated with better coping and adjustment as well as with greater dysfunction and stress. The following is a brief summary of some of these coping strategies.  Additional information can be found in the second in the series of pain management courses: Evaluation and Treatment of Chronic Pain.

Catastrophizing and Learned Helplessness

The term “catastrophizing” means dwelling on, magnifying, and “blowing up” the negative aspects of a situation and expecting the worst. Simply put, people who catastrophize think negatively, cope poorly, and feel no sense of mastery or self-efficacy. The term “learned helplessness” was coined by the University of Pennsylvania research psychologist Martin Seligman, Ph.D. (Seligman 1975). It means feeling resigned to having no control over a bad situation, the way things will turn out, and believing that nothing you can do will make a difference, or change the situation. Catastrophizing and learned helplessness lead to “throwing in the towel”, giving up, and getting depressed.  This, of course, impedes effective coping. These two stress-producing habits (or states) have been identified as the most significant predictors of poor coping and adjustment to persistent pain (France et al., 2002; Rosenstiel and Keefe 1983). The methods in this course can help a patient overcome these two traps.

The Four A’s of Pain Coping

Brown and Fromm (1987) have classified functional, psychologically oriented pain-coping strategies into four groups: avoidance, alleviation, alteration, and awareness. They have termed these the “Four A’s.”  The following can be explained and discussed with the patient.  Determining the patient’s preferred method of coping can be helpful in designing a treatment strategy.

The Six D’s of Pain Coping

In treatment, I use another functional scheme for classifying psychological strategies for coping with pain (Eimer 2000a, 2000b; Eimer and Freeman 1998) labeled the “Six D’s.” Each of the “D’s” will be covered in detail subsequently, but here is an overview (See Table 8; Again, worded for the patient):

Each of the six D’s highlights an important aspect of using self-hypnosis for reducing pain. These should be shared and reviewed with the patient.  As will be discussed, these concepts are an important part of the hypnosis treatment.

Understand What Hypnosis Is and Isn’t

Myths and misconceptions about hypnosis abound. Much of what people think of as hypnosis is simply not true. The public, as well as many health professionals, have been misled about the true nature of hypnosis, the result of myths and distortions that have been promoted by movies, stage shows, and story books for purposes of entertainment. It’s also the result of just plain misinformation.

What Hypnosis Is Not

Hypnosis is not sleep. When a person is in a hypnotic trance state, he or she is not sleeping. Therefore, a hypnotized person hears everything that is going on and is capable of responding to their surroundings appropriately. In fact, hypnosis has the unique quality of heightening or diminishing a person’s sensory awareness, depending on what is needed at the time. The key phrase is “depending on what is needed at the time.” Hypnosis can give a person more flexible control over his or her awareness, attention, and thinking processes.

You cannot be hypnotized against your will. No one can be hypnotized against their will. No one! You have to consciously want to be hypnotized to experience the altered state of consciousness we call hypnosis. If someone were to try to hypnotize you against your will, you simply wouldn’t cooperate. I think any practitioner experienced in hypnosis (along with the research) will attest to the fact that they have never been able to hypnotize any patient who was consciously resisting for any reason.  The use of hypnosis could only proceed after the session was stopped and the issues were discussed with the patient in detail.  At that point, if the patient desired to continue, conscious consent to proceed and a commitment to full cooperation is obtained. If this was not possible, let’s say because the patient had some ulterior motive, alternative agenda, or just didn’t want to be in my office, hypnosis could not proceed or would be “unsuccessful”.

In such cases, I discuss with the patient that using hypnosis and doing effective psychotherapy is not one-sided (the practitioner does not simply “do” something to the patient, as in many medical procedures).  Rather, it must be a collaborative relationship in which both the patient and the therapist enter for really valid and purposeful reasons. In other cases, when I have detected unconscious resistance to cooperation, I stop the treatment and empathically confront the patient so we can discuss and explore the issues in a waking state.  Depending on the outcome, treatment may or may not continue. 

Hypnosis is not about swinging pocket watches. Swinging pocket watches, pendulums, and crystal balls are the stuff of movies and story books. There is nothing special about a swinging pocket watch or crystal ball for the purpose of inducing hypnosis. These things can be employed as a visual fixation object (something to fix your attention to), but so can many other small objects. If a swinging, shiny pocket watch is used as a prop or aid to induce hypnosis, its purpose is to focus the subject’s attention. Fixing your visual attention on any nearby interesting object can serve the same purpose.

Hypnotized individuals cannot not wake up. Hypnotized individuals cannot not wake up because they were never asleep in the first place! If you do fall asleep while you are in hypnosis, then you are no longer in hypnosis; you are sleeping. When you wake up, you’ll probably feel more refreshed, alert, and relaxed than you did before you fell asleep. If this is an issue for the patient, then an important question related to this myth is to ask the following: How often do you worry about not waking up when you take a nap or go to bed at night? If you worry about this often, it has nothing to do with hypnosis. It is a fear. In fact, if your worries about this are severe, frequent, and interfere significantly with your life, you could have a specific phobia. Phobias can be effectively treated by a qualified mental-health professional. If a fear or phobia is very frequent, very severe, and impairs your functioning, it should be treated.

Hypnotized individuals do not become zombies. A hypnotized individual is not paralyzed, incapable of taking care of him or herself, or incapable of refusing to carry out the hypnotist’s suggestions or commands. The will of the person being hypnotized does not become subordinate to the will of the hypnotist. In hypnosis, you do not lose your decision-making capabilities. You cannot be made to accept suggestions that are not acceptable to you. No hypnotist can make you do anything, experience anything, or change anything against your will. Some people call and ask if I can “make them” stop smoking. My answer, of course, is “No.” I tell them that, if they are ready, I can use hypnosis to help them stop smoking more easily without withdrawal symptoms, but only if they want to stop.

Hypnosis is not about the hypnotist exercising his or her control or “mental powers” over the person who is the hypnotic subject. Hypnosis, in truth, is about learning to exercise more control over yourself, your experience, and your behavior. Hypnosis is really about being helped to tap your own untapped inner strengths and resources so that you can have increased self-control.

Hypnotized individuals cannot be made to bark like a dog. “So,” you may ask, “how do you explain why people do such silly things in hypnosis stage shows?” If you have seen such a show, you may have seen people acting as if they were a dog, a chicken, a person of the opposite sex, and so on, when the hypnotist gives them the command. The context of the show (acting zany or silly or absurdly, acting hypnotized and having fun) gives the volunteer participants a sort of “license” to act out in outlandish ways, and “let go.” In the context of a show, it is considered acceptable to go along with the hypnotist’s outrageous commands for entertainment purposes.

Most onlookers are also unaware that stage hypnotists screen their volunteers for their heightened suggestibility and willingness to comply with the hypnotist’s commands and suggestions. Stage hypnotists also frequently have previously trained accomplices or “shills” in the audience, and they are good at selecting only those new participants who will be cooperative. Members of the audience who want to be part of the show and who have possible exhibitionist tendencies make the best subjects for entertainment purposes.

Hypnosis is not a truth serum. Finally, hypnosis is not a truth serum. Also, when you are in hypnosis, you cannot be compelled to say or blurt out things that you do not want to share. You retain control at all times.

What Hypnosis Is: It is a State and a Procedure

In defining what “hypnosis” is, we first need to distinguish between the hypnotic state of consciousness and the method or procedure that is employed for inducing or producing this particular altered state. These are often confused by interchangeably calling both of them simply “hypnosis.” Because the use of the blanket term “hypnosis” can be confusing, I will clarify the way I use the terms.

The method or procedure for inducing or producing the hypnotic state is technically called a hypnotic induction method. The mental state induced through the employment of a hypnotic induction method is called the hypnotic trance state. There are hundreds of different hypnotic induction methods. Many books have been written that are devoted entirely to the induction of hypnosis. When a patient seeks treatment from a health professional that uses hypnosis clinically, then that professional’s use of hypnosis is termed clinical hypnosis. When someone outside of a professional treatment situation helps you induce the hypnotic state, it is technically called “hetero-hypnosis.” When you do it yourself, it is called “self-hypnosis.” Irrespective of whether someone else helps you to enter the hypnotic state, or you do it yourself, the method used to enter hypnosis is called an “induction”, or hypnotic induction. If you employ an induction to help yourself into hypnosis, this is called “self-hypnosis” or a self-hypnosis induction.

Official Definitions of Hypnosis

Just to compare and contrast, definitions of hypnosis used by two leading organizations are provided in the following Table.   

My Definition of Hypnosis

For the purposes of this course, my simple and concise definition of hypnosis follows. It emphasizes the key ingredients that make hypnosis such an effective treatment for relieving pain.

“Hypnosis” or “hypnotic trance” is an altered state of consciousness that involves comfortable relaxation, a redirection of attention, and active sensory imagination. It is a special state of resting alertness. While a person is in this altered state, that person’s focus of attention can be redirected to what is important for the purpose at hand.

The term “altered state of consciousness” bears explanation. The hypnosis altered state is unique but natural. It is induced whenever the unconscious or subconscious mind is alerted to pay attention to a unique form of communication. This spontaneously produces a divided state of attention or consciousness. So you may wonder, how is your attention divided? The answer is that your conscious mind is pleasantly absorbed in relaxing, enjoyable sensations, a pleasant memory, or an imaginative fantasy while your unconscious attends to the communication that initiated or continues to maintain the hypnosis altered state. It is like you are here and there at the same time. Your conscious mind may be on the beach (or wherever your favorite place is), but your unconscious is functioning like a “hidden observer” (Hilgard and Hilgard 1996). Now here’s the clincher: to the degree that the initiating communication (the hypnosis induction) is compelling, engaging, and absorbing, the division or split in consciousness is heightened or deepened. And, the deeper the split in consciousness is, the more your unconscious or hidden observer is awakened and responsive to the initiating hypnotic communication.

When the unconscious is very responsive, one’s responses to hypnotic suggestions feel automatic, spontaneous, and involuntary. They happen easily and comfortably with little or no conscious deliberation. In hypnosis, and self-hypnosis, the depth of the division consciousness will vary. However, what is most important is not the depth of this division or split, but rather the quality of the experience. The patient will be able to choose the self-hypnosis induction that is most effective and, because it is his or her choice, it will be a good quality experience.

A focusing mechanism. Hypnosis is also a focusing mechanism and a way of communicating precisely with the unconscious, subconscious, or inner mind. All three of these terms are different names for the same thing. They are generally employed interchangeably and I will follow this convention throughout this course. When your body is comfortably relaxed and at ease and your conscious mind is absorbed in an interesting experience involving compelling sensory imagery, your inner mind or unconscious mind is alerted to pay attention. This frees your inner mind to be open and receptive to acceptable positive ideas and suggestions. Once your inner mind accepts an idea, it transforms that idea into a reality. This can help the patient (or you, or anyone) change his or her experience in the way that is desired.

All hypnosis is really self-hypnosis. You may find it surprising that all hypnosis is really self-hypnosis. That is because, while the patient is given positive suggestions for change, in order for that change to occur, those suggestions must be accepted and “made your own.” As such, all suggestions that are accepted by the patient become self-suggestions.

Hypnosis and self-hypnosis are simply tools for making positive changes more easily and quickly. However, like any other tool, these tools can be used correctly or incorrectly. When they are used correctly, their positive benefits become quite evident. When we learn how to use self-hypnosis correctly, we begin to notice positive changes in our thinking, feeling, behaving, and experience. When we use it incorrectly, we simply fail to produce the results we intend or desire. Subsequently, this course will teach the practitioner (and patient) how to use this tool effectively.

Hypnosis is easier than you may think. For the patient, the induction of self-hypnosis first involves resting, giving oneself permission to be at ease, and letting go of tensions. While restfully easing into relaxation without falling asleep, the patient becomes absorbed in the pleasant experience and redirects his or her focus of attention. Then, the patient begins to experience a suspension of habitual critical judgment. In other words, the “inner critic” temporarily shuts down or quiets. This leads to a feeling of relative effortlessness as responses become relatively automatic. While the patient is in this altered state, the doorway to the unconscious opens, and with the permission of the conscious mind, the unconscious becomes receptive to the information it needs to change the experience or behavior desired. From the patient’s perspective, once the unconscious accepts this information, it can’t ignore it. It must act on it and begin to change (Zarren and Eimer 2001).

A three-step process. The first step in learning self-hypnosis is to be guided into hypnosis by the practitioner who understands how to communicate with the unconscious mind and who also is experienced in practicing self-hypnosis. This would be an experienced and well-trained health-care professional who has also been trained in the clinical and personal use of hypnosis. The second step is to teach the patient how to repeat the process on his or her own. The third step is to “practice, practice, practice.”  This will imprint the experience in the unconscious. This process is summarized in Table 10.

Hypnotic Analgesia

When either hypnosis or self-hypnosis is utilized to produce pain relief, it’s known as hypnotic analgesia or hypno-analgesia. Hypnotic analgesia employs hypnotic suggestions to reduce the intensity of pain and suffering. This process involves “EASING” into an altered, neutral or pleasurable state. Remember that pleasure is the opposite of pain. A “persistent pain state” is characterized by opposing qualities to those involved in EASING into self-hypnosis. These contrasting states are illustrated in Table 11.

This is why, when it comes to relieving pain, hypnosis is a great tool!

Hypnotic Suggestion

When we talk about hypnotic suggestion, we have to distinguish between suggestions as ideas and the process of giving yourself or others suggestions. A positive suggestion is an idea that automatically creates the expectation that you are going to feel a positive change in your experience. You expect it to happen. You feel it and know it, and there is no doubt.

The process of suggestion is the means of making this happen. It involves establishing an image in the unconscious mind of a specific idea, action, feeling, or experience so that the desired change can take place. The patient does not have to be in a hypnotic trance state to benefit from positive suggestion. For example, the patient might be asked something like: “Can you recall a time when your doctor prescribed a remedy and told you something like ‘This is a very effective (or powerful) medicine,’ or, ‘This medicine will really work.’ Did you experience some relief? Your doctor was capitalizing on the power of positive suggestion.”

The value of hypnosis is that when you’re in a hypnotic trance state, your expectation of positive changes in feelings and experience and behavior automatically leads to the realization of those changes. Once the patient learns how to enter and exit self-hypnosis, he or she will be able to use this skill to change the experience of pain. The patient will expect to feel more comfortable. Then, when self-hypnosis is entered, his or her mental expectation of increased comfort will be transformed into increased comfort in reality.

A Definition of Suggestion

A suggestion is the transmission of an idea by one person to another person with the intention of automatically, spontaneously, and unconsciously affecting the recipient’s actions, motivations, and experience. This happens without any or much conscious deliberation by the recipient. The recipient is open to the suggestion to the degree to which they are receptive toward the expressed wishes or directives (implied or overt) of the sender. Suggestion depends upon adequate rapport and is different from arbitrary commands. Rapport means being in harmony with the person delivering the suggestions. It means feeling an affinity for that person (patient to therapist) and requires that the patient feel understood.  Proceeding with suggestions without rapport is not likely to succeed.

Hypnosis and Memory

Human brain cells, or neurons, retain and recall specific images long after a person has actually seen, heard, felt, smelled, or tasted the actual object of experience. The amazing brain appears to have a system of calling up and replaying the same cellular event that was activated at the time of the original experience and that led to the formation of the memory. Apparently, this system is reinforced and strengthened by repetition and practice. Therefore, by using our memories, we can keep them from getting “rusty.” Hypnosis involves recalling pleasant experiences, memories, and images and becoming absorbed in them.

When the patient gets into the habit of making pain-relieving, pleasurable, and comforting images in the mind’s eye, the brain is actually fooled into believing that those images are real. The brain then begins to get into the habit of creating those feelings and strengthening those memories. On the other hand, maintaining the habit of thinking repeatedly about pain and discomfort keeps the brain stuck in the habit of generating negative images and memories. The goal is to close the pain gate by imprinting a “comfort neuro-matrix” or “comfort cycle.”

Sensory Memory Systems and Active Sensory Imagination

People differ in terms of which memory systems are strongest for them. Different sensations can be recalled in differing degrees of intensity and vividness; sights, sounds, smells, tastes, touch, pressure, movement, and so on. For some people, visually recalling pleasant sights is what are most compelling and absorbing. Other people respond more strongly to the memory of sounds, such as being at a great concert or having a good conversation. Still other people become most engaged when they remember scents and/or flavors (such as when I recall the scent and flavor of my grandmother’s freshly baked bread and cookies right out of the oven.) As part of the treatment, ask the patient to, “Take a moment to consider what positive sensory impressions are most pleasant and compelling for you. What comes to mind?”

Other physical feelings that some people can become actively absorbed in recalling are movement and touch. For example, you can become actively involved in recalling the physical feelings associated with the last time you took a good walk, went swimming, went skiing, played tennis, laid on the warm sand on the beach, experienced the sensual touch of a lover, or had a great meal. Many people find that they can become most absorbed in a memory by recalling multiple sensory impressions; feelings, scents, sights, sounds, flavors and so on.

Active sensory imagination refers to the deliberate and conscious, or spontaneous and unconscious, recall of sensory impressions and experiences. This is an important part of self-hypnosis. So, how does this apply to controlling one’s pain? It applies because, on one level, pain is a sensation. In actuality, pain is a lot more than just a sensation (it’s an unpleasant experience). The fact that we can look at pain as just a sensation is a therapeutic advantage because it makes it amenable to being changed. That is because no sensations are permanent, and all sensations can be changed. Active sensory imagination is one means of changing sensations. The fact that pain is also a lot more than just a sensation is also an advantage. It makes pain amenable to methods of alleviation other than those that are just physical.

Research has shown that, under the right conditions, hypnosis is one of the most effective psychological, nondrug methods of relieving and controlling pain (See Patterson, Jensen and Montgomery, 2010 for a review). The “right conditions” means adequate mental and psychological preparation.

Alert Hypnosis. As mentioned earlier, self-relaxation is an important part of entering and enjoying the hypnotic state. When you’re relaxed, you cannot be uncomfortable! Relaxation is good for us and an antidote to pain. Additionally, most people can become focused and enter what is called “alert hypnosis” by becoming actively mentally and/or physically involved in an activity without relaxation. For example, you might ask the patient the following: “Can you remember the last time you were totally, pleasantly, and actively absorbed in a physical or mental activity? Depending on your interests, talents, and schedule, that might have been while playing a sport, exercising, studying, doing your job, or working at a hobby. You probably were calm but alert and focused and ‘in the flow.’ Were you feeling alert or deeply relaxed? Can you remember if you felt a lot of pain at the time?”

Generally, when patients are asked about this state, the extent to which they were absorbed in the activity limited the degree to which they were paying attention to the pain (even though nociception was still occurring). Perhaps the pain limited how long the patient could stay absorbed in the activity, and this is not surprising.  Pain has a way of breaking through. One task of the therapist is to help the patient explore active sensory imagination to discover which sensory memory systems are most compelling and absorbing for pain management. These are the systems that the patient finds most helpful for inducing and utilizing self-hypnosis to change the pain experience. The following exercise will help explore the patient’s sensory imagination.  This exercise can be directed by the therapist and, then self-directed by the patient.  The instructions are written from the viewpoint of the therapist guiding the exploration.

Reading into self-hypnosis. Most of us have had the experience at one time or another of reading ourselves to sleep. You know the feeling. You are sitting in a comfortable chair, or laying in bed reading. As you continue to read, your eyes start to feel tired, your eyelids start to feel heavier and blink more frequently. You start to read word by word and the same things over again. Soon it becomes a struggle to keep your eyes open! Your eyes begin to close all by themselves, and you fall into a restful, comfortable, very well-earned and deserved sleep state. The following exercise can be given to patient to practice at home.

Practice Inducing Self-Hypnosis

One of the primary goals of the therapist is to help the patient experience the pleasure of repeatedly entering and exiting the hypnosis and self-hypnosis trance state (both with the assistance of the therapist and also in between sessions). To achieve this goal successfully, the patient (with the help of the therapist) will need to choose an induction method that is appealing.

With this goal in mind, the following describes eight self-hypnosis induction methods. They should all be explored and then one chosen to practice. Once a method is chosen, the patient should spend a week or so practicing it twice a day for about ten to fifteen minutes each time. Ideally, this should be once in the morning (some time before eating breakfast) and once in the late afternoon or early evening (before eating dinner/supper). There is no need to be rigid about these times. It’s simply best to do self-hypnosis when the patient is neither full nor very hungry, so that he or she can concentrate.

An Initial Goal

One of the first goals is for the patient to simply imprint the experience in the unconscious of entering and exiting self-hypnosis and self-relaxation—nothing more and nothing less. But please provide the patient with the following warning:

You should only practice self-hypnosis when and where it is safe and appropriate for you to do so. This would be in a place where you will be undisturbed for fifteen to twenty minutes. You should never practice self-hypnosis, self-relaxation, or any other inner-focusing methods while you are operating dangerous machinery such as a motor vehicle. You should never practice self-hypnosis when you need to be alert and responsive to external events, other people, etc. Doing otherwise is likely to be dangerous to both yourself and others.

A pertinent reminder. Persistent pain is primarily kinesthetic (physical) and internal (within you and your body). Therefore, one of the goals of treatment is to have the patient accomplish being able to externalize the pain sensations; that is, move them to an “outer” body experience. Another treatment goal is to substitute more pleasant kinesthetic physical sensations for the unpleasant ones. If the patient found that one of his or her dominant sensory systems is tactile-kinesthetic (your sense of touch and physical, bodily feelings), then a tactile-kinesthetic method of inducing self-hypnosis may be appealing. If the patient is predominantly visual, then a procedure that primarily relies on visual attention and eye fixation may work best. Explore all the following methods and choose the one that works best for the patient. All of the following exercises have been adapted and worded as being self-guided by the patient.  However, these can be initially done by the therapist and then practiced at home by the patient. 

Sitting Down Comfortably

Instructions to the patient.  For this exercise and all of the self-hypnosis exercises to follow that involve the patient reading to induce self-hypnosis, he or she will need to be comfortable that the exercise can be read without disturbing the level of relaxation or trance. (Again, if being done by the therapist, the patient will simply be listening to the transcript). In fact, when the patient is situated comfortably, absorbed in the self-hypnosis experience, he or she will become more absorbed and go deeper into self-hypnosis with continued reading.

Self-Hypnosis Method 1: Zarren’s Marble Method. The first induction method that is going to be explored is “Zarren’s Marble Method” (Zarren and Eimer, 2001). It is an ideal method for externalizing physical discomfort and negative thoughts and feelings. It combines visual and tactile-kinesthetic sensory systems, and redirects your focus of attention away from your pain and other physical symptoms. This method provides a source of neutral, pleasant, visual and tactile-kinesthetic counter-stimulation that can temporarily inhibit or lessen the negative stimulation of pain. This counterstimulation comes from holding, manipulating, and concentrating on a marble.

Self-Hypnosis Method 2: Eye Fixation, Attention-to-Breathing Method. The following self-hypnosis induction method is brief, direct, and conducive to producing a physiologically calm and relaxed state. It redirects the patient’s attention internally to breathing. So it is a kinesthetic induction. But it is a visual method also, because it also has the patient focusing visual attention while are paying attention to breathing.

Your breathing is your road to relaxation. The following should be discussed with the patient as a rationale for this and other induction methods.  Here is an example script:

Your breathing is a physical reflection of your relative state of calm versus arousal. When you are calm, relaxed, and feeling restful, your breathing tends to be slow and regular, even and rhythmic. When you are in this state, you naturally tend to breathe more from your diaphragm and belly and less from your upper chest, upper back, and shoulders. Breathing from your diaphragm is easier on your back and neck and also a more natural and comfortable way to breathe.

On the other hand, when you are not calm, but restless, clammed up, nervous, anxious, tense, or in a lot of pain, your breathing tends to reflect this also. Your breathing tends to be uneven, labored, shallow, quicker, and more irregular. It also tends to come more from your chest, upper back, and shoulders. You even may gasp for and swallow air.

When you’re feeling relaxed and breathing calmly, you cannot at the same time be clammed up, tense, stressed, and breathing nervously, because they are opposite physiological states. Your breathing reflects the status of your nervous system: calm versus aroused, relaxed versus tense. By slowing down your breathing and breathing calmly, evenly, and easily, you can induce a state of relaxation and calm.

When you concentrate on your breathing without trying to change your breathing, the normal rhythm of your breathing begins to exert a natural calming effect on your mind and body. As you become increasingly absorbed in the natural rhythm of your calm, easy breathing, you ease into self-hypnosis trance. Your breathing really is the “royal road to relaxation and calm.”

The following self-hypnosis method will enable you to read yourself into self-hypnosis and relaxation. This exercise focuses on helping you attain a calm and restful physiological state primarily through concentration on your breathing without consciously trying to change your breathing.

Self-Hypnosis Method 3: Dr. Cheek’s Pencil-Drop Method. This method was described by Dr. David Cheek (Cheek 1994). It combines both visual and tactile-kinesthetic sensory systems. It also adds an auditory component through counting down and the use of the cue word “relax.” Dr. Cheek’s method makes it possible to go very deeply into self-hypnosis and relaxation. Remember that the patient doesn’t have to go very deep, but the deeper he or she goes, the more effectively will be the reduction of discomfort. Dr. Cheek pointed out that the altered state we call “hypnosis” can occur directly, when you sit back in a comfortable, balanced, and open position. As you did earlier, read slowly, silently or quietly aloud, a few words at a time, keeping your head as still as you comfortably can.

Awakening or Alerting Methods

There are alternative ways to alert the patient.  These can be used as part of self-hypnosis when the patient:  comes to the point of “awaken yourself” or “emerge” or “comes back” out of self-hypnosis. The alerting method I have been using in the examples communicates a “win-win” situation to the patient’s unconscious. That is, the patient will agree to become alert when he or she agrees to feel better, pure and simple, and not before! That is why I like it. I owe this alerting routine to Dabney Ewin, who first made me aware of it.

Another simple, alternative alerting method for bringing the patient out of hypnosis (or self-hypnosis) is to count up from 1 to 5. The patient can be given these simple suggestions: “When you are ready to awaken from your self-hypnosis and bring your comfort and relaxation with you, count to yourself from 1 up to 5. When you say 5, you will feel wide awake and alert, but also very relaxed, calm, and comfortable at the same time. So, if you’re ready to exit self-hypnosis now, you may begin counting. 1, 2, 3, 4, 5. Wide awake, alert and yet relaxed at the same time.”

Self-Hypnosis Method 4: The Arm-Drop Method. The following self-hypnosis method is simple, brief, and easily learned. It is visual and tactile-kinesthetic. It takes advantage of several natural, physical phenomena, most notably gravity. This method is a popular induction and has been used in one form or another by various well-known hypnosis practitioners. Read the script below several times first to get the steps of the method down.

Self-Hypnosis Method 5: The Magnetic-Hands Method. The following is a visual and tactile-kinesthetic self-hypnosis induction method. It is one of my personal favorites because it involves paying attention to part of the energy system in your body. The steps are given below. As in earlier exercises, read each step, then do what it says. Then, read the next step, do that one, and so on. Work your way through the entire exercise in this manner. After you have practiced going through all of the steps several times and understand them, do the method in one continuous flow.

Self-Hypnosis Method 6: The Eye-Roll Induction Method. This is a tactile-kinesthetic induction method originated by Dr. Herbert Spiegel (Spiegel and Spiegel 1978) and adapted by many others. My version is an adaptation of Dr. Spiegel’s Eye-Roll Method and Dr. Ewin’s Rapid Eye-Roll Induction (Ewin and Eimer, 2006). There are three basic steps.

At the count of “one,” you do one thing,

At the count of “two,” you do two things, and

At the count of “three,” you do three things.

Then you deepen your relaxation experience through progressive muscle relaxation and active sensory imagination. After you’ve read the step-by-step instructions several times, and know what to do, practice the procedure without reading and experience how it feels. (Again, if this is being done by the therapist initially, the instructions can be read to the patient).

Learning to Use Self-Hypnosis to Cope with Pain

The previous section describes alternative methods for entering and exiting self-hypnosis. Once the patient has experienced several different ways to enter a self-hypnosis trance and has chosen a method that is appealing to practice, the next issue is what can be done with self-hypnosis? How can a person actually utilize self-hypnosis skills for coping with pain? One answer to the question is to use self-hypnosis regularly to alter one’s state of consciousness and enter deep relaxation. That is a valid use. When you are relaxed, you cannot be tense, pressured, stressed, or in pain at the same time. The regular practice of self-relaxation through self-hypnosis recharges the individual’s batteries, so to speak. It replenishes and restores the energy reserves that have been drained by continued pain.

Choose the right hypnotic coping strategy. Now that the patient knows how to enter and exit self-hypnosis, it is best if he or she practices the chosen method twice a day for about ten to fifteen minutes at each session. The self-hypnosis practice sessions repeatedly imprint the healing experience of deep relaxation. After about a week of continuing this process faithfully, the patient will become more confident that the process of positive change has begun. At this point, you (and the patient) are ready to explore different ways of employing and extending the self-hypnosis skills to cope more comfortably with pain and change the pain experience.

The Six D’s of Hypnotic Coping

In this section, I briefly explain the 6 D’s.  The first one, Deep Relaxation, has been previously reviewed and will only be cursorily discussed. The next two are the thinking and behavioral methods of coping including Decatastrophizing and Direction. The remaining three include the distraction and imagination methods of Distraction, Distortion, and Dissociation.

Deep Relaxation

The first D of pain coping is deep relaxation. We have already covered this “D” in detail previously and not much more needs to be said about it. Recall, as I stated earlier, that when I talk about trance depth, I’m referring to the quality of the self-hypnosis and relaxation experience. As I shall discuss subsequently, self-hypnosis can be used to change the pain experience. You need not go deep into “la-la land” to do this.

The list below provides choices of deep relaxation self-suggestions to augment and amplify the experience of deep relaxation. In working with the patient, simply choose two to three of the suggestions in the list below to read several times before hypnosis or self-hypnosis is initiated.  The patient should work with a few self-suggestions repeatedly for a while and then switch to several others. By working in this way, the patient will find it easy to remain focused.

Decatastrophizing

Catastrophizing is the belief that your discomfort will lead to the worst possible consequences and that the situation or your life will turn into a disaster. Catastrophizing intensifies an individual’s suffering, worsens the pain, and adds to one’s problems. It elevates the status of an uncomfortable experience from bad to worst. Therefore, the second D of pain coping is decatastrophizing. It means dispelling the disaster from the patient’s experience of discomfort. It also means diminishing the calamity or catastrophe of the pain experience. Decatastrophizing suspends the suffering element from the pain and arrests the person’s anguish.

It is important for the patient (and therapist) to understand that decatastrophizing is not a way to ignore reality or sugarcoat the “badness” of a difficult situation. It’s a way to keep one’s thoughts, feelings, and reactions in check so that the person can function and achieve important goals. Our minds have a tendency to imagine calamities, catastrophes, and disasters when circumstances are adverse, but things usually aren’t that bad. “Bad” does not equal “disastrous” or “awful.” Therefore, to cope effectively, the patient has to train him or herself to control mental activity. The patient cannot afford to let negative thoughts and feelings “get out of hand.” Tell the patient:

You must tame your thoughts in order to tame your pain.

Decatastrophizing and the brain. Decatastrophizing works from the top down. It is initiated in the highest levels of the brain, the frontal and prefrontal cortex. This part of the brain is the seat of the conscious mind and has connections (nerve fiber pathways) that transmit information to and from the deepest, innermost parts of the brain, called the subcortex. The sub-cortex is one of the seats of your inner mind or unconscious.

There are areas deep inside the brain (the subcortex) that control emotional reactions as well as physiological drives, such as hunger and thirst. Deep within the brain’s subcortex there also resides a central relay station where physical sensations, including pain, are initially processed. This relay station is called the thalamus. Once physical sensations are identified and processed in the thalamus, their sensory signals are routed and dispatched. The thalamus is like a central mail room. As with the mail, not every message passes through intact all the way up to your brain’s central processing and control center. Some messages are intercepted, held back, or inhibited. Others are damaged, dampened, or distorted. Still others do pass through intact, and some are actually accentuated, amplified, or sent through as overnight, express mail. The subcortical areas deep inside your brain are connected to the brain stem. The brain stem controls all of the essential physiological functions that keep you alive (breathing, heartbeat, blood pressure, alertness, sleeping, basic reflexes).

Decatastrophizing thought processes begin in the brain’s frontal and pre-frontal cortex, the seat of executive control functions. This is the part of the brain that makes us distinctly human. It enables us to plan, organize, and execute behaviors; symbolize, represent, and recall information; and, interpret our experiences. When a person chooses to decatastrophize, the brain sends messages from the frontal and prefrontal cortex down the pathways described above. This results in closing the pain gate in the spinal cord.  The previous example of the patient who had pain but found out it was not a cancerous tumor, illustrates this point.

Waking state decatastrophizing. A person does not need to be in a trance (self-hypnosis induced or otherwised) to decatastrophize. In fact, when one first learns how to decatastrophize,  practice should be done in a waking state. After the patient gains experience with the method, decatastrophizing can be done either in or out of a self-hypnosis trance. Disputation (explained below), which is one method of decatastrophizing, is a conscious waking state procedure. On the other hand, reframing (explained below), which is another method, is both a conscious and unconscious process.

Disputation. Disputation is one method of decatastrophizing. Disputation means challenging negative, unhelpful thoughts, and changing them. This technique is done in the waking state because the patient needs to be consciously aware of what it is that needs to be challenged and changed. It is a rational and logical procedure. The process includes teaching the patient to “catch” a negative thought that is causing aversive emotions.  Once the cognition is identified and “caught”, the patient can practice letting go of that stress-producing thought. One method of “letting go” is to interrupt the thought and redirect one’s attention to something else that is neutral, such as breathing. Another way is to challenge or dispute the thought. When the patient realizes that the thought is not true (e.g. negative, irrational, etc.), it can be canceled and replaced with a functional, stress-reducing thought. This is done in the waking state. With repetition and practice, however, disputation tends to become automatic and unconscious.  This process is very similar to cognitive restructuring as explained in the pain management course: Evaluation and Treatment.

Reframing. The most important coping tool that the patient always has available is reframing. Reframing means changing the way a person thinks about something without necessarily changing that something (Zarren and Eimer, 2001). It means changing the meaning of the beliefs that continue to produce dysfunctional behavior and experiences. This may not change the substance of the problem, but it does change the way the person thinks about himself in relation to the problem. To decatastrophize, or cut the calamity or catastrophe out of an unfortunate experience and arrest one’s anguish, an individual must reframe the experience. Changing the way a person thinks about the pain (reframing it) provides the basis for taking constructive action, as opposed to continuing to have destructive reactions. For example, continuing to think that one’s pain is fixed, permanent, constant, unpredictable, uncontrollable, and mysterious is likely to foster continuing feelings of helplessness and hopelessness. How does a person cope when he or she feels that nothing that is done will make any difference? The answer is that the patient tends to be passive and reactive as opposed to being active and proactive. Rather than seeing options and alternatives, the chronic pain patient sees only more suffering.

Considering the following contrasting beliefs that might be held by a pain patient:

If you believe, “there is a vicious pain loop in my central nervous system and there is nothing I can do to break the circle”, then you will take very little action.  If you perceive your pain to be an unyielding medium of torture and your life to be a torture chamber with no escape hatch, then what is there left to do but continue to suffer?

However, what if you were willing to consider (believe) the possibility that your pain is not all bad—that it has something to teach you? That it could offer a very valuable lesson you might as well try to learn since you’ve already paid for it (“pained” for it) many times over? This would open up different possibilities, would it not?

Reframing is crucial for countering helplessness and hopelessness. When a patient feels helpless and hopeless, his or her problems feel unsolvable and the situation feels like a disaster or a catastrophe. The pathway out of such despair is to reframe the problematic situation; to put a new frame on an old situation. Reframing enables the patient to neutralize and replace negative thoughts or beliefs that make the pain problem feel insurmountable.  Reframing is a way of changing the patient’s belief that he or she is trapped to the belief that there are choices. It can involve changing the meaning of any of the following: beliefs, attitudes, habit patterns, negative or destructive labels, feelings, or behaviors, and helps to open the way for positive emotional and behavioral change. The way a person thinks about something can be changed even though “the facts” may remain the same. The original situation may in fact remain unchanged, but the individual can perceive the situation from a new point of view. What is changed, as a result of reframing, is the meaning that is given to the situation. This change in meaning can change the consequences of the situation, although its concrete facts may remain unchanged, at least initially. The task of the pain therapist is to make the patient an expert at reframing (among other things).

Negative emotional overlay. Negative, dysfunctional thoughts like the one Christine suffered under make persistent pain worse by creating a negative emotional overlay on top of the physical pain. This increases the emotional distress and suffering and hoists up the “hurt level” of the pain—how much the pain is actually felt. Therefore, it is helpful to teach the patient to “catch” such thoughts and then dispute or reframe them. This can lift off the negative emotional overlay.

“Taming your thinking”. One of the key coping tools for “taming” persistent pain is “taming” one’s thinking processes. Taming the thinking processes largely involves getting into the habit of consciously and subconsciously responding to one’s internal chatter in a constructive manner. Decatastrophizing (including reframing and disputation), are a great way for a person to “talk back” to unhelpful thoughts. Since the mind is always active, a person cannot stop thoughts from automatically popping into his or her head in the first place. But the patient with pain need not let an unproductive or destructive thought stream continue without adding constructive and corrective conscious input. The person has choices in terms of how to respond to the pain, and thoughts about it. The list below (Table 14) provides the patient with choices of decatastrophizing self-suggestions to help in reframing the pain.

Direction

The third D of pain coping is direction. “Direction” refers to the act or process of controlling, guiding, governing, instructing, or supervising thoughts and actions. It involves setting goals to achieve and then behaving in a way that leads to the achievement of those goals. Self-hypnosis coping skills help the patient direct or guide his or her thoughts and behaviors in line with agreed-upon positive and healthy intentions.

Applied to coping, direction means controlling one’s own behaviors and thoughts to maximize short-term and long-term pleasure and well-being, and minimize short-term and long-term pain. It involves instructing oneself to think and behave in a functional way in day-to-day life. It includes using “positive self- talk” and “positive self-suggestion.” For the patient, these two tools entail:

saying positive affirmations,

preparing yourself to handle difficult, uncomfortable, or painful situations,

talking yourself through those situations, and

giving yourself direct suggestions for desired changes in your experience.

Pain behaviors and wellness behaviors. Given that nobody is perfect, we all engage in behaviors that we would like to do less of, either because the behaviors are dysfunctional or just because we do too much of them (like drinking or eating too much, working out physically too hard, working too many hours, sleeping too much, etc.). These are termed “behavioral excesses.” In addition, we all have things that we would like to start doing that we are not doing currently, as well as things we would like to do more of. These can be termed “behavioral deficits” (like starting to exercise, sleeping more, eating regularly, working fixed hours, controlling our temper, etc.).

We can set limited goals for ourselves to start doing one thing that we are not doing, or diminish doing something that we need to cut down on. This can help us begin to establish new, healthy habit patterns. Establishing healthy habits is especially important for people who have the added burden in life of having to cope with a chronic illness or chronic pain. As for everyone, it is a necessity to lead some semblance of an orderly life. Healthy habits help to conserve precious energy. There are certain behavioral coaching principles that can be taught to the patient to help establish and maintain healthy habits. Being aware of, and following, these principles can also help him or her create and maintain more order and discipline in daily life. This will help the patient restore more control over his or her life and the pain. The overall goal of this intervention is to help the patient identify pain behaviors (overt and covert) and wellness behaviors.  Once this is done, the treatment goal is it increase wellness behaviors and decrease pain behaviors (See Table 15).   

Twelve Behavioral-Coaching Principles

The following are twelve principles that can be taught to patients to help them adopt more healthful behaviors.  These are written in the first person, as they might be explained to the patient.

Mental rehearsal. What’s the best psychological way to counter fatigue instantly? The answer is mental rehearsal to activate dormant or temporarily inactive “action potentials” (firing capabilities of the sensory and motor nerves that innervate or excite the sensory receptors and muscle fibers involved in adaptive behaviors) (Evans 2001). So when you are feeling too tired to engage in an activity you want or need to engage in now (such as getting out of bed), visualize yourself doing that activity (like getting out of bed) for thirty to sixty seconds before actually doing it. Visualize using all of your preferred sensory systems (your active sensory imagination). See, feel, and hear (and if relevant, smell and taste) yourself engaging in the activity. This is a technique that actually is borrowed from sports psychology.

Positive reinforcement. Enhance your motivation to engage in an unpleasant, nonreinforcing activity that is good for you (such as exercise or eating your vegetables) by rewarding yourself after you do it with something that is very pleasant for you. For example, if you love to eat ice cream (unless you are allergic to ice cream, and then choose something else that you like), give yourself ice cream as a reward after you do your prescribed back exercises. That’s positive reinforcement. But remember also to positively reinforce yourself internally for doing the right thing. Praise yourself. Give yourself a “pat on the back.” If you can’t reach your back (pun intended), just tell yourself that you’ve done well.

Take baby steps. Don’t bite off more than you can chew all at once. That’s a sure recipe for re-injury whether you’re dealing with working in the garden, or sitting at the computer, or exercising. Take small steps. Each step moves you closer and closer to your goal. But set realistic and reasonable goals. Be patient with yourself. Patience is the ability to wait calmly for something desired. Patience is a virtue, and virtue is its own reward. Pace yourself. You may just have to acknowledge and bring yourself to accept that, since your injury, you are not the same person you once were, and that you may never be capable of doing what you used to do.

Be flexible and conserve. Plan your days and your week, but be flexible (in more ways than one). You may have to alter your plans. Learn to tolerate uncertainty; after all, nobody can predict the future. Learn to tolerate the frustration of not always finishing an important task. You can do the rest tomorrow and are more likely to be able to do so if you are comfortable. When energy is in short supply, it’s important to conserve it.

Be persistent. When you have persistent pain, perseverance, determination, resolve, and persistence are good qualities to have. They help you keep going when you would rather lay down in bed. It is understandable if you feel like giving up at times. But you need not! However, don’t be like that battery bunny on TV. Don’t keep going and going and going and going. You will run out of energy. Remember to pace yourself.

Stop doing pain behaviors. We went through a pretty exhaustive list of pain behaviors earlier. Pain behaviors breed further dysfunction and more grief, pain, and suffering. So, develop the habit of catching yourself when you’re doing pain behaviors and simply stop doing them. Then reward yourself for doing so.

Counter your deconditioning. If necessary, work with a physical therapist who understands chronic pain and your particular medical condition. People with chronic pain have the unfortunate tendency to get out of shape and become deconditioned because exercise often hurts (See the Introduction to Chronic Pain Management for a discussion of the deconditioning syndrome). Unfortunately, the more deconditioned a person becomes, the more pain-prone the person becomes also. So, it is important to prevent or address deconditioning. Also, exercise, especially aerobic exercise, such as walking, helps the body to release its own internal opioid-like chemicals, which are called endorphins and enkephalins. These natural products can help with your pain. Thus, it is important to exercise as much as possible, keeping your own particular physical limitations and condition in mind. Physical exercise in moderation and doing things you enjoy helps your body unlock and release these chemicals.

Learn assertiveness and make it a habit. Assertiveness, as opposed to aggressiveness or hostility, can be defined as the ability to stand up for yourself in an argument, defend your interests and position, and protect your rights without losing control. Assertiveness means being able to say “no” make your preferences and decisions clear about matters of direct concern to you, and express your feelings or disagreement in a clear and appropriate manner.  It also involves being able to set limits and make choices about what you will do or not do in an interpersonal relationship. Many people lack skills that would allow them to do these things. It is important to develop such skills. Practicing your assertiveness skills can make them become second nature. Becoming more assertive can help you feel more in control and better able to get your needs met (and control your pain).

Avoid unfair comparisons. You are unique. There is nobody else exactly like you in the entire world. Avoid comparing yourself to others, or at least catch yourself when you are doing it and stop it. I promise you that this will help you avoid needless grief. It is true that there are commonalities amongst humans because we are all human. And there are typically even more commonalities within different groups of humans (like for people with chronic pain within the same cultural, ethnic, or religious group). However, in truth, everyone’s individual circumstances are unique. It isn’t helpful to waste your precious energy on making unfair and probably invalid comparisons between yourself and others.

Embrace self-acceptance. You have as much intrinsic self-worth as the next person. You are no less worthy as a person, as a human being, than is the queen of England or the President of the United States! By the same token, you are no more worthy as a person than the beggar on the street corner. Your self-worth as a person is a given. You are worthy because you are alive. You can rate your skills and accomplishments, but it is invalid to rate your whole being. That is, in effect, what you do when you rate your self-worth. You deserve to do everything you can to live as comfortably as you can—you have suffered enough. Remember, pain may be mandatory, but suffering is optional.

It should be explained to the patient that these twelve points are principles, ideals to reach for and strive toward. As ideals, they are not going to be a snap to adopt. Admittedly, some principles are harder to follow than others. There are many shades of gray. Reassure the patient to “be easy on yourself” in gradually adopting these principles. Remind them, “You have your whole lifetime to practice!”

Distraction

Distraction refers to diverting or redirecting your attention away from one thing toward another; for example, away from pain and toward something neutral, pleasant, or less uncomfortable. Distraction is an effective pain-control strategy because the conscious mind can only process a finite or limited amount of input and information at one time. The unconscious, on the other hand, can process many things at the same time. So the goal in using the strategy of distraction is to introduce stimuli and sensations that compete with the pain sensations for conscious attention. If these competing sensations get to the brain first, they can prevent the pain sensations from ever reaching it. They can at the least slow down the transmission of the pain sensations up the spinal cord.

Distraction works from the bottom up. When the conscious mind is paying attention to the sensations created by rubbing or massaging the area of the body that hurts, it has less capacity to pay attention to pain sensations. The nerve fibers that transmit sensations of pressure, touch, and vibration carry information to the brain faster than those nerve fibers that transmit pain sensations. So, when the faster fibers are fired up through the introduction of tactile-kinesthetic stimulation such as touch, pressure, rubbing, or massage to the area of discomfort, their sensory signals get to the brain before the pain messages do. This tends to close the pain gate in the spinal cord. A great example for patients is when you hit your head on a cabinet corner.  The immediate response of rubbing the area to decrease the pain is an example of the Gate Theory in action.  The rubbing stimulates nerve transmissions that override the sharp pain.

Similarly, when the conscious mind is deeply absorbed in other tactile-kinesthetic activities such as paying attention to breathing, enjoying the beach, writing, or painting, it cannot pay as much attention to pain. This also closes the pain gate. Distraction is probably the easiest and simplest pain-coping strategy. In sum, distraction works by introducing stimulation that competes with the pain in the nervous system. The distractors generate competing nerve signals that beat the pain to the brain. They get there first and close the gate on pain.

Some distraction exercises. Distraction is easy. You just redirect your attention away from your discomfort and onto something else that is neutral, interesting, compelling, captivating, or engaging. You can do it in the waking state or in self-hypnosis. Please be aware that when you employ any of the self-hypnosis induction methods described previously, you’re distracting yourself from discomfort. Entering and exiting self-hypnosis removes you from the pain. Once you’ve chosen any self-hypnosis method that works well for you, it’s possible to create an almost instant alert or waking version of your chosen method to relax yourself in seconds, whenever you need to, wherever you are, without anyone knowing you’re doing it. The use of the marble for instant relaxation is one example. Another example is taking several slow deep breaths while you focus your visual attention on some object not too far away. Another example is paying attention to your breathing without trying to change your breathing, with or without focusing your visual attention on some object not too far away at the same time.

Distortion

Distortion is a hypnotic coping strategy that involves re-interpreting the pain sensations so that they are experienced as if they are something else. This involves changing, recoloring, and transforming the perception of pain sensations. For obvious reasons, this can be a very useful thing to do with pain sensations that are unnecessary remnants of a long-term physical condition (e.g. chronic pain). When the pain no longer serves a useful signalling function, distortion can be used to turn down or change the signal and filter the “hurt” out of the pain (Patterson, 2010; Spiegel and Spiegel 1978).

Distortion works from both ends. Distortion works both from the bottom up and the top down neurologically. That is because it incorporates both distraction and re-interpretation (also called reframing). Distortion combines shifting one’s attention away from the pain to something else (distraction) with changing the interpretation of the pain (re-interpretation). Distraction involves refocusing or shifting one’s attention to alternative stimulation that competes with the pain stimulation, and thus, blocks the pain signals on their way up the spinal cord to the brain. Re-interpretation or reframing involves changing the way an individual thinks about the pain sensations. This sends new and different messages from the brain down the spinal cord to the place in the back of the spinal cord where the pain transmitting nerve fibers interact. Both distraction and reframing contribute to closing the pain gate.

The components of distortion. The hypnotic strategy of distortion incorporates new sensory input (the distracting stimulus) and changes how the brain interprets the original sensory input (the pain). The bottom line is that distortion changes or transforms the pain sensations into something else—other, less painful sensations. Everyone can distract themselves from pain temporarily. However, once a person is distracted, it is important to move on and transform the pain. The following are the three steps related to distortion and transformation that should be outlined for the patient:

1.   First, you shift your attention to different sensations, thoughts, or feelings. As I stated above, these can be stimuli unrelated to the pain or an element or facet of the pain sensations themselves.

2.   Second, you let these sensations, thoughts, or feelings become the generator of less uncomfortable (or more comfortable) countersensations that oppose the pain.

3.   Third, you let yourself become absorbed in these countersensations and employ your active sensory imagination to shape and develop them into a changing experience that’s more comfortable and easier to handle.

When the patient distorts his or her pain it is transformed into something else that is less uncomfortable and more tolerable. Patients should be warned that distortion takes a little practice. The idea is to find a strategy or several strategies that are right for the patient and encourage him or her to keep practicing. As with distraction, an individual can distort the pain in the waking state or in self-hypnosis. There are innumerable exercises to help achieve this goal.  Table 16 is an example of one.

Some additional distortion self-suggestions. The list in the Table below provides choices of distortion self-suggestions to help transform or alter pain symptoms. These can be discussed with the patient and initially done by the therapist.  Ultimately, these are incorporated into home practice and self-hypnosis.

Dissociation

Finally, we reach dissociation, the sixth D. Dissociation is the “pure gold” of all self-hypnosis strategies for getting out of pain. Basically, the coping strategy of dissociation means detaching, disconnecting, and disengaging oneself from pain. It means isolating or separating the pain from the person and the person from the pain.

Remind the patient of the following: Dissociation depends on the fact that the mind is made up of two parts (Zarren and Eimer 2001). One part we call the conscious mind. You have control over your conscious mind, and it controls conscious behavior; things you can’t do without knowing that you are doing them. Behavior and experience can’t change without the cooperation of the conscious mind. So, it is important for your conscious mind to be fully aware of all of the important issues relating to coping effectively with chronic pain. The other part of the mind we call the unconscious, the subconscious, or the inner mind. All three names mean the same thing. The unconscious controls all of your automatic functions. These include your breathing, heartbeat, pulse rate, blood flow, digestion; all of the things that keep you alive that you pay little or no attention to. They are automatic.

The unconscious also controls all the things that you do every day automatically without thinking much about them (Zarren and Eimer 2001). These things include your habits and automatic behaviors; for example, which side of the bed you sleep on, which shoe you put on first when you get dressed in the morning, driving (if you drive), daily maintenance chores, such as taking out the trash, putting dirty dishes in the dishwasher, running your washer and dryer, and so forth. Your unconscious or inner mind also controls your coping habits; for example, how you talk to yourself, how you handle anger and frustration, how you cope with your pain, and so forth.

Dissociating pain, that is, isolating or separating the pain from you and you from the pain, creates a very special situation that is one of the main characteristics of hypnosis. This involves freeing your conscious mind from the immediate perception of pain and relegating or transferring the pain to your unconscious. Your unconscious is entrusted with the job of holding your pain while your conscious mind enjoys freedom from pain. Part of you gets comfortable and pain-free, while another part of you, your inner mind, remains aware of the pain on an unconscious level.

As with the strategy of distortion, the intentional employment of the strategy of dissociation requires that you believe in your creative imagination and active sensory imagination. To understand dissociation fully, however, we need to examine several examples of normal, everyday dissociation.

Everyday, spontaneous dissociation. We all have the ability to dissociate to greater or lesser degrees. One rather undramatic example of everyday spontaneous dissociation is when you are driving your car to and from a familiar location. If you have taken the same route countless times before, you don’t have to think about which turns to make, what streets to take, etc. You can use the driving time to listen to the radio or review your day. You mentally dissociate from the task at hand - driving. While your unconscious carries out the rote, over-learned task of operating your vehicle and ensuring you arrive at your destination safely, your conscious mind is free to go somewhere else. Only if something unexpected happens that draws your conscious attention do you turn it back to the driving task.

When you learn something new it typically requires all of your conscious attention. Remember when you first learned to read? Now you no longer have to think about such things. It’s automatic and unconscious. In fact, you can read and write and think about something else at the same time.

How can the patient make the pain mostly unconscious? The answer is by learning and practicing the basic self-hypnosis coping skills that they become automatic habits. By practicing these skills over and over again, their use will become spontaneous and automatic. Table 18 presents a script for a dissociation exercise.

Using dissociation as a coping tool. Now that the patient knows something about dissociation, how can it actually be employed to cope with pain? The exercises in Table 18 and 19 provide example methods. Once again, the exercise can be initially guided by the therapist (hypnosis) ant then practiced and taken over by the patient (self-hypnosis).  The initial instructions are the same as given previously for exercises in distraction and distortion.

Changing the Pain Experience

The exercises discussed in this course can provide the patient with a notable number of alternative ways to reduce and relieve pain. Some of approaches do not require much in the way of hypnotic relaxation, absorption, focused attention, and imagination; while, others do. Success is achieved with the cooperation of the conscious and unconscious mind. The suggestions in the preceding exercises will make sense to the degree that that they have been accepted by the patient’s unconscious. Having the patient practice the methods (including self-suggestions) helps to “fix” or imprint them in the unconscious.

How to Construct Effective Self-Suggestions

In order to create effective, personal self-suggestions, certain principles or rules are useful. These rules pertain to the phrasing of the self-suggestions and when to employ them. In this section, the following will be discussed:

how to phrase self-suggestions effectively

determining when to use them

how to use self-suggestions in the waking state and with self-hypnosis to change the pain experience.

The following can be presented to the patient.

Rule 1: Use your preferred sensory systems. The first rule is to use the language of your preferred sensory systems. That is the language your unconscious understands best and will respond to the most. You already know what your preferred sensory systems are based on the previous exercises. So, for example, if you are an auditory person, you are likely to be more receptive to sounds than to visual images. On the other hand, if you are a really tactile-kinesthetic person, then you are likely to be most receptive to remembering and imagining the feel of your physical experiences. If you are primarily a tactile-kinesthetic person, then the feeling of floating will probably be more compelling than the sounds of waves washing onto the beach. If you are primarily a visual person, then the visual or pictorial image of colored lights in different parts of your body that represent physical sensations including pain will probably be most compelling. So, work your preferred sensory systems into your suggestions.

Rule 2: State it in the positive. Suggestions should usually be stated in the positive as opposed to the negative. For example, you can suggest to yourself, “Every day, as I practice my self-hypnosis and read on in this book, I will notice that I am feeling better and better and more and more comfortable.” This suggestion will probably be more effective than the suggestion, “I will not feel as much pain.” As another example, it would probably be more effective to suggest to yourself, “I will enjoy feeling more comfort in my shoulder,” than to suggest to yourself, “I will not feel pain in my shoulder.”

It is generally best to avoid using the word “not,” as in the form “do not,” or “you will not.” So, why not use “not”? The reason is that your unconscious may just forget to notice the not! By telling yourself not to do or experience something that you don’t want, you are focusing mental attention on that very thing! While your conscious mind can make the distinction, your unconscious probably won’t.

Remember this; if you are trying to avoid something, directing your attention to what you’re trying to avoid, or not think about, just makes you think about it more. What you need to do is to direct your attention to something else, for instance on what you want. So, suggest to yourself what it is that you want, as opposed to what it is that you don’t want.

Rule 3: Don’t tell yourself to “Try”! Don’t try. Do it! The harder you try to do something, or try not to do something, the more difficult it becomes to do it or not do it. This is known as the “Law of Reverse Effect,” which states that when the conscious will comes up against the imagination, the imagination always wins. What it really boils down to is this: the harder you consciously try to do something that depends on your unconscious for its execution (like falling asleep, going to the bathroom, being attracted to someone), the more likely you are to produce the reverse effect. For example: Try not to think of a pink elephant. The harder you try, the more difficult it becomes to get the thought out of your mind. Isn’t that so? Now, try not to notice that itch on your nose. The harder you try, the stronger the itch becomes. You may not have even noticed an itch before I drew your attention to it! Now try not to scratch it. The harder you try not to, the greater the urge becomes.

Rule 4: Set a time frame. It is usually helpful to place a time frame on suggestions, especially when you want to suggest the lessening or end of a behavior or experience that may be worsening your pain. For example, it might be therapeutically effective to suggest to yourself, “I no longer need to clench my teeth to release tension. I now have other more effective ways of releasing tension.” On the other hand, it would be less desirable to suggest to yourself something like, “I do not need to clench my teeth to release tension,” or “I will not clench my teeth.” This latter phrasing of the suggestion does not set any time frame. What else is wrong with these latter two suggestions?

Once again, in the above suggestions, the use of the word “not” could be misleading to the unconscious. It could possibly be interpreted by your unconscious as “I do need to clench my teeth to release tension” (minus the “not”), especially if dysfunctional clenching behavior or the idea of having no control over clenching has been imprinted in your unconscious. However, it could work to suggest, “I will no longer clench my teeth.” Your unconscious will probably interpret this as meaning, “I will do the following . . .” that is, “no longer clench my teeth.”

Rule 5: Emphasize the present tense. It helps to make suggestions in the present tense and to link these with suggestions of what will happen as long as these suggested changes are believable and attainable. For example:

I am feeling enthusiastic about exercising my new self-hypnosis coping skills, and I have more energy and feel more comfortable as I exercise these new skills. As I continue to exercise those new skills and as I learn new ones, my energy and comfort increase.

Rule 6: Keep it simple and specific (KISS). Be as precise and specific as possible in crafting suggestions to give yourself. This will make them easier to follow. The less wordy your suggestions are, the better. Your unconscious processes not just the words, but the entire flow and feeling created by the suggestions. So be selective about your choice of words. Keep it simple and specific. When you create self-suggestions, “KISS” them! Limit the scope of your suggestions. Do not try to tackle too many problems at once. Self-hypnosis trance is a focusing mechanism. Too much at once tends to diminish focus and bring you up, out of trance.

Rule 7: Repeat, Repeat, Repeat. What are the three R’s of self-suggestion? That’s right! It really is a good idea to repeat suggestions several times, at different times, during and outside of the self-hypnosis trance state, with and without slight modification. This helps to promote the imprinting of the desired suggestions into your unconscious. I have been following this practice throughout this book. This is why I have repeated several ideas in different places using similar or slightly different wording.

Post-Hypnotic Suggestion

Post-hypnotic suggestion is the process of giving the patient instructions and suggestions before or during the hypnosis (or self-hypnosis) trance about conscious or unconscious behavior that is desired after the person emerges from the trance and re-enters the waking state. This is an important part of using self-hypnosis effectively to start and continue the process of change. Post-hypnotic suggestions can be rehearsed before or while the person is in the self-hypnosis trance state. It’s the choice of the patient (with the assistance of the therapist).

One valuable application of post-hypnotic suggestion is the imprinting or conditioning of instant relaxation as an immediately available coping skill. Instant relaxation is a conscious or unconscious behavior the patient will engage in when out of self-hypnosis and in the waking state. The therapist can use post-hypnotic suggestions to condition the patient to employ a specific instant relaxation procedure to interrupt stressful feelings whenever he or she first becomes aware of them.  In that way, the stress does not escalate; it is stopped in its tracks (this is also termed cue-controlled relaxation).

By repeatedly employing instant relaxation, it becomes an automatic habit. Many methods of teaching instant relaxation have been reviewed in this course.  Table 18 is one example of a post-hypnotic suggestion for instant relaxation. The can be adapted as a script for the therapist or for the patient to practice as a self-hypnosis technique.

Summary: Seven Steps for Hypno-Analgesia

Following are seven simple steps for patients to learn, rehearse, and practice to help get relief from pain.  These steps summarize the important concepts in this course.  The steps are written as a handout for the patient that can be discussed as part of the treatment.

Step 1: Waking-State Reframing. Decatastrophize and reframe the main negative, dysfunctional thoughts associated with your negative emotional feelings in the waking state. You can’t afford the luxury of languishing in negative thoughts! After you have done this, formulate one or two positive self-suggestions based on your reframing of those negative, dysfunctional thoughts. Write these self-suggestions down.

Step 2: Record Your Purpose, Time You’ll Spend in Trance, And How You Want To Feel. Prepare for your self-hypnosis trance experience by telling yourself:

1. why you are entering trance,

2. how long you will remain in trance, and

3. how you will feel when you awaken from the trance state.

Write down a preparatory suggestion that approximates the following format: I’m going into self-hypnosis for around twenty minutes for the purpose of [. . .]. When my deepest mind is fully aware of how [. . .] I feel, and knows it can maintain that feeling of [. . .] for some time after I awaken, my eyes will blink several times, they will open wide.  I will come back feeling fully alert, sound in mind, sound in body, and in control of my feelings.

Step 3: Consciously Choose A Hypnotic Coping Strategy. Next, consciously choose a hypnotic

coping strategy. You now have many to choose from. Go back through the exercises and choose a particular deep relaxation, de-catastrophizing, direction, distraction, distortion, or dissociation strategy. After a while, you will no longer need to refer back to written instructions or notes.  The process will become automatic, one smooth flow, and you’ll be able to choose the right exercise and strategy for each occasion. After you’ve chosen a hypnotic coping strategy, go through it and review it in your mind. Use all of your preferred senses and your active sensory imagination. Feel yourself doing it. Feel the feelings and physical sensations, see the sights, hear the sounds, smell the scents, and taste the tastes. Then, formulate one to three self-suggestions based on your strategy. Write these self-suggestions down.

Step 4: Read Your Self-Suggestions. First, read your preparatory self-suggestion regarding why you’re entering trance, when and how you will awaken, and how you will feel after you emerge from self-hypnosis. Then, read your coping strategy self-suggestions five times. Then, put away your self-suggestions sheet or notebook.

Step 5: Induce the Self-Hypnosis Trance State. Use your chosen method for inducing self-hypnosis. Trust your unconscious to monitor the time you stay in self-hypnosis trance.

Step 6: Enjoy the Neutral Self-Hypnosis Trance State. Don’t think about giving yourself suggestions at this point. Just enjoy the experience of being in the pleasant, neutral, relaxed state of self-hypnosis. Let your unconscious work for you!

Step 7: Further Unconscious Imprinting and Awakening. Remain in self-hypnosis for a little while longer until you are ready to awaken. Then, when your deepest mind is fully aware of how much [your desired feeling state] you feel and knows it can maintain that feeling of [. . .] for some time after you awaken, your eyes will blink several times, and then they will open wide, and you will come back feeling fully alert, sound in mind, sound in body, and in control of your feelings.

Practice, Practice, Practice. Those are the seven steps for hypnotizing yourself out of pain. Your repeated practice of this sequence will imprint effective hypnotic coping skills. This will mentally condition you so that you’re prepared to employ the right hypnotic coping skills automatically whenever you need to and when it’s appropriate. You will be prepared to handle typical pain or pain flare-ups, or breakthrough pain. This builds your inner resources so that you can cope better and feel more comfortable more of the time.

Waking State Suggestion. You can employ waking-state suggestion anytime to reinforce your coping resources and comfort. You can do this by writing down on an index card, and in your notebook, the self-suggestions associated with the hypnotic coping strategies that your conscious and unconscious minds have selected. Carry the index card around with you and read the self-suggestions written on the card whenever you think to do it during the course of your day. This will further imprint the coping strategies in your unconscious and make them more immediately and automatically available whenever you need them most. Also, read these self-suggestions in your notebook as your first step when you do your regular, twice or three times daily self-hypnosis sessions.

Resources

·         The American Society of Clinical Hypnosis (ASCH)

·         The International Journal of Clinical and Experimental Hypnosis (IJCEH)

·         The International Society of Hypnosis (ISH)

·         The International Society for the Study of Dissociation (ISSD)

·         The Milton H. Erickson Foundation

·         Hypnosis News & Discussion Group on ChicagoPsychology.org

·         The Society for Clinical and Experimental Hypnosis (SCEH)

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