Hypnosis and Suggestion in the Treatment of Pain

WENDY IS AN appealing 13-year-old girl who probably has leukemia. A bone marrow aspiration is essential to make the diagnosis that will guide her treatment. The physician has informed Wendy and her parents that the procedure involves inserting a needle into one of her large bones, usually the iliac crest of the pelvic bone. After insertion, a syringe is attached to the needle, and a small amount of marrow is aspirated. The physician emphasizes that, although it sounds frightening, the procedure will be very quick. Wendy understands “needle” and “bone,” but she notices a change in the physician’s voice and that he looks away when he tells her not to worry. Wendy clutches her mother’s hand and begins to cry.

The physician knows Wendy is frightened, but he is at a loss for comforting words. Since general anesthesia will not be used in this procedure, how can he reassure her? He imagines her lying on the treatment table with her hip exposed. He imagines her crying as the local anesthetic numbs the skin over her hip. When she sees the bone marrow needle, almost as thick as a pencil, he knows she will lose control. She will pull away, and the nurse will come to restrain her.

The physician knows that insertion of the needle through the skin is not painful, thanks to the local anesthetic. He also knows, though, that the pressure required to force the needle through the tough outer layer of bone will be more than any pressure or any pain Wendy has ever felt. She will think that her hip is surely being crushed. Once the needle has penetrated the bone, there will be a moment of rest as the syringe is attached. Then, as suction begins to draw the marrow from its place deep in the hollow of the bone, there will be a sudden, electric, stabbing pain, felt throughout her leg and hip. The physician knows that Wendy’s body and mind will be squeezed by a fist of pain for a few seconds. He is grateful that it will then be over.

Afterward, the physician knows that Wendy will turn away from him, from the nurse, and from her parents. She will cover her eyes, wet with tears, and remain quiet and still for a long time.

Pain in children has been generally ignored by clinicians until recently (Barber, 1989; Schechter, Berde, & Yaster, 1993). This has been due in part to a lack of both knowledge and skills—but only in part. Our own attitudes toward pain and toward children, as well as clinical restraints introduced by managed care, also contribute substantially to the way we deal with painful procedures and painful conditions in children (Barber, 1989). With no better alternatives available, many clinics and hospitals continue to perform painful medical procedures in children using the “hold ’em down” method. This is a source of stress not only for the children and their parents, but for clinicians as well.

Children with chronic and recurrent pain due to conditions such as arthritis, sickle cell anemia, headaches, hemophilia, and abdominal pain are not ordinarily provided with sufficient analgesic medication or other effective remedies, and are often left to suffer in silence. Referral to a mental health professional for psychological intervention is often a measure of last resort, made only after extensive medical testing and attempted medical treatments have failed to relieve or lessen the child’s pain. Often the referring physician has been trained to think that if there is no identifiable physical finding, then the child’s distress must be attributable to a psychological cause. It is hoped that the psychologist or psychiatrist will identify and treat that cause. Often, though, by the time the problem has reached the mental health professional’s office, it has become a substantial one, much more difficult to treat than it would have been initially.

Our goals in this chapter are to discuss some of the underlying reasons for the persistent undertreatment of pain in children, and then to guide you through an introduction to psychological interventions for chronic and acute pain in children.

There are many reasons why pain and its treatment in children have not been adequately considered in the past. Throughout history—and still in some cultures—children have been viewed as parental possessions, to be handled and used or discarded as parents saw fit. Corporal punishment of children has always been tolerated, because parents have always been regarded as final arbiters of their children’s fate. This acceptance of substantial pain and suffering in children has cultural roots in traditions—extant in virtually every culture around the globe—that viewed the ability to tolerate pain either as a virtue or as a fate to be accepted gracefully.

It has been only since the late 1960s, in North America, that the concept of “child abuse” has been viewed as within the scope of pediatrics, with physical findings first described by Kempe and Helfer (1980). Now a physician is required by law to report suspected abuse, often on the basis of some physical evidence. The irony is that the medical establishment itself continues to abuse children, with the justification that inflicting pain is a necessary part of medical care.

What are the consequences of the undertreatment of pain in children? We now know that repeated painful experiences tend to lead to feelings of helplessness and the development of anticipatory fear of future medical care. Clinicians see children in whom chronic pain has led to anxiety or depression. There is evidence that early, prolonged, intense, and/or repeated pain experiences can disrupt not only psychological growth but also normal neural development and may actually lead to increased pain sensitivity (lowered threshold for pain stimuli, overlapping somatic dermatomes, and possibly the development of visceral hyperalgesia). There is reason to speculate that significant childhood pain may lead to adult chronic pain (Zeltzer, Arnoult, Hamilton, & DeLaura, 1994).

With modern availability of analgesic medication and of psychological techniques, it is not usually necessary to inflict pain with medical procedures. However, misconceptions about pediatric pain, difficulties in pediatric pain assessment, and lack of knowledge regarding how best to reduce children’s suffering have led to the continuing association of pain and medical care. This is true in adults, but especially in children.

Thus, often physicians inflict or do not adequately treat pain in children because they have been trained to believe that there is no alternative, that “all that can be done is being done in the child’s best interests,” or that “the benefits outweigh the risks.” We continue in our painful ways not out of malice but because we lack the skills and knowledge necessary to change. Our hope is that the awareness of our limitations may help us to become less grim, dry, and inattentive to the cries of children who remind us how much we hurt them even as we try to help.

Let us evaluate each of these issues, since they hold critical relevance for treatment of pain—including psychological treatment—and for facilitating a team approach to treating children’s pain.

There are a number of misconceptions about pain in infants and children that have fostered a delay in the adequate treatment of pediatric pain.

This belief was the justification for performing major operations on children without anesthesia. It seems unbelievable that, in America, neonatal surgery was customarily performed with little or no anesthesia until the last decade (Anand, Sipple, Schofield et al., 1988). The belief was that newborns, especially premature infants, do not have a nervous system sufficiently developed to feel pain, because of insufficient myelinization. What was not considered was the relatively shorter distances that nociceptive impulses had to travel from the periphery to the spinal cord and brain compared to adults. How physicians could observe obvious signs of pain and hold to the belief that the child was not suffering requires a psychological analysis beyond the scope of this chapter; however, the theme is explored by Perry (1984). But this fact should alert all of us to the power of our own personal limitations in the context of apparently providing patient care.

As if it were necessary to do so, it has recently been demonstrated that afferent sensory pathways are sufficiently developed in newborns for them to feel pain. However, the pain inhibitory system is not well developed. Thus, newborns, infants, and perhaps children (to what age is unknown) may actually feel more pain with the same amount of stimulation, compared to an adult. In 1987, the American Academy of Pediatrics published a statement indicating that it was not ethical to perform painful procedures on newborns without appropriate anesthesia.

Another misconception is that, even if infants and young children feel pain, they will not remember it. Some physicians believe that even in older children and adolescents it is unnecessary to treat acute pain, since pain of relatively short duration will have no long-lasting effects. Thus, children in any hospital setting, and in emergency departments in particular, are heard screaming variations of “Stop it! You’re hurting me!” or “No more owie!” Often, the smaller the child, the more likely the child is to be held down during a medical procedure (circumcision is the prime example), while shame is the method often used to restrain adolescents (“You should be able to take it like a man!”).

When children cry in the emergency room or in hospitals, it is typically believed that the underlying reason is fear rather than pain. Thus, children are expected to be fearful. What amounts to torture is justified by statements such as, “Can’t do much about that!” and “The child will get over it.” Since we know that most clinicians do not wish to torture children, how do we understand this behavior?

Until the advent, in the nineteenth century, of modern anesthetic techniques, this belief was unfortunately accurate; in the context of contemporary analgesia, however, it is without foundation. Nonetheless, it still exerts powerful influences: Unaided by adequate analgesics, children are typically restrained to get through any painful procedures as fast as possible. Unfortunately, clinicians who understand how to treat pain in children and who can help them to cope with pain are not ordinarily available in clinics to provide intervention for children undergoing painful medical procedures. Unless such a professional is part of the treating team and integral to the child’s care, referral to a mental health professional for acute pain management is typically made only in those circumstances where either the parent insists or the child is so uncooperative that the procedure cannot be performed.

Concern about added cost is typically given as the reason for delayed referral in cases where problems were apparent long before the referral. However, with the development of pain management services carried out by departments of anesthesiology, such children are now often referred to anesthesiologists, who provide general anesthesia for painful procedures. Anesthesia costs far exceed those of psychological intervention and may not be the best mode of pain treatment for every distressed child.

Another misconception related to the undertreatment of pain is that if children, especially adolescents, receive opiates, they will become addicted. This view promotes a treatment strategy that revolves around trying to use as little narcotic analgesic medication as possible. This approach is based on ill-conceived fear of medications, rather than evidence.

Many clinicians confuse the physiological, psychological, and social phenomena associated with drug tolerance, addiction, and drug-seeking behavior. Tolerance is an increasing need for higher doses to obtain the same effect. This is a purely physiological phenomenon. Addiction, a more complex phenomenon, is the experience of craving a substance. Drug-seeking behavior may result from tolerance, addiction, or of inadequate treatment of pain.

All of us, when we are in pain, manifest drug-seeking behavior, searching for a bottle of analgesics in our medicine cabinet. One may generally expect a relationship between intensity of pain and intensity of drug-seeking behavior, but this is not always the case. It is easy for us to become confused when our judgment is impaired by a suspicion that a patient’s requests for pain medication are not a reflection of the patient’s pain. At these times, we infer that the drug-seeking behavior is not motivated by pain but by a wish to enjoy the pleasurable qualities of opioids. This issue is full of emotional, ethical, and legal questions that cause us to have passionate, though not always rational, opinions. The topic deserves a fuller exploration than we are presently devoting to it.

There is no evidence that providing opiods to children for adequate pain relief results in addiction. On the contrary, there is evidence that pain, if left untreated, may result in a significant psychological and physiological burden.

In many respects, the differences between treating children and adults are quite obvious. Yet, it may be helpful to review some of these differences briefly in order to be mindful of children’s special needs.

As Erik Erikson (1968) has pointed out, children and their adult caregivers pass through a lifelong series of developmental challenges. Young children need to feel secure in their world. They need to depend on and trust their caregivers. By doing so, children learn that their physical and social environment is safe and secure enough to permit exploration. Without this basis, children have difficulty moving on to subsequent challenges that involve the development of competence and a greater maturity in relationships and action.

Pain or a major painful illness or trauma can pose a major threat to a successful passage through these early developmental stages, impeding the development of self-esteem, intimacy, and self-efficacy. Fortunately, close support from parents and clinicians can safeguard the child, so pain, if treated appropriately, may become ultimately a source of strength rather than a handicap.

Adolescents, ironically, often need this close support, even while they may reject it in their struggle to develop independence and mastery over life challenges. Indeed, adolescents in pain are particularly notorious for expressing anger and confusion. Helping an adolescent in pain is not difficult if the clinician respects the naturalness of the adolescent’s behavior—and the inevitable conflict between needs for autonomy and for dependence on reassuring adults. Adolescents often frustrate us because they seem unpredictable regarding their needs from one day to another—and because they confront us with our own unresolved conflicts. Yet, these apparently contradictory needs are not, after all, very different from what we need as adults. In an acute crisis, we need and hope for a style of care that is relatively directive and parental; when the clinical problem becomes more chronic, we want to be more in charge of our destiny. We prefer in this case a clinician who encourages our autonomy, a clinician who acts more as a consultant, who helps us identify a series of alternatives from which we will choose. This shift in paradigm from “acute pain/directive, comforting treatment”—to “chronic pain/consultant clinician” is one that generally works as well with adults as it does with children and adolescents (LeBaron, Reyher, & Stack, 1985).

Clinicians can generally assume that the model described above is a good place to start. But we need to remember that adolescents, whether in acute or chronic pain, may momentarily resist. The physical threat at a given moment may mobilize a strong counterreaction in the adolescent. The attempt to maintain autonomy may take the form of withdrawal, sarcasm, rage, tears, or rejection of all help, including any medical treatment. The clinician who feels frustrated or at a loss in this situation needs to remember that no clinical situation is fixed and static. The clinical dilemma is more like a dance: one step back, one to the side, two forward, pause, and begin again. It is our challenge to find ways to offer both comfort and gentle reassurance to that part of the adolescent that is a frightened four-year-old and respect the adolescent’s need to step back before moving closer again.

Effective pain intervention occurs within a context of recognizing varying developmental, emotional, and cognitive needs. Imagery techniques singularly utilize the child’s developmental level. Images are often invoked to assist with systematic desensitization, relaxation, or hypnosis. Although hypnotic techniques for children often make use of imagery, the two are not at all the same. If one looks at the hypnotic experience as a sort of intense involvement in thoughts, ideas, images, or actions that results in a dissociative state, this helps to explain the great diversity of “hypnotic” phenomena in children. Whether we are physically playing with a child, asking her to imagine a scene, or telling a story that blends action and fantasy, we are implicitly inviting (and assisting) the child to dissociate from a “reality” orientation.

Thus, “hypnosis” with children two or three years old is more likely to utilize an object such as a stuffed animal or soap bubbles floating in the air (Kuttner, Bowman, & Teasdale, 1988), whereas children four to six years old have a greater capacity for active “make believe,” without props. Older children are more likely to enjoy internal images and dramas. This transition from involvement with external objects, to make-believe play, to the internal elaboration of diverse images depends on increasing cognitive and social maturity (Hilgard & LeBaron, 1984; LeBaron, Zeltzer & Fanurik, 1989). Our choice of intervention, then, must accommodate these natural variations, described more specifically below.

Between the ages of one to about two or three years old, children can be observed spending hours imitating parents, each other, and characters from stories and TV programs. At times, the two-year-old may repeat the same scene over and over, every detail and nuance present in each repetition. This slavish insistence on repetition both amuses and frustrates the parent who reads the same bedtime story to his two-year-old for the hundredth time, while the child seems as entranced as if it were the first time. When the parent attempts an ad lib variation on the story, hoping to make it more interesting, the child insists indignantly, “But that’s not the way the story goes!” Clearly, the child obtains satisfaction and pleasure from the faithful repetition of details, some of which will probably be replicated in play the next day. The child this age typically has little interest in elaboration and embellishment of familiar storylines, since he does not yet have the ability to focus attention on internalized images or to develop these images into a storyline or a fantasy.

Favorite and familiar objects become important props for this imitative play. Children want to imitate a parent sweeping a floor, hammering a nail or washing dishes. So they seek a broom, a hammer, some dishes, or objects that are a close facsimile.

Psychological interventions designed to reduce pain or anxiety of a child this age make use of objects such as picture books, toys, stuffed animals, soap bubbles—all designed to involve the child in a more pleasant experience. A suggestion that this child imagine (rather than play with) an object or a scene is much more difficult and less engaging for the child.

Gradually, pretend play becomes less dependent on objects and begins to include concepts and roles. This play is also characterized by its social qualities. Whereas the younger child is the producer, director, and star of her own show, the five-year-old wants to include playmates. There is discussion and negotiation about the roles and lines that each character will speak. These are often rehearsed and elaborated and may evolve as the play continues. Props are still an important part of this play, but there is clearly an ability to include sustained imaginative sequences, with little or no external props. Sociodramatic play represents a transition from the earlier form of play with its total dependence on external objects to the complete representation of images and events in one’s imagination—the development of a rich and varied fantasy life.

In contrast to younger children, who have much greater difficulty projecting an idea of their behavior into the future, children four to five years old can benefit from play therapy to help rehearse new ways of coping with difficult situations. Unlike older children, the four-year-old child may be unable (or is only beginning) to describe conceptually the relation between rehearsing a behavior and its application to a future situation, but the learning of new behavior and development of enhanced confidence can occur nevertheless.

In both the early action play with objects and the subsequent sociodramatic play, the imagined events are acted out overtly. As children pass through the early years of school, they learn to restrict and control their overt behavior. Understandably, an adaptive way of coping with these physical restrictions is to imagine “What if … ?” At the same time, there is a rapid growth in the ability to hold concepts and images in the child’s mind. These abilities are readily observed in the child’s ability to consider past events, to develop hypotheses about future events, or even to consider events that are improbable—all completely on a cognitive level.

At this stage of maturity, children (as well as adolescents and adults) can benefit from physically rehearsing events, but they have the additional benefit of complex imaginary rehearsal—fantasizing—that may include imagined overt behavior, imagined emotions, and alternate behaviors of both self and others. You will find a more complete discussion of the developmental view of fantasy in Singer (1973) and J. Hilgard and LeBaron (1984).

Traditionally, hypnotic phenomena have been thought to include relaxation, focused attention, suggestion, and responses that are subjectively perceived by the patient as some combination of somatic, cognitive, and emotional experience. These are characteristic of the immediate associations that most of us have to the idea of hypnosis, in the same way that many of us associate the idea of meditation with sitting motionless, breathing deeply, and remaining very quiet. However, just as there are active forms of meditation that teach the student to meditate while going on with activities of daily life, so, too, there are forms of hypnotic experience that involve hetero- or self-suggestion while remaining alert and active.

When working with children, it is particularly important to understand that, while the concept of giving suggestions and guiding the patient’s attention appears to be useful regardless of age, the techniques for accomplishing that goal differ in important ways depending on age.

We adults are proud of our critical abilities. We value independent thinking. These are among the qualities that seem to help us achieve success in adult life. Thus, it is often difficult to suspend those treasured qualities and experience what (initially at least) feels like a passive, dependent mode of behavior, with another person directing our attention and physical behavior.

It is difficult, when in a critical frame of mind, to so intensely imagine having a bag of ice on a sore joint that both the idea and the image become real and compelling. But if we are first invited to sit quietly in a soft chair, to breathe deeply, to relax, to let go of our cares and concerns, to pay attention to the therapist’s voice, etc., then we may be able—temporarily—to suspend our usual level of critical evaluation. Then, the ice bag has a chance to become more real to us.

It is clear to us, as we enter into this interaction with the clinician, that our suspension of critical evaluation is not only temporary but also conditional. The implication is, “I will agree to not be critical of what you say as long as it doesn’t violate our social contract.” In other words, we understand that the interaction is intended to be safe, respectful, interesting, and helpful in some way. Paradoxically, then, we are not really agreeing to suspend our critical faculties entirely. Rather, we are agreeing that our critical faculties will be sent off to “patrol the perimeter”—to keep us safe—while letting us have a good (and/or therapeutic) time.

In most instances, all of this appears to happen easily; yet, it’s so complicated! It’s no wonder that we adults have a more compelling and interesting reaction to suggestion when we undergo a settling in period of a few minutes referred to in hypnosis jargon as an “induction.” During this time, the instructions to relax, close our eyes, focus on the clinician’s voice, and so on, provide just the transition many of us need. This process also provides a psychological transition for us as clinicians as we move from an everyday conversational tone of voice to one that is more dramatic, intense, or in various other ways more compelling to ourselves and to our patients.

What about children? Do they need an “induction” to make a transition from a critical mode of thinking to a more make-believe orientation? As any observer of children knows, they’re already there, ready for fantasy, much of the time. As any parent and teacher knows, the more common challenge is how to get children from the land of make-believe back to our adult version of reality. With this in mind, the idea of an adult-style “induction” as a prelude to using imagery and suggestion in children seems redundant.

Observation of children at play and in conversation gives some clues about what’s needed:

Four-year-old Kevin, sitting on his mother’s lap: “I don’t want a shot! It’s going to hurt!”

Mother: “Oh, look! This story is about a baby elephant! What do you think he does when he bumps his nose on a tree?”

Mother: “He thought he was going to cry, but instead the mommy elephant gave the baby elephant a kiss on the nose, and he felt all better.”

Children at play consciously establish necessary rules for their drama in somewhat the same way that some movies begin with a spoken or printed introduction, to “set the stage.” Once the dramatic flow begins, however, the action can acquire a sense of reality, and the distinction between reality and make-believe may become blurred. The following example illustrates this transition:

Allison, six years old to her friends: “Let’s play school. I’ll be the teacher, and you be the students.…”

Later, Mom comes in the room and observes their play: “Are you pretending to be their teacher, dear?”

Mario, nine years old, walks slowly, with a limp: “Hey, wait for me, Steve! My ankle hurts.”

Mario: “My dad said I sprained it last week when we were up in the mountains.”

Steve: “Hey, I know! Let’s say we’re in the army. You got your foot shot!”

From observation of children, we can notice that the need for an induction (that is, for a process that assists the transition to an easy involvement in fantasy) develops as the child’s critical reasoning abilities become stronger. This usually occurs somewhere between nine to twelve years of age. Prior to that time, children at play do not stop to “induce a trance.” They just begin to play. To be more precise, they just begin to play after a brief explanation to themselves or others of what the premise of the drama will be: “Let’s play house.” “Let’s play with our dolls.” “Let’s be cops and robbers. I’ll shoot you and just before you die, you’ll shoot me.” And so on.

In addition to appreciating the child’s developmental stage of imagination and hypnotic ability, in order to treat children in pain it is crucial to assess their degree of suffering. This assessment helps us to determine a baseline of behavior and experience, as well as to predict the eventual effectiveness of treatment. It is often difficult to obtain a report of pain directly from the child. For example, self-reports of pain are impossible for the infant and preverbal young child. For young children, therefore, assessment is based on observation of behavior, such as whimpering, crying, and so on. Even for older children, the evaluation can be difficult, since the same word to describe pain may have a different meaning for the child than for the adult. For example, during one intervention, the image and sensation of cold air from an air conditioner were used to help 11-year-old Lloyd with a bone marrow aspiration. It was suggested that the sensation of cold air would make the skin on the hip feel numb. When Lloyd was asked how the imagined air conditioner had helped him, he replied that it “nauseated his hip” so that he was not bothered by the needle. When asked whether Lloyd meant that the air conditioner anesthetized or numbed his hip, he replied “Yeah!” Typically, when children are asked to describe their pain, they reply, “It just hurts!” Further differentiation between a “little hurt” and a “big hurt” often presents a challenge.

It is much easier to obtain a useful assessment of pain if the clinician practices careful observation. In situations where a child is unlikely to provide a rating or description of his or her own pain, we must rely entirely on observation. This presents some interesting challenges. For example, how can we differentiate between behaviors that represent anxiety and those signaling pain? During acute pain, the child’s behavior often represents a combination of anxiety and pain, commonly labeled as “distress.” Withdrawn behavior in the child with long-standing pain may represent a combination of pain and depression, with either factor predominating.

Additionally, there are individual, developmental, familial, and cultural differences in pain expression. Some children tend to be very expressive when in pain, while others tend to suffer in silence. Older children and adolescents, who have learned more cognitive coping strategies, tend to be less vocally demonstrative when in pain. However, we still look for age-appropriate body language, such as muscle rigidity, sweating, or clenching of fist or jaw, which may represent attempts to cope with anxiety and/or pain.

Families tend to create implicit and explicit rules for their children of what constitutes appropriate behaviors to display in public, including pain-related behavior. A common example is the father or mother who admonishes the 10-year-old boy, “Stop crying! You’re not a girl!”

Some medical conditions present particular challenges for the assessment of associated pain. For example, with recurring or long-lasting pain related to illnesses such as arthritis or bone cancer, caregivers often require “proof” that a child’s continued pain complaints are justified. Unfortunately, one still hears caregivers ask, “Is this child’s pain real?” The ability of a child momentarily to divert attention to a game, movie, or television but then complain of pain as a caregiver enters the room is sometimes mistakenly interpreted as evidence that the pain is either bogus or exaggerated. This behavior is typically labeled as “attention-getting” (for the younger child), “drug-seeking behavior” (for the adolescent), or simply “manipulative.” In any case, since this behavior is seen as an unpleasant characteristic of the child, “limit-setting” is often the clinical response, rather than a thoughtful reevaluation of the meaning behind the child’s behavior.

Pain specialists are often made to feel “ancillary” and therefore somewhat unimportant. This is unfortunate, because many pain problems are treated more effectively with a psychological intervention than with a medical one. It is essential for physicians, psychologists, social workers, nurses, psychiatrists—all who treat the child—to communicate and collaborate as part of the team. It is equally important for the child to recognize that these caregivers function effectively as members of a team, all with equal status, but with different roles.

In the case of an acute pain situation such as a medical procedure, the concept of a team is more difficult to achieve, because the physician is rightly perceived as having the greatest power by virtue of the ability to inflict pain (e.g., by using a needle) or to relieve pain (e.g., by administering a medication). Therefore, in the acute pain situation the patient will typically focus more attention on the physician. This focus of attention may be a source of anxiety (if the physician is perceived as one who is about to inflict pain, for example) or of relief and comfort, or an ambivalent mixture of both.

Therefore, it is very helpful if the treating physician and the pain specialist, as well as the nurse and other providers, can discuss their preferred styles of handling various challenges that arise in the acute pain situation. While working with the child, each can give information and instructions to the child, and refer to each other by name, as a way of demonstrating equal status and authority as they work in partnership to help the child. This will instill confidence in the child that it is OK to shift the focus of attention from the physician to the colleague who is interacting with the child.

Attitudes and practices in the medical environment often minimize the importance of parents. Often, they seem to be tolerated, as if they were present only because of their biological or legal status with the child. This is unfortunate, because parents are usually welcome and helpful allies in understanding and treating their children. Parents spontaneously treat their children’s pain in ways that are well-known across many cultures: with a kiss, a hug, a song, a distracting joke or story, and with reassurance. Yet, in the presence of physicians, nurses, and other clinicians in the medical setting, they frequently stand back, both literally and figuratively, out of deference to what they may perceive as a greater power. Through our words and our behavior, we need to invite the parents to act as members of a team that will create a circle of concern and knowledge around the child.

The primary goal of psychological intervention for pain control is to decrease suffering and enhance the child’s feeling of security and comfort. In addition, clinicians and parents need to help the child develop successful coping strategies.¹ Coping is a self-regulatory process serving the basic motive of control over oneself and one’s world. “Successful coping” occurs when children’s appraisal in anticipation of an event (anticipatory coping) and during the event (encounter coping) results in an experience of mastery or accomplishment. Obviously, children facing the same pain event will differ in their coping abilities, as well as in their perception of the situation, for a number of reasons, including past experiences, age, and temperament.

Hilgard and LeBaron (1984) described a variety of self-directed coping techniques developed by children and adolescents who underwent repeated painful medical procedures. These techniques included physical as well as cognitive behaviors.

Martin was a sociable, bright boy who initially experienced a great deal of pain during bone marrow aspirations. Like many children, he soon developed a great anticipatory anxiety to these repeated traumas.

Martin complained to his father about the anxiety and the pain. His was a family with a strong Christian tradition, so the father suggested that Martin try to relax by reciting Psalm 23 to himself. In fact, his father told him that if he would do this, the bone marrow aspiration would not hurt. Fortunately, this suggestion was very effective.

Following his father’s suggestion, Martin was able to remain relaxed and calm throughout subsequent procedures. His description of the pain suggested it was now greatly diminished. He was quite enthusiastic about the improvement. He said that as long as he kept his mind on Psalm 23, there was no pain. When asked to describe his experience, he said, “It’s like going to sleep, but you don’t close your eyes.”

Dan surprised his nurses and physicians by the unusually low level of anxiety and pain that he seemed to experience during most of his bone marrow aspirations. He appeared relaxed and good-humored during these procedures. He often engaged in an active banter with the nurses. Apparently, he had independently learned these very effective ways of managing his distress.

When asked to describe what helped him cope, he replied that conversations (with the staff) as well as deep breathing kept his mind busy. He added that, when the nurse and doctor did not talk, he kept his mind busy by imagining he was back in Idaho, swimming with his grandpa.

Edward was a large, husky boy. He had been diagnosed with leukemia three years previously. He was observed to be completely relaxed and calm during preparations for a bone marrow aspiration. His feet dangled off one end of the table because he was so tall. As the female physician (who was rather small) was about to insert the bone marrow needle, Edward said in an ironic tone, “Dig in.” Later, as she was pushing hard to get through the bone, he continued to tease her: “You’re getting some exercise!”

During an interview afterwards, Edward described some of the techniques he had learned: “On [the television show] ‘Emergency’ they rescue people, take people to hospitals, and they’ve got some comedy there. I think about the comedy of it … I’m related to the movie. I’m actually a part of it. Today I was thinking about the old man who is always complaining of something. The doctors know it’s a fake. First day it’s his back, the next day it’s his leg. Next day he thinks he’s having a heart attack. I seemed to be really there. I was a part of it.”

The first few bone marrow aspirations had been very painful for Edward, but when he discovered that becoming a part of the TV program diminished his pain, he continued with that technique. In an interview focused on how Edward’s past experiences may have predisposed him to his self-directed intervention, he described some prior encounters with pain. At age eight, he had cut his hand on a plate glass window and required 20 stitches. He had enjoyed playing Monopoly with his mother and found that, during suturing, playing the game in his mind took him away from the pain. Later, when a toenail was removed, Edward made the pain “disappear” by concentrating on an image and sensation of ice around the toe and telling himself that the toe was too cold to feel anything.

These children’s capacity for self-directed coping is impressive. We can learn much from them in our efforts to help other children develop coping strategies.

Some attention has been paid to tailoring interventions to children’s individual coping styles. For example, in a laboratory investigation of pain in children (LeBaron, Zeltzer, & Fanurik, 1989; Fanurik, Zeltzer, Roberts, & Blount, 1993), children whose natural coping style was to focus their attention away from the acute pain (“distractors”) developed significantly higher pain tolerance than other children when provided with a brief hypnotic intervention. Conversely, pain tolerance in these same children was dramatically reduced when a sensory monitoring intervention was administered in which they were helped to focus their attention on the nonpainful aspects of the sensory experience. However, neither type of intervention significantly improved pain control for children who naturally focused their attention on the sensory stimulus (“attenders”). Interestingly, though, those children who were exposed to the hypnotic intervention, regardless of coping style, were more likely to use distraction when exposed to the same laboratory pain paradigm two years later (Fanurik, Mizell, & Zeltzer, unpublished manuscript).

This concept of goodness-of-fit between the child’s coping style and psychological intervention becomes more complicated when considering parental coping style and needs as well (Blount, Corbin, Sturges, et al., 1989). Providing psychological intervention for children in pain must take into account qualities of the child’s family, especially of the parents. For example, Schechter, Bernstein, Beck, et al. (1991) found that parents’ predictions of their child’s distress during a medical procedure were significantly correlated with the actual distress of their children. This suggests to us that parents play a significant role in teaching children not only how to behave but also how to experience pain. Understanding the parents’ perceptions, then, often helps us to better understand the child’s perceptions.

There are other considerations when providing interventions for children in pain. The amount of adequate sleep can play a key role in the efficacy of the intervention. Children with sleep deprivation tend to become more irritable and are less able to cope with daily hassles. They are certainly less able to cope with a significant pain event. When children have somatic symptoms, such as pain, itching, nausea, or vomiting, their sleep may be disrupted.

Hospitalization can disrupt children’s sleep because of unfamiliarity of surroundings, repetitive sleep disruption related to medical monitoring or nearby noise from other children, or fear. If they have been exposed to multiple pain experiences, these children tend to be hypervigilant, fearfully anticipating the next pain event. Such sleep disruption can substantially attenuate a child’s ability to cope with pain and anxiety.

Also, most sedating agents, such as benzodiazepines (e.g., lorazepam), reduce amounts of both REM and stage III-IV sleep (deeper, restorative sleep). Thus, by making the child appear more “sleepy” (but not providing restorative sleep), such agents may serve to falsely reassure the care-provider or parent of the child’s good sleep, while doing little to benefit the child. Psychological interventions, especially for the hospitalized child or for the child with long-standing pain, may be most effective if they are also aimed at facilitating restorative sleep.

Previous unpleasant experiences with pain can lead to anticipatory anxiety in future similar situations (e.g., medical procedures). Unsuccessful coping attempts can lead to decreased self-confidence, poor perception of coping abilities, and negative expectations for coping with future procedures. Conversely, successful use of coping skills can contribute to feelings of mastery and confidence. For these reasons, the Consensus Conference on the Treatment of Cancer Pain in Children (Zeltzer, Altman, Kohen et al., 1990) has recommended adequate pharmacologic intervention for the first invasive medical procedure for the newly diagnosed child with cancer and psychological interventions for all other procedures after the staff has more time to get to know the child and family. Pharmacologic pain control strategies for later procedures can be used more selectively.

Efficacy of interventions should be assessed frequently with behavioral and self-report data and, in the medical setting, with psychological measures as well. In the hospital, optimal communication with the child’s medical team can be facilitated if the pain specialist makes a note in the patient’s medical record regarding the decision leading to a particular type of intervention and the results of that intervention. Interventions should be flexible in approach, based on changing situations and children’s needs and abilities.

The mental health professional who is called to a treatment room to “Do something!” to calm a screaming, flailing child must have realistic expectations. Although the staff may expect the therapist to “hypnotize” the child, who would then be expected (unrealistically) to act as if he or she had just received a general anesthetic, the clinician often can do no more than assess the child and situation (which may, in fact, be sufficient). Actually, this calm, objective observation may be quite useful in designing subsequent practice, desensitization, and support.

Ultimately, the goal of intervention is to offer comfort, during a procedure, and to help the child cope, rather than to get the child to “behave” while suffering silently (Bush & Harkins, 1991; McGrath, 1990).

The treatment of pain with techniques such as sensory-cognitive preparation, distraction, relaxation, and hypnosis have been described elsewhere (J. Hilgard & LeBaron, 1982, 1984; Katz, Kellerman, & Ellenberg, 1987; Kellerman, Zeltzer, Ellenberg, & Dash, 1983; Kuttner et al., 1988; Olness, 1981; Siegel & Peterson, 1981; Zeltzer & LeBaron, 1982).

Psychological intervention “packages,” which include a combination of breathing, imagery, rehearsal, and modeling, have demonstrated efficacy (Jay, Elliott, Ozolins et al., 1985). Distraction techniques that involve competitive sensory input (e.g., music, video games) may be sufficient for some children to help them to cope with medical procedures. However, if a child is extremely anxious, or the procedure is very painful or invasive, then the child may require intensive pharmacologic intervention. Of course, psychological and pharmacological interventions are not mutually exclusive. Such children should be offered psychological therapies for their pain experiences as well, especially if they are highly anxious.

There are a number of common psychological interventions for pain control, which are outlined here. The reader interested in greater detail is referred to Berde, Ablin, Glazer, Miser, et al. (1990); Hilgard and LeBaron (1984); Olness and Gardner (1988); Kuttner, Bowman, and Teasdale (1988); Zeltzer (1994); Zeltzer, Anderson, and Schechter (1990); Zeltzer, Jay, and Fisher (1989); Zeltzer and LeBaron (1986).

Preparation typically involves providing mechanical and sensory information. Information can shape cognitive expectations, thus increasing a sense of control over the pain event (Ludwick-Rosenthal & Neufeld, 1988; Routh & Sanfilippo, 1991). How much information to provide depends especially on the child’s developmental status, level of anxiety, perceived control, and coping style.

Desensitization is particularly helpful for children experiencing anticipatory distress. The child may be gradually exposed to the impending stimulus with imagery and/or doll play and may practice with a mock procedure. Modeling and rehearsal through use of videos, dolls, or other techniques can help children visualize the procedure they will undergo. Videotapes for parents can teach them coping skills that they can demonstrate to their children or use themselves. Positive self-statements (e.g., “I know what to do,” “I’ve done this before”) can be combined with thought-stopping and positive reinforcement to encourage feelings of self-efficacy.

Distraction techniques, such as counting or blowing bubbles, are particularly helpful for children who have difficulty focusing on imagery. Hypnosis, imagery, and other forms of imaginative involvement enable dissociation from an unpleasant experience, while maintaining continued attention on a pleasant one. Suggestion is also often used to help “reframe” or redefine the sensory experience, to render it more tolerable.

The following examples demonstrate the use of various psychological interventions, including hypnotic treatment. For further reading on child hypnotic treatment, readers are referred to Barber and Adrian (1982); Olness and Gardner (1988); J. Hilgard and LeBaron (1982); Zeltzer and LeBaron (1986). We emphasize that hypnotic treatment is not merely a technique to be applied to all children in pain; nor is a child who has received one type of intervention destined to continue to receive that same intervention indefinitely. Children’s individual needs and the particular type of pain situation guide both initial interventions and later shifts in approach.

Johnny was brought to the treatment room in the hospital to undergo a bone marrow biopsy as part of his evaluation for a suspected diagnosis of leukemia. His nurse carried him with his connected IV line, crying and struggling, to the treatment room, with his parents following. Once in the treatment room, he was allowed to sit on his father’s lap while the staff awaited both the physician and the pain specialist, who was to provide sedation. During the next ten minutes, Johnny screamed and struggled, while his tearful father held him. When I (LZ) entered the room, the nurse appeared stressed, Johnny was screaming, and his father was crying.

The first thing I did was to acknowledge the father, approach Johnny, and exclaim, “Johnny! One of your noses just landed on your dad’s arm! Look!” Johnny (as well as his father) seemed bewildered and immediately stopped crying, looking intently at his father’s arm. Crouching down at the boy’s level, I then said, “Oh, look! There’s another nose on your knee!” Johnny, still confused, looked at his knee. After I pointed to another “nose” on dad’s other arm, Johnny began to smile. I began pointing out and counting still more “noses,” as Johnny chuckled. During this time, I directed the nurse to begin administering midazolam (a short-acting sedative) into Johnny’s intravenous line. As the play behavior continued, monitoring leads for EKG and pulse oximeter were placed and Johnny was then administered propofol, an intravenous anesthetic. As he became unconscious, he was gently laid on the table. The father was offered the option of waiting outside the treatment room, where he would be informed when the procedure was completed, so that he could reenter the room before Johnny awoke.

The above case might have begun less traumatically for all if a mental health specialist had initiated some general approaches for nursing when confronted with Johnny’s first medical procedure. For example, the play intervention could have been initiated in Johnny’s hospital room, and the father, rather than the nurse, could have carried Johnny to the treatment room. There was an underlying assumption that since Johnny was to receive sedation/anesthesia for the procedure, he did not require any prior “psychological” intervention. Everyone simply waited for the pain specialist to bring the “magic drugs,” rather than engaging Johnny in play behavior intended to capture his attention by appealing to his curiosity—and preventing the trauma.

Bewilderment can be a benign “attention-grabber,” because a child’s natural curiosity can often override extreme anxiety and help focus the child’s attention on something other than the impending expected pain. If the bewilderment is maintained, the child’s attention focuses on trying to understand what is happening, rather than catastrophizing. With a young child, soap bubbles unexpectedly blown by the child as he exhales can also serve to maintain focus of attention, especially if these become incorporated into the fantasy.

Johnny’s case illustrates the efficacy of combining psychological and pharmacologic interventions, and demonstrates that even the use of anesthesia does not obviate the need for a psychological approach to pain management.

Sally had been fearful of the repeated bone marrow aspirations that she must undergo as part of her cancer treatment. Her previous experiences involved being physically restrained while she screamed and struggled. After each procedure, she remained silent and withdrawn. Her mother described her increasingly difficult experiences of bringing Sally to the clinic on procedure days, including one day in which Sally ran out of the clinic and into the hospital parking lot, refusing to reenter the clinic. After that episode, her mother avoided informing Sally in advance of a procedure.

However, after the first “unexpected” procedure, Sally refused to come to the clinic at any time. After Sally’s mother reported that she had great difficulty getting Sally to come to the clinic for any more treatments, I (LZ) was asked to see Sally. I met with Sally and her mother on a non-procedure day and learned that Sally had an excellent imagination. She described in detail how the “bone arrow” crunched through her bones and how she could feel it “sucking out her marrow.” She said she felt helpless and could not stop thinking about the pain of the procedure and “how awful it will be.”

I then learned that Sally loved to swim in the ocean and “ride the waves.” When I asked her to describe riding the waves, she was able to do so in great detail (with helpful prompting), as if she were there experiencing it. Questions about the feel of the water, the taste of the salt, and the wind on her face helped her to become increasingly involved in this imaginary experience.

Because of Sally’s extreme conditioned anticipatory anxiety related to procedures, I arranged two more sessions, during which we went on an imaginary trip to the beach. While this occurred, I also asked her simultaneously to imagine undergoing the bone marrow aspiration. The next step was to imagine being at the beach again while I simulated some of the fearful steps of the procedure, such as washing her skin with alcohol, creating a pinching sensation and a pressure sensation to simulate the pressure of the needle against her bone. After each practice session, I complimented Sally about her coping abilities and her excellent imagination.

I also repeatedly mentioned that when people use the part of their brain where imagination exists, the sensations (feelings) in their body tend to feel “different,” and that it would be interesting to notice in what way her next procedure would feel “different” to Sally. I encouraged Sally to use her imagination at home in ways that felt pleasant, so “that part of her brain would get stronger.” Eventually, she might notice that “pokes” and other “medical things” that used to bother her would begin to feel different and not bother her in the same way anymore. Sally’s mother was present for all sessions and was encouraged to practice with her if Sally wanted her mother’s help.

The day of the next planned procedure, Sally and I met early to practice in the treatment room itself, with her mother’s help. With Sally’s direction, we rehearsed a bone marrow aspiration. Later, when the time for the actual procedure was announced, Sally became tearful. I reminded her that her brain had learned some new ways to change feelings in her body. Just like riding a bicycle, once she learned these new skills, they were there to help her. She was encouraged to take some slow deep breaths and picture herself blowing up a big balloon filled with helium, which she allowed to help lift her forward to the treatment room.

Once in the treatment room, Sally again began to cry, and again her mother and I helped her to become involved in an imaginary adventure involving the beach and riding the waves. As her mother worked alongside me, she became increasingly active in helping Sally to maintain imaginative involvement, while I increasingly took the role of encouraging mom to continue to help Sally in this way. Sally screamed briefly during the needle stick but immediately became involved again in her imaginative adventure, as mom introduced new surprises that helped recapture Sally’s attention during the adventure. After the procedure, everyone in the treatment room praised Sally for being so brave as she rode the ocean waves so well. Sally appeared pleased with herself and said that the procedure “wasn’t so bad.”

Sally’s case illustrates the development of anticipatory anxiety related to unsuccessful coping and the child’s understandable expectations that the pain event (the painful aspiration procedure) would necessarily overwhelm her abilities to cope with future procedures.

Earlier referral to a pain specialist might have facilitated Sally’s abilities to cope and reduced staff time by helping her to be much easier to manage. Because learned helplessness impeded effective coping, Sally required desensitization before she could practice effective coping during mock procedures, culminating in a practice session in the treatment room itself. I not only learned about her interests but helped her to utilize her own imagination to alter her situational experience. I helped Sally to have a variety of sensory experiences (touch, smell, visual, auditory) during the imaginary event and appealed to her curiosity by including surprises in the adventure. During this time, I was also modeling behavior for her mother that would help her to enhance Sally’s coping efforts. It is important to note that, although Sally cried at various points before and during the procedure, I did not respond as if we had failed. Moreover, Sally was reinforced after the procedure for her effective coping excellence and learned that she really did have substantial control over the comfort of her experience during the procedure.

It should be noted that not all children have the degree of success that Sally did. When a child continues to experience a high degree of pain and anxiety, the possibility of pharmacologic treatment should be seriously considered. In this event, it is also important to reassure the patient and the parent that this does not represent a failure on their part. It is essential that medication not be seen as a solution to problem patients, but as an important part of any child’s effective care.

Erik, the son of a prominent physician and a noted psychologist, was referred by his parents to the pain clinic after they attended a lecture by the director of the clinic about nonpharmacologic approaches to pain management. An honor student and star athlete, Erik had been evaluated and treated unsuccessfully by three different neurologists for headaches for the past three years. Radiographic studies and other tests failed to identify the cause of the headaches, and a variety of drugs had been tried.

In our first meeting, I (LZ) inquired about Erik’s pain (location, duration, timing, palliative and aggravating factors, bis own view of etiology and treatment), his family, school, hobbies, friends, and personal ambitions. Erik seemed to be a well-adjusted young man, who was basically quite happy. However, he seemed to feel very pressured toward high achievement in all spheres of his life and found it difficult to relax physically, mentally, and emotionally. Therefore, the emphasis of treatment was to teach Erik techniques for relaxation.

He was guided in progressive relaxation, focusing his attention first on his toes and then slowly moving up toward his head. I then encouraged Erik to imagine being in a place where he knew “how to feel good.” I asked him to signal with his finger when he was “there,” which he did. After a few minutes to allow him to do something “fun” and “enjoyable” there, I suggested that part of his brain could listen and learn something new, while the “rest” of him could continue to enjoy his experience of feeling good. I suggested that he “find” that part of his brain that was the “central relay station” for sensations and feelings. Various examples were provided (e.g., “like a pilot would see … different knobs and switches, and colored lights”).

Please let me know by lifting an index finger when you locate this part of your brain.… Good.… Now find the switches that control the areas of your head where your headaches are located.… Can you see them? … Good.… Now you can begin to gradually turn the knobs or move those switches to decrease the amount of signals … or electricity … or sensations that get to the brain. It might be like a traffic light changing color to keep all the traffic you don’t want from coming into the city.… As you observe this part of your brain, you can notice your brain doesn’t have to be asleep. In fact, it may feel quite active, and you may notice, perhaps ever so slightly at first, some differences in the sensations in your head.… Gradually, you can notice these new pleasant feelings replacing your headaches.

Five more weekly sessions followed, with Erik indicating that his headaches were significantly relieved. One more follow-up session took place a month after the fifth session, during which Erik reported that his headaches were gone. His parents, who came to that session with Erik, confirmed that report. A Christmas card a year later indicated that the headaches had not returned.

Erik was clearly a healthy, energetic, achievement-oriented adolescent from a high-achieving family. The pressure to achieve may have been the major cause of Erik’s headaches; no other problems emerged during the initial evaluation. Thus, a symptom-focused approach was used, with considerable success. This approach involved progressive relaxation to help Erik narrow the focus of his attention, pleasant imagery to promote a sense of enjoyment, and a suggestion to change the headaches, using “a brain central sensation station” imagery. Suggestions giving Erik permission to have time to relax and engage in enjoyable imagery—just to have fun-probably contributed to the relief of his symptoms.

While she was playing soccer, Kerrie’s chin collided with another player’s head. She was brought to my [SL] office for sutures of her split chin. When the physician entered the room, Kerrie was holding a piece of bloody gauze to her chin. As her mother described how the accident had happened, Kerrie’s eyes filled with tears.

“I hope you can get some of my special magic stitches,” I answered with a cheerful voice. “Let me take a look, and I can tell you how much fun we’ll have. Oh, that’s a beauty! This is your lucky day! You can get some of my special stitches. They’re blue! When your friends see your chin, they’re going to want stitches too.”

Kerrie seemed quite thoughtful, and she looked a little less afraid. “Will it hurt?” she asked in a fearful whisper.

I continued reframing her experience by gently whispering in Kerrie’s ear: “Ever felt what fairies feet are like? Sometimes tingle, sometimes prickle, sometimes tickle. That’s what it will be like. Hurt? Naw … I don’t think so—but if it does, you let me know, and I’ll stop.”

Kerrie had a deep, jagged laceration on her chin, which would require three small sutures. I signaled to the nurse to bring in a tray with the lidocaine syringe and suturing equipment, all covered with a towel, of course, to avoid frightening Kerrie.

“First, I’ll wash your chin with some magic soap—It feels so good, so cool, that maybe you’ll feel some tingling. Let me know if you do.”

Kerrie laid back on the treatment table with her mom at her side. I washed her chin with enthusiasm and a flourish, as if creating a work of art. “Aha! Look, Mom, what a beautiful chin!”

At the same time, I asked Kerrie if she believed in fairies. Of course she did, although she had never seen any.

“I’m going to put this magic tent over your face so you can feel fairies dance on your chin,” I said, while opening a paper sheet with a hole in the middle to create a sterile field for the suturing. “By the way, you and your mom can peek at each other under the edge of the tent.”

This way of communicating with Kerrie allowed me to continue the technical medical procedure while simultaneously attending to Kerrie’s (and Mom’s) needs for comfort and security.

With one hand, I lightly pinched the chin. “Now you can feel the fairy toes dancing across your chin.” At the same time a small amount of lidocaine was dribbled from a syringe and infused into the surrounding tissue (thus, I was not depending solely on psychological pain management, since medical management was so readily available).

All the while, Kerrie, her mother, and I chatted cheerfully about fairies, tiny giraffes, and a pet kitten, all of whom were having a picnic on Kerrie’s chin. Three sutures were then easily placed, with no discomfort to Kerrie. As she sat up afterward, Kerrie grinned. She blinked her eyes the way people do when they come out of a darkened movie theater into the sunlight. “Are we done? Do I have stitches?”

Unlike Johnny, Kerrie had no previous horrible experiences to convince her that this one would also be horrible. But she had enough information to suspect that needles (and, therefore, pain) would inevitably be part of her experience. Yet, she was willing to trust that I could help her without causing pain. She was receptive to my suggestion of “special,” “magic” stitches. Further, a tone of voice that conveyed excitement and pleasure, rather than regret, helped support the expectation of magic and wonder, rather than pain and fear.

The involvement of the child’s interest in fantasy and in comforting attention to her chin served two purposes: It provided a more pleasant focus than worrying about pain (which already existed because of the injury); and it offered a way for the child to reinterpret the sensations that she did feel. For example, if the momentary stinging that occurs as the anesthetic is injected is interpreted as “fairies’ feet dancing” or a “kitten licking my chin,” the child can perceive it as tolerable, sometimes even pleasurable. Without this reinterpretation, children are very likely to worry that the stinging is a harbinger of greater pain yet to come, and their fear and vigilance escalate quickly.

It is important to note that, although Kerrie’s case demonstrates a physician providing psychological intervention while suturing her chin, the intervention could have also been provided by a psychologist, social worker, nurse, or other professional. In that case, it is helpful for the physician and pain specialist to work together, communicating shared expectations and intentions, so that the child knows they are working in collaboration.

Alejandro came to the clinic with his older sister because he had experienced nagging headaches for several months. He was sure he had a brain tumor. He had received a thorough evaluation from a neurologist, including a CT scan. But in spite of the neurologist’s insistence that the headaches were most likely due to muscle tension, and not a tumor, the boy was not convinced. Consequently, Alejandro was referred to me for further exploration of this issue.

I [SL] reviewed the boy’s medical history and symptoms. Then I obtained a developmental and psychosocial history, including current family functioning, school performance, peer relations, and use of drugs and alcohol. My physical examination further confirmed the neurologist’s conclusion that there was no evidence of a brain lesion.

Alejandro’s family had split up about a year earlier. The father had returned to Mexico because he was unable to find steady work in the United States. The mother moved to another city 200 miles away for a better job, and Alejandro and his younger sister were to stay with an older sister, 23, who had obtained a secure and well-paying job.

The mother had promised that within a few months she would come for Alejandro and his younger sister, but as the year passed she changed her mind. She said that by the following summer she would be able to move to a larger apartment and provide better for Alejandro and his younger sister. This was a great disappointment to Alejandro. He often felt sad, and his academic performance gradually slipped from A’s and B’s to D’s and F’s. He became withdrawn and angry.

During the past Christmas, the entire family was reunited at the older sister’s apartment, including the father, who traveled from Mexico for a few days. Alejandro seemed to be his former cheerful self during the holidays. But as January and February passed, he began to complain of headaches. When June arrived, his anticipated move to be with his mother was crushed when she announced that she could not afford the larger apartment. So they would have to wait yet one more year. By the end of September, when he was seen in clinic, Alejandro was complaining of daily severe headaches.

I asked Alejandro if he could get a picture in his mind of what the tumor looked like. With little hesitation, he answered: “It’s dark red. It looks really ugly.”

“Does the tumor feel like anything? Does it have feelings in it, like happy or sad, weak or strong, angry or pleasant?”

The headaches appeared to be emotionally based, related to the disintegration of the family structure—particularly to the loss of parental contact—and to feelings of having been betrayed. After consideration of this, I said “I’m glad you came to see me. I think your headaches are serious. In fact, I agree with you. I think you do have a brain tumor, but of a different kind. The kind you have comes from feeling lonely, sad, and disappointed. I think I can help you to feel better.”

Alejandro’s eyes widened and he sat up straight in his chair. He appeared to be very, very interested. “You think you can cure my brain tumor?” he asked, with no little amazement.

“Yes. But this isn’t the kind of brain tumor that comes from cancer, so you don’t need surgery or medicine. It comes from hurt feelings, so what you need is for all of us to talk about how to help the family.”

Alejandro sat quietly, staring at me. “Now I want you to look at your tumor again, one last time,” I said. “Does it need anything else?”

Alejandro sat for a moment, eyes wide open, staring into space. He appeared to be intensely involved with the mental image of his tumor. After a while, he said, in a soft voice, “No. It doesn’t need anything more.”

There was no further visualization used. From this point on, what occurred was a series of planning sessions with Alejandro and his older sister, who was initially astounded by my approach but quite supportive nonetheless. The older sister contacted the mother by phone, and they discussed how to have more contact with the children and how to rearrange the family finances so as to support their living together again. As these discussions were occurring, Alejandro received some extra academic help from a tutor at school. His mother came to visit more often. His school work steadily improved. By Christmas, Alejandro and his younger sister were able to rejoin their mother. After the initial visit, he did not complain of another headache.

This case illustrates the importance of the clinician’s knowledge that pain symptoms do not necessarily require a medical solution. (Alejandro did not require surgery or chemotherapy to treat his “tumor.”) Alejandro’s case also illustrates that, once the clinician hypothesizes the nature of the problem, imagery and suggestion can be used in a brief, focused intervention. In this case, implicit messages were given to the patient that his tumor was the projection of his emotions. These messages eventually proved to be quite helpful.

Often, children (and adolescents even more so) find it very difficult to say “I’m afraid” or “I’m lonely.” You may ask in five different ways how the adolescent feels, and the response will be a variation of “I dunno” or “OK, I guess.” Attribution of feelings to a tumor or, in other instances, to a sore joint or to a drawing the patient might create, helps the patient project emotional feelings somatically, and thereby to express them safely. In this case, I invited Alejandro to look at his “‘tumor’ one last time”—an implicit suggestion that the “tumor” would soon disappear.

The effectiveness of this kind of intervention depends on the patient’s confidence that the clinician will truly be helpful. Fundamental to this trust was the clinician’s respectful acknowledgment of the patient’s point of view—but with the inclusion of the clinician’s own judgment. Therefore, it was crucial that I communicate my judgment (that this was an example of somatizing) in a kind and respectful way.

It is important to note that the crucial intervention in most psychological problems is not a clever or subtle suggestion or image, but, rather, respectful, competent counseling. Indeed, it is likely that a well-trained family therapist would have been successful in “curing” this boy’s “tumor” by providing appropriate family intervention and support, without using imagery at all. The use of imagery and suggestion in this case was an efficient and useful way of harnessing the energy and anxiety attached to the idea of a tumor to facilitate the basic therapeutic work that needed to occur in the family. While not a clinical necessity, it appeared to be greatly facilitative of rapid change.

J. Hilgard and LeBaron (1984) described an 18-year-old adolescent who was disabled by phantom limb pain. Tom’s left leg had been amputated following a diagnosis of a malignant bone tumor (osteosarcoma). During the year since surgery, he had been plagued by a variety of unpleasant sensations in his absent leg and foot. The least annoying of these were mild sensations of tingling and itching. More troublesome were recurrent aching sensations and painful jerking. These were severe enough to disrupt sleep as well as Tom’s activities during the day. The most bothersome sensations were severe stabbing pains—“like a thousand pins”—in the sole of his phantom foot.

Because of the frequent disruption of sleep, Tom said that he often felt tired and irritable; yet, he was very pleasant and enthusiastic about receiving some help with this problem. In fact, Tom described himself as the sort of person who loved challenges and did not like to give in to adversity. He had been a member of his high school varsity wrestling team at the time of his surgery. Since then, he had been working assiduously to get back in shape and rejoin the team. As he talked enthusiastically about returning to the team and driving his car (modified to accommodate his amputation), it seemed clear that he loved tackling difficult problems. He appeared to meet challenges in a critical, logical manner.

Clearly, Tom liked being in control. He had achieved success through effort, rather than relaxation, so he was more likely to develop confidence in our work together if we practiced muscle tension first, rather than relaxation. So I [SL] asked him to tighten all the muscles in his scalp, then his face, neck, arms, and so on, in a progressive fashion, letting each muscle group relax as we moved on to the next group … but without really emphasizing the relaxation component.

When we came to the leg muscles, Tom seemed quite intrigued with the idea of tensing the muscles of both legs. For a moment, he stared at me with a grin, as if he thought maybe I was joking. I suggested it might be easier if he first leaned back in his chair and got a picture of his left leg in his mind … imagine it reattached to his body … try to feel it reattached, moving, responsive to his brain, so he could tighten both legs, together. Once he understood what I had suggested, he sat back in his chair and closed his eyes. I waited in silence for only a few seconds.

“That was easy!” he said suddenly, opening his eyes. He grinned, like a kid who has just learned to ride his bike.

“I’m glad it was so easy,” I said. “What was it like, feeling your left leg do what you asked it to do?”

“Kinda weird! But it was great! First I wiggled my toes, then I moved my leg a little, then I tightened the muscles, then all of a sudden, both my legs felt more relaxed.”

Then I asked Tom to repeat the entire process again, but this time we would take a little longer, following the tensing of each muscle group by focusing on relaxation of those muscles before moving to the next group.

After Tom completed this process he reported that he felt very, very relaxed. Even better, he said that some annoying sensations like tingling and mild cramps in his phantom leg, which had bothered him at the beginning of the procedure, had now resolved. I suggested that, because we had reached the end of our allotted time together, we would meet again in a few days. Tom readily agreed. He said he would continue to practice the muscle exercises, because he felt they would be quite helpful.

At the beginning of the next treatment, I mentioned to Tom that mental alertness is compatible with muscle relaxation, because I wanted to reassure him that he could maintain all of the control and autonomy he needed while still practicing this relaxed state. I then asked him to pay attention to sensations in the back of his left hand. I wanted to begin exploring how well he could focus his attention on various sensations. If he could gain some control over the sensations in his hand, this skill and confidence might be applied to treating the sensations in his phantom limb.

Now pay close attention to whether you feel more warmth or coolness in your hand … or whether there is more heaviness or lightness … or perhaps you may notice some slight twitching or tingling. Whatever you notice is okay. Whatever you notice, you can experiment with it if you wish.… Try increasing or decreasing one sensation or another.… Or, if you prefer, just continue to notice what’s happening, without needing to do anything about it at all.…

After a few minutes of silence, I added the following thought, accentuated with a bit of a dramatic whisper, hoping to emphasize the importance of the message:

If you pay very, very close attention, it’s possible that you may notice something else in the middle of the tingling and all of the other feelings.… Somewhere among all those other sensations, you may notice some little empty spaces, where there are no sensations at all—little spots of numbness.

My hope was not only to emphasize the importance of this idea, but also to convey a feeling of “magic” about it—an impression given through the tone of my voice (or my whisper, in this case)—that there was an experience here that was out of the ordinary. We all enjoy drama and intrigue and readily associate them with out-of-the-ordinary, even magical experiences. My hope was that Tom would find the thought as intriguing as I did, and that he would consider it very carefully … and imaginatively.

Tom sat very still in his chair and, without my suggesting it, closed his eyes as if he were absorbed in deep concentration.

I then continued expressing some thoughts that were intended to serve two purposes: First, I wanted to emphasize the idea that he could experience some numbness in his hand; second, I wanted to put the suggestion in a context that would be relevant to his own experience:

While wrestling, you might well have suffered a bruise or a strain that you really didn’t notice until the match was over. In order to win the match, you somehow kept the pain out of your mind, so it was numb.… You enjoy adventures and interesting experiences.… What an interesting experience it could be to discover how much of the same numbness you can notice right now in the back of your hand. Why don’t you test any numbness in your hand, by pinching the back of both hands?

After Tom noticed the numbness, I encouraged him to continue to explore and practice whatever he was learning about his sensations. He continued to do all of this with his eyes closed, apparently still deeply focused on his inner experience. I suggested that he now open his eyes and refocus his attention on the surrounding environment. He promptly opened his eyes, although he looked a little dazed for a few seconds.

I asked him what the experience had been like. He described how he had allowed himself to slip easily into an extremely relaxed state, just like when he had done the muscle exercises. This had made it easier for him to concentrate on the task I had given him. He had been surprised by how relaxed, yet how alert he had felt. He found himself very attentive to each word I had said, because each word had become “very real and true” to him.

Tom reported that the numbness in the back of his hand had spread quickly from a few isolated spots to include, finally, his entire hand. He then mentioned, with great enthusiasm, that a numbness in his phantom limb had occurred without any conscious thought or effort on his part. It seemed to me that he recognized an implicit suggestion that the experience of numbness of his hand could transfer to his left leg.

During the next session, I gave Tom similar suggestions and added further that the same numbness could occur in his leg, any time he wished. This portion of the treatment was audiotaped. I then gave Tom the tape to listen to at home, to practice with if he felt the need.

At the next meeting about two weeks later, Tom described considerable reduction in all of the unpleasant sensations in his phantom leg, ranging from 50 percent to 100 percent relief. He usually experienced a complete remission of symptoms after listening to the tape recording at home. At other times, he achieved variable but very satisfactory success, just using his own suggestions.

“At times,” Tom said, “The pain doesn’t go away the way I want it to, but I’ve learned to just go with the pain now, and it doesn’t bother me as much as it used to.” An additional change was that, since Tom was no longer awakened from sleep by pain, his sleep pattern returned to normal.

An appreciation of the variation in children’s needs and preferences is essential to effective treatment. Some children appear to be inherently very interested and responsive to the use of suggestion, imagery, and fantasy to help relieve their pain. Others, although seemingly very motivated to feel comfort, simply do not respond well to these approaches.

A significant amount of this variability seems to be related to early childhood involvement in make-believe fantasies and experiences of story telling with their parents (LeBaron, Zeltzer, & Fanurik, 1989). However, other situational variables also play a very significant role in determining the child’s receptiveness. These include the child’s level of anxiety, alertness, and general feeling of well-being.

Some children present a very interesting challenge to the clinician who invites their involvement in imagery and fantasy:

Clinician: “Would you like to feel some little fairies dancing across your chin?”

Clinician: “How would you like to have Fluffy, that little kitten you were telling me about, curled up right here on you lap while we do this?

Such interactions are not infrequent, even with children who are at an age and of a predisposition to enjoy stories and fantasies about fairies, kittens, and other sympathetic creatures. Whatever the reason—because of underlying predisposition or temporary anxiety—these children simply do not find the images and make-believe offered by the kindly clinician to be at all helpful.

Here is one of many ways that you might respond to such a child (the physician is preparing to suture a laceration over the eyebrow):

Clinician: “You’re right, we can have a great time without any fairies or kittens. While Dr. Jones is fixing your eyebrow, would you prefer to know everything she’s doing, or do you want to tell me about the camping trip you just finished?”

Child: “I don’t want her to stick me with a needle! That’s going to hurt!”

Clinician: “OK, then. So let’s let Dr. Jones cover both of our faces with this sheet. I’ll put my face down here too, so we can see each other. Like a tent. Like camping.”

Physician: “Oh, you two are so lucky to go camping! Have fun! I’ll give you a phone call if there’s anything I need to tell you.”

Clinician: “Thanks, Dr. Jones! Now, Dr. Jones is just washing your eyebrow with soap. That will help it. So you went camping up in the mountains?”

Clinician: “Like this one. Like this tent that you and I are under. Except bigger.” (The clinician notices that Dr. Jones is about to infuse a local anesthetic into the eyebrow.) “When you were camping, you could have woke up in the morning … and there’s the sun coming up, shining right in your face! Kind of warm. Not hot, really … more warm, warm sun, so that you think of wearing a hat to keep it out of your eyes, then you begin to wonder if somebody’s going to do some pancakes over the campfire.… Did you have any?”

Clinician: “Would you like some pancakes for breakfast while you’re camping?”

Child: “Oh, yes! Of course! I love pancakes! But we didn’t bring any pancake mix. What are you doing? Are you going to stick me with a needle?”

Clinician: “Dr. Jones put the special medicine in your eyebrow so it would feel good while we’re camping. Right now, she’s just pressing on it with her finger. Just like when you put your hat on to keep the sun out of your eyes while you’re camping. So what would you like for breakfast?”

Clinician: “What if I had a bag of magic pancake mix right here in my pocket? Mmmm … tastes great. With maple syrup. Let’s stir it up and put some in a pan. If you have a glove to protect your hand, you could hold the frying pan. Be careful when you bend close to the fire. The heat can feel good and warm on your face in the early morning.…”

But what if, in spite of our most compassionate and creative intervention possible, the child still seems uninterested or does not benefit from our efforts? We are understandably more personally invested in our behavioral interventions than we are in the pills or ointments we recommend. This investment is an important support for the challenges of our work. This great personal investment springs from the compassion and commitment we feel toward the patient.

Yet we will inevitably have the experience, repeated again and again, of children who do not benefit from our intervention as much as we hope. We may feel inadequate, and even angry at these children for frustrating our good intentions. Or, rather than blaming the children, we might blame the parents, the physician, or ourselves. But what we imagine to be a “failure” may be, in a larger context, more successfully comforting to the patient than we realize. Whatever else is the case, our calm and compassionate presence is a value to our patients. Our challenge is to balance our enthusiastic need to help with a calm and intelligent detachment, so that even in the greatest physical and emotional turmoil the patient and parents know they have not been abandoned: We are there, doing our best. Even as the patient tries to reject adult help, there is also a lonely hope that the adult will never leave.

There is much to learn when we help children and adolescents with pain. Sometimes we have been most helpful when we have made little use of the standard techniques. Specific techniques may be either quite powerful or quite inadequate, depending on our skill and sense of timing, as well as the child’s acceptance of those skills. When we feel the most uncertain regarding what specific techniques to use, it is often helpful to become less active, less clever—and to become quieter, calmer, and more observant. This often inspires children to bring their own clever creativity to life, knowing that we are still there, ready to receive and value them.