Hypnosis and Suggestion in the Treatment of Pain

UNTIL RECENTLY, pain was thought to be a natural concomitant of various ailments. By and large, physicians and other health-care practitioners did not treat pain in and of itself as a problem for which intervention was necessary or appropriate. Needless to say, psychological treatment for pain was not even considered.

Beginning in the 1950s, anesthesiologist John Bonica pioneered anesthetic interventions (most notably the epidural) to treat pain. Almost single-handedly, Bonica founded the International Association for the Study of Pain, the first organization to focus on the science and practice of pain treatment. In 1960, Bonica established the world’s first clinic devoted entirely to the investigation and treatment of pain, the University of Washington Pain Center. This clinic was among the first to integrate both medical and psychological evaluation and treatment. Its success was partly a result of similar pioneering work of such psychologists as Wilbert Fordyce (a colleague of Bonica) and Richard Sternbach, whose research and treatment methods led to our contemporary appreciation of the psychological dimensions of pain.

The seminal contribution of Fordyce, Fowler, Lehmann, and DeLateur (1968) demonstrated the effective rehabilitation of pain patients by behavioral methods, stimulating more interest in the substantial role to be played by psychologists in the evaluation and treatment of pain. Bonica’s recognition and support of that role, demonstrated by his inclusion of psychologists on the staff when he developed the first pain clinic, provided inspiration to a new generation of psychologists, who have now been trained in the clinical evaluation and treatment of pain. It is now accepted that the experience of pain and suffering, like the experience of pleasure, is a psychophysiological phenomenon, not a purely physiological phenomenon to be treated by purely medical approaches.

Let us briefly review the types of pain presented in Chapter 1: Acute pain is the pain that results immediately from noxious stimulation. Recurring pain results from injury or disease that produces repeated noxious stimulation over time. Chronic benign pain is distinguished from both of these by the fact that, although the patient experiences pain and suffering, this experience endures beyond the noxious stimulation itself. Psychogenic pain is one of the somatoform disorders and, among all the syndromes causing pain, is rare. (An example of this disorder is that of Nero, which I describe later in this chapter.)

When acute pain is properly treated, it tends to resolve and does not usually have enduring psychological effects. On the other hand, both recurring pain conditions and chronic benign pain syndrome produce enduring psychological effects, reflected in alterations in the patient’s mood and behavior. In part, the purpose of psychological evaluation is to uncover those effects in the patient who has suffered pain over a period of time.

A thorough and comprehensive psychological evaluation can provide information essential to understanding why some patients’ pain persists beyond normal expected healing time, as well as to the planning and implementation of successful treatment. (Turner & Romano, 1991, p. 595)

One can assume that an organic basis for pain exists or did exist, in nearly every case of chronic pain, even when current organic sources cannot be found. In any case of pain that persists over time—no matter what the nature of the pain—psychological factors tend to have significant influence on the degree of suffering and the extent of disability experienced by the patient. Except in cases of acute pain, medical treatment of the pain does not tend to ameliorate these psychological factors, and when these factors are sufficiently influential the medical treatment does not satisfactorily resolve the pain syndrome.

In recognition of these issues, it is now common for psychologists to be an integral part of the staff of most pain clinics. Additionally, psychologists in private practice are increasingly called upon to evaluate and/or treat pain patients.

One reason why physicians and psychologists refer pain patients to a multidisciplinary pain clinic is because such a clinic has greater interdisciplinary resources than private practitioners usually have, including the capacity for extensive psychological evaluation. Although it is more difficult for private practitioners to provide such psychological evaluation, it is certainly possible to do so. This chapter is intended to be a guide toward such an evaluation.

The details of how to do a complete psychological evaluation are described elsewhere (Turner & Romano, 1991); here we will focus on the principal issues of the psychological evaluation: what constitutes adequate evaluation, how it is done, and what the consequences are of adequate and inadequate evaluation.

The process of psychological evaluation reveals the extremely complex interplay between psychological variables and the patient’s experience of suffering from long-term pain. Personality variables, as always, interact with situational variables (in this case, the experience of hurting and probably some loss of participation in life’s activities) to generate what is sometimes a bewildering array of symptoms. Fortunately, the energies of researchers and clinicians who have gone before us have led to a satisfying means to clarify what might otherwise only confound us.

It is important to keep in mind that the goal of psychological evaluation of the pain patient is to identify those psychological factors that are associated with pain, suffering, and disability. For example, depression is often though not always present to some extent in pain patients. It is useful, then, to determine the extent to which the patient’s pain and suffering have resulted in that depression. Conversely, it is important to determine, for example, what aspect of a patient’s premorbid depression may be serving to exacerbate the pain, suffering, and disability. Similarly, overattentiveness to health issues is usually found in patients with pain. It is important to know if such “hypochondriasis” existed prior to the pain condition. Evaluation will identify such psychological qualities and pertinent treatment goals.

There are other psychological factors that play a powerful role in the prognosis of a pain patient; these should also be evaluated. A history of alcohol or substance abuse is associated with frustrated pain treatment. Patients with certain personality disorders (especially borderline and antisocial) have much greater difficulty achieving treatment success than others, since their goals are likely to conflict with clinicians’ goals. In elderly patients, dementia can be an important prognostic influence, because, to the extent that the patient has difficulty understanding or remembering treatment requirements, treatment gains will be especially difficult and frustrating to achieve.

An adequate evaluation also takes into account social and environmental factors. How the patient’s spouse or children or other family members cope with the patient’s symptoms is a powerful determinant of the patient’s own coping patterns. The system of monetary compensation for illness and disability that rewards what Fordyce (1976) has coined “pain behavior” further complicates the problem. Exploration of the role of such rewards is essential to understanding any patient’s pain problem.

(As an aside, it is worth noting that such variables need to be seen in context. I have evaluated patients who live in countries where the cultural expectations around disability and its compensation are different from ours. For instance, if a worker lives in a culture where it is simply assumed that pain complaints following injury should be unquestionably granted substantial monetary compensation for the rest of the worker’s life, the clinician’s options are severely limited.)

As Turner and Romano (1991) have described (and as experienced clinicians know), pain patients tend to be resistant to the prospect of psychological evaluation, believing that such evaluation implies that they are either crazy or faking their symptoms. Clearly, then, your first conversation with the patient about such evaluation needs to address the patient’s needs. The patient needs to be taken seriously, to receive compassion and sympathy for his or her suffering, and to be told that all humans—even mentally healthy ones—are affected psychologically by the experience of suffering. It can be surprisingly salutary to explain to the patient that, whatever the source of the pain and suffering, your purpose is to reduce that pain and suffering. A thorough evaluation will make that possible.

Respectful discussion with the patient of the clinical reasons for the evaluation (“to really help you as quickly and as fully as possible”) is essential. Equally crucial is your ability to listen to the patient’s fears or frustrations about evaluation, in order to better understand how to fully meet the patient’s needs.

As Fordyce (1976) and others have revealed, noxious stimulation causes pain, but the way the patient experiences and responds to that pain is substantially determined by environmental contingencies. Essential to this process is to clarify the nature of such environmental forces upon the patient. It is clear that the dynamic interplay of economic, social, familial, and personal forces tends to create pain behaviors in patients who suffer from pain. Even if a patient seems to have an exaggerated response to symptoms or seems less than enthusiastic about some aspects of rehabilitation, this does not mean that the patient is malingering, nor does it mean that the patient is intent on manipulation. It is unfortunate that the phrase “secondary gains” has come to connote manipulation or malingering. Perhaps the current usage of the term “social and financial disincentives” will help us to recognize that, as organisms capable of learning, all humans—even pain patients—are susceptible to influence by environmental contingencies. It would be a strange and unusual (and perhaps uneducable) patient who was not affected by the ways his family and friends respond to symptoms, by the prospect of monetary reward without returning to a perhaps unattractive job, or by the compassionate attention of clinicians.

When a patient does not respond well to treatment, it is easy for us to conclude that the patient is resistant to treatment or is manipulative, malingering, or otherwise cause for hostile and untherapeutic attitudes on our part. As we describe in the Afterword, the interaction between environment, patient, and treatment variables is complex and dynamic. Therapeutic failures cannot always be attributed to patient characteristics—even in patients who seem troublesome!

When a patient presents for psychological pain treatment, these basic psychological issues need evaluation:

1. Depression, including suicidality

2. Anxiety, including posttraumatic stress disorder (PTSD)

3. Mental status, especially in patients who are elderly, who have suffered head injury, or whose history includes alcohol or substance abuse

4. Pain behaviors, including reinforcers and punishers

5. Presence of ongoing substance abuse

Most evaluations begin with interviews of the patient and family members (and, if appropriate, coworkers and friends). Details of such interviews have been widely published over the years. A succinct and detailed discussion can be found in Turner and Romano (1991).

When the patient is asked specifically about the nature of the pain experience, the distinction is made between the pain’s sensory and affective components (see Chapter 5 for discussion of this issue). In most cases, it is valuable to ask the patient to keep a “pain diary” (Fordyce, 1976), which documents the level of pain, noting both sensory and affective components throughout the day. In this way, both you and the patient can become aware of antecedents and patterns in the waxing and waning of pain. It is very helpful for the patient to discover what activities or events tend to make the pain better or worse. (And it is the rare patient who can correctly identify these antecedents before using the pain diary.) Such a diary can also help a patient determine if the medications he or she is taking are effective in relieving the pain, and if so, for how long and to what extent.

We ask the patient to evaluate the sensory and affective components of the pain using either the VAS or a numerical scale, as described in Chapter 1, to determine the felt intensity and bothersomeness of the pain—at this moment, at its worst, and at its best. This assessment provides substantial information not only about the pain but also about the patient’s attitude toward it—his or her readiness to evaluate it and render it treatable. (We also learn if the patient tends to evaluate the pain in a straightforward or an exaggerated fashion. For instance, if a patient rates the intensity or the bothersomeness of the pain as “10,” we might carefully explore with the patient what it means for something to be as much as we can imagine it to be.)

The implications of the pain powerfully determine both the extent of the patient’s suffering and the patient’s readiness for treatment. Discussion with the patient and with the patient’s spouse, partner, or close family member should reveal, among other things, what the pain means (e.g., for future good functioning), what illness means, and what recovery will mean. How the patient evaluates the affective component also tells us something about the meaning of the pain.

It is essential to know what medications the patient has been taking and specifically whether the patient takes a medication that affects mood (e.g., tranquilizers, muscle relaxants, opioids). While such medications can be very beneficial in the treatment of acute pain, they can exert a maleficent influence on the course of long-term pain (Monks, 1991). There are two very important exceptions: (1) the use of analgesics for recurring pain (including but not limited to cancer pain, migraine headache, and arthritis pain) when tolerance is not an issue; and (2) the use of antidepressant medications, which can have a substantial beneficial effect on both pain and depression (Monks, 1991).

What are the likely consequences if the patient’s pain experience is changed (made better or worse)? Sometimes exploring this question will uncover a rich lode of expectations (realistic or fantastic) and attributions of life’s dissatisfactions to the pain (rather than to all of the other sources of dissatisfaction with which we are familiar). This will facilitate your understanding of how the patient may be affected, for good or ill, by a reduction in pain and suffering.

If you learn that the patient is likely to become involved in litigation concerning the pain, explore this issue carefully. Although the evidence is mixed and indicates that some patients benefit from treatment even when they are involved in litigation, I find that generally patients tend to achieve little relief from their pain and suffering if they are simultaneously working to establish a legal case that depends upon the stability of that same pain and suffering. I have encountered the occasional patient who is willing to forego litigation in favor of pain treatment; such a patient is likely to benefit from treatment. However, if the patient is not willing or able to forego litigation, it is likely that treatment will be unsuccessful and frustrating for all concerned. It has been my practice to explain this to the patient and to offer treatment after litigation has been finally settled. Frequently, patients experience substantial relief from their suffering upon the successful outcome of litigation. Fordyce has referred to this as the successful application of “the green poultice.” This does not mean that such patients did not suffer from pain; however, it does reflect the complex and powerful interaction between external reward systems and internal suffering.

There are important exceptions to my equation of litigation with treatment failure. In any case that involves litigation, I would recommend a full evaluation of this issue; unless the evaluation strongly suggests otherwise, a treatment trial may be undertaken to see if this case is an exception. It is important to keep in mind, however, that early indications of unresponsiveness to treatment may reflect the influence of the litigation.

To evaluate the patient’s attitude toward and expectations about hypnotic treatment, we ask: What does the patient expect of hypnosis? Are his or her expectations realistic? Has the patient had experience with hypnotic treatment? Was that experience satisfactory or disappointing? If the patient has a recurrent pain syndrome, is he or she prepared to use self-hypnotic methods for the foreseeable future?

Some argue that the conscientious clinician should also evaluate the patient’s hypnotic responsivity; while I believe otherwise, I find it helpful to administer the Tellegen Absorption Scale (Tellegen & Atkinson, 1974) as a way of gaining an impression of the patient’s readiness for the general experience of altered consciousness. Of course, as for any patient for whom one is considering the use of hypnotic treatment, evaluation of the appropriateness of this treatment is also indicated at the earliest opportunity; this is discussed in Chapter 5.

In addition to the interview, a minimal psychological assessment includes administration of the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Check List 90 (SCL-90), and perhaps one of the depression inventories (e.g., the Beck Depression Inventory [Beck, Ward, Mendelson et al., 1961]).

Sometimes pain patients are referred to a mental health practitioner who correctly identifies a psychiatric syndrome. However, the presence of psychiatric difficulties is not prima facie evidence that the patient’s pain is not organically based. Psychiatric patients may also sometimes suffer from chronic pain. Of course, if the syndrome is identified as a somatoform disorder or if significant depression is present (especially if the patient has a premorbid history of depression), then effective treatment may well focus on the psychiatric syndrome.

The evaluation process is often a source of dissatisfaction, even frustration, for a patient. It is unwise, however, to act hastily because the patient insists that the evaluation be curtailed and treatment begun. This can be especially challenging when the patient is suffering greatly while being asked questions that seem to have no relevance to the pain. Only after you are confident of the thoroughness of the evaluation, and after the information gained from that evaluation has been understood and integrated into a treatment model, is it likely that the subsequent treatment will benefit the patient.

It is worthwhile here to remember that, while formal evaluation takes place prior to treatment, such evaluation is never truly complete or accurate. Pretreatment evaluation cannot, of course, take into account the information available about the patient’s responses to treatment. The effective clinician is constantly making informal, often subtle evaluations throughout the course of treatment. It is the openness of this ongoing evaluation that provides for “course corrections” in the process of treatment.

Archie was a factory worker, married and the father of two young children. A mishap with a manufacturing machine very nearly took his life. He was frequently to remark, later, that he sometimes wished he had died that day, rather than suffering chronic pain and disability. At the time of this evaluation, two years post-accident, he was referred for treatment of chronic headaches (a consequence of head injury) by his neurologist.

What was remarkable about Archie’s initial interview was his lack of guile, his sweet smile, and, more to the point, the unusual degree to which he remained a passive recipient of care—jobless, almost totally sedentary, and deeply depressed (despite several trials of antidepressants).

He reported that the intensity of his pain was 10 (out of 10), but that it only bothered him 2 out of 10. Yet, despite this denial of suffering, each and every time he was asked about the possibility of increasing his activity, he replied that he was not able to because of the pain.

He received Social Security compensation, but this was sufficient only to maintain a minimal standard of living—not the comfortable life he and his family had enjoyed while he worked. He was anticipating the successful outcome of a lawsuit brought against the manufacturer of the machine that had injured him. (My interview with his wife revealed that she was far less optimistic about the likely outcome of the lawsuit; she was confident only that the attorneys “will get most of the money.”)

Archie was superficially very cooperative, yet he found it impossible to comply with even the simplest therapeutic directives. He was unwilling to maintain a pain diary, for example, because he said the pain was unvarying, so there was no point to such a diary. He was unwilling to undergo physical therapy or even to begin undertaking incremental increases in his activity level, because “my head hurts too much.” (Curiously, he also refused to take analgesic medication offered by the neurologist, because “it doesn’t help.”)

After four meetings, it was suggested to Archie that he defer treatment of his pain until his lawsuit was settled. He took this advice with the same equanimity as he did all of the other advice offered him, and he agreed to call me at the completion of litigation.

Fifteen months later, to my surprise, Archie did call. His lawsuit was settled, he said, and so he was calling, as he said he would. He had had a satisfactory resolution of the case, so that there was a substantial amount of money available to him and his family even after the attorneys’ fees were paid. Archie reported the same level of pain as he had more than a year before, but he now seemed more prepared to follow through with treatment.

A treatment plan was created that combined a variety of approaches, including a behavioral program to facilitate his increased activity, exploration of vocational opportunities, and hypnotic treatment of his pain.

Within two weeks, Archie was working out daily in a gym and was responding sufficiently well to hypnotic interventions so that the intensity of his pain showed a steady decrease to a level between 1 and 3 (out of 10).

One year later, Archie was physically more fit, continued to work out almost daily in the gym, and experienced pain intensities rarely greater than 2. More important, he was now a full-time student in the business school at the university. Over the next year, Archie continued to report that the pain no longer bothered him and successfully completed his first year at the university.

Archie’s case demonstrates the usefulness of gathering appropriate information early on to prevent frustration and, perhaps, therapeutic failure. This case also may represent confirmation of the value of applying Fordyce’s “the green poultice.” It is difficult, in this case, to distinguish between the benefit of having no further stressful litigation to cope with and the benefit of no further financial requirement for the pain and suffering.

Nero, a very pleasant man and a successful dentist well-known in the community, was referred to me by his cardiologist, who could find no organic basis for the pain that troubled Nero. For some months now, Nero had suffered increasingly from an intense, aching pain in his anterior chest wall. While his cardiologist was convinced that Nero had no heart disease, Nero was very concerned that he did, and that the chest pain warned that he was in danger of a heart attack. It was only because Nero was a somewhat obedient man, concrete in his thinking, that he accepted his cardiologist’s recommendation that he see me, since Nero believed the problem was cardiac, not psychological.

After reviewing his medical records and discussing the symptoms with Nero, I was reasonably certain that his pain was not caused by either damage to tissue or disruption of the pain transmission system—it was neither nociceptive nor pathogenic pain. Rather, his pain—or, at least, his fear about it—reflected an as yet unidentified psychological issue. Nero was most aware of the pain when he lay in bed, sometimes before falling asleep, and sometimes after awakening. The pain was of moderate intensity (varying from 4 to 6), but it was extremely worrisome to him (varying from 9 to 10), since it meant to him that he was dangerously ill.

As I continued to listen to Nero’s description of the pain, it became clear to me that Nero was desperately afraid of dying. In order to understand better what dying meant to him, I asked, “What do you believe will happen to you when you die?”

He looked at me very gravely as he paused for a moment, and then he said, “I am Catholic. When I die, I will go to Hell.”

His reply confirmed that Nero was feeling substantial guilt about something, and it was this guilt that had been converted into his experience of life-threatening pain.

Nero’s face reddened with shame. He sat silently for a moment, not looking at me any longer, and then said, very quietly, “I am a homosexual, and as a Catholic I know that is a mortal sin. When I die, I will go to Hell.”

I did not know anyone who still believed such a thing. But I wanted to understand his circumstances better, to see why he was so troubled. “Do you have a lover?” I asked.

“Yes, and we have lived together for ten years. We are both Catholic, we both know it’s wrong, and we have tried to stop being lovers. We have separated several times over the years, each time trying to stop being homosexual, but we really love each other, and we can’t stand living apart.” There were tears in Nero’s eyes as he spoke.

As I asked him more about his circumstances, I learned that Daniel, his lover, was a surgeon, that the two were devoted to each other, that they enjoyed respect in their community, where they both played active roles in civic functions. I gently asked Nero more about the details of his life. His modesty made him reluctant to talk about himself; nonetheless, it became apparent that these men contributed substantially to the benefit of their friends and community. Nothing he told me suggested that either Nero or Daniel deserved punishment, but clearly my own values were not relevant to Nero’s concerns.

I said, “You believe that God will punish you for your love affair with Daniel. I cannot tell you what God will or will not do, of course. But I have a friend, a gay Catholic priest, who may be in a better position to discuss this matter with you.”

“Well, my friend is a Jesuit priest, and he has talked with me about his sexuality, so I am convinced that there is at least one gay priest. From what my friend tells me, there are many. In any case, would you be willing to talk with him?”

Nero could barely recover from his astonishment at my words. But he agreed that I would call my friend (who was both a Jesuit priest and a psychologist), relate Nero’s story, and ask if they could meet. As he left, Nero did not look relieved; however, he did look very, very thoughtful.

Later that day I telephoned my friend Cramer, the priest-psychologist, and told him about my meeting with Nero. It was arranged that the two of them would meet.

One week later, Nero came for his appointment with me. He looked well, and he reported that he no longer had any chest pain. When I asked him about his conversation with Cramer, he smiled, saying it had been one of the most amazing conversations he’d ever had. He related their conversation, which essentially involved Cramer’s assertion that God loves people who lead homosexual lives even as he loves people who lead heterosexual lives. Cramer further told Nero that homosexual behavior was not a mortal sin.

Just as Nero’s simplicity of character had led him to accept the Church’s assertion that his behavior would lead to eternal damnation, so this same quality now led him to readily accept Cramer’s contradictory assertion. This acceptance gave him substantial relief from the guilt and shame—and growing anxiety—he had been carrying for so many years.

Nero’s case demonstrates the importance of understanding the nature of the problem before proceeding to treat it. Clearly, any attempt to directly treat the pain, hypnotically or otherwise, would have failed, since the pain was a symptom of an existential problem of profound importance to Nero. We often think of the role of a symptom as protecting a patient from change. In Nero’s case, however, the symptom was a somatization of his anxiety, the root of which was Nero’s fear of eternal damnation. His anxiety was warning him of the need for change. It turned out, of course, that he did not have to change his behavior, though he did need to reevaluate his beliefs.

Nero maintained occasional contact with me, letting me know that he continued to do well.

Lily, an attorney, suffered from pain in her elbows, wrists, and knees. She referred herself for treatment of this pain. According to Lily, this pain had become more and more intolerable over the course of the past three years. Oddly (for someone with her level of education and social awareness), she had not consulted a physician about this pain. During the initial interview it was evident to me that she was severely depressed and had apparently been so for much of her life. Subsequent review of the MMPI taken that same week confirmed my impression.

At the second visit I shared with Lily my judgment that she had an arthritic condition that needed evaluation and treatment by a physician, and that she was also depressed, a condition that might respond best to a combination of antidepressant medication and psychotherapy. With evident relief that someone was able to offer her care, she agreed to see a rheumatologist whom I recommended, to consult with a psychiatrist whom I recommended to evaluate for medication, and to begin psychotherapy with me for the purpose of treating her depression.

Three months later, Lily had already benefited from anti-inflammatory medication prescribed by the rheumatologist, to the extent that her joints were visibly less inflamed and she reported substantial relief of her pain. She was also working well with me and taking an antidepressant medication; she was significantly less depressed. I am confident that if I had simply attempted to treat Lily’s pain, I would have failed. (Even if she had not required medical attention for her arthritis, her deep depression would have presented a challenging obstacle to pain relief.)

If you undertake to treat pain, you must be sufficiently trained in the medical evaluation of pain problems that you can read a medical record and determine the nature of the problem, what tests and procedures have been done, and what the findings or results imply about whatever treatment plan you might devise. As we learned in Chapter 2, the medical evaluation of a pain complaint usually identifies the nature of the problem, but not always. When an organic basis for pain is not identified, it can be very tempting for the physician to suggest that the problem must be psychogenic. While this may be the case, we must recognize that absence of evidence is not evidence of absence: Sometimes an organic cause lurks beyond our ability to search for it. It helps to remember the ridiculous drunk in the classic joke: He preferred to look for his lost keys under the convenient (and comforting) illumination of the street lamp, although the keys had been lost elsewhere (in the inconvenient darkness). We, too, may prefer to look in “well-lighted places,” when the source of the problem may be in the unpleasant darkness.

What follows are two very different clinical examples that illustrate why it is essential for a nonmedical clinician who treats pain problems to routinely review not only psychological, but also medical, records.

Sol was a retired businessman who telephoned me, asking for an appointment to “cure my arm pain.” He lived in a distant city and had been referred by his internist. He declined referral by me to someone near him, so I made an appointment with him and arranged that his medical records be sent to me. From his description of his pain, given to me during this telephone conversation, I tentatively hypothesized that he suffered from postherpetic neuralgia. This syndrome can be very satisfactorily treated with hypnotic methods.

So it is good that I asked for his medical records. When the records arrived from his internist about a week later (a day before his scheduled appointment), I began to review them. What I read pointed to the obvious solution to his pain. Sol had begun to complain to his internist about the arm pain about three months previously. For reasons not entirely clear to me, his internist referred him to the Mayo Clinic for evaluation. In his chart was a summary letter from the physician at the Mayo Clinic, who indicated that Sol was suffering from syphilitic neuropathy and recommended a course of penicillin. Again, for reasons not entirely clear to me, there was no indication that Sol had been seen subsequently by his internist, and there was no indication that he had begun the course of penicillin treatment.

I telephoned Sol and told him it was unnecessary for him to travel the next day to see me, but that he should make an appointment with his internist, who would be able to treat his arm pain. Sol was very reluctant to take this advice, saying that his internist really wanted him to see me. I prevailed, however, and suggested that I would also speak with his internist.

Subsequent telephone conversation with his internist satisfied my wish that the Mayo Clinic physician’s recommendation would be followed by the internist. The internist indicated to me that he thought Sol was “a crock,” that he had not taken his complaint of arm pain seriously (“He’s always been strong as a horse, but he complains a lot”), and that he had thought this would be an interesting opportunity to “see what you could do with him.”

Two months later, when I telephoned Sol to follow-up, I was pleased to learn that he had been well treated and no longer had arm pain.

Fritz, a 58-year-old writer, was referred to me by his internist after an extensive medical workup, which had identified no organic basis for intense abdominal pain that had begun about four months previously. In our first discussion about his pain, Fritz described it in unusual, florid ways, thus introducing me to his customarily imaginative turn of mind. His style of relating to his pain also confirmed his internist’s view that this was psychogenic pain. He described the pain variously as “angry,” “hurt,” “lonely,” and “frightened.” Only when pressed was he likely to describe its physical attributes: “burning,” “cramping,” or qualities of physical sensations. He also told me, not once but several times in the first conversation, that he was a hypochondriac.

Fritz’s pain was relatively constant, and he rated its intensity as 9 out of 10 most of the time, with occasional ratings of 10 out of 10. His pain was least intense in the morning and worst in the middle of the night. He reported that pain medication made no difference and that the only effective remedies were taking a hot bath and playing the piano.

Fritz was wryly amused that his hypochondriac personality style had “chosen” such an excruciatingly painful symptom. His MMPI profile also indicated a hypochondriac profile. Every bit of information seemed to point in the direction of a somatoform disorder, and no information tended to contradict this. Fritz talked like a hypochondriac, acted like a hypochondriac—and no organic explanation could be found as the cause for his pain.

Assuming that Fritz’s pain was of a somatoform type and that hypnotic treatment would be beneficial in confirming this and perhaps facilitating a readiness for effective psychotherapy, I undertook hypnotic treatment. Fritz, to my surprise, experienced substantial pain relief during the treatment and for an hour or so afterward. Not surprisingly, though, the pain returned unabated, as before.

At the second treatment appointment, the next day, I initiated hypnotic treatment again. This time, however, I concurrently said to Fritz that this pain might represent some psychological difficulty and inquired about things that might be bothering him. For the next two weeks we had daily conversations that seemed productive and were reasonably satisfying to Fritz, but the pain in his abdomen did not change, except, temporarily, with hypnotic treatment. Fritz experienced occasional significant relief from pain and occasional significant insights; however, his suffering was still substantial, and he frequently called me after hours to ask for my help or to contribute a newfound insight that he thought might be helpful to our work. Because I had no serious doubt about the diagnosis, I felt confident that the treatment would eventually bring relief to Fritz. I did not know when this would occur, but I believed that relief was imminent.

Two weeks after treatment began, Fritz abruptly traveled to the Mayo Clinic and sought further medical evaluation. It seemed to me that he was acting out of his need to defend against the psychological conflicts our work had been raising.

Physicians at the Mayo Clinic interpreted the CT scan he’d initially had and diagnosed Fritz with pancreatic cancer. They repeated the scan and confirmed their diagnosis.

Only in retrospect did I realize that all of us—the various medical consultants who had seen Fritz and myself—had placed our confidence in the “psychogenic” diagnosis primarily on the basis of one radiologist’s report. Although Fritz sought many “second opinions,” none of these consultants reviewed the original CT scan itself; rather, each read the lone radiologist’s report of a negative finding.

This case is instructive because it involves a tragic and unnecessary mistake. My familiarity with Fritz’s internist gave me substantial confidence in her conclusion that Fritz’s pain was psychogenic. As a consequence, I did not seriously reconsider this diagnosis. Moreover, Fritz’s psychological evaluation confirmed this diagnosis. What was lacking in this otherwise rational process was the opinion of a second radiologist. Each consultant was less likely to look more thoroughly into this particular medical diagnosis because Fritz so clearly demonstrated the qualities of a hypochondriac. Sadly, Fritz is a painful example that even hypochondriacs can become ill.

Psychologists have a crucial role to play in the evaluation of pain patients. Since the experience of pain both influences a patient’s psychology and is influenced by it, effective treatment of the pain must be informed by this evaluation.

While the hypnotherapeutic approach to pain benefits from additional information gained by such evaluation, all treatment benefits from such information.