One day last year, toward the end of a brief course on the hypnotic treatment of pain that I was teaching in Heidelberg, Germany, a student asked “where all of this is written.” The question made clear that, though I’d given these students a series of journal publications on the topic, most of what I was teaching about the practical implementation of hypnotic treatment was taken from clinical experience—my own and that of colleagues with whom I’ve discussed clinical cases. I realized that this material, central to an understanding of hypnotic treatment for pain, was not available in the literature.
Further consideration of the student’s question focused my thinking, and I began to examine topic areas that might fill this lacuna in the literature. While my own knowledge and experience do not extend throughout the full range of pain populations and pain treatment, I have colleagues whose knowledge and experience complement mine. Happily, they were willing to contribute to this clinical guide, for which I am very grateful.
FOCUS OF THE BOOK
This book takes as its focus the treatment of patients who are suffering pain from a variety of recurring syndromes, and whose nervous systems continue to be bombarded by noxious stimulation. We will not be discussing patients who are suffering chronic benign pain syndrome (Sternbach, 1982a), for which hypnotic treatment is not usually helpful, and for which multidisciplinary pain treatment programs probably offer the best treatment.
Recurring pain syndromes represent a broad range of injuries or illnesses that create ongoing noxious stimulation—perhaps daily, as might be the case with the pain of cancer or arthritis, or perhaps less often, as might be the case with the pain of migraine or trigeminal neuralgia. Obvious examples of diseases or syndromes that create recurring pain include, in no particular order: cancer; headaches of many kinds (migraine, cluster, tension, vascular, and posttraumatic); facial pains; arthritis, both rheumatoid and osteoid; postpolio syndrome; irritable bowel syndrome; burns; various neuralgias, including postherpetic and trigeminal; temporomandibular joint (TMJ) syndrome; phantom limb; sickle cell anemia; low back pain caused by the compression of nerves, and many, many more injuries or illnesses that produce intense, sometimes intractable pain.
Except in the chapters covering painful medical procedures, burn pain, and dental pain, the term “pain patients” refers to patients who have been suffering pain over several months.1 While effective treatment of acute pain tends to resolve the patient’s suffering, persistent or recurring pain creates other changes over time, both physiologically and psychologically. Consequently, aside from whatever injury or disease continues to generate the pain, the pain is now a syndrome to be treated, in and of itself.
As you read, please keep in mind that this book explores only those approaches to pain treatment that utilize the imagination of the patient.2 As I discuss in Chapter 1, “hypnosis” is a word laden with some unfortunate associations, and I have attempted, throughout this book about hypnosis, to avoid its use. I prefer, instead, to refer when possible to “hypnotic process,” “hypnotic methods,” or other alternatives. This struggle against historical baggage and toward greater precision of experience and expression sometimes yields more awkwardness than accuracy; occasionally, then, I have reverted to the use of “hypnosis.” You will notice, though, that this reverting does not extend to the word “trance,” which is even more heavily laden with wrong-headed connotations.
The fact that we have confined our exploration of pain treatment methods to “hypnosis and suggestion” should not be construed as a dismissal of other treatments, which, in any particular case, may be more appropriate and effective. I risk belaboring this point because of my observation that clinicians trained in hypnotic methods often develop a narrow perspective on clinical treatment, perhaps even forgetting their broader clinical training as they become fascinated by hypnotic phenomena. However, when a patient suffers from pain, hypnotic treatment is rarely the first choice that occurs to the experienced clinician. Only after adequate evaluation of the patient and the patient’s symptoms can we make a well-informed treatment choice.
ORGANIZATION OF THE BOOK
Though I hope this book will be a useful reference to those who wish to be reacquainted with a particular issue or technique, my primary goal is to comprehensively explore the domain of pain treatment by hypnosis and suggestion.
Section I, which provides an orientation to this complex domain, begins with an introduction to hypnosis and suggestion and to their application in the clinical treatment of pain.
When a patient first presents with the complaint of pain, the clinician’s task is to identify the nature and source of the pain. Does the pain signal the presence of injury or disease that needs timely treatment? A patient complaining of abdominal pain, for example, might be experiencing a painful inflammation of the appendix, requiring immediate surgical treatment. Beyond these emergency questions, is the pain caused by disease or injury that can be effectively treated? This question is especially pertinent, given that most long-term pain conditions represent inadequately treated disease or injury. If the cause of the pain had been adequately treated acutely, perhaps there would be no long-term pain to treat. There are also many patients, suffering from a variety of conditions, whose suffering does not seem amenable to medical treatment.
Clearly, then, the initial evaluation of a pain complaint must be primarily a medical, not a psychological, process. In Chapter 2, “Medical Evaluation of the Patient with Pain,” John Bonica and John Loeser describe the principles and techniques that guide a physician through the process of examining a patient and determining the nature of the patient’s pain.
Effective treatment also depends upon adequate psychological evaluation of the patient, which is explored in Chapter 3, and on realistic understanding of the nature of the treatment. To this end, in Chapter 4, Donald Price distills his considerable knowledge of the neurophysiological substrates of hypnotic analgesia, gained from long experience as an investigator of both pain and hypnotic phenomena. He offers a clinically meaningful, cogent explanation of the psychological and neural mechanisms that underlie the phenomenon of hypnotic analgesia. Understanding this model can be very helpful in formulating imaginative and effective hypnotic treatment plans.
Particular hypnotic induction techniques, treatment plans, and the process of choosing appropriate suggestions are discussed in Chapter 5. However, for the reader not yet trained in hypnotic methods, the contents of this book should not be seen as an alternative to formal clinical hypnotic training. Such training is essential to use these methods safely and effectively.
Section II explores pain syndromes most clinicians who treat pain are likely to confront. Surely one of the most painful syndromes is associated with various forms of metastatic disease. Cancer carries with it an enormous emotional loading of fear and dread, and so particular sensitivity is required in the treatment of cancer pain. Karen Syrjala and Sari Roth-Roemer bring substantial clinical experience to bear on their discussion of the management of cancer pain in Chapter 6. Since the hypnotic treatment of headache particularly interests me, and it is well-suited to hypnotic treatment, I provide an account of these methods in Chapter 7. Roseann Mulligan provides the reader with a rare exploration of the world of dental pain, and how it can be psychologically managed, in Chapter 8. A remarkable anesthesiologist who enjoys listening to patients as well as talking with them (even when they are anesthetized), Christel Bejenke brings her broad experience to us in Chapter 9. She discusses the complex problem of helping patients manage anxiety and pain, as she shares techniques for preparing patients who must undergo painful medical procedures. David Patterson has been at the forefront of the relatively modern innovation of hypnotic treatment of the pain associated with burns and their care; he discusses this challenging work in Chapter 10.
Section III concerns the clinical treatment of particular populations of patients. Samuel LeBaron once worked as a pediatric psychologist. After early research with Josephine Hilgard, his collaborations with Lonnie Zeltzer enriched the experimental and clinical literature over a number of years. They work together again in Chapter 11, as they explore the treatment of children in pain. LeBaron, now also trained as a physician, joins with Stanford colleague William Fowkes in Chapter 12 to give readers a splendid view of the humane care of those who have grown beyond childhood, through adulthood, and now suffer the particular pains associated with growing old.
Despite our best efforts, sometimes we fail—the patient leaves our care, still suffering from pain. In the Afterword, Samuel LeBaron and I take up the difficult inquiry of how such failure happens and what we might learn from it.
The treatment of pain with hypnosis and suggestion was once considered an “alternative” treatment, at best, and an example of quackery, at worst. As a consequence of the years of productive research, careful clinical approaches, and the training that has resulted from both, we now know quite a lot about how best to treat pain in this way. This volume is intended as a clinically useful guide to the practical knowledge and skill that has developed from this research tradition, organized so that you can use it as a guide your clinical judgment.
The treatment of pain is one of the most intellectually challenging and personally demanding clinical tasks we can undertake. I hope the material in this book will serve to make this task easier.
Joseph Barber, Ph.D.
Seattle, Washington