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THE MEDICAL POST | NEWS

SEPTEMBER 29, 2015

CanadianHealthcareNetwork.ca

Hypnotherapy
for pain management

Give your chronic noncancer pain patients a safe alternative to medication

BY DR. JEFFREY ENNIS

Addressing fears
Before we begin, it would be helpful to have a definition of hypnosis. Perhaps the best definition was put
forward by Dr. David Spiegel and Dr. Jose Maldonado,
psychiatrists at Stanford University in California:
Hypnosis is a natural state of aroused, attentive focal
concentration with relative suspension of peripheral
awareness. It involves an intensity of focus that allows
the hypnotized person to make maximal use of innate
abilities to control perception, memory and somatic
function.11

In other words, hypnosis makes a person more

inwardly focused and better able to take control
of certain experiences that might otherwise seem
uncontrollable. Pain is a good example of this.
However, as a result of the dramatic behaviours
induced in stage hypnosis, patients are often fearful
of clinical hypnosis. They worry that their minds can
be controlled and they might not wake up from a
trance. There is no evidence in the literature to support these myths. However, before beginning hypnotherapy, it is important to deal with patients fears.
They should be reassured that they have complete
control of their behaviour while in a trance and they
can come out of a trance any time they want. Patients
should also be made aware there is medical evidence
to support the use of hypnotherapy for control of
chronic pain.12
In our clinic, we teach patients self-hypnosis skills.
We show them how to do the inductions. They must
practise these skills and eventually use them on their
own. We have found that learning self-hypnosis skills
can result in patients lowering their opioid dose and
increasing their level of function. If patients take the
time to learn and practise self-hypnosis, it gives them
a self-efficacious method of managing their pain.
Induction
In order to show you how to use hypnotherapy for
pain control I have developed a simple-to-learn

method of induction. There are more involved methods that are best learned with the guidance of an
expert in the field. However, there is no clear evidence
that a complicated induction method is more efficacious than a simple one. In order for you to learn
how to perform a clinical induction, you must be
able to do it on yourself. If you try to induce a trance
in a patient without understanding how the process
works, it is unlikely you will be successful.
There is a basic structure to this process. It begins
by regulating breathing, followed by the induction.
Next a method of deepening is used. At this point,
the intervention of interest, such as pain control,
is instituted. Finally, there is a return to the here
and now. The patient and the clinician process the
session. The patient is then encouraged to practise
what they have learned, and over time, to take over
the hypnotherapy and do it on their own without the
input of the clinician.
To begin, have your patient get as comfortable as
possible. The process begins with a yogic breathing
technique called bhramari or bumble bee breathing. Have the patient begin by simply breathing in
and out. Encourage them to slow their breathing rate
and pay attention to the movement of the air. Now
instruct them to make a humming sound with exhalation. This can sound like a bumble bee. Encourage
them to extend the buzzing sound for as long as possible. This will lengthen inhalation. As they breathe

Eye fixationhaving the patient focus on their palmis central to many hypnotic inductions. The
banter of the hypnotherapist should be done to the rhythm of the patients breathing.

Brett Ruffell

hronic noncancer pain affects 18%1 to

25%2 of Canadians. It is not surprising
that practitioners often turn to opioids
for treatment. For thousands of years,
these medications have been our best
analgesics. To date, no better analgesic has been found
for the management of acute pain. Unfortunately, the
same cannot be said of opioids and chronic noncancer
pain. A 2008 review concluded the analgesic effects
of opioids will wear off within months to years
in this patient population.3 Furthermore, a large
Danish epidemiologic study comparing opioid
users and nonusers with chronic noncancer pain
showed the treatment group faired poorly compared
with the untreated group in terms of pain control,
employment, health-care utilization, general state of
health and quality of life.4
In addition, opioids are not without significant
side-effects. These include the development of tolerance with reduction in efficacy,5 constipation in
85% to 95% of patients associated with a reduction
in quality of life,6 hypogonadism,7 opioid-induced
hyperalgesia,8 addiction associated with aberrant
behaviour9 and death.10
In light of this, the search for effective alternative
treatments with limited side-effects has taken on a
certain urgency. Fortunately, such a treatment does
exist. It has been with us for as long as opioids have. I
am referring to clinical hypnosis. Clinical hypnosis is
used for the purpose of improving a patients clinical
situation and quality of life. It is important to differentiate this from stage hypnosis. Stage hypnosis is
familiar to most people, and is a form of entertainment. The two forms of hypnosis are quite different
and the focus here is on clinical hypnosis.

CanadianHealthcareNetwork.ca

in and out, encourage them to relax their muscles.

This simple exercise relaxes the patient and, for some,
induces a light trance.
The trance
I use eye fixation, which is central to many hypnotic
inductions. Have your patient put their hands close
to their face, with one hand lying in the palm of
the other. Both palms should be facing the person.
Instruct your patient to look at some point on the
palm of their hand while maintaining their deep
breathing, without the sound. Now suggest that with
each inhalation they are bringing fresh healing into
their body. With each exhalation they are expelling
something negative. This can even be their pain.
The banter of the hypnotherapist, a critical part
of the induction, should be done to the rhythm of
the patients breathing. It continues throughout the
process. Encourage the breathing and eye fixation.
Eventually, you might notice your patients eyes flutter. This indicates the beginning of a light trance.
At this point, your banter might include: Your eyes
might start to feel heavy. Perhaps they are watering a
bit. It becomes difficult to keep them open, but resist
the desire to close them. Just continue to breathe, and
imagine inhaling something positive and exhaling the
negative feelings in your body. Look closely at your
hand. Notice the lines, the swirls, the minute details.
These types of statements can help increase the depth
of the process.
At some point, many of your patients will not be
able to keep their eyes open. Let them close their
eyes. As they do, such phrases as relax, let yourself
become even more relaxed with every breath can
help the process along. If your patient does not feel
like closing their eyes, at some point instruct them
to do so. Remember, your goal is to teach them the
method of hypnosis that they will practise and eventually do on their own. Some people have difficulty
going into trance and they might need a fair bit of
practice before they are ready to do so. This is not a
failure. It simply means that practice is required.

References

1. Schopflocher D, Taenzer P, Jovey R. The Prevalence of Chronic Pain

in Canada. Pain Res Manag. 2011 Nov-Dec;16(6):445-50.
2. Boulanger A, Clark AJ, Squire P, et al. Chronic pain in Canada: have we
improved our management of chronic noncancer pain? Pain Res Manag.
2007 Spring;12(1):39-47.

THE MEDICAL POST | NEWS SEPTEMBER

Deepening
The next step is a deepening process. There are multiple
different methods available. One of the classic methods involves the image of a stairwell. Ask your patient
to imagine a stairwell in as much detail as possible.
They have complete control of this image. Once this is
accomplished, have them walk down it in their imagination. The further they walk down, the deeper their
feeling of relaxation will become. Take your time with
this. When you think your patient is ready, ask them to
create a landing on the stairwell and come to a stop.
In our hypnotherapy program, patients begin to
learn specific pain control methods at about session
five (out of 10). The first five sessions focus on learning induction methods, deepening and relaxing. In
session five, relaxation is replaced with methods of
pain control. However, it should not be forgotten that
relaxation alone can reduce pain. A simple method of
relaxation is to have the patient recall a place or scene
they know that they find very relaxing, and have them
spend time in that place. In the trance state, a person
can create a very vivid scene.
If you think your patient is able to easily induce a
trance and deepen it, pain control methods can be
introduced instead of relaxation. There are multiple
methods available, but a well-known one is the colour
potpourri. Ask your patient to imagine their pain as
a colour. Fill their minds eye with this colour. Some
people imagine that their pain is hot and they see red.
For others their pain is cold and they might see blue. It
can be any colour. Now ask them to imagine the opposite colour. They do not have to know colour theory. The
opposite colour is whatever they choose. Now ask them
to slowly introduce the opposite colour into their image
of the painful colour. As more and more of the opposite
colour comes into the image, it replaces the painful
colour until eventually, the painful colour is gone and
all that is left is the opposite colour. What is important
for your patient to understand is that the mixing of
these colours must go slowly. With each addition of the
opposite colour they should feel some change in their
pain before they mix any more colour into the image.

Int J Clin Pract. 2007 Jul;61(7):1181-7.

7. De Maddalena C, Bellini M, Berra M, et. al. Opioid-induced
hypogonadism: why and how to treat it. Pain Physician. 2012 Jul;15 (3
Suppl):ES111-8.
8. Guntz E, Talla G, Roman A, et al. Opioid-induced hyperalgesia.
Eur J Anaesthesiol. 2007 Feb;24(2):205-7.

3. Ballantyne J, Shin N. Efficacy of opioids for chronic pain: a review of

the evidence. Clin J Pain. 2008 Jul-Aug;24(6):469-78.

9. Kotalik J. Controlling pain and reducing misuse of opioids: ethical

considerations. Can Fam Physician. 2012 Apr;58(4):381-5, e190-5.

4. Eriksen J, Sjgren P, Bruera E, et al. Critical issues on opioids in

chronic non-cancer pain: an epidemiological study. Pain. 2006
Nov;125(1-2):172-9.

10. Fischer B, Rehn J. Deaths related to the use of prescription opioids.

CMAJ. 2009 Dec 8;181(12):881-2.

5. Collett BJ. Opioid tolerance: the clinical perspective. Br J Anaesth.

1998 Jul;81(1):58-68.
6. Panchal SJ, Mller-Schwefe P, Wurzelmann JI, Opioid-induced
bowel dysfunction: prevalence, pathophysiology and burden.

11. Spiegel D, Maldonado JR. Hypnosis, Textbook of Psychiatry; Talbot J,

Yudosky S (Eds.) 1999: 1243-1247.
12. Adachi T, Fujino H, Nakae A, et al. A meta-analysis of hypnosis for
chronic pain problems: a comparison between hypnosis, standard care, and
other psychological interventions. Int J Clin Exp Hypn. 2014;62(1):1-28.

29, 2015

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Return
Once you have completed your induction process, all
that is left is to return the patient to the neutral start
position. A simple method is to tell your patient you
are going to count from one to 10. By five, their eyes
will open. As you say each number you tell your patient
they are slowly becoming more aware of their surroundings. Remind them they can allow (themselves)
to leave the trance without becoming more tense.
They can be completely relaxed and fully alert. Continue counting, repeating the instruction that by five
their eyes will open. Count upwards, always encouraging the patient to become more aware while staying
calm and relaxed. At five, their eyes should open. This
will tell you how well they listened and if they can
respond to a simple suggestion. Continue to count to
10. You have now finished the induction.
Once you have completed the induction it is
always useful to sit with the patient and find out how
the experience was for them. Did they feel relaxed?
Did it help them in any way with tension or pain? It is
important to learn from your patients experience and
make appropriate adjustments to your method based
on their feedback.
This particular induction contains a number of
interesting methods and techniques. It also contains
a method of pain control, so you might get a response
even at this early stage. The final step is to outline to
the patient the importance of practice and your plan
for followup in order to encourage them to practise.
Compliance can be improved by using a chart to mark
when they practised and for how long.
Hypnosis can get much more complex than this
induction. However, this induction contains all of the
basics. If you find you develop an interest, the next
step is to find a competent instructor who can teach
you more about clinical hypnosis. It is worth giving
hypnosis a try as it can give your patient with chronic
pain a safe option for pain control.
Dr. Jeffrey Ennis is medical director of the Ennis Centre for Pain Management in Hamilton.

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Exclusive video extras

Two specially commissioned videos
featuring Dr. Jeffrey Ennis and
one of his patients are available
in the tablet edition of this issue
(downloading details on page 4)
and at the Medical Posts website,
CanadianHealthcareNetwork.ca:

(1) Hypnotic induction for managing pain: A video

documentary (3:46)
(2) A step-by-step demonstration of an actual hypnotherapy
session (3:05)