The effects of anxiety and pain in the postoperative period

Preoperative hypnosis.

A controlled study to assess the effects on

anxiety and pain in the postoperative period.
By Maurizio Massarini, Francesco Rovetto, Claudio Tagliaferri and the "Preoperative
Hypnosis" Study Group: Giuseppe Leddi, Umberto Montecorboli, Paola Orifiammi,
Franco Rebecchi, Stefano Lucchini, Luca Larini and Giulia Parvoli

Dr. Maurizio Massarini: Consultant neurologist at the Hospital of Castei San Giovanni, Vice president and lecturer at the
school of the itaiian Medical Society of Psychotherapy and Hypnosis in Bologna

Dr. Claudio Taqliaferrl: Director of the Emergency department of the local health authority in Piacenza

Dr. Francesco Rovetto: Professor of Clinical Psychology at the Faculty of Letters and Philosophy (Psychology Depart-
ment) In Parma, Head of the section of Investigative Psychology and Psychopathology of criminal conduct set up at the
Psychology Department of the University of Parma.

Abstract: Our study was designed to establish whether a single sitting of hypnosis during the preoperative
period would reduce postoperative anxiety levels (both state and trait anxiety) and to reduce the perception
of postoperative pain (both its sensory and affective components). Forty-two patients from the Surgery and
Orthopaedics wards, who were to undergo surgery, were randomly assigned either to an experimental group
(where preoperative hypnotic treatment was carried out during the twenty-four hours preceding the opera-
tion) or to a control group (with no particular preoperative treatment). During the weeks leading up to the
operation, the patients were asked to fill in guestionnaires (STAI-X and OD) to assess anxiety levels (state and
trait) and problems of a depressive nature; certain physiological parameters were also measured. During the
days following the operation ttie questionnaires were repeated to assess postoperative anxiety and depres-
sion values; postoperative physiological indices were measured and pain perception (sensory and affective
components) was assessed using the NRS every day, for four days after the operation. The patients from the
experimental group showed lower levels of anxiety (both state and trait) and lower pain perception in the first
two days after the operation (both in the sensory and affective components) compared to the patients from
the control group. No difference emerged for the other variables examined (depressive problems, physiological
parameters). This controlled study showed that brief hypnotic treatment carried out in the preoperative period
leads to good results with surgery patients in terms of reducing anxiety levels and pain perception,

Key words: preoperative hypnosis; anxiety; pain; depressive problems; physiological indices; postoperative
period.

Acknowledgements: We would lilte to thank Andrea Bianchi M.D.. The Health Director of the local health authority in
Piacenza. We would also like to thank the ward sisters of the Surgery and Orthopaedics wards and the day Hospital of the
Hospital in Castei San Giovanni and all the nursing statf of these three wards. Our particular thanks go to all the patients
who believed and took part in the study.

8 European Journal ot Clinical Hvpnosis; 2005 volume 6 - issue '

Dr Maurizio Massarini, Dr Francesco Rovetto. Dr. Claudio Tagliaferri
Any surgical operation is ;i dangerous situation, where
various anxiety-induciny components are almost al-
ways prcscni and can be ideiititied according tt> the
patient's psychic balance, culture and conception (Ai-
oncdi BcTtolino. 2003):
1) The illness itself (an appendicectomy is obvi-
ously experienced in a completely different way to
a heart transplant).
2) Recovery expectations and the (real or supposed)
consequences (an operalion ihat is considered de-
cisive has a different emotional impact compared
to. for example, diagnostic tests that may have a
nasty surprise in store).
3) The patient is in a situation in which he is to-
tally helpless and is not even able to follow or fully
understand what is being done to him or what may
hiippen.
4) Whereas what is happening is everyday routine
for ihc opcmting team, taking place in familiar
surroundings and among people they know, it is an
exceptional, dangerous and negative event for the
patient, in unfamiliar and mysterious surround-
ings and basically in the hands of strangers. It is
hard for those who experience this everyday situ-
ation in ail normality to understand the emotions
of thtise who are terrified. It is precisely this dif-
ference between the two experiences that leads to
misunderstandings and a lack of communication,
which cause anxiety and are not uncommonly psy-
chopathogenetic.
Apart from anxiety, there is another fundamental as-
pect closely linked to the operation that needs to be
considered: pain.
Surgery determines two different kinds:
1) intraopcrative pain;
2) postoperative pain, following surgery, caused by
lesions of the tissue and produced by the stimula-
tion of peripheral receptors (Woolf. 1989).
1 he effects of postoperative pain and the physiologi-
cal responses to surgical lesions and stress have been
k[u>wii for a long time. They include pulmonary, car-
diovascular, gastrointestinal and urinary disorders and
neuroendocrine and metabolic variations.
In this sense postoperative pain is a complication of
surgery (as are infections, hydroelectrolytic imbal-
ances, etc.) and as such must be treated or preferably
prevented. In fact, it has been recognised that appro-
priate postoperative pain treatment contributes signifi-
cantly to imprt)ving pcrioperative morbidity, asses.scd
in terms of a lower incidence of postoperative com-
plications, fewer days spent in hospital and reduced
costs, particularly for high-risk patients undergoing
European Journal of Clinical Hypnosis: 2005 volume 6 - issue 1
major surgery.
Although it has been widely accepted that pt)st sur-
gical pain control is essential for the patient, and de-
spite progress in knowledge of physiopathology and
pharmacology of analgesics and the development of
effective techniques to cure postoperative pain, many
patients continue to suffer considerably (Varrassi. Ca-
pogna, Celleno. & De Nicola. 1990a. 1990b; Warlield.
1993).
This was why we tried to demonstrate, through a
controlled study, the need for and the effectiveness of
a support technique (e.g. a preoperative hypnosis sit-
ting). It had to meet the surgical patient's requirements
with respect to anxiety (like, for example, receiving
more care and attention as well as more information)
and pain (for example with treatment able to provide
positive suggestion about the outcome of the operati<in
and the recovery) linked to the operation.
Materials and methods
Our work was carried out on the basis of the pilot
study by Massarini. Oriliammi. Rebecchi and Taglia-
ferri (2001) performed in the same hospital about two
years before.
We tried to screen all the patients admitted to the
hospital in Castel San Giovanni (Piacenza), from Feb-
ruary to April 2004. except for those attending day
hospital.
The sample was made up of 42 patients. 22 male and
20 female, ranging from 16 to 79 years of age (average
= 51.12), from the Surgery and Orthopaedics wards.
They were divided into two independent groups at ran-
dom, an experimental group made up of patients that
would receive preoperative hypnotic treatment and a
control group, that would not receive any treatment.
It must be specilied that the protocols for postop-
erative acute pain management (analgesic protocols)
were standardised and planned fora duration of 24-48
hours. The medical and nursing staff were not aware
of which group the patients belonged to; the research-
ers were the same for both groups and the preoperative
hypnosis sitting was carried out by an external psycho-
therapist consultant.
The patients were contacted for the first time during
the preoperative anaesthetics examination, normally
carried out during the weeks preceding the surgical
operatii)n; if the patients agreed to take part in the
research they signed the so-called "informed con-
sent" and the questionnaires were tilled in (described
below). The patients from the experimental group
received hypnotic treatment during the twenty-ftiur
hours before the operation. During the diiys following
the operation the researchers examined the patients on

the ward and repeated the questionnaires (retest).
The appropriate tools were administered to patients
every day for tour days after the surgical operation in
order to assess postoperative pain.
Anxiety
The tools used to measure emotional parameters came
from battery CBA 2.0 (Sanavio. Bcrtolotti. Michielin.
Vidotto, & Zotti. 1986).
The State-Trait Anxiety Inventory {STAl-X) was used
to measure anxiety levels., which enabled us to find
two different results:
- Stale anxiety: a transitory emotional state or
condition o( the human body characterised by con-
sciously perceived subjective feelings of tension
and apprehension and by the increased activity of
the autonomous nervous system. It may vary and
lluctuate in time (Spielberger. Gorush. & Lushene.
1970).
- Trait anxiety: the relatively stable individual dif-
ferences in the disposition towards anxiety, i.e. the
differences between people who tend to respond to
situations they see as threatening with a rise in the
intensity of state anxiety (ibid.).
The STAI-X consists of 40 items, distributed into two
scales of 20 items each: one of State, called XI and
one of Trait, called X2.
Depressive state
Questionnaire D was used to assess any depressive
problems. It forms page 8 of battery CBA 2.0. This tool
was created from scratch by the authors of the battery
to measure even the slightest displays of depression
and to have an easy tool to administer. High scores
indicate the existence of a depressive condition that
may not necessarily be of a clinical nature; a depres-
sive state may be secondary to several other disorders
both of a medical and a psychological nature.
Pain
To assess the perception of postoperative pain in the
patient we thought it fitting to use a numerical rating
scale (NRS) lo which we combined it scale of facial
expressions (Faces Pain Rating Scale) made up of spe-
cific graphic elements (drawings of faces expressing
various degrees of pain) which were used to facilitate
the assessment of the patient's pain, thus improving
the comprehensibility of the NRS.
10
The effects of anxiety aiid pain i[i the postoperafive period
Through the NRS patients could express a personal
rating relative to the postoperative pain perceived (self-
assessment). Moreover the NRS. being an eleven-point
Likert scale (0-10). enabled the patients to quantify the
entity of pain perceived.
We overcame the limits of this tool, its one-dimen-
sionality, administering it so as to be able to assess at
least two different aspects of pain :
- the affective component
- the sensory component (more spCLitically pain
intensity)
The psychometric properties of the NRS are appropri-
ate and highlight the positive and significant correla-
tions with other valid and well-established pain rating
tools (Dovvnic. Leatham. Rhind. Wright. Branco. &
Anderson. 1978: Jensen. Karoly, O'Riordan. Bland,
& Burns. 1989: Kremer. Atkinson. & Ignelzi. 1981;
Seymour. 1982: Wallenstein. Heidrich. Kaiko. &
Houde. 1980) including the visual analogue scale
(VAS [Huskisson. 1974|) which has been rated as
one of the most reliable and valid means for assess-
ing pain (Gift. 1989). According to some authors there
would be no difference in pain assessment whether the
Likert-type scales (like the NRS) or VAS were used
(Guyatt. Townsend. Berman. & Keler. 1987: Huang.
Wilkie. &Ber>. 1990).
Physiological parameters
To have a complete picture of the patients" experience,
we recorded certain physiological parameters at dif-
ferent times: heart rate (before, during and after the
operation), blood pressure (before, during and after),
oxygen saturation (during) and body temperature (be-
fore and after). These were noted on the appropriate
card after consulting the patients' medical records.
Treatment
The method u.sed was the so-called "brief or very brief
technique, with a duration of somewhere between fif-
teen and thirty minutes. The adoption of a uniform
method allowed us to standardise the case histories.
Furthermore, the sittings wore carried out by the same
person: in this way a guideline was adopted that was
as coherent as possible and could be repeated, though
with the necessary limitations. The psychotherapist
needed certain inibrmation for a basic knowledge of
the patients. Apart from the diagnosis and the type of
surgery that the patient would undergo, it was neces-
sary to know some characteristics of each patient.
such as education, family problems, work, hobbies and
anything else that would be useful to describe their
lifestyle. This information was gathered by the re-
searchers during the Iirst contact with the patients and
integrated later on in light of elements arising during
European Journal ol Clinical Hypnosis: 2005 volume 6 - issue l
Dr Maunzio Massarini, Dr Francesco Rovetto, Dr. Claudio Tagliaferri

the bricl' interview Ihc iherapisl had with the patienl
hefore the sitting.
The sitting look place in a secluded place and the pa-
tient could choose his own position, either lyint; dinvn
on the bed or sitting comlorlably in u chair.
The sitting began with a brief exercise to relax the mus-
cles and relieve tension just before the surgical opera-
tion, which was useful for concentraliny the patient's
attention totally on himself. Trance induction was me-
dium level i)r slight, the sensory channels could all be
involved, but in nuist cases it was the visual one. Then
the part of the body to be operated on was visualised.
particularly through ihe use ol positive metaphors
about one's own body being completely recovered af-
ter the operation. The information about the patient's
habits were useful as it enabled us to create ad hoc
images for each patient, made to lit their own charac-
teristics; the mental images were meant to encourage
the use of one's own resources (hobbies, interests) to
imagine the part of the body healed and the body fully
restored to health. These visualisations were accom-
panied by positive .suggestions about the possibility of
influencing one's own state of health through thought,
namely that all that we think about ourselves, of our
body in its entirety or even small parts of it. may inllu-
ence its state more than we think (a clear referenee
to the mind-body relationship). At the end a thought
was suggested: that the surgical wounds would heal up
quickly and that the pain would be less than expected.
State anxiety
The Wilcoxon test was used to check if there were
any statistically signilicant differences in the scores
recorded in the STAI-XI at the two moments of as-
sessment within each group.
E.G. Z=-3.784. p=().()()()
C.G. Z=-1.214. p=().225
The values obtained demonstrate that it was only
within the experimental group that there was a signiti-
cant change in the score recorded in the state an.viety
test before and after the operation, which highlights
the significant reduction of the score in the retest.
The application of the preoperative hypnotic method
enabled a significantly lower perception of state anxi-
ety levels.
Trait anxiety
The Wilcoxon test enabled us to verify if there were
any statistically signilicant differences between the
scores recorded in the STAI-X2 at the two moments of
assessment within each group.
3
? 60

The thought suggested for each patient depended on ^ SO

44 14

his personal experience {e.g. a farmer would be told to - ^

visualize a plant grafted onto a root as a metaphor fov
^ ^ " " ^ ^ - ^
a successful knee replaeement operation.
30.67
20
Expenmeiitiil
1 2
Results Moment of assessment

The values obtained according to the different varia-

Figure 1: Intergroup comparison STAI-Xl
bles being considered were processed statistically with Experimental Group and Control Group
the help of the SPSS programme. The seores recorded
on the questionnaires and analyzed were the so-called E.G. Z=-2.697. p=().()07
r t ) u g h s c o r e s {.\ee Tahk' I ) .
C.G. Z^-O.fas. p=().526

Anxiety STAI STAI STAI STAI 80

XI XI X2 X2 70

TO TI TO Tl ieo
L.xporinicn 8

lal (irtiup
(Average .
Score) 44.14 30.67 40.33 34.81 30
14 86 34 Z*
20
1 2
Control Moment ot assessment

Group
37.95 34.90 34.86 34.24
Score) Figure 2: Interqroup comparison STAI-X2
Table 1: Anxiety Experimental Group and Control Group

European Journal of Clinical Hypnosis: 2005 volume 6 - issue 1 11

 The effects of anxiety and pain in the postoperative period

The values obtained demonstrate that it was only Sensory component: day I. U=112.()()(), p=0.006:
within the experimental group that there was a sigiiifi- day 2. U=l()5.5()(). p=0.(){)3: day 3. U=I55.OOO,
cant change in the score recorded in the trait anxiety p={).097: day 4. U^2(){).5()(). p^().6O8.
test before and after the operation, which highlights
the significant reduction of the score in the retest. Affective component: day 1. U=120.()0{). p^O.OIO;
day 2. U=l 19.500. p=().()l(): day 3, U=I70.500,
The patients who underwent preoperative hypnotic p=().2O4; day 4, U=205.500. p=O.7()2.
treatment showed a signitieant reduction of Irait anxi-
These data tell us that, relative to the two variables
ety levels after the operation (sec Figure I and Figure
considered, there is a significant difference between
2).
the two groups in days I and 2, but not in days 3 and
4.
Depressive state
In other words, this means that the patients from the
The Wilcoxon test allowed us to verify whether any experimental group claimed that they felt less pain (on
significant changes were obtained in the scores re- a scale from 0 to R)) both in terms of intensity (sen-
corded in Questionnaire D between the two moments .sory component) and discomfort and unpleasanttiess
of assessment within eaeh group. (affective eoniponcnt) with respect to patients from the
conlrol group (in a statistically significant way) during
E.G. Z=-0.488. p=0.626
the two days after the operation (see Fij^ure 3).
C.G. Z^-1.458, p=0.145
No significant changes were shown either within the
experimental group or the control group in the scores
recorded before and after the surgical intervention.
The preoperative hypnosis sitting shows no significant
effect on the depressive stale of the patienls.

Sensory Day 1 Day 2 Day 3 Day 4

pain
Ciroup 2.61904S >.952..., 2.S57I43 1.952 IS 1 D>y>

Score)
Com rol Figure 3: Intergroup comparison of the sensory
Group 5.7.,9.)5 4.47M9U 4.2X5714 2.571429 component and affective component of pain
Score)
Physiological parameters
Table 2: Sensory pain
Student s t test for indcpcEident samples was used to
Affective Day 1 Day 2 Day 3 Day 4 compare the experimental group and the control group
for the averages regarding physiological parameters at
pain
Bxperimcntal
the different Eiioments of assessment. The results of
Group 2.7,42., 2.,)9.S23. 3.095238 2.571429 the test did not show any statistically significant dif-
(Average ferences between the experimental group and the con-
Score) trol group in the averages of the various parameters
C onirol Group
(Average 5.190476 4.2S5714 2.7(. 19(15
assessed at different moments.
Score)

Table 3: Affective pain

Pain
(See Table 2 ami Table 3). The Mann-Whitney U test
was used for unmatched data to verify if Iherc were
any statistically significant differences between the
experimental patients and the control patients in pain
perception in its sensory and affective components
during [he four days following the operatitjn in which
we assessed the variables.
Discussion
The aim of our controlled study was to demonstrate
the advantages that a surgical patient can benefit from
by undergoing hypnotic treatment during the preoper-
ative period. The results led us to conclude that we had
achieved our aim; the patients who were interviewed
under hypnosis had lower anxiety levels (both state
and trait) and a reduction in the perception of post-
operative pain in the first two days after the operation
(both in its sensory and affective components) with
respect to patients who did not receive any particular

12 European Journal ot Clinical Hypnosis: 2005 volume 6 issue 1

Dr Maurizio Massarini, Dr Francesco Rovetto, Dr. Claudio Taqliaferri
treatment.
As can be seen in Figures I ;uid 2, ihere are higher ini-
tial levels of state and trait anxiety in the experimental
group than the control group.
This condition is obviously linked to the random
choice of patients put into the experimental and con-
trol groups.
The different preoperative values for state anxiety re-
corded by Ihe two groups are due to the different reac-
tions of the individual patients to the stressful event.
The different preoperative values in trait anxiety re-
ctirded by the two groups are due., however, to the spe-
cific characteristics of personality for thc individual
patients.
To go into detail, as far as state anxiety is concerned,
the experimental patients (Average = 44.14. Standard
Deviation = 11.68) attained higher points than the con-
trol patients (Average = 37.95. Standard Deviation =
15.44), However, the application of the Mann Whitney
U test highlighted the fact that there are no significant
statistical differences between the two groups regard-
ing these points (U = 143.000. p = 0.051). Therefore it
can be said that., as far as these data are concerned, the
two groups belong to the same statistical universe.
On the other hand, as far as preoperative administering
of STA1-X2 is concerned, which assesses trail anxi-
ety, (experimental group: Average = 40.33. Standard
Deviatitin = 10.92; control group: Average = 34.86.
Standard Deviation = 10,03). a signilicant difference
was reeorded between the two groups with reference
to these points (Mann Whitney U test = 136.500, p =
0.034).
In conclusion, there is only a stalistically significant
difference between the two groups with reference to
preoperative trail anxiety, for the above-mentioned
reasons.
This situation, however, reinforces the results obtained
by our study concerning the possible advantages that
a patient can benetit from by being subjected to hyp-
notic treatment during thc preoperative period, when
undergoing surgery. In fact, the experimental patients
(who underwent treatment) recorded a fall in anxi-
ety levels (both state and trait) despite starting from
higher initial levels of preoperative anxiety (though
only different in a statistically signilicant way for trait
anxiety) compared to thc control group. The patients
of the control group, despite the lower initial levels of
preoperative anxiety (though only different in a statis-
tically significant way for trait anxiety) did not show
any statistically significant difference between the
STAl-XI and STAI-X2 points (state and trait anxiety)
obtained before and af ler surgery.
We v\ould like to point out that various authors
European Journal of Clinical Hypnosis: 2005 volume 6 - Issue 1
(Benedetti & Murphy. 1985: Turk. Meichenbaum. &
Genest. 1983) have found that high anxiety is likely to
lead to increases in patient's pain perception (although
the authors did not differentiate between pain dimen-
sions).
According to Barber (1990. I99I). hypnosis produces
more changes in the motivational-affective component
than in the sensory-diseriminative component of pain.
This result was obtained by Price and Barber (1987).
but also other research has conlirmed this information
(Mauer. Burnett. Ouellette, Ironson,, & Dandes. 1999).
This does not occur in our study, in fact the two com-
ponents show a rather similar trend. However, in t)ur
research it is shown how hypnotic treatment is able to
reduce both the sensory and affective components of
pain (this is a fundamental result and common to other
studies).
The reduction of pain perception and anxiety in the
patients of the experimental group occurred without
the respective reductions in the physiological param-
eters (which in any case may not be linked exclusively
to these two variables). As far as sensory pain percep-
tion is concerned the laek of, or anyhow the reduced,
attenuation of involuntary signs of the pain itself (e.g.
physiological indices) would agree with the theory of
neodissociation (Hilgard & Hilgard. 1994).
The results we have achieved enable us to understand
the importance of hypnotic treatment, and mt)re
generally psychotherapeutic support techniques, in
surgery, in fad. through these indispensable tools it is
possible to provide appropriate information, instruc-
tion and also suggestion to the patient that must face
a surgical operation. It is precisely in this way that it
is possible both lo reduce anxiety (particulariy preop-
erative) and to allow better treatment of postoperative
pain which, as is well known, if appropriately treated
can contribute signilicantly to improving cooperation
on the patient's side., and of perioperative morbidity
(assessed in terms of minor incidence of postoperative
complications and fewer days spent in hospital) which
as a consequence would lower eosts.
Research shows the ambit of the operation of the so-
called "Mind-Body Therapies", or rather those opera-
tions that include diverse techniques to facilitate the
capacity of the mind to influenee the bodily funetions
and symptoms. The aim is therefore to annul the nega-
tive effects of stress on health, by using the healing po-
tentials inherent in behaviour and positive emotions,
induced through various relaxation techniques. The
Mind-Body therapies are self-regulation techniques.
or rather all that an individual ean do for himself to
make the most of the healing potential inherent in
positive emotions.
Finally, we would like to point out that most research
relating to psychological factors affecting recovery
13

after surgery has focused on anxiety and pain, li has
been demonstrated that anxiety plays a decisive role
in reeovery inasmuch as it is supposed that the anxi-
ety itself increases the level of pain perceived by the
patient (Barber. 1982; Benedetti & Murphy, 1985:
Chaves. 1993; Sternbach. 1986; Turk. Meielienbaum.
& Genest. 1983). Furthermore it has been ascertained
that aeute pain interferes with the body's natural
responses of healing and eieatrisation (Hall. 1986;
Holden-Lund. 1988; Park & Fulton. 1991; Sunnen,
1988). increases complications (Yates & Smith. 1989)
and reduces the patient's cooperation with the medical
staff (Boyne. 1982; Zahourek. 1990).
An interesting study by Kain. Sevarino. Alexander.
Pincus and Mayes (2000) has pointed out a complex
pattern of relationships between preoperative anxiety
and postoperative pain. In particular, it has emerged
how state anxiety assessed just before the surgical
operation is a direct predictor of immediate postop-
erative pain (1-2 hours after the operation) and also of
state anxiety during the stay in hospital during the first
2 days after the operation. The results of this study,
whieh eonflrm most of those already published, un-
derline the need to reduce the amount of preoperative
anxiety in patients who have to undergo surgieal op-
erations, a goal that can be achieved by administering
drugs and also, and above all. by using p.sychothcra-
peutie techniques.
According to Egbert's elassie studies with surgieal
patients (1986: Egbert, Battit. Turndorf. & Beeeher.
1963; Egbert. Battil. Welch & Barllett. 1964) an in-
formative preoperative examination earried out by the
anaesthetist makes patients significantly calmer; these
patients also needed lower do.ses of painkiller in the
postoperative stage.
Joseph Barber has made a fundamental eontribution to
pain management through hypnosis. Aecording to this
author the use of hypnotic treatment for pain control
is justified by the clinical advantages of this teehnique
for:
1. eliminating or at least signifieantiy redueing
pain.
2. treating pain without side effects, increasing the
pain threshold (which maintains its value for pro-
tecting the organism), reducing its level of activ-
ity.
3. reinforcing the action of any other treatments in
progress.
4. offering the patient the chanee to use this tech-
nique himself (self-hypnosis), making him more
conlident and less dependent on the medical and
psychological environment.
In faet, detailed studies have established that pain eon-
14
The effects of anxiety and pain in the postoperative period
trot aehieved by means of hypnosis is higher than that
aehieved through other psyehologieal means (Hilgard
& Hilgard. 1994; Orne, 1980; Turner & Chap-
man. 1982). For Barber (1996) "no other psychological
approach is so effective in giving eomfort from pain
without producing negative side effects due to medi-
cal treatments of comparable effectiveness""; however
the use of hypnotie methods does not preclude the use
of other treatments, particularly the administration of
painkillers.
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www.lcch.co-uk

European Journal of Clinical Hypnosts: 2005 volume 6 - issue 15