Teaching Self-Hypnosis to Patients

With Chronic Pain

Paul Sacerdote, M.D., Ph.D.

For the past twenty years hypnotherapy arid selj-hypnosis have been
utilized as valid tools .for the successful matiagemerit of severe protracted
pain. Control often has been achieved in cases where other modalities of'
pain management had been inadequate. Hypnosis properl-v applied can
bring some degree of improvement to 90 percent o j patients. More
remarkable degree of pain relief is achievable in the 25 percent of' patients
who have high hypnotic "talent." and with very limited expenditure of
time and effort. The author discusses basic theories of' p i n , pain-control
and hypnosis, and he clarifies the ejfects of physiological. biochemical.
and psychological variables which can aflect the procedures and the
results. Presentation o j a clinical case with quoted excerpts of' verhaliza-
tion serves to illustrate the most important points.

During more than 20 years of clinical experience I
have found hypnosis to be useful as a principal or a
subsidiary tool in managing chronic pain. Eclectic
approaches which take into account the complex
biochemical and neurophysiological realities, as well
as the cognitive and psychological background, have
been especially effective. Also, I have always con-
veyed to my patients my belief that their pain is real,
even when etiology and pathology can not be ascer-
tained and demonstrated. This attitude is useful in
eliminating from our minds and from the minds of
the patients any artificial distinctions between real
pain and psychogenic pain. As a consequence, even
in those instances where hypnotherapy seems to
bring about almost miraculous relief, no doubt will
arise about the reality of the preexisting pain. This
does not exclude the causative roles that hysterical
Dr. Sacerdote is Attendirig Physiciari it1 the Oncology
Department q/' Monteji'ore Hospital arid Medicul Center.
New York. New York. and President of the S o c i e p j o r
Clinical arid Experimental Hvpnosis.
conversions, verging on malingering, depressive
reactions. psychotic equivalents, consciously or sub-
consciously motivated, can play in the origin and
persistence of pain.
The subjective experience of pain is indeed the
result of many interacting variables, sensory, motor,
cognitive, motivational and emotional. They do not
occur in a vacuum, rather they are based upon the
functions of the infinitely complex microscopic
anatomical substratum of the central and peripheral
nervous systems. Essential biochemical interactions
involving various neurotransmitters and specific
chemical receptor sites are activated or inhibited at
cellular. intercellular and molecular levels. Pain,
especially intractable pain of a chronic and re-
current nature, creates intense physiological and
psychological stress which is often insufficiently
relieved by analgesic, narcotic, and psychothropic
drugs and by neurosurgical interventions.
From a practical viewpoint it is important to keep
in mind that at least one out of five persons suffering

18 Journal oJ'Humar1 Stress

SACERDOTE
from severe chronic pain is probably an excellent
potential hypnotic subject who can learn to utilize
hetero- and self-hypnosis in two or three hours of in-
telligent training. It then becomes possible to spare
these patients long periods of suffering and
hospitalization, to eliminate the need for neuro-
surgical interventions, to reduce the use of nar-
cotic drugs and to improve the quality of life. At the
same time, precious hours of physicians’ and nurses’
time can be saved. It is probable that in some cases
of malignancy, lengths of comfortable survival are
prolonged.
In all of these cases where pain has lost (if it ever
had had them) the characteristics of being “the
psychical adjunct of an imperative protective
reflex,”’.2 hypnosis permits function without un-
necessary suffering.
The gate-control theory of pain modulation in-
troduced by Melzak and the discovery of
prostaglandins and other naturally occurring chemi-
cals in the production of pain, the related under-
standing of the “modus operandi” of antirheumatic
and other anti-inflammatory agent^,^ the recent ex-
citing discoveries of specific receptor sites for nar-
cotics and their relationship to naturally occurring
narcotic-like polypeptides, (endorphins and enka-
phalins)’ has brought us closer to an understanding
of pain and “pain-killers.” But at the same time
these discoveries have brought us nearer a logical
explanation for the success of hypnosis and other
“psychological” approaches to the modification of
pain.
Pain, even more than sight, hearing, smell, taste
and touch, is the result of an integration and
abstraction by the central nervous system of various
peripheral stimuli acting upon specific structures,
and of preexisting memories and experiences stored
and catalogued in biochemical language in various
cells and centers of the central nervous system.6
Similar ideas are expressed by Sternbach, in the
context of learning theory to explain pain persisting
in the face of apparent “organic recovery” and to
suggest different approaches to pain control, in-
cluding biofeedback models.’ Hilgard and Hilgard*
have noted that, even when chemical or hypnotic
analgesia or anesthesia does eliminate the pain ex-
perience, certain physiological correlates of pain do
persist. The concept of a “hidden observer,” a
dissociated entity reporting the existence of pain
while the subject himself consciously experiences no
June. 1978
pain, somehow conveys the idea that chemical and
hypnotic anesthesia and analgesia alter the quality
rather than the totality of the pain experience.
Since readers of this article probably have little
familiarity with the theories, techniques and ap-
plications of the complex phenomena of hypnosis, I
shall illustrate as clearly as possible some of the in-
duction techniques and applications to severe
chronic pain by reporting in detail the conduct of
hypnotherapy with a patient of mine. I shall explain
the rationale for what I am doing or saying. I shall
interpret step by step the patient’s physical, emo-
tional and intellectual responses to my verbal and
nonverbal activities and indicate how the resulting
modulation and elimination of chronic pain is
achieved and maintained.
Insofar as I generally attempt to make the patient
self-sufficient through self-hypnosis, I must at least
give an operational definition of self-hypnosis: It is a
state of hypnosis achieved, maintained, and utilized
without the immediate direct assistance and
guidance of the physician or psychologist. The
methodologies for teaching self-hypnosis include:
1. Written instructions.
2. Oral instructions administered in person or
by audiotapes and videotapes.
3. Observation of other subjects who are learn-
ing or have learned self-hypnosis.
The instructions may be received by the learner
while he is in individual or in group hypnosis, or
before any formal hypnosis is induced. I have util-
ized all of the above modalities; but my personal
preference has been for individual teaching of the
patient while he is in hypnosis according to the
model of hypnotherapy illustrated by the following:
CASE REPORT
Mrs. I.M.T., age 59, had been in chronic pain
since twisting her back two years previously.
Repeated investigations by competent orthopedists
and neurologists had concluded that the pathology
consisted of multiple osteoarthritic hypertrophic
spurs of her vertebral column which impinged
especially upon the posterior roots. The main area of
her pain and consequent disability was the one in-
nervated by the left sciatic nerve. For two years all
therapeutic interventions, including traction and
acupuncture and hospitalizations, had been unsuc-
cessful, and she had been advised by her physicians
“to learn to live with it.” She had been forced to
19
SELF-HYPNOSIS & CHRONIC PAIN
abandon the majority of her activities.
When seen by me, the pain and disability which
had continued for over two years consisted of fre-
quently recurring pain in the neck radiating to the
ears, shoulders and upper extremities, moderate
backache, and almost constant intolerable burning
pain from the left gluteal region to the toes. She had
lost over 20 pounds. Two aspirins four times daily, 5
mg of diazepam afternoons and nights, aspirin and
phenacetin with codeine every 3 hours, and a
sedative for sleep every night were insufficient to give
her comfort. She stated “ I am angry at the world, I
have been a good person, I don’t deserve this.”
I introduced her to hypnosis with my approach of
“conducted reversed hand levitation ,” which in just
a few minutes pinpoints patients with very good
“hypnotic talent.” These are the ones who can learn
hypnosis and self-hypnosis and thereby achieve ade-
quate hypnotic and posthypnotic pain control in
just a few hours, especially if they can be unshackled
from their own and their physicians’ preconceived
anxieties about hypnosis.
In applying the reversed hand levitation technique
of induction and self-induction I had Mrs. I.M.T. sit
near me in an easy chair whereupon I took her right
hand and asked her to observe it with the utmost at-
tention and detachment, “like a sculptor studying
the hand of a model.” This maneuver and verbaliza-
tion usually elicit the development of psychological
and physiological “distance” between the hypnoti-
zand’s own hand and perceptual centers.*
The subliminal changes of support alternating
with tentative abandonment that my hand provides
to the patient’s hand and wrist nonverbally suggest
catalepsy, which develops as a consequence of
postural reflexes with neurological and psychological
di~sociation.~ The hand can become so thoroughly
dissociated that, without specific suggestions, it
becomes as anesthetized as if the brachial plexuy
had been injected. The hand and arm thus set an un-
conscious example for other body parts. As with all
patients, I immediately explained to Mrs. I.M.T.
that, during those few minutes. she had developed
circuits in her brain which would permit her to rein-
duce a state of hypnosis under similar appropriate
circumstances (this also acting as a posthypnotic
suggestion). I added that the hand would be moving
imperceptibly downwards, that her eyelids would be
*For instance. during a teaching nork\hop a phl\ician perceived
his right hand as ot marble
20
closing and that consequently a state of relaxed hyp-
nosis would develop. A spontaneous rotation of her
head from right to left would indicate further
developing hypnosis.
Additional deepening was achieved with the in-
struction that, as I counted down from 10 to 1 , she
would visualize each number in bright colors against
a background of her choice. Simultaneously with
each lower number there would ensue deeper levels
of relaxation in every muscle.
I then explained that, .with the progressive relaxa-
tion, her neck and back muscles would become free
of spasms, thus decreasing the pressure that the
bone spurs had been exerting upon the nerve roots. I
also gave a simplified version of the gate-control
theory: “Your brain is now sending messages to the
gate-control stations to tune down the intensity and
quality of the pain signals, so that you will feel less
and less discomfort . . . your brain will produce a
sufficient amount of your own morphine . . . in the
next six months the spurs in your spine may even
become smaller and less sharp . . . you have been a
good person, I believe you have suffered enough, you
have been punished more than enough . . .” She was
then deepened by “fractionation”: “You mentally
count from 1 to 10 visualizing again each number
until your eyes reopen; they then look at the leaves of
the large houseplant behind my desk, enjoying the
leaves until your eyes close again and sleep begins;
you may just enjoy the sleep or you may have a
dream14.1S.lb - which you can keep from me and
possibly even from yourself until an appropriate
time.” (This is an approach to developing amnesia.)
“You will maintain the learning and the improve-
ment between successive visits to me. During night-
time sleep you will again experience pleasant and
useful dreams.” After dehypnotization she practiced
self-hypnosis by simply lifting her hand and looking
at it in the way she had done before. Following these
instructions: “Then the same sequence will occur
automatically from the moment you first look at
your hand,” the experiences of hetero-hypnosis were
promptly reproduced in self-hypnosis.
Four days later she reported being very relaxed,
having slept better and having been able to take a
walk. The second visit was dedicated to further
rehearsing of the experiences of the previous visit.
In the following week, having continued to prac-
tice self-hypnosis at home for periods of 10 minutes
(during which she heard my voice as if she were in
Journal of Human Stress
SACERDOTE
my office) she began to function in a more normal
way, almost free of pain. The dream that she had
had in my office during hypnosis had involved reex-
periencing lovemaking with her husband, an activity
which had been impossible for over two years. More
practice of hetero- and self-hypnosis was conducted
during the third hour, with suggestions of age
regression to a much younger and much healthier
period of her life. The hour was concluded with sug-
gestions that her body was becoming stronger and
her joints regaining full range of motion, and that
her mood would continue to improve and she would
avoid any further “punishment.”’o~’’~’2~13 Further
improvement continued without additional visits.
Occasional sciatic pain in her left leg did not prevent
the maintenance and consolidation of further gains,
with resumption of a completely normal, active life.
In this clinical case most categories of hypnotic
pain-control were utilized: (a) neurophysiological
and biochemical alterations, (b) perceptual changes,
(c) psychodynamic interventions, (d) creation of dif-
ferent behavioral patterns, (e) alteration in time and
space appraisal. Neurophysiological alterations and
perceptual changes were ushered in immediately by
eliciting dissociation of hand and postural reflexes,
as described. Deepening by visualizing the numbers
10 to 1 prepared her to realistically envision and
utilize a simplified gate-control system and an out-
pouring of endorphins; the muscular relaxation with
elimination of the vicious cycle of spasm-pain-spasm
probably decreased the pressure of spurs upon the
dorsal roots. Psychodynamically, as “idealized
father,” I accepted her belief that she was a good
person and “absolved” her from further “punish-
ment.” She actually introjected me so perfectly that
in self-hypnosis she would hallucinate my voice. This
“regression in the service of the ego” helped her to
re-perceive her body as it was before her invalidism,
thus reactivating healthy, productive behavior. The
induced dream, which she “forgot” for 10 days and
later recollected, tested her capacity to accept the
reality of a healthy, painless future with enjoyable
sexual activity.
CONCLUSIONS
Within the limitation of space I have presented
some of the principles and techniques of hypnosis as
it relates to pain control. I stress again that, while
the vast majority of patients with chronic pain can
benefit from hypnotic approaches, approximately
June, 1978
one out of five have so much innate capability for
hypnosis that excellent results can be achieved with
limited expenditure of effort and time. Only lack of
information and distorted views are still preventing
the healing professions from a routine, systematic
utilization of hypnosis in the relief of pain.
INDEXTERMS
hypnosis, pdn.
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21