Institute for the Study of
Healthcare Organizations & Transactions
Plenary address presented at the annual meeting of the American Pain Society, Atlanta, Georgia, November 3, 2000. The point of view represented in this paper is based on research supported by Grant #MH-35856 from the National Institute of Mental Health. I thank Lucy Canter Kihlstrom for her comments. Painting by Richard Bergh (1887).
In 1843, John Elliotson (1791-1868), Professor of Medicine at University College, London, and the first physician in Britain to adopt the stethoscope for medical examinations, reported on Numerous Cases of Surgical Operations Without Pain in the Mesmeric State (Elliotson, 1843/1977). Mesmer's doctrine of animal magnetism had been discredited more than half a century earlier by a French royal commission appointed to investigate his practices. But this same commission had expressly declined to discredit Mesmer's cures, attributing them to "imagination" rather than to Mesmer's hypothesized physical force (an interesting observation about hysteria and psychosomatics, but one for which 18th-century science was simply unprepared). Partly for this reason, mesmerism continued to be practiced, both as a popular entertainment and as a medical technique. In 1829, a case of mastectomy under "mesmeric coma" was reported to the French Academy of Medicine by Jules Cloquet, professor of surgery at the University of Paris, who was in turn dismissed as a dupe and his patient as an imposter by the former surgeon-in-chief of the Grande Armee. Other, less-well-documented cases go back as far as 1797 (Gravitz, 1988). (Painting by Richard Bergh, 1887.)s
Elliotson himself had
witnessed a demonstration of mesmerism by a visiting French
colleague, and detailed a number of instances in which the
state dramatically altered somatosensory function.
Nevertheless, the Royal Medical and Chirurgical Society of
London dismissed his and others' cases as fraudulent and
banned the technique, leading Elliotson to resign from the
Society and found his own journal, The Zoist, to
publish reports of mesmeric phenomena.
same year, another English physician, James Braid (1795-1860),
attempted to rescue what was worthwhile in mesmerism for both
science and practice by changing its name to neurhypnology
(soon shortened to hypnosis) and offering a new theory
couched strictly in physiological terms (Gravitz & Gerton,
1984; Kihlstrom, 1992b; Kravis, 1988).
protege, the Scottish physician James Esdaile (1808-1859), had
more freedom to practice as a medical officer in the British
East India Company, especially if he was operating on Indians
rather than Englishmen. In 1846, Elliotson published his
observations in a book entitled Mesmerism in India, and
its Practical Application in Surgery and Medicine
(Esdaile, 1846/1977). Included among his many successful cases
were one amputation each of an arm and a breast, two
amputations of penises, three cataracts removed, five cases of
removing enlarged toenails by their roots, seven operations
for fluid buildup in various body cavities, and the removal of
fourteen scrotal tumors, ranging from 8 to 80 pounds in
weight. At a time when surgical mortality was about 40%,
Esdaile reported a rate of about 5% -- a reduction that he
attributed to successful relief of pain with mesmerism.
It is worth remembering that, up until this time, medical and dental surgery was performed without anesthetic, for the simple reason that no anesthetics were available. Like Elliotson, Esdaile hoped that mesmerism would become widely available for the benefit of the public, but he feared it would never happen: "that not many of this generation will live to benefit by Mesmerism, if they wait till it is admitted into the Pharmacopoeia" (1847/1977, p. 9).
words were prophetic, but for different reasons. On October
18, 1846, less than six months after Esdaile's book went to
press, the dentist William T.G. Morton applied an ether-soaked
sponge to the patient Gilbert Abbot, and the surgeon John
Collins Warren, who himself had experimented unsuccessfully
with mesmeric anesthesia earlier in his career, removed a
tumor from Abbott's neck without the patient showing any signs
of pain. Within two years, ether, nitrous oxide, chloroform,
and other chemical anesthetics were widely used in dentistry,
and surgery; and mesmerism was consigned to the dustbin of
history -- at least as an approved medical technique.
fact mesmerism and hypnosis continued to thrive as a source of
popular entertainment. In England, Charles Dickens, who was a
close friend of Elliotson, mesmerized his family and friends
for entertainment, although he would never let himself be
hypnotized. In 1847, Jane Carlyle entered into a "battle of
wills" with a mesmerist who claimed his powers reflected his
moral and intellectual superiority, but who (as she wryly
noted) did not pronounce his hs (Winter, 1998). Later
in the century, in France, observation of hypnotized subjects'
insensibility to pain and other stimuli led Jean-Martin
Charcot and his protege Pierre Janet to draw parallels between
hypnotic and hysterical anesthesia. On the other hand, Milne
Bramwell and Albert Moll, two followers of Charcot's rival
Ambroise Liebeault, debated the effectiveness of hypnosis in
the relief of pain. Janet and his rival, Sigmund
Freud, both used hypnosis in the treatment of hysteria, but
few people gave much thought to the use of hypnosis in the
treatment of real diseases, or real pain (for
an excellent treatment of this early history, see Gauld,
In this era, one
medical application of hypnosis does stand out. In 1862, Mary
Baker Eddy, suffering from an aching back, consulted Phineas
Parkhurst Quimby, a hypnotist in Portland, Maine. His
treatment worked. Quimby, as it happens, had also coined the
term "Christian Science". In 1875, nine years after Quimby's
death, Eddy published the first edition of Science and
health with Key to the Scriptures, and a new religion
Laboratory Research in the Modern Era
For the most part, however, for 100 years after Elliotson (1843) and Esdaile (1846), interest in hypnosis and pain was largely academic, and confined to experimental work. Robert Sears (Sears, 1932) conducted a pioneering study of hypnotically induced pain analgesia, while Frank Pattie (Pattie, 1937) did the same for tactile anesthesia. They and others (e.g., Brown & Vogel, 1938; West, Niell, & Hardy, 1952) showed clearly that hypnotic suggestions altered conscious perception of the pain or touch stimuli, if not always of involuntary or indirect responses as well -- a topic to which I will return later. In the late 1950s and early 1960s, when experimental research on hypnosis was revived by Martin Orne, Ernest Hilgard, J.P. Sutcliffe, Theodore Barber, and their associates, hypnotic analgesia was there in the center of things (e.g., Barber, 1963; Barber & Hahn, 1962; Shor, 1962; Sutcliffe, 1961).
The attraction of analgesia to the first generations of modern hypnosis researchers was, I think, threefold. (1) With the possible exception of hypnotic amnesia (which after all gave hypnosis its very name), analgesia is the most dramatic of the alterations in consciousness observed in hypnosis. (2) It is also the most susceptible to "objective" measurement -- although, as I will indicate later, this feature has been somewhat overstated. (3) And, of all the phenomena of hypnosis, it has the most potential for practical use. Therefore, it is not surprising that when Jack Hilgard began his systematic study of hypnosis, he would quickly come to focus on analgesia.
single most important fact about hypnosis is that there are
individual differences in response to hypnotic suggestion.
Unfortunately, hypnotizability cannot be predicted by the usual
sorts of paper-and-pencil questionnaires, but must be assessed
directly by means of performance-based assessments of
hypnotizability analogous to intelligence tests. The Stanford
Hypnotic Susceptibility Scales, devised by Hilgard and Andre
Weitzenhoffer in the late 1950s and early 1960s, begin with a
standardized hypnotic induction procedure followed by a series
of suggestions for imaginative experiences. The subject's
response to each of these suggestions is scored according to an
objective behavioral criterion. When these scales are
administered to unselected samples, they yield a roughly normal
distribution of scores: while relatively few subjects are
entirely refractory to hypnosis, what Hilgard referred to as
"hypnotic virtuosos" comprise only about 10%-15% of the
relevance of hypnotizability to hypnotic analgesia is shown
clearly in an early laboratory study by Hilgard involving
cold-pressor pain stimulation in which subjects' hands and
forearms are immersed in circulating ice water (Hilgard, 1967;
Hilgard, 1969, 1978). The result is a very good laboratory
analog of clinical pain. Under normal conditions, pain
mounts rapidly over the course of a minute or so, as indicated
by subjects' reports on an open-ended scale. However, when
hypnotized and given suggestions for analgesia, subjects of
relatively high hypnotizability gain substantial pain relief:
they may still feel some pain, but even after 60 seconds the
majority find the levels to be tolerable.
course, pain has two components, measured on the McGill Pain
Questionnaire as sensory pain, providing information
about the location and severity of an injury, and suffering,
or the "meaning" of the sensory pain. During his
psychophysical investigations Hilgard found that hypnosis alters
both of these components. In one study, involving ischemic
muscle pain produced by cutting off the flow of blood to the
forearm, both pain and suffering were reduced essentially to
zero in a group of highly hypnotizable subjects (Knox, Morgan,
& Hilgard, 1974).
recent brain-imaging study by Rainville and his associates
showed that strategically worded suggestions can dissociate the
two components of pain, selectively altering one but not the
other (Rainville, Duncan, Price, Carrier, & Bushnell,
1997). These investigators then used this dissociation in
a provocative brain-imaging study which indicated that the two
components of pain have different biological substrates: sensory
pain in the primary somatosensory cortex, and suffering in the
anterior cingulate cortex -- the same place where other
investigators have recently located romantic love! (The
figure shows activation in the right hemisphere because the pain
stimulus was applied to the left hand.)
same lines, an unbelievably spartan study by John Stern and his
associates compared the effectiveness of seven different
challenging agents -- hypnosis, acupuncture, placebo
acupuncture, morphine, aspirin, diazepam, and placebo pill --
against two kinds of pain in a within-subjects design that
entailed a total of 280 pain trials per subject (Stern, Brown,
Ulett, & Sletten, 1977). Analysis of the subjects'
cold-pressor pain ratings showed that hypnosis was superior to
all other challenging agents, especially for those subjects who
were highly hypnotizable. Interestingly, only hypnotic analgesia
was correlated with hypnotizability. Similar findings were
obtained for ischemic muscle pain.
recently, a meta-analysis of clinical and experimental studies
reported by Montgomery and his colleagues compared hypnosis
against a number of other cognitive-behavioral interventions
(Montgomery, DuHamel, & Redd, 2000). The studies in
question were a mix of the clinical and experimental, with most
of the experimental studies involving cold-pressor pain and the
clinical studies including patients suffering from both burns
and cancer. Comparing hypnosis to a no-treatment control,
Montgomery et al. found that the effect of hypnosis corresponded
to a standardized effect size of d = .74, which counts
as a moderately large effect size by conventional standards.
More than a quarter of the comparisons yielded very large ds
of 1.0 or more.
bigger in clinical patients than in experimental subjects,
and especially large among those of high hypnotizability.
Comparing hypnosis to a variety of other cognitive-behavioral
treatments tested in the same studies, Montgomery et al. found
no particular advantage for hypnosis, but this analysis did not
take hypnotizability into account. It is likely that
hypnotizable subjects would have gained more from hypnosis than
from any other psychological treatment.
Even before systematic laboratory studies appeared to support the practice, clinicians in the field were returning to hypnosis. In part, the revival of interest in clinical hypnosis was stimulated by the successful use of the technique during World War II, where chemical analgesics and anesthetics were not always available for the treatment of wounded soldiers. In preparing their authoritative review of Hypnosis in the Relief of Pain, Hilgard and Hilgard uncovered more than two dozen cases, published between 1955 and 1974, in which hypnosis served as the sole analgesic or anesthetic agent (Hilgard & Hilgard, 1975). One enthusiastic practitioner of clinical hypnosis even had a film made of her own cosmetic dermabrasion, essentially sandpapering off whole layers of facial skin with hypnosis as the sole analgesic, just to show it could be done. Recently, a group of Belgian investigators reported a series of 1,650 surgical cases attempted with "hypnosedation", in which fewer than 1% required a switch to general anesthesia (Faymonville, Meurisse, & Fissette, 1999). Nevertheless, the general consensus is that vanishingly few patients, far fewer than the 10% or so who qualify as hypnotic virtuosos, are hypnotizable enough to tolerate such procedures with hypnosis alone. This should only be attempted as a last resort, and the real applications of hypnosis lie elsewhere.
One of these
applications is obstetrics. So far as labor pain is concerned,
regional and general anesthetics will do the job, but ever since
Queen Victoria took chloroform during the delivery of her eighth
child, there has been concern that drugs might increase the risk
to the fetus, detract from the experience of childbirth, or
interfere with the mother-child bond. These concerns help
explain why chemical anesthesia, quickly embraced for other
surgical procedures, was not widely adopted for obstetrics until
late in the 19th century (Pernick, 1985). By the
1950s, obstetricians were already familiar with other
psychological techniques for pain reduction, such as Dick-Read's
"natural childbirth", the "Lamaze method", and Schultz's
autogenic training. It seems likely that the desire to avoid
drugs whenever possible explains why some of them looked to
hypnosis as a scientifically respectable, more mainstream
event, a pioneering large-scale study by Ralph August reported
on 1000 consecutive cases, in which hypnosis was attempted in
850 (August, 1961). Of these, 58% required no medication at all,
38% required only minor analgesics such as Demerol, and 4%
abandoned hypnosis entirely in favor of local or general
anesthetics. At about the same time, Davidson reported
that the benefits of hypnosis were equal to those of natural
childbirth in the first stage of labor, and superior in the
second stage (Davidson, 1962). Other early reports indicated
that hypnosis is associated with decreased frequency of
premature labor (and thus spontaneous abortion), reduced
duration of labor, more rapid recovery from birth asphyxia in
the neonate, and increased satisfaction with the childbirth
experience on the part of the mothers.
results were obtained in cancer treatment. Some enthusiasts have
tried to treat cancer directly with hypnosis, suggesting that
subjects imagine "good cells" fighting off "bad cells" and the
like. This rarely works, of course, and when it does seem to
work the remission is almost certainly adventitious and has
nothing to do with hypnosis. Nevertheless, the patients often
obtain considerable relief from pain caused either by cancer or
its treatment. Cangello studied 81 patients, 73 of whom
seemed to be at least moderately hypnotizable (Cangello, 1961).
Of this subgroup, his clinical impression was that almost 70%
achieved good to excellent relief of chronic pain. For the 22
patients for whom narcotics had been prescribed for pain
control, 63% showed an immediate decrease in medication usage to
50% or less of base levels; this reduction lasted for a week in
54%, and for 1 to 3 months in 18%, with no reinforcement of the
Unfortunately, these studies appeared on the eve of a revolution in medical practice. Clinical medicine has always been based on biology, of course, but the golden age of antibiotics, in the 1940s and 1950s, culminated in the apparent conquest of infectious disease and prompted advances in immunology that promised to prevent disease at its source. New generations of analgesics and anesthetics came onto the market, as well as new procedures such as epidural anesthesia for childbirth and conscious sedation for outpatient procedures. These developments led physicians once again to turn away from hypnosis and toward drugs.
study of hypnosis in dentistry makes the point (Gottfredson,
1973). Gottfredson found that 56% of hypnotizable patients
were able to complete their procedure without any chemical
analgesic at all, and this figure was 75% for those of
relatively high hypnotizability. However, local anesthetic
produced a comparable effect, without any individual differences
in response. Although mesmeric coma was used for dentistry prior
to the introduction of chemical anesthesia, and many dentists
still use hypnosis to treat anxiety in the chair, chemical
analgesics and anesthetics are simply more reliable, and these
days hypnosis is rarely used for the relief of dental pain.
In the late 1970s, Joseph Barber (Barber, 1977) claimed a 99% success rate with an innovative technique, which he calls "rapid induction analgesia", in a series of unselected patients. A follow-up study by Gillett and Coe (Gillett & Coe, 1984) yielded a success rate more like Gottfredson's, 52%. Outcome was uncorrelated with hypnotizability, however, suggesting that whatever effects RIA has are not mediated by hypnosis.
these promising results, there have been virtually no
controlled, quantitative studies of hypnotic analgesia in
clinical settings (Chaves, 1989; Chaves & Dworkin, 1997;
D'Eon, 1989; Holroyd, 1996; Milling & Costantino, 2000;
Pinnell & Covino, 2000). One exception is in the area of
obstetrics, where more recent studies have confirmed and
extended the early results of August and Davidson (Brann &
Guzvica, 1987; Freeman, MacCauley, Eve, & Chamberlain, 1986;
Jenkins & Pritchard, 1993). Another is cancer, where a
number of studies support the use of hypnosis. In a
pioneering study, Josephine Hilgard and Sam LeBaron (Hilgard
& LeBaron, 1982) offered hypnosis to 63 consecutive children
who were receiving bone marrow aspirations required for
treatment of leukemia. Of the 24 who accepted the referral, 19
proved to be at least moderately hypnotizable. After only one
session of training, 10 of these patients were able to reduce
felt pain during the procedure by at least three points on a
10-point scale; with a single additional training session, the
success rate rose to 15 of 19 when the procedure was repeated
about six weeks later. None of the five less hypnotizable
subjects reported substantial relief of pain on either occasion.
Similar findings were obtained in another study of children with
leukemia being treated with bone marrow transplants (Syrjala,
Cummings, & Donaldson, 1992).
Although many early clinical studies were relatively primitive by the standards of modern research, they clearly demonstrated that hypnosis is an effective challenging agent for both clinical and experimental pain. The next question is how hypnosis works, and for that we must return to the laboratory. One theorist, taking a skeptical view of things, suggested that the reason hypnosis works is that most surgical procedures don't really hurt anyway, and to the extent they do, hypnotized subjects try to please their physicians by reporting otherwise. I think that Esdaile had the most effective response to this claim when he wrote of the large numbers of patients flocking to his clinic for the removal of tumors:
One thing we know is that hypnosis is not mediated by stimulating the flow of endogenous opiates. In a collaboration with Jack Hilgard, Avram Goldstein, who originally discovered the existence of specific opiate receptors in the brain, showed that naloxone, an opiate antagonist, has no effect on hypnotic analgesia (Goldstein & Hilgard, 1975). This finding has been subsequently been confirmed by other investigators (Barber & Mayer, 1977; Spiegel & Albert, 1983). For example, Moret and his colleagues gave unselected subjects suggestions for hypnotic analgesia during cold-pressor pain. The suggestions were successful in relieving pain by about 50% on average, but this success was not accompanied by increases in serum beta-endorphin levels. Nor did the infusion of Naloxone have any effect on the effectiveness of hypnotic analgesia. I don't wish to sound like a dualist, but it appears that hypnotic analgesia is mediated by psychological processes, not by any indirect physiological effects.
There must be some reason for this, and I only see two ways of accounting for it: my patients, on returning home, either say to their friends similarly afflicted, "Wah! brother, what a soft man the doctor Sahib is! he cut me to pieces for twenty minutes, and I made him believe that I did not feel it. Isn't it a capital joke? Do go and play him the same trick...". Or they say to their brother sufferers, -- "look at me; I have got rid of my burthen..., am restored to the use of my body, and can again work for my bread: this, I assure you, the doctor Sahib did when I was asleep, and I knew nothing about it...".
some theorists have linked hypnosis to expectancy processes, it
also appears that hypnotic analgesia is more than a
placebo. In one study, McGlashan, Evans, and Orne
recruited subjects for a study comparing hypnosis to medication
in the relief of ischemic muscle pain (McGlashan, Evans, &
Orne, 1969). Unbeknownst to the medical student who was running
the study, during the drug trials the subjects received placebo
packed in Darvon capsules. Insusceptible subjects got equivalent
pain relief from hypnotic suggestion and from placebo. However,
the hypnotizable subjects obtained substantially more relief
from hypnosis than they did from placebo. The study suggests
that hypnosis, like all effective analgesics, has a placebo
component mediated by expectancies of success. Placebos are
important, and they're ubiquitous, but, in hypnotizable subjects
at least, hypnosis is more than placebo.
As an alternative to the endorphin and placebo theories, Jack Hilgard has proposed that hypnotic analgesia involves a division of consciousness, in which an amnesia-like barrier prevents conscious awareness of pain (Hilgard, 1973; Hilgard, 1977). This proposal helps make sense of one of the paradoxes of hypnosis, which is that it alters people's self-reports of pain but not their physiological responses to the pain stimulus. One interpretation of this difference is that the subjects are really feeling the pain after all, but we also know on independent grounds that physiological measures are relatively unsatisfactory indices of the subjective experience of pain. From the perspective of Hilgard's neodissociation theory of divided consciousness, the reduced self-ratings are accurate reflections of the subjects' conscious experience of pain, while the physiological measures show that the pain stimulus has been registered and processed outside of conscious awareness by the sensory-perceptual system. Put another way, hypnotic analgesia impairs the explicit perception of pain while leaving the implicit perception of pain intact (Kihlstrom, 1987; Kihlstrom, 1996; Kihlstrom, Barnhardt, & Tataryn, 1992). This dissociation is of considerable interest to those of us who are interested in consciousness and unconscious mental life. But because it is the conscious awareness of pain that bothers both experimental subjects and medical patients, the fact that hypnosis does not affect some physiological responses should not stand in the way of its clinical use.
On the other hand, the late Nicholas Spanos (Spanos, 1986) argued that hypnotic analgesia is achieved by the deployment of certain coping strategies identified by Donald Meichenbaum and others as stress inoculation (Meichenbaum, 1975; Meichenbaum & Turk, 1982). Now, there's no doubt that distraction, relaxation, imagining situations inconsistent with pain, and resistance to "catastrophizing" can result in substantial pain relief -- the question is whether these strategies account for hypnotic analgesia. Apparently, they do not (Hargadon, Bowers, & Woody, 1995; Miller & Bowers, 1986, 1993).
test of the stress-inoculation theory, Miller and Bowers ran
groups of hypnotizable and insusceptible subjects through an
experiment involving cold-pressor pain. One third of the
subjects in each group was hypnotized, and given suggestions for
analgesia. Another third was hypnotized, but not given any
analgesia suggestions. The remaining subjects were not
hypnotized at all, but were instructed in the use of stress
inoculation strategies of the sort that Spanos had proposed as
mediators of hypnotic analgesia. The result was a highly
significant, and revealing, interaction between treatment
condition and hypnotizability: stress inoculation worked as
expected, producing substantial pain relief, but hypnotizable
and insusceptible subjects achieved the same effect. By
contrast, hypnotic suggestions for analgesia were much more
effective for hypnotizable than for insusceptible subjects.
Note, too, that for hypnotizable subjects, hypnotic analgesia
produced more pain relief than stress inoculation. But the
important observation is that hypnotic analgesia is mediated by
hypnotizability, while stress inoculation is not.
later study, Miller and Bowers assigned subjects of low and high
hypnotizability to stress inoculation and hypnotic analgesia
conditions, but with a somewhat fiendish twist: during the
cold-pressor tests the subjects were also administered a
difficult vocabulary test. The idea was that consciously
deployed cognitive strategies, such as those taught in stress
inoculation, ought to consume attentional capacity and impair
performance on the vocabulary test. This was, in fact, the
outcome for the subjects in the stress inoculation condition. In
the hypnotic condition, however, vocabulary scores were
essentially unaffected, and for hypnotizable subjects actually went
up a little.
third and final paper in the series, Hargadon, Bowers, and Woody
gave hypnotizable subjects analgesia suggestions of two types --
one suggested a lot of counterpain imagery, the other did not.
Of course, some subjects in the imagery condition didn't use
imagery, and some in the no-imagery condition used imagery
anyway, and some just focused on the pain and catastrophized.
The important result was that the use of imagery, whether
instructed or spontaneous, had no impact on the success of
hypnotic analgesia in these hypnotizable subjects -- suggesting,
once more, that counterpain imagery is not central to hypnotic
This set of results
strongly suggests that whatever its underlying mechanisms,
hypnotic analgesia is not mediated by stress inoculation and
other consciously deployed cognitive strategies. For
insusceptible subjects, incapable of responding to hypnotic
suggestions, stress inoculation strategies can produce
considerable benefit; but for hypnotizable subjects, hypnotic
analgesia is probably preferable to stress inoculation as a
psychological technique to control pain. In my view, this leaves
Hilgard's neodissociation theory as the most viable explanation
of hypnotic analgesia. We may hope that our growing
understanding of unconscious mental life will shed more light on
the mechanisms by which this dissociation takes place
(Kihlstrom, 1992a; Kihlstrom, 1997).
set theoretical considerations aside and return to the practical
utility of hypnotic analgesia in clinical situations. Perhaps
the best evidence in this regard comes from two randomized
studies reported by Lang and her colleagues with patients
undergoing a variety of invasive diagnostic and treatment
procedures (Lang et al., 2000; Lang, Joyce, Spiegel, Hamilton,
& Lee, 1996). In the more recent of these, reported in
the Lancet earlier this year, all patients received
standard patient-controlled conscious sedation for the
procedure, with one third receiving hypnosis and another a
structured attention manipulation. The addition of hypnosis
afforded significantly greater pain relief than did conscious
sedation alone, with the attentional manipulation falling
somewhere between. In addition, patient anxiety levels
were also lower with hypnosis.
receiving the adjunctive psychological treatment requested, and
received, less medication than did those in the standard group.
Finally, there were fewer adverse events, such as oxygen
desaturation, hemodynamic instability, bleeding from the
puncture site, oversedation, and vomiting to distract the
for these reasons, the surgical procedures took significantly
less time for the hypnosis group than for the standard care
group, by about 15 minutes on average. Unfortunately, Lang
and her colleagues did not assess hypnotizability in their
patients, but it is a pretty certain bet that these benefits
were much greater for those who were at least moderately
Twice in its history, hypnosis has sought a place in the clinician's repertoire of methods for pain control. The first time was in the middle of the 19th century, before hypnosis even had its name. Unfortunately, it was quickly overshadowed by the discovery of chemical anesthetics. The second time was in the middle of the 20th century, in parallel with the emergence of a substantial body of laboratory research on hypnosis and its underlying mechanisms. This time, although the scientific status of hypnosis was widely acknowledged, the practical use of hypnosis fell victim to the renewed biologization of medical practice. Even so, there is no question that hypnotic analgesia deserves the status of an empirically supportive psycholoical treatment for pain (Chambless & Hollon, 1998; Lynn, Kirsch, Barabasz, Cardena, & Patterson, 2000; NIH Technology Assessment Panel, 1996). To be blunt, hypnotic analgesia is efficacious and specific: its efficacy is supported by a large number of methodologically sophisticated studies conducted by many independent investigators; it is not merely a placebo; in those who are hypnotizable, it is superior to both placebo and alternative psychological treatments such as stress inoculation. Based on the available evidence, approximately 50% of unselected patients can obtain significant pain relief from hypnosis.
The current environment
of healthcare, in which consumers are seeking effective
alternatives to the chemical interventions that are the standard
of care, provides hypnosis with an opportunity to rise again. It
is complementary medicine that works, and which rests on an
impressive base of laboratory research. But this same
environment also offers hypnosis a new challenge: that it be not
simply effective, but cost-effective as well.
These days, when I tell practitioners about hypnosis, they
believe the evidence, but they ask whether it is reimbursable by
managed care. Fortunately, many health plans now pay for
complementary treatments, so long as there is evidence of their
effectiveness. But this practice is likely to continue only so
long as the treatments in question are cost-effective as
well. The available evidence strongly indicates that adjunctive
hypnosis can improve the quality of care, by reducing patient
anxiety and the number of adverse events; and that it is
cost-effective, by reducing the length of procedures and the use
of expensive medications. Now that healthcare consumers have
become interested in "natural" alternatives to traditional
medicine, and demanding that their health plans pay for them,
the time is ripe for a new look at hypnosis and pain, with
quality of care and cost-effectiveness in mind.
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