Hypnosis in the Relief of Pain

JOHN W. LAUER, M.D.*

HISTORICAL PERSPECTIVE
The condition known as hypnosis has been recognized through the
ages, and recorded descriptions of it date back to the eighteenth century
B.C., in China. 33 Hypnosis is known to have been practiced in other
ancient cultures, including those of the Hebrews, Celts, Egyptians and
Greeks. Instances of mass hypnotic performances in the Middle Ages-
the "dancing manias" - are legion. The trance state is a part of medical
and religious experience in currently existing primitive societies, such
as those of the Eskimos, American Indians, South American Indians,
many Africans and Hawaiians. It is also possible to induce hypnotic
phenomena in modern, civilized people. This unive:rsality of the trance
state, in a wide range of times and cultures, indicates that it is in the
natural order of man's experience. Additional proof that the trance
is an ordinary event is the common phenomenon of highway hypnosis.
Bright headlights, focusing on the unending white line painted on black
asphalt, the rhythmical beat of the wind shield wiper and the monoto-
nous whirr of the engine have induced trances in many motorists.
Introduced and popularized as a treatment modality in formal medi-
cal practice by Mesmer in the eighteenth century, l hypnosis immediately
became a controversial issue. Mesmer attempted to explain hypnosis
under the concept of "animal magnetism." He postulated the existence
of an imperceptible fluid that bathed man inside and out and which,
through the influence of magnets, could be made to flow from person
to person. 25 By having a group of subjects hold hands he was able to per-
form multiple simultaneous trance inductions, using suggestion and
artifacts, including the "baguette" and special lighting techniques.
The Marquis de Puysegur, a follower of Mesmer, accidentally dis-
covered the somnambulistic state (deep trance or hypnotic sleep),
with associated amnesia, which became recognized as the classical hyp-
notic phenomenon. 8 The hypnotic sleep state was utilized initially for
surgical anesthesia for a mastectomy by the French surgeon Cloquet on
April 12, 1829. 25 Braid coined the term hypnotism and reported the use

':'Assistant Professor of Neurology and Psychiatry, Northwestern University Medical School;

Associate Attending Psychiatrist, Chicago Wesley Memorial Hospital

Medical Clinics of North America- Vol. 52, No. 1, January, 1968 217
218 JOHN W. LAUER

of the technique to produce anesthesia for surgical procedures. Elliot-

son and Esdaile employed the method similarly. But with the advent of
chemical anesthetics, hypnosis was all but abandoned in the operating
suite.
In the following decades interest in hypnotism waxed and waned,
and it was condemned or favored in an irregular cycle. In Mesmer's
time the question was raised as to whether the trance state was real or
simulated. In the late nineteenth century, the N ancy School, founded by
Liebeault and championed by Bernheim, contended that hypnosis was
only suggestion. Opposing this view was the physiologically oriented
Salpetriere School of Charcot, represented by Babinski, teaching that
hypnosis was a pathologic state found only in hysterics and that it could
be induced and terminated with magnets. Today, the existence of the
trance state is generally accepted, but some investigators question
whether it enhances the relief from pain obtained by suggestion in the
waking state. 2

THE ESSENTIAL ELEMENTS

Hypnotic procedures initiated for the relief of pain are dependent for
success upon the combined efforts of doctor and patient. The doctor must
be skilled in a method of trance induction and utilization. Erickson
advocates using the presenting behavior of the patient as an actual part
of induction, rather than the traditional formalized techniques. 9 He
believes that this method can be continued smoothly in deepening and
in utilizing the trance successfully, once it has been achieved. He notes
that South American, Asiatic and Italian colleagues only occasionally
encounter patients resistant to trance induction. 6 Cultural differences,
particularly in attitudes toward authority figures, are important. Investi-
gators in this field all stress the fact that the operator's skill in using the
trance in attaining the desired goal is far more important than the
method of induction.
However it is initiated, the trance is arbitrarily divided into three
stages. The light trance, or hypnoidal phase, is characterized by a feel-
of calmness, muscular relaxation, lethargy and increased receptivity
to the operator's suggestions. The second stage, or medium trance, is
marked by intensification of the features of the first stage plus sensory
and specific or generalized motor alterations. Catalepsy, tactile halluci-
nations and responsiveness to posthypnotic suggestion can be demon-
strated in this phase. The third stage, deep trance or somnambulism,
is distinguished by profound muscular relaxation and a tendency to
develop spontaneous amnesia for that period. During this stage, age
regression is possible, permitting recall of long-repressed material.
Positive and negative hallucinations, the latter a denial of perception of
an object that is present, time distortion and profound anesthesia can
be produced in the third stage.
HYPNOSIS IN THE RELIEF OF PAIN 219
This division into stages is arbitrary and related as much to the de-
gree of muscular relaxation as to the various phenomena elicited. These
characteristics, excepting amnesia, can occur at any point in the pro-
cedure. The "Braid effect." which consists of alternating pupillary size-
constriction then dilatation - "wavy" pupil motion, eyelid closure, gen-
eral tonic rigidity, specific catalepsies associated with rises in the pulse
rate, hypersuggestibility and stupor, was thought by Braid to represent
an unequivocal sign of the trance state. 32 Orne delineated four subjec-
tive signs which he believes the patient experiences when in a trance.
These are discontinuity from normal waking experience, a compulsion
to follow the cues given by the hypnotist, a potentiality for feeling as real
any distortions of perception, memory or feeling suggested by the hyp-
notist and the ability to tolerate logical inconsistencies that would be
distrubing to the awake individual.2°
The patient seeking relief from pain through hypnosis is usually a
willing subject. Although desirable, willingness might be secondary in
importance to the "hypnotic attitude" and the attitude of trust in oneself
and in others.3 The "hypnotic attitude" is defined as waking behavior
wherein the subject tends to be responsive only to selective stimuli for
extended periods of time. This characteristic is found frequently in
somnambules and much less often in unresponsive hypnotic subjects.
Estimates of the hypnotizability of the general population range from 10
to 95 per cent. 21 Most investigators agree that 20 per cent of the popula-
tion can attain the somnambulistic stage. Marmor contends that fewer
than 10 per cent of surgical patients can reach a level of trance suffi-
ciently deep to permit major procedures with hypnosis alone. IS Barber
questions whether the hypnotic trance relieves pain above and beyond
suggestion in the waking state. 2 He cites a case of major abdominal
surgery performed with only suggestion in the waking state, without
chemical anesthesia or a trance. The complexity of the physiology of
pain is discussed elsewhere in this volume. Not to be overlooked is the
inseparably interlaced affective component.

EMOTIONAL REACTION TO PAIN

The soldier wounded in battle frequently will not experience pain
from his injury, although he may complain of discomfort from an in-
jection. His wound is a badge of heroism, an honorable passport out of
combat and proof that he has survived the threat of death.
A stable, emotionally mature pregnant woman, interested in her own
physiology, eager to have a baby and enthusiastic about observing and
experiencing the birth process, bears her child in the waking state with-
out suffering from the pain of labor. Another woman, equally sensitive
and bright, but reared in an atmosphere that emphasizes the terrors of
childbirth, requires heavy sedation throughout labor, and deep anes-
thesia for the moment of delivery.
A spectator at a football game incurs a simple ankle sprain leaving
220 JOHN W. LAUER

the grandstand. He is incapacitated and unable to work for several

weeks. He may limp for months and complain indefinitely of discomfort
with weather changes. A player in the same game suffers a Colles' frac-
ture. He is eager to play by the following week and may actually return
to the lineup in two to three weeks. He is neither suffering with pain
nor using it.
Receptor end organs, neuroanatomic pathways and neurophysio-
logic processes provide the route and the chemical processes for the
transmission of painful stimuli to the brain. The emotional reaction
to the pain determines the degree of suffering experienced. Physiological
processes and anatomical structures provide the substrate for the emo-
tional reaction too, but past experiences stored in these structures are
the reference against which the new stimulus is evaluated to deter-
mine the emotional reaction.
Hypnosis cannot alter an organic lesion initiating a painful stimu-
lus. The depth of the trance appears unrelated to the degree of success
achieved in therapeutic results. 5 Despite these facts, hypnosis is em-
ployed over a wide range of painful conditions in an effort to reduce
discomfort.

HYPNOSIS AND PAINFUL STATES

Malignant disease, often accompanied in the terminal stages by
excruciating pain, holds most people in terror. Cancer evokes more fear
and is considered more personally threatening than nuclear warfare.
Generations have come and gone living in the shadow of malignant dis-
ease. Small wonder that a diagnosis of cancer provokes suicide in some,
anticipation of long suffering in others. Physicians, identifying with
the suffering and hopelessness of the patient, all too frequently supply
generous quantities of analgesic and narcotic drugs to curb the pain.
The patient, dreading his fate, liberally doses himself and early in the
illness suffers the additional discomforts of mental confusion and fear
of addiction. The quantity of drug used and the frequency with which it
is taken often push the reaction to the border of toxicity. In these cir-
cumstances the patient is not only facing death from the underlying
disease but is deprived of utilizing the precious time that remains in a
meaningful way with his loved ones. Through the utilization of the
various phenomena of the hypnotic state, substantial relief may be
achieved in such a situation. 4 • 10, 16, 27, 29
Once the trance state is induced, a variety of tools that can be used
to relieve pain become available, including body disorientations and
dissociations, anesthesia and analgesia for superficial and deep sensa-
tion and suggestion to alter the character of the pain or the patient's
attitude to it. Evaluation of the total patient and his needs, including
the secondary gains derived from the environment in relation to the suf-
fering, must be considered. Positive results are frequently achieved
through medium or light trances.
Patients with malignant disease are frequently better candidates
for successful pain relief through hypnosis than patients with other
HYPNOSIS IN THE RELIEF OF PAIN 221
painful states. This may relate to their desperate need for pain relief or
to the fact that denial of pain is compatible with the wish to deny the
existence of the disease. The best results are noted when the idea to use
hypnosis originates with the patient or his personal physician. Con-
flicting attitudes between physicians about the use or effectiveness of
hypnosis in an individual case ensures certain failure for the procedure
and can have adverse effects on the patient. 29 In most cases of terminal
malignant disease, neither pain nor the need for some medication will be
completely abolished. If medication can be limited to a non-narcotic
analgesic or a small infrequent dose of a narcotic, a great service is
accomplished for the patient.
The suffering experienced in labor and delivery varies widely. Obste-
tricians are acutely aware that attitudes toward pregnancy and antici-
patory sets of ideas about delivery are significant factors in determining
the degrees of discomfort reported by patients. Immature or negative
maternal attitudes toward labor or delivery may indicate similar re-
sponses that might occur in the relationship of the mother with her
newborn child. An anesthetized woman misses the significant mo-
ments of relating to her child that take place at delivery and immediately
afterward. Narcotic analgesics during labor and general anesthetics
during delivery present the threat of fetal anoxia. The nine-month
gestation period presents an excellent opportunity and ample time to
train the parturient in the utilization of the trance state. Maternal
attitudes that might have far-reaching effects on the delivery and on the
newborn can at least begin to undergo alterations if exposed and dealt
with during this period. Should cesarean section be necessary, preopera-
tive tranquility is better and a lighter plane of anesthesia can be main-
tained when the trance state is utilized. Hypnosis can abolish the fear
of the surgical procedure and the operating room. Postoperative mor-
bidity, including nausea, vomiting and complaints of pain, can be signifi-
cantly reduced by posthypnotic suggestions given during operation. The
amount of postoperative analgesic drugs required becomes [Link]
The sight or thought of the dentist and his equipment causes most
people some degree of discomfort. Aching teeth frequently become pain-
less when one enters the dental office. The pain is quick to return, how-
ever, if the necessary work is not performed. Perhaps it is because of
these strong but ordinary emotional reactions to his profession that the
dentist has been in the foreground in efforts to conquer pain. The use of
hypnosis in dental practice today is commonplace. Most dentists utiliz-
ing the trance state do not always attempt to avoid analgesics com-
pletely. They employ local, regional or general anesthetics when neces-
sary to relieve pain.17 They do report, however, that considerably smaller
amounts of chemical agents are required for pain relief when hypnosis
is used concurrently in their operative procedures. Hypnosis can also
overcome gagging, which is probably second only to pain in hampering
the smooth completion of dental work.
As noted, hypnosis was all but abandoned in general surgery as
chemical anesthetic agents became safer. In the past 20 years the re-
awakening of interest in hypnosis has returned it to the operating suite
222 JOHN W. LAUER

as an adjunctive to chemical anesthetics. Marmor lists eight indications

for the use of hypnosis in anesthesiology. (1) To overcome anxiety and
reduce the tension associated with the anticipated anesthesia and
operation. (2) For sedation, in conjunction with or in place of drug
medication. (3) To increase patient cooperation. (4) To produce analgesia
or anesthesia, thereby reducing the amount of chemical agents used or
replacing them altogether. (5) To provide a more comfortable post-
operative period. (6) To allow for posthypnotic suggestions, useful in
reducing nausea and vomiting. This can also make deep breathing and
coughing less painful and help to reduce postoperative pulmonary com-
plications. Raising the pain threshold will reduce the need for post-
operative narcotics, as well as encourage earlier oral fluid intake and
better urinary output. (7) To produce operative amnesia. (8) To improve
postoperative morale and motivate the patient toward health. 19
Hypnosis alone or in conjunction with other measures has been
reported as useful in relieving suffering in a number of painful medical
and surgical conditions. 34 Discomfort associated with trigeminal neu-
ralgia, causalgia, postherpetic neuralgia, cervical disk disease, peptic
ulcer, burns and painful conversion reactions has been decreased
through use of the hypnotic trance. Along with producing analgesia,
hypnosis has been helpful in burned patients by improving their coopera-
tion with treatment, fluid balance, nutritional status and the will to live.

HAZARDS OF HYPNOSIS
Hypnosis is a simple procedure, relatively innocuous compared to
the administration of many analgesic or anesthetic drugs, but used
injudiciously it is not without danger. Some skill and a little knowl-
edge on the part of the operator make it possible to induce the hypnotic
state and carry it to deeper levels. But successful utilization of the
trance for therapeutic purposes requires that the operator be informed.
No one should use hypnotic techniques unless he has either a thorough
acquaintance with psychodynamics or an awareness of his limitations in
this area. Only such knowledge will enable him to terminate the trance
safely if the patient's responses suggest danger. In the hands of the
experienced, hypnosis is an invaluable research tool and therapeutic
device. Dentists, surgeons, internists, anesthesiologists and other physi-
cians, although not sophisticated in psychological matters, with their
scientific background and with some formal training, can learn hyp-
notic techniques and use them safely for certain procedures. The uses of
hypnosis should be taught in medical and dental schools primarily by the
department of psychiatry. Unfortunately few medical or dental schools
teach hypnosis and postgraduate programs are scarce, but they are
available in some large medical centers.
Patient selection is as important as the operator's training if mis-
haps are to be avoided. Nothing can replace careful history taking as a
means of screening out subjects who might suffer untoward effects in
the trance state. Individuals with severe psychiatric disorders are gen-
erally difficult or impossible to hypnotize. Frustrated by failure, however,
they may well make the operator the object of pent-up rage. Patients
HYPNOSIS IN THE RELIEF OF PAIN 223
with neurotic disturbances, on the other hand, often readily hypnotized,
may experience a severe panic reaction if their defenses are inadvert-
ently tampered with during a trance. Acute anxiety related to an illness
or injury makes for increased susceptibility to suggestion and renders
the individual more easily hypnotizable.
Traditionally, novice hypnotists are advised to have a woman assist-
ant within earshot when working with a female subject. Although this
precaution is usually satisfied by the office nurse, it seldom is neces-
sary. Rarely will an hysterical patient claim sexual assault based on
wish-fulfillment in the trance. If the patient displays strong sexual
fantasies or if the waking behavior is seductive, caution must be ob-
served.
Unexpected results from attempts to remove symptoms by means of
hypnosis merit consideration. Formerly, most medical treatment was
aimed at symptom removal or improvement. The causes of the illness
were not usually considered. If the patient was ready to give up his
symptom at the suggestion of cure implied by the bad-tasting medicine,
he did so. If he needed to retain his symptom, for whatever reason,
the ineffective medication did not interfere. A similar approach with
hypnosis in the removal of symptoms is safe. Recognition that the pa-
tient may satisfy certain needs through his symptoms - and respect of
these needs-insure safety in the use of the trance. The hypnotic state
induced in a nondirective fashion and devoid of directive-authoritative
or demanding suggestions cannot inadvertently remove a needed symp-
tom. Illogical as it may appear, a symptom that the patient clings to is
performing an adaptive or defensive service. A persistent but highly un-
desirable symptom can be removed with safety by a skillful operator
who, by suggestion, substitutes a dynamically related and more agree-
able symptom which will adequately allay anxiety.
Posthypnotic suggestion, valuable as a reinforcing mechanism in
prolonged pain relief, commands respect. Observation of subjects re-
sponding to this indicates that they re-enter a spontaneous trance while
executing the prescribed behavior. In susceptible subjects, the per-
formance of the posthypnotic suggestion can be successfully directed
to take place a year or longer after the request is made. Extreme care and
good judgment must be exercised by the operator when posthypnotic
suggestion is used.
Many hypnotic subjects can be successfully trained in autohypnosis
or deliberate spontaneous trance induction. In conjunction with post-
hypnotic suggestion, autohypnosis can be an excellent additional rein-
forcing device to insure prolonged pain relief in chronic painful states.
The subject must be trained to respect this powerful tool and to reserve
its use for appropriate circumstances. With practice, autohypnosis can
be induced and terminated briefly and still give satisfying results to
patients with chronic pain. This procedure, however brief, could be quite
hazardous if inadvertently induced while the subject is driving. Specific
posthypnotic suggestion restricting the use of autohypnosis to safe
settings can be added to the usual warning.
ACKNOWLEDGMENT
The author wishes to thank Dr. Benjamin Bashes for help in preparing the manuscript.
224 JOHN W. LAUER

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