Clinical Hypnosis and Mindfulness-Based Interventions in the Treatment of Spinal Pain

Lindsey C. McKernan

Rogelio A. Coronado

David R. Vago

LEARNING OBJECTIVES

After reading this chapter, you should be able to:

Understand the foundational concepts behind clinical hypnosis and mindfulness-based interventions.
Understand the efficacy of clinical hypnosis and mindfulness-based interventions for chronic pain.
Understand the applications in clinical practice of clinical hypnosis and mindfulness-based interventions.
Understand the similarities and differences between the interventions.
Understand the use and application of clinical hypnosis and mindfulness-based interventions in the treatment of spinal pain.

“Be gentle with yourself. You are a child of the universe, no less than the trees and the stars. In the noisy confusion of life, keep peace in your soul.

–MAX EHRMAN

Problem of Chronic Pain

The treatment of acute and chronic spinal pain is complex and involves a variety of issues to address. Acute pain involves dramatic changes in function, is often preceded by injury, and/or may be a result of medical intervention. Reactions to these circumstances can vary but range from mild psychological distress to fear and avoidance symptoms consistent with trauma and stress-related disorders. Untreated psychological distress in response to pain can shape behavior, amplify peripheral sensations, and subsequently lead to the development of chronic pain.¹^,² Chronic pain is a multifaceted problem that impacts a person’s physical, behavioral, emotional, and cognitive well-being.³ Additionally, a person’s sense of self and future is affected, prompting major adjustments, an overhaul of one’s life expectations, and often a period of grief.⁴

As of yet, there is no “magic bullet” for the treatment of chronic pain. Pharmacologic interventions are commonly prescribed by primary care practitioners,⁵^,⁶ but many of these are ineffective or worse, and can harm a person’s health.⁷ For example, opioids have been linked with excessive use, misuse, and death.⁸^,⁹^,¹⁰ The need for careful consideration of opioid use has led to recent guidelines from the Centers for Disease Control and Prevention (CDC).¹¹ Although much of the emphasis in these guidelines is on proper patient selection and management with opioid medications, it is clear that the preferred option for chronic pain management is conservative intervention.

Accompanying the recommendations from the CDC regarding reduced opioid use, the most recent National Pain Strategy¹² highlights the importance of taking an integrated, multimodal approach to managing pain in order to address the biopsychosocial factors influencing acute and chronic pain. In this model, physical disorders are considered a result of a complex and dynamic interaction among interdependent physiologic, psychological, social, and environmental factors that influence the development, course, and/or resolution of illnesses.¹³^,¹⁴ Recommended psychological interventions generally include self-management programs, which aim to provide education and support to help patients build confidence and skills in preventing, coping with, and reducing pain. Treatment is short term in nature and has overarching goals of improving mood, increasing physical functioning, and decreasing the subjective experience of pain.¹⁵ These programs can be self-directed, integrated into health care settings, or offered by community providers.¹²

Recognizing this need, recent studies have integrated self-management strategies into physical rehabilitation programs or approaches.¹⁶ Hall et al¹⁷ conducted a systematic review on physical therapist-delivered, cognitive behavioral interventions for patients with nonspecific low back pain. Hall et al¹⁷ identified five studies that integrated goal setting, cognitive restructuring, and pain education in either a one-on-one or a group format. The results suggested that there is high-quality evidence supporting cognitive behavioral self-management interventions delivered by physical therapists for improving low back pain and disability.

Psychological self-management interventions can be useful in both adjusting to new life circumstances as a result of pain, while also learning a myriad of skills to manage symptoms and improve one’s functioning and quality of life. A driving intervention for pain is cognitive behavioral therapy (CBT).¹⁵ Two additional methods of building self-regulation skills to improve physical functioning include clinical hypnosis and mindfulness-based interventions (MBIs). These interventions are longstanding—hypnosis has been practiced for over 100 years and mindfulness for over 200. Historically, these treatments have been underutilized, in part due to shortcomings in their systematic evaluation, health care professionals holding beliefs about hypnosis based on misinformation, and lack of provider knowledge.¹⁸ Burgeoning research over the past two decades has reinforced their efficacy, provided a structure for clinicians to practice from, and made them widely accessible.

This chapter’s purpose is to provide an overview of mindfulness-based and clinical hypnosis interventions for pain. We first review foundational concepts behind clinical hypnosis and MBIs, their efficacy in the treatment of pain, and applications in clinical practice. We then discuss the similarities and differences between these interventions. Finally, we explore their utility in the treatment of spinal pain, with specific recommendations for clinicians. A conservative strategy for chronic pain should be flexible in targeting the multidimensional nature of the condition.¹² Collectively, the presence of chronic pain along with its associated impact on psychosocial well-being can lead to maladaptive lifestyle changes and avoidance behaviors that are further detrimental. Self-management interventions that engage and/or modulate these processes, as well as promote functional recovery and behavioral change, would appear to be an ideal choice for management. Physical therapists and chiropractors are in need of strategies to integrate into their physical rehabilitation approach to address the emotional and
behavioral needs of patients with chronic pain.¹⁹ Cognitive behavioral strategies are widely accepted and have been successfully integrated into physical therapy practice.²⁰ Clinical hypnosis and MBIs uniquely show promise in this area, providing additional options for treatment. It is our hope that this chapter not only provides a practical overview for interested providers but also encouragement to expand clinical practices to include these powerful tools to reduce suffering in patients with pain.

Clinical Hypnosis: A Brief Introduction and Key Terms

Clinical hypnosis has been used for over a century for pain control, including during the Civil War when army surgeons used hypnosis in lieu of sedation for soldiers undergoing amputations. Jean Charcot largely established the foundations of hypnosis at the turn of the 19th century. After World War II (WWII), in the 1940s to 1960s, there was an explosion of research on the subject in order to define what hypnosis is and is not, and to adopt a definition of hypnosis that worked for both clinicians and researchers alike.²¹ Most recently, the American Psychological Association’s Society of Psychological Hypnosis defined hypnosis as a “state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion.”²² Key terms to understand in the hypnosis process include induction, suggestion, and hypnotizability. We overview these briefly.

Although hypnosis is a psychological state, it does not constitute psychotherapy by itself. Hypnosis is an adjunctive psychological treatment that incorporates a number of components including relaxation, focused attention, imagery, interpersonal processing, and suggestion.²³ Prior to engaging in hypnosis, practitioners often assess a patient’s hypnotizability, or ability to respond to suggestion. Hypnotizability is a stable trait and can be formally assessed through brief procedures.²⁴ Individuals generally fall into three categories of hypnotizability—low, medium, and high. It is not necessary for a patient to be highly responsive to hypnosis in order to benefit from it in pain management; however, there is evidence that those who are more responsive benefit to a greater degree.²¹ In order to engage in hypnosis, patients need to be at least (1) willing to experience hypnosis and (2) able to attend to instruction from the practitioner.²³

During hypnosis, one person (the practitioner) guides another (the subject) through an initial induction—or the first extended suggestion for using one’s imagination—followed by a series of suggestions for experiences involving alterations in perception, memory, and voluntary action.²⁵ Suggestions vary based on the presenting issue. In the treatment of pain, examples of suggestions include deep relaxation, comfort, pain reduction, alterations in the perception of time, and/or displacement of pain. For further examples of pain-specific suggestions, we highly recommend books by Hammond²⁶ and Patterson.²⁷

In general, hypnosis is used as an adjunctive treatment—for example, it can be used in medicine, dentistry, and has been found to significantly enhance the impact of cognitive behavioral treatments.²⁸^,²⁹ It is a flexible tool that can be used in short-term treatments and/or medical settings. It can also facilitate treatments involving needles or injections. With appropriate training in its science, art, and ethical practice, hypnosis can be used by non-psychological providers such as dentists, nurses, anesthesiologists, and physical therapists. One of the most widely studied applications of hypnosis is in the treatment of pain through hypnotic analgesia.

The Neurophysiologic Underpinnings of Hypnosis

Over the past two decades, scientific advances through neuroimaging have led to an outpouring of research to understand the impact of and mechanisms behind hypnotic analgesia. Researchers have concluded over time that there is not a specific “pain” center of the brain, and that pain is instead processed through a complex “network” of systems involving activity in the central and peripheral nervous systems, cortical and subcortical regions of the brain, the brain stem, and the spinal cord.³⁰ The mechanisms of hypnotic analgesia have been studied through examining activity in specific areas of the brain with positron emission tomography (PET), functional magnetic resonance imaging (fMRI), and electroencephalography (EEG) to evaluate brain states. Rather than having a single mechanism, hypnosis can affect pain processing on multiple levels, altering (a) brain states and (b) activity in different cortical areas known to be associated with the pain experience.²³

Regarding pain states, hypnosis can have “cortical calming” effects on the brain. This has been studied with the use of EEG, measuring brainwave activity. When an individual perceives pain, cortical oscillations occur, with neurons firing at faster rates
throughout the pain network that represent, code, assess, and integrate sensory input and the pain response.³¹ As a result, this rapid potentiation causes neurons to fire at higher frequencies (α, 8-12 Hz) and less at slower frequencies (θ, 4-7.5 Hz). Hypnosis has been found to slow brain activity by enhancing θ wave activity in the brain and altering γ activity.³² These changes tend to be observed in individuals based on hypnotic responding, such that greater differences and changes in brainwave activity are evident in individuals with higher hypnotizability.³²

Virtually all of the brain areas involved in the processing of pain have been shown to respond to hypnosis and hypnotic analgesia, including the thalamus, sensory cortices, insula, anterior cingulate cortex, and prefrontal cortex—with frontal and cingulate cortical areas impacted most often.³²^,³³ Pinnacle studies investigating the impact of hypnosis on pain have found that hypnosis can alter pain processing in specific areas of the brain based on the type of suggestion used.³⁴ For example, the suggestion for reduced pain both-ersomeness alters activity in the anterior cingulate cortex (ACC)—which is responsible for affective distress in relation to pain.³⁴^,³⁵ Conversely, when given a suggestion for reduced pain intensity, or “analgesia,” subjects displayed alterations in the primary somatosensory cortex (s1)—which signals the location and severity of nociception—and not in the ACC.³⁵^,³⁶

In summary, hypnosis and hypnotic analgesia can affect brain functioning at multiple sites and levels. Currently, there is no known brain “signature” of hypnosis.³² Brain activity changes in response to hypnosis, and hypnosis is effective by both “targeting” isolated brain areas and through altering brain “states” consistent with pain relief.²³ Although most individuals can benefit from hypnosis to some degree, these neurophysiologic responses to hypnosis are consistently different for individuals with high hypnotizability.³² For the practicing clinician, the implications are to utilize a multitude of suggestions addressing pain and the cognitive, emotional, and behavioral factors that accompany it, knowing that those high in hypnotic response may have more powerful experiences and a stronger response to suggestions.

The Efficacy of Hypnosis

There is overwhelming empirical support for the efficacy and use of clinical hypnosis in treating chronic and acute pain. We provide an overview of empirical studies, focusing on interventions for back pain, and discuss the application of these findings in medical and clinical settings.

Clinical Hypnosis for Chronic Pain

Hypnosis interventions consistently produce significant decreases in pain associated with a variety of chronic pain problems, such as low back pain,³⁷ headaches/migraines,³⁸ cancer pain,³⁹ fibromyalgia,⁴⁰ and temporomandibular disorder.⁴¹ Recent meta-analyses have concluded that hypnosis is an effective intervention in the treatment of chronic pain, with benefits lasting over time and extending far beyond pain relief. More specifically, even when patients did not experience pain relief per se, they experienced additional benefits including increased perceived control, reduced anxiety, improved sleep, and enhanced quality of life.⁴² When evaluating the impact of hypnosis on chronic pain, Adachi and colleagues⁴³ concluded that hypnosis was more effective than usual care or standard psychological interventions for non-headache chronic pain.

Specific Back Pain Trials

In these meta-analyses, two randomized controlled trials have been conducted specific to chronic low back pain (CLBP). McCauley and colleagues⁴⁴ conducted a prospective trial comparing hypnosis to relaxation training for CLBP. After 8 weeks of individual treatment and at follow-up, participants reported significant reductions in pain in both conditions, with those using hypnosis also reporting improved sleep functioning and less problematic use of medications after treatment. Spinhoven and Linssen³⁷ compared hypnosis to a pain education program through a crossover study design, with patients receiving both treatments at different time points while tracking pain and medication use daily. Posttreatment, patients showed significant improvements on all measures except pain intensity. The authors concluded that the treatment facilitated better pain coping and adjustment to pain.

Clinical Hypnosis for Acute Pain

The utilization of hypnosis in the treatment of acute pain differs drastically from that of chronic pain. In general, treatment is brief (generally one 30-minute session), and addresses intense, temporary pain often induced by a medical procedure. Hypnosis has been studied in this context in both minor and major surgical/procedural interventions, ranging from bone marrow aspirations⁴⁵ and lumbar punctures⁴⁶ to burn wound care⁴⁷ and surgical procedures.⁴⁸^,⁴⁹ Meta-analyses consistently conclude that hypnosis reduces acute pain associated with medical procedures for both children and adults, and is significantly more effective than usual care or an attentional control.³⁸^,⁵⁰^,⁵¹^,⁵²

The specific benefits of hypnosis for acute pain include improved hemodynamic stability, less pain, reduced use of anesthesia during procedures, and less procedural time.⁴⁸^,⁴⁹^,⁵⁰ These benefits extend to improved surgical outcomes, where patients have less surgical side effects, shorter recovery times, and require less narcotic medication. Taken together, cost analyses revealed that as a whole the use of hypnosis could cut procedural costs by as much as 50%.⁴⁸^,⁵³

Regarding interventions localized to the spine, for patients undergoing lumbar punctures, Liossi and colleagues⁴⁶^,⁵⁴ studied the use of hypnosis in a total of 125 pediatric cancer patients repeatedly undergoing this procedure during their treatment process. The use of hypnosis significantly reduced behavioral distress, anxiety, and pain ratings.⁵⁴ These associations were strongest when a therapist was present giving the intervention (versus self-hypnosis). Researchers have argued that these results justify the treatment as empirically supported; however, it needs to be replicated in more heterogeneous populations to extend generalizability.

Improving Future Research

Two of the most consistent criticisms within the literature are the heterogeneity of studies in hypnosis research and lack of a treatment manual in clinical trials. In fact, this is most often what has hampered hypnosis from obtaining the “Empirically Supported Treatment” accolade,⁵⁵ although many argue that the efficacy data alone is sufficient to categorize clinical hypnosis as empirically supported.³⁸^,⁵² Current leaders in the field (i.e., Jensen, Elkins) have developed individual and group-based manuals, some specific to chronic pain, to address this concern. In addition, there are now published recommendations for conducting clinical trials to increase replication and consistency in outcomes measurement and study control conditions.⁵⁶^,⁵⁷

In summary, clinical hypnosis is a valuable and effective tool in the management of acute and chronic pain, with no negative side effects. For spinal pain, there are opportunities for providers to integrate hypnotic techniques into procedures or care practices that may improve outcomes. For example, because hypnosis for chronic pain is associated with increased motivation and self-efficacy, this could benefit physical therapy home practice and decrease fear of movement, which can hamper the rehabilitation process. We will discuss this in more detail in our clinical applications section.

Clinical Hypnosis in Practice—A Few Words on Approach

As we have alluded to, hypnotic approaches to acute and chronic pain management differ greatly. For a detailed and comprehensive review of these concepts and practical outlined treatment approaches to each, we suggest McKernan et al²¹ and Patterson.²⁷ We briefly highlight the separate treatment processes for chronic and acute pain.

Acute Pain Hypnosis for acute pain is brief, with the duration of treatment lasting between 1 and 4 sessions. As the situation varies, the practitioner may use hypnosis when first meeting the patient, such as in an emergency setting. Similarly, a patient could undergo hypnosis when approaching a medical procedure, and/or seek out hypnosis to help prepare for and use during a procedure. The type of pain experienced is generally intense, short-lived, and accompanied by high anxiety, which impacts the clinical approach and content of suggestions. Specifically, the style of induction used by the practitioner is often short, straightforward, and direct. Furthermore, suggestions used tend to be highly targeted toward pain relief and comfort.

Chronic Pain Hypnosis for chronic pain has a longer treatment duration, lasting anywhere from 4 to 16+ sessions. The first treatment session generally consists of a thorough biopsychosocial assessment, evaluating the biologic, psychological, and social factors contributing to the pain experience. These evaluations are crucial in chronic pain treatment because they allow the practitioner to assess the nature of the patient’s pain, treatment needs, comorbidities, and coping style. Moreover, this assessment assists the practitioner in crafting suggestions, many of which extend beyond pain. For example, suggestions could target sleep improvement, motivation for change, and/or fear of movement, which could improve other aspects of patients’ lives impacted by pain. The style of induction also varies, where inductions can be extensive (e.g., up to 25 minutes) and less directive. Sessions are generally recorded, where patients are instructed to listen to tapes between appointments. Manualized and scripted approaches to treatment have been developed by both Jensen⁵⁸ and Patterson.²⁷

Importantly, hypnosis can be utilized as an adjunctive therapy to standard treatments, such as cognitive behavioral approaches.¹³^,¹⁵ When evaluating the benefit of doing so, Kirsch and colleagues²⁸ found that patients who were treated with CBT and hypnosis benefited at far greater rates (70%) than those receiving CBT alone.

An Introduction to Mindfulness

Mindfulness is defined as “the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding of experience moment to moment.”⁵⁹ Mindfulness involves cultivating a greater awareness of one’s internal (and external) sensory experiences, and seeing them without any cognitive reframing, but rather with a sense of curiosity, acceptance, and equanimity.⁶⁰^,⁶¹^,⁶²^,⁶³^,⁶⁴^,⁶⁵ Being in a mindful state is contrasted with the typical self-reflexive mental state that involves thinking about past experiences, dealing with current situations, and preparing for future events. Often times, these mental preoccupations (e.g., judgmental view) are seasoned with a negative evaluation and causally linked to one’s unhappiness or exacerbation of negative experiences.⁶⁶^,⁶⁷ It is well established that individuals with chronic pain often report psychosocial distress (i.e., anxiety, depression, stress) and related feelings of worry, guilt, and anger.⁶⁸ Pain severity, pain-related interference with ongoing task demands, quality of life, and negative mood are often reinforced and perpetuated by catastrophizing pain, including excessive rumination, magnification of symptoms, and feeling helpless.⁶⁹ Such catastrophizing may preoccupy a person’s thoughts and beliefs, contributing to an overall lack of control.

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