Foreword
This is my essay for the Psychotherapy studies module of the Specialist certificate in Clinical Hypnotherapy from the London College of Clinical Hypnotherapy. It explores the role of psychotherapy in chronic pain management and how hypnotherapy can assist the process.
Introduction
Pain is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (Mersey & Borduk 1994). Nociception, that is, the body’s normal response to tissue damage or noxious insult to tissues or visceral organs, is in itself insufficient to cause pain.
Pain is one of the responses from the brain to nociception to protect the body from harm or further harm. The brain weighs the sensory component of pain against the affective (emotional) component of pain in the context of the situation to decide whether to send the pain response. For example, a swimmer’s leg is bitten off by a shark. The brain might not decide to give injured swimmer pain from the injury as he might get killed if he focuses on the pain. However future similar nociceptive incidents without the context of danger, may spark extreme pain as memories of the traumatic incident surface.
Pain Management Models
There are currently two models of pain management in the medical world: the biomedical model that is based on bio-mechanics, anatomy and tissue pathology; and the biopsychosocial model that takes into consideration the ‘variable interaction of biological factors (genetic, biochemical etc.), psychological factors (mood, personality, behaviour etc.) and social factors (cultural, familial, socioeconomic, medical etc. )(Mosley & Butler 2017, Loeser 1982). Psychotherapy approaches in pain management belong to the latter category.
When contemplating the efficacy of the biomedical model, it is of note though that tissue-based pain decreases rapidly after injury. Any continuation of pain is likely to be psychosomatic or in a chronic pain situation, arising from a sensitised nervous system (Mosley & Butler 2017).
When discussing the biopsychosocial model, it is worth noting that pain and emotion processing partially share the same common neural structures- the insula, primary and secondary somatomotor cortex, with an interaction of emotion and pain in the insula and secondary somatosensory cortex. Further, the insula is involved in the coding of pain intensity related to both discriminatory-sensory and affective aspects of pain (Orenius et al 2017). Loeser (1982) goes so far as to say that pain and suffering are not the same thing. Suffering is dependent upon the patient’s social environment, attitudes and beliefs etc in layers like an onion skin (‘the onion skin model’).
The Neuromatrix theory (Melzack & Wall 1965) proposes that the brain evaluates nociceptive stimuli by referencing sensory and affective ‘neurotags’, which are chains of neurons representing a particular sensory-discriminative behaviour or an affective behaviour (emotion, belief, thought pattern etc). These neurotags may bolster each other or conflict with each other. Smudging of sensory-discriminative neurotags may occur from previous maladaptive motor behaviour. A nociceptive experience causes the brain to run through these neurotags joined together in a net of connected behaviour called a ‘neuromatrix’, and decide whether or not pain is an appropriate response.
Types of Pain
There are three types of of pain. They are : inflammatory, neuropathic and nociceptive.
Inflammatory pain is the result of a nociceptive pathway becoming sensitive after tissue inflammation. Examples of inflammatory pain are: irritable bowel syndrome (IBS), appendicitis and rheumatoid arthritis.
Neuropathic pain arises from a primary lesion or disease in the somatosensory nervous system. Some examples of this type of pain are phantom limb pain and pain connected with spinal cord injury.
The third category pain is nociceptive pain where the brain decides to choose pain as a response to tissue damage or noxious insult to tissues or internal organs.
There are two main categories of pain which are characterised by their duration.
Acute pain lasts for three to six months. Acute pain is a normal response to tissue damage or noxious insult to tissues or internal organs e.g. stepping on a nail; appendicitis. Other examples of acute pain include pain from childbirth or labour, dental pain, surgery pain, broken bones etc.
Chronic pain is pain persisting for more than three to six months, usually after healing has occured. Some examples of chronic pain are fibromyalgia pain, migraine, arthritis, cancer pain, nerve pain and back pain.
It is worth noting that the evolution of acute pain to chronic pain is known to be catalyzed by psychological processes and that psychological interventions designed to reduce chronicity have shown positive effects (Linton & Shaw 2011). Fear learning processes affect perceptual discrimination contributing to the development of chronic pain as well as more maladaptive attitudes, beliefs and fear-avoidance behaviours (Zaman et al 2015).
The Role of Psychotherapy in Pain Management
Csazar et al (2014) suggest that psychotherapies for pain work at four aspects : sensory, affective, cognitive and behavioural. These four levels are strongly interrelated and may be influenced or may in turn cause other maladaptive changes in physiological systems such as the sleep-wake cycle, mood and stress regulation that may result in a vicious downward spiral for the patient. Different psychotherapies may be used in conjunction with one another to deal with different aspects of the pain experience (Krietler & Krietler 2007) .
Psychotherapies and the Pain Experience
A. SENSORY ASPECT
Hypnotherapy
Therapies that modify the sensory aspect of pain work by changing the sensation of pain experienced by the patient by modifying its emotional and cognitive meaning. Hypnosis excels in this area of pain management, working even better than drugs in the migraine pain management (Hammond 2007).
Hammond (1990) proposes four major areas of hypnotic pain management: ‘I. Unconscious exploration to enhance insight or to resolve conflict; II. Creating analgesia; III. Cognitive-perceptual alteration of pain; and IV. Decreasing awareness of pain’.
Hypnoanalgesia dates back to before the 1830s. Surgeons James Braid, Jules Cloquet and John Elliotson performed surgeries with only hypnosis as the only anaesthetic. Surgeon James Esdaile performed nearly three hundred surgeries in India under hypnoanalgesia. The use of hypnoanalgesia fell out of favour with the introduction of chemical anaesthetics (ether in 1846 and chloroform in 1847) (Wobst 2007) but is now enjoying a resurgence especially in the area of childbirth and labour (Mullen 2008).
Some tools of pain management with hypnosis that assist in the management of the sensory aspect of pain are: glove analgesia, use of guided imagery and visualisation, creating analgesia through direct and indirect suggestion, use of metaphors, gradual diminution of pain, increasing and decreasing pain intensity levels, dissociation, symptom substitution, displacement of pain, replacing, substituting or re-interpreting sensations, increasing pain tolerance, time dissociation, imagining a pleasant scene or favourite place of relaxation and distraction via direction of attention from pain to the external environment (Hammond 2016).
Factors predicting the efficacy of hypnosis are: the subject’s motivation, hypnotizability, dissociation and regression (Patterson et al 1997). Patients may be subject to a hypnotizability test beforehand to determine their suitability for therapy.
The Italian Consensus Conference of Pain in Neurorehabilitation (ICCPN) which was formed by different scientific studies to assess the efficacy of psychological treatments and psychotherapies in rehabilitating pain at the neurological level, recommends hypnotherapy for the treatment of all chronic pain, phantom limb pain, neuropathic pain secondary to spinal cord injury, chronic tension-type migraine or headache, temporomandiular disorders, amyotrophic lateral scoliosis, Parkinson’s Disease, Gullain-Barre syndrome, HIV and post-polio syndrome (Castelnuovo et al 2016).
B. COGNITIVE ASPECT
Patients’ attitudes and beliefs about and surrounding the pain experience can affect pain intensity (Loeser 1982).
The three pain beliefs that put patients at the greatest risk of a poor prognosis are: I. Pain catastrophizing (negative thought patterns and an exaggeration of the pain experience); II Fear avoidance (a belief that all activity should be avoided in order to prevent pain re-occurrance); and III Low expectations of recovery (Nicholas et al 2011).
Pain catastrophizing is a marker of long-term problems while activity restrictions from ill-advised beliefs may result in long-term pain and disability as well as physical, mental and emotional degeneration. Unfulfilled expectations of recovery from unrealistic goals, may generate further negative thoughts and maladaptive behaviours (Linton & Shaw 2011).
Cognitive Therapy (CT)
Developed from depression research, Aaron T. Beck’s (1927-) Cognitive Therapy (CT) promotes clear thinking by helping patients find and identify cognitive distortions (schema) in their thinking.
Therapists actively look for reasoning errors such as selective abstraction, overgeneralisation, catastrophizing, labelling and mislabeling etc, and teach patients to do the same in their everyday lives through reading assignments, letting patients come to their own conclusions about the pain experience.
For example, a patient may make the statement ‘my arthritis always flares up when it rains.’ A therapist may recognise this statement as a generalisation and ask ‘what makes you think so? Were there any occasions when it did not?’ In questioning the association between rain and arthritis flare-ups, the patient learns that he may have made a faulty association and becomes more self-aware in his thinking.
When Hypnosis is combined with CT, the absence of the intervention of the conscious mind in trance can help the quicker integration of new positive beliefs from the session. The deep relaxation also helps the therapist probe the patient’s subconscious for more limiting beliefs and their source. In addition, Hypnosis can help generate personal resources necessary to support the process of change.
C. BEHAVIOURAL ASPECT
Fordyce (1976) proposed that pain should be analysed as learnt behaviour. While pain normally occurs as a response to nociception, Fordyce argues that it can also occur as an anticipatory response from prior learning and experience e.g. feeling imagined pain from an injection before the injection; and also as a contingent response to a stimuli e.g. experiencing pain-related difficulty in movement whenever the patient’s partner is around because the patient’s partner does everything that the patient would otherwise have to do if he/she were mobile.
Operant conditioning techniques use reinforcement and punishment in chronic pain management, rewarding behaviours that foster positive behaviour and punishing fear-avoidance behaviours. Some tools used by therapists include in vivo exposure, graded patterns of activity and time-based medication management.
Systematic desensitization
Developed by Joseph Wolpe (1925-), systemic desensitisation has at its heart the concept that one cannot be relaxed and anxious at the same time. Patients are first taught relaxation exercises. Then they are asked to come up with a scale rating various situations from least anxiety-provoking to most anxiety-provoking. They are brought through each situation and asked to relax. The therapist moves up or down the scale depending on the patient’s reaction to each stimulus.
When this process is carried out in trance, it is known as ‘hypno-desensitisation’. The relaxation of the trance state coupled with heightened suggestibility, make for a more vivid, faster change experience than systematic desensitization on its own.
Systematic desensitization and hypno-desensitization are great tools for pain-related fear, especially fear of re-injury in movement-based rehabilitation.
Stage dissociation and positive phobia replacement are other hypnosis methods that may be used in conjunction with systematic desensitization/hypnos-desensitization in in order to negate the negative emotional charge of anxiety-causing stimuli for faster resolution.
In Stage dissociation, the patient is asked to imagine himself or herself as a member of the audience, watching himself or herself perform the pain-causing activity on a imaginary movie or television screen. If this image triggers pain, the patient is asked to imagine someone who is dressed in the same manner as he or she is, performing the pain triggering activity. The patient is further and further disassociated from the triggering activity until thinking of performing that activity no longer triggers the pain.
Positive phobia replacement replaces negative associations e.g. worry, fear of re-injury, anxiety etc that the patient may have with positive ones, in a trance state. The trance state prevents the conscious mind from intervening with habitual negative associations. The patient is asked to associate positive experiences e.g calmness, laughter, happiness with the triggering activity instead.
In both of the methods mentioned above, the therapist asks the patient to rate the pain experience before-and-after the therapy. The patient is asked to imagine performing the activity as homework before finally proceeding to perform the activity in vivo.
Cognitive-Behavioural Therapy (CBT)
CBT is a family of therapies that originated in the Behavioural Therapy work of B.F Skinner (1904-1990) and Albert Bandura (1925-).
Cognitive-behavioural psychotherapies help to assist in pain management by changing a patient’s beliefs and attitude towards his or her pain experience. A more positive attitude and more helpful beliefs, translates into behaviour that it is more supportive of the pain experience and ultimately, promotes an overall improvement of quality of life. Cognitive-behavioural psychotherapies, with their high reliance on empirical evidence and use of scientific data, have greatest amount of evidence supporting their benefits (Turk et al 2010).
CBT uses the ABC model of change (antecedent, behaviour, consequences). It is problem-centred. It does not delve into the patient’s past but instead focuses on resolving the problem at hand.
Therapists conduct functional assessments of antecedents and behaviour in a scientific manner and work with patient to change the problem behaviour in a highly customised program. Therapist and patient have a collaborative relationship and therapy is viewed as a form of education.
Tools include operant conditioning techniques, relaxation training, in vivo exposure and flooding, eye movement desensitization and reprocessing, social skills training and self-modification programs/self-directed behaviour.
CBT has been proven to be useful in the treatment of pain related to irritable bowel syndrome, cancer, lower back, chronic migraines, chronic headaches, chronic pro-facial pain, complex regional pain syndrome, fibromyalgia, HIV/AIDS, non-specific heart pain, multiple sclerosis, non-specific musculoskeletal pain, osteoarthritis, rheumatoid arthritis, whiplash-associated disorders, spinal cord injury and systemic lupus erythematosus (Sturgeon 2014).
Brugnoli et al (2016) found that Hypnotherapy used in conjunction with CBT produced better results than CBT alone. To date, a hybrid field comprising of CBT and Hypnotherapy, known as Cognitive Behavioural Hypnotherapy (CBH) has emerged. CBH uses the trance state to reinforce the lessons of the ‘talk therapy’ (CBT) portion of the therapy for greater effect. CBH has been proven to be effective in the treatment of chronic pain, cancer pain, tempuromandibular disorder pain, non-cardiac chest pain and disability-related chronic pains (Elkins et al 2012).
Mindfulness-based Stress Reduction (MBSR)
Developed by Jon Kabat-Zinn (1944-), MBSR borrows from Eastern esoteric spiritual traditions and combines it with psychotherapy. The focus of MBSR is to be present in the moment, being aware of the thoughts and feelings as they come and go, in every aspect of life e.g. walking, eating, standing etc. In doing so, the patient stops worrying about the past and the future but instead focuses on the present where the pain experience may be currently be absent, reducing pain catastrophizing and negative pain expectancy.
When focussing on the pain experience as it is happening, the patient gains awareness and insight into the nature of his/her pain, and his/her attitudes, cognitions, avoidance-behaviours etc related to the pain.
MBSR is delivered over a 8-10 week group program consisting of sitting meditation, mindful yoga and mindful body scan activity. Patients are expected to meditate for 45minutes daily as part of homework that increases body awareness and proprioception as well as inculcates a ‘nonstriving’ attitude towards pain (Sturgeon 2014).
MBSR has been proven effective for arthritis, cancer pain, chronic lower back pain, chronic headache, chronic migraine, complex regional pain syndromes, fibromyalgia, chronic neck pain and irritable bowel syndrome (Sturgeon 2014)
When Hypnosis is introduced to the Mindful Body Scan, the deep relaxation of the trance state allows direct execution of the body scan instructions by the subconscious. There is less likelihood of intrusive thoughts in trance than in meditation as the conscious mind takes time to quiet down.
The Loving Kindness Meditation is one of the tools used in MBSR. It reduces pain by influencing the affective aspect of pain. Positive feelings generated in this Meditation stimulate the anterior cingulate cortex for emotional regulation. By wishing loving kindness on a neutral party, someone the patient likes, themselves and finally someone the patient does not like, the meditation tunes down the pain experience. Performing this Meditation in trance makes the experience more real and thus more deeply felt.
Acceptance and Commitment Therapy (ACT)
ACT was created in 1982 by Steven C Hayes (1948-). Part of the third wave of CBT (along with MBSR), ACT too incorporates elements of mindfulness. Patients are encouraged to accept their pain and the inconveniences that it creates and go about their daily activities with some degree of psychological flexibility (‘acceptance’). Hayes (2004) says, ‘acceptance is not tolerance, rather it is the active nonjudgmental embracing of the experience in the here and now’. The willingness to accept pain helps protect against negativity linked to the pain experience. Carrying on with daily activities contributes to a positive mindset (Kranz et al 2010).
Realistic goals are set jointly by therapist and patient with a high degree of patient consultation and customisation based on the patient’s values. Commitment entails making mindful decisions about what is important in life and what the person is willing to do to live a valued life (Wilson 2008). Patients are given value-centric homework which they are to complete to the best of their efforts in spite of the pain (‘commitment’). Therapy is an educational and collaborative endeavour.
ACT’s efficacy has been proven in the treatment of whiplash associated pain and musculoskeletal pain (full body, lower back, lower limb, neck and upper limb) (Sturgeon 2014).
Hypnotic time distortion, amnesia, distraction, confusion techniques may be used to support the ACT therapist to make it easier for the patient forget the pain and go about his or her life.
D. AFFECTIVE ASPECT
Some pain-related emotions are anxiety, fear, guilt, frustration and depression. As mentioned earlier, the emotional experience and the pain experience are intertwined at the neural level. Brugnoli et al (2016) found that emotional and mental issues can manifest as pain. Research by Orenius et al (2017) shows that emotions can intensify and prolong pain. Therefore skills for self-directed management of emotions related to the pain experience are a valuable complement to physiological pain management.
Rational Emotive and Behavioural Therapy (REBT)
One of the first Cognitive Behavioural Therapies, REBT was developed by Albert Ellis (1913-2007) on the basis that it is a patient’s perception of reality that makes makes him/her a contributor to his/her own troubles. Reality on its own is rarely troublesome.
For example, pain may be viewed as a ‘punishment from God’ or a ‘helpful signal from the body to do something else’. The emotional repercussions from both of these perspectives are vastly different. Ellis believed that unhelpful perceptions from faulty beliefs and learning acquired throughout life are reinforced by the patient. In the example given where pain is a ‘punishment from God’, the patient could have learnt that by modelling his religious mother and may have had a religious upbringing. It follows that if the person believes that he has been given pain as a ‘punishment’, he also believes that he is not a good person and therefore deserves to be punished by God.
REBT also adopts an ABC framework. It is the patient’s beliefs (‘B’) that results in an activating event (‘A’) with emotional consequences (‘C’). The therapist’s role is to dispute (‘D’) A by detecting, debating and discriminating, so that a new feeling (‘F’) is generated.
In the above example, the therapist may analyse A (the pain) to understand the patient’s belief system around it and its related emotions (guilt, shame etc.). By disputing the pain, the patient learns that he is not responsible for the pain and does not need to feel bad about it. Pain intensity decreases.
Some tools used by REBT Therapists are: replacing ‘should’s and ‘musts’ with preferences, rational emotive imagery, role-playing, shame-attacking exercises, cognitive restructuring, Socratic questioning and homework assignments.
Hypnotherapy may be used in conjunction with REBT to promote greater adherence to new cognitions in a faster time; to understand the patient’s belief system at a deeper level by accessing the patient’s subconscious with Parts Therapy and to allow the patient to access inner resources that will assist in stabilisation and growth within the REBT framework.
Inner Child Therapy
Inner Child work derives from, amongst other origins,the concept of subpersonalities developed by Robert Assagioli (1888-1974). In his theory of Psychosynthesis, he postulated that everyone has a child self, irrespective of their age. If as a child, there was inappropriate or improper parenting, the child’s maladaptive behaviour may carry over into adulthood, affecting behaviour in a negative manner. Eric Berne (1910-1970), founder of Transactional Analysis, took this concept one step further by suggesting that just as everyone has an inner child, everyone has an inner parent. The adult inner parent can be made to parent the inner child, ameliorating his or her behaviour in the present.
For example, a patient could present with a pain in the hand for which no medical cause can be found. In therapy, she finds that her father used to hit her on that hand whenever she misbehaved. Her hand pain occurs in response to feelings of guilt, shame and anxiety- the same feelings that she felt when her father punished her.
Inner child therapy can be used for her to become her own adult parent in the present and re-parent her child self in the past. The depth of relaxation in hypnosis helps the inner child emerge more easily and the utilisation of subconscious (vs conscious) processing in re-parenting allows for a more personalised and customised manner of re-parenting for the client that operates at a deeper level.
Inner child therapy can also be supported by journaling, awareness exercises, expressive arts homework etc. By healing the inner child, the emotional reasons for the pain are resolved and so is the physical pain.
Affect Bridge
Memory is state-dependent. How a memory is characterised depends on the emotional state that a person is in at the time. An affect bridge allows the patient and therapist to access memories that are linked to the current pain state by focussing on and intensifying the emotions experienced by the patient in a pain state. For example, if a patient feels frustrated at not being able to perform an accustomed movement due to his or her injury, the therapist may ask the patient to focus on and intensify the frustration. This will then bring him or her back in time to the memory of the first time the patient experienced the frustration. Therapist and patient are then free to discuss the memory and its implications.
While the affect bridge need not be carried out in trance state, the relaxation created by hypnosis helps patients access memories stored deeply in their subconscious mind. The memories would otherwise not be readily accessible in a conscious state. Hypnosis is therefore highly recommended for use together with affect bridges in pain management psychotherapy.
Conclusion
A study conducted by Linton & Shaw showed that only 63% of physical therapists in a primary care setting were aware of the importance of psychological factors involved in pain. Only 47% reported knowledge of how to deal with psychological factors clinically, citing difficulties in addressing psychosomatic factors and the lack of clear guidelines to do so (Linton & Shaw 2011).
In dealing with chronic pain, it is the mental and emotional aspects of pain that take the spotlight, rather than resolution of pain (Sturgeon 2014). While an ‘integrated neurological rehabilitation’ model of pain management (Castelnuovo et al 2016) that includes psychotherapy may be the goal, more needs to be done on the ground to ensure proper training and clear implementation of psychotherapeutic measures in pain management.
Where psychotherapy is actively implemented e.g. in chronic pain management, therapists should be aware of the potential benefits of combining Hypnotherapy with their existing framework for faster, deeper and more meaningful resolution for all.
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