2. Suggestions for analgesia : Following the induction, while the client maintains a relaxed state, the hypnotherapist provides various suggestions for reduced pain or discomfort. These suggestions might target one or more of the following: decreased pain unpleasantness (“… all the sensations you can feel, all the feelings you can notice can become more and more a part of your experience of comfort and well- being …”), direct pain diminution (“… you can notice, almost as a side effect, that any uncomfortable feelings are drifting farther and farther away …”), sensory substitution (“… you may begin to notice other, more pleasant sensations now … sensations that can slowly and easily fill your awareness …”), and hypno-anesthesia (“… your leg is filling with a cool, numbing sensation … notice how the anesthesia sensations absorb and block out any discomfort …”). 3. Arousal : The arousal stage serves as a transition from the hypnotic or “trance” state back to wakefulness. This process typically involves a reverse of the steps included in the hypnotic induction (for example, having patients count backward from 10 while imagining that they are walking back up a flight of stairs and becoming more awake, alert, and calm with each step upward, until they reach the number 1, at which point they may open their eyes and reorient to the room). Some clinicians use an auditory cue, such as the snap of fingers or a bell, to signal the transition back to normal wakefulness. For home practice (the self-part of self-hypnosis training), patients are provided with a CD or a recording of one or more sessions so they can practice the skills they have learned on their own between sessions. Hypnosis and self-hypnosis training for pain are gaining more acceptance in the scientific literature. In one review, Bonshtein reviewed various studies about the efficacy of hypnotic analgesia (Bonshtein, 2018). These studies assessed efficacy in a variety of chronic illnesses including fibromyalgia (Zech, et al., 2017); disability related pain (Bowker and Dorstyn, 2016) and chronic pain (Hauser, et al., 2016). Hypnosis has Barriers to effective pain care Despite the availability of empirically supported interventions for chronic pain, a number of barriers exist that may prevent individuals from obtaining effective treatment. Barriers include: provider attitudes and training, insurance coverage, attitudes of pain patients, geographic barriers, and regulatory barriers. These types of barriers are discussed briefly below. Addressing these challenges requires an open discussion with patients about barriers to addressing their pain and a personalized approach to removing these barriers. Provider attitudes and training ● There can be implicit bias and racial stereotypes which have can affect clinical judgement. ● Language and communication gaps can cause a misunderstanding about the initial complaint, the treatment plan and the expected outcome of treatment. ● A lack of the awareness of the socioenvironmental and cultural issues preclude the development of an ideal relationship between the provider and the patient. ● The provider may make a hasty judgement about patient adherence to a proposed course of therapy. ● Preconceived notions that patients of all races may use chronic pain as a means to obtain opioid medications (Ghosal, 2020). Insurance coverage ● Patients with low incomes can face financial challenges in meeting co-pays that are assessed for office visits, hospitalization, physical therapy and for prescription medications especially when novel medications do not exist is a generic form (American Academy of Pain Medicine, 2019). Following the passage of the Patient Protection and Affordable Care Act in 2010 2.2 million people enrolled
been found to reduce the pain frequency and duration and improve the functional capacity among temporomandibular joint patients (Mazzola, et al., 2017). Hypnosis has also been efficacious in treating chronic pain of varied etiologies (Bowker and Dorstyn, 2016). Hypnosis is also considered an effective adjunctive mode of treatment to decrease pain and anxiety among cancer patients and in those patients with severe chronic diseases who are receiving palliative care (Brugnoli, et al., 2017). However, evidence suggests that not everyone with pain benefits from self-hypnosis training, nor is everyone a candidate for hypnosis as the response to hypnosis and self-hypnosis is variable (Brugnoli, 2018). Patients with severe untreated severe psychological disorders, those under the influence of alcohol or recreational drugs and those who object to hypnosis on the basis of cultural or religious beliefs are candidates for other CAM techniques (Cosio, 2020). Hypnosis used for the management of chronic pain has been found to be more effective than non- pharmacologic treatments such as pain education (Cosio, 2020). Patients who utilize self-hypnosis report a variety of beneficial side effects of hypnotic treatment, including increased pain management self-efficacy, decreased perceived stress, increased well-being, and psychosocial and spiritual healing at the end of life (Brugnoli, et al, 2018) There is also evidence that combining self-hypnosis training with traditional CBT and psychoeducation and physiotherapy favors a more active process in the use of coping strategies and for a reduction in the perception of pain (Vanhaudenhuyse, et al., 2017). Several professional associations exist which promote the practice of clinical hypnosis and which have specific requirements for membership and a code of ethics which members must follow (The International Society of Hypnosis, 2018; The British Society of Clinical Hypnosis, 2021). The American Society of Clinical Hypnosis requires members to be licensed healthcare workers who, at minimum, must hold a doctorate, PA certification, APRN or a master degree in a health care field that is deemed appropriate by the Society (American Society of Clinical Hypnosis, 2021). during the initial enrollment period yet many people then and now remain uninsured or underinsured for medical / health insurance (American Academy of Pain Medicine, 2019). ● An inability to pay for pain care is especially prevalent among members of racial and ethnic minorities and among women (Ghosal, 2020). ● Medical procedures such as surgical interventions are reimbursed at a higher rate than psychosocial care or nonprocedural treatments and many CAM therapies that are available and recommended by providers are not covered by traditional medical insurance (Kiesel, 2017). Attitudes of pain patients ● Patients may not want to acknowledge or confront pain or may fear that reporting pain will distract the clinician from treating the underlying condition. ● Patients (especially older patients) may fear being stigmatized as “junkies” or “drug seekers” if they receive prescriptions for opioid pain medication. ● Patients may harbor a tradition of stoicism, making them reluctant to report pain. ● Patients may feel hopeless or fatalistic in the face of pain and therefore abandon attempts to control it. Geographic barriers ● America’s rural areas have significant shortages of primary care physicians and pain specialists. ● Shortages of primary care physicians and pain specialists may leave military veterans, farm workers, people with chronic illness that impacts mobility, and others living in rural areas without competent pain management.
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