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Bringing mind and body together to reduce pain with self-hypnosis.
In this edition of Airing Pain we hear how healthcare professionals can use hypnotic techniques to help people in pain. This is not the hypnosis of stage performances, but rather simple skills that can be mastered by most people. When patients enter the ‘meditative-type’ state of hypnosis they are able to use the imagination to change the perception of their pain and even reduce its intensity, says retired GP Dr Ann Williamson. More than just relaxation, hypnosis, she argues, gives us access to ‘mind-body links’ that are ideally suited for addressing both the physical and emotional dimensions of pain. Dr Jane Boissiere, also a doctor practising hypnosis, calls the lack of availability of hypnosis on the NHS ‘a tragedy’. She believes it is the most effective way of addressing medically unexplained symptoms by targeting emotional trauma in a way that puts the patient in control.
Paul Evans: Hello, I’m Paul Evans and welcome to Airing Pain. A programme brought to you by Pain Concern; the UK charity that provides information and support for those who live with pain and health care professionals. This edition is being funded by a grant from the Dorothy Howard Charitable Trust.
Harnessing the power of the mind to control or manage pain is something we have explored many times on Airing Pain, be it through mindfulness, cognitive behavioural therapy, mirror therapy or even ground breaking research into neuro-engineering where patients have trained themselves to identify the part of the brain that controls their pain and then reduce that pain. With such innovation, it is tempting to think that only now, in this age of discovery, are we beginning to fully understand the potential of the mind to manage pain but, go back through the millennia, even to pre- history and we find that priests, shamans and witchdoctors have attempted to bring about healing by inducing an altered state of consciousness, in effect, hypnosis.
Now, you might associate hypnosis with entertainment programmes where members of the public are induced to perform weird and wonderful acts of stupidity in front of an audience – that is stage hypnotism, not to be confused with anything beyond the shallow realms of showbiz.
The British Society of Clinical and Academic Hypnosis promotes the safe and responsible use of hypnosis in medicine, dentistry and psychology. Its aim is to educate both professionals and the public about hypnosis and its uses. In the British Pain Society’s Annual Scientific Meeting of 2014, I met Dr Ann Williamson, a retired GP who’s been involved in hypnosis since the late 1980s and who has been training health professionals for more than twenty years. So what is hypnosis?
Dr Ann Williamson: My way of thinking of hypnosis is that it is a meditative type state, I suppose, where you have your normal outside awareness and you have your internal awareness. In hypnosis you focus internally, but within a session that can go up and down, so that somebody can be more aware of what is going on outside and then less aware. It is a bit like reading a good book, you get lost in a good book and you lose awareness of what is outside, but if someone was to call your name or shout ‘fire’, you’d be off and up.
Evans: So how does it differ from meditation?
Williamson: The aim is different – the aim in meditation is to empty your mind and become one with the ‘life force’, God, however you want to language it – in hypnosis, the aim is emotional management of some sort or experiencing a goal. Hypnosis is very experiential – you step into the you that you want to be and associate with it and feel it. It is a much more experiential way of working with something.
Evans: So the me that I want to be could well be a completely fit person.
Williamson: It has got to be realistic. If I am twenty or thirty stone and my goal is to climb Everest, that is not going to be realistic, but when I step into that imagining, I’ll know it is not realistic – the intuitive part of me will understand that. For instance, a pain patient will be wanting to reduce their pain, feel comfort, feel calm, so you can go in the hypnotic state and you can go to places and times when you had those feelings and re-access them. You can link them to things that you can bring to the front of your mind which will then take you back into it.
There is interesting work being done with phantom limb pain by colleagues – I don’t know whether you are aware that one of the treatments for phantom limb pain is the mirror box. Well, what she does is get the person to imagine moving that hand, or that arm, or that leg in hypnosis. And we know from neuro science findings that what you imagine in hypnosis – the same parts of brain light up as in reality or very similar – whereas just thinking about it, it doesn’t. So, there is something there that is giving us access to – if you like – to these mind body links. So hypnosis is more than just relaxation.
Evans: I suppose thinking about being well, being without pain, is maybe wishful thinking – it is thinking about something that is not there and maybe thinking about it, is not a good thing to do anyway because you are trying to imagine what will never happen.
Williamson: That’s why I think it’s got to be tailored to the individual case. I have met people with fibromyalgia, for instance, who have had a lot of pain and been very disabled by it. Giving them the tool of self-hypnosis, using imagery to help reduce the pain directly (which some people can do) and then also to look at the psychological drivers of the fibromyalgia – like anything else, mind and body and it is very interlinked – that can actually reduce the pain, not just through relaxation. It can actually reduce the pain intensity.
We know people can modulate pain intensity from … you know … they can have surgery under hypnosis – some people can, who have got that ability. It is wishful thinking, yes, but if you focus on the pain, then you are just going to focus more and more into the pain. If you focus on what you want which would be comfort or a greater degree of comfort or being more able to cope, feeling more able to take an interest in something outside of your pain, then that will in itself reduce the pain.
Evans: How does this differ in outcome from a talking therapy like acceptance and commitment therapy?
Williamson: I think that any talking therapy, if you are in deep rapport with someone and talking, they enter, if you like, a semi-hypnotic state anyway. So, I think a lot of good therapists are using the hypnotic state, even though they are not aware of it. When someone is in a great deal of pain or a great deal of anxiety, they are already in/or working… their brain is already processing in, if you like, a hypnotic state. That is why hypnosis can be used very effectively in things like, emergency medicine – when somebody is already in that frame of mind. I think hypnosis facilitates lots of different therapeutic approaches.
Hypnosis on its own is just a state of mind – it’s what you do with it that’s important. It is altering the person’s focus of attention and by altering their focus of attention internally in that hypnotic state, suggestions are more readily taken on board because they can experience them, they can feel them. If you like, another way of looking at it, would be a story teller – I don’t know whether you have ever experienced a really good story teller coming in to the room and holding a whole audience entranced – we say it is ‘entranced’, it is the same way – they are all in that kind of hypnotic state at that point – but what they are doing with it is different than in clinical hypnosis. So it is a state we go in and out of, quite naturally.
Evans: Sportsmen refer to ‘the zone’…
Williamson: Yes, being in the zone, same thing.
Evans: … and it’s that business I guess of being able to shut off all the pressures, all that is going on around…
Williamson: it’s just totally focused.
Evans: I’m thinking of somebody kicking a penalty at Wembley.
Evans: If that were me, the fear of humiliation, of failure…
Williamson: But of course, it’s as soon as you start thinking of that, that will put your performance off, so they learn to be completely focused. That’s why hypnosis and hypnotic techniques are used in a lot of sports and athletics – by a lot of Olympic athletes – because to get that edge, you need to be able to do that and some people are more able to do it than others. Some people find it really hard to actually focus attention but everyone has got an ability – if you use a right-left brain model – if we are functioning normally in our conscious waking state in our left brain then going into a relaxed state or focus of attention tends to be a right brain process…
Evans: I’ve got one brain and I know it’s got two sides, what’s going on?
Williamson: If you think of the left side of the brain as our intellectual, rational, reasoning, conscious awareness part (I mean this is a model, it’s not the truth – it’s just a way of looking at things) and the right side of our brain is the emotional, creative, intuitive, memory part.
Take, say, a phobia of a spider – logically it is totally crazy to be so terrified of that little spider down there, but telling myself that, doesn’t really help – I still get that overwhelming feeling.
We know some of the brain pathways of why that happens but to be able to work with both types of processing, you need something that links them and one thing that links is visualisation. You can paint a word picture and the right brain thinks in pictures, symbols, metaphor and the left brain uses words. So, we can talk if you like, to both types of our processing, to our heart and our head by using imagery – I mean if you think of all the great teachers, they use parables, stories, metaphor – why? Because it is a good way to get something across.
We tend to very much to think in the cognitive side of things but actually, the bit that drives us more than anything is our emotion part – so we need something that will work at both levels, that’s where I think hypnosis and that type of approach works.
Evans: If I were to draw a diagram of me, I would think – tell me if I am wrong – that I would do all my reasoning on this, my left hand side but the real me – the emotion, the arts, what makes me, me is on my right side and somehow you need to join those two sides together.
Williamson: That’s what the aim of all therapy is, isn’t it? To marry and make links between our intellectual understanding and our emotional understanding, to make those links, to make those processes work together. If you are in great pain, or if you are in great distress, you are in that emotion and you have not got access to your adult, rational, cognitive processing. You are in to the emotion, in to the feeling and you need both.
Evans: It was rational to be afraid of spiders in our evolutionary past…
Evans: …and that still stays there, which links in with fight and flight and pain mechanisms…
Evans: So, how does hypnosis come into to break some of those things?
Williamson: It depends on the causation of the pain, to some extent. I mean the fight and flight – obviously, if you are tense and are in an adrenalin state, then your pain is going to be worse or your perception of pain is going to be worse, so anything that will reduce that, would be helpful, but then, you’ve also got the psychological underpinnings of pain. Pain isn’t just tissue damage or organ damage, it’s all the rest, it’s the whole pain neuro matrix that gets involved and hypnosis can help psychotherapeutically. Using the hypnotic state can kind of help people to explore and resolve whatever ever might be underlying those problems, giving rise to the pain.
Evans: Dr Ann Williamson of the British Society of Clinical and Academic Hypnosis. Dr Jane Boissiere, also of the Society, was a GP for twelve to thirteen years. She was also a house practitioner in psychiatry.
Dr Jan Boissiere: When I was trying to persuade my GP patients to come and see me at my day psychotherapeutic hospital, I would say to them: ‘Imagine the brain is a room and you have a cupboard at one end – we all have a room and a cupboard – and what we do, during the course of our life, we put all the rubbish in the cupboard, we close the door and we live in the tidy part of the room. Then one day along comes another bit of rubbish, it might not be that big a piece of rubbish – you try to fit it into the cupboard and there is no more room. The cupboard door bursts open and you have rubbish all over the room and you are in a state of panic, anxiety, depression, whatever – and what you do is you try to put all that rubbish back in the cupboard and close the door tight. You might manage to do that to begin with but you are sitting on top of a volcano. So, if you have too much rubbish in your cupboard, what you need to do is sort it out.’
And that’s what we used to do at the day psychotherapy hospital – we would have to spring clean. Now, spring cleaning is not a good job, alright, they have to pull out all the rubbish, sort it all out, throw away or put it back tidily, because obviously you can’t get rid of those things. But if you put it back tidily, then you will have more room in that cupboard for all the other rubbish that is bound to occur during the course of your life. So, that was how I would explain what we were going to do at the day psychotherapy hospital. But spring cleaning is incredibly messy.
When I stopped being a GP and doing the psychiatry, I was really missing seeing patients and it was then that I discovered hypnosis and what I discovered with hypnosis was that, all this rubbish that was in the cupboard, you did not have to pull it all out, sort it all out and put it back. It was so much easier than that, so much easier, it was like having an ultrasound scan, because all you had to do was ask the unconscious mind, which bit of rubbish was causing the trouble, it would sort itself out with a few clues and tips, whatever – and all would be well. You did not need to pull all this rubbish out, you didn’t need to cause a huge mess in the room – you could actually go straight to the point that was causing it.
Often, it would be something very minor, you know, because my training was in psychiatry, I would do a full psychiatric history before I would do anything at all. So you do the full psychiatric history, you know, some people have had horrendous lives, a huge amount of trauma and distress. And you could come up with all kinds of theories or what might be causing their symptoms and very often you would be wrong. It would be something, much smaller, minor, which you had not even considered to be important, had caused the upset or distress.
So you cannot always make assumptions. We think that our frontal lobes are in control, but actually it is your unconscious mind often, that is in control. So, if you have a behavior or a symptom that you do not understand, you do not know what it is about… I would say to patients that were referred to me – ‘if you have this symptom and you don’t know what has caused it, if the symptom goes away and you don’t know why it has gone away – will that matter? No.’ In other words, you don’t necessarily need to know what it is. Sometimes, the unconscious mind does not want your conscious mind to know what the problem is.
Evans: The analogy of rubbish in the cupboard is something that we can all get hold of but, what constitutes rubbish?
Boissiere:Traumatic events, deaths, we can go with very major things, as I say, sometimes you will find… being bullied – events that have upset you in the past.
Evans: I would say that the things that might upset me, are things that I have done that are out of character, say when I’ve lost my temper with somebody in public and I don’t do that – those are the things that stick in my mind.
Boissiere: And that’s because you have not adhered to your own standards. You have set yourself a standard and if you break that rule, that you’ve set for yourself, then you beat yourself up about it. Now, you could be more forgiving, you could find ways of not being quite so angry as well, you could find out what it was that triggered you to behave in that sort of a way. There are all sorts of ways that we could help with that. You could look at what the triggers are for you losing your temper in that way and that is fascinating – I love dealing with anger, because repressed anger is not good for you.
Evans: In terms of somebody with persistent pain, the anger comes from everybody, the doctors, the employers, life, the politicians, the health service ….
Boissiere: Absolutely, there’s nothing worse.
Evans: Everybody is to blame for my condition.
Boissiere: Absolutely, absolutely, I fully understand – if you have been through the mill, with fibromyalgia, the degree of anger with the lack of understanding, the lack of people dealing with it appropriately, not knowing the effect of the heart-sink – are you with me? – so that if you go to the doctor and, you know, if we’ve got a simple diagnosis – ‘I know, you’ve got wax in your ear’, and we can take the wax out – we’ve got a happy patient and a happy doctor, everybody is happy. We have got a diagnosis and we have got a treatment and everybody knows where they are. Once you are into the realms of the medically unexplained, once we are dealing with symptoms that don’t fall neatly into that sort of category, you have got the doctor feeling miserable and the patient feeling miserable – then we are into a very negative sort of cycle here.
Now, if I saw patients, who had defeated other practitioners – shall we say – I was always delighted to see them. I’d say ‘come on in – this is great – [laughing] because we are going to get some solutions now.’
I used to say that I loved doing psychiatry for two reasons: I meet the nicest people and I love watching people get better. It is a joy treating people, having discovered these sorts of ways of accessing the part of the mind that can actually help you heal yourself.
It’s the way you deliver the message. If you go to the doctor and the doctor says ‘I can’t find anything wrong with you.’ The patient thinks, ‘They can’t find anything wrong with me, there isn’t going to be a treatment – that means I am going to suffer forever.’ But there is a possibility of you being completely normal, if we can just find some answers.
Now, most things are multi-factorial – a bit of this – a bit of the other – what we have to do, is get all the factors going in the right direction. When you see somebody who has been through the mill, you end up with a vicious circle with everything going in the wrong direction, all spinning in the wrong direction. What you have got to do, is get in there, get all the factors right and get it spinning in the right direction.
If you get it spinning in the right direction, then you can start feeling good and better but there is a part to be played – I am not saying that I have all the answers to all these things – we have an important part to play and unfortunately hypnosis is completely underutilized by the NHS. It is a complete tragedy.
Evans: So how do people get to see a recognised hypnotherapist?
Boissiere: Within the NHS, it is virtually impossible – you can’t even use the word ‘hypnosis’. Some people who have even been trained in hypnosis, as I understand it, can’t then practice it within the NHS. They will say that it is not, for example, for the treatment of post- traumatic stress disorder, we have got lots of evidence but we have not got sufficient, for it to be considered strong enough to be an evidence-based treatment. But if you don’t have enough people doing it, you are in a catch-22.
What you’ve got to be able to do, is to be… most of the NICE guidance for pain, for example, they say more research is required – how can you do that research if you don’t have enough people practicing it and they can’t get funding to come on the courses? Because it is, hypnosis, it is considered an alternative therapy. Now, I don’t know why we are considered an alternative therapy, we have been around for two hundred years. Freud started with hypnosis then decided maybe not and everybody became very frightened of the unconscious – there is nothing to be frightened of at all, really nothing at all. All hypnosis is self-hypnosis and is about you being in more control, not less control. OK, we think that it is the frontal lobes are the bit that is controlling everything, it is not – as we go back to what we said earlier, about behaviours – that you’ve got behaviours that you don’t like and that you can’t help and you just lose your temper and you don’t want to….
Evans: It’s only happened twice, but sadly I can remember each one.
Boissiere: [laughing] Indeed, but forgiveness is one thing and knowing how to handle that differently is another one. It is not just that, certainly, from the repressed angle point of view, you might be so busy, trying not to explode, that won’t be doing your pain any good.
Evans: Dr Jane Boissiere. So what approach would a health professional practicing hypnosis take with a new patient.
Williamson: Well, if a patient came to me and wanted hypnosis for pain relief or pain management, we’d talk about it first and talk about what it is and what it isn’t and kind of… dispel misconceptions, because people often think of hypnosis as a magic wand and it isn’t. It is a brain state that you can utilise to help yourself develop skills and abilities to help you manage pain.
Evans: Well, actually most people would think of hypnosis as a music hall act.
Evans: That you can make me run around naked as a chicken
Williamson: Well, only if you wanted to [laughing] Evans: I don’t.
Williamson: No [laughing] and only if you’re a good hypnotic subject because we all have different hypnotic ability in the same way that we all have different musical ability.
Evans: So, this is not stage hypnosis, I will be conscious.
Williamson: You’d be aware of whatever is going on around you, then if you were going more focused internally, you might get less aware. If I am doing a session with somebody and somebody opens a door or the phone rings, it disturbs me more than the person I am working with, very often. The first stage obviously, would be taking a history and finding out about the person, what they like, what they dislike, because people very often, have used kind of semi-hypnotic tools already without even knowing that they have done it. I worked with one guy once, who said, ‘when I start to get stressed, I sing my tune in my head’. He had this little tune – he was a musician – he did this tune in his head, so he already had a link to feeling calmer. People often have things that they do, that help them already and hypnosis can help them more.
They often don’t feel any different in the hypnotic state than in the awake state except that they are more focused internally. You see when people come out of the hypnotic state, it takes a moment or two to re-orientate back into the here and now. One uses all sorts of things with people. It is not just a question of getting them to access a calm and relaxed feeling which you can do – you might get them to use imagery of a special place, that they would love to be which would be calm and relaxed, which could be imaginary or it could be real. You could get them to imagine what their pain or discomfort looked like and then, if they could go in and make a change, which would make it more comfortable, what would they do – and that can often help.
You can have classic imagery, turning dials down or going to your pain control centre in the back of your mind and turning the lever down more towards comfort, certainly not in the first session, but it might be the second or the third session that I would work with somebody to see whether there is anything psychological underpinning their pain that they need to address or that they want to address, because they might not want to. The important thing is giving the patient tools which they can then take away and use.
I give them the kind of metaphor of a child. Anyone who has had children knows that a toddler will be clamouring for attention just at your busiest moment in the kitchen and you say ‘go away, mum is busy’. And what does the toddler do? Clamours even louder until you give it attention. Well, your pain can just whisper as long as you are aware when you need to give it attention, so instead of being, kind of a seven or eight out of ten, it can be two or three out of ten.
Evans: So instead of grabbing you by the throat, it can just tap you on the shoulder.
Williamson: Yes, and you can pay attention to it and do what you need to do, to keep yourself comfortable.
Evans: That’s Dr Ann Williamson of the British Society of Clinical and Academic Hypnosis.
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So for those wanting to find out more about hypnosis – be you a patient or medical professional – where should you look for advice?
Williamson: Our society, the British Society of Clinical and Academic Hypnosis believes that you should only treat with hypnosis, things that you can treat without hypnosis and I think that is a really good safety guideline. So, someone looking for someone to work with using hypnosis needs to find someone they would be going to anyway, like a physio or a doctor or whatever.
Evans: And as you were saying, members of the British Society of Clinical and Academic Hypnosis, they are practitioners in other areas as well?
Williamson: They are all working health professionals, yes.
Evans: So what standards, should people with chronic pain look for in choosing a hypnotherapist?
Williamson: You need to find someone who has some knowledge or your condition I think. You see hypnosis is very easy; it is what you do with it that is more difficult.
Evans: I can find any number of hypnotherapists in yellow pages or on the internet.
Williamson: You need someone who is either a psychologist or a doctor or certainly someone who is UKCP accredited, something like that – United Kingdom Council for Psychotherapy.
Evans: For health professionals listening to this, where should they go if they are interested in using hypnotherapy?
Williamson: Well, if you go on to our website, www.bscah.com, you will find lots of information there. You will find information on our training courses which are around the country. Usually the foundation training is three weekends which gives a basic grounding in hypnosis and hypnotic techniques and the third weekend we tailor to whoever we have participating – so if we have got a lot of dentists, we’ll get a dental trainer in, if we’ve got a lot of anaesthetists, we’ll get an anaesthetist who uses hypnosis – so it is tailored to the people that are attending.
• Dr Ann Williamson, British Society of Clinical and Academic Hypnosis
• Dr Jane Boissiere, British Society of Clinical and Academic Hypnosis