Alternative Health Practitioner, Vol. I , No.

1, Spring 19;s

Hypnosis and Therapeutic Suggestions

for Managing Pain and Stress

Rothlyn P. Zahourek, MS, RN, CS

Amherst, MA
Dorothy Larkin, MA, RN, CS
N e w York, NY

Ericksonian hypnotic procedures can be used by a wide range of alternative

practitioners. They do notrequire the traditional trance and can be adapted based on
the client’s health needs, using conversational speech. Whether practitioners are
aware of it or not, they give suggestions. This article presents ways alternative
practitioners can readily use to make sure the suggestions they use are positive and
support healing.

Ancient healers and shamans as well as modem-day clinicians have explored the value
of tapping unconscious resources through altered states and hypnotic suggestions.
Many clinicians are integrating hypnotic interventions to manage a variety of mind/
body conditions. Those unfamiliar with the field of hypnosis seldom realize that several
approaches to ‘hypnosis exist. Many clinicians are currently utilizing hypnotic ap-
proaches associated with Milton E. Erickson, MD, who has been described as “the
world’s leading medical hypnotist” (Haley, 1986,p. 18). Ericksonian approaches have.
particular applicability for alternative health care practitioners because they are c-
ommunication techniques based on knowledge, observation, and utilization of the
client’s unique patterns. They are often short-term interventions that are individually
tailored in the con- text of a therapeutic relationship, and are often implemented without
the use of formal hypnosis. In contrast to the standardized, more traditional form of
hypnosis, Ericksonian approaches focus on the unique interaction and relationship with
the client, and the use of direct and indirect suggestions to formulate an individualized
conversational and naturalistic hypnotic induction consistent with thc client’s health-
related needs.
Therapeutic hypnosis and therapeutic suggestions are holistic interventions based on
the premise that the mind can influence physiology and emotional responses to pain and
stress. Research and case studies permeate the psychology, medical, and. more recently,
nursing literature. They support the successful integration of hypnosis and hypnotic
techniques in a therapeutic regime for managing pain and stress associated with life-

0 1995 Springer Publishing Company 43

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44 R. P . Znhorrrek and D. Larkin

threatening illnesses, surgery, labor and delivery, cardiovascular disorders, emergency

room visits, dental care, habit, anxiety, and phobic, obsessive-compulsive, and depres-
sive disorders (Daley & Greenspan, 1979; Smith, 1982; Vandurra & Butts, 1982;
Zahourek, 1983, 1990).

T I E HYPNOTIC TRANCE
The experience of hypnosis is typically described as altered or expanded awareness in
which an individual is more receptive to new perceptions and ideas, and hence is more
likely to initiate new health-promoting behaviors (Zahourek, 1987). In trance, the
limitations of one’s usual frame of reference and beliefs are altered so one can be
receptive to new patterns and perceptions that are more conducive to problem-solving
(Erickson & Rossi. 1979) and well-being.
Hypnosis has been described as occurring on a continuum of awareness between
sleep and wakefulness. Electroencephalographic (EEG) studies of the electrical activ-
ity of the brain indicate that hypnosis is not sleep, but more closely resembles the
waking state. During the relaxed, relatively immobile state, hypnotized individuals are
usually mentally active, highly focused, and rousable. After the trance they may feel
drowsy, relaxed, alert, refreshed, and/or partially or completely amnestic depending on
offered and accepted suggestions.
Variability of trance depth occurs from a light change in consciousness and focus of
attention (driving for a period of time on a boring highway and sensing loss of time and
orientation while remaining completely awake. or being immersed while reading a good
book) to a deep level of somn,arnbulism where amnesia is characteristic. Concern with
and measuring the depth of trance, although useful for research purposes, arc less
important for achieving most clinical goals than the person’s motivation, receptivity,
and trust and belief in both the therapist and the potential effectiveness of hypnosis
(Barber & Wilson, 1977).
As an altered state of consciousness or experience of focused awareness, the
hypnotic trance is a natural phenomenon that may occur spontaneously when one is
deeply involved in a thought or activity. It is a learned ability that easily improves with
practice. Hypnosis may be induced by one’s self or another. Monotonous rhythms,
boredom, confusion, stress, and anxiety all may spontaneously and/or therapeutically
produce a trance. During an intense experience of stress or pain, an altered or trance
state may result.
Because trances are easily induced and may occur spontaneously, hypnosis may be
induced without the clinician’s intent when relaxation, imagery, meditation, or biofeed-
back procedures are employed. During this altered experience, people can be more
receptive to suggestions. For example, a massage therapist may help an individual into
a very deep state of relaxation or hypnotic trance. During this, individuals will be more’
susceptible to suggestion and therefore it will be important to phrase ideas in a positive
manner to the client, e.g., while yoit are so pleasantly relaxed you will find that the
stressesofthe daysimply seerit to riielt aivay. The person in this light trance might appear
immobile and exhibit the “glassy-eyed” stare that is characteristic.
Although beginning practitioners worry about how to “do a hypnotic trance,” the
therapeutic utilization of trance and devising and delivering therapeutic suggestions
within the context of the therapeutic relationship are the real clinical challenges.

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Hypnosis for Pain Managetilent 45

Although usually appearing relaxed, the individual in trance may be mentally so

active that perception of physical sensations is blocked or altered (Hilgard. 1979).
Hypnosis facilitates relaxation and slows the sympathetic neuromuscular responses to.
provide relief and promote healing. It also alters both the psychophysiological experi-
ence and perception of such negative affects as pain and stress by enhancing distraction
and dissociation (a sense of disconnection). Various induction procedures include
progressive relaxation and the use of guided imagery. The standard scripts for relaxing
muscles (either starting with the feet and working up the body or from the top of the head
down the body) will induce a deep relaxed condition, or a trance. Similarly, elaborately
described images will also provide the distraction and intense mental focus that will
promote trance, e.g., imagine yourselfsitting in a cabin in tlie woods. It is cozy and
relaxed. There is afire in tliejireplace; imagine how pretty it is with its bright orange
and redfla~nes.It is warm. Feel the warnilii on your face. Hear its crackling.
Milton Erickson (Erickson & Rossi, 1980) describes highly individualistic induc-
tions using such techniques as utilization, therapeutic doiible binds, permissive and
interspersed suggestions, confitsion, and therapeiiric stories and tiietapliors. An Erick-
sonian permissive suggestion might sound like... I wonder when tlie relaxation you ’re
beginning to feel will bring you contfort and calm.... Other examples of his simple
conversational and more elaborate forms of suggestion will follow later in this article.
“Traditional.” standardized, and directive forms of hypnosis can be authoritarian,
emphasizing the “power” of the therapist and the subject’s susceptibility (Gilligan,
1987). Results of early studies on hypnotic susceptibility are today considered incom-
plete, due to their failure to acknowledge and utilize each individual’s unique capabil-
ities and interests (Larkin, 1990). The “interactional” approach, derived from Milton
Erickson’s work, emphasizes a cooperative relationship bctween the hypnotic facilita-.
tor and client. Hypnosis based on this cooperative model “requires adaptive rather than
standardized instructions, as the hypnotist follows and then guides the ongoing behav-
ior of the subject” (Gilligan, 1987, p. 11). Important in this model is the acceptance and
utilization of the subject’s phenomenological perspective of reality. Once the therapist
has aligned with the client’s world view, suggestions for altering perceptions or
experience of that reality are more readily accepted. For example, do not use a water
image for someone who has a fear of water. Start with their preferences and then
therapeutically lead.

SUGGESTION

Suggestion is described as a “process by which sensory impressions are conveyed in a

meaningful manner to evoke altered psychophysiological responses” (Kroger, 1977).
Traditionally suggestion was defined as a stimulus that evokes an uncritical acceptance
of an idea. This, however, implies that the client is a “passive recipient, void of a
capacity to reason” (Larkin, 1990). Generally, the unconscious mind screens and rejects
inappropriate or immoral suggestions. The conscious mind, however, with its learned
limitations and prejudices often benefits from being opened to alternative ideas through
suggestions.
Ericksonian therapeutic suggestions involve interactional communication. Individ-
uals are considered to be potential artists <andco-therapists with potentials for respond-

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46 R. P. Zahourek and D. Larkin

ing to suggested themes and ideas in order to creatively restructure their own reality
(Field, 1979). Suggestions are not given with an expectation that they will be
followed to the letter, but rather as a basis for change in perceptions, behavior, or
world view.
Positive response to suggestions is related to motivation, expectation, and trust.
The manner in which suggestions are given, frequency, and congruence of suggestion
with the individual’s psychological makeup, background, and life experience will
influence the client’s response to suggestion.
The impact of negative suggestions can be observed when frightened, stressed
patients selectively overhear negative remarks or conversation and subsequently
interpret those remarks as true for them. Heard through an altered state or focused
awareness, the negative or erroneous idea may be accepted because it receives little
conscious editing. For example, a clinician might tell a patient anticipating a
procedure, “Now. don’t move because it will hurt worse if you do!” As a result the
individual tenses to bear the anticipated pain and subsequently intensifies the
perception of discomfort. Similarly, positive suggestions for comfort, increased self-
esteem, and personal growth can have profound impact if given when the individual
demonstrates trance behavior. Health care professionals can teach a patient about a
procedure and include therapeutic suggestions on how he/she can experience that
procedure. For example. “You might experience some pressure as I gently position
your arm, and you can take some deep breaths to feel more comfortable and rest
quietly so that pressure will ease,” is more positive and likely to help the patient relax,
cooperate, and perceive less pain.

WAKING SUGGESTIBILITY

Waking suggestibility occurs when an individual responds to suggestions without a

preliminary trance induction. The placebo effect (a response to suggestion) is
apparent when a patient becomes more comfortable almost immediately following an
injection for pain relief or when toothache symptoms seem to disappear when one
finally meets with the dentist.
Waking suggestibility’has particular relevance for general practitioners who feel
time constraints for and/or lack of skill in doing a formal hypnotic induction. A
waking trance-like state is noticeable when the patient exhibits a sudden fixation of
attention, is very still or immobile, or is staring off into space. As conscious critical
faculties are reduced, suggestions are more readily accepted. Utilizing this more
receptive focused awareness, the health practitioner might, in a soothing voice, offer
suggestions of comfort. reassurance, and health-promoting activities such as main-
taining a healthy diet or exercise program. Through continued assessment and
observation, other sudden shifts in attention can be noted; the practitioner then might
modify the interaction and implement suggestions to meet the patient’s needs.
Current literature attests to the ease and brevity of utilizing waking suggestion to
enhance patient cooperation (Holdegby, 1981; Larkin, 1988; Orndorf & Deutch,
1981; Zahourek, 1983, 1987, 1990). When hospitalized patients intensely focus on
their condition, they are frequently hypersuggestible, and any idea presented may act
like a posthypnotic suggestion (Rogers, 1972). The above applies to individuals
anticipating an anxiety- or pain-producing experience.

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Hypnosis for Pain Managernenr 47

DESIGNING A POSITIVE SUGGESTION

Four elements of communication are useful for congruently designing suggestions

(Kroger & Fezler, 1976): words; body language and gestures; intonations; and the
implications of words and gestures. These are all aspects of therapeutic communication
and elements essential to the development of a therapeutic alliance.
Suggestions are also classified as direct or indirect. A direct suggestion is usually
more authoritative. The expected results are made clear. Often associated with a formal
trance induction, they may be phrased like, “You will open your eyes and feel more
rested and comfortable.”
An indirect suggestion, more subtle and generally more permissive, may or may not
be associated with a formal induction and may be a part of a conversation. The above
statement phrased indirectly might be, “When you feel ready, perhaps in a minute or
two of clock time, you can open your eyes and notice how rested you feel, and how that
comfort can remain with you ....” These techniques are general tools of therapeutic
communication that can be used with or without hypnosis. Indirect suggestions invite
client participation, and emphatically relate directly to their experience and world
view.
Indirect suggestions often include preliminary permissive phrases such as:
“Perhaps you’ve already noticed that the developing relaxation in that arm....”
“You can discover many pleasing sensations while in this state.”
“You might be surprised to discover how those feelings can progress in helping you
feel more comfortable.”
These phrases encourage the client to “notice relaxation,” “discover pleasing
sensations,” and “progress towards feeling comfort.” Their permissive nature invites
active participation, communicates choice, and avoids the potential resistance that can
develop from direct suggestions.
Commonly, direct and indirect suggestions are incorporated into the same interac-
tion. A desired outcome might be phrased both metaphorically, or indirectly, and also
more authoritatively and directly in the same interaction. For example, helping a
patient feel less stress and more comfort can be suggested through metaphor, “You may
begin to feel soothing sensations like a gentle internal massage, as your body becomes
softer and more relaxed,” and more directly, “You are getting more relaxed and
comfortable while that medication spreads through your bloodstream.” Such therapeu-
tic suggestions can similarly augment the care provided by dentists, physical and
occupational therapists, chiropractors, and massage therapists.
In crisis situations, more direct suggestions may be more appropriate to obtain the
patient’s immediate attention and response. Clinical practice and observing patient
responsiveness and reactions over time enable clinicians to balance and tailor their
suggestions to fit individual client needs.
Acceptance and utilization of client strengths, characteristics, and potentials can be.
developed into therapeutic suggestion by initially commenting on something that is
indisputably true about the client’s ongoing experience and then permissively linking
it with something that you would like the client to experience. For example, While
you are lying on that table and breathing in and out (indisputably true) you can begin
to experience a pleasant sense of softening and relaxation throughout your body, and

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48 R. P . Zuhoiirek and D. Larkin

I will tell you everything I run going to do, so you don’t need to be concerned about what
is going to happen next.” While I exatnine that leg there, you can take your mind to
someplace more comfortable, and be there, perhaps a pleasant place in nature like the
beach. Sinell the salt air,feel the wartntli, hear the waves.... This provides a dissociative
suggestion helping the individual replace pain with a sense of pleasure.
Although the efficacy of direct or indirect suggestions continues to be an issue, some’
research exists that substantiates the effectiveness of indirect suggestions. Barber
(1977) studied the effect of a 15-minute indirect hypnotic induction that permissively
guided 100 dental patients to “the awareness that experience can be modified“ (Barber
& Adrian, 1982, p. 177). Ninety-nine were able to achieve analgesia throughout a
variety of operative dental procedures. The unresponsive person was a woman who had
her hypnotic experience interrupted by a dental assistant who rushed in during the
middle of the procedure and shouted, “The president’s been shot!” Reality suddenly
became more important to that patient than a hypnotic state. Barber emphasized
hypnotic analgesia occurs by redirecting attention andlor reinterpreting. He claimed
there was zero correlation between a subject’s susceptibility (as observed on a standard-
ized susceptibility scale that utilizes direct suggestions) and the ability of subjects to
develop hypnotic analgesia.
A review of the research by Yapko (1983), Hammond (1990). and Lynn, Neufeld.
and Marc (1993) suggests minimal difference in the efficacy of direct and indirect
suggestions. Bady (1992) recommends practitioners be versed in phrasing suggestions
both directly and indirectly, and fit the form of suggestion to the observed responsive-
ness of the subject. If the client responds positively to direct suggestions, use direct
suggestions. However, when clients resist direct suggestions, instead ofpresuming they
are not susceptible to hypnosis the more flexible practitioner will simply shift the
linguistic patterns to be more indirect.

REALIZATION OF SUGGESTION
The realization of most forms of suggestion depends on three processes: (a) the
emotional rapport between the patient and clinician; (b) the acceptance of the suggested ’
idea; and (c) the effeci created by the idea once it has been incorporated into the
personality (Jones, 1978). The need for suggestion to take effect and the frequency of
exposure to suggestion similarly enhance the realization of suggestion. Individuals
respond to suggestions in two ways: voluntarylconscious, and irivoluntarylwithout
conscious participation. When suggestions bypass higher cortical processes and elicit
a nonvoluntary response, one can presume unconscious participation and lhat accep-
tance has occurred (Weitzenhoffer, 1980).
Some of the controversies in the field of hypnosis are as follows (Zahourek, 1987).
How suggestions are given is debated as well as how and when one type of suggestion
is more effective than another. Is the observed effect the result of hypnotic suggestion
or other uncontrollable variables inherent in the interpersonal process? More recent
concerns pertain to the inconsistent and insufficient training provided by numerous
organizations who provide certification to unqualified lay persons. Repukble organi-
zations require participants to be health care professionals who are licensed in their
field. They teach the ethical guideline that hypnosis is a tool to be used within the
auspices of your own profession. Hence dentists, chiropractors, massage therapists, and

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Hypnosis for Pain Manageriienf 49

physical therapists should use hypnotic approaches to help patients manage their pain
and stress; however, they should not be using hypnosis for age regression.
Another area that warrants serious concern pertains to the use of hypnosis for
memory retrieval (Inrernafional Journal of Clinical and Experimental Hypnosis,
1994). Research on memory emphasizes memory is fallible in both waking and
hypnotic states. Litigation procedures are mounting with defendants claiming false
accusations of abuse. Therapists may also be sued for hypnotizing clients who request
memory retrieval work, because emerging memories, which may or may not correspond
to historical reality, may be deleted from courtroom testimony as potential con-
fabulations. Using hypnosis with any person involved in litigation procedures warrants
careful consideration and a protective legal stance with a signed informed consent
document.

RESEARCH IN HYPNOSIS

In discussing the scientific basis of hypnosis, Weitzenhoffer (1986) states that he would
give a qualified “yes” and a qualified “no” to whether or not hypnosis has a scientific
basis. He believes the problems in evaluating the research are threefold: (a) hypnosis
denotes a state of being; (b) hypnosis is a class of behavioral phenomena, and (c)
hypnosis is the study and use of the state and the complexities of interaction involved
in using hypnosis. Researching hypnosis is similar to researching other psychophysi-
ological and relationship-oriented phenomena. Numerous variables exist including: the
personality and expertise of the clinician, the personality style of the patient, the level
of trust and motivation in the patient (client), the technique used, and the meaning of
the problem or symptom to be changed for the individual. Because these variables
cannot be consistently quantified, much of the research is necessarily qualitative.
Research reports, theoretical papers. journals, and books abound in the field of
hypnosis. Research in controlled laboratories as well as in clinical settings has explored
susceptibility and suggestibility, the nature of hypnosis, and its effect on various
physiological and psychological states. To date, hypnosis has been found to be effective
in treating several health problems including altering many physiological and psycho-
logical states, i.e., bleeding, heart rate, blood pressure, pain, anxiety, stress, and
depression (Rossi, 1986). Hypnosis is beneficial in virtually all areas of alternative
practice. It is used in patients with chronic conditions and for short-term problems and
may be incorporated into work with individuals, groups, and families.

PAIN

The pain phenomenon is complex. Both acute and chronic states as well as functional
and organic pain have bcen described in the literature (McCaffery, 1979). The therapeu-
tic process differs for each as well as the hypnotic interventions chosen. Hypnotic
intervention has been especially effective in acute. organically based pain (Crasilneck
& Hall, 1985). People with acute pain can describe their symptoms, their motivation is
high, and secondary gain (more characteristic of chronic pain) is low. A person with a
broken bone, for example, may describe the pain as aching, hot and gnawing, and
running down the limb. Pain medication has helped some, but the entire experience has
produced tension, fear, and subsequent muscle spasms. Because hypnosis and therapeu-

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50 R. P . Zohoiirek and D.Larkin

tic suggestions can produce relaxation, they are helpful adjunctive interventions for
easing pain and stress. This combined with suggestions to, while relaxing, cool and
soothe the ache can be utilized to alter the perception of pain sensations.
Because change in amount or type of pain can be a useful protective symptom, it may
nol be appropriate to eliminate all pain, but rather to encourage the ability to relax and
feel more comfortable while still maintaining the ability to evaluate the illness or
healing progression. In some cases (surgery, painful procedures, or with some chronic
or acute pain), suggestions of numbness or lack of sensation are provided. Total pain
removal can be induced with glove anesthesia (a process of encouraging numbing
sensation in the hand and then mentally transferring that lack of sensation to another
body part). Often patients utilizing hypnosis for pain relief realize that if they attend to
the pain they notice it still exists, but they no longer need to pay attention to it or feel
bothered by it.
Since functional and chronic pain is often associated with psychosocial overlay and
secondary gain, or reward, caution is encouraged. Guidelines f o r intervention are
documented throughout the hypnosis literature. First, all pain is seldom removed and
secondary gains need to be identified. Depression may complicate recovery and require
additional medical/psychotherapeutic management. Medical complications or coexist-
ing problems need to be ruled out.
Hypnosis is often helpful in such complex cases to augment a regimen of medica-
tions, psychotherapy, and/or other alternative or complementary therapies. The follow-
ing case example demonstrates how traditional and alternative approaches can combine
to create a positive outcome.
An 80-year-old man had suffered for many years with debilitating back pain. He was
skeptical but willing to try alternative approaches in addition to working with his
orthopedic surgeon, who was not enthused about operating on him. He was willing to see
a chiropractor and to enter psychotherapy with a clinician who also practiced hypnosis. He
was also depressed and had been in recovery from alcoholism for many years. He was
isolated and stayed in bed for fear that the pain would get worse if he moved. In the process
of therapy and working closely with his medical doctor and chiropractor, he learned
relaxation and self-hypnosis techniques. Low-dose antidepressants, which are now com-
monly used with chronic pain, were also started. The combination of psychotherapy,
regular chiropractic visits. hypnosis, and medication all finally helped this man have
relief. Gradually he developed more self-confidence and was leaving his house more
often. Nursing home placement and surgery were prevented and his quality of life greatly
improved.

STRESS

Stress has both positive and negative effects. When it becomes chronic, it produces
wear and tear on the body and can exacerbate illness. 1Iypnosis has been used to counter
the chronic tension and anxiety associated with stress. Specifically, hypnosis has
combated test anxiety and phobias and has helped individuals to both experience
relaxation in stressful situations and perceive stressors in a more positive light. This is
an example of reframing. or changing the meaning of a situation.
A couple anticipating childbirth can be stressed both in preparing for the delivery and
in worrying about the kind of parents they might become. Helping them in a trance state

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Hypnosis for Pain Managenlent 51

project themselves into the future picturing the experience positively can be both
instructive and comforting. Similarly, helping individuals to perceive and reframe life
events in a different or more positive framework can combat an important aspect of the
stress experience-that of perceiving an event(s) as overwhelmingly stressful. A
clinician can help individuals interpret events as a challenging opportunity. or to regard
their reactions as nonnal and understandable rather than as symptoms of “craziness.”
Hypnotic approaches are also helpful in group process. A stress management/
meditation support group for persons living with AIDS/HIV provided training in self-
hypnosis as a form of meditation for stress management. Because hypnosis is easily
learned, people become self-sufficient at inducing their own experience of relaxation
and focused attention. Accumulating research in psychoneuroimmunology suggests
immunological benefits when clients utilize such strategies as hypnosis for managing
stress. One participant in the support group described his experience utilizing hypnotic
approaches as follows:
Since attending the meditation sessions I have been able to enhance my life, spiritually,
emotionally. and physically. Being a person living with the IIIV virus, I am sure that these
sessions have helped me with my health. I take no medication and have been infected for
5 years. My T-cell count was 640 last time I tested in September. As far as I am concerned,
meditation has improved my life and I feel this can help many others who are willing ...
nothing is limited ...everything is expanding.

SUMMARY

Health care practitioners can easily learn to rccognize the waking trance experience and
begin to employ the use of therapeutic suggestion in their usual interactions with
patients. This article presents a brief introduction to the therapeutic use of hypnosis and
direct and indirect suggestions. They are tools to be utilized within Lhe auspices of one’s
own profession. To bccome proficient in utilizing these approaches, formal training
with reputable organizations is necessary.

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Hypnosis for Pain Management 53

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Biographical Data. Rothlyn P. Zahourek’s biographical data are given in the Practice
Issues column in this issue. Dorothy Larkin, MA, RN. CS, is President and on the
faculty of the New York Milton H. Erickson Society for Psychotherapy and Hypnosis.
She is a pain management consultant for Cabrini Hospice in New York City, and has a
private practice for pain and stress management in New Rochelle, NY, and in Manhat-
tan. Ms. Larkin is the author of chapters and articles on hypnosis, therapeutic sugges-
tions, metaphors, and storytelling, and she is a doctoral candidate in Nursing Science
at New York University.

Offprints. Requests for offprints should be directed to Rothlyn P. Zahourek, MS, RN,
CS, 20 Gatehouse Road, Amherst, MA 01002.

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