Publications
APS Bulletin • Volume 14, Number 2, 2004
Pain Clinic Perspectives
Steven Sanders, PhD, Department Editor
Is It Time to Propose a Continuum of Self-Regulation Treatments for the Control of Pain? Evidence for Effectiveness of Hypnosis and Relaxation
Rodger S. Kessler, PhD
In 1995, a National Institutes of Health consensus conference concluded that hypnosis and relaxation methods effectively treat a variety of pain conditions. Recent evidence supports such treatments can have positive clinical and cost outcomes. Despite the interest and appeal, relatively few randomized clinical studies have been published that evaluate the efficacy of such psychological interventions to assist in pain reduction. This article reviews the research in this area (Kessler, Patterson, & Dane, 2003).
In reviewing the available research, it is useful to view hypnosis and relaxation on a continuum of self-regulation techniques along the dimensions of impact on the sensory and/or affective dimensions of pain and ease and portability of independent use by patients (Dane & Kessler, 1994). From this position, hypnosis and relaxation are viewed as points on that continuum that share certain similarities and maintain certain distinctions.
Evidence for Efficacy
The findings from acute pain studies demonstrate hypnosis is superior to a waiting list or no treatment control conditions, and often superior to other viable pain treatments. While there is moderate support for relaxation interventions with acute pain, it does not appear as robust as support for hypnotic interventions, particularly in relation to other self-regulation treatments. Chronic pain study findings suggest hypnotic treatment is consistently superior to no treatment, and often as effective as, but not superior to, other viable treatments. Likewise, relaxation is superior to control in the treatment of chronic pain. It is no better than a variety of other self-regulation interventions, however.
There are several methodological issues that limit research interpretation. These are endemic to much psychological research and include constraints of sample size, variability of interventions from study to study, and lack of assurance regarding the same content and intervention administration from procedure to procedure. Likewise, suggestibility, non-specific versus specific effects, and practice/dose effects are potential confounding variables.
For studies that measured suggestibility, most demonstrated a positive association between suggestibility and at least one outcome measure. In several studies, patients scoring high on tests of hypnotic suggestibility often showed more improvement with nonhypnotic psychological measures such as autogenic training, relaxation, and cognitive-behavioral treatment. It appears the association between clinical effect and suggestibility exists for a range of psychological treatments. This warrants that future investigations of all psychological self-regulation treatments include evaluation of suggestibility.
Clinical trials not only determine that a treatment is effective relative to no treatment or to a no-treatment waiting period, but also to a treatment condition designed to control for nonspecific effects. Designing such controls in self-regulation research is difficult. Interventions have many dimensions common to conditions being contrasted. Relaxation is sometimes part of hypnotic induction. Suggestion is clearly part of many relaxation interventions. If we are to identify treatments that are effective for certain conditions or populations, further research needs to control as much as possible for intervention component overlap.
Some studies reviewed used interventions that were spread over a longer period of time or introduced at longer session intervals. It is unsatisfactory to assume intervention equivalence with such a broad variation in dose and without the ability to relate dose amount to outcome variation. Future research needs to determine the dose effect for self-regulation treatments associated with specific levels of pain reduction.
Conclusions
Results from the reviewed literature support that both hypnotic and relaxation interventions can significantly reduce different indices of pain in certain medical conditions. Hypnosis appears to be the more robust intervention, demonstrating effectiveness for both chronic and acute pain. Relaxation has only moderate research support for acute pain, with more convincing evidence for chronic pain. Neither hypnosis nor relaxation techniques have consistently been shown better than other self-regulation methods.
Our observations suggest effective acute and chronic pain treatments are not the same, and present distinct issues in the design and implementation of self-regulation treatment strategies. Chronic pain treatment involves broader multidimensional assessment and treatment that likely requires broader multidisciplinary interventions to produce the best care. Further, specific methodological issues limit current interpretation and effect future research efforts.
We continue to search for a continuum of self-regulation techniques on complexity of dimensions accessed, number of component parts, portability, and intervention effectiveness. This review tells us there are additional dimensions to be understood, specifically the role of suggestibility and dose effect. At this time, we are not yet able to clearly define the continuum of effective self-regulation in reducing clinical pain.
References
Dane, J., & Kessler, R. (1994). A matrix model for the psychological assessment and treatment of acute pain. In R. Hamill & J. Rowlingson (Eds.), Handbook of critical care pain management (pp. 53–82). New York: McGraw Hill.
Kessler, R.S., Patterson, D.R., & Dane, J. (2003). Hypnosis and relaxation with pain patients: Evidence for effectiveness. Seminars in Pain Medicine, 1(2), 67–78. Reprinted with permission from Elsevier.
Rodger Kessler, PhD, is a clinical psychologist at Berlin Family Health, and is on the staff of Central Vermont Medical Center, where he serves as chair of the care management committee.