Chronic Pain and Hypnotherapy

I had this article published some months ago but wasn't available outside of the hypnotherapy fraternity so I'd like to share a slightly adapted version. Editing credit Sally Hare - Hypnotherapy in Bristol UK (sallyharehypno.co.uk)

This article will explain pain, chronic pain, and the gate theory, and offer recommendations for

Solution Focused Hypnotherapists

The International Association for the Study of Pain’s revised definition encompasses a plethora of pain types: 

‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.’ 1 This first new definition in 40 years encompasses pain perception when there is no clear evidence or tissue damage, such as in primary chronic pain.

Pain sensations can be broadly divided into two types. Ad fibres mediate ‘fast pain’ which is bright, sharp or stabbing. I remember the fibres by thinking of ‘Aargh! pain as in A’. The second type is the dull, throbbing, aching type mediated by C-fibres: these signal chronic or ‘slow pain’, or as I like to think of it, ‘Coooooor! pain as in C’.

Nociceptive pain refers to pain that is associated with tissue damage or inflammation. Nociceptors detect a stimulus to the tissue and activate neurons, sending signals to the brain which enable us to take action, either by removing ourselves from the stimulus or seeking help. 2  This pain is acute and lasts for a short period of time. 

Pain that persists or recurs for more than 3 months is considered to be chronic. The World Health Organisation in 2020 defined chronic pain as: 

‘Pain in one or more anatomical regions that is characterized by significant emotional distress (anxiety, anger/frustration, or depressed mood) or functional disability (interference in daily life activities and reduced participation in social roles). Multifactorial – biological, psychological, and social factors contribute to the pain syndrome.’

The reference to the limbic system’s responses of anxiety, anger and depressed mood link the very physical sensations with our emotional responses. This therefore allows Solution Focused Hypnotherapists to theorise about their role in managing chronic pain. The National Institute for Care Excellence (NICE) 3 notes that there is no substantial evidence for hypnotherapy/hypnosis’ per se. Cognitive Behavioural Therapy (CBT), however,

improved quality of life for people with chronic primary pain but demonstrated less evidence for improving sleep. Now I know you will be wanting to interject with ‘… but Solution Focused Hypnotherapy helps with sleep and therefore pain!’ NICE are appointed to establish the cost benefit of interventions, so evidence for treatment is calculated using a cost benefit formula.

Without evidence, of which randomised controlled trials (RCTs) are the

preferred measure, they will not recommend an intervention. This does not mean that Solution Focused Hypnotherapy is ineffective, it means that it hasn’t been researched alongside an economic evaluation and/or in the format of an RCT. Elkins 4 et al in 2007 reviewed 13 studies and found that ‘hypnosis’ consistently decreased pain in a variety of chronic pain problems. The ‘hypnosis’ benefits outweighed other interventions such as physical therapy and education. If we take the review at face value, it sounds positive for ‘hypnosis’, however there was lack of standardisation of the intervention. The number of participants was also low and lacked long

term follow-up, thus reducing its generalisability for chronic pain management in the NHS. Elkins et al also did not specify what sort of hypnosis they reviewed.

There is positive news from NICE. There are many interventions which NICE categorically advise against. Hypnotherapy is not within their list. What can Solution Focused Hypnotherapists do to help people with chronic pain? Firstly, the client must demonstrate that they have had an alternative diagnosis excluded. Many cancers or other conditions can present as persistent pain which in itself may be managed by SFH, however for obvious reasons this should be diagnosed and appropriate medical treatment offered first.

My previous nursing role was a specialist nurse in rheumatology for many years and I now work as an advanced nurse practitioner in primary care as well as being a SF Hypnotherapist. This by default means I see many patients with painful conditions, often chronic. Once a differential diagnosis is excluded I am comfortable to say to a patient that ‘… it is good that we have excluded anything worrying and it is likely that you have chronic pain that we can work together to manage.’ In my nursing career I have learnt that chronic to many people means ‘terrible,’

so it is important for them to understand that chronic pain is persistent, unexplained, but not worrying, pain and there are non-drug ways of managing it.

As Solution Focused Hypnotherapists we won’t be focusing on what has gone, but many clients will have had a physical or psycho-social trigger for the pain, which may be disclosed as they establish a rapport with their therapist. It is important to consider how this disclosure may impact on the therapist personally and how they may respond. Therapists don’t want to dwell on the trauma trigger but a gentle, non-judgemental acknowledgement will be important, initially to facilitate trust in the therapeutic relationship. The therapist may wish to contact their

Supervisor for personal and professional support as they may be the first person that the client has disclosed to; there may be a risk of transference of their emotions onto the therapist whilst disclosing. As we know, the Initial Consultation (IC) underpins practice in SFH. There is some useful information which may support the information given during the IC. Explaining the pain gate theory is helpful and may give the client confidence, knowing they have the power to make important changes.

In my nursing role pre-hypnotherapy training, my room was opposite a busy road. I would say ‘… if you had injured yourself, and then a loved one went to walk into the road, you would immediately save them, and for that moment your pain would not be dominant, and it’s this overriding that we want to encourage.’ This scenario would be the limbic system kicking in appropriately, but we don’t want to encourage its involvement in managing pain. It is, however, useful for clients to understand the concept of being able to override pain messages. The pain gate theory can be adapted using what is known about our client, making it relevant to their specific pain eg back pain. The pain gate theory is explains how the nerves from all over the body connect to spinal cord, which send impulses (messages) to the brain identifying a stimulus ie chronic pain. If we imagine there are physical gates on these impulses’ routes to the brain then we can imagine we have the power to open and close these gates in chronic pain, blocking the impulses’ journey. If the gates are closed, then the impulses are reduced, which in

chronic pain is extremely beneficial in reducing pain. It is unlikely that acute pain such as a burn or finger prick will be significantly blocked by a closed pain gate, therefore closing the gate is safe.

The charity Versus Arthritis UK Versus Arthritis | All of us pushing to defy arthritis offers training in chronic pain which includes the recommendation for understanding pain in five minutes supported by an animated video explaining chronic pain which may help the therapist and the client. It and can be found on YouTube, titled Understanding Pain in less than 5 minutes, and what to do about it!  

Stress, tension, anxiety, worry, anger and depression – states influenced by the primitive mind, are a common way of opening the pain gates and allowing pain messages to get to the brain. Boredom and focusing on the pain also keeps the gate open, as does inactivity. In order to close the gate we need to consider ways to relax, feel content and be generally happy. Being involved in physical activity or distracting actions such as watching TV, reading and taking the right amount of exercise can all assist with helping close the pain gates. SF therapists will have quickly identified the 3 Ps amidst the above NHS 5 -recommended activities, and therefore management of the SF sessions should be intuitive.

In summary, pain is complex and chronic pain is multifactorial. There is useful information in the video mentioned above which will enhance the IC and it is therefore worth doing a little homework! The principle of SFH remains the same when helping someone with chronic pain. SF therapists should avoid being seduced by the problem and continue to facilitate emptying the stress bucket and initiating positive interactions, activities and thoughts.

References 1.

1. International Association for the Study of Pain cited in https://pubmed.ncbi.nlm.nih.gov/32694387/

accessed 20.10.21

2. Scott A. Armstrong , Michael J. Herr Physiology, Nociception In: StatPearls [Internet]. Treasure Island

(FL): StatPearls Publishing; 2021 Jan.2021 May 9.

3. National Institute for Care Excellence Chronic Pain in Over 16s 2-2-(2020) Management | Chronic pain |

CKS | NICE accessed 28.10.21

4. Gary Elkins, Mark P. Jensen, and David R. Patterson (2007) Hypnotherapy for the Management of

Chronic Pain, Int J Clin Exp Hypn. 2007 Jul; 55(3): 275–287.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752362/

5. NHS (Derbyshire) 2012 The Gate Control Theory of Pain.pdf (dchs.nhs.uk) accessed 28.10.21