Hypnosis
Research has provided support that Hypnosis is effective for reducing pain perception. (Hilgard and Hilgard 1983, Hilgard and LeBaron 1984, Nickelson, et. al. 1999 and Simon and Dahl 1999). Hypnosis provides effective intervention on a number of different levels. It is an effective means of inducing deep relaxation that is helpful in itself. It can use suggestion to create dissociative states that can result in analgesic reduction of pain, change the meaning or type of pain sensation, and help create lifestyle or attitudinal changes that can have a significant impact on reducing pain intensity. It is unfortunate that hypnosis has had bad publicity because it is relatively straightforward to do with a willing subject. Key issues to keep in mind with hypnosis include the importance of clarifying to the patient that they do not lose control of their mind and cannot to be made to do things that run counter to their belief or value systems. Trance is in fact a normal part of life and everyone is used to falling into a reverie at different times during moments of strong emotion, during exercise, during deep relaxation, during boredom, or while performing a repetitive task. Any previous experience of “reverie” can be remembered and used as a means of inducing a trance in the here and now. It does not require a great deal of time to help a person focus their attention on a concept or image and talk through a relaxation process that leads the patient into a trance.
Related areas include using visual imagery to distract the patient from their experience and to trigger internal states that are pleasant and which can help reduce pain by the release of neuropeptides associated with the more pleasant experiences being imagined. When using visual or other imagery to assist with relaxation it is a good rule of thumb to make it simple and use as many sensory descriptions that utilize as many of the 5 senses as possible. It is possible to start the process by having the patient describe a situation the actually experienced not only in terms of what happened but also in terms of what they felt, saw, heard and tasted as well as their emotional reaction. This starting point draws attention to the way that as a person accesses a memory that has positive associations they often feel a “sense” of the same experiences they had during the original experience. By focusing on the positive internal sense as opposed to the original situation it is possible to increase the intensity of the positive experience and then teach the patient how to utilize positive experience to inhibit pain or distress.
Applied Psychophysiology
The key approach in this category is Biofeedback. Biofeedback is any approach that increases the understanding of the patient of their own physiological processes by means of giving them feedback of one of other physiological process. These approaches are now very well researched and have proven reliability documented in a wide range of reputable journals.
At the simplest level the use of a towel held loosely around the chest to monitor chest breathing is a form of biofeedback. However, biofeedback is generally much more sophisticated and includes:
Measurement of peripheral physiological changes such as temperature or skin conductivity (a measure of anxiety), which can provide a good indication of levels of autonomic activation.
sEMG (or surface electromyography) which measures the intensity of electrical activity in millivolts in a muscle. This approach is useful as a means of helping teach a patient to isolate and relax specific muscles that are very tense (training down) and learn to use a muscle or muscle group again following loss of function due to injury (training up).
Heart rate variability (HRV): uses changes in the breathing rate to influence the heart beat. This process triggers a number of changes in both the brain stem and the midbrain which can trigger the relaxation response, balance the autonomic nervous system and reduce the experience of pain.
Neurofeedback (the use of Electro encephalography, EEG): measures the electrical activity of neurons in the cerebral cortex. Since neurons tend to fire at specific rates during particular mental states such as normal focused attention, anxiety, relaxed awareness and sleep it is possible to measure patterns of brain activity in different areas of the brain to obtain a wide range of useful information. Using a variety of computer mediated feedback modalities; it is possible to train a person to create internal states that are conducive to particular patterns of brainwaves. This has now reached a very sophisticated level of technological ability to provide a form of conditioning that can help provide a range of remedies to different pain conditions.
Haemo-encephalography (HEG): is similar to Neurofeedback and is often seen as being one form of it but instead of measuring electrical activity in the cortex, it measures blood flow in the cortex through the use of near infra-red spectroscopy. Initial research has shown that it is very effective in reducing the effect of migraines and in dealing with autistic conditions.
Posttraumatic stress counselling
It is not surprising that many of the insights gained from dealing with sexual abuse victims and victims or accident, war or natural disaster will also apply to patients suffering chronic pain. However, it is wise to keep in mind that the emotional trauma involved is not only related to the precipitating event but also to the difficulties in adjusting to the losses during the course of the pain experience and the pain itself can also be a traumatizing experience.
Counselling approaches that focus on anxiety reduction, reducing the sense of overwhelm or helplessness, increasing awareness of emotional strengths and resources providing a sense of empowerment are all very helpful in providing assistance with most pain conditions.