Increasing the effectiveness of cognitive behavioral therapy with hypnosis
7 Jul 2015 | Print
Pain often requires multimodal treatment, with pharmacotherapies frequently supplemented by non-pharmacological approaches. Cognitive behavioral therapy (CBT) is a good example; hypnosis is another, albeit less commonly used.
CBT is a form of ‘talking therapy’ that can help patients to manage their pain by changing the way they think and behave. It can involve a wide variety of techniques, including psychoeducation about behavior and mood, strategies for relaxation, effective communication, and cognitive restructuring for distorted and maladaptive thoughts about pain. CBT has improved a variety of outcomes in chronic pain populations, including reductions in pain and disability, as well as improvements in functioning.
In the past, CBT might have been considered somewhat unorthodox, perhaps even ‘alternative’. However, its positive effects are now well recognized, and CBT has moved into the mainstream of pain management.
In truth, hypnosis remains a relatively unconventional therapy, and not one that many physicians would regularly advocate.
However, there is a substantial body of the evidence to show that hypnosis can be an effective treatment for chronic pain. Indeed, a meta-analysis of 13 trials found that hypnosis consistently produced significant decreases in pain. It was also found to be generally more effective than many other interventions, such as physical therapy or education.
Until recently, there was relatively little data regarding the combination of hypnosis with CBT. This is now changing, with evidence emerging that hypnosis can be effectively used as an adjunct to CBT in the management of pain.[3,4]
CBT combined with hypnosis
The first data on the use of hypnosis as an adjunct to CBT came from non-pain-related therapy areas. A meta-analysis of results from 18 studies showed that CBT plus hypnosis substantially improved outcomes compared with CBT alone across a variety of medical conditions – particularly in the treatment of obesity.
In the past few years, the combination of CBT and hypnosis has also been studied in pain. For example, Jensen and colleagues recently published a report on the effectiveness of cognitive restructuring (a key element of CBT) and self-hypnosis in 15 multiple sclerosis patients with chronic pain. All of those enrolled received four sessions of each of four different treatment modules: (a) an education control intervention; (b) self-hypnosis training; (c) CBT; and (d) combined hypnosis and CBT.
They found that hypnosis was more effective than CBT with regard to reducing pain intensity, and that the combination of hypnosis and CBT had beneficial effects greater than either therapy alone. The combined approach also had a greater effect on pain interference and catastrophizing than either therapy alone.
A larger study was subsequently conducted to compare the effectiveness of CBT plus hypnosis with CBT alone in 93 patients with fibromyalgia. Patients were randomly assigned to one of three therapies: (a) multicomponent CBT; (b) multicomponent CBT combined with hypnosis; or (c) standard care (control group). Various outcome measures were assessed, including pain intensity, catastrophizing, psychological distress, functionality and sleep disturbances.
The study found that patients who received CBT alone or in combination with hypnosis showed greater improvements than patients who received only standard care. Furthermore, the addition of hypnosis enhanced the effectiveness of CBT.
How does hypnosis work?
Given the positive data now available for the use hypnosis in pain management, it will be important to better understand the underlying physiological mechanisms.
It has been suggested that the effectiveness of hypnosis could at least partly result from alterations in brain states. In particular, hypnotic suggestions for reducing pain – for example, based on relaxation, decreased negative response to pain, and imagined analgesia – have been associated with increases in brain theta-wave activity. Furthermore, individuals with greater baseline theta-wave activity may be more responsive to hypnosis. This implies that theta activity, which is strongly associated with learning and memory, may facilitate responses to hypnosis.
Given that responsiveness to other neuromodulatory treatments, such as biofeedback and meditation, is associated with different brain states compared with hypnosis, it is possible that variations in brain activity could be used in future to match patients to appropriate treatments.
In safe hands – the use of appropriate practitioners
When referring pain patients for psychological therapy, including CBT and hypnosis, it is important to select an appropriate caregiver. The use of these therapies – particularly when performed by non-traditional practitioners – can show variable effectiveness unless treatment approaches are appropriately managed.However, well-designed psychological interventions can be effectively administered by a wide variety of healthcare professionals. This may include physiotherapists, physical therapists, nurses, and occupational therapists.
The likelihood is that these therapies will continue to grow in popularity with both patients and practitioners as further supporting data become available. Increased use of psychological treatments may result in significant reductions in the emotional, physical and financial burdens of pain.
- 1. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag 2014;7:115-124.
- 2. Elkins G, Jensen MP, Patterson DR. Hypnotherapy for the management of chronic pain. Int J Clin Exp Hypn 2007;55:275-287.
- 3. Jensen MP, Ehde DM, Gertz KJ, et al. Effects of self-hypnosis training and cognitive restructuring on daily pain intensity and catastrophizing in individuals with multiple sclerosis and chronic pain. Int J Clin Exp Hypn 2011;59:45-63.
- 4. Castel A, Cascón R, Padrol A, Sala J, Rull M. Multicomponent cognitive-behavioral group therapy with hypnosis for the treatment of fibromyalgia: long-term outcome. J Pain 2012;13:255-265.
- 5. Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an adjunct to cognitive-behavioral psychotherapy: a meta-analysis. J Consult Clin Psychol 1995;63:214-220.
- 6. Jensen MP, Sherlin LH, Askew RL, et al. Effects of non-pharmacological pain treatments on brain states. Clin Neurophysiol 2013;124:2016-2024.
- 7. Jensen MP, Sherlin LH, Fregni F, et al. Baseline brain activity predicts response to neuromodulatory pain treatment. Pain Med 2014;15:2055-2063.
- 8. Bastiaansen M, Hagoort P. Event-induced theta responses as a window on the dynamics of memory. Cortex 2003;39:967-992.
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