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Audiotaped hypnosis for chronic back pain : a case study Taylor, Susan Carol 1991

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AUDIOTAPED HYPNOSIS FOR CHRONIC BACK PAINA CASE STUDYBySusan Carol TaylorB.A. University of British Columbia 1963B.S.W. University of British Columbia 1980A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(Department of Counselling Psychology)We accept this Thesis as conformingto the required standard.THE UNIVERSITY OF BRITISH COLUMBIADecember, 1991© Susan Carol Taylor 1991(Signature)In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department ofThe University of British ColumbiaVancouver, CanadaDate^(›)7, /9?/DE-6 (2/88)IIAbstractThe purpose of this research was to investigate the effectiveness ofaudiotaped hypnosis as a treatment for chronic pain using physiological aswell as psychological measurements. The research design is a modifiedsingle case study employing an A-B format; the A phase constituted theresponses of the Control Group, which provided a stable baseline and theB phase constituted the responses of the Experimental Group whichreceived the treatment. Both groups received 25 sessions of biofeedback. Arandomized selection of a variety of audiotapes (hypnosis, guided imagery,relaxation) was given to the Control Group. The same audiotape ofhypnosis was used as the independent variable over a period of 25 sessionsfor the Experimental Group. The modified form of Melzack &Torgerson's Present Pain Intensity Scale which evaluates pain on a scale ofincreasing intensity both verbally and numerically was used as a subjectiveself-report measure. Electromyographic (EMG) readings were taken as anobjective physiological measurement. An interrupted time-series analysiscalled, The Box Jenkins Analysis provided statistical data. This data wascorroborated by a Binomial Test. The eight subjects, six of whom weremale were all chronic pain patients who were referred by the Workman'sCompensation Board for work related injuries. The patients in this settingare resistant to change. The results showed a statistically significant resultof the data in the Experimental Group which may be viewed as a trendtowards improvement. However the results should be viewed with cautionas external validity is weak. This study was meant as a pilot study and willneed further research to corroborate the findings.Table of Contents Abstract ^  iiList of Tables  viiList of Figures   viiList of Appendices ^  viiAcknowledgements  viiiChapter IINTRODUCTION TO THE PROBLEM ^ 1Chronic Back Pain ^  1The Injured Worker  2Stages of Chronicity ^  3The Chronic Pain Patient  4PURPOSE OF THE STUDY ^  4HYPOTHESES ^  7RATIONALE  8Limitations of the Study ^  8Chapter IIREVIEW OF THE LITERATURE ^ 10History of Pain ^  10Acute Versus Chronic Pain ^  13Chronic Pain ^  18Measurement of Pain ^  19Clinical Pain Assessment  22THEORIES OF PAIN ^  25Specificity Theory of Pain  25i vChapter IIPattern Theory of Pain ^  26Gate Control Theory of Pain  26TREATMENTS FOR THE MANAGEMENT OF PAIN 29Cognitive-Behavioral Methods ^ 29Biofeedback ^  31Medical Treatment for Pain ^  38Pain Clinics ^  40Drugs  41HYPNOSIS ^  44History of Hypnosis ^  44Theories of Hypnosis  47Hypnosis in the Treatment of Pain ^ 55Audiotaped Hypnosis as a Treatment for Pain ^ 64Clinical Studies ^  67Experimental Studies on Hypnosis and Pain ^ 68Clinical Studies on Hypnosis and Pain ^ 74Chapter HIMETHODOLOGY ^  79Single-Case Experimental Design ^ 79Sample Selection ^  82Description of the Sample ^  83Control Group ^  83Experimental Group  83Procedure ^  84The Setting  85VChapter IIITreatment ^  85Electromyographic Feedback (EMG) ^ 85Audiotaped Hypnosis ^  86Control Group  86Experimental Group ^  87Dependent Measures  871) Electromyographic (EMG) Readings ^ 872) Verbal Self-Report ^  89Statistical Analysis of the Data ^ 90Box Jenkins Time-Series Analysis  90Binomial Test^ 90Chapter IVRESULTS ^  92Statistical Analysis of the Data ^ 92Hypothesis 1 ^  92Box Jenkins Time-Series Analysis ^ 92Binomial Test ^  92Hypothesis 2  93Hypothesis 3 ^  94Hypothesis 4  97viChapter VDISCUSSION^ 98INTRODUCTION ^  98THE MAIN HYPOTHESIS ^  98Box Jenkins Time-Series Analysis  100Hypothesis 2 ^  101Hypothesis 3  104Hypothesis 4 ^  105Threats to Causal Inference ^  105Threats to Valid Inference  106Internal Validity ^  107External Validity  108CONCLUSIONS ^  109Implications for Future Research ^ 112REFERENCES ^  113Appendix A  126Appendix B ^  132Appendix C  136Appendix D ^  138Appendix E  140Appendix F ^  142Appendix G  148viiList of Tables Table 1 Summary of Change Scores in Present Pain Intensity Scale^94Table 2 Summary of Scores from Tape Effectiveness Questionnaire^96_List of FiguresFigure 1. Box Jenkins AnalysisFigure 2. Binomial TestList of Appendices: Appendix A Pain Patients ^  126Appendix B Chronic Pain Patient Profile ^  132Appendix CConsent Form ^  136Appendix D Present Pain Intensity Scale ^  138Appendix E Verbal Self-Report Tape Effectiveness Questionnaire^140Appendix FTranscript of the Audiotape ^  142Appendix G Binomial Test^ 148v i i iACKNOWLEDGEMENTS There are many people who have made it possible for me to producethis thesis and I would like to take this opportunity to acknowledge andthank them for their generous support.Dr. Du-Fay Der, the chairperson of my thesis committee hasprovided me with encouragement and insight with his perceptive adviceand wonderful examples of audiotaped hypnosis. Dr. John Allan and Dr.Jaime Peredes have my thanks for sitting on my committee and for theirenthusiasm towards my research. I would also like to thank Dr. WalterBoldt who taught me more about research than I would ever have dreamedpossible and never discouraged my endeavours. I would also like tomention the Department of Counselling Psychology and Graduate Studiesfor their support.I want to thank my husband for supporting me in my years of studythrough adversity as well as accomplishment. My two sons, Robin andBrian have my thanks and love. They have been invaluable in helping me inthe preparation of my thesis on a computerI want to acknowledge the Columbia Centre for their generoustreatment of me at their clinic. In particular, Dr. Charles Gregory, whoaccepted a student, Dr. Bart Jessup for generously sharing his time andincluding me in his groups and JoAnne Dodson, the physiotherapist whogave me information about the patients and gladly offered me her helpwhen asked.Without the patients at the pain clinic, I would not have been able tocollect data or understand the complexities of doing clinical research. Mythanks to them for accepting me and allowing me to use them as subjects.And finally, I would like to thank Dr. George Klimczynsky whostarted me on my quest many years ago.CHAPTER 1INTRODUCTION TO THE PROBLEMChronic Back PainThe term chronic back pain (CBP) is commonly used to refer toback pain whose assumed origin is in the spine or the surroundingmuscular, or inflammatory origin, and has lasted for more than six months(Fordyce, 1986; Sternbach, 1974, 1984). It is estimated that 70% of lowback pain and most headaches have no known organic cause. Statistics varyfrom 10% to 80% of adult Canadians suffering from back pain to 33%suffering from chronic back pain (Fraser, 1991; Hall, 1986; Jenish &Deacon,1991). All low back pain patients experience acute pain at first and50% are successfully treated at this stage while 50% become chronic lowback patients (LaFreniere, 1979).In Canada it has been reported that three million Canadians sufferfrom chronic pain which results in $4 billion a year in lost income, medicalexpenses and disability payments. It has been estimated that in BritishColumbia 300,000 people live with chronic pain (Wigod,1991). Jenish &Deacon (1991) reported that back pain "is the second most common causeof absenteeism in the workplace, behind the common cold"(p. 52). TheWorker's Compensation Board of Ontario stated that back problemsaccounted for approximately one-quarter of all compensation claims inCanada; in Ontario alone, $399 million was awarded in 1984 for work-related back injuries (Hall, 1986) and "back problems resulted in moreclaims for lost wages than any other type of injury last year" (Jenish &Deacon, 1991, p.54). In 1980 the total cost of chronic pain to the American1public ranged from $14 billion dollars in 1977 to approximately $110billion dollars in 1990 (Chapman, 1986, 1988).One researcher suggested that litigation-related chronic pain shouldbe considered a diagnostic entity distinct from other types of chronic painand that a "two-tiered" system of compensation should award more forpain of "organic" origin (Weber, 1989). Pain clinics reported that "30-40%of their clientele have back-related pain as their major presentingcomplaint (whatever the real cause)" (Clarke, 1987, p.1).The Injured WorkerChapman (1988) studied the injured worker and found that employedindividuals spend about one-fourth to one-third of their waking time atwork. Work serves as one of the most important factors in the formationof self-esteem and personal identity. It provides the individual with securityand the "ability to make more choices in life, gives life a purpose, makes itmore meaningful and serves as a social outlet. Loss of work is associatedwith "loss of work status" (p.103). Chapman found that:Chronic pain is frequently associated with a loss of work status. Forexample, a random sample of a mixed group of chronic pain patientsat the Emory Pain Control Center indicated that only 12% wereworking full-time at the time of admission into the program; 40%were on Workers' Compensation and 23% had established SocialSecurity disability. This loss of work status often is associated withvery strong affect regarding returning to work, despair regardingphysical limitations, and rage toward previous health care personnelwho had stated or implied that they should be working when theywere not. Several factors often contribute to this strong affect,including inconsistent messages regarding work ability fromprevious health care personnel, stigmas placed on individuals withoutobvious physical disability who are not working, financial stresses,frequent souring of relationships with insurance companies and withthe last employer, and progressive loss of mental and physical2abilities and self-confidence with long-term physical disuse and drugdependency. In addition the adversarial nature of legal systems oftenputs the patient in the position of maximizing pain and disability inorder to receive a more substantial settlement, while the insurancecompany may look for evidence to minimize the patient's claims andattribute them to a desire for secondary financial gains. (p. 105)Stages of ChronicityIn another study Chapman, Brena and Bradford (1981) theorized afour stage-process by which industrial accidents can lead to a permanentdisability status:1. Premorbid stage: Characterized by increased stress at work orat home and by difficulty in performing work tasks adequately.2. Establishment of the sick role: Involves repeated medicaltesting and interventions which fail to relieve pain. Many patientscontinue to remain inactive and take habit-forming pain medicationsduring this stage, leading to increased depression and dependency.Many also have unsuccessful surgeries for back pain: two-thirds ofpatients referred to the Emory Pain Control Center with pending orcurrent disability had previous pain-related surgery, with a mean of2.8 surgeries per person. (Chapman, S.L.; Brena, S.F.; andBradford, L.A. 1981; cited in Chapman et al. 1988 p.103)3.^Stabilization of chronicity: As time passes, the patient developsthe identity of being disabled, which may help satisfy dependencyneeds and provide some level of financial security. Drug use andinactivity frequently have become habitual by this point, andcontinue to create additional physical and emotional deteriorationwhich erodes the injured worker's ability to manage the painproblem or return to a normal lifestyle. Lawyers also often becomeinvolved and may reinforce the crystallization of disability throughsuits for large settlements contingent on the continuation of adisabled status. Many lawyers work on contingency and thus have adirect financial interest themselves in establishing a permanentdisability status for the patient. Some are paid a percentage of thepatient's Workers' Compensation benefits, which can reinforce themfor delaying settlement through legal delays and encouragement offurther testing and therapy before settlement. (p. 103)344.^Learned helplessness: At this stage, the patient is likely to havedeveloped the 'Disease of the D's' (Morse cited in Chapman, 1988)characterized by depression, dysfunction, disuse, drug use,dependency on doctors, dramatization of pain complaints, anddisability income. As these roles persist (and sometimes arereinforced) over long periods of time, they become increasinglyrefractory to change. (p. 103)The Chronic Pain PatientChapman (1988) cited a study by Yelin, Nevitt, and Esteom (1980)who surveyed 245 individuals with rheumatoid arthritis and looked at ahost of demographic, medical, and social variables. They found thatprevious surgery and heavy reliance on medications such as steroids wereassociated with reduced likelihood of return to work, even when the stageof illness was held constant; however, control over the pace of work andself-employment were by far the most predictive variables (p.106).In his review of chronic pain, Chapman (1986) described the chronicpain patient as one who suffers physical deterioration caused by sleep, lackof appetite, reduced physical activity and dependence on drugs. As well,there was enormous strain on family and social life.PURPOSE OF THE STUDYHypnosis has been used by clinicians for hypnotherapy in thetreatment of pain (Erickson,1967b, 1983b, 1989; Hilgard,1986) and as aneffective adjunct when it is used on an individual basis as an adjunct toformal hypnosuggestive procedures (Ellis 1986; Tarnowski, 1986), orcombined with other approaches. (Barber, 1986; Finer, 1982; Golden,1986; Guck 1985; Melzack & Wall, 1965; Pinsky & Malyon's study, citedin Spino, 1984).Research on hypnosis has been found to be useful in the reduction ofexperimentally induced pain (Barber, 1960, 1970, 1971; Crasilneck, 1979;Evans, 1970; Hilgard, 1975, 1980; Hilgard & Hilgard, 1986; McGlashan,1969; Sternbach, 1984) and in single case studies of chronic pain(Erickson, 1983b). However, investigators reported that studies of clinicalresearch on the use of hypnosis in the reduction of chronic pain are fewand mainly consist of uncontrolled case studies (Hilgard, 1986; Sternbach,1986a; Tan, 1982, Turner & Chapman, 1982). Some researchers found thatclinical research in relieving chronic pain failed to demonstrate thathypnosis has more than a placebo effect (Turner & Romano, 1984) andothers found that there was no reliable evidence that hypnosis is effective inthe treatment of chronic pain (Hilgard & Hilgard, 1986). There are fewdocumented clinical studies using audiotaped hypnosis as a treatment forchronic pain and no previous investigations directly comparing theeffectiveness of listening to the same audiotape of hypnosis over timeversus listening to a random selection of audiotapes which use soothingsounds, mood music, or hypnosis, as a treatment for chronic pain.The purpose of the study is to:1. Explore the effectiveness of audiotaped hypnosis as atherapeutic treatment for the reduction of chronic pain, using relaxation,visualization, guided imagery, hypnotic ego-strengthening techniques at aunconscious level and positive posthypnotic suggestions;2. To assess change over time using outcome measures to provideboth subjective and objective evidence that during the period of treatmentthere was a significantly quantifiable trend towards the reduction ofchronic low back muscle tension (which may reduce pain) as measured bylowered electromyographic (EMG) readings, lowered self-report pain5intensity scores and positive self-report on the effectiveness of usingaudiotaped hypnosis for reducing chronic pain.6HYPOTHESES Stated in the null form, the hypotheses this single case experimentaldesign investigated were:Hypothesis 1 Listening to audiotaped hypnosis will have no statistically significanteffect on chronic pain as measured by electromyographic (EMG) readingsover time in the Control and Experimental Group.Hypothesis 2There will be no reduction in perceived pain after daily treatment inthe Experimental group as measured by subjective self-reports of painusing words and numbers on a continuum of increasing value.Hypothesis 3 Audiotaped hypnosis will have no effect on perceived pain after aperiod of twenty-five treatments over five weeks as measured by subjectiveself-report.Hypothesis 4A combination of electromyographic (EMG) biofeedback incombination with audiotaped hypnosis will not be effective in the reductionof chronic pain.7RATIONALEResearch on the effectiveness of hypnosis on pain has focused mainlyon acute pain which is experimentally induced employing either the coldpressor test or muscle ischemia to find a pain threshold and/or tolerance,using subjective pain ratings as the main dependent variable (Hilgard &Hilgard, 1986; Tan, 1982). There are few documented clinical studies usingaudiotaped hypnosis as a treatment for chronic pain. Current theories ofpain (Crue, 1976; Erickson, 1983b; Le Roy, 1976; Hilgard, 1975; Melzack& Wall, 1982) look at both the psychological and physiologicalcomponents.The definition of hypnosis is based on the theories of hypnosis as analtered state of consciousness (Erickson, 1983; Barber, 1976), a state ofdissociation (Hilgard, 1973), and a state of modified attention (Wyke(1986). This is an exploratory study which evaluates the effectiveness ofaudiotaped hypnosis by studying both the psychological and physiologicalcomponents of chronic pain through the use of subjective and objectivevariables measured over time. A modified single case experimental designwas chosen to evaluate audiotaped hypnosis because of the practicallimitations and difficulties of clinical research (Hersen & Barlow, 1982,Hilgard, 1986). The A-B design, which is the most suitable for a pilot study(Borg,1963b), was modified in order to establish stability of repeatedmeasures (Hersen & Barlow, 1982).Limitations of the StudyThe cause-effect relationships are difficult to isolate in the A-Bdesign but changes in the dependent variable may be "attributed to theeffects of treatment" (Hersen & Barlow, 1982, p.169). Due to the8difficulties inherent in clinical research, obtaining a large sample size andrandom distribution was not possible. The findings are not readilygeneralizable because the group results were averaged and therefore theindividual differences of the pain patients were not adequately sampled.9CHAPTER 2REVIEW OF THE LITERATUREThe review of the literature will focus on four areas of interest:history of pain ; theories of pain; treatments for chronic pain and chroniclow back pain; research on experimental and clinical pain, with anemphasis on therapeutic methods of hypnosis for pain reduction.History of PainFrom the time of Aristotle, who theorized that pain was the oppositeto pleasure and therefore was an emotion, to the present day, controversyhas continued over how to define and conceptualize pain (Meizack & Wall,1988). Pain, and the infliction of pain has been viewed as a societalinstrument of social control both within the family unit, in society at large,and as a sign of courage in initiation ceremonies in many countriesthroughout the world (Hilgard & Hilgard, 1986).In 1664 Descartes proposed that pain was transmitted in a straightchannel from the skin to the brain. This was not challenged until thenineteenth century when physiologists began to wonder if there weredifferent qualities of sensations for the senses of seeing, hearing, taste,smell and touch. Johannes Muller, theorized that there was, " a straight-through system from the sensory organ to the brain centre responsible forthe sensation." Max von Frey, a physician, published articles in 1894 and1895 in which he postulated that nerve endings were pain receptors,corpuscles were touch receptors and that there were receptors for cold andwarmth as well. This theory was extended over the next twenty-five yearsto include specificity theories which proposed that the different sensory10fibres of touch, smell, taste, hot, cold, etc. had specific ( italics added)pathways to the brain centre. Finally, anatomical studies on humans andanimals discovered that certain areas of the spinal cord were important forpain sensation and provided a "pain pathway" to the brain (Melzack &Wall, 1982, p. 151).The thalamus is thought to be the 'pain centre' by some specificitytheorists, and is debated by others (Melzack & Wall, 1982). Critics of thespecificity theory of pain theorized that there is psychological evidence torefute that there is a one-to-one relationship between pain perception andintensity of the stimulus. Melzack & Wall (1982) cited Pavlov'sexperiments with dogs who were given electric shocks, burns and cuts,followed by food and then when they were conditioned to respond to thestimuli as signals for food, failed to show 'even the tiniest and most subtle'signs of pain. Clinically, Melzack & Wall cited phantom limb pain,causalgia, and the neuralgias as evidence against the theory and othertheories, under the heading of 'pattern theory' which dispute the specificitymodel of pain. (p.156)Goldscheider (1894) was the first to propose that stimulus intensityand central summation ( the accumulation of pain over long periods),produced a "patterning of the input" which is essential for any theory ofpain. This theory takes into account chronic pain of intractable origin.Melzack & Wall (1982) posited that while the "development of sensoryphysiology and psychophysics during the twentieth century has givenmomentum to the concept of pain as a sensation and has overshadowed therole of affective and motivational processes....this sensory approach topain, fails to provide a complete picture of pain processes." The authorstheorized that "sensory motivational and cognitive processes occur in1 1parallel, interacting systems at the same time" and distinguished between"physiological specialization and psychological specificity" and stated:Neurons in the nervous system are specialized to conduct patterns ofnerve impulses that can be recorded and displayed. But no neurons inthe somatic projection system are indisputably linked to a single,specific psychological experience....If we can all agree that`specificity' means physiological specialization, without implyingthat specialized neurons must give rise to the experience of pain andonly to pain or that pain can never occur unless they are activated,then we will have eliminated a major source of unnecessarycontroversy. (p. 164)The Gate Control Theory of pain proposed by Melzack & Wall in1965, took into account both physiological and psychological processes byproposing that neural mechanisms in the spinal cord act like 'gates' whichmay be inhibited by descending messages from the brain. The authorsstated that in order for, " A new theory of pain to be useful," it "mustincorporate known facts about the nervous system, provide a plausibleexplanation for clinical pains, and stimulate experiments to test the theory,including procedures that are potential new therapies" (p. 165).Historically, medical treatment for pain relied on surgery, drugs,and counterirritants. Many of the psychological methods of today can betraced back to treatments based on folk methods. Faith healing has existedas long as man and many religious groups have claimed to have the answerto curing pain (Hilgard, 1986). Ether and chloroform were discovered 150years ago and used as anesthesia in surgery. Morphine and other narcoticsderived from opium have been the most successful pain-killers for therelief of nonsurgical pain and pain that persists after surgery (Hilgard,1986).12During the past two decades there has been a scientific revolution inthe research of pain. Until the middle of this century pain was believed tobe a symptom of disease or injury. Chronic pain is now seen as a problemin its own right which at times can be more debilitating than the diseaseprocess which caused it (Melzack, 1982).Since the 1960s and the advent of space age technology, bioengineersand behaviorists have developed methods for the nonsurgical treatment ofintractable and chronic pain through bioelectric stimulation, either throughimplants or by external electronic systems (Le Roy, 1976). Behavioral andcognitive-psychological methods have been combined in pain clinics for thetreatment of chronic pain (Wall & Melzack, 1984). At the same time drugresearch has discovered new chemical pain inhibitors called "beta-endorphins" and natural pain inhibiting endorphins which are releasedwhen deep regions of the brain are stimulated (LeRoy, 1976).Recently, there has been a shift away from the medical model wherethe patient has no input into the treatment received, to an emphasis onholistic medicine and personal self-regulation in therapy (Elton, 1980;Rossi, 1986). The study of neurophysiology has increased our knowledgeof the mind/body connection. Pain is now viewed as a psychophysiologicalprocess which has neurological, physiological, behavioral and affectivedimensions (Sternbach, 1986; Wolf, 1982).Acute Versus.Chronic PainPain is derived from the Latin word "poena," meaning a penalty(Spino, 1984). Descriptions of pain, reflect the particular theoreticalbackground of researchers in neurology, physiology, psychology or thebehavioural sciences (Sternbach, 1986; Fordyce, 1986). Sternbach13emphasized that pain was the common denominator but the processes weredifferent.The amount and quality of pain an individual experiences isdetermined by the individual's past experience of pain, their culturalvalues, their negative or positive perception of the event causing the injuryand their anticipated projection into the future of the outcome of thetrauma (Sternbach, 1986). Studies of cultural experiences of women inchildbirth illustrated this theory (Melzack, 1961; Keefe, 1982). Studies byBeecher (Cited in Melzack 1961) of World War II soldiers injured duringthe war, and civilians who had undergone surgery after the war,demonstrated how a positive or negative perception of the event changedtheir perception of pain. The soldiers viewed their injuries as a means ofescaping from the battlefield and needed a significantly lower dosage ofmorphine than the civilians who viewed the surgery as a "depressing,calamitous event" (p. 4).During the 1960s the classical view of pain as a specific sensoryexperience, whose intensity is directly proportional to the intensity of theinjury received, was challenged by researchers (Melzack, 1961; Sternbach,1968). Early clinical studies on prefrontal lobotomies provided evidence oftwo distinct dimensions of pain; the sensory component and the sufferingor affective component. Patients with intractable pain (pain resistant totreatment) stated that after surgery, the pain was still there but that it nolonger bothered them. In other words, the sensory pain was still there butthe suffering had been relieved (Barber, 1959; Melzack, 1961).Hilgard & Hilgard (1975) categorized the experience of pain in two14ways:151. That pain is a sensory response to an injury and the reaction toit is the suffering part; or2. That the two components happen simultaneously rather thansuccessively, with two parts of the nervous system activated at the sametime.Sensory physiology and psychophysical analyses of sensory qualitieshave been examined in detail (Craig, 1984). Pain from a biomedicalviewpoint was thought of as both a warning signal of impending injury oras a need-state for rest in order for the injury to heal (Sternbach, 1984).However, researchers found that the experience of pain does not alwaysaccompany injury signals (Mcglashan, 1969; Melzack, 1961; Wall, 1979).Intractable or prolonged pain such as phantom limb pain, arthritis, bonecancer or chronic low back pain do not provide these functions to theindividual. It is only recently that researchers have studied the differencesbetween acute and chronic pain (Sternbach, 1984).Some researchers (Hilgard & Hilgard, 1975) classified theuncertainty of the source of pain into three descriptive categories:Referred pains are those felt in one place although the source ofirritation is somewhere else. Psychosomatic pains are complex andare intricately related to the emotional life of the individual, andtheir perception of the pain and the subtle purpose it may serve.Phantom limb pains are the perception of pain after a limb has beenamputated. (pp. 31-32)The authors noted that these pains take into consideration thepsychological aspects of pain.The main aspect of chronic pain which differentiates it from acutepain is the time element or duration of the pain (Fordyce, 1986; Melzack,1983, 1989; Melzack & Wall,1984; Sternbach, 1968). Chronic pain hasbeen defined as a pain that is benign in origin and that is present on a.constant, daily basis for longer than six months months by someresearchers (Fordyce, 1986; Sternbach, 1974), or pain which persistsbeyond the required time for healing (Craig, 1984). Others think the "sixmonth time frame...is arbitrary and often inappropriate...and the use of theterm chronic should be restricted to those individuals who, in addition tocomplaints of pain, display evidence of affective distress and/or behavioraldisruption" (Grzesiak & Ciccone, 1984, p. 165).Melzack (1989) classified pain into three stages: 1. Acute pain whichhas two components: 2. The phasic component which has a rapid onset, and3. a subsequent tonic component which persists for variable periods oftime. He cited as examples of acute pain, " a burned finger or a rupturedappendix" (p. 6526). Chronic pain may pass through the two stages of acutepain, but "may persist long after the injury has healed...may spread toadjacent or more distant body areas...is resistant to surgical control, and itsprolonged time-course is characteristically associated with high levels ofanxiety and depression" (p. 6526). Examples of chronic pain are chroniclow back pain, intractable myofascial pain, the neuralgias and phantomlimb pain.Physiologically, autonomic activity (involuntary activity such asheart rate, muscle tension etc.) is regarded as an indicator of activity ofacute or chronic pain (Sternbach, 1984, 1986). Autononomic activity withacute pain is characterized by a "fight or flight" syndrome with changes inthe autonomic activity roughly proportional to the intensity of the stimulus;chronic pain is characterized by a "habituation of the autonomicresponses," a "vegetative" state accompanied by "sleep disturbance, appetitechanges, decreased libido, irritability, withdrawal of interests, weakening16of relationships, and increased somatic preoccupation" (Sternbach, 1986,p.223).Some behaviorists described three stages of pain: acute, prechronic,and chronic (Fordyce, 1986). Each stage was explained in terms of a"conditioning process" in which patients learned behavior patterns thathelped them to reduce pain or helped them maintain pain. At the "chronicstage-12-months or more" patients may become bedridden and drugdependent. Fordyce, described pain medication, financial compensation,avoidance of work responsibilities as "powerful positive consequences ofthese behaviors" (p. 326).Nigl, (1984) in his review on chronic pain cited Crue (1976) whodivided chronic pain into two subtypes; recurrent acute pain which can bemistaken for chronic pain (migraine headaches, osteoarthritis, andrheumatoid arthritis) and chronic pain which is constant pain with noorganic basis. Crue (cited in Nigl, 1984) noted that recurrent acutedisorders may become chronic disorders if they persist after the acute painis treated with medication. Two classes of pain were distinguished; thosewith pain due to malignancy or cancer and those with chronic pain which isbenign and intractable. Chronic benign pain disorders were listed as havingthe following characteristics:Patients have pain all of the time; it is constant.The pain is functional in nature; it is central pain not peripheral.It is accompanied by reactive depression.Patients fail to cope with their pain unlike other patients with chronicpain states who do not seek treatment.17There is an underlying, premorbid personality pattern thatpredisposes an individual to have chronic pain disorder, regardlessof diagnosis or treatment. (p. 98)Chronic PainThere is considerable disagreement about which disorders can beproperly labeled as chronic pain disorders, and some authors made adistinction between chronic pain and chronic pain syndrome (Nigl, 1984).Pinsky (cited in Nigl, 1984) developed the concept of chronic intractablebenign pain syndrome (CIBPS) to differentiate between patients who hadintractable pain and no psychological problems and those patient's who,"present symptoms of constant pain that cannot be related to any activepathophysiologic or pathoanatomic disorder" (p. 98). Patients sufferingfrom CIBPS were characterized by the following factors:Drug dependency or abuse, physical decline, generalized dysphoria,psychosocial withdrawal and interpersonal dysfunction, intensifiedfeelings of hopelessness and helplessness, chronic conflicts withmedical professionals accompanied by anger and hostility, and ageneral loss of self-worth and self-esteem. (p. 99)Pinsky (cited in Nigl, 1984) theorized that chronic pain was a"psychologic disorder which represented an individual's attempt to copewith intrapsychic conflicts" and he stated that it "can be thought of as anadaptive attempt to counteract anxiety or resolve a particular conflict;however, in almost all cases, it is destined to fail. Signs of adaptive failureinclude unresolved grief response, depression, tension and anxiety, shameand guilt, feelings of rejection, isolation....symptoms of grief which normalindividuals experience over a loss; namely somatic distress, preoccupationwith premorbid self-image, anger and bitterness toward medical treatment18'failures' and significant behavioral changes (e.g., restlessness, insomnia)"(p. 101-102).Measurement of PainChapman, Casey, Dubner, Foley, Gracely, and Reading (1985)reviewed the advantages and limitations of physiological and behavioralmethods of pain measurement in animal research, human subjects, and inlaboratory and clinical studies. The authors noted that pain measurement iscomplex and could be quantified only indirectly. They quantified researchin human laboratory studies into four types of procedures:1. Psychophysical methods that attempt to define a threshold forpain;2. Rating scale methods in which subjects rate pain experienceson structured scales with clearly defined limits;3. Magnitude estimation procedures in which direct judgments ofstimulus intensity or quality are made by number assignment orcross-modality matching techniques such as handgrip force;4. The measurement of performance behavior on laboratorytasks, usually to obtain indices of discrimination ability or detection.(P. 7)In addition to these methodologies, some investigators have assessedphysiological or facial expression correlates of pain but these techniqueshave not been used alone as indicators of pain. Chapman et al.(1985)pointed out that:Tolerance methods are limited by individual differences in paintolerance, rating scales are difficult to assess because individualperception of categories is not equal, and statistical analysis can bemisleading if the scores are used as interval or ratio scales. (p. 10)19However, they concluded that these scales are often used, "becausethey are simple, economical and easy for subjects to comprehend" (p. 10).They found that cross modality methods, while more complicated, have theadvantage over other methods in that they scale pain on more than onedimension and can be used for both laboratory and clinical studies.Other methods reviewed included laboratory research usingperformance measure (measures which do not directly measure pain); andSensory Decision Theory (SDT), which is used for laboratory research onhuman pain and as an evaluative tool for chronic pain patients.Chapman et al. (1985) noted that while there had been a need forobjective evidence of pain experience, it was difficult to, "reduce humanpain to measures of neuronal activity alone even though such signals are thebasic building blocks of pain" (p. 14). They defined a physiologicalcorrelate of pain as serving three purposes:1. It could help confirm the validity of the experiment inquestion by providing supporting evidence that the verbal painreports of subjects are linked to the stimulus rather than to anextrinsic psychological state.2. It could contribute to the statistical power of an experiment byproviding additional information to be used in hypothesis testing.3.^In certain cases such a measure could help in quantifyingaspects of the human pain experience such as anxiety that arepresently ignored in most studies. (p.14)Chapman et al.(1985) defined four human physiological correlates:1. Direct recording from peripheral nerves;2. Electromyographic (EMG) measures;3.^Autonomic indices and evoked potentials and20214.^Electroencephalography (EEG) measures (p. 14).Peripheral nerve studies have recorded frequencies which reflect, theactivity of peripheral nerves, which can then be compared to the volunteersubject's report of sensory changes and the area of involvement. Chapmanet al.(1985) cited studies of recordings made from electrodes implanted inhuman teeth. They cautioned that this is not a perfect relationship ofperipheral activity to pain because, "the modulation processes occurring atthe dorsal horn and higher centers are not reflected in such signals" (p.14).Several studies (Budzynski, 1973; Haynes, 1975; Jessup, 1984; Keefe,1982; Large, 1983; Nigl, 1984; Pearce, 1987; Schuman, 1982;Wickramasekera, 1972; Wolf, 1982) reported using electromyographic(EMG) measures to relate muscle tension in chronic pain patients withmyofascial disorders, chronic back pain, tension headache,temperomandibular joint pain, and muscle tension pain in the neck andshoulders. Autonomic indices included pulse rate, skin conductance andresistance, skin temperature, and finger pulse volume. The AutonomicPerception Questionnaire (APQ) was devised by Mandler et al. (Cited inChapman et al., 1985).and has been used by researchers to "study painrelated arousal associated with ice water immersion of a limb." They foundthat "APQ data were not related to pain tolerance" (p. 15).Evoked potentials (EPs) and electroencephalographic (EEG) are bothcentral nervous system measures. Researchers cited in Chapman etal.(1985) studied the EPs of "short and long waves" and have concludedthat, "waveform amplitude increases with the amount of stimulus energydelivered" and when analgesics are given they decrease. Both of thesemeasures correlated well with subjective pain reports. (p. 16)EEG measures are used to "quantify or monitor non-specific arousalduring pain studies in human subjects". and to "assess the effects ofanalgesic drugs" or "psychological interventions on arousal, a methodologytermed pharmacoelectroencephalography." Chapman et al. (1985)concluded that physiological measures are objective measures which mayprovide information about the "underlying pain or analgesic state" but maynot be "less susceptible than subjective report to psychological variablessuch as expectancy or attention" (p. 16).Jenish & Deacon (1991) reported that a "new approach" to themeasurement of back pain was developed by a professor of engineering,Serge Gracovetsky, who developed a "spinoscope." It allows physicians "tomeasure with unprecedented accuracy the movement of spinal muscle,ligament and fibre, which are known as 'soft tissue,' as opposed to the hardtissue of the spinal cord itself'. (p. 52).Clinical Pain AssessmentChapman et al. (1985) credit Beecher (1957, 1959) with influencingthe "emotional dimension" of pain, the "importance of experimental design,including double blind procedures".and " the scaling of pain as opposed tothe measurement of pain relief." The measurement of behavior as a basisfor inference about clinical pain, and pencil and paper test instrumentswhich quantify multiple dimensions of the pain experience from subjectivereport, have been developed to provide both quantitative and qualitativeaspects of pain. (p. 17)22A review of behavioral methods for the assessment of chronic painhas been provided by Keefe (1982) and Nigl (1984c). Some of the variablesreported were: 1. activity (e.g., moving in bed) and activity diaries; 2.measures of the amount of time spent standing, sitting or reclining (up-timevs. down-time); 3. sleep patterns; 4. sexual activity; 5. medication demandor intake; 6. food intake; 7. normal household activities such as mealpreparation and gardening; and 8. engagement in recreational activity.Chapman et al. (1985) reported that pain investigators had attemptedto categorize chronic pain behavior for clinical observation; had devised arating scale for scoring or quantifying pain behavior in chronic backpatients; had developed a rating instrument "to assess behavior generallyindicative of pain", and had designed an "automated monitoring deviceworn by the patient" which quantified "up-time" and quantified facialbehavior with a videotape. (p.18) Self-reported behaviors in the form ofdiaries or pencil and paper tests had been used by investigators todetermine normal daily activity levels or pain medication but the authorsnoted that "patients are sometimes biased or incorrect in their reporting"(Chapman et al.,1985, p.18).Subjective pain reports are used to scale both pain itself and painrelief following treatment. Pain category ratings and Visual Analog Scale(VAS) judgments are the simplest report scales. Category scales have beenused to guage pain relief in cancer patients following morphine treatmentand with children following surgery. With category scaling it is difficult tospecify the size of each category or know if the categories are equallyspaced. (Chapman et al., 1985)The qualitatively different types of pain have been described aspricking or sharp, burning, and dull or aching. Pricking and burning pain23is easy to locate. Aching pain usually originates in deep tissues, includingthe viscera, muscles, and bones, and is difficult to localize (Spino, 1984).Syrjala (1984) in an overview of clinical pain measurement, citedtwo scales which measure pain using word descriptors. Melzack &Torgerson, cited in Syrjala (1984) developed a five point scale of worddescriptors of pain dimension which represented universal descriptions forsensory, emotional or other aspects of pain. Melzack (1975) then developedthe McGill Pain Questionnaire (MPQ) which was based on this work. TheMcGill Pain Questionnaire quantifies three dimensions of pain experience;sensory, affective, and evaluative. Patterns for different clinical painsyndromes have been obtained which include arthritis, labor and childbirth,cancer pain, and low back pain.The advantage of the MPQ is that it measures both quantitative andqualitative aspects of pain and scales pain multidimensionally. Critics of thescale pointed out that some patients had difficulty with the complexity ofthe words; that sensory aspects of pain are weighted more than affectiveaspects and that it was more time consuming to administer than the VAS(Chapman et al., 1985). Others noted that a test should show reliably that agiven "clinical pain state changes after the patient is administered anopiate," or after surgery and that the "placebo effect" should show adifferent pattern of responses (Syrjala, 1984). The statistical manipulationof MPQ scores has also been criticized for not being "standardized." It hasbeen suggested that "spatial distribution of chronic pain conditions" beassessed as well because "behavioral variables change significantly as afunction of pain location and distribution" (Chapman et al., 1985, p. 22).An eight point facial expression picture scale has been developed which has24been found to correlate well with visual analog and numeric rating scales(Syrjala, 1984).Chapman et al., (1985) found four problem areas in their review ofthe literature on pain measurement. These included the following:1. The literature lacks an integrated overview of pain assessmenttechnology and a critical evaluation of the methods commonlyemployed.2. There is a need for integration of work on pain measurementin animal, human laboratory, and clinical areas of investigation.3. There is need for broader, more comprehensive operationaldefinitions of pain.4. The area of clinical pain in animals needs to be exploredfurther in order to validate and extend the findings of laboratoryresearch. (p. 24-25)THEORIES OF PAINThere are three main theories of pain: specificity theory, patterntheory and gate control theory.Specificity Theory of PainThe traditional specificity theory of pain, which is still taught insome medical schools, proposes that pain is a specific sensation and that theintensity of pain is proportional to the extent of tissue damage. The theoryimplies a fixed, straight-through transmission system from somatic painreceptors to a pain center in the brain. However, recent evidence showsthat pain is not simply a function of the amount of bodily damage alone,but is influenced by attention, anxiety, suggestion, and other psychological25variables. Moreover, pain is not only a sensory experience but also hasobvious emotional properties that demand immediate attention, disruptongoing behavior and thought, and drive the organism into activity aimedat stopping the pain. These data refute the concept of a straight-throughsensory transmission system (Melzack, 1989, p. 652).Pattern Theory of PainThe pattern theory of pain, a rival theory to the 'specificity theory',was proposed by Goldscheider who believed that pain depended on the"summation of neural inputs that must reach a critical level for pain to befelt. Peripheral stimulation is not enough, because central systems areimportant in this summation" (Hilgard & Hilgard, 1975, p. 34). Thistheory does not support the concept of peripheral sites which transmitpainful stimuli along a set of peripheral nerves.Modern theories include both peripheral and central summation, andas did earlier theories, attempt to explain why pain may endure beyond theinitial stimulation (Hilgard & Hilgard,1986; LeRoy, 1976; Melzack &Wall, 1982).Gate Control Theory of PainMelzack & Wall (1965) proposed that neural mechanisms in thedorsal horns of the spinal cord act like a gate which can increase ordecrease the flow of nerve impulses from peripheral fibers to the spinalcord cells that project to the brain. Somatic input is therefore subjected tothe modulating influence of the gate before it evokes pain perception andresponse. The theory suggests that large-fiber inputs tend to close the gate,while small fiber inputs generally open it, and that the gate is also26profoundly influenced by descending (italics added) activities from thebrain. It further proposes that the sensory input is modulated at successivesynapses throughout its projection from the spinal cord to the neural areasresponsible for pain experience and response. Pain occurs when thenumber of nerve impulses arriving at these areas exceeds a critical level.The theory, therefore, proposed a mechanism to explain pain relief by avariety of different procedures which close the gate by selective activationof large fibers (i.e., physiotherapy ) or by activation of descendinginhibitory influences from the brain (i.e., distraction of attention).Melzack (1989) theorized that there are "three major psychologicaldimensions of pain: sensory-discriminative, motivational-affective, andcognitive-evaluative....these are subserved by physiologically, specializedsystems in the brain, as follows:1. The sensory-discriminative dimension of pain is influencedprimarily by the rapidly conducting spinal systems.2. The powerful motivational drive and unpleasant affectcharacteristic of pain are subserved by activities in reticular andlimbic structures which are influenced primarily by the slowlyconducting spinal systems.3.^Neocortical or higher central nervous system processes, suchas evaluation of the input in terms of past experience, exert controlover activity in both the discriminative and motivational systems. (p.6525)All three forms of activity can then influence motor mechanismsresponsible for the complex pattern of overt responses that characterizepain. Acute and chronic pain are influenced by two different (italicsadded) ascending spinal cord pain-signalling pathways. One set ofpathways, the 'lateral pathways' convey phasic information, while the other27set of pathways are slower and 'are unlikely to signal the need forimmediate action'....These 'medial pathways' carry 'tonic' information and"they continue to send information as long as the wound is susceptible tore-injury. These messages may prevent further damage, and foster rest,protection, and care of the injured areas, thereby promoting healing andrecuperative processes' (Melzack, 1989, p. 6525).As well as the ascending pathways, Melzack (1989) theorized thatthere is in the brain a 'powerful descending (italics added) system which isable to inhibit, or 'close the gate' to incoming pain signals (Melzack, 1961;1989). Melzack theorized that memory may account for the persistence ofcertain kinds of pain. He cited experiments where a rat with an injuredhindpaw showed a heightened sensitivity to pain not only in the injured pawbut in the opposite paw and continued to have sensitivity to pain in theinjured paw after the nerves from the injured paw were cut. Melzack(1989) concluded that, 'These results show clearly that the hyperalgesia(heightened sensitivity to pain) is dependent on abnormal activity in thecentral nervous system, probably the spinal cord' (p. 2530).From studies of chronic phantom body pain in paraplegics whosustained total spinal cord lesions, Melzack and Loeser (1978) proposedthat synaptic areas along the major sensory projection systems, from -thespinal cord to somatosensory projection areas in the thalamus and cortex,may become pattern-generating mechanisms. Once the pattern-generatingmechanisms become capable of producing pain signals, any input may actas a trigger.28TREATMENTS FOR THE MANAGEMENT OF PAINCognitive-Behavioural Methods During the last decade, cognitively based therapies have proliferated.Therapy methods are based on the assumption that emotional disturbance isthe function of maladaptive thought patterns which must be restructured.The three most influential cognitive-behavioral therapies are Ellis' (1975)rational-emotive therapy; Beck's (1970) cognitive training therapy, andMeichenbaum's (1977) self-instructional training. All three therapies makeuse of imagination procedures such as imagining the desired behavioral andemotional responses while thinking rational thoughts discussed duringtherapy (Rachman & Wilson, cited in Spinhoven, 1987).Sternbach (1986) noted that there are "philosophic and psychologic"differences in the assumptions "underlying cognitive and behavioralinterventions. Cognitive theories assume that if one changes the ways ofthinking, there will be changes in affect and behavior that will follow.Behavioral theories assume that if behavior changes, there will beconsequent changes in affect and—especially—in cognition, as through theprocess of cognitive dissonance" (p. 235). Tan (1982) in a review articlenoted that evidence for the efficacy of cognitive-behavioral techniqueswere good for experimental pain but meager for clinical pain.More than 30 different illnesses and anatomic dysfunctions have lowback pain as a symptom (Grzesiak and Ciccone, 1986, p. 175). Chronic lowback pain, migraine headaches and cancer pain are the most difficult painsyndromes to treat (Melzack & Wall, 1988). Flor & Turk (1984)categorized low back pain as inflammatory, degenerative, structural,29traumatic and muscular ligamentous processes but the specific (italicsadded) process which caused back pain were unclear.The psychological treatment of patients with chronic low back pain isvery difficult and has been avoided by psychiatrists and psychologistsbecause they:Deny psychologic distress, reject suggestions that their pain problemsmay have psychologic basis, have little or no insight, and are notintrospective....this group of patients tends to be very resistant toexploring personal issues and frequently reacts negatively, oftenvituperatively, when referred for psychologic treatment. (Nigl,1984, p. 127-128)Behavioral methods of dealing with chronic pain, "derive chieflyfrom the classical conditioning of Pavlov, as represented by thedesensitization therapy of Wolpe (1958) from the operant conditioning ofSkinner (1969) and from the social learning theory of Bandura (1969)"(Hilgard, 1980, p. 261). Operant conditioning, as practiced in pain clinicswhich treat chronic pain, focus on the theory that pain responses have beenlearned and therefore can be unlearned. The patient is "rewarded" for"non-pain" responses and pain responses are "countered or extinguished"(Sternbach, 1974, 1978; Fordyce, 1978). Hilgard (1980) gave the followingexample:A person with joint pains can walk only so far before the painbecomes so great as to require rest. Looking forward to that rest islike expecting a reward for experiencing pain. Hence, having foundthe distance that can be walked without excessive pain, the patient atfirst is requested to walk less than this distance, so that the pain is notreinforced following the walk. Each day the walk is lengthened alittle, and, not surprisingly, the person walks beyond the originaltolerance limit without experiencing the rest-demanding pain.30Corresponding methods are used to reduce dependence on pain-reducing drugs. A 'drug-cocktail' consisting of the usual dosagemixed with a taste-concealing fruit drink, is taken at regularintervals, so that it is no longer associated with the relief of pain thathas mounted to some disturbing level. With the pain thus controlled,without being contingent on the timing of the drug intake, theamount of drug is gradually reduced until the patient remainscomfortable with the "cocktail' no longer containing any painmedication. (p. 261)BiofeedbackClinically, biofeedback therapy "is a blend of physiological andpsychotherapeutic intervention" (Schuman, 1982, p.164). Biofeedback is aform of behaviour therapy but it differs from the more "strictlyconditioning therapies" because there is an emphasis on "achievingvoluntary control" through "amplification of the changes inelectrophysiological or neuromuscular processes over which control issought. Examples are learned control over muscular tension throughobserving the signals from selected muscle groups by way of theelectromyogram, and control of blood flow through amplification oftemperature changes in the figures" (Hilgard, 1980; p. 262).Karoly and Jensen (1987) described electromyographic feedback(EMG) as the measurement of:small amounts of electrical activity that are produced by muscleswhen they are active (that is, tense)....electromyography has thepotential to be useful in the assessment of pain conditions that are ormay be associated with abnormal muscle response. Pain disordersstudied with EMG include back pain, headache, and the myofacialpain dysfunction (MPD) syndrome. (p. 76)31Two assumptions are made by the biofeedback clinician; one, thatmuscle tension and spasm have a causal relationship to pain and that thereduction of muscle tension thus reduces pain; and two, that a generalizedstate of relaxation should contribute to pain relief, either by diminishingaffective concomitants related to the problem or through some centralgating mechanism. Muscle pain is frequently associated with a pattern ofchronic muscle tension (Grzesiak, 1984; Schuman, 1982).Hilgard (1980) noted that the rationale between pain control throughhypnosis and pain control through biofeedback differed; in hypnosis, painis removed through a process of denial, whereas in biofeedback there is a"realistic sensitivity to bodily processes, such as relaxation," thereforeindividuals who are good at hypnosis might not be good at biofeedback (p.262). Hilgard also pointed out that biofeedback could in itself be a form ofdistraction from pain. In a review of psychological approaches to themanagement of chronic pain, Schuman (1982) noted that some researcherstheorized that:Hypnosis and biofeedback involve different skills and mechanisms.Biofeedback involves a focus on an external stimulus, which maydistract some subjects from the inwardly directed experience thatcharacterizes deep relaxation or hypnosis. (p. 164)Schuman (1982) defined biofeedback from two very differentperspectives: the specificity model which theorized that the individual is"trained to vary a target function in a quite differentiated and specificmanner" and the state model which theorized that the individual "shapes amore general change in behaviour along a continuum of arousal-relaxation" (p.153). As an example, if the individual wished to decreaseheart rate through the use of biofeedback; with the specificity model, the32individual would learn "to become aware of cardiac activity and learn todecrease heart rate at will," whereas with the state model the individualwould learn "to produce a state of deep bodily quiet that happens to beassociated with a decrease in heart rate" (p. 153).Schuman (1982) concluded that "biofeedback therapy for chronicpain has no specific psychophysiological basis: it becomes instead apsychotherapeutic (italics added) context for teaching relaxation orexploring the mind-body relationship." However, relaxation "which is acommon clinical objective in biofeedback training" may sometimes reducepain by interrupting the "pain-tension" cycle, or in some cases it "mayworsen pain" (p. 165).Nouwen and Solinger (1979) compared chronic low back patientswho received low back EMG feedback with a control group over 20sessions and reported that the treatment group had lowered EMGrecordings and lowered pain self-report at the end of treatment but thatboth had returned to baseline levels at a one month follow-up. Theyconcluded that the biofeedback training given to the treatment groupproduced a sense of control (italics added) which changed the patient'sattitude towards pain and that this was more important than thephysiological function of pain.In another comprehensive review of the literature on low back painand EMG biofeedback, Nouwen and Bush (1984) came to the conclusionthat there was no consensus on the role of paraspinal muscle tension in theproduction of low back pain. However, they did note that pain avoidancemay cause patterning of the muscles in the low back which are the result ofposturing which in turn causes muscle spasm. The authors stated that theseresults were not "atypical" and cited other studies (Epstein et al.,1977;33Penzien et al., 1983) which showed similar findings with tension headachesand studies (Ciccone and Grzesiak 1984; Turner and Chapman, 1982)which concluded that the advantages of biofeedback have more to do withthe psychological (italics added) rather than the biological aspects of paintreatment.Fowler and Kraft's study (cited in Schuman, 1982) found thatpatients with muscle pain generally do sustain a level of tension asevidenced by electromyographic readings (EMG) which is significantlyhigher than normal. Schuman (1982) reported that some researchersreported EMG training was successful without resulting in pain relief andothers reported that pain relief was maintained and even improved whileEMG readings reverted to pretraining levels.There is considerable controversy in the literature regarding theefficacy of using EMG readings as an indication of reduced pain. Syrjala(1984) reviewed the literature and came to the conclusion that researchershad found that patients suffering from identical diagnoses of low back paindid not have identical EMG readings; some were elevated and some werereduced. Schuman (1982) cited Phillip's study which found that if EMGreadings decreased within a session, the readings tended to show aprogressive decline over many sessions but noted that biofeedback trainingdid not necessarily enable either a lasting reduction in EMG or one thatgeneralized outside the office or laboratory. Another study by Phillipfound that when pain patients tensed or activated painful muscles, there wasa disproportionate amount of EMG activity from each side of the back ascompared to normals.In spite of these conflicting findings, Schuman (1982) concluded thatEMG feedback is a useful clinical technique in treating muscle tension pain34because it can facilitate the learning of muscle relaxation skills; it can trainthe patient to recognize the maladaptive muscular response and this in turncan facilitate identification of situational factors that are related to thisresponse and even temporary reduction in muscle tension may interrupt thepain-tension cycle. Because researchers have found that EMG readings aresignificantly higher in chronic pain patients they are therefore one of themost frequent applications of biofeedback for the reduction of muscletension in chronic pain patients.Researchers differ on the effectiveness of frontalis EMG for thereduction of muscle contraction headache. Grzesiak and Ciccone (1986)cited studies (Gottlieb et al., 1977, 1982; Johnson et al., 1983) of muscletension and pain reduced by EMG frontalis feedback but disputed thefindings because the EMG component was not the only intervention used toreduce pain. They disagreed with the theory that a state of relaxation in onearea of the body can "generalize" to another part of the body and statedthat, "The idea that frontalis tension can serve as an indication of generalmuscle tension has not met with empirical support" (p.176). The authorsconcluded that, "It is unlikely that there is such a phenomenon as generalmuscle tension contraction" (p. 176).Some researchers found EMG feedback to be effective on tensionheadaches (Budzynski, 1973; Wickramasekera, 1972; Haynes, 1975; Jessup,1984). Haynes (1975) found both EMG feedback and relaxation trainingsuperior to a no-treatment group in the reduction of muscle contractionheadaches. Others, (Large, 1983) found EMG to be useful in musclerelaxation but not in pain reduction. Chapman et al. (1985) cited one studywhich compared pain perception of pain patients with normals and foundno correlation with EMG recordings.35Keefe, Block, Williams & Surwit (1981) cited a study by Keefe of111 chronic low back pain patients who participated in a comprehensivebehavioral treatment program emphasizing relaxation procedures. Over thecourse of treatment, significant reductions were obtained on measures ofsubjective tension, EMG activity, and pain. Fordyce et al. (cited in Keefe etal.,1981) demonstrated the utility of operant conditioning techniques inmodifying well entrenched behavior patterns of chronic low back painpatients, such as narcotic dependence and inactivity. Keefe et al. (1981)stated "recent studies employing behavior therapy techniques such asassertive training, progressive relaxation and electromyographic frontalisbiofeedback" showed "interesting results" but didn't state which studiesthey referred to. The authors noted that, "More clinical studies with largenumbers of chronic low back pain patients are needed" (p. 222).Other researchers found that combining therapies proved moreeffective in the treatment of pain. Melzack & Perry (1975) studied theeffects of alpha biofeedback training and hypnosis by comparing them in astudy on the treatment of chronic pain. Both treatments produced increasedalpha activity but both were unsuccessful in the reduction of pain.However, when the authors "combined (italics added) the alpha biofeedbacktraining with hypnosis, the patients reported significant pain suppression"(p. 820). The authors concluded:The multidimensional nature of the relaxation response may explainits success in the alleviation of pain. Since the relaxation responsecombines increased alpha with attentional modification andsuggestion, the synergistic effects may account for the successful useof the relaxation response in the treatment of pain. (p. 820)3 6Similarly, Melzack & Wall (1988) reported that "multipleconvergent therapy using several psychological procedures is effectivebecause each kind of therapy may have its predominant effect on adifferent mechanism" (p.261). The authors theorized that:The data indicate that multiple convergent therapy using severalpsychological procedures is effective because each kind of therapymay have its predominant effect on a different mechanism.Relaxation, for example, may reduce muscle tension and generallyreduce activity in the sympathetic nervous system. Hypnosis,however, may have its predominant effect by activating controlprocesses that modulate the input as it is transmitted through thebrain. Procedures which involve the diversion of attention (so thateven spinal reflexes may fail to occur) may, conceivably, activate thedescending systems of the brainstem so that inputs are modulated atspinal levels. (p. 261)37Medical Treatment for PainMedical treatments for pain focus on eliminating or altering theproblem which produces the pain. Analgesics are commonly used for painrelief but many other techniques ranging from ancient methods of magnets,copper bracelets, acupuncture, etc., to more modern methods ofphysiotherapy, transcendental meditation, surgery, homeopathicmedications and drug therapy are used (Spino, 1984).Surgery is commonly used for chronic back pain (CBP). Flor andTurk (1984) reported that in 1982, surgeons in the United States, which hasthe highest number of back surgeries in the world, excised approximately"200,000 discs" (p.111). The authors concluded that the results of backsurgery are disappointing and cited Finneson (1979) who suggested that,"80% of the surgical patients should never have entered surgery. Often,surgery increases the pain problem instead of attenuating it" (p.112).Physical therapy is encouraged with chronic pain patients who oftenbecome inactive, lose muscle tone and become intolerant of physicalexertion (Fordyce,1986; Guck, 1985). Physical therapists use exercise,heat, cold and massage to alleviate muscle spasm and restore spinalmobility and muscle strength. Very little research has been done on theeffectiveness of these treatments (Flor & Turk, 1984).Blumer (cited in Spino 1979) found that chronic pain patients haveconsiderable emotional problems and recommended various types ofpsychotherapy for helping patients cope with their depression and focus onpain. He included, "dynamic therapy, hypnotherapy, behavioral therapy,and group therapy" as treatments which have "moderate success" withchronic pain (p. 38).38Transcutaneous electrical stimulation (TENS) is a current treatmentfor chronic pain, however there is controversy over its analgesiccomponent. Some researchers believe any benefit is due to the placeboeffect (Spino, 1984) while others believe that electrical stimulation iscarried through large nerve fibers, or afferents, which close the 'gate'(Melzack & Wall, 1965) thus disrupting input along small diameter fibers(which transmit pain stimuli).Some medical researchers advocated an eclectic approach to thetreatment of chronic pain. Pinsky & Malyon (Cited in Spino, 1984)theorized that effective therapy for chronic pain patients in an "intensiveseven-week program" should include, "psychodynamic psychotherapy,existential approaches, and cognitive-behavioral therapies" (p.111).The authors stated:Neurosurgeons, psychiatrists, and psychologists all appear to agreethat the most effective treatment methods are those that focus on thepatient's general personality and emotional make-up. The primarygoal is to re-educate the chronic pain patient in order to reduce hisor her overpreoccupation with pain and pain behavior. Traditionalpain relief methods, such as neurosurgery or medication, are de-emphasized and often discouraged. Chronic pain is conceptualized asprimarily a psychologic problem which does not fit a disease modelfor either diagnostic or treatment purposes. (p. 111)Melzack (Melzack & Wall, 1965) stated that while it is possible toreduce many kinds of clinical pain by means of analgesic and antidepressantdrugs, sensory modulation (e.g. nerve blocks or transcutaneous electricalnerve stimulation) as well as by different psychological therapies....theyrarely abolish pain entirely and are not equally effective for everyone" (p.261). He concluded:39We have learned, as a result of literally hundreds of experiments,that there is a limit to the effectiveness of any given therapy but,happily, the effects of two or more therapies given in combinationare cumulative. Two therapies, each with slight effects that may notreach statistical significance compared to a placebo, may producesignificant reductions in pain when given together. For this reason,multiple convergent therapy (italics added) is increasingly becomingthe standard approach to pain problems. (p. 261)Melzack & Perry (cited in Weisenberg, 1984) conducted a clinicalstudy of alpha training alone, hypnosis alone, and a combination of the twosuggested benefits with three groups of chronic low back patients. Theauthors concluded that:The combination of hypnosis and alpha-training significantlyrelieved pain compared to the baseline measures; 58% of the patientsreported a decrease of pain of 33% or greater. Hypnosis aloneachieved a substantial but statistically insignificant change frombaseline while alpha training alone was ineffective. The authorsinterpret the combined procedure as consisting of alpha training as adistractor of attention combined with relaxation, suggestion and asense of control over pain. The increase in percentage alphaproduction alone, a measure often used to indicate relaxation, wasnot adequate. (p. 165)Pain Clinics In response to the challenge of treating chronic pain patients, Dr.John Bonica of the University of Washington Medical School decided to trya new approach and developed the concept of a pain clinic which wouldtreat the patient with a variety of approaches using the talents of "surgeons,neurologists, psychiatrists, psychologists....who meet the patients bothindividually and as a group." (Melzack & Wall, 1988, p. 263). During the40last decade, this idea has spread so that there are pain clinics in most majorcities throughout North America. Melzack & Wall (1988) stated that theadvantages of having different specialists treat the same patient arethreefold:The professional can learn not only from a special group of patientsbut also from each other; by grouping many pain patients and manyconcerned professionals together, new therapies are developed; datacan be accumulated on the relative effectiveness of differenttherapeutic procedures which are often lost when a patient visits eachspecialist in his own clinic. The pain clinic allows for thecombination of pharmacological, sensory, and psychological methodsof pain control, which may be used in different combinationsdepending on the type of pain and the needs of the individual painpatient. (p. 263)DrugsPain medication is an important aspect in treating the chronic painpatient. Chronic pain patients often receive excessive doses of opiates(drugs derived from opium) which may cause drug dependency and abuse(Gorsky, cited in Nigl, 1984). Flor & Turk (1984) reviewed chronic painand reported that medication was the "physician's treatment of choice" forchronic back pain (p.111). They questioned the value of both narcoticdrugs (e.g., morphine and codeine), and the non-narcotic drugs (e.g.,aspirin) as a treatment:Although analgesics undoubtedly relieve pain for brief periods,tolerance, habit formation and side-effects pose various problemsand make their prolonged use not advisable. Other medications, suchas antidepressants, muscle relaxants and anti-inflammatory agents areincreasingly used, but few controlled trials are available to assesstheir efficacy. ( p. 111)41The authors noted that the evidence is inconclusive because moststudies are done on acute (italics added) back pain patients.During the 1970s advances were made in the investigation of thephysiological effects of pain (Nigl, 1984). Naturally occurring substancescalled endorphins and enkephalins which are morphine like pain inhibitorswere isolated in the brain. Spino (1984) posited the theory that patientswhom he calls 'placebo responders' (patients who respond well to a sugarpill in the belief that the pill is a drug), have the ability to release thesenatural analgesic substances from receptors in the central nervous system(CNS) in response to a placebo. He noted that "so-called 'real' as well as'psychogenic' pain may be relieved by a placebo" (p. 39).At the same time researchers found that pain impulses could betransmitted by both chemical and electrical systems. They discovered newpain inhibitors called 'beta-endorphins' which are 48 times as potent asmorphine when injected into animals and they found that the brain (italicsadded) produced endorphins when deep regions were stimulatedelectrically (LeRoy, 1976). Although enkephalins and endorphins both havestrong analgesic and other properties, their physiological role and theirinvolvement in endogenous pain control is not yet fully known. Hilgard(1986) noted that some experiments eliminated endorphins as part of theopiate class because naloxone which is an "antagonist" to endorphins doesnot appear to reverse "hypnotic analgesia" (p. 209).Hilgard (1986) cited a study by Barber & Mayer of a dental patientwho used hypnosis as the sole anesthetic for the removal of four impactedmolars. Her EEG activity was monitored and it was concluded that"hypnotic responses may be a right hemisphere function, in part as a resultof direct EEG studies, in part because of the relationship of hypnosis to42imagery and fantasy, also predominantly right hemisphere function" (1986,p.210). Hilgard noted that further interviews of the patient "showed thatthe pain control had been achieved largely through enriched fantasies withhypnosis, a form of dissociative distraction that reduces felt pain,regardless of the physiological stresses that the surgical insults may haveproduced" (p.210).43HypnosisHistory of Hypnosis Both waking and hypnotic suggestion have been practiced sinceancient times. Witch doctors, magicians, medicine men and shamans inprimitive cultures have used monotonous drumbeats, chanting and dancingas a form of trance induction. The healing powers of trance induction havebeen referred to in the early civilizations of Syria, Egypt, and Greecewhere patients went to "sleep temples" and were hypnotized or talked toduring their sleep and given suggestions for relief of their symptoms.Persian magi and Hindu fakirs used eye fixation techniques to intensifycataleptic states. Techniques of waking suggestion have been used by thechurch in the form of faith healing, however the western Christian worldthroughout the middle ages regarded the use of hypnosis for healing assacrilegious and the work of the devil (Pulos, 1980).Hypnosis as a therapy has gone through cyclical stages since itsinception in the 1700s; at times popular and supported by those in theacademic psychological community and at other times unsupported and indisrepute (Hilgard, 1969). Most researchers (Ambrose, 1980;Gorsky,1981; Miller, 1979; Mutter, 1988; Pulos, 1980; Rosen,1960) referto Dr. Anton Mesmer (1734-1815) as the father of medical hypnosis. Hewas influenced by Grassner, a German priest who performed "miraculoushealings" and by English physicians who believed in the curative powers ofmagnets. He termed this power "animal magnetism," a redistribution of afluid circulating in the body, to distinguish it from "mineral magnetism."He theorized that the individual had a "electrochemical relationship" with44the planets through this fluid.and disease was caused by a "disequilibriumin this system."Mesmer believed that he had magnetic rays which flowed from hisfingers to cure his patients. He developed a bath-like structure, or"bacquet," lined with iron filings and magnets in which a patient wasimmersed for a cure. His success was due largely to the power ofsuggestion and the patient's expectation of a cure and not the iron filingswhich his patients held. He became famous after he cured a child ofhysterical blindness. She was a pianist; a child prodigy who was a favouriteof Empress Maria Theresa. Unfortunately, the child again developedblindness and this put Mesmer in disfavour with the Empress. A FrenchRoyal Commission was set up at the insistence of the medical establishmentof the time and they discredited his theories. Mesmer was denounced as afraud, lost his license to practice and was forced to retire (Hershman &Secter, 1961; Pulos, 1980). Seventy years later Elliotson and Braid, Britishdoctors, explored Mesmer's methods. Braid coined the word "hypnotism"and was the first to substitute visual optic fixation for hypnotic passes toinduce trance (Chertok, 1967).Hypnosis has been used for the management of pain since the early19th century when it was used to provide analgesia for surgery (Crasilneckand Hall, 1985b; Hilgard, 1986; Sternbach, 1984). In the 1800's JamesEsdaile, a Scottish physician, was the first to use hypnosis as a means ofanesthesia and was reported to have performed over three hundred majorand several thousand minor operations quite painlessly on patients. Shortlyafterward in France, Dr. Ambroise August Liebeault of the Nancy Schooldiscovered that by combining verbal sleep suggestion and Braid's methodof fixed gazing he was more effective in hypnotizing patients. He wrote a45book about his methods but sold only one copy due to criticism from theSalpetriere School of medicine which opposed the psychological orientationof hypnosis as a treatment (Chertok, 1967).Bernheim, a famous neurologist, initially opposed Liebeault but aftertrying out his methods on patients recognized the significance of the verbalsuggestion used by Liebeault. He was the first to demonstrate that thephenomenon of suggestion was the real underlying factor of hypnosis andthat hypnosis was due exclusively to psychological rather then physicalcauses, thus disproving the original conclusions of Mesmer, Braid, Charcotand others (Cheek & LeCron, 1968; Miller, 1979).The French neurologist, Charcot, in 1878 revived Mesmer's theoryof animal magnetism and was opposed by the Nancy School headed byBernheim. Miller (1979) related an incident which was pivotal in changingCharcot's mind:It appears...that Charcot did not realize that the hypnotic influencewas exercised by means of suggestion; rather he believed thatphysical phenomena were involved. For instance, on one occasion,Charcot presented a man whom he believed was quite deaf, in thehypnotic state. He then announced that a magnet would produce acertain effect. Bernheim than demonstrated that the effect was duepurely to the suggestion and not magnetic force; that the subjectcould hear perfectly well and that a wooden imitation "magnet"produced the same remarkable effect. (p. 22-23)During the last three decades hypnosis has increased in popularity.Single case studies have been reported on integrating hypnosis with Gestalttherapy (Barber, 1986), Rational Emotive Therapy (Ellis, 1986), andEricksonian and cognitive-behavioral therapy ( Golden, 1986). Althoughhypnosis was not fully accepted by the medical establishment, after World4 6War II, it was given official sanction by the British medical association in1955 and American medical association in 1958 (Hilgard, 1986).Crasilneck & Hall (1985) cited a survey by Sachs (1982) which reportedthat:A 1978 survey revealed that one third of American medical anddental schools were offering courses in hypnosis, twice as many as asimilar survey in 1974. It is estimated that more than 10,000physicians, psychologists, and dentists in North America are trainedin the use of hypnotherapy as an adjunct to traditional forms ofmedical and dental treatment. (p. 3)Theories of Hypnosis Chertok (1967) posited three approaches to hypnosis: physiological,experimental psychological, and psychoanalytical. Physiological theoriesuse Pavlovian concepts and regard hypnosis as an incomplete sleep whichallows a communication between the hypnotist and the subject due to"waking points" in the brain. Pavlovians use animal experiments to confirmtheir theory. For example, a dog conditioned to the sound of a trumpetawakens only to this sound and remains insensitive to other sounds even ifthey are more intense. (Birman, cited in Chertok, 1967) Chertok noted thatexperiments on animals cannot be compared to man; that language cannotbe compared to a "physical stimulus" and that even Pavlov admitted that thesimilarity between hypnosis and sleep has "received noelectroencephalographic confirmation whatsoever" (p. 4).Experimental psychology is based on the concepts of Bernheim(1884) and in the United States was developed by Hull in the thirties. Hulltheorized that "suggestibility" was the basis of hypnosis and that hypnosiswas "a kind of learning" (Chertok, 1967, p. 5). Chertok cited47Weitzenhoffer, Hilgard and Orne as researchers who attempted to quantifyhypnosis. Hilgard (cited in Chertok, 1969) studied the psychologicalcharacteristics of hypnosis and classified seven:1. Subsidence of the planning function;2. Redistribution of attention;3. Availability of visual memories from the past, and heightenedability for fantasy-production;4. Reduction in reality testing, and a tolerance for persistentreality distortion;5. Heightened suggestibility;6. Aptitude for role behaviour;7.^Amnesia for what transpired with the hypnotic state (Chertok,1969, p. 5).Hilgard (1986) concentrated on the problem of hypnotizability fromthe point of view of quantification but found that this approach did notanswer the question of why one individual is easier to hypnotize thananother.The psychoanalytic theory of hypnosis was originally interpreted as"a gratification of the subject's instinctual wishes. It was seen as amasochistic type of relationship and a form of transference (Ferenczi,1909; cited in Chertok, 1967).During World War I, hypnoanalysis, the merging of hypnotictechniques with psychoanalytic techniques, was developed by Ernst Simmel,a German psychoanalyst. At the same time other psychoanalysts used"barbituates to induce a state of drug hypnosis (narcosynthesis) in order tobring traumatic experiences to the surface." These techniques were used48during World War II to treat "combat fatigue and other neuroses"(Hershman & Secter, cited in Hilgard,1986, p. 9).Pierre Janet (1859-1947) was one of the first to attempt to explainhypnosis. Janet was a philosopher and physician at the Saltp'etriere Schoolin Paris and was the first to use the expression "subconscious" (Haule,1986). He posited the theory of progressive dissociation which occurredduring hypnotic induction. He believed that the subconscious mind tookover during deep hypnosis particularly if the conscious mind wassuppressed and inhibited. Joseph Breuer, a physician who with Freud hadused hypnosis on mental patients, discovered at the same time as Janet, theimportance of uncovering traumatic experiences through the use ofhypnosis. Later, these methods were used successfully to treat soldiersduring World War II (Miller,1979).Freud became interested in hypnosis after witnessing Dr.Breuer curea case of hysteria. He studied hypnosis under Charcot, Bernheim andLiebeault but became discouraged when he found that he could nothypnotize all his patients. However, Freud was very analytical and gainednew insights into the dynamics of the unconscious mind during hypnosis.He observed that repressed memories and experiences could be recapturedby means of association while a patient was in a hypermnestic (unusualability to remember) state. From this he developed the technique of "freeassociation" which was the beginning of the development of psychoanalysis(Sternbach, 1984). He observed "the intense affective reactions of theunconscious in the phenomena of abreaction and catharsis" (Miller, 1979,p. 24). Jung also used hypnosis from which he evolved the technique of"active imagination" (Barber, cited in Araoz, 1985, p. X).49Rossi (cited in Araoz,1985) suggested that, "Milton H. Erickson(1902-1980) would have called free association and active imaginationindirect forms of hypnosis" (p. X). Erickson was a psychiatrist whoseindirect methods of hypnosis are well documented (Erickson, 1967, 1983).Erickson (1989) developed concepts and techniques which differed fromthe traditional authoritarian direct approach to hypnosis which gave thehypnotist magical powers over the subject, like the stereotypical stagehypnotist. He viewed therapy as an "interactional process" between thetherapist and client in which the relationship between the hypnotist andtherapist was one of "cooperation based upon mutually acceptable andreasonable considerations" the subject therefore "cannot be forced, as afunction of hypnosis itself, to do things against his will, as is sometimesclaimed. He can be aided in achieving possible desired goals, but frequentfailures in hypnotherapy attest to the limitations of hypnosis inaccomplishing even wanted purposes, and extensive and reliably controlledstudies discredit the possibilities of antisocial use of hypnosis" (Araoz,1985, p. 1).Erickson stressed the individuality of each person and tailoredtherapy to the uniqueness of each individual (Yapko, 1984). Haley (cited inYapko, 1984) explained Erickson's approach as that of "teacher andstudent" in the sense of developing a situation in which the patient or clientis forced to view it from a different perspective. Rossi (1986) reported thatErickson's approach emphasized the use of the patient's conscious andunconscious resources. Erickson theorized that we communicate with botha "conscious language" and an "unconscious language" and that this"communication" was "in the form of body movement, vocal intonation,and the metaphors and analogies implicit in our verbal speech" (p. 545).50Rossi (1986) referred to Rank's theory that the source of "complexesand neuroses" stem from "the original trauma of birth" and he posited thetheory that, "the entire edifice of psychoanalysis could be said to rest uponthis effort to explain how trauma gave rise to emotional complexes byinitiating dissociation repressions, and amnesia." He cited Erickson asdemonstrating, "how amnesias caused by psychological shocks andtraumatic events are psycho-neuro-physiological dissociations that can beresolved by 'inner resynthesis' in hypnotherapy" (p. 39).Rossi (1986) posited the theory of "state dependent learning" whichhe explained as follows:We would submit that hypnotic trance itself can be most usefullyconceptualized as but one vivid example of the fundamental nature ofall phenomenological experience as "state-bound". The apparentcontinuity of consciousness that exists in everyday normal awarenessis in fact a precarious illusion that is only made possible by theassociative connections that exist between related bits ofconversation, task orientation, etc. We have all experienced theinstant anmesias that occur when we go too far on some tangent sowe "lose the thread of thought" or "forget just what we were goingto do," etc. Without the bridging associative connections,consciousness would break down into a series of discrete states withas little contiguity as is apparent in our dream life". (p. 41)Kebrdle and Roeder (1986) cited other theories of hypnosis whichincluded defmitions of hypnosis as:An altered state of consciousness (Barber, 1976), heightenedexpectancy (Barber, 1976), increased compliance and belief in thehypnotic state (Wagstaff, 1981), increased suggestibility (VonDendenroth, 1968), a unique cognitive state (Hilgard, 1977), role-taking (Sarbin & Slagle, 1979), regression (Gill & Brenman, 1961),dissociation (Hilgard, 1977; Nogrady, McConkey, Laurence &51Perry, 1983), and heightened imagery. (Barber, Spanos & Chaves,1974, p. 22)In the 1970s Hilgard (1973) posited a "neodissociation" theory ofhypnosis based on Janet's (1889) theory of progressive dissociation.Hilgard (1973) referred to Freud's theory of repressed thoughts and wishesin the unconscious as a 'closed' form of the theory and posited that in the'open' form of the theory, "the subconscious layer is not only moreextensive than the conscious layer, but it has access to some broader sets ofexperience that may never have been in the waking consciousness" (p. 405).Hilgard cited Jung's collective unconscious, universal archtypes andmandala symbols in dreams as a more recent example of the theory.Hilgard explained his theory as follows:Many of the arguments over classical dissociation theory and theefforts to provide experimental tests have assumed that if systems aredissociated there should be no interaction between them or at thevery least that the interaction should be reduced by hypnoticdissociation. I propose, instead that the problem of separation, bothin awareness and in behavior, is an empirical one and may be amatter of both dimensionality and degree. That is, cognitive andbehavioral systems that are separated in one dimension may beinteracting in another, and the separation or interaction need not besharp in order for some dissociative process to be demonstrated.Hence there may be partial dissociations, according to variouscriteria, and these may tell us about important aspects of cognitivefunctioning. For example, in experiments on dichotic listening toconversations, in which one message comes to one ear and a separatemessage to the other ear, the listener readily processes one messageand ignores the other. Here one cognitive control system is dominantover another, and the two systems can be thought of as dissociated,because messages are surely reaching both ears. It is knownhowever, that while fully processing only one message, a subject maystill report whether the other message is being delivered by a male52or female voice, and, if interrupted, he can often tell you somethingof what was said to the nonattending ear. In other words, thedissociation is incomplete. Similar evidence can be found for theincompleteness of the dissociations in hypnotic experiments. (pp.404-405)Hilgard (1973) cited an experiment on task interference to show thatthere is a 'cognitive cost' in maintaining hypnotic dissociation. A subjectwho in the waking state was given the task of alternatively pressing twokeys with the index and middle fingers of the right hand, did so with fewerrors. Under hypnosis, with posthypnotic suggestion with the task out ofawareness, the subject made approximately 20% errors. He stated:Keeping the task out of awareness apparently uses some of hisattentive ability and interferes with the performance. If there isadded a simultaneous task, such as naming colors aloud from a panelof colors before him, with full awareness of what he is doing, thiswill, of course interfere with conscious key pressing. If the keypressing is performed out of awareness, the errors again rise, so thatthe performance with the two tasks dissociated is less efficient thanwhen both tasks are conscious. This task interference, exaggeratedwhen one of the tasks is performed automatically through hypnoticsuggestion, is compatible with neodissociation....The basicassumption of neodissociation theory proposes that the unity whichexists in personal cognitive functioning is somewhat precarious andunstable. An executive ego provides a basis for self-perception andfor conceiving the self as an agent (Hilgard, 1949). Its integrity isprovided largely through the continuity of the personal memories,not through any unusual self-consistency either in awareness orbehavior. This executive ego has many constraints upon it, boththrough internal conflict and insufficiencies, and throughenvironmental pressures, physical and social, including hypnoticinteractions. There are many subordinate control systems thatrepresent fractions of total cognitive functioning. It is proposed thatthese substructures have at any one time a hierarchical arrangement,53but their hierarchical positions can shift. For example, in sleep, thecognitive control system that produces dreams is more prominentthan it is in waking, though it is doubtless present at a lower level inwaking also, as in daydreams and fantasy production generally. Oncea system is activated, it may exert its controls autonomously, eventhough it is a subordinate system. When, for whatever reason, youstart humming a haunting tune while working at something elsehigher in your hierarchy, the humming may have startedspontaneously and continue unchecked. Daily life is full of manysmall dissociations, if we look for them. Where hypnosis will enterinto this framework is in shifting the hierarchies of control, so thatwhat is normally voluntary may become involuntary, what isnormally remembered may be forgotten, and (under somecircumstances) what is normally unavailable to recall may berecalled. Furthermore, the dominance of the normal executive ego isreduced, though not obliterated. For example, if the hypnotic subjectis given a suggestion that violates his self-conception, he is likely tobe aroused from hypnosis, and the executive ego may be responsiblefor this arousal. (p. 405-406)In the 1980's Rossi (1986) linked "the psychobiologicalcharacteristics of ultradian rhythms" (a multioscillatory system ofpsychophysiological processes involving many parasympathetic and right-hemispheric functions which have a 90-minute periodicity throughout the24-hour day) .and the "common everyday trance" that Erickson utilized forhypnotherapeutic healing to formulate the ultradian theory ofhypnotherapeutic healing, in which he proposed:1. The source of psychosomatic reactions is in stress-induceddistortions of the normal periodicity of ultradian cycles;2. The naturalistic approach to hypnotherapy facilitates healing bypermitting a normalization of these ultradian processes. (p. 43)54More recently, Barber referred to the "New Hypnosis" whichfocuses on techniques developed over the last thirty years. These techniques"are 'client-centered hypnosuggestive approaches," of the 1980s as opposedto, 'hypnotist-centered approaches,' focusing on ritualistic hypnoticinduction procedures and direct suggestions which were still dominant inthe 1950s" (Barber, cited in Araoz, 1985, p. Xiii).Hypnosis in the Treatment of PainHypnosis has been used for the management of pain since the early19th century when it was used to provide analgesia for surgery (Crasilneck& Hall, 1985b; Hilgard, 1986; Sternbach, 1984). There is unequivocalevidence that psychological factors play a part in pain perception andresponse (Barber, 1982; Hilgard & Hilgard,1986; Melzack 1988;McGlashan, 1969) but there is much controversy over how hypnosisworks. Some researchers theorized that hypnosis produced physiologicalchanges which mediate symptom relief (Finer, 1982; Hilgard, 1969).Mutter, (1986) reviewed the current uses of hypnosis in medical, dentaland psychological practice:Hypnotic suggestions for pain control and time distortion can begiven to increase comfort, save time and enhance healing potential.Similar suggestions can be given to patients undergoing surgery toreduce swelling and blood loss, increase healing and resistance toinfection, and speed postoperative recovery. Quite often, patients canbe discharged earlier and return to normal functioning morequickly". (p. 271)Hypnosis has been successfully used for pain reduction in thetreatment of burns, obstetrics, migraine headaches, low back pain; habit55disorders such as smoking, nail biting; eating disorders and more recentlywith cancer patients not only to alleviate pain but as a direct intervention tocombat it (Hilgard, 1967; Mutter, 1986). Hypnosis is also used.as  an"adjunct to psychiatry and psychology particularly in the treatment of"depression, psychoneuroneses, psychosis in remission, personality andcharacter disorders and sexual disorders" and is "the treatment of choice"for post traumatic stress disorder because of its effectiveness as a "directroute to the unconscious mind" and the ability to "uncover repressedtraumatic material within a very short period of time, in contrast withother forms of psychotherapy; which could take months or years ofintensive treatment before meaningful material is uncovered" (Mutter,1986, p. 272). Mutter stated:Because hypnosis has a direct connection to the autonomic nervoussystem psychosomatic disorders such as...migraine headaches, ulcers,colitis, hypertension, certain skin disorders...respondto...hypnotherapeutic intervention....Many behavior modificationtechniques used with hypnosis are highly effective in symptomcontrol....Hypnosis is also used effectively with chronic pain patientswho suffer from a....loss of control...anxiety and depression. Painclinics use hypnosis to help patients break...the pain/depression cycle.simultaneously....As well, it reduces the patient's dependency onnarcotics and therefore the risk of addiction. (p. 272)Crasilneck (1979) posited the theory that "the hypnotized patientblocks the perception of pain in the same manner that psychosurgeryobliterates intractable pain. It is akin to the 'gate control theory of pain'(Melzack, 1973) with a cortical hypnotic change service as the 'gate closingstimulus.' He cited as an example a female physician in labour who washypnoanesthetized and "described herself as having a 'psychologicalprefrontal lobotomy' (p. 76).56Wyke (1986) posited the theory of hypnosis as "applied neurology,"or "a state of modified attention, created by modification brought about inthe central nervous system, by external or internal stimuli." He stated thatthe opposite of attention was "habituation" which refers to "a diminution inthe intensity of a particular perceptual experience in circumstances of itsmonotonous presentation: monotonously repetitive presentation" (p. 2). Hetheorized that:On the one hand we have the phenomenon of attention, which is theprocess by which a particular perceptual experience is intensified,and on the other hand, we have the process of habituation in which aparticular sensory experience is diminished or in certain instances istotally abolished....Hypnosis is a state of modified attention, createdby modification brought about in the central nervous system, byexternal or internal stimuli of one kind or another....gatewaysynaptic neurons are activated by the incoming input, then thatactivity is further transferred up the neural axis into the brainstem...and it is in these synaptic systems of these limbic sectors ofcortex that all emotion experiences are generated. When one ishappy, one is happy there; when one is depressed, one is depressedthere; and since pain is an emotional state and not a sensation (italicsadded) that is where things hurt as well, not in any kind of sensorycortex. (p. 5)Wyke (1986) stated that contrary to what he learned in medicalschool, "There is no necessary correlation between the intensity of aperceptual experience and its emotional concomitants and the intensity ofthe evocative stimulus at all!" (p. 5). Like Melzack & Wall (1982) Wyketheorized that with pain there were "facilitating and inhibitory modulatingsystems" which can be modulated at the gateway synapses at the base of thespinal cord by "peripheral or central sources." The peripheral sourcesrelease "inhibitory endorphins" which block the pain messages at the57"gateway synapses." Wyke believed that this is a system which is "peculiarto pain" and gave the following example to explain "how a change in theenvironmental situation" could bring about a "perceptual switch" or a"change in the direction of attention from one input system to another" (p.7).It all started with this famous experiment^This experimentinvolves a cat....This cat is sitting in a cage here, unanesthetized andquite happy, with a micro electrode in its left cochlear nucleus.Remember, the cochlear nucleus consists of the gateway neurones ofthe acoustic system. It is the first group of neurones, the gateneurones, on the acoustic pathway into the brain....Now, this catsitting quietly in its cage, is being presented with a series of clicks,and these are single sweep oscilloscope recordings of the synapticpotentials evoked in this cochlea nucleus by each click. Each potentialthat you see there, indicates that the incoming impulses from thecochlea have crossed the cochlea synaptic system, the gatewaysynapse in the cochlea nucleus, have activated the post synaptic celland the activity has gone up to the animal's acoustic cortex and theanimal hears each click. In the second picture, a beaker containing amouse is being introduced into the animal's cage, and I assure youthat from a cat's point of view, a mouse is a much more interestingobject than a click. As a result, the animal's attention is switchedfrom its acoustic input to its visual input and it is looking as you see,very intently at the mouse. Its attention is canalized on its visualinput. But look what has happened to its acoustic input, because theclicks are continuing unabated. There is practically no trans-synapticdischarge in the cochlea nucleus and the animal is not hearing theclicks any more because the activity is not passing beyond thegateway synapse, and not reaching its acoustic cortex. As far as thatcat is concerned, the clicks have gone and boy, look at that mouse.When you take the mouse away, and the clicks are still continuing,the evoked trans-synaptic potentials return once more and now thecat is again paying attention to the clicks. (p. 8)58Wyke theorized that through monotonously repetitive stimulation theanimal became bored and that boredom is the "neurological mechanism ofhabituation--inhibitory inhibition of gateway synaptic transmissions as aresult of enhanced activity of the inhibitory modulating systems which is aphenomena of the exposure of individuals to monotonously repetitiveenvironmental changes" (p. 8). He argued that in humans the brain is a"one channel system" and that, "The more intensely information is drivenin through one system, the less possible does it become to drive ininformation through other systems. The more intensely somebodyconcentrates on something, the less they are aware of other things going onaround them" (p. 12). He noted that contrary to what was once believed,"The administration of barbituates to patients," instead of facilitating theinduction of hypnosis, "militates against" it. He concluded that, "It hasbecome apparent that the neurons of certain parts of the brain stemreticular system are very much involved in the processes of attentionmodulation which underlie,...the processes of the induction and themaintenance of hypnosis" (p. 8).On the question of pain and hypnosis Erickson (1989) theorized thatwe can have "pain" habits in much the same way as we have "speech,""eating," "olfactory and gustatory habits." He believed that, "You can takevarious stimuli and habitually translate them into pain responses. (And youcan also learn to do the reverse.)" and he cited as an example tasting veryhot Mexican food for the first time and then learning to "translate thestimulation of the pepper into a pleasant sensation." He used this example totalk about the tongue developing , "callous formation" in order to makeMexican food pleasant and compared this analogy to a woman with chronicpain in her hip who was encouraged to form "nerve callouses down her59hip." Evidently his suggestions worked because the woman "Arrivedhome....free of pain and very proud of the fact that somehow she wasmanaging to translate the experience of pain into a feeling of comfort."Erickson explained that he would have failed with this patient if he hadattempted to "diminish her pain by directly inducing an anesthesia or ananalgesia," because the concept of pain was part of her reality and hehelped her "use that reality in a manner that allowed her to experiencecomfort as well" (p. 113).Barber (1982) suggested four basic hypnotic methods for paincontrol:1. Analgesia or anesthesia can be created in the hypnotizedindividual by simply suggesting that the perception of pain ischanging, is diminishing, or that the area is becoming numb, so thatthe pain is gradually disappearing. It may be easier for a patient tonotice growing comfort rather than diminishing pain; thus a specificfeeling of comfort such as that associated with anesthesia can besuggested specifically.2. Substitution of a painful sensation by a different, less painfulsensation can frequently enable a patient to tolerate some persistentfeeling in the area but not to suffer from it. A sensation of stabbingpain may be substituted with a sensation of vibration.3. Displacement of the locus of the pain to another area of thebody, or sometimes, to an area outside the body, can again providean opportunity for the patient to continue experiencing thesensations, but in a less vulnerable, less painful area. The choice ofthe area is usually based on its lesser psychological vulnerability, andsuggestions can leave the choice to the patient.4. Dissociation of awareness can be created when the patient doesnot need to be very functional (e.g., during a medical or dentalprocedure) or when some condition renders the patient virtually60immobile (e.g., during the last stages of a terminal illness).Thepatient can be taught simply to begin to psychologically experiencehimself or herself as in another time, place, or state, as in a vividdaydream. (p. 46)Barber (1982) emphasized that the effectiveness of pain controldepends on the patient's imagination and the ability of the clinician to"evoke or capitalize on that imagination" (p. 47). He theorized that whilepain may be completely removed, more often pain control means"modifying the particular experience of a quality of the pain, eithersensory or affective, in a way that alleviates suffering" (p. 47). He believedthat the "psychological management of the pain patient" included:Issues such as secondary gain, reinforcement of disability, familydynamics, self-esteem and using pain as a focus to deflect attentionaway from other important problems may need to be dealt withbefore pain can be successfully managed. Awareness of such issuesdoes not itself guarantee reduction in pain, however. (p. 49)Barber suggested that the need for pain was necessary as a "warningfunction" but that patients had many reasons for not wanting their pain tocompletely disappear. He thought that hypnotic suggestions for somepatients "may require the framing of suggestions that explicitly allow theretention of some aspect of the pain at certain times. He gave the followingexample:A 55-year-old woman with a 30-year history of low back painfollowing laminectomy was able, within a few minutes of the firsttreatment by hypnosis, to completely eliminate her pain. Her reliefwas dramatic and very pleasant to her. Within a few days, however,the recognition that she had relieved her pain through her ownpsychological power - and that she would need to learn to continue to61take care of her pain - illuminated for her an importantcharacterological issue: her need for dependence on others for help.She quickly discovered that she resented having to take care ofherself, and she became aware of a tendency to disown her ownhealing ability in favor of seeking cures from the outside - notably,she was interested in seeking further surgery. Such awareness did notmake possible the resolution of this characteristic, since it was verycentral to her personality and she did not want to change it, but theawareness did make it possible for her to disengage from this need inthis one context. She was able to understand why she was havingdifficulty maintaining her motivation for using self-hypnosis, andthis understanding protected her from seeking further needlesssurgery. She learned that she could continue to enjoy herindependence in this one area of taking care of her pain. (p. 50)Barber cautioned clinicians to "be more sensitive to psychologicalissues" and not assume that because "a psychological characteristic inhibitstherapeutic success," the patient either has no pain or "doesn't want to letgo of the symptom" (p. 21).Similarly, Erickson (1989) believed in utilizing the imagination forthe reduction of pain He stated: "When you want to use hypnosis indentistry, medicine, or psychological experimentation, you need to beaware of what it is your patient should include in the situation" (p. 101). Hesuggested removing the patient's imagination from the body which is leftbehind in the office and gave the example of a patient in a dentist's officewho under hypnosis imagines going to the beach. Thus, "everything thathappens in the office is in relationship to the body being left behind. Youhave restricted and limited the patient's body orientation to the work thatyou are going to do" (p. 102). Erickson, theorized that:In a trance state or at an unconscious level we are not too concernedtoo much with concrete reality....For example at a concrete level we62expect to actually see a glass of water in the waking or consciousstate but in the unconscious or trance state you substitute a visualmemory or a concept of what a glass of water is....As soon as yourecognize the tendency of the unconscious to rely upon memories,ideas, and concepts in place of concrete reality then it is much easierfor you to ask your hypnotic subject to hallucinate....You're askingyour patient to substitute for that state of pain the memory of a verypleasant feeling because in the unconscious there is a memory of avery pleasant feeling....All you want to do is take your patient'sattention away from the concrete reality of the state of pain anddirect it to that very real and very genuine concept or learning ormemory or experience of comfort that exists within the unconsciousmind. (p. 104)Erickson used the metaphor of a runner in a race to explain the hypnoticprocess:At the races the starter fires the pistol, but it is the runner who winsthe race....The firing of the pistol only announces the beginning ofthe race; it doesn't enter into the process of running the race....So itis with hypnosis....What the hypnotist says is like the firing of thepistol....The patient then has to do all of the 'running' himself, andhe can only do that in accordance with his own understandings....Assoon as you introduce the memories of comfort and ease into a painsituation the pain begins to diminish because you have only so muchattention to give....You can give all of your attention to the pain, oryou can give most of it to the pain and a little of it to the memoriesof comfort and ease....Then you can give progressively more andmore attention to the ease and comfort, and less and less attention tothe pain. (p. 104)Erickson (1983b) emphasized avoiding words such as pain whichreminded the patient of their problem. He summarized his views onhypnosis and pain as follows:You approach pain as a subjective experience. You try to dissect it,to analyze it; you try to get the patient to recognize the various6 3attributes of the various psychologically subjective ways he dealswith it; and then you use direct hypnotic suggestion, when possible,or permissive, indirect hypnotic suggestion, for its total abolition.You can use any or all of the following: amnesia, hypnotic analgesia,hypnotic anesthesia, hypnotic replacement or substitution, hypnoticdissociation, time distortion, body disorientation, the reinterpretationof pain, the relocation of pain, and the diminution of pain. Younever know which measure will be useful, nor do you know to whatdegree any one of them is going to be helpful. But you ought to havethem all on hand, so to speak, so that you can shift from one toanother with ease. You might use disorientation to reduce a burningpain, while a cutting pain seems to call for referral or dissociation.You can never know ahead of time how you are going to handle theindividual aspects of the pain. (p. 237)Audiotaped Hypnotherapy as a Treatment for PainIn 1900, a Parisian physician, Hippolyte Baraduc presented a reportto the Second International Congress of Experimental and TherapeuticHypnosis in Paris on phonographically induced hypnosis as a treatment,which may be the first time a phonograph was used to produce hypnosis(Gravitz, 1983). Baraduc claimed to have 'effective' results in ten patientsand stated that, 'One obtains nothing without expectant attention, or if therecording on the cylinder is contrary to the individual's philosophical orreligious ideas.' He prepared individual cylinders for each patient but "usedthe same recorded set of instructions for several patients who presentedsimilar problems" (p. 281). Liebeault ,1885 (cited in Barber, 1979)concluded that pain reduction with subjects who were in a hypnotic trancewas due to "mediating processes" which focused "attention on thoughts orideas other than those concerning pain" (p. 237). Similarly, Barber &Calverly, (cited in Barber, 1979) reported that 'waking control' subjects64and 'hypnotic trance' subjects who were asked to remember details of aninteresting story presented on a tape recording were both distracted andreported equal pain reduction after receiving a "pain-producingstimulation" (p. 237).Controversy exists over the need for one-on-one therapist/clientsituation for successful hypnotherapy. Erickson (cited in Beahrs, 1971)believed that it was important for the therapist to be flexible in hisapproach to the patient, "always adapting techniques to the presentingintellectual and emotional needs of the patient" (p. 90). Several researchersquestioned the role of the therapist in hypnotherapy. Levitan (1988) positedthe view that the hypnotherapist only "speaks words" to the patient and thatit is "the patient who causes trance to occur" (p. 71). Edelstein (1986)recommended that patients use a tape prepared by the therapist at home inorder to increase the effectiveness of suggestion by repetition.Hilgard (1967) found in laboratory studies that hypnoticsusceptibility under ordinary laboratory conditions is a fairly consistentcharacteristic of the individual, as shown by reinductions on otheroccasions with different hypnotists. He found that hypnotist skill isrelatively unimportant and success appears to be, "about as great withbeginners as with experienced hypnotists....Susceptible subjects respondvery well to inductions delivered by an unfamiliar voice onelectromagnetic tape, with what is said having nothing to do withcapitalizing on their responses" (p. 126). He cautioned that transferenceeffects may be more important in a clinical setting and noted that in thelaboratory there are certain "expectations" which do not exist in a clinicalsetting. However, he pointed out that there is little evidence to back this up65as there does not seem to be a uniform definition of what constituteshypnosis.Levitan (1988) reported that patients who had difficulty with self-hypnosis were helped by taping the session for use at home. He cited acontrolled study by Hammond, Bartsch, Grant, & McGhee (1988) in whicha group using self-hypnosis was compared to a group using tape-assistedhypnosis. The results "found that subjects who were newly trained in self-hypnosis consistently reported a higher quality experience when using tapescompared with doing self-hypnosis unaided" (p. 71).He stated:It is necessary at the beginning to dispel the misconception held bymany patients that a hypnotic state can only be achieved through thesuggestions of their therapist....It is useful for patients to understandthat all hypnosis is self hypnosis and that each of us does self-hypnosis frequently throughout the day....We have learned to turnoff awareness of a variety of sensations, such as the feel of theclothing on our bodies or the shoes on our feet....Once patientsappreciate that they are already accomplished in this kind ofinformal self-hypnosis, they are often more receptive to learning adifferent variety or applications. (p. 71)Audiotaped hypnosis was found to be a useful adjunct to self-hypnosis in an investigation by Hammond (1988) who studied therelationship between heterohypnosis and either self-directed self-hypnosisor tape-assisted hypnosis:Forty-eight inexperienced volunteers were hypnotized and taughtself-hypnosis by posthypnotic suggestion and immediate practice inthe office. They were randomly assigned to one of two experimentalorders to practice self-directed and tape-assisted self-hypnosis. Nodifferences were found between heterohypnosis or either type ofself-hypnosis in response to behavioral suggestions. Experiential66rating, however, consistently favored heterohypnosis over eithertype of self-hypnosis. Tape assisted self-hypnosis was consistentlyevaluated as superior to self-directed practice by newly trainedsubjects. (p. 128)Although the subjects rated heterohypnosis as superior to either typeof self-hypnosis, the researchers noted that when the subjects were usingtape-assisted practice they were "more focused and absorbed experience ofgreater depth and richness." The subjects also were more convinced that"they had been in an altered state of consciousness" and by using a tapethere was a more powerful effect than if they hadn't used a tape (p. 133).Paul and Trimble (1970) studied the effectiveness of recorded versus'live' relaxation training and hypnotic suggestion to stressful imagery withthree groups of female college students who received two sessions, oneweek apart. Their results showed that recorded relaxation was inferior to'live' procedure on all the physiological measures taken (heart rate,respiratory rate, tonic muscle tension, skin conductance) except for self-report.Clinical Studies Clinical studies on the effectiveness of audiotaped hypnosis as atreatment for pain are scarce. Hilgard (1986) cited a study by Bennett,Davis and Giannini (1985) in which 33 patients who underwent varioussurgical procedures under a general anaesthetic, wore earphones andlistened to either a prerecorded tape of music and "suggestions ofpostoperative healing" or a "tape of natural operative sounds ended with athree minute personal message not included in the control tape. Themessage was given about five minutes before the anesthesia was reversed."67It was suggested that the patient should "pull on his or her ear to assure theinterviewer that the message on the tape had been heard" (p. 202).The results showed that a "substantially higher proportion of thepatients who had received the personal message pulled their ears during theinterview than those in the control condition who did not have the message"(p. 203). Hilgard concluded that:The result bears more on dissociation than on the recovery ofmemories by hypnosis, for in fact none of the subjects recalledhaving received the ear pulling suggestion, either before or afterhypnosis in the interview session. The bearing on dissociation is thata comprehended verbal message may have behavioral consequenceseven though the memory is not available for verbal report. (p. 203)Budzynski (1977) discussed the need for developing "a physiologicalpattern that is incompatible with the 'flight or fight' or defense-alarmpattern" which causes muscle tension and anxiety and stress relatedproblems. Budzynski theorized that the use of "several kinds of feedbacksequentially and simultaneously....trained a generalized 'cultivated'relaxation in the individual. He advocated using "EMG feedback incombination with a cassette tape home practice course as an excellentstarting point for the training of cultivated relaxation" (p. 445).Experimental Studies on Hypnosis and PainMost of the studies on pain are experimental and some researchersquestion whether or not these studies are relevant to clinical pain problemsbecause of the difference between clinical and experimental pain. (Fordyce,1976, cited in Nigl, 1984b) lists the following differences betweenexperimental and clinical pain:68691. Experimental pain is produced by a known stimulus; clinicalpain often occurs in the absence of an identifiable stimulus.2. Experimental pain tolerance is time-limited; the subject knowsit will end within a particular time frame. Clinical pain patients donot know how long their pain will last; chronic pain patients oftenhave constant pain.3. Because experimental pain is short-lived, it is not under theinfluence of learning effects. Clinical pain, especially chronic pain,can be influenced by conditioning factors which can prolong painand reduce tolerance.4. Experimentally induced pain usually does not affect otheraspects of the subject's existence; however, clinical pain can reducethe quality of life for the patient who cannot work, interact withfriends, or engage in any meaningful activity. (p. 95)Hilgard (1986) stated that laboratory experiments have advantagesover clinical experiments because the setting in a laboratory is more easilycontrolled and motivation of pain patients in a clinical setting variesaccording to the degree of illness and the duration of the pain being treatedwhich makes "appropriate controls with well-matched untreated patients ordouble-blind procedures...difficult to arrange...and in some circumstancesunethical" (p.203). He noted that the "major disadvantage of laboratorystudies is that "the motivational condition of a suffering patient cannot beduplicated, and the typical doctor-patient relationship cannot be capitalizedupon....placebo effects appear to be more prevalent in real-life settings thanin the artificial laboratory" (p. 204).Hilgard (1969) reviewed the literature on experimental psychologyand hypnosis and stated that he included methods that were physiological,psychophysical and that sometimes involved "verbal interactions." Hereported that in clinical research, patients go to the investigator for help,but in experimental research the subjects are there by invitation. However,he noted that there was some overlap in that subjects could also be patients;for example, those suffering from painful bums. He referred to five topics"as illustrative of efforts to make objective various scientific approaches toproblems that have long been in the folklore of hypnosis" (p. 125). Thesefive are:1. The nature of susceptibility;2. The effects of induction upon suggestibility and depth oftrance;3. Amnesia;4. Analgesia;5.^Hallucinations;Hilgard concluded that the issue of susceptibility is still unresolvedbut noted that subjects who are resistant to hypnosis can be "improved" andthat susceptibility is a very important issue particularly in the area of pain(p. 125).Kebrdle & Roeder (1986) noted that susceptibility is an importantfeature of positive treatment outcome for some disorders and cited anumber of standardized measures for assessing Low, Medium and Highsusceptibility in individuals and groups (i.e. The Harvard Group Scale ofHypnotic Susceptibility, Form A (HGSHS:S); Forms A, B,and C of theStanford Scale of Hypnotic Susceptibility (SHSS:AB: SHSS:C), and theBarber Suggestibility Scale (BSS),(p.24). The authors noted that someresearch indicated that conditions which had "non-volitional nature" such asclinical pain, asthma, or warts, were "more related to susceptibility levels,"70than those of a "volitional nature" such as weight loss or cigarette smoking"(p. 25).Barber (cited by Hilgard, 1973) does not believe in the effectivenessof induction and has taken the position that "the behaviour in induction isitself a response to suggestions given in the normal state (eye closure,relaxation, appearing to be in a sleep-like condition), and that it does notnecessarily follow that this state is an essential preliminary to otherphenomena of hypnosis, such as amnesia, or responsiveness to posthypnoticcommands" (p. 128).Hilgard and Tart (cited in Hilgard, 1973) in a series of experiments,attempted to show that Barber's results were misleading. The experimentswere concerned with responsiveness to waking and imagination instruction,compared to responsiveness to the same items following hypnoticinduction. They concluded that the effects of induction were not as great asthey expected but noted that the hypnotizability of the subjects and the sizeof the sample were very important criteria for designing the experiment.Amnesia of events within the trance state is one of the marks of thehighly hypnotizable subject but Hilgard (Hilgard & Cooper, cited inHilgard, 1973) stated that this may be due to the "subject's expectations thatthis is what is called for, possibly by the manner in which the interrogationis done, possibly for the inference that hypnosis is like sleep, and you donot remember what happens when you are asleep" (p.129). Hilgard'sexperiments showed very little spontaneous amnesia but found that amnesiaexisted when it was suggested. Evans and Thorn (cited in Hilgard, 1973)defined two kinds of amnesia: content amnesia and source amnesia. Whensubjects remembered something learned under hypnosis, but forgot thatthey had learned it there, it was defined as source amnesia.71Analgesia in hypnosis has been disputed by experimenters (Sutcliffe,Barber, cited in Hilgard, 1967) who theorized that subjects are either"heroic" and do not admit that they have pain or that they can not bebelieved unless there is a physiological measurement of the pain.Laboratory pain can be produced in a variety of ways but twostressors are most commonly used: ischemic pain, in which pain is causedby cutting off the circulation of blood in an arm which is being exercisedand cold-pressor pain, in which a hand and forearm are placed incirculating ice water for a standard period of time not exceeding 60seconds (Hilgard, 1986). Hilgard (1973) reviewed the experiments withhypnosis and stated:When unselected subjects, with a minimum of prior exposure tohypnotic procedures, are studied under laboratory conditions, thesuggestion of hypnotic anesthesia or analgesia results in a markedreduction in felt pain, honestly reported, and the amount by whichquantitatively estimated pain is reduced is positively correlated withhypnotic susceptibility as measured on standardized scales. (p. 396)Hilgard (1986) cited studies by Stern, Brown, Ulett and Sletten(1977) which "compared various psychologic methods of pain reduction,such as hypnosis, acupuncture, biofeedback, and chemical agents such astranquilizers, aspirin, and morphine. Hypnosis provided the greatest painrelief for both cold-pressor and tourniquet pain, morphine was second, andacupuncture was third, whereas for these pains, aspirin, diazepam (Valium)and placebos proved ineffective" (p. 203).Hilgard (1973, 1986) found a curious paradox during laboratoryexperiments on cold-pressor pain.in which there is a discrepancy betweenphysiological indicators of stress and felt pain. He stated:72It has been shown that some part of the person's cognitive systemmay be registering and processing pain while that person is hypnoticallyanalgesic, so that the pain is not being cognitively processed at a consciouslevel. The concealed or covert cognitive apparatus has been described as a'hidden observer' that knows things that the overt cognitive apparatus inhypnotic analgesia is not aware of (p.211). Hilgard (1986) explained howthe hidden experience is explored:The hypnotized person, after the test of analgesia has beencompleted, can be told that the hypnotic consciousness may knowonly a limited part of the total information being processed, some ofwhich is processed subconsciously. This is plausible because thehypnotized part commonly fails to attend to voices other than thehypnotist's or comes out of hypnosis with amnesias for memoriesthat are obviously stored in some manner because they can berecovered when the amnesia is reversed. The covert cognitive systemof the subject is able to recall the highest pain report given in wakingand in hypnosis and can add a supplementary report on what the painwas like to the concealed part while the subject was analgesic.Commonly covert pain is reported as near to but below the normalwaking pain and above the hypnotically reported overt pain. Ifquestioned about the distress felt at the concealed level, the distress isoften reported as less than was felt at the same level of sensory painwhen not hypnotized or when not hypnotically analgesic. (p. 212)Another method for exploring the hidden observer is automaticwriting. The subject is asked to report verbally any pain felt by the hand inice water according to a numerical scale. The other hand is in a box whichhas numerical keys, "appropriate to reporting numerical pain magnitudeestimates. The subject will then be giving two reports simultaneously, oneovert by word of mouth, the other covert via key-pressing by a hand ofwhich she or he is not conscious" (p. 212). Hilgard (1973, 1986) cited cold-7 3pressor experiments with hypnotically suggested analgesia in which thesubject's results were averaged. The experimenters found that the covertreports of pain went higher than the overt (verbal) reports as the painincreased in the subjects. They also found that the covert report was lowerthan the normal pain report. Hilgard concluded that the hidden observerprovided "at least a partial resolution of the paradox of the persistence ofsome physiological signs of stress even when the subject feels no pain" (p.213).Clinical Studies on Hypnosis and PainAs compared with the sophisticated clinical outcome studies done inthe medical disciplines, there have been few and relatively unsophisticatedclinical research studies of the psychologic therapies in chronic pain(Stembach, 1984; Tan, 1982). In his review of 21 studies on hypnotherapyand behavior therapy, Spinhoven (1987) assessed 7 of the studies for therelationship between the level of hypnotizability and the outcome ofhypnotherapy studies. He reported that 3 of the 4 studies (Land, 1969;Schubot, 1967; Sullivan et al., 1974), in which a significant positivecorrelation was found, were related to the treatment of anxiety disorders.In 3 studies (Devine & Bornstein, 1980; Perry, Gelfand, & Marcovitch,1979; Wadden & Flaxman, 1981) on the treatment of obesity and smoking,no relationship was demonstrated. Only Deyoub and Wilkie (1980)reported a significant positive correlation between hypnotizability andweight reduction in hypnotherapy.Spinhoven (1987) posited that these findings further validate thehypothesis that in hypnotherapy, hypnotizability is especially relevant in the74treatment of psychosomatic and anxiety disorders as opposed to habitdisorders which have a more voluntary component.In none of the six behavior therapy studies in which the relationshipbetween hypnotizability and outcome was measured did significantcorrelations emerge. The fact that in behavior therapy irrespective of thenature of the disorder no relationship between hypnotic capacity andoutcome was found, sheds a critical light on the position of Murray &Litvak (cited in Spinhoven, 1987), who hold that imagination proceduresused in behavior therapy inadvertently induce a hypnotic state. In 5 of these6 studies, an imagination procedure was investigated and, in contrast to, thehypnotic condition, hypnotizability was not therapeutically relevant.Spinhoven (1987) concluded that:The finding that behavior therapy procedures with a high ingredientof relaxation and imagination do not tap the hypnotic capacities ofpatients possibly can be explained by the issue of control. Behaviortherapists typically emphasize a rational and explicit use ofscientifically based procedures. This emphasis on voluntary controlmay prevent the occurrence of more involuntary and dissociativeexperiences characteristic of hypnosis per se. (p. 22)Elton, Burrows & Stanley (cited in Hilgard, 1980) studied clinicalpain in patients complaining of migraine, tension headaches, lower backpain, generalized arthritis, and miscellaneous other symptoms. All had beenresistant to other forms of treatment. Five groups were compared: control(waiting list, untreated), placebo, social interaction only, hypnosis, andbiofeedback. All treatment methods were beneficial beyond no-treatmentand placebo. Biofeedback and hypnosis were both highly successful over 12months post-treatment. The effectiveness of hypnosis was dramatically75demonstrated in those of the placebo group who were later transferred tohypnosis (p. 264-265).In another study Elton et al. (cited in Hilgard, 1980) compared twochronic pain groups of 10 pain-prone patients and 10 organic-pain patientsat a 'Pain Clinic' with two normal pain-free groups of 10 pain-free studentsand 10 pain-free patients. "The treatment procedure involved hypnosis,biofeedback, placebo and interaction....Such psychological techniques wereassumed to alter the subject's self-concept" (p. 275). The authorsconcluded:The results of this study indicated a relationship between low self-esteem and 'persistent' pain. Patients in the pain-prone group showedsignificantly lower self-esteem ratings than the control groups. Therewas no significant difference in self-esteem between the two controlgroups, which suggests that this concept may not be strongly relatedto age, or socio-economic class. There was no significant differencein self-esteem between the organic pain patients and the two controlgroups. This indicates that, in the groups studied, self-esteem was notaffected significantly by chronic illness, of known pathology, whichresponded to treatment. (p. 276-277)The study of self-esteem of the 'pain prone' patients demonstratedthe importance of psychological approaches to chronic pain. In anotherstudy Elton et al. (cited in Hilgard, 1980) compared three groups ofchronic pain patients who were randomly selected for each group andcontracted to attend the groups once a week for 14 weeks. The groups weredivided into a psychotherapy group, a placebo group, and a hypnosisgroup. The authors found the following:The results showed that the placebo group did not improvesignificantly on any of the pain parameters....Both interaction andhypnosis groups reported significant inter-and intrapersonal gains,76and felt much better about themselves and their copingabilities....Most of the patients in the hypnosis group showedsignificant improvements....A 3-year follow-up showed that theresults appeared lasting for most of the patients. (p. 283)Elton et al. (cited in Hilgard, 1980) concluded that, "Hypnosis hasbeen shown to be more effective than behavioural psychotherapy....Its usecan be recommended as a method of choice in the treatment of chronicpain" (p. 283).In a clinical study of pain patients suffering from headaches,arthritis, dental, abdominal, and other pains, Elton et al. (Cited in Hilgard,1986) compared a control (nontreatment) group, a placebo, biofeedback,hypnosis, and social-interaction therapy, with the result that hypnosis andbiofeedback were similar in their rates of effectiveness. Hilgard concluded:The hypnosis method...appeared to be the method of choice, partlyon the basis of convenience, because less equipment was needed, andalso because less pain was reported between treatments than for thebiofeedback group. (p. 203)McCauley, Thelen, Frank, Willard & Callen (1983) compared self-hypnosis to relaxation in chronic low back patients attending an outpatientclinic. The results suggested that both treatments were effective in thereduction of pain and the authors concluded that, "Hypnosis and relaxationare both manifestations of the relaxation response," a theory posited byEdmondston and Benson (cited in McCauley et al., 1983, p. 551). However,they noted that more patients dropped out of the relaxation group, whichthey attributed to the fact that "relaxation training is more mechanical andhas less intrinsic appeal than self-hypnosis" (p.551). Benson, Pomeranz andKutz (1984) cited studies (Benson et al., 1974, Benson, 1975) which77supported the hypothesis that "a physiological response, termed therelaxation response, underlies an altered state of consciousness" (p. 817).Crasilneck (1979) used hypnotherapy as a treatment for 24 patientswith chronic low back pain. Twenty patients responded positively; fourpatients failed to respond to the hypnotic induction techniques and wereconsidered failures. Sixteen reported an average of 80% relief during thefirst four sessions, and all 20 patients reported an average of 70% relief(based on verbal estimates by patients) by the sixth session. Fifteenvoluntarily discontinued medication by the third week of therapy, and therest were withdrawn by their physicians during the ensuing four weeks.Most patients were seen daily the first week, three times the second week,twice the third week, and thereafter as necessary. The mean number of out-patient sessions was 31 over an average of nine months. All patients weretaught self-hypnosis. None of the individuals retained their addiction, andonly occasionally did they require analgesics. Patients were seen by theirreferring physicians as needed during the course of hypnotherapy, andfrequent consultations between the therapists created a combination oftreatments best suited for each patient. Crasilneck concluded that:Hypnotherapy appears to be the major factor in controlling mostproblems of back pain which has been resistant to recovery prior totreatment. It is my contention that every referring physician hadpreviously used all the psychotherapeutic wisdom at his disposal inthe treatment of each referred patient. The back pain finally cameunder control only after the use of hypnosis. (p. 71)78CHAPTER 3METHODOLOGYSingle-Case Experimental DesignCampbell and Stanley (1963) coined the term quasi-experimentto describe "experiments that have treatments, outcome measures,and experimental units, but do not use random assignment to createthe comparisons from which treatment-caused change is inferred" (p.6).Gottman (1976) in his book on time-series analysis, pointedout that:In planned experiments, randomization of the experimental design isintroduced to validate analysis conducted as if the observations wereindependent. However, a great deal of data in business, economics,engineering and the natural sciences occur in the form of time serieswhere observations are dependent and where the nature of thedependence is of interest in itself. The body of techniques availablefor the analysis of such series of dependent observations is calledtime series analysis. (p.IX)This design goes beyond observations within treatment to includeobservations from repeated measures in a period preceding and following agiven intervention (Hersen & Barlow, 1982). The authors theorized thatthis is basically an A-B design and that, "while there is a baseline," thisdesign is, "basically correlational in nature and is unable to isolate effectsof therapeutic mechanisms or establish cause-effect relationships" (p. 27).However, they noted, "with some major reservations, changes in thedependent variable are attributed to the effects of treatment" (p. 169).Borg (1963) in describing single-subject designs noted that, "Iftwo or more subjects are treated as one group, this also is considered79a single-subject experiment" (p. 706). The A-B design is the simplestof the single-subject designs and should only be used when nosuitable alternative is available or when the researcher intends it as apilot study to be followed by more rigorous designs. The A phase ofa study which is defined as the baseline involves the repeatedmeasurement of "the natural frequency of occurrence of the targetbehaviors under study" (Hersen & Barlow, 1976, p. 176). Thebaseline establishes a standard, "by which the subsequent efficacy ofan experimental intervention may be evaluated." Statistically, thebaseline period, "functions as a predictor for the level of the targetbehavior in the future" Riley & Wolf, (cited in Hersen & Barlow,1982, p. 169).The question of how long a baseline should be in order toestablish stability is one which Hersen & Barlow (1982) explored.They pointed out that researchers concur that "repeated measurementbe applied until a stable pattern emerges," but that practicallimitations make this difficult when the experimenter is working inan institution where, "the subject under study will have to bedischarged within a designated period of time, whether upon self-demand, familial pressure, or exhaustion of insurance companycompensation" (p. 74). Borg (1963) noted that, "As a general rule,there should be approximately the same length of time and numberof measurements in each phase of a single-subject design. Otherwisethe imbalance complicates the statistical analysis of interpretation oftreatment effects" (p. 711).Due to the practical limitations of the experimenter in aclinical setting, and in order to establish a stable baseline, it was80decided to use a modified A-B time series design in which the Aphase constitutes the responses of the Control Group and the Bphase.constitutes the responses of the Experimental Group.Electromyographic (EMG) readings were used as a continuingbaseline measurement for both phases, with the intervention of ahypnosis audiotape as the independent variable. The Control Groupof four chronic back patients was compared to the ExperimentalGroup of four chronic back patients. The mean ofelectromyographic (EMG) readings was calculated for the ControlGroup before treatment and after treatment for each day and thedifference of the means produced a mean calculation of EMGreadings for each day for 25 days. The same calculations were madefor the Experimental Group. As the electrodes were individuallyplaced on different parts of the body for each patient each day,(some parts, such as the shoulders have two readings) andtemperature readings were not included; by taking the mean for thefour patients each day, this averaged out body effect and allowed forthe confounding variable of EMG readings for different parts of thebody. This also took into account days when patients were away. Alower mean EMG reading for the Experimental Group than theControl Group over 25 sessions was an indication that the treatmentwas effective. This study is exploratory in nature and is meant to beused as a beginning for future research where there is theopportunity to develop experiments and theoretical assumptions in amore controlled setting.This research on audiotaped hypnosis in the treatment of chronicback pain focused exclusively on chronic back patients who had been81referred to a pain clinic for a six-week in-patient program. The purpose ofthis study was to investigate the effectiveness of audiotaped hypnosis as atherapeutic method in the reduction of chronic pain. The psychological andphysiological components of pain were also examined.As well, the study explored the theoretical view that a combinationof cognitive and behavioural therapies or multiple convergent therapieswere more effective than any one therapy in the treatment of chronic pain.Knowledge of the mind/body connection and the effectiveness of audiotapesas an adjunct to other therapies could facilitate one-on-one client-centeredtherapy or any therapy which involves cognitive processes either singly orin combination with behavioural therapies. Audiotapes could also provide asafe, economical method of enhancing and providing a faster resolution totraditional psychological therapies or hypnotherapy.In this chapter, a description of the sample selection, procedures,treatment and dependent measures are presented.Sample SelectionThe sample employed in the study was selected from a six-week in-patient program at a pain clinic. The subjects were patients who werereferred from the Workman's Compensation Board of British Columbiaand all were diagnosed as having chronic pain from work-related injuries.The clinic had a 40% success rate in returning patients to work but ifpatients were found not fit to work at their prior jobs, they were retrainedor received pensions if they could no longer work. The patients (AppendixA) in both groups fitted the profile of the chronic back patient as describedby Gentry, Shows, and Thomas (cited in LaFreniere, 1979). (Appendix B)82The Control Group was drawn from a prior group of chronic backpain patients who had previously attended a six-week in-patient program,and were matched as closely as possible to the Experimental Group. TheExperimental Group was selected at the convenience of the therapists at thepain clinic who agreed to allow the experimenter to conduct research at aspecified time.Description of the SampleControl Group Patients in the sample ranged in age from 40 to 48 years old. Themean age of the control group was 45.1 years. All suffered from chronicback pain. There were three males and one female in the group. The maleswere unemployed or in blue collar manual jobs; the female was employedin a blue collar manual job. The mean number of surgeries was 2.2; theleast number for one patient was two surgeries, the most for one patientwas three surgeries.Experimental Group Patients in the sample ranged in age from 30 to 50. The mean age ofthe treatment group was 39.5 years. All suffered from chronic back pain.There were three males and one female in the group. The female wasemployed in a white collar clerical-type job; the males were all employedas blue collar manual workers. The mean number of surgeries was 1.7; theleast number for one patient was one surgery; the most for one patient wastwo surgeries. Two male patients were not included in the sample; onebecause he was dropped from the program; the other because he was going8 3to have more surgery and was absent at various times during the treatmentperiod.ProcedureThree days before treatment began, the experimenter met with theExperimental Group to explain and discuss the procedure. Theexperimenter explained some of the myths about hypnosis; namely that itwas not a form of sleep; that the subjects would not lose control and couldnot be forced to reveal secrets or do things against their will. Hypnosis wasdefined as an altered state of consciousness which allowed the individual tofocus attention and was a state which often occurred to varying degrees ineveryday life. The experimenter gave as examples: thinking about an eventand missing a familiar exit from a highway while driving; and a personwho has a sore tooth, goes to a movie and forgets the tooth while watchingthe movie but is in pain as soon as the movie ends. The experimenterencouraged the subjects to ask questions about hypnosis. One subject wasconcerned about subliminal messages and was assured that there were none.The subjects were told that they would receive a copy of the hypnosisaudiotape at the end of the experiment.Each subject in the Experimental Group signed a written consentform (Appendix C) which explained that during their biofeedback sessionswhich recorded their electromyographic (EMG) readings, they would alsoreceive 25 treatments of listening to a 25 minute audiotape of hypnosisover a five week period. The subjects would also be required to fill out apain questionnaire (Appendix D) before and after treatments on eachMonday and Friday of the week and a questionnaire (Appendix E) on theeffectiveness of the audiotape, at the end of the treatment period. The84subjects were told that their involvement was voluntary and that theirconfidentiality would be respected. They were given the right to refuse toparticipate in the study without it affecting their treatment.The SettingResearchers have noted that "hypnotic response is facilitated bymaking the subject comfortable and eliminating all distracting influences; asoundproof room free from interruptions helps to promote relaxation"(Kroger, 1960, p. 667). The experiment was conducted in a sound-attenuated room which contained cubicles in which there were comfortablepadded reclining armchairs. Each chair was hooked up to a biofeedbackmachine (EMG Biofeedback System: Boulder Colorado) which recordedthe subject's individual EMG readings as measured in microvolts. Subjectslistened to audiotaped hypnosis from a speaker which was situated at theback of the room. During the session the lights were dimmed.TreatmentSubjects received both Electromyographic feedback (EMG) andaudiotaped hypnosis at the same time.Electromyographic Feedback (EMG) EMG biofeedback has been discussed in a previous chapter.Schuman, (1982) stated that EMG biofeedback relies on the followingpremises: 1. Painful muscles are characterized by elevated EMG; 2. EMGbiofeedback training enables a reduction in muscle tension; and 3. areduction in muscle tension produces a reduction in pain (p. 154). It is used"to help patients become more aware of excessive muscular activities inspecific muscle groups, to help them concentrate on relaxing these muscle85groups and to increase motivation to practice general relaxationprocedures" (Keefe, Block, Redford, Williams, Surwit, 1981, p.223). Withsufficient repetition the feedback sensitizes the individual to subtle, or atleast previously unrecognized, proprioceptive cues associated with muscletension, which may lead to a reduction of a pattern of chronic muscle pain(Grzesiak, 1984; Schuman, 1982). Once the person has learned how arelaxed muscle feels, they can practice relaxing the muscle voluntarily(Schuman, 1982). However, as previously pointed out biofeedback mayfacilitate relaxation and pain reduction either through diminishing affectivecomponents or through some central 'gating' process as theorized byMelzack & Wall (1965, 1984).Audiotaped Hypnosis Control Group Subjects listened to a 25 minute tape every week day for five weeks.The tapes were chosen at random from a selection of tapes which included:1. Healing Image:-direct suggestion, music in the background,imagery;2. subliminal messages, ocean sounds, bird sounds;3. subliminal messages, heartbeat, music;4. double induction using music, waves and heartbeat in thebackground;5. double induction using heartbeat and waves in the background;6. relaxation from head to toe;7. A Trip To The Beach; imagery, relaxation, waves, deepeningtechniques;8. hypnotic induction, mood music in the background.8 6Experimental Group Subjects listened to the same audiotape (Appendix F) during the weekdays for five weeks. Subjects received a five minute hypnotic inductionbeginning with progressive relaxation adapted from Crasilneck's (1988)deepening technique and indirection suggestions (Erickson, 1983d) tocombat resistance. This was followed by visual imagery of a pleasant scene(Margolis, 1983) which may facilitate the reduction of pain (Barber &Mayer, cited in Hilgard, 1986; and Pelletier, 1979); soothing sounds ofmusic to enhance relaxation and the use of guided imagery of a "healinglight" which penetrated to the center of the brain to facilitate the release ofhealing chemicals or endorphins (Bloom et al., cited in Benson et al., 1984)and absorb discomfort. Suggestions which evoked past memories of a timewhen the subject felt in control were used for ego-strengthening (Levitan,1988) and to promote self-esteem (Elton et al., 1980). Physiological andpsychological messages were linked to produce a mind/body connection(Rossi, 1986). This was followed by deepening techniques to allow thesuggestions to reach the unconscious (Erickson, 1983d). Before the trancewas terminated positive cognitive (Ellis, 1977) post hypnotic suggestionswere used to reinforce mental and physical health. Termination of thetrance followed by adapting Golan's (1988) technique for "re-alerting" sothat after the procedure each subject would feel "exhilarated" and full ofenergy (p. 53).Dependent Measures1. Electromyographic (EMG) Readings ,EMG readings are in microvolts.of electricity Loeb & Gans (1986)stated that "An EMG at best represents the major changes in currents and87voltages that occur whenever muscle fibers are being activated by theirmotor neurons " (p. 3). The authors found that EMG feedback "by itselfhas limited ability". (p. 4)For the treatment of pain, electrodes may be applied to any area ofmuscle spasm or to specific trigger points. In clinical practice certain areasare commonly targeted. "Frontalis, or forehead placement, which measuresmuscle activity not only in the forehead but over the entire head, includingeyes, jaw, face, and neck" has been used "despite the fact that correlationsbetween EMG and other muscles tend to be rather low. For generalizedrelaxation training, wrist-to-wrist and ankle-to-ankle placements are usefulfor measuring upper body and lower body tension respectively. Trapezius,neck, upper back, and masseter placements are also useful, since mostpeople have tension in one or more of these muscle groups" (Schuman,1982 p. 151).Subjects were connected to individual biofeedback machines byelectrodes.placed on different parts of their body; (deltoids, forearm,forehead, shoulders, temperomandibular joint, intrascapula, low back,posterior back, and quads). Each subject had an individual program whichwas designed by a trained physiotherapist.who placed electrodes on thesubject's body each day starting from the least painful areas to the mostpainful areas during the course of the treatment. Prior to the audiotapedhypnosis treatment the subjects had received several sessions in learninghow to operate the biofeedback machines. Normal EMG readings rangefrom 3 to 5 microvolts for frontalis (forehead) and low back. The EMGreadings ranged from 0 to 10 (microvolts x 100). Trained physiotherapiststook readings before treatment began and 15 minutes after the treatmenthad started.882. Verbal Self-ReportSelf-report scales which use either words or numbers presented on ascale of increasing value are commonly used among pain specialists toprovide a quick and understandable measure of pain intensity (Melzack &Torgerson, 1971).Hersen's study (cited in Hersen & Barlow, 1982) on the self-assessment of fear argued that, "Verbalizations of discomfort fromdistressed patients cannot be discounted either for clinical, ethical, or moralreasons". The authors cautioned researchers to consider the following"biasing factors" in experimental single case investigation: "self-monitoringeffects, demand characteristics, impression management, faking, and othermore subtle forms of response bias" (p.132).Subjects in the Experimental Group were asked to fill out a painquestionnaire based on Melzack & Torgerson's (1971) five point PresentPain Intensity (PPI) scale ( Appendix D) which rated pain from the leastpainful (1) mild; to the most painful, (5) excruciating. The subjects wereasked to fill out the pain intensity scale on Mondays and Fridays only sothat they would not get sensitized to the scale. The total number ofmeasurements taken for each patient was ten.At the end of the treatment period of five weeks, the subjects wereasked to fill out a simple questionnaire created by the experimenter(Appendix E) which consisted of one question which scaled how helpful theaudiotape was in reducing pain from a score of least helpful=0, to mosthelpful=10; seven questions on the content of the tape; one question on theeffect between sessions and one question on the words used in the PainIntensity Scale. A final space was left for additional comments.89Statistical Analysis of the DataBox Jenkins Analysis In this study a deviation from common practice in analyzing time-series data was used. In particular the method described by Cook &Campbell (1979 ) called The Statistical Analysis of Simple InterruptedTime-Series was applied. This is a particularly powerful technique oftencalled the Box Jenkins Time-Series Analysis. It is used for modeling theintervention as well as testing for statistical significance for the treatmenteffect. The computer program BMD P:2T was used for this analysis. Themodel showed that there was an abrupt drop after the intervention and itremained at the same level throughout the experimental phase.Binomial TestThe Binomial Test is used to "describe the process of change in anindividual's behavior rather than as a tool to assess statistical significance....If the null hypothesis upon which the test is made is that there is nochange in performance across A and B phases....then the celeration line ofthe baseline phase should be a valid estimate of the celeration line of theintervention phase. Assuming the intervention had no effect, the splitmiddle slope of baseline should be the split middle slope of the interventionphase, as well. Thus, 50 percent of the data in the intervention or B phaseshould fall on or above and 50 percent of the data should fall on or belowthe slope of baseline when that slope is projected into the interventionphase. To complete the statistical test, the slope of the baseline is extendedthrough the B phase" (Hersen & Barlow, 1982, p. 307).90Another simple comparison of the percentage of times the EMGreadings were lowered was calculated to find out if the groups differed inthe number of positive or lower EMG readings.91CHAPTER 4RESULTSStatistical Analysis of the DataHypothesis 1 Box Jenkins Time-Series Analysis (Figure 1)The first hypothesis stated that listening to audiotaped hypnosis willhave no statistically significant effect on chronic pain as measured byelectromyographic ( EMG) readings over time in the Control Group andExperimental Group.The Null Hypothesis upon which the test is made is that there is nochange in performance across A (Control Group) and B (ExperimentalGroup) phases. As there was a statistically significant difference in theExperimental Group in a positive direction, the Null Hypothesis wasrejected.Binomial Test (Figure 2)The probability of x points lying above the baseline by sheer chance,in the case of a significant intervention should be small-- it is, in fact; (withp=0.5 for each data point). In the Control Group the probability is p=.06that 16 points would fall by chance above the line. In the ExperimentalGroup the probability is p=.000009 that 23 points would fall by chanceabove the line. Results showed that there was a change of 2.06 gv(microvolts) in average EMG readings in the direction of improvement inthe B phase. (Appendix G)A comparison of the Control Group and the Experimental Groupshowed that the probability of 23 cases lying above the baseline by chance92Ar^626384^ FIGURE 1.05806766697071729a a_PRINT^VAR IS PAINVARIABLE IS PAIN.920000 -1.50000 . 2.32000^-.740000^-1.10000^2.13000^1.23000^-2.58000 -2.13000^1.43000-1.50000 -.530000^1.19000 -.770000^.500000 -1.38000^-5.50000 •2.50000^.190000 -.2500006.33000 -1.67000^Ammo -2.05000 -8.13000 -2.00000^•5.57000 -3.33000 -3.19000 -2.17000-1.83000 -.360000 -2.50000^-3.50000 -.950000 -2.90000 -2.53000^-5.00000 -.830000 -.580000-.500000^-1.33000'PAGE^3^8M0P2T PAIN STUDYTPLOT^VAR IS PAIN./acDPAIN-6.12^-6.87^-5.82^-4.37^-3.12^-1.87^-.625^.626^1.87-7.50^-6.25^-5.00^-3.76^-2.50^-1.25^0.00^1.25^2.508.253.12^4.37^5.823.75^5.00-.250000 - 1.60000-1.10000 - .060000-.920000 -2.12000-.130000 1.590007374757877787960816283848566878869C.1)C/3^121^I -^---)--1^120 I90^I91 I92 I93^I94 5 •95 I98^I97 I98 I99^10 •100 I101 I102^I103 I104 16105^I108 I107•Ilos^IP4.0!^109 20 •5q .^III1101I1.-1^112^I'.2.2.4^113 ICO^114^26 •--•A^• 116^IZ^Ile It-4>^117 I1-4^118^I^A- -.....^119 30 •142^ 1122 I123 I124^35 •125 I128 I127^I128 I129^40 •130 I131 I132^I133 I^ /......^134^46 •135 I138 I137^I138 I139^50 •140 (PAGE 4 6►OP2T PAIN STUDY141148^ -ID147 ^7- q‘ ACE,..., -.148^ACF^VAR IS PAIN./^ ,^T C. CD149-: ^rt. CZ,1 k1511 1 :-0 1^-^.FIRST CASE NUMBER TO BE USED^■^ 1^*-1- C.,152^LAST CASE NUMBER TO SE USED ■ 25 1 i " }..153 NO. OF DES. AFTER DIFFERIENCINO ■ 25 tilt155^STANDARD ERROR OF THE MEAN^■^-0.2900154 MEAN OF TOE (DIFFERENCED) SERIES ■158 7-VALUE OF MEAN (AGAINST ZERO)^■0.4371157-0.6635158169180161182183154165toe167188169170171143 BLOCK^RANGE IS 1.25./4 ^(' t145 (PAGE^5 RIADP2T PAIN STUOY^ 3 a^3 7:7.'AUTOCORRELATIONSq^c.1.^12^.10^-.22^.05^.11^-.16^-.31^.03^.02^-.09^.14^.13^-.11ST.E. .20^.20^.21^.21^.21^.22^.24^.24^.24^.24^.24^.2413.^23^-.26^.06^.12^21^-.16^.06^.11^-.06^-.01^.14^-.07 •11,ST.E. .25^.28^.25^.26^.27^.27^.27^.27^.27^.27^.26PLOT OF AUTOCORRELATIONS-1.0^-0.8^-0.6^-0.4^-0.2^0.0^0.2^0.4^0.6^0.8^1.0LAO^CORR.^•^**^•^• •^.....................II^IitlittnutAControl Group Experimental GroupB10-ve Difference of E.M.G. Readings indicates improvement+vs Difference of E.M.G. Readings indicates no improvement86-2-4-6-84MeanE.M.G. 2R eadings0- 1 01^3^5^7^9 11 13 15 17 19 21 23 25 1^3^5^7^9 11 13 15 17 19 21 23 25Time (day of treatment)^ BINOMIAL TESTMean E.M.G. differences for Control Group and Experimental Group.alone was very small. From this we inferred a significant interaction effectand these results led to a rejection of the hypothesis as stated in the Nullform.To corroborate these results a comparison of the percentage oftreatments which were an improvement was tabulated for the ControlGroup and the Treatment Group. For the Control Group, 51 % showedimproved (lowered) electromyographic (EMG) readings. For theExperimental Group, 67% showed improved (lowered) EMG readings. Asthe Control Group results were statistically shown to be sheer chance, 51%improvement for the Control Group would confirm these results.Hypothesis 2The second hypothesis stated that there will be no reduction inperceived pain after daily treatment in the Experimental Group asmeasured by subjective self-reports of pain using words and numbers on acontinuum of increasing value.A modified version of Melzack & Torgerson's (1971) Present PainIntensity Scale (Appendix D) which describes pain intensity through wordsand a numerical scale.of increasing value was used as a subjectivemeasurement of pain intensity. The reports were taken before and aftertreatment and the results and the numerical change in pain intensity weretabulated (Table 1) for ten sessions for each individual of the ExperimentalGroup. The results of the 40 reports taken found that 12 reports werepositive; 10 were negative and 18 showed no change. Therefore out of 40reports, 28 reported no change or negative change in pain and 12 reporteda reduction in pain, thus, the Null Hypothesis must be accepted.93Table 1Summary of Change Scores in Present Pain Perception ScaleChange ASubjectsC DG+3+2 2 1+1 1 1 3 40 6 4 4 4-1 4 3 1-2 1-3 1Total 10 10 10 10Number of Reports = 40Note+= positive change; decrease in pain = 12-= negative change; increase in pain = 100= no change in pain = 18Hypothesis 3 The third hypothesis stated that audiotaped hypnosis will have noeffect on perceived pain on the Experimental Group after twenty-fivetreatments over five weeks as measured by subjective self-report.A questionnaire (Appendix E) of nine questions was devised to assessthe subjective reports of the subjects after the five week period. Onequestion rated the effectiveness on pain reduction using a rating scale of 094to 10; 0=least helpful; 10= most helpful. The other eight questions focusedon the most and least helpful aspects of the tape; how the subjects wouldimprove the tape; the words used on the Present Pain Intensity Scale; theability of the subjects to go deeper into hypnosis, and whether or not thesubjects would use tapes in the future for the control of pain. Evidence wasobtained for a positive perception of the effectiveness of audiotapedhypnosis (Table 2) but the question pertaining to pain perception wasnegative, thus, the third hypothesis was accepted as stated in the Null form.95Table 2Summary of Scores from Tape Effectiveness OuestionnaireExperimental GroupPositive Negative NQN/AComments Comments Comment1) 1 32) 43) 44) 1 35) 1 36) 3 17) 48) 2 29) 1 2 1Total 16 10 2 8Note. Nine Questions-Four Subjects=36 answersNote. N/A refers to answers which had to do with the quality of the taperecording (i.e., volume, tape static) or the quality of the furniture(chairs), and not the effectiveness of the tape.96Results: 16 comments were positive; 12 were negative or no comment.Hypothesis 4The fourth hypothesis stated that a combination ofelectromyographic (EMG) biofeedback in combination with tapedhypnotherapy will not be effective in the reduction of chronic pain.If the objective physiological EMG readings are used as a measure,then the Null Hypothesis is rejected. However, if the subjective self-reportstatements are used as a measure then the Null Hypothesis must be acceptedfor the self-report of Present Pain Intensity.97CHAPTER 5DISCUSSIONINTRODUCTIONThe general purpose of this case study was to provide evidence forthe efficacy of audiotaped hypnosis as a therapeutic intervention forchronic back pain. Hypotheses, written in the Null form, made statementsof no change in the reduction of chronic back pain. Continuous monitoringof electromyographic (EMG) readings over time, before and duringtreatment as well as self-report assessment before and after daily treatmentand at the end of the final time period, provided the criteria for change.Both statistical and verbal report analyses were used to assess impact; onehypothesis was rejected; two were accepted, and one was equivocal in itsfindings.THE MAIN HYPOTHESISThe rationale for Hypothesis One stems from theories of pain asposited by Sternbach (1968) as having both sensory and affectivecomponents (Barber, 1959; Erickson, 1967; Melzack & Wall, 1982;Pinsky, cited in Nigl, 1984; Hilgard & Hilgard, 1975) the dynamics of painas proposed by the 'gate control' theory of Melzack & Wall (1982) andhypnosis as a treatment for pain as posited by Crasilneck (1979) whoagreed with the gate theory. Hilgard's (1973) neodissociation theory ofhypnosis illuminated the processes of the conscious and unconscious in theperception of pain.and provided an insight into the difference between theconscious and the unconscious in acute and chronic pain. Wyke's (1986)neurological theory of hypnosis as a form of 'habituation' (a process of98repetition over time) and Erickson's theories (1983a, 1983b, 1989) of painas habit forming provided a plausible explanation for the use of audiotapedhypnosis over time as a treatment for chronic back pain. Barber (1970,1971a, 1971b, 1976, 1982, 1984) and Hilgard (1867, 1969, 1973, 1980,1986) and Hilgard & Hilgard, (1986) provided a background of theoreticaland experimental knowledge of acute pain and chronic pain; itsphysiological as well as psychological components and of hypnosis andhypnosis as a treatment for pain which explored the difference betweenacute and chronic pain and experimental versus clinical studies.Audiotaped hypnosis appears to be effective in reducing chronic backpain over a five week period of time. Success of treatment can be evaluatedby the statistically significant lowered mean score of electromyographic(EMG) readings over time.in the Experimental Group (B phase) ascompared to the Control Group (A phase).Hersen & Barlow (1982) cited studies which indicated that autonomicvariables (in the area of biofeedback), "are subject to modification viainstructional feedback, and reinforcement procedures." However, theynoted that "considerable training is required before changes approachclinical significance" and that "the results of training...are ratherephemeral, as indicated by long-term follow-ups." They concluded that,"physiological responses seem to be less subject to conscious distortion onthe part of the patient or client when used as dependent variables inexperimental single case research. Only a highly sophisticated and equallyhighly trained subject (in terms of biofeedback for the particular responsemodality under consideration) would have the capacity to willfully controlhis physiological responses" (p. 138).99Hersen & Barlow (1976) cautioned that with "physiologicalmeasurement" and "repeated presentation of stimuli" there is "decreasingresponsivity" (p. 139). This theory is consistent with Wyke's (1986) theoryof neurological habituation and corroborates Melzack & Wall's (1965) gatetheory of pain and Crasilneck's (1979) theory that the hypnotized patientblocks the perception of pain in the cortex.Box Jenkins Time-Series Analysis (Figure 1.)The data which has been analyzed fits the model of the Box JenkinsInterrupted Times-Series Analysis (Cook & Campbell, 1979) which is asophisticated statistical technique which takes all the information intoaccount. For the Experimental Group it not only modeled an abrupt changeafter the intervention but showed a statistically significant change of 2.06microvolts in lowered electromyographic (EMG) readings, which indicateda significant reduction in muscle tension which remained steady for the restof the treatment period.The time-series was stationary for the Control Group and followedstochastic (probabilistic) processes. This is a typical pattern in the ControlGroup and the chart shows that all the data lie within the 95% confidenceinterval. If one looks at the chart, it shows that by daily use of theaudiotape the pattern of change which is measured by loweredelectromyographic (EMG) readings remains at a lowered level for theExperimental Group. If the data lie outside the confidence interval, thenthe data is said to be deterministic. This tells us that on the average,everything is correlated with everything else so that the occasional spikes in100the chart could be attributed to chance deviation and should not beinterpreted as deterministic.In so far as could be ascertained, the Experimental Group and theControl Group were very much alike. Nonetheless, there may have beensome bias which was overlooked. Therefore, the reader is cautioned toaccept the results accordingly.The Binomial Test (Appendix G) (Hersen & Barlow, 1982), whichCook & Campbell (1979) refer to as "eyeball tests" (p.233) was used as asimple corroboration of the statistical results. As well, a simple comparisonof positive change in EMG readings in the Control and ExperimentalGroups showed that the Control Group had a 51% improvement and theExperimental Group had a 67% improvement. This provided a furthercorroboration. It was clear from these results that the intervention waseffective.Hypothesis 2There will be no reduction in perceived pain after daily treatment inthe Experimental Group as measured by subjective self-reports of painusing words and numbers on a continuum of increasing value. The NullHypothesis was accepted as there were fewer reports of pain reduction thanreports of no change or an increase in pain.The results of the self-report in this study are contrary to otherclinical studies (Crasilneck, 1985b; Elton, Burrows & Stanley, cited inHilgard, 1980) on hypnosis and experimental studies (Hilgard, 1973) inwhich subjective self-reports by subjects under hypnosis reported less pain.There are several theories which may provide plausible explanationsfor this conclusion. Experimental studies (Hilgard, 1986) of acute pain and101hypnosis found that through the" hidden observer" and the process of"automatic writing," subjects reported that at an unconscious level, thesubjects felt pain but at a conscious level the pain is not processed. Thephysiological mechanism (Hilgard & Hilgard, 1975) of acute pain ("fightor flight") is different from the mechanism of chronic pain ("habituationpattern"). It could be postulated that the chronic pain patient has over timeaccumulated pain memories so that under hypnosis the processes arereversed and at the conscious level the individual perceives pain but underhypnosis, at an unconscious level this perception is blocked or inhibited andpain is not felt.Another explanation may lie in the subjects pain perception at aconscious level. Herson & Barlow (1982) stated that "Of the three responsesystems (motoric, self-report, physiological) that can be monitored insingle case strategies, the self-report system is the one that is most subjectto conscious distortion on the part of the patient or client (p. 131). Thebiasing factors include: self-monitoring effects, demand characteristics,impression management, faking, and other more subtle forms of responsebias" (p. 132). The authors discussed the relationship among motoric, self-report, and physiological measures and stated that, "In addition to motoricand physiological target measure, the clinical researcher is most concernedwith his patient's perception (italics added) of improvement....in short,there would be no reason to assume a high degree of correlation among thethree response systems" (p.144). Lang (1968) corroborated the use ofphysiological and psychological measurements by suggesting that "specifictechniques" should be applied to the "different behavioral systems that weare trying to change-verbal, overt-motor, and somatic, and that therapyshould be a self-conscious, multidimensional process" (p. 92).1 02Another explanation for this discrepancy of the conscious responsesversus the unconscious responses under hypnosis may lie with the profile ofthe chronic pain patient (Chapman et al., 1981) which corroborates thetheory that patients who stand to gain something from their pain(secondary gain) will not acknowledge a reduction in pain or wish to giveup their perception of pain.Hilgard (1969) cited studies by Lewin, which found that, "Theamount of pain felt in laboratory experiments has been shown to be relatedto how much pay is offered the subjects: the higher the reward the greaterthe pain, even though the amount of reward is determined by lot" (p. 139).Barber (1970) cautioned that accepting the hypnotic patient's verbal reportin experimentally induced pain may not be valid indices of suffering aspatients in a hypnotic situation may be motivated to "inhibit overt signs ofpain and to deny pain experience" (p. 214).Hersen & Barlow (1982) cited studies by Braginsky & Braginsky;Braginsky, Grosse, & Ring, in which both acute and chronic psychiatricpatients presented themselves "as either 'healthy' or 'sick' in structuredinterviews and on standardized self-report inventories" (p. 136). Theauthors also reported that with respect to "demand characteristics," self-report is the "most vulnerable to bias" and that "biases in verbal reporting"include "lying and faking" (p. 136). Barber (1982) stressed that "secondarygain, reinforcement of disability, family dynamics, self-esteem and usingpain as a focus to deflect attention away from other important problems"(p. 49) were issues which had to be considered.1 03Hypothesis 3 Audiotaped hypnosis will have no effect after twenty-five treatmentsover five weeks on perceived pain as measured by subjective self-report.The Null Hypothesis was accepted as there were 16 positive responses and12 negative responses out of 28 possible responses which related to theeffectiveness of the audiotape. However on question #1 which was the onlyquestion which rated pain reduction on a scale of 0=least helpful to10=most helpful, there was only one response which was above a 4, andthis response was from the subject who was most cooperative towards theresearcher. Hersen & Barlow (1982) cited studies (Ome, 1962, 1969,1970; Ome & Evans, 1965; Ome & Holland, 1968) in which "It has beenshown that experimental subjects frequently respond in accordance with theexperimenter's hypotheses and expectations as soon as they become awareof their existence" (p. 134). The subjects in this study may have beeninfluenced by wanting to please the experimenter with positive self-reportson the efficacy of the effectiveness of the tape while at the same timeexcluding any positive ratings or descriptions of a reduction in pain forfear of losing any of the benefits from secondary gain as well as therealistic gains of a pension if they were not fit to work. Chapman, Brena &Bradford (1981) studied pain patients in a chronic pain rehabilitationprogram and stated:In addition the adversarial nature of legal systems oftenputs the patient in the position of maximizing pain anddisability in order to receive a more substantialsettlement, while the insurance company may look forevidence to minimize the patient's claims and attributethem to a desire for secondary financial gains. (p. 105)1 04However, the possibility exists that the patients really did find thetapes to be helpful but did not experience a reduction in pain.Hypothesis 4A combination of electromyographic (EMG) biofeedback incombination with audiotaped hypnosis will not be effective in the reductionof chronic pain. The Null Hypothesis was rejected by the measurement ofEMG readings and accepted by self-report measurements. However, asphysiological responses are less likely to be affected by demandcharacteristics (Barlow, Agras, Leitenberg, Callahan and Moore, cited inHersen & Barlow, 1982, p. 135) and physiological responses are lesssubject to distortion, (Hersen & Barlow, 1982) than self-report, there ismore statistically significant evidence for a rejection of the Null Hypothesiswhich is corroborated by theories which propose that the combination oftwo or more therapies (Melzack & Perry, cited in Weisenberg, 1984:Pinsky & Malyon, cited in Spino, 1984) or multiple convergent therapy,(Melzack & Wall, 1965) is more effective than any given therapy.Threats to Causal Inference Random assignment is the main criteria for causal inference (Cooke& Campbell, 1979) but the authors noted that this is difficult to implementin a "field" or clinical setting. (p. 4) Kebrdle & Roeder (1986) agreed thatrandom assignment "allows for greater generalization and extrapolation ofthe findings but pointed out that "several factors mitigate against its use inthe research of hypnosis" (p. 22). The authors cited studies by Hilgard &Tart (1966) which reported that "only 30 percent of the population ishighly susceptible to hypnosis and 42 to 45 percent are minimally105susceptible" (p. 22). Hilgard argued that because many subjects are notsusceptible to hypnosis, any positive effects by those subjects who aresusceptible to hypnosis would be obscured. Kebrdle & Roeder (1986)suggested using subjects of varying levels of susceptibility "in sufficientnumbers to allow for comparisons of meaningful susceptibility categories"(p. 23). Hilgard (1980) theorized that if careful measurements were used,there was less need for large numbers because they "may conceal as muchas they reveal" (p. 249). He argued that statistical significance alone wasnot a guarantee of practical significance. As this case study involved a smallgroup of subjects, hypnotic susceptibility was not measured and randomassignment was not possible but by taking the mean EMG readings for thefour patients each day, this averaged out the effect of the treatment andallowed for the confounding variable of susceptibility.Threats to Valid Inference In both the Control Group and the Experimental Group thedependent variable was the same. In order to rule out threats to validinference (Cooke & Campbell, 1979) one has to look at the "three senses ofcontrol" (p. 6). These include: the research environment; control over theindependent variable; awareness of single threats. The authors noted that"The amount of control is at issue and not whether there is control or not"as "no environment offers total control" (p. 5). The research environmentwas in a controlled setting for both groups. The independent variablediffered in content for each group but the equipment (an audiotape) was thesame. As well, the individuals who recorded the electromyographicmeasurements were trained physiotherapists who had no "experimenterexpectancies" for the results of the measurements (Cook & Campbell,1061979, p. 67). In a clinical setting the experimenter has less control overextraneous outside variables and as Cook & Campbell (1979) pointed outcausal inference is therefore more problematic to infer than in a laboratoryexperiment and that "experiments probe but do not prove causalhypotheses" (p. 18).Internal ValidityThe internal validity of an experiment implies "that the relationshipbetween two variables is causal or that the absence of a relationship impliesthe absence of cause" Campbell & Stanley (cited in Cook & Campbell,1979, p. 37). The independent variable (audiotaped hypnosis) was presentin both the control and experimental groups but in the Control Group theaudiotapes were not all the same. Some were relaxation, some mood music,some hypnosis and they were chosen at random, whereas in theExperimental Group the audiotape was the same over the period oftreatment. The treatment for the Experimental Group was repetitive overtime.When physiological measurements are monitored in single caseresearch there are certain difficulties which may cause problems. Theseinclude: "Mechanical problems, adaptation phases, stimuli, experimenterand contextual variables, and the question of stimulus-response specificityin the absence of confirmatory verbal reports. (Hersen & Barlow, 1982,p.139). The researcher found that mechanical problems were a veryimportant variable because the tape recorder did not function well on thefirst day and had to be replaced. However, measurements were stillrecorded and averaged for the day. Checking out equipment beforehand issuggested for future studies.1 07Hersen & Barlow (1982) suggested allowing "sufficient time foradaptation during each trial" (p. 140). EMG readings were taken 15minutes after each session started which allowed for adaptation time tooccur. Galvanic skin response (GSR) has been shown "to diminish in sizewith repetition of the stimulus" by some researchers (Solyom & Beck, citedin Hersen & Barlow, 1982, p.141) and to be "quite reliable by others"(Barlow, Leitenberg, & Agras, 1969, cited in Hersen & Barlow, p.141).The authors noted that "all physiological response systems do not showequal decrements in the face of repeated presentations" (p.141).External Validity These results rely on the assumption that the Control Group and theExperimental Group have equivalent characteristics but as randomselection was not possible external validity is somewhat weak. The criteriafor selection was that all the subjects were in the in-patient program at thepain clinic and all were being treated for chronic back pain. In order tostrengthen external validity to allow for generalizing the findings tosubjects, settings and occasions, future research would need to replicate thisexperiment in a different setting, at a different time of day and on differentoccasions in order to substantiate that the intervention effect which wasobserved was in fact steady and didn't vary with these other factors. Ifthere was a difference in any of the factors, then the experimenter wouldhave another variable to worry about. However, as this is an exploratorystudy, at this moment in time, one can generalize to these subjects, thisparticular setting and this particular occasion.1 08CONCLUSIONSIf acute pain is a warning (Hilgard & Hilgard, 1975) then themessage to the brain is a fight or flight signal and is short in duration.Melzack & Wall's (1982) gate theory of pain postulated that when painoccurs it sends information to higher centers in the brain stem andultimately to the cerebral cortex. As well, "The higher cerebral and brainstem centers can influence the volume (italics added) of pain informationallowed to reach conscious levels by opening or closing the gate at thespinal cord level." As there is an affective component to pain (Barber,1959; Hilgard & Hilgard, 1975; Melzack & Wall, 1982a, 1982b; Sternbach,1968) and a mind/body connection (Rossi, 1986) then perception of pain isa key issue in the treatment of chronic pain. If pain is perceived as positiveas in the example of World War II soldiers who when wounded requiredlittle or no pain medication because they were relieved to be taken out ofbattle, then the "higher cerebral centers clearly not only influenced butturned off the volleys of pain information reaching their spinal cords"(Paul, 1937,. p37). Melzack & Wall (1988) posited the belief that thepredominant effect of hypnosis may be in activating control processeswhich modulate input as it is transmitted to the brain. Experimental studies(i.e. studies on the "hidden observer" and "automatic writing," Hilgard,1975, 1986) on hypnosis and acute pain, have shown that under hypnosisthis 'gating' process occurs so that at a conscious level there is noperception of pain even though pain is felt at an unconscious level. Thismay be the reverse for chronic pain. As well, through hypnosis, powerfulnatural inhibiting chemicals called endorphins may be released from thebrain (LeRoy, 1976).109Chronic pain builds over time (Fordyce, 1986; Melzack, 1983, 1989;Melzack & Loeser, 1978; 1965; Sternbach, 1984) and a pattern of pain islearned (Erickson, cited in Lankton, 1989; Fordyce, 1986). Messages to thebrain are patterned so that a stimulus not associated with pain (anxiety,cognitive self-defeating messages) cause muscle tension which in turn maylead to pain, thus building a pain-cycle.and a chronic pain personality(Chapman, 1986, 1988; Mutter 1986; Pinsky, cited in Nigl, 1984) or "sickrole" personality (Pilowsky, cited in Sternbach, 1984) which is similar toGlasser's (1965) "failure identity" in which the individual has no controlover their life and becomes a "negatively addicted person" who escapesemotional pain by giving up and developing psychosomatic diseases. Studies(Elton, Burrows & Stanley, cited in Hilgard,1980) have shown that there isa relationship between low self-esteem and persistent pain.If chronic pain takes time to establish a pattern in the brain and ifhypnosis depends on repetition of a monotonous stimuli (Wyke, 1986)which reduces the perception of acute pain, then it could be postulated thathypnosis for chronic pain would require repetition over an extended periodof time. This could be accomplished by the repeated use of audiotapedhypnosis.Hypnosis has been shown to be a powerful tool for the therapist,alone (Erickson, 1983) or in combination with other therapies (Ellis, 1986;Erickson, 1986; Golden, 1986; Melzack & Wall, 1982). Individualsfunction at all times with many levels of consciousness; some voluntary,some involuntary (Fromm, 1979; Hilgard, 1973). Audiotaped hypnosisover time which includes deepening techniques, indirect suggestions to theunconscious (Erickson, 1983d), relaxation which produces a physiologicalpattern to combat the 'fight or flight' defense pattern of pain messages,110(Budzynski, 1977) visual imagery which may reduce pain, (Barber, 1982;Erickson, 1989) guided imagery to facilitate the release of inhibitingendorphins from the brain, (Blum et al., cited in Benson et al., 1984; Nigl,1984) and ego-strengthening suggestions (Levitan, 1988) which promote asense of control and self-esteem (Ellis, 1977; Elton et al., 1980) may beeffective in producing cumulative positive processes which will break the`pain cycle,' (Grzesiak, 1984; Keefe et al.; Schuman, 1982) change painmemories (Melzack & Loeser, 1978) and prevent the chronic painpersonality, (Chapman et al., 1981) from developing further.This study has shown that audiotaped hypnosis in combination withbiofeedback may prove to be a more effective treatment for chronic painwhen the same audiotape is used over time. Both physiological andpsychological evidence of the effectiveness of audiotaped hypnosis wasreported. However, the reader should be cautioned that while thephysiological data is statistically significant, because the electromyographicreadings were taken from different sites of the body and the differences inEMG readings were averaged each day, the clinical significance of theanalysis of the data should be viewed not as a numerical value of changebut as a tendency to deviate in a positive direction of change.The use of hypnosis audiotapes provides a safe, economical, methodof treating patients with chronic pain in either a pain clinic in combinationwith behavioral and other treatment methods or as an adjunct to individualtherapy. As well, audiotaped hypnosis may prove to be a valuable adjunctto the therapist who wishes to speed up therapy with patients or clients whohave differing personality disorders but are unable to pay for lengthyperiods of individual therapy.111Implications for Future ResearchBiofeedback has been reported as a successful treatment of chronicback pain (Nouwen & Solinger, 1979; Schuman, 1982). Hypnosis has beenreported to be successful in inducing an altered state of consciousness(Erickson, 1983d, Hammond, 1988; Hilgard, 1975) and has been successfulin reducing chronic back pain (Crasilneck, 1979; Elton, Burrows &Stanley,1980; Elton et al., cited in Hilgard, 1980). Audiotaped hypnosis hasbeen shown to be effective in educating clients with self-hypnosis (Levitan,1988) and in cultivating relaxation (Budzynski, 1977) which promotes areduction in anxiety and muscle tension, which may reduce pain.The role of the "hidden observer" (Hilgard, 1973) has been exploredin laboratory studies of hypnosis and acute pain. Further studies on chronicpain with patients in a clinical setting may provide more information onconscious versus unconscious processes with chronic pain patients.Studies have shown that a combination of therapies is more effectivethan one therapy (Melzack & Perry, 1975; Melzack & Wall, 1988).However,further studies with more rigid controls are necessary to confirm theresults of this study which combined audiotaped hypnosis and biofeedback.112REFERENCES Ambrose, G., & Newbold, G. (1980). History of medical hypnotism. Ahandbook of medical hypnosis: Fourth edition (pp. 1-10). 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Implications of the Ericksonian and neurolinguisticprogramming approaches for responsibility of therapeutic outcomes.American Journal of Clinical Hypnosis, 27(2), 137-143.125APPENDIX APAIN PATIENTS126The following information was taken from any available material towhich the experimenter was given access and a daily log which theexperimenter kept on the pain subjects.Pain PatientsSubject AA. was a forty-two year old man who was injured when the loggingtruck he was in rolled over. He has not worked since 1987. He has ayounger sister and brother. His father died at 54. His childhood was verydisruptive as he moved many times. He is an alcoholic who stoppeddrinking five years ago and does ACOA work. He was separated from hissecond wife who is living with their two sons (he has two other childrenfrom his first wife) and her boyfriend in their home. He still cares for hiswife. A. described himself as a "cowboy". He liked country and westernmusic, horseback riding, fishing, camping, running and other outdoorsports.A. worried about money and his future and was often depressed andsometimes suicidal. His test results on the MMPI showed that he wasseverely depressed, had low self-esteem, autistic daydreaming anddepressive ideation. He had high levels of anxiety, tension and insecurity.The psychologist reported that, "It is probable that his somatic complaintsare used for dependency gratification, particularly in interpersonalrelationships." The Beck Inventory indicated a moderate to severe level ofdepression. The Life Impact Assessment Questionnaire revealed that hisactivity was restricted and he had no real satisfaction in life. He had nosocial contacts and acknowledged low self-esteem and low sexual desire.127The Pain Disability Index showed that he was only minimally effected inlife support activities and self-care. The McGill Pain Questionnaire showedthat he had low back pain and leg pains. He had been on pain medicationand was in a rehabilitation program at the Workman's Compensation Boardfor three weeks.During the course of treatment A. reported having "out of body"experiences. He was concerned about subliminal messages in the tape. Hetalked about his wife and children and feeling "like a nine year old" when,due to miscommunication, his family didn't show up at the hotel.Over the period of the treatment his moods fluctuated depending on themoods of the therapists and the other patients reactions to him. Hecomplained about the quality of the tape, especially one word which"popped" and he told the experimenter that he knew a good recordingstudio. A. said that when he was on the bus and "having problems" hewould remember "three deep breaths" from the tape, which helped him.The psychologist at the clinic said that A's past history as a child ofalcoholics and his lifestyle of drugs and alcohol precluded his making anylong lasting changes.Subject GSubject G. was a 50 year old man who was injured moving a 45gallon drum at a brewery. He was the youngest of three children and grewup in the prairies. His father was an alcoholic who died at the age of 76. G.married recently and had three children from two previous marriages. Hehad no contact with two of his children. He has a grade nine education andspent three years in the army and worked for five years in a grain elevator128and six years at a gas station prior to his job at the brewery. He had beenon compensation before but had been cut off two or three times.G. had undergone two back surgeries and several mild seizures andone grand mal seizure. He had tried to go back to work but found it toodifficult. He was angry at the WCB for the delays for his claims. He wassuspicious of questionnaires. He questioned the value of being retrained forwork.G. had a supportive wife but the marriage was stressed because of hispain and sexual dysfunction. The psychologists report stated that he"appeared tense, frustrated, irritated, and angry" and that he was searchingfor a medical resolution to his pain problems. He denied any problems withdepression. The doctor at the clinic stated that he "needs to learn to managepain" and that he has been "leading an inactive, sedentary lifestyle withgradually increasing protective accident behaviors."During the course of treatment, G. had several seizures. Hecomplained of the noise at the hotel, the uncomfortable chairs during theaudiotaped hypnosis, other patients' comments and the physiotherapistscomments about his posture. He got upset when he thought that his progresswas being unfairly compared to another patient. G. was angry with theWCB because he thought that if he was off medication, they would think hewas fit to work.G. said that he would use the audiotape at home and thought hewould loan it to his mother-in-law, who had problems but didn't like"being told what to do." He thought the "non-directional suggestions" werebetter than "being told what to do."129Subject C. C was a single 30 year old female who had chronic low back paindue to an injury when she twisted her back while filing. She had atherapeutic abortion on her doctor's advice that it would be too difficult tocarry the baby to term. She was depressed afterwards. The report on theBeck Inventory showed that she had significant depression and wasdespondent about her interpersonal relationships. Sexually she had lessdesire.C. participated in a rehabilitation program prior to this in 1987.She walked and swam twice a week and her general attitude improved asshe was more active. Her family was supportive; her father has heartdisease and chronic bronchitis; her mother is healthy.During the course of treatment, C was good-natured but complainedof nightmares and not sleeping well. She found the chairs uncomfortable atthe clinic. C. flirted with one of the other patients and sometimes laughedat jokes during the sessions. The physiotherapist thought that her smilemasked a passively aggressive person and queried possible sexual abuse.C. expressed impatience with WCB and said that she would like towork part time in an office and part time at home on a computer. She saidthat she would use the audiotape at home but didn't think that it helped herwith pain during the sessions.Subject D D was a 36 year old man from the prairies who was separated fromhis wife. He had six children. His prior jobs included working as a B.C.lineman and a roustabout in the oil fields. He hadn't worked since 1983. Heinjured his back in 1974 and had been to the WCB rehabilitation program.130He tried to return to work twice but had to stop. He enrolled in a Fine Artscourse and enjoyed it.D. has had a lot of physiotherapy without much success. He used tobe active in horseback riding for up to two hours a day and canoed, hunted,walked, did woodworking and worked with leather. He had a homeexercise program he did for 20-30 minutes a day. His social activity wasseverely limited due to his pain. However, he expressed a desire to returnto work.During the course of treatment he complained that the placements of theelectrodes were painful. After eight treatments with audiotaped hypnosis,he said that he could "relax better now but that it had nothing to do withthe biofeedback." After the tenth treatment he said that he noticed thatthere were two places in the tape where he relaxed more but he couldn'tremember where they were. He said that every time he listened to the tapeshe heard "something new" and wondered if the experimenter had made anew tape.Towards the end of the sessions there were several conflicts with thestaff and the patients and the patients amongst themselves. The groupdivided into two parts. There were many upheavals at the hotel due torenovations. Usually the patients went home at the weekends and theirmood on Monday reflected whether or not the weekend was good for them.All the male patients in the Experimental Group came fromdysfunctional families and there was a history of alcohol and drug abuse intheir families of origin and with themselves. All the patients had sufferedsevere loss in their lives and had also experienced a loss of physical andmental control due to their pain. The experimenter did not have access tothe personal files of the Control Group.1 31APPENDIX BCHRONIC PAIN PATIENT PROFILE1 32Chronic Pain Patient ProfileFrom intensive investigation of chronic low-back patients, theemergence of the following profiles are presented. They broadlycharacterize the patient who suffers with severe, intractable, disabling backpain for which no specific abnormality is found, and are presented only toalert the therapist to additional descriptive "signs" of patients who have thepropensity to chronicity.Biological Profile  (Gentry et al., 1972; Cairns et al., 1976)The potential chronic low-back patient:- has an initial onset of symptoms at a relatively young age; 30.6 forfemales,^35.7 for males, 33.5 average;- attributes his or her symptoms to a wide variety of minor causes, usuallysprains, strains, or other minor trauma;- tends to have less formal education: 11.7 years formal education forfemales, 10 years formal education for males, 10.8 average;- begins work at an early age; 20 years old for females, 14.5 years old formales, 16 average;- tends to be later-born child with many siblings;- places an emphasis on family togetherness and interaction;- may have had model figures who experienced chronic low-back pain thatwas unresponsive to conventional treatment (23% do).1 33Socioeconomic Profile (Gentry et al., 1972; Cairns et al., 1976)The chronic low-back patient:- most were married at the onset of pain (98%);- most had some form of compensation available at the time of initial onset;-most had a stable work history: Average length of time at job at onset ofinitial symptoms was 7.2 years, and on the average patients held only twoprevious jobs;- tended to be employed in jobs that required physically strenuous oroverly^routinized responsibilities;- tended to work at blue collar manual or white collar clerical-type jobs(64%), to be housewives (18%), or to be professionals (11%);- 59% tended to have a life experience including familial models for painand/or major disability;- often experienced little satisfaction from their jobs;- often were a drug and/or alcohol abuser.Preexisting Personality ProfileAt the time a patient experiences an "acute" episode of low-back pain, anyof the following psychic states or conflicts may already be present oremerge under the added stress:AnxietyDepression1 34Conversion hysteriaMasochismPain and lossStrong dependency needsThe "need" for pain13 5APPENDIX CSUBJECT CONSENT FORM136Subject Consent FormTitle of Project: An Investigation into the Use of Audiotaped Hypnosisfor Chronic Back PainPrincipal Investigator: Susan TaylorI am doing a Master's thesis to investigate the effectiveness oflistening to hypnotic suggestions on an audiotape in order to reduce chronicpain. I will be asking you to fill out a questionnaire before and after thesessions on each Monday and Friday and isten to an audiotape for onetwenty-five minute session per day for five weeks. Each session will betracked by EMG readings as well. The information given will be strictlyconfidential. Confidentiality will be maintained by deleting any personalreferences and only the first initial of your first name will be used.Your participation is voluntary. You have the right to refuse toparticipate in the study without having your decision affect your treatment.In light of these facts, I consent to be a subject in this study.Subject:^Researcher:^Date:^,19891 37APPENDIX DPRESENT PAIN INTENSITY SCALE (PPI)138Present Pain Intensity Scale (PPI)Please check the appropriate number which describes your pain at thismoment.-1 - mild-2 - discomforting-3 - distressing-4 - horrible-5 - excruciating139APPENDIX EVERBAL SELF-REPORT TAPE EFFECTIVENESS QUESTIONNAIRE140Tape Effectiveness QuestionnaireFirst name:  ^Date:Please circle the number which corresponds to how effective the tape wasfor you in reducing pain during the sessions.0^1^2^3^4^5^6^7^8^9^10least mosthelpful helpfulWhat did you find most helpful about the tape?What did you find least helpful about the tape?At what point or points in the tape did you drift off?If you wanted to make improvements in the tape what would you change?Did you find that there were any lasting effects of the tape betweensessions? If so, what?Do you think you will use tapes in the future to help you manage yourpain?141APPENDIX FTRANSCRIPT OF THE HYPNOSIS AUDIOTAPE1 42143Appendix C^ Trance InductionHypnosis Tape TranscriptJust make yourself comfortable. Put your handson your sides, uncross your legs and close youreyes and become aware of any sensations aroundyour eyes, your eyelids and your eyebrows.Allow those muscles there to becomes more andmore relaxed, more and more relaxed^^so relaxed and so calm andallow the relaxation to drift down and down todown and down toand let it drift andall the waydown to your feet^and while you'rerelaxing the different parts, imagine that you aremore and more relaxed^and asyou hear the music in the distance,^—allow yourself to drift and drift and relax^and now be aware of your breathing take in the oxygen to your lungs andas you breath out, relax the muscles in your chesta little bit more feel the com-fort^feel the relaxation^every time you breath in, in a normal, regularmanner^and while you're listening to me andthe music in the background^just allow yourself and your body to become alittle bit more relaxed andallow your mind to drift and drift and drift^Everything I'm going totalk about will be taken up by your unconsciousmind and you will use it to help yourself in everyway, every day, the unconscious will understandand utilize everything I'm going to tell you,Progressive relaxationinduction(Crasilneck,1985)Relaxation (Hammond1988)Deepening techniqueyour chin,^your neck^^drift and drift^Deepening techniquePosthypnotic sugges-tions (Hammond, 1988)without your even being aware of it in thedaytime consciously, or at night^for your unconscious will always help youimprove ^tally,^ally^physically, men-and emotion-and while I'm talking toyou just allow yourself to becomemore and more relaxed Andjust allow the music, or any surrounding noiseto become part of your comfort, part of yourrelaxation just allow your-self to drift and drift and drift^drift, deeper and deeper and deeper^—so relaxed, so calm and while you're relaxingyourself or imagining you're relaxing, I'll countfrom 5 backwards to guide you ^and every time I count from 5 to 1allow the body to become even more relaxed—^more calm^comfortable^don't need to move^even need to think^need to do anything ^don't even need to listendrift and drift^5^deeper and deeper^you hear the music and my voice, 3so relaxed, becoming more and morecomfortable ^relaxing,^calm,—2 very relaxed, verycalm^ 1^relaxed, calmAsyou breath in, allow the oxygen to enter yourlungs^and then as you breath out,allow yourself to become more and more re-laxed each time^and now,just relax^Your breathing rate now144moreYou see, youYou don'tYou don'tand youJust4 and asContingent suggestion isuseful for utilizing exter-nal environmental noises(Hammond, 1988, p. 63)Deepening technique-breathing and counting(Hartland, 1971; cited inHammond,1988 p.65).Hypnotic suggestion: notknowing, not doing:these suggestions facili-tate unconscious respon-siveness rather thanconscious effort (Ham-mond, 1988, p.84).-Counting down; deepen-ing technique, (Ham-mond, 1988, p. 62, 65).145is changing, down and down^and down,to a normal, regular, restful, rate^ Yourbreathing heart rate is going down and down,and down to a normal, regular, beat^^Your metabolism now is driftingdown and down^brainwaves are shiftingEverything in your body is changing to amuch, slower, relaxing rate—CALM,RELAXED, and while I'm talking and as youhear my voice and the music in the background,consciously you don't need to pay attention tome at all^and now just picture yourself in my office lyingback in a comfortable reclining chair, lookingout the window imagining, enjoying the oceanand the fresh air,^Youmight just enjoy the sounds of the ocean tum-bling onto the sand, or the music in the back-ground^—Picture a beautiful healing light all aroundyou or you might just sense it, as though youare in an energy field surrounding you^Just feel the comfort allow the energycausing you discomfort, to evaporate, and at thesame time, allow the light to absorb the discom-fort or an sensations you don't need^^imagine one beam brighter than all theothers which will shine right in the middle ofyour forehead^ and willgo right inside to the centre of your brainYou may feel the sensation there or you mightrelax and go into the music^andallow the part of you unconscious mind torelease healing chemicals or endorphins whichConscious-unconsciousdouble bind (Ericksonand Rossi,1976).Visual imagery developsan internal absorption ofattention (Ham-mond,1988, p.65)Hypnotic suggestion of atruism; a statement offact which person hasexperienced and can'tdeny (Hammond, 1988,p. 84).Visual imagerywill reduce any discomfort or tightness in yourbody^Allow the chemicals to release and to flowthroughout your whole body. With every breaththat you take in, the oxygen will increase theenergy, increase the healing^which will flow throughout your system^^and now imagine that yousee a large T.V. screen in front of you. Con-sciously you don't need to listen^your unconscious mind will listen for you^Picture yourself whenyou were healthy and happy and enjoy that feeling of comfort and onenesswith your body A sense of harmony,^feeling a senseof inner control, of warmth,^—of health^Let those feelings beimprinted on your mind.—Now allow yourself to enlarge that pictureand see them in technicolour^—sense them and enjoy themAllow these feelings to be imprinted onyour mind and know that any time you wish touse them these feelings will help you in thefuture and any time you need them you willtake three deep breathes and know that yourunconscious mind will bring forth these feel-ings and healing chemicals from the centre ofyour brain, without your being aware of thisconsciously^146-Suggestion throughvisual imageryCognitive restructuring(Ellis, 1977)Hypnotic positive sug-gestion linked to the pastwhen the person is incontrol (Hammond,1988)Contingent suggestion,(Hammond, 1988, p.85)'^And every night when you fallasleep---your unconscious mind will re-solve the problems that you encounter everyday and will get rid of any negative self-defeat-ing thoughts, without your being aware of it^Posthypnotic suggestionconsciously, because your unconscious mindwill do it for you^and know that all the different functions ofyour muscles and nerves within your body willhelp you feel a sense of inner harmony andcalm^inner peace^and we know that every moment of the day, thatevery moment, there are thousands of cellsbeing replaced^so that in any one day thereare billions of new cells which are healthy andstrong^as if they have give you a newbeginning, a new start^—Now, allow yourself to relax, enjoy the mu-sic, allow the light to surround you, like a vi-brant, healing energy field^and the next time when you hear this quietmusic and my voice, allow yourself to drifteven deeper than before^and allowyourself to become more and more relaxed,more and more peaceful^Now, I will count from 1to 5. Allow yourself to awaken feeling re-freshed, revitalized, calm^1—2-3, beginning to awake feeling re-freshed and calm, mentally and physically, 4—just about awake^feeling calm,refreshed^5—wide awake, wide awake.147Re-alerting,(Golan,1988)Termination of formal-ized trance.APPENDIX GBINOMIAL TEST148Binomial  TestThe probability of an observation point being either below thebaseline is .5. For n points, the probability of 50% lying above the baselineand 50% below, is.5.If there is a significant intervention effect, x-points could lie abovethe baseline and n-x could lie below the baseline, +x should be significantlylarger than n-x.Lowered mean EMG readings are an indication that audiotapedhypnosis is effective. In this study, for the control group (A phase), 16points are above the baseline and 9 points are below the baseline. In theexperimental group (B phase), 23 points are above the baseline and 2 pointsare below the baseline.The probability of x points lying above the baseline by sheer chance. in the case of a significant intervention should be small-- it is, in fact;p=0.5. In the Control Group, p=.06. In the Experimental Groupp=.000009.Results showed that there was a change of 2.06 ilv (microvolts) inaverage EMG readings in the direction of improvement in the B phase(Figure 1).A comparison of the Control Group and the Experimental Groupshowed that the probability of 23 cases lying above the baseline by chancealone was very small. From this we inferred a significant interaction effectand these results led to a rejection of the hypothesis as stated in the Nullform.149


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