Complementary and alternative medicine approaches to pain management
Complementary and Alternative Medicine Approachesto Pain Management
Gabriel Tan and Julie A. AlvarezMichael E. DeBakey Veterans Affairs Medical Centerand Baylor College of Medicine
Mark P. JensenUniversity of Washington School of Medicine
This article argues for and illustrates incorporating complementary andalternative medicine (CAM) interventions into pain treatment plans. TwoCAM treatments, cranial electrotherapy stimulation (CES) and self-hypnosis training, are offered in a multidisciplinary pain treatment pro-gram. Because these interventions focus on pain relief, they may be ofparticular interest to patients who have chronic pain who begin treatmentwith a primary interest in pain reduction. Two cases that illustrate theclinical application of CES and self-hypnosis are presented. When effec-tive, these interventions can help patients have greater confidence in treat-ments offered by psychologists for pain management and may help makethem more open to participating in other psychological interventions thathave established efficacy for pain management (e.g., cognitive-behavioraltherapy). Because of their brevity, these treatments also can be offeredalone to patients who may not have the resources or time to participate inmore time-intensive treatment. 2006 Wiley Periodicals, Inc. J Clin Psy-chol: In Session 62: 1419–1431, 2006.
Keywords: pain management; complementary and alternative medicine(CAM); hypnosis; cranial electrotherapy stimulation
In the practice of Western medicine, individuals suffering from chronic pain oftenseek medical care with the hope of obtaining a specific diagnosis and curative treatment. When a curative treatment is not available, patients who have chronic pain fre-quently expect a prescription for analgesic medications (“painkillers”) for pain relief.
Correspondence concerning this article should be addressed to: Gabriel Tan, Michael E. DeBakey VeteransAffairs Medical Center (Anesthesiology 145), 2002 Holcombe Boulevard, Houston, TX 77030; e-mail:[email protected]
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 62(11), 1419–1431 (2006)
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20321
1420 Journal of Clinical Psychology: In Session, November 2006
Unfortunately, specific diagnoses for most chronic pain problems are difficult to make,and treatments are rarely curative. Moreover, although analgesic medications can be effec-tive in relieving acute pain in the short term, their utility for treating chronic pain iscontroversial and efficacy is, at best, marginal. For example, in a recent review of theefficacy of various treatments for patients who have chronic pain, it was noted that theaverage pain reduction for patients placed on long-term opioids is only 32% (Turk, Loeser,& Monarch, 2002). In addition, anticonvulsants, tricyclic antidepressants, and topicalpreparations (considered the treatment of choice for neuropathic pain) seldom producepain reductions to below a rating of 4 on 0 to 10 numerical scales. Turk (2002, p. 355)concluded that “none of the currently available treatments eliminates pain for the major-ity of patients.” Thus, despite the availability of multiple biomedical treatments for chronicpain, there remains ample room for additional, and perhaps for some patients even moreefficacious, treatments.
Psychological Interventions for Pain Management
Cognitive-behavioral therapy (CBT) and other psychological interventions provide a via-ble alternative to traditional Western biomedical pain treatments. A growing body ofresearch supports their efficacy for helping patients better manage chronic pain (e.g.,Keefe, Abernathy, & Campbell, 2005; Morley, Eccleston, & Williams, 1999). However,like more traditional biomedical-focused pain treatments, psychological interventions arenot universally effective (McCracken & Turk, 2002).
Furthermore, psychological interventions are not without their limitations. First, in
order to be successful, they require significant effort and motivation from the patient(Jensen, Nielson, & Kerns, 2003). These treatments also tend to be time-intensive (10 ormore 1-hour individual or group sessions is not unusual), and they usually require sig-nificant practice of the cognitive and behavioral management skills outside the treatmentsessions. In addition, some patients who have chronic pain are so wedded to the tradi-tional medical model, in which treatments are done “to” them and not by them, that theymay have little interest in treatments that require their own efforts. Many such patientswho desire a biomedically focused treatment will not participate in or follow throughwith psychologically based therapies such as CBT.
Along these lines, there may be a subset of patients who are particularly skeptical,
rational, analytic, and hyposensitive to the emotional somatic component of psychosocialthreats (Wickramasekera, 1998). Such patients tend to be reluctant to examine the causeof negative emotional somatic information and instead tend to search for physical expla-nations of and physical solutions for their distress. When these patients are referred forpsychological treatment (for a pain problem), they may not attend the sessions or followthrough with homework assignments or practice recommendations that are often a part ofthese psychological approaches. One reason for this apparent resistance may be the beliefthat seeing a psychologist for pain problems amounts to an admission that their pain is “inthe head” and not real. Complementary and alternative medicine (CAM) has been defined as a “diagnosis, treat-ment and/or prevention which complements mainstream medicine by contributing to acommon whole, satisfying a demand not met by orthodoxy, or diversifying the concep-tual frameworks of medicine” (Ernst, 2000, p. 252). According to the National Center forComplementary and Alternative Medicine, CAM includes “treatments and healthcare
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practices not taught widely in medical schools, not generally used in hospitals, and notusually reimbursed by medical insurance companies” (Arnold, 1999, p. 1104). CAMencompasses both nontraditional treatments used in association with conventional West-ern medical practices as well as alternative medical interventions intended to replacetraditional Western medical practices (Chiappeli, Prolo, & Cajulis, 2005).
CAM interventions have been increasing in popularity over the past two decades
because of dissatisfaction with traditional Western medicine, the availability of informa-tion on the Internet, the influence of marketing forces, and the desire of patients to bemore actively involved in their own medical decision making (Engel & Straus, 2002). Eisenberg and colleagues (1998) estimated that the U.S. public spent between $36 billionand $47 billion on CAM treatments in 1997. A recent U.S. national health survey of31,044 adults found that 36% of the population surveyed used CAM therapies during theprevious 12 months (Barnes, Powell-Griner, McFann, & Nahin, 2004). This percentageincreased to 62% if prayer for health reasons was included in the definition of CAM. Back pain, neck pain, and joint pain are among the problems for which CAM therapiesmost commonly are used (Barnes et al., 2004).
In addition to traditional psychological treatments, we frequently use two CAM modal-
ities: cranial electrotherapy stimulation (CES) and self-hypnosis training. CES involves“the application of a small amount of current, usually less than one milliampere, throughthe head via ear clip electrodes” (Kirsch & Smith, 2000, p. 85). The CES device we use,called “Alpha-Stim,” has been approved by the U.S. Food and Drug Administration (FDA)as a treatment for depression, anxiety, and insomnia (Lichtbroun, Raicer, & Smith, 2001). On the basis of the finding that patients who have chronic pain frequently have comorbidaffective disorders, CES began to gain popularity as an adjunctive intervention for painmanagement in the 1990s.
The mechanism(s) by which Alpha-Stim produces effects is not fully known. How-
ever, on the basis of previous and ongoing studies, it appears that the Alpha-Stim microcur-rent waveform activates particular groups of nerve cells that are located at the brainstem,a site at the base of the brain that sits atop the spinal cord. These groups of nerve cellsproduce the neurotransmitters serotonin and acetylcholine, which can affect the chemicalactivity of nerve cells that are both nearby and at more distant sites in the nervous system. In fact, these cells are situated to control the activity of nerve pathways that run up anddown the spinal cord to the brain. By changing the electrical and chemical activity ofcertain nerve cells in the brainstem, Alpha-Stim appears to amplify activity in someneurological systems and diminish activity in others. This neurological “fine tuning,”called modulation, occurs either as a result of or together with the production of a certaintype of electrical activity pattern in the brain known as an alpha state, which can bemeasured on brain wave recordings (called electroencephalograms [EEGs]). Such alpharhythms are accompanied by feelings of calmness, relaxation, and increased mental focus. The neurological mechanisms that are occurring during the alpha state appear to decreasestress effects, reduce agitation and stabilize mood, and control both sensations and per-ceptions of particular types of pain. These effects can be produced after a single treat-ment, and repeated treatments have been shown to increase the relative strength andduration of these effects. In some cases, effects have been stable and permanent, suggest-ing that the electrical and chemical changes evoked by Alpha-Stim have led to a durableretuning back to normal function (Kirsch, 2006).
A small, but growing, body of controlled studies has reported on the efficacy of CES
in reducing pain in patients who have fibromyalgia, tension headaches, spinal pain, den-tal pain, and unspecified chronic pain (e.g., Kirsch & Smith, 2000; Lichtbroun et al.,2001). For instance, in a double-blind, placebo-controlled study in which 60 randomly
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assigned fibromyalgia patients either were given three 1-hour-daily CES treatments, three1-hour-daily sham CES treatments, or were held as wait-listed controls, treated patientsshowed significant improvements in pain, sleep, well-being, and quality of life and noplacebo effect was found among the sham-treated controls (Lichtbroun et al., 2001). Inanother double-blind study in which 50 patients (30 receiving real CES and 20 receivingsham CES) were randomly assigned to receive different dental procedures, 24 of the 30patients (80%) who received CES were able to undergo dental procedures without otheranesthesia, while 15 of the 20 (75%) sham CES patients requested anesthesia (Clarket al., 1987). Our own double-blind placebo control pilot study on central neuropathicpain (below the level of injury) associated with spinal cord injury indicated significantreduction in pain intensity post session that was greater for the active CES treatment thanthe sham CES treatment (Tan et al., 2006). Although the mechanism(s) of action of CESon pain is still unclear, it is generally believed that the effects are mediated through adirect action on brain activity in the limbic system, hypothalamus, and/or reticular acti-vating system. It also has been suggested that CES reduces anxiety and depression, therebyindirectly elevating the pain threshold (Kirsch & Smith, 2000). In addition, CES (andself-hypnosis training) can serve a useful “Trojan horse” function to persuade patients tobecome involved in psychologically based interventions. A practical feature of CES isthat a psychologist simultaneously can carry out psychotherapy while the patient is “hookedup” to the device. Once patients learn that they can modify pain with changes in brainactivity by using CES, they may become more willing to consider other treatments thatalter brain activity, such as CBT.
Providing self-hypnosis training alone, or in conjunction with CBT and other psy-
chological therapy, is a common practice for many psychologists. In Handbook of Hyp-notic Suggestions and Metaphors (Hammond, 1990), the following hypnotic strategiesand techniques for managing pain are described in detail: unconscious exploration toenhance insight or resolve conflict, creating anesthesia or analgesia, cognitive-perceptualalteration of pain (and pain behavior), and decreasing awareness of pain (distractiontechnique). In addition to these hypnotic approaches to pain management, we use themind-body healing approach of Rossi (1993). In this latter approach, hypnotic sugges-tions can be given during the session for the patient to regress and access past learning,memory, and experience. As an example, a patient who had intractable headaches notamenable to conventional treatment was asked to regress and access memory that wouldhelp her manage her pain. While in a hypnotic state, she recalled several incidents of herfirst-grade teacher’s “knocking” her on the head with a pencil when she was not able toanswer questions. The experience was very embarrassing, and she kept it to herself all herlife. This moment of awareness and insight led the patient to report in a subsequentsession that her headaches no longer were bothering her.
There is a growing body of research suggesting that hypnosis is an efficacious treat-
ment for acute procedural pain and chronic pain conditions (Patterson & Jensen, 2003). Ameta-analytic study examining the effect of hypnosis for pain reduction found that itoffered considerable pain relief for 75% of the populations included in the analysis (Mont-gomery, DuHamel, & Redd, 2000). Hypnosis generally has a significantly greater impacton pain reduction as compared to no treatment, medication management, physical ther-apy, and education/advice (Jensen & Patterson, in press).
Evolution of the Houston VA Pain Management Program
The Michael E. DeBakey VA Medical Center (MEDVAMC) pain management programis an anesthesiology-based multidisciplinary program that serves a tertiary teaching hospital. Journal of Clinical Psychology: In SessionCAM Approaches to Pain 1423
The psychologist and trainees in the program are involved primarily in outpatient care,providing a variety of individual and group psychological services. Initially, the psycho-logical services consisted primarily of assessment and treatment services for patients(referred by pain anesthesiologists) who were experiencing psychological distress relatedto pain (e.g., depression, anxiety, and relationship conflicts) or suspected of drug seekingor abuse. In addition, these patients often were unresponsive to pain medications, nerveblocks, and other traditional biomedical interventions.
We soon noted a number of limitations to the services we offered, the most notable
of which was a consistently high rate of nonattendance at the initial appointment and/orlimited follow through after the initial appointment. This pattern led us to consider pro-viding CAM interventions for pain, which we thought would be of interest to at least asubset of our patients. A second limitation of the services we initially offered was relatedto the nature and characteristics of our pain population. Many of our patients travel longdistances (60 to 150 miles) to reach the MEDVAMC and have limited means to get tothe center. To serve their needs, our interventions need to be brief and provide relativelyquick results. A third factor that led us to consider CAM approaches was the severity ofthe pain conditions in our veteran population, which made pain relief a primary goal formany of our patients—a goal that is not entirely consistent with CBT, which tends tofocus on improvement in function rather than pain relief per se. Veterans who receivecare from a VA Medical Center also differ from the population at large in several sig-nificant ways. They are more likely to be older, have poorer health status, be smokers,be heavy drinkers, have psychiatric problems, be socioeconomically disadvantaged, behomeless, and have more severe pain intensity, pain interference, depression, and dis-ability when compared to nonveterans (e.g., Tan, Jensen, Robinson-Whelen, Thornby, &Monga, 2001).
We have found that VA patients who have chronic pain referred to our services
usually are not prepared for psychotherapy because they do not view their pain as affec-tive or psychological in nature. Rather, as do many patients who have chronic pain, thesepatients consider their pain as primarily a physical problem, and they want a “real” phys-ically focused treatment. Our experience also has been that patients referred to our ser-vice are not likely to continue with an intervention that does not provide symptom reliefin a short period. Therefore, we have developed a case management approach in whichwe aim at “connecting” quickly with the patient and focusing at first on providing quicksymptomatic relief. Here is a typical sequence of service provision:
1. All patients referred to the pain program complete and return by mail a clinical
questionnaire, which is scored for risk factors and needs for psychosocialinterventions.
2. Patients, thus identified, are scheduled to attend an education/orientation meeting
followed by a brief 30-minute screening, before or while seeing a pain anesthe-siologist. The meeting is structured to educate patients about chronic pain byquestioning and (ideally) debunking a purely biomedical focus and introducingthe notion that decreasing pain interference and mind and body reconditioningalso might be important. By conceptualizing pain management as “brain” man-agement, alternative interventions such as cranial electrotherapy stimulation (CES)and self-hypnosis training, as well as CBT, are introduced. The expected impact isthat patients will begin to adopt a different perspective on the management oftheir pain.
3. CAM interventions, designed specifically to achieve initial pain relief (and indi-
rectly to initiate the process of teaching patients self-management skills), are
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explained and made available to those interested. On average, 90% of patientswho attended this initial orientation/education class and screening have indicateda desire to pursue CAM interventions.
4. When the patients are seen in subsequent individual sessions, the focus is to
utilize CAM interventions such as CES to provide a “physical” treatment thattypically results in immediate relief in pain or other symptoms. A preliminaryanalysis of 97 individual sessions in which CES has been used since the begin-ning of this program indicates an average postsession pain reduction of 2.02 pointson a 0 to 10 Likert scale or 33.3% average reduction. Psychological interventionsare not the main focus of treatment at first but are woven into the sessions forthose who are interested. Patients are encouraged to participate concurrently inour education, support, and skills training groups.
In the section that follows, we present two cases in which CES plus hypnosis or
hypnosis alone was used successfully to help veterans who have chronic pain bettermanage their symptoms. Presenting Problem /Client DescriptionIdentifying Data. JS is a 60-year-old African American male who was referred to the
Pain Clinic by his primary care physician (PCP). He had worsening pain in his lowerback and hip secondary to an injury in Vietnam. Pretreatment Pain Interference and Distress
When asked to rate how much pain interfered with his daily life by using the Brief PainInventory Pain (BPI) Interference scale, he rated the amount of interference as 9/10 forgeneral activity, 9/10 for mood, 8/10 for walking ability, 8/10 for normal work, 8/10 forrelations with people, 9/10 for sleep, and 9/10 for enjoyment of life. In addition, on acategorical scale of distress, he rated his current level of distress as “high.”
Previous treatments for his pain conditions included (1) chiropractor (“caused a lot morepain”), (2) massage (“made me feel really good but cost money”), (3) physical therapy(“made me feel good but did not do anything with the pain”), and (4) medications (onvarious pain medications in the past; currently has good relief from tramadol (Ultram)and naproxen (Aleve, Naprosyn) as prescribed by his PCP). Family and Social History. JS was born in a small town in Texas and reported having
a normal, happy childhood. His father was White, his mother African American, and hisparents reportedly were happily married. He is the second oldest child of 14 children. Educational, Vocational, and Military History. JS obtained an associate degree in
elementary education after completing high school. He was drafted into the MarinesCorps at age 20, served 13 months including a tour of duty in Vietnam, and was releasedfrom active duty in the late 1960s. While in Vietnam, JS served in a gunnery unit. He wasinjured when a bunker, which was hit by an enemy mortar round, collapsed on him. He
Journal of Clinical Psychology: In SessionCAM Approaches to Pain 1425
also was shot accidentally in the leg by a fellow soldier who was cleaning a rifle. Hesubsequently suffered from combat-related posttraumatic stress disorder (PTSD). Afterdischarge from active duty, JS worked for 8 years with the postal service until he wasterminated for dereliction of duty. He filed a grievance with the union and was awardedcompensation for harassment and unfair discharge. JS has not worked for the past 5 yearsbecause of pain in his knees and back. He receives medical disability. Mental Health Treatment. JS has been enrolled in the Mental Health Trauma Recov-
ery Program for veterans suffering from PTSD for the past 5 years. He first was seen by men-tal health professionals because of sleep problems and nightmares. He endorsed symptomsof intrusive thoughts from his Vietnam experiences, hypervigilance, heightened startle reflex,and isolation. He said he did not use alcohol or illicit drugs because of his religious beliefs. Current Living Situation. JS has been married for 33 years to his second wife. They
have three children: one died of acquired immunodeficiency syndrome (AIDS), one diedat 2 months of age of unspecified cause, and the third child, a son, is 26 years old. Hiswife has five children from her previous marriage. They also care for four to five fosterchildren. JS describes their relationship as “very good” and his wife as “very supportive.”He stays at home most of the time doing household chores and helping out the neighborswith chores. Although generally isolated from others, he maintains frequent contact withhis brother and neighbor.
JS’s back injury and PTSD developed while he was serving in combat in Vietnam. Aswith many Vietnam veterans who suppressed their emotional trauma without full resolu-tion, he “went on with life as usual.” As he grew older and retired from employment, hehad more unoccupied time to himself and some of the unresolved conflicts began tosurface. The reexperiencing of his trauma in the form of nightmares probably has led toincreased muscle tension and bracing postures, which, in turn, triggered, escalated, andexacerbated his previous chronic back pain condition. In Pavlovian terms, the pain thathas been paired with the emotional trauma has returned with the reexperiencing of thetrauma. If this formulation is correct, the treatment of the pain would need to go hand inhand with the resolution of his emotional trauma in order to be optimally effective. Hisrecord shows that he was quite active in his PTSD treatment and was able partially toresolve his emotional trauma, an outcome that was considered a positive sign and indic-ative of at least a fair prognosis for his pain treatment.
The initial treatment goals were to reduce pain, stabilize and improve sleep, and help himregain a sense of control over his daily activities. The treatment plan consisted of CES toreduce anxiety and improve sleep, self-monitoring skills, and hypnosis to help modulatehis pain while making a long-distance trip and to begin the resolution of his trauma. Afteran initial screening, JS was seen for a total of nine individual sessions. A typical sessioncommenced with his completing a Likert scale in which he was asked to rate his painintensity from 0 to 10. The CES device and the way it works were briefly explainedtogether with the common sensation of “tingling” or “pins and needles” on his ear lobesas the current was increased. He also was made aware that some individuals might feel
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slightly light-headed initially as the body adjusted to the introduction of microcurrent tothe brain, but that this sensation typically disappeared after a few minutes. He then wouldbe connected to the CES device via two ear clip electrodes, followed by a fine tuning ofthe level of current intensity from 0 to 6. After the unit was turned on, he would be askedto report when he first noticed any sensation to the point of discomfort, at which point thecurrent would be reduced until the discomfort disappeared. Then his progress and theprevious session would be discussed. The content of the discussion varied, depending onhis needs and desired treatment goals. Each session ended with a posttreatment painrating and homework assignment if appropriate. See Table 1 for a synopsis of the sessions.
In addition to the patient’s self-reported improvement in his pain and related symptoms, com-parison of pre- and post-psychometric testing using the BPI and the abbreviated form of theCenter for Epidemiological Scale-Depression (CES-D) indicated a number of improve-ments, including significant reductions in pain intensity, pain interference, and depressivesymptoms. The findings indicate that JS benefited from the interventions, which includedCES and self-hypnosis training. In addition to decreased pain intensity, he reported mean-ingful reductions of pain interference in all aspects of his daily functioning. Although hewas only mildly depressed before treatment, some improvement in depression also was noted. Perhaps equally significant were the substantial reduction in pain medication use and theability to function with minimal assistance from health care providers.
Some readers may have noticed an apparent discrepancy between the high level of
pain initially reported by the patient and the relatively lower pain level reported duringthe sessions. The patient explained this discrepancy with the scheduling of all the ses-sions in the mornings, when his pain was relatively milder. Nevertheless, it is clear thatthe patient reported substantial improvement in his experience of pain as shown in thetable. Presenting Problem /Client Description
Unlike the case of JS, in which hypnosis was “adjunct” to CES and psychotherapy, thefollowing case illustrates the use of hypnosis as the primary CAM modality. Although ECterminated his therapy prematurely because of transportation difficulties, his case wasselected because it represents a classic example of how hypnosis can be used to treat painin a person who appears to have moderately high hypnotic ability. Identifying Data. EC is a 63-year-old White male who sought treatment of chronic
low back pain. He sustained an injury in 1980 while working on an oil rig and spent8 days in traction. He previously was examined by the anesthesiologist-pain specialistand given the diagnoses of lumbar spondylosis and facet disease. EC also reported severeintractable headaches that significantly interfered with his ability to focus and concentrate. Pretreatment Pain and Interference. Before treatment, EC reported in the BPI that
his worst pain was 9/10, least pain was 6/10, average pain was 6/10, and “now” pain was9/10. Pain interference was reported as 8/10 for general activity, 5/10 for mood, 5/10 forwalking ability, 7/10 for normal work, 7/10 for relations with other people, 8/10 forsleep, and 8/10 for enjoyment of life. Satisfaction with life was rated as 6 to 7 out of 10. Journal of Clinical Psychology: In SessionCAM Approaches to Pain 1427
Table 1Synopsis of Sessions for the Case of JS
relaxing in a quiet room washelpful in reducing pain
(which he attributed tocranial electrotherapystimulation)
of “body flowing withthe motion of the carand being able to relax”
therapy stimulation and hyp-nosis; he has not been takingany pain medication; his sleepis now quite regular and satis-factory; his pain has beenunder control and “milder”
Journal of Clinical Psychology: In Session1428 Journal of Clinical Psychology: In Session, November 2006 Pain and Other Treatment History. EC had been responding partially to acetaminophen/
oxycodone (Percoset) as prescribed by his PCP. He found a chiropractor helpful for a while,and he had been treated with traction and nonsteroidal antiinflamatory drugs (NSAIDs). Hedenied having any history of mental health problems or treatment, but he did acknowledgesome symptoms of depression (fatigue, depressed mood, irritability). He consumed two tofour beers and one pack of cigarettes per day before treatment, but he denied using any illicitdrugs. He reported a history of heavy alcohol use and previously was smoking two to threepacks of cigarettes per day. He previously had tried to quit smoking by using the nicotinepatch and bupropion (Zyban), which did not help. However, he reported that he sub-sequently was able to cut down on his smoking with the help of hypnosis (provided by otherclinicians before he was seen for pain). Family, Marital, and Social History. EC had been separated for 7 years from his
wife after many years of marriage. He was residing at his daughter’s house because hishouse had been destroyed in a fire and was being rebuilt with help from his son. Hereported that he was not active in the community; however, he maintained contact withhis family and a few friends. Employment history. EC worked as a welder and pipe fitter for most of his life. He
was unemployed and receiving social security disability because of asbestosis when hestarted treatment. He stated that he could not find a job because of his back pain and age.
It was clear that EC was a “no-nonsense” type of person whose primary expectation oftreatment was to achieve pain reduction so that he could “move on” with his life. Althoughhe acknowledged some depression, he denied having any mental health problem or treat-ment in the past. The fact that he was able to obtain some help from hypnosis to reducehis cigarette smoking was a clue that he might be able to follow through and benefit fromthis intervention. Treatment goals were pain reduction in order to be able to enjoy activ-ities, such as offshore fishing and golf, and improved physical condition. Treatment focusedon training in self-hypnosis, but a stretching exercise program also was initiated as ameans of increasing his ability to engage in daily activities.
After the initial screening, EC was seen for a total of five sessions with hypnosis as theprimary intervention. The far eye fixation induction procedure was used, followed byseveral deepening procedures. After the induction, the suggestion was given that ECwould be able to use his mind to decrease his pain intensity and that, as he gained masteryof hypnosis, his pain would interfere less with his life activities. He was given the furthersuggestion that he would be able to transfer his pain from one location to another if he sodesired. He reported pre- to post-session pain reduction from 7/10 to 4/10 at the firstsession, suggesting a moderate degree of responsivity to hypnotic analgesia suggestions.
At the beginning of the second session, EC reported that he was able to transfer his
pain from his head to his hand and to make his pain go away at times, which allowed himto focus on accomplishing more tasks involved in the rebuilding of his house. He alsoreported that his pain had been less “bothersome” and that he had been practicing the“relaxation” he had done in the last therapy session. During this session, hypnotic induc-
Journal of Clinical Psychology: In SessionCAM Approaches to Pain 1429
tion and deepening procedures were repeated with the posthypnotic suggestion of beingable to increase his behavioral activities without being bothered by pain. He reported apre- to post-session pain reduction from 6/10 to 0/10. In addition to hypnotherapy, hewas shown several slow-motion reconditioning stretches from Chinese Qigong, and theneed for reconditioning was emphasized.
During the third session, EC continued to report his ability to transfer pain from his
head to his hand. He stated that his back pain had decreased and that he had been feelingmore comfortable in general. In addition, he reported being able to mow his lawn for thefirst time in over a year. Finally, he reported reducing the use of his pain medication fromfour to two pills a day. He said that he practiced the slow-motion stretching taught in theprevious session. The hypnotic training was repeated as before along with the suggestionthat he would be able to substitute the sensation of “drifting and floating” for “rockingand jerking.” Pre- and post-session pain ratings were not completed during the thirdsession because of an oversight.
EC was seen again for hypnosis with further focus on transforming the sensation of “rock-
ing and jerking” to “floating and drifting” to prepare him for a future deep sea fishing trip. He reported a pain reduction from 8/10 to 5/10 during the fourth session. At the beginningof the fifth and final hypnotherapy session, EC reported continued progress. He also reportedbeing “stressed” by having to baby-sit several children of his friends and relatives whounexpectedly dropped them off at his daughter’s house where he was residing. Despite thehigher level of stress, he reported pre- to post-session pain reduction from 8/10 to 0/10.
At the end of the fifth and final session, EC stated that he would have to take a break fromthe treatment because of lack of transportation. He lived far away, and, because of alimited budget, he could not afford to continue paying someone to give him a ride to thesessions. He noted that he was much more comfortable now than he was before treat-ment, and he expressed confidence in his ability to apply his hypnotic skills on his own.
The cases presented illustrate the potential for CES, self-hypnosis training, and their com-bination in helping individuals with chronic pain experience less pain, gain control over painsymptoms, and minimize the effects of pain on their lives. The focus of both CES and theself-hypnosis training provided to these patients was on pain relief. In the second case, thehypnosis also included suggestions for increased activity and ability to function despite pain,hypnotic suggestions that may be underutilized in the treatment of chronic pain conditions(Patterson & Jensen, 2003). Many, but not all, patients are able to achieve meaningful reduc-tions in the severity of pain with these interventions. For some of these patients, the painrelief can last weeks, months, and even years (Patterson & Jensen, 2003).
Many patients who have chronic pain begin treatment with a bias toward wanting
treatments that are biomedically focused and that directly impact their experience of pain. For these patients who subsequently respond well to CES and/or self-hypnosis training,CAM interventions can be an effective means of engaging them and helping them achievesome reduction in their experience of pain. When effective for reducing pain and alsoimproving other symptoms, such as global distress and sleep interference (Jensen et al.,in press), these interventions also can be used as a way of helping patients learn that aperipheral “cause” of their pain need not necessarily be diagnosed and “fixed” in orderfor them to achieve relief. Journal of Clinical Psychology: In Session1430 Journal of Clinical Psychology: In Session, November 2006
Improvements that occur in some patients after CES and hypnosis may be sufficient
for many of them. However, for patients who seek additional pain relief or reduced inter-ference with functioning, the benefits obtained from CAM treatments such as CES or self-hypnosis training can be used as evidence for the potential efficacy of other psychologicaltreatments that alter the way the brain processes pain information, such as CBT. As more islearned about the specific effects of these and other CAM treatments for pain, they can beincorporated into and used in conjunction with other more traditional pain treatments, as away to maximize the overall efficacy of pain treatment. In this way, we can seek to ensurethat the greatest number of patients obtain the greatest benefit from the care that we offer.
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Measuring the Quality of Surgical Care:Structure, Process, or Outcomes?John D Birkmeyer, MD, FACS, Justin B Dimick, MD, Nancy JO Birkmeyer, PhDWith widespread recognition that surgical outcomesstandard in cardiac surgery and in hospitals of the De-vary by providersurgeons and hospitals are increas-ingly being asked to provide evidence of the quality ofIn this article, we consider the relativ
The Pediatric Infectious Disease Journal • Volume 29, Number 11, November 20103. Makhoul IR, Sujov P, Smolkin T, et al. Epidemiological, clinical, andmicrobiological characteristics of late-onset sepsis among very low birthweight infants in Israel: a national survey. Pediatrics . 2002;109:34 –39. Therapies Used in 2008 (Before Prophylaxis) and 20094. Stoll BJ, Hansen N, Fanaroff AA, e