Barber-Effects Hypnosis Pain

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The Effects of "Hypnosis" on PainA Critical Review of Experimental and Clinical Findings

THEODORE XENOPHON BARBER, Ph.D.

Experimental and clinical studies concerned with the effects of "hypnotically-sug-gested analgesia" in surgery, in labor, and in chronic pain are critically evaluated. Thereview suggests that "hypnotic analgesia" at times produces not a reduction in painbut an unwillingness to state directly to the hypnotist that pain was experienced or atempo rary "am nesia" for the pain experienced. In other instances, suggestions of painrelief given under "hypnosis" produce some degree of diminution in anxiety and painas indicated by reduction in physiological responses to noxious stimuli and by reduc-tion in requests for pain-relieving drugs. Th e data suggest that "the hyp notic trancestate" may be an extraneous variable in ameliorating pain experience in situations de-scribed as "hyp nosis;" the critical variables appea r to includ e: (a ) suggestions of painrelief, which are (b) given in a close interpersonal setting.

A N U M B E R OF I NVE ST I GAT OHS 34 contendthat "hypnotically-suggested analgesia"lessens or entirely prevents pain, whileothers82 are of the opinion that hypnoticsuggestions produce verbal denial of painexperience witho ut affecting pa in and suf-fering. This paper critically evaluates theeffects of "hypnosis" on pa in. Relevantclinical and experimental studies are re-viewed to answer two questions: (1)Does "hypnotically-suggested analgesia"refer to reduction of pain, to verbal de-nial of the pain experienced, or to a com-bination of both of these effects? (2) Ofthe many independent and interveningvariables subsumed und er the term "hyp-

Fro m the Medfleld Fo und ation, Medfleld,Mass., and the Division of Psych iatry, BostonUniversity School of Medicine, Boston, Mass.The writing of this paper was made possibleby Research Grant MY+825 from the NationalInst i tute of Mental Health, U.S.P.H.S.Received for publication O ct. 3,196 2.

notically-suggested analgesia"e.g., thesuggestions of analgesia, "the hypnotictrance state," the close relationship be-tween patient and physicianwhich areeffective and which are superfluous toproducing "pain relief"?

Denotations of Critical TermsThe Term "Hypnosis"

When investigators report that "anal-gesia" was pro duce d und er "hypnosis" orin a "hypnotized" subject, they appear tobe saying in an abbreviated w ay tha t painand suffering were ameliorated in a sub-ject who was selected as meeting criteriaof "hypnotizability;" who was placed in"a state of trance;" and who was givensuggestions of pain relief by a prestigefulperson with whom he had a close inter-personal relationship.17 This confound-303


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304ing of a number of independent and in-tervening variables und er th e single term"hypnosis" leads to serious problem s. Itma y be that one or two of these variables(e.g., suggestions of pain relief given ina close interpe rsona l se tting ) are sufficientto reduce pain and that the other vari-ables"the hypnotic trance state," theselection of subjects as "hypnotizable"are extraneous. In the following discus-sion we shall at first use the word "hyp-nosis" as it is commonly used, to refer toall of these variables in combination.After we have reviewed clinical and ex-perimental investigations concerned with"hypnotically-suggested analgesia," weshafi turn again to the term "hypnosis"and w ill place this concept und er criticalanalysis.The Term "Pain"

"Pain" is a multidimensional concept.First, "pain" refers to an unpleasant sen-sation which varies not only in intensity(from "mild" to "excruciating") but alsoin quality (from the lancinating sensationassociated with trigeminal neuralgia, tothe b urn ing sensation found in causalgia,to the deep, aching sensation of abdomi-nal cramps). Secondly, the term "pain"subsumes not only these various "sensa-tions of pain" but also a "reaction pat-tern" which is generally categorized bysuch terms as "anxiety" or "concern overpain." Although these two componentsof the "pain experience" "sensation ofpain," and "anxiety" or "reaction to pain"are normally intimately interrelated, aseries of studies, summarized below, sug-gests that they can be partly dissociatedunder certain conditions.Beecher28 ' ^ has presented cogent evi-dence that similar wounds which pre-sumably produce similar "pain sensa-tions" may g ive rise to strikingly different"reaction patterns." He studied 215 seri-ously woun ded soldiers in a com bat zonehospital. Two-thirds of the men did notshow signs of suffering, were in an "opti-

HYPNOSIS EFFECTS ON PAINmistic, even cheerful, state of mind," andrefused pain-relieving drugs. This ap-parent lack of anxiety and suffering wasnot due to shock, and it was not due to atotal "pain block;" the men were clearmentally and complained in a normalmanner to rough handling of theirwounds or to inept venipunctures.Beecher compared the "reaction pattern"of the wounded soldiers with the reac-tions shown by 150 male civilians whohad undergone major surgery. Althoughthe postoperative patients were sufferingfrom less tissue trauma, only one-fifth ofthese patients (as compared to tw o-thirdsof the soldiers) refused medication for re-lief of pain. The striking difference inreaction to injury in the two groups wasapparently due to differences in the sig-nificance of the wound. The soldierviewed his wound as a good thing; it en-abled him to leave the battlefield withhonor. Th e civilian viewe d his surgeryas a calamitous event. Beecher28 notesthat "one cannot know whether in theabove instances [of the wounded sol-diers] the pain sensation or the reactionto pain is blocked; however, since theconscious ma n bad ly wound ed in w arfareoften does not suffer at all from his greatwound, yet is annoyed by, and suffers ap-parently normally from, a venipuncture,one can conclude that the nervous sys-tem can transmit pain sensations butthat somehow the reaction to them isthe altered element."Hill et al.-" and Kornetsky86 havepresented evidence to suppo rt the hypo th-esis that pain relief following morphineadm inistration is closely relate d to "reliefof anxiety" or "reduction in fear of pain."Cattell,43 Beecher,28 and Barber11 -12 havereviewed other studies which suggest thatmorphine and other opiates at times al-leviate suffering by minimizing "anxiety"and "concern over pain" without neces-sarily elevating the pain threshold or al-tering "awareness of pain." Data indicat-ing that placebos also at times ameliorate

PSYCHOSOMATIC MEDICINE


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BARBER 305"pain experience" by alleviating "anxi-ety" or "reaction to pain' have been re-viewed by Beecher-" and by Barber.11

Additional evidence that "the reactioncomponent" of the "pain experience" canbe at least partly dissociated from "painsensa tion" is foun d in th e effects of suchsurgical procedures as pre trontal leukoto-my and topectomy of Brodmann's areas9 and 10. These and other operations onthe frontal areas at times appe ar to amel-iorate intractable pain by alleviating"anxiety," "worry," and "concern overp a i n . " 1 1 " 9 7 Leukotomized patients char-acteristically state that their pain is thesame, but it does not bother them any-more. Investigators who have studied th eeffects of frontal operations appear toagree with O stenasek's11 3 conclusion that"when the fear of pain is abolished, theperception of pain is not intolerable."The above and other data11 -12 >13 2 sug-gest that in attempting to delineate theeffects of "hypnotically-suggested anes-thesia or analgesia,"" it may be more rel-evant to focus on the "reaction" compo-nent of the "pain experience" rather thanon "pain sensation per se." If "hypnotical-ly-suggested analgesia" relieves "anxiety"or "concern over pa in" bu t does not af-fect pain as a sensation or exerts only anindirecT effect or a minor effect on pa insensation, it can be said tha t it (1 ) affectsa major component of the "pain experi-ence" and (2 ) it may b e exerting as mucheffect on "pain experience" as powerfulanalgesics such as morphine.18 2

"Hypnotic Analgesia," "PosthypnoticAmnesia," and D enia l of P ainA series of clinical reports indicatesthat suggestions of analgesia given under"hypnotic trance" at times result not in a'Since "anesthesia" (insensibil ity to all stimu-li) also includes "analgesia" (insensibility topainful stimuli), studies concerned with relief ofpain by hypnosis rarely made a distinction be-tween these terms, and the terms will be usedinterchangeably in the present review.

VOL. XXV, NO. 4, 1963

reduction in pain and suffering but in anapp aren t am nesia tor the pain and suffer-ing experienced. In a num ber of investi-gations37- 63 '80-93-114> 128 the hypnotizedpatients cried, moaned, or showed signsof shock during surgery or parturition bu tmaintained afterwards that they had for-gotten the experience. For instance,Schultze-Rhonhofl!M reported that obstet-ric patients who had received extensiveantenatal training in entering "deeptrance" showed overt behavioral signs ofpain during laborsome groaned, otherscried, others showed marked agitationbut the patients maintained on awaken-ing that they were not aware of havingsuffered. This investigator interpreted hisfindings as indicating that hypnotic sug-gestions of pain relief rarely if ever pro-duce a complete suppression of pain: "Inthe majority of cases, the complete anal-gesia which is claimed on awakening isthe result of the amnesia."

Raginsky124 refers to cases of minorsurgery performed under hypnosis inwhich the patients appeared "amnesic"immediately after surgery; however,when hypnotized at a later date, the pa-tients could " . . . u sually recall the site ofpain and describe accurately the pain ex-perienced at the time of the operation."Myers,112 Perchard,12 1 and Dorcus andShaffer53 have also presented data indi-cating that "posthypnotic amnesia" forpain experienced during surgery or dur-ing parturition is temp orary a nd easily re-versible.

Other findings, recently reviewed in de-tail elsewhere,19 also indicate that "post-hypnotic amnesia" is labile and superfi-cial. Thesefindings nclud e the following:1. With few if any exceptions, investi-gators repo rt tha t "amnesic hyp notic sub-jects recall the "forgotten" events if thehypnotist states, "Now you remember "*Subjects who have been deeply hypno-tized also recall the "forgotten" happen-ings when given implicit permission toremem ber. Such tacit permission may b e


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306 H Y P N OS IS E FF EC TS O N P A INgiven by asking, "Do you remember?,"with the intonation that the subject ispermitted to remember;14 3 by giving a"hint;"

11 0by instructing th e subject to al-low his han d to write a utom atically;11 0'14 4and so forth.2. Experimental evidence indicatesthat "amnesic" hypnotic subjects recog-nize the material which they claim not toremember; this recognition is indicatedby overt behaviore.g., avoidance of"amnesic" material but not of similar con-trol material8-144and by alterations inpulse and respiration when presentedwith the "forgotten" material but notwhen presented with comparable controlmaterial.81

3. Experimental evidence indicatesthat "somnam bulistic" subjects who show"complete amnesia" when interviewed bythe hypnotist show very little if any ef-fects of the "amnesia" when tested by in-uirect methods which do not depend onverbal reports, such as assessment ofpractice effects or of retroactive inhibi-tion effects.10 1'10 8' m4. "Amnesic" hyp notic subjects charac -teristically make such statements as: '1haven't any inclination to go back overit;" "I do remember but I can't say;" "Iknow it bu t I can't think ab ou t itI knowwhat it is but I just kind of stop myselfbefore I think of it." 3 2 1 4 6 These andother remarks made by "amnesic" hyp-notic subjects can be interpreted as sup-porting "... not a dissociation theory, butrather a motivational theory, a theorythat such amnesia is due to an unwilling-ness to remember, an attempt to occupyoneself with other things than an effort torecall."11 8The above and other data 19 suggesttha t "posthypn otic amnesia for pain" maybe more labile and temporary than is attimes supposed and may be difficult todifferentiate from purposive denial of thepain experienced or from unwillingness toadmit to the hypnotist that pain was ex-perienced. It should be noted here that

the verbal reports of "good" hypnoticsubjects often appear to be closely cor-related with what the hypnotist leads thesubject to believe he is expected to re-p O r t 7, s, io, la, i is I f t h e hypnotist im-plies when interviewing the subject thathe should state that no pain was experi-enced, the '"good" hypnotic subject maycomply on a verbal level even thoughpain was experienced. On the other han d,if the h ypno tic subject is given a means ofstating wh at occurred without at the sametime directly contradicting the hypno-tist's explicit suggestions and the hypno-tists's apparent desires and expectations,he may give a different report. Kaplan*2has presented an interesting case studywhich can be interpreted along theselines. A highly trained hypn otic subjectwas placed in "a very deep trance" andgiven two suggestions: that his left armwas analgesic and insensitive and that hisright hand would continuously performautomatic writing. The "analgesic" leftarm was pricked four times with a hypo-dermic needle; when receiving this stim-ulation, the subject's right hand wrote,"Ouch, damn it, you're hurting me."After a minute or two, the subject askedthe experimenter, "When are you goingto begin," apparently having "forgotten"that he had received the painful stimuli.Kaplan interpreted these findings as indi-cating that hypnotic suggestions of anal-gesia produce "... an artificial repressionand/or denial of pain, but that at somelevel pain is experiencedmoreover, ex-perienced as discomfort at that level."

The motivation for denial of pain ispresent in the hypnotic situation. Thephysician has invested time and energyhypnotizing the patient and suggestingtha t pain will be relieved; expects and de -sires that his efforts will be successful;and by his words and manner communi-cates his desires and expectations to thepatient. The patient in turn has oftenformed a close relationship with thephysician-hypnotist and would like to



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BARBER 307please him or at least not to disappointhim. Furthermore, the patient is awarethat if he states that he suffered, he isimplying that the physician's time andenergy were wasted and his efforts futile.The situation is such that even though thepatient may have suffered, it may be dif-ficult or disturbing for him to state di-rectly to the physician-hypnotist that heexperienced pain and it may be less anx-iety provoking to say that he did not suf-fer.

It should be noted that the motivationto deny pain is not necessarily a functionof the patient's having been hypnotized.Similar findings may be obtained in anysituation, hypnotic or nonhypnotic, inwhich the physician invests time and ef-fort attempting to support the pa tient andto ameliorate the patient's suffering.These conditions making for denial ofpain appear to be present, for instance,in situations described as "natural child-birth." Mandy et al.102 have presenteddata indicating that the "natural child-birth" patient who reports to the physi-cian and to the physician's associates thatshe was "delighted with natural child-birth" may state, when interviewed by anindependent observer, that her deliverywas more painful than she had antici-pated or believed was necessary "but shecouldn't admit it to the house staff forfear of disappointing them."

Carefully controlled studies are neededin which patien ts who have ostensibly ex-perienced "hypnotic analgesia" are inter-viewed not only by the hypnotist but alsoby a person who is not associated with"hypnosis" and to whom the patient iswilling to confide. It can be hyp othe-sized from the data presented above thatsome hypnotic subjects who deny pain orwho appear to have amnesia for painwhen questioned by the hypnotist willstate that they experienced pain and thatthey suffered when interviewed by a per-son whom they trust and who is not as-sociated with the "hypnosis."VOL. XXV, NO. 4, 1963

Overt Behavioral Reactions as Criteria of"Analgesia" or "Pain ReliefThe data cited above suggest cautionin using the hypnotic patient's verbal re-port as given to the hypnotist as an indexof pain relief. Caution is also necessaryin using the hypnotic patient's lack ofovert behavioral reactions to noxiousstimulation as indicating that pain andsuffering have been abolished; as notedabove, the hypnotic subject is often moti-vated to please the hypnotist or to try notto disappoint the hypnotist and this mayat times be sufficient for him to try to in-hibit overt signs of pain such as moaning,wincing, or restlessness.The findings presented by Javert andHardy81 with respect to "natural child-birth" may also apply to the patient un-dergoing labor under "hypnosis." Thesubjects consisted of 26 untrained laborpatients and 5 patients who had been"trained" in "natural childbirth" by others(not by Javert or Hardy). During laborthe untrained patients showed evidenceof anxiety and pain, while the "naturalchildbirth" patients appeared relatively"serene." Between uterine contractionsboth groups were asked to compare thepain of labor with the pain produced byapplication of radiant heat to the fore-limb. (These measurements were madein both groups prior to the administration

of analgesic or anesthetic drugs). The"natu ral childbirth" patients did not dif-fer from the untrained patients in esti-mates of pain intensity; both groups ratedthe pain of labor as relatively severe andequal in maximal intensity to blister-pro-ducing thermal stimulation. Javert andHardy interpreted these findings as indi-cating that the regimen known as "naturalchildbirth" produces a "satisfactory reac-tion pattern" but has little if any effecton the intensity of the pain experiencedduring labor.

An additional consideration should benoted here: Velvovski et al.1S9 claims that


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308 HYPNOSIS EFFECTS ON PAINfrom 7 to 14% of unselected patients inthe Soviet Union give birth without m edi-cations, without showing signs of pain,anxiety, or suffering, and without receiv-ing any training or prepa ration. Are morethan 14% of unselected hypnotized pa-tit nts able to perform this feat? No da taare available to answer this question; re-ports concerned with the effects of hyp-nosis in parturition are in all cases basedon volunteers or selected patients.

Th e proportion of selected hypnotic pa-tients able to deliver without medicationsand without exhibiting signs of sufferingmay not greatly exceed the 7 to 14% ofunselected patients which Velvovskiclaims can deliver in this way withoutany training at all. Although some inves-t igators46107- 109 report that more thanone-third of selected hypnotic patientsare able to deliver without anodynes,others4 '4 0 '1 4 T find that no more than 14%of patients who volunteer for hypnosistraining are able to deliver without m edi-camen ts and without showing gross signsof pain.Similar considerations may apply insurgery: The proportion of selected pa-tients who are able to undergo surgerywith "hypnoanesthesia" alone may notgreatly exceed the proportion of unse-lected patients who were able to undergosurgery in the preanesthetic period with-out manifesting signs of pain. Data pre-sented by Trent,13 8 Leriche,98 Elliotson,58and Chertok44 indicate that althoughsome surgical patients, prior to the ad-vent of anesthetics, struggled andscreamed, a small proportion of patients" . . . bravely ma de no signs of suffering atall." Although it is often stated that atthe present time app roximately 10% of thepopu lation is able to undergo surgery u n-der "hypnotic trance," Wallace and Cop-polino 14 1 note the following:

Our percentage of success in the completesubstitution of hypnoanesthesia for chemoanes-thesia has been less than the previously quoted10 per cent. There have not been any pub-

lished series of cases in which a statistical anal-ysis would indicate that approximately 10 percent of the patients are aole to withstand asurgical intervention with hypnoanesthesia asa sole modality. Therefore, it is our conclusionthat the 10 per cent estimate is an often-re-peated but unsubstantiated quantity and thatthe true percentage of successful cases is muchbelow that figure.The above data suggest two conclu-sions:1. Caution is necessary in accep ting th ehypnotic patient's verbal report or lackof overt behavioral reactions as valid in-dices that the patient did not suffer. Thehypnotic situation is often structured insuch a manner that the patient is moti-vated to inhibit overt signs of pain andto deny pain experience.2. The proportion of selected hypno-tized patients who are able to undergolabor or surgery without m anifesting m o-toric signs of pain and without receivinganodynes m ay not greatly exceed the pro-

portion of unselected patients who areable to do the same thing without anypreparation at all. Careful controls areneeded to de term ine if the effects attribu -ted to "hypnosis" are due to the selectionof patients.Physiological Indices of Anxietyand Fain

The data presented above suggest thatan objective index of pain which is diffi-cult or impossible to affect voluntarily isneeded in studies concerned with "hyp-notically-suggested analgesia." Unfortu-nately there appears to be no single in-dex and no combination of indices whichunequivocally indicate the presence orabsence of pain and suffering. However,a series of studies demonstrate that a sat-isfactory, although not conclusive, objec-tive index of anxiety and pain consists ofan alteration in one or more systemicphysiological functions which are diffi-cult to alter by voluntary effort.



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BARBER 309In normal subjects painful stimulationalmost always produces alterations in oneor more of the following: blood pressure,heart rate, respiration, digital vasomotortone, skin resistance, and degre e of tensionin localized muscles.24 ' 2K-4- 48> Bfii 89'12WAlthough nonpainful stimuli at times alsoproduce alterations in these physiologicalindices, they rarely p rodu ce th e same de-gree or the same pattern of alteration aspainful stimuli.24 'S9 -92 There is also evi-dence to indicate that morphine, meperi-dine, nitrous oxide, and other analgesicsand anesthetics drastically reduce these

normally expected responses to noxiousstimulation. The galvanic skin responseto painful stimulation is apparently mark-edly reduced by morphine at low doselevels (8 mg.) 3 and is apparently abol-ished by nitrous oxide anesthesia,38 bymeperidine (100 mg.), and by morphineat higher dose levels (20-100 m g.) .3 It al-so appears that morphine (8-16 mg.)and codeine (32-64 m g.) reduce the vas-oconstriction response to noxious stimu-lation to near the vanishing point12 9 andthat the elevation in blood pressure whichnormally follows painful stimulation iseliminated by anesthetic doses of barb itu-rates.08

Before turning to experimental studieswhich used physiological variables to as-sess the effects of "hypnotically-suggestedanalgesia," two considerations should beemphasized. (1) Subjects differ in theirphysiological patterns of response to thesame noxious stimulus, and the same sub-ject may show different patterns of phys-iological response to different types ofnoxious stimuli.92 When physiologicalvariables are used to assess "hypnotic an-algesia," it is necessary to tak e inter- andintrasubject variability into account. (2)Alterations in physiological variablesduring painful stimulation appear to bemore closely correlated with the "anxiety"or "reaction" component of the pain ex-perience than with "pain sensation perse"2i ,w, 74,9, 127 x i j i s consideration, how -VOL. XXV, NO. 4, 1963

ever, is not a major object ion to the use ofautonomic indices to assess the e ffec ts of"hypno t i ca l ly - sugges t ed ana lges i a . " "Anx-i e ty ' o r "conce rn ove r pa in" appea rs t o bea ma jor componen t o f t he t o t a l pa in ex-per ience , and i f ""hypnot ic ana lgesia" re -duces anx ie ty and conce rn ove r pa in , i tcan be sa id to exer t an important e f fec ton pa in expe r i ence even i f i t does no ts igni f icant ly a f fec t pa in as a sensa-t i on .1 1 ' 12> 28> 72> 76 '77> 88> 132

Experimental Studies of"Hypnotic Analgesia"

D y n e s 5 6 m o n i t o r e d h e a r t r a t e , r e sp i r a -to ry ra t e , and change in sk in r e s i s t ance inre sponse to p inch and p inpr i ck in 7" t r a i n e d so m n a m b u l e s " u n d e r c o n t ro lcond i t i ons and a f t e r sugges t ions o f ana l -g e s i a w e r e g i v e n u n d e r t r a n c e . T h e n o x -i o u s s t i m u l a t i o n p r o d u c e d a n a v e r a g e i n -crease in respi ra tory ra te of 3 cyc les perm i n u t e u n d e r t h e c o n t r o l c o n d i t i o n a n dof 1 cyc l e pe r m inu te und e r t h e t r an cec o n d i t i o n . H e a r t r a t e sh o w e d a m e a n i n -crease of 2& b e a t s p e r m i n u t e u n d e r t h econ t ro l cond i t i on and fa i l ed to show aninc rease un de r t he t r an ce cond i t i on . Al lsub jec t s showed ga lvan ic sk in r e sponses( G S R ) o f t h e s a m e o r d e r o f m a g n i t u d eu n d e r t h e c o n t r o l a n d t r a n c e c o n d i t i o n s .Th i s s tudy i s open to a t l e a s t one ma jorc r i t i c ism: Th e s t imul i w e r e a lways a d-min i s t e red f i r s t unde r t he con t ro l cond i -t i o n a n d t h e n u n d e r t r a n c e . A s S h o r 1 3 8has po in t ed ou t , s i nce phys io log ica l r eac -t i ons t o pa in fu l s t imu la t ion gen e ra l lyshow a hab i tua t ion o r adap ta t ion e f -fect,48 - 64> 74> 131 t e n d i n g t o d e c r e a se d u r -i n g a s e c o n d a n d su b se q u e n t s t i m u l a t i o n s ,t he poss ib i l i t y was no t exc luded tha t as imi l a r r educ t ion in hea r t r a t e and re sp i r -a t o r y r a t e m i g h t h a v e b e e n o b se r v e d d u r -ing the second s t imula t ion i f the subjec tsh a d n o t b e e n p l a c e d i n " h y p n o t i c t r a n c e "and had no t been g iven sugges t ions o fa n a l g e s i a . T h i s e x p e r i m e n t a n d t h e o t h e re x p e r i m e n t s r e v i e w e d b e l o w w e r e c o n -


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310 HYP NOS IS EFFECTS O N P AINcerned primarily with the effects on painexperience of explicit suggestions of anal-gesia given under "hypnotic trance." Anum ber of studies34' wu -131> '1M> 145 also as-sessed the effects of "hypnotic trance perse" on physiological responses to noxiousstimuli; these studies were unable todemonstrate differences in autonomic re-activity to painful stimulation under awaking condition and a trance conditionwhich did not include explicit suggestionsof analgesia.

Sears13 0 employed facial flinch, respira-tory depth, respiratory variability, pulseamplitude, pulse variability, and GSR asindices of pain. Seven carefully selected"deep-trance" subjects participated. Thepain stimulus consisted of a sharp steelpoint pressed against the calf of the legfor 1 sec. with a pressure of 20 oz. withoutbreakin g the skin. This stimulus was firstapplied in a waking control series to de-termine which of the physiological varia-bles we re reliable indices of pain. In asubsequent hypnosis series the subjectswere placed in deep trance, suggestionsof anesthesia were given for the left leg,the right leg was employed as a control,and the stimulus was applied alternatelyto the two legs. In a third series of experi-ments (voluntary inhibition), the sub-jects were instructed to try to inhibit re-actions to the painful stimulus.

Sears presented the following findingswith respect to the critical hypnosis se-ries: When the painful stimulus was ap-plied to the "anesthetic" leg, the hypno-tized subjects showed significantly lessfacial flinch, respiratory depth, respira-tory variability, pulse variability, andGSR than when the stimulus was appliedto the control leg. The amplitude of thepulse did not differ significantly when the"anesthetic" and control limbs were stim-ulated.Sears' findings have been generally interpreted as a convincing demonstrationof the effect of hypnotic analgesia onphysiological reactions to painful stim-

uli TO, 75,84,142 However, Shor13- has re-cently reanalyzed Sears' data and foundthat some of the computations were in-correct. Shor's analysis shows that respir-atory depth, pulse variability, and pulseam plitu de were not significantly differentwhen the stimulus was applied undertrance to the "anesthetic" and controllimbs. Facial flinch, respiratory v ariabili-ty, and GSR differed significantly underthe "anesthetic" and control conditions.A further problem arose when the prob-abilities for the waking control serieswere recom puted: Shor found th at in thisseries respiratory variability was not sig-nificantly different before and after pain-ful stimulation and was thus of question-able adequacy as a criterion of physio-logical response to painful stimulation.In brief, Shor's careful reanalysis of Sears'original data indicates that only 3 meas-ures instead of 6 as reported originallywere significantly affected by hypnotical-ly suggested analgesia. However, of thes ethree measures, one (respiratory varia-bility) was of questionable adequacy un-der th e conditions of the exp eriment as anindex of response to painful stimulationand another (facial flinch) is not a physi-ological variable and is amenable to vol-unta ry control. Sears' major finding, then,was that the GSR to painful stimulationwas reduced by 22% under hypnoticallysuggested analgesia. This mean reduc-tion in GSR was due to 4 of th e 7 subjects;the other 3 subjects showed a GSR of thesame order of magnitude when the stimu-lus was applied to the "anesthetic" andcontrol limbs.

As mentioned above, Sears performedan additional series of experiments inwhich the same subjects were instructedto try to inhibit all responses to the pain-ful stimulus. In this voluntary inhibitionseries significant physiological reactionswere found and the subjects showed fa-cial flinch. Sears interpreted these find-ings as indicating that "Voluntary inhibi-tion of reaction to pain does no t present a



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BARBER 311picture even remotely resembling thereaction under true hypnotic anesthesia."However, the subjects' failure to inhibitflinching renders this conclusion ques-tionab le. In pilot studies Sears had foundthat the flinch response to the stimuluscould be inhibited "by most people withlittle difficulty." As Hul l80 has pointedout, since the flinching response is nor-mally und er vo luntary control, it a ppearspossible that the "trained" hypnotic sub-jects participating in the Sears experi-ment did not actually try to suppress re-actions to pain when instructed to do so.The Sears study thus appears to be opento the same criticism that applies to otherstudies in "hypnosis" which employed"trained" hypnotic subjects "as their owncontrols," namely, when a single group of"trained" hypnotic subjects is tested un-der both the experimental and the controlconditions, it is difficult to exclude thepossibility that the subjects may pur-posively give an inferior performance un-der the control condition in order to com-ply with what they correctly or incorrect-ly surmise are the wishes or the expecta-tions of the experimenter.17 '133

Doupe et al.&i studied the effect of hyp-notically suggested analgesia on the vaso-constriction response to painful stimula-tion. Eight subjects were used, but dataare p resented only on 5 subjects. These 5subjects participated in 11 experiments.After the subject was deeply hypnotized,digital vasodilatation was produced byplacing his legs in warm water. Sugges-tions were then given that one arm wasinsensitive and analgesic with the und er-standing that the alternate arm would re-main normally sensitive. Pin-prick stimu-lation (and, at times, ice stimulation)was then applied alternately to the "anes-thetic" and no rmal limbs. From 6 to 40stimulations w ere applied to each limb ineach experiment. Eigh t of the 11 experi-ments failed to show a significant differ-ence between the "anesthetic" and nor-mal limbs in vasoconstriction response toVOL. XXV. NO . 4, 1963

the noxious stimuli. In the remaining 3experiments, stimulation of the "anes-thetic" limb produced less vasoconstric-tion than stimulation of the control limb,the reductions ranging from 36 to 40%.Doupe et al. also recorded respiration andpulse in these experiments but did notpresent the data obtained on these meas-ures. They state only that "No significantchanges in pulse rate were reco rded" and"A slight alteration in respiratory rhythmwas caused by stimuli applied to either[the "anesthetic" or normal] side, bu t thistended to be greater when the normalside was stimulated."Brown and Vogel38 compared physio-logical responses to noxious stimulationunder hypnotically suggested analgesia,waking-imagined analgesia, local anal-gesia produced by Novocain," and gen-eral anesthesia prod uced by nitrous oxide.Three pain stimuli were used (lancet,weighted thumbtack, and water at 49C ) ; three physiological measures weremonitored (GSR, pulse, and blood pres-sure) ; and 3 carefully selected "deep-trance " subjects participated. T he a uthorspresented the results in the form of rawdata without statistical analysis. Fromthese data they deduced the followinggeneral conclusions: (1) Waking-imag-ined analgesia m ay be as effective as sug-gestions of analgesia given under trancein reducing physiological responses tonoxious stimulation. (2 ) Nitrous oxideanesthesia is totally dissimilar to hyp-notically suggested analgesia; nitrousoxide anesthesia b ut not hypnotically sug-gested analgesia abolishes physiologicalreac tions to noxious stimulation. It is dif-ficult to determin e from the raw data pre-sented in the report if these general con-clusions are justified. However, a carefulanalysis of Brown and Vogel's data hasrecently been performed by Shor,182 whoreports the following: (1) Physiologicalresponses to the noxious stimuli did notdiffer significantly under hypnotically

Winthrop Laboratories, New York, N. Y.


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312 HYPNOSIS EFFECTS ON PAINsuggested, waking-imagined, and Novo-cain analgesia. Given the small numberof subjects and the variability of the data,it was not possible for statistically signifi-cant effects to eme rge. (2 ) W ith respectto the conclusion that nitrous oxide anes-thesia is totally dissimilar to hypnoticanalgesia, it appears that this is valid forthe galvanic skin response, but it is notclear if it also applies to the pulse andblood-pressure responses. The GSR tonoxious stimulation dropped out undernitrous oxide but not under hypnoticanalgesia. (3 ) W ith respect to the con-clusion that waking-imagined analgesiamay be as effective as hypnotically sug-gested analgesia in attenuating physio-logical reactions to noxious stimulation,it appears that what is being said is thatsince neither waking-imagined nor hyp-notically suggested analgesia had anymeasurable effect, they both by defaulthad about equal effectiveness.

In addition to performing reanalyses ofthe data of previous experiments, Shor132also carried out an experimental study ofhis own. The experimental group con-sisted of 8 "somnambulistic" subjects; thecontrol group consisted of 8 subjects whohad demonstrated in a series of prelimi-nary sessions that they were not suscepti-ble to hypnosis. Prior to the experimentprope r all subjects chose a level of electricshock which they found painful butwhich they were willing to tolerate withequanimity for an extended series of ex-periments. Each subject was then pre-sented with his chosen level of electricshock under 5 experimental conditionswhile skin resistance, respiration, andheart rate were recorded continuously ona polygraph . Th e experimental condi-tions (counterbalanced to control for or-der effects) were as follows: (1) wakecontrol (the effect of the wake statealone); (2) hypnotic control (the effectof hypnosis alone); (3) wake inhibition(voluntary suppression of reactions topain in the waking state); (4) hypnotic

inhibition (voluntary suppression of re-actions to pain n the hypnotic s tate);and (5) hypnotically suggested anal-gesia. The experimental group ("som-namb ulistic" hypn otic subjects) w as hy p-notized un der Conditions 2, 4, and 5; thecontrols (subjects insusceptible to hypno-sis ) were instructed to prete nd as if theywere hypnotized under these three ex-perimental conditions. Shor presentedthe following findings: (1) The experi-mental group did not show significantlydifferent physiological responses to thenoxious stimuli under any of the five ex-perimental conditions. (2) The controlgroup also failed to show significant dif-ferences in physiological responses underany of the experimental conditions. (3 )Th ere appe ared to be a trend (no t signifi-cant) for over-all reactivity to be less un-der the waking inhibition condition. Shorconcluded that his data offered no sup-port to the hypothesis that hypnoticallysuggested analgesia has special effects onphysiological responses to painful stimuliwhich are beyond the bounds of wakingvolitional control.

Since skin-resistance change (GSR) iseasily monitored and is markedly respon-sive to painful and to anx iety-arousingstimulation, it has been employed in anextensive series of studies concerned withthe effects of "hypnotic analgesia." Fiveearly studies which used the GSR as thesole criterion of physiological response topain reported contradictory findings.Peiper,12 0 working with 4 subjects, Pri-deaux,12 3 with 4 subjects, and Levine,88with 1 subject, reported that noxious stim-ulation applied to a skin area for whichanalgesia had been suggested undertrance prod uced a normal GSR. Georgi,65working with 3 subjects, and Moravc-sik,111 with 1 subject, reported that hyp-notic suggestions of analgesia reduced theGSR to painful stimuli. In these earlystudies the experimental procedures arenot presented in detail, and the data arenot analyzed statistically. Two recent



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BARBER 313studies, summarized below, were carriedout more rigorously; here again, contra-dictory results were obtained.

West et al.us

monitored skin resistancein an extensive series of repeate d sessionswith 7 subjects. (A total of 45 experi-mental sessions was held, an average ofmore than 6 sessions per subject.) Eachexperimental session included a wakingcontrol condition followed by a hypnosiscondition. Under the control conditioneach subject received a series of painfulstimuli of increasing intensity producedby radian t he at app lied to a forelimb; fol-lowing these control trials, hypnosis wasinduced, suggestions were given that thelimb was anesthetic, and the painfulstimuli were again presented in the sameorder. The mean GSR to the painfulstimuli was significantly reduced underthe hypnotic-analgesia condition for allsubjects, the reductions ranging from 26to &7%. West et al. note th at the GSR wasat times reduced, even when ". . . therewas no alteration in pain perception, ac-cording to subjective reports," and duringthe con trol periods a stimulus evoking re-ports of relatively severe pain at timesfailed to produce a GSR. The findingsthus appear to be consistent with earlierreports84 that the galvanic skin responseto noxious stimulation m ay be mo re close-ly related to the "threat-content" or "anxi-ety" aroused by a noxious stimulus ra therthan to "pain perception p er se." This studyappea rs to be open to one major criticism:The control trials always preceded thehypnotic trials with 3 subjects and wereonly "occasionally" reversed with theother 4 subjects; since the GSR to noxiousstimulation tends to decrease over a seriesof trials,48- T4>131 the effects of hyp-notically suggested analgesia may havebeen confounded with possible adapta-tion effects.132 In a recent experimentwhich controlled adaptation effects, Sut-cliffe184 presented contradictory findings.

Sutcliffe recorded the galvanic-skin re-sponse to noxious stimulation under nor-VOL. XXV, NO. 4, 1963

mal w aking conditions, hypnotically-sug-gested analgesia, and waking stimulationof analgesia. Ad apta tion of the GSR tothe noxious stimuli was controlled byemploying different subjects under eachexperimental condition. In pre-experi-mental sessions, 24 subjects were given aseries of electric shocks, and a level ofshock was established which invariablyproduced pain. The subjects were thenrandomly assigned to three experimentalgroups with 8 subjects (4 "somnam bu-lists" and 4 "nonsomnambulists") ineach group . Group 1 received 4 electrie shocks at intervals of 1 min. un-der normal waking conditions. Group 2received the 4 electric shocks after sug-gestions of analgesia were given undertrance. Grou p 3 received the 4 shocksafter receiving instructions un de r wak ingconditions to act as if the shocks werenonpainful. Th e GSR to the shocks wasthe same under the waking control condi-tion, the hypnotic analgesia condition,and the waking acting condition. The"somnambulists" did not differ from the"nonsomnambulists" under any of the ex-perimental conditions. Sutcliffe's studyalso included th ree add itional experimen-tal conditions designed to determine ifhypnotically-hallucinated shock or wak-ing-acting as if receiving electric shockproduce a CSR similar to that foundwhen electric shock is actually received.Hypnotically-hallucinated shock did notproduce a GSR comparable to that foundduring actual shock; waking-acting as ifreceiving a shock produced a GSR of thesame order of m agn itude as actual shock.Most of the experiments describedabove were limited in scope as follows:(1) The pain-producing stimulipin-prick, electric shock, or radiant heat ap-plied to a limb for no more than 3 secwere of brief or mo men tary duration . (2 )Pain reactivity under hypnotically sug-gested analgesia was compared with re-activity under an uninstructed wakingcondition. Although four of these experi-


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314 HYPNOSIS EFFECTS ON PAINmentsM -M - i: m- U5 found that suggestionsof analgesia given under "trance" weremore effective than no-instructions in re-ducing physiological responses to noxiousstimulation of short duration, this doesnot demonstrate that "hypnotic trance"was a necessary condition in producingthis effect. As Brown a nd Vogel38 hy-pothesized, it may b e possible to prod ucea similar reduction in physiological reac-tivity to painful stimuli by instructing acontrol group to try to imagine that anoxious stimulus is nonpainful. Barberand Hahn-4 recently presented a carefullyconducted experiment designed to testthis hypothesis. Th e Barber and H ahn ex-periment was performed as follows.

Prior to the experiment proper, a stand-ardized suggestibility scale was adminis-tered under nonhypnotic conditions to192 female students. The 48 most "sug-gestible" subjects (ranking in the upperquartile with respect to scores on the sug-gestibility scale) were selected to partici-pate in the critical experiment. Theseselected subjects, who w ere hom ogeneouswith respect to sex, age, social back-ground, and level of pre-existing sugges-tibility, were allocated at random to oneof four experimental conditions (hyp-notically suggested analgesia, uninstruct-ed condition, control condition, and wak-ing-imagined analgesia) with 12 subjectsto each cond ition. Subjects assigned tothe hypnosis condition were given astandardized 20-min. trance inductionprocedure followed by a series of tests toassess suggestibility. All subjects in thisgroup appeared to enter trance (i.e., ap-peared drowsy and showed psychomotorretardation and lack of spontaneity andinitiative) and responded positively tothe test suggestions. Suggestions werethen given for a period of 1 min. to induc eanesthesia of the left hand; followingthese suggestions the hypnotized subjectimmersed the "anesthetic" hand in waternear the freezing point (2 CC.) for 3 min.(Previous investigators29 -59 '9fl 149 had re-

ported that "aching pain" is elicited innormal subjects by water near the freez-ing point within 10-60 se c ; if the stimulusis not removed, pain continues for 2-4min. before adaptation sets in; and theintensity of the pain experienced is close-ly related to increments on such physio-logical variables as hea rt rate, systolic anddiastolic pressure, and respiratory vari-ability.) Subjects assigned to the un-instructed, control, and waking-imagina-tion conditions were not hypno tized. U n-der the uninstructed and control condi-tions the subjects were simply asked toimmerse the left h and in wa ter: th e unin-structed group imm ersed the hand in wa-ter near the freezing point (2C.) for 3min., and the control group immersed thehand in water at room temperature forthe same period of time. Subjects allo-cated to the waking-imagined analgesiacondition were instructed and motivatedfor a 1-min. period to imagine a pleasantsituation when the noxious stimulus (wa-ter at 2C.) was applied (" ... W hen yourhand is in the water, try to imagine thatit is a very hot day, that the water feelspleasantly cool, and that your hand is re-laxed and comfortable...").

Soon after stimulation all subjects com-pleted a questionnaire designed to assesssubjective experiences. This question-naire yielded the following findings: (1)the hypnosis and waking-imaginationgroups did not differ in subjective reports,stating that, on the average, the stimuluswas experienced as uncomfortable butnot painful. (2 ) Th e hypnosis and wak-ing-imagination groups differed signifi-cantly from the uninstructed group,which rated the stimulus as painful, andfrom the control group, which rated thestimulus as not uncomfortable. Physio-logical variables (heart rate, skin resist-ance, forehead-muscle tension, and res-piration) monitored prior to and duringstimulation were analyzed in terms ofLacey 's autonomic lability scores91 to con-trol for differences in base (prestimulus)



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BARBER 315levels of physiological functioning. Thisanalysis showed the following: (1) Thehypnosis and waking-imagination groupsdid not differ on any physiological re-sponse to the noxious stimulus. (2) Ascompared to the uninstructed condition,both hypnotically suggested analgesiaand waking-imagined analgesia were ef-fective in reducing muscle tension andrespiratory irregularities during the nox-ious stimulation. (3) Under hypnotical-ly suggested analgesia and waking-imag-ined analgesia, muscle tension but notrespiratory irregularity was reduced tothe low level found un de r the control con-dition. (4) Hea rt rate and skin-resistancelevel du ring the period of noxious stimu-lation did not differ under the hypnoticanalgesia, waking-imagined analgesia,and uninstructed condition; under theseconditions subjects showed significantlyfaster heart rate and signfiicantly lowerskin resistance than under the controlcondition. In brief, the Barber and Hahnexperiment found that hypnotically sug-gested analgesia is effective in attenuat-ing pain experience as indicated by sub-jective reports and by reduction in fore-head muscle tension and respiratory ir-regularities; although pain experience isreduced under hypnotic analgesia, it isnot abolished; and the experience of painappears to be as effectively mitigated bywaking-imagined analgesia as by hyp-notically suggested analgesia.Th e findings reviewed above appea r toindicate that hypnotically suggested an-algesia at times has some effect on physi-ological reactions to noxious stimuli, butthis effect is by no means as drastic as isimplied in previous reviews.70 ' "84> 142Brown and Vogel,38 Sutcliffe,134 andShor132 failed to reject the null hypothe-sis of no difference in autonomic re-sponses to painful stimuli under hypnot-ically suggested analgesia and a wakingcontrol condition. Doupe et al.6* foundthat hypnotically suggested analgesia re-duced the vasoconstriction response to

VOL. XXV. NO. 4, 1963

pin prick in three experiments but failedto do so in eight experiments. Sears13 0observed a 22 % reduction in mean GSRto noxious stimuli under hypnotic anal-gesia. In Dynes '56 experiment, hypnotic-ally suggested analgesia reduced the ex-pected increase in heart rate, and in res-piratory rate, by 2% beats per m inute, andby 2 cycles per m inute, respectively. Westet a/.145 observed a 26-67$ reduction ingalvanic-skin response topainful heat un-der hypnotically suggested analgesia.However, in the Dynes experiment andin the West et al. experiment, the hyp-notic trials almost always followed thecontrol trials, and it appears possible thatsome of the observed reduction in auto-nomic reactivity associated with hy pnoticanalgesia was produced by adaptation tothe stimuli. Further, in the experimentspresented by Dynes,58 Sears,13 0 Doupeet al.,5* andWest et a?.,14"1 inwhich physi-ological reactivity was reduced underhypnotic analgesia, the comparison wasmade w ith anuninstructed waking condi-tion. Barber and Hahn24 also found thatas com pared to an uninstructed co ndition,hypnotically suggested analgesia reducedsome physiological responses to noxiousstimulation (muscle tension and irregular-ities in resp iration ); how ever, these inves-tigators also found that instructions giv-en under waking conditions to imagine apleasant situation when noxious stimula-tion was applied were as effective as sug-gestions of analgesia given under hyp-notic trance in producing these effects.A substantial number of "hypnotic-analgesic" subjects participating in theabove experimen ts man ifested gross phvs-iological responses to relatively "mild"pain stimuli such as pinprick. This raisesa crucial question: Does the "hypnoticanalgesic" subject undergoing surgeryshow autonomic responses indicative ofanxiety or pain? In searching the litera-ture, no studies were found which pre-sented data on a series of physiologicalvariables recorded continuously during


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316 HYPNOSIS EFFECTS ON PAINsurgery performed under "trance." Asmall number of surgical studies werefound which presented a few discontinu-ous pulse or blood-pressure measure-ments; these studies are reviewed below.Surgery Under "Hypnotically SuggestedAnalgesia"

Discussions concerned with the effec-tiveness of "hypnotically suggested anal-gesia" in surgery2 '39 > 75>124> 13 e generallyfollow an outline as follows: It is firststated tha t th e effectiveness of "hypnosis"is beyond disp ute since Esda ile performedamputations and many other major oper-ations "painlessly" under "mesmerictrance" in India during the years 1845 to1851; the authors then present a few sub-sequent cases of surgery preformed un-der "trance" and then conclude that "hyp-notic analgesia" produces a drastic reduc-tion in pain experience. The argumentto support this contention almost alwaysrelies heavily on Esdaile's series.Although Esdaile's cases are generallyreferred to as "painless" surgery per-formed under "trance," a close look atEsdaile's original report61 suggests thathis operations may not have b een free ofanxiety and pain. Esdaile did not claimthat all or even a majority of his patientsremained quiet during surgery.10 3 Somepatients showed "disturbed trances" andothers awakened from "trance": "Shemoved and moaned" (p. 200); "Hemoved, as in an uneasy dream" (p . 204);"About the middle of the operation hegave a cry" (p. 222); "He awoke, andcried out before the operation was fin-ished" (p. 232); "The man moved, andcried out, before I had finished. . . . onbeing questioned he said that he had feltno pain" (pp. 145-146). Esdaile claimedthat many of his operations were success-ful even though pain may have been ex-perienced because the patients forgot thepain: ". . . the trance is sometimes com-pletely broken by the knife, but it can

occasionally be reproduc ed by continuingthe process, and then the sleeper remem-bers nothing; he has only bee n disturbedby a night-mare, of which on waking heretains no recollection" (pp.145-146).In 1846, the governor of Bengal ap-pointed a committee consisting of theinspector-general of hospitals, three phy-sicians, and three judges to investigateEsdaile's claims.35 Esdaile removed scro-tal tumors from 6 carefully selected pa-tients who had been placed in "mesmerictrance" by "passes" made over the bodyover a period of about 6-8 hr. (T hree ad-ditional patients who were to undergosurgery before the committee were dis-missed when it was found that they couldnot be mesmerized after repeated at-temp ts extending up to 11 days.) Th ecommittee reported that during surgery3 of the 6 patients showed "convulsivemovements of the upper limbs, writhingof the body, distortions of the features,giving the face a hideous expression of

suppressed agony; the respiration b ecam eheaving, with deep sighs." The other 3patients did not show gross signs of pain;however, 2 of these 3 showed markedelevations in pulse rate during the sur-gery on the o rder of 40 beats per minu te.In brief, it appears that some of Es-daile's surgical cases awakened from"trance" and suffered and some remainedin "trance" but showed either "a hideous

expression of suppressed agony" ormarked tachycardia. How ever, a certainnumber of Esdaile's surgical patients didnot show overt signs of pain and statedon awakening that they had not suffered.Although this is indeed remarkable, cau-tion should be exercised in generalizingfrom these cases. In the first place, theproportion of Esdaile's patients that fellinto this category cannot be determinedfrom the data presented in his report.Secondly, if facilities had been availablefor recording blood pressure, pulse, skinresistance, and othe r autonomic variablescontinuously, it appears possible that



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BARBER 317these patients may also hav e shown phys-iological reactions indicative of anxietyand pain. Thirdly, it cannot be assumedthat these patients would have moanedor cried during the surgery if they hadnot been in "mesmeric trance;" althoughmany of Esdaile's nonm esmerized surgicalpatients cried and struggled, his reportsuggests tha t a few of his surgical patientswho could not be placed in "mesmerictrance" did not show gross signs of pain(pp. 214-215).

Following Esdaile's report, scatteredcases ha ve been pu blished of surgery pe r-formed under "hypnosis."36-4T- 6 0 Typi-cally these reports state tha t an operationwas performed under hypnotically sug-gested analgesia, e.g., dental extraction,avulsion of fingernail, incision of infecteddigit,12 9 removal of cervicouterine tu-mors,12 5 and the ". . . cooperation of thepatient was perfect, the operation waspainless and there was no post-operativepain"12 6 or the pa tien t". .. woke up with-out pain or any physiological disturb-ance."125 The procedures employed andthe patient's overt behavior and subjec-tive reports are not presented in detail,and physiological measures monitoredduring the surgery are not reported.

Th e few reports that present some phys-iological data suggest the possibility thatthe "hypnotic-analgesic" surgical patientmay experience some degree of anxietyand pain. Finer and Nylen62 presented asuccessful case of excisions and skin graftsperformed upon a severely burned pa-tient under 'Tiypnoanesthesia;" althoughthe patient did not show overt motoricsigns of pain, blood pressure and pulseshowed significant elevations. Kroger andKroger and DeLee 8 7 8 8 employed "hyp-notic analgesia" in the removal of breasttumor, in subtotal thyroidectomy, in ex-cision biopsy for breast tum or, and in ce-sarean section and hysterectomy ; no phys-iological data are presented with the ex-ception of the cesarean section and hys-terectomy; in this case, Kroger and De-VOL. XXV, NO . 4, 1963

Lee8x write that during the surgery theblood pressure varied from 125/85 to80/60 and pulse varied from 76 to 100.Taugher13 5 has presented 3 cases of sur-gery (tonsillectomy, curettage, and ce-sarean section) performed und er "trance."Although the patients did not complainof p ain, blood pressure an d pulse showedmarked variability; in the cesarean sec-tion, for instance, blood pressure variedfrom 140/90 to 80/20, and pulse ratevaried from 86 to 120.Mason106 has presented a case of mas-toplasy performed under hypnoticallysuggested analgesia. With the exceptionof sodium amy tal, adm inistered th e nightbefore surgery, no other m edications weregiven. Du ring the operation th e entrancedpatient did not show noticeable signs ofpain; on awakening, she appeared to beamnesic for any pain th at may have beenexperienced. M ason writes that at somepoint during the operationthe precisetime is unspecifiedthe patien t's ".. .pulse

rate stabilized at 96 and respiratory rateat 24 per minute," with the implicationthat these measures may have been un-stable prior to this period.In other recent surgical cases the ef-fects of hypnotically suggested analgesiawere confounded with the effects of seda-tive and analgesic drugs. Manner,10 5 forinstance, employed hypnosis in an exten-sive series of surgical cases (bu nion ecto -

my, laminectomy, thyroidectomy, hemor-rhoidectomy), but substantial quantitiesof analgesic agents (nitrous oxide, meper-idine, caudal block with lidocaine) werealways used, no control cases are report-ed, an d it is difficult to sep ara te the effectsof "hypnosis" from the effects of the dru gs.Tinterow 13 7 has presented 7 cases of hyp-notic surgery (cesarean section, bilateralvein ligation, vaginal hysterectomy, de-bridements and skin grafts, hemorroid-ectomy, appendectomy, and open-heartsurg ery ); in most of these cases, secobar-bital, atropine sulfate, chlorpromazine,and promethazine were administered


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318 HYPNOSIS EFFECTS ON PAINsingly or in com bination. Similarly,Owen-Flood11 4 presented a case of ap-pendectomy performed under "hypnoan-esthesia" in which the effects of "hypno-sis" were confounded with the effects ofa regular dose of scopolamine and one-half the routine dose of morphine.

In other surgical cases, hypnotic sug-gestions of analgesia were sufficient toproduce a satisfactory reaction patternduring part of the operation, but chemi-cal agents were required before surgerywas completed. Anderson- reports thatan entranced subject showed little if anyovert signs of pain a t the comm encementof an abdominal exploration; however,before the operation was completed, thepatient ". . . practically broke his hyp-notic trance," and thiopental was admin-istered. Butler39 presented similar find-ings concerning an abdominal explora-tion: As the fascia was being incised, thehypnotized patient showed signs of painand was given cyclopropane.The above data suggest the possibilitythat surgery performed under "hypnotictrance" may not be as painless and as freefrom anxiety as has at times been sup-posed. Although highly selected subjectswere used in all of these studies, somesubjects showed physiological reactionswhich appear to be indicative of anxietyand pain, others "broke the trance," andothers required the assistance of chemical

agents. These findings app ear not to con-tradict Bernheim's30 contention th at "hyp-notism only rarely succeeded as an anes-thetic , that ab solute insensibility is the ex-ception am ong hypn otizable subjects, andthat the hypnotizing itself generally failsin persons disturbed by the expectationsoi an op eration." Th e findings also do notcontradict Moll's11 0 contention that "acomplete analgesia is extremely rare inhypnosis, although authors, copying fromone another, assert that it is common."Additional studies are needed to delin-eate more precisely the effects of hyp-notically suggested analgesia on surgical

pain. Such studies should meet the fol-lowing minimum requirements: (1) Aseries of physiological variablesbloodpressure, pulse, skin resistance, respira-tionshould be recorded simultaneouslyand continuously during surgery per-formed on two groups of subjects, onegroup undergoing the surgery under hyp-notically suggested analgesia and theother under chemical anesthesia. ( 2) Thetwo groups should be matched as closelyas possible with respect to such back-ground variables as age, sex, and socialclass and with respect to type of surgery.(3) The data should be analyzed by ap-propriate statistical techniques55 '91 totake into account differences in physio-logical base levels under hypnotic anal-gesia and chemical analgesia. Th e find-ings reviewed above suggest that if theseminimal requirements are included insurgical studies, it will be found tha t"hypnotic analgesic" subjects show sig-nificantly greater physiological reactionsindicative of anxiety and pain than anes-thetized subjects.Reduction in Anodyne Requirements asan Index of Pain Relief

Some patients in labor, some postoper-ative patients, and some terminal cancerpatients who are given suggestions ofpain relief under "hypnotic trance" stateto the hypnotist that their pain has beenredu ced or abolished. Since the state -ments of the hypnotic subject, as given tothe hypnotist, do not always correspondto the true state of affairs,9 15< 1T a numberof investigators have focused on a reduc-tion in the hypnotic patient's need foranodynes as a somewhat more objectiveand som ewhat m ore reliable index of painrelief.

August5

compared drug requirementsduring labor of 850 trained hypnotic pa-tients who had chosen "hypnosis" as thepreferred form of anesthesia and 150 con-trol patients who had refused hypnosis.PSYCHOSOMATIC MEDICINE


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BARBER 319Th e control group received an average of53.7 mg. of meperidine (D em ero l9) and22.7 mg. of barbiturates (Seconalf orNembutalJ); the hypnotic group re-ceived, on the average, 30.3 mg. of me-peridine and 2.2 mg. of barbiturate.Abramson and Heron1 compared narcot-ics requirements during labor of 100 hyp-notic patients and of 88 controls picked atrandom from the hospital files. The hyp-notic group had participated on the aver-age in 4 prelabor hypnotic training ses-sions, each session requiring a period of30 min.; the controls had been deliveredpreviously by other obstetricians and hadnot received antena tal training. The con-trol group on the average received 123.6mg. of meperidine; the hypnotic groupreceived an average of 103.5 mg. of me-peridine, a reduction of 16%

The studies of August5 and Abramsonand Heron1 are open to a num ber of criti-cisms : (1 ) Th e hypn otic group consistedof volunteers who may have representeda selected group of patients who werelikely to be more cooperative during la-bor. (2) The obstetricians gave moretime and attention to the hypnotic pa-tients than to the control patients. (3)Th e hyp notic group w as apparently givenmedication only on demand, while thecontrol group received medicam ents moreor less routinely. Perchard12 1 has carriedout a large-scale study which attemptedto control some of these va riables. A totalof 3083 primigravidas were observed, ofwhom 1703 did not volunteer for ante-natal classes. The other 1380 primiparas,who volunteered for classes, were as-signed to three experimental treatmentsas follows. Group 1 (268 patients) re-ceived three instructional talks concern-ing parturition plus a visit to the laborwards. Group 2 (126 patients) was giventhe three instructional talks, plus a visitto the labor wards, plus three physical re-

Breon Laboratories , New York, N. Y.fEli Lil ly and Company, Indianapolis, Ind.JAb bott Lab oratories, Nor th C hicago, 111.VOL. XXV, NO. 4, 1963

laxation classes conducted by a physio-therapist. Gioup 3 (986 patients) re-ceived the three instructional talks, thevisit to the labor wards, plus three train-ing sessions in hypnosis. In the hypnotictraining sessions this group was givenpractice in entering trance; practice in re-sponding to suggestions of anesthesia;suggestions that labor would b e painless;and suggestions that amnesia would fol-low the labor. (Fifty-six pe r cent, 26!?,and 18$ of the subjects in Group 3 wererated as "good," "moderately good," and"poor" hypnotic subjects, respectively.)There were no significant differencesamong the four groups (nonvolunteers,Group 1, Group 2, and Group 3) in:duration of labor; calmness, relaxation,and cooperation during labor; number ofpatients judged to have had severe pain;incidence of amnesia for labor; and pro-portion of patients eager to have morechildren. There was a small difference inthe amount of sedation requested duringlabor: 40% of the hypnosis group and 32,34, and 353? of Groups 1,2, and nonvolun-teers, respectively, requested less than100 mg. of meperid ine . (T he 403> figurefor the hypnotic group was increased to44$ in the sub group rated as "good" hyp -notic subjects.) Perchard concluded that"It would appear that no detectable b ene-fits were derived from the simple relaxa-tion exercises and that not more than alimited subjective benefit with slightlyreduced need for sedation resulted fromthe h ypnosis."

Papermaster et al.,us Bonilla et a/.,s*and Laux95 assessed the effects of hyp-notically suggested pain relief on narcot-ics requirements in postoperative cases.Papermaster et al.116 worked with 33 un-selected patients undergoing major ab-dominal surgery. An attempt was madeto hypnotize each patient 3 times, twiceprior to and once after surgery; duringthe hypno sis sessions it was suggested thatthe area of incision would produce nopostoperative discomfort. A matched con-


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320 HYPNOSIS EFFECTS ON PAINtiol group, consisting oi 33 patients un-dergoing similar surgery but not receiv-ing hypnosis training, was selected fromthe hospital files. The hypn otic group re-quested and received an average of 4.21doses of meperidine (50 mg. per dose)postoperatively as compared to 7.57 dosesfor the control group, a reduction in nar-cotics requirements of 45 per cent. Theauthors do not present data for the indi-vidual subjects, stating only that therange in doses of meperidine receivedvaried from 0 to 44 and from 0 to 29 inthe control and hypnosis groups, respec-tively.Bonilla et al.33 worked with 10 male pa-tients undergoing uncomplicated arthrot-omy of the knee. Each patient partici-pate d in from 1 to 4 30-min. hyp notic ses-sions prior to surgery and received sug-gestions tha t he would experience no post-operative discomfort; in some instances,hypnotic sessions were also conducted inthe postoperative period. This group wascompared on postoperative narcotics re-quirements with 40 preceding male pa-tients undergoing uncom plicated arthrot-omy for similar knee afflictions. The con-trol group received an average of 360 mg.of meperidine postoperatively as com-pared to 275 mg. for the hypnosis group,a reduction of 24$.

It appears that in the Papermasteret al.116 and Bonilla et al.as studies thehypnotic group received medicamentsonly on demand while the control groupwas given medication routinely. Laux85presented an experimental study whichcontrolled this factor. Fo rty veteran s un-dergo ing urological surgery we re assignedeither to an experimental hypnosis group(20 subjects) or to a nontreated controlgroup (20 subjects). Th e two groups werematched with respect to type of surgery,age, sex, and socioeconomic status. Th eexperimental subjects received sugges-tions intended to relieve postoperativepain in 3 presurgery and 1 postsurgeryhypnosis sessions. Criteria for postoper-

ative pain relief included: (1) numberof requests for anodynes; (2) amount ofdrugs given; and (3 ) the charge nurse'sevaluation of the amount of pain suffered.The assessment period extended over 5days. During the first postoperative daythe number of requests for anodynes bythe hypnosis group was 34 per cent lessthan for the control group. Th ere were nosignificant differences between the twogroups on any of the criteria during theremaining 4 days of the assessment peri-od.Butler,39 Cangello,41 and Perese12 2 as-

sessed th e effect of suggestions given u n-der "trance" on pain associated with ter-minal cancer. Butler found that after aseries of intensive tran ce sessions with 12selected hypnotizable cancer patients, 1patient showed a 503? reduction in narcot-ics requirements for a few days andanother showed a 100? reduction for 3weeks. (Of the remaining 10 patients, 8manifested subjective relief of pain dur-ing and, at times, for a brief period fol-lowing the trance sessions.) Cangello41reported that after a series of intensivehypno tic sessions 18 of 31 selected cancerpatients m anifested from 25 to 100* re-duction in narcotics for a period extend-ing from 2 days to 12 weeks. Pere se12 2reported that "hypnosis" was "useful" inrelieving pain in 2 of 16 cancer patientsand tha t with another 4 patients it dimin-ished narcotic requirements "slightly." Inthese studies the physicians worked in-tensively w ith their hypn otic patients, anda control group receiving a similaram oun t of attention was not used for com-parison . It is thus difficult to de term ineto what extent the reported pain reliefwas due to the support the patients re-ceived from the physician and to whatextent it was due to other factors sub-sumed under the term "hypnosis." Thisfactorthe supp ort and attention receivedby the patient from the physicianwillbe discussed again below.In summary, the studies reviewed



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B A R B E R 321above appear to indicate that hypnotical-ly suggested pain relief produces somedegree of reduction in anxiety and painin some patients undergoing surgery orpartu rition and in some patien ts sufferingfrom postoperative pain or cancer pain.However, these studies also suggest thatalthough p ain experience is at times amel-iorated, it is only in very rare cases abol-ished. A more precise statemen t of the ef-fects of hypnotically suggested analgesiain surgery, in labor, and in chronic painappears to be th at w hen given suggestionsof pain relief under "hypnotic trance,"some patients are able to endure what-ever degree of pain is present, are notoverly anxious, and do not seem to sufferto the degree expected when anxiety ispresent.The Effects of "Hypnotic Suggestions"on "Functional" or "Conditioned" Pain

Although it appears that hypnotic sug-gestions rarely if ever abolish pain experi-ence in conditions in which noxious stim-ulation is continually presente.g., in sur-gery, in chronic painthis does not ex-clude the possibility tha t hypno tic sugges-tions may at times eliminate some types ofpain , specifically, those types of pain whichappear to be produced by a "condition-ing or learning process." Dorcus andKirkner

52have presented experimentalfindings which support this contention.These investigators worked with twogroups of selected patients: a group of 5males suffering from pain associated withspinal-cord injuries and a group of 5 fe-males suffering from chronic dysmen-orrhea. (No pathology could be foundin the latter group that could account forthe chronic painful menstrual condition.)Each of the spinal-cord cases particip atedin approximately 16 hypnotic sessions;the dysmennorheics participated in from1 to 5 hypnotic sessions. The method oftreatment included: induction of hyp-notic trance; suggestions of anesthesia to

VOL. XXV, NO. 4, 1963

needle pricks and burns; suggestions toinduce hallucinatory pain;" suggestionsto remove the "hallucinatory pain;" andposthypnotic suggestions that wheneverpain arose in the waking state, it woulddisappear immediately. The spinal-cordcases showed a reduction in requests foranodynes and repo rted less pain, but nonewere free from pain. The dysmenorrheics,on the other hand, ". . . were relativelyfree from pain upon discontinuance oftherapy and have remained relativelyfree from pain for at least tw o years." Th eauthors presented the following interpre-tation of these findings:

We believe that dysmenorrhea is a condi-tioned process brought about in the followingmanner. Pain above threshold levels has beenpresent at some time during menstruation.When the experience has once occurred, suchchanges as extra-cellular edema, basal tem-perature change, muscle tonicity, vascularchanges, and breast change which were origi-nally associated with the painful experience re-instate the pain even in the absence of the or-ganic factors that originally brought it about. . . In the dysmenorrheic, when we break thechain of expectancy and tension, we breakdown the conditioned process, whereas in thespinal nerve injury cases we are not destroyinga conditioned process, but suppressing the pri-mary pain-arousing mechanism. This is heldin abeyance only insofar as the factors thattend to focus the individual's attention on thepain is concerned and in that respect the painmay appear abated. It does not remain in-hibited because the source is continually pres-ent.

Dorcus and Kirkner's findings with re-spect to dysmenorrhea may be relevantto other "functional" painful conditionssuch as certain types of headaches orbackaches. There is evidence to indicatethat some headaches are associated with"emotional tension, anxiety, and conflict"and with prolonged contraction of themuscles of the head and neck, and thatalleviation of the "conflicts and anxieties"and/or relief of the muscle hyperfunctionat times relieves the headache.1"1 There


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322 HYP NO SIS EFFECTS O N PA INis also evidence to indicate that somebackaches are associated with sustainedcontraction in the muscles of the back;the sustained skeletal-muscle hyperfunc-tion is one component of a more gener-alized pattern of response to "anxiety,hostility, and conflict;" and the backachemay be ameliorated by relieving eitherthe "anxiety" or the muscular contrac-tions.78 Th e findings presented by Dorcusand Kirkner,52 Wolff,151 and Holmes andWolff78 suggest the hypothesis that sometypes of headaches and backaches canbe effectively relieved by suggestions(given with or without 'hypnotictrance") intended to eliminate the ten-sion-anxiety-conflict pattern and the sus-tained muscle contractions in the neck orback. Experiments are needed to test thishypothesis.

Significant Variables in "HypnoticAnalgesia"The general conclusion indicated bythis review is that some degree of reduc-tion in pain experience can at times beproduced by suggestions given under"hypnosis." The question may now beraised: Which of the many variables sub-sumed under the concept of "hypnosis"are effective and which are irrelevant toprod ucing this effect? To answer thisquestion, it is necessary first to specify

the referents of the term "hypnosis."Although formal definitions of "hyp-nosis" and "hypnotized" differ widely, inpractice the terms are used more or lessinterchangeably and appear to deriveme aning from a consensual frame of ref-erence; that is, when it is stated th at sub -jects were "hypn otized" or "placed in hy p-nosis," it is implied that: (a) one of vari-ous types of procedures that have beenhistorically categorized as "trance induc-tions" was administered and (b) the sub-jects manifested a number of character-istics which by consensus are presumedto signify the presence of "the hypnotic

trance." These two interrelated referentsof the term "hypnosis" can be furtherspecified as follows.1. Investigators ag ree that a w ide varie-ty of procedures can be classified as"trance inductions." At the present timesuch "induction procedures" generally in-clude verbal suggestions of relaxation,drowsiness, and sleep, and often also in-clude some type of "physical stimulation"such as the sound of a metronome or eyefixation on a "hypnodisk." However,other types of "induction procedures,"comprehensively described by Pattie119and by Weitzenhoffer,143 have been usedin the past and are at times used now, in-cluding hyperventilation, compression ofthe carotid sinus, stimulation of "hypno-genic zo nes," and use of "passes" or "ha ndgestures." Although the administrationof one of these "induction procedures"appears to be necessary to induce an in-experienced subject to enter "the hyp-notic trance ," a consensus exists tha t aftera subject has had experience with or"training" in "hypnosis," he may be in-duced to enter "trance" by a drasticallyabbreviated "induction procedure" con-sisting of a prearranged signal or cueword.

2. Numerous attempts have been m adeto find physiological indices of "the stateof trance" which is said to be producedwhen the "induction procedure" is "suc-cessful." These attem pts have failed toyield an acceptable criterion15 and thepresence of "the trance state" is inferredfrom the subject's observable character-istics and behaviors. These "trance char-acteristics" according to Erickson et al,90include a loss in mobility, tonicitythroughout the body, rigid facial expres-sion, and literalness in response. Otherinvestigators list similar indices. Pattie119refers t o ". .. passivity, a disinclination totalk . . . a great degree of literal-minded-ness, and a lack of spontaneity and initia-tive." Weitzenhoffer143 notes that "Thereseems to be some agreement that hyp-



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BARBER 323notized individuals, even when behavingin a most natural manner, still show aconstriction of awareness, a characteristiclileral-mindedness, some psychomotor re-tardation, and possibly a degree of auto-matism." Gill and Brenman68 similarlywrite that entranced subjects who havebeen instructed to behave as if they arenot hypnotized show ". . . momentarylapses into somewhat stiff or frozen pos-tural attitudes . . . an impression of aslight slowing dow n of the pace of bodilymovement . . . [and] a fleeting glazingof the eyes, the 'unseeing look' normallyfound in reverie or in a Tjrown study.'"It has often been assumed that "hyp-notic trance," as inferred from the char-acteristics and behaviors described above,is crucial to producing "pain relief bysuggestions. A series of recent investiga-tions, summarized below, suggest thatthis assumption is open to question."The Hypno tic Trance " as aFactor in "Hypnotic Analgesia"The presence of "hypnotic trance" isnot sufficient to produce "analgesia" bysuggestions. Esdaile61 presented cases ofpatients manifesting many if not all ofthe characteristics of "deep trance" who"shrunk on the first incision" and showednormal responses to painful stimulation.Winkelstein and Levinson,14 8 Anderson,2Butler,39 Liebault10 0 and others alsofound that some "deeply entranced" pa-tients did not respond positively to sug-gestions intended to produce pain relief.The crucial question, however, is not, Is"hypnotic trance" sufficient to produce"analgesia" by suggestions?, but, Is "hyp-notic trance " a necessary or an extraneousfactor in prod ucin g this effect? Contraryto what the early literature on "hypnosis"might lead one to expect, recent studiesindicate that subjects who are in "a verylight trance " and subjects who are not "intrance" are often as responsive and attime more responsive to suggestions ofpain relief than "deep-trance" subjects.VOL. XXV, NO. 4, 1963

Barber and Hahn-4 found that wakingcontrol subjects instructed to imagine apleasant situation during painful stimula-tion showed as much reduction in painexperience, as indicated by subjective re-ports and by reduction in muscle tensionand respiratory irregularities, as "en-tranced" subjects given suggestions of an-esthesia. Von Dede nroth 14 0 has presenteda series of cases in which patients whomanifested the characteristics of "deeptrance" did not respond to suggestions ofpain relief, and patients whoappeared atbest to be "in a light hypn oidal state" andpatients who insisted that they were nothypnotized at all, showed dramatic re-lief of stubborn headache or underwentdentistry without analgesics or anes-thetics even though these agents hadbeen demanded consistently for priordental work. Von Dedenroth interpretedhis data as indicating that "each instanceof hypnotherapy is dependent upon thepatient's inner responsiveness and thecharacter and nature of his motivationrather than upon trance level or depth."Lea et a/.96 arrived at a similar conclu-sion in an investigation concerned withthe effects of "hypnosis" on chronic pain:"We assumed that our success would de-pend upon the depth of hypnosis, but, toour surprise, we found that this was notnecessarily the case. As a matter of fact,tw o of our best patients obtained onlylight to medium trances, and significantresponses were noted in even the verylightest hypnoidal states." Along similarlines, Cangello41 found in a study of theeffects of "hypnosis" on pain associatedwith cancer that "an individual who en-tered a deep trance might be unable toobtain relief of pain while another whowas at best in a hypnoidal or light stateexperienced complete pain relief." Laux95presented com parable results in an exper-imental investigation on postoperativepain: "Some of those whoappeared to bethe most deeply hypnotized had markedpain, and some who showed little re-


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324 HYPNOSIS EFFECTS ON PAINsponse to the hypnosis had little pa in andattributed their comfort to the effects ofhypnosis."

Comparable findings have been pre-sented in a series of recent studies em-ploying "hypnosis" in obstetrics. Mi-chael10 7 found that some patients who atbest attained only "a very light hypnotictrance" underwent labor without medi-cations and without manifesting overtsigns of pain while others who attained" a deep trance" experienced severe painand required standard doses of narcot-ics. Winkelstein14 7 observed that "Somewomen, hypnotized only to the lightestdegree managed their delivery success-fully, while others, deep in the somnam-bulistic state were unable to cope withthe discomfort of labor." Similarly,Mody10 9 noted norelationship inhis sam-ple of 20 selected patients between "thedepth of hypnosis" and the degree of painexperienced during parturition.The data cited above suggest that "thehypnotic trance state" may not be a criti-cal factor in producing "pain relief" bysuggestions. The data reviewed belowsuggest that the critical factors in so-called "hypnotic analgesia" may include:(a) suggestions of pain relief; which are(b) given in a close interpersonal set-ting.The Interpersonal Relationship

Butler39 attempted torelieve pain asso-ciated with carcinoma in 12 selected pa-tients whowere able to attain "a mediumor deep trance." Each patient receivedsuggestions of pain relief in a series oftrance sessions held daily and at times2-4 times per day. Ten of the 12 patientsstated that their pain was reduced duringand, at times, for a brief period followingthe hypnotic sessions; however, when"hypnosis" and the relationship betweenpatient and physician were terminated,the patients showed a return of the origi-nal pain syndrome. The significant find-in g in these cases was that when "hypno-

sis" was discontinued, but the physiciancontinued to give the same amount ofpersonal attention to the patient, the pa-tient continued to show pain relief.Manner10 4 has also pointed to the atten-tion and support given to the patient as asignificant variable, writing that "Therealization that the anesthesiologist iswilling to invest time, effort, warmth andunderstanding in an attempt of hypnosiswill give most patients add ed security andtrust in the physician and will result indecreased tension and anxiety." Lea eta/.96 reported similar observations in astudy on chronic pain: "At times it washard to decide whether benefit was ac-tually being derived from hypnosis itselfor such extraneous factors as the second-ary gain a patient would derive from anunusual amount of personal attentionfrom the hypnotherapist."

Recent reports concerned with the ef-fects of "hypnosis" on the pain of parturi-tion also emphasize the significance of in-terpersonal factors. In a study with 200obstetrical patients, Winkelstein14 7 foundthat toproduce some measure of pain re-lief by suggestions, it was necessary forthe physician todevote a great amount oftime and attention to each patient. Thisinvestigator de-emphasized the impor-tance of "the trance state" in producingpain relief by suggestions, poin ting to thefollowing variables as crucial: (1) thesuggestions themselves; (2) the mentalattitude of the patient toward pregnancyand delivery; (3) the will to succeed; (4)the confidence of the patient in the pro-cedure as well as in the obstetrician; and(5) the patient-obstetrician rapport.Chlifer46 had similarly observed that theeffectiveness of suggestions of pain reliefin labor is not correlated with "the depthof trance;" pain may be ameliorated bysuggestions given to nontrance subjects;and "the success of verbally indu ced ana l-gesia is closely related to the personalityof the subject and the relationship estab-lished between the doctor and the par-



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BARBER 325turient wom an." After wide experience inthe use of "hypnosis" for relief of laborpain, Kroger and Freed89 proffered thehypothesis that if a close relationshipexists between patient and obstetrican,abo ut 10-15% of non medica ted patien tswill be free of discomfort during laboreven though the hypnotic trance state isnot induced.The above studies suggest that thecritical factors in so-called "hypnoticanalgesia" may include "suggestions ofpain relief given in a close interpersonalsetting. The interpersonal variable hasbeen emphasized above; the "suggestionsof pain relief" require further comment."Suggestions of Pain Relief as aCritical Factor in "Hypnotic Analgesia"

The effects of "suggestions of pain re-lief pe r se" hav e at times been confound-ed with the effects of "hypnotic trance."In a number of studies 1 '5 '3 3 '1 1 3 the ex-perimental group w as placed "in hypnotictrance" and then given suggestions to re-lieve pain; the control group was notplaced "in trance" and was not givenpain-relieving suggestions. These studiesfailed to exclude the possibility that theeffective factor in ameliorating pain inthe experimental group was not "the hyp-notic trance" but "the suggestions of painrelief per se;" if the control group hadbeen given suggestions of pain reliefwithout trance, it might also have showna reduction in pain experience. Support-ing evidence for this supposition is foundin the Barber and Hahn2* experiment inwhich a nontrance control group giveninstructions or "suggestions" intended toameliorate pain showed a similar reduc-tion in pain experience as entranced sub-jects given suggestions of anesthesia.Sampimon and Woodruff1-6 have pre-sented data indicating that direct sug-gestions given without "hypnotic trance"are at times sufficient to alleviate pain.In 1945 these investigators were workingunder primitive conditions in a prisonerVOL. XXV, NO. 4. 1963

of war hospital nea r Singapore. Anes-thetic agents were not available, and"hypnosis" was employed for surgery.Two patients could not be "hypnotized;"since the surgical procedures (incision forexploration of abscess cavity and extrac-tion of incisor) h ad to be performed with-out drugs, Sampimon and Woodruff pro-ceeded to operate after giving "the meresuggestion of anesthesia." To their sur-prise they found that both patients wereable to undergo th e normally painful pro-cedures without complaints and withoutnoticeable signs of pain. These investiga-tors write that "As a result of these casestwo other patients were anesthetized bysuggestions only, without any attempt toinduce true hypnosis, and both had teethremoved painlessly." Other workers14 ' 20>22,23,67,86,150 n a v e p r e s e n t e d c o m p a r a b l efindings with respect to the effectivenessof "direct suggestions" given without theinduction of "hypnotic trance."

Similar findings have bee n presented instudi

Barber-Effects Hypnosis Pain

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