Burns (1988) 14, (5).

399-lO4 Printed in Great Britain 399

Hypnosis and pain in patients with severe

burns: a pilot study

A. J. W. Van der Does*

Burn Centre, Red Cross Hospital, Beverwijk
and Psychiatric Centre, Academic Hospital, University of Amsterdam, The Netherlands
R. Van Dyck
Free University, Amsterdam, The Netherlands
R. E. Spijker
Burn Centre, Red Cross Hospital, Beverwyk, The Netherlands

Summary I. Reduction of negative side-effects.

This report presents a pilot study on the effectiveness of 2. No extra load on circulation, respiration, liver
hypnosis in the control of pain during dressing changes of or kidneys.
burn patients. Eight patients were treated, and all
3. The patient remains fully conscious and is able
evaluated the interventions as beneficial. The treatment of
to communicate and cooperate with the doctor.
four patients was more closely analysed by obtaining pain
and anxiety ratings daily. Results show a 50-64 per cent 4. The possibility of posthypnotic suggestions,
decrease in reported pain level for three patients and a 52 e.g. pain reduction, increase of appetite.
per cent increase of pain for one patient. The mean de-
crease for these four patients was 30 per cent (for overall The disadvantages of hypnosis are the time-
as well as worst pain during dressing changes). A 30 per consuming nature of the procedure compared with
cent reduction of anxiety level and a modest reduction of chemical anaesthesia, and the fact that its effective-
medication use were achieved concurrently. ness is limited by the patient’s capacity to respond
It is concluded that hypnosis is of potential value
to hypnotic suggestions. The convenience of both
during dressing changes of burn patients. Comparison of
local and general anaesthesia is such that hypnosis
global evaluations and daily pain ratings shows that
systematic research in some cases leads to conclusions is seldom used as the sole anaesthetic in major sur-
opposite from clinical observations or follow-up evalu- gery, for example. In some instances however,
ations. Limitations of this study are discussed and recom- when chemical anaesthesia may be dangerous to a
mendations for future studies are given. patient (e.g. in case of allergy or poor physical con-
dition), hypnosis may be the preferred method. In
many other cases, hypnosis may be a very useful
INTRODUCTION method to reduce the amount of the chemical ag-
THE relief of pain is one of the oldest and most ents needed. This may be particularly valuable for
important aims of medical hypnosis, the use of chronic pain and in the case of repeated painful
which, although not widespread, has increased procedures within a short time-period (e.g. dressing
over the last decades. Also, during the same period, changes in the treatment of burns).
the effectiveness of hypnosis in the control of pain Since the successful use of hypnosis on a burn
of various origins has been investigated, in the units was first reported more than 30 years ago
clinic as well as in the laboratory. Udolf (1981) lists (Crasilneck et al., 1955), a number of reports have
several advantages of ‘hypnoanaesthesia’ or supported the value of hypnosis in obtaining pain
‘hypnoanalgesia’, alone or in combination with relief in burn patients. As shown in two recent lit-
medication, which include: erature reviews (Patterson et al., 1987; Van der
d; 1988 Butterworth & Co (Publishers) Ltd
0305%4179/88/050399-06 $03.00
400 Burns (1988) Vol. 14/No. 5

Does, 1987) most of these publications involve therapist was limited to one dressing change, and
poorly controlled case studies. The few experi- an audiotape was made for self-hypnosis practice.
mental studies available can be criticized for ques-
tionable methodology, so firm conclusions about Techniques
the effectiveness of hypnosis for burn patients are During the practice session, one or more of the
not yet warranted (Van der Does, 1987). In order to formal induction techniques were used: eye fix-
establish more clearly the value of hypnosis, studies ation, hand levitation or relaxation, depending on
with improved methodology are needed. This the patient’s preference and limitations caused by
paper addresses some of the relevant issues, based his/her injuries. After induction it was attempted to
on the experience from a pilot study, that was con- counter conditioned fear for the dressing changes,
ducted at the Burn Centre of the Red Cross Hos- if any, by hypnotic imagination of a relatively com-
pital in Beverwijk, The Netherlands. The results of fortable dressing change. During the dressing
this pilot study as well as some of the clinical and changes several hypnotic techniques were used (re-
methodological problems that we encountered dur- laxation, distraction, dissociation and direct sug-
ing the experiment will be discussed. gestion), depending on the patient’s preference and
capabilities.
METHODS
Patients Measures
Patients hospitalized at the burn centre were asked On both patient and nurse questionnaires, ex-
to participate in the study if they met the following perienced or observed pain and anxiety were rated
criteria: on a IO-cm visual analogue scale (VAS), which has
been shown capable of measuring subtle changes in
Native language Dutch or English; pain experience reliably (Ohnhaus and Adler, 1975;
No expected surgery for a period of at least 10 Jensen et al., 1986; Scott and Huskisson, 1976). The
days; questionnaire consisted of two pain ratings: overall
No severe inhalation trauma; pain and worst pain during today’s dressing change
No major psychiatric illness or organic brain (with ‘not painful’ and ‘extremely painful’ at the
dysfunction; extremes of the scale), and two anxiety ratings: ten-
No hard drug dependence. sion just before and overall tension during today’s
dressing change (with ‘not tense’ and ‘extremely
Procedure tense’ at the extremes of the scale). The scores on a
First, baseline pain and anxiety level was assessed VAS are measured with 0.5-cm accuracy, and range
by asking patients to fill in a short (self-rating) from 0 to 10. Both questionnaires took less than
questionnaire for 3-5 consecutive days, and by 1 min to complete.
monitoring medication use. After this baseline Hypnotizability was measured by individual ad-
period patients were informed about the possibility ministration of the Stanford Hypnotic Clinical
of using hypnosis as an adjunct to analgesic medi- Scale (SHCS) (Hilgard and Hilgard, 1975). Addi-
cation (morphine), and, if interest was shown, an tional data were percentage of total body surface
appointment was made for a ‘practice session’ on area (% TBSA), depth of burns and medication, all
the same day. This practice session served the pur- of which were obtained from the medical records.
poses of dealing with anxiety and/or misconcep- Between 3 and 6 months after discharge from
tions on hypnosis the patient might have, and of hospital, all patients were sent a follow-up ques-
investigating his or her talents for obtaining pain tionnaire in which they were asked to give overall
relief through hypnosis. The patient was then infor- evaluations of the effect of the hypnotic interven-
med that the therapist would be present during the tions on their pain level, to indicate which hypnotic
next five dressing changes, during which his in- techniques they rated to be most effective, and to
volvement would gradually diminish, thereby indicate whether they had continued to use the
trying to shift the procedure to self-hypnosis. After techniques by themselves.
these five dressing changes patients were en-
couraged to continue using the techniques by them- RESULTS
selves, and were asked to continue completing daily Eight patients participated in this pilot study. The
pain and anxiety questionnaires. During the whole effectiveness of hypnosis was estimated by compar-
hospitalization period, the nursing staff completed ing the mean level of reported pain during the five
daily observational pain and anxiety question- dressing changes during hypnosis to the mean level
naires. One patient was treated with a modified of reported pain during the five previous days.
procedure. For this patient the presence of the (Table I, Method I). However, because of organiz-
Van der Does et al.: Hypnosis and pain in patients with severe burns 401

Table 1. Self-reported pain level during hypnosis compared to five (Method 1) and two (Method 2) previous days

Method 1 Method 2
Overall Worst Medication Overall Worst Medication
Patient pain pain intake pain pain intake

4 - 58% -47% - 35% -73% -63% - 35%

5 ~ 50% -32% 0% -29% -2% ~ 40%
6 + 52% +20% 0% + 43% + 20% 00/o
7 - 64% -59% ~ 13% - 64% - 57% - 19%

Mean ~ 30% ~ 30% -12% -31% - 26% -24%

Table II. Self-reported anxiety level during hypnosis 10

compared to five (Method 1) and two (Method 2) pre- t
vious days

Method 1 Method 2
Before During Before During
Patient dressing dressing dressing dressing

4 + 33% - 28% - 9% - 56%

5 - 82% - 74% -88% - 66%
6” 0% 0% 0% 0%
7 -41 % - 29% - 40% -9%

Mean -23% -33% - 34% -33%

‘This patient’s ratings were all 0. cl- ’ ’ ’ ’ ’’ ’ ’ ’ ’ ’ ’ ’ ’ ’ ’ ’

0 1 2 3 4 5 6 7 8 9 101112 13141516 17
HHHHH
ational problems in the initial part of the study too Time postburn (days)
many pain ratings are missing to analyse the results :
10 mg 7.5 mg 5 mg
Ir
of patients 1.2 and 3. Therefore, in Table Zonly the IE
I I
results of patients 4, 5, 6 and 7 are shown. r”
Results show a 50.~64 per cent decrease of Fig. I. Representation of overall and worst pain scores for
overall pain for three patients, and a 52 per cent patient 4 (self-rating). x __ x1 Overall pain; :1--n,
incrcwe of pain for one patient. The mean decrease worst pain; H, hypnosis.
in pain level for four patients is 30 per cent, for
overall as well as worst pain. There was also a small IO-
decrease of medication use. 9-
Because of the fact that reported pain is usually
low or absent during postburn day 1 and 2, and
then starts to rise, the results were recalculated,
comparing the dressing changes during hypnosis to
the two previous days. This led to similar results
(Tub/e I, Method 2). The same calculations were
made for patients’ anxiety just before and during
dressing changes. Table II shows that both calcu- l-
lation methods reveal a 30 per cent decrease in o “““““““‘I”“’
0 1 2 3 4 5 6 7 8 9101112 14 16 18 20
anxiety level approximately, which is very com-
H HHHH s
parable to the result obtained for pain reduction.
Patient 8, who used audiotapes, achieved a 50 Time postburn (days)

per cent reduction of pain with self-hypnosis. This I Omg I 5 mg

would raise the mean reduction slightly, but s
because these means are based on the results of only Fig. 2. Representation of overall and worst pain scores for
a few patients, not too much value should be atta- patient 6 (self-rating). x~ x , Overall pain; C---3,
ched to them. Inspection of Figs 1 and 2 gives more worst pain; H, hypnosis; S, surgery.
402 Burns (1988) Vol. 14/No. 5

from the day hypnosis was started. The small peak
at postburn day 10 and 11 may be explained by the
fact that those were the first days on which he tried
self-hypnosis (at postburn day 10 in the presence of
the therapist).
There were some interpretative difficulties for the
results of patient 6 (Fig. 2). Despite a positive evalu-
ation (at follow-up as well as during the experi-
ment), a high hypnotizability score and very low
observational pain ratings, his self-ratings, after a
small decline on the first day (postburn day 7) con-
tinued to rise. There was no change in medication
use. Considering the unreliability of the obser-
vational pain ratings (Teske et al., 1983; Iafrati,
1986; Van der Does, in prep.), we decided that the
most correct conclusion was to consider this pa-
tient as a treatment failure.
Not depicted in Figs 1 and 2 is the pattern that
was observed with patient 7. Notwithstanding
clinical impression of substantial pain relief, a high
hypnotizability score, and a clear reduction of self-
rating scores for dressing changes during hypnosis,
this patient continued to express the belief that
hypnosis did not work for him. Sometimes during
afternoons or evenings he complained or talked
very negatively about the whole procedure to the
nursing staff. At follow-up, this patient indicated
that he had experienced marked relief of pain,
thanks to relaxation and distraction. He also in-
dicated not to have experienced any relief of pain
by hypnosis, ‘because I’m unhypnotizable’. So,
either this patient filled in the pain questionnaires
in a way to please the therapist or his negative reac-
tions must be explained by his objection to ex-
periencing something he did not completely com-
prehend. In our opinion, the latter possibility is the
more likely. This patient’s strong scepticism, ex-
pressed from the beginning, was not influenced by
the fact that he turned out to be highly
hypnotizable.
Follow-up
All patients returned the follow-up questionnaire.
These data are summarized in Table III.
All patients gave a positive evaluation: four pa-
tients indicated a small relief of pain through hyp-
nosis, and four indicated a marked relief of pain.
The techniques that were most successful, as judged
by these eight patients, were relaxation (five
patients) and distraction (seven patients): drawing
attention away from the pain and its source by
imaginative involvement in other (pleasant) activ-
ities. Direct suggestion of pain relief was successful
with one patient only, who was highly hypno-
tizable. Seven patients indicated that they used self-
hypnosis successfully after the experiment.
a
DISCUSSION
The effectiveness of hypnosis in pain
control
For reasons of clinical utility as well as research
methodology, the study was concentrated on the
daily dressing changes. The overall conclusion of
this study-whether one looks at rating scores, pa-
tients’ evaluation, clinical judgement or a combin-
ation of these measures-is that hypnosis is of
potential value for pain control with burn patients.
Although the effects are not always very impressive
clinically, in our opinion any reduction of analgesic
medication in these severely injured patients is
meaningful. Furthermore, their psychological well-
being may benefit from the experience of having
some control in a situation in which they are highly
dependent on other people.
An observation of equal importance, however, is
that if one considers only part of the data, as was

Table 111.Follow-up evaluations

Age
Patient (v) Sax %TBSA (2/3) SHCS Pain red. Mechan. S-H Limit

1 75 M 35 (5130) 3 ++ 1.2 yes

2 15 M 21 (9/12) 3 ++ 2 yes -
3 18 M 34 (28/6) 3 + 2 yes
4 29 M 28 (28/O) 3 + 2 yes -
5 38 M 5 (5/O) 0 ++ 1.2 yes 3
6 26 M 18 (3/15) 4 + 1,2,3,6 yes 3. 4
7 51 M 28 (23/5) 5 ++ A,2 no 2
8 48 M 34 (14/20) 2 + 1 yes -

%TBSA (Z/3). % total body surface area burned (2nd/3rd degree); SHCS, hypnotizability score (O-5); Pain red,, estimated
average pain reduction by hypnosis; (max.= + + +) Mechan., answer to ‘what happened during hypnosis?’ (1, relaxation; 2.
distraction; 3, anaesthesis; 4. dissociations; 5, nothing; 6, other); S-H, answer to ‘did you try self-hypnosis with success?‘; Limit,
answer to ‘what limited the effectiveness of hypnosis’ (1, I don’t believe in hypnosis; 2. I’m unhypnotizable; 3. too much noise or
distraction; 4. too much pain).
Van der Does et al.: Hypnosis and pain in patients with
done in earlier studies. the decisions about treat-
ment success or failure could in some cases (pa-
tients 5 and 7) be reversed. It is noteworthy that all
the retrospective global ratings were favourable to
hypnosis, while the results from day-to-day ratings
were more modest and in one case even negative.
This shows that one should be very cautious with
case reports based on global outcome ratings only.
As data from self-report may be conflicting with
observational data, we would suggest attaching
more importance to the self-report.
Baseline
The choice of a baseline poses a separate problem.
In the first days, little or no pain at dressing changes
is reported, by most patients. If started early,
hypnosis may appear to make little difference over
the baseline period. However, waiting for more
pain to develop engenders ethical as well as tech-
nical problems, since pain and fear at dressing
changes may become conditioned phenomena,
progressively harder to combat.
Techniques
As was found at follow-up, relaxation and distrac-
tion were the most valuable techniques. The im-
portance of relaxation is not surprising, because
many patients rapidly develop a conditioned fear
for the daily dressing changes. The success of the
distraction techniques is less obvious because these
techniques must be used under very unfavourable
circumstances. These circumstances include: a
poor physical and emotional condition, interrup-
tions coming from the environment (intercom,
noise, doctor walking in and out), sometimes hav-
ing to walk to a shower, and the fact that the desire
to keep paying attention to what the nurses are
doing can easily hamper deep involvement in sug-
gestions. It may also be difficult if not impossible to
maintain constant imaginative involvement in the
same pleasant activity for one and a half hours or
more. These problems may be resolved by doing a
short induction before the dressing change, and
practising a brief signal for re-entering or deepen-
ing hypnosis, such as eye closure and counting from
1 to 3. With this technique the patient can learn to
decide himself when to go in and out of hypnosis,
thereby avoiding the negative effect of constant
repetition of the same suggestions and at the same
time meeting the desire to keep knowing what is
going on and when more painful moments can be
expected. Especially low and moderately hypno-
tizable patients are willing to lengthen and deepen
their involvement in imaginations only after they
have experienced that it works and that they keep
control. When using distraction techniques in this
severe burns 403
way, it is still advisable to practise several different
fantasies, otherwise the negative effect of repetition
will occur after a few dressing changes.
The results for patient 8, who used audiotapes,
indicate that it may be possible to limit extra pro-
fessonal time needed per patient to one practice ses-
sion (45560 min) plus, in some cases, one dressing
change (60-120min).
Hypnotizability
Due to the small number of patients in this study,
no conclusions can be drawn about the (predictive)
value of hypnotizability scores. It can be observed
however that direct suggestion of pain relief was
only successful (as indicated at follow-up) with one
highly hypnotizable patient. On the other hand,
this patient’s pain rating scores continued to be at
high levels.
Anxiety
Patients’ anxiety ratings show a decrease similar to
the one found in their pain ratings. This finding is
not surprising, because hypnosis was also used to
counter conditioned fear for the dressing changes.
It does raise some questions however about the
specificity of hypnosis. Therefore it would be of in-
terest to compare the effectiveness of hypnosis with
progressive relaxation training, a procedure known
for its effectiveness in reducing anxiety. This com-
parison would clarify whether the effects of hyp-
nosis should be explained by anxiety reduction, or
whether there are in addition more specific anal-
gesic effects.
Reactions of patients and staff
Patients’ reactions to the proposal of hypnosis
varied from enthusiasm (sometimes) to curiosity
and hopefulness (mostly) and refusal. One patient
declined for religious reasons, three because they
felt they could do without (which was reflected in
their baseline pain ratings), and one patient was so
scared of hypnosis that he could not be persuaded
to try. Several patients were excluded from the
study for reasons of severe psychopathology or
drug abuse.
The attitude of the medical and nursing staff of
the burn unit to hypnosis and the experiment was,
on the whole, very cooperative. In the initial part of
the study it was attempted to let the nursing staff do
some of the research part of the work: pain ratings
were to be obtained by a nurse who did not do the
dressing change on that day. The objective of this
strategy was to minimize the possibility that pain
ratings would reflect a willingness to please the
therapist. However, because of the already very
high workload on the nursing staff, this resulted in
404 Burns (1988) Vol. 1 ~/NO. 5

too many missing data for the first three patients. REFERENCES
Furthermore, it must have been clear to the pa- Crasilneck H. B., Stirman J. A., Wilson B. J. et al. (1955)
tients that the pain ratings were used to evaluate the Use of hypnosis in the management of patients with
hypnotic interventions, no matter what the strategy burns. JAMA 158, 103.
of data sampling. Therefore it was decided that the Hilgard E. R. and Hilgard J. R. (1975) Hypnosis in the
Relief of Pain. Los Altos, CA, Kaufmann.
therapist would explain all procedures to the pa-
Iafrati N. S. (1986) Pain on the burn unit: patient vs. nurse
tients, and that he, or if possible someone else who
perceptions. J. Burn Care Rehabil. 1,413.
was not involved in the dressing changes, would Jensen M. P., Karoly P. and Braver S. (1986) The meas-
remind them to fill in their pain questionnaire. The urement of clinical pain intensity: a comparison of six
therapist urged the patients that the amount of time methods. Pain 27, 117.
he would spend with them was standardized (five Ohnhaus E. E. and Adler R. (1975) Methodological
dressing changes) and independent of their pain problems in the measurement of pain: a comparison
ratings. Also, patients were told that their ratings between the verbal rating scale and the visual analogue
were not used to evaluate the skill of the nurse(s). scale. Pain 1, 379.
Patterson D. R., Questad K. A. and Boltwood M. D.
(1987) Hypnotherapy as a treatment for pain in pa-
CONCLUSION tients with burns: research and clinical considerations.
In summary, we believe that this pilot study shows J. Burn Care Rehabil. 8,263.
that hypnosis is of potential value for obtaining Scott J. and Huskisson E. C. (1976) Graphic represen-
pain relief in some burn patients. Although we tation of pain. Pain 2, 175.
acknowledge that there are no definite solutions to Teske K., Daut R. L. and Cleeland ChS. (1983) Relation-
some of the methodological problems raised in this ships between nurses’ observations and patients’ self-
paper, it is clear that the value of the case reports is reports of pain. Pain 16,289.
Udolf R. (1981) Handbook of Hypnosis for Professionals.
considerably enhanced by systematic gathering of
New York, Van Nostrand Reinhold.
objective as well as subjective data. The importance Van der Does A. J. W. (1987) The use of hypnosis in painful
of controlled research for hypnosis in burn treat- burns: clinical and methodological considerations.
ment should be stressed, for only by this means will Paper presented at the IVth European Congress of Hyp-
it become possible to address important issues like nosis, Oxford, United Kingdom, July 1987.
indications and contraindications, timing of the in- Van der Does A. J. W. (in prep.) A comparison of patients’
terventions, the role of individual differences in and nurses’ ratings of pain and anxiety. (Submitted for
hypnotizability, and the effectiveness of hypnosis publication.)
compared to placebo.

Acknowledgement
This study was supported in part by a grant from
the Dutch Burns Association to A.J.W.V.D.D. Paper accepted 29 March 1988.

Correspondenceshouldbeaddressedto: DrA. J. W. vander Does, PsychiatricCentre, AcademicMedicalCentre,Tafelbergweg25,1105 BC

Amsterdam. The Netherlands.