116464219 Audiotaped Hypnosis Chronic Back Pain

7/28/2019 116464219 Audiotaped Hypnosis Chronic Back Pain

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A U D I OTA P ED HY P N O SI S F OR C HR O N I C BA C K P A I NA C A S E S T U D YBy

Susan C arol TaylorB.A . University of British Co lumbia 1963B.S.W . University of British Co lumbia 1980

A T H E S I S S U B MITTED I N P A R TIA L F U LF I LLM EN T O FT H E R E Q U I R E M E N T S F O R T H E D E G R E E O FM A STER OF A R TSin

T H E F A C U L T Y O F G R A D U A T E S T U D I E S(Department of C ounsel ling Psychology)

W e accept this Thesis as conformingto the required standard.

THE U N I V ER SITY OF BR I TI SH C OLU M BI ADecember, 1991

S u s a n C a r o l T a y l o r 1 9 9 1


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(Signature)

In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.

Department ofThe University of British ColumbiaVancouver, Canada

Date )7, /9?/

DE-6 (2/88)


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I I

Abstract

The purpo se of this research wa s to investigate the effectiveness ofaudiotaped hy pnosis as a treatment for chronic pain using physiological aswell as psychological measurem ents. The research design is a mod ifiedsingle case study employing an A-B format; the A pha se constituted theresponses of the Control G roup , which provided a stable baseline and theB ph ase constituted the responses of the Experimental Group whichreceived the treatmen t. Both grou ps received 25 sessions of biofeedba ck. Arand om ized selection of a variety of audiotapes (hypnosis, guided ima gery,relaxation) was given to the Co ntrol Gro up. The same aud iotape ofhypn osis was used as the ind ependent variable over a period of 25 sessionsfor the Experimental Grou p. The mo dified form of M elzack &To rgerson's Present Pain Intensity Scale which evaluates pain on a scale ofincreasing intensity both verbally and n umerically was used as a subjectiveself-report measure. Electromyographic (EMG) readings were taken as anobjective physiological measurement. An interrupted time-series analysiscalled, The Box Jenkins An alysis provided statistical data. This data w ascorrobo rated by a B inomial Test. The eight subjects, six of who m w erema le were all chronic pain patients who were referred by the Work ma n'sCom pensation B oard for work related injuries. The patients in this settingare resistant to chang e. The results showed a statistically significant resu ltof the data in the Experimental Grou p which ma y be viewed as a trendtoward s imp rovem ent. H owever the results should be viewed w ith cautionas external validity is weak. This study wa s mean t as a pilot study a nd w illneed further research to corr obora te the findings.


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Table of Co ntentsAbstract^iiList of Tables viiLst o Fgures vList of Appendices^viiAcknowledgements^viiiChapter IIN T R O D U C T I O N T O T H E P R O B L E M 1Chronic Back Pain 1The Injured Worker^2Stages of Chronicity^3The Chronic Pain Patient^4PURPOSE OF THE STUDY^4HYPOTHESES^7RATIONALE 8Limitations of the Study^8Chapter IIR E V I E W O F T H E L IT E R A T U R E^10History of Pain^10Acute Versus Chronic Pain^13Chronic Pain 18

Measurement of Pain^19Clinical Pain Assessment^22THEORIES OF PAIN^25Specificity Theory of Pain^25


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i v

Cha pter IIPattern Theory of Pain^26Gate Control Theory of Pain 26TREATMENTS FOR THE MANAGEMENT OF PAIN 29Cognitive-Behavioral Methods^29Biofeedback^31Medical Treatment for Pain^38Pain Clinics^40Drugs^41HYPNOSIS 44History of Hypnosis^44Theories of Hypnosis^47Hypnosis in the Treatment of Pain^55Audiotaped Hypnosis as a Treatment for Pain 64Clinical Studies^67Experimental Studies on Hypnosis and Pain 68Clinical Studies on Hypnosis and Pain^74Chapter HIMETHODOLOGY^79Single-Case Experimental Design^79Sample Selection^82Description of the Sample 83Control Group^83Experimental Group^83Procedure^84The Setting^85


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V

Chapter IIITreatment^85Ele ctromyo graphic Fe e dback (EM G ) 85Audiotaped Hypnosis^86Control Group^86Experimental Group^87Dependent Measures^871) Electromyographic (EMG) Readings 872) Verbal Self-Report^89Statist ical A nalys is of the D ata 90Bo x Jenkins Time-Series A nalys is^90Binom ial Test^0Chapter IVRESULTS^92Statist ical A nalys is of the D ata^92Hypothesis 1^92Box Jenkins Time-Series Analysis^92Binomial Test^92Hypothesis 2^93Hypothesis 3^94Hypothesis 4^97


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viChapter V

DISCUSSION^8INTRODUCTION^98T H E M A I N H Y P O T H E S IS^98Box Jenkins Time-Series Analysis^100Hypothesis 2^101Hypothesis 3^104Hypothesis 4^105Threats to Causal Inference^105Threats to Valid Inference 106Internal Validity^107External Validity^108CONCLUSIONS^109Imp l icat ions for Fu ture Research^112REFERENCES^113Appendix A^126Appendix B^132Appendix C^136Appendix D^138Appendix E^140Appendix F^142Appendix G^148


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viiList of TablesTable 1

Sum mary of Change Scores in Present Pain Intensity Scale 4Table 2

Sum mary of Scores from Tape Effectiveness Questionnaire^6List of FiguresFigure 1. Box Jenkins A nalysisFigure 2. Binomial Test

List of Appendices:Appendix A

Pain Patients^126Appendix BChronic Pain Patient Profile^132Appendix CConsent Form^136Appendix DPresent Pain Intensity Scale^138Appendix EVerbal Self-Report T ape E ffectiveness Qu estionnaire^40Append ix FTranscript of the Audiotape^142Appendix GBinomial Test 48


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v i i iACK NO WL E DG E M E NT S

There are ma ny people who ha ve mad e it possible for me to produ cethis thesis and I wou ld like to take this opportunity to ackn owledg e andthank them for their generous sup port.D r. Du-Fay D er, the chairperson of my thesis comm ittee hasprovided m e with encou ragem ent and insight with his perceptive adviceand w onderful examples of audiotaped hypnosis . Dr. John A llan and D r.Jaime Peredes have m y thanks for sitt ing on my comm ittee and for theirenthusiasm towards m y research. I would also l ike to thank Dr. W alterBoldt who taught me more about research than I wo uld ever have dreamedpossible and never discouraged my endeavours. I would also l ike tomention the Department of Coun sell ing Psychology and G raduate Studiesfor their support.I wan t to thank my husband for supporting me in my years of studythrough adversity as w ell as accom plishment. My two sons, Robin an dBrian have m y thanks an d love. They have been invaluable in helping me inthe preparation of my thesis on a com puterI wa nt to acknow ledge the Columbia C entre for their generoustreatmen t of me at their cl inic. In part icular, Dr. Cha rles Gregory, w hoaccepted a student, Dr. Bart Jessup for generously sharing his time andincluding m e in his groups and JoAn ne D odson, the physiotherapist whogave m e information abo ut the patients and glad ly offered m e her helpwhen asked.W ithou t the patients at the pain clinic, I wo uld n ot have been a ble tocollect data or u nd erstand the com plexities of do ing clinical research. Mythanks to them for accepting m e and allowing me to use them as subjects.An d f inally , I wou ld l ike to thank D r. G eorge Klimczynsky w hostarted me on m y quest many years ago.


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C HA P TER 1INTRODUCTION TO THE PROBLEM

Chron ic Back PainThe term chronic back pain (CB P) is com mo nly used to refer to

back pain w hose assumed origin is in the spine or the surround ingmu scular, or inf lamma tory origin, and has lasted for m ore than six mon ths(Ford yce, 1986; Sternb ach, 1974, 1984). It is estima ted that 70% of lowback pain and most headaches have no known organic cause. Statist ics varyfrom 10% to 80% of adult Can adians suffering from back pain to 33%suffering from chronic back pain (Fraser, 1991; Ha ll , 1986; Jenish &Deaco n,1991). All low back pain patients experience acute pain at f irst and50% a re successfully treated at this stage while 50% becom e chronic lowback p atients (La Fren iere, 1979).

In C anada i t has been reported that three m ill ion Can adians sufferfrom chronic pain w hich results in $4 bil lion a y ear in lost income, med icalexpenses an d disability pay men ts. It has been estimated that in BritishCo lumbia 300,000 people l ive with chron ic pain (W igod,1991). Jenish &Deacon (1991) reported that back pain "is the second m ost comm on causeof absenteeism in the wo rkplace, behind the com m on cold"(p. 52). TheW orker's Compen sation B oard of O ntario stated that back problemsaccounted for a pproximately o ne-quarter of al l compensation claims inC anad a; in O ntario alone, $399 million was aw arded in 1984 for work-related back injuries (Hall, 1986) and "ba ck problem s resulted in m oreclaims for lost wages than any o ther type of injury last year" (Jen ish &Deacon , 1991, p.54) . In 1980 the total cost of chronic pain to the A merican


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public ranged from $14 billion dollars in 1977 to approxim ately $110billion dollars in 1990 (Cha pm an, 1986, 1988).

One researcher suggested that litigation-related chronic pain shouldbe considered a diagnostic entity distinct from other types of chron ic painand that a "two-tiered" system of comp ensation should aw ard m ore forpain of "organic" origin (Weber, 1989). Pain clinics reported that "30-40%of their clientele have back-related pain a s their major pr esentingcom plaint (whatever the real cause)" (C larke, 1987, p.1).

The Injured WorkerChap man (1988) studied the injured worker and found that employed

individuals spend about on e-fourth to on e-third of their waking time atwor k. Wor k serves as one of the most impor tant factors in the formationof self-esteem and person al identity. It provides the individua l with securityand the "ability to m ake m ore cho ices in life, gives life a pu rpose, ma kes itmo re mean ingful and serves as a social outlet. Loss o f work is associatedwith "loss of work status" (p.103). Chapman found that:

Chro nic pain is frequently associated with a loss of w ork status. Forexample, a random sample of a mixed group of chronic pain patientsat the Emory P ain Con trol Center indicated that only 12% w ereworking full-time at the time o f adm ission into the program ; 40%were on W orkers' Compensation and 23% had established SocialSecur ity disability. This loss of work status often is associated w ithvery strong affect regard ing returning to work, despair regardingphysical limitations, and rage toward previous health care personn elwho ha d stated or implied that they should be working w hen theywere n ot. Several factors often contribute to this strong a ffect,including inconsistent m essages regarding w ork ability fromprevious health care personnel, stigmas placed on individuals w ithoutobvious physical disability who are not working, financial stresses,frequent souring of relationships with insurance com panies and withthe last employer, and progr essive loss of mental and physical


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abilities and self-confidence w ith long-term phy sical disuse and dr ugdepen dency . In addition the adversarial nature of legal systems oftenputs the patient in the position of m aximizing pa in and disability inord er to receive a mo re substantial settlement, while the insura ncecompan y m ay look for evidence to m inimize the patient's claims andattribute them to a d esire for second ary f inancial gains. (p. 105)

Stages of Chron icityIn another study Chap man , Brena and B radford (1981) theorized a

four stage-process by w hich industrial accidents can lead to a perm anentdisability status:

1. Premorbid stage: C haracterized by increased stress at work orat home and by d iff iculty in performing wo rk tasks adequa tely .2. Establishm ent of the sick role: Involves repeated m edicaltesting and interventions w hich fail to relieve pain. Ma ny p atientscontinue to remain inactive and take habit-forming pain medicationsdur ing this stage, leading to increased d epression and d epend ency.M any also have un successful surgeries for back p ain: two-thirds ofpatients referred to the Emo ry Pa in Con trol Center with pending orcurrent disability had p revious pain-related surgery, with a mean o f2.8 surgeries per person. (Chap ma n, S.L.; Brena, S.F.; andBrad ford, L.A. 1981; cited in Cha pm an et a l . 1988 p.103)3. tabilization of chro nicity: A s time pa sses, the pa tient developsthe identity of being disabled , which may h elp satisfy depend encyneeds an d provide som e level of financial security . Dru g use andinactivity frequently have becom e habitual by this point, andcontinue to create additional physical and em otional deteriorationwh ich erodes the injured w orker's ability to mana ge the painproblem o r return to a norm al l ifestyle . Law yers also often becom einvolved and ma y reinforce the crystallization of disability throughsuits for large settlements con tingent on the continua tion of adisabled status. M any lawyers w ork on con tingency and thus have adirect finan cial interest themselves in establishing a perm anen tdisability status for the patient. Som e are paid a percentage of thepatient's W orkers' Co mp ensation benefits, which can r einforce themfor delaying sett lement through legal delays and encouragement offurther testing an d therap y before settlement. (p. 103)


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4. earned helplessness: A t this stage, the pa tient is likely to havedeveloped the 'Disease of the D's' (M orse cited in C hapm an, 1988)characterized by depression, dysfun ction, disuse, drug use,dependency on d octors , dramatization of pain com plaints , anddisabili ty incom e. As these roles persist (and som etimes arereinforced) over long periods of t ime, they become increasinglyrefractory to change. (p. 103)

The C hronic Pain PatientC hapm an (1988) cited a study by Yelin, Nevitt , and Esteom (1980)

who surveyed 245 individuals w ith rheum atoid arthritis and looked at ahost of demo graphic, medical , and social variables. They found thatprevious surgery and heavy reliance on medicat ions such as steroids w ereassociated with reduced l ikelihood of return to wo rk, even w hen the stageof i llness was held con stant; however, control over the pace of work an dself-employm ent w ere by far the m ost predictive variables (p.106) .

In his review of chron ic pain, Ch apm an (1986) described the chronicpain patient as one w ho suffers physical deterioration caused by sleep, lackof appetite, reduced physical activity and d epend ence on dr ugs. As w ell,there was enorm ous strain on fam ily an d social l ife .

P U R P O S E O F T H E S T U D YHy pnosis has been used by cl inicians for hypnotherapy in the

treatm ent of pain (E rickson,1967b, 1983b, 1989; Hilgard,1986) and as aneffective adjunct wh en it is used on an ind ividua l basis as an ad junct toformal hyp nosuggestive procedures (El l is 1986; Ta rnow ski, 1986) , orcom bined w ith other approa ches. (Barber, 1986; Finer, 1982; Golden,1986; G uck 1985; Melzack & W all , 1965; Pinsky & M alyon's study , citedin Spino, 1984).


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Research on hypno sis has been foun d to be useful in the reduction ofexperimentally ind uced pain (B arber, 1960, 1970, 1971; Crasi lneck, 1979;Evan s, 1970; Hilgard, 1975, 1980; H ilgard & Hilgard, 1986; McG lashan,1969; Sternbach, 1984) and in single case stud ies of chronic pain(Erickson, 1983b). However, investigators reported that studies of clinicalresearch on the use o f hypnosis in the reduction of chronic pain are fewand m ainly consist of unco ntrolled case stud ies (Hilgard , 1986; Sternbach,1986a; Tan, 1982, Turn er & C hapm an, 1982). Some researchers foun d thatclinical research in relieving chronic pa in failed to d emo nstrate thathypnosis has mo re than a placebo effect (Turner & Ro man o, 1984) andothers found that there was n o reliable evidence that hy pno sis is effective inthe treatment of chronic pain (H ilgard & Hilgard, 1986). There are fewdocu m ented clinical studies using audiotaped hy pno sis as a treatment forchronic pain and no previous investigations directly comparing theeffectiveness of listening to the same au diotap e of hypno sis over timeversus listening to a rand om selection of audiotapes w hich use soothingsounds, m ood music, or hypnosis , as a treatment for chronic pain.The pu rpose of the stud y is to:

1. Exp lore the effectiveness of audiotaped h ypno sis as atherapeutic treatmen t for the reduction of chron ic pain, using relaxation,visualization, guided im agery, hypn otic ego-strengthening techniqu es at aunco nscious level and p ositive posthypno tic suggestions;

2. To assess change over t ime u sing outcome m easures to provideboth subjective and ob jective evidence that during the period of treatmentthere was a significantly qu antifiable trend towa rds the reduction ofchronic low back m uscle tension (which may reduce pain) as m easured bylowered electrom yograph ic (EM G ) readings, lowered self -report pain


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intensity scor es and positive self-report on the effectiveness of usingaudiotaped hypn osis for reducing chronic pain.


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HYPOTHESESStated in the nu ll form , the hypotheses this single case experim ental

design investigated were:

Hypothesis 1Listening to aud iotaped hyp nosis will have no statistically significant

effect on chronic pain as m easured by electromyo graphic (EM G) readingsover t ime in the Con trol and Experimental Group.

Hypothesis 2There w ill be no red uction in perceived pain after daily treatment in

the Experimen tal group as m easured b y subjective self-reports of painusing words an d num bers on a continuum of increasing value.

Hypothesis 3Au diotaped h ypno sis will have no effect on perceived pain after a

period of twen ty-five treatments over f ive weeks as m easured by su bjectiveself-report.

Hypothesis 4A com bination of e lectromyogra phic (EM G ) biofeedback in

com bination with aud iotaped hyp nosis w ill not be effective in the reductionof chronic pain.


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R A T I O N A L EResea rch on the effectiveness of hypno sis on pain has focused m ainly

on acu te pain which is experimen tally indu ced em ploying either the coldpressor test or m uscle ischemia to find a pain threshold a nd /or tolerance,using subjective pain ratings as the main depen dent variable (Hilgard &H ilgard, 1986; Tan , 1982). There are few d ocum ented cl inical studies usingaud iotaped hypn osis as a treatmen t for chronic pain. Curren t theories ofpain (Cru e, 1976; Erickson, 1983b; Le Ro y, 1976; H ilgard, 1975; Melzack& W all , 1982) look a t both the psychological and physiologicalcomponents .

The def init ion o f hypnosis is based o n the theories of hypn osis as analtered state of consciousness (Erickson, 1983; Barber, 1976), a state ofdissociation (H ilgard, 1973), and a state of m odif ied attention (W yke(1986). This is an exploratory study which evaluates the effectiveness ofaudiotaped hypn osis by studying both the psychological and physiologicalcom ponen ts of chron ic pain throu gh the use of subjective and objectivevariables measured over t ime. A m odif ied single case experimental designwas chosen to evalua te audiotaped hy pno sis because of the practicall imitat ions and difficulties of cl inical research (H ersen & Barlow , 1982,H ilgard, 1986) . The A -B d esign, which is the most suitable for a pilot study(Bor g,1963b), was m odified in ord er to establish stability of repeatedmea sures (H ersen & Barlow, 1982) .

Lim itations of the StudyTh e cau se-effect relationships are d ifficult to isolate in the A -B

design but changes in the depend ent variable may be "attributed to theeffects of treatment" (H ersen & Bar low, 1982, p.169) . Due to the


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difficulties inherent in clinical research, obtaining a large sam ple size andrand om d istribution wa s not possible. The findings are not readilygeneralizable because the group results were averaged a nd therefore theindividual differences of the pain patients were not ad equa tely sam pled.


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C H A P T E R 2

R EV I EW OF THE LITER A TU R ETh e review of the literature w ill focus o n four a reas of interest:

history of pain ; theories of pain; treatments for chronic pain an d chro niclow ba ck pain; research on experim ental and clinical pain, with anemphasis on therapeutic methods of hypn osis for pain redu ction.

History of PainFro m the time of Ar istotle, wh o theorized that pain wa s the opposite

to pleasure and therefore wa s an emo tion, to the present day, controversyhas continued over how to d ef ine and conceptualize pain (Meizack & W all,1988). Pain, and the infl ict ion of pain ha s been viewed as a societalinstrum ent of social control both within the family unit, in society at large,and as a sign of courage in initiation cerem onies in man y coun triesthroughout the world (H ilgard & Hilgard, 1986).

In 1664 D escartes proposed that pain w as transm itted in a straightchan nel from the skin to the brain. This was n ot challenged un til thenineteenth century w hen phy siologists began to wo nder if there weredifferent qua lities of sensations for the sen ses of seeing, hearing, taste,smell and tou ch. Johann es M uller, theorized that there was, " a straight-through system from the sensory organ to the brain centre responsible forthe sensation." M ax von F rey, a physician, published articles in 1894 and1895 in which he postulated that nerve endings were pain receptors,corpu scles were touch receptors and that there were receptors for cold andwarm th as w ell. This theory was extended over the next twenty-f ive yearsto include specificity theories which pro posed that the different sensory


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fibres of tou ch, sm ell , taste, hot, cold, etc. had specific ( italics added )pathways to the brain centre. Final ly, anatomical studies on hum ans an danim als discovered that certain areas of the spinal cord were impo rtant forpain sensation and provided a "pain pathway " to the brain (Melzack &Wall, 1982, p. 151).

The tha lamu s is thought to be the 'pain centre' by som e specificitytheorists , and is debated by others (M elzack & W all , 1982). Crit ics of thespecificity theory of pa in theorized that there is psycholo gical evidence torefute that there is a one-to-one relationship between pain percep tion andintensity of the st imu lus. M elzack & W all (1982) cited Pavlov'sexperiments with dogs w ho w ere given electric shocks, burns a nd cuts,fol low ed by food a nd then w hen they were cond itioned to respond to thestimuli as signals for food, failed to show 'even the tiniest and m ost subtle'signs of pain. Clinically , M elzack & W all cited phantom limb pain,causalgia, and the neura lgias as evidence against the theory an d othertheories, und er the head ing of 'pattern theory' w hich dispute the specificitym odel of pain. (p.156)G oldscheider (1894) w as the first to propo se that stimu lus intensityand central summ ation ( the accum ulation o f pain over long periods),prod uced a "p atterning of the input" which is essential for any theory ofpain. This theory takes into accoun t chronic pain of intractable origin.M elzack & W all (1982) posited that while the "developmen t of sensoryphysiology an d psych ophy sics during the twentieth century has givenmom entum to the concept of pain as a sensation and has overshadow ed therole of affective and m otivational process es. .. .this sensory ap proa ch topain, fails to provide a com plete picture of pain processes." The au thorstheorized that "sensory mo tivational and co gnitive processes occu r in


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parallel, interacting systems at the same time" an d distinguished between"physiological specialization and psycho logical spec i f ic i ty " and stated:

Neuron s in the nervous system are spec ia l i zed to conduct patterns ofnerve impulses that can be recorded and displayed. But no neurons inthe soma tic projection system ar e indisputably linked to a single,specific psycholog ical experience... .If we can a ll agree that`specificity' means physiological specialization, w i th o u t implyingthat specialized neurons m u s t give rise to the experience of pain a ndo n l y to pain or that pain can n e v e r occur u nless they are activated,then we w ill have el iminated a major sou rce of unnecessarycontroversy. (p. 164)The G ate Control Theory of pain proposed by M elzack & Wa ll in

1965, took into account both physiological and psy chological processes bypropo sing that neural mecha nisms in the spinal cord act like 'gates' wh ichmay be inhibited by descending messages from the brain. The authorsstated that in ord er for, " A n ew theory o f pain to be useful," it "m ustincorporate known facts about the nervous system, provide a plausibleexplana tion for clinical pains, and stim ulate experiments to test the theory,including pro cedures that are potential new therap ies" (p. 165).

H istorically , med ical treatment for pa in relied o n surgery, d rugs,and counterirritants. M any o f the psychological methods of today can betraced back to treatm ents based on folk method s. Faith healing has existedas long as man and m any religious groups have claimed to have the answerto curing pain (H ilgard, 1986) . Ether an d chloroform were d iscovered 150years ago and used as an esthesia in surgery. M orphine and other narcoticsderived from o pium have been the m ost successful pain-killers for therelief of nonsurg ical pain and p ain that persists after surgery (Hilgard ,1986).


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D uring the past two d ecades there has been a scientific revolution inthe research of pain. Un til the midd le of this century p ain w as believed tobe a sym ptom o f disease or injury. Chronic pain is now seen as a problemin its ow n right which at times can be m ore debilitating than the diseaseprocess wh ich caused it (M elzack, 1982).

Since the 1960s and the advent of space age technology, bioengineersand b ehaviorists have developed m ethods for the non surgical treatm ent ofintractable and chr onic pain throu gh bioelectric stim ulation, either throughimplants or by external e lectronic systems (Le R oy, 1976). Behavioral andcognit ive-psychological methods have been com bined in pain cl inics for thetreatmen t of chronic pain (Wall & M elzack, 1984). A t the sam e t ime d rugresearch has discovered new ch emical pain inhibitors called "beta-endorp hins" and n atural pain inhibiting endorphins w hich are releasedwhen deep regions of the brain are st imu lated (LeR oy, 1976).

Recently , there has been a shift away from the m edical model wherethe patient has no input into the treatment received, to an emp hasis onholistic med icine an d personal self -regulat ion in therapy (E lton, 1980;R ossi , 1986). The study o f neurophysiology has increased our kno wledgeof the m ind/body con nection. Pain is now viewed as a p sychophy siologicalprocess w hich has neurological , physiological , behavioral and affect ivedimen sions (Sternbach, 1986; W olf , 1982) .

Acute V ersus.Chronic Pa inPain is derived from the Latin word "p oena," meaning a penalty

(Spino , 1984). D escriptions of pain, reflect the particular theoreticalbackgroun d of researchers in neu rology, physiology, psychology or thebehavioural sciences (Sternbach, 1986; Ford yce, 1986). Sternbach


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emphasized that pain w as the common denom inator but the processes weredifferent.

The am ount and quali ty of pain an individual experiences isdetermined by the individua l's past experience of pain, their culturalvalues, their nega tive or p ositive perception of the event cau sing the injuryand their anticipated pr ojection into the future of the outcom e of thetrauma (Sternbach, 1986). Studies of cultural experiences of wo men inchildbirth illustrated this theory (M elzack, 1961; Keefe, 1982). Stud ies byBeecher (Cited in M elzack 1961) of Wo rld W ar II soldiers injured duringthe war, and civi lians who had undergone su rgery after the war,dem onstrated ho w a po sitive or negative perception of the event changedtheir perception of pain. The soldiers viewed their injuries as a m eans o fescaping from the batt lefie ld a nd needed a significantly low er dosag e ofmo rphine than the civilians who viewed the surgery as a "depressing,calam itous event" (p. 4).

Du ring the 1960s the classical v iew of pa in as a specific sensoryexperience, wh ose intensity is directly pro portiona l to the intensity of theinjury received, wa s challenged by researchers (M elzack, 1961; Sternbach ,1968). Early cl inical studies on p refrontal lobotomies pro vided evidence oftwo distinct dimen sions of pain; the sensory com pon ent and the sufferingor affective compon ent. Patients with intractable pain (pain r esistant totreatmen t) stated that after surgery, the pa in was sti ll there but that it nolonger bothered them . In other wo rds, the sensory pain wa s still there butthe suffering had been rel ieved (Barber, 1959; M elzack, 1961).

H ilgard & H ilgard (1975) categorized the experience of pain in twoways:


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1. That pain is a sensory response to an injury and the reaction toit is the suffering pa rt; or

2. That the two compon ents happen simultaneously rather thansuccessively, with two pa rts of the nervou s system activated at the sametime.

Sensory phy siology a nd psychophysical analyses of sensory qualit ieshave been exam ined in detai l (Craig, 1984). Pain from a biomed icalviewpo int wa s thought of as both a warning signal of imp ending injury oras a need -state for rest in ord er for the injury to heal (Sternb ach, 1984).Ho wever, researchers found that the experience of pain do es not alway saccom pany injury signals (M cglashan, 1969; M elzack, 1961; Wa ll, 1979).Intractable or prolonged p ain such as phan tom limb pain, arthritis, bonecancer or chro nic low back pa in do not provide these functions to theindividual. It is only recen tly that researchers have studied the d ifferencesbetween acute and ch ronic pain (Sternbach, 1984).

Som e researchers (Hilgard & H ilgard, 1975) classif ied theuncertainty of the sou rce of pain into three descriptive categories:

Referred pains are those felt in one place although the sou rce ofirritation is som ewhere else. Psychosomatic pains are complex andare intricately related to the emotiona l life of the individu al, andtheir perception of the pain and the subtle purpose it may serve.Phantom limb pains are the perception of pain after a limb has beenam putated. (pp. 31-32)The au thors noted that these pains take into consideration the

psychological aspects of pain.Th e ma in aspect of chronic pain w hich differentiates it from acute

pain is the time element or d uration of the pain (Ford yce, 1986; M elzack,1983, 1989; Melzack & W all,1984; Sternbach, 1968) . Chronic pain has


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been defined as a pain that is benign in origin an d that is present on a.constant , dai ly basis for longer than six m onths m onths by som e

researchers (Fordy ce, 1986; Sternbach, 1974), or p ain w hich persistsbeyond the required t ime for healing (C raig, 1984). Others think the "sixm onth time fram e... is arbitrary an d often inapp ropriate. ..and the use o f theterm chro nic should b e restricted to those individu als who , in ad dition tocom plaints of p ain, display evidence of a ffect ive distress and/or behavioraldisruption" (Grzesiak & Ciccone, 1984, p. 165) .

M elzack (1989) classified pain into three stages: 1 . Acute pain w hichhas two com ponents: 2. The phasic com ponent which has a rapid on set, and3. a subsequent tonic com ponent w hich persists for variable periods oftime. He cited as exa mp les of acute pain, " a burn ed finger or a rup turedappendix" (p. 6526). Chronic pain ma y pass through the two stages of acutepain, but "ma y persist long a fter the injury has healed.. .may sprea d toad jacent or m ore distant bod y areas. . .is resistant to surgical control, and itsprolonged time-course is characteristically associated with high levels ofanxiety and d epression" (p. 6526). Exa mp les of chronic pain are chron iclow back pa in, intractable my ofascial pain, the neuralgias and pha ntoml imb pain.

Phy siologically, autono m ic activity (involuntary a ctivity such asheart rate, muscle tension etc.) is regarded a s an indicator o f activity ofacute or ch ronic pain (Sternbach, 1984, 1986). Autonono m ic act ivity w ithacute pain is characterized by a "fight or flight" synd rom e with changes inthe autonom ic activity rou ghly prop ortional to the intensity of the stimulus;chronic pain is characterized by a "hab ituation of the autonom icresponses," a "vegetative" state accom panied by "sleep disturbance, appetitechan ges, decreased libido , irritability, withdra wa l of interests, weaken ing


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of relationships, and increased somatic preoccupation" (Sternbach, 1986,p.223).

Som e behaviorists described three stages of pain: acu te, prechron ic,and chronic (Ford yce, 1986). Ea ch stage was explained in terms of a"conditioning process" in which patients learned behavior patterns thathelped them to reduce pain or helped them m aintain pain. A t the "chronicstage-12-months or more" pa tients may becom e bedridden and drugdependent. F ordyce, described pain medication, f inancial compensation,avoidance of wo rk respon sibil it ies as "po werful posit ive consequ ences ofthese behaviors " (p. 326).

Nigl , (1984) in his review on ch ronic pain cited Cr ue (1976) whodivided chron ic pain into two subtypes; recurr ent acute pain which can bemistaken for chron ic pain (migraine heada ches, osteoarthritis, andrheum atoid arthritis) and chron ic pain wh ich is constant pain with noorganic basis . Cru e (cited in N igl, 1984) noted that recurrent acutedisorders m ay beco me chro nic disorders if they persist after the acute painis treated with m edication. Two classes of pain were d istinguished; thosewith pain due to m alignancy or cancer an d those with chronic pain which isbenign an d intractable. Ch ronic benign pain disord ers were listed as havingthe following c haracteristics:

Patients have pa in all of the time; it is con stant.The p ain is functional in nature; it is central pain not peripheral.It is accom pan ied by reactive depression.Patients fail to cope w ith their pain un like other patients with chron icpain states who do not seek treatment.


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There is an underlying, premorbid personali ty pattern thatpredisposes an ind ividua l to have chronic pain disord er, regard lessof diagn osis or treatmen t. (p. 98)

Chron ic PainThere is considerable disagreement abou t which disorders can be

properly labeled as chronic pain disorders, and some au thors made adist inct ion between chronic pain and chronic pain synd rom e (Nigl , 1984).Pinsky (cited in N igl, 1984) developed the concept of chronic intractablebenign pa in syndrome (CIB PS) to differentiate between patients who hadintractable pain and n o psychological problems and those patient's who ,"present symp toms of constant pain that cannot be related to any activepathoph ysiologic or pathoan atom ic disorder" (p. 98). Pa tients sufferingfrom C IBP S w ere characterized by the following factors:

Dru g depend ency or abuse, physical decline, generalized d ysphoria,psychoso cial withdraw al and interpersona l dysfunction, intensifiedfeelings of hop elessness and helplessness, chronic con flicts withmedical professionals accompan ied by anger an d hostil ity, and agener al loss of self-worth a nd self-esteem . (p. 99)Pinsky (cited in Nigl , 1984) theorized that chronic pain w as a

"psycho logic disorder w hich represented an individua l's attempt to copewith intrapsychic conflicts" and he stated that it "can be thought of as anadap tive attempt to coun teract anxiety or resolve a particular conflict;how ever, in alm ost all cases, it is destined to fail. Signs of ada ptive failureinclude un resolved grief response, depression, tension and an xiety, sham ean d guilt, feelings of rejection, isolation ... .sym ptom s of grief wh ich norm alindividuals experience over a loss; namely som atic distress, preoccu pationwith premorbid self-image, anger and bitterness toward medical treatment


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'failures' and significant behavior al chan ges (e.g., restlessness, insomn ia)"(p. 101-102).

M easurement of PainCha pma n, Casey, Dubner, Foley, Gra cely, and R eading (1985)

reviewed the advantages an d limitations of physiological and behavioralmethods of pain m easurement in animal research, human su bjects, and inlaboratory and clinical studies. The au thors noted that pain measu remen t iscomplex and could be q uantified on ly indirectly. They qu antified researchin hum an laboratory studies into four types of procedures:

1. Psychophysical methods that attempt to define a threshold forpain;2. Rating scale methods in which subjects rate pain experienceson structu red scales with clearly defined limits;3. M agnitude estimation procedures in w hich direct judgments ofstimu lus intensity or q uality are m ade by n umber a ssignmen t orcross-modality m atching techniques such a s hand grip force;4. The measur ement of performa nce behavior on laboratorytasks, usually to obtain ind ices of discrimination ability or d etection.(P. 7)In addition to these methodologies, some investigators have assessed

physiological or facial expression cor relates of pain but these techniqueshave not been used alone as indicators of pain. Chapm an et al.(1985)pointed out that:

Tolerance m ethods are limited by individual d ifferences in paintolerance, rating scales are difficult to assess because ind ividualperception o f categories is not equ al, and statistical analysis can bemisleading if the scores are u sed as interval or ratio scales. (p. 10)


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H owever, they concluded that these scales are often u sed, "becausethey are simple, econom ical and easy for subjects to comprehend" (p. 10).They foun d that cross m odality methods, while more complicated, have theadvantage over other methods in that they scale pain on m ore than onedimension an d can be used for both laboratory an d clinical studies.

Other m ethods reviewed included laboratory research usingperformance m easure (measures which do no t directly measure pain); andSensory D ecision Theory (SD T), which is used for labora tory research onhum an pa in and as an evaluative tool for chronic pain patients.

Ch apma n et al. (1985) noted that while there had been a need forobjective eviden ce of pain experience, it was difficult to, "reduce hu ma npain to m easures of neuron al activity alone even though such signals are thebasic building blocks of pain" (p. 14). They defined a physiologicalcorrelate of pain as serving three purposes:

1. It could h elp confirm the va lidity of the experiment inquestion by providing supporting evidence that the verbal painreports of subjects are linked to the stimu lus rather than to anextrinsic psychological state.2. It could con tribute to the statistical pow er of an experim ent byproviding add itional information to be used in hypothesis testing.3. n certain cases such a m easure could help in qu antifyingaspects of the hum an pa in experience such as anxiety that arepresently ignored in m ost studies. (p.14)Cha pman et al.(1985) defined four huma n phy siological correlates:1. Direct recording from peripheral nerves;2. Electromyographic (EMG) measures;3. utonomic indices and evoked potentials and


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4. lectroencephalograph y (EEG ) measures (p. 14).

Peripheral nerve studies have record ed frequen cies which reflect, theactivity of peripheral nerves, wh ich can then be com pared to the volunteersubject's report of sensory changes and the area of involvement. C hapm anet al .(1985) cited studies of recordings m ade from electrodes im planted inhum an teeth. Th ey cautioned that this is not a perfect relationsh ip ofperipheral activity to pain because, "the mo dulation processes occu rring atthe dorsal ho rn an d higher centers are no t reflected in such signa ls" (p.14).

Several studies (Budzyn ski , 1973; Hay nes, 1975; Jessup, 1984; K eefe,1982; Large, 1983; N igl, 1984; Pearce, 1987; Schum an, 1982;W ickramasekera, 1972; Wolf , 1982) reported using electromyo graphic(EM G ) measures to relate m uscle tension in chronic pain patients withmyofascial disorders, chronic back pain, tension headache,temperoman dibular joint pain, and m uscle tension pain in the neck andshoulders. Autonom ic indices included pulse rate, skin conductance an dresistance, skin temp erature, and finger pulse volum e. The A utono m icPerception Q uest ionnaire (APQ ) was devised by M andler et al . (Cited inChap man et a l ., 1985).and has been u sed by researchers to "study painrelated arousa l associated with ice water imm ersion of a limb ." They foundthat "AP Q d ata were no t related to pain tolerance" (p. 15).

Evoked potentials (EPs) a nd electroencephalographic (EEG ) are bothcentral nervous system m easures. Researchers ci ted in C hapma n etal.(1985) studied the EP s of "short and long wa ves" and ha ve concludedthat, "waveform amp litude increases with the amou nt of st imulus energy


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delivered" and w hen an algesics are given they decrease. Both of thesem easur es correlated w ell with subjective pain repor ts. (p. 16)

EE G measures are used to "qu antify or m onitor non-specif ic arousaldur ing pain studies in hum an su bjects". and to "assess the effects ofanalgesic drugs" or "psychological interventions on arousal, a methodologytermed pharm acoelectroencephalography." C hapman et a l . (1985)concluded that physiological measures a re objective measures which m ayprovide inform ation about the "underlying pain or ana lgesic state" but ma ynot be "less susceptible than subjective report to psychological variablessuch as exp ectancy or a ttention" (p. 16).

Jenish & D eacon (1991) reported that a "new approach" to themeasu rement of back pain w as developed by a pro fessor of engineering,Serge Gra covetsky, who developed a "spino scope." It allows phy sicians "tomeasure w ith unprecedented accuracy the m ovement of spinal muscle ,ligament an d fibre, wh ich are know n as 'soft tissue,' as opp osed to the hardtissue of the sp inal cor d itself'. (p. 52).

Clinical Pain A ssessmentCh apm an et a l . (1985) credit Beecher (1957, 1959) with influencing

the "emotional dimen sion" of pain, the "imp ortance of experimen tal design,including d ouble bl ind procedures".and " the scal ing of p ain as opposed tothe measu remen t of pain relief." The measu remen t of behavior as a basisfor inference about clinical pain, and pencil and pap er test instrum entswh ich quan tify mu ltiple dimension s of the pain experience from subjectivereport, have been developed to pro vide both quan titative and qua litativeaspects of pa in. (p. 17)


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A review o f behavioral methods for the assessment of chronic painhas been pro vided by K eefe (1982) and N igl (1984c). Some o f the variablesrepo rted w ere: 1. activity (e.g., m oving in bed ) and activity diaries; 2.mea sures of the amo unt of time spent standing, sitting or reclining (up-timevs. dow n-time); 3. sleep patterns; 4. sexual activity; 5. medication d ema ndor intake; 6. food intake; 7. norm al househo ld activities such as m ealpreparation and gardening; and 8. engagement in recreational activity.

C hapm an et al. (1985) reported that pain investigators had attemptedto categorize chronic pain behavior for clinical observation; had d evised arating scale for scoring or qu antifying pain behavior in chronic backpatients; had developed a rating instrum ent "to assess behavior generallyindicative of pain", and had d esigned an "automated m onitoring d eviceworn by the patient" which quan tified "up -time" an d qu antified facialbehavior with a videotape. (p.18) Self-reported behaviors in the form ofdiaries or pencil and pa per tests had been used by investigators todetermine no rma l daily activity levels or pain medication but the authorsnoted that "pa tients are som etim es biased or incorrect in their reporting"(Chapm an et a l .,1985, p.18) .

Sub jective pain repor ts are used to scale both pain itself and painrelief following treatment. Pain category ratings and V isual Ana log Scale(VA S) judgm ents are the simplest report scales. Ca tegory scales have beenused to gua ge pain relief in canc er patients follow ing mo rphine treatmentan d w ith children follow ing surgery . W ith categor y scaling it is difficult tospecify the s ize of each category or k now if the categories are equa l lyspaced. (Chapm an et al . , 1985)

The q ualitatively different types of pain have been described a spricking or sharp, burning, and d ull or aching. Pricking and burning pain


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is easy to locate. Aching pa in usua lly originates in d eep tissues, includingthe viscera, muscles, and bon es, and is difficult to localize (Spino, 1984).

Syrjala (1984) in an overview of cl inical pain m easuremen t, citedtwo scales which measure pa in using word descriptors. M elzack &To rgerson, cited in Sy rjala (1984) developed a f ive point scale of worddescriptors of pain dimen sion which represented un iversal descriptions forsensory, emotional or other aspects of pain. M elzack (1975) then d evelopedthe McG ill Pain Quest ionnaire (MP Q) w hich was based on this work. TheMcGill Pain Questionnaire quantifies three dimensions of pain experience;sensory, a ffective, and evaluative. Patterns for d ifferent clinical painsynd rom es have been obtained wh ich includ e arthritis, labor an d childbirth,cancer pain, and low back pain.

The ad vantage of the MP Q is that it measures both qu antitative andqua litative aspects of pain and sca les pain mu ltidimen sionally. Critics of thescale pointed out that som e patients had difficulty with the complexity ofthe word s; that sensory asp ects of pain are weighted m ore than affectiveaspects and that it was m ore t ime consum ing to administer than the VA S(Cha pm an et al. , 1985). Others noted that a test should show reliably that agiven "clinical pain state changes a fter the patient is adm inistered anopiate," or after surgery and that the "placebo effect" should show adifferent pattern of respo nses (Sy rjala, 1984). The statistical man ipulationof M PQ scores has also been criticized for not being "standard ized." It hasbeen sugg ested that "spatial distribution of chron ic pain conditions" beassessed as w ell because "behavioral variables change significantly as afunction of pain location and distribution" (C hapm an et al. , 1985, p. 22).An eight point facial expression picture scale has been developed w hich has


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been found to correlate well with visual analog an d nu meric rating scales(Syrjala, 1984).

Ch apm an et al . , (1985) found four problem a reas in their review o fthe literature on pa in measu remen t. These included the following:

1. The literature lacks an integrated overview of pain assessmenttechnology a nd a crit ical evaluation o f the methods com mon lyemployed.2. There is a need for integration of w ork on pa in measurementin anima l, hum an labor atory, and clinical areas of investigation.3. There is need for broader, more com prehensive operationaldefinitions of pain.4. The area o f clinical pain in animals need s to be exploredfurther in order to validate and extend the finding s of laboratoryresearch. (p. 24-25)

THEO R I ES OF P A INThere are three m ain theories of pain: sp ecificity theory , pattern

theory and gate control theory.

Specificity T heory o f PainTh e traditional spec ificity theory of pa in, which is still taugh t in

som e med ical schools, proposes that pain is a specific sensation an d that theintensity of pain is pro portional to the extent of tissue d am age. The theoryimplies a fixed, straight-through transm ission system from som atic painreceptors to a pain center in the brain. H ow ever, recent evidence show sthat pain is not simply a function of the amou nt of bodily dam age alone,but is influenced by attention, anxiety, suggestion, and other psycho logical


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variables. Mo reover, pain is not only a sensory exp erience but also hasobvious emotional properties that demand immediate attention, disruptong oing behavior and thou ght, and d rive the organism into activity aimedat stopping the pain. These data refu te the concep t of a straight-throughsensory transm ission sy stem (M elzack, 1989, p. 652).

Pattern Theory o f PainTh e pattern theory o f pain, a rival theory to the 'specificity theory',

was proposed by G oldscheider who bel ieved that pain depend ed on the"sum m ation of neural inpu ts that must reach a critical level for pain to befelt. Peripheral stim ulation is not enough , because central systems areimpo rtant in this summ ation" (Hilgard & H ilgard, 1975, p. 34). Thistheory do es not support the concept of peripheral sites which transm itpainful st imu li along a set of peripheral nerves.

M odern theories include both peripheral and central summ ation, andas did earlier theories, attempt to explain why pain m ay end ure beyon d theinitial stimulation (Hilgard & H ilgard,1986; LeR oy, 1976; M elzack &Wall , 1982).

Gate Con trol Theo ry of Pa inM elzack & W all (1965) proposed that neural mechanisms in the

dorsal horn s of the spinal cord a ct like a gate which can increase ordecrease the f low of n erve impulses from peripheral f ibers to the spinalcord cells that project to the brain. Som atic inpu t is therefore subjected tothe mo dulat ing inf luence of the gate before it evokes pain perception an dresponse. Th e theory sugg ests that large-fiber inpu ts tend to close the gate,wh ile sm all f iber inpu ts generally op en it , and that the gate is also


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profound ly inf luenced by descending (italics add ed) ac tivities from thebrain. It further pro poses that the sensory inpu t is mod ulated at successivesyna pses throughou t its projection from the spinal cord to the neura l areasresponsible for pain experience and respon se. Pa in occurs when thenum ber of nerve im pulses arriving a t these areas exceeds a critical level .The theory, therefore, proposed a mecha nism to explain pain relief by avariety of different procedu res wh ich close the gate by selective activationof large fibers (i.e. , phy siotherapy ) or by a ctivation o f descend inginhibitory influences from the brain (i .e., distraction of attention).

M elzack (1989) theorized that there are "three m ajor psych ologicaldim ensions of pa in: sensory-d iscriminative, mo tivational-affective, andcogn itive-evaluative.. ..these a re su bserved by physiologically, specializedsystems in the bra in, as fol low s:

1. Th e sensory-discrimina tive dimension o f pain is influencedprimarily by the rapidly conducting spinal systems.2. The powerful motivational drive and unpleasant affectchara cteristic of pain are su bserved b y ac tivities in reticular andlimb ic structures w hich are inf luenced prima rily by the slowlyconducting spinal systems.3. eocortical or higher central nervou s system processes, suchas evalua tion of the input in terms of past experience, exert con trolover activity in bo th the discriminative and m otivationa l systems. (p.6525)All three forms of act ivity can then inf luence mo tor mechan isms

responsible for the complex pa ttern of overt responses that chara cterizepain. Acute and chro nic pain are inf luenced by two different (italicsadd ed) ascending spinal cord pain-signall ing pathw ays. On e set ofpathw ays, the 'lateral pathway s' convey pha sic inform ation, while the other


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set of pathways a re slower an d 'are un likely to signal the need forimm ediate action'. .. .Th ese 'medial pathwa ys' carry 'tonic' inform ation and"they continue to send inform ation as long as the wou nd is susceptible tore-injury. These m essages ma y prevent further dam age, and foster rest,protection, and care of the injured areas, thereby prom oting healing andrecuperative processes' (Melzack, 1989, p. 6525).

As well as the ascending pathway s, M elzack (1989) theorized thatthere is in the brain a 'powerful descending ( ital ics ad ded) sy stem w hich isable to inhibit, or 'close the gate' to incom ing pain signa ls (M elzack, 1961;1989). M elzack theorized that mem ory m ay acco unt for the persistence ofcertain kinds of pain. He cited experiments w here a rat with an injuredhindpa w sho wed a heightened sensitivity to pain not only in the injured pa wbut in the opposite paw an d con tinued to have sensitivity to pain in theinjured pa w after the nerves from the injured paw were cut . Melzack(1989) concluded that, 'These results show clearly that the hypera lgesia(heightened sensitivity to pa in) is dependen t on ab norm al activity in thecentral nervous system, proba bly the spinal cord' (p. 2530).

From studies of chronic phantom bod y pain in paraplegics whosustained total spinal cord lesions, Melzack an d Lo eser (1978) proposedthat synaptic areas along the major sensor y projection systems, from -thespinal cord to soma tosensory p rojection areas in the thalamus an d cortex,may become p attern-generating m echanisms. O nce the pattern-generatingmechanisms becom e capable of producing pain signals, any input may actas a trigger.


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T R E A T M E N T S F O R T H E M A N A G E M E N T O F P A INCognitive-Behavioural Methods

Du ring the last decad e, cognitively based therapies have pro liferated.Therapy methods are based on the assum ption that emotional disturbance isthe function of malad aptive thoug ht patterns which m ust be restructured .Th e three most influential cognitive-beha vioral therapies are Ellis' (1975)rational-emo tive therapy; B eck's (1970) cognitive training therapy , andM eichenbaum 's (1977) self-instructional training. All three therapies mak euse of im agination proced ures such as imagining the desired behavioral andemo tional responses while thinking rationa l though ts discussed du ringtherapy (Rachm an & W ilson, cited in Spinhoven, 1987).

Sternba ch (1986) noted that there are "philosophic and psycho logic"differences in the assumptions "underlying cognitive and behavioralinterventions. C ognitive theories assum e that if one chang es the ways o fthinking, there will be chan ges in affect and behav ior that will follow.Beha vioral theories assume that if behavior changes, there will beconsequen t changes in affect and especially in cognition, as through theprocess of cognit ive dissonan ce" (p. 235) . Ta n (1982) in a review articlenoted tha t eviden ce for the efficacy o f cognitive-beha vioral techniqu eswere good for experimen tal pain but meager for cl inical pain.

M ore than 30 different illnesses and an atom ic dy sfunctions have lowback pain as a sym ptom (G rzesiak and Ciccone, 1986, p. 175). C hronic lowback pain, migraine head aches and can cer pain are the most difficult painsynd rom es to treat (M elzack & W all, 1988) . Flor & T urk (1984)categorized low back pa in as inflamm atory, degenerative, structural,


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traumatic and mu scular l igamentous processes but the specific (italicsadded) process which caused back pa in were unclear.

The psy chological treatment of patients with chronic low back p ain isvery difficult and has been avo ided by psy chiatrists and psycho logistsbecause they:

D eny psy chologic distress, reject suggestions that their pain problemsma y have p sychologic basis , have l i tt le or no insight , and are n otintrospective... .this group of pa tients tends to be very resistant toexploring person al issues and frequ ently reacts negatively, oftenvituperatively, when referred for psychologic treatment. (Nigl,1984, p. 127-128)Beha vioral method s of dealing with chron ic pain, "derive chiefly

from the classical cond itioning of Pa vlov, as represented by thedesensitizat ion therapy of W olpe (1958) from the operant cond itioning ofSkinner (1969) and from the social learning theory of B and ura (1969)"(H ilgard, 1980, p. 261). O peran t cond itionin g, as practiced in pain clinicswh ich treat chron ic pain, focus o n the theory that pain responses ha ve beenlearned and therefore can be un learned. The patient is "rewarded" for"non-pain" responses and pain responses are "countered or extinguished"(Sternbach, 1974, 1978; Ford yce, 1978) . H ilgard (1980) gave the followingexample:

A person with joint pains can walk on ly so far before the painbecom es so great as to requ ire rest . Looking forwa rd to that rest isl ike expect ing a reward for experiencing pain. Hen ce, having foun dthe distance that can be w alked w ithout excessive pain, the patient atfirst is requested to walk less than this distance, so that the pain is notreinforced fol lowing the walk. Each d ay the wa lk is lengthened alittle, and , not surprisingly, the person w alks beyon d the originaltolerance limit without experiencing the rest-dem and ing pain.


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Correspond ing methods are used to reduce dependence on pain-reducing d rugs. A 'drug-cock tail' consisting of the usual dosagemixed with a taste-concealing fruit drink, is taken a t regularintervals, so that it is no long er associated w ith the relief of pain thathas m oun ted to some disturbing level. W ith the pain thus controlled,without being con tingent on the tim ing of the drug intake, theamou nt of drug is gradually redu ced unti l the patient remainscom fortable with the "cocktail' no long er containing any pa inmedication. (p. 261)

BiofeedbackC linically, biofeedback therap y "is a blend of physiological and

psycho therapeutic intervention" (Schum an, 1982, p.164). Biofeedback is aform of behaviour therapy but i t dif fers from the mo re "strict lycond itioning therap ies" because there is an em phasis on "achievingvoluntary co ntrol" through "am plification of the changes inelectrophysiological or neurom uscular processes over w hich control issought. Examples are learned con trol over muscular tension throughobserving the signals from selected m uscle groups by w ay of theelectromyo gram , and con trol of blood f low throu gh am plification oftemperature chan ges in the f igures" (Hilgard, 1980; p. 262).

Karoly and Jensen (1987) described electromyographic feedback(EM G ) as the measurem ent of:

sma ll amou nts of electrical activity that are produced b y m usclesw hen they are active (that is, tense). .. .electromy ogra phy ha s thepotential to be u seful in the assessment of pain co nditions that are ormay be associated with abnormal m uscle response. Pain disordersstudied w ith EM G include back pain, headache, and the myofacialpain dysfunction (M PD ) synd rom e. (p. 76)


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Tw o assum ptions are mad e by the biofeedback cl inician; one, thatmu scle tension and spa sm have a cau sal relationship to pain and that theredu ction of muscle tension thus reduces pain; and tw o, that a generalizedstate of relaxation shou ld con tribute to pain relief, either by dim inishingaffective concom itants related to the problem o r through som e centralgating mecha nism. M uscle pain is frequently associated with a pattern ofchronic mu scle tension (Grzesiak, 1984; Schuma n, 1982).

H ilgard (1980) noted that the rationa le between pa in control throughhypn osis and pain con trol throu gh biofeedback differed; in hypn osis, painis removed throu gh a process of denial, whereas in biofeedback there is a"realistic sensitivity to bod ily processes, such as relaxa tion," thereforeindividuals who are good at hypnosis might not be good at biofeedback (p.262). Hilgard also pointed ou t that biofeedback cou ld in i tself be a form ofdistraction from pain. In a review of psycho logical approaches to theman agement of chronic pain, Schuman (1982) noted that some researcherstheorized that:

Hy pnosis and biofeedback involve different skil ls and mechanisms.Biofeedback involves a focus on an external st imu lus, which maydistract some subjects from the inward ly directed experience thatcharacterizes d eep relaxation or hypno sis . (p. 164)Schum an (1982) def ined biofeedback from two very d ifferent

perspectives: the specificity m odel w hich theorized that the individua l is"trained to vary a target function in a q uite differentiated and specificma nner" an d the state model wh ich theorized that the individual "shapes amore general change in behaviour along a continuum of arousal-relaxation" (p.153). As an examp le, if the individua l wished to decreaseheart rate through the use of biofeedback; w ith the specificity mod el, the


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individual w ould learn "to become aware o f cardiac act ivity and learn todecrease hea rt rate at will ," wh ereas with the state mod el the ind ividua lwould learn "to produce a state of deep bodi ly quiet that happens to beassociated w ith a d ecrease in heart rate" (p. 153).Schum an (1982) concluded that "biofeedback therapy for chronicpain has no sp ecific psychop hysiological basis: it becomes instead apsychotherapeutic (italics added) con text for teaching relaxation orexploring the mind-bo dy relationship." How ever, relaxation "wh ich is acommon clinical objective in biofeedback training" may sometimes reducepain by interru pting the "pain-tension" cycle, or in som e cases it "m aywo rsen pain" (p. 165).

Nou wen a nd S olinger (1979) compared chron ic low back patientswho received low back EM G feedback with a control group over 20sessions and reported that the treatment group had lowered EM Grecord ings and lower ed pain self-report at the end of treatment but thatboth had return ed to baseline levels at a one m onth follow-up. Th eyconclud ed that the biofeedback training given to the treatment grou pproduced a sense of control (italics added) w hich changed the patient'sattitude toward s pain and that this was more impo rtant than thephysiological function of pain.

In ano ther comp rehensive review of the literature on low bac k painand E M G biofeedback, Nou wen and Bush (1984) came to the conclusionthat there was n o consen sus on the role of paraspinal m uscle tension in theproduction of low ba ck pain. How ever, they did note that pain avoidancema y cause pa tterning of the muscles in the low ba ck w hich are the result ofposturing w hich in turn cau ses muscle spasm . The authors stated that theseresults were n ot "atypical" an d cited other stud ies (Epstein et al.,1977;


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Penzien et al . , 1983) which show ed similar f indings with tension heada chesand studies (Ciccone and G rzesiak 1984; Turner and Chapm an, 1982)which concluded that the advantages of biofeedback have m ore to do withthe psychological (italics added ) rather than the biological aspects of paintreatment.

Fow ler and K raft's study (cited in Schum an, 1982) found thatpatients with muscle pain genera lly do sustain a level of tension asevidenced by electrom yograph ic readings (EM G ) which is s ignif icantlyhigher than norm al. Schuman (1982) reported that som e researchersreported EM G training wa s successful withou t resulting in pain relief andothers reported that pain relief was ma intained and even impro ved wh ileEM G read ings reverted to pretraining levels.

There is considera ble controversy in the literature regarding theefficacy of using EM G readings as an indication of reduced pain. Syrjala(1984) reviewed the literature and ca me to the conclusion that researchershad fou nd that patients suffering from identical diagnoses of low bac k paindid not have identical EM G read ings; some w ere elevated and some w erereduced. Schum an (1982) cited P hill ip's study w hich found that i f EM Greadings d ecreased within a session, the readings tended to show aprogressive decline over man y sessions but noted that biofeedba ck trainingdid not n ecessari ly enable either a last ing reduction in EM G or one thatgeneralized o utside the off ice or laboratory. An other study by P hill ipfound that when pain pa tients tensed or activated painful mu scles, there wasa disproportionate amo unt of EM G activity from each side of the back ascompa red to normals.

In spite of these confl ict ing f indings, Schum an (1982) concluded thatEM G feedba ck is a useful clinical technique in treating m uscle tension pa in


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because it can facilitate the learning of m uscle relaxation sk ills; it can trainthe patient to recognize the maladaptive mu scular response an d this in turncan facilitate identification of situational factors that ar e related to thisresponse and even temp orary redu ction in m uscle tension may interrupt thepain-tension cycle. Because researchers have found that EM G readings aresignificantly higher in chro nic pain patients they are therefore one of themost frequent ap plications of b iofeedback for the redu ction o f muscletension in chronic pain patients.

R esearchers differ on the effectiveness of frontalis EM G for thereduction of muscle contraction headache. Grzesiak and Ciccone (1986)cited stud ies (Gottlieb et al., 1977, 1982; Johnson et al., 1983) of mu scletension an d pain redu ced by E M G frontalis feedback but disputed thefindings because the EM G compon ent was not the only intervention used toreduce pain. They disagreed with the theory that a state of relaxation in o nearea of the body can "generalize" to another part of the body and statedthat, "T he idea that frontalis tension can serve as an in dication of generalmu scle tension has n ot met w ith em pirical support" (p.176). The au thorsconcluded that, "It is unlikely that there is such a phenom enon as generalmuscle tension contraction" (p. 176).

Som e researchers found EM G feedback to be effective on tensionheadaches (Budzyn ski, 1973; Wickrama sekera, 1972; H aynes, 1975; Jessup,1984). Ha ynes (1975) found both EM G feedback and relaxation trainingsuperior to a n o-treatment grou p in the reduction of m uscle contractionheadaches. Others, (Large, 1983) found E M G to be useful in m usclerelaxation bu t not in pain redu ction. C hapm an et al. (1985) cited one studywhich compared pain perception of pain patients with normals and foun dno correlation with EM G record ings.


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K eefe, Block, W ill iam s & Surw it (1981) cited a study by K eefe of111 chronic low back pain pa tients who p articipated in a com prehensivebehavioral treatment program emphasizing relaxation procedures. O ver thecourse of treatment, significant reductions were obtained on m easures ofsubject ive tension, EM G activity , and pain. Ford yce et al . (cited in K eefe etal. ,1981) dem onstrated the utility of opera nt cond itioning techniqu es inmo difying well entrenched beh avior patterns of chron ic low ba ck painpatients, such a s narco tic dependen ce and inactivity. Keefe et al. (1981)stated "recent studies emp loying behavior therapy techniques such asassertive training, progressive relaxation an d electromy ograp hic frontalisbiofeedback" showed "interesting results" but didn 't state which studiesthey referred to. The a uthors no ted that, "M ore clinical stud ies with largenum bers of chronic low back pa in patients are needed" (p. 222).

Other researchers found that com bining therapies proved m oreeffect ive in the treatment of pain. M elzack & Perry (1975) studied theeffects of alpha biofeedback training an d hypnosis by comparing them in astudy on the treatment of chronic pain. Both treatments prod uced increasedalpha a ctivity but both were un successful in the reduction of pain.Ho wever, when the authors "combined (italics added) the alpha b iofeedbacktraining with hypno sis, the patients reported significant pain supp ression"(p. 820). The authors con cluded:

Th e multidimensiona l nature of the relaxation respon se may explainits success in the alleviation of pa in. Since the relaxation respon secom bines increased alpha w ith attentional mod ification andsuggestion, the synergistic effects may accou nt for the successful useof the relaxation respo nse in the treatmen t of pain. (p. 820)


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Similarly, M elzack & W all (1988) reported that "multipleconvergen t therapy using several psycho logical procedu res is effectivebecause each kind of therapy m ay have its predominant effect on adifferent mechanism " (p.261). Th e authors theorized that:

Th e data indicate that mu ltiple convergen t therapy u sing severalpsycho logical procedu res is effective because each k ind of therapym ay have its predo mina nt effect on a different mech anism .Relaxation, for example, may reduce m uscle tension and generallyredu ce activity in the symp athetic nervous system . Hypn osis,how ever, ma y have its predo mina nt effect by activating controlprocesses that mod ulate the input as it is transmitted through thebrain. Proced ures w hich involve the diversion of attention (so thateven spinal reflexes may fail to occur) m ay, conc eivably, activate thedescending systems of the brainstem so that inputs are mo dulated atspina l levels. (p. 261)


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M edical Treatment for PainM edical treatm ents for pain focus on elimina ting or altering the

problem wh ich produces the pain. Analgesics are comm only used for painrelief but man y other techniques ranging from ancient methods of m agnets,copper bracelets , acupun cture, etc., to m ore m odern m ethods ofphysiotherapy, transcendental meditation, surgery, homeopathicmedications an d d rug therapy are used (Spino, 1984).

Surgery i s commonly used for chronic back pain (CB P). Flor andTu rk (1984) reported that in 1982, surgeons in the U nited S tates, which hasthe highest num ber of back surgeries in the world , excised appro ximately"200,000 discs" (p.111). The au thors conclud ed that the results of backsurgery are d isappointing a nd cited F inneson (1979) w ho su ggested that ,"80% o f the surgical patients should never ha ve entered surgery. O ften,surgery increases the pain problem instead of attenuating it" (p.112).

Phy sical therapy is encouraged w ith chron ic pain patients who oftenbecom e inactive, lose mu scle tone an d becom e intolerant of physicalexertion (Fordyce,1986; Guck, 1985). Physical therapists use exercise,heat, cold and massage to al leviate muscle spasm and restore spinalm obility and mu scle strength. Very little research has been d one on theeffectiveness of these treatments (Flor & Tu rk, 1984) .

Blum er (cited in Spino 1979) foun d that chronic pain patients haveconsiderable emotional problems and recomm ended various types ofpsycho therapy for helping patients cope w ith their depression an d focus onpain. He included, "dyn amic therapy, hypnotherapy, behavioral therapy,and grou p therapy" as treatments which have "moderate success" withchronic pain (p. 38).


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Transcutaneous electrical st imu lation (TE NS ) is a current treatmentfor chronic pain, how ever there is controversy over its ana lgesiccom ponen t. Som e researchers believe any benefit is due to the placeboeffect (Spino , 1984) w hile others believe that electrical stimu lation iscarried thro ugh la rge nerve fibers, or afferents, wh ich close the 'gate'(M elzack & W all, 1965) thus disrup ting input along sm all diameter fibers(which transm it pain stimu li).

Som e medical researchers advocated an eclectic appro ach to thetreatmen t of chronic pain. Pinsky & M alyon (C ited in Spino, 1984)theorized that effective therapy for chron ic pain patients in an "intensiveseven-week program " should include, "psychodynam ic psychotherapy,existential approa ches, and cognitive-behavioral therap ies" (p.111).The au thors stated:

N eurosu rgeons, psychiatrists, and p sycholog ists all appea r to agreethat the most effective treatm ent metho ds are those that focus on thepatient's general personali ty a nd emotional mak e-up. The p rimarygoal is to re-educate the chronic pain patient in order to reduce hisor her o verpreoccupation with pain and pain behavior. Traditionalpain relief methods, such as neuro surgery or m edicat ion, are de-emphasized and often d iscouraged. C hronic pain is conceptualized asprimarily a psychologic problem w hich does not f it a disease mo delfor either diagn ostic or treatment pur poses. (p. 111)M elzack (M elzack & W all , 1965) stated that while i t is possible to

reduce m any kinds of c l inical pain by means of analgesic and antidepressantdru gs, sensory m odu lation (e.g. nerve blocks or transcutaneo us electricalnerve stimu lation) as w ell as by different psycholo gical therapies. .. .theyrarely abolish pain entirely a nd are no t equally effect ive for everyone" (p.261). He concluded:


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W e have learned, as a result of literally hundred s of experim ents,that there is a limit to the effectiveness of an y given therapy but,hap pily, the effects of two o r mo re therapies given in com binationare cum ulative. Tw o therapies, each w ith slight effects that may notreach statistical significance com pared to a placebo, ma y prod ucesignificant redu ctions in pain when given together. For this reason ,multiple convergent therapy (italics added ) is increasingly becom ingthe standard approach to p ain problems. (p. 261)M elzack & P erry (cited in W eisenberg, 1984) conducted a cl inical

study of alpha training alone, hypnosis alone, and a com bination of the twosuggested ben efits with three group s of chronic low b ack pa tients. Theauthors concluded that:

The com bination of hypnosis and a lpha-training significantlyrelieved pain compa red to the baseline m easures; 58% of the patientsreported a decrease of pain of 33% or greater. Hypnosis aloneachieved a substantial but statistically insignificant cha nge frombaseline while alpha training alone w as ineffective. The authorsinterpret the com bined proced ure as consisting of alpha training as adistractor of attention com bined w ith relaxation, suggestion and asense of control over pain. The increase in percentage a lphaprod uction alone, a measure often used to indicate relaxation, wa snot ad equate. (p. 165)

Pain C linicsIn respon se to the challenge of treating chro nic pain patients, Dr.

John B onica of the University of W ashington M edical School decided to trya new approach an d d eveloped the concept of a pain clinic which w ouldtreat the patient with a variety of approach es using the talents of "surgeon s,neuro logists, psychiatrists, psychologists. .. .wh o m eet the patients bothindividua lly and as a group." (M elzack & W all , 1988, p. 263). During the


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last decade, this idea has spread so that there are pain clinics in most m ajorcities throughout North A merica. Melzack & W all (1988) stated that theadvantages of having different specialists treat the same patient arethreefold:

The professional can learn not only from a special group of patientsbut also from each other; by grouping m any pain patients and manyconcerned professionals together, new therapies are d eveloped; datacan be accumulated on the relative effectiveness of differenttherapeutic procedures which are often lost when a patient visits eachspecialist in his own clinic. The pain clinic allow s for thecombination of pharm acological, sensory, and psychological methodsof pain control, which may be used in different combinationsdepending on the type of pain and the needs of the individual painpatient. (p. 263)

DrugsPain m edication is an important aspect in treating the chronic pain

patient. Chronic pain patients often receive excessive doses of opiates(drugs derived from opium ) which may cause drug depend ency and abuse(Gorsky, cited in Nigl, 1984). Flor & Turk (19 84) reviewe d chronic painand reported that m edication w as the "physician's treatment of choice" forchronic back pain (p.111). They questioned the value of both narcoticdrugs (e.g., morphine and codeine), and the non-narcotic drugs (e.g.,aspirin) as a treatment:

Although analgesics undoubtedly relieve pain for brief periods,tolerance, habit formation and side-effects pose various problemsand m ake their prolonged use not advisable. Other medications, suchas antidepressants, m uscle relaxants and anti-inflammatory agen ts areincreasingly used, but few con trolled trials are available to assesstheir efficacy. ( p. 111)


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The a uthors noted that the evidence is inconclusive because m oststudies are done on acute (italics added ) back pa in patients.

Du ring the 1970s advances w ere mad e in the investigation o f thephysiological effects of pain (N igl, 1984). Natur ally occurring substancescalled end orphins and enkephalins which are morp hine l ike pain inhibitorswere isolated in the brain. Spino (1984 ) posited the theory tha t patientswhom he calls 'placebo responders' (patients who respond well to a sugarpill in the belief that the pill is a dru g), have the a bility to r elease thesenatural analgesic substances from receptors in the central nervous system(CN S) in response to a placebo. H e noted that "so-called 'real' as well as'psychogenic' pain may be relieved by a p lacebo" (p. 39).

At the same time researchers found that pain impulses could betransmitted by both chemical and electrical systems. They discovered newpain inhibitors called 'beta-end orphin s' which are 48 times as poten t asmorp hine when injected into animals and they found that the brain (italicsadded) prod uced endorphins w hen deep regions were stimu latedelectrically (LeRoy, 1976). Although enkephalins and endorphins both havestrong analgesic and other properties, their physiological role and theirinvolvement in endogeno us pain control is not yet fully know n. Hilgard(1986) noted that som e experiments eliminated en dorphins as part of theopiate class because naloxon e which is an "an tagonist" to endorp hins doesnot appear to reverse "hypnotic analgesia" (p. 209).

H ilgard (1986) cited a study b y Bar ber & M ayer of a dental patientwho used hy pnosis as the sole anesthetic for the removal of four impactedmolars. Her EE G a ctivity was m onitored and it was concluded that"hypnotic responses may be a right hemisphere function, in part as a resultof direct EEG studies, in part because of the relationship of hypn osis to


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imagery an d fantasy, a lso predom inantly right hemisphere function" (1986,p.210). H ilgard noted that further interviews of the patient "show ed thatthe pain control had been achieved largely through en riched fantasies withhypn osis, a form of d issociative distraction tha t reduces felt pain,regardless of the phy siological stresses that the surgical insults may haveproduced" (p.210).


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Hypnosis

History of HypnosisBoth w aking and hypnotic suggestion have been p racticed s inceancient t imes. W itch doctors , magicians, med icine men and shamans in

primitive cultures have used m onotonous d rum beats, chanting an d da ncingas a form of trance induction. The healing powers o f trance induction h avebeen referred to in the early civilizations of Sy ria, Egypt, and G reecewhere pa tients wen t to "sleep temples" and w ere hypn otized or talked toduring their s leep and given su ggest ions for rel ief of their sym ptoms.Persian m agi and H indu fakirs used eye fixation techniques to intensifycataleptic states. Techn iques of wak ing suggestion have been u sed by thechurch in the form of faith healing, however the western C hristian w orldthrougho ut the mid dle ages regarded the use of hypn osis for healing assacrilegious and the work of the devil (Pulos , 1980).

H ypn osis as a therapy has gon e through cy clical stages since itsinception in the 1700s; at tim es popu lar and su pported b y those in theacademic psychological comm unity and at other t imes u nsupported an d indisrepute (Hilgard, 1969). M ost researchers (Am brose, 1980;G orsky ,1981; Mil ler, 1979; M utter, 1988; Pu los , 1980; Ro sen,1960) referto Dr. A nton M esmer (1734-1815) as the father of med ical hypnosis . H ewas influenced by G rassner, a Germ an priest who performed "m iraculoushealings" and by E nglish physicians who believed in the curative pow ers ofmagn ets. He termed this power "an imal magn etism," a redistribution of afluid circulating in the bod y, to distinguish it from "m ineral mag netism."He theorized that the individual had a "electrochemical relationship" w ith


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the planets through this fluid.and d isease was caused b y a "disequ ilibriumin this system."

M esmer believed that he had m agnetic rays w hich f lowed from hisfingers to cure his patients. H e developed a bath-like structure, or"bacqu et," lined with iron fi lings and m agnets in which a patient wasimm ersed for a cure. His success was d ue largely to the power ofsuggestion an d the pa tient's expectation o f a cure an d n ot the iron filingswh ich his patients held. He becam e famou s after he cured a child ofhysterical blind ness. She was a pianist; a child prod igy who w as a favouriteof Em press M aria Theresa. Unfortunately , the child again d evelopedblindness and this put M esmer in disfavour w ith the Emp ress. A FrenchRo yal Co m mission wa s set up at the insistence of the med ical establishm entof the time and they discredited his theories. Mesmer w as denou nced as afraud, lost his license to practice and wa s forced to retire (Hershm an &Secter, 1961; Pu los, 1980). Seven ty years later Elliotson and Bra id, Britishdoctors, explored M esmer's methods. Braid coined the word "hypnotism"and wa s the first to substitute visual optic fixation for hyp notic passes toinduce trance (Chertok, 1967).

Hy pnosis has been used for the man agement of pain s ince the early19th century when it wa s used to provide analgesia for surgery (C rasilneckand H all, 1985b; H ilgard, 1986; Sternbach , 1984). In the 1800's JamesEsd aile, a Sco ttish physician, wa s the first to use hy pnosis as a m eans ofanesthesia and was reported to have performed over three hundred majorand severa l thousa nd m inor operations quite painlessly on patients. Shortlyafterward in France, Dr. Am broise August Liebeault of the Nan cy Schooldiscovered that by combining verbal s leep suggest ion and Braid's methodof f ixed ga zing he w as m ore effect ive in hypn otizing patients. He w rote a


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book ab out his methods but sold only on e copy du e to crit icism from theSalpetriere School of medicine wh ich opposed the psycho logical orientationof hypno sis as a treatment (Chertok, 1967).

Bern heim, a famo us neur ologist, initially opposed L iebeault but aftertrying out his method s on pa tients recognized the significance of the verbalsuggestion used by Liebeau lt. H e was the first to dem onstrate that thephenomeno n of suggest ion w as the real underlying factor of hypnosis andthat hypnosis wa s due exclusively to psycho logical rather then phy sicalcauses, thus d isproving the o riginal conclusions of M esmer, Braid, Ch arcotand others (Ch eek & L eCron , 1968; M iller, 1979) .

The F rench neuro logist, Charcot , in 1878 revived

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116464219 Audiotaped Hypnosis Chronic Back Pain

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