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International Journal of Clinical and Experimental Hypnosis

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Mark P. Jensen ; Kristin D. McArthur ; Joseph Barber ; Marisol A. Hanley ; a a a a Joyce M. Engel ; Joan M. Romano ; Diana D. Cardenas ; George H. Kraft ; a 1a Amy J. Hoffman ; David R. Patterson a University of Washington. Seattle, Washington. USA To cite this Article: Mark P. Jensen, Kristin D. McArthur, Joseph Barber, Marisol A. Hanley, Joyce M. Engel, Joan M. Romano, Diana D. Cardenas, George H. Kraft, 1 Amy J. Hoffman and David R. Patterson , 'Satisfaction with, and the Beneficial Side Effects of, Hypnotic Analgesia', International Journal of Clinical and Experimental Hypnosis, 54:4, 432 - 447 To link to this article: DOI: 10.1080/00207140600856798 URL: http://dx.doi.org/10.1080/00207140600856798

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Intl. Journal of Clinical and Experimental Hypnosis, 54(4): 432447, 2006 Copyright International Journal of Clinical and Experimental Hypnosis ISSN: 0020-7144 print / 1744-5183 online DOI: 10.1080/00207140600856798

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Intl. Journal 1744-5183 0020-7144 of Clinical and Experimental Hypnosis, Vol. 54, No. 4, July 2006: pp. 127 NHYP Hypnosis

SATISFACTION WITH, AND THE BENEFICIAL SIDE EFFECTS OF, HYPNOTIC ANALGESIA

MARK P. JENSEN, KRISTIN D. MCARTHUR, JOSEPH BARBER, MARISOL A. HANLEY, JOYCE M. ENGEL, JOAN M. ROMANO, DIANA D. CARDENAS, GEORGE H. KRAFT, AMY J. HOFFMAN, AND DAVID R. PATTERSON1,2
MARK P. JENSEN ET AL. Hypnotic Analgesia Benefits and Satisfaction

University of Washington, Seattle, Washington, USA

Abstract: Case study research suggests that hypnosis treatment may provide benefits that are not necessarily the target of specific suggestions. To better understand satisfaction with and the beneficial side effects of hypnosis treatment, questions inquiring about treatment satisfaction and treatment benefits were administered to a group of 30 patients with chronic pain who had participated in a case series of hypnotic analgesia treatment. The results confirmed the authors clinical experience and showed that most participants reported satisfaction with hypnosis treatment even when the targeted symptom (in this case, pain intensity) did not decrease substantially. Study participants also reported a variety of both symptom-related and nonsymptom-related benefits from hypnosis treatment, including decreased pain, increased perceived control over pain, increased sense of relaxation and well-being, and decreased perceived stress, although no single benefit was noted by a majority of participants.

There is substantial empirical support that hypnotic analgesia can reduce perceived pain intensity in patients with chronic pain (see review by Patterson & Jensen, 2003). Anecdotal reports suggest that
Manuscript submitted August 3, 2005; final revision received January 19, 2006. 1 This research was supported by Grant # R01 HD42838 from the National Institutes of Health, National Institute of Child and Health, National Center for Medical Rehabilitation Research, Grant # H133B031129 from the Department of Education, National Center of Disability and Rehabilitation Research, Grant # R01 GM4272509A1 from the National Institutes of Health, and the Hughes M. and Katherine G. Blake Endowed Professorship in Health Psychology awarded to MPJ. A portion of this work was conducted through the Clinical Research Center Facility at the University of Washington and supported by the National Institutes of Health, Grant # M01-RR-00037. The authors gratefully acknowledge the assistance of Chiara LaRotonda in data collection and data entry. We would also like to extend our thanks to Professor Masuo Koyasu and the Division of Cognitive Psychology in Education, Graduate School of Education, Kyoto University, for providing the physical resources that allowed this study to be completed. 2 Address correspondence to Mark P. Jensen, Ph.D., Department of Rehabilitation Medicine, Box 356490, University of Washington, Seattle, WA, 98195-6490, USA. E-mail: [email protected] 432

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such decreases in pain can last for months, or even years, after treatment (e.g., Barber, 1998; Gonsalkorale, Miller, Afzal, & Whorwell, 2005; Jack, 1999; Jensen et al., 2005; Simon & Lewis, 2000). Case studies of hypnotic analgesia treatment also report other benefits in addition to decreased pain, such as improved sleep (cf. Crasilneck, 1979; Crawford et al., 1998; Jack, 1999; Melzack & Perry, 1975; Sachs, Feuerstein, & Vitale, 1977), creativity (cf. Jack), overall self-efficacy and confidence (cf. Jack; Melzack & Perry), mood (cf. Crasilneck; Crawford et al.; Melzack & Perry; Sachs et al.), and socializing (cf. Melzack & Perry; Sachs et al.). None of these case studies report any negative side effects associated with hypnosis treatment, suggesting that beneficial effects occur more frequently than adverse effects (see also Mott, 1992; Stewart, 2005). In a recent case series that examined pre- to posttreatment changes in average pain intensity in a sample of 33 individuals with a physical disability and chronic pain, Jensen and colleagues found that 30% of the participants reported a clinically meaningful decrease in average daily pain that was generally maintained at 3-month follow-up (Jensen et al., 2005). Anecdotally, the clinicians who provided treatment in this study noted that the participants often spontaneously reported high levels of satisfaction with treatment and benefits of hypnosis that were not always related to the specific suggestions made during the sessions. For example, some study participants reported improvements in the quality of their sleep, as well as an increase in overall well being, despite the fact that there were not any suggestions for either of these experiences in the suggestions included in the study protocol. To our knowledge, there has not yet been a systematic examination of satisfaction with, and the beneficial side effects of, hypnosis. Yet, knowledge about both of these could serve a number of important purposes. If a large number of individuals report that they are highly satisfied with hypnosis treatment, even when targeted symptoms do not improve, then it is possible that the process of hypnosis itself might have a number of general beneficial effects. Understanding the frequency and types of these benefits could guide decisions about when and how to use hypnosis. For example, if improved sleep is found to be a common side effect of hypnotic analgesia treatment over and above any effects of pain, then this treatment may be particularly indicated for patients who report significant pain-related sleep problems in addition to ongoing pain. Also, if the frequency of unintended, or at least unexpected, benefits of hypnotic analgesia can be quantified, then this information can serve as the basis for the development of a measure of hypnosis effects. Such a measure could be used to determine whether the benefits that seem to be associated with hypnosis treatment are observed at a similar rate across different patient populations, or even across other psychological interventions, such as cognitive-behavior therapy or relaxation training.

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Given this background, we designed the current study to examine global satisfaction with hypnotic analgesia treatment and to identify the specific benefits that patients who participated in a hypnosis clinical trial reported beyond improvement in pain and pain control. We were particularly interested in identifying the treatment benefits identified by study participants who expressed satisfaction with hypnotic analgesia treatment but who did not report clinically meaningful changes in daily pain with treatment.

METHOD
Participants The participants in this study were drawn from those in our previously published case series of hypnotic analgesia for chronic pain in 33 persons with physical disabilities (Jensen et al., 2005). We designed the study, and the questions for assessing treatment benefits, after a number of patients had already been treated. By the time that the benefits questions used in this study were written and approved by the University of Washingtons Institutional Review Board for administration, the first participant in the study had completed treatment 16 months previously. At that time, 1 of the study participants had dropped out of the study and requested no further contact with study personnel (indicating that he was too busy to respond to follow-up interviews), and 2 had been lost to follow-up. Thus, responses to the study measures were obtained and available from 30 of the original 33 study participants. Of these respondents, 13 had a spinal cord injury, 9 had multiple sclerosis, 6 had an acquired amputation, 1 had cerebral palsy, and 1 had postpolio syndrome. The average age of the 30 study participants was 49.7 years (range = 2879). Seventeen (57%) of the subjects were women, and 28 (93%) were white. One participant (3%) was African-American and 1 (3%) was Asian-American. As indicated above, there was variability in the timing of the administration of the benefits questions (mean = 4.47 months, range = immediately posttreatment to 16 months posttreatment), because data for these analyses were collected some months after the ongoing case series study had already begun. To determine if the length of time since treatment ended was associated with the study variables, Pearson correlation coefficients were computed between the time since treatment ended and (a) total number of treatment benefits mentioned, (b) rating of global treatment benefit, and (c) rating of overall satisfaction with treatment. All of the coefficients were weak (rs range, .21 to .17) and nonsignificant, suggesting that time since treatment ended did not have a significant impact on how the treatment or treatment benefits were viewed.

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Measures All measures were obtained after treatment was completed by a phone interview conducted by a research study assistant who was not the treating clinician. The research assistant used a standardized script to introduce the study as well as to collect data on the variables of interest. Rating of global treatment benefit. All participants were asked to rate their general perception of treatment benefit from treatment on a 5-point Likert scale (1 = no benefit, 2 = a little benefit, 3 = some benefit, 4 = a lot of benefit, 5 = extreme benefit). List of treatment benefits. Participants who rated themselves as obtaining at least a little benefit were asked to provide a list of any benefits they received by responding to the question, If you feel you benefited at least a little from this treatment, in what ways did you benefit? and the interviewer wrote down the benefits listed by the participant verbatim. When the participant finished listing any benefits, he or she was cued to provide more information about benefits by responding to the question, Were there any other ways you felt you benefited? Again, the interviewer recorded any benefits stated by the participant verbatim. Global evaluation of satisfaction/dissatisfaction with treatment. Participants rated their global evaluation of satisfaction/dissatisfaction with hypnotic analgesia treatment on a 7-point Likert scale (1 = very satisfied, 2 = somewhat satisfied, 3 = slightly satisfied, 4 = neither satisfied nor dissatisfied, 5 = slightly dissatisfied, 6 = somewhat dissatisfied, 7 = very dissatisfied). Reasons for satisfaction or dissatisfaction with treatment. Participants were asked to state the reasons they had for feeling satisfied or dissatisfied with treatment by responding to the question, Can you please tell me the primary reasons that you felt satisfied or dissatisfied with the treatment? Again, the interviewer was instructed to write down what the participant said in response to this question verbatim and to cue the participant for any additional reasons for satisfaction or dissatisfaction after the participant's original answer. Classification of reported treatment effects (benefits and reasons for satisfaction/dissatisfaction). The responses to the questions concerning benefits of treatment and reasons for being satisfied or dissatisfied with treatment had a great deal of overlap; for example, participants who listed pain relief as a benefit of treatment often listed pain relief as a reason for being satisfied with treatment. In addition, there were some responses to the request to list reasons for satisfaction or dissatisfaction with treatment that clearly indicated a specific benefit with treatment but were not always provided in response to the benefits of treatment question. Therefore, participant responses to both (a) the question asking participants to list treatment benefits and (b) the

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question asking participants to list any reasons for satisfaction or dissatisfaction with treatment were combined and then initially classified into different types of treatment effects within three domains: (a) painrelated versus nonpain-related; (b) beneficial, neutral, or negative effect; and (c) specific type (e.g., reduces pain, more control over stress). To assist with the classification, each individual participant response that represented a unique perceived treatment benefit, reason for satisfaction, or reason for dissatisfaction was written on a 3 5 index card; one effect per card. The first author (MPJ) then performed an initial classification of each treatment effect within the three domain categories listed above. For example, the reported effect of pain relief was classified as being pain-related in the first domain, beneficial in the second domain and as representing decreased pain in the third domain. The categories in the first two domains (pain- vs. nonpainrelated and negative-neutral-beneficial effect) were created before the responses were classified, whereas the subtypes in the third domain (specific type of benefit or reason) were created as classification proceeded. To check for the reliability of classification, another author (KDM) then classified each participant response using the same procedures, except that she had available the list of specific types created by the first author to assist with classification for the third domain. Any differences in classification that occurred were resolved by discussion and consensus between MPJ and KDM. Data Analysis Descriptive statistics were computed to examine the participants' global ratings of benefits and level of satisfaction/dissatisfaction with treatment as well as to describe the types and frequencies of treatment effects reported by the study participants. Next, to better understand the potential reasons that individuals might describe themselves as benefitting from and being satisfied with hypnotic analgesia treatment in the absence of substantial decreases in average daily pain following treatment, data from the 20 study participants who did not show a substantial and clinically meaningful decrease in pain were closely examined to determine: (a) the number and percent of these who reported that they benefited from and were satisfied with treatment and (b) the types of benefits and reasons for satisfaction/dissatisfaction listed by these participants. The operational definition of a clinically meaningful decrease in pain used in this study was a decrease of 30% or more in a composite average pain intensity score made up of four 010 ratings of average pain over the previous 24 hours, assessed four times in a 1-week period before treatment began and again after treatment was completed (Jensen et al., 2005). We believe this represents a fairly conservative measure in that participants had to demonstrate substantial and consistent reductions in pain intensity for

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a number of days after treatment was completely stopped to be classified as having a clinically meaningful reduction in pain.

RESULTS
Description of Global Ratings The average rating of overall treatment benefit for all 30 participants was 3.40 (SD = 1.13; median response = 4, which indicates a lot of benefit). Only 1 (3%) study participant reported no benefit. Seven (21.2%) reported a little benefit; 6 (18.2%), some benefit; 11 (33.3%), a lot of benefit; and 5 (15.2%), extreme benefit. Overall satisfaction with treatment was very high, on average (mean rating, 1.80; SD, 1.32; recall that 1 = very satisfied and 7 = very dissatisfied). More than half of the participants (17, or 56.7%) gave the highest satisfaction rating possible. Most of the remaining participants (8, or 26.7%) reported that they were somewhat satisfied, and 3 participants (10.0%) reported that they were slightly satisfied with the treatment. No one rated his or her satisfaction as Neither satisfied nor dissatisfied, Slightly dissatisfied, or Very dissatisfied. However, 2 participants (6.7%), indicated that they were Somewhat dissatisfied with the treatment. Types and Frequencies of Benefits and Reasons for Satisfaction or Dissatisfaction Agreement between the two investigators who classified the benefits/reasons listed by the study participant was 99% for classification into pain and nonpain categories (first domain); 96% for classification into the extent to which the effect was beneficial, neutral, or negative (second domain); and 96% for classification into a specific type of effect (third domain). All differences in classification were resolved with discussion, and the final analyses were performed using classifications that represent complete agreement between the two investigators who performed the classifications. Overall, 40 specific types of benefits/reasons were given by the 30 study participants. Nine of these (23%) were classified as pain-related benefits/reasons for satisfaction, 23 (58%) were classified as nonpainrelated benefits/reasons for satisfaction, 5 (13%) were classified as being neutral, and 3 (8%) were classified as being negative. All three of the negative effects/reasons for dissatisfaction were pain-related and reflected statements indicating disappointment that (a) the treatment was ineffective (It didn't work; 1 participant said this), (b) the treatment was less effective than the participant hoped (3 participants indicated this), or (c) the treatment's benefits did not last as long as the participant hoped (1 participant indicated this). The study participants mentioned no other negative effects or reasons for being dissatisfied.

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The three most common pain-related benefits were: (a) pain reduction (12 participants, 40.0%), (b) increased sense of control over pain (12 participants, 40.0%), and (c) a sense of having a new option or tool for pain management (10 participants, 33.3%). All of the remaining pain-related benefits or reasons for satisfaction listed were mentioned much less frequently (by only 1 to 3 participants each) and included decreased analgesic medication use, the fact that self-hypnosis can be used to distract oneself from pain, an improvement in function or decreased impact of pain on activities, increased knowledge about pain, and a sense that the pain is more tolerable. One participant gave what we considered an unusual response to the question concerning benefits, indicating both that (a) he felt he had benefited from treatment and also that (b) one reason for this was that he now felt freer to take pain medications. The most common of the 23 nonpain-related benefits were simple general positive comments (e.g., It helps, I liked it; mentioned by 11 or 36.7% of the participants) and an overall sense of increased relaxation (mentioned by 7 or 23.3% of the study participants). An increase in positive affect was reported more often than a decrease in negative affect; the four positive affect benefits (increased relaxation, wellbeing, acceptance,and a better attitude) were spontaneously mentioned by twice as many of the participants (10 or 33.3%; 8 participants mentioned one and 2 mentioned two such benefits) as the three negative affect benefits (decreased stress, anxiety, and depression; mentioned by 5 participants). All of the other nonpain-related benefits were less frequently mentioned (range, 1 to 4 participants each) and included positive statements about therapist, social benefit, increased energy, satisfaction that therapy could be provided at home, surprise at how easy self-hypnosis was, significant positive impact on life, increased self-awareness, provided meditation practice, follow-up calls helpful, increased focus, all natural, and lowered blood pressure. Two of the nonpain-related benefits deserve special mention. First, and inconsistent with one of the study hypotheses, improved sleep was only listed spontaneously by 3 (10.0%) of the participants, despite the fact that this benefit appears to be the one most frequently mentioned in case reports. Second, 2 of the participants attributed major positive shifts in perspectives to the hypnotic analgesia treatment. One of these mentioned that the treatment had a . . . profound implication in every aspect of my lifeI got to do things like get a job, and a second participant stated that the treatment . . . gave me a whole different perspective on my life and how I was approaching it. These large positive shifts in overall perspective were reported and attributed to the hypnosis intervention by these 2 participants despite the fact that the intervention was script-driven (i.e., not tailored to individual patients) and focused exclusively on pain management.

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The five types of neutral comments mentioned by the study participants included simple descriptions of hypnosis (e.g., It's like meditation) or planned use for how they intend to use the skills they learned for other applications (I plan to use it to quit smoking), and comments about practicing hypnosis. Results Among Participants Who Did not Achieve a Substantial Decrease in Pain Following Treatment As reported in the original case series paper (Jensen et al., 2005), about one third of the study participants reported a substantial, clinically meaningful decrease in average daily pain intensity from pre- to posttreatment. Yet a much larger percentage than this reported high levels of treatment satisfaction and treatment benefit in the current study. To help understand the possible reasons for the high level of satisfaction with treatment among the 20 participants in the sample who did not report a substantial decrease in average pain with treatment, we examined treatment satisfaction and the types of treatment benefits listed by this group, specifically. Concerning the treatment satisfaction ratings, the subsample of 20 participants who did not report substantial decreases in pain contained the only participants (2 of them) who indicated any level of dissatisfaction at all with treatment (both rated themselves as being somewhat dissatisfied with the treatment). However, 10 of these 20 participants (half of the subsample) still rated themselves as being very satisfied with treatment, 5 (25%) indicated that they were somewhat satisfied with treatment; only 3 participants (15%) rated themselves as being only a little satisfied with treatment. As might be expected, the benefit ratings among the 20 participants who did not report a substantial reduction in average pain was significantly lower (mean benefit rating = 3.10, SD = 1.12, median rating = 3, which indicates some benefit) than these same ratings among the 10 participants who did report a substantial reduction in pain intensity (mean benefit rating = 4.00, SD = 0.94; t(18) = 2.18, p < .05). One (5.0%) of those who did not report substantial pain reductions indicated that he experienced no benefit from treatment. Six (30.0%), however, reported that they experienced a little benefit, 5 (25.0%) indicated that they experienced some benefit, 6 (30.0%) indicated that they experienced a lot of benefit, and 2 (10.0%) indicated that they experienced extreme benefit from the treatment. A close examination of the specific types of benefits mentioned by this subsample provides some clues regarding the possible reasons that they tended to report high satisfaction with treatment, despite the lack of a substantial decrease in average daily pain. First, and what might initially be considered inconsistent with the classification of these subjects as not obtaining clinically meaningful reductions in average pain,

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a substantial subset of these participants reported that they thought that the treatment decreased their pain (8, or 40.0%), that it resulted in them having a greater sense of control over pain (8, or 40.0%), and that the treatment provided them with another tool for pain management (6, or 30%). In addition, other than the three exceptions discussed below, the rates of both pain-related and nonpain-related benefits were very similar between the patients who did and who did not report a clinically meaningful change in daily average pain. One of the exceptions to the similarity in benefits listed between the two groups of participants was in the area of treatment effects on mood. About twice as many participants whose pain decreased to a clinically meaningful extent also reported that hypnosis treatment resulted in a decrease in negative mood states (2 of 10, or 20.0%) or an increase in positive mood states (5 of 10, or 50.0%) compared to participants whose pain did not decrease to a meaningful extent, pre- to posttreatment (frequency/percentage rates of decrease in negative mood and increase in positive mood were 2 of 20/10.0% and 4 of 20/ 20.0%, respectively). Second, both of the participants who reported a major shift in their perception or world view following treatment were among the 10 who also reported a clinically meaningful decrease in pain; none of the 20 participants who did not show a large decrease in average daily pain reported that the treatment also resulted in a significant positive shift in their world view. Finally, none of the 10 participants whose pain decreased substantially had any negative comments about treatment, whereas 5 (25%) of the participants whose pain did not decrease more than 30%, pre- to posttreatment, expressed some disappointment about the lack of efficacy of the treatment on pain.

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DISCUSSION
This survey of 30 patients who participated in a clinical case series of hypnotic analgesia for chronic pain indicates that substantially more patients report benefit from and satisfaction with treatment than reported clinically meaningful changes in the symptom (pain) targeted in treatment. Another major finding was that no participants reported any adverse events or negative effects from treatment other than disappointment that the treatment did not work as well as they had hoped. These negative views of outcome were expressed by only a small subset of the study participants. The study findings have important implications for understanding the effects of hypnotic analgesia treatment (and, perhaps, other hypnosis treatments as well) and for assessing treatment outcome in hypnosis clinical trials. High rates of treatment satisfaction among patients who receive pain treatment are common (e.g., Comley & DeMeyer, 2001; Dawson

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et al., 2002; Jamison et al., 1997; Miaskowski, Nichols, Brody, & Synold, 1994), and previous research suggests that pain treatment satisfaction has more to do with the relationship between the patient/client and treatment provider than with the outcome of treatment on pain (e.g., Dawson et al., 2002; Riley, Meyers, Robinson, Bulcourf, & Gremillion, 2001). Therefore, the similar findings in this study, even among those who reported little improvement in average daily pain with treatment, should not be surprising. However, a closer look at the specific treatment benefits listed by the study participants may shed light on some additional factors that may contribute to treatment satisfaction. Interestingly, a large subset of patients (even within the group that did not demonstrate strong reductions in average daily pain) reported that the treatment resulted in an overall decrease in pain, that they felt more in control of their pain, and that they felt they now had a tool for managing their pain. What is surprising about this finding is that even participants who did not evidence a large decrease in daily pain frequently listed pain-related benefits. This might be explained, at least in part, by the conservative nature of the primary outcome variable used in the clinical trial (Jensen et al., 2005). Based on the manner in which pain was measured, in order for there to be a substantial decrease on this outcome variable, participants would have to experience substantial and sustained decreases in pain intensity that last for up to 7 days after treatment was discontinued. It is possible, however, that the self-hypnosis training resulted in a subgroup of participants whose overall daily pain might not have been affected to a large degree, but who still nevertheless might be able to use the hypnosis skills to experience short-term decreases in pain. The conservative outcome measure used in the clinical trial may not have been sensitive enough to detect these short-term effects on pain experience or on some participants' abilities to use hypnosis for management of pain during flare-ups. Future hypnosis clinical trials might try to address this by asking participants to monitor their pain intensity immediately before and then again for a number of hours after they practice self-hypnosis analgesia once they have learned self-hypnosis skills. Systematic decreases in pain intensity that might last for minutes to a very few hours may not appear substantial on measures of pain intensity averaged over an entire week but nevertheless may have important meaning to patients and be perceived as helpful and beneficial. A close examination of the specific benefits and reasons for treatment satisfaction listed by the participants indicated that many viewed hypnotic treatment effects on nonpain-related outcomes as important. In fact, more nonpain-related benefits were listed than pain-related benefits, despite the fact that the sole focus of the hypnotic intervention was on pain. A substantial subset of patients

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reported that the intervention decreased negative mood states and, even more so, increased positive mood states. This suggests the possibility that such effects might be enhanced further if specific suggestions were made for the participant to experience less stress and anxiety and to experience an overall increase in perceived relaxation, calmness, and well-being. One of the surprising outcomes of this study, given the frequency with which improved sleep is mentioned as a positive side effect in clinical case studies of hypnotic analgesia (e.g., cf. Crasilneck, 1979; Crawford et al., 1998; Jack, 1999; Melzack & Perry, 1975; Sachs et al., 1977), was that only 3 (10%) of the participants spontaneously mentioned that they experienced improvements in sleep or sleep quality with treatment. Perhaps sleep was not a major concern for a number of the participants, although this seems unlikely in a chronic pain sample (Roehrs & Roth, 2005). It is also possible that the specific script used in the study was different enough from the protocols used by other investigators so that substantial improvement in sleep quality was less likely overall. However, the fact that sleep was listed by at least some participants indicates that hypnosis's impact on sleep and sleep quality should be more closely monitored in future hypnosis research. Previous reviews of negative effects of hypnosis indicate that negative effects are relatively rare when hypnosis is provided by an experienced clinician (Mott, 1992; Stewart, 2005). The current findings are consistent with this conclusion. No negative effect of treatment was reportedonly reasons for dissatisfaction with treatment and these were relatively rare. The worst thing that any one participant had to say was that the treatment did not work. The responses of the two participants who reported a significant impact on their worldview with treatment suggest the possibility that hypnosis has the potential for more far-reaching, unanticipated positive effects. These effects have been discussed as ripple effects of hypnosis in the literature and were first mentioned in a case report (of three cases) that describes how effective elimination of a bothersome symptom with hypnosis can act as a springboard for making other important life changes (Spiegel & Linn, 1969). That such effects were noted in this study (when they were not expected or suggested) provides further support for the occurrence of such ripple effects, at least for 2 out of 30 patients in our sample. To the extent that positive benefits of hypnosis found here generalize to other populations of patients and other hypnosis treatments, it may make sense to consider using the findings of this study as a basis for the development of a measure of general hypnosis benefits. Such a measure would help determine whether such benefits generalize to other populations or are specific to patients being treated for pain. A

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potential measure such as this would include as core items those that assess perceived control over the targeted symptom, a sense of decrease in negative mood states (such as stress, tension, anxiety, and depression), and a sense of increase in positive mood states (such as relaxation, well-being, and general acceptance). While the present findings suggest the possibility that not a lot might be gained by assessing the impact of hypnosis on sleep quality as a secondary outcome domain, improvement in this area is frequently reported in case studies, so we would recommend that a measure of hypnosis side effects include items that assess this domain as well, at least until it is proven that this benefit occurs infrequently enough to warrant eliminating it from consideration. This study has a number of important limitations that should be considered when interpreting the results. First, the data were collected after treatment had ended for the majority of participants. For some, treatment had ended up to 16 months before the study questions were asked. Although correlational analyses suggest that time since treatment ended did not have a large systematic effect on the study variables, it is possible that it did have an impact on the reliability or accuracy of the findings. We do not know the extent to which the types of benefits, and the detail and accuracy with which they are described, might have differed if all participants had been asked about benefits immediately after treatment. Future research could look at this issue more carefully by assessing treatment effects immediately after treatment, and perhaps again some months after treatment, to see if people show a change in their recollection of benefits of treatment over time. Another limitation of this study is that we did not ask specifically about negative effects; much of the wording and focus of the questions was on treatment benefits, although some provision was made to list negative effects if the participants expressed dissatisfaction with treatment. Given the opportunity to report satisfaction or dissatisfaction, it may be that patients are inclined towards the former choice. It is possible, therefore, that the high number of positive benefits reported could be an artifact of our method of assessment and that the findings were biased in a positive direction. Future research should examine the potential of adverse events more closely by asking about negative effects specifically as well as comparing satisfaction between different treatments. The relatively small number of subjects in this study also limits our ability to thoroughly assess all the benefits that participants could potentially attribute to hypnotic treatment as well as the possible negative effects of hypnosis that might occur when this treatment is administered to large numbers of patients. In addition, 3 participants in the original case series did not participate in the current survey study; 1

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specifically had requested that we not contact him during the followup period because he was too busy to participate in follow-up interviews, and 2 others were lost to follow-up. It is possible that 1 or more of these 3 individuals might have listed some negative effects of hypnosis not mentioned by the other participants or at least been less enthusiastic about the treatment and its benefits than those in the current sample. Thus, although no negative side effects were reported in this sample of patients, we cannot use this finding to conclude that hypnosis analgesia treatment is without negative side effects for all individuals. Future research should examine these questions in larger numbers of subjects and seek to assess perceived benefits and negative effects in all consecutive study participants, if possible, to help determine the generalizability of the findings. Also, although the study participants attributed all of the treatment benefits listed to the hypnotic analgesia intervention, there was no comparison group, and it is clearly possible that patients who receive nonhypnotic interventions or even placebo treatments might experience similar beneficial side effects. Although many of the patients seemed to have benefited in unexpected ways, and they attributed this benefit to hypnosis, it is possible that they might also have benefited in similar ways had they participated in a study of acupuncture or pharmacologic analgesia, for example. For some, it may have been the experience of pain reduction (which can be produced by a number of interventions, not just hypnosis), the expectation of receiving help, or other nonspecific treatment-related factors such as the attention of a therapist, that contributed the most to the unintended benefits observed. This possibility provides further support for the need to develop a measure of such benefits and perhaps to administer it to patients with chronic pain who participate in clinical trials testing different interventions; it would be very interesting, for example, if acupuncture, medication management, cognitive-behavior therapy, and exercise management of chronic pain provide the same or different effects, on average, on perceived control over pain, sleep, and improved overall well-being. Despite the study's limitations, the findings indicate that hypnosis treatment for chronic pain is associated not only with a substantial decrease in daily pain for a subset of patients but with high levels of treatment satisfaction and other nonpain-related benefitsor at least the perception of other benefits. Learning self-hypnosis itself appears to be associated with decreases in negative mood states and increases in positive mood states, as well as a number of other benefits that are unique to each individual client or patient. Future research is needed to determine whether these findings are replicated in controlled treatment trials, and whether they generalize to other populations of persons with pain, as well as to other hypnosis treatments, and whether

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these benefits are shared by other psychological interventions such as cognitive behavior therapy and relaxation training.
REFERENCES
Barber, J. (1998). The mysterious persistence of hypnotic analgesia. International Journal of Clinical and Experimental Hypnosis, 46, 2843. Comley, A. L., & DeMeyer, E. (2001). Assessing patient satisfaction with pain management through continuous quality improvement effort. Journal of Pain and Symptom Management, 21, 2740. Crasilneck, H. B. (1979). Hypnosis in the control of chronic low back pain. American Journal of Clinical Hypnosis, 22, 7178. Crawford, H. J., Knebel, T., Kaplan, L., Vendemia, J. M. C., Xie, M., Jamison, S., & Pribram, K. H. (1998). Hypnotic analgesia: 1. Somatosensory event-related potential changes to noxious stimuli and 2. Transfer learning to reduce chronic low back pain. International Journal of Clinical and Experimental Hypnosis, 46, 92132. Dawson, R., Spross, J. A., Jablonski, E. S., Hoyer, D. R., Sellers, D. E., & Solomon, M. Z. (2002). Probing the paradox of patients' satisfaction with inadequate pain management. Journal of Pain and Symptom Management, 23, 211220. Gonsalkorale, W. M., Miller, V., Afzal, A., & Whorwell, P. J. (2005). Long-term benefits of hypnotherapy for irritable bowel syndrome. Gut, 52, 16231629. Jack, M. A. (1999). The use of hypnosis for a patient with chronic pain. Contemporary Hypnosis, 16, 231237. Jamison, R. N., Ross, M. J., Hoopman, P., Griffen, F., Levy, J., Daly, M., Schaffer, J. L. (1997). Assessment of postoperative pain management: Patient satisfaction and perceived helpfulness. Clinical Journal of Pain, 13, 229236. Jensen, M. P., Hanley, M. A., Engel, J. M., Romano, J. M., Barber, J., Cardenas, D. D., Kraft, G. H., Hoffman, A. J., & Patterson, D. R. (2005). Hypnotic analgesia for chronic pain in persons with disabilities: A case series. Journal of Clinical and Experimental Hypnosis, 53, 198228. Melzack, R., & Perry, C. (1975). Self-regulation of pain: The use of alpha-feedback and hypnotic training for the control of chronic pain. Experimental Neurology, 46, 452469. Miaskowski, C., Nichols, R., Brody, R., & Synold., T. (1994). Assessment of patient satisfaction utilizing the American Pain Society's quality assurance standards on acute and cancer-related pain. Journal of Pain and Symptom Management, 9, 511. Mott, T., Jr. (1992). Untoward effects associated with hypnosis. Psychiatric Medicine, 10, 119128. Patterson, D. R., & Jensen, M. P. (2003). Hypnosis and clinical pain. Psychological Bulletin, 129, 495521. Riley, J. L., Meyers, C. D., Robinson, M. E., Bulcourf, B., & Gremillion, H. A. (2001). Factors predicting orofacial pain patient satisfaction with improvement. Journal of Orofacial Pain, 15, 2935. Roehrs, T., & Roth, T. (2005). Sleep and pain: Interaction of two vital functions. Seminars in Neurology, 25, 106116. Sachs, L. B., Feuerstein, M., & Vitale, J. H. (1977). Hypnotic self-regulation of chronic pain. American Journal of Clinical Hypnosis, 20, 106113. Simon, E. P., & Lewis, D. M. (2000). Medical hypnosis for temporomandibular disorders: Treatment efficacy and medical utilization outcome. Oral Surgery Oral medicine Oral Pathology, 90, 5463. Spiegel, H., & Linn, L. (1969). The ripple effect following adjunct hypnosis in analytic psychotherapy. American Journal of Psychiatry, 126, 5358. Stewart, J. H. (2005). Hypnosis in contemporary medicine. Mayo Clinic Proceedings, 80, 511524.

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Zufriedenheit mit hypnotischer Analgesiebehandlung und weitere vorteilhafte Auswirkungen Mark P. Jensen, Kristin D. McArthur, Joseph Barber, Marisol A. Hanley, Joyce M. Engel, Joan M. Romano, Diana D. Cardenas, George H. Kraft, Amy J. Hoffman und David R. Patterson Zusammenfassung: Forschung anhand von Fallstudien zeigt, dass eine Hypnosebehandlung auch vorteilhafte Wirkungen mit sich bringt, welche nicht Ziel spezifischer Suggestionen waren. Zum besseren Verstndnis der Zufriedenheit mit Hypnosebehandlung sowie ihrer vorteilhaften Nebenwirkungen, wurden einer Gruppe von 30 Patienten, die zuvor an einer Reihe von Sitzungen zur hypnotischen Analgesiebehandlung teilgenommen hatten, einige Fragen zur Zufriedenheit und zum Nutzen der Behandlung vorgelegt. Die Ergebnisse besttigten die klinischen Eindrcke der Autoren. Es zeigte sich, dass die Mehrzahl der Teilnehmer mit der Behandlung selbst dann zufrieden war, wenn die Zielsymptomatik (hier die Schmerzintensitt) nicht substantiell abnahm. Die Teilnehmer berichteten darber hinaus von symptombezogenen und nicht symptombezogenen Vorteilen der Hypnosebehandlung, wie etwa verminderte Schmerzen, eine Erhhung der wahrgenommenen Schmerzkontrolle, Verbesserung von Entspannung und Wohlbefinden sowie verminderten Stress. Allerdings wurde keiner dieser Vorteile allein von der Mehrzahl der Teilnehmer angegeben. RALF SCHMAELZLE University of Konstanz, Konstanz, Germany Satisfaction l'gard de l'antalgie hypnotique et effets secondaires positifs de cette mthode Mark P. Jensen, Kristin D. McArthur, Joseph Barber, Marisol A. Hanley, Joyce M. Engel, Joan M. Romano, Diana D. Cardenas, George H. Kraft, Amy J. Hoffman et David R. Patterson Rsum: Une tude de cas semble indiquer que le traitement hypnotique peut apporter des bienfaits qui ne sont pas ncessairement la cible de suggestions particulires. Pour mieux comprendre la satisfaction des patients l'gard du traitement hypnotique et les effets secondaires bnfiques qui en dcoulent, nous avons administr un questionnaire un groupe de 30 patients souffrant de douleur chronique, ayant particip une srie de traitements hypnotiques analgsiques. Les rsultats ont confirm l'exprience clinique des auteurs et ont dmontr que la plupart des sujets ont exprim leur satisfaction vis--vis du traitement hypnotique, et ce, mme lorsque les symptmes cibls (dans ce cas-ci, l'intensit de la douleur) n'avaient pas diminu de faon notable. Les sujets ont galement mentionn une grande varit d'avantages pouvant tre attribus au traitement hypnotique, ces avantages pouvant tre relis ou non aux symptmes, y compris une diminution de la douleur, une augmentation de la perception du contrle sur la douleur, une augmentation de la sensation de dtente et

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de bien-tre, et une diminution du stress peru, bien qu'aucun bienfait particulier n'ait fait l'unanimit chez la majorit des sujets. JOHANNE REYNAULT C. Tr. (STIBC) La satisfaccin con la analgesia hipntica y sus efectos benficos Mark P. Jensen, Kristin D. McArthur, Joseph Barber, Marisol A. Hanley, Joyce M. Engel, Joan M. Romano, Diana D. Cardenas, George H. Kraft, Amy J. Hoffman, y David R. Patterson Resumen: La investigacin de estudios de caso sugiere que el tratamiento hipntico puede proporcionar beneficios no necesariamente asociados con las sugestiones especficas Para entender mejor la satisfaccin con y los efectos benficos secundarios del tratamiento hipntico, administramos preguntas sobre la satisfaccin con el tratamiento y los efectos benficos a un grupo de 30 pacientes con dolor crnico quienes haban participado en una serie de casos de tratamiento hipntico de analgesia. Los resultados confirmaron la experiencia clnica de los autores y mostraron que la mayora de los participantes mencionaron satisfaccin con el tratamiento de hipnosis aun cuando los sntomas a tratar (en este caso la intensidad de dolor) no disminuyeron considerablemente. Los participantes del estudio tambin mencionaron varios beneficios relacionados o no con los sntomas del tratamiento de hipnosis, incluyendo menos dolor, percepcin de mayor control sobre el dolor, aumento de relajacin y bienestar, y disminucin en la percepcin de tensin percibida, aunque ningn beneficio especfico fue mencionado por la mayora de participantes. ETZEL CARDEA University of Lund, Lund, Sweden