Review Article

Hypnosis, anesthesia, pain management, and preparation for

medical procedures
Donald Moss1, Eric Willmarth2
1
College of Integrative Medicine and Health Sciences, 2Department of Applied Psychophysiology, Saybrook University, Pasadena, CA, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: D Moss; (III) Provision of study materials or patients: All authors;
(IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Donald Moss, PhD. Dean, College of Integrative Medicine and Health Sciences, Saybrook University, 55 Eureka Street, Pasadena,
CA 91103, USA. Email: [email protected].

Abstract: Hypnosis has a long history of use for anesthesia and pain management, as well as in assisting
patient to prepare for medical procedures. This article reviews the history of hypnosis applications in
clinical medicine and dentistry. Research on hypnotic susceptibility or hypnotic ability shows that the
ability to respond effectively to hypnosis is a relatively stable trait, partially heritable, and measurable
by means of several standard procedures. Persons low in hypnotic ability may benefit from alternative
therapeutic interventions; however, the majority of medical patients will benefit from the integration of
adjunctive hypnotic therapies into their medical and dental care. The article closes with a discussion of
the stronger evidence-based applications of hypnosis in healthcare, and the need for well-trained certified
hypnosis practitioners.

Keywords: Hypnosis; anesthesia; pain management; hypnotic ability; evidence-based applications

Submitted Jun 18, 2019. Accepted for publication Jun 20, 2019.
doi: 10.21037/apm.2019.07.01
View this article at: http://dx.doi.org/10.21037/apm.2019.07.01

History medical procedures.

Hypnosis has long had a role in anesthesiology and pain

management. James Esdaile, a Scottish surgeon, utilized Hypnosis in obstetrics
hypnosis (then known as “Mesmerism”) in hospitals
Ralph August applied clinical hypnosis to facilitate delivery
in India, and performed 261 painless surgeries using of 295 babies, in a clinical series from 1957 to 1958. In
hypnosis, described in his book, Mesmerism in India, 94% of the cases, hypnosis was the sole form of anesthesia.
and its Practical Application in Surgery and Medicine (1). In the remaining 6% of cases, hypnotic anesthesia was
The introduction of chloroform and ether into medical not adequate, and was supplemented with local or general
practice in India in 1848 reduced the impact of Esdaile’s anesthesia. August reported on his methods and the results,
discoveries. Nevertheless, hypnosis continued to be used emphasizing the decreased anesthetic hazard to mother
as sole anesthetic and in combination with ether and and infant, and the enhanced rapport between patient and
chloroform. In 1906, Magaw reported on 14,000 surgeries physician (3,4). More recently, Werner et al. (5,6) conducted
completed at the Mayo Clinic, utilizing a combination of a randomized controlled trial (RCT) with 1,222 first time
hypnosis and chemical anesthesia (2). mothers, and those women in the group receiving brief self-
Since the time of Esdaile, hypnosis has been applied hypnosis training reported a better experience of childbirth.
widely for pain relief and to facilitate patient cooperation in There were no differences across groups in duration of

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019 | http://dx.doi.org/10.21037/apm.2019.07.01
2 Moss and Willmarth. Hypnosis, anesthesia, pain

labor, but the women in the hypnosis required fewer strong” and by books such as Hypnosis in the Relief of Pain by
emergency C-sections. Ernest Hilgard and Josephine Hilgard (15) and Hypnosis and
Suggestion in the Treatment of Pain by Joseph Barber (16). More
recently this focus has been maintained by Mark Jensen’s
Hypnosis in dentistry
Hypnosis for Chronic Pain Management (17).
The first documented application of hypnosis in dentistry
was a dental extraction under hypnotic anesthesia, reported
Hypnosis for chronic pain
in 1829 (7). By 1900, hypnosis was commonly used by
dentists for managing dental patients’ fears and pain. Today, Similar to his table related to acute pain, Patterson (11)
hypnosis is widely used by dentists to effectively moderate presented a table related to chronic pain that included
fears of dental procedures, excessive gag reflex, treatment 14 controlled studies of hypnosis (12 randomized), in
of orofacial pain conditions, moderating bleeding and chronic conditions including fibromyalgia, headaches,
salivary flow, and managing procedural pain (8,9). Hypnotic cancer-related pain, back pain, and irritable bowel
strategies such as distraction, re-framing, and imagery are syndrome (IBS)-related pain. Again, all studies found
also useful in managing pediatric patients (10). that hypnosis was equal to or better than standard care
treatments which included group support, biofeedback,
medication, relaxation, Autogenic training, attention
Hypnosis for acute pain
control and CBT. In a video interview (18), Michael Yapko
In 2010, The American Psychological Association published pointed out that the salient question isn’t whether hypnosis
Clinical Hypnosis for Pain Control by David Patterson (11). is better than other treatments, but rather whether the
In this book Patterson presented a table of 21 controlled addition of hypnosis to existing treatment enhanced the
hypnosis studies (18 randomized) with acute pain disorders. treatment effects. In his understanding of the literature,
These studies included the treatment of burn wounds and “the answer is clearly yes!” This approach is described by
debridement pain, bone marrow aspiration pain, labor Willmarth, Davis, and Fitzgerald (19) who for over 30 years
pain, pain following chemotherapy for cancer, pain during have combined traditional medical interventions offered by
angioplasty, pain during plastic surgery, pain related to anesthesiologists with the treatment of physical therapists,
large core needle biopsies of the breast and multiple other social workers, and psychologists who offer group therapy,
surgical pain situations. The outcome of these studies hypnosis, biofeedback, and individual psychotherapy for
showed that in all cases hypnosis was at least equal to the patients suffering from chronic pain conditions.
existing standard of care and in the majority of studies
hypnosis proved more beneficial than the standard of care or
Hypnosis for pre-surgical preparation
other treatment controls which included attention control,
relaxation, emotional support, medication (Lorazepam), The use of hypnosis for anesthesia during surgery has
cognitive behavioral therapy (CBT), deep breathing and already been mentioned. Hypnosis has proven to be one
non-directed play (for children). of the most powerful tools in enhancing surgical recovery.
Kendrick et al. (12) completed a similar review of RCTs Montgomery et al. (20) reviewed the evidence on hypnosis
related to surgical procedural pain. Their results were as an adjunctive approach for surgery patients: “Patients
consistent with the Patterson findings. The authors observed receive standard surgical and anesthesia care according to protocol
that: “Results from the 29 RCTs meeting inclusion criteria but with hypnosis added to the treatment package” (p. 1,639).
suggest that hypnosis decreases pain compared to standard care Montgomery et al. reviewed 20 well-controlled research
and attention control groups and that it is at least as effective as studies, using meta-analytic techniques, and concluded that
comparable adjunct psychological or behavioral therapies” (p. 75). hypnosis is an effective adjunctive treatment for patients
While the use of hypnosis or trance-like states for pain undergoing surgery.
relief has been documented for hundreds of years (13), the The meta-analysis showed a broad beneficial impact of
modern era of hypnosis for pain management was energized hypnosis with surgical patients, across outcome categories.
by a statement from the NIH Consensus Development Subjective measures such as anxiety and pain, objective
Program (14) that “The evidence supporting the effectiveness of measures such as analgesia use, physiological measures,
hypnosis in alleviating chronic pain associated with cancer seems recovery time, and treatment time, all showed comparable

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019 | http://dx.doi.org/10.21037/apm.2019.07.01
Annals of Palliative Medicine, 2019 3

beneficial outcomes for patients in the groups receiving of patients are inquiring about non-pharmacological
hypnosis. The patients in the hypnosis groups showed approaches to healthcare, hypnosis provides a practical
better medical and psychological outcomes than 89% of the alternative.
patients who did not receive hypnosis. Later research by
Montgomery et al. (21) showed that not only could hypnosis
The place of hypnosis in clinical medicine and
reduce patients suffering, enhance healing, and optimize
dentistry
recovery time, but that the savings to the hospital were
substantial, mainly in reduced time in surgery. The patient seeking medical or dental care for a broad
range of conditions may benefit best from an integrative
healthcare program that includes adjunctive hypnosis as an
Hypnotic ability or hypnotizability
integral component within the total treatment package.
Not all human beings respond equally well to hypnotic
intervention. The researcher Ernest Hilgard (22) defined
Evidence-based hypnotic interventions
hypnotic susceptibility as an “ability in which men differ, just
as they differ in intelligence or athletic skill” (p. 65). Hypnotic For this to happen, it is critical that the patient’s
ability is a relatively stable and measurable trait over the complaint be one for which there is a strong research
human lifetime, somewhat normally distributed. One base supporting the value of hypnotic treatment. There is
landmark study administered a standard test of hypnotic good research support for the application of hypnosis for
susceptibility at baseline and after 10, 15, and 25 years. The anxiety disorders, depression (including major depression),
test/re-test correlations were 0.64, 0.82, and 0.71 over these post-traumatic stress disorder, stress management, sleep
extended time periods (23). Morgan (24) conducted a study disorders, smoking cessation, weight management and
of hypnotic susceptibility in monozygotic and dizygotic eating disorders, and the addictions. There is also strong
twins and calculated a heritability index of 0.64. research support for the use of hypnosis for acute and
The original tests of hypnotic susceptibility included the chronic pain, IBS, colitis, diabetes mellitus, hypertension,
Stanford Hypnotic Susceptibility Scale and the Harvard skin conditions including psoriasis, chemotherapy induced
Group Scale of Hypnotic Susceptibility and typically nausea, and pediatric problems such as anxiety, school
required a full hour for administration. More recently the phobia, and recurrent abdominal pain (27,28).
Elkins Hypnotizability Scale (25) was developed for brief,
efficient administration in clinical and research settings,
Competent, well-trained hypnotic practitioners with
with relatively strong correlations with the older and longer
competence in the area of patient’s complaint
measures.
For medical applications of hypnosis, it is important to It is essential that the hypnotic practitioner is a licensed
remember that some patients (approximately 20%) may healthcare or mental healthcare professional, with state-
respond poorly to hypnosis and may therefore require of-the-art training in clinical hypnosis, and adequate
alternative interventions. Some authors claim that with a knowledge and experience in the areas of the patient’s
well-trained practitioner, adequate preparations to enhance presenting problems and diagnoses. Licensed psychologists,
hypnotic ability, and an individualized hypnotic approach, physicians, physical therapists, and dentists all are eligible
almost all human beings can benefit from hypnosis. for training in clinical hypnosis and must apply hypnosis in
However, Lynn, Laurence, and Kirsch (26) concluded that the areas of their licensure and expertise.
even after credible interventions to enhance suggestibility, a
sizable minority of individuals remain who do not respond
Interprofessional and collaborative care
to hypnosis or suggestion. They hypothesized that these
“low-suggestible individuals lack key hard-wired abilities Integrative medicine is increasingly interprofessional
compared with highly suggestible participants” (p. 323). and collaborative in nature. The interprofessional model
Fortunately, the majority of patients display medium suggests that coordination, communication, and a team
to high hypnotic ability, and for this larger population approach enhance the quality and safety of patient care (29).
therapeutic outcomes for hypnosis are comparable to The hypnotically trained social worker may then provide
traditional medical interventions. Since increasing numbers therapeutic support and hypnotic pain management while

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019 | http://dx.doi.org/10.21037/apm.2019.07.01
4 Moss and Willmarth. Hypnosis, anesthesia, pain

Table 1 Professional organizations in clinical hypnosis

Society Website Education Certification program(s)

Society for Clinical & www.sceh.us Annual meeting, SCEH Certified Clinicians
Experimental Hypnosis workshops,
journal

American Society of Clinical www.asch.net Annual meeting, Certification in Clinical

Hypnosis workshops, Hypnosis and Approved
journal Consultants

American Board of Medical http://www.abmh.info/ Certification only Certified Diplomates

Hypnosis/Dental Hypnosis/ in Medical, Dental,
http://www.abdh.info/
Psychological Hypnosis/ Psychological, Social Work,
Social Work Hypnosis/Nursing http://marcoster.homestead.com/ABPH.html Nursing Hypnosis
Hypnosis
http://lankton.com/dahb/index.htm (Website for nursing
pending)

Society for Psychological http://www.apadivisions.org/division-30/ Annual meeting, No certification process

Hypnosis (Division 30 of workshops,
the American Psychological journal
Association)

Milton Erickson Foundation https://www.erickson-foundation.org/ Meetings, No certification process

workshops,
training
SCEH, Society for Clinical and Experimental Hypnosis.

the oncologist provides medical supervision, chemotherapy professionals in clinical hypnosis, provides assurance for
and radiation. Hypnotically trained nurses and health the patient and the referring physician that the provider
coaches can master and provide the protocol for pre- has a foundation of training and knowledge. At present,
surgical hypnotic training for patients, working under there are five national professional organizations providing
supervision and in close communication with surgical and reliable education and training in hypnosis for licensed
anesthesia teams, and must refer any serious mental health healthcare professionals. The Society for Clinical and
symptoms to consulting psychologists or physicians. Experimental Hypnosis (SCEH) is dedicated to the
promotion of evidence-based hypnotic applications,
integrating research and clinical practice for physicians,
Certification by a professional hypnosis organization
dentists, and mental health professionals. The American
for licensed healthcare providers is the gold standard for
Society for Clinical Hypnosis (ASCH) focuses on providing
trustworthy professionals
training to licensed healthcare providers. The Society
Determining which “certified hypnotherapists” should be for Psychological Hypnosis is a Division of the American
trusted is often confusing. There are many lay hypnosis Psychological Association (APA, Div. 30) and provides
organizations providing “certificates” and certification training and education in hypnosis for psychologists. The
based on minimal training to lay persons without regard American Boards of Hypnosis concentrate on a high-
to education or licensure in healthcare. Steve Eichel quality certification in hypnosis for physicians, dentists,
demonstrated the danger of such lay hypnosis certifications psychologists, social workers, and most recently nurses.
by applying for and receiving hypnosis certification The Milton Erickson Foundation promotes the approach
for his cat, Zoe D. Katze, from three lay hypnotherapy of the gifted hypnotherapist Milton Erickson and provides
programs, and gained membership for Zoe in a fourth such hypnosis training and education to both medical and mental
organization (30). health professionals. Table 1 shows these professional
Certification by one of the recognized professional organizations, their websites, and whether they sponsor
hypnosis associations, limited to licensed healthcare certification programs.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019 | http://dx.doi.org/10.21037/apm.2019.07.01
Annals of Palliative Medicine, 2019 5

Conclusions 8. Armfield JM, Heaton LJ. Management of fear and anxiety

in the dental clinic: a review. Aust Dent J 2013;58:390-407;
In summary, hypnosis is most helpful and effective for
quiz 531.
patients in healthcare, dentistry, and mental healthcare,
9. Facco E, Zanette G, Casiglia E. The role of hypnotherapy
when evidence-based hypnosis protocols are followed,
in dentistry. SAAD Dig 2014;30:3-6.
based on current research. Referrals are best made to
10. Peretz B, Bercovich R, Blumer S. Using elements of
licensed healthcare professionals, who practice in close
hypnosis prior to or during pediatric dental treatment.
communication and coordination with other involved
Pediatr Dent 2013;35:33-6.
healthcare professionals, and whose training and
11. Patterson DR. Clinical Hypnosis for Pain Control.
competence are demonstrated by certification through one
Washington, DC: American Psychological Association, 2010.
of the professional hypnosis organizations shown in Table 1. 12. Kendrick C, Sliwinski J, Yu Y, et al. Hypnosis for Acute
Procedural Pain: A Critical Review. Int J Clin Exp Hypn
Acknowledgments 2016;64:75-115.
13. Tinterow MM. Foundations of Hypnosis: From
The authors would like to acknowledge Saybrook Mesmer to Freud. Springfield, IL: Charles C. Thomas
University for its ongoing support for education and Publisher, 1970.
training in clinical and experimental hypnosis. 14. National Institutes Health. Integration of behavioral and
relaxation approaches into the treatment of chronic pain
Footnote and insomnia. NIH Technology Assessment Statement
1995, 1-34. Available online: https://consensus.nih.gov/19
Conflicts of Interest: The authors have no conflicts of interest 95/1995behaviorrelaxpaininsomniata017html.htm
to declare. 15. Hilgard ER, Hilgard JR. Hypnosis in the Relief of Pain.
Los Altos, CA: William Kaufmann, 1975.
Ethical Statement: The authors are accountable for all 16. Barber J. Hypnosis and Suggestion in the Treatment of
aspects of the work in ensuring that questions related Pain. New York: W.W. Norton and Company, 1996.
to the accuracy or integrity of any part of the work are 17. Jensen M. Hypnosis for Chronic Pain Management. New
appropriately investigated and resolved. York: Oxford, 2011.
18. Willmarth E. The Willmarth Hypnosis Interviews:
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Cite this article as: Moss D, Willmarth E. Hypnosis, anesthesia,

pain management, and preparation for medical procedures. Ann
Palliat Med 2019. doi: 10.21037/apm.2019.07.01

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2019 | http://dx.doi.org/10.21037/apm.2019.07.01