CLINICAL HYPNOSIS IN PAIN

THERAPY AND PALLIATIVE CARE

 ABOUT THE AUTHOR

Dr. Paola Brugnoli, M.D., with Specialization in Anesthesia and

Critical Care and master’s in Pain Therapy and Palliative Care,
Pediatric Anesthesiology and Psychogerontology and Psychogeriatric.
She is a Palliativist and Pain Therapist in Medical Staff of Pain
Therapy, at University Department of Anesthesiology, Critical Care
and Pain Therapy, University of Verona, Italy.

She is internationally recognized for her work in clinical hypnosis,

pain therapy and palliative care, routinely teaching to professional
audiences in Europe, United States, and all over the world and in
schools of specialization in psychotherapy.

She is the author of seven books, in Italian and English. She is AIST
President, the Italian Association for the study of Pain Therapy and
Clinical Hypnosis (www.aist-pain.it).

E-mail: [email protected]
CLINICAL HYPNOSIS IN PAIN THERAPY
AND PALLIATIVE CARE
A Handbook of Techniques for Improving the Patient’s
Physical and Psychological Well-Being

By

MARIA PAOLA BRUGNOLI, M.D.

Department of Anesthesiology
Critical Care and Pain Therapy
University of Verona
Verona, Italy

Foreword by Julie H. Linden and Consuelo C. Casula

 Published and Distributed Throughout the World by

CHARLES C THOMAS • PUBLISHER, LTD.

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Springfield, Illinois 62704

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© 2014 by CHARLES C THOMAS • PUBLISHER, LTD.

ISBN 978-0-398-08765-4 (hard)

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Library of Congress Catalog Card Number: 2013023179

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Library of Congress Cataloging-in-Publication Data

Brugnoli, Maria Paola, author.

Clinical hyponosis in pain therapy and palliative care : a handbook of
techniques for improving the patient’s physical and psychological well-
being / by Maria Paola Brugnoli ; foreword by Julie H. Linden and
Consuelo C. Casula.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-398-08765-4 (hard) -- ISBN 978-0-398-08766-1 (pbk.) --
ISBN 978-0-398-08767-8 (ebook)
1. Title.
[DNLM: 1. Hypnosis—methods. 2. Hypnosis, Anesthetic. 3. Pain
Management—methods. 4. Palliative Care‚methods. 5. Spiritual
Therapies. WM 415]

RC499.A8
615.8¢5122—dc23
2013023179
 FOREWORD

nesthetist and pain specialist, Paola Brugnoli, brings together her expe-
A rience, knowledge and emotional intelligence in this integrative work
on clinical hypnosis and pain management. Unlike many other books that
address the topic of pain treatments, this one is expansive. Conceptually,
Brugnoli explores the links between ancient philosophy and quantum phys-
ics, reviews consciousness and modified states of consciousness, and updates
our understanding of neurophysiology and neuropsychology as they each in-
fluence our understanding of how to relieve pain and suffering.
A clinical hypnotherapist, she considers the shared roots of clinical hyp-
nosis and mindfulness and provides a spiritual overview of the universal con-
tributions to healing that come from the practices of many meditative states
in different philosophies and religions. Finally, she is able to frame this in a
life-span perspective noting the diverse approaches with children and adults.
Her deep sensitivity is most notable in her attention to the dignity of the
person in pain. She gathers together the techniques for distracting them from
the painful present and transporting them to another dimension. One can
imagine her psychological hand-holding and support as she moves her
patients from suffering to relief.
Practically, Brugnoli is generous in providing the reader the scripts for many
inductions. The handbook is enriched by medical and hypnotic techniques for
pain analgesia as well as hypnotic deepening techniques to activate spiritual
awareness. It also indicates when and how to use them with children and adults.
With extensive references, this book offers accessible concepts and prac-
tical suggestions to the reader. It highlights the relational and the creative
process, encouraging each clinician to find his or her own way of facilitating
the mechanisms in the patient to alleviate pain and suffering. The book
demonstrates the vast experience Brugnoli accumulated in her work as anes-
thesiologist, palliative care specialist and Pain Therapist at University Depart-
ment of Anesthesiology.
JULIE H. LINDEN, P H.D.
CONSUELO C. CASULA, P SY.D.

v
 INTRODUCTION

And a man said, speak to us of self knowledge.

And he answered saying:
Your hearts know in silence the secrets of the days and of the nights.
But your ears thirst for the sound of your heart’s knowledge.
You would know in words that which you have always known in thought.
You would touch with your fingers the naked body of your dreams.
And it is well you should.
The hidden well-spring of your soul must rise and run murmuring to the sea;
And the treasure of your infinite depths would be revealed to your eyes.
Kahlil Gibran

Yesterday I thought myself a fragment quivering

without rhythm in the sphere of life.
Now I know that I am the sphere,
and all life in rhythmic fragments moves within me.
Kahlil Gibran

linical Hypnosis in Pain Therapy and Palliative Care refers to the conscious,
C calm awareness of cognitions, sensations, emotions, and experiences.
This state can be achieved through mindfulness and meditative states, which
are practices that cultivate nonjudgmental awareness of the present moment.
Mindfulness (from Pali;- sati; and Sanskrit; smrti; furthermore, translated as
awareness) is a spiritual or psychological faculty (indriya) that is considered
to be important in the path to enlightenment according to the teaching of the
Buddha. It is one of the seven factors of enlightenment. “Correct” or “right”
mindfulness is the seventh element of the noble eightfold path. Mindfulness
meditation can also be traced back to the earlier Upanishads, part of Hindu
scripture.
The Abhidhammattha Sangaha, a key Abhidharma text from the Thera-
vada tradition, defines sati as follows: “The word sati derives from a root
meaning ‘to remember,’ but as a mental factor it signifies the presence of

vii
viii Clinical Hypnosis in Pain Therapy and Palliative Care

mind, attentiveness to the present, rather than the faculty of memory regard-
ing the past. It has the characteristic of not wobbling, not floating away from
the object. Its function is the absence of confusion or nonforgetfulness. It is
manifested as guardianship, or as the state of confronting an objective field.
Its proximate cause is strong perception (thirasanna) or the four foundations
of mindfulness.”
Mindfulness practice, inherited from the Buddhist tradition, is increas-
ingly being employed in Western psychology to alleviate a variety of mental
and physical conditions. Scientific research into mindfulness, generally falls
under the umbrella of positive psychology. Research has been ongoing over
the last twenty or thirty years, with a surge of interest over the last decade in
particular.
In 2011, the National Institutes of Health’s (NIH) National Center for
Complementary and Alternative Medicine (NCCAM) released the findings
of a study in which magnetic resonance images of the brains of 16 partici-
pants, two weeks before and after mindfulness meditation practitioners joined
the meditation program, were taken by researchers from Massachusetts Gen-
eral Hospital, Bender Institute of Neuroimaging in Germany, and the
University of Massachusetts Medical School. It concluded that “these find-
ings may represent an underlying brain mechanism associated with mindful-
ness-based improvements in mental health” (National Center, 2011).
The high likelihood of recurrence in depression is linked to a progressive
increase in emotional reactivity to stress (stress sensitization). Mindfulness-
based therapies teach mindfulness skills, designed to decrease emotional
reactivity in the face of negative affect-producing stressors. Given that emo-
tional reactivity to stress is an important psychopathological process under-
lying the chronic and recurrent nature of depression, mindfulness skills are
important in adaptive emotion regulation when coping with stress (Britton,
Shahar, Szepsenwol, & Jacobs, 2012).
In this model, self-regulated attention (an important component of con-
sciousness) involves conscious awareness of one’s current thoughts, feelings,
and surroundings. Consciousness is extremely elusive from the empirical
point of view. Scientists of consciousness usually proceed as if such a defini-
tion were already available. In clinical hypnosis, mindfulness, and meditative
states, we assume a priori that consciousness is an object and exists in an
observer-independent way.
A primary point of contention among the major theories of conscious-
ness is whether attention is generally necessary for consciousness. The glob-
al workspace theory (Deahene et al., 2006) holds that an inability to accu-
rately report supraliminal stimuli that are unattended indicates that they are
processed unconsciously (inattentional blindness).
 Introduction ix

The neurogenetics of consciousness has three main components:

1. The neurophysiological neurogenesis, brain morphogenesis, and neu-

ron maturation, which are all under the guidance of genes
2. The neuron-based continuum of consciousness that involves neuro-
logical and epigenetic factors, microtubules and neuroplasticity
3. The end of life processes that involves neurodegeneration

This suggests that it is important to go beyond the mask of brain anatomy to

explore the fine spatiotemporal patterns and the underlying mechanisms of
consciousness. The human brain consists of about one billion neurons, and
each neuron has synapses on the order of 1000. Thus, the capability of the
human brain is 1016 operations per second. We know that each neuron in the
human brain consists of large number of microtubules. Penrose and Hamer-
off (2007) proposed that consciousness involves sequences of quantum com-
putation in microtubules inside brain neurons.
Recent studies (Demertzi et al., 2009) show that awareness is an emer-
gent property of the collective behavior of frontoparietal top-down connec-
tivity. With this network, external (sensory) awareness depends on lateral
prefrontal parietal cortices, and internal (self) awareness correlates with pre-
cuneal mesiofrontal midline activity. Both functional magnetic resonance
imaging (MRI) and electrophysiology suggest that attention and conscious-
ness share neural correlates. The fields of pain and palliative care have un-
dergone a great revolution, and this volume reflects these exciting advances.
We are so accustomed to viewing pain as a sensory phenomenon that we
have long ignored the fact that injury does more than produce pain; it also dis-
rupts the brain’s homeostatic regulation system, thereby producing “stress”
and initiating complex programs to reinstate homeostasis. Stress can be de-
fined as an activation of the limbic system of the central nervous system (CNS)
that then activates neurohumoral mechanisms of arousal. Stress produced by
painful experiences initiates a cascade of neurophysiological, humoral, and
phenomenological events that challenge our understanding but also provide
valuable clues in dealing with chronic pain (Melzack, 1998, 1999).
I wrote this textbook as a contribution to pain and suffering therapy in
palliative care. Advances in pain and suffering therapy have tremendously
influenced the development of new nonpharmacological and noninvasive
pain management. Psychological therapies that were generally used when
drugs or anesthesiology or neurosurgery failed are now integrated into main-
stream pain management strategies.
The stress associated with advancing and incurable illness inevitably
causes distress for patients, families, and caregivers. A palliative approach to
x Clinical Hypnosis in Pain Therapy and Palliative Care

care aims to improve the quality of life for patients with a life-limiting illness
by reducing suffering through early identification; assessment; and optimal
management of pain and physical, cultural, psychological, social, and spiri-
tual needs.
This book is quite different from others in its unique focus on the assess-
ment of pain and suffering therapy through clinical hypnosis and mindful-
ness, rather than through conventional pharmacological, anesthesiological,
and invasive techniques that have previously been dealt with in many other
texts. The book explores the fields of clinical hypnosis and mindfulness as
applied to the therapy of suffering and various type of acute and chronic pain
and in dying patients. We were conscious of how much there is to learn in
these areas, we believe that the dissemination of this rapidly growing body
of knowledge will stimulate further research and exploration into the use of
specific consciousness states for healing and wellness work.
This book is organized in order to show all scientific neuropsychological
theories currently in use regarding various types of pain and suffering. Re-
cent advances in the understanding of fundamental neurobiological mecha-
nisms of nociception have provided insights into the evaluation and treat-
ment of clinical pain (Melzack, 2002). Acute pain serves the purpose of alert-
ing the organism to the presence of harmful stimuli in the internal or exter-
nal environment. Acute pain may be repetitive in circumstances in which re-
current and/or progressive tissue injury is experienced.
The chronic “pain state” term is usually used in the context of patients
who report pain on a long-term basis with no apparent tissue injury compo-
nent or at least no apparent evidence of persistent nociceptor activation. The
psychological counterparts to the chronic pain state include depression, anx-
iety, and other affective states and are key to understanding the disability
associated with this condition (Cleeland & Syrjala, 1992). The different as-
pects of pathophysiological pain (neurophysiology and psychology), are de-
scribed followed by a classification of anatomiconeurophysiological and neu-
ropsychological pain.
Scientific literature distinguishes the philosophy of neuroscience and neu-
rophilosophy. The former concerns foundational issues within the neuro-
sciences. The latter concerns application of neuroscientific concepts, to tradi-
tional philosophical questions. Exploring various neurological concepts of rep-
resentation employed in neuroscientific theories is an example of the former.
Examining implications of neurological syndromes for the concept of a
unified self and in different states of consciousness, as in clinical hypnosis
and mindfulness, is an example of the latter. I will discuss examples of both
in the therapy of pain and suffering and will describe hypnosis techniques
useful for the management of physical pain and mental suffering.
 Introduction xi

Therefore, I have chosen to describe many different techniques of clini-

cal hypnosis and mindfulness. This book has been carefully studied, edited,
and strongly desired by the author, who has a vast experience in the specif-
ic field of physical, mental, and spiritual suffering therapy in subjects afflict-
ed by various types of pain, acute and chronic; disability; and cancer illness
in order to relieve, within limits their anxiety and worry regarding a better
quality of life.
If we look at the Contents, we can see that the arguments are dealt with
in a scientific way but also from a psychological and spiritual point of view.
The book highlights the importance the author gives to the study of clinical
hypnosis and interior awareness, consolidating the studies carried out by psy-
chologists at first and then by scientists through neurosciences. The World
Health Organization (WHO) defines palliative care as “The active total care
of patients whose disease is not responsive to curative treatment.” One of the
primary issues of palliative care for patients with advanced cancer is symp-
tom control and quality-of-life issues.
This book presents a hypnotic model for improving the patient’s physi-
cal and psychological well-being. There exists a need for a broad and inclu-
sive model of mind-body interventions for pain therapy and palliative care.
This is supported by the observation that symptoms related to psychological
distress and existential concerns are even more prevalent than are pain and
other physical symptoms among those with life-limiting conditions.
The hypnotic trance is a consciousness state of heightened awareness and
focused concentration that can be used to manipulate the perception of pain
and has been effective in the treatment of cancer-related pain. Our ordinary
state of consciousness is not something natural or given but is a highly com-
plex construction, a specialized tool for coping with our environment (Tart,
1972).
The last change comes from the new techniques of brain imaging, for
which we must know the traditional separation of sensory and motor mech-
anisms of consciousness. The chapter titles of this book show how the author
has incorporated this fundamentally new thinking about the origins of pain
and suffering and the direction of new therapies. The conscious mind is one
of the most unresolved problems of neuroscience. What are the conscious
sensations that accompany neural activities of the brain? What is the bridge
between pain perception and the experience of anxiety and suffering? More-
over, how can we cure suffering and pain in all their aspects, not only phys-
ical but also mental? How does a neurochemical phenomenon like pain,
which starts from a biological state, transform into a psychological sensation?
Even if our neurophysiological knowledge should one day enable us to
identify the exact neurochemical correlation of a psychic phenomenon, we
xii Clinical Hypnosis in Pain Therapy and Palliative Care

must not forget that neurochemical knowledge is not sufficient to explain all
the subjective experiences in people. The conscious mental properties inter-
act in causal and lawlike ways with other fundamental properties such as
those of physics; however, their existence is neither ontologically dependent
upon nor derivative from any other properties (Chalmers, 1996).
A major turning point in philosophers’ interest in neuroscience came
with the publication of Patricia Churchland’s Neurophilosophy (1986). The
Churchlands (Pat and husband Paul) were already notorious for advocating
eliminative materialism. In her book, Churchland distilled eliminativist argu-
ments of the past decade, unified the pieces of the philosophy of science
underlying them, and sandwiched the philosophy between a five-chapter in-
troduction to neuroscience and a seventy-page chapter on three then-current
theories of brain function (1986). She was unapologetic about her intent. She
was introducing philosophy of science to neuroscientists and neuroscience to
philosophers (Bickle, 2003).
Science still does not know the mechanisms that produced awareness
experiences, however, and does not have a clear definition of them. Con-
sciousness then is more than the sum of its constituent neurophysiological
events and substrates. The physician and mathematician John Taylor recent-
ly observed “the study of consciousness is like a black hole for those that
study it. Once the scientific study is done they lose sight of their normal sci-
entific activity and give an explanation of the phenomena that does not cor-
respond to a scientific explanation” (Taylor, 2000).
In cancer patients and in palliative care, pain is neurophysiological, psy-
chological, social, and spiritual. As David Chalmers wrote, “even if we
explained all the physical events inside and around the brain and how all the
neural functions operate something would be missing: consciousness” (1996).
The question then naturally arises: Is it possible to incorporate both science
and mysticism into a single, coherent worldview? Quantum mechanics
shows that the materialistic common sense notion of reality is an illusion.
The appearance of an objective world distinguishable from a subjective self
is but the imaginary form in which consciousness perfectly realizes itself
(McFarlane, 1995). How can one approach consciousness in a scientific man-
ner? There are many forms of consciousness, such as those associated with
seeing, thinking, emotions, pain, suffering and so on.
Clinical hypnosis can help the patients to improve their self-consciousness
and self-awareness. The techniques of relaxation, hypnosis, and mindfulness
in meditative states are open gates on the self in pain and suffering therapy.
Psychological interventions are an important part of a multimodal approach
to pain and suffering management. Such interventions frequently are used in
conjunction with appropriate analgesics for the management of pain.
 Introduction xiii

One goal is to help the patients gain a sense of control over pain and suf-
fering. Changing how they think about pain, we can change their sensitivity
to it and their feelings and reactions toward it. In Analysis Terminable and
Interminable (1937) Freud wrote, “Only the simultaneous working together
and against each other of both primordial drives, of Eros and death drive,
can explain the colourfulness of life, never the one or the other all by itself.”
Erickson, like Freud, suffered all his life. His basic attitude toward his
patients also reflected this basic dialectic of the life and death drive: “I think
that you should take a patient as he is. He is only going to live today, tomor-
row, next week, next month, next year. His living conditions are those of
today” (Erickson, Rossi, & Rossi, 1976).
There is therefore a permanent task for the beginner and for the experi-
enced practitioner as well: through symbolization, through clinical and
experimental researches and theorizing, we have to convert the mirage of
hypnosis into a disciplined analysis of our condition as human subjects made
of body, mind, and spirit. Several techniques can be used to achieve a men-
tal and physical state of relaxation. Muscular tension, and mental distress
exacerbate pain (Benson, 1975; Brugnoli, Brugnoli, & Norsa, 2006; Cleeland,
1987; Loscalzo & Jacobsen, 1990).
Hypnosis can be a useful adjunct in the management of pain and clinical
trials (Erickson, 1959; Jensen & Patterson, 2005; Levitan, 1992; Spiegel, 1985).
The hypnotic trance is a essentially a state of heightened and focused con-
centration, and thus it can be used to manipulate the perception of pain. The
use of hypnosis involves control over the focus of attention and can be used
to make the patient less aware of the noxious stimuli (Bates, Broome, Lillis,
& McGahe, 1992)
The use of clinical hypnosis and mindfulness in pain therapy and pallia-
tive care, makes us give to the patients empathy and listening skills; empath-
ic listening sometimes leads to good therapy, relationships, and emotional
intimacy. Their use may also lead to a conversation partner feeling like she
or he is receiving a hug, a “psychological hug.” The consciousness approach
through clinical hypnosis and meditative states can be used not only in a ver-
bal channel, but also in patients with cognitive disorders through feelings and
perceiving sensations. The realm of emotional responses constitutes the per-
sonal sphere wherein one interacts with the environment, past, thoughts, and
one’s and others immediate and ultimate values.
Components of emotional events include liminal-subliminal perception
of real, or imaging of imaginary, objects, representations of those objects, re-
flexive motor responses, and a range of unattended higher and higher-order
emotional experiences. The problem faced by both sciences and psychology
is dualism: The apparent duality between subjective and objective or con-
xiv Clinical Hypnosis in Pain Therapy and Palliative Care

sciousness and matter. The solution is in clinical hypnosis and mindfulness:

It is not to side either with brain but somehow—whether through neuro-
science, psychology, philosophy, or spiritual practice—to attain nonduality.
Consciousness study has been the focus of an extensive practice in spiri-
tual traditions since ancient times. Many spiritual meditations have provided
detailed revelations of different states of consciousness. It is enlightening to
study clinical hypnosis, mindfulness and the modified states of consciousness
in different traditions, to achieve the primary objective of self-realization and
higher consciousness. Generally, we know various “states of consciousness,”
in particular, wakefulness; dreams; and sleep, which the physiologists divide
into “slow sleep” and “paradoxical sleep.” Methods of relaxation allow us to
describe a “modified state,” a particular state of consciousness to which we
can give a special value. This state comprises peace, serenity, “absorption,”
even “presence,” and ineffability.
In this book, I present a new system approach to study the neurophysio-
logical states of consciousness to improve the use of clinical hypnosis and
mindfulness in pain therapy and palliative care. The contents of the book
cover:

• What consciousness is
• Neurophysiology and neuropsychology of pain
• The modified states of consciousness in pain therapy and palliative
care
• A new system approach and classification of clinical hypnosis and
mindfulness in consciousness states
• The hypnosis techniques, the meditative states, and mindfulness tech-
niques to relieve pain in palliative care
• Relaxation and hypnosis in pediatric patients: techniques for pain and
suffering relief
• Music therapy to achieve deep hypnosis and mindfulness
• Metaphor’s techniques in pain therapy and palliative care
• Modified states of consciousness and quantum physics: the mind be-
yond matter

Our ordinary state of consciousness is not something natural or given but

a highly complex construction, a specialized tool for coping with our envi-
ronment and the people in it. In this book, I propose a new approach, using
neurophysiologic and neuropsychological explanations that help to formu-
late empirically testable hypotheses about the nature of consciousness states.
Because we are creatures with a certain kind of body and nervous system, a
large number of human potentials are, in principle, available to use, but each
 Introduction xv

of us is born into a particular culture that selects and develops a small num-
ber of these potentials, rejects others, and is ignorant of many.
The small number of experiential abilities selected by our culture, plus
some unplanned factors, constitutes the structural elements from which our
ordinary state of consciousness is constructed. After all, we are the victims of
our culture’s particular selection. The power and the possibility of tapping
and developing latent potentials that lie outside the cultural norm by enter-
ing a modified state of consciousness, by temporarily restructuring con-
sciousness, are the basis of the great interest in such states (Tart, 1990). As we
look at consciousness closely, we see that it can be analyzed into many parts:
neurophysiology of the brain, neuropsychology of the mind, spirituality, and
awareness. These parts function together in a pattern, however: they form a
system. Although the components of consciousness can be studied in isola-
tion, they exist as parts of a complex system, consciousness, and can be fully
understood only when we see this function in the overall system.
In this book, I carefully examine the role and use of specific states of con-
sciousness, clinical hypnosis techniques, and meditative states for the best
management of pain and relief of suffering in adults and children. This book
is intended for all the professionals working every day with pain and suffer-
ing. Every day, because the mind reflects habitual thoughts, it is therefore
our responsibility to influence our brain with positive emotions, thoughts,
and energy as the dominating factors in our mind and in our life.
After experiencing many levels of consciousness and the higher con-
sciousness, we become able to live in its energy continuously. Then, with fur-
ther practice and development, we become permanently awakened and live
in uninterrupted higher consciousness. We can direct our inner strength to
move and express itself in our own life and the lives of our loved ones.

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SUGGESTED READINGS

Armstrong, D. M. (1978). Naturalism, Materialism and First Philosophy. Philosophia,

8, 261–276.
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 ACKNOWLEDGMENTS

would like to thank my family for the support, strength, and encourage-
I ment they gave me throughout my life. Particularly, I appreciate the love
of my husband Andrea, my two sons Luca and Alessandro, my parents
Angelico and Elda, my brother Marco, and my sister Angelica.
I would like to express my immense gratitude to my master and father
Dr. Angelico Brugnoli, M.D., for improving my knowledge and studies in
clinical hypnosis and stages of consciousness. I appreciate his vast knowledge
and skills in many areas: in 1965, he and Dr. Gualtiero Guantieri, M.D.,
founded in Verona, Italy, the Italian Institute for the Study of Psychotherapy
and Clinical Hypnosis “H. Bernheim.”
I especially thank my colleagues and friends: Dr. Daniel Handel (past
president of American Society of Clinical Hypnosis [ASCH]), and professors
Sylvain Néron, Alladin Assen, Dabney Ewin, Donald Moss, Camillo Loriedo,
Giovanni Gocci; Dr. Michael Yapko, Dr. Alessandro Norsa, Dr. Consuelo
Casula (president elect of European Society of Hypnosis [ESH]), Professors
Éva Bányai and Katalin Varga, Dr. Nicole Ruysschaert (president of ESH),
and Dr. Julie Linden (past president of ASCH and president of International
Society of Hypnosis [ISH]) for sharing with me workshops and studies in the
United States, in Europe, and in Italy about clinical hypnosis.
I thank my friends Dr. Mike Flynn, psychologist and Christian priest,
and Giampaolo Mortaro, theologist, anthropologist and Catholic Comboni
priest, for improving my studies about the Christian religion.
The information and Eastern religious studies contained in this book are
obtained by following several practice periods and studies with the following
teachers: Pandit Kanta Prashad Mishra, Brahmin and Hindu monk, and
Pandit Marco Shivchandra Parolini, Brahmin and Hindu monk, from Vara-
nasi Benares, India. In conclusion, I recognize that the Eastern religious
knowledge would not have been possible without their assistance.
I greatly thank my colleagues and friends of Agra University in India, Dr.
Anirudh Kumar Satsangi, director of the Dayalbagh Educational Institute,

xxi
xxii Clinical Hypnosis in Pain Therapy and Palliative Care

and Dr. Siddharth Agarwal, M.D., for willingly sharing our researches about
meditative stages and clinical hypnosis.
I am very grateful to all the Professors of Nanjing University of Tra-
ditional Chinese Medicine (NJUCM); I attended NJUCM in China in 2007
to improve my knowledge in traditional Chinese medicine (TCM) and my
spiritual life in my practice of Chinese medicine, receiving TAO in Italy,
2013.
Very special thanks go out to my friends and English teachers Gary
Judge, Vlatka Kalecak, Ricci Gementiza, Letizia Fenzi Stephenson, and Dr.
Stefania Dodoni for helping me in translations; it was a pleasure to collabo-
rate with you.
Furthermore, I would like to extend my gratitude to Professor Harvey
Max Chochinov. He is internationally recognized as a leader in palliative
care research; he is professor of psychiatry at the University of Manitoba and
Director of the Manitoba Palliative Care Research Unit, Canada. Thank you,
Harvey, for your enthusiasm in sharing your vast knowledge and, then, our
conversations about dignity therapy in palliative care.
It is a great pleasure to thank my colleagues and friends: Professor Enrico
Polati, director of the Unit Anesthesiology, Critical Care and Pain Therapy
at Verona University, and Dr. Vittorio Schweiger, chief of the pain therapy
team, for having offered me the opportunity of working with the university
team of pain therapy in Verona and developing exciting research projects.
I would also like to thank my publisher, Michael Thomas, and all those
who helped this book to become a reality. There are no words that can
express the gratitude I feel toward these special people.
Finally, thanks to all my angels who have left this world but are close to
me every day (especially my brother Michele) and the One, who perfectly
manifests creative excellence and love. Thank you God, for giving me anoth-
er day, another chance to give and experience love and awareness. Thank
you for the energy that feeds my soul. Stay connected to me today and al-
ways. God, make me a channel of your energy and help me understand suf-
fering people. Keep us all close to you.
 CONTENTS

Page
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Chapter
I. CONSCIOUSNESS IN CLINICAL HYPNOSIS AND
MINDFULNESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1. PHILOSOPHY, NEUROPHYSIOLOGY AND NEURO-
PSYCHOLOGY OF CONSCIOUSNESS . . . . . . . . . . . . . . . . . 3
A. What is Consciousness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
B. The Philosophy of Consciousness: The “Hard” and the
“Easy” Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
C. Qualia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
D. Neurophysiology of Consciousness and Quantum
Consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2. CONSCIOUSNESS IN PAIN AND SUFFERING
RELIEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. INTRODUCTION TO CONSCIOUSNESS, HIGHER
CONSCIOUSNESS AND AWARENESS . . . . . . . . . . . . . . . . . 17

II. PAIN AND SUFFERING: NEUROPHYSIOLOGICAL

AND BEHAVIORAL ASSESSMENT . . . . . . . . . . . . . . . . . . . . . 27
1. PAIN DEFINITION (IASP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2. NEUROPHYSIOLOGY AND NEUROPSYCHOLOGY
OF PAIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3. CLASSIFICATION OF PAIN TYPES . . . . . . . . . . . . . . . . . . . 30
4. PAIN MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

xxiii
xxiv Clinical Hypnosis in Pain Therapy and Palliative Care

5. PAIN EVALUATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
A. Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
B. Pain Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6. THE PSYCHOLOGICAL AND COGNITIVE/
BEHAVIOR STRATEGIES IN PAIN THERAPY AND
PALLIATIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
A. The Dignity Therapy in Palliative Care . . . . . . . . . . . . . . . . . 42
B. Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
C. Clinical Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
D. Meditative States and Mindfulness . . . . . . . . . . . . . . . . . . . . . 49

III. THE RELATIONSHIP BETWEEN CLINICAL

HYPNOSIS AND MINDFULNESS: A NEW
CLASSIFICATION OF MODIFIED STATES OF
CONSCIOUSNESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
INTRODUCTION: THE MODIFIED STATES OF
CONSCIOUSNESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
1. ACTIVE CONCENTRATION: TYPES AND
TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
A. Awake State, Wakefulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
B. Relaxed Awakening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
C. The Progressive Muscle Relaxation of Edmund
Jacobson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
D. The Light Sleep (Consciousness and the Stages of Sleep) . . . 83
E. Repetitive Vocal and Mental Prayer . . . . . . . . . . . . . . . . . . . . 84
F. The Exercises and the Postures of Yoga . . . . . . . . . . . . . . . . . 86
2. PASSIVE CONCENTRATION: TYPES AND
TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
A. Autogenic Training of Schultz . . . . . . . . . . . . . . . . . . . . . . . . . 90
B. Light Hypnosis, Medium Hyponosis, and
Self-Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
C. Lucid Dreams, Hypnagogic, and Hypnopompic
States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
D. The REM Phase of Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
E. Free Mental Prayer and Mental Meditation . . . . . . . . . . . . . 101
F. The Breathing Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
3. DEEP CONCENTRATION: TYPES AND
TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
A. Deep Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
 Contents xxv

B. Extreme Thoughts: A Clear Mind, The Flow States . . . . . . 110

C. Medium Self-Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
D. Deep Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
E. Meditative Stages of Contemplation and
Mindfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4. SUPERIOR CONCENTRATION (HIGHER
CONSCIOUSNESS): TYPES AND TECHNIQUES . . . . . . 115
A. Medium to Deep Self-Hypnosis: Annulment of the
Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
B. The Higher Consciousness . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
C. Absorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
D. The Meditative Stages: Awareness, Contemplation and
Ecstasy, Living with God . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
5. TRUE CONCENTRATION OR AWARENESS
ACTIVATION: TYPES AND TECHNIQUES . . . . . . . . . . . . 126
A. Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
B. Deep Self-Hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
C. Contemplation and Mystical States Leading to
Spiritual Enlightenment: Samadhi, Living in God . . . . . . . . 129

IV. CLINICAL HYPNOSIS TECHNIQUES IN PAIN AND

PALLIATIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
1. THE TECHNIQUES OF PAIN ANALGESIA WITH
CLINICAL HYPNOSIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
A. The Benefits of Hypnosis in Pain . . . . . . . . . . . . . . . . . . . . . 142
B. What is Hypnosis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
C. What Happens During the First Visit of the
Hypnotherapist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
D. The Techniques of Pain Analgesia with Hypnosis . . . . . . . . 148
2. DEEP HYPNOSIS IN PAIN AND SUFFERING
RELIEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
A. The Deep Self-Hypnosis and Deepening Techniques to
Achieve Deeper Levels of Trance . . . . . . . . . . . . . . . . . . . . . 155
3. CLINICAL HYPNOSIS IN PALLIATIVE CARE . . . . . . . . . 158
4. THE TECHNIQUE OF HYPNOSIS FOR THE
ACTIVATION OF SPIRITUAL AWARENESS . . . . . . . . . . . 161
xxvi Clinical Hypnosis in Pain Therapy and Palliative Care

V. MINDFULNESS AND MEDITATIVE STATES IN

SPIRITUAL CARE: TYPES AND TECHNIQUES . . . . . . . . . . 179
1. BUDDHISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
A. The Experience of Enlightenment (it is in Buddhism) . . . . . 183
B. The Four Noble Truths of Buddhism . . . . . . . . . . . . . . . . . . 184
C. The Noble Eightfold Path . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
D. The Four Noble Truths State . . . . . . . . . . . . . . . . . . . . . . . . . 187
E. Nondualism is the Belief that Dualism or Dichotomy is
Illusory Phenomena . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
F. The Way to Enlightenment . . . . . . . . . . . . . . . . . . . . . . . . . . 188
G. The Seven Steps Buddhist Breath Meditation . . . . . . . . . . . 188
2. ZEN BUDDHISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
A. Zen Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
B. The Zen Meditation Technique . . . . . . . . . . . . . . . . . . . . . . . 192
3. CHRISTIAN MEDITATION . . . . . . . . . . . . . . . . . . . . . . . . . . 194
A. St. Francis of Assisi’s Vocation Prayer . . . . . . . . . . . . . . . . . . 195
B. Mystical Experiences and Unconscious Mind . . . . . . . . . . . 197
C. The Way of Meditation is the Way of Silence . . . . . . . . . . . 198
D. The Lectio Divina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
E. Practicing Holy Reading, Lectio Divina . . . . . . . . . . . . . . . . 200
4. HINDUISM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
A. The Language of Consciousness . . . . . . . . . . . . . . . . . . . . . . 201
B. The Yoga Sutras of Patanjali . . . . . . . . . . . . . . . . . . . . . . . . . 203
C. The Nonduality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
D. The Vedas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
E. Raja Yoga Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
F. Kriya Yoga Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
G. Vipassana Meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
H. Yoga-nidra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
5. ISLAM MEDITATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
A. Meditation in the Sufi Traditions . . . . . . . . . . . . . . . . . . . . . . 220
B. Annihilation, The State of Oneness with the Holy
Prophet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
6. JAINISM: JAIN SADHVIS MEDITATING . . . . . . . . . . . . . . 221
A. The Navkar Mantra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
7. JUDAISM AND KABBALAH MEDITATION . . . . . . . . . . . 223
A. What is Kabbalah? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
B. The Aim of Kabbalah Meditation . . . . . . . . . . . . . . . . . . . . . 224
 Contents xxvii

8. NATIVE AMERICANS SPIRITUALITY AND

PRAYERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
A. The Circle of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
B. Native American’s Words of Wisdom . . . . . . . . . . . . . . . . . . 229
C. Ancient Lakota Instructions for Living . . . . . . . . . . . . . . . . . 231
9. TAOISM’S WU WEI MEDITATION . . . . . . . . . . . . . . . . . . . 231
A. The Way . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
B. The Three Treasures SAN BAO: Essence (Body),
Energy (Breath), and Spirit (Mind) . . . . . . . . . . . . . . . . . . . .234
C. Taoist Meditations (it is Taoism) . . . . . . . . . . . . . . . . . . . . . . 236
D. The Enlightening in Taoist Meditation (it is Taoism) . . . . . . 238

VII. CLINICAL HYPNOSIS, MINDFULNESS AND

MUSIC THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
1. NEUROPHYSIOLOGY OF MUSIC . . . . . . . . . . . . . . . . . . . 244
2. NEUROPSYCHOLOGY OF MUSIC . . . . . . . . . . . . . . . . . . . 247
A. The Main Psychophysiological Elements of Music in
Assagioli’s Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
B. Music as Help/Supplement to Clinical Hypnosis and
Mindfulness in Pain Therapy and Palliative Care . . . . . . . . 253
3. MUSIC AND THE HIGHER CONSCIOUSNESS . . . . . . . 255
A. Music and the Self-hypnosis Technique . . . . . . . . . . . . . . . . 257
4. MUSIC AND MINDFULNESS . . . . . . . . . . . . . . . . . . . . . . . . 260
A. Mindfulness and the Chanting of Om . . . . . . . . . . . . . . . . . 262
B. The Technique of Inner Silence . . . . . . . . . . . . . . . . . . . . . . 264

VIII. CLINICAL HYPNOSIS, MINDFULNESS AND THE

LANGUAGE OF METAPHORS . . . . . . . . . . . . . . . . . . . . . . . . . 269
1. ALLEGORIES AND METAPHORS IN POETRY
AND SPIRITUAL VERSES . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
A. Is Poetry Mindfulness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
B. Hypnosis and Allegory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
C. Hypnosis and Poetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
D. The Movement of the Verses and Rhythm in
Hypnosis Suggestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
2. METAPHORS, SPIRITUAL VERSES, POETRY,
HYPNOSIS AND FIGURES OF SPEECH . . . . . . . . . . . . . . 277
xxviii Clinical Hypnosis in Pain Therapy and Palliative Care

3. CLINICAL HYPNOSIS, MINDFULNESS AND THE

LANGUAGE OF METAPHORS: THE TECHNIQUES . . . 280
A. Metaphors and Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

VIII. RELAXATION AND HYPNOSIS IN PEDIATRIC

PATIENTS: TECHNIQUES FOR PAIN RELIEF AND
PALLIATIVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
1. PAIN THERAPY AND PALLIATIVE CARE IN
INFANTS AND CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . 295
A. Neurophysiology and Neuropsychology of Pain in
Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
B. Pain Assessment and Management in Children . . . . . . . . . . 302
C. Pain Treatment in Children . . . . . . . . . . . . . . . . . . . . . . . . . . 304
D. Psychological and Behavioral Factors in Pain Treatment
in Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . 306
2. PERCEPTION, CONSCIOUSNESS, AND HYPNOSIS
IN PEDIATRIC AGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
A. Perception and Mind in Children . . . . . . . . . . . . . . . . . . . . . 308
3. DISTRACTION, RELAXATION, AND HYPNOSIS
TECHNIQUES FOR CHILDREN . . . . . . . . . . . . . . . . . . . . . 316
A. Distraction Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
B. Relaxation Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
C. Clinical Hypnosis Techniques for Children . . . . . . . . . . . . . 328

IX. CONCLUSION: QUANTUM PHYSICS AND

MODIFIED STATES OF CONSCIOUSNESS: THE
MIND BEYOND MATTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
1. THE HUMAN BEING AND THE RELATIONSHIP
BETWEEN BODY, MIND AND SPIRIT . . . . . . . . . . . . . . . 352

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
 CLINICAL HYPNOSIS IN PAIN
THERAPY AND PALLIATIVE CARE
 Chapter I

CONSCIOUSNESS IN CLINICAL
HYPNOSIS AND MINDFULNESS

1. PHILOSOPHY, NEUROPHYSIOLOGY AND

NEUROPSYCHOLOGY OF CONSCIOUSNESS

A. What is Consciousness?
onsciousness poses the most enigmatic problems in the science of the
C mind. Consciousness is a term concerning the ability to perceive; to
feel; or to be conscious of events, objects, or patterns, which does not neces-
sarily imply understanding. “I see nothing but Becoming. It is the fault of
your limited outlook and not the fault of the essence of things if you believe
that you see firm land anywhere in the ocean of Becoming and Passing”
(Heraclitus, 500 B.C.).
I find the unification of ancient metaphysics and philosophy with mod-
ern physics and cosmology very fascinating and inspiring. Certainly, it is
now clear that matter interacts with all other matter in the universe. The
wave structure of matter provides a very simple sensible explanation of why
this is so. “There is nothing that we know more intimately than conscious
experience, but there is nothing that is harder to explain. All sorts of mental
phenomena have yielded to the scientific investigation in recent years, but
consciousness has stubbornly resisted” (Chalmers, 1995).
Although in general speech, we tend to use the terms awareness and con-
sciousness to represent basically the same thing, I use them here with some-
what different meanings.
In medicine, consciousness is assessed by observing a patient’s arousal
and responsiveness and can be seen as a continuum of states ranging from
full alertness and comprehension; through disorientation, delirium, loss of

3
4 Clinical Hypnosis in Pain Therapy and Palliative Care

meaningful communication; and finally to loss of movement in response to

painful stimuli.
In recent years, consciousness has become a significant topic of research
in psychology and neuroscience. The primary focus is on understanding
what it means biologically and psychologically for information to be present
in consciousness, that is, on determining the neural and psychological corre-
lates of consciousness. Consciousness is the quality or state of being aware of
external neurophysiological stimuli or object or something within oneself.
The philosophy of the mind has given rise to many stances regarding
consciousness. In this book, I analyze how we can use the modified states of
consciousness in clinical hypnosis, meditative states, and mindfulness to re-
lief pain and suffering.
Awareness is much more than consciousness; it is the state or ability to
perceive; to feel; or to be conscious of events, objects, or sensory patterns. In
this higher level of consciousness, sense data can be confirmed by an observ-
er without necessarily implying understanding. More broadly, it is the state
or quality of being aware of something.
Through the different modified states of consciousness, we can reach
higher consciousness and awareness: it refers to the awareness or knowledge
of an ultimate reality that traditional theistic religions have named God and
Gautama Buddha referred to as the unconditioned element and knowledge.

B. The Philosophy of Consciousness:

The “Hard” and the “Easy” Problems
According to the philosopher David Chalmers (1995), there is not just
one problem of consciousness. Consciousness is an ambiguous term, refer-
ring to many different phenomena. Each of these phenomena needs to be
explained, but some are easier to explain than others. Chalmers divides the
associated problems of consciousness into “hard” and “easy” problems. The
easy problems of consciousness are those that seem directly susceptible to
the standard methods of cognitive science, whereby a phenomenon is ex-
plained in terms of calculative or neural mechanisms. The easy problems of
consciousness include those of explaining the following phenomena:

• the ability to be discriminate, categorize, and react to environmental

stimuli
• the integration of knowledge by a neurocognitive system
• the different mental states
• the capacity of a system to access its own internal states
• the focus of attention
 Consciousness in Clinical Hypnosis and Mindfulness 5

• the control of behavior

• the difference between wakefulness, hypnosis and sleep

The hard problems are those that seem to resist those methods: the real-
ly hard problem of consciousness is the problem of experience and knowl-
edge.
There is no real matter about whether these phenomena can be ex-
plained scientifically. All of them are straightforwardly vulnerable to an ex-
planation in terms of computational or neural mechanisms. Consciousness
generally refers to awareness in a much more complex way; consciousness is
awareness as modulated by the structure of the mind. Mind refers to the
totality of both inferable and potentially experienced phenomena, of which
awareness and consciousness are components.
I agree with Charles Tart (1972) that awareness refers to the basic knowl-
edge that something is happening, to perceiving or feeling or cognizing in its
simplest form. What are the conscious sensations that accompany neural ac-
tivities of the brain? Can we share the problem of consciousness only bio-
logically or should we develop other methods?
This book is organized in order to show the scientific neurophysiological
theories currently in use regarding the many modalities of consciousness
states. Consequently, I have chosen to describe many different states of con-
centration, relaxation, hypnosis, mindfulness, and meditative states to help
patients in pain and suffering relief. I will purposefully not examine the
pathological modified states of consciousness, such as coma states or states of
modified consciousness through drugs or medicines.
Popular ideas about consciousness suggest the phenomenon describes a
condition of being aware of one’s awareness, or self-awareness. Efforts to
explain consciousness in neurological terms have focused on describing net-
works in the brain that increase awareness of the qualia, developed by other
networks.

C. Qualia
“Qualia” (singular “quale,” from the Latin for “sort of” or “what kind”) is
a term used in philosophy, to describe the subjective quality of conscious
experience. Examples of qualia are the pain of a headache, the taste of wine,
or the redness of an evening sky. Daniel Dennett (1991) writes that qualia is
“an unfamiliar term for something that could not be more familiar to each of
us: the ways things seem to us.”
Balduzzi and Tononi (2009) studied a new theory of consciousness ex-
plained by qualia at the Department of Psychiatry, University of Wisconsin,
6 Clinical Hypnosis in Pain Therapy and Palliative Care

Madison, WI, USA. According to their integrated information theory, the

quantity of consciousness is the amount of integrated information generated
by a complex of elements, and the quality of the experience is specified by
the informational relationships it generates.
Their study outlines a structure for characterizing the informational rela-
tionships generated by such systems. They think that qualia space (Q) is a
space having an axis for each possible state (activity pattern) of a complex.
Within Q, each submechanism specifies a point corresponding to a reper-
toire of system states. Arrows between repertoires in Q define informational
relationships. Together, these arrows specify a quale: a shape that complete-
ly and univocally characterizes the quality of a conscious experience. Qualia
is the quantity of consciousness associated with the experience and knowl-
edge.
There are several conclusions from these premises: the quale is deter-
mined by both the mechanism and the state of the system. Thus, two distinct
systems having identical activity patterns may generate different qualia.
Conversely, the same quale may be generated by two systems that differ in
both activity and connectivity. Both active and inactive elements specify a
quale, but elements that are inactivated do not. Furthermore, the activation
of an element affects the experience by changing the shape of the quale. The
present framework may offer a good way for translating qualitative proper-
ties of experience into mathematics and biophysics.
Basic awareness of one’s and external world depends on the brainstem.
“Higher” forms of consciousness and awareness, including self-awareness,
require cortical inputs. The “primary consciousness” or “basic awareness” as
an ability to integrate sensations from the background of one’s immediate
goals and feelings in order to guide behavior springs from the brainstem,
which human beings share with most of the vertebrates.
Psychologist Carroll Izard emphasizes that this form of primary con-
sciousness consists of capacity to generate emotions and an awareness of a
one’s not an ability to talk about what one has experienced. In the same way,
people can become conscious of a feeling that they cannot describe, a phe-
nomenon that is especially common in infants.
Daniel Dennett (1991) identifies four properties that are commonly as-
cribed to qualia.
According to Dennet, qualia are

• ineffable; that is, they cannot be communicated or apprehended by any

other means than direct experience
• intrinsic; that is, they are nonrelational properties that do not change
depending on the experience’s relation to other things
 Consciousness in Clinical Hypnosis and Mindfulness 7

• private; that is, all interpersonal comparisons of qualia are systemati-

cally impossible
• directly; or immediately apprehensible in consciousness; that is, to ex-
perience a quale is to know one experiences a quale and to know all
there is to know about that quale.

D. Neurophysiology of Consciousness
and Quantum Consciousness
Consciousness depends on spontaneously emitted pulses from brainstem
neurons that ascend in a complex mesh of activating circuits to awaken neu-
rons in the limbic system, thalamus, and cerebral cortex. Without this as-
cending activation, humans lapse into a coma. Damasio (1994) has suggest-
ed that whereas the senses of vision, hearing, touch, taste, and smell function
by nerve activation patterns that correspond to the state of the external world,
emotions are nerve-activation patterns that correspond to the state of the
internal world. If we experience a state of fear, our brains subsequently will
record this body state in nerve cell-activation patterns obtained from neural
and hormonal feedback, and this information may, then be used to adapt
behavior appropriately.
Four neurotransmitters appear to be most important in creating con-
sciousness: norepinephrine, serotonin, dopamine, and acetylcholine. Drugs
such as anesthetics, which interrupt consciousness, interfere with cortical ac-
tivation (Vertes, 2002). In their review of ten years of studying the connec-
tions of thalamic nuclei in rats, Van der Werf, Witter, and Groenewegen
(2002) stated, “The thalamic midline and intralaminar nuclei, long thought
to be a non-specific arousing system in the brain, have been shown to be
involved functions seems to be a role in awareness.” They proposed that the
midline and intralaminar nuclei mediate awareness.
Each of the groups has a distinct role in a different aspect of awareness:
there are separate and definite brain functions, such as specific cognitive,
sensory and motor functions. They ar fundamental to the participation of the
midline and intralaminar nuclei:

1. a dorsal group, consisting of the paraventricular, paratenial, and inter-

mediodorsal nuclei, involved in visceral-limbic functions
2. a lateral group comprising the central lateral and paracentral nuclei
and the anterior part of the central medial nucleus, involved in cogni-
tive functions
8 Clinical Hypnosis in Pain Therapy and Palliative Care

3. a ventral group made up of the reuniens and rhomboial nuclei and the
posterior part of the central medial nucleus, involved in multimodal
sensory processing
4. a posterior group consisting of the central medial and parafascicular
nuclei, involved in limbic motor functions.

Because the thalamus is so complexly interconnected with all other parts of

the brain, a thalamic model of executive function is misleading, to some ex-
tent. A combination of frontal lobe and thalamic circuits are essential, for ex-
ample, for anticipatory planning, one of the more recent and complex attrib-
utes of cognition (Van der et al., 2002).
In 1989, Roger Penrose published his first book on consciousness, The
Emperor’s New Mind (1989b). Based on Godel’s incompleteness theorems,
Penrose argued that the brain could perform functions that no computer or
system of algorithms could. From this, it could follow that consciousness
itself might be fundamentally nonalgorithmic and incapable of being mod-
eled as a classical Turing machine type of computer. By contrast, the idea that
it could be explained mechanistically was prevalent in the field of artificial
intelligence at that time.
Roger Penrose saw the principles of quantum theory as providing an al-
ternative process through which consciousness could originate. He further
argued that this nonalgorithmic process in the brain required a new form of
the quantum wave reduction, later given the name objective reduction (OR),
which could link the brain to the fundamental space-time geometry. At this
stage, he had no precise ideas as to how such a quantum process might be
instantiated in the brain (Penrose, 1989a).
Penrose went on to consider what it was in the human brain that might
not be driven by algorithms. The physical law is described by algorithms, so
it was not easy for Penrose to come up with physical properties or processes
that are not described by them. He was forced to look to quantum theory for
a plausible candidate. In quantum theory, the fundamental units, the quanta,
are in some respects quite unlike objects that are encountered in the large-
scale world described by classical physics. When sufficiently isolated from
the environment, they can be viewed as waves. These are different from mat-
ter waves, such as waves in the sea however. The quantum waves are essen-
tially waves of probability, the varying probability of finding a particle at
some specific position. The peak of the wave indicates the location with max-
imum probability of a particle being found there. The different possible posi-
tions of the particle are referred to as superpositions or quantum superposi-
tions. We are speaking here of the isolated form of the quanta. When the
quanta are the subject of measurements or of interaction with the environ-
 Consciousness in Clinical Hypnosis and Mindfulness 9

ment, the wave characteristic is lost, and a particle is found at a precise point.
This change is commonly referred to as the collapse of the wave function.
When the collapse happens, the choice of position for the particle is ran-
dom. This is a drastic departure from classical physics. There is no cause-
and-effect process and no system of algorithms that can describe the choice
of position for the particle. This provided Penrose with a candidate for the
physical basis of the suggested noncomputable process that he proposed as
possibly existing in the brain.
Penrose now proposed that existing ideas on the wave function collapse
might only apply to situations in which the quanta are the subject of mea-
surement or of interaction with the environment. He considered the case of
quanta that are not the subject of measurements or interactions but remain
isolated from the environment and proposed that these quanta may be sub-
ject to a different form of wave function collapse.
In this area, Penrose draws on both Einstein’s general theory of relativity
and on his own notions about the possible structure of space-time (Penrose,
1989a,b). General relativity states that space-time is curved by massive
objects. Penrose, in seeking to reconcile relativity and quantum theory, has
suggested that at the very small scale, this curved space-time is not continu-
ous but constitutes a form of network. Penrose postulates that each quantum
superposition has its own piece of space-time curvature. According to his the-
ory, these different bits of space-time curvature are separated from one an-
other and constitute a form of blister in space-time.
Stuart Hameroff was inspired by Penrose’s book to contact Penrose
regarding his own theories about the mechanism of anesthesia and how it
specifically targets consciousness via action on neural microtubules. Hamer-
off’s contribution to the theory was derived from studying brain cells (neu-
rons). His interest centered on the cytoskeleton, which provides an internal
supportive structure for neurons, and particularly on the microtubules (Ham-
eroff, 1987), which are the important component of the cytoskeleton. As neu-
roscience has progressed, the role of the cytoskeleton and microtubules has
assumed greater importance. In addition to providing a supportive structure
for the cell, the known functions of the microtubules include transport of
molecules, including neurotransmitter molecules bound for the synapses,
and control of the cell’s movement, growth, and shape (Hameroff, 1987).
Hameroff (1987) proposed that microtubules were suitable candidates to sup-
port quantum processing.
The two met in 1992, and Hameroff suggested that the microtubules
were a good candidate site for a quantum mechanism in the brain. Penrose
was interested in the mathematical features of the microtubule lattice, and
over the next two years the two collaborated in formulating the orchestrated
10 Clinical Hypnosis in Pain Therapy and Palliative Care

objective reduction (Orch-OR) model of consciousness.

Mainstream theories assume that consciousness emerges from the brain
and focus particularly on complex computation at connections known as
synapses that allow communication between brain cells (neurons).
In the case of the electrons in the tubulin subunits of the microtubules,
Hameroff has proposed that great numbers of these electrons can become
involved in a state known as a Bose-Einsten condensate. These occur when
large numbers of quantum particles become locked in phase and exist as a
single quantum object. These are quantum features at a macroscopic scale,
and Hameroff suggests that a feature of this kind quantum activity, which is
usually at a very tiny scale, could be boosted to be a large-scale influence in
the brain. Hameroff has proposed that condensates in microtubules in one
neuron can link with microtubule condensates in other neurons and glial
cells via gap junctions (Hameroff, 1987, 2008, 2010).
In addition to the synaptic connections between brain cells, gap junctions
are a different category of connections, where the gap between the cells is
sufficiently small for quantum objects to cross it by a process known as quan-
tum tunneling. Hameroff proposes that this tunneling allows a quantum
object, such as the Bose-Einstein condensates, to cross into other neurons
and thus extend across a large area of the brain as a single quantum object.
He further postulates that the action of this large-scale quantum feature is the
source of the gamma synchronization observed in the brain, and sometimes
viewed as a neural correlate of consciousness (Bennett & Zukin, 2004). In
support of the much more limited theory that gap junctions are related to the
gamma oscillation, Hameroff quotes a number of studies from recent years
(Buhl, Harris, Hormuzdi, Monyer, & Buzsáki, 2003; Fries, Schröder,
Roelfsema, Singer, & Engel, 2002).
Antonio Damasio theorized extended consciousness to arise in the struc-
tures in the human brain he described as image spaces and dispositional
spaces (2004). Image spaces imply areas where sensory impressions of all
types are processed, including the focused awareness of the core conscious-
ness. Dispositional spaces include convergence zones, which are networks in
the brain where memories are processed and recalled and where knowledge
is merged with immediate experience. The image processing in the cere-
brum is regionally specific to various senses but is highly distributed and
interconnected, with images such as visual, spatial, and perhaps linguistic im-
pressions stored in diverse areas then assembled when recalled as a thought.
Most humans are so proficient at reading printed words that they cannot
easily ignore them. In fact, it takes considerable attentional effort to do so.
This tendency to quickly read a word is used in the Stroop task. The Stroop
ask is a psychological test of our mental (attentional) vitality and flexibility.
 Consciousness in Clinical Hypnosis and Mindfulness 11

The task takes advantage of our ability to read words more quickly and auto-
matically than we can name colors, if a word is printed or displayed in a
color different from the color it actually names. The cognitive mechanism
involved in this task is called directed attention; you have to manage your
attention by inhibiting or stopping one response in order to say or do some-
thing else.
Recent data indicate that, under a specific posthypnotic suggestion to cir-
cumvent reading, greatly suggestible subjects successfully eliminated the
Stroop interference effect. Stroop data were collected from six greatly hyp-
notizable and six not as suggestible subjects using an optical setup that guar-
anteed either sharply focused or blurred vision. The highly suggestible per-
formed the Stroop task when naturally vigilant, under posthypnotic sugges-
tion not to read, and while visually blurred. The less suggestible ran natural-
ly vigilant, while looking for another place and visually blurred. Although
visual accommodation was precluded for all subjects, posthypnotic sugges-
tion effectively eliminated Stroop interference and was comparable to look-
ing away in controls. “These data strengthen the view that Stroop interfer-
ence is neither robust nor inevitable and support the hypothesis that post-
hypnotic suggestion may exert a top-down influence on neural processing”
(Raz, 2012; Raz et al., 2003).
Although humans are theorized to share extended consciousness with
some animals, theorized neural mechanisms for extended consciousness do
not provide answers to philosophical or cosmological questions about con-
sciousness, such as why we perceive ourselves as a limited part of a larger
universe.
There are many theories of consciousness. Perhaps the largest division is
between general metaphysical theories that aim to locate consciousness in
the overall ontological scheme of reality and more specific theories that offer
detailed accounts of its nature, features, and role. The line between the two
sorts of theories blurs a bit, especially insofar as many specific theories carry
at least some implicit commitments on the more general metaphysical issues.
Nonetheless, it is useful to keep the division in mind when surveying the
range of current theoretical offerings (Van Gulick, 2004).
Even if our neurophysiological knowledge should one day enable us to
identify the exact neurochemical correlation of a psychic phenomenon, we
must not forget that neurochemical knowledge is not sufficient to explain all
the subjective experiences in people. A major turning point in philosophers’
interest in neuroscience came with the publication of Patricia Churchland’s
Neurophilosophy (1986). The Churchlands (Pat and husband Paul) were al-
ready notorious for advocating eliminative materialism. In her (1986) book,
Churchland distilled eliminativist arguments of the past, unified the pieces of
12 Clinical Hypnosis in Pain Therapy and Palliative Care

the philosophy of science underlying them, and sandwiched the philosophy

between a five-chapter introduction to neuroscience and a seventy-page
chapter on three then-current theories of brain function. She was unapolo-
getic about her intent. She was introducing philosophy of science to neuro-
scientists and neuroscience to philosophers (Bickle, 2003).
Consciousness depends on spontaneously emitted pulses from brainstem
neurons that ascend in a complex mesh of activating circuits to awaken neu-
rons in the limbic system, thalamus, and cerebral cortex. Without this
ascending activation, humans lapse into a coma. Four neurotransmitters ap-
pear to be most important in creating consciousness: norepinephrine, sero-
tonin, dopamine, and acetylcholine. Drugs such as anesthetics that interrupt
consciousness interfere with cortical activation. Pulses of electrical activation
are accompanied by pulses of chemicals released to topically activate regions
of the brain. The thalamus, in turn, activates the cerebral cortex and links all
subsystems in meaningful packages of activity that deliver monitor images of
their activity to consciousness. The cortical neurons return signals to the thal-
amus, so the cortical activation can be regarded as a looping system that
recurs and resonates (Vertes, 2002).
The physicist and mathematician John Taylor observed, “the study of
consciousness is like a black hole for those that study it. Once the scientific
study is done they lose sight of their normal scientific activity and give an
explanation of the phenomena that does not correspond to a scientific expla-
nation” (Taylor, 2000).
Our ordinary state of consciousness is not something natural or given,
but a highly complex construction, a specialized tool for coping with our
environment and the people in it (Tart, 1972). Many have tried to explain
consciousness, but the explanations always seem to fall short of the target.
The ambiguity of the term “consciousness” is often exploited by both phil-
osophers and scientists writing on the subject (Chalmers, 1995).
In his neurophysiological studies, the scientist Antonio Damasio offers a
thought-provoking view of consciousness centered on feelings. Through his
arguments, we found that there is much to learn from neuropathology about
different levels of consciousness. There is more work to do on psychological
levels and the corresponding neural structures (Mosca, 2000).
Several techniques can be used to achieve a mental and physical state of
relaxation and the different states of consciousness. Hypnosis is a state of
heightened awareness and focused concentration. Some call it a trance; some
call it an altered state of consciousness, during which your attention is turned
inward, allowing you to be more open to new feelings and to the inner self.
 Consciousness in Clinical Hypnosis and Mindfulness 13

2. CONSCIOUSNESS IN RELIEF OF PAIN AND SUFFERING

The field of pain and suffering has undergone a great revolution, and this
volume reflects these exciting advances. We are so accustomed to viewing
pain as a sensory phenomenon that we have long ignored the fact that injury
does more than produce pain; it also disrupts the brain’s homeostatic regu-
lation system, thereby producing stress and initiating complex programs to
reinstate homeostasis. Stress and suffering can be defined as an activation of
the limbic system of the central nervous system (CNS) that then activates
neurohumoral mechanisms of arousal. Stress produced by painful experi-
ences initiates a cascade of neurophysiological, humoral, and phenomeno-
logical events that challenge our understanding but also provide valuable
clues in dealing with chronic pain (Melzack, 1998, 1999).
Pain and suffering, especially associated with advancing and incurable
illness, inevitably cause distress for patients, families, and caregivers. A psy-
chological and spiritual approach to care aims to improve the quality of life
for patients with a life-limiting illness. We can reduce suffering through early
identification, assessment, and optimal management of pain, providing to the
patient physical, psychological, social, and spiritual needs.
The psychological counterparts to the chronic pain state include depres-
sion, anxiety, and other affective states and are keys to understanding the dis-
ability associated with this condition (Cleeland & Syrjala, 1992).
The oldest and persistent questions of humanity are why sorrow, why
suffering? How can individuals triumph over adversities? What can be done
to transform despair to hope, pain to comfort, and sorrow to joy? What are
the roles of religion, science, and medicine?
What are the explanations of neuroscience? How is it that the instru-
ments used by neuroscientists (e.g. neuroimaging, cell recordings, genetic
manipulations, simulations) yield knowledge? What is a neuroscientific
explanation of consciousness? What is the meaning of pain, sickness, and
death? Why is the world full of troubles and pain?
Valerie Hardcastle (1997) focused her study on the anatomy and physi-
ology of the pain transmission system. Hardcastle proposes a dissociable
dual system of pain transmission consisting of a pain sensory system closely
analogous in its neurobiological implementation to other sensory systems
and a descending pain inhibitory system. She argues that this dual system is
consistent with recent neuroscientific discoveries and accounts for all the
pain phenomena that have tempted philosophers toward particular theories
of pain experience.
The neurobiological uniqueness of the pain inhibitory system, contrast-
ed with the mechanisms of other sensory modalities, renders pain processing
14 Clinical Hypnosis in Pain Therapy and Palliative Care

atypical. In particular, the pain inhibitory system dissociates pain sensation

from stimulation of nociceptors (pain receptors). Hardcastle concludes from
the neurobiological uniqueness of pain transmission that pain experiences
are atypical conscious events and hence not a good place to start theorizing
or generalizing (Bickle, 2003).
Ronald Melzack is a legend in the field of pain science. Together with
Patrick Wall, he introduced the gate control theory from which thousands of
research studies have sprung (Melzack & Wall, 1965). Melzack’s later neuro-
matrix theory of pain proposes that pain is a multidimensional experience,
produced by characteristic “neurosignature” patterns of nerve impulses, gen-
erated by a widely distributed neural network—the “body-self neuromatrix”—
in the brain. These neurosignature patterns may be triggered by sensory in-
puts, but they may also be generated independently of them. The neuroma-
trix, which is genetically determined and modified by sensory experience, is
the primary generating mechanism of the neural pattern, responsible for the
production of pain. The neuromatrix theory is evolving and the brain func-
tions and mechanisms in this schema still need to be elucidated.
The pain theories have traveled from the peripheral pain fibers to pain
as a “feeling” state. This is paralleled by the evolution of the treatment of
pain in pharmacology and psychology. The science of pain continues to ex-
plore the genetic, endocrine, and immune systems, all of which may con-
tribute to the neuromatrix (Melzack, 2001, 2002; Melzack & Wall, 1965).
Perhaps one of the hardest things in life is coping with illness, pain, and
suffering. Chronic pain and suffering can have devastating effects on pa-
tients’ quality of life. The specialty of pain management has developed in
medicine and other disciplines to address the need for comfort, functional
restoration, and treatment of associated problems. The treatment of pain and
suffering includes a broad range of interventions that together help the pa-
tient and family maintain a good quality of life while living with the disease,
and allow the patient with advanced illness to face the end of life with com-
fort ensured, values and decisions respected, and family supported.
Should the anxiety symptoms associated with the stress in chronic pain
require only treatment with an anxiolytic drug? Tranquillizer and analgesic
medications are intensively marketed and continue to be heavily prescribed
worldwide. Inevitably, this practice can result in an increased psychological
and physical dependence on these types of medications. For well over 2000
years, noninvasive therapy in pain was practiced in every culture as a folk
tradition. It was all there: heat, cold, massage, manipulation, acupuncture, re-
flexology, mindfulness, prayer, meditation, and so on. Therapists need to
consider when they should incorporate different psychological approaches in
their management of people with pain and suffering.
 Consciousness in Clinical Hypnosis and Mindfulness 15

In this book, I will consider the treatment of pain and suffering with
modified states of consciousness, mindfulness, meditative states, and clinical
hypnosis therapy that could be used to help pharmacological and anesthesic
therapies, or in some cases substitute them completely.
Hypnosis, relaxation, and meditative techniques are used to achieve a
state of mental and physical relaxation. Mental relaxation means alleviation
of anxiety; physical relaxation means a reduction in skeletal muscle tension
and relief of suffering. Simple relaxation techniques should be used for epi-
sodes of brief pain, or in cases of chronic pain, during procedures, as well as
when the patient’s ability to concentrate is compromised by severe pain, a
high level of anxiety, or fatigue. Relaxation is a state of physical and emo-
tional calmness, the opposite of stress or “fight or flight” response. When you
are relaxed, your muscles are free of tension, and you feel little or no anxi-
ety or irritability. The hypnotic trance is a consciousness state of heightened
awareness and focused concentration that can be used to manipulate the per-
ception of pain and has been effective in the treatment of cancer-related pain
(Reeves, Redd, Storm, & Minagawa, 1983; Spiegel & Bloom, 1983; Syrjala,
Cummings, & Donaldson, 1992). Hypnosis is a condition of altered con-
sciousness state and attention in an individual, achieved by an induction
process. Hypnosis may help by altering the pain sensations, by directing the
person’s attention away from the pain, or by suggesting pain relief.
Our ordinary state of consciousness is not something natural or given but
a highly complex construction, a specialized tool for coping with our envi-
ronment and the people in it, a tool that is useful for doing some things but
not very useful, and even dangerous, for doing other things. Hypnosis is a
different state of consciousness (Tart, 1972). As an adjunct to psychotherapy,
hypnosis can help clients enter a relaxed, comfortable, trance state for ob-
taining specific therapeutic outcomes. With clinical hypnosis, the therapist
can make suggestions designed to help the client formulate specific internal
processes (feelings, memories, images and internal self-talk) that will lead to
mutually agreed upon outcomes. Hypnotic suggestions can influence behav-
ior when the listener is:

1. Relaxed, receptive, and open to the suggestions

2. Experiences visual, auditory, and/or kinesthetic representations of the
suggestions
3. Anticipates and envisions that these suggestions will result in future
outcomes.

What are the conscious and unconscious sensations that accompany

neural activities of the brain? What is the bridge between pain perception
16 Clinical Hypnosis in Pain Therapy and Palliative Care

and the experience of anxiety and suffering? Moreover, how can we cure suf-
fering and pain in all their aspects, not only physical but also mental? How
does a neurochemical phenomenon like pain, which starts from a biological
state, transform into a psychological and suffering sensation? Even if our neu-
rophysiological knowledge should one day enable us to identify the exact
neurochemical correlation of a psychic phenomenon, we must not forget that
neurochemical knowledge, is not sufficient to explain all the subjective expe-
riences in people. In the past, philosopher John Searle wrote that “to study
the brain without studying consciousness is like studying the stomach with-
out studying digestion” (Searle, 1992).
Some very interesting and excellent protocols regarding pain and suffer-
ing therapy have been written. For the management of pain, the Agency for
Health Care Policy and Research (AHCPR) was established in December
1989 under the Omnibus Budget Reconciliation Act of 1989 (Public Law
101-239) to enhance the quality, appropriateness, and effectiveness of health
care services. AHCPR carried out its mission by conducting and supporting
general health services’ research, including medical effectiveness research.
The guidelines assisted practitioners in the prevention, diagnosis, treatment,
and management of clinical conditions.
AHCPR also classified the nonpharmacological and noninvasive man-
agement in pain. They said that psychological interventions should be intro-
duced early during illness as part of a multimodal approach to pain man-
agement. Psychological therapies can be used concurrently with drugs and
other modalities to manage pain. These interventions can be carried out by
professional staff and often by the patient or family members.
One goal is to help the patient gain a sense of control over pain and suf-
fering.
A simple rationale underlies such an intervention; how people think
affects how they feel, and changing how they think about pain can change
their sensitivity to it and their feelings and reactions toward it (Agency for
Health Care Policy and Research [AHCPR], 1989; McGrath, 1990). These
interventions should be introduced early throughout illness, so that patients
can learn and practice these strategies while they have sufficient strength and
energy. When introduced early, they are more likely to succeed, which fos-
ters the patient’s motivation to continue using them.
For most people, suffering is a hard and difficult word, a word to be kept
out of one’s thoughts. For this reason, when it touches us, we are not pre-
pared to deal with it. For professional people who live constantly in close
contact with all types of suffering, it may become more difficult to be able to
efficiently help those who are challenged in facing inevitably difficult life
events.
 Consciousness in Clinical Hypnosis and Mindfulness 17

Many dictionaries define suffering only from a physical point of view,

but suffering also includes the mind and the soul. One of the best-written
books, on the subject of suffering, is the book of Job in the Bible, the source
of ideas for many philosophers, even though its meaning may be difficult to
understand. Therefore, suffering must be analyzed from all aspects that make
up the human being. The aspects of suffering are derived from

• a physical pain (illness)

• difficult situations of life
• stress
• physical trauma
• psychological trauma
• a state of depression
• social problems
• spiritual suffering

As a doctor I talk about suffering when physical pain includes mental

and spiritual suffering. Sources of pain are often multiple, with the combina-
tion of chronic neuropathic, inflammatory, chemical, mechanical, ischemic,
or acute pain. These may be from the primary pathology, from treatment
modalities, from bedsores and skin ulcers, from preexisting concurrent dis-
ease, in critical care by the discomfort of an endotracheal tube or an intra-
venous line, or in palliative care for dying patients. Pain may be considered
as contributing significantly to an overall sense of suffering.
Psychosocial and spiritual processes strongly influence the impact and
expression of pain and these need to be taken into account in assessing and
treating pain. This needs a holistic approach to the patient (Kolcaba & Fisher,
1996), as well as some novel approaches to the treatment of suffering.

3. INTRODUCTION TO CONSCIOUSNESS,
HIGHER CONSCIOUSNESS, AND AWARENESS

In everyday life, as each of us lives in our “normal” state of conscious-

ness, our awareness is usually focused on the particular thoughts, emotions,
or perceptions we experience on the surface level of reality. They are the
experiences and perceptions we move through in our life, in the outer world,
or the thoughts and feelings that we have in our inner world. As we move
through life, we perceive, think, act, and feel with the assistance of our
“thinking mind,” the active portion of our mind that deals with this surface
18 Clinical Hypnosis in Pain Therapy and Palliative Care

level of reality, through the use of thoughts, feelings, interpretations of per-

ceptions, and actions.
Higher consciousness is our awareness state: it is the state or ability to
perceive, to feel, or to be conscious of events, objects, or sensory patterns. In
this level of consciousness, sense data can be confirmed by an observer with-
out necessarily implying knowledge. More broadly, it is the state or quality
of being aware of something. Although all these particular components of
our life are important, when we remain identified with—and therefore limit-
ed to—these surface activities, we are far less able to perceive and act from a
more fundamental level of greater awareness. The tendency of our “thinking
mind” to remain preoccupied with the particulars of life inhibits our ability
to move to the level of pure consciousness that is actually the source of all
these particular states of mind.
Neural systems that regulate attention serve to attenuate awareness
among complex animals whose central and peripheral nervous systems pro-
vide more information than cognitive areas of the brain can assimilate.
Within an attenuated system of awareness, a mind might be aware of much
more than is being contemplated in a focused extended consciousness. Ex-
tended consciousness is said to arise in the brain of humans with substantial
capacity for memory and reason. The perception of a historic and future self
arises from a stream of information from the immediate environment and
from neural structures related to memory.
The scientist Antonio Damasio (1994) theorized extended consciousness
to arise in the structures in the human brain he described as image spaces
and dispositional spaces. Image spaces imply areas where sensory impres-
sions of all types are processed, including the focused awareness of the core
consciousness. Dispositional spaces include convergence zones, networks in
the brain where memories are processed and recalled and where knowledge
is merged with immediate experience.
During relaxation, clinical hypnosis states, and meditative states, higher
consciousness and awareness move you back to your calm center. Awareness
helps you lose habits that have held you pinned to the world’s way of doing
things so long. Relaxation techniques, clinical hypnosis, and imagery are
used to achieve a state of mental and physical relaxation in consciousness
stages. Relaxation techniques include simple focused-breathing exercises,
progressive muscle relaxation (PMR), meditation, and music-assisted relax-
ation (AHCPR, 1992; McCaffery & Beebe, 1989). Hypnosis works with the
subconscious mind to create results. Your subconscious is the part of your
mind that stores all of your experiences, dreams, and beliefs.
The hypnotic trance is a essentially a state of heightened and focused
concentration, and thus it can be used to manipulate the perception of pain
 Consciousness in Clinical Hypnosis and Mindfulness 19

and suffering. The use of hypnosis involves control over the focus of atten-
tion and can be used to make the patient less aware of the noxious stimuli
(Broome, Lillis, McGahe, & Bates, 1992). Pleasant mental images can be
used to aid relaxation and awareness, for example, visualizing a peaceful
scene, such as waves softly hitting the beach, or taking slow, deep breaths as
one visualizes pain leaving the body. Both pleasant imagery and PMR have
been shown to decrease self-reported pain intensity and pain distress (Graf-
fam & Johnson, 1987).
In the practice of clinical hypnosis, relaxation, mindfulness, and medita-
tive stages, we seek to free ourselves from this mental “chatter” in which our
“thinking mind” engages and instead seek connection to a higher level of our
being. We free ourselves from the surface level of the mind, and by doing so,
we make it easier for ourselves to come into connection with a higher con-
sciousness, a reality. These states are processes by which we seek to recondi-
tion our conscious awareness so that we release our attachment to the surface
level of reality and instead allow the awareness to gravitate toward a state of
pure awareness, pure consciousness.
As we pass through these stages in the proper manner, the experience of
pure awareness itself moves more to the forefront, instead of a primary iden-
tification with the highly active surface level of the mind. In learning and
practice of modified stages of consciousness, we can develop some higher
sense of self-consciousness and awareness, a pure awareness beyond habitu-
al identifications with the thoughts, feelings, and perceptions of the surface
level of the mind. They are, in the beginning, the journey inward and pro-
vide an inward awareness of self.
At the beginning of an inner self-practice, our higher consciousness often
begins to draw inward, and progresses inward. During our practices, there
are moments when our higher consciousness is focused outward, moments
when we are aware of our existence in the outer universe, perhaps with a
sense of the sky or heavens above, of being in the universe. It is an instanta-
neous reversal in the focus of awareness, and there is often a sense of elation
or euphoria at this point when the inward higher consciousness expands.
This point is not a point in time or space, but it is a state of being. It is
subtle, yet discernible with practice. This precise point of change in aware-
ness is called the point of pure being. The purpose of this book is to awaken
in us the skylike nature of mind and to introduce us to that which we really
are, our unchanging pure higher consciousness and awareness that underlies
the whole of life. These states of mind are intensely personal and spiritual
experiences.
The desired purpose of each technique is to channel our awareness into
a more positive direction by totally transforming one’s state of mind; to turn
20 Clinical Hypnosis in Pain Therapy and Palliative Care

inward, to concentrate on the inner self.

In this world, we are constantly under physical and/or mental stress. The
reason for this stress is that we have become slaves of endless desires and
uncontrolled emotions such as hatred, jealousy, anger, and so on. We feel
powerless and limited in what we can do.

When you abandon every desire, that rises up within you, and when you
become content with things as they are, then you experience inner peace. When
your mind is untroubled by misfortune, when you desire no pleasures, when
your emotions are tranquil, and when you are free from fear and anger, then you
experience inner calm. When you are free from all attachments, when you are
indifferent to success and failure, then you experience inner serenity. When you
can withdraw your senses from pleasures of the senses, just as a tortoise with-
draws its limbs, then you experience inner wisdom. When no pleasure and no
desire can touch the soul, then you experience the highest state of consciousness.
(Bhagavad-Gita, 2.55-61)

The stillness and silence of consciousness stages, we glimpse and return to that
deep inner nature that we have so long ago lost sight of amid the busyness and
distraction of our minds.

Consciousness stages and meditation, then, are “bringing the mind home.”
(Rinpoche, 2002)

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 Chapter II

PAIN AND SUFFERING:

NEUROPHYSIOLOGICAL AND
BEHAVIORAL ASSESSMENT

1. PAIN DEFINITION

he International Association for the Study of Pain (IASP) is an interna-

T tional professional organization promoting research, education and poli-
cies for the knowledge and management of pain. The often-quoted IASP def-
inition of pain as “an unpleasant sensory and emotional experience associat-
ed with actual or potential tissue damage, or described in terms of such dam-
age” (International Association for the Study of Pain [IASP], 2009).
The inability to communicate verbally does not negate the possibility
that an individual is experiencing pain and is in need of appropriate pain-
relieving treatment. Pain and suffering are universal human experiences. We
all know what it is like. Few of us, however, know enervating and debilitat-
ing chronic pain. What is it that distinguishes the disease chronic pain from
the inevitable and sometimes incessant pain that we all endure? It is difficult
to make a certain distinction. Unfortunately, there is as yet no adequate def-
inition of the disease. The reasons for this are several, and they are worth
exploring.
Serious chronic illnesses are a major health issue in modern society. Any
illness is called “chronic” if it is long lasting or even lifelong. The opposite of
chronic is “acute,” referring to diseases that come on quickly and often do
not last long (if they last, they are said to become “chronic”). In the United
States, more than 90 million people have a chronic illness, and the top five

*This often-quoted definition was first formulatd by an IASP Subcommittee on Taxonomy (bonica,
1979).

27
28 Clinical Hypnosis in Pain Therapy and Palliative Care

chronic illnesses (heart disease, cancer, stroke, COPD and diabetes) togeth-
er cause more than two thirds of all deaths. In chronic disease anxiety/de-
pression, self-focused attention, pain, and suffering, are significant predictors
of panic-fear symptoms, lower self-efficacy, and more perceived interference
in well-being of the patient.
Pain and suffering are always subjective. Everyone learns the application
of the word through experiences related to injury in early life. Biologists rec-
ognize that those stimuli that cause pain are liable to damage tissue. Ac-
cordingly, pain is that experience we associate with actual or potential tissue
damage. It is unquestionably a sensation in a part or parts of the body, but it
is also always unpleasant and therefore, also an emotional experience. Ex-
periences that resemble pain but are not unpleasant, for examples, pricking,
should not be called pain. Unpleasant abnormal experiences (dysesthesias)
may also be pain but are not necessarily so because, subjectively, they may
not have the usual sensory qualities of pain (IASP, 2009).

2. NEUROPHYSIOLOGY AND NEUROPSYCHOLOGY OF PAIN

Pain is a complex phenomenon involving both neurophysiological and

psychological components. The transmission of pain-related information
from the periphery to the cortex depends on signal integration at three lev-
els of the nervous system: the spinal medulla, brainstem, and telencephalon.
In fulfilling its task of safeguarding human health, pain may develop as a
result of damaged or altered primary afferent neurons (stimulus dependent)
or arise spontaneously without any apparent causal stimulus (stimulus inde-
pendent).
Hyperalgesia (i.e., an exaggerated perception of pain after a painful stim-
ulus) is due to an anomaly in the processing of nociceptive and behavioral
inputs in the central and peripheral nervous systems leading to the activation
of the primary afferents by stimuli other than the usual stimuli.
The neuromatrix theory of pain proposes that pain is a multidimension-
al experience produced by characteristic “neurosignature” patterns of nerve
impulses generated by a widely distributed neural network—the “body-self
neuromatrix”—in the brain (Melzack, 2005). These neurosignature patterns
may be triggered by sensory inputs, but they may also be generated inde-
pendently of them.
Acute pains evoked by brief noxious inputs have been meticulously
investigated by neuroscientists, and their sensory transmission mechanisms
are generally well-understood. In contrast, chronic pain syndromes, which
are frequently characterized by severe pain associated with little or no dis-
 Pain and Suffering 29

cernable injury or pathology, remain a mystery. Furthermore, persistent psy-

chological or physical stress is often associated with chronic pain, but the
relationship is poorly understood.
The neuromatrix theory of pain provides a new conceptual framework
to examine these problems. It proposes that the output patterns of the body-
self neuromatrix activate perceptual, homeostatic, and behavioral programs
after injury, pathology, or chronic stress. Pain, then, is produced by the out-
put of a widely distributed neural network in the brain rather than directly
by sensory input evoked by injury, inflammation, or other pathology. The
neuromatrix, which is genetically determined and modified by sensory expe-
rience, is the primary mechanism that generates the neural pattern that pro-
duces pain. Its output pattern is determined by multiple influences, of which
the somatic sensory input is only a part, that converge on the neuromatrix
(Melzack, 2005).
Pathophysiological mechanisms involve neural pathways, and a variety
of pain-producing substances and modulating mechanisms. These include
acetylcholine, serotonin, histamine, bradykinin, prostaglandins, substance P,
somatostatin, cholecystokinin, vasoactive intestinal polypeptide, noradrena-
line, and endogenous opioid peptides. The opioid system controls pain, re-
ward, and addictive behaviors. Opioids exert their pharmacological actions
through three opioid receptors—mu, delta, and kappa—whose genes have
been cloned (Oprm, Oprd1, and Oprk1, respectively). Opioid receptors in
the brain are activated by a family of endogenous peptides like enkephalins,
dynorphins and endorphin, which are released by neurons (Contet, Kieffer,
& Befort, 2004). Opioid receptors can also be activated exogenously by alka-
loid opiates, the prototype of which is morphine, which remains the most
valuable painkiller in contemporary medicine. In assessing patients with pain,
it is essential to evaluate the cause of the pain, and its severity, type, location,
duration, quality, and response to therapies, among other factors (Lasagna,
1986).
It is the perception of pain and the individual’s physical and emotional
reaction to the pain perception that give us the opportunity to create treat-
ment approaches that can provide relief. An endogenous CNS pain-modu-
lating network with links in the midbrain, medulla, and spinal cord has been
discovered. This system produces analgesia by interfering with afferent trans-
mission of neural messages produced by intense stimuli. Although other neu-
rotransmitters are involved, the analgesia produced by this system depends
on the release of endogenous opioid substances, generically referred to as
endorphins. The system is set in motion by clinically significant pain, such as
that resulting from bony fractures or postoperative pain. The analgesia net-
work monitors the pain and controls it at the level of the spinal cord.
30 Clinical Hypnosis in Pain Therapy and Palliative Care

In 2010, a group of Japanese scientists discovered the association be-

tween personality, pain threshold, and a single nucleotide polymorphism
(rs3813034) in the 3¢-untranslated region of the serotonin transporter gene
(SLC6A4). In 181 healthy Japanese volunteers they examined the relation-
ship among personality, sensitivity to pain, and a single nucleotide polymor-
phism (rs3813034) in the 3¢-untranslated region (3¢ UTR) of the serotonin
transporter (5-HTT) gene (SLC6A4). Pain sensitivity was assessed by using
cold and pressure thresholds. Personality was assessed by the Temperament
and Character Inventory (TCI). Males without the T allele (G/G) showed a
significantly higher spiritual acceptance (ST3) score than those who had the
T allele (T/T and T/G) did. Females with the T allele (T/T and T/G) showed
considerably stronger transpersonal identification (ST2) and self-transcen-
dence (ST) scores than did those without the T allele (G/G) (Aoki, Ikeda,
Murayama, Yoshihara, Ogai, & Iwahashi, 2010).
Complex psychological factors play an important role in the variability
of perceived pain, partly because of their ability to trigger this pain-suppress-
ing system. The patient with pain in chronic diseases and in palliative care,
should be reassured. It is understood that the patient is suffering, and an
appropriate cause for this suffering and the most effective treatment will be
sought. The physicians can offer a useful service in the diagnosis and treat-
ment of pain in many complex cases.

3. CLASSIFICATION OF PAIN TYPES

In 1994, responding to the need for a more useful system for describing
chronic pain, the IASP classified pain according to specific characteristics:
(1) region of the body involved (e.g., abdomen, lower limbs), (2) system
whose dysfunction may be causing the pain (e.g., nervous, gastrointestinal),
(3) duration and pattern of occurrence, (4) intensity and time since onset, and
(5) etiology.
The work of the Task Force on Taxonomy in the era of 1979 to 1994 has
been continued by the Committee on Taxonomy, which has worked to up-
date both pain terms and the classification of pain syndromes. All of the
terms have been carefully reviewed and their utility assessed in reference to
new knowledge about both clinical and basic science aspects of pain. The
Scheme for Coding Chronic Pain Diagnoses (updated in 2011 by the IASP
Taxonomy Working Group) and List of Topics and Codes is as follows:

A. Relatively Generalized Syndromes

B. Relatively Localized Syndromes of the Head and Neck
 Pain and Suffering 31

C. Spinal Pain, Section 1: Spinal and Radicular Pain Syndromes

D. Spinal Pain, Section 2: Spinal and Radicular Pain Syndromes of the
Cervical and Thoracic Regions
E. Local Syndromes of the Upper Limbs and Relatively Generalized
Syndromes of the Upper and Lower Limbs
F. Visceral and Other Syndromes of the Trunk Apart From Spinal and
Radicular Pain
G. Spinal Pain, Section 3: Spinal and Radicular Pain Syndromes of the
Lumbar, Sacral, and Coccygeal Regions
H. Local Syndromes of the Lower Limbs

There are two basic types of pain: acute and chronic. Acute pain occurs
for brief periods of time and is associated with temporary disorders. It is
always an alarm signal that something may be wrong, however. Chronic pain
is continuous and recurrent. It is associated with chronic diseases and is one
of their symptoms. Pain intensity depends not only on the type of stimulus
that caused it but also on the subjective perception of the pain.
Chronic pain may be divided into “cancer” and “benign.” In chronic
pain, guidelines often are not universally accepted by those involved in pain
management, and pain treatment seems to be driven mainly by tradition and
personal experience. Other factors include poor communication among pa-
tients, nurses, and physicians; the side effects of analgesic drugs; and limited
individualization of therapy. Difficulty in maintaining the balance between
adequate pain relief and acceptable tolerability, particularly with strong opi-
oids, can lead to the establishment of a “vicious circle” that alternates be-
tween lack of efficacy and unpleasant side effects, prompting discontinuation
of treatment. The medical community’s understanding of the physiological
differences between nociceptive pain and neuropathic pain, which is often
more severe and difficult to treat, could be improved.
Neuropathic pain is a complex, chronic pain state that usually is accom-
panied by tissue injury. With neuropathic pain, the nerve fibers themselves
may be damaged, dysfunctional, or injured. These damaged nerve fibers
send incorrect signals to other pain centers. The impact of nerve fiber injury
includes a change in nerve function at both the site of injury and areas
around the injury.
What causes neuropathic pain in chronic diseases? Neuropathic pain
often seems to have no obvious cause; however, some common causes of
neuropathic pain include

• cancer (primary tumor or metastatic disease)

• amputation
32 Clinical Hypnosis in Pain Therapy and Palliative Care

• back, leg, and hip problems

• chemotherapy
• diabetes
• facial nerve problems
• HIV infection or AIDS
• multiple sclerosis
• shingles
• spine surgery

What are the symptoms of neuropathic pain? Symptoms may include

shooting and burning pain and tingling and numbness.
The Neuropathic Pain Special Interest Group of the IASP recently spon-
sored the development of evidence-based guidelines for the pharmacological
treatment of neuropathic pain. Tricyclic antidepressants, dual reuptake in-
hibitors of serotonin and norepinephrine, calcium-channel alpha(2)-delta lig-
ands (i.e., gabapentin and pregabalin), and topical lidocaine were recom-
mended as first-line treatment options based on the results of randomized
clinical trials. Opioid analgesics and tramadol were recommended as sec-
ond-line treatments that can be considered for primary use in certain clinical
circumstances (Dworkin et al., 2010). The increasing number of negative
clinical trials of pharmacological treatments for neuropathic pain and ambi-
guities in the interpretation of these negative trials must also be considered
in developing treatment guidelines.
Chronic neuropathic pain is a prevalent problem that eludes cure and
adequate treatment. The persistence of intense and aversive symptoms in
chronic diseases, inadequacy of available treatments, and the impact of such
pain on all aspects of functioning underscore the important role of several
psychosocial factors in causing, maintaining, and amplifying the perception of
pain severity, coping adequacy, adaptation, impaired physical function, and
emotional distress responses (Turk, Audette, Levy, Mackey, Stanos, 2010).
Older people are at high risk of neuropathic pain because the incidence
of many diseases that cause neuropathic and chronic pain increases with age.
Depending on their underlying health, older adults with chronic pain may
have to cope with multiple coexisting diseases, polypharmacy, and impaired
functional ability.

4. PAIN MANAGEMENT

Pain management in patients must reflect aged heterogeneity, multimor-

bidity, and polypharmacy; selection of treatment in an effort to maximize
 Pain and Suffering 33

patients’ functional abilities in addition to relieving their pain; more careful

dosing (usually lower) and monitoring of pharmacotherapy relative to
younger patients due to age-related changes in pharmacokinetics and phar-
macodynamics; and underrepresentation of older adults in clinical trials of
neuropathic pain treatments, which further compromises the physicians abil-
ity to make informed treatment decisions (Schmader et al., 2010).
Anesthesiologists have always played a leading role in research into pain
and its treatment. Their efforts, however, have been focused on acute or
postoperative pain problems. It was the American anesthesiologist John J.
Bonica who fought for an increased interest in chronic pain. The establish-
ment of the first Multidisciplinary Pain Center at the University of Wash-
ington in Seattle, the foundation of the IASP, and Melzack and Wall’s now
old gate-control theory were the driving forces behind rapid developments
in research and treatment in the area of chronic pain.
The classic anesthesiological topics, such as operative anesthesia, emer-
gency medicine, and intensive care, have been extended to include acute
pain services and chronic pain treatment facilities. This reflects the under-
standing that anesthesiological knowledge and techniques can be valuable to
patients in severe acute pain and those in lingering long-term chronic pain
phases in chronic diseases and in palliative care. Special ways of administer-
ing narcotic analgesics, such as epidural infusion or patient-controlled anal-
gesia, have already alleviated the pain problems of many patients.
Anesthesiological techniques are also crucial in diagnosis. Sequential dif-
ferential blockade and simple nerve blocks can be helpful in the diagnosis
and classification of the pain problems. Interventional procedures (typically
used for chronic pain) include epidural steroid injections, facet joint injec-
tions, neurolytic blocks, spinal cord stimulators, and intrathecal drug deliv-
ery system implants.
The art and science of anesthetic practice has existed as a unique med-
ical discipline for less than 150 years. During that time, the focus has changed
from helping the patient tolerate surgical stress by rendering him insensible
to pain to controlling stress and the patient’s physiological responses to the
perioperative period by careful titration of powerful pharmacological means
and the appreciation of sound medical judgment.
Anesthesiologists can not only use their nerve blocking and analgesic-
prescribing skills, but also can coordinate some of the other treatment strate-
gies, such as relaxation techniques and hypnosis. By joining with colleagues
skilled in behavioral, psychiatric, and surgical management of pain states, the
anesthesiologist can give a useful approach to these problems (Murphy,
1986). The anesthesiologist’s goals are to render the patient pain free and
amnesic to preserve vital functions during the operations and procedures,
34 Clinical Hypnosis in Pain Therapy and Palliative Care

and to offer to the patient during regional anesthesia a quiet, relaxed state of
consciousness.

5. PAIN EVALUATION

The pain evaluation consists of pain assessment and pain treatment.

A. Pain Assessment
• Ask about pain
• Surgical or procedural pain
• Pain score
• Physical exam
• Diagnostic studies
• Pain mechanisms

Nociceptive
Somatic
Visceral

Neuropathic

The patient’s pain should be acknowledged to be a very real problem for

the patient. Attempts to differentiate between “real” and “unreal” pain and
“organic” and “psychosomatic” are usually fruitless and only succeed in chal-
lenging such patients to attempt to prove further the “reality” of their suffer-
ing.
The patient can appreciate that there may not always be a technological
or invasive solution to the problem, such as the use of a nerve block or a pill,
so the patient must be willing to undergo psychological and behavioral eval-
uation. Many factors may contribute to the symptoms. Concomitant depres-
sion, impaired cortical function, and chronic anxiety may all be conditions
in which the patients use the language and behavior of pain to communicate
their distress and suffering.
Physiological indications of acute pain in adults are

• dilated pupils
• increased perspiration
• increased rate/force of heart rate
• increased rate/depth of respirations
 Pain and Suffering 35

• increased blood pressure

• decreased urine output
• decreased peristalsis of GI tract
• increased basal metabolic rate

Sometimes during acute pain, growth hormone levels significantly in-

creased within minutes, and beta endorphin and prolactin were elevated pro-
portionately with severity of injury. Cortisol was inversely correlated with in-
jury severity, possibly reflecting impaired release from the adrenal cortex after
very severe injury (Hetz, 1996).
In the final analysis, pain is communicated as a behavior, for it is only by
word, grimacing, posturing, and other behavioral signals that we know an-
other individual is in pain. The pain behaviors in the cognitively Impaired
are

• facial expression
• slight frown, frightened face
• rapid blinking
• verbalizations, vocalizations
• verbally abusive
• calling out, chanting, grunting
• body movements
• rigid, tense
• fidgeting
• increased pacing, rocking
• changes in interpersonal interactions
• aggressive, combative, resisting care
• decreased social interaction
• socially inappropriate, disruptive
• changes in activity patterns or routines
• refusing food
• increased rest periods
• sleep pattern changes
• mental status changes
• crying, tears
• increased confusion
• irritable

Patients may acquire behavioral aspects of their pain problems in chron-

ic diseases and in palliative care and along with psychological and tissue-
damaging problems. Thus, such patients are unlikely to respond to therapy
36 Clinical Hypnosis in Pain Therapy and Palliative Care

directed primarily at the tissue-damaging aspects but may well need the com-
bined efforts of conventional therapy aimed at the degenerative disease, psy-
chological support, pharmacological treatment, and some behavior modifi-
cation in an attempt to restore normal function.
The possible physiological and psychological signs of acute pain in the
neonates and in children are (Stallard et al., 2002):

Physiological Variables

• Heart rate, respiratory rate, pressure breathing

• Shallow respirations
• Vagal nerve tone (shrill cry)
• Pallor or flushing
• Diaphoresis, palmar sweating
• O2 saturation
• EEG changes

Behavioral Variables

Vocalizations

• Crying (often with apneic spells)

• Whimpering, groaning, moaning

State Changes

• Changes in sleep/wake cycles

• Changes in activity level
• Agitation or listlessness

Bodily Movements

• Limb withdrawal, swiping, or thrashing

• Rigidity
• Flaccidity
• Clenching of fists

Facial Expression (Most Reliable Sign)

• Eyes tightly closed or opened

• Mouth opened
 Pain and Suffering 37

• Furrowing or bulging of brow

• Quivering of chin
• Deepened nasolabial fold

Acute pain signals pass through the thalamus, and then on to the senso-
ry cortex. Chronic pain travels through the hypothalamus, which is con-
nected to the limbic system, where emotional states (emotion-related symp-
toms such as anxiety or depression) seems to originate.
No aspect of our mental life is more important to the quality and mean-
ing of our existence than emotions are. In view of the proliferation of increas-
ingly fruitful exchanges between researches of different stripes, it is no longer
useful to speak of the philosophy of emotion in isolation from the approach-
es of other disciplines, particularly psychology and neurology (De Sousa,
1987). If the view that emotions are a kind of perception that can be sustained,
then the connection between emotion and cognition will have been secured.
There is yet another way of establishing this connection, compatible with
the perceptual model. This is to draw attention to the role of emotions as pro-
viding the framework for cognitions of the more conventional kind. De
Sousa (1987) and Amélie Rorty (1980) proposed this sort of account accord-
ing to which emotions are not so much perceptions as they are ways of see-
ing, species of determinate patterns of salience among objects of attention,
lines of inquiry, and inferential strategies. Emotions make certain features of
situations or arguments more prominent, giving them a weight in our expe-
rience that they would have lacked in the absence of emotion (De Sousa,
1987; Roberts, 1988).
Pain is considered to be chronic if it has remained essentially unrelieved
for six months or longer. Chronic pain can be of many types and locations
and may or may not have specific tissue damage associated with it. This is to
contrast it with temporary acute pain that is related to specific tissue damage
and reduces in intensity as the damaged area heals.
Chronic pain differs from acute pain in several important ways. It is now
believed that different neural circuits are traveled by chronic and acute pain.
In chronic pain there exits a relationship between emotions, psychological
state, and the intensity of the pain experience. Stress, depression, or anxiety
can all increase the intensity of the pain experience. Consequently, proce-
dures that reduce stress, depression, and anxiety can have the opposite effect
and can reduce the intensity of the pain experience.
While pain is going on, the body tries to immobilize the inflamed tissue
(muscle or joint area) by putting extra fluid there (edema), much as a garden
hose becomes stiff if the flow is stopped. Eventually, the chronic stiffness and
disuse cause muscle atrophy. The body begins to deposit calcium in the tis-
38 Clinical Hypnosis in Pain Therapy and Palliative Care

sues and around the joints, in effect making an internal cast and mechani-
cally immobilizing the area. Therefore, the longer a pain patient does not use
an area, the harder it will be to ever use it, and the more painful it will be-
come. Taking medicine for pain can also be a factor that prolongs and main-
tains the chronic pain condition. Most painkillers have powerful effects on
other parts of the CNS. A percentage of chronic pain patients may become
addicted to pain medications. Patients may also have to increase their dose
periodically in order to get the same level of relief (this is called developing
a tolerance to the drug). Their pain level escalates, and severe autonomic
arousal develops with blockade or sudden discontinuance of the analgesic
drug (an example of physical dependence causing withdrawal or abstinence
syndrome). Chronic pain patients may be controlling and focused on their
medication, understandably, because the drug is the only thing that has
brought them any feeling of relief, and it is the only thing that gives them a
feeling of control over their pain management.
Chronic pain is different from acute pain in several ways. It is now
believed that different neural pathways are traveled by chronic and acute
pain. Acute pain passes through the thalamus and then on to the sensory cor-
tex; chronic pain travels through the hypothalamus, which is connected to
the limbic system where emotional functioning (emotions or problems, such
as anxiety or depression) seems to originate.
In chronic pain, there is a relationship between emotions, psychological
state and the intensity of the pain experience. A variety of methods are avail-
able to help the acute and chronic pain patient manage depression, anxiety,
and stress level, including relaxation techniques and hypnosis. Usually, some
combinations of these with therapies are applied for the best results.
Typically, a pain evaluation consists of several approaches to discovering
which factors play the largest role in maintaining the pain. We perform psy-
chological testing to determine any underlying causes of depression or anxi-
ety, which should be treated in addition to the pain and which could be help-
ing to maintain it.

AHCPR Recommendations for the Examination of Pain

• Health professionals should ask about pain, and the patient’s self-
report should be the primary source of assessment.
• Clinicians should assess pain with easily administered rating scales
and should document the efficacy of pain relief at regular intervals
after starting or changing treatment. Documentation forms should be
readily accessible to all clinicians involved in the patient’s care. (Panel
Consensus)
 Pain and Suffering 39

• Clinicians should teach patients and their families to use assessment

tools in their homes in order to promote continuity of effective pain
management across all settings. (Panel Consensus)
• The initial evaluation of pain should include
– detailed history, including an assessment of pain intensity and char-
acteristics
– physical examination
– psychosocial assessment
– diagnostic evaluation of signs and symptoms associated with the
common cancer pain syndromes (Panel Consensus)
• Clinicians should be aware of common pain syndromes. Prompt
recognition may hasten therapy and minimize the morbidity of unre-
lieved pain.
• Changes in pain patterns or the development of new pain should trig-
ger a diagnostic evaluation and modification of the treatment plan.
(Panel Consensus)
• Health professionals should ask about pain, and the patient’s self-
report should be the primary source of assessment. The self-report
should include a description of the pain; its location, intensity/severi-
ty, and aggravating and relieving factors; and the patient’s cognitive
response to pain.

Neither behavior nor vital signs should be used in lieu of a self-report

(Beyer, McGrath, & Berde, 1990). It is best to use brief, easy-to-use assess-
ment tools that reliably document pain intensity and pain relief and to relate
these to other dimensions of pain, such as mood. One routine clinical
approach to pain assessment and management is summarized by the
mnemonic “ABCDE”:

A. Ask about pain regularly. Assess pain systematically.

B. Believe the patient and family in their reports of pain and what
relieves it.
C. Choose pain control options appropriate for the patient, family, and
setting.
D. Deliver interventions in a timely, logical, and coordinated fashion.
E. Empower patients and their families.

Three commonly used self-report assessment tools are

• Simple Descriptive Pain Intensity Scale

• 0–10 Numeric Pain Intensity Scale
40 Clinical Hypnosis in Pain Therapy and Palliative Care

• Visual Analog Scale (VAS)

If the patient understands the scale and is capable of answering and if

end points and adjective descriptors are carefully selected, each of these
instruments can be valid and reliable (Gracely & Wolskee, 1983; Houde,
1982; Sriwatanakul, Kelvie, & Lasagna, 1982).
Knowing factors that aggravate or relieve pain helps clinicians to design
a pain treatment plan. The initial pain assessment should elicit information
about changes in activities of daily living, including work and recreational
activities, sleep patterns, mobility, appetite, sexual functioning, and mood.
A psychosocial assessment should emphasize the effect of pain on
patients and their families, as well as patients’ preferences among pain man-
agement methods. Patients who are able to answer should be asked about the
effectiveness of past and present pain treatments, such as antineoplastic ther-
apy or specific pharmacological and nonpharmacological therapies.

B. Pain Treatment
The recommendations about the assessment and management of pain
(IASP and WHO), include the use of the following.

Analgesics and Adjuvant Medicines: WHO’s Pain Ladder

WHO has developed a three-step “ladder” for pain relief. If pain occurs,
there should be prompt oral administration of medicines in the following
order:

1. Nonopioids (aspirin and paracetamol)

2. Then, as necessary, mild opioids (codeine)
3. Then, strong opioids, such as morphine, until the patient is free of pain

To calm fears and anxiety, additional medicines—“adjuvants”—should be

used. To maintain freedom from pain, drugs should be given “by the clock”;
that is every 3–6 hours, rather than “on demand.” This three-step approach
of administering the right drug in the right dose at the right time is inexpen-
sive and 80 to 90 percent effective. Surgical intervention on appropriate
nerves may provide further pain relief if drugs are not wholly effective.

Palliative and Ablative Surgery and Anesthesiology

• Nerve blocks
• Local anesthetics
 Pain and Suffering 41

• Epidural
• Intrathecal
• Cordotomy: anteriolateral spinothalamic tract is ablated

Physical Modalities
• Physiatry. Physical medicine and rehabilitation (physiatry/physio-
therapy) employs diverse physical techniques such as thermal agents
and electrotherapy, as well as therapeutic exercise and behavioral
therapy, alone or in tandem with interventional techniques and con-
ventional pharmacotherapy to treat pain, usually as part of an interdis-
ciplinary or multidisciplinary program.
• Transcutaneous electrical nerve stimulation (TENS)
• Palliative radiation
• Acupuncture. Acupuncture involves the insertion and manipulation of
needles into specific points on the body to relieve pain or for thera-
peutic purposes.
• Laser Therapy

Nonconventional Remedies and Herbals

The Psychological and Cognitive/Behavior Strategies

Because the mechanisms of pain in chronic diseases and in palliative care
may be complex, involving several causes, such patients often have difficul-
ty obtaining an adequate diagnostic evaluation. Sometimes we ignore the
psychological and behavioral components of pain. To evaluate patients with
complaints pain encountered in palliative medicine, therefore, the specific
psychological, social, and environmental characteristics as well as a conven-
tional medical examination should be reviewed. There are several ways in
which anesthesiologists, depending on their inclinations, can become in-
volved in the management of pain patients in this setting. The patient can
appreciate that there may not be only one solution to this problem, such as
the use of nerve block, an operation, or a pill. In chronic diseases and in pal-
liative care, acute and chronic pain and depression are often associated in the
same patient. Furthermore, the successful treatment of the depression is often
associated with pain relief.
42 Clinical Hypnosis in Pain Therapy and Palliative Care

6. THE PSYCHOLOGICAL AND COGNITIVE/BEHAVIOR

STRATEGIES IN PAIN THERAPY AND PALLIATIVE CARE

A. The Dignity Therapy in Palliative Care

Dignity therapy is a novel psychotherapeutic intervention for patients
near the end of life (Harvey Chochinov, CancerCare, University of Man-
itoba, Canada). It is designed to address psychosocial and existential distress
among terminally ill patients and invites patients to discuss issues that mat-
ter most or that they would most want remembered. Sessions are transcribed
and edited, with a returned final version that they can bequeath to a friend
or family member. The objective of this study is to establish the feasibility of
dignity therapy and to determine its impact on various measures of psy-
chosocial and existential distress.
The outline of the dignity therapy interview guide is based on themes
and subthemes that arise from the dignity model. Therapeutic sessions, run-
ning between thirty and sixty minutes, are offered either at the patients’ bed-
side for those in hospital or, for outpatients, in their residential setting, at
home, or at a long-term care facility (Chochinov et al., 2005).

B. Psychotherapy
Psychotherapy is a general term referring to therapeutic interaction or
treatment contracted between a trained professional and a client, patient,
family, couple, or group. The problems addressed are psychological in
nature and of no specific kind or degree but rather depend on the specialty
of the practitioner. Psychotherapy aims to increase the individual’s sense of
his or her own well-being. Psychotherapists employ a range of techniques
based on experiential relationship building, dialogue, communication, and
behavior change that are designed to improve the mental health of a client
or patient, or to improve group relationships (such as in a family).
Psychotherapy is a word of Greek origin, deriving from Ancient Greek
psyche meaning breath, spirit, soul) and therapeia (healing, medical treatment).
According to the Oxford English Dictionary, psychotherapy first meant
“hypnotherapy.” The original meaning, “the treatment of disease by ‘psy-
chic’ [i.e., hypnotic] methods,” was first recorded in 1853 as “psychothera-
peia, or the remedial influence of mind.” The modern meaning, “the treat-
ment of disorders of the mind or personality by psychological or psy-
chophysiological methods,” was first used in 1892 by Frederik van Eeden,
translating “Suggestive Psycho-therapy” for his French “Psychothérapie
Suggestive.”
 Pain and Suffering 43

Most forms of psychotherapy use spoken conversation. Some also use

various other forms of communication, such as the written word, artwork,
drama, narrative story, or music. Psychotherapy with children and their par-
ents often involves play, dramatization (i.e. role-play), and drawing, with a
coconstructed narrative from these nonverbal and displaced modes of inter-
acting.
Psychotherapy occurs within a structured encounter between a trained
therapist and client(s). Purposeful, theoretically based psychotherapy began
in the nineteenth century with psychoanalysis. Since then, scores of other
approaches have been developed and continue to be created. There are sev-
eral main broad systems of psychotherapy:

• Psychoanalysis. This was the first practice to be called a psychotherapy.

It encourages the verbalization of all the patient’s thoughts, including
free associations, fantasies, and dreams, from which the analyst for-
mulates the nature of the unconscious conflicts that are causing the
patient’s symptoms and character problems.
• Behavior Therapy and Applied Behavior Analysis. This system focuses on
changing maladaptive patterns of behavior to improve emotional
responses, cognitions, and interactions with others.
• Cognitive Behavior Therapy. This therapy generally seeks to identify mal-
adaptive cognition, appraisal, beliefs, and reactions with the aim of
influencing destructive negative emotions and problematic dysfunc-
tional behaviors. Cognitive and behavior therapy is the use of stress
reduction and relaxation, to reduce chronic pain in some patients
(Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, 1982; Kwekke-
boom, Cherwin, Lee, & Wanta, 2010). Applied behavior analysis
views chronic pain as a consequence of both respondent and operant
conditioning, in which a patient learns to display pain behavior in the
presence of specific environmental antecedents and consequences.
Biofeedback based on behavioral principles has shown some success
for chronic pain, demonstrating greater improvement in one study
than peers undergoing cognitive behavior therapy and conservative
medical treatment have (Flor & Birbaumer, 1993).
• Psychodynamic Therapy. This is a form of depth psychology whose pri-
mary focus is to reveal the unconscious content of a client’s psyche in
an effort to alleviate psychic tension. Although its roots are in psycho-
analysis, psychodynamic therapy tends to be briefer and less intensive
than traditional psychoanalysis is.
• Existential Therapy. This is based on the existential belief that human
beings are alone in the world. This isolation leads to feelings of mean-
44 Clinical Hypnosis in Pain Therapy and Palliative Care

inglessness that can be overcome only by creating one’s own values

and meanings. Existential therapy is philosophically associated with
phenomenology.
• Humanistic Therapy. Emerged in reaction to both behaviorism and psy-
choanalysis, this therapy is known as the Third Force in the develop-
ment of psychology. It is explicitly concerned with the human context
of the development of the individual with an emphasis on subjective
meaning, a rejection of determinism, and a concern for positive
growth rather than pathology. It posits an inherent human capacity to
maximize potential–“the self-actualizing tendency.” The task of
humanistic therapy is to create a relational environment where this
tendency might flourish. Humanistic psychology is philosophically
rooted in existentialism.
• Brief Therapy. Brief therapy is an umbrella term for a variety of
approaches to psychotherapy. It differs from other schools of therapy
in that it emphasizes (1) a focus on a specific problem and (2) direct
intervention. It is solution based rather than problem oriented. It is
less concerned with how a problem arose than with the current factors
sustaining it and preventing change.
• Systemic Therapy. This system seeks to address people not at an indi-
vidual level, as is often the focus of other forms of therapy, but as peo-
ple in relationship, dealing with the interactions of groups, and their
patterns and dynamics (includes family therapy and marriage coun-
seling). Community psychology is a type of systemic psychology.
• Transpersonal Therapy. This addresses the client in the context of a spir-
itual understanding of consciousness.
• Body Psychotherapy. This addresses problems of the mind as being close-
ly correlated with bodily phenomena, including a person’s sexuality,
musculature, breathing habits, physiology, and so on. This therapy
may involve massage and other body exercises as well as talking.

There are hundreds of psychotherapeutic approaches or schools of

thought. By 1980, there were more than 250; by 1996, there were more than
450. The development of new and hybrid approaches continues around the
wide variety of theoretical backgrounds. Many practitioners use several
approaches in their work and alter their approach based on client need.

C. Clinical Hypnosis
Clinical hypnosis is practiced for both chronic and acute pain conditions:
(1) hypnotic analgesia consistently results in greater decreases in a variety of
 Pain and Suffering 45

pain outcomes compared to no treatment or standard care, (2) hypnosis fre-

quently out-performs nonhypnotic interventions (e.g., education, supportive
therapy) in terms of reductions in pain-related outcomes, and (3) hypnosis
performs similarly to treatments that contain hypnotic elements (such as
PMR) but is not surpassed in efficacy by these alternative treatments (Stoelb,
Molton, Jensen, & Patterson, 2009; Jensen, 2009).
Many chronic pain patients often have reversed diurnal rhythms where-
by they catnap during the day, reclining on couches, and spend the night
awake and restless. Hypnosis can often be quite successful in reestablishing
a normal sleep pattern in such patients, often resulting in an improved sense
of well-being and pain relief.
A 2007 review of thirteen studies found evidence for the efficacy of hyp-
nosis in the reduction of pain in some conditions. The authors concluded that
“although the findings provide support for the general applicability of hyp-
nosis in the treatment of chronic pain, considerably more research will be
needed to fully determine the effects of hypnosis for different chronic-pain
conditions” (Elkins, 2007).
The neural mechanisms underlying the antinociceptive effects of hypno-
sis still remain unclear. A group of scientists in 2009, using a parametric sin-
gle-trial thulium-YAG laser fMRI paradigm, assessed changes in brain acti-
vation and connectivity related to the hypnotic state as compared to normal
wakefulness in thirteen healthy volunteers. Behaviorally, a difference in sub-
jective ratings was found between normal wakefulness and hypnotic state for
both nonpainful and painful intensity-matched stimuli applied to the left
hand. In normal wakefulness, nonpainful range stimuli activated the brain-
stem, and contralateral primary somatosensory and bilateral insular cortices.
Painful stimuli activated additional areas encompassing the thalamus; bilat-
eral striatum; and anterior cingulate, premotor, and dorsolateral prefrontal
cortices. In hypnosis, intensity-matched stimuli in both the nonpainful and
painful range failed to elicit any cerebral activation. The interaction analysis
identified that the contralateral thalamus, bilateral striatum, and anterior cin-
gulate cortex activated more in normal wakefulness compared to hypnosis
during painful versus non-painful stimulation (Vanhaudenhuyse et al., 2009).
Clinical hypnosis in pain therapy and palliative care may be useful to

• have a good relaxation of body and mind

• facilitate mechanical ventilation and physiological tidal volume in crit-
ical care
• reduce anxiety (in palliative care increases breathing in patients)
• reduce panic
• have a good acute and chronic pain relief
46 Clinical Hypnosis in Pain Therapy and Palliative Care

• altered perception of pain

• facilitate new patterns of thoughts, feelings, and consciousness
• reduce depression
• reduce sleep disturbances
• reduce preoperative anxiety
• reframe or redefine a problem or situation
• bypass normal ego defenses
• suggest solutions and new options
• provide a gateway between the conscious and the unconscious mind
• increase communication
• facilitate retrieval of resource experiences
• improve mind-body relationship
• improve psychology of self and self-realization
• understand the higher self
• understand the evolution of consciousness
• lighten up the “spiritual” dimension in dying patients
• accept death and dying

Pain and anxiety can cause hypoventilation (decreased tidal volume) and
hypoxemia (decreased PaO2) and increase airway resistance. Posture, pain,
and anxiety may restrict or interfere with movements of the diaphragm: tidal
volume is reduced and breathing will be rapid and shallow. Rapid shallow
breathing may cause a decrease in functional residual capacity and promote
atelectasis. If tidal volume is decreased and respiratory rate does not increase
proportionately, minute ventilation will decrease, PaO2 may decrease, and
PaCO2 may increase (Miller, 1986). With hypnosis, most symptoms may be
reduced significantly.
Pain is a necessary physical sensation to warn a person of damage.
Research indicates that after the organism notes the disease or injury site,
pain interferes with healing and retards the eventual course leading to vital-
ity. Reduction of pain and suffering is one of the primary targets of all treat-
ment because reduction of pain is the beginning of recovering quality of life.
Many researchers and clinicians have demonstrated that management of
pain is a natural capacity housed in each person. Yet pain is a deeply sub-
jective experience. Successful treatment utilizes hypnotic trance to help pa-
tients relearn subcortical activity in the brain and then to alter (self-talk) it.
Symptoms are defined as preverbal conditioned reflexes that at some
sensate level make sense to patients and are subconsciously designed and
then used to prevent awareness of experienced or subconscious distress.
Relaxation and hypnotic trances attempt to accelerate a patient’s ability
to reorganize thinking, to have a unique experience, and simultaneously to
 Pain and Suffering 47

learn the responsibility of personal pain relief through self-involvement.

Anton Mesmer and other physicians reported on the use of “animal mag-
netism” for pain relief in the 1700s; the era of hypnoanesthesia began as early
as 1821. Cloquet performed a breast amputation using mesmerism in a
demonstration to the French Academy of Medicine in 1829, but it was a Scot-
tish surgeon, James Esdaile, who became most famous for the use of hypno-
sis as a surgical anesthetic (Esdaile, 1847; Kroger, 1963).
Esdaile reported on hundreds of painless operations performed with
mesmerism between 1840 and 1850. In the preface to his book Mesmerism in
India (1847), Esdaile wrote that “painless surgical operations and other med-
ical advantages” were the “natural birthright” that mesmerism provided his
patients in Bengal. Esdaile’s work overlapped the development of chemical
anesthesia with the first use of nitrous oxide in 1844, ether in 1846, and chlo-
roform in 1847. By the 1860s, chemical anesthesia had essentially eliminated
the use of hypnoanesthesia, although dramatic examples of its use are still
seen today.
In April 2000, the International Journal of Clinical and Experimental Hypno-
sis published a special issue entitled “The Status of Hypnosis as an Em-
pirically Validated Clinical Intervention.” Within this issue, Guy Mont-
gomery and colleagues presented a meta-analysis of eighteen studies of hyp-
notically induced analgesia (Montgomery, DuHamel & Redd, 2000). As had
been found in several earlier studies, this report supported hypnotic analge-
sia as a valid and reliable phenomena, with 75 percent of the clinical and
experimental subjects reporting pain relief. The authors conclude that, based
on the criteria set forth by Chambless and Hollon (1998), “hypnotically sug-
gested analgesia should be considered a well established treatment.” Patter-
son and Jenson (2003) supported this position for both acute and chronic
pain conditions (Willmarth & Willmarth, 2005). Hypnosis is used for this
purpose as an addition to or substitute for chemical anesthesia in many sur-
gical procedures because it is completely nontoxic and shows excellent
results for the hypnotizable subject (Patterson, 2010).
The greatest limit to its use in today’s palliation is the lack of education
by hospital personnel in its use and their resulting failure to recommend its
use for patients. There are also too few hypnotherapists with specific training
and experience in this field. Clinical hypnosis is very useful in chronic dis-
eases and in palliative care.
The special problems in palliative care are

• fear of increasing functional deficits

• concerns with cognitive function
• high number of cognitively impaired
48 Clinical Hypnosis in Pain Therapy and Palliative Care

• fear of hastening death in the frail elderly

• more depression
• decreased socialization
• sleep disturbances
• communication barrier due to sensory or cognitive impairment
• reluctance to report pain
• pain may be perceived as metaphor for serious disease or death

From a clinical perspective, the use of clinical hypnosis to alter perception

can be applied to the perception of pain in a number of effective ways. This
is true not only for the sensation of pain but also for the cognitive and emo-
tional factors including attention, attitude, affect, attribution, and arousal.
Although hundreds of creative suggestions and metaphors for pain con-
trol have been presented in the literature, Hilgard and Hilgard (1994) pro-
pose three general classes of pain management approaches. These include

1. direct suggestion of pain reduction

2. alteration of the experience of pain
3. redirection of attention (Willmarth & Willmarth, 2005)

We could use specific suggestions to help the patients achieve this state
in palliative care. The author explains that hypnosis is not mind control; the
patient is not going to be asked to do anything embarrassing. It is not like
taking a powerful drug that leaves the patient zonked out. It is more like
focused attention, focused concentration, in which the patient is able to let
himself or herself relax and be the person in charge.
Chronic pain often requires more effort, but hypnosis provides many
individuals with a way to experience focused, narrow attention, which redi-
rects attention to thoughts or memories more pleasant than the pain. This
“hallucination” may itself create physiological change (Willmarth &
Willmarth, 2005). Dabney Ewin, a surgeon and gifted hypnotist, notes that if
patients with severe burns can be placed in a trance soon after their injury
and can imagine cool or cold conditions on the skin, the course of the injury
changes (Ewin, 1986).
Once hypnotized, suggestions can be made specifically related to recov-
ery from procedures in chronic diseases and palliative care. First, suggest
them this state “Now, every time you are lying in bed at night, go deep into
this state. . . .” Second, they will be trained to enter this state while starting a
procedure and to remain in this state throughout the procedure: “Now, when
you lie on the gurney, and you feel its vibrations under your body, you auto-
matically go deep. . . .” Third, the patient is taught to to access this state while
 Pain and Suffering 49

lying in the recovery room and/or his or her own bedroom to activate the
recovery suggestions (Ewin, 1986).
The way to work with patients is to train them to use all of these process-
es every day in the quietness of their own beds. A hypnosis tape or CD cus-
tom made for the patient can be very helpful. In chronic diseases, heightened
anxiety increases the chances of pain, analgesic consumption, and also hos-
pital stay and recovery. Hypnosis can help the patient have less anxiety
before and less pain later.
There are good neurophysiological studies to prove that hypnosis is
potentially a powerful tool to alter perception of pain and associated anxiety.
It is entirely possible to substantially alter pain perception during surgical
procedures by inducing hypnotic relaxation, transforming perception in
parts of the body, or directing attention elsewhere. The key concept is that
this psychological procedure actually changes pain experience as much as
many analgesic medications and far more than placebos (McGlashan, Evans
& Orne, 1969; Raz, Fan & Posner, 2005; Spiegel, Kraemer & Carlson, 2001).
There is recent evidence from studies of the placebo effect that activity
in the anterior cingulate gyrus is linked to that in the periaqueduct gray, a
brainstem region that is crucial to pain perception (Wager, Scott & Zubieta,
2007). Hypnotic analgesia is real, no less palpable an analgesic than medica-
tion is, although the pathways are different and do not seem to involve
endogenous opiates (Spiegel & Albert, 1983). Rather, hypnosis seems to in-
volve brain activation via dopamine pathways (Lichtenberg, Bachner-Mel-
man, Gritsenko & Ebstein, 2000; Raz, 2005; Spiegel & King, 1992). Thus, it
is not surprising that hypnosis, which mobilizes attention pathways in the
brain, can be used effectively to reduce pain perception and attendant anxi-
ety.

D. Meditative States and Mindfulness

Mindfulness therapy is simply being “aware,” aware of what you are
choosing to think moment by moment, and then learning simple techniques
to evaluate your own thoughts for what they really are: just glitches in your
mind. Mindfulness is the detachment from our mind, from our self. Once
you become aware of your inner thoughts, you will learn how to stop your
own reactions to the “stressors” (triggers) in your own life.
Mindfulness is a common translation of a term from Buddhist psycholo-
gy that means awareness or bare attention. It is frequently used to refer to a
way of paying attention that is sensitive, accepting, and independent of any
thoughts that may be present. Differences can be discerned in how different
practitioners, many different religions, and ancient philosophies use mind-
50 Clinical Hypnosis in Pain Therapy and Palliative Care

fulness. Some of these reflect the hazards of translation, and others reflect
long-standing ambiguities within Buddhist psychology.
In this book, the author explains numerous distinct types of mindfulness
in many different philosophies and religions that we can use in pain therapy
and in palliative care as spiritual care, not only at the end of life, but also in
our everyday life.

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 Chapter III

THE RELATIONSHIP BETWEEN CLINICAL

HYPNOSIS AND MINDFULNESS: A NEW
CLASSIFICATION OF MODIFIED STATES
OF CONSCIOUSNESS

n neurophysiology, an altered state of consciousness, also called altered

I state of mind, is any condition that is significantly different from a normal
waking beta wave state. The expression was used as early as 1966 by Arnold
M. Ludwig and brought into common usage in 1969 by Charles Tart. It
describes induced changes in one’s mental state, almost always temporary.
The material in this chapter was originated from an intuition based on
self-knowledge by my father, Dr. Angelico Brugnoli, M.D., born in Verona,
Italy, in 1929. He was a pioneer in clinical hypnosis in Italy: in 1965, he
founded, with some colleagues and friends, the Italian Institute for the Study
of Psychotherapy and Clinical Hypnosis “H. Bernheim.” I was very lucky to
be one of their students and to have Angelico Brugnoli as father and master.
He has been studying the different modalities of modified states of con-
sciousness for many years and I am very grateful to him for explaining his
intuitions for a new approach and classification to me.
There are some states in which consciousness seems to be abolished,
including sleep and coma. There are also a variety of circumstances that can
change the relationship between the mind and the world, producing what are
known as altered or modified states of consciousness, clinical hypnosis,
mindfulness, and other meditative states. Some modified states occur natu-
rally; others can be produced by drugs or brain damage. Altered states can
be accompanied by changes in thinking, disturbances in the sense of time,
feelings of loss of control, changes in emotional expression, alterations in
body image, and changes in meaning or significance. The two most widely
accepted modified states are sleep and dreaming. Although dream sleep and

55
56 Clinical Hypnosis in Pain Therapy and Palliative Care

nondream sleep appear very similar to an outside observer, each is associat-

ed with a distinct pattern of brain activity, metabolic activity, and eye move-
ment and also with a distinct pattern of experience and cognition. During
ordinary nondream sleep, people who are awakened report only vague and
sketchy thoughts, and their experiences do not cohere into a continuous nar-
rative.
As explained in the first chapter, the author prefers to talk about modified
states of consciousness and in this classification will describe only the physio-
logical states of consciousness, obtained with hypnosis, meditative states, and
mindfulness, and not the pathological states or those induced by drugs.
We can now begin to look at a conceptual framework that the author has
been developing for several years about the nature of consciousness, and
particularly about the nature of states and stages of consciousness.
Popular ideas about consciousness suggest the phenomenon describes a
condition of being aware of one’s awareness, or self-awareness. Efforts to
describe consciousness in neurophysiological terms have focused on describ-
ing networks throughout the brain that develop awareness of the qualia,
developed by other networks. This book also discusses a new methodologi-
cal classification in research, from the neurophysiological point of view, of
the different stages of consciousness.
Many people make distinctions among only a few states of consciousness
because they experience just a few. Everyone, for example, probably distin-
guishes among ordinary waking state, dreaming, and dreamless sleep. Still
others, who have personally experimented with modified states, may want to
distinguish between meditative and hypnosis-induced states. Consciousness
is not just a bunch of different levels; it is a group of different states, of which
the best worked out are those involving wakefulness, the different stages of
sleep, and the different stages of concentration.

INTRODUCTION: THE MODIFIED

STATES OF CONSCIOUSNESS

The physiological mechanisms that underlie consciousness and uncon-

sciousness, are the sleep/wake mechanisms. Sleep is a state of physiological
reversible unconsciousness. The change from that state to awake state is
mediated by the reticular activating mechanism.
In 1929, the German psychiatrist Hans Berger discovered that the elec-
trical activity within the brain could be recorded as brain waves and that
these waves changed as awake gave way to sleep. This discovery of the elec-
troencephalogram (EEG), as it is now known, made the objective study of
 The Relationship Between Clinical Hypnosis and Mindfulness 57

sleep possible. Loomis provided the earliest detailed description of various

stages of sleep in the mid-1930s, and in the early 1950s, Aserinsky and
Kleitman identified rapid eye movement: the REM sleep.
Sleep is generally divided into two broad types: nonrapid eye movement
(NREM) sleep and REM sleep two. Based on EEG changes, NREM is divid-
ed further into four stages (stage I, stage II, stage III, stage IV). NREM and
REM occur in alternating cycles, each lasting approximately 90 to 100 min-
utes, with a total of four to six cycles.
By detecting synchronous activity of cortical neurons and recording volt-
age fluctuations in terms of the amplitude of the resulting waves and their fre-
quency, the EEG is thus used to differentiate the neurophysiological changes
in alertness and sleep stages. For the analysis of the stages of sleep and awake
state, EEG frequencies are conveniently grouped into bands:

• Delta: 0.5 to 4 Hz. Delta is the frequency range up to 4 Hz. It tends to

be the highest in amplitude and the slowest waves. It is seen normally
in adults in slow wave sleep.
• Theta: 4 to 8 Hz. Theta is the frequency range from 4 Hz to 8 Hz
regardless of their sources. Cortical theta is seen normally in young
children. It may be seen in drowsy, meditative, or sleeping states or in
arousal in older children and adults but not during the deepest stages
of sleep. Cortical theta rhythms, observed in human scalp EEG, are a
different phenomenon, with no clear relationship to the hippocampus.

Theta frequency EEG activity is also manifested during some short term
memory tasks (Vertes, 2004). Studies suggest that they reflect the “online”
state of the hippocampus, one of readiness to process incoming signals
(Buzsáki, 2002). Conversely, theta oscillations have been correlated to vari-
ous voluntary behaviors (exploration, spatial navigation, etc.) and alert states
(piloerection, etc.) in rats (Vanderwolf, 1969), suggesting that it may reflect
the integration of sensory information with motor output (Bland & Oddie,
2001). A large body of evidence indicates that theta rhythm is likely involved
in spatial learning and navigation (Buzsáki, 2005).

• Alpha: 8 to 12 Hz. Alpha is the frequency range from 8 Hz to 12 Hz.

Hans Berger named the first rhythmic EEG activity he saw the “alpha
wave.” It is brought out by closing the eyes and by relaxation. It was
noted to attenuate with eye opening or mental exertion.
• Sigma: 12 to 14 Hz. Sleep spindles (sometimes referred to as “sigma
bands” or “sigma waves”) may represent periods when the brain is in-
hibiting processing to keep the sleeper in a tranquil state.
58 Clinical Hypnosis in Pain Therapy and Palliative Care

• Beta: 14 to 30 Hz. Beta is the frequency range from 14 Hz to about 30

Hz. It is seen usually on both sides in symmetrical distribution and is
most evident frontally. Low amplitude beta with multiple and varying
frequencies is often associated with active, busy, or anxious thinking
and active concentration.
• Gamma: 30 to 50 Hz. Gamma is the frequency range approximately 26
to 100 Hz. Gamma rhythms are thought to represent binding of dif-
ferent populations of neurons together into a network for the purpose
of carrying out a certain cognitive or motor function.

EEG data are combined with those from concurrent recording of eye
movements, from the electro-oculogram (EOG), and muscle tone from the
electromyogram (EMG) to define the states of sleep and wakefulness. In con-
trast to wakefulness (beta and gamma waves), sleep is characterized by high-
er voltages and slower waves, a pattern called synchronized EEG. NREM
sleep is the usual term for this state. In humans, NREM sleep is further sub-
divided into four Stages I through IV, which depend on the extent of EEG
slowing, especially in the delta frequency range. Stage II is notable for the
presence of spindles, which are waxing and waning bursts of frequencies, in
the sigma band. Stages III and IV, with delta waves providing more than 50
percent of the signal, are further grouped under the term slow wave sleep
(SWS).
During this state, the EOG can show gradual rolling eye movements, and
there is low or minimal muscle activity. Slow sleep is interrupted by periods
of REM (i.e., active or paradoxical) sleep, when, despite all the overt signs of
continuing sleep, the activity of the brain is remarkably different. In fact, the
EEG in humans during REM sleep is essentially identical to that recorded
during wakefulness, but the EOG reveals rapid bursts of eye movements,
hence the name of the state. Importantly, and in all species, the EMG shows
the complete loss of muscle tone (i.e., atonia) that is a characteristic of REM
sleep. The reverse change, from wakefulness to sleep, is also an active pro-
cess effected by an arousal inhibitory mechanism based on a partial block-
ade of the thalamus and upper brainstem associated with thalamic sleep spin-
dles and also with cortical subdelta activity (<1 Hz). The deactivation of the
thalamus, has been demonstrated both electrically and by positron emission
tomography (PET) during deep sleep (Evans, 2003). The structure of sleep
across the night, as expressed by the hypnogram, is characterized by repeat-
ed transitions between the different states of vigilance: awake, light, and deep
NREM sleep and REM sleep.
Normally, awake state or wakefulness is associated with instant aware-
ness (defined as the ability to integrate all sensory information, from the
 The Relationship Between Clinical Hypnosis and Mindfulness 59

external environment and the internal environment of the body). Awareness

may be a function of the thalamocortical network in the cerebral hemi-
spheres that forms the final path, of the sleep/wake mechanism. Anatomical
and physiological studies suggest that there may be a double thalamocortical
network being one relating to cortical and thalamic areas, with specific func-
tions, and the other being global, involving all cortical areas and so-called
nonspecific thalamic nuclei. The global system might function as a cortical
integrating mechanism, permitting the spread of information between the
specific cortical areas and thus underlying awareness. The global system may
also be responsible for much of the spontaneous and evoked electrical activ-
ity of the brain. The cognitive change between sleep and wakefulness is ac-
companied by changes in the autonomic system, the cerebral blood flow,
and the cerebral metabolism.
Awareness is an essential component of total consciousness (defined as
continuous awareness of the external and internal environment, both past
and present, together with the emotions arising from it). In addition to aware-
ness, full consciousness requires short-term and explicit memory and intact
emotional responses (Evans, 2003). At the cellular level, it has been proposed
that, under the influence of circadian and homeostatic factors, transitions be-
tween wake and sleep may be determined by mutually inhibitory interaction
between sleep-active neurons, in the hypothalamic preoptic area and wake-
active neurons in multiple arousal centres. These two fundamentally differ-
ent behavioral states are separated by the sleep onset and the sleep inertia
periods, each characterized by gradual changes in which neither true wake
nor true sleep patterns are present (Merica & Fortune, 2004).
The process of automatic sleep stage scoring consists of two major parts:
feature extraction and classification. Features are normally extracted from
the polysomnographic recordings, mainly EEG signals. The EEG is consid-
ered a nonstationary signal, which increases the complexity of the detection
of different waves in it. Your brain waves move fast when you are awake.
These are known as “beta” waves. When you lie down, close your eyes, and
become drowsy, your brain wave tend to start slowing down; this is known
as the “alpha” state. Five minutes into the alpha state, your body slips into
the Stage I sleep.

The Stages of Sleep

Stage I
Stage I sleep is also referred to as drowsiness or presleep and is the first
or earliest stage of sleep. The earliest indication of transition from wakeful-
60 Clinical Hypnosis in Pain Therapy and Palliative Care

ness to stage I sleep (drowsiness) usually consists of a combination of (1) drop

out of alpha activity and (2) slow rolling eye movements. Stage I is light
sleep. You experience a drifting in and out of sleep. You can be easily awak-
ened. Your eye movement and body movements slow down. You may expe-
rience sudden jerky movement of your legs or other muscles. These are
known as hypnic myoclonia or myoclonic jerks. These “sleep starts” can give
a sensation of falling. They are caused by the motor areas of the brain being
spontaneously stimulated.

Stage II
Stage II is the predominant sleep stage, during a normal night’s sleep.
The distinct and principal EEG criterion to establish stage II sleep is the
appearance of sleep spindles. The presence of sleep spindles is necessary and
sufficient to define stage II sleep. Another characteristic finding of stage II
sleep is the appearance of K complexes, but because K complexes are typi-
cally associated with a spindle, spindles are the defining features of stage II
sleep. Except for slow rolling eye movements, all patterns described under
stage I persist in stage II sleep.
Around 50 percent of your time sleeping is spent in stage II sleep.
During this stage, eye movement stops, and your brain waves (a measure of
the activity level of the brain) become slower. There will also be brief bursts
of rapid brain activity, called sleep spindles. The criteria of stage II sleep—
spindles and K complexes—are usually easy to identify and are less subject to
over interpretation or misinterpretation than are the patterns of stage I sleep.
Sleep spindles have a frequency of 12 to 16 Hz (typically 14 Hz).

Stage III
Stages III and IV of sleep are usually grouped together as “slow wave
sleep” or “delta sleep.” Stage III is the first stage of deep sleep. The brain
waves are a combination of slow waves and faster waves. During stage III
sleep, it can be very difficult to wake someone up. If you are woken up dur-
ing this stage, you may feel groggy and disoriented for several minutes.

Stage IV
Stage IV sleep is the second stage of deep sleep. In this stage, the brain
is making the slow delta waves almost exclusively. The distinction between
stage III and stage IV sleep is only quantitative and has to do with the
amount of delta activity. Stage III is defined by delta activity that occupies
20 to 50 percent of the time, whereas in stage IV, delta activity represents
 The Relationship Between Clinical Hypnosis and Mindfulness 61

greater than 50 percent of the time. In this stage, it is also very difficult to
wake someone up. Both stages of deep sleep are important for feeling re-
freshed in the morning. If these stages are too short, sleep will not feel satis-
fying.

The REM Stage of Sleep

REM sleep is defined by (1) rapid eye movements, (2) muscle atonia, and
(3) EEG desynchronization (compared to slow wave sleep).
REM sleep normally is not seen on routine EEGs because the normal
latency to REM sleep (100 minutes), is well beyond the duration of routine
EEG recordings (approximately 20–30 minutes).
Sleep typically and predictably proceeds from one stage to the next
(Carskadon & Dement, 2005). As sleep progresses, a stepwise descent from
wakefulness to stage I, through to stage IV, sleep occurs, followed by an
abrupt ascent back through a stage II, like an EEG with spindles towards
stage I with irregular theta activity. At stage I, however, the first REM sleep
episode usually occurs, about 70 to 90 minutes after sleep onset in the
human. Following the first REM sleep episode, the sleep cycle repeats, with
the appearance of NREM sleep. Then, about 90 minutes after the start of the
first REM sleep period, another episode occurs. This rhythmic cycling per-
sists throughout the night. Hence the sleep cycle duration is about 90 min-
utes in humans, and, on average, REM sleep episodes last for about 20 min-
utes, gradually increasing in duration throughout the night. Over the course
of the night, delta wave activity declines, and as sleep progresses, the EEG
of NREM sleep is comprised increasingly of waves of higher frequencies and
lower amplitude.
These descriptions of the physiological basis for consciousness and sleep
stages constitute an important first step toward the integration of behavioral
and neurophysiological evidence and theory of modified states of conscious-
ness and the relationship among sleep, hypnosis, and meditative states.
All the electrical changes in our brain are in practice electrochemical.
That is, complex chemical changes underlie the electrical correlates of atten-
tion. To take just one instance, the passage of electrical signals from nerve
cell to nerve cell depends on a range of neurotransmitter substances. Each of
the neural systems already discussed depends on the action of one, or some-
times combinations, of these neurochemicals. One transmitter substance,
noradrenaline, is particularly prominent in alerting processes, along with its
close relative transmitter substance dopamine. The total amount of another
transmitter substance, acetylcholine, in the brain, is found to be inversely
related to the level of CNS activity.
62 Clinical Hypnosis in Pain Therapy and Palliative Care

Neurophysiology of Concentration and Attention

Neural systems regulate attention to activate consciousness, concentra-
tion, and awareness. The author calls this framework for studying conscious-
ness a new systems approach because she takes the position that conscious-
ness, as we know it, is not a group of isolated psychological functions but a
system—an interacting, dynamic configuration of neurophysiological and
neuropsychological components—that performs various functions in greatly
changing environments. Knowledge about the nature of the components is
useful, but to understand any system fully, we must also consider the envi-
ronments with which it deals and the goals of its functioning. So in trying to
understand human consciousness, we must get the feel of the whole system
as it operates in its world, not just study isolated parts of it.
In this book, we will not examine pathological modified states of con-
sciousness, such as coma states or states of modified consciousness through
drugs or medicines. A wide variety of unusual experiences in different states
of consciousness, of changes in time, emotion, memory, sense of identity,
cognitive processes and feelings will be studied.
Our ordinary state of consciousness is not something natural or given but
a highly complex construction. As we look at consciousness closely, we see
that it can be analyzed into many parts. These parts function together in a
pattern, however. They form a system (Tart, 1972). The term states of con-
sciousness has come to be used too loosely to mean whatever is on one’s
mind at the moment.
To understand the constructed system we call a state of consciousness, we
begin with some theoretical postulates based on human and neurophysio-
logical experience.
One postulate is the existence of a basic awareness. Because some voli-
tional control over the focus of awareness is possible, we generally refer to it
as attention/awareness. We must also recognize the existence of self-aware-
ness, the awareness of being aware.
In recent years, there has been significant neurophysiological uptake of
meditation and related relaxation techniques as a means of alleviating stress
and maintaining good health. Despite its popularity, little is known about the
neural mechanisms by which meditation works, and there is a need for more
rigorous investigations of the underlying neurobiology. Several EEG studies
have reported changes in spectral band frequencies during hypnosis and
meditation inspired by techniques that focus on concentration.
In 2009, Lagopoulos and colleagues examined EEG changes during non-
directive (concentrative) meditation. The investigational paradigm involved
20 minutes of acme meditation, during which the subjects were asked to
 The Relationship Between Clinical Hypnosis and Mindfulness 63

close their eyes and adopt their normal meditation technique, as well as a
separate 20-minute quiet rest condition during which the subjects were asked
to close their eyes and sit quietly in a state of rest. Both conditions were com-
pleted in the same experimental session with a 15-minute break in between.
Significantly increased theta wave power was found for the meditation con-
dition, when averaged across all brain regions. On closer examination, it was
found that theta was considerably greater in the frontal and temporal central
regions, as compared with the posterior region. There was also a significant
increase in alpha power under the meditation condition compared with the
rest condition, when averaged across all brain regions, and it was found that
alpha was considerably greater in the posterior region, as compared to the
frontal region (Lagopoulos et al., 2009). These findings from this study sug-
gest that nondirective meditation techniques alter theta and alpha EEG pat-
terns significantly more than regular relaxation in a manner that is perhaps
similar to methods based on mindfulness or concentration.
Gentle and medium self-hypnosis is a natural state of mind we go into
everyday. Getting caught up in a good book or movie or studying for an
exam and losing track of time are simple examples of being in the hypnosis
state. A person doing positive statements or, for that matter, visualizing a
scene or desired outcome is using a form of self-hypnosis.
To go into hypnosis and enter the subconscious mind, you must bypass
the critical factor of the conscious mind, the thought stream. This can be
done quickly, easily, and effectively. One does not need to be relaxed to go
into a trance; relaxation is a by-product of having been in hypnosis. Why?
Because you have relaxed the body and mind together, which allows the ner-
vous system to flush out all the pent-up stress and tension. When the mind
relaxes, it can let go. Why is hypnosis the same as meditation?
Meditation describes a state of concentrated attention to some object of
thought or awareness. It usually involves turning the attention inward to the
mind itself. The neurophysiological shifts, the same EEG patterns, the bodi-
ly tranquility, the pleasures of mental freedom are all part of all the modified
stages of consciousness.
There are many different states of hypnosis and meditation and there are
many neurophysiological correlations. The definition of true meditation is
the absence of all thought and to just be. If a person is mulling over a prob-
lem during meditation, he or she is, in reality, now contemplating the situa-
tion and is no longer considered to be doing meditation. These techniques
can be used, as clinical hypnosis is, for stress and pain management. With the
activation of spiritual consciousness in people who are dying, they are excel-
lent ways to reduce suffering.
64 Clinical Hypnosis in Pain Therapy and Palliative Care

The contraindications for the use of relaxation, hypnosis, and meditative

stages are the same general cautions that apply to the use of other fantasy or
imagery tools. The use of this way may be ill-advised with patients who have
difficulty distinguishing between fact and fantasy. Patients with a dissociative
history, such as in dissociative identity disorder, may find the experiences
too threatening or disorienting because of the tendency for altered states to
weaken or lower the protective barriers of dissociative amnesia.
The similarities and differences between hypnosis and meditation, are
used to shed light on perennial questions:

1. Does hypnosis involve an altered state of consciousness?

2. Does a hypnotic induction increase awareness?

A model for hypnosis should include altered states as well as capacity for
imaginative involvement and expectations. Hypnosis is a great way to
enhance meditation and awareness. You can use the scientific approach of
hypnosis to enter your subconscious mind. Once in a trance, you can release
the old thinking patterns. Once you have done that and your mind is clear,
you can move into a quiet state of meditation and awareness. You have re-
connected with yourself as a spirit.
That is the meditative state. Relaxation, hypnosis, self-hypnosis, and
mindfulness are the doors to get there. Clinical hypnosis, consciousness, and
mindfulness through meditative states are already part of psychological and
spiritual care in chronic diseases.
In everyday life, as each of us lives in our “normal” state of conscious-
ness, our awareness is usually focused on the particular thoughts, emotions,
or perceptions we experience at the surface level of reality. They are the
experiences and perceptions we move through in our life in the outer world
or the thoughts and feelings that we have in our inner world. As we move
through life, we perceive, think, act, and feel with the assistance of our
“thinking mind,” the active portion of our mind, that deals with this surface
level of reality through the use of thoughts, feelings, interpretations of per-
ceptions, and actions. Our awareness is usually identified with, preoccupied
with, and attached to whichever of these specific activities we engage in
through the use of this thinking mind. Although all these particular compo-
nents of our life are important, when we remain identified with, and there-
fore, limited to, these surface activities and these surface appearances of our
deeper being, we are far less able to perceive and act from a more funda-
mental level of greater awareness. The tendency of our thinking mind to re-
main preoccupied with the particulars of life inhibits our ability to move be-
 The Relationship Between Clinical Hypnosis and Mindfulness 65

yond the level of pure consciousness that is actually the source of all these
particular states of mind.
In the practice of deep hypnosis and meditation, we seek to free our-
selves from this mental chatter in which our thinking mind engages and in-
stead seek connection to the higher level of our being. Meditation is a
process by which we seek to recondition our conscious awareness so that we
release our attachment to the surface level of reality and instead allow the
awareness to gravitate toward a state of pure awareness, pure consciousness.
Mindfulness is the meditative state that we can reach in many different reli-
gions and prayers.
In the learning and practice of meditation, mindfulness, and self-hypno-
sis, we can develop some inner sense of self-awareness, a pure awareness be-
yond habitual identifications with the thoughts, feelings, and perceptions at
the surface level of the mind. It is an instantaneous reversal in the focus of
awareness, and there is often a sense of elation or euphoria at this point
where the inward awareness expands. This point is not a point in time or
space, but it is the pure state of being. It is subtle, yet discernible with prac-
tice. This precise point of change in awareness, is called the point of pure
being.
The purpose of hypnosis and self-hypnosis, meditation and mindfulness
in pain therapy and palliative care is to awaken in us the skylike nature of
mind and to introduce us to that which we really are, our unchanging pure
awareness, which underlies the whole of life and death. Clinical hypnosis,
meditation, and prayers are intensely personal and spiritual experiences. The
desired purpose of each meditation technique is to channel our awareness
into a more positive direction by totally transforming one’s state of mind. In
the stillness and silence of meditation, we glimpse and return to that deep
inner nature that we have so long ago lost sight of amid the busyness and dis-
traction of our minds.
We do not know who we really are or what aspects of ourselves we
should identify with, or believe in. So many contradictory voices, dictates,
and feelings fight for control over our inner lives that we find ourselves scat-
tered everywhere, in all directions, leaving nobody at home (Rinpoche,
2002).

When you abandon every desire that rises up within you, and when you become
content with things as they are, then you experience inner peace. When your
mind is untroubled by misfortune, when you desire no pleasures, when your
emotions are tranquil, and when you are free from fear and anger, then you
experience inner calm.
66 Clinical Hypnosis in Pain Therapy and Palliative Care

When you are free from all attachments, when you are indifferent towards suc-
cess and failure, then you experience inner serenity.

When you can withdraw your senses from pleasures of the senses, just as a tor-
toise withdraws its limbs, then you experience inner wisdom.

When no pleasure and no desire can touch the soul, then you experience the
highest state of consciousness. (Bhagavad-Gita, 2.55–61)

Different stages of consciousness can be experimented with through hyp-

nosis and meditative stages, which must be done through psychophysical
states of concentration.
Let us now look at the basic elements of this new systems approach, the
basic postulates, about what lies behind the phenomenal manifestations of
experience. The slow path toward the states of consciousness, will not only
cure our pain and suffering but will also benefit us in knowing ourselves, our
higher consciousness and our internal personal world and of all the hidden
qualities that every person has within their rational and intuitive mind.
There are many types of mental concentration and consciousness, states
linked to hypnosis and meditative states, and there are many different rela-
tionships among meditative states, mindfulness, relaxation, self-hypnosis,
and hypnosis. When our mind is focused, our energies are not dissipated on
irrelevant activities or thoughts. This is why developing concentration is
essential to anyone who aspires to take charge of his or her life. Concen-
tration has been defined as “the ability to direct one’s thinking in whatever
direction one would intend.” We all have the ability to concentrate some of
the time. At other times, however, our thoughts are scattered, and our minds
race from one thing to another. To deal with such times, we need to learn and
practice concentration skills and strategies. To concentrate, we have to learn
a skill, and as with any skill this means practice, repeated day after day, until
we achieve enough improvement to feel that we can concentrate when we
need to. Our ability to concentrate depends on

• commitment
• enthusiasm for the task
• skill at doing the task
• our emotional and physical state
• our psychological state
• our environment
 The Relationship Between Clinical Hypnosis and Mindfulness 67

This power can be described as focused attention. It is the ability to direct

the attention to one single thought or subject, to the exclusion of everything
else.
Attention is one of the most intensely studied topics within psychology
and cognitive neuroscience. In his textbook Principles of Psychology, William
James remarked, “Everyone knows what attention is. It is the taking posses-
sion by the mind, in clear and vivid form, of one out of what seem several
simultaneously possible objects or trains of thought. Focalization, concentra-
tion, of consciousness are of its essence” (1890).
While breathing, we do not need to pay attention to each inhalation and
exhalation. We become conscious about the process of breathing only when
we have some difficulty with breathing, such as when our nose is clogged
because of a cold, or when we are in an unventilated room. It is the same
with thinking. We become conscious of the constant onslaught of our thoughts
and of our inability to calm them down only when we need to concentrate,
solve a problem, or study. We are also acutely aware of them when we have
worries or fears. Concentration is exclusively to focus on, to give one’s atten-
tion to, the task at hand by habitually bringing one’s digressed attention back
to quicker focus than that of attention and to focus that attention more accu-
rately. Concentration or concentrating is also being able to refocus attention
if and when one is much distracted or immediately after any rest. The
strength of the ability to concentrate or focus of attention for concentration
is by mental conditioning. Concentration, attention, focus, involve the
thought. The thought outwardly directs itself creatively when uncontrolled.
Focus and refocus and attention and concentration, however, are aided
by a network of nerve fibers within the brainstem. Because this reticular acti-
vating system dispatches signals to other parts of the brain, the brain is capa-
ble of being stimulated for attention, also by conscious attitude. Attention is
a very basic function that often is a precursor to all other neurological and
cognitive functions. As is frequently the case, clinical models of attention dif-
fer from investigation models. One of the most used models for the evalua-
tion of attention in patients with very different neurological pathologies is the
model of Sohlberg and Mateer (1989). This hierarchic model is based on the
recovering of attention processes of brain-damaged patients after coma. Five
different kinds of activities of growing difficulty are described as the model,
connecting with the activities that patients could do as their recovering pro-
cess advanced.
Attention is part of focus, concentration, a component of intelligence.
Attention, the focus of attention, only lasts a few seconds and is the act or
process of focusing on one or more particulars in the content of one’s con-
sciousness to give special clearance to the essentials by restricting one’s sen-
68 Clinical Hypnosis in Pain Therapy and Palliative Care

sory input, from the environment’s unwanted aspects. Attention is never en-
tire; it digresses but can be refocused at will.
Concentration and attention are subject to will. When one is trying to
concentrate—paying attention—waves of electricity called alpha rhythms are
given by one’s brain at a frequency of 8 to 12 Hz on an EEG. Practice helps
improve attention.
Attention is best described as the sustained focus of cognitive resources
on information while filtering or ignoring extraneous information.
F OCUSED ATTENTION. This is the ability to respond discretely to specific
visual, auditory, or tactile stimuli.
Sustained Attention. This refers to the ability to maintain a consistent
behavioral response during continuous and repetitive activity.
S ELECTIVE ATTENTION. This level of attention refers to the capacity to
maintain a behavioral or cognitive set in the face of distracting or competing
stimuli. Therefore, it incorporates the notion of freedom from distractibility”
ALTERNATING ATTENTION. It refers to the capacity for mental flexibility
that allows individuals to shift their focus of attention and move between
tasks having different cognitive requirements.
DIVIDED ATTENTION. This is the highest level of attention, and it refers
to the ability to respond simultaneously to multiple tasks or multiple task de-
mands.
This model has been shown to be very useful in evaluating attention in
very different pathologies, correlates strongly with daily difficulties and is es-
pecially helpful in designing stimulation programs such as attention process
training, a rehabilitation program for neurological patients, of the same
authors (Solberg & Mateer, 1989).
The external manifestations of attention are accompanied by physiolog-
ical changes, particularly within the brain and nervous system. These physi-
ological changes can be studied by examining responses to novel stimuli.
Growing out of Pavlov’s research, the orienting response to novel stimuli has
come to be characterized by a broad complex of physiological changes.
These include changes in heart rate, in the electrical conductivity of the skin,
in the size of the pupils in the eyes, in the pattern of respiration, and in the
level of tension in the muscles. If the novel signal is an interesting one, the
heart transiently slows down; if it is startling, the heart transiently speeds up.
Most of the other types of change reflect similar reactions. Thus, the startling
signal increases the level of skin conductance and the size of the pupils, caus-
es respiration to pause or briefly become irregular, and increases tension in
certain muscles.
Sensory inputs travel through the brain via primary sensory pathways
that converge on a central relay structure, the thalamus, from which they are
 The Relationship Between Clinical Hypnosis and Mindfulness 69

sent to relatively specific and localized receiving areas in the higher (cortical)
levels within the brain. On their way from the sensory receptors to the thal-
amus, the signals pass an area of the brainstem and midbrain to which the
sensory pathways have lateral connections. This area, called the reticular for-
mation, is important in changing the overall level of arousal. When it is dam-
aged, the individual may be unarousable. It has interconnections with the
higher brain centers, and it projects pathways to the cerebral cortex. Unlike
the primary sensory projections, which are limited to specific sensory modal-
ities, many of the reticular formation cells respond to signals from any of the
sensory modalities. When this ascending reticular activating system is oper-
ating, the individual is alert, aroused, and attentive.
The reticular system seems to account physiologically for the sustained,
tonic shifts in an individual’s level of involvement with the environment,
including the control of sleep wakefulness. One nonspecific route to the cere-
bral cortex via the thalamus—the diffuse thalamic projection system—appears
to be concerned with moment to moment fluctuations in the focus of atten-
tion. Collectively, the primary sensory pathways associated areas of the cere-
bral cortex, and the more diffuse projection systems, cooperate in the process
of registering the incoming sensory signal, evaluating its contents, and mobi-
lizing brain resources in response to the demands made.
Inevitably, this account is an oversimplification. In the human brain,
other structures, particularly the hypothalamus, are involved in regulating
states of sleep and wakefulness; limbic structures, such as the hippocampus,
take part in arousal when rewards, punishments, or other emotional factors
are involved.
In many cases, attention produces changes in the EEG. Many animals,
including humans, produce gamma waves (40–60 Hz) when focusing atten-
tion on a particular object or activity (Kaiser & Lutzenberger, 2003). Most
experiments show that one neural correlate of attention is enhanced firing. If
a neuron has a certain response to a stimulus, when the animal is not attend-
ing to the stimulus, then when the animal does attend to the stimulus, the
neuron’s response will be enhanced, even if the physical characteristics of the
stimulus remain the same.
In a recent review, Knudsen (2007) describes a more general model tat
identifies some core processes of attention, with working memory at the cen-
ter:

• Working memory temporarily stores information for detailed analysis.

• Competitive selection is the process that determines which information
gains access to working memory.
70 Clinical Hypnosis in Pain Therapy and Palliative Care

• Through top-down sensitivity control, the higher cognitive processes can

regulate signal intensity in information channels that compete for ac-
cess to working memory, and thus give them an advantage in the pro-
cess of competitive selection. Through top-down sensitivity control,
the momentary content of working memory can influence the selec-
tion of new information and thus mediate voluntary control of atten-
tion in a recurrent loop: the endogenous attention (Pattyn, Neyt, Hen-
derickx & Soetens, E., 2008).
• Bottom-up saliency filters automatically enhance the response to infre-
quent stimuli or stimuli of instinctive or learned biological relevance:
the exogenous attention (Pattyn et al., 2008).

Working memory is a theoretical construct, within cognitive psychology as

to the structures and processes used for temporarily storing and manipulating
information in short-term memory. Many theories exist both as to the theoret-
ical structure of working memory and as to the role of specific parts of the
brain involved in working memory. Most research identifies that the frontal
cortex, parietal cortex, anterior cingulate, and parts of the basal ganglia are cru-
cial for its functioning. The neural basis of working memory mostly comes
from lesion experiments in animals and functional imaging in humans.
The term “working memory” was coined by Miller, Galanter, and
Pribram and was used in the 1960s in the context of theories that likened the
mind to a computer. Atkinson and Shiffrin (1968) also used this term, work-
ing memory to describe their short-term store. What we now call working
memory has been referred to as a “short-term store,” primary memory,
immediate memory, operant memory, or provisional memory (Fuster, 1997).
The short-term memory is the ability to remember information over a brief
period of time (in the order of seconds). Most theorists today use the concept
of working memory to replace or include the older concept of short-term
memory, thereby marking a stronger emphasis on the notion of manipula-
tion of information instead of passive maintenance.
Baddeley and Hitch (1974) introduced and made popular the multicom-
ponent model of working memory. Baddeley (2003) extended the model by
adding a fourth component—the episodic buffer—that holds representations
that integrate phonological, visual, and spatial information and possibly
information not covered by the slave systems (e.g., semantic information,
musical information).
Localization of brain functions in humans has become much easier with
the advent of brain imaging methods (PET and fMRI). This research has
confirmed that areas in the prefrontal cortex are involved in working mem-
ory functions. During the 1990s, much debate centered on the different func-
 The Relationship Between Clinical Hypnosis and Mindfulness 71

tions of the ventrolateral (i.e., lower) and the dorsolateral (higher) areas of the
prefrontal cortex. One view was that the dorsolateral areas are responsible
for spatial working memory and the ventrolateral areas for nonspatial work-
ing memory. Another view proposed a functional distinction, arguing that
ventrolateral areas are mostly involved in pure maintenance of information,
whereas dorsolateral areas are more involved in tasks, requiring some pro-
cessing of the memorized material. The debate is not entirely resolved, but
most of the evidence supports the functional distinction (Owen, 1997).
Research suggests a close link, between the working memory capacities
of a person and his or her ability to control the information from the envi-
ronment, which he or she can selectively enhance or ignore (Fukuda & Vogel,
2009). Such attention allows, for example, for the voluntary shifting in regard
to the goals of a person’s information, processing to spatial locations or ob-
jects, rather than to those that capture their attention due to their sensory
saliency (such as an ambulance siren). The goal directing of attention is dri-
ven by top-down signals from the prefrontal cortex that bias processing in
posterior cortical areas (Desimone & Duncan, 1995) and saliency capture by
bottom-up control from subcortical structures and the primary sensory cor-
tices (Yantis & Jonides, 1990).
The ability to override sensory capture of attention differs greatly among
individuals, and this difference closely links to their working memory capac-
ity. The greater a person’s working memory capacity, the greater his or her
ability to resist sensory capture (Fukuda & Vogel, 2009). Concentration
means holding the mind to one form or object steadily for a long time. When
our mind is focused, our energies are not dissipated on irrelevant activities
or thoughts. This is why developing concentration is essential to anyone who
aspires to take charge of his or her life. This skill is essential for every kind
of wellbeing. Without it, our efforts get scattered, but with it, we can accom-
plish great things.
Concentration has many uses and benefits. It assists in studying and
understanding faster; improves the memory; and helps in focusing on any
task, job, activity, or goal and achieving it more easily and efficiently. It is
also required for developing psychic abilities, and it is a powerful tool for the
efficient use of creative visualization. When this ability is developed, the
mind obeys us more readily and does not engage in futile, negative thoughts
or worries. We gain mental mastery, and we experience true peace of mind.
Concentration, attention, and working memory play a very great part in
the different states of consciousness. They are the basis of will. When they
are properly guided and directed toward the internal world for purposes of
introspection, they will analyze the mind and illumine very many astound-
ing facts for your awareness.
72 Clinical Hypnosis in Pain Therapy and Palliative Care

The force with which anything strikes the mind is generally in propor-
tion to the degree of attention bestowed upon it. Moreover, the great art of
awareness is concentration. Concentration is focusing of external conscious-
ness and inner consciousness. It is one of the signs of trained will. It is found
in people of strong mentality. It is a rare faculty. Attention and concentration
can be cultivated and developed by persistent practice. All the great people
of the world who have achieved greatness have risen up through this facul-
ty.
It is through the power of attention and concentration that our mind car-
ries out all its activities. Concentration may be either subjective and internal
or objective and external on any object. Throw your entire concentration
into whatever you happen to be doing at the moment. It is easy to fasten the
mind on an object that the mind likes best.
Concentration also plays an important role in meditation. Without it, the
mind just jumps restlessly from one thought to another, not allowing us to
meditate properly.
Concentration can be fun if approached in the right way. It should be
practiced with joy, fun, optimism, and understanding of its great possibilities.
It has to be approached in a positive manner and then success dawns.
Thought is a dynamic force. Thought moves. Thought creates. The mind
is intimately connected with the body. The mind acts upon the body, and the
body reacts upon the mind. Mind has influence over the body. A pure,
healthy mind means a healthy body. Grief in the mind weakens the body.
The body influences the mind also in its turn. If the body is strong and
healthy, the mind also becomes strong and healthy. If the body is sick, the
mind also becomes sick.
Sometimes you can find strong powers of concentration in yourself. To
do so, you need to practice special exercises on a daily basis. Here is what
you can gain by developing the concentration’s power:

• The ability to focus your mind

• Peace of mind
• Freedom from futile thoughts
• Better memory
• Better attention
• Better consciousness
• Better awareness
• Self-confidence
• Better knowledge of Inner self
• The ability to study and comprehend more quickly
• Inner happiness
 The Relationship Between Clinical Hypnosis and Mindfulness 73

• Enhanced capability to develop psychic abilities

• Enhanced capability to develop spiritual abilities
• More powerful and efficient use of creative work
• Enhanced ability to meditate
• Pain and suffering relief
• Awareness.

When the mental rays are concentrated on the mind’s illumination, the
consciousness and higher self begin. Be introspective and watch the mind
carefully.
We can divide the many different states of consciousness, in the distinct
modalities of mind’s concentration so it is easier to understand the neuro-
physiological and psychological correlation between them. Concentration
seems in some way, to be at the very core of mental activity. Training the
mind in the variety of ways concentration is the beginning.

INTRODUCTION: THE MODIFIED

STATES OF CONSCIOUSNESS

1. ACTIVE CONCENTRATION: TYPES AND TECHNIQUES

A. Awake state, wakefulness
B. Relaxed awakening
C. Progressive relaxation
D. Light sleep (consciousness and the stages of sleep)
E. Repetitive vocal and mental prayer
F. The exercises and physical postures of Yoga
2. PASSIVE CONCENTRATION: TYPES AND TECHNIQUES
A. Autogenic Training of Schultz
B. Light hypnosis, medium hypnosis, and self-hypnosis
C. Lucid dreams, hypnagogic and hypnopompic states
D. The REM phase of sleep
E. Free mental prayer and mental meditation
F. The breathing exercises
3. DEEP CONCENTRATION: TYPES AND TECHNIQUES
A. Deep sleep
B. Extreme thoughts: the ‘flow state’
C. Medium self hypnosis
D. Deep hypnosis
E. Meditative stages of contemplation and Mindfulness
74 Clinical Hypnosis in Pain Therapy and Palliative Care

4. SUPERIOR CONCENTRATION (HIGHER CONSCIOUSNESS):

TYPES AND TECHNIQUES
A. Medium to deep self-hypnosis: Annulment of the normal consci-
ousness;
A. The Higher Consciousness
B. Absorption
C. Meditative stages: awareness, contemplation and ecstasy, living with
God
5. TRUE CONCENTRATION OR AWARENESS ACTIVATION:
TYPES AND TECHNIQUES
A. Deep self hypnosis
B. Contemplation and mystical states leading to Spiritual Enlighten-
ment: Samadhi, living in God

THE STAGES OF CONSCIOUSNESS

Concentration Stages of Meditative Meditative Meditative Stages

Stages Relaxation Stages in Stages in in Hindu Religion
and Hypnosis Christianity Buddhism (The Yoga Saltras
(The Noble of Patanjali)
Eightfold Path)

1. Active • wakefulness repetitive vocal Sila. It includes Yama and niyama.

Concentration • relaxed and mental - (vaca):
• vac - Ethical and dis-
awakening prayer speaking in a ciplined lifestyle:
• progressive truthful and control, indiffer-
relaxation nonhurtful way ence, detachment,
• light sleep • karman renunciation,
(kammanta): charity, celibacy,
acting in a non- vegetarianism,
harmful way cleanliness, and
- ivana
• aj - -
(ajiva): nonviolence.
a nonharmful Asanas involves
livelihood the development
and care of the
body through the
use exercises and
postures yoga.
Pranayama breath-
ing exercises.
Pratyahara involves
meditation by
means of which
one withdraws
consciousness from
the senses.
 The Relationship Between Clinical Hypnosis and Mindfulness 75

THE STAGES OF CONSCIOUSNESS—Continued

Concentration Stages of Meditative Meditative Meditative Stages

Stages Relaxation Stages in Stages in in Hindu Religion
and Hypnosis Christianity Buddhism (The Yoga Saltras
(The Noble of Patanjali)
Eightfold Path)

2. Passive • light sleep free mental Prajña- is the Pranayama

Concentration • deep relaxation prayer and wisdom that breathing exercises.
• light and mental purifies the mind. Pratyahara involves
medium meditation • ditthi: viewing meditation, by
hypnosis and reality as it is, means of which
self-hypnosis not just as it one withdraws
appears to be consciousness from
• sankappa: the senses.
intention of
renunciation,
freedom, and
harmlessness

3. Deep • deep sleep stage of - ama

vyay -
Concentration • deep relaxation contemplation - -
(vayama): Dharana, which
• extreme making an effort means concentra-
thoughts, flow to improve tion. An object of
• medium self- contemplation is
hypnosis held fixedly in the
• deep hypnosis mind.

4. Superior • medium to deep contemplation sati: awareness Dhyana occurs

Concentration hypnosis and and ecstasy to see things for when the sense of
self-hypnosis living with God what they are separateness of
• annulment of with clear con- the self from the
the normal sciousness, being object of concen-
• higher aware of the tration disappears
consciousness present reality = absorption
within oneself,
without any
craving or
aversion

5. True • deep hypnosis enlightenment -

samadhi samadhi absolute,
Concentration • annulment of living in God • understood as ecstatic cosmic
the normal means of access consciousness
consciousness to absorption enlightenment:
• higher enlightenment cosmic
consciousness • cosmic consciousness
consciousness

Source: Maria Paola Brugnoli, M.D. and Angelico Brugnoli, M.D.

76 Clinical Hypnosis in Pain Therapy and Palliative Care

1. ACTIVE CONCENTRATION: TYPES AND TECHNIQUES

A. Awake state, wakefulness

B. Relaxed awakening
C. Progressive relaxation
D. Light sleep (consciousness and the stages of sleep)
E. Repetitive vocal and mental prayer
F. The exercises and physical postures of Yoga

A. Awake State, Wakefulness

Wakefulness is the absence of sleep and is marked by consciousness,
awareness, and activity. It occurs when the human body is completely vigi-
lant, and above all when the cerebral cortex keeps all the circuits perfectly
open to all sensory stimulation coming from the outside through the five
senses and also through other superficial or deep stimulations. Awake refers
to the state of being conscious and can be understood in biological terms as
the behavioral manifestation of the metabolic state of catabolism. It is the
daily recurring period in an organism’s life during which consciousness,
awareness, and all behaviors necessary for survival exist. Attention and
awareness can be volitionally directed to some extent. If asked to become
aware of the sensations in your left knee now, you can do so, but few would
claim anything like total ability to direct attention.
The physiological mechanisms of wakefulness and sleep are highly inter-
related. Wakefulness is defined by a low voltage fast frequency EEG pattern
called desynchronized or activated EEG that consists primarily of frequen-
cies in the beta and gamma ranges.
Wakefulness and EEG desynchronization require excitatory innervations
of the forebrain. Being awake depends on the discharge activity in several,
apparently redundant, parallel ascending neurotransmitter pathways. None
of these systems, which include glutamate, acetylcholine (ACh), and the
monoamines (serotonin and norepinephrine), is absolutely necessary for the
expression of wakefulness, but all appear to contribute ( Jones, 2005). Recent
research reveals that there are distinct differences in the active brain pro-
cessing and the specific neurochemical systems involved in the two states.
There are specific neuronal pathways, transmitters, and receptors composing
the ascending arousal system that flow from the brainstem through the thal-
amus, hypothalamus, and basal forebrain to the cerebral cortex (Schwartz &
Roth, 2008). These scientists also discussed the mutually inhibitory interac-
tion between the core neuronal components of this arousal system and the
 The Relationship Between Clinical Hypnosis and Mindfulness 77

sleep-active neurons in the ventrolateral preoptic nucleus, which serves as a

brainstem switch, regulating the stability of the sleep-wake states.
This basic attention and awareness is something we can both conceptu-
alize and (to some extent) experience as distinct from the particular content
of awareness at any time. I am aware of a plant beside me at this moment,
and if I turn my head I am aware of a chair. The function of basic awareness
remains in spite of various changes in its content. A second basic theoretical
and experiential given is the existence, at times, of an awareness of being
aware—self-awareness. The degree of self-awareness varies from moment to
moment. At one extreme, I can be very aware that at this moment I am
aware, that I am looking at the plant beside me. At the other extreme, I may
be totally involved in looking at the plant but not be aware of being aware
of it (Tart).

Active Concentration in Aware State

This is the state of consciousness often used colloquially to describe be-
ing awake and aware and responsive to the environment, in contrast to being
asleep or in a coma state. In philosophical and scientific discussion, howev-
er, the term is restricted to the specific way in which humans are mentally
aware, in such a way that they distinguish clearly between themselves (the
thing being aware) and all other things and events. A characteristic of con-
sciousness is that it is reflective, an “awareness of being aware.” This “self-
awareness” may involve thoughts, sensations, perceptions, moods, emotions,
and dreams.

Active Concentration and Empathy State

There is some debate concerning how exactly the conscious experience
of empathy should be characterized during active concentration. Empathy
(from the Greek empatheia, “to suffer with”) is commonly defined as one’s
ability to recognize, perceive, and directly experientially feel the emotion of
another.
The human capacity to recognize the bodily feelings of another is relat-
ed to one’s imitative capacities and seems to be grounded in the innate
capacity to associate the bodily movements and facial expressions one sees
in another with the proprioceptive feelings of producing those correspond-
ing movements or expressions oneself. The basic idea is that by looking at
the facial expressions or bodily movements of another or by hearing their
tone of voice, one may get an immediate sense of how they feel. When seek-
ing to communicate with another, it may be helpful to demonstrate empathy
78 Clinical Hypnosis in Pain Therapy and Palliative Care

with the other, to open up the channel of communication with the other.
Empathy is not agreement or approval. It is simply understanding, the intu-
itive sensing of another person’s underlying feelings, wants, and psychologi-
cal dynamics, looking at the world from behind the other’s eyes. “What
would I be feeling if I were him or her?” Empathy in therapy is the expres-
sion of four basic skills:

• Pay attention: Attention is like a spotlight, illuminating its object.

• Inquire: Empathy is a process of discovery.
• Dig down: You can imagine the insecure, scared, suffering person
behind the other’s eyes.
• Double check: When we receive a communication, we need to tell the
sender “message received.”

B. Relaxed Awakening
The second type of active concentration, which is also defined as an
active disinhibited concentration, occurs when the patient inhibits all the five
senses and also other superficial or deep sensations. In this way, he or she
always keeps those circuits open, which can well elaborate and interpret all
the stimulations, that come through the activation of the limbic areas of the
brain.
The relaxed awakening is referred to as relaxed wakefulness. This is the
stage in which the body prepares for sleep. All people fall asleep with tense
muscles, their eyes moving erratically. Then, normally, as a person becomes
sleepier, the body begins to slow down. Muscles begin to relax, and eye
movement slows to a roll. Humans can experience the different stages of con-
centration through relaxed awakening, which need to be achieved through a
psychophysical concentration: physical because it is necessary to learn slow-
ly to inhibit the rationality of the cerebral cortex and psychological in order
to activate the limbic areas of the brain.
Studies of human evolution over the course of the centuries and millen-
nia and the neurophysiological development of the brain and the mind can
give us some help in providing medical therapy for the suffering of the body,
a therapy that we can learn through the path toward the relaxation techniques.

How Stress Affects the Body

Your emotional and physical reactions to stress are partly determined by
the sensitivity of your sympathetic nervous system. This system produces the
fight or flight reaction in response to stress and excitement, speeding up and
 The Relationship Between Clinical Hypnosis and Mindfulness 79

heightening the pulse rate, respiration, muscle tension, glandular function,

and circulation of the blood. If you have recurrent anxiety symptoms, either
major or minor lifestyle and emotional upsets may cause an overreaction of
your sympathetic system. If you have an especially stressful life, your sym-
pathetic nervous system may always be poised to react to a crisis, putting you
in a state of constant tension. In this mode, you tend to react to small stress-
es the same way you would react to real emergencies. The energy that accu-
mulates in the body to meet this “emergency” must be discharged in order
to bring your body back into balance. Repeated episodes of the fight or flight
reaction deplete your energy reserves and, if they continue, cause a down-
ward spiral that can lead to emotional burnout and eventually complete ex-
haustion.

Simple Relaxation Technique

This simple relaxation technique is usually used for body and mind
relaxation. This is where you will begin your journey into a new level of re-
laxation.
Each relaxed awakening and meditation serves a specific purpose, de-
pending on what you want to achieve. Choose freely and feel free to perform
more than one relaxation. Here are some hints to get you started:

• Make sure you are in a quiet room with no distractions.

• Allow some time for your relaxed awakening. These relaxations last
from 3 to 10 minutes.
• As you listen to the words of your inner self, picture the images that
are being described in your mind.
• Be open to the relaxed awakening:

My body . . . in time passing by . . .

is becoming more and more pleasantly calm . . .
Even more pleasantly calm . . .
and a feeling of great well-being . . .
Great calm . . .
great tranquility . . . it becomes part of me . . .
the time goes by . . .
I feel well . . . I feel well . . . I feel really well . . .
and everything else does not bother me anymore . . .

• For this exercise please repeat the sentences slowly, calmly, at least ten
times.
80 Clinical Hypnosis in Pain Therapy and Palliative Care

Relaxing Awakening Technique to Improve

Self Well-Being and Self-Esteem
Self-esteem is a term used in psychology to reflect a person’s overall eval-
uation or appraisal of his or her own worth. Self-esteem encompasses beliefs
(for example, “I am competent”) and emotions, such as triumph, despair,
pride, and shame. A person’s self-esteem may be reflected in behavior, such
as in assertiveness, shyness, confidence, or caution. Use these relaxation ex-
ercises to rediscover your latent self-esteem and creativity and rebuild your
confidence in your skills and talents.

I enjoy my own well-being.

I enjoy my own self-esteem.
I am blessed with a vivid imagination.
I love to express myself in creative ways.
Imagine yourself in a wonderful place . . .
a room surrounded by windows looking out on the sky . . .
In this room there are many small areas, and you can move freely around the
room, trying each of the areas to see how you feel . . .
these are just some of the areas into which you may choose to channel your own
creativity . . . and where no one else need judge or approve.
Only your opinion matters . . . and the joy of translating the inner world of the
imagination into a form or expression that suits you.
Imagine yourself using one of the areas in this marvelous room . . .
Or out of the room . . .
in order to create your response to the world around you, or your inner world . . .
Be aware of the feeling of having time and energy to channel into this creative
activity . . .
Be aware of the focus of attention that this creates for you . . .
nothing else seems to matter . . .
Enjoy your creativity, well-being, and imaginative power and translate it into the
world around you.

C. The Progressive Muscle Relaxation of Edmund Jacobson

Progressive muscle relaxation (PMR) is a technique of stress manage-
ment developed by the physician Edmund Jacobson in the early 1920s.
Jacobson argued that since muscular tension accompanies anxiety, one can
reduce anxiety by learning how to relax the muscular tension. Jacobson
trained his patients to voluntarily relax certain muscles in their body in order
to reduce anxiety symptoms. He also found that the relaxation procedure is
effective against ulcers, insomnia, and hypertension.
 The Relationship Between Clinical Hypnosis and Mindfulness 81

The PMR procedure teaches you to relax your muscles through a two-
step process. First, you deliberately apply tension to certain muscle groups
and then you stop the tension and turn your attention to noticing how the
muscles relax as the tension flows away. Through repetitive practice, you
quickly learn to recognize, and distinguish, the associated feelings of a tensed
muscle and a completely relaxed muscle. With this simple knowledge, you
can then induce physical muscular relaxation at the first signs of the tension
that accompanies anxiety. With physical relaxation comes mental calmness
in any situation.
This type of concentration is reachable almost only in a state of relaxed
awakening or in the first stages of self-hypnosis, with a prevailing activity of
the right-brain hemisphere and with a minimum activity of the left-brain
hemisphere.
PMR entails a physical and mental component. The physical component
involves the tensing and relaxing of muscle groups over the arms, legs, face,
abdomen, and chest. With the eyes closed, and in a sequential pattern, ten-
sion in a given muscle group is purposefully held for approximately 10 sec-
onds and then released for 20 seconds before continuing with the next mus-
cle group. The mental component focuses on the difference between the feel-
ings of tension and relaxation. Because the eyes are closed, one is forced to
concentrate on the sensation of tension and relaxation.
Progressive relaxation, therefore, involves alternately tensing and relax-
ing the muscles. A person using PMR may start by sitting or lying down in
a comfortable position. With the eyes closed, the muscles are tensed (10 sec-
onds) and relaxed (20 seconds) sequentially through various parts of the
body.

The Technique for Jacobson’s Progressive Muscle Relaxation

• Assume a comfortable position. Your entire body, including your head,
should be supported.
• Try to pay attention to the feelings of muscular relaxation and tension.
• When you tense a particular muscle group, do so vigorously without
straining for 7 to 10 seconds.
• Concentrate on what is happening. Feel the buildup of tension in each
particular muscle group. It is often helpful to visualize the particular
muscle group being tensed.
• When you release the muscles, do so abruptly, and then relax, enjoy-
ing the sudden feeling of limpness.
• Allow the relaxation to develop for at least 15 to 20 seconds before go-
ing on to the next group of muscles.
82 Clinical Hypnosis in Pain Therapy and Palliative Care

Tense forcefully the following muscles:

• legs: tense energetically . . . suddenly let go . . . and breathe . . .

• thighs: tense energetically . . . suddenly let go . . . and breathe . . .
• gluteus: tense energetically . . . suddenly let go . . . and breathe . . .
• pelvis: tense energetically . . . suddenly let go . . . and breathe . . .
• abdominal: tense energetically . . . suddenly let go . . . and breathe . . .
• back: tense energetically . . . suddenly let go . . . and breathe . . .
• chest: tense energetically . . . suddenly let go . . . and breathe . . .
• neck: tense energetically . . . suddenly let go . . . and breathe . . .
• jaw: tense energetically . . . suddenly let go . . . and breathe . . .
• forehead: tense energetically . . . suddenly let go . . . and breathe . . .
• shoulders: tense energetically . . . suddenly let go . . . and breathe . . .

Let go of all the tension and relax completely . . .

Feel the immediate sensation of well-being . . .
Mentally scan your body for any residual tension . . .
If a particular area remains tense . . .
repeat one or two tense-relax cycles for that group of muscles . . .
Now imagine a wave of relaxation slowly spreading throughout your
body . . .
starting at your head . . .
and gradually penetrating every muscle group . . .
all the way down to your toes . . .

The immediate effects of PMR include all the benefits of the relaxation
mind-body response. Long-term effects of regular practice of PMR include

1. A decrease in generalized muscle tension

2. A decrease in generalized anxiety
3. A decrease in anticipatory anxiety related to phobias
4. Reduction in the frequency and duration of panic attacks
5. Improved ability to face phobic situations through graded exposure
6. Improved concentration
7. An increased sense of control over moods
8. Increased self-esteem
9. Increased spontaneity and creativity

There are no contraindications for PMR.

 The Relationship Between Clinical Hypnosis and Mindfulness 83

D. The Light Sleep (Consciousness and the Stages of Sleep)

Stage I is the Lightest Sleep Stage

During Stage I your body is very busy. Your muscles begin to relax, your
heart rate and brain temperature rise, and your breathing begins to slow
down. This stage occurs while you are still awake. EEG waves begin to take
over the brain wave activities. If you were awakened during this stage of
sleep, you would not feel like you were asleep. This stage lasts for only a few
minutes.

Stage II is the K-Spindle Sleep Stage

Stage II is a light level of sleep in which a burst of electrical activity (spin-
dles) intrudes into your EEG. Your brain waves seem to slow down even
more. Sleep walking and sleep talking normally occur in this stage. You
would feel as if you were sleep if awakened now. This stage usually lasts
about 15 to 30 minutes.
As sleep begins and progresses into Stage II, spindle pacemaker
GABAergic nucleus reticularis thalamic neurons, which are hyperpolarized
during wakefulness, gradually depolarize. Spindle waves then arise as a dis-
charge pattern caused by network interactions between these spindle pace-
maker neurons and thalamocortical projection neurons (Steriade &
McCarley, 2005). As sleep progressively deepens, spindle waves are blocked
by continuing changes in input to the thalamus. These changes affect the
level of depolarization of thalamic spindle pacemaker neurons as well as
thalamocortical projection neurons. At this time, NREM sleep becomes
increasingly characterized by high voltage, slow wave, delta activity in the
cortex. The cellular basis of this activity depends on thalamocortical neurons
maintained in a hyperpolarized state by the absence of depolarizing input
and generating synchronous bursts of discharges (McCormick & Bal, 1997;
Steriade et al., 1993). Delta waves reflect these bursts of activity, transferred
through the thalamocortical network and synchronized as oscillations with
cortical pyramidal cells, which are themselves discharging in a similar mode.
Importantly, this burst discharge mode in thalamic cells prevents the trans-
fer of sensory information through the thalamus to the cortex, so maintain-
ing the block on sensory input that is characteristic of sleep.
At sleep onset in humans, the low voltage, high frequency EEG pattern
of wakefulness, often with alpha waves when the eyes are closed, gradually
changes to Stage I sleep as the EEG frequencies slow. Stage I, a brief transi-
tional phase after wakefulness, is followed by Stage II sleep when EEG fre-
84 Clinical Hypnosis in Pain Therapy and Palliative Care

quencies slow further. During Stage II, the episodic bursts of rhythmic, 12-
to 14-Hz waveforms occur in the EEG. These bursts are sleep spindles, an
important characteristic of sleep onset.
Sleep spindle correlations include positive correlations in the thalamus
and right hippocampus. K-complex correlations include positive correlations
in the frontomedian prefrontal cortex and cerebellum. Delta wave correla-
tions include negative correlations in the thalamus, frontomedian prefrontal
cortex, dorsal pons, and primary visual cortex. Each pattern of correlations
may suggest a functional significance for these waveforms that relates to a
waking outcome (Picchioni, Killgore, Balkin & Braun, 2009).

E. Repetitive Vocal and Mental Prayer

A review of scientific studies identified relaxation and concentration, an
altered state of awareness, a suspension of logical thought, and the mainte-
nance of a self-observing attitude as the behavioral components of medita-
tion (Perez-De-Albeniz & Holmes, 2000). Prayer and meditation are accom-
panied by a host of biochemical and physical changes in the body that alter
metabolism, heart rate, respiration, blood pressure and brain chemistry
(Lazar et al., 2000). Three priests were tested by EEG during prayer. The re-
sults indicated three periods: generalization, bilateral desynchronization
(spontaneous), and a period of suppression of main rhythms, but local pulsa-
tions were taking place.
As we know, there are three functional conditions of the brain: sleep,
wakefulness and paradoxal sleep. These new conditions may therefore be
marked as a new condition of the brain (V. Slezin, Laboratory of Psycho-
physiology, Bekhterev Institute, Russia, I. Rybina). When we pray, it is con-
sidered advantageous to spiritual growth to pray selflessly. Prayer and med-
itation have been used in clinical settings as a method of stress and pain re-
duction. Meditation has also been studied specifically for its effects on stress
(Kabat-Zinn, Lipworth & Burney, 1985; Davidson et al., 2003; Ospina et al.,
2007).

The Stage of Active Concentration (State of Aware Waking)

Corresponds in Christianity to the First Phase of Prayer
One moment of the “repetitive vocal prayer” is the prayer of believers
going to church. The Holy Rosary in honor of the Virgin Mary, one of the
traditional Roman Catholic family prayers at the beginning of the last cen-
tury, belongs to this kind of prayer. The recitative prayers have a pregnant
and evocative meaning in great solemnities in any kind of liturgy (with
 The Relationship Between Clinical Hypnosis and Mindfulness 85

music, hymns, and processions) because they happen in important and great
religious events. In this phase we can include the moment of the “repetitive
mental prayer,” in which the believer thinks to the traditional formulas with-
out pronouncing (or singing) them out loud.

The “Repetitive Mental Prayer”

Sit quietly in your sacred place. Relax and center yourself. Witness your-
self praying to God. Witness silently, detached, without commentary, judg-
ment, or comparisons. Say a prayer for yourself. Say a prayer for someone
else. Say a prayer for everyone and everything. Do this again and again for
a total of three cycles or do it for a total of twelve times or until it feels like
you’ve done it enough. You will clearly see that you feel really good when
you pray for others.
The simple prayer of St. Francis of Assisi provides a blueprint to use to
pattern our living in our thoughts, speech, and actions, within our day to day
relationships with our fellow beings and with all life around us. Therefore,
the prayer of St. Francis is a precious document for us—an indispensable,
invaluable frame of reference by which to achieve consciousness in our own
daily life.

The Peace Prayer of Saint Francis

“O Lord, make me an instrument of Thy peace!

Where there is hatred, let me sow love.
Where there is injury, pardon.
Where there is discord, harmony.
Where there is doubt, faith.
Where there is despair, hope.
Where there is darkness, light.
Where there is sorrow, joy.

Oh Divine Master, grant that I may not

so much seek to be consoled as to console;
to be understood as to understand;
to be loved as to love.

For it is in giving that we receive;

it is in pardoning that we are pardoned;
and it is in dying that we are born to eternal life.”

Saint Francis of Assisi

(baptized as Giovanni di Bernadone, 1182–1226 A.D., Italy
86 Clinical Hypnosis in Pain Therapy and Palliative Care

The Repetitive Vocal and Mental Prayer in

Buddhism, Hinduism, and Other Religions
The same state of consciousness can be reached with the purification of
the mind, exerting nonviolence, with the chastity of the body and the seren-
ity of the mind. (See the meditative techniques in Chapter V, “Mindfulness
and Meditative States in Spiritual Care.”) It is necessary to dominate all kinds
of desires, and every kind of gift must be refused. The applied study of all
disciplines, the capability of enjoying small things, the abstinence from food,
and the worship of God are extremely important in order to reach the active
concentration in a state of aware waking.
Active concentration uses mainly the short-term memory, which is not
definitively fixed in the subcortical group of neurons.

F. The Exercises and the Postures of Yoga

The practice of yoga exercises means practicing with both your body and
your mind. The body is held poised and relaxed, with the practitioner expe-
riencing no discomfort. During yoga exercises (and transcendental medita-
tions), the medial prefrontal cortex and anterior cingulate cortex work in the
generation of EEG alpha activity (Yamamoto, Kitamura, Yamada, Naka-
shima & Kuroda, 2006).

Asanas Yoga: Yoga Exercises and Postures

Asana (Sanskrit: sitting down) is a body position typically associated in
the practice of yoga, intended primarily to restore and maintain a practi-
tioner’s well-being, improve the body’s flexibility and vitality, and promote
the ability to remain in seated relaxed meditation for extended periods.
These are widely known as yoga postures or yoga positions, which is cur-
rently practiced for exercise and as alternative medicine.
It takes willpower and perseverance to accomplish each yoga pose and
to practice it daily. The practice of yoga exercises or yoga asanas can im-
prove your health, increase your resistance, and develop your mental aware-
ness. Doing the yoga poses, requires you to study each pose and execute it.
In the yoga sutras, Patanjali suggests that the only requirement for prac-
ticing asanas is that it be “steady and comfortable.” Asana is a body posture;
it is a Sanskrit word used to describe a position of the body. Patanjali, the
founder of Ashtanga yoga defines asana as “Steady and comfortable pos-
ture.” Traditionally, many asanas are practiced in Hatha Yoga tradition, prin-
cipally to achieve better physical and mental health. Asanas have a deep
 The Relationship Between Clinical Hypnosis and Mindfulness 87

impact on the entire body and mind complex; they affect different systems
within the body, such as the muscular, respiratory, circulation, digestive,
excretory, reproductive, endocrine, and nervous systems.
When control of the body is mastered, practitioners free themselves from
the duality of heat and cold, hunger and satiety, and joy and grief, which is
the first step toward the unattachment that relieves suffering. This nondual-
istic perspective comes from the Sankya school of the Himalayan Masters.

How the Yoga Asanas Work

The asanas are based on five principles:

1. THE U SE OF G RAVITY. The inverted postures such as the headstand,

shoulder stand, and reverse posture take advantage of gravity to increase the
flow of blood to the desired part of the body: in the headstand, to the brain,
in the shoulder stand, to the thyroid gland; and in the reverse posture, to the
gonads (sex glands).
2. ORGAN MASSAGE. The position of the asana causes a squeezing action
on a specific organ or gland, resulting in the stimulation of that part of the
body.
3. STRETCHING M USCLES AND LIGAMENTS. This causes an increase in
blood supply to the muscles and ligaments as well as relaxing them. It also
takes pressure off nerves in the area. The stretching is involved in all the
asanas, because it has such a beneficial effect on the body.
4. DEEP B REATHING. While holding the yoga posture, we breathe slowly
and deeply, moving the abdomen only (abdominal or low breathing). This
increases the oxygen and prana supply to the target organ or gland, thereby
enhancing the effect of the asana.
5. CONCENTRATION. As well as breathing slowly and deeply, we also
focus our attention on the target organ or gland. This brings the mind into
play and greatly increases the circulation and prana supply to the organ or
gland. This concentration has the second benefit of increasing general pow-
ers of concentration through regular practice. This benefits every aspect of
life. Your mind is less distracted and swayed by external events, and you are
therefore calmer and worry less. You will be able to solve day-to-day prob-
lems better and have more success in whatever activity you undertake.
Night and day, hot and cold, Inhale and exhale, work and rest—every-
thing has an opposite. So it is with life and yoga. Below are a series of poses
known as “The Salutation to the Sun.” Give it a try; you are invited to expe-
rience the “joy of cycles” right now.
88 Clinical Hypnosis in Pain Therapy and Palliative Care

The Technique of Yoga Pose: Surya Namaskar or Sun Salutation

-
Surya Namaskara (Surya -
namaskara) or Sun Salutations (lit. “salute to the
sun”) are a common sequence of Hatha Yoga asanas. Its origins lie in a wor-
ship of Surya, the Hindu solar deity. This sequence of movements and poses
can be practiced on varying levels of awareness, ranging from that of physi-
cal exercise in various styles to a complete sadhana, which incorporates
asana and pranayama (Sri K. Pattabhi Jois, Suryanamaskara, 2005).

Begin: Shivasana
INHALE

Laying down, heels together, arms by your side, palms facing upward.
With each exhale let your entire body melt through the floor. Let go and melt
until every cell in your body is completely relaxed, allowing each cell to melt
over the next. Give yourself a few minutes. Now melt even more!

Next, roll to your left side and stand.

Surya Namaskar (The Sun Salutation) includes twelve different positions:

1. Inhale and maintain the standing position with hands joined togeth-
er near chest, feet together, and toes touching each other. EXHALE
2. Raise the arms upward. INHALE
Slowly bend backward, stretching arms above the head.
3. Uttanasana (Standing Forward Bend) EXHALE
Exhale and bend forward in the waist until palms touch the ground
in line with the toes. Do not bend the knees while performing. At first
you may find it difficult to attain the ideal position but try to bend as
much as possible without bending the knees.
4. Inhale and take the left leg back with left toes on the floor, press the
waist downwards and raise the neck, stretch the chest forward, and
push shoulders backwards. Keep the right leg and both the hands in
the same position. Keep the right leg folded.
5. Adho Mukha Svanasana (Downward-Facing Dog)
Hold the breath and raise the knee of left leg. Take the right leg back-
wards and keep it close to the left leg. Straighten both the legs and
both hands. Keep the neck straight and sight fixed. Keep the toes
erect. Take care that the neck, spine, thighs, and feet are in a straight
line.
 The Relationship Between Clinical Hypnosis and Mindfulness 89

6. Ashtanga
Exhaling, bend both the hands and elbows and touch forehead on
the ground, touch the knees on the ground, keep both the elbows
close to chest. The forehead, chest, both palms, both sets of toes, and
knees should touch the ground and the rest of the body is not touch-
ing the floor. Since only eight parts rest on the ground, it is called
“Ashtanga” (8-limbed yoga) position.
7. Naga-asana (Cobra)
Inhale and straighten the elbows, stretch the shoulders upwards,
press the waist downward but do not bend the arms. Keep the knees
and toes on the floor. Push the neck backwards and look upward.
8. Hold the breath, bend the neck downward and press the chin in the
throat, push the body backward and touch the heels on the ground,
raise the waist upward, but do not move the palms on the floor.
9. Hold the breath, bring the left leg to the front and place it in between
the hands while the right foot stays in place with the right knee and
right toes touching the ground.
10. Exhale and bring the right leg forward as in position 3 and place it in
between both the arms.
11. INHALE
Raise the arms upward. Slowly bend backward, stretching arms
above the head.
12. EXHALE
Hands joined together near chest, feet together, and toes touching
each other.
Completing 1 Cycle:
Shivasana—Laying down, heels together, arms by your side, palms
facing upward, breathe in and out, letting your entire body melt
through the floor. Let go until every cell in your body is completely
relaxed, as though you are melting through the floor. Give yourself a
few minutes. Now relax.

Surya Namaskar is an appreciated yoga exercise among people of all

ages from children to the elderly. The Surya Namaskar postures are a very
effective means to limber up. Hence, they are generally carried out before
the other asanas. At the end of the twelve postures, you will feel refreshed
and relaxed.
90 Clinical Hypnosis in Pain Therapy and Palliative Care

2. PASSIVE CONCENTRATION: TYPES AND TECHNIQUES

Passive concentration is the opposite of what you are probably well-

acquainted with as “active” concentration. In this stage we find autogenic
training, the hypnagogic and hypnopompic states, the REM phase of sleep
(with dreams), and some initial stages of self-hypnosis and light and medium
hypnosis, with the presence of brain activity of both the right and the left
hemispheres, even if the latter is to a lesser degree.
With active concentration, you are goal (and result) oriented, with the
likely notion in the background that the harder you concentrate and the
harder you work, the more likely you are to achieve your goals. Passive con-
centration is the permissive and accepting attitude out of which you inten-
tionally relinquish any effort and willpower during your practice of relax-
ation and meditation.
Indifferent toward any outcome, you become the observer of what is
happening in your body. You concentrate “passively” for example on your
right arm to become heavy without any effort to bring about the sensation of
heaviness. You allow the sensation of heaviness to arise as you allow the
pleasant sensation of deep relaxation to permeate you gradually. The more
passive your concentration is, the more profound and lasting the experience
of relaxation will be.
Passive concentration has similarities to “mindfulness” as a spiritual con-
cept in some Eastern meditation traditions. Here, you learn to become the
observer or “watcher” of the mind, allowing each thought, each emotion,
each sensation to arise and then to dissipate into the next moment. Your
awareness and your knowing that you are watching leads to detachment
from and nonidentification with your mind’s content.
If you want to relax, then passive concentration is essential. How do you
do it? Well, in a few words, you allow sensations, images, and thoughts to just
float on by: just notice them and let them go, like a leaf floating by you on a
stream. You do not hold on to anything that your attention is drawn to. Just
let it go. This kind of concentration is great to develop anytime you want to
relax now and then.

A. Autogenic Training of Schultz

Autogenic training is the passive concentration relaxation technique
developed by the German psychiatrist Johannes Schultz and first published
in 1932. The technique involves daily practice of sessions that last approxi-
mately 15 minutes. Autogenic therapy (or autogenic training as it is often
known), has spread to many parts of the world, and more than 3000 research
 The Relationship Between Clinical Hypnosis and Mindfulness 91

papers have shown its efficacy. Autogenic training can have a positive effect
on many chronic health problems, while preventing invasive treatments for
many acute symptoms. Phrases for autogenic training with active concentra-
tion could be: “I want my right arm to become heavy!” or, “Right arm, be-
come heavy!” The result, however, would be like trying to fall asleep with
force.
In the 1920s, a German neuropsychiatrist named Dr Johannes Schultz
became intrigued by the physiological implications of a person in a deeply
relaxed state, such as when under hypnosis or when going to sleep. Taking
the observations of researchers into the hypnotic state (the work of Vogt and
Brodmann), Schultz constructed a set of simple autosuggestions (mental exer-
cises) incorporating those observations. Over time, these were developed
into the standard exercises of autogenic training that we know today: heavi-
ness in the limbs, then warmth, focusing on the heartbeat or pulse, breath-
ing, an idea of warmth in the abdomen, and coolness in the forehead. If these
are the perceived sensations of mind and body in a deeply relaxed state, then
Schultz simply made a conscious exercise of that perception.

Example of an Autogenic Training Session

• Sit in the meditative posture and scan the body
• “my right arm is heavy”
• “my arms and legs are heavy and warm” (repeat 3 or more times)
• “my heartbeat is calm and regular” (repeat 3 times)
• “my solar plexus is warm” (repeat 3 times)
• “my forehead is cool”
For any exercise, please repeat the sentences slowly, with calm, for at
least three to ten times.

All of the previous exercises are suitable to the passive concentration, but we
will consider some examples.

My Body is Pleasantly Warm

My body . . . in the time passing by . . .
is becoming more and more pleasantly warm . . .
Even more pleasantly warm . . .
and a feeling of great well being . . .
Great calm . . . great tranquility . . .it becomes part of me . . .
the time goes by . . . I feel well . . . I feel well . . .
I feel really well . . . and everything else does not bother me anymore . . .
92 Clinical Hypnosis in Pain Therapy and Palliative Care

For this exercise, please repeat the sentences slowly with calm at least ten
times.

My Forehead is Cool
This can be another exercise used for the pain relief therapy, depending
on the patient’s personality and character. It is also a very important exercise
to control chronic headache.
This is how to carry out the technique of the cool forehead:

• Concentrating on your forehead please repeat

My head is light . . .
All the muscles of my face are rested . . .
I am calm . . . calm . . .
Perfectly calm . . . in a state of great well-being . . .
My forehead is cool . . . pleasantly cool . . .
Even more pleasantly cool . . .
The coolness is all around me and gives me well-being . . .
Wellbeing of the body and well-being of the mind . . .

• Repeat this formula between five and ten times.

my neck and shoulders are heavy (repeat three times)

I am at peace (repeat three times)

The mind, the body, and the spirit, are all interrelated and interdepen-
dent. All holistic practitioners know the principle of this statement, and they
all know that the human being’s innate capacity for self-healing is largely
untapped. Autogenic training has been subject to clinical evaluation from its
early days in Germany and from the early 1980s worldwide. In 2002, a meta-
analysis of sixty studies was published in Applied Psychophysiology and Biofeed-
back (Stetter & Kupper, 2002) finding significant positive effects of treatment
when compared to normals over a number of diagnoses, finding these effects
to be similar to best recommended rival therapies, and finding positive addi-
tional effects by patients, such as their perceived quality of life.

B. Light, Medium Hypnosis and Self-Hypnosis

Practitioners of clinical hypnosis have long observed often dramatic
emotional, cognitive, behavioral, and physiological changes, occurring dur-
ing and as an apparent consequence of passive concentration hypnotic
 The Relationship Between Clinical Hypnosis and Mindfulness 93

trance. EEG activity at the midfrontal region was recorded during pre and
post baselines, live hypnotic induction, arm levitation, progressive relaxation
deepening, and therapeutic ego-enhancing suggestions among sixty college
student volunteers previously screened with the Stanford Hypnotic Sus-
ceptibility Scale. Comparisons across conditions for delta, theta, alpha, and
beta activity were made among low, moderate, high, and very high hypnoti-
zable groups. The results indicated significant increases in theta EEGs, across
the hypnosis process with a peak at progressive relaxation and a drop in
theta thereafter to termination, with highs showing significantly more dra-
matic effects than moderates (Stevens et al., 2004).

Light Hypnosis and Self-Hypnosis

This is the first stage of hypnotic passive concentration that anyone can
enter as soon as eyes closure is achieved. During light hypnosis we can ob-
serve

• eyes closed
• movements are reduced
• posture and facial features begin to relax
• breathing begins to deepen
• body indicators of tension begin to decrease

Medium Hypnosis and Self-Hypnosis

This is the next step of hypnosis. We can observe

• deep breathing
• slumped posture
• mouth may open
• feelings of lethargy
• retardation in responsiveness
• reduction in sensory awareness

During the induction into medium hypnosis and self-hypnosis, the hyp-
notherapist guides the client to narrowly focus his or her attention to the
point that sensory impressions are blocked out. The client can then reach the
state of complete relaxation necessary for hypnosis to occur. The hypno-
therapist’s office usually is quiet and dimly lit to create a relaxing atmos-
phere. The hypnotherapist chooses a particular method or combination of
methods (see Chapter IV, for induction based on the assessment of the client).
94 Clinical Hypnosis in Pain Therapy and Palliative Care

An induction script may use different types of verbal and visual cues, includ-
ing the following.
M ETAPHORS AND I MAGERY. The hypnotherapist suggests images or
describes a scene for the patient (e.g., “Let your mind drift to a calm and
peaceful place. See the wind blowing through the trees, the flowers in the
meadow.”). A mental image is an experience that, on most occasions, signif-
icantly resembles the experience of perceiving some object, event, or scene
but occurs when the relevant object, event, or scene is not actually present to
the senses (Finke, 1989; McKellar, 1957; Richardson, 1969; Thomas, 2003).
There are not infrequently, however, episodes, particularly on falling asleep
(hypnagogic imagery) and waking up (hypnapompic), when the imagery,
being of a rapid, phantasmagoric and involuntary character, defies percep-
tion, presenting a kaleidoscopic field in which no distinct object can be dis-
cerned.
Philosophers such as Berkeley and Hume and early experimental psy-
chologists such as Wundt and James understood ideas in general to be men-
tal images, and today it is very widely believed that much imagery functions
as mental representations, or mental models, playing an important role in
memory and thinking (Barsalou, 1999; Egan, 1992; Paivio, 1986; Prinz, 2002).
Indeed, some have gone so far as to suggest that images are best understood
as by definition of a form of inner, mental, or neural representation (Block,
1983; Kosslyn, 1983).
If the patient is having trouble obtaining sufficient imagery, it may be
helpful to ask questions that will provide more context. Particularly if the
patient is more auditory or kinesthetic than visual, these questions can sur-
vey different sensory experiences. “You might notice what you are wearing,
if anything, on your feet.” “What time of day or night does it seem to be?”
Other questions can address such things as whether the person is indoors or
not, if others are present, if there is an awareness of any smells, or if any
sounds can be heard (Schenk, 1999).
Repetition of words: The therapist repeats key words or sounds (e.g.,
“Breathe in deeply . . . ,” “As you breathe in . . . ”).
Emotional cues or probes: A hypnotherapy session may be used to gather
more information about painful experiences or to help patients cope with dif-
ficult emotions. The therapist integrates the inquiries or instructions into the
induction script (e.g., “You are in control and will choose to experience or
ignore any suggestions during the session.”).
Analogies, metaphors, and associative statements: Metaphors and poetry in
hypnosis, are a trance state characterized by a very relaxed, drowsy, and le-
thargic appearance (see Chapter VII). During this trance state, the person
who has been hypnotized loses initiative to carry out his or her own plans,
 The Relationship Between Clinical Hypnosis and Mindfulness 95

redirects attention away from the activity in which he or she was engaged
toward the instructions of the hypnotist, has heightened ability to produce
fantasies, and has an increased susceptibility to suggestions. The biology of
cognition attributes a practical and connotative role to language but also
gives importance to emotions, which together braid with language in form-
ing the consensual domain of conversations of living organisms. In hypnosis,
we use rhythm, with consciously creating recognizable patterns. The hyp-
notherapist uses comparisons to familiar experiences or images to help cli-
ents achieve physical relaxation (e.g., “Your legs are sinking into the couch,
heavy as logs.” “Feel your body, heavy and relaxed, being supported by the
tree behind you, the ground beneath you.”). Hypnosis and metaphors can be
the power of words in the modified states of consciousness.
Rhythm is unique and privileged in communication with patients. Rhythm
(or “measure”) in writing is like the beat in music. In poetry, in hypnosis, and
in spiritual mantras and prayers, rhythm implies that certain words are pro-
duced with more force, more fully than others, and may be held for longer
duration. The repetition of a pattern of such emphasis is what produces a
rhythmic and hypnotic effect. The word rhythm comes from the Greek
rhythmos, meaning “measured motion.”
Descriptive words in poetry and rhythm make their sound like a feeling;
mindfulness of feeling is the mind experiencing awareness of the thoughts. A
language more and more spontaneously and hypnotically indirect, implicit,
symbolic, it can activate new mental associations.
Metaphor can rouse old and repressed ones as well as we can imagine a
road network actively and continuously developing, amidst the swarming of
synaptic connections and links (Hopkins). The relation between the structure
and functioning of our mind, the structure and modes of operation of our
physical brain, and also the structure and conduct of the outside world has
been the issue of debate for ages.
We can use metaphors and poems as “indirect” Ericksonian suggestion in
hypnosis and during therapeutic modified states of consciousness. With poet-
ry and metaphor, any creative space is opened, followed, listened to, but
then encircled and defined within one’s way of individuation. Repetition of
a sound, syllable, word, phrase, line, stanza, or metrical pattern is a basic uni-
fying device in hypnosis.

The Technique of the Self-Hypnosis or Autogenic Hypnosis

This is a method of mental, meditative-type exercises that bring about
profound relaxation in mind and body. The word autogenic means self-gen-
erating. This can be a twofold concept. First, the treatment is carried out by
96 Clinical Hypnosis in Pain Therapy and Palliative Care

the client; autogenic exercises are applied by the self to the self. There is no
middle-man in the shape of a therapist except in the role of guide and sup-
port in the initial teaching of the method. Second, the result of practicing the
exercises is entirely spontaneous and unpredictable. The system of rebalance
knows exactly what is required and will bring it about if left alone to do so.
Metaphors and hypnosis are amazing experiences that teach you feelings
from inside yourself you could never ever begin to imagine. They are a way
of using the mind that is so easy, so natural, so simple and yet produces an
endless resource stream of truly mind-blowing proportions. I have learned to
ask certain parts of myself to give me a stream of data for a specific purpose
and how to interpret these data into words, or sounds, or movements, or
images; I have learned how to do this consciously and how to cooperate so
this can happen.
In self-hypnosis with metaphors, some factors are absolutely important:

• You must use “all five senses” in your descriptions. If you see a snow-
covered mountain, for example, do not just describe how it looks.
Describe its taste, its texture, its smell, and the sound of the wind howl-
ing across the peak.
• Phrase all your descriptions in the “present tense.”
• Close your eyes and describe out loud anything you can “see.”
• Later on in the image-streaming process, you can use it for problem
solving and a great many other things besides.

A symbol is the smallest unit of metaphor, consisting of a single object,

image, or word representing the essence of the quality or an attribute it
stands for. The following is Jung’s definition of a symbol: “A word or an
image is symbolic when it implies something more than its obvious and im-
mediate meaning. It has a wider ‘unconscious’ aspect that is never precisely
defined or fully explained. Nor can one hope to define or explain it. As the
mind explores the symbol, it is led to ideas that lie beyond the grasp of rea-
son.” This is therefore the basis for the emergence of the world experienced
by each individual. Within the context of our experienced world, it is con-
ventionally valid to say that the physical objects we perceive in the world
around us, such as planets and stars, exist within the external, subjective
space of consciousness. The mental objects we perceive, such as thoughts
and mental images, exist in the internal, subjective space of the conscious-
ness of each individual. Although we may believe in the existence of space
independent of consciousness, all our concepts of such real, objective space
arise within the space of consciousness. As for the relation between sensory
images and their related objects, believed to exist in the objective world inde-
 The Relationship Between Clinical Hypnosis and Mindfulness 97

pendent of consciousness, neurologist Antonio Damasio acknowledges,

“There is no picture of the object being transferred from the object to the
retina and from the retina to the brain.”
To generalize, to our senses, the appearances are not replicas or repre-
sentations of phenomena in objective, physical space. They are fresh cre-
ations arising in the space of consciousness.

Music and Sounds

The hypnotherapist speaks in a steady, evenly paced rhythm without
varying voice tone. Sometimes, the therapist plays music in the background.
What we feel as music is a mental content generated by the ears and the
brain responding to external vibration stimuli. These stimuli cause the musi-
cal perception but are substantially different from it. Because each individual
is unique, cerebrally and psychologically, each one has its own particular way
to respond to the external stimuli, thus having a more or less different expe-
rience while listening to the same music. It is not possible to express objec-
tive and absolute judgments about a tune, without a reference version of it;
in a certain sense, there are as many versions as there are listeners. We may
say that what we call music, and its beauty (or feeling), exists only in the sub-
jectivity (this means in the minds) of the listeners. Music has the ability to
affect our emotions, intellect, and our psychology; lyrics can assuage our
loneliness or incite our passions.
Organic life is based on different kind of rhythms: the rhythm of breath-
ing, of pulsations, of muscles in their different physiological functions, let
alone the more subtle vibratory rhythm of each single cell, of each molecule,
of each atom. Therefore, it should not come as a surprise that the musical
rhythms exert a powerful influence on those organic and psychological
rhythms, sometimes stimulating them and sometimes calming them, creating
harmony and peace.

C. Lucid Dreams, Hypnagogic and Hypnopompic States

A lucid dream is a dream in which the sleeper is aware that he or she is
dreaming. A lucid dreamer can actively participate in (during a state of pas-
sive concentration) and manipulate imaginary experiences in the dream
environment. Lucid dreams can seem extremely real and vivid, depending
on a person’s level of self-awareness during the lucid dream. Lucid dreaming
is also known as dream consciousness or conscious dreaming. Lucid dream-
ing is a modified state of consciousness, with aspects of waking and dream-
ing combined in a way so as to suggest a specific alteration in brain physiol-
ogy. It constitutes a hybrid state of consciousness, with definable and mea-
98 Clinical Hypnosis in Pain Therapy and Palliative Care

surable differences from waking and from REM sleep, particularly in frontal
areas.
Results show lucid dreaming to have REM-like power in frequency
bands delta and theta and higher than REM activity in the gamma band, the
between states difference peaking around 40 Hz. Power in the 40-Hz band,
is strongest in the frontal and frontolateral region. Overall coherence levels
are similar in waking and lucid dreaming and significantly higher than in
REM sleep throughout the entire frequency spectrum analyzed. Regarding
specific frequency bands, waking is characterized by high coherence in alpha,
and lucid dreaming by increased delta and theta band coherence (Voss,
Holzmann, Tuin & Hobson, 2009).
Hypnagogic hallucinations and visualizations can occur as one is falling
asleep, and hypnopompic hallucinations occur when one is waking up. They
are considered normal phenomena.
The role of dreams as a significant source of information about the pa-
tient’s inner life has been richly studied by many theorists and therapists, in-
cluding Freud, Jung, Perls, and others. The visualization involves one or
more of your five senses (hearing, taste, touch, smell, sight). We can use a
word or phrase to stimulate the memory of those senses. A lucid dream is an
emotionally charged event that stands apart from the rest of your day. To
conquer the recidivism of these old familiar patterns, we must turn inward
and ask, “What is the message in this lucid dream?” What aspects of my per-
sonality are symbolized by these people, objects, animals, actions, and so on?
Symbols are the language of the psyche and the soul. Curiosity with emo-
tional detachment and mindful reflection are key factors in the decoding
process. This is the first step on the path to higher consciousness.
Early references to hypnagogia are to be found in the writings of Aris-
totle, Iamblichus, Cardano, Simon Forman, and Swedenborg (Mavromatis
1987). Romanticism brought a renewed interest in the subjective experience
of the edges of sleep (Pfotenhauer & Schneider, 2006). In more recent cen-
turies, many authors have referred to the state; Edgar Allan Poe, for exam-
ple, wrote of the “fancies” he experienced “only when I am on the brink of
sleep, with the consciousness that I am so” (Mavromatis, 1987).
Serious scientific enquiry began in the nineteenth century with Johannes
Peter Müller, Jules Baillarger, and Alfred Maury and continued into the
twentieth with Leroy (Leroy, 1933).
The advent of electroencephalography has allowed the introspective
methods of these early researchers to be supplemented with physiological
data. The search for neural correlates for hypnagogic imagery began with
Davis and colleagues in the 1930s (Davis, Davis, Loomis, Harvey & Hobart,
1937) and continues with increasing sophistication to this day.
 The Relationship Between Clinical Hypnosis and Mindfulness 99

Although the dominance of the behaviorist paradigm led to a decline in

research, especially in the English-speaking world, the later twentieth centu-
ry saw a revival, with investigations of hypnagogia and related subjects play-
ing an important role in the emerging multidisciplinary study of conscious-
ness (Susan, 2003; Vaitl et al., 2005).
Nevertheless, much remains to be understood about the experience and
its corresponding neurology, and the topic has been somewhat neglected in
comparison with sleep and dreams. Hypnagogia has been described as a
“well-trodden and yet unmapped territory” (Mavromatis, 1987). Important
reviews of the scientific literature have been made by Leaning (1925),
Schacter (1976), and Richardson and Mavromatis (1987).
Physiological studies have tended to concentrate on hypnagogia in the
strict sense of spontaneous sleep-onset experiences. Such experiences are
associated especially with stage I of NREM sleep (Rechtschaffen & Kales,
1968), but may also occur with presleep alpha waves (Foulkes & Schmidt,
1983; Foulkes & Vogel, 1965). Davis and associates found short flashes of
dreamlike imagery at the onset of sleep to correlate with drop-offs in alpha
EEG activity (Davis et al., 1937).
Hori, Hayaskie, and Morikawa regard sleep-onset hypnagogia as a state
distinct from both wakefulness and sleep, with unique electrophysiological,
behavioral and subjective characteristics (Hori, Hayashi, & Morikawa, 1993;
Vaitl et al., 2005). Germaine and coworkers have demonstrated a resem-
blance between the EEG power spectra of spontaneously occurring hypna-
gogic images, on the one hand, and those of both REM sleep and relaxed
wakefulness, on the other (Germaine & Nielsen, 1997; Nielsen, Germain &
Ouellet, 1995).
To identify more precisely the nature of the EEG state that accompanies
imagery in the transition from wakefulness to sleep, Hori and colleagues
(1993) proposed a scheme of nine EEG stages, defined by varying propor-
tions of alpha (stages 1–3), suppressed waves of less than 20mV (stage 4),
theta ripples (stage 5), proportions of sawtooth waves (stages 6 and 7), and
presence of spindles (stages 8 and 9). Germaine and Nielsen (1977) found
spontaneous hypnagogic imagery to occur mainly during Hori sleep, onset
stages 4 (EEG flattening) and 5 (theta ripples).
The covert-rapid-eye-movement hypothesis proposes that hidden ele-
ments of REM sleep emerge during the wakefulness-sleep transition stage
(Bodizs, Sverteczki, Lazar & Halasz, 2005).
Support for this comes from Bódicz et al., who note a greater similarity
between WST (wakefulness-sleep transition) EEG and REM sleep EEG than
between the former and stage 2 sleep (Bodizs et al., 2005).
100 Clinical Hypnosis in Pain Therapy and Palliative Care

D. The REM Phase of Sleep

REM Sleep, Rapid Eye Movement

REM sleep is the sleep stage in which dreaming occurs. When you enter
into REM sleep, your breathing becomes fast, irregular, and shallow. Your
eyes will move rapidly, and your muscles become immobile. Heart rate and
blood pressure increase. Men may develop erections. About 20 percent of
sleep is REM sleep. This sleep phase begins about 70 to 90 minutes after you
fall asleep. The first sleep cycle has a shorter phase of REM sleep. Toward
morning, the time spent in REM sleep increases and the deep sleep stages
decrease.
Researchers do not fully understand REM sleep and dreaming. They
know it is important in the creation of long-term memories. If a person’s
REM sleep is disrupted, the next sleep cycle does not follow the normal
order but often goes directly to REM sleep until the previous night’s lost
REM time is made up.
REM sleep is distinguishable from NREM sleep by changes in physio-
logical states, including its characteristic rapid eye movements. Polysomno-
grams show wave patterns in REM to be similar to stage I sleep, however. In
normal sleep (in people without disorders of sleep-wake patterns or REM
behavior disorder), heart rate and respiration speed up and become erratic,
while the face, fingers, and legs may twitch. Intense dreaming occurs during
REM sleep as a result of heightened cerebral activity, but paralysis occurs
simultaneously in the major voluntary muscle groups, including the sub-
mental muscles (muscles of the chin and neck).
Because REM is a mixture of encephalic (brain) states of excitement and
muscular immobility, it is sometimes called paradoxical sleep. It is generally
thought that REM-associated muscle paralysis is meant to keep the body
from acting out the dreams that occur during this intensely cerebral stage.
The first period of REM typically lasts 10 minutes, with each recurring REM
stage lengthening, and the final one lasting an hour. Neuroscientists think

The function of rapid-eye-movement (REM) sleep is still unknown. One pre-

vailing hypothesis suggests that REM sleep is important in processing memory
traces. Here, using positron emission tomography (PET) and regional cerebral
blood flow measurements, we show that waking experience influences regional
brain activity during subsequent sleep. Several brain areas activated during the
execution of a serial reaction time task during wakefulness were significantly
more active during REM sleep in subjects previously trained on the task than in
non-trained subjects. These results support the hypothesis that memory traces
are processed during REM sleep in humans. (Maquet et al., 2000)
 The Relationship Between Clinical Hypnosis and Mindfulness 101

E. Free Mental Prayer and Mental Meditation

The Passive Concentration in Meditative Stages

There are different ways, depending on the different schools of thought,
to reach this phase. For example, according to Ignacio of Loyola ‘s school,
the most quoted in Catholicism, the best way to practice mental meditation
is to analyze every single word of repetitive prayers, concentrating the thought
on their intrinsic meaning without letting the mind wandering. In Buddhism
and Hinduism, the same state can be reached through meditation. Medi-
tation is integration: therefore, its main goal is to reassemble the divided part
of the human being. If you say that the body is different from the mind, and
that the mind is different from the soul, this means that you are disaggregat-
ing. How can meditation take us back to the integration if it is something that
separates the body from the brain, the brain from the mind, or the mind
from the soul? If when we close our eyes and we keep silent, we consider this
meditation then we all meditate for hours during our sleep. Why do we not
call it meditation? Is not that silence? During sleep, the mental function
stops, but we cannot consider this meditation. All of us can meditate, but the
goal is far, far from us, because we are not able to control our senses, our
mind, and our intelligence.
Three main transformation take place while we meditate. In Hindu phi-
losophy, at the beginning of his Yoga Sutra, Patanjali says that yoga is the
appeasement of the mind. He then affirms that when a person tries to ap-
pease the mind, a sort of resistance develops as new thoughts and/or new
ideas arise. A sort of tug-of-war starts between our attempt at control and the
arising thoughts. The asana can be reached with a particular control of the
physical posture, keeping the body completely free from nervous and mus-
cular tensions, even with unusual positions. The way of meditation is the way
of silence. Silencing the ceaseless chatter of a mind buzzing with thoughts is
not easy. The way to silence is the way of the mantra. A mantra is a sound,
syllable, word, or group of words that is considered capable of “creating
transformation.” Mantras (Devanagar - i)- originated in the Vedic tradition of
India, becoming an essential part of the Hindu tradition and a customary
practice within Buddhism, Sikhism, and Jainism. In the context of the Vedas,
the term mantra refers to the entire portion that contains the texts called Rig,
Yajur, or Sama, that is, the metrical part as opposed to the prose Brahmana
commentary. It is advisable to choose a word of four syllables and pro-
nounce them with equal length. The recommended word in the Christian
tradition is Ma-ra-na-tha. In Aramaic, the language of Jesus’ time, it means
“The Lord comes.”
102 Clinical Hypnosis in Pain Therapy and Palliative Care

Once we commence this daily practice, a few guidelines can enable us to

go deeper. First, we are not to assess our progress. The feeling of success or
failure may be the biggest distraction of all. We are not to look for experi-
ences in our meditation. We come to meditation in poverty of spirit. So be
faithful to the recitation of the word or mantra during the period of medita-
tion and to the daily practice, twice a day, morning and evening. The mini-
mum time prescribed is 20 minutes, the optimum 30 minutes. “The way of
saying your word, your mantra, is the way to stillness.”
Eastern Christians call it hesychia. It is pure prayer, worship in spirit and
truth. It purifies the heart of contradictory desires and unifies us. The place
of unity is the heart, where we find our deepest and most natural orientation
toward God as our personal source and goal.

Meditative Free Mental Prayer and Meditation (Angelico Brugnoli)

From your immensity Lord,
you looked at me
and I felt comforted,
and I could arise my eyes up to you.
From your immensity Lord,
you looked at me.
From your place without space and without time, you heard me,
and I dared to speak to you.
From your place without space and without time, you heard me, Lord.
You immerged into my time, Lord,
and I could feel that you were forever close by me.
Since you planned to create me, Lord, I felt you,
I invoked your name from the abyss, and you helped me
to feel as a thinking being, to feel as a being that wants,
that wishes, that longs to be near you.
Since you planned to create me, Lord,
you thought of me, and I felt your warm love for me.
Since you planned the universe, Lord,
since beyond time and space, I was totally swallowed up by nothingness,
Lord, you wanted me, you loved me, you heard me,
and in this moment, I offer you my heart, my soul, my spirit.
Since I was totally swallowed up by nothingness,
Lord, since the elementary particles that form my body, Lord,
drifted inert in the space but with their potential life,
you thought of me. You wanted me.
You loved me, Lord.
Therefore, I devote myself to you, Lord.
Since you wanted me,
 The Relationship Between Clinical Hypnosis and Mindfulness 103

you loved me, and you only expect that I remember you,
that I want you, and I love you as you wanted and loved me
since the elementary particles that form my body were still inert in the space.
Since, Lord, you thought of me, I started living.
Since you wanted me, I began my way of being.
Since you loved me, you gave me the heat of life.
So I am here, in this moment to entrust you
all that little moment of love,
that in my own small way I can have for you, Lord.
Accept my heart, Lord,
accept my soul, Lord,
accept my spirit, Lord, and let this little moment
of life in this world
become the instant that lasts forever together with you, Lord.
since you wanted me,
since you loved me,
Since you thought of me.
Lord, while we praise and thank you,
we want to express you all our bliss in knowing, feeling, seeing
that you are with us, that you guide us, that you live among us.
Lord of our tears,
we praise you and thank you.
As we know that tears,
as our way of being.
In order to get nearer to you,
to feel you,
to be more and more clear minded,
to appreciate you with our heart,
to feel you with our soul,
to rejoice in you with our spirit.
Lord of our tears,
we ask you to turn them into tears of joy,
when we are able to hear your voice and see your face,
when at the end of the life path that leads to you,
we will be able to hug you and live with you forever outside time,
outside space,
in a world that we cannot even imagine,
not even with the most fervent fantasy.
Lord of our tears,
turn them into tears of joy,
turn them into tears of love,
for the consciousness of being together with you,
feeling you inside our heart
while you lead our soul to be always closer
104 Clinical Hypnosis in Pain Therapy and Palliative Care

to the reasons of the spirit.

Lord of all our moments,
we praise you and thank you for the consciousness
that each moment we lived with you is a step that leads us always higher
along the path towards you.
So we humbly ask you
to warm our heart,
to strengthen our soul,
to cultivate, as a precious flower, our spirit,
so that we can be warmed by your heart,
we can be strengthened in our soul by your word,
we can be cultivated in our spirit by your thought,
that thought that created us and thus wanted us inside time and space,
so to come up to you closer and closer,
you who love the planet earth,
who love all nations,
who love each single ethnic group,
who love each of us.
Lord of our illusions,
we humbly ask you to see that our illusions
may be canceled,
so that you can remain the only and prime reason for us,
that we can absorb your energy,
we can see your light,
we can feel your light,
we can appreciate the bliss that only you can give
to the heart, to the soul, and to the spirit,
that we can feel you, as our only starting point,
our only point of far-off arrival,
each of us, from the illusion that our society creates on this planet.
Lord of our illusions,
see that we all, and each of us, do not get lost in the illusions
that our world can give.
Lord of our illusions,
see that they do nott become
just great disappointments
because in this way the illusions of our society
make of us disappointed and depressed beings, because these illusions take
away,
day after day, the energy of the heart, the energy of the soul,
the energy of the spirit, until we become always more depressed,
always more disappointed beings.
Lord of our illusions,
here assembled in your name,
 The Relationship Between Clinical Hypnosis and Mindfulness 105

we all praise and thank you

for all the advice you give us every day.
Therefore, we pray you to see that
we do not become disappointed in our same illusions.
However, instead we try to overcome our illusions
in order to enter your world and your will
so that we become more and more full of energy
in our heart, in our soul, in our spirit
that we can obtain overcoming our illusions in your name
and trying to fulfill, day after day, only your will
so that we too
can become beings satisfied for your joy, for your energy, for your will.
Lord of our illusions,
help us.
We are conscious that you only will never disappoint anyone,
that you only can give the right energy to overcome the problems of the heart,
to overcome our illusions, so that we enter your world
that give us a new life, a life without illusions,
therefore, without disappointments.
Lord of our happiness,
we thank you because we are conscious,
through all that you give us,
that it is impossible to obtain the true happiness without you.
Lord of our personal happiness,
each of us humbly asks you to see that
each of us can follow your will always and anyway,
so that we can obtain the happiness of the heart, of the soul, and of the spirit,
even if we are conscious that
we cannot obtain it in this world,
however, only going up just one step
in the path that leads to you.
Therefore, we humbly ask you to give us the strength of will
to follow your will always and anyhow,
even if apparently
alternatively, strongly in contrast with ours,
with our own or with the collective one.
Lord of our happiness,
as we are conscious that in this world, it is never possible
to obtain it fully neither through our heart, nor trough our soul, nor trough our
spirit,
while we humbly praise and thank you,
we ask you to give us at least
just a moment of happiness that you only can give,
a moment of happiness of heart,
106 Clinical Hypnosis in Pain Therapy and Palliative Care

a moment of happiness of soul,

a moment of happiness of spirit,
as, for instance, in this particular moment in which
we completely immerse ourselves deep in you, with all our senses,
the normal and the hidden ones,
we completely immerse ourselves deep in you,
with the feelings of our heart,
with the moments of gratitude of our soul,
with all can exalt our spirit.
Lord of our happiness,
we completely immerse ourselves deep in you,
we trust you and your will,
trying to penetrate, as far as possible for a human being,
your way of being, in order to be better immersed in the only bliss,
that you can give whom approach you in this way,
with heart, with soul, with spirit.
We feel quite near you, Lord, in this way, we feel you ours,
we feel between us, and we are always more willing and conscious
to follow your will always and anyhow.
Lord,
help our heart to feel you more.
Help our minds to be on the same wavelength as yours.
Help our spirit to enter you in order to be fortified
until we follow the path that leads to you
each moment of our life.
From your immensity,
Lord,
you looked at me,
and I felt comforted,
and I could arise my eyes up to you.

F. The Breathing Exercises

The Techniques of Deep Breathing

A technique that is usually taught in both passive concentration medita-
tion and hypnosis, classes alike that can instantly reduce stress, is called deep
breathing—breathing exercises.
Anytime during the day or evening, if you feel overwhelmed, anxious, or
stressed in any way, it would be extremely beneficial to just stop for a
moment and take five to ten deep, relaxing breaths. We all started out our
life doing deep breathing, but as we got older, some, because of certain fac-
tors in their life, switch over to shallow breathing. So, if you want to look at
 The Relationship Between Clinical Hypnosis and Mindfulness 107

it as relearning the type of breathing you did when first born, then do so,
because as an unknowledgeable newborn baby, you came into this world
knowing at the subconscious level or soul level what was best for your sur-
vival. If you have difficulty in doing deep breathing, try it while lying down.
The more you do it, the more it will become automatic, and the need to con-
sciously think about it will eventually be gone.

The Pranayama
Vialatte and colleagues (2009) discovered EEG paroxysmal gamma
waves during Bhramari Pranayama: the yoga breathing technique. The
Pranayama can be obtained with a great and constant training aimed at a
persistent and progressive control of the respiration until one is able to keep
it calm, deep, quiet and regular with two or three respirations per minute.
“When the Breath wanders, the mind is unsteady, but when the Breath is
still, so is the mind still” (Hatha Yoga Pradipika).
Breathing is life. It is one of our most vital functions. One of the Five
Principles of Yoga is Pranayama or Breathing Exercise, which promotes
proper breathing. From a yogic point of view, proper breathing is to bring
more oxygen to the blood and to the brain and to control prana or the vital
life energy.
Pranayama Yoga also goes hand in hand with the asanas. The union of
these two yogic principles is considered as the highest form of purification
and self-discipline, covering both mind and body.

Breathe:

Hold the posture, but try not to tense up. Breathe.

As you inhale, imagine the breath coming up through the floor, rising through
your legs and torso and up into your head.
Reverse the process on the exhale and watch your breath as it passes down from
your head, through your chest and stomach, legs and feet.
Hold for five to ten breaths, relax . . . and repeat.
On your next inhale, raise your arms over head (Urdhava Hastasana, Upward
Salute)
and hold for several breaths.
Lower your arms on an exhale.
As a warm up, try synchronizing the raising and lowering of your arms with
your breath . . . raise, inhale; lower, exhale.

Repeat five times.

108 Clinical Hypnosis in Pain Therapy and Palliative Care

The Corpse—Savasana
Possibly the most important posture, the Corpse, also known as the
Sponge, is as deceptively simple as Tadasana, the Mountain pose. It relaxes
and refreshes the body and mind, relieves stress and anxiety, quiets the
mind. Usually performed at the end of a session, the goal is conscious relax-
ation. Many people find the “conscious” part the most difficult, because it is
very easy to drift off to sleep while doing Savasana.

Begin by lying on your back, feet slightly apart, arms at your sides with palms
facing up.
Close your eyes and take several slow, deep breaths.
Allow your body to sink into the ground.
Try focusing on a specific part of the body and willing it to relax.
For example, start with your feet and imagine the muscles and skin relaxing, let-
ting go, and slowly melting into the floor.
From your feet, move on to your calves, thighs and so on up to your face and
head.
Then simply breathe and relax.
Stay in the pose for at least 5 to 10 minutes.

In this specific modified state, it is possible to live differently the flow of

time, getting close to the flow of the rhythms, of the Great Cosmic Time.
The passive concentration state, particularly needs long-term memory, in
addition to short-term memory. This kind of memory is fixed on groups of
cortical and subcortical neurons or some programs active in our brain since
the first two or three years of life.

Meditative Self-Hypnosis: “The Seven-Minute Practice”

• First Minute:

Connecting ourselves to our inner self

through the awareness of our breathing . . .
Putting our attention on it . . . attention . . . or passive concentration.

• Five Minutes:

Let’s stay like this . . . breathing . . .

paying attention to it . . . without effort . . . naturally.
When something distracts us, a thought, a sound, a voice far away,
without effort, naturally we return our attention on our breathing,
observing it . . .
Inhaling and exhaling each time we distance ourselves,
 The Relationship Between Clinical Hypnosis and Mindfulness 109

we gently return to it,

so the saying goes
“Hundred times I fall and one hundred and one times I get up.”

• Seven Minutes:

Let’s widen our awareness of ourselves . . .

and the universe . . .
so our breathing
is the breathing of the whole world . . .
So our meditation benefits all other human beings.

3. DEEP CONCENTRATION: TYPES AND TECHNIQUES

It is in deep sleep, in circular sleep with paradoxical thought (i.e., in the

NREM sleep), in the state of medium self-hypnosis, or even in deep hypno-
sis that deep concentration prevails.
At this level the activity of the right-brain hemisphere prevails over that
of the left one.
A light or medium state of self-hypnosis, with the consequent loss of the
awareness of the flow of time, and the activity of the right-brain hemisphere
make the achievement of this state easier. We also find, at this point, the
beginning of an active participation of the subconscious.

A. The Deep Sleep

Since the early twentieth century, human sleep has been described as a
succession of five recurring stages: four NREM stages and the REM stage.
Stages III and IV are deep sleep stages, with stage IV being more intense
than stage III is. These stages are known as SWS, or delta sleep. During
SWS, especially during stage IV, the EMG records slow waves of high
amplitude, indicating a pattern of deep sleep and rhythmic continuity.
What exactly is the difference between REM and NREM sleep? REM
dreams and NREM dreams are very different from each other in a few major
ways. The first difference between the two is that NREM dreams consist of
brief, fragmentary impressions. They are also less likely to involve visual
images compared to REM sleep and are more frequently forgotten. NREM
dreams are like thinking about something during the day for a brief period
of time, whereas REM dreams are comparable to thinking deeply about
something. REM sleep consists of about two hours a night, whereas NREM
sleep lasts about four to six hours.
110 Clinical Hypnosis in Pain Therapy and Palliative Care

Delta waves are produced from the brain in the third stage of sleep.
These brain waves become slower when the sleep cycle begins. During this
cycle, your heart rate, blood pressure, and arousal decline (NREM sleep).
Stage IV is very similar to stage III because delta waves continue in the
brain. During this stage of sleep, most dreams and nightmares occur (NREM
sleep).
Stages III and IV are the SWS stages (deepest sleep). Your brain waves
slow down tremendously. These are called delta waves. These two stages last
a total of 30 to 40 minutes on top of your first sleep cycle.
During stage III your breathing becomes very slow and your heart rate
slowly drops. Your brain generates stronger electrical impulses than the
impulse it produces while you are awake. Stage III is the stage you are in
when it takes a great deal to wake you up. Most of your dreaming takes place
in this stage. Your body can not move; it is temporarily paralyzed. This is
why you sometimes feel that you cannot run or scream in a nightmare,
because the sleeping brain believes what it sees. This stage is where dream-
ing and REM sleep occur.
Stage IV is the deepest level of sleep, and your brain during this period
will show large, slow EEG waves. Certain hormones and chemicals are re-
leased into the body, growth hormones are one of them. Teenagers need
more stage IV sleep than older people do. Once you get over the age 70,
stage IV sleep may disappear from your sleep cycle. This stage gets shorter
and shorter as your rest cycle continues, and by the end of your cycle, stage
IV may not exist any more. Once stage four has been reached, we descend
back through stages III, II, and I before beginning REM sleep.

B. Extreme Thoughts: A Clear Mind, The Flow State

Our right brain (unlike our left, reasoning brain) is intuitive and nonrea-
soning and deals with ethereal matters. Extreme thoughts are right brain or
intuitive mind. How can we foster a clear intuitive mind? A mind with no
thoughts? A total sensing mind? The body’s internal network of sensory
receptors provides us with proprioception (awareness of the precise position
of our body) and kinesthesia (the awareness of direction of movement) that
combined function as a sixth sense, allowing us to know where we are in
space and time. On yet another energy level (the spiritual), we become aware
of influences and information through intuition. When we lay the ground-
work for a spiritual connection to one another and to the inner self, we sharp-
en these higher senses of receptivity. Intuition is our greatest link to our high-
er selves (our spiritual selves).
 The Relationship Between Clinical Hypnosis and Mindfulness 111

How do we know when we are receiving intuitive information? How do

we discern that particular type of information from the thousands of impuls-
es we receive every day? As with the different types of information experi-
enced by individuals, confirmations of intuition come to us in a variety of
ways.

The Flow State

Flow is the mental state of consciousness in which the person is fully im-
mersed in what he or she is doing by a feeling of energized focus, full in-
volvement, and success in the process of the activity. Proposed by Mihály
Csíkszentmihályi, the positive psychology concept has been widely refer-
enced across a variety of fields. Colloquial terms for this or similar mental
states include to be in the “zone.” The concept of “being in the zone” during
a performance fits within Csíkszentmihályi’s description of the flow experi-
ence. We consider flow in terms of challenge level and skill level.
Csíkszentmihályi identifies the following factors as accompanying an
experience of flow. According to Csíkszentmihályi (1975, 1997; Csíkszent-
mihályi & Rathunde, 1993), the components of flow are

• Clear goals. Expectations and rules are discernible and goals are attain-
able and align appropriately with one’s skill set and abilities. More-
over, the challenge level and skill level should both be high.
• Concentrating and focusing. A high degree of concentration on a limited
field of attention. A person engaged in the activity will have the oppor-
tunity to focus and to delve deeply into it.
• A loss of the feeling of self-consciousness. The merging of action and aware-
ness.
• Distorted sense of time. One’s subjective experience of time is altered.
• Direct and immediate feedback. Successes and failures in the course of the
activity are apparent, so that behavior can be adjusted as needed.
• Balance between ability level and challenge. The activity is neither too easy
nor too difficult.
• A sense of personal control over the situation or activity.
• The activity is intrinsically rewarding. There is an effortlessness of action.
• People become absorbed in their activity. Focus of awareness is narrowed
down to the activity itself, action awareness merging.

Not all are needed for flow to be experienced.

For millennia, practitioners of Eastern religions such as Hinduism,
Buddhism, and Taoism have honed the discipline of overcoming the duality
112 Clinical Hypnosis in Pain Therapy and Palliative Care

of self and object as a central feature of spiritual development. Eastern spiri-

tual practitioners have developed a very thorough and holistic set of theories
around overcoming duality of self and object, tested and refined through
spiritual practice instead of the systematic rigor and controls of modern sci-
ence.
The phrase “being at one with things” is an example of Csíkszent-
mihályi’s flow concept. Practitioners of the varied schools of Zen Buddhism
apply concepts similar to flow to aid their mastery of art forms, including, in
the case of Japanese Zen Buddhism, Aikido, Cheng Hsin, Kendo, and
Ikebana. In yogic traditions such as Raja Yoga, reference is made to a state
of “flow” in the practice of Samyana, a psychological absorption in the object
of meditation.
When I write, I feel out of control in a lovely way. The analogy that
comes to mind is flow: a heightening of senses, a rush, no concept of time, a
dimming of the external world, an altered state in which creation is the
unconscious though central intent.
A flow state is, in many ways, the opposite of being stressed. Instead of
feeling pressured, self-conscious, oppressed by time or out of sync, this is a
great “zone” in which what you are doing feels natural with great results. The
term describes the highest achievements of athletes, musicians, writers, spir-
itual gurus, masters in practically every field of activity. Most people, in fact,
have found themselves in this state of mind at some point, and it is not as
hard to bring about as it might seem.

The Technique to Find a Flow State

• Focus completely on what you are doing. That means doing whatever
you have to so that distractions are not on your mind. Pay attention to
the results you are getting and not your role in the process.
• Recreate the flow state by repeating the same steps. Each time you
practice your activity and think about how exactly you did it so well
when you are finished, should make finding that flow state easier. This
builds the trust in yourself needed to let go of your self-consciousness
and put that awareness in a more rewarding place—on the thing you
want to do well.
 The Relationship Between Clinical Hypnosis and Mindfulness 113

C. Medium Self Hypnosis

and
D. Deep Hypnosis

The Deep Concentration in Hypnosis and Self-Hypnosis

During these stages, medium self-hypnosis is as deep as deep hypnosis is,
because in self hypnosis, awareness of your immediate surroundings decreas-
es faster, and you lose the awareness of space and time.
In this stage we can observe

• decreased awareness of immediate surroundings

• very deep breathing
• suggestions are best received
• partial or total amnesia of hypnotic events
• depersonalisation, disappearance of self
• analgesia or anesthesia
• external awareness periodically closing down

Deep Hypnosis and Anesthesia in Pain Therapy

When a state of deeper hypnosis is achieved through different tech-
niques, the patient is trained as to how to interpret the feeling of pain com-
ing from a specific place in the body and to transform it slowly from a feel-
ing of pain to a feeling of different nature, for example light or medium ten-
sion, moderate pressure, beneficial warmth, or a cold sensation of anes-
thetizing nature.

Example of Anesthesia

While in a state of relaxation, you can imagine immersing your hand in a con-
tainer of melting ice cubes . . .
and from the wrist up to the tip of your fingers the ice acts on your hand like a
very powerful anaesthetic . . . making it feel more and more insensitive . . .
You will feel your hand becoming more and more insensitive . . .
and the anaesthesia will increase . . .
You will also know that the anaesthesia will last until you repeat to yourself three
times:
“Everything is normal.”
114 Clinical Hypnosis in Pain Therapy and Palliative Care

Other techniques of deep self-hypnosis are in Chapter IV.

The ability of bringing up the meditation object of concentration to the
point of access concentration and self-hypnosis just before absorption in-
volves the building up of the mental factors of concentration skillfully, so that
it becomes powerful enough to fall into absorption.

E. Meditative Stages of Contemplation and Mindfulness

Factors in Development of Deep Concentration and Contemplation

Sabom (1982) summarized a similar set of core consciousness experi-
ences:

• a mind’s “separation” from the physical body

• a dark region or void
• a brilliant source of light
• a transcendental environment
• the nearness of some other personage
• a life review
• a return to the physical body

Some important factors in development of deep concentration and contem-

plation are given below.

Mindfulness
As the main controlling faculty of the mind, mindfulness is of course
indispensable. It brings the mind to the point of concentration skillfully. It
also guards against defilements and extraneous thoughts. Then it causes us to
take the appropriate action to remedy them. It also keeps the mind flexible,
workable, soft, and so on.
Therefore, there must be plenty of mindfulness at various depths of con-
sciousness. It will, however, have to be that suited to the tranquility form of
concentration and not the insight form. In tranquility meditation, the con-
centration faculty is comparatively much stronger than is the energy faculty,
and so its unique balance has to be maintained. It has also to be continuous.

Detachment
Right concentration is often referred to as concentration detached from
the five senses. We can understand this if we know that our object is solely
that of the mind door. Its concentration is that above the five sense doors. If
 The Relationship Between Clinical Hypnosis and Mindfulness 115

we still have rampant cravings for sense pleasures, we can never get near the
absorptions. If one is really detached, however, then it lifts one off from the
valleys of the five senses. Detachment has the power to remove the bondages
that tie us to the lower worlds. When deep concentration comes with pleas-
antness and joy, the detached attitude is an important consideration.

Patience
Patience is the opposite of impatience or anger, which are associated with
agitation. If we preserve patience, our mind by itself will calm down. In this
case, patience is synonymous with the undisturbed aspect of tranquility. It
can remain with the object for longer periods of time, for with nonanger
there follows equanimity, another factor of concentration. The correspond-
ing stage in Christianity is “contemplation.”
During the contemplation phase it is always necessary to be in a “passive
mental position in front of God,” so that He can enter in our heart. For this
reason, the heart must be free from all our ambitions. It is indeed essential
“to free the heart from whatever is unnecessary.” Otherwise, God cannot
bring His light in after the dark night of the renunciation of the common real-
izations of life.
Contemplation is a state similar to hypnosis or to light or medium self-
hypnosis, with a prevailing activity of the right-brain hemisphere.
During the phase of ecstasy, God inundates our heart with love with a
consequent feeling “real presence.” We are aware that the energy that we
receive is transformed into further information that then transforms itself into
knowledge, consciousness, and awareness. Therefore, every moment in our
life becomes of interest about who we are and where we are, becomes a joy
of living and participating to the whole universe of life, and becomes minute
by minute a moment of life in a “continuum time space” that will adapt and
expand to the infinite within ourselves and in the macrocosm.

4. SUPERIOR CONCENTRATION (HIGHER CONSCIOUSNESS):

TYPES AND TECHNIQUES

A. Medium to Deep Self-Hypnosis:

Annulment of the Normal Consciousness
The path to the consciousness, the knowledge, the awareness and, in the
end, to the spiritual awareness always depends from person to person, and
has unique and particular characteristics. Every human being is unique in all
aspect of physical, mental, and spiritual being. The annulment of the normal
consciousness it is prevailing in the state of medium to deep self-hypnosis.
116 Clinical Hypnosis in Pain Therapy and Palliative Care

Time and space disappear, and we live in a particular world in which we live
experiences indescribable with everyday words.
The hypnotic state is inconsistent, and changes with each individual.
Changes in the hypnotic state occur in relation to a person’s own experience
and his or her reactions to the ongoing experience of hypnosis and its induc-
tion in relation to time, the people involved, the purposes being served, and
the ongoing situation. Past studies have found that most subjects seem to re-
spond much better to internal fixations on personally imagined object or
sounds (intrapsychic behavior).
Another important factor to consider as mentioned earlier is time. Some
subjects enter hypnosis quickly: others may take a great deal of time. Milton
Erickson notes that on average a total of four to eight hours of hypnotic
induction training is required for most subjects. Along the same lines, certain
trance-induced behavior, such as the ability to speak while in a deep trance,
could take countless hours of training. Such abilities require learning because
subjects might yet have no understanding or realization that it is possible to
speak at an unconscious level of awareness. When functioning at a deep
trance level, subjects perform with unconscious understandings, independent
of ordinary conscious responses. Things are taken in a literal sense, and ex-
ternal realities are relevant only as utilized within the hypnotic experience.
Erickson has conceptualized the deep trance as somnambulistic and stupor-
ous, hence his description of deep hypnosis: “Deep hypnosis is the level of
hypnosis that permits subjects to function adequately and directly at an un-
conscious level of awareness without interference by the conscious mind.”
Charles T. Tart said, “I think we can expand the scientific framework to
take in most of the humanistic phenomena, maybe all. For instance if I say
that by a certain kind of Yoga breathing exercise, I can reach a state of ecsta-
sy, that is basically a scientifically testable statement. I’ve said, here’s a con-
dition, you breathe in a certain way. Here’s an observable outcome: some-
body says—I’ve got this kind of an ecstatic experience” (Tart, 1970). Through
medium self-hypnosis and deep hypnosis, we can experiment with higher
consciousness.

B. The Higher Consciousness

Who or what we perceive ourselves to be in any given moment directly
affects what we think and believe in the world, the goals and interests we pur-
sue, and every aspect of our spiritual lives. During Transcendental
Meditation (TM) techniques, the mind effortlessly attends to a specific object
and automatically transcends the normal boundaries of conscious percep-
tion, experiencing a shift from active, waking consciousness to one without
 The Relationship Between Clinical Hypnosis and Mindfulness 117

boundaries—pure consciousness. Past research suggests that the TM tech-

nique produces a state of profound rest and relaxation in subjects. Ob-
jectively, measurements of blood chemistry, skin galvanic response, and EEG
recordings while subjects are practicing the technique indicate profound
changes occur in the physiology. Subjectively, subjects report the experience
of awareness alone without an object of perception (Arenander). This expe-
rience has been described as “restful alertness.” It has also been described in
some of the oldest known written records.
The Vedas, more than 5000 years old, are the classic texts describing this
fundamental human experience. The Vedas call this experience of aware-
ness,without an object of perception pure awareness. According to the Vedas,
this state of restful alertness or transcendental consciousness is considered to
be the fundamental mode or ground state of human conscious experience.
Thought processes represent fluctuations of this underlying abstract, pure
field of intelligence.
A model is proposed to explain the process of transcending that is based
upon cognitive and neural mechanisms similar to the well-known orienting
reflex. In this model, the state of restful alertness is produced by a coordi-
nated response of orienting and habituating processes. The prefrontal cortex
and the basal forebrain interact to produce a sequence of progressive de-
excitations of neuronal activity, while conscious awareness is maintained.
The brainstem core, in particular the mesencephalic reticular formation and
the locus coeruleus, are suggested to be involved in maintaining awareness
by producing orienting reflexes to the object of perception (stimulus) used in
meditation at each stage in the sequence of de-excitation and generating
global neural coherence. The regulation of attentional processes during tran-
scending is via an integrated hierarchy of control converging on the thalam-
ocortical system (Arenander).
The coherent integration of corticaltholamic processing loops would lead
to a global state of neural integration corresponding to a transcendental state
of awareness (Arenander). It is no wonder that we are continually evolving
our understanding and awareness of the truth of who we are and our rela-
tionship with God as we wind our way down the path of self-realization.
When we are born, there is no sense of self, no sense of differentiation or
separation from anything else in our awareness. As we grow older, we
become identified with our bodies, personalities, families, and all of the
thoughts and beliefs that make up our experience of life. As time progresses,
we take on new identities: husbands and wives, mothers and fathers, man-
agers, lawyers, office workers. As one begins to earnestly pursue a spiritual
path, it is natural to question these roles and identities and try on new ones.
As we move deeper and deeper into experiencing the truth of who we are—
118 Clinical Hypnosis in Pain Therapy and Palliative Care

beyond what we can see with our eyes, hear with our ears, or believe with
our mind—the pursuit of a direct and personal experience with our True
Nature begins to grow, until experiencing and knowing this true self eventu-
ally becomes the primary goal in our lives.

What Is Our Higher Consciousness?

There are many great words to describe who or what your highest iden-
tity or self truly is. Below are just a few:

• Higher consciousness
• Higher self
• I am presence
• Pure being
• Nonduality
• Love
• Spirit
• Essence of life
• Cosmic consciousness
• Universal mind
• Universal love
• The TAO
• God
• Christ
• Holy Spirit
• and the list goes on . . .

Depending on your spiritual path, background, or religious influence, you

may be attracted to one or more of these terms. Ultimately, these words are
only ideas that point to the unlimited and infinite nature of your true self. In
the end, it does not matter which words you use. It is directly experiencing
your higher self that you ultimately seek in your heart.

Cosmic Consciousness, Universal Mind, and Your Higher Self

Incorporating new beliefs about your higher self or true identity is an
important aspect of spiritual growth, but no matter how powerful, inspiring,
or life-changing these new ideas and beliefs may be, they eventually run out
of steam because who you are is beyond thought or belief.
When one reaches this stage of desire and intention, developing a spiri-
tual practice that can consistently restore you to a direct experience of your
 The Relationship Between Clinical Hypnosis and Mindfulness 119

higher self becomes essential. One realizes that spiritual belief is essentially
meaningless and hollow without a personal and direct experience of the
divine.
There are countless practices in the world that serve the purpose of
restoring your awareness to one of pure being. Ultimately, it does not matter
which practice you choose, but choosing one and applying it consistently is
what will lead you to a continual and ever-present state of enlightenment . . .
the state of directly experiencing your self or God in every moment. The
path that has led us to this direct experience of self on an ongoing basis, and
that countless others share along with us, is the path of hearing God’s voice
within as a means of restoring our awareness to the truth of who we are in
every moment.
It is possible to experience yourself as pure energy and consciousness.
You can enter a period of deep meditation or deep hypnosis and temporari-
ly put aside the limitations of body, mind, and emotions to transcend regu-
lar human limitations into infinite or universal consciousness. Certainly, this
is one of the marvelous aspects of higher consciousness. Free of the mind’s
chatter or any negative emotion, your consciousness soars beyond mortality
for a period of cosmic consciousness, as it is often called. You are able to
experience the source of life in its essence. You are able to transcend form
and float free in the formless and infinite realm of conscious energy that is
profoundly wonderful. Experiences of this nature revivify your whole being.
Coming back from cosmic consciousness into bodily awareness, you find
your mind is fresh with insights and intuitions. Your emotions are washed
free and clean, and deep calmness and joy easily establish themselves in a re-
newed heart. Breathing and circulation seem to work better, and you marvel
at your body’s increased strength and coordination.
The higher self is the “you” inside of you, the living force that grows and
changes in your body throughout your time on earth. It is the “you” behind
all of the defenses and images you have created for yourself . . . the you that
really knows why you are here, what it is you need, and how you can get it.
By transcending to your personal core—the higher self—you discover your
true nature, a blissful self of infinite worth. The spiritual needs we all have
for love, compassion, meaningfulness, total acceptance, devotion, and inner
peace are not grand goals to be achieved in a distant time and place. They
exist here and now and exert powerful influences on our lives. Only by tran-
scending to the higher self can you achieve total, spontaneous fulfillment of
these needs.
120 Clinical Hypnosis in Pain Therapy and Palliative Care

In The Higher Consciousness State, Through

Hypnosis and Meditative States You Can
• eliminate fear and other obstacles to spiritual growth
• rejoin the stream of life through willingness and trust
• utilize more fully the true solver of problems—intuition
• untangle pain from suffering
• liberate your emotional body
• experience infinite worth
• learn to heal as a conscious activity
• establish a relationship with your personal and cosmic mind
• break the circular trap of addictions and find new pleasures that sur-
pass them
• develop a quiet mind that can experience the truth of this new reality
• attain spontaneous right action

From Self-Hypnosis to Higher Consciousness and Awareness

Through hypnosis we can activate the concentrative mental stages that
will help us to develop the mental energies toward the higher consciousness.
People can experience the different stages of concentration through hypno-
sis, which needs to be achieved through a psychophysical concentration.

• Physical because it is necessary to learn slowly to inhibit the rational-

ity of the cerebral cortex.
• Psychological in order to activate the limbic areas of the brain.

After you break the dominance of thoughts, awareness becomes quite

easy and natural. In the alpha zone, you can balance focusing and awareness.
You can be with the breath half the time and watch the stream for the rest.
You still have to be vigilant, but as the body settles, you get even more free-
dom. It becomes possible to watch the show as a spectator. This is how focus-
ing, which is so important at the start, gradually gives way to a tolerant and
versatile awareness.
As you watch what flows downstream, you become familiar over time
with its huge variety and the way it changes as you relax. This is actually
“you.” It is the texture and contents of your mind. You become able to watch
every last thought, sensation, feeling, and image, just as it is, without being
entranced by it. You also see how it connects causally; how a thought leads
to a feeling, which leads to a response in the body, and often to action as
well. These are some of the fruits of awareness that make it worth cultivat-
 The Relationship Between Clinical Hypnosis and Mindfulness 121

ing. It matches the Christian seventh phase, in other words, with the moment
of the “annihilation of the normal consciousness.” According to many
authors, this means slowly learning how to “live with God.” In other words,
we live in a state of complete annihilation of our personality, having the feel-
ing of living experiences taking place in a different time from the terrestrial
time. A time that could be defined cosmic time or unified time.
The superior concentration is fulfilled in a state of medium or deep self-
hypnosis with an appreciable increase of the subconscious activity. It is a
modified state of consciousness, achievable when all the mental waves
merge, without any kind of thoughts, without material experiences, out of
time and space.
According to many Western and Eastern schools of philosophy, superoir
concentration facilitates the long-term memory, with a consequent memory
of past lives. It helps the accomplishment of karma, so one can free oneself
from it definitively. It is specifically in this state of superior concentration and
higher consciousness that the heart starts operating, of course along with
both brain hemispheres. With the term heart we mean not the hydraulic
pump of our body, but instead the complex of all our cells united in a phys-
ical and mental synchrony. When we experience the awareness, we will feel
it for certain because we will experience a wave of inner joyful emotions: the
physics and metaphysic level have become one.
This arrival at the state of awareness can be compared to what some call
illumination, samadhi, ecstasy, or nirvana. It is not perfectly clear what ecsta-
sy is; the word in any spiritual context indicates the sensation (along with a
vivid desire) of transcending, at least for a moment, the normal condition of
the consciousness in order to reach a type of experience set in a different
time and in a different space.
Plutarch describee the predeath experience, which is often similar to cer-
tain states of deep hypnosis and meditative stages of contemplation. The per-
son who is near death is, without reaching the limit of letting life go, experi-
ences an initiatory situation, or a situation similar to ecstasy. Plutarch wrote,

At the moment of death the soul experiences feeling similar to that experiment-
ed by people facing a mystery (the unknown). . . . At the beginning, you are feel-
ing as if you were getting lost in circular movements following fearful tracks that
won’t take you anywhere. Before the last moment the fear, the shivering being
frightened, the cold sweats everything is felt at the maximum. And then a won-
derful light comes to the eyes; you go through wonderful places with lovely
echoes of sound and sights of beautiful dance, holy words and images of divine
nature inspire a religious respect. It is there where the initiated is now free from
anything. He can walk around crowned with a garland, celebrating the party
with the other pure souls, and he is looking from above towards the crowd of
122 Clinical Hypnosis in Pain Therapy and Palliative Care

those who are not initiated and not purified in the mud and in the darkness.
(Plutarch, p. 168)

Studies of human evolution over the course of the centuries and millen-
nia and the neurophysiological development of the brain and the mind can
give us some help in providing medical therapy for the suffering of the body.
They are of no help, however, for the emotional suffering, a therapy that we
can learn through the path toward spiritual consciousness. It is therefore,
important to study the expansion of the conscience to take us toward new
horizons, especially in pain therapy and in palliative care.
At least we can agree that the only material life as we see it today has no
reason to exist just on its own, because we are aware that there exists an
entropic relationship between all of us, and we know that together we can
follow the path of spiritual awareness.

C. Absorption
Many aspirants experience difficulty concentrating their attention and
keeping it fixed on one point. Their minds tend to readily wander away from
a focal point, even in bands of the conscious and subconscious mind, close
to the surface of waking awareness. Going to profound states of absorption
in the superconscious mind is extremely difficult for these beginning medi-
tators. Spiritual teachers use seven primary methods for helping focus the
attention of meditation students on the key inner centers of the ensouling
entity, the spirit, and the attentional principle. In some cases, these methods
may actively lock the attention of the meditator in an altered state of con-
sciousness, for long periods of time.

Breathing Absorption
Called remembering the holy name, ajapa japa, or pranava laya in vari-
ous traditions, the attention is kept focused on subtle aspects of breathing.
The attention may be variously abstracted through these methods into the
union with the attentional principle (mindfulness), with the self. We concen-
trate our attention into habitually remaining in a specific altered state of con-
sciousness and identifying with it.

Contemplative Mantra
Called mantra japa, the attention is focused on the spirit by a contem-
plative mantra. The mantra is repeated by the attention, in contrast to speak-
 The Relationship Between Clinical Hypnosis and Mindfulness 123

ing it aloud, whispering it, or breathing it. Different contemplative mantras

may be used to focus the attention on varying octaves of the spiritual path.

Guru Mantra
Chanted aloud or silently within the mind, this transformation or bija
mantra can become an unbroken focus on the attention, resulting in full
identification with an altered state of awareness. Some gurus often use this
method of control over the attention.

Prayer Without Ceasing

This method is used in the Christian faith to hold the mind in union with
the soul. One form of this method is to repeat a ritual prayer such as The
Lord’s Prayer or Hail Mary continuously.

Light Immersion or Absorption

This method temporarily guides the attention to inner centers within the
vehicles or into the union with the attentional principle, the spirit, or the enti-
ty by holding it in a ray or beam of light.
Some spiritual teachers do not favor the grounding of attention after the
meditation experience but have the meditator remain absorbed in the focal
point for extended periods of time. This leads to a state of detachment from
normal personality functioning, a witnessing of the activity of the mind from
a higher vantage point, and, often, identification with the focal point about
the method used to control the attention.
These methods of sustained absorption facilitate the shunting or subli-
mating of energy from the personality and energy channels of the higher self.
This may permit better control of passions and behavior from a higher stra-
tum of the mind.

D. The Meditative Stages: Awareness,

Contemplation and Ecstasy, Living With God

Dhyana
“Dhyana heyah tad vrttayah”
Dhyana means absorption in meditation
heyah means eliminate
tad means that or these
vrttayah means movements of the thought
124 Clinical Hypnosis in Pain Therapy and Palliative Care

The absorption in the meditation eliminates these movements from the

thought about the pain. These thoughts or movements of pain are rejected and
silenced by meditation. One eliminates these movements from the thought
about the pain by absorption in the meditation. It is through the tools for learn-
ing meditation and absorption in meditation that movements of the thought of
pain, which besiege the unconscious mind, are dispelled, rejected, avoided, or
silenced. When elements of mental distress besiege the unconscious mind,
they can be eliminated with the tools fore learning meditation and absorption
in the meditation. When elements of mental distress become disgusting and
operative, they can be dispelled with the tools for learning meditation and ab-
sorption in the meditation. Tools of the learning of meditation and absorption
in the meditation destroy the unpleasant movements of the thought, which
strangle the unconscious mind. There are some kinds of distress provoking
pain, however. There are several causes underlying these pains and move-
ments of the thought. Their main cause is lack of tools for learning meditation.
So long as the causes leading to distress provoking movements of the thought
do not get destroyed, the flow of distress provoking movements of the thought
keep on undulating and swelling in the unconscious mind.
These movements of the thought keep on moving as ripples across the
surface of the unconscious mind. The flow of pain provoking movements of
the thought is of three kinds. It is in form, subtle, and subtlest. Such a flow
keeps on floating on the unconscious mind, the conscious mind and the inte-
rior core of the conscious mind, respectively. So long as the disciple the
unconscious mind, the conscious mind, and the interior core conscious mind
does not experience the lack of tools for learning meditation, pain, and dis-
tress-provoking movements of the thought will not get destroyed. Further
preparatory yogic discipline is of three kinds.
The yogic discipline consists if tools for learning meditation and absorp-
tion in the meditation in the conscious mind. This discipline entails perfec-
tion and disciplining of the yogic limbs of absorption in the meditation and
spiritual union.
Patanjali says that with the perfecting and disciplining of the tools for learn-
ing meditation and absorption in the meditation, the flow of pain-provoking
movements of the thought in their gross form gets destroyed. These move-
ments of the thought however continue to remain in their subtle seed form.
These tools for learning meditation and absorption in the meditation
occur when a disciple enters the final field of preparatory yogic discipline. It
is only by the elimination of the seeds of pain-provoking movements of the
thought of the unconscious mind that these movements of the thought get
completely restrained and nullified. It is only by the restraint and nullifica-
tion of movements of the thought that the mind gets deactivated from their
 The Relationship Between Clinical Hypnosis and Mindfulness 125

activity. It is then that the stranglehold of subtlest nature essence on the con-
centration meditation and self-conscious of the soul gets broken.
It is then that the individual self-conscious of soul gets into the pure form.
It is in this state that knowledge about realization of true self-conscious, soul,
and God essence is realized. It is in this state that knowledge about birth and
death of life of subtlest nature essence over self-conscious is realized. It is in
this state that the liberation from birth and death of life of mind that is sub-
tlest nature essence is attained.

From Maha-Satipatthana Sutta (DN 22.21)

And what is right meditation (sama-samadhi). There is the case where an
aspirant, quite withdrawn from sensuality, withdrawn from unskillful (men-
tal) qualities, enters and remains in the first jhana: joy and ecstasy born from
withdrawal, accompanied by applied and sustained concentration (vitakka
and vicára).

With the stilling of applied and sustained concentration (vitakka and vicára), one
enters and remains in the second jhana: joy and ecstasy born of tranquillity, uni-
fication of awareness free from directed applied and sustained concentration
(vitakka and vicára), internal assurance.

With the fading of joy one remains in equanimity, (aware) and alert, physically
sensitive of ecstasy. One enters and remains in the third jhana, of which the
Noble Ones declare, “Equanimous and (aware), one has a pleasurable abiding.

With the abandoning of (grasping and aversion for) pleasure and pain — as with
the earlier disappearance of pleasure and pain—one enters and remains in the
fourth jhana: purity of equanimity and awareness, neither pleasure nor pain.

This is called right meditation.

Higher consciousness and awareness are the idea of having a higher

appreciation, knowledge of, and consciousness of your connection between
the physical plane and the spiritual plane. When you are thoughtless aware-
ness, when your brain is just in the state of witness, and you understand
everything that is divine. Words do not exist to describe the state of aware-
ness: the “I” disappears completely, the borderline between you and the rest
of the world dissolving totally. Awareness is the pure expansion of the mind.
In his commentary of Patanjali’s Yoga sutras, His Holiness Sri Sri Ravi
Shankar says,
126 Clinical Hypnosis in Pain Therapy and Palliative Care

With spiritual growth, there is a keenness of observation. You become totally

relaxed, yet at the same time you possess sharpness of awareness, strength of
intelligence. Your senses become so clear. You can see better, think better, hear
better. Like a pure crystal, your senses come to reflect all objects as one Divinity.

In the state of awareness, we think neither of the past nor of the future.
We are entirely in the present moment, in the state of being and do not waste
the precious moments of life, thinking about times that are finished forever
or yet to come. We start enjoying our self, our spirit, our own inner beauty,
and the beauty of creation. We start to enjoy being.

Contemplation and Ecstasy, Living With God

“I entered into unknowing,
and there I remained unknowing
transcending all knowledge.” (St. John of the Cross)

“Lead me from the Unreal to the Real.

Lead me from darkness to Light.
Lead me from death to Immortality.” (Brihadaranyaka Upanishad)

“Being and non-being create each other.

Difficult and easy support each other.
Long and short define each other.
High and low depend on each other.
Before and after follow each other.” (Tao Te Ching, Verse 2)

5. TRUE CONCENTRATION OR AWARENESS ACTIVATION:

TYPES AND TECHNIQUES

A. Awareness
Watch your consciousness closely, this feeling and sensation of being
aware and alive, and observe what you feel. I do not mean that you look at
the contents of your mind. I mean becoming fully aware and conscious of the
sensation of being alive and existing. Some concentration ability is required
to perform this simple exercise, because the mind and its thoughts will prob-
ably try to stand in your way. This consciousness I am referring to is not the
awareness of having a body, emotions, or thoughts but of something beyond.
Awareness is the state or ability to perceive; to feel; or to be conscious of
events, objects, or sensory patterns. In this level of consciousness, sense data
 The Relationship Between Clinical Hypnosis and Mindfulness 127

can be confirmed by an observer without necessarily implying understand-

ing. More broadly, it is the state or quality of being aware of something.

Meditation for Inner Awareness

Begin this meditation by taking a few slow . . .
deep breaths . . .
breathing in peace and stillness with each breath . . .
and then slowing exhaling... releasing any tension . . . worry or irritation . . .
Now visualize the energy in you . . .
as a feeling of energy . . . rising upwards to you as you inhale . . .
See your center transmuting negative emotional feelings into positive . . .
loving feelings as you exhale . . .
loving feelings as you inhale . . .
loving feelings as you exhale . . .
Now inhale again . . .
this time visualizing the energy rising up from you . . .
and in the interlude before exhaling . . .
dedicate the energy to helping others in some way . . .
Then exhale . . .
visualizing the energy . . . flowing out . . .
through your throat center to release creativity and energy.
Repeat this sequence a few times . . .
seeing the energy rising all the way up to you . . .
and then lift your consciousness higher . . .
invoking your soul . . .
Invoke soul consciousness through your intention to align with it . . .
and by affirming the soul as your essential identity . . .
the presence of God within . . .
the presence of God in you . . .
the presence of you in God . . .
. . . Then hold the silence for 10 to 15 minutes . . .
. . . listening inwardly to the voice of your soul . . .
the still . . . small voice that provides inspiration and guidance for your life . . .
Close the meditation by visualizing love . . .
light and spiritual power . . .
flowing out to the world . . . to where it is most needed for peace . . .
healing and transformation . . .
Use your intention to direct your attention: practice consciously focusing your
attention where you choose it to go.

Give conscious attention to something that is close to your heart, that you
do not usually attend to because you think you have other more pressing or
128 Clinical Hypnosis in Pain Therapy and Palliative Care

important things to deal with. Meditate daily to experience the joy in your
soul and to receive inner guidance in your life. The life into the soul and
awareness is a life of meaning. It imbues each gesture, thought, and deed
with the full integrity of being that comes from conscious connection with the
source of life. It infuses all responsiveness to life in the love that is part of this
connection. “I was once spiritually ill , we all pass through that, but one day
the intelligence in my soul cured me” (Meister Eckhart). This, then, is the
beginning of soul awareness, an awareness founded in love and in the knowl-
edge of the sacred oneness within which we draw breath.
Although for centuries a wakeful and tranquil state or experience vari-
ously called samadhi, pure awareness, or enlightenment has been said to be
a normal experience and the goal of meditation in Vedic, Buddhist, and
Taoist traditions, there was little known about this behavior until recently,
when the practice of TM* became available for study in Western scientific
laboratories. Derived from the Vedic tradition, TM is unique because it re-
quires no special circumstances or effort for practice. Based on a wide spec-
trum of physiological data on TM, we can hypothesize that meditation is an
integrated response with peripheral circulatory and metabolic changes sub-
serving increased CNS activity. Consistent with the subjective description of
meditation as a very relaxed but, at the same time, a very alert state, it is like-
ly that such findings during meditation as increased cardiac output and prob-
able increased cerebral blood flow and findings reminiscent of the “extraor-
dinary” character of classical reports—apparent cessation of CO2 generation
by muscle, fivefold plasma AVP elevation, and EEG synchrony—play critical
roles in this putative response ( Jevning, Wallace & Beidebach, 1992). Outside
of neuroscience, biologists Humberto Maturana and Francisco Varela con-
tributed their Santiago theory of cognition, in which they wrote, “Living sys-
tems are cognitive systems, and living as a process is a process of cognition.”
This statement is valid for all organisms, with or without a nervous system
(Capra, 1996). Lagopoulos and associates (2009) found increased theta and
alpha EEG activity during nondirective meditation.
This theory contributes a perspective that cognition is a process present
at organic levels that we do not usually consider to be aware. Given the pos-
sible relationship among awareness and cognition and consciousness, this
theory contributes an interesting perspective in the philosophical and scien-
tific dialogue of awareness and living systems theory.
This consciousness is your inner being, and there is nothing mysterious
or mystical about it. We all experience this consciousness constantly but
never investigate or try to be consciously and intently aware of it. This is

*TM = Transcendental Meditation.

 The Relationship Between Clinical Hypnosis and Mindfulness 129

because the mind and the attention flow outside, and rarely inside. You are
this consciousness; it is your being, and you therefore need to know about it.
You did not lose consciousness during this experience. It was a happy and
joyous experience, in which you became aware of something beyond your
ordinary awareness. Meditation deals with contacting the consciousness
within us, which by its very nature is peaceful, calm, and rejuvenating. The
whole universe is nothing but pure consciousness. Scientific researches have
taken us up to the point where we can convincingly say that at the quantum
level it is just the play of energy that is going on in the entire universe.
Everything has a mass and thus can be converted into energy. Remem-
ber the famous Einstein equation: E = MC2. The spiritual world, however, is
of the view that in the ultimate analysis, at a more deeper level (something
still beyond even the reach of quantum physics), everything in the whole uni-
verse is pure consciousness, known also as supreme consciousness or God. It
is just the play of this consciousness that is going on. The whole universe is
a manifestation of this supreme consciousness.

B. Deep Self- Hypnosis

and
C. Contemplation and Mystical States Leading to
Spiritual Enlightenment: Samadhi, Living in God
Hypnosis is often thought of as a mental state in which the conscious
mind ceases analyzing the meanings of expressions and permits the hypno-
tist to directly chat with the subconscious mind. In this state of mind, one
being is more responsive to another individual’s words or feelings.
Drawing on the same “relaxation response” that drives meditation, self-
hypnosis helps you to relax your body, lets stress hormones subside, and dis-
tracts your mind from unpleasant thoughts. The relaxation achieved with
self-hypnosis can be intense. Unlike meditation, we often use affirmations as
part of self-hypnosis to manage stress and build self-confidence. Affirmations
are the positive statements (based on rational thinking) that we make to our-
selves to counter stress and unpleasant thoughts.
Sometimes it is possible to reach a state of deep self-hypnosis after
months or, better, years of constant training in every other state we have ana-
lyzed. Even then not everybody can completely achieve this last step. De-
veloping the power of concentration and self-hypnosis, practicing meditation
and trying to be aware of your awareness, consciousness, and being are the
way to the golden key that opens the door of enlightenment. Spiritual en-
lightenment and spiritual awakening are the primary goal of almost all spir-
itual practices, traditions, and religions and for any spiritual seeker. There are
130 Clinical Hypnosis in Pain Therapy and Palliative Care

many names for this awakened state of consciousness depending on what

culture and tradition we belong to.

A human being is a part of a whole, called by us universe, a part limited in time

and space. He experiences himself, his thoughts and feelings as something sep-
arated from the rest . . . a kind of optical delusion of his consciousness. This delu-
sion is a kind of prison for us, restricting us to our personal desires and to affec-
tion for a few persons nearest to us. Our task must be to free ourselves from this
prison by widening our circle of compassion to embrace all living creatures and
the whole of nature in its beauty. (Albert Einstein)

Looking for spiritual light is part of our purpose as soul for living in this
world. The goal of spiritual enlightenment is the goal in life for every human
being born on this earth, and it awaits each of us just over the horizon, in our
own mind. Stay on the path until the goal is reached.
We can learn to follow the light of divine spirit, through the events of our
lives. In Christianity, it corresponds to the eight steps of prayer. It is the
moment of the enlightenment of the living in God, as it has been narrated
from all the greatest Christian mystics of all times.
It is an experience we make out of time, without time or lived, according
to the latest theories of modern physics (especially the ones related to the
quantum mechanics and to the Anthropic Principle) in a unified time. It is
conducted in a self-hypnosis state with the surfacing or emersion of subcon-
scious contents. It is a state of “Immersion in the Absolute.” In Buddhism
and Hinduism, we are at the last step of meditation, the samadhi, the most
elevated state a human being can reach.
Deep inside each of us, there is a space of pure happiness. Without stress.
Without worry. Without illness. Only happiness. Each of us can connect with
this divine space. It can be reached through the experience of the super-con-
scious through contemplation, through identification with the cosmos, through
interior enlightenment with the dispersion of thought inside some kind of
imagined contents. All that baggage of particular experiences very often orig-
inated from spontaneous visualizations.
The Tipitaka, the Buddhist canon, is replete with references to the factors
of enlightenment. Further says the Buddha, “Just as, monks, in a peaked
house all rafters whatsoever go together to the peak, slope to the peak, join
in the peak, and of them all the peak is reckoned chief: even so, monks, the
monk who cultivates and makes much of the seven factors of wisdom, slopes
to Nibbana, inclines to Nibbana, tends to Nibbana.” The seven factors are

1. Mindfulness (sati)
2. Keen investigation of the dhamma (dhammavicaya)
 The Relationship Between Clinical Hypnosis and Mindfulness 131

3. Energy (viriya)
4. Rapture or happiness (piti)
5. Calm (passaddhi)
6. Concentration (samadhi)
7. Equanimity (upekkha)

When concentrated on right thoughts, with right understanding, the

effects the mind can produce are immense.
Let us now deal with the enlightenment factors, one by one. The first is
sati, mindfulness. It is the instrument most efficacious in self-mastery, and
whosoever practices it has found the path to deliverance. It is fourfold: mind-
fulness consisting in contemplation of the body (kayanupassana), feeling
(vedananupassana), mind (cittanupassana), and mental objects (dhammanu-
passana). Right mindfulness or complete awareness, in a way, is superior to
knowledge, because in the absence of mindfulness, it is just impossible for a
person to make the best of his or her learning.
The second enlightenment factor is dhammavicaya, keen investigation of
the dhamma. It is the sharp analytical knowledge of understanding the true
nature of all constituent things, animate or inanimate, human or divine. It is
seeing things as they really are. The whole universe is constantly changing,
not remaining the same for two consecutive moments. All things in fact are
subjected to causes, conditions, and effects. All things are impermanent. What
is impermanent and not lasting we see as sorrow fraught. What is imperma-
nent and sorrow fraught, we understand as void of a permanent and ever-
lasting soul, self, or ego entity.
The third enlightenment factor is viriya, energy. It is a mental property
(cetasika) and the sixth limb of the Noble Eightfold Path, there called samma-
vayama, right effort.
The fourth enlightenment factor is piti, rapture or happiness. This, too, is
a mental property (cetasika) and is a quality that suffuses both the body and
the mind. The person lacking in this quality cannot proceed along the path
to enlightenment.
Passaddhi, calm or tranquility, is the fifth factor of enlightenment.
Passaddhi is compared to the happy experience of a weary walker who sits
down under a tree in a shade or the cooling of a hot place by rain. It is only
when the mind is tranquillized and is kept to the right road of orderly
progress that it becomes useful for the individual possessor of it and for soci-
ety.
The sixth enlightenment factor is samadhi, concentration. It is only the
tranquilized mind that can easily concentrate on a subject of meditation.
Concentration is the intensified steadiness of the mind, comparable to an
132 Clinical Hypnosis in Pain Therapy and Palliative Care

unflickering flame of a lamp in a windless place. It is concentration that fixes

the mind aright and causes it to be unmoved and undisturbed.
The seventh and the last factor of enlightenment is upekkha, equanimi-
ty. In the Abhidhamma, upekkha is indicated by the term tatramajjhattata,
neutrality. It is mental equipoise and not hedonic indifference. Equanimity is
the result of a calm concentrative mind. It is hard, indeed, to be undisturbed
when touched by the vicissitudes of life, but the person who cultivates this
difficult quality of equanimity is not upset. Santideva writes in Bodhicarya-
vatara,

Some there be that loathe me; then why

Shall I, being praised, rejoice?
Some there be that praise me; then why
Shall I brood over blaming voice?
Who master is of self, will ever bear
A smiling face; he puts away all frowns
Is first to greet another, and to share
His all. This friend of all the world, Truth crowns.

The goal in life is spiritual enlightenment to unite the conscious mind with
the soul.
What is enlightenment? The act of enlightening is defined as “the act of
enlightening or casting light where there was darkness.” Spiritual enlighten-
ment is pretty much what all spiritual studies strive for. It is the hope of any-
one studying the topics within spirit and sky to come to this stage of being.
Imagine understanding life, the universe, and everything? It is not likely any-
one of us will achieve “total” spiritual enlightenment in our lifetimes, but
many have and will at least gain partial enlightenment. Spiritual enlighten-
ment is a universal subject and quite difficult to define. It actually refers to
the concept of self-realization, which can be achieved by years of dedication,
meditation, and spiritual growth. Self-realization is a Hindu concept of look-
ing into one’s inner self.
The correct spiritual path for you is the one that resonates with you, that
helps you to become a better person, achieve a loving, whole feeling of being
connected to everyone and everything, at peace inside and in tune with our
true nature as spiritual beings.
When you seek a way to open your heart, to love all including yourself,
and to feel your connection with life, you have started on your path toward
spiritual enlightenment.
Consciousness is personalized energy that knows itself, and its abilities go
far beyond human understandings. You soul is conscious energy in all its
forms. The brain is a vital organ that facilitates the link between your mind
 The Relationship Between Clinical Hypnosis and Mindfulness 133

and matter, yet without a brain the physically focused portions of your con-
sciousness would become refocused elsewhere.
How you do that is of course up to you, there are many spiritual tools
that you can use to lead you to experiencing your spiritual self. Meditation,
yoga, clinical hypnosis and self-hypnosis, Reiki, spiritual churches, and
more. There are many earth angels who will assist you on your spiritual jour-
ney, many books written to guide you, but ultimately listening to your intu-
ition is at the very core of all of these processes. When you can intuitively lis-
ten and trust your internal guidance, then your life will take on a new dimen-
sion.

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 Chapter IV

CLINICAL HYPNOSIS TECHNIQUES

IN PAIN AND PALLIATIVE CARE

1. THE TECHNIQUES OF PAIN ANALGESIA

WITH CLINICAL HYPNOSIS

A. The Benefits of Hypnosis in Pain

n the previous chapter, we learned many different techniques of relax-
I ation, hypnosis, and mindfulness in the modified states of consciousness.
Many people worldwide, have learned these very important techniques, peo-
ple of all ages, cultures, philosophies, and religions. The mindfulness and
hypnosis techniques allow your mind to settle inward beyond thought to
experience the source of thought, pure awareness, also known as transcen-
dental consciousness or higher consciousness. This is the most silent and
peaceful level of consciousness, the awareness of your innermost self (Samraj,
2005). In this state of restful alertness, your brain functions with significant-
ly greater coherence and your body gains deep rest (Austin, 1999).
The aim of mindfulness is to bring inner peace within ourselves and the
world in a positive mental and spiritual way. Research has shown clinical
hypnosis and mindfulness to be helpful for acute and chronic pain.
Pain is the major problem in the treatment of patients with chronic dis-
eases and cancer. During prolonged illnesses, the best way that we can
change our suffering is to modify our thoughts from being negative to bring
positive. The positive discovery about meditation and clinical hypnosis, is
that we are focusing within ourselves and becoming free of negativity.
Clinical hypnosis improves psychological resilience. It helps an individ-
ual’s tendency to cope with stress and adversity. This coping may result in
the individual’s “bouncing back” to a previous state of normal functioning or
simply not showing negative effects. In all these instances, resilience is best

142
 Clinical Hypnosis Techniques in Pain and Palliative Care 143

understood as a process. It is often assumed to be a trait of the individual, an

idea more typically referred to as “resiliency.” Most research now shows that
resilience is the result of individuals being able to interact with their envi-
ronments and the processes that either promote well-being or protect them
against the overwhelming influence of risk factors. These processes can be
individual coping strategies or may be helped by clinical hypnosis (Casula,
2001).
Meditation and hypnosis techniques simply involve a process of trans-
forming ourselves and our thoughts and recognizing the negative thoughts
and changing them into beneficial and peaceful thoughts (A. Brugnoli, 2005;
Brugnoli, Brugnoli & Norsa, 2006; Casula, 2001; De Sousa, 1987; Erickson,
1959; Linden, 1999).
The best attitude toward mindfulness and hypnosis is to be very patient,
because the mind does not always want to focus. Having a sense of expecta-
tion toward positive results can create uncomfortable pressure and thus take
away the enjoyment of the experience. By practicing mindfulness and hyp-
nosis regularly, the person gains a wonderful sense of the inner self. Medi-
tation and hypnosis are self-healing processes; any form of pain is a sign of
our negative thinking and unease within our mind. If we don’t attend to
unase in the mind, we may find that chronic suffering can lead to disease of
the body.
The human mind and body are intrinsically linked, something that mys-
tics from time immemorial have been indicating. The state of the mind, to a
great extent, controls the well-being of the body. This is something that has
recently been proven by scientific researchers (Fourie, 1997; Handel, 2001;
Patterson, 2010).
In Chapter III, we saw that there are various methods of practicing relax-
ation, hypnosis, and mindfulness. Each method depends on our objective in
practicing it. One of the common objectives of these practices is to acquire a
tension-free, relaxed, happy, and peaceful state of mind, so that we can face
the day-to-day challenges of life and relationships, healing inwardly in a
more creative, balanced, and objective manner.
In this chapter, we improve the knowledge of some specific hypnosis
techniques to relieve acute and chronic pain. Pain management (also called
pain medicine or algiatry) is a branch of medicine employing an interdisci-
plinary approach for easing the suffering, and improving the quality of life of
those living with pain.
Pain management (also called pain medicine or algiatry) is a branch of
medicine employing an interdisciplinary approach for easing suffering and
improving the quality of life of those living with pain. Medicine treats injury
and pathology to support and speed healing and manages distressing symp-
144 Clinical Hypnosis in Pain Therapy and Palliative Care

toms, such as pain, to relieve suffering during treatment and healing. When
a distressful injury or pathology is resistant to treatment and persists after the
injury or the pathology has healed, and when medical science cannot identi-
fy the cause of pain, the task of medicine is to relieve suffering.
We have studied in detail the neurophysiological and behavioral assess-
ment of pain and suffering (see Chapter II). WHO has developed a three-step
pharmacological “ladder” for pain relief. If pain occurs, there should be
prompt oral administration of drugs in the following order:

1. nonopioids (aspirin and paracetamol);

2. mild opioids (codeine), as necessary;
3. strong opioids, such as morphine, until the patient is free of pain

To calm fears and anxiety, additional adjuvant drugs should be used. To

maintain freedom from pain, drugs should be given “by the clock”; that is
every 3 to 6 hours, rather than “on demand.” This three-step approach of ad-
ministering the right drug, in the right dose, at the right time, is inexpensive
and 80 to 90 percent effective. Surgical or anesthesiological interventions on
appropriate nerves may provide further pain relief, if drugs are not wholly
effective.
Treatment approaches to chronic pain include pharmacological mea-
sures, such as analgesics, tricyclic antidepressants and anticonvulsants; inter-
ventional and anesthesiological procedures; physical therapy; and psycho-
logical measures, such as cognitive behavioral therapy, clinical hypnosis, and
mindfulness. Clinical hypnosis can be considered a nonpharmacological in-
tervention as adjuvant in pain therapy.
Nonpharmacological interventions adjuvant in pain therapy can be clas-
sified as either cognitive behavioral interventions or physical agents. Cog-
nitive and behavioral approaches include several ways to help patients un-
derstand more about their pain and take an active part in its assessment and
control. The goals of interventions, classified as cognitive behavioral thera-
pies, are to change patients’ perceptions of pain, alter pain behavior, and pro-
vide patients with a greater sense of control over pain. The goals of inter-
ventions classified as physical agents or modalities are to provide comfort,
correct physical dysfunction, alter physiological responses, and reduce fears
associated with pain-related immobility or activity restriction.
Nonpharmacological approaches and hypnosis are intended to supple-
ment, not substitute for, the pharmacologic or invasive techniques described.
Nonpharmacological interventions are appropriate in chronic diseases, in
cancer patients and in palliative care for the patient who
 Clinical Hypnosis Techniques in Pain and Palliative Care 145

1. finds such interventions appealing

2. expresses anxiety or fear, as long as the anxiety is not incapacitating
or due to a medical or psychiatric condition that has a nonspecific
treatment
3. may benefit from avoiding or reducing drug therapy (e.g., history of
adverse reactions, fear of or physiological reason to avoid overseda-
tion)
4. is likely to experience, and needs to cope with, a prolonged interval of
postoperative pain, particularly if punctuated by recurrent episodes of
intense treatment or procedure-related pain
5. has incomplete pain relief following appropriate pharmacological in-
terventions
6. needs physical and psychological suffering relief, and in palliative care
at the end of life

Cognitive behavioral approaches include preparatory information, simple

relaxation, imagery, and hypnosis. Physical therapeutic agents and modal-
ities include application of superficial heat or cold, massage, exercise, immo-
bility, and electroanalgesia such as transcutaneous electrical nerve stimulator
(TENS) therapy or electroacupuncture.
The conitive behavioral stratgies require greater professional involve-
ment; these include complex imagery, hypnosis, biofeedback, mindfulness,
and combined therapies. Such strategies can be commonly applied when
patients have acute or chronic pain.
I have worked for 15 years as an anesthetist in surgical rooms and in crit-
ical care, and now I work as a pain therapist. Since 1985, I have been inter-
ested in and have studied clinical hypnosis to help the relief of pain and suf-
fering. In this chapter I explain the use of clinical hyponosis techniques in
pain therapy. The techniques of hypnosis in pain therapy have two objec-
tives:

1. physical pain relief (Patterson & Jensen 2005; Patterson, 2010)

2. psychological and spiritual suffering relief (Casula, Preti & Portaluri,
2005; Linden, Bhardwaj & Anbar, 2006; Perez-De-Albeniz & Jeremy,
2000)

B. What is Hypnosis?
Hypnosis is a state of inner absorption, concentration, or focused atten-
tion that assists a client in altering some aspects of thought, emotion, behav-
ior, or perception. “Hypnosis is a procedure during which a health profes-
146 Clinical Hypnosis in Pain Therapy and Palliative Care

sional or researcher suggests that a client, patient, or subject experience

changes in sensations, perceptions, thoughts, feelings or behavior. The hyp-
notic context is generally established by an induction procedure most
include suggestions for relaxation, calmness and well-being” (APA, Div. 30,
Kirsch, 1994).
Hypnosis typically involves an introduction to the procedure during
which the subject is told that suggestions for imaginative experiences will be
presented. The hypnotic induction is an extended initial suggestion for using
one’s imagination and may contain further elaborations of the introduction.
A hypnotic procedure is used to encourage and evaluate responses to sug-
gestions. When using hypnosis, one person (the subject) is guided by anoth-
er (the hypnotist) to respond to suggestions for changes in subjective experi-
ence and alterations in perception, sensation, emotion, thoughts, or behav-
ior. Persons can also learn self-hypnosis, which is the act of administering
hypnotic procedures on one’s own. If the subject responds to hypnotic sug-
gestions, it is generally inferred that hypnosis has been induced. Many be-
lieve that hypnotic response and experiences are characteristic of a hypnot-
ic state. Whereas some think that it is not necessary to use the word hypno-
sis as part of the hypnotic induction, others view it as essential.
During my work in critical care, I was always very touched by pain, suf-
fering, and sometimes the death of young people, and now that I work on
the pain relief therapy, I happen to deal with many cancer patients. The suf-
fering of these patients is not only physical but also psychological and spiri-
tual, and in my experience, hypnosis can help all of these types of sufferings,
in chronic diseases and in the last stage of the dying patient.
During hypnosis, your body relaxes and your thoughts become more
focused. Like other relaxation techniques, hypnosis lowers blood pressure
and heart rate and changes certain types of brain wave activity. In this re-
laxed state, you will feel at ease physically yet be fully awake mentally and
may be highly responsive to a suggestion.
There are several stages of hypnosis in pain therapy:

• Reframing the problem (pain and suffering)

• Becoming relaxed, then absorbed (deeply engaged in the words or
images presented by a hypnotherapist)
• Dissociating (letting go of critical thoughts)
• Responding (complying with a hypnotherapist’s suggestions)
• Returning to usual awareness
• Reflecting on the experience
 Clinical Hypnosis Techniques in Pain and Palliative Care 147

C. What Happens During the First Visit of the Hypnotherapist?

During the first visit, you will be asked about your medical history and
what brought you in and what condition you would like to address. The hyp-
notherapist may explain to you what hypnosis is and how it works. You will
then be directed through relaxation techniques, using a series of mental
images and suggestions intended to change behaviors and relieve symptoms.
The hypnotherapist will also teach you the basics of self-hypnosis and, some-
times, give you a CD to use at home so you can reinforce what you learn dur-
ing the session.
Each session lasts about an hour, and most people start to see results
within two to five sessions. You and your hypnotherapist will monitor and
evaluate your progress over time. Children are easily hypnotized and may
respond after only one or two sessions (Linden, Bhardwaj & Anbar, 2006).
Hypnosis is used in a variety of pain therapy settings: from emergency
rooms, to critical care to anesthesiology to anesthesiological procedures to
chronic diseases to palliative care (Accardi & Milling, 2009; Patterson &
Jensen, 2003; Patterson, 2010).
Clinical studies suggest that hypnosis may improve immune function,
increase relaxation, decrease stress, and ease pain and feelings of anxiety.
Hypnotherapy can reduce the fear and anxiety that some people feel before
medical or surgical procedures. For example, hypnosis may improve recov-
ery time and reduce anxiety as well as pain following surgery. Clinical trials
on burn patients suggest that hypnosis decreases pain (enough to replace
pain medication) and speeds healing. Generally, clinical studies show that
using hypnosis may reduce your need for medication, improve your mental
and physical condition before an operation, and reduce the time it takes to
recover.
A hypnotherapist can teach you self-regulation skills. For instance, some-
one with arthritis or cancer pain may learn to turn down pain like the vol-
ume on a radio. Hypnotherapy can be used to help manage chronic illness.
Self-hypnosis can enhance a sense of control and improve pain and suffering
relief, which is often lacking when someone has a chronic illness. Clinical
studies on children in emergency treatment centers show that hypnotherapy
reduces fear, anxiety, and discomfort.
Pain management distills down to a very simple endpoint: patients’ relief
and comfort. If patients feel better, feel comforted, feel less stressed and
more functional in life, and their practice poses no health risk, then support-
ing complementary and alternative therapies creates a true holistic partner-
ship in health care.
148 Clinical Hypnosis in Pain Therapy and Palliative Care

In my profession, pain, suffering, and death are always very close, and
when I started to experiment on the process of clinical hypnosis in its deep-
est way, I discovered not only pain relief but also the awakening of the spir-
itual experience in palliative care. I discovered that in chronic suffering
relief, hypnosis can be an experience similar to what the patient faces in the
predeath state. As was explained by people who survived a cardiopulmonary
resuscitation, they felt a state between life and death, and they say it was a
state of psychological and spiritual well-being.
At the beginning, I use the classic techniques of physical and psycholog-
ical relaxation until the finalized hypnosis aimed to the pain therapy. In help-
ing patients with chronic diseases, the first step is to take away the physical
pain. Besides the different drugs available and the anesthetics, there are sev-
eral methods of hypnosis that help the patient not only in physical pain but
also in need of controlling anxiety. What follows are some hypnosis methods
to be used as pain relief suitable for all patients.

D. The Techniques of Pain Analgesia With Hypnosis

• Technique of a different interpretation of the symptoms
• Technique of the transferred symptoms
• Technique of the transport of the symptoms
• Technique of positive and negative visualizations
• Technique of partial or total hypnotic amnesia
• Technique of the activation of a type of conditioned reflex
• Technique of switching attention
• Hypnosis technique of the self-training of Shultz
• Technique of self-hypnosis in pain relief
• Schedule of relaxation with hypnosis for acute pain

Technique of a Different Interpretation of the Symptoms

When a state of a lighter or deeper relaxation is achieved through differ-
ent techniques, the patient is trained how to interpret the feeling of chronic
pain coming from a specific place in the body and to transform it slowly from
a feeling of pain to a feeling of a different nature, for example, light or medi-
um tension, moderate pressure, beneficial warmth, or cold sensation of an
anesthetizing nature.

EXAMPLE OF ANESTHESIA TO ONE HAND

While in a state of relaxation, you can imagine immersing your hand in a con-
tainer of melting ice cubes and from the wrist up to the tip of your fingers the
 Clinical Hypnosis Techniques in Pain and Palliative Care 149

ice acts on your hand like a very powerful anesthesia . . . making it feel more
and more insensitive. You will feel your hand becoming increasingly insensitive
. . . and the anesthesia will increase. You will also know that the anesthesia will
last until you repeat to yourself for three times “Everything is normal.”

EXERCISE “WARM HANDS”

During this exercise you will repeat to yourself:

“My hands are warm”
During the period of “deep relaxation,” you will imagine you are keeping your
hand in front of the flames of an open fire under a solar lamp (UVB lamp), or
immersed in hot water, or any other thought of this kind that might come easy
to you.
Duration: 5 (or also only 3) minutes.

EXERCISES WITH DIFFERENT TYPES OF PAIN RELIEF F EELINGS

During this training, imagine finding yourself in the circumstances correspond-

ing to the situation indicated here:

• My feet are warm.

Duration: (5 or also only 3) minutes.

During this exercise, repeat to yourself:

• My feet are warm.
• My feet are cold.
• My hands are cold.
• My hands are warm.

Technique of the Transferred Symptoms

After achieving relatively strong analgesia in a certain part of the body
with the techniques just described, you aim to mentally transfer the analge-
sia to another part of the body (for instance, from the hands to the abdomen
or to the back), obtaining this way a gradual and progressive reduction of the
global suffering.

Technique of the Transport of the Symptom

When the patient has achieved a medium or, better, a deeper state of
relaxation, you do an intense analgesia on one hand, preferably the one that
is most used. You then proceed by moving the analgetic hand on to the
painful side of the body or wherever the patient wants to direct the analge-
150 Clinical Hypnosis in Pain Therapy and Palliative Care

sia. In this way, with repeated procedures, you lessen the suffering, especial-
ly if this pain has not been there for a very long time.

Technique of the Positive and Negative Visualizations

When the patient remains in a state of relaxation or in medium hypno-
sis status, introduce particular visualizations that will cause, after a certain
time, major feeling visualization that is capable of modifying the painful in-
formation in the CNS and, therefore, reduce the pain to the patient. What
follows is an example.

THE SCHEDULE FOR THE DESENSITIZATION OF PAIN. Since 1800, certain

methods have been used in the Western world to induce the modification of
the pain threshold through hypnotic techniques in the field of surgery anal-
gesia. During the deep hypnotic state, the patient does not seem to react to
the surrounding environment and usually seems to have a reduced sensitiv-
ity to painful stimulation. This happens even if you can have some or all of
the reflexive or vegetative signs of the painful stimulation. Therefore, the
best use for this technique is to induce deep relaxation up until the uncon-
scious can register and activate through hypnotic suggestion a minor sensi-
tivity to pain for a longer time even in a state of normal awakening,
The use of this technique is to diminish the anxiety connected with pain,
in the case of headaches, for example, when besides the body pain, a great
emotional dysfunction arises; in the case of phantom arm or leg pain after an
amputation; or in the chronic pain of cancer patients.
The methods most used during the state of deep relaxation or hypnosis
are

• Direct instructions for the reduction of pain

• The use of metaphors
• The transportation of the painful symptom
• The detachment of pain through imagination

Technique of Partial or Total Hypnotic Amnesia

For this technique, you need the patient to be in a medium or deep hyp-
notic state. It is possible to achieve a better result by taking the patient back
to the state of well-being and healthy status from before the illness started
through specific questions. In this way, the patient will eventually forget the
memories of the bad experiences, which are related to his or her pain, and
in some cases also forget the memories of the anxiety related to the pain in
chronic diseases.
 Clinical Hypnosis Techniques in Pain and Palliative Care 151

Technique of the Activation of a Type of Conditioned Reflex

This technique, called the “non painful pain,” uses the same methods that
Pavlov applied to dogs. He created a typical conditioned reflex for dogs by
showing them the food together with or soon after a painful stimulation.
After a certain number of tests, depending also on the breed and the sex of
the dog, the painful stimulation was not felt thanks to the gratification of the
food.
Almost the same thing happens with human beings thanks to a mecha-
nism of emotional restructuring in the perception of painful stimulation at
the level of the brain areas. During a deep state of relaxation, it is possible to
activate a conditioned reflex through images and music preferred by the
patient so that the pain is reduced.

EXERCISE BASED ON THE “CHOSEN I MAGE”

Train yourself to accept your favorite image for 5 minutes . . .

Then you look at the image for 4 minutes . . .
Then 3 minutes of your favorite image . . .
Then 2 minutes of you favorite image . . .
Then 1 minute of your favorite image . . .
Obviously this exercise will last about 15 minutes.
Every “entrance” of the favorite image will be preceded by a countdown from
twenty to one . . .
Think that by counting down your pain also decreases . . . progressively.

The patient can train herself or himself to do this exercise.

Technique of Switching Attention

This method used by Kroger can be very useful for chronic pain by train-
ing the patient to move his or her attention to those parts of the body that are
not affected by pain.
Using gratifying visualization, you train the patient to move his or her
attention to another pleasant sensation of his or her body that is past or pre-
sent. This method is also useful in chronic pain when it is not too strong, but
it is understood that the patient must participate actively in the visualization.
Sometimes this is easier than the previous systems, especially by sug-
gesting gratifying visualization. If the patient cannot do the self-training you
can use the following method:
152 Clinical Hypnosis in Pain Therapy and Palliative Care

M ETHOD OF THE CD. This consists of simply recording the desired sug-
gestion on a CD and then listening to it when you are relaxing. This will be
very effective for people who have difficulty visualizing.

Hypnosis Technique of the Self-Training of Shultz

When the patient has been well-trained to practice the easier exercises of
the self-training of Shultz, we can use these exercises during the hypnotic
state to obtain good relief of pain. The simple exercises of the self-training of
Shultz are as follows:

• Exercise of feeling heavy

• Exercise of heat
• Exercise of the heart
• Exercise of the breath
• Exercise of the abdomen
• Exercise of the cool forehead

All of these exercises are suitable for pain therapy, but we will consider only
a few examples.

The Technique of the Heat

My body . . . in the time passing by . . . is becoming more and more
pleasantly warm . . .
Even more pleasantly warm . . . and a feeling of great well-being . . .
Great calm . . . great tranquility . . . it becomes part of me . . . the time goes by
I feel well . . . I feel well . . . I feel really well . . .
and everything else does not bother me anymore . . .

For this exercise, please repeat the sentences slowly with calm at least ten
times.

EXERCISE OF THE COOL F OREHEAD. “My forehead is pleasantly cool.”

This can be another exercise for pain-relief therapy, depending on the pa-
tient’s personality and character. It is also a very important exercise for con-
trolling chronic headache and for different types of cancer as well. This is
how to carry out the technique of the cool forehead:

Concentrating on your forehead please repeat . . .

My head is light . . . all the muscles of my face are rested . . .
I am calm . . . calm . . . perfectly calm.. in a state of great well-being . . .
 Clinical Hypnosis Techniques in Pain and Palliative Care 153

My forehead is cool . . . pleasantly cool . . . even more pleasantly cool . . .

The coolness is all around me and gives me well-being . . .
Well-being of the body and wellbeing of the mind . . .

Repeat this formula between five and ten times.

Technique of the Self-Hypnosis in Pain Relief

This is one of the most efficient techniques and is carried out in three
phases:

1. You are living a pleasant feeling in deep relaxation.

2. You connect this feeling mentally to your symptoms.
3. You are using it mentally to cancel your symptoms.

The most efficient way to achieve this feeling is to repeat this technique until
you achieve your goal, and sometimes this will take quite a while.
Imagine that we are going to use this technique of posthypnotic state to
achieve the following goal: “I can hear very soft music that helps my pain.”

Phase 1. You are living this moment in a status of relaxation.

You relax for 5 minutes and concentrate on remembering the last time you
could hear soft music.
You can hear the harmony of this music, and of all the other times that you
heard soft music in your past.
You imagine hearing this music in the ears of your mind; after you have recap-
tured that moment, you go to phase 2.

Phase 2. You make the connection with the hypnosis.

Yet again in a state of relaxation, you can see yourself in different circumstances;
use the key words:
“Let me hear the soft sound of the music,” and at that point, you will be here.

Phase 3. You use this system to eliminate the pain.

Try to examine the result of your experiment and, if necessary, repeat the whole
procedure again.

To achieve the best results in these techniques, it is important to learn,

first of all, to relax and concentrate without being distracted by anything and
take the focus of your attention within yourself. At the beginning, this can be
difficult, but with the practice, you will achieve surprising results. Try to cre-
ate within yourself the sentiment that what you wish is real and that it can be
achieved through your will.
154 Clinical Hypnosis in Pain Therapy and Palliative Care

It is advisable to remember this willingness or condition that you want to

achieve during your normal day so that this becomes part of your everyday
life.

Schedule of Relaxation With Hypnosis for the Treatment of the Acute

Pain
With this exercise, you will be under hypnosis for different lengths of
time, measured in minutes or seconds (acute pain in emergency and in crit-
ical care).

Before you count down from twenty to one always think:

“Now I will sleep for X minutes; meanwhile, my pain will decrease.”
Then, begin to count down from twenty to one.
While you are practicing this experiment, you must use the following sugges-
tion:
Every time faster and deeper.
This means of course that every time you go to sleep your eyes will close faster,
and you will sleep more deeply.
Try this exercise for different lengths of time.
Try to do self-inductions that last 10, 15, and 20 seconds.

This technique can be used in the acute pain relief.

2. DEEP HYPNOSIS IN RELIEF OF PAIN AND SUFFERING

Hypnosis is a form of deep mental and physical relaxation that allows

you to access your inner emotions, memories, and inner self. Hypnotherapy
uses this state of relaxation to enable you to tap into your inner resources and
gain access to the root cause of a problem.
Have you ever caught yourself daydreaming? When you are daydream-
ing, it is as though you are not in the here and now. You are somewhere else,
you are very calm and still, you are actually caught up in the moment, but
you are perfectly aware of what is going on around you. We go into hypnot-
ic states several times during our day and do not even know it is hypnosis.
This is exactly what it is like when you are hypnotized. You experience
an overall feeling of calmness throughout your entire body and mind. At all
times, you are totally aware of what is going on around you. You are in com-
plete control, and you can communicate clearly and effectively with the hyp-
notherapists, with your inner self, and with you higher consciousness.
 Clinical Hypnosis Techniques in Pain and Palliative Care 155

What is so important about the relationship between hypnosis and your

subconscious mind? Deep hypnosis is the door to your mind, your inner self,
and your higher consciousness. The subconscious is the part of the mind that
is utilized in hypnosis, and your subconscious mind looks after every organ,
muscle, and cell in your body 24 hours a day. It never sleeps. Your subcon-
scious mind regulates all involuntary bodily functions, including your heart
rate, breathing, blood pressure, hormone production, and elimination sys-
tem (Vannoni & Brugnoli, 1971; Vaitl et al., 2005). Your subconscious mind
is also the seat of your emotions, your feelings, and your sensations. It is also
where your permanent memory is stored.
The brain and nervous system respond only to mental images. It does
not matter whether the image is imagined or real. Like a computer, your sub-
conscious mind holds good programs and “bad” ones. Hypnosis is like a
virus scan for your computer, detecting the “bad” programs and upgrading
your “software” (inner self).

A. Deep Self-Hypnosis and Deepening Techniques

to Achieve Deeper Levels of Trance
Going into a trance is a skill. For many things, ultradeep trances are not
necessary. If you are going to create anesthesia in pain therapy or have some
need to create a deeper hypnotic phenomenon, having a deeper trance is
helpful (Spiegel, 1985). You can do this for yourself or for your subjects.
The techniques should contain some types of suggestions:

• Deepening suggestions
• Suggestions that each time you are hypnotized, you more easily and
quickly go into a much deeper and relaxing state of hypnosis.
• Suggestions that you enjoy the hypnosis state.

Deepening Suggestions
The deepening suggestions that are easiest to use in this situation are sug-
gestions that relate to breathing, escalators, elevators, and counting. Here are
some examples.

BREATHING

And every single deep and natural breath you take allows you to deepen your
relaxation.
156 Clinical Hypnosis in Pain Therapy and Palliative Care

COUNTING

In a moment, I’m going to count from ten down to one . . .

And in allowing each number to help your body grow more relaxed . . .
your mind go more relaxed . . .
so that certain thoughts just fade away . . .
like sand slipping through your fingers . . .
You can find that easy relaxation of mind and body . . .
because of these words... just happens now . . .
ten . . . easily relaxing all over again . . .
9 . . . then . . .
8 deeper still . . .
. . . feeling great
7...6...5...
mind and body relaxed . . .
4 . . . relaxing more . . .
. . . 3 then
2...
your deepening grew at
1 . . . derful deep levels
going deeper . . .
. . .That’s right . . .

E LEVATORS AND E SCALATORS

In a moment, I’m going to ask you to imagine yourself at the top of an escala-
tor. I’m going to count down from ten to one. As I say the number ten, in your
imagination step onto the escalator. Allow yourself to go deeper into relaxation
with each number I say. When I reach the number one, step off the escalator
into a state of relaxation deeper than you’ve ever felt before.
ten steps on the escalator and go much deeper . . .
nine relaxing more and more with each number . . .
eight allowing yourself to go deeper and deeper with each number . . .
seven, each number and each easy, natural breath you take helps you relax
more fully . . .
six . . .
five . . . doing deeper into relaxation . . .
four. . . . feeling relaxation flow and every area of your body . . .
three . . .
two . . . allowing your body to feel a wonderful . . . at the relaxation . . .
one . . . now more deeply relaxed than ever before . . .
 Clinical Hypnosis Techniques in Pain and Palliative Care 157

Go Easily and Go Quickly Into a Much Deeper

and Relaxing State of Hypnosis
And each time you relax yourself, you more easily and quickly go into a much
deeper state of hypnosis.

And because you are learning . . . really learning what hypnosis is, the next time
you are hypnotized you will easily and quickly, effortlessly and wonderfully en-
ter a deep and profoundly useful trance.

Enjoy Going Into the Hypnosis State

You enjoy going easily and effortlessly achieving deeper and deeper levels of
hypnosis.
In a nutshell, here it is . . .
Create your deepening hypnosis state.
Create a posthypnotic reinduction cue for yourself or your subject.
Sit or lie down, get comfortable and relaxed, and start the self-hypnosis.
Give yourself your posthypnotic re-induction cue.

The Instant Trance and Posthypnotic Reinduction Cues

A posthypnotic reinduction cue is simply a posthypnotic suggestion to
enter a trance at a later time at some prearranged signal. This can save you
from having to go through a lengthier induction process in chronic pain.
Posthypnotic reinduction may be what is happening when you see a
stage hypnotist snap his fingers or say a word and have his subjects immedi-
ately go into trance. The subjects were first hypnotized and then given the
cue. After that time, they respond to the cue. An example would be “And
when I look at you directly in the eyes and snap my fingers like this (snap
fingers), you’ll instantaneously go to this level of trance or deeper.”

. . . Good, now you’ve achieved a wonderful level of relaxation . . .

and I’d like to make sure that we can have this relaxation available to us any
time we want it . . .
That way, we can get the maximum amount of good done in the time we have
available . . .
From this day forward, in my office, any time I say the phrase “blue moon” . . .
instantaneously go to this level of trance or deeper . . .
“Blue moon” takes you deeper . . .
In a moment, I’m going to say that phrase again . . .
just feel how wonderfully you relax when I say it . . . “blue moon”
. . . that’s right . . . even deeper.
158 Clinical Hypnosis in Pain Therapy and Palliative Care

Good . . . in a moment I’m going to count from one to three . . .

when I reach the number three allow your eyes to become open . . .
Then I’ll say the phrase “blue moon” again . . . that’s right . . .
When I do . . . close your eyes and go to this level of relaxation or deeper . . .
one . . .
two . . .
three . . . open your eyes . . . “blue moon” . . .
That’s right . . . even deeper . . .
In a moment, I’m going to count from one to five . . .
When I reach the number five, be oriented to this room, this time, this place
feeling alert and refreshed and wonderful in every way.
• feeling good
• re-orienting more to this room, time and place
• in a moment your muscles will begin to stir
• on the next number open your eyes and feel great
• open you eyes and feel great.

After Hypnosis Induction Slowly Return to Being Awake

Now let’s take a deep breath . . .
And slowly . . . return to being awake . . .

I regain my normal waking state.

I can start my first movements of my feet and hands, calm . . . without rushing
. . . slowly . . .
I can start to slowly open my eyes . . . slowly . . .
and regain . . . always slowly . . . my normal waking state,
moving my arms and my legs . . .
I move again . . . good.
I am awake.
. . . How are you?
How are you? Did you reach a calm state?
Good . . . very good.

3. CLINICAL HYPNOSIS IN PALLIATIVE CARE

When we allow death and awareness of life to occupy their natural posi-
tion in our life, we are presented with many opportunities to open ourselves
to the beauty of life, and we will never fear the unexpected but gain strength,
love, and compassion when we understand that all this is a natural part of our
life. It is a rewarding feeling to be able to sit with your dying friend and
patient to make him or her understand the mystery of love. It is rewarding
to be able to make him or her relax in the face of death, with peace and spir-
 Clinical Hypnosis Techniques in Pain and Palliative Care 159

ituality, and to feel that this love is growing in his or her heart. It is reward-
ing to communicate that death is not the end but is “the natural way of life”
and is something much bigger and more divine than will ever be possible in
our physical life.
Studies of human evolution over the course of the centuries and millen-
nia and of the neurophysiological development of the brain and the mind
can give us some help in providing medical therapy for the suffering of the
body but are of no help for emotional suffering; that is a therapy we can
learn through the path toward the spiritual consciousness ( Jung, 1952; Kallio
& Revonsuo, 2003; Rinpoche, 1994; Sherman, 2004). It is, therefore, impor-
tant also in the medical therapy and in palliative care, to study the expansion
of the conscience to take us toward new horizons.
There are a lot of studies these days connected with the latest physical
and neurophysiological theories that will help depressed individuals who are
tired and bored with the everyday life. Through these new studies and inter-
ests, this work might solve “life’s struggle,” “the obscure fear” that is the
cause of so many depressive diseases and often reaches an intensity when,
with death, we let go of all our life work (Assagioli, 1991; Brugnoli, 1974a,
1974b, 2004, 2005). Instead, this is the moment of most strength and aware-
ness to face our life with more enthusiasm.
In truth, there is a slow path toward spiritual awareness, and even if it
does not cure all our illnesses, it will be certainly a good and valid help for
the conquest and the knowledge of ourselves, of the deepest self and the
internal personal world, and of all the hidden qualities that everyone has
within their rational and intuitive mind. We need to reflect more on the spir-
itual sides—“the vital spirit” or “vibration energy”—of the most advanced
physicians, mathematicians, cosmologists, and philosophers who are study-
ing to understand the holistic conscience and global conscience of the human
being. We need to wake up our mind to the new wind of our spirit. We need
to wake up our mind to new important paths. We need to wake up our mind
and brain with the new discoveries in all the fields of the human being and
even the ones that are less observed and analyzed in all the moments of life.
We need to consider our soul as part of the whole being. We know
through our intuition that we are reaching a new stage of evolution that will
develop more during this century. We need to reflect more on the spiritual
sides of all the matters that concern and surround the microcosm and macro-
cosm from everything down to the smallest particle and the heaviest, the
most enormous galactic bodies that lie among the millions of stars where we
will find other beings more advanced than we are.
What we could call the superintelligence or cosmic superconscience or,
in other words, the spiritual awareness, is waiting for us, is observing us, so
160 Clinical Hypnosis in Pain Therapy and Palliative Care

that when we are ready, we will become part of it, and thereby we will under-
stand the reason for our life and especially to give meaning to life (A.
Brugnoli, 2004, 2005).
At least, we can agree that the only material life, as we see it today, has
no reason to exist just on its own. We are aware that there exists an entropic
relationship among all of us because we know that together we can go
through the path of spiritual awareness. We are aware that the energy we re-
ceive is transformed into further information that then transforms itself into
knowledge, consciousness and awareness.
Therefore, every moment in our life becomes of interest about who we
are and where we are, becomes a joy of living and participating to the whole
universe of life, and becomes minute by minute a moment of life in a “con-
tinuum time and space” that will adapt and expand to the infinite within our-
selves and in the macrocosms.
When we experience the awareness, we will feel it for sure because we
will experience a wave of happy emotions. We can call this a mystic experi-
ence, and this is described in all religions and cultures throughout the histo-
ry of humanity. This means we have arrived. We have understood and dis-
covered the basis of existence where the physic and metaphysic level have
become one.
Everybody can feel this sooner or later, maybe by watching a wonderful
sunset, or looking at a work of art, or by listening to the words of someone
you love. If we could muster the courage, we would call it a divine experi-
ence or a spiritual experience. This entrance to the state of consciousness can
be compared to what someone might call illumination, samadhi, ecstasy, or
nirvana.
We need to understand that our mind allows us to have two lives, one
that is the everyday life, which we can call the exterior life; the other one is
the internal life that continuously searches, sometimes spasmodically, for the
truth of the eternal image of our life after death.
The philosopher Jidd Krishnamurti was quite clear in his thesis at the
beginning of the century. He said, “every being is the world.” Again, we have
not yet reached the point where everyone contains the whole world, we con-
tain the whole cosmos, and therefore, it contains the “path to the spiritual
awareness” or the “spiritual awareness” (A. Brugnoli, 2004, 2005). We can
call this by several different names depending on our culture, from our
awareness in understanding the life within and outside ourselves and also
depending on our religion and beliefs and faith.
So the names we can give to this path to spiritual awareness or spiritual
awareness are varied. The absolute power, the infinite power, the spiritual
conscience, God, but no matter what we call it, we all mean the same thing,
 Clinical Hypnosis Techniques in Pain and Palliative Care 161

the arrival point of the personal and collective evolution and the cosmic and
planetary evolution.
Through this path, we will find the presence of happiness and calm at the
end of our life’s journey, when all mystic people consider it to be the dark-
est time of our soul and all philosophers consider it to be a night of depres-
sion. In reality, this will be the moment of the “light,” the light that will never
blind and never end, the light of the spirit that will envelop our heart and
soul until the fusion of all matter.
This is a journey of the deepest analysis within ourselves and of all the
possibilities of the vital spirit of all the beings; it isthe search of the direct
presence of the unknown being, that the philosophers talk about. Thomas
Merton, the Trappist monk and author, who died in 1968, he offered a mar-
velous description of his experiences in his mystic state within half a minute
in his book Dialogues with Silence.

What can I say about the void and the freedom I experienced when I passed the
threshold of that half a minute. This experience was enough for a whole life
because it was a completely new life? There is nothing that I can compare this
with. I could call it the void, but it is an infinite freedom, to be able not to have
any needs nor to feel myself and be in the pure joy which lies beyond all beings.
Do not let me build walls around it otherwise I will be forever locked outside.
(A. Brugnoli, 2004, 2005)

Let us now look at a technique for inducing the awakening of spiritual aware-
ness, or for the awakening of our deepest self, or for the awakening of the
“internal world”; the objective is one of personal achievement, but it also
should be therapeutic.

4. THE TECHNIQUE OF HYPNOSIS FOR THE

ACTIVATION OF SPIRITUAL AWARENESS

I would like to express my immense gratitude to my father Dr. Angelico

Brugnoli for improving my knowledge and studies in clinical hypnosis and
stages of consciousness. He wrote this technique, and together we studied the
meaning of every particular word, in Italian and in English, to make enter-
ing the state of spiritual well-being in palliative care better (A. Brugnoli,
2004, 2005; M. P. Brugnoli, 2004, 2009a, 2009b).
I would like to point out that for this type of induction I will, during my
verbal instructions with the patient, use the word us, so that the patient feels
reassured, as if I am going with him or her, hand in hand, toward something
162 Clinical Hypnosis in Pain Therapy and Palliative Care

that at first can be unknown. You can also reassure your patient that in self-
deep hypnosis, he or she can enter the state of sleep.
Let us start with a physical relaxation, which can be achieved fairly
quickly, then we will go on to a visualization of a natural, relaxing place that
will help with the mental relaxation, and then we will go on to the technique
of activating of our spiritual awareness, our inner light, and well-being.
You, my colleagues and friends, may try this just relaxing in your seat, if
you wish.

Technique of Hypnosis for the Activation of Spiritual Awareness

Let’s dedicate a little time only for ourselves . . .
outside of all the things we must do . . .
away from all our thoughts . . .
to find our energy . . .
our well-being . . .
our serenity . . .
let’s find the most comfortable position possible . . .
with eyes open or closed . . .
whichever way we like . . .
as time passes serenely . . .
as time passes slowly . . .
as time passes . . . very slowly
we enter in a state of well-being . . .
great serenity . . . great tranquility . . . great well-being . . . serenity . . .
tranquility . . .
nothing else matters
we take a deep breath . . .
and exhaling we slowly let go of all our thoughts . . .
we let go . . .
we let ourselves go . . .
in this great serenity . . . great calm . . .
great well-being . . .
relaxing . . . great relaxing of our body and mind . . .
relaxing muscles . . .relaxing tendons . . .
relaxing nerves . . . as time passes . . .
nothing bothers us any more . . .
our hearts contemplate this peace
outside noises slowly . . . slowly disappear . . .
and as time passes . . .
and as time passes slowly . . . nothing bothers us any more . . .
this sweet well-being cradles us
our heart cradles us in this peace
immersed in this serenity
 Clinical Hypnosis Techniques in Pain and Palliative Care 163

we let go . . . we let go serenely . . .

in this particular state of relaxation . . .
which is not awake . . . not sleep
a great sense of well-being . . . relaxing . . .
great calm . . . tranquility . . . great serenity . . . and well-being . . . physical well-
being . . . well-being of the mind . . .
and calm . . . at every level . . .
with great relaxing of the tendons . . .
relaxing of the muscles . . . and relaxing of the nerves . . .
as time passes serenely . . .
everything else does not matter anymore
good . . . we let go completely . . . we let go . . .
within this state which is not awake . . .
and not sleep . . . while we feel our well-being . . .
the calm . . . the tranquility . . . and relaxing . . .
we feel much better this time in this particular state of relaxation and well-being
...
while the outside noises disappear . . .
disappear slowly . . .
good . . .
we are enjoying this particular state of the relaxation of our body . . . of our mus-
cles . . . of our tendons . . .
and of our nerves . . .
and for some moment . . . while time passes . . .
and everything around us . . . everything within us . . .
is at great calm . . .
is at great tranquility . . . well-being . . . relaxing . . . relaxing . . .
relaxing the body . . . relaxing of the muscles . . .
relaxing of the tendons . . .
relaxing of the nerves . . .
all our body is relaxed . . . relaxing . . .
well-being . . . tranquility . . . relaxing . . .
while time goes by . . . and everything is calm . . . serene
. . . again great well being of the body . . .
well being of the mind . . . great calm . . .
great tranquility . . . at all levels . . .
of the tendons . . . of the muscles...of the nerves . . .
while time passes . . .
we are relaxing even more and even better . . .
this is a moment only for us . . .
beyond all that can disturb us . . . only serenity . . .
well being . . . peace . . . we are relaxing . . .
we are relaxing . . .
we are relaxing even more and even better . . .
only calm . . . only serenity . . .
164 Clinical Hypnosis in Pain Therapy and Palliative Care

muscular relaxation . . . peace . . . tranquility

our body is relaxing . . .
our heart is cradled by this peace
and our thoughts pass . . . without stopping calmly . . .
our body relaxes . . .
our heart is at peace . . .
we let our body relax . . . our muscles relax . . .
our tendons relax . . . our nerves relax slowly . . .
submerged in this peace . . . in this serenity
Let’s imagine now, we are walking towards the sun . . . on a wonderful clear day
...
with a pleasant temperature . . .
a light breeze is caressing and relaxing us . . .
a beautiful blue sky . . .
with a few white clouds on the horizon . . .
we are walking on a path of small white pebbles . . .
we are waling in the midst of this green natural place . . .
while this breeze is caressing our body . . .
and is giving us such a pleasant feeling . . .
the temperature and the landscape are so sublime . . .
and relaxing . . . very relaxing . . .
we walk down this path very slowly . . .
and in the distance . . .
we see a great beach of white sand and the sea
the sea is the color of emeralds . . .
some sailboats are on the horizon . . .
slowly we arrive at the sea . . .
and we dive into the waves . . .
while our body . . . and our mind are perfectly relaxed . . .
in this serene atmosphere of peace . . .
and tranquility . . .
we are relaxing . . . relaxing . . . relaxing . . .
deeply and completely . . . deeply and completely . . . deeply and completely .
. . deeply . . . deeply . . . deeply . . . deeply . . . deeply . . . deeply and completely
...
even more deeply . . . even more completely . . .
we are immersing ourselves in a sea of tranquility . . . of relaxation . . . of calm
. . . calm . . .
of pleasant feelings . . .
at all levels . . .
at all levels . . .
at physical level . . . at physical level . . .
at mental level . . . at mental level . . .
at spiritual level . . . at spiritual level . . .
we immerse ourselves again in a sea of tranquility . . . of tranquility . . . of relax-
 Clinical Hypnosis Techniques in Pain and Palliative Care 165

ation . . . of relaxation . . . of calm . . . of calm . . .

of pleasant feeling . . . of pleasant feeling . . .
at all levels . . . at all levels
physical level . . . physical level . . .
mental leve . . . mental level . . .
spiritual level . . . spiritual level . . .
and now that we are immersed
in this welcoming and cool sea . . .
welcoming and cool sea . . .
slowly we go towards the light . . .
towards the light of our conscience . . .
the light of our deepest self . . .
the light of the cosmos . . .
the light of the cosmos . . .
the light that never goes out
the light that never goes out
the light that never goes out . . .
and now that we are immersed
in this welcoming cooling sea . . .
welcoming cooling sea . . .
slowly we go towards the light . . .
the light of our conscience . . .
the light of our deepest self . . .
the light of the cosmos . . .
the light of the cosmos . . .
the light that never goes out
the light that never goes out
the light that never goes out . . .
every moment is a step forward towards the light . . .
a step forward towards the light . . .
a very important step towards the light of the infinite . . .
towards the light that shows us the way . . .
the light that shows us the way
in the unknown path . . . never explored . . .
where our soul is resting . . .
where our soul is resting cradling in the light . . .
where our soul cradles us in this sea of light . . . of light . . .
of light that never goes out . . .
and the spirit is enjoying the infinite . . .
is enjoying the infinite . . . is enjoying the infinite . . .
all of our being is immersing
like in the welcoming cooling sea . . .
like in the welcoming cooling sea . . .
in the same way in this great sea of light, great sea of light, which is bringing a
great physical . . . mental . . . and spiritual well-being . . .
166 Clinical Hypnosis in Pain Therapy and Palliative Care

a well-being all over our body . . .

a great well-being in the soul and in the spirit . . .
a great well-being in the soul and in the spirit . . .
everything is taking us towards the light . . .
the light that surround us . . . the light that embraces us . . .
the light that is around us in this sea of well-being . . . sea of tranquility, . . .
sea of tranquility . . .
a sea of intense and continuous spiritual feeling
a sea of intense and continuous spiritual feeling
intense and continuous . . .
intense and continuous . . .
everything takes us towards the light . . . the light that surround us . . . the light
that embraces us . . .
the light that makes us feeling this sea of well-being . . . within a sea of well-being
. . . a sea of tranquility . . . a sea of tranquility . . .
the light of intense and continuous spiritual feeling
the light of intense and continuous spiritual feeling . . .
intense and continuous...intense and continuous . . .
the light is all around us . . .
and it send us more towards friendly untouched places . . .
towards places which are unknown but where there is love . . .
towards places which are unknown but exciting . . .
towards unknown and untouched places . . .
unknown and untouched places . . .
the light is all around us . . .
and it send us more towards friendly untouched places . . .
towards places which are unknown
but where there is love . . .
towards places which are unknown but exciting . . .
towards unknown and untouched places . . .
towards unknown and untouched places . . .
every moment is used to strengthen our body and our spirit and enjoying the
light . . . the light . . .
the brightest light . . . the surreal light . . . the light that never goes out . . . the
light that never goes out . . . the light that never goes out . . .
we are here now to enjoy this moment
of immersion in the light . . . in the light of our soul . . .
in the light of our spirit . . .
which is slowly embracing us in its comforting way . . .
in its encouraging embrace . . .
in its welcoming embrace . . . in its infinite embrace . . .
in its infinite embrace . . . in its infinite embrace . . .
and all the rest is not important anymore . . .
nothing bothers us anymore . . .
only to live this moment . . .
 Clinical Hypnosis Techniques in Pain and Palliative Care 167

only to appreciate this moment . . .

only to enjoy this moment . . .
a moment of great joy for the soul
and for the spirit . . .
this moment of great joy for the soul and for the spirit . . .
this moment of immersion in the light of the soul and the spirit . . .
the light that never goes out . . . the light of the cosmos . . . that never goes out
...
nothing bothers us anymore . . .
only to live this moment . . .
only to appreciate this moment . . .
only to enjoy this moment . . .
a moment of great joy for the soul and for the spirit . . .
this moment of immersion in the light of the soul and the spirit . . .
the light that never goes out . . .
the light of the cosmos . . .
that never goes out . . .
that never goes out . . .
in this very particular moment, feel the intense light,
the encouraging light, the comforting light,
the soul and the spirit have reached home . . .
the soul and the spirit are comfortable with each other . . .
. . . immersed in the light of the cosmos . . . in the light that embraces everything
...
the light that surrounds everything . . .
the light that covers everything . . .
the light that never goes out . . .
in the great light of the soul and the spirit . . .
beyond the time and space . . .
beyond time and space . . .
beyond time and space . . .
the time and the space . . .
towards the infinite . . .
towards the infinite . . .
within the infinite . . . within the infinite . . .
within the infinite . . .
now we immerse ourselves again in a sea of tranquility . . . of tranquility . . .
of relaxation . . . of relaxation . . . of calm . . . of calm . . .
a sea of tranquility . . . a sea of tranquility . . .
a sea of intense and continuous spiritual feeling
in a beautiful natural place . . . our favorite place . . .
our favorite place . . .
our hearts contemplate this peace
and now that we are immersed in this welcoming and cool sea . . . welcoming
and cool sea . . .
168 Clinical Hypnosis in Pain Therapy and Palliative Care

we look at the sky . . . look at the sky . . .

a beautiful blue sky, with a few white clouds . . .
they move slowly, almost rocking . . .
a beautiful blue sky, a light breeze which caresses our faces . . . and the bright
sun . . . which gives us new energy . . .
energy of the body and of the mind . . .
we are in our favorite place . . .
with beautiful blue sky and white clouds slowly moving . . .
the peaceful sky calming . . .
the serene sky calms my soul . . .
. . . on a wonderful clear day . . . with a pleasant temperature . . .
a light breeze is caressing and relaxing us . . . a beautiful blue sky . . . with a few
white clouds on the horizon . . .
the sea is the color of emeralds . . .
some sailboats are on the horizon . . .
in a beautiful natural place . . . our favorite place . . .
our favorite place . . .
and now we are walking again on a path of small white pebbles . . .
we are walking in the midst of this green natural place . . . while this breeze is
caressing our body . . . and is giving us such a pleasant feeling . . . the tempera-
ture and the landscape are so sublime . . . and relaxing . . . very relaxing . . .
while our body . . . and our mind are perfectly relaxed . . . in this serene atmos-
phere of peace . . . and tranquility . . .
we are relaxing . . . relaxing . . . relaxing . . . deeply and completely . . . deeply
and completely . . . deeply and completely . . . deeply. deeply . . . deeply . . .
deeply . . . deeply . . . deeply and completely . . . even more deeply . . . even
more completely . . .
. . . well-being is all around us . . . well-being surrounds us . . . and it gives us
new energy . . .
very good . . . very good . . .
we are living this moment so intensely . . .
charged with new energy . . .
this moment of great physical and psychic relaxation
and we are recharging all of our body . . .
and our mind . . . here, in our favorite place . . .
in our favorite place . . .
we are recharging our body and mind . . .
we are again recharging our body and mind . . .
and when we are going to restart our day,
after this relaxation . . .
all of our mind and body will be recharged . . .
all of our mind and body are recharged . . .
full of physical and mental energy . . . rich of mental and physical energy . . .
now let’s take a deep breath . . .
and let’s leave with our mind from this wonderful natural place . . .
 Clinical Hypnosis Techniques in Pain and Palliative Care 169

let’s start to feel where our body makes contact with what we lying . . .
. . . but still keep this feeling of well-being . . .
well-being of our mind and body . . .
and this feeling of wonderful new energy we have just experienced . . .
let’s start slowly to return to our being awake,
but still keeping within ourselves this feeling of calm, tranquility and happiness
that we have just experienced.
now let’s take another deep breath.
and slowly . . . return to being awake.
we can also slowly start to move our feet and hands, very slowly . . . with no
hurry . . . slowly . . .
while the time goes by . . . while the time goes by.
let’s take another deep breath . . . and let’s start to move slowly all our body . . .
especially arms and legs . . .
and let’s keep within ourselves just for a little longer . . . the calm . . . the tran-
quility . . . the relaxation and the happiness that we have just experienced at all
levels . . .
. . . we can slowly open our eyes . . . slowly and
return to being awake . . . always slowly . . .
very slowly we awake . . . moving slowly our arms and legs . . .
let’s start to move very slowly . . . good . . . very good . . . normal movements .
..
and still keep within ourselves just a little longer the calm . . . and tranquility . . .
that we have achieved in this exercise.
we move again . . . good, we are awake.
how are you? how are you? . . . have you achieved the state of calm, tranquili-
ty, happiness, relaxation and concentration?
or may be is it still a little early?
good . . . very good . . .
we are awake.

The more you repeat this exercise the easier it will come and it will be also
more spontaneous and more enjoyable for your well-being.

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Assagioli, R. (1991). Psicosintesi terapeutica. Rome, Italy: Casa Editrice Astrolabio.
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 Chapter V

MINDFULNESS AND MEDITATIVE STATES IN

SPIRITUAL CARE: TYPES AND TECHNIQUES

editation is a powerful technique to help all of us make more of our

M own potential and to relate better to others at the workplace, at home,
in the community, and in our lives generally.
Recent research by prominent neuroscientists in the United States has
shown that for experienced meditators, activity in the area of the brain asso-
ciated with happiness is more persistent. Moreover, it also appears that expe-
rienced meditators do not get nearly as flustered, shocked or surprised by
unpredictable events as do nonmeditators (Flanagan, 2003).
Meditation and hypnosis can help us develop our potential, in ways that
have a positive effect on our life, suffering, and general well-being. They can
help individuals to

• Cultivate a better understanding of others, leading to increased har-

mony and shared sense of purpose
• Deal more calmly with potentially stressful circumstances
• Experience increased energy at work and at home
• Decrease pain and suffering
• Bring greater concentration and focus to the mind and inner self
• Develop the ability to see and respond to situations with clarity and
creativity
• Develop higher consciousness and the knowledge of higher self
• Help suffering people in pain therapy
• Help dying people in palliative care

When we start practicing hypnosis and meditative states, we start feeling

relaxed, peaceful, and happy. This is a kind of intergenerative process. You
meditate, and you get the reward in the form of joy and happiness, which in

179
180 Clinical Hypnosis in Pain Therapy and Palliative Care

turn motivates you to meditate more. Over time, it becomes your automatic
practice, a kind of “sanskar.” You feel uneasy and think something is missing
from your life if you do not meditate on any particular day. When you start
your day with meditation, the peace and joy generated last the whole day.
whatever the nature of your activities. It is like having a healthy and nour-
ishing meal before the start of a strenuous and stressful routine during the
day.
Hypnosis and meditative states enable you to become aware of your
inner resources of joy and peace. You can tap them whenever you feel
stressed and worried. You acquire a habit of detached observation. So, if
something wrong and irritating happens during the course of your day, you
can view it as a detached observer. You thus get an inner poise that ultimately
percolates into your daily life.
Research shows that even skeptics cannot stifle the sense that there is
something greater than the concrete world we see. As the brain processes
sensory experiences, we naturally look for patterns and then seek out the
meaning in those patterns.
In the world, there are many important religions and spiritual philoso-
phies and groups. It is impossible to cover all of them in this chapter. Our
apologies if your own religion or philosophy is not here. We have included
those we were able to study. In this chapter, the philosophies of religions are
in alphabetical order.
Spirituality means something different to everyone. For some, it is about
participating in organized religion: going to church, a synagogue, a mosque,
and so on. For others, it is more personal: some people remain in touch with
their spiritual side through private prayer, yoga, meditation, quiet reflection,
or even long walks. In palliative care, spirituality is very important to relieve
suffering and help people to perceive higher consciousness.
In spirituality, I believe in

• Personal worth: The inner worth of every person. People are worthy
of respect, support, and caring simply because they are human.
• Lack of discrimination: Working toward a culture that is relatively free
of discrimination.
• Dignity: The dignity of the human person.
• Freedom of speech: The freedom to compare the beliefs of faith
groups with each other and with the findings of science.

Spirituality is the concept of an ultimate or an alleged immaterial reality,

an inner path enabling a person to discover the essence of his or her being,
or the deepest values and meanings by which people live. Spiritual practices,
 Mindfulness and Meditative States in Spiritual Care 181

including meditation and mindfulness, prayer and contemplation, are in-

tended to develop an individual’s inner life. Spiritual experiences can include
being connected to a larger reality, yielding a more comprehensive self; and
joining with other individuals or the human community, with nature or the
cosmos, or with the divine realm.

1. BUDDHISM

Buddhists believe that they are temporary vessels in this world and that
until they attain enlightenment or Buddhahood, they do not know their own
self or soul. They believe that this world is an illusion and that, as a result,
one cannot know one’s true nature. Buddhism teaches its followers that in
this life they are only temporary vessels of body, emotions, thoughts, ten-
dencies, and knowledge. A fundamental concept of Buddhism is the notion
that the goal of one’s life is to break the cycles of death and birth. Rein-
carnation exists because of the individual’s craving and desires to live in this
world. The ultimate goal of a Buddhist is to achieve freedom from the cycle
of reincarnation and attain nirvana.
Buddhism is a family of beliefs and practices considered by most to be a
religion. Buddhism is based on the teachings attributed to Siddhartha Gau-
tama, commonly known as “The Buddha” (the Awakened One), who lived
in the northeastern region of the Indian subcontinent and likely died around
400 BCE. Buddhists recognize him as an awakened teacher who shared his
insights to help sentient beings end their suffering, by understanding the true
nature of phenomena, thereby escaping the cycle of suffering and rebirth,
that is, achieving Nirvana.
Among the methods various schools of Buddhism apply toward this goal
are ethical conduct and altruistic behavior, devotional practices, ceremonies
and the invocation of bodhisattvas, renunciation of world matters, medita-
tion, physical exercises, study, and the cultivation of wisdom. In the yoga
meditation of the Himalayan tradition, one person systematically works with
senses, body, breath, and the various levels of mind and then goes beyond,
to the center of consciousness.
When dealing with the feelings and body, there is the emphasis on
exploring and examining, being open to all the thoughts, emotions, and sen-
sations. When attention goes further inward, there is the mind field itself. In
this stage of practice, the perceptions have been withdrawn, and there is no
longer any sensory awareness of the body, nor of the physical. One is now
fully in the level of mind itself. Here is still another form of mindfulness, ex-
clusive of bodily sensation, and once again, concentration is its companion.
182 Clinical Hypnosis in Pain Therapy and Palliative Care

Finally, one comes at the end of the mind and all of its associated thoughts,
emotions, sensations, and impressions. Concentration is essential at this stage.
As Patanjali notes in the Yoga Sutras (4.31) there is then little to know
because the experiences have been resolved into their causes. By working
with both mindfulness and concentration, it is easy to see three skills in
which the mind is trained and how these go together.
Focus. The mind is trained to be able to pay attention, to not be drawn
here and there, whether due to the spontaneous rising of impressions in med-
itation or due to external stimuli.
Expansion. The ability to focus is accompanied by a willingness to ex-
pand the conscious field through that which is normally unconscious, in-
cluding the center of consciousness.
Nonattachment. The ability to remain undisturbed, unaffected, and
uninvolved with the thoughts and impressions upon the mind is the key
ingredient that must go along with focus and expansion.
While speaking here of integrating the practices of mindfulness and con-
centration, it is useful to note that, in a sense, integrating is not quite the right
word. The science of yoga meditation as taught by the Himalayan sages is
already a whole, complete science that has been torn into smaller pieces over
time. Individual parts have been cut out from the whole, given separate
names, and then taught as unique systems of meditation. Mindfulness and
concentration have both been part of the same, one process of meditation for
a very long time.
Concentration. In this approach, one intentionally focuses the attention
on only one object, such as the breath, a mantra, a chakra center, or an inter-
nally visualized image.
Mindfulness. In this approach, one does not focus the mind on one
object but rather observes the whole range of passing thoughts, emotions,
sensations, and images.
To the sages of the Himalayas, both methods are used in yoga medita-
tion. In fact, they are not seen as different choices at all. Mindfulness and
concentration are companions in the same one process that leads inward to
the center of consciousness.
If you go deeper in meditation, you will find that both processes are
essential. If one practices only mindfulness, the mind is trained to always
have this surface level activity present. Having this activity constantly pre-
sent may be seen as normal, and the attention simply does not go beyond the
mind field. Attention can “back off” from experiencing deeper meditation
and samadhi to remain in the fields of sensation and thoughts. If one prac-
tices only concentration, or one-pointedness, the mind is trained not to expe-
rience this activity of thoughts, sensations, emotions, and images. The activ-
 Mindfulness and Meditative States in Spiritual Care 183

ity is seen as something to be avoided, and the attention may not even be
open to the existence of these experiences. Attention can back off from the
deeper aspects of the mind field and thus prevent deeper meditation and
samadhi.
By practicing both mindfulness and concentration, one can experience
the vast impressions, learning the vital skill of nonattachment, while also
using concentration to focus the mind in such a way as to be able to tran-
scend the whole of the mind field, where there is only stillness and silence,
beyond all the impressions. Finally, one can come to experience the center
of consciousness, the absolute reality.
When exploring the mind, mindfulness may be emphasized while re-
maining focused. Then, if a particular thought pattern or samskara is to be
examined to weaken its power over the mind, concentration is the tool with
which this examination is done. This allows an increase in vairagya, nonat-
tachment.
When settling the mind, trying to pierce the layers of our being, includ-
ing senses, body, and breath, concentration carries the attention inward
through the layers. When attention moves into that next deeper level of our
being, then concentration and mindfulness once again work together to ex-
plore that layer, to once again move beyond, or deeper.
According to Tibetan medicine, the human microcosm, just as the
macrocosm, is made of these five fundamental energies: Earth, Water, Fire,
Air, and Ether, which monitor the vitality of the mind and the body. The
whole world, the human body, but also illnesses and medicaments, are in
communication with one another. The five elements are represented in us by
the three body energies: Lung (the principle of motion), Tripa (the principle
of warmth), and Beken (the stabilizing and cooling principle). In a healthy
body, these three principles are balanced. This balance and, therefore health,
depends on the mind because on the mental level disharmony leads to an
imbalance of these energies that then manifest as illness in the physical body.
Ignorance is the cause of illness. Ignorance provokes the illusion of being
separated from the environment. The perception of “I” and “Mine” creates
the Three Interior Poisons: Hatred, Ignorance, and Desire.

A. The Experience of Enlightenment

The Four Noble Truths of Buddhism are about dukkha, a term usu-
ally translated as suffering. The Four Noble Truths are one of the most fun-
damental Buddhist teachings. In broad terms, these truths relate to suffering’s
(or dukkha’s) nature, origin, cessation, and the path leading to the cessation.
184 Clinical Hypnosis in Pain Therapy and Palliative Care

They are among the truths Gautama Buddha is said to have realized during
his experience of enlightenment.
The Four Noble Truths were the first teaching of Gautama Buddha after
attaining nirvana. Life as we know it ultimately is or leads to suffering in one
way or another. Suffering is caused by craving for or attachments to worldly
pleasures of all kinds. This is often expressed as a deluded clinging to a cer-
tain sense of existence, to selfhood, or to the things or people that we con-
sider the cause of happiness or unhappiness. This interpretation is followed
closely by many modern Theravadins, described by early Western scholars,
and taught as an introduction to Buddhism by some contemporary Mahay-
ana teachers (e.g., the Dalai Lama).
According to other interpretations by Buddhist teachers and scholars and
lately recognized by some Western non-Buddhist scholars, the “truths” do
not represent mere statements, but are categories or aspects that most world-
ly phenomena fall into.

B. The Four Noble Truths of Buddhism

1. Life Means Suffering

To live means to suffer, because the human nature is not perfect and nei-
ther is life. During our lifetime, we inevitably have to endure physical suf-
fering such as pain, sickness, injury, tiredness, old age, and death, and we
have to endure psychological suffering such as sadness, fear, frustration, dis-
appointment, and depression.
Although there are different degrees of suffering and there are also posi-
tive experiences in life that we perceive as the opposite of suffering, such as
ease, comfort, and happiness, life in its totality is imperfect and incomplete
because our world is subject to impermanence. This means we are never able
to keep permanently what we strive for, and just as happy moments pass by,
we ourselves and our loved ones will pass away one day, too.

2. The Origin of Suffering is Attachment

The origin of suffering is attachment to transient things and the ignorance
thereof. Transient things include not only the physical objects that surround
us, but also ideas and, in a greater sense, all objects of our perception. Ig-
norance is the lack of understanding of how our mind is attached to imper-
manent things. The reasons for suffering are desire, passion, pursuit of wealth
and prestige, and striving for fame and popularity, or, in short, craving and
clinging. Because the objects of our attachment are transient, their loss is
 Mindfulness and Meditative States in Spiritual Care 185

inevitable, thus suffering will necessarily follow. Objects of attachment also

include the idea of a “self,” which is a delusion because there is no abiding
self. What we call self is just an imagined entity, and we are merely a part of
the ceaseless becoming of the universe.
Impermanence is one of the Three Marks of Existence. The term
expresses the Buddhist notion that all compounded or conditioned phenom-
ena (things and experiences) are inconstant, unsteady, and impermanent.
Everything we can experience through our senses is made up of parts, and
its existence depends on external conditions. Everything is in constant flux,
and so conditions and the thing itself are constantly changing. Things are
constantly coming into being, and ceasing to be. Nothing lasts.
According to the impermanence doctrine, human life embodies this flux
in the aging process, the cycle of rebirth (samsara), and in any experience of
loss. The doctrine further asserts that because things are impermanent, at-
tachment to them is futile and leads to suffering.
According to Buddhism, life against death is a delusive way of thinking.
It is dualistic: the denial of being dead is how the ego affirms itself as being
alive, so it is the act by which the ego constitutes itself. To be self-conscious
is to be conscious of oneself, to grasp oneself, as being alive. Then death ter-
ror is not something the ego has; it is what the ego is. This fits well with the
Buddhist claim that the ego-self is not a thing, not what I really am, but a
mental construction.
The aim of meditation is to bring inner peace within ourselves and the
world in a positive and spiritual way. The world is not a peaceful place and
within every soul, there is some form of tension and stress. It is therefore
essential to create positive and peaceful thoughts to bring peace to our mind.
Meditation is one of the best methods to bring about transformation and nur-
ture the natural qualities within.

3. The Cessation of Suffering is Attainable

The cessation of suffering can be attained through nirodha. Nirodha
means the unmaking of sensual craving and conceptual attachment. The
third noble truth expresses the idea that suffering can be ended by attaining
dispassion. Nirodha extinguishes all forms of clinging and attachment. This
means that suffering can be overcome through human activity, simply by
removing the cause of suffering. Attaining and perfecting to dispassion is a
process of many levels that ultimately results in the state of nirvana. Nirvana
means freedom from all worries, troubles, complexes, fabrications, and
ideas. Nirvana is not comprehensible for those who have not attained it.
186 Clinical Hypnosis in Pain Therapy and Palliative Care

4. The Path to the Cessation of Suffering

There is a path at the end of suffering, a gradual path of self-improve-
ment, which is described more detailed in the eightfold path. It is the middle
way between the two extremes of excessive self-indulgence (hedonism) and
extreme self-mortification (asceticism), and it leads at the end to the cycle of
rebirth. The latter quality discerns it from other paths, which are merely
“wandering on the wheel of becoming” because they do not have a final
object. The path at the end of suffering can extend over many lifetimes,
throughout which every individual rebirth is subject to karmic conditioning.
Craving, ignorance, delusions, and their effects will disappear gradually, as
progress is made along the path.

C. The Noble Eightfold Path

The eightfold path illustrates the moral principles in which all Buddhists
should practice the way of enlightenment. It goes into detail about the basis
of all Buddhist teachings: morality, meditation, and wisdom. This is the
eightfold path.

1. Right Knowledge
2. Right Thinking
3. Right Speech
4. Right Conduct
5. Right Livelihood
6. Right Effort
7. Right Mindfulness
8. Right Concentration

Following The Noble Eightfold Path helps a person realize that greed
and selfishness cause all earthly suffering. With this new understanding, one’s
suffering may end. The Noble Eightfold Path, the fourth of the Buddha’s
noble truths, is the way for the cessation of suffering. It has eight sections,
each starting with the word samyak (Sanskrit, meaning correctly, properly,
or well, frequently translated into English as right) and presented in three
groups:

1. Prajña- is the wisdom that purifies the mind, allowing it to attain spiri-
tual insight into the true nature of all things.
2. Sila is the ethics or morality.
-
3. Samadhi is the mental discipline required to develop mastery over
one’s own mind. This is done through the practice of various contem-
 Mindfulness and Meditative States in Spiritual Care 187

plative and meditative practices, and includes

• vyay- ama
- - ama):
(vay- making an effort to improve
• sati: awareness to see things for what they are with clear conscious-
ness, being aware of the present reality within oneself, without any
craving or aversion
-
• samadhi -
(samadhi): correct meditation or concentration, explained
-
as the first four dhyanas.

The eighth principle of the path, right concentration, refers to the devel-
opment of a mental force that occurs in natural consciousness, although at a
relatively low level of intensity, namely concentration. Concentration in this
context is described as one-pointedness of mind, meaning a state where all
mental faculties are unified and directed onto one particular object. Right
concentration on the purpose of the eightfold path means wholesome con-
centration, in other words, concentration on wholesome thoughts and ac-
tions. The Buddhist method of choice to develop right concentration is
through the practice of meditation.
The meditating mind focuses on a selected object. It first directs itself
onto it, then sustains concentration, and finally intensifies concentration step
by step. Through this practice, it becomes natural to apply the elevated lev-
els of concentration also in everyday situations.
The practice of the eightfold path is understood in two ways: as requir-
ing either simultaneous development (all eight items practiced in parallel) or
as a progressive series of stages through which the practitioner moves, the
culmination of one leading to the beginning of another. Bodhi is both the P-
ali and Sanskrit word traditionally translated into English as “enlighten-
ment.” Bodhi is also frequently (and more accurately) translated as “awak-
ening.” Suffering ends when craving ends, when one is freed from desire.
This is achieved by eliminating all delusion, thereby reaching a liberated
state of enlightenment (bodhi).

D. The Four Noble Truths State

The nature of suffering, its cause, its cessation, and the way leading to its
cessation, is The Noble Eightfold Path. Buddhism considers liberation from
suffering as basic for leading a holy life and attaining nirvana.
In Shingon Buddhism, the state of bodhi is also seen as naturally inher-
ent in the mind, the mind’s natural and pure state (as in Dzogchen), and is
viewed as the perceptual sphere of nonduality, where all false distinctions be-
tween a perceiving subject, and perceived objects are lifted and the true state
of things (nonduality) is revealed.
188 Clinical Hypnosis in Pain Therapy and Palliative Care

E. Nondualism Is the Belief That Dualism

and Dichotomy are Illusory Phenomena
Examples of dualisms include self/other, mind/body, male/female, good/
evil, active/passive, and many others. A nondual philosophical or religious
perspective or theory maintains that there is no fundamental distinction
between mind and matter or that the entire phenomenological world is an il-
lusion. The term nondual is a literal translation of the Sanskrit term advaita.
To the Nondualist, reality is ultimately neither physical nor mental. To
achieve this vision of non-duality, it is necessary to recognize one’s own
mind. Nonduality means that reality is essentially unitive and that both unity
and multiplicity are irreducible truths of our experience.

F. The Way to Enlightenment

Enlightenment is more than an intellectual understanding, however, it is
also an intuitive knowing. It is a total transformation of the heart and mind.
When a person realizes enlightenment, the “Great Compassion” cannot
but arise in his or her heart. This person is no longer able to view the world
in the same way he or she did before Enlightenment. He or she can now see,
feel, know, and understand. He or she views the world as an ocean and is
directly connected to each being in the same way the ocean connects to
every single wave. This person is most compassionate and most loving,
knows the path, is expert in the path, is adept at the path. His or her disci-
ples now keep following the path and afterwards become endowed with the
path.

Enlightenment, for a wave in the ocean, is the moment the wave realises it is
water. (Thich Nhat Hanh, 1999)

G. The Seven Steps Buddhist Breath Meditation

B UDDHIST B REATH M EDITATION ONE. Start out with three or seven long
in-and-out breaths.
B UDDHIST B REATH M EDITATION TWO. Be clearly aware of each in-and-
out breath during this meditation.
B UDDHIST B REATH M EDITATION THREE. Observe the breath as it goes in
and out, noticing whether it is comfortable or uncomfortable, broad or nar-
row, obstructed or free-flowing, fast or slow, short or long, warm or cool. If
the breath does not feel comfortable, change it until it does. For instance, if
breathing in long and out long is uncomfortable, try breathing in short and
 Mindfulness and Meditative States in Spiritual Care 189

out short. As soon as you find that your breathing feels comfortable, let this
comfortable breath sensation spread to the different parts of the body.
To begin with, inhale the breath sensation at the base of the skull and let
it flow all the way down the spine. Then, if you are male, let it spread down
your right leg to the sole of your foot, to the ends of your toes, and out into
the air. Inhale the breath sensation at the base of the skull again and let it
spread down your spine, down your left leg to the ends of your toes and out
into the air. If you are female, begin with the left side first, because the male
and female nervous systems are different.
Then let the breath from the base of the skull spread down over both
shoulders, past your elbows and wrists, to the tips of your fingers and out into
the air. Let the breath at the base of the throat spread down the central nerve
to the front of the body, past the lungs and liver, all the way down to the
bladder and colon. Inhale the breath right at the middle of the chest and let
it go all the way down to your intestines. Let all these breath sensations spread
so that they connect and flow together, and you will feel a greatly improved
sense of well-being.
B UDDHIST B REATH M EDITATION F OUR. Learn four ways of adjusting the
breath:

• in long and out long

• in short and out short
• in short and out long
• in long and out short

Breathe whichever way is most comfortable for you. Better yet, learn to
breathe comfortably all four ways, because your physical condition and your
breath are always changing.
B UDDHIST B REATH M EDITATION F IVE. Become acquainted with the bases
or focal points of the mind, the resting spots of the breath, and center your
awareness on whichever one seems most comfortable. A few of these bases
are

• the tip of the nose

• the middle of the head
• the palate
• the base of the throat
• the breastbone (the tip of the sternum)
• the navel (or a point just above it)
190 Clinical Hypnosis in Pain Therapy and Palliative Care

If you suffer from frequent headaches or nervous problems, do not focus on

any spot above the base of the throat. Do not try to force the breath or put
yourself into a trance. Breathe freely and naturally. Let the mind be at ease
with the breath, but not to the point where it slips away.
B UDDHIST B REATH M EDITATION S IX. Spread your awareness, your sense
of conscious feeling, throughout the entire body.
B UDDHIST B REATH M EDITATION S EVEN. Coordinate the breath sensa-
tions throughout the body, letting them flow together comfortably, keeping
your awareness as broad as possible. May your meditation bring you inner
peace and harmony.
One of the fundamental statements of Buddhism is that our conscious-
ness is selfless. Our feeling of self is seen to be a form of attachment that has
to be overcome in order to eliminate suffering. It is remarkable that in order
to obtain this insight, one has to overcome a strong emotional resistance, the
so-called attachment to self: that we are manipulated by our emotions
because these consist of several components that diligently reinforce each
other.
Both Spinoza and Freud have remarked that our behavior is determined
only partially by our conscious will but much more by something else. For
Spinoza this something is our feeling, for Freud it is our unconscious.
Often these distinct forces (conscious will versus feeling/unconscious)
cause conflicts. Buddhism holds that if we are no longer attached to our feel-
ing, then we are free.

2. ZEN BUDDHISM

Zazen is a particular kind of meditation, unique to Zen, that functions

centrally as the very heart of the practice. In fact, Zen Buddhists are gener-
ally known as the “meditation Buddhists.” Basically, zazen is the study of the
self.
The great Master Dogen said, “To study the Buddha Way is to study the
self, to study the self is to forget the self, and to forget the self is to be enlight-
ened by the ten thousand things.” To be enlightened by the 10,000 things is
to recognize the unity with the self and the 10,000 things.
Upon his own enlightenment, Buddha was in sitting meditation; Zen’s
practice returns to the same sitting meditation repeatedly. For 2500 years that
meditation has continued, from generation to generation; it is the most
important thing that has been passed on. It spread from India to China, to
Japan, to other parts of Asia, and then finally to the West. It is a very simple
practice. It is extremely easy to describe and very comfortable to follow. Like
 Mindfulness and Meditative States in Spiritual Care 191

all other practices, however, it takes doing in order for it to happen.

We tend to see body, breath, and mind separately, but in zazen they
come together as one reality. The first thing to pay attention to is the position
of the body in zazen. The body has a way of communicating outwardly to
the world and inwardly to oneself. How you position your body has a lot to
do with what happens with your mind and your breath.
Either in isolation or as a spiritual belief, Zen is a tradition or philosophy
that is nondual. It can be considered a religion, a philosophy, or simply a
practice depending on one’s perspective. It has also been described as a way
of life and work and an art form.

A. Zen Meditation
If you have never meditated before, it is suggested that you follow your
breaths or count your breaths. Let all thoughts pass. If thoughts arise, treat
them as clouds passing by. Acknowledge them, and let them pass. Focus your
attention on your breath or on the counting. If you count breaths, you can
count from one to ten, either as you inhale and exhale, or on the inhalations
or exhalations. The more common method is to count as you exhale. How-
ever, find the method that suits you. Count from one to ten, then start the
sequence over and continue this cycle. If you follow your breaths, simply put
your attention on your breath, as you inhale and exhale. When your mind
wanders, return your attention to the breath, or to the counting. Do not chas-
tise yourself if your attention wanders.
The purpose of the mind is to produce thoughts; they are with us always.
The idea is to keep returning our attention to our breath, or our counting,
and our thoughts will settle down naturally.
Zen teachers suggest that we sit for short periods in the beginning. Ten
minutes is a good goal to start with. Later, as you gain experience and con-
fidence, you can extend the periods up to 20 or 30 minutes.
It is a good idea to take a break after 25 or 30 minutes of sitting. The right
hand is made into a fist, with the thumb tucked in, and held to the chest,
palm down. The left hand is placed, palm down, on top of the right. The
arms are held level, with elbows projecting at the side. Walk slowly and
deliberately, placing one foot in front of the other.
Your attention is placed on the feeling of walking; notice how your feet
touch the floor, how your muscles contract and relax as you take each step.
If you make a misstep, simply experience that and let it pass. If your mind
wanders, return your attention to the slow, deliberate movement of just walk-
ing. After a few minutes, you may return to sitting meditation.
192 Clinical Hypnosis in Pain Therapy and Palliative Care

The point of Zen’s meditation is to open our eyes to our true nature, to enable
us to live a truly awakened life. Simply put, it gets us in touch with our pure
being. In Buddhist terms, it opens us to the realization of emptiness. (The Heart
Sutra)

The seemingly nonsensical Zen practice of “thinking about not thinking”

could help free the mind of distractions, new brain scans reveal. This sug-
gests Zen meditation could help treat attention-deficit-hyperactivity disorder
(ADHD), obsessive-compulsive disorder, anxiety disorder, major depres-
sion, and suffering in pain therapy and palliative care.
Zen meditation vigorously discourages mental withdrawal from the
world and dreaminess and instead asks one to keep fully aware with a vigi-
lant attitude. It typically asks one to silently focus on breathing and one’s
posture with eyes open in a quiet place and to calmly dismiss any thoughts
as they pop up, essentially thinking nothing. Over time, one can learn how
to keep one’s mind from wandering, become aware of otherwise unconscious
behaviors and preconceived notions, and hopefully gain insights into one-
self, others, and the world.
Imaging of the brain’s conventional working people who meditate regu-
larly revealed increased thickness in cortical regions related to sensory, audi-
tory, and visual perception, as well as internal perception, the automatic
monitoring of heart rate or breathing, for example.

B. The Zen Meditation Technique

ZEN MEDITATION allows the mind to relax. Please follow these easy
instructions.

Sit on the forward third of a chair or a cushion on the floor.

ARRANGE YOUR LEGS in a position you can maintain comfortably. If they
are in the half-lotus position, place your right leg on your left thigh. In the
full lotus position, put your feet on opposite thighs. You may also sit simply
with your legs tucked in close to your body, but be sure that your weight is
distributed on three points: both of your knees on the ground and your but-
tocks on the round cushion. On a chair, keep your knees apart about the
width of your shoulders, feet firmly planted on the floor.
TAKE A DEEP BREATH, exhale fully, and take another deep breath, exhal-
ing fully.
WITH PROPER PHYSICAL POSTURE, your breathing will flow naturally into
your lower abdomen. Breathe naturally, without judgment or trying to
breathe a certain way.
 Mindfulness and Meditative States in Spiritual Care 193

KEEP YOUR ATTENTION ON YOUR BREATH eracticing this Zen meditation.

When your attention wanders, bring it back to the breath again and again (as
many times as necessary). Remain as still as possible, following your breath
and returning to it whenever thoughts arise.
B E FULLY, VITALLY PRESENT WITH YOURSELF. Simply do your very best.
At the end of your sitting period, gently swing your body from right to
left in increasing arcs. Stretch out your legs, and be sure they have feeling
before standing.
P RACTICE EASY ZEN MEDITATION EVERY DAY for at least 10 to 15 minutes
(or longer), and you will discover for yourself the treasure house of the time-
less life of zazen, your very life itself.
In the process of working with the breath, the thoughts that come up, for
the most part, will be just noise, just random thoughts. Sometimes, however,
when you are in a crisis or involved in something important in your life, you
will find that the thought, when you let it go, will recur. You let it go again
but it comes back, you let it go and it still comes back. Sometimes that needs
to happen. Do not treat that as a failure; treat it as another way of practicing.
This is the time to let the thought happen, engage it, let it run its full course.
Watch it, however, and be aware of it. Allow it to do what it has got to do,
let it exhaust itself. Then release it, let it go. Come back again to the breath.
Start at one and continue the process.
Do not use zazen to suppress thoughts or issues that need to come up.
Scattered mental activity and energy keep us separated from each other,
from our environment, and from ourselves. In the process of sitting, the sur-
face activity of our minds begins to slow down. The mind is like the surface
of a pond: when the wind is blowing, the surface is disturbed and there are
ripples. Nothing can be seen clearly because of the ripples; the reflected
image of the sun or the moon is broken up into many fragments. Out of that
stillness, our whole life arises. If we do not get in touch with it at some time
in our life, we will never get the opportunity to come to a point of rest.
In deep zazen, deep samadhi, a person breathes at a rate of only two or
three breaths a minute. Normally, at rest, a person will breathe about fifteen
breaths a minute, even when we are relaxing, we do not quite relax. The
more completely your mind is at rest, the more deeply your body is at rest.
Respiration, heart rate, circulation, and metabolism slow down in deep
zazen. The whole body comes to a point of stillness that it does not reach
even in deep sleep. This is a very important and very natural aspect of being
human. It is not something particularly unusual. All creatures of the earth
have learned this and practice this.
It is a very important part of being alive and staying alive: the ability to
be completely awake.
194 Clinical Hypnosis in Pain Therapy and Palliative Care

The model of suffering and its purification explains well an important

incident in the history of Chinese Buddhism. At the time that Hung Jen, the
fifth patriarch of Zen Buddhism in China, felt that he wanted to appoint his
successor, he asked his disciples to write a poem expressing their under-
standing of the teachings. Then the head monk Shen Hsiu wrote the follow-
ing poem.

The body is like the bodhi [enlightenment] tree,

the mind is like a mirror bright.
Constantly we should wipe them clean,
Not allowing any dust to align. (Shen Hsiu)

Monks at the monastery were impressed and expected that the head monk
would become the successor of the fifth patriarch. There was, however, a
novice named Hui Neng that could not read or write. When he heard the
verse of the head monk he asked a friend to write down the following poem.

There is no body,
there is no mind.
Since fundamentally nothing exists
where is the dust to align? (Hui Neng)

It was Hui Neng who was chosen as sixth patriarch.

How can we understand this? The head monk was describing the state of
mysticism, in which one has to keep working to keep the volume of feeling
at level. Hui Neng described the state of nirvana, in which no work needs to
be done.

3. CHRISTIAN MEDITATION

The practice of Christian meditation dates back to the beginning of

Christianity; its objective is to empty the self daily to experience the fullness
of God. It is consonant with Jesus’s invitation to his disciples to take up their
cross daily and follow him. It is central to Christian celebrations, dying to
rise to a new life.
Jesus taught a way of life based on love that would unite all people in the
common bonds of brotherhood and orient them to a more exalted state of
consciousness in which they would have communion with God the Father.
He called humanity back toward the primordial state described in Genesis in
which Adam and Eve lived in harmony with each other and with nature in
the original state of paradise.
 Mindfulness and Meditative States in Spiritual Care 195

The Christian doctrine of the Trinity defines God as three divine persons
or hypostases: the Father (God), the Son ( Jesus Christ), and the Holy Spirit.
The three persons are distinct, yet are one substance, essence or nature. A
nature is what one is, whereas a person is who one is. The Trinity is consid-
ered to be a mystery of Christian faith. According to this doctrine, there is
only one God in three persons. Each person is God, whole and entire. For
the large majority of Christians, the Holy Spirit (or Holy Ghost, from Old
English gast, “spirit”) is the third divine person of the Holy Trinity.
The theology of spirits is called pneumatology. The Holy Spirit is the cre-
ator spirit, present before the creation of the universe, and through his power
everything was made in Jesus Christ, by God the Father. Christian hymns
such as Veni Creator Spiritus reflect this belief.
In early Christianity, the concept of salvation was closely related to the
invocation of the Father, Son, and Holy Spirit. Since the first century,
Christians have called upon God with the name Father, Son, and Holy Spirit
in prayer, baptism, communion, exorcism, hymn singing, preaching, confes-
sion, absolution and benediction. This is reflected in the saying, “Before
there was a ‘doctrine’ of the Trinity, Christian prayer invoked the Holy
Trinity.”
Jesus of Nazareth is the central figure of Christianity, and most Christian
denominations hold him to be the Son of God. He is regarded as a major
Prophet in Islam and in the Hindu religion. Christians hold Jesus to be the
awaited Messiah of the Old Testament and refer to him as Jesus Christ or
simply as Christ, a name that is also used secularly. Most Christians believe
that Jesus was conceived by the Holy Spirit, born of a virgin, performed mir-
acles, founded the church, died sacrificially by crucifixion to achieve atone-
ment, rose from the dead, and ascended into heaven, from which he did or
will return. Most Christians worship Jesus as the incarnation of God the Son,
and the second person of the Holy Trinity.
Christian traditions have various practices that can be identified as forms
of meditation. Monastic traditions are the basis for many of these practices.
Practices of repetitive prayers such as the rosary, the Adoration (focusing
on the Eucharist) in Catholicism, or the Hesychast tradition in Eastern Orth-
odoxy may be compared to forms of Eastern meditation that focus on an
individual object. Christian meditation is considered a form of prayer.

A. St. Francis of Assisi’s Vocation Prayer

There is probably no saint more revered and well-known in all of
Christian history than St. Francis of Assisi. Today, Christians, and many non-
Christians alike, celebrate the life and legacy of this medieval Italian man,
196 Clinical Hypnosis in Pain Therapy and Palliative Care

who is known the world over for his exemplary life of holiness and the
model of peaceable living he leaves to us nearly 800 years after his death.
The most well-known writing of St. Francis is probably the Canticle of
the Creatures, in which the saint from Assisi poetically praises God in and
through various elements of the created order. The fundamental spiritual
insight of the Canticle is that each aspect of God’s creation gives glory and
praise to God by being what it was created to be. The sun praises God by
giving the world light; the wind praises God by bringing every kind of weath-
er; and the earth praises God by sustaining us through producing fruits, flow-
ers and herbs. All of God’s creation perfectly praises God because each ele-
ment does what it was intended to do. Near the end of the Canticle, St.
Francis finally introduces humans. He writes,

Praised be You, my Lord, through those who give pardon for Your love,
and bear infirmity and tribulation.
Blessed are those who endure in peace,
for by You, Most High, shall they be crowned.

In this sense, the so-called “Prayer of St. Francis” reflects the spirit and
outlook of the man for whom it is named. To be most authentically human
is to be an instrument of peace or, to put it in the sense of the prayer’s fol-
lowing lines, one who sows love, pardon, faith, hope, light, and joy in our
world.

Most High, Glorious God, enlighten the darkness of our minds. Give us a right
faith, a firm hope and a perfect charity, so that we may always and in all things
act according to Your Holy Will. Amen. (Prayer of St. Francis)

Psalm 19:14 states, “Let the words of my mouth, and the meditation of
my heart, be acceptable in Thy sight. . . .” The psalmist asks that his words
and thoughts be equal. Words of the mouth are a sham if they are not backed
up by meditation of the heart.
Christian meditation is an active thought (thinking, resolving) process
whereby you give yourself to study of the Word, praying over it, asking God
to give you understanding by the Spirit, putting it into practice in daily life,
and allowing it (the Scriptures) to become the rule for life and practice as you
go about your daily activities. This causes spiritual growth and maturing in
the things of God, as taught you by His Holy Spirit dwelling within you as a
believer.
 Mindfulness and Meditative States in Spiritual Care 197

B. Mystical Experiences and Unconscious Mind

St. Teresa of Avila wrote in The Interior Castle that in the orison of union,

the soul is utterly dead to the things of the world, and lives solely in God . . . I
do not know whether in this state she has enough life left to breathe. It seems to
me she has not; or at least that if she does breathe, she is unaware of it.

Interior Castle is one of the most celebrated books on mystical theology in

existence. It is the most sublime and mature of Teresa of Avila’s works and
expresses the full flowering of her deep experience in guiding souls toward
spiritual perfection. In addition to its profound mystical content, it is also a
treasury of unforgettable maxims on such ascetic subjects as self-knowledge,
humility, detachment, and suffering. Above all, this account of a soul’s
progress in virtue and grace is the record of a life, of the interior life of Teresa
of Avila, whose courageous soul, luminous mind, and endearingly human
temperament hold so deep an attraction for the modern mind.
In its central image and style, Interior Castle, like so many works of genius,
is extremely simple. Teresa envisioned the soul as “a castle made of a single
diamond . . . in which there are many rooms, just as in Heaven there are
many mansions.” She describes the various rooms of this castle (the degrees
of purgation and continual strife), through which the soul in its quest for per-
fection must pass before reaching the innermost chamber, the place of com-
plete transfiguration and communion with God. Teresa was an incredibly
gifted teacher whose devotion to the sublimest task—the guidance of others
toward spiritual perfection—has resulted in the widespread fame of her writ-
ings. There is no life more real than the interior life, and few persons have
had such an extraordinarily rich experience of that reality as has Teresa. In
Interior Castle, she exhorts and inspires her readers to participate in the search
for this ultimate spiritual reality, the source of her own profound joy.
In Interior Castle, Teresa is entering more deeply into the psyche, into the
unconscious part of the psyche. Teresa experienced the transpersonal layer
of the psyche, the layer Jung called collective unconscious. “Religion is obe-
dience to awareness,” said Jung. Teresa wrote, “the gate to entry to this cas-
tle is prayer and reflection.” The Interior Castle is the document in which both
psyche and soul relate the story that emerged as one Christian prayerfully
attended to depth experiences.
In the prayer of quiet, ego activity is minimal, and we can encourage let-
ting the intellect go. There is an outer and inner stillness with a loving open-
ness to God. It is a time of healing contact with depth of the self, and the
absorption in God brings peace to the soul. The individual’s personal identi-
198 Clinical Hypnosis in Pain Therapy and Palliative Care

fication has cracked, and ego consciousness no longer has the total control of
the psyche. A new, more powerful center, is emerging.

C. The Way of Meditation is the Way of Silence

Silencing the ceaseless chatter of a mind buzzing with thoughts is not
easy. The way to silence and to the inner self of prayer is how.

I began to think of the soul

as if it were a castle
made of a single diamond . . . (St. Teresa D’Avila)

The Lord appears in this center of the soul,

Not in an imaginative vision,
But in an intellectual One. (St. Teresa D’Avila)

The result of this meditative state is an identification in Christ. This real-

ity is experienced as graced by a divine presence. The movement into per-
sonhood, in the Interior Castle, is a response to a divine call. The free, auto-
nomous person emerges as the relationship in God deepens. The sign of the
union in God does not lie in an ecstatic phenomenon but in the quality of
reflective awareness that characterizes a Christian.
In the Hesychastic practice, the recitation of the Jesus Prayer is used:

“through the grace of God and one’s own effort, to concentrate the nouns
in the heart.”

Prayer as a form of meditation of the heart is described in the Philokalia, a

practice that leads towards. In 1975, the Benedictine monk John Main intro-
duced a form of meditation based on repetitive recitation of a prayer-phrase,
traditionally the Aramaic phrase “Maranatha,” meaning “come, Lord,” as
quoted at the end of both Corinthians and Revelation.
The World Community for Christian Meditation was founded in 1991 to
continue Main’s work, which the Community describes as “teaching Christ-
ian meditation as part of the great work of our time of restoring the contem-
plative dimension of Christian faith in the life of the church.”
The Old Testament book of Joshua, sets out a form of meditation based
on scriptures:

Do not let this Book of the Law depart from your mouth; meditate on it day and
night, so that you may be careful to do everything written in it, then you will be
prosperous and successful. ( Joshua 1:8)
 Mindfulness and Meditative States in Spiritual Care 199

This is one of the reasons why Bible verse memorization is a practice among
many evangelical Christians. The predominant form of worship among
Quakers, or the Religious Society of Friends, has historically been commu-
nal silent prayer or meditation that consists of focusing on the Inner Light of
Christ, listening for and awaiting the movement of the “still, small voice with-
in,” which may or may not result in being moved to spoken ministry.
Thomas Merton was a Catholic monk who lived from 1915 to 1968.
Having studied Eastern meditation techniques, he is credited with reviving
an interest in Christian meditation and contemplative prayer. He wrote:

Some people may have a spontaneous gift for meditative prayer, but this is
unusual. Most people have to learn how to meditate. And meditation is some-
times quite difficult. But if we bear with it and wait patiently for the time of
grace, we may well discover that meditation is a joyful experience. Contempla-
tive prayer raises the question: Is there something we can do to prepare our-
selves, instead of waiting for God to do everything? In my experience, there is.
We can use Centring Prayer to calm the mind, and to cultivate interior silence.
(Thomas Merton)

Speaking to fellow monks, Merton recommended silent contemplation, writ-

ing,

Contemplative prayer has to be always very simple, confined to the simplest of

acts and using no words or thoughts. This prayer of the heart introduces us into
deep interior silence so that we learn to experience its power. We seek the deep-
est ground of our identity with God, a direct experiential grasp just like St. Aug-
ustine sought when he prayed, “May I know you, may I know myself.” (Thomas
Merton)

Thomas Merton loved the contemplative life, the quiet, the wondrous
ways of nature that are provided free of charge by the Holy Spirit. In New
Seeds of Contemplation, he has some inspiring thoughts about meditation.

Learn to meditate on paper. Drawing are writing are forms of meditation. Learn
how to contemplate works of art. Learn how to pray in the streets or in the coun-
try. Know how to meditate not only when you have a book in your hand but
when you are waiting for a bus or riding the train. (Thomas Merton)

In other words, meditate when there is quiet, but also meditate when there
is not or when you are doing some other task. What a novel idea, one that
permits us to find the contemplative life even during the hustle and bustle of
daily life. Do you meditate? Do you simply call it prayer, as I do. No matter,
200 Clinical Hypnosis in Pain Therapy and Palliative Care

finding the time to be one with God, with the Holy Spirit, or with any high-
er spirit that is calling you is one of the most exciting things about life.

The Thomas Merton “Magical” Methods

In meditation we should not look for a method or a system but cultivate
an attitude, an outlook: faith, openness, attention, reverence, expectation,
supplication, trust, joy. All these finally permeate our being with love in so
far as our living faith tells us we are in the presence of God, that we live in
Christ, that in the Sprit of God we “see” God our Father without “seeing.”
We know Him in “unknowing.” Faith is the bond that unites us to Him in the
Spirit who gives us light and love.

D. The Lectio Divina

The Lectio Divina is a Christian form of meditation aimed at allowing
the individual to experience the presence of the triune God, the God of the
Christian trinity, who comprises of the Father, the Son ( Jesus), and the Holy
Spirit.
The practice of the Lectio Divina (meaning holy reading) was first docu-
mented in the early third century. Lectio Divina involves concentrated study
of Biblical scripture and the subsequent meditation upon the facets of the
particular area of scripture upon which you have focused.

E. Practicing Holy Reading, Lectio Divina

Holy reading is much like meditation and involves first clearing the mind
in a quiet setting, preferably dedicated for the purpose of reading and con-
templation. Once you have calmed yourself and are ready to dedicate your-
self to reading, you may wish to pray first for guidance from God before pro-
ceeding.
Following this there are four stages to the Lectio Divina.

• First, the lectio involves reading the passage diligently, slowly, and
several times over.
• Second, meditation involves a considered and slow contemplation of
the text, akin to meditation yet more, in which any area of the text that
stands out, if only one word, is to be focused upon.
• Third, oratio involves intuitively opening your heart to God in order
to feel the meaning of the text and to invite a dialogue with God.
• Fourth, contemplatio involves listening to God. This stage involves
completely clearing the mind and noting the impressions that arise
 Mindfulness and Meditative States in Spiritual Care 201

and is most akin to meditation in the sense that it is practiced in other

spiritual disciplines, where the aim might be to listen to the essence of
the universe or to attain a oneness with all things.

Although clear parallels can be seen between this form of contemplation

and meditation, it must be noted that this form depends on a deep held belief
in God and Christianity. The Lectio Divina does not entail entering literally
into a discussion with God, however, in which his voice is audible to us, and
can rather be seen as a discussion with our own inner calm in the form of an
acknowledgment that it exists as more truthful than the complex lives we
erect around us.

4. HINDUISM

Contemporary Hindu culture originated primarily with the Aryans who

invaded India about 1500 BC bringing with them the Sanskrit language and
the Vedic religion. For at least 1000 years prior to this invasion, however,
there existed a culture in India about which we know very little. From some
fragmentary evidence that does remain, scholars conclude this early culture
contained within it many elements that were later incorporated into the
Hindu religion.

A. The Language of Consciousness

The exploration of consciousness has developed to a remarkable degree
in the Hindu culture. In fact, the Sanskrit language has shown itself to be suf-
ficiently precise in describing the subtleties of consciousness exploration, and
many Sanskrit words, with no adequate English equivalents, have become
commonplace in our own contemporary culture. Consider, for example,
these terms:

akasha: The ether; primordial substance that pervades the entire universe; the
substratum of both mind and matter. All thoughts, feelings, or actions are
recorded within it.
asanas: postures used to stimulate flow of life force through the body and to aid
meditation.
atman: The human soul or spirit, the essence of the inner being.
Brahman: Hindu god who represents the highest principle in the universe; the
essence that permeates all existence. Brahman is the same as atman in the phi-
losophy of the Upanishads.
202 Clinical Hypnosis in Pain Therapy and Palliative Care

dharma: One’s personal path in life, the fulfillment of which leads to a higher
state of consciousness.
dhyana: The focusing of attention on a particular spiritual idea in continuous
meditation.
Ishwara: Personal manifestation of the supreme; the cosmic self; cosmic con-
sciousness.
karma: The principle by which all of our actions will effect our future circum-
stances, either in the present or in future lifetimes.
mandala: Images used to meditate.
mantras: Syllables, inaudible or vocalized, that are repeated during meditation.
maya: The illusions the physical world generates to ensnare our consciousness.
nirvana: The transcendental state that is beyond the possibility of full compre-
hension or expression by the ordinary being enmeshed in the concept of self-
hood.
prana: Life energy that permeates the atmosphere, enters the human being
through the breath, and can be directed by thought.
pranayama: Yogic exercises for the regulation of the breath flow.
samadhi: State of enlightenment of higher consciousness. The union of the indi-
vidual consciousness with cosmic consciousness.
yoga: Sanskrit word meaning union; refers to various practices designed to attain
a state of perfect union between the self and the infinite.

The capacity for awareness and experience, for logical analysis and joy-
ful interaction, constitutes the intangible component in the fleeting persis-
tence of Homo sapiens. This is the essence of what we call the human spirit.
Just as there is more to a flower than soil and tree branch, the spirit is more
than neural network, heartbeat, and vital breath, although these are what cre-
ate and sustain it here below.
How are we to explain these extraordinary features of human con-
sciousness in relation to its temporal and spatial insignificance? How can we
comprehend the fact that to none but the human brain the universe is com-
prehensible? Science’s suggestion that evolution led to this extraordinarily
powerful complexity is one persuasive hypothesis, and it has found ample
observational support. The sage-poets of Hinduism, who probed into the
ultimate nature and roots of consciousness, arrived at a startlingly different
conclusion.
If the splendor of the perceived world and the pattern in its functioning
can result in the grand experiences of life and thought, then even prior to the
advent of humans, there must have been a consciousness of a vastly superi-
or order, an Experiencer who spanned the range in space and time. This un-
dergirding cosmic principle is the Brahman in Hindu vision. Moreover, our
consciousness is but an echo of something of far grander dimensions. Ex-
pressed through the pithy Upanishadic aphorism, tat tvam asi: [Thou art
 Mindfulness and Meditative States in Spiritual Care 203

That], the Hindu vision is that every conscious entity is a spark from an un-
derlying effulgence and flashes its radiance as its source alone can.
Just as the expanse of water in the seas is scattered all over land in ponds,
lakes, and rivers, all-embracing Brahman finds expression in countless life
forms. We are miniature lights, one and all. We have emanated from that pri-
mordial effulgence like photons from a glorious galactic core, destined for
the terrestrial experience for a brief span on the eternal time line, only to re-
merge with that from which we sprang.
Brahman, the ground-stuff, subdivides itself into purusha, the cosmic
consciousness, and prakriti or nature. These are the experiencer and the ex-
perienced, not unlike the res cogens and the res extensa of Descartes. Prakriti is
now bifurcated into animate and the inanimate realms with only a fuzzy di-
viding line separating them. On the other hand, purusha separates out into
countless jîvâtmans or individual units of consciousness that fuse into the
mind and body of the animate branch of prakriti. The conscious jîvatman
endeavors to recognize its source, namely purusha, through religion and spir-
ituality and tries to understand prakriti through science.

B. The Yoga Sutras of Patanjali

The Yoga Sutras of Patanjali prescribe a system of eight stages, or limbs for
one’s higher development of the consciousness. In The Yoga Sutras of
Patanjali, which is a 2000-year-old collection of the oral teachings on yogic
philosophy, there are 195 statements that are a kind of philosophical guide-
book for dealing with the challenges of being human. The Yoga Sutras provide
an eightfold path called ashtanga, which literally means “eight limbs.” These
eight steps are basic guidelines on how to live a meaningful and purposeful
life. They are a prescription for moral and ethical conduct. They direct atten-
tion toward one’s health, and they help us to acknowledge the spiritual as-
pects of our nature.
The first four steps or stages concentrate on refining our personalities,
gaining mastery over our body, and developing an energetic awareness of
ourselves, all of which prepare us for the second half of the journey, which
deals with the senses, the mind, and attaining a higher state of consciousness.

1. Yama
The first step deals with one’s moral or ethical standards and sense of
integrity, focusing on our behavior and how we conduct ourselves in our
interpersonal life. These are, literally, the controls or “don’ts” of life. They
include areas where we must learn to control tendencies that, if allowed
expression, would end up causing us disharmony and pain. They are the
204 Clinical Hypnosis in Pain Therapy and Palliative Care

same moral virtues that you find in all the world’s great religious traditions.
The five yamas are

Nonviolence: Refrain from harming or demeaning any living thing,

including yourself, by action, word, or thought.
Not lying: Control any tendency to say anything that is not truthful,
including not being truthful to yourself.
Not stealing: Curb the tendency to take anything that does not belong
to you, which includes not only material objects but also things such as
praise or position.
Not sensuality: Learn the art of self-control; to control the tremendous
energy expended in seeking and thinking about sensual pleasure and to
abstain from inappropriate sexual behavior.
Not greedy: Learn not to be attached to or desirous of “things”; to learn
to discriminate between “needs” and “wants.”

2. Niyama
Niyama, the second step, comprises individual practices having to do
with self-descipline, self-development, and spiritual observances. These are
the non-controls or the “dos” of the path. The five niyamas are

Purity: Strive for purity or cleanliness of body, mind, and environment.

Contentment: Seek contentment and acceptance with what you have
and with things as they are right now, but, also, seek ways to improve
things in the future.
Self-control: Learn to have control over your actions and to have the
strength and determination to do what you decide to do; to replace neg-
ative habits with positive ones.
Self-study: This requires introspection; studying our actions, words, and
thoughts to determine if we are behaving in a harmonious and positive
manner in order to achieve the happiness and satisfaction we strive for.
Devotion: Devotion is the turning of the natural love of the heart toward
the Divine rather than toward the objects of the world.

3. Asana
Asana, the postures practiced in yoga, are the third step. In the yogic
view, the body is a temple of the spirit, the care of which is an important
stage of our spiritual growth. Through the practice of asana, we develop the
habit of discipline and the ability to concentrate, both of which are necessary
 Mindfulness and Meditative States in Spiritual Care 205

for meditation. If the body is in proper working order and comfortable in

one position for a long time, it can ultimately become a vehicle for spiritual
powers, instead of preventing progress by bothering its owner with physical
distress.

4. Pranayama
Generally translated as breath control, this fourth step consists of tech-
niques designed to gain mastery over the respiratory process while recog-
nizing the connection between the breath, the mind, and the emotions. The
literal translation of pranayama is “life force.” Yogis believe that it not only
rejuvenates the body but actually extends life itself. You can practice
pranayama as an isolated technique (simply sitting and performing a number
of breathing exercises) or integrate it into your daily Hatha Yoga routine.

5. Pratyahara
Pratyahara, the fifth step, means withdrawal or sensory transcendence. It
is during this stage that we make the conscious effort to draw our awareness
away from the external world and outside stimuli. We direct our attention
internally. The practice of pratyahara provides us with an opportunity to step
back and take a look at ourselves. This can happen during breathing exer-
cises, during meditation, during the practice of yoga postures, or during any
activity requiring concentration. Detachment is a great technique for pain
control and an excellent way to deal with uncomfortable symptoms or
chronic conditions.

6. Dharana
The practice of pratyahara creates the setting for dharana, or concentra-
tion. Having relieved ourselves of outside distractions, we can now deal with
the distractions of the mind itself. In the practice of concentration, which pre-
cedes meditation, we learn how to slow down the thinking process by con-
centrating on a single mental object. The goal is to become aware of nothing
but the object on which you are concentrating, whether it is a candle flame,
a flower, a mantra you repeat to yourself, a specific energetic center in the
body, or an image of a deity. The purpose is to train the mind to eliminate
all the extra, unnecessary junk floating around, to learn to gently push away
superfluous thought. Extended periods of concentration naturally lead to
meditation.
206 Clinical Hypnosis in Pain Therapy and Palliative Care

7. Dhyana
Meditation or contemplation, the seventh step of ashtanga, is the unin-
terrupted flow of concentration. Although concentration (dharana) and med-
itation (dhyana) may appear to be one and the same, a fine line of distinction
exists between these two stages. Where dharana practices one-pointed atten-
tion, dhyana is ultimately a state of being keenly aware without focus. At this
stage, the mind has been quieted, and in the stillness it produces few or no
thoughts at all. Meditation occurs when you have actually become linked to
the object of your concentration so that nothing else exists. It is a keen
heightened awareness, not nothingness. Your mind is completely focused
and quiet but awake and aware of truth. Many methods exist to bring you to
this state, but oneness with the object of your meditation, and subsequently,
oneness with the entire universe, is the objective. It is quite a difficult task to
reach this state of stillness, but it is not impossible. This state is a goal to keep
striving for, and, even if it is never attained, there is benefit from each stage
of progress.

8. Samadhi
Patanjali describes this eighth and final step of ashtanga as a state of
ecstasy. All the paths of yoga lead to this stage. This stage is one which most
of us are unlikely to attain in this lifetime. At this stage, the meditator merges
with his or her point of focus and transcends the self altogether. When in this
state, you understand not only that you and the object of your meditation are
one, but also that you and the universe are one. There is no difference be-
tween you and everything else. The meditator comes to realize a profound
connection to the Divine, an interconnectedness with all living things. What
Patanjali has described as the completion of the yogic path is what, deep
down, all human beings aspire to: joy, fulfillment, freedom, and peace
The first two limbs are known as yama and niyama. They involve a high-
ly ethical and disciplined lifestyle: control, indifference, detachment, renun-
ciation, charity, celibacy, vegetarianism, cleanliness, and nonviolence. The
third step involves the development and care of the body through the use of
exercises and postures called asanas. The fourth stage involves pranayama
breathing exercises. The next stage, pratyahara, involves meditation, by
means of which one withdraws consciousness from the senses. The next limb
of yoga is called dharana, which means concentration. An object of contem-
plation is held fixedly in the mind; it must not be allowed to waver or change
its form or color, as it will have a tendency to do. Often the yogi will con-
centrate on different chakras, or focal points, within the body. Self-analysis is
used to observe breaks in concentration. Often he will carry a string of beads
 Mindfulness and Meditative States in Spiritual Care 207

and one is pulled over the finger every time a break begins. The next stage
of dhyana occurs when the sense of separateness of the self from the object
of concentration disappears and one experiences a union or oneness with
that object. In the final stage, samadhi, one experiences an absolute, ecstat-
ic, cosmic consciousness. This does not, as some suppose, entail a loss of
individuality. “The drop is not poured into the Ocean; the Ocean is poured
into the Drop.” The self and the entire universe are simultaneously experi-
enced.
In past decades, Western scientists have begun to study the abilities yogi
practitioners can achieved. Body functions such as heartbeat, temperature,
and brainwaves, which had been previously thought of as totally autonomic,
have been shown to be under the conscious control of some yogis. This
research has paved the way for the newly emerging science of consciousness.

C. The Nonduality
In Hindu religion, the basic cause of human suffering, pain, conflicts, and
unhappiness is dualism, as distinct from duality. The core of this difference
needs to be thoroughly analyzed and clearly understood. In fact, such a clear
understanding could itself be the solution of human unhappiness because it
would relieve people from the double bind in which they find themselves in
their relentless pursuit of unalloyed happiness.

That which is free from duality; which is infinite and indestructible; distinct from
the universe and Maya, supreme, eternal; which is undying Bliss; taintless, that
Brahman art thou, meditate on this in thy mind. (Vivekacudamani 261)

No philosophy, sermon, or concept will help relieve that suffering imme-

diately. It is useful, however, to remember that at the core of any pain-caus-
ing conflict there is duality. We are part of a cycle that contains both pain and
pleasure, creating a split between mind and body, delaying the healing pro-
cess.
Duality is all pervasive; it is present in everything around us. Every one
of our daily actions is preceded by a struggle, to come to a decision on this
or that, pain or pleasure, day or night, north or south pole, hot or cold, left
or right. All through life we keep on playing this game of duality. Duality is
our own creation. We describe breathing as something that involves inhala-
tion and exhalation, but actually there is only one breath.
In reality, however, there is no duality. There is only an all-pervasive
Oneness. There is no day and night, since the sun never sets. There is no
beginning and no end, no birth and no death. In that space there is total
silence. This silence emanates not from the mind but from the very depth of
208 Clinical Hypnosis in Pain Therapy and Palliative Care

the heart, wherein only one thing remains: that is love emerging from the
very source, the atman, the consciousness that exists in every being.
We are all part of that same cosmic force. Despite being a part of it, every
one of us is as complete as the whole universe. The body will die but the soul
or atman is eternal; it never dies. It is only in the stillness of deep silence that
thoughts are not active, they get dissolved. Those are the moments when
body and mind are one and duality is absent. The silence of meditation or
yoga dissolves the senses and the mind transcends to a higher level of con-
sciousness. There emerges immense energy and compassion—the moment of
creativity when you become one with nature.
Nature has bestowed on us abundant power or atmashakti to overcome
any amount of pain. We seldom leave the task of alleviating pain to nature;
rather, we want instant solutions. Pain and suffering, however, give us the op-
portunity to look within and experience that oneness or wholeness where no
duality is present.
In order to get to your real self, you have to go inward, where there is no
past and no future, but there is only the present. In this state of meditation,
you may get in touch with your inner being, the nondual state. Once this
insight is gained, one is awakened. This is nirvana or enlightenment, where
there is no duality; there is only completeness.
The fact of the matter is that duality is polarized, interrelated, and, there-
fore, not really separate, whereas dualism is opposition, separation, and,
therefore, conflict. Phenomenal manifestation is a process of objectification
that basically requires a dichotomy into two elements: a subject that per-
ceives and an object that is perceived. This is the process that is known as
duality: all phenomena that are sensorially perceivable are the correlation of
a subject (object-cognizer) and the object (the object cognized). This process
of duality makes it evidently clear that without such a process there cannot
exist any phenomena and that neither of the two phenomenal objects (nei-
ther the cognizer subject nor the cognized object) has any independent exis-
tence of its own. The existence of one depends on the existence of the other.
When the basis of duality is clearly apperceived, there is no question of
either any samsara (phenomenal day-to-day living) or any bondage for any
conceptual individual for the simple reason that the individual concerned is
merely the psychosomatic apparatus, the instrument through which the pro-
cess of perceiving and cognizing takes place. Our unhappiness, our conflict,
our bondage arises as the effect of the identification of What We Are (con-
sciousness) with the object-cognizer element in the dichotomy of the whole-
mind (Consciousness) into subject and object in the process of duality. This
identification or entitification as a separate independent entity (as the pseu-
do-subject) is the dualism, the maya, which results as the practical applica-
 Mindfulness and Meditative States in Spiritual Care 209

tion in day-to-day living of the original principle of duality, that is polarized,

interrelated and, therefore, not separate. It is this illusory identification that
causes all the conflict, all the suffering, all the unhappiness that is collectively
termed bondage. The instantaneous apperception of this very fact of the illu-
soriness of the pseudosubject as an independent doer-entity means the free-
dom from the bondage.
Holds that suffering follows naturally from personal negative behaviors
in your current life or in a past life (see karma). People must accept suffering
as a just consequence and as an opportunity for spiritual progress. Thus, the
soul or true self, which is eternally free of any suffering, may come to mani-
fest itself in the person, who then achieves liberation (moksha). Abstinence
from causing pain or harm to other beings (ahimsa) is a central tenet of
Hinduism.
Advaita (nonduality) simply means that the source, by whatever name
known—primal energy, consciousness, awareness, plenitude, God—is uniqe-
ness, oneness, nonduality. The manifestation that arises or emerges from the
source is based on duality, the inevitable existence of interconnected oppo-
sites: male and female, beauty and ugliness.

Fear not, O learned one, there is no death for thee; there is a means of crossing
this sea of relative existence; that very way by which sages have gone beyond it,
I shall inculcate to thee. (Vivekacudamani 43)

By which this universe is pervaded, but which nothing pervades, which shining,
all this [universe] shines as Its reflection. This is That. (Vivekacudamani 128)

The bodily pain of physical illness and deterioration is part of this suf-
fering. Hindu belief is, however, that the physical body wears out, like our
clothes do. The soul, which is immortal, lives on when the body perishes.
Like a person changes worn out clothes, the soul changes deteriorated bod-
ies. Hindus cremate their dead so that the elements of the body return to na-
ture, from whence they came. Then there is rebirth. The cycle continues.
Anger, hate, guilt, insecurity, and fear are the weaknesses and limitations
of people. When we overcome these limitations and weaknesses, we will be
able to accomplish our goals and perform our duties
The central theme of Bhagavad Gita, one of the holy books of Hinduism,
is to overcome reluctance (not necessarily fear) to do our duty (do what is
right). The scriptures tell us that we do our duty, without regard to its conse-
quences (and without expecting anything in return). If we do good things, we
have nothing to fear. We are asked not to be afraid of our limitations and
weaknesses. The Bhagavad Gita is considered by Eastern and Western schol-
ars alike to be among the greatest spiritual books the world has ever known.
210 Clinical Hypnosis in Pain Therapy and Palliative Care

In a very clear and wonderful way the Supreme Lord Krishna describes the
science of self-realization and the exact process by which a human being can
establish his or her eternal relationship with God.
Bhagavad Gita is a part of the Mahabharata, comprising 700 verses. The
teacher of the Bhagavad Gita is Sri Krishna, who is regarded by the Hindus
as the supreme manifestation of the Lord Himself and is referred to as
Bhagavan, the divine one. The Bhagavad Gita is commonly referred to as the
Gita for short. In order to clarify his point, Krishna expounds the various
yoga processes and understanding of the true nature of the universe. Krishna
describes the yogic paths of devotional service, action, meditation, and
knowledge. Fundamentally, the Bhagavad Gita proposes that true enlighten-
ment comes from growing beyond identification with the temporal ego, the
False Self, the ephemeral world, so that one identifies with the truth of the
immortal self, the absolute soul, or atman. Through detachment from the
material sense of ego, the yogi, or follower of a particular path of yoga, is able
to transcend his or her illusory mortality and attachment to the material
world and enter the realm of the Supreme.
Only God is Truth (ultimate reality) The world is an illusion. It is the veil
that masks the Truth. Unless one can break free from the bonds of the world
(human bondage) we cannot see the Truth.

D. The Vedas
The Vedas (Sanskrit; knowledge), the most sacred books of Hinduism
and the oldest literature of India, represent the religious thought and activi-
ty of the Indo-European speaking peoples who entered South Asia in the sec-
ond millennium BC, although they probably also reflect the influence of the
indigenous people of the area. The Vedic texts presumably date from
between 1500 and 500 BC. This literature was preserved for centuries by an
oral tradition in which particular families were entrusted with portions of the
text for preservation. As a result, some parts of the texts are known by the
names of the families they were assigned to.
In its narrowest sense, the term Veda applies to four collections of hymns
(samhita): Rig Veda, Sama Veda, Yajur Veda, and Atharva Veda. These hymns
and verses, addressed to various deities, were chanted during sacrificial ritu-
als. The Upanishads are Hindu scriptures that constitute the core teachings of
Vedanta.

In the Darsana Mala (a Garland of Visions of the Absolute) (VIII. Bhakti

Darsanam, Vision by Contemplation), we can read,
 Mindfulness and Meditative States in Spiritual Care 211

1. Meditation of the Self is contemplation,

Because the Self consists of bliss,
A knower of the Self meditates by the Self,
Upon the Self, for ever.
It is the Self alone that contemplates the Absolute;
The knower of the Self
Meditates on the Self, and not on any other.
That which is meditation on the Self
Is said to be contemplation.

It is because a wise man is a knower of the Self that he meditates on the Self.
Not only does he meditate on the Self, but he meditates on nothing other
than the Absolute, consisting of existence, subsistence, and value (i.e. bliss).
He does not meditate on the inert and unreal non-Self, which is the cause of
suffering. He does not (even) meditate on the world. Because of meditating
on the Self, it is called bhakti or contemplation. So, the man who meditates
on the Self is the real contemplative.
The Self is the Absolute, and the knower of the Self is the same as the
knower of the Absolute. This is the same as saying he is a true contempla-
tive.

Similarly, discarding the body, the Buddhi and the reflection of the Chit in it,
and realising the Witness, the Self, the Knowledge Absolute, the cause of the
manifestation of everything, which is hidden in the recesses of the Buddhi, is dis-
tinct from the gross and subtle, eternal, omnipresent, all-pervading and extreme-
ly subtle, and which has neither interior nor exterior and is identical with one
self fully realising this true nature of oneself, one becomes free from sin, taint,
death and grief, and becomes the embodiment of Bliss. Illumined himself, he is
afraid of none. For a seeker after Liberation there is no other way to the break-
ing of the bonds of transmigration than the realisation of the truth of one’s own
Self. (Vivekacudamani 220-222)

Sankara called his work on the Vedantic Absolute the Vivekacudamani

(the Crest-Jewel of Discriminative Wisdom). Narayana Guru continues the
same tradition, after him and thinks of not one ornament for the head but of
a whole garland in which no vision of any religious or philosophical school
would be neglected or left out. Each would be kept in mind by him, as the
architect of the total integrated edifice. Thus would be commemorated the
dignity and wisdom possible for humanity, from which alone should be
derived the legitimate ornament to enhance his human quality as homo sapi-
ens.
The garland further represents, in the symbolic gesture language of
India, the whole of one’s precious wealth. It is implied as when a bride gives
212 Clinical Hypnosis in Pain Therapy and Palliative Care

herself to the bridegroom at the time of marriage. It represents the Sarv-

asvam (total good) that one surrenders to God or the Absolute or submits to
Humanity itself, in an extended sense of the analogy. When this epistemo-
logical secret has been understood, in all its bearings and applications in sci-
ence or philosophy, a man becomes able to see clearly through mazes of per-
cepts and concepts. He can then organize them into ramified hierarchies rep-
resenting values ranging from the actual to the nominal, with the perceptual
and the conceptual, fitted between these extremes. The structure of the series
of visions in Narayana Guru’s Darsana Mala conforms broadly to the scheme
that we have just referred to.
The Avadhuta Gita is a text of extreme Advaita-Vedanta. People like
Nisargadatta, who speak in ways not different than what Advaita-Vedanta
teaches, may come from distant backgrounds, even within Hinduism. They
are not formally Advaita-Vedantists, yet speak as one. Nondualism is the
same as Advaita-Vedanta. Only contexts differ.
The universe, the macrocosm, is in apparent chaos, and the individual
body, the microcosm, is in apparent order. Energy in each atom is chaotic.
In that chaos there is order. Chaos with order is cosmic intelligence. The
stars and planets move in order, with no apparent regulatory authority.
Nature is not just matter and power, it is also intelligence. Believing that the
universe is just matter is what causes conflict. If we believe that the universe
is intelligent energy, that it is compassionate, and that it responds to us then
peace prevails. When you experience the order in cosmic chaos, you expe-
rience bliss; when you realize the chaos within you as order, you exude com-
passion; that compassion then leads you to enlightenment.
The Hindu spiritual vision paints individual consciousness on a cosmic
canvas. It recognizes the transience of us all as separate entities yet incorpo-
rates us into the infinity that encompasses us. It does not rule out the possi-
bility of other manifestations of Brahman, sublime and subtle, carbon- or sil-
icon-based, elsewhere amid the stellar billions. It recognizes the role of mat-
ter and the limits of the mind but sees subtle spirit at the core of everything.
It does not speak of rewards and punishments in anthropocentric terms or of
a He-God communicating in local languages. Yet, it regards the religious
expressions of humanity as echoes of the universal spirit, even as volcanic
outbursts reveal submerged forces of far greater magnitude.

E. Raja Yoga Meditation

The basis for attaining an experience in Raja Yoga meditation is to un-
derstand the self and the mind. The human mind is the most creative, pow-
erful, and wonderful instrument we possess. Using this energy called mind
 Mindfulness and Meditative States in Spiritual Care 213

we have been able to search the deepest oceans, send humans to the moon,
and scan the molecular fabric of the building blocks of nature, but have we
found our true self? We have become the most educated and civilized soci-
ety in our history, but are we civil toward each other?
The soul has three main faculties; the mind or consciousness, the intel-
lect, and the subconscious. Thoughts flow from the subconscious mind to the
conscious mind. Feelings and emotions form in accordance with the montage
of thoughts flowing in the mind. Therefore, our state of mind at any given
moment is determined by the thoughts in our consciousness and also with
the feelings that we associate with those thoughts. Because our subconscious-
ness contains all our previous thoughts and experiences, it is necessary to
selectively control the flow of thoughts that emerges from the subconscious
mind.
The intellect is the controller that is used to discriminate so that only pos-
itive and benevolent thoughts flow into our mind. With meditation or deep
contemplation, the individual is able to strengthen and sharpen the intellect.
The end result is a constant state of well-being. If we are able to understand
the self as the source of energy that creates our feelings, then the following
will become our aims.

• Become aware of our state of mind and of the thoughts that flow into
the mind from our subconscious.
• Strengthen the intellect so that the individual can discriminate and
thereby only allow positive and peaceful thoughts to flow into the
mind.

Through this process of self-development, the individual develops more con-

trol over the mind.
The act of Raja Yoga meditation for at least 15 minutes in the early morn-
ing will have a positive effect during the entire day. Upon waking have the
thought: I am a peaceful soul, my aim today is to radiate peace to every per-
son that I come into contact with. Try to experience the stillness of mind of
being a peaceful soul as other thoughts emerge in the mind do not judge or
focus on them but repeat

I am a peaceful soul . . .
I am a peaceful soul . . .
My mind is filled with peace . . .
I radiate peace to the world . . .
I feel the gentle waves of peace flowing across my mind . . .
As these peaceful thoughts emerge in my mind . . .
214 Clinical Hypnosis in Pain Therapy and Palliative Care

I feel the stillness and silence envelopes my mind . . .

I am the peaceful soul . . . I am a peaceful loving soul . . .
My mind feels light and free from worries . . .
I realize my real nature is peace . . .
Peaceful thoughts flow through the mind . . .
and I feel the self becoming light . . .
I am a being of light shining like a star . . .
I radiate peace and light to the world . . .
The light and peace envelopes me . . .
and the waves of peace and light shine like a lighthouse . . .
This is the wonderful journey of self-discovery . . .

F. Kriya Yoga Meditation

Kriya Yoga meditation refers to actions designed to get rid of obstruc-
tions involving body and mind. Kriya Yoga meditation is a complete system
covering a wide range of techniques, including mantras and techniques of
meditation for control of the life force, bringing calmness and control of both
body and mind. The goal is to unite with pure Awareness. Since pure Aware-
ness is our original condition, it is also referred to as self-awareness.
Around 1920, Paramahansa Yogananda introduced Kriya Yoga medita-
tion to the West and founded the Self-Realization Fellowship. Preparing the
mind, Kriya Yoga is said to be a combination of the more useful yoga tech-
niques. Like Raja Yoga, Kriya teaches the laws of general conduct, including
harmlessness, truthfulness, and not stealing:

1. Life-force control (pranayama). At this point the difference from other

systems, like Raja Yoga meditation, becomes quite obvious. Kriya
pranayama is not as much about increasing the time of retention of
breath as it is about magnetizing the spine and directing life force to
the brain, with the effect of refining the brain and nervous system.
2. Initiation and shaktipat (transfer of energy). The seeker is initiated in
the proper use of Kriya pranayama. When the seeker is ready, a trans-
fer of energy might occur either from the outside or from within. To
experience Kundalini (energy) on its way up the spine is an event pow-
erful enough to change the way we think and function.
3. Higher Kriyas. For advanced students, there are still a few higher
Kriya meditation techniques. Full self-realization may be achieved by
practicing faithfully the mantras given for regular meditation.
 Mindfulness and Meditative States in Spiritual Care 215

G. Vipassana Meditation
Vipassana, one of the oldest techniques of meditation practiced in India,
was rediscovered by Gautama the Buddha around 2500 years ago. The
knowledge of the technique of Vipassana, however, disappeared from India
nearly five centuries after Buddha. The torch lit by the Buddha was kept
alive by some of his devoted disciples in other countries, particularly Burma.
The teachings of Vipassana were preserved by a chain of devoted teachers,
and they were transferred to the dedicated lineage of successive generations
in their pristine purity. Vipassana is a simple and practical way to achieve
real and lasting peace of mind and happiness by seeing things as they really
are. This process of self-observation leads to mental and physical purifica-
tion. It eliminates the frustration and disharmony from our life. This tech-
nique librates us from suffering and its deep-seated causes and takes us to our
highest spiritual goal through a step-by-step approach. The liberation from
fear helps the practitioners attain high levels of achievements in all the
spheres of human activity.
What follows is a daily meditation to attain peace of mind.

The act of meditation for at least 15 minutes in the early morning will have a
positive effect on your mind during the entire day.
Upon waking have these positive thoughts:
I am a peaceful soul. My aim today is to have a peaceful mind and radiate peace
to every person that I come into contact with.
Try to experience the stillness of mind of being a peaceful soul.

This technique aims for the total eradication of mental impurities and the
resultant highest happiness of full liberation. Healing, not merely curing dis-
eases, but the essential healing of human suffering, is its purpose.
Vipassana is a way of self-transformation through self-observation. It
focuses on the deep interconnection between mind and body, which can be
experienced directly by disciplined attention to the physical sensations that
form the life of the body and that continuously interconnect and condition
the life of the mind. It is this observation-based, self-exploratory journey to
the common root of mind and body that dissolves mental impurity, resulting
in a balanced mind full of love and compassion.
The scientific laws that operate one’s thoughts, feelings, judgments, and
sensations become clear. Through direct experience, the nature of how one
grows or regresses, how one produces suffering or frees oneself from suffer-
ing, is understood. Life becomes characterized by increased awareness, non-
delusion, self-control, and peace.
216 Clinical Hypnosis in Pain Therapy and Palliative Care

H. Yoga-nidra
Yoga relaxation reduces tension and anxiety. The autonomic symptoms
of high anxiety such as headache, giddiness, chest pain, palpitations, sweat-
ing, and abdominal pain respond well. It has been used to help soldiers from
war cope with posttraumatic stress disorder (PTSD). Yoga-nidra or “yogi
sleep” is a sleeplike state that yogis have reported experiencing during their
meditations. It is the conscious awareness of the deep sleep state referred to
as “prajna” in Mandukya Upanishad (Rama, 1982) and was experienced by
Swami Satyananda Saraswati (1974), when he was living with his guru Swami
Sivananda in Rishikesh. He began studying the tantric scriptures and, after
practice, constructed a system of relaxation that he began popularizing in the
mid-twentieth century. He explained yoga-nidra as a state of mind between
wakefulness and sleep that opened deep phases of the mind, suggesting a
connection with the ancient tantric practice called nyasa, whereby Sanskrit
mantras are mentally placed within specific body parts while meditating on
each part (of the body-mind). The form of practice taught by Swami Satya-
nanda includes eight stages (internalisation, sankalpa, rotation of conscious-
ness, breath awareness, manifestation of opposites, creative visualization,
sankalpa, and externalization).
Teachers such as Osho and Anandmurti Gurumaa, define yoga-nidra as
a state of conscious deep sleep. One appears to be sleeping, but the uncon-
scious mind is functioning at a deeper level: it is sleep with a trace of deep
awareness. In normal sleep, we lose track of our self, but in yoga-nidra, al-
though consciousness of the world is dim and relaxation is deep, there
remains an inward lucidity and experiences may be absorbed to be recalled
later. Because yoga-nidra involves an aimless and effortless relaxation it is
often held to be best practiced with an experienced yoga teacher who ver-
bally delivers instructions.
Anandmurti Gurumaa taught two techniques based on creative visual-
ization. Yoga-nidra as Yoga of Clear Light is proposed as a spiritual path (sad-
hana) in its own right, held to prepare and refine a seeker (sadhaka) spiritu-
ally, emotionally, mentally, and physically for consciousness and awareness.
The yogi may work through the consequences of deeds (karma), cleansing
the stored consciousness and purifying the unconscious mind. The state may
-
lead to realization (samadhi) and being-awareness-bliss (satchitananda). The
yogi is held to be in communion with the divine. A tantrika engaged in this
sadhana may become aware of past or future lives or experience the astral
planes (Saraswati, 1974).
Experimental evidence of the existence of a fourth state of unified, tran-
scendental consciousness that lies in the yoga-nidra state at the transition
 Mindfulness and Meditative States in Spiritual Care 217

between sensory and sleep consciousness was first recorded in 1971 in the
United States at the Menninger Foundation in Kansas. Under the direction
of Dr. Elmer Green, researchers used an electroencephalograph to record
the brainwave activity of an Indian yogi, Swami Rama, while he progres-
sively relaxed his entire physical, mental and emotional structure through
the practice of yoga-nidra. What they recorded was a revelation to the sci-
entific community. The swami demonstrated the capacity to enter the vari-
ous states of consciousness at will, as evidenced by remarkable changes in
the electrical activity of his brain. Upon relaxing himself in the laboratory,
he first entered the yoga-nidra state, producing 70 percent alpha wave dis-
charge for a predetermined 5-minute period, simply by imagining an empty
blue sky with occasional drifting clouds. Next, Swami Rama entered a state
of dreaming sleep that was accompanied by slower theta waves for 75 per-
cent of the subsequent 5-minute test period. This state, which he later
described as being “noisy and unpleasant,” was attained by “stilling the con-
scious mind and bringing forth the subconscious.” In this state he had the
internal experience of desires, ambitions, memories, and past images in
archetypal form rising sequentially from the subconscious and unconscious
with a rush, each archetype occupying his whole awareness.
Finally, the swami entered the state of (unconscious) deep sleep, as veri-
fied by the emergence of the characteristic pattern of slow rhythm delta
waves. He remained perfectly aware throughout the entire experimental per-
iod, however. He later recalled the various events that had occurred in the
laboratory during the experiment, including all the questions that one of the
scientists had asked him during the period of deep delta wave sleep, while
his body lay snoring quietly.
Such remarkable mastery over the fluctuating patterns of consciousness
had not been demonstrated under strict laboratory conditions previously.
The capacity to remain consciously aware while producing delta waves and
experiencing deep sleep is one of the indications of the superconscious state
(turiya). This is the ultimate state of yoga-nidra in which the conventional
barriers between waking, dreaming, and deep sleep are lifted, revealing the
simultaneous operation of the conscious, subconscious, and unconscious
mind. The result is a single, enlightened state of consciousness and a per-
fectly integrated and relaxed personality (Green, 1972).
Yoga nidra is the same as deep hypnosis. One looks to be sleeping, but
the unconscious mind is functioning at a deeper level. It is sleep with a dis-
cover of deep awareness. In normal sleep, we lose track of ourselves, but in
yoga nidra, and in deep hypnosis, while consciousness throughout the world
is dim and relaxation is deep, there remains an inward lucidity, and experi-
ences may be absorbed to be recalled later.
218 Clinical Hypnosis in Pain Therapy and Palliative Care

In the Hindu religion and philosophy, yoga and meditative states are the
way to overcome pain and suffering. The word yoga can describe either a
state of consciousness or an effort to attain that state. The state of conscious-
ness is characterized by transcendental knowledge and bliss.

Mistaking the body or not-I for the Self or I, is the cause of all misery, that is, of
bondage. That bondage comes through ignorance of the cause of birth and
death, for it is through ignorance that men regard these insentient bodies as real,
mistaking them for the Self and sustaining them with sense objects and finally
getting destroyed by them. (Vivekacudamani)

Prana is born of the Self. Like a man and his shadow the Self and Prana are
inseparable. Prana enters the body at birth, that the desires of the mind, contin-
uing from past lives, may be fulfilled. (Prasna Upanisad)

There are two causes of the activities of the mind; (1) Vâsana (desires) and (2)
the respiration (the Prana). Of these, the destruction of the one is the destruction
of both. Breathing is lessened when the mind becomes absorbed, and the mind
becomes absorbed when the Prana is restrained. (Hatha Yoga Pradipika)

For those who are afflicted, in the way of the world, by the burning pain due to
the (scorching) sunshine of threefold misery, and who through delusion wander
about in a desert in search of water—for them here is the triumphant message of
Shankara pointing out, within easy reach, the soothing ocean of nectar, Brah-
man, the One without a second—to lead them on to Liberation. (Vivekacuda-
mani 580)

5. ISLAM MEDITATION

Prayer is one of the most important aspects of a successful Islamic

lifestyle. When we consciously adopt Islam for ourselves, we do so through
recognition and cognizance of the Oneness of God. We contemplate and rec-
ognize that Allah is worthy of worship and that nothing else is. We recognize
truth in His words and in the guides He sent to us for our benefit. None of
this is possible without contemplation, reflection, concentration, observation,
and presence of mind.

Allah said, Remember Me and I will remember you. (Surat al-Baqara, 2:152)

The word dhikr means remembrance, and in the Islamic context, it is

used in the sense of remembrance of Allah. On the journey to the Divine
 Mindfulness and Meditative States in Spiritual Care 219

Presence the seed of remembrance is planted in the heart and nourished with
the water of praise and the food of glorification, until the tree of dhikr be-
comes deeply rooted and bears its fruit. It is the power of all journeying and
the foundation of all success. It is the reviver from the sleep of heedlessness,
the bridge to the one remembered.
The shaikhs strive to remember their Lord with every breath, as the
angels are always in the state of dhikr, praising Allah. One of our shaikhs
said, “I remembered You because I forgot You for a moment, and the easiest
way for me is to remember You on my tongue.” If the seeker will mention
his Lord in every moment, he will find peace and satisfaction in his heart, he
will uplift his spirit and his soul, and he will sit in the presence of his Lord.
The Prophet(s) said in an authentic hadith mentioned in Ahmad’s Musnad,
“The people of Dhikr are the people of My presence.” So the gnostic is the
one who keeps the dhikr in his heart and leaves behind the attachments of
the lower worldly life. A good Muslim has to pray at least five times a day:

1. once before dawn

2. at noon
3. once in the afternoon
4. at sunset
5. and once at night.

During prayer he or she is to focus and meditate on God by reciting the

Qur’an and engaging in dhikr in order to reaffirm and strengthen the bond
between creator and creation. This has the effect of guiding the soul to truth.
Such meditation is intended to help maintain a feeling of spiritual peace in
the face of whatever challenges work, social, or family life may present. The
five daily acts of peaceful prayer are to serve as a template and inspiration
for conduct during the rest of the day, transforming it, ideally, into one sin-
gle and sustained meditation. Even sleep is to be regarded as but another
phase of that sustained meditation.
Meditative quiescence is said to have a quality of healing and of enhanc-
ing, as contemporary terminology would have it, creativity. The prophet Mu-
hammad, whose deeds and devotions Muslims are to emulate, is reported to
have spent sustained periods in contemplation and meditation. It was during
one such period that the Prophet began to receive the revelations of the
Qur’an.
Tafakkur or tadabbur means reflection upon the universe; this is considered
to permit access to a form of cognitive and emotional development that can
emanate only from the higher level, in other words, from God. The sensa-
tion of receiving divine inspiration awakens and liberates both heart and
220 Clinical Hypnosis in Pain Therapy and Palliative Care

intellect, permitting such inner growth that the apparently mundane actual-
ly takes on the quality of the infinite. Muslim teachings embrace life as a test
of one’s submission to, and one’s acceptance, the literal meaning of the word
Islam, of Allah, the unconditioned, the one God beyond all mere human
imaginings.

A. Meditation in the Sufi Traditions

Largely based on a spectrum of mystical exercises, meditation in the Sufi
traditions varies from one lineage to another. Numerous Sufi traditions place
emphasis on a meditative procedure similar in its cognitive aspect to one of
the two principal approaches to be found in the Buddhist traditions: that of
the concentration technique, involving high-intensity and sharply focused
introspection. In the Oveyssi-Shahmaghsoudi Sufi order, for example, this is
particularly evident, where muraqaba takes the form of tamarkoz, the latter
being a Persian term, that means concentration.
The goal and purpose of Sufi meditation is to manifest perpetual pres-
ence in the reality. The more people keep to this vital practice, the more its
benefit will manifest in their daily lives to the point that they reach the state
of annihilation.
When people sit for Sufi meditation and close their eyes, they focus their
mind on one single point. The point in this case is usually the concept of their
spiritual mentor; that is, they focus all their witnessing abilities concentra-
tively in thinking about their spiritual teacher in order to get the image of
their mentor on the mental screen, as long as they remain in the state of med-
itation. The properties, characteristics, and potentialities related to an image
also transfer on the screen of the mind when the image is formed on the
mental screen, and the mind perceives them accordingly. For instance, a per-
son is looking at fire. When the image of fire transfers onto the mental
screen, the warmth and heat of the fire are perceived by the mind. A person
who is present in a garden enjoys the freshness and coolness of trees and
plants present in the garden to create their image on her mental screen.
Similarly when image of the spiritual mentor transfers on the screen of mind,
the presented knowledge, which is operative in the spiritual teacher, also
transfers with it and the mind of the student gradually assimilates the same.

B. Annihilation, the State of Oneness With the Holy Prophet

In the state of “Oneness with the Holy Prophet” a spiritual associate be-
cause of his passion, longing and love gradually, step by step, assimilates and
cognizes the knowledge of the Holy Prophet. Then comes that auspicious
 Mindfulness and Meditative States in Spiritual Care 221

moment when the knowledge and learning is transferred to him according to

his capacity from the Holy Prophet. To be a thing nonexistent, a crystal clear
vessel for whomever wishes to fill your being from Allah’s Divine Kingdom,
this affinity, in Sufism, is called “Annilation in Allah Love.”

6. JAINISM: JAIN SADHVIS MEDITATING

Jainism is an ancient religion with its origins in India. Pacifism and com-
passion are central tenets of the Jain following, and it is these elements that
have greatly influenced Eastern mysticism for several millennia. The Jainists
believe that divine truth is communicated on Earth by Tirthankars, who
communicate otherworldly knowledge to other humans. Tirthankars appear
in groups of twenty-four, their lives following in succession. The twenty-
fourth Tirthankar to have existed in our realm, Lord Vardhaman Mahavira,
died in 527 BC. However, the Jains believe that there will be an ongoing suc-
cession of Tirthankars across time and space. For this reason, they do not
worship Lord Vardhaman or any of the twenty-three Tirthankars that pre-
ceded him, as such, but rather follow the virtues that they taught through
example.
The Jainists believe that all humans have an eternal soul (or Jina) that is
capable of reaching spiritual Enlightenment or Moksha, by living a spiritual
life that is strict and based principally around the virtue of respect for all liv-
ing forms. Like Buddhists and Hindus, Jainists believe in karma, the notion
that all your actions will come back to you; hence their desire to lead a life
that is humble and free of aggression toward others. Jainists follow a strict
ethical code prohibiting violence, dishonesty, stealing, promiscuousness, and
possessiveness.

A. The Navkar Mantra

Jains pray daily, reciting the Navkar Mantra which reinforces the true
path to becoming a Siddha, or Enlightened person, via the principles out-
lined earlier, and through an official commitment to the Jainist way of life by
becoming a nun or monk. This Navkar Mantra is undoubtedly similar in
form to other forms of meditation and can be recited by Jainists at any point
of the day for as long as they wish.
Although there are clear parallels between Jainists and Buddhists, includ-
ing their desire for spiritual Enlightenment and their teaching of compassion
for all beings, Jainism is principally an ascetic religion that believes in attain-
ing Enlightenment through self-denial.
222 Clinical Hypnosis in Pain Therapy and Palliative Care

Jainist meditation focuses on emptying the mind in order to better real-

ize truth and is often also focused around denial. Mahavira often meditated
outside with no clothes for warmth and sometimes meditated standing up.
This kind of meditation is subject to leading the practitioner down an unhelp-
ful path because the pain associated with asceticism can be sought as an end
in itself and is quite at odds with the prevailing instinct in our society. Jainism
may well suit some individuals, the path to Enlightenment being a personal
road; however, due to its severity and strictness, most of what can be gleaned
from it may be best found elsewhere. Specific Jainist mantras can be easily
recited where they are felt to be helpful.
The Jains use the word Samayika, a word in the Prakrit language derived
from the word samay (time), to denote the practice of meditation. The aim
of Samayika is to transcend the daily experiences of being a “constantly
changing” human being, Jiva, and allow for the identification with the
changeless reality in the practitioner, the Atma. The practice of Samayika
begins by achieving a balance in time. If the present moment of time is taken
to be a point between the past and the future, Samayika means being fully
aware, alert, and conscious in that very moment, experiencing one’s true na-
ture, Atma, which is considered common to all living beings. The Samayika
takes on special significance during Paryushana, a special eight-day period
practiced by the Jains.
Jain meditation techniques were available in ancient Jain scriptures that
have been forgotten with time. A practice called preksha meditation is said
to have been rediscovered by the tenth Head of Jain Swetamber Terapanth
sect Acharya Mahaprajna and consists of the perception of the body, the psy-
chic centers, breath and of contemplation processes that will initiate the pro-
cess of personal transformation. It aims at reaching and purifying the deep-
er levels of existence. Regular practice is believed to strengthen the immune
system and build up stamina to resist against aging, pollution, chemical tox-
ins, viruses, diseases, and food adulteration.
Meditation practice is an important part of the daily lives of the religion’s
monks. Acharya Mahaprajna says,

Soul is my god.
Renunciation is my prayer.
Amity is my devotion.
Self-restraint is my strength.
Non-violence is my religion.
 Mindfulness and Meditative States in Spiritual Care 223

7. JUDAISM AND KABBALAH MEDITATION

There is evidence that Judaism has meditative practices that go back

thousands of years For instance, in the Torah, the patriarch Isaac is described
as going lasuach in the field, a term understood by all commentators as some
type of meditative practice (Genesis 24:63), probably prayer. Similarly, there
are indications throughout the Tanach (the Hebrew Bible) that meditation
was central to the prophets. In the Old Testament, there are two Hebrew
- which means to sigh or murmur, but also to med-
words for meditation: hagâ
itate, which means to muse or rehearse in one’s mind.
In modern Jewish practice, one of the best known meditative practices is
called hitbodedut or hisbodedus iand s explained in Kabbalah and Hassidic
philosophy. The word hisbodedut, which derives from the Hebrew word
“boded” (a state of being alone), means the process of making oneself under-
stand a concept well through analytical study.
Kabbalah is inherently a meditative field of study. Kabbalistic meditative
practices construct a supernal realm that the soul navigates through in order
to achieve certain ends. One of the most well-known types of meditation is
merkabah, from the consontal root r-k-b, meaning to ride.

A. What is Kabbalah?
Kabbalah is an ancient Jewish mystical system of meditation that teach-
es the profoundest insights into the essence of God, how He interacts with
the world, and the purpose of creation. Kabbalah and its teachings are an
integral part of the Torah, the entire body of Jewish wisdom and teachings,
both the oral law, and the written law. Some Jewish scholars suggest that the
Torah is the hand-written scroll of the Divine Law or the Five Books of
Moses.
In the evolutionary chain of forms, we humans are the first form in that
evolving chain to have self-consciousness added to the subconscious forms of
the mineral, plant, and animal realms. A creature with upright posture,
opposing thumbs for manipulating physical things, and a separate sense of
“I”-ness or individuality. The “lower” three kingdoms evolve through physi-
cal adaptation to changing physical conditions, such as heat, cold, moisture,
dryness, availability of food, and changes in predators. Humans differ in that
our transformations are brought about by resolving differences between
other individuals and groups. In time, such experiences assist us to realize
our unity or oneness.
One of the foremost purposes of human existence is to create and main-
tain a bridge between subconscious life (the animal, vegetable, mineral
224 Clinical Hypnosis in Pain Therapy and Palliative Care

realms) and superconscious existence and expression. Self-consciousness, the

awareness of the divinity within each one of us and all of creation is that
bridge. This acknowledges and celebrates both, The One in the all and the
all in The One.
When spelled with the letter “Q,” the word Qabalah refers to the
Universal Qabalah. The Universal Qabalah is a body of esoteric and practi-
cal wisdom that encompasses both Judeo-Christian mysticism and the teach-
ings of other traditions such as yoga, Buddhism, Sufism, Hermetics (tarot,
astrology, alchemy, numerology, and sacred geometry) among them. Qaba-
lah is a Western tradition that serves as a bridge between the inner traditions
of the East and West. Study and practical application of the teachings of the
Qabalah, Tree of Life, and Tarot may be used to enhance and augment the
teachings of all spiritual disciplines.
Kabbalah meditations were devised by the Jewish mystics over 2000
years ago to enhance the awareness and access higher planes of consciousness. The
Qabalah uses the Tree of Life as its major symbolic representation of the pro-
cesses of evolutionary unfoldment. By studying and meditating on the Tree
of Life, which is a pictorial representation of the descent of consciousness,
into deepest matter, and its ascent back into the highest level of conscious-
ness, the student can use the processes of evolutionary unfoldment to jour-
ney back to the highest levels of consciousness and simultaneously manifest
these higher levels in deepest matter.

B. The Aim of Kabbalah Meditation

The aim of Kabbalah mditation is to make the practitioners the true car-
riers of the light of God. Kabbalah meditation continues to flourish in the
oral tradition and rises above the written word. This system will enable you
to attain peace and happiness through the union with God. The objective of
Kabbalah meditation transcends the need for relaxation and quieting the
mind. Kabbalah meditation enables the seekers to directly interact with the
higher worlds and bring about positive changes in life. It wipes off the nega-
tive influences from both your body and your mind and establishes the
power of mind over the matter. The essence of Kabbalah meditation is to
bring new resources of joy, love, and understanding to everything you do.
Kabbalah meditation explores the complex character of the divine reali-
ty, particularly the inability of the human thought to grasp Him. It uses var-
ious techniques, including meditations on Hebrew letter permutations and
combinations and the ways in which sefirot or the supernatural forces har-
monize and interact with each other. These meditative techniques produce
visionary experiences of the angels and their residential chambers.
 Mindfulness and Meditative States in Spiritual Care 225

Another important objective of Kabbalah is to rectify the imperfections

of the soul rather than to create spiritual knowledge.
Kabbalah explains that all events in the universe are connected. Two fun-
damental concepts influence these connections:

1. There is a spectrum of space running through the universe, from ab-

solute largeness, containing everything, to absolute smallness or noth-
ingness at the other end. The largeness is referred to as Ein Sof (all-
ness, without end); nothingness is known as Ayin. This spectrum of
space is encountered in many religions.
2. This in turn vivifies the second major concept, which is that all events
within this spectrum are manifestations of the workings of the ten
Sephirot.

Sephirot, meaning “enumerations,” are the ten attributes or emanations

in Kabbalah through which God (who is referred to as Ein Sof, The Infinite)
reveals himself or herself and continuously creates both the physical realm
and the chain of higher metaphysical realms. The sephirot are related to the
structure of the body and are reformed into Partsufim (personas). Underlying
the structural purpose of each sephirah is a hidden motivational force that is
understood best by comparison with a corresponding psychological state in
human spiritual experience. The ten Sephirot are a step-by-step process illu-
minating the Divine plan, as it unfolds itself in Creation.
Because all levels of Creation are constructed around the ten Sephirot,
their names in Kabbalah describe the particular role each plays in forming
reality. These are the external dimensions of the Sephirot, describing their
functional roles in channelling the Divine, creative Ohr (Light) to all levels.
Because the sephirot are viewed to comprise both metaphorical “lights” and
“vessels,” their structural role describes the particular identity each Sephirah
possesses from its characteristic vessel. Underlying this functional structure
of the Sephirot, each one possesses a hidden, inner spiritual motivation that
inspires its activity. This forms the particular characteristic of inner light with-
in each Sephirah.
Identifying the essential spiritual properties of the soul, gives the best
insight into their Divine source, and in the process reveals the spiritual beau-
ty of the soul.
226 Clinical Hypnosis in Pain Therapy and Palliative Care

THE 10 SEPHIROT

Category Sephirah

Above-consciousness 1 Keter “Crown”

2 Chokhmah “Wisdom”
Conscious intellect
3 Binah “Understanding”

Primary emotions
4 Chesed “Kindness”
5 Gevurah “Severity”
6 Tiferet “Beauty”
Secondary emotions
Conscious emotions
7 Netzach “Eternity”
8 Hod “Splendour”
9 Yesod “Foundation”
Vessel to bring action
10 Malkuth “Kingship”

In Hasidic philosophy these inner dimensions of the Sephirot are called the
Powers of the Soul (Weiser S., 1997).
Two alternative spiritual arrangements for describing the Sephirot are
given, metaphorically described as “Circles” and “Upright.” Their origins
come from Medieval Kabbalah and the Zohar. In later sixteenth-century
Lurianic Kabbalah, they become systemized as two successive stages in the
evolution of the Sephirot during the primordial cosmic evolution of
Creation. This evolution is central to the metaphysical process of tikkun (fix-
ing) in the doctrines of Isaac Luria.

8. NATIVE AMERICANS SPIRITUALITY AND PRAYERS

The Native American attitude is that everything is animated by divinity.

Therefore, ordinary people, animals, and places are divine. Among all tribes
there is a strong sense that behind all individual spirits and personifications
of the divine, there is a single creative life force, sometimes called the Great
Mystery, which expresses itself throughout the universe, in every human,
animal, tree and grain of sand. Every story, too, is a working out of this life
force.
An aspect of this outlook is the major role played in the stories by ani-
mals, who often speak to humans and assist them. Most tribes thought of
individual members of a species as expressions of the spiritual archetype of
that species, which in turn embodied a particular spirit power.
 Mindfulness and Meditative States in Spiritual Care 227

Another key feature of the Native American spiritual outlook is found in

the powers ascribed to the Four Directions, which occur either literally or in
symbolic form throughout the stories. These are often represented by partic-
ular colors, or by animals. The Four Directions have to be in balance for all
to be well with the world, and often a central point of balance is identified as
a fifth direction. For example, four brothers represent the outer directions,
and their sister the center.
The Medicine Wheel is often representative of Native American Spiritu-
ality. The Medicine Wheel symbolizes the individual journey we each must
take to find our own path. Within the Medicine Wheel are The Four Cardin-
al Directions and the Four Sacred Colors.

A. The Circle of Life

The Circle represents the Circle of Life, and the Center of the Circle, the
Eternal Fire. The Eagle, flying toward the East, is a symbol of strength,
endurance, and vision. East signifies the renewal of life.

• East = Red = success; triumph

• North = Blue = defeat; trouble
• West = Black = death
• South = White = peace; happiness

There are three additional sacred directions:

• Up Above = Yellow
• Down Below = Brown
• Here in the Center = Green

WINTER: The color for North is blue, which represents sadness, defeat. It
is a season of survival and waiting.
S PRING: The color for East is red, which represents victory, power.
Spring is the reawakening after a long sleep, victory over winter, the power
of new life.
S UMMER: The color for South is white for peace, happiness, and sereni-
ty. Summer is a time of plenty.
AUTUMN: The color for West is black, which represents death. Autumn is
the final harvest; the end of Life’s Cycle.
Red was symbolic of success. Red beads were used to conjure the red
spirit to ensure long life, recovery from sickness, success in love and ball play
or any other undertaking where the benefit of the magic spell was wrought.
228 Clinical Hypnosis in Pain Therapy and Palliative Care

Black was always typical of death. The soul of the enemy was continual-
ly beaten about by black war clubs and enveloped in a black fog. In conjur-
ing to destroy an enemy, the priest used black beads and invoked the black
spirits, which always lived in the West, bidding them to tear out the man’s
soul and carry it to the West and put it into the black coffin deep in the black
mud with a black serpent coiled above it.
Blue symbolized failure, disappointment, or unsatisfied desire. To say
“they shall never become blue” expressed the belief that they would never
fail in anything they undertook. In love charms, the lover figuratively cov-
ered himself with red and prayed that his rival would become entirely blue
and walk in a blue path. He is entirely blue approximates the meaning of the
common English phrase “He feels blue.” The blue spirits lived in the North.
White denoted peace and happiness. In ceremonial addresses, as the
Green Corn Dance and ball play, the people symbolically partook of white
food and, after the dance or game, returned along the white trail to their
white houses. In love charms, the man, to induce the woman to cast her lot
with his, boasted, “I am a white man,” implying that all was happiness where
he was. White beads had the same meaning in bead conjuring, and white was
the color of the stone pipe anciently used in ratifying peace treaties. The
White spirits lived in the South.
Two numbers are sacred to these traditions. Four is one number; it rep-
resented the four primary directions. At the center of their paths is the sacred
fire. Seven is the other and most sacred number. Seven is represented in the
seven directions: north, south, east, west, above, below, and here in the cen-
ter. the place of the sacred fire. Seven also represented the seven ancient cer-
emonies that formed the yearly religious cycle. The medicine wheel is a sym-
bol for the wheel of life, which is forever evolving and bringing new lessons
and truths to the walking of the path. The Earthwalk is based on the under-
standing that each one of us must stand on every spoke of the great wheel of
life many times and that every direction is to be honored.
The medicine wheel teaches us that all lessons are equal, as are all talents
and abilities. Every living creature will one day see and experience each
spoke of the wheel and know those truths. It is a pathway to truth, peace, and
harmony. The circle is never ending, life without end.
In experiencing the Good Red Road, one learns the lessons of physical
life, or of being human. This road runs South to North in the circle of the med-
icine wheel. After the graduation experience of death, one enters the Blue or
Black Road that is the world of the grandfathers and grandmothers. In spirit,
one will continue to learn by counseling those remaining on the Good Red
Road. The Blue Road of the spirit runs East to West. The medicine wheel is
life, afterlife, rebirth, and the honoring of each step along the way.
 Mindfulness and Meditative States in Spiritual Care 229

The medicine shield is an expression of the unique gifts that its maker
wishes to impart about his or her current life journey. This can be a new level
of personal growth or illustrate the next mountain a person wishes to climb.
Every shield carries medicine through its art and self-expression. Each shield
is the essence of a time and space that carries certain aspects of knowledge.
All persons carry shields of the lessons they learned from the four directions
on the medicine wheel. They are the healing tools we give ourselves to
soothe the spirit and empower the will. The truth needs no explanation, just
reflection. This allows intuition to guide the heart so that humanity may cel-
ebrate more than it mourns.
The medicine wheel is sacred, the native people believe, because the
Great Spirit caused everything in nature to be round. The Sun, Sky, Earth
and Moon are round. Thus, man should look upon the Medicine Wheel (cir-
cle of life) as sacred. It is the symbol of the circle that marks the edge of the
world and therefore, the Four Winds that travel there. It is also the symbol
of the year. The Sky, the Night, and the Moon go in a circle above the Sky,
therefore, the Circle is a symbol of these divisions of time. It is the symbol
of all times throughout creation.
The elements and majestic forces in nature, Lightning, Wind, Water,
Fire, and Frost, were regarded with awe as spiritual powers, but always sec-
ondary and intermediate in character. Natives believe that the spirit pervades
all creation and that every creature possesses a soul in some degree, though
not necessarily a soul conscious of itself. The tree, the waterfall, the grizzly
bear, each is an embodied Force, and as such an object of reverence.

B. Native American’s Words of Wisdom

Love your life, perfect your life, beautify all things in your life. Seek to make
your life long and of service to your people. Prepare a noble death song for the
day when you go over the great divide. Always give a word or sign of salute
when meeting or passing a stranger if in a lonely place. Show respect to all peo-
ple, but grovel to none. When you arise in the morning, give thanks for the light,
for your life and strength. Give thanks for your food and for the joy of living. If
you see no reason for giving thanks, the fault lies in yourself. (Tecumseh, 1768–
1813)

The first peace, which is the most important, is that which comes within the souls
of people when they realize their relationship, their oneness with the universe
and all its powers, and when they realize that at the center of the universe dwells
the Great Spirit, and that this center is really everywhere, it is within each of us.
(Black Elk, 1863–1950)
230 Clinical Hypnosis in Pain Therapy and Palliative Care

Black Elk Speaks is a 1932 book that relates the story of Black Elk, an
Oglala Sioux medicine man, as told by John Neihardt (1932). Black Elk’s son
Ben Black Elk translated Black Elk’s words from Lakota into English. In the
summer of 1930, as part of his research into the Native American perspec-
tive on the Ghost Dance movement, Neihardt contacted an Oglala holy man
named Black Elk, who was present as a young man at the 1876 Battle of the
Little Big Horn and the 1890 Wounded Knee Massacre.
As Neihardt tells the story, Black Elk gave him the gift of his life’s narra-
tive, including the visions he had had and some of the Oglala rituals he had
performed. The two men developed a close friendship. The book Black Elk
Speaks grew from their conversations continuing in the spring of 1931. The
current popularity of the book shows the growth of interest in the social and
ethical analysis of Native American tribes.
The Ghost Dance was a religious movement that was incorporated into
numerous Native American belief systems. The traditional ritual used in the
Ghost Dance, the circle dance, has been used by many Native Americans
since prehistoric times. Referred to as the “round dance,” this ritual form
characteristically includes a circular community dance held around an indi-
vidual who leads the ceremony. It was used in many community rituals.
Often accompanying the ritual are intermissions of trance, exhortations, and
prophesying.
Native American myths include all the types found worldwide, such as
stories of creation and of heroic journeys. They are particularly rich in trick-
ster myths, however. Notable examples are Coyote and Iktome. The trickster
is an ambiguous figure who demonstrates the qualities of early human devel-
opment (both cultural and psychological) that make civilization possible and
yet cause problems. He is an expression of the least developed stage of life,
which is dominated by physical appetites. Spirituality is not religion to
Native American. Religion is not a native concept, it is a nonnative word,
with implications of things that often end badly, like holy wars in the name
of individuals’ gods, and so on. Native people do not ask what religion anoth-
er native is because they already know the answer. To Native people, spiri-
tuality is the Creator.

May the Warm Winds of Heaven

Blow softly upon your house.
May the Great Spirit
Bless all who enter there.
May your Moccasins
Make happy tracks
in many snows,
 Mindfulness and Meditative States in Spiritual Care 231

and may the Rainbow

Always touch your shoulder. (Ancient Cherokee Prayer Blessing)

C. Ancient Lakota Instructions for Living

Friend do it this way—that is,
whatever you do in life,
do the very best you can
with both your heart and mind.
And if you do it that way,
the Power of The Universe
will come to your assistance,
if your heart and mind are in Unity.

9. TAOISM’S WU WEI MEDITATION

Taoism originated in China long ago and is composed of a number of dif-

ferent disciplines that together help the individual live in harmony with
nature and advance toward states of greater happiness and fulfillment. Taoist
meditation is more like a sort of wisdom achieved by close observation of the
things and phenomena in the world surrounding us. Such wisdom should
help us go along with things and not against them and is surely related to the
nondoing concept and practice. Chinese wu (not); wei (doing) is a term with
various translations (e.g., inaction, nonaction, nothing doing) and interpreta-
tions designed to distinguish it from passivity. From a nondual perspective, it
refers to activity that does not imply an “I.” What is Nondoing (Wu Wei)?
Wu Wei, usually translated as nonaction, inaction, or nondoing, is one of
the most important Taoist concepts. When linked to the Tao, the creator and
sustainer of everything in the Universe, nondoing means the actionless of
Heaven, like in the following abstract from Tao De Ching (Lao Tze):

The Tao in its regular course does nothing (for the sake of doing it), and so there
is nothing which it does not do. Linked with the human behavior, nondoing
refers to not forcing the things on their way, on the action without effort. (Tao
De Ching, Lao Tze)

Thus nondoing refers to a specific form of intelligence and, at the same time,
to the urge of following the Tao (Way). These two are linked: one follows the
Tao because it has (holds) the intelligence to do so, or because it has this intel-
ligence he or she is able to follow the Tao.
232 Clinical Hypnosis in Pain Therapy and Palliative Care

A. The Way
The Way that can be experienced is not true;
The world that can be constructed is not true.
The Way manifests all that happens and may happen;
The world represents all that exists and may exist.
To experience without intention is to sense the world;
To experience with intention is to anticipate the world.
These two experiences are indistinguishable;
Their construction differs but their effect is the same.
Beyond the gate of experience flows the Way,
Which is ever greater and more subtle than the world. (Tao De Ching, Lao Tze)

Taoist meditation methods, have many points in common with Hindu

and Buddhist systems, but the Taoist way is less abstract and far more down-
to-earth than the contemplative traditions that evolved in India. The prima-
ry hallmark of Taoist meditation is the generation, transformation, and cir-
culation of internal energy.
Once the meditator has “achieved energy” (deh-chee), it can be applied
to promoting health and longevity, nurturing the spiritual embryo of immor-
tality, martial arts, healing, painting and poetry, sensual self-indulgence, or
whatever else the adept wishes to do with it. The two primary guidelines in
Taoist meditation are jing (quiet, stillness, calm) and ding (concentration,
focus). The purpose of stillness, both mental and physical, is to turn attention
inward and cut off external sensory input, thereby muzzling the “Five
Thieves.” Within that silent stillness, one concentrates the mind and focuses
attention, usually on the breath, in order to develop what is called one-point-
ed awareness, a totally undistracted, undisturbed, undifferentiated state of
mind which permits intuitive insights to arise spontaneously.

Without Action
Not praising the worthy prevents contention,
Not esteeming the valuable prevents theft,
Not displaying the beautiful prevents desire.
In this manner the sage governs people:
Emptying their minds,
Filling their bellies,
Weakening their ambitions,
And strengthening their bones.
If people lack knowledge and desire
Then they can not act;
If no action is taken
Harmony remains. (Tao De Ching, Lao Tze)
 Mindfulness and Meditative States in Spiritual Care 233

Harmony
Embracing the Way, you become embraced;
Breathing gently, you become newborn;
Clearing your mind, you become clear;
Nurturing your children, you become impartial;
Opening your heart, you become accepted;
Accepting the world, you embrace the Way.
Bearing and nurturing,
Creating but not owning,
Giving without demanding,
This is harmony. (Tao De Ching, Lao Tze)

Taoist masters suggest that when you first begin to practice meditation,
you will find that your mind is very uncooperative. That is your ego, or emo-
tional mind, fighting against its own extinction by the higher forces of spiri-
tual awareness.

Self
Both praise and blame cause concern,
For they bring people hope and fear.
The object of hope and fear is the self
For, without self, to whom may fortune and disaster occur?
Therefore,
Who distinguishes himself from the world may be given the world,
But who regards himself as the world may accept the world.
(Tao De Ching, Lao Tze)

The last thing your ego and emotions want is to be harnessed: they revel
in the day-to-day circus of sensory entertainment and emotional turmoil,
even though this game depletes your energy, degenerates your body, and
exhausts your spirit. When you catch your mind drifting into fantasy or
drawing attention away from internal alchemy to external phenomena, there
are six ways you can use to “catch the monkey,” clarify the mind, and rees-
tablish the internal focus:

1. Shift attention back to the inflow and outflow of air streaming through
the nostrils or energy streaming in and out of a vital point such as
between the brows.
2. Focus attention on the rising and falling of the navel, the expansion
and contraction of the abdomen, as you breathe.
3. With eyes half-closed, focus vision on a candle flame or a mandala
(geometric meditation picture). Focus on the center of the flame or pic-
ture but also take in the edges with peripheral vision. The concentra-
234 Clinical Hypnosis in Pain Therapy and Palliative Care

tion required to do this usually clears all other distractions from the
mind.
4. Practice a few minutes of mantra, the “sacred syllables” that harmo-
nize energy and focus the mind. Although mantras are usually associ-
ated with Hindu and Tibetan Buddhist practices, Taoists have also
employed them for many millennia. The three most effective syllables
are “Om,” which stabilizes the body; “ah,” which harmonizes energy;
and “hum,” which concentrates the spirit. Om vibrates between the
brows, ah in the throat, and hum in the heart, and their associated col-
ors are white, red, and blue, respectively. Chant the syllables in a
deep, low-pitched tone and use long, complete exhalations for each
one. Other mantras are equally effective.
5. Beat the “Heavenly Drum” as a cool-down energy-collection tech-
nique. The vibrations tend to clear discursive thoughts and sensory
distractions from the mind.
6. Visualize a deity or a sacred symbol of personal significance to you
shining above the crown of your head or suspended in space before
you. When your mind is once again still, stable, and undistracted, let
the vision fade away and refocus your mind on whatever meditative
technique you were practicing.

B. The Three Treasures or San Bao:

Essence (Body), Energy (Breath), Spirit (Mind)
The Three Treasures or Three Jewels are basic virtues in Taoism. The Tao
Te Ching originally used san bao to mean compassion, frugality, and humili-
ty. San bao first occurs in Tao Te Ching, Chapter 67, which Lin Yutang (1948;
292) says contains Lao-tzu’s “most beautiful teachings”:

Every one under heaven says that our Way is greatly like folly. But it is just
because it is great, that it seems like folly. As for things that do not seem like
folly, well, there can be no question about their smallness!
Here are my three treasures. Guard and keep them! The first is pity; the second,
frugality; the third, refusal to be “foremost of all things under heaven.”
For only he that pities is truly able to be brave;
Only he that is frugal is able to be profuse.
Only he that refuses to be foremost of all things
Is truly able to become chief of all Ministers.
At present your bravery is not based on pity, nor your profusion on frugality,
nor your vanguard on your rear; and this is death. But pity cannot fight without
conquering or guard without saving. Heaven arms with pity those whom it
would not see destroyed. (Waley, 1958)
 Mindfulness and Meditative States in Spiritual Care 235

In the millenary Taoist tradition, the concept of San Bao refers to three
mysterious subtle structures of the human being, known as the three tan tien,
structures that are particularly important. They are regarded by the Taoist
sages to be some real treasures inside every human being, and their knowl-
edge through direct experience is extremely valuable in spiritual practice.
They correspond to a potential of a primordial natural innate force, on which
the very life of the human being depends.
In short, we could define the tan tien as a subtle cavity, a kind of a reser-
voir, where the elixir of immortality obtained through alchemy is stored. The
Taoist tradition states that in every human being’s microcosm the subtle
energy travels through a complex network of subtle energy channels, but
alongside them there are certain mysterious places of concentration of ener-
gy that constitute genuine focal points. Out of these, the three tan tien are the
most important structures.
These real “inner treasures,” the three tan tien, are associated with the
three basic energies of the human being, which in the Taoist tradition are
associated with the vital energy, the pranic energy and the energy of the soul.
These are known as Jing (essence), Chi (energy), and Shen (the soul).
Like all genuine spiritual traditions of our planet, Taoism has a complex
and global vision of humans and their existential condition. Thus, the desire
of inner evolution and spiritual transformation that allows the achievement
of the state of godhood is founded by a coherent and consistent philosophi-
cal vision that describes the process of the universal creation, and how the
creation (and by implication humans) can return to its divine unique Source.
Taoist meditation works on all three levels of the Three Treasures: es-
sence (body), energy (breath), and spirit (mind).

1. The first step is to adopt a comfortable posture for the body; balance
your weight evenly, straighten the spine, and pay attention to physical
sensations such as heat, cold, tingling, trembling, or whatever else aris-
es.
2. When your body is comfortable and balanced, shift attention to the
second level, which is breath and energy. You may focus on the breath
itself as it flows in and out of the lungs through the nostrils or on ener-
gy streaming in and out of a particular point in tune with the breath.
3. The third level is spirit. When the breath is regulated and energy is
flowing smoothly through the channels, focus attention on thoughts
and feelings forming and dissolving in your mind, awareness expand-
ing and contracting with each breath, insights and inspirations arising
spontaneously, visions and images appearing and disappearing. Event-
ually you may even be rewarded with intuitive flashes of insight re-
236 Clinical Hypnosis in Pain Therapy and Palliative Care

garding the ultimate nature of the mind: open and empty as space;
clear and luminous as a cloudless sky at sunrise; infinite and unim-
peded.

Just as all the rules of Qigong (chee gung) practice can be boiled down
to the three Ss: slow, soft, smooth, so the main points of meditation practice
may be summed up in the three Cs: calm, cool, clear. As for proper postures
for practice, the two positions most frequently used in Taoist meditation are:

• Sitting cross-legged on the floor in half-lotus position, with the but-

tocks elevated on a cushion or pad. The advantages of this method are
that this position is more stable and encourages energy to flow up-
wards toward the brain.
• Sitting erect on a low stool or chair, feet parallel and shoulder width
apart, knees bent at a 90-degree angle, spine erect. The advantages of
sitting on a stool are that the legs do not cramp, the soles of the feet
are in direct contact with the energy of the earth, and internal energy
tends to flow more freely throughout the lower as well as the upper
torso.

Most meditators who follow Taoist meditation use both methods, de-
pending on conditions. When sitting cross-legged, those whose legs tend to
cramp easily, are advised to sit on thick firm cushions, perhaps with a phone
book or two underneath, in order to elevate the pelvis and take pressure off
the legs and knees. This also helps keep the spine straight without straining
the lower back. The way the hands are placed is also important. The most
natural and comfortable position is to rest the palms lightly on the thighs, just
above the knees. Some meditators, however, find it more effective to use one
of the traditional mudras, or hand gestures. Experiment with different com-
binations of posture and mudra until you find the style that suits you best.
Taoist meditation masters teach three basic ways to control the Fire mind of
emotion with the Water mind of intent, so that the adept’s goals in medita-
tion may be realized.

C. Taoist Meditations
1. The first method is called stop and observe. This involves paying close
attention to how thoughts arise and fade in the mind, learning to let
them pass like a freight train in the night, without clinging to any par-
ticular one. This develops awareness of the basic emptiness of all
 Mindfulness and Meditative States in Spiritual Care 237

thought, as well as nonattachment to the rise and fall of emotional im-

pulses. Gradually one learns simply to ignore the intrusion of discur-
sive thoughts, at which point they cease arising for sheer lack of atten-
tion.
2. The second technique is called observe and imagine, which refers to visu-
alization. The adept employs intent to visualize an image, such as Bud-
dha, Jesus, a sacred symbol, the moon, or a star, in order to shift men-
tal focus away from thoughts and emotions and stabilize the mind in
one-pointed awareness. You may also visualize a particular energy
center in your body, or listen to the real or imagined sound of a bell,
gong, or cymbal ringing in your ears. The point of focus is not impor-
tant; what counts is shifting the focus of your attention away from idle
thoughts, conflicting emotions, fantasies, and other distracting antics of
the monkey mind and concentrating attention instead on a stable
point of focus established by the mind of intent, or ‘wisdom mind’.
3. The third step in cultivating control over your own mind is called using
the mind of intent to guide energy. When the emotional mind is calm and
the breath is regulated, focus attention on the internal energy. Learn
how to guide it through the meridian network in order to energize
vital organs, raise energy from the sacrum to the head to nourish the
spirit and brain, and exchange stale energy for fresh energy from the
external sources of heaven (sky) and earth (ground). Begin by focusing
attention on the Lower Elixir Field below the abdomen, then moving
energy from there down to the perineum, up through the coccyx, and
up along the spinal centers into the head, after which attention shifts
to the Upper Elixir Field between the brows. Although this sounds
rather vague and esoteric to the uninitiated, a few months of practice,
especially in conjunction with Qigong and proper dietary habits, usu-
ally suffices to unveil the swirling world of energy and awareness hid-
den within our bodies and minds. All you have to do is sit still and be
quiet long enough for your mind to become aware of it.

It is always a good idea to warm up your body and open your energy
channels with some Qigong exercises before you sit down to meditate. This
facilitates internal energy circulation and enables you to sit for longer peri-
ods without getting stiff or numb. After sitting, you should avoid bathing for
at least 20 minutes in order to prevent loss of energy through open pores and
energy points.
If you live in the northern hemisphere, it is best to sit facing south or east,
in the general direction of the sun. In the southern hemisphere, sit facing
north or east. Still, what is Tao’s Movement and what does it mean to empty
238 Clinical Hypnosis in Pain Therapy and Palliative Care

your mind of the wishes not fitted with it? The answer is simple, but our
minds are very complicated, so we are not able to enjoy it. Chuang-tzu
(Master Chuang), who followed the teachings of Lao-tzu, describes the
empty mind in his monumental work that bears his name by stating,

The still mind of the sage is the mirror of heaven and earth, the glass of all
things. Vacancy, stillness, placidity, tastelessness, quietude, silence, and non-
action—this is the Level of heaven and earth, and the perfection of the Tao and
its characteristics. (Lao-tzu)

The still mind is a mind that is not moving, or put another way, it is the
mirror of the universe. This is the pure mind of ancient Taoist masters. When
we speak about emptiness, we think of the verses Lao-tzu himself dedicated
to it. In his Tao Te Ching, emptiness is related to the Tao, the Great Principle,
the Creator and Sustainer of everything in the universe (the 10,000 things).
Emptiness is also the state of mind of the Taoist disciple who follows the Tao.
In this respect, to be empty means to have your mind empty of all wishes
and ideas not fitted with the Tao’s Movement (direction).

D. The Enlightenment in Taoist Meditation

Enlightenment
The enlightened possess understanding
So profound they can not be understood.
Because they cannot be understood
I can only describe their appearance:
Cautious as one crossing thin ice,
Undecided as one surrounded by danger,
Modest as one who is a guest,
Unbounded as melting ice,
Genuine as unshaped wood,
Broad as a valley,
Seamless as muddy water.
Who stills the water that the mud may settle,
Who seeks to stop that he may travel on,
Who desires less than may transpire,
Decays, but will not renew. (Tao De Ching, Lao Tze)

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 Chapter VI

CLINICAL HYPNOSIS, MINDFULNESS,

AND MUSIC THERAPY

1. NEUROPHYSIOLOGY OF MUSIC

europhysiology of music may be regarded as a branch of either psy-

N chology or musicology. It aims to explain and understand musical be-
havior and melodious experience. The modern international field of music
psychology is gradually exploring a multitude of neurophysiological issues
that surround this central question. Music neurophysiology may be regard-
ed as scientific research about human culture. Music affects the brain at dif-
ferent levels. The results of many researchers have, and will continue to
have, direct implications for matters of general concern: compassionate val-
ues, human identity, human neurophysiology and nature, and quality of life.
Music consists of sound sequences and experiences that require a neu-
ronal integration over time. As we become familiar with music, the associa-
tions among notes, melodies, and entire symphonic movements become
stronger and more complex. These associations can become so tight that, for
example, hearing the end of one album track can elicit a robust image of the
upcoming track while anticipating it in total silence.
Leaver and associates (2009) studied this predictive “anticipatory imag-
ery” at various stages, throughout learning and investigate activity changes,
in corresponding neural structures, using functional magnetic resonance
imaging. The anticipatory imagery (in silence) for highly familiar naturalistic
music was accompanied by pronounced activity in rostral prefrontal cortex
and premotor areas. Examining changes in the neural bases of anticipatory
imagery during two stages of learning conditional associations between sim-
ple melodies, however, demonstrates the importance of frontostriatal con-
nections consistent with a role of the basal ganglia in “training” the frontal
cortex (Pasupathy & Miller, 2005).

244
 Clinical Hypnosis, Mindfulness, and Music Therapy 245

People have used music and song to comfort one another since time
immemorial. Aristotle and Plato wrote about their beliefs in the healing pow-
er of music. Pythagoras of Samos conducted perhaps the world’s first physics
experiment. By playing strings of different lengths, Pythagoras discovered
that sound vibrations naturally occur in a sequence of whole tones or notes
that repeat in a pattern of seven: like the seven naturally occurring colors of
the rainbow, the octave of seven tones. His experience affirms Pythagoras’s
assertion in the fifth century BC that “There is geometry in the humming of
the strings. There is music in the spacings of the spheres.”
Since the time of the ancient Romans, music has been a basic art, large-
ly used in the recovering process. This is very well-represented by the Greek
and Roman god Apollo, who was a master of both music and medicine.
During medieval times, the tradition of monastic chants developed. The
Benedictine Order, which embraced communal living, supported their ill or
dying community members through formal musical rituals.
Today in the Western world, most doctors and people consider chants,
music, and medicine to be different methods belonging to completely sepa-
rated fields. We never hear things like “you are in your awareness, what you
are listening to” or “let the music be your medicine.”
In the 1800s, the era of romanticism in music, some composers and
music critics, argued that music should and could express ideas, images,
emotions, or even a whole literary plot. In 1832, composer Robert Schu-
mann stated that his piano work “Papillon” was “intended as a musical rep-
resentation” of the final scene of Flegeljahre, a novel by Jean Paul. A group of
modernist writers in the early twentieth century, including Walter Pater and
Ezra Pound, believed that music was essentially pure, because it did not rep-
resent anything or refer to anything beyond itself. Bucknell (2002) disagreed
with this view and argued against the alleged purity of music in the classic
work on Bach, stimulating our emotions and imagery.
At McGill University (Montreal, Canada), two fMRI experiments, ex-
plored the neural substrates of a musical imagery task that required manipu-
lation of the imagined sounds: temporal reversal of a melody. Musicians
were presented with the first few notes of a familiar tune (Experiment 1) or
its title (Experiment 2), followed by a string of notes that was either an exact
or an inexact reversal. The task was to judge whether the second string was
correct or not by mentally reversing all its notes, thus requiring both main-
tenance and manipulation of the represented string. Both experiments
showed considerable activation of the superior parietal lobe (intraparietal
sulcus) during the reversal process. Ventrolateral and dorsolateral frontal cor-
tices were also activated, consistent with the memory load required during
246 Clinical Hypnosis in Pain Therapy and Palliative Care

the task. They also found weaker evidence for some activation of the right
auditory cortex in both studies, congruent with results from previous simpler
music imagery tasks. They interpreted these results in the context of other
cerebral transformation tasks, such as mental rotation in the visual domain,
which are known to recruit the intraparietal sulcus region, and they proposed
that this region, subserves general computations that require transformations
of a sensory input.
Mental imagery tasks may thus have both task or modality-specific com-
ponents as well as components that supersede any specific codes and instead
represent an amodal mental manipulation (Zatorre, Halpern & Bouffard,
2010).
Sound has, therefore, been with us throughout the evolutionary process,
and it is an integral part of all our activities. Music is a product of sound and
is, therefore, a natural outcome of this evolutionary process.
Each single element in the universe is in a state of constant physical
vibration that becomes apparent to us as light, sound, or music. The human
senses can be aware of only a fraction of the infinite scale of vibrations.
In Western science, sounds, music, voice, and silence are seen as air
vibrations that can vary in specific frequencies measured in Hertz, which
includes the entire range of audible or inaudible sounds.
Let us consider the electron, the molecule, or any bigger form of matter.
We know that each form of matter constantly emits some kind of energy.
Each form has its own characteristic resonance or “radiation” in time and
space. The electron’s (or the molecule’s) typical radiations are well-known
and have already been the subject of several studies. We can suppose that
this pulse or “sound” is characteristic of the same frequency band initially
emitted when the universe was created and that kept resounding.
The human senses can be aware of just a fraction of the infinite scale of
vibrations. In fact, our ears can perceive only few frequencies that we can
also use to produce various genres of music. What we feel as music is a men-
tal content generated by the ears and the brain, responding to external vibra-
tion stimuli. These stimuli cause the musical perception but are substantially
different than is. Because each person is unique, cerebrally and psychologi-
cally, each has his or her own particular way to respond to the external stim-
uli, having thus a more or less distinctive experience from listening to the
same piece of music.
It is impossible to express objective and absolute judgments about a tune
in the absence of a reference version of it; in a certain sense, there are as
many versions as there are listeners. We may say that what we call music,
and its beauty (or feeling), exists only in the subjectivity (the minds) of the
listeners.
 Clinical Hypnosis, Mindfulness, and Music Therapy 247

Music is generated by the brain from external stimuli, and because they
are aesthetic sensations, they are based on our mental musical content. Cer-
tainly sometimes the environment (at visual andv social levels and emotions)
in which the listening takes place has a certain influence on the listening. The
biological and psychological structure of the listener may also enter into
play; it creates the mental representations of the environment and feelings.
Thus, generalizing, it is very improbable that two or more persons can
have identical listening experiences of a sound. The next frontier in the re-
search on awareness could be represented by the discover of the effects of
music and rhythm on the brain functions. Recently, the interest has been
mainly focused on

• Music to increase the learning process

• Music therapy
• Emotional reactions to music
• The connection between tonality and physics
• The beneficial and pathological effects of certain sounds and/or
rhythms
• Music has been a help or supplement to meditation practices and to
different state of consciousness.

Steven Halpern, musician and director of the Palo Alto Spectrum Research
Institute (California), believes that “dissonance can literally knock out the
body’s tuning.” Halpern argues that “noises, even the ones under the thresh-
old of consciousness, could provoke a permanent tension which irritates both
mind and body in a substantial way.” His label produces a specific genre of
music aimed to counter this effect.
Music involves the right hemisphere of the brain. This could explain its
effectiveness in therapy. Harmonic sounds are a logarithmic sequence,
acoustically perceptible and traceable in each single sound (as the sound of
wind, the murmuring of a stream, a musical instrument, the human voice).
In each of these sounds, there is an ascending and infinite harmonic se-
quence as the prime numbers. This harmonic sequence is not clearly per-
ceptible by the average human ear, for the most part, subjugated by a mind
that is not very aware (Silva, 1999).

2. NEUROPSYCHOLOGY OF MUSIC

What is music? What is silence?

Silence transcends thoughts, concepts, images, and reasoning. It is a state
248 Clinical Hypnosis in Pain Therapy and Palliative Care

of consciousness, in which there are no words or images. In silence, any

words or images should merge from inside and not from outside. Silence
recharges our body and mind.
In psychology, we can look for silence in two ways: inner silence and
outer silence. Outer silence helps us to find inner silence. Inner silence is
more precious, however. There are two kinds of inner silence: passive and
active. In passive inner silence, the heart and mind are at rest at the uncon-
scious level, whereas in active inner silence, the heart and mind are at rest at
the conscious level.
Modern life, with all its distractions and features, seems particularly
unsuited to silence. Even if we have actual outer silence, our mind is rarely
silent. If we analyze our thoughts, there seems to be a never-ending stream
of worries, anxieties, and regrets. In clinical hypnosis and in mindfulness, we
try to do a very difficult thing, silence our thoughts completely. It is difficult
only because we are so unused to this idea. The mind is so used to thinking
that it is easy to think and our existence is defined by our thoughts, and this
must be our only existence.
Descartes said, “I think, therefore, I am.” Clinical hypnosis and mindful-
ness, however, teach us, that what we are is unencumbered by thoughts. The
real “I” is ourselves, which is beyond thought. There is some inner self that
can decide whether to pursue thoughts or not. It is when we are able to stop
thoughts entering our mind that we will start to experience real silence.
In musical theory, silence is not always referred to as the point where
musical sounds actually cease to exist. Moments of silence are experienced
during sustained fermatas and extreme pianissimos or when a complex har-
mony dissipates into a sparing use of the tone material.
Cage says there is no such thing as silence. If so, what is what we thought
was silence? Is silence sound? Music? Emotions? Mindfulness? Silence is not
just the canvas on which music is painted. Music and silence move humans
to a deeply interiority. Music and silence calm the mind and produce a great
sense of well-being and energy. Music and silence have the ability to affect
our emotions, intellect, and psychology; lyrics can assuage our loneliness or
incite our passions. Some kinds of music and silence could be used to help
patients in relief of pain and suffering.
Emotion, in its most general definition, is an intense mental state that
arises autonomically in the nervous system, rather than through conscious
effort, and evokes either a positive or negative psychological response. An
emotion is often differentiated from a feeling.
According to Plutchik (1980), feeling can be viewed as the subjective
experience of an emotion that arises physiologically in the brain. As such,
music is a powerful art of feelings, whose aesthetic appeal is highly dependent
 Clinical Hypnosis, Mindfulness, and Music Therapy 249

on the culture in which it is practiced. Many psychologists adopt the ABC

model, which defines emotions in terms of three fundamental attributes:

A. physiological arousal;
B. behavioral expression (e.g., facial expressions);
C. conscious experience, the subjective feeling of an emotion.

All three attributes are necessary for a full-fledged emotional event, although
the intensity of each may vary greatly.
Some scientists make the following distinctions among affect, feeling, and
emotion:

• affect is an innately structured, noncognitive appraising sensation that

may or may not register in consciousness
• feeling is affect made conscious, possessing an evaluative capacity that
is not only physiologically based but also often psychologically (and
sometimes relationally) oriented
• emotion is a psychosocially constructed, dramatized feeling

Some of the aesthetic elements expressed in music include feelings, emo-

tions, lyricism, harmony, hypnotism, resonance, playfulness, and colors.
Music and science may seem to inhabit different universes, one of beauty
and emotion, the other of logic and reason. Now, however, neuroscientists
are placing them in the same solar system.
Norman M. Weinberger, professor of neurobiology and behavior at the
University of California at Irvine has explained that new researches are
beginning to reveal the role of music in brain function and in our lives. He
explained that a particular chunk of brain is musical. It is complex because
music has many elements: rhythm, melody, and so on. For example, certain
cells in the right hemisphere respond more to melody than to language.
Neurons learn to prioritize some sounds. This finding revolutionized think-
ing about brain organization by showing that learning is not a “higher” brain
function but rather one that occurs in the sensory systems themselves.
Music exercises the brain. Playing an instrument, for instance, involves
vision, hearing, touch, motor planning, emotion, and symbol interpretation,
all of which activate different brain systems. This may be why some Alz-
heimer’s patients can perform music long after they have forgotten other
things (Ruytjens, Willemsen, Van Dijk, Wit & Albers, 2006).
Music psychologists investigate all aspects of melodic behavior by apply-
ing methods and knowledge from all aspects of psychology. Because music
reaches a deep, nonrational part of the human spirit, it is ideally suited as an
250 Clinical Hypnosis in Pain Therapy and Palliative Care

adjunct service that can affect feelings such as grief, fear, anxiety, sadness,
and anger that stand in the way of a clear passage. Music can release blocked
or painful feelings and can stimulate positive ones, such as hope, love, and
gratitude. Sharing music together, can lead to sharing of the emotions that
the music brings up.

A. The Main Psychophysiological

Elements of Music in Assagioli’s Studies
A scientific music therapy should be founded on the exact knowledge of
each single musical element and on the effect that each of these elements
produces, both on the physiological functions and on the psychological con-
ditions. Concerning this last regard Assagioli’s studies about music therapy
are extremely interesting.
Roberto Assagioli (1888-1974) was the first Western psychologist to incor-
porate psychology, feelings, and spirituality into an overall view of the
human psyche. He began psychosynthesis in 1910. He wanted to expand be-
yond Freud’s analysis and “talking cure.” He added synthesis and a broader
use of our human abilities, such as will, imagination, and intuition. He in-
cluded even our spiritual side, our higher aspirations, and our center, which
he called the self. People use psychosynthesis as a way of life and in a wide
variety of fields, such as education, psychology, business, and spirituality.
Psychosynthesis offers delightful tools for many purposes: embracing
opposed parts of our inner worlds, enriching each other with our differences,
making groups and organizations function with greater purpose, and enjoy-
ing a respectful interchange with the world that envelops us. The main goal
of the broad-ranging theory and methods of psychosynthesis is to enhance
the full range of human experience and support our movement toward self-
realization (Assagioli, 1977).
According to Assagioli, the main psychophysiological elements (that we
can find in music) are (1) rhythm, (2) tone, (3) melody or tune, (4) harmony,
and (5) timbre.

1. Rhythm. The primordial and fundamental element of music, rhythm

influences the human being more intensely and immediately. This great
influence is basically due to direct action on body and emotions. Organic life
is based on the different kind of rhythms: the rhythm of breathing and heart.
Therefore, it should not come as a surprise that the musical rhythms exert a
powerful influence on those organic and psychological rhythms, at times
stimulating them and sometimes calming them, creating either harmony or
inconsonance.
 Clinical Hypnosis, Mindfulness, and Music Therapy 251

2. Tone. Each note, while it is physically produced by a specific vibratory

frequency, generates particular psychological and physical effects.
3. Melody. The combination of rhythms, tones, and accents produces
those musical “units” called melodies. Melodies, being a synthesis of various
musical elements, are very suitable means to express emotions.
4. Harmony. Whereas melody is produced by a succession of sounds, har-
mony is created by the superimposition of various notes and different vibra-
tory frequencies.
5. Timbre. Various musical instruments, including the human voice, are
very different in nature and structure. This gives a peculiar quality to the
sound, which, therefore, generates very specific emotional reactions.
We can use all these elements in clinical hypnosis and in mindfulness,
with the association of music, silence and our voice. Through the rhythm and
the sweet sound of music, silence, and voice, in clinical hypnosis and mind-
fulness, and through the rhythm and emotions of our verbal suggestions of
calm . . . tranquility . . . comfort . . . more and more intense . . . more and
more profound . . . (and pauses of silence . . .) holding us in a warm embrace
. . . we can create an indirect hypnosis, in the patient. We can help a patient
stir up a positive thought about pleasant emotions, so to diminish the per-
ception of pain and suffering.
Rhythm and sound in music can acquire different values when they
come in contact. In general, with the word rhythm we indicate a regular suc-
cession (in a certain period of time) of sounds, cadences, and movements. In
harmony terms, this concept can be further specified: with the term rhythm
we indicate the succession of the accents and their position in the musical
phrase or simply the structure of the musical beat. Cyclicity indicates the
modalities of the recurring repetition of the rhythmic phenomenon. The
cyclic irregularities can have a strong expressive meaning, especially when
they modify an otherwise regular rhythm.
Music provides tools that patients can learn to use to decrease their expe-
rience of pain and suffering at the end of life. In almost all cases, this should
occur within the context of a setting that includes medical and psychological
support and education.
Alteration in the experience of pain can include changes in affect, as well.
Willmarth (1998) demonstrated that hypnotic modification of mood also re-
sulted in changes in the perception of pain. As we said, music can also be
used as a powerful curative or healing element.
As Assagioli underlines, “There are several ways in which it (i.e., music)
can exert a beneficial influence on the body and on the soul. First of all, the
effect of music can be relaxing and comforting” (Assagioli, 1977). It is not
necessary to emphasize how this can be valuable in these days of physical ex-
252 Clinical Hypnosis in Pain Therapy and Palliative Care

haustion, nervous strain, and mental and emotional excitation. A period of

rest is the generic and obvious prescription in order to eliminate such con-
ditions. Chronic pain often requires more effort, but music, hypnosis, and
mindfulness provide many individuals with a way to experience focused,
narrow attention that redirects attention to thoughts or memories more
pleasant than the pain. We can use music with or without hypnosis and mind-
fulness in pain therapy.
We can measure the physiological parameters causing or maintaining
pain. These parameters may include excessive muscle tension or improper
breathing, among others (Sherman, 2004).
The studies on the mechanism of suggestions and on the importance of
the subconscious in the psychic life have demonstrated that unconsciously
received impressions can have broad positive (or negative) repercussions,
not only on the psyche, but also on the body (Assagioli, 1977).
Music is a real “spiritual alchemy,” able to transform the most resistant
and dark pain to some sort of “sweeter” pain, and then into acceptance, and
lately even into joy, self-expansion, and even an expansion of personal
awareness.
Therese Schroeder-Sheker developed a field, specifically of music in pal-
liative care, called “music thanatology.” The term thanatology is derived
from “Thanatos,” the Greek god of death. Music thanatology sometimes is
used in a strict sense to refer to a specific way of using live harp music at the
bedside of acutely dying patients. Music thanatologists view their work as a
compassionate, spiritual, and contemplative practice. Music thanatology
does not presume that the listener has a reserve of energy that can respond
actively to the music. A person who is actively dying may be very weak, with
limited communication capacity. In some cases, the person may be comatose
or in an altered state of consciousness on the threshold of death.
Music in pain therapy and palliative care recognizes the need to care for
the whole person, including mind, body, and spirit. The principles that
should govern care at the end of life are well-accepted. They include respon-
siveness to the patients’ wishes—truthful, sensitive, empathic communication
and meticulous attention to the physical, spiritual, and psychosocial needs of
patients and family (American Society of Clinical Oncology, 1998). Music
applied to the experience of pain and suffering at the end of life permits a
clinician to address the source of felt pain and the perception of pain itself.
With the use of hypnosis, we have studied that “pain is real if you feel it.”
“Why suffering? Does my doctor think this pain is all in my head and in
my mind?” These are not uncommon questions from patients who have been
referred for behavioral medicine services connected to a pain management
program.
 Clinical Hypnosis, Mindfulness, and Music Therapy 253

Before one can begin using hypnosis, music, and mindfulness for pain
management, the properties of the pain itself must be considered. In his
excellent book Pain Assessment and Intervention from a Psychophysiological
Perspective, Rich Sherman (2004) points out that the simplest classification,
considers pain as either inflammatory or neuropathic. This system focuses
primarily on identifying the underlying cause of the pain. No one can argue
that identifying the source of pain is not a wonderful achievement. Unfor-
tunately, in the real world of pain management, two obstacles appear.
First, in spite of numerous new diagnostic imaging and assessment tools,
we still often fail to identify the cause of pain.
Second, often, when we do identify the problem generating the pain,
there is nothing that can be done to directly “fix” the problem.
It is the perception of pain and the individual’s physical and emotional
reaction to the pain perception that give us the opportunity to create treat-
ment approaches that can provide relief. The underlying principle of music
in pain therapy and in palliative care focuses on improving the patient’s
physical, psychological, and spiritual comfort and quality of life.
In whatever setting it is administered, palliative care is generally provid-
ed by an interdisciplinary team, which may include physicians, nurses, social
workers, home-health aides, pharmacists, chaplains, physical and occupa-
tional therapists, musicians, and trained volunteers (Last Acts®, 2001).
To better describe and provide care with music during the current chron-
ic trajectory that many cancer patients experience, it will be necessary to
integrate palliative and supportive efforts long before patients are within
days to hours of dying. For example, advance care planning with music may
be beneficial after diagnosis and after treatment has begun, when the patient
feels less anxious.
Improving the quality of end-of-life care for patients will require the
improved awareness, knowledge, and skills of the health professionals who
provide their care. Patients would benefit greatly from end-of-life care re-
sources, with music made available in a wide variety of settings.

B. Music as Help and Supplement to Clinical Hypnosis

and Mindfulness in Pain Therapy and Palliative Care
The music is offered uniquely for the needs of that patient. If family or
friends are present in the room, naturally they will also react to the music.
The entire group present may be affected, but the process of creating the
music is primarily guided by the state of the patient.
People who use music in health care are convinced that music can have
somatic benefits when used as one component of holistic multidisciplinary
254 Clinical Hypnosis in Pain Therapy and Palliative Care

palliative care. Creating a supportive musical field, may be helpful to the pa-
tients who are anxious to calm down or become more at peace. Many scien-
tific studies have demonstrated that music with or without therapeutic sug-
gestions (as clinical hypnosis) may have some beneficial effects on pain.
At Linköping University, Sweden, Nilsson, Rawal, Enquist, and Unosson
(2004) demonstrated that music with or without therapeutic suggestions in
the early postoperative period has a beneficial effect on patients’ experience
of analgesia. They have also observed that intraoperative music and music in
combination with therapeutic suggestions may have some beneficial effects
on postoperative recovery (Frid, Berezkin, Evtiukhin, Beliaev & Aleksandrin,
1981; Nilsson, Rawal, Uneståhl, Zetterberg & Unosson, 2001).
In recent years, Tsao and Zeltzer at David Geffen School of Medicine at
UCLA, studied the use of complementary and alternative medicine (CAM)
in pediatric populations. The efficacy of the CAM interventions was evalu-
ated according to the framework developed by the American Psychological
Association (APA) Division 12 Task Force on Promotion and Dissemination
of Psychological Procedures. According to these criteria, only one CAM
approach reviewed herein (self-hypnosis/guided imagery/relaxation for re-
current pediatric headache) qualified as an empirically supported therapy,
although many may be considered possibly efficacious or promising treat-
ments for pediatric pain. Several methodological limitations of the existing
literature on CAM interventions for pain problems in children are highlight-
ed and future avenues for research are outlined (Tsao, 2005).
Distraction with music therapy may facilitate habituation to painful stim-
uli (Arntz, Dreessen & Merckelbach, 1991), perhaps because engaging in an
alternative, attentionally demanding task limits the capacity to process pain,
thereby reducing pain sensitivity (Farthing, Venturino & Brown, 1984). In an
early study, Fowler-Kerry and Lander (1987) compared the following four
conditions on injection pain in 200 children (age 4.5–6.5 years): (1) music
distraction (music played over headphones before and during injection), (2)
suggestion (verbal instructions that the experimenter would help the child
during the injection), (3) distraction plus suggestion, and (4) two control
groups (i.e., no intervention; headphones without music). Music distraction
was superior to a suggestion in reducing pain. More recently, another study
(Megel, Houser & Gleaves, 1999) in ninety-nine children (age 3–6 years)
found that those who listened to lullabies during immunization showed fewer
behavioral distress than no intervention controls, although the groups did
not differ on physiological responses or reported pain.
Another study examined the effects of live music therapy for pain relat-
ed to intravenous starts, venipunctures, injections, and heel sticks in twenty
pediatric patients age 0–7 years and twenty children matched for age and
 Clinical Hypnosis, Mindfulness, and Music Therapy 255

type of needle insertion who did not receive the intervention (Malone, 1996).
The results indicated that the music group showed less behavioral distress
than the control group during pre-needle and postneedle stages.
Music may be considered a promising intervention for procedural pain
(American Society of Clinical Oncology, 1998).
Before the music performance, it is necessary for the patients to be in-
formed about the piece and its effects so that they can contribute to the influ-
ence of the music on their consciousness. It is advisable to have the patients
relax, before and during the performance, in order “to open the doors to the
unconscious.”
According to Assagioli (1977), there is a specific psychosynthesis process
feasible even through music, constituted of three stages:
Spiritual psychosynthesis produces the inclusion and the integration of
superior psychospiritual elements (higher self or higher consciousness) in the
conscious personality. Good examples of this kind of music are the Greg-
orian chant; Palestrina’s compositions; and the music of some great com-
posers, such as Bach, Handel, Wagner, César Franck, and Scriabin.
Interindividual psycho-synthesis takes place between individuals and other
people belonging to a group to which they belong (interaction therapist-
patient or self-help groups). In this situation, the consciousness of the single
individual embraces in a harmonic relationship, all humanity.
We may mention Beethoven’s Ninth Symphony, which reaches its apex
with Schiller’s words “Seid umschlungen, Millionen” (Be embraced, mil-
lions).
Cosmic psychosynthesis consists of increasing the individual’s acknowledg-
ment and acceptance of the laws governing the relationship and rhythms of
the life of the universe itself: spirituality and the relationship between life and
death.

3. MUSIC AND THE HIGHER CONSCIOUSNESS

This is where all our higher feelings and thoughts enter consciousness,
such as artistic or scientific intuition and inspiration. All our noble ethical
feelings, such as altruistic love or self-sacrifice, are derived from this higher
consciousness. It is also the place of genius and higher spiritual forms, such
as ecstasy and the power of enlightenment. Here, the hidden psychic ener-
gies are enormous.
The music choice requires a great care for the different effects it can pro-
duce in the unconscious. Each person can react differently to the same piece,
according to his or her experiences, emotions, and background. The analo-
256 Clinical Hypnosis in Pain Therapy and Palliative Care

gies traceable in physics, biology, astronomy, and acoustics are of great inter-
est for us.
History tells us that Pythagoras introduced his disciples to mathematical
and astronomical theories using the monochord, and it is well-known that
Kepler used this instrument for his studies and his “harmonic model” of the
universe. This is coherent with the most recent discoveries. The latest theo-
ries of important physicists, such as Bohm and Sheldrake, describe a universe
in which the smallest particles are not to be considered as matter but instead
as pure energy. This takes us back to considering the acoustic phenomenon
as the sound and silence, pure energy.
The allusion of various mystical traditions, unanimous in affirming that
at the origin of the creation there was the “Logos,” or the Word or that the
creation is nothing else than a mantra, does not seem to be accidental.
A Tibetan tradition says that elements are the essence of the universe, the
essence of the elements is color, the essence of color is light, that the essence
of light is sound. We could agree here with Bohm, who says that the origin
of matter is not matter itself but vibration or pure energy.
Great music moves humans and gods alike, deeply. Music calms the
mind and produces an extreme sense of well-being and euphoria. One also
gets a similar experience during deep meditation and samadhi.
In the beginning was the Word. Almost all the great religions of the
world talk about it. In Patanjali’s Yoga Darshan, Ishwara is defined as a spe-
cial Being who is expressed by the original word Pranav.

Life should be happiness and if you’re not happy, you’re wasting your existence
and the time remaining you to live your life. Happiness is the final goal of cre-
ation and evolution and his expansion. Therefore, have you to consider it if you
decide to undertake any action. If it derives no happiness from an action, this
action fails its very own goal, and his accomplishment cannot be justified.
(Bhagavad-Gita)

What that original word was nobody is sure although in major yoga com-
mentaries, it is called “om.” Recently, however, scientists have discovered
that very soon after the Big Bang, and before anything else appeared in the
universe, primordial sound waves were produced. This could have formed
the basis of Brahma Nad, mentioned in the Upanishads. Sound has, for that
reason, been with us throughout the evolutionary process and is an integral
part of all our activities. Music is a product of sound and is, therefore, a nat-
ural outcome of this evolutionary process.
Music affects the brain at different levels. Our moods change with dis-
tinct types of music. At a deeper level, however, its effect is similar to that of
meditation. This is probably why all great religions have stressed the need
 Clinical Hypnosis, Mindfulness, and Music Therapy 257

for music as a means for praying and meditation. Hindu classical music, one
of the oldest musical systems of the world, has spiritual roots and traces its
origins to Vedic hymns. Similarly, in other religions, harmonious chants,
hymns, and other forms of music have been used since ancient times to
express the glory of God or to help focus the mind on the transcendent
thoughts.
Recent PET studies conducted by scientists have shown that certain
types of music activate neural pathways similar to those associated with
euphoria and reward. Although fMRI is replacing PET in many neuroimag-
ing studies, PET still holds unique advantages and can give us valuable
knowledge about the auditory cortex and auditory perception (Ruytjens et
al., 2006). These same pathways are activated in response to other pleasur-
able activities that give emotional happiness. Similarly, in deep meditation,
the mind focuses on a single thought for a long time. Thus, when contem-
plation, reflection, and samadhi (together called sanyam according to Patan-
jali’s Yoga Darshan) are done on a single thought, it produces the sense of well-
being and happiness.
In this process, a major portion of the 100 billion neurons of the brain
are being used in a laser-like fashion for a single thought. This deep medita-
tion process helps stimulate or “tickle” the pituitary gland, which gives the
feeling of well-being. The exact mechanism, however, is still not understood.
When we hear soul-stirring music, we feel good, very like what we feel dur-
ing deep meditation. This is the principle of equivalence. The brain, therefore,
appreciates and absorbs the music by creating the same complex thought pat-
tern as that during meditation. Similar effects are also seen in different types of
music, which stimulate feelings of anger, sadness, and other emotions.
Music

• It reaches the deepest levels of sensations and consciousness

• It obtains greater clarity and insight
• It enters higher states of awareness
• It reduces stress and anxiety
• It deepens your spiritual connection

A. Music and the Self-Hypnosis Technique

Music, in a modified state of consciousness and in hypnosis, provides all
the benefits of profound meditation without endless hours of discipline.
Within minutes, you feel yourself lifted from physical tension and mental
anxieties. As stress dissolves, you feel a higher, more refined energy moving
through your body. A powerful combination of brain wave frequencies
258 Clinical Hypnosis in Pain Therapy and Palliative Care

guides you into the extraordinary self-hypnosis state known as body asleep-
mind awake. While your mind vibrates in resonance with the music, it be-
comes balanced, energized, and open. You feel refreshed, revitalized, and
nourished at the deepest levels.
Self-hypnosis techniques with music are not new. They have been around
for thousands of years. Anyone can do self-hypnosis, regardless of religious
or cultural background. Consider these suggestions to get you started:

• Select a hypnosis technique that fits your lifestyle and belief system
and a music you like. Many people build self-hypnosis into their daily
routine.
• Set aside some time. Start with 5-minute relaxation sessions once or
twice a day and work up to 20 minutes each time.
• Keep trying. Be kind to yourself as you get started. If you are relaxing
and your attention wanders, slowly return to the object, sensation, or
movement you are focusing on.
• Make relaxation and self-hypnosis part of your life.

Many people prefer to start and end their day with a period of relaxation.
Others prefer to take relaxation breaks during the day. Experiment and find
out what works best for you.
We live in a universe of infinite complexity, and many forces operate on
us. Yes, it is true that we are not in control of everything that happens be-
cause we are not in control of most of those infinite other parts of the uni-
verse. In fact, the only thing you have total and complete control over is your
own mind.
Listening to music increases your ability to be consciously aware. As you
continue with the program, doing this becomes easier and more automatic.
That “watcher” part of you becomes stronger and stronger until it is watch-
ing over everything, and with that degree of conscious awareness, it is pret-
ty difficult to create anything that is not beneficial for you.
Some of the motives for which we can use music and self-hypnosis are

1. To relax the body and mind and to rejuvenate one’s flow of energy
in order to more effectively face the responsibilities of one’s demand-
ing and active life.
2. To heal illnesses (especially psychosomatic ones).
3. To overcome emotional problems.
4. To develop a more relaxed and positive view towards life.
5. To develop a peaceful and more clearly functioning mind.
6. For greater ability to penetrate into the core of problems and find
 Clinical Hypnosis, Mindfulness, and Music Therapy 259

inspirational solutions. This has been found especially useful by sci-

entists and businessmen.
7. To increase relief of pain and suffering.
8. As a method of self-observation and self-discovery.
9. To develop the latent powers of the mind.
10. Locus of Self. The experiencing of one’s self borrows from several di-
mensions, some physical, some psychological, others spiritual.
11. Complete word silence in the context of profound peacefulness.
12. Perceptible lapses in the experience of the continuity of time.
13. Sensation of the irrelevance of time passing, in the context of feeling
enlightened by this new perception.
14. Nonduality.
15. Higher Consciousness.

With music, you learn that you are your mind, body, spirit, and emotions
and that you are not separate from everything else. Once you begin to expe-
rience the fact that everything is connected in an infinitely complex matrix
and an infinitely complex dance of creation and that you are that dance,
something shifts.
The pioneering studies of Dr. Marcel Vogel and Irzhak Bentov revealed
that, in a state of deep relaxation or meditation, the electromagnetic field sur-
rounding our head literally attunes to the basic electromagnetic field of the
earth itself. The earth’s harmonic resonance has been measured at approxi-
mately eight cycles per second, or 8 Hz. The frequency range of the electri-
cal activity of the brain that we access in states of deep relaxation is also cen-
tered around 8 Hz. Is this correspondence just a coincidence? Perhaps that
is why we feel so rejuvenated when surrounded by nature in a forest, in the
mountains, or by the ocean. Perhaps this is also a key to understanding how
our inner and outer environments can be orchestrated to a higher level of
harmony. At this point, the search for what to be or do, where to go, what to
avoid or get, or what to change in order to be happy and peaceful ceases.
Exploring the inner space of the human spirit has to equal the explo-
ration of outer space. Music, silence, mindfulness, hypnosis, and self-hypno-
sis all have the capacity to reach special states of the mind, which center up-
on an universal consciousness.
Indeed, hypnosis may be called the most potent nonpharmacological
relaxant known to science. They may seem like separate entities. On closer
look and in their long-term practice, however, they are found to share com-
mon principles. Most importantly, they all can bring to light the knowledge
of higher self: comprehension, relaxed self-control, relief of pain and suffer-
ing, existential centeredness, and spiritual blossoming in dying patients.
260 Clinical Hypnosis in Pain Therapy and Palliative Care

4. MUSIC AND MINDFULNESS

Each single element in the universe is in a state of constant vibration that

becomes apparent to us either as light, or sound, or music. At the beginning,
there were aeons of silence. From the Big Bang to the whole universe, every-
thing could be interpreted as music.
In many gnostic systems, the various emanations of God, who is also
known by such names as the One, the Monad, Aion teleos (The Broadest
Aeon), Bythos (“depth or profundity”), Proarkhe (“before the beginning”),
the Arkhe (“the beginning”), are called aeons. This first being is also an æon
and has an inner being within itself, known as Ennoea (“thought, intent”),
Charis (“grace”), or Sige (“silence”). Along with the male Caen comes the
female æon Akhana (“love”).
What is silence? Aeons? Love? Music? It is to retreat in wordless inner
self, gazing out the window of our heart and going for slow meandering
walks through a garden. Silence transcends thoughts, concepts, images, and
reasoning. It is a higher state of consciousness in which there are no words
or images. There is a time for silence. There is a time to let go and allow peo-
ple to hurl themselves into their own destiny. There is a time to prepare to
pick up the pieces when it is all over.
According to the philosopher Plato, there are five mathematical sciences:

1. Arithmetic
2. Plane geometry, or the study of numerical proportions
3. Three-dimensional geometry, including the “Platonic Solids”
4. Astronomy
5. Music, which illustrates the harmonious composition of the universe

Near the end of Kant’s book on the structure of the cosmos, he declared,
“In the universal silence of nature and in the calm of the senses, the immor-
tal spirit’s hidden faculty of knowledge, speaks an ineffable language and
gives (us) undeveloped concepts, which are indeed felt, but do not let them-
selves be described.”
Mindfulness is an open, kind, nonjudging attention to what is happening
in the present moment as it is happening. It shapes a wise and compassion-
ate relationship with and response to experience as it unfolds moment by
moment. This is a moment-to-moment intimate spiritual experience. When
we are in silence, all that becomes moot. In silence, nothing more is needed.
Spiritual teaching should always be received with caution and ambiva-
lence, by teachers and students alike. When we attempt to convey spiritual
truth, we are tending towards transcendent meaning. Transcendence, by def-
 Clinical Hypnosis, Mindfulness, and Music Therapy 261

inition, is above or beyond the separative, cognitive world of words and con-
cepts. Mental cognition imposes structure and form, which clarify most areas
of knowledge. Spirituality and transcendence, however, are always compro-
mised by description and definition. We might try to convey the ecstatic
qualities of great music, but words, at best, will lead only to a pale imitation
of what they attempt to describe. As Krishnamurti pointed out, “The descrip-
tion is never the described.” You have to experience and be affected by art
and nature to truly commune with them.
At the beginning, there were aeons of silence. In the beginning was the
Word. What that original word was nobody is sure, although in major yoga
commentaries, it is called “om.”
Recently, however, scientists have discovered that very soon after the Big
Bang and before anything else appeared in the universe, primordial sound
waves were produced. This could have formed the basis of “Brahma Nad,”
mentioned in the Upanishads.
The Om (or Aum) sign and sound are the main symbols of Hinduism.
Most religions indicate that creation began with sound. For the Hindus and
Buddhists, Om is the primordial sound, the first breath of creation, the vibra-
tion that ensures existence. Om sign and sound signify God, Creation, and
the Oneness of all creations. This mystical and sacred Hindu word Om is the
highest mantra (chant), symbolizing the vibration of the Supreme and of di-
vine energy (Shakti). It is believed that the whole universe, in its fundamen-
tal form, is made up of vibrating, pulsating energy and Om is considered the
humming sound of this cosmic energy. It means oneness and a merging of
our physical body with our spiritual being. The great Hindu sage Patanjali
once said, “He who knows Om, knows God.” Using Om or Aum is a way of
deepening the concentration of the mind.
Sound has, therefore, been with us throughout the evolutionary process
and is an integral part of all our activities. Music is a product of sound and
is, therefore, a natural outcome of this evolutionary process. This is probably
why all great religions have stressed music as a means for praying, mantra,
and meditation.
A mantra is a spiritual word, poem, or prayer repeated during medita-
tion. Traditionally, mantras are used by Hindus and Buddhists as a means to
focus the mind and attain a form of spiritual enlightenment or realization.
The repetition of a mantra that has either a spiritual significance linked to a
sacred text or a personal significance allows the individual to consistently
explore and reflect upon spirituality on a subconscious level. At the same
time, deep focus on a single phrase helps to clear the mind, restoring it to a
state that is free from the physical and time-bound concerns of our everyday
life.
262 Clinical Hypnosis in Pain Therapy and Palliative Care

Om begins many Hindu mantras and is also used by Buddhists. The

Buddhist mantra “Om Mani Padme Hum” is one example of a mantra for
which Om is the root.
Indian classical music, one of the oldest musical systems of the world, has
spiritual roots and traces its origins to Vedic hymns. In other religions, musi-
cal chants, hymns, and other forms of music have also been used since an-
cient times to express the glory of God or to help focus the mind on spiritu-
al thoughts.
Om is the most often chanted sound among all the sacred sounds on
earth. This sound is considered as the sound of the existence. It is believed
that the whole universe, in its fundamental form, is made up of vibrating,
pulsating energy. Om is considered as the humming sound of this cosmic
energy. Om is said to be the original primordial creative sound from which
the entire universe has been manifested. It is the primal sound of the uni-
verse that contains all sounds in itself. It is the sound of the supreme con-
sciousness. Om is said to be the essence of all mantras, the highest of all
mantras or divine word (shabda), Brahman (ultimate reality) itself. Om is
said to be the essence of the Vedas. By sound and form, Om (the sound is
Aum) symbolizes the infinite Brahman (ultimate reality) and the entire uni-
verse. A stands for creation, U stands for preservation, M stands for destruc-
tion or dissolution. Repetition of Om or Aum dissolves the mind it its divine
source.

A. Mindfulness and the Chanting of Om

Sit in a comfortable undisturbed place . . .
Take some deep breaths . . .
Now chant Om in succession at least seven times . . .
Make each breath last as long as possible . . .
Take deep breath and chant
Oooooo . . . hhhhhhhh . . . Mmmmmmm . . .
Then again, repeat this chanting of Om . . .
Do this for seven times . . .
After this, stop chanting and sit for a moment of silence . . .
You will be amazed by the inner peace you will get in such a small chanting of
Om . . .
Listen to the sound of universe . . .
Let us listen to the sound of Om . . .
You are requested to listen carefully . . .
This sound of Om produces instant positive vibrations and takes the listener to
a state of mental stillness . . .
 Clinical Hypnosis, Mindfulness, and Music Therapy 263

Thus when silence, contemplation, reflection, and samadhi (together

called Sanyam according to Patanjali’s Yoga Darshan) are done on a single
feeling, then it produces the sense of well-being and happiness. In this
process, a major portion of the 100 billion neurons of the brain are being
used in a laser-like fashion for a single thought.
In the Vedas, Om is the sound of the Sun, the sound of Light. Om is the
sound of nonduality. Silence is the sound of nonduality.

To understand how delusion arises, practice watching your mind.

Begin by simply letting it relax. Without thinking of the past or the future, with-
out feeling hope or fear about this thing or that, let it rest comfortably, open and nat-
ural. In this space of the mind, there is no problem, no suffering. (Chagdud
Rinpoche’s)

The Soul of Thoughts

The soul is dyed the colour of its thoughts.
Think only on those things that are in line with your principles
and can bear the full light of the day.
The content of your character is your choice.
Day by day, what you choose, what you think, and what you do is what you
become.
Your integrity is your destiny . . . it is the light that guides your way. (Heraclitus)

The separate self dissolves in the sea of pure consciousness, infinite and immor-
tal. Separateness arises from identifying the Self with the body, which is made
up of the elements; when this physical identification dissolves, there can be no
more separate self. This is what I want to tell you, beloved. (Brihadaranyaka
Upanishad, Chapter 2, 4:12)

As the rivers flowing east and west

merge in the sea and become one with it,
Forgetting they were ever separate rivers,
So do all creatures lose their separateness.
When they merge at last into pure Being. (Chandogya Upanishad, 10:1-2)

The Self who is free from sin, free from old age, from death and from grief, from
hunger and thirst, which desires nothing but what it ought to desire, and imag-
ines nothing but what it ought to imagine, that it is which we must search out,
that it is which we must try to understand. He who has searched out that Self and
understands it, obtains all worlds and all desires. (Chandogya Upanishad, 8.7.1)

According to the teaching of the Indian philosophy of Chandogya

Upanishad (Vedic text), there is no separate self, all is One. It is only illusion,
264 Clinical Hypnosis in Pain Therapy and Palliative Care

Maya, that clouds our vision. If we accept this premise, then we can say that
the absolute self, the one, or whatever name you give to the absolute princi-
ple, “creates” bodies and looks at its “creations” through the body’s eyes.
This causes the illusion of many selves. The absolute is one, homogenous
whole, but through illusion, delusion, ignorance, and wrong thinking, there
is a belief in separation of multitudes of units.
Music, silence, hypnosis, self-hypnosis and mindfulness all have the
capacity to reach special states of the mind that center on relaxation. Indeed,
mindfulness may be called the most potent nonpharmacological relaxant
known to science. They may seem like separate entities. On closer look and
in their long-term practice, however, they are found to share common prin-
ciples. Most importantly, they all can bring to light the knowledge of higher
self: comprehension, relaxed self-control, relief of pain and suffering, exis-
tential centeredness, and higher consciousness.
Look inside yourself and try to examine and be conscious of the feeling
or sensation you have of yourself. I mean just the feeling that you are alive
and existing. Concentrate on what you sense to be your essence.
This feeling of universal consciousness is actually always with you, no
matter what you are doing or where you are. It is an invariable and contin-
uous factor, but it is clouded by the five senses and by thoughts. It is not
something theoretical, metaphorical, or mystical. It is a fact. It is knowledge.
Inner silence is a peculiar state of being in which thoughts are canceled
out and one can function from a level other than that of daily awareness.
Inner silence means the suspension of the internal dialogue, the perennial
companion of thought, and is therefore, a state of profound quietude.

B. The Technique of Inner Silence

I become aware of the sounds around me . . .
where I am now . . .
Both near and distant sounds . . .
nothing bothers me any more . . .
my heart contemplates this peace . . .
Then, I imagine I am sitting on my favorite river bank . . .
and watching the whirlpools forming and dissolving in the water . . .
flowing before me . . .
I have no desire to interfere with or disturb the water or the whorls . . .
I am just witnessing the unfolding patterns as they arise and move on in the river
of mind . . .
Now I bring my awareness back to the sounds around me . . .
where I am now . . .
and I move on in the river of mind . . .
 Clinical Hypnosis, Mindfulness, and Music Therapy 265

and I move on in the river of mind . . .

I listen to the sound of my breathing . . .
I develop a dispassionate witness . . .
that doesn’t get involved in the experience . . .
that leaves it alone to unfold and surrenders to its effect in the body . . .
without limitation or judgment . . .
and move on in the river of mind . . .
and move on in the river of mind . . .
and listen to the sound of the breathing . . .
and silence . . .

Inner silence is the avenue that leads to a true suspension of judgment,

to a moment when sensory data emanating from the universe at large ceas-
es to be interpreted by the senses; a moment when cognition ceases. At the
beginning, there were aeons of silence. It is in the vessel of silence, that inner
transformation can appear.

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 Clinical Hypnosis, Mindfulness, and Music Therapy 267

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268 Clinical Hypnosis in Pain Therapy and Palliative Care

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 Chapter VII

CLINICAL HYPNOSIS, MINDFULNESS,

AND THE LANGUAGE OF METAPHORS

1. ALLEGORIES AND METAPHORS

IN POETRY AND SPIRITUAL VERSES

very time we read poetry or a meditative spiritual verse we are engaged

E in a miracle that we do not even recognize: the wind; a blue sky; white
clouds; green leaves; the black; curious eyes of a child; the unnatural atmos-
pheres; and feelings. Feelings, love and death—Eros and Thanatos, are the
themes of the play. Communication in clinical hypnosis is speech, feelings,
and emotions: the language plays a basic role in emotions.

Your soul is as a moonlit landscape fair,

Peopled with maskers delicate and dim,
That play on lutes and dance and have an air
Of being sad in their fantastic trim. (. . .)
The melancholy moonlight, sweet and lone,
That makes to dream the birds upon the tree,
And in their polished basins of white stone
The fountains tall to sob with ecstasy. (“Clair de Lune,” Paul Verlaine)

Don’t run after your thoughts . . . find joy and peace in this very moment
...
Mindfulness is not a discursive reflection on philosophy; it is a penetra-
tion of mind into mind itself. Images flow in a quick succession and often
swiftly change their field of reference: from science to theology, from astron-
omy to philosophy and to the soul.
Everything in poetry and metaphor could become a meaning and even
the meaning of meaning. Hypnosis, metaphors, and mindfulness can be the
power of emotions and the door to higher consciousness in relief of suffering.
269
270 Clinical Hypnosis in Pain Therapy and Palliative Care

A. Is Poetry Mindfulness?
Poetry is mindfulness, and we are told to set our minds on the higher
consciousness. Mindfulness or meditation is a spiritual practice that forms
part of the believer’s prayer life. It creates awareness and aligns our being to
the will and purposes of inner awareness. Spiritual verses in many different
religions involve more than just talking and asking God for things. It involves
listening and being filled with the streams of living water.
Through the practice of spiritual verses you can experience many bene-
fits:

• Quiet your racing thoughts

• Increase your ability to concentrate
• Increase creativity
• Increase wisdom
• Decrease generalized anxiety
• Reduce panic attack
• Promote a sense of well-being
• Keep you centered and rooted in love and truth
• Help you to understand life
• Give you peace of mind
• Help you make contact with yourself and discover who you really are.

As long as the Self is in bondage to the false personal self of evil, so long is there
not even a possibility of freedom, for these two are contraries. However, when
free from the grasp of selfish personality, he reaches his real nature; Bliss and
Being shine forth by their own light, like the full moon, free from blackness. But
he who in the body thinks “this is I,” a delusion built up by the mind through
darkness; when this delusion is destroyed for him without remainder, there aris-
es for him the realization of Self as the Eternal, free from all bondage. (Vedanta,
Verses 299–378).

Commit to the Lord whatever you do, and your plans will succeed.
(Proverbs, 16:3 NIV)

Delight yourself in the Lord and he will give you the desires of your heart.
(Psalms, 37:11 NIV)

The imagery in hypnosis, mindfulness, and spiritual care is a network

that has a great semantic and psychological relevance in verses, and it should
be not considered a mere decorative pattern superimposed on a given theme.
Hypnosis, mindfulness and spiritual care, are usually associated with sugges-
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 271

tions and allegories. In all the world, people know the inner strength of
Psalm 23:

The Lord is my shepherd, I lack nothing.

He makes me lie down in green pastures,
he leads me beside quiet waters,
he refreshes my soul.
He guides me along the right paths
for his name’s sake.
Even though I walk
through the darkest valley,
I will fear no evil,
for you are with me;
your rod and your staff,
they comfort me.
You prepare a table before me
in the presence of my enemies.
You anoint my head with oil;
my cup overflows.
Surely your goodness and love will follow me
all the days of my life,
and I will dwell in the house of the Lord forever. (Psalm 23, A Psalm of David)

There are two therapeutic “hypnotic” allegories in this psalm that are
admirably well-adapted to the purpose for which they are produced and sup-
ported to induce both a state of mindfulness and inner strength. The first is
that of a shepherd; the second is that of a great feast. They have the most
excellent pasture; as guests, they have the most nutritive and abundant fare.
God condescends to call himself the Shepherd of his people, and his follow-
ers are considered as a flock under his guidance and direction; He who called
them from darkness into his marvelous light.

1. He leads them out and in, so that they find pasture and safety.
2. He knows where to feed them, and through his grace and providence,
leads them in the way in which they should go.
3. He watches over them and keeps them from being destroyed by rav-
enous beasts.
4. If any have strayed, he brings them back.
5. He brings them to the shade in times of scorching heat; in times of per-
secution and affliction, he finds an asylum for them.
6. He takes care that they shall lack no manner of thing that is good.
272 Clinical Hypnosis in Pain Therapy and Palliative Care

“The Lord is my shepherd.” In these words and allegory, the believer is

taught to express his or her satisfaction in the care of the great Pastor of the
Universe, the Redeemer and Preserver of men in a universal love. Are we
blessed with the green pastures of the ordinances? Let us not think it enough
to pass through them, but let us abide in them. The consolations of the Holy
Spirit are the still waters by which the saints are led and the streams that flow
from the fountain of living waters. In these paths, we cannot walk unless God
leads us into them and leads us on in them.

B. Hypnosis and Allegory

Allegory is a device in which characters or events represent or symbol-
ize ideas and concepts. Allegory has been used widely throughout the histo-
ry of philosophy and spirituality in different religions. A reason for this is that
allegory has an immense power of illustrating complex ideas and concepts in
a digestible, concrete way. In allegory, a message is communicated by means
of symbolic figures, actions, or symbolic representation.
As a literary device, an allegory in its most general sense is an extended
metaphor. One of the best known examples is Plato’s allegory of the cave. In
this allegory, there are a group of people who have lived chained to the wall
of a cave, facing a blank wall all of their lives. The people watch shadows
projected on the wall by things passing in front of a fire behind them and
begin to ascribe forms to these shadows. According to the allegory, the shad-
ows are as close as the prisoners get to viewing reality.
The history of imaginative hypnosis is very ancient. We can consider as
imaginative hypnosis the symbolic contents in ancient philosophy, verses,
and prayers.
As Jung studied, the archetypes have been inside ourselves since a long
time before us and come back in our dreams, memories, and images through
metaphors. The metaphors get filled with symbolic contents that stay alive
and are activated during the hypnotic sessions.
Metaphors and poetry in hypnosis and spiritual care are a trance state
characterized by a very relaxed, drowsy, and lethargic appearance. During
this trance state, the person who has been hypnotized loses initiative to carry
out his or her own plans, redirects attention away from the activity in which
he or she was engaged toward the instructions of the hypnotist, has height-
ened ability to produce fantasies, and has an increased susceptibility to sug-
gestions.
In pain therapy, we have begun to discover the various therapeutic ben-
efits of these practices. The state of relaxation and the altered state of con-
sciousness in hypnosis are especially effective in chronic pain and in the ther-
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 273

apy for suffering. Relaxation, mindfulness, and hypnosis are intensely per-
sonal and spiritual experiences. The desired purpose of each technique is to
channel our consciousness into a more positive direction, by totally trans-
forming one’s state of mind. A modified state of consciousness is to turn in-
ward and concentrate on the inner self.
It is quite difficult to understand the internal functioning and manage-
ment of information of the brain. Pavlov coined the word conditioning.
Watson adopted it and invented “behaviorism” and later Skinner came up
with “reinforcement.” The school of epiphenomenologists considered the
mind as the product of the brain’s “hardware” and “wiring” complexity,
however, all of them failed to address only one key linked to the brain.
A number of cognitive scientists, including George Lakoff, Mark Turner,
and their colleagues, have recently argued that metaphor should not be seen
as a linguistic device but rather as a form of thought that is pervasive, sys-
tematic, and fundamental (Hopkins, 2004). Spanos and Barber (1974) indi-
cated that “hypnosis is, in part, a process of involvement in suggestion-relat-
ed imaginings.” By using metaphors, a language full of analogies, the hyp-
notist can activate phenomena that have been defined as “transderivational”
(Casula, 2001; Casula, Preti & Portaluri, 2005; Gulotta, 1980).
According to Haley (1963), “one way of confronting the problem of a
subject who is resistant to the directives of the therapist, is to communicate
in analogical or metaphorical manner. If the subject shows resistance to A,
the therapist can speak of B, and when A and B are on metaphorical terms,
the subject will make this connection spontaneously and will respond ade-
quately. In the complex situation of hypnotic induction, the metaphor can be
communicate both at a verbal and non verbal level.”
In the past, I have engaged in research examining the relationship be-
tween various forms of hypnosis. I believe that the form of consciousness
with poetry and metaphors is a bridge to modified states of consciousness
and inner self. When the main road is blocked, as Milton Erickson often said,
then we must find other roads, perhaps more winding, that will ultimately
take us to our destination (Casula, 2001; Casula, Preti & Portaluri, 2005).
Humanity is increasingly turning toward various mindfulness and medi-
tation techniques in order to cope with the increasing stress of modern-day
lifestyles and to attain peace of mind.

C. Hypnosis and Poetry

The metaphorical, rhetorical, and linguistic aspects are very important in
the study of the door to consciousness and to enter into the inner self of the
patient. Poetry text can become a good catalyzer within a hypnotic treat-
274 Clinical Hypnosis in Pain Therapy and Palliative Care

ment. In poetry and metaphors, images and the rhythm of the voice and
sound are what make the deep communication. We can experiment with the
hypnotically power of the rhythm and suggestions in one of Shakespeare’s
sonnets.

Shall I compare thee to a summer’s day?

Thou art more lovely and more temperate:
Rough winds do shake the darling buds of May,
And summer’s lease hath all too short a date;
Sometime too hot the eye of heaven shines,
And often is his gold complexion dimm’d;
And every fair from fair sometime declines,
By chance or nature’s changing course untrimm’d;
But thy eternal summer shall not fade,
Nor lose possession of that fair thou ow’st;
Nor shall Death brag thou wandrest in his shade,
When in eternal lines to time thou grow’st:
So long as men can breathe or eyes can see,
So long lives this, and this gives life to thee. (Sonnet 18, Shakespeare)

Sound and rhythm, are very important in the relationship with the
patient. Rhythm in hypnosis is a musical quality produced by the repetition
of stressed and unstressed syllables (Casula, 2001; Casula, Preti & Portaluri,
2005; Preminger & Brogan, 1993). The sonnet consists of three quatrains fol-
lowed by a couplet and has the characteristic rhyme scheme: abab cdcd efef gg.
The durations of time (“day” in line one, “May” in line three, “summer”
in line four) lead toward the “eternal” in lines nine and twelve. Whereas the
first two quatrains are characterized by constant change, the second half of
the sonnet is increasingly focused on the eternal (González, 2006).
In the first interpretation, the poem reads that beautiful things naturally
lose their fanciness over time. In the second, it reads that nature is a ship with
sails not adjusted to wind changes in order to correct course. This, in com-
bination with “nature’s changing course,” creates an oxymoron: the un-
changing change of nature or the fact that the only thing that does not change
is change. This line in the poem creates a shift from the mutability of the first
eight lines, into the eternity of the last six. Both change and eternity are then
acknowledged and challenged by the metaphor in the final line ( Jungman,
2003).
Rhythm occurs in all forms of language, both written and spoken, but is
particularly important in clinical hypnosis. The original form of a sonnet’s
rhythm was the ancient Italian sonnet, developed by the fourteenth-century
poet Petrarch. It consisted of an octet (eight line) (also known as the “Italian
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 275

octave”) and a sestet (six lines) (also known as the “Sicilian sestet”). Each sec-
tion of an Italian sestet has a specific rhyme scheme and a specific purpose.
The rhyme scheme for the octet is ABBA ABBA, and the purpose of the
octet is to present a situation or a problem. The rhyme scheme for the sestet
can be either CDECDE or CDCDCD, and the purpose of the sestet is to
comment on or resolve the situation or problem posed in the octet.
The poem carries the meaning of an Italian or Petrarchan sonnet, which
typically discussed love ( Jungman, 2003).
The most obvious king of rhythm, is the regular repetition of stressed and
unstressed syllables found in some poetry. The rhyme scheme of the English
sonnet is aab cdcd efef gg. As noted, Shakespeare has eliminated the close
linking, via rhymes, of the individual quatrains, presumably to allow more
flexibility in English, which does not provide as many rhyming possibilities
as Italian does.
Rhythm is the distinguishing founding element in a metaphor, or in a
poetic or spiritual text, rhythm is unique and privileged in communication
with the patient (Casula, 2001; Casula, Preti & Portaluri, 2005).

D. The Movement of the Verses

and Rhythm in Hypnosis Suggestions
Whitman’s use of metaphors and hypnotic rhythms is notable. A line of
his verse, if scanned in the routine way, seems like a prose sentence, or an
advancing wave of prose rhythm. The line is the unit of sense in Whitman.
Whitman experimented with meter, rhythm, and form because he thought
that experimentation was the law of the changing times and that innovation
was the gospel of the modern world.
Imagery means a figurative use of language in hypnosis. Whitman’s use
of imagery shows his imaginative power, the depth of his sensory percep-
tions, and his capacity to capture reality instantaneously. He expresses his
impressions of the world in language that mirrors the present. He makes the
past come alive in his images and makes the future seem immediate. Whit-
man’s imagery has some logical order on the conscious level, but it also
delves into the subconscious, into the world of memories, producing a
stream of consciousness of images. These images seem like parts of a dream,
pictures of fragments of a world.

This is thy hour O Soul, thy free flight into the wordless,
Away from books, away from art, the day erased, the lesson done,
Thee fully forth emerging, silent, gazing, pondering the themes thou
lovest best.
Night, sleep, death, and the stars. (“A Clear Midnight,” Walt Whitman)
276 Clinical Hypnosis in Pain Therapy and Palliative Care

From this point of view, poems, thanks to their symbolic, metaphorical,

and visual content, are quite up to carrying the therapeutic messages used by
clinical hypnotic treatments. If the first rule within the therapeutic rapport is
to synchronize your breath according to the rhythm of your patient and then
lead it, little by little, varying yours, then, in a parallel way, as soon as the
meter of the poetic lines varies, the nonverbal underlying deep message
varies too.
Metaphors, poetry, spiritual verses, and hypnosis have much in com-
mon. They interpret the universe through sensory perceptions. The symbols
are highly personal; in poetry the use of the symbol is governed by the
objects observed: the sea, the wind, nature, the universe.
Next to the rhythm, another important nonverbal element is the “sound”
of vowels, consonants, and syllable groups that all help build it. This is
achieved by making the rhythm slower, faster, softer, harsher, soothing, and
sweet or by means of devices you can easily recognize, rhymes, assonances,
different shades of sounds, suggesting different shades of inner meaning and
emotions.
Descriptive words in poetry and rhythm make their sound like a feeling;
mindfulness of feeling is the mind experiencing awareness of the thoughts.

Sweet love, renew thy force; be it not said

Thy edge should blunter be than appetite,
Which but to-day by feeding is allay’d,
To-morrow sharp’ned in his former might.
So, love, be thou; although to-day thou fill
Thy hungry eyes even till they wink with fullness,
To-morrow see again, and do not kill
The spirit of love with a perpetual dullness.
Let this sad int’rim like the ocean be
Which parts the shore, where two contracted new
Come daily to the banks, that, when they see
Return of love, more blest may be the view;
[Or] call it winter, which being full of care,
Makes summer’s welcome, thrice more wish’d, more rare.
(Sonnet 56, Shakespeare)

Sweet love is an adjuration initially to the beloved, but the syntax soon
changes the direction of the appeal to the love that the poet himself feels,
which he fears is in danger of atrophying. On the other hand, an ocean is
such a wide expanse that one could hardly expect to catch a glimpse of the
beloved on the other side. The expectation is therefore perhaps of a ship
coming in to view, the “return of love” which carries the loved one.
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 277

Can you see that ocean? Can you feel the slow rhythm of the waves? Can
you sense the essence of feelings? Once you really understand that it is not
the words, but the event of the poem or message that lies beyond the words,
you will be able to make sense of the metaphor in general and open up your
world in a significant way.
The most recent psychologist to have an impact in the field of hypnosis
was the father of modern hypnosis, Milton Erickson. His nonverbal and ver-
bal pacing techniques with metaphors are still used today.
The term metaphor comes from the Greek word metapherein, meaning
“to carry over, or transfer.” Rhythm (or “measure”) in writing and meta-
phors, is like the beat in music.
In poetry, metaphors, and hypnosis, rhythm implies that certain words
are produced more forcefully than others and may be held for longer dura-
tion. The repetition of a pattern of such emphasis, is what produces a rhyth-
mic effect.
The biology of cognition attributes a practical and connotative role to
language but also gives importance to emotions, which together with lan-
guage form the consensual domain of conversations. In hypnosis, we use
rhythm with consciously creating recognizable patterns.
In poetry, hypnosis, and metaphors, language becomes the medium for
producing aesthetic events that grasp the domain of emotions of hypnotist
and patient. When applied to deeper levels of experience, what is carried
over by a metaphor are relationships and placement of attention, feelings,
beliefs, and thoughts. A language more and more spontaneously and hyp-
notically indirect, implicit, and symbolic can activates new mental associa-
tions (Casula, 2004; Casula & Clerici, 1995).

2. METAPHORS, SPIRITUAL VERSES, POETRY,

HYPNOSIS, AND FIGURES OF SPEECH

Figures of speech are a mode of expression in which words are used out
of their literal meaning, or out of their ordinary use, in order to add beauty
or emotional intensity or to transfer the poet’s sense impressions by com-
paring or identifying one thing with another that has a meaning familiar to
the reader. Some important figures of speech in poetry, spiritual verses, and
hypnosis are simile, metaphor, personification, hyperbole, and symbol.
According to Padgett (2000), we can consider these figure of speech:
SIMILE: An explicit comparison is made between two essentially unlike
things, usually using like, as, or than, as in Burns’ “O my Love’s like a red,
red rose. . . .”
278 Clinical Hypnosis in Pain Therapy and Palliative Care

M ETAPHOR: A word or phrase literally denoting that one object or idea

is applied to another, thereby suggesting a likeness or analogy between them.
P ERSONIFICATION: Distinctive human characteristics, for example, hon-
esty, emotion, volition, and so on, are attributed to an object or idea. Per-
sonification is commonly used in allegory.
SYMBOL: An image transferred by something that stands for or represents
something else, like flag for country or autumn for maturity. Symbols can
transfer the ideas embodied in the image without stating them.
HYPERBOLE: A bold, deliberate overstatement not intended to be taken
literally; it is used as a means of emphasizing the truth of a statement.
LITOTES: A type of meiosis (understatement) in which an affirmative is
expressed by the negative of the contrary, as in “not unhappy” or “a poet of
no small stature.”
I MAGERY, I MAGE: The elements in a literary work used to evoke mental
images, not only of the visual sense, but also of sensation and emotion. Al-
though most commonly used in reference to figurative language, imagery is
a variable term that can apply to any and all components of a poem that
evoke sensory experience, whether figurative or literal, and also to the con-
crete things so imaged.
F IGURE OF SOUND: Sometimes called sound devices, these include ono-
matopoeia, alliteration, assonance, consonance, euphony, resonance, and
others. Not all of these are considered figures of speech, exactly, but they are
included here because they are part of what you will find if you look closely
at the language and word choice of a poem. They work hand in hand with
rhythm and all types of rhyme.
ALLITERATION: Also called head rhyme or initial rhyme, the repetition of
the initial sounds (usually consonants) of stressed syllables in neighboring
words or at short intervals within a line or passage. Alliteration has a grati-
fying effect on the sound, gives a reinforcement to stresses, and can also
serve as a subtle connection or emphasis of key words in the line. Alliterated
words, however, should not “call attention” to themselves by strained usage.
ASSONANCE: The relatively close juxtaposition of the same or similar
vowel sounds but with different end consonants in a line or passage, thus a
vowel rhyme, as in the words date and fade.
ONOMATOPOEIA: Strictly speaking, the formation or use of words that
imitate sounds, like whispering, clang, and sizzle, but the term is generally
expanded to refer to any word whose sound is suggestive of its meaning.
Because sound is an important part of poetry, the use of onomatopoeia is
another subtle weapon in the poet’s arsenal for the transfer of sense impres-
sions through imagery.
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 279

CACOPHONY: Discordant sounds in the jarring juxtaposition of harsh let-

ters or syllables, sometimes inadvertent but often deliberately used in poetry
for effect, as in the lines from Whitman’s “The Dalliance of the Eagles”:

. . . The clinching interlocking claws, a living, fierce, gyrating wheel,

Four beating wings, two beaks, a swirling mass tight grappling,
In tumbling turning clustering loops, straight downward falling. . . .

Sound devices are important to poetic and hypnotic effects to create sounds
appropriate to the content. The use of words with the consonants b, k, and
p, for example, produce harsher sounds than do the soft f and v or the liquid
l, m, and n.
CAESURA: A rhythmic break or pause in the flow of sound that is com-
monly introduced in about the middle of a line of verse but may be varied
for different effects. Usually placed between syllables rhythmically connect-
ed in order to aid the recital as well as to convey the meaning more clearly,
it is a pause dictated by the sense of the content or by natural speech pat-
terns, rather than by metrics. It may coincide with conventional punctuation
marks, but not necessarily.

We can use the different figures of speech, metaphors, verses, and poems
as indirect suggestion in hypnosis and during therapeutic modified states of
consciousness.
The departure point of metaphor is indicated in the problem presented
by the subject requesting therapeutic intervention. The hypnotist must first
accurately note the content of the problem because to be able to use
metaphor, he or she must create a structure analogous to this content. The
arrival point to be reached through metaphor is indicated by the request of
the subject. The request may take many forms: for help, for change, to stop
suffering, to stop pain, and so on. The motivations can be used by the hyp-
notist to reach the therapeutic goal more easily. To arrive at the destination
by means of the metaphor, we must proceed along a new path that allows us
to avoid obstacles blocking the main route.
Through poetry, spiritual verses, and metaphors, we can have a real pos-
sibility that we should misconstrue a representation of the physical space
inside our consciousness in this way (Hopkins, 2004).
Hypnosis can be a kind of relationship made up of unrepeatable mo-
ments when it is experienced in an integrated way, using the indirect Erick-
sonian communication through the poetry, the metaphors, the hypnotic
trance. Hypnosis becomes than a creative experience when the choice of a
certain tool or a different one from the therapist’s knowledge stock can even
280 Clinical Hypnosis in Pain Therapy and Palliative Care

be extemporary or unconscious. Its power, if activated in a relationship,

open to the future and to changes, allows a person to feel and experience
unrepeatable moments of synchronicity, such as to reveal new opportunities
and interventions (Piazza & Carletti, 2006).
How can I use poetry, metaphor and rhythm in mindfulness and clinical
hypnosis?
According to Battino (2002),

1. listen to the problem as offered

2. be guided by the areas of desired outcomes
3. list dramatic themes that are part of the current and desired situation
4. choose a poem, or a metaphor or a mindfulness technique that paral-
lels those themes
5. design appropriate general outcomes
6. arrange the outcome to create suspense or mystery

With poetry, spiritual verses, and metaphor, any creative space is opened,
followed, listened to, but then encircled and defined within one’s way of indi-
viduation.
Repetition of a sound, rhythm, syllable, word, phrase, line, stanza, or
metrical pattern is a basic unifying device in hypnosis. Repetition of sounds
is the basis for rhyme and alliteration. Repetition of patterns of accents is the
basis for rhythm. Repetition of key words, phrases, and sentence patterns is
often important in hypnosis. The repetition of similar endings of words, or
even of identical syllables (rime riche), constitutes rhyme, used generally to
set up relationships within the same line (internal rhyme). Sometimes, repe-
tition reinforces, or even substitutes for, meter (the beat), the other chief con-
trolling factor of poetry and metaphors. Ancient spiritual chants from all cul-
tures, show repetition. Repetition is found extensively in free verse, which
does not have a traditional, recognizable metrical pattern. Repetition in free
verse includes parallelism (repetition of a grammar pattern) and the repeti-
tion of important words and phrases, and is always used in clinical hypnosis.

3. CLINICAL HYPNOSIS, MINDFULNESS AND THE

LANGUAGE OF METAPHORS: THE TECHNIQUES

The procedures for inducing relaxation and hypnosis are many and var-
ied, but certain steps are common also with metaphor induction. The first
such step usually involves having you sit or lie comfortably so you do not
have to exert any effort to maintain your bodily position and telling you not
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 281

to move and to relax your body as much as possible. This step has a variety
of effects. For one thing, if you are somewhat anxious about what is going to
happen, your anxiety, which intimately related to bodily tension, is at least
partially relieved if you relax. You limit your ability to feel anxiety. This
makes it easier for you to alter your state of consciousness.
Second, the hypnotist commonly tells you to listen only to his or her
voice and ignore other thoughts or sensations that come into your mind, or
the therapist simply tells you the metaphor. Ordinarily, you constantly scan
the environment to see if important stimuli are present. This constant scan-
ning keeps up a continuous, varied pattern of information and energy ex-
changes among subsystems, which tends to keep subsystems active in the
waking state pattern.
The metaphor can be a kind of relationship made of unrepeatable mo-
ments when it is experienced in an integrated way, between the indirect
Ericksonian communication through the metaphor and the hypnotic trance.
The psychotherapeutic journey with the patient becomes then a creative
experience. Good poets have a repertoire of stories that they can pull out on
any occasion. The following will be provided for each theme:

• A title
• The intended audience, in other words, the purpose of this particular
metaphor
• Opening: setting the stage by giving basic elements such as time, set-
ting ambience, conditions, background
• Development: components of the narrative in step-by-step sequence
• Closing: morals, punch lines, special reorientation. (Battino, 2002).

There are many approaches to teaching the patient for the simple use of
metaphors and poetry in self-relaxation. The following exercise is very easy:

• Following your breath while reading a poem

• Read a poem
• Breathe long, light, and even breaths
• Follow your breath and be master of it while remaining aware of the
feelings and sentiments of the poetry
• Continue as with the poetry
• This can be practiced in any time and place
• Breathe quietly and more deeply than usual

During hypnosis, metaphors, poetry, spiritual verses, and suggestions

may be proffer creativity, fluidity of associations, spontaneity, primary pro-
282 Clinical Hypnosis in Pain Therapy and Palliative Care

cess thinking, and comfort. As they are focused on a single concept, they give
a single aligned image in return; if we want to talk about combinations of
concepts, question, and answers or explore a topic further and wider, we get
combinations of metaphors, or sequences of metaphors leading from one
into another.
Do you like poems? Do you think of scenarios and play them in your
mind, dreaming and living dreams in an altered state of consciousness? In
hypnosis with poetry, spiritual verses, and metaphors, some factors are
absolutely important:

• You must use “all five senses” in your descriptions. If you see waves
on the ocean, for example, do not just describe how it looks. Describe
its light, its smell, and the sound of the wind howling across the waves.
• Phrase all your descriptions in the present tense.
• Close your eyes and describe out loud anything you can “see.”
• Later on in the image streaming process, you can use it for problem
solving and a great many other metaphors besides.

Metaphors and poetry need emotion, but we need to create positive

emotion with words and this creation is called imagery. A metaphor is the
comparison of two unlike things by saying one is the other. Remember the
nursery rhyme (author unknown): “Twinkle, twinkle little star, How I won-
der what you are. Up above the world so high, Like a diamond in the sky.
. . .” Comparing the star to a diamond is a simile that creates imagery.
Psychologists identify seven kinds of mental images: those of sight,
sound, taste, smell, touch, bodily awareness, and muscular tension. All are
available to poets and are used by poets. Metaphor, simile, allegory, person-
ification, metonymy (attribute for whole) and synecdoche (part) all involve
imagery. The following list of hypnosuggestions with metaphors should be
considered as a frame of work:

• Simply relax and feel happy

• Have a fantasy accompanied by feelings of relaxation and well-being
• Go in fantasy to a favorite place
• Have a fantasy about himself or herself
• Fantasize about a specific problem (and its resolution)
• Imagine the future when the problem will be resolved
• Imagine possible solutions and their consequences
• Enact, in fantasy, an interpersonal problem or conflict that involves
interaction or confrontation with an antagonist (Lynn, Neufeld &
Matyi, 1987)
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 283

A. Metaphors and Healing

That metaphor is the omnipresent principle of language can be shown by
mere observation. We cannot get through three sentences of ordinary fluid
discourse without it (Richards, 1936). Therapeutic metaphor is one of the
most important tools available for assisting people in the process of person-
al transformation, well-being and healing.

As darkness, which is distinct (from sunshine), vanishes in the sun’s radiance, so

the whole objective universe dissolves in Brahman. (Vivekachudamani, Verses
564–6)

The major purpose of therapeutic metaphor is to pace and lead an individ-

ual’s experience through the telling of a story that helps that individual
access resources necessary for change. In a therapeutic context metaphors
are used as tools for transformation, facilitating new patterns of thoughts,
feelings and behavior. Consider using imagery to:

• Externalize thought
• Create mood and atmosphere
• Give continuity by recurring leitmotifs
• Develop plot or increase dramatic effect by abrupt changes in imagery
• Exploit the etymology of words to subtly revive their original mean-
ings

The first object using metaphors is the knowledge of our own mind.
Every object of the mind is itself mind. In Buddhism and mindfulness, we
call the object of mind the dharmas. Dharmas are usually grouped into five
categories:

1. bodily and physical forms

2. feelings
3. perceptions
4. mental functionings
5. consciousness

These five categories are called the five aggregates. The fifth category, con-
sciousness, however, contains all the other categories and is the basis of their
existence (Nhat Hanh, 2007).
Through hypnosis with metaphors, we are conscious of the presence of
bodily form, feelings, perception, mental functioning, and consciousness.
With the use of poetry, mindfulness, and metaphors—the language, more and
284 Clinical Hypnosis in Pain Therapy and Palliative Care

more spontaneously and hypnotically indirect, implicit, symbolic, and imag-

inative—can activate new mental associations and knowledge.
When this phenomenon is expressed in a state in which the conscience
level is modified, the cathartic and metaphoric effect may be slower and
more intense. The employment of a hypnotic methodology can be inserted
magically into some eye-opening moments of the therapy, according to the
experienced life, the resistances, and the metaphorical spontaneous content
of the emotions. The metaphor is perhaps one of man’s most fruitful poten-
tialities. Its efficacy verges on magic, and it seems a tool for creation that God
forgot inside one of His creatures when he made him (Ortega y Gasset,
1925).

The milky sky, the hazy, slender trees,

Seem smiling on the light costumes we wear,
Our gauzy floating veils that have an air
Of wings, our satins fluttering in the breeze.
And in the marble bowl the ripples gleam,
And through the lindens of the avenue
The sifted golden sun comes to us blue. (A La Promenade, Paul Verlaine)

At night, when the sea cradles me

And the pale star gleam
Lies down on its broad waves,
Then I free myself wholly
From all activity and all the love
And stand silent and breathe purely,
Alone, alone cradled by the sea
That lies there, cold and silent, with a thousand lights.
(Hermann Hesse, At Night On The High Seas)

The compulsion of Hermann Hesse to make explicit in language what

was implicit in his deepest experience typifies our own present day problem
of the cognitive exploration of our inner self. The words go from personal to
cosmic level. Can you feel that sea? Can you feel the slow rhythm of the
waves? Can you sense the essence of tranquility? Do you understand the
concept of tranquility better now? Do you feel more tranquil in having
touched this?
The intensity of therapeutic suggestion in poetry derives from the ex-
tremely thick verbal interplay in the poem, whose rhetorical structure and
visual imagery establish an extraordinary semantic concentration in each
stanza. Several of Hesse’s novels depict the protagonist’s journey into the
inner self. A spiritual guide assists the hero, in his quest for self-knowledge
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 285

and shows the way beyond the world “deluded by money, number and
time.” The poem carries all the emotional power of direct and indirect
speech.
“Indirect” suggestion is conceptualized in two distinct ways in the litera-
ture. From an Ericksonian perspective, indirect suggestions are theoretically
approached as suggestions that can circumvent the censorship of conscious-
ness, to reach the unconscious, where they can activate dormant potentials.
In contrast, from a research perspective, indirect suggestion is operationally
defined as a technique. Based on Ericksonian theory, it was claimed that
“indirect” suggestion was more effective than traditional, direct suggestion
(Fourie, 1997).
A symbol is the smallest unit of metaphor, consisting of a single object,
image, or word representing the essence of the quality or an attribute it
stands for.
The following is a Jung’s definition of a symbol: “A word or an image is
symbolic when it implies something more than its obvious and immediate
meaning. It has a wider ‘unconscious’ aspect that is never precisely defined
or fully explained. Nor can one hope to define or explain it. As the mind ex-
plores the symbol, it is led to ideas that lie beyond the grasp of reason.” The
underlying assumption, is that in order to be effective a metaphor needs to
be processed outside of conscious awareness (Matthews & Langdell, 1989).
The value of metaphor is that it can bypass conscious resistances and serve
to stimulate creativity, and lateral thinking, in relation to a problem.
Neuroscientists believe the brain exists in real, objective space and is as
devoid of consciousness as is the physical space conceived of by physicists.
Neither the external space of the physical senses nor the internal space of the
mind exists in the brain. Within the context of the experienced world, the
demarcation between external and internal space is one of convention, not
absolute reality. We may experience mental images, for example, not only in
our “mind’s eye,” with our eyes closed, and our attention withdrawn from
the physical world (Wallace, 2006).
The philosophy of consciousness was pronounced by many studies of the
human being, long before we knew about the source of self-knowledge and its
pros and cons. The experience of the suffering-pleasure dimension has been
historically accepted as an intrinsic part of life from various religious traditions
and by various anthropologists, doctors, philosophers, and literary authors
(Hayes, Stroshal, & Wilson, 1999; Luciano, 2001; Wilson & Luciano, 2002).
Therapeutic metaphors encourage people to focus on the deeper struc-
ture relationships between their reality and that of the story. The therapeutic
value of the metaphor lies in the similarity of its deep structure to the deep
structure of the problem (formal properties), even though the surface level
286 Clinical Hypnosis in Pain Therapy and Palliative Care

characters and details (the content) are very different. Metaphors, spiritual
verses, and poetry, in a hypnosis therapeutic context, may be useful

• To have good relaxation of body and mind

• To have good relief of pain
• To have good relief of suffering
• As distraction, to have good relief of pain
• To provide a key mechanism for improving a sense of greater connect-
edness with others
• To open up possibilities and strategies
• To facilitate new patterns of thoughts, feelings, and consciousness
• To stimulate lateral thinking and creativity
• To reframe or redefine a problem or situation
• To introduce doubt into a position that holds that there is only one way
• To bypass normal ego defences
• To allow the client to process directly at a subconscious level (indirect
suggestions)
• To suggest solutions and new options
• To provide a gateway between the conscious and the unconscious
• To understand the subconscious mind
• To increase communication
• To facilitate retrieval of resource experiences
• To lighten up the “spiritual” dimension
• To involve a higher mode of consciousness in which the ordinary men-
tal-egoic self is transcended
• To improve mind-body relationship
• To accept near-death experiences, death, and dying
• To improve psychology of self and self-realization
• To understand the higher self
• To understand the evolution of consciousness
• To understand the Integral approaches to knowledge

A land whose suns’ moist rays,

Through the skies’ misty haze,
Hold quite the same charms for my spirit
As do your scheming eyes
There all is only order:
Comfort and beauty, calm and bliss.
See how the ships, asleep
They who would ply the deep!
Line the canals: to satisfy
Your merest whim they come
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 287

From far-flung heathendom

And skim the seven seas.
On high, the sunset’s rays enfold
In hyacinth and gold,
Field and canal; and, with the night,
As shadows gently fall,
Life sleeps, and all
Lies bathed in warmth and evening light.
There all is only order:
Comfort and beauty, calm and bliss.
(“Invitation to the Voyage,” Charles Baudelaire)

Central to Baudelaire’s poetry is the platonic division between the body and
the soul and its rebuttal by the philosophers of the Enlightenment Move-
ment. According to Plato, what belongs to the body is temporary, open to
error and corruption, and can never achieve perfection. What belongs to the
soul, however, is infinite and may attain true knowledge and perfection
through acquaintance with the ultimate forms of truth and beauty. Thus,
when philosophers such as Locke, Hume, Voltaire, Rousseau, and even
Descartes proffered philosophies based on reason, and knowledge based on
the bodily senses rather than through the soul, this represented an immense
challenge, even an attack, on the status quo. Baudelaire frequently empha-
sizes the temporary nature of moments of pleasure. These are fleeting
moments that make life more bearable, but the pleasure he takes from them
is double-edged. He is left with the feeling that physical experience is lack-
ing in some way. He is happy to indulge in his freedom but regrets the lack
of spirituality and the depth that would lend the experience, and a sense of
control over these events.
Very often, imagery experiences are understood by their subjects as
echoes, copies, or reconstructions of actual perceptual experiences from their
past. At other times, they may seem to anticipate possible, often desired or
feared, future experiences. Thus imagery has often been believed to play a
very large, even pivotal, role in both memory (Paivio, 1986; Yates, 1966) and
motivation. It is also commonly believed to be centrally involved in visuo-
spatial reasoning and inventive or creative thought.
Recent experiments have shown that the saccadic eye movements that a
subject spontaneously and unconsciously makes when experiencing a visual
mental image do indeed tend to reenact the stimulus-specific pattern of sac-
cades made when actually looking at the equivalent visual stimulus (Richard-
son, 1999). Thomas (1999) argues that enactive theory depicts both imagery
and creative thinking as manifestations of the more basic imaginative capac-
ity of intentionalistic perception or “seeing as.”
288 Clinical Hypnosis in Pain Therapy and Palliative Care

This solitary hill has always been dear to me

And this hedge, which prevents me from seeing most of
The endless horizon.
But when I sit and gaze, I imagine, in my thoughts
Endless spaces beyond the hedge,
An all encompassing silence and a deeply profound quiet,
To the point that my heart is almost overwhelmed.
And when I hear the wind rustling through the trees
I compare its voice to the infinite silence.
And eternity occurs to me, and all the ages past,
And the present time, and its sound.
Amidst this immensity my thought drowns:
And to flounder in this sea is sweet to me. (“The Infinite,” Giacomo Leopardi)

This Italian poem concentrates in a few lines the theme of philosophical

and psychological progression from circumstance to inner consciousness and
awareness. The solidarity of man and creation stated in the final line links the
man to divinity, and it is such a revelation that it will replace all previous
questioning. In this poem the world is as a vast divine system of metaphors,
and the mind is at its fullest stretch when observing them.
The ever-recurring microcosm-macrocosm conceit in this poetry appeals
greatly to an original relation to the universe, a relation in which every man
could express his peculiar self. The metaphoric success of this determination
is linked to each man’s ability to transcend the limitation of experience by
submitting external events to his mind. Leopardi’s keen sensitivity to the
larger aspects of nature, his mastery and daring with the visual image, and
his appreciation of the connotative value of single words place him among
the most original and provocative poets in the language of inner self.
Metaphor and poetry, being a powerful distillate of human emotional
experience, can translate the theorical proposals into effective procedures
that are words written in a communicative emotional code, speaking direct-
ly to the unconscious mind. Everybody’s personal imaginative journey de-
veloped and got enriched more and more, stimulated by feelings.
Whitman brought vitality and picturesque metaphors to his descriptions
of the physical world. He was particularly sensitive to sounds and described
them with acute awareness. His view of the world was dominated by its
change and fluidity in imagery. “Spirit That Form’d This Scene” was written
in Platte Canyon, Colorado.

Spirit that form’d this scene,

These tumbled rock-piles grim and red,
These reckless heaven-ambitious peaks,
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 289

These gorges, turbulent-clear streams, this naked freshness,

These formless wild arrays, for reasons of their own,
I know thee, savage spirit—we have communed together,
Mine too such wild arrays, for reasons of their own;
Wast charged against my chants they had forgotten art?
To fuse within themselves its rules precise and delicatesse?
The lyrist’s measur’d beat, the wrought-out temple’s grace—column
and polish’d arch forgot?
But thou that revelest here—spirit that form’d this scene,
They have remember’d thee. (“Spirit That Form’d This Scene,” Walt Whitman)

Metaphor presents some undeniable advantages in the relationship with

patient:

• reduction of the patient’s attention field

• suggestions toward conditions of well-being
• consolidation of the state of well-being as a personal affective and
emotional experience
• possibility of talking about the trouble in acceptable emotional condi-
tions
• the development of symbolic processes and their interpretation in an
alert state
• posthypnotic suggestions

The method allows the patient to reach an objective as a result of direct per-
sonal action, in as much as he realizes he has a new instrument: the knowl-
edge of the state of well-being. The spoken, verbal message achieves the
maximum effectiveness when verbal and nonverbal are synchronized so that
they flow together and harmoniously. It is this great opportunity, given by
the poetic text, for an emotional communication that suggests its therapeutic
potentiality.
After having defined for the patient the field of therapeutic intervention,
metaphor and poetry are used with the specific intention of letting the patient
perceive feelings and, consequently, sense a condition of well-being that
gives the patient an inner motivation to recover.
Your consciousness is simultaneously experiencing many realities in the
slinky loops of time. The base, linear time, is part of the illusion of third di-
mension or physical reality to enable souls to experience emotions. The third
dimension is the slowest moving level of consciousness, the base of the
slinky. Once there, you forget the other realities, dots on the slinky above,
and the experience you are having can give you the peace of mind.
290 Clinical Hypnosis in Pain Therapy and Palliative Care

Poetry and spiritual verses are primarily about capturing and recording
a fleeting image of emotion. Feelings frequently rise and fall without any
examination, putting them into words, recording them for feelings. Poetry
and spiritual verses are ways to examine our inner thoughts and recognize
the fleeting and impermanent nature of emotion. Poetry and spiritual verses
hold magical emollient for each of us—if we enthusiastically embrace them.
In doing so, we will extemporize our ardent devotion where indoctrination
and intellect abound, where inspiration is sublime, and where the mind is
captive but surrenders into a radiance of zeal and harmony.

If beyond earthly wont, the flame of love

Illume me, so that I o’ercome thy power
Of vision, marvel not: but learn the cause
In that perfection of the sight, which soon
As apprehending, hasteneth on to reach
The good it apprehends. I well discern,
How in thine intellect already shines
The light eternal, which to view alone
Ne’er fails to kindle love; and if aught else
Your love seduces, ‘t is but that it shows
Some ill-mark’d vestige of that primal beam.
This would’st thou know, if failure of the vow
By other service may be so supplied,
As from self-question to assure the soul.
(The Divine Comedy. Paradise: Canto V, Dante Alighieri.
Translated by The Rev. H. F. Cary, Trans.)

. . . and the original Italian version with the rhythm and musical sound:

S’io ti fiammeggio nel caldo d’amore

di là dal modo che ‘n terra si vede,
sì che del viso tuo vinco il valore,
non ti maravigliar; ché ciò procede
da perfetto veder, che, come apprende,
così nel bene appreso move il piede.
Io veggio ben sì come già resplende
ne l’intelletto tuo l’etterna luce,
che, vista, sola e sempre amore accende;
e s’altra cosa vostro amor seduce,
non è se non di quella alcun vestigio,
mal conosciuto, che quivi traluce.
Tu vuo’ saper se con altro servigio,
per manco voto, si può render tanto
che l’anima sicuri di letigio.
 Clinical Hypnosis, Mindfulness, and the Language of Metaphors 291

In Dante’s Christian universe, every motion, from the petty choices of hu-
mans to the cosmic revolutions of the stars, is motivated by love. Thus love
for God gives the entire universe its proper order, for everything moves in
accord with God’s will. Appropriately then, God’s love is represented as
light, which grows ever brighter the closer to heaven one gets. Death is some-
thing that all must face at some time or another or in one way or another.
Dante sees something reflected in Beatrice’s eyes as in a mirror and turns to
see a single intense point of light un punto, around which nine concentric cir-
cles wheel (the different levels of the modified states of consciousness?), turn-
ing faster and brighter, the nearer they are to the inner point, through their
closeness to the ultimate truth (higher consciousness, God).
As in Aristotle (Metaphysics), heaven and all nature hang from this point,
the prime mover, which is without magnitude, but without parts and indivis-
ible: the nonduality. In spiritual verses, images and the rhythm of the voice
and sound, are what makes the deep communication with higher conscious-
ness.

True nature is always elusive,

Only the heart of no-heart
can grasp-it.
Up in the mountain,
the burning jade stays brilliant.
And in the roaring furnace,
lotus blossoms keep their fragrance.
(Ngo An, Korea, Zen (Chan) Buddhism, 1090)

Dualistic conceptions in the Atman, the Infinite Knowledge, the Absolute, are
like imagining castles in the air. Therefore, always identifying thyself with the
Bliss Absolute, the One without a second, and thereby attaining Supreme Peace,
remain quiet. (Vivekachudamani, verses 524–526)

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294 Clinical Hypnosis in Pain Therapy and Palliative Care

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 Chapter VIII

RELAXATION AND HYPNOSIS IN

PEDIATRIC PATIENTS: TECHNIQUES FOR
PAIN RELIEF AND PALLIATIVE CARE

1. PAIN THERAPY AND PALLIATIVE

CARE IN INFANTS AND CHILDREN

ediatric suffering in chronic diseases is a significant and psychophysio-

P logically complex problem, involving the fundamental interaction of a
neurophysiological response with age, cognitive set, personality, ethnic cul-
ture, and emotive state (Legrain et al., 2009).
Acute and chronic pain management in children is increasingly charac-
terized by either a multimodal or a preventive analgesia approach. Smaller
doses of opioid and nonopioid analgesics, such as nonsteroidal anti-inflam-
matory drugs, and local anaesthetics, are commonly used alone or in com-
bination with nonpharmacological therapies to maximize pain control and
minimize drug-induced adverse side effects. A multimodal approach uses
nonpharmacological complementary and alternative medicine therapies.
These include distraction, guided imagery, clinical hypnosis and relaxation
techniques.
Using the neurophysiology of pain as a pattern, multimodal pain and suf-
fering management, is described in this chapter.
The effects of tumor and its therapy, and the mechanisms and experience
of pain in the child with cancer, have a serious impact on neurocognitive
functioning and psychosocial issues of the children and family. At a time of
enlarging interest in palliative care children’s pediatric oncology programs
may be failing to deliver adequate help to children with cancer. Not all can-
cer patients suffer pain from their disease, although most have pain related
to treatments or procedures or to psychological suffering. The combination
of pharmacological and non pharmacological approaches may be optimal
295
296 Clinical Hypnosis in Pain Therapy and Palliative Care

for acute and chronic pain in children. The evaluation of pain and suffering
in the newborn and children is difficult because pain is mainly a subjective
phenomenon.
Until a few years ago, several myths persisted. First, the myth that chil-
dren, especially infants, do not feel pain the way adults do, and therefore
there are no untoward consequences for them. The second myth is the lack
of assessment and reassessment for the presence of pain. The third myth is
the misunderstanding of how to conceptualize and quantify a subjective
experience (Loizzo, Loizzo & Capasso, 2009).
Pediatric oncologists and those charged with developing pediatric pallia-
tive care programs must deal with the different physiological and develop-
mental stages encountered while caring for infants, children, and adoles-
cents. When discussing palliative care in children with cancer, where few die
but many suffer, a paradigm shift must occur that does not equate palliative
care with end-of-life care (Harris, 2004).

Palliative care for children represents a special, albeit closely related field to
adult palliative care. Palliative care for children is the active total care of the
child’s body, mind and spirit, and also involves giving support to the family. It
begins when illness is diagnosed, and continues regardless of whether or not a
child receives treatment directed at the disease.

Health providers must evaluate and alleviate a child’s physical, psychological,

and social distress. Effective palliative care requires a broad multidisciplinary
approach that includes the family and makes use of available community
resources; it can be successfully implemented, even if resources are limited. It
can be provided in tertiary care facilities, in community health centers and even
in children’s homes. Palliative care improves the quality of life of patients and
families who face life-threatening illness, by providing pain and symptom relief,
spiritual and psychosocial support to from diagnosis to the end of life and
bereavement. (WHO)

According to the WHO, palliative care in children

• provides relief from pain and other distressing symptoms

• affirms life and regards dying as a normal process
• intends neither to hasten nor postpone death
• integrates the psychological and spiritual aspects of patient care
• offers a support system to help patients live as actively as possible until
death
• offers a support system to help the family cope during the patients’ ill-
ness and in their own bereavement
 Relaxation and Hypnosis in Pediatric Patients 297

• uses a team approach to address the needs of patients and their fami-
lies, including bereavement counseling, if indicated
• will enhance quality of life and may also positively influence the
course of illness
• is applicable early throughout the illness, in conjunction with other
therapies that are intended to prolong life, such as chemotherapy or
radiation therapy, and includes those investigations needed to better
understand and manage distressing clinical complications

The care of disabled children or those at the end of life may be particu-
larly complex.

A. Neurophysiology and Neuropsychology

of Pain in Infants and Children
“Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage, or described in terms of such damage. The
inability to communicate verbally does not negate the possibility that an
individual is experiencing pain and is in need of appropriate pain-relieving
treatment. Pain is always subjective. Everyone learns the application of the
word through experiences related to injury in early life” (IASP).
For most children with cancer, the primary goal of cure is to achieve the
alleviation of pain. “Many people report pain in the absence of tissue damage
or any likely pathophysiological cause; generally, this happens for psycho-
logical reasons. There is usually no way to distinguish their experience from
that due to tissue damage if we take the subjective report. . . . If they regard
their experience as pain, and if they report it in the same ways as pain caused
by tissue damage, it should be accepted as pain” (IASP). Considerations of the
toxicity of cancer therapy, the quality of life, and growth and development are
usually secondary to this goal. As a result, it may be difficult for physicians to
change their focus even when there is little hope of a cure (Anton, 2009).
Children who die of cancer receive aggressive treatments and procedures at
the end of life. Many have substantial suffering in the last month of life and
attempts to control their symptoms are often unsuccessful. Greater attention
must be paid to pain and suffering therapy for these children.
“As with the pain threshold, the pain tolerance level is the subjective
experience of the individual. The stimuli which are normally measured in
relation to its production are the pain tolerance level stimuli and not the level
itself. Thus, the same argument applies to pain tolerance level as to the pain
threshold, and it is not defined in terms of the external stimulation as such”
(IASP).
298 Clinical Hypnosis in Pain Therapy and Palliative Care

Unrelieved pain and suffering in infants and children, can permanently

change their nervous system and may give “prime” them, for having chron-
ic pain. Barriers to good pain management are numerous and reflect biolog-
ical, psychological, and social factors (Hester, Foster & Kristensen, 1990).
The biological barriers to pediatric pain management are as follows (Andrews
& Fitzgerald, 1997):

• Complete myelination of nerve pathways not required for pain trans-

mission.
• C-fibers are unmyelinated and A-delta fibers are thinly myelinated.
• Incomplete myelination results in slower conduction velocity but off-
set by shorter distances.
• Complete myelination of pain pathways to brainstem and thalamus by
30-week gestation; thalamus to the cortex by 37 weeks.
• Nociceptive nerve endings in cutaneous and mucous surfaces by 20
weeks of gestation.
• Threshold for responding to cutaneous stimulation is lowest in the
youngest neonates.
• Inhibitory pathways do not develop until after birth.

We must remember that children and adolescents do not tolerate pain

and suffering better than adults:

• Infants feel pain (Loizzo, Loizzo & Capasso, 2009).

• The youngest premature infant has the anatomical and physiological
components to perceive pain or “nociception” and demonstrates a
severe stress response to painful stimuli (Silva, Gomez, Máximo &
Silva, 2007).
• Children beyond childhood can accurately point to the body area or
mark the painful site on a drawing; children can use pain scales.
• Inadequate analgesia for initial procedures (bone marrow aspiration,
lumbar puncture, or both) in young children may diminish the effect
of adequate analgesia in subsequent procedures (Weisman, Bernstein
& Schechter, 1998).
• Pain is a common experience during childhood. All children en-
counter “everyday” pain associated with minor bumps and bruises,
and many endure pain resulting from serious injuries, diseases, and
other health conditions requiring medical care. Regardless of its preva-
lence, pain in infants, children, and adolescents, is often underesti-
mated and undertreated.
 Relaxation and Hypnosis in Pediatric Patients 299

• Survivors of cancer during adolescence show an elevated risk of de-

monstrating symptoms of posttraumatic stress, anxiety and/or depres-
sion during adulthood, which is also reflected in a greater number of
DSM-IV diagnoses when in comparison to controls. Extensive follow-
up assessments should include the examination of possible late psy-
chological effects of a cancer diagnosis in adolescence in order to iden-
tify survivors needing psychosocial interventions even years after the
conclusion of successful medical treatment (Seitz et al., 2010).

Recent advances in neonatal intensive care include, and are partly attrib-
utable to, growing attention for comfort and pain control for the term and
preterm infant requiring intensive care or procedure in chronic illnesses.
Limitation of painful procedures is certainly possible, but most critically ill
infants require unavoidable painful or stressful procedures such as intuba-
tion, mechanical ventilation, or catheterization. Many analgesics (opioids
and nonsteroidal anti-inflammatory drugs) and sedatives (benzodiazepines
and other anesthetic agents) are available, but their use varies considerably
among units (Durrmeyer, Vutskits, Anand & Rimensberger, 2010).
A child’s pain is what finally gets his or her attention, and this pain is the
result of a condition that has triggered a series of physical, psychological and
neurological events. Since the 1980s, the problem of pain experienced by
newborns has met with increasing interest both in research work and in clin-
ical practice. It is worth noting that significant progress in the neurophysio-
logical basis of pain and in diagnostic and therapeutic methods has occurred
during that time.
The low tactile threshold of preterm infants when they are in the neona-
tal intensive care unit (NICU), while their physiological systems are unstable
and immature, potentially renders them more vulnerable to the effects of
repeated invasive procedures. There is a small but growing literature on pain
and tactile responsive following procedural pain in the NICU.
Acute pain follows injury to the body and generally disappears when the
bodily injury heals. It is often, but not always, associated with objective phys-
ical signs of autonomic nervous system activity. Chronic pain, in contrast to
acute pain, rarely is accompanied by signs of sympathetic nervous system
arousal. The lack of objective signs may prompt the inexperienced clinician
to say the patient does not “look” like he or she is in pain (American Pain
Society, 1999).
Chronic pain in children is the result of a dynamic integration of biolog-
ical processes, psychological factors, and sociocultural context considered
within a developmental trajectory. This category of pain includes persistent
(ongoing) and recurrent (episodic) pain with possible fluctuations in severity,
300 Clinical Hypnosis in Pain Therapy and Palliative Care

quality, regularity, and predictability. Chronic pain can occur in single or

multiple body regions and can involve single or multiple organ systems.
Ongoing nociception can result in a sensitization of the peripheral and cen-
tral nervous systems to produce neuroanatomical, neurochemical, and neu-
rophysiological changes. It is important that assessment and treatment strate-
gies be based on this definition and related dimensions (American Pain
Society).
Understanding the central modulation of pain perception was greatly
advanced by the finding that electrical or pharmacological stimulation of cer-
tain regions of the midbrain produces relief of pain. This analgesic effect aris-
es from activation of descending pain-modulating pathways that project, via
the medulla, to neurons in the dorsal horn, particularly in Rexed’s lamina II,
that control the ascending information in the nociceptive system. The major
brainstem regions that produce this effect are located in poorly defined
nuclei in the periaqueductal gray matter and the rostral medulla (Latre-
moliere & Woolf, 2009). In acute and chronic pain central sensitization is a
generator of pain hypersensitivity by central neural plasticity.
Central sensitization represents an enhancement in the function of neu-
rons and circuits in nociceptive pathways caused by increases in membrane
excitability and synaptic efficacy as well as to reduced inhibition and is a
manifestation of the remarkable plasticity of the somatosensory nervous sys-
tem in response to activity, inflammation, and neural injury. The net effect of
central sensitization is to recruit previously subthreshold synaptic inputs to
nociceptive neurons, generating an increased or augmented action potential
output: a state of facilitation, potentiation, augmentation, or amplification.
Central sensitization is responsible for many of the temporal, spatial, and
threshold changes in pain sensibility in acute and chronic clinical pain set-
tings and exemplifies the fundamental contribution of the central nervous
system to the generation of pain hypersensitivity (Latremoliere & Woolf,
2009).
The sympathetic nervous system and pain interact on many levels of the
neuraxis. The sympathetic nervous system is part of the autonomic nervous
system (involuntary) and prepares the body for the “fight or flight” reaction.
Its activity is normally balanced in pain by that of the parasympathetic ner-
vous system, which tends to return the body to its normal state after a “Fight
or flight” episode. In the sympathetic nervous system, the preganglionic
nerves leave the central nervous system between T1 and L2 to join the sym-
pathetic ganglia (junction box). The ganglia form a chain that runs down the
front of the spinal vertebral bodies. Postganglionic nerves leave the ganglia
to supply their target organ.
 Relaxation and Hypnosis in Pediatric Patients 301

Of note is the fact that every part of the peripheral nervous system, from
dorsal root ganglion all the way to the pain receptors in the periphery, has a
postganglionic sympathetic supply that increases both sensory receptor sen-
sitivity and nerve conduction speeds. In the peripheral nervous system, the
preganglionic nerves leave the central nervous system via the tenth cranial
nerve (vagus) and also via the sacral parasympathetic nerves (craniosacral
outflow). They join ganglia just before their target organ. Postganglionic
nerves then leave the ganglia to supply their target organ.
In light of recent advances in understanding of the neurophysiological
basis of pain, mechanisms-based clinical reasoning strategies for pain were
identified. These are (1) nociceptive, (2) peripheral neurogenic, (3) central,
and (4) autonomic/sympathetic. There was some evidence to suggest that
reasoning within these categories variously influenced therapists’ prognostic
decision making as well as the planning of physical assessments and treat-
ment (Smart & Doody, 2007). Even subtle changes in pathophysiology can
dramatically change the effect of sympathetic nervous system on pain, and
vice versa. In the periphery, inflammation or nociceptive activation is en-
hanced, spinal descending inhibition is reversed to spinal facilitation, and
finally the awareness of all these changes will induce anxiety, which further-
more amplifies pain perception, affects pain behavior, and depresses mood
(Wright, 1999; Schlereth & Birklein, 2008).
Stress responses to acute pain in neonate provides physiological and bio-
chemical changes include (Stallard et al., 2002)

• stress hormones
• corticosterone
• adrenaline, noradrenaline
• glucagon
• aldosterone
• metabolites
• glucose
• lactate
• pyruvate

Several studies have exhibited the psychological processes that are

implied in the stress response and have shown, according to Selye’s research,
the participation of the hypothalamic-pituitary-adrenal (HPA) axis and the
major role of cortisol. The activation of the HPA axis represents one of the
several important responses to stressful events and pain in critical illnesses.
The stress response takes a biological aspect: increased cortisol plasma lev-
els is observed (Boudarene, Legros & Timsit-Berthier, 2002).
302 Clinical Hypnosis in Pain Therapy and Palliative Care

The metabolic effects of stress are known to have significant effects in

children. Most of these effects are mediated by the major stress hormonal
axis in the body, the HPA axis. Within the central nervous system, the hip-
pocampus, the amygdala, and the prefrontal cortex, as part of the limbic sys-
tem, are believed to play important roles in the regulation of the HPA axis.
With the advent of structural and functional neuroimaging techniques, the
role of different central nervous system structures, in the regulation of the
HPA axis, can be investigated more directly in pain.
PET results demonstrated that stress causes the dopamine release if sub-
jects reported low maternal care early in life. By employing fMRI, we can
understand how exposure to stress and activation of the HPA axis is associ-
ated with decreased activity in major portions of the limbic system, a result
that allows us to speculate on the effects of stress on cognitive and emotion-
al regulation in the brain. Taken together, the use of neuroimaging tech-
niques in psychoneuroendocrinology opens exciting new possibilities for the
investigation of stress effects in the central nervous system (Pruessner et al.,
2010).

B. Pain Assessment and Management in Children

To evaluate and treat chronic childhood pain efficiently and effectively,
the mind-body dualism must be abandoned. It is meaningless to dichotomize
chronic pain as organic versus nonorganic, because all pain is associated
with, at a minimum, neurosensory changes. Maintaining this dichotomy is
harmful because such faulty thinking leads to over-medicalization (inappro-
priate investigations, procedures, and interventions) or insufficient acknowl-
edgment of the child’s multidimensional experience and underlying neuro-
physiology (American Pain Society).
The measurements of pain are needed to identify patients who require
intervention and to evaluate the effectiveness of intervention. The terms
measurement and assessment are widely used in the pain literature and dif-
ferentiated in the following manner. Measurement refers to the assignment
of a number or value and is commonly associated with the dimension of pain
intensity. Assessment describes a more complex process in which informa-
tion about pain, its meaning, and its effect on the person is considered along
with quantitative values (O’Rourke, 2004).
VAS have a number of convenient and favorable properties. A pain scale
measures a patient’s pain intensity or other features. Pain scales are based on
self-report, observational (behavioral), or physiological data (Melzack &
Katz, 2001). Self-report is considered primary and should be obtained if pos-
sible. Pain scales are available for neonates, infants, children, adolescents,
 Relaxation and Hypnosis in Pediatric Patients 303

adults, seniors, and disabled persons whose communication is impaired.

Children ages eight and above can generally apply standard VAS success-
fully. Several self-report scales, have been developed for children ages three
to eight; these have been primarily on scales that use pictures or drawings of
faces (McGrath & Unruh, 1999; Johnston, 1998; Turk & Melzack, 2001;
Pediatric Pain Sourcebook of Protocols, Policies and Pamphlets, 2007).

From Tears to Words: The Development of

Language to Express Pain in Young Children
Behavioral observation is the primary assessment approach for preverbal
and nonverbal children and is an adjunct to assessment for verbal children.
Observations focus on vocalizations (e.g., crying, whining, or groaning), ver-
balizations, facial expressions, muscle tension and rigidity, ability to be con-
soled, guarding of body parts, temperament, activity, and general appear-
ance.
For infants, very young children, and children with severe cognitive or
communication impairments, it may be impossible to use self-report mea-
sures; therefore, behavioral measures are required. Behavioral measures
include measures of crying, facial expression, body posture and movements,
daily routines, or some combination of these items (Prkachin K. M., 2009).
The Neonatal Facial Coding System and the Child Facial Coding System are
behavioral measures of pain intensity (McGrath & Unruh, 1999; Johnston,
1998; Melzack & Kate, 2001).
A mother’s responsiveness to her infant’s signals and pain is important
for developing their personal relationship and the child’s social and cognitive
competence. While interacting, both mother and infant emit signals to cap-
ture each other’s attention and to indicate whether to join, sustain, or termi-
nate their interaction. Maternal sensitivity to these signals is a central feature
in the development of optimal or secure attachment (Leavitt, 1999).
Maternal love, which may be the core of maternal behavior, is essential
for the mother-infant attachment relationship and is important for the
infant’s development and mental health. Little has been known about these
neural mechanisms in human mothers, and the relationship between mater-
nal love, pain and infant behavior, however.
When first-time mothers see their own infant’s face, an extensive brain
network seems to be activated wherein affective and cognitive information
may be integrated and directed toward motor/behavioral outputs. Dopa-
minergic reward-related brain regions are activated specifically in response
to happy, but not sad, infant faces.
304 Clinical Hypnosis in Pain Therapy and Palliative Care

Understanding how a mother responds uniquely to her own infant when

she or he is smiling or crying, may be the first step in understanding the neur-
al basis of mother-infant attachment and relief from pain and suffering (Strat-
hearn, Li, Fonagy & Montague, 2008). The single cue of a screwed up or dis-
tressed-looking face is the strongest predictor, and on its own correctly clas-
sified 87 percent of pain and nonpain episodes (Stallard et al., 2002). Child-
ren rapidly develop an extensive vocabulary to describe pain between
twelve and thirty months of age, with words for pain from injury emerging
first and reflecting the development of normal speech acquisition.
The differences in verbal expressions in the context of illnesses and
injuries suggest that children make a cognitive distinction between the origins
and the sensory aspects of pain. These findings can help parents and childcare
and healthcare professionals to appreciate the early communication capabili-
ties of young children and to engage in more effective pain assessment and
management for young children (Franck, Noble & Liossi, 2010).
Adequate reliability and validity documentation is lacking for behavioral
observations; consequently, most such observations offer only a second-best
approximation of the child’s experience, even though clinicians often attri-
bute greater importance to nonverbal expression than to self-report (Craig,
1992). Observations are problematic in that the stimulus for behaviors or
changes is not always clear. For example, children cry in response to pain, as
well as fear, loneliness, and overstimulation.
Infants and children with an intellectual disability are sometimes unable
to verbalize and describe their painful experience; therefore, family mem-
bers and health professionals can assess the intensity of the pain only from
the behavior exhibited by the children.
Pain expression modalities are extremely different between children able
to verbalize their pain and those unable to do so (Dubois, Capdevila,
Bringuier & Pry, 2008). There is the necessity to take into account the par-
ticularities of each child in order to individualize the pain management and
avoid misdiagnosis and the undertreating of pain in nonverbal children. The
verbal indications of pain in children are are much less common than in
adults. They may not understand a term, such as “pain.” They speak global-
ly, such as “I don’t feel good,” or deny pain for fear of being given an injec-
tion. They may cry, scream, groan, or moan or use a variety of words to de-
scribe pain, such as ow, boo-boo, ouch, hurt.

C. Pain Treatment in Children

Pain and suffering, are managed within a therapeutic alliance among the
child, his or her parent(s), nurses, physicians, and other health-care profes-
 Relaxation and Hypnosis in Pediatric Patients 305

sionals. The beliefs and preferences of the child and family should be elicit-
ed, respected, and carefully considered. At the same time, the primary oblig-
ation of the health-care professional is to ensure safe and competent care.
The presence of divergent beliefs and goals among members of the team can
interfere with effective pain and symptom management, but these can often
be resolved through discussion and negotiation. Medical interventions in-
clude analgesics, adjuvant agents (e.g., corticosteroids, tricyclic antidepres-
sants, stimulants), palliative chemotherapy, radiation therapy, regional anal-
gesia-anesthesia, and neurosurgical approaches. In most cases, analgesics
either alone or supplemented with chemotherapeutic agents, radiation ther-
apy, and adjuvants provide adequate pain relief. Regional analgesia-anesthe-
sia is occasionally helpful.
In children with chronic pain in palliative care we have to use the
WHO’s pain ladder. If pain occurs, there should be prompt oral administra-
tion of drugs in the following order (WHO):

1. nonopioids (aspirin and paracetamol)

2. then, as necessary, mild opioids (codeine)
3. then strong opioids such as morphine, until the patient is free of pain

To calm fears and anxiety, additional drugs, “adjuvants,” should be used. To

maintain freedom from pain, drugs should be given “by the clock.” In other
words, every three to six hours, rather than “on demand” (WHO). This
three-step approach of administering the right drug, in the right dose, at the
right time, is inexpensive and 80 to 90 percent effective. Local anesthesia
and regional nerve block anesthesia or surgical intervention on appropriate
nerves may provide further pain relief, if drugs are not wholly effective.
The physical examination should include an appropriately directed neuro-
logical and musculoskeletal evaluation. Appropriate diagnostic procedures may
be conducted as part of a patient’s evaluation, based on a patient’s clinical pre-
sentation. The choice of an interventional diagnostic procedure (e.g., selective
nerve root blocks, medial branch blocks) should be based on the patient’s spe-
cific history and physical examination and anticipated course of treatment.
Standard dosing of opioids adequately treats most cancer pain in children; how-
ever, a significant group requires more extensive management. These problems
occur more commonly among patients with solid tumors metastatic to the spine
and major nerves (Collins, Grier, Kinney & Berde, 1995).
Drugs for cancer and chronic pain include anticonvulsants, antidepres-
sants, benzodiazepines, N-methyl-D-aspartate receptor antagonists, nons-
teroidal anti-inflammatories, opioid therapy, skeletal muscle relaxants, and
topical agents (American Society of Anesthesiologists, 2010).
306 Clinical Hypnosis in Pain Therapy and Palliative Care

The purpose of these guidelines for chronic pain management is to opti-

mize pain control, enhance functional abilities and physical and psychologi-
cal well-being, enhance quality of life, and minimize adverse outcomes. The
psychosocial evaluation should include information about the presence of
psychological symptoms (e.g., anxiety, depression, or anger), psychiatric dis-
orders, personality traits or states, history of substance in adolescents or cur-
rent medication use or misuse, and coping mechanisms.

D. Psychological and Behavioral Factors in

Pain Treatment in Children and Adolescents
Children and adolescents with chronic illnesses or cancer present an
exceptional stress. The emotional needs of adolescents with cancer are a seri-
ous factor in the recommendation for the establishment of adolescent cancer
units, in major cancer centers, and parental anxiety scores, especially those
of mothers, is much higher than reported norms (Allen, Newman &
Souhami, 1997).
In a study conducted at the Royal Children’s Hospital, Melbourne, par-
ents of children who had died of cancer over the period from 1996 to 2004
were interviewed between February 2004 and August 2006. Parents also
completed and returned self-report questionnaires. Eighty-four percent of
parents reported that their child had suffered “a lot” or “a great deal” from
at least one symptom in their last month of life, most commonly pain (46%),
fatigue (43%), and poor appetite (30%). Of the children treated for specific
symptoms, treatment was successful in 47 percent of those with pain, 18 per-
cent of those with fatigue and 17 percent of those with poor appetite.
Relatively high rates of death at home, and low rates of unsuccessful medical
interventions suggest a realistic approach at the end of life for Australian chil-
dren dying of cancer. Many suffer from unresolved symptoms, however, and
greater attention should be paid to palliative care for these children (Heath
et al., 2010).
What is needed is a systematic and comprehensive approach to all chil-
dren with significant life-threatening diseases to ensure that their special
needs are met. If timely palliative care is to be available to the terminally ill
child, a shift in perspective is required as to how and when such support is
introduced. Developing resources with the people who provide frontline
care for these children and their families enables health professionals to as-
sume this special aspect of care with more confidence and competence.
In children and adolescent, nonpharmacological methods demonstrated
efficacy for procedures—lumbar punctures, bone marrow aspirations, biop-
sies and anesthesiology procedures—and include
 Relaxation and Hypnosis in Pediatric Patients 307

1. clinical hypnosis used in the therapy of pain, suffering, and procedures

in children (Brugnoli, 2009, Jensen & Patterson, 2006; Richardson,
Smith, McCall & Pilkington, 2002; Ziltzer & LeBaron, 1982).
2. a multidimensional psychological intervention that includes disctrac-
tion, breathing exercises, relaxation, reinforcement, and imagery
(Brugnoli, A., 2005; Brugnoli, M. P., 2009; Jay et al., 1985).

Clinical hypnosis appears effective in reducing pain and anxiety in chil-

dren undergoing lumbar punctures (Accardi & Milling, 2009). Lumbar punc-
ture, also known as spinal tap, involves the removal of cerebral spinal fluid
from the spinal canal. This fluid contains glucose, proteins, white blood cells,
and many other substances that are also found in blood. Doctors use lumbar
punctures to diagnose and monitor many different severe neurological dis-
eases, including cancers of the spinal cord and brain.
Hypnosis was shown to be more effective than nonhypnotic techniques
were for reducing procedural distress in children and adolescents with can-
cer (Zeltzer & LeBaron, 1982). As defined by the American Cancer Society,
hypnosis “is a state of restful alertness during which a person can be rela-
tively unaware of, but not completely blind to, their surroundings.”
A team of researchers in the psychology department at the University of
Wales conducted a controlled clinical trial of eighty pediatric cancer patients
between the ages of six and sixteen. Each group of children received one of
four different types of treatment:

1. direct hypnosis with standard medical treatment

2. indirect hypnosis with standard medical treatment
3. attention control with standard medical treatment
4. standard medical treatment alone.

Standard medical treatment for all patients consisted of lumbar puncture.

Patients who underwent hypnosis, direct or indirect, reported less anxiety
and pain than did their unhypnotized counterparts. In addition, all the forms
of hypnosis appeared equally effective. Hypnotized patients were also rated
by the investigators as demonstrating less behavioral distress than the control
groups did. An important factor associated with the efficacy of hypnosis was
the ease with which a patient could become hypnotized. These British re-
searchers concluded that hypnosis appears effective in preparing children
with cancer for lumbar puncture and procedures (Liossi & Hatira, 2003). A
comprehensive, methodologically informed review of studies of the effec-
tiveness of hypnosis for reducing procedure-related pain in children and ado-
lescents was provided. To be included in the review, studies were required to
308 Clinical Hypnosis in Pain Therapy and Palliative Care

use a between-subjects or mixed model design in which hypnosis was com-

pared with a control condition or an alternative intervention in reducing the
procedure-related pain of patients younger than age nineteen. An exhaustive
search identified thirteen studies satisfying these criteria. Hypnosis was con-
sistently found to be more effective than control conditions were in alleviat-
ing the discomfort associated with bone marrow aspirations, lumbar punc-
tures, voiding cystourethrogram, and post-surgical pain (Accardi & Milling,
2009).

2. PERCEPTION, CONSCIOUSNESS,
AND HYPNOSIS IN PEDIATRIC AGE

We can understand the use of clinical hypnosis in children’s pain if we

know the different interpretative hypotheses (according to the different ap-
proach of various theoretical trends or schools of thought) concerning the
cognitive and the consciousness development.

A. Perception and Mind in Children

How do perception and consciousness develop in children? What role
does experience play? Are there distinct phases in development? Is there a
general common sequence in such phases? Psychology is called to answer to
such and many other questions. To exemplify, we could distinguish between
two major schools, very far apart on the value to assign to experience.
The first school (Langer, 1973) recognizes—through theorization and
empirical research—a key role for environmental influence. The individual
development will be achieved modeling oneself to personal experience.
Although a radically empiric interpretation of development finds less and
less success nowadays, for many years, huge branches of developmental psy-
chology were influenced by this model (Bandura, 1963; Skinner, 1959).
On the other hand, the second school—which includes Werner and Piaget
among its most important scholars—assigns to the mind an active role in
structuring the experience. According to this theory, the development takes
place through a self-constructive activity that takes the child from a primitive
stage, to more and more evolute ones.
As far as movement is concerned, we can say that a certain amount of
physical exercise corresponds to a primary bodily need (Stevens, 1950).
Werner upholds the idea that the main principle of development has to
be sought in the progressive differentiation of mental structures and distinc-
tions and simultaneously in their advanced integration.
 Relaxation and Hypnosis in Pediatric Patients 309

The mind is equipped with a self-regulation system aimed to balance the

structure once an imbalance has occurred, either in one of its parts or in its
whole. So the psychophysical balance becomes the fundamental element in
the mental development because it does not simply “repair” the disturbance
caused by experience but tends to restore the balance, considering both the
disturbing elements and the mechanism activated by them. Therefore, the
new balance will reach a higher level of organization. The latest generated
mental action could then integrate and anticipate eventual future distur-
bances. This information is extremely relevant for the use of hypnosis in pain
therapy. The cognition development in a child will have a spiral progression
in which experience plays a key role in the coordination with the preexistent
balance (Piaget, 1972; Travis, Arenander & Dubois, 2004).
In 1915, Groos already advanced the hypothesis that, in children, game
represents a way to exert the same capabilities necessary at a more adult age to
sustain anxiety itself, and even tensions generated by the relation with the world.
Cognitive abilities do not occur in isolation. Infants remember the items
they have attended to and perceived, and their emotional state will influence
their perception and representation of the events they encounter. Moreover,
by examining the development of the whole cognitive system, or the whole
child, we gain a deeper understanding of mechanisms developmental change
(Oakes, 2009). Game has also to be seen as an organized expression of the
primary needs of perception and manual ability (Benedetti, 1969). We should
add that the role of the game in the hypnologic approach is really crucial, as
will be explained later.
As far as the relationship psyche-soma is concerned, it is by now consol-
idated, so that the quantity of sensory information reaching the cortex can
change with the variation of the state of consciousness. The sensory infor-
mation reaches its apex in the states of selective attention, which do not nec-
essarily correspond to the awake state and do not necessarily decrease in the
absence of attention. The important research conducted on the subject by
Hernandez Peon deserves a mention. He demonstrated that distraction
induces a reduction in potentials in the visual cortex, evoked by flashing
lights, until their complete disappearance for the modest intensity of the
stimuli. Vice versa, the neurological reaction becomes iterative as a conse-
quence of the increasing of the attention. The control of sensory information
by central structures begins at a peripheral level, for example, retinal
(Hernandez-Peon & Hagbarth, 1955) or cochlear, and then at reticular for-
mation. Only a minimum part of the sensorial stimulation, as Moruzzi states,
becomes probably part of our perceptive process.
Moruzzi could demonstrate this phenomenon through an electrophysio-
logical study of sleep. He observed that the great activity of cortical neurons
310 Clinical Hypnosis in Pain Therapy and Palliative Care

did not decrease compared to the awake state. The discharge of the laby-
rinthic receptors or of the retina, in a dark environment, are all examples of
an independent nervous activity of consciousness. This research is extreme-
ly interesting for a better study of the psyche (Moruzzi, 1981; Wong et al.,
2007; McKown & Strambler, 2009).
Perception of the dispositions of others, revealed by movements, is an
essential ingredient of adaptive daily life social behavior. Brain’s imaging
points to several brain regions, involved in visual processing of social inter-
action, represented by the motion of geometric shapes.
Keeping in mind that successful visual social perception depends on
intact communication throughout the brain, we focus here on analysis of the
induced gamma neuromagnetic response to social interaction revealed by
motion. A peak of induced gamma activity of 62 Hz was found at first from
the stimulus onset over the right parietotemporal junction. Two further en-
hancements in gamma response of lower frequency of 44 Hz, occurred at 1.4
seconds over the medial prefrontal and posterior temporal cortices in the
right hemisphere. Subsequent boosts of 44 Hz were found at 1.6 seconds
over the left temporal and right posterior temporal cortices. For the first time,
the findings identify the cortical network engaged in visual processing of
social interaction, revealed by motion, and help to better understand proper
functioning of the social brain circuitry (Pavlova, Guerreschi, Lutzenberger
& Krägeloh-Mann, 2010). Neurophysiology also considers the possibility that
the limits of unconscious could not be defined simply by the organic struc-
ture. The way in which the latter is used, especially in the human being (as
Moruzzi noted), depends, for the most part, on the individual cultural for-
mation, imagination, personality, and psyche (Eccles, 1966; Franck, Noble &
Liossi, 2010).
Currently it is necessary to conceive in a dynamic way even the bound-
ary between conscious and unconscious phenomena. The integration of all
these data through a long learning process, constitutes the so-called “subjec-
tive integration” (Held, 1961). Consciousness poses the most enigmatic prob-
lems in the science of the mind. There is nothing that we know more famil-
iarly than conscious knowledge, but there is nothing that is harder to explain.
There is not just one problem of consciousness. Consciousness is an unclear
term, referring to many different phenomena. Each of these phenomena
needs to be explained, but some are easier to explain than others.
According with the philosopher David Chalmers, it is useful to divide the
associated problems of consciousness into “hard” and “easy” problems. The
easy problems of consciousness are those that seem directly susceptible to
the standard methods of cognitive science, whereby a phenomenon is ex-
plained in terms of computational or neural mechanisms. The hard problems
 Relaxation and Hypnosis in Pediatric Patients 311

are those that seem to resist those methods (Chalmers, 1998). In line with
Chalmers, the hard problems are related to these phenomena:

• The ability to discriminate, categorize, and react to environmental

stimuli
• The integration of information by a cognitive system
• The different states of consciousness
• The ability of a system to access its own internal states
• The focus of attention
• The deliberate control of behavior
• The difference between awake state and sleep

The really hard problem of consciousness is the problem of experience.

When we think and perceive, there are billions of pieces of information pro-
cessing, but there is also a subjective aspect (Chalmers, 1998).
Damasio has suggested that the senses of vision, hearing, touch, taste and
smell function by nerve activation patterns that correspond to the state of the
external world. Emotions are nerve activation patterns that correspond to the
state of the internal world. If we experience a state of fear, then our brains
will record this body state in nerve cell activation patterns obtained from
neural and hormonal feedback, and this information may then be used to
adapt behavior appropriately. Emotions are based on internal body envi-
ronment and act as input into the brain, just as visual or auditory informa-
tion is an input to the brain from the external environment. Certainly in evo-
lutionary terms, the brain is primarily an organ for homeostasis, a center that
collects and collates feedback on body states and performs to maintain con-
stancy of the internal environment. This concept vastly clarifies the role and
nature of emotions and allows them to be studied using the full force of inte-
grated modern neuroscience (Damasio, 1999).
We have already considered how, from a neurophysiological point of
view, soma and psyche constitute a wholeness. Now it is important to ana-
lyze a new acquisition of modern neurophysiological thought: the involve-
ment of emotions in perception.
The relevancy of the interaction between emotions and perceptions has
already been demonstrated by several studies, and it has been shown in the
congenital defects observed after a parietal damage. In this case we are in
front of both a sensorial deficit and an emotional deficit for everything lying
in such a space (Benedetti, 1969; Franck, Noble & Liossi, 2010).
Emotions exemplified well how an increasing of adaptability, in con-
junction with the activation of an automatism suitable to predispose a prompt
and appropriate body reaction, corresponds to the occurrence of uncon-
312 Clinical Hypnosis in Pain Therapy and Palliative Care

scious process and mechanisms (Bandura, 2001). Emotions also clarify how
the persistence of unconscious mechanisms could constitute an obstacle on
the path of personal growth and of social progress.
Whereas in some cases, a good chunk of our intelligence and cultural
realization is due to emotions, in other situations, we are able to preserve our
well-being only by keeping them under control.
When we talk about relaxation and clinical hypnosis techniques in chil-
dren, we earlier underlined how the soma-psyche interaction is important for
the understanding of neuropsychomotricity. We have to remember also that
knowledge about this interaction is in ongoing evolution and represents a
vast sector of research. Psychomotricity plays a key role in individual devel-
opment, and this premise makes it important to understand both the relation
perception-soma-psyche and the hypnosis techniques.
It is useful to recall Milton H. Erickson’s experiences in pediatric hyp-
nosis since they could demonstrate themselves to be suitable for a wide range
of situations.
As we said, a change in the state of consciousness could modify cortex
perceptions, increasing their amount in a state of concentration and new abil-
ities (Benedetti, 1969; Travis, Arenander & DuBois, 2004). This underlines
the advantage in the formation of a balance in the psychosomatic develop-
ment. Whereas psychomotricity develops only a deeper awareness of motion,
relaxation techniques, including hypnosis, facilitate a deeper level of self-
motion consciousness and a better perception of one’s own body. Moreover,
they help (through the data perceived and known during a situation of mus-
cular relaxation and calmness) the self.
In pediatrics, according to Erickson, any kind of therapist-patient inter-
action has to be specifically adapted to the child, since he has his own needs.
This requires an accurate physical and psychic assessment of the patient age.
Therefore, any intervention must be based on the own child needs and never
on an arbitrary classification. The psychologically oriented treatment, if used
in an appropriated way, must refer to the child capability of expressing his
feelings and of understanding the events.
The relaxation and hypnosis techniques used on children are the ones
usually employed with adult patients. The only difference lies in the admin-
istration of the treatment. It is important to keep in mind that a child is
indeed a “complete” person though a young and little one. His view of the
world (and of the events) is not the adult’s views. His experiences and his
knowledge are limited and different. When we use the relaxation or hypno-
sis techniques with a child, the central aim is to make him understand in a
more complete and in a better way, what is happening around him.
 Relaxation and Hypnosis in Pediatric Patients 313

This “modus operandi” is not always necessary with adult patients and
makes the use of specific techniques easier with a child, for in pediatric age,
there is a pressing need of knowing and discovering.
Since relaxation, especially with hypnotic techniques, entails a deeper
awareness, it could also offer a child a new and easy area of psychomotor ex-
ploration (Erickson, 1978). This work has to match with the child dignity,
with his experiences, and with all he learned during his life. It would be a
huge mistake to talk to the pediatric patient in a childish way or, even worse,
to look down on him. It is therefore crucial that the therapist-patient inter-
action be first of all an interaction between “two persons.”
The therapist must present to the patient a serious concept with sinceri-
ty in order to reach a common goal through a mutual understanding.
Independently of the age, the patient should never sense the presence of
a threat. The adult physical or intellectual strength, his authority, and his sta-
tus are so much superior to the child’s that their undue use represent a threat
to his adequacy as an individual. The effective verbalization of pain requires
progressive cognitive development and acquisition of social communication
skills.
Use of self-report in pediatric pain assessment assumes children have
acquired a capacity to understand and use common words to describe pain
(Stanford, Chambers & Craig, 2005). Because a child cannot rely on a solid
ground of experiences, a therapist will necessarily work with the patient and
not on the patient. It should be always kept in mind that for a child it is not
easy to accept a passive participation in the treatment. It is fundamental to
address a pediatric patient without altering the usual tone of voice and way
of talking.
The best way to establish a relationship with a child is to use a familiar
language and to support what is explained with images and ideas suitable for
catching his attention. Talking to a child in a puerile way is usually perceived
as some sort of insult because any average intelligent child knows that an
adult can talk perfectly. It is also necessary to respect the child’s ability with-
out ever minimizing it, to grasp most concepts. It gives a better result to hope
in a better understanding, rather than to hurt the patient by implying a lack
of knowledge on his part.
Any child must be respected as a thinking being. He has his own feelings,
he can formulate thoughts and ideas. He is also able to integrate his thoughts
with his experience even if he has to do that according to his way of relating
with the world (Erickson, 1978). No adult can do this for him, and this should
always be taken into consideration in whatever therapeutic approach to a
child.
314 Clinical Hypnosis in Pain Therapy and Palliative Care

The relaxation and hypnosis techniques to administer to children are often

for them, the most intuitive ones. The treatment should resemble a game to
which the child can respond actively and so personally participate in the
development of a therapy. A child has an extraordinary power of imagina-
tion, and his curiosity, along with his quickness, enable him to have a com-
petent and satisfying reaction to the most variegate techniques. The most
adequate results have been achieved by giving a child the satisfaction of hav-
ing learned something new.
Erickson reports an interesting example concerning the use of hypnotic
relaxation technique in pediatrics. He describes the case of a very belligerent
two-year-old girl. She did not want to deal with anyone, and she was ready
to keep her position by all means. Erickson had noticed that the girl’s
favorite toy was a little rabbit. He therefore approached the girl in a challeng-
ing way by saying,

I think your rabbit does not know how to sleep.

“Oh no, my rabbit knows how to sleep,” and the battle had so started.
“Even if you show him how to sleep I think your rabbit is not able to lie down
putting his head on the pillow.”
“The rabbit is able to do so. Look!”
“And can he stretch his/its legs and arms as you do?”
“Yes he can! Look!”
“And can he also close his eyes, breath deeply and fall asleep?”
“The rabbit sleeps.”

The last declaration was made with some sort of satisfaction. The girl and her
rabbit fell asleep and kept sleeping in a state of deep relaxation.
In this particular case, the adopted technique consisted of meeting the
girl at her level, as an individual, and in second instance, in presenting ideas
to which she could actively respond. So she was able to participate to the
achievement of a common goal acceptable for both her and her therapist
(Erickson, 1978).
The described technique of indirect suggestion can be useful to approach
a child during procedures, in an emergency room, in a doctor’s office, as well
as in palliative care. It is in fact easy enough to make a toy by blowing up a
latex glove and then painting eyes and a mouth on it. The reason for the suc-
cess of this trick is simple: in pediatric psychology the main duty of a doctor
or therapist is to meet the child’s immediate needs. This is what the child can
grasp, and once his needs have met it has also been created a better situation
in which to treat him.
If it is necessary to treat a pediatric patient with any “traumatic therapy”
or procedures (i.e., injections, stitches etc.), however, it is probably better to
 Relaxation and Hypnosis in Pediatric Patients 315

implement a different technique. In fact, Erickson describes another inter-

esting way to deal with a pediatric patient suffering from a severe pain. The
child, according to Erickson, wants not only sympathy but also the acknowl-
edgement of his pain. This implies that there should not be a falsification of
the real situation.
Another effective behavior could be helping the pediatric patients to
develop their self-esteem with direct suggestions. This should be obtained by
using affection rather than severity, by showing care for the children’s needs
(either physical or cognitive), and by the demonstration of knowing how to
do interesting and beautiful games. To all of this should also be added the use
of positive motivations.
One could therefore follow the interiorization of experiences with the
subsequent reinforcement of the self, along with an ability to express opin-
ions and of taking decisions on the basis of rational and objective considera-
tions (Petter, 1989; Travis, Arenander & DuBois, 2004). Erickson describes in
this regard to an episode of his family life. His three-year-old son had fallen
down the stairs; he broke his lip and one tooth dug into his lower jaw. The
child was bleeding profusely, and he was crying out in pain and fear. Erick-
son got near his son and, while the latter had momentarily stopped crying in
order to breathe, said in a affable but firm voice, “It hurts, I know it hurts ter-
ribly.” The child understood that his father recognized his pain. Then Erick-
son added, “And it will keep hurting.”
It is never emphasized enough that one of the most important things in
pediatric psychology is to talk to the pediatric patient in a sympathetic and
understanding way. He should always feel that we grasped his situation and
we know perfectly that he is suffering. Erickson kept talking to his son, “I
know you would like the pain to stop.” By saying so, he recognized the
child’s urgent need that the pain stop. Only at this point, Erickson said to the
child with a certain confidence, knowing that only then the information could
be accepted: “Maybe in a couple of minutes it won’t hurt so much.” This sort
of direct suggestion perfectly harmonizes with the patient needs, and it can
therefore be easily accepted.
A central point of this therapy is represented by the understanding of the
rational meaning of the injuries, of the pain, and of the physical damage.
This had implied the acknowledgment of what was important for the
child who—as a consequence—cooperated in the treatment of the traumatic
event (Erickson, 1978). The example just described is a direct suggestion and
a hypnosis technique.
The work on the patient started with the first sentence addressed to him.
It became more obvious when the child began to pay attention to whatever
was happening around him, during the medical treatment of his problem.
316 Clinical Hypnosis in Pain Therapy and Palliative Care

Never was he lied to and never was he given false information in conflict
with the reality and with his understanding capability. In situations such as
the one described, the patient has a strong and urgent need of seeing some-
body taking care of him. The acknowledgment of such a need, along with the
promptness in acting on the cause of the need, constitutes a very effective
suggestion. It indeed helps the therapist in gaining the patient’s complete
cooperation, to adopt the adequate therapy.
As far as the “going through the body,” clinical hypnosis and the relax-
ation techniques (for example, the Jacobsonian ones) are concerned, they
can surely help the child in a variety of situations in which it could be nec-
essary for some kind of relaxation. They are also indicated in specific situa-
tions, however. They can indeed represent a therapy even in acute and
chronic pain disorders.
Children’s palliative care encompasses the clinical, psychological, ethi-
cal, and spiritual aspects of care for children with life-threatening and life-
limiting conditions. Children affected by these conditions have unique and
multiple care needs that are very different from those of adults. Whereas in
some countries child-specific palliative care services and practices have been
in place for a number of years, in many others the recognition of needs and
the development of dedicated pediatric palliative care services are still at an
early stage.

3. DISTRACTION, RELAXATION, AND

HYPNOSIS TECHNIQUES FOR CHILDREN

To ensure the best pain control, support has to be offered right from the
first intrusive procedure in order to avoid anticipatory anxiety. Respiration,
relaxation, visualization, desensibilization through the “switch technique”
and the “magic glove,” distraction and involvement, and muscular relaxation
all have the common aim of focusing the child’s mind and attention away
from body perception of pain connected to the procedure. Different meth-
ods are utilized depending on the child’s age and the level of consciousness
required for the procedure:

A. Distraction Techniques
B. Relaxation Techniques
C. Clinical Hypnosis Techniques
 Relaxation and Hypnosis in Pediatric Patients 317

A. Distraction Techniques
A few simple techniques can make a difference in a child’s hospital expe-
rience. Considering areas such as distraction, environment, positioning, and
language may help a child have a positive hospital experience. Giving pa-
tients something else to focus on is especially effective. Age-appropriate dis-
traction facilitates coping, helps manage pain, decreases the use of pharma-
cological methods, and builds trust between the staff and patient (Sharar et
al., 2008).

Using Play Therapy in Pediatric Palliative Care:

Listening to the Story and Caring for the Body
Parents and caregivers of dying children are generally the primary deci-
sion-makers in the child’s care and can find the transition from active to pal-
liative care particularly difficult. Nurses who understand the parents’ per-
spective can better support them.
To be greatly comprehensive, palliative care for children must address
more than pain control and symptom management (Van Breemen, 2009).
Holistic care also encompasses attention to the child’s relationships, hopes,
fears, and wishes. Children reveal their hopes and fears through play. By
being attuned to symbols and themes in play, nurses can better interpret the
child’s journey. Nurses can facilitate communication and connection be-
tween parents and children.

The Technique of Play by Play in Pain Procedures

Increase a child’s understanding by explaining each step of the painful
procedure and what to expect and telling him a story within a story. A story
within a story, is a literary device or conceit in which one story is told dur-
ing the action of another story (the procedures). Stories within stories can be
of these types:

1. The inner story is told completely in the real world and could be
extracted and told separately
2. Only fragments of it exist in the real world
3. None of the text of the inner story exists in the real world

THE TREASURE BOX. A box with small gifts or toys can be given to the
child during or after their procedures. It is a behavioral intervention (the
Treasure Chest) that employs the behavior modification techniques of self-
318 Clinical Hypnosis in Pain Therapy and Palliative Care

monitoring and positive reinforcement to increase adherence to therapy in

children (Cass, Talavera, Gresham, Moser & Joy, 2005).
THE P INWHEELS (ORIGAMI). Pinwheel (origami) is a type of traditional
origami form that can be used as a toy pinwheel, as a base for more compli-
cated models, or as a component of modular origami.
THE MAGIC B LANKET. We can give “magic powers” to a blanket for
relaxation, comfort, and protection.
THE MAGIC WAND. For children, the plastic “wands” with shiny stars
inside can be used for diversion
The Choices. Let the child have choices if any are possible, such as pop-
up books. Reading and using the pop-ups can allow mind stimulation and
distraction and may divert the child and alleviate some anticipatory pain. Be
permissive regarding when pain will go away.
THE B LOWING B UBBLES. Blowing bubbles relaxes children by slowing
and deepening the breath. Helping children experience fun, engaging activ-
ities is important. Not only does it keep them happy, creating positive bonds
between the child and the family, it also encourages healthy development. In
the early years, providing a variety of stimulations actually encourages the
development of the brain. No wonder bubble blowers are one of the world’s
oldest and most popular toys. Children have to blow out air repeatedly dur-
ing the injection, or procedures, as if they are blowing bubbles.
A simple distraction technique can be effective in helping children cope
with the pain. The use of such a technique to relieve the pain and distress
associated with even a brief painful procedure should be encouraged (French
MD, Painter & Coury, 1994).

Counting
Have the school-age child count during a difficult part of the treatment
or procedures:

. . . Allow yourself to feel passive and indifferent . . .

Counting each breath slowly from 10 to 1 . . .
With each count feel yourself more and more relaxed . . .
With each exhale allow the tension to leave your body . . .

The Use of Virtual Reality for Pain Control

Virtual reality is a relatively new technology that enables individuals to
immerse themselves in a virtual world. This multisensory technology has
been used in a variety of fields and most recently has been applied clinical-
ly as a method of distraction for pain management during medical proce-
 Relaxation and Hypnosis in Pediatric Patients 319

dures. Investigators have posited that virtual reality creates a nonpharmaco-

logical form of analgesia by changing the activity of the body’s intricate pain
modulation system (Mahrer & Gold, 2009).
Pain management in cancer patients is primarily achieved by potent
pharmacological analgesics (e.g., opioids) but is necessarily complemented
by nonpharmacological techniques, including distraction or hypnosis. Im-
mersive virtual reality provides a particularly intense form of cognitive dis-
traction during such brief, painful procedures and has undergone prelimi-
nary study by several research groups treating burn patients over the past de-
cade.
Immersive virtual reality is logistically feasible, safe, and effective in
ameliorating the pain and anxiety experienced in various settings of pain.
Furthermore, the technique appears applicable to a wide age range of pa-
tients and may be particularly well-adapted for use in children (Sharar et al.,
2008).
Emotions are often object related. It is yet an open question whether
emotions and the associated perceptual contents that they refer to are pro-
cessed by different parts of the brain or whether the brain regions that medi-
ate emotions are also involved in the processing of the associated content
they refer to. Using fMRI, it was demonstrated that simply combining music
(rich in emotion but poor in information about the concrete world) with neu-
tral films (poor in emotionality but rich in real-world details) yields increased
activity in the hippocampus and lateral prefrontal regions. The finding that
these regions, the heart of the emotional brain, respond increasingly to an
emotional stimulus when they are associated with realistic scenes supports a
fundamental role for concrete real-world content in emotional processing
(Eldar, Ganor, Admon, Bleich & Hendler, 2007).

Mindfulness: Look Around You

Mindfulness is the here-and-now approach to living that makes daily life
richer and more meaningful. It is approaching life like a child, without pass-
ing judgment on what occurs. Mindfulness means focusing on one activity at
a time, so forget multitasking! Staying in the present tense can help promote
relaxation and provide a buffer against anxiety and depression.
Practice it by focusing on your immediate surroundings. If you are out-
doors, enjoy the shape and colors of flowers, hear a bird’s call, or consider a
tree. In the mall, look at the details of a dress in the window, examine a piece
of jewelry and focus on how it is made, or window-shop for furniture, check-
ing out every detail of pattern and style. As long as you can keep your mind
focused on something in the present, stress will take a back seat. Attentional
320 Clinical Hypnosis in Pain Therapy and Palliative Care

and emotional states alter the way we perceive pain. Recent findings suggest
that the mechanisms underlying these two forms of pain modulation are at
least partially separable. This concept is supported by the observation that
attention and emotions differentially alter the sensory and affective dimen-
sions of pain perception and apparently implicate different brain circuits
(Villemure & Schweinhardt, 2010).

The Distancing From Pain

. . . Moving self away from pain, for example, imagine going to a favorite place
. . . Moving pain away from self, for example, imagine putting the discomfort in
a balloon and watching it float away.
. . . Transferring it to another part of the body, for example, put all the discom-
fort in the little finger of the right hand.

Music
Music helps to soothe or distract, especially when the child picks the
music. Music can calm the heartbeat and soothe the mind. So, when the go-
ing gets rough, take a musical stress detour by aligning your heartbeat with
the slow tempo of a relaxing song.
Language and music, two of the most unique human cognitive abilities,
are combined in song, rendering it an ecological model for comparing speech
and music cognition. Variations in musical features affect word processing in
sung language. Implications of the interactions between words and melody
are discussed in light of evidence for shared neural processing resources
between the phonological or semantic aspects of language and the melodic
or harmonic aspects of music (Gordon et al., 2008).

Singing (Play Songs and Lullabies)

A child who has not gone too far in fear or anxiety may be soothed with
singing or being sung to. Preverbal infants are conditioned to the different
emotional messages contained in play songs and lullabies. However, it is
unclear which performance properties of singing underlie infants’ perception
of the communicative intent of infant-directed singing. The overall pitch of a
song is communicative to infants, and the affective nature of music can affect
infants’ pitch preferences (Tsang & Conrad, 2010). Lullabies promote new
awareness, adaptation, and expression. A music therapist can enable the
lulling through providing opportunities for music-contextualized “restorative
resounding,” expressed psychobiologically, verbally, musically, and meta-
phorically (O’Callaghan, 2008).
 Relaxation and Hypnosis in Pediatric Patients 321

Pawuk and Schumacher introduced music therapy in hospice and pallia-

tive care. An eight-year-old boy with cancer wrote songs and records for a
CD for his family. This demonstrates the role that music therapy plays in
attending to the physical, emotional, and spiritual needs of hospice and pal-
liative care patients and families while respecting their dignity and celebrat-
ing their lives (Pawuk et al., 2010).

The Diversional Talk

Talking about the weather, your last vacation, the child’s family, an so on,
with a comforting, rhythmic voice, can be calming.

Show Some Love, Give Your Patient a Fast Hug, at Least Once a Day
Induce the relaxation response by cuddling your pet, giving or receiving
an unexpected hug with a friend or family member, snuggling with your
spouse, or talking to a friend about the good things in your lives. When you
do, you will be reducing your stress levels (Vincent, 2005). Social interaction
helps your brain think better, encouraging you to see new solutions to situa-
tions that once seemed impossible. Physical contact, like petting your dog or
cat or soft toys, may actually help lower blood pressure and decrease stress
hormones.

Massage and Self-Massage

Massage is a very good way to release tension on the muscles. Exercise
and massages are great ways to relax and can be very helpful in relieving
pain and tension from muscles. Soft tissue massage is currently used in pal-
liative care for the relief of anxiety and pain. Patients in palliative care can
received soft tissue massage (hand or foot) every day. Soft tissue massage
appears to be an appreciated source of support to dying patients in palliative
care. The method is easy to comprehend and relatively short (20 minutes)
which may imply that it is a suitable complement in nursing care for the
patient (Cronfalk, Strang, Ternestedt & Friedrichsen, 2009).
Providing gentle massage to children is one of the great joys a massage
therapist and a child can experience. Children respond very differently to
touch and are often willing and excited recipients. Typically, they like to
engage more actively than adults when receiving massage and a variety of
different techniques can be used to enhance their massage experience. Sur-
prisingly, pediatric massage is a field that has been given very little attention
until now.
322 Clinical Hypnosis in Pain Therapy and Palliative Care

Powell, Cheshire, and Swaby (2010) studied children’s experiences of

their participation in a training and support program involving massage. This
study reports on a research project that aimed to extrapolate the value of the
Training and Support Programme, involving massage among children with
cerebral palsy. Results showed that children enjoyed the relaxing aspects of
massage and reported a number of improvements in their health, such as
improved muscle relaxation, mobility and bowel movements and reduced
pain.
Pediatric massage is a natural extension of working with the whole fam-
ily in chronic pain relief and in cancer pain. At the University of Minnesota
School of Nursing, massage therapy was studied for children with cancer.
This pilot study aimed to determine the feasibility of providing massage to
children with cancer to reduce symptoms in children and anxiety in parents.
Changes in relaxation (heart and respiratory rates, blood pressure, and sali-
vary cortisol level) and symptoms (pain, nausea, anxiety, and fatigue) were
assessed in children. Anxiety and fatigue were measured in parents. Massage
was more effective than quiet time was at reducing heart rate in children,
anxiety in children less than fourteen years of age, and parent anxiety (Post-
White et al., 2010). Pediatric massage differs from infant massage and in-
cludes massage for toddlers, preschool and school-age children, and adoles-
cents and young adults.
There is some evidence to support the use of massage therapy to im-
prove quality of life for people living with HIV/AIDS, particularly in com-
bination with other stress-management modalities (Hillier, Louw, Morris,
Uwimana & Statham, 2010).
Children at each stage of growth and development have different physi-
cal, emotional, and psychological needs. One of the pleasures of massaging
children is that practitioners become attuned to providing what is needed at
each life stage, and the relationship between the massage therapist and child
evolves over time. Physiologically, children’s bodies differ from adult bodies
in significant ways. In children, the nervous system develops progressively
and is somewhat predictive by age. For this reason, massage therapists work-
ing with children need to practice ongoing communication so they can best
understand the sensations that children are feeling. Open communication is
a key element of massaging children.
Light, calming strokes and feather touch create physical and emotional
patterns of deep relaxation. Deepening and slowing of the breath and
relaxed blood flow to the hands and feet are greatly desired.
 Relaxation and Hypnosis in Pediatric Patients 323

A S IMPLE MASSAGE OR S ELF-MASSAGE TECHNIQUE

Place both hands on your shoulders and neck . . .

Squeeze with your fingers and palms . . .
Rub sweet, keeping shoulders relaxed . . .
Wrap one hand around the other forearm . . .
Squeeze the muscles with thumb and fingers . . .
Move up and down from your elbow to fingertips and back again . . .
Repeat with other arm

For massage on children you can use simple, moderate-pressure strokes to

the child’s head and neck, arms, torso, legs, and back. Dividing time between
these areas, say 4 minutes each, will address the full body and is enough to
get the desired effect. Most children do fine fully clothed. A comfortable bed
or chair in a quiet room is best. For parents seeking skilled bodywork for
their kids, the massage is a great choice, done for about 20 to 30 minutes at
a time.
In the process of maturing from infancy to adolescence, significant emo-
tional and psychological development takes place. At each stage of growth
and development, there are important considerations for massage therapists.
Verbal and nonverbal communication significantly affect whether chil-
dren and adolescents feel safe and enjoy the massage. In approaching chil-
dren and adolescents, friendly body language is important. For very young
children, maintaining close proximity to the parent can minimize tension.
When possible, clearly establishing a positive relationship with the parent
can help the child to relax.
Many health-care professionals have long known the benefits of massage
therapy for their pediatric patients. Massage has been shown to be beneficial
to children with chronic pain. We highly recommend massage therapy for
newborns, sick children, those with chronic disease, and those at end of life.
Massage is an effective therapy for treatment of somatic pain of subhealth
without adverse reactions and it should be generalized to application (Pang
et al., 2010).

Soothing Touch
Rhythmic touch alleviates loneliness and fear and promotes relaxation in
infants and children. The role of infant touch during early mother-infant in-
teractions is very important. The way in which infant touch is organized with
gaze and affect changes with the interactive context and underscores the
important regulatory, exploratory, and communicative roles of touch during
early socioemotional development (Moszkowski, Stack & Chiarella, 2009).
324 Clinical Hypnosis in Pain Therapy and Palliative Care

Distraction with the Magic Glove

For children age three to ten, the Magic Glove can be a simple distrac-
tion technique or a hypnotic technique if there is a deeper trance. According
to Leora Kuttner, it can be used for blood draws, injections, and procedures.
It may also be used on different areas of the body and presented as a magic
patch, hat, sock, and so on. For a simple distraction technique, begin by
explaining to the children that are in awake state that you will be teaching
them a “special way” to help them change how much they feel. You can say
that “you may feel something, but it will not bother you” or “I can help you
change how your arm feels.” It’s important to avoid saying, “you won’t feel
any pain.” Explain to the caregivers that you are teaching the children a strat-
egy to help them use their mind to minimize their level of pain.
Begin by “testing” each arm prior to the placement of the Magic Glove.
Apply equal pressure with the tip of a pencil to test each arm. Ask the child
where you can press on each arm. Tell the child that you will press gently on
each arm and full sensation should be felt. Reinforce the point that there is
full sensation now and there will be less feeling after the Magic Glove is on.
Ask the child to rate the feeling: a little, a lot, or not at all. This is not a pain
assessment, just a feeling assessment. Ask the patient to put the hand or arm
into yours to relax. You might say, “Relax into my hand or arm.”
You may ask the child, “Where would you like the glove to begin and
end?” Focus your touch on that area, making sure that you include the site
of the needle insertion. Take the Magic Glove out of your pocket and stroke
gently upward over designated area. Do this four to six times. Include the fin-
gers as well. Enhance sensory focus on the glove by talking about it (Kuttner,
1991, 1996).

Positioning
Hold the younger child in any position that is most comforting and sup-
portive to him or her.

Take an Attitude Break

Thirty seconds is enough time to shift your heart’s rhythm from stressed
to relaxed. The way to do that is to engage your heart and your mind in pos-
itive thinking. Start by envisioning anything that triggers a positive feeling, a
vision of your parents or friends, the image of your pet, a memento from a
vacation, whatever it is, conjuring up the thought will help slow breathing,
relax tense muscles, and put a smile on your face. Creating a positive emo-
 Relaxation and Hypnosis in Pediatric Patients 325

tional attitude can also calm and steady your heart rhythm, contributing to
feelings of relaxation and peace.

B. Relaxation Techniques
Children are not immune to stress and pain; it is an inevitable part of
existence for everyone. Given the right tools, however, children can learn to
effectively manage pain’s suffering.

The Deep Breathing

Deep breathing is very useful for any person. Your child can learn to take
a breath hold it and then release it; this slows breath, blood pressure, and
heart rate and will feel healthier. Conversely, becoming aware of our breath-
ing and learning to slow down and deepen each breath allows us to feel more
relaxed. Becoming aware of our breathing is a simple strategy.

Breathing involves taking a moderately deep breath in through nose and, paus-
ing only briefly, letting the air out slowly through your nose . . .
The slow gentle exhale is the key to sigh breathing . . .
Be sure to lengthen your outward breath . . .
Now, as you breathe out let go . . . relax your muscles of your face . . . your jaw
and your shoulders . . .
Let go of tension in your chest and stomach . . .
Let your arms and legs relax . . .
As your breath out feel a wave of relaxation, flow from the top of your head and
all the way down to your feet. . . . As you continue to breathe in this manner for
at least 10 to 20 cycles, direct your attention outside yourself . . .
And deeper . . . and deeper . . . you relax your body . . . and your mind.

Breathe Deeply
Feeling stressed evokes tense, shallow breathing, while calm is associat-
ed with relaxed breathing. So to turn tension into relaxation, change the way
you breathe.

Let out a big sigh . . . dropping your chest . . . and exhaling through gently
pursed lips . . . Now imagine your low belly . . . or center . . . as a deep . . . pow-
erful place . . .
Feel your breath coming and going as your mind stays focused there . . .
Inhale . . . feeling your entire belly . . . sides and lower back expand
Exhale . . . eeling peace and relaxation
Repeat ten times, relaxing more fully each time.
326 Clinical Hypnosis in Pain Therapy and Palliative Care

The Progressive Muscles Relaxation

PMR is a technique of stress management developed by American phys-
ician Edmund Jacobson in the early 1920s. Jacobson argued that since mus-
cular tension accompanies anxiety, one can reduce anxiety by learning how
to relax the muscular tension. Jacobson trained his patients to voluntarily
relax certain muscles in their body in order to reduce anxiety symptoms.
PMR involves alternately tensing and relaxing the muscles.
A child, practicing it like play, may start by sitting or lying down in a
comfortable spot and taking some deep breaths, and then he or she will pro-
ceed to tense, then relax, groups of muscles in a prescribed sequence (one
such sequence is starting with the hands and moving up to the arms, shoul-
ders, neck, and head and then down the torso and legs to the feet). You are
going to focus on different muscles of the body and relax them in a progres-
sive way. For example, you can focus on your arms, stretch them, hold them,
and then release them at the same time that you release your breath.

The Progressive Muscle Relaxation of Jacobson in Children

• Assume a comfortable position. Your entire body, including your
head, should be supported.
• We will try to pay attention to the feelings of muscular relaxation and
tension.
• When you tense a particular muscle group, do so vigorously without
straining, for 7 to 10 seconds.
• Concentrate on what is happening. Feel the buildup of tension in each
particular muscle group. It is often helpful to visualize the particular
muscle group being tensed.
• When you release the muscles, do so abruptly, and then relax, enjoy-
ing the sudden feeling of limpness.
• Allow the relaxation to develop for at least 15 to 20 seconds before
going on to the next group of muscles.

Now tense forcefully all the muscles in your body. All the muscles will now
become tight and tense.
Now tense forcefully the following muscles:
• legs: tense energetically . . . suddenly let go . . . relax and breathe
• gluteus: tense energetically . . . suddenly let go . . . relax and breathe
• abdominal: tense energetically . . . suddenly let go . . . relax and breathe
• back: tense energetically . . . suddenly let go . . . relax and breathe
• chest: tense energetically . . . suddenly let go . . . relax and breathe
• neck: tense energetically . . . suddenly let go . . . relax and breathe
 Relaxation and Hypnosis in Pediatric Patients 327

• forehead: tense energetically . . . suddenly let go . . . relax and breathe

• shoulders: tense energetically . . . suddenly let go . . . relax and breathe
Now let go of all the tension and relax your body completely . . .
Feel the immediate well-being sensation . . .
Mentally scan your body for any residual tension . . .
If a particular area remains tense . . . repeat one or two tense-relax cycles for that
group of muscles . . . Now imagine a wave of relaxation slowly spreading
throughout your body . . . gradually penetrating every muscle group . . . and
relax your body.

The immediate effects of PMR, include all the benefits of the relaxation
mind-body response. The long-term effects of regular practice of PMR in-
clude

• A decrease in generalized anxiety

• A decrease in anticipatory anxiety related to procedures
• Reduction in the frequency and duration of panic attacks in chronic
pain
• Improved ability to face pain situations through graded exposure
• An increased sense of control over moods
• Increased self-esteem

There are no contraindications for PMR. The effect of the tension-relaxation

sequence is to cause deeper relaxation than would be achieved by simply
attempting to relax.

Visualization, Metaphors, and Imagery

Visualization, metaphors, and imagery are very useful ways to relax chil-
dren. The children should imagine beautiful places, with peace, and happi-
ness and with people that they love.
Several lines of evidence suggest that mental motor imagery is subserved
by the same cognitive operations and brain structures that underlie action.
Additionally, motor imagery is informed by the anticipated sensory conse-
quences of action, including pain (Coslett, Medina, Kliot & Burkey, 2010).
Imagery is an important aspect of teaching children any symbolic lan-
guage. Before the age of 6, a child must have a rich imagination to master
this relationship between symbols. Imagination helps us to create. By previ-
sualizing things, it can then be transferred to paper, to the action in the phys-
ical world to create. Imagination creates the whole universe, and it is essen-
tial in the evolution of humans.
328 Clinical Hypnosis in Pain Therapy and Palliative Care

Another important aspect of imagination is that it allows the psyche to

experience things safely. The psyche does not know the difference if some-
thing is real or imagined. Mythic play and visualization give a safe container
to act out negative feelings, fears or aggressions, and desires that human’s
experience. We need to visualize things that give us pleasure to evoke that
feeling within and satisfy ourselves. Bringing imagination to a child’s world
is one of the most important things we can do. We can easily explore and
develop the vastness of a child’s inner world through storytelling and also
guided relaxations using imagery.
Allow children to create their own images that are appealing to them.
What do they like? What makes them happy? Allow them to imagine peo-
ple they love. You can create guided visualizations by starting one off on a
journey, beginning with a place, such as a forest, outer space, a boat sailing
to an island. Have them imagine it in detail. What sounds, smells, and sights
do they experience? You can add characters, such as an animal guide, a fairy,
a person who greets them. What happens next? Have them reach a special
place. What is it? A bubbling pot, a magic door, a secret well? What comes
out of it? What message is there for them? What image, object, animal is
there just for them? Have them return, saying goodbye, returning with a
magical object that was found, having a feeling of safety, comfort, joy, pain
relief or relaxation.

Audiorecorded Guided Imagery

Audiorecorded guided imagery is a home-based, guided imagery treat-
ment protocol, using audio and video recordings; it is easy for health-care
professionals and patients to use, is inexpensive, and is applicable to a wide
range of health-care settings. Guided imagery treatment plus medical care is
superior to standard medical care only for the treatment of pain (van Tilburg
et al., 2009).

C. Clinical Hypnosis Techniques for Children

Hypnosis and Self-Hypnosis in Children

Hypnosis is an altered state of consciousness. Some people describe hyp-
nosis as a normal state of focused attention. They say they feel very relaxed
and calm. During hypnosis, the mind is more open to suggestion than usual
(Brugnoli, 1974). Hypnosis is a natural mental state. For example, children
are often in a state of self-hypnosis when they are playing imaginary games.
Children are open to suggestion while in a hypnotic state; they can learn to
 Relaxation and Hypnosis in Pediatric Patients 329

change their thoughts, feelings, behavior, and attitudes. Children can take
these changes that happen during hypnosis and use them for self-improve-
ment in their usual state of consciousness. Hypnosis can be used to help
reduce anxiety, control pain, control the perception of discomfort during
medical procedures, and lessen discomfort of physical symptoms.
There is broad agreement that a phenomenon we call hypnosis exists
(Sutcher H., 2008). With children, the world revolves around them until ex-
perience helps expand that world. Because they are the center, everything is
where they are.
When children are experiencing unrelenting stress or are worried, wheth-
er or not they are conscious of it, there are warning signs for those who have
the eyes to see.
The imagination of children is very keen until parents, teachers, and oth-
ers interfere. In many schools, the style of teaching in the classroom can tend
to rule out the playful and imaginative, once children pass the second or
third grade. When adults consider daydreaming worthless, when they call
attention to its “cuteness,” and associate imagination with lying, or otherwise
imply ridicule and disbelief, the child gradually lets it weaken.
The doorway between the conscious and the unconscious mind is the
imagination. For children, it is relatively easy to reach at the deepest levels
in much less time than required by a good many adults. Stories, adventures,
visualization, imaginative games, role-playing, magic, puppets, and costumes
work most effectively with children. Any tools that stimulate the imagination
should be at the hypnotherapist’s disposal.
Hypnosis is an example of dissociation, whereby areas of an individual’s
behavioral control separate from ordinary awareness. Hypnosis would re-
move some control from the conscious mind, and the individual would re-
spond with autonomic, reflexive behavior. Weitzenhoffer describes hypnosis
via this theory as “dissociation of awareness from the majority of sensory and
even strictly neural events taking place.”
When a child is hypnotized, it might be that his or her imagination is dis-
sociated and sends the imagined content back to the sensory cortex, result-
ing in dreams or visualizations, or that some senses are dissociated, resulting
in hypnotic anesthesia. According to recent evidence, neurophysiological
processes coupled to pain are closely related to the mechanisms of con-
sciousness. This evidence is in accordance with findings that changes in states
of consciousness during hypnosis strongly affect conscious perception and
experience of pain and markedly influence brain functions. Past research in-
dicates that painful experience may induce dissociated state, and information
about the experience may be stored or processed unconsciously.
330 Clinical Hypnosis in Pain Therapy and Palliative Care

Reported findings suggest common neurophysiological mechanisms of

pain and dissociation and point to a hypothesis of dissociation as a defense
mechanism against psychological and physical pain that substantially influ-
ences functions of consciousness. The hypothesis is also supported by find-
ings that information can be represented in the mind or brain without the
subject’s awareness. The findings of unconsciously present information sug-
gest possible binding between conscious contents and self-functions that con-
stitute self-representational dimensions of consciousness. The self-represen-
tation means that certain inner states of one’s own body are interpreted as
mental and somatic identity, whereas other bodily signals, currently not ac-
cessible to the dominant interpreter’s access, are dissociated and may be
defined as subliminal self-representations (Bob, 2008).

Techniques of Indirect or Direct Suggestions

THE I NDIRECT S UGGESTIONS. The specific use of any word is important
in indirect suggestions:

“That hand” rather than “your hand”

“Pretend for a while that . . .
doesn’t belong to you, think of it as a part of a sculpture or toy. . . .”

We can consider hypnosis delivered through immersive virtual reality

(Patterson, Wiechman, Jensen & Sharar, 2006).

THE DIRECT SUGGESTIONS FOR ANALGESIA AND ANESTHESIA IN CHILDREN

Request for numbness

Re-create positive anesthetic experience
“Imagine painting a numbing medicine on . . .”
“Imagine putting an anesthetic into . . .”

DIRECT S UGGESTIONS: THE MAGIC G LOVE (IN HYPNOSIS STATE) FOR

CHILDREN AGE 3 TO 10. In the hypnotic technique, we use a deeper relax-
ation state and trance than we did in the distraction technique. Hypno-
analgesia using The Magic Glove dramatically reduces the child’s pain and
anxiety when a medical procedure is necessary.

1. Explain that you are going to apply the Magic Glove to protect his
arm. “You will know what is going on but you won’t be bothered.
You’ll feel some pressure, but it won’t bother you.”
 Relaxation and Hypnosis in Pediatric Patients 331

2. You have to induce the child in a deep relaxation and hypnotic state.
3. Use firm strokes over the child’s hand, over each finger, up over the
wrist, up to the elbow and the upper arm.
4. Stroke firmly but gently, repeating that the glove is going to protect
hum.
5. Test that the other hand has full sensation with a pencil tip and test the
arm with the Magic Glove.
6. Confirm the difference with the child.
7. Now the medical procedure can be started.

When the procedure is finished, “remove the glove,” wake up the child, and
test that there is no longer a sensation difference.

Deep Hypnosis Techniques in Children

Going into a trance is a skill. For many things, ultra-deep trances are not
necessary. If you are going to create anesthesia in pain therapy or have some
need to create a deeper hypnotic phenomenon, having a deeper trance is
helpful.
The technique for deep hypnosis should contain three types of sugges-
tions: (1) Deepening suggestions, (2) Suggestions that each time the children
are hypnotized, they more easily and quickly go into a much deeper and
relaxing state of hypnosis, and (3) Suggestions that children enjoy hypnosis
state.

1. DEEPENING S UGGESTIONS. The deepening suggestions that are easiest

to use in this situation are suggestions that relate to breathing, escalators, ele-
vators and counting. Here are some examples:

Breathing

. . . and each and every deep and natural breath you take allows you to deepen
your relaxation . . .

Counting

. . . In a moment, I’m going to count from 10 down to 1 . . .

And in allowing each number to help your body grow more relaxed . . .
your mind go more relaxed . . .
so that certain thoughts just fade away . . .
like sand slipping through your fingers . . .
You can find that easy relaxation of mind and body . . .
332 Clinical Hypnosis in Pain Therapy and Palliative Care

because of these words . . . just happens now . . .

ten easily relaxing all over again . . .
. . . nine . . . then eight deeper still . . .
. . . feeling great seven . . . six . . . five . . . mind and body relaxed . . .
four . . . relaxing more . . . three then two . . .
your deepening grew at one . . . deep levels . . . going deeper . . .
That’s right . . .

Elevators and Escalators

In a moment I’m going to ask you to imagine yourself at the top of an escalator.
I’m going to count down from ten to one . . . as I say the number ten in your
imagination, step onto the escalator . . .
Allow yourself to go deeper into relaxation with each number I say.
When I reach the number 1, step off the escalator into a state of relaxation deep-
er than you’ve ever felt before.
ten . . . step on the escalator and go much deeper . . .
nine . . . relaxing more and more with each number . . .
eight . . . allowing yourself to go deeper and deeper with each number . . .
seven . . . each number and each easy, natural breath you take helps you relax
more fully . . .
six . . . five . . . doing deeper into relaxation . . .
four . . . feeling relaxation flow and every area of your body . . .
three . . . two . . . allowing your body feel a wonderful . . . at the relaxation . . .
one . . . now more deeply relaxed than ever before . . .

2. GO MORE EASILY AND QUICKLY GO INTO A

M UCH DEEPER AND RELAXING STATE OF HYPNOSIS

. . . And each time you relax yourself . . . you more easily and quickly go into a
much deeper state of hypnosis . . .
. . . And . . . because you are learning . . . really learning what hypnosis is . . .
the next time you are hypnotized you will easily and quickly . . .
effortlessly and wonderfully enter a deep and profoundly useful trance . . .

3. E NJOY GOING INTO THE HYPNOSIS STATE

. . . You enjoy going easily and effortlessly achieving deeper and deeper levels
of hypnosis . . .
In a nutshell, here it is . . .

Create the child deepening hypnosis state with visualizations. Create a

posthypnotic reinduction cue for your subject.
 Relaxation and Hypnosis in Pediatric Patients 333

Hypnosis Technique of Visualization

For Older Children or Adolescents
Have the child imagine going to a favorite place, talking with someone
special. Try creating a peaceful visualization or “dreamscape.”
To start, have the child simply visualize anything that keeps his or her
thoughts away from current tensions. It could be a favorite vacation spot, a
fantasy island, or something “touchable,” such as the feel of silk. The idea is
to take the child’s mind off her or his stress and replace it with an image that
evokes a sense of calm. The more realistic the daydream, in terms of colors,
sights, sounds, even touch and feel, the more relaxation he or she will expe-
rience.
This hypnosis technique lasts from 3 to 10 minutes.

. . . As you listen to the words of your inner self . . . picture the images that are
being described in your mind . . .
. . . Be open to the relaxation . . . and peace . . .
My body . . . in time passing by . . .
is becoming more and more pleasantly calm . . .
Even more pleasantly calm . . .
and a feeling of great well-being . . .
imagine now a beautiful natural place . . . my favorite place . . .
my favorite place . . .
and look at the sky . . . look at the sky . . .
a beautiful blue sky, with a few white clouds . . .
they move slowly, almost rocking . . .
a beautiful blue sky, a light breeze that caresses my face . . .
and the bright sun . . . that gives me new energy . . .
energy of the body and of the mind . . .
I find my favorite place . . . in my favorite place . . .
with beautiful blue sky and white clouds slowly moving . . .
as time passes . . . time passes . . . and everything inside me becomes serene . . .
. . . and calm . . . Great calm . . .
great tranquility . . . it becomes part of me . . . and the time goes by . . .
I feel well . . . I feel well . . . I feel really well . . .
and everything else does not bother me anymore . . .

For this exercise repeat the sentences slowly, calmly at least ten times.

Relaxation, Hypnosis, and Music Therapy in Children

In children we can use music with relaxation and hypnosis techniques.
There are some types of soft music and classical music that can really help
334 Clinical Hypnosis in Pain Therapy and Palliative Care

focus and relax the mind. Songs that are recognized by children add to the
enjoyment of the music. Therapeutic music helps children fall asleep sooner
and with greater peace of mind. Adding nature sounds to music and hypno-
sis makes the heart rate respond to a slower beat, which in turn relaxes the
body and mind.
Children need words, music, and nature sounds to be calmed and
relaxed. The nature sounds include ocean waves, birds, ducks, horses, cows,
heartbeats, sea gulls, streams, and many more. This is not only for a child’s
enjoyment; an adult will feel the same peace.
Therapeutic music is a gift to the senses that reassures the child that
everything will be alright. Visual objects around the room or about the crib
can only serve the child while the eyes are open. Therapeutic music contin-
ues to soothe and reassures as the eyes close and peaceful rest sets in (van
Tilburg et al., 2009).
Functional neuroimaging studies show that music-evoked emotions can
modulate activity in virtually all limbic and paralimbic brain structures.
These structures are crucially involved in the initiation, generation, detec-
tion, maintenance, regulation and termination of emotions that have survival
value for the individual and the species. Therefore, at least some music-
evoked emotions involve the very core of evolutionarily adaptive neuroaf-
fective mechanisms (Koelsch, 2010).
The origins of using music in hypnosis are not easy to find, but there are
a few hints. Before the general use of the record player in the twentieth cen-
tury, the hypnotherapist was limited to visual induction methods or the use
of the humble metronome. The metronome is still in use today by some
practitioners for inductions. It is a repetitive, slow, monotonous stimulus that
focuses the conscious mind, allowing the hypnotherapist to communicate
directly to the subconscious. We can use the metronome in hypnosis or
music, with the power and the rhythm of words. Rhythm is what makes
music and hypnosis move and flow. Rhythm is made up of sounds, emotions,
and silences.
Music is capable of evoking exceptionally strong emotions and of reli-
ably affecting the mood of individuals. The functional imaging studies, con-
ducted so far on the investigation of emotion with music basically showed
involvement of limbic and paralimbic cerebral structures (such as the amyg-
dala, hippocampus, parahippocampal gyrus, temporal poles, insula, ventral
striatum, orbitofronal, as well as cingulate cortex) during the processing of
music with emotional valence, such as pleasant places (Koelsch, 2005).
Hypnosis in children works well because there are fewer years of rein-
forcing imprints on one’s mind. Children are more susceptible to hypnosis.
They have the drive to discover, and they hunger for new experiences.
 Relaxation and Hypnosis in Pediatric Patients 335

Children are usually easily relaxed and focused. In order for this to happen,
it is necessary to do a connection with the child, to give him the possibility
of communicating with the adult, as well as he could do with a friend of the
same age (and even better). Never has he to feel judged or being asked to be
different. He must feel accepted as he is, so a therapist will be able to inter-
est him in learning the physical and mental training necessary to reach a par-
tial state of calm. Through this step, he will have the chance to excel in any
situation because he will be able to exert an extraordinary self-control.
Another crucial moment of the therapy is represented by the explanation
to the child how calm is the most important characteristic of a strong man.
The information should be enriched with simple but effective examples
taken from real life. The therapist could take a basketball player as a model:
a champion waits for the right moment before launching the ball, he does not
lose control, and then he scores a basket. This arouses the child’s curiosity
and makes the child willing to start training as soon as possible. He will sense
that in this way that through relaxation, he could empower his capabilities,
and he will be able to feel his spaces. Creativity is fundamental for the cog-
nitive and emotional development of any child. First of all, it increases the
quality of his thoughts, and second it makes the child understand his fears.
Therefore, it enables him to get through them (Biondi, 1984).
So even in the pediatric patient the conscious and unconscious relation-
ship acquires a key role only if we deal with the patient as with a complete
being capable of self-regulation. The pediatric patient is, in fact, provided
with a system of “self-able” to integrate the various functions necessary for
interacting with the different situations one has to face in life. It is important
to add that the state of calm, reached through relaxation and hypnosis tech-
niques, showed itself to be therapeutic and anxiolytic. It could eliminate
fears, and it could provide support.
In the end, it should be considered that in pediatrics, relaxation and hyp-
nosis techniques have several uses, but it is necessary to keep in mind a few
key steps: (1) to establish immediately a good relationship with the child and
(2) to maintain his motivation high in pain therapy (Ferioli, 1974). The ben-
efits of the therapeutic effect of hypnosis techniques are especially significant
when either there is an urgent need of a state of relaxation we are in front of
chronic diseases. In this last situation, the therapist—through relaxation
and/or hypnosis—will be able to intervene precociously without leaving
unresolved problems, which could become more difficult to treat with time.
Greater attention to symptom and pain control and the overall well-
being of children with advanced disease might ease their suffering. Recog-
nition of this problem by the medical community should prompt efforts to
improve both communications between parents and caregivers and the qual-
336 Clinical Hypnosis in Pain Therapy and Palliative Care

ity of life for children who are dying of cancer and their family (Pearson,
2010).
Children are not supposed to die. Parents expect to see their children
grow and mature. Ultimately, parents expect to die and leave their children
behind. This is the natural course of life events, the life cycle continuing as it
should. The loss of a child is the loss of serenity. The theme of parental
mourning has been a universal one throughout the centuries. In the literature
on bereavement, writers repeat certain themes, thoughts, and reflections;
they talk of the powerful and often conflicting emotions involved in “the pain
of grief and the spiral of mourning.”
Sociologists and psychologists describe parental grief as complex and
multilayered and agree that the death of a child is an incredibly traumatic
event, leaving parents with overwhelming emotional needs. They also agree
that this grief must be acknowledged and felt in its intensity. Death is an ex-
perience that is common to all mankind, an experience that touches all mem-
bers of the human family. Death transcends all cultures and beliefs; there are
both commonality and individuality in the grief experience. When a loved
one dies, each person reacts differently. A child’s death, however, is such a
wrenching event that all affected by it express sadness and dismay and are
painfully shaken.
Moreover, those who seek to comfort grieving parents need to recognize
and understand the complexities of the parents’ emotions and should avoid
relying on preconceived ideas about the way a couple is supposed to grieve
if their child dies. Reactions of grieving parents may seem overly intense,
self-absorbing, contradictory, or even puzzling. For bereaved parents, the
death of a child is such an overwhelming event that their responses may
often be baffling not only to others but also to themselves. It is important
obtaining help from traditional support systems, such as family, friends, pro-
fessionals, or church groups; undergoing professional counseling; joining a
parent support group, or acquiring information on the type of death that
occurred as well as about their own grief (Warland, O’Leary, McCutcheon &
Williamson, 2010).

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 Chapter IX

CONCLUSION: QUANTUM PHYSICS AND

MODIFIED STATES OF CONSCIOUSNESS—
THE MIND BEYOND MATTER

hich are the scientific and philosophic relationships between neuro-

W physiology of the brain and the modified states of consciousness? Can
we explain them?
Jean-Emile Charon was a physicist, an engineer, and a nuclear scientist.
In 1959, however, he moved into metaphysics (while continuing to do his
nuclear research), trying to extend the ideas of Albert Einstein as he searched
for a unified theory to encompass the description of all physical phenomena.
Charon published the results of his metaphysical inquiries in a number of
works that have been translated throughout the world.
In “L’Esprit cet inconnu,” his masterwork, he shows us how the entire
universe is happening in each electron of each atom in creation. He writes,
“My research focuses on unitary theories—those which strive to unify observ-
able laws, by demonstrating that they are singular parts of a more general
law—valid for all phenomena-defined as unitary law. If such a law exists, then
it should be valid and verifiable at all dimensional levels, because it analyses
the smallest up to the largest—from elementary particles to the entire cosmos”
(Charon, 2004).
To discover what the universe is made of and how it works is the chal-
lenge of particle physics. Quantum universe presents the quest to explain the
universe in terms of quantum physics, which governs the behavior of the
microscopic, subatomic world. It describes a revolution in particle physics
and a quantum leap in our understanding of the mystery and beauty of the
life and the universe.

The development during the present century is characterized by two theoretical

systems essentially independent of each other: the theory of relativity and the

349
350 Clinical Hypnosis in Pain Therapy and Palliative Care

quantum theory. The two systems do not directly contradict each other; but they
seem little adapted to fusion into one unified theory. . . . Experiments on inter-
ference made with particle rays have given brilliant proof that the wave charac-
ter of the phenomena of motion as assumed by the theory do, really, correspond
to the facts. . . . de Broglie conceived an electron revolving about the atomic
nucleus as being connected with a hypothetical wave train, and made intelligi-
ble to some extent the discrete character of Bohr’s “permitted” paths by the sta-
tionary (standing) character of the corresponding waves. (Albert Einstein, 1940)

The Bohr-Einstein debates were a series of public disputes about quan-

tum mechanics between Albert Einstein and Niels Bohr who were two of its
founders. Their debates are remembered because of their importance to the
philosophy of science. An account of the debates has been written by Bohr
in an article titled “Discussions with Einstein on Epistemological Problems in
Atomic Physics.”

A careful analysis of the process of observation in atomic physics, has shown

that the subatomic particles have no meaning as isolated entities, but can only
be understood as interconnections. (Capra, 2000)

Roger Penrose (1989) presents the argument that human consciousness is

nonalgorithmic and thus not capable of being modeled by a conventional
Turing machine type of digital computer. Penrose hypothesizes that quantum
mechanics, plays an essential role in the understanding of human conscious-
ness. The collapse of the quantum wave function is seen as playing an impor-
tant role in brain function.
“There is no one reality. Each of us lives in a separate universe. That’s
not speaking metaphorically. This is the hypothesis of the stark nature of
reality suggested by recent developments in quantum physics. Reality in a
dynamic universe is non-objective. Consciousness is the only reality.” With
those words, M. R. Franks, a life member of the Royal Astronomical Society
of Canada, a member of that organization since high school, and also a law
professor, begins his new book The Universe and Multiple Reality. What is mul-
tiple reality? What are the exact processes by which mind interacts with mat-
ter at the quantum level?
Some say the universe is made of information. David Chalmers’ “dual
aspect theory” says that such information has both a physical aspect and an
experiential (qualia) aspect. This is similar to what William James had said
and Bertrand Russell’s neutral monism, in which an underlying entity gives
rise to both physical and mental qualities.
The conventional view is that the neural correlate of consciousness is in
networks of neurons connected by chemical synapses, axons to dendrites,
 Conclusion 351

which are serial, though you can have parallel lines of serial connections.
Axonal depolarizations, or spikes, are relatively easy to record and are
robust. Therefore, the view is that spikes are the currency of consciousness.
The vast majority of actual processing, however, occurs in dendrites (numer-
ous dendites per neuron). Electrophysiological correlates of consciousness
(e.g., gamma EEG, coherent 40 Hz) are produced by dendrites, and den-
drites are interconnected by gap junctions (forming what I call hyperneu-
rons) that actually do account for gamma EEG/40 Hz. Consciousness occurs
in dendrites ( John Eccles, Karl Pribram, Stuart Hameroff, Roger Penrose).
A hyperneuron may include tens or hundreds of thousands of gap junc-
tion, connected neurons. The quantum state may extend through the gap
junctions, so that quantum computations in the collection of microtubules
within the many dendrites of a single hyperneuron at a particular time medi-
ate consciousness.
Professor Carlo Rovelli, scientist and quantum gravity theorist, pointed
out that the Wheeler-DeWitt equation does not mention space either, sug-
gesting that both space and time might turn out to be artifacts of something
deeper. “If we take general relativity seriously,” he said, “we have to learn to
do physics without time, without space, in the fundamental theory” (2006).
Recent discoveries in quantum physics (the study of the physics of sub-
atomic particles) and in cosmology (the branch of astronomy and astro-
physics that deals with the universe taken as a whole) shed new light on how
mind interacts with matter and universe. These discoveries compel accep-
tance of the idea that there is far more than just one universe and that we
constantly interact with many of these “hidden” universes.
Our brain inside our skull has no experience of the external world. The
brain only responds to internal states like, pH, electrolytes, hormones, ionic
exchanges across cell membranes, and electrical impulses. So, how does the
brain see an external world? That question goes back at least thousands of
years, and the Greeks said that the world outside is nothing but a represen-
tation in our head.
Then of course Descartes recognized the same thing—that the only thing
about which he could be sure was that he is, that he is conscious. I think,
therefore I am. So, we are not really sure the outside world is as we perceive
it. Some people would say it is a construction, an illusion. Some people
would say it is an accurate representation. It is kind of a mix of views, and
then when you add quantum properties to it, it is really uncertain if the world
we perceive is the actual world out there.
According to the scientist Stuart Hameroff, it is also possible that quan-
tum information is transduced in the retina in the cilia between the inner and
outer segments before the photon even gets to the rhodopsin in the very back
352 Clinical Hypnosis in Pain Therapy and Palliative Care

of the eye. So it is possible that there is additional quantum information

being extracted from photons as they enter your eye through the retina.
They might somehow more directly convey the actual essential quality or
properties of the rose and the redness of the rose. Of course this gets right to
the hard problem of conscious experience: that we have an actual quality of
redness, pain, grief, sorrow, joy, happiness, and all feelings that are conscious
awareness.
Since the structure of space-time geometry, what emptiness is made of is
kind of holographic by quantum processes our retina and brain are able to
access and connect to the essential qualities of the rose so that we have it in
our head. Because space-time is sort of holographic, we are able to access it
via quantum processes inside our brain.
“Second is guidance by Platonic wisdom. Penrose also embedded Pla-
tonic values in spacetime geometry which can guide our actions, and be
viewed as following the way of the Tao, or divine guidance, or whatever you
want to call it. And finally, even conceivably the possibility of afterlife or
consciousness outside of the body” (Hameroff, 2010).
Robert Jahn and Brenda Dunne will describe the research carried out
over the past quarter century in their PEAR laboratory, housed in Princeton
University’s School of Engineering and Applied Science. The results of
numerous carefully controlled experiments provide strong evidence that
human consciousness can play a proactive role in the establishment of phys-
ical reality. Initially intended to address the potential vulnerability of sensi-
tive engineering systems and processes, these findings carry much broader
implications that bear on our view of ourselves, our relationship to others,
and to the cosmos in which we exist.
I think more like a quantum Hindu or Buddhist, in that there is a uni-
versal proto-conscious mind, which we access, and can influence us.

1. THE HUMAN BEING AND THE RELATIONSHIP

BETWEEN BODY, MIND AND SPIRIT

Hypnotic therapy, mindfulness, and the meditative stages consider

human beings as a whole of mind body and spirit. I am very glad to intro-
duce you this theory, elaborated with my father Angelico Brugnoli.
How can we clearly explain the relationship between mind-body and
spirit and the connections among hypnosis, mindfulness, meditative stages,
and the activation of spiritual awareness and higher consciousness?

The human being is constituted by

 Conclusion 353

1. the physical being (body)

2. the psychic being (mind)
3. the spiritual being (spirit, soul, higher consciousness)

To understand this concept we can imagine a cube where the width and the
length are the physical and psychic side and the height is the spiritual side.
We need to consider the human being in a part that forms the human being
in a three-dimensional way:

therefore we will be talking of three sides of the human being

body
mind
spirit

These three different components are intersecting one another to shape our
three-dimensional cube, and they are part of the same person or entity.
For the human being, therefore, we are mind-body and spirit, and God
that can be called the unknown being.

1—the physical side (the body) includes everything in the three-dimen-

sional form that exists in the universe and also the time is part of it, which
we can call time coordinate (because it differs from area to area on the earth
and in the cosmos). The really physicality of the universe side includes all the
cosmos, all the universe, and this also allows the psychic side to be part of it.
The time coordinate is part of the body or physic side but relates also to the
psychic.

2—the psychic side is the mind, and it is related to the body, or physic
side, by the time coordinate and by the activation of the different cerebral
zones.

3—the spiritual side (the spirit)

The psychic universe is related to the spiritual universe, as the point

(focus) is to the whole. Therefore, what differentiates the transaction from the
psychic field to the spiritual one is that the coordinate of time is not impor-
tant any more. Like the vision of the universe, which is composed by the
electric, the electromagnetic, magnetic, and gravitational fields, which are
considered as a whole, we can consider also the psychic field connected with
the physical one and creating a whole unit.
354 Clinical Hypnosis in Pain Therapy and Palliative Care

Let us try to find a rational explanation in the relationship be-

tween mind-body and spirit.

We can find a comparison in physics considering, for instance, the speed

of light as a universal constant.
We call the speed of light V1 and in this case it is a known speed.
V1 is understood as the speed of light, of 300.000 km/second.
V0 represents the absolute quiet of all material; therefore, there is no
physical side when the speed of light is equal to 0
Between V0 and V1 exists the entire physical field that we know, such as
from the subatomic world to the atomic aggregation; consequently, the mol-
ecular one up to the chemical compositions of all the metals, and different
chemical essences up to man (human being) as a physical being.
Between V0 and V1 exists the entire physical universe we know.
In this field, therefore, between V0 and V1 exists also the time, under-
stood as a measure and as a coordinate; the time therefore is part of the space
so called of the four dimensions, between V0 and V1 time is measurable.
To understand the physical concept of mind and spirit, we can imagine
the mind and the spirit, as power of V1.
Obviously in the power of V at two, three, and so on, also the concept of
time will change up to when it will not be measurable any more, and then
perhaps until it disappears.

Throughout the power of V1 you could find a physical explanation for

the psychic field and the spiritual one. You can explore more deeply the
analysis in this field. It is easy to understand that going in exponential pro-
gression, Infinite power of V exists, and maybe in the future it will be possi-
ble to explain other forms of knowledge until:

the Unknown Spiritual Being = Vn

Around 1990, Rovelli and Smolin obtained an explicit basis of states of

quantum geometry, which turned out to be labelled by Roger Penrose’s spin
networks, and showed that the geometry is quantized, that is, the (nongauge-
invariant) quantum operators, representing area and volume, have a discrete
spectrum. The quantum mind hypothesis proposes that classical mechanics
cannot fully explain consciousness and suggests that quantum mechanical
phenomena, such as quantum entanglement and superposition, may play an
important part in the brain’s function and could form the basis of an expla-
nation of consciousness.
 Conclusion 355

Next, we will investigate whether this quantum world, like the classical
world, is really composed of separate, independently existing entities. In
other words, is this new world of potentiality a “Many” or a “One”? Our neu-
ropsychological consciousness, made not only of the matter of mind but also
of awareness and spirit, is potentiality a “many” or a “one”? Our Higher
Consciousness and our spirituality, is potentiality a “many” or a “one”?
I leave you the answer, my friends, with your next scientific researches.

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 INDEX

A alliteration, 278,
alpha activity, 60
Abhidhammattha Sangaha, vii alteration of the experience pain, 48
ability level and challenge, 111 altered state of consciousness, 64
ability to concentrate, 66 alternating attention, 68
absolute, 211 American Pain Society, 302
absorbed in activity, 111 anaesthesiology, 40
absorption, xiv, 122 analgesia, 29
activation of spiritual awareness, 162–169 for procedures in children, 298
active concentration, 76–77, 84–85 with clinical hypnosis, 142–153
and empathy state, 77 analgesic medicines, 40
in aware state, 77 analogies, 94, 273
types and techniques, 76–89 Ancient Lakota instructions for living, 231
activity intrinsically rewarding, 111 anesthesia
acupuncture, 41 in pain therapy, hypnosis, 113
acute pain, 34–36 to one hand, hypnosis, 148–149
in neonate, 301 anesthesiological techniques, 33
management in children, 295 anesthesiological topics, 33
adjuvant medicines, 40 anesthetics agents in children, 299
adolescents, psychological and behavioral Annihilation, 220
factors, 306–307 annulment of the normal consciousness, 115
adrenal cortex, 34 anterior cingulate, attention, 70
adrenaline, noradrenaline, 301 antidepressants, 32
Advaita Vedanta, 209, 211 anxiety
affect, 249 and pain, 46
after hypnosis induction, return to being symptoms, 14
awake, 158 APA division 12, 254
AHCPR, 16 areas, cerebral cortex, 69
aldosterone, 301 arousal, 3, 69
alert, 69 Asana, 203–206
algiatry, 143 ascending nociceptive system, 300
algorithms, 8 Assagioli’s studies, music in, 250–252
allegories, 271 associative statements, 94
and metaphors in poetry and spiritual assonance, 278
verses, 269–276 atman, 208
allegory and hypnosis, 272 atomic physics, 350

359
360 Clinical Hypnosis in Pain Therapy and Palliative Care

attachment, 187 MRI, ix

attention, 66–68 brainstem and thalamus in children, 298
alternating, 68 breathe deeply, technique, 325–326
divided, 68 breathing
EEG, 69–70 absorption, 122
focus of, xiii, 19 deepening suggestions, 155
focused, 67, 68 exercises, 106–108
neurophysiology, 62 technique in children, 331
physiological changes, 68 brief therapy, 44
selective, 68 Brihadaranyaka Upanishad, 126
self-regulated, viii Brugnoli, Angelico, meditative free mental
sensory inputs, 68–69 prayer, 102–106
auditory cortex, 257 Buddhism, 181–190
autogenic Buddhist breath meditation, 188–190
hypnosis, 95–96
training of Schultz, 90–92 C
training session example, 91–92
awake state, 76–77 cacophony, 279
awareness, 4, 59, 64, 120, 117, 123–126 caesura, 279
activation, 126 calm, passaddhi, 131
external sensory, ix CAM, 254
introduction to, 17–26 cancer
axonal depolarizations, 351 children and adolescents, 306
psychological effects in adolescence, 299
B survivors in adolescence, 299
Casula, Consuelo, 143, 145
balance between ability level and challenge, CD use, 147
111 central sensitization, 300
barriers to pediatric pain management, 298 cerebral
basal ganglia, attention, 70 cortex areas, 69
behaviorism, 273 cortex, 12
behaviour therapy, 43 cessation
behavioural measures, pain intensity in chil- of suffering is attainable, 185
dren, 302 of suffering, 187
being at one with things, 112 Chalmer, David, 4
benefits of hypnosis in pain, 142–144 chanting of OM, 262–263
Bhagavad-Gita, 20 children, 295–307
Black, Elk, 229–230 acute pain management, 295
blowing bubbles, technique, 318 at the end of life, 336
Bodhicaryavatara, 132 audio-recorded guided imagery, tech-
body nique, 328
mind and spirit, 352, 358 central modulation of pain perception,
psychotherapy, 44 300
Bohr-Einstein debate, 350 chronic pain management, 295
Bose-Einsten condensate, 10 deep breathing, technique, 325
bottom-up saliency filters, 70 direct suggestions, the magic glove, 330–
Brahman, ultimate reality, 263 331
brain, ix, 8, 10 distraction techniques, 317–324
function, theories, 12 diversional talk, 321
 Index 361

enjoy going into the hypnosis state, 332 collapse

Ericksonian hypnosis, 310–315 of quantum wave function, 350
facial coding system, 302 waves, 9
fast hug, technique, 321 communication, 279
hypnosis techniques, 328–348 competitive selection, 69
magic glove, distraction technique, 324 concentrated attention, 63
massage, technique, 321 concentrating and focusing, 111
medical interventions, 304 concentration, 67–68, 182
mind, 308–315 neurophysiology, 62, 71
neurophysiology of pain, 297–301 power, 72
neuropsychology of pain, 297–301 right, 186
nociception, 298 Samadhi, 131
pain assessment, 302–303 conduct, right, 186
pain expression modalities, 304 conscious
pain management, 302–303 experience, 249
pain treatment, 304–305 resistances, 285
pain, self-report scales, 302 consciousness, 3
perception and mind, 308 and hypnosis in pediatric age, 308–315
positioning, technique, 324 and the stages of sleep, 83
preventive analgesia approach, 295 classification, 73–74
psychological and behavioral factors, consciousness, what is?, 3
306–307 hard and the easy problems, 4
regional nerve block anesthesia, 305 higher, 18
relaxation techniques, 325–327 highest state of, 20
with cancer, 295 in clinical hypnosis and mindfulness,
Chochinov, Harvey, 42 3–12
choices, technique, 318 in pain and suffering relief, 13–16
Christian meditation, 194–195 in pediatric age, 308–315
Christianity steps of prayer, 130 introduction to, 17–26
chronic neurogenetics of, ix
illnesses, 28 neuron-based continuum, ix
pain in infants and children, 298–299 neurophysiology, 7–12
pain management in children, 295 normal state of, 17
pain, 27, 29, 37–38 Orch-OR model, 10
Churcland, P., 11–12 ordinary state of, 15
Circle of Life, Native Americans, 227–228 philosophy, neurophysiology and neu-
clear ropsychology of, 3–12
goals, 111 pure, 19
mind, 110–112 stages, 20
CNS, ix states and stages, 55
Coding Chronic Pain Diagnoses, 30 states, xiv
cognition development, 309 theories, viii, 11
cognitive contemplation
behavior strategies in pain therapy, 41– and ecstasy, 123–126
54 and mystical states leading to Spiritual
behavior therapy, 43 Enlightenment, 129–141
mechanism, 11 meditative stages of, 114
system in children, 310 contemplative mantra, 122–123
362 Clinical Hypnosis in Pain Therapy and Palliative Care

contents of the book, xiv waves, 110

cordotomy, 41 Dennet, Daniel, 5
cortical descending pain modulating pathways, 300
activation, 7 detachment, 114–115
neurons, 12 dhammavicaya, 130–131
corticosterone, 301 Dharana, 203–206
cortisol plasma levels, 301 Dhyana, 123–124, 203–206
cosmic different interpretation of the symptoms,
consciousness, 118 148
Psychosynthesis, 255 dignity therapy in palliative care, 42
cosmology, 351 dignity, 180
counting direct
deepening suggestions, 156 immediate feedback, 111
technique in children, 331 suggestion, 47, 285
technique, 318 technique in children, 330
cytoskeleton, 9 distancing from pain, technique, 320
distorted sense of time, 111
D distraction
music therapy, 254
Damasio, Antonio, 7, 18 techniques in children, 317–324
Darsana Mala, 210–211 divided attention, 68
deep concentration dreams, role, 98
and contemplation, 114 dualism or dichotomy, 188
in hypnosis, 113 duality, xiii
in pain and suffering relief, 154–178 dysesthesias, 28
in pain therapy, 113
self-hypnosis, 113 E
types and techniques, 109–114
deep hypnosis, 65, 113 EEG, 56–59
techniques in children, 331 alpha activity, 85
deep self hypnosis, 129, 155–157 changes during meditation, 62–63
deep sleep, 109–110 changes in attention, 69–70
deepening suggestions synchrony, 128
breathing, 155 effort, right, 186
counting, 156 Einstein, Albert, 350
elevators & escalators, 156 Einstein equation, 129
hypnosis, 154 Einstein relativity theory, 9
technique in children, 331 electrophysiological correlates of conscious-
deepening techniques to achieve deeper ness, 351
levels of trance, 155–157 elevators & escalators
deeper deepening suggestions, 156
and relaxing state of hypnosis, 156 technique, 332
levels of trance, 154–157 emotional cues, 94
deepest sleep, 110 emotions, 6, 249, 277, 310
delta empathic communication, 252
activity, 60 emphasis, 95
sleep, 60 end of life processes, ix
wave correlation, 84 Energy, viriya, 130–131
 Index 363

enjoy going into the hypnosis state, 157 gate-control theory, 33

Enlightenment, 119, 132, 183, 188 Genesis, 223
in Taoist Meditation, 238–243 glucagon, 301
the experience of, 183–187 God, 118–119
the way to, 188 light of, 224
epidural, 41 guru mantra, 123
equanimity, upekkha, 131
Erickson, Milton, 116, 277 H
Ericksonian
hypnosis in children, 310–315 Hameroff, Stuart, 9, 10, 349–351
suggestions, 95 Handel, Dan, 143
Ewin, Dabney, 48 hard and easy problems, consciousness, 4
existential therapy, 43–44 Hardcastle, Valerie, 13–14
expansion, 182 harmonic model, 256
experience of enlightment, 183 harmony, 251, 290
external healing, 283–294
consciousness, 72 Heraclitus, 3
sensory, awareness, ix hesychia, 102
extreme thoughts, 110–112 higher awareness, 6
higher consciousness, 6, 18, 116–121, 259,
F 291
and music, 255–259
fantasies, 95 introduction to, 17–26
feedback, direct and immediate, 111 state, 120
feelings, 249, 283 types and techniques, 115–125
fight or flight response, 15 higher self, 118
figure Hinduism, 201–217
of sound, 278 Holy Spirit, 200
of speech, 277–278 humanistic therapy, 44
flow state, 110–112 hyperalgesia, 28
technique, 112 hyperneuron, 351
focus, 182 hypnagogia, 99
of attention, 19 hypnagogic
of awareness, 19 states, 97–99
focused visualizations, 98
attention, 67, 68 hypnopompic states, 97–99
concentration, 15, 18 hypnosis, 44–48, 279, 283
Four Noble Truths of Buddhism, 184–187 and allegory, 272
free mental prayer, 101–105 and figures of speech, 277–278
frontal cortex and meditative states, 179–180
attention, 70 and mindfulness, relationship, 55
music, 244 and poetry, 273–274
and self hypnosis in children, 328–330
G anesthesia to one hand, hypnosis, 148
149
GABAergic nucleus, 83 exercise based on the chosen image, 151
gamma synchronization, 10 exercise of the cool forehead, 152
gap junctions, 10 exercise warm hand, 149
364 Clinical Hypnosis in Pain Therapy and Palliative Care

fMRI, 45 suggestion, 279, 285

for acute pain, 154 suggestions, technique in children, 330
in children, 307 infants and children, 295–307
in pain therapy and palliative care, 45– inner
46 consciousness, 72, 288
in pain therapy, 146 peace, 20
in pain, 142–144 self, 20
in palliative care, 158–178 silence, technique, 264–265
in pediatric age, 308–315 instant trance and post hypnotic re-induc-
light, 92–96 tion cues, 157–158
medium, 92–96 intellectual disability, children, 304
mindfulness and music therapy, 244–268 interindividual Psychosynthesis, 255
mindfulness and the language of meta- internal word, 161
phors, 280–294 intralaminar nuclei, 7
perception, 48 intrapsychic behavior, 116
purpose in pain therapy and palliative intrathecal, 41
care, 65 Islam Meditation, 218–220
state of, 12
technique of the self-training of Shultz, J
152
technique of visualization, children and Jacobson, progressive relaxation 80–82
adolescents, 333 Jacobson, technique, in children, 326–327
techniques in pain and palliative care, Jain Sadhvis Meditating, 221
142–178 Jainism, 221
techniques, children, 328–348 Judaism and Kabbalah Meditation, 223–225
what is?, 145–146
hypnotherapist, 94, 147 K
hypnotic
analgesia, 48 Kabbalah, 223
suggestions, 15 meditation, 224–225
trance, xi, xiii, 15, 18 Kahlil, Gibran, vii
hypothalamic-adrenal-pituitary axis, 301 karma, 209
hypothalamus, 69 kinesthetic representations, 15
hypoventilation, 46 knowledge, right, 186
Kriya Yoga Meditation, 214
I K-spindle sleep stage, 83

IASP, 27, 296 L

imagery, 278
experiences, 287 language
technique, 94 of consciousness, 201–202
technique in children, 327 of metaphors, 269–294, 280–294
immersion in the absolute, 130 Lao, Tze, 231
impermanence, 185 laser therapy, 41
inattentional blindness, viii learning meditation, 124
increasing functional deficits, 47 Lectio Divina, 200
indirect life means suffering, 184, 187
Ericksonian suggestion, 95
 Index 365

light self hypnosis, 113

hypnosis, 92–96 to deep self-hypnosis, 115
immersion, absorption, 123 Meister, Eckhart, 127
of God, 224 melodic behavior, 249
sleep, 83 Melzack, Ronald, 13
limbic structures, 69 memory, 18
limbic system, 12 mental
Linden, Julie, H., 143, 145, 147 distress, xiii
litotes, 278 images, 94
livelihood, right, 186 meditation, 101–106
living phenomena, 3
in God, 129–141 relaxation, 15
with God, 123–126 metaphors, 96, 273, 275, 277–284, 288
locus of Self, 259 and healing, 283–294
loss of the feeling of self-consciousness, 111 and imagery, 94
lucid dreams, 97–99 and poetry in self-relaxation, 282
lymbic system, ix, 302 in poetry and spiritual verses, 269–276
technique in children, 327
M the language of, 269–294
microtubules, ix, 9
magic mind
blanket, technique, 318 beyond matter, 349–351
wand, technique, 318 in children, 308–315
Maha-Satipatthana Sutta, 125 illumination, 73
mantra, 101 mindfulness, xiii, 114, 182, 260, 263, 270,
japa, 122–123 283
maternal sensitivity, 302 and clinical hypnosis, 55, 143
matter, 3 and clinical hypnosis, relationship, 55
waves, 8 and consciousness, 3–12
meditation, 179 and meditative states in spiritual care,
and hypnosis, 143 types and techniques, 179–243
for inner awareness, 127 and meditative states, 49–54
purpose in pain therapy and palliative and music therapy, 244–268
care, 65 and poetry, 270–271
state, 63 and the chanting of OM, 262–263
transcendental, 116 and the language of metaphors, the tech-
meditative niques, 280–294
free mental prayer, 102–106 definition, vii
self-hypnosis, the seven minute practice, look around you, technique, 319–320
108–109 music and, 260–268
stages of contemplation, 114 practice, viii
stages, 123–125 purpose in pain therapy and palliative
states and mindfulness, 49–54 care, 65
states in spiritual care, types and tech- right, 186
niques, 179–243 Sati, 130–131
states, 64, 48, 120 therapy, 48
medium modified states of consciousness, 15
hypnosis, 92–96 a new classification of, 55–128
366 Clinical Hypnosis in Pain Therapy and Palliative Care

mind beyond matter, 349–351 neural pathways, 29

modulating mechanisms, 29 neuraxis, 300
motor/behavioural outputs, children, 302 neurochemical changes in children, 300
movement of the verses and rhythm in neuromatrix theory of pain, 14
hypnosis suggestions, 275–276 neurons, 9
MRI, brain, ix neurophilosophy, xii, 11
multiple reality, 350 neurophysiological
muscular tension, xiii and behavioral assessment, pain, 27–54
music, 97 neurogenesis, ix
and higher consciousness, 255–259 studies, 48
and mindfulness, 260–268 neurophysiology
and self-hypnosis technique, 257–259 of music, 244–245
emotional reactions, 247 of pain in infants and children, 296–301
evoked emotions in children, 334 of sleep, 56–75
in Assagioli’s studies, 250–252 neuropsychology
in pain therapy and palliative care, 253– of music, 247–249
254 of pain in infants and children, 297–301
neurophysiology of, 244–246 neuroscience philosophy, x
neuropsychology of, 247–249 neurosignature, 14
technique, children, 320 patterns, 28
thanatology, 252 neurotransmitters, 7
therapy in children, 254–255, 333–334 new classification, modified states of con-
therapy, 244–268 sciousness, 55–128
musical imagery tasks, 245–246 NICU, 299
mystical experiences, 197 NIH, viii
nirvana, 181
N Niyama, 203–206
Noble Eightfold Path, 186
Native Americans nociception, 300
spirituality and prayers, 226–230 in children, 298
words of wisdom, 229–230 nociceptive nerve in children, 298
nature of consciousness, conceptual frame- nonattachment, 182
work, 55 nondirective meditation, 128
Navkar Mantra, 221 nondualism, 188
NCCAM, viii nonduality, xiv, 207–209, 259, 263
near death experience, 286 nonopioids, 40
neonatal nonpharmachological
facial coding system, 302 intervention in pain, 144
intensive care and pain, 299 methods in children and adolescents,
procedures, 299 306
nerve NREM, 58
blocks, 33 numeric pain intensity scale, 39
conduction speeds, 301
myelination in children, 298 O
nervous system, 28
neural Om, OM, Aum, 256, 261, 262–263
correlates, ix onomatopoeia, 278
correlates of consciousness, 350
 Index 367

opioids, 40 perception, 29
receptors, 29 peripheral neurogenic, 301
Orch-OR model of consciousness, 10 physiological variables in children, 36
Osho, 216 postoperative, 29, 33
relief feelings, hypnosis, 149
P relief in pediatric patients, 295–348
relief, 31
pain, 13, 28 scales, 302
acute, 31, 34–36 simple descriptive pain intensity scale,
assessment in children, 302–303 39
assessment, 34–39 spinal, 31
autonomic/sympathetic, 301 state, x
behavior, 34–36 stimulus, 31
behavioral variables in children, 36 theories, 14
central, 301 therapy in infants and children, 295–307
chronic, 31 therapy, cognitive/behavior strategies,
codes, 30 42–54
definition (IASP), 27 transmission, 13–14
emotions in, 37 treatment in children, 304–305
evaluation in children, 296 treatment, 40–41
evaluation, 34–41 types, classification of, 30–31
examination, 38–39 VAS visual analog scale, 40
expression modalities, children, 304 visceral, 31
free, 33 and suffering relief, 5, 13–16
hypersensitivity, 300 painful procedures in children, 299
hypnosis use, 45–46 palliative care, 158–169, 252
in childhood, 298 definition, xi
in newborns, 299 dignity therapy, 42
in preterm infants, 299 hypnosis, 158–178
inhibitory system, 13–14 in infants and children, 295–348
intensity in children, behavioural mea- music, 253–254
sures, 302 psychological cognitive/behavior strate-
intensity, 31 gies, 42–54
local syndromes, 31 palliative radiation, 41
management in children, 302–303 paradoxical, sleep, xiv
management, xiii, 32–33, 143 parasympathetic nerves, 301
mechanisms, 34 parental grief, 336
neuropathic, 31–32 parietal cortex, attention, 70
neurophysiological and behavioral passive concentration
assessment, 27–54 in meditative stages, 101
neurophysiology and neuropsychology types and techniques, 90–108
of, 28–29 Patanjali, 124
neuropsychology in infants and children, path to the cessation of suffering, 186–187
296 patience, 115
nociceptive, 301 Patterson, David R., 47, 147
numeric pain intensity scale, 39 peace
patterns, 39 of mind, 289
perceived, 30 prayer of Saint Francis, 85
368 Clinical Hypnosis in Pain Therapy and Palliative Care

pediatric psychoanalysis, 43
age, hypnosis, 308–315 psychodynamic therapy, 43
palliative care, play therapy 317 psychological
patients, techniques for pain relief and cognitive/behavior strategies in pain
palliative care, 295–348 therapy, 42–54
suffering, 295 elements, in Assagioli’s studies, 250–252
Penrose, Roger, 8 hug, xiii
perception and mind in children, 308–315 interventions, 16
perceptions, 283 strategies, 41
personal control over the situation, 111 psychosocial processes, 17
philosophy Psychosynthesis, 250–255
of consciousness, 4 psychotherapy, 42–43
of the mind, 4 body, 44
physiatry, 41 pure awareness, 18
physical modalities, 41 pyruvate, 301
physiological
arousal, 249 Q
indications acute pain, 34
pinwheels origami, technique, 318 Qigong, 236
Platonic wisdom, 352 qualia, 3–6
Plutarch, 121–122 properties, 6–7
PMR, 81 quality of conscious experience, 5
poetry quanta, 8
and figures of speech, 277–278 quantum
and hypnosis, 273–274 computation, ix
and mindfulness, 270–271 consciousness, 7–12
and spiritual verses, 269–276 mechanics, xii
point of pure being, 19 physics, 349, 351
postganglionic nerves, 300 processing, 9
posthypnotic theory, 8
re-induction cues, 157–158
suggestion, 11 R
Practicing Holy Reading, 200–201
Prajna, 186 Raja Yoga Meditation, 212–213
Pranayama, 107, 205 rapture or happiness, piti, 130–131
Pratyahara, 203–206 Raz, Amir, 11
prayer reality, 220
repetitive vocal and mental, 84–85 redirect attention, 95
without ceasing, 123 redirection of attention, 48
preventive analgesia approach in children, reflection upon the universe, 219
295 regional
primary consciousness, 6 analgesia-anesthesia, 304
procedural pain in NICU, 299 nerve block anesthesia, children, 305
procedures reinforcement, 273
anesthesiological, 33 relationship
in children, 295 between body, mind and spirit, 352–358
progressive muscles relaxation, children psyche-soma in children, 308
technique, 326 with the child, 335
 Index 369

relaxation, 15 sensory
and hypnosis in pediatric patients, 295– capture of attention, 71
348 imputs, 14
techniques, children, 325–327 receptor sensitivity, 301
relaxed awakening, 78–79 Sephirot, 225–226
relaxing seven minute practice, 108–109
awakening technique, 80 seven steps Buddhist breath meditation,
state of hypnosis, 156 188–190
REM show some love, technique, 321
phase of sleep, 100 Sila, 186
stage of sleep, 58, 61 silence, 248
repetitive practice, 81 simple descriptive pain intensity scale, 39
resiliency, 143 simple relaxation technique, 79
return to being awake, 158 singing (play songs and lullabies), technique,
Rexed’s lamina II, 300 320–321
rhythm, 95, 250 situation, personal control over the, 111
in hypnosis suggestions, 274–276 sleep
on brain functions, 247 active neurons, 59
right concentration, 114 neurophysiology of, 56–75
Rinpoche, 20 onset experiences, 99
Rovelli, Carlo, 351 paradoxical, xiv
slow wave, 60
S slow, xiv
soothing touch, technique, 323
Samadhi, 129–141, 186–187, 203–206 sound frequency, 246
living in God, 129–141 sounds, 97
Santideva, 132 space of consciousness, 97
sati, vii space-time
schedule for the desensitization of pain, curvature, 9
hypnosis, 150 geometry, 352
Schultz, autogenic training of, 90–92 speech, right, 186
Searle, John, 16 spindle waves, 83
selective attention, 68 spiritual
self esteem, 80 awareness technique, 162–169
self hypnosis technique with music, 258 care, types and techniques, 179–243
self well-being, 80 Enlightenment, 129–141
Self, 211 light, 130
self-awareness, xii poetry, hypnosis and figures of speech,
self-consciousness, xii 277–278
self-healing processes, 143 practice, 119
self-hypnosis, 63, 92–96, 147 processes, 17
in pain relief, 153 Psychosynthesis, 255
purpose in pain therapy and palliative suffering, 17
care, 65 verses, 269–276
technique and music, 257–259 spirituality, 180
self-massage, technique, 322–323 spontaneous sleep onset experiences, 99
self-observing attitude, 84 Sri Sri Ravi, Shankar, 125–126
self-regulated attention, viii St. Francis of Assisi’s Vocation Prayer,
sensitivity control, 70 195–196
370 Clinical Hypnosis in Pain Therapy and Palliative Care

St. John of the Cross, 126 activation of spiritual awareness, 162–

St. Teresa of Avila and Interior Castle, 197 169
stages deep breathing, 106–107
of consciousness, 66 different interpretation of the symptoms,
of consciousness, table, 74–75 148
of hypnosis in pain therapy, 146 heat, hypnosis, 152
of sleep, 59–60 inner silence, 264
Stanford Hypnotic Susceptibility Scale, 93 pain analgesia with clinical hypnosis,
state of being, 19, 65 142–153
states partial or total hypnotic amnesia, 150
of consciousness classification, 73–74 play by play in pain procedures, 317–318
of quantum geometry, 334 positive and negative visualizations, 150
stress progressive relaxation of Edmund
affects the body, 78–79 Jacobson, 81–82
chronic, 29 relaxation and hypnosis in children, 316–
hormonal axis, 302 348
hormones, 301 self-hypnosis in pain relief, 153
in cancer children and adolescents, 306 spiritual awareness in palliative care,
stressful procedures in children, 299 162–169
strong perception, viii transferred symptoms, 149
stroop task, 10–11 transport of the symptoms, 149
suffering, 13, 16–17, 184 treasure box, 317
is attachment, 184 witching of attention, 151–152
pediatric, 295 Tecumseh, 229
Sufi traditions, meditation in, 220 TENS, 41
suggestions, 15, 48 thalamic midline, 7
Ericksonian, 95 thalamus, 8, 12
hypnosis, 154 the corpse, Savasana, 108
superior concentration, types and tech- The Four Noble Truths of Buddhism, 183,
niques, 115–125 187–188
surgery, palliative and ablative, 40 The Noble Eightfold Path, 186–187
symbol, 278 the seven steps Buddhist breath meditation,
symbolic visual content, 276 188–189
sympathetic nervous system, 300 The Way, Taoism’s Wu Wei Meditation,
synaptic connections, 10 232–233
systemic therapy, 44 theories, consciousness, viii
therapeutic metaphor, 283
T therapy
behaviour, 43
table, the stages of consciousness, 74–75 brief, 44
take an attitude break, technique, 324 cognitive-behavior, 43
Tao Te Ching, 126, 231 dignity, 42
Taoism’s Wu Wei Meditation, 231–243 existential, 43–44
Taoist Meditations, 236–243 humanistic, 44
Tart, C. Charles, 4, 116 psychodynamic, 43
technique systemic, 44
activation of a type of conditioned reflex, transpersonal, 44
151 Theravada, tradition, vii
 Index 371

theta band coherence, 98 Vitakka-vicara, 125

thinking Vivekakudamani, 209, 211, 218
mind, 17, 64 Vocation Prayer, 195–196
right, 186
thirasanna, viii W
Thomas, Merton methods, 200
thought, 72 wakefulness, 76–77
Tibetan medicine, 183 way
timbre, 251 of meditation, 198–199
time, distorted sense of, 111 of silence, 198
Tipitaka, 130 Tao Te Ching, 126, 231
tone, 251 to enlightenment, 188
total consciousness, 59 well-being, xi, 28
transcendental meditation, 116 Wheeler De Witt equation, 351
transpersonal therapy, 44 WHO, xi
treasure box, technique, 317 pain ladder in children, 304
true concentration or awareness activation, pain ladder, 40
types and techniques, 126–141 pharmacological ladder for pain relief,
144
U working memory, 69–70

ultimate reality, Brahman, 263 Y

unconscious, 96
mind, 197 Yama, 203–206
unitary theories, 349 Yoga
universal mind, 118 asanas yoga, exercises and postures,
Universal Quabalah, 224 86–87
universe, reflection upon the, 219 breathing technique, Pranayama, 107
unrelieved pain in children, 298 surya namaskar technique, 88–89
Upanishads, vii, 218 Sutras of Patanjali, 182, 203–206
Yoga-Nidra, 216–217
V yogic discipline, 124

VAS visual analog scale, 40, 302 Z

Vedanta, 270
Vedas, 117, 210–211, 263 Zazen, 190
Vedic hymns, 257 Zen
verses and rhythm in hypnosis suggestions, Buddhism, 190
275–276 meditation technique, 192–193
Vipassana Meditation, 215 zone, 111
virtual reality, for pain control, 318–319
visualizations, 98
technique in children, 327