International Handbook of Clinical Hypnosis - E-Lib FK UWKS

CHRONIC PAIN MANAGEMENT 255
The importance of the initial therapeutic contact must be emphasized when
hypnosis is to be used with the chronic pain patient. A direct approach is required
to evaluate secondary gain and masked depression: it will be these issues that will
determine the focus of the treatment plan. Four direct questions are usually helpful
Evans, 1989, 2001). The ®rst two help evaluate secondary gain, while the second
two are primarily therapeutic contractual questions.
1. `What difference would it make to your life if suddenly you had no pain'? The
patient will often hedge an answer with anger, which will reveal hints about
the psychic utility of the pain as a reinforcing event. For example, one patient
replied: `My poor, poor, husband. Why, he looks after me so well. He could
stop cooking and cleaning for me. He hates cleaning. He would rather be out
with his friends.' Her response gives clear insight into the psychic economy of
the pain which will need to be addressed before any hypnotic or other intervention
will be useful in reducing her pain.
2. `Do youwant to get better'? Many chronic pain patients react with anger to
this question. `What do you mean? Of course I want to get better'! Even after
repeating the question three times, failure to obtain an unequivocal `yes' is
common, and indicates the patient may not be ready to relinquish the pain.
3. `Would you be satis®ed if your pain could be reduced by about half'?
Acquiescence is necessary to help evaluate whether the patient has realistic
expectations, although it is stressed that the goal of treatment is to maximize
pain relief.
4. `Are you willing to work hard to get better'? This question is useful to ascertain
that the patient does not have unrealistic expectations about a magical cure
with hypnosis, and helps establish a contract that the patient must be
responsible for his/her own progress.
Although it is uncommon, positive answers to each of these questions usually
indicate that secondary gain is not an issue in the patient's pain behavior. Direct use
of hypnotic techniques may be successful quite rapidly.
Some additional useful questions set the stage for later hypnotic interventions.
When the chronic pain patient is asked to describe: `What do youlike about
yourself'?, there is usually a long silence, with little response. In contrast is the
verbal torrent usually accompanying the question: `What do you dislike about
yourself'? Both answers will provide a framework for later hypnotic ego-strengthening
techniques, as well as indicate the major areas of dysfunction associated with
the pain.
The manner in which the patient is asked to describe the pain may be useful for the
selection of appropriate imagery and cognitive strategies when it is time to use
hypnotic interventions. Because of the depression and years of feeling misunderstood,
many patients ®nd it dif®cult to describe pain verbally, but can write about it.
Techniques such as asking about the `color' and `shape' of the pain, drawing the pain,
and exploring conditions under which it is more or less intense heat, cold, sitting,