CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 2 MARCH 2008 S39 KAREN OLNESS, MD
Professor of Pediatrics,Family Medicine,and Global Health,
Case Western Reserve University,
Helping children and adults with hypnosis
Hypnosis and biofeedback are cyberphysiologic
strategies that enable subjects to develop voluntary
control of certain physiologic processes for the pur-
pose of improving health.Self-hypnosis has been
used with and without biofeedback for a wide range
of therapeutic applications,and both laboratory stud-
ies and clinical trials have shown it to be effective in
improving symptoms and outcomes in various disor-
ders.More formal Cochrane reviews of hypnothera-
peutic interventions are currently under way.
Thorough patient assessment should precede training
in self-hypnosis in order to properly tailor training
strategies to patient preferences and characteristics,
especially for children.Workshops offered by various
clinical societies are available to train health profes-
sionals in self-hypnosis.
raining in self-hypnosis, with or without
biofeedback, is a valuable adjunct for children
and adults with chronic illnesses or behavioral
problems. After defining terms and briefly
reviewing the evolution of medical hypnosis, this arti-
cle provides an overview of the clinical utility and
applications of self-hypnosis and various issues in its
use, including patient assessment, concurrent use with
biofeedback, and how health care providers can
become trained in self-hypnosis instruction. Because
my experience is primarily with medical hypnosis in
children and adolescents, portions of this discussion
will devote particular attention to the use of hypnosis
Hypnosisis a state of awareness, often but not always
associated with relaxation, during which the partici-
pant can give him- or herself suggestions for desired
changes to which he or she is more likely to respond
than when in the usual state of awareness. Spon-
taneous self-hypnosis may happen while reading, lis-
tening to music, watching television, jogging, dancing,
playing a musical instrument, doing tai chi, doing yoga,
or performing similar activities. Terms often used to
describe mind-body training include relaxation imagery,
guided imagery, or visual imagery. These include the
same training strategies as those used in hypnosis.
Biofeedbackis a term coined in 1969 to describe
procedures (developed in 1940s) for training subjects
to alter physiologic responses such as brain activity,
blood pressure, muscle tension, or heart rate. With
biofeedback, participants are trained to improve their
health and performance by using signals from their
own bodies. In so doing, they strengthen awareness of
the connections between their mind and body.
Cyberphysiologywas defined by Dr. Earl E. Bakken
at the first Archaeus Congress, held in Santa Fe, New
Mexico, in 1986. “Cyber” derives from the Greek
kybernan, meaning steersman or helmsman. From
kybernancame the Latinate term govern, meaning “to
control.” Thus, cyberphysiology means to control a
physiologic response. In scientific terms, cyberphysiol-
ogy is the study of how neurally mediated autonomic
responses⎯usually viewed as automatic, reactive
reflexes⎯can be modified by a learning process that
appears to be significantly dependent on modification
of mental images. Both hypnosis and biofeedback are
cyberphysiologic strategies that enable the user to
develop voluntary control of certain physiologic
■HISTORICAL BEGINNINGS OF HYPNOSIS
Franz Mesmer developed a training system that he
called animal magnetism. Mesmer believed that nor-
mal body processes were disrupted when there was
improper distribution of magnetism, a kind of fluid
that could penetrate all matter. He described his abil-
ity to direct this magnetic fluid through his presence
Dr.Olness reported that she has no financial relationships that pose a poten-
tial conflict of interest with this article.
with the waving of a metallic rod and contact with a
a large wooden tub called a baquet. Mesmer was con-
vinced that the successful therapeutic effects he
observed depended on the magnetic rods he used.
When jealous and hostile colleagues challenged
Mesmer’s clinical successes, King Louis XVI of France
called for an investigative commission chaired by
Benjamin Franklin, who was then the American
ambassador to France. Other commission members
included Dr. Antoine Lavoisier, the first to isolate the
element of oxygen, and Dr. Antoine Guillotine, well
known for developing a machine for beheading.1After
the commission conducted some clever experiments,
they concluded that Mesmer’s success was related to
application of the imagination. In fact, we are not far
beyond that concept today, although we now have
brain imaging documentation of changes in the brain
associated with the practice of hypnosis.2–5
■CORRECTING MISCONCEPTIONS ABOUT HYPNOSIS
Hypnosis is not sleep
Modern hypnosis is considered to have begun with
Mesmer, although the term hypnosiswas first used by
James Braid, a Scottish ophthalmologist, in 1843. His
decision to derive the word from hypnos, the Greek
word for sleep, was unfortunate. Hypnosis is not sleep,
but the name confuses people.
All hypnosis is self-hypnosis
Another major misconception about hypnosis is that
someone⎯ie, the hypnotist⎯is in control of a per-
son. In fact, the hypnotist is a coach or teacher who
helps the patient to increase his or her self-regulation
abilities.6 All hypnosis is self-hypnosis; after the ini-
tial training, the learner must reinforce the training
with daily practice. Adult learners should anticipate
practicing approximately 10 minutes twice daily for
about 2 months in order to condition the desirable
physiologic change or outcome. Children learn more
easily and often can achieve desired changes over a
period of a few weeks.
■IMPORTANCE OF PATIENT ASSESSMENT
BEFORE TEACHING SELF-HYPNOSIS
Every candidate for self-hypnosis therapy deserves a
thoughtful, careful diagnostic assessment that
includes appropriate laboratory procedures, radiologic
procedures, or both prior to decisions about treat-
ment. Patients are sometimes referred for specific
cyberphysiologic interventions, such as hypnosis,
without adequate diagnostic assessments.7 When a
patient is referred for hypnosis training, the health
professional who will provide the training should
evaluate the extent of the previous diagnostic assess-
ment and do more if indicated. It is also important
that the health professional be knowledgeable and
competent with respect to the patient’s specific prob-
lem. For example, a dentist who is board-certified in
dental hypnosis should not be teaching hypnosis to
children with migraine, just as a pediatrician who is
board-certified in medical hypnosis should not be
extracting teeth using hypnosis.
Mental imagery varies from individual to individ-
ual. Many children have visual, auditory, kinesthetic,
and olfactory/taste imagery abilities and can use these
easily in the process of self-hypnosis. In contrast,
many adults do not generate multiple types of mental
imagery, and many lack clear visual imagery. It is
important that the therapist identify which types of
mental imagery the patient prefers before embarking
on a therapeutic approach.
■CONCURRENT USE OF BIOFEEDBACK AND HYPNOSIS
Much common ground exists between hypnosis and
biofeedback. Both have the potential to provide a
powerful validation of mind–body links, contribute to
a lowered state of sympathetic arousal, heighten
awareness of internal events and sensations, facilitate
imagery abilities, narrow the focus of attention, and
enhance the internal locus of control.
Adding biofeedback games to self-hypnosis training
can make the experience much more interesting for
children. Children see evidence on the screen that, by
changing their thinking, they have control over a body
response such as skin temperature, electrodermal activ-
ity, or pulse rate variability. Adults also benefit from the
addition of biofeedback to self-hypnosis training. A
patient cannot effect a change in a biofeedback
response without a change in his or her mental imagery.
■A WIDE RANGE OF THERAPEUTIC APPLICATIONS
As outlined in Table 1, hypnosis has been used, both
with and without biofeedback, for a wide range of
Hypnosis training is valuable as a primary interven-
tion for prevention of juvenile migraine8,9as well as for
many performance problems (eg, fear of public speak-
ing or playing tennis), insomnia, and many habit prob-
lems (eg, nail-biting, tics, hair-pulling). For treatment
of juvenile warts, hypnosis is at least as effective as top-
ical treatment and associated with fewer relapses.10
Hypnosis is valuable as an adjunctive intervention
during painful procedures,11–13 and many adults and
children use self-hypnosis to teach themselves to be
HELPING CHILDREN AND ADULTS WITH HYPNOSIS AND BIOFEEDBACK
S40 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 2 MARCH 2008
comfortable through procedures without any pharma-
Training in self-hypnosis is a valuable adjunct for
both children and adults with chronic illnesses such as
cancer, cardiac failure, asthma, hemophilia, sickle cell
disease, and arthritis. Self-hypnosis helps to reduce
anxiety and increase comfort, and it provides a thera-
peutic tool over which the patient has control. Several
recent studies have demonstrated the efficacy of hyp-
nosis in the treatment of irritable bowel syndrome.15
Hypnosis and cardiac disease
With respect to cardiac disease, training in hypnosis
can help to reduce symptoms both preoperatively and
postoperatively, to enhance the success of rehabilita-
tion following myocardial infarction, and to reduce
anxiety associated with chronic heart disease.16
Hypnosis also is helpful for motivating behaviors
associated with prevention of cardiac disease, such as
regular exercise, eating a low-fat diet, and smoking
cessation. Several studies have found hypnosis to be a
helpful adjunct to cognitive behavioral therapy for
treatment of obesity.17Additionally, a number of stud-
ies have demonstrated that hypnosis is useful as an
initial intervention for smoking cessation,18 although
only about 45% of persons who stop smoking with
hypnosis continue to abstain 6 months later. In the
case of both obesity and smoking cessation, hypnosis
has modestly better efficacy compared with other
treatments for these conditions.
SPECIAL CONSIDERATIONS WITH CHILDREN
Self-hypnosis has great potential in children, as children
delight in recognizing their own control over problems
such as bed-wetting or wheezing or test anxiety.
As noted above, success with hypnosis requires that
the patient practice self-hypnosis daily. In the case of
children, it is essential that the coach or teacher
emphasize that the child is in control and can decide
when and where to use self-hypnosis. The message
should be that self-hypnosis belongs to the child and
that he or she needs to practice to become more
skilled (as with learning soccer or some other sport),
but that no one can force him or her to practice.
The choice of strategies for teaching self-hypnosis
varies depending on the child’s age and developmen-
tal stage. As children mature, their cognitive abilities
change. Preschool children are concrete in their
thinking, so therapists working with children of this
age must select words carefully. Children between
ages 2 and 5 years spend a great deal of their time in
various types of behavior based on imagination and
fantasy. They enjoy stories and may enter a hypnotic
state as a parent or teacher reads a story to them.
Unlike adults, they often prefer to practice their self-
hypnosis with their eyes open. Although adolescents
may enjoy learning self-hypnosis methods that are
similar to those preferred by adults, immature adoles-
cents may prefer methods that also appeal to younger
children. A child with cognitive impairment can
learn self-hypnosis if the therapist selects a teaching
approach appropriate for the child’s actual develop-
mental stage. Because of developmental changes, a
child of 9 years is unlikely to enjoy a method he or she
was taught at age 4. Therapists who work with chil-
dren should be familiar with a variety of hypnosis
induction strategies and be capable of creative modi-
fication to accommodate a child’s changing develop-
■HYPNOSIS RESEARCH WITH CHILDREN
Substantial research in child hypnosis has been done
over the past 50 years. Initial research measured child
hypnotic susceptibility using scales such as the
Stanford Hypnotic Clinical Scale for Children.21,22
Research laboratory studies have demonstrated chil-
dren’s ability to control voluntarily autonomic
responses such as peripheral temperature23–25 and
immunologic responses.26,27Several controlled labora-
tory studies have revealed an association between
learning self-hypnosis and changes in humoral and/or
cellular immunity in children. This work was the
basis for a clinical trial by Hewson-Bower, who
demonstrated that training in self-hypnosis for chil-
dren with frequent upper respiratory tract infections
resulted in a reduction of infectious episodes and
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 2 MARCH 2008 S41
Therapeutic applications of hypnosis
with or without biofeedback
Asthma Painful procedures
Burns Performance anxiety
Chronic pain Pruritus
Conditioned fears Sleep problems
Enuresis Sports performance
Habit problems Warts
Irritable bowel syndrome
fewer illness days when infections did occur.28,29
Most subsequent research has consisted of clinical
studies documenting the efficacy of hypnosis with
children in areas such as pain management, habit
problems, wart reduction, and performance anxiety.
A recent study completed in Cleveland, Ohio, taught
stress-reduction methods, including self-hypnosis, to
8-year-old schoolchildren.30 This study concluded
that a short daily stress-management intervention
delivered in the classroom setting in elementary
school can decrease feelings of anxiety and improve a
child’s ability to relax. Many of the children in the
study continued to use self-hypnosis in their daily
lives after the study was completed.
A host of variables complicate research design
The variability in preferences, learning styles, and
developmental stages among children complicates
the design of research protocols for studying hypnosis
in children. These protocols are often written to
describe identical hypnotic inductions, often tape-
recorded, to be used at prescribed times. Measured
variables do not include whether or not a child likes
the induction, listens to the tape, or focuses on entirely
different mental imagery of his or her own choosing.
Learning disabilities, such as auditory processing
handicaps, may interfere with children’s ability to
learn and remember self-hypnosis training.
Furthermore, learning disabilities are often subtle and
may not be recognized without detailed testing.
Each of these variables complicates efforts to per-
form meta-analyses of hypnosis and related interven-
tions. Analyses of studies on the efficacy of hypnosis in
children should include all strategies that induce hyp-
nosis in children⎯eg, visual imagery, guided imagery,
and/or progressive relaxation. Some research studies
that are defined as controlled nevertheless mix differ-
ent therapeutic interventions. An example would be a
comparison of hypnosis with guided imagery.
The International Society of Hypnosis is currently
sponsoring Cochrane reviews of hypnotherapeutic
interventions, including those with children.
■TRAINING IN HYPNOSIS INSTRUCTION
Health professionals who wish to teach self-hypnosis
should take workshops sponsored by the American
Society of Clinical Hypnosis or its component sec-
tions, or by the Society for Clinical and Experimental
Hypnosis. The Society for Developmental and
Behavioral Pediatrics also provides annual workshops
to prepare health professionals for teaching self-
hypnosis to children. Contact information for these
organizations is provided in the sidebar on this page.
The basic workshops should include at least 22
hours of supervised practice of hypnosis techniques
and didactic information. After completing such
basic training, the professional should seek a mentor
who, by phone or e-mail, can provide guidance and
support. The professional who is developing skills in
self-hypnosis instruction should also attend follow-up
workshops, watch videotapes of other teachers, and
read basic textbooks and hypnosis journals recom-
mended by professional hypnosis societies.
Hypnosis board examinations are given in four
areas: medicine, dentistry, psychology, and social work.
The American Society of Clinical Hypnosis has devel-
oped a hypnosis certification program for professionals
who use hypnosis in their practice and teaching.
Importantly, the professional who is developing
skills in self-hypnosis instruction should learn self-
hypnosis for him- or herself. Learning self-hypnosis is
a valuable lifelong skill that provides many benefits.
We anticipate that appropriate and early training in
self-hypnosis and biofeedback can enable children to
learn to control autonomic responses relating to car-
diovascular function. Preventive work by pediatric
health professionals may include monitoring of auto-
nomic responses early in life, identification of children
most at risk because of autonomic lability, and inter-
ventions to reduce that risk via hypnosis and biofeed-
back training. We anticipate that laboratory and brain
imaging studies will provide increasing documentation
of the impacts of hypnotic suggestions on neural pro-
cessing, and that Cochrane reviews will demonstrate
increasing evidence for the clinical value of hypnosis.
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Organizations that offer training
in hypnosis instruction
Society for Developmental and Behavioral Pediatrics
Society for Clinical and Experimental Hypnosis
American Society of Clinical Hypnosis⎯bimonthly training
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Correspondence: Karen Olness, MD, Case Western Reserve
University, 11100 Euclid Avenue, Cleveland, OH 44106;
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • SUPPLEMENT 2 MARCH 2008 S43