Helping children and adults with hypnosis and biofeedback

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,

Cleveland,OH

Helping children and adults with hypnosis

and biofeedback

ABSTRACT

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.

T

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

in children.

DEFINITIONS

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

processes.

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

therapeutic applications.

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-

cologic treatment.14

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.

TEACHING SELF-HYPNOSIS:

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-

mental circumstances.19,20

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

OLNESS

TABLE 1

Therapeutic applications of hypnosis

with or without biofeedback

Anxiety Migraine

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.

THE FUTURE

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.

REFERENCES

1. Barabasz A, Watkins JG.The history of hypnosis and its relevance

to present-day psychotherapy. In: Hypnotherapeutic Techniques.

HELPING CHILDREN AND ADULTS WITH HYPNOSIS AND BIOFEEDBACK

Organizations that offer training

in hypnosis instruction

Society for Developmental and Behavioral Pediatrics

(www.sdbp.org)

Society for Clinical and Experimental Hypnosis

(e-mail:dabby@MSPP.edu)

American Society of Clinical Hypnosisbimonthly training

workshops (www.asch.net)

S42 CLEVELAND CLINIC JOURNAL OF MEDICINE      VOLUME 75 • SUPPLEMENT 2      MARCH  2008

2nd ed. New York, NY: Brunner-Routledge; 2005:1–26.

2. Rainville P, Duncan GH, Price DD, Carrier B, Bushnell MC.

Pain affect encoded in human anterior cingulate but not somatosen-

sory cortex. Science 1997; 277:968–971.

3. Rainville P, Carrier B, Hofbauer RK, Bushnell MC, Duncan GH.

Dissociation of sensory and affective dimensions of pain using hyp-

notic modulation. Pain 1999; 82:159–171.

4. Raz A, Kirsch I, Pollard J, Nitkin-Kaner Y.Suggestion reduces the

Stroop effect. Psychol Sci 2006; 17:91–95.

5. Oakley DA, Deely Q, Halligan PW.Hypnotic depth and response

to suggestion under standardized conditions and fMRI scanning. Int

J Clin Exp Hypn 2007; 55:32–58.

6. Yapko MD. The myths about hypnosis and a dose of reality. In:

Trancework: An Introduction to the Practice of Clinical Hypnosis.

New York, NY: Brunner-Routledge; 2003:25–55.

7. Olness K, Libbey P. Unrecognized biologic bases of behavioral

symptoms in patients referred for hypnotherapy. Am J Clin Hypn

1987; 30:1–8.

8. Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis

and propranolol in the treatment of juvenile classic migraine. Pedi-

atrics 1987; 79:593–597.

9. Olness K, Hall H, Rozniecki JJ, Schmidt W, Theoharides TC.

Mast cell activation in children with migraine before and after train-

ing in self-regulation. Headache 1999; 39:101–107.

10. Felt B, Hall H, Olness K, et al. Wart regression in children: com-

parison of relaxation-imagery to topical treatment and equal time

interventions. Am J Clin Hypn 1998; 41:130–137.

11. Ewin D. The effect of hypnosis and mindset on burns. Psychiatr

Ann 1986; 16:115–118.

12. Kuttner L.No Fears, No Tears: Children with Cancer Coping with

Pain [videotape]. Vancouver, BC: Canadian Cancer Society; 1986.

13. Kuttner L. No Fears, No Tears: 13 Years Later [videotape].

Vancouver, BC: Canadian Cancer Society; 1999.

14. Olness KN.Perspectives from physician-patients. In: Fredericks LE,

ed. The Use of Hypnosis in Surgery and Anesthesia: Psychological

Preparation of the Surgical Patient. Springfield, IL: Charles C.

Thomas; 2001:212–222.

15. Palsson OS, Turner MJ, Johnson DA, Burnelt CK, Whitehead

WE.Hypnosis treatment for severe irritable bowel syndrome: inves-

tigation of mechanism and effects on symptoms. Dig Dis Sci 2002;

47:2605–2614.

16. Novoa R, Hammonds T. Clinical hypnosis for reduction of atrial

fibrillation after coronary artery bypass graft surgery. Cleve Clin J

Med 2008; 75(Suppl 2):S44–S47.

17. Kirsch I. Hypnotic enhancement of cognitive-behavioral weight

loss treatments⎯another meta-reanalysis. J Consult Clin Psychol

1996; 64:517–519.

18. Green JP, Lynn SJ. Hypnosis and suggestion-based approaches to

smoking cessation: an examination of the evidence. Int J Clin Exp

Hypn 2000; 48:195–224.

19. Olness K, Kohen DP. Hypnosis and Hypnotherapy with Children.

3rd ed. New York, NY: Guilford Press; 1996.

20. Wester WC II, Sugarman LI, eds. Therapeutic Hypnosis with

Children and Adolescents. Bethel, CT: Crown House Publishing;

2007.

21. London P, Cooper LM. Norms of hypnotic susceptibility in chil-

dren. Dev Psychol 1969; 1:113–124.

22. Morgan AH, Hilgard JR.The Stanford Hypnotic Clinical Scale for

Children. Am J Clin Hypn 1978; 21:148–169.

23. Dikel W, Olness K. Self-hypnosis, biofeedback, and voluntary

peripheral temperature control in children. Pediatrics 1980;

66:335–340.

24. Olness KN, Conroy MM. A pilot study of voluntary control of

transcutaneous PO2 by children: a brief communication. Int J Clin

Exp Hypn 1985; 33:1–5.

25. Hogan M, MacDonald J, Olness K. Voluntary control of auditory

evoked responses by children with and without hypnosis. Am J Clin

Hypn 1984; 27:91–94.

26. Olness K, Culbert T, Uden D.Self-regulation of salivary immuno-

globulin A by children. Pediatrics 1989; 83:66–71.

27. Hall HR, Minnes L, Tosi M, Olness K. Voluntary modulation of

neutrophil adhesiveness using a cyberphysiologic strategy. Int J

Neurosci 1992; 63:287–297.

28. Hewson-Bower B. Psychological Treatment Decreases Colds and

Flu in Children by Increasing Salivary Immunoglobin A [PhD the-

sis]. Perth, Western Australia: Murdoch University; 1995.

29. Hewson-Bower B, Drummond PD. Secretory immunoglobulin A

increases during relaxation in children with and without recurrent

upper respiratory tract infections. J Dev Behav Pediatr 1996; 17:

311–316.

30. Bothe DA, Olness KN. The effects of a stress management tech-

nique on elementary school children [abstract]. J Dev Behav Pediatr

2006; 27:429. Abstract 5.

Correspondence: Karen Olness, MD, Case Western Reserve

University, 11100 Euclid Avenue, Cleveland, OH 44106;

karen.olness@case.edu.

CLEVELAND CLINIC JOURNAL OF MEDICINE      VOLUME 75 • SUPPLEMENT 2      MARCH  2008 S43

OLNESS