Welcome back to the Pain Science Podcast with David Spiegel, MD

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Hi there, Dr. Spiegel. Thanks for joining me this week on the podcast.

Thank you, Joe. I’m glad to be here with you.

You have many decades of work in the field of hypnosis, studying everything from chronic non-communicable diseases to cancer to chronic pain. We’re going to cover many of those today. I think a good place to start is just give us kind of an overview of, or maybe a understanding of how the view of hypnosis has changed from the time when you first started using it to kind of where we are today in 2024.

Well, Joe, I’d say not enough. Hypnosis is the oldest Western conception of a psychotherapy. It’s the first time a talking interaction was thought to have therapeutic potential, some 250 years old. And yet, people still have serious misconceptions about it. They either think it’s a stage show trick, or it’s useless, or it’s dangerous, or all three. What they don’t recognize is the power that it has to help people better manage their brain to manage pain. The strain and pain lies mainly in the brain, as you know well, and hypnosis is a powerful way of helping people with it. And so, It’s the wonderful thing about it is that the worst thing that happens with hypnosis is that it sometimes doesn’t work, but we’re finding four out of five of our users of our every app, get immediate pain relief using hypnosis. And there are no side effects. And so, if it doesn’t work, it doesn’t work. But most of the time, it really helps.

More and more practitioners are interested in using it. They’re adding it to kind of a clinical toolbox, if you will. Some are using it as their primary method in practice. What do you think has been the biggest advancement as far as the literature goes that has caused practitioners to really say, okay, I’m going to pay attention to this and read about it and pursue training and start to use this in practice?

Well, Joe, first of all, there’s a science base that has developed over the last 50 years that, number one, shows what happens in the brain when people use hypnosis, that it has real effects in reducing pain perception. Same pain signals use hypnosis and people feel less pain when you use it. Secondly, we understand why it works. We know about specific using functional magnetic resonance imaging and EEG. We can demonstrate how hypnosis helps resolve anxiety related to pain, but actually reduce the pain signals themselves. It’s an evidence-based practice and people like those.

Yeah, and I’ve read some of your studies, those functional MRI studies. And of course, we’re, you know, we’re perfecting those techniques and learning more and more every day. What can you tell us about what’s happening in the brain, as far as when someone is under hypnosis or being influenced by hypnosis?

There are three main things happen, Joe. The first is that you turn down activity in the anterior cingulate cortex, the dorsal part of the ACC. It’s like a C sitting on its ends in the middle of the front and back part of the brain. The dorsal part, the front part, is our alarm system. It’s called the salience network. And it basically, when you hear a loud noise and you wonder what’s happening, that’s your salience network matching patterns and saying, this one doesn’t match. There’s something wrong. You better do something. So, it keeps your guard up. When you turn down activity in that region, it allows you to focus your attention. Hypnosis is highly focused attention coupled with dissociation, putting outside of conscious awareness things that would ordinarily be in consciousness. Right now, Joe, you’ve got sensations in your body touching the chair you’re sitting in, presumably, but hopefully you weren’t aware of them. If you were, we can just stop the interview now. And so, it’s a state in which you can put outside of awareness things you don’t want to pay attention to and intensely focus on what you want to. The dorsal ACC is rich in GABA receptors, gamma-aminobutyric acid. It’s an inhibitory neurotransmitter in the brain. It’s the target of benzodiazepines, anti-anxiety and some anti-pain drugs, and sleeping pills. Turn down activity. Use GABA to inhibit arousal and activity. And that’s what you do with hypnosis. You’ve got your own little pharmacy store here in the dorsal ACC, and you can mobilize these inhibitory neurotransmitters. So that’s number one. Turn down activity in the ACC. The second is you increase functional connectivity. When one region is active, the other is. Between the executive control network, the dorsolateral prefrontal cortex, And the insula, which is a part of the brain also in the salience network that controls mind-body interactions. So, it’s when the brain tells the body to do something, it goes through the insula. And it’s also a path for interoception. How does the brain perceive what’s happening in the body? So, you enhance connectivity between the brain and the body. Number three, there’s inverse functional connectivity between the executive control network and the posterior cingulate cortex. That’s what we call the default mode network. It’s a part of the brain. When you’re not doing anything else, you reflect on who you are, what you are, what people think of you, how you’re supposed to be as a person. I call it the my fault mode network. It’s the part where you just think, what did I do wrong? And by inhibiting activity to the extent that the executive control network is active, you’re actually able to try out being different. And so that’s the part with hypnosis. So, it really has to do with cognitive flexibility. We’ve done studies that show that people who are more hypnotizable are more likely to catch on to new ways of doing things, new ideas, and can try out being different. So, the very thing that scares people when they went to that stage show and they saw the football coach dance like a ballerina is actually an opportunity. I don’t like making fun of people, but it shows that people can try out being different and see what it feels like, and that is a great context for change.

Yeah, moving in and out of different identities is something that we’ve explored on this podcast, because it’s important for people with pain. Oftentimes, they’re connected to this one sense of self. And helping them in any way connect to a different sense of self or identity is really important. I love hearing about the neuroanatomy and the neurophysiology and the brain mechanisms. As you’re talking about them, of course, it’s really interesting. But what comes up for me is if we have such a rich evidence base on this, why do we have so many misconceptions that we encounter about hypnosis? And maybe you can kind of go through what those misconceptions might be.

Well, the biggest one, Joe, is that hypnosis is a loss of control. know, somebody takes over your mind and makes you do things. Now, you know, we’re social creatures, we’re all susceptible of social influence. And, you know, if you wonder whether or not human, some humans can influence others to believe things that are patently false, just listen to the current political season, and you’ll kind of get the idea. But hypnosis is a state in which, yes, you’re highly focused, so you can take on a new point of view intensely and see what you think about it and maybe put aside your usual preconceptions. That’s what we call learning, actually. But hypnosis is a state in which you actually enhance control. over your brain and your body. It’s not a loss of control. It’s a skill. This three-pound object on the top of our shoulders is our major evolutionary advantage, other than the opposing thumb, which is good. But it doesn’t come with a user’s manual. So, it doesn’t mean we know everything in everyday life about how to make it work better. And hypnosis is a special kind of focus skill that many people have ability to access that we can learn more about and use to better effect. I had a colleague who was learning about Revri, our self-hypnosis app. and practicing it, and he went, and he had to have an injection in his finger, just trigger fingers. And he says, I hate this, because it’s intensely painful. It doesn’t take that long, but you’re squeezing liquid into a narrow, tight space, and it hurts like hell. And he said, so I tried doing self-hypnosis, and I told my doc who was injecting me, I said, wait until my hand floats up, and then make the injection. And he said it was by far the least painful trigger point injection I’ve ever had in my life. And he said the dermatologist who was doing it said, hey, that’s really interesting. I’ve got to learn more about this. So, when your doctor is feeling better as well as you, you know something’s happening. So, it’s a way of enhancing your ability to control your perception of pain, your understanding of what’s going on, manage your anxiety. So, it’s not a loss of control, it’s a gain in control.

I think that example is a really great example for our audience to listen to, because you’re talking about a dermatologist who, for the most part, is not involved in pain management. Right. But yet sees an application. Okay, I need this. You know, in my practice, this might help, so to speak. I think currently, when we talk about, you know, psychological interventions, psychosocial interventions, they’re kind of sitting in the mental health domain, so to speak, right? Do you see something like hypnosis as maybe fitting into, of course, all the rehab practices, dental practice, I think about all the different places in healthcare, where people do experience pain, discomfort, that there might be an opportunity to bring in some simple tools like this.

You’re absolutely right, Joe. And I, there are many fine dentists who use it as an alternative to Novocain. Um, there are, uh, other docs, dermatologists and others, uh, and physical therapists who are starting to use it. Now I’ve met with a lot of physical therapists who are interested in it. They, they tell me that physical therapy is half psychotherapy anyway. You know, you’re, you’re dealing with you know, how people relate to their bodies. And anybody who does that for pain and stress and exercise and injury, post-injury, recognizes that your attitude toward your body is a big part of the whole pain experience. And I find that, you know, people get angry and frustrated with their bodies in a way that they never would with any other creature that depends on them, like their children or their pets or anything like that. But when they get frustrated and angry, all it does is make the pain even worse. And so, I tell them, in hypnosis, imagine your body is your baby, because it’s as dependent on you as your baby is. And just picture what you would do if your baby were hurt. Would you get angry? Would you yell at him? Hell no. No, I’d pick him up, and I’d hug him, and I’d say, I’m sorry, and we’ll try and fix you. And just that kind of an emotional attitude toward your body can change not just how you feel, but how much pain your body presents you with.

And it’s brilliant. Along the lines of pain, and we’re talking about kind of this intersection of the body and the insert cortex, which is really important interception. My brain is going toward trauma responses. And we know there’s really like a bi-directional relationship between chronic pain and trauma. And I’m really at the place where I really see these as almost two very, very similar conditions that at times can be really hard to tweeze out. Um, knowing that, so there’s a, I think a group out there who still thinks about trauma as a cognitive challenge. And there’s a group that is starting to look at trauma as no, there’s also a big body component that’s happening here. Where does, um, hypnosis fit in, I guess, you know, in both, both the mind and the body component, as far as addressing things like, um, traumatic stress or, um, you know, diagnosable PTSD.

Sure, Joe. Well, there’s a wonderful book that my old buddy, residency mate Bessel van der Kolk wrote called The Body Keeps the Score. And it’s been on the Times bestseller list for years. Because he points out that it makes sense that the body would be a repository of traumatic experience because it’s the victim of traumatic experience. And the problem with trauma isn’t just pain or fear. It’s the experience of being made into an object, a thing. Someone or something turns your body into an object, and you suffer for it. And people who suffer that way have a body problem as well as a mind problem. So, their memories bring up physical discomfort because that’s what trauma is all about. And it feels like a constant re-infliction of the trauma. And trauma is basically an experience of being made into an object that people often feel inappropriately guilty about. They’d rather blame themselves, feel that, you know, if you blame yourself, they’d rather feel guilty than helpless. And if you, somehow blame yourself for it, you can sort of imagine that you could replay the movie, and it would come out different. You know, if you’d just done this instead of that, when the essence of trauma is that you didn’t have any choice over what was happening to you. And so, it complicates the traumatic reaction because you relive the physical discomfort, and you also now have the emotional discomfort of there must be something wrong with me. for this to have happened. And it’s even worse for children, of course, because children don’t understand independent causation. So, you know, I was, I was a good girl, you know, why, why would this happen to me? I, when I was working in pediatrics, you know, there’d be these kids who would be so sick and they just say, I’ve been good, you know, why am I having all this pain? And so, it’s, it’s a, um, a kind of tragedy of combination. And hypnosis, because of the mind-body connection and modulation of it that’s possible, can help people see these things from a different point of view. So, it can be helpful psychotherapeutically and also psychophysiologically to use hypnosis to help people. And I’ve used it with many people suffering from post-traumatic stress disorder.

Yeah, we know the insular cortex is like the sensor in your brain that helps you interpret, obviously, what’s coming up from the periphery. That’s right, filtered and as well that. downward direction as well, which can be so important. I’m curious, you know, I know you’ve done some work with updating the DSM-5 with regards to the trauma diagnosis and the criteria that’s in there. Did hypnosis come into the conversation? Or hypnotic, you know, a component that was part of something that we should pay attention to with this particular condition?

Well, the way in which it came up indirectly through dissociation, Joe, the DSM is a diagnostic manual, but it’s not a treatment manual, so it doesn’t talk much about treatment. But we did introduce in the DSM-5 a dissociative subtype of PTSD, because many people suffer in addition to the intrusion avoidance, hyperarousal, and demoralization symptoms that are standard with PTSD, There are people who have depersonalization, feeling disconnected from their own body, and derealization, feeling like the world is unreal or dreamlike, which people use as a defense at the time of trauma. You know, I’d just rather not be here. I’d rather be somewhere else. I had a patient who said that when her father and his friends were sexually abusing her, she would go to a mountain meadow full of wildflowers. She just, I want to be somewhere else. So, it’s a very useful defense mechanism to detach yourself from traumatic experience while it’s occurring, because you don’t want the big picture. You just want to know what you need to know to stay alive. And so, the fact that there is a dissociative subtype now means also that there is a place for using hypnosis to help people access and modulate their dissociative experiences and dissociative symptoms in relationship to their memories of trauma.

Does this start to point to hypnosis having an impact or in some way influence our unconscious or what people call the subconscious mind?

Well, certainly, yes. Hypnosis is a way of getting at things that you ordinarily might not be aware of. The brain processes thousands of things all the time. memory, body sensations, body management, and very few of them actually float up to conscious awareness. And hypnosis is a kind of focused search engine that allows you to go back and see what were things like at a certain time and place that you may not have thought about for a long time. Now, we do that anyway. You know that if you go back to your elementary school, you know, you’re amazed at this, how small the lockers are and all these other things, but you also start to have memories. of people and events that you hadn’t thought of in 30, 40 years. So, our memory is associational. And if you can focus on certain things, you will have different memories. I was regressing a Stanford student in a class to relive what it felt like as he was a little boy. What’s your third birthday like? And he starts giggling and talking about that. And I had him go back actually to when he was just a few days old. What do you remember? I was just curious what he might remember. And you would, you’d light a match, and he would try to grab it the way a baby would, you know, not knowing that it could be heard. And then I started to tickle him under his arm, you know, and he burst out in tears. I thought, oh my God, what happened? And so, I stopped doing that and I got him calmed down. And afterwards I said, do you know anything about whether you were sick when you were first born? He said, well, of course I don’t remember it, but my mother told me that I had an abscess on my left shoulder. And so, what I was doing was tickling this, he had this memory still that this was what happened. So, hypnosis can be a way of, doing a kind of deep dive on certain memories in certain contexts, it doesn’t mean that everything you remember is true. But it doesn’t mean, because you were called it in hypnosis, that it isn’t true either. So, it is a kind of search engine for memories.

I think that’s good news to a lot of people because people are aware that they have these unconscious beliefs, so to speak, that that do influence them. And some people have been able to work through that in various ways. Psychotherapy is one, sometimes I just work through it in life. But I think when we talk about, you know, the biopsychosocial model, the social influence on us can be really powerful. A lot of times, you know, we subconsciously absorb that, and we don’t have an awareness of that. Is there a role, I guess, for hypnosis in starting to break those patterns that weren’t even ours, they were just kind of layered on top of us throughout life?

Sure, Joe, and that’s where the inverse connectivity between the prefrontal cortex and the posterior cingulate, the default mode network, is so important that you can kind of just drop a lot of the sort of habitual ways of thinking about yourself become more cognitively flexible about alternative ways of being or alternative aspects of yourself that you hadn’t thought about very much. It kind of allows you to disconnect from your maybe unconscious assumptions about yourself and who you are that you may never even have thought about, but that are governing some of what you do. And it’s a way of trying out what it would feel like to be different before you decide that you want to be. And that’s a wonderful opportunity for therapeutic change.

So, we have this research base. Obviously, we have therapists, clinicians using it in practice. How would you like to see like if someone’s new, and they’re curious, how would you recommend they start with something like this?

Well, Joe, there are many well-trained, but not a lot, but many well-trained psychologists, psychiatrists, dentists, physicians who do know how to use hypnosis. But it’s the exception, not the rule. And I’ve used hypnosis with about 7,000 people in my career. It’s a lot of people. But I thought, yeah, I’m not going to be able to do it forever. So, my kind of legacy project is to make it available to anybody with a smartphone. And so, I, with my co-founder, Ariel Poehler, decided to build Reverie. It’s an interactive digital hypnosis app. The interactivity is important because it’s more like being in the office with me. So, you download Reverie from the App Store, Google Play, or from the website. And you can have a real experience, because I’ll ask you, is your hand floating up in the air? Is it feeling light? If they say yes, I go on to something else. If not, I give them another instruction about that, and so on. And you can try out reducing pain. Imagine you’re floating in a bath, like a hot tub, floating in space. filter the hurt out of the pain. And people can do that and see within 10 minutes whether it’s likely to help them or not. They can feel it there and they can then use it for themselves, hearing my mellifluous voice whenever they want. So, my idea is, if you want a taste of it that might really help you, just download the Reverie app and try it. Then if you get into something complicated or you want professional reinforcement by all means, get referred to somebody who practices hypnosis clinically. But it’s a great starting point to just see to what extent you can control your anxiety, you can get to sleep, you can focus your attention better, you can stop smoking. There are a lot of things that people can learn to do. So, it’s worth a try.

Know, pain relief, improved sleep, and focus attention not on pain is something that definitely in our community and always when there’s something that’s brief and easy and accessible. It’s always a big one, especially for people who have pain or for clinicians who are busy and looking for more tools.

Right.

So oftentimes, I’ll reach out to our community. And I’ll ask, you know, I’ll say, hey, I’m having someone on about hypnosis. What are your questions? So, I think we’ve covered like everything, there’s always the one question that comes up. And this always comes from the smartest clinicians out there. And they always say, I want to know, is this just placebo? And what’s the difference between the placebo effect and the effect that we see in a hypnotic session?

Sure. Well, first of all, let’s not be contemptuous about placebos, you know. It’s the single, probably more people get analgesia from placebo effects than anything else. So, I don’t knock placebos. Having a positive expectation that a treatment may help or that you’re in an office with somebody who really wants to help you has therapeutic potential. The brain’s set on what the experience is gonna be has an effect. But hypnosis, if you’re hypnotizable is more powerful than placebo. There was a study done, McGlashan, Evans, and Oren some years ago, where they had people stick their hand in circulating ice water, and the more pain inflicted, the colder the temperature of the water was. And they compared placebo instructions with hypnotic analgesia. For non-hypnotizable people, they were about the same. For hypnotizable people, the hypnotic effect was much more powerful. They could tolerate keeping their hand in the cold water longer than people who weren’t hypnotized. So, hypnosis is more than placebo. But you know what? It’s about as easy to use as placebo, so it’s worth the effort.

Right. So obviously, there are there are real physiologic changes that happen with the placebo effect. But there are changes above and beyond that they’re happening with something like hypnosis. That’s exactly right. Yeah. Um, do you see this as a first line intervention for conditions? Because there’s always, you know, there’s always the, well, we have to fully evaluate someone and screen them and assess them and go, you know, the other thing that comes up with practitioners and our community kind of send this into, what are the precautions or contraindications that might be appropriate for people with, let’s say, chronic pain?

Well, look, you know, if you’re having crushing substernal chest pain, you probably want to go to an ER, you know. So obviously, if it’s sudden new severe pain, you probably want to have a doctor examine you and figure it out. And I do that in my practice. But at the same time, if you know what the pain is, or it’s mild or minor, and if you learn that you have some ability to regulate how much the pain bothers you, you can at least live with it while you find out what else might be going on that can make it worse. And so, I would say in general, it’s a safe and effective thing to do if you don’t have reason to believe that it’s a really serious physical problem. Let’s compare it with what the more common practice is. Opioids, Oxycontin and other drugs. There were 88,000 opioid overdose deaths in the United States last year. Drug overdoses are a leading cause of death in young people. It’s terrifying. And you’re not gonna do anything to someone with hypnosis that’s anywhere near as dangerous as that. So, you know, I understand the question, Joe, but if, if, if you ask the same question, but said, well, maybe you shouldn’t use, you know, opioids and pain control medications for pain before, you know, you find out what it is, people would say, what are you, cruel, crazy, you know, what is this? And, and yet they’re far more dangerous than hypnosis is.

Yeah. I mean, it’s interesting because I agree with you that there are prescribers who will choose an opioid. and believe that’s the solution way before they would say, hey, you know, why don’t you give hypnosis a try? It’s safe. It’s easy. It’s quick. There’s practically no side effects to this.

That’s exactly right, Joe. And you try it. If it works, good. And four out of five people using Reverie find that hypnosis gives them instant reduction in pain. I had a young woman who was seven months pregnant and had really bad lower back disease. And they couldn’t use opioids because she was pregnant. and they implanted a nerve stimulator, that didn’t work and she’s so suffering with pain. And as the baby grew, of course, it got worse and worse. And I had her imagine in hypnosis she was floating in a warm bath, that made her feel good. And if you think about it, so your brain gets in a certain state with a real pain problem, when you’re experiencing relief. And there’s no reason why the brain can’t get back into that state, even if you’re not in the warm bath at the time. So, she did, and her pain went from seven out of 10 to three. And I said, how are you feeling? And she looked angry. And I said, what are you angry about? She said, why in the hell are you the last doctor I got sent to instead of the first? And she was right. You know, she was right. So, it should be a first resort, not a last resort.

Yeah, I agree. We should be telling people or helping them understand that there’s a pain relief stimulator in their body, and it’s their brain and it’s in many ways more powerful than anything we have yet to invent, not that I’m not very open to innovation and biomedical medicine. But I’m also extremely open to let’s use the tools and resources we have that are safe, that can help people. So as we start to wrap up, people are going to want to know again about that website so they can access the app and then how they can just learn more information about you and follow your research and work.

Sure. Well, the website is www.reveri.com. And there’s lots of information there about the scientific basis, our research, and how to access and utilize reverie to manage pain and stress and anxiety and insomnia and bad habits like smoking. So, my hope is that people will give it a try. We’ll see what it feels like and see if it can help them, because It’s easy. We’ve made it as available as we can make it, and it can go along with other treatments. It can replace other treatments if you’re lucky, and that’s a good thing. I encourage people to try out hypnosis. You’ll like it. You can try out being different and feeling different. And you make a very good point, Joe, and Reverie reinforces this, that the brain is not just the sort of, you know, involuntary reporter of physical discomfort. It also is a manager of discomfort, and it’s an opportunity to experience it, but also to modulate it. And so, your brain is your friend, not your enemy when it comes to pain, and hypnosis can help you do it.

Well said, I want to thank Dr. Spiegel for joining us on this week’s episode of the Pain Science Education Podcast. You can find all the links that he mentioned, including the one to Reverie on the website at theintegratedpainscienceinstitute.com. Of course, please make sure to share this episode with your friends who are interested in safe and effective non-drug and non-invasive treatment for chronic pain. You can find me on Facebook, LinkedIn, Twitter, as well as Instagram. Tag me there and I’ll be sure to be social and tag you back. I’m Dr. Joe Tatta. See you next week.

Thank you very much and keep up your good work on pain science education.

Important links

https://www.reveri.com/

https://med.stanford.edu/profiles/david-spiegel

Dr. David Spiegel is Willson Professor and Associate Chair of Psychiatry & Behavioral Sciences, Director of the Center on Stress and Health, and Medical Director of the Center for Integrative Medicine at Stanford University School of Medicine, where he has been a member of the academic faculty since 1975, and was Chair of the Stanford University Faculty Senate from 2010-2011. Dr. Spiegel has more than 40 years of clinical and research experience studying psycho-oncology, stress and health, pain control, psychoneuroendocrinology, sleep, hypnosis, and conducting randomized clinical trials involving psychotherapy for cancer patients. He has published thirteen books, 404 scientific journal articles, and 170 book chapters on hypnosis, psychosocial oncology, stress physiology, trauma, and psychotherapy. His research has been supported by the National Institute of Mental Health, the National Cancer Institute, the National Institute on Aging, the National Center for Complementary and Integrative Health, the John D. and Catherine T. MacArthur Foundation, the Fetzer Institute, the Dana Foundation for Brain Sciences, and the Nathan S. Cummings Foundation. He was a member of the work groups on stressor and trauma-related disorders for the DSM-IV and DSM-5 editions of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. He is Past President of the American College of Psychiatrists and the Society for Clinical and Experimental Hypnosis, and is a Member of the National Academy of Medicine. He was invited to speak on hypnosis at the World Economic Forum in Davos in 2018.