Is high hypnotic suggestibility necessary for successful hypnotic pain intervention?
ABSTRACT Hypnotic suggestibility is a trait-like, individual difference variable reflecting the general tendency to respond to hypnosis and hypnotic suggestions. Research with standardized measures of hypnotic suggestibility has demonstrated that there are substantial individual differences in this variable. Higher suggestibility has been found to be associated with greater relief from hypnotic pain interventions. Although individuals in the high suggestibility range show the strongest response to hypnotic analgesia, people of medium suggestibility, who represent approximately one third of the population, also have been found to obtain significant relief from hypnosis. Thus, high hypnotic suggestibility is not necessary for successful hypnotic pain intervention. However, the available evidence does not support the efficacy of hypnotic pain interventions for people who fall in the low hypnotic suggestibility range. However, some studies suggest that these individuals may benefit from imaginative analgesia suggestions, or suggestions for pain reduction that are delivered while the person is not in hypnosis.
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ABSTRACT: Childbirth is a demanding event in a woman's life. The aim of this study was to explore whether a brief intervention in the form of an antenatal course in self-hypnosis to ease childbirth could improve the childbirth experience. In a randomized, controlled, single-blinded trial, 1,222 healthy nulliparous women were allocated to one of three groups during pregnancy: A hypnosis group participating in three 1-hour sessions teaching self-hypnosis to ease childbirth, a relaxation group receiving three 1-hour lessons in various relaxation methods and Mindfulness, and a usual care group receiving ordinary antenatal care only. Wijmas Delivery Expectancy/Experience Questionnaire (W-DEQ) was used to measure the childbirth experience 6 weeks postpartum. The intention-to-treat analysis indicated that women in the hypnosis group experienced their childbirth as better compared with the other two groups (mean W-DEQ score of 42.9 in the Hypnosis group, 47.2 in the Relaxation group, and 47.5 in the Care as usual group (p = 0.01)). The tendency toward a better childbirth experience in the hypnosis group was also seen in subgroup analyses for mode of delivery and for levels of fear. In this large randomized controlled trial, a brief course in self-hypnosis improved the women's childbirth experience.Birth 12/2013; 40(4):272-280. · 2.93 Impact Factor
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ABSTRACT: Identifying personality traits and neural signatures that predict placebo responsiveness is important, both on theoretical and practical grounds. In the present functional magnetic resonance imaging (fMRI) study, we performed multiple-regression interaction analysis to investigate whether hypnotic susceptibility (HS), a cognitive trait referring to the responsiveness to suggestions, explains interindividual differences in the neural mechanisms related to conditioned placebo analgesia in healthy volunteers. HS was not related to the overall strength of placebo analgesia. However, we found several HS-related differences in the patterns of fMRI activity and seed-based functional connectivity that accompanied placebo analgesia. Specifically, in subjects with higher HS, the placebo response was related to increased anticipatory activity in a right dorsolateral prefrontal cortex focus, and to reduced functional connectivity of that focus with brain regions related to emotional and evaluative pain processing (anterior mid-cingulate cortex/medial prefrontal cortex); an opposite pattern of fMRI activity and functional connectivity was found in subjects with lower HS. During pain perception, activity in the regions reflecting attention/arousal (bilateral anterior thalamus/left caudate) and self-related processing (left precuneus and bilateral posterior temporal foci) was negatively related to the strength of the analgesic placebo response in subjects with higher HS, but not in subjects with lower HS. These findings highlight HS influences on brain circuits related to the placebo analgesic effects. More generally, they demonstrate that different neural mechanisms can be involved in placebo responsiveness, depending on individual cognitive traits.Pain 03/2013; · 5.64 Impact Factor
Is High Hypnotic Suggestibility
Necessary for Successful Hypnotic
Leonard S. Milling, PhD
Leonard S. Milling, PhD
University of Hartford, Department of Psychology, 200 Bloomfield
Avenue, West Hartford, CT 06117, USA.
Current Pain and Headache Reports 2008, 12:98–102
Current Medicine Group LLC ISSN 1531-3433
Copyright © 2008 by Current Medicine Group LLC
Hypnotic suggestibility is a trait-like, individual differ-
ence variable reflecting the general tendency to respond
to hypnosis and hypnotic suggestions. Research with
standardized measures of hypnotic suggestibility has
demonstrated that there are substantial individual dif-
ferences in this variable. Higher suggestibility has been
found to be associated with greater relief from hypnotic
pain interventions. Although individuals in the high
suggestibility range show the strongest response to
hypnotic analgesia, people of medium suggestibility,
who represent approximately one third of the popula-
tion, also have been found to obtain significant relief
from hypnosis. Thus, high hypnotic suggestibility is not
necessary for successful hypnotic pain intervention.
However, the available evidence does not support the
efficacy of hypnotic pain interventions for people who
fall in the low hypnotic suggestibility range. However,
some studies suggest that these individuals may benefit
from imaginative analgesia suggestions, or suggestions
for pain reduction that are delivered while the person is
not in hypnosis.
At one time, hypnosis was associated with fringe psychol-
ogy and paranormal phenomena. However, empirical
research has since proven that hypnosis is a very effec-
tive tool for managing clinical pain [1,2]. Hypnosis is
a procedure in which a patient or subject is guided by
a hypnotist to respond to suggestions for changes in
subjective experience, such as alterations in sensations,
perceptions, affects, cognitions, and behaviors . A
recent meta-analysis of research on the effectiveness of
hypnotic pain interventions showed that the average per-
son treated with hypnosis achieved more pain reduction
than 75% of those in no-treatment and standard treat-
ment control conditions . Generally, higher hypnotic
suggestibility has been shown to be associated with
greater response to hypnotic pain interventions . This
review evaluates empirical research on the effectiveness
of hypnotic pain interventions for individuals who do
not score in the high range of hypnotic suggestibility.
What is Hypnotic Suggestibility?
Hypnotic suggestibility is a stable, trait-like, individual
difference variable reflecting the general tendency to
respond to hypnosis and hypnotic suggestions . Hyp-
notic suggestibility is sometimes referred to as hypnotic
susceptibility or hypnotic responsiveness in the literature.
Hypnotic suggestibility can be measured with standard-
ized instruments consisting of a hypnotic induction and a
series of test suggestions. The induction usually consists
of instructions for relaxation, accompanied by introduc-
tory suggestions that the subject is becoming hypnotized.
The test suggestions are delivered after the induction and
consist of three types.
In an ideomotor suggestion, the person is invited to
experience a motor movement (eg, “Your hand feels
heavy, and as it feels heavier and heavier, the hand begins
to move down.”). In a challenge suggestion, the person is
told he or she will not be able perform a particular behav-
ior and then is asked to carry out the prohibited action
(eg, “Your arm is becoming stiff and rigid, as if your arm
were in a splint, so that the elbow cannot bend. Now go
ahead and try to bend your arm.”). In a cognitive sugges-
tion, the person is invited to experience an alteration in
cognitive functioning (eg, “You are beginning to notice
a sour taste in your mouth, as if you had some lemon in
The extent of the individual’s response to the test sug-
gestions provides an index of his or her level of hypnotic
suggestibility, with higher scores indicating greater sug-
gestibility. The Stanford Hypnotic Suggestibility Scale,
Form C , consisting of an induction and 12 test sugges-
Suggestibility and Hypnotic Pain Reduction Milling 99
tions, is generally considered the gold standard of hypnotic
suggestibility measures. However, there are many other
reliable and valid hypnotic suggestibility scales that are
administered in either individual or group format .
Hypnotic suggestibility scales typically incorporate a
classification system in which individual scores can be
grouped into ranges such as high, medium, and low.
Research with hypnotic suggestibility scales has
shown that there are large individual differences in
suggestibility . Most individuals respond to some,
but not all of the test suggestions. A small number of
people respond to very few or none of the test sugges-
tions. Likewise, a small number of individuals respond
to most or all of the test suggestions. Indeed, normative
data for popular measures of hypnotic suggestibility
indicate that no more than about 25% of the popula-
tion falls in the high suggestibility range [10,11]. For
example, Figure 1 shows the distribution of suggest-
ibility scores on the Stanford Hypnotic Suggestibility
Scale, Form C . Only 26% of the normative sample
scored in the high or very high ranges of suggestibility,
whereas 29% scored in the medium range, and 45% in
the low range. Hypnotic suggestibility has also been
shown to be extremely stable over time. For example,
one study reported that assessments of hypnotic sug-
gestibility made 25 years apart showed a test–retest
correlation of .71 . The presence of substantial indi-
vidual differences in suggestibility and their stability
over time support the view that hypnotic suggestibility
is a personality trait, or at least a trait-like variable.
Hypnotic Suggestibility and Hypnotic
Hypnotic pain interventions traditionally involve making
direct suggestions for symptom reduction , although
some clinical hypnotists prefer to deliver standard cognitive-
behavioral pain techniques (eg, guided imagery, progressive
muscle relaxation) within the context of hypnosis . Gen-
erally, higher hypnotic suggestibility has been found to be
related to greater hypnotic pain reduction. For example, in
their meta-analysis of 23 studies of the hypnotic reduction
of clinical and experimental pain, Montgomery et al. 
calculated 35 effect sizes evaluating the relationship between
suggestibility and pain relief. These scholars obtained mean
weighted effect sizes of D = 1.16 for participants in the high
suggestibility range, D = 0.64 for those in the medium range,
and D = -0.01 for those in the low range.
Cohen  classifies an effect size of 0.20 as small,
0.50 as medium, and 0.80 as large. Accordingly, an effect
size of D = 1.16 for individuals in the high suggestibility
range would be considered large. Among highly suggest-
ible research participants, the typical person treated with
hypnosis achieved more relief than approximately 87% of
those in control conditions. An effect size of D = 0.64 for
individuals in the medium suggestibility range would be
classified as a medium effect. For those of medium sug-
gestibility, the average participant treated with hypnosis
obtained more relief than approximately 74% of those
in control conditions. Finally, an effect size of D = -0.01
for those in the low suggestibility range would be classi-
fied as small (and is virtually nonexistent). For those of
low suggestibility, the typical participant treated with
hypnosis obtained more relief than only about 50% of
those in the control conditions. The mean weighted effect
size for individuals in the high suggestibility range was
significantly greater than that of participants in the low
suggestibility range. Indeed, the mean weighted effect
size for those in the medium suggestibility range was not
significantly different from that of participants in the
high (or low) range.
In interpreting their results, Montgomery et al. 
highlighted two cautions. First, participants from stud-
ies in which hypnotic suggestibility was not measured
were assigned to the medium suggestibility range.
Second, there was a relatively small number of effect
sizes for participants in the low and high suggestibility
ranges. With these caveats in mind, the results of the
meta-analysis clearly indicate that hypnotic pain inter-
ventions are of benefit not only to people in the high
suggestibility range, but also to those of medium sug-
gestibility. Indeed, many people in the population score
in the medium suggestibility range. For example, on the
Stanford Hypnotic Suggestibility Scale, Form C, 29% of
people fall in the medium range. Thus, the findings of
this meta-analysis convincingly argue that hypnosis may
be effective in reducing pain experienced by everyone,
except the 45% of the population that scores in the low
range of suggestibility.
The meta-analysis by Montgomery et al.  evalu-
ated existing studies of the effect of hypnosis on both
experimental and clinical pain. In two more recent
Current Pain and Headache Reports PA 12-2-1-04 Fig. 1
240 pts. W/ 198 pts. D (20 x 16p5)
Author: Milling Editor: Chris Artist: TE
Number of cases
012345678 9 10 11 12
Figure 1. Distribution of scores on the Stanford Hypnotic Suggestibility
Scale, Form C (n = 307). (Data from Hilgard .)
100 Psychiatric Management of Pain
articles, Patterson and Jensen [1,2] reviewed controlled
trials of hypnotic interventions for acute and chronic
clinical pain. The reviewed studies included seven con-
trolled trials that evaluated the relationship between
hypnotic suggestibility and treatment outcome. Higher
suggestibility was found to be associated with more pos-
itive outcomes in the treatment of pain associated with
bone marrow aspirations , labor and delivery ,
migraine headaches [18,19], tension headaches ,
and osteoarthritis . Patterson and Jensen  noted
that unlike many of the experimental pain studies in
which subjects had been selected only from the high and
low suggestibility ranges, participants in these clinical
trials represented the full range of suggestibility in the
population. Because most people in the population do
not score in the high range of suggestibility, many par-
ticipants who benefited from hypnosis in the reviewed
studies likely were of medium suggestibility, or possibly
of low suggestibility. Indeed, Patterson and Jensen 
emphasized that “the fact that an association exists
between hypnotic suggestibility and treatment outcome
does not necessarily mean that only persons with high
screening scores should be offered hypnotic analgesia.
Just because highly suggestible patients benefit more, on
average, than those low on this variable does not mean
that patients falling in the medium or low range would
Together, the seminal meta-analysis by Montgomery
et al.  and the important qualitative reviews by
Patterson and Jensen [1,2] strongly suggest hypnosis
is beneficial for alleviating pain experienced by people
in the high range of suggestibility and also by those in
the medium suggestibility range. However, the existing
research does not support the effectiveness of hypnotic
pain interventions for people in the low range of sug-
gestibility. This comment should be tempered by an
important observation. Most of the studies included
in the meta-analysis by Montgomery et al.  and the
reviews by Patterson and Jensen [1,2] were not designed
and analyzed in a way that allows us to evaluate the
effectiveness of hypnotic pain interventions for people
of low suggestibility. The number of studies that clearly
speak to this issue is small, and the evidence is conflict-
ing [22–26]. More research, from multiple investigative
teams, is needed to determine whether hypnosis is more
effective than control conditions, or is as effective as
logical comparison conditions (eg, cognitive-behavioral
interventions), in treating pain experienced by those of
low hypnotic suggestibility.
In any event, if hypnosis is not effective in reducing
pain experienced by people who fall in the low range of
suggestibility, are there alternative interventions from
the domain of hypnosis that may be of value to in help-
ing these individuals? A possible answer to this question
comes from research on imaginative suggestibility and
imaginative suggestions for analgesia.
What is Imaginative Suggestibility?
A hypnotic suggestion consists of a hypnotic induction,
followed by an invitation to experience an imaginary
state of affairs. In contrast, a nonhypnotic imaginative
suggestion involves an invitation to experience an imagi-
nary state of affairs, but without providing a hypnotic
induction beforehand. In the literature, suggestions of
this kind have sometimes been called waking suggestions.
However, the term “waking” is misleading because people
who are hypnotized are not asleep. The same responses
generated by hypnotic suggestions can also be produced
by imaginative suggestions, and on average, adding a
hypnotic induction to imaginative suggestions (thereby
making them hypnotic suggestions) results in a small, but
significant increase in responding [27–31].
Just as hypnotic suggestibility is the general tendency
to respond to hypnosis and hypnotic suggestions, imagi-
native suggestibility is the general tendency to respond to
imaginative suggestions delivered without a prior hypnotic
induction . Imaginative suggestibility can be measured
by administering a series of test suggestions in which the
person is invited to use his or her imagination to experience
each of the suggestions. The Barber Suggestibility Scale
was explicitly developed to assess both imaginative suggest-
ibility and hypnotic suggestibility . In the nonhypnotic
version, the eight test suggestions are delivered without a
hypnotic induction. Other researchers  have measured
imaginative suggestibility by removing the induction and all
references to hypnosis from a standardized hypnotic sug-
gestibility scale and instructing participants to experience
the test suggestions with their imagination. Afterwards,
the scale can be administered in the usual manner, permit-
ting a direct comparison of an individual’s imaginative and
hypnotic suggestibility scores.
There has been much less research on imaginative
suggestibility, compared with hypnotic suggestibility.
However, like hypnotic suggestibility, imaginative sug-
gestibility appears to be a trait-like, individual difference
variable. There are large individual differences in imagi-
native suggestibility . Moreover, the association
between imaginative suggestibility and hypnotic sug-
gestibility is high, with correlations between the two
variables ranging from 0.54 to 0.99 [27–31]. Of note,
some people score higher on imaginative suggestibility
than they do on hypnotic suggestibility. For example,
Braffman and Kirsch  reported that 25% (n = 43) of
a large sample of 170 participants achieved higher scores
on a measure of imaginative suggestibility than on a
measure of hypnotic suggestibility composed of the iden-
tical test suggestions. Thus, for a substantial minority of
people, delivering a suggestion outside of hypnosis may
have a greater effect than delivering the same suggestion
in hypnosis. This observation may point to a way that
analgesia suggestions could be effectively used to man-
age the pain experienced by people who fall in the low
range of hypnotic suggestibility.
Suggestibility and Hypnotic Pain Reduction Milling 101
Imaginative Suggestibility and Imaginative
A hypnotic analgesia suggestion traditionally consists of
a hypnotic induction, followed by a direct suggestion for
pain reduction (eg, the affected body part is numb and
insensitive). In contrast, an imaginative suggestion for
analgesia consists of a direct suggestion for relief with-
out a hypnotic induction provided beforehand. Instead,
the individual is invited to use his or her imagination to
experience the affected body part as numb and insensitive.
Both imaginative and hypnotic analgesia suggestions have
been shown to reduce pain, although studies of the rela-
tive effectiveness of the two have produced contradictory
findings. Some studies show that there is no difference
between imaginative and hypnotic analgesia suggestions
[34–37]. Other research suggests the superiority of hyp-
notic suggestions for pain reduction [26,38]. Another
study argues that when participants are given both types
of suggestion in a within-subjects design, differences can
be a function of order . In addition, a fourth set of
studies indicates that low-suggestible individuals derive as
much benefit from imaginative suggestions for pain reduc-
tion as highly suggestible persons do from either hypnotic
or imaginative analgesia suggestions [23,24].
The contradictory nature of this literature may, in
part, be due to intra-individual differences in imagina-
tive and hypnotic suggestibility. Just as some people
score higher on imaginative suggestibility and others
score higher on hypnotic suggestibility, some individu-
als are likely to respond more strongly to imaginative
analgesia suggestions and others to hypnotic analgesia
suggestions. The findings of Braffman and Kirsch 
and Spanos et al. [23,24] are important because they
raise the possibility that for some people who score in
the low range of hypnotic suggestibility, delivering the
analgesia suggestion imaginatively rather than hypnoti-
cally is likely to produce more relief. Research examining
the relationship between imaginative pain reduction
and imaginative suggestibility is in its infancy , and
appears to be a potentially fruitful area of inquiry.
Without a doubt, hypnosis is an extremely potent inter-
vention for pain experienced by people who score in the
high range of hypnotic suggestibility. The empirical litera-
ture indicates that the analgesic effect of hypnosis is large
for highly suggestible individuals . Indeed, hypnosis
may be the psychological treatment of choice for patients
who fall in the high suggestibility range. However, high
hypnotic suggestibility is not necessary for successful hyp-
notic pain intervention. People who score in the medium
range of hypnotic suggestibility are also likely to achieve
substantial pain reduction by hypnosis. Studies suggest
that the analgesic effect of hypnosis can be classified as
medium for those in the medium suggestibility range .
Together, individuals who fall in the high and medium
ranges of suggestibility represent approximately 55% of
the population. Thus, for most people, hypnosis is likely
to be an effective pain management tool.
On the other hand, the available research does not
currently support the effectiveness of hypnosis for reduc-
ing pain experienced by people who fall in the low range
of hypnotic suggestibility. The analgesic effect of hyp-
nosis for people of low suggestibility has been shown
to be small and nonsignificant . However, there may
be an effective alternative for people who fall in the low
range of hypnotic suggestibility. Imaginative suggestions
for analgesia (ie, suggestions for pain reduction without
a preceding hypnotic induction) have been found to be
effective in reducing pain. In some studies, individuals
in the low suggestibility range who received imagina-
tive suggestions for analgesia achieved as much relief as
people in the high suggestibility range who were treated
with hypnosis [23,24].
Hypnotic suggestibility is a stable, trait-like indi-
vidual difference variable . Imaginative suggestibility
also appears to be a stable, trait-like individual differ-
ence variable . Some people score higher on hypnotic
suggestibility, others score higher on imaginative sug-
gestibility, and some score identically on measures
of both constructs . More research is needed on
intra-individual differences in hypnotic and imaginative
suggestibility and how these differences are related to
differential responding to hypnotic and imaginative sug-
gestions for pain reduction. Such research may help us to
better understand who benefits the most from hypnotic
pain interventions and who benefits the most from imagi-
native pain interventions.
No potential conflict of interest relevant to this article was reported.
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