The positive message in negative findings: brief psychosocial intervention can lead to lasting pain reduction using hypnosis, education, or cognitive approaches.

The article by Jensen et al. 7 in this issue describes the comparison of 4 brief psychosocial interventions for chronic pain: clinical hypnosis, cognitive therapy, cognitive therapy enhancedwith hypnosis, and an educational control. The authors found all 4 treatments to perform equally, an unexpected result not supporting the initial hypothesis that cognitive therapy with hypnosis would lead to greater reductions in patients’ day-to-day pain. All 4 treatments significantly reduced patients’ average pain levels, with medium to large effects (0.60-0.80) maintained over a 12-month period. Prior studies examining the efficacy of clinical hypnosis have struggled with a host of methodological shortcomings. The authors’ research design addresses frequently cited pitfalls in the hypnosis literature concerning sample size, power, randomization, long-term follow-up, and the use of an active control group. Furthermore, the authors formally assessed hypnotizability as a moderator variable, which is recommended (although not often performed) in hypnosis trials. Hypnotizability is known to moderate hypnotic analgesia in experimental pain studies, and planned analyses of this issue within their data will be a key addition to the clinical literature. This study has numerous encouraging clinical implications. First, all 4 of the study interventions are considered brief, requiring only 4 sessions. Second, all interventions had high rates of attendance and adherence to assignments, with over 90% attending all sessions. Moreover, patients reported high overall satisfaction with treatment they received, although a significantly higher proportion of patients reported dissatisfaction with education alone (eg, 13% in education vs 0% in hypnosis)—an interesting finding that could benefit from further study. Finally, the effects of these brief treatments are similar to those reported in meta-analyses of standard cognitive–behavioral treatments for pain, and self-management interventions for pain. Thus, this study highlights clinically effective and pragmatic interventions that are likely to have high patient acceptance. Regarding hypnosis specifically, effects parallel those reported in meta-analyses in clinical and experimental contexts. This finding introduces the possibility that patients might experience the same degree of benefit from brief hypnosis treatment but in half the typical time. Future studies may consider examining treatment dose—eg, will all patients benefit equally from 4 sessions of hypnosis as 8? What are the patterns of the change process? Also, what role does home practice between sessions have in the change process? Learning whether patients benefit from using hypnosis between appointments, and how practice occurs (eg, audio-guided vs self-guided hypnosis) has important clinical implications for both trial design and clinical work. This study’s “negative” findings, that all 4 treatments performed equally,may highlight the challenge of using education as an active control condition in chronic pain intervention research. Selfmanagement programs for chronic pain consider psychoeducation a core tenet of treatment, with proven lasting treatment effects. The use of pain education as a control might therefore have diluted treatment effects. The authors suggest a usual care condition as a passive control. Beyond this, future hypnosis research might consider “sham hypnosis” control such as that outlined by Kendrick et al., using white noise and therapeutic interaction to manage placebo and expectancy effects. This studywas powered on a pilot investigationwith 15 subjects, all of whom received each of the 4 interventions studied, albeit in slightly different sequences. By receiving 16 consecutive sessions of psychotherapy with the same therapist, individuals in the pilot trial couldhavedevelopedstrong therapeuticalliances influencingchange. Also, participants may have practiced skills learned in one treatment course while receiving another, possibly introducing cumulative effects. As the authors noted, the pilot investigation had (larger) effect sizes and it is possible this trial was not adequately powered (p.29). It may also indicate a need for more sessions to detect a difference. Additional questions remain regarding the distinction between hypnotic cognitive therapy and hypnosis with suggestions for analgesia for pain. The inductions for both treatments were likely similar, with different suggestions provided. Does the type of suggestion used result in significantly different effects on pain in the long term? Are different mechanisms involved? Does this treatment design contradict previous ideas that hypnosis should occur by layering suggestions that target different brain regions corresponding to pain relief? Knowing how these treatments are affected by hypnotizability levels and practice between sessions is of utmost importance in answering these questions. Particularly time sensitive is scaling psychosocial interventions for pain to a wider audience. With COVID-19, the demand for Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.