by Jo Marchant
Over the past few weeks, Terrell has had four or five surgeries (he can’t remember which), to graft skin from his right leg onto the burns of his left. He’s still on hefty doses of the opioid drugs methadone and hydromorphone for his pain, which make him permanently drowsy. When the anonymous man starts shouting, “My pain is at ten, someone get down here now!” I struggle to hear Terrell’s soft, slurred speech.
He tells me he’s from Renton, a city just south of Seattle, where he lives with his mother and his girlfriend. I ask what Renton is like and he says there are “some dangerous people” and that he didn’t finish high school because he was “being bad.” He’s currently unemployed, but when he gets out of the hospital he hopes he might get a job at the fast-food chain Popeye’s, washing dishes: “They hire felons and people like that.”
Tattoos cover Terrell’s arms and chest. Among the swirling faded designs, I make out an empty-eyed clown face and several figures with bared teeth and protruding ribs. He dismisses them—“just art,” he says. Small letters on his right arm read “Son of God,” while larger initials on his left spell out “M.O.E.” His girlfriend? No, he laughs. “Money over everything.”
An assistant wheels in a clunky gray cabinet carrying a laptop and a set of goggles. Terrell settles back on his pillows with the headset and phones, while the open laptop reveals what he’s watching.
It’s just like the equipment that transported me to Snow World, but this is a very different scene. Terrell is floating along a stream, a rocky trickle at first, which gradually opens out into clear, shallow river with sandy banks. On either side there’s grass then a dense forest of pine trees. Straight ahead, snowy-topped mountains are visible beneath a clear blue sky. This isn’t a game; there are no penguins or snowballs to shoot. Instead, it’s a session of hypnosis. The numbers one to ten float past, then a soothing male voice delivers suggestions for feeling relaxed and free of pain.
Terrell has never heard of hypnosis. But two days ago, after he complained to staff that his pain was “a ten” despite the drugs he was taking, they asked if he wanted to try a relaxation aid and he said, “Yes.” “When I did that I couldn’t feel no pain,” he says. “I wasn’t worrying about it.” Today, he’s keen to try it again. Terrell lies still as the program runs, at first absorbed in the peaceful forest scene. But then his eyes close, and his mouth drops open. He’s asleep.
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IT’S A common problem, says Hoffman’s psychologist colleague David Patterson, when I recount this story to him later. Patterson has worked with burn and trauma patients at Harborview for the past 30 years, looking for non-pharmacological methods to ease their pain beyond the relief they get from drugs. Although Snow World is extremely good at distracting patients from their pain for short periods of time, the effects disappear as soon as they take off the goggles. So Patterson is also investigating whether positive suggestions delivered by hypnosis can reduce pain and aid their recovery in the longer term.
The idea of using hypnosis as an anesthetic was pioneered by James Esdaile, a Scottish surgeon working in India in the mid-nineteenth century. He saw thousands of patients affected by lymphatic filariasis, a parasitic infection that causes huge fluid-filled swellings, but had difficulty persuading sufferers to let him remove these protuberances. At the time, there were no available anesthetic drugs. Without them, the operation was excruciatingly painful, and many patients died from the shock.
Esdaile had read about the analgesic effects of mesmerism, which was popular back in Europe at the time. Although he had never seen anyone being mesmerized, he decided to give it a try and was surprisingly successful. The surgeon kept detailed notes of the patients he operated on, including a 40-year-old shopkeeper named Gooroochuan Shah, who had a giant, 80-pound scrotum that he used as a writing desk.
Esdaile cut off the monster swelling after Shah was rendered “insensible” by mesmerizing him, and was convinced that the procedure saved the man’s life. “I think it extremely likely,” he wrote, “that if the circulation had been hurried by pain and struggling, or if shock to the system had been increased by bodily and mental anguish, the man would have bled to death.”13 As the word spread, patients with lymphatic filariasis flocked to see Esdaile, and his hospital became a kind of “mesmeric factory” in which he carried out thousands of operations with very low death rates for the time.
Today, Esdaile’s techniques have been largely forgotten. Now that we have effective chemical anesthetics, most of us have no need to undergo surgery drug-free. (There are many situations, however, in developing countries and in war and disaster zones, where this isn’t the case. Four thousand people had limbs amputated after a devastating earthquake hit Haiti in 2010, for example, mostly without any form of pain relief.) But a few researchers are pursuing whether hypnosis can help to reduce drug use for wound care, recovery from surgery and chronic pain.
Patterson tells me that he became interested in hypnosis after a “life-changing” experience within a few months of starting on the burn unit at Harborview.14 A badly burned patient in his sixties was struggling to cope with his wound-care sessions. “He was maxed out on every drug—morphine, tranquilizers. He said, ‘I can’t go back in there, I’d rather die.’ ” Patterson’s mentor, a pain psychologist named Bill Fordyce, suggested that he try hypnosis.
So Patterson found a script for inducing hypnosis in a book, and read it out to the patient. It was designed so that when the nurses later touched the man on the shoulder during his wound care, he would go into a trance. “When I went back to see what had happened, the ward was buzzing,” says Patterson. “They said, ‘What did you do to that guy? We touched him on the shoulder and he fell asleep.’ It was astounding.”
Since then, brain-scanning studies have revealed that suggestions of pain relief delivered under hypnosis influence areas of the brain involved in pain perception. And several small, randomized controlled trials suggest that adding hypnosis to conventional treatment significantly reduces chronic and acute pain in a range of conditions.
The trouble is, most of the people whom Patterson sees are not straightforward to hypnotize. Harborview caters to all major traumas and burn cases in the region, from gunshot wounds to car accidents, regardless of whether they have medical insurance. Many patients there have psychiatric problems, or are addicted to alcohol or drugs. And like Terrell, they’re generally in pain and doped up on powerful painkillers, which means they’re sleepy and find it hard to concentrate, and they may have no idea what hypnosis is. They often aren’t able or willing to focus on a traditional hypnotic induction.
Another downside to conventional hypnosis is that it can be expensive, because you need a staff member to deliver it. So Patterson wondered if he could solve both problems by using virtual reality to immerse patients in a hypnotic trance. With a pre-recorded virtual session, patients don’t have to generate their own visual imagery, and the treatment can be delivered anywhere, anytime, without a live hypnotist.
The first patient Patterson tried it on, in 2004, was a 37-year-old volunteer fireman named Grant. Six weeks earlier, Grant had poured gasoline into a barbecue pit, not realizing that it still contained the embers of a previous fire, and in the resulting fireball suffered deep burns to 55% of his body. Since then he had endured six agonizing operations to graft skin onto the burns and was still in excruciating pain. Unless he was kept heavily sedated, he became delirious and suffered violent panic attacks, particularly during the daily sessions when medical staff needed to clean and dress his wounds. “He was at his wits’ end,” says Patterson. “All we had was Snow World.”
Rather than an interactive game, Patterson asked Grant to watch apre-recorded sequence. Floating igloos showed the numbers one to ten as he floated down through the ice canyon. At the bottom, Patterson’s voice suggested to the patient that he would feel relaxed and pain-free during subsequent sessions of wound care.
On the first day of the study, before any hypnosis, Grant scored his pain
at a maximum of 100, despite being on sky-high doses of painkillers—15 times higher than the typical dose used for burn patients at Harborview. The next morning he watched a session of virtual reality hypnosis. During his wound care later that day, Grant’s pain score came down to 60, and on the third day, after a top-up session of audio hypnosis, he rated his pain at just 40. In the meantime, the drug dose he needed came down by a third. On the last day of the study, Grant again had no hypnosis. His pain score shot back up to 100; in fact he was so distressed by the pain that he was unable to complete the rest of Patterson’s questionnaire.15
Since that case study with Grant, Patterson has developed the relaxing forest scene for delivering VR hypnosis, and he has reported positive results in several other burn patients, as well as trauma patients like Terrell. In a pilot trial of 21 patients in severe pain from broken bones and gunshot wounds, Patterson compared VR hypnosis against the Snow World game, or no treatment.16 The patients had a virtual reality session in the morning, then were asked to rate their pain for the rest of the day. After Snow World or no treatment, the patients’ pain rose over the course of the day, whereas in the hypnosis group it went down.
Patterson is now carrying out a bigger trial of 200 trauma patients to compare VR hypnosis with audio-tape hypnosis and standard care. But for now, “It’s brand-new,” he says. “The jury’s out.”
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HERE’S SOMETHING you can try at home. Place your right hand on a table in front of you. Keep your left hand out of sight underneath the table or behind a screen, and place a fake hand (a stuffed rubber glove will do) on the table in its place. Now ask a friend to stroke both left hands—the visible fake hand and the hidden real one—at the same time. After a few seconds, you should experience a strange effect; it will feel as if the rubber hand is in fact your own hand.
This is a phenomenon known as the “rubber hand illusion.” Even though you know that the fake hand isn’t part of your body, you feel as if it is. Once the illusion is established, it affects brain activity and behavior. People respond more quickly to objects that they see on or near the fake hand (just as with their own hand), and instinctively flinch or try to remove the hand if someone approaches it with a needle or knife.
But it also has physical effects. Neuroscientist Lorimer Moseley at the University of South Australia in Adelaide has recently shown that during the rubber hand illusion, blood vessels in the unseen hand constrict, decreasing the flow of blood to this body part and causing its temperature to drop. Allergic responses in the unseen hand also appear to be boosted in a way that’s consistent with immune rejection.17 It’s as if the lost hand is no longer treated as such an integral part of the body.
This supports the claims of hypnosis researchers, described in chapter five, that through using suggestions and illusions it is possible to influence blood flow and immune responses. Moseley concludes from his studies that we all have a “mind map” of ourselves—a mental representation of our physical body—held in the brain.18 This keeps us updated about the extent of our bodies and where we are in space, and may also play a crucial role in controlling and regulating our physiology (including things like immune responses and blood flow). Changes to the mind map, in this case achieved through a simple visual trick, are felt not just in the brain but in the body too.
This could have major implications for our health. Moseley speculates, for example, that the brain’s unconscious perception of different parts of the body might play a role in some autoimmune diseases. A mismatch between the mind map and reality can also be a cause of chronic pain—if sensory information coming from a particular body part clashes with what the brain expects, for example, it triggers pain to warn us of potential danger.
Phantom limb pain, in which amputees feel pain from a limb that no longer exists, is one obvious example, but problems with perceived ownership might be involved in other chronic conditions, such as complex regional pain syndrome (CRPS). Patients with this condition suffer intense burning pain after injuries such as wrist fractures, long after the bone itself has healed. The affected hand gets cooler in CRPS, just as it does during the rubber hand illusion.
Even relatively minor injuries can trigger alterations to the mind map as the brain struggles to interpret sensory information it receives, says Candy McCabe, a professor of nursing and pain sciences at the University of the West of England. “Quite quickly you can move into a system where everything is healed up on the periphery, but the central nervous system becomes over-sensitized to things that shouldn’t normally cause pain.”19
For example, in osteoarthritis, a condition caused by mechanical damage and inflammation in the joints, there’s no close correlation between the degree of structural damage and how much pain people feel. What’s often driving the pain, McCabe argues, is not the problem joint itself but how the brain perceives that joint. Just as with the central governor theory of fatigue, pain researchers are repeatedly finding that although messages from the body are important for pain, these are always modulated by our perceptions (conscious and unconscious) of how much danger we are in.
Researchers including McCabe and Moseley are now investigating whether tricking the brain into seeing a healthy limb can reduce pain in phantom limb syndrome, CRPS, stroke patients and osteoarthritis.20 In a variation of the rubber hand illusion, they are placing patients in front of a mirror or screen so that instead of their diseased limb they see the reflection or image of a healthy one. Whereas the virtual reality hypnosis and distraction developed at Harborview create an overall illusion that we are in a safe place, perhaps mirror therapy can perform a more focused trick, convincing the brain that an affected body part is safe and well.
Unfortunately, despite the public health disaster being wrought by prescription painkillers, there is relatively little research interest in non-pharmacological methods to help people deal with pain, and as we saw with hypnosis research in the last chapter, the studies so far are small. A recent review concluded that there isn’t enough high-quality evidence to say for sure that mirror therapy works better than placebo.21
Stanford hypnosis researcher David Spiegel suggests that part of the reason for the lack of enthusiasm is economic. Pain relief is a billiondollar market, and drug companies have no incentive to fund trials that would reduce patients’ dependence on their products, he points out. And neither have medical insurers, because if medical costs come down, so do their profits. The trouble with hypnosis and other psychological therapies, he says, is that “there’s no intervening industry that has the interest in pushing it.”22
That could be about to change, however. In March 2014, Facebook bought a little-known California startup called Oculus for $9 billion. The company specializes in VR gaming and has just developed a headset called Oculus Rift, similar in size and shape to a scuba mask. Whereas the VR equipment that Hoffman and Patterson use costs tens of thousands of dollars, Oculus sells its headsets for just $350 each. That promises to bring virtual reality within reach of ordinary consumers, who will be able to run wireless masks from their tablets or smartphones. Hoffman says he’s already tried running Snow World on an Oculus Rift headset, with a burn patient undergoing physical therapy. “It worked real well,” he says.
Developments like this mean that people will soon be able to use virtual reality pain relief—whether distraction games, hypnosis, or mirror-type illusions—at home. It also means that virtual worlds are about to get much more sophisticated, predicts Hoffman, as video game companies throw resources at developing software to go with the new headsets. As well as better games, he says, that could lead to better pain therapies too. It also makes me wonder whether we might soon see pain relief trials funded not by drug companies, but by the gaming industry.
In the future, Hoffman envisions entire libraries of off-the-shelf virtual worlds that those in pain can choose to match their interests. And the possibilities go beyond pain relief—he’s still interested in using virtual worlds to treat psychological dis
orders, for example, and has designed World Trade Center world, terrorist bus bombing world and Iraq world, to allow patients with post-traumatic stress disorder to face their fears.
Maybe virtual reality will even become powerful enough to shift attitudes in the medical community. “VR distraction is valuable for patients now,” says Hoffman. “But I think it has enormous potential for precipitating a paradigm shift in how pain is treated. The results are so strong, it’s encouraging the medical community to start exploring the use of non-pharmacologic analgesics in addition to pain meds. Who knows where that is going to lead?”
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TWO DAYS after our first groggy meeting, I go back to see Terrell, and I’m surprised to find him alert and smiling. He’s got a shoe on his bandaged foot—“I call it my ‘do anything shoe,’ ” he jokes. He has just taken a shower on his own for the first time since his accident and has even been to the gym. Whereas the doctors had previously said that he would be in the hospital for another two weeks, they have now promised that he can go home by Monday, in three days’ time.
Does he think the virtual reality helped? Since trying it, his injuries still hurt. “But I’ve felt a little bit different,” he says. “More at ease.” This impression is confirmed by one of the nurses, who tells me that Terrell underwent a “personality change” after his first session of hypnosis, from being downright sullen to polite and friendly.
When I ask him what he liked about it, he decides it was the trees. “There ain’t no better place than a forest,” he says. “If you was mad, you could go to a forest and get all of that out.”
All of what? I ask. “All of the pain.”