Hypnosis in chronic pain: from new hope to emerging standard?

Introduction Hypnosis can be described as an experience of focused attention and reduced peripheral awareness, during which some individuals show increased responsiveness to suggestions.24,55 Clinical hypnosis can be used alone or in combination with other treatments to enhance outcomes.44,86 Clinical hypnosis typically begins with an induction, a set of techniques designed to increase focused attention and responsiveness to the clinical suggestions that follow. The induction phase may last from a few seconds to several minutes, depending on the patient's response and needs. The induction is followed by clinical suggestions intended to elicit sensorimotor, perceptual, emotional, cognitive, or behavioral changes aligned with treatment goals.36 Hypnotic sessions are typically delivered over 4 to 8 sessions, spaced a few days to several weeks apart, and may include self-hypnosis training.44,52 Hypnosis has experienced periods of enthusiasm and neglect. In the preanesthetic era, it was commonly applied for surgical procedures and battlefield injuries. However, its use declined once chemical anesthetics became available. More recently, Jensen (2009)36 discussed the reasons for a surging scientific interest in clinical hypnosis for pain management. One reason is the convincing evidence that chronic pain is largely the result of supraspinal neurophysiological processes, supporting the rationale for top-down interventions such as clinical hypnosis. Research continues to expand our understanding of how pain experiences develop and persist. A growing number of studies show that pain originates from distributed, interconnected, and dynamic neural systems, in which supraspinal structures exert crucial modulatory influences.4,53 The supraspinal areas typically associated with pain include the thalamus, insula, primary (S1) and secondary (S2) sensory cortices, anterior cingulate cortex (ACC), prefrontal cortex (PFC), and supplementary motor area.4,12 However, recent findings support the idea that pain is generated by person-specific brain responses, rather than by a universal neural signature,12,49,53,82 supporting the potential efficacy of tailored top-down interventions, such as clinical hypnosis, which uses suggestions to modulate the psychological and neuropsychological factors that influence an individual's pain experience. Although pain neuroimaging research faces challenges with reproducibility, replication, the lack of longitudinal data, and robust causal inference methods,7 a consistent finding is that as pain becomes chronic, brain activity progressively shifts from primarily sensory processing to broader engagement of threat-related brain regions.3,9,12,34,51,66 This shift is important to consider when developing treatments that might affect chronic pain. In addition to evidence on the neurophysiology of pain, Jensen (2009)40 noted that interest in hypnosis is further supported by growing evidence that hypnotic suggestions can influence neurophysiological processes related to pain and that hypnotic analgesia seems to be effective, with minimal adverse effects. Here, we provide an update to Jensen's (2009) Topical Review,40 summarizing more recent evidence on the use of clinical hypnosis for pain management. 2. Methods We conducted a literature search in PubMed and PsycINFO for publications between 2009 and October 2025, combining the terms “pain” and “hypnosis” with additional keywords such as “definition,” “neuroimaging,” “meta-analysis,” and “clinical practice guidelines,” supplemented by the authors' knowledge of the field. We updated the evidence on the supraspinal effects of hypnosis, reviewed the effectiveness reported in meta-analyses, and examined freely available clinical practice guidelines that mention hypnosis for chronic pain, discussing challenges and opportunities for clinical practice and research. We report only meta-analyses that included randomized controlled trials (RCTs). When multiple reviews existed for the same pain condition, we prioritized the most recent reviews and those with the largest number of participants.33 3. Imaging evidence demonstrates that clinical hypnosis has direct effects on pain-related supraspinal sites Neuroimaging studies have revealed that verbal suggestions can modulate pain and pain-related brain activity, mostly through cognitive and emotional processes.48,89 In the 2000s, landmark studies demonstrated that pain-related brain regions are more strongly modulated when suggestions are delivered after a hypnotic induction, compared with when suggestions are provided through imagery or as nonhypnotic suggestions.18,20,25 This evidence positioned hypnotic suggestion as a research tool to enhance the detectability of brain responses associated with pain modulation in experimental settings.64,67 The studies also demonstrated that pain can be generated in the absence of nociceptive input20 through activation of pain-related brain regions.14,15,20 A 2019 systematic review of 85 studies found that hypnotic suggestions reduce experimental nociceptive pain in healthy volunteers by 29% to 42% compared with inactive control.79 Neuroimaging evidence had suggested that pain modulation occurs in response to suggestions rather than the hypnotic induction itself.20–22,25 Another systematic review concluded that suggestions can selectively target brain regions associated with pain experience.78 This finding might compromise homogeneity when studies are summarized in meta-analyses of hypnosis (ie, given that “hypnosis” involves procedures that can have widely varying suggestions), but it opens the opportunity to target suggestions based on individual differences, such as preferences, presence of maladaptive factors, and capacity to respond to a particular suggestion. Two studies published since 2009 warrant particular attention. Nusbaum et al. (2011)63 showed that a hypnotic induction in individuals with chronic back pain activates emotion-related regions, including the frontotemporal cortex, IC, and ACC. The delivery of pain-focused suggestions further modulated activity in the PFC, whereas well-being suggestions engaged a broader emotional network involving the ACC and IC. In fibromyalgia, Derbyshire and colleagues19 found that identical pain-related suggestions (ie, imagining a dial turning to increase/decrease current pain) delivered after an induction produced greater changes in pain ratings and in ACC, IC, and PFC activity than when delivered without a hypnotic induction. Despite these advances, current research designs limit causal inference; future work should integrate multimodal neurophysiological measures, longitudinal approaches, and advanced analytics to clarify the neural mechanisms underlying suggestion-driven pain modulation.68 4. Recent meta-analyses support the efficacy of clinical hypnosis for chronic pain management Clinical hypnosis has been investigated in a variety of chronic pain populations. We identified 11 meta-analyses since 2009. For adults, data were provided for mixed chronic pain conditions,2,56,71 musculoskeletal and neuropathic pain,52 fibromyalgia,88 cancer-related pain,11 pelvic pain,10 and irritable bowel syndrome (IBS).29 For children, data were provided for functional abdominal pain disorders.30,72,75 Overall, meta-analyses suggest that clinical hypnosis can reduce pain intensity after a few sessions over several weeks. However, the certainty of the evidence ranges from very low to moderate (Table 1), due to study quality, inconsistency, and variability in suggestions and controls. Table 1 - Summary of the analgesic effects of clinical hypnosis for chronic pain from recent meta-analyses. Review Population Intervention** Comparison Primary outcome of the review Effect size, number of trials, and sample size Certainty of the evidence using GRADE or CINeMA (reason) Review quality (reason) according to AMSTAR-2 Mixed chronic pain Jones and Rizzo (2024)44 Adults with chronic pain Clinical hypnosis + usual care Usual care alone Pain intensity (0-100 pain scale) MD = −8.2; 95% CI: −11.8 to −4.6; 15 trials, n = 929 Very low (risk of bias and inconsistency) Low (downgraded one critical item because excluded studies were not reported) Musculoskeletal and neuropathic chronic pain Langlois (2022)52 Adults with musculoskeletal and neuropathic pain Clinical hypnosis No treatment and active control Pain intensity SMD = −0.42, 95% CI: −0.78 to −0.07, 9 trials, n = 475 Moderate* (inconsistency) High Chronic back pain Jones and Rizzo (2024)44 Adults with chronic back pain Clinical hypnosis + pain science education Pain science education alone Pain intensity (0-100 pain scale) MD: −11.5, −19.7 to −3.3, 2 trials, n = 109 Low (risk of bias and imprecision) Low (downgraded one critical item because excluded studies were not reported) Chronic pelvic pain Coitinho-Biurra (2023)10 Adults with chronic pelvic pain Clinical hypnosis Usual care, rest advice, medication Pain intensity SMD = −0.80, 95% CI = −2.12 to 0.52, 3 trials, n = 100 Not reported (post hoc: low due to risk of bias, and imprecision) Critically low (more than one critical item) Gastrointestinal chronic pain disorders Goodoory (2024)29 Adults with abdominal pain in irritable bowel syndrome Clinical hypnosis No treatment (waiting list) Number of participants who improved and those who did not improve RR = 0.77, 95% CI 0.61 to 0.96, 3 trials, n = 159 Low (risk of bias, imprecision) Low (downgraded one critical item because excluded studies were not reported) Sinopoulou (2025)75 Children with abdominal pain in irritable bowel syndrome Clinical hypnosis No treatment (wait list) and usual care Number of pain-free days MD = −5.4, 95% CI –8.2 to −3.0, 5 trials, n = 197 Moderate* (imprecision) High Fibromyalgia Zech (2017)88 Adults with fibromyalgia Clinical hypnosis and guided imagery with and without suggestions No treatment (wait list), usual care, active control (cognitive behavioral therapy CBT, physiotherapy, autogenic training, attention) Number of ≥50% of pain relief RD = 0.24, 95% CI 0.06 to 0.42, 6 trials, n = 299 Very low (risk of bias, indirectiveness, imprecision) Critically low (more than one critical item) Cancer-related chronic pain Danon (2021)11 Women with breast cancer Clinical hypnosis Usual care (medication), no treatment (wait list) Pain intensity SMD = −0.80, 95% CI −1.21 to −0.40, 3 trials, n = 130 Not reported (post hoc: very low due to risk of bias, imprecision, and inconsistency) Critically low (more than one critical item) The order is based on conditions and population (adults, children). Certainty of the evidence was reported as presented in the original systematic reviews and reflects the authors' own judgments. The first author assessed the certainty of the evidence in cases where there was inconsistency between the certainty classification and the justification for downgrading across certainty domains. The first author assessed the quality of the review based on GRADE recommendations.*We considered reviews to be less stringent if they did not downgrade for risk of bias related to blinding of participants and outcome assessors. GRADE (Grading of Recommendations, Assessment, Development, and Evaluations). AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews, version 2). CINeMA (Confidence in Network Meta-Analysis). * *The clinical use of hypnosis is a flexible approach. The induction phase may last from a few seconds to several minutes. It can include suggestions to enhance relaxation and absorption, along with prespecified or individually tailored suggestive techniques aimed at modulating pain intensity and pain-related maladaptive processes, either in the short or longer term. The use of hypnosis in research commonly involves an induction procedure, such as eye fixation followed by eye closure and progressive relaxation, followed by a prespecified script read aloud to participants, often in a calm, steady voice. The suggestions typically target relaxation and pain relief, with some studies additionally incorporating suggestions aimed at maladaptive psychological processes (eg, pain catastrophizing, fear, and avoidance behaviors), as well as posthypnotic suggestions intended to support the maintenance of benefits in daily life. Although hypnosis has been reviewed for other chronic pain conditions (eg, headache26,76), no meta-analyses for these other conditions have been conducted, likely due to limited RCTs and outcome heterogeneity. In addition to benefits on pain intensity, one systematic review concluded that clinical hypnosis may also reduce pain interference compared with no treatment and active groups in adults with musculoskeletal and neuropathic conditions (SMD = −0.39, 95% CI = −0.73 to −0.06, 6 trials, n = 339).52 A few studies have investigated the effects of clinical hypnosis on sleep, fatigue, and medication use; however, meta-analyses are rarely possible.44,80,88 Given the possibility of adapting hypnotic suggestions to address selective pain domains,39,78 further investigation of goal-oriented hypnotic suggestions is warranted. Regarding adverse effects, the evidence from recent high-quality RCTs suggests that clinical hypnosis is not associated with any greater harms than those associated with other psychological interventions.8,43,70,84 5. Recent clinical practice guidelines that mention clinical hypnosis for chronic pain management Treatment recommendations in clinical practice guidelines should primarily be based on high-quality systematic reviews, and, in their absence, on high-quality RCTs.23,85 Guideline development involves experts and consumers in discussing whether and how the interventions should be recommended.85 The discussion often considers contextual factors such as resource availability and expenditures, feasibility, acceptability, equity, and the current values and preferences of the target population.23,32,85 Practice guidelines typically classify recommendations as favoring, opposing, or neither favoring nor opposing a specific approach. The recommendation is often as or based on the of benefits and the certainty of the and other and moderate certainty evidence is more likely to support recommendations that the may be for some individuals and more from to in the guidelines to in in the available are to be updated when clinical practice guidelines for chronic pain and their Clinical hypnosis has been in several of with varying of support (Table 2). Table 2 - available clinical practice guidelines clinical hypnosis for chronic pain and their of recommendation for recommendation Chronic primary pain Chronic primary pain seconds for and Chronic pain in over Not for use Low certainty evidence from a study suggested that hypnosis may improve pain, but there was no for quality of or psychological for with chronic primary that hypnosis is not widely used to chronic primary pain in current clinical practice and the evidence did not to warrant further Chronic pain of the of and by the Low certainty evidence on literature these were found to be and have evidence of to be as of care for the clinical hypnosis is used for disorders and pain management. clinical is and of clinical hypnosis is by the clinical hypnosis based on and the of clinical hypnosis be delivered in the When care is delivered the the clinical hypnosis of are used to be clinical hypnosis on the and clinical hypnosis is for delivery through research support hypnosis delivered through to be and Gastrointestinal pain disorders bowel of recommendation for with psychological factors and with evidence for but evidence for for suggest that in with psychological may be to those with psychological as an therapy to improve control and quality of for and between and to the of and often by psychological interventions may potential benefits and are considered in pain evidence is bowel syndrome of recommendation for Low certainty evidence is one of the psychological for with the largest evidence for and efficacy in of the to may be the of its including intensity, and the for a However, has been to have benefits including in reduced at improved quality of and effects on bowel syndrome of recommendation for Very low certainty evidence (eg, are low risk when used by are benefits of these after they are are and can address the of with or for treatments are Gastrointestinal pain in disorders pain as of pain management practice should be considered as of pain management and on in bowel syndrome for and bowel syndrome in and recommendation after response to certainty evidence and interventions psychological for after of bowel syndrome and recommendation certainty evidence recommendation for after the benefits and harms of the of had the certainty of evidence treatment reviewed for these that is considered the of research data no between or should be based on the availability of and Cancer-related care care Network recommendation as an for pain and certainty evidence interventions as clinical alone or in with interventions as important in (eg, in interventions may be less or based on who may from may be to a in cognitive behavioral hypnosis, or of This of Clinical recommendation evidence quality systematic review the effectiveness of hypnosis on pain in with breast cancer reported that hypnosis had a influence on pain and in due to may or to other to provide the interventions (eg, clinical to chronic pain or improve pain-related in cancer Fibromyalgia Fibromyalgia of recommendation as a Not reported certainty evidence interventions without adverse effects or as hypnosis, relaxation, should be discussed the of the care specific conditions of of of the and by the in of no Fibromyalgia of of for nor Very low certainty evidence is evidence to for or the use of guided imagery and hypnosis in with and consistent with fibromyalgia or irritable bowel benefits the potential harms given that there is no evidence of Hypnosis not because they can be at once the is in Hypnosis are treatment when are The order is based on population and of available that or is not to the The for and The for and abdominal pain Pain for and clinical practice guidelines provide recommendations in of clinical hypnosis, evidence of a and the for chronic pain in adults did not clinical hypnosis, likely the of recent systematic reviews and its limited the This lack of a recommendation is to based on size and evidence The therapy and and therapy for pain intensity, effects and certainty with those reported for clinical and opportunities to support recommendations The supporting included in the available guidelines opportunities to increase in the enhance and broader evidence certainty Clinical hypnosis is a which may provide pain relief as a and including However, the certainty of evidence to improve to et al. included RCTs in a clinical hypnosis as a however, only one had low risk of bias for and Jones and Rizzo et al. (2024)44 included 15 RCTs of hypnosis, and only 5 had a low risk of Although the that study quality did not influence the the GRADE typically downgrading certainty when are In these with trials, high-quality studies are to the study quality the GRADE should be considered by when and should use to improve the A to increase in the available evidence be to meta-analyses by pain or This has been used in and be applied to other pain For the of one high-quality in a for chronic back pain has the certainty of the evidence from very low to and a few trials certainty to moderate or Recent RCTs have data on and adverse effects, which be meta-analyses to increase in and efficacy A growing understanding of and that for and to for clinical hypnosis to provide pain relief, may the development of more hypnotic A few recent studies have potential to chronic pain relief with clinical hypnosis, cognitive factors, including and have included of pain intensity, and pain-related and The is that reduced cognitive processes associated with and (eg, it and (ie, and the delivery of suggestions might responses to hypnotic suggestions focused on pain However, brain (ie, might be to hypnotic suggestions aimed at pain-related and This evidence whether hypnotic suggestions to and combining multiple the same might increase Regarding Jensen et al. the potential effects of pain-related factors and on pain intensity in the of clinical hypnosis and chronic pain. Although not specific to clinical hypnosis, control over pain and the number of days of of sessions Rizzo et al. demonstrated that may to across Clinical hypnosis can reduce pain intensity in the short without changes in pain catastrophizing, due to However, in the changes in pain may be to pain can be used to develop hypnotic suggestions to increase treatment effects in the and and that their recommendation of clinical hypnosis, one it as a reason for supporting the of clinical hypnosis The availability of to integrate clinical hypnosis with other treatments by in cases of only a few sessions are to treatment response to other (eg, for treatment delivery in delivery (eg, individual or sessions, or across pain (ie, a The potential to individuals for current treatments lack efficacy or availability be by some individuals over other available interventions or psychological Despite the lack of of an from a network found that clinical hypnosis first active including relaxation, and A recent study a with hypnotic suggestions management to the of clinical hypnosis to with chronic back of including and that they clinical hypnosis as a effective, and A recent study demonstrated the of a clinical hypnosis for chronic pain management including and In of clinical hypnosis have been interventions (eg, pain as well as treatment approaches, including pain science and brain and have the potential to be However, these and and of practice limit We summarized the challenges and opportunities in Table 3. Table 3 - and to evidence enhance the effectiveness of hypnosis, and support and and opportunities in the evidence high-quality randomized controlled trials to recommendations for the and guidelines (eg, sample clinical experts and consumers from the of the research study to quality and and as well as in clinical trials high-quality systematic reviews with by chronic pain to reduce the influence of a of trials in the certainty of the evidence by suggestion and primary outcome of interest to reduce in the systematic review experts from the of the research study to quality the effectiveness of clinical hypnosis and develop to factors studies and randomized controlled trials to factors associated with treatment and as well as improve (eg, cognitive and emotional processes, and contextual and (eg, to for suggestions and hypnotic treatments hypnotic suggestions evidence from and to hypnotic suggestion the effectiveness of suggestions the effectiveness of hypnotic suggestions randomized controlled trials (eg, and to and of clinical the neurophysiological mechanisms of hypnosis multimodal neuroimaging and (eg, with experimental designs and to how hypnotic suggestions modulate pain-related neural processes and experiences and of expand and develop between and to hypnosis practice and integrate clinical hypnosis with other treatments and clinical studies to clinical hypnosis to using in and their growing to hypnosis trials to the effectiveness and of hypnotic suggestions through evidence on hypnosis to increase in and of treatment with scientific in and to who are less with hypnosis Summary and In reasons for interest in clinical hypnosis. This updated review supported evidence that chronic pain is largely the result of supraspinal neurophysiological hypnotic suggestions can modulate these processes, and hypnotic analgesia seems to be an and for chronic pain. clinical guidelines clinical hypnosis for chronic primary pain (eg, and cancer-related pain in adults, and for in can further and clinical hypnosis as an for chronic pain. of interest provided on pain education and clinical hypnosis to a over the 2 is the author of 2 is the of 5 and related to the of from and for the In in a developing a that is designed to clinical hypnosis for pain and management.