What is Hypnosis?
Hypnosis is a process by which an individual is guided from his or her usual state of consciousness to a condition that is marked by psychological and physical relaxation; altered perceptions such as the slowing down of time or a change in one’s body image; and a shift from analytic to synthetic thinking, that is, the mind shows less dependence on logic and a greater receptivity to sensations and feelings. The resulting change in perception and thinking is known as a trance. The nature of the trance state varies from one individual to another.
The ability of hypnosis to induce deep multilevel relaxation, to quell anticipatory anxiety, to increase tolerance to adverse stimuli, and to intensify affirmative imagery can be adapted to the hospital setting for maximizing the mind’s contribution to healing.
Hypnosis has recently seen a resurgence in its medical applications, with increasing sophistication in the ways it has been used for many clinical problems, in and out of the hospital.(1) Equally important, modern hypnotists, in contrast to earlier ones who tended to be authoritarian in their approach, encourage patients to determine the nature of their own experiences, that is, to develop their unique potential in their trance. They are also mindful of psychodynamic considerations. Thus, they use permissive and often frankly meditative methods and function as a guide to point the way to conditions of consciousness that are conducive to psychological adjustment and growth.(2)
Hypnosis in Special Procedures
Procedures performed under local anesthesia with or without sedation are often anticipated by the patient with the same apprehension as those requiring general anesthesia. The idea of being conscious during a procedure may be reassuring in one respect and unsettling in another. On one hand, the patient’s sense of control is maintained; on the other hand, the patient may feel uncertain as to how he or she will deal with the experience. Even a simple procedure, like a spinal tap, can be approached with dramatic imagery: the mental picture of a needle may be much larger than the actual size of the needle. Similar distortions may also occur with regard to other procedures, such as cardiac catheterization, bone marrow biopsy, or sigmoidoscopy.
The anticipatory anxiety generated by the patient’s fantasies about a procedure should not be neglected. It can turn a routine stay in the hospital into a nightmarish experience and negatively sensitize the patient to future hospitalizations.
The following case history illustrates some of the principles of hypnosis when used in the hospital with certain medical procedures:
A 52-year old woman who had never been hospitalized was admitted for workup of a lung shadow. She was to undergo a bronchoscopic examination the following day. When she became agitated and highly anxious, a consultation was requested. Hurriedly wiping away some traces of tears to appear more presentable, she looked distraught and restless in her bed. Anticipation of the procedure, which had been explained to her in a cursory and hurried fashion, had left her in a state of panic. She imagined a large, cold, straight metallic tube being pushed into her throat and saw herself in the agonies of choking. Yet, on another level, she spoke amazingly candidly and rationally: “Doctor, I’ve been a smoker for many years. I think tomorrow they will find that I have cancer. But I think I can come to terms with it.” The procedure was explained once more to her. The tube was described—a picture of it was even drawn—as flexible and as leaving plenty of space for air to pass. She was told that the more relaxed she would be, the more easily air could pass. The benefits of deep, autonomic nervous system relaxation were evident to her, and she heartily agreed to attempt a hypnotic experience.
Because of her high level of anxiety, an approach more directive than normally used for outpatient office procedures was invoked. With her permission, her wrist was taken; gently and slowly her arm was brought straight out in front of her. She was presented with images of heaviness and relaxation, and her arm slowly waved itself downward, the hand gently releasing itself until it came to rest on the bed. With her eyes closed, all muscle tightness disappeared; her respiration adopted a slow, tempered rhythm; her face appeared serene and seemed to communicate a profound peacefulness.
Once the hypnotic induction had taken place, the goal centered on achieving the most profound relaxation possible. Then, the patient was encouraged to dispel the fear-laden images and to replace them with images that would be more consonant with her well-being. “You will feel the tube,” he said, “but at the same time your throat and all your air passages can be relaxed, and it need not bother you. You will have plenty of air and with each breath you can feel more and more relaxation sweeping through you. You may in fact be so relaxed that the whole experience will seem to be occurring some distance from you, far away. Until then, you may find yourself thinking very little about the procedure, if at all, leaving time for you to rest fully.”
The next day the patient underwent the bronchoscopy. The procedure was completed in just a few minutes; the patient was remarkably calm throughout. The tube met so little resistance and there were so few bronchial secretions that the surgeon called the hypnotherapist to gain a better understanding of this phenomenon. When asked about the experience, the hypnotherapist described how, conscious of the whole procedure and feeling peaceful, the patient had felt the tube inside her chest, as from a distance, and had mused to herself making a game of it, imagining it was a little train coursing through some tunnels.
Hypnosis in Surgery
The hypnotic phenomenon that perhaps inspires the most awe involves the patient who undergoes major surgery without chemical anesthesia.(3) According to Moll,(4) the first surgical operations on “magnetized” subjects were those performed by Recamier in 1821. (At that time, hypnotic phenomena were thought to be produced by the influence of magnetized objects.) Jules Cloquet followed him in 1829, Dr. John Elliotson in England, Dr. Albert Wheeler in the United States, and the well-known Dr. James Esdaile in India in 1840.
It is postulated that in certain individuals through hypnotic mechanisms, a sufficient level of endogenous agents—that is, those agents that occur naturally in the body—may be produced to block all perceptions of pain.(5) However, many author(6)(13) point out that pain is a sensation intimately intertwined with fear and that surgical procedures performed with hypnotic anesthesia may owe their success to the modulation of anxiety as much as to the neutralization of pain. Since 1950, interest in hypnoanesthesia has rekindled. Suppressed by the discovery of chloroform, ether, and nitrous oxide for more than a century, this renewed interest has been fueled not only by the growing sophistication in understanding hypnosis, but by new philosophies of patient care, such as the belief that patients should have access to any treatment modality capable of easing the stress of illness and its treatment.
It is estimated by some investigators(7) that 10 percent of the population could undergo major procedures with hypnoanesthesia. Others(8) estimate the figure to he far lower. Patient selection appears to be very important. Adequate studies are lacking, but good candidates for hypnoanesthesia are likely to be highly hypnotizable and especially adept at altering the processing of painful stimuli. While probably only a small percentage of patients can negotiate major surgery using the hypnotic trance as the sole anesthetic, a far more important percentage can benefit from the “softer” or more subtle therapeutic influence of hypnosis, as it is applied in an integrated fashion through the continuum of the hospitalization sequence. As such, hypnotic intervention can begin in the preoperative period, can be continued during the operation itself, and can be maintained through the postoperative stage to assist the patient through all phases of psychological and physical adjustment.
As is the case with hypnosis preceding medical procedures, preoperative hypnotic preparations center on exploring the patient’s fantasies about the operation, neutralizing the mental set of anxious anticipation, and correcting the nefarious effects of destructive imagined scenarios. The patient is introduced to the idea of deep relaxation, taken through the steps of experiencing the hypnotic trance, and presented with affirmative images and statements relating to the sequence of events likely to be encountered in the operative procedure. If the medical hypnotherapist intends to be present during the operation, this fact is mentioned before surgery so that hypnotic contact may be more easily reestablished while the patient is anesthetized.
It has been assumed for decades that a patient in the deeper or even moderate levels of chemical anesthesia was in a state of other-worldliness and had shed all semblance of consciousness. However, some clinicians and researchers have reported patients who have remembered events that occurred during surgery when they were presumed to be unconscious. Crile(9) reported the case of a patient receiving nitrous oxide (as well as his own case in his autobiography) where some awareness of the environment was preserved. While nay-sayers have attributed these reports to insufficient levels of anesthesia, reports of more occurrences of partial awareness in documented deep anesthesia prompted studies to investigate this phenomenon.
In one study, Wilson and Turner questioned 150 post cesarean patients.(10) They found three patients who accurately recalled actual events and 46 who retained some dreamlike remembrances of the operation. More recent studies have focused on the hypnotic recollection of the operative experience, that is, asking the hypnotized patient to recall an operation. Consciously, some patients may have little or no recall, but others—especially those who are highly hypnotizable—are able, in the context of trance, to re experience important events within the operative procedure. It has been reasonably well established that such patients are attuned, in such situations, to meaningful communications by the personnel who are present in the operating room, especially surgeons and anesthesiologists. It is therefore possible that surgical patients may be aware of negative comments on their progress by surgical personnel, to which patients may react.(11) If, for example, a surgeon says, “There’s a lot of blood loss here,” the patient may respond with a rise in blood pressure and increased heart and respiratory rate, making cardiovascular instability more likely, Hypnotherapists, in anticipation of this phenomenon, may add preoperative suggestions such as, “You will remain calm, deeply relaxed, peaceful, totally undisturbed by any conversation around you. Your mind centers on feelings of well-being throughout the operation.”
As far as the hypnotherapist is concerned, the clinical implication of the retention of some awareness during anesthesia is that some degree of hypnotic contact and rapport may be established—or reestablished, if the groundwork has previously been done—during the course of the operation, for purposes of assisting the patient adjust to its vicissitudes. It is well known, for example, that if the patient’s abdominal muscles are tight, the surgeon may order more anesthesia. This may not be necessary if the hypnotherapist gently whispers suggestions to the deeply anesthetized patient to relax his or her muscles.
Postoperatively, the patient who has already experienced the trance state can easily be given suggestions for dealing with all aspects of the recovery process, including rest, comfort, and return to harmonious biological rhythms (that is, normal appetite and sleep).
People who have suffered catastrophic illnesses or accidents usually have a long journey to recovery, and may require global adjustments in life goals, family dynamics, and self-image. Stroke victims, amputees, and individuals with spinal cord injuries, for example, need multi-level support to help them cope with their shattered world. Rehabilitation. therefore, is both a physical and a psychosocial process, aimed at assisting destabilized patients to regain optimal physical competency and psychological integrity. In the face of cataclysmic loss (of bodily function—as in hemiparesis (paralysis of one side of the body), aphasia (impairment or loss of speech), or quadriplegia (paralysis of both arms and legs)—the patient often questions his or her will to live. Other traumatic though less debilitating injuries, such as the loss of a finger, can engender severe depression, withdrawal from others, self-destructive thoughts, and a loss of self-esteem. It is clear that adaptations to such tragedies may have as much to do with their symbolic representations as with their objective realities.
The heartening advances of rehabilitation medicine are tied not only to technology but also to an appreciation of the complex psychological needs of patients. Staff members know how important their self-generated enthusiasm is in mobilizing their patients’ optimism and how loss of motivation can stunt progress or foster regression. The following case history illustrates the application of hypnosis to the difficult process of rehabilitation.
A 35-year-old executive returning late from a company meeting was injured while driving on a rainy highway. His only memory of his accident was of being carried on a stretcher from a ditch, with the lights of ambulances flashing. He remembered the slow realization that he could not move his arms or legs; even worse, that the feelings in his limbs and torso had been snuffed out. He could only move his head from side to side and sink into his quadriplegic nightmare.
A consultation with a hypnotherapist was requested three weeks into his rehabilitation, because he was not progressing satisfactorily. He did poorly on the tilt table, which is used for physical therapy, and he was not eating well. This highly intelligent man talked lucidly to the hypnotherapist about his visions of his future: he would no longer be able to work, his already shaky marriage would crumble, and he would most likely need a full-time caretaker. With all this against him, he asked, how could he find a reason to live? Such questions are difficult to counter rationally. Given the premises, he had drawn his own conclusions. To tap into his motivational reservoir, his intellectualizing network would have to be bypassed.
This man agreed to undergo hypnosis and responded to hypnotic induction. Whereas before the accident his analytical mind may have posed a defensive barrier to induction, his despair and wish to be helped facilitated the process. The therapist placed his thumb in the middle of the patient’s forehead, providing a sensory focus for centering awareness. With the patient’s eyes closed and with his focus turned internally toward the contact point, a count was started. In synchrony with the patient’s breathing, each number symbolized a progression into a relaxed mindfulness, toward a state of mind freed from the incessant pressure of thinking.
During the ensuing ten treatments, hypnotic therapy was aimed at different dimensions of his condition. Aside from suggestions of physical comfort, efforts were made to extend the range and intensity of the patient’s sensory awareness. The boundaries of his sensitivity to touch were determined, and suggestions were given to expand them farther into his torso, as far as he could each time, and progressively he regained some, albeit minute, sensory ground. The therapist also guided him to experience feelings of peace and to contemplate acceptance mixed with a willingness to try his very best to improve. Finally, the patient was asked to dissolve all negative future scripts created by his imagination. For the moment, he would have to attend fully to his rehabilitation therapy. To this end, he began to apply himself diligently. He graduated from the tilt table, grew stronger, and was eventually sent home with outpatient support services.
For hospitalized patients with catastrophic illnesses, hypnotic treatment does not stop after the first consultation. A series of treatments over time is generally effective, as in the above example, since the goals are approached in small steps over the course of weeks or months. In such cases, it is advantageous to teach patients the skill of self-hypnosis so that they will he able to surmount periods of private distress, regain autonomy, and participate in their own recovery.
Hypnotic Approaches to Cancer Treatment
Cancer affects a person on many levels, from the cellular to the psychological. While the baffling varieties of its manifestations continue to he elucidated, there is an evolving awareness of its complex psychological dimensions. Cancer patients are likely to experience intense distress and pain—pain from the disease itself, from its treatments, and from the deep psychological and social changes the disease and its treatments induce.
Recently there has been a growing appreciation of the needs of cancer patients for support, open communication, understanding, and for the sensitivity and professionalism with which life-threatening illnesses need to be approached.
Hypnosis is used at several levels of cancer care.(5)(6)(12-14) First, it is useful as a means of dealing with the symptoms of the disease itself: pain and symptoms associated with specific or organ systems; and nonspecific symptoms such as fatigue, malaise, irritability, and insomnia. Second, hypnosis may be helpful in the management of the side effects of cancer treatments. This is very important because the side effects of chemotherapy and radiation—such as nausea and vomiting—are often so unpalatable that they may cause the patient to drop out of therapy. Third, cancer patients are faced with major psychological adjustments. Many view their diagnosis with nihilism and are forced to grapple with profound existential issues. Lastly, and still somewhat controversially, hypnosis has been aimed at modifying the course of the disease process itself through the medium of mental images.(15)(16)
The individual in deep hypnotic trance may experience any one of a variety of shifts in body image. The perception of oneself in space including, if appropriate, the presence of pain, can then be modulated by the influence of hypnosis on cognitive processes and self-perception. “I”—the core of the experiencing self—can be asked, in hypnosis, to modify its relationship to the feeling of pain. When contemplated, pain may take on qualities that were not immediately appreciated. It may he perceived as sharp, diffuse, warm or cold, as having volume, shape, color, and even sound.
Painful stimuli are recognized consciously and then elaborated into complex variegated sensations.(17) The mind can alter or neutralize the perception of painful stimuli. The wounded soldier continuing to engage in battle is one example of the mind’s influence on pain and, by extension, all perception.
In a hypnotic trance, the field of consciousness has the potential of having more direct access to pain, to its associative networks in the central nervous system, and to the mechanisms underlying its processing. Thus, “hot” pain may be made to feel cool; pain that is perceived to be large and looming may be made smaller in volume; pain that seems oppressively close can be made to seem farther away; and, under certain conditions, pain can be abolished altogether.
In altering or removing pain, care must be taken not to block its warning function. In the early stages of an illness, a new sensation of pain or discomfort may be an important indicator for revising the therapeutic strategy. In more advanced cases, this is not as relevant. The following case history demonstrates some principles of hypnotic alleviation of symptoms due to cancer.
A 55-year-old man with carcinoma of the left colon that had been diagnosed two years previously was referred by his oncologist for hypnotic treatment of pelvic pain. A recent checkup had revealed metastatic liver nodules, and a bone scan showed a solitary lesion in the pelvic bone. He had started taking aspirin, propoxyphene, and occasionally codeine. This highly educated man was able to appraise the complexities of his situation with composure and open-mindedness. He did not wish to discuss death at any length. He said that he had come to terms with death. He stated succinctly, however, that he did not wish to squander his precious time and that he wanted to be with his family, have time to take care of certain business matters, and be as free of discomforts as possible. His intermittent pelvic pain interfered with walking and sexuality. Because he was very ambivalent about plans for chemotherapy and radiation, he opted for more time to make decisions about these matters.
This patient successfully learned to experience a medium level of trance—a perfectly workable depth of hypnotic relaxation—which was induced using an arm levitation technique. The hypnotherapist then helped the patient achieve glove anesthesia—a phenomenon marked by a sensor void in an area of the body, in this case a hand—was achieved. The patient perceived a prick of a skinfold near the thumb as a faraway flicker of touch. By way of the same mechanism and progressive extension, he was taught to induce numbness to other parts of his body. The hypnotherapist moved the patient’s numbed hand to the patient’s pelvis and told him: “Imagine the numbness and coolness in your hand, seeping through your skin, extending into your thigh, spreading. Like rings of water on the smooth surface of a pond, concentric rings of numbness flow as deeply as you can imagine.”
The learning process, extended to self-hypnosis gave him variable relief. Sometimes he could dispel the pain completely.
At other times, especially when his mood was low, he could obtain only partial relief. But overall, he felt more relaxed and consequently had more energy and was more active.
In the last few years, we have witnessed an interest in exploring the uses of mental techniques not only to guide cancer patients to a better frame of mind, but also to influence the disease process itself.(15)(18) Techniques span a wide array of approaches, most of which confine themselves to visualization in the context of hypnosis and/or meditation. Reports of positive results using these techniques are largely anecdotal. In spite of mounting evidence of links between the mind and the neurohumoral, immunological, and autonomic nervous system mechanisms,(18-24) the efficacy of mental techniques such as imagery, with or without the use of hypnosis, has not been demonstrated scientifically to affect the course of cancer. There is a need for more systematized investigations of these methods.
Summary and Future Directions
In the evolving philosophy of patient care, not only traditional and state-of-the-art therapies, but all modalities capable of enhancing comfort and well-being are approached with a willingness for evaluation, with a special awareness given to the importance of psychological factors in the healing, convalescent, and rehabilitative processes.
Today, hospitalized patients, faced with an alien environment, time constraints, and a panoply of novel procedures, are apt to need therapeutic approaches that attend to their psychological needs and to the human dimensions of their experience.
Medical hypnosis, a clinical science has undergone extensive conceptual evolution and technical sophistication in recent years, is increasingly understood as a treatment modality with the capacity to be applied, in selected situations, to a wide range of problems encountered in the hospital milieu.(25)
Of the phenomena potentially manifested during trance, multi-level (psychophysiological) relaxation, the modulation of painful sensations, the alleviation of drug side effects and nonspecific symptoms such as malaise and insomnia, the reduction of anticipatory anxiety, and the strengthening of motivation for recovery find the most usefulness. Lastly, and still somewhat controversially, is the application of hypnotic imaginal techniques in an attempt to influence the neurohumoral and immunological components of healing. As the healing process becomes more acutely appreciated as a multidimensional, dynamic phenomenon, and as therapeutic trance states become more accepted as valuable gateways to the enhanced communication between mind and body, medical hypnosis will increasingly solidify its role as an agent capable of assisting the individual toward achieving global health and well-being.
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