Hypnosis as a Modality of Care in a General Hospital Setting

1. Hypnosis as a Modality of Care in a General Hospital Setting Frank McDonald Psychologist Consultation-Liaison Service TTH November 2009

2. You won’t make me take my clothes off & make me cluck like a chicken will you?

3. Overview • Intro • What can hypnosis do? Areas of application • What is hypnosis? • How is hypnotherapy done? • How does it work? • Why do it? • Recent & past hospital applications • severe (hospitalisable) hyperemesis gravidarum • (Acute) Pain Disorder (non-cardiac chest pain) • sleep onset problems • anxiety management • breakthrough pancreatic cancer pain • chronic musculoskeletal and neuropathic pain • needle phobia • children’s burns debridement • dysphonia

4. Intro • As surrounding mythology gradually dispelled, hypnosis seen now as an increasingly well-understood, ubiquitous (e.g. ‘highway hypnosis’) & useful method for studying & influencing common psychological phenomena e.g. memory, perceptual processes, affective states & dissociative mechanisms • Whilst not the ‘magic bullet’ some pts expect it to be, hypnotherapy has well-grounded evidence base in several conditions seen in medical settings

5. Areas of application Medical • Asthma • Burns • Enuresis • Hypertension • Childbirth • Migraine • Minor Surgical Procedures • Obesity • Pain Control • Gastro-intestinal Disorders (especially IBS) • Warts Source: Australian Society of Hypnosis

6. Areas of application Psychological Practice & Psychiatry • Anxieties • Apathy and lack of Motivation • Confidence Problems • Eating Disorders • Depression • Nail-biting • Fears and Phobias • Psychosomatic Syndromes • Panic Attacks • Sleep Disorders • Sexual Dysfunction • Thumb-sucking • Stuttering Source: Australian Society of Hypnosis

7. Areas of application Dentistry • Anaesthesia • Anxiety / Apprehension • Bleeding Control • Bruxism • Dental Phobia • Denture Problems • Gagging • Nausea • Pain-control • Restlessness • Salivation-control • Tempro-mandibular Joint Dysfunction Source: Australian Society of Hypnosis

8. What is it? • Hypnosis: oldest (cognitive) psychological strategy – predates written history – Egyptian records go back 4 000 years. Aboriginal Australians & Africans amongst earliest users • A phenomenon of heightened attention in which brain suspends authentication of raw sensory input. Focus is on internal representation of input. Working with that to change S’s experience • Often described as an altered state of consciousness; as ‘resting arousal’ that contrasts with waking state on various continua (arousal, anxiety, attention, behav’l inertia, thinking, perc’d control of psych’l f’n)

9. What is it? • Results in heightened suggestibility (a cognitive flexibility resulting in reduced critical analysis) • In turn, increased openness to suggestion allows access to therapeutically- & experimentally-useful psychological & physical abilities termed hypnotic phenomena

10. What is it? • Principle Hypnotic Phenomena Suggestions for these can be used to test or deepen hypnosis or for therapeutic /experimental purposes • Dissociation Disconnection of thoughts, feelings, memories, physical sensation or knowledge/awareness from usual conscious experience of reality.Essence of ‘trance’. Reality testing suspended • Hallucinations can be positive (something is there that is not real) or negative (something is not there that actually is) in any given representational system (sight, sound, touch etc.) Subjectively reported as more real & absorbing than ordinary imagination • Anaesthesia Insensitivity to pain. Loss of feeling • Analgesia Reduction of sensitivity to pain • Catalepsy Unable to consciously move but have a waxy flexibility if repositioned

11. What is it? • Principle Hypnotic Phenomena • Ideomotor behaviorAs someone thinks about a movement or response it actually happens. Allows access to involuntary nervous system functions e.g. vasomotor centres (blood flow, blood pressure, heart rate) & other motor centres (peristalsis of digestive tract) • Ideosensory behaviorAs someone thinks about a sensory response they experience it • Automatic behaviorAutomatic writing or drawing. Just happens, no volition • Post hypnotic suggestionThis is a suggestion that happens after hypnotic experience on a particular cue • Time distortionTime can be experienced as longer or shorter (slower or faster)

12. What is it? • Amnesia Forgets something that actually happened • Hyperamnesia Remembers very vividly something they hadn't realized that they remembered • Age regressionS’s actually get so absorbed in an experience that they begin reliving the experience • Attentional narrowing S’s appear to be processing less information from the environment & report focus on H’s voice and being unaware of other people

13. How is it done? (Procedural stages of traditional direct hypnotherapy) 1. Preparation (e.g. removing misconceptions, assess interests that may be incorporated in procedure) 2. Assessment of hypnotisability. Often not done psychometrically in clinical practice. One reason: not selecting ‘highs’; want to use what’s available (however, some in/formal ax of capacity for concentration, imagery & suggestibility may be helpful to discover pt talents) 3. Induction procedure 4. Deepening stage 5. Trance ratification e.g. via arm levitation test 6. Utilisation of trance/heightened suggestibility & direct suggestions for therapeutic purposes 7. Post-hypnotic suggestions including self-hypnosis instructions 8. Termination of the trance. Can take a few minutes. Further ratification: “How long under?” Typically, significant time distortion e.g. 40 mins = “10”(reflects R parietal cortical changes) 9. Discussion of the experience. Problems?

14. How does it work? • How hypnosis works is not clear – absence of a clear scientific explanation has limited its acceptance. Age-old debates e.g. Charcot “it’s unconscious intrapsychic process &/or physiological” (below) vs. Bernheim (“it’s all suggestion”) & current ‘state’ v. ‘non-state’ have made it controversial

15. How does it work? • How? Answer results in a division into two academic camps (& there’s heterogeneity within those) • Some say hypnotic behaviour reflects unique changes in brain function (Bowers, 1976; Evans, 2000; Hilgard, 1986) • ‘Special state’ theorists explain hypnotic responsiveness as effects of partly autonomous ‘cognitive control systems’ in the brain creating discontinuities in experience caused by dissociation or altered states of consciousness

16. How does it work? • One theory is Hilgard’s (1986) neo-dissociation theory • Experimental evidence has supported his concept of a ‘hidden observer’ – a second stream of consciousness that remains the most viable explanation for H phenomena like hypnoanalgesia

17. How does it work? • Others (Barber,1999; Spanos,1989) say social-psychological & ordinary cognitive-behavioural factors like role playing, social pressure & placebo explain it - albeit hypnosis more effective than sham pills • Whilst it has been polarising, debate has helped theorists & practitioners to appreciate its complex multifactorial nature

18. How does it work? • Assuaging the non-acceptance effect of controversies somewhat, EEG, PET scan & fMRI studies showing modulations of activity in specific & relevant areas are starting to allay prejudices against its application in certain fields, such as pain mx • The images differ from those of well-instructed, well-motivated role-players • Evidence that hypnosis different from normal waking state comes from studies into neural mechanisms underlying specific experiences, since neural mechanisms are less prone than reported experiences to deliberate distortion

19. How does it work? • View Graham Jamieson UNE ABC-TV Catalyst Hypnosis (2005) segment @ 7’00” to 9’45” • One example of many recent neurophysiological studies supporting ‘state’ theory • Anterior cingulate cortex (1 role: detect & monitor errors) in ‘highs’ in H, shows conflict awareness heightened but link to pre-frontal cortex that produces full awareness de-couples • So other-wise rejectable suggestions may go elsewhere, e.g. to motor centres, after bypassing verification or ‘reality check’ by pre-frontal cortex

20. How does it work? • So, not just “imagination”, “faking”, “play-acting”, “stage-show gimmickery”. For high & moderate hypnotisables (roughly 2 in 3 people), hypnosis can bring benefits beyond those of imagination, willing or placebo • Different from CBT strategy of ‘(guided) imagery’. Main distinction is hypnosis’s use of suggestion. Hypnosis may or may not use visual imagery (Syrjala & Abrams, 1996). But utilisation of enhanced suggestibility a constant featureof hypnosis (Kroger, 2007)

21. Why do it? • Major value: It can capitalise on the power of increased openness to suggestion e.g. greatest effect sizes of all CBT strategies for pain are imagery based (Gatchel and Turk, 1996). Hypnosis can, thru suggestion, create an ‘as if’ experience indistinguishable from real stimulus exposure • It’s a safe, side-effect free modality if practiced with basic safeguards, e.g. remembering to cancel temporary suggestions; not getting enmeshed in psychotic thought processes • It has the capacity to enhance standard therapy by virtue of the ‘psychological tunnel vision’ /attention-narrowing on to core aspects of your therapy • It can have appeal to those pts w. higher self-efficacy/more internal locus of control who seek some degree of involvement in their management

22. Why do it? • Can raise sense of self-efficacy – learn a skill based on something internal and personally administered rather sole dependency on meds or professionals • In children (peaking at ages 9-12) it provides a structure that capitalises on their capacity for imaginative involvement

23. Case applications • Author’s recent & past hospital applications • severe (hospitalisable) hyperemesis gravidarum • (Acute) Pain Disorder (non-cardiac chest pain) • sleep onset problems • anxiety management • breakthrough pancreatic cancer pain • chronic musculoskeletal and neuropathic pain • needle phobia • children’s burns debridement • dysphonia

24. Resources • www.fmcdonald.com Download recording & self instructions. Other PowerPoints on hypnosis e.g. for pain, its value in mx substance dependence • Australian Society of Hypnosis http://www.ozhypnosis.com.au/ • http://www.youtube.com/watch?v=u34HoFVxSNc Google “Dabney Ewin Burns youtube”