Acknowledgements

1. Clinical HypnosisCaroyl Gilbert, RN, MSN, CPNP-PCBaylor College of MedicineDepartment of PediatricsGastroenterology, Hepatology, and Nutrition

2. Acknowledgements This presentation was adapted with permission from: Melanie A. Gold, D.O. Clinical Associate Professor of Pediatrics University of Pittsburgh School of Medicine University of Pittsburgh Student Health Service

3. Objectives • Define clinical hypnosis • Define typical hypnotic phenomena • Identify the appropriate application of hypnosis in the clinical setting • Know how to introduce hypnosis to patients and their families • Know how to obtain training and certification in clinical hypnosis • Have participated in/observed clinical hypnosis

4. Definition • Derived from the term "neuro-hypnotism" (nervous sleep) coined by Dr. James Braid, 1841. (Wikipedia)

5. Hypnosis • An altered state of consciousness • Usually, but not always, involving relaxation (which may or may not be evident) • A heightened concentration on a particular idea or image • Purpose of altering a symptom

6. Misconceptions About Hypnosis

7. Misconceptions • Patient is under control of hypnotherapist • Patient is asleep • Only a few people can be hypnotized • Only the weak-willed or minded can be hypnotized • Hypnosis masks symptoms • All the patient’s psychiatric defense mechanisms are abolished in trance

8. All hypnosis is self hypnosis

9. 3 Laws of Hypnosis • Subject must have a clear image of what the result would feel and be like • When will and imagination (or belief) are in conflict, imagination wins out • A suggestion is more likely to be accepted when tied to a positive emotion or affect with which the subject can identify

10. Cognitive Characteristics Relaxation Concentration Increased suggestibility Hypermnesia/Amnesia Increased control of physiologic responses Perception of different states Concrete thinking Physical Characteristics Muscle relaxation Twitching Lacrimation Fluttering eyelids Eye closure Eye movements beneath lids Changes in respiratory rate/depth Changes in pulse Jaw relaxation (drooling) Catalepsy (suspended animation) Decreased postural tone Hypnotic Phenomena

11. Rapport Catalepsy Ideo-motor activity (not reflex) Ideo-sensory activity Memory modification Ambulation in trance Time distortion Hypnotic dreaming Age regression Post-hypnotic suggestion Hypnotic phenomena

13. Associated Effects Relaxation Headache Dizziness Nausea Anxiety Tearing or crying Adverse Effects Precipitate psychotic or panic reaction Precipitate suicidal behavior Symptom substitution Associated and Adverse Effects

14. Problems that Respond to Hypnosis • Acute and chronic pain • Anxiety associated with procedures or illness • Asthma • Attention deficit disorder • Cerebral palsy • Conditioned nausea and vomiting

15. Problems that Respond to Hypnosis • Diabetes mellitus • Dysfluency • Encopresis • Enuresis • Facial tics • Habit coughs • Insomnia

16. Problems that Respond to Hypnosis • Migraine syndromes • Nail biting • Nightmares • Performance anxiety • Pruritis • Psychogenic seizures

17. Problems that Respond to Hypnosis • Thumb sucking • Tongue thrusting • Tourette syndrome • Trichotillomania • Warts

18. Changes in pain intensity scores during and after treatmentVlieger, A.M., Menko-Frankenhuis, C., Solfkamp, S.C.S., Tromp, E. & Benninga, M.A. (2007). Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: A randomized controlled trial. Gastroenterology, 133, 1430-1436.

19. Hypnosis Reduces Distress and Duration of an Invasive MedicalProcedure for ChildrenLisa D. Butler, PhD; Barbara K. Symons, BA; Shelly L. Henderson, MA; Linda D. Shortliffe, MD; and David Spiegel, MDPEDIATRICS Vol. 115 No. 1 January 2005 TABLE 1. Number, Means, and SDs by Study Condition of Additional Variables Assessed or Used to Create Summary Scores n Hypnosis n Routine Care Child report Fear before procedure 21 1.81 (1.40) 19 2.42 (1.50) Fear during the procedure 21 2.48 (1.21) 21 2.95 (1.12) Pain during the procedure 21 2.71 (0.96) 21 2.90 (0.94) Crying during the procedure 21 4.24 (1.30) 22 4.68 (1.09) Parent report Fear before procedure 21 3.43 (0.93) 23 3.52 (1.08) Fear during the procedure 21 3.67 (1.11) 23 3.96 (0.82) Pain during the procedure 21 3.05 (0.92) 23 3.13 (0.81) Crying during the procedure 21 2.62 (1.28) 23 3.26 (1.25) How traumatic was VCUG overall? 21 3.10 (1.09) 23 3.39 (0.94) Observational rating Lowest distress level 15 1.83 (0.64) 22 2.39 (0.75) Highest distress level 13 3.68 (1.30) 17 4.53 (1.07) Medical staff rating Difficulty of overall procedure: radiologist 19 3.00 (1.92) 23 4.04 (1.60) Difficulty of overall procedure: technician 19 2.58 (1.78) 23 3.43 (1.62) Difficulty of catheterization: radiologist 12 2.83 (1.64) 14 4.36 (1.98) Difficulty of catheterization: technician 12 2.08 (0.79) 14 3.86 (1.70)

20. A randomized clinical trial of a brief hypnosis intervention to controlvenepuncture-related pain of paediatric cancer patientsChristina Liossi, Paul White, Popi HatiraPAIN 142 (2009) 255–263 Table 2 Pain and anxiety outcomes for children across time. Mean Standard deviation T1 T2 T3 T1 T2 T3 Anticipated anxiety EMLA 5.28 5.31 5.31 0.79 0.74 0.75 EMLA + Hypnosis 2.43 2.36 2.37 0.45 0.45 0.44 EMLA + Attention 4.36 4.38 4.39 0.33 0.33 0.32 Observed distress EMLA 7.26 7.03 7.35 0.83 0.79 0.84 EMLA + Hypnosis 5.07 4.67 4.80 0.59 0.72 1.01 EMLA + Attention 6.30 6.14 6.22 0.91 1.12 1.06 Self-reported pain EMLA 4.79 5.09 5.09 0.69 0.84 0.84 EMLA + Hypnosis 2.74 2.89 2.89 0.83 0.79 0.77 EMLA + Attention 4.17 4.91 4.89 0.44 0.51 0.50 Self-reported anxiety EMLA 5.12 5.16 5.17 0.72 0.72 0.73 EMLA + Hypnosis 2.35 2.42 2.38 0.52 0.48 0.53 EMLA + Attention 4.17 4.33 4.39 0.38 0.38 0.39 Note. EMLA, eutectic mixture of local anaesthetics; T1, T2, and T3, Times 1, 2, and 3, respectively.

21. Appropriate Use of Hypnosis Hypnosis is indicated when: • One is responsive to hypnotic suggestion • A problem is treatable with hypnosis • Good rapport exists between the patient and the therapist • Patient is motivated to remedy the problem • No iatrogenic harm is anticipated by use

22. Inappropriate Use of Hypnosis Hypnosis is contraindicated when: • It would lead to physical endangerment • It may aggravate existing problems or create new ones • It is used for “fun” or entertainment • The problem is more effectively and appropriately treated with a different treatment modality (e.g. medication or family therapy)

23. Rules for Using Hypnosis • Never treat a condition you are not qualified to treat without hypnosis • Never use authoritarian symptom removal • Do not use for entertainment

24. Patient Age Intellectual ability Context of symptom Acceptability of hypnosis Hypnotizability (?) Provider Attitude towards hypnosis Belief in hypnosis Skill in developing rapport Skill in encouraging trance capacity Factors Affecting Efficacy

25. Factors Affecting Efficacy Milieu • Attitude of family towards symptoms and hypnosis • Societal or cultural attitudes toward symptom and hypnosis • Attitude of staff towards symptom and hypnosis

26. Introducing Hypnosis • Learn about the patient • Learn about the problem • Explain “hypnosis”.. Or not • Elicit patient and family beliefs • Demystify • Use resources • Consider the context

27. Introducing Hypnosis • Using your mind, Pretending about, Imagery, Imagining, Imaging, Using Imagery, Biofeedback, Personal biofeedback, Mind-body interactions, Inside thinking, Inside talking with your [stomach, head, breathing tubes, muscles, bladder..], Relaxing and imagining, Daydreaming, Daydreaming on purpose, Thinking to help yourself, Meditation on your…, Learning how you work the controls in your mind, Learning about what you didn’t know that you knew, Finding out what breathing can do

28. Goals of Clinical Hypnosis • Develop skills in psychophysiological self-regulation • Balance allopathic therapy (medical treatment) with self-efficacy • Develop integrity in therapeutic relationships

29. Steps in Clinical Hypnosis • Induction • Intensification • Therapy in Trance • Usual Awareness • Ratification/Reflection • Follow-up

30. Clinical Hypnosis • Useful therapeutic tool – not a cure all • An adjunct to medical or psychiatric therapy, usually not the primary treatment • Requires self-motivation • Not effective when there is a significant secondary gain maintaining symptom • Essentially no adverse effects • Gives patient a sense of mastery and control of symptoms

31. Training • American Society of Clinical Hypnosis (www.asch.net) • Society for Developmental and Behavioral Pediatrics (www.sdbp.org) • American College of Hypnotherapy(www.aihcp.org) • Society for Clinical and Experimental Hypnosis (www.sceh.us) • The Tad James Company (www.nlpcoaching.com) “neuro-linguistic programming”

32. Certification Available through the American Society for Clinical Hypnosis (see website) Certification indicates that the practitioner: • Has undergone advanced training in his/her profession to obtain a legitimate advanced degree from an accredited institution of higher education; • Is licensed or certified to practice in his/her state/province; • Has had his/her education and training in clinical hypnosis reviewed by qualified peers and approved consultants and such training has met the minimum requirements established by a Standards of Training Committee of qualified peers; • Has been determined to have received at least the minimum educational training that ASCH, the largest such interdisciplinary organization in North America, considers as necessary for utilizing hypnosis.

33. Referral Resources • Institute for Family Psychology (www.mhehouston.com) • American Society for Clinical Hypnosis (www.asch.net) • Society for Developmental and Behavioral Pediatrics (www.sdbp.org)

34. Demonstration

35. Questions & Answers

36. Contact Information Caroyl Gilbert, RN, MSN, CPNP-PC Phone: 832-822-1096 Fax: 832-825-3633 cmgilber@bcm.edu