It must feel weird. Learning a new approach is always a leap. But just remember, you've been in trance all day. And so has your patient. It's already there. You're just learning how to use it.
Ut fringilla erat id arcu gravida iaculis. Vivamus nec est tellus. Duis feugiat vulputate eros, in auctor augue pharetra non.
Patients in ER are in trance. Trance is simply a state of dissociated focus. Are you aware of the feeling of the clothes on your body, or the glasses on your nose?
Everyone is in trance, all the time. It goes up and down during the day. It goes up when doing mundane routine things like driving, brushing your teeth, or jogging. There are both positive trances, like being intimate with someone, or working on your favorite stamp collection. Time just flies. There are negative trances like being in acute pain, when all other concerns are forgotten, and time just drags. Pain expands, and becomes more fluorescent.
Trance can be used to help the patient. But, trance alone is NOT what clinical hypnosis is about.
Patients using hypnosis experience dissociated focus with a difference, in essence attention with intention. Symptoms can be blunted non-pharmacologically.
Many patients in ER with marked symptoms are in deep trance. Concerns re “inducing” hypnosis or “deepening” it can often be forgotten. They're already there!
Yes, "Trance" is archaic. Most researchers don't use the word. It implies something mystical, and arcane. It isn't.
Hypnosis: 1) a set of tools. For focus induction, for deepening attention, and for suggesting
direction...intention. 2) the trance experience when used with intention, be it behaviour change, cognitive, emotional or spiritual awareness.
Use the richness of language to defervesce the situation, and enhance your interventions.
You already know this. A prescription has more power, and a better chance of working, when given with this kind of description: “This is a clean, effective medicine. Most people don’t even know they’re on it. I’ve seen some cough with it, but it’s trivial. I think I’ve seen a couple of rashes, but most drugs can do that with some people. It’s really uncommon...” Compare this to: “...this has a 67% chance of working alone. We may have to add a drug to it. Remember, 10% of people have an intractable cough with this drug. But that’s ok, we have some others almost as good, that shouldn’t give you a cough. Well, at least usually. Call me if you get any swelling.”
If a person reports they're in pain, for example, ask them to describe it. They will often use graphic descriptors like stabbing, or squeezing, burning, or vice-like.
By all means, use the word, “pain” once. But make every attempt to continue to de-escalate the descriptors. Use pain, then their word, such as vice-like. It proves you heard the history. Then, drop down the intensity. Say things like, “...so it’s really really heavy?”, then use the word, “heavy”, and then “pressure.”
“Pain” > “stabbing” > cutting > knife-like > sharp.
“Pain” > “squeezing” > pushing > heavy > pressure.
“Pain” > “burning” > hot > warm.
“Suffocating” > hard to breathe > short of breath.
Use power words in your distraction/ new focus imagery, like healing, soothing, elixir, balm, tranquil, peaceful, blissful, cleansing, mountain-fresh, catharsis, release, rapture...Can you think of some others?
A couple of AVOID words are “try”, and “relax”, believe it or not. Try infers failure. It’s a three letter word that stands between do and don’t. Relax is a command that often brings about the exact opposite, occasionally very strong response.
What did you feel the last time someone suggested that you relax? Or worse, told you to? Yes, we want the person to relax. Don’t use the word.
Enough about the actual words. Telling a patient a drug will work, while looking at them in the eye is more effective than the same line said in a stammered fashion, eyes downcast. Think about tone. Body language. Mirroring. About the occasional raised voice. A laugh. Or the use of a forced whisper.
Life is but a stage. Right?
Remember, the usual ER patient is “already there.” You don’t need induction or much deepening. That’s done...the whole thing is half done for you! You don’t need to do much. Introduce yourself with friendly eye contact, shake hands warmly, and show you care. Done. Taking your ER history is an ideal path to rapport. Showing your confident ordering of tests, direction of nursing staff etc will build confidence.
This is often forgotten in hypnosis, but important. A response set is a series of universal truths that will get the patient agreeing with you. Once again, you’re the ER doc. They’re very usually already there, wanting to agree with you. The response set is meant to develop a “yes” mindset. You want your suggestion (to stop focusing on the distressing symptoms) to stick.
Say something along the lines of: “human beings focus on some things, and ignore other things. When you come home from work, and you’ve had a great day, full of accomplishments, but encounter your child’s poor report card, that’s all you can think about. Or when you buy your new Maserati, the red one you’ve always wanted, and can only think about the scratch you’ve put on the mirror. We focus. We all do. We block out some things, and magnify others. When you have discomfort, that discomfort seems to crowd out other thoughts, sensations. Your entire body can’t be in total pain. Hypnosis techniques can help you focus your attention on something other than your pain, and potentially get rid of it. Interested?"
Summary of Script…remember the script is NOT NECESSARY and often gets in the way! Read it and FORGET IT! But here's the structure...
Rapport building: This all stems from a natural interaction with the patient. You’re already expert here.
Response Set: (“...we all focus on things, and block other things out…” ~ 2-3 truisms about focus to get the patient agreeing.)
Metaphor: Push on the back of the patient’s hand after gaining consent. Fingerprint. Lift the hand. So much good feeling you can transfer those sensations at will…
Post hypnotic suggestions: Being aware of symptoms and reporting, cooperation, continuing to heal and improve, a new life.
Reversal: Bring the patient back to the here and now, in a new mindset, retaining control, remaining more comfortable.
Dr. David Reid is a clinical psychologist in Charlottesville, VA. This clear renegade actually supports ER physicians learning this technique he developed without formal ASCH training. He'll likely get into all sorts of trouble!
Contact Info for the "Reid" of RTAP!
David B. Reid, Psy.D.Certification in Clinical Hypnosis and Approved Consultant (American Society of Clinical Hypnosis)Adjunct Faculty Saybrook University College of Integrative Medicine and Health SciencesAdjunct Faculty James Madison University Department of Health Sciences
(Please contact Ron Ireland re questions about this technique, applications, feedback, etc.)
Formal training in hypnosis will help you in spades:
The American Society of Clinical Hypnosis offers an introductory weekend, and intermediate and advanced weekend workshops: http://www.asch.net/
Michael Yapko offers intensive 100h training workshops spread over 3 separate weeks in Carlsbad: https://yapko.com/
This section will of course include some other sections, such as response set, and post hypnotic suggestions, as an attempt is being made here to give an example.
Scripts are NOT NECESSARY for hypnosis, and most practitioners feel they inhibit good interaction with the patient. Scripts make you focus on what you are going to say, instead of really looking at and interacting with your patient, responding to their cues, responding to and using information in your particular setting, etc. Focusing on a script INCREASES the chances that interaction with the patient will trip you up. Please clearly note that the script included here is only given for illustrative purposes. Practitioners are encouraged to individualize this at their discretion. It’s the best idea if you just approach this with a general idea of what you’re going to do, and wing it.
What if you stutter? What if you use some of those "forbidden" words like try, and relax? If you have done your job developing rapport, and demonstrating competence by confidently handling the situation, the patient will usually respond anyway. Look at how you’re going the extra mile to help make them comfortable! What an investment!
It does makes things easier if you’re smooth, and practiced. Practice at home with a family member...or your dog!
Here is an example of a patient suffering an acute MI. I've tried to pick a tough one! Few of your interactions will be this interrupted. The goal here is not to replace morphine, but to perhaps use less, and improve the symptoms overall. By all means use morphine, use oxygen, and all the usual tools that you usually use. We don’t want the patient to ignore his chest pain. The normal measurements of pain can continue, the use of morphine and nitrates of course continue.
The patient has given a history, and has described the pain as vice-like, or an elephant sitting on his chest. You’ve given orders for blood work, done an EKG, and have started all your usual interventions. This technique is of course not to replace, or at all intervene with the usual flow of emergent interventions that are so important.
You’ve diagnosed the MI. ST’s are up. Orders have been given. You will find an interval of time when you can intervene with this technique…
“Doc, it still really hurts…”
“Let’s get some more morphine. We’re going to get rid of that pain for you. Would you like to learn how to decrease the squeezing feeling without morphine, or to use less of it? I can teach you a hypnosis technique that really works...”
“Just get rid of it. If I can help, sure.”
“It’s all about focus. I’m going to help you focus on something else. We all do this. Human beings focus on things, and block other things out. Do you notice the feel of your heels on the sheets?”
“Doc, my chest freaking hurts. I don’t care about my heels!”
“Exactly. You’ve got it. That’s right! You’re incredibly focused right now on that pushing feeling, that heaviness in your chest. You’ve actually blocked out other body sensations. Sort of like forgetting your great day after your kid hands you a bad report card. Can I touch your hand?”
“Doc, do what you need to do. You’ve already been sticking needles in me, sure!”
“You’re right! This is just a finger. I’m going to push my finger on the back of your hand, fairly firmly. As I push on your hand, I invite you to shut your eyes, and concentrate on the feeling on the back of your hand…”
Push your forefinger firmly on the back of the patient’s hand, and leave it there, gradually increasing pressure.
“As I push on your hand, you’ll notice the pressure. Firm pressure, helping pressure. Use all your senses and really explore that feeling. Perhaps that feeling has all sorts of other aspects. You can really use your imagination, and even experience that feeling like a colour. Perhaps that feeling is a beautiful clear blue tone, or a vibrant yellow. Perhaps a vibrant green, a blissful, cleansing colour that can grow. Notice all the swirls and eddies of the fingerprint, perhaps the blues and greens are swirling together, intensifying...Do you hear something? Perhaps the beeps, the tones you can hear in the room around you are actually signs of that healing, crystal clear tone building on and in your hand, the voices around you becoming more meaningless as you focus on my voice and notice that feeling spreading, the feeling of that fingerprint persisting on the back of your hand and intensifying…”
At this point lift your finger from the back of the hand, and gently touch the back of their hand around where you touched them, slowly and lightly in a circumferential, radiating kind of way, out to the edges of the back of their hand. It's ideal here if you promote dissociation by moving from saying things like "your hand", to "that hand." It's important to bring in linking: the image and feel of the fingerprint, linking with deepening and comforting.
“And now as I lift my finger off that hand, perhaps you can see...very clearly ... (a leading suggestion) the imprint of my fingerprint...right there...on the top of that hand. And the more vivid you can see and maybe even feel that fingerprint, the deeper and deeper you can go into trance...the more comfortable you can feel...Feel that beautiful feeling spread, that beautiful, light, buoyant feeling spread, and grow, moving through your hand, consuming your entire hand, so light…”
At this point start to touch underneath their hand, slowly nudging their hand and wrist upwards, lifting it very gently. Remember of course the clinical presentation. Is it appropriate here to ask if the patient is in any pain? You can interview the person during hypnosis. They’re not unconscious.
“And as your hand and wrist start to lift, so light, so beautiful, that amazing colour, that wonderful hue, that tone, that vibration, that perfect temperature, do you have a taste, a smell that you can use to describe it…?”
Remember that the patient can talk during this interaction. They usually won’t, but occasionally asking a question like this gives a chance to check in with the patient, and allows more building of rapport, and an experience that is more uniquely appropriate for them. This is why scripts HURT the process… but to illustrate…
“Doc, what is this, some kind of hocus pocus? But I actually feel it lighter. It’s sort of green, like a leaf…”
“It’s called hypnosis, Fred. (Use their name, fairly often…) Hypnosis can smash pain. The amazing, funny thing is, that your body can continue to give you information to help us, help me, your doctor. As you continue to focus on your hand, assess that sensation in your chest. On a scale of 1 to 10, where would you put it? Is it still there?”
“Doc, yup. Still there. Funny, about the same level, but doesn’t bug me as much.”
“Amazing how a leaf can do that, isn’t it? A leaf, so light, feeling the breeze, moving gently, absorbing the sun’s rays...We’re going to get you a bit more morphine. Do you feel the sun’s rays on your hand?”
“Nurse, can you give him another 2 morphine please? And is that blood panel back?”
Sometimes you’ll get a nod from the patient, sometimes an answer, and sometimes nothing...if they respond, work with it. Go off the rails with the script. It’s for them. Make it theirs. If they say their hand is some kind of space shuttle, go off to Mars… Suppose Fred nods, or says nothing…
“Intensify that wonderful feeling. Feel those rays of the sun, penetrating into the skin, into the leaf, moving gently in the breeze. Perhaps you can even hang your leaf on a hook…”
At this point you can take your finger away from the wrist. Many people will leave their hand suspended in the air. If they don’t, and it falls back to the bed, don’t assume that for the patient, in his own experience, does not feel it to be suspended. It doesn't MATTER.
“So intense, Turn up the dials. Move that dial right up to maximum, that beautiful, cleansing, healing feeling so intense. So much of it that it’s spreading up your arm, actually consuming less comfortable feelings, getting stronger thereby. So much of it that you can actually move it around, splash it around, move it to where you need it…”
“Doctor, the CXR is up on the viewbox.”
“Move it to where you need it, Fred. Let your hand move to where you need that beautiful, healing, blissful, peaceful feeling…And as you do that, the sounds of people here in this room, helping you, helping me, will be but raindrops on the windowpane...You’ll continue to listen to that inner self, that body that protects you, to share with me signals, symptoms that may be important...”
“Please give 40 of lasix, iv.”
At this point most patients will move the hand to the chest. Now if they don’t, don’t assume that they haven’t done this internally! It doesn't MATTER!
“Feel that beautiful, healing, cleansing feeling spread through your chest, that heavy feeling dissipating, that elephant becoming a friendly little baby elephant, morphing into a little friendly chimpanzee eating a banana, or even just that banana. Or even just the peel. Or maybe it’s just completely...gone.”
You’ll get different responses. Greet all of them with confidence. Many people will keep their eyes closed...as it does work well for many.
Let’s say you get: “So you’re going to keep using that morphine, right?” Or “Sorry, Doc, Nada!” Confidently respond. Of course use the morphine! You can say things like, “It can take time to build focus." (Work with what they are giving you. Is their hand up in the air? Suggest they continue to focus on the hand, and intensify those good feelings. Is their hand on their lap, and they’re looking at you, looking around the room? Encourage them to look at a spot on the wall above eye level, perhaps the corner of the room at the ceiling. [This is an induction technique.] Encourage them to keep their eyes on one spot, and don’t move them. To focus on not moving their eyes...and then describe what you know they’ll see, the fading, the sparkling, the moving of that spot back and forth…)
Time to put in some post hypnotic suggestions. You need the patient to continue to focus on the good feelings they can conjure, while still reporting to you symptoms they perceive, while still being able to converse with you and cooperate.
“And as you continue to focus on those amazing, healing, blissful, beautiful feelings, the sounds around you will only serve to deepen those feelings. People talking amongst and between themselves will be meaningless mutterings, raindrops against the glass. Nurses and physicians talking to you will be loud and clear communications that you will effortlessly respond to. That body of yours, that has taken care of you for so long will continue to do so even now, even now that it is so focused on healing, will continue to observe symptoms, feelings that may have pertinence for us, and you will report these feelings…”
“...and as you continue to heal, and get stronger, minute to minute, hour to hour, day to day, week by week and month by month, you’ll come to recognize this event, this day, as being a turning point, a new beginning, a rebirth of your healthy new life, full of growth decisions, turning away from those toxins and noxious fumes, a turning towards the sun, a rebirth, a new life…”
(Working in of course suggestions re turning away from tobacco, junk food, starting to exercise at physician’s direction, etc… And now for reversal...)
“...Now, Fred, just slowly become more aware of your surroundings. Retaining all that wonderful feeling of contentment, comfort, and control, slowly recognize the sound of a doctor’s voice in the hospital, a place where you’re safe, a place where you’re meant to be right now, a place of healing. Hear the sounds around you, reassuring sounds of competent business, an entire team around you, supporting you...Feel the sheets on your skin, the firm mattress under you. And when you’re ready...come on back, Fred.”
Remember, everyone is in trance, all the time that they are awake. Post hypnotic suggestions help maintain the effects gained, despite the realities of state dependent learning.
In a formal hypnosis session in office, the clinician reorients the patient to the room, the environment, and pulls them back to the here and now at the end of their session. Reorientation is also something you want to do in ER. However, of course you want that diminished sense of pain, that increased sense of control and peacefulness to continue.
Post hypnotic suggestions come right before this reversal…
Suggestions that will be helpful in ER, and should be seriously considered for inclusion, include things like…
>Continuing to be comfortable, and in control.>Continuing to report symptoms that the patient experiences.>Cooperating with healthcare providers>Using this event as a new starting point, a new path towards good health, a new life>Work on risk factors, like tobacco, EtOh, inactivity, etc.
Just gently encourage them to come back to the here and now. You can be quite specific, mentioning sounds that are around you, the sensations you know they will be experiencing (such as the feel of clothes on their body, the mattress under them, etc.) Specifically mention the sound of your voice, and identify yourself as a physician treating them at your site.
Of course build in things that would be reassuring, and comforting.
At the end of your session, you can ask them for feedback. Ask them where they are, when it is, and ask them their understanding of what’s happening.
All of us are in trance, every waking moment. Hypnosis is special in that the patient has been very attentive, and doing some special goal directed work during that time. We want to bring that session of attention with intention to a close, after those post hypnotic suggestions.
Becoming observant of what one does, documenting the intervention and the effect is simply approaching life in a scientific way. Teachers do this all the time with their classes. The goal is to teach item x. Different approaches include showing a movie, giving reading assignments, bringing in a speaker, doing a craft, or doing a field trip. After this, the teacher usually has a quiz in order to ascertain the effectiveness of the teaching approach, in order to continue to improve learning in the class.
This can be done in clinic. For example, if one wishes to increase the uptake of flu vaccine, different maneuvers include direct mailing, emailing, phone calls to invite for an appointment, videos in the waiting room, one to one personal advice, flu shot clinics, or advertising how many clinic staff have received their flu shot. Year to year, observing the success of these interventions can shape the approach for next flu season.
Simply observing response to a hypnosis intervention for symptom control should not necessitate a consent for inclusion in a study. Measurement of symptom levels before and after an intervention is what we all do. Morphine is given, and the nurse asks what the pain is like on a scale of 10. Scores like this help guide administration of medications. A health care provider that notes a dose of 1 mg of morphine works well for most smaller patients where a dose of 2 mg is better for the morbidly obese is simply practicing good health care. Writing down responses more formally does not mean one is doing a “study”, where consent is needed.
It’s an idea when applying any new intervention to note effectiveness. Learning hypnosis is a skill set for a healthcare provider. Your interventions will improve with practice. Noting what works, and what doesn’t, will simply help you.
To this end, included here is a form where you can document symptom scores pre and post intervention with a Likert scale. There is also an area where you can write down some notes, be it reminders for yourself or interesting observations.
Until we accumulate some physician participants, and acquire consent from an ethics board, etc, etc, please print this off and keep it for your own development.
Contact me please with any feedback, questions, etc.
I desperately want to get hypnosis training back into medicine. Let me know how I can help you, or do it better.