Pulse 0507

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[ continuing ed ]

Clinical hypnosis: what you should know BY TONY PATERNITI, PH.D., RN, NURSE EDUCATOR, METHODIST HEALTH SYSTEM

Aging baby boomers generally have more discretionary spending power than previous generations and are better able to afford nontraditional treatment modalities that may not be covered by third-party insurers. As they consider alternatives such as hypnosis, they often ask nurses for advice about these treatment modalities.

They seek a knowledgeable response about the subject, even though the nurse may not be directly involved in administering such treatments. Since basic nursing textbooks include information about alternative therapies (Perry & Potter, 2005), nurses are expected to learn about nontraditional treatment modalities so that they can help patients to better understand them. Nontraditional modes of treatment are attracting a growing interest from health-care workers. Some acute health-care institutions are even offering alternative therapies as a part of their treatment regimens. Because hypnosis therapy has long attracted the attention of many health-care professionals, a group of clinicians formed the American Society of Clinical Hypnosis (ASCH). Their work is organized under one banner to conduct scientific studies, which are published in the American Journal of Clinical Hypnosis, as well as in a variety of other professional and refereed journals (Hammond, 1990). Hypnosis techniques are used in such clinical applications as pain management for surgical procedures or labor and delivery, as well for the treatment of depression (Yapko, 2003). Responsible nurses must be aware of such effective treatments as health care moves increasingly toward evidence-based practice — the standard for nursing care in a multitude of settings. At the most basic level, a nurse should have knowledge of the many clinical and nonclinical applications for hypnosis, because a patient may ask about its effectiveness for such problems as smoking cessation or weight management. Addressing such health behaviors is a vital part of the nurse’s role in educating the public. Nurses should possess at least enough knowledge to be able to explain how hypnosis does and doesn’t work and where to find a hypnotherapy clinician. At a higher level, a nurse may be called upon to address the use of hypnosis to manage the pain of cancer, or during labor and delivery — hypno-labor — or at the dentist’s office — hypno-dentistry. Upon completing this program, learners will have an understanding of hypnosis and its use in clinical and nonclinical situations, and be able to explain the nurse’s role in hypnosis in everyday practice. HISTORY OF HYPNOSIS Hypnosis began with Franz Anton Mesmer, who believed he could magnetically unlock an invisible body fluid and cure individuals of whatever afflicted them (Hathaway, 2003). Later, James Baird renamed Mesmer’s technique “hypnotism,” from the Greek word hypnos, which means “to sleep” (Hewitt, 2005). The medical profession became interested when physician John Elliotson used hypnosis to treat epilepsy, hysteria and asthma, as well as to perform more than 200 painless operations during the 1840s and ’50s (Hathaway, 2003). Its use as an anesthetic before surgery waned with the discovery of chemotherapeutic agents at the end of the 19th century, when it was replaced by such drugs as ether, nitrous oxide and chloroform (Hathaway, 2003). Sigmund Freud was known to have used hypnosis, but abandoned it as being authoritative, causing his patients to substitute one symptom for another — known today as symptom substitution (Ewin & Eimer, 2006). The renewed use of hypnosis during the 1950s was inspired by an

Registrants who read this self-study article and score at least 75 percent on the accompanying test will receive EARN one continuing education credit certificate from the Texas Nurses Association, District 4. For details, see ONE the test on page15. This article is approved through CREDIT May 7, 2010. The author declares no real or perceived conflict of interest that relates to this educational activity.

[ MAY 2008 ]

PULSE 11

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Objectives ●

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Explain hypnosis to a client interested in knowing more about it.

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State two reasons nurses should be knowledgeable about hypnosis. List three uses of hypnosis for medical conditions. List two uses of hypnosis for nonmedical conditions.

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Define the phases of the hypnosis session.

interest in more holistic treatments. Practitioners began using hypnosis as a treatment technique for a variety of physical and psychological problems. Its modern use in medicine began with the work of Milton Erickson, a psychiatrist who dedicated the latter half of his career to advancing hypnosis as a therapeutic entity (Ewin & Eimer, 200). Dr. Erickson revolutionized hypnosis, taking it from a direct to an indirect type of communication. He introduced and perfected the use of the indirect suggestion and metaphor as a means of getting the patient “unstuck.” His techniques and strategies were based on information he received from the client, which veered from the traditional protocol that was authoritative and direct. Dr. Erickson developed a body of knowledge that is studied throughout the world as Ericksonian Hypnosis. Some schools specialize in teaching his techniques (Yapko, 2003). CONTEMPORARY USES Today, hypnosis is used to treat acute and chronic pain, ranging from that which is associated with dental procedures to the refractory pain from cancer. Self-hypnosis techniques that help women control labor pain enable them to deliver their babies without the use of drugs. Since their mental processes are not chemically altered, they maintain greater mental clarity. The work of Ewin and Eimer (2006), a physician and psychologist, might be of particular interest to nurses, since they have written about clients with a variety of problems commonly understood by most nurses. The duo has done extensive work in pain management and developed a detailed protocol for conducting a history and carrying out the hypnotic session. Because hypnosis has many health-care applications, nurses must be prepared to explain its uses as:

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An adjunctive technique with cognitive therapy to treat depression (Yapko, 2003); An effective therapy for illnesses lacking a well-defined etiology or originating psychosomatically, such as headaches, itching, spastic or irritable bowel syndrome, and asthma (Ewin and Eimer, 2006); A treatment for conditions controlled by the autonomic nervous system — clients in hypnosis can alter their heart rate, body temperature and blood pressure, which are physiologic functions associated with autonomic activity; and A method to alter or modify such detrimental health habits as smoking or overeating.

Hypnosis even has been effective in removing warts. Other applications include using hypnosis to help individuals: ● ● ● ● ●

Overcome fears; Become better public speakers; Enhance sports performance; Reduce anxiety about taking exams; and Improve study habits.

To formalize the hypnosis-related work of physicians, psychologists, dentists, counselors, social workers and nurses with advanced degrees, Dr. Erickson founded the ASCH, an organization that seeks to advance the use of hypnosis through clinical and experimental research and to provide a body of knowledge that practitioners are encouraged to incorporate when using hypnosis. The organization works to legitimize hypnosis as an effective treatment modality when used adjunctively with clinical interventions. The group discourages the practice of hypnosis by nonclinicians. Nurses advising a patient about hypnosis services should caution against hypnotists who lack preparation in a clinically oriented profession. Anyone trained over the Internet, for example, or in a mass-production school for hypnotists isn’t a good choice. WHAT IS HYPNOSIS? Hypnosis is erroneously associated with the antics of stage hypnotists whose primary objectives are to entertain and make money. Hypnosis isn’t an altered state of mind, and therefore, those who bark like a dog or quack like a duck are doing so with complete knowledge of what they are doing. The relationship between the stage hypnotist and the volunteer is well thought out and

planned prior to the performance (Hathaway, 2003). Nurses must have a clear understanding of hypnosis in order to objectively answer client questions about its clinical use. Hypnosis is a daydream-like state of mind or mode of communication when one individual is exceptionally focused and attentive to the suggestions of another individual — the hypnotist. Self-hypnosis or auto-hypnosis also is possible (Hewitt, 2005). The communication occurs at two levels, the first level being the conscious mind. Consciously, the mind functions objectively and measurably with censors telling it what is good or bad, right or wrong. The conscious mind gets people through the day, reminding them of activities and serving as a gateway to the unconscious mind. The second level of communication is the unconscious mind, which is less concerned with the objective world and is prone to accept, rather than judge, and to store emotion as well as release it. The keeper of all memories, it operates in the subjective domain and is capable of simultaneously managing multiple activities. Since the unconscious has a poor understanding of negative statements, tending to interpret statements about not doing something as a command to do it, a hypnotist may say: “You remain smoke free,” rather than “You do not smoke.” Permanent change occurs in the subconscious mind, which can be accessed through hypnosis. A definitive model for hypnosis doesn’t exist, although Dr. Erickson came closest to defining a theory. Most practitioners agree on these guiding beliefs or principles: People tend to create their own beliefs (Hammond, 1990). A skilled clinical hypnotist will listen for a client belief, which usually surfaces during the history-interview session, such as, “I always get a bad cold in the winter,” or “The women in my family get breast cancer.” The hypnotist understands that the first client is self-programmed to get a cold while the second client is doing the same in relation to developing breast cancer. The hypnotist accepts the well-known relationship between thoughts and body processes. (Consider that many surgical nurses have put a hold on surgery for clients who have stated the belief that they won’t survive the surgery.) Emotions often collide. When two emotions are in contest, the more powerful one tends to override the weaker one. The powerful emotion generally originates in the subconscious, with the discrepancy in feel-

The views expressed in Pulse are those of the authors and do not necessarily represent the opinions and views of Pulse magazine or of The Dallas Morning News, L.P.

12 PULSE [ MAY 2008 ]

ings revealed in the interview process. “I want to go to church and know I should but something just keeps me from getting there.” The hypnotist knows that the “should” statement comes from the judging, conscious mind and the vague “something” statement is the undefined unconscious emotion that acts more powerfully to keep the client from going to church. Less is better. A skilled clinical hypnotist will use the least necessary means to accomplish the client’s objective. The client is always right. This last principle is imperative if the hypnotist is to establish a trusting relationship that will maximize the client’s ability to enter into hypnosis. The goal of clinical hypnosis is to assist clients in engaging their own resources to bring about change. This requires accessing the subconscious mind by speaking in a manner that makes sense to that part of the mind. Although hypnosis lacks a clearly defined theory or conceptual model, it is driven by principles universally accepted by most hypnotists educated and trained in hypnosis. HOW HYPNOSIS WORKS Hypnosis involves several phases and processes, beginning with an interview similar to those which nurses perform when admitting clients to health-care settings. For the clinical hypnotist, the interview is an information-gathering session to assist the client in defining the problem or issue. The clinician is attentive to the client’s choice of words, the use of metaphors in describing the problem and the feelings associated with a thought or events. These descriptors are meaningful to the client’s subconscious mind and are important for designing the hypnotic script to be used during hypnosis (Yapko, 2003). History and interview: The history-interview session indicates how the client processes information. Is the client’s dominant learning mode visual, auditory or kinesthetic? The hypnotist uses this dominant learning mode when addressing the client during hypnosis, encouraging a visually dominant learner to picture or see with the mind’s eye. An auditory learner is encouraged to hear or listen. Induction: To prepare for the induction phase, the client rests comfortably in a recliner or similar type of chair — lying horizontally is closely associated with sleep, and hypnosis cannot occur during sleep. Induction directs the client’s attention internally, with particular attention paid to breathing and muscle relaxation — a slow, progressive process. For clients who have difficulty relaxing, a quicker orientation into the hypnotic state might involve a visual focal point or other stimulus. Deepening: The client focuses more attention internally, and is taken metaphorically down a staircase, escalator or elevator as a way of deepening the relaxation. The hypnotist avoids disturbing imagery discovered during the interview — a staircase metaphor is likely to disturb a client who has fallen down a staircase. Special place: During a second type of deepening, the client may be asked to describe a special place where everything is perfect with nothing to do but relax. This special place belongs only to the client and represents a safe haven from life’s stresses. Working: The client’s primary problem is addressed in the working phase of hypnosis. Clinicians classically trained in hypnosis tend to use direct suggestion, while those trained in Ericksonian hypnosis tend to be indirect. Studies indicate that both work equally well, but the client is the best information source for the most appropriate method (Hammond, 1990). Generally, individuals from authoritative and centralized settings — soldiers and police officers, for example — tend to respond well to direct suggestion. Individuals who tend to draw their structure intrinsically seem to respond better to indirect suggestion (Yapko, 2003). Between 10 to 20 percent of the population is so hypnotically prone that they respond well to all types of suggestion. Depending upon the client, the problem and the goal of the

CELEBRATING NATIONAL NURSES WEEK MAY 6-12, 2008 As your CNOs, we thank you for the gift of caring and compassion you bring to us and our patients every single day. And congratulations to our DFW Great 10 0 Nurses for your dedication, support and commitment to delivering excellence in patient care. • Racine Reid - Doctors Hospital at White Rock Lake • Glenda Cox - Lake Pointe Medical Center All the best, Jim Murphy, CNO Centennial Medical Center Rusty McNew, CNO Doctors Hospital at White Rock Lake Debbie Moeller, CNO Lake Pointe Medical Center

EOE

[ MAY 2008 ]

PULSE 13

hypnotic session, a variety of techniques may be used, including regression in which clients regress or go back in time to an earlier period in their lives. Some hypnotists prefer to work in the present. The client’s primary problem is addressed from a positive frame of reference to circumvent the subconscious mind’s lack of skill in processing negative statements. Framing a negative thought in a positive perspective, the hypnotist may say, “Imagine that you are free from cigarette smoke.” Such framing directs the subconscious to consider what life will be like after the problem is resolved. Termination: There are generally two ways to end a hypnosis session. The hypnotist may count the client out of hypnosis back into an alert state or take the client from hypnosis into sleep. The sleep method is useful if a recording of the session is given to the client to listen to at bedtime. IMPLICATIONS FOR NURSES Nurses should know that every client who seeks health-care services actually is in a mild state of hypnosis. They are hypnoidal, because they are generally mildly to moderately anxious when they enter the healthcare system. They are seeking assistance for problems they are unable to resolve indepen-

dently. As a result, their attention is extremely focused, which causes them to be open to suggestion. They are in need and are attentively listening for a solution to their problem. Doctors and nurses are authority figures and, under such circumstances, tend to have a great deal of influence over their patients. To illustrate this influence, consider the typical nurse interview in which the nurse asks a client to rate pain intensity on a scale from zero to 10. For the client with chronic pain, the nurse may ask about the client’s pain goal. Because every nurse has been taught to re-evaluate pain intensity after giving medication in a hospital setting, the nurse brings the patient the pain medication. Everything about the language of the nurse is directed toward the client having pain. Every time the nurse makes reference to pain the message to the client’s subconscious level is, “I expect you to have pain.” Compare that to a nurse, trained in hypnosis, who would request the client to provide a comfort score, asking about the client’s level of comfort. Medication would be referred to as “your comfort medication.” Many other clinical situations could similarly assist the client toward a positive direction. Language that directs the client away

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from pain and toward comfort requires a level of understanding by the nurse acquired through education and training. Nurses who familiarize themselves with hypnosis services will be much more helpful to clients who are wondering whether hypnosis might be a helpful option. CONCLUSION More health-care workers are becoming adept at using hypnosis as clients increasingly seek alternative therapies. Nurses often are the primary information resource for patients and, therefore, have a responsibility to be knowledgeable about the use of hypnosis services. Many resources are available to nurses, from local hypnosis groups in most large metropolitan areas to national organizations that can provide speakers and other forms of education. The Internet is a good starting place for nurses to learn about such sources. ■

EDITOR’S NOTE: Due to space limitations, references will be made available upon request. Call Jon Garinn at 214-977-8992 or e-mail [email protected].

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14 PULSE [ MAY 2008 ]

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[ ce evaluation ] TITLE: “Clinical hypnosis: what you should know”

(Please PRINT clearly)

PURPOSE: This self-study is designed to provide information about hypnosis and its use as a nontraditional treatment modality.

NAME:________________________________________________________ TELEPHONE: __________________________________

To receive continuing nursing education credit, the registrant must: 1. Read the self-study. 2. Complete the post-test (score of at least 75 percent). 3. Complete the evaluation form. 4. Mail the Post-Test (with $10 payment) and Evaluation Form to TNA, D–4. Upon receipt of the required forms (the post-test with a score of at least 75 percent, and evaluation form) by TNA, D–4, the registrant will be mailed a CE certificate. This activity provides 1.0 contact hours for the nurse. TNA, D-4 is an approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. This activity meets Type 1 criteria for mandatory continuing education requirements toward relicensure as established by the Board of Nurse Examiners for the State of Texas. EVALUATION FORM: “Clinical hypnosis: what you should know” OBJECTIVE: To gain an understanding of hypnosis and its use in clinical and nonclinical situations, and to be able to explain the nurse’s role in hypnosis in everyday practice.

ADDRESS: ____________________________________ CITY: ________________________ STATE:___________ ZIP:____________ E-MAIL (TO RECEIVE CERTIFICATE ELECTRONICALLY) _______________________________________________________________ BIRTH MONTH/YEAR: _________________________________________________________________________________________ PROGRAM EVALUATION: Please rate how well objectives were met by circling the appropriate number: 1 — Not Met 2 — Partially Met 3 — Met 4 — Well Met 1. Explain hypnosis to a client who is interested in knowing more about it. 2. State two reasons nurses should be knowledgeable about hypnosis. 3. List three uses of hypnosis for medical conditions. 4. List two uses of hypnosis for non-medical conditions. 5. Define the phases of the hypnosis session.

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

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Please rate the quality of teaching materials by circling the appropriate number: 1 — Strongly Disagree 2 — Disagree 3 — Agree 4 — Strongly Agree 1. The objectives were relevant to overall purpose. 2. The teaching/learning materials were effective. 3. The program was organized. 4. The program was easy to follow.

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

If you answered 1 to any of the above, please provide comments. How long did it take to complete the program?_________________ Date completed:_____________________ MAIL the completed evaluation with your test results and $10 payment to: TNA, D–4, P.O. Box 35503, Dallas, TX 75235.

[ ce questions ] Complete the following test questions: 1. Who is credited with first using modern hypnosis? a. Milton Erickson b. Anton Mesmer c. Sigmund Freud d. John Elliotson 2. Who revolutionized hypnosis by introducing indirect suggestion and the use of metaphor? a. Milton Erickson b. Anton Mesmer c. Sigmund Freud d. John Elliotson 3. Which of the following is a basic tenet of hypnosis? a. Women go into hypnosis more readily than men. b. Children should never be hypnotized. c. What one tends to believe, one tends to create. d. Hypnosis is a state of sleep. 4. For which of the following conditions is hypnosis known to be effective? a. Spastic bowel syndrome b. Kidney stones c. Angina pectoris d. Myopia 5. The client states that she is thinking about using hypnosis during her labor and delivery. What is the best response? a. Hypnosis has not been proven effective in labor and delivery. b. That is one way of managing labor and delivery. It’s important that you share

[ classified ] that information with your physician. c. Do you have a backup plan in case it doesn’t work? d. Hypnosis isn’t for everyone. Make sure it works before you do it. 6. In what order is a hypnosis session generally conducted? a. Induction, deepening, special place b. Induction, deepening, termination c. Deepening, induction, termination d. Deepening, special place, termination 7. The client asks for information on how to select a hypnotist for weight management. Which of the following responses is most appropriate? a. Find a hypnotist who has been doing weight management for many years. b. Limit your search to a physician or health-care worker trained in hypnosis. c. The Internet is a great place to find that type of information. d. Think about it carefully because it can be very expensive. 8. The nurse should understand which of the following? a. The relationship between the conscious and subconscious minds. b. How information travels from the brain through the body.

c. The relationship between the central and peripheral nervous systems. d. How the autonomic nervous system functions. 9. Which of the following client statements demonstrates the principle that individuals tend to create what they believe? a. “We have gone on vacation to the Bahamas twice in the past three years.” b. “I never saw a Disney movie I didn’t like.” c. “I always get the flu in the late spring.” d. “My grandson insists on hearing a bedtime story before he goes to sleep.” 10. Which of the following images is often used during the deepening phase in hypnosis? a. A ladder b. A staircase c. An automobile d. An ocean 11. The nurse is preparing to administer a medication for the client’s complaint of pain at a level 8 on a scale of zero to 10. Which statement would divert the client’s attention from pain toward comfort? a. “I have your pain medication.” b. “This medicine ought to reduce your pain to a level 2 or 3.” c. “I have your comfort medication.” d. “These pills will take your pain away.”

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congratulates the Great 100 Nurses!

[ MAY 2008 ]

PULSE 15