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Medical Hypnosis: An Underutilized Treatment Approach

Abstract
Context: Use of hypnosis in medical practice has long been controversial, but recent developments in medical hypnosis--in particular, the understanding that the power of hypnosis resides mainly in the patient--have profound implications for treatment.

Objective: To illustrate and explain the therapeutically useful application of hypnosis in medical practice.

Design: Case series.

Setting: Department of Preventive Medicine at Kaiser Permanente Medical Center, San Diego.

Patients: Five outpatient Health Plan members referred to a department of preventive medicine for alleviation of physical, emotional, or behavioral symptoms.
Main outcome measures: Extent and duration of clinical recovery.

Results: Patients in all five cases had dramatically successful clinical outcomes after three or fewer intensive hypnotherapeutic sessions.

Conclusions: Medical hypnosis is an underutilized therapeutic modality which can be learned easily for everyday use in medical practice, especially when taking the medical history. In this era of emphasis on cost-effectiveness, both medical hypnosis and certain parahypnotic techniques (eg, closed-eye history taking) may be of special interest to physicians.

Introduction
Hypnosis is a state of highly focused attention (trance) in which external stimuli are disattended and suggestion becomes far more effective than usual.1 The fundamental usefulness of hypnosis in medicine and healing has been controversial for more than 200 years, ie, since Anton Mesmer produced the body of work now recognized as the beginning of clinical hypnosis. Does medical hypnosis work? If so, how? Does it produce real bodily healing at the physiologic level, or is its therapeutic effect merely the result of imagined comfort--and thus to be found in the mind only? These questions are reasonable and can best be addressed by clinical observation aided by modern technology.

The most clinically significant recent development in medical hypnosis is our understanding that the power of hypnosis actually resides in the patient and not in the doctor. This simple statement has profound implications because it implies existence of useful potential within each patient. The goal of modern medical hypnosis is to help patients use this unconscious potential--a revolutionary shift from the direction-focused, authoritarian therapeutic techniques of the past.

By contrast, modern medicine involves a highly rational belief system that minimizes the importance of autonomous therapeutic processes. This belief system has created an expectation that everything can be accomplished on a conscious and voluntary level, even though such voluntary efforts can sometimes obstruct natural healing processes. Notwithstanding this possible obstruction, a cumulative effect can be attained by simultaneously using the opposing concept that underlies modern medicine with medical hypnosis.

To support these statements and to illustrate the range of possible treatments, this article describes five patients who were treated with medical hypnosis after being referred to me from the Kaiser Permanente (KP) Department of Preventive Medicine in San Diego. Focusing on these five clinical examples presents the opportunity to answer three questions:

     What is medical hypnosis?
     How does medical hypnosis work, especially when no specific
           directions or suggestions are given?
     When should medical hypnosis be used?

Case Examples
Case 1
Cerebral angiography showed mild thrombosis in the right posterioinferior cerebellar artery of a 57-year-old male physician. Intractable hiccups ensued as a recognized complication of a brain lesion; the hiccups did not respond to therapeutic trials of several medications. Two weeks after the condition began, a 1.5-hour hypnotherapy session was conducted, immediately after which the hiccups permanently ceased. Although the patient did not believe he had been hypnotized, he described several psychophysiologic changes that he had never experienced before the hypnotherapy session: a complex visual hallucination, brief but pronounced sialorrhea, and brief periods of marked acoustic and olfactory hyperacuity. Three months after the hypnotherapy session, the patient suddenly realized that he no longer used the bronchodilator and steroid inhalers that he had previously used twice daily for ten years. I made no suggestions specifically relevant to the physiologic changes he manifested and was not aware that he had asthma.

At follow-up seven years later, the patient remained free of hiccups and asthma, and the results of pulmonary function tests were normal.

Case 2
A 41-year-old obese, chronically depressed female nurse had grown up in an abusive household. She later married an abusive man whom she repeatedly had the sheriff remove from the home during moments of violence; after each such episode, she relented and forgave her husband. Once, after completion of such a cycle, the patient compulsively became unable to dispose of the kitchen garbage and stored this garbage, wrapped in plastic bags, in the bedrooms of her home. Complaining to her physician that the odor prevented her from inviting anyone into her home, she stated, "If my house is dirty, then no man will want to come in my house"--but she saw no link between this statement and the problems with her husband. The patient had three hypnotherapy sessions, during which no specific hypnotic suggestion was made to her directing that she dispose of the garbage; nonetheless, after the three sessions, she spontaneously cleaned her house. She saw no link between this change and the sessions.

Case 3
A 65-year-old housewife had been both a war orphan and an inmate of Nazi concentration camps. Over a ten-year period, she generated four volumes of KP medical records, largely describing recurrent, acute inability to swallow. Multiple esophagoscopy procedures done by two gastroenterologists produced normal results as did several esophageal dilations; no obstruction was found.

Three hypnotherapy sessions resolved her problem of choking. She recognized some link of this change to the sessions, stating, "I was liberated from my esophagus." This assertion was reminiscent of an earlier statement she had made, which referred to events that occurred "... when the Russian soldiers liberated me from [the camp]." I gave no direct suggestion relating to choking or dysphagia.

Case 4
A 51-year-old successful professional woman who had a highly abusive childhood was seen on an emergency basis because she was concerned that her plan for suicide that day would interfere with her obligation to give the keynote address at a national meeting later that afternoon. Suicide was not her problem--it was her solution--but it interfered with her sense of responsibility. A 90-minute hypnotherapy session enabled the patient to fulfill her obligations. A few follow-up sessions conducted during the next 18 months relieved her depression substantially. An interview was conducted with the patient 18 months later and was videotaped. The videotape, titled "I'll Be Polite Before I Die," is available from the KP San Diego Department of Preventive Medicine. (Contact Vincent.J.Felitti-MD@kp.org.)

Case 5
A middle-aged woman with demyelinating disease was seen for treatment of depression that responded poorly to antidepressant medication. Unexpectedly after a session of hypnotherapy, the patient almost immediately had marked improvement in gait that enabled her to give up using Canadian crutches; in addition, her dysarthric speech improved noticeably, and her depression became less severe. Her physician believes that these improvements occurred far too abruptly to be attributable to remission of illness. The improvement persisted at a two-year follow-up.

Discussion
Historically, medical hypnosis was identified with surgical anesthesia2 and with removal of symptoms. Medical hypnosis was defined as a state of heightened suggestibility in which something is done to a patient. From this interpretation--one in which hypnosis commands away the symptom--our definition has evolved to a subtler form that more effectively brings basic, long-lasting change. Because this description may seem undramatic to those who are familiar only with the commands of stage hypnosis--or with its often magical depiction in motion pictures--the distinction bears some elaboration.3

Medical hypnosis is quite different from the "command performance" of stage hypnosis, an activity that depends heavily on the practitioner's ability to quickly select from an audience those subjects who can be readily hypnotized.4 Stage hypnosis is also highly directed as to outcome ("You will sing like Frank Sinatra," "You will quack like a duck," etc). This directiveness can be dramatic and engaging, but it has limited utility. Unlike practitioners of stage hypnosis, physicians do not have the luxury of selecting subjects on the basis of perceived ease of outcome. In fact, for many patients, the problem is so complex that its resolution requires total dependence on unconscious processes occurring within the patient.5 For example, in none of the cases described were outcomes suggested; indeed, some outcomes were unanticipated. Research has shown that attempts to cure by specific direction and command have a high failure rate because of the unrecognized complexity underlying many patient problems.6

When we speak of medical hypnosis, we refer to a special type of interchange between two people--an interchange that involves trance. Trance can occur at many levels ranging from rapt attention with eyes open (entranced) to deep states that resemble somnolence. Whatever its depth, hypnotic trance has consistently been determined to have no relation to the state of sleep; hypnotic trance is physiologically a type of waking state. Moreover, just as an abdominal incision is itself not treatment but is instead the means through which surgical treatment may be done, hypnotic trance is not a treatment per se; instead, hypnotic trance is the framework in which treatment can more effectively be carried out. The goal is not to hypnotize someone; the goal is to accomplish a therapeutically valuable result during hypnotic trance.

For clarity, I have selected examples of dramatically successful hypnotherapeutic outcomes. Cases 1 and 5 in particular show that certain important aspects of organic disease are poorly understood and that they evidently are sometimes altered by processes that indicate possible existence of involuntary neural or neurochemical control (other processes about which we know little). Indeed, important or difficult human problems are likely to have complex and covert underpinnings that resist change and that thus require the hypnotherapist to avoid the patient's rejection of suggestions. Two common ways of avoiding this rejection are 1) to offer the patient several choices and 2) to provide the suggestion as a metaphor.7 Metaphor is the language of the unconscious and thus may often be accepted when direct suggestion would be rejected. Another helpful observation is that, in trance states, we sometimes allow our unconscious to solve complex problems8 or gain a fresh perspective. A famous example of the power of the unconscious is the example of the great German chemist Kekule, who conceived the structure of the benzene ring after dreaming of a snake swallowing its own tail.

Foundational Theories of Medical Hypnosis
Dr Milton Erickson--physician, psychotherapist, teacher, and arguably the consummate medical hypnotherapist of the 20th century--emphasized the need for practitioners to individualize their approach to hypnosis.9 Erickson believed that the hypnotherapist must understand, evaluate, accept, and use the unique aspects of each patient. Erickson's often-extraordinary results occurred precisely because they activated and further developed what was already within the patient instead of trying to impose from the outside an element that might be unacceptable for that individual's personality. Although easy to describe, this process is difficult to accomplish without extensive practice. To understand what can be accomplished in medical hypnosis--and to obtain a detailed explanation of the underlying concepts--I suggest you read "The February Man."10 This monograph provides a verbatim transcript and detailed explanation of one remarkable case in which Dr Erickson definitively treated the patient in four sessions, during which the patient believed that she was merely providing background information as the prelude to treatment.

In Dr Erickson's approach, all symptoms are viewed as signals. In this approach, the hypotherapist asks, "What is this patient trying to tell us with a headache, chronic fatigue, or recurring, stress-related skin disorder?" Some patients may present through their own imagery a metaphor about their emotions that ultimately helps expand the patient's conscious understanding.11

How Hypnosis Works
That medical hypnosis works is clear from the case examples given and from extensive clinical and experimental literature. However, the mechanisms of hypnosis and reasons for its effectiveness raise vastly more complex questions. Nonetheless, this situation is not different from that of aspirin, which was used effectively for more than half a century without anyone understanding how or why it worked. Like uses of hypnosis, some of aspirin's uses have been discovered only recently--and more may well be found. The five cases described in this article illustrate only our current understanding that the power of hypnosis resides in the patient.9,12 The power of hypnosis certainly need not originate in commands; indeed, none were given to our patients. Moreover, enhanced physiologic function (as in Case 1) must be interpreted as resulting from release phenomena, because biologic functions cannot be inserted. This interpretation implies existence of a wealth of material in the patient's unconscious that can be used in healing. This wealth of material is what current medical hypnosis techniques attempt to stimulate.

Erickson and Rossi brought together extensive evidence from psychoneuroimmunology, neuroendocrinology, molecular genetics, and biology to show that no mysterious gap exists between mind and body.13 Instead, state-dependent memory, learning, and behavior encoded in the limbic-hypothalamic system of the brain are major information transducers forming the mind-body connection.14 This model underlies the mechanics of consciousness and the subtleties of the hypnotic process. For example, the mind has long been recognized to modulate cellular activity via the autonomic nervous system. We all know how provision of "simple" reassurance from a doctor or nurse can greatly mitigate the stress-induced aspects of an emergency by attenuating the sympathetic alarm reaction and substituting the calming effects of the parasympathetic system.14,15

Researchers16-18 have found that the human brain's unconscious continues an exhaustive search throughout its entire memory system even after it has found an answer that is satisfactory at a conscious level. The mind apparently can scan more than 30 items per second even when we are unaware that the search is taking place. The results of such unconscious searches are clear from experiences of everyday life: How often do we forget a name only to have it pop up all by itself a short time later, after our conscious mind has moved on to something else? How often are we consciously satisfied with a solution but have a better answer emerge spontaneously a little while later? Conversely, how often have we ever not seen the physically obvious (eg, as when we look for our eyeglasses while wearing them)? This situation is not categorically different from failing to notice pain when it is present. Perhaps more difficult for the inexperienced hypnotherapist to acknowledge is the observation that hypnosis can modify aspects of organic disease, as several of our cases illustrate.

Use of Hypnosis in Medical Practice
As these case examples suggest, medical hypnosis differs from most forms of psychotherapy, particularly those that are insight-based. This difference is an advantage when treating patients who are not introspective, who are amnesic, or who refuse to consider the psychologic impact of particular events in their lives.18 Their lack of insight is of small matter; insight has been shown to have poor correlation with outcomes.19 One of the great surprises of medical hypnosis is that beneficial change can be effected without the patient's awareness; indeed, Cases 1, 2, and 5 illustrate benefit without understanding or insight. However, medical hypnosis can also be used as an adjunct to conventional psychotherapy. M Gerald Edelstien, MD, a psychiatrist from The Permanente Medical Group, has edited, with others, a definitive book20 on medical hypnosis based on his experience using it at Kaiser Permanente.

Medical hypnosis (therapeutic trance) involves careful planning that places significant demands on the hypnotherapist and initially requires an allocation of uninterrupted time.15 This fact, combined with the need for experience and the unfamiliar therapeutic use of metaphor, probably explains the infrequent use of hypnosis in medicine today--despite many physicians being trained in its use. Nonetheless, when such treatment plans are well made and executed, substantial change can occur through hypnotherapy. As shown in Case 3, the initial investment of time can save much physician time later on.

Become a Practitioner of Medical Hypnosis
Trance induction is relatively simple, but becoming accomplished in medical hypnosis requires interest, training, and experience. Interest in the practice is typically an outgrowth of awareness and exposure to what can be accomplished with medical hypnosis. Training may be obtained from the American Society of Clinical Hypnosis (ASCH) or from the Milton Erickson Foundation,21,22 but practice is totally up to you.

Clinicians who instead choose to refer their patients for treatment can contact the referral desk at the ASCH to locate local physicians, psychologists, and dentists who are experienced in medical hypnosis.23 Clinicians may reasonably assume that some patients will fear hypnosis, anticipating a loss of control.24 This situation is particularly true for people who have been raped or otherwise sexually abused. For these people, the issue is present--not past--loss of control over part of their lives; the clinician may properly point this out to the patient and note that hypnosis will return this control to them. For patients who claim that they cannot be hypnotized, the clinician may simply point out that this is not their problem but that of the treating doctor.

My hope is that the examples provided here will enable you to identify patients for whom medical hypnosis would be a prime treatment option and whom you might consider referring to a consultant experienced in these techniques. Hypnosis is useful in medicine when patients have physical or emotional problems that are due at least in part to the patients' own unconscious limitation of their capacities: Medical hypnosis helps these patients break through their limitations to free their unconscious potential for solving problems.3,25 Although responsiveness to hypnotherapy cannot always be predicted, referral will most likely be suitable for patients with certain medical conditions--eg, chronic headache, chronic back pain, psychogenic weakness or paralysis, chronic constipation, and irritable bowel syndrome--that typically respond well to medical hypnosis. Panic attacks and phobias often lessen substantially in response to hypnosis as do conditions associated with amnesia. Seemingly straightforward organic conditions may improve unexpectedly, as the cases described here illustrate. Identifying underlying issues during trance and removing some stumbling blocks to success can help intractably obese patients. As is true for the addictions, the problems underlying obesity are usually so complex that seeking definitive cure through hypnosis or through any other single approach is not realistic; nonetheless, hypnosis can be a key technique for preparing patients to accept change and to refrain from thwarting their own success.

Related Treatment Tips
This article discusses heterohypnosis only; a variant of this technique is self-hypnosis, which involves the same processes but is done at the patient's own direction.2,26 Self-hypnosis may be facilitated initially through heterohypnosis. I teach self-hypnosis to most of my patients as a way to provide affordable daily reinforcement. In this respect, self-hypnosis bears some similarity to meditation.27 Practice Tips
Important or difficult human problems are likely to have complex and convert underpinnings that resist change and that require practitioners to avoid the patient's rejection of suggestions. Two common ways to avoid rejection are 1) to offer the patient several choices, and 2) to provide the suggestion as a metaphor.

Simple reassurance from a doctor can greatly mitigate the stress induced aspects of an emergency by attenuating the sympathetic alarm reaction and substituting the calming effects of the parasympathetic system.
Hypnosis is suitable for patients with the following medical conditions: chronic headache, chronic back pain, psychogenic weakness or paralysis, chronic constipation, irritable bowel syndrome, panic attacks and phobias.
"Closed-eye history taking": Have your patients tell you their own story with their eyes closed so that they convey experiential recollections instead of intellectualizations.

Even if you later decide to learn hypnosis, one simple skill--"closed-eye history taking"--can be helpful for diagnosis right now.9,28 For difficult cases, this technique can be a powerful adjunct to the traditional method of obtaining the medical history. Closed-eye history taking is a simple, effective technique that involves only one activity: asking the patient to close his or her eyes while the medical history is being obtained, "... the better to focus on things." Dr Albert Ray describes his experience with this technique in "Closed-eye History Taking,"29 a videotape available from KP San Diego's Department of Preventive Medicine. (Contact Vincent.J.Felitti-MD@kp.org.) Dr Ray was bold enough to try this approach for the first time in the urgent appointment clinic. This videotape includes long-term follow-up of his patient so you can see the often-profound results of this small change in practice.

Whether using medical hypnosis or parahypnotic techniques such as closed-eye history taking, you should understand that a unique treatment approach is necessary for each patient and for each situation.2,30 Recognize that the patient's condition will naturally improve when unconscious obstacles within the patient are removed.3,31 Expect change to be not only possible but inevitable. Emphasize the positive, including the effort to discover what is right about that person's life. Have your patients tell you their own story with eyes closed so that they convey experiential recollections instead of intellectualizations. Understand that whatever you do, you will influence each patient; the question is how to ensure that the influence is beneficial.32 Offer patients an alternative to their symptoms--an alternative more positive than the patient's current belief. Use metaphors and stories to plant the right suggestion, and then be willing to give each patient supportive follow-up by telephone and e-mail. I use a computer-driven system of automated telephone calls that pose questions and that record the patient's answers while interposing supportive responses.33

Summary
Medical hypnosis offers physicians the ability to effect beneficial change even in difficult cases. Often this change occurs quickly, and sometimes it appears in unexpectedly beneficial ways. To the disadvantage of patients as well as physicians, medical hypnosis is underutilized as a therapeutic modality. In addition, certain parahypnotic techniques are simple to learn and can be readily used in everyday medical practice, especially in taking the medical history. Especially in this era of emphasis on cost-effectiveness, both medical hypnosis and certain parahypnotic techniques (eg, closed-eye history taking) may be of special interest to physicians.

References

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