Frank McDonaldPsychologist

Consultation-Liaison ServiceTTH

November 2009

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

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

IntroAs 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

Areas of applicationMedicalAsthmaBurns EnuresisHypertension ChildbirthMigraine

Minor Surgical Procedures

Obesity Pain ControlGastro-intestinal

Disorders (especially IBS)Warts

Source: Australian Society of Hypnosis

Areas of applicationPsychological Practice

& Psychiatry

Anxieties Apathy and lack of

Motivation Confidence ProblemsEating DisordersDepressionNail-biting Fears and Phobias

Psychosomatic Syndromes

Panic Attacks Sleep Disorders Sexual Dysfunction Thumb-sucking Stuttering

Source: Australian Society of Hypnosis

Areas of applicationDentistryAnaesthesia Anxiety /

ApprehensionBleeding Control Bruxism Dental Phobia Denture Problems

GaggingNausea Pain-control Restlessness Salivation-control Tempro-mandibular

Joint Dysfunction

Source: Australian Society of Hypnosis

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)

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

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

What is it?Principle Hypnotic Phenomena Ideomotor behavior As 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 behavior As someone thinks about a sensory response they experience it

Automatic behavior Automatic writing or drawing. Just happens, no volition

Post hypnotic suggestion This is a suggestion that happens after hypnotic experience on a particular cue

Time distortion Time can be experienced as longer or shorter (slower or faster)

What is it?• Amnesia Forgets something that actually happened

• Hyperamnesia Remembers very vividly something they hadn't realized that they remembered

• Age regression S’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

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 procedure4. Deepening stage5. Trance ratification e.g. via arm levitation test6. Utilisation of trance/heightened suggestibility & direct

suggestions for therapeutic purposes7. Post-hypnotic suggestions including self-hypnosis instructions8. 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?

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

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

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

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

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

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

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 feature of hypnosis (Kroger, 2007)

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

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

Case applicationsAuthor’s recent & past hospital applications

severe (hospitalisable) hyperemesis gravidarum(Acute) Pain Disorder (non-cardiac chest pain)sleep onset problemsanxiety managementbreakthrough pancreatic cancer painchronic musculoskeletal and neuropathic painneedle phobiachildren’s burns debridementdysphonia

Resourceswww.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”