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Emergency room use of hypnosis
Emergency Room Use of Hypnosis Harold J. Wain, Ph.D. Director, Consultation Liaison Service, Department of Psychiatry, Walter Reed Army Medical Center, Washington, D.C.
Daniel G. Amen, M.D. Psychiatrist in Residence, Department of Psychiatry, Walter Reed Army Medical Center, Washington, D.C.
Abstract: Myths about hypnosis have interfered with its use in emergency settings. Specifically, included are myths about who induces the hypnotic state, the length of induction time, and the traumatized patient‘s inability to concentrate on a focal point. It is suggested, however, that altered states of awareness occur rapidly and spontaneously in the patient who has experienced acute trauma andlor pain. Two cases are presented that illustrate spontaneous trancelike states occurring in traumatic situations. The cases also show how the recognition of these altered states can facilitate the patient’s care and treatment in an emergencysetting.
Introduction Hypnosis has been found useful in the emergency room setting for many conditions, Goldie [l] and Jamieson [2] both report successful uses of hypnotic intervention for minor surgical procedures in acute situations. Ewing [3] described the usefulness of hypnosis with the burn patient in the emergency room, particularly its role in promoting early tissue healing. Unfortunately, this useful, adjunctive treatment modality is often overlooked in the emergency (traumatic) setting. One of the primary reasons for this may be that the staff is more preoccupied with the physiologic manifestations of trauma than the accompanying psychologic states. Myths and misconceptions about hypnosis may also interfere with the medical staff’s willingness to use hypnosis in emergency situations. One misconception is the notion that doctors cause hypnosis. In reality, it is the patient who develops the altered General HospitalPsychiatry
8, 19-22, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
state that allows distancing from physical and/or psychologic trauma. Hypnotic states can occur spontaneously (i.e., be self-induced) and often do not require the formal ceremony of induction [4]. The doctor’s role is to facilitate the patient’s entry into the trance state and to provide the appropriate suggestions or strategy [5]. Another myth is that it requires a long time to induce a hypnotic state. However, hypnosis, which is induced by focal concentration, may occur spontaneously in patients who focus in on their symptoms and/or pain. Many patients may already be in a trancelike state, and the time necessary to help the patient into the induced state is minimal. At this point, by directing the patient’s attention, the doctor can help the patient utilize appropriate strategies. A third misconception regarding hypnosis is the notion that patients in traumatic states cannot focus their attention in order to utilize hypnosis. This is again dispelled by the knowledge that patients may already be in a hypnotic state by focusing in on their symptoms. Knowledge of hypnotic states will help the doctor to redirect the patient’s attention away from symptoms and onto other focal perspectives. This may be accomplished by the emergency room staff who have no specialized training in hypnosis simply through the words they use, i.e., “Relax, everything is going to be just fine.” With specialized training it seems that this capacity could be significantly enhanced. Supporting the above hypothesis, the literature suggests that altered states of awareness frequently 19 ISSN 0163-8343/86/$3.50
H.
Wain and D. G. Amen
accompany physical trauma [6]. Grinker and Speigel[7] and Beecher [8] all describe altered states of awareness with dissociative qualities (spontaneous hypnotic states) occurring in the traumatic combat environment. Although the emergency room is not a combat environment, the altered states of awareness associated with the trauma and the feelings of helplessness and anxiety manifested by patients may be similar. Suggesting that altered states accompany a physical trauma implies that these states have “trancelike” features. Characteristics of a trance state include a temporary suspension of critical judgment [9], a capacity for trance logic-making an incongruent idea or feeling congruent [lo]-and rapid assimilation of internal or external data [ll]. These characteristics can be utilized to help the patient gain greater control and understanding of the symptoms, and/or achieve the reduction of psychologic dissonance. The capacity to alter perception may be the necessary ingredient in helping individuals cope effectively with a traumatic event. Thus, self- or heterohypnosis may be the milieu to accomplish this task. Patients may use regression in the service of the ego in order to establish a therapeutic alliance [12]. The doctor is perceived as a facilitator in the reduction of the distress. Thus, patients become more open to suggestions and directions, especially when they perceive that the doctor can help decrease their discomfort. Not all patients are capable of achieving a deep level of hypnosis, but for the most part every patient can benefit by the resultant relaxation or at least the distraction caused by shifting their focal attention. The depth of hypnotic capacity may be based on a patient’s inherent “gift” [13] or talent [9]. Suggestions that can enhance the trance depend on patients’ personality styles, motivations, cultures, and so forth. The more knowledge a doctor has of his or her patients, the easier it will be to determine the type of suggestions given. Recognition of these naturally occurring altered states by the staff can help patients tap into their own resources to facilitate their own care and treatment. By directing patients to use their own capacity and shift their attention, the staff may increase the patient’s sense of control over anxiety and perceived discomfort. This may also facilitate more ego participation in treatment and give a greater share of responsibility to the patient. Two cases are presented that illustrate the recognition of an altered state, and how it can be utilized to facilitate treatment in the emergency room.
Case A
married female with a deep venous
of
emboli episode 2% years previous) presented to Walter Reed Army Center Room pain, swelling, and in right ankle spreading up the calf. The pain been increasing severity over several hours prior to entering the room. On physical examination, the patient’s right ankle and leg were erythematous, swollen, warm. She a positive sign (flexion of ankle producing pain), tenderness present from the to the A tentative diagnosis of deep thrombosis made and venogram was uled. This required an to be in foot, but this area swollen, no adequate veins could be The internist, and surgeon to start an in her foot success. about 1 hour enduring the failures of staff in the the patient very cried, pleaded that she not want more needles. also complained the excruciating pain in right leg. consult the service to help the patient, decrease her anxiety, and facilitate pain with ic intervention. During history taking it was disthat patient has previously to use hypnosis to help stop smoking. Though had been unsuccessful, the remembered as a relaxing Upon the patient focusing on exaggerating her pain sponse, that had been long since she entered the emergency room, and paying to some external stimuli (by to staff comments), was hypothesized that she probably entered a state without the positive results were The patient’s betrance phenomenoq including blocking peripheral critical judgment, time distortion, and focal concentration It was then to her field of concentration and capacity help calm her condition. the trance by shifting from the symptoms to simple eye fixation concentration followed strategy was where the was imagine herself near a mountain cabin surrounded snow. It that she walk a long time a snowy road, and that minute in the room would seem like hour in mountains. a desigplace she pictured her hand plunging into snow making fist around icy wetness, and a
Emergency Room Use of Hypnosis After achieving this in her hand she transferred the anesthesia to her right leg and related that the pain was gone. The results achieved to this point reinforced the perception that this patient was receptive to the utilization of her trance, and that an effective set for its use had been achieved. While in a trance she was directed to perceive more control over the blood vessels in her right foot. As she did this the radiologist was now able to find an adequate vein and successfully placed a 20-gauge needle in her foot. The lack of pain in her right leg persisted during the venogram and several hours thereafter. During the procedure she was relaxed and comfortable.
Case Two A lo-year-old boy was brought to the emergency room after being hit by a car. He was screaming, bleeding, and in obvious pain. The staff noted that he was belligerent and uncooperative. When it was recognized that the child was focusing in on his symptoms, he was asked if he would Like to go to the movies. He was so surprised and taken off guard that he momentarily stopped crying. With that signal he was able to close his eyes and enter a more focused trance. He was then given the suggestion that he could watch a movie on the imaginary screen in front of him. The ceremony of induction simply consisted of shifting the boy’s attention away from his pain and onto a movie. While he was watching the movie he began moving his hand from his thigh to his mouth. The significance of this motion was not immediately obvious. Later the boy explained that he usually eats popcorn while watching a movie. The surgeon was able to set the boy‘s fractured tibia and fib& and further evaluate the extent of his injuries with a cooperative patient.
Discussion The presented cases have several implications for treatment of patients who have experienced trauma and/or acute pain, especially in emergency type settings. Not unexpectedly, the examining medical staff is so involved with the presenting signs and symptoms that the psychologic states, unless overtly a problem, are often ignored. Specifically, recognizing the existence of spontaneous altered states of awareness often associated with trauma or acute pain facilitated the patients’ treatment and recovery. These cases also appear to highlight one of the cardinal features of an altered state-namely, suspension of critical judgment. While in the altered state the individual becomes more receptive to suggestions and directions, especially when the staff is perceived as a facilitator in reducing distress. The
patient’s motivation for reduction of distress and the need to regress [6] in order to receive appropriate treatment also contribute to a positive outcome. In emergency room settings the patient who is in acute distress has a strong need to effect a positive transference with the staff in order to accomplish the goal of receiving help. From a psychologic perspective this behavior can be seen as paradoxical: on one level it is a regressive pattern due to the trauma and feelings of helplessness that occur; however, as Gill and Brennan [12] suggest, regression in the service of the ego may facilitate treatment for the patient by helping him or her become more compliant and cooperative. Hypnotic intervention also facilitates a sense of control in patients by allowing them to become more involved in the treatment process. In particular, the first case appears to present support for the above hypothesis in that at a previous time the patient did not effectively utilize her trance to give up an unwanted habit. Perhaps this occurred because of lack of positive transference, low motivation, inadequate regression, and/or a previous lack of desire to suspend critical judgment. However, when conditions are right it may be easier for patients to utilize hypnotic states, especially when it appears to be important or necessary for them. Erickson emphasized this when he stated that hypnosis occurs spontaneously and the primary role of the hypnotherapist is to set the stage for hypnosis to occur [5]. In the second case, by shifting the patient’s awareness and recognizing that his anxious state and his preoccupation with crying was a trance state, the ambience was established which helped the patient dissociate and remove himself from the traumatic situation and find relief. The use of the hypnotic state facilitated an expeditious evaluation and treatment. In both cases, the attention focused by the patients on the pain set up a reciprocating cycle of anxiety where the patient became more frightened and the treating staff grew more frustrated. Clearly, the hypnotic redirection interrupted this cycle of escalation. In conclusion, it would appear that the use of spontaneous hypnotic-like states can be an outstanding adjunctive procedure for emergency room staff to utilize. One precautionary note is warranted for the higher hypnotic subject: in such a patient the necessary perception of pain may be blocked. It is, therefore, important to know the source of the pain before hypnotic pain relief is attempted. 21
H. J. Wain and D. G. Amen
References 1. Goldie L: Hypnosis in the casualty department. Br Med J 2:1340, 1956 2. Jamieson, RM: Hypnosis for minor surgical procedure. Br J Anaesth 35:269, 1963 3. Ewing D: Uses of hypnosis for the burn patient in the emergency room. Am J Clin Hypn 26(1):12-17,1983 4. Crasilneck HB, Hall JA: Clinical Hypnosis. New York, Grune & Stratton, 1975 5. Wain H: Film. Interview with M. Erickson on Hypnotic Technique, 1979 6. Strain J, Grossman S: Psychological Care of the Medically Ill. New York, Appleton-Century-Crofts, 1975 7. Grinker RR, Spiegel JP: Men Under Stress. New York, Irvington, 1945 8. Beecher HK: Relationship of significance of wound to pain experiences. JAMA 161:1609-1613, 1956
22
9. HiIgard EH Hilgard JR: Hypnosis in the relief of pain. Los Altos, CA, William Kaufmann, 1975 10. Orne MT: The nature of hypnosis: Artifact and essence. J Abnorm Sot Psycho1 58:277-299, 1959 11. Spiegel H, Spiegel D: Trance and Treatment: Clinical Uses of Hypnosis. New York, Basic Books, 1978 12. Gill MM, Brennan M: Hypnosis and Related States: Psychoanalytic Studies in Regression. New York, International Universities Press, 1959 13. Wain H: Clinical Hypnosis in Medicine. Chicago, Year Book, 1980
Direct reprint requests to: Harold J. Wain, Ph.D. Department of Psychiatry Walter Reed Army Medical Center Washington, DC 20037
Daniel G. Amen, M.D. Psychiatrist in Residence, Department of Psychiatry, Walter Reed Army Medical Center, Washington, D.C.
Abstract: Myths about hypnosis have interfered with its use in emergency settings. Specifically, included are myths about who induces the hypnotic state, the length of induction time, and the traumatized patient‘s inability to concentrate on a focal point. It is suggested, however, that altered states of awareness occur rapidly and spontaneously in the patient who has experienced acute trauma andlor pain. Two cases are presented that illustrate spontaneous trancelike states occurring in traumatic situations. The cases also show how the recognition of these altered states can facilitate the patient’s care and treatment in an emergencysetting.
Introduction Hypnosis has been found useful in the emergency room setting for many conditions, Goldie [l] and Jamieson [2] both report successful uses of hypnotic intervention for minor surgical procedures in acute situations. Ewing [3] described the usefulness of hypnosis with the burn patient in the emergency room, particularly its role in promoting early tissue healing. Unfortunately, this useful, adjunctive treatment modality is often overlooked in the emergency (traumatic) setting. One of the primary reasons for this may be that the staff is more preoccupied with the physiologic manifestations of trauma than the accompanying psychologic states. Myths and misconceptions about hypnosis may also interfere with the medical staff’s willingness to use hypnosis in emergency situations. One misconception is the notion that doctors cause hypnosis. In reality, it is the patient who develops the altered General HospitalPsychiatry
8, 19-22, 1986 0 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Avenue, New York, NY 10017
state that allows distancing from physical and/or psychologic trauma. Hypnotic states can occur spontaneously (i.e., be self-induced) and often do not require the formal ceremony of induction [4]. The doctor’s role is to facilitate the patient’s entry into the trance state and to provide the appropriate suggestions or strategy [5]. Another myth is that it requires a long time to induce a hypnotic state. However, hypnosis, which is induced by focal concentration, may occur spontaneously in patients who focus in on their symptoms and/or pain. Many patients may already be in a trancelike state, and the time necessary to help the patient into the induced state is minimal. At this point, by directing the patient’s attention, the doctor can help the patient utilize appropriate strategies. A third misconception regarding hypnosis is the notion that patients in traumatic states cannot focus their attention in order to utilize hypnosis. This is again dispelled by the knowledge that patients may already be in a hypnotic state by focusing in on their symptoms. Knowledge of hypnotic states will help the doctor to redirect the patient’s attention away from symptoms and onto other focal perspectives. This may be accomplished by the emergency room staff who have no specialized training in hypnosis simply through the words they use, i.e., “Relax, everything is going to be just fine.” With specialized training it seems that this capacity could be significantly enhanced. Supporting the above hypothesis, the literature suggests that altered states of awareness frequently 19 ISSN 0163-8343/86/$3.50
H.
Wain and D. G. Amen
accompany physical trauma [6]. Grinker and Speigel[7] and Beecher [8] all describe altered states of awareness with dissociative qualities (spontaneous hypnotic states) occurring in the traumatic combat environment. Although the emergency room is not a combat environment, the altered states of awareness associated with the trauma and the feelings of helplessness and anxiety manifested by patients may be similar. Suggesting that altered states accompany a physical trauma implies that these states have “trancelike” features. Characteristics of a trance state include a temporary suspension of critical judgment [9], a capacity for trance logic-making an incongruent idea or feeling congruent [lo]-and rapid assimilation of internal or external data [ll]. These characteristics can be utilized to help the patient gain greater control and understanding of the symptoms, and/or achieve the reduction of psychologic dissonance. The capacity to alter perception may be the necessary ingredient in helping individuals cope effectively with a traumatic event. Thus, self- or heterohypnosis may be the milieu to accomplish this task. Patients may use regression in the service of the ego in order to establish a therapeutic alliance [12]. The doctor is perceived as a facilitator in the reduction of the distress. Thus, patients become more open to suggestions and directions, especially when they perceive that the doctor can help decrease their discomfort. Not all patients are capable of achieving a deep level of hypnosis, but for the most part every patient can benefit by the resultant relaxation or at least the distraction caused by shifting their focal attention. The depth of hypnotic capacity may be based on a patient’s inherent “gift” [13] or talent [9]. Suggestions that can enhance the trance depend on patients’ personality styles, motivations, cultures, and so forth. The more knowledge a doctor has of his or her patients, the easier it will be to determine the type of suggestions given. Recognition of these naturally occurring altered states by the staff can help patients tap into their own resources to facilitate their own care and treatment. By directing patients to use their own capacity and shift their attention, the staff may increase the patient’s sense of control over anxiety and perceived discomfort. This may also facilitate more ego participation in treatment and give a greater share of responsibility to the patient. Two cases are presented that illustrate the recognition of an altered state, and how it can be utilized to facilitate treatment in the emergency room.
Case A
married female with a deep venous
of
emboli episode 2% years previous) presented to Walter Reed Army Center Room pain, swelling, and in right ankle spreading up the calf. The pain been increasing severity over several hours prior to entering the room. On physical examination, the patient’s right ankle and leg were erythematous, swollen, warm. She a positive sign (flexion of ankle producing pain), tenderness present from the to the A tentative diagnosis of deep thrombosis made and venogram was uled. This required an to be in foot, but this area swollen, no adequate veins could be The internist, and surgeon to start an in her foot success. about 1 hour enduring the failures of staff in the the patient very cried, pleaded that she not want more needles. also complained the excruciating pain in right leg. consult the service to help the patient, decrease her anxiety, and facilitate pain with ic intervention. During history taking it was disthat patient has previously to use hypnosis to help stop smoking. Though had been unsuccessful, the remembered as a relaxing Upon the patient focusing on exaggerating her pain sponse, that had been long since she entered the emergency room, and paying to some external stimuli (by to staff comments), was hypothesized that she probably entered a state without the positive results were The patient’s betrance phenomenoq including blocking peripheral critical judgment, time distortion, and focal concentration It was then to her field of concentration and capacity help calm her condition. the trance by shifting from the symptoms to simple eye fixation concentration followed strategy was where the was imagine herself near a mountain cabin surrounded snow. It that she walk a long time a snowy road, and that minute in the room would seem like hour in mountains. a desigplace she pictured her hand plunging into snow making fist around icy wetness, and a
Emergency Room Use of Hypnosis After achieving this in her hand she transferred the anesthesia to her right leg and related that the pain was gone. The results achieved to this point reinforced the perception that this patient was receptive to the utilization of her trance, and that an effective set for its use had been achieved. While in a trance she was directed to perceive more control over the blood vessels in her right foot. As she did this the radiologist was now able to find an adequate vein and successfully placed a 20-gauge needle in her foot. The lack of pain in her right leg persisted during the venogram and several hours thereafter. During the procedure she was relaxed and comfortable.
Case Two A lo-year-old boy was brought to the emergency room after being hit by a car. He was screaming, bleeding, and in obvious pain. The staff noted that he was belligerent and uncooperative. When it was recognized that the child was focusing in on his symptoms, he was asked if he would Like to go to the movies. He was so surprised and taken off guard that he momentarily stopped crying. With that signal he was able to close his eyes and enter a more focused trance. He was then given the suggestion that he could watch a movie on the imaginary screen in front of him. The ceremony of induction simply consisted of shifting the boy’s attention away from his pain and onto a movie. While he was watching the movie he began moving his hand from his thigh to his mouth. The significance of this motion was not immediately obvious. Later the boy explained that he usually eats popcorn while watching a movie. The surgeon was able to set the boy‘s fractured tibia and fib& and further evaluate the extent of his injuries with a cooperative patient.
Discussion The presented cases have several implications for treatment of patients who have experienced trauma and/or acute pain, especially in emergency type settings. Not unexpectedly, the examining medical staff is so involved with the presenting signs and symptoms that the psychologic states, unless overtly a problem, are often ignored. Specifically, recognizing the existence of spontaneous altered states of awareness often associated with trauma or acute pain facilitated the patients’ treatment and recovery. These cases also appear to highlight one of the cardinal features of an altered state-namely, suspension of critical judgment. While in the altered state the individual becomes more receptive to suggestions and directions, especially when the staff is perceived as a facilitator in reducing distress. The
patient’s motivation for reduction of distress and the need to regress [6] in order to receive appropriate treatment also contribute to a positive outcome. In emergency room settings the patient who is in acute distress has a strong need to effect a positive transference with the staff in order to accomplish the goal of receiving help. From a psychologic perspective this behavior can be seen as paradoxical: on one level it is a regressive pattern due to the trauma and feelings of helplessness that occur; however, as Gill and Brennan [12] suggest, regression in the service of the ego may facilitate treatment for the patient by helping him or her become more compliant and cooperative. Hypnotic intervention also facilitates a sense of control in patients by allowing them to become more involved in the treatment process. In particular, the first case appears to present support for the above hypothesis in that at a previous time the patient did not effectively utilize her trance to give up an unwanted habit. Perhaps this occurred because of lack of positive transference, low motivation, inadequate regression, and/or a previous lack of desire to suspend critical judgment. However, when conditions are right it may be easier for patients to utilize hypnotic states, especially when it appears to be important or necessary for them. Erickson emphasized this when he stated that hypnosis occurs spontaneously and the primary role of the hypnotherapist is to set the stage for hypnosis to occur [5]. In the second case, by shifting the patient’s awareness and recognizing that his anxious state and his preoccupation with crying was a trance state, the ambience was established which helped the patient dissociate and remove himself from the traumatic situation and find relief. The use of the hypnotic state facilitated an expeditious evaluation and treatment. In both cases, the attention focused by the patients on the pain set up a reciprocating cycle of anxiety where the patient became more frightened and the treating staff grew more frustrated. Clearly, the hypnotic redirection interrupted this cycle of escalation. In conclusion, it would appear that the use of spontaneous hypnotic-like states can be an outstanding adjunctive procedure for emergency room staff to utilize. One precautionary note is warranted for the higher hypnotic subject: in such a patient the necessary perception of pain may be blocked. It is, therefore, important to know the source of the pain before hypnotic pain relief is attempted. 21
H. J. Wain and D. G. Amen
References 1. Goldie L: Hypnosis in the casualty department. Br Med J 2:1340, 1956 2. Jamieson, RM: Hypnosis for minor surgical procedure. Br J Anaesth 35:269, 1963 3. Ewing D: Uses of hypnosis for the burn patient in the emergency room. Am J Clin Hypn 26(1):12-17,1983 4. Crasilneck HB, Hall JA: Clinical Hypnosis. New York, Grune & Stratton, 1975 5. Wain H: Film. Interview with M. Erickson on Hypnotic Technique, 1979 6. Strain J, Grossman S: Psychological Care of the Medically Ill. New York, Appleton-Century-Crofts, 1975 7. Grinker RR, Spiegel JP: Men Under Stress. New York, Irvington, 1945 8. Beecher HK: Relationship of significance of wound to pain experiences. JAMA 161:1609-1613, 1956
22
9. HiIgard EH Hilgard JR: Hypnosis in the relief of pain. Los Altos, CA, William Kaufmann, 1975 10. Orne MT: The nature of hypnosis: Artifact and essence. J Abnorm Sot Psycho1 58:277-299, 1959 11. Spiegel H, Spiegel D: Trance and Treatment: Clinical Uses of Hypnosis. New York, Basic Books, 1978 12. Gill MM, Brennan M: Hypnosis and Related States: Psychoanalytic Studies in Regression. New York, International Universities Press, 1959 13. Wain H: Clinical Hypnosis in Medicine. Chicago, Year Book, 1980
Direct reprint requests to: Harold J. Wain, Ph.D. Department of Psychiatry Walter Reed Army Medical Center Washington, DC 20037