Hypnosis and EM

Authors: Honeyia Minhas, Charlotte Davies / Editor: Liz Herrieven /  Codes: CC24, SLO1, SLO10, SLO11, SLO12, SLO2, SLO3, SLO4, SLO5, SLO6, SLO7, SLO8, SLO9 / Published: 04/05/2021

Conflict of Interest: Both authors use hypnosis in their work. CD is a unofficial council member of the British Society of Clinical and Academic Hypnosis.

If we told you we knew of a medical practice that’s been around since the 18th century, with a strong evidence base, that can be utilised by any emergency physician, for the majority of patients (and colleagues), that’s free to deliver, costing only time, you’d probably think we were deluded. We’re not… it’s hypnosis. 

Hypnosis is a useful adjunct for the patient, and the practitioner, in the emergency department. Considered by many an optional “complementary therapy”, we believe it’s a tool we all use unknowingly in our clinical work, and a small amount of training will help us to use it properly. As you start by using it as an adjunct, you will notice the patient’s heart rate slows, and that you need less medication.

What is Hypnosis?

Hypnosis is generally accepted to be the name given to utilising focused concentration to achieve a state where the mind is more susceptible to suggestion. This state can be induced in many ways including:

– by a patient who has suffered a severe shock – a trauma, or chest pain etc.
– by a paediatric patient engrossed in their colouring-in, bubbles or a story
– by a hypnotist performing a trance induction
– as part of a stage show – vilified for centuries, as mostly charlatans practicing in an unprincipled way
– as part of a “planned” therapy session delivered by a non-medical provider e.g. hypnotherapy.
– as part of a “planned” therapy session delivered by a psychiatrist or psychologist.
– as part of a “planned” session delivered by a medical professional.
– as part of an unplanned session delivered by a medical professional.

What training have people had?

Training for non-medical hypnotists is well regulated by the Complementary and Natural Healthcare Council and other regulatory bodies. Healthcare Professionals are regulated by professional bodies such as the General Medical Council or Health Care Professions Council (e.g. psychologists) and rely upon their prior professional training to make appropriate clinical decisions. If these clinicians act unprofessionally complaints can be raised against them with their professional body and they can face professional sanctions. As such, there is no minimum training needed for a Clinician to perform hypnosis.

It is recommended that clinicians performing hypnosis routinely as part of their work complete a formal training course, such as the BSCAH Foundation course or Staffordshire diploma, so they can fully understand hypnosis. BSCAH is currently the only society that offers training specifically for health care professionals, delivered by health care professionals. BSCH and LCCH offer excellent similar courses and there are many other courses available.

What’s the difference between hypnosis and…

The key difference between hypnosis and other techniques is effective deepening and utilisation of the trance state. Hypnosis utilises many different techniques including guided imagery and neuro-linguistic programming, NLP (Erikson pioneered both NLP and hypnosis (Pitkänen 2016)). There have always been practices that have use focused concentration to achieve a state where the mind is more susceptible to suggestion. Yoga, meditation, mindfulness, faith healing and prayer may all be utilising an individual’s capacity for hypnosis.

Adoption of Hypnosis in Emergency Medicine: indications and contraindications:

Nearly all patient groups in Emergency Medicine are suffering from pain and anxiety around their illness or injury. Often this pain leads to muscles being tensed thereby leading to more pain. Conversely this distressed state could make them more susceptible to hypnosis, leading to a larger than expected susceptible population in the acute setting compared to laboratory studies.

Do I need consent?

Consent is important and controversial. Hypnosis could be considered a treatment, with side effects like the expression and release of previously repressed emotions (abreactions) and the possible creation of false memories or multiple personalities (Braun 1984). One could argue the patient is already in a trance state, and hypnosis merely gives us the training to utilise the altered state to make therapeutic suggestions.

There was a case where a medically qualified homeopath was dismissed by the GMC for failure to take informed consent (Ernst 2009).  If we are to obtain ethics committee approval for research into the effectiveness of clinical hypnosis in the clinical arena, then consent must be taken, and this is explored more fully on a BSCAH blog here, and by an anaesthetist who uses hypnosis here.

Personal ED examples

  • Dislocated shoulder
    After two failed attempts at reduction by the usual methods the patient was asked if he would like me to help relax his shoulder, avoiding the need for further drugs and to relieve his pain. His shoulder was then re-located.
  • Headache – resistant to analgesia
    After a full examination ruling out red flags, the patient was asked to close their eyes and find their pain gauge in their head – a bit like the petrol gauge in the car. They were highly susceptible and self induced a trance without any further comment. The dial was pointing towards a 7. They were asked to kick it to an 8, and then down to the number that was right for them. They kicked it to a four and were amazed.
  • Chronic pain
    A trance was induced, and suggestions made to “cool” the burning pain.
  • Induced stridor
    A patient attended with a pronounced stridor and gave a history of recent intubation for anaphylaxis. After nebulised and IM adrenaline, they improved rapidly. Notes were found showing that during the last ICU admission, no laryngeal oedema had been identified. Shortly after that, the patient developed stridor again. A suggestion was given merely that the patient had everything they needed to treat the stridor already and that their symptoms would soon resolve. They disappeared quickly.
  • The shaking trauma patient
    After primary survey, we checked they weren’t cold, and kept them warm. A nice positive suggestion was given (“the worst is over, you are in the right place, with a team of people who are trained to help your body heal itself”), and then we started doing some box breathing with them. We suggested they were safe, and that the shaking was going to stop NOW and that they are now in control, along with the specialist team trained to help them. Patients stop shaking as if by magic and the breathing helps team members too, as they reflexly join in.

Other examples

There is good evidence for irritable bowel syndrome (Agrawal 2006), headaches in children (Kohen 2007), abdominal pain (Anbar 2001), asthma symptoms (Zobeiri 2009), needle phobia (Usman 2006) and autoimmune disease (Atousa 2016, Wentz 2013). It’s also useful as an adjuvant to sedation for procedures in children (Butler 2005) and adults and some evidence from small trials that positive suggestion reduces length of stay in ITU. There’s evidence for lots of other things too – but we started here! 

How does this save money?

It’s obvious that patients who have hypnosis for shoulder relocation rather than procedural sedation spend less time in the department, have less drugs and do not need a resuscitation bay, repeated nursing observation or escort to x-ray post procedure. This is better for patient safety in addition to the cost savings. In our current crowded departments, it also means that patients are not left waiting for a Resus bay or nursing staff and can be rapidly treated and discharged.

Careful use of language can also help prevent reattendance and further harm. “See you later” for example implies “I think you’ll be back, as my treatment is unlikely to work”. “You have to learn to live with the pain” implies that the only way to be pain free is to not live aka die.

Who shouldn’t we hypnotise?

  • Patients with schizophrenia should not undergo hypnosis.
  • In learning disability, dementia or any gross impairment of mental function, hypnosis is not possible due to the patient’s inability to understand and process words (Huguet 2009).

How do I start?

You probably already use hypnosis without realising it. A few simple steps will improve your hypnotic skills, and your patient’s experience, very quickly.

  • Give positive, calming messages like “the worst is over, you are in the right place, with a team of people who are trained to help your body heal itself”. It doesn’t give false hope, but is reassuring and effective, and reminds the subconscious that it’s the body needing to do the healing. A short study (unpublished) -the Kansas study – proved that just saying something like this reduced mortality in pre-hospital trauma. 
  • Images are something we all think we’re good at using in ED. We say “imagine you’re on a beach” as we sedate patients. We can make this better by using all of the five senses, and using the patient’s own experiences. “Smell the salt”, “Feel the water washing away the discomfort”, “Taste the seaweed”. Remember everyone will enjoy different imagery.
  • Use only positive phrasing: “you’re feeling clear headed” is better than “you’re not feeling dizzy any more”.
  • Give people a positive suggestion, using a double bind if possible. “Let’s find out how much comfort this procedure will give you” – saying this means it will give some – whether that’s lots or not!
  • Setting expectation is equally important: “I expect that after we’ve relocated your shoulder, you’ll be home for dinner”, or even simply “I expect your blood tests will be normal, and we’ll have you home before your car parking ticket expires”.
  • Directives are useful for most patients in the Emergency Department. Direct directives like “stop that bleeding now” can work, but indirect are often more successful. Next time you see a bleeding patient, say “when your arm stops bleeding in just a few moments, I’d like you to hold this cold pack on your knee”. Tell us how much this worked!  Alternatively, you can try “when your paracetamol starts working in a few moments, I’d like you to cross your legs”.
  • Avoid talking about pain, and instead talk about increasing comfort. Instead of asking for a pain score on a scale of 1- 10, why not ask for a comfort score?
  • Avoid introducing any sort of pain (nocebo) – don’t say “sharp scratch”. Say “when I put this tourniquet on, most people feel that their arm goes numb, then I can put in a cannula to give you fluid and medication which will make you feel better”.
  • Box breathing is good for anxious patients.
  • 7/11 breathing good for patients in pain. It can be used with entonox, then progress further to guided imagery or better still to the patient’s own special place, using all the senses
  • Slow down your speech and use pacing.

In conclusion

In the future clinical hypnosis will be a tool in the armamentarium of all Emergency Physicians (Iserson 2014). It is likely that up to one half of those attending ED have used alternative therapies in the past (Gulla 2000) and so will be amenable to using hypnosis.

Almost all processes in the body are electro-biological and it is only modern medicine that has created an artificial separation between the workings of the mind and body.  The brain controls all the functions of the body. Hypnosis using the brain to control body functions is a physiological manipulation, achieved by the patient through focused concentration. The art is in the skill of the clinician in facilitating this process and adding post-hypnotic suggestions with patient consent.

We have a duty not only to find the evidence, but to make sure it is presented to the public in a way that can lead to informed consent. Modern medicine is now shedding its paternalistic attitudes in favour of clinician and patient working together to achieve relief of symptoms. This means the time is now right for hypnosis to be accepted, as an important part of mainstream medicine.

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References and Further Reading

3 Comments

  1. Dr Askari Hasan Syed Reza says:

    Interesting read, will give it a try

  2. Dr Shafi Ejas Tharimoopantavida says:

    Completely agree with the statement that modern medicine has created an artificial separation between the workings of the mind and body.

  3. Dr Noorul Shihama Aboobucker says:

    Absolutely love this. I’ve always felt holistic treatment plan included healthy dose of reassurance and affirming constantly ‘you’ll feel much better soon’,’I’m going to give you strong antibiotics ‘, offering timely analgesia, anti-emetic,food and drink to the relevant groups accompanied by the assurance that they will shortly feel ‘much more comfortable ‘..these are all extremely important ‘treatments’. In 2nd year of med school I contracted pneumonia with a terrible pleuritic chest pain one night which ended in my being taken to Ed by housemates. I remember feeling afraid and very vulnerable and how kind and gentle everyone was to me. I still remember how I felt after all those years ago. So whenever I see patients, even those I discharge from triage, I do most of the above. It doesn’t take long, and it leaves both me and the patient comforted. So I love my job and work is a happy place(inspite of recent 10hour +waits).

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