The history of hypnosis as a healing art dates back millennia. Its modern expression as a medical treatment emerged in the eighteenth century, with proponents such as Franz Anton Mesmer, an Austrian physician who practiced in Vienna and Paris in the late 1700s. Mesmer, from whose name the term “mesmerize” was derived, believed that illness was caused by an imbalance of magnetic fluids in the body, which could be corrected by the “personal magnetism” of the hypnotist. Discredited in 1784 by a French royal commission appointed to investigate Mesmer’s techniques and chaired by Benjamin Franklin, hypnosis has since regained respectability. Franklin himself wrote an opinion that the patient’s beliefs could influence bodily effects. The Scottish surgeon James Braid in 1843 coined the term “hypnosis,” from the Greek word for “sleep,” and espoused its use as a medical treatment. In the 1930s, Clark Hull and his student Milton Erickson conducted early research on hypnosis. Erickson went on to become a pivotal practitioner, researcher, and teacher of a generation of hypnotherapists. In the 1950s, the British and American Medical Associations recommended incorporating hypnosis into the medical curriculum. The American Psychological Association in 1960 endorsed hypnosis as a branch of psychology. In 1995, the US National Institutes of Health issued a consensus statement with evidence supporting the use of hypnosis for the alleviation of chronic pain.

Hypnosis appears to be a special manifestation of the mind–body system’s ability to process information by transforming it from a semantic to a somatic modality. Its therapeutic effectiveness is supported by both research and clinical experience. Today, hypnosis is widely used to treat a variety of conditions—pain, airway restriction, gastrointestinal disorders, skin lesions, burns, and anxiety—as well as to prepare patients for surgical procedures and to facilitate behavior change (such as smoking cessation or weight loss).

Trance and suggestion occur naturally throughout human experience and are a function of how the mind works. Becoming absorbed in a novel and being unaware of surrounding sounds, or daydreaming while driving and not remembering the last few miles, are common experiences that illustrate the ubiquitous nature of trance. Responding to subliminal messages in advertising by purchasing a product represents a familiar reaction to suggestions made in a carefully crafted trance. These common experiences of trance and suggestion also occur with patients in health care.

This chapter will describe the therapeutic use of suggestion within the context of the patient’s naturally occurring trance states and in the course of clinician–patient discourse. This application can be used routinely by clinicians in all patient encounters. We will also describe the role of therapeutic hypnosis, usually provided by a specialist trained in this procedure, in treating a variety of medical conditions.

Derived from a Greek word meaning “sleep,” hypnosis is, in fact, a therapeutic procedure that requires active cooperation on the part of the patient. The following definitions, used in this chapter, describe the states and processes involved:

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  Trance: A state of focused attention, in which a person becomes uncritically absorbed in some phenomenon and defocused on other aspects of reality. Trance states can be positive or negative.

  
  
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  Suggestion: A communication that occurs in trance, with special power to elicit a particular attentional, emotional, cognitive, or behavioral sequence of events.

  
  
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  Hypnosis: A communicative interaction that elicits a trance in which other-than-conscious processes effect therapeutic changes in the subject’s mind–body system. Hypnosis can be either other- or self-induced.

  
  
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  Induction: The process by which a trance is initiated. This can occur naturally or as the first phase of hypnosis.

  
  
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  Utilization: The therapeutic use of trance to achieve desired outcomes and the phase of hypnosis following induction in which this occurs.

Both patient and clinician may undergo a mutual trance induction that, depending on the self-awareness of the participants, can leave either more susceptible to suggestion by the other. This state is neither pathological nor unwarranted, but part of the natural pattern of human awareness in this environment. Generally, because of the power imbalance inherent in help-seeking situations, the patient is more vulnerable to suggestion. Being cognizant of trance and suggestion can give clinicians greater flexibility and influence in leading their patients to more positive outcomes.

Many patients waiting in an examining room are in a trance that has developed through a series of events that started with the onset of the symptom. The patient’s awareness of this symptom then leads to an internal search for meaning. Prior beliefs, personal experience, or prompting of family or friends may lead the patient to attribute a particular meaning to the symptom. This attribution constitutes the initial suggestion, perhaps solidifying into a concern, “I wonder if that can be something serious.” This preoccupation, in turn, increases awareness of the sensation and further restricts the patient’s attentional field. Increased absorption in the symptom and decreased awareness of other sensations are the essence of the trance.

The decision to see the doctor further deepens the trance, and this process continues as the patient, waiting first in the doctor’s office and then in the examining room, rehearses how to describe the symptom and discuss it with the doctor. As noted earlier, this process of trance induction around a symptom is not pathological, but is part of the natural unfolding of awareness surrounding a medical visit.

By the time the physician enters the examining room, the patient is in a trance and consequently susceptible to suggestion. Whatever the clinician says or does not say in the course of the interview can, because of the power generated by the patient’s suggestibility, further develop the patient’s trance, shift its focus, augment or diminish the patient’s somatic awareness, and influence ongoing patient emotions, cognitions, and behaviors surrounding the symptom.

The clinician is also susceptible to trance. Patients can sometimes unwittingly induce a trance in the clinician through a combination of verbal and non-verbal techniques such as the initial verbalization of the problem, hand gestures, grimacing, and changes in voice tone and tempo. All these contribute to focusing the attention of the clinician on the problem or on what hurts. This narrowing of the physician’s focus (even while a differential diagnosis is being developed) may preclude other internal images, such as the future good health of the patient or a positive doctor–patient relationship, that could otherwise give rise to helpful discussions. A too-rapid response by the clinician results in premature closure on the nature of the patient’s problem and solidifies the clinician’s initial trance. However, attending to and eliciting the whole story from the patient (see Chapters 1 and 2) keeps that focus fluid. Sometimes patients induce a recurrent negative trance in the provider, leading to antagonism or aversion for the patient or to feelings of powerlessness in the face of the patient’s problem (Chapter 4).

This case illustrates several components of trance in both patient and doctor. The patient’s recurring chest pain induces a trance in which her attention becomes narrowly focused on her suffering and disability. Anticipation of a visit to her doctor further restricts her focus, and her rehearsal of how she can convince the doctor of how bad it really is further heightens the trance. She has learned to associate the image of her doctor’s face and the sound of his voice with frustrating discussions about the intractable nature of her pain. Her continued presence at these appointments corresponds with a belief that the power to alleviate her suffering lies outside of herself. If only this doctor knew everything there was to know about her pain, he would be able to help. This expectation keeps her in a suggestible state.

The doctor, too, has shifted into a negative trance by the time he enters the examining room. The induction begins as he anticipates seeing the patient and continues as his accompanying somatic responses shift him from his habitual openness to the field of possibilities to absorption in his own powerlessness to effect change. His trance is deepened by the patient’s non-verbal and verbal communications about her continuing pain. The doctor becomes more vulnerable to suggestion, and the patient’s plea to do something for her creates the expectation in him that he must. This expectation, in the face of the patient’s persistent pain, deepens his sense of powerlessness.

Therapeutic Uses of Trance & Suggestion in the Medical Encounter

The clinician can use the patient’s trance to make specific suggestions that enhance therapeutic outcomes. The language used in medical encounters can lead to unintended patient beliefs and behaviors that influence both illness and healing. For example, the prediction of continued problems for a patient with a weak knee—“You’ll probably always be bothered by some pain in that joint”—in the first postsurgical visit has an enhanced power to influence negatively the patient’s future awareness of and belief in the knee’s integrity. The warning becomes a self-fulfilling prophecy as the patient unwittingly guards the knee and develops a compensatory gait. A positive suggestion—“Whatever residual discomfort you feel, in time you will notice more freedom of motion and activity”—can create expectations that are more likely to enhance healing and the resumption of activity.

A more subtle strategy is the use of positive images and avoidance of negative modifiers. Consider the following statement to a patient after surgery:

In the context of discussing sleep hygiene with an insomniac patient, the well-intended suggestion, “When you go to bed, try not to worry about staying awake,” might contain several unintended messages leading to disturbed sleep. The word “try” connotes effort; it becomes associated with “bed;” the negative modifier “not” is deleted by the unconscious mind, leaving the additional message to “worry about staying awake.” The suggestion could be positively restated:

The implied suggestion is that you will begin to feel better, and when you do, positive changes will already have occurred.

The clinician can also reframe uncomfortable side effects of some medications as an indicator of their potency, thus enhancing the placebo effect. In prescribing an antidepressant, a physician could disclose the anticipated side effects:

The message contains two positive associations with the side effects: adjustment to the medication and movement toward the desired outcome.

The clinician who appreciates the trance-like nature of the medical encounter can use the patient’s openness to suggestion not only to present positive suggestions and avoid those that are negative but also to promote healing. This is true for both the clinician’s own trance and that of the patient.

Shifting from a Negative Trance to a Positive Trance

Clinicians have several options to shift a dysfunctional trance in a more open direction.

Changing Body Position

This works directly with the somatic configuration that maintains a trance state. A depressed patient may have a frozen, slumped posture, downcast eyes, and shallow breathing. This frozen posture amplifies negative images and self-statements and inhibits any focus on possibilities for change. The physician can comment on this posture and suggest modifications, such as raising the eyes while walking outside to observe cloud formations, birds, or airplanes, and shifting breathing to the abdomen. The clinician might also suggest that the patient occasionally put on some music and dance—even alone—at home. Clinicians, too, can use a shift of physical position to break an unwanted trance in themselves. A physician who feels ineffectual in the face of an inordinately blaming or demanding patient and reacts physically with chest tightness and throat constriction can stand up, say “Excuse me while I adjust the light,” walk to the window, adjust the blinds or shade, move the chair to a slightly different location, and then sit down. During this activity, the physician can shift breathing to the abdomen and prepare to open a new line of discourse with the patient:

Confusion

Confusion can be helpful in breaking a pattern that locks patient and clinician into repeatedly acting out a script whose negative outcome both can predict. The following caricature illustrates a common script: