5: Suggestion & Hypnosis

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:

• 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.

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

• 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.

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

• 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:

When the clinician becomes aware of such a circular pattern, it is helpful to ask “What is the patient anticipating I will say or do next?” If at this point the clinician can do something unpredictable, the result will be temporary confusion, which can be used to shift the patient’s trance in a more resourceful direction. The unpredictable action might be the “Columbo technique” (named for the television detective). In this technique, the physician suddenly and dramatically remembers some minor personal problem (e.g., forgetting a spouse’s birthday gift), asks the patient’s forgiveness for the distraction, and requests the patient’s aid (e.g., in suggesting a store to purchase the gift). The momentary confusion that ensues (whether or not the patient is able to offer any help) breaks the previous trance and allows the formation of a new one. This temporary role reversal is only one example of the use of unpredictable behavior to induce confusion and interrupt the pattern, thus allowing greater rapport and more effective communication.

Mining For Gold

This phrase refers to a technique that shifts the focus of discussion away from distress and toward an exploration of the patient’s resources. Useful at any time, this strategy is especially helpful when the tone of meetings with the patient is persistently hopeless, when the patient appears to legitimize the visit by focusing exclusively on somatic complaints, or when the patient’s continuing complaints make the clinician feel ineffective or frustrated. In “mining for gold,” the physician may inquire about things the patient is proud of—past successes, hobbies, travels, relationships, and obstacles overcome. The clinician observes when the patient becomes animated or otherwise shifts out of the negative trance and notes the topic in the chart, returning to this topic briefly in subsequent sessions. Sometimes the change in the patient’s state leads to a change in behavior, emotions, or outlook that had been precluded by the “what’s wrong with me” trance. Similarly, the clinician’s feeling about the patient may change; renewed interest and curiosity about the patient’s personal resources may transform a previously difficult relationship.

Eliciting Target States

Here the clinician engages the patient in thinking and talking about a future well-state, asking the patient to describe what things will be like when the medical problem is resolved or no longer interferes with the patient’s life. It is important that the patient be able not only to name the target state (“I want to feel good again” or “I want to be free of pain”) but also generate visual, auditory, and kinesthetic images of activities associated with that state. This discussion helps physician and patient establish criteria for knowing when the problem is resolved; it also engages the patient in imagining a future well-state unrelated to and incompatible with present suffering. This trance shift may be accompanied by positive physiologic changes and increased animation and hope.

The doctor and patient proceeded to discuss various rivers they had fished. The patient had momentarily shifted her mental imagery and her kinesthetic state away from the pain trance toward future health. This created a context in which she could construct a full sensory image of that future well-state that was incompatible with the pain behaviors she had displayed. In addition, her image of the doctor, previously associated exclusively with her pain awareness, became, in subsequent visits, associated with images of recovery and hope. The doctor’s impression of the patient also changed, so that he looked forward to their meetings instead of dreading them.

Hypnosis can be an effective therapeutic option for a variety of problems. The neurophysiologic processes by which hypnosis can effect change in such a wide range of complaints are still a subject of exploration. One current theory uses information processing as a heuristic model, with the body, brain, cells, and organs regarded as an information-processing system. In the brain, semantic information (encoded in language) is transduced into molecular information, which uses neurochemical and neurohormonal channels to cause changes in diverse organ systems.

Recent brain imaging studies, employing PET and MRI, have shown that the hypnotic state is related to a widespread set of cortical areas involving the occipital, parietal, precentral, premotor, and ventrolateral prefrontal and anterior cingulate cortices. The anti-nociceptive effects of hypnosis correlated with activity in the mid-cingulate cortex.

In deciding whether to use hypnotic procedures with patients (or to refer them to a hypnotherapist), it is important to consider patients’ beliefs about hypnosis, their openness to other therapeutic modalities, and their locus of control. Some religious groups (e.g., Jehovah’s Witnesses) forbid use of hypnosis, and some patients may fear that they will surrender control to a powerful “other,” who can then control their minds. Brief education by the physician about the nature of hypnosis and its usefulness as a tool to help patients increase control over their symptoms may correct these beliefs. If the patients are not convinced, they are probably not good candidates for hypnosis.

Furthermore, some patients may resist hypnosis because they infer that the physician thinks the problem “is all in their head.” For such patients, anything other than a biomedical intervention may be viewed with suspicion. Assuring them that hypnosis is simply part of a comprehensive medical management of their problem may increase their openness.

Locus of control—internal or external—is also a significant factor. Patients with an internal locus of control believe that they can influence many of life’s rewards or punishments, and they may be better candidates for hypnosis than those with an external locus of control. This latter group may respond better to biofeedback, which relies on equipment that is external to the patient.

In the following brief descriptions of clinical situations, hypnosis can be considered as an adjunctive or, in some cases, primary treatment.

Relaxation & Stress Management

One of the physiologic effects of therapeutic hypnosis is stimulation of the parasympathetic nervous system (see Chapter 34, Figure 34-2). Several stress-related conditions have been attributed to hyperstimulation of the sympathetic nervous system, which is modulated by the parasympathetic nervous system in a dynamic interrelationship. Sympathetic activation can be part of the fight-or-flight response to perceived threats. Given the plethora of real or perceived threats in today’s world, stress-related illnesses may be a common presentation of patients’ habitual levels of sympathetic arousal (see Chapter 34). Sympathetic responses include tachycardia, muscle tension, adrenaline release, pupil dilation, inhibited intestinal mobility, shortness of breath, and sweating. This autonomic activation is downregulated during hypnosis, and with parasympathetic stimulation the individual becomes relaxed, leading to energy restoration, conservation, and renewal.

Anxiety

Hypnosis can be quite effective as a primary or adjunctive treatment for anxiety. Patients with an internal locus of control will find self-hypnosis an especially satisfying alternative to anxiolytic medication. When introducing this as an alternative treatment, the physician can say:

The clinician can devote 15–20 minutes to inducing a trance, during which the patient is led to form a full sensory recall of an experience in which he or she felt deeply relaxed. In this process, it is important that clinicians avoid imposing their own images of relaxation, instead facilitating the patient’s exploration by means of non-specific suggestions. These suggestions can lead the patient through each sensory modality (e.g., vision) and submodality (e.g., color, brightness, and quality of reflected light) to allow the patient to become absorbed in a full sensory representation of an actual experience associated with relaxation. If the session is audio recorded, patients can take the recording home for daily practice, thereby learning to self-induce trances and regulate their own levels of autonomic nervous system arousal. The extra time taken for the hypnotic induction can often be compensated by a decrease in time spent on phone calls from anxious patients, since the audio recording allows the patient to access the clinician’s voice and suggestions whenever needed.

Pain Management

Because cortical elaboration of nociception is a component of pain, hypnosis can be used to shift the focus of attention away from pain sensations. In some surgical or dental procedures, hypnosis can be used as an adjunct to, or instead of, anesthesia. In addition, patients with chronic pain can be taught to relax the muscles they tense around areas of pain as part of their “guarding” or bracing efforts. This hypnotic relaxation reduces the component of the pain that is due to muscle contraction. Patients with migraine headaches can be taught to dilate blood vessels in their hands and feet through hand- and foot-warming imagery—sitting in front of a campfire, for example. In the early prodromal stage of migraine, this procedure can sometimes reverse the progress of the headache, possibly by increasing peripheral vasodilation and allowing relaxation of blood vessels in the head. Temporomandibular disorders, pain from repetitive strain injuries, and tension headaches have also been treated effectively with hypnosis. For pain relief during childbirth, a meta-analysis showed that hypnosis reduces analgesia requirements in labor. In one study, older female patients with osteoarthritis experienced significant increase in their health-related quality of life following a 12-week treatment using guided imagery with relaxation. Brain imaging studies have suggested that in hypnosis-induced analgesia prefrontal and anterior cingulate cortices form important structures in a descending pathway that modulates incoming nociceptive input.

Hospice & Palliative Care

Hypnosis has been used adjunctively with other therapies to help patients with chronic and terminal illnesses. Relaxation, overcoming insomnia, relief from pain and dyspnea, and enhancing relationships with relatives and other support persons are some of the benefits of this modality in the hospice setting.

Cancer

There is evidence that hypnosis is effective in alleviating the chronic pain associated with cancer. In addition, hypnosis can control symptoms such as nausea, anticipatory emesis, and learned food aversion; it is also helpful in managing anxiety and other emotions associated with cancer. Hypnosis may also be effective in reducing hot flashes in breast cancer survivors.

Skin Problems

Certain dermatological conditions, such as warts and alopecia, have been treated successfully with hypnosis. While in trance, patients are given the suggestion to experience tingling or flushing in the affected area. Warts may respond to these suggestions by shrinking in size or—in some cases—disappearing. Burns have also responded to hypnotherapeutic suggestion, both in lessening the degree of the burn and in controlling pain. Other dermatoses for which therapeutic hypnosis may be helpful are acne, atopic dermatitis, herpes simplex, hyperhidrosis, pruritus, psoriasis, and rosacea.

Immune System Function

Hypnosis has been used successfully to treat genital herpes, both in reducing the number of flare-ups and in decreasing the duration of flare-ups. Hypnosis has been shown to decrease blood levels of herpes simplex virus and to increase T-cell effectiveness, NK-cell activity, secretory immunoglobulin A (IgA), and neutrophil adherence. A meta-analysis has shown that hypnosis can reliably alter immune system function. Hypnosis incorporating immune suggestions showed a positive influence on total salivary IgA concentration and neutrophil adherence, along with a modest suppression of intermediate-type hypersensitivity erythema. These effects were mediated through relaxation. Some studies have shown differential delayed skin sensitivity reactions on the right and left arm of subjects depending on which arm was suggested under hypnosis to show no changes.

Respiratory Problems

Patients with asthma have been taught to use self-hypnosis to expand airways and minimize stress-induced attacks, as well as reduce anticipatory anxiety about having an attack. Some patients are able to decrease their bronchodilator use with daily self-hypnosis. Weaning patients off a ventilator in the intensive care unit has been facilitated by the use of hypnosis.

Hypertension

Hypnosis for relaxation can be a useful adjunct to other therapies for hypertension. Individual hypnosis treatments for eight sessions was shown to reduce mild essential hypertension immediately posttreatment and at one-year follow-up.

Gastrointestinal Problems

Problems such as irritable bowel syndrome (IBS), are amenable to adjunctive treatment with hypnosis. The primary approach is to reduce anxiety, induce relaxation, incorporate abdominal breathing, and suggest warmth in the abdomen and proper functioning in the bowels. Preoperative suggestions have been used successfully to promote an early return of gastrointestinal motility following intraabdominal surgery, leading to shorter hospital stays.

Sleep Problems

Sleep-onset insomnia—associated with anxiety, obsessive worrying, or sympathetic arousal conditioned to the cue of getting into bed—can be treated with hypnotherapy. By making an audio recording of an induction in which the patient is led into a relaxed state and invited to form positive associations with lying in bed before falling asleep, the clinician can give the patient a new nightly ritual that will enhance relaxation. A relaxing trance can also help the patient return to sleep more quickly after waking up.

Pediatrics

Pediatricians and family physicians skilled in hypnosis find it a useful adjunct in the treatment of children. Children are often amenable to the use of imagination and story-telling as trance induction techniques. Some of the conditions that respond well to primary or adjunctive use of hypnosis include nocturnal enuresis, night terrors, functional abdominal pain, surgical and other office procedures, chronic dyspnea, and symptoms related to cystic fibrosis. Hypnosis was shown to be effective in reducing distress and the duration of an invasive diagnostic test in children with urinary tract abnormalities. In a review of studies on psychological interventions to reduce needle-related procedural pain in children, hypnosis showed the most promise in reducing self-reported pain.

Pregnancy

Hypnosis has been used successfully to reduce symptoms of hyperemesis gravidarum. Habitual aborters have been helped to relieve anticipatory anxiety and lessen the psychogenic risks of spontaneous abortion when organic etiologies have been ruled out.

Preparing for Surgical and Other Difficult Procedures

Patient expectations appear to play a role in the degree of pain and distress felt with surgery and procedures such as colonoscopy. Hypnosis has been used to anesthetize patients who are allergic to anesthetic drugs and to decrease the use of postoperative pain medication. Usually hypnotic anesthesia requires a deep level of trance, which calls for advanced skill on the part of the hypnotist along with the patient’s ability to be hypnotized. Using the naturally occurring trance of patients anticipating surgery, physicians can make simple suggestions to enhance surgical wound healing and reduce postoperative pain. Referring to pain as “discomfort” or an “unusual sensation,” the physician can offer the patient a statement such as:

Presurgical hypnosis can also decrease disorientation and confusion following surgery.

Habit Change

For patients in the preparation/determination or action stage of readiness to stop smoking or to change eating behavior (Chapter 19), hypnosis can be a useful ally. The ritual pattern of patient behavior around smoking can be viewed as a trance phenomenon. There is an automatic, other-than-conscious sequence of kinesthetic (tactile, visceral, emotional, and postural) awareness and behavior usually set in motion by contextual cues (e.g., finishing a meal, drinking coffee or alcohol, and talking on the telephone). Hypnosis can be described to patients in the preparation/determination stage as a useful tool “to help you come out of the smoker’s trance and into a more satisfying, health-promoting trance.” The clinician can call patients’ attention to the automatic behavioral sequence while taking a smoking history (Table 5-1). Asking patients to describe in detail which hand they use to pick up the cigarette pack, take the cigarette out of the pack, hold the lighter or strike the match, and so on, will call their attention to the automatic, trance-like nature of their behavior. After inducing a hypnotic trance, the clinician can suggest that patients visualize in slow motion the entire sequence prior to lighting each cigarette. When the previously automatic behavior is raised to the level of awareness, patients are able to break the previous pattern and approach each episode of smoking with increased deliberation. Once patients are in the action stage of cessation, the parasympathetic effects of self-hypnosis can be used as an alternative stress-reducing activity.

Hypnosis, when combined with cognitive-behavioral therapy, has been shown to be effective in promoting weight loss.

With proper training, patients who respond well to hypnotic trances can learn to self-induce hypnosis to achieve both relaxation and specific therapeutic effects. A useful transition to confidence in self-hypnosis is the patient’s regular use of a recorded hypnotic induction made by the clinician (primary care provider or referral specialist) in the office, thereby extending the clinician’s presence into the patient’s milieu. As the patient gains experience going into a therapeutic trance by listening to the tape, the clinician can teach the patient one of several self-induction protocols, such as the one shown in Table 5-2 (this can also serve as a handout). Some patients are able to develop their skill at self-hypnosis and retain it as a life-long health resource.

One use of a self-induced trance is to enhance one’s inner awareness or state of mind by accessing somatic memories of positive resource states. This can be useful for either patient or clinician when preparing for a stressful encounter. The method (Table 5-3) is based on the observation that various sensory cues (e.g., music or smell) can trigger associated memories of feeling states. By choosing a desired resource state, constructing a full sensory memory in which that state was felt, then anchoring that feeling state to a tactile cue, the desired state can be reactivated in the new situation. Clinicians might find this especially helpful in shifting toward a positive trance before a patient encounter.

The various medical applications of hypnosis described in the above sections require one or more sessions with a trained hypnotherapist. Skilled hypnotherapists spend time with patients prior to hypnosis discussing their understanding and expectations of the hypnotic experience and addressing their anxieties and misconceptions. The aim is to establish rapport and raise positive expectations in the patient’s mind. When this preliminary discussion is completed, the clinician proceeds to the induction of a trance, using one of several approaches. (The specifics of these inductions are too numerous and complex to be discussed in detail in this chapter, and special training is required to use them appropriately and with flexibility to the patient’s responses.) Once the patient exhibits signs of a trance, the clinician proceeds to the utilization of that trance for the specific benefit desired. This involves offering suggestions for the patient to imagine changes in somatic sensations, emotions, or future behaviors. The clinician then concludes by alerting and reorienting the patient to the external surroundings. After the procedure, the hypnotherapist can discuss the patient’s subjective experiences and answer questions.

As noted earlier, some clinicians become trained in hypnosis (see final section) so they can integrate this treatment into their medical practices. Others may choose to refer patients to a specialist (psychiatrist, psychologist, clinical social worker, or psychiatric nurse practitioner) trained in hypnosis and familiar with its medical applications. To maximize the therapeutic outcome, it is essential that the referring practitioner communicate with the specialist—before the visit—about the nature of the medical problem, the desired clinical outcome, and the patient’s expectations about treatment. It is also important to prepare the patient by explaining the nature of therapeutic hypnosis and by explaining that its intent is to increase the patient’s control over symptoms and their impact.

Hypnosis has a long tradition as a healing art and as adjunctive treatment for many medical conditions and primary or preferred treatment for some conditions. Clinicians can refer patients for hypnotherapeutic treatment to licensed psychologists, clinical social workers, nurse practitioners, or physicians who have formal training in hypnosis through an accredited organization such as the American Society of Clinical Hypnosis or the Milton Erickson Foundation. Whether or not formally trained in hypnosis, the astute clinician can utilize the naturally occurring trance states frequently found in patients in the medical setting, including the primary care encounter and presurgical consultations, to reduce fear through the reframing of symptoms manifest in common presentations such as chronic nonmalignant pain or anxiety disorders. In these naturalistic trances, careful attention to language is paramount in using suggestion. Avoiding the unwitting use of negative suggestions and maximizing positive expectations for a future experience of healthy functioning can mobilize mind–body healing potentials inherent in the patient.

Clinicians who are interested in developing their own skills in hypnosis are encouraged to receive formal training from an accredited training program or receive supervision from a licensed health professional with formal training in hypnosis. Several of the organizations listed here provide accredited training:

• The American Society of Clinical Hypnosis (ASCH) http://www.asch.net (Accessed July 2013).

• The Society of Psychological Hypnosis http://psychologicalhypnosis.com/ (Accessed July 2013).

• The Milton H. Erickson Foundation http://www.erickson-foundation.org (Accessed July 2013).

• Society for Clinical and Experimental Hypnosis http://www.sceh.us/ (Accessed July 2013).

• Societies of Hypnosis http://www.societiesofhypnosis.com/ (Accessed July 2013).

• International Society of Hypnosis http://www.ish-hypnosis.org/ (Accessed July 2013).