Medical Hypnosis in the Hospital
by Gérard V. Sunnen, M.D.
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Hypnosis has many applications for relieving
distress in hospitalized patients. Gérard
V. Sunnen, M.D., a psychiatrist and hypnotherapist,
describes the ways in which hypnotic techniques
can help patients undergo medical procedures,
surgery, and rehabilitation therapy and cope
with life-threatening illness. Sunnen cites
evidence from the research literature of the
benefits of hypnosis for hospitalized patients
with medical conditions and presents several
case illustrations.--Editor, Journal of the
Institute for the Advancement of Health
Hospitalization, even with all available medical
technology, remains a trying experience. The same
concerns, apprehensions, and fears exist today as
they did centuries ago in the face of dangers to well-being
and sometimes to life itself. The psychological well-being
of hospitalized patients is, therefore, not only for
humane considerations but also for reasons connected
to health and recovery: patients may do better when
undergoing procedures, recovering from operations,
or surmounting the side effects of treatments if they
are relaxed, rested, and feeling hopeful.
Hypnosis is a process by which an individual is guided
from his or her usual state of consciousness to a
condition that is marked by psychological and physical
relaxation; altered perceptions such as the slowing
down of time or a change in one's body image; and
a shift from analytic to synesthetic thinking, that
is, the mind shows less dependence on logic and a
greater receptivity to sensations and feelings. The
resulting change in perception and thinking is known
as a trance. The nature of the trance state varies
from one individual to another.
The ability of hypnosis to induce deep multilevel
relaxation, to quell anticipatory anxiety, to increase
tolerance to adverse stimuli, and to intensify affirmative
imagery can be adapted to the hospital setting for
maximizing the mind's contribution to healing.
Hypnosis has recently seen a resurgence in its medical
applications, with increasing sophistication in the
ways it has been used for many clinical problems,
in and out of the hospital.(1) Equally important,
modern hypnotists, in contrast to earlier ones who
tended to be authoritarian in their approach, encourage
patients to determine the nature of their own experiences,
that is, to develop their unique potential in their
trance. They are also mindful of psychodynamic considerations.
Thus, they use permissive and often frankly meditative
methods and function as a guide to point the way to
conditions of consciousness that are conducive to
psychological adjustment and growth.(2)
Hypnosis in Special Procedures
Procedures performed under local anesthesia with
or without sedation are often anticipated by the patient
with the same apprehension as those requiring general
anesthesia. The idea of being conscious during a procedure
may be reassuring in one respect and unsettling in
another. On one hand, the patient's sense of control
is maintained; on the other hand, the patient may
feel uncertain as to how he or she will deal with
the experience. Even a simple procedure, like a spinal
tap, can be approached with dramatic imagery: the
mental picture of a needle may be much larger than
the actual size of the needle. Similar distortions
may also occur with regard to other procedures, such
as cardiac catheterization, bone marrow biopsy, or
The anticipatory anxiety generated by the patient's
fantasies about a procedure should not be neglected.
It can turn a routine stay in the hospital into a
nightmarish experience and negatively sensitize the
patient to future hospitalizations.
The following case history illustrates some of the
principles of hypnosis when used in the hospital with
certain medical procedures:
A 52-year old woman who had never been
hospitalized was admitted for workup of a lung
shadow. She was to undergo a bronchoscopic examination
the following day. When she became agitated
and highly anxious, a consultation was requested.
Hurriedly wiping away some traces of tears to
appear more presentable, she looked distraught
and restless in her bed. Anticipation of the
procedure, which had been explained to her in
a cursory and hurried fashion, had left her
in a state of panic. She imagined a large, cold,
straight metallic tube being pushed into her
throat and saw herself in the agonies of choking.
Yet, on another level, she spoke amazingly candidly
and rationally: "Doctor, I've been a smoker
for many years. I think tomorrow they will find
that I have cancer. But I think I can come to
terms with it." The procedure was explained
once more to her. The tube was described--a
picture of it was even drawn--as flexible and
as leaving plenty of space for air to pass.
She was told that the more relaxed she would
be, the more easily air could pass. The benefits
of deep, autonomic nervous system relaxation
were evident to her, and she heartily agreed
to attempt a hypnotic experience.
Because of her high level of anxiety, an approach
more directive than normally used for outpatient
office procedures was invoked. With her permission,
her wrist was taken; gently and slowly her arm
was brought straight out in front of her. She
was presented with images of heaviness and relaxation,
and her arm slowly waved itself downward, the
hand gently releasing itself until it came to
rest on the bed. With her eyes closed, all muscle
tightness disappeared; her respiration adopted
a slow, tempered rhythm; her face appeared serene
and seemed to communicate a profound peacefulness.
Once the hypnotic induction had taken place,
the goal centered on achieving the most profound
relaxation possible. Then, the patient was encouraged
to dispel the fear-laden images and to replace
them with images that would be more consonant
with her well-being. "You will feel the
tube," he said, "but at the same time
your throat and all your air passages can be
relaxed, and it need not bother you. You will
have plenty of air and with each breath you
can feel more and more relaxation sweeping through
you. You may in fact be so relaxed that the
whole experience will seem to be occurring some
distance from you, far away. Until then, you
may find yourself thinking very little about
the procedure, if at all, leaving time for you
to rest fully."
The next day the patient underwent the bronchoscopy.
The procedure was completed in just a few minutes;
the patient was remarkably calm throughout.
The tube met so little resistance and there
were so few bronchial secretions that the surgeon
called the hypnotherapist to gain a better understanding
of this phenomenon. When asked about the experience,
the hypnotherapist described how, conscious
of the whole procedure and feeling peaceful,
the patient had felt the tube inside her chest,
as from a distance, and had mused to herself
making a game of it, imagining it was a little
train coursing through some tunnels.
Hypnosis in Surgery
The hypnotic phenomenon that perhaps inspires the
most awe involves the patient who undergoes major
surgery without chemical anesthesia.(3) According
to Moll,(4) the first surgical operations on "magnetized"
subjects were those performed by Recamier in 1821.
(At that time, hypnotic phenomena were thought to
be produced by the influence of magnetized objects.)
Jules Cloquet followed him in 1829, Dr. John Elliotson
in England, Dr. Albert Wheeler in the United States,
and the well-known Dr. James Esdaile in India in 1840.
It is postulated that in certain individuals through
hypnotic mechanisms, a sufficient level of endogenous
agents--that is, those agents that occur naturally
in the body--may be produced to block all perceptions
of pain.(5) However, many author(6)(13) point out
that pain is a sensation intimately intertwined with
fear and that surgical procedures performed with hypnotic
anesthesia may owe their success to the modulation
of anxiety as much as to the neutralization of pain.
Since 1950, interest in hypnoanesthesia has rekindled.
Suppressed by the discovery of chloroform, ether,
and nitrous oxide for more than a century, this renewed
interest has been fueled not only by the growing sophistication
in understanding hypnosis, but by new philosophies
of patient care, such as the belief that patients
should have access to any treatment modality capable
of easing the stress of illness and its treatment.
It is estimated by some investigators(7) that 10
percent of the population could undergo major procedures
with hypnoanesthesia. Others(8) estimate the figure
to he far lower. Patient selection appears to be very
important. Adequate studies are lacking, but good
candidates for hypnoanesthesia are likely to be highly
hypnotizable and especially adept at altering the
processing of painful stimuli. While probably only
a small percentage of patients can negotiate major
surgery using the hypnotic trance as the sole anesthetic,
a far more important percentage can benefit from the
"softer" or more subtle therapeutic influence
of hypnosis, as it is applied in an integrated fashion
through the continuum of the hospitalization sequence.
As such, hypnotic intervention can begin in the preoperative
period, can be continued during the operation itself,
and can be maintained through the postoperative stage
to assist the patient through all phases of psychological
and physical adjustment.
As is the case with hypnosis preceding medical procedures,
preoperative hypnotic preparations center on exploring
the patient's fantasies about the operation, neutralizing
the mental set of anxious anticipation, and correcting
the nefarious effects of destructive imagined scenarios.
The patient is introduced to the idea of deep relaxation,
taken through the steps of experiencing the hypnotic
trance, and presented with affirmative images and
statements relating to the sequence of events likely
to be encountered in the operative procedure. If the
medical hypnotherapist intends to be present during
the operation, this fact is mentioned before surgery
so that hypnotic contact may be more easily reestablished
while the patient is anesthetized.
It has been assumed for decades that a patient in
the deeper or even moderate levels of chemical anesthesia
was in a state of other-worldliness and had shed all
semblance of consciousness. However, some clinicians
and researchers have reported patients who have remembered
events that occurred during surgery when they were
presumed to be unconscious. Crile(9) reported the
case of a patient receiving nitrous oxide (as well
as his own case in his autobiography) where some awareness
of the environment was preserved. While nay-sayers
have attributed these reports to insufficient levels
of anesthesia, reports of more occurrences of partial
awareness in documented deep anesthesia prompted studies
to investigate this phenomenon.
In one study, Wilson and Turner questioned 150 postcesarean
patients.(10) They found three patients who accurately
recalled actual events and 46 who retained some dreamlike
remembrances of the operation. More recent studies
have focused on the hypnotic recollection of the operative
experience, that is, asking the hypnotized patient
to recall an operation. Consciously, some patients
may have little or no recall, but others--especially
those who are highly hypnotizable--are able, in the
context of trance, to reexperience important events
within the operative procedure. It has been reasonably
well established that such patients are attuned, in
such situations, to meaningful communications by the
personnel who are present in the operating room, especially
surgeons and anesthesiologists. It is therefore possible
that surgical patients may be aware of negative comments
on their progress by surgical personnel, to which
patients may react.(11) If, for example, a surgeon
says, "There's a lot of blood loss here,"
the patient may respond with a rise in blood pressure
and increased heart and respiratory rate, making cardiovascular
instability more likely, Hypnotherapists, in anticipation
of this phenomenon, may add preoperative suggestions
such as, "You will remain calm, deeply relaxed,
peaceful, totally undisturbed by any conversation
around you. Your mind centers on feelings of well-being
throughout the operation."
As far as the hypnotherapist is concerned, the clinical
implication of the retention of some awareness during
anesthesia is that some degree of hypnotic contact
and rapport may be established--or reestablished,
if the groundwork has previously been done--during
the course of the operation, for purposes of assisting
the patient adjust to its vicissitudes. It is well
known, for example, that if the patient's abdominal
muscles are tight, the surgeon may order more anesthesia.
This may not be necessary if the hypnotherapist gently
whispers suggestions to the deeply anesthetized patient
to relax his or her muscles.
Postoperatively, the patient who has already experienced
the trance state can easily be given suggestions for
dealing with all aspects of the recovery process,
including rest, comfort, and return to harmonious
biological rhythms (that is, normal appetite and sleep).
People who have suffered catastrophic illnesses or
accidents usually have a long journey to recovery,
and may require global adjustments in life goals,
family dynamics, and self-image. Stroke victims, amputees,
and individuals with spinal cord injuries, for example,
need multi-level support to help them cope with their
shattered world. Rehabilitation. therefore, is both
a physical and a psychosocial process, aimed at assisting
destabilized patients to regain optimal physical competency
and psychological integrity. In the face of cataclysmic
loss (of bodily function--as in hemiparesis (paralysis
of one side of the body), aphasia (impairment or loss
of speech), or quadriplegia (paralysis of both arms
and legs)--the patient often questions his or her
will to live. Other traumatic though less debilitating
injuries, such as the loss of a finger, can engender
severe depression, withdrawal from others, self-destructive
thoughts, and a loss of self-esteem. It is clear that
adaptations to such tragedies may have as much to
do with their symbolic representations as with their
The heartening advances of rehabilitation medicine
are tied not only to technology but also to an appreciation
of the complex psychological needs of patients. Staff
members know how important their self-generated enthusiasm
is in mobilizing their patients' optimism and how
loss of motivation can stunt progress or foster regression.
The following case history illustrates the application
of hypnosis to the difficult process of rehabilitation.
A 35-year-old executive returning late
from a company meeting was injured while driving
on a rainy highway. His only memory of his accident
was of being carried on a stretcher from a ditch,
with the lights of ambulances flashing. He remembered
the slow realization that he could not move
his arms or legs; even worse, that the feelings
in his limbs and torso had been snuffed out.
He could only move his head from side to side
and sink into his quadriplegic nightmare.
A consultation with a hypnotherapist was requested
three weeks into his rehabilitation, because
he was not progressing satisfactorily. He did
poorly on the tilt table, which is used for
physical therapy, and he was not eating well.
This highly intelligent man talked lucidly to
the hypnotherapist about his visions of his
future: he would no longer be able to work,
his already shaky marriage would crumble, and
he would most likely need a full-time caretaker.
With all this against him, he asked, how could
he find a reason to live? Such questions are
difficult to counter rationally. Given the premises,
he had drawn his own conclusions. To tap into
his motivational reservoir, his intellectualizing
network would have to be bypassed.
This man agreed to undergo hypnosis and responded
to hypnotic induction. Whereas before the accident
his analytical mind may have posed a defensive
barrier to induction, his despair and wish to
be helped facilitated the process. The therapist
placed his thumb in the middle of the patient's
forehead, providing a sensory focus for centering
awareness. With the patient's eyes closed and
with his focus turned internally toward the
contact point, a count was started. In synchrony
with the patient's breathing, each number symbolized
a progression into a relaxed mindfulness, toward
a state of mind freed from the incessant pressure
of thinking .
During the ensuing ten treatments, hypnotic
therapy was aimed at different dimensions of
his condition. Aside from suggestions of physical
comfort, efforts were made to extend the range
and intensity of the patient's sensory awareness.
The boundaries of his sensitivity to touch were
determined, and suggestions were given to expand
them farther into his torso, as far as he could
each time, and progressively he regained some,
albeit minute, sensory ground. The therapist
also guided him to experience feelings of peace
and to contemplate acceptance mixed with a willingness
to try his very best to improve. Finally, the
patient was asked to dissolve all negative future
scripts created by his imagination. For the
moment, he would have to attend fully to his
rehabilitation therapy. To this end, he began
to apply himself diligently. He graduated from
the tilt table, grew stronger, and was eventually
sent home with outpatient support services.
For hospitalized patients with catastrophic illnesses,
hypnotic treatment does not stop after the first consultation.
A series of treatments over time is generally effective,
as in the above example, since the goals are approached
in small steps over the course of weeks or months.
In such cases, it is advantageous to teach patients
the skill of self-hypnosis so that they will he able
to surmount periods of private distress, regain autonomy,
and participate in their own recovery.
Hypnotic Approaches to Cancer Treatment
Cancer affects a person on many levels, from the
cellular to the psychological. While the baffling
varieties of its manifestations continue to he elucidated,
there is an evolving awareness of its complex psychological
dimensions. Cancer patients are likely to experience
intense distress and pain--pain from the disease itself,
from its treatments, and from the deep psychological
and social changes the disease and its treatments
Recently there has been a growing appreciation of
the needs of cancer patients for support, open communication,
understanding, and for the sensitivity and professionalism
with which life-threatening illnesses need to be approached.
Hypnosis is used at several levels of cancer care.(5)(6)(12-14)
First, it is useful as a means of dealing with the
symptoms of the disease itself: pain and symptoms
associated with specific or organ systems; and nonspecific
symptoms such as fatigue, malaise, irritability, and
insomnia. Second, hypnosis may be helpful in the management
of the side effects of cancer treatments. This is
very important because the side effects of chemotherapy
and radiation--such as nausea and vomiting--are often
so unpalatable that they may cause the patient to
drop out of therapy. Third, cancer patients are faced
with major psychological adjustments. Many view their
diagnosis with nihilism and are forced to grapple
with profound existential issues. Lastly, and still
somewhat controversially, hypnosis has been aimed
at modifying the course of the disease process itself
through the medium of mental images.(15)(16)
The individual in deep hypnotic trance may experience
any one of a variety of shifts in body image. The
perception of oneself in space including, if appropriate,
the presence of pain, can then be modulated by the
influence of hypnosis on cognitive processes and self-perception.
"I"--the core of the experiencing self--can
be asked, in hypnosis, to modify its relationship
to the feeling of pain. When contemplated, pain may
take on qualities that were not immediately appreciated.
It may he perceived as sharp, diffuse, warm or cold,
as having volume, shape, color, and even sound.
Painful stimuli are recognized consciously and then
elaborated into complex variegated sensations.(17)
The mind can alter or neutralize the perception of
painful stimuli. The wounded soldier continuing to
engage in battle is one example of the mind's influence
on pain and, by extension, all perception.
In a hypnotic trance, the field of consciousness
has the potential of having more direct access to
pain, to its associative networks in the central nervous
system, and to the mechanisms underlying its processing.
Thus, "hot" pain may be made to feel cool;
pain that is perceived to be large and looming may
be made smaller in volume; pain that seems oppressively
close can be made to seem farther away; and, under
certain conditions, pain can be abolished altogether.
In altering or removing pain, care must be taken
not to block its warning function. In the early stages
of an illness, a new sensation of pain or discomfort
may be an important indicator for revising the therapeutic
strategy. In more advanced cases, this is not as relevant.
The following case history demonstrates some principles
of hypnotic alleviation of symptoms due to cancer.
A 55-year-old man with carcinoma of the
left colon that had been diagnosed two years
previously was referred by his oncologist for
hypnotic treatment of pelvic pain. A recent
checkup had revealed metastatic liver nodules,
and a bone scan showed a solitary lesion in
the pelvic bone. He had started taking aspirin,
propoxyphene, and occasionally codeine. This
highly educated man was able to appraise the
complexities of his situation with composure
and open-mindedness. He did not wish to discuss
death at any length. He said that he had come
to terms with death. He stated succinctly, however,
that he did not wish to squander his precious
time and that he wanted to be with his family,
have time to take care of certain business matters,
and be as free of discomforts as possible. His
intermittent pelvic pain interfered with walking
and sexuality. Because he was very ambivalent
about plans for chemotherapy and radiation,
he opted for more time to make decisions about
This patient successfully learned to experience
a medium level of trance--a perfectly workable
depth of hypnotic relaxation--which was induced
using an arm levitation technique. The hypnotherapist
then helped the patient achieve glove anesthesia--a
phenomenon marked by a sensor void in an area
of the body, in this case a hand--was achieved.
The patient perceived a prick of a skinfold
near the thumb as a faraway flicker of touch.
By way of the same mechanism and progressive
extension, he was taught to induce numbness
to other parts of his body. The hypnotherapist
moved the patient's numbed hand to the patient's
pelvis and told him: "Imagine the numbness
and coolness in your hand, seeping through your
skin, extending into your thigh, spreading.
Like rings of water on the smooth surface of
a pond, concentric rings of numbness flow as
deeply as you can imagine."
The learning process, extended to self-hypnosis
gave him variable relief. Sometimes he could
dispel the pain completely.
At other times, especially when his mood was
low, he could obtain only partial relief. But
overall, he felt more relaxed and consequently
had more energy and was more active.
In the last few years, we have witnessed an interest
in exploring the uses of mental techniques not only
to guide cancer patients to a better frame of mind,
but also to influence the disease process itself.(15)(18)
Techniques span a wide array of approaches, most of
which confine themselves to visualization in the context
of hypnosis and/or meditation. Reports of positive
results using these techniques are largely anecdotal.
In spite of mounting evidence of links between the
mind and the neurohumoral, immunological, and autonomic
nervous system mechanisms,(18-24) the efficacy of
mental techniques such as imagery, with or without
the use of hypnosis, has not been demonstrated scientifically
to affect the course of cancer. There is a need for
more systematized investigations of these methods.
Summary and Future Directions
In the evolving philosophy of patient care, not only
traditional and state-of-the-art therapies, but all
modalities capable of enhancing comfort and well-being
are approached with a willingness for evaluation,
with a special awareness given to the importance of
psychological factors in the healing, convalescent,
and rehabilitative processes.
Today, hospitalized patients, faced with an alien
environment, time constraints, and a panoply of novel
procedures, are apt to need therapeutic approaches
that attend to their psychological needs and to the
human dimensions of their experience.
Medical hypnosis, a clinical science has undergone
extensive conceptual evolution and technical sophistication
in recent years, is increasingly understood as a treatment
modality with the capacity to be applied, in selected
situations, to a wide range of problems encountered
in the hospital milieu.(25)
Of the phenomena potentially manifested during trance,
multi-level (psychophysiological) relaxation, the
modulation of painful sensations, the alleviation
of drug side effects and nonspecific symptoms such
as malaise and insomnia, the reduction of anticipatory
anxiety, and the strengthening of motivation for recovery
find the most usefulness. Lastly, and still somewhat
controversially, is the application of hypnotic imaginal
techniques in an attempt to influence the neurohumoral
and immunological components of healing. As the healing
process becomes more acutely appreciated as a multidimensional,
dynamic phenomenon, and as therapeutic trance states
become more accepted as valuable gateways to the enhanced
communication between mind and body, medical hypnosis
will increasingly solidify its role as an agent capable
of assisting the individual toward achieving global
health and well-being.
Gérard V. Sunnen, M.D., is Associate Clinical
Professor of Psychiatry at the New York University
Bellevue Hospital Medical Center. He is in private
practice of psychiatry and clinical hypnosis in New
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Gérard V. Sunnen
200 East 33rd St.
New York, NY 10016