Post Hypnotic Suggestion

Preface:

This basis of this essay was written during the period of time that I worked in the recovery rooms of the operating department at a General Hospital sometime in 1995. I was soon to become an outspoken and controversial critic over the standards of care delivered in that department at that time. Many others felt prevented from speaking out. A climate of fear perfused the department and a power differential between grades of staff existed with strange loyalties between them, both hidden and overt. These issues aside, the recovery nurse is essentially there to oversee the safe waking up of the patient post surgery from the anaesthesia. Prior to leaving the operating rooms, the anesthetist will usually have stabilized the patient and the patient will be breathing on their own without the aid of a ventilator, but often the “breathing tube” (laryngeal mask) would remain in place until the patient was more fully conscious. What concerned me was the mechanical style that my colleagues would awaken their patients – usually aggressively, with a few pinches and shouts and often a painful grating of knuckles on the sternum. Some had taken to pushing the laryngeal mask down into the trachea to trigger the gag or cough reflex to try to wake up the patient.

As a consequence, patients would often awaken disorientated, frightened and in pain and yet all this was considered a standard and normal practice. I took to talking to my apparently unconscious patients, telling them that the operation was finished and I would orientate them to where they now were and what would be happening next. I would also suggest that they could awaken comfortably and peacefully and, as a suggestion against nausea, would look forward to their next meal (all patients are starved for a significant number of hours prior to surgery). I found that I had fewer complications than my colleagues; my patients reported less pain and rarely woke up disorientated and confused. Meanwhile, my colleagues continued to pinch and shout at their patients offering nothing more than a rude and sometimes dangerous awakening. I offered this essay as an attempt to explain a different approach, but it was dismissed and ignored without consideration. Following the submission of a written complaint by myself to the operating department management outlining my concerns and specifying names and specific incidents of malpractice that I witnessed, my employment in that department was quickly discontinued.

The Unintentional Delivery of Post Hypnotic Suggestion

“Until 1935 physicians relied heavily on God and the deep seated, instinctive will of patients to survive grave threats to life. Since the advent of sulphonamides, antibiotics, corticoids, blood banks, biologic monitoring devices, intensive care units and computers, there has been a tendency to forget the patient. This is a plea for the recognition of the fact that patients are people who can be frightened to death, condemned to long hospitalization, or helped to overcome great odds according to the quality of the information they receive from their attendants.”



Ernest Rossi and David Cheek.

It is not necessary for hospital staff (or any other person for that matter) to be trained in the formal hypnosis models in order to deliver effective hypnotic suggestions to another person. These things are already happening all the time. I am sure I am not the first person to suggest that giving staff formal hypnosis training would actually act to help them stop giving hypnotic suggestions that inadvertently interfere with the well being of their patients.

Whilst the terms “hypnosis” and “hypnotic suggestion” will conjure up different things for different people, I suspect that most laymen will consider hypnosis to be a special or even magical skill that lies in the possession of very few. For the sake of this essay, I would like to consider hypnosis as simply referring to a communication that asserts an effect upon the recipient’s psychophysiology.

By “effective hypnotic suggestion” I do not intend to imply that this refers to only beneficial suggestions and outcomes, but rather is a suggestion that creates a psycho-physiological change in the recipient, regardless of whether the psycho-physiological change is beneficial or not. I also recognize that these changes can occur independently of the intentions of the speaker. It was several years ago that myself and two hospital porters were taking a partially sedated patient to the operating rooms for surgery when a senior nurse called out to him, “Good luck, James!” A few seconds later as we moved down the corridor, James looked up to me and asked, “Do I really need luck? What does she know [that I don’t know]?”

Awareness Under Chemical Anaesthesia: “…particularly impressive have been some of the reports about what we may call ‘fatty’ comments where a surgeon made an insulting remark in reference to someone’s weight during surgery. It is particularly impressive that such comments, unconsciously registered, seem to be capable of causing continuing psychosomatic problems and can be traumatic enough to cause post operative complications, depression and vegetative responses. A lawsuit has now been settled out of court concerning a ‘beached whale’ comment made by a surgeon around an anaethetised patient, which was recalled several days later by the patient and confirmed by a nurse who was present.”

It is my experience that all too often, innocuous and seemingly friendly remarks and communications have an adverse effect upon the patient, independent of the member of staff’s intention and even if not directed at the patient himself. Imagine for example the simple comment from a tired nurse to a colleague as she expresses, “You know, I cannot wait for this shift to be over!” It may be just that she is tired, or maybe that she has a great party to go to, but how would such a comment be viewed (and felt) by the overhearing patient who owing to their condition has been dependent of this particular nurse all day?

Such a comment, without negative intention, may be the difference that tilts the patient towards helplessness and thus depression and impedes recovery.

A while ago I asked a colleague to return to me some important research papers I had lent to him. I wasn’t going to see him again until the following Wednesday and I asked that he return them to me then.

“I’ll try to remember to bring them,” he told me. My brain registered the word “try” and inside my head I pictured him saying to me next Wednesday, “I am sorry, but I did try to remember.” I strongly suspected that without intervention, I would not be seeing my research papers when I needed them.

Hypnotists will often utilize the word “try” to imply failure as it provides permission to fail. People will also hear it differently. For example, the stage hypnotist in the process of selection of volunteers may well have the audience collectively clasping their hands together, being urged to do so ever tighter and tighter. And then, with the same amount of urgency, the hypnotist will suggest that they all now try to pull their hands apart. Now, there is no secret to this. Whilst in a big enough audience, there may well be one or two people genuinely hypnotically stuck with their hands together, what is going on for the majority who remain standing, hands apparently stuck is that they haven’t been told to pull their hands apart. Of course, they really could if they wanted to, but what they are doing is the activity of trying.

I have often heard inexperienced hypnotists tell their clients to “try to relax” and on one occasion, to an already happily relaxed client, “try to relax and try to forget about all your worries and concerns that will stop you from going into trance.” The physiological shift in this client from one of comfort to discomfort was noticeable as he was inadvertently reminded to consider all the worries and concerns that might prevent him from relaxing further.

In any form of healthcare provision, rapport is very important as people tend to move away (either physically or mentally) from anyone that makes them feel bad – this may play a huge factor in the non-compliance behaviours so often witnessed in healthcare environments. In the West, with the impact of science and anaesthesia, medical treatments are not expected to hurt. An effective medicine no longer needs to taste very bitter in order that it is perceived as being a good medicine. It is unfortunate then that within the strong hierarchies that exist within hospital cultures we persistently find a small but significant number of individuals who wield their status and power to coerce, intimidate and dominate junior colleagues. It would be hard to correlate, but I cannot help but think that such behaviours have a knock-on effect throughout the social system of the care environment ultimately manifesting as delayed healing times in the care recipients.

A mistake that is common to many therapists of various fields is the operating belief that the subject or patient responds to the techniques employed by the therapist rather than to the quality of the delivery and the behaviour of the therapist themselves. The relationship the therapist forms with the patient is also critical in this context. In the case of hypnotherapy, a situation commonly arises whereby the subject sits there with eyes compliantly closed as the hypnotist laboriously reads a pre-written script at the subject. Meanwhile, the client is running an internal dialogue to the effect of, “this isn’t working, I cannot be hypnotized.” To hypnotists who do read scripts at the clients, I offer this advice. Just send them a copy of the script so they can read it themselves and save themselves on the bus fare.

With an ever-increasing emphasis on standardization of medical treatments, we see a two-fold result occurring. Firstly, and most importantly, the overall standard in the delivery of care countrywide increases. But secondly, we also witness a squashing of ingenuity and creatively it becomes increasingly harder to be outstanding in the field when the behaviours of care staff are reduced to that of a set of automated responses set against sets of automated criteria. Of course, the net effect of all this is that the person that is behind the set of symptoms and criteria is frequently forgotten. And, with the increase in the use of modern technology to monitor and measure these patients, we have a situation best summed up by neurologist Dr Richard Cytowic: “Care is something we deliver when we don’t have a machine to do it for us.”

When a patient is in intensive care – his blood pressure is monitored both by automated cuff and via an indwelling arterial catheter; his breathing maintained and supported by a ventilator, his blood pressure and renal function supported by inotropes, parenteral nutrition supplied intravenously, pressure sore risk eliminated by use of flotron mattresses etc, when surrounded by all this life-supporting technology and monitoring, it is easy to understand how medical and nursing staff dismiss something as apparently trivial as their use of their voices as an aid to healing and recovery.

As one surgeon suggested to me in ITU – we don’t really make people well here, the body heals itself, we just try to keep them alive long enough to allow that to happen.

Two useful patterns utilized in hypnosis are those of the contingent and adjunctive suggestion. These are common in everyday language and are an exceptionally effective hypnotic tool. Most people use these patterns every day without realizing that they are doing so. The effectiveness of this type of suggestion comes from the way that the suggestion is given on the back of an activity or behaviour that is already occurring. For example, “When you are in town, will you please buy me a pint of milk” and “If you go past the kitchen, will you make me a cup of tea.” Now an aspect of these suggestions to bear in mind is that they are not asked as questions, in so much that they are not stated with an upward inflexion (indicating a question) but rather with a downward inflexion (command). There is no need to overemphasise the intonation, as a casual tone will usually suffice.

In the anaesthetic rooms, I often hear anaesthetists say something like, “as I inject this you will begin to drift off to sleep” and then stop there, missing a rich opportunity to deliver additional suggestion. Some will encourage their patient to try to count from one to ten to see how far they can get – few make it past 7, as intravenous barbiturate has a rapidly sedating effect.

Since drifting off to sleep is an inevitability and is perfectly predictable in terms of the anaesthetic rooms, we have ourselves an opportunity to create a chain of suggestion.

<Injection> causes <drowsiness> causes <unconsciousness> causes <XYZ> where XYZ may be an inoculation against any careless talk occurring during the operation. So we may have a situation such as,

“I am now going to give the anaesthetic which will make you feel very sleepy, that’s right, now start counting from one to ten and see how far you can get….that is right….now as you begin to feel increasingly sleepy…that’s right, you can begin to dream a wonderful dream that takes you to your far away special place where you know that any sounds and sensations that may be down here can leave you feeling good that soon you will be back on the ward with a feeling of comfort and wellness…”

And the number one reason hospital staff don’t use deliberate hypnosis? They feel silly talking in this way. It is important to realize that hypnosis is not just saying a script, but rather it is about knowing where you want to direct the subject’s attention, and knowing how to do so.

Now, this may seem all a little strange at first, but is anything as strange as saying, “Now Mr. Jenkins, just try to relax. Try not to worry too much about the operation.”

Walking down the street behind a young mother and her delightful 4-year-old son. He is happily playing with a small plaything as they walk towards the shops. The child drops the plaything. His mother looks at him and says, “Now put that in your pocket before you lose it.” The child picks up the plaything and puts it in his pocket. They walk a few steps, he reaches back into his pocket and fumbles around. He cannot find it and starts to cry but his mother doesn’t understand.

He did exactly what he was told to do – he put the toy in his pocket……before he lost it.

It was several years ago whilst working in the managerial offices that Stan Straight was summoned to his boss following some financial disaster for the company. The conversation went something like this:

“Now Stan, I want you to know that no one is blaming you…”

Poor Stan, he went a bit pale. He hadn’t considered that anyone was blaming him, and now there is this no-one character and he is blaming Stan. As the colour drained from his face, Stan’s brain began to wonder who else might be blaming him too.

“Sit down Stan, just try to relax – there is nothing to worry about, I am sure…” the boss continued. Stan sat down and failed to relax – right now was definitely not the right time to be relaxing, he was too busy thinking about what it was that he shouldn’t be worrying about. He was handed a glass of water.

“Don’t worry about it too much,” said the boss helpfully, “as I say, no one is blaming you. Try to get a good nights sleep and I’ll read your report tomorrow.” There it is again, thought Stan’s brain, this no-one character is blaming him all over the place. Stan Straight spent the night trying not to worry too much, but the problem was he didn’t know how much was too much and he couldn’t stop his brain from going over all the things he wasn’t supposed to be worrying about in the first place.

When I listen to the language patterns commonly used by ward staff at the hospital, I often hear some accidental negative hypnotic suggestions. More often than not, the staff remain unaware of the responses that they are triggering in their patients. Or at best, they observe the response but do not connect it to their own behavioural and communicative outputs.

One such example that I hear often during the nurse’s drug rounds takes the form of, “Hello Mr. So-and-So, how much pain do you have? I.e. the speaker offers a presupposition that Mr. So-and-So has pain. Thus the recipient of such a presupposition is required to enter into the paradigm of pain in order to answer the question. This is similar in format to, “How is your headache, Mr. So-and-So?” All too often the patient had forgotten about the headache until he is reminded. Possibly the best answer to this question I have heard was the cryptic, “I don’t know, why don’t you ask it?” The nurse walked away slightly confused. An hour later, and probably only by coincidence, I observed this nurse taking some paracetamol, “I just don’t know,” she lamented, “some of these patients really give me a headache.”

Several years ago, I observed a hypnotherapist begin his induction with, “Now, I am going to invite you to sit back and relax. Take a deep breath and as you do so, let all your worries and stresses about the day just melt away. Up until that moment, the client was already looking pretty relaxed (I guess the hypnotherapist failed to notice that) but he flashed a look that said, “Oh yes, I’d forgotten about those things, but now you mention them, I’ll try to forget about them as you ask.”

After a while, the client began to relax again and once more the hypnotherapist said, “…and relaxing all the way now, without worrying about those things in your life that stress you…” The client once again had to do the activity of getting stressed and worried in order to carry out the command to stop doing so. Just being in the same room as this hypnotherapist began to make me feel a bit stressed too. Needless to say, the session wasn’t entirely successful, but this hapless hypnotherapist reassured himself by telling me and the client that the changes would occur at the unconscious level, whatever that is supposed to mean.

Remember this: when someone tells you to not do something, you have to do it in order to carry out the command of not doing it. So in order to not think of a fish, you must first make a fish in order not to think about it.

The problem arises from the issue of the brain’s ability to process negations – essentially, it finds such an activity very difficult. So, if we tell the patient that they won’t feel sick, we are more likely to predispose them towards nausea. So how do we frame and suggest against nausea?

Psychiatrist and hypnotherapist Milton H. Erickson suggests that we shift direction. So for example, instead of “you won’t feel sick” we could, in fact, suggest, “…and when you wake up, you will feel pleasantly hungry” since pleasant hunger excludes the experience of nausea. This suggestion is positively framed and congruent with the fact that the patient will have been starved for a significant time prior to surgery.

Erickson wrote: “…you are going to use words to influence the psychological life of your patient today; you are going to use words to influence his organic life today; you are going to use words to influence his organic life and his psychological life twenty years from now. So you had better be willing to reflect upon the words that you use, to wonder what their meanings are, and to seek out and understand their many associations.” Life Reframing in Hypnosis.

In the casualty department: A young, fit and muscular man is brought by ambulance from a building site. I was on the receiving team and we had been pre-warned of his impending arrival. An incident had occurred whereby somehow a fully loaded dumper truck had driven over this man’s abdomen, left arm and left side of chest. His arm is clearly broken but there is little in the way of visible damage other than a huge tire imprint across the affected areas. Urgent X-rays and ultrasound scans are arranged to look for internal damage. The man was in good spirits and joking with the staff.

Because of the pain in the arm, the doctor cannulates the patient and injects him first with morphine, carefully titrating++ the dose and then when the desired effect is achieved follows up with a second injection of metoclopramide. The doctor says, “…and this injection will stop you from feeling sick.” To which the man replies, “But I don’t feel sick.” To which the doctor ordered, “oh, but you will, because of the morphine I gave you.”

As directed, the man immediately began to feel sick.

Many people are simply unaware of their internal visual representations – for too long the psychotherapeutic fields have focused on the kinesthetic system – feelings – and this has infused through popular culture. People spatially place their pictures and regularly I need to introduce clients with whom I work to their internal pictures and need to guide them to understand that pictures are indeed spatially located. All too often when I started out and asked clients, “And where do you see that picture?” the reply would be simply, “In my mind” or “In my imagination.”

So here’s one way to redirect the response into the paradigm required:

Write on a piece of paper – “THE CAT SAT ON THE TABLE”.

Ask the client to read the sentence out loud, assure them that this isn’t a trick question. Immediately they have finished reading the sentence ask: “And what colour is the cat?” and “Which way is the cat facing?”, “What shape is the table?”, “How high is the table?”, “Is there anything in the background?”, “What shape is the table?” and then ask them to point to the cat and say roughly how far away it is.

Other submodality differences can be introduced at this point, such as, “is the picture in colour?”; “How bright is the picture?”; “Is it moving or still?”; “3D or 2D” etc. but at this stage, I often just stick with content and will build in the understanding of submodalities at a later stage of the work.

I have never had anyone fail to do this and I then explain just how much visual information is created simply by reading that small sentence, and that there are undoubtedly more visual details included in their visual representation of the sentence. About two-thirds of the brain is involved in visual processing in one form or another and the two main speech and language centres (Broca’s and Wernicke’s areas) are the just size of a large coin. Quite often, just to check for understanding I will ask that if I asked a small group of people to do the same exercise at the same time, would they all make the same pictures? Only the control freaks tend to say “yes” to that question.

Now write on a piece of paper – “THE CAT IS SITTING ON THE TABLE” and ask the client to read that sentence out loud too. Now some people will have read the first sentence in the past tense and the second one in the present tense. I ask if the picture is any different and if so, how?

This exercise begins to guide the client to notice the subtle shifts in the visual representations according to the language used and also serves as a nice covert directing of the attention inwards – a subtle framing for a hypnotic induction.

Next write: “THE TABLE IS SAT ON BY THE CAT” and ask the client to read it out loud. Then ask what happens to the picture. Essentially the syntax and meaning is the same, all we have done is a shift to the passive tense with regards to the cat – the table now forms the central theme. Ask the client what happens to their picture. Typically one of two things occurs – the representation changes around and the table is now on top of the cat, or the table gets bigger (or closer) and the cat gets smaller (or further away). About one in five people (and most children under eight years of age) struggle with this sentence and enter a state of confusion as their pictures scramble around.

This offers a nice confusional technique for hypnosis for when we want the client in a state of confusion so that they more readily accept the direction in which we want them to move. For example: “…and as you find yourself moving along your desired path, your desired path finds you moving along it now…beginning to form new solutions…” and, “as you really begin to focus on how comfortable you can feel, your comfort is focused on by you..” and “you are sitting in the chair and the chair is sat on by you…listening to the sound of my voice deep inside…” The reversing of the active and passive modes creates an ambiguity – i.e. is it them or is it the chair that hears the sound of my voice deep inside?

Next write: “THE CAT IS NOT SAT ON THE TABLE” and ask, “Where is the cat?” Because the theme of this sentence involves the cat first, typically the client will have a representation of the cat but it will be somewhere else other than the table, but the representation will always involve a cat somewhere.

So we can readily see that the brain makes pictures as it processes language and people generate feelings in response to both the content and the manner in which they make their pictures (size, proximity and brightness will all directly influence the intensity of any feeling that occurs in response to a visual representation. So ideally, we should be directing our patients, both overtly and covertly towards them making good internal pictures.

On the neuro-surgical ward, postoperative intra-muscular injections of DF118** were common. DF118 is useful in that it is the closest you can get to a true opioid type of analgesia without sedating the patient (effective doses of opioids tend to produce a set of behaviours and symptoms too similar to neurological deterioration and so tend to be avoided in neurosurgery). DF118 does have a small problem though – it can sting like hell when injected. So, having to sit on a hornet’s nest in order to receive a drug that is substandard in effect to morphine is most definitely not a good prospect. I have even heard nurses say, “I’m sorry I cannot give you anything decent, you’ll have to make do with this DF118” thus framing the administration of the drug as both painful and possibly pointless.

Now, very few people actually enjoy injections so I figured a great big lie was in order. There’s no getting away from the fact that the injection stings quite a lot so there’s no point in lying about it hurting, but I could add a frame such as: “This is going to sting a lot – sorry about that, but that is because it is a very strong painkiller” and neurosurgical ptients tend to be habitually tired owing to both the surgery and the regular neurological observations they receive, so I would often go as far as:

“This is going to sting a lot – sorry about that, but it is a very strong painkiller, just let me know if it makes you feel too sleepy.”

The aim here is to reframe the reason for the sting (true opioids don’t sting at all) as being a demonstration of the efficiency of the drug and also, the ongoing fatigue is now legitimized and also becomes a demonstration of the drug’s efficiency. And you know what?

It worked like a dream.



++ The morphine is mixed in a ratio of say, 10mg morphine into 10mls of saline. The solution is then injected slowly intravenously until the pain disappears. As all people will have a differing level of response to the drug, this method means that the patient is not going to receive too much or too little but rather receives just the right amount to reduce the pain adequately.

** Also known as dihydrocodeine [hydrochloride]