ABSTRACT

Within the context of medical procedures, surgical interventions, and hospitalization, the science of human psychological adaptation has not kept pace with the meteoric advances witnessed in the technical dimensions of medicine. Techniques such as hypnosis and self-hypnosis, however, can easily be enlisted to enhance the well-being and adjustments patients make to their medical trajectories. The science of adaptation to medical stress incorporates the notion that beyond relaxation, patients can develop active and potent self-mastering strategies. Clinical examples illustrate the wide therapeutic spectrum these techniques have in all phases of diagnostic and operative interventions.

As the pace of medical advances soars into our new century, we are left with excited wonderment and inspiration. The accelerating discoveries of innovative diagnostic tests, novel medical procedures, and revolutionary operative interventions attests to the energy and creativity of all medical sciences today. Our imagination becomes unbridled as therapeutic possibilities illuminate medicineís new promises.

Such advances delve ever more deeply into the human body, probing its wondrous anatomy, exploring its magical physiology and biochemistry, and finally thrusting into the secrets of the interface between life and matter itself, namely the human genome.

While the progress of medical technologies blazes into new frontiers, however, it is increasingly apparent that parallel dimensions of human wellness need commensurate attention. Indeed, while these revolutionary medical advances succeed in diagnosing and righting the physical health of organ systems, how do they attend to the spectrum of the individualís psychological and spiritual dimensions?

INDUCTION INTO PATIENTHOOD

Faced with entry into the medical system ushered by some medical difficulty, the individual takes on a new identity, namely that of patienthood. Confronted by an expanding array of medical tests, complex treatment options, and befuddling interventions, the mind often reacts with perplexity and uncertainty. How, for example, does one approach procedures such as bronchoscopy, laparoscopy, arteriography, cardiac stress test, myelography, cystoscopy, needle biopsies, dental implants, or spinal taps, among many others? Or major operative interventions? Even non-invasive procedures such as MRI (magnetic resonance imaging), brain scan, CT (Computed tomography), or ultrasound, can elicit distressing concern.

In spite of cheerful colors and pleasant personnel, hospitals remain alien environments, mitigating against much needed feelings of comfort, confidence, and optimism. Hospitalization, even with all available medical technology, too often remains a trying experience. Indeed, the same concerns, apprehensions, and fears exist today as they did centuries ago in the face of potential dangers to well being and sometimes to life itself, even if it is in the mission of healing.

The psychological well-being of patients, in or out of the hospital is of paramount importance, not only for humane considerations but for reasons connected to health and recovery: patients do better when undergoing procedures and operations, or when negotiating the side effects of treatments, if they are relaxed, rested, and feeling optimistic and hopeful.

THE SCIENCE OF HUMAN ADAPTATION

The science of human adaptation to stress and trauma is clearly demonstrating the importance of psychological factors in achieving success. Until recently, however, assisting patients to negotiate the labyrinths of their medical trajectories, consisted of supportive or suggestive approaches, emphasizing relaxation in any one of its physical, psychological, and emotional dimensions. A relaxed patient, it was correctly thought, had a better chance of being a successful patient.

The new science of psychological adaptation goes a step further. Its premise incorporates the notion that beyond relaxation, the mind, through its innate capabilities, can proactively contribute to the organismís response to stress. Within this perspective, the successful patient is one who can relax and, in addition, who can mobilize special mental processes to gain psychological mastery of medical interventions from the time of their planning to full recovery (Briham, 1994).

The study of these beneficial mental processes borrows from different yet related disciplines, namely hypnosis, self-hypnosis, and meditation. In all of these disciplines the mind makes use of special dynamics to privilege beneficial intra-psychological communications.

THE LANGUAGE OF HYPNOSIS

Hypnosis can extend the range of influence of the conscious mind into normally unconscious bodily networks. To establish contact with deep physiological functions, hypnosis utilizes communications, which because of their special characteristics, may be called the language of hypnosis.

Communication venues for hypnosis may include affirmations and mental images. The mind continuously creates mental images. They appear in consciousness in many varieties with wide individual differences. Not necessarily visual in form, mental images can involve all the senses. Images are more likely to have therapeutic impact if they incorporate emotions. So-called positive images tend to be synergistic with wellness and energy; in the mind they resonate with self-confidence, self-esteem, optimism, and creativity. Negative images, which include negative scenarios about the future and privilege feelings critical of oneself, tend to be inhibitory to self-expression, enticing guilt, pessimism, and fatigue. Therapeutic mental images carefully select their ingredients to respect the unique psychological makeup and imagery style of each individual.

No one can say for sure why negative images exist in the first place. After all, on the surface of things, they do not appear to be beneficial. Why would such depression-promoting mental processes as negative self-esteem find purpose if they do not (by surface observation) benefit the organism? Whatever the admittedly complex answers to this question, the fact remains that negative mental images are universally observed in the human psyche. Negative mental images find their home in the repositories of the unconscious mind and are usually absorbed through the repercussions of unfortunate experiences and relationships accumulated during a lifetime. Paradoxical as they may seem, they usually intend to serve, through the dynamics of the unconscious, to protect the organism from future harm. They can nevertheless exert powerfully nefarious influence upon the process of mastering medical stress. It is helpful to discover and understand them lest they deflect from therapeutic thrust.

Although the mindís output of thoughts, emotions, memories, and images has been likened to the continuous flow of a stream, this is not to say that the mind remains a passive experiencer of its own creations. In this analogy, streams can be altered to change their course and can even be played with to channel them into new territories. The executive functions of the mind describe mental capacities that enable the evaluation of information, the direction of attention, and the planning for future action. This executive branch of the mind, judiciously enlisted in hypnotherapy, can also devote its energy to privilege the type of mental images it wishes to favor and to discourage those it wants curtailed. A closely related mental dimension, creativity, has the therapeutic capability of spawning entirely novel thoughts and images.

BOUNDLESS NEURAL PATHWAYS FOR THE MIND

Mental events have their corresponding resonance in the circuitry of the nervous system. Penfield in the 1930ís, stimulating discreet locales of the exposed brain cortex in conscious patients undergoing neurosurgery, demonstrated how thoughts, emotions, and memories, many of which were hitherto unconscious, could be brought into consciousness by pinpointed electrical instigation. It was deduced, as Freud is said to have predicted (Ellenberger, 1970), that each thought owns its proprietary neural circuit. While this notion is not globally false, it is equally true that each mental event has nervous system ramifications that connect it to all other areas of the brain.

While every neuron connects in some way to every other cell in the nervous system and projects its influence into the most delicate tendrils of its outer reaches, it also interfaces with all organ systems from heart and endocrine, to gastrointestinal and immune. Recently, the field of psychoneuroimmunology has gathered extensive data to show the closely interlaced relationships of nervous and immune systems to mental functions (Hannigan, 1999).

Mental images, through these neural pathways, are thus able to travel from their yet undetermined sites of origin to transport messages into the entire matrix of the organism.

APPROACHES TO SELF HYPNOTIC SKILLS

The cornerstone ingredients of self-hypnosis are relaxation and the capacity to generate mental constructs. Relaxation decreases the background noise of the mind. In relaxation, the body adopts natural rhythms of repose, and the mind allows its spontaneous creation of thoughts to slow down. Within this tranquility, creative imagination finds opportunities for sustaining mental processes that project intensity and therapeutic direction.

Self-hypnotic communications have greater impact if they involve a variety of senses. In so doing, they recruit more areas of the brain. Pictorial images correspond to the activity of visual and visual association areas in the occipital lobes. Adding language or music recruits auditory regions within the temporal lobes. Integrating movement invites participation of the parietal lobes. Very importantly, emotions animate the limbic system and its wealth of connections to autonomic neural networks and to the neuroendocrine system.

Certain techniques have the capacity to deepen relaxation and to heighten the impact of mental images. Hypnosis is a special state of mind permitting the experiencing of relaxation in its most profound realms. While relaxation is generally believed to be the mere dissolution of tension, it actually is a far-reaching cascade of events comprising physical and psychological components (Sturgis, 1990). Beyond the dissipation of tension, the body drifts into a state where breathing slows down to become deeply abdominal; where heart rate assumes a mellifluous cadence and blood pressure decompresses; and where EEG rhythms shift into cerebral harmony (De Pascalis, 1993). In the exploration of relaxation, the mind enters layers of feelings that traverse calm and move into deep peacefulness, finally entering states that, because of their essence, may be called spiritual. Indeed, it may be said that relaxation knows no limits in its depths nor in its boundaries.

Self-hypnosis seeks the attainment of similar experiences. As in hypnosis, deep relaxation is created, and mental constructs may thus achieve greater clarity and focus; and energizing feelings such as self-confidence can more easily be conjured. In self-hypnosis, however, the individual acts both as guide and experiencer, solely through the impetus of self-regulation. Self-hypnosis gives patients the opportunity to develop a sense of self-determination toward their condition (Fromm, 1990).

THE THREE PHASES OF OPERATIVE INTERVENTION: FIRST PHASE

Hypnosis may be applied to any one of the three phases of operative intervention. The first phase spans from the diagnostic search, to the decision to operate, to the actual procedure. Data about the medical problem is defined and therapeutic options are delineated. Psychological demands are great. The need to grasp the complexities of the situation may be clouded by denial and fear. Anxiety, in any of its many psychological and somatic faces usually plays a central role and may distort a proper evaluation of the situation. The procedure is often perceived as a threat to personal integrity and primal mechanisms of response are recruited. Fight, flight, or freeze reflexes are routinely mobilized. Anticipatory anxiety may disrupt sleep and appetite rhythms thus weakening the organism. Medications to counter these symptoms may only sedate and further compromise vitality.

A first mission of hypnotherapy in the first phase of operative intervention is achieving maximum relaxation. Physically, the body may be driven by anxiety to a much higher resting level than need be, and the patient may be quite unaware of it. The body needs to conserve its biological forces. An effective self-hypnotic technique pairs the meditative experiencing of the entire body with a gentle and persistent repeating of the word "relax." This message can achieve potent beneficial effects with practice. Meditating on feelings of soothing detachment may assuage anticipatory anxiety. Proactive imagery may center upon visualizing the procedure in the context of feeling self-assurance and poise.

In this first phase, anxiety about the intervention needs to be explored. Some anxieties are freely expressed while others are unconscious. Anxieties acting below awareness are often responsible for reactions about a procedure far beyond its actual significance. The anticipatory anxiety generated by a patientís fantasies about a procedure should not be neglected. It can turn a visit to a diagnostic facility or a routine stay in the hospital into a nightmarish experience and negatively sensitize the patient to future medical interventions. Anxieties respond to reality checks and appropriate reassurance.

The hypnotherapeutic goal for this first phase is achieving a state of psychological preparedness where the patient shows interest about the procedure but is devoid of the anxiety of worry. Ideally, in the weeks, days, and the day preceding an operation come heartfelt sentiments of optimism and pervasive composure. Hypnotherapy, in this phase, acts as a powerful relaxant of anticipatory anxiety and a potent enhancer of hopeful imagery (Dreher, 1998; Kessler, 1999; Levitan, 1992; Pinnel, 2000).

THE SECOND PHASE

The second phase of an operative procedure is the operation itself. The patient enters the hospital and undergoes all preparatory tests. Food or water past midnight before the operation is withheld. In the morning, transfer to the operating suites is followed by preoperative anesthesia. The intervention proceeds until transfer to the recovery unit. It may be asked: How can mental imagery be of any benefit when the patient is in the throes of anesthesia and for all purposes unconscious?

It had been assumed for decades that a patient in the deeper or even moderate levels of chemical anesthesia was in a state of otherworldliness and devoid of any consciousness. However, a growing number of clinicians and researchers have reported instances when patients recalled events that had occurred during surgery and deep anesthesia. This phenomenon, called anesthesia awareness, implies that even though the perception of pain may be absent, portions of mental function remain active, and enough so that memory traces persist (Wilson 1969).

The implications of anesthesia awareness form the foundation for the utilization of preoperative imagery to beneficially influence the procedure as it is taking place. The phenomenon of post hypnotic suggestion in hypnosis is well recognized for the ability of the hypnotized individual to activate mental events, seemingly automatically, subsequent to their hypnotic experience (Lynn and Rhue, 1991).

Hypnotic preparation for the operative procedure may thus favor the creation of therapeutic mental reflexes, which automatically actualize during the event. Images evoking intraoperative repose, blood pressure stabilization, cardiac equilibrium, respiratory ease, and relaxed detachment, can serve to heighten the psycheís contribution to operative success. Hypnotherapy, in this phase, can directly modulate the mindís response to operative challenge (Adams, 1992; Blankfield, 1996; Lang, 2000; Weinstein, 1991; Zimmerman, 1998).

THE THIRD PHASE

The third phase of an operative procedure is the recovery phase. The body is engaged with repairs at hand. In its labors, the body invariably generates any one of a spectrum of discomforts referable to specific organ systems involved, the most distressing of which is pain.

The fact that the perception of pain may be profoundly modified by mental functions suggests fruitful therapeutic avenues (Barber, 1996). In individuals with superior abilities to experience hypnosis, for example, pain, if not modified, may sometimes be totally abolished. The mind has the capacity to transform pain much as a sculptor changes the shape of clay. Thus pain which feels hot may be mixed with feelings of coolness; pain that is perceived in the mind as large and looming may be made to feel smaller in volume; and pain that seems oppressively close can be made to seem more distant, vanishing beyond the horizon.

It has been amply documented that mental processes may accelerate tissue repair (Holden-Lund, 1988). Thus, swelling and inflammation may resolve more quickly with modification of accompanying pain. In rehabilitation medicine, the recovery from orthopedic procedures is smoother if the patient shows motivation and hopefulness. Recuperation also signifies the return of functionality in all dimensions of the patientís life. Self-image and self-esteem may be challenged by the more serious spectrum of interventions and may need judicious repair and growth.

The following clinical histories illustrate the usefulness of psychological techniques in the three phases of operative intervention.

A PULMONARY CANCER EXPLORATION

A persistent cough of a few months duration increasingly irritated this engaging 46-year-old realtor. When the cough became mildly productive and took on accompanying pain, she sought consultation. The process of investigation eventually demonstrated an egg-sized lung mass in her right upper lung. She had not smoked for many years, a fact that added to her initial disbelief in her diagnosis. Imaging studies were highly suggestive of a neoplasm. She would have to undergo a surgical exploration with possible tumor excision. A thoracotomy was scheduled. She had spoken to the surgeon but admitted that, in the throes of her emotional turmoil, she had either omitted to ask the proper questions, or failed to process them clearly. Her mind straining under excess anxiety had retained only the most ominous eventualities. She remembered being told that she would be intubated during the operation and that a portion of her lung might have to be removed. Great concern came upon her. She recalled being stuck in a smoky elevator as a little girl and the intensity of her fright. Would she be able to breathe freely with this tube in her throat? How much of her lung would they take out? Could it leave her breathless subsequent to, or even during the operation?

The procedure was explained to her once again. A diagram was drawn to show her how the operation would proceed. There would be wide patency of breathing conduits. She was told that the greater the relaxation of her entire respiratory system, the easier air would flow.

A method of hypnotic induction which may be called the arm drift was used. With her permission her wrist was taken and her arm brought straight in front of her, in the image of a piece of wood floating on a lake. Eyes closed, she was asked to let her arm float and to create the feeling in her mindís eye that a sense of comfortable heaviness was beginning to fill it, growing more so with each breath. As the strength of her mental image increased, it was suggested, her arm would follow its directive. Her arm, feeling ever heavier, slowly drifted downward until it came to rest on her lap. This pleasant feeling of heaviness could now begin to flow into her other arm, into all her muscles, and finally into the deepest networks of her entire body.

Therapeutic affirmations were then invited to dispel her fear-laden images. She would be calm and composed in the days preceding the operation. She could visualize herself feeling rested in the hospital, sleeping well, and unbothered by the activity of the personnel. During the procedure she would not fight with operative interventions but would easily move through them. Her breathing would be cadenced and unhurried.

Everything proceeded as in the imaginationís best scenario. Before the operation she noted her surprise at her lack of any anxious concern. In the hospital, she was able to observe all the activity around her with a mental attitude of interest, and even at times of amusement. The surgeon had known about the relaxation training of his patient. She called the day after the procedure to report that she had seldom seen a patient so relaxed. As a consequence, she said, the operating team was less challenged and time was saved.

In the recuperation phase, the patient used self-hypnosis to accelerate healing. Initially bothered by shortness of breath with exertion because of the resection of a portion of her lung, she worked on building her pulmonary reserve. Pain with movement of her right shoulder due to scar formation and the severing of nerves was modulated so as to permit gradually greater ranges of motion. Fleeting yet persistent feelings of being a partial invalid based upon thoughts of having a cancer diagnosis were prevented from taking hold. She progressively replaced them with feelings consonant with her core spiritual convictions.

A CORONARY BYPASS

Annoying shortness of breath during the walking of stairs, poorly describable vague chest discomfort, and occasional sweating at night increasingly entered the life of this active attorney. At times, especially when under stress, he felt his heart momentarily skip uncomfortably. He had received antihypertensive treatment for eight years and only recently adopted a cardiovascular dietary regimen. Imagery studies confirmed that he had severe blockage in two of his coronary arteries. At 52, he had never entered a hospital, and he reacted with a mixture of denial and apprehension when he was advised to undergo coronary bypass surgery.

A preoperative stress test had not been normal. A call to his cardiologist confirmed that he showed intermittent atrial flutter with exertion, but that this did not warrant special concern. The patient, however, focused upon this finding with deep anxiety. What, he asked, could be a worst case scenario given his history of hypertension and recent findings of cardiac instability. He reported that thinking of himself as a "cardiac" was seriously beginning to gnaw at his self-esteem.

He related how he had always been interested in gambling and drawn to the calculation of odds in evaluating lifeís decisions. "What are my chances of succumbing to anesthesia? "After all, he said, my own father died of a heart attack." Attempts to reassure him with quotes of almost negligible statistics did not appease him. He focused upon negativities enough to impair appetite, sleep, and even family relationships. He became fatigued and irritable.

He agreed that learning hypnosis could improve his chances for successfully going through what he perceived as a monumental ordeal. He initially expressed doubts that he could ever relax. Nevertheless, he felt comfortable with the hypnotic technique of awareness of breath, an ancient discipline central to many practices of meditation. Eyes closed, he could dispatch his feelings into his breathing and even experience the air touching the inside of his lungs. With perseverance he was able to gradually disconnect from the incessant stream of thoughts usually generated by his questioning mind and enter a mental state of quietude.

Because he reported frequent and vivid dreams, he was asked to create mental scenery with dreamlike qualities. Would it not be to his advantage to let go of his proclivity for the calculation of odds so that he could work fully on the positive aspects of dealing with his procedure? The question posed during the depth of his exercise attained unusual poignancy. In hypnosis, thoughts can often connect strongly to their corresponding emotions. It became clear that this was so. The procedure would be met with stability and poise. Could he clearly invite beneficent feelings to color his dream images? Everything that was to be done during the operation would be met with feelings of stability and equilibrium. Could he feel his unperturbed heart rate, envision an unwavering blood pressure and a comfortable enveloping sense of warmth? After several repetitions the visualization became firmly established in his mind.

The cardiac bypass was performed with the utmost ease. The surgeon reported that cardiovascular parameters had been remarkably stable. No flutter occurred. Post operatively, the patient learned to reproduce this hypnotic state by himself. His new self-hypnotic capacities enabled him to progressively strengthen his cardiac functions and to replenish his challenged self-esteem.

OPHTHALMOLOGIC DILEMMA

In the last several years, worries about his right eye increasingly plagued this retired stockbroker. Now at age 62, he fretted on the vagaries of his vision, even though his ophthalmologist had assured him that the problem was simply a benign cataract. Eventually, he was told, it could easily be corrected. "Not so easy in my mind " he said, "When I was 19, I got hit with a baseball in my left eye. Many years later I underwent a number of operations for retinal detachment. Unfortunately each operation could not prevent deterioration, and now I can only see some light and shadows. So with my left eye practically blind, Iím afraid for my right and frankly terrified to be completely blind." As a boy he recalled a blind man who lived in his neighborhood. One time he saw him trip on the curb and he distinctly remembered wondering how it could ever be possible to live like that.

As the cataract in his right eye worsened, his vision became severely compromised. He avoided walking in the street and taking buses. A decision had to be made. Either he allowed his sight to worsen relentlessly; or he took a chance on a benign procedure to regain clear vision. To clarify the medical realities of his situation his ophthalmologist was contacted. He confirmed that his cataract was not complicated by any other pathology.

He looked forward to a hypnotic exercise, expressing the hope that it could move him forward. Everyone has different gateways to hypnosis, and on first attempt he found a slight difficulty finding his own. Offhandedly, he mentioned being musically inclined. He could, upon prompting, "hear" music of his choice, although he made clear that the sounds he perceived were not like actual notes. More akin to distant impressions, he often conjured his favorite pieces and enjoyed his own creative renditions. One in particular, Bolero by Ravel, carried "happy vitality" and a certain engaging Èlan.

Boleroís melody, in his mindís ear, ushered him into hypnosis. He later described how the melody had gradually slowed down, finally reaching a standstill. His body followed. Sitting, eyes closed, breathing almost imperceptibly, he was presented with the following: "As you now come in contact with awareness of your body, it becomes possible to contact other dimensions of your mind. So let us contact a part of your mind that knows a lot about you, and maybe even everything. It knows about your past, your present, and possibly about your future. It also knows about the procedure you are facing. Let us call this part of you your wisdom mind. Your wisdom mind also knows about the fears your unconscious mind is creating to keep you safe. But your unconscious mind is acting in a reflex manner; it does not understand all the complexities of whatís involved. What is really best for you, your wisdom mind is aware of. Take as long as you like and let it offer you clarity about this situation."

He sat still for a full ten minutes, then slowly opened his eyes. Indeed, clarity had come to him. He likened it to fogging windows with his breath when he was a boy, then seeing the window become transparent again. It was evident to him that he should undergo the procedure. Anxiety disappeared. His cataract was removed without incident.

SUMMARY

Within the context of medical procedures, surgical interventions, and hospitalization, the science of human psychological adaptation has not kept pace with the meteoric advances witnessed in the technical dimensions of medicine. Techniques such as hypnosis and self-hypnosis, however, can easily be enlisted to enhance the well-being and adjustments patients make to their medical trajectories. The science of adaptation to medical stress incorporates the notion that beyond relaxation, patients can develop active and potent self-mastering strategies. Clinical examples illustrate the wide therapeutic spectrum these techniques have in all phases of diagnostic and operative interventions.

BIBLIOGRAPHY