Hypnosis-facilitated relaxation using self-guided imagery during dermatologic procedures

American Journal of Clinical Hypnosis,  Jan 2003  by Shenefelt, Philip D

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Many patients experience some degree of anxiety and/or discomfort during dermatologic procedures. For most patients this anxiety or discomfort is tolerable, but a few find it intolerable to the point of interference with the accomplishment of the procedure. A case is presented in which a 51-year-old female experienced so much anxiety that it jeopardized the continuation of a necessary procedure. When (with her consent) a trance state was induced through hypnosis, she relaxed and remained in a pleasant mental condition for the remainder of the procedure. This case illustrates the usefulness of hypnosis in selected situations where it can alleviate anxiety and discomfort associated with dermatologic procedures. Suggested trance induction, maintenance, and termination scripts are included to assist those with adequate training and experience in providing this comfort to selected patients through hypnosis.

Key Words: Analgesia, anxiety, dermatology, hypnosis, imagery, melanoma, selfguided

Introduction

Hypnosis is a tool with multiple uses in dermatology (Shenefelt, 2000). It can help reduce anxiety, needle phobia, and pain during dermatologic surgery, as well as reduce postoperative discomfort. The utility of hypnosis for relief of pain during surgery has been known for centuries. Nevertheless, it is still infrequently employed in mainstream modern medical practice. James Esdaile (1850/1957) reported his success beginning in 1845 in achieving hypnotic anesthesia while performing surgery in Calcutta, India. Over a period of seven years he performed over two thousand pain-free operations. Of these about three hundred were what would be considered major surgeries such as amputations; the remainder were minor surgeries. Unfortunately, when Esdaile returned to Scotland in 1852 his use of hypnoanesthesia was rejected by the majority of his colleagues. Following the discovery of inhalation anesthesia with ether or chloroform, hypnoanesthesia for major surgery was largely abandoned, despite its advantage in lessening intra-operative and postoperative shock (Watkins 1987, p. 12).

With the recent emphasis on adequate pain management in patient care, innovative means of pain control such as hypnosis during minor procedures are again gaining some favor in mainstream medicine. Marmer (1959, p. 65) stated that indications for the use of hypnosis in anesthesiology are: 1) to overcome fear, apprehension and anxiety; 2) to induce analgesia and anesthesia; 3) to raise the pain threshold postoperatively; and/or 4) to aid in postoperative recovery.

A hypnotic state is a temporary condition of altered attention in an individual, a natural part of human behavior that affects the person's psychological, social, and physical experience. A hypnotist is a person who assists another to enter, maintain, and end a hypnotic state. Self-hypnosis features self-direction in entering, maintaining, and ending a hypnotic state. Essentially all hypnosis is really self-hypnosis, with or without the assistance of another person, audiotape, videotape, or other device (Watkins, 1987). On a broader level, we all enter altered states daily. Examples include absorption while watching a movie or television or reading. Other altered states include active imagination, daydreaming, fantasy, guided imagery or visualization, kundalini experience, lucid dreaming, meditation, out of body experience, and shamanic trance.

Fick, Lang, Logan, Lutgendorf, and Benotsch (1999) used self-guided imagery content during non-pharmacologic analgesia in the radiology procedure suite on 56 non-selected patients referred for interventional procedures. They were guided into a state of self-hypnotic relaxation according to a standardized protocol and script. Providers had been trained in advanced rapport techniques and hypnosis interventions with didactic instruction and role play, study of a treatment manual and video, and supervised practice. Subsequently, patient hypnotizability was assessed with the Hypnotic Induction Profile (HIP). They found that all 56 patients developed an imaginary scenario and that the chosen imagery was highly individualistic. Imaginary scenarios included nature scenes at a beach, a walk, travel scenes involving a drive, cruise, or trip, or while floating down a river or through the air. Other images were of family or home activities or personal skills, hobbies, or tasks such as woodworking, fishing, dancing, etc. The authors concluded that average patients can engage in imagery, and topics chosen are highly individualistic. They also found the use of pre-recorded tapes or provider directed imagery likely to be less effective than self-directed imagery.

According to Rudyard Kipling, "Words are the most powerful drugs used by mankind." Aldous Huxley said that "Words have a magical effect in the way they affect the minds of men," and Mark Twain quipped that "The difference between the right word and the almost right word, is like the difference between lightning and the lightning bug!" (Marmer, 1959, p 115). Words can have a special impact when used to induce an altered state of consciousness such as a hypnotic state. In the setting of dermatologic surgery, words can guide a patient into a state of self-directed imagery that produces relaxation and comfort during the procedure.