Case Study 1: Karie is an 8 year old girl who has end stage renal disease from obstructive uropathy, she developed hypertensive crises, and PICU management. She emerged from the process feeling frightened & vulnerable.
Her erythropoietin injections became the weekly focus of this fear & anxiety. It took 20 min of discussion &negotiation to give the injection. Her pediatrician recommended hypnosis to diminish her procedure associated fear & anxiety.
She was given an introductory pamphlet on hypnosis to read and share with her parents. After two visits using hypnosis, she used her relaxation for all her injections. Her mother now injects Karie's GH & erythropoietin at home.
Case Study 2: Seven-year old Sarah came to the office with a facial laceration requiring sutures. Her anxiety was controlled effectively when she was taught to focus her attention on breathing and change her perception of discomfort. Upon leaving the office, she told her mother, "This is the best day of my life!"
HYPNOSISis a term coined in the mid 1800 by the English surgeon James Braid from the Greek, hypnos, for sleep. Braid reviewed, as a complete skeptic, the controversial work on "animal magnetism" of the Frenchman Antonie Mesmer, some 60 yrs before him.
Although Braid refuted Mesmer's theory that induced magnetic fields were the medium of behavioral change in his subjects, he reasoned that some innate ability involving imagination was the core of hypnotic phenomena.
Hypnotic capacity is the ability to focus narrowly & intensify one's concentration & perception while reciprocally diminishing awareness of all other stimuli.
Children are particularly endowed with the ability to use hypnosis to modify their behavior & psychology. This is not surprising; their lack of experience allows them to blur the boundaries between our rational world & their inner world of imagination.
Too often our medical therapeutics devalues the child's inner world. The attitude & belief systems we present to youngsters can & do affect their behavior, including their responses to therapeutic interventions. Hypnosis builds a bridge between the child's inner world & real therapeutic change.
Children & adolescents benefit from learning self regulation by assuming a more central role in their therapy. The confidence & ability they achieve enhances self-esteem.
What is Hypnosis? We all enter hypnotic trance states frequently & intentionally, as in deep thought or prayer. Fear & anger can trigger spontaneous trance states. With children, often in medical settings, we call these tantrums.
The person in hypnosis is more willful than in usual, less intense states of awareness. He or she is mentally active rather than passive. Young children are likely to their eyes open & remain physically active in hypnosis.
There are no unique physical or physiologic manifestations of hypnotic trances.
Although the theoretical bases of what constitutes the psycho-socio-cultural aspects of hypnosis are debated, hypnotic phenomena are not in dispute.
Hypnosis is not a placebo effect. Studies of transduction of neurologic impulses at the thalamus to affect endocrine, immune, & autonomic activity & their links to state dependent learning are well described.
The emerging fields of psychoneuroimmunology & neuroendocrinology have clinical roots & leaves in the evolution of modern clinical hypnosis.
Although hypnosis uses imagination, relaxation, & imagery, it is more than these exercises. Thus, many prefer to use the historically accurate & more general term“Hypnosis".
What is Achievable with Hypnosis? It is used for managing pain, irritating medication side effects. As children can alter their responses to painful stimuli, airway reactivity, salivary IG A, brainstem evokes responses, peripheral blood flow, electro-dermal activity & even neutrophil adhesiveness via hypnosis in structured lab settings.
Hypnosis has been shown to reduce childhood migraine more effectively than propranolol or placebo. It also helps to reduce emesis in patients with ALL. It is also successful in ER, diminishing anxiety during immunization.SEE TABLE 1.
Methodology: Can be divided into 4 steps; Fig 1; but these steps represent a continuum of interaction with the child, & throughout the practitioner's language is important.
Language: The tone, pace, & semantics all must suggest confidence in the child's ability, creating a sense of positive expectancy. Words as try, perhaps, maybe, can, & might are less effective than will & is.
Rapport: The 1st step establishes therapeutic rapport by assessing & joining in the young person's motivation & goals. Take a good history & use the opportunity to teach about the pathogenesis of the symptoms & the methods of treatment, including hypnosis.
Trance Initiation (Induction): There are innumerable methods for helping children narrow their focus of concentration & absorb their imagination. Possible methods by age group are presented in Fig 2.
Therapy in Trance: This often follows from the trance initiation technique as in, "Now that you're enjoying swimming in your magic swimming pool, you'll begin to notice that relaxed numbness in your back. Can you? See how your back does not mind the needle touching you? Isn't that interesting?"
Kohen, September 1994, university of Minnesota, Division of Behavioral Pediatrics, personal communication, has complied ten "hypnotic methodologies" for reducing pain & suffering among children. Table 3.
Ratification & Reflection: After the child is asked to return to "usual awareness" or to "finish imaging for now," the experience is reviewed. This helps the youngster confirm & understand the experience.
The child knows that he or she has shifted away from being entranced by pain & anxiety. A simple statement of the truth- "Well, now you know how to do it!"- may be enough. Excessive praise is stigmatizing & detrimental.
This is the time to ask for feedback from the child. For example, "Did I say or do anything that made you uncomfortable or that you did not like?"
Practical Applications A common misconception is that the practice of clinical hypnosis requires a large amount of time beyond that of the normal patient care. This is understandable but incorrect. This time required varies with the context, rapport, & experience of the practitioner.
For example using hypnosis in the process of giving injection to the child; when the injection is over & the child realizes his or her success at self control, the practitioner can say, "Now you know how to make painful things bother you less." This adds no time to the visit & may reduce the time required with that child at future visits.
Hypnosis can be taught during consultations for specific problems. This takes the young person out of the often fearful setting of an office visit. An audiotape of the hypnosis session can be given to the child to use at home. Consultations often take less than 30 minutes at the beginning or end of the daily schedule. These can be the most rewarding of clinical encounters for the child & the practitioner.
Parents' Roles The role of parents in hypnotherapy is pivotal because they 1- So often transmit their anxiety to the child. 2- Have great insight into their child's experiences & 3- Have preconceptions about hypnosis that may either interfere with or aid their child's therapy.
Educational pamphlets on hypnosis, videotapes, & teaching parents about hypnosis all are useful methods to gain their understanding & support in the process. Methods of hypnosis can be a natural addition to parenting.
In general, there is a positive correlation between the young's person needs for autonomy & the degree of parental involvement. Issues of dependency, which often "cloud" chronic diseases & psycho -physiologic symptoms, may impair the therapeutic rapport & motivation of the child who is in hypnotherapy.
Family therapy may be indicated before parents can allow children to develop mastery over their discomfort or behavior.
Training As with other therapeutic skills, training & ongoing evaluation are crucial. The practitioner learning about hypnotherapy should enroll in a basic workshop sponsored by the Society for Behavioral Pediatrics, the Society for Clinical & Experimental Hypnosis, the American Society of Clinical Hypnosis, or at the University school of medicine or a department of psychology. There's a 3 part examination which include written, oral, & practical clinical demonstration sections.