Hypnosis and Human History
Schematically we can divide the history of hypnosis into 2 parts: the period before
the appearance of medical hypnosis and the period after. The continuum is not that
obvious but it already allows the layman to better understand what could be assimilated
to hypnosis and make it a corollary with modern times. At the time of the druids,
sorcerers, and other priests the hypnotic state was already widely used to induce
trance in particular to perform rituals and ceremonies, hypnosis was also used to
predict the future and already to heal. This is well documented for example 3000 years
ago in Egypt under Ramses 2 but also in ancient Greece. Of course in no case will
we find the appellation hypnotic state and even less medical hypnosis in these ancient
times.
Going back to the Middle Ages, one quickly understands why, under the dominant influence
of the Church, one passes from so-called ritual practices, commonplace, to practices
considered as occult. At the time, hypnosis was close to witchcraft.
It was not until 1778 with a famous German doctor in Paris, Franz-Anton Mesmer [1], that the theory of animal magnetism appeared: according to him, all beings are
traversed by magnetic fluids generating interactions among themselves and with celestial
bodies. According to Mesmer, a bad distribution of these fluids would be at the origin
of many diseases. Personalities such as Mozart or Marie-Antoinette will benefit from
his care where the patient is placed standing in a tub of "magnetized" water, holding
on to iron rods. It was not until a few years later that a medical commission created
under the impetus of Louis XVI and composed of people like Lavoisier and Franklin,
among others, discredited the care provided by Mesmer without, and this is certainly
the most striking fact, rejecting the possible therapeutic effects due, according
to them, to the «imagination». Despite this, Mesmerism will continue to be disseminated
in some universities.
From the Marquis de Puységur to Jean-Marie Charcot
The story will include periods of infatuation and abandonment and key characters such
as the Marquis de Puységur or James Braid who will be inspired by Mesmer in evolving
the very concept of hypnosis. The Marquis de Puységur will, among other things, define
a therapy based on speech in order to empower the patient. James Braid, a Scottish
surgeon, also gradually detached himself from mesmerism and defined hypnosis in 1843
as “A nervous sleep in which it is easy to plunge a person into using induction by fixation
on a shiny object” [2], he was even one of the precursors of hypnoanalgesia by putting it into practice
in his own operating room.
It was not until the end of the 19th century with Jean-Marie Charcot, a famous neurologist
at the Salpêtrière hospital in Paris, that the medical world began to revive the use
of hypnosis, and this did not stop afterwards. Yet at the time Charcot associated
hypnosis with a hysterical state and was opposed to another current of the Nancy school
represented by Hippolyte Bernheim which was based on the work of Braid. It is indeed
Bernheim who had advanced hypnosis in great strides, he described the powers of hypnosis
as the ability to inhibit pain, to produce a pleasant emotion, to inhibit anxieties ...
and above all a natural ability to be treated [3]. This is in direct opposition to Charcot who describes the hypnotic state as a hysterical
state, although wrongly this may have reintroduced hypnosis into large institutions.
Freud also benefited from Charcot’s courses by doing an internship there in 1929,
and Freud also attended classes at the Ecole de Nancy. Freud then rejected hypnosis
as random and developed psychoanalysis, however he wrote in 1923 “... psychoanalysis manages the legacy it has received from hypnosis.” This is best understood by knowing Freud’s student background [4].
Hypnosis will then go through a phase of decline, even if Bernheim’s theory is speaking
to us today, at the time its lack of explanation “by physiology” discredited it, even
if it took precedence over Charcot’s theory.
From Authoritarian to Permissive Hypnosis
Hypnosis will then evolve from an authoritarian to a more permissive mode. To better
understand this it is necessary to apprehend the techniques of Charcot, Braid, Freud...
as hypnosis techniques with a directive and authoritative practitioner, made of repetitions
of directive orders.
It was in the United States that Milton H. Erickson (1901–1981) quickly understood
why a significant proportion of the population claimed to be “resistant” to hypnosis.
For him it was logical that some people would want to oppose these orders. Erickson
detached himself from this dominant aspect of the therapist while remaining deeply
rooted in the relationship with the patient. Erickson brought the notion of proposals
rather than orders, he let the patient decide, gave him the power. Erickson is the
“how” to solve a problem rather than the “why” the problem is present. He redefined
the unconscious as a resource center, a data center, which everyone has at their disposal
and which allows them to solve their problems. Erickson proposed to the patient to
reach his resources through hypnosis, resources that he does not have spontaneous
access to [5]. In the United States, hypnosis will undergo a tremendous expansion during this
period, especially used to treat post-traumatic neurosis during the two world wars.
Research and its introduction into university teaching then gradually gave it an unavoidable
place. The development of scientific research allowed the medical community to adhere
to this powerful tool that is hypnosis. Among others, we must mention Professor E.
Hilgard who started his work at the end of the 1950 s.
We must mention those who brought the much later revival to Europe, Chertok, Michaux
Nardone... Chertok defined hypnosis as a “modified state of consciousness, in which
the operator can cause distortions in memory and sensory perceptions, in this case
in the processing of algogenic information”. Chertok allowed the entry of hypnosis
as a therapeutic practice in the early 1970 s in the hospital setting [6]. Other currents appeared later, variations of the previous techniques. We can cite
humanistic hypnosis dating from the early 2000 s, not discussed in this article.
Hypnosis in Scientific Literature
More than 300 randomized controlled trials and over 80 systematic reviews or meta-analyses
are indexed in the Medline database under the keyword "hypnosis".
Rainville [7] had profoundly modified the pathophysiological approach to hypnosis, in particular
by using MRI in 1999 and then in other works using PET (positron emission tomography),
which this time allowed a more precise observation of the active brain through local
variations in blood flow. This made it possible to demonstrate that during the hypnotic
state, areas such as the anterior cingulate cortex and the neuronal network involved
in pain (prefrontal cortex, striatum, insula...) are attenuated during painful stimuli.
It is also worth mentioning the work of Faymonville [8] and his team of anaesthetists at the University Hopital of Liège who published a
lot in the early 2000 s with the use of PET and showed that hypnosis is a particular
state of consciousness where a subject, in a semblance of drowsiness, experiences
a perennial and multimodal mental imagery, imagery that invades his consciousness.
This difference with the state of sleep was more easily demonstrated by Faymonville
who even associated polysomnography with PET to ensure the absence of true sleep. Indeed
this difference had been shown a few years earlier by the electroencephalogram of
a hypnotized subject but was still controversial.
Hundreds of studies have been carried out, both in the clinical and cognitive science
fields, and through these publications hypnosis regularly showed a beneficial effect
on pain and anxiety [9]. It would be difficult today to make a synthesis of all these works, as the scope
is so vast. What we know today in the light of these studies and modern imagery is
that hypnosis is not limited to a state but has an undeniable reality on the cerebral
level.
To conclude this point about this short review of the literature, an article published
in 2017 allows us to better understand the use of hypnosis in University Hospitals
in France [10]. The autors contacted every French University Hospital to find out if hypnosis was
practiced for the care of pain (hypnoanalgesia), for surgical procedures (hypnosedation)
and in adult psychiatry care units (hypnotherapy). Hypnoanalgesia is practiced by
all and two-thirds offer hypnosedation. Hypnotherapy is practiced by 40 % of the University
Hospitals. Therefore, hypnosis seems to have found its place in the care of pain and
as an anesthetic to replace standard procedures. However, the use of hypnotherapy
in psychiatry is less frequent. This shows us the place of hypnosis within the training
structures of today’s doctors.
Thermal Varicose Treatment and Hypnoanalgesia
Thermal varicose treatment for the treatment of varicose veins of the lower limbs
are safe and effective minimally invasive procedures, which are the subject of numerous
high-grade recommendations and used in daily practice. They are performed under local
anaesthesia. The steps of catheter insertion and tumescent anesthesia are often described
[10] by the patient as discomfort, anxiety and pain.
According to the International Association for the study of pain, pain is defined
as “an unpleasant sensory and emotional experience associated with actual or potential
tissue damage, or described in terms suggestive of such damage” [12]. Several theories try to explain what hypnoanalgesia is, neuro-physiological or
neuro physiopsychological approaches are well documented with authors such as Hilgard,
Barber, Peyro, Rainville. What seems to emerge from all this is that during hypnosis
it is described a reduction in the inhibition of mental and neurological representations
in competition with the implementation of a mechanism that will prevent the painful
information from reaching the cortical area that is usually dedicated to it and the
implementation of a mechanism to control somato-sensory information. There is no secretion
of endogenous opioids during hypnosis.
Hypnosis during a Thermal Varicose Vein Treatment About the Experience of a French
Center
Preoperative Consultation
The patient for whom an operative indication has been made for thermal varicose vein
treatment of one or more varicose venous trunks of the lower limbs will be offered
this consultation in the same way as an anaesthetic consultation, which of course
was not necessary before (all patients have only tumescent anaesthesia, which can
be supplemented according to the patient’s state of anxiety by the use of nitrous
oxide).
This pre-operative consultation is fundamental. The hypnosis we use is Ericksonian
hypnosis, what is its essence is the relationship between the practitioner performing
the hypnosis (who can be the surgeon (trained in hypnosis) or another person not practicing
the treatment of varicose veins) and his patient. The purpose of this consultation
will be to obtain an alliance. It will increase the subject’s adherence and participation,
decrease resistance and facilitate letting go. A patient who opposes hypnosis according
to his own beliefs is not a patient for whom hypnosis is indicated. Similarly, a patient
who does not adhere to hypnosis but asks for this technique on the advice of his entourage
is not a good indication.
We’re gonna have to explain to the patient what hypnosis is and its purpose. It is
important that the practitioner who performs hypnosis, especially if he or she is
not performing the procedure, knows what is going to happen. This will be important
during the pre-operative consultation but also during the procedure in order to detect
any undesirable or even harmful effects during the procedure.
The ideal is not to use the term hypnosis repeatedly, because the use that the film
industry or show business makes of it, deeply devalues medical hypnosis. It is necessary
to speak from experience, to give a concrete example of it, for example the phenomenon
of dissociation, the one that allows access to the data center, this is naturally
shared by each one of us daily in a controlled environment where automatism can take
control: for example driving, has it ever happened to you while driving that you get
lost in your thoughts? This is natural, however you often don’t remember certain sections
of the road you have taken while you were in your thoughts, this is called a dissociated
state, from which you naturally emerge when you need to. It is the same when you are
absorbed by a book or a good movie. It’s a spontaneous trance. This dissociation is
what the patient will experience during hypnosis, the idea being to give him access
to his data center to look for resources that will allow him to control his pain and
anxiety. Erickson started from the principle that we are all, from birth, equipped
with all the resources we need to face all the situations we will encounter.
In this consultation you will need to take the time to explain the process that will
be used, especially the 3 major times of the hypnosis session: induction, trance,
exit from the hypnotic state ([Table 2]).
Table 2
The 3 major times of an hypnosis session.
|
induction
|
restricting the field of consciousness, capturing the patient's attention, mental
and intellectual activity and directing towards internalized mental activity
|
|
trance
|
a high level of consciousness oriented towards the inner self, associated with an
attenuation of external vigilance
|
|
release from hypnotic state
|
return to a state of consciousness usual for the subject
|
What will also be important in this consultation will be to gather a lot of information
about the patient, including what makes him or her happy, the environments in which
he or she feels safe. In all these cases there must always be a positive interaction
with other individuals, this will help to identify so-called safe places, but beware a place where a patient feels good isolated from the rest of the world
is said to be a place of avoidance and will not be usable in hypnosis. Ask him/her
for details, especially sensory details, the colors of his/her memories, smells, noises...it
is important to remember that these are the details that will allow the patient to
access his/her data center.
Surgically, the patient will have to be re-explained all the steps of the surgery,
and no attempt should be made to reassure the patient about the sensations and pain
they may experience. Too many doctors try to minimize, but it is necessary to legitimize
the symptoms, to install the patient in reality and not to transform it. This is the
price you pay to gain his trust.
Induction Phase
It’s surgery day. This phase will begin as soon as the patient is installed in the
operating room and will immediately allow the patient to gain confidence. It is important
to keep the conception and the relationship to hypnosis simple. The goal of all hypnosis
is to allow the patient to access his resources. It is therefore necessary to connect
the patient with himself while stress forces him to control everything. There is no
single technique the important thing is to understand the concept, each patient is
different.
One technique is to go from the outside to the inside, the patient must become aware
of his body. Be aware of the position you are in by reading this article, it is the
same thing for a patient. Some examples:
“You are comfortably settled, you can feel good, You may feel a touch of air, you
can see light in this room, you can also close your eyes if you wish.”
“You hear sounds around you but they do not bother you, let my voice guide you. You
can talk if you wish.” Note here the permissive aspect, you have to leave the choice, otherwise resistance
will be generated.
“You feel the contact of your head with the table, you feel the whole of your body,
the air that enters your mouth, that flows down your throat and fills your lungs,
you feel the air that flows out and leaves room for a new burst...”.
Several techniques exist, of course it is difficult to describe everything here, the
important thing is to understand the concept. The objective is to restrict the field
of consciousness. Each caregiver during a painful act naturally does this, diverting
the patient’s attention, directing him towards happy moments in his own life, this
is called conversational hypnosis: “how many children do you have?”, “what are you going to do this weekend or during your holidays?”..
Don’t forget that the brain doesn’t hear negation. If I say “Don’t think about a red car” it doesn’t work, no need to explain it. By the way, observe it, it is the same with
pain, “it’s not going to hurt” is not a good approach. It will also often be necessary
to reframe the patient and go from “I am anxious” to “I feel anxious”. Your goal here
is to get the patient’s attention. The people working with you need to know this beforehand
of course, you need to limit noise and background interactions.
Hypnotic Trance
The step following induction is the hypnotic trance. It is a state of high consciousness,
an inward orientation of the patient with an attenuation of external vigilance. Signs
such as a fixed gaze, the tendency that the patient will develop to do what you ask
him/her to do, a very high sensitivity to suggestions, paleness... are all signs that
indicate that the trance state is installed. The patient may describe sensations of
heaviness, lightness, paresthesias, changes in body schema, sensation of being here
and elsewhere.
Beforehand, we can agree with the patient on gestures, small movements that will allow
us to make sure of his well being in this phase. This is when the patient will be
able to access his inner resources. You should not ask the patient to respond to you
with words.
To maintain this phase there again many techniques exist. It will be necessary to
communicate according to what you have decided with your patient. It is important
to keep in mind that for the practitioner there is no need to talk continuously, you
must keep a slow pace. You can use the sensitive details given to you by the patient
during the initial consultation or use other procedures such as suggestions, questions,
confusion, sensory alteration... This phase should start just before the first painful
gestures such as catheter insertion but must stop before the thermal ablation. The
power of hypnosis should not be underestimated; to deprive oneself of the patient’s
feedback on the phase of application of caloric energy within the vein, which must
be painless, would be a mistake and potentially a source of injury. It is also important
to keep in mind that the patient is conscious. He must be reassured about what is
happening, the practitioner must not let any signs of anxiety appear in his voice,
and he must remain congruent (like telling an angry child to calm down by shouting
it out, this is often counterproductive). Similarly, the patient may or may not perceive
sensations. You will have to accompany them, bring the patient a “neo-reality”, for
example when you disinfect the operating area, say that he will feel a cold liquid
running down his leg, put it in the context of his holidays, with hot weather for
example, the patient will then associate this with a pleasant memory.
Release from Hypnotic State
This step must be systematic, we have to let the patient return to his usual state
of consciousness, make him regain awareness of his surroundings, of the operating
room, of the people who are there.. It can be suggested that the patient forget the
unpleasant moments of the surgery, explain that he will feel tension in the treated
area but that this is positive and corresponds to the healing phase. Project him on
his future state, on the follow-up consultation. The return is the moment that will
allow the patient to regain his ordinary consciousness. It is also a crucial moment
because the experience lived in trance will be integrated for the first time in the
patient and in his life. Also, at the end of the treatment, the therapist and the
patient discuss the effects of the trance on the patient and the therapist interprets
them in a way that helps the subject to understand what he or she felt.
Patients will almost always describe hypnosis as a relaxing experience, a moment of
well-being. For some the pain for the entire surgery is nil, for others the pain have
been transformed by a simple discomfort. However do not forget that some patients
refuse and that the failure of the technique outside of your own skills as a hypnotherapist
also comes from a bad selection or preparation of your patients. Finally, we can also
draw attention to the fact that many publications demonstrate the positive impact
of hypnosis on healing and more generally on the improvement of the postoperative
phase. These publications can also be found in the obstetrical field. Hypnosis occupies
a non-negligible place in pediatrics, but also in palliative care. Emergency departments
are increasingly training their nursing staff to manage acute pain.
Side effects are rare. Some mild effects have been described in the literature: Asthenia,
dizziness, anxiety, headache, feeling unwell.
