Barber, Theodore Xenophon (1956). ‘Sleep’ and ‘hypnosis’: A reappraisal. Journal of Clinical and Experimental Hypnosis, 4, 141-159.
NOTES
“Some recent experiments and a reevaluation of the electroencephalographic findings indicate that the term ‘hypnosis’ has subsumed at least two more or less distinct phenomena: (a) ‘hypnosis’ preceded by ‘trance-inducing suggestions’ which is closely related to ‘light sleep’ and (b) ‘hypnosis’ without ‘trance-inducing suggestions’ which is often a ‘waking’ state.
“From this viewpoint we can begin to reevaluate the contradictory physiological experiments comparing sleep and hypnosis, the most favorable conditions for producing hypnosis, amnesia and decreased suggestibility in very deep hypnosis, and the reports of waking and sleeping hypnosis. We can also reappraise such thorny problems in hypnotic theory as the production of hypnosis by artificial means, autohypnosis, and animal hypnosis.
“The argument presented calls for further research. We should investigate (a) suggestibility during extreme relaxation; (b) response on hypnotic tests when the subject is told, “Go to sleep and I’ll be back later to give you some tests’; (c) deep trance phenomena during sleep; (d) hypnotizability of good sleepers and insomniacs; (e) beneficial suggestions during sleep; (f) physiological functions during ‘light sleep’ and hypnosis; (g) the response of ‘sleep-walkers’ to standard hypnotic tests; (h) the relationship of ‘light sleep’ dreams to hypnotically induced dreams; and (i) the relationship of sleep amnesia to hypnotic amnesia” (pp. 153-154).
SURGERY
1995
Lang, Elvira V.; Joyce, Janet S.; Spiegel, David; Hamilton, Donna; Lee, Kelvin K. (1995, November). Self-hypnotic relaxation: Effect on use of intravenous medication during invasive procedures. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental
NOTES
I’m an interventional radiologist. Interventional radiologists do things like placing needles into the body, putting guide wires through them, advancing instruments (to get into vessels, to treat blockages, make diagnoses, drain urine, drain pus, remove gall stones) while progress is imaged. Procedures are usually performed on awake patients and may take 1-5 hours. Traditionally intravenous drugs are given for these procedures, most commonly a mixture of morphine derivatives and sedatives. Annually about 10 million invasive procedures are performed in the U.S. Among those 47,000 patients per year are estimated to be at risk of serious cardiovascular complications and 2,600 patients per year are estimated to die as a direct consequence of sedation. Hospital regulations also require a dedicated observer to be with the patient throughout the entire procedure and for extended times afterwards, when any intravenous drugs are given. This becomes very expensive.
We started self-hypnotic relaxation with patients because of a nursing shortage. We used rapport techniques, relaxation training, imagery (neutralizing distressing imagery, enhancing pleasant imagery) and suggestions. Members of the procedure team apply these methods while the procedure takes place. During the time patients are prepared for the procedure, induction can be performed. Hypnosis can also be initiated in the procedure room, and a nurse or assistant reads a script. We give patients control over what happens, over the whole process, including even rejection of the self-hypnotic process.
We did a randomized study with male veterans. Sixteen were attributed to a self- hypnotic relaxation group, 14 served as a control group. All patients had access to patient control intravenous analgesia. We assessed pain and anxiety on visual analogue self rating scales giving intensities between 0 (none at all) to 10 (maximum). We also recorded increases in blood pressure and heart rate, side effects that could be attributed to drugs or overexcitation. In the self-hypnotic relaxation group 50% of the patients reported distressing imagery at the onset. We helped them transform this negative imagery into imagery with neutral content, then enhanced the pleasant imagery, (often a pleasant scene at home). Twelve of 16 patients in the self-hypnosis group did not request medication at all; and only 1 in the control group did not request medication. The maximum pain perception was significantly less (2 vs 5) and procedural interruptions were fewer (2 vs 7) for the self-hypnosis group. There was no difference in the increases in blood pressure and heart rate.
We concluded that use of self-hypnotic relaxation is a valuable adjunct for invasive procedures.
1993
Bejenke, Christel J. (1993, October). A clinician’s perspective. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
Presents point of view of a private practice anesthesiologist in Santa Barbara, California. Used hypnosis for 20 years.
Use of hypnosis as hypnoanesthesia is rare since Esdaile, with brief resurgence in 50’s, because surgery techniques advanced before anesthesias did in areas that were very risky. Now it is a matter of choice, and may be undertaken because of a patient’s extreme fear of anesthesia, previous bad experience with anesthesia, fervent belief in holistic method, allergy, or previous experience with hypnosis. Still advised to use hypnosis for MRIs, radiation procedures, former drug addicts (who may have problems with drugs), burn patients, release of neck contractions, and medical procedures–especially with children–like lumbar puncture.
She disagrees with Kroger’s estimate of only 10% of patients being able to use hypnoanesthesia; she does not believe it requires a lot of training, or profound muscle relaxation.
There is no indication of how many cases are actually done with hypnosis. Also, published cases are not representative of the quantity or complexity of cases; most published cases have a few extraordinary characteristics. The Irish surgeon Jack Gibson has done more than 4000 cases, some very complicated.
I have used it for D & Cs, and complex cases that were not published. Most of my patients elected to be alert during the hypnosis and conversed with their surgeons. The most common benefit is that recovery from anesthesia is not necessary; but these days with newer anesthesias recovery from anesthesia is rapid anyway. However, if as we suspect anesthesia affects immune function, that would be another reason to use hypnosis.
Preparation for surgery may be of three types: 1. formal hypnosis techniques 2. “hypnoidal” techniques that aren’t formal 3. unprepared patients in whom hypnosis is used at last moment.
Examples. 1. Formal hypnosis: This symposium deals with this type of approach. Three groups derive particular benefit — those requiring prolonged artificial ventilation postoperatively (because otherwise sedation must be used, which leads to complications), where prepared patients tolerate interventions calmly and comfortably — cancer patients, for whom this can be first experience of patient to see self as active participant in care rather than a victim of the illness and of complicated technology — pediatric patients. 2. Hypnoidal (hypnosis like) techniques: This is the most important application. Time doesn’t permit much discussion here. Patients are in an altered state when they come for surgery, highly suggestible, and suggestions appear to be as effective as during formal trance state. The doctor can elicit positive responses during “casual conversation” while seemingly giving information to the patient. (The reverse is true also, with inadvertent negative suggestions, to the detriment of the patient.) Scrupulous adherence to medical facts is important during this type of conversation.
Operating room fixtures are useful for focus of attention, and I have published this information in an article.
Recovery room also is place where case specific information and appropriate suggestions can be given. Patient can experience his ability to alter sensations, for the first time, following suggestions.
Remainder of the hospitalization offers opportunity for reinforcing case specific positive suggestions.
Bennett, Henry L. (1993, October). Hypnosis and suggestion in anesthesiology and surgery. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
He began by saying that he is opposed to using hypnosis for surgery, though he favors a theory of how hypnosis effects physiological change, and cites T. X. Barber’s classic “Changing Unchanging Bodily Processes.”
Relaxation puts patient in a “psychological strait jacket” because surgery is so highly stressful. He gives information “about how to go through the surgery more comfortably,” gets across the idea about coping style, tells them surgery is exertional and that they are tired afterward, that he can help them “using things you already know how to do,” and specifies exactly what they can do–using model of himself as a trainer.
In some recent research he used pairs of pictures, some of which lead to pupillary constriction (blood pressure goes down) or dilation (blood pressure goes up). Instructing them to look, patients looked twice as long at the pictures than they did during free gaze. When not instructed to look, heart rate went down; when told to look, heart rate went up. So the researchers went back to free gaze. He uses this as a metaphor for many of the pre- surgery preparation activities that encourage relaxation “inappropriately.”
He cites Cohen & Lazarus re vigilant copers, Price et al (1957), and some other studies on epinephrine effects. He uses examples of work patients may have done (e.g. planting a garden) when talking with patients prior to surgery, that gives them a sense of accomplishment later.
You have to give specific instructions or suggestion, not general relaxation suggestions.
Question from the audience: Can preoperative instructions (not hypnosis) diminish blood loss.
In Bennett’s answer he seems to be reporting the earlier study: they found 150- 4000 cc blood loss, high variability. Extent of blood loss was determined by extent of surgery, by instructions to patients vs no instructions.
This study was replicated by Enqvist, Bystedt, & von Konow in the Anesthesia conference at Emory University in 1992.
May 1993 Western Journal of Medicine article, Disbrow, Bennett, & Owinos, with 40 lower abdominal surgery patients who got specific instructions or not. The SHCS was used to measure hypnotizability: highs resolved quicker than low hypnotizable patients. They also found that instructed patients did better than those who did not get specific instructions.
There are now 3 replications of McClintock’s study: people use less medications after surgery, when tapes about rapid recovery are played *during* surgery.
Bennett is now using tapes with suggestions for recovery during surgery.
Blankfield, Robert P. (1993, October). Suggestion, hypnosis, and relaxation as adjuncts for surgery patients: Lessons from studies involving cardiac surgery patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
The author stated that his research and the few other studies of cardiac surgery patients do not support idea that cardiac surgery patients benefit from hypnosis and suggestion.
Types of intervention have varied: hypnosis, suggestion, relaxation; pre-op, during, or post-op; with many different outcome variables.
Aiken & Henrichs (1971) study was nonrandomized, nonblinded, for 30 patients getting open heart surgery. Treated patients had benefits.
Surman, Hackett, Silverberg, & Behrendt (1974) had a randomized, single-blind design for 40 patients taught Self Hypnosis (S-H), for elective mitral valve surgery. No difference in benefits. But 45% of patients taught S-H reported a subjective sense of benefit (though objective indicators didn’t support that). [He says the difference between subjective/objective outcome ratings is important.]
Hart (1980) used randomized, single-blind design for 40 patients who had open heart surgery. No differences found except initial 3 days post surgery.
Greenleaf et al (1992) – see her paper presentation of this date.
Blankfield et al (presented at Society of Clinical and Experimental Hypnosis meeting in 1992) used a randomized, single-blind design for 95 patients, who were randomly assigned to taped suggestions, music, or controls. No differences were found in benefits.
Our data were re-analyzed: patients who felt tape was helpful were compared to the remaining 62 patients, but there again were no differences in amount of narcotics used for pain, though there was a trend in the right direction; nursing assessments failed to identify less anxiety.
The point is, whereas the bulk of publications suggest benefits, there is little evidence with this population. Could these patients be different in personality, ability to respond to intervention, amount of external stimuli? They should be studied because there are a lot of these patients with only a few surgeons and you don’t have to gain the cooperation of a lot of different surgeons to do this kind of research. Also, there is uniformity in cardiac surgery whereas standard operating surgery is in a state of flux in other areas (e.g. movement from generous incisions to micro procedures, and patients receiving this type of surgery remain in hospital for a week whereas this opportunity to study them during inpatient post-surgical period is disappearing in other areas). It is my opinion that cardiac patients may not be highly receptive to suggestion.
Curiously, according to Surman and my research, 1/2 the subjects report benefits. Either some benefits are subtle, or they are reporting a placebo effect.
Future studies need more patients, and the investigators must stratify on personality inventory variables such as Type A personality, hypnotizability, motivation, anxiety, depression, family support, social support systems. This is labor intensive, to determine which characteristics determine differing outcomes. The patients used in this type of research require more presurgery evaluation than previously has occurred.
The MMPI can be self administered and is widely acceptable, but is cumbersome, not well suited to people who are acutely ill. Assessment of Type A personality is important because Type A’s might be less receptive to suggestion. Structured interview is time consuming, but a 52-item questionnaire can be self administered. Other factors listed above are important.
Don, Norman S. (1993, October). Trance surgery in Brazil. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
Showed a videotape of a Brazilian trance surgeon, who cuts without analgesia or asepsis. Patients later report no pain, infections, etc. The healer/surgeon is believed by everyone to be in a trance state, and the body is believed to be taken over by a spiritual doctor. The people involved deny that the patient is in trance.
Greenleaf, Marcia; Fisher, Stanley; Miaskowski, Christine; Du Hamel, Katherine (1993). Hypnotizability and recovery from cardiac surgery. American Journal of Clinical Hypnosis, 35, 119-128.
NOTES
Notes were taken from author’s presentation of this material at the Annual Meeting of the Society of Clinical and Experimental Hypnosis, Arlington Heights, Illinois. The paper presentation was part of a Symposium: Towards a Theory of Surgery: Hypnosis, Suggestion, Anesthesiology and Surgery, Methodological and Theoretical Issues and Dilemmas.
Authors outlined the reported advantages of using hypnosis. Their review found problems in much of the research on this topic published to date: many single subject studies, subjects were often selected and trained by the investigator, hypnotizability wasn’t evaluated.
Used the Hypnotic Induction Profile (HIP) before assignment of patients to groups, and also equated groups for age. Groups 1 & 2 had formal hypnosis and then either relaxation-imagery (Jancks’ autogenic training) or specific outcome suggestions (e.g. to have a clean dry wound, and to look forward to being able to function well); Group 3 were controls.
No differences were found in outcome measures of length of time in ICU, time on respirator, length of stay, and cumulative index of recovery. Didn’t publish our data on pain medications because learned it was poorly charted.
Only difference found was: the relaxation imagery group got more wound drainage. It was degree of hypnotizability, independent of group, that made a difference in total number of hours on Nipride – highs were on it almost twice as long. On cumulative stability (having need of medications or respirator) the mid-range people did better. Not statistically significant but nevertheless clinically important, the lows were in the hospital 5 days longer.
This was counter-intuitive though it supports Herbert Spiegel’s theory. We, as experimenters, were independent of the treatment team. We didn’t have DRGs then and now we may have hit a ceiling effect in the amount of time people stayed in the hospital, because they had excellent pre-surgery education.
We had difficulty continuing the study because the intervention seemed to other staff to be so useful: after 6 months the surgeons began requesting hypnosis for their anxious patients; the chief anesthesiologist had started using it routinely.
Sample size is problematic. They were patients who were actively recruited, not people who sought hypnosis.
CONCLUSIONS. High hypnotizables in the hospital intensive care unit (ICU) demonstrate sensitivity to external stimuli without critical ability to screen; we see this reversed in the postoperative period. Mid range hypnotizables can decide which external cues to pay attention to. Lows are less able to incorporate new suggestions. They are bound by pre-existing views and also vigilance.
Hypnosis = Dissociation + Absorption + Suggestibility (Spiegel’s theory)
We must focus more on the state-trait phenomena, the context, and then select the treatment.
Kessler, Roger S. (1993, October). Suggestion and hypnosis in anesthesiology and surgery: A simple and complicated analysis. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington Heights, IL.
NOTES
Cites three reviews: Blankenfield; Rogers & Reich; and Mumford. These reviews leave us with several questions: – What does the addition of hypnosis add? – What is importance of hypnotic ability? – What techniques are most effective? – How useful are standardized tailored interventions? – What are psychological, physiological, and biochemical markers?
We lack a general theoretical framework (see H. Bennett), and there are a broad variety of pre-surgical interventions, which may influence different aspects of functioning.
Evans & Richardson found no differences between people with and without preparatory interventions. Bonke & colleagues found no differences in length of hospitalization for people with and without preparatory interventions (except for people 55 and over). Relaxation training for surgery finds mixed results.
Blankenfield obtained negative findings in cardiac surgery. His recent IJCEH article reports those negative results.
What does presurgical intervention influence? – Psychological dimensions – Biochemical & physiological dimensions – Time/cost dimensions
Correspondence across these dimensions has not been consistently demonstrated, e.g. there is a lack of correlation between cortisol (physiological dimension) and anxiety (psychological dimension).
Why are there conflicting findings? 1. Possibly patient’s coping style is responded to inappropriately, e.g. people who deny vs those who sensitize seem to require different interventions. Must assess the patient’s idiosyncratic coping style. 2. Four studies suggest hypnotic ability may be a factor in recovery.
a. Disbrow, Bennett, & Owings (1993)
b. Rondi et al. (high hypnotizables use less morphine via Patient Controlled Analgesia)
c. Greenleaf et al. (hypnotizability predicts recovery independently)
d. Rapkin, Straubing, & Holroyd (high hypnotizables had less blood loss during surgery) 3. Is hypnosis per se necessary?
Comparative evaluation of strategies has been ignored. Enqist found hypnosis had a greater effect than non-hypnotic treatment in blood loss. Another study of bone marrow transplant patients found the hypnosis treatment superior.
When it comes to clinical interventions, we need to assess the patient’s historic and current beliefs, their experience with medical procedures, their coping style, and then form a brief tailored intervention.
1992
Adams, P. C.; Stenn, P. G. (1992). Liver biopsy under hypnosis. Journal of Clinical Gastroenterology, 15, 122-124.
Two patients underwent outpatient percutaneous liver biopsy under hypnosis without complications. One patient had severe anxiety about the procedure because of a previous adverse experience with liver biopsy, and the other had a history of severe allergy to local anesthesia. Both patients had undergone a session of hypnosis at least once prior to the biopsy. One received no local anesthesia, and the other received 1% lidocaine as a local anesthetic. Both patients were completely cooperative during the procedure with the required respiratory maneuvers. Both patients stated that they were aware of the procedure under hypnosis but described no pain and would be most willing to have the procedure done under hypnosis in the future.
Alden, Phyllis (1992, October). The use of hypnosis in the management of pain on a spinal injuries unit. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
NOTES
[Author is at Royal National Hospital in England]
To have a spinal injury is one of the most devastating injuries that can happen, reducing you suddenly from a normal life to situation of loss of control, helplessness, etc.- -with nothing to say about what is being done in surgery or other aspects of treatment.
In UK patients come for acute care and rehabilitation all in one place. Over 2 1/2 yrs we had 46 referrals. 7 refused hypnosis (“witch doctoring”). 30 benefitted
Anonymous (1992, May). Studies: Learning can occur while under anesthesia. Daily Breeze (South Bay, Los Angeles County).
NOTES
Surgical patients can absorb information while they’re knocked out, and even learn tips that help with recovery, researchers reported Friday at a symposium on memory and anesthesia.
“Researchers at Papworth Hospital in Cambridge, England, studied 51 cardiac patients, one-third of whom heard a tape of positive ‘therapeutic suggestions’ during surgery. Another third heard batches of word associations; the rest heard a blank tape.
“Patients who were played the suggestion tape – which told them they were doing well, or wouldn’t feel much pain – left the hospital 1 1/2 days earlier on average than other patients.
“Another study, from the University of Arizona College of Medicine, found that surgical patients who heard specific pain-relief suggestions recovered more easily than those hearing vague advice such as, ‘Think of being well.’
“‘These are still early days to invest in every operating suite buying a tape recorder to play for the patients,’ said Dr. Sunit Ghosh, a researcher with the Papworth team. ‘But this definitely does hold promise.’
“Scholars at the second annual Symposium on Memory and Awareness in Anesthesia said patients rarely wake up recalling – unprompted – something that happened during anesthesia.
“But several studies showed subconscious learning while the patients were out cold.
“Not everyone accepted the findings.
“‘It shows an enormous sensitivity on the part of the brain, if it can be shown,’ said Eugene Winograd, an Emory University psychologist and organizer of the Emory- sponsored conference. ‘I’m not confident it has been shown yet.’
“Some researchers in other studies found no association between messages heard during anesthesia and learning.
“Dr. Alan Aitkenhead, professor of anesthesia at the University of Nottingham in England, found no significant difference between patients who heard recuperative suggestions and patients who were treated to a deliberately dull history of the hospital where they were.
“Aitkenhead said his study kept all patients quite deeply anesthetized, and that may be why they might not have learned as much as patients in other studies.
“‘By far, most likely, it’s a difference in levels of anesthesia,’ he said.
“The Papworth researchers, in another study, found that some patients showed strong word associations after hearing tapes of groups of words during surgery; but other patients under a different anesthesia didn’t.
“‘There needs to be standardization of our testing,’ Ghosh said. ‘I think it’s partly related to the anesthesia technique and partly related to the way in which material is presented to the patient.’
“Dr. Peter Sebel, an Emory anesthesiologist and conference organizer, said that if patients can retain information about a speedy recovery, they probably retain other information, too – for example, a surgeon’s discouraging operating-room assessment of their prognosis.”
Blankfield, Robert; Scheurman, Kathleen; Bittel, Sue; Alemagno, Sonia; Flocke, Sue; Zyzanski, Stephen (1992, October). Taped therapeutic suggestions and taped music as adjuncts in the care of coronary artery bypass graft patients. [Paper] Presented at the annual meeting of the Society for Clinical and Experimental Hypnosis, Arlington, VA.
NOTES
18 studies have explored the issue with an experimental design; half used tapes, half didn’t; majority of studies found benefits; 2 were of heart surgery patients.
This study used taped suggestions with coronary bypass patients. Used tape recorder rather than person delivering suggestions because it was more convenient; used tape intra-surgery and post-operatively for more impact.
We hypothesized: shorter length of stay, less narcotic analgesia, less anxiety, faster recovery, more positive mental outlook, resume activities sooner, have less symptoms postoperatively, etc.
Used a prospective, randomized, single-blind trial in 2 community hospitals in Cleveland with coronary artery bypass graft surgery patients. Study was done between Dec 1989 – Feb 1992.
3 groups were involved: (1) Suggestion, (2) music, and (3) tape. Control subjects had a blank tape. Tapes were played continuously and repeatedly with headphones. Postoperatively, a different tape was played.
Excluded: Patients with emergent surgery, hearing impairment, poor comprehension of English, patients who died in hospital, patients whose hospital stay lasted longer than 14 days (3 of them). 5% of sample were eliminated for last 2 reasons.
Music: Herb Ernst, Dreamflight II. Suggestions: Music background, permissive, based on Evans & Richardson’s study.
Outcome Measures: Nurse assessment of anxiety and progress post operatively, Symptom scale, Depression scale.
Mean age 62, 3/4 men, 92% white, 75% married. The groups were same on a variety of preoperative variables (status of heart and arteries). Length of stay was 6.5 in all 3 groups. No difference in narcotics use, in nurse assessment of anxiety or of progress; of depression scale, or activities of daily living.
Recategorized data into patients who said the tapes were helpful (both music and suggestion) N = 33 vs the other patients N = 62. No difference in the variables evaluated.
Kostka, Marion (1992). Personal experience with ‘Use of Hypnosis Before and During Angioplasty’ [Letter]. American Journal of Clinical Hypnosis, 34, 281-282.
NOTES
Author read the article referred to after his/her heart attack and before angioplasty. Goal was to control preprocedure anxiety and assist by being relaxed and cooperative; also to be able to tolerate inflations of the balloon for as long as needed. Used self-hypnosis “and by the time I entered the laboratory my anxiety was under control. … None of the physiological responses that can occur (i.e., nausea, pain, etc.) did occur and, for the most part, my postprocedure recovery was uneventful. … Had two procedures because the artery again occluded. … My cardiologist commented later that the time of inflation was longer than he had even attempted with any of his patients and he attributed this to my lack of symptoms. I felt this was due in part to the use of self- hypnosis. …. my subjective feeling was that both my discomfort and anxiety were minimal” (Pp. 281-82). No blood was sampled to measure catecholamine levels.
Levitan, Alexander A.; Harbaugh, Thomas E. (1992). Hypnotizability and hypnoanalgesia: Hypnotizability of patients using hypnoanalgesia during surgery. American Journal of Clinical Hypnosis, 34, 223-226.
Administered Stanford Hypnotic Suggestibility Scale (Form A) to 10 patients from a population of 20 who had undergone surgery in the previous 10 years using hypnoanalgesia as the sole or principal analgesic agent. Time since surgery ranged from 2 days to 10 years. Scores on the SHSS ranged from 5 (medium susceptibility) to 12 (high susceptibility) with a mean of 8.6, significantly higher than the SHSS:A normative group (p <.001). The relationship between severity of surgery and the use of hypnoanalgesia as the sole or principal analgesia was significant for our patient population (N = 20) but not for our patient sample (N = 10). NOTES No referrals were rejected or dissuaded from the use of hypnoanalgesia. The medical reasons for referral included (1) the presence of anatomic abnormalities precluding use of inhalation anesthesia, (2) a history of cardiac arrest accompanying prior use of chemoanesthesia, and (3) excessive bleeding associated with previous attempted surgery. Self-referred patients had previous experience with meditation or self hypnosis and wished to avoid the potential complications associated with the use of chemoanesthesia" (pp. 223- 224). The second author, who was unknown to the patients, administered the SHSS:A. "Those four patients using hypnoanalgesia alone achieved a mean SHSS:A score of 8.25. Those [five patients] using a combination of hypnosis and chemoanesthesia achieved a mean SHSS:A score of 8.80" (p. 224). (One did it both ways, in two surgeries, and is not included in this analysis.) "Hypnoanalgesia alone was unlikely to be used for major surgery [as rated by independent rater, on major vs minor surgery] and, for whatever reasons, is most likely to be employed alone during minor surgery" (p. 224). 64% of the major surgical procedures (in their 10 patients) used combination of hypnoanalgesia and chemoanesthesia; 69% of procedures that used only hypnoanalgesia were minor surgeries. This suggests that "the use of hypnoanalgesia as the sole analgesic agent during major surgical procedures is an option seldom taken in the presence of reliable chemoanesthetics. Hypnoanalgesia as the sole analgesic agent may be a practical alternative for patients of moderate to high hypnotic susceptibility during minor surgical procedures. Hypnoanalgesia used as the principal or adjunctive analgesic may be useful to patients of moderate to high hypnotic susceptibility during major surgical procedures" (pp. 225-226). 1991 Blankfield, Robert P. (1991). Suggestion, relaxation, and hypnosis as adjuncts in the care of surgery patients: A review of the literature. American Journal of Clinical Hypnosis, 33, 172-186. NOTES He notes that the authors provide little information re complications, and length of stay (LOS) is one of the most sensitive response measures used in these studies. The mean difference in LOS for 5 studies that have randomized assignment is 1.3 days. The N's are 80-100 for 3 of the studies, 39 and 60 for others. For two well controlled studies that did not achieve significance, the N's were 40 and 45. Many studies mixed the diagnosis and types of surgeries, making it difficult to interpret the results. Block, Robert I.; Ghoneim, M. M.; Sum Ping, S. T.; Ali, M. A. (1991). Efficacy of therapeutic suggestions for improved postoperative recovery during general anesthesia. Anesthesiology, 75, 746-755. There have been claims that the postoperative course of patients may be improved by presentation during general anesthesia of therapeutic suggestions which predict a rapid and comfortable postoperative recovery. This study evaluated the effectiveness of such therapeutic suggestions under double-blind and randomized conditions. A tape recording predicting a smooth recovery during a short postoperative stay without pain, nausea, or vomiting was played during anesthesia to about half the patients (N = 109), while the remaining, control patients were played a blank tape instead (N = 100). The patients were primarily undergoing operations on the fallopian tubes, total abdominal hysterectomy, vertical banding gastroplasty, cholecystectomy, and ovarian cystectomy or myomectomy. The anesthesia methods consisted of either isoflurane with 70% nitrous oxide in oxygen to produce end-tidal concentrations of 1.0, 1.3, or 1.5 MAC; or 70% nitrous oxide in oxygen combined with high or low doses of opioids. Assessments of the efficacy of the therapeutic suggestions in the recovery room and throughout the postoperative hospital stay included: the frequency of administration of analgesic and antiemetic drugs; opioid doses; the incidence of fever; nausea, retching, and vomiting; other gastrointestinal and urinary symptoms; ratings of pain; ratings of anxiety; global ratings of the patients' physical and psychological recoveries by the patients and their nurses; and length of postoperative hospital stay. There were no meaningful, significant differences in postoperative recovery of patients receiving therapeutic suggestions and controls. These negative results were not likely to be due to insensitivity of the assessments of recovery, as they showed meaningful interrelations among themselves and numerous differences in recovery following different types of surgery. Widespread utilization of therapeutic suggestions as a routine operating room procedure seems premature in the absence of adequate replication of previously published positive studies. (Key words: Anesthesia, depth: Awareness, Memory, Recall, Learning.) NOTES Patients ages 19-55 were accepted into the study and they were paid for participation. (Older patients were excluded to guard against memory or hearing problems.) Other criteria for exclusion were: ASA physical status 4 or 5 indicating significant systemic disease, visual or hearing problems, middle ear disease (because it increases probability of nausea and vomiting), if their condition might require heavy sedation, if they were currently taking medication that interferes with memory (e.g. benzodiazepines, if there were intolerance to opioids, or if there were a likelihood of using postoperative pain treatment other than opioids. The Spielberger State-Trait Anxiety Inventory was administered before surgery. Either suggestions (lasting 6 minutes) or a blank tape were played through headphones, starting 5 minutes after the surgical incision. The tape was played once for the first 59 patients, continuously for the remaining 150 patients. The first 139 patients received additional verbal materials on the tape, for memory tests to test possibility of learning under anesthesia. Operating room sounds were recorded by a tape recorder near the patient's head, throughout period of unconsciousness (except when tape was being played). After the first 25% of cases, the team decided that lack of effect on therapeutic suggestions attributable to type of anesthesia did not warrant restriction to a single anesthetic method; also, multiple presentations of the suggestions on tape did not show an effect different from a single presentation. After the patient regained consciousness and was reoriented, pain, nausea, retching, and vomiting were assessed every 30 minutes. Pain was rated orally on a scale from 1 to 10 in the recovery room, then on visual analogue scales every 2 hours on the day of surgery and the second day, and every 4 hours on subsequent hospital days during waking hours. Variables that were rated by staff every 24 hours included: opioids, other analgesics, antiemetics, nausea, vomiting, retching, presence or absence of nasogastric tube, passage of flatus, bowel movement, fluid intake, solids intake, urination. Temperature was recorded every 4 hours for the first 2 days after surgery, and after that less often. The anxiety measures were repeated on Day 3 postsurgery, as well as self ratings and nurse ratings on physical and psychological recovery. Staff recorded length of postoperative hospital stay and reasons for any delay of discharge. Separate analyses were performed for patients receiving opioids via patient-controlled analgesia (52%) vs traditional administration (48%), but no differences were found for effects of therapeutic suggestions except on postoperative Day 8. "The inability to detect beneficial effects of therapeutic suggestions probably was not due to insensitivity of the measures of recovery. These measures were sensitive enough to show numerous significant differences in recovery after different types of surgery" (p. 751). The authors supported their contention that the measures were sufficiently sensitive by demonstrating meaningful correlations among the measures themselves; and by demonstrating adequate statistical power for detecting the effects of theoretical interest--at least 1 day in postoperative hospital stay or one half day in fever. Discussion: The authors note that a recent investigation that found positive results in a double-blind, randomized design with 39 hysterectomy patients (Evans & Richardson, 1988. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anaesthesia. Lancet, 2:491-493) may not have controlled for variables such as presence of malignancy, physical status of patients before surgery, or ethnicity. Authors note that Evans and Richardson observed shorter periods of pyrexia despite there being no relevant suggestions, but no differences in pain intensity, nausea, vomiting, or urinary difficulties despite there being suggestions relating to those symptoms. There also were no differences in mood and anxiety test scores postoperatively for the experimental and control groups. The authors note that McLintock, Aitken, Downie, & Kenny (Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. Br M J 301:788-790. 1990) reported a 23% reduction in opioids by patients receiving suggestions, but no reduction in pain, nausea, or vomiting. They contrast the present study with these earlier studies that had obtained positive results. "We studied patients who had more than one type of surgery to obtain a large sample size and to assess the possibility that beneficial effects of therapeutic suggestions would be restricted to certain types of operations. Had this been the case, interactions of therapeutic suggestions with type of surgery would have been significant in the overall analyses, and follow-up analyses would have indicated that they were attributable to beneficial effects of therapeutic suggestions for certain surgeries. This did not occur. The two types of surgeries involving the largest numbers of patients seemed particularly promising for demonstrating beneficial effects. It has been reported that therapeutic suggestions presented during anesthesia are likely to be less successful with major and extensive surgery. Certainly, surgery on the fallopian tubes and gastric stapling did not involve a great deal of tissue trauma and blood loss. Patients were motivated to have the surgery and to recover quickly; particularly motivated were those having operations on the fallopian tubes, who were very eager to become pregnant, and those having vertical banding gastroplasties, who wanted desperately to lose weight" (pp. 753-754). "In practice, we observed no beneficial effects of therapeutic suggestions, and there was no hint that anesthesia methods influenced the efficacy of the therapeutic suggestions. Interestingly, anesthetic methods also did not influence learning under anesthesia in the implicit memory tests we have used previously. Patients anesthetized with nitrous oxide and opioids did not differ from those anesthetized only with inhalational agents. In general, implicit or unconscious memory occurs in patients regardless of anesthesia methods or dosages of drugs" (p. 754). "The few significant effects of therapeutic suggestions in our study did not point toward a beneficial influence of these suggestions. We found, in fact, an increased frequency of retching (but not nausea or vomiting) in the experimental group. The multiple variables examined in this study increased the likelihood of significant differences arising by chance, such that the null hypothesis was rejected when it should have been accepted. This is the way we interpret the effect on retching---i.e., as a type I error. We used in our therapeutic suggestions one negative or exclusionary sentence, 'You won't feel nauseous or have to vomit', among several positive or affirmative statements, e.g., 'You will enjoy eating, drinking...You will swallow to clear your throat and everything will go one way, straight down. . . The food will taste good....Your stomach will feel fine.' We do not think that the negative sentence led to paradoxical results. Evans and Richardson (personal communication) used in their therapeutic suggestions a negative sentence ('You will not feel sick'), which they repeated, yet the reported incidence of nausea and vomiting did not differ between the experimental and control groups" (p. 754). Brown, Peter (1991). The hypnotic brain: Hypnotherapy and social communication. New Haven, CT: Yale University Press. NOTES Notes are taken from a review of this book: Diamond, Michael (1993). Book review. Bulletin of the Menninger Clinic, 57 (Winter), 120-121. Brown "posits that because the fundamental matrix of the human brain is metaphoric, hypnosis results from skillful matching of metaphorical communication with the brain's biological, rhythmic alterations. The most significant feature of trance experience is thereby located in the hypnotist-subject interaction" (p. 120). "The middle section [of the book is comprised largely of] literature reviews in support of Rossi's (1986) ultradian rhythm theory of hypnosis and Lakoff and Johnson's (Johnson, 1987; Lakoff & Johnson, 1980) experientialist theory of conceptual thought" (p. 120). The final section includes "research evidence on medical uses of hypnosis, a theory of dissociation and multiple personality disorders, and an uncritical discussion of Milton Erickson's naturalistic hypnotherapeutic approach ... [and also] a brief discussion of the social-cultural functions of possession states among the Mayotte culture" (p. 120). Cochrane, Gordon J. (1991). Client-therapist collaboration in the preparation of hypnosis interventions: Case illustrations. American Journal of Clinical Hypnosis, 33, 254-262. Therapists can use hypnosis in a variety of situations to help clients utilize their own resources effectively. In both heterohypnosis and tape-assisted self-hypnosis, the respectful collaboration of therapist and client in the development of specific intervention strategies can be effective. I have described four cases to illustrate the collaborative aspect of heterohypnosis in a surgical setting and tape-assisted self-hypnosis for anxiety, tinnitus, and situational depression. In each case the clients were willing and able participants. NOTES Hypnotic interventions as adjunctive therapeutic modalities for a variety of surgical procedures have been well documented (Frankel, 1987; Gravitz, 1988; Nathan, Morris, Goebel, & Blass, 1987). The availability, relative safety, dependability, and ease of use have made chemical agents the anesthetic of choice in the majority of surgical situations, but hypnosis, either alone or in conjunction with chemical agents, can have a number of advantages for some patients (Udolf, 1987, p. 248). Some patients who have extreme preoperative pain and anxiety can learn to use self-hypnosis (Frankel, 1987); others may use hypnosis when experiencing postoperative nausea and other uncomfortable side effects of chemical anesthetics. Some may fear death under general anesthesia or react to a previous trauma arising from general anesthesia and the operating room procedures in general (Udolf, 1987, p. 250) and therefore choose hypnotic strategies. In the following case illustration the patient feared general anesthesia because of a previous negative postoperative experience" (p. 255). While collaboratively planned hypnosis often empowers the patient, contributing to a sense of personal control and well being, some patients are not able to participate in that manner. Cochrane cites patients who are severely depressed or "who struggle with narcissism and other severe pathologies" (p. 260). He notes that audiotapes are useful for supplementing in-session therapy, contributing to skill development, attitude change, and a sense of self-worth. He cites Eisen and Fromm (1983) as indicating that self hypnosis is also useful for clients "who struggle with issues of control and intimacy" (p. 260). Kleinhauz, Moris (1991). Prolonged hypnosis with individualized therapy. International Journal of Clinical and Experimental Hypnosis, 39 (2), 82-92.