IN HER article published on 20 November 2017, Jane McCredie pointed to a Viewpoint by Barsky published in JAMA that reminded us about the harm that doctors can do when they are not aware of the possible implications of what they say to patients. The other side of this coin that is not discussed by Barsky is an awareness of the positive therapeutic potential of the words that doctors use to convey information and advice to patients, and how they deliver those words.
An understanding of the beneficial or harmful effects of what doctors say to patients is fundamental in the practice of therapeutic hypnosis.
Hypnosis is frequently defined as “a state of focused or concentrated attention”. This means that in every live interaction with a doctor, the patient is in a hypnotic state. Anything that the doctor says acts as a post-hypnotic suggestion, with the potential to influence the patient’s beliefs, sense of wellbeing, expectations, behaviour and subsequent health not just in the consultation, but for years into the future.
This is illustrated by the case of a man who consulted Dr Moore after having open heart surgery. His surgeon and cardiologist were very pleased with the outcome of his treatment as his prognosis had been poor. They were puzzled that he continued to experience severe midline chest pain 6 months after his operation. It transpired that his surgeon had told him shortly after the operation: “You will have to live with this pain”. The patient’s subconscious mind had heard: “This pain is a sign that I have survived, and I am alive. To not have pain is to be dead.”
Experience in the use of therapeutic hypnosis has taught us that what is referred to for convenience as the “unconscious mind” has a different logic and way of understanding concepts from that of what is called the “conscious mind”. In the unconscious mind, words are interpreted in a literal, concrete sense. Fortunately for this man, this unintended negative hypnotic suggestion was able to be removed using hypnosis.
The following are examples of choices of words that can help and support patients:
- “You might experience some discomfort or pressure” instead of “This will hurt,” to decrease the distress of medical procedures;
- “Most patients find this medicine very helpful for this condition,” to add the placebo effect to a prescribed treatment; and
- “Let me explain how the treatment plan has changed to deal with what is currently happening,” to convey hope and collaboration, instead of “I’m sorry, there’s nothing we can do”.
Pessimistic remarks made when it is assumed that the patient is not listening or can’t hear, such as when the patient is on the other side of a curtain, appears to be asleep, or before, during or after anaesthesia or sedation can have harmful effects. Deliberately making positive remarks in these situations, such as “The operation is going well”, “I believe that Mr Smith will be very comfortable when the surgery is finished,” or “You have a very strong heart,” can enhance post-operative recovery and decrease anxiety and distress.
What are called indirect suggestions in the world of therapeutic hypnosis have been found to be particularly powerful in helping patients to change their perceptions, attitudes, expectations and behaviour for the better in ways that they want. Indirect suggestions include the telling of stories (“A patient like you with a similar problem got better when she …”), the use of metaphors (“When this storm has blown over, I wonder what beautiful new calm waters you will be sailing in”) and the use of apparently paradoxical negative suggestions (“You can keep all of the discomfort that you need to keep, and you can let go of the discomfort that you no longer need”).
In clinical practice, remarks, comments or predictions made to the patient’s family, friends or carers, or to other health professionals involved in the patient’s care are one form of indirect suggestion and can have powerful positive or negative effects. It is important to know that statements that the doctor regards as throwaway lines or casual comments, rather than as formal advice, are sometimes all that the patient hears and remembers after a consultation or other interaction.
An understanding of how the unconscious mind interprets suggestions using what has been called “trance logic” has influenced a number of popular approaches to helping people to change their behaviour for their own and for society’s benefit. Doctors who are wondering what information to give when obtaining informed consent might be interested in the research in the field of economics and behavioural psychology. In their book, Nudge (Thaler and Sustein, 2008), the authors show how human beings are easily influenced in their decision making, and what can be done to help people make better decisions and avoid making bad ones.
Because the principles of therapeutic hypnosis can be applied beneficially in many situations in routine daily medical or surgical practice, without any formal declaration of “doing hypnosis”, it would be useful for all medical courses and post-graduate training to provide a basic understanding of the power of what we say to patients.
The Australian Society of Hypnosis is a not-for-profit professional body that offers training courses in various states of Australia, leading to the Diploma in Clinical Hypnosis. For the latest information, please contact the federal secretariat of the society by emailing firstname.lastname@example.org.
We thank the Australian Society of Hypnosis for their advice in the preparation of this article.
Dr Oliver Frank is a GP and specialist family physician in South Australia, and a University Senior Research Fellow in the Discipline of General Practice at the University of Adelaide.
Dr Monica Moore is a GP psychotherapist and medical educator in Sutherland, NSW.
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