HYPNOTHERAPY AND FAMILY MEDICINEHow HYPNOTHERAPY CAN COMPLEMENT CLINICAL WORK IN FAMILY MEDICINE

by: Sherry M. Hood and Fred Janke

Sherry M Hood MH, C. CHt is thefounder, curriculum developer and headinstructor for The Pacific Institute ofAdvanced Hypnotherapy where she teaches

both full time and part time hypnotherapy courses. In August 2009Sherry was appointed Clinical Lecturer in the Department of FamilyMedicine, University of Alberta. Her hypnotherapy course becamea medical elective for post graduate residents from The University ofAlberta in December 2010. A pilot study through The University ofAlberta was conducted using Sherry's smoking cessationintervention. A two year study using her same smoking cessationintervention isplanned for thefuture.

Dr. Janke completed his medical education atthe University of Calgary in 1982 and has beenpracticing in Sylvan Lake, Alberta as a familyphysician since 1984.He became involved with the University of Alberta as site director in RedDeerfor a new rural stream family medicine program in the year 2000.Since then he has become increasingly involved with teaching familymedicine at the post-graduate level. He became the "Rural ProgramDirector" for the Department of Family Medicine in 2008 and morerecently; in October 2011, took on a broader position as "Director of Ruraland Regional Health "for the Faculty of Medicine. Although he isfull timefaculty his clinical work remains in Sylvan Lake.

In April 2012, Dr. Fred Janke and Sherry Hood were given theopportunity to present at a national conference for ruralphysicians held at Whistles; British Columbia, Canada. Thiswas unique because the topic of hypnosis and hypnotherapy israrely seen on the program of conferences for medicalprofessionals. It was all opportunity to present howhypnotherapy could complement clinical care.

The objectives of the presentation were as follows: Tounderstand the basic premises behind hypnosis/hypnotherapy;

To be able to outline a variety of clinical conditions forwhich there is good evidence supporting the use ofhypnotherapy;

To understand criteria with which to identify reputablehypnotherapists;

To understand ways of accessing hypnotherapy in smallercommunities via referral, telephone and Skype.

As noted the first objective was to present a basicunderstanding of what hypnosis is and what it is not.Following a very simplistic introduction into the basics ofhypnosis, some of the more recent research on hypnosis andbrain physiology was provided. Brain imaging studies usingeither Positron Emission Tomography (pET) or MagneticResonance Imaging (MRI) have shown where in the brain,neuronal activity may be taking place during hypnotic statesor, alternatively, may be blocked or inactivated. Imagingstudies show that the brain is affected by hypnosis in the samelocation in which the actual experience might take place. Forexample, kinesthetic suggestion would take place in the area ofthe brain related to the same kinesthetic input. The actuallocation may vary depending on the actual hypnoticexperience taking place. The importance of this work istwofold: I) Brain activity related to hypnotherapy is in quite adifferent location than where imagination takes place and so issomething much more profound than simple imagination; 2) Itprovides evidence of real changes in the brain related toh . 1-4ypnosrs.

Four main areas of clinical hypnotherapy were covered8

during this presentation: 1) the use of hypnotherapy insurgery; 2) hypnotherapy as an adjunct to pain management;3) addressing psychiatric conditions; and 4) addressingfocused areas of therapy such as smoking cessation.

The use of hypnosis in surgical management was reviewedin detail. Although hypnosis has been used in surgery foralmost 200 hundred years, there has been only minimalinterest and research until quite recently. By comparisonthere have been many more pharmacological advances inanesthesia and analgesia. Contemporary clinicalinvestigations have shown that the combination of analgesiaand hypnosis is superior to conventional pharmacologicanesthesia.' Hypnosis can enhance conscious sedation. All ofthese techniques are used regularly for surgical cases at theUniversity Hospital at Liege, Belgium.Y Cost analyses showthat adjunct hypnotherapy used with conscious sedationreduces overall costs." In fact, using hypnotherapy even foroutpatient interventional radiology procedures can reducecosts by half. 9 Perioperative hypnotherapy can significantlyreduce costs by decreasing postoperative stays, particularlyamongst children." There are reduced post-surgical costsrelated to less nausea and emesis as well as less analgesiarequired when hypnotherapy is used peri-operatively.., AtLiege, in a high quality prospective study, Faymonvilledemonstrated that patients who experienced hypnotherapyfor surgery had significantly lower pain scores, required lessopioids and experienced less postoperative nausea. 12

There is a BBC documentary available on hypnosis andsurgery." A small clip of this documentary was used in thepresentation showing dental surgery taking place in Glasgow,Scotland. Dr. Mike Gow and Dr. Avid Faquir used thetechnique of anesthetic glove to provide local anesthesia in apatient undergoing oral surgery for a dental implant drillingdirectly into the maxilla." For individuals who have neverseen hypnotherapy used in a clinical situation, this video cliphad a profound influence.

Hypnotherapy has also shown its usefulness in treatingburn patients. Arandomized control trial (the highest form ofevidence) compared hypnotherapy with other stress

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reduction strategies as an adjunct to regular analgesia whenchanging bum dressings. Visual analogue scores for anxietyand pain control were significantly improved usinghypnotherapy."

Hypnotherapy interventions have been shown toconsistently decrease pain associated with a variety of chronicpain conditions such as cancer pain, chronic low back pain,fibromyalgia, temporomandibular pain and mixed chronicpain conditions. Studies have compared hypnotherapy withno treatment, medication or other non-hypnotic interventionssuch as physical therapy and have found hypnotherapy to be

I 1617comp ementary. .Another recurrent pain condition is headache; studies

investigating hypnotherapy are generally quite dated whichmakes them less useful. The criteria for headache diagnosishave become much more stringent and one type of headachemay respond quite differently to hypnotherapy than anothertype of headache. The rigor of some of these older studies isalso inferior. There is one excellent study published in 1987involving children with classic juvenile migraine. Subjectswere used as their own controls going through three phases ofthe study: placebo/propranolol/self-hypnosis. With self-hypnosis the mean number of migraines per child dropped by60 percent, and in general there was a reduction in the severityof migraine headaches. IX

The use of hypnotherapy in the condition of irritable bowelsyndrome is perhaps one of the most studied uses ofhypnotherapy. One review showed that there is a medianresponse rate of 86 percent with a decrease in overallsymptoms of 50 percent. In addition there is an improvementin overall function. 19 The therapeutic gains obtained throughhypnotherapy are generally well maintained as shown by astudy that followed patients for a year after treatment. 20 In fact,the group of patients who had received hypnotherapy seemedto continue improvement over time post-interventioncompared to patient groups treated more conventionally.

Cancer patients also benefit from hypnotherapy in a varietyof ways . One study showed a decrease in the use of analgesia,a decrease in nausea and vomiting and a decrease in anxietyrelated to medical procedures and interventions." There canbe other benefits as shown by a study in which there was asignificant reduction in hot flashes in breast cancer survivorsusing hypnotherapy compared to conventional therapy."

One powerful place for the use of clinical hypnotherapy isin maternity care including labour and delivery.Hypnotherapy has a role to play in decreasing the amount andintensity of pain during labour. In so doing, hypnotherapydecreases the amount of analgesic medications, which leads tobetter newborn outcomes. Improvement in newbornassessments is shown by better APGAR scores (an acronymstanding for Appearance, Pulse, Grimace, Activity,Respiration and is a simple and repeatable method to quicklyassess the health of the newborn). Hypnotherapy has beenshown to shorten the stages of labour and has been shown to

decrease the amount of augmentation oflabour through the useof oxytocin (a hormone that is used to stimulate uterinecontractions). Of note: there is a reduction of C-section rates.Hypnotherapy also improves post-pactum recovery includingreductions in breast pain, nausea, headache and possiblyreduces the incidence of post-pactum depression.f:" Ofparticular importance is that hypnosis may be instrumental inhalting pre-term labour. One small pilot study done in Halifax,Nova Scotia, showed a 55 percent success rate in prolongingpregnancy."

Hypnotherapy can be useful throughout maternity care, notjust in labour and delivery. It is useful to help control back painand abdominal discomfort and can help with pre-labouranxiety. Especially useful, hypnotherapy can help control thenausea and vomiting of pregnancy. The severe form of this,hyperemesis gravidarurn, often requires hospitalization forfluid and electrolyte imbalances and may require manymedications to control. Hypnotherapy has shown someencouraging results in this area but more rigorous studies areneeded."

Anxieties and phobias respond well to hypnotherapy. Forexample, David Kraft presents quite a complete literaturereview on the subject of hypnotherapy and agoraphobia andsocial phobia." More contemporary studies in the area ofinsomnia, generalized anxiety and obsessive compulsivedisorders would be very useful. Small often-flawed studiesshow a trend that hypnotherapy can be a useful adjunct tocognitive behavioural therapy, however we need randomizedcontrol trials (RCTs) confirming this.

There have been RCTs investigating the use ofhypnotherapy in depression. One recent meta-analysis (2009)combining these RCTs showed a significant positive effect. 2M

Because of the lack of high quality studies, the evidenceregarding the use of hypnotherapy in smoking cessationremains controversial. As suggested in our last article,Cochrane reviews suggest that there is insufficient evidence torecommend hypnotherapy as an intervention for smokingcessation." The authors specifically comment on the fact thatthere are too many different techniques used to adequatelystudy the effectiveness in any rigorous manor. On the flip side,there are concerns about the adverse effects from some of themedications used. Recent publications suggest seriousconcerns with using varenicline in the presence ofcardiovascular disease with varenicline." The adverse effectsof medications makes alternatives much more attractive. Avery small pilot study completed by the authors would suggestthat a single intensive hypnotherapy session would be at leastas successful as the pharmacological interventions available."The hope is to go on to a larger prospective cohort study.

The use of hypnotherapy in pediatrics is quite successfulbecause of the high degree of suggestibility in children. Asmentioned above, hypnotherapy can significantly reducestress around medical procedures and decrease length ofhospital stays postoperatively." Hypnotherapy can reduce the

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distress and negative memories around cancer treatment. 33

Some conditions more specific to childhood such as enuresisseem to be amenable to treatment by hypnotherapy," althougha Cochrane review again suggests that further rigorousresearch is needed."

Overall the presentation was very well received.Attendees were quite engaged asking many questions andmany stayed afterward to talk further. A number of resourcesincluding the Little Book of Change by Daniel Cleary", ahypnosis CD on Stress Reduction recorded by Sherry Hood, aprevious article published in Family Health Magazine andprevious articles from Unlimited Human were madeavailable. Providing more such sessions at other medicalconferences will be one way to advance the use ofhypnotherapy into the mainstream of clinical use.

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