HYPNOTHERAPY AS A COPST EFFECTIVE AID TO PHC IN …



HYPNOTHERAPY AS A COST-EFFECTIVE

TOOL FOR ENHANCING PRIMARY HEALTH CARE - DRAFT 5

Dr. Bob Boland MD, MPH, DBA (robertboland@wanadoo.fr)

Abstract

The article begins with a quotation from Michael Yapko , which relates hypnosis to healing, to words that influence belief systems and to the promotion of patient empowerment. He suggests hypnosis as a cost-effective enhancement to proven health care therapy.

At an international level, the WHO policy for the 21st Century", sets priorities for cost-effective health care and for mental health. Perhaps this provides the opportunity for hypnosis and hypnotherapy to be recognised as a practical cost-effective tool for PHC (the worker and the patients), which in the past was often forced by poverty and global epidemics, to be essentially "drug-based" curative care.

Hypnosis is simply explained as a focus of the mind on the subconscious, to develop new perceptions and motivations. It requires "rapport" to co-operate with confidence, concentration and expectation, which can so easily be achieved in a good health care setting.

Hypnotherapy (a very general term) uses hypnosis to help with all mind/body health problems and thus enhances all health care therapy. It can be highly cost-effective (compared to drugs) with no side effects. It is usually more powerful with "Self hypnosis" which is simply explained with an example of DHI (Daily Health Induction) and takes only a few minutes to learn and use.

Past fears and emotional misconceptions about hypnosis are discussed, and related to hypnotic techniques used in biofeedback, LaMaze birth method, meditation etc. Since 1985, hypnosis, hypnotherapy and self-hypnosis are becoming more accepted as part of enhanced treatment for a wide variety health problems and they are now recognised by the AMA and BMA.

For basic hypnotherapy, PHC workers could be trained in about six days for simple practice which can be easily adapted to the local cultural norms. Practice would initially to deal with enhanced general health care and basic problems of: pain, anxiety, smoking, compliance, stress etc. Such healing enhancement to therapy could bolster immunity functions, by stimulating white blood cell, and antibody production.

More specific applications could be created for reinforcing compliance with critical TB/Malaria/HIV protocols, confidence to seek treatment early, improved health education, preventive health care, HIV/AIDS prevention etc. Hypnotherapy is almost guaranteed to reduce health care costs, for simple reason that when people feel empowered to better cope with life, they require less health care.

The key proposal of the article, that hypnotherapy can enhance health care and can be highly cost-effective for PHC (the worker and the patients). This could justify a

multi-country test project, financed by a major donor, to train health workers and to verify, with control groups, the efficiency and effectiveness of basic hypnotherapy in PHC. Perhaps this could be achieved by collaboration between WHO and the American Society of Clinical Hypnosis or the Milton H. Erickson Institute.

QUOTATION FROM DR. MICHAEL YAPKO ON HYPNOSIS

Healing takes place in a social as well as a medical context, but physicians often work on their medical skills but not their social skills. A well placed suggestion, a skilled directive, a strategic comment can all go far, in health care.

The starting place for teaching hypnosis is that words can heal because words influence belief systems. Furthermore, most physicians acknowledge that patients too often want something done with them, rather than done to them. Hypnosis is a valuable means for empowering people to participate in the health care treatment process.

Numerous cost-effectiveness studies have been done comparing medical interventions with and without psychological intervention, and the results consistently show that while adding psychological interventions (like hypnosis) initially increases cost, the cost is quickly made up by the lesser reliance on the physician, reduced use of expensive tests and drugs and fewer visits for health care.

Simply put, proven health care therapy works and hypnosis enhances therapy.

Michael D. Yapko Ph.D.

Clinical Psychologist and Director of the Milton H. Erickson Institute.

1. INTRODUCTION

The WHO policy for the 21st Century sets out for the first two decades of the 21st century, some new global priorities and targets, which recognise why progress was hampered by lack of political commitment, slow socio-economic growth, demographic changes, disasters, poverty etc. PHC in the past, was often forced by poverty and global epidemics, to be essentially a "drug-based" curative care.

The policy involves global health targets and an openness to new technologies, which set a new priority for "cost-effective" health care and for "mental health" care (the precursor of sickness and disease). This could be critical to the success of PHC in poverty environments, since currently half of the world survives on less than $2 per day, and thus drugs may be too costly!

This may provide an opportunity for hypnotherapy to be recognised as a "drug-free" tool for PHC; it is simple and requires no apparatus, machines or supplies. But currently there is almost no reference to hypnotherapy in WHO reports and data bases, even though it was recognised in 1985 by the AMA and BMA, as an enhancement to general health care therapy, and a useful part of therapy for a whole range of problems such as: depression, pain, smoking, stress, phobias, obesity, hypertension, colds, influenza, allergies, cardiac problems, colitis, migraine, muscle spasms, stomach disorders, peptic ulcer, asthma etc.

The article deals briefly with hypnosis, hypnotherapy and self- hypnosis, to suggest the potential for hypnotherapy as a highly cost-effective tool forenhancement of PHC in developing countries.

2. PHC

PHC envisages health care at several levels: Home, Community, First Level Care Centre and District Hospital. In all of these levels mind/body effects of illness are clearly evident and thus a potential for hypnotherapy exists. PHC seeks to be promotive, preventive, curative and rehabilitative, based on the principles of equity, community participation, inter-sectoral approach and appropriate methods.

In practice PHC may be become a "drug-based" curative care (despite drug shortages and cost) for the epidemic problems of diarrhoea, pneumonia, measles, malaria, anaemia, aids and tuberculosis. All of these conditions can be prevented by training to increase the natural resistance of the organism, to infection. But in poverty and crisis it may be difficult for PHC to give emphasis to mental health care, preventive care and health education, despite current reports of the global epidemic of mental health problems. In such critical conditions, perhaps limited drug therapy may be less cost effective than hypnotherapy.

Currently in developing countries, some forms of hypnotherapy are practised under other names (faith healing, meditation etc.) by traditional healers who are said to also treat perhaps 70% of health care problems in countries, where medical PHC is not well accepted. Perhaps when PHC adopts hypnotherapy as one of its health care tools, many more patients will come to PHC for care, and thus both care and health education can be enhanced, more widespread and more effective.

3. HYPNOSIS

The word "Hypnosis" is feared and poorly understood by most doctors, health staff and patients. The starting place for teaching hypnosis is that words can heal because words influence belief systems. Healing takes place in a social as well as a medical context, but physicians often work on their medical skills but not their social skills. A well placed suggestion, a skilled directive, a strategic comment can all go far in health care.

But, the concept of hypnosis has been severely damaged, by "stage-hypnosis" for vulgar entertainment. It has been damaged by emotional misconceptions about loss of power, mental breakdown and side effects. It has been damaged by interpretation as "just another placebo effect". It has been damaged by confusing research theories such as: suggestion, modified sleep, Charcot pathology, dissociation, psychoanalysis, role playing, atavistic regression, neuro-physiology, hemispheric specificity etc.

Despite these conflicting theories, perhaps hypnosis best explained as a focus of the mind on the subconscious. It can be related to "a level awareness", which we all experience (unknowingly) several times daily. It is almost a "natural phenomena" of concentrating intently, perhaps on a film, a book, driving at car, or on the subconscious mind. It is a "focus of the mind" on the subconscious, which requires a willingness to co-operate with confidence and concentration, and can lead to new perceptions and new very powerful motivations.

Many experienced doctors and health care workers, refuse to learn "hypnosis" and yet those same people may be thrilled to learn "progressive muscle relaxation" which is a specific hypnotic technique. Similarly "biofeedback" is self-hypnosis with electronic equipment. Meditation is self-hypnosis with a meaningless "Mantra" as a focal point, instead of a meaningful purpose. Visualisation is hypnosis limited to one visual modality. The LaMaze method of childbirth, employs breathing and relaxation exercises as a hypnotic induction. Other less fearful names for "hypnosis" include: autogenic training, guided imagery, mental imagery, mind over body etc.

But it is not merely a "placebo" effect and the difficulty of producing adequate scientific research on hypnosis using classical medical research methodology and criteria, has caused hypnosis to be rejected by the medical profession until about 1985.,

On an individual basis, we must recognise that an individual cannot be hypnotised against his/her will. Under hypnosis, no-one can be forced to do things that conflict with their own very personal values. This is because all hypnosis is really self-hypnosis (SH) helped by a therapist with "rapport" who inspires confidence, relaxation, expectation and motivation. This "rapport" is so natural and easy for the doctor and health care worker, in the emergency health care or the general health care setting.

On a group basis, hypnosis becomes a very powerful tool for influencing small groups in health education. It can also be used to influence very large populations with positive suggestions, where personal values may have less control, as in crowd conditions.

4. HYPNOTHERAPY

Hypnotherapy is a rather vague term often confused with hypnosis itself. However hypnotherapy uses hypnosis very carefully and ethically, as a part of medical, dental and overall health care. The routine of hypnotherapy with (or without) a formal "trance", usually involves: induction, mental and physical relaxation, analysis and positive affirmations, reinforcement and awakening. It has nothing in common with "stage" hypnosis, and is under the control of the patient who can terminate the "trance" at any time, but usually is much happier not to do so! It is a very wonderful experience to feel in close touch with your subconscious mind!

Hypnotherapy is a valuable tool for empowering people to participate in the health care treatment process. Most physicians acknowledge that patients too often want something done "with" them, rather than done "to" them. Simply put, proven health care therapy works and hypnotherapy is the tool that enhances therapy.

Thus applications of hypnotherapy as an enhancement to proven medical therapy, may be expected to:

a. Improve patient motivation, empowerment and immune systems.

b. Produce anaesthesia in the body, to greatly reduce or eliminate

pain.

c. Improve sleep and control painful symptoms some poor health habits

(smoking, ETOH etc.).

d. Reduce stress and depression,

e. Control some organic functions such as bleeding, hear rate, respiration,

endocrine etc.

f. Make possible partial age regression, reliving an experience in the distant

past, just as it occurred, with the senses operating as they did at the time

of the original experience.

g. Develop abilities for concentration, and increase the capacity to

learn and to remember in detail.

h. Compress a great deal of thinking and recall into a short amount of real

time.

All of the functions listed above, relate to the thinking and action of the patient. All applications are under his/her control and his/her personal efforts (with help from the therapist) he/she can allow "suggestions" to be accepted, and action to occur. Such action may promote life style changes, minimally or significantly, for general well being.

Sometimes in hypnotherapy, no formal "trance" is needed for suggestions to be accepted. Cases are reported of surgical patients under total anaesthesia (but not in hypnotic trance), who are significantly affected by conversations overheard during surgery!

Hypnotherapy is currently useful to support in almost all health problems where the mind/body interaction is recognised and accepted, including: depression, smoking (a key problem in developing countries) , pain, stress, phobias, natural childbirth, colitis, spasms, ulcers, self-esteem, motivation, learning, sports, creativity, sleep, anxiety and panic, child abuse, loss and separation, surgery etc. It is not a magic cure, but just a tool for therapy, and like drug therapy, hypnotherapy is not always successful in every patient.

There are many styles of hypnotherapy. Traditional older styles tended to be "authoritative", but currently more participative styles are "individualised" to the personal values and the "world view" of each patient. Thus personal and cultural adaptation is always necessary. Hundreds of alternative induction and scripts exist for different problems, but a strictly individualised approach, is usually the most effective.

The key to effective hypnotherapy is "rapport" with the therapist, which inspires the patient towards concentration, confidence, expectation and motivation. In health care settings such "rapport" is so easy for doctors and health staff to achieve, and so powerful for the success of all health care procedures!

5. SELF-HYPNOSIS (SH)

Hypnotherapy is always more effective when the patient learns a self-hypnosis (SH) technique and a trance may take only 5 - 20 minutes. Like any other personal skill, SH initially requires daily practice to achieve efficiency and effectiveness. The SH routine involves the same: induction, mental and physical relaxation, repetition of positive affirmations, reinforcement and awakening.

SH is best learned from a therapist, but may be self-learned. For a personal experience you may care to try the DHI example in Exhibit A, provided you have the necessary "rapport" which inspires you towards concentration, confidence, expectation and motivation to achieve a special benefit for your conscious and unconscious mind.

6. A SIMPLE EXAMPLE OF SH

To apply DHI to a personal problem of stress, takes only about five minutes, after mastering the technique, with the same routine of: induction, identifying the problem, asking for comfort and calm, and using specific repetitive positive affirmations, such as:

" I am calm and relaxed. My body is warm, heavy and relaxed.

I move towards my goals. My mind is peaceful. I know I will

survive. My negative thoughts are disappearing. I allow

myself to feel well, happy, calm, confident and motivated. I feel

more and more relaxed, calm and confident that all will be well."

which is followed by reinforcement and awakening. Thus stress can often be resolved or reduced within minutes, sometimes with no drug therapy at all!

Hypnotherapy is not a treatment, but a tool for treatment, which can enhance physical and mental health care. Such treatment must be carefully individualised for each patient, and may either be short with positive affirmations or longer (with an expert therapist) for accelerated psycho-analysis under hypnosis. Some case reports suggest that 100 hours of classic therapy can sometimes be achieved in 20 hours under hypnosis with an expert therapist. Such claims need further research and are not relevant to basic use of hypnotherapy in PHC.

7. RESEARCH

Despite hundreds of positive many case reports, rigorous research on the efficiency and effectiveness of hypnotherapy is difficult because every therapist and every patient are different. Research has often failed to reach the classical scientific standards of medical science with control groups and double-blind treatment etc. But now strong efforts are now being made to reach these standards, so that hypnotherapy can achieve professional recognition. However to be fair, much general medical research has been recognised and accepted for years, but has subsequently been disproved by later more advanced and rigorous research studies.

In 1985 both the AMA and BMA recognised the validity and usefulness of hypnosis, hypnotherapy and self-hypnosis, for health care. Now several societies are engaged in rigorous scientific research, including: The American Society of Clinical Hypnosis and The Society for Clinical and Experimental Hypnosis and The International Society of Hypnosis, The Milton Erickson Society for Clinical Hypnosis etc. The International Journal of Clinical and Experimental Hypnosis publishes research results quarterly.

Numerous cost-effectiveness studies have been done in USA comparing medical interventions with and without psychological intervention, and the results consistently show that while adding psychological interventions (like hypnosis) initially increases cost, the cost is quickly made up by the lesser reliance on the physician, reduced use of expensive tests and drugs and fewer visits for care. In developing countries where poverty and poor health care are the causes of an almost traditional low health status of the rural population, such research needs to be done.

Hundreds of books (of varying quality) have been published on hypnosis, hypnotherapy and self hypnosis, some of which are listed in the bibliography for further study. Currently the WHO library has only about four books and no professional journals on hypnosis and hypnotherapy.

8. POTENTIAL FOR HYPNOTHERAPY IN PHC

Research and practice will be necessary to determine how hypnotherapy can be used extensively in different developing countries so that the key issues of training, cultural adaptation, relationship to traditional healers etc. can be resolved.

However since all physical illness or health problem are becoming recognised to have direct or indirect mental effects on the patient, then the benefit from some kind of hypnotherapy as "part of the treatment" could relate to stages of disease prevention, care and recovery:

And here the ideas of Michael Yapco are worth repeating. Healing takes place in a social as well as a medical context, but health care workers may often work on their medical skills but not their social skills. A well placed suggestion, a skilled directive, a strategic comment can all go far. The starting place for teaching hypnotherapy is that words can heal because words influence belief systems. Furthermore, most health care workers acknowledge that patients too often want something done with them, rather than done to them. Hypnotherapy is a valuable means for empowering people to participate in the health care process. Simply put, proven health care therapy works and hypnotherapy can enhance therapy in the PHC setting.

After about six days of training, the PHC health workers could enhance the general therapy they provide and begin to use simple hypnotherapy applications for:

Motivation to comply with drug therapy

Pain control and improving self-esteem

Smoking problems

Anxiety, depression and panic prevention

DHI

Stress reduction and phobias,

Anaesthesia for minor surgery and injections

Post traumatic stress

Vaccination stress reduction

Reducing anxiety before surgery etc.

With practical experience and further training other applications become possible:

Overcoming depression

Reinforcing compliance with the strict TB/Malaria protocols

Improving patient confidence to seek treatment early (before seeing tradational healers)

Reinforcing compliance with health care and disease prevention instructions

Child drug prevention

Reinforcing health education

Reducing post traumatic distress

Asthma attack prevention

Rebuilding self-esteem of HIV and other patients,

Influencing HIV prevention by teenagers etc.

Natural childbirth

Treatment for minor psycho-somatic illness

Self-esteem reinforcement in chronic illness or age etc

but never deep psychotherapy which requires a qualified psychiatrist or psychologist.

Thus from basic pain and anxiety reduction, hypnotherapy provides a highly creative potential to support for all sorts preventive, curative and rehabilitative health care, where the mind/body influence is clear, and cultural adaptation can be achieved.

Hypnotherapy is an enhancement to proven therapy which can be highly cost-effective.

9. CONCLUSIONS

1. The new WHO health care initiative for cost-effectiveness, mental health care as

priorities, may provide an opportunity for hypnotherapy to contribute to PHC.

2. Hypnosis, hypnotherapy and self-hypnosis are useful cost-effective tools for

therapy with, no danger, no side effects and less need for drugs, which may be

costly for poverty environments in many developing countries.

3. There is need for an education/training program on hypnosis, hypnotherapy and

self-hypnosis, to correct the uninformed fears and misconceptions of doctors,

health staff and patients.

4. Hypnotherapy is more effective with self-hypnosis which can be easily learned and

performed in five minutes. DHI is a simple example of preventive health care.

5. Some culturally adapted hypnotherapy can enhance almost all health care

treatments, where the mind/body impacts are recognised..

6. There is need for rigorous research to justify the case reports of hypnotherapy so

that it can be more easily accepted by the medical international profession.

7. The key proposal of the article, is that hypnotherapy is a highly cost-effective

therapy for PHC (workers and patients), which justifies a multi-country testing

project financed by a major donor, to train health workers and verify, with control

groups, the efficiency and effectiveness of hypnotherapy. Perhaps this could be

achieved by collaboration between WHO and the American Society of Clinical

Hypnosis.

Postscript:: Hypnotherapy enhances treatment of empirically established health care interventions. It places emphasis on greater self-reliance, adaptability, greater responsibility for one's own health care, and on the cost effectiveness of implementing health care therapies. It is almost guaranteed to reduce health care costs, for simple reason that when people feel empowered to better cope with life, they require less health care treatment. Surely it is time we begin to recognise the potential of hypnotherapy, and to make it available for international health care in developing countries, where there is so much poverty and so little affordable health care ...

EXHIBIT A DHI - DAILY HEALTH INDUCTION

EVERY DAY, TAKE A LITTLE TIME, FOR YOUR MENTAL AND PHYSICAL HEALTH, BY GOING INTO A TRANCE WITH VERY GENTLE SELF-HYPNOSIS. TELL YOURSELF HOW LONG, YOU WISH TO REMAIN IN TRANCE, E.G. 5 MINUTES,15 MINUTES ETC.

TO GO INTO A TRANCE

1. Tell yourself that you are going to do your self-hypnosis.

2. Make yourself comfortable. Begin to breath very deeply.

3. Close your eyes and pretend that you cannot open them for five minutes.

4. Relax your whole body ... by visualizing each part carefully ... from the top of your head

to the tips of your toes ...

5. Begin slowly and mentally ... to count down from 10 to 0.

6. Imagine a beautiful white healing light ... coming from above your head ... relaxing and

healing every part of you ... as it passes through your whole body ... and out of your toes.

7. Imagine a beautiful soothing golden fluid ... coming in from your toes ... to sooth and

heal every part of your body ... right up to the top of your head ...

8. Then make simple positive suggestions to yourself ... about your body and your health ...

so that you ... help yourself ... to feel better ... day by day ...

TO WAKE UP FROM THE TRANCE:

Tell yourself that when you wake up you will feel very well, very happy and very motivated

to achieve what you need.

Slowly and mentally count up from 0 to 10 and open your eyes.

Stretch the arms and neck. Relax.

NOTES

Practice: For the first ten days, try to practice twice a day. On awakening in the morning,

to plan for the day and, just before sleeping at night, to hand over one key problem to your

subconscious mind. When you practice before going to sleep, do not awaken with a count

of 0 to 10, simply tell yourself that it will turn into natural sleep from which you will

awaken in your own time in the morning.

Suggestions: Determine what you want. Make only those suggestions that are simple

and positive. Repeat them several times. Always be clear on how you want to think, feel

and behave. Never suggest anything you do not want!

Brief Bibliography

Hartland's Medical and Dental Hypnosis

(Dr. David Waxman, Bailliere Tindall1998)

Hypnosis and Hypnotherapy with Children

(Dr. K. Olness and D. P. Kohen, Guilford Press, 1996)

Hypnosis for Change

(Dr. J. Hadley & C. Staudacher, New Harbinger Publications 1996)

Hypnosis in the Relief of Pain

(Dr. E. Hilgard and J.R. Hilgard, Briunner/Mazel 1994)

Self-Hypnosis

(B.M. Alman and P. Lambrou, Brubnner/Mazel, 1992)

Trancework - An Introduction to the Practice of Clinical Hypnosis

(Dr. M.D. Yapko, Brunner Mazel 1990)

Clinical and Experimental Hypnosis in Medicine, Dentistry and Psychology

(Dr. W Kroger, Lippincott 1977)

Hypnotherapy

(Dave Elman, Westwood Publishing, 1977)

Feeling Good (with Cognitive Therapy)

(Dr. David D. Burns, Avon Books, 1999)

A fuller bibliography of several thousand books and articles is available from several societies engaged in rigorous scientific research on hypnosis, including:

The American Society of Clinical Hypnosis

The Society for Clinical and Experimental Hypnosis

The International Society of Hypnosis

The Milton Erickson Society for Clinical Hypnosis etc.

BRIEF CV FOR DR BOB BOLAND

Formerly a FCA/CPA and consultant for Arthur Andersen; trained at Harvard Business School to become a professor of management at Cranfield, INSEAD, UCT/GSB, Columbia etc. Completed a doctorate in learning systems at Stellenbosch University. Subsequently trained in medicine and joined Johns Hopkins School of Public Health for the residency in preventive medicine and public health, with specialization in international health. Work for Baltimore Public Health Clinics, IRC in Thailand, AID, WB, APHA, WHO, Peace Corps and AID. Work for United Nations/ILO (Geneva), as senior research officer in the management development branch, engaged in: development projects for finance, environment, health and training systems; health care missions in developing countries, evaluations for ILO, WHO, World Bank, WFP etc. Current work as consultant in Geneva in management training and more recently, in practice and research in hypnotherapy and self-hypnosis.

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