shaping the experience of behavior

Shaping the Experience of Behavior:Construct of an Electronic Teaching Module inNonpharmacologic Analgesia and Anxiolysis1

Elvira V. Lang, MD, Eleanor Laser, PhD, Brad Anderson, BA, Jeffrey Potter, BFAOlga Hatsiopoulou, MD, Susan Lutgendorf, PhD, Henrietta Logan, PhD

Rationale and Objectives. The authors’ purpose was to develop an electronic teaching module in nonpharmacologic anal-gesia and anxiolysis for use in the radiology department.

Materials and Methods. The teaching document was derived from previous training courses validated by patient out-come. Skills in structured empathic attention and guidance of self-hypnotic relaxation were tested in a previous prospec-tive, randomized study with 241 patients and shown to affect positively patients’ perception of pain and anxiety. Patientsundergoing hypnosis had the greatest relief and most hemodynamic stability. The skills applied also saved, on average, 17minutes of procedure time and approximately $340 in sedation cost per case. With these validated behavioral skills, anelectronic teaching module was constructed.

Results. The mode of teaching reflected the content of teaching, which was achieved through a multimedia format con-taining text, audio, video, pictures, and animation. Advanced navigation tools put the students in control of their learningexperience. Inclusion of experiential components, congruity of language with Ericksonian syntax, and provision of anelectronic journal catered to the development of greater biobehavioral awareness.

Conclusion. Electronic teaching modules for biobehavioral skill training are feasible and promise to reduce the time needfor life interactions with instructors.

Key Words. Analgesia; anxiolysis; behavioral skills; electronic teaching module; hypnosis.

© AUR, 2002

The Accreditation Council for Graduate Medical Educa-tion in the United States has recently added competencyin interpersonal and communication skills to its list ofcore requirements. Little material is available, however, toaddress training in these skills. Currently, training in be-

havioral skills typically follows a classroom format, withor without role play. Such training, however, is time in-tensive and requires major scheduling adjustments, espe-cially in the present climate of general personnel short-ages. With the increasing demand by patients for compre-hensive and integrative patient care (1), the demand fortraining in biobehavioral integrative skills likely will soonexceed the capacity of conventional training mechanisms.Consequently, appropriate supplemental teaching materi-als are needed. These materials will not replace the hu-man interface in training but will shorten and enhance therequired time spent with instructors. Such materials canthen be used either to prepare for a live course or to rein-force memory and skills after such a course.

Acad Radiol 2002; 9:1185–1193

1 From the Department of Radiology, Beth Israel Deaconess Medical Cen-ter, Harvard Medical School, 330 Brookline Ave, West Campus 308 CC,Boston, MA 02215 (E.V.L., E.L., B.A., J.P., O.H.); Department of Psychol-ogy, University of Iowa, Iowa City (S.L.); and Division of Public Health andResearch, University of Florida College of Dentistry, Gainesville (H.L.). Re-ceived April 25, 2002; revision requested May 16; revision received and ac-cepted May 22. E.V.L. supported by NCCAM RO1 AT00002-04 and K24AT01074-01. Address correspondence to E.V.L.

© AUR, 2002

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Radiologic Education

Written media are helpful for describing biobehavioralskills, but they fall short of conveying the subtle nuancesof human interactions and lack a multisensory experience.Videotapes and audiotapes can allow for observation ofcase studies and the experience of the spoken word, buttheir typically linear nature tends to make such study bothtedious and time consuming. Electronic media, however,have the potential to overcome these limitations.

During the past several years, we have investigatedhow the behavior of procedure personnel toward patientsaffects the patients’ well-being. We have shown that per-sonnel who are adept at advanced rapport skills and atguiding self-hypnotic relaxation in the interventional radi-ology site reduce patients’ pain, anxiety, complications,and procedure time (2) while saving an average of $340per case in total cost of sedation (3). Using the experi-ence that we gained in the education of radiology suitepersonnel as a guide, we have constructed an electronicteaching module in nonpharmacologic analgesia and anxi-olysis that should (a) teach time-sensitive behaviors thathave been validated by clinical outcome in the radiologydepartment and (b) reflect, in the form of the education,the content of the education to provide a more holisticapproach. This report details our approach to and execu-tion of this project and provides an example of how anelectronic module can be constructed.

MATERIALS AND METHODS

Development and Validation of Teaching Content

Teaching content in nonpharmacologic analgesia andanxiolysis was based on a perception of training needsthat we observed during 10 years of training physicians,psychologists, nurses, technologists, medical and psychol-ogy students, and other health care professionals in radi-ology departments and at national and regional meetingsof hypnosis societies. The first consolidation of teachingcontent was in the form of a training manual for use ininterventional radiology in 1993. It included elements ofinstant rapport building, induction of relaxation, imagery,and anxiety conversion. An entire procedure team in atertiary university medical center at the University ofIowa Hospitals and Clinics, Iowa City, was trained inthese techniques during a 2-day training course, whichwas then followed by an interval of practicing the newskills and a second, day-long training session. Because ofpersonnel turnover, the training was repeated 3 years laterwith an extended training manual (4). Unknown to us, thehospital had started collecting patient satisfaction data,

including assessment of the patients’ pain during proce-dures throughout both these periods. Review of these datashowed that patients reported significantly (P � .001) lesspain when they had been attended by personnel who weretrained in nonpharmacologic analgesia techniques thanwhen they were attended by compassionate but untrainedpersonnel (5). This was the first validation of the trainingcontent based on patient outcome.

After this initial experience, validation of the biobe-havioral skills was then planned in the form of a large,prospective, randomized study funded by the NationalInstitutes of Health. For this purpose, standardization ofteaching content became necessary. This standardizationclosely followed the framework of a long-standing experi-ence developed by David Spiegel’s research group intraining health care providers to structure expressive-sup-portive group therapy for women with breast cancer (6,7).The content was adapted for use in a busy interventionalradiology suite, summarized in a training manual (8), andpublished in abbreviated form (9). This manual served asthe basis on which biobehavioral interventions in the pro-cedure suite were tested. The manual contained trainingin structured empathic attention, which comprised ad-vanced rapport skills and encouragement, and self-hyp-notic relaxation, which comprised induction of relaxationand self-hypnosis, imagery, correct use of suggestions andhypnotic syntax, and anxiety conversion—all skills to beused in conjunction with structured empathic attention.The manual also received an additional segment on “trou-bleshooting” (eg, overcoming resistances and what itmeans when a patient cries).

These behaviors were then tested in a prospective, ran-domized study involving 241 patients undergoing periph-eral vascular or percutaneous renal interventions in amodel of patient-control analgesia with intravenous fenta-nyl and midazolam (2). One-third of the patients receivedstandard care by personnel instructed to do their best butto abstain from imagery and hypnosis, one-third receivedempathic structured attention, and one-third received self-hypnotic relaxation, which consisted of empathic struc-tured attention and self-hypnotic relaxation. The studydesign permitted us to distinguish the effect of the differ-ent behavioral interventions. Under conditions of standardcare, patients’ pain increased linearly over time, regard-less of the amount of medication given (Fig 1). The in-crease was less steep when patients received empathicattention by their providers, and the trend was altogetherreversed with hypnosis. Anxiety decreased in all threegroups but decreased faster in the group receiving em-

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pathic attention. Additionally, the decrease was even morepronounced in the group receiving self-hypnotic relaxation.

Patients in both the empathy and hypnosis groups usedhalf the amount of drugs that patients in the standard caregroup used and, accordingly, had a lower incidence ofrespiratory depression. Interestingly, the patients undergo-ing hypnosis had significantly (P � .0009) fewer hemo-dynamic disturbances and complications, indicating thatthe hypnotic element in the biobehavioral skill set eliciteda fundamentally different response. Although hypnosiswas applied in the procedure room and counted as proce-dure time, cases in the hypnosis group were completedsignificantly (P � .0016) faster (on average, 17 minutesearlier) than those in the standard care group. The reduc-tion in complications and incidences of over- and under-sedation also resulted in a savings in terms of the overallsedation cost of approximately $338 per case (3).

From the treatment manual, a behavioral checklist wasderived and used as an adherence check to ensure thatproviders in each group used the behaviors that were pre-scribed and avoided those that were proscribed. All inter-ventional procedures in the prospective, randomized studywere videotaped, and analysis of 50 randomly chosentapes by two independent research assistants confirmedthat the behaviors were displayed as intended, thus com-pleting the sequence of behavioral validation. After theteaching content was further refined, an additional inde-pendent research assistant reviewed all the tapes and ex-tracted examples that highlighted the teaching content. Onthe basis of this review, additional foci of interest were

added, predominantly under the category of special con-siderations. This review also identified that avoidance ofnegative suggestions and correct use of suggestions had amost pronounced effect on the outcome and, therefore,needed special attention.

Construction of the Electronic ModuleWe felt strongly thatthe method of the teaching should

reflect the content of the teaching. Just as respect and cater-ing to different sensory preferences of the patient is a con-tent of teaching, the student should be able to choose his orher preferred mode of learning. Software development andmode of presentation were based on this principle. Clinicalscenarios were used as observational examples. We found itto be equally important, however, to include experientialcomponents: Before shaping another individual’s experience,it is important to develop self-awareness. Last, syntax andvisuals of any single information packet were designed todovetail harmoniously with the principles of any other perti-nent teaching packet in the module.

On a technical level, many applications were used indeveloping the module. One of the main objectives wasfor the finished project to be comprehensive yet simple touse. The module needed a unique interface that wouldaccomplish the goals of the project without the distractionof other application interfaces (eg, Web browsers andapplications). With this in mind, Macromedia Directorsoftware (Macromedia, San Francisco, Calif) was chosenfor its ability to create a discrete learning environment.Moreover, Director is the industry multimedia standardand can handle multiple media formats (ie, text, anima-tion, video, and sound). Additionally, it offers integrationwith the World Wide Web, which is important when con-sidering the scalability and accessibility of the module,and a means of monitoring student progress for certification.Director’s combined features provide a proven, stable plat-form for both Mac and PC while offering the latest technol-ogies for multimedia presentations and teachings.

Regarding elements within the module, various applica-tions were used. The interface and graphic treatments weredesigned with PhotoShop (image editing; Adobe Systems,San Jose, Calif), After Effects (animation/video; Adobe Sys-tems), and Macromedia Flash (Web animation; Macromedia)software. Additionally, QuickTime software (Apple, Cuper-tino, Calif) was chosen for the presentation of video ele-ments in the course, because it integrates well with Macro-media Director and is easily distributable. The videos thatappear in the module were edited with Final Cut Pro soft-ware (Apple).

Figure 1. Effect of provider behavior on patient outcome. Datafrom pain scores represent group means and were measured onself-reporting scales from 0 to 10 (0, no pain at all; 10, worst painpossible).

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RESULTS

Teaching Content

The behaviors to be taught are summarized in the Ta-ble. They were grouped in four phases that reflect thesuccessive steps in learning. Phase 1 included instant rap-

port techniques, encouragement, and empowerment withthe provision of the perception of control. Phase 2 con-tained all techniques that induce and maintain a state offocused attention. Phase 3 involved the successful reori-entation to the waking state, and phase 4 dealt with spe-cial considerations. Supporting information included a

Translation of Teaching Content in the Electronic Module

Teaching Content Electronic Module

Phase 1: instant rapportMatching nonverbal communication (body posture, spacing,breathing)

Experiential components of images at different magnifications to identify“comfort zone”

Choice of font size in navigation toolMatching verbal communication (recognition and matchingof the patients preferred sensory mode, [ie, visual,auditory, kinesthetic, olfactory, gustatory])

Choice of text, audio, pictures, video

Understanding the principle of matching and leading to aresourceful state

Attentive listeningCorrect use of suggestions (avoidance of negativesuggestions)

Text syntax: Ericksonian language (eg, “You may be surprised to learnhow much you already know about . . .” rather than “this will not bedifficult to do,” which focuses on difficult; use of “try” only whenanticipating failure)

Differentiation between encouragement and praiseEmpowerment and the provision of the perception ofcontrol

Choice in the navigation modes; choice of access to material, depth ofmaterial, prioritization of written word, pictures, videos, or sound

Phase 2: focused attentionPrinciples of the induction of focused attention/relaxation/self-hypnosis

Provision of listening to induction—with eyes closed or while readingtext; ability to read induction text beforehand to allay fears of whatsuggestions under hypnosis may be

Provision of induction that the student can use to achieve a resourcefulstate him- or herself

Different techniques of induction Provision of multiple scripts with audiosPatient video clips

Use of imagery Have “bad” news fade into distance, have “good” news colorful and inthe foreground

Hypnotic syntax, use of metaphorsOvercoming resistance to imagery and self-hypnosisTechniques for pain controlTechniques for anxiety conversion Provision of experiential components*(Deepening and ideomotor signals)*

Phase 3: waking stateReorientation into the waking stateTrance terminationPosthypnotic suggestions

Phase 4: special considerationCreating a resourceful state for the practitioner Choice of self-hypnosis scripts for practionerConcomitant use of intravenous sedatives and narcoticsAssisting patients who cryManaging recall of abusive situationsAnchoringAppropriate response to patients’ misbehavior

*These elements were included as useful, although they were not considered to be essential during the validation process.


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history of hypnosis, familiarization with the concept sothat students could overcome any misconceptions, a sylla-bus, and a resource segment.

Flow ChartThe project originated as a manual. To translate this

material into a multimedia format, the manual was sec-tioned into small bites (or “packets”) of information thatcould be worked through quickly because of the timeconstraints on the target users (ie, medical and alliedhealth professionals). A flow chart was developed to helpplan the structure and content of the module (Fig 2).

InterfaceThe interface was designed with two priorities: to be

simple and to be intuitive. It was important that a user beable to reach any section of the module without having toclick through numerous layers of hierarchic navigation.From the main menu (ie, the starter screen), a user canenter any phase of the course by means of a single click.Once inside that phase, a specific scene menu allows theuser to access any packet of learning material with onemore click. Last, one click returns the user to the mainmenu.

To make the interface intuitive, three components weredeveloped. First, the main navigation component allowsaccess to all the separate elements of the project (ie, thecourse, the resources, frequently asked questions, and thesyllabus) (Fig 3). A second component contains the sub-navigation, or the navigation within each element. Thisincludes advancing either from frame to frame throughthe course or to the next packet of learning material. Thefinal component is a grouping of user settings. In thiscomponent, users can customize the settings (eg, text sizeor volume level) for their own comfort. The combinationof a simple structure and an intuitive interface allows thecourse to be simultaneously accessible, user-friendly, andcontent rich.

Reflection of the Teaching Content in theTeaching Method

The Table provides an overview of our approach. Theinteractive technologies facilitate bringing the context ofexperience to learning. The student is in control of learn-ing (ie, is “empowered”) by rapid access to the desiredtopic, additional resources for in-depth study, and theability to work both in and out of sequence. Differencesin learning styles (ie, sensory preferences) are accommo-

Figure 2. Flow chart for planning the structure and content of the electronic module.


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dated by providing written words, pictures, sounds, mov-ies, and fast-forward capability (Fig 4).

As an example of the presentation of teaching content,the flow of information and experience in the nonverbalrapport section has been structured as follows: First, ashort overview is given. The student is then familiarizedwith the notion that the skills to be learned are not new(eg, “Who can resist the smile of a baby?” and “Once wewere all babies.”). Next, the student is presented withfull-screen images of situations and is to report his or herreaction. After viewing the images, a composite screenwith a journal appears in which the student can recordhow the images affected him or her (Fig 5). This journalserves as documentation of personal growth but also can

be used to connect with an instructor over the Web as afeedback mechanism. Finally, a task follows (eg, “Exer-cise of the day”) (Fig 3).

Students who are curious about being hypnotized canlisten to an induction script or choose to read the scriptbefore or after listening—or even while listening. Read-ing alone does not transmit the same experience. The stu-dent can choose inductions from “personal” experiencethat he or she is most comfortable with. The student canalso watch examples of patients experiencing hypnosis.Additionally, they can witness the rapidity of the process,because the reshaping of human interactions is fast. Thetext can illustrate the power of suggestions and use of“hypnotic” syntax, but experiential components and video

Figure 3. Screen shot demonstrates the navigation tools of the interface.


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clips sharpen the students’ awareness of subtle and non-verbal interactions.

In the segment concerning imagery and anxiety con-version, the teaching content conveys that distressing, or“bad,” imagery should be moved into the background andmade small, black and white, and unimportant. “Good”imagery should be brought into the foreground and madeattractive and intensive for all the senses. This principlewas incorporated into the module by moving bad news orexamples away from the screen, decreasing their size, andfading them into a black-and-white background, whereasthe good content was brought forward and made bothcolorful and large.

In the special considerations section, short segmentsfrom our case collection are included as good and badexamples. Students are also presented with difficult sce-

narios on either video or text and are instructed to findsolutions and record them in the journal. Then, a varietyof solutions are offered for the given situation. Offeringseveral solutions was thought to be important to supportthe creativity of the student and provide comfort. Therecan be many ways to help a patient, and there is no sin-gle right way of providing comfort.

DISCUSSION

The challenge of constructing a teaching module inbiobehavioral skills is the need for an experiential compo-nent that enhances the student’s perception of the pa-tient’s sensibilities. A common approach in current teach-ing modules is the presentation of PowerPoint (Microsoft,Redmond, Wash) slides with a lengthy audio lecture in

Figure 4. Screen shot demonstrates the choices in learning. A QuickTime video can be viewed in the left upper corner. The screenopens with a voice-over that can be muted or adjusted to the desired volume by using the subnavigation tool in the lower right corner.The text can be displayed in different desired sizes and can be fast-forwarded.


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either electronic or video format. The linear structure ofsuch presentations leaves students who want to learnfaster at a loss. The lack of interactivity also risks induc-ing boredom and signing off from the teaching module.We therefore determined that our biobehavioral skillsmodule should leave the student with as much choice aspossible. The student should be at liberty to choose thespeed at which to proceed by using fast-forward func-tions, what to learn when and at what depth, and whatpriority to give the written words, pictures, videos, orsound. We deliberately used Ericksonian syntax in theform of embedded commands (10) whenever appropriate(eg, “You may be surprised to learn much you alreadyknow about rapport,” or use of the wordtry only in situa-tions when one is expected to fail). This served threefunctions: to enhance the learning, to familiarize the stu-

dent with the vocabulary, and to keep the module inter-esting for students who have already mastered the basicknowledge.

An electronic journal was included as a tool for thestudent to record his or her personal growth by permittingperiodic review and reassessment of perceptions. Thejournal can also be used to record attendance and testknowledge in a meaningful fashion should continuingmedical education credit be sought for the study of thismodule.

Use of hypnotic syntax and methods raises questionsregarding their applications in teaching settings and prac-tice encounters. When is informed consent needed? Ad-vertising media that commonly use such syntax and pre-sentation to lure a person’s subconscious to commercialexploits do not seek the audience’s authorization—unless

Figure 5. Experiential components and electronic journal. Before this screen, the student has already viewed the individual images (fullsize) with instructions to focus on the experience they provoke. On this screen, the student can click each image and restore it to fullsize as a memory aid and can enter solutions and thoughts into the electronic module.


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turning on the television or radio is construed as such.Because use of nonpharmacologic methods of analgesia inthe clinical setting is not credentialed, informed consentremains a gray area. We always ask patients whether theywould like to have a relaxation exercise, hypnosis, or away to help themselves through the procedure, but we donot obtain written consent at this time unless the patientis enrolled in a research study.

Because credentialing of biobehavioral and alternativeinterventions is a gray area, additional issues need to beconsidered. Who can be trained by whom, and how? Un-til 2 years ago, the National Hypnosis Societies (ie, theSociety for Clinical and Experimental Hypnosis and theAmerican Society of Hypnosis) permitted training onlyfor physicians, psychologists, dentists, and social workers,but many lay hypnosis institutions will train nearly any-one. Through efforts by one of the authors (E.V.L.),nurses are now officially permitted to be trained, and aproposal is pending at the executive board of the Societyfor Clinical and Experimental Hypnosis to include tech-nologists and other licensed health professionals, as well.The ideal goal is to have consistent training throughout ahospital structure so that patients can benefit from theenhanced biobehavioral skills at all levels of an entireinstitution. Our experience has shown that electronicteaching modules for biobehavioral skill training are fea-

sible and promise to reduce the time needed for life inter-actions with instructors. We hope that teaching modulessuch as the one presented here will play an important rolein achieving this goal.

REFERENCES

1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medi-cine use in the United States, 1990–1997: results of a follow-up na-tional survey. JAMA 1998; 280:1569–1575.

2. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive nonpharmacologicanalgesia for invasive medical procedures: a randomized trial. Lancet2000; 355:1486–1490.

3. Lang EV, Rosen MP. Cost analysis of adjunct hypnosis with sedationduring outpatient interventional radiologic procedures. Radiology 2002;222:375–382.

4. Laser ED, Lang EV. Methods of nonpharmacologic analgesia: asourcebook for practitioners. Chicago, Ill: Laser, 1997.

5. Lang EV, Berbaum KS. Educating interventional radiology personnel innonpharmacologic analgesia: effect on patients’ pain perception. AcadRadiol 1997; 4:753–757.

6. Spiegel D, Bloom JR, Yalom ID. Group support for patients with meta-static cancer: a randomized prospective outcome study. Arch GenPsychiatry 1981; 38:527–533.

7. Spiegel D, Bloom J. Group therapy and hypnosis reduce metastaticbreast carcinoma pain. Psychosom Med 1983; 45:333–339.

8. Lang EV, Spiegel D, Lutgendorf S, Logan H. Empathic attention andself-hypnotic relaxation for interventional radiological procedures. IowaCity, Iowa: University of Iowa Press, 1996.

9. Lang EV, Lutgendorf S, Logan H, Benotsch E, Laser E, Spiegel D.Nonpharmacologic analgesia and anxiolysis for interventional radiolog-ical procedures. Semin Interv Radiol 1999; 16:113–123.

10. Anue R. Zebu: the hypnotic language card game. Robert Anue, 1992.


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shaping the experience of behavior

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