· web view10. irritable bowel syndrome. 11. headaches and migraines 12. cancer patient care etc....

BASED UPON MANY CONTACTS AND THE TEXTBOOK: MEDICAL HYPNOSIS PRIMER - CLINICAL AND RESEARCH EVIDENCE

which was developed by: SCEH - Society of Clinical and Experimental Hypnosis and ISH - International Society of Hypnosis,

DRAFT TO MOTIVATE TESTING

MEDICAL HYPNOSIS PRIMER - CLINICAL AND RESEARCH EVIDENCE - TRAINING SUPPORT PROGRAM

2-3 DAY FULL TIME COURSE OR PART TIME IN 10-12 SESSIONS

WORK PACK(see also GUIDE and DIARY)

ALL IDEAS WELCOME Version 14 – January 18, 2010

Copyright: RGAB 2009/14 Available on request

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SPECIFIC OBJECTIVES

This brief cost effective program provides course members with the opportunity to both understand and practice modern medical hypnosis.

It is training support for the new 2009 textbook - Medical Hypnosis Primer - Clinical and Research Evidence and supporting DVD’s published with SCEH (Society of Clinical and Experimental Hypnosis) and ISH (International Society of Hypnosis)

Training for medical and nursing students can be covered in 10-12 two hour regular course sessions. The program can also be a 2-3 day full time training course for doctors, nurses and primary health care workers.

The specific learning objectives are to:

1. Briefly present the basic concepts of modern medical hypnosis.

2. Encourage health practitioners to use hypnosis as an adjunct and reinforcement to medical care.

3. Support the teaching and practice of hypnosis as a part of the requires syllabus of medical schools, nursing schools and primary health care training units.

4. Develop confidence in using basic cost effective brief hypnosis techniques with patients.

5. Motivate further study in the future with the courses run by the professionally recognized national and international hypnosis societies.

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SPECIAL NOTE ON THE LEARNING

UP TO 2009:

1. With so many new health care developments and publications to absorb each year, With so many new health care developments and publications to absorb each year, how will and doctors and nurses be motivated to read the Primer on Medical Hypnosis?

2. So many doctors and nurses are skeptical about the validity of medical hypnosis. Many patients are frightened by the word hypnosis.

3. Getting medical hypnosis into the required regular syllabus of medical and nursing schools in 2010 is a severe challenge.

4. The medical school syllabus is already over-flowing with new EBM scientific developments and yet medical hypnosis does not seem to be very scientific.

5. Doctors are concerned about patient anxiety but they simply do not have the time for 30 minutes of psychological care, which belongs more to psychiatrists.

BUT:

1. Medical hypnosis can often reinforce medical care in only five minutes.

2. Self hypnosis helps the patient to help himself, to feel in control of mind and body, and thus to feel like part of the health care team.

3. Medical hypnosis is highly cost effective with no side effects.

4. Self hypnosis can benefit not only the anxious patient but also the stressed doctor, nurse and other members of the health care team.

FROM 2010:

1. A rigorous trial of medical hypnosis is justified.

2. The program presents a new way to learn and practice basic medical hypnosis, in a flexible 2-3 day course for doctors, nurses and primary health care workers, or In 10-12 two hour sessions for medical and nursing students, with special support.

3. The program is based upon the concept that experienced health care professionals will only read and accept the new Primer on Medical Hypnosis, when it is supported by a challenging interactive learning experience.

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Based on the Primer, this draft standard basic medical hypnosis training course, is designed to be validated with rigorous testing of relevance, efficiency and effectiveness.

This training can be highly cost effective when it requires only one local professional hypnosis instructor as course Organizer with key resources.

Critical choice of lecture notes, videos and exercises needs to be finalized with testing.

The initial planned brief extracts (about 12-15 minutes) from classic professional hypnosis videos are:

Sugarman – “Therapeutic Hypnosis with Children and Adolescents” (Crown House) by Professor William Wester & Dr Laurence Sugarman

Rossi - “Hypnosis techniques” Professor Ernest Rossi (published by Erickson) Kuttner (1) - "No Tears, No Fears" (Fanlight Productions) by Dr. Leora Kuttner Kuttner (2) - Follow up videotape of the reactions of same children, ten years later.

with alternatives as decided by the Organizer.

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: MEDICAL HYPNOSIS PRIMER - CLINICAL AND RESEARCH EVIDENCE TRAINING SUPPORT PROGRAM

INDEX

Unit Page No.

Flexible Course Outline

1. Hypnosis Concepts 6

2. Hypnotic Testing 13

3. Acute pain 19

4. Chronic Pain 24

5. Childhood Problems 31

6. PTSD 39

7. Surgery 45

8. Childbirth 50

9. Sleep 57

10. Depression 62

11. Stress & anxiety & Procedural Hypnosis 68

12. Summary & Review Session 72

Appendix: Olness PHC Training Program 77

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MEDICAL HYPNOSIS PRIMER - CLINICAL AND RESEARCH EVIDENCE TRAINING SUPPORT PROGRAM

FLEXIBLE COURSE OUTLINE

Required pre-course study: Review the Medical Hypnosis Primer -Clinical and Research Evidence. Test the supporting DVD Hypnotic

Induction Demonstrations (Barabasz & Christensen)Day 1: 08.00 - 10.00 Unit 1 Introduction & Concepts (MG & SG)10.00 - 10.15 Break10.15 - 12.15 Unit 2 Hypnotizability (CSG)12.15 - 01.15 Lunch01.15 - 03.15 Unit 3 Acute Pain (new SG)03.15 - 03.30 Break03.30 - 05.30 Unit 4 Chronic pain (CSG)05.30 - 06.00 Discussion & Homework (MG)

Day 2: 08.00 - 10.00 Unit 5 Childhood Problems (new SG)10.00 - 10.15 Break10.15 - 12.15 Unit 6 PTSD (CSG)12.15 - 01.15 Lunch01.15 - 03.15 Unit 7 Surgery (new SG)03.15 - 03.30 Break03.30 - 05.30 Unit 8 Childbirth (CSG)05.30 - 06.00 Discussion & homework (MG)

Day 3: 08.00 - 10.00 Unit 9 Sleep (new SG)10.00 - 10.15 Break10.15 - 12.15 Unit 10 Depression (CSG)12.15 - 01.15 Lunch01.15 - 03.15 Unit 11 Stress, Anxiety & Proc. Hypnosis (new SG)03.15 - 03.30 Break03.30 - 05.30 Unit 12 Summary and Review (CSG)05.30 - 06.00 Discussion & Post course Study (MG)

NOTE: THE BASIC THREE DAY COURSE OUTLINE INCLUDES ALL TWELVE UNITS.SOME UNITS MAY NOT BE OF IMMEDIATE INTEREST OR RELEVANCE TO SPECIFIC LEARNERS OR THE COURSE TIME MAY BE TOO INTENSE.. ALTERNATIVE COURSE OUTLINES: THREE DAYS WITH TEN UNITS AND TWO UNIT TIMES AS PRACTICE WITH MINICASES; OR THREE DAYS WITH ONLY NINE UNITS AND SHORTER HOURS; OR TWO DAYS WITH ONLY EIGHT UNITS. ANY UNITS NOT SELECTED CAN BE USED FOR POST-COURSE/ HOMEWORK STUDY.

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UNIT 1 - HYPNOSIS CONCEPTS (BARABASZ/CHRISTENSEN)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10

2. AGL 5

3. QUIZ 40

4. REVIEW OF PRIMER 10

5. NARRATED LECTURE 15

6. VIDEO 15

7. DEMO/PRACTICE EXERCISE 15

8. SUMMARY 10

120

NOTE:

ALL INSTRUCTIONS ARE GIVEN IN MG FOLLOWED BY CONTINUOUS SG DISCUSSION AND INTERACTION.

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UNIT 1 - HYPNOSIS CONCEPTS

1.1 OBJECTIVES OF THE PROGRAM (10 minutes)

a. To stimulate the learner knowledge, skills and attitudes for efficient and effective basic medical hypnosis practice and to motivate further study and practice in the future.

b. Based on the Medical Hypnosis Primer the key pre-learning textbook for the course, to get medical hypnosis training into the required syllabus of every medical/nursing school and PHC training facility in 2010.

c. To use the AGL (Autonomous Group Learning) system to create 24 hours of highly interactive training, in 2 hour units, which can be organized and provided by one qualified hypnosis instructor. Each unit can be adapted to local culture,

d. To give in each unit an inspiring learning mixture of: narrated lecture, group discussion, Primer study, video, practical exercise and quiz

e. To create a website with training materials (with controlled access by code) to encourage free access and translation of the textbook and training materials, into local languages. To use this web site as a resource for post training help, feedback and support of further study.

f. To promote and support the Olness Training program and for primary health care workers in developing counties. See Appendix.

g To use a rigorous alternative choice quiz (80 questions) in the first and last units of the training, to measure and reward the learning achieved.

h To provide allow alternative scheduling as a 2-3 day course for Doctors, nurses and primary health care workers, or in 10-12 two hour sessions for medical and nursing students, with individual support as needed.

1.2 AGL (AUTONOMOUS GROUP LEARNING)

a. AGL was designed as an intensive highly interactive learning experience with a variety of 2 hour units which may be selected. Some parts may be less challeng ing for the experienced health worker with many years of experience.

b. AGL creates a very special group learning environment that is new to the group members. It is a highly effective but rather challenging learning experience. Members should therefore try to keep an open mind on their reactions until the second day of the program.

c. Members can and do solve ALL the problems and answer ALL the questions, from the special materials (Workpack, Guide, Diary and DVD) provided and the

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experience of other members of the group.


d. The Organizer can respond directly to technical questions, but the learning is better when members help each other. The critical skill of the Organizer is to HELP the participants to WORK TOGETHER to resolve successfully, all questions arising. Thus by the end of the program EVERY QUESTION is resolved!

e. In AGL the learning will be done:

IND - Individually, or SG - Small Group (four members or just partners which change), or CSG - Combined Small Group (two small groups together), or

MG - Main Group (short lectures with visual aids).

f We hope you too will find the program stimulating, efficient and effective for you in every unit! The specific objectives Unit 1 are to present and practice:

1. Basic hypnosis concepts.2. Common evidence-based uses of hypnosis3. Definitions of hypnosis 4. Hypnotizability5. Using self hypnosis yourself6. Examples of a hypnotic-like experiences.

NOW IN SG START THE REGISTRATION FORM IN THE DIARY. COMPLETE IT AS HOMEWORK TONIGHT.

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1.3 QUIZ (40)

Instructions SG::

1. Individually complete on the answer sheet provided in the Diary, the 80 question alternative choice quiz which is in the GUIDE. Choose questions only the selected units included in the course.

2. Hand your answer sheet to the Organizer who will give you a score of hypnosis learning at the start of the course.

3. The same quiz will be completed in the last learning unit, to give you feedback on your achievement.

1.4 REVIEW OF PRIMER (10)

Instructions SG:

1. Briefly review the Primer – Introduction & Ch. 1.

2. Discuss following questions:

a. What are your reactions?

b. How will your patients react?

1.5 NARRATED LECTURE (15)

A. OVERVIEW

Hypnosis is a set of procedures used by health professionals to treat a range of emotional and physical problems. Hypnosis is an altered state of awareness one can enter spontaneously. However, for health care purposes it is attained by an induction procedure.

Most hypnotic inductions engage patients’ imaginative capacities and include suggestions of focused attention, relaxation, and calmness.

Patients respond to hypnosis in different ways. Some describe their experiences as a state of deepened awareness, others as calm state of focused attention.

Prior to using hypnosis, always familiarize the patient with “hypnotic-like” experiences, to reinforce debunking of myths about hypnosis. Self-hypnosis is the key to hypnosis efficiency and effectiveness.

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UNIT 1 - HYPNOSIS CONCEPTSB. HYPNOSIS DEFINED

A short definition of hypnosis is ‘attentive perception and concentration, which leads to controlled imagination’. Hypnosis operates from one’s latent cognitive ability (hypnotizability).

Social influences such as ‘expectancy’ have only a modest influence on responsiveness. It is altered state of consciousness and an interpersonal relationship of trust.

The initial suggestion can constitute the hypnotic induction.

Clinical hypnotic inductions usually involve progressive phases to reach a depth for a medical or psychotherapeutic purpose.

The hypnotic state is characterized by the patient’s ability to sustain a state of attention, receptive, intense focal concentration with diminished peripheral awareness.

Thus, the hypnotic state involves a contraction of awareness of involvement with other points in space and time, thereby creating a dialectic between focal and peripheral awareness.

C. COMMON EVIDENCE BASED USES OF HYPNOSIS

Clinical hypnosis has proven useful reinforcement in health care of:

1. Acute and chronic pain (including medical procedures; surgeries, pre-post op) 2. Post Traumatic Stress Disorder (PTSD) with EMDR. 3. Childhood and adolescent problems. 4. Childbirth pain and Trauma 5. Insomnia. 6. Depression

7. Weight control/healthy eating and exercise 8. Psychosomatic Disorders 9. Habit control

10. Irritable Bowel syndrome.11. Headaches and Migraines12. Cancer patient care etc.

D. HYPNOTIZABILITY

Hypnosis is a matter of degree.

Some individuals may enter a deep state and exhibit behaviors such as regression, time distortion, and hallucinations.

Others, however, may reach a plateau, where they are able to experience only simple suggestions..

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Some hypnotherapeutic techniques and experimental research responses require deep states (e.g. surgery).

Others can be effectively employed with the patient only lightly hypnotized (e.g. minor medical procedures, irritable bowel syndrome [IBS], many forms of psychotherapy).

Researchers and clinicians alike may first assess the level of hypnotizability and then the level of depth capability.

The scales of hypnotizability, useful as they are, only predict responses to hypnosis about 50% of the time Standardized Tests of Hypnotizability are discussed in UNit 2.

E. CONCLUSIONS

Hypnosis is an essentially culturally free adjunctive treatment modality that has been shown to be effective in a wide range of medical and psychological disorders.

It is especially cost effective in contrast to standard medical care, well accepted by patients and adaptable to multi-cultural settings.

But is most often used to reinforce standard medical and psychological interventions to improve patient tolerance of initial and long-term treatment outcomes.

Hypnosis is an altered state of awareness involving attentive perception, concentration and controlled imagination. In most cases, an induction procedure is employed.

The ability patient to use hypnosis (hypnotizability) is a stable trait easily measured by standardized procedures. Measurement affords a fit between a specific procedure and the patients responsiveness

1.6 VIDEO (15)

Instructions:

1. MG – Play the video extract: Sugarman 1 of 3

2. SG – Discuss the following questions:

a. What are your reactions to the video?

b. How will your patients react?

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1.7 DEMO/EXERCISE (20)

Instructions: Study the Organizer demo and then role play the experience with a partner, reading this brief SH - self hypnosis script.

1. Tell yourself that you are going to do SH, because to help patients to use it, you must be able to do it yourself.

2. Make yourself comfortable. Gently grip the LEFT THUMB into the left.fist. This is your “anchor sign” for instant SH. Begin to breathe very deeply.

3. Focus your attention on a spot high up on the wall. As you concentrate feel more relaxed. Concentrate intently so that other things begin to fade into the background. As this occurs, notice a relaxed heavy feeling and allow your eyes to close. Then pretend that you cannot open them for two minutes. Nod you’re head when you have done it.

4. Relax your whole body, by visualizing and smiling at 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 … saying … deeper… deeper

6. Imagine a beautiful white light ... coming from above your head ... cleaning every part of you ... as it passes through your whole mind and body ... and out of your toes.

7. Imagine a beautiful soothing golden fluid ... coming in from your toes ... soothing and healing every part of your mind and body ... right up to the top of your head.

8. Then RELAX , as you make one or two POSITIVE suggestions to yourself ... to find new strengths within yourself that help YOU to learn and achieve … in YOUR OWN WAY …

9. And then REPEAT your suggestions two or three times. Think deeply and gently talk with yourself about these things … for a few moments … and then … in your own time … when YOU are ready …..

10. TO COME BACK FROM SH, tell yourself that when you come back … counting from 1 to 5 and as you say 4 …eyes will open and you will feel very well … calm, contented and very CONFIDENT and MOTIVATED … to achieve what you need. 11. Slowly release the thumb from the left fist ( anchor sign). Slowly count up from 1 to 5 and open your eyes. 12. Stretch the arms and neck. Relax. Feel calm, confident and pleased with yourself.

1.8 SUMMARY (10)13

Instructions: MG – Questions, answers and discussion

UNIT 2 - HYPNOSIS TESTING (SPIEGEL) TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10

2. STUDY OF PRIMER 20


4. VIDEO 20


6. SUMMARY 10

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2.1 OBJECTIVES (10 minutes)

To learn and practice:

1. Hypnotizability

2. Measurements

3. Clinical tests of hypnotizability

4. Other clinical scales

5. Stability of hypnotizability

6. Setting the context for treatment

7. A method of self-hypnosis

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UNIT 2 - HYPNOSIS TESTING

2.2 STUDY OF PRIMER (20)

Instructions:

a. Individually study on the Primer – Ch. 2.

b. In SG – discuss the answers to the following questions:

1. What are your reactions?

2. How will your patients react?

2.3 NARRATED LECTURE (30) A. INTRODUCTION

Many hypnotic induction techniques are used to gett trance, ranging from eye fixation on fixed or moving targets, through eye closure, body sway, touch by the hypnotist, evoking numbness, paresthesias or paralysis, counting up and down stairs, etc.

Trance phenomema may occur spontaneously, or in response to a variety of induction techniques..

Variability in the hypnotic response depends more on the hypnotic capacity of the individual being hypnotized than the induction or the skill of the clinician.

Clinical measurement of hypnotizability is part of the medical and psychiatric and /psychological examination.

The setting is appropriate for both the patient and the therapist, for transformation into trance to occur quickly and to the person’s optimal capacity.

B. MEASUREMENTS

Hypnotizability is a stable and measurable trait.

Several well-standardized scales of hypnotizability, hypnotic capacity, or hypnotic susceptibility have been developed.

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With Harvard Group Scales patients themselves score them in twenty minutres. They correlate with the Stanford Hypnotic Susceptibility Scale, which requires one hour.


Tests standardized on college student populations often reflect concern with only a limited sample of age and education, not the wide range characteristics of a patient population.

Since hypnosis is an expression of integrated concentration. Factors which impair concentration such as drugs, psychopathology, and neurological deficits should be taken into account

C. CLINICAL TESTS OF HYPNOTIZABILITY

The Hypnotic Induction Profile (HIP) takes five to ten minutes to administer. It is both a procedure for trance induction and a disciplined measure of of hypnotizability standardized on a patient population in a clinical setting.

In HIP the hypnotist is the measuring instrument. It is brief and clinically appropriate. Once a hypnotizability score is determined, the time for the shift into trance is a few seconds.

The HIP is moderately and positively correlated with the Stanford Scales.

D. OTHER CLINICAL SCALES

The need is for briefer clinical measures of hypnotizability that are practical and appropriate to the pressures of clinical work, and yet reliable and valid.

The Hilgards introduced two briefer scales, one the Stanford Hypnotic Clinical Scale, which takes about 20 minutes and the Stanford Hypnotic Arm Levitation Induction Test which takes 5 minutes.

E. STABILITY OF HYPNOTIZABILITY

Hypnotizability is stable trait, like IQ.

A patient’s baseline hypnotizability score is the same 25 years later.

F. SETTING THE CONTEXT FOR TREATMENT

Patients fear that hypnosis represents a loss of control. In fact, it is an opportunity to enhance their control over both mental and physical states.

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Hypnotizability can demonstrate to the patient how easily he can enhance and expand his own sense of control of himself and his body, utilizing intensely focused imagination.


Hypnotizability testing can be used to decide whether or not it to employ hypnosis.

The degree of intact hypnotizability is a useful clue to the style of interaction with the patient.

Highly hypnotizable individuals often what to know ‘what’ to do, while low hypnotizables want to know ‘why.’ The former want direction, the latter explanation.

Low hypnotizables often prefer various introspective, analytically oriented psychotherapies.

Those who are mid-range in hypnotizability group and respond better to consolation and confrontation from the therapist.

Highly hypnotizable individuals benefit most from firm guidelines to enhance their capacity to generate their own decisions and directions.

G. SUMMARY

Low-hypnotizable patients do best with a therapeutic strategy that employs reason to free and mobilize affect.

High-hypnotizable patients do best with a therapy which employs affective relatedness to the therapist in the service of enhancing rational control.

Those in the mid-range respond to an approach which employs a balance of rational and affective factors in helping the patient confront and put in perspective his own tendency to oscillate between periods of activity and despair.

2.4 VIDEO (20)

Instructions:

a. MG – Play extract of the video Sugarman 2 of 3 or alternative..

b. In SG – Discuss the following questions:



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2.5 DEMO/PRACTICE EXERCISE (30)

Instructions: First EXERCISE 1. - another self hypnosis method. Then EXERCISE 2 . - test your hypnotizability. Study the Organizer demo and then role play the experience with a partner.

EXERCISE 1 - Self Hypnosis

This is how it is done:

I am going to count to three. Follow this sequence again. One, look up toward your eyebrows, all the way up; two, close your eyelids, take a deep breath; three, exhale, let your eyes relax, and let your body float.

As you feel yourself floating, you concentrate on the sensation of floating and at the same time you permit one hand or the other to feel like a buoyant balloon and allow it to float upward. As it does, your elbow bends and your forearm floats into an upright position. Sometimes you may get a feeling of magnetic pull on the back of your hand as it goes up.

When your hand reaches this upright position, it becomes a signal for you to enter a state of meditation. As you concentrate, you may make it more vivid by imagining you are an astronaut in space or a ballet dancer.

NOTE: In this atmosphere of floating, you focus on whatever strategy is relevant for the patient’s goal Formulate the approach in a self-renewing manner which the patient is able to fit into his everyday life style.

Then bring yourself out of this state of concentration called self-hypnosis by counting backwards this way … Three, get ready. Two, with your eyelids closed, roll up your eyes (and do it now). And, one, let your eyelids open slowly.

Then, when your eyes are back in focus, slowly make a fist with the hand that is up and, as you open your fist slowly, your usual sensation and control returns. Let your hand float downward.

That is the end of the exercise. But you will retain a general feeling of floating.

Do this exercise as often as ten different times a day. At first the exercise takes about a minute; but as you become more expert at it, much less time.

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EXERCISE 2 - Hypnotizability - Arm-Drop Test

The patient is told, "I would like to test your reflexes. Would you please sit up straight in your chair or hospital bed (or stand) and extend both arms straight out in front of you, palms down. The patient then imagines that more and more water is being placed into the left hand bucket, one liter at a time. Slowly on and on.

Hypnotizability is indicated by the following movements:

1. The patient’s perception of the experience is the key factor, out weighing the objective distance the arm drops

2. The hand gradually lowers shows either compliance or veridical hypnotic response.

3. If the hand lowers somewhat, the patient is responsive to hypnosis, but may either be resistant, a slow responder, or capable of reaching only a light or medium trance.

4. The response for lack of hypnotizability is no movement at all.

NOTE: The Arm-Drop test is a valuable test that it can be applied in a very short period of time.

The word "hypnosis” need not be mentioned to the patient. It is an easily administered rapid indicator of a patient’s response. positive response, indicated by both the patient’s behavior and perception of the experience on this test typically means that he or she is likely capable of responding favorably to a hypnotic induction.

The Arm-Drop test can be turned into an induction.

When the practitioner is uncertain of their chances for success in inducing hypnosis are minimal. Patient confidence in the practitioner is critical.

When the test is favorable, the practitioner, begins induction procedures with confidence, transmitted to the patient..

Never qualify or disqualify a patient for hypnosis on a single test item.

QUESTIONS FOR DISCUSSION:

1. Did your arm go down because it felt heavier and heavier as the water was poured into the bucket or did you just lower it because you that was the goal of the exercise?

2. Why? How can you adapt the exercise to your cultural environment?

2.6 SUMMARY (10)

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20

UNIT 3 - ACUTE PAIN (PATTERSON)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10

2. STUDY OF- PRIMER 20


4. VIDEO 20


6. SUMMARY 10

180

3.1 OBJECTIVES (10minutes)


1. Evaluating the patient2. Development and negotiation of the treatment plan.3. Acute pain crises.4. Procedures that help acute pain


Instructions:

a. IIndividually study again the Primer – Ch. 3.

b. In SG – discuss the following questions:

1. What do you feel about pain control?

2. What applications may be most useful in your health care work.


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UNIT 3 - ACUTE PAIN

3.3 NARRATED LECTURE (20)A. OVERVIEW

Pain control is the area of clinical hypnosis that has the most empirical support.

Acute pain is usually related to suffering and anxiety...

Patients experiencing acute pain will frequently be in a medical crisis with tissue damage or inflammation, trauma (e.g., cuts, blunt force injury, amputations) or acute illness (e.g., sickle cell anemia, cancer).

A second common cause of acute pain is from medical procedures. where pain can be predicted, which gives the patient and clinician the ability to prepare for it e.g. childbirth.

Acute pain substantially interacts with psychological factors, particularly anxiety.

The conditioned anxiety from acute pain can become as significant a problem as the pain itself.

B. EVALUATING THE PATIENT WITH ACUTE PAIN

Evaluation of patients with acute pain is less complex than for chronic pain.

Acute pain that is not associated with a medical procedure is often a warning sign, and the first step of an evaluation is typically a thorough medical workup.

Medically, it is appropriate to treat patients aggressively with opioid analgesics as well as anesthetic agents. Opioid analgesics (i.e., morphine and its derivatives) used to treat acute pain, is seldom addicting.

Also relevant are: useful procedures such as epidural delivery of agents, patient controlled analgesia, blocks and anesthetic agents.

Medical evaluation of patients should include assessment of previous history of acute pain and trauma, as well as their potential response and side effects to interventions.

Clinicians should assess history of previous mental health disorders and anxiety disorders, frequently the key acute pain complication.

Patients with histories of problems with medical procedures may develop phobic reactions to future ones.

Determine how patients cope with medical procedures, as “repressors” (avoiders) r “sensitizers” (exquisite attention).

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UNIT 3 - ACUTE PAIN

C. DEVELOPMENT AND NEGOTIATION OF THE TREATMENT PLAN

Once the medical reasons for an acute pain episode are determined, the goal of treatment becomes quite simply to reduce suffering as quickly as possible.

With procedural pain, clinicians can work with patients well in advance and apply cognitive behavioral interventions over several treatment sessions to cope with a procedure long before it occurs.

Pre-surgical evaluations address pain control and investigate factors that are likely to make the patient show better health outcome.

Reducing recovery time and time back to work, improving sleep, and facilitating health-promoting behaviors are potential treatment plans from hypnosis.

D. HYPNOSIS FOR ACUTE PAIN CRISES

Patients in acute pain find it extremely difficult to focus their attention on this approach.

Patients with anxiety may have , shallow breathing and dissociation. Induction must capture the patient’s attention, to achieve deep level of relaxation in a short amount of time.

Relative to other applications, hypnosis with acute pain crises may become much more direct and authoritarian with suggestions.

Clinician needs to recognize the patient’s vulnerability and dependence and take control in a respectful manner. A patient in intense pain will show high trust and cooperation and will proceed with an induction. If the patient is hesitant, then more education about hypnosis or even abandon hypnosis..

Once the patient has reached a level of relaxation, any number of suggestions can be made for comfort, relaxation, well-being and rapid healing. Generally, finger signals are extremely useful for quick inductions,

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UNIT 3 - ACUTE PAIN

E. HYPNOSIS FOR PROCEDURES THAT CAUSE ACUTE PAIN

Medical procedures can cause substantial pain and anxiety.

However, the clinician can work with the patient before the procedure, several times, and ideally in calm, pain-free circumstances, even in one hour.

The steps for using hypnosis for anticipated procedures include:

1) Establishing rapport. 2) Identifying stimuli with procedure and a “safe place” for the Patient. 3) performing the induction- 4) providing post-hypnotic suggestions linked to cues with the procedure5) providing additional suggestions that benefit.

Before returning the patient to a waking state, the clinician gives post-hypnotic suggestions based on individual needs, for improved sleep, healing time or responses to other procedures.

Note: The patient can use self hypnosis for temporary pain relief with powerful imagination potential including: floating in the air, going to another happy place, changing position, changing location, asking pain to stop in two minutes or you will have to get up and do an necessary unpleasant job, ice water in the pain area, numbing, transfer of pain to another body area etc. F. CONCLUSIONS

Controlled studies demonstrate that hypnosis is superior not only to control groups but to alternative interventions.

Hypnosis reduces pain and anxiety with procedures and reduces use of costs of: anesthetics, the operating room rime and hospitalization.. 3.4 VIDEO (20)

Instructions:

a. MG – Play the video extract Rossi 1 of 3.

b. SG – Discuss following questions:

1. What reactions to the video?


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UNIT 3 - ACUTE PAIN


Instructions: Study the Organizer demo and then role play with a partner:

I am going to ask you to stare at this coin that I am holding in my hand and you do so, pay no attention to any other sounds or noises. You are aware that you are- breathing more rapidly and also that as you stare intensively at this coin, your eyelids are beginning to blink and to feel heavy.

As you feel them-getting heavy and drowsy, just let them close . . . that's it. . . they are fluttering … closing and closed . . . closing and closed … and as I continue talking you will enter a very very deep level of hypnosis . . for in so a very deep and sound level ..for in doing so you are going to get well … a very deep and sound level

As you are aware of a heavy feeling in your extremities, your arms and legs ... as you are aware of this . . . nod your head … Good a deeper and a sounder state . . Now the finger that I touch will lose all feeling … Now that finger is and feels numb . . . nod your head, yes …

Good. Now open your eyes. You will note that I am stimulating that finger very hard with the point of my nail file, but you have absolutely no sensation of pain. Pressure, but no pain. Now normal sensations return to your finger.

As you feel the file just barely stimulating your finger, pull it away. . .. Good, . . . Relax . . now you can realize the power of the mind over the body and if you can block pain . . . real pain . . . then, you can allow your body to respond to other suggestions equally well.

You are now in a very deep state of relaxation. . . . You are going to hear some soft music that is pleasurable to you . . . and as this occurs nod your head, yes. Good now in a now a very deep and relaxed state of mind and body.

Because of the power of your mind over your body you are going to be able to feel pressure but no pain. Think about it deeply.

Now as I slowly count from ten to one you will awaken …relaxed, well, at ease and ready to heal yourself in so many ways.

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3.6 SUMMARY (10)


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UNIT 4 - CHRONIC PAIN (JENSEN)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180



1. Evaluating the patient2. Development and negotiation of the treatment plan.3. Chronic pain management.4. Induction5. Suggestions for enhanced outcome6. Analgesia and comfort.


Instructions:

a. Individually study again the Primer – Ch. 4.




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UNIT 4 - CHRONIC PAIN


A. OVERVIEW

Chronic pain persists beyond the normal healing time after an injury, or as pain that is the result of an ongoing disease process (such as cancer or arthritis).

Self hypnosis strategies can both (a) reduce background daily pain, and (b) provide patients with specific skills to reduce the suffering and impact of pain.

Chronic pain has many inter-related factors, including:

(a) Ongoing physical damage and resulting nociceptive input from nerves that transmit pain information to the central nervous system (which is responsible for nociceptive or non-neuropathic pain);

(b) Previously damaged peripheral (outside of the spinal cord) or central (within the brain or spinal cord) nervous system neurons (which is responsible for neuropathic pain);

(c) Inactivity that results in weakened muscles and tendons, which then makes the patients more susceptible to injury;

(d) Discomfort from even normal activity;

(e) Overuse of medications

(f) Learning history (that is, the presence of a history of reinforcement for pain and illness behavior); mood and distress; beliefs about the meaning of pain; and coping strategies (maladaptive strategies, such as pain-contingent rest or guarding) used to manage pain.

B. EVALUATION THE PATIENT WITH CHRONIC PAIN

No treatment for chronic pain until medical and psychological evaluation, to determine changes in medication regimens

Medical evaluation to determine how inactivity and guarding may be contributing to weakened muscles and tendons, with chronic pain. Physical therapy or graded reactivation programs may be indicated.

Patients may be so “pain focused” and unable to focus on any other aspect of life

Initial evaluation includes medical and psychological factors contributing to the pain problem, and the development of treatment goals that address all of these factors.

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C. DEVELOPMENT AND NEGOTIATION OF THE TREATMENT PLAN

Treatment goals will be identified and more easily achieved if hypnotic interventions are utilized:

(a) Increased activity, mobility and strength;

(b) Decreased use of analgesics or sedatives agreed with the evaluation physician;

(c) Decreased overall (baseline) pain and increased ability to reduce pain using self-hypnosis skills;

(d) Improved sleep;

(e) Decreased anxiety/depression and increased well-being;

(f) Decreased pain focus (increased ability to ignore pain); and

(g) Decreased catastrophizing, and other components of a negative cognitive set.

(h) Self hypnosis training for pain reduction, decreased pain focus, and improved sleep.

Effective treatments include: graded activity and quota-based exercise programs, non pain contingent medication tapers, sleep hygiene education (with cognitive-behavioral therapy), cognitive restructuring, contingency management and self-hypnosis training.

D. PAIN MANAGEMENT - INDUCTIONS

All hypnosis inductions begins with the same cue. Post-hypnosis suggestions rhe cue and subsequent hypnosis. This makes it easier for the patient to begin self-hypnosis with the cue.

Start relaxation induction with suggestions that the patient will experience each body part or muscle group as becoming increasingly relaxed and comfortable), because::

(a) Individuals respond with changes subjective experience of relaxation, with positive outcome expectancies and self-efficacy;

(b) Perceived relaxation is inconsistent with suffering, so the induction brings increased comfort;

(c) SH is easy to learn and use at home..

Experiment with a other inductions as treatment progresses, to find what works best with any particular patient.

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UNIT 4 - CHRONIC PAINE. PAIN MANAGEMENT - ENHANCE OUTCOME

Do not apply self-hypnosis training only for chronic pain. Seek multiple goals: improved sleep, increased activity, reduced analgesic or sedative medication, physical therapy, and decreased catastrophizing, anxiety control etc. .

Suggestions should build confidence (self-efficacy), effortlessness, with a neutral or positive mood of relaxation or even excitement).

F. PAIN MANAGEMENT - ANALGESIA AND COMFORT

Use what the patient gives you to develop two types of outcome for hypnotic treatment of chronic pain:

(a) A substantial and relatively permanent reduction in daily baseline pain, and

(b) An increase in the patient’s ability to reduce or ignore pain for a period hours or longer. with post-hypnotic suggestions.

Note: The patient can use self hypnosis for temporary pain relief with powerful imagination potential including: floating in the air, going to another happy place, changing position, changing location, asking pain to stop in two minutes or you will have to get up and do an necessary unpleasant job, ice water in the pain area, numbing, transfer of pain to another body area etc

G. CONCLUSIONS

Each patient responds to different suggestions in unique ways. Use what the patient gives you and his imagination, to provide a wide variety of possible suggestions for benefit from, and gradually eliminating those not liked or with poor response..

Types of suggestions to consider include those that:

(a) Reduce pain experience directly;

(b) Reduce the affective component of pain (how much any pain bothers the patient);

(c) Increase the patient’s ability to ignore pain;

(d) Alter the meaning of pain from a signal of harm or danger to a signal that has little meaning;

(e) Shift pain from a location that is more bothersome (e.g., low back) to an area that is less bothersome (e.g., the little finger);

(f) Alter the quality of the sensation from one of “pain” to one of “pressure” or other not unpleasant sensation; and

(g) Alter the patient’s sense of time around any flare-ups (that they are perceived as lasting for very short periods of time). Audio tapes may enhance outcomes, for some patients and be used to reinforce a patient’s ability to use hypnosis without the recording.

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UNIT 4 - CHRONIC PAIN4.4 VIDEO (20)

Instructions:

MG – Play the video extract Rossi 2 of 3 or alternative..

SG – Discuss the following questions:

1. What are your reactions?.

2. How will your patients react? 4.5 DEMO/PRACTICE EXERCISE (30)

Instructions: Study the Organizer demo and then role play with a partner, these two EXERCISES of suggestions.

EXERCISE 1 - Suggestions for pain reduction

With every breath you take, breathing comfort in and tension or discomfort out, you can wonder how it is that you may be feeling more and more comfortable, right here and now. You may be pleased, of course, but you may also be surprised that it’s so much easier now to simply not notice uncomfortable feelings, to simply not pay attention to anything other than your comfort. So much easier to enjoy the relaxing, peaceful comfort of each breath. So simple, so natural, to attend to your breathing.

As we continue, you can enjoy discovering that the uncomfortable feelings just seem somehow to change. With every breath you take, you can notice how those feelings seem to become less and less clear, less and less strong… as if they are becoming farther and farther away…or smaller and smaller, taking up less and less space in your awareness. You can trust that your unconscious mind will notice any feelings that you need to pay attention to. If your health requires that you notice any uncomfortable feelings, you will do so. It’s so nice, though, that any old, chronic discomforts can fade away, come less and less strong. You can picture putting these feelings in a box, and then putting this box in another box, and then putting this box in yet another box, and placing that box in a room down a long hallway. So that even if you are aware of these sensations at some level, it is almost as if they are buried…far away… so easy to ignore.

It’s so easy to feel the comfort of every breath. So easy to let yourself daydream about a pleasant place, maybe to remember a happy time in your life or maybe to imagine a happy time you’d like to have in your life. Letting yourself feel free, right now, to just let your mind wander…to wander over pleasant memories or to wander over a pleasing image of something you’d like in your life right now.

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With every breath you take, breathing comfort in and tension or discomfort out, let yourself notice greater and greater comfort. Let every breath you take contribute to your sense of peaceful comfort and well-being. As you breathe, and as you notice the sensations of each breath, notice, too, that any remaining uncomfortable feelings are less and less clear, less and less strong… as if they are becoming farther and farther away…or smaller and smaller, taking up less and less space in your awareness.

I wonder if you’ll be pleased or surprised…or perhaps both…as you become more and more aware of feeling more and more comfortable.

EXERCISE 2 - Post Hypnotic Suggestions

All right, it is now time to extend any comfort and skills you have gained in this session into your daily life. Begin by closing your eyes, and taking a deep, comfortable, relaxing breath and hold it….hold it for a moment… and then let it slowly out. That’s right. Really feel the sensations of each breath.

Notice that breathing in feels different than breathing out. Now, I’d like you to imagine something with me. Imagine that you are breathing comfort in each time you breathe in… actual comfort, each time you breathe in… and imagine you are breathing tension or discomfort out each time you breath out. As you do so, maybe you already notice that you can feel relaxation and comfort washing over you, like warm water in a bath. As you allow yourself to relax more and more…

Breathe comfort in and tension out, with each breath you take. Really focus your mind on each breath, and let each breath contribute to your comfort. When you do this, your mind will automatically select one or more of the skills you are learning, and you will be able to experience the benefits of these again.

Remember, any time you want to feel more comfortable, just rest back and take a very deep, very satisfying breath, and hold it … and then, as you let it all the way out, let your eyelids close and focus on your breathing. Breathe comfort in, and tension out with each breath you take. Really focus your mind on each breath. Let each breath contribute to your comfort.

Your mind will automatically use and practice the skills you are learning so that you will feel more comfortable and any remaining sensations will bother you less, and less. And the benefits will stay with you.

You may choose to practice for a minute or two every hour, or for several minutes just a few times a day. I don’t know how you will choose to do it, but the more you practice, the better you will feel, and the more your mind will be able to use these skills, automatically, throughout the day, so that you can feel more and more comfortable.

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As you are practicing, when you need to end the experience, you’ll find that you’re sitting up automatically, your eyes are open, your mind is clear and alert…yet the comfort remains with you. No matter how clear and alert your mind remains, this inner comfort, this inner sense of ease, can remain with you and grow. Because this is your experience. And you can have it whenever you need. The more you practice this, the easier it will be to keep the comfort with you.In a moment I am going to count from ten back to one, and as I do, come back up with me, feeling more and more aware and alert.

When I reach the number “one” you will be fully alert, but still comfortable. The feelings of comfort, relaxation, and calmness you have been feeling, these feelings will stay and linger. And the more your practice, the better you will be at allowing yourself to feel comfortable, until this becomes automatic.

QUESTIONS FOR DISCUSSION

1. How might the suggestions be altered to address different types of pain problems?

2. How might the suggestions be altered to adapt to your cultural environment?

3. What other suggestions or types of suggestions do you think individuals with chronic pain might benefit from?

4. Other issues?

4.6 SUMMARY (10)


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UNIT 5 - CHILDHOOD PROBLEMS (OLNESS & KOHEN)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

5.1 OBJECTIVES (10)


1. Preparing to teach children self-hypnosis 2. Research in hypnosis with children3. Assessment of the child4. Approaches to teaching children

5. Self-hypnosis and pain management.


Instructions:

a. IND - Individually study again the Primer – Ch. 5.


1. Why are children good at hypnosis?


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UNIT 5 - CHILDHOOD PROBLEMS


A. OVERVIEW

Hypnosis can help children in stress and pain.Children learn self hypnosis easily, with a sense of personal participation in treatment that enhances his/her sense of mastery and competency.

Hypnosis is primary or adjunct therapy for:

Habit problems such as nail biting, hair pulling, or thumb sucking.Chronic conditions, including migraine, asthma, hemophilia, diabetes, or cancer.Performance anxiety including sports, music, speaking in class, or test performance.EnuresisWartsConditioned fears or anxietySleep problems: Falling asleep, night-waking, nightmares, night terrorsPain with procedures such as dental work, lumbar punctures, or venipunctures.Chronic pain

All of the above are EBM !!!.Children reduce anxiety associated with pain by practicing self hypnosis, and reducing the sensory component of pain. The teaching and application of self hypnosis may be enhanced by providing a biofeedback opportunity to the child.

B. PREPARING TO TEACH CHILDREN SELF HYPNOSIS

The professional must practice self hypnosis himself. Learning self hypnosis is a valuable lifelong skill that provides many benefits.

Professionals should take more advanced hypnosis workshops of at least 20-24 hours and include at least six hours of supervised practice.

After basic training the professional should seek a mentor who, by phone or email, can provide guidance and support, and attend follow up workshops etc. .

C. RESEARCH IN HYPNOSIS WITH CHILDREN

Clinical research documents the efficacy of hypnosis with children in areas such as pain management, habit problems, wart reduction, and performance anxiety.

Learning disabilities, such as auditory processing handicaps, interfere with the ability of children to learn self hypnosis training.

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Interventions may called “relaxation imagery”, “imagery”, “visual imagery”, or “progressive relaxation” each lead to a hypnotic state. A hand warming biofeedback group received four sessions of cognitive behavioral stress management training, thermal biofeedback, progressive muscle relaxation, imagery training of warm places, and deep breathing techniques. These children were clearly also being taught self hypnosis without calling it such.

E. ASSESSMENT OF THE CHILD

Know the child well before teaching him/her self-hypnosis.

Is the problem more significant to parents or caretakers than to the child?

Is the child motivated and interested in learning how he/she can help him/herself?

What are his/her likes/ interests, dislikes and/or fears?

How does h/she learn best?

Does the child have learning disabilities? What is the preferred mental imagery of a child? This may be visual, auditory, kinesthetic, and/or olfactory/taste.

If a child has the presenting problem of enuresis, has a careful evaluation ruled out causes, such as a urinary tract infection, that would not respond to self hypnosis? .

E. APPROACH TO TEACHING CHILDREN

Emphasize that the child is in control and can decide when and where to use self hypnosis.

Self hypnosis belongs to the child, that he needs to practice to become more skilled just as he must practice to learn soccer.

Parents should understand that self-hypnosis is a skill to be developed and refined and that only the child can do so, hopefully with their support and encouragement.

Strategies for teaching self hypnosis varies depending on the child’s age and developmental stage. As children mature their cognitive abilities change.

Pre school children are very concrete in their thinking and, for this reason, the therapist must choose words very carefully.

Children between ages two and five years spend much time in various types of behavior based on imagination and fantasy.

They enjoy stories and may enter a hypnotic state as the parent or teacher reads a story to them. Unlike adults they often prefer to do self hypnosis practice with their eyes open.

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Although adolescents may enjoy learning self-hypnosis methods that are similar to those preferred by adults, immature adolescents may prefer to use methods which also appeal to younger children. UNIT 5 - CHILDHOOD PROBLEMSChildren with cognitive impairment can learn self hypnosis if the therapist selects a teaching approach appropriate for their actual developmental stage.

F. SELF HYPNOSIS AND PAIN MANAGEMENT

Practicing self hypnosis reduces the anxiety components of pain. It is of special benefit to children with chronic pain illnesses such as sickle cell disease, hemophilia, cancer, or migraine.

General principles for teaching hypnotic pain control include the following:

a. Assess personal experience about pain The clinician who had negative experiences with painful procedures when he was a child may unconsciously project his fears and negative expectations onto his patient.

b. Assess parental perceptions and expectations about pain. Children are sensitive to their parents’ fears and anxieties. It may be beneficial for parents also to learn self hypnosis.

c. Consider the impact of the pediatric treatment team The attitudes and expectations of adults on the treatment team are also understood by the child. Changes in the voice, movement, or demeanor of adults may increase anxiety in a child even before a procedure begins.

d. Consider the age and development of the child For a toddler, a distraction approach, such as blowing bubbles may be most appropriate.

e. Consider a child’s interests, likes and dislikes. It is easier to learn self hypnosis by focus on something he enjoys.

f. Emphasize the child’s control and mastery

g. Select a pain assessment tool appropriate to the child and understood by the child. This might be a ruler if the child understands numbers. “number 10 is a lot of discomfort and number 1 is a tiny bit of discomfort, and 0, of course, is NO discomfort”. h. Explain what you plan to do and what the child may do.

Avoid prescribing the child’s images or pain perceptions:

It is incorrect to say that something will not hurt.

it is also incorrect to say that something will hurt.

The doctor or nurse can say:

“Some children say this feels like cold ice, some say it feels like a thorn from a bush, and some say it feels like a cat scratching. I wonder what it will feel like for you.”

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UNIT 5 - CHILDHOOD PROBLEMSG. APPLICATIONS

There are many hypnotic techniques to teach children, depending on their age and preference.

One approach is to offer the child a pretend “magical glove” to make your hand numb. The doctor or nurse then slowly puts on the pretend glove, finger by finger, encouraging the child to notice the numb feeling.

A prior careful history will allow the doctor or nurse to know if, for example, the child had a previous ‘numbing’ experience like another cut or a dental extraction, in which the memory of the absence of discomfort can be recalled and helpful in using the magic glove.

Another favorite approach is to explain about nerves going from all parts of the body to the brain. It helps to make a drawing of nerves from the legs, the tummy, and arms and the head. One can explain to a school age child that it is impossible to pay attention to more than one or two body sensations at the same time, and that we are continually turning off our awareness to many of our nerves.

Thus, the child can learn to voluntarily turn off body suggestions. The doctor or nurse can also ask the child to think about what might be a favorite type of switch e.g. flips switch, dimmer switch, pull switch, push button switch. The child can then practice turning off the switches that connect his brain to various areas of the body. This method is easily understood by most children and very effective.

Sometimes children like the analogy of one part of the body communicating with the brain by “imaginary cell phones” which allow, for example, a “sore part” to talk to the brain and ask for the switch to be turned off, or for the bladder to call the brain and tell the brain when it is full.


5.4 VIDEO (20)

Instructions:

a. MG – Play video extract Sugarman 3 of 3 or alternative.

b. In SG – Discuss the following questions: 1. What are your reactions?.


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DEMO/PRACTICE EXERCISE (30)

Instructions: Study the Organizer demo and then role play the two EXERCISES with a partner.

One person plays the role of the clinician and the other plays the role of the patient who shares the experience.

EXERCISE 1 - Ann, age 5 years, was brought into the emergency room by her mother because she had a big cut on her left leg. She had been playing with an old tricycle and fell on its sharp edges.

The doctor who greeted them noted Ann’s tears and said, “Hello, Ann, Wow!. You have very healthy red blood and you have beautiful tears. And your body is washing the germs away with that blood. How did you know just how to do that?”

Ann stopped crying and paid attention. The doctor explained to her that he knew some of the things in the emergency room might look strange but everything was there to help her. He asked her to sit on a gurney while he looked at the cut.

We can fix that,” he said. “We just have to close the cut with a few stitches and your strong body will do the rest for you.” “I will put some medicine around the cut so it will be numb when I do the sewing.” “And when you go home, what is the first thing you want to do?”

Ann said she wanted to play when she got home.

“Good idea,” said the doctor. “Just pretend you are at home now and playing, and I will fix the cut. Some people say it feels like a feather touching and some say it feels like a mosquito bite when I put the numbing medicine in. I wonder what it will feel like for you.”

“Tell me what game you are playing,” said the nurse who was assisting.

“I’m playing hide and seek,” said Ann. Her mother added, “She loves to play hide and seek.”

In a few minutes the suturing was completed and the wound was bandaged. “You did very well using your imagination,” said the doctor, “and now you can go home with a bandage on your cut. When you see your friends, you can tell them all about it.”

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UNIT 5 - CHILDHOOD PROBLEMSNOTE: This approach may seem very simple. When children and adults are anxious in a strange situation, they are receptive to either positive or negative suggestions. This vignette represents important points related to communication and suggestions with young children. Bleeding is scary to most children.

The doctor made a positive about the bleeding, telling her that she has strong, red blood. His statement was very meaningful to a concrete thinking five year old girl.

He did not say, “Everything will be all right. Stop crying.” He said her tears were beautiful. The average child is afraid when he or she enters an emergency room. The doctor acknowledged that things might look strange to her. .

The doctor reassured her that he would make the wound area numb. And then he implied that she would be going home by asking what she would like to do when she got home.

This type of indirect suggestion was undoubtedly reassuring to her. He incorporated her answer into the hypnotic induction. She could imagine something which she liked. It was helpful that both the nurse and the mother reinforced Ann’s imagery.

When the procedure was over the doctor gave her more positive reinforcement, increasing the likelihood that this child would have less anxiety the next time that circumstances might bring her to a hospital.

Unfortunately, there are many adults who are still struggling with unresolved fears related to inappropriate treatment in a hospital or in a dental office when they were children.

EXERCISE 2 - Role play with a partner. One person plays the role of the clinician and the other plays the role of the patient who shares the experience.

Jason, age 9 years, came to the doctor because he was having trouble falling asleep every night. He would cry, want his parents to sit with him for an hours, and, after they said goodnight, he would come into their room to sleep with them.

He said he was afraid of monsters and “can’t turn off my brain which keeps thinking about everything at school.”

Jason’s favorite activity was to play soccer. He was eager to learn self hypnosis and followed well as he was taught a “simple, fun breathing game called 3 and 6.

Breathe in through your nose while you count to 3 slowly and then breathe out slowly through your mouth while you count to 3 slowly and then breathe out slowly through

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your mouth while you count to 6….that’s right! Now notice how automatically your shoulders go down and get soft and relaxed when you breathe out… Great!


Now let that feeling keep moving down from your shoulders down to your arms, and hands and chest…and tummy.

And while your body is doing that…. notice in your mind you can be having a wonderful soccer game, running, doing headers, scoring goals.. and it’s so FUNNY that while you are active in your mind your body is soon relaxed here…

And every time you score a goal in your mind, your body gets more relaxed.. and I don’t know if you’ll be all asleep before the second half starts or if your muscles will get all relaxed before you win the game….Good night!” After Jason practiced this self hypnosis technique for just a few nights, his parents reported that he was now falling asleep quickly and easily. Furthermore, he was very proud of what he had accomplished himself.

QUESTIONS FOR DISCUSSION

1, What are your reactions?


5.4 SUMMARY


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UNIT 6 - PTSD - POST TRAUMATIC STRESS DISORDERS (VERMETTEN/CHRISTENSEN)

(THIS UNIT - NEW SG OF 4 CHANGED TO CSG OF 8)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

6.1 OBJECTIVES (10)


1. Overview of posttraumatic stress disorder (PTSD)

2. Diagnostic categories

3. Assessment

4. Treatment

5. PTSD and hypnosis

6. Psychological treatment of PTSD using hypnosis

7. Hypnosis for release of unbound affect.

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UNIT 6 - PTSD - POST TRAUMATIC STRESS DISORDERS 6.2 STUDY OF PRIMER (20)

Instructions:



1. What are your reactions to PTSD?



A. OVERVIEW OF PTSD

Human violence, including rape, robberies, assault, natural disaster, and accidents can leave the individual with intense terror, fear, and paralyzing helplessness.

About 60% of men and 50% of women have experienced psychological trauma (defined as threat to life of self or significant other) at some time in their lives. PTSD is increasingly recognized as being present in diverse cultures.

PTSD is defined as: A mental disorder characterized by a preoccupation with traumatic events beyond normal human experience; events such as rape or personal assault, combat, violence against civilians, natural disasters, accidents or torture precipitate this mental disorder; patients suffer from recurring flashbacks of the trauma and often feel emotionally numb, are overly alert, have difficulty remembering, sleeping or concentrating, and may feel guilty for surviving.

B. DIAGNOSTIC CATEGORIES

Symptoms of PTSD are divided into three categories: a) Re-experiencing of the event, b) Avoidance of stimuli, and c) Persistent symptoms of increased arousal. The symptoms must lead to social and functional impairments in order to meet diagnostic threshold.

Symptoms of PTSD generally become evident within the first months following the trauma; sometimes acute stress disorder (ASD) develops into PTSD.

ASD is a rather similar disorder compared with PTSD that may occur immediately after traumatic stress exposure and may last from 2 days to 4 weeks and includes symptoms of dissociation, such as de-realization and depersonalization.

There may also be profound feelings of guilt and blaming themselves for surviving when others did not, keeping the guilt inside. This conflict, in its most acute presentation, typically resembles

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an agitated depression and is described as being associated with frequent dreams of friends dying (e.g., in battle) and avoidance of intimacy due to fear other party may abandon or die.

UNIT 6 - PTSD - POST TRAUMATIC STRESS DISORDERS

PTSD can result from a single type trauma, sometimes referred to as type I trauma (rape, assault) or from repetitive, chronic trauma exposure, referred to as type II trauma (child abuse, war.

Can have its onset early in life or later as adult. This has important consequences for therapy. In early life trauma therapy the psychopathology is usually complex and requires longer treatment.

C, ASSESSMENT

Trauma measures vary widely ranging from self-report checklists assessing the presence or absence of a limited range of potentially traumatic events to comprehensive protocols assessing a wide range of stressors through both self-report and interview.

The caveat for the diagnosis of PTSD is non-disclosure (not talking about the trauma out of reasons of shame, guilt, fear for prosecution).

D. TREATMENT

Control, rapport, and history are key elements in the treatment of patients with PTSD. Patients have no difficulty in remembering and over-engaging in the traumatic scene; they need to be able to resolve the underlying issues through hypnotic abreactive or adjunctive alternative hypnotic interventions.

Such resolution restructures the patient’s personality to function more adaptively.

Antidepressant medications are the mainstay of treatment and are the best studied in controlled clinical trials.

E PTSD AND HYPNOSIS

PTSD patients as a group are moderately high in hypnotizability

Traumatic experiences can mobilize hypnotic responses that resemble the ‘hypnotic state’ during which intense absorption in the hypnotic focal experience can be achieved by means of a dissociation of experience. Subsequent reactivation of traumatic memories can also have trance-like features:

There are a number of emotional states that characterize PTSD in addition to exaggerated fear responses to threat. As reviewed earlier, these include symptoms of dissociation, loss of self-agency, feeling worse with traumatic reminders, amnesia, and flashbacks upon visual imagery of the traumatic event that plays back like a movie. F. PSYCHOLOGICAL TREATMENT OF PTSD USING HYPNOSIS

Hypnotic treatment allows modifying ownership and agency of traumatic memories. Hypnosis in treatment of PTSD is often embedded in a phase-oriented approach in which three elements need to be timed sequentially:

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(a) symptom stabilization; relaxation based, anxiety management, w/o medication(b) exposure; ‘working through’ the trauma, abreaction and alternatives to abreaction(c) closure; usually with ritual, providing a perspective treatment of stress response syndromes. .


G HYPNOSIS FOR RELEASE OF UNBOUND AFFECT

Ego State Therapy targets PTSD by allowing the fullest expression by the traumatized ego state while providing the needed recourse to respond to the threatening agent.

Once resolved in this brief therapy the symptoms of PTSD disappear because they are no longer driven by an underlying state that carried the unresolved trauma. The patient has overcome the fear and can quickly return normal range functioning, at ease, and empowered.

Thus, hypnosis is a powerful contribution to the treatment of PTSD, which makes it the treatment of choice for experienced clinicians treatment of posttraumatic conditions: an evidence-based approach. .

Hypnosis can facilitate the revivification of emotionally disturbing experiences that happened to the individual and can release the affect that has been connected to that experience.

The first line procedure for skilled clinicians is the use of hypnotically facilitated abreaction. A variation of the technique also developed by the Spiegel’s, asks the patient to divide the screen, the patient can project a left sinister side, that is the trauma side, and then the right side a picture of how they could protect themselves and stand up to the perpetrator or perpetrators or otherwise adaptively handle the abuser or the incident.

H CONCLUSIONS

The role of hypnosis in traumatic recall helps patients with trauma related disorders.

Patients with trauma related psychopathology like PTSD or other trauma-related disorders can alternate between states of consciousness in which they experience their trauma over and over again as if it were happening on the spot, with the same vividness and psycho-physiologic changes, and episodes in which they are apparently unaware of it..

High hypnotizable and can use their hypnotic capacity to block pain and traumatic recall.

The challenge for a patient is to learn to control.

Combining biological, psychological, and psychosocial treatment may well yield best results.

Rehabilitative goals should replace curative techniques in those patients with chronic PTSD.

Similar to the importance of pharmaco-education, the importance of psycho-education should not be underestimated.

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6.4 VIDEO (20)

a. MG – Play the video extract Rossi 3 of 3 or alternative. b. In SG – Discuss the following questions:

1. How will you recognize PTSD?

2 How will your patients react?


Instructions: Study the Organizer demo and then role play with a partner. Learned Helplessness, using a description of the laboratory experiments in which animals were exposed to aversive uncontrollable events, can be a useful therapeutic metaphor to deliver to the client in trance:

And there's an experiment I'd like to tell you about that you about that you may learn a lot from . . . and I wonder just how many different possibilities will occur to you about your own experience changing as you consider some laboratory dogs that were divided into two groups.

One group was harnessed dangling in mid-air unable to be mobile…the others were unharnessed , free to run.

The harnessed dogs were given painful shocks, but could not escape them . . . the others were also given shock, but could run away ... a sensible reaction to pain . . .

And when the harnesses: dogs were unharnessed and were again shocked, though they could now escape but they did not even try to …their previous experience led them to conclude they could do nothing . . . even though ±hey really could do something . . .

Because now isn't then . . . and was true then may no longer be true now . . . and you won't know until you try . . . and I wonder if you realize that depression clouds our ability to discover the harness is gone … and there's more for you to do than you've realized . . . and you can discover your ability to develop effective ways to manage your life …one day at a time …

6.6 SUMMARY (10)


47

UNIT 7 –SURGERY (THOMSON)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

7.1 OBJECTIVES (10)


1. Using hypnosis before surgery2. What the research has shown3. Obtaining the history4. Trancework


Instructions:



1. What is your reaction?


48

UNIT 7 –SURGERY


A. INTRODUCTION – HYPNOSIS BEFORE SURGERY

Preparing patients hypnotically for their surgery can have an enormous positive impact on both their surgical course and their recovery.

Hypnosis can be very effective in enhancing the patient’s coping skills, managing stress, anxiety, reducing pain and increasing a sense of self-mastery in the patient having surgery.

B. WHAT THE RESEARCH HAS SHOWN

Hypnosis can be used as a sole anesthetic for patients with above average hypnotizability but most often hypnosis is used to potentiate the effects of analgesics and anesthetics, facilitate postoperative healing, and to help maintain stability of vital signs.

Patients in the hypnosis groups had better outcomes than 89% of the patients in control groups.

With hypnosis there is less pain and infection, faster recovery, less nausea and vomiting etc. as used. A randomized, controlled study showed faster wound healing and improved functional recovery in women following breast surgery..

C. OBTAINING THE HISTORY

Hypnosis can be used pre-operatively, intra-operatively and post-operatively.

A careful history should be obtained by the clinician while building rapport with the patient.

Previous experience with hospitalizations, surgery and hypnosis should be established and the patient’s particular thoughts, wishes, worries and fears.

Determine how their life will be better after the surgery so that this can be reflected back in trance.

Spiritual belief system is important. Patient may request scripture, prayer or a poem with special meaning be included in the trance work.

The building of the therapeutic alliance between patient and clinician can reduce anxiety and increase the patient’s positive expectation for a successful surgical outcome.

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UNIT 7 –SURGERY

D. TRANCEWORK - LANGUAGE

The careful use of language is essential when working hypnotically with a surgical patient. Feelings of helplessness and dependency create fear and frustration. The individual often feels that they have lost control of the situation.

Patients with a negative expectancy are more likely to have a negative outcome. Through the careful use of language, hypnosis can control for the nocebo response. Hypnosis uses language to create a new paradigm.

Surgery is a traumatic injury that stimulates the stress response. Stress delays healing and surgical recovery. Hypnosis can mitigate that response

E. TRANCEWORK – STRESSTo establish a low stress, low anxiety environment, create a safe place of comfort needs to be created. This would be a safe place that the patient can return to in his imagination whenever he wants or needs to.

Offer a technique for getting rid of unwanted thoughts or worries such as floating them off on a cloud. As the patient awaits his surgery in the operating room and pre-operative area, there will be many interruptions that can be utilized for fractionation to take the patient deeper into trance.

A suggestion might be:

You will be interested to note that as you are asked to answer questions or are asked to do anything, that it does not disrupt your level of comfort. In fact anytime during your journey that you open your eyes or are asked to move from one place to another, you will notice when you close your eyes again, you will feel yourself going even more deeply relaxed.

With children eyes open alert hypnosis can be used as children enter the hypnotic state best by active engagement and are typically reluctant to close their eyes during medical intervention.Not everything the patient hears in the operating room and pre-operatively will be therapeutic or even pertains to the patient. The hypnotic suggestion may be given:

Pay attention only to the voice that is speaking directly to you. All other sounds will seem pleasantly far away. And if anyone says anything to you that is less than helpful, it will be as if they are speaking in a foreign language that you do not understand.

Since operating rooms are kept cool, suggestions for warmth or a healing light are useful. The high tech equipment in hospitals and operating rooms can be quite frightening. The patient may be given the suggestion that

50

The equipment is all there to help your surgery go well and perhaps you will notice how safe it makes you feel

UNIT 7 –SURGERY

F TRANCEWORK - MEDICAL STABILITY AND HEALING.

Hemodynamic stability can be enhanced with a hypnotic suggestion that as the operative area is being washed with the antiseptic solution, it will be a signal to constrict the blood vessels to that area diverting blood flow to all other areas.

Suggestions concerning homeostasis are given.

Your inner mind knows how to regulate your blood flow, blood pressure and blood glucose at the level that is perfect for you.

The patient will find it especially reassuring to hear in hypnosis:

Your doctor and nurses will take good care of you, but know also that you can do anything you need to do to increase your level of comfort. When your procedure is over, the healing can begin immediately.

To enhance post-operative pain control the hypnotic suggestion can be given:

The sensations that you feel will be those of healing and mending and need not bother you.

Earlier return of GI function and decreased postoperative vomiting can be accomplished with the following suggestions.

Note with pleasure how soon all of your bodily functions return to normal. You will swallow to clear your throat and that will be the signal to your digestive track – one way going down, only going down.

Hypnotic suggestions to enhance healing might include:

You can look forward to feeling better, getting better so you can enjoy life fully. As your body heals different changes occur and you can cooperate with the work of your body by remaining as calm as you are now. Your only responsibility is for healing. Everything else is being taken care of. There are no demands on you and no expectations. At any time during your recovery period you can go right back to this place of comfort and relaxation.

The patient may be offered amnesia for the uncomfortable portions of the procedure and ego strengthening for their hypnotic success.

You may choose to remember to forget or forget to remember as much or as little of this experience as you want or need to. You may remember to remember that you were able to give yourself an amazing amount of comfort.

51

UNIT 7 –SURGERY

7.5 SUMMARY

The clinician skilled in hypnosis has the wonderful opportunity to use this powerful modality with patients who are facing surgery.

The patients will be significantly more relaxed, experience greater comfort, and have faster healing than those who are not hypnotically prepared.

With hypnotic interventions the patient is empowered to take charge of his or her recovery.

Surgery with hypnosis can be cost effective and management effective with the relaxed environment for patient and staff.

7.4 VIDEO (20)

Instructions:

a. MG – Play the video extract Kuttner (1) 1 of 3 or alternative b. In SG – Discuss and record on the SG flip-chart, the answers to the follow the following questions:

1. What are your reactions? 2. How will your patients react?


Instructions: Study the Organizer demo and then role play with a partner. One person plays the role of the clinician and the other plays the role of the patient, who is anticipating surgery. Use the phrases in the chapter.

Develop a list of questions to ask the patient to elicit his history and find out about his upcoming surgery

Plan the session:

1. Align goals with the patient

2. Anxiety reduction

3. Positive expectancy

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UNIT 7 –SURGERY

4. Hypnotic suggestions for post-operative period:

Self hypnosis Increase comfort

Pain ManagementNausea and vomiting reductionExpedite mobility and functionHasten healing

REVERSE ROLLS AND REPEAT THE EXERCISE


1, How effective was the exercise?

1. Why?

2. How can you adapt the exercise to your cultural environment?

3. Other reactions?

7.6 SUMMARY (10)

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54

UNIT 8 – CHILDBIRTH (IRLAND)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

8.1 OBJECTIVES (10)


1. Self-hypnosis for childbirth

2. Childbirth as an adventure

3. The childbirth partner

4. Pain management

5. Variations in sensory preferences

6. Hypnosis for operative childbirth

7. Working with varying cultures and religious beliefs.

55

UNIT 8 – CHILDBIRTH


Instructions:


b. SG – discuss the following questions:

1. Whar are your reactions?


8.3 LECTURE (30)

A. INTRODUCTION – SELF HYPNOSIS FOR CHILDBIRTH

Often during childbirth, a woman engages a “fight or flight” response which increases her perception of pain intensity and decreases internal blood flow.

With the ability to use self hypnotic techniques women and their partners can effectively enter the childbirth experience with calm and focus.

When internal blood flow is optimal, there is also increased uterine blood flow and increased oxygen perfusion through the placenta.

Hypnotizability testing is unnecessary prior to working with a woman or couple. Motivation seems to be the greatest predictor of success during childbirth.

The specific skills needed for childbirth include self induction for the woman, resting techniques, pain management, using several sensory options for focus, techniques to deal with external distractions, development of birthing metaphors, and helping skills for her partner.

Some women interviewed immediately after giving birth, reported that hypnotic techniques totally eliminated their perception of contraction pain.

The majority testified, however, that the success of hypnosis was related rather to decreased anxiety; their perception that they were engaged in a birthing adventure; the continual presence of a partner or care giver who provided comfort, safety, and focus; and their ability to rest and calm themselves.

56


B CHILDBIRTH AS AN ADVENTURE

Childbirth can be approached as a painful obstacle to be overcome or as a journey to be traveled and experienced, using all the skills and options available.

The movement of contractions can become the peaks and troughs of waves, hills, or gusts of wind. The laboring woman may find herself working intensely through her contractions, or moving away from the physical sensations to a distant image, a sound, or a tactile sensation.

Because contractions come and go as do waves, hills, and gusts of wind, these often provide the most useful metaphors for childbirth.

The most important skill she must develop for this journey is, however, the ability to rest deeply between the contractions. This should become an automatic response to moving over the peak of a contraction, as the intensity decreases and she can rest.

This experience is more successful if she is accompanied by a partner or care giver who provides companionship, comfort, and safety.

C THE CHILDBIRTH PARTNER

This partner can be a spouse, friend, family member, or medical care giver.

The partner’s role is to protect, mediate, calm, sooth, and provide focus; allowing the laboring woman to do her important internal work without fear of journeying alone or of a sudden intrusion from outside.

If possible the partner is taught self hypnosis techniques for their own use and to better understand the needs of the laboring woman.

D. PAIN MANAGEMENT

In most cases the pain of labor contractions is not a constant pain.

Anxiety and fear of pain and loss of control can, however, cause the perception that the contraction pain never subsides.

Self hypnosis practice with pain simulation should be provided in the same manner that contractions occur. Contractions occur for approximately 1 minute with resting between contractions for 2 to 3 minutes.

57

To simulate contractions, the partner can apply ice to both of the woman’s wrists or pinch the area of her hand between her forefinger and thumb for one minute followed by 2 to 3 minutes of rest. UNIT 8 – CHILDBIRTH

While using self hypnosis, images, sounds, and feelings of working through the sensations or moving away can be suggested, followed by hypnotic suggestions of deep rest and soothing when the stimulus is removed.

Ice and pinching work well because these can be easily practiced away from training sessions.

E. VARIATIONS IN SENSORY PREFERENCES

The partner should be sensitive to the sensory language that will be most helpful to her. All of the following can be woven into her hypnosis training and practice.

Recordings of waves, rivers or streams, storms and rain can be used to induce and deepen her trance during practice sessions and childbirth. Marbles or stones, cloth textures, clay or play dough work well as options for tactile focus. Visual imagery, candles, and pictures are options for visual focus. During childbirth most women are very sensitive to olfactory stimuli.

Providing aroma therapy with elements such as lavender, mint, or many others depending on the woman’s preferences may help calm or energize, while masking other odors that can interfere with her focus.

If a woman is birthing away from home she should also be encouraged to bring soothing items from home, such as her pillow, pictures, cloth pieces, etc.

F. HYPNOSIS FOR OPERATIVE CHILDBIRTH

The use of hypnosis during the cesarean can provide a focus distant from the operative environment and help her to feel safe and calm.

Once again the goal is to teach a skill set that will enable the woman to comfort and soothe herself while providing increased blood flow internally to her uterus and oxygen to her baby.

This way she decreases her sympathetic response to this experience.

G WORKING WITH VARYING CULTURES AND RELIGIOUS BELIEFS

Working with individuals of other backgrounds rather than women and couples of European descent, it seems that prayer and deep spiritual beliefs can often play an important role.

In these individuals there seems to be a much more open response to the physical, ment

58

al, and emotional changes that accompany trance experience


I. SUGGESTED TRAINING CURRICULUM

Session 1. Discuss hypnosis, benefits and limitations.

Session 2. Hypnotic experience for woman and partner using tactile focus (marble, stone) and pain stimuli (pinching) for one minute followed by suggestions for resting for two to three minutes.

Session 3. Discuss options for woman to communicate needs during labor

Session 4 Discuss hypnotic experience for couple using labor metaphors, resting, time distortion.

Session 5 Hypnotic rehearsal through each phase of childbirth for couples with possible metaphors, images, sounds, feelings, interventions.

J. CONCLUSIONS

The success of hypnosis in childbirth is related to decreased anxiety; and a positive perception of the birthing adventure, with the continual presence of a partner, to provide comfort, safety, and to focus on the ability to rest and be calm.

8.4 VIDEO (20)

Instructions:

a. MG – Play the video extract Kuttner (1) 2 of 3 or alternative. b. c. - Irland? d. In SG – Discuss the following questions:

1. What are your reactions?.


59



Instructions: Study the Organizer demo and then role play with a partner.

The woman is directed to enter a trance state either with the suggestions from the practitioner or through self induction (as taught from previous training). She is then asked to indicate nonverbally when she is ready to begin the exercise. Her partner is then directed to either pinch the area of her hand between her forefinger and thumb, or place ice cubes on the palm side of both wrists.

She is then given hypnotic suggestions by the practitioner to change the sensation in some way, move away from the sensation, or use her own imagination to move over or through the sensation she is experiencing. She is reminded that she is safe and her partner is close by helping to prepare for the childbirth adventure they will share. She is also given hypnotic suggestions to look ahead to the resting that will take place when the sensation is gone.

After approximately one minute the pinching is stopped or the ice is removed. Her partner then soothes the area of her hand or wrists that was affected by the stimuli. The practitioner gives suggestions for deep rest and allowing the memory of the sensation to disappear into the past. Her partner is directed to give the same suggestions following the lead of the clinician. This resting and soothing period lasts from two to three minutes. This is similar to the rest period that occurs between contractions during labor.

The sequence is then repeated five to six times using the same suggestions. Her partner is encouraged to provide more of the hypnotic suggestions with each practice while the practitioner speaks less.

The woman is encouraged to rest more deeply and experience the confidence, calm, and safety that increases as she works closely with her partner preparing for their adventure. After she reorients from her hypnotic experience she and her partner are encouraged to discuss the experience with each other.

The practitioner should allow five minutes for this to occur without interruption before asking for feedback from the partners. The woman should also be encouraged to experience the sensation without the use of self hypnosis and to be aware of any differences in her experience.

8.6 SUMMARY (10)


60

UNIT 9 – SLEEPING (YAPKO)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

9.1 OBJECTIVES (10)


1. Insomnia as a risk factor for depression

2. Treatment options for depression-related insomnia

3. Hypnosis and psychotherapy for insomnia

4. Targeting rumination, and enhancing sleep

5. Hypnotic approaches

6. Indications and contraindications.

61

UNIT 9 – SLEEPING (YAPKO)


Instructions:


b. In SG – discuss the answers to the following questions:


2. Reactions of your patients?.



A. INTRODUCTION – HYPNOSIS & SLEEP

The relationship between secondary insomnia and major depression.

Depression is the most common mood disorder in the world, and, according to the World Health Organization (WHO), is a leading cause of human suffering and disability that is still increasing in prevalence.

Insomnia is the most common sleep disorder related to depression.. Insomnia is defined as:

“A complaint of difficulty initiating sleep, maintaining sleep, and/or non-restorative sleep that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

Thus, an individual may complain of having difficulty initially falling asleep or staying asleep, the latter condition manifesting as either middle of the night or early morning awakenings.

The negative consequences of chronic insomnia are substantial. Occupationally, these include a higher rate of absenteeism from work, greater use of health services, a higher number of accidents, and decreased productivity.

On a personal level, chronic insomnia sufferers report a decreased quality of life, loss of memory functions, feeling fatigued, unable to concentrate well, and diminished interest in socializing or engaging in pleasurable activities, further increasing depressive symptoms.

A sleep disturbance can increase the risk for alcohol-related problems. Survey respondents who reported sleep disturbances, more than 12 years later, had twice as high a rate of alcohol-related problems.

62

UNIT 9 – SLEEPING

B. INSOMNIA AS A RISK FACTOR FOR DEPRESSION Because insomnia and depression are so often found together, it is logical to wonder whether insomnia causes depression, depression causes insomnia, or whether they cause each other.

The onset of insomnia may serve as an “early warning signal” for an impending depressive episode.

Thus, an early diagnosis of insomnia may prevent depression’s onset if it is recognized and treated appropriately.

Only about 33% of those suffering insomnia report it to their physicians, and only about 5 percent of those with insomnia actively seek treatment for it.

C. TREATMENT OPTIONS FOR DEPRESSION-RELATED INSOMNIA

Interventions fall into two general categories: medications and psychotherapy. Self-help strategies, including hypnosis, however, are a viable option.

The use of self-help techniques for enhancing sleep offers several key advantages: Self-help will not lead to either addiction or dependence, it can be applied under all conditions, and it will not lead to potentially harmful interactions with other interventions .

D. HYPNOSIS AND PSYCHOTHERAPY FOR INSOMNIA

Hypnosis may be of greatest benefit a patient with insomnia. He can learn skills including:: relaxation, good sleep hygiene and another target for a well crafted hypnotic intervention called “rumination” (repetitive thinking).

Rumination is the cognitive process of spinning around the same thoughts over and over as stress leading to depression

Rumination can be thought of as a pattern of avoidance that actually increases anxiety and agitation.

Ruminative responses include repeatedly expressing to others how badly one feels, thinking to excess why one feels bad, and catastrophizing the negative effects of feeling bad. By ruminating, the person avoids having to take decisive and timely action, further compounding a personal sense of inadequacy.

Rumination leads to more negative interpretations of life events, greater recall of negative autobiographical memories and events, impaired problem-solving, and a reduced willingness to participate in pleasant activities.

Rumination generates both somatic and cognitive arousal, both of which can increase insomnia, but the evidence suggests cognitive arousal is the greater problem. Minimal cognitive processing and special effort towards sleep are key treatment goals.

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UNIT 9 – SLEEPING

E. HYPNOSIS, TARGETING RUMINATION AND ENHANCING SLEEP

Hypnosis can teach the ability to direct one’s own thoughts rather than merely react to them. t. Reducing the stressful wanderings of an agitated mind and also relaxing the body while simultaneously helping people create and follow a line of pleasant thoughts and images that can soothe and calm the person..

To achieve these aims, important components to include in treatment include:

1) How to efficiently distinguish between useful analysis and useless ruminations. 2) Time-organization. - separate bed-time from problem-solving time

3) Establishing better coping skills.

4) Effective strategies for choosing among a range of alternatives.

5) Addressing attitudes and issues of sleep hygiene.

6) Teaching “mind-clearing” or “mind-focusing” strategies.

F. HYPNOTIC APPROACHES

Hypnosis teaching gives the client effective ways to make distinctions between useful analysis and useless ruminations, time-organization (compartmentalize) various aspects of experience, develop better coping skills, develop more effective decision-making strategies, and develop good behavioral and thought habits regarding sleep.

Such hypnosis sessions are quite different in their structure than is a session designed specifically for the purpose of enhancing to actually to fall and stay asleep.

In standard therapy sessions involving hypnosis, the opposite is true: The clinician takes active steps to prevent the client from falling asleep during the session. It has been well established that hypnosis isn’t a sleep state, and that sleep learning is a myth.

Thus, clinicians employing hypnosis encourage the client to become focused, relaxed, yet maintain a sufficient degree of alertness to be capable of participating in the session by listening and actively adapting the clinician’s suggestions to his or her particular needs.

The content of the strategy (e.g., progressive relaxation, imagery from a favorite place, recollection of a happy memory, creation of fantasy stories, counting sheep, etc.) is a secondary consideration. The primary consideration is that whatever the client focuses on, it needs to be something that reduces both physical (somatic) and cognitive arousal.

A permissive style is both gentler and more consistent with an attitude of allowing sleep to occur instead of trying to force it to occur.

The use of recorded hypnotic approaches (i.e., tape recordings or compact disc recordings) can be a useful means of helping the client to develop the skills in focusing on calming suggestions. Generally, these should be considered a temporary help in the process so that the person is eventually able to fall and stay asleep independently using self-hypnosis.

64

UNIT 9 – SLEEPING

G. INDICATIONS AND CONTRA-INDICATIONS

There are no known contraindications to teaching clients to focus and relax. However, it is important that the client understand that hypnosis is a valuable tool for relaxing and reducing ruminations.

The rest of the larger treatment plan involves learning time-organization skills (compartmentalization), that will support the use of hypnosis in order to make a more enduring contribution to enhancing sleep.

The client needs to be able to place the hypnosis in the context of the larger therapy.

9.4 VIDEO (20)

a. MG – Play the video Kuttner (1) 3 of 3 or alternative. b. In SG – Discuss the following questions:

1. Reactions?

2. How will your patients react? 9.5 DEMO/PRACTICE EXERCISE (30)


When you are laying down, ready to sleep, make a point of saying slowly (either out loud in a quiet voice or silently in your thoughts in a soothing voice) positive statements about favorable environmental conditions or pick a particularly pleasant memory to tell yourself in story form, as though you were telling the story to someone else.

Examples might be: “The room temperature is really comfortable…my pillow is so soft…the night sounds are so comforting…there’s nothing else I need to do or think about right now besides how good it feels to fall asleep…” or “There was a time when I was out in nature in the most beautiful setting and it I remember….”

If and when you have an intrusive or unwanted thought, simply say calmly “I’ll pay attention to that some other time” and resume your descriptions of favorable conditions until you fall asleep. Train your mind to focus on immediate comfort of sleep.

9.6 SUMMARY


65

UNIT 10 – DEPRESSION (ALLADIN)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO ??? 20


6. SUMMARY 10

180

10.1 OBJECTIVES (10)


1. Hypnosis for major depression 2. Major depressive disorder (MDD) 3. Stages of cognitive hypnotherapy for depression

4. Clinical assessment & First aid for depression - protocol 5. Hypnotic cognitive behavior therapy 6.. Cognitive restructuring using hypnosis 7.. Attention switching and positive mood induction 8. Interactive training & social skills training 9. Ideal goals/reality training

10. Booster and follow-up sessions

66

UNIT 10 – DEPRESSION


Instructions:






A. INTRODUCTION – HYPNOSIS FOR DEPRESSION

Hypnotherapy for major depressive disorder (MDD).

MDD is among one of the most common psychiatric disorders. Can be treated successfully with antidepressant medication and psychotherapy, but a significant number of depressives do not respond to these approaches.

Cognitive Hypnotherapy (CH), a multimodal treatment approach to depression that may be applicable to a wide range of people with depression.

B. DESCRIPTION OF MAJOR DEPRESSIVE DISORDER (MDD)

MDD (used interchangeably with depression in this chapter) is characterized by feelings of sadness, lack of interest in formerly enjoyable pursuits, sleep and appetite disturbance, sense of worthlessness, and thoughts of death and dying.

Depression is on the increase (World Health Organization,1998). Estimated that out of every 100 people, approximately 13 men and 21 women are likely to develop MDD some point in life. About one-third of the population may suffer from mild depression..

By 2020 clinical depression will become the second (chronic heart disease) international health disease burden cause of death, disability, incapacity to work.

Approximately 60% of people who has a major depressive episode will have a second episode. Among those who have experienced two episodes, 70% will have a third, and among those who have had 3 episodes, 90% will have a fourth.

67


C. COGNITIVE HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 1-2

CH generally consists of 16 weekly sessions..

1. CLINICAL ASSESSMENT

2.. FIRST AID FOR DEPRESSION – PROTOCOL –

Encourage patient to talk;

Plausible biological explanation

Hypnotic induction to alter depressive posture

Encourage smile by imagining looking in a mirror

Iimagine a "funny face"

{Play a happy mental tape"

Condition to a positive cue-word:

“From now on, whenever you feel down or depressed, and don’t want to feel this way, all you have to do is to repeat the word BUBBLES and soon the bad feeling will ease away, replaced by good feeling.”

D. COGNITIVE HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 3-6

COGNITIVE BEHAVIOUR THERAPY (CBT)

Coach on access

Restructuring deeper self-schemas.

Advise to constantly monitor and restructure negative cognitions until it becomes a habit.

68


E. HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 7-8

HYPNOSIS

Focus two hypnotic sessions on relaxationSomatosensory changesPower of the mindEgo-strengthening Increasing confidence in the ability to utilize self-hypnosis. Post-hypnotic suggestions (PHS) offered to counter negative self-hypnosis (NSH), with self-hypnosis to induce relaxation, positive mental set, and ego-strengthening..

F. HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 9-12

COGNITIVE RESTRUCTURING USING HYPNOSIS

Guide to focus attention on a specific area of concernOnce the negative cognitions are identified, encouraged patient to restructure the maladaptive cognitions and then to attend to the resulting (desirable) responses. Positive Mood Induction technique in of five steps: (1) education, (2) making a list of positive experiences, (3) positive mood induction, (4) posthypnotic suggestions, and (5) home practice.

G. HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 13-14

ACTIVE INTERACTIVE TRAINING Break "dissociative” habits and Encourage "association" with the pertinent environment. Prevent reflexive dissociation. Patient (1) must become aware of the automatic occurrence of such a process, (2) actively attempt to inhibit it by switching attention away from "bad anchors", and (3) actively attend to pertinent cues or conceptual reality. SOCIAL SKILLS TRAINING

H., HYPNOTHERAPY (CH) FOR DEPRESSION SESSIONS 15-16

IDEAL GOALS/REALITY TRAININGUnder hypnosis image ideal but realistic goalsThen imagine planning appropriate strategiesTake necessary actions for achieving. .BOOSTER AND FOLLOW-UP SESSIONSSome depressed patients may, however, require fewer or more sessions. Further booster follow-up sessions provided as required.

69

I. CONCLUSIONS

1. MDD is one of the most common psychiatric disorders treated by psychiatrists and psychotherapists.

2. Although MDD can sometimes be treated successfully with antidepressant medication and psychotherapy, a significant number of depressives do not respond to these approaches

3. Cognitive Hypnotherapy (CH), a multimodal treatment, may now become available to a wide range of people with MD, with validated benefits.

4. Further research is needed.

10.4 VIDEO (20)

Instructions:

a. MG – Play the video Kuttner (2) 1 of 3 or alternative.

b. SG – Discuss the following questions:

1. Does the video help patients? .


70

UNIT 10 – DEPRESSION 10.5 DEMO/PRACTICE EXERCISE

Instructions: Study the Organizer demo and then role play 3 EXERCISES with a partner.

EXERCISE 1 Practice:\

FIRST AID FOR DEPRESSION

Encourage patient to talk. plausible biological explanation; hypnotic induction to alter depressive posture; encourage smile by imagining looking in a mirror; i imagine a "funny face";"play a happy mental tape"; condition to a positive cue- word:

“From now on, whenever you feel down or depressed, and don’t want to feel this way, all you have to do is to repeat the word BUBBLES and soon the bad feeling will ease away, replaced by good feeling.”

EXERCISE 2 Use of a CD

Practice: Day by day, as you listen to your self-hypnosis CD, you will become more relaxed, less anxious, and less depressed.

As a result of this treatment and as a result of you listening to your self-hypnosis CD every day, you will begin to feel more confident and you will begin to cope better with the changes and challenges of life every day.

You will begin to focus more and more on your achievements and successes than on your failures and shortcomings.

EXERCISE 3 Rumination

Depressives tend to constantly ruminate with negative thoughts, feelings and images (a form of NSH); especially following a stressful experience: (e.g. “I will not be able to cope.”). Practice:

While you are in an upsetting situation, you will become more aware of how to deal with it rather than focusing on your depressed feeling.

When you plan and take action to improve your future, you will feel more optimistic about the future.

As you get involved in doing things, you will be motivated to do more things.

10.6 SUMMARYInstructions: MG – Questions, answers and discussion

71

UNIT 11 – STRESS & ANXIETY (KAHN) & PROCEDURAL HYPNOSIS (LANG)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10



4. VIDEO 20


6. SUMMARY 10

180

11.1 OBJECTIVES


1. Anxiety research2. Assessment3. Stages of anxiety treatment4. Development of procedural hypnosis5. Evidence of efficacy6. Application considerations

72

UNIT 11 – STRESS & ANXIETY & PROCEDURAL HYPNOSIS


A. INTRODUCTION – HYPNOSIS FOR STRESS & ANXIETY

The most common disorders of anxiety are phobias, including agoraphobia, and generalized anxiety disorder. More serious anxiety disorders such as Post-Traumatic Stress Disorder or Obsessive Compulsive Disorder involve more complicated treatments.

B. RESEARCH

Research on the on the efficacy of hypnosis with anxiety is clearly evidenced in many published treatment protocol..

C. ASSESSMENT

First Session. Assessment includes: history, changes in the symptoms over time, symptom coping strategies, associated stresses and impact on lifestyle, patient’s strengths, including both cognitive and emotional resources, self-soothing and relaxation..

Homework self-monitoring of the symptoms on an hourly basis including what influences their appearance and disappearance and any associated stresses.

Many patients with generalized anxiety disorder ascertain triggers they did not realize were affecting them.

High-risk times and/or situations can be utilized as factors that decrease anxiety become clearer. Self-monitoring decreases anxiety.

D. FOUR STAGES OF TREATMENT OF ANXIETY - VISCERAL

The specific treatment of anxiety involves four stages with each resting on the earlier stage.

Visceral Control - Hypnosis and self-hypnosis to teach the patient to relax in non-stressful circumstances. Post-hypnotic suggestions achieve easier relaxation can be given.

If the patient can achieve a reasonable depth of trance and relaxation, then a recording (cassette or CD) can allow practice at home, twice a day, whjen patient is relaxed and removed from internal or external distractions.

For a patient unable to achieve a relaxed state, the therapist can discuss resistance or even use paradox or other indirect methods like Erickson to get the patient to relax and allow self-hypnosis.

Patient’s achieves ability to go to a deep level of relaxation in just a few minutes daily.

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E FOUR STAGES OF TREATMENT OF ANXIETY - DESENSITIZATION

Patient creates a hierarchy of feared situations or objects.

Graded exposure (starting with the least-feared circumstance) in hypnosis allows the patient to experientially process his reactions and learn to modulate them by inducing the relaxation response in the imagined presence of anxiety-producing situations

A television screen can give more distance and put the control (remote control) in the patient’s hands, where the patient can shift from the anxiety situation to “the relaxation channel”.

F FOUR STAGES OF TREATMENT OF ANXIETY - COGNITIVE

Cognitive - Cognitions, particularly catastrophizing and generalization can be rewritten since the anxiety can be countered with the thought “I have mastered my fear and feel confident I can manage my anxiety which is under control.

G. FOUR STAGES OF TREATMENT OF ANXIETY - REHEARSAL

Rehearsal - is the final stage utilizing his new coping strategies to relieve his stress and anxiety.

Once this has been mastered in imagination, i.e. little or no anxiety throughout the whole stressful situation, the patient is ready for controlled rehearsal in vivo.

Patient with flying phobia, can simulate his trip to the airport, approaching the gate and even waiting in line to board, before he actually attempts the flight.

Preventive intervention for a patient who will undergo surgery or any invasive medical procedure.

Can be a used alone or as reinforcement to anesthesia etc.

Effective and powerful for most stress and anxiety, including panic disorder, phobias and social anxiety which could cause distress.

H CONCLUSIONS

Both curative and preventive hypnosis is an effective and powerful intervention for most types of phobias and for generalized anxiety.

With more severe situations, such as OCD and PTSD, intervention is much more complex and varied.

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11.4 VIDEO (20)

Instructions:

a. MG – Play the video. Rossi 3 of 3 again. b. In SG – Discuss the following questions:





1. Picture the day that is coming up when you will have your medical procedure (e.g., childbirth, dental care, surgery etc). Picture the building where this will occur. Imagine the door you might walk in. Think about the room where it will take place. Who will be there? What sort of preparations will they take immediately before the procedure? Establish a clear image of this series of scenarios in your mind.

2. Use all of your talents to put yourself in the deepest state of relaxation possible. Start by concentrating on your breathing, and slow it down. Then start with one part of your body (your head, toes or fingers) and progressively relax each part until you have covered all areas. Repeat to yourself: "My fingers are warm, my finger are relaxed, my fingers and becoming very heavy." Repeat for all parts of the body.

3. After achieving a deep state of relaxation, begin to picture the cues on the day of your procedure. Walk yourself through the event, beginning with entering the building. Watch yourself calmly and painlessly going through all of the events.

4. Now picture yourself at some point in the future, well after the procedure is over. See yourself as healthy, relaxed, and at peace.

11.6 SUMMARY (10)


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UNIT 12 – SUMMARY & REVIEW SESSION (THIS UNIT - SG OF 4 CHANGED TO CSG OF 8)

TIME SCHEDULE

Activity Minutes

1. OBJECTIVES 10


3. VIDEO 20

4. QUIZ 30

5. SUMMARY LECTURE 20

6. FEEDBACK REPORT (DIARY) 20

7. POST COURSE SUPPORT 10

120


The whole program was designed to achieve learning and practice basic medical hypnosis with confidence.

The objectives stated in Unit 1 were:

a. To stimulate the learner knowledge, skills and attitudes for efficient and effective basic medical hypnosis practice and to motivate further study and practice in the future.

b. Based on the Medical Hypnosis Primer the key pre-learning textbook for the course, to get medical hypnosis training into the required syllabus of every medical/nursing school and PHC training facility in 2010.

c. To use the AGL (Autonomous Group Learning) system to create 24 hours of

highly interactive training, in 2 hour units, which can be organized and provided by one qualified hypnosis instructor. Each unit can be adapted to local culture,

d. To give in each unit an inspiring learning mixture of: narrated lecture, group discussion, Primer study, video, practical exercise and quiz

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UNIT 12 – SUMMARY & REVIEW SESSION

e. To create a website with training materials (with controlled access by code) to

encourage free access and translation of the textbook and training materials, into local languages. To use this web site as a resource for post training help, feedback and support of further study.

f. To promote and support the Olness Training program and for primary health care workers in developing counties. See Appendix.

g. To use a rigorous alternative choice quiz (80 questions) in the first and last units of the training, to measure and reward the learning achieved.

h. To provide allow alternative scheduling as a 3 day course for Doctors, nurses and primary health care workers, or In 12 two hour sessions for medical and nursing students, with individual support as needed.

i. To provide allow alternative scheduling as a 3 day course for Doctors, nurses and primary health care workers, or In 12 two hour sessions for medical and nursing students, with individual support as needed..


Instructions:

a. IND – Review the Primer.




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UNIT 12. SUMMARY & REVIEW SESSION

12.3 VIDEO (20)

Instructions:

a. MG – Play again video Sugarman. b. In SG – Discuss and record on the SG flip-chart,

the answers to the follow the following questions:

1. What are your reactions now? 2. How will your patients react?

12.4 SUMMARY LECTURE (20)

Some guidelines for clinical practice:

1. Clinician must have confidence and create empathy rapidly with the patient.

2. Recognize that medical hypnosis is based upon self hypnosis and upon powerful imagination.

3. Clinician must be skilled in self-hypnosis.

4. Patient must understand hypnosis, believe in it and expect it to work.

5. Use what the patient gives you, in both verbal an body language, to plan a therapy which directly relates to the patient’s values, culture and expectations, and meets his needs.

6. Practice simply and gently with a skilled Mentor available as needed.

7. Work with a professional hypnosis society for further study.

8. Give confidence to the patient to feel an essential part of the health care team.

9. Etc etc …

10. - 20

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12.5 QUIZ (40)

a. IND Instructions:

1. Complete on the answer sheet provided, for the 80 question alternative choice quiz which is in the GUIDE. Choose only the questions for units you have covered inn the course.

2. Hand your answer sheet to the Organizer who will give you a score of hypnosis learning at the start of the course.

3. This is the same quiz you completed in Unit 1 to give you feedback and reward your achievement. An 80% score is expected.

12.6 FEEDBACK REPORT (20)

Instructions:

a. IND – Complete the first feedback report in the DIARY for the Organizer..

b. After one month of practice, please send us the final feedback report.

12.7 POST COURSE SUPPORT (10)

a. A web site is available to give help, advice and response to questions.

b. International and national societies of hypnosis are available (see Primer) with current published journals and more advanced training courses.

c. Vlaamse Wetenschappelijke Hypnose Vereniging 517 3070 Kortenberg Belgium E-mail: [email protected] Web site: http://www.vhyp.be

d. Video ans DVD are available. Barabasz A., & Christensen, C. (2009). Hypnosis induction demonstrations: Techniques, metaphors, and scripts. DVD. So many books are available.

e. Barabasz A., & Watkins, J. G. (2005). Hypnotherapeutic techniques. New York: Brunner-Routledge.

f. Michael D. Yapko Trancework – An Introduction to the Practice of Clinical Hypnosis (Taylor & Francis)

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g. Jensen, M. P., & Patterson, D. R. (2006). Hypnotic treatment of chronic pain, journal of Behavioral Medicine, 29, 95-124.

h. McCarthy, P. (2001). Hypnosis in obstetrics and gynecology. In L. E. Fredericks (Ed.), The use of hypnosis in surgery and anesthesiology (pp. 163-211). Springfield, IL: Charles C. Thomas.

i. Olness, K., & Kohn, D. (1996). Hypnosis and hypnotherapy with children (3rd ed.). New York: Guilford.

j. Paterson, D. R. Clinical hypnosis in pain control and management (unpublished manuscript). Washington, DC: American Psychological Association.

k. Spiegel, H., & Spiegel, D. (2004). Trance and treatment: Clinical uses of

hypnosis. Washington, DC: American Psychiatric Association Publishing.

l. Thomson, L. (2005). Hypnotic intervention therapy with surgical patients. Hypnos, 32(2), 88-96.

m. Watkins, J. G., & Barabasz, A. F. (2008). Advanced hynotherapy: Hypno-dynamic techniques. New York: Routledge.

n. Note: Dr. D.Croydon Hammond suggests: “The need for a comprehensive bibliography of clinical hypnosis outcome studies with the websites of the major organizations. In this day of evidence based medicine, this will be well received. I have done something similar in the field of neurofeedback (see the Comprehensive Neurofeedback Bibliography at www.isnr.org ), but I think that (unlike the bibliography I just referred to), it should not include anything except the controlled studies“.

o. Dr William C. Wester suggests: “The critical need to effective communicate with doctors, nurses and patients to clarify the new reality of medical hypnosis in 2010”. See a six column pamphlet: “Questions and Answers about Clinical Hypnosis” freely available from Ohio Psychology Association, 2734 East Main Street, PMB 140, Columbus, Ohio 43209, USA.

p. Michael D. Yapko, DVD Sleeping Soundly.

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12.8 FINAL CONCLUSIONS

1. FOR THE HEALTH CARE PROFESSIONAL, SUCCESS IN CLINICAL MEDICAL

HYPNOSIS, COMES WITH COMPETENCE IN SELF-HYPNOSIS AND THE

CONFIDENCE, TO USE WHAT THE PATIENT GIVES YOU, TO ALLOW MEDICAL

HYPNOSIS TO REINFORCE THE HEALTH CARE WITH NEW SKILLS AND

ATTITUDES.

2. FOR THE PATIENT, SUCCESS IN CLINICAL MEDICAL HYPNOSIS, COMES FROM

THE CONVICTION AND CONFIDENCE TO USE SELF- HYPNOSIS TO MOBILIZE

INNER RESOURCES FOR HEALING, AND THUS WITH CONFIDENCE, TO BECOME

AN ACTIVE MEMBER OF THE HEALTH CARE TEAM.

3 GOOD LUCK FOR THE FUTURE … ON WE GO TOGETHER …

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APPENDIX A

Olness Team Hypnosis Training Programfor Developing Countries

OBJECTIVES

This pediatric workshop training program for developing countries is offered at three levels (introductory, intermediate, advanced) depending on previous experience in hypnosis.

It provides training in the use of hypnosis and its applications in clinical pediatric settings. Emphasis is placed on supervised practice of hypnotic techniques. AdvancedParticipants must bring an audio or videotape of patient and a typed case vignette.

The objectives of the introductory workshop are to:

1) Use 3-5 techniques of hypnotic induction in children

2) Use one or more self-hypnosis techniques

3) Appreciate the range of applications of hypno-therapeutic strategies in pediatrics.

The intermediate and advanced workshops refine hypno-therapeutic skills and build personal confidence and competence, through case discussion and review and supervised rehearsal and practical skill building.

The course has been approved by the American Society of Clinical Hypnosis for certification and has been used in Mexico, Haiti, and Khon Kaen University. in the Northern Thailand.

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Olness Team Hypnosis Training Programfor Developing

Countries (continued)

INTRODUCTORY WORKSHOP SCHEDULE:

DAY 1 (Thursday)

8:00 - 8:30 Registration 8:30 - 8:45 Introduction of Faculty 8:45 - 9:30 Introduction to Hypnosis (Definitions, History, Theories of Hypnosis, Myths and Misperceptions, Susceptibility, Hypnotic Phenomena) 9:30 -10:00 Group Experience

10:00 -10:15 Break

10:15 -10:45 Stages of Hypnosis and Principles of Induction; Presenting Hypnosis to the Patient10:45-12:00 Methods of Induction and Hypnotic Phenomena, Demonstrations of Induction Methods: 4 @ 15 minutes each

12:00 -1:15 Lunch

1:15 - 1:30 Introduction to Small Group Practice 1:30 - 3:00 Small Group Practice #1: Inductions

3:00 - 3:15 Break

3:15 - 4:00 Developmental Considerations: Hypnotic Approaches at Different Ages 4:00 - 4:30 Preschool Techniques 4:30 - 4:45 Intensification (Deepening Involvement) and Alerting 4:45 - 6:00 Small Group Practice #2: Deepening 6:00 Adjourn for the Day

Evening viewing and discussion of videotape:

"No Tears, No Fears" (Fanlight Productions)

by Dr. Leora Kuttner and the follow-up videotape of the reactions of samechildren, ten years later.

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Olness Team Hypnosis Training Programfor Developing Countries

INTRODUCTORY WORKSHOP SCHEDULE (continued):

DAY 2 (Friday)

8:30 - 9:15 Formulating Suggestions: The Language of Hypnosis 9:15 -10:15 Integrating Hypnosis into Clinical Practice: Approaches to Anxiety

10:15 - 10:30 Break

10:30 -12:00 Small Group Practice #3: Language, Adding Suggestions

12:00 - 1:15 Lunch

1:15 - 2:15 Integrating Hypnosis into Clinical Practice: Hypnotic Approaches to Pain Management 2:15 - 2:45 Integrating Hypnosis into Clinical Practice: Acute Pain 2:45 - 3:30 Integrating Hypnosis into Clinical Practice: Chronic Pain 3:30 - 3:45 Break 3:45 - 5:15 Small Group Practice #4: Language, Suggestions 5:15 - 6:00 Self-Hypnosis for Clinicians, Children, and Parents

6:00 Adjourn for the Day

Evening viewing and discussion of the DVD: “Therapeutic Hypnosis with Children and Adolescents” (Crown House) by Professor William Wester & Dr Laurence Sugarman

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