Hypnosis and Dentistry
Australian Society of Hypnosis
Hypnosis and Dentistry
Recognition of Trance
It is very important to realize that trance depth is a continuum from the light hypnoidal state to deep somnambulism and that the depth of trance experienced by patients will vary from session to session and within any given session. A person in a light or a deep trance may have eyes open or closed, may or may not speak and may or may not have spontaneous physical movement, so these are not very reliable indications. For most people, the trance state is seen as physical stillness, slow and relaxed breathing, often an unblinking stare, or eye closure, and lack of voluntary movement except to the extent requested for treatment. Patients can and do quite easily move in and out of trance and from level to level within their trance, so the formal concept of trance depth is of much less use to clinicians than is the observed response of patients to the clinical situation.Patients can’t see what you are doing (and often don’t want to), they can’t participate in a conversation while you are working (and you don’t want them to), and this may be the first time for quite a while that they have had an opportunity to put up their feet in the middle of the day and just relax. If pain free and comfortable, many will take the opportunity of their dental visit to become internally absorbed in their thoughts and memories. This is especially true if the treatment room environment is conducive to free associations – quiet music, interesting pictures, perhaps a mobile within view from the treatment position.You can potentiate this tendency by structuring the clinical situation to create as little disturbance as possible to the patient’s thought processes. For example, to ask a patient “is that hurting?” compels the cooperative patient to pay attention to something that he may have been quite happily unaware of and so disturb the state which had been achieved. If the question is “are you comfortable?” the patient can easily answer “yes” or “no” without being involved in this inner search process to obtain an answer, thus leaving the internal state undisturbed. Avoid startle responses by mentioning what you are about to do. For example, run the air turbine for a few seconds well away from the patient before use in the mouth; test the triple syringe so the patient hears the air and perhaps say “this might be slightly cold” before drying a tooth. Paradoxically, patients may not react to nearby loud noises (a dropped tray of instruments, for example) if it is not perceived as relevant to them. An effective way to defuse events of this sort is to comment on them in an accepting way: “perhaps we should have carpet on the floor!” You thus ratify the experience for the patient, and by accepting it yourself make it all right for the patient to accept it also, and then to forget it as being unimportant.Gentle handling of patients also assists them to maintain their dissociation. Be aware of how patients experience what you are doing. If force is required for a procedure, just mentioning that you are aware how it feels and that you are ensuring that everything is being done to protect the patient is very reassuring. Use of non-verbal cues minimises disturbances to patients conscious thought processes. Hand signals can easily be used to request the required local anaesthetic (long/short needle, 2, 3 or 4 % etc). The head can be repositioned by gentle pressure on one side or the other, the mouth can be opened by gentle taps with a finger tip on the anterior part of the chin or closed by similar taps under the chin, all with no words needed.
Rapport building
There are many good books and seminars on practice management and promotion and one of the central themes of all of them is that of building rapport with your patients. This commences when the patient first contacts the practice and should be developed by the attitudes of your staff and the public areas of your rooms so that the patient has a positive mental attitude before his or her first meeting with you. It is not difficult during your history-taking to show the interest you have in the patient as a person, and in their feelings and experiences.You not only increase rapport in this way but obtain useful information which you can use later in “distracting” the patient during treatment. Look for “themes” which can be used: fishing, cross-country skiing, flying, painting, music, and so on. It is much more effective to focus your distraction on a theme the patient enjoys and has experience of than to talk about something which he does not like. Some patients may like to hear of your interests and this gives you an opportunity to use a theme with which you are familiar and incorporate appropriate language to suit the situation.
Language
As experienced dental clinicians, we strive to avoid ambiguities in our communications with others so that we are able to convey our meaning and information as clearly as possible. The listener then interprets our words, to arrive (hopefully) at an understanding which is close to our original thought. This process places us at a distinct disadvantage when using indirect hypnotic techniques, because we want the listener to become so involved in his own thought processes that he literally becomes “lost in thought”.There are various linguistic techniques which may be learned to help you to start influencing patients in this way. In case you feel that this is slightly underhanded or “dishonest” in some way, consider the subtle use of words and images with which we are bombarded every day in commercial advertising. When you become sensitized to subtleties in language you may be surprised to realize how much “spin” is placed on news stories by the media. High ethical standards and an ability to deliver the treatment you recommend will ensure that you are most unlikely to be criticised for your use of these techniques.They have been divided into several sections for ease of study and practise, and several examples of each are presented to give some guidance towards constructing your own word patterns. Note the use of pauses (…..) and emphasis (italics) to highlight particular aspects of the message.
Truisms
These are used to “set the scene”, that something different is happening, and that the patient is an active partner in the endeavour. “Dental chairs are designed to support your back in the most comfortable way”“Many patients experience profound relaxation with this technique”“Many patients become so relaxed they forget to remember what happened during the appointment”“Patients respond differently to nitrous oxide at different times.”
Permissive Language
Avoid the use of imperatives (“you will”) which can be challenged (if only unconsciously) by the patient. Use permissive verbs instead: “you can, may, might; maybe, perhaps” etc. which cannot be refuted. Observe your internal reaction to “this will relax you” and “this can relax you”.Undoubtedly nitrous oxide can relax you, but the extent it will depends very much on the way you allow it to affect you.“You might begin to feel a little more relaxed… as you lie back in the chair”“Perhaps you are able to remember a pleasant experience… when you last went.. (skiing)”“Maybe this visit will be quite different… than you expect”
Embedded Commands
These are direct suggestions camouflaged within a statement or question. They are marked out by emphasis or pause so that the unconscious mind hears the secondary meaning. This “marking” can be quite subtle, and the degree can only be determined with practice.“You can experience things in different ways, but just now you can experience how you can really relax.”“I wonder whether you can dream comfortably while you relax.”“Isn’t it interesting how just a little gas can help you…. really let go.”
Use of Curiosity
This is to start the process of inner search and so create a dissociation from the present reality situation. Key words here are: wonder, surprise, curious, know, doubt, hope.“I wonder whether you will be curious about how it feels to… really relax.”“Wouldn’t it be interesting if you discover something totally unexpected today.”“I doubt that you will have experienced anything as relaxing as this before.”“You may find this experience to be unlike anything else you have ever known.”When used in sequence you might have: “Dental chairs are designed to support your back in the most comfortable way. You might be surprised to….. realise that you can begin to… feel a little more relaxed… as you lie back in the chair, and I wonder whether you will be curious about how it feels to…. really relax and just let go.”
Open Ended Suggestions
These are more abstract than truisms and intended to open more possibilities for the patient. “You can experience this relaxation on many levels.”“You may be surprised by the memories that can appear.”“You can forget the past, experience the present, and enjoy the difference.”
Spiral of Belief
This refers to the tendency we all have that the more often predictions come true the more we expect them to come true. In a purely hypnotic situation, suggestions are made at times the experienced clinician expects the event to be experienced or when he first notices the early signs of something happening.For example, increased rate of blinking is usually beyond conscious awareness but can be used as a “predictor” of eyelid heaviness and eye closure. Suggestions can be “clustered” to cover all possibilities so that whatever happens has already been predicted.If a patient has a hand cataleptically suspended, the suggestions can be made that the hand might go up or down, move left or right, or stay just where it is. No matter what the patient’s response, it has been predicted, and so reinforces the expectation that other predictions will also come to pass.As the patient reports some of these feelings, the suggestions are made that they will increase in a pleasant way and that others may be noticed. This is coupled with suggestions of relaxation and comfort.“As you notice that heavy feeling increasing you can be pleasantly surprised at how warm and comfortable you begin to feel and that with the tingling becoming more apparent you just want to let go and enjoy the experience, feeling that sense of comfort and control increase with each breath.”
Awakening
Patients will normally arouse spontaneously when the cerebral nitrous oxide level drops shortly after the gas is turned off at the end of treatment. Those who do not either consciously want to prolong their feelings of relaxation and well-being or are in trance and enjoying their freedom of thought without necessarily having a normal awareness of their surroundings. There is an implicit suggestion in the termination of the sedation that treatment is finished and it is now time to go, but this need not be perceived by the patient in trance.There are several ways you can overcome this. “When I count three you will be wide awake and ready to go home – one, two, three – wide awake!” or “It seems that (the patient) is still nicely sedated so perhaps we should continue and do some of that other work we had planned.” It can be nicer to say “Now that you know how comfortable you can feel, isn’t it nice to really know that you have the ability to find that place of comfort any time you wish. Just so you can be really sure, come on back now, and then see how easily you can go back there and back again before you leave.”
Positive Suggestions
When you really learn to hear to what people say it is quite surprising how many negative suggestions are in our everyday communications. “You have to bite on that swab for half an hour so that you won’t bleed.” (If you don’t do this you will bleed!) “That was a really deep filling so I expect you will have some pain when the anesthetic wears off.”
This is one way of informing a patient! The same information can be conveyed by saying “That filling was much larger than what I like to see because you left it so long, but I have done …….. to minimise the shock to the tooth, and I think you will be pleasantly surprised how little discomfort you will have once the initial irritation goes, (and you can help that by avoiding hot foods and taking some analgesics if you really need to).”
Which dentist would you rather see: “After your wisdom teeth are removed you will get a lot of pain and swelling” or “Some patients who don’t keep their cold packs on long enough after their wisdom teeth are removed or who don’t follow the post-operative instructions carefully have been known to have some pain and swelling, but if you do just as you have been advised you will be pleasantly surprised at just how little discomfort you can have as long as normal healing is occurring.”
The first dentist’s communication is concise, but that is not what the patient needs to hear right then! The second dentist takes a little longer to give the message, but it is so much more positive and gives the patient choice about how their healing will progress.
Patients in trance can be very receptive of subtle nuances in your communications. It is probably fair to say that if there is a possible alternative interpretation for what you have said then the patient will hear that also.
Which meaning the patient chooses to remember is difficult to determine as it involves so many internal associations, so your intended meaning needs to be quite unambiguous if the patient is to hear what you intend them to hear.
However, sometimes you may want to be ambiguous. “Some patients have great difficult grasping simple techniques of oral hygiene. They need to practice carefully the things they have been told. You can surely appreciate that.”
As you learn to listen to what you say and to hear it with the patient’s ears you will become a better communicator and enjoy even better rapport with your patients and staff. But you have to learn to talk!
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