POTENTIAL OF HYPNOTIC TECHNIQUES: The perception of pain depends on many variables, including the situation, the meaning to the individual, expectations for relief, anxiety, and perception of control (Beecher 1956; Chapman 1986; McGrath 1983; Melzack 1970; Pennebaker 1977). Many of us happily accept bodily insults and temperature challenges during outdoor recreational activities that, if experienced in another context, would be unacceptable. People willingly go up on ski lifts in subzero temperature, but shiver when their bedroom thermostat goes below 70° F. Even if a painful or frightening stimulus cannot be removed, a change in perception can nevertheless take the "hurt" out of the experience. Some patients, confronted with pain and distress, resort to their own cognitive "nonpharmacological" means of coping, such as imagination of pleasant scenes, distraction, relaxation, self-hypnosis, or meditation (Anand 1961; Chaves 1974; Hilgard 1977; Quirk 1989a; Spanos 1981; Spanos 1984; Spanos 1979).

Reduction of anxiety decreases pain and symptoms (Barber 1959; Barber 1960; Hilgard 1969; Hill 1952; Hill 1952b; Martin 1991; Shor 1962). Hypnosis as a means of anxiety reduction has proven highly beneficial for patients undergoing MRI examinations (Friday 1990) and was shown to reduce drug use during coronary angioplasty (Weinstein 1991). In these studies, however, additional physicians/psychologists were needed for about 30 minutes, and this is impractical in most settings. Tapes promoting relaxation have been used to reduce (98) drug use during dental surgery (Corah 1979), gastrointestinal endoscopy (Wilson 1982), and femoral angiography (MandIe 1990). Tapes, however, have a 13% rejection rate (Feher 1989) and can result in the withholding of needed drugs in nonreceptive patients. Also, presence of a "live therapist," who is a member of the treating team, is believed to be superior (Blankfield 1991). Selfhypnotic techniques including relaxation training and imagery, applied by members of an interventional radiology team, were highly effective in reducing pain and drug use during invasive procedures (Lang 1994; Lang 1996). In a prospective randomized study with patients undergoing invasive procedures, hemodynamic instability and procedure interruptions were significantly less frequent when patients had self-hypnotic relaxation (Lang 1996). Overall, self-hypnotic relaxation greatly increased procedural safety by reducing the occurrence of drug-related complications.

The Concept of Nonpharmacological Analgesia: The Clinical Practice Guidelines for Acute Pain Management, published by the United States Department of Health and Human Services (Acute Pain Management Guideline Panel 1992), recognizes the limitations of intravenous conscious sedation and suggests that use of nonpharmacological analgesia methods be induded in the repertoire of acute pain management. Because there are no guidelines for how these methods should be employed, we undertook to identify methods that regular staff members of a radiology department can apply in a safe fashion. These methods were elaborated during four training courses with different interventional radiology team members and encompass a spectrum of hypnotic techniques (Lang 1996b). We chose the designation nonpharmacological analgesia as a descriptive, generally acceptable term to allow for the individual adaptation of the techniques that are presented in the "Methodology" section of this chapter.

Economic Impact of Managing Pain and Anxiety Managing patients' anxiety and pain materially affects the health care budget. If a patient receives any amount of intravenous conscious sedation, stringent monitoring requirements and a full set of conscious sedation policies in accordance with the standard of care must be followed (Association of Operating Room Nurses 1992; Lang 1996; Steinbrich 1993). The patient's history must be taken, an anesthesia plan must be developed, and a dedicated observer who is not allowed to engage in any other activities must remain with the patient for the duration of the examination and afterward for at least 30 minutes after the last drug dose. The patient requires a responsible adult to accompany him or her home and is not permitted to drive, operate machinery, or conduct important legal business for the next 24 hours. Avoiding these inconveniences and costs to patient and hospital by use of nonpharmacological means is a highly economical alternative.

Based on data obtained from 34 consecutive patients treated in the Interventional Radiology Suite at the University of Iowa Hospital and Clinics, materials and observation requirements for intravenous conscious sedation added an average of $140 to every interventional radiology procedure. If it were possible to reduce the need for intravenous conscious sedation to 25% of all procedures and to reduce the need for procedure interruptions from 35-50% to 14%, as was the case for a randomized trial (Lang 1996), the average cost for procedure analgesia and anxiolysis could be reduced from $140 to $39 per case, a very substantial saving. The economic impact becomes obvious when extrapolating this cost reduction to the millions of procedures performed annually.

The time slots on MRI, CT, or PET scanners are tightly booked and are expensive. When a patient panics, and the examination cannot be concluded, the department loses $400 to $3000 in charges. When intravenous conscious sedation is used to overcome the patient's panic, costs incur as pointed out previously.

Ethical considerations alone are a professional imperative for reducing patients' suffering. The recent emphasis on enhancing patients' comfort levels is additionally driven by the increasing economic importance of patients' satisfaction surveys. Such surveys are used by third party payers to determine choice and reimbursement of health care facilities. Therein lies a great incentive for introducing behavioral therapy in the radiology department.

METHODOLOGY: Overview: The goal of nonpharmacological analgesia in radiology is to induce a pleasant state of temporary dissociation in the time available. Patient contacts with individual personnel in the radiology department are relatively short. There is no time for lengthy intervention. Fortunately, a small investment of attention delivered up front can go far toward interrupting the spiral of distress. If, on the other hand, a patient's emotional needs are neglected, attention likely will be required later, often in the form of costly interruptions at inopportune (99) moments. Nonpharmacological analgesia starts from the moment the patient is met. It is appropriate at every stage: while walking with the patient down the hallway, while inserting intravenous access or an enema tip, while positioning the patient on the procedure table, while applying antibiotic solution and draping the patient, and during the procedure. One staff member can take over for another without interruption of work flow.

Hypnotic methods span a continuum from correct use of suggestions at one end to deep hypnotic analgesia on the other. Time constraints, prevailing anxiety, and invasiveness of intervention have to be taken into account when applying non pharmacological analgesia. Appropriate choice of words may be all that is needed to provide comfort for a noninvasive examination in a patient with low anxiety levels. Patients who panic at the sight of equipment, as well as those who undergo invasive procedures, require more treatment. Imagery is particularly useful in highly anxious patients (Lang 1994). As has been found in phobic patients (Frankel 1976), individuals with the most vivid fears are likely to be those with high levels of hypnotizability, high imagery potential, and, therefore, high susceptibility to suggestions. We speculate that persons capable of dissociating from reality by imagining a worst-case scenario also possess superior ability to dissociate and can imagine a pleasant scenario, if guided appropriately (Lang 1996a). On the other hand, a poorly hypnotizable patient may lack the ability to create vivid fears, may appear stoic, and may benefit from simple distraction.

The methods can easily be integrated in the work flow so that time is not wasted. Rapport is essential for all subsequent interventions. Therefore, we first address rapport skills and expression of empathic attention, then follow with imagery and self-hypnotic relaxation.

Rapport Skills: Personnel should be nonthreatening and should be able to adjust to the patients' preferred mode of verbal and nonverbal communication. Radiology personnel may meet a patient for the first time either in a clinic office, on the ward, in the reception area, the preparation room, in a hallway, or the procedure suite. Patients may be ambulatory, in a wheelchair, in a hospital bed, or on a gurney. The patient should be greeted while still in street clothes if at all possible or at least while covered by some clothing or drapes. It is advisable to find out how the patient wishes to be called: by first name, last name, or a nickname.

Assuming body positions at different heights or placing barriers between the patient and the health care provider (such as tables or desks) imposes a relationship of superiority/inferiority. Towering over a seated patient or over a patient on a gurney or examination table tends to portray the health care worker in a dominating, controlling fashion. Bending over or sitting down and adjusting to the patient's level makes a difference. Some patients may seek closeness and physically move toward the health care workers, others need space. It is important to respect and adjust to this preference and not to misinterpret it as "coming on" or "withdrawal." If a patient's demeanor is quiet, slow, or reflective, a busy, chipper attitude of the health care worker can raise an emotional barrier. If, on the other hand, the patient is excited and gesticulates wildly, a display of reserved calm is unwarranted and may annoy the patient. Initial matching of the patient's body posture, demeanor, or level of activation by the health care worker establishes necessary rapport so that the next steps of the process can be successfully accomplished. Subsequently, patients are guided to a more serene and relaxed demeanor by transition from the matched behavior toward the desired state.

Distressed patients may be breathing rapidly or in a shallow, constricted fashion. Following the patient's breathing pattern for a few breaths and then leading toward a relaxed deep inspiration and expiration can be very effective. This technique works well when verbal communication is not immediately possible, as with trauma patients, patients under oxygen masks, or intubated patients. A deep inspiration by the staff, followed by a gentle long expiration, indicates to the patient that the staff has time and is not hurried. In addition to matching the body signals, it is desirable to match the patients' language. The health care worker can match volume, tone, and tempo, and then guide toward a relaxed level.

Correct Use of Suggestions: Anticipation of discomfort, abdication of control, or /enhanced anxiety can alter awareness and greatly in. crease susceptibility to suggestions (Barber 1962; Blankfield 1991). Health care providers can purposefully build on this pre-existing suggestible state by using positive suggestions, evoking a desired ideation and experience, and thereby enhancing the patients' feeling of wellbeing (Erickson III 1994).

The heightened suggestibility of patients prior to and during procedures makes choice of words crucial. Phrases designed to reassure patients can produce the opposite effect. "We will put you out" may evoke allegorical notions of death rather than comfort. Words with negative emotional content, such as "pain" or "hurt," reinforce anxiety and fear and thereby worsen the experience of pain. Even disclaimers such as "you will feel no pain" tend to evoke seemingly paradoxical effects

(100) (Barber 1962; Blankfield 1991). There is a misconception that catastrophizing an upcoming event will ease the experience. In procedure suites one may hear a variety of phrases: "Pain and pressure now"; "Bee sting now"; "You may throw up"; "The contrast dye will burn like hell"; "What shall I tell you, this really hurts"; or "Don't gag."

We use the following alternative phrases for negatively loaded suggestions: Prior to application of local anesthetic, we say, "Please concentrate on a feeling of numbness spreading through the tissues" or "I will be giving you the numbing medicine; you may feel coolness or some tingling." Prior to contrast medium injection, we say, "You will feel warmth spreading throughout your body" or "This may feel like the rising sun in your belly." Prior to an MRI scan (if you know that the patient likes music) we might say, "You will hear a rhythmic noise like a metronome. You can think of your favorite melody for accompaniment."

Provision of Perception of Control: Fear of loss of control to the disease, to personnel, or to technology can be daunting. Therefore, it is important to give patients at least some perception of control. This perception can be provided by swift response to requests and asking the patient what he or she wishes (e.g., "Please let us know at any time what we can do for you to make you more comfortable"). The patient needs to be anchored in a sense of security and should be reassured that his or her requests will be taken seriously and will be acted upon. Fulfilling of seemingly unimportant requests can mean very much for the patient, establish trust, and improve the entire interaction.

Self-Hypnotic Relaxation and Imagery: Hypnosis is defined as a state of focused concentration. Absorption in the self-hypnotic process permits dissociation from or reframing of a (painful) reality. It is, in fact, the purposeful utilization of a process that happens naturally. Examples of self-hypnosis in everyday life are absorption in a movie or daydreaming. Relaxation, imagery, and hypnosis are interrelated and are not separable in the nonpharmacological analgesia process. Imagery and self-hypnotic relaxation can be easily introduced even when time is limited. "Where would you rather be" or "Imagine a safe (pleasant, happy, comfortable) place" and instructions to focus on the sights, sounds, smells, feelings of this place may be all that is needed for induction. Focusing the patient's attention by combining an imaginative experience with relaxation breathing constitutes the essence of medical hypnosis.

The goal of hypnosis is to allow the patient's mind to transport to a safe and happy place while the patient's body is cared for in the examination suite. The patient is assisted to become associated with his or her preferred setting. The process can be interactive (the patient participates verbally in communication), or staff reads a script guiding the patient's experience based on knowledge of the patient's preferences. To do the latter well, staff profits from having talked to the patient during procedure preparation and having learned about occupation, hobbies, or the like. If, with more expertise, or for particularly painful procedures (such as biliary drainages or transjugular portosystemic shunts) a deeper state of hypnosis is desired, cues such as ideomotor signals can provide valuable feedback.

Poor Example: The anesthesiologist who provided stand-by for an arteriogram in a patient with suspicion of pheochromocytoma (a condition in which contrast medium injection can elicit severe hypertension, hypotension, and possibly death) did not establish a sufficient relationship with

(101) the patient. Instead, he indulged in his own trip-to-theHawaii-beach-imagery in great detail with no regard for the patient's interests. The patient happened to be afraid of water but was never given a chance to say so.

Good Example: A 19-year-old patient with a liver transplant and stricture in the bile chooses to go to a park of her childhood and to take a friendly stroll. The staff instructs, "Imagine you are here now in the park, in your body, looking out through your eyes. What do you see? Are there any sounds? Can you feel the air on your skin? Is it warm or cold? Are there any smells? How does it feel to be here?" All sensory aspects are addressed in the process.

Once the patient is associated with the preferred place, a deep relaxed breath of the staff can help integrate relaxation breathing with the experience. The patient can be asked "Are you in your body or do you see yourself?" The goal is to give patients an immediate bodily experience of the safe and pleasant environment. When patients experience distressing imagery, it is important to have them see themselves from a distance (as on a screen) and to dissociate from their bodies. The patient is associated with the pleasant situation and dissociated from the unpleasant situation.

Guidance toward imagery that involves little or no movement is best suited for use in the radiology department. Physical action imagery such as skiing, swimming, or running can induce motion and interfere with a procedure or imaging. For example, a patient, whose preferred place was at home, started to rock as if on his favorite rocking chair, making accurate placement of an angioplasty balloon in his diseased legs difficult.

Deepening of the hypnotic state can be achieved by words, including the notion of drifting further "down": a down blanket, fish that are caught further down and down in the water, walking the path further down into the forest, and so on. Deepening can be sustained with a simple "good," or "hmmm" from time to time. Patients who are having their own hypnotic experience can be left without interference for 5 to 20 minutes if no significant changes in the procedure are anticipated. When potentially painful procedure stimuli arise, deepening and appropriate suggestions should be used.

About half of the patients we see present with vivid distressing imagery. The goal is to dissociate the person from the threatening experience.

Some strategies include the following:

* Moving the distressing feeling out and away from the body.

* Viewing the threatening image from greater and greater distance.

* Making it less threatening or removing it altogether.

* Converting it into something manageable.

If, for example, the answer to the question "How do you feel" elicits "As if two vultures are coming down to get me," options include having the vultures fly into the sunset and disappear behind the horizon, having the patient grow into something bigger than the vultures and chase them away, having the vultures become smaller, transforming the vultures into a small photograph in the distance and giving the patient the power to turn the viewing light on and off, or transforming the threatening vultures into an ally by turning them into a cozy, warm down bed.

Use of ideomotor signals can be useful in the procedure room. Ideomotor responses are believed to tap a deeper level of consciousness than is possible with verbal communication (Hammond 1988). The staff teaches the patient to indicate "yes" or "no" by moving a particular finger. The motion of the finger can be very subtle, a minimal motion, or a little twitch. Determination of this mode of communication becomes valuable when talking could interrupt a deeper state of hypnosis or when a patient may not want to speak. Choice of a finger also is helpful when nodding of the head would disturb imaging, such as during MRI or PET scans.

SAMPLE SCRIPT: An example for progressive muscle relaxation, relaxation breathing, and self-hypnosis is given in the following script. The reading of the script can be started when the patient is placed on a gurney in the holding area or on the procedure table. One half to two thirds of the script can already be read while the patient is prepped, draped, and connected to the monitoring equipment.

I would like to invite you to begin, either with your eyes open or closed, by allowing your body to relax and rest comfortably against the table. Now slowly take a breath in through your nose ... hold ... then exhale out through (102) your mouth. Once again, take a deep breath in through your nose ... hold it ... then exhale through your mouth.

Now, as you continue this deep, relaxing breathing, I would like you to notice how just the act of breathing alone can help your body to relax and feel more comfortable. I would like you to continue the breathing, slowly taking a deep breath through your nose, and out through your mouth, and continue focusing on the sound of my voice, and allow yourself to relax completely, feeling calm and comfortable and fully at ease.

As you focus on the sound of my voice, and on your breathing, I would like to do an exercise with you to show your body the difference between tension and relaxation. We can do this by focusing on some of the smallest muscles in your body: the muscles in your eyes. I would like you to continue focusing on your breathing, in through your nose, out through your mouth. And now I would like to invite you to focus on the muscles in your eyes. Tense those muscles as hard as you can. Really allow them to become tight and hard. That's right, really tense. Tighten your eye muscles.

In a moment I am going to count to three, and when I get to three, you will be able to release all the tension in your eyes, allowing them to become fully relaxed and at ease. One ... really feel the tension ... two ... tight, tight, tight ... three. Now, allow your eye muscles to become completely relaxed and limp. Good

Now, notice the sensation of this relaxing feeling. You might experience this as a feeling of warmth, or you might see a calming white light. Now allow this relaxing sensation to flow from your eyes, up into your eyebrows, and now up over the top of your head. Continue breathing deeply, and with each breath, allow the relaxation to spread ... over the top of your head, now down the back of your head, over your ears, and down into your neck. Let this pleasant and soothing sensation now cause your whole head and neck to become completely relaxed and at ease.

With each breath you inhale, you inhale relaxation. And with each breath you exhale, you exhale any tension and let go whatever you want to let go of. Good. Now, allow the sensation to spread down your shoulders ... down your arms and your hands, and right down to the tips of your fingers. Let the relaxation spread across your back, and down through your abdomen ... into your legs, and down through your calves, to the tips of your toes. Good. And now, to show how successful you are at relaxing, I'd like to ask you if there's any place in your body that would like to feel even more relaxed than it already is (wait for response). So take a very deep breath ... hold this breath ... now exhale. This is called a signal breath. It is your way of signaling your body to allow yourself to become even more fully relaxed and comfortable. When you take your signal breath, imagine that you are inhaling relaxation and comfort, and allow that breath to focus on the very spot of your body that you would like to feel even more relaxed. Now inhale relaxation, and allow the exhaled breath to go right to that spot, and breathe any tension right out through the skin at that spot. Let the relaxation and calm replace any feeling of tightness, discomfort, or tension.

Now any time during the procedure that you would like to feel more relaxed and more comfortable, you will be able to remember to use your signal breath to breathe calming relaxation to that spot to help you feel completely at ease. You will notice lots of noises around you during the procedure; people will be talking and moving, the equipment will make noises, and the lights will go on and off quite often. As you are aware of these things, you will be able to allow them to take you even deeper into a state of complete relaxation and comfort.

While the procedure is under way, you may have questions about what's going on around you. You know that you can remain in your fully relaxed state of calm, and still be able to ask whatever questions you would like. I will try to answer them for you, or I will find out the answers for you.

When the procedure is over, or whenever you decide, you can return to your regular alert state by simply counting from one to three, either in your head or out loud. When you do this, you will find that even in your alert and fully attentive state you will continue to benefit from the calming sense of relaxation you now feel. And you can return to this place of calm whenever you like, by simply closing your eyes for a moment, counting back from three to one, and taking your signal breath. (103)

TROUBLESHOOTING: Resistance to Imagery: Some patients may claim that they are incapable of imagery, which does not necessarily mean that they cannot be guided toward imagery-based mental activities. In these cases alternative words or inductions can be used. "Do you dream?"; "Would you like to have a nice dream during this procedure?"; "Where would you rather be?"; "Is there any place you always wanted to go?"; "What do you like to do?"; "Do you have fantasies?" In general, patients will follow with some type of description in which they can be directed to experience all sensory dimensions. Some patients may choose scenes that are action oriented. For example, they may choose to go fishing and take the entire operating team with them, or go gambling to Las Vegas, or visit with friends. Topics from small talk can be brought up and the patient can be instructed to elaborate on the event. One patient, for example, told the story of his honeymoon that occurred 50 years ago and described many details in an imagery-like process. It is worthwhile to search for a wording or a concept for imagery that is acceptable to the patient. Another patient, a young male veteran who resisted all other approaches, was finally asked to describe his home. Arriving at the kitchen, he was instructed to list the contents of his refrigerator. He suddenly showed interest and described all the food there in great detail and all the dishes he could prepare, becoming fully absorbed in a self-hypnotic process.

Resistance to Self-Hypnosis: To let go into a state of relaxation and self-h.ypnosis requires trust. The process of relaxation or imagery may be under way when something prevents progress. In this situation it is best to ask, "What do you want?" or "What is stopping you?" Some patients reveal their concerns faster than others.

CONCLUSIONS: Nonpharmacological analgesia in the radiology department is a worthwhile endeavor that enhances the patient's experience and satisfaction with service provided. Increased procedure safety and improved resources utilization are additional potential benefits. Implementation of hypnotic techniques in medicine requires a paradigm shift. Radiologists have repeatedly pioneered new diagnostic and therapeutic modalities that subsequently have been adopted by other specialties. The radiology department is an ideal setting to introduce mind-body therapy into conventional "high-tech" medicine. (104)

[Eleanor D Laser, Ph.D.: Specialties: Hypnotherapy, Chronic Illness, Smoking Cessation, Eating Disorders, Mind-Body Therapy, EMDR, NLP, Anxiety, Phobias. MIND BODY THERAPY: AN ALTERNATIVE THERAPEUTIC METHOD: Specializing in therapeutic techniques which specifically help patients identify the origin of their problems. The client is regressed to the origin of the symptom which developed in early experiences. These early memories can be reimprinted. The symptoms disengage and become desensitized. With this type of therapy, patients immediately understand how patterns manifested themselves and caused problems. The link between past and present behavior is readily understood, and can be changed. The brain works like a computer. New input can be inserted, and the old deleted. A new framework is developed. Now the patient can make positive choices and the new behavior can take over. Since old patterns are interrupted, the patient not only feels relieved but experiences a new sense of well being. Using techniques such as medical hypnotherapy, neuro-linguistic programming (NLP), eye movement desensitization and reprocessing (EMDR), and Adlerian Psychology. The following are some health related mind body symptoms that this work can alter: *Allergies. *Eating Disorders and Weight Loss. *Headaches. *Hypnosis for Labor and Delivery. *Surgical Hypnosis *Panic Attacks. *Phobias. *Smoking Addictions. *Anxiety and Stress.]