5th August 2020
An Elliotson Prize essay by Dr John Duthie.
It was a fine, crisp, Friday morning in spring, as I skipped gaily into the Dental Practice in a part of Liverpool, soon to be ‘termed’ a ‘European Area of Deprivation’. My first patient was a woman who complained of a sore mouth. She skillfully ‘palmed’ her full dentures from her mouth into her pinafore pocket in one seamless movement and sat back and opened her mouth. The yawning chasm immediately displayed a range of oral pathology that would cause any recently qualified dental surgeon to regurgitate an entire text book of terms. There was every kind of fungal presentation, atrophic mucosa, speckled leukoplakia, a large suppurating ulcer with raised, rolled edge and a tongue like a map of the world.
I duly regurgitated the text book to the patient along with the advice to leave the dentures out, rinse with salt water, apply the foul tasting ointment I prescribed and come back on Monday.......
She failed to return. This created in me, a range of emotions including anger, guilt and panic.
She was contacted and attended three weeks later. She was unrecognisably better to the extent that I doubted what I had seen. I then proceeded to congratulate myself by saying “I told you the foul tasting ointment would help”. To which she replied “Oh. It wasn’t that. I went to see Letty. She gave me a flat mushroom and told me to suck this onto the roof of my mouth of a night, and another thin mushroom to put in my teeth during the day.”
This caused me to have much the same emotions with adrenaline, noradrenaline and cortisol release as my last encounter with this patient but for a different reason.
I regained my composure and asked if it would be possible to speak to Letty about her case.
The British Society for Medical and Dental Hypnosis Foundation course was the first postgraduate course that I attended after qualification in 1975. It was the perfect preparation for my first encounter with the ‘White Witch of Wavertree’.
Letty was about 85 years of age at the time and had served the community as a ‘wise woman’ since returning from the Great War. She had silver hair, a broad beaming smile and all her own teeth. I had visited her to discuss the rationale for advising my patient to “suck a mushroom”!
I explained my concerns to her, she smiled, extended her hand for me to take and indicated for me to sit down. She placed her hand over mine and said “Mr Denis ( all dentists in Liverpool are referred to as ‘Denis’! ), I want you to imagine that you are one of your patients….and I want you to pretend….”…..
Oh yes, she was very good.
She explained, “the trouble with you young doctors and dentists is that you think that if you
give things labels; you know everything - but you don’t”.
“How else was I going to get a young woman like that to leave her teeth of a night”. “And, Mr Denis, if you smear your ointment on the mushroom; they’ll not notice”!
The community respected Letty. It was only the doctors, dentists and pharmacists who disparagingly and incorrectly labelled her “the White Witch of Wavertree”.
The White Witch used body language, built rapport, used pacing and leading naturally. She used it as a standard way of communicating all the time; with everyone. Using these principles of hypnosis, she empathised with peoples problems, spreading happy feelings with her infectious smile, getting them to imagine being better as she handed over a remedy or reassuring them that their GMP had given the right advice. When they left the doctor they felt worried; but after 5 minutes with Letty; they felt better. What a shame that I didn't hand over the prescription with the same care and hypnotic technique rather than a misplaced belief that the drug would do everything, ignoring the placebo effect and assuming she would follow instructions because I was a professional.
So, is there a rationale for using either of these terms?
Hypnosis is the established term we use to describe the range of techniques we employ as tools to enhance healing and well-being. Personally I don't’ like the term as it implies ‘sleep’; which it is not. The term has as many definitions as people reading the essay but the concept is understood and not open for discussion.
It is more difficult to define where bedside / chair-side manner stops and hypnosis starts. Professionals who understand hypnosis use hypnotic technique with patients in shock or who are acutely anxious; but we don’t label it. People who are good nurses use it unconsciously; and can’t label it.
This is ‘the therapeutic use of hypnosis’ as a tool.
In my view, there is no such thing as ‘Hypnotherapy’. Hypnosis is a tool; not a therapy. Hypno- infers sleep; it is not sleep. The term shows a misunderstanding of both the term ‘hypnosis’ and the term ‘therapy’.
Despite this, the term ‘Hypnotherapy’ has entered the vernacular and is here to stay. However, it would be best if we restricted the term to refer to what non-medical ‘Hypnotherapists ‘on the National Hypnotherapy Registers do.
Hypnosis was a term introduced to get away from the term ‘animal magnetism’. With our knowledge of electromagnetic fields of the heart and brain; maybe ‘animal magnetism’ was not as far from the mark as first thought.
Cognitive Behavioural Therapy is accepted via NICE guidelines for NHS referral. Unfortunately, Hypnosis and Hypnotherapy are not. If CBT was delivered with hypnosis as the therapeutic tool it would be more effective.
In contemplating this discussion, I find myself sat in tree; like A.A. Milne’s Christopher Robin, watching his friends Pooh and Piglet walk earnestly round a group of trees wondering if they were tracking two ‘woozles’ and a ‘wizzle’ or two wizzles’ and a ‘woozle’. Both in great danger of falling into their own ‘heffalump trap’ and getting caught with their head in honey pot; so to speak.
The problem with the label ‘Hypnosis’ is that it suggests it is an entity whereas in fact it is a wide range of states. If we use it as a ‘proper noun’ we may fall into the same trap as ‘Hypnotherapy’ and allow it to become the subject of medico-legal litigation.
Use of the term Hypnotherapy by doctors and dentists is counter-productive. The use of hypnotic technique should be part of an over-arching holistic philosophy which is used at all levels of healthcare interaction.
In healthcare establishments it would be better to use the term ‘therapeutic use of hypnosis’. Anaesthetists in particular can use hypnosis as a therapeutic tool to reduce anxiety in children and adults; to reduce the dosage of drugs required and deliver suggestions during both the induction of sedation or anaesthesia and also at the time the patient emerges. Positive reinforcement will help. The use of hypnosis during operative procedures will be beneficial to both the patient and the surgical team. This is not Hypnotherapy.
The term Hypnotherapy has become a ‘proper noun’ and requires an explanation of - what it is, an informed consent, a complaints procedure, a code of ethics and a contract. It is no wonder a hard pressed GMP doesn’t think of using it or feels they have to refer to someone with more ‘time on their hands’! Then, they have to worry about vicarious negligence of referring to someone who may be insufficiently qualified or experienced. Best be safe and refer to a Consultant Psychiatrist or Clinical Psychologist. Where is the ‘White Witch of Wavertree’ when you need her?
So to summarise, paraphrase, reflect and ensure that you hear what I am saying:- The term Hypnotherapy is not an appropriate word in Medical and Dental settings. Hypnotherapy is the realm of the ‘Hypnotherapists’.
Hypnosis should be used as part of a phrase and not as a ‘single’ term. The word should be used a sparingly as possible.
Hypnosis training should be incorporated into an over-arching philosophy to deliver a holistic approach throughout the healthcare sector.
In this way, hypnosis can be used as a therapeutic tool in rapid intervention in general medical and dental practice.
The debate about which terms to use and when, has been going on for some time. We are in danger of coming up with a ‘consensus view’. It is my opinion that this would be a mistake as the ‘consensus view’ by definition will tend to be wrong most of the time. It just confirms that no-one can agree.
We should heed the warning of the “White Witch of Wavertree” and be careful not to label and define things too rigidly, lest we forget that - we don’t know everything. We should remember her advice; otherwise we may fail the communities we serve.