Helping Clients Prepare for Medical Procedures
by Judith E. Pearson, Ph.D.
Karla called me with a hint of panic in her voice. "I want an appointment to see you right away. My doctor has scheduled me for surgery in two weeks. I've never been in a hospital before! I feel terrified!"
I scheduled an appointment as soon as I could. Karla (not her real name) had been my psychotherapy client for two years and in that time she had made remarkable strides in her life. She had stopped using illegal drugs, left an unsatisfying intimate relationship, found a better-paying job, and was creating a circle of supportive friendships. Now she faced a new challenge. The prospect of surgery was terribly frightening for her, not just because it was the unknown, but because it activated emotional remnants of an abusive childhood. The prospect of general anesthesia evoked the remembered terror of having someone else in control of her body, and the necessity of a long bed rest during recovery recalled fears associated with previous episodes of pain, loneliness and abandonment. No wonder she was upset!
Over the past few years it has been my privilege to work with clients facing various medical procedures, and to apply NLP in helping them overcome unrealistic fears, relax more easily under anesthetics, and have a smoother recovery. My interest in this regard actually began several years ago, when a friend elected to have some minor surgery. Her physician routinely recommended an overnight hospital stay, with general anesthesia for the operation. She bargained for an outpatient procedure at the hospital, with local anesthesia and pain relievers, promising to use deep relaxation techniques during the operation. Her physician was dubious, but agreed to the request, with the condition that he could use any measures he deemed necessary in the event of a medical emergency. The operation was a success. My friend was awake the whole time, and went home that evening.
In recent years, numerous books and articles have described the beneficial effects of hypnosis, relaxation training, and guided visualization for medical patients before, during and after surgical interventions. This article will describe some ways in which NLP practitioners can apply their skills to help clients undergo medical procedures with minimal discomfort. The material here in no way states or implies that NLP or any form of psychotherapy should replace medical procedures or properly prescribed medications. I advise NLP practitioners to encourage their clients to take a proactive role in their own medical care, seek appropriate medical advice and opinion, and work cooperatively with their medical team for the best possible treatment and recovery.
This article is primarily about clients who have a reasonable probability of survival, and not those who have been labeled as "terminal." or whose prognosis is extremely poor. These clients may have additional difficulties, needs, and sensitivities that I will not address here. I hope NLP practitioners who work with the latter group will submit future articles to Anchor Point to share their methods and learning.
Fears and Phobias
Many people have unrealistic fears regarding medical procedures. No one enjoys pain or discomfort of course, but for some, the anticipation is so terrifying they may actually avoid getting necessary and/or life-enhancing medical care. Common phobic stimuli include needles, the sight of blood, the antiseptic smells of a hospital, or the white coats of medical personnel. For some people, like Karla, medical procedures revivify traumatic childhood experiences or touch off memories of previous injuries and pain. When working with clients who have been abused and/or who have issues with control, I avoid any implication that they should be passive or submissive with their physicians. Instead, to respect their ecological issues, I carefully suggest that they can take an active interest in their health care, playing a vital, unique role in partnership with medical personnel.
For fearful clients, begin by reframing the fear. Point out that fear is a natural reaction based on innate survival mechanisms. Help the client appreciate that a part of the self wants to ensure survival, avoid pain, and promote comfort and safety. This part needs to understand that the medical procedure is desirable for long-term benefits and that the client can learn many ways to minimize pain and maximize comfort -- and one way is to relax and cultivate feelings of inner security. Then spend a session with your client using a post-trauma anxiety reduction method such as Visual-Kinesthetic Dissociation (Bandler, 1985), Eye Movement Integration (Andreas and Andreas, 1991), Thought Field Therapy (Gallo, 1996), or the Fast Phobia Method (Andreas and Andreas, 1989). Begin each intervention by installing anchors for inner security and be prepared to gently interrupt abreaction, should it occur. Throughout the procedure, give consistent reassurances and encourage the client to carry resources and resources into the future, during the hospital stay. Once you've helped your client reduce or neutralize fear, then you can move on to some of the additional methods described below.
Resources for Healing
In Heart of the Mind (1989), Connirae and Steve Andreas describe a method for engaging the body's natural ability to heal. I often borrow from this method to help clients "future rehearse," their hospital stay. First I clear all ecological considerations in advance. Is there any reason the client needs to be ill or in pain? Is there any part of the self that would object to minimal pain and a timely recovery? Then I discuss all concerns and considerations with the client, helping the client seek alternatives for implementing positive intentions (See Reframing by Bandler and Grinder, 1982).
Next I anchor feelings of inner security and ask the client to search out a time in the past when he or she recovered or healed satisfactorily from an illness or injury. It helps if the past event bears some resemblance to the current situation. For example, I recently worked with a woman about to undergo epidermabrasion, who chose as her reference event a time when she healed from bad sunburn. Then you can conduct the following steps on the client's timeline.
1. Ask the client to step off the timeline, move back along side the timeline and review the past event (the previous illness or injury), stepping into the healing phase. Anchor the healing phase. To intensify the anchor, ask the client, "How did you know you were getting well? What did you notice, think, and feel?"
2. Ask the client to move off the timeline and return to the present. Apply the anchor for healing and tell the client to travel forward through time into the future, holding onto the anchor, through all the medical procedures, past the recovery period, until the time they are well again. Then have him or her look back and see all they accomplished along the way, and how the ability to heal was always there. Release the anchor for healing.
3. Have the client move off the timeline, moving back toward the present, and reorienting to the present. Remind the client to appreciate his or her healing abilities.
Occasionally you might encounter a client who has a limiting belief that could interfere with optimism about healing and recovery, and that belief may be increasing the client's stress. Unrealistic beliefs may take the form of "I deserve this illness," or "I'll never get well," or "Others in my family have died from this, so I will too." In Beliefs: Pathways to Health and Well-being (1991) Robert Dilts addresses many methods for helping clients overcome such beliefs. Applicable belief change methods include Reimprinting (Dilts 1991), timeline interventions (Woody, 1996), submodalities methods (Bandler and MacDonald, 1988), and the Walking Belief Change Pattern (McDonald, 1994).
When I wrote my doctoral dissertation in 1983 I investigated the role of social support in relation to other health factors. I found over 80 journal articles documenting research indicating that social support has a beneficial role in health and healing. Encourage your clients to access and mobilize their social support networks as an external resource. If your client is a child, or an infirm individual with special needs, you may want to include family members in your sessions. You can also encourage the client and/or the family to work with appropriate hospital staff such as medical social workers, family and child life coordinators, and psychiatric nurses, who can help make the patient's hospital stay more comfortable in many ways.
Honoring Body, Mind, and Spirit
Many cultures engage in healing rituals that call upon the healing powers of the body, mind, and spirit. While the role of spirituality is sometimes absent from today's modern operating theaters, there are still many patients who derive comfort from their spiritual beliefs and rituals, during times of illness. The emerging interest in alternative therapies and holistic medicine speaks to the need to honor the spiritual and metaphysical aspects of healing. For some patients, there is reassurance in knowing that friends and loved ones hold them in their prayers during times of illness, and many believe that prayer provides healing assistance. Others envision guardian angels or spiritual entities ready to help them back to health. For some, the return to health takes place through an attunement of the body's healing energies. What the mind believes, the body can make come true.
As NLP practitioners, we can assist our clients in confronting their illnesses, and throughout the course of medical intervention and healing, by honoring their spiritual beliefs, and integrating those beliefs in mind-body work. Drawing upon the work of many metaphysical and spiritual healers (Hay, 1984; Holmes, 1949; Silva and Stone, 1991; Matthews-Simonton, Simonton, and Creighton, 1984), I have devised a Healing Meditation visualization process for clients who are preparing for medical procedures. The purpose of this visualization process is to help clients honor their spiritual beliefs about healing, engage their body's own healing energies, draw upon resources from previous healings, and future rehearse a successful recovery. The following paragraphs will describe the generic visualization process, which you can modify to accommodate the needs of individual clients.
The process begins with a short interview, asking the client for information which you will later incorporate into the visualization process. The interview consists of these questions:
Do you consider yourself a spiritual person? If so, what aspects of your spirituality or spiritual beliefs do you want to use as resources to help you through the medical procedure and on into the recovery process? Are there other people who love you and care about you and are helping you in some way? Who are they and how do they help you?
Note: As your client accesses the positive feelings that come from these resources, anchor the feelings (an auditory anchor is probably best here).
If you could visit a safe, healing place, real or imaginary, what would it be like?
Ask specifically about colors, surroundings, lighting, sounds, temperatures, smells, tastes, and even tactile sensations associated with this healing place.
Is there some person or entity you'd like to have with you in this healing place?
Examples are guardian angels, helpful spirits, departed or distant loved ones, animals, mythical figures, or religious personages.
If you could see your body's own healing energy, what would it look like? Where, in your body does it originate, and what are its dimensions and colors?
After the interview, get a congruent contract from the client to engage in a trance-inducing visualization process, clear all ecological concerns about the procedure, and ask the client to get comfortable and relax. Begin with almost any trance-induction process of your choosing, making suggestions about relaxation, comfort, safety, and an inward focus. You may choose to install anchors for security and safety and maintain them throughout.
The Healing Meditation
1. Ask the client to visualize his or her healing place. Help the client to focus on visual, auditory, and kinesthetic details from his or her previous description, obtained from the interview. Suggest ways to heighten the experience by intensifying the submodalities in comfortable ways.
2. Remind the client of his or her spiritual resources. Describe those resources and apply the anchor.
3. Suggest that the healing companion(s) can now join the client in the healing place. These companions can relate to the client in comforting ways. These ways might include, sitting beside the client, engaging in some activity with the client, walking beside the client, speaking or singing to the client, or perhaps offering some symbolic gift.
4. Suggest that the client can imaging sitting or resting in the healing place, and having a conversation with his or her body, in the following ways:
First, thank your body for all it does for you. It works hard for you, day and night without your having to remind it, to digest food, keep your heart beating, circulate your blood, conduct elimination, respiration, and a number of other complicated processes. Thank your body for all the good things it is doing for you right now as you are relaxing here and visualizing a healing place.
Note: If the client will be undergoing treatment for a diseased or malfunctioning organ, remind him or her that the other organs, muscles, and bodily systems are doing just fine, in spite of the problem. Encourage the client to appreciate that so many parts of the body continue to function, even though some parts are sick or injured. This is a way of "chunking down" the problem, so that it may seem more manageable or, at least, less overwhelming.
Second, remind your body about other times in the past when you were hurt or injured and your body healed or recovered. Remember how your body let you know that you were going to get well again. Remember your expectations of getting well, and the pleasant discoveries about your body's ability to heal. Praise your body for its healing abilities and remind it to use those healing abilities again.
Third, gently explain to your body the necessity for the upcoming medical procedure, and tell your body the outcomes you want, before, during, and after the procedure.
Note: Depending on the medical procedure, desirable outcomes might include maintenance of normal breathing and heartbeat during surgery, minimal bleeding, only moderate swelling, optimum functioning of the immune system, efficient dissipation of the anesthesia after surgery, and a restful, timely recovery, with minimal pain or discomfort.
Send loving messages throughout your body, especially to the parts that are in need of help and attention.
5. Suggest that the client can visualize a healing, comforting, protective glow surrounding his or her body, as the body activates its positive energies and internal wisdom.
6. Self-appreciation: Ask your client to appreciate that he or she has the capacities to seek help, activate his or her own resources, confront challenges and move beyond them.
7. Build positive expectations: Future Pace the experience of resources, coming through the procedure, recovery and healing. First, tell the client to thank their healing companion(s) for being present, and ask the companion(s) to watch over him or her before, during, and after the medical procedure. Second, suggest that the client can memorize the details of this healing place so that the unconscious mind can return to this place again and again in the days and weeks to come. Have the client create a dissociated image of a future self, in fast-forward time, who successfully completes the medical procedure, manages a timely recovery, takes care of the self in healthy ways, and is eventually well again.
Note: Do not automatically assume your client wants or needs a "speedy" recovery. Recovery takes time. Recovery rates vary, and a client may welcome the rest. Some clients may feel unduly pressured if asked to have a speedy recovery, or even a recovery that is time-specific. Ask your client to appreciate that the body has the wisdom to recover on its own schedule.
8. Reorient the client to alertness and conscious awareness of immediate surroundings.
You can adapt this procedure for children by having the child draw or paint pictures of himself or herself in the healing place, surrounded by loving family members, with the healing companions, and enveloped in a healthy glow. The child can draw, act out, sing songs about, or watch an imaginary movie of going to the hospital, meeting the doctors, waking up after operation, resting and getting better every day, going back home, getting well, and eventually returning to normal activities. HOORAY!
You can also facilitate healing through the use of therapeutic metaphor and storytelling, a ritual which adults enjoy as much as children. Healing metaphors can feature characters that represent body parts and functions. The immune system, for example, might be characterized as an army that chases away invaders, or perhaps as the street cleaners, who sweep up the streets of debris after a ticker-tape parade. In a 1993 issue of Anchor Point, Robert Fletcher presents a healing metaphor in which he portrays the patient's body as an ocean liner that has just run into a storm at sea. The Captain calls upon various officers, such as the Chief of the Boiler Crew, Chief of Maintenance, Chief of Sanitation, Chief Navigator, etc., to quickly repair damage, clean up debris, tighten all fittings, maintain pressure, and keep the ship afloat for passage into a safe port.
The roles of ritual and symbology are often overlooked methods for healing. Ask your client about healing rituals and symbols within the context of his or her ethnic traditions, religious practices, and personal and/or family mythology. Additionally, your clients may want to borrow rituals and symbols from other cultures, or make up their own. Explore with your clients how they may incorporate these rituals and/or symbols into the preparation and recovery process.
Suggestions for Hospital Personnel
Physicians and medical personnel are becoming increasingly receptive to the possibility that the mind can play a vital role in the process of healing and recovery, and that a patient's expectations can influence medical outcomes. Research conducted during the 1970's showed that patients rating high in anxiety fared worse during their hospitalizations than patients with low anxiety. High anxiety patients needed more medication, had more post-operative difficulties, and spent more post-operative days in the hospital (Cohen and Lazarus, 1973; Goldstein, 1973).
Physicians and medical personnel can allay a patient's anxiety through rapport building, by explaining procedures, thoroughly answering the patient's questions, and addressing the patient's ecological issues. In Love, Medicine, and Miracles, Bernie Siegel, M.D. eloquently stated that a physician must help patients maintain a fine balance between realistic expectations and hopeful optimism. Siegel states that the physician's attitude is an essential element in establishing rapport with patients, influencing a patient's emotions, and in promoting recovery, even when a patient is asleep, in coma, or under anesthesia. He cites studies by physicians, including Milton Erickson, showing that under anesthesia, patients respond to known voices. Siegel states that he informs his patients about their medical status, and encourages positive responses when they are in a coma or under anesthesia. The unconscious mind always listens.
Several surgeons have now begun using the anesthetized mind's powers to help prevent complications.... In the operating room, I'm constantly talking to patients about what is happening....Talking reassuringly to patients who are having cardiac irregularities during surgery can reverse irregularities or slow a rapid pulse....Many anesthesiologists...have begun speaking to their anesthetized patients, giving them calming messages....It is especially important to avoid negative messages because the anesthetized patient's conscious defense mechanisms aren't functioning. I always make sure that operating room personnel don't say anything they wouldn't say if the patient were awake.
Siegel recommends that physicians make positive statements to anesthetized patients, suggesting, for example that the patient can reduce bleeding, or that he or she will wake up feeling comfortable. In some operating rooms, upon their own request, anesthetized patients are now allowed to use headphones to listen to tapes of soothing music, or instructions for relaxation and healing. NLP practitioners can even tape record the Healing Meditation described above, and have the client listen to the tape up until the time of surgery, or perhaps even in the operating room, if the physician agrees.
NLP practitioners can educate medical personnel regarding ways to facilitate rapport and to make the unconscious mind an ally in the client's recovery. One way we can accomplish this is through speaking engagements and by networking with medical personnel in our communities. We can encourage our clients to seek physicians who respect the healing power of the mind and are willing to utilize it to the client's advantage. We can even coach our clients on how to interact with medical personnel to get answers to their questions, state concerns, and use respectfully assertive methods to have their needs addressed.
Post-operative Follow-up
Your clients can also benefit from NLP interventions after the medical procedures are complete. Ask your clients to come to your office for a follow-up therapy session after the hospital stay or outpatient procedure. Plan to celebrate even the smallest victory and reinforce positive learning. You can also address post-operative issues, such as pain management, grief work, and trauma.
You can assist clients with pain management through the use of submodality interventions; Submodality interventions help the client to visualize (versus feel) the pain----its size, shape, color, texture, substance, weight, location and density. By changing these submodalities, and calibrating the client's response, you can teach your client to decrease pain for varying periods of time. To measure the success of pain management interventions, ask your client to scale the pain on a scale from one to ten, before and after each intervention. The difference in the rating will provide feedback on the effectiveness of the method. Vary the methods until the client achieves some reduction in pain.
Relaxation can also alleviate pain, because some pain results from muscle tension accompanying anxiety about having pain. For some post-operative clients, I tape-record our relaxation training sessions so the client can listen to the tape at home. When clients learn NLP pain management methods, they require fewer pain-relieving medications, and have fewer of the associated side effects from those medications.
You can accompany relaxation with pain management metaphors built around analogies for (1) numbness (Have you ever played in the snow for so long that your hands were so cold that you couldn't feel your finger tips?) or (2) ignoring/distraction (You can be wearing shoes, but not even feel them on your feet for a time, because you are busy paying attention to other things instead) or (3) forgetting to remember (Sometimes you can stub your toe and it hurts, until you get involved in a really good conversation or an intriguing movie, and you forget all about that stubbed toe for a while.). When talking to your client about the future (future rehearsal) suggest that in the days and weeks to come, he will often be surprised about how often he had forgotten to remember to think about the pain.
Following a hospital stay, some clients may benefit from grief work. Grief work is not just for the loss of the loved one. Illness or surgery may bring the loss of a body function, a physical capability, or a body part. A person who is recovering from a serious injury or illness may mourn the loss of the illusion of immortality. Connirae and Steve Andreas describe NLP grief resolution processes in Heart of the Mind (1989; also see Watson, 1993). The method primarily involves mapping across submodalities from a resolved loss to an unresolved loss. Ron Klein (1994) also describes a grief pattern, called Good Grief, that relies on metaphors and anchored resources to move the client through the grief process.
Illness and injury can be traumatizing, and surgery and other medical procedures can sometimes leave emotional scars, no matter how well one prepares for the ordeal. If your client seems unduly emotionally troubled as a result of the medical procedure, apply one of the post-trauma anxiety reduction methods mentioned earlier in this article.
Conclusion
At the time when I was working with Karla, my methods were less well defined. I saw her for one session before her scheduled surgery, and discussed her fears. Then I helped her anchor a sate of security and invited her to relax and imagine herself in a lovely place of healing. I asked her to remember previous times when she had been ill, and had eventually become well. I asked her to take the security and relaxation into the future and mentally rehearse everything she thought would happen at the hospital, in fast motion, getting all the way through the ordeal until she was at home again in her own bed.
She called me two weeks later, from her bed at home. While she was still in some pain and discomfort, and complained about the inconveniences of extended bed rest, she was triumphant in the knowledge that she had survived. She spoke with pride about how she had bravely coped with the operation, and about the interesting things she had learned about medical procedures, and about how the hospitalization was a terrible experience, but not as traumatic as she had originally imagined. She had found a deeper appreciation for her own resilience.
Whenever we work with clients undergoing medical procedures, it is important to remember that unforeseen difficulties do arise and there are no guaranteed cures. While we can approach our work with faith and optimism, we cannot and should not make grandiose promises of health and recovery. We can help our clients increase their comfort, and at least promote the hope and/or possibility that their bodies will make the best possible choices. Ultimately, all healing is self-healing.