Abstract

Patients, as well as the general public, are often limited in their perception of the mind-body connection. When viewed through the lens of behavioral medicine, it is often thought of as treating symptoms that are “all in the mind.” This conscious view or, perhaps more often, subconscious view of modalities such as psychoneuroimmunology (PNI), clinical hypnosis, and self-hypnosis training, and related complementary modalities limit patient participation and responsiveness to treatment. The purpose of this paper is to highlight the direct impact of the mind-body connection and related treatments upon the physical health of the patient in such areas as cancer, diabetes, hypertension, etc. Thus, it is not all in the mind, but very much in physical bodies with scientifically verifiable diagnoses.

Introduction to Integrative Medicine

The interactive effect found when measuring several treatments, for example in working with pain, stress, hypertension, cancer, or just about anything that causes suffering in the human person, is a response to treatment wherein “the whole is greater than the sum of its parts.” Simply put, if one factor is about changing a food plan for a type two diabetic patient, and a second factor is motivation, and a third is positive expectation, the probability of those factors interacting together for a positive outcome is considerably higher than if only one of those factors is present. My reading of the literature and my own clinical experience has found this to be very much the case when utilizing psychoneuroimmunology,¹ which we can call simply PNI for convenience’s sake.

Specifically, utilizing clinical hypnosis and self-hypnosis training in combination with PNI is what I am suggesting herein. Additional modalities such as clinical nutrition, exercise, Eastern practices, such as qigong, and the use of supplements, can be used to foster a positive interactive response as well. This writer has long surrendered to the struggle of trying to parse out the strength of the various factors when employing a multimodal approach to healthcare. While grateful to those scientists who do this type of research, being more of a clinician, I simply celebrate the progress of my patients as I embrace the often-unknown weights of the various factors involved.

Kelly Turner² lists nine key factors found in people who have survived and flourished after dire diagnoses (often cancer but other conditions as well) after she literally traveled the world to study people documented to have had this experience. These factors include the following:

• Radically changing your diet
• Taking control of your health
• Following your intuition
• Using herbs and supplements
• Releasing suppressed emotions
• Increasing positive emotions
• Embracing social support
• Deepening your spiritual connection
• Having strong reasons for living

What is fascinating about her findings is the fact that there were a variety of medical conditions, a variety of treatments, cultures, and conscious and subconscious attitudes involved, yet they all responded favorably. This is integrative medicine at it’s best, not limited by prejudices such as biopsychosocial interventions only working on “all in the mind” psychological conditions and not on verifiable medical situations. I prefer the word “integrative” to “complementary” because the latter can suggest an “add on” to “real” treatment; and behavioral medicine using PNI is indeed real and effective treatment, as the people Kelly Turner studied demonstrate.

Psychoneuroimmunology (PNI): What It Is and What It Is Not

It is generally accepted that our immune system is suppressed by stress. Such suppression makes us vulnerable to a wide variety of health challenges. A common example is that when we are physically run down, we catch a cold or the flu more easily and it can take longer to resolve. When our immune system is working well, it identifies sick cells and removes them. We all have cancer cells that are dealt with in this fashion. When this process is not working up to par, we get sick, and that is when people get diagnosed. Managing stress allows immunity to function optimally and lowers the probability of getting cancer, for example, along with many other disorders. PNI is a natural, non-invasive mind-body way of boosting immunity in order to help lower the probability of illness.

Oncologist O. Carl Simonton³ offers readers a clear and compelling rationale for utilizing PNI as at least one tool for a return to maximal health. He and his fellow authors and researchers provide some simple exercises one can employ, along with a host of science-based references in an extensive bibliography in his writings.

This is how my love of PNI began. I remember being at a Society of Behavioral Medicine conference in the early 1980s and viewing case history slides of a little girl’s eye returning back into its socket as a tumor shrank behind it—an eye that surgeons wanted to remove. The homework this child was faithful to was simply squeezing an eyedropper in a bowl of red food coloring and thinking about it taking away the “bad blood” (her words) from behind her eye. Since it was so long ago and was early on in my career, I do not recall which faculty members presented the above case or the one that follows; but such luminaries as Jeanne Achterberg, PhD, Robert Ader, PhD, Gary Schwartz, PhD, were on the faculty, andt I am clear that I have reaped the fruit of those early experiences ever since.

We were also shown scans of the brain of a little boy and watched the inoperable tumor in the center of his brain shrink into a little white dot. When his dad asked him why he didn’t want to play the Star Wars visualization game of getting rid of a foreign invader, the little boy said that all he “saw” now was a white dot.

Helping to heal the body directly through the power of the mind, imagination, words, etc. was something I have long been fascinated with. Being at that conference solidified my call to work as a clinical psychologist in the field of behavioral medicine, specifically PNI, which I have done throughout my life and continue to do decades later. Thus, I strongly support continuing education, journal reading, and professional workshops beyond formal training.

It is important to work within the parameters of one’s scope of practice, as well as ethically and legally. One never undercuts or disparages other professionals also working with the same patient. Nor does one make unsubstantiated claims. Simply and clearly presenting information about modalities, such as PNI, that might be useful for a person is appropriate. This is also empowering to people who feel at the mercy of a system that is sweeping them along like a leaf in a whirlwind over which they feel little control.

Decades ago, cancer patients came to me after extensive chemotherapy, radiation, and/or surgery. They were typically extremely weak and professionals such as me were thought of as a last resort, or perhaps palliative at best. Today, given advances in medicine and better collaboration among various types of professionals, referred patients or those who seek me out by themselves are often stronger and somewhat more optimistic at the outset of treatment; and prognosis is therefore much better.

Clinical Hypnosis and Self-Hypnosis Training

A tool which I have found to be the perfect complement to PNI is clinical hypnosis, along with self-hypnosis training. The term “clinical” implies that this modality is being utilized by someone trained and licensed to diagnose and treat illness, as distinct from stage hypnotists who use hypnosis for entertainment. The Society of Psychological Hypnosis (Division 30 of the American Psychological Association) defines hypnosis as “a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion.”⁴ Various definitions have been crafted over the years by a variety of professional organizations, but they generally include some suggestion of an altered state of consciousness through focused attention, and nothing mystical or implying the controlling of the will of another.

The unique neurological wiring of some people empower them to visualize scenes easily, others are more auditory such that they can imagine the sound of ocean waves or leaves in the wind, yet others are more kinesthetic and they report feeling sensations such as lightness, heaviness, expansion, or floating in the physical body. The clinician utilizes these tendencies when evoking trance in the patient as well as when providing hypnotic suggestions. It is crucial that good patient education free the patient from stereotyped expectations such as one needs to have a blank mind, be a good visualizer, or that hypnosis is a battle of wills. The patient is encouraged to have his or her own unique experience of trance and see it as activating a capacity within him or her with the clinician simply as a guide to access this innate capacity.

Excellent training and respected credentialing are available through the American Society of Clinical Hypnosis (www.asch.net). This multi-disciplinary organization offers training throughout the country and an annual convention. Comprised initially of doctoral psychologists, physicians, and dentists, it now embraces other professionals such as licensed counselors, social workers, and nurses. This diversity of membership exemplifies the integrative nature of the modality under discussion and adds to the richness of training and membership therein.

How a Session Flows

When we initially meet for treatment, I take the usual history and instruct the patient on what PNI and clinical hypnosis and self-hypnosis training are and are not. I cannot emphasize enough the need for good patient education concerning clinical hypnosis, which includes dispelling myths and utilizing language that empowers the patient. APA Division 30 offers a downloadable handout about hypnosis called “Hypnosis: What it is and how it can help you feel better.” It is available at https://www.apadivisions.org/division-30/about/hypnosis-brochure.pdf.

During history taking and in all subsequent conversations, I listen for patient areas of interest which I can later utilize in the hypnotic induction and suggestion phases of treatment. Things such as flying in an airplane, going to the beach, and visiting grandchildren are thoughts many people resonate with well.

Please remember to keep in mind the fact that hypnosis can be done without formal induction, because trance is a normal part of life. Examples of this type of trance include times when we are fascinated by a sunset, or lost in a book or movie. “Guided imagery” or “a guided meditation” can be useful terms to employ if one is not trained in clinical hypnosis or if a patient is excessively insecure or still locked into stereotypes about it even after patient education. A journal article by this author⁵ demonstrates that type of reframing in a clinical situation.

Follow up sessions usually include half psychotherapy and half hypnosis/PNI. We discuss the patient’s treatment and responses to it by other providers. This often includes anxiety management before a PET scan, waiting for results, and then feelings about the results.

Training in self-hypnosis can be especially empowering in a situation where people are recently diagnosed and typically left feeling a tremendous loss of power. Some years ago, I would tape the hypnotic portion of our sessions for the patient to work with at home. Today I ask them to bring their cell phone if they have one and use that to record sessions. Some people are able to do that easily; others say they don’t know if their phone records or not, but it usually does; and we figure that out together—which becomes another experience of empowerment as well as a way to deepen the therapeutic alliance.

It is not essential, but I typically have the person sit back in a reclining chair for hypnotic treatment. I use a brief and quick induction technique taught by Spiegel and Spiegel⁶ both in the office and as a teaching tool for patients to build upon and utilize for their self-hypnosis between sessions. I can’t begin to count the number of people who smile and look at the chair as they are sitting down and remark about how much it has helped them. They are spontaneously moving toward trance without me saying anything. After taking a few minutes to help the patient move into whatever experience of trance he or she typically experiences, I remind the subject that there is no need to have any special feeling and that each person is unique and that most hypnotic work is done in a light trance, which helps eliminate patient performance anxiety and unnecessary expectations.

Next, suggestions are offered. Remember to use all the senses when creating suggestions both in the induction phase as well as in the suggestion phase. These can include things like “the quiet sound of water flowing as joints loosen up” or “the warmth of the sun to relax and ease an area of the body” or “the colorful process of the luminous body to create healing properties to boost immunity.” Paradoxical phrasing to confuse the logical part of the brain with its long-held ways of viewing situations can be something like “floating down (not up) through the chair” and “how fascinating and freeing confusion is.”

After ten to fifteen minutes in the suggestion phase, alternating between silence and a few “booster suggestions” about enjoying the experience and how the patient is doing well, it is time to transition to the alerting phase. This consists in helping the patient shift gently back into a more conventionally alert state of mind while using words about being refreshed, better than when we started, and enjoying the possibility of additional time in this state both in the office and during self-hypnosis time at home.

Due to the volume of patients in my practice, the distance they sometimes travel from, their other doctor appointments for things such as chemotherapy, radiation, and PET scans, I normally meet with individuals approximately every two to four weeks. This gives them time to practice at home and helps them look forward to getting together again.

Complementary Possibilities

Always working within one’s scope of practice, and in communication with other providers the patient may be under the care of, the clinician can include or recommend additional modalities that are minimally invasive such as lifestyle change education and motivation, nutrition, therapeutic massage, medical qigong, meditation, and dietary supplements if appropriately trained. The latter modality is the one to be especially sure to work in close collaboration with their chemotherapist if this becomes part of their treatment regime.

The Chinese treatment of medical qigong, which can include a personal qigong practice on the part of the patient, is something I have found patients to be especially responsive to. It typically includes some form of simple moving, breathing, and mediating. It has been called “Chinese yoga” by some practitioners. A small study⁷ with an n of 97 in the treatment group and an n of 30 in a control group found significant differences in improvement in strength, appetite, being diarrhea free, weight gain, and phagocytic rate (the ability of the immune system to identify and remove unhealthy cells) in people with advanced cancer who were also receiving chemotherapy. Information and training opportunities about qigong can be found by visiting the National Qigong Association’s website (www.nqa.org).

Practice Sample

In applying for board certification in behavioral health practice (www.abbhp.org) I was asked to include a practice sample with my other application materials. A version of it is provided here in order to illustrate all that has been discussed previously and is appropriately altered for purposes of confidentiality.

Diagnosis (Dx): F54 – Psychological & Behavioral Factors Associated with Disorders or Diseases Classified Elsewhere

A smiling man approaching 60 years of age who struggles with mobility presented with multiple medical conditions, including Dx of widespread cancer, i.e., colon, rectum, plus a 2-week prior Dx of tumor in esophagus. He had gout and pain manifesting in feet and knees and was approx. 100 lbs. overweight. His first name is now redacted as Manny.

This pleasant gentleman was on blood thinners for A-fib, as well as medication to lower his blood pressure. He is married and has a blended family of grown children and is self-employed. He has no history of substance abuse or of being abused, and reports sleeping well. His diet is poor, i.e., overeating and not making healthy food choices.

Patient reported that his oncologist told him that he likely had several months left to live and that: “I’m ready to go but would like to stay around.” His treatment goals consisted of preparing for death, as well as opting for some complementary and/or alternative therapies. Patient had not determined if he would comply with chemotherapy or not initially, if offered.

I said that his physician and I would need to work collaboratively on his case, and I encouraged him to continue with PET scans and any other support provided through conventional medicine. He eventually determined that he would avail himself of both conventional and natural and non-invasive treatments, and so I worked in conjunction with his conventional providers in an integrative fashion. Manny was clear that he would limit conventional therapy if his quality of life deteriorated and was still convinced that he had little time left on this earth.

This patient was open to mind-body approaches to his illnesses, and I referred him to a book called Getting Well Again by Simonton (1992), which is essentially psychoneuroimmunology (PNI), which I provided clinically via clinical hypnosis. We discussed the dying process and he, being a serious Christian, stated: “I wonder what the next life will be like.” I assured Manny that I had no direct knowledge but helped him process his wonderment, feelings, and long-term plans and goals.

We did clinical hypnosis every session, so the sessions were half psychotherapy and half clinical hypnosis. We recorded the hypnosis sessions for him to utilize for self-hypnosis purposes. Because the patient is a very concrete thinker, having a brain that pictures and draws things well, it took a few sessions for him to understand that feelings are not what is important in hypnosis, but rather outcome is what matters. I also utilized a Chinese medical specialty in which I am trained called “medical qigong.” He was fascinated with that, having visited Asia as a younger man, so I capitalized on that part of his history by including this Asian healing practice.

The outcome of his integrated treatment plan was that his PET scans vastly improved and within a few months he was out of danger of imminent death. He no longer was fixated on death, but rather on life, and his quality of life never deteriorated.

It has been approximately three years since we began treatment, and we continue meet every four to six weeks for supportive therapy. The patient enjoys our sessions and has made multiple referrals to me at his infusion center, actually more than my schedule can manage.

I could not motivate this good man to clean up his diet or to do much homework between sessions in terms of reading or self-hypnosis. I worked through my own counter transference feelings on that matter and trusted the process. It is an honor to know Manny, along with the people he has since sent to me, some of whom have a story similar to his.

Conclusion

Helping people heal or stay well is an ancient and honorable profession practiced in various cultures and includes various modalities. Unfortunately, some people presume that because one practices behavioral medicine or complementary and alternative treatments, that the professional is opposed to conventional medicine. This writer is grateful for every form of clinical and research endeavor whose goal is the betterment of humankind. Thus, conventional medicine is respected by me; and practitioners such as myself have as much to offer as well beyond what is considered conventional.

When I initially began practice in the 1970s, many of the patients I saw came to me as a “last resort” and were more difficult to treat because of the progression of disease and the unfortunate and unintended ravages previous treatment may have produced. Today practitioners such as myself are often consulted very early on and in an integrative fashion. Conventionally trained physicians appear to be more comfortable with the types of treatments under discussion and are often a referral source.

We have made a great deal of progress in recent years. Please don’t be afraid to work in this fashion but do work ethically and within your scope of practice and training. You will have discouraging moments, but many more moments of joy in seeing your patients adjust to what is, or progress far beyond what might have been.

References

1. Daruna, J. Introduction to Psychoneuroimmunology (2^nd ed.). Cambridge MA: Academic Press; 2012.
2. Turner, K. Radical remission: Surviving cancer against all odds. San Francisco CA: Harper One; 2015.
3. Simonton, O. et al. Getting well again. New York NY: Bantam Books; 1992.
4. American Psychological Association. Society of psychological hypnosis policy and procedures manual. Washington DC: American Psychological Association; 1993.
5. Seif, B. Hypnosis in a man with fear of voiding in public facilities. American Journal of Clinical Hypnosis. 1982; 24, 288-289.
6. Spiegel, H. & Spiegel, D. Trance and treatment: Clinical uses of hypnosis (2^nd ed.). American Psychiatric Association Press: Washington DC; 2004.
7. Sancier, K. Medical applications of qigong. Alternative therapies. 1996; 2 (1), 40-46.

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