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American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports Philip R. Appel Ph.D.
a
a
National Rehabilitation Hospital , USA Published online: 21 Sep 2011.
To cite this article: Philip R. Appel Ph.D. (1990) Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports, American Journal of Clinical Hypnosis, 33:2, 85-93, DOI: 10.1080/00029157.1990.10402909 To link to this article: http://dx.doi.org/10.1080/00029157.1990.10402909
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
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AMERICAN JOURNAL OF CLINICAL HYPNOSIS
VOLUME 33, NUMBER 2, OcroBER 1990
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Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports! Philip R. Appel National Rehabilitation Hospital Hypnosis is useful in the rehabilitation setting to help patients master skills, to increase their sense of self-efficacy and self-esteemand, in general, to facilitate and accelerate their rehabilitation program. I used hypnosis with three patients where patient behaviors and beliefs were interfering with the rehabilitation treatment goals set by the patient and the health care team. Collectively, these cases demonstrate the use of hypnotic techniques in diagnosing and treating problems with patient compliance and assisting patients to gain greater benefit from their rehabilitation regimen.
Only a limited amount has been published to date about the use of hypnosis in the specialty of physical medicine and rehabilitation. Both Wright (1960) and Becker (1960) have argued that hypnosis can be a valuable tool in the rehabilitation setting, as hypnosis can be utilized to facilitate both psychological and physical change. Wright (1960) stated that the primary importance of hypnosis in rehabilitation is its potential for facilitating change and accelerating learning. Alexander
(1966) found that hypnosis is an effective tool with patients who have primarily organic illness, because the psychological sequelae of those illnesses often intensify the disabilities, and because changes in attitude often bring about better compensation and rehabilitation outcomes. As most traditional psychological efforts in rehabilitation are aimed at facilitating" . . . cognitive mastery over the emotional impact of disability .... " (Coulton, 1984, p.126), hypnosis as a tool in altering perception, reframing perspectives, accessing resources, and providing experiences of mastery readily achieves this goal. Martin (1983), speaking about the use of hypnosis in rehabilitation, argues that health care providers should use every adjunctive treatment in their arsenal to achieve better outcomes. Eisenberg and Jansen (1983) review positively the use
I Paper presented at the Annual Scientific Meeting of the American Society of Clinical Hypnosis, Nashville, TN, March 11, 1989.
For reprints write to Philip R. Appel, Ph.D., Psychology Service, National Rehabilitation Hospital, 102 Irving St., N. W., Washington, DC 20010.
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of clinical hypnosis as an adjunctive tool for the rehabilitation psychologist in the treatment of neuromuscular disorders. Becker (1960) described the use of hypnosis in neuromuscular rehabilitation and how it could be applied to mitigate the effects of "the law of reversed effort" (Baudoin, 1921). Crasilneck and his coworkers (1955) used hypnosis in the rehabilitation of burn patients. Crasilneck and Hall (1970) and Alexander (1966) reported on the applications of hypnosis with cerebrovascular or traumatic brain injury patients. There have been other scattered reports in the literature about paraplegia (Chappell, 1964), stroke (Crasilneck & Hall, 1975; Manganiello, 1986), cerebral palsy (Ortega, 1978; Spankus & Freeman, 1962), multiple sclerosis (McCord, 1966; Brunn, 1966; Dane, 1987), and juvenile rheumatoid arthritis (Cioppa & Thai, 1975). Hypnosis has also been used in "neuromuscular re-education" (Shires, Peters, & Krout, 1954), "neuromotor facilitation" (Garver, 1977), "hypnotically hallucinated physical therapy" (McCord, 1966), and "mental practice" (Warner & McNeill, 1988) to enhance the performance and outcome of physical tasks and objectives. Unlike traditional general medical and surgical settings where health care objectives are determined by the physician, in the rehabilitation setting, goals and objectives are set by an interdisciplinary team. The role of the psychologist in the team is varied and multiple. One of the primary roles of the psychologist is to facilitate patient and staff interactions toward the accomplishment of the treatment goals. Often the exaggerated emphasis on goal attainment in the rehabilitation setting (Gans, 1987, p. 185) leads to conflicts between patients and staff. Psychological consultation is often requested to facili-
tate patient compliance with the treatment regimen. Much of the existing hypnosis literature related to Physical Medicine and Rehabilitation deals with the clinical applications of hypnosis to obtain treatment outcomes established by the hypnotist. The three cases I will present, two inpatients and one outpatient who were all seen in a freestanding acute rehabilitation hospital, demonstrate how hypnotic techniques can be used to help diagnose and treat "compliance" problems. Case Reports
Case 1 The patient was an 81-year-old, righthanded, caucasian female, who was graduate-school educated. She had been a creative dance teacher until she sustained a right cerebral vascular accident which resulted in left hemiparesis and neglect. She had been living alone and had been teaching dance for 60 years. Her psychologist referred her to me for hypnotic intervention because she was quite impatient, had difficulty waiting, and was generally perceiving much delay in the response time to her requests for assistance. Although her perception was sometimes accurate, her frequently distorted perception of time resulted in inability to tolerate delay; she became quite frustrated and was frustrating for the nursing staff. I agreed to see her to help her become more relaxed and tolerate waiting better. On a brief mental status exam, most of her higher cognitive functions were intact, with the exception of the abovementioned problems and of her moderately impaired immediate and delayed memory. She described her mood as quite good given the circumstances. She acknowledged being rather impatient, had
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good insight into her condition, and was aware of what was expected of her as far as her rehabilitation treatment regimen was concerned. The patient was willing to learn how to relax and recognized the wisdom of being able to feel comfortable while waiting for her call button to be answered. Because of her musical and interpretative dance background, she was asked to close her eyes and try to musically interpret the environment and her frustration with it. I asked her to hear the sound of her impatience and to hear the sounds of the hospital. She described a sound with a very staccato rhythm. I suggested that she alter the rhythm she heard, to vary the pattern until the rhythm became a tempo rather pleasing and relaxing to her, and then to construct a backdrop scene for the music she was hearing. As she did, she experienced comfort and peace. While in trance, she was given positive suggestions that, whenever the pace and rhythm of the hospital were becoming uncomfortable while she was waiting for someone to attend her, she could choose to go inward and hear a different rhythm and see a different scene. Her attending psychologist reported that the interactions between the patient and the nursing staff greatly improved after the intervention, and they believed that the patient's use of self-hypnosis had contributed to her gaining more self-control and feeling more comfortable with her self and her circumstances. On follow-up visits the patient, said that she was practicing self-hypnosis and it helped her to relax and feel more in control.
Case 2 A 16-year-old, single, caucasian, wheelchair-bound female, currently in the
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l l th grade, was admitted to the Rheumatology Service with a diagnosis of juvenile rheumatoid arthritis and bilateral knee replacements (for the second time). She developed arthritis when she was 3 and was ambulatory until she was 12. When she was 11 years old she had bilateral hip replacements, and the following year she had bilateral total knee replacements for the first time. Her present rehabilitation goal was to recover postoperatively, to be able to transfer independently, and to walk for limited distances. As part of a comprehensive interdisciplinary treatment plan, she was referred to Psychology for general evaluation and assistance with meeting rehabilitation goals. Her mental status was within normal limits and there were no diagnoses on either Axes I or II. The conclusion from the evaluation was that she could benefit from learning relaxation techniques, pain-management techniques, and techniques to increase her performance in her physical and occupational therapies. Her arthritis had led to deformities in her hands which decreased their functional usage, and her range of movement of all limbs was rather limited. The stiffness in her joints, particularly her ankles and shoulders, led to much discomfort. I taught her a progressive muscle-relaxation exercise using awareness of gravity and body temperature, combined with suggestions that her exhalations would induce more comfort and relaxation. She learned how to go into a trance state quite easily. The next phase involved teaching her to influence her perception of the pain while in a trance state. She learned to transform physical sensations of discomfort into visual images, which she would then manipulate via an image that represented her body's capacity to heal. In
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addition, I taught her glove anesthesia and techniques of distraction and inattention in which she could retire to an inner laboratory (she wanted to be an astrophysicist) and engage in imaginary activities. She was able to reduce her discomfort significantly, in particular her morning stiffness, by relaxing, by going into trance, and by engaging in mental rehearsal of her physical exercises when she w.oke in the morning. Her occupational therapist reported that bedside therapy had improved with the patient's intentional reduction of discomfort and stiffness; she was able to accomplish her exercises more easily and was attaining a greater range of movement. Hypnosis also was used to increase her range of motion of upper extremities and to facilitate performing daily tasks of living, such as dressing. She was taught techniques of mental rehearsal in which she would visualize and experience the range-of-motion exercises or activities first, thereby learning the activity cognitively. For example, one exercise to increase extension of the arm is to place cones on top of one another, building a column. During a co-treatment therapy session with her occupational therapist, a baseline was established in which she was offered no encouragement; she placed 19 and 27 cones on top of each other with her right and left arms respectively. After she hypnotized herself and the trance was deepened, I told her to imagine just moving her arms up and down effortlessly, with each movement upward, imagining that her arms went higher and higher, easily and effortlessly, as if she were allowing the arms to move up an down like in jumping jacks. I suggested that when she had rehearsed the activity in her mind sufficiently, she could alert herself and open her eyes. Her occupational therapist (also without en-
APPEL couragement) then had her continue to add cones until she could no longer do so. With mental rehearsal she was able to add an additional 7 cones with each arm for a total of 26 with her right arm and 34 with her left arm. Her occupational therapy goal was to be able to stack 36 cones bilaterally. One week later, with daily selfhypnotic practice, her performance had increased to 37 and 40, respectively. Although it is difficult within the context of multi-disciplinary interventions to determine to what extent the self-hypnosis actually contributed to her goal attainment, at a minimum, the hypnotic work was desensitizing her performance anxiety and allowing her anticipatory anxiety (about the pain associated with the therapies) to lessen so that she could actually perform better. She applied the same techniques of mental rehearsal to learn how to don a pullover shirt, a task which required considerable effort for her and with which she was requiring maximum assistance. She was able to reduce her need for assistance to a minimum. Her occupational therapist and the supervising occupational therapist ratified her superior performance in accomplishing the task, which served to reinforce her use of self-hypnosis. The interdisciplinary team reported a substantial increase in her progress in therapy with the use of self-hypnosis. Following this feedback from the team and the patient's report of improvement, I suggested to her that she could use mental rehearsal in all her rehabilitation tasks, and when she woke in the morning she could go through a routine of kinesthetically imaging all her exercises for reducing stiffness and for accomplishing daily living skills. Her occupational therapist specifically reported that once the patient
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started using hypnosis her progress in therapy had substantially increased and continued throughout her hospital stay. Follow-up 7 months later by the physician indicated that she still was using self-hypnosis, and her hypnotic practice made daily living easier.
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Case 3 This 26-year-old, wheelchair-bound, right-handed, single, caucasian, female graduate student in philosophy was in a motor vehicle accident when she was 23 years old; she sustained a ruptured aorta resulting in T-8 incomplete paraplegia secondary to ischemia to the spinal cord. She was referred by her physiatrist to assist with her continuing outpatient rehabilitation goal of learning how to walk with braces and crutches. The presenting problem was that only marginal gains were being made in therapy, and her physical therapist wanted to terminate treatment. At one point in her rehabilitation at a another hospital, she had been learning how to brace walk; however, in her move east and while waiting to start physical therapy again she lost much of what she had functionally gained. Her physical therapist deemed that the patient had lost so much function that she wanted to just concentrate on wheelchair skills. Her physical therapist reported that the patient appeared to be afraid of falling and the fear impacted on their work together; she was unable to achieve the goals set for her. Her physiatrist felt that she could eventually relearn how to walk and psychological intervention might facilitate progress in this regard. Her mental status was essentially within normal limits. She did, however, have mild anxiety, pressured speech, and rapid thought. Although she appeared hypo-
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manic, there were not enough symptoms to diagnose her on Axis I or Axis II. She also had obsessive and dependent character traits. She had very vivid images of falling, images in which she saw herself fall into a heap backwards, sustaining compound fractures. She described seeing the broken bones sticking through her skin. I asked her to think about her fear of faIling and to remember the last time she felt that fear. A naturalistic induction was utilized which focused on her experience of her tension and where in her body it was located. I then used the "corridor-in-time" (Edelstein, 1988) technique, an uncovering technique which strives to find the origins of particular soma to-affective states. Briefly, the technique is: The patient is asked to be aware of a target sensation while she is descending a flight of stairs or elevator that takes her to a corridor with many doors. The patient is instructed that this is the "corridor of time" and the corridor has many doors. Behind each door is a scene from the past. As she descends she is instructed to feel the target sensation slightly increasing in intensity. Once she is in the corridor, she is to travel along the corridor until she comes upon the door where as she stands in front of it, the sensation becomes even more intense. Once she finds the door to the past, she is to open it and behold the scene that is there.
When using the above technique, the patient described a scene in a hospital in which she was standing, terrified, and tottering around as her physical therapist walked away. I suggested that she could view the situation and study it as she would any problem in graduate school until she realized something about the situation that her younger self had not been aware of. She realized that her fear was not related to her standing, as she had been standing for some time before her therapist had left. Her fear was of being left alone. Using
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ego-state techniques, I suggested that she approach her younger self and share this insight with her. I encouraged her to dialogue with the image of her younger self. As the younger self was still fearful, I suggested that she inquire of the younger self if she had felt anger at her physical therapist for leaving her. The patient spontaneously reported that she couldn't be angry with her therapist because her therapist cared for her and always helped her (except in this instance). The patient then recognized her tremendous rage at her therapist for leaving and the younger self reported feeling betrayed. I suggested that the fear might have been about the intense rage she was experiencing about being "abandoned" and she did not feel she could express her anger toward the therapist because she was probably afraid of what her rage might do to their relationship. I told her that she could talk to her younger self and help that younger self understand what the issues were, and, as she had not fallen that day, she could assure her younger self with great certainty that the tension and anxiety she had been experiencing were not based on an experience of having fallen but on being abandoned. The patient was allowed time to dialogue with her younger self until the issue no longer was focused on falling. To reinforce insight, I told her to imagine seeing the younger self brace-walking, feeling confident and eager to learn how to regain balance and use compensatory motor skills. She was able to do this quite easily. I then suggested that she tell her younger self she would have many experiences in rehabilitation through which she could learn many things and she would be able to take with her and build upon this experience of having once walked. With appropriate suggestions she then took leave of the younger self and went
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back into the "corridor of time." There she felt the feelings of anger at being betrayed and abandoned and once again went by the doors until she found the door where her feelings intensified. This time she found herself when she was 20 years old and in the midst of a relationship that was breaking up. She had found another situation in which she felt betrayed and unloved. I suggested that she could study the circumstance until she could learn something about the predicament her younger self was in, that the younger self could not have known or realized because of the stress at that time. Once again through ego-state work, she gained insight into how she participated in the demise of the relationship and the dependency needs that had brought about that demise. She was able to approach the younger self in that situation and to share her understanding of what her younger self was going through. I suggested that the patient ask the younger self if it would be all right for her, the patient, to take care of the younger self, providing the patient thought it was a good idea. The patient responded affirmatively, and further suggestions were given as to how the adult ego state could be an emotional resource for the other ego state. The patient was allowed further time for internal dialogue and was then given the suggestion that she could tell the younger self she would be back to help the younger self learn how to deal with her anger. After taking her back through the "corridor of time" and giving her egostrengthening suggestions, I alerted her. On follow-up, the patient was able to engage in high kneeling without fear and was able to take her wheelchair down paths with steep sides that heretofore she had feared and avoided. Her physical therapist reported that the fear of falling was no longer an inhibiting factor in their ses-
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sions. In later hypnotherapy sessions it became apparent that much of these conflicts stemmed from early conflicts with her mother and repressed rage at her mother for not meeting her dependency needs. I discussed the patient's dependency needs and fear of abandonment with both her physiatrist and physical therapist and counseled them as to how to interact with her. Discussion
In the first case, hypnosis was used to help the patient to relax, to feel more in control, and to give her a sense of mastery. In rehabilitation, the patient's emotional state and personality influence the rehabilitation team's response to the patient. As in any general medical setting, demanding patients become the bane of the nursing staff. Patients who have sustained a stroke are often frustrated not only as a result of the emotional sequelae to the injury but as a result of the organic insult. It is not uncommon for patients with a right frontal eVA to be disinhibited and frustrated. By using the patient's creative dance background and love of music, a trance state was created rapidly to which she had immediate positive associations. By developing a hypnotic approach emphasizing "utilization," her interests became the focal point of the induction and kept her concentration; the patient was able to utilize old abilities in a new setting and was able to feel some mastery again and identify with a familiar sense of self. She was able to channel her emotional energy and creative drives in a more positive manner. As a former dancer who delighted in creativity, by being creative she could decrease her frustration which then led to less negative interactions with the nursing staff. This then al-
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lowed her to receive help and attention in a more timely fashion, as she was now no longer avoided. This case points out how hypnosis can be used effectively to help elderly patients regain a sense of selfcontrol and esteem by allowing them to re-interpret their present experience in light of their old experience. The past becomes an anchor which can provide a sense of stability. More importantly, by using this approach the patient was acknowledged to have an identity other than being a patient in our hospital, and her skills and experience were valued as being able to help solve the present dilemma. In the second case, where hypnosis was used for pain control and "increased performance" to facilitate her involvement with her other therapies, it helped an adolescent to experience herself as masterful and competent. For the first time she was able to intervene in her own behalf. Undoubtedly this contributed to changes in self-esteem and self-efficacy. She was able to actually take delight in using her mental faculties to influence her body in a different way than ever before. The literature is replete with information about hypnosis in pain control, and, therefore, achieving pain relief is not as important as is the fact that pain control became another part of her rehabilitation regimen, reinforcing the overall goal of independence. She learned to become functionally independent in the management of her body sensations. She was subtly introduced to the notions that she needed to rehabilitate her mind as well as her body. She began to realize that she could use her mental capacities to achieve a certain amount of functional independence rather than relying on just sheer willpower to make her body work as she intended. Selfhypnosis became a way of experiencing
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metaphorical freedom of movement as well, and it changed her own self-image of being handicapped. This case is an example of how hypnosis can contribute to and facilitate the rehabilitation process, whether working with the emotional sequelae of the illness, managing the experience of pain and discomfort, or facilitating the achievement of functional goals. In addition, with adolescents who have chronic ilInesses, hypnosis can be helpful by allowing the adolescent who is struggling with identity and control issues to experience himself! herself in a more masterful way. It can also have an element of play to which the adolescent can respond because of partial regression due to hospitalization and the illness. The third case is an example of where rehabilitation efforts had been stymied because the patient's dynamics had not only interfered with goal attainment but where nonpsychologist health care providers became part of a reoccurring dynamic theme in the patient's life. This can be seen in terms of her physical therapist wanting to terminate treatment, which activated issues of dependency and abandonment. The patient, unable to tolerate her anger at projected and perceived abandonment, had repressed her rage and had actually become anxious over the intensity of the rage that she felt toward her therapist, who was also a source of displacement for the rage she felt toward her mother. This case demonstrates the need for understanding how the individual's personality and emotional conflicts can interfere with the rehabilitation process, and that health care procedures and treatment can become compromised because of existing unconscious conflicts that the patient brings with him/her to traditional treatment settings. It also demonstrates how
the hypnotherapist acting as a consultant can make rapid and brief interventions to facilitate rehabilitation outcomes. The above vignettes demonstrate how hypnosis can not only potentiate the rehabilitation regimen and treatment of physical medicine patients but how it can be used to perform psychological interventions to achieve specific outcomes. For the psychologist in the rehabilitation setting, hypnosis is an effective tool in the diagnosis and treatment of problems and facilitates goal attainment. However, anecdotal clinical material is not sufficient in itself to prove the efficacy of the inclusion of hypnotic interventions with this population. Research is warranted and needed, particularly in looking at the outcomes of hypnotic interventions in the areas of skill acquisition, self-efficacy andself-esteem, and selfcontrol. Research is also needed to determine if the use of hypnosis can reduce the amount of time the patient spends receiving rehabilitation therapies.
References Alexander L. (1966). Hypnosis in primarily organic illness. American Journal of Clinical Hypnosis. 8, 250-253. Baudoin, C. (1921). Suggestion and autosuggestion. London: George Allen and UnWIn.
Becker, F. (1960). Medical hypnosis in Physical Medicine and Rehabilitation. Journal of the Medical Association of Georgia, 49. 233235. Brunn, J. T.(1966). Hypnosis and neurological disease: A case report. American Journal of Clinical Hypnosis, 8, 312-313. Chappell, D. T. (1964). Hypnosis and spasticity in paraplegia. American Journal of Clinical Hypnosis, 7, 33-36. Cioppa, F. J. & Thai, A. D. (1975). Hypnotherapy in a case of juvenile rheumatoid
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arthritis. American Journal of Clinical Hypnosis, 18, 105-110. Coulton, C. (1984). Person-environment fit and rehabilitation. In D. W. Kreuger, (Ed.), Rehabilitation psychology: A comprehensive textbook, pp. 119-129. Rockville, MD: Aspen Publishers. Crasilneck, H. B., Stirman, J. A., Wilson, B. J., & Fogelman, M. J. (1955). Use of hypnosis in the management of patients with burns. Journal of the American Medical Association, 158, 103-106. Crasilneck, H. B. & Hall, J. A. (1970). The use of hypnosis in the rehabilitation of complicated vascular and posttraumatic neurological patients. International Journal of Clinical and Experimental Hypnosis, 18, 145-159. Crasilneck, H. B. & Hall, J. A. (1975). Clinical hypnosis: Principles and applications. New York: Grune & Stratton. Dane, J. R. (1987). Hetero- and self-hypnosis for pain control and neuromuscular rehabilitation in a case of multiple sclerosis. Paper presentation at the Annual Scientific Meeting of the Society for Clinical and Experimental Hypnosis, Los Angeles, CA, October 30, 1987. Eisenberg, M. G. & Jansen, M. A. (1983). Rehabilitation psychology: State of the art. Annual Review of Rehabilitation, 3, 1-31. Edelstein, G. (1988). Comments during a meeting at the Annual Scientific Meeting of the American Society of Clinical Hypnosis, Chicago, lL, March, 1988. Gans, J. S. (1987). Facilitating staff/patient
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interaction in rehabilitation. In B. Caplan (Ed.), Rehabilitation psychology desk reference, pp. 185-216. Rockville: Aspen. Garver, R. B. (1977). The enhancement of human performance with hypnosis through neuromotor facilitation and control arousal level. American Journal of Clinical Hypnosis, 19,177-181. Manganiello, A. 1. (1986). Hypnotherapy in the rehabilitation of a stroke victim: A case study. American Journal of Clinical Hypnosis, 29, 64-68. Martin, J. (1983). Hypnosis is also useful in rehabilitation therapy. Journal of the American Medical Association, 249, 153-618. McCord, H. (1966). Hypnotically hallucinated physical therapy with a multiple sclerosis patient. American Journal of Clinical Hypnosis, 8, 313-314. Ortega, D. F. (1978). Relaxation exercise with cerebral palsied adults showing spasticity. Journal ofApplied Behavioral Analysis, 11, 447-451. Shires, E. B., Peters, J. J., & Krout, R. M. (1954). Hypnosis in neuromuscular re-education. U. S. Armed Forces Medical Journal, 5, 1519-1523. Spankus, W. H. & Freeman, L. G. (1962). Hypnosis in cerebral palsy. International Journal of Clinical and Experimental Hypnosis, 10, 135-139. Warner, L. & McNeill, M. Eo (1988). Mental imagery and its potential for physical therapy. Physical Therapy, 68, 516-521. Wright, M. Eo (1960). Hypnosis and rehabilitation. Rehabilitation Literature, 21,2-12.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports Philip R. Appel Ph.D.
a
a
National Rehabilitation Hospital , USA Published online: 21 Sep 2011.
To cite this article: Philip R. Appel Ph.D. (1990) Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports, American Journal of Clinical Hypnosis, 33:2, 85-93, DOI: 10.1080/00029157.1990.10402909 To link to this article: http://dx.doi.org/10.1080/00029157.1990.10402909
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden.
Downloaded by [University of New Hampshire] at 16:46 14 February 2015
Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
AMERICAN JOURNAL OF CLINICAL HYPNOSIS
VOLUME 33, NUMBER 2, OcroBER 1990
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Clinical Applications of Hypnosis in the Physical Medicine and Rehabilitation Setting: Three Case Reports! Philip R. Appel National Rehabilitation Hospital Hypnosis is useful in the rehabilitation setting to help patients master skills, to increase their sense of self-efficacy and self-esteemand, in general, to facilitate and accelerate their rehabilitation program. I used hypnosis with three patients where patient behaviors and beliefs were interfering with the rehabilitation treatment goals set by the patient and the health care team. Collectively, these cases demonstrate the use of hypnotic techniques in diagnosing and treating problems with patient compliance and assisting patients to gain greater benefit from their rehabilitation regimen.
Only a limited amount has been published to date about the use of hypnosis in the specialty of physical medicine and rehabilitation. Both Wright (1960) and Becker (1960) have argued that hypnosis can be a valuable tool in the rehabilitation setting, as hypnosis can be utilized to facilitate both psychological and physical change. Wright (1960) stated that the primary importance of hypnosis in rehabilitation is its potential for facilitating change and accelerating learning. Alexander
(1966) found that hypnosis is an effective tool with patients who have primarily organic illness, because the psychological sequelae of those illnesses often intensify the disabilities, and because changes in attitude often bring about better compensation and rehabilitation outcomes. As most traditional psychological efforts in rehabilitation are aimed at facilitating" . . . cognitive mastery over the emotional impact of disability .... " (Coulton, 1984, p.126), hypnosis as a tool in altering perception, reframing perspectives, accessing resources, and providing experiences of mastery readily achieves this goal. Martin (1983), speaking about the use of hypnosis in rehabilitation, argues that health care providers should use every adjunctive treatment in their arsenal to achieve better outcomes. Eisenberg and Jansen (1983) review positively the use
I Paper presented at the Annual Scientific Meeting of the American Society of Clinical Hypnosis, Nashville, TN, March 11, 1989.
For reprints write to Philip R. Appel, Ph.D., Psychology Service, National Rehabilitation Hospital, 102 Irving St., N. W., Washington, DC 20010.
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of clinical hypnosis as an adjunctive tool for the rehabilitation psychologist in the treatment of neuromuscular disorders. Becker (1960) described the use of hypnosis in neuromuscular rehabilitation and how it could be applied to mitigate the effects of "the law of reversed effort" (Baudoin, 1921). Crasilneck and his coworkers (1955) used hypnosis in the rehabilitation of burn patients. Crasilneck and Hall (1970) and Alexander (1966) reported on the applications of hypnosis with cerebrovascular or traumatic brain injury patients. There have been other scattered reports in the literature about paraplegia (Chappell, 1964), stroke (Crasilneck & Hall, 1975; Manganiello, 1986), cerebral palsy (Ortega, 1978; Spankus & Freeman, 1962), multiple sclerosis (McCord, 1966; Brunn, 1966; Dane, 1987), and juvenile rheumatoid arthritis (Cioppa & Thai, 1975). Hypnosis has also been used in "neuromuscular re-education" (Shires, Peters, & Krout, 1954), "neuromotor facilitation" (Garver, 1977), "hypnotically hallucinated physical therapy" (McCord, 1966), and "mental practice" (Warner & McNeill, 1988) to enhance the performance and outcome of physical tasks and objectives. Unlike traditional general medical and surgical settings where health care objectives are determined by the physician, in the rehabilitation setting, goals and objectives are set by an interdisciplinary team. The role of the psychologist in the team is varied and multiple. One of the primary roles of the psychologist is to facilitate patient and staff interactions toward the accomplishment of the treatment goals. Often the exaggerated emphasis on goal attainment in the rehabilitation setting (Gans, 1987, p. 185) leads to conflicts between patients and staff. Psychological consultation is often requested to facili-
tate patient compliance with the treatment regimen. Much of the existing hypnosis literature related to Physical Medicine and Rehabilitation deals with the clinical applications of hypnosis to obtain treatment outcomes established by the hypnotist. The three cases I will present, two inpatients and one outpatient who were all seen in a freestanding acute rehabilitation hospital, demonstrate how hypnotic techniques can be used to help diagnose and treat "compliance" problems. Case Reports
Case 1 The patient was an 81-year-old, righthanded, caucasian female, who was graduate-school educated. She had been a creative dance teacher until she sustained a right cerebral vascular accident which resulted in left hemiparesis and neglect. She had been living alone and had been teaching dance for 60 years. Her psychologist referred her to me for hypnotic intervention because she was quite impatient, had difficulty waiting, and was generally perceiving much delay in the response time to her requests for assistance. Although her perception was sometimes accurate, her frequently distorted perception of time resulted in inability to tolerate delay; she became quite frustrated and was frustrating for the nursing staff. I agreed to see her to help her become more relaxed and tolerate waiting better. On a brief mental status exam, most of her higher cognitive functions were intact, with the exception of the abovementioned problems and of her moderately impaired immediate and delayed memory. She described her mood as quite good given the circumstances. She acknowledged being rather impatient, had
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good insight into her condition, and was aware of what was expected of her as far as her rehabilitation treatment regimen was concerned. The patient was willing to learn how to relax and recognized the wisdom of being able to feel comfortable while waiting for her call button to be answered. Because of her musical and interpretative dance background, she was asked to close her eyes and try to musically interpret the environment and her frustration with it. I asked her to hear the sound of her impatience and to hear the sounds of the hospital. She described a sound with a very staccato rhythm. I suggested that she alter the rhythm she heard, to vary the pattern until the rhythm became a tempo rather pleasing and relaxing to her, and then to construct a backdrop scene for the music she was hearing. As she did, she experienced comfort and peace. While in trance, she was given positive suggestions that, whenever the pace and rhythm of the hospital were becoming uncomfortable while she was waiting for someone to attend her, she could choose to go inward and hear a different rhythm and see a different scene. Her attending psychologist reported that the interactions between the patient and the nursing staff greatly improved after the intervention, and they believed that the patient's use of self-hypnosis had contributed to her gaining more self-control and feeling more comfortable with her self and her circumstances. On follow-up visits the patient, said that she was practicing self-hypnosis and it helped her to relax and feel more in control.
Case 2 A 16-year-old, single, caucasian, wheelchair-bound female, currently in the
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l l th grade, was admitted to the Rheumatology Service with a diagnosis of juvenile rheumatoid arthritis and bilateral knee replacements (for the second time). She developed arthritis when she was 3 and was ambulatory until she was 12. When she was 11 years old she had bilateral hip replacements, and the following year she had bilateral total knee replacements for the first time. Her present rehabilitation goal was to recover postoperatively, to be able to transfer independently, and to walk for limited distances. As part of a comprehensive interdisciplinary treatment plan, she was referred to Psychology for general evaluation and assistance with meeting rehabilitation goals. Her mental status was within normal limits and there were no diagnoses on either Axes I or II. The conclusion from the evaluation was that she could benefit from learning relaxation techniques, pain-management techniques, and techniques to increase her performance in her physical and occupational therapies. Her arthritis had led to deformities in her hands which decreased their functional usage, and her range of movement of all limbs was rather limited. The stiffness in her joints, particularly her ankles and shoulders, led to much discomfort. I taught her a progressive muscle-relaxation exercise using awareness of gravity and body temperature, combined with suggestions that her exhalations would induce more comfort and relaxation. She learned how to go into a trance state quite easily. The next phase involved teaching her to influence her perception of the pain while in a trance state. She learned to transform physical sensations of discomfort into visual images, which she would then manipulate via an image that represented her body's capacity to heal. In
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addition, I taught her glove anesthesia and techniques of distraction and inattention in which she could retire to an inner laboratory (she wanted to be an astrophysicist) and engage in imaginary activities. She was able to reduce her discomfort significantly, in particular her morning stiffness, by relaxing, by going into trance, and by engaging in mental rehearsal of her physical exercises when she w.oke in the morning. Her occupational therapist reported that bedside therapy had improved with the patient's intentional reduction of discomfort and stiffness; she was able to accomplish her exercises more easily and was attaining a greater range of movement. Hypnosis also was used to increase her range of motion of upper extremities and to facilitate performing daily tasks of living, such as dressing. She was taught techniques of mental rehearsal in which she would visualize and experience the range-of-motion exercises or activities first, thereby learning the activity cognitively. For example, one exercise to increase extension of the arm is to place cones on top of one another, building a column. During a co-treatment therapy session with her occupational therapist, a baseline was established in which she was offered no encouragement; she placed 19 and 27 cones on top of each other with her right and left arms respectively. After she hypnotized herself and the trance was deepened, I told her to imagine just moving her arms up and down effortlessly, with each movement upward, imagining that her arms went higher and higher, easily and effortlessly, as if she were allowing the arms to move up an down like in jumping jacks. I suggested that when she had rehearsed the activity in her mind sufficiently, she could alert herself and open her eyes. Her occupational therapist (also without en-
APPEL couragement) then had her continue to add cones until she could no longer do so. With mental rehearsal she was able to add an additional 7 cones with each arm for a total of 26 with her right arm and 34 with her left arm. Her occupational therapy goal was to be able to stack 36 cones bilaterally. One week later, with daily selfhypnotic practice, her performance had increased to 37 and 40, respectively. Although it is difficult within the context of multi-disciplinary interventions to determine to what extent the self-hypnosis actually contributed to her goal attainment, at a minimum, the hypnotic work was desensitizing her performance anxiety and allowing her anticipatory anxiety (about the pain associated with the therapies) to lessen so that she could actually perform better. She applied the same techniques of mental rehearsal to learn how to don a pullover shirt, a task which required considerable effort for her and with which she was requiring maximum assistance. She was able to reduce her need for assistance to a minimum. Her occupational therapist and the supervising occupational therapist ratified her superior performance in accomplishing the task, which served to reinforce her use of self-hypnosis. The interdisciplinary team reported a substantial increase in her progress in therapy with the use of self-hypnosis. Following this feedback from the team and the patient's report of improvement, I suggested to her that she could use mental rehearsal in all her rehabilitation tasks, and when she woke in the morning she could go through a routine of kinesthetically imaging all her exercises for reducing stiffness and for accomplishing daily living skills. Her occupational therapist specifically reported that once the patient
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started using hypnosis her progress in therapy had substantially increased and continued throughout her hospital stay. Follow-up 7 months later by the physician indicated that she still was using self-hypnosis, and her hypnotic practice made daily living easier.
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Case 3 This 26-year-old, wheelchair-bound, right-handed, single, caucasian, female graduate student in philosophy was in a motor vehicle accident when she was 23 years old; she sustained a ruptured aorta resulting in T-8 incomplete paraplegia secondary to ischemia to the spinal cord. She was referred by her physiatrist to assist with her continuing outpatient rehabilitation goal of learning how to walk with braces and crutches. The presenting problem was that only marginal gains were being made in therapy, and her physical therapist wanted to terminate treatment. At one point in her rehabilitation at a another hospital, she had been learning how to brace walk; however, in her move east and while waiting to start physical therapy again she lost much of what she had functionally gained. Her physical therapist deemed that the patient had lost so much function that she wanted to just concentrate on wheelchair skills. Her physical therapist reported that the patient appeared to be afraid of falling and the fear impacted on their work together; she was unable to achieve the goals set for her. Her physiatrist felt that she could eventually relearn how to walk and psychological intervention might facilitate progress in this regard. Her mental status was essentially within normal limits. She did, however, have mild anxiety, pressured speech, and rapid thought. Although she appeared hypo-
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manic, there were not enough symptoms to diagnose her on Axis I or Axis II. She also had obsessive and dependent character traits. She had very vivid images of falling, images in which she saw herself fall into a heap backwards, sustaining compound fractures. She described seeing the broken bones sticking through her skin. I asked her to think about her fear of faIling and to remember the last time she felt that fear. A naturalistic induction was utilized which focused on her experience of her tension and where in her body it was located. I then used the "corridor-in-time" (Edelstein, 1988) technique, an uncovering technique which strives to find the origins of particular soma to-affective states. Briefly, the technique is: The patient is asked to be aware of a target sensation while she is descending a flight of stairs or elevator that takes her to a corridor with many doors. The patient is instructed that this is the "corridor of time" and the corridor has many doors. Behind each door is a scene from the past. As she descends she is instructed to feel the target sensation slightly increasing in intensity. Once she is in the corridor, she is to travel along the corridor until she comes upon the door where as she stands in front of it, the sensation becomes even more intense. Once she finds the door to the past, she is to open it and behold the scene that is there.
When using the above technique, the patient described a scene in a hospital in which she was standing, terrified, and tottering around as her physical therapist walked away. I suggested that she could view the situation and study it as she would any problem in graduate school until she realized something about the situation that her younger self had not been aware of. She realized that her fear was not related to her standing, as she had been standing for some time before her therapist had left. Her fear was of being left alone. Using
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ego-state techniques, I suggested that she approach her younger self and share this insight with her. I encouraged her to dialogue with the image of her younger self. As the younger self was still fearful, I suggested that she inquire of the younger self if she had felt anger at her physical therapist for leaving her. The patient spontaneously reported that she couldn't be angry with her therapist because her therapist cared for her and always helped her (except in this instance). The patient then recognized her tremendous rage at her therapist for leaving and the younger self reported feeling betrayed. I suggested that the fear might have been about the intense rage she was experiencing about being "abandoned" and she did not feel she could express her anger toward the therapist because she was probably afraid of what her rage might do to their relationship. I told her that she could talk to her younger self and help that younger self understand what the issues were, and, as she had not fallen that day, she could assure her younger self with great certainty that the tension and anxiety she had been experiencing were not based on an experience of having fallen but on being abandoned. The patient was allowed time to dialogue with her younger self until the issue no longer was focused on falling. To reinforce insight, I told her to imagine seeing the younger self brace-walking, feeling confident and eager to learn how to regain balance and use compensatory motor skills. She was able to do this quite easily. I then suggested that she tell her younger self she would have many experiences in rehabilitation through which she could learn many things and she would be able to take with her and build upon this experience of having once walked. With appropriate suggestions she then took leave of the younger self and went
APPEL
back into the "corridor of time." There she felt the feelings of anger at being betrayed and abandoned and once again went by the doors until she found the door where her feelings intensified. This time she found herself when she was 20 years old and in the midst of a relationship that was breaking up. She had found another situation in which she felt betrayed and unloved. I suggested that she could study the circumstance until she could learn something about the predicament her younger self was in, that the younger self could not have known or realized because of the stress at that time. Once again through ego-state work, she gained insight into how she participated in the demise of the relationship and the dependency needs that had brought about that demise. She was able to approach the younger self in that situation and to share her understanding of what her younger self was going through. I suggested that the patient ask the younger self if it would be all right for her, the patient, to take care of the younger self, providing the patient thought it was a good idea. The patient responded affirmatively, and further suggestions were given as to how the adult ego state could be an emotional resource for the other ego state. The patient was allowed further time for internal dialogue and was then given the suggestion that she could tell the younger self she would be back to help the younger self learn how to deal with her anger. After taking her back through the "corridor of time" and giving her egostrengthening suggestions, I alerted her. On follow-up, the patient was able to engage in high kneeling without fear and was able to take her wheelchair down paths with steep sides that heretofore she had feared and avoided. Her physical therapist reported that the fear of falling was no longer an inhibiting factor in their ses-
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sions. In later hypnotherapy sessions it became apparent that much of these conflicts stemmed from early conflicts with her mother and repressed rage at her mother for not meeting her dependency needs. I discussed the patient's dependency needs and fear of abandonment with both her physiatrist and physical therapist and counseled them as to how to interact with her. Discussion
In the first case, hypnosis was used to help the patient to relax, to feel more in control, and to give her a sense of mastery. In rehabilitation, the patient's emotional state and personality influence the rehabilitation team's response to the patient. As in any general medical setting, demanding patients become the bane of the nursing staff. Patients who have sustained a stroke are often frustrated not only as a result of the emotional sequelae to the injury but as a result of the organic insult. It is not uncommon for patients with a right frontal eVA to be disinhibited and frustrated. By using the patient's creative dance background and love of music, a trance state was created rapidly to which she had immediate positive associations. By developing a hypnotic approach emphasizing "utilization," her interests became the focal point of the induction and kept her concentration; the patient was able to utilize old abilities in a new setting and was able to feel some mastery again and identify with a familiar sense of self. She was able to channel her emotional energy and creative drives in a more positive manner. As a former dancer who delighted in creativity, by being creative she could decrease her frustration which then led to less negative interactions with the nursing staff. This then al-
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lowed her to receive help and attention in a more timely fashion, as she was now no longer avoided. This case points out how hypnosis can be used effectively to help elderly patients regain a sense of selfcontrol and esteem by allowing them to re-interpret their present experience in light of their old experience. The past becomes an anchor which can provide a sense of stability. More importantly, by using this approach the patient was acknowledged to have an identity other than being a patient in our hospital, and her skills and experience were valued as being able to help solve the present dilemma. In the second case, where hypnosis was used for pain control and "increased performance" to facilitate her involvement with her other therapies, it helped an adolescent to experience herself as masterful and competent. For the first time she was able to intervene in her own behalf. Undoubtedly this contributed to changes in self-esteem and self-efficacy. She was able to actually take delight in using her mental faculties to influence her body in a different way than ever before. The literature is replete with information about hypnosis in pain control, and, therefore, achieving pain relief is not as important as is the fact that pain control became another part of her rehabilitation regimen, reinforcing the overall goal of independence. She learned to become functionally independent in the management of her body sensations. She was subtly introduced to the notions that she needed to rehabilitate her mind as well as her body. She began to realize that she could use her mental capacities to achieve a certain amount of functional independence rather than relying on just sheer willpower to make her body work as she intended. Selfhypnosis became a way of experiencing
APPEL
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metaphorical freedom of movement as well, and it changed her own self-image of being handicapped. This case is an example of how hypnosis can contribute to and facilitate the rehabilitation process, whether working with the emotional sequelae of the illness, managing the experience of pain and discomfort, or facilitating the achievement of functional goals. In addition, with adolescents who have chronic ilInesses, hypnosis can be helpful by allowing the adolescent who is struggling with identity and control issues to experience himself! herself in a more masterful way. It can also have an element of play to which the adolescent can respond because of partial regression due to hospitalization and the illness. The third case is an example of where rehabilitation efforts had been stymied because the patient's dynamics had not only interfered with goal attainment but where nonpsychologist health care providers became part of a reoccurring dynamic theme in the patient's life. This can be seen in terms of her physical therapist wanting to terminate treatment, which activated issues of dependency and abandonment. The patient, unable to tolerate her anger at projected and perceived abandonment, had repressed her rage and had actually become anxious over the intensity of the rage that she felt toward her therapist, who was also a source of displacement for the rage she felt toward her mother. This case demonstrates the need for understanding how the individual's personality and emotional conflicts can interfere with the rehabilitation process, and that health care procedures and treatment can become compromised because of existing unconscious conflicts that the patient brings with him/her to traditional treatment settings. It also demonstrates how
the hypnotherapist acting as a consultant can make rapid and brief interventions to facilitate rehabilitation outcomes. The above vignettes demonstrate how hypnosis can not only potentiate the rehabilitation regimen and treatment of physical medicine patients but how it can be used to perform psychological interventions to achieve specific outcomes. For the psychologist in the rehabilitation setting, hypnosis is an effective tool in the diagnosis and treatment of problems and facilitates goal attainment. However, anecdotal clinical material is not sufficient in itself to prove the efficacy of the inclusion of hypnotic interventions with this population. Research is warranted and needed, particularly in looking at the outcomes of hypnotic interventions in the areas of skill acquisition, self-efficacy andself-esteem, and selfcontrol. Research is also needed to determine if the use of hypnosis can reduce the amount of time the patient spends receiving rehabilitation therapies.
References Alexander L. (1966). Hypnosis in primarily organic illness. American Journal of Clinical Hypnosis. 8, 250-253. Baudoin, C. (1921). Suggestion and autosuggestion. London: George Allen and UnWIn.
Becker, F. (1960). Medical hypnosis in Physical Medicine and Rehabilitation. Journal of the Medical Association of Georgia, 49. 233235. Brunn, J. T.(1966). Hypnosis and neurological disease: A case report. American Journal of Clinical Hypnosis, 8, 312-313. Chappell, D. T. (1964). Hypnosis and spasticity in paraplegia. American Journal of Clinical Hypnosis, 7, 33-36. Cioppa, F. J. & Thai, A. D. (1975). Hypnotherapy in a case of juvenile rheumatoid
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arthritis. American Journal of Clinical Hypnosis, 18, 105-110. Coulton, C. (1984). Person-environment fit and rehabilitation. In D. W. Kreuger, (Ed.), Rehabilitation psychology: A comprehensive textbook, pp. 119-129. Rockville, MD: Aspen Publishers. Crasilneck, H. B., Stirman, J. A., Wilson, B. J., & Fogelman, M. J. (1955). Use of hypnosis in the management of patients with burns. Journal of the American Medical Association, 158, 103-106. Crasilneck, H. B. & Hall, J. A. (1970). The use of hypnosis in the rehabilitation of complicated vascular and posttraumatic neurological patients. International Journal of Clinical and Experimental Hypnosis, 18, 145-159. Crasilneck, H. B. & Hall, J. A. (1975). Clinical hypnosis: Principles and applications. New York: Grune & Stratton. Dane, J. R. (1987). Hetero- and self-hypnosis for pain control and neuromuscular rehabilitation in a case of multiple sclerosis. Paper presentation at the Annual Scientific Meeting of the Society for Clinical and Experimental Hypnosis, Los Angeles, CA, October 30, 1987. Eisenberg, M. G. & Jansen, M. A. (1983). Rehabilitation psychology: State of the art. Annual Review of Rehabilitation, 3, 1-31. Edelstein, G. (1988). Comments during a meeting at the Annual Scientific Meeting of the American Society of Clinical Hypnosis, Chicago, lL, March, 1988. Gans, J. S. (1987). Facilitating staff/patient
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interaction in rehabilitation. In B. Caplan (Ed.), Rehabilitation psychology desk reference, pp. 185-216. Rockville: Aspen. Garver, R. B. (1977). The enhancement of human performance with hypnosis through neuromotor facilitation and control arousal level. American Journal of Clinical Hypnosis, 19,177-181. Manganiello, A. 1. (1986). Hypnotherapy in the rehabilitation of a stroke victim: A case study. American Journal of Clinical Hypnosis, 29, 64-68. Martin, J. (1983). Hypnosis is also useful in rehabilitation therapy. Journal of the American Medical Association, 249, 153-618. McCord, H. (1966). Hypnotically hallucinated physical therapy with a multiple sclerosis patient. American Journal of Clinical Hypnosis, 8, 313-314. Ortega, D. F. (1978). Relaxation exercise with cerebral palsied adults showing spasticity. Journal ofApplied Behavioral Analysis, 11, 447-451. Shires, E. B., Peters, J. J., & Krout, R. M. (1954). Hypnosis in neuromuscular re-education. U. S. Armed Forces Medical Journal, 5, 1519-1523. Spankus, W. H. & Freeman, L. G. (1962). Hypnosis in cerebral palsy. International Journal of Clinical and Experimental Hypnosis, 10, 135-139. Warner, L. & McNeill, M. Eo (1988). Mental imagery and its potential for physical therapy. Physical Therapy, 68, 516-521. Wright, M. Eo (1960). Hypnosis and rehabilitation. Rehabilitation Literature, 21,2-12.
