We are pleased to share with you some perspectives from our beloved NPHTI faculty member, Leora Kuttner, Ph.D. Dr. Kuttner is a clinical psychologist in private practice and professor of pediatrics at the British Columbia Children’s Hospital in Vancouver. In 2007 the American Pain Society presented her with the Jeffrey Lawson Award for Advocacy in Children’s Pain Relief, and she is the author of a seminal text in pediatrics, A Child in Pain: What Health Professionals Can Do to Help. Her films, including the No Fears, No Tears series, have won numerous awards. (Portions of this interview have been adapted by Dr. Kuttner from her interview with Mark Jensen, Ph.D., which appeared in Contemporary Hypnosis & Integrative Therapy, June 2013, Vol. 30 Issue 2, pages 77-).
What led you to take your first workshop in hypnosis?
I first learned hypnosis for adults 1976 in South Africa during my clinical master program from the eccentric, talented psychologist Professor George Wiehahn who was trained in Holland. That was the same year the child psychiatrist Josephine Hilgard presented her groundbreaking research on hypnosis with children (Hilgard & Morgan, 1976). This is nicely synchronistic: Josie had influenced Lonnie (Lonnie Zeltzer) and Sam’s (Samuel LaBaron) research, and in 1981 I drew inspiration from them and Josie’s research to bring hypnosis into BC Children’s Hospital, Vancouver Canada – my new home.
Sometime in 1984 or ’85, I met Dr. Karen Olness after giving a presentation on hypnosis for pediatric pain relief. She invited me to join the SDBP [Society for Developmental and Behavioral Pediatrics] Hypnosis Faculty where I met a group of pediatric professionals who became and remain my friends and teaching colleagues to this day!
How do you view hypnosis?
I experience and know hypnosis to be an extremely natural, effortless experience. It’s a common feature of our lives and of children’s lives– a frequent natural state of focused narrowed attention. Children and teens move in and out of trances more easily than we, adults do. I regard therapeutic hypnosis as engaging with that capacity to further a positive outcome, and develop a desired therapeutic change.
With children, I need to pay close attention to my words because hypnosis starts from the moment of our first encounter. I think of hypnosis a tacit agreement, to undertake this wanted change process together by using imagination and focused attention, and by practicing and refining this process until the goal is achieved.
How were your first experiences using with yourself — in other words, doing self-hypnosis?
I truly can’t remember my first self-hypnosis experiences, but I do recall how for years I’ve turned to self-hypnosis to prepare for any medical, surgical or dental procedure. The first was arriving from England to South Africa where I developed horrid allergies, which required skin testing. I was 6 years old and the nurse was fascinating. She had a little white funny hat ontop of her black hair and was so pretty that I felt nothing of those many little skin injections along my outstretched arms.
As I grew older I learned to turn inwards and ‘let go’ into acknowledging, and trusting the bedrock of healing that I have within my body. It feels very simple, but the effect is profound. This releases all the overlay of tension, fear and worries. It’s going to the knowing, and subverting all the angst and fears. But—and this is a big BUT – I have to ensure before hand that I can indeed trust the professional/s doing the procedure. Once that is in place, I breathe deeply and let go with the words, that ‘my healing will be rapid and smooth’ …and that has been the outcome so far!
Can you give an example of one of your first successes with hypnosis with a patient?
At the beginning of my career in 1979 I used hypnosis for treating children’s abdominal pains. But it was only from 1980 onwards, when working in Oncology that I grew to appreciate what a remarkable therapeutic asset hypnosis could be. Early on I worked with a teen with Ewings Sarcoma, Jenny, for her dreaded IV access. After she gained some mastery she asked to use hypnosis to support her recovery from this nasty disease. I taught her how to use hypnosis to scan her body and bring healing, ease and well-being to every part of her body.
Oncology staff raised the concern: ‘I’m really worried about Jenny, because she’s putting so much into this hypnosis, and what if it doesn’t work and she relapses? Will she blame herself for not trying hard enough?’ We discussed that it isn’t about trying hard enough; it’s about using everything to maximize the chances for healing and to gain comfort, peace of mind and spirit. My big lesson here was how to negotiate minimizing uncertainty without giving false hope.
Who decides when or how hypnosis would be helpful?
The children do their own practice in the way that gives them meaning and contentment. When very ill, it’s remarkable how wise children are—and I learned to take my lead from them. Jenny had used hypnosis as part of her pain management over four years of intense medical treatment. One day she came to clinic and said, ‘I was doing my hypnosis body scan for comfort and I saw something quite different’. I asked, ‘Different how?’ And she said, ‘Well, I thought I better come in and have a bone scan’. She knew before anybody that something wasn’t right, and through her regular self-hypnosis practice picked up a recurrence of tumour growth. So sad! But that developed connection within herself and her body, gave her considerable internal strength and acceptance for the tough road ahead. Jenny was one of my remarkable early teachers about how far teens/children can go in their healing journey, when taught hypnosis early in their treatment and within flexible creative forms.
How do you use hypnosis nowadays with your patients and their families?
Now, I work with children and teens suffering from complex, ongoing pain conditions, such as complex regional pain syndrome, abdominal diseases and pain, chronic diseases, migraines, persistent headaches, and various painful musculo-skeletal conditions.
Because of the persistent nature of these physical pains there are many overlays of emotional, cognitive, social and family issues that compound the pain experience. Often there’s a history of successive failures and withdrawal from school and friends. Hypnosis is my most powerful therapeutic tool, and I want to use it early on while developing the therapeutic alliance, thereby increasing the patient’s capacities to engage more productively with her/his body and life.
First I educate about pain: ‘Do you know how pain works?’ They often shake their heads. ‘Has anybody explained how pain is processed in the body?’ Clinicians often don’t have or take the time to explain the brain’s role as a pain modulator to inhibit pain. Hypnosis informs my language while educating about pain mechanisms. “Let me tell you because it’s fascinating!” I use diagrams of pain pathways, anatomy books, charts and model of the brain, or draw on the white board,–whatever is appropriate for the developmental age of the child or teen.
For which kinds of problems do you use or suggest hypnosis?
Hypnosis is helpful to me working in palliative care. I’m now working with a divine little girl who is living with a relapsed astrocytoma. It’s a disheartening, bumpy process living with a condition that is incrementally killing your brain’s capacity to function. She uses hypnosis to travel to restore her energy, and reconnect with what gives her life meaning. She returns heartened. She says these ‘trips away’ (dissociation) ‘are cool!’ They seem to sustain her spirit and lessen her suffering, loneliness and despair.
What do you think is essential or important for hypnosis to be most effective?
BE PLAYFUL . All of us learn when we’re engaged and enjoying the experience. Creating that emotional fascination is important. Jokes can be problematic –as a child said, ‘I like doctors to tell jokes, but I don’t like the jokes where the doctor’s the only one laughing!” Those are not child-focused jokes. So I’m not very jokey, but I do find humor in the interaction and play by evoking curiosity, engaging fun and inviting surprise, or rhyming words which I find ‘easy peasy, lemon squeezy’.
INVITE THE CHILD TO HAVE THE HYPNOTIC EXPERIENCE. I introduce hypnosis with an invitation. ‘Would you like to travel inside? I wonder what you’ll see? Maybe it’ll be a surprise, maybe it’ll be so different that you’ll start feeling more comfortable, and you’ll certainly be surprised how easy and fun it is.’ l do a lot to soften apprehension of the environment, indirectly providing the message of safety and ease.
ENABLE PARENTS TO BE HELPFUL ALLIES. Many pediatric pain problems are compounded by anxiety, poor sleep and accumulated sleep debt that snowballs into stomachaches, headaches, family distress and parental anxiety. For hypnosis to have an effective therapeutic outcome, parents need to be onboard, understand what and why self-hypnosis has a place at home—not to interfere with the child’s initiative and to support follow through.
What are some of the things that you do that build rapport or enhance response to hypnosis?
Hypnosis unfolds within the relationship. My task is to read, track and attune myself to the child at all times. As the creative potential unfolds through our interaction, I focus on developing a relationship of trust and openness. I feel alive in this process— it’s amazing how much one can pick up in this process, like a highly tuned sort of instrument, attentive, absorbed, hearing information between the child’s or teen’s words and observing spontaneous behavior.
I use language very deliberately: ‘When this pain is down’; or with surprise, ‘You didn’t know, did you, that your brain and your bladder can talk directly to each other.. even when you’re asleep they can help keep you dry’; “You are boss of your body. So your brain can be a great boss right now and help close the gates so your body has less and even less, and even less pain.
When change is slowed or not occurring, I ask directly “What are the blocks (or barrier’s or things that stand in your way) to you experiencing (your goal)? The more I understand what the child/teens beliefs are about why this negative problem is happening, or how it arose, and what is preventing the needed change, the better I can help shift or resolve it. I would rather spend more time talking and exploring the child/teen expectancy to enhance responsiveness, than repetitively do hypnosis. With this new information I can create optimal more effective hypnotic experience that had previously been distanced by despair or suffering.
Are there specific techniques, strategies, or exercises that you have found particularly useful that you use routinely in many or most cases, or in particular situations?
I love the Magic Glove as a hypnotic experience for regional analgesia for needle procedures in children 3 to 13 years old. I’ve developed it over the years to address different needle procedures: for blood-work, IM injections, port-a-cath, children with needle phobia and palliative care applications. It is versatile, quick and once learned, can be used by parents. We recently made a video on it.
With children, especially of elementary or younger, I find it beneficial to be use direct suggestion outside of an induced trance experience. My language is simple, hopeful and positive. This leads me to restate the problem from the beginning into a workable goal. For example, in the first encounter with a young child who has daily headaches; ‘So you want to have your head feel good and clear so that you can think easily and have fun at school … right?” I redefine the territory hypnotically, stating our therapeutic goal and her potential to get there; ‘Remember when you didn’t have any headaches? That’s what we’re going to help happen again. We’ll work together with you as the “chief detective” so put your detective hat on! I’ll be your expert consultant and Mom or Dad will be the expert parent!’ This means that hypnosis is not only the trance, a private or dissociated state, it’s the moment of first encounter and is embedded in our developing therapeutic relationship.
Change can happen quite quickly with hypnosis, so I heighten whatever will move the child through the door to her optimal outcome. I don’t want to work with the same kid for 42 sessions! I will intensify and hearten the child’s experience and absorption in our therapeutic relationship dedicated to making life better.
Do you make recordings of your sessions to give to your patients for home practice?
Audio recording are a crucial part of my hypnosis work. Children are part of the digital world, and now it’s easy to record hypnotic sessions and know it will be easy for children to listen to them. I record 3- to 8-minute experiences, short enough to do before school or during recess. I use MP3s, CDs, and more commonly now record directly onto their iPods or iPhones. Rare is the time I do hypnosis without recording it. Each session we create another short recording dealing with the next step in the movement towards full recovery and wellbeing. These become stepping stones to self- hypnosis, but for more complex problems the audio recordings are both a ‘security blanket’ and therapeutic aid.
Children with complex pain often collect a library with a different name for each recording, and know which works for what problem. There could be one for sleep; when in pain; after school when energy is low; or when homework needs attention and there’s pain; or in the morning when it’s hard to face the day. They let me know what works for when, and we tailor a hypnosis experience to fit, so that they become more independent, relying on their growing resources and practice. I love the analogy of an athlete training her body to work more effortlessly and easily. Athletes only succeed through regularly attending to what needs improving– and doing it (not trying but doing!).
Tell us about your favorite research studies about pediatric hypnosis, either things you or others have published or discovered?
Olness, MacDonald and Uden (1987) prospective study using single-blind, placebo cross-over design comparing propranolol with self-hypnosis and placebo treatments for children’s juvenile classic migraines is my all-time favorite! It’s a brilliant and elegant study – a real classic. The researchers showed conclusively that children are able to self-regulate physiological processes previously not believed to be subject to voluntary control; that non-pharmacological interventions are preferable and more effective than pharmacological options for juvenile migraines (and which still has not been fully taken up in pediatric neurology) and that there are adjunct benefits of enhanced self-esteem, validation of coping skills and attendance at school. Pretty powerful findings over 30 years ago and still highly relevant today.
What else would you like people to know about you?
My first career was as a documentary filmmaker for SABC Television while living in South Africa. I went on to do clinical psychology, then left the country on a doctoral fellowship to come to Canada and never thought I would ever make another film. But life has surprises.
Through my hypnosis work in Oncology, I’ve had the opportunity to make a film on pediatric pain management and then made four others. First was: No Fears, No Tears (Kuttner, 1986) on eight young children in the oncology pain program. I explored how pain is managed in different areas of a pediatric hospital in the documentary Children in Pain: An Overview (Kuttner, 1990). I made a follow up on the long-term impact of learning hypnosis when so young, in No Fears, No Tears—13 Years Later (Kuttner, 1998). With the National Film Board of Canada we explored the state-of the art of pediatric palliative care, Making Every Moment Count (Kuttner, 2003). I’ve recently completed a short film Dancing with Pain loosely built on Melzack’s ‘Neuromatrix’ exploring teens managing chronic pain.
Hypnosis is a key part of all the films. Children and teens are compelling when telling their own stories. Watching them on film allows the viewer to directly hear and learn about children’s experiences, and provide a rich appreciation. Films are after all hypnotic experiences (which makes me appreciate how so many aspects of our lives, which at first seem appear divergent, are in fact intertwined into a coherent whole)!