Melbourne, Australia-based journalist and novelist, and author of Anesthesia: The Gift of Oblivion and the Mystery of Consciousness
Some years ago, I arrived at hospital for an operation to fuse most of the vertebrae of my spine. I brought with me my mother, a collection of lucky charms and a rumbling disquiet at the prospect of going under a general anesthetic. I confided to a receptionist that, after more than a decade of research, I thought I might know too much; “Oh dear,” she said. “That’s not good.” My research had taken me from the blithe certainties of my old life into a netherworld of shifting, slippery questions. (Can we hear under anesthesia? Or learn? Or feel pain?) It was unsettling. Yet, it had also equipped me with some ideas I hoped would help me through: The strangest of these was the notion that, during surgery, I would be able to limit the amount of blood I lost under the knife.
When I first began researching the odd and fascinating process of general anesthesia, I assumed that it was a sort of switch – on/off – a hiatus during which we (the anesthetized) are entirely absent. Certainly this was my recollection of my own previous brief encounters with the practice. The reality, it turns out, is more complex and far more interesting. Under general anesthesia, our brains, while altered, are still active, with possible implications for the anesthetized patient. For many years now, small groups of doctors have been exploring the possibilities of using hypnosis before surgery to help patients during and afterward.
Hypnosis, like anesthesia, is an imprecise art, and not entirely understood. It conjures images of dangling fob watches and people behaving like chickens at the behest of stage hypnotists. Definitions differ but, in essence, it is a state of inner absorption and focus that can leave us receptive to suggestion (our own or other people’s) and in which we can experience disturbances in sensory perception (how things feel, look, sound, smell or taste) and memory.
It has long been known that hypnosis can be weirdly effective in treating pain. Before the official discovery of general anesthesia in Boston in 1846, it was often a patient’s best hope. In the 1830s, French and British doctors documented several major operations using only hypnosis. In the 1840s, Scottish surgeon James Esdaile reported having performed 300 painless surgeries in India (including removal of 17 scrotal tumours) using only hypnosis. All that fell away after Oct. 16, 1846, when Boston dentist William Morton famously used his new inhaler to administer the gas ether as doctors operated to fix a tumour in the jaw of 20-year-old Edward Gilbert Abbott.
But in recent years – amid soaring health budgets and the human fallout of the opioid crisis – there has been a sharpening focus on the potential of non-pharmacologic approaches to pain control in and out of the operating theatre. The findings suggest that, as patients, we may be more powerful than we think, even when unconscious.
In 2002, a team from New York’s Mount Sinai school of medicine published an analysis of 20 studies and found that surgical patients who received hypnotic suggestions before surgery did better than 90 per cent of those in control groups on measures including pain, anxiety, depression, duration of surgery and of hospital stay. Several years later, members of the same team staged a study that hinted we might also do better on (and off) the operating table if we see ourselves as playing an active role in our own surgeries.
They took 200 women going in for breast-cancer surgery and split them into two groups. Before going under anesthesia, each woman had a short meeting with a psychologist. Those in the control group were told the sessions were a chance to chat or ask questions, but the women in the experimental group were hypnotized and given specific suggestions, including that they would feel reduced pain, nausea and fatigue when they woke. The results were startling. The hypnotic group used less drugs, spent less time in surgery and reported less pain, nausea and distress afterward. The hypnotic intervention was estimated to have saved the hospital more than $770 a patient, mainly in reduced surgery time.
“If a drug were to do that, everyone would by now be using it,” psychiatrist David Spiegel wrote in an editorial in the same edition of the Journal of the National Cancer Institute, “So why don’t they?”
In a recent interview, Dr. Spiegel (who is Willson Professor and associate chair of psychiatry and behavioural sciences at Stanford University school of medicine) said he did not have an answer to that question. “I wish I knew. I used to think if we just provided enough science people would come around. And we provided the science – and people haven’t exactly come around.”
Part of the problem, he said, only half-joking, was the lack of a business model for hypnosis. “Maybe we should have stuck with dangling watches because at least the watchmakers might have been interested, but there’s nothing to sell.”
But the deeper problem was one of perception. As far back as 1963, the Canadian Medical Association’s Special Committee on Hypnosis recommended that hypnosis be permitted in obstetrics and anesthesia “as an alternative technique when indicated.” But, Dr. Spiegel says, many patients and doctors simply don’t have confidence in it.
“I think most doctors and most patients still have this fundamental prejudice that the only real treatments are the biological ones. And the only way to relieve pain is to numb people’s brains in one way or another. We think of our bodies, including our brains, as a kind of machine that needs to be tinkered with or have parts replaced, rather than a really interesting finely tuned instrument that can manage itself in ways that we don’t give it credit for.”
In January this year, Dr. Spiegel was invited to the Swiss town of Davos to speak about the role of hypnosis in pain control, as part of the 2018 World Economic Forum. Hypnosis may not seem to have much to do with economics. But pain does. Dr. Spiegel points to the costs, direct and indirect, of an overreliance on pharmaceutical solutions. Apart from the human toll of opioid addiction and drug-overdose deaths, he says, the finances simply don’t stack up. “By the middle of the century, there’s going to be 9.7 billion people on the planet, and the way we’re delivering health care just is not going to work. So we need to enlist people’s brains to help them manage their bodies. We just aren’t doing it.”
In 1986, American psychologist Henry Bennett published a strange and seemingly improbable study. He took 92 patients facing major spinal surgery – typically a bloody affair – and assigned them to three groups. One group, the control, was simply given some information about monitoring. The other two each got additional relaxation exercises; and one, the experimental group, was also given a very specific instruction: “that ‘the blood will move away’ from the area of surgery beginning then and continuing though the operation, after which it would return to the area.”
It was a small study, but the results were startling. People in the “blood-shunting” group lost on average 650 millilitres, a third less than those in the control group (who averaged a litre). Those in the relaxation group lost even more. Dr. Bennett subsequently made a longer tape recording of his preoperative instructions, and in the lead-up to my own back operation in 2010, I contacted him and asked if I could listen to it. In my book, I talk about his looping, dreamy syntax and his suggestions about waking without undue pain or nausea, with my stomach relaxed; and, of course, the idea that under anesthesia I would somehow draw the blood in my body away from the 19-inch wound in my back. I was not entirely convinced. But I was strongly drawn to the idea of the patient – me – not just as a passive recipient, but an active participant in my own surgery, conscious or not. So I listened.
In fact, Dr. Bennett argues all this is possible without relying on hypnotic techniques to deliver the instructions. He didn’t use hypnosis in the original blood-shunting study. Instead, and based on the teachings of the late psychologist Theodore Barber, he says he simply delivered “believable physiological instructions … to an attentive subject in language he can understand.” Just words.
It turns out that part of the power of words is in shaping the expectations we carry around with us, often unexamined. At Davos, in that same session, Stanford psychologist Alia Crum told the assembled leaders and policy makers that our minds – and mindsets – change our futures in ways both concrete and literal. Words, images and expectations that are poured into us by our parents, culture and advertisers “have an uncanny authority to craft how we expect ourselves to be.” She has done experiments that show the power of those expectations. Hotel cleaners who were simply told the work they were doing was good exercise lost weight, slimmed down and lowered their blood pressure with no change in their behaviour.
So might those expectations also affect us as we go into surgery? The third member of the party was Beth Darnall, clinical professor in the department of anesthesiology and pain medicine at Stanford. “Your thoughts, your beliefs, your expectations – your mindset – impacts your health, how quickly you heal and how well your medications work, including powerful opioid painkillers,” she said.
And when we expect the worst – or “catastrophize” – that is what we tend to get. “A negative pain mindset is more predictive of postsurgical outcomes than the disease, the surgery or the surgeon.” This has implications for long-term chronic pain, estimated, she said, to cost the U.S. economy US$635-billion each year. Pain, whether in your head or hand, is processed through the brain and spinal cord and is closely linked to individual expectations and psychology.
Dr. Darnall has developed an online presurgical pain psychology treatment that she hopes will soon be freely available to help patients reprogram their mindsets and in doing so change the ways their brains process pain after their operations.
Dr. Spiegel says such instructions may also influence patients during their surgeries. “There are people who are still processing information during general anesthesia and we don’t know to what extent, but the brain is sufficiently complex that we are not consciously aware of even a small fraction of all the things our brains are doing. There’s no reason to think that your set of expectations has no effect on how the brain processes what’s happening.”
So what of my own far-from-scientific attempts to enlist my own brain to help manage my body during surgery? The operation was long, but neither longer nor shorter than expected. I didn’t feel nauseous when I awoke; I felt very, very high. Was I pain-free? Nooo! Not then and not for a long time after. But there was one measure on which I came through remarkably well. When I asked my surgeon some time afterward how much blood I had lost on the operating table, he cast me what might have been a speculative glance. “Not much. Surprisingly little. About 400 millilitres.” Less even than the experimental group in Dr. Bennett’s 1986 experiment.
Of course it proves nothing. Would I do it again if I ever have to face more major surgery? Absolutely.