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In the severely burned patient there are a number of complicating factors that often constellate a vicious negative cycle, too frequently leading to death. These factors are (1) the constant pain, (2) loss of appetite, (3) the requirement for repeated painful procedures, such as debridement of dead tissues, (4) contractures resulting from failure to exercise because of pain, and (5) a syndrome of severe psychological regression and negativism, which may greatly slow rehabilitation,

Hypnosis has been shown to be of benefit in all of these problem areas.

In the early 1950s our group was the first to report that hypnosis could aid greatly in the treatment of severely burned patients

(Crasil-neck et al., 1955). A young woman had been burned (second and third degree) over 90 percent of her body surface. She was fearful and in constant severe pain, It was possible with hypnosis to give her relief from most of the pain, produce calmness, and alleviate much of her anxiety. Although she died 3 days later in spite of heroic medical and

surgical care, it was clearly established that hypnosis was of great benefit in allowing the woman to die with minimal pain and suffering,

One of the problems of the severely burned patient, as already noted, is loss of appetite. In the past this has sometimes led to severe negative nitrogen balance at a time when the need to build new tissues is great. Hypnosis was found to be of marked aid in increasing food intake. A case illustrating how hypnotherapy increased food intake.

decreased pain, and calmed the patient follows:

A 24-year-old man was subjected to hypnosis after 18 months of hospi-talization for a 45-percenl body surface burn. His course in the hospital had been progressively on the downgrade and was characterized by a weight loss of 40 lbs [18.1 kg] from 130 to 90 lbs [59 to 40.8 kg]: a loss of muscle mass;

multiple unsuccessful skin-grafting attempts; chronically infected granulating wounds and infected donor skin sites; extreme weakness with refusal to attempt to leave the bed or to move his extremities: the development of decubitus ulcers and severe contractures of hands, ankles, knees, arms, and neck; the persistent complaint of pain and request for narcotics; an increasing dependence and regression to puerile behavior at times; the refusal to eat despite the attentions and compassionate pleas of resident surgeons, dietitians,

nurses, and relatives, despite lengthy explanations of the importance of food to his recovery and despite a blunt coercive approach; the failure to improve significantly while being force fed through a small polyethylene nasogastric tube; complaints of fullness and nausea with forced feedings of varied volumes and composition and finally refusing to permit the tube for feedings: and the failure to obtain lasting improvement in appetite with the administration of corticotropin.

Soon after rapport was established between the patient and the therapist and hypnotic and posthypnotic suggestions were started, the patient began to anticipate with eagerness each meal; within a few days he was consuming about 4200 calories each day. Six weeks after hypnosis was started, he gained 30

pounds [13.6 kg]; he became ambulatory, exercised faithfully, gained strength and muscle mass rapidly; skin-grafting procedures were rewarded by 90 percent

"takes;" spontaneous epithelialization was rapid, and small granulating areas healed; he began doing things for himself that he had previously de-manded that others do: he became cheerful, left his room frequently, and sought the company of nurses and other patients. Narcotics were discontinued, and there were no complaints of pain. Twelve weeks after beginning hypnosis he was discharged from the hospital in an ambulatory state with nearly all wounds healed. In this patient a progressively downward course was arrested and reversed after the application of hypnotic suggestion. The food intake became adequate, his attitude improved, he complained of no pain, he became ambulatory, and recovery ensured.*

*Reprinted from Crasilneck HB. McCranie EJ, Jenkins MT. Special Indications for Hypnosis as a Method of Anesthesia. JAMA. 162:1606-1608. 1956. With permission.

Figure 8-3. A severely burned patient is placed in hypnosis for pain relief using an arm-levitation induction technique. Suggestions were given that the arm would be cold, numb, devoid of pain sensation from the fingers to the

shoulder " a s if it is enclosed in a thick leather glove."

We have had very good results in increasing food intake with severely burned patients. A typical preparation of a burned patient follows:

"I am going to ask you to stare at this coin that I'm holding and as you do so. pay no attention to any other sounds or noises. You are aware that you are

Figure 8-4- Hypnotic suggestions for "feelings of pressure but no pain" were continued throughout the surgical debridement of dead tissue and changing of bandages. Posthypnotic suggestions were Then given for relaxation and for

"only a remnant of discomfort."

breathing more rapidly and also That as you stare intensively at this coin, your eyelids are beginning to blink and to feel heavy, As you feel them getting heavy and drowsy, just let them close . . . that's it . . . they are fluttering . . . closing and closed . . . closing and closed . . . and as I continue talking, you will enter a very deep level of hypnosis . . . for in so doing you are going to get well. . .

a very deep and sound level. . . . As you are aware of a heavy feeling in your extremities, your arms and legs . . . as you are aware of this . . . nod your head . . . Good. . . . a deeper and a sounder state. . . . Now the finger that I touch will lose all feeling. . . . Now as that finger feels and is numb . . . nod your head, yes. . . . Good. . . Now open your eyes. . . . You will note that I am stimulating that finger very hard with the point of my nail file, but you have absolutely no sensation of pain. Pressure, but no pain. Now normal sensations return to your finger. As you fee! the file just barely stimulating your finger, pull it away. . . . Good, . . . Relax . . . now you can realize the power of the mind over the body and if you can block pain . . . real pain . . . then, you can allow your body to respond to other suggestions equally well. You are now in a very deep state of relaxtion. . . , You are going to hear some soft music that is pleasurable to you . . . and as this occurs, nod your head, yes. . . . Good . . . and now a very deep and relaxed state of mind and body. Because of the power of your mind over your body . . . you are going to be able to definitely increase

your food intake. This food intake is going to help you to get well . . . it is an integral part of your rehabilitation, and you will eat all the food prescribed by your doctor- The food will taste good. . . - You will enjoy your food . . . realizing that with every mouthful you digest you are improving your physical and mental state. . . . Food intake is going to help you get well. . . . You will be hungry much of the time and you will eat not only the regular meals, but also the supplemental food ordered for you. You will be hungry and your appetite will definitely increase . . . you will have a craving for each meal because in your case food intake is an absolute necessity to health and you will eat every meal with enjoyment . . . knowing this food is making you get well very rapidly. As I slowly count from ten to one backwards, you will fully awaken . . . relaxed, at ease, and hungry."

Skin grafting is usually necessary in severely burned patients. This can be a painful procedure, and the fear and apprehension of the patient may be a complicating factor for the staff and for himself or herself.

Pain may also interfere with exercise that is necessary to prevent contractures as the burned and grafted area heals. Both the pain and anxiety associated with the treatment of burns may be decreased with hypnotherapy (Hartley, 1968; Papermaster et al., 1960).

T h e use of hypnosis for both of these problems is shown in the case that follows:

A 33-year-old man was admitted to the hospital with a burn over 45 percent of the body surface. During the first 30 days he was operated on several times for the removal of devitalized tissue and for skin grafting. Because of pain it became necessary to administer a general anesthesia for dressing changes.

The patient complained bitterly of pain in the donor and other operative sites after each procedure under general anesthesia. He refused to exercise his hands and fingers, which had been burned. With these first 30 days serving as a control period, hypnosis was used as the analgesia for subsequent dressing changes and debridement. These procedures were then performed without complaint; with hypnotic sleep used as anesthesia, a split-thickness skin graft was cut. There was no manifestation of discomfort. The patient was given the posthypnotic suggestion that there would be no pain in the donor area, that he would exercise his hands, and that he would be hungry. On awakening he complained of hunger and reported an absence of sensation in the donor area.

Three days later norma! sensations were returned to the area by hypnotic suggestion. He exercised his hands as instructed, every 30 minutes, so faith-fully that it was necessary to limit this activity, for he even exercised them

during sleep! Subsequent posthypnotic suggestion had to be made so that he would exercise only during waking hours. After the patient had entered a moderate to deep level of trance, he was told the following;

"Exercise is most important to your recovery. . . . You can and will exercise your hand for 15 minutes out of each waking hour, as prescribed by

your doctor. . . . There will be only minimal, if any, discomfort. . . .However, you will protect your hand . . . but you will stretch the muscles . . . make a fist as the doctor showed you and will want to do this, because exercise will help you to get well. . . . You will exercise for 15 minutes out of each waking hour . . . because you want to get well. . . . You can reinforce these suggestions yourself, and anytime we are ready to work together you can attain a deep level of trance when I give you the posthypnotic suggestion of tapping on this table five times with this fountain pen . . . you will awaken and you will follow these instructions carefully . . . as I count from ten to one, you will be fully awake."

The avoidance of repeated general anesthetics and narcotics, in addition to establishing a will to exercise his hands were the therapeutic benefits obtained from hypnotic suggestion in this patient.*

Hypnosis can decrease the use of narcotics that may otherwise be demanded in large quantity by the burn patient who is in severe pain.

A 32-year-old man was admitted to the hospital with a mixed superficial and deep dermal burn over 35 percent of the body surface. He was subjected to hypnosis after arriving at the hospital about 4 hours after the injury. No

narcotics were required during the acute phase of injury or at any time during his 18 days of hospitalization. Complete alleviation of pain was obtained with hypnosis in this man throughout his hospital course.

Schafer (1975) described his effective use of tape-recorded hyp-notic suggestions that were employed on a burn ward when dressings

were to be changed. Bernstein (1963) asserted that hypnosis did not always produce anesthesia, but it did increase pain tolerance.

Dehen-terova (1967), Finer and Nylen (1961), and Pellicone (1960) have also described the use of hypnosis in the treatment of burns.

Dabney Ewin of Tulane Medical School has produced a prodigious amount of work in the use of hypnosis in the treatment of burns (Ewin 1978, 1980, 1983). Ewin stresses that the more rapidly hypnotherapy can be instituted after injury, the better the results are likely to be, He cites one example (Ewin, 1978) of a young man who stepped into a vat of molten metal that had a temperature of 1750°F. Hypnosis was

instituted within 4 hours of the injury and was of great benefit in pain relief as well as possibly decreasing swelling and edema and increasing blood flow to the injured tissues. In a clinical study, Kaplan and Moore (1983) have attemped to measure increased blood flow to one of two bilaterally injured limbs following hypnotic suggestions. The psycho-logical value of hypnotherapy in decreasing anxiety and speeding

recovery in burn patients is widely appreciated (Crasilneck, 1978a,b,

*Reprinted from Crasilneck HB. McCranie EJ, and Jenkins MT. Special Indications for Hypnosis as a Method of Anesthesia JAMA 162:1607. 1956.

1979, 1981; Finer, 1980; Hart, 1980; Margolis and De Clement, 1980;

Schafer, 1978; Wakeman and Kaplan, 1978).

After the pain of the burned area is under control, and the anxiety of the patient is in a state of quiescence, the rapport with the patient is at its zenith. As the hypnotherapy continues to control food intake, exercise, and ambulation, the therapist at this point must use psycho-therapy in order for the patient to vent his anger, resentment, and frustration. Combining hypnotherapy and psychotherapy in conjunc-tion with hypnoanesthesia works well for most b u m victims (Crasil-neck, 1978a, 1979, 1981).

A research design by Hammond, Keye, and Grant (1983) evaluated the effects of sunburn equally distributed on both thighs with hypno-analgesia given in treating only one thigh. None of the 6 subjects reported pain in the anesthesized thigh, temperatures were significantly lower, and there was much less redness on the skin.

Bernstein (1963, 1965) has reported on the use of hypnosis on a ward caring for burned children, outlining the reaction and interaction

of the staff. He cautions against a magical overexpectation of hypnosis by the staff, as it later may lead to a rejection of the usefulness of hypnotherapy. The tendency to overexpectation apparently is related to an underlying sense of helplessness in a situation that mobilized a great affective desire to be of benefit to the children. The use of hypnosis with children who have been burned is discussed by Gardner and Olness (1981) and by La Baw (1973b).