Have Hypnosis, May Travel…

“You want me to do what?”

Janet’s smile never waivered; it broadened if anything. “Hypnotize my friend.”

I rolled my eyes in a maudlin attempt to emphasize my frustration at her answer. “But your friend is a male, Janet…”

She blinked slowly –her version of an eye-roll, no doubt. “Given that you are as well, I don’t see an ethical problem.”

“I’m an obstetrician, Janet. By definition, we see females. We have nothing against males; we just don’t see them as patients.”

She shifted slightly in her chair, as if this would somehow work to her advantage in the discussion. We were sitting in the hospital cafeteria by a window that mirrored the whole room in the early morning darkness. Neither of us could be mistaken for fashionable in our rumpled scrubs that still bore traces of an emergency Caesarian section.

Now a freshly minted GP, Janet had been present at a class of residents I had been assigned to teach a few years ago. I don’t even remember what I had intended to talk about, but they had taken a vote before I arrived and decided the topic would be hypnosis. I had made the mistake in a previous class of regaling them with tales of my adventures in using it to treat hyperemesis gravidarum – nausea and vomiting in pregnancy. Unfortunately I agreed and promptly managed to hypnotize myself in attempting to demonstrate it with a volunteer using a little cut-glass pendant necklace I borrowed from the student. They loved it.

“You could see him at the end of the day, if that would make it easier for your waiting room.”

I took a deep breath and let it out slowly, but noisily for effect. “Janet, you don’t seem to understand. In the Canadian medical system, we get paid a fee-for-service amount for specific items in our specialty. There are no items in it for men.”

She thought about it for a moment. “Okay, suppose I refer his female friend to you and he just happens to come with her?”

I shook my head.

“He’s willing to pay privately…”

I shook my head again, but less vigorously. I’ve never liked the idea of paying privately for medical services; it smacks of privilege. Of jumping the queue. “You still haven’t told me why he needs the hypnosis so badly. Is he a smoker, or something?”

Her turn to shake her head. “Death!”

My eyes went wide; I couldn’t stop them. “I don’t do Death, Janet.” I considered that response for a moment. “I mean, we’re all going to die…”

She smiled -a thin, made-up, wan sort of lip stretch- and turned on her eyes. “Not like he figures.”

I didn’t like where this was going. In a specialty that deals mainly with new life, I’ve always felt uncomfortable with the other end. “What sort of illness does he have?”

Her smile brightened and her eyes twinkled. “Politics.”

I decided to look at her reflection in the window; it seemed safer, somehow. “I just know that you’re going to explain.”

“He asked me not to.”

My eyes involuntarily sought the source. “Too dangerous?” I was getting into this now.

She nodded, but mischievously. Playfully.

“And might this be… foreign politics?” I asked, attemping to make my voice serious.

She tried to keep her expression the same, but I could see little microscopic worry lines beginning to gather on her forehead. “Well, his sexual orientation is domestic…”

What did that mean? Janet was exasperating and I was tired, but she still pulled out the big gun: “Look, will you do this as a favour for me?”

I stared into my empty cardboard coffee cup for a moment. “Well, make sure he brings his partner…I’ll figure out some condition for her so he doesn’t have to pay.” I thought about it for a moment. “Maybe infertility…”

“That’ll work,” she said, but her eyes were much too twinkly for me to ignore.

“Something else you’re not telling me Janet?”

She shrugged. “He’s gay.”

I shrugged back and smiled. I love twists like this. We had an understanding, however –but an agreement that I, for one at least, did not understand.

*

He seemed quite at ease in my waiting room. A short, ebony man with a shiny bald head that reflected the flickering of one of the flourescent lights above him, he was dressed in a dark suit and grey-blue tie. A similarly well-dressed woman sat beside him, quietly reading a magazine from the table in front of them while he smiled and studied the room like a text book.

“Come in Jonathan and…”

“Flora,” he responded in a deep sonorous voice that seemed to fill the room. She smiled and took his hand. The perfect couple.

I led them into my office and seated him in the least-uncomfortable chair somewhat guiltily. But he smiled disarmingly and accepted. Then he nodded to her and she touched his sleeve and left the room. “It is best she leave,” he said softly. “The less she knows…” he added, and the unfinished sentence hung in the air like the sword of Damocles.

And then… nothing. I felt unaccountably nervous and neither of us spoke. He just watched me for a moment and then closed his eyes. “You may proceed, doctor,” he said after a few seconds. “Teach me how to hypnotize myself.”

I took a deep breath to steel myself. I felt like a child chosen at random by the teacher to come and write something on the blackboard in front of the class. “Well, first I need to know a few things, Jonathan. Janet said you’d explain,” I said with as much courage as I could muster.

His eyes suddenly opened and he stared at me like a lion who’d spotted a zebra on the plain.

“Different problems require different solutions,” I lied, and then shrugged in what I hoped was a take it or leave it gesture.

A smile spread slowly over his face, but it was a condescending expression, a bored acquiescence -the smile of a king. “I am running for office in my country,” he said in a booming voice that managed to be soft, yet vibrate the leaves of the plant on my desk at the same time.

I nodded to encourage him further, but I suppose he assumed he had given me what I had requested and he closed his eyes once more. Waiting.

I tried again. “So you need hypnosis to..?” I’ve never been good at unfinished sentences. They always sound like I’ve just forgotten what I intended to say. When his face looked like he’d fallen asleep I thought I’d better finish it. “…To help you to relax when you have to make a speech in front of a large crowd?” That sounded reasonable; I’m afflicted with acute amnesia and random mispronounciations whenever I am asked to speak at a meeting.

Still nothing. Maybe he really had fallen asleep. I decided it deserved one last try, and then I would wake him up if I had to. “What is it that worries you about running for election in your country?” I said, even though I hadn’t the faintest idea what country it was. And he certainly didn’t look worried.

Then, from the depths of his chest, a regal whisper: “Death threats.”

“Oh…” I didn’t know what else to say.

I taught him to hypnotize himself -and it seemed to work. Then for weeks after he left, I scanned the newspapers for foreign political assassinations, but without knowing the country or the office he was running for, it was all to no avail. You’d be amazed at just how many people are getting shot at political rallies around the world. And Janet was no help; she was sworn to secrecy or something.

But I can’t help wondering if it actually worked. Did the hypnosis lull him into accepting danger, or allow him to rationalize his way out of it entirely? There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy… And if he did get shot in that unknown country, would would he still thank me for the lesson if he survived? Or is he angry..?

As for me, I’m much more careful where I go when I travel. Just in case…

 

 

 

 

 

 

 

 

 

 

The Ethics of Counselling

Primum non nocere -First, do no harm. I remember the phrase was used in one of the first lectures I attended in medical school and it nested -sometimes uncomfortably- in my conscience as the lectures and the years progressed. It would signal me from the back seat in Pharmacology lectures and tug on my sleeve in Physiology labs when we would be asked to subject laboratory rats to unconscionable ‘experiments’ whose outcome was already known and whose purpose would have been questionable even had we been seeking a Nobel Prize rather than a passing grade.

It especially fought for my attention after I’d graduated, when my decisions would actually be accorded credence. I would be asked to see someone in pain -with endometriosis, say- who had decided she’d had enough and wanted a hysterectomy. Often she would have been aware of other options -medications or ablative surgeries- and have tried them all unsuccessfully; sometimes she might be speaking out of frustration or desperation. But in none of these situations would she have felt in control, a full and willing participant in her destiny, able to make a reasoned, or at least equitable decision for herself.

One might argue the role of the dispassionate physician here: the person who can consider the ramifications of each option, present them in a reasonable and sensitive fashion, and help the patient decide. And yet, one might also point out the possibility that the patient might be unable to make a truly informed decision for herself under duress. There’s a term used in Medical Ethics that we were also taught in medical school: non maleficence. This is a concept that suggests that it is important -no, necessary– to consider whether a particular decision might do more harm than good, no matter how well-intentioned. It is yet another version of the primum non nocere phrase that so influenced me.

If I feel the patient actually understands the ramifications of her decision, and has at least considered and then rejected other possible pathways, then I am more than willing to accede to her request and help in whatever way she feels would be in her best interest.

But I have always believed that informed, or at least insightful empowerment -if I dare use that overworked and voguish neologism- is the key to compassionate decision-making. It’s object is not so much to convince or direct, as to allow her to come to an appropriate and acceptable decision, as much as possible unencumbered by all the trappings and emotional accoutrements of pain and frustration… As I have already mentioned, the problem of counselling someone in dire straits is that her pain or anxiety, quite apart from its obvious distraction, often permeates her entire being and impedes her ability to look out for her own ultimate best interest. Sometimes, the person can hear nothing but her own suffering. Counsel has to be heard as well as given.

I’ve explored many techniques to help the person help herself: meditation, relaxing exercises, music… But apart from the latter, they do not lend themselves readily to a half-hour appointment in a busy gynaecological office. And although music is my constant companion through the day, it is often background noise, if heard at all, for the patient stressed by more immediate problems. Most are unwilling, or more likely, unable to believe that meditation or relaxing exercise, will contribute anything to the resolution of their particular issues. It is difficult for them to see through the fog of their distress, and in many circumstances they do not need to do so.

If the problem does not admit of any other solution, then action of some sort is required. If the patient has a ruptured ectopic pregnancy and shows up in the Emergency Department, the solution is obvious and immediate. If she is hemorrhaging from a miscarriage, an explanation of a reasonable approach to the problem and then a D&C is appropriate.

I am not so concerned about the conditions that do not beg for a decision, or ones that cannot be resolved in any other way -conditions for which choice is mandated by necessity. But for those afflictions for which options are available and for which none are paramount, there should be other constraints to the decisions made. These are questions of ethics again: autonomy -the patient has a right (and indeed a duty) to decide for herself, and beneficence –the doctor should act in the best interests of the patient. And sometimes this requires techniques to enable the patient to exercise this right, and the doctor to feel he is in fact acting in her best interests.

Hypnosis is one approach to this that lends itself to an office setting. It is not for everybody, nor is it necessarily attainable in each and every patient, however willing. But I feel that in my office at least, it should be a non-directional tool if it is used at all -one that seeks not to influence or counsel, but merely to engender some symptomatic relief. It is an easily teachable skill, and because the relaxation is so readily apparent to her once she has encountered it, probably an effective one that she may well decide to try again. And with some goal-direction.

I am reminded, however, of the time when I initially began to use the technique. I seemed to attract rather unfortunate referrals then. At first the referrals were for innocent things: stress relief, panic attacks… even smoking. I had to quickly disavow myself of these consultations: although gynaecology entails a lot of psychology, I don’t see myself as the answer to panic attacks.

Then, undiscouraged, they began to send me more difficult problems: warts (yes there exists a body of literature of immune enhancement to engender a bodily response to the viral scourge of warts, et alia), endometriosis, PMS… anything for which the family doctor felt she was losing the confidence of her patient.

I have always felt more comfortable dealing with topics for which I am nominally trained, so I attacked the gynaecological issues with contemporary skill and knowledge. Only on the third or fourth visit and when all else seemed to have failed would I delve into the alternative toolbox in desperation. Sometimes it worked; often it helped. Visualization was especially popular I remember. Endometriosis? Right: visualize a field of flowers and with each breath in, you pick some, and with every breath out, you throw them away. Yes, the flowers are endometriosis implants.

When planetary eco-consciousness took hold, I had to modify the picture, however and switched it to picking up litter on the street then depositing it in a suitable refuse container… Anyway, same idea, same results if they remained enthusiastic adherents. Placebo? I don’t know, but even placebo works for a while, doesn’t it?

The problems worsened from the die-hard family doctors, however. Elated by the success of diverting their problems to me I began to get referrals that really made no sense. One that stands out particularly colourfully in my mind was the woman who was sent to me because she was anxious.

At first I assumed there was a gynaecological reason for the visit, but she quickly informed me that she was actually healthy: normal non-painful periods, no mood swings, no pelvic pain… Her pap smears were even normal and up to date, and she’d just had a mammogram.

I was beginning to despair of helping her when she admitted the reason for her visit: she was running for public office in the Philippines and was anxious about getting up in front of a crowd and speaking. She’d heard about hypnosis and wanted to try it.  Although a little out of my line of work, I thought maybe I’d try a little standard hypnosis to alleviate her anxiety since she was in the office anyway.

She looked relieved and smiled at me. “Thank you doctor,” she said relaxing in her chair. “I’ve tried everything I could think of -even tranquilizers- but I’m still terrified each time I get up there to speak.”

Although I sometimes try to explore the reasons under hypnosis and help the patient to recognize what might reasonably be expected to work for them, I decided to ask her beforehand if there was anything in particular that  worried her about speaking in front of an audience.

She didn’t give it a moment’s thought. “Oh yes, doctor. It’s in the Philippines, you know…”

I nodded pleasantly, and assumed perhaps the venue, or maybe heckling from the crowd was her concern.

“And there’s a lot of opposition to my stance on Birth Control, you know.”

I assured her we run into the same thing on occasion even here. “Sometimes it’s hard taking a stand on something isn’t it? You can never please everybody, can you?” It was so banal a comment I immediately regretted saying it, but she seemed to take some solace from my words.

“No you can’t please everybody, it’s true. And I’m glad you understand; that’s exactly where my problem lies. It’s why I want you to teach me hypnosis.”

I smiled the doctor smile, satisfied, benevolent, convinced that I was perceptive and could recognize her difficulty despite our difference in cultures and gender. I could help.

“Yes,” she continued, ” Every time I get up to speak in front of a new crowd in a strange village I’m afraid I’m going to get shot.”

I believe in counselling and I try to take the time to listen for what they sometimes cannot verbalize. I like to believe I can make a difference, but I don’t think I really helped her, you know… Maybe I should have referred her to someone else, but she left the office happy. Beneficence sometimes trumps non-maleficence, I guess -even if it’s only in the beholder’s eyes.