Case study 1

A young woman who had avoided dental treatment for years had developed so many dental problems that she was in constant pain and had to take sick leave from work. She knew that she needed to solve her problem or lose her job, but despite discussing her situation with a very sympathetic dentist, and being offered sedation, she could not bring herself even to attend the dental clinic.

When I first saw her, she did not smile and held her mouth semi-closed all the time, to hide her teeth. I saw her for two sessions, hypnotising her and working systematically through her fears, giving her re-education and reassurance, while she was in a hypnotic trance. She was able to tell me how her fears had started, as a young child receiving dental care, and I was able to address these fears, using areas of her cognitive and emotional resources that are much more readily accessible in hypnosis than in the usual waking state.

I gave her a recording which I had made for her, to reinforce the suggestions I had given her and to train her in bringing about a hypnotic trance for herself, without my presence. She practised with this regularly and was able to undergo dental treatment calmly, to the amazement and relief of her dentist. Originally I had been prepared to go to the dental clinic to hypnotise her while she was being treated, but this proved unnecessary and she was able to do it on her own. She is delighted to be able to smile again, and to get back to her job.

It is estimated that anything from 5% to 10% of the population is so fearful of dental treatment that they will not go to the dentist under any circumstances.1 A larger proportion is so fearful that they will only go under duress, that is when they have an acute dental problem, usually being in severe pain. Up to 75% of the population has a degree of anxiety about dental treatment.2 In addition, there is an approximate 10% of the population which suffers from needle phobia, who are also likely to avoid dental treatment.3

Learning, unlearning and relearning: how phobias are acquired tells us how hypnosis works with phobias

Direct experience

The most common route for acquiring any kind of phobia is a direct negative experience – eg a phobia of flying is often acquired through a frightening experience on a flight, a phobia of dogs acquired through being bitten or attacked. The experience makes a powerful impression on the individual, and has an effect similar to a trauma. The parts of the brain involved, usually considered to include the amygdala and the hypothalamus, do not respond readily to logical arguments, proofs etc. Hence an intelligent person, capable of holding down a job and running their own life, can be unable to convince themselves to have dental treatment that they urgently need. Once having been vividly impressed with the idea that the phobia trigger (dentistry, flying etc) is a threat to survival, these more ‘primitive’, emotional parts of the brain override any counteracting information and arguments.

The most common route for acquiring dental phobia is an experience of dental treatment which was both painful and where the dentist was experienced as being unsympathetic and uncaring.4,5 This usually occurs in childhood, where pain and fear are more likely to make an impression as a threat to survival, as the child's vivid imagination and emotional responses are not moderated by much experience or knowledge.

Imitation

Another method of acquiring a phobia is through imitation of the fears of others, particularly significant others such as parents. I have often found that a client's fear of mice, or spiders, for instance, can be traced back to repeated exposure as a child to a parent's terror of these creatures. The issue here is taking things on trust – a child's brain does not generally have the capacity to question the validity of a parent's actions, or the actions of another significant figure who is accepted as a source of valid information by the child. This kind of ‘authority’ is a major source of information acquisition in early life; our first guiding principles are acquired without question and often without our conscious awareness – we take them for granted.

Transfer of a fear from another setting to the dental setting

Phobias such as claustrophobia are easily transferred to the setting of being confined in a dentist's chair. A fear of being helpless, of losing control, is a major element in many phobias. Hence, traumatic experiences such as physical or sexual abuse can also manifest in a fear of dental treatment.

Hypnosis

The core element in hypnosis is a shift of focus of attention. The particular shift that is used for therapeutic purposes involves the brain's imaginative faculty, which has direct and powerful connections with emotions. These are the parts of the brain that form and maintain the phobia, so using hypnosis to gain access to them is a particularly effective approach. After many years of disputes as to whether hypnosis was ‘just’ role-playing etc, neurological observations have provided strong evidence that hypnosis has effects in the brain distinct from other cognitive operations.6

The core element in a successful shift of focus of attention is trust between the person hypnotising and the person receiving hypnosis. For people suffering from severe anxiety or phobia, it is much easier for them to cooperate with hypnotic suggestions from a trusted person, than to use self-hypnosis in the first instance. The hypnotist can then train them in self-hypnosis, as part of the therapy. The process of achieving the shift of focus is called induction and the resulting ‘shifted’ mental state is called a trance, or hypnotic state.

The rapport between the hypnotist and the patient enables powerful mechanisms such as reassurance and re-education to be accepted at a profound emotional level, which is necessary for effective change.

The hypnotic state enables a strong rapport between the hypnotist and the patient, in which emotions are more easily accessible and the imagination is facilitated. In this state, carefully scripted suggestion sets instilling confidence and calmness, rather than fear and panic, will be accepted at a deep level, which would have little effect if heard in a normal state of mind.

This is particularly useful, for instance, in the case of past traumatic experiences which have resulted in phobias. Recall of such events in hypnosis involves a much fuller range of emotion than normal recall and the intensity of this experience allows for an effective re-shaping of the client's interpretation of these events. It is the ‘blanket’ nature of this interpretation that causes the ongoing problems from a past trauma. In particular, a child's brain is highly susceptible to ‘blanket’ or ‘global’ interpretations, to see something associated with a threat in a particular circumstance as representing a threat in every circumstance. The rapport between the hypnotist and the patient enables powerful mechanisms such as reassurance and re-education to be accepted at a profound emotional level, which is necessary for effective change.

Case study 2

A woman in her thirties had avoided visiting the dentist for many years, but now faced an urgent need for treatment, suffering severe pain. Despite a sympathetic dentist and the offer of sedation, she was unable to bring herself to sit in the dentist's chair, even to have her teeth cleaned. I hypnotised her and rapidly uncovered a vivid recall of repeated abusive experiences she had undergone as a child, being held down by her abuser, unable to move or escape. She was unable to bear any situation where she could not move if she wanted to and went to great lengths to avoid any such circumstances. Although she had always remembered that these abusive events had occurred, the recall she experienced in hypnosis was sufficiently powerful to allow her to re-open the interpretation she made at the time. The experience had translated into ‘global’ beliefs such as ‘I am small and weak, and cannot escape when someone holds me down’, ‘people can be so dangerous that I can never trust anyone to have the power to hold me down’. I worked with her in hypnosis to accept a new interpretation, integrating her present experience of being an adult into the memory of what had happened in the past, and this was effective. She was able to sit calmly and have her teeth cleaned, and I attended for the further dental treatment she needed, hypnotising her during the procedure. She was calm throughout, and felt elated, feeling she would never be so afraid again.

Dental professionals are in a very favourable position for integrating hypnosis within their practice.

Dental professionals are in a very favourable position for integrating hypnosis within their practice. A structured situation, a clearly-defined role given authority by complex high-level skills and professional reputation, and high motivation on the part of patients (dental decay and pain if they avoid treatment) all combine to provide circumstances in which hypnosis can be very effectively and easily operated. Research has indicated that whereas for a general hypnotherapist a major task in therapy is to establish rapport and trust, in clinical settings, particularly with patients suffering from pain or in acute or urgent situations, this can be rapidly achieved by professionals with clear and visible roles.7

A dental practice is therefore well-equipped to provide effective support through hypnosis for phobic and anxious patients. Hypnosis is likely to be readily accepted by such patients, when provided by a sympathetic and appropriately trained member of the dental team.

www.drjohnbutler.com

www.hypnotherapytraininginstitute.org (includes links to video clips)

www.ihmdp.org (includes details of two one-day Hypnodontics courses for dental professionals taking place in October 2011 in London)