Brice Lemaire: Doctor en Cirugía Dental.
Introduction
Elmanian hypnosis has, until now, been poorly disseminated and understood in France, whereas in Anglo-Saxon countries it constitutes one of the foundations of modern hypnosis. There are two reasons for this. Firstly, the French are generally not very keen on the English language and have not been aware of developments in modern hypnosis in the USA or England. Secondly, the reintroduction of hypnosis in France in the early 1980s was marked by a predominance of neo-Ericksonian hypnosis, mainly conversational, to the detriment of formal hypnosis and the practice of deep trance. Ultimately, in France, the few people familiar with Elmanian hypnosis know very little about this hypnosis: an induction that of Elman, a work «Hypnotherapy», and videos by Gerald F. Kein.
Through the DEHIF, we wanted to pass on Elmanian hypnosis by giving access in French to the entirety of Elmanian hypnosis in its original form and in all its specificity.
What is so special about Elmanian hypnosis?
Framework and posture
Elmanian hypnosis is formal hypnosis. It does not use the strategies of conversational hypnosis or masked hypnosis. The aim is involve the patient in the process. The operator must do 50% of the work and the subject 50% too. Involving the patient in the process reduces resistance because hypnosis is a state of consent.
Elman’s approach is client-centred hypnosis, which does not use standard scripts or suggestions but rather adapts them to the patient, the subject and the context.
It is a hypnosis of freedom which aims to empower the subject. The operator is simply the dream pilot, who acts as a guide to the subject. It is an egalitarian position.
In trance, the operator is the pilot and the subject the co-pilot
Elmanian hypnosis is neither authoritarian nor directive. The suggestion is direct but the method is always indirect.
Too often we confuse the style of suggestion (direct, indirect) with the method used (direct, indirect). Metaphorically speaking, the style of suggestion corresponds to the ingredients a recipe, whereas the method corresponds to the different styles of cooking.
In hypnosis, the direct method has long been used. It starts from the outside and works inwards. The aim is for the operator to bring an external element to the subject’s interior. A suggestion (direct or indirect), or a metaphor, is simply an external element that the operator brings to the subject’s subconscious in order to influence it. It’s like planting a seed and hoping it will sprout.
Dave Elman has introduced another strategy: the indirect method. We start from the inside out. The operator is only there to guide the subject, to work actively with the subconscious. He offers a suggestion to the subject’s subconscious to work on, and the subject then has to find his or her own response. Hypnosis is a state of intense activity and not a state of physiological or psychological passivity.
Deep trance
The trance is then only an element to amplify the subconscious. It is merely a catalyst which disappears after the session. To achieve this active trance, sleepwalking is the preferred working stage.
Elman’s hypnosis focuses on trance management. It enables us to learn and understand the management of deep trance and the production of hypnotic phenomena. Hypnotic phenomena are consequences of deep trance, but they are also used as trance generators. To produce a specific state of trance, Elman proposes producing the characteristics of a state to obtain the state in hypnosis.
In Elmanian hypnosis, the focus is on exploring the different depths of trance. The operator learns to produce and manage 4 levels of trance: light trance or physical relaxation, somnambulism, Esdaile, and hypnosleep (hypnosis attached to sleep and sleep attached to hypnosis). Elman adds a 5th state, awake hypnosis (production of hypnotic phenomena without the associated trance) which has nothing in common with conversational hypnosis. The practitioner, depending on the indications for operative, medical and therapeutic hypnosis, chooses the type of trance and the level of trance he uses. This is pragmatic hypnosis because the end justifies the means. The operator uses the deep trance, not for its depth per se, but for the use that can be made of it.
In surgical hypnosis, for example, if hypnoanesthesia is required, deep trance is de rigueur. In medical hypnosis, if you want to access the subject’s automatic physiological processes, deep trance is essential. In therapeutic hypnosis, if you want to use regression, which is the classic therapeutic format in Elmanian hypnosis, a deep trance is essential.
This is why, in Elmanian hypnosis, we prefer to work in deep hypnosis with somnambulism.
Medical and scientific hypnosis
Between 1948 and 1962, D. Elman gave his «Courses in Medical Hypnosis» in the USA. He trained more than 10,000 practitioners and treated more than 30,000 patients brought in by practitioners. This teaching was intended exclusively for medical practitioners (doctors, gynaecologists, paediatricians, psychiatrists, ENT specialists, dermatologists, dentists, etc.). The spread of this medical hypnosis to so many practitioners led to the recognition of hypnosis by the American Medical Association in 1958 as a medical and scientific discipline. He was the first hypnotist in the world to assist an obstetrician in giving birth under hypnosis without any chemical anaesthetic, and to assist a heart surgeon in open-heart surgery under hypnosis without any chemical anaesthetic.
As he is not a doctor, he has never crossed the red line so as not to be accused of practicing medicine illegally. He never taught hypnosis to non-medical people (even less to Gerald F. Kein) but never received patients personally in a practice. He invited practitioners to bring their patients to his courses in medical hypnosis and then showed them how to use hypnosis to work with them.
In his courses on medical hypnosis, Dave Elman insisted on developing a scientific form of medical hypnosis, free from myths and superstitions.
To do this, he used an inductive and deductive approach. The inductive approach was inherited from his reading of the great authors French hypnosis in particular. This empirical approach enabled Elman to develop a hypnosis inspired by the discoveries of his predecessors…
But Elman also uses a deductive approach on many occasions in development of his hypnosis, both from a practical and theoretical point of view. Over a period of more than 10 years, he trained so many medical hypnosis practitioners that he was able to experiment with certain hypnotic techniques on numerous patients, in particular the Esdaile state. We have more than 5 versions of his course between 1948 and 1962, and they bear witness his constant desire to experiment and advance his approach to hypnosis, both theoretically and practically. He sought to understand hypnosis from the inside rather than from the outside. He very often questioned the patients he treated in order to understand the elements at play in the trance.
Over and above his medical approach, D. Elman was a great reader of twentieth-century psychology. He knew Edward Bernays personally, Freud’s nephew, and was a reader of Freud, as his lecture notes testify. But he was also influenced by the great authors of Anglo-Saxon psychology (W. James, K. Meninger, John B. Watson, etc.).
From an epistemological point of view, this hypnosis has always sought a balance between the validation of facts from a scientific point of view, and the opinions emanating from the operators and subjects, which stimulated the research.
Clinical cases
We use two types of hypnosis in dental practice: operative hypnosis and therapeutic hypnosis. Operative hypnosis aims to treat the patient in conditions of comfort and well-being, i.e. to manage the patient’s stress, anxiety and pain.
Therapeutic hypnosis is designed to treat all types of psychological disorders (stress, anxiety, phobias), behavioural disorders (bruxism, smoking, eating, nausea, onychophagia, sucking, atypical swallowing).
This clinical case describes the many Elmanian strategies that we will use in operative hypnosis.
Clinical case: Wisdom tooth extraction under hypnoanesthesia
A 26-year-old patient came to the practice for dental treatment including multiple dental procedures and the extraction impacted wisdom teeth. This anxious patient was referred by his wife, for whom we had carried out all the dental treatments under hypnosis. After a clinical and radiological assessment, we drew up a treatment plan and suggested that the patient use operative hypnosis. After establishing a rapport with the patient and completing a more specific questionnaire, we made a differential diagnosis between his anxiety and a dental phobia. We reassure the patient that hypnotic treatment can be carried out in the best possible conditions of comfort and well-being. We then give a brief three-step speech to inform the patient about hypnosis.
First step: describe hypnosis as a natural state, and trance as a state of daydreaming that we are going to amplify and exploit in the context of care.
Second stage: removing all inhibitions linked to false beliefs about hypnosis (you don’t sleep, you don’t lose consciousness, you don’t lose control, etc.).
Third step: create expectations at the subconscious level, explaining to the patient that all hypnosis is self-hypnosis. We are only there to guide them, and they must have an open mind, be curious to experiment and become a spectator of everything that happens during the trance. Elmanian hypnosis is a formal hypnosis that encourages the patient to participate in the dynamic process of trance.
A phobia would have required a hypnotherapy session beforehand, whereas dental anxiety (which is quite legitimate, given that the mouth is an emotional zone) is easily managed by hypno-sedation.
A few definitions of operative hypnosis will give a better understanding of the techniques used in this treatment.
Hypno-sedation is a hypnotic strategy that reduces awareness of the body and mind. It is used to manage stress and anxiety and is combined with a local chemical anaesthetic (at a lower dose, 20% of the usual dose). It is based on the management of deep stuporous trance (relaxation trance called deep stuporous trance by Erickson, Esdaile state or hypnotic coma by Elman, lethargic trance, etc.).
Hypnoanalgesia is a partial loss of sensitivity. In the dental field, it allows many minimally invasive procedures to be carried out without any anaesthetic. For example, we can perform cavity preparations, prosthetic dental preparations on living teeth, surfacing, light periodontal surgery, etc. It is based on the management of the somnambulic trance (activation trance known as somnambulism, deep somnambulic trance, dreamlike trance, etc.).
Hypnoanesthesia is a total loss of sensation. It allows invasive procedures to be carried out without any anaesthetic. For example, we can perform dental extractions, periodontal surgery, bone surgery, etc…. It is also based on the management of somnambulic trance. In this case, it is necessary to obtain a deep somnambulic trance complete with negative kinaesthetic hallucination.
The difference between the two types of deep trance (stupor and somnambulism) is qualitative.
The difference between hypnoanesthesia and hypnoanalgesia is quantitative, relating to the depth of trance and the production of hypnotic phenomena. The modelling proposed by the OXO© gives us a better understanding of the management of deep trances and enables us to combine these two trances if necessary.
The first dental treatment session in operative hypnosis is carried out with a classic pre-test (book balloon type). The patient’s ideomotor movements are initially very rapid and fluid, indicating that he is quickly in trance. As the patient responds very well to suggestion, we follow this up, in a hypnotic continuum, with a rapid induction (Dave Elman Induction 1 minute) followed by deepenings (splits, 10-1 countdown) and then we test the level of trance obtained by creating hypnotic phenomena through direct suggestion. The tests are an integral part of Elmanian hypnosis. They have three functions: as an evaluation for the operator of the level of trance obtained, as elements of persuasion for the subject and as a technique for deepening trance. Hypnotic phenomena occur gradually, according to H. Arons’ scale: physical phenomena (levitation, rigid catalepsy of one arm), emotional phenomena (calm, serenity, confidence), cognitive phenomena (amnesia), sensory phenomena (analgesia, anaesthesia by direct suggestion) and hallucinatory phenomena (positive and negative). Once this level of deep trance has been established, the compounding technique is used to create a subconscious automatism enabling the patient to deepen his trance during the treatment. This elmanian hypnosis is a very powerful technique based on two concepts: Braid’s monoideism (the subject’s ability to focus attention on a single idea) and Pavlov’s conditional reflex (creating a cerebral automatism). This technique enables the practitioner, who is both the operator of hypnosis and the dental technician, to carry out the dental treatment without having to speak, in order to maintain the trance. It is therefore a valuable technique in operative hypnosis.
During this first hypnosis treatment session, the patient demonstrates the ability to go into a deep trance (Arons level 4) and we take advantage of this to carry out this first treatment session (scaling, cavity treatment) under hypnoanalgesia without any chemical anaesthetic. Then, once the treatment is complete, before the patient is discharged, we apply positive suggestions with a post-hypnotic effect (optimisation of biological healing functions, ability of the patient to return to trance lower, faster and further the next session, confidence and serenity in the treatment).
The second session is used to finalise the dental caries treatment. To do this, there is no need for any prior speech or pre-tests. We carry out an instant induction (Jacquin powerlift induction type) which creates and tests a rigid catalepsy of the arm (private hypnotic phenomenon). The deepening is obtained by suggesting the descent of the arm, automatically, involuntarily and effortlessly, at the same time as the subject goes further, lower and deeper in hypnosis.
We test the level of trance by inducing rigid catalepsy and then amnesia of one digit on a countdown. We then develop genuine hypnoanesthesia by direct suggestion (A. Moss’s original dental pressure technique) and carry out the dental treatment in complete silence, using the Elman compounding technique. Then, once the treatment is complete, before the patient emerges, we give as many positive suggestions as possible with a post-hypnotic effect.
The third session involves avulsion of the impacted wisdom teeth. As the patient has developed a remarkable capacity for deep trance, we offer to perform the avulsion under hypnoanesthetic, with his agreement, explaining of course that a chemical anaesthetic can be administered at any time if he feels the need or comfort.
The instant induction used is that of our colleague and friend Dr. Albrecht Schmierer, a pioneer of dental hypnosis in Germany: turbo induction. It enables us to develop a deep somnambulic trance and to rapidly induce hypnoanesthesia in suggestible patients. We deepen the trance by inducing hypno-sedation through respiratory focusing.
The wisdom tooth extraction is carried out in optimal conditions of comfort and well-being. Before emergence, the patient is given a number of post-hypnotic suggestions for comfort, natural activation of biological functions and healing.
The full video is available at:
Reflections on hypnoanesthesia
Over more than 20 years operative hypnosis, at a rate of approximately 5-6 hypnoses performed daily, we have performed more than 15,000 operative hypnosis sessions, filmed and recorded, as a database for the needs of our university teaching (D.U Operative Dental Hypnosis, theses for doctoral students). More than 2,500 operations (dental avulsion, implantology, periodontology) were carried out under hypnoanaesthesia, i.e. around 15%, which corresponds to the epidemiological data commonly accepted in operative dental hypnosis.
In our practice of operative hypnosis, hypnosedation and hypnoanalgesia are daily tools for treating patients in the best possible conditions. They are a major asset in establishing a therapeutic alliance. The practice of hypnoanesthesia is more experimental and cannot be envisaged for all patients, as it requires several elements: motivation on the part of the patient to carry out the treatment in hypnosis without recourse to chemical anaesthesia, a selection of patients capable of achieving a complete somnambulic trance, possible training to obtain the depth of trance necessary to obtain negative kinaesthetic hallucinations, and great confidence in the operator, in hypnosis and in themselves to have no inhibitions (inhibition or fear being the enemy of deep trance).
In the framework of this practice of hypnoanesthesia, there is no need to look for operator performance. We continue to practise it whenever possible and to teach it, because it enables us to manage deep trances perfectly (stuporous and somnambulic) and to develop numerous hypnotic strategies for managing pain (acute and chronic).
Conclusions
The hypnosis developed by D. Elman is pragmatic hypnosis. It is a formal hypnosis oriented towards the management of the depth of the trance and the production of hypnotic phenomena.
It can be used in the three main areas of hypnosis: operative, medical and therapeutic.
Hypnosis is relatively simple to transmit. But this simplicity is only apparent, as it requires experience to master all its subtleties.
From a historical perspective of contemporary hypnosis, Elman is a bridge-builder between classical and modern hypnosis.
He had a considerable influence on many currents in modern hypnosis (Ormond McGill – Encyclopedia hypnotherapy, Gil Boyne – Transforming therapy, Edwin Yager – Subliminal therapy, Randal Churchill – Regression therapy).
There are no Elmanians in the true sense, because the practitioners who use Elman’s techniques and philosophy have then appropriated his hypnosis and developed it according to their context and practice.
His hypnosis remains an excellent introduction to modern hypnosis.
References
- Lemaire Brice. Les indispensables de l’hypnose Elmanienne (15 tomes) éditions DEHIS 2022- 234
- Lemaire Brice, Pouyssegur Valérie. Operative and therapeutic dental hypnosis . Éditions Satas, 2019.
- Stolzenberg Jacob Psychosomatics And Suggestion Therapy In Dentistry. Literary Licensing, 1948
- Moss Aaron Hypnodontics. Brooklyn NYC. 1952
- Frost Thomas. Hypnosis in General Dental Practice. Kimpton Editions 1957
- Shaw S. Clinical Applications of Hypnosis in Dentistry. Saunders Co LTD, 1958
- Erickson M. The Practical Application of Medical and Dental hypnosis. Routledge, 1961
- Cherchève Raphaël L’hypno-sophrologie en art dentaire. Privat, 1970
- Hartland John Medical & dental hypnosis, Churchill Livingstone, 1977
- Robert Simpson. Hypnosis in dentistry. Thomas Editions 1985
- Daniel Simons. Hypnosis And Communication In Dental Practice. QB Editions, 2007
- Schmierer Albrecht. Zahnärztliche Hypnose: Erfolgreiche Hypnose und Kommunikation in der Zahnarztpraxis. Published by QB, 2007.
- Acosta Juan. Hypnodontics. Editions Indpt, 2014
- Comar Beryl. Hypnodontics. Editions DEHI 2016