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CH: The three editions of your book Hypnosis and Hypnotherapy with Children have spanned nearly twenty years, from a time when the very idea of using hypnosis with children was radical and new, through years when hypnotic approaches proliferated, inspiring and influencing schools of psychotherapy from solution-focused to cognitive-behavioral, into the current era of managed care and the dominance of psychopharmacology. How has your experience as a researcher, clinician and teacher of hypnosis changed over time?
KO: Well, certainly there's no doubt but that hypnosis with children is more readily accepted, and that's manifest by a number of things. For example, the American Academy of Pediatrics, the primary professional organization for pediatricians with 50,000 members, has published many articles in their journals. They just sponsored an audiotape program on hypnosis with children. That sort of thing has led to tens of thousands of pediatricians becoming aware of this as a possible tool. So that has changed and that's been very gratifying.
In terms of clinical applications, there are some changes. Twenty, twenty-five years ago we really needed to use this tool with children who were undergoing treatment for cancer, for example, because we didn't have the indwelling catheters that they have now, and every day children were subjected to sticks and painful procedures. That has changed. It is still my view that every child with chronic illness should learn self-hypnosis, because of the sense of coping and competence it gives them. But in terms of pain management, I would say it's not used any more than it was twenty-five years ago.
CH: What kind of impact do you hope for with your research into the measurable physiological and biochemical chagnes produced by hypnosis?
KO: I still hope for more funding support so that we can do more research. Right now I'm not doing any. And what we have done over the last twenty-five years has been done mainly on a shoestring, but right now we just have no funding support to do any. That's always a problem. I think people are somewhat amazed, because we hear all the hub-bub about public interest in mind-body stuff, but in fact it's still extremely difficult to get support for good research.
CH: Well, it makes sense that the drug companies would only fund the drug research, where has the money come from for researching hypnosis?
KO: From foundations and the National Institute of Health. And there's more, but I'm not convinced today that any of the research I know about related to children is really very high level research. And that kind of research, especially when you're measuring, say, immune measures, is extremely expensive. I did quite a few studies in that area and most of the money went to pay the labs, because the tests are so expensive. So, what do I hope for? Well, I hope we can explain how these non-pharmacologic strategies effect the physiologic processes of the body, and that we can do that in a way which will be acceptable to the vast majority of the so-called "allopathic" medical community.
We have documented some things that are very exciting. For example, we've been working for many years teaching self-hypnosis to children with migraines to prevent migraines. We've documented that there are changes in mast cell products in the urine of those children as they learn self-hypnosis, which is consistent with what has been noted in adults about the association between mast cell lability and the symptoms of migraine.
CH: What seem to be the next unanswered questions to study?
KO: I think it would be wonderful to have a biofeedback technique for immune responses, so that you could give the person if not second-to-second then minute-to-minute feedback of some of the immune parameters. We know that they do shift very rapidly, but we don't yet have a way of measuring that that would not be horribly painful. Providing that feedback to a person on a computer screen or some kind of instant feedback could allow a person to work at controlling it instantly. I think that would be great.
I also think an unanswered question relates to the future of training children: At what age should we start training children in self-hypnosis? Shouldn't this be included in our anticipatory guidance for children at a very young age, so that they grow up knowing that they have these kind of controls instead of assuming that they always need to run to the drugstore? I have done some work in that area. About seven years ago we developed a prototype, something called "The Mind-Body Unit." It's about a seven or eight minute experience for a child using a touch-screen format that teaches them that by changing their thinking they can change a body response. They pick an animal that they like, a bear or tiger or dinosaur. There's a galvanic skin response sensor which they put their hand on. A child's voice instructs them to think about some favorite safe, comfortable place. As they do relax, the animal gradually smiles. And at the end it makes a very nice noise - the fish goes glub, glub, glub. Kids really enjoy that. Even some kids with Attention Deficit Hyperactivity Disorder, who have such a hard time focusing on anything, they will focus on this.
CH: I find reading Barclay on ADHD can be discouraging at times - I like his rigor in debunking approaches to treating ADHD that demonstrably don't help, but sometimes you get the feeling he's suggesting nothing helps but Ritalin.
KO: Talk about needs - there's an area that calls for research with non-pharmacologic techniques. The good research in that area has not been done.
CH: Is your computer program available for clinics or individual clinicians?
KO: Yeah, in the last year or two we've managed to convert it to a CD-ROM for home computers, so it is available. The person who is basically making copies at home is Glenn Emelko. He's the programmer who did the programming for the project.
CH: Kids are so into computers, it's a perfect format to choose for them.
KO: There will probably be other versions. Our version is most appropriate to kids age 5 to 10. And then there will need to be something appropriate to kids who are somewhat older.
CH: That kind of control is such a fundamental gift that hypnosis offers. I remember Kay Thompson's film of a root canal procedure on a 30-year old hemophiliac. He used self-hypnosis for both pain management and control of bleeding, after about three months of pre-operative training. She said that when she first explained to him that he could control his bleeding with self-hypnosis, he cried in her office. He said it was the first time in his life he could remember anyone telling him he wouldn't be completely dependent on doctors. It was absolutely motivating for him.
KO: Yeah, it is the fundamental gift. I worked with hemophilia for ten years, and I saw that sort of response. And we began teaching them when they were two and three years old. We had two and three year olds who were able to do these self-regulatory things.
CH: Unbelievable. And it shouldn't be unbelievable - it really just demonstrates how the capacity for self-hypnosis is natural and available. I guess you could say we learn how not to use it. It does surprise me to know you can measure self-regulatory effects in kids so young.
How integrated are hypnotic techniques - either explicit or intuitive - in the approaches of most child clinicians that you meet?
KO: Oh, I think we're still a long way from the majority of clinicians using hypnosis. I think at this point maybe ten to twenty percent have taken courses or training and are somehow using it. But we have a long, long way to go. We have a relatively small but committed teaching group, but all most of us manage to do is one or two workshops a year, and we need to do more in child health.
CH: Are there any particular myths or misunderstandings that persist?
KO: The same ones that apply to all of hypnosis. The idea that there is a powerful hypnotist who is in control, which is of course not true. The idea that somehow this is messing up the mind, when in fact it helps the person to have more control over his or her mind.
CH: Where do you see hypnosis holding the most promise in the future?
KO: In all chronic illness - sickle cell disease, hemophilia, cancer. I think it should be taught to all children with chronic disease. That includes asthma.
CH: Besides insufficient funding and the persistence of the myths and misconceptions, any other roadblocks to dissemination?
KO: I think the major roadblock is lack of funding. To this day I can be sure that if I were to mark biofeedback or hypnosis on my billing sheet it would not get reimbursed. That's an incredible inequity. A person can work with a child with migraines and give them a drug that has not been subjected to a controlled trial and get reimbursed, and a person can spend an hour with a child teaching them something that's really going to help them and not get reimbursed. It's unfair and that is one of the things that prevents a lot of clinicians from doing it. And they're at the mercy of the HMO's or whoever are their bosses currently, who insist that, "No, when a child walks in with a migraine you spend five minutes with them and write a prescription for something that hasn't been tested." It's unethical. And it shows a lack of scientific approach.
CH: There's an air of pseudo-science around a lot of the managed care limitations, but you don't find the spirit of inquiry or the value of patient care that underlies true scientific investigation.
How did you first become interested in cultural sensitivity as a clinical issue?
KO: Well, I suppose that was because I fell in love and married my husband, who at that time was a Foreign Service officer in southeast Asia. So I went to Laos, this very naive young physician, and gradually became aware that, when considering the needs of patients, you also really need to consider where they're coming from in terms of their cultural norms. And then that became quite another interest of mine, and has remained so to this day.
CH: Did you know your chapter on "Cultural Issues in Primary Pediatric Care" was cited in Anne Fadiman's The Spirit Catches You and You Fall Down [a study of culture clash between an epileptic Hmong girl and her American doctors]?
KO: No kidding - I read that book and I didn't even notice it. It's a great book.
CH: What direction do you see us going in terms of broadening our awareness of cultural diversity?
First of all, in term of cross-cultural sensitivity - tolerance of different cultural norms and values - the most successful country is the United States. We are far and away beyond any other country, although we do have our problems. So many societies are so insular and so intolerant of other cultures. I like to use the example that when I go to the rural areas of southeast Asia I will be followed by children, who are very friendly children, but they will be running behind me yelling "Foreigner! Foreigner!" And when I go to east Africa the same thing happens. A group of children will follow you yelling "Foreigner, foreigner!" Not in a mean way. But can you imagine in the U.S. that a foreign visitor would come and would have a group of children running after him or her? That wouldn't happen. Because we are much more accustomed to different appearances. The issue of tolerance of other cultures, of other values, of other ways of doing things is such a major, major issue in the world. It is true that we need to do more in this country.
I'm very aware of foreign students because I have a lot of them. They have tremendous culture shock about a lot of things when they come over here. And things that you wouldn't think would be culture shock. For instance, most of them will have culture shock over the myriad of our choices. As one of them told me, "You can't go to buy gasoline without having to look at all these choices - it's so confusing!"
But the real problems are in many of the other countries, where you have so many people who are prevented by poverty or by their government from recognizing how other people live. And so they become extremely discriminatory, extremely opinionated about there being only one way. And that leads to conflicts and wars. My main focus these days in terms of international child health is the effect of complex humanitarian emergencies on children, both acutely and long-term. Although we've improved a great deal in terms of the ability of UN agencies and large NGO's to respond to the acute needs for food and water and so on, these programs do not recognize the psychological disruption to children, which can last a lifetime. So we're teaching a course now in that - we've written a little book on it which is being distributed worldwide. We're trying to get funding to teach this course overseas so we can teach it in some of the areas that are subject to these events, so that local child health specialists can become more knowledgeable about that.
CH: And who's "we"?
KO: The Rainbow Center for International Child Health in Cleveland. Most of us working there are completely volunteers, but I have wonderful, wonderful volunteers working with me.
CH: I like your model that prejudice and bigotry are due to deficits of experience or poverty. It suggests that the natural course of growing up or becoming healthy would mitigate for tolerance of difference.
KO: Well, I hope so.
CH: It doesn't seem too controversial to advocate for thorough treatment and good rule-outs, but were any psychologically-minded associates surprised by your paper on misdiagnosed "somaticizing" patients who turned out to have treatable medical disorders?
KO: That's one of my favorite papers. It's been years since that paper was written, but I still see it happening all the time. I recently got a patient referral of a boy with behavioral and developmental problems, and I think they were hoping I'd teach him some self-hypnosis and biofeedback. I noticed he had difficulty getting in and out of the chair. He couldn't sit down and bounce up the way an average ten-year-old could. It's taken us a couple months, but I had confirmation a couple weeks ago he has myotonic dystrophy, which is associated with a cognitive impairment. And he has severe learning disabilities which explain his behavior problems. It's a genetic disease, and it turned out the father had been diagnosed with same thing. It's a great example of why one has to be so broad in terms of one's diagnostic ability.
CH: Do you have any suggestions for non-physician clinicians treating pain and somaticization on when a referral to mental health, or especially a diagnosis of psychogenesis may have been made too quickly?
KO: My suggestion is to find a pediatrician who is also a subspecialist in behavior development, and develop a link-up and friendship with that pediatrician. I have so many psychologist colleagues who are themselves now are able to prescribe the diet for constipated children. There are a lot of things they can do that they don't need to write a scrip for, that they can explain in detail. One psychologist I've written papers with, Howard Alt, has become so astute in recognizing possible biologic explanations that he gets referrals from pediatricians! The ongoing relationship is so important, both parties benefit.
CH: I was fascinated by the wide range of responses to the "Five Questions on Intentionality in Mind-Body Healing" in Advances in Mind-body Healing, from very reductionist, conservative positions to pretty wide-open New Age outlooks. What did you think of the piece as a whole?
KO: I thought it was very interesting. You know, twenty, twenty-five years ago, at every annual meeting the American Society of Clinical Hypnosis had a workshop on hypnosis and religion. They were often led by Bertha Roger, who was a wonderful anesthesiologist. It's interesting how many people in psychology and medical and dental fields who use hypnosis are also quite spiritual people.
CH: In your experience does that association ever alienate more conservative or reductionist clinicians?
KO: Well, the people who cause the most problems are the people who do not have a professional degree who are using hypnosis. They sometimes do things which are incorrect and lead to difficulties.
CH: In the "Five Questions" piece your discussion of the relationship between imagination and intentionally was particularly adroit in expanding the meaning of intention beyond merely will-power. I find myself talking to clients explicitly about the Second Law of Hypnosis a lot lately, in contexts as diverse as coaching parents of kids with ADHD to adults overcoming addictions.
KO: "When will and imagination are in conflict, imagination always wins."
CH: It seems to me to unite the spirit of engineering and poetry in psychotherapy. Have you found it to have special significance in working with children?
KO: Yes, it does. I think it has special significance for life in general, for all of us. Whether it's accomplishing and educational goal or a work goal or a goal related to child-raising, if one cannot imagine a good outcome, then in spite of all the cognitive things one does, all the willing, it's not likely to turn out to be any different than what the imagination perceives.
CH: Tell me about a clinical experience you've had with hypnosis with a child that was particularly inspiring or rewarding to you.
KO: One of my patients was a child who was born without legs, and also had a lot of problems related to the lower abdomen, so she had urinary tract problems, and needed a lot of procedures to deal with those. She learned hypnosis to gain confidence in undergoing all those procedures. She's an adult now, and my former colleague Dan Cohen sent me a photo of her from the Minneapolis paper. She was out in front of some sort of a public parade or demonstration, in her wheelchair, speaking out on behalf of children. I just thought it was so great.
CH: What do you hope people will take away from the workshop in April?
KO: Well, I hope they'll take away a tolerance for uncertainty!
CH: That's a large gift!
KO: You know, we teach things, we have approaches, but as culture changes, as time passes, these have to be adapted. Like learning that we can help kids a lot more if we can give them some feedback from a computer game. I also hope they can take away a sense of the importance of melding therapeutic techniques, that there's not just one technique.
CH: What's the growing edge of your work nowadays?
KO: My role now is much more advocacy for the importance of research and teaching non-pharmacologic techniques with children. I sit on the NIH Council for Complementary and Alternative Medicine. I'm one of two pediatricians, two child health people on that committee. It tends to be very adult-oriented. So my role tends to be as an advocate for the importance of doing more research with children, for the value of teaching children early, before all their physiologic processes are hardened and congealed.
CH: What can individual clinicians do to address the issues of funding inequities that you've raised?
KO: One thing is to develop collaborative research groups. It gets you into the business of seeking funding. Once you start to seek funding and realize how hard it is, you become more of an advocate in terms of talking to people who are on boards of funding agencies, talking to people in legislative activity that decide how much money NIH gets for what. I think you have to be involved before you can be a good advocate. If people don't want to do research themselves, it's always helpful to talk to people in funding capacities, if you happen to know people in these organizations, or if they know their legislators. It's more helpful if you actually have an example from your own work.
CH: I understand you've made a training video about teaching self-hypnosis to children. Is it generally available?
KO: That was put together by a small group of us, but the principal is Larry Sugarman. He's in Rochester, New York. He's the person who's distributing them. His email is LSugarman@compuserve.com.
CH I wanted to say before we stop that I was particularly moved by the preface to the second edition of Hypnosis and Hypnotherapy with Children in which you describer your relationship with your late friend and mentor Gail Gardner, who co-authored the first edition with you. It was a very moving tribute, and, if I may be so bold, I would say you've done her memory proud.
KO: Well, thanks very much.
CH: I very much look forward to meeting you in April, and receiving inspiration and good teaching from you, continuing that legacy. Thanks again for taking the time to chat with me. It's been a real pleasure.
KO: You're most welcome.
Copyright © 2002 Chuck Holton All rights reserved.