It is common to hear of hypnotherapy being referred to as a complementary therapy, complementary to mainstream medical care, but we don’t often hear much about its application in the area of Dental Medicine. This week I am going to focus on dealing with highly anxious patients with some ideas relevant to dentistry and any other area where you need to deal with anxious patients or clients.
Waiting
I’m writing my blog today whilst I await the arrival of a potential client. As is typical for people interested in hypnotherapy we have an initial fact finding session – a free assessment which takes about 15-20 minutes. This is a bi-directional process – I want to find out about this person and their issue and be in a position to advise them on the suitability of hypnotherapy and discuss how we could help them, how many sessions it should take and the likely outcome for them. They get to meet me, ask any questions and raise any concerns and generally get a feel for how hypnotherapy works and my particular style and approach. The end goal is for us to jointly decide if hypnotherapy with me is the right approach for them and if so plan the way forward.
Nervousness
It is not unusual for people to be slightly nervous at this first meeting. They are often taking a step into the for them unknown world of hypnosis, or if not that, then they may have some anxiety over sharing their issue with a stranger, what they might reveal about themselves and being subjected to ‘therapy’.
Of course I quickly put them at ease – mainly by dealing with any misconceptions, fears or just lack of knowledge they have. We form a therapeutic partnership to work towards their outcome as a team – they are the expert in how they experience their issue, I am the expert in a range of approaches to deal with it.
Dental Anxiety
Anxiety is of course something that dentists have to deal with on a daily basis and generally this level of slight anxiety is of the helpful type that prompts you to be aware and pay attention. So when we talk about Dental Anxiety from a therapeutic context we are considering more extreme levels.
From a patient and dentist perspective this anxiety becomes an issue, and of interest to a therapist, in two situations:
1. The patient’s anxiety is preventing them from seeking dental treatment at all.
2. The patient’s anxiety makes treatment a difficult experience and/or prolonged
Avoiding Treatment
As a strategy, completely avoiding check-ups and treatment has an obvious flaw; you lose the opportunity for the dentist to spot issues and deal with them when they are reasonably minor. In addition to the familiar issues that people have with their teeth, dentists are also trained to spot oral cancers and other issues.
Like many fears, this level of anxiety in this context is irrational. The dental patient may not even be able to describe with any specificity the object of their fear and anxiety. I would suggest that because of this, rationalising and attempting to use logical argument to dispute the fear, is unlikely to succeed.
Clearly the issue of people needing but too scared to get dental treatment is beyond the influence and scope of individual dental practices. Let us focus here on what the dentist can and does have to deal with – the people who do make the appointment and attend but are suffering a high level of anxiety.
Anxiety Feedback Loop
This is a variation of a common scenario in therapy – a client will describe their issue, tell their story to the therapist. Possibly a well-worn story, played and replayed in their mind many times. The story that explains and rationalises why they think, act or feel the way they do. They will tell the story in some detail, eliciting nods of agreement, sympathy and complicity from the therapist as they draw the therapist into their reality. Therapists are trained to not play ball and will stop the client and question and challenge. They have a range of techniques to get past the ‘story’.
In a similar way the very anxious patient will draw the dentist into their fear state, they will exude fear and communicate it through their body language, tension, flinching, stiffness of motion all picked up almost unconsciously by the dentist. The dentist adapts their behaviour to suit, perhaps becomes cautious, stressed, tense even – their patient is difficult, interaction is perhaps strained and the procedure taking longer than the allotted appointment time.
There is a principle from the field of Neuro Linguistic Programming (NLP) which states that ‘we cannot not communicate’; meaning that we both exhibit and are sensitive to others non-verbal cues and that this process - both the exhibition and the detection - are generally unconscious.
So as the dentist is drawn into the patient’s display of anxiety, if only in adapting their behaviour and approach to suit the situation, this can be picked up by the patient and re-enforce their anxiety.
The principle is the same as a nervous speaker stepping out in front of an audience. The audience notices and responds to their anxiety, the speaker ‘feels’ the shift in the audiences level of relaxation or tension and this can fuel their anxiety.
Strategies: Rapport
We are now assuming that the patient has overcome their anxiety to at least the extent where they can make an appointment and arrive at the dental practice.
The first step is to build rapport with the patient. Rapport is a an unconscious (meaning not something you are aware of thinking, cognitions, the self-talk voice in your head) process and a feeling of commonality, knowing and being known. People in rapport are easy to spot, they agree to the point of mimicking, they will mirror each other’s body language, use the same words and phrases.
I suggest that a good starting point, if their anxiety is obvious, is simply to acknowledge it without attempting to overtly change it. Remember that the fear is probably not rational in is its beliefs or level so rationalising would not be my choice of strategy, at least at this point.
Strategies: Covert Suggestion
You can be covert here, say you notice the anxiety and say ‘I can see you are a little anxious’ (that’s the acknowledgement done) ‘we get a lot of people who are anxious before we get settled’.
You don’t need to be in hypnosis to be suggestible, indeed a good trainer of stage hypnosis I know believes that anxiety alone increases suggestibility. We also respond well to authority figures – in particular those wearing white coats.
So what did we suggest there – ‘we get a lot of people’ immediately challenges the inward focus of their anxiety and they suddenly become part of some group of people like them, who get anxious. Their anxiety ceases to be unique and special and takes a step towards some kind of normal.
What else did we do? ‘Who are anxious before we get settled’, not so subtle to the speaker but is unlikely to be consciously noticed by the anxious patient, the suggestion being that the anxiety they feel now will change, diminish once they ‘get settled’.
Strategies: Don’t be a mirror
A dentist is an authority figure. The patient is entering your domain and accepting you as expert and to some degree in control.
As I have mentioned in a previous blog, I have some friends who are professional performers including a couple of magicians. If one of them is doing a card trick and they fumble an drop an unimportant (to the trick) card they will do one of two things; they will completely ignore it or perhaps pick it up, ask an observer to ‘look after it’ and carry on.
All is fine – because of one simple principle about authority figures. If something is or appears to be wrong then the audience/patient will look to the authority figure to confirm this. If this confirmation is missing they are likely to discard the notion. If the magician had sworn, or just given the hint of a grimace this would have confirmed the dropped card as a mistake.
In the same way, and referring back to the point about the dentist being drawn into the patients state of anxiety, the dentist must be mindful of this, their own mental state, as this will be projected back to the subject. If the anxious patient senses anxiety, stress, irritation, whatever on the part of the dentist this will not help matters.
What do you think the effect of the anxious patient observing the whole dental team acting as if the patient and their anxiety was ok, normal and indeed they didn’t need to do anything special to cope with them? The anxious person looks for problems and sees only mentally calm and professionally relaxed people going about their work.
Strategies: Control Their Focus
The anxious person is going to be directing a fair proportion of their mental focus inside their head servicing the anxiety. Isn’t that part of the unconscious cues that suggest someone is anxious; you feel like you have quite got their full attention, there is a level of internal distraction?
So if you can engage them in conversation and move more of their mental focus from the internal to the external you are going to limit their ability to stoke the anxiety fire. Anticipate possibly resistance to this, at least initially. The anxious person will want to focus on the most significant stimuli - you need to coax, invite and engage. Once you succeed you will of course also be building upon the rapport and relieving the patient of the mental and emotional effort of maintaining a higher level of anxiety.
Strategies: Reframe the Bad News
This statement simply means that if there is ‘bad’ news then state it in a plausibly positive light.
So if they need an injection, state this as the need to take care of pain and to ensure they are numbed and comfortable. You have simply moved the focus of your statement away from the needle to the benefit.
If they need some extensive work perhaps compliment them on their decision to come in and see the dentist as they can now deal effectively with the issue and the on-going/worsening problems that will be avoided by the suggested treatment plan.
I’m sure you get the idea. Keep it positive and plausible to keep rapport and help the patient manage their anxiety.
Finally
The field of hypnotherapy includes a number of different approaches to helping people manage and overcome anxiety. The purpose of this blog isn’t to turn dentists into hypnotherapists but to offer what I hope are some useful insights and ideas.
My closing idea is the easiest, I suggest referring the highly anxious patients to your local, accredited hypnotherapist and let them help the patient manage or overcome the inappropriate level of anxiety; leave the dentist to fix their teeth.
Further Reading
I came across two good books on using hypnotherapy as a complimentary therapy to dentistry which I thought worth sharing with you:
Firstly: ‘Hypnosis and Communication in Dental Practice’ by Simons, Potter and Temple (Pub. Quintessence 2007). This was recommended by a dentist friend of mine, himself a trainee hypnotherapist, when I discussed with him my interest in this area. It is aimed at dental professionals and I think (from the opposite perspective of a non-dental/medical hypnotherapy professional) does a pretty good job. It is well written and an informative, engaging read. It does include some advanced processes such as regression; the process of taking a subject back to an earlier time in their life to re-evaluate a sensitive event and release any repressed emotion. I suspect most readers and probably the authors will agree with me that this, while good to see if covered here, should be left to the trained therapist.
Secondly: a book I know very well as it was a course text book for my Diploma in Clinical Hypnotherapy; ‘Hartland’s Medical and Dental Hypnosis’ by Heap and Aravind (I have the 4th Edition, Pub 2002 Churchill Livingstone) . This is a much more academic and comprehensive book aimed at the hypnotherapist, only 1 of its 34 chapters is specifically dedicated to dentistry though there is much else of relevance, for example analgesia, anxiety, cancer.