HYPNOSIS WITH CHILDREN:
DAVID SIMONS, CATH PORTER, GRAHAM TEMPLE: HYPNOSIS AND COMMUNICATION IN DENTAL PRACTICE: QUINTESSENCE PUB CO: CHICAGO: 2007
The child you will see as a dental patient is often the product of a background in which dentistry has a poor press. Even a caring parent may have told them that the dentist “won’t hurt”, thereby introducing the concept of pain. With children, possibly even more than with adults, all forms of negative suggestions must be minimized, and this particularly applies to the language that you and your staff use. Appreciate too that hypnosis is not a panacea. There will be children with whom, for a variety of reasons, it is virtually impossible to establish rapport. In some cases the immediate necessity may be for emergency extractions, and this may require a general anaesthetic. However, provided you can engage the interest of the child even to a limited extent at your first contact, it should be possible to develop rapport and to move forward on subsequent visits.
It has been proposed that when you treat a child “you treat at least three people: the child, the parent, and that child as an adult”. Certainly many dentally anxious patients will relate their anxiety to an episode with a “cold, unfriendly, uncaring dentist”.
Hypnosis can be an extremely valuable aid to dentistry with children and studies indicate that, in general, children make good hypnotic subjects. Most authorities agree that hypnotic susceptibility increases in children, being at its peak between nine and thirteen, and then gradually declines throughout life. Hypnotic susceptibility is often further enhanced if children are encouraged to use their imagination in stories and play!). However, although children have been said to be more hypnotizable than adults with a peak at pre-adolescence, things may not be as simple as that. For example, the child’s attention span may be much shorter than that of an adult and in many cases a high degree of skill is needed in order to establish rapport.
Hypnosis with a child differs from its use with adults for a number of reasons. For the young child in particular there are generally few, if any, preconceptions of hypnosis and so little explanation is necessary. The presenting problem is usually fairly clear-cut and normally there is no secondary gain involved. Quite often your major challenge will be in dealing with the parent- child relationship.
DIFFERENCES BETWEEN CHILDREN AND ADULTS: Although, given trust and understanding, most children will accept hypnosis readily, the induction process will differ from that used with the adult patient. You will rarely use suggestions of eye-closure or relaxation, particularly when working with younger children.
Their natural curiosity and energy, and lack of cultural awareness of the expected role of the hypnotic subject, mean that children in hypnosis will behave differently from adults. This can be disconcerting if you and your surgery staff are not expecting it. The child will often appear to shift in and out of hypnosis, moving, talking, and with eyes sometimes closed and at other times open. Indeed often the child will not appear to be in the state we recognize as hypnosis, but despite that will remain deeply involved in their fantasy world. Hypnosis gives a format to relationship and sometimes can even be treated as “playing a game” with the child. Your main aim therefore is to get the child so involved in the process that they are using their vivid imagination to maximum effect.
The surgery ambience, however comfortable you may feel it to be, is likely to appear strange, alien and hostile to the young child. You and your staff might also seem huge and intimidating. Paying attention to the ambience of the surgery and welcoming the child from a seated position may help to overcome this initial barrier. It is also important that you direct remarks and questions at the child rather than talking to his parent about him over his head in the “third person invisible”: ” … and how long has he been having this toothache?” It is, however, important not to usurp the parent’s role and therefore it might seem sensible to cast yourself as a favorite auntie or uncle rather than as a parental figure. In this context touch can be a valuable facilitator, particularly with the younger child, and it is imperative that this is explained to the parent and that their approval is obtained.
Right from the beginning your greeting and conversation with the child must be “user- friendly” to the child. (An actual case shown on BBC TV some years ago depicted an anaesthetist saying to a four-year-old ”I’m just going to give you an intravenous anaesthetic for the operation. It’ll just be a little injection and it won’t hurt a bit.”)
However keen the parents may be that their child has hypnosis for his dental treatment, the essential factor is that the child himself is motivated and interested. Parents will need a brief explanation of hypnosis, what it involves and what it can achieve. The child, on the other hand, will generally need little or no explanation other than that you are going to show them how they can have a good time when they have their teeth done.
Parental presence: Should a parent remain in the surgery while their child is having hypnosis? Our response to this is that as long as the parent behaves themselves they are welcome. (234)
However, there are conditions:
1) Is the child happy for the parent to stay? Does the child express a need for the parent to stay? Or does the child want the parent to leave? (The needs and views of the child are paramount.) 2) Will the parent accept that the relationship is between the dentist and the child and there must be no interruptions or other intervention, however well-meaning, from the parent?
3) Will the parent stand or sit quietly and out of mutual eye contact with the child? Usually these conditions are acceptable and the whole procedure is uncomplicated.
Sometimes the child may feel insecure and will initially want to have their parent around. Here you can use the well-behaved parent as a partner and as the child becomes more comfortable and secure in your presence you might ask the parent to gradually take a more passive role, eventually leaving the surgery. The more anxious parent may be reluctant to stay in the surgery because of their own fears about dentistry. Here a useful strategy might be for a member of your staff, having warned the parent to be silent, quietly to invite them back when their child is happily having their treatment, while keeping out of the child’s line of vision. This approach can do much to dispel anxieties the parent might have about the child, hypnosis and even their own dental treatment.
The child’s world: The trust and rapport – the use of the child’s language and involvement in that child’s world – are the crucial factors behind using hypnosis successfully with children. In order to build this rapport it is important to find out as much as possible about their likes and dislikes, hobbies and interests, favorite TV program and character, favorite computer games and so on.
If the procedure is likely to involve TV-watching, it is important that this is placed in the right context. Maybe the child has a favorite room and chair or bit of floor from which they watch TV, and maybe they are alone or with their best friend or a parent. However, it is
important that you give the child the freedom to choose this. A statement such as ” … sitting on your mother’s knee in your sitting room ” may cause discordance, whereas ” … in your favorite place … maybe on your own maybe with someone you really like … ” will give the child that choice.
Obviously the choice of words and phrases you will employ in speaking with children differ from adult language and, in general, the younger the child the simpler the words and style you will use. Quite often, it may be simpler to begin talking to the child without any explanation, simply introducing the process as telling them a story. Formal deepening is normally not needed as the storytelling itself will accomplish this. Remember that the child will probably not understand words such as “imagination” and “relaxation”, and so you might use alternatives such as “comfy”, and “tell me if you can see this picture even when (235) your eyes are closed” or “just like watching telly”. Remember too that most children, particularly the younger ones, will have no concept of hypnosis, and so words normally associated with sleep, such as “dreamy … drowsy … sleepy” can be very acceptable.
Working with children it becomes even more important to use their (preferred) name, more often than with adults. This will give the child a sense of importance, will increase rapport and will also tend to focus their attention on what you are saying and its applicability to themselves. Remember that children tend to have a short attention span, so ideas should be presented in very small chunks.
Compliance will also be increased by the use of permissive-sounding phrases rather than orders. For example, compare the effect of ” … close your eyes and you can see pictures behind your eyes … ” with ” … I wonder if, when you close your eyes, you can see pictures behind them … I bet you can … “. By making instructions sound almost like a challenging game, you are more likely to raise the child’s interest, so phrases such as ” … I bet you can’t … ” and ” … do you know that … ?” will gain the child’s cooperation.
Tell, show, do: A number of authorities propose the “tell, show, do” procedure as a useful form of desensitization for the nervous child. But this is reinforcing the dental scene, however gently, to the child. In using hypnosis one is attempting in effect to “take the child away” from the dental scene. As you will find from our examples, it is important when using hypnosis to forewarn the child of certain possible sensations, but more often the “tell and show” can be used after the dental treatment and hypnosis, when it can act as a very powerful form of ego-strengthening. ” … gosh) you have done SO well … do you know what you have just done? … would you like me to show you? …”
Never lie to a child; they will find you out and all chance of rapport will be lost. This becomes an issue when the child asks either “will you be giving me a needle?” or “was that an injection?”. If the question is asked after the local has been given, this can be used as ego- strengthening as described above, but the question asked before the procedure is more problematic. In this instance the “tell, show, do” technique is sometimes beneficial provided the “tell” is focused on the positive aspects, such as the use of “magic” cream and the comfort of a good anaesthetic.
USES OF HYPNOSIS: As with adults, hypnosis is a facilitator for any and all dental procedures with children and is particularly effective in the circumstances listed below. For practical purposes the age limit will probably be around six years, although younger children are also sometimes suitable. (236)
USES OF HYPNOSIS IN DENTISTRY FOR CHILDREN:
• Management of fear and anxiety
• Pain control in conservation and extractions • Impression-taking
• Fissure sealing
• Where the child needs to be still for a long time (e.g. orthodontic procedures) • As an adjunct to inhalation sedation
• As part of the induction of general anaesthesia
• Habit elimination (thumb-sucking, nail-biting)
TABLE 31.1: SYNOPSIS OF INDUCTION TECHNIQUES: (adapted from K. Olnes)
Tactile stimulation, stroking, patting, etc.
Kinesthetic stimulation, rocking,
moving an arm back and forth
Auditory stimulation, music or other soothing sounds
Visual stimulation, mobiles, etc. Dolls and stuffed animals
Blowing bubbles Storytelling Favorite activities Puppets
Guided fantasy, e.g. flower garden, beach, football game, etc. Storytelling
Bouncing ball or ball in a bucket Videos
Video games, real and imagined Riding a bike Arm-lowering
Hands moving together
Most adult methods, especially:
Fantasy methods, e.g. video and computer games Music, real and imagined (237)
Some general notes on techniques with children: Although it is our intention within this section to describe the use of hypnosis with dental patients from approximately six years old upwards, we will preface it with a few words suggesting techniques for use with the younger child. Here the well-behaved parent can be a valuable silent ally, and provided you can get the full attention of the child there is no reason why they should not sit on their parent’s knee. Although children under six may enter a trance-like state, hypnosis for dental treatment is not realistic unless the operator has specialist skills. Even when the child is over the age of six you must use your judgement regarding their maturity and likely cooperation to decide whether or not you feel hypnosis will be the strategy of choice. In all of the cases described below, we will
assume that rapport has been developed with the child and that the parent has given the requisite approval and permission for the procedure.
Some induction methods for the very young child: In the days of the cord-driven slow hand piece, the late George Fairfull Smith used a beautiful technique in which he would attach pieces of cotton wool to the drive cord and gently get the little child to concentrate on watching ” … the wee foxy-woxy chasing the little bunny rabbit”. Lulled by Fairfull-Smith’s gentle Scottish burr, the child would enter a trance state in which the dental work would be tenderly carried out. A modern-day alternative is to have available a number of dolls, toy animals and pupppets with which you can enact the child’s problem in metaphorical form, generally bringing into the story sleepiness, dreaminess and the solution to the problem (see the discussion of metaphors later in this chapter).
THE SLIGHTLY OLDER CHILD: Smiley thumb levitation: This is a simple technique that incorporates involvement, arm levitation and eye closure, and can be used with dental patients from approximately six years old upwards. Begin by drawing the familiar smiley face on the child’s thumb nail. You might also start by asking the child what color they would like you to use, and what name they are going to call the face. Show the child how to hold his arm out straight and sightly raised with the thumb nail clearly visible, and ask them to stare at the smiley face as hard as they can. (238)
“… so Suzie … I wonder if you can keep staring at Billy as hard as you can … and the funniest thing is that the harder you stare, Suzie … it’s as if Billy really wants to look at your face … and ever so slowly, Suzie, he’s going to float up right up to your face … and then it becomes magic cos when Billy just touches your face your eyes close … and you’ll feel so dreamy … drowsy and sleepy … and it’s just like you’re in your special place … and you’re watching your very best thing on telly … and, Suzie … now Billy can just flop down and go to sleep and you can just watch … ” [here describe the program that the child has previously told you of)
Smiley thumb heaviness: Begin as above, but rather than suggesting arm elevation suggest: “.. and now, Suzie … the harder you stare at Billy … do you know what’s going to happen … Billy is going to get so-o-o heavy … heavier and heavier … and so tired … and sleepier and sleepier … and I wonder how long it’ll take, Suzie, before Billy is so heavy and tired and sleepy … that soon, Suzie … he’s going to be fast asleep … ” [take hand and rest it comfortably and continue with TV dream as above]
Coin drop: This method, in addition to the game-playing and involvement of the child, also carries the promise of a minimal bribe. The idea is that you give the child a (low-denomination) coin and ask them to hold it with their arm raised and at arm’s length between thumb and forefinger. “…Debbie … I wonder if you can stare really hard at that coin really hard, Debbie … and as you do, I think your arm is going to get heavier and heavier really so heavy, Debbie … and tired … and soon it’ll feel so very heavy and tired that that coin will just drop on its own …” [here it is sensible to be ready to catch the coin as it falls, to avoid noise] … and it doesn’t matter, Debbie `cos we’ll keep it safe for you for later … and as it drops you’ll be so dreamy and drowsy and sleepy that … ” [take hand and rest it comfortably and continue with TV dream as above]
Informal dissociation by TV imagery: This technique will utilize the child’s natural ability to daydream, and this will be coupled with your status and the status and responsibility you have given to the child by treating them as a person. (239) Rapport can be enhanced by a brief discussion with the child to determine their interests, siblings, pets, TV viewing habits and so on. Wording and language should obviously be appropriate to the child’s age, and tone should
be friendly and conversational, giving the child the feeling that this is a very personal and important meeting. Eye closure might be suggested, but at this stage is not important. Case history: Simon – a TV dream
The patient: Simon was a particularly bright and imaginative boy aged six. His mother, Judy, had previously suffered from severe dental phobia and I had used hypnosis with her, after which she had become an excellent and happy dental patient. Simon had probably been influenced by his mother’s earlier dental anxieties and was quite obviously terrified about the two deciduous tooth fillings he now needed. Judy prepared Simon well by telling him how gentle and kind I was, and how with me he could have a “special dream about Popeye” (his favourite television character). Simon asked if it was going to be hypnosis and Judy told him that it was. At that stage Simon said he wanted his mother to stay and they both agreed that she would sit quietly in a corner of the surgery.
Treatment plan: My plan was to use hypnosis informally with Simon, particularly as his mother had prepared him to the extent even of the content of his dream. Our rapport was good and I felt we could use his powerful imagination to create sufficient dissociation for me to carry out the two fillings without local anaesthetic.
Procedure: [beginning in slow conversational mode and moving into quieter, slower, dreamy hypnotic tones]
“… Now, Simon … you know when you want to see pictures sort of in your head … do you do it best when your eyes are shut or open?” (Simon said it was best with his eyes closed) ” … so why don’t you just close your eyes … and I know that you like Popeye … so here’s what you can do … do you have a best place when you watch telly, Simon? [Simon nodded] … I bet you can see that now … your best place … just how you like it …. and there’s Popeye on the telly … he’s so strong and so funny and maybe he’s got a tin of spinach … and maybe Olive Oyl’s there as well … that very) very) very thin lady … and Bluto … isn’t he huge … I wonder what they’re doing … I bet you can make up the story, Simon … maybe you can even be in the story … (240) [here, using “vague exactness”, a story involving a tin of spinach and Popeye’s success was described] … and now it’s nearly finished … and I bet Popeye’s won again ‘cos he always wins … and now it’s all finished and you can open your eyes again and I’m here and mum is here and you have been amazing Simon … and guess what we’ve made those teeth all better for you and all the time you’ve just been having a lovely dream watching telly”
During this time (about 10 minutes) I prepared cavities with a slow-speed drill in both lower Es and restored them in amalgam. Simon occasionally moved a little and opened his eyes on a couple of occasions, but was obviously comfortable and happy, to the extent that I didn’t sense a need even to explain to him what I was doing or to prepare him for the different sounds or sensations, and he made no response to them.
An amusing sequel: Simon from then on was a model patient and apparently had few anxieties regarding dentistry. However, there was an amusing sequel about two years after this episode when his mother told me that he had confided in her, telling her, ‘It can’t have been hypnosis cos although I told the dentist I was dreaming about Popeye I was really dreaming about Tom and Jerry!”
Another informal technique: You will have noted that in the previous example dental work was barely mentioned. In the following case the child is given suggestions preparing her for each subsequent stage of her experience of dentistry. Observe that the language and imagery and verbal delivery employed are hypnotic. Note, too, the important step of warmly congratulating
Pam on achieving each target. This will help to strengthen rapport, encourage further goal-setting and act as a powerful form of ego-strengthening. Case history: Pam – reframing the treatment:
The patient: Pam was a very anxious six-year-old girl with pain in an upper deciduous molar needing urgent treatment. She’d never attended a dental practice before and her mother was not a patient. (241)
Treatment plan: After gaining the parent’s consent, it was planned that I would relieve Pam’s pain without distressing her, and at the same time begin to build up her trust and confidence, using an informal storytelling approach.
Procedure: I began by chatting about her school, her friends, TV programs and so on before explaining that some nasty little “bugs” had eaten their way into her tooth, and this is why it was hurting. I asked her if she would like me to gently chase these bugs away, then clean up after them, give it a good wash and fill in the hole that the bugs had made so they could not get back in. After Pam had agreed, the explanation continued, quietly and rhythmically, as she began to be more and more involved in the story.
She was allowed to see and smell the “magic jelly” (flavored topical anaesthetic) that would start to send that part of her mouth to sleep. This was then gently placed next to the upper left first deciduous molar, suggesting that the bugs were starting to get sleepy.
Next, when the surface of her gum was “asleep” (this was tested by carefully torching that area) I would squirt some “magic water” at that place so that everything went to sleep in and around the painful tooth. I explained that she would feel something, and gently pinched her hand telling her that would be just like it would feel near her tooth:
“Some little girls say it feels like a tickle) others say it is like a squeeze) I wonder what you will say it felt like?”
I told her that although she did not have to, the magic worked better if she closed her eyes, and when she did so, the injection was given very slowly while asking her to think about all the bugs going to sleep, just like Sleeping Beauty. When the injection was given, Pam was praised lavishly and congratulated on helping the magic to work so well.
Then, she was shown a probe and the point was carefully pressed onto her hand. When she said that her mouth was feeling “bigger” the probe was pressed against the gum at the side of her tooth. When the girl confirmed that she could not feel it like she could when it touched her hand, the praise was repeated and she was told that all the bugs would be fast asleep. (242)
I started the hand piece and slowly let it play over my arm, before allowing it to run over her finger. When she felt this, she shivered and giggled, and I told her that when the bugs were tickled they all came out of the hole in her tooth. By now the little girl was so interested in what was happening she was not aware of the previous pain.
The tooth was gently made caries free, with a continuous commentary on how all the bugs were running away. She was shown some of the caries and she was amazed to see the “sleeping bugs”. After this, I praised her again for being so good. Then I explained that because the bugs were so dirty (she had seen the brown slush previously) the hole needed to be washed out and vacuumed, like her mother did at home, so everything was nice and clean. I showed Pam the water syringe and aspirator tube. She was a little apprehensive at first, mainly because of the noise, but after she had felt it on her hand, and after a “practice”, where the tube was held next to the tooth very briefly, she allowed the cavity to be flushed. Once again, Pam was highly praised.
The next step was to start filling in the hole, firstly with some “special paint”, and some calcium hydroxide was placed. Then it was time for some more magic. She was shown some glass ionomer cement and was told that by shining a “magic light” I would make the cream turn very hard, sealing up the hole. The filling was then cured.
Finally, Pam was told enthusiastically how well she had done. Both the girl and her mother were very pleased.
Outcome: Over the next few weeks a similar routine was followed to restore her other carious teeth, and Pam now attends regularly without anxiety.
The “ball in bucket” game (with acknowledgment to Don Ibrahim): In this technique you will introduce the child to your suggested imagery and incorporate “automatic movement”, arm levitation and a useful bribe. (243)
Case history: Sam – ball in bucket and arm levitation:
The patient: Sam was a very active six-year-old who needed a small filling in a deciduous tooth, but possibly did not even know how to sit still. It seemed sensible to use an inducction method that would take advantage of his restlessness.
Strategy. “. .. and Sam, we are now going to playa little game. You’d like that, wouldn’t you? … and
with this game you’ll see lots ofpictures of some lovely things and you’ll able to see them even with your eyes closed … doesn’t that sound great, Sam are you ready … super … so now I’d like you to close at your eyes … that’s lovely … and I wonder if you can see a picture behind your eyes, Sam … and the picture is a bucket of a water … just like the sort of bucket you might have if you go to the seaside … can you see that? .. and what color is the bucket? … blue? …
[it is important to get a positive response here to indicate that the child has created an image] … that sounds really lovely, Sam … and can you see that there’s water nearly to the top of the bucket? … good … and on top of that water there’s a ball floating … can you see that? … and what colour is that ball? … red … so there’s a red ball floating on the water in that blue bucket … and now we’re going to play our game, Sam … I’ll just take your hand and I’m going to put it on top of the ball …
[I lifted his left hand and positioned it as if on top of a ball about 30 cm (12 inches) above the armrest, keeping my hand above and gently holding his wrist] … and I wonder if you can push the ball down into the water … and what happens? … yes, isn’t it funny how it floats back up [I moved Sam’s hand slowly up and down, establishing automatic movement] … and down again … and up … and down again … and up … I wonder if you can just carry on doing that on at your own … [I let him continue the motion] … up … down … up … down … and now a funny thing will happen … because that ball is going to turn into balloon … a beautiful big balloon … and do you know what? .. it’s going to float up higher and higher and your hand will float up with it, Sam … and when your hand floats up to your face the balloon can just float away, and it doesn’t matter because we’ve got another balloon here for you later … And now, Sam … you can just let your hand brush against your face … and when it does you will start to feel really dreamy and drowsy and sleepy … and you can just let your hand drop back down and … [continued as in earlier examples] (244)
DISSOCIATIVE TECHNIQUES: A number of imaginative techniques particularly applicable to the older child have been described by Karen Olness.
Switching a sensation on and off: Using language appropriate to the child’s age, suggest in hypnosis that the child visualizes some form of switch, for example a light switch, push-button or lever, and then practices turning that switch on and off Propose to the child that the switch turns on and off the connections from the various parts of the body to the brain, so that they cannot feel a certain area, such as the part of the mouth that needs attention. Computer analogy: The computer now plays a large part in the lives of many children, and its potential as a hypnotic metaphor is boundless. Build on the suggestion that the child is sitting before their computer, gazing at the screen, and let them set up their own programs to deal with their present difficulty. This may involve wiping the current behavior program, rebooting the computer and setting an alternative, or placing a current document in the “recycling bin”. The vast array of computer games available to children and their ability to manipulate them also opens up many opportunities for hypnotic imagination and involvement. These opportunities can be used to wipe out any obstacles to change or to achieve any goals that may be required.
Detachment: Ask the child to imagine that a part of them does not belong to them; as if it is detached from them, or is artificial, so that any sensation there cannot be felt. This can be enhanced by getting the child to imagine a mask or a doll/toy animal facing them and transferrring all sensation to the equivalent area on the imagined toy. Be sure to build in the sense of security that at the end of the session they will be whole again.
Displacement: Ask the child to “imagine that all the feelings are going into your little finger on this hand, then, after it has all gone into that finger, you may want to let it just float away”. Alteration of cognitive variables: Some children find it difficult to be distracted or to dissociate. An alternative is to ask the child to give a detailed description of their discomfort, and you can then gradually give suggestions that change their perception for the better. Depending on the age and inclination of the child, responses can be given either verbally or by an ideomotor response. (245)
The questioning might then be as follows:
“Has it got a color?”
“Or has it got a sharper”
“What size is it?”
“Is it rough, or is it smooth”
“Does it make a noise”
“Does it have a smell?”
“What color/size/shape/texture/sound/smell would it have to be to fiel better? I wonnder if you can start to change it [to a more desirable characteristic]”
Glove analgesia: A variation of the imagery as used for adults can be effective for an appreciable number of children. You might say, for example:
“I wonder if you’ve ever been playing in the snow and maybe you lost a glove, or your gloves got ever so cold and wet … and your hand was so cold that you could move your fingers, and just couldn’t feel anything at all … ” [on receiving a positive response this can be extended into transferring the resultant numbness to the area of the dental work]
Stories and metaphors with children: “Once upon a time the famous physicist Albert Einstein was confronted by an overly conncerned woman who sought advice on how to raise her small son to become a successful sciientist. In particular she wanted to know what kinds o/books she should read to her son. ‘Fairy tales; Einstein responded without hesitation. ‘Fine, but what else should I read to him after thatt the mother asked. ‘More fairy tales,’ replied the great scientist,
and he waved his pipe like a wizard pronouncing a happy end to a long adventure.” (Breaking the Magic Spell”)
Storytelling is a hypnotic technique. It can produce the distinctive narrowing of focus of attention, altered sensation and time distortion that characterize hypnosis.
The power of stories and metaphors lies in their ability to be understood on several levels. • Superficially: as entertainment or distraction.
• Deeper: as a reminder of other story times, such as being at home feeling contented at bedtime. • Deeper still: as a representation of a part of the child’s life or experience. The story may suggest solutions, or at least give a role model for the child to emulate. (246)
Any parent who has read to their children must be aware of a child’s ability to become totally immersed in a story and the almost ritualistic role the story can take on in that child’s life. Children will have a favorite bedtime story and in a short space of time, even for a normally excitable child, this can become an anchor to peacefulness, settling down and sleep. Sometimes one might be reading a child a much loved story while the child is apparently totally engrossed in some other activity and the child will instantly snap into awareness if a single word is omitted or altered. We are surrounded by such evidence of the child’s ability to dissociate; to become absorbed in fantasy at the expense of reality. Much of children’s game-playing involves the acting out of make-believe characters who to the child’s mind can assume reality. Sometimes the barrier that for most adults separates fantasy from reality seems barely to exist in the world of the child.
Stories and game-playing therefore present you with a remarkably effective route to utilizing these qualities within hypnosis in dentistry.
“For a story truly to hold the child’s attention, it must entertain him and arouse his curiosity. But to enrich his lift, it must stimulate his imagination; help him to develop his intellect and to clarify his emotions; be attuned to his anxieties and aspirations; give full recognition to his difficulties, while at the same time suggesting solutions to the problems which perturb him. In short, it must at one and the same time relate to all aspects ofhis personnality – and this without ever belittling but, on the contrary, givingfull credence to the seriiousness of the child’s predicaments, while simultaneously promoting confidence in himself and in his future.” Bettleheim.
Ingredients of a therapeutic metaphor: For a metaphor to be used successfully it should ideally contain certain key elements. Here we will present a real case study followed by a deconstruction in order to point out these elements.
Case history: George- a Liverpool Football Club supporter
The patient: George was an eight-year-old boy who came along crying with pain from a very carious upper deciduous molar. He was extremely distressed and nervous, and not in the mood even to let someone look at the tooth. I noticed that he had a Liverpool football bag and so I started to talk about football, especially the Liverpool team. (247)
Treatment plan My intention was to use a dissociative technique. I would tell George a story centered around the football team, using the “another person” metaphor and gradually integrating George into this character and into the story. I planned to inject local anaesthetic and to extract the carious tooth
“Do you remember when Steven Gerrard had very bad toothache just bifore the last Champions League match? [George gave a hesitant nod] … well it was really painful, but he knew that unless he went to the dentist and let him sort it out, he would not be able to play well in the big match. Now, how do you think Steven Gerrard was when he went to the dentist? Can you imagine him
going in to the dentist, and listening to what the dentist had to say? Although Steven Gerrard knows lots and lots about football, he also knew that dentists know lots and lots about making toothache better, and because he trusted the dentist, he knew that he had to do whatever the dentist said to make that toothache go away, so he would be ready for the big match.
Now, shall we do the same things that Steven Gerrard and the dentist did? [George nodded again] Great! … the dentist told him that he would make the tooth and the gum around it go to sleep. First he would rub some special ointment on his gum, just like the ointment that they use when footballers get injured in a game. So, shall we do that?
Next, the dentist told him that he would squirt some liquid at the place where the gum was starting to go to sleep, and do you know what Steven Gerrard did? He closed his eyes so that he could imagine that he was playing in the big game. And guess what, if you close your eyes, you will be able to imagine that you are playing in that game with Steven Gerrard, and all the other Liverpool players! So, let me know when you can imagine yourself walking out onto the pitch … [after a few moments George nodded again]
Now I’m going to squirt that liquid and you will probably feel something … Steven Gerrard said it filt a bit tingly [the injection was given slowly and evenly, at the same time as further suggestions about the game were being made] … can you hear how loud the fans are cheering? And can you hear some of the songs? [and so on]
That was brilliant – just like Steven Gerrard! So, you can let yourself get right on with the game, has it kicked off yet? [once again, George nodded) Good, now you will have (248) concentrate on the game so that you play at your very best and of course, when you play in a big game like that, you get pushed and pulled about a lot … [I pushed his arm, and tugged at his shirt while saying this] … and you can get pushed on your body, your legs, your arms and even on your face, around your mouth … [all these statements were accompanied by some pushing and pulling] … but you can handle tha0 playing for Liverpool you know that you are the best! And you know that you always get pushed and pulled, its all part of the game, but it does not stop you from scoring goals, does it? And I bet if you play really well now, even though the other team are trying very hard to stop you, you can score! [the tooth was quickly extracted, without any pause in the dialogue] … even when they try and foul you, they can’t stop you from scoring, and the fans are chanting, they are chanting your name! So, when the game is over, you can open your eyes, you have done ever so well just like Steven Gerrard! I can’t wait for you to tell me the score!”
Outcome: After a short time, the boy opened his eyes. He seemed a little bemused, but with myself and his mother and the dental nurse all telling him how well he had done, he was able to leave the surgery calmly, marvelling at the extracted tooth that we had given him.
Analysis of this case:
1) The story must interest the child and must meet the child at his level without imposing the view of the therapist. An effective way of doing this is to interweave elements of the child’s particular interests, for instance their favorite animals or TV programs, within the story. “… Do you remember when Steven Gerrard had very bad toothache just before the last Champions League match? … well it was really painful but he knew that unless he went to the dentist and let him sort it out, he would not be able to play well in the big match … “
2) The story must represent the child’s problem accurately enough for them to identify with the characters and events portrayed. The significant events and characters of the child’s real situation must be present in the metaphor, preserving the relationships and emotions, but not the context.
“… Although Steven Gerrard knows lots and lots about football he also knew that dentists know lots and lots about making toothache better, and because he trusted the dentist, he knew that he had to do whatever the dentist said to make that toothache go away, so he would be ready for the big match …” (249)
3) The goals represented within the metaphor must be realistically within the reach of the child.
“.. and because he trusted the dentist, he knew that he had to do whatever the dentist said to make that toothache go away, so he would be ready for the big match. Now, shall we do the same things that Steven Gerrard and the dentist did?”
4) The emotional content of the metaphor should be strong and must mirror the child’s experience
“. .. and of course, when you play in a big game like that, you get pushed and pulled about a lot … and you can get pushed on your body, your legs, your arms and even on your face, around your mouth … but you can handle that, playingfOr LiverpooL you know that you are the best!”
5) The metaphor must show a resolution to the problem, and indicate how the child can achieve this.
“And you know that you always get pushed and pulled, it’s all part of the game, but it does not stop you from scoring goals, does it? And I bet if you play really well now, even though the other team are trying very hard to stop you, you can score!”
6) There must be a celebration at the end to show the child that there is a reason to change and to acknowledge their effort and achievement. ” … even when they try and foul you, they can’t stop you from scoring, and the fans are chanting, they are chanting your name! So, when the game is over, you can open your eyes, you have done ever so well just like Steven Gerrard! I can’t wait fOr you to tell me the score!”
Other person metaphors: A few moments spent in identifying the child’s interests, pets, icons and anti-heroes will pay rich dividends, and with practice you will find that you are able to build simple stories such as this. It can be incorporated into a story about “another child”; “I once saw
a pretty little girl just like you … ” A further way of using this technique is to compose a story in which the child’s hero succeeds in conquering a problem analogous to the one that the child has. For the young child the doll or animal can be used as the metaphor, and you might talk to the animal in much the way you would to the child, at the same time possibly making it slightly more dramatic or comical.
Fairy tales and cartoons: One of the simplest ways of constructing metaphors is to take as a “template” characters and situations with which the child is already acquainted. The fables of Aesop and the stories of the Brothers Grimm and Hans Christian Andersen offer a wealth of material, (250)
and it is not difficult to modify the story and even to include the child as one of the characters, confronting problems and attaining success and glory at the end.
In a similar vein many children are fixated on children’s TV cartoons and characters, and this may be exploited in a similar way. It is important that you adhere to the key elements referred to above and essential that the story ends in triumph. After all, the child will have heard enough stories giving the negative side of dentistry.
“I think a job like this requires
The services of Mr Myers.”
I shouted, “Not the dentist! No!
Oh mum why don’t you have a go?”
I begged her twice,
I begged her thrice
But grown-ups never take advice.
She said, “A dentists very strong.
He pulls things out the whole day long.”
She drove me quickly into town,
And then they turned me upside down
Upon the awful dentists chair,
While two strong nurses held me there.
Enter the dreaded Mr Myers
waving a massive pair of pliers …
He started pulling one by one
And yelling “My, oh my, what fun!”
I shouted, “Help!” I shouted “Ow!”
He said, ‘Its nearly over now.
For heavens sake, don’t squirm about!
Here goes! The last ones coming out!” …
From “The Porcupine” by Roald Dahl.
Remember all expansions are stories – make yours a good one! (251)