Dentistry has credibility issues. Over many years we have reassured ourselves that we are a much loved and appreciated profession, However, the reality is actually worse than we have lead ourselves to believe. How do we know this? The Canadian Dental Association commissioned an Ipsos-Reid survey. The results are sobering.
Apparently only nine percent of Canadians completely agree that they trust dentists, while only seven percent completely agree that dentists provide good value. Sadly, the cross-country statistics are the same. There is no regional variability to at least keep us warm at night. To diminish the impact of the survey, I can hear the naysayers quoting Mark Twain about lies, damned lies and statistics or perhaps suggesting that the wrong questions were asked. This may be valid argument, but the percentages speak against this.
So what do our patients and especially the non-patients want? The survey says they want us to be:
• Patient-focused
• Show personal attention
• Trustworthy
• Good communicators and
• Have up-to-date dental skills.
Most of us would like to think that we and our practices already possess these attributes.
Intrinsically communicating well, should address most of the patient wants and to some degree resolve them. If we have adhered to the practice management consultants’ suggestions for effective communications and it is still not working ideally, what then? What are the obstacles? Is there a factor that is not obvious, perhaps inherent to our makeup, yet rarely enunciated?
Do fish know they swim in water? I suppose that they take water for granted like we do air. They are unaware of how it impacts on them. Yet, when acute changes happen, all creatures take notice. This refocusing of awareness and lack of awareness has survival value. These range from energy conservation in the brain, a metabolically expensive organ, to resource management in cognitive functions. Evolutionary psychology contends that all of our behaviours are steeped in adaptations for our survival. The ability to function on auto-pilot in most day-to-day activities is one such adaptation. These subconscious auto-pilot programs are inherent or acquired trances.
Trance States are the unstated inherent factors that either enhance or impede communications. This is an alternative model of communication. To quote Stephen Wolinsky, “… trance states are a crucial part of the fabric of our daily life experience as well as of our symptomatology.” Like all models, the ‘map is not the terrain’, but it is a symbolic representation of it. It is a construct to explain that has practical applications.
Before we delve into this alternative model of communication, let’s review the conventional principles of effective communication. Communication is inevitable. It has been said that one cannot not communicate. The very act of mutely standing in front of another conveys information that is apprehended by them. It may not however, be what we wanted to say!
Communication is irreversible. Any answer, even damming silence to the infamous ‘Do I look fat in this?’ question, reverberates with thunderous volume! In this example, once uttered … or not, the message can’t be retracted.
Interpersonal communication occurs on several levels. In the example of The Question, silence as well as comment, touches deeply on several levels – enumerating them should not be necessary.
Interpersonal communication is influenced by the physical setting. Using the question again, a positive answer to looking fat at home resonates differently at the gym than in a physician’s office. Thus, the interpretation of the answer will be different depending on where it is posed and received.
Communication follows a simple process. Broken down into its components the scheme is summed up as follows.
1. The sender has something to communicate. This may be verbally or nonverbally, consciously or unconsciously.
2. The sender encodes the message in a set of stimuli that they think the receiver will understand. This may be intentional and conscious or again it may operate under the threshold of awareness. A pithy example is the axiom “to dress for success”.
3. The message is sent.
4. The recipient receives and decodes the message. As before, this may be with full awareness or below its threshold unconsciously.
5. The recipient responds by providing feedback that indicates how he has interpreted the message. Once more the response may be verbal, non-verbal, conscious or unconscious.
6. The sender receives and interprets the feedback and the cycle is repeated.
Essential to this scheme is an implicit understanding that the message is sent and received accurately. Accuracy may be impacted by problems with coding and decoding. Regardless of what we may casually think, all of our perceptions of our world are first apprehended by our unique individual senses. No two of us have identical sensory organs. The information acquired in this fashion is then processed in the wetware of our brains using those metaphors and paradigms that have been inculcated in us since birth.
Accuracy will also be dependent on the discrepancy between the sender’s and receiver’s frames of reference. As an example, let us use cultural distinctions to illustrate the subtle differences in world views (frames of reference) that underlie languages. Adler and Rodman illustrate this using the actions of a mischievous child. Listed below are four languages describing this inappropriate behaviour. Each has an underlying linguistic implication and the corrective phrase that would be said to this child.
There are very subtle differences in meaning between “be good”, and “be wise”; whereas there is no subtlety in the distinction between an act of unkindness versus one of non-conformity. Hence, there are two different frames of reference for the same child’s actions that would impact on the communication with and about this child.
Message complexity has a bearing on accuracy. The exercise of having someone whisper a message into the ear of person who does likewise in a line of people illustrates this well. A very simple message will become distorted by the time it reaches the last person. A complex message will bear no resemblance to the original. Accuracy will also be impacted by the availability of feedback. E-mail return receipts underscore this nicely. If you did not request one and the intended recipient did not respond, then you do not know whether your message got through and was understood. Overlay the concept of a trance on to the determinants of accuracy and it becomes apparent that Trances can be both the hindrance and facilitator of communication.
To this point I have not defined trance, yet from popular culture, we all have an idea. There is not a single consensus definition of trance across the disciplines, but all who work with trance know what it looks like! Trance, throughout this discussion will be considered as a broad continuum of cognitive states that include the following general subsets – Relational, Situational, Inner-mind and Group-mind. Each of these has several specific subcategories. Adam Crabtree, who promulgated these concepts, has defined the mechanisms of trances as “a state of profound abstraction and absorption” and “a state in which a person is absorbed in one thing and oblivious to everything else.”
Let us further characterize each of the four types of trance. (You could for all intents and our purposes use the word hypnosis interchangeably with trance.) A Group-mind Trance is the least recognized, but most significant. In this trance, an individual is the “carrier of the values and drives that characterize the group as a whole.” If one expands a group to a people, it is a cultural trance. The world is today replete with examples of the conflict caused by the collision of trances. Refer to the preceding example of the mischievous
child’s behavior as a simple example.
The value of a group-mind trance is that it is a way of enculturation of its children into the group. If a child, had to consciously absorb all of the information needed to function in society, childhood would last into old age. Think of the herculean effort to learn to ride a bike with conscious awareness and compare it to the ease of riding unconsciously once mastered. (Bruce Lipton’s The Biology of Belief gives a nice foundation to this concept.) “Children are in trance until proven otherwise!” is the axiom most clinical hypnotists start from when working with children.
Relational Trance has “one person absorbed in another and oblivious to other matters.” These states may range from annoyance to the sociopathic; interest to obsession; mild to profound. Obviously, they can be quite pleasant or quite traumatic depending on the context. Gender differences illustrate the complexity of a relational trance versus a situational one. Can you hazard a guess which gender favours which trance?
Situational Trance “involves immersion in an activity, project, work, or enterprise to the exclusion of other interests.” Instrumenting MB2 of 17 during endodontics demonstrates this concept. All of us are aware of this type of procedural involvement. It permits us to be effective and adept in the performance of our tasks.
An Inner Mind Trance has “your attention diverted from the concerns of the external world and focused on images of your inner mind.” This is the concept we are most familiar with when relating to trances. Hypnosis, auto- and hetero-, meditation, martial arts training, yoga, and the like, including addictions, fall into this category.
We are most familiar with the ‘sleep’ variety of hetero-hypnosis that is induced by using a series of artfully delivered direct or indirect verbal suggestions. These types of trances may also be self-initiated as with self-hypnosis and meditation. Situational context may also engender trance e.g. the dental phobic. As the clinician, we may unknowingly induce a trance state by the turn of phrase we use.
Other characteristics of trance include heightened suggestibility with a reduction of critical screening. It is these features that are utilized in stage hypnosis for entertainment. A good stage hypnotist spends most of his time in a performance selecting the best subjects. They have to be willing participants, who can fall back to the excuse that it was the hypnosis or the hypnotist that was responsible for any ‘out of-character behaviour’. In reality, entranced subjects do not do anything that is contrary to their moral codes. Axiomatically all hypnosis is self-hypnosis. The control rests with the individual, not the hypnotist.
Trance states never seem complete; there is a timeless quality to them. Alterations in the typical operations of mental functions along with an altered sense of one’s physical self-image may also occur. Imaginal processes like imagery and the vividness of the imagery through the senses may also increase. One of the classic features of trance is an altered sense of time. There is a distortion – either increasing or decreasing perceptions of the length of time in trance. This may be spontaneous or suggested for a particular purpose. Physiologically, these features are mediated through the autonomic nervous system. Brain imaging of these states has correlated activity in the anterior cingulate cortex in conjunction with other areas.
“Hypnosis is communicating with someone or some groups ‘mind’ where the receiver of the message is using significantly less critical thought (questioning the message) to evaluate the message than they normally would.” This statement by Kevin Hogan is the synthesis of the model.
Let us take a patient encounter to illustrate these concepts. Let us make the patient an elderly woman of eastern European background. She presents with a toothache related to ‘old country’ dentistry which she managed to get at a bargain price while visiting ‘home’. She has been a sporadic patient of record to the practice. The dentist is a young thirty-ish male of North American descent. While reading the characteristics of the example, you should notice what mental images and associations sprang to mind. Also note that with each, your focus was becoming narrowed and internalized. Now ask, from where were your thoughts and images derived – clinical experience, cultural contexts, childhood experiences?
This lady is seated in the dental chair in the operatory, while the dentist hovers above her going about his business. It is very likely, that she is anxious, has had little sleep and poor nutrition in the last few days. He may be speaking “dentalese” in what he perceives as a neutral, factual manner.
Examining the encounter through the various general Trance types we arrive at the following. This list is by no means exhaustive. From the cultural trance perspective she will likely reify the lifetime suggestions of relating deferentially to the Doctor both because he is the authority figure and a male. Her deference may prevent her from either asking questions or will cause her to accede to any proposed treatment intervention. This may also be exacerbated by the age difference. She no doubt has had similar experiences in the past; since the pervasive motto of her childhood was go to the dentist only when it hurts. She will likely be regressed into one of those previous episodes reliving the anchored emotions.
The doctor may view the interaction from the lens of his generational cohort and their expectations in this type of interpersonal encounter. His own personal dental and medical experiences will colour his behaviours. This may limit his ability to appreciate the patient’s concerns, beliefs and experiences. Based on his training, his use of language will likely exacerbate her state.
The situational trance elicits the memories and emotions associated with the operatory. For this lady, they are all likely traumatic. For the doctor, they may be purely work related associations. Had he a previous experience with this patient or a similar one, he may also be revivifying those associations. Each and every time one relieves an experience the focus becomes internal to the exclusion of the external. If the experience is especially emotionally laden, the absorption becomes more profound. The dentally phobic patient is in such a state.
From the relational trance perspective, when the patient is lower than the doctor, sitting or lying prone, a parent – child relationship ensues by the patient’s regression to the child. Thus one is not talking to an equal in this context. This state for the patient may revivify past dental and other similarly negative experiences. The resulting anxiety will further prevent good communication. Depending on the doctor’s ability to recognize the situation’s dynamics, his comfort in the role projected on him, his ability to provide care may be impaired or enhanced.
Filtering by the inner mind trance concept; the patient will be in a sympathetic nervous system mediated trance. Her anxiety will narrow her focus to look for danger in her environment and when possible to flee. She may however elect to ‘fight’. Depending on the degree of her anxiety and whether it may be a true phobia, the attached emotions, the ability to communicate will be severely hampered until her trance state is resolved. The doctor’s response to her anxiety may be calm or a ramping of his own anxiety. Anxiety tends to be infectious. He may also be frustrated by the experience. The more he tries to render care, the more he will likely enter into a profound limited awareness and focus of attention. Thus, we now have two inner mind trances in opposition to each other.
All of the preceding trances are constantly in flux and overlapping throughout the patient-doctor encounter. For simplicity, none of the other office staff or attending friends or relatives has been entered into the example, yet they also have an impact.
Briefly, consider the parent of a pediatric patient who may be phobic and remains in the operatory to ‘help’.
Learning about trances, particularly hypnosis, offers an enhancement to our ability to communicate both personally and professionally. The investment is nominal and has far greater application. Rest assured that for those that do not understand the mechanics, others do as illustrated by Armour’s statement. “Communication systems are structured by economic forces which use them to optimize sales, and politicians who increasingly live by slogans and repeated sound bites. Both want people to act without much reflection…communication systems channelled goods and services, structured political geography, and created their own pictures of the world. Now communication systems try to structure our inner lives.” Smart phone anyone?
As we have evolved from our days fearfully scurrying across the African savannas to populate every square inch of the globe, our psychophysiology has not. Thus, the societal forces we have unleashed have and are taking advantage of our innate trance capabilities. If we rouse ourselves out of our trances, we should better perceive reality and be better able to communicate. Ultimately this leads to a more conscious self-determining life. For the interested, the following list of resources is a good start. OH
Dr. Filo is a Diplomate of the American Board of Hypnosis in Dentistry, a member, past faculty and Fellow of the American Society of Clinical Hypnosis; a member of the Society of Clinical and Experimental Hypnosis. He has presented and taught hypnosis nationally and internationally. He is also a Fellow of the Pierre Fauchard Academy. Since graduating from Uof T, he has also been active in organized dentistry both locally in Hamilton, ON and at the Ontario Dental Association. Dr. Filo can be reached at: gfilo@cogeco.ca or www.dentistry870.ca
Oral Health welcomes this original article.
Please note a joint hypnosis meeting between the Society for Clinical and Experimental Hypnosis and the Canadian Society of Clinical Hypnosis – Ontario Division Oct. 10 -14, 2012 to be held at the Delta Chelsea Hotel, Toronto.
Resources
The following organizations offer training opportunities from introductory to advanced levels; certification and from the ABHD Diplomate status for competency.
– American Board of Hypnosis in Dentistry – www.abdh.info
– American Society of Clinical Hypnosis www.asch.net
– Canadian Society of Clinical Hypnosis – BC Division www.hypnosis.bc.ca
– Canadian Society of Clinical Hypnosis – ON Division www.hypnosisontario.com
– Canadian Federation of Clinical Hypnosis – www.clinicalhypnosis.ca with Alberta, Quebec and Atlantic Divisions
– Society for Clinical and Experimental Hypnosis – www.sceh.us
References
1. Adler, Ronald B. and Rodman, George. (2006) Understanding Human Communication 9th ed. Oxford: Oxford University Press.
2. Armour,L. (2001) The business of inner life: economics, communication, consciousness and civilisation. Intl J of Soc Economics: 28 (5-7), 476-505.
3. Crabtree, Adam. (1997) Trance Zero breaking the spell of conformity. Toronto: Sommervile House
4. Feinmann, Charlotte (ed.) (1999) The Mouth the Face and the Mind. Oxford: Oxford University Press.
5. Geboy, Michael J. (1985) Communication and Behavior Management in Dentistry. Baltimore: Williams & Wilkins, Ltd.
6. Kane, Saralee and Olness, Karen (eds.) (2004) The Art of Therapeutic Communication the Collected works of Kay F. Thompson. Williston, VT: Crown House Publishing, Ltd.
7. Kent,G. and Croucher, R. (1999) Achieving Oral Health the social context of dental care. 3rd ed. Oxford: Wright.
8. Lang, Elvira and Laser, Eleanor (2009) Patient Sedation without Medication rapid rapport and quick hypnotic techniques. Victoria, BC: Trafford Publishing.
9. Lakoff, George and Johnson, Mark. (1999) Philosophy in the Flesh the challenge to western thought. NY, NY.: Basic Books.
10. Navarro, Joe. (2008) What every Body is saying. NY,NY.: Harper Collins Books.
11. Lipton, Bruce H. (2005) The Biology of Belief. Santa Rosa, CA.: Mountain of Love/Elite Books.
12. O’Connor, Joseph and Seymour, John. (1990) Introducing Neuro-Linguistic Programming the new psychology of personal excellence. London: Mandala.
13. Rubenstein, Ed. (1999) An Awakening from the Trances of Everyday Life. Marshall, NC.: Sages Way Press.
14. Simons, Dave; Potter, Cath; and Temple, Graham. (2007) Hypnosis and Communication in Dental Practice. London: Quintessence Books.
15. Taylor, Eldon. (2009) Mind Programming from persuasion and brainwashing to self-help and practical metaphysics. Hay House, Inc.
16. Wolinsky, Sephen (1991) Trances People Live healing approaches in quantum psychology. Falls Village, CT.: The Bramble Company.
