Beverly Levinson pictured herself sitting by the large outdoor fireplace at her mountain house in North Carolina, the Blue Ridge and Great Smoky mountains unrolling before her. She breathed in deeply, filling her nose with earthy notes of the surrounding forest. A warm breeze touched her skin, and she could hear the leaves rustling in the old oak trees. Voices murmured overhead, but in her semiconscious state, all Levinson could make out was the calm tenor of hypnotist Rosalinda Engle telling her to relax her jaw.
In reality, Levinson was lying on the operating table in a surgical suite at MD Anderson Cancer Center while her doctor resected a tumor from her right breast — a far cry from the tranquil scene she imagined. An anesthesiologist gave her the painkillers fentanyl and novocaine to numb the site of the incision, but Levinson was awake for the entire two-hour surgery, guided into a trance by Engle’s soothing voice.
“It was such a pleasant experience,” Levinson says. “I loved it. If I had to have surgery again, I would do it again.”
Hypnosedation is part of a growing trend in medicine to avoid giving people general anesthesia whenever possible. The initiative is partly born out of the opioid crisis and fears of painkiller addiction and partly due to concerns about anesthesia’s harmful side effects. According to one study, 30% to 40% of people experience cognitive dysfunction — like memory issues — from general anesthesia immediately after surgery, and 5% to 12% still have impairments three months later. Anesthesia may also dampen the immune system, and there is some evidence that people who undergo surgery using general anesthesia have a higher probability of their cancer returning than people who receive only a local anesthetic. (The immune system normally kills micrometastases — small cancer cells that break off from the primary tumor—but if someone is immunosuppressed, these cells survive and thrive.)
“We’re at a point in our society now where, certainly when we’re talking about pain medications, less is better,” says Lorenzo Cohen, director of the Integrative Medicine Program at MD Anderson. “Patients are scared of this stuff and scared of addiction, so anything we can do from a nonpharmacological perspective is really critical.”
In an effort to reduce the use of pain medication, Cohen launched a clinical trial at MD Anderson to use hypnosurgery instead of general anesthesia on women undergoing lumpectomies for breast cancer. During hypnosurgery, a local anesthetic blocks the pain from the site of the incision, while the hypnosis helps the person relax and dissociate from what’s going on.
“There’s a feedback loop between anxiety and pain, and similar brain structures are activated. If you’re feeling anxious, you’re going to have an increase in pain sensitivity, and if you’re having an increase in pain, you’re going to feel anxious,” Cohen says. “We’re trying to decouple that association by getting the patient in this deeply relaxed state.”
Before her surgery, a woman in the clinical trial meets with the hypnotherapist to go through a test run and guide her through what will happen in the operating room. The hypnotherapist asks the woman to choose a “happy place” to go to in her mind and gather sensory details to make this place come alive for her during the procedure. The practice itself starts with slow deep breathing and progressive muscle relaxation, particularly focusing on the feet, hands, and jaw. Next, the hypnotherapist guides the woman to call up her happy place.
“Patients are scared of this stuff and scared of addiction, so anything we can do from a nonpharmacological perspective is really critical.”
“Should I see that they are completely relaxed and at ease, I start talking less and less and allow them to enjoy where they are and what they’re imagining in their minds with very few cues,” says Engle, a mind-body intervention specialist at MD Anderson. “If they are opening their eyes, if their breathing changes to a little more rapid than we would like, then we coach them to slow their breathing down again.”
During the procedure, the doctors monitor the woman’s breathing, heart rate, and brain activity. An anesthesiologist is present the entire time; should the woman appear to be in excessive pain or discomfort, they can put her under immediately. Cohen says that’s only happened twice out of the more than 50 people who’ve undergone the therapy, and one of those instances was because the surgery needed to be more invasive than initially thought.
People naturally differ in their ability to be hypnotized, and Engle says there’s plenty of diversity in how the women in the trial react. “Not everyone is geared to go very deeply into a state of ‘I’m no longer here, I’m at the beach, I am at the top of my favorite mountain,’” she says. “Some people [are] able to go very intently into a different place and time, and others [are] enjoying the pleasant image in their mind but still very fully aware. The level of hypnosis depth that someone can go to is very personal.”
In addition to the women’s experience during the surgery, the researchers are measuring differences in pain, nausea and vomiting, recovery time, and opioid use after the operation. An early report from the study showed increased activity in visual areas of the brain and decreased activity in a region associated with pain perception, which suggests the hypnosis was successful at helping the woman visualize herself elsewhere and reducing her pain.
The study is far from the first to use hypnosis during surgery; the practice has been administered either in lieu of or in addition to anesthesia in Europe for decades. A study presented at the American Society of Anesthesiologists (ASA) in 2017 by researchers in Paris revealed that out of 125 women who were hypnotized while undergoing either a partial or full mastectomy, only two required general anesthesia. Breast tumor resection is a common target for hypnosedation because it’s a relatively noninvasive surgery and typically the start of what can be a long treatment process, so doctors don’t want to give people potentially immune-suppressing pain medications more than they have to.
In the United States, physicians are also starting to use the technique for other minimally invasive but painful procedures, such as bone marrow biopsies and inserting or removing intravenous catheters. Other trials administer hypnosis before surgery to alleviate people’s anxiety or afterward as a pain-control strategy.
Daniel Cole, MD, a professor of clinical anesthesiology at the University of California, Los Angeles, and former ASA president, says anesthesiologists already implement relaxation techniques like a calm soothing voice, positive suggestions, and slow deep breathing in their practice. “Things that get your mind in focused attention and a heightened sense of awareness give you more control over your mind and body,” he says. “Hypnosedation can be very valuable to the patient’s well-being in the perioperative period.”
However, Cole adds, “Hypnosedation, in and of itself, is probably not something that I would use as the sole anesthetic for something like a hip replacement surgery. It would be more used for minor-type surgeries.”
Engle agrees with this perspective. “Is it going to replace anesthesia? Of course not, not ever. And is it for everyone? Of course not,” she says. “And that’s the beauty of 21st-century medicine — it will be more tailored to a patient’s unique needs and personality.”