Originally published in the Australian Journal of Clinical Hypnotherapy and Hypnosis
Volume 14, Number 1, March 1993
HYPNOTIC INTERVENTIONS IN PSYCHOLOGICAL
AND PHYSIOLOGICAL ASPECTS OF AMPUTATION
James McGarry, Psychologist
The traumatic effects of amputation including modification of the sense of self,
the sense of loss, awareness of mortality, loss of confidence, disfigurement,
loss of balance, guilt and phantom limb sensations are discussed. A case history
is presented illustrating the role of hypnosis in overcoming these effects.
Amputation of part of the body is a traumatic event, or perhaps more correctly consists of a number of simultaneous causes of trauma of both a physiological and psychological nature. Each of these causes, and their effects, can be considered separately in a theoretical paper but must be seen to be concomitant dimensions to each other in any approach to healing.
Amputations may be a medical option which has been fully discussed with the patient beforehand. The advantages to the patient of the surgery may have been fully explained, the patient given time to consider options, the decision to go ahead eventually made. Hysterectomy is a common example of this type of amputation.
Alternatively amputation may be the result of an accident. Motor vehicles and power tools become surgical instruments usually without any warning to the amputee.
However, prepared or not, the amputee will undergo a number of traumas for some of which hypnosis may be the treatment of choice.
It has been noted by social psychologists (Madge, 1953), (Kaufman, 1979) that our sense of self is a dynamic process which is modified by both our behaviour and our environment. When we purchase a new car, initially we are functionally unfamiliar with is dimensions and tend to underestimate the size of spaces it can be driven through or parked in. But with familiarity we are capable of manoeuvering the vehicle into tighter spots. Leibowitz (1965) describes this process as being akin to extending our 'awareness of self' into the vehicle so that with practice we know where the boundaries of the car are as automatically as we know where extremities of our bodies are.
The amputee is placed in a similar position by having to relearn where the new boundaries of the physical body extend to. There is perhaps an even greater degree of difficulty attached to this relearning due to the lifetime of experience of knowing where the old boundaries were.
Hypnosis can be a valuable adjunct to physical therapies to accelerate the learning process by providing a subconscious blueprint of the post-amputation body and thorough mental rehearsal of actions which require the use of the affected part of the body.
Most people have had the unpleasant experience of losing some object which they have imbued with sentimental value. Even the loss of an old photograph is capable of producing a sense of sadness in some people - simply because it can't be replaced.
This sense of loss is magnified a hundredfold in the amputee, who it may confidently be assumed, has more than a sentimental interest in the part of the body which has been severed.
A deep reactive depression triggered by the loss of part of the 'self' which is gone forever with no possibility of replacement is usual in the amputee patient (Miller 1970). Acceptance of the loss seems to be the only way out of such depression (Berelson, 1964) and the use of hypnosis in implanting the subconscious blueprint mentioned earlier can play an important role in the amelioration of the sense of loss within the patient.
Central to the recent amputee's self-image is a profound awareness of one's own mortality. Statements like "part of me is already in the grave'' are common and belie a re-newed, or in many cases completely new, realisation that life is limited.
This is part of the normal grieving process and it will be necessary for the amputee to 'say goodbye' to the severed part in exactly the same way that they would to a deceased loved one. Counselling will necessarily go through all the stages of grief (Bensing, 1960) and progress can be maximised by the judicious use of hypnotherapeutic techniques.
A common effect observed in recent amputees, whose amputation is due to accident, is a generalised loss of confidence in existing abilities (Bushell, 1968).This seems especially to be the case where the cause of the accident is due to the use of a power tool (Duffy, 1962).
The usual manifestation of this loss of confidence is a disproportionate respect, bordering on fear, of all power tools combined with an almost obsessive preoccupation with ways to make such tools, or the manner in which they are used, safer. Whilst there is an element of self-preservation in this, and safer working practices will hopefully prevent a recurrence of the same type of accident, the motivating force behind this activity is essentially phobic.
In a society which places a premium on beauty and physical appearance the amputee's perception of self is that of being a monster. Until full acceptance of the amputation has been developed the amputee will perceive the disfigured part of the body as the most prominent feature of the 'self'.
Prosthetics, where available, may provide some substitute mobility or dexterity and therefore allow the patient to feel less handicapped but will do nothing to restore confidence in the amputee's ability to be seen by society as a normal member of the group (Spence, 1985). Acceptance of the loss, development of the post-amputation blueprint and a return of confidence - all internal factors, are necessary prerequisites to a rebalancing of the personality and to one's perception of acceptance by society as non-monstrous.
Mason (1984) has demonstrated that amputees often suffer from clumsiness and a lack of balance due to the re-distribution of the centre of gravity in the body so that even simple tasks have to be relearned. Physical exercises designed to teach the body where the new centre of gravity is can be greatly enhanced and more smoothly facilitated by hypnotic rehearsal of the exercise activities.
A great deal of frustration is experienced by most amputees who must 'relearn' switching on a light switch (when both hands are intact), or walking up stairs (when both legs are unaffected). The amputee is likely to be given labels like, 'clumsy' by family members who perceive ineptitude in tasks not obviously made difficult by the amputation.
Dependent on the amputee's philosophical and religious beliefs it is possible to experience guilt about the amputation. Common themes are "why has God/the Gods punished me like this? what terrible thing have I done to deserve such retribution?" and "How could I have been so stupid!I'm not as clever as I think or I wouldn't have let myself get into this situation."
This sense of self perceived wrongdoing (guilt) is primarily a rationalisation in an attempt to make sense of the event, to instil some logic into mental chaos.
Concomitant with this feeling is some regression (Meares, 1969) to a more primitive view of a dangerous world which is not under our control.
The return to a 'normal' rosy glow of optimism where-in we entertain our delusions of adequacy is concurrent with the re-development of confidence and acceptance.
An enigmatic aspect of amputation is the "phantom limb'' sensations which many amputees report (Csikszentmihalyi, 1990). An ability to feel or be aware of the missing part may be partially explained by random nerve firing or the triggering of what remains of the nerve pathway. Some further explanation may be found in the brain's motor homonculus model of the complete (pre-amputation)body (Hulse, 1983).
However some residue of phenomena remain. It is possible for some amputees to be aware of activity in the space previously occupied by the new missing limb. For example: the amputee with both legs amputated at the knee who can be woken up by his cat rubbing against his "feet"; the amputee who uses his missing hand to test the temperature of the bath water: "I can feel the heat but it can't burn me this way"; the amputee who can use her missing finger to detect electrical current flowing in a power cord ''It tingles but it's not like a shock".
Current research into "morphogenic fields" (Reid, 1989) and ''bio-energetic fields" (O1iver, 1993) may eventually explain some of these phenomena.The following case which I was privileged to witness from the beginning is presented to illustrate some of these points and to demonstrate that the amount of body which has been amputated does not determine the degree of trauma. An amputee who loses, for example, a finger can be expected to experience as much of a sense of loss as one who loses an arm.
"Patient A'' was feeding a piece of timber through a jointer, a woodworking machine which planes a flat edge on rough timber, when his hand slipped and entered the revolving blades amputating (and shredding) part of his left index finger.
Ambulance officers and first aid workers who practise hypnosis are familiar with the ease with which someone suffering from shock may be inducted into a hypnotic state. In fact, in as much as shock is an altered state of consciousness it may be a naturalistic form of the hypnotic state.
Certainly in this case a couple of deepening suggestions were all that were required before the patient could be instructed to stop the flow of blood and to implement immediate and long lasting absence of pain.
Although the nearest hospital was 30 minutes drive away, the patient was kept calm and comfortable.
Medical intervention required that some further bone and tissue be removed so that a flap of skin could be sown over the end of the wound. Some local anaesthetic was administered, partly for the surgeon's peace of mind for this operation, 'Patient A' remaining relaxed and interested in the proceedings.
Rehabilitation began the next day with the patient feeling sorry for himself about the things he would no longer be able to do. He had played the flute and guitar and considered that his music had been taken away from him. He was a keen target archer and didn't think he would be able to learn to shoot left-handed.
And so the list went on. It was requested that he make two lists - one headed "I can't do this because'' and a second list of the same activities "I can do this if". Examples on the constructive list went: "I can play the flute if certain keys are modified", "I can shoot a bow if I use a finger release mechanism (mechanical aid)". The second list took a great deal longer (three months) than the first "I can't" list.
Meanwhile hypnosis was employed to:
1. Ensure the wound remained pain free.
2. Ensure that the finger was held higher than the heart to reduce blood pressure at the wound. So successfully that the patient's wife reported that he slept with it in the air, even turning in his sleep without letting it drop.
3. Maximise white blood cells to the area to prevent infection and promote healing.
4. To release the sense of loss and sadness about the "part of me is gone forever and can't ever be replaced''.
5. Placing in perspective of the loss “part of me has died”' - as “it's with my appendix and all that hair that has been cut and shaved off and all those fingernail and toenail clippings and my tonsils. It won't be lonely.''
6. The building of a new subconscious blueprint.
The patient was requested (in hypnosis) to see himself "standing in front of a mirror and to make the image in the mirror sharp and clear. As the image is focused pay attention to the details ... observe the index finger, notice that it is shorter now and that it is fully healed and is perfectly healthy ... and you are a normal beautiful short index fingered person".
This mind mirror technique was used in a number of ways to:
(a) relearn the shape of the body, or as Patient A prefers, to learn the shape of the new body (McGarry, 1992)
(b) mentally rehearse actions which require the use of the left hand
(c) in conjunction with balancing exercises: standing on one foot etc. to learn the new centre of gravity. Even such a small amputation as this required these exercises - the patient had a tendency to fall to the left when attempting to slip on his shoes.
During this time the push-stick, a notched stick used by woodworking to feed timber past cutting blades, was reinvented 6 times and the plans for the Mark VI were sent to "Fine Woodworking Magazine" for inclusion in the workshop tips section.
(d) to overcome the fear of power tools (potenlis-instrumentumphobia?) via considerations of selling the tools versus not ever smelling fresh cut wood again and never standing in a pool of satisfaction saying "I built that" through the possibility that "with the Mark VI a jointer will never be dangerous again" to concentration and due respect for all tools are the most important pieces of safety equipment.
(e) overcome "phantom limb" sensations. "Patient A" found that placing his stub of finger into his ear produced the subjective sensation of putting his finger tip inside his head. This sensation progressively withdrew to the surface of the ear as the post-amputation mental blueprint became firmly established.
One year later "Patient A" is back at work, fully healed and pain free, uses the jointer without trepidation and is relaxed and confident in his new body.
There are more safety jigs in his work-shop and it's possible to play the guitar with a short index finger if you twist the wrist a bit more. Oh, and I'm learning to shoot my bow left-handed too.
© Copyright James McGarry 1993. All Rights Reserved.
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