Dr Krauss, you are working at the emergency department at Boston Children’s Hospital and I have understood that you have specialized in a set of skills for how you approach and treat kids in a way that takes their minds of their pain and even makes them sit still when you stitch them, by free will – is this correctly understood?
Yes. And its not just that… in the emergency department, children often need to have procedures done, stitches to be made, broken bones need to be set… and its different for children compared to adults.
When children are anxious they simply do not cooperate. They have not developed that ability yet – and for me this translates into two goals that go hand in hand: to make their visit non-traumatic and to minimize their experience of anxiety and pain.
I have a commitment to give children who come to the emergency department a painless and non-traumatic experience, because as you know this is incredibly important since a psychic trauma can carry on into future encounters with the medical system.
I want to give them this experience and be able to decrease their anxiety and their pain experience – for several reasons – for example, in order to make an appropriate diagnosis of a child with abdominal pain – the stomach needs to be relaxed. We are not just talking about procedures, we are also talking about any kind of examination of the child.
I’ve read the article about the young girl who needed stitches and saw the movie her parents filmed where you are doing this and she seems ignorant of whats going on in a good way – it’s almost like you are tending her hair instead of stitching her forehead. I find your techniques to appear simple and elegant in how you approach the kids gradually, kinestetically – creating rapport and taking their mind off the situation by talking about what they like, asking this particular girl to mix colors engaging her creative and rational mind – when I read about it there were so many hypnotic skills jumping out at me – you must have a background in hypnosis, how did you learn this?
Everything I do is very intentional. I have a set of principles that form my techniques. However, each child is an improvisation – they have different needs and personalities and different circumstances and developmental levels. I have a whole repertoire of techniques and every time I meet a new child I improvise around these principles.
I know where I want to get to. I want to relax the child, have them cooperate, but it’s not formulaic. I don’t give a coloring book to every child. I’m eliciting what they are interested in so I can use that to shift their awareness.
So, your first goal is to get the child relaxed?
My first goal is to assess their level of anxiety and most of all the anxiety level of their parents. The most critical first step is this assessment, because only through this do I know what I need to do.
Basically I need to assess how much they will cooperate. If i can do this correctly i can find the right interventions and techniques. So it’s critical to assess their anxiety accurately. To find the appropriate interventions. This skill is critical and took a long time to develop. Because as you know each child is going to manifest things differently.
Is there a big difference between children and grown ups?
Yes – and particularly between young children and adults. Adults will cooperate. They will inhibit their own anxiety, but children under five can’t do this – they don’t have that brain function yet. They cannot calm themselves. Thats why assessing the anxiety is so important.
Secondly young children are very concrete thinkers – and literal. You have to be very careful with words and metaphors – adults understand the difference in this. Young children do not have this distinction. So, the language that is used needs to be very precise compared to the language you may use with adults. The principles are the same but the techniques are different but applicable to both.
Can you list the four principles you work after, in no specific order?
1. Be careful with what you say, and how you say it.
Preparatory information does not help children control their anxiety. Actually it doesn’t help adults either but that’s a different story altogether. But here is a conflict in learning because the information health professionals feel they need to give children, has the opposite effect of what people want; it causes more anxiety.
Young kids have little sense of time or occurrence, they take things literally and once they become anxious they cant stop it. An example of a bad idea would be: “it’s only gonna hurt for a minute”.
Some adults do want to hear information about what is going to happen every step of the way and find it soothing. You have to identify them but you also have to identify if giving the information is more soothing than simply shifting their awareness – which is at any age more powerful I find. There are circumstances where they will continually ask for information – it is then clear they need it to be soothed so I give it to them, carefully and preciseLY. Words like “needle” or “shot” are avoided.
2. Children are fearful of strangers and strange places and things.
All the things in the room are these. All that stuff creates fear. You have to desensitiZe children to the fear of you, your touch, the instruments you are going to use, the lights, the stretcher. Dismount these barriers.
3. Assess their physical boundaries.
There is a space each person has, depending on your relationship with the person and their baseline personality it may be small and you can get close, or it may be very wide, if you get closer than 3 feet they get very anxious. One child has no physical boundary, you can walk in and put them in your lap. Another child, you walk in the room and they are very anxious. This is all about recognizing these things with kids.
You can probably extrapolate the same principles to adults but absolutely for all children.
4. Establish raport, focus and shift awareness.
This is a vital part of the procedure.
Yes, but shifting awareness is quite a skill, isn’t it?
Yes, and as you know it has components – to determine an area of interest – what is it they are interested in that will grab their attention? Some will come into the emergency department with their attention all over their place, so first I have to focus their attention because they are unfocused – because they are traumatized, in pain or anxious or whatever. So first I need to focus their attention – because in order to shift their attention I need to focus IT down to a beam of light that can be handled. If it’s all over the place I can’t shift it. So, I find out what grabs their attention and use that to focus their attention and shift their awareness. Sometimes this takes time. And as you know you can’t impose it, you have to elicit this from them.
Develop you ability to figure out how to: Focus their attention. Keep it focused. Shift it. And then keep it shifted. Push pain and anxiety into the periphery – Keep it in the periphery, and once you do that you need a set of techniques to constantly reassess how effective the tool you just have used is at every new moment. Some techniques are only efficient for a while, then you need new tools to keep their pain and anxiety in the periphery. It’s a constant matter of assessing their emotional state. If its not working I need to do a real time refocus of their attention.
What are the signs you look for to see if they are slipping out of focus?
Degrees of motion – they become more anxious they become more mobile. The other factors are breathing patterns, facial muscles, facial expressions, eyes, how they are performing the task you may have given them to shift their attention – all kinds of non-verbal physiological cues.
These are all the signs of going out of trance.
Yes – Erickson was an expert in reading these signs.
What is your background in hypnosis?
I took a great hypnosis course that an emergency physician in California who had developed these techniques did a weekend course that got me started – and for a while I was using straight trance work in the emergency department – but it was too cumbersome, you couldn’t use it on a 2-year old – you can’t do arm catalepsy on a 2-year old. So I was forced to rethink when I worked with adults and then children – there was also a lot of noise and stuff going on around us that you have to take in account. I basically extracted the principles I learned and began to develop my own framework and ideas on how to do this with kids.
What would you change in an emergency department for grownups?
Good question….. I would just adapt my techniques to adults – I know this is a very general statement – I would take the pediatrics out of there…. I would still have the same principles. Desensitizing them to me – establishing rapport, assessing anxiety – shifting awareness.
Pain control seems less important than anxiety control?
Yes with kids pain and anxiety go hand in hand – if they are anxious they will feel pain. Because if you want something to be painful you have to focus on that.
Can you develop that?
Well, we all have the experience of playing a sport where you hurt yourself but you are so absorbed that you don’t notice until the game is over – then you become aware of the gash and become aware of the pain – while before you weren’t – you need to focus for something to be painful…. also, another approach is that pain is just a sensation that can be broken down and experienced as different sensation when you are in hypnosis. Pain is a word – not a sensation. The sensation may not have emotional valence – so for example I had a double hernia repair with just local analgesia and trance and i had sensations but no pain. other people going through that would say it was painful.
How deep a trance did you need to regulate pain?
Depends on the procedure. In my hernia I was deep. In my colostomy and endoscopy I was not as deep. But as you know, that depth can be almost an autonomic function – your unconscious can regulate this depth.
If you were to give an advice to medical personnel that face kids in these circumstances that would like to develop a basic skill set, what would it be?
I would say that in order there is a couple of things they would have to do first. The procedural skills would have to be highly refined. In other words If I amd thinking about where to make the stitching – I have no attention left to do everything else. They have to be on automatic. 90 percent of my attention is on the management. i don’t need more for my skills.
Second I think the way to do this is an apprenticeship. It’s very hard to do a lecture on this stuff – its very experiential. You have to have someone int the room that can ask you on 1-10 how anxious is this child? What were the cues? How did you arrive at this? What did you do? and when you make an intervention – how do you decide which to make? this cannot be taught ina didactic way. It is an apprenticeship experience.
I agree completely. In addition I think you need a devotion to learn these kinds of skills.
This is right. That period in the 1800s when anesthesia was developed until the 1980s was a high time for mechanistic medIcine – there is the mind – very cartesian – and the body – and the body can be separated and the body be worked as a machine. this was the predominant philosophy in medicine.. Then people started becoming interested in mind-body-stuff and the more holistic perspective stuff and this movement of complementary and alternative medicine. There is more receptivity now than there was then, however, I don’t think there are many people in the hypnosis community that are very able to clearly articulate what they do – like Erickson was – to be very clear about the techniques that apply.
Thats probably why some people could learn this as an apprentice better than reading a book?
Right – not that there isn’t a value in the book but it’s not the same.
I think video can be great and has potential as a medium for this….
Yes – to convey and experience it has large potential. Before you could only describe and now you can demonstrate it – I think though, that the potential has not been fully realized – because I think that you can integrate in the video – not only demonstrations – but break down interactions and show all the techniques that are going on under the surface in slow motion.
Do you have a handy advice for parents when their kids get hurt?
I would say that parents know their children well, you know what calmS your children and what makes them anxious. When their child is injured they have to be focused on the child and not on their own emotional reaction – focused on ways of keeping the child safe and calm and comforted. Anything more than that won’t be intuitive. Focus all they have on their child’s needs. They should be aware that anxiety is contagious and so is calm.
Anything you would like to add?
It sounds pretty clear – I think you’ve asked great questions.
Thanks and thanks for sharing!