VA Interview with Dr. Elvira Lang

Courtney Armstrong: Well, hello everybody. I have the great privilege today to be talking with Dr. Elvira Lang. She is an interventional radiologist and the developer of an intervention, or procedural hypnotic intervention called Comfort Talk. Thank you for being here, Dr. Lang.

Dr. Elvira Lang:  Courtney, thank you so much, I’m delighted. As you may know, my heart goes out for the VA. I’ve been, this is where I started a big part of my career here in United States. And so, I’m delighted to be with you.

Courtney: Well, let’s start with that because I believe you told me that your idea for Comfort Talk grew out of your work at the VA in Palo Alto, California, is that correct?

Dr. Lang: Yeah, right, this is the very first time where I saw how a quick hypnotic imagery intervention could make a big difference. I was, the chief of interventional radiology there and I still remember the patient. I mean, it was this, let me say, just a kid. I mean, he was a Vietnam veteran, and he had this relatively simple procedure exchanging a tube in his intestines which should be about as involved as changing earrings out of one’s ear, where it was in a long time.

But see he was so scared to get on the table. That’s where I saw it [hypnosis] made a big, huge difference. And at the time, the office for alternative medicine had just started to look for grant proposals and our grants director at Stanford, Dr. Judy Ellis, she said, you should be looking into this more. And so, she introduced me to David Spiegel at Stanford, who is like the Pope of hypnosis, and here it kind of started.

But the VA was the very first agency that funded the project as an educational project, and it got a little boost. We had the Loma Prieta earthquake and half the hospital got condemned. So, if you have to run two procedure units and you’re limited in the amount of drugs you can give because you can’t recover the patients afterwards then suddenly having non-pharmacologic methods becomes extremely attractive unless you want to go home at ten o’clock every night.

Courtney: All right, wow– what an experience. But really you have some significant research studies. I mean, a study with 700 participants. I mean, large scale that I think really validates your methods and what you’re teaching clinicians how to do.

Dr. Lang: We dug into the literature to look at what is empathic behavior. And so, you go back to Milton Erickson pick some of his behaviors and that’s how we called it. And we use that because we felt you need that. If somebody walks in to get a procedure, or, to dentistry, they don’t come for hypnosis. You have to get that concept across very quickly. So, we use these rapport skills or empathic attention as we call them. And then we added to it in the third group, a formal structured script. That was the first trial.

Dr. Lang (continued): Then we repeated the same with women with large core breast biopsies- it’s a very anxiety provoking procedure. And then we did the same with tumor embolizations, which is a very invasive procedure. Your full hypnotic sequence including the empathic attention made the procedures more comfortable, safer and faster.

Courtney: So, I know, you mentioned rapport building, and that empathic communication, it starts there. But you have developed simple ways to create that when you don’t have very long to build that rapport

Dr. Lang: Yeah, you have about maximally 90 seconds. Psychologists kind of know all that about matching body position. You match the body position, and you match let’s say initially the voice or the affect. And then you very quickly lead [the patient] to a more resourceful state.

Courtney: Yes.

Dr. Lang: That is often the hardest thing to train because a lot of healthcare professionals are trained that you should always have the open position, stare at the patient in the eye. And if the patient screams then you should be even quieter, which typically enrages a person even more.

Courtney: Yes

Dr. Lang: Also, just space. You don’t tower over people, nowadays everybody’s gowned up. Yeah, you adjust to body position by matching the body to feel like that person is feeling, this is what you do. And you are not mimicking or doing any of that. You just for a short moment, accept this other person, exactly as who and where they are.

Courtney: That’s right.

Dr. Lang: And then though the idea is not that you’re both screaming or that you’re both being depressed, but there then you very quickly get to a resourceful state.

Courtney: Yes.

Dr. Lang: You know where they can say, “Ahhh…” [Exhales slowly]

Courtney: So, you talk about the negative suggestions that we unintentionally put into someone’s mind. So, talk a little bit about that and how you kind of reframe how to present certain things.

Dr. Lang:  When we did the large core breast biopsy trial, the breast biopsy team was absolutely convinced that the more negative suggestions you have the better the patient feels. And sometimes the only way you can convince people is by doing a clinical trial. I said, fine, we are going to now go into interventional radiology and do videos and audios of what people say [to patients]. And then we asked patients’ pain perception. We did not interfere with what people said. They could say whatever they wanted to say.

So, what we found out that if these negative suggestions are used, “Oh, it’s just a little sting. It’s just a little burn. It’s not going to be that bad,” then patients had significantly more pain and significantly more anxiety. If you came in afterwards and said passively, “Oh, that wasn’t that bad, was it?” then it fortunately did not increase pain for the next stimulus but Dr. Lang (continued): it cut the anxiety for that. So, once we had settled that even that team very reluctantly agreed to get off the negative suggestions.

Courtney: Wow, yeah, they had to see it and hear it from the patients themselves or at least just see the results that the people who use that language were implanting that expectation in the patient’s mind. So, when you want to prepare the patient for something that might be painful or uncomfortable what do you say instead, like before you put in an IV?

Dr. Lang: You might feel some warmth, or coolness, or a delicious sense of tingling– because nobody really knows what that is.

Courtney: That’s right.

Dr. Lang: And it really takes the mind off. It gives into a big thought process. Like, what is that?

Courtney: Right.

Dr. Lang. If I just put an IV in, then I’ll be just very formal. I’ll just place the IV. I don’t even describe anything. But then let’s say if you infuse something or come in or local anesthetic, then you say “You may feel some warmth or coolness or a delicious sense of tingling.”

Courtney: Yes

Dr. Lang: Or if a patient says, “Oh God, I’d rather be out smoking.” That’s fine. I’ll say, “Just in your mind, go there and just really enjoy that one. It is a really, really special cigarette. It’s the best one.”

Courtney: Yes, you had a story about that, where a man wanted coffee and a cigarette and you–

Dr. Lang: You give them what you can and if you can’t and again, you’re not judgmental. They pick what they like to do.

Courtney: Yeah, so he could mentally go smoke in his mind, and it relaxed him. And you had like, just a little taste of coffee or something on a gauze or something that, so he could get that.

Dr. Lang: He wants what he wants. I once had this other gentleman. And again, control is very important for the patient so you have to keep that in mind. Patients will ask you for perhaps some unreasonable things. So, I had this one gentleman and we really had to do his case, but he didn’t get breakfast. He was extremely upset at that. He said, “I want chocolate.” Fortunately, I always have a little stash of nice chocolate. So, I go to my office bring the whole box, and offered for him to pick one. And he took it, but he knew he shouldn’t eat it. So, he took it and he smeared it on his chest for this whole two hour case. But again, you have to respond to what people’s needs are because if you do not in the beginning it will revenge later. They will then want to have it at the most inopportune time of your procedure.

Courtney: Right, and you mention other things with language that help. For instance instead of telling patients they can push the “panic” button, you suggest calling it a “call” button.

Dr. Lang: That makes a huge difference. Yeah, particularly in MRI. The whole MRI situation, where again, if you take any of these procedures or even MRI, if you had to design a psychological experiment that is best suited in recalling past trauma, that’s what you would do. You would take people’s clothes off. You would put them on a device where they cannot move. You darken the room. And somehow their livelihood depends on what you’re going to find out too. You could not design an experiment any more challenging than that.

Courtney: Good point.

Dr. Lang: Yeah, and so, it was interesting what I hadn’t known when we started this whole project– how much abuse there is around. Like, you never talk with patients about it. And so, when we started training MRI teams and I said, okay, claustrophobia is PTSD They said, “Nah it’s not.” Then when we came back for another training said, “Yup, you’re right.”

Courtney: Like you said, feeling vulnerable and restrained will activate some of those old memories, yeah.

Dr. Lang: I mean, one of my proudest teaching experiences, is where an MRI technologist cured PTSD. The patient actually allowed us to use the story. And actually, he wrote the story for us to tell how it was. But just to give you a bit of the intricacies, this was in Texas. The technologist was this relatively slight young man with a relatively, strong Texas woman who could not get onto an MRI scanner for 11 years.

He described how from the waiting room, how he already, sat down with her for a moment, then led her step-wise to the dressing area. Already at the dressing area, when he talked with her a bit, she said she didn’t think she could do the MRI. And he said, “Well I’m not going to do your scan then.” She said, “Why not?” He said, “Well, I’m only going to do it when you’re ready. I’m not going to do it otherwise.”

She actually took his hand and said, “Thank you, God, that you are with me.” Then they go to the MRI scanner. So, he kind of does a gradual desensitization. He said, “First, just get on the scanner. I’m not going to do your films. As I said, I’m not going to do this. You first just test it out how it is.”

They tested it out a bit and then she gets panicked. But before they even get into it, he takes her out. Woman goes out into a hallway, sits on the floor and cries. Well, obviously well-trained in rapport. He sits on the floor with her and they kind of pause it there. Then they go back into the room and then he asks her, “Where would you like to go? Where would you rather be right now? She says, “Oh, I like to go to the coast to this one area where I really like to be. And he says, “Well, yeah, just go there.”

So he puts her back there, he puts the fan on and says, “You know, this is just the breeze of the wind.” They go in, the scanner starts all going. His student’s sitting there and can’t believe the whole situation. But then it also happened what we always see happening both people get into hypnosis. The technician said, “I could just imagine myself back at home at the water works and the sound of it.” And he just had given her thoughts to imagine how it is there. He said, “You know when there are birds around, but you don’t need to be concerned, feeding them now. You can do this later.” I mean, beautiful future projection there.

We also, at the end always tell patients to be very proud of themselves. Because all we do is help them help themselves. And the next day she called back, to the whole hospital to tell them this was this incredible experience. I mean, her PTSD was cured.

Courtney: Wow, wow! That’s amazing. You also have a basic induction that you teach people that they can adapt to the patient. Do you want to take us through that?

Dr. Lang: Right, and the way we use the script now, I mean this thing in pretty much 90% of cases, it can just go very conversationally. You may not even need to do the whole script. Although you can do the whole script in 90 seconds, the fastest, the shortest if somebody doesn’t have any other issues. The way we now use the script a lot, because we are working with a very short patient interactions. We are training the Dutch national breast cancer service and that entire interaction from the moment a patient walks into registration to changing the clothes getting the mammogram and walking out five minutes. So, they’re not many words, right. But where the script helps people take individual sentences out appropriate for the situation. And that’s how we often do.

So the first start of the script, the introduction you can use that while you walk a patient from the waiting room to the scanner or while you put them on basically starts, “Well all we want is to help you to to help us so that we can help you to have a positive experience. It’s just a form of concentration, like reading a book or watching a movie or getting lost on the internet. And you know, you’re fully in control because if you don’t like the book, you close it, you don’t like the movie, we change the channel. So you’re fully in control of doing that. Did you ever have such an experience of getting lost in the book or the internet and most people say, “Oh yeah.”

Then we say, well, and you know “Use all the sounds to deepen your own experience.” Sometimes this is the only sentence you need to say for MRI— use all the sounds to deepen your own experience. That’s our complete induction. And it works wonders because patients can do what they want with them. And then the next sentence, which is a big immunization “And use only suggestions that are helpful for you.” Because people might come in and say things that are not helpful. So again, we just say this one part, “Use all the sounds to deepen your own experience and listen only to suggestions that are useful for you.”

Next, we say, “And there are many ways to relax but there’s a very simple one. Okay, and you can do this here. You can do it later at home in a recovery whenever you want. So, on one, you do one thing you look up. You can pick any spot on the ceiling you like. On two do two things, slowly close your eyes and take a deep breath in and on three, three things breathe out, relax your eyes and let your body float. That’s right, with each breath, easier and deeper.

Now, if your patient hasn’t followed you by that time you can say, okay, now you know how it works. And you start it again, they still don’t want to do it. Then you say, okay some people first close their eyes and then relax. And other people first relax, and then close to eyes. Or you can do this with your eyes open or closed, whatever works. And you don’t need to speak any slower than that either.

Next we say, “and imagine you’re floating like right through the table with each breath, easier and deeper. And with each breath in take in strength… and with each breath out, think calm.”  Again, that is a sentence which may be all other people use. If it’s pretty hectic, and you don’t know what to do. Just say, “With each breath in, take in strength, and with each breath out, think calm.” You can do a variation. Each breath in, take in strength. Each breath out, let go, whatever you wish to let go of blowing all the discomfort right through the skin whatever is appropriate for the situation.

And then just imagine yourself floating in a lake, a bathtub or just free in space. That’s right. Okay, and then we may ask, well where do you imagine yourself being?

Dr. Lang (continued): So, some people tell you where they imagine themselves and then you can work with their imagery. But some people don’t tell you so you can say, “Well, you can tell me or you can enjoy that just for yourself.”

Then you want to deepen them into the sensory details of the experience—“And just notice while remaining in this state of concentration, what do you see around yourself? What do you hear? How does it feel like? There may be smells and tastes. Just use this as your safe and comfortable place. And you can use it in a way to play a trick on this whole procedure because the body has to be here, but you can go wherever you would like to go.” That by the way, is a sentence we also sometimes just use in isolation. “Yes. You can go wherever you’d like to go.”

And then we do an immunization, which is “and this is your safe and comfortable place where you can always return to it.” See if somebody then later gets an abreaction because somebody comes in or does something really atrocious. Then I can always pull them back to that. So, you put in these safeguards in.

Courtney: Yes.

Dr. Lang: So, we make clear as long as they do anything hypnotic you want to have these things: “Use only suggestions that are helpful, use all the sounds and noises to deepen your own experience. And then you can always return to this place.” For some people, the term “safe place” may be a problem. If somebody lived in a safe house for a long time, that wasn’t all that pleasant. We exchange that term for children too, because what mom thinks is safe they may not enjoy. So we just invite them to “imagine a place where you enjoy the way you feel there.”

Courtney: Yes.

Dr. Lang: So, it’s, I mean, you kind of get a little gist of that.

Courtney: Yes, and you also include the suggestion, “ and if you can’t imagine it, perhaps you can just recall what it might feel like to be there,” It’s very permissive.

Dr. Lang: Oh yeah, and then if they still don’t do that and they don’t do fantasy and they don’t do anything. Oh, that’s one case from the VA, you say, “Okay, fine. So, then what’s your refrigerator? Count out what is in there in the front and the back end.” I mean, you use whatever you feel.

Courtney: That’s right, right. Just to get them so absorbed in something else and dissociated from what’s going on in the procedure.

Dr. Lang: There’s a very different quality when a patient tells you where they’d rather be. It’s very relaxing when you do a case. As compared to the patients who want to talk, and nobody talks to them. And then they’re going to start to ask you all the questions and tell you things that you really don’t have the bandwidth to listen to at that moment. But it’s a very different quality. That’s true. You get to the point right away. And that’s why actually with Comfort Talk you end up talking less to patients than you would without it, interestingly enough.

Courtney: Yeah.

Dr. Lang: We can also do also a bit of immunization for pain upfront by saying, “If there should be any discomfort just imagine you could place a hot pack or a cold pack on it. Or, it might be a delicious sense of tingling, which nobody knows what it is. So, it keeps the mind occupied. And often then you don’t need to do anything else. But we check also early on to see how a patient is feeling. If they indicate pain, we’re going to be working on that. So, they can rub their fingertips together and focus on these delicate sensations they have in their hand. They might even transfer this sense of wellbeing to another body part. We might use some distraction. If let’s say we work on the head or neck, then we have them focus on their toes.

Courtney: Yes.

Dr. Lang:” Okay why don’t you focus on your right big toe, but if you prefer, you can take the little toe or actually the left foot or the third toe. If you just say to just curl the toe then every so often and you will know how often.” So, you can kind of do that in a distractive mode.

Courtney: Yes.

Dr. Lang: If a patient indicates how it feels, say it feels like a big red ball of fire. Then you work with the submodalities you change the color and make it smaller. Actually, in our first case at the VA, he imagined himself like a big piece of red meat with a butcher knife all the way through. So, you know, you can change the butcher knife into smaller knife and then to a plastic knife and you can take the knife out and then you can make this meat image a little bit more faded and you can kind of move it like all off into the distance and just have something else nice come up then instead of it.

Courtney: Right.

Dr. Lang: So that is another approach to use the submodalities. With a big ball of fire, you make it blue perhaps, and then smaller, and then it rolls off. Or you play soccer with it or football, or you go to the Super Bowl and you go play and you win, the winning team! Again, whatever comes out spontaneously, but I know it can sound wacko out of context.

Courtney: Yes, but in the moment, it’s a welcome relief to the patient to think of something else.  Sometimes the more absurd the image, the better because they think, “Wow, I’ve never imagined it that way before!” It really does grab their attention away from the procedure and into something else.

Dr. Lang: Yeah, and you can ask them to imagine a dial in their brain as this big processing station. And you know, what would you say you’re experiencing right now on the comfort level? Zero, no pain at all to 10, worst possible. If the patient says, “Well, it’s an eight.” You say, “Okay, well, can you go to your control station and just dial a little bit back and forth and just see what it does perhaps put it to 7.8? You can put it to five, but that may be pretty drastic. Just 7.8 may be a good idea. Why don’t you check this out and then you could go from there?

Courtney: Well, Elvira is there anything else that you’d like to say or let people know that, that we haven’t mentioned yet? There’s so much to your work and I know we’re just scratching the surface.

Dr. Lang: I think there’s one more aspect to it, and also a reason why we focus so much on frontline staff. There’s a lot of stress in medicine now. Everything has to go faster. There is so much paperwork. You really have to get through a case in a very specific unit of time. And it gets very, very stressful. If there’s just one patient that you can’t get through, then just to call and reschedule that with the referring clinician is a huge undertaking. Plus, you have the whole patient satisfaction movement. Patients become more demanding and sometimes can get somewhat insulting to the staff. Or as one manager said one technologist came in today and said there was not a single patient today whom I could make happy. And she says, you know what? I know she’s going to go home. She’s not going to enjoy coming back to work tomorrow.

We found that for healthcare professionals to be able to help these patients, even in these very short interactions can make a huge difference in how they enjoy their work. And you want to ideally keep your staff happy because happy staff makes happy patients. We even did a trial on that. We know that when staff gets stressed and you tell them you get either transferred or fired, then their patients have higher claustrophobia numbers. So happy staff, happy patients. Happy patients make happy managers which means then you also, it is a virtual circle. That’s, that’s one thing we do now, a lot. This interaction between healthcare professionals and patients, how would they all rub off on each other.

Courtney: Wow, well, thank you so much for being here today.

Dr. Lang: Thank you again so much for having me and exchanging ideas with you was just very wonderful.