Carmen, the manager of an intermediate care unit, has been watching Frank, a senior staff nurse, care for patients for several months now. He makes it look so easy. Patients just seem to do whatever he tells them. At first she thought it was because Frank was a man, but the other men who are nurses were struggling just as much as the rest of the department. “Now, if I could just figure out what he’s doing and teach it to the rest of the staff, we’d be golden,” she says to herself.

Over coffee, Carmen asks Frank about his success with patients and is surprised when he tells her about a hypnosis class he took a few years ago where he learned about the Laws of Suggestion. He explains how he has incorporated those laws into his practice and has found ways to constantly direct his patients’ minds toward the desired outcome. “I won’t be obvious about it,” Carmen says, “but I’d like to watch you while you work.”

In fact, the word “hypnosis” startled Carmen, and she was both curious and skeptical. Now she really watches Frank in action. None of his patients look glassy-eyed or zombielike. In fact, Frank and his patients seem quite engaged with each other. As she listens in on their conversations, Carmen finds that Frank rarely uses words like “pain” or “nausea.” Instead he says “comfortable” and “stomach feeling better.” One time she hears him say to a patient receiving a respiratory treatment for asthma, “I wonder when you’ll notice that you’re breathing easy and begin thinking about going back home.”

When Carmen talks with Frank again, she tells him what she has noticed. He explains that many patients are in an altered state because of illness or medication, and he sees this as an opportunity to direct their minds toward the solution instead of focusing on the problem. He further explains that anytime a person concentrates on a specific stimulus he goes into a trance for a brief time to perceive and make sense of the information.¹ Frank says that once you capture someone’s attention, the opportunities to embed suggestions are plentiful.

Suggestions surround us

Defining suggestions, Milton Erickson, MD, a psychiatrist and the founder of the American Society of Clinical Hypnosis, calls them statements the patient cannot possibly argue with.² If a person sniffs the air and then asks if you smell smoke, he or she has given you a suggestion, planted an idea in your mind. You may or may not notice a hint of real or imagined smoke, but the suggestion nudges your mind in a direction. In a movie, dramatic music may suggest imminent danger. Commercials suggest an enhanced love life with a special brand of toothpaste. A flashing red light suggests potential danger. All these suggestions nudge the mind to act or react.

Suggestion as opposed to persuasion, threat, or force is a powerful way to influence change. Persuasion, threat, and force often set up mental barriers that prevent an idea from taking root in the mind. Suggestion implants an idea into the mind in such a way that it bypasses critical thinking and enters freely. The mind takes over once the idea has entered.³ Whether intentionally or unintentionally, healthcare staff constantly offer both beneficial and negative suggestions. The Laws of Suggestion, as Frank has told Carmen, explain some of the workings of the mind so that a nurse who understands them can influence the patient’s progress.

In front of a TV set or in a hospital bed, a person’s unconscious mind responds — the “uh-oh” in the dentist’s office suggests more time in the chair, the eerie music in a horror movie points to danger, and a white, sparkly smile suggests confidence and sex appeal.

Laws of Suggestion

The Laws of Suggestion were developed in the early 1900s by Emile Coué, a French pharmacist. As Coué dispensed medications, he made positive suggestions about their effectiveness. In time, he noticed that his words seemed to enhance results from the remedies. In addition, Coué noted that his suggestions weren’t the main variable, but rather the individual’s ability to accept the suggestion. In the field of hypnosis, Coué is credited for discovering that all hypnosis is self-hypnosis.⁴ A recent review of research by the Cochrane Review <www.ncbi.nlm.nih.gov/pubmed/17054243>, found preliminary evidence that a variety of cognitive-behavioral interventions, including hypnosis, can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedure, such as immunizations, venipuncture, lumbar puncture, IV insertions, bone marrow aspiration, and intramuscular injections.⁵ Interventions best supported by the evidence exist for the efficacy of distraction, combined cognitive-behavioral interventions, and hypnosis in reducing pain and distress in children.⁵ Comparative studies show the efficacy of hypnosis in reducing pain in adults, with 75% of those who use hypnosis experiencing some relief of pain.⁶ Hypnosis has also been found to reduce pain in a variety of patient populations, such as those with burns, cancer, irritable bowel syndrome, and fibromyalgia and for coping with procedural pain.⁷

The Laws of Suggestion developed by Coué include the Law of Reverse Effect, the Law of Concentrated Attention, and the Law of Dominant Effect. These laws explain the mind’s ability to accept and reject suggestions.

The Law of Reverse Effect basically states that the harder a person tries to accomplish something, the more difficult it is to reach the goal.^8,9 For example, many people fail when they try really hard to lose weight, quit smoking, or cope with anxieties. At one time or another most nurses have asked a patient to try hard to relax. They may have even repeated the direction in a louder voice when the patient became more tense or agitated — the exact opposite response they were hoping for. In their own lives, nurses may have found that trying hard to relax, fall asleep, or stay awake usually produces the opposite effect.

The Law of Reverse Effect addresses will power, a short-term solution. It works for a couple of days or weeks for dieting or smoking cessation. For a panic attack, it might last a nanosecond. Trying hard is not the mind’s way of getting things done.⁴

This law also explains why force and threats are ineffective. Although a heavy-handed approach garners short-term results, resistance directs the mind away from the desired outcome.

The Law of Concentrated Attention explains how misdirection leads to opposite results. It states that an idea tends to realize itself when we focus our attention on it.^8,9 Basically, the mind goes in the direction of the pictures it takes in, and this can lead to a critical situation in some cases. For instance, toddlers may instill terror in their parents when they climb on top of a kitchen counter or onto the rail of a two-story deck. Following the Law of Concentrated Attention, children set their sights on forbidden territory and get there.

As we age, many of us focus on the things we want to avoid. We may concentrate on avoiding debt, the terror we feel when we speak before a group of people, or the inevitability of severe pain after surgery. The Law of Concentrated Attention explains how worries or fears come to pass.

Another important aspect of this law is that the mind is unable to make a “not picture.” So, for example, if you tell someone not to think of peaches, or peach ice cream, or peach blush, those items will fill his or her mind. We use words to make mental pictures, so when we tell people what not to do, they will make a mental picture of the activity. For example, if you tell children not to play in the street, they will paint a mental picture of playing in the street. Our minds go in the direction of the pictures we create.

Nurses often tell patients not to do something — “Don’t eat or drink anything after midnight,” or “Don’t take this medicine with food.” Later, to their dismay, nurses often find that many patients do exactly what they’ve told them not to do. The Law of Concentrated Attention prevails although the nurse might label the behavior nonadherent.

Frank explains to Carmen that when he talks with his patients, he imagines a TV monitor with a picture of what he’s saying. He then adjusts his words to create the picture he wants to implant in his patient’s mind. For example, if he is talking to a patient about taking medication to prevent a stroke, Frank emphasizes that the medication will keep blood vessels in good shape and allow oxygen to flow through the blood stream to all areas of the brain. Then, depending on the patient’s situation, he might go on to talk about a future that includes lively conversations with grandchildren and solving crossword puzzles.

Coué observed the Law of Concentrated Attention when he told patients about the positive effects of medications and saw good results. His patients had been concentrating on these positive effects. Similarly, the placebo effect exemplifies this law. Placebos used in drug studies have a 30% efficacy rate.¹⁰

Factors contributing to the placebo response include the patient believing in the treatment or susceptibility to suggestion and trust in the medical provider.¹¹ In addition, placebo investigators believe that intention, expectation, culture, and meaning are central to placebo-effect phenomena.¹² Benedetti, a current investigator into the placebo effect suggests it is a psychobiological phenomenon due to a number of aspects such as expectation and conditioning.¹³ Carmen has noticed that Frank’s patients seem less anxious than others in the same situation and asks him to tell her more. To explain, he describes the Law of Dominant Effect.

The Law of Dominant Effect states that when a person accompanies a suggestion with a strong emotion, the strength of the suggestion is enhanced. The suggestion-emotion combination replaces any previous suggestion.⁸ Basically this law says that when two emotions are present, the stronger emotion prevails.

Emotion intensifies mental pictures. When we are angry, afraid, full of guilt, or madly in love, that emotion and all the pictures that go with it occupy a front row seat in our mind. We may try to think other thoughts, but our mind keeps returning to the mental pictures associated with the strong emotion. Such intensity closes our minds to mental pictures of other suggestions. Before we use suggestion to shift the mind’s concentration, we first need to neutralize the emotion holding the mind captive.

For many years, Carmen had noticed that when nurses told patients not to be angry or afraid, the words had the opposite effect — patients became angrier, more afraid, and more resistant. On the other hand, Frank seemed to create an environment that encouraged patients to vent their feelings. He didn’t tell them what they should or should not feel. However, he did ask his patients how they would like to feel. While the patients poured out their feelings, Frank was developing a plan to match his suggestions to the patient’s desired emotion. For example, after encouraging an angry athlete to vent about the sprained ankle that was keeping him out of a tennis match, Frank asked, “When this sprain has healed, how are you going to feel?” The patient admitted he would feel relieved and talked about his passion for tennis. Frank’s discharge instructions started: “I want you to care for your ankle with the same respect you’d give a good tennis racket.” Emotion is a key to embedding suggestions into the mind. As Frank explains to Carmen, “Sometimes you need to tone down the emotion, and other times you need to crank it up.”

The dominant emotion, be it relief or fear, becomes the strong emotion — the one that wins out and colors the experience. Carmen saw that Frank had a funny way of practically congratulating a patient for having pain. He was pleased that the patient’s nervous system was functioning well, and was giving the patient medicine to ease the discomfort.

Another example of the Dominant Effect law in action appears in a study of soldiers injured in battle during World War II. Caregivers noted that these men required fewer analgesics than men in U.S. hospitals with similar injuries. Interviews of the soldiers revealed a common thread of meaning — their wounds meant that the war was over for them. The feeling of relief was the stronger emotion, stronger than the discomfort from their injuries.¹⁰

Embed the suggestion

Milton Erickson, MD, a psychiatrist who used hypnosis throughout his professional practice, developed the therapeutic use of embedded suggestions, which are suggestions implanted within a conversation. The suggestions bypass the conscious mind and go directly to the unconscious.⁴

In a healthcare setting, the nurse might say, “In a few minutes you may notice your stomach feels better,” “As you inhale this medicine, you’ll notice you naturally breathe more easily,” or “Thank you for keeping your arm still while I insert your IV line.” Each suggestion paints a picture without directly telling the patient what to do, and the indirect delivery style facilitates entry into the patient’s mind. All too often, however, caregivers have learned to give nontherapeutic embedded commands, such as “It’s very important that you don’t move now,” “Do you feel sick to your stomach?” or “Do not blow your nose.” Without realizing it, patients may pick up these types of statements as suggestions.

Innocent phrases like “Don’t forget,” “No problem,” or “You can’t miss it,” can lead the unconscious mind away from the desired intent. Those interested in better understanding the art of suggestion might try observing the mind-pictures they create when another person is speaking. Likewise, nurses can teach themselves to become aware of the pictures they wish to create when they speak to patients.

Frank explains to Carmen that, when used therapeutically, embedded suggestions can easily move a patient in a desired direction. The next day, Carmen watches as Frank admits a patient with dyspnea and inserts nasal prongs. When the patient shakes his head and gasps a protest, Frank says calmly, “You want to breathe better, so I’m giving you oxygen. You don’t need to like it, but you do need to wear it.” Although the words sound impertinent to Carmen, Frank’s manner is respectful, and she sees the patient accepting the oxygen. Frank has made a picture of accepting the nasal prongs and breathing more comfortably.

When you wish to embed a suggestion, you need to make the suggestion stand out. Several techniques work. For example, altering your voice to a slightly louder or softer, higher or lower tone. Faster or more drawn out speech also helps, or a slight pause before and after the suggestion.⁴ Embedded suggestions simply state the desired result of a medical intervention, for example, “This medication will make you sleep,” “This extra IV fluid will raise your blood pressure,” or “Raising the head of your bed will help you breathe easier.”

The key point to remember is that embedded suggestions are directed toward the unconscious mind. Whatever tool you use to make the suggestion stand out needs to be subtle so that the suggestion stays embedded. Another powerful way to embed a suggestion is through an implied question, for instance, “I’m wondering how long it will take for this medication to make you comfortable enough to go for a walk,” “I’m wondering when you will first notice you are breathing more comfortably,” or “Who will be the first person to notice you’ve lost 10 pounds?”

A different approach

Carmen has started incorporating the Laws of Suggestion into her management style. When staff members come to her with complaints, she encourages them to vent their feelings and then works with them to develop a picture of the desired solution.

Instead of restating the problem, which had been her usual style, she now asks rhetorical questions, directed at the solution. “I wonder how long it will take for us all to work well together,” or “It takes time to see improvement.” Instead of counseling staff about sick days, she addresses the challenge of staying healthy.

She hopes to expand her responsibilities through a promotion in the near future. She is making a concerted effort to embed suggestions about her competence. Recently her manager commented that Carmen’s reports were thorough, clear, and always on time. Carmen replied, “Thank you for noticing the quality of my reports. That’s important to me.”

Carmen used to pride herself on being the type of nurse manager who tackled a problem head-on. Now she concentrates her attention on creating a well functioning unit, coaching her staff, and developing her own career.