Psychological Asepsis
by Dr. Richard Bolstad and Margot Hamblett

The Discovery Of Asepsis And Ignaz Semmelweis

In 1851, Hungarian medical doctor Ignaz Semmelweis made an extraordinary discovery. Doctors were killing their patients. At the time, Semmelweis himself was a surgeon and obstetrician at the Allgemeines Krankenhaus general hospital in Vienna. Nine out of ten surgical operations at the hospital resulted in the death of the patient, from what we would now recognise as wound infection. Demoralised, the 33 year old Dr. Semmelweis wrote “Everything they are trying to do here seems to me quite futile. Deaths follow one another with regularity. They go on operating, however, without seeking to find out why one patient succumbs rather than another in identical circumstances.” (quoted in Bendiner, 1990, p. 222).

The death rate was also high amongst women giving birth in hospital. Almost half of them died of infection in the days after birth. Ignaz Semmelweis noted that the death rate was a quarter this level in the section of the hospital run by midwives instead of by surgeons. When he pointed this out, his boss, Professor Johan Klein, was furious at the implication that something his staff did was causing patients to die. His response was to fire Semmelweis. However, the young doctor continued his studies, identifying what the source of the problem was. Surgeons were in the habit of moving straight from the dissection of infected cadavers in the morgue to hospital work. They wiped their hands to remove obvious dirt, but this was not enough. The surgeons were bringing infections from previous patients who had died of them, and contaminating healthy patients with them.

Once the surgeons followed Semmelweis suggestion and washed their hands after dissections in a solution of chlorinated lime, the deaths stopped. Semmelweis termed such preventive measures asepsis (anti-infection). Klein, however, now set about destroying Semmelweis’ career, having him banned from work in most medical hospitals. Semmelweis retaliated in 1861 by publishing “The Etiology, Concept and Prophylaxis of Puerperal Fever,” and writing angry letters to people throughout the medical field. As a result, in 1865 he was committed to a psychiatric hospital diagnosed with “paranoia.” A month later he was dead, according to the autopsy as a result of being beaten by staff.

It Can’t Happen Now, Or Can It?

Asepsis, as such, is now a well understood process. Doctors no longer feel it insults their professionalism to wash their hands between patients. But, as we shall see, Semmelweis’ complaint could still be made of surgeons today. “They go on operating, without seeking to find out why one patient succumbs rather than another in identical circumstances.”

Why does one person do well after an operation, while another suffers all sorts of complications? Why does the same operation produce dramatic healing in one person and not in another? In this article we will propose that the next important answer to this question will lead to the creation of Psychological Asepsis. Our surgeons are now more careful about the cleanliness of their hands, but not about the cleanliness of their words. They do not drag bacteria from their previous patients to their next clients, but they do drag what Donald Lofland and others in the NLP community have called “thought viruses” (Lofland, 1997).

Dr. Bernie Siegel is one surgeon who has identified this problem. He warns that psychological asepsis is necessary even when the patient is anesthetised. “When a surgeon makes a quip like ‘If he ever leaves here it’ll be feet first.’ It’s no wonder the patient wakes up crying in the recovery room.” To extend the metaphor of Semmelweis’ work, such a surgeon has come in with their psychological “hands” still dirty from other patients who have died, and then contaminated the next person. The expectation of death implanted by this statement is as powerful as a virulent infection. Siegel urges, “One can be honest about the diagnosis and still implant positive thoughts about the future treatment.” (Seigel, 1988, p. 49)

Does The Mind Really Matter?

The evidence suggests that the mind is at least as powerful as surgery itself in predicting surgical outcomes. In a previous article (Bolstad and Hamblett, 2000) we studied the results in terms of cancer. This time, we’ll take the examples of coronary heart disease and back surgery. In 1958, a study was done to evaluate the effectiveness of a new surgical treatment for heart disease (Cobb et alia, 1959; Diamond et alia, 1958; also reported in McDermott and O’Connor, 1996, pp. 75-76). The surgery has since been shown to be completely useless, but the effect for the patients in the study was wonderful. The patients were all told that their surgery would probably help, and indeed ten of the seventeen patients in the study reported great improvement. Their use of heart medication dropped to 1/3 over the next weeks. What is most interesting is that only eight of these patients had actually been given the surgery. Nine of them simply had a skin incision made and sutured up again. Of those nine, five reported they felt much better, and reduced their medication to 1/3. When doctors expressed disbelief, another surgery team replicated the study, with even better results.

These studies demonstrate the life–threatening and life-saving results of psychological interventions. In another study of heart disease, the effectiveness of cholesterol–lowering drugs was tested. Half the patients were given placebos (the study was controlled so that other factors such as smoking and eating habits were the same in the placebo group as in the treated group). In both groups, of course, many patients did not take their pills. In the placebo group, there were many “non-compliers.” These noncompliers had a 57% higher mortality over the next 5 years when compared to the compliers who took all their placebos (Coronary Drug Project research Group, 1980). They didn’t get around to taking the drugs, but they did swallow their doctor’s beliefs, with often fatal consequences.

In 1972, Dr. E. Spangfort reviewed 2504 surgical treatments for lumbar spine problems. In a large percentage of cases no surgically treatable disorder was found, so that, as with the surgery for heart disease, the person was simply opened up and sewn together again, without any actual treatment. As a result of this non-treatment, 37% reported complete relief of sciatic nerve pain, and 43% reported complete relief of back pain. In cases where some abnormality was actually treated, the overall success rate was 64%. That is to say, placebo treatments were 2/3 as successful as real surgery.

These are extraordinary studies, indicating clearly that much of the success of modern medicine is being achieved by the same methods that shamans and witch doctors across the world have always used. All surgery is, to a large extent, “psychic surgery”: it creates powerful expectations of healing, which are the real source of most of the positive results.

Saving Blood, Speeding Recovery

But the healing effect of surgery is dependent on how it is presented by the surgeon and other health practitioners. Psychologist Henry Bennett has collected several hundred studies showing that preparing patients psychologically before surgery will markedly alter the surgical and post-surgical results. Simple changes in what the doctor says will reduce need for pain medication, reduce blood loss, and result in fewer medical complications.

At the Department of Anesthesiology at the University of California, Bennett himself conducted a study on patients admitted for spinal surgery (Bennett, Bensen and Kuiken, 1986). Each patient received a 15 minute preoperative talk with a health practitioner from the centre. There were three subgroups. Group A received basic information about the procedure they were to go through. Group B received a brief training in how to relax their muscles before and after surgery. Group C were given an NLP style intervention. The health professional pointed out that everyone has experienced blushing as a result of a few words said by someone else, so we know that the mind can cause blood to shift around in the body. They then explained that it would help if the person’s blood moved away from the spine during surgery (to prevent blood loss), and then moved back afterwards (to promote healing). They then slowed down their voice and said, “Therefore, the blood will move away from the spinal cord during the operation. Then, after the operation, it will return to that area to bring nutrients to heal your body quickly and completely.”

The result of this simple conversation was dramatic. Patients in Group A and Group B lost, on average 900 cc’s of blood, which is the normal level of blood loss over the course of this operation. Patients in Group C lost an average of 500 cc’s of blood during the operation –only half as much.

In 1993, Bennett conducted another study on patients undergoing gastrointestinal surgery. The main complication in such surgery is due to slow recovery of movement in the digestive system after the operation. Patients were divided into two groups. In Group B the patients were told “Your stomach will churn and growl, your intestines will pump and gurgle, and you will be hungry soon after your surgery.” This group regained gastrointestinal movement in an average of 2.6 days instead of the usual 4.1 days, resulting in them being discharged from hospital two days earlier (at a saving in medical costs of US$1200 per person).

Research on pain relief as a result of preoperative suggestion is abundant. In fact, here the pioneer study was done way back in 1964 by anaesthesiologist Larry Egbert in Massachusetts (Egbert et alia, 1964). After being given presurgical instruction on how to prevent pain by relaxing muscles, patients required less pain medication and returned home sooner.

Bennett also discusses the effects of surgeons talking during surgery itself (Bennett and Disbrow, 1993). In a famous 1960 study by Wolfe and Millet, 50% of surgical patients followed suggestions during surgery to such an extent that they required no medication for pain relief at all afterwards. Bennett demonstrated that such response does not require conscious memory of the surgery (Bennett et alia, 1984, 1985). In a three minute message played during surgery, he instructed patients that they were to touch their ear during their postoperative interview (which was to happen a week later). The interviewers a week later did not know which patients had been told to touch their ears. 82% of those told to did touch their ears, and the average time spent “ear–touching” was 15 times as long in this group as in the control group. These patients did not “remember” the instruction to touch their ears. But they did follow it. In the same way, Bennett cautions, patients do not remember their surgeons negative suggestions during surgery, but they do follow them.

Our Experience

We have two perspectives on this; as health practitioners and as health clients. Both of us have trained nurses and other health professionals in effective communication, and our textbook Transforming Communication has been used by both medical and nursing schools in New Zealand. A couple of years ago, when Margot went into hospital for surgery, we got to look from the other side too. Before her operation, the surgical procedure was explained to her in minimal terms, and there was no suggestion that her attitude could affect the outcome. After her surgery, the surgeon came to check her, and made a single comment looking at the area operated on: “Oh yes; there is a discrepancy isn’t there.” Margot was left to puzzle over the meaning of this, and to make her own internal representations of how well the surgery had gone, based on this single comment, so devoid of encouragement or reassurance. At her next check–up a couple of weeks later, the doctor actually warned her that her health could get worse as a result of the surgery she had had!

The other comment Margot heard repeatedly from staff postoperatively was “How is your pain?” (rather than “How is your comfort?”). This was particularly strange because Margot had no pain. Having used a hypnotic relaxation tape before and during surgery, as well as suggestions from Richard, she found that the “anchor” she had set worked better than the intravenous morphine that was offered her. She was quite comfortable. Nursing staff told her that not having pain medication was very dangerous, and would cause her to take longer to heal. In fact she left hospital over a day earlier than expected. The thing that struck us most about all this was the energy it took us to protect our own positive expectations in the hospital situation. And we were fairly well informed and aware of the value of positive internal representations of healing. We knew that our attitudes could affect the healing process. Hospitals remain, for most people, quite dangerous sources of thought virus “contamination.” We strongly recommend that people who decide on surgery collect all the resources they can to create a safe aseptic haven within the hospital system (support people, books, audiocassette tapes, posters, etc.).

Beyond The Semmelweis Effect

Are surgeons and hospitals leaping to buy the audiotapes Henry Bennett has made to pass on his successful psychological asepsis? No, they are not. In fact, some large hospital organisations have bought his tapes after studying the research, but left them on the shelf due to resistance from medical staff. As Bennett says “Viewing the patient as anything other than a warm set of organs raises the anxiety of the healthcare profession.” (Dreher, 1998, p. 221)

Nonetheless, there are health professionals who are aware of the need for psychological asepsis. Surgeon Bernie Siegel, cited earlier, is one. Henry Bennett is another. Dr. Milton Erickson was another. General Practitioner Bob Britchford is one health professional applying Erickson’s skills to ensure psychological asepsis (Britchford, 1988, p 113-114). He writes about his use of Ericksonian positive suggestions in his ten minute consultations, “Throughout my initial contact, I am formulating my questions in such a way as to lead the patient away from negative associations and towards therapeutic ones… One has to say something and one might as well say things in such a way as to influence the patient’s view of themselves, provided that it is a true view and is congruent with the actual findings in the examination.”

Ericksonian hypnotherapist and social worker Juliet Auer discusses the use of these principles in a busy Renal Unit at a British hospital. She gives an example of the kind of work she needs to do coping with “ward rounds” (where the doctors check on each patient). In one example, a doctor says, “I don’t like the look of the AF on this ECG. No MI on enzymes, but long-standing malignant hypertension. Pyrexial too, uh-huh (significant look). Have we looked for vegetation? Do you think we’re missing SBE? Perhaps we ought to. Hm (knowing nod).” Auer says “As they move to the next bed, I try to mop up the worst of the psychological damage.” She explains that in this case “malignant” has nothing to do with cancer, vegetation just means germs, and they’re planning to check why the person still has a temperature. She then reframes the situation so that the person feels in charge of their treatment and feels that they are using it to reach their own objectives.
Does this make any difference? K. Thomas is a British General Practitioner who has written a number of articles on his use of the placebo effect in clinical practice (Thomas, 1987, 1994, also quoted in McDermott and O’Connor, 1996). In one study he took 200 patients without any specific diagnosis, but with general ill–health. Half of them were told they had a definite complaint, and given a reassurance that they would get better. The other half were told that he was not sure what was wrong, and to return if the situation did not improve. Two weeks later, 64% of the first group had improved, while only 39% of the second group were better. Thomas had almost doubled his success by simply talking positively to the first group.

Happy Endings

In 1867 Lord Joseph Lister introduced British surgery to handwashing, and the use of phenol as an antimicrobial agent for surgical wound dressings. Although reluctantly, his principles were gradually adopted in Britain, and mortality from amputation fell from 45 to 15 percent. The Listerian technique was approved in the U.S. at the first official meeting of the American Surgical Association in 1883, twenty years after Semmelweis’ initial publications. We have waited an equivalent time since the first experiments in psychological asepsis. Now is the time for health professions to adopt psychological asepsis as expected practice. The results will be as dramatic as the results of Semmelweis’ and Lister’s work.

The concept we are proposing is simple. Once we as health practitioners understand that expectations shape our clients’ outcomes more powerfully than the concrete medical interventions, we will change what we say. We will automatically talk about chances of success rather than chances of failure. We will automatically point out just how much is possible in terms of healing, rather than only mentioning the risks of disease and of treatments. We will automatically draw our clients’ attention to the most dramatic possible health results that they could be capable of.

And as we do this, our satisfaction will also increase. We will experience our very words as powerful healing agents that we direct to the client. We will be continuously fascinated by the specific words which have had the most powerful therapeutic effect. That, after all, is why we came into the field of helping others. Because we want to express our love for humanity through this work. By keeping our language “clean” we ensure that each new client receives our belief in their healing capacity in its original pure state. And there are many more benefits we receive too. Because every time we speak to a client about their enormous healing capacity, our own body is also listening.

Bibliography

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©2000, Dr. Richard Bolstad and Margot Hamblett

This page and all contents are Copyright 2000 by the author and by Anchor Point Magazine Salt Lake City, Utah, May not be reprinted without permission from Anchor Point, info@nlpanchorpoint.com.