Kingman Regional Medical Center has increased therapy compliance among struggling patients via PAP-NAPs that incorporate self-hypnosis techniques.
Through the combined efforts of all medical staff including technical and management, the intention at Kingman Regional Medical Center (KRMC) Sleep Disorders Center is to explore new ways of improving therapy compliance. One such alternative method we are trying is motivational self-hypnosis for PAP (positive airway pressure) therapy for sleep apnea patients.
We have found that integrating motivational self-hypnosis techniques with a PAP-NAP desensitizing procedure is highly beneficial in helping patients overcome negative feelings and anxiety toward treatment. Our clients range from young to elderly, and despite occasionally having different therapeutic goals, they commonly require guidance on how to achieve compliance.
Some studies say the average noncompliance rate for patients requiring PAP therapy and not receiving additional compliance support is approximately 50%.1-2 Other research abstracts show a range from 29% to 83%.
In 2013, our sleep lab staff began performing two to three self-hypnosis PAP-NAP procedures per month. For those of you who aren’t familiar with a PAP-NAP, it is a daytime sleep study conducted to desensitize patients to PAP therapy. It includes individual PAP coaching, an attended cardiopulmonary recording involving at least four channels, and instruction and fitting of the equipment. Patients are then left to sleep briefly with the PAP to familiarize them with the sensations in a controlled setting. To learn PAP-NAP protocols, I took an online course by Barry Krakow, MD, and modeled our PAP-NAP program to his. (Krakow’s courses are available at www.sleeptreatment.com/sleeppros.) In comparison with patients not receiving a PAP-NAP, KRMC Sleep Disorders Center found a significant PAP compliance increase in those undergoing PAP-NAP visits. Today we perform 12 to 16 PAP-NAPs per month, helping those who also struggle with anxiety, claustrophobia, and PAP pressure intolerance.
Prior to June 2013, 40% of noncompliant patients (those who expressed unwillingness to continue with therapy) who underwent PAP-NAPs met compliance criteria at the 3-month mark. Today, with integrated motivational hypnosis, including deep relaxation techniques, we are showing an even greater success rate. According to our local ResMed account representative, we now have a 92% PAP compliance rate. Prior to implementing the PAP-NAP and hypnosis program, we hovered around 60%.
Of course, this is not a controlled research project but rather a small real-world sampling in a short period of time. Regardless, this experience is still a good indicator, and it shows success at moving patients in a positive direction to meet their compliance demands and in turn leading them on a continued path of improved quality of health.
Introduction to Hypnosis
Hypnosis is a natural yet altered state of mind that allows a filtering component in the brain called the critical factor (CF) to become relaxed. Bypassing the CF allows replacement of existing negative beliefs with positive suggestions, which in turn help create a positive self-belief. As with any treatment modality, both the patient and the practitioner must clarify the intended outcome of using self-hypnosis techniques to overcome barriers to prescribed therapies.
The practice dates back thousands of years, most commonly being used for pain control. It is not mystical, supernatural, or based on an individual’s belief system (despite what popular culture often depicts). Individuals cannot be made to act or speak against their will. Today hypnotherapy techniques are used clinically for weight control, smoking cessation, decreasing anxiety, overcoming fears and phobias, insomnia, and many other undesirable unconscious behaviors. Hospitals currently integrating hypnosis techniques within their sleep programs include Mayo Clinic, Johns Hopkins University, Stanford University, and Harvard University.
I (Hopkins) attended the Hypnotherapy Academy of America in Albuquerque, NM, and graduated with more than 300 hours of hypnotherapy education and the credential of certified hypnotherapist. It took me a year to get certified. Hypnosis training is poorly regulated in most states, so if you are interested in pursuing a credential, I caution you to be wary of programs that offer bare-minimum training (such as 50-hour courses).
In the sleep center setting, the clinical or certified hypnotist acts as a facilitator, guiding and eventually teaching the patient how to perform self-hypnosis independently. Self-hypnosis techniques are not the practice of medicine, psychology, mental health counseling, or psychiatry. Although physicians do use hypnosis in these specialties, it is not to be confused with self-help or motivational hypnosis as referred to here on the clinician level.
To understand how hypnosis works, it is important to have a basic understanding of the dynamics of the three layers of the conscious mind.
Model of the Mind
1. Conscious Mind. Sometimes noted as the “unconscious” conscious mind (which refers to how we are on autopilot through application of programmed learning and storage of past experiences, beliefs, and behaviors). Dr Ivan Pavlov described the conscious level as a very active level of consciousness that does all the work automatically “behind the scenes.” It is the intelligent mind that operates the autonomic nervous system (ANS), reflexes, and so on. This is the part of the mind that guides analysis/choice and inductive and deductive reasoning/logic and our will and volition utilizing the five cognitive senses.
2. Subconscious Mind. This level was discussed extensively by Dr Sigmund Freud. It is who you really are, what makes up your personality. It guides the ANS, which is divided into the sympathetic nervous system (SNS) and parasympathetic nervous system (PSNS). Hypnosis operates on the PSNS, maintaining body homeostasis and putting the brakes on the SNS “fight or flight response,” thus further supporting the immune, digestive, and reproductive systems, higher mind and problem-solving functions, lowering blood pressure and promoting healing, and improving overall quality of life.
3. Super Conscious Mind. This level refers to your universal mind, your higher self, your spirit, and where you find love, forgiveness, healing, peace, love, and intuition, inspired creativity, and grace.
When the patient understands and agrees to enter into self-hypnosis, they are induced into a peaceful trance that consists of several different degrees of consciousness.
b. Daydreaming (light)
These levels have no rigid boundaries and can mix or blend into one another. In many trance states, the patient is sometimes more alert than when they are awake and often actively involved with a two-way dialogue with the facilitator.
With PAP-NAP patients, we’ve averaged a 92% success rate in helping patients attain sleep in less than 5 minutes through the use of progressive relaxation induction. This is normally accomplished on one visit; however, addressing other issues such as smoking cessation or weight control may take up to 6 or 8 weeks of seeing a certified facilitator or physician one or two times each week.
At this time, we do not have solid cost analysis of the impact this process has on a person’s health or readmission statistics. It is our goal in the upcoming year to obtain a wider patient base to research this. Research at the University of Washington School of Medicine Department of Anesthesia and Rehab Medicine showed patients abstinent from tobacco at follow-up 6 months to 3 years post-treatment, which represents a 90.6% success rate using hypnosis.3
Motivational or self-hypnosis has helped thousands of individuals accomplish and succeed in meeting desired goals where other processes have failed. Within our scope of practice of pulmonary and sleep medicine, we can assist many patients by offering this valuable tool along with other treatment modalities and accelerating them to a more healthy and refreshed life of wholeness, peace, and happiness.
Mark H. Hopkins, CHt, RPSGT, is clinical supervisor at KRMC Sleep Disorders Center in Kingman, Ariz, and has more than 20 years’ experience in the field of sleep technology. Haven R. Malish, MD, FCCP, is medical director for KRMC Sleep Disorders Center. He is certified in critical care and pulmonology. The authors may be reached at mhopkins[at]azkrmc.com.
1. Stepnowsky CJ Jr, Moore PJ. Nasal CPAP treatment for obstructive sleep apnea: developing a new perspective on dosing strategies and compliance. J Psychosom Res. 2003 Jun;54(6):599-605.
2. Ballard RD, Gay PC, Strollo PJ. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure. J Clin Sleep Med. 2007 Dec 15;3(7):706-12.
3. Barber J. Freedom from smoking: Integrating hypnotic methods and rapid smoking to facilitate smoking cessation. Int J Clin Exp Hypn. 2001 Jul;49(3):257-66.