Light-hearted and easy to read, Mary Guinan’s account of her career as an epidemiologist accomplishes its goal, “To help readers better understand and value the public health system that exists for the protection of the nation’s health and for the prevention of disease and injury.” From the early definition of the “hole in the sole,” the epidemiologist’s trademark, to the description of the Sherlock Holmes method, the epidemiologist’s approach to public health puzzles, Guinan’s stories embody the modesty and humor inherent in the culture of epidemiology as practiced by the Epidemiologic Intelligence Service (EIS) of the Centers for Disease Control and Prevention.Young readers will be surprised, indeed as Guinan herself was surprised, at the challenges posed each day in public health, and in the end, they too may “find something to believe in,” as she did during her days in the Smallpox Eradication Program. Her colleagues, EIS alumni and those now in the EIS Program, will see themselves in her description of the demands for instant, on the spot, expertise on complicated health emergencies or unknown sexually transmitted infections. They will recognize the unlikely developments so much a part of human interaction during epidemiologic investigations: pink elephants, unplanned media presentations, expert witnesses, hostile refugee camps, veiled women, seedy hotels, life-threatening needlestick injuries, famous movies featuring you, a challenging milk industry.Investigation surprises abound in Dr. Guinan’s account. Some involve the investigator herself. “I don’t think anyone grows up wanting to be a physician who specializes in sexually transmitted diseases.” “I was never the most important leader. A medical detective has a small part in a team effort, usually a very large team… the medical detectives who collect clues, analyze data, investigate suspected cases, and carry out their public health mission.”Some surprises involve the context of the investigation: for example, the Mujahideen in an Afghan refugee camp asking Dr. Guinan for weapons to fight in the Haj in 1980. She worked in the cramped quarters of a hotel in the Tenderloin District of San Francisco, identifying what would eventually be called the first AIDS cases. She later had to explain to the public that “nice” women can get AIDS.Guinan and Mather wrote a book that is readable and free of technical jargon. The book is a woman’s account because it reflects the experiences of a woman traveling the paths women have not traditionally traveled. During Guinan’s first outbreak investigation, “I walked up to the uniformed four men and one woman and identified myself. The men were clearly shocked that ‘Dr. Guinan’ was a woman, and they were apologetic. They had not known that CDC was sending a woman.”


Exercise-based cardiac rehabilitation reduces morbidity and mortality. Walking is a convenient activity suitable for people with cardiac disease. Pedometers count steps, measure walking activity and motivate people to increase physical activity. In this study, patients participating in cardiac telerehabilitation were provided with a pedometer to support motivation for physical activity with the purpose of exploring pedometer use and self-determined motivation for walking experienced by patients and health professionals during a cardiac telerehabilitation program.autonomy, competence and relatedness. Twelve cardiac patients, 11 health professionals, 6 physiotherapists and 5 registered nurses were included.A qualitative research design consisting of observations, individual interviews and patient documents made the basis for a content analysis. Data was analysed deductively using Self Determination Theory as a frame for analysis and discussion, focusing on the psychological needs of autonomy. The patients felt consciously aware of health benefits of walking, and the pedometer provided feedback on walking activity leading to an increased competence to achieve goals for steps. Finally, the pedometer supported relatedness with others. The health professionals’ surveillance of patients’ steps, made the patients feel observed, yet supported, furthermore, their next of kin appeared to be supportive as walking partners.The pedometer offered independence from standardised rehabilitation since the pedometer supported tailoring, individualised walking activity based on the patient’s choice. This led to an increased Cardiac patients’ motivation for walking was evident due to pedometer use. Even though not all aspects of motivation were autonomous and self determined, the patients felt motivated for walking. The visible steps and continuous monitoring of own walking activity made it possible for each individual patient to choose their desired kind of activity and perform ongoing adjustments of walking activity. The immediate feedback on step activity and the expectations of health benefits resulted in motivation for walking. Finally, pedometer supported walking made surveillance possible, giving the patients a feeling of being looked after and supported.Current study is a part of The Teledi@log project. Cardiac rehabilitation (CR) decreases morbidity and mortality , 2. Home. In relation to physical activity, Self Determination Theory (SDT) provides a theoretical framework for long-term motivation for behaviour change. Thus, researchers have begun to implement physical activity recommendations grounded in SDT  I wasn’t given any marker on how many steps to walk a day. I was just told to walk; now I walk longer distances about 7000 steps 8000 steps on one trip” (ID2). Similarly, the health professionals expressed that monitoring steps made it possible to assist in tailoring each patient’s individual training program. A physiotherapist explained, “In worst case scenarios they only walked 2000 steps in a day. You have to be aware of their starting point when you plan their individual activity level” . The new possibilities for tailoring activity plans were also expressed in the PHRs. The RN wrote, “John experiences leg pain when walking. We agreed to measure how far he can walk (numbers of steps). After that we will determine goals for daily steps” (PHRpatientID1). As stated above, monitoring the patient’s steps made it possible to adjust and tailor walking activity for each individual patient. As such, individual strategies for walking activity became obtainable.The patients used the pedometers to monitor steps across different activities. They chose activities suitable for their lifestyle and developed strategies to achieve their step goals through these activities. This made them independent of standardised walking programs, i.e. some walked to the grocery store instead of driving. Furthermore, they modified their activity by going for a walk if their amount of steps had not reached a satisfactory level, at a time suitable for their daily life. As such, the pedometer became a tool that made it possible for them to tailor activity individually: One patient expressed, ““It’s nice to see that I did actually walk many steps today.” (ID1). A nurse expressed that consciousness about patients’ walking activity increased due to the visibility of step activity: “Previously it seemed blurred, whereas now, with this [the pedometer], it is easier to keep track on their activity” . Likewise, the notes in the PHR revealed that patients were consciously aware of walking and became dissatisfied if they forgot the pedometer: “Unfortunately I forgot the pedometer this morning, and I went for a long walk, which unfortunately didn’t get registered” (ID2). Another patient wrote in the PHR: “Hi Mette [nurse at the hospital], the pedometer is really motivating. I wore it at the gym, I went there with my wife, and it gave me 2 – 3.000 steps at the cross trainer” (PHRpatientID12). Visibility, as the immediate feedback on walking activity, supported the patients’ competence in walking activity because it made both the patients and health professional consciously aware of patients achieved steps.The visibility of steps on the pedometer and in the PHR provided the patients with immediate feedback on the amount of steps walked. The patients wanted to achieve step goals because it gave them satisfaction. A patient expressed, Some of the patients don’t consider walking as a health related issue; they just consider walking as an act to get from one place to another. The pedometer changed that” . This was supported by a patient: “It is all about health. I try to keep as healthy as possible, and it appears that exercise makes a difference” (ID10). Another said, “Walking is my work. I want to be in a good shape, because it’s good for me” (ID2). Some patients deliberately tried to increase their awareness of their walking by placing the pedometer visibly on the body: “A patient had the pedometer placed visibly at the shirt, expressing that for him this was an appropriate place because it reminded him of walking” (Field note ID11). As such, the pedometer increased their focus on health benefits of walking activity, and made patients aware of walking. This knowledge supported the feeling of being competent in performing the activity.Health professionals and patients jointly expressed that the awareness of health benefits from walking made patients walk with intent. Walking became more than an everyday activity of getting around, it became a conscious activity supporting health. A nurse said: “You lose face if the pedometer shows too few steps. I mean, you lose face if you don’t do what they [the health professionals] told you to do” (ID4). In the PHR a patient evaluated the surveillance: “It’s a safe feeling, that the nurse follows your rehabilitation status in the PHR. I haven’t reach my goals yet, but I am determined that I will” (PHR ID9). They wanted to explain their activity to the health professionals, as seen in a PHR: “Hallo Mette [nurse at the hospital]. As you can see, I don’t walk much. I am extremely affected by the new drug. Immediately after intake, my pulse and blood pressure drops and I need to lie down” (PHRpatientID4). This illustrated that the patients were motivated to walk more because they were under surveillance by the health professionals. In addition, the health professionals used the PHR to support the patients’ motivation by giving feedback on their activity. A physiotherapist expressed: “For the patients, it´s the immediate result each evening. It’s like a close surveillance of activity, like a: ‘well done today, Peter’” , and, in a patient’s PHR a nurse wrote: “Hi Hans. I can see that you have been really active, that’s good☺. Enjoy the lovely weather today, maybe you feel like a long walk on the beach?”(PHR patientID5). As stated above, the relation between patients and health professionals involved surveillance in a supportive way. The patients strived at achieving and documenting sufficient walking activity and the health professionals aimed at supporting motivation by positive comments on walking activity.The patients seemed aware of their step activity being monitored by health professionals, and they did not want to “lose face” or to disappoint the health professionals due to inactivity. They felt motivated to verify their step activity: “They helped me to get started. And when you have the pedometer, then you look at it, ‘how many steps have I been walking?’, then we have been out for an evening walk” (ID3), and another walked with a friend: “I just call my friend and ask her; ‘don’t you need some fresh air?’ It’s like; ‘two for the price of one’ because then we talk and talk, and suddenly, without noticing, we have been walking a long trip (ID6)”. A physiotherapist had noticed a friendly competition between a man and his wife: “His wife bought a pedometer herself, they compared, and talked about how many steps they had reached. I think that it was motivating for them, to see the spouse feeling good” . As such, relatives and friends seem to support the patients’ motivation for walking due to friendly competition and a wish to walk with others.Patients expressed that relatives and friends may be supportive for walking motivation. A patient walked with her children and expressed: autonomy. In SDT, intrinsic motivation forms the basis for autonomous or self determined behaviour [The present study revealed that the pedometer offered independence from standardised rehabilitation. Step goals became flexible and the pedometer provided opportunities to tailor activities in respect to daily living. This led to an increased independence and ehaviour . In addiehaviour , 50. Thiehaviour –5, 50. Tcompetence to achieve goals for steps. Furthermore, the increased awareness of health benefits of walking made walking activity an informed choice. According to SDT, competence is formed by the person’s beliefs of being able to carry out the desired behaviour change [The pedometer provided a conscious awareness of walking activity. The immediate feedback on step activity supported the awareness of walking activity for both patients and health professionals leading to an increased r change , 25, 37.r change . In thisr change , pedometr change . Studiesr change , 35. As r change –35 and mRelatedness was expressed both as surveillance and support, as the patients felt observed, yet supported by health professionals and helped by their next of kin. Surveillance put pressure on the patients supporting their attempt to achieve and document sufficient walking activity, despite that, the health professionals maintained a supportive role. The surveillance increased the attempt to fulfil goals for daily steps thereby motivating patients to walk. In addition, the health professionals gave positive feedback by writing supportive comments in the PHR. According to SDT this can be seen as an integrated extrinsic motivation that support the motivation for walking, despite the fact that SDT consider surveillance and feedback (e.g. standardised text messages) as failing to provide long term motivational changes, because the behaviour stops as the surveillance and feedback stops [The pedometer supported interaction with others in relation to walking activity. ck stops , 35. Furck stops . In SDT,ck stops , 20. Furck stops . HoweverThe participant observations and patient interviews were conducted in private settings that provided a relaxed and comfortable atmosphere for the participants. The in-depth reading and analysis was undertaken only by the first author leading to a risk of mis-interpretation. To avoid this risk of bias an ongoing discussion of the analysis and interpretation was made with the co-authors. De-contextualisation of the text might appear when using Nvivo10, but the critical reading and discussion between the authors was performed to avoid this. Even though the pedometer Fitbit Zip seems to be valid in measuring free-living physical activity , 52 it hThe researchers were part of the Teledi@log project, which might provide blind spots in the analysis and interpretation because familiarity to Teledi@log may lead to truisms. On the other hand, this familiarity may have provided a deeper understanding of the research topic.Pedometers offered independence from standardised rehabilitation and made it possible for the patients to tailor, choose and decide time and place for walking activity. Furthermore, the pedometer provided a conscious awareness of walking activity due to the immediate feedback on step activity for both patients and health professionals. Besides that, patients felt an increased awareness of health benefits of walking and they strived to achieve goals for steps. Finally, the pedometer supported interaction with others in relation to walking activity. The patients felt under surveillance and supported by health professionals and they felt helped by their next of kin. Even though not all aspects of motivation were entirely intrinsic they seemed integrated. Thus, the patients felt motivated and engaged in walking activity.ACS, acute coronary syndrome; CR, cardiac rehabilitation; CTR, cardiac tele-rehabilitation; PHR, personal health record; RN, registered nurse; SDT, self determination theory


Empathy is an outcome-relevant physician characteristic and thus a crucial component of high-quality communication in health care. However, the factors that promote and inhibit the development of empathy during medical education have not been extensively researched. Also, currently there is no explicit research on the perspective of practicing physicians on the subject. Therefore the aim of our study was to explore physicians’ views of the positive and negative influences on the development of empathy during their medical education, as well as in their everyday work as physicians.We administered a written Qualitative Short Survey to 63 physicians in seven specialties. They were able to respond anonymously. Our open-ended question was: “What educational content in the course of your studies and/or your specialist training had a positive or negative effect on your empathy?” We analyzed the data using thematic content analysis following Mayring’s approach.Forty-two physicians took part in our survey. All together, they mentioned 68 specific factors  from which six themes emerged: 1. In general, medical education does not promote the development of empathy. 2. Recognizing the psycho-social dimensions of care fosters empathy. 3. Interactions with patients in medical practice promote empathy. 4. Physicians’ active self-development through reflective practice helps the development of empathy. 5. Interactions with colleagues can both promote and inhibit empathy through their role modeling of empathic and non-empathic behavior. 6. Stress, time pressure, and adverse working conditions are detrimental to empathy development.Our results provide an overview of what might influence the development of clinical empathy, as well as hypothetical conclusions about how to promote it. Reflective practice seems to be lacking in current medical curricula and could be incorporated. Raising physicians’ awareness of the psycho-social dimension of disease, and of the impact of peer influence and role modeling, seems promising in this regard, too. Stress and well-being seem to be closely related to physician empathy, and their modulation must take into account individual, social, and organizational factors. Further research should investigate whether or how these hypothetical conclusions can deepen our understanding of the determinants of physician empathy in order to help its promotion. S9),,9]; shorIn contrast to the aim of fostering empathic interaction with patients, a recent systematic review by two of this article’s authors and other colleagues has described a statistically significant decline in the self-assessed empathy of medical students and residents in 16 of 18 studies from 1990 to 2010 . They id• entering the clinical practice phase, including patient contact, and• stress on the part of students and residents.MEDLINE search conducted via MEDPILOT (http://www.medpilot.de), last updated on September 19, 2013, and using the syntax (empathy OR compassion OR sympathy) AND  AND (doctor* OR physician* OR student*) AND  OR (data AND collection) OR ), did not yield any result for explicit research on the perspective of practicing physicians.While changes in empathy during medical education and the effects and components of physician empathy have been reviewed and described in detail in earlier research ,29, therBecause there was no systematic research on the physician-specific determinants of clinical empathy, we designed this study to explore the following question: What do physicians in different specialties experience as promoting and inhibiting the development of empathy during postgraduate training and in their memories of undergraduate medical education?An analysis of physicians’ understanding of empathy, their perceptions of how empathy affects health outcomes, and their identification of barriers to empathic behavior in medical practice was recently published by two of this article’s authors and other colleagues, using additional data from the present study . They idas if they were one’s own. However, an empathic response always includes disentangling one’s own emotions from those of the other person. Sympathy, in contrast, does not entail an emotional separation from the other person’s emotional state and is therefore thought to interfere with clinical objectivity  exclusively  my own initiative, learning by doing” “There were no elements of medical education or specialist training that considered empathy at all.” (no details given)not negatively influenced their development of empathy, for example: A few respondents explicitly stated that their medical studies had “There were neither explicit nor implicit elements of training which taught me that empathy was not desirable.” Maybe for this reason one respondent wondered whether empathy could be taught in medical school or if a person is naturally endowed with it. Another said that empathy is an individual skill that can be taught.Among the factors that the respondents said fostered physician empathy were specific curricular elements of medical education. These had in common that they focused on patient-physician interaction and/or the psycho-social characteristics of a patient. For example, respondents mentioned training in psychology, psychosomatic medicine, or psychotherapy, medical interviewing courses, the subject medical ethics, and attentiveness training. “Training in interviewing!!!” “training in psychiatry and psychotherapy” “training in the subjects of medical ethics, psychology” “In the course of my studies, I took part in ‘attentiveness training’, which also covered the theme of projection; this opened my mind to it”. Additional areas mentioned were general practice, palliative care, complementary and alternative medicine, and salutogenesis.In contrast to patient-centered educational elements, which most respondents considered valuable in fostering empathy, a few physicians mentioned that focusing on scientific facts, diagnostic results, and guidelines negatively influenced their development of empathy. “I find the numerous guidelines and ‘checking them off’ counterproductive .” “Suffering/pain were reduced to scientific phenomena, to be treated pharmacologically.” Another group of factors centered on medical practice and, during undergraduate education, practice-based learning with patient contact. These two factors were perceived as helpful in developing clinical empathy. Respondents described this relationship in different ways and noted, for example, clerkships as medical students or daily practice as physicians. Also, interdisciplinary cooperation and constructive communication with patients were perceived to foster physician empathy. “during training … what the patient wanted to tell” “critical feedback from patients” One participant also emphasized that patient contact on a personal level was a positive factor, while two physicians said that patient contact was a barrier to the development of empathy. One said that his intensive care training required maintaining distance from patients in order to remain functional; the other had experienced disappointment when patients neglected her level of commitment to the patient’s well-being.This theme comprises the extracurricular activities of respondents which they reported improved their empathy. Because these activities were not required by the formally endorsed medical curriculum, respondents took part on their own initiative. One respondent even emphasized that his empathy development was “exclusively  …[his] own initiative” . These extracurricular activities were characterized by reflection and active self-development. For example, some reported conducting active reflection on biographies and psycho-social conditions of patients, or on the interactions they observed between colleagues and patients. Others spoke of both reflection and active self-development, such as Balint group participation and discussing end-of-life questions as part of a working group. “self-organized student history-taking group student self-examination course interviewing course in psychosomatic medicine Balint group encounter group in child and adolescent psychiatric training … project leader of the children’s hospital working team in the death and dying project at [name of hospital]” “being supervised, and development of my own personality” Respondents also mentioned other non-medical private, academic, and religious experiences as supporting the development of empathy, such as “encounters with experienced, wise individuals”  and “general studies, attending lectures on other subjects, such as psychology” (no details). One respondent stated: “My empathy is more closely connected to my Christian perception of human beings.” In this theme we summarized the emergent impact on physician empathy from interactions with colleagues, teachers, and superiors.Physicians viewed colleagues who demonstrated empathic and considerate behavior towards patients as role models with a positive influence. Colleagues who did not demonstrate such behavior, or who were cynical and detached were perceived as negative role models. The descriptions of role modeling seemed especially vivid. “experienced colleagues who cultivate an empathic manner with patients” “During the studies and training, we were frequently instructed: ‘Try to put yourself in the patient’s situation”’. “Examples of empathy were … provided by colleagues/superiors, who set both positive and negative examples.” “rather, many other colleagues  who were not responsive to their patients and their problems ” “cynicism and [physicians who saw] patients as fodder for [clinical] trials” The respondents also mentioned other ways in which physicians influenced each other. Professional exchanges, learning from one another and a non-hierarchical and cooperative interdisciplinary working style were perceived as positive. In contrast, “hierarchical structures instead of teamwork on eye level”  were viewed negatively. In addition, physicians valued expertise and high-quality teaching as helping them practice empathy, e.g., good clinical teachers and exemplary lectures. Correspondingly, “bad instructors”  were not viewed as helpful.A group of adverse conditions for the development of physician empathy centered on stress at the workplace or during medical school. Respondents reported that pressure to perform, competition, “cramming for exams” , being overworked, exhaustion, or simply “the general stress in hospital”  all had a negative impact on their empathy or its development.Additionally, in their comments on working conditions, nine of our 42 respondents mentioned lack of time and time pressure as inhibiting empathetic behavior. Sometimes, the time factor was mentioned in relation to other working conditions, thus making a connection between environmental factors and the respondent’s internal condition: time pressure [italics were simply underlined in the original] and the number of patients, [it is] not possible to be empathic towards parents and patients.” “Frequently, because of “Because of time pressure caused by the health care system and hospital practice conditions, my patience is often put to the test and strained; an impatient and rushed physician is the opposite of empathic.” Only one participant mentioned that having enough time had helped her develop or maintain empathy.Bad time management and other aspects of workplace organization and structure were perceived as negative, too, for example: “Time taken up by tasks that are far away from the patient  is not available for deepening empathetic approaches.” “The medical health care system in Germany hardly allows it.” This study explored physicians’ perceptions of what promoted and inhibited their empathy development, and what was influential in the course of their training and medical education. The respondents to our survey mentioned various factors related to the medical curriculum, including some of its subjects, regular contact with patients, interactions with other physicians, their own reflection and active self-development, and workplace organization and structure. We have summarized these main themes with specific examples in Figure From these results, we reach two hypothetical conclusions: 1. The “complex, multi-dimensional concept” of empathy [2. A number of factors can be a starting point for the promotion of clinical empathy.In the following subsections, we further elaborate on these conclusions.Medical education should aim to develop clinical empathy and professionalism ,24,26-28Some physicians did mention positive aspects of the formal medical curriculum. Yet these were mainly located “on the fringe” of the curriculum, addressed as ways to teach communication between physician and patient and including a discussion of psycho-social issues. Examples are communication and attentiveness training, medical ethics, complementary and alternative medicine, and training in psychology/psychiatry/psychotherapy. Of the core medical subjects, general practice and palliative care were mentioned as positive influences on the development of empathy. The respondents did not mention other disciplines—e.g., internal medicine, surgery, or pediatrics—as either positive or negative, although we had asked them to consider any aspect of their medical education.Qualitative research with medical students on factors influencing their empathy also found that some “fringe subjects” provided a positive influence—e.g., “classes on empathy and ethics” , “too strict adherence to guidelines” , and the reduction of pain and suffering to scientific phenomena were negative influences. In contrast, education fostering a focus on physician-patient interaction and psycho-social aspects of care were described as promoting empathy. Could an cing it” . And a rcing it” . Medicalcing it” . This coThere are a number of limitations to our study. First, the written, semi-standardized survey did not allow for the interpretation of hidden meanings, which would have required more in-depth data collection and analysis. Interviews would likely have produced more complex and nuanced results because they would have allowed us to explore the relationship between medical education and its impact on physician empathy in greater depth. However, the data produced by interviews would have exceeded the exploratory character of our study. For those reasons, our findings cannot be the basis for theory-building but instead produced hypothetical conclusions .Also, our survey question was based on the assumption that physician empathy is influenced by specific elements during medical training in either a positive or a negative way. This limitation might have excluded other important influences on our respondents’ empathy. Still, many participants expanded in their responses on the factors they believed influenced the development of empathy.A third limitation is the fact that our sample was generated from the researchers’ network and the respondents represented only four disciplines. On the one hand, this sampling procedure might have generated a generally positive self-selection bias towards clinical empathy and excluded vital experiences of other types of physicians.On the other hand, it elicited responses from physicians in both in-patient and out-patient institutions, and it achieved a good response rate of 67%, which certainly broadened the scope of our study.A second advantage was collecting the data anonymously; anonymity encourages respondents to answer questions honestly, rather than in ways that are deemed “socially acceptable” .Third, our study seems to be the first that explicitly asked physicians for their view on the determinants of empathy development during their medical education. In addition, while many studies have treated physician empathy as completely separate from the biomedical side of medicine, or have focused on the influence of the “informal” or “hidden curriculum,” or on negative influences within the formally endorsed medical curricula ,53, we iFinally, our results show parallels with existing research, and our hypothetical conclusions are valuable as an empirical basis for future research and possible implications for practice.In what ways might our conclusions be incorporated into ideas about medical training in order to improve physician empathy? Certainly the elements of the curriculum that are intended to foster good physician-patient interaction and to include psycho-social aspects of care should be used more extensively. (A complete list of those elements mentioned in our study is included in the coding scheme in the Additional file However, when considering specific interventions to enhance empathy development, it might be wise to include learners’ individual needs in such approaches and base them on experiential learning ,2. For ePractice-based training is very likely to have an important influence on the development of empathy, too. Special attention could be given to longitudinal care for the chronically ill and the disabled ,67, in oSuch approaches, together with self-awareness training, the especially well-researched mindfulness-based stress reduction, and coaching/mentoring on a personal level could also be promoted to reduce stress and its detrimental effect on physician empathy ,58,67,70There is still a need for more empirical research to define the ways in which empathy can be promoted and how we can create a “culture of care” . Both thThis study is an exploration of the physician’s perspective on the determinants of clinical empathy during medical education. Our most important finding is that influences on the development of physician empathy probably include a wide field of factors—curricular, social, organizational, and individual. Our results identify main themes and manageable practices that seem to influence empathy. These are good starting points for the development of theories, and for the investigation of sound interventions to improve physician and medical student empathy. The ultimate goal is better quality of care and quality of life for both physicians and patients.The authors declare that they have no competing interests.FA helped to transcribe the responses, analyzed them, developed the hypothetical conclusions, and wrote the manuscript. MN and CS planned and conducted the study and supervised FA in his research. HG revised the manuscript critically for important intellectual and methodological content. EGH was involved in the counseling of FA on medical education issues, and revised the manuscript for important intellectual content. All authors reviewed the manuscript and approved of the final version.FA’s medical dissertation on medical education and clinical empathy.This publication is part of The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/14/122/prepubAppendix. The Appendix contains a translation of the questionnaire we administered, the original questionnaire in German, more quotations from our survey, the original quotations in German, and the coding scheme we used.Click here for file


This review article addresses the process, intention, and therapeutic value of clinical hypnosis with children and adolescents. A brief historical perspective is followed by a digest of the published laboratory and clinical research that has accelerated substantially over the past two decades. This review lends appropriate credence to the benefits and integration to clinical practice of this powerful tool for teaching young people self-regulation skills. The breadth of application is described, and several clinical vignettes are provided as examples of what is possible. In addition to the provision of the most relevant citations in the pediatric, psychological, and neuroscience literature, this synopsis concludes with information regarding availability of skill development training in pediatric clinical hypnosis. The review that follows is designed to be a panoramic snapshot of the current state of the art, science, and clinical practice of child hypnosis and hypnotherapy. While substantial reference resource material is provided and clinical examples described, this is nonetheless a synopsis, and readers are advised and strongly encouraged to consult the resources and to avail themselves of “hands-on” skill-development workshop training to develop skills necessary to begin helping children with clinical hypnosis.From a backdrop focus on societal and cultural beliefs and norms to a context of fostering respect for the child’s creativity, imagination, unique perceptions, and choices.on the individual to an interactive, dynamic “dance-like” experience between two individuals, with the clinician sometimes “leading” and other times “pacing” while the child leads.From the view of hypnosis as a ritual completed by an authority figure i.e., physicians and psychologists, to the broadened utilization by and contributions from various types of health care providers with advanced degrees.From the use, writings, and research by a select group of clinicians, From apprenticeship learning at the bedside of highly specified hypnotic techniques to the richness of multi-modal and multi-sensory training within a group setting, based on research about adult learning and skill acquisition, emphasizing the multiple paths toward similar clinical goals.From definitions based on the fixed views and narrow theoretical concepts of a few to the fertile exchange by many within a global community.all patients to open-ended, permissive, and individualized suggestions utilizing the specific needs, resources, and interests of each child or teen.From precise suggested commands applied rigidly to From making conclusions and generalizations about the hypnotic experience based solely on behavioral observation to incorporating double-blind research studies evaluated in Cochrane reviews and state-of-the-art neuroimaging to correlate with the varying types of hypnotic behavior.The field of pediatric hypnosis has blossomed in many ways and directions over time:In ancient times hypnotic-like techniques were utilized in healing and other ceremonies . , the British Surgeon John Elliotson (1791–1868) who also introduced the stethoscope to Great Britain, James Braid (1795–1860) who coined the word hypnosis, and Jean-Martin Charcot (1835–1893) whose descriptions of hypnosis in neurological terms gave it a new measure of scientific respectability. Of import, Liebault 1823–1904) and Bernheim (1840–1919) founded the School of Nancy devoted to the scientific investigation of hypnosis and described the first research on children’s hypnotic susceptibility, describing over 750 subjects and the peak “susceptibility” thought in those days to occur between the ages of 7 and 14 years  tFor a detailed and wide-ranging description of the myriad of clinical conditions for which hypnosis is applicable and effective in children and youth, readers are encouraged to consult the two standard texts in this field, Kohen and Olness’ 2011 fourth edition Hypnosis the Hypnotherapy with Children .Additionally, we refer to the following et al., (2012) [et al., (2007) [et al., (2006) [et al., (2008) [et al., (2013) [The value of brain imaging in amplifying how hypnotic suggestions impact mental and physical experience is described by Lifshitz, Cusumano, and Raz (2013) . It is a, (2012) , Gold et, (2007) , Landier, (2007) , McClaff, (2007) , Rickard, (2006) , Schnur , (2008) , and Uma, (2013) .The remainder of this paper offers several case vignettes to illustrate common applications of hypnosis and hypnotherapy in every-day child and adolescent health care. These case examples also demonstrate the nature and value of these empowering hypnosis strategies for children who previously struggled substantially before developing various self-regulation skills:J. is a 9-year-old fourth grader who presented with a long history of anxiety about not measuring up to his own very high standards. This was associated with poor emotional and behavioral self-regulation when frustrated and disappointed with his mistakes, which was particularly detrimental when playing his beloved sport, baseball. Despite his Dad’s coaching tricks to let go of these feelings, he typically needed to be assisted off the pitcher’s mound due to uncontrollable tears, kicking the dirt, and hitting himself with his glove. He was unable to “regroup” from this marked emotional and behavioral disintegration and the sobbing continued, resulting in reduced playing time, embarrassment, and later regret and further anxiety.how they accomplished past mastery experiences.As with all initial encounters with new patients, developing rapport with the child and parents is critical to the process and outcome of the treatment. Similarly, the clinician learns the child’s personal and family history, and assesses motivation, expectations, strengths and other internal resources, such as capacity to accurately discriminate or interpret a situation and to self-regulate their emotions, thoughts, and behavior in other areas of their life. Time is spent to appraise the child’s understanding of the “problem” as well as per se and discussion and demystification of hypnosis may not take place until subsequent visit(s). Given this child’s strong interest in sports, the clinician linked the explanation about hypnosis to references about top athletes’ learned skills in focused attention, mental rehearsal, and being “in the zone”. She emphasized that “learning to do ‘self-hypnosis’ like those athletes do will certainly help his game”.While there may be some exceptions, the more formalized introduction of hypnosis Children in this age range are particularly receptive and responsive to hypnosis. The clinician capitalizes on this developmental phase, by utilizing the child’s expanded attention span, intellectual curiosity, motivation to master new skills, capacity to understand and create metaphors, and the ability to access memories of the past and to richly imagine the future.This child saw his “hypnosis coach” weekly for several sessions, during which hypnosis was incorporated into other interventions, including Cognitive Behavior Therapy (CBT) to address his faulty beliefs and perfectionism, computerized biofeedback to enhance his psycho-physiological reactivity, and parent counseling to shift from their sense of helplessness to learning how to support their son’s own growing capacities to dampen strong emotions. He also kept a calendar to record his improving self-regulation skills, using a scale from 0 to 10 to indicate level of control over behavioral outbursts.When designing a hypnotic or hypnosis trance experience, the clinician “utilizes” the child’s interests, capacities, and goals. J’s notable strengths included his passion and knowledge of baseball, his overall congenial personality and sportsmanship, and his motivation to gain self-control. Given his pronounced passion for baseball, the child and therapist made an agreement: He would teach her baseball terms and she would teach him “tricks” to improve his self-control and focus during baseball games. Accordingly, sports terminology, the self-calming rituals of his favorite star ball players, and his capacity to focus his attention were incorporated into therapeutic suggestions. In this regard, J. was asked to “teach” the clinician about sports slang and to tell some stories about key players. This language and information became “hooks” woven into suggestions during the hypnosis work.For example, the phrase “on to the next one!” was introduced to J. as self-talk, an immediate inner response, to dissociate from any personal errors during the game and to sustain positive expectations. He also learned to “turn off the faucets” just before each practice and game, in order to control his past tearful responses and to regulate his intense emotional reactivity to mistakes. While he imagined playing a close game, he was taught to pair or link a calming breath with the touch of the ball when pitching, bat when hitting, and base when running.loser by being tricked by curve balls inside his head that were stealing his attention, focus and control. First, he found a specialty coach to work with on his mental game during his spring training and he found immediate relief with the assist of calming breaths. Second, he taught himself to throw away any errors that were running around in his head, in order to quickly catch on to practicing new plays. Third, he worked hard on drills to line up his new strategies in his mind. Before the end of his inner strength training, he struck out the old disappointment and frustration that had fouled up his game. He became a champion as a triple threat with his MVP—Most Valuable Playing—with full attention, focus, and self-control. Watch him keeping his eyes on the ball, instead of bawling!He was also told a metaphoric story about a boy who decided it was time to no longer feel like a This story was recorded and given to him, with instructions to listen to it daily as part of his ongoing practice doing self-hypnosis exercises to foster calmness and an enhanced capacity to modulate his emotions when coping with normal, every day “hassles”. In subsequent sessions, the clinician reviewed his progress calendar and added other hypnosis experiences for him to listen to daily.Within a number of weeks, this child showed significantly enhanced self-regulation of his emotions and behavior, both on and off the field. He became an athlete who shared his self-control strategies with his teammates.Almost 10-year-old “Z” was brought by his parents for “issues” of angry behavior and not wanting to do what he is told or asked, occurring exclusively at home. He has had no problems in school or in after-school programs, but acknowledged “issues” with stomping his feet, slamming doors, and defiantly refusing to do things he is “supposed” to do at home, either on his own or when asked.The day before his first visit he had a public tantrum at a local store when his mother said he could not get the toy he wanted. As a “consequence” of his tantrum, he was “grounded” from using his electronic games for a week. His mother reported that she was surprised that he had spontaneously come to her to apologize that same evening before bed. He was surprised and proud when the clinician spontaneously gave him a “high 5!” for that spontaneous apology.how we get angry and how we act, not if we get angry. We are not allowed to hurt people or things when we get angry. The clinician noted Z’s spontaneous focused attention (spontaneous hypnotic trance) and complimented all those other times that you might have gotten angry and did not.During the initial visit the clinician inquired what “issues” Z wanted to work on. He said he did not like the way he gets angry and was surprised when the clinician told him that “feeling angry is okay, everyone I ever met got angry or gets angry sometimes, and then they get un-angry. It is only okay or not okay During the first visit the clinician identified Z’s strengths, including cooperation at school (i.e. no behavior problems or acting out there), great soccer skills, and being a “quick learner”.never wakes up in a dry bed. When asked about the reason for this, they said “because he sleeps too soundly, he’s a heavy, deep sleeper”. When he told the clinician that there was no problem with daytime wetting ever, the clinician purposely and dramatically showed pleasant surprise: “really? Well, that’s going to make this much easier to solve than I thought, we’ll work on this as soon as you know how to manage the angry feelings.” This “waking hypnotic suggestion” was planted as a seed for building upon at a future visit.Almost as an after-thought Z. mentioned that he had an “issue” with his bladder and he and his parents noted that he do this too… Sometimes when I feel angry I just close my eyes or I look inside my mind with my eyes open—either way is fine—and I picture what color and shape angry is…. Let’s see, hmmmm, right now it’s a red square! Then, I imagine or pretend there is a faucet or drain pipe in the side of that square. I turn it on and the angry feeling runs out of my thinking (touching each next part while describing it) down the side of my neck, down my shoulder on my (either) arm and down and around the bend at the elbow and all the way down into the palm of my hand  until all of the angry feeling has filled up my hand. Then I roll it up into a tight fist, take a deep breath and hold it, then as I blow out I throw it away!! (forcibly crumpling up the piece of paper as tight as possible and throwing it onto the floor!). At the end, I look back into my thinking to see the color and shape of comfortable or relief or relaxed…wow, now it’s a yellow circle, smiley face!! Okay, your turn!” He reproduced it, reporting different colors and shapes than the clinician’s. It was suggested that he have a pile of scrap paper in his room to use “as needed”.At the second visit, Z. was taught a hypnotic anger (or other feeling) management strategy called the “jettison technique”. Offering a “personal” example, the clinician gave a blank piece of paper to Z. and one for himself. Without formally mentioning hypnosis, the clinician said “Just listen and watch first. Then you’ll have a chance to dry at night. He was told quite directly that his brain and bladder know each other very well, that they work together great, and are in a good pattern of talking to each other, so much so that he does not wet his pants even if he has to “go really, really badly…” He agreed, and said that what was just described was exactly what he does every day all day except that he does not say it out loud.At the next visit he and his parents reported considerably fewer tantrums and much more cooperation. He asked about getting Z. demonstrated another spontaneous hypnotic state while focusing carefully on a participatory drawing of genitourinary anatomy and physiology, capitalizing on his curiosity about how the body works, and his quick learning.i.e., the brain, when it is full. The drawing showed the brain and bladder connection, with bi-directional arrows communicating between the full bladder and the brain, keeping the gate “closed” until the right time and place.In the drawing, urine was depicted being sent from the kidneys (aka “pee factory”) to the bladder, shown as a “sack with a muscle around it” with a “gate” made of muscle that is closed most of the time, opening only upon signal from the “main computer”, i.e. that his brain and bladder accidentally got into an accidental habit or pattern of not talking with each other at night. Therefore, he has to remind them before he goes to sleep because he is going to be asleep. Since the bladder and brain have perfect communication all day long, they “are already friends and know how to talk to each other, so all you have to do is remind them before you go to sleep.”Z. was taught that nighttime accidents are just that, nice, warm, comfortable dry bed, or, instead tell the bladder gate to stay closed and locked all night until morning, and then wake up happy and proud in a nice warm dry bed” With either choice, the bed is dry in the morning.Z. committed to giving instructions at bedtime to his brain and bladder “taking no longer than 5 min to do so”. “For example, you could say “Bladder, tonight let the brain know when you’re full. Brain, you have a choice: WHEN the bladder says it’s full, tell me to wake up, walk to the bathroom, open the gate, pee in the toilet, close the gate, flush , and go back to my dry, or 91% dryness. His parents were astounded, and he was very proud.Z listened carefully. His parents and he agreed to discontinue using “diapers” (pull-ups) that he had worn—and soaked—nightly. Although they missed the scheduled appointment 2 weeks later, they returned in 4 weeks to report 29 out of 32 nights being totally K. was a 10-year-old fifth grader who asked her parents to see the “special doctor” who helped her good friend get over daily tummy aches while at school when she was away from her Mom. K. wanted to get over her long-time fear of shots. She was also highly motivated to get rid of several large warts on her knees. She was tired of always wearing pants to cover them for fear of being teased.The evaluation showed that her fear of injections met criteria for a Specific Phobia, given her excessive and developmentally inappropriate level of fear reactivity regarding the procedure. Her mother described K’s intense distress and panic whenever faced with this procedure in the past. She begged loudly for a delay, tried to hide in the corner of the exam room, cried and screamed in protest when the nurse approached her. Her screeches “No! No! No!” lasted until some minutes after the administration.Given her panic symptoms of high psychophysiological and emotional reactivity, K. was taught diaphragmatic breathing (aka “belly breathing”) to activate the parasympathetic nervous system . She was urged to practice this new skill several times a day.in vivo” exposure, she was taught self-hypnosis to be used as repeated “imaginal exposure” that focused on her capacity for self-regulation of her body’s “false alarm” that had prompted such strong reactions with her emotions, thoughts, and behavior.Because Exposure Therapy with Systematic Desensitization is the treatment of choice for phobias, K. was gradually exposed to the equipment  and procedure for injections, until those items and “pretend” shot-giving no longer evoked activation of panic symptoms. In addition to this “safe place where she was completely in charge and in control of herself”. She was invited to “just enjoy being there where she could also now turn on a special TV in her mind”. Suggestions were offered “to use your imagination to watch a Mastery Movie on the K Channel. Instead of watching the old disaster film of being out of control while getting a shot, this is a ‘future film’, you are the scriptwriter, the producer, the director, and the star of the show”.Given her gift for creative writing and love of biographies about strong-willed girls who became famous women, she was encouraged to “go to a special as if you are really there: calmly and confidently walking into the waiting room, becoming even more relaxed and completely in control as you enter the exam room. Now notice how easily you deepen your sense of calmness by using your belly breathing and self-hypnosis when the nurse comes in to give the medicine that keeps you healthy. Pay attention to how you go so quickly to your Special Place so you can be more there where you’d like to be, there where you don’t care while the nurse takes care of the arm and the medicine. And, when it’s over, then you’ll be done, so when you’re ready you can now return to your usual alertness and awareness”.She was encouraged to use her five senses to intensify the experience “K was also taught to use self-hypnosis to get rid of “those warts you don’t need anymore”. In each session, she experienced hypnosis so she could “use your imagination and creative mind to shrink yourself down in order to travel inside your body”. She had already been taught about the blood vessels underneath the warts. The suggestion was given to “decide for yourself your own special way to stop the blood supply from feeding the warts”. She heard a few ideas used by other children, such as a rope and lasso, a knife, a detour. Within a few moments her dominant handmade slashing gestures, as if she held a knife. Such ideomotor gestures are common during hypnosis.K. practiced her self-hypnosis three times daily for two weeks, re-enacting the “scenes” elicited above. Upon return the warts were notably smaller, and she indicated readiness for the needed immunization. Two weeks later she returned again, wearing a lovely skirt, and proudly announced her successful experience with that immunization procedure. The warts were gone.W was 15-2/12 at the time of her first visit. She was referred by one of her two pediatric neurologists for help with chronic, daily, severe headaches.A detailed history was taken, revealing headaches since early childhood that increased in frequency, duration, and severity over time. There was a very strong family history of migraines. Over the years, she was evaluated by many physicians at various clinics and hospitals for the continuing severe headaches triggered by “lack of sleep/water, MSG, scents, physical activity, thinking, breathing, living in general.” Diagnostic testing for autonomic dysfunction revealed no positive results. Interventions included multiple medication trials, and a recent three-month intensive inpatient rehab program that involved a comprehensive and multi-modal approach: physical therapy, “group biofeedback”, relaxation including diaphragmatic breathing, listening to music, meditation, progressive relaxation, distraction, socialization with games, reading, movies, peers and positive self-talk, and an agreement to avoid opioids and daily pain medications. There was no mention of hypnosis.W.’s academic history was marked by absence and numerous changes in locations and types of schooling.assessment scale to measure pain severity scale was also used therapeutically. Using an agreed upon range of 0–12 , her average was eight. Surprised with the question: “What would you prefer?” she replied, “Four or less but I don’t think zero would be a good idea because I do feel I have this for a reason and it has enabled me to meet people.” When asked the last time it was zero she indicated “before it became daily 17 months earlier”.During the initial visit, the typical re-framing idea that it is zero “whenever you are asleep” and in a purposely constructed “waking hypnotic suggestion”, the clinician said “So, all we have to do really is find out how to move the file in your brain called no headache from only at night to also when you’re awake”. As with most patients with chronic recurrent pain, the clinician introduced the possibility of change while simultaneously assessing motivation through the use of embedded suggestions with carefully selected wording in the following questions:Will you miss the HA’s when they’re gone? ➔ “No.”Is there anything good about the HA’s? ➔ “No”Do you need them for anything? ➔ “No”Do you think you have had them long enough? ➔ “Yes”The clinician gently corrected her by offering a shift her focus from over-investment in her pain to positive expectations for self-healing. W. agreed to keep a written HA diary, and was given a therapeutic suggestion “to track the reduced frequency and intensity. The clinician also asked W. if she “needed to find or know the “reason” for the HA if she could find a way for it to not bother her”, and she said she did NOT need to know the reason. Of course had she said she did need to know the reason, additional and alternative clinical approaches would have been the appropriate next step.Given W.’s very chronic and severe headache history without relief despite multiple interventions, the clinician then set a therapeutic goal to help her help herself, that everyone whom he had ever met with a HA problem had gotten better without exception, and that she was invited to leave all past, present, and future headaches in the clinician’s file cabinet. She laughed.During the initial visit, multiple therapeutic seeds of “waking suggestions” were planted for her consideration, including (1) pain is pain, suffering is optional; (2) pain is a signal, nothing more, nothing less; and (3) when everything that can be done and should be done, has been done, there is no reason for pain to bother. At the end of this visit the clinician again evoked positive expectations when telling W. that he was absolutely sure he could other young people got rid of their HA’s….I knew this one 12-year-old boy who had migraines and he used the idea of being on an elevator, so if he had a migraine that was a ’10’, he’d push the button to ride down to nine, and then the light would go off at 10 and on at nine, and then eight….and then . . . . . . six or five . . . . . and . . . then . . . . all the way to one or zero,” I met this one little girl who was only five; and she had a stomach-ache problem and she didn’t like elevators, so what she did in her imagination was imagine being on a water slide; and the 12 was at the top and the zero was at the bottom in the cool refreshing water, and whenever she had a tummy ache she would get on the water slide in her mind and zooooommmm down from 11-10-9-8-7-6-5-4-3-2-1-splash! A few years ago, I worked with a 17-year-old young woman, with migraine problems, who rode horses. To control her migraines she’d imagine riding on the beach with the horses’ hooves gradually erasing the zero–12 numbers in the sand. And, of course, when it got to zero it stayed there. I don’t know which of those stories you’ll use, or maybe some combination, or probably you’ve already come up with a couple in your own mind from your experiences. And, like everything, the more you practice, the better you’ll get. Whichever works best for you is the best for you.”At the second visit, training in hypnosis and self hypnosis began with viewing a couple of videos of youngsters both talking about and doing self-hypnosis. Induction (initiation) of hypnosis was easily accomplished with “favorite place imagery”. Suggestions for multisensory imagery along with progressive relaxation served to intensify (or “deepen”) the hypnotic experience. To amplify that self-hypnosis training emphasizes personal choice and self-control, therapeutic hypnotic suggestions for controlling HA were offered as a “menu” from which W could choose. For example, she was told “I don’t know how you will lower those HA’s that used to be there more, but somewhere in your inner mind you know how because you want to be and can be the boss of those HA’s instead of them begin the boss of you. I’d like to tell you some stories of how W. practiced self-hypnosis a couple of times each day as suggested. She improved gradually. She agreed to also keep a concurrent diary of “How am I dealing with it?” ratings, with zero = dealing with it best, and 12 = worst. W. soon reported much less use of medication for “severe” HA, and decrease of migraine prevention and anxiolytic medications.stunned it is astonishing… I never thought I could do it… you know, change my body with my mind. I did continue what you told me to do, so I imagine being at the cabin, and reading and then I swim in the lake and the closer I come back to shore the lower the number of my HA is and when I get to shore it’s fine!”By the middle of the following school year she was substantially improved. Nine months after the first visit, W. reported that her average HA rating was now down to 3.6 (from average of 8.5) and her “dealing with it” had improved 23%! to 2.3 With the intention of increasing her awareness of and empowering her own abilities the clinician asked W. “How did you DO that?” She replied “I am and common responses to hypnotic interventions, it is essential to note that not everyone responds so positively and so quickly. Like any strategic therapeutic intervention, positive rapport is essential to good clinical work, and ongoing re-evaluation, flexibility, and engagement in brainstorming with patients and families are fundamental to ultimate progress, problem resolution, and healing.While the foregoing cases are representative of common conditions versus interference, and encourage children and youth to come to appointments with their hypnosis and not only for it. Not unlike other therapies, however, inconsistent follow-up appointments and/or inconsistent attention to home rehearsal are potential contributors to less than desired outcomes.As with any clinical intervention, treatment with clinical hypnosis is not without obstacles or roadblocks. As with any skill, rehearsal (“practice”) of self-hypnosis skills enhances competence, confidence, and positive outcomes whereas absence of regular rehearsal is more likely to result in slower and/or less positive results. We give “homework” assignments involving practice of self-hypnosis, counsel parents about their level of involvement etc.) [For some children’s problems—as noted in the foregoing tables, hypnosis may be clearly the treatment of choice  and have the best “track record” compared to what might otherwise have been considered “traditional” approaches to that problem. By contrast, for other problems/conditions  hypnosis may be clearly more adjunctive, but nonetheless highly valued as an important ingredient in an overall management plan  ,30.Hypnosis should not be utilized for entertainment. As we have discussed and illustrated, hypnosis is a very effective clinical tool; and often may have powerful and dramatic positive effects on medical and mental health. We strongly advocate against the use of hypnosis for public entertainment as is seen commonly during high school graduation parties.Hypnosis should only be used by clinicians trained in the appropriate use of hypnosis and hypnotherapy and within the scope of their clinical practice. Thus, while hypnosis/hypnotherapy are very appropriate and useful adjuncts to help children with anxiety and/or discomfort during dental work, it would of course be unethical and inappropriate for a pediatrician or a psychologist who has learned hypnosis to start doing dental extractions! Of course it would be appropriate for those professionals to teach their clients how to use self-hypnosis WHEN they go to the dentist).There are a few absolute contraindications to the utilization of hypnosis with children, and several more relative contraindications .HypnosiHypnosis should not be used to treat a condition for which there is already a fundamentally appropriate, acceptable, accessible, and effective treatment. One example might be strep throat. Or appendicitis. Of course, however, one might well learn self-hypnosis to help allay anxiety or discomfort associated with having a throat culture; or learn methods of control of anxiety, discomfort, and return of normal bodily functions pre- and post-operatively for an appendectomy.Hypnosis should be tailored to the developmental level and capacities of the individual child. Designing a hypnosis session to address clinical anxiety for a six-year-old would be very different for a nine-year-old. Typically, developing toddlers and those children with significantly impaired intellectual and language abilities and limited capacity for internal absorption would benefit from repetitive sensorimotor stimuli known to induce a calmer, steadier state of comfort, such as rhythmic rocking, patting, swaying, or music.Analogously, though hypnosis can be a very helpful tool in treating posttraumatic stress disorder (PTSD), clinicians who learn hypnosis yet have no specialized training in treating children with PTSD should not start offering hypnosis for PTSD.caveatnotable  that the involved experienced pediatric clinicians were very well trained in pediatric clinical hypnosis before they began to apply these skills in their clinical work.While this article is intended to be an overview of the value of clinical hypnosis in children, it is neither a “HOW to do it…” nor a manual or a written suggestion to imply that clinicians reading this article can now go to the office and begin using hypnosis. Quite the contrary, even the case illustrations noted carry the It is our hope and intention that the foregoing will serve as a stimulus for further study, inquiry, and most importantly, for appropriate clinical skill development through training by licensed health care professionals. Pediatric-specific didactic presentations and experiential learning through supervised practice by licensed pediatric professionals are essential to the development of the expertise required to help children and families help themselves through the learning of self-hypnosis in fostering self-regulation abilities and other internal resources, as well as symptom reduction.As briefly noted earlier, starting in 1987, a cadre of multidisciplinary faculty of licensed health care professionals began teaching what has become the longest-running pediatric clinical hypnosis workshop training in the United States, sponsored by the Society for Developmental and Behavioral Pediatrics (SDBP). Beyond those twenty-four years of workshops, the enduring and growing Faculty initiated the National Pediatric Hypnosis Training Institute (NPHTI = nifty!) in 2010 which continues to provide the tri-level pediatric hypnosis training workshops annually. Over the past 4 years over 400 child health professionals with graduate degrees have availed themselves of the NPHTI skill development workshops. These past participants, representing over forty states in the U.S.A. and seven foreign countries, include pediatricians, pediatric subspecialists , pediatric psychologists and child and adolescent psychiatrists, pediatric social workers, marriage and family therapists, Child Life Specialists, advanced practice pediatric nurses , and pediatric occupational therapists and physical therapists.www.nphti.com).NPHTI is a rapidly growing professional organization open to inquiries from licensed professionals with advanced degrees and would be pleased to welcome qualified applicants to future training. (See