April 29, 1996 VOLUME 5 NUMBER 9
By Marsha A. Green
Who among us hasn't been a dentist's chair, a doctor's office, or an emergency room,
awaiting a procedure we fear will be painful and wishing we were anywhere else but there?
Now there are Duke employees who can help you fulfill that wish. During March and April,
30 DUMC employees completed two weekend training sessions in Anodyne Imagery, a technique
that uses communication skills, relaxation, and guided imagery to help patients reduce
their anxiety about painful procedures.
Terry Alford, a former neurosurgery patient a DUMC, says the technique really works.
"My first angiogram was a horrible experience, and I was very anxious about having
another one. AS I waited for the procedure, dreading what was coming, the staff asked me
whether I would like to learn a new relaxation technique to help me get through the
procedure. I said yes and they introduced me to Donna Hamilton."
Hamilton, co-director of the Anodyne Training Center at San Rafael, California, was
visiting Duke at the time to give Radiology Grand Rounds, but agreed to work with Alford.
"I was very skeptical at first," says Alford, "especially when I heard she
was from California! But she showed me how to do some relaxing breaths and then asked me
"Where would you rather be right now? "When I said 'At my cottage on Bald Head
Island' she helped me visualize myself rocking in my chair on the porch. We had a
conversation about the geese I could hear, the salt water I could smell, the breezes I
could feel. She continued this dialogue with me during the entire procedure, and I was
able to relax and enjoy the images while my body underwent the angiogram. The best part
was that I didn't have to have any sedative, so instead of having a two-day hangover from
the medication I felt wonderful by the end of the evening."
"'Anodyne' means to relieve pain or to soothe the mind, "Says Hamilton.
"Anodyne Imagery (AI) is simply a technique for helping patients use their
unconscious mind and their imagination to relieve anxiety and control pain during medical
procedures."
In AI training, health professionals first learn how to approach patients. "Teaching
professionals skills to build rapport with the patients in probably the most important
part of this course," says John Pateros, co-director of the Anodyne Training Center.
"Often, a patient relaxes enough to make the procedure more comfortable simply by
having a sense of trust with the AI practitioner.
"Rapport-building behaviors happen all the time, but we are ordinarily unconscious of
them. AI trains people to consciously modify their behaviors to achieve better rapport
with others. For example, you can lower yourself to the patient's physical level, a
patient's body language and gestures, match the volume and tome of the other person's
voice, and even match his or her breathing pattern. These behaviors create a sense of
trust very quickly."
Once rapport is developed, AI practitioners spend a few moments teaching patients simple
techniques such as relaxation breathing. As patients become more relaxed, the AI
practitioners help focus their attention on something other than the procedure. "We
do this by asking them, 'Where would you like to be now?'" says Hamilton.
"Invariably, the answer is someplace other than a procedure table!"
"We use specific, sensory questions to elicit feedback from patients about their
preferred places," she explains. "We ask them to describe what they are seeing,
smelling, hearing, even tasting. This dialogue continues throughout the procedures we
are actually asking the patients to go to their preferred place with their imagination and
live there for the duration of the procedure."
"Of course, because the patients are not sedated, we can still ask them to change
their position, or to aid us in the procedure in some way, if needed," adds Pateros.
"We keep them fully informed about what is happening, but we frame the information so
that is helpful to maintaining their association with the preferred spot. For example, we
may warn a patient that we will be putting pressure on this leg, but say 'And as you feel
the pressure, you can become more aware of the sensation of the rocking chair beneath
you.'"
AI practitioners also learn to reframe "painful" statements into neutral
statements by coupling the expected painful even with competing sensations. For example,
instead of warning a patient that an injection of anesthesia will sting, the practitioner
can say "We will inject some anesthesia now, and notice how quickly the are becomes
numb. "The training also includes other, more potent techniques for the management of
acute pain during procedures.
AI Training at DUMC
"Last summer Dr. Carl Ravin, chairman of the Radiology Department, funded the initial
Anodyne training with Donna and John, which was limited to radiology personnel," says
Dr. Larry Burk, a radiologist who is the driving force behind Anodyne training at Duke.
"It was successful, and we are pleased that we could repeat the training."
"For the current training we received funding from both Dr. Snyderman and Dr.
Rogers," says Burk. "Dr. Snyderman was particularly interested in the potential
of increased patient satisfaction. "Because of the wider funding, the class was
expanded to include other departments besides radiology. The class of 30 (27 of whom
completed the training) consisted of nurses, physicians, clinical specialists,
technologists, and even Dr. Emil Petrusa, associate dean for medical education.
Petrusa attended the training because he wanted to evaluate whether Anodyne techniques
might be useful for medical students. His answer? A resounding "Yes."
"I saw direct, immediate results accomplished by Duke people who completed the
training," say Petrusa. "Several reports from my classmates exceeded what I
thought was possible. And I heard of no problems with any patients. I believe Anodyne
would be included among the other techniques currently used to increase patient coping and
comfort at Duke, such as therapeutic touch, other relaxation techniques, and spiritual
support."
Benefits to Patients and Professionals
Because the AI technique relies almost entirely upon conversation, the practitioner can
assist in the procedure at the same time.
"We have found that AI does not add extra time to radiological procedures,"
says Burk. "And the benefits are significant. We normally give patients anti-anxiety
medication as well as pain medication, but with AI we can reduce or eliminate the
sedative. That not only lessens the risk of complications, but greatly reduces the
recovery time. In fact, most patients who use AI during a procedure feel quite good
afterwards they have had a good time, wherever they were!" It is particularly
useful for helping claustrophobic patients cope with MRI.
"The training was a big investment of time two full weekends but I got back
more than what I put into it," says Peggy Bridges, a nurse in the Department of
Urology. "I was also particularly interested in this because in the fall the urology
department will be switching from using an in-house lithotripter to an outpatient
lithotripter, so we won't be able to use full anesthesia we will have to depend on
sedation or other techniques such as AI to help our patients cope with the procedure. I
expect to be using these techniques a lot."
Gail butler, and Advancement of Patient Care Systems clinical specialist, agrees.
"Anodyne imagery is great because it is really self-care. The patient can learn it so
quickly that they don't have to rely on others to come in time and time again to walk them
through it."
The participants discovered that Anodyne training is not only useful for their patients,
but also for themselves. "It not only empowers the nurses, technicians, and
physicians. It give them an effective tool to deal with even the most anxious patients in
a compassionate manner."
Not only that, the trainers can use it on themselves. "I'll definitely use these
techniques for relaxation and reduction of discomfort at work or at home," says
Petrusa. "Especially at the dentist's!"
© Inside DUMC 1996: April 29, 1996, Vol 5 Number 9
Duke University Medical Center Office of Publications