Myalgic encephalomyelitis (M.E.) has been very little discussed in the hypnosis literature. The many books on clinical hypnosis deal with pain, cancer, obstetrics and dentistry (to name a few) but no mention of M.E. The popular book on M.E. by Dr Charles Shepherd, entitled Living with M.E. , dismisses the use of hypnosis in two brief paragraphs, arguing that it may be useful in dealing with the emotional difficulties of M.E. but not with M.E. itself. Such a dismissal of the use of hypnosis in dealing with M.E. is unjustified. Yet a more recent book by Joyce Fox entitled Surviving M.E . makes no reference to hypnosis whatsoever! Undoubtedly it can be used for the emotional difficulties attached to M.E., but it can also be used to help M.E. sufferers deal directly with their problems. It is this aspect which is emphasised in this article.
The number of M.E. sufferers is increasing, and the medical profession at the moment has little to offer them. The fact that a person can suffer from M.E. for many years, sometimes up to ten or more years, with little comfort from the medical profession is itself disheartening to such individuals. As with other difficulties, sufferers of M.E. are turning to hypnotherapists for help. In this article just one particular approach is offered as a possibility. The approach is eclectic for the obvious reason that the cause of M.E. is unknown at the present time. Some of its obvious symptoms are clearly visible: the most conspicuous being muscle fatigue and being unable to concentrate for any long periods of time. Given this lack of knowledge, then only the symptoms can be dealt with in any positive way. Even so, the approach does allow the individual themselves to take some control over their own rehabilitation. This is important. M.E. sufferers tend to be ignored and left to fend for themselves, and yet are given little guidance in what to do in this regard B except to rest. This is the typical passive role of the patient in traditional medicine. But individuals want to be, and can be, more directly involved in their own improvement.
To use hypnosis in dealing with M.E. it is important to have some idea of what M.E. sufferers go through. This is essential for two reasons. First, the approach needs to deal with the two basic characteristics of the problem: namely, muscle fatigue and loss of concentration. Second, the approach needs to emphasise the role of the client. If the problem is going to be around for many years, then the approach needs to be one which leaves the client capable of handling the situation themselves and not attending therapy every week (not least because the average sufferer could not afford it).
In the next section we outline a case history B a typical M.E. suffer. It was based on Robert's (not his real name) treatment that the approach taken here was devised. I am grateful to Robert for the long discussions about his problem and his views on M.E. Although no two persons are alike, the symptoms of M.E. appear to be fairly consistent across individuals. To see this the next section gives a general outline of what typically M.E. patients go through. The final section deals with a treatment plan. In line with the Journal's policy, Robert kindly agreed to give his own views on the approach taken here.
A Case History
Robert was a very fit 39 year old. Running two miles twice per week, weight training three or four times per week and was very rarely ill. This exercise was to balance his demanding job, which was very much mental.
Aching in the joints began in 1991 but he put this down to the exercise. As the following year progressed the aches in the joints increased and there was more frequent pain. During this year he was working excessively, with work related stress occurring. By 1993 he began to sleep badly and found himself very exhausted on many mornings. Even so, he drove himself on as if quite normal. It was during this year that poor concentration developed, which was occurring on a regular basis. But again, forced himself into effort and trying to perform as normal.
It was during 1993 that he came to realise he needed more rest, fresh air and sunshine. He was feeling overloaded at work and was taking life far too seriously. Although aware of all this, he rarely reduced his workload. In the second half of the year he came to the realisation that his tiredness was related to the way he felt and was not arising because of the exercise. He became grouchy and lacked enthusiasm. His concentration continued to deteriorate and at work became somewhat dull witted and slow. He became progressively more tired and ached all over. Furthermore, he began to look tired. Throughout this year he progressively reduced the amount of exercise he undertook.
During the following year he noted increased tiredness and doziness, with his mind drifting. His lack of concentration now began to concern him, more so because his job required a clear head. His physical symptoms now increased, with more aching joints and more bouts of exhaustion. Eventually he stopped exercising altogether. By April of 1994 he had begun to have a number of memory lapses and was unable to sleep at all well. By June/July of this year he began to deteriorate rapidly, which coincided with major frustration with his circumstances at work. In August of 1994 he was diagnosed as having M.E. but was given little guidance of what to do - other than rest. He began to see me in March 1995.
M.E. usually arises after an acute infection, which can be triggered by something specific or at other times can be traced back to some mild upset. The initial symptoms are like bouts of flu, with general feeling of being unwell and tired. The main symptoms now begin, with occurrences of muscle fatigue and brain malfunction. Both these symptoms increase in intensity with stress. Although generally M.E. develops after some specific infection, for others it just gradually develops.
The symptoms of M.E. can be usefully grouped under three headings:
Muscle fatigue and pain.
Brain fatigue and malfunction.
Responses of the nervous system.
Muscle fatigue and pain
Exercise-induced muscle fatigue is a necessary but not a sufficient condition for the presence of M.E. It is the arms and legs which are most affected, with the legs bearing the main brunt, which become tired merely by the individual standing still for long periods of time. If the individual persists in doing what they are doing when such fatigue is present, then exhaustion soon follows. In a number of cases, severe fatigue leads the individual to be house-bound. Where patients find themselves involved in physical and mental activities they can become very tired. There appears to be no medical solution to muscle fatigue.
Muscle pain (myalgia) affects about three quarters of M.E. sufferers, and can become the most prominent feature of the illness. It can also become the most distressing. It often starts in the shoulders, neck and chest and then generalises. Another common feature is muscle twitching, which can occur in any part of the body (i.e., in both the large and the small muscles). It varies throughout the day and is often associated with bright light. It is, however, intermittent.
Brain fatigue and malfunction
These are a major part of the illness and vary according to exertion. Mental malfunction can be devastating to individuals whose work is largely mental. The two most common signs are (a) loss of concentration, and (b) loss of recent memory. Very few M.E. patients can carry on a mental task beyond thirty minutes, and this can often be much shorter.
The typical problems patients encounter are:
switching words - usually their opposite;
inability to remember familiar words;
difficulty in coordinating legs on stairs or escalators;
deterioration in handwriting when writing a long letter or report.
Such intellectual malfunction fluctuates over the illness.
Responses of the nervous system
It appears that the hypothalamus is affected, resulting in difficulty in maintaining body temperature. The individual can experience severe cold resulting in shivering or can experience night sweats. The resulting overactivity of the sympathetic nervous system can result in a rapid increase in their pulse rate and heart beat. Reduced blood flow to the tiny blood vessels can also occur, which leads to cold hands and feet.
M.E. sufferers can feel faint, especially when suddenly standing up from a lying position. Problems with balance is also common.
In our discussion of the symptoms, and in highlighting Robert's situation, we emphasised the fatigue felt by M.E. sufferers and their lack of concentration. It is essential to deal with these two aspects separately. But we also highlighted an often held view that M.E. is more likely in individuals who are involved in constant stress which possibly has some impact on their immune system. There is little point in dealing only with the symptoms of fatigue and concentration. It is also necessary to aid the individual to change their life-style and either reduce stressful situations or provide better coping strategies for handling stress.
The treatment plan has eight elements to it as follows.
Establish the individual's circumstances.
Establish the person's life-style, especially prior to the on-set of M.E.
Train the individual to enter trance and to utilise imagery.
Establish imagery to represent the individual's immune system.
Establish a variety of images for building up energy.
Teach the individual self hypnosis.
Discuss a possible new life-style.
Construct an individualised set of tapes.
Some comments on each of these elements are necessary.
1. Establish the individual's circumstances . This is the case history. It should deal with their treatment, if any; the symptoms they have and their present copying strategies.
2. Establish the person's life-style . Again, part of the case history. It is necessary to establish their work/family situation when M.E. began. Emphasis here is on the degree of stress they were under and whether they felt they were not coping with the stress.
Comment: It is possible to establish this information over a number of sessions. It is important to establish trance and begin to provide the M.E. sufferer with new possibilities. They are likely to be quite negative, especially if they have been suffering for many years, and so positive suggestions at an early stage will be beneficial.
3. Entering trance and utilising imagery . The client must be trained to enter and deepen the trance. This is no different from any other hypnotherapy. What this therapist emphasises, however, is imagery and so a number of basic images are pursued to establish the individuals most effective mode of imagery. This is an important preliminary step to later therapy. At this stage such images can be used for relaxation, deepening and confidence building.
4. Imagery of the immune system . This is one of the most important parts of the therapy, and may be done in one or two session. The aim is to get the client to imagine their immune system as a sort of regulator, where some of the body's chemicals (or whatever) require enhancing while others require subduing. It is necessary to establish three things.
a) An image of the immune system which is the individual's own image.
b) An image which shows what is ‘normal' or ‘balanced'.
c) An emphasis on the right amount of change at the present moment of time.
This imagery once established to the client's satisfaction should be utilised from then on. Emphasis throughout should be on just the right amount of change .
imagery of immune system
5. Images for energy . It is necessary to raise the client's energy. This can be done by direct suggestion or the use of metaphors, especially imagery metaphors. After trying a variety it will be possible to establish those the client likes or feels comfortable with. The client will need to balance sufficient rest with a sufficient increase in energy. Again emphasis should be on just the right amount of rest and just the right amount of energy.
6. Teach self hypnosis . As the therapy builds up it is essential to convince the client that they are to take control over their improvement and that they can do this through self hypnosis. The client should be trained in this and in the use of imagery.
7. Discuss a possible new life-style . Throughout the sessions the importance of reducing stress should be emphasised. But also the importance of changing their life-style if that is what contributed to their stress and to the on-set of M.E. Training in a variety of coping strategies would be most beneficial.
8. Tapes . The final element is to make a series of four individualised tapes (or 2 tapes with four topics on the four sides). The four topics are:
c) Immune system
d) Change of life-style
The tapes should include all the features established in the earlier sessions , utilising the client's imagery . One important consideration is no tape (or side) should exceed 30 minutes. This is important in the early treatment. Too much concentration on suggestions - consciously or unconsciously - can drain the client's already low energy level. Anything longer will be counter productive.
It is also necessary to keep the themes quite distinct in the tapes. The client can then pick and choose what they feel they require at any moment of time. The first, and most general, can of course be used frequently.
A final observation is worth making. Throughout the therapeutic sessions constant use of IMR's can be very useful. One reason for this is because the client needs to obtain just the right amount of something - whether this be rest, energy, or changes in the immune system. Only the client will know when this occurs, and a simple IMR is enough to indicate to the therapist that he or she can move on. Unfortunately this is not possible in the use of tapes, but sufficient time on the tapes should be allowed for appropriate responses to take place.