Hypnosedation and hypnosurgery

1. Introduction

Version followed: the Liège hypnosedation model (Marie-Elisabeth Faymonville and colleagues, Department of Anaesthesia, CHU de Liège, routine use since 1992), as the group describes it in its papers from 1995 to 2008. Hypnosedation combines three parts: hypnosis, light conscious intravenous sedation, and local anaesthesia infiltrated by the surgeon. The full method sections of the group's clinical trials are not drawn on (only abstracts and the group's French reviews). Induction and language details therefore also draw on later francophone teams (UCL Brussels; French hospital practice) and are tagged as such. [source: Faymonville et al. 2007; Vanhaudenhuyse et al. 2008; Faymonville et al. 1995 abstract; Defechereux et al. 1999 abstract]

What it is. Hypnosedation is an anaesthesia technique for selected, mostly superficial operations: thyroid and parathyroid, plastic, ENT, breast, gynaecological, hernia and vascular surgery, plus burns dressing changes. It is used in place of general anaesthesia, not in place of anaesthesia care. The anaesthesia team still monitors the patient, sedates, and decides when to add local anaesthetic or convert to general anaesthesia. The hypnotic part is a continuous, individualised conversation that guides the patient into reliving a pleasant life experience and keeps them there for the whole operation. In Liège the hypnosis is done by an anaesthesia clinician trained in hypnosis. The group reports more than 6,000 patients by 2008 and a 1% conversion rate to general anaesthesia in its cervical endocrine series. [source: Vanhaudenhuyse et al. 2008; Meurisse et al. 1999 abstract; Defechereux et al. 1999 abstract]

Core idea of change. The patient is described as actively placing themself in the hypnotic state. Absorption in a vivid personal memory takes attention away from the operating theatre and changes how noxious input is perceived. The group's imaging and pain-rating research found that during hypnosis high-intensity stimuli were rated as less painful while low-intensity sensation was largely preserved. Clinically, the group reports less anxiety and pain, lower sedative and opioid needs, greater perceived control, less postoperative nausea and faster recovery than with stress-reducing support alone or general anaesthesia. [source: Faymonville et al. 2007; Vanhaudenhuyse et al. 2008; Faymonville et al. 1997 abstract; Defechereux et al. 2000 abstract]

Who this guide is for. For a psychotherapist, the realistic roles are these:

Preparing and supporting patients before and after hypnosedation.
Teaching related coping skills.
Delivering the intraoperative hypnotic communication only when credentialed by the hospital and working inside an anaesthesia team that keeps clinical responsibility. In the published model this role is held by anaesthesiologists or nurse anaesthetists.

This guide describes the hypnosis practitioner's role only. Selection for surgery, sedation, local anaesthesia, monitoring and conversion are medical and anaesthetic decisions and are named here, not taught. [source: Vanhaudenhuyse et al. 2008; infirmiers.com 2017] [synthesis]

2. Framework

Hypnosedation is a single perioperative episode, not a course of therapy. It has one preoperative consultation and one intraoperative hypnotic session lasting the whole operation, followed by recovery. The Liège team reports giving no hypnotisability test and no prior training sessions. [source: Vanhaudenhuyse et al. 2008]

Phase	Goal	Who leads	Move on when
0. Indication	Decide whether the operation and the patient suit local anaesthesia plus sedation plus hypnosis	Surgeon and anaesthetist (medical decision)	Medical team judges the patient suitable. Patients judged unsuitable or who decline have general anaesthesia [source: Defechereux et al. 1999 abstract]
1. Preoperative consultation	Explain the technique, screen for contraindications, obtain free consent, learn the patient's pleasant memories and preferences	Anaesthetist; hypnosis practitioner contributes the hypnosis part	Patient understands and accepts, a usable pleasant memory or place has been identified, and no contraindication is present [source: Vanhaudenhuyse et al. 2008; infirmiers.com]
2. Theatre set-up	Quiet room, one speaking voice, rapport kept up during IV access and monitoring	Anaesthesia team; hypnosis practitioner starts focusing attention	Patient is settled and monitoring is in place (anaesthesia team) [source: ESA/ScienceDaily 2011; Bernard et al. 2019 headings]
3. Induction	Narrow attention and begin reliving the pleasant memory	Hypnosis practitioner	Signs of absorption appear before the surgeon infiltrates local anaesthetic and starts [source: Faymonville et al. 2007; Faymonville et al. 1995 abstract]
4. Maintenance	Keep absorption and comfort for the whole operation, adapting to surgical events	Hypnosis practitioner speaks; anaesthesia team adjusts sedation and local anaesthesia	Continues until the end of surgery. Discomfort is signalled to the anaesthesia team, which decides on extra local anaesthetic, sedation or conversion [source: Vanhaudenhuyse et al. 2008]
5. Re-alerting	Gradual return, postoperative suggestions	Hypnosis practitioner	Patient is oriented and alert [source: infirmiers.com]
6. Debrief and recovery	Review the experience, consolidate a sense of success	Hypnosis practitioner and ward team	Usual postoperative discharge criteria (medical) [synthesis]

Levels reached. In the 1995 series, "hypnosis" meant patients reached a trance level with age regression (revivification of a past experience). "Relaxation" meant hypnosis was induced but trance was not reached. Both levels still ran alongside titrated sedation and local anaesthesia. [source: Faymonville et al. 1995 abstract]

Session format. The Defechereux et al. abstract calls the hypnotic style "Erikson's method", i.e. Ericksonian, permissive and conversational. The exact Liège induction script is not drawn on here. [source: Defechereux et al. 1999 abstract] [uncertain]

3. Guiding principles

Hypnosis is one leg of a three-part technique. Never offer it as a stand-alone anaesthetic. Local anaesthesia and conscious sedation always accompany it. [source: Faymonville et al. 2007; Defechereux et al. 2000 abstract]
Medical decisions stay with the anaesthesia team. The hypnosis practitioner reports what they observe; the anaesthetist decides on drugs, local anaesthetic top-ups and conversion. [source: Vanhaudenhuyse et al. 2008]
The patient is the active agent. Frame hypnosis as something the patient does ("you take yourself there"), not something done to them. [source: Vanhaudenhuyse et al. 2008]
Free choice, with general anaesthesia always available. Patients who decline have general anaesthesia. Telling patients that switching remains possible relieves anxiety. [source: Defechereux et al. 1999 abstract; infirmiers.com]
No hypnotisability gatekeeping. Liège does not test hypnotisability. Motivation, cooperation and trust in the team are what UCL Brussels clinicians emphasise. [source: Vanhaudenhuyse et al. 2008; ESA/ScienceDaily 2011]
Individualise the imagery. Use the patient's own pleasant memory or preferred place, gathered beforehand, rather than generic scenes. [source: Faymonville et al. 2007; infirmiers.com]
One voice, quiet room. Only the hypnosis practitioner talks to the patient; staff limit conversation. [source: ESA/ScienceDaily 2011; infirmiers.com]
Positive, present-tense, sparing language. Speak little, choose words carefully, and avoid alarming terms and negatives. [source: ESA/ScienceDaily 2011; infirmiers.com; Bernard et al. 2019 headings]
Permissive and open suggestions. Let the patient go where they want in the memory, and follow rather than impose. [source: infirmiers.com; Defechereux et al. 1999 abstract ("Erikson's method")]
Continuous presence and observation. Keep talking through the whole operation and watch for signs of discomfort. [source: Vanhaudenhuyse et al. 2008]
Team choreography. The surgeon works gently, avoids tugging and stays calm. The whole team adapts its behaviour. [source: ESA/ScienceDaily 2011; infirmiers.com]
Perceived control is a therapeutic target. Patients in the 1997 trial reported more control under hypnosis. Give real choices and signals. [source: Faymonville et al. 1997 abstract] [synthesis for the signal system]
Work within competence. Clinical hypnosis only, by licensed professionals trained in perioperative hypnosis and credentialed locally. No stage techniques, no covert induction. [synthesis]

4. Intervention inventory

All example wording below is illustrative and paraphrased; none of it is a Liège script. Each item states whether it comes from the Liège papers, from other teams, or is synthesis.

4.1 Preoperative information and consent conversation

Purpose: Let the patient make an informed, free choice between hypnosedation and general anaesthesia, and correct misconceptions about hypnosis. In Liège this happens in an interview with the anaesthetist, after which the patient accepts or declines. [source: Vanhaudenhuyse et al. 2008]
Steps:
1. Explain the three components: hypnosis, light sedation through a drip, and local anaesthetic by the surgeon. Say that the anaesthesia team monitors throughout. [source: Faymonville et al. 2007; Vanhaudenhuyse et al. 2008]
2. Describe hypnosis as a state the patient enters themself: leaving the theatre mentally to relive a pleasant memory. [source: Vanhaudenhuyse et al. 2008]
3. State that the patient stays conscious, can speak, and can ask for more comfort at any time. [source: infirmiers.com]
4. State that switching to general anaesthesia remains possible. The decision to switch belongs to the anaesthesia team, with the patient. [source: infirmiers.com; Meurisse et al. 1999 abstract]
5. Screen for contraindications (see 4.2) and record consent according to hospital policy. [synthesis for documentation]
6. Make clear that declining has no consequence for their care. [synthesis]
Example language (illustrative): "You won't be asleep, and you won't be under anyone's control. You'll be using your own imagination to spend the operation somewhere you like, while the team keeps you numb and comfortable. If at any point you'd rather be fully asleep, that can be arranged."
Watch for: Acceptance out of deference to the surgeon. Fear of losing control, or of saying something embarrassing. A belief that they will feel nothing at all; correct this by explaining they may feel pressure or touch [synthesis]. Consent is real when the patient can restate the plan and the fallback in their own words. [synthesis]

4.2 Screening and contraindications

Purpose: Exclude patients for whom the technique is unsafe or unworkable.
Contraindications given by the Liège group: deafness; severe cognitive impairment (dementia, intellectual disability); severe psychiatric disorder; allergy to local anaesthetics; inability to lie on the back. [source: Vanhaudenhuyse et al. 2008]
Further limits named by other sources: surgery too deep for local anaesthesia to be enough (a surgical decision); patient refusal or lack of cooperation; hearing impairment. Frail, very elderly or multimorbid patients are described as especially suitable candidates (a medical judgement). [source: infirmiers.com]
Added screening points [synthesis]:
- Active psychosis or mania.
- Severe dissociative disorder.
- PTSD or trauma linked to medical settings, restraint, suffocation or being covered (surgical drapes).
- Untreated panic disorder or severe claustrophobia.
- No shared fluent language with the hypnosis practitioner.
- Recent bereavement that may colour the pleasant memories.
- Strong religious or personal objection to hypnosis. These are reasons for discussion with the anaesthetist, not automatic exclusions; the decision is medical.
Steps: Ask directly about hearing, psychiatric history, trauma history (without asking for detail) and fears about the operating theatre. Pass any concern to the anaesthetist. [synthesis]
Watch for: Patients who minimise anxiety in order to qualify. [synthesis]

4.3 Eliciting the pleasant-memory resource

Purpose: Gather the personal material the induction and maintenance are built on. The Liège induction relies on reliving a pleasant life event. French teams ask before surgery which places, moments or situations calm the patient. [source: Faymonville et al. 2007; infirmiers.com]
Steps:
1. Ask the patient for one or two pleasant, calm, emotionally uncomplicated memories or places (e.g. a beach holiday, a mountain walk). [source: infirmiers.com]
2. Collect sensory detail across senses: what they see, hear, smell, feel on their skin, the temperature. [synthesis, consistent with the sensory-detail emphasis in French practice]
3. Check the memory has no link to a lost person, an illness or a conflict, and offer a second choice. [synthesis]
4. Note the patient's own words for key details so you can use them in theatre. [synthesis]
5. If the patient prefers an imagined place or an activity (sport, music) to a memory, accept it. [synthesis]
Example language (illustrative): "Think of a time or place where you felt really at ease. Where are you? What can you hear there? What's the light like?"
Watch for: The patient's face softening and spontaneous detail mean the resource is good. Hesitation, sadness or "it was nice, but..." means pick another. [synthesis]

4.4 Theatre environment and the "one voice" briefing

Purpose: Protect absorption and avoid negative suggestion from the surroundings. [source: ESA/ScienceDaily 2011; infirmiers.com]
Steps:
1. Before the patient arrives, agree with the team that only the hypnosis practitioner speaks to the patient. Agree that side conversations are minimal, quiet and neutral, and that alarming words are avoided. [source: ESA/ScienceDaily 2011; infirmiers.com]
2. Agree on a discreet way to tell the anaesthetist about discomfort (eye contact, hand signal, a pre-agreed word) so the trance is not broken. [synthesis]
3. Ask the surgeon to warn you (quietly or by gesture) before infiltration, traction or noisy instruments, so you can pace the suggestions. [synthesis, consistent with the published emphasis on gentle surgical handling]
Example language to staff (illustrative): "Once she's settled I'll be the only one talking to her. If you need something from her, tell me and I'll pass it on."
Watch for: Staff chatting about other patients, alarm sounds, or remarks about bleeding or difficulty. Patients may hear and remember these. [synthesis]

4.5 Rapport and focusing during set-up

Purpose: Start shifting attention while the anaesthesia team inserts the drip and attaches monitors. French practice treats patient reception, positive language, drip insertion and focusing as distinct stages before formal hypnosis. [source: Bernard et al. 2019 (abstract and section headings only)]
Steps:
1. Greet the patient by name and stay at the head end, in their field of view. [synthesis]
2. Use the drip insertion or block as a chance to direct attention elsewhere, to the breath or to a chosen point. Tell the patient what will happen in neutral terms. [source: Bernard et al. 2019 abstract: attention guided to neutral or pleasant elements] [synthesis for steps]
3. Reframe sensations neutrally ("a cool feeling", "pressure"). [synthesis]
Example language (illustrative): "You'll feel the cool of the cleaning liquid on your hand, and you can just notice how your breathing is already slowing down."
Watch for: Breathing slowing, shoulders dropping and gaze steadying show readiness for induction. [synthesis]

4.6 Induction by revivification of a pleasant life experience

Purpose: The core Liège induction. The patient relives a pleasant autobiographical memory "as in surgery" (the same procedure was used in the group's research), which displaces attention from the operation. [source: Faymonville et al. 2007; Vanhaudenhuyse et al. 2008]
Steps (structure only; the Liège wording is not drawn on [uncertain]):
1. Invite the patient to find a comfortable position and let their eyes close when they're ready. Many inductions start with a relaxation suggestion. [source: Vanhaudenhuyse et al. 2008 (relaxation component)]
2. Bring in the chosen memory using the patient's own details, in the present tense as though happening now. [source: infirmiers.com (present tense, "as if we were there")]
3. Move through the senses one by one, pausing to let the patient fill in detail. [synthesis]
4. Use permissive phrasing ("you may notice...", "perhaps...") rather than commands. [source: Defechereux et al. 1999 abstract ("Erikson's method")] [uncertain about specific Liège phrasing]
5. Invite the patient to let the body stay on the table, comfortably cared for, while the mind is in the scene. French practice describes inviting detachment from the body. [source: infirmiers.com]
6. Let the anaesthesia team and surgeon know discreetly that the patient is absorbed. [synthesis]
Example language (illustrative): "And now you can let yourself go back to that morning on the beach... it's happening now... feel the sand under your feet... notice what you hear first... and your body can stay right here, looked after, while you enjoy being there."
Watch for: Facial muscles relaxing, slow regular breathing, few spontaneous movements, delayed answers, sometimes eyelid flutter. In the 1995 terms, "trance" was reached when the patient re-experienced the event (age regression). Patients who only relax were classed as "relaxation" and still had sedation titrated to need. [source: Faymonville et al. 1995 abstract] [synthesis for observable signs]

4.7 Alternative attention-fixing inductions: eye fixation and progressive muscle relaxation

Purpose: Other entry points for patients who find it hard to go straight into a memory. The UCL Brussels hypnosedation team describes focusing attention on one point, such as eye fixation, progressive muscle relaxation or a pleasant memory. Whether Liège routinely uses eye fixation is not confirmed in the sources. [source: ESA/ScienceDaily 2011] [uncertain for Liège]
Steps (eye fixation):
1. Ask the patient to pick a point above eye level (e.g. on the ceiling or lamp) and keep looking at it.
2. Suggest the eyelids becoming heavy and that they can close when ready.
3. Link eye closure to going into the memory. [synthesis for sequence]
Steps (progressive muscle relaxation):
1. Move attention from feet to head.
2. Invite each area to loosen, linking each release to the out-breath.
3. Lead into the memory. [synthesis for sequence]
Example language (illustrative): "Just rest your eyes on that small mark up there... and as you keep watching it you may notice your eyelids wanting to close... and when they do, you can drift off to that place you told me about."
Watch for: Fluttering lids, watering eyes or a deep sigh mean it is working. Persistent scanning of the room means move straight to talking about the memory with eyes open. [synthesis]

4.8 Intraoperative maintenance talk

Purpose: Keep the hypnotic state going for the whole operation. In Liège the anaesthetist keeps talking to the patient "to maintain the hypnotic state" while monitoring vital signs. [source: Vanhaudenhuyse et al. 2008]
Steps:
1. Keep a slow, steady flow of present-tense description of the patient's scene, with pauses. Speak little but never disappear for long. [source: infirmiers.com; Vanhaudenhuyse et al. 2008] [synthesis for pacing]
2. Follow the patient. If they go elsewhere in the memory, go with them ("let her go where she wants"). [source: infirmiers.com]
3. Check in from time to time with a question that needs little effort to answer (a nod, a word). The patient is conscious and can talk with the team. [source: infirmiers.com] [synthesis for check-in format]
4. Pace to surgical events: before an expected stimulus (infiltration, traction, cautery noise), add a matching image to the scene. Examples: a wave's pressure, a friendly tap, the sound of seagulls. [synthesis]
5. After each stimulus, return to the most absorbing detail of the scene. [synthesis]
Example language (illustrative): "...and the sun is moving a little higher now... you might notice the water's coolness around your ankles... that's fine, a wave comes and goes... and you can go back to watching the boats."
Watch for: Rising heart rate, grimacing, clenched hands, eyes opening or restlessness. Pass these to the anaesthetist at once; responding medically is their decision. A calm face and slow, even breathing mean it is working. [source: Vanhaudenhuyse et al. 2008 (anaesthetist watches for discomfort)] [synthesis for cue list]

4.9 Comfort and ease suggestions

Purpose: Strengthen comfort and lessen perceived intensity of sensation. French regional-anaesthesia practice uses suggestions of comfort, analgesia and ease. The Liège research shows hypnosis mainly reduces perceived intensity of strong stimuli. [source: Bernard et al. 2019 abstract; Faymonville et al. 2007]
Steps:
1. Offer comfort images linked to the patient's scene (warmth, lightness, softness).
2. Offer distance or numbness images for the operated area (e.g. a cool, numb, far-away feeling), always alongside the local anaesthetic, never instead of it.
3. Let the patient choose the image that works. [synthesis for these steps]
Example language (illustrative): "Whatever the team is doing over there can feel more and more distant, like something happening on the other side of the beach... your neck can stay pleasantly cool and calm."
Watch for: Never promise "you will feel nothing"; local anaesthesia does not remove touch and pressure. Breakthrough pain is a medical signal, not a hypnosis failure; report it. [synthesis]

4.10 Positive language discipline

Purpose: Avoid unintended negative suggestion during heightened suggestibility. UCL clinicians advise avoiding negatives. French practice lists positive language as a stage of care and advises avoiding anxiety-provoking terms. [source: ESA/ScienceDaily 2011; Bernard et al. 2019 headings; infirmiers.com]
Steps:
1. Replace warnings such as "this will sting" or "don't worry" with neutral or positive descriptions ("a cool feeling, then pressure", "you can stay calm").
2. Avoid medical alarm words near the patient.
3. Brief staff on this beforehand (4.4).
Example language (illustrative): Instead of "Don't move, it's going to hurt", say "You can keep your head nicely still, resting on the pillow, while you feel a little pressure."
Watch for: Your own reflexive phrases, and staff remarks. Note any that seem to upset the patient so you can address them in the debrief (4.13). [synthesis]

4.11 Responding to discomfort and supporting conversion

Purpose: Respond quickly when comfort drops, without overstepping the medical role. In Liège the anaesthetist watches for discomfort, adjusts conscious sedation and can supplement local anaesthesia. Conversion to general anaesthesia was needed in about 1% of cervical endocrine cases. [source: Vanhaudenhuyse et al. 2008; Meurisse et al. 1999 abstract]
Steps (hypnosis practitioner's part):
1. Tell the anaesthetist straight away using the agreed signal.
2. Acknowledge the sensation without dramatising it ("you noticed something; the team is taking care of it").
3. Offer a strong re-entry into the scene.
4. If the anaesthesia team decides to convert, keep talking calmly and frame the change as part of the plan agreed beforehand, not as failure. [synthesis for steps 2 to 4]
Example language (illustrative): "The team has heard you and they're making it more comfortable right now... and as they do, you can go back to the path through the trees..." / If converting: "Just as we agreed, the team is going to let you sleep for the rest of it; you've done really well."
Watch for: Patients apologising or feeling they "failed". Address this in the debrief. [synthesis]

4.12 Re-alerting and postoperative suggestions

Purpose: End the hypnotic state gradually and give suggestions for recovery. French practice describes reversing the hypnosis progressively, helping the patient reconnect with reality, and giving postoperative suggestions about healing, energy and appetite. [source: infirmiers.com]
Steps:
1. Tell the patient the operation is finished.
2. Invite them to bring something good from the scene back with them.
3. Give brief recovery suggestions (comfortable healing, energy returning, appetite) without making medical promises.
4. Count or describe a gradual return of alertness, sensation in the body and awareness of the room.
5. Invite them to open their eyes when ready.
6. Check orientation. [source: infirmiers.com for the elements; synthesis for order]
Example language (illustrative): "The operation is done, and it went smoothly. You can take a little of that calm from the beach with you... your body knows how to heal... and in your own time you can come back to the room, feel the bed under you, move your fingers, and open your eyes."
Watch for: Grogginess from sedation (a medical matter), disorientation, or an emotional response to the memory. Make sure the patient is fully alert before transfer, or as the ward protocol says. [synthesis]

4.13 Postoperative debrief

Purpose: Consolidate what the group describes as a sense of success and active participation, and catch any distress. [source: Vanhaudenhuyse et al. 2008 (benefits: sense of success, active participation)]
Steps:
1. Ask what the experience was like, what helped, and anything that bothered them (including overheard remarks).
2. Correct any misunderstandings.
3. Praise the patient's own contribution.
4. If the patient is interested, mention that the same skill can be used for future procedures or with a psychologist for anxiety or pain. [synthesis]
Example language (illustrative): "You did that by focusing your own attention. What part of it worked best for you?"
Watch for: Intrusive memories of the operation, or shame after conversion. Refer for follow-up where distress persists. [synthesis]

4.14 Lower-intensity alternatives: relaxation level and stress-reducing support

Purpose: Some patients do not reach trance. In 1995 the group recorded a "relaxation" group where hypnosis was induced but trance was not reached. In the 1997 trial, stress-reducing strategies, delivered by the same anaesthesiologist, were the comparison condition and produced less benefit than hypnosis. The content of those strategies was not described in the sources. [source: Faymonville et al. 1995 abstract; Faymonville et al. 1997 abstract] [uncertain about content]
Steps [synthesis]:
1. Keep it conversational with eyes open: guided breathing, talking about the memory, or ordinary reassuring conversation.
2. Keep the one-voice rule.
3. Tell the anaesthesia team, since medication needs may differ.
Example language (illustrative): "We don't need you to go anywhere special. Let's just talk about that trip while you breathe slowly."
Watch for: Treat this as a legitimate outcome, not failure.

4.15 Adaptations reported by other teams (not Liège)

Children: A Spanish paediatric trial used a rapid conversational hypnosis. The anaesthetist built an alliance at the pre-anaesthesia visit; children chose a preferred imaginative experience suited to their age; children and parents had a session to reduce fear; suggestion continued through surgery; the whole team was trained in conversational hypnosis. Children with intellectual disability, attention or behavioural disorders were excluded. [source: Peláez Pérez et al. 2021]
Breast and video-assisted thyroid surgery: Done at UCL Brussels by an anaesthesia team specialised in hypnosis, using local anaesthesia plus hypnosis. [source: ESA/ScienceDaily 2011]
Self-hypnosis practice before surgery: The Liège sources state that no prior training is needed. Optionally teaching a short self-hypnosis routine in the pre-op visit, so the patient rehearses entering their scene, is [synthesis], not part of the published model.
Watch for: Do not transfer adult wording to children. Use play, choice and the parent's presence where the anaesthesia team allows. [synthesis]

5. Handling problems

The Liège and related sources say little about problem management beyond three points: the anaesthetist adjusts sedation and local anaesthesia when discomfort appears; conversion to general anaesthesia remains available (about 1% in cervical surgery); and declining or unsuitable patients have general anaesthesia. [source: Vanhaudenhuyse et al. 2008; Meurisse et al. 1999 abstract; Defechereux et al. 1999 abstract] Everything below is [synthesis] unless tagged otherwise. Throughout, any problem with pain, vital signs, sedation depth or safety goes to the anaesthesia team, who decide.

Patient cannot find or stay in a pleasant memory (stuck). Switch to an imagined place, a hobby, music or a step-by-step activity they know well (e.g. cooking a favourite dish). Or use an outer focus (eye fixation, breath counting; see 4.7). Or move down to relaxation-level conversation (4.14), which the 1995 series treats as a recognised level. [source for levels: Faymonville et al. 1995 abstract]
The memory turns sad or distressing (e.g. a deceased person appears, an abreaction). Acknowledge it softly and offer a choice: "you can keep them with you in a peaceful way, or move to another part of the day." If distress continues, move to the backup resource or to neutral present-moment focus with eyes open, and inform the anaesthetist. Never explore the material during surgery. Note it for the debrief and possible referral. Do not use the memory work to uncover past events.
Anxiety spike at drip insertion, infiltration, draping or noise. Pre-empt it with pacing (4.8): tell the patient what is coming in neutral terms and link it to the scene. For drapes over the face, agree beforehand on keeping an airspace and contact (a hand on the shoulder if the team allows). Persistent panic is for the anaesthetist to manage medically.
Overwhelm or dissociation beyond the intended absorption (blank, unresponsive in a way that does not fit sedation, or fearful detachment). Hypnosis does not deepen it. Ground with present-tense facts ("you're in the operating room, the team is here, you're safe"), invite a small movement such as squeezing a hand, and tell the anaesthetist at once, since sedation effects must be ruled out medically. Patients with known severe dissociation should have been discussed at screening (4.2).
Resistance or fear of losing control. Stress that the patient is the active agent and can open their eyes, speak or ask for more comfort at any time. [source for the active framing: Vanhaudenhuyse et al. 2008] Give a real signal they control (raising a finger means "I need something"). Perceived control was a reported benefit in the 1997 trial. [source: Faymonville et al. 1997 abstract]
Pressure-based "consent" (from the surgeon, family or cost concerns). Revisit choice privately. Remind the patient that general anaesthesia is an equal option. Do not proceed with a reluctant patient.
Patient talks a lot or keeps opening eyes. The patient stays conscious and can talk, so this is allowed. [source: infirmiers.com] Use the talking: ask them to describe the scene aloud and treat their description as the induction.
Patient drifts into sleep. Sedation depth is a medical matter. Tell the anaesthetist, and keep a light voice presence in case they surface.
Team non-adherence (chatter, alarm words, rough handling). Remind them quietly. Debrief the team afterwards. Build the one-voice rule and gentle surgical handling into the local protocol. [source for the rules: ESA/ScienceDaily 2011; infirmiers.com]
Rupture of trust after a painful moment or a careless remark. Name it in the debrief, apologise on behalf of the team where fitting, and check for lasting distress. Offer referral if intrusive memories persist beyond a few weeks.
Conversion to general anaesthesia felt as failure. Prepare for it in the consent talk (4.1), frame the switch as agreed during surgery (4.11), and debrief (4.13).
Language, hearing or cognitive barriers. Deafness and severe cognitive impairment are listed contraindications. [source: Vanhaudenhuyse et al. 2008] Interpreter-mediated hypnosis in theatre is untested in the sources; generally discuss alternatives with the anaesthetist.
Hypnosis practitioner outside the anaesthesia team (e.g. a psychologist). Work only under a written local protocol with clear lines of responsibility, credentialing, theatre training (sterility, positioning, emergencies) and the anaesthetist's agreement. Never comment on, request or decline medications or the switch to general anaesthesia yourself.
Medical-adjunct boundary. Do not present hypnosedation as treating any disease, including cancer. Claims that local anaesthesia with hypnosis might affect metastasis were described by the UCL presenters as a possibility only. [source: ESA/ScienceDaily 2011] Do not repeat them to patients as a benefit.

Sources

Sources:

Full texts not reachable (permission not granted): the ORBi PDFs of Faymonville et al. 1997, Faymonville et al. 1998 and Vanhaudenhuyse & Faymonville 2018, and the Zdrav Vestn PDF. The step-by-step Liège induction wording is therefore [uncertain] and is not reproduced or reconstructed here.

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