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Clinical Hypnosis for the Palliative Care of Cancer Patients

Clinical Hypnosis for the Palliative Care of Cancer Patients

Clinical hypnosis has been defined as a mind-body therapy that involves a deeply relaxed state, individualized mental imagery, and therapeutic suggestion. Clinical hypnosis has a very long history, with reports of medical application dating back to the 18th century. Some have suggested that there is even evidence for the use of clinical hypnosis since ancient times, with inscriptions of hypnotic-like phenomena on a stone stele from Egypt during the reign of Ramses XII, some 3,000 years ago. The word hypnosis, derived from the Greek word for sleep, was coined by James Braid in 1841. Clinical hypnosis is a mind-body therapy, one of the fastest-growing and most commonly employed categories of complementary and alternative medicines (CAM), as defined by the NCCAM (National Center for Complementary and Alternative Medicine) of the National Institutes of Health. A national health interview survey of medical usage in 2007 found that 4 out of 10 US respondents reported having used complementary and alternative medical treatments in the previous year.[1] Further, research suggests that CAM use continues to be highest among those with chronic diseases (eg, cancer).[2,3] Mind-body interventions such as clinical hypnosis are also becoming popular for their ease of integration into an overall cancer survivorship treatment plan with relatively low risks.[4]

Hypnosis produces an altered state of consciousness, awareness, or perception. The hypnotic state is a highly relaxed state in which the patient’s mind (conscious and subconscious) is focused and receptive to therapeutic suggestion. It involves learning to use one’s mind and thoughts to manage emotional distress, (eg, anxiety, stress), unpleasant physical symptoms (eg, pain, nausea), or to help change certain habits or behaviors (eg, smoking). While hypnosis sessions may vary depending on a patient’s needs, a clinical hypnosis session typically comprises two basic phases:

Induction. During this phase, the therapist helps the patient to relax, and may ask the patient to imagine a peaceful scene that helps him or her to become more focused and concentrate on what is to be accomplished during the session.

Application. During this phase, the patient receives suggestions. Hypnotic suggestions, the key ingredient of hypnosis, are special statements that are designed to suggest relief from troubling symptoms.

There are several professional associations dedicated to clinical hypnosis that conduct research and provide education, as well as ethical standards of care. One of the largest such associations, the American Society of Clinical Hypnosis (ASCH), was founded in 1957 and has nearly 2,000 members; its members are required to hold a doctorate in medicine, dentistry, podiatry, chiropractic, or psychology, or a minimum of a master’s level degree in nursing, clinical social work, or psychology. All applicants must be licensed or certified in the state in which they practice. The ASCH administers a program of credentialing and training workshops accredited by the Accreditation Council for Continuing Medical Education (ACCME), the American Psychological Association, the Academy of General Dentistry, the National Association of Social Workers, and the California Board of Behavioral Sciences. ASCH also maintains a Standards of Training, which ensures that participants receive quality, comprehensive training.[5]

A meta-analysis of randomized controlled studies of clinical hypnosis identified 57 studies that demonstrated hypnosis as an effective treatment for a number of health disorders and conditions including pain, smoking cessation, migraines, allergies, analgesia in labor, asthma, dermatology, dentistry, anxiety, hypertension, tinnitus, and postoperative recovery in surgery.[6]

What is the Evidence Related to Hypnosis and Cancer?

Clinical hypnosis has been described in the medical literature to relieve a broad spectrum of symptoms, including treatment of common symptoms associated with cancer care, as discussed below.

Pain

Hypnosis is the most frequently cited form of nonpharmacologic cognitive pain control.[7] Hypnotherapy for the management of chronic pain has been demonstrated to provide relief for the symptoms of pain in cancer, arthritis, sickle cell disease, temporomandibular disorder, and fibromyalgia. Hypnosis has demonstrated positive outcomes for the reduction of chronic and procedural-related pain in oncology.

A study of breast cancer patients found that those assigned to treatment (standard care or expressive-supportive therapy) that included clinical hypnosis demonstrated significantly less pain. In addition, patients who underwent hypnosis reported significantly less of an increase in pain over time.[8] Another study of advanced-stage cancer patients with malignant bone disease was conducted by randomizing patients to receive either hypnotherapy or supportive attention (eg, encouragement, active listening).[9] Results showed the hypnosis intervention group had a significant overall decrease in pain.

Syrjala and colleagues studied 45 cancer patients to evaluate the efficacy of hypnosis for pain relief following chemotherapy.[10] Participants were randomized into the following conditions: hypnosis, cognitive behavioral therapy (CBT), attention control, and standard care. There were no reported significant differences among the groups for nausea, presence of emesis, nor opioid intake; however, the hypnosis group showed a significant reduction in oral pain. Montgomery and colleagues studied 200 patients undergoing excisional breast biopsy or lumpectomy.[11] Participants in this study were randomly assigned to a hypnosis session or to a control condition involving nondirective empathic listening. The hypnosis group had significant reductions in pain intensity, self-reported pain unpleasantness, nausea, fatigue, and discomfort compared with the control. Moreover, the per-patient cost to the medical institution was $772.71 less for those in the hypnosis group compared with patients in the control group, because of reduced surgical time. Lang and colleagues conducted a randomized controlled trial evaluating hypnosis for women (n = 236) undergoing large core breast biopsy.[12] During the procedure, in addition to standard of care, participants received either empathetic attention or a hypnotic relaxation treatment. Results indicated that hypnosis reduced pain and anxiety compared to empathetic attention, which only showed a reduction in pain.

A recently published review examined the evidence from clinically controlled trials, evaluating hypnosis for procedural-related pain in pediatric oncology.[13] Eight randomized controlled trials were analyzed, demonstrating positive outcomes in clinical hypnosis for pain management in pediatric oncology.

Nausea

It has been reported that 70% to 80% of all cancer patients who receive chemotherapy experience nausea and vomiting.[14] Clinical hypnosis has been studied for relief of nausea and vomiting secondary to chemotherapy. In a randomized study of the efficacy of hypnosis in reducing nausea and vomiting in children receiving chemotherapy, researchers found children participating in hypnosis had less anticipatory nausea and vomiting and less overall vomiting compared with controls who did not undergo hypnosis.[15] This finding was replicated in a later study also demonstrating that patients using clinical hypnosis showed a reduced need for antiemetic medication.[16] A review by Richardson and colleagues of six randomized, controlled trials suggests there were large effect sizes for hypnotic treatments when compared with treatment as usual, and these were at least as large as the effects of CBT.[13] In a study of mediators of a brief hypnosis intervention to control side effects in breast cancer surgery patients, Montgomery and colleagues concluded that clinical hypnosis works to a significant extent through the two psychological mechanisms of cognition and emotion. Results of a study of a 200 breast cancer patients who underwent a presurgical hypnosis intervention to improve postsurgical side effects suggest that, to reduce postsurgical nausea, clinical hypnotic interventions should be designed to specifically target patient expectancies and distress.[17]

Fatigue

Cancer-related fatigue has long been recognized as one of the most difficult symptoms to manage during cancer treatment, and it remains the most common unrelieved symptom of cancer.[18] Research suggests that fatigue is a multidimensional syndrome which results from both cancer and cancer therapies, such as chemotherapy and radiotherapy. Estimates of the prevalence of fatigue in cancer patients undergoing radiotherapy are diverse. Literature suggests that fatigue can affect 60% to 90% of patients receiving chemotherapy or radiation therapy.[19] This condition is managed through education of patients and caregivers about current evidence-based strategies to reduce fatigue, nonpharmacological interventions including exercise, and pharmacological therapies.[18] Despite the high prevalence of cancer-related fatigue, few intervention options exist.[20] A study was conducted to test the effectiveness of CBT and hypnosis for radiotherapy-related fatigue.[21] Breast cancer patients were randomly assigned to receive either standard care or CBT and hypnosis. Results show that with the cognitive-behavioral/hypnosis intervention, patients’ fatigue did not increase over the course treatment, whereas fatigue among patients receiving standard care increased linearly. Although this initial result is promising, additional research is critically needed in this area. To determine relative contributions of various interventions to fatigue relief in cancer patients, future studies should be designed with subjects assigned to groups providing hypnosis-only, CBT only, and combined cognitive-behavioral hypnotherapy, as well as a control group offering structured attention.

Hot Flashes

Clinical hypnosis for the treatment of hot flashes has been investigated. In two studies of breast cancer survivors, participants received five sessions of hypnotherapy, (provided approximately weekly) and were instructed in self-hypnosis. The hypnotic intervention was individualized to facilitate a hypnotic state, feelings of coolness, and control of symptoms. The results showed a 69% reduction of hot flashes relative to baseline,[22,23] and are comparable or superior to results from open-label studies with paroxetine and venlafaxine.[24] In a large ongoing randomized clinical trial of hypnosis for hot flashes, 184 post-menopausal women have been randomized to either clinical hypnosis or to structured-attention control that provides supportive, non-directive counseling. Preliminary unpublished results concur with earlier studies suggesting that hot flashes can be reduced by 70% at 3 months follow-up among post-menopausal women.[25]

Sleep

Hypnosis can also be an effective treatment option for cancer patients suffering from sleep problems. Cancer patients experience sleeping difficulties for a number of reasons, including anxiety related to diagnosis, depression, pain, fatigue, and other treatment-related side effects. Cancer patients have been reported to be nearly three times more likely than members of the general population to meet diagnostic criteria for insomnia.[26]

While sleep disorders can be treated with pharmacotherapy, this treatment modality carries with it the inherent risks of dependence and potentially dangerous drug interactions. Furthermore, pharmacotherapy does not treat the underlying source of the sleep disturbance. Hypnosis provides cancer patients with a safe alternative treatment option that not only improves the ability to obtain restful sleep, but also leads to improvements in other symptom areas.

A study conducted by Elkins et al supports the efficacy of clinical hypnosis in improving the quality of sleep for cancer patients.[23] During this study, 51 breast cancer patients (all female) were assigned to either five weekly sessions of hypnosis or a waitlist control group. The main outcome for this study was a reduction in hot flash occurrence. At the conclusion of the 5-week treatment period, not only did cancer patients report fewer hot flash related daily disturbances, but they also reported significant improvements in sleep quality, as well as fewer symptoms of anxiety and depression. This study provides an example of how hypnosis may be effective at treating a target symptom and improving the patient’s overall quality of life.

How Is Hypnosis Currently Used in Cancer Care?

Hypnosis has been specifically employed in the palliative care of cancer patients to reduce symptoms associated with radiation and chemotherapy, such as pain, nausea, fatigue, hot flashes, and sleep dysfunction. Length of hypnotic treatment varies depending on the nature and severity of the problem. Clinical hypnosis treatment for cancer patients may range from a single session to multiple sessions. In research, cancer patients undergoing clinical hypnotherapy typically receive approximately five sessions or more of clinical hypnosis, each involving a hypnotic induction and instruction in self-hypnosis. The practice of self-hypnosis helps patients achieve a relaxed, therapeutic, hypnotic state. Professionals serve as facilitators of self-hypnosis, often providing hypnosis audio recordings for patients to use between sessions.

Hypnosis is frequently offered in conjunction with other therapies such as cognitive behavioral therapy (CBT). Research suggests that using a combination of hypnosis and CBT improved outcomes more than those achieved for at least 70% of patients who used CBT alone.[27] Additionally, CBT techniques can be utilized in a hypnotic context by preceding the CBT technique with a hypnotic induction.[28]

What Are the Potential Risks?

Clinical hypnosis has been commonly described as a safe method when used correctly, having few harmful side effects.[8] However, individuals may initially feel drowsy following hypnosis, due to its focus on increasing relaxation and decreasing anxiety. Unexpected delusional thoughts and trancelike states are also possible. Therefore, clinical hypnosis for patients with psychological disorders involving delusions is unadvisable. The clinical hypnosis literature has commonly listed exclusions for study participants with diagnoses of schizophrenia or borderline personality disorder.

What's the Bottom-Line Message?

Clinical hypnosis is a viable option for cancer patients, who, once trained in self-hypnosis, may employ these techniques to manage myriad symptoms.

In particular, hypnosis as an adjunct treatment for cancer patients and survivors can be effective in treating pain, nausea, fatigue, hot flashes, and sleep disorders. While current research into the efficacy of clinical hypnosis for the palliative treatment of cancer patients is extremely encouraging, some studies have been limited by less-than-desirable sample sizes, and there is a dearth of large randomized controlled trials. Additional research will be needed for clinical hypnosis to become a well-established evidence-based treatment for the palliative care of cancer patients. However, the existing evidence from all clinical research supports inclusion of clinical hypnosis as an effective adjunct therapy in the palliative cancer treatment milieu, and therefore hypnosis should be considered for patients with cancer on a case-by-case basis.

Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

Acknowledgment: Dr. Elkins is supported by NCCAM grant 5U01AT004634 and NCI grant R21CA131795.

References

References

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2. Eisenberg D, Davis R, Ettner S, et al: Trends in alternative medicine use in the United States, 1900-1997: Results of a follow-up national survey. JAMA 280(18):1569–1575, 1998.

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4. Kwekkeboom K., Cherwin C, Lee JW, et al: Mind-body treatments for the pain-fatigue sleep disturbance cluster in persons with cancer. J Pain Symptom Manage 39(1):126–138, 2010.

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9. Elkins GR, Cheung A, Marcus J, et al: Hypnosis to reduce pain in cancer survivors with advanced disease: A prospective study. J Cancer Integ Med 2(4):167–172, 2004.

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11. Montgomery GH, Bovbjerg DH, Schnur JB, et al: A randomized clinical trial of a brief hypnosis intervention to control the side effects in breast surgery patients. J Natl Cancer Inst 99(17):1304–1312, 2007.

12. Lang EV, Berbaum KS, Faintuch S, et al: Adjunctive self-hypnotic relaxation for outpatient medical procedures: A prospective randomized trial with women undergoing large core breast biopsy. Pain 126(1–3):155–164, 2006.

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