Psychological approaches are importantin the management of cancer pain, andhypnosis is an especially useful techniquethat can be integrated into the total careof the patient. Although a major application of hypnosis to cancer patients isthe direct relief of pain,1'2 there are widerpsychotherapeutic benefits as well: innerstrength or will to live can be increasedand directed to the patient's developmentof greater personal responsibility for hisor her well-being. Hypnosis can belearned and skillfully employed by thephysician, by consulting psychologists orpsychiatrists, and by the nursing staff.

Hypnosis has been used throughoutthis century, both as a medical technique(for analgesia, muscle relaxation, and insome cases, to facilitate healing) and asa psychotherapeutic tool (to alleviatesymptoms, uncover forgotten material,and facilitate behavioral change). Historically, it has been associated with mysticism. However, the current scientificunderstanding of hypnosis is rooted inrational, demonstrable psychologicalprinciples. Hypnosis is a natural humanability, not an aberration or neurotic

Dr. Barber is Assistant Professor, Department of Anesthesiology/Pain ManagementClinic, University of California School ofMedicine, Los Angeles, California.Ms. Gitelson is Associate in Psychology,Department of Psychiatry, Neuropsychiatric Institute, University of CaliforniaSchool of Medicine, Los Angeles, California.

symptom, as once was believed; it is analtered state of consciousness characterized by changes in perception (i.e., analgesia) or memory (i.e., amnesia or bypermnesia).

Although individuals differ in the facility with which they can be hypnotized, we find that the degree of “¿�hypnotic susceptibility― is not critical to theclinical result. Controversy surroundsthis issue, but there is evidence that evenpersons of low hypnotic susceptibilitycan achieve clinical hypnotic success.340In the clinical context, we suggest thatthe issue of susceptibility be ignored.Every patient should be presumed capable of attaining a clinically useful hypnotic state.5

A “¿�clinicallyuseful― hypnotic statesimply means that quality or degree orlevel of hypnosis that facilitates therapeutic progress. Like other states of consciousness (including the normal wakingstate), the state of hypnosis varies overtime and circumstance. Although it is notclear what determines the “¿�depth―that aparticular patient will achieve at a giventime, depth is partly dependent on thetrust felt by the patient in the situation,how much time is allowed, and to someextent, on hypnotic technique. A discussion of the techniques of hypnosis isbeyond the scope of this paper. However,clinical training in the use of'hypnosisincludes training in certain techniquesused to promote adequate clinical depth.

130 CA-ACANCERJOURNALFORCLINICIANS

Cancer Pain: PsychologicalManagementUsingHypnosis

Joseph Barber, Ph.D.Jean Gitelson

This can lead to increased chances ofadaptive rehabilitation and/or greateracceptance of discomfort and prematuredeath.

Such use of hypnosis assumes a widerpsychotherapeutic context, however. Bythis we mean that a psychological approach to a patient is intended to fostera patient's own resources: to support the

“¿�Hypnosiscan help the cancerpatient when medication or surgery

cannot..

patient's self-esteem and to explore waysof increasing it; to expand the patient'sawareness of his or her inner life andawareness of the extent to which this canaffect the patient's experience of self,family, work, and the illness. We are impressed with the value of gestalt techniques11 in providing a model of psychological intervention. While affording thepatient an opportunity to experience insight, the gestalt approach also suggestsconcrete behavioral changes to facilitatetherapeutic goals. It is important, then,that the use of hypnotic techniques be apart of other psychological treatment.While this fact does not preclude the useof hypnosis by psychologically untrainedclinicians, it is necessary to understandthe importance of taking the patient'spsychological needs into considerationwhen formulating a treatment plan.

Behavioral techniques are significantconcomitants when hypnosis is used tomanage pain. The use of psychologicaltechniques assumes, of course, that patients are motivated and committed towork on their own outside the therapeutic setting. It is important to formulaterealistic goals for the therapist and patient, and a specific time in which behavioral assignments will be performed.For instance, one goal in managing cancer pain is to develop self-control overpain and its associated anxieties. It isimportant that a patient spend a certainamount of time daily to initiate and prac

l@@ 131EHC8-15F-6ZAX ____

Although it was once thought that theability to develop hypnotic analgesia wasdependent on significant hypnotic depth,our experience suggests, to the contrary,that significant analgesia can be achievedin only a “¿�light―state of hypnosis. Forpurposes of analgesia, then, depth is notnecessarily an important consideration.

In the psychological management ofcancer pain, we view hypnosis as onecomponent to be appropriately integrated into the wider therapeutic context—¿�incontrast to the view that hypnosis is,by itself, a complete and adequate intervention. The incorporation of hypnosisinto a treatment plan to control cancerpain has three principal advantages:

•¿�Hypnosis can alleviate pain withoutunpleasant or destructive side effects.The degree of pain relief achieved canrange from moderate control to totalanalgesia.

•¿�Hypnosis does not reduce normalfunctioning and does not mentally incapacitate the patient in any way, nordoes the patient develop tolerance toits effects.

•¿�Hypnosis can be used to promote lifeenhancing attitudes in the patient, andthe attitude toward the cancer can bealtered in beneficial ways.

Hypnosis, then, can help the cancerpatient when medication or surgery cannot, and has none of the disadvantagessometimes associated with medicationand surgery. Further, hypnosis can accelerate the psychological processes thatmust be activated in the effective management of chronic illness. For reasonsnot yet understood, the development ofsuch an altered state of consciousness inconjunction with appropriate therapeuticguidance can rapidly reduce obsessional,destructive thoughts, and can nourish apatient's self-esteem by helping him orher to focus on personal capabilities andactive participation in the therapy. Thissupports the patient's capacity to function and reduces the otherwise inevitablesense of helplessness. Through hypnosisa patient may be freed from anxietiesassociated with pain, disease, or death.

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tice self-hypnosis. This strategy requiresthat a patient participate in his or herown care.

Involving family members is also important when hypnosis is used as a therapeutic modality, and it is helpful forthem to actually learn how to participatein the patient's hypnosis. This not onlydiminishes the experience of helplessnesson the part of the patient and familymembers, but also facilitates meaningfulcommunication that otherwise is oftencompromised as the disease progressesand medical treatment becomes moreintrusive.

Six hypnotic strategies may be usedto control cancer pain:•¿�directly blocking awareness of pain

through the suggestion of anesthesiaor analgesia;

•¿�substituting another feeling (such aspressure) for the pain;

•¿�moving the perception of the pain toa smaller or less vulnerable area of thebody;

•¿�altering the meaning of the pain so itbecomes less important and less debilitating;

•¿�increasing tolerance for the pain; and•¿�in extreme cases, dissociating percep

tion of the body from the patient'sawareness.

The following case reports describepatients with pain secondary to malignant disease who used clinical hypnosis:

Case 1. Lynn, a 47-year-old, recentlymarried woman diagnosed with acutemyelogenous leukemia, complained ofpain in the pelvic and lower back areas.Physical findings did not explain suchdiscomfort. After six months of remission, Lynn was rehospitalized to beginan intensive course of chemotherapy. Itwas noted by her physicians and nursesthat she was becoming despondent andpassive about her treatment, characteristics not evident during prior hospitalizations. In addition, she was becomingincreasingly dependent on her husbandand physicians and reported a growingsense of fear and helplessness when theywere not available. Paranoid obsessional

thinking developed, and she began toaccuse her husband of seeking lovers.

Hypnosis was employed to help reduce her escalating anxiety and depression and to enable her to use her owncapabilities to relieve discomfort and obsessional thinking. Additional psychotherapy sessions in conjunction with hypnosis enabled Lynn to become aware thatshe was using pain as a means of securingher husband's attention and maintainingher doctors' interest in her.

Two different techniques were usedin Lynn's case. First, structured guidedimagery enabled her to focus on emotional issues in an indirect manner bycreating mental images associated witha relaxed setting. Second, deeper hypnotic inductions were employed to reduceher pain and to begin the process of accepting the terminal nature of her illness.

The value of hypnosis was its positiveeffect in increasing Lynn's sense of innerstrength and enhancing self-directed efforts at relaxation and pain reduction.In addition, changes in her attitude developed that helped her to face her impending death and separation from herhusband.

Case 2. Mark, a 42-year-old pharmaceutical company representative, was diagnosed with testicular cancer. He hadintense pain in his pelvic area and wasfearful of becoming addicted to the narcotics used to treat the pain. Mark wasunable to face his physicians' reports thathis cancer was progressing rapidly andrefused to accept the fact that his illnesscould not be cured. He insisted that theremust be a drug to help him and beganto make plans to travel to Mexico forlaetrile treatments.

Mark presented doctors and nurseswith difficulties because he would notcomply with instructions and attemptedto plan his own treatment. Psychologicalconsultation was requested because hewas assessed as being depressed and defiant, showing inappropriate denial, andmaking unrealistic plans for marriage inspite of the unfavorable prognosis.

Hypnosis was indicated at first as ameans of helping Mark to relax and to

132 CA-A CANCER JOURNAL FOR CLINICIANS

reduce his anxiety. Resistance to thisform of intervention was resolved whenMark was taught techniques to hypnotizethe therapist (as a means of increasinghis trust). Once he began to feel he wasnot being “¿�usedas a guinea pig,―he became amenable to hypnotic inductions.Suggestions to relax and develop bettercommunication with the hospital staffhelped relieve some of his feelings ofhelplessness. With a growing sense ofability to communicate his needs to thehospital staff, Mark became less defensive when presented with test results.

The treatment plan for hypnotherapyhad three components. Initial effortswere focused on helping the patient relaxand interact cooperatively with the medical and nursing staff. Relaxation suggestions were given, and the patient beganto experience less anxiety. Second, thepatient learned self-hypnosis to helpcounteract pain in his pelvic area.

The third phase of treatment involved the patient working on psychological issues relating to the progress ofhis disease and the inevitability of separation from his loved ones. As a result ofthe successful results of the previous twophases of treatment, Mark became increasingly involved in assessing his relationship with his girlfriend and gradually accepted the physicians' reportsabout his future. Using a hypnotic technique that allowed him to visually projecthimself and his girlfriend onto a hallucinated movie screen, he was able to distance himself from his own psychologicalconfficts about separation. Some resolution was achieved in acknowledging thelimitations of his treatment and the reality that he would die within a few weeks.

As he became more willing to facedeath, Mark was determined to reconcilefamily differences. Age regression was employed when he felt ready to explore painful childhood memories. Mark requestedhis parents and brother to fly from theEast Coast to be with him while he wasstill conscious. He was able to spend aweek before his death talking, laughing,and crying with his family in a way thatwas impossible prior to hypnotherapy.

Pain control was maintained withoutnarcotics until two weeks prior to hisdeath. Even then, narcotic dosages wereminimal, thus allowing cognitive functioning during the reunion with his family and the process of separation from hisgirlfriend. Psychological distress was decreased with self-hypnosis, and he wasless anxious in the hospital than he had

“¿�Paincontrol was maintained withoutnarcotics until two weeks prior to

(the patient's) death.―

been prior to hypnotherapy. It was to thecredit of the medical and nursing staffthat practical issues could be attended to:with their help, it was possible to avoidfrequent interruptions and thus ensuretime for the patient to engage in selfhypnosis. This was made possible by administering medication at regular intervals and posting signs on his door duringprearranged 20-minute periods for selfhypnosis.

Case 3. Debra, a 27-year-old singlewoman with breast cancer, suffered severe phantom pain following mastectomy. Although she was enrolled ingraduate school prior to her surgery, shedropped out because pain interfered withher concentration. For seven years priorto her illness, she had lived alone or withher boyfriend, but during her recoveryfrom surgery she returned home to becared for by her parents. Debra's physicians were optimistic about her chancesfor rehabilitation and a full life. However, she began to regress psychologically, depending on her parents to helpher with such tasks as dressing and cooking, which she realistically could performherself. She was referred for hypnotherapy by her physicians when effortsat rehabilitation failed, causes and treatment for prolonged pain remained unclear, and she became despondent andprepared to die.

Debra presented as a passive, withdrawn woman, reportedly different from

VOL.30, NO.3 MAY/JUNE1980 133

the woman she was prior to mastectomy.She admitted feeling that she had lost herfemininity and was no longer attractiveto males. Recently, she had broken upwith her boyfriend and felt she would notpursue relationships with other males.Hypnotherapy centered on relieving heranxiety and increasing her feelings ofself-esteem. She was asked to visualizethe woman she was prior to her diagnosisand the woman she was after surgery.She made her own connections and associations regarding the changes that hadoccurred. In fact, she was surprised athow much she had regressed and acknowledged that complaints of pain kepther family and friends attentive to herbecause they felt sorry for her.

Under hypnotic suggestion, Debrahad conversations with her former selfand then with the dependent, pain-riddenwoman she had become. Suggestionswere made about her becoming increasingly active and more oriented towardliving. Self-hypnosis was initiated as ameans to help Debra relax, to enjoyphysical contact with her boyfriend, andto become less aware of physical pain.Her poor self-image and fear of rejectionwere overcome as she slowly became desensitized to her surgical scar. In thisprocess she was able to tolerate the painuntil it was significantly relieved.

Within a year, Debra was attendingschool full time and was no longer afraidto date. Although still involved with herboyfriend, she expressed a desire to remain single for a longer period of timeto avoid rushing into marriage with thefirst person who had accepted her assomebody who had had a mastectomy.Continued use of self-hypnosis took theform of daily meditation. In addition, shereported developing greater self-confidence, increasing relief from physicaldiscomfort, and an ability to distanceherself from fears of dying.

Case 4. This case is included to illustrate that although hypnosis is often helpful in the management of cancer pain,it is not always entirely successful. Loiswas a 73-year-old woman with pain frombone cancer. She had had a full career

as an elementary school administrator andfor the past 25 years had operated herown private school. She was angry aboutdeveloping cancer and frustrated thatthe pain was interfering with her abilityto work. She found narcotic analgesicsineffective. Hypnosis was suggested as ameans to help her gain control over thepain and to deal with her anger and senseof helplessness. Although Lois seemedwilling to engage in hypnotherapy, shewas unable to significantly reduce thepain outside of the therapeutic setting.

Lois had been in a position of authority most of her adult life and haddifficulty accepting suggestions to relaxand to alter her cognitions to develop asense of control over her pain. As shestruggled against the awareness of herpoor prognosis, she may have generalizedher defenses to fight off all outside forces,including therapeutic ones. Lois experienced frustration when progress wasslow, and she prematurely terminatedtherapy.

It is unfortunate that Lois left therapy without the opportunity to explorepsychological issues impinging on herpain and illness (such as the issue ofcontrol by others), because it may bethat further therapy would have enabledher to be open to pain relief that mighthave lasted beyond the office sessions.

In the three successful cases described, hypnosis was used for immediaterelief, with suggestions to reduce anxietyand to promote analgesia and relaxation.This phase was followed by the teachingof self-hypnosis to significantly increasethe patient's sense of self-control. Andfinally, therapy was broadened to dealwith the psychological issues related topain, disease, separation, and death.These cases illustrate that hypnosis isbeneficial as part of the total treatmentplan in managing patients with cancerpain. Hypnosis is not always successful,however, and should not be perceived aseither a panacea or a “¿�lastresort.―

Although hypnotherapy has beensuccessful in reducing pain and anxiety,it is not magical. Patients must be informed about its nature, benefits, and

CA-A CANCER JOURNAL FOR CLINICIANS134

limitations, and it is imperative that theybe receptive and motivated to accept theservices of the clinician for psychotherapy or hypnotherapy. To facilitate treatment success, the clinician must evaluatethe patient's needs and motivations andapply this knowledge in choosing hypnosis and/or other psychological strategies.Expectations of instant improvementscan lead to frustration and disappoint

ment for both therapist and patient, andtend to result in abortive treatment. Patients must be willing to actively engagein therapy; they face treatment failureif they expect to be passive recipients.Short but structured periods of time,especially in the initial phases of therapy,must be allotted, and an effort to practiceself-hypnosis must be part of the patient'scommitment to treatment.

VOL. 30, NO.3 MAY/JUNE 1980 135

tients deal with death and separation.Ultimately, the value of hypnosis lies

in enabling an individual to potentiateinner capacities for creating psychological quiescence and physical comfort. Fora suffering cancer patient, relief thatcomes from within can provide a muchneeded experience of personal efficacyand strength.

SummaryIn the treatment of cancer, particularlywhen pain is a serious symptom, psychological support of a patient is importantand can, in fact, facilitate ongoing oncologic treatment. Hypnosis represents apsychological technique of great potencyfor reducing pain, increasing patients'life-enhancing attitudes, and helping pa

References

1. Hilgard ER: Hypnosis in the Relief ofPain. Los Altos, William Kaufman Inc.1975, pp 86-103.2. Barber J: Hypnosis as a psychologicaltechnique in the management of cancerpain. Cancer Nurs J 11:361-363, 1978.3. Barber J: The efficacy of hypnotic analgesia for dental pain in individuals of bothhigh and low hypnotic susceptibility. Unpublished doctoral dissertation, Universityof Southern California, 1976.4. Barber J: Maximizing the effectiveness ofhypnosis through indirect suggestion. Paperpresented at the meeting of the AmericanPsychological Association, Toronto, Canada, Aug 31, 1978.S. Diamond M: Issues and methods formodifying responsivity to hypnosis. Ann NYAcad Sci 296:119-128, 1977.6. Wickramasekera I: On attempts to modify hypnotic susceptibility: some psycho

logical procedures and promising directions.Ann NY Acad Sci 296: 143-153, 1977.7. Sachs L: Construing hypnosis as modifiable behavior, in Jacobs A, Sachs L (eds):The Psychology of Private Events. NewYork, Academic Press, 1971.8. Alman B: Consequences of direct andindirect suggestions on success of posthypnotic behavior. Paper presented at the meeting of the American Society for ClinicalHypnosis, San Francisco, California, 1978.9. Schafer D, Hernandez A: Hypnosis, painand the context of therapy. mt@ Clin ExpHypn 26:143-153, 1978.10. Perry C, Gelfand R, Marcovitch P: Therelevance of hypnosis susceptibility in theclinical context. J Abnorm Psychol 88:592-603, 1979.11. Polster E, Polster M: Gestalt Therapylntegrated. New York, Vintage Books, 1973.

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WAR AND PEACE

It is the greatest tragedy of the scientific community that so large a proportion of itsactivity is devoted to the learning of war and so little to the learning of peace. Itcould well be that because of this the overall long-run impact of science is to bringcloser the day of human extinction.

Nevertheless, science is also the greatest hope of the human race.

From: Boulding KE: Science: our common heritage. Science 207:836, 1980. Copyright1980 by the American Association for the Advancement of Science.