HYPNOSIS AND PALLIATIVE CARE
The World Health Organization (WHO) defines “palliative” that branch of medicine which provides global and proactive care for patients who are affected by diseases that no longer respond to treatments and that lead to death. This discipline focuses on the management of pain, of other symptoms and of psychological, social and spiritual consequences of the disease. The aim of palliative care is, therefore, to reach the best possible quality of life for patients and their families. This kind of medicine, in other words, does not consist only in medical procedures; it can lead to a path of reconciliation and pacification that includes both patients and the people around them1. Being a discipline that considers patients as a “whole” that expresses many different kinds of needs (on biomedical, psychological and existential levels), it spontaneously includes, among its therapeutical instruments, integrative approaches that consider mind-body connections.
From this point of view, hypnosis represents a useful instrument because it can be applied in many forms to the management of terminal patients (R. Peynovska, 2005). In addition to controlling the symptoms of the disease, that can include pain or aspecific symptoms such as fatigability, irritability, insomnia, or general sensations of discomfort, it can help to manage side effects of treatments that, especially in pathologies such as cancer, can become very impairing (e.g. vomit, refusal of food). From a psychological standpoint, hypnosis can contribute to regulate anxiety, depression, feelings of anger, guilt, frustration and loneliness, typical states of such conditions. Finally it can improve self-esteem, active involvement in treatment programs and the re-acquisition of control on one’s own life.
Among patients who suffer from an advanced state cancer, 84% report of being afflicted by intense pain, 49% by respiratory difficulties and 33% by nausea (C. Liossi, 2001); additionally, pharmacological treatment of these symptoms can cause side effects such as opioid induced constipation, delusions and states of excessive sedation. Many of these problems are generalizable to other kinds of terminal patients, such as those who suffer from multiple sclerosis: in these people pain is a very common symptom and the vast research in this field reports estimates that swing from 40% to 80% (M.P. Jensen et al., 2009).
In addition to difficulties related to the symptomatic component of the disease, these patients can encounter many difficulties in facing, accepting and adapting to the idea of imminent death. This aspect, along with the inevitable modification of daily life, can often lead to depression and anxious states.
Especially regarding these states, psychological interventions – group or individual ones – have lead to reductions in psychological stress and depressive symptoms, to improve quality of life of cancer patients and to even have positive effects on survival rate (Spiegel & J.R., 1983; Spiegel et al., 1981; Spiegel et al., 1989; Walker et al., 1999). Many approaches have been experimented in this area, among these there are existential, familial, supportive-expressive and cognitive-behavioural interventions.
Clinical hypnosis has demonstrated to be effective both in treatment of children (Liossi, 2000; Liossi, 1999; Liossi & Hatira, 1999) and of adults affected by cancer. Beneficial effects include improvements of the immune system’s functionality (Fox et al., 1999; Gruzelier, n.d.), of anxiety states, pain, dyspnoea and insomnia. Specifically, in the matter of pain, patients treated with a combination of psychotherapy and self-hypnosis benefit, in addition to a reduction of pain intensity, which is obtained also by patients attending only psychotherapy, also from a reduction of frequency and duration of painful episodes. It is also noteworthy that in these same patients, an improvement of survival rate can be observed.
To better understand potential benefits of hypnosis, Liossi (Liossi & White, 2001) compared in a randomized trial two groups of patients, the first one artreated with a standard protocol and the second one with the addition of hypnosis sessions. The first group followed a pharmacological protocol aimed to manage pain and other symptoms, as suggested by WHO guidelines, plus 4 weekly, half an hour sessions of cognitive-existential counselling. The second group, in addition to standard protocol, included 4 weekly hypnosis sessions of 30 minutes each.
Results, as previous research indicated, (Spiegel et al., 1981; Spiegel & J.R., 1983; Moorey et al., 1998; Walker et al., 1999), demonstrate that the hypnosis group had greater reductions of anxiety and depression; patients also reported a higher quality of life, especially in areas concerning psychological variables such as their relationship with the disease. This aspect becomes more relevant if we consider that variables such as psychological stress in terminal patients constitute a risk factor for the development of psychiatric conditions such as anxiety or depressive mood disorders. Also regarding physical symptoms, patients in hypnosis group showed great improvements.
Similar results have been replicated in other studies (R. Peynovska, 2005; Rajasekaran et al., 2005), providing promising data about the management of typical problematic aspects of terminal patients, such as changes in body image, loss of functionality in daily activities and the inevitable loss of a part of their independence. Especially when the hypnotic treatment starts immediately after diagnosis, it can improve patients’ adaptation to the disease and thus prevent the onset of conditions such as anxiety states, depressive disorders or panic attacks. Early beginning of treatment also improves adherence to therapy and general psychological response, which is a prognostic factor connected to survival rate.
Another way in which terminal patients can benefit from hypnosis is through self-hypnosis trainings. A recent study (M.P. Jensen, 2009) compared two groups of patients who were affected by multiple sclerosis with chronic pain. Interventions in both groups focused on pain but, while in the first group progressive muscle relaxation techniques were taught, in the second one patients were trained in self-hypnosis techniques. Researchers payed close attention to contain potential effects of expectations of both interventions by communicating to participants that an approach that contained both relaxation and hypnotic elements would have been used. Results showed that patients who received a self-hypnosis training reported greater pain reductions than patients who were assigned to progressive muscle relaxation, even if expectations of efficacy were similar for both treatments. In the group trained in self-hypnosis, while suggestibility was irrelevant, an effect of positive expectation was observed: in other words, the higher the expectations, the higher the result. This finding is consistent with the hypothesis that patient’s expectations can play a role both on immediate and long-term effects of hypnotic analgesia of chronic pain. In other words, being aware of the potential of hypnosis can be useful to patients to reach more satisfying results.
In conclusion, we report an interesting article (Cassileth & Keefe, 2010) that investigates integrative approaches for the treatment of neuropathic cancer-related pain. Neuropathic pain is caused by a direct consequence of a lesion or of a disease that targets the somatosensory system. Cancer patients often suffer from this specific kind of pain because of nerve compression or because the neurotoxicity of chemotherapy. Researchers report that actually there are no specific substances to manage neuropathic pain and that commonly used agents tend to have low success rates (Santiago-Figueroa & Kuffler, 2009; U.S. Food and Drug Administration, 2009). Considering that the fact that pain is a complex process, which involves the whole psychosocial unity of patients, is generally ignored, it becomes clear how necessary it is to get to an integrated pain treatment. Interventions can be applied to different aspects. An example that comes from research (Cassileth & Keefe, 2010) reports that catastrophizing patients (who tend to ruminate or to feel hopeless) are more prone to suffer from intense pain. By using self-hypnotic techniques, patients can relax and anesthetize pain, restructuring it in a less negative frame. One study in particular (Jensen et al. 2009) demonstrates that patients with persistent pain, who are trained in self-hypnosis, obtain a quick and remarkable decrease in pain that remains stable in time.
That said, we can state that applying hypnosis, in its different forms, can be extremely useful to terminal patients in crucial aspects of their existence, such as efficacious and long term management of impairing symptoms and pain and such as better coping with existential aspects of the disease in order to obtain better quality of life, a variable that is, among the rest, related to survival rate.
1. Cancer Pain Relief and Palliative Care", World Health Organization Technical Report Series, 804, 1990
Bibliography
From this point of view, hypnosis represents a useful instrument because it can be applied in many forms to the management of terminal patients (R. Peynovska, 2005). In addition to controlling the symptoms of the disease, that can include pain or aspecific symptoms such as fatigability, irritability, insomnia, or general sensations of discomfort, it can help to manage side effects of treatments that, especially in pathologies such as cancer, can become very impairing (e.g. vomit, refusal of food). From a psychological standpoint, hypnosis can contribute to regulate anxiety, depression, feelings of anger, guilt, frustration and loneliness, typical states of such conditions. Finally it can improve self-esteem, active involvement in treatment programs and the re-acquisition of control on one’s own life.
Among patients who suffer from an advanced state cancer, 84% report of being afflicted by intense pain, 49% by respiratory difficulties and 33% by nausea (C. Liossi, 2001); additionally, pharmacological treatment of these symptoms can cause side effects such as opioid induced constipation, delusions and states of excessive sedation. Many of these problems are generalizable to other kinds of terminal patients, such as those who suffer from multiple sclerosis: in these people pain is a very common symptom and the vast research in this field reports estimates that swing from 40% to 80% (M.P. Jensen et al., 2009).
In addition to difficulties related to the symptomatic component of the disease, these patients can encounter many difficulties in facing, accepting and adapting to the idea of imminent death. This aspect, along with the inevitable modification of daily life, can often lead to depression and anxious states.
Especially regarding these states, psychological interventions – group or individual ones – have lead to reductions in psychological stress and depressive symptoms, to improve quality of life of cancer patients and to even have positive effects on survival rate (Spiegel & J.R., 1983; Spiegel et al., 1981; Spiegel et al., 1989; Walker et al., 1999). Many approaches have been experimented in this area, among these there are existential, familial, supportive-expressive and cognitive-behavioural interventions.
Clinical hypnosis has demonstrated to be effective both in treatment of children (Liossi, 2000; Liossi, 1999; Liossi & Hatira, 1999) and of adults affected by cancer. Beneficial effects include improvements of the immune system’s functionality (Fox et al., 1999; Gruzelier, n.d.), of anxiety states, pain, dyspnoea and insomnia. Specifically, in the matter of pain, patients treated with a combination of psychotherapy and self-hypnosis benefit, in addition to a reduction of pain intensity, which is obtained also by patients attending only psychotherapy, also from a reduction of frequency and duration of painful episodes. It is also noteworthy that in these same patients, an improvement of survival rate can be observed.
To better understand potential benefits of hypnosis, Liossi (Liossi & White, 2001) compared in a randomized trial two groups of patients, the first one artreated with a standard protocol and the second one with the addition of hypnosis sessions. The first group followed a pharmacological protocol aimed to manage pain and other symptoms, as suggested by WHO guidelines, plus 4 weekly, half an hour sessions of cognitive-existential counselling. The second group, in addition to standard protocol, included 4 weekly hypnosis sessions of 30 minutes each.
Results, as previous research indicated, (Spiegel et al., 1981; Spiegel & J.R., 1983; Moorey et al., 1998; Walker et al., 1999), demonstrate that the hypnosis group had greater reductions of anxiety and depression; patients also reported a higher quality of life, especially in areas concerning psychological variables such as their relationship with the disease. This aspect becomes more relevant if we consider that variables such as psychological stress in terminal patients constitute a risk factor for the development of psychiatric conditions such as anxiety or depressive mood disorders. Also regarding physical symptoms, patients in hypnosis group showed great improvements.
Similar results have been replicated in other studies (R. Peynovska, 2005; Rajasekaran et al., 2005), providing promising data about the management of typical problematic aspects of terminal patients, such as changes in body image, loss of functionality in daily activities and the inevitable loss of a part of their independence. Especially when the hypnotic treatment starts immediately after diagnosis, it can improve patients’ adaptation to the disease and thus prevent the onset of conditions such as anxiety states, depressive disorders or panic attacks. Early beginning of treatment also improves adherence to therapy and general psychological response, which is a prognostic factor connected to survival rate.
Another way in which terminal patients can benefit from hypnosis is through self-hypnosis trainings. A recent study (M.P. Jensen, 2009) compared two groups of patients who were affected by multiple sclerosis with chronic pain. Interventions in both groups focused on pain but, while in the first group progressive muscle relaxation techniques were taught, in the second one patients were trained in self-hypnosis techniques. Researchers payed close attention to contain potential effects of expectations of both interventions by communicating to participants that an approach that contained both relaxation and hypnotic elements would have been used. Results showed that patients who received a self-hypnosis training reported greater pain reductions than patients who were assigned to progressive muscle relaxation, even if expectations of efficacy were similar for both treatments. In the group trained in self-hypnosis, while suggestibility was irrelevant, an effect of positive expectation was observed: in other words, the higher the expectations, the higher the result. This finding is consistent with the hypothesis that patient’s expectations can play a role both on immediate and long-term effects of hypnotic analgesia of chronic pain. In other words, being aware of the potential of hypnosis can be useful to patients to reach more satisfying results.
In conclusion, we report an interesting article (Cassileth & Keefe, 2010) that investigates integrative approaches for the treatment of neuropathic cancer-related pain. Neuropathic pain is caused by a direct consequence of a lesion or of a disease that targets the somatosensory system. Cancer patients often suffer from this specific kind of pain because of nerve compression or because the neurotoxicity of chemotherapy. Researchers report that actually there are no specific substances to manage neuropathic pain and that commonly used agents tend to have low success rates (Santiago-Figueroa & Kuffler, 2009; U.S. Food and Drug Administration, 2009). Considering that the fact that pain is a complex process, which involves the whole psychosocial unity of patients, is generally ignored, it becomes clear how necessary it is to get to an integrated pain treatment. Interventions can be applied to different aspects. An example that comes from research (Cassileth & Keefe, 2010) reports that catastrophizing patients (who tend to ruminate or to feel hopeless) are more prone to suffer from intense pain. By using self-hypnotic techniques, patients can relax and anesthetize pain, restructuring it in a less negative frame. One study in particular (Jensen et al. 2009) demonstrates that patients with persistent pain, who are trained in self-hypnosis, obtain a quick and remarkable decrease in pain that remains stable in time.
That said, we can state that applying hypnosis, in its different forms, can be extremely useful to terminal patients in crucial aspects of their existence, such as efficacious and long term management of impairing symptoms and pain and such as better coping with existential aspects of the disease in order to obtain better quality of life, a variable that is, among the rest, related to survival rate.
1. Cancer Pain Relief and Palliative Care", World Health Organization Technical Report Series, 804, 1990
Bibliography
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| 2. | Liossi C, White P. Efficacy of Clinical Hypnois in the Enhancement of Quality of Life of Terminally Ill Cancer Patients. Contemporary Hypnosis. 2001;18(3):145-160. |
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