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Cancer Pain: Psychological

Management UsingHypnosis

Joseph Barber, Ph.D.


Jean Gitelson

Psychological approaches are important symptom, as once was believed; it is an


in the management of cancer pain, and altered state of consciousness character
hypnosis is an especially useful technique ized by changes in perception (i.e., anal
that can be integrated into the total care gesia) or memory (i.e., amnesia or by
of the patient. Although a major appli permnesia).
cation of hypnosis to cancer patients is Although individuals differ in the fa
the direct relief of pain,1'2 there are wider cility with which they can be hypno
psychotherapeutic benefits as well: inner tized, we find that the degree of hyp
strength or will to live can be increased notic susceptibility is not critical to the
and directed to the patient's development clinical result. Controversy surrounds
of greater personal responsibility for his this issue, but there is evidence that even
or her well-being. Hypnosis can be persons of low hypnotic susceptibility
learned and skillfully employed by the can achieve clinical hypnotic success.340
physician, by consulting psychologists or In the clinical context, we suggest that
psychiatrists, and by the nursing staff. the issue of susceptibility be ignored.
Hypnosis has been used throughout Every patient should be presumed capa
this century, both as a medical technique ble of attaining a clinically useful hyp
(for analgesia, muscle relaxation, and in notic state.5
some cases, to facilitate healing) and as A clinicallyuseful hypnotic state
a psychotherapeutic tool (to alleviate simply means that quality or degree or
symptoms, uncover forgotten material, level of hypnosis that facilitates thera
and facilitate behavioral change). His peutic progress. Like other states of con
torically, it has been associated with mys sciousness (including the normal waking
ticism. However, the current scientific state), the state of hypnosis varies over
understanding of hypnosis is rooted in time and circumstance. Although it is not
rational, demonstrable psychological clear what determines the depth that a
principles. Hypnosis is a natural human particular patient will achieve at a given
ability, not an aberration or neurotic time, depth is partly dependent on the
trust felt by the patient in the situation,
Dr. Barber is Assistant Professor, Depart how much time is allowed, and to some
ment of Anesthesiology/Pain Management extent, on hypnotic technique. A dis
Clinic, University of California School of cussion of the techniques of hypnosis is
Medicine, Los Angeles, California. beyond the scope of this paper. However,
Ms. Gitelson is Associate in Psychology, clinical training in the use of'hypnosis
Department of Psychiatry, Neuropsychi
atric Institute, University of California includes training in certain techniques
School of Medicine, Los Angeles, California. used to promote adequate clinical depth.

130 CA-ACANCERJOURNALFORCLINICIANS
Although it was once thought that the This can lead to increased chances of
ability to develop hypnotic analgesia was adaptive rehabilitation and/or greater
dependent on significant hypnotic depth, acceptance of discomfort and premature
our experience suggests, to the contrary, death.
that significant analgesia can be achieved Such use of hypnosis assumes a wider
in only a light state of hypnosis. For psychotherapeutic context, however. By
purposes of analgesia, then, depth is not this we mean that a psychological ap
necessarily an important consideration. proach to a patient is intended to foster
In the psychological management of a patient's own resources: to support the
cancer pain, we view hypnosis as one
component to be appropriately inte
grated into the wider therapeutic context Hypnosis
can help the cancer
incontrast to the view that hypnosis is, patient when medication or surgery
by itself, a complete and adequate inter
cannot..
vention. The incorporation of hypnosis
into a treatment plan to control cancer
pain has three principal advantages:

Hypnosis can alleviate pain without patient's self-esteem and to explore ways
unpleasant or destructive side effects. of increasing it; to expand the patient's
The degree of pain relief achieved can awareness of his or her inner life and
range from moderate control to total awareness of the extent to which this can
analgesia. affect the patient's experience of self,
family, work, and the illness. We are im

Hypnosis does not reduce normal
pressed with the value of gestalt tech
functioning and does not mentally in
niques11 in providing a model of psycho
capacitate the patient in any way, nor
logical intervention. While affording the
does the patient develop tolerance to patient an opportunity to experience in
its effects.
sight, the gestalt approach also suggests

Hypnosis can be used to promote life concrete behavioral changes to facilitate
enhancing attitudes in the patient, and therapeutic goals. It is important, then,
the attitude toward the cancer can be that the use of hypnotic techniques be a
altered in beneficial ways. part of other psychological treatment.
Hypnosis, then, can help the cancer While this fact does not preclude the use
patient when medication or surgery can of hypnosis by psychologically untrained
not, and has none of the disadvantages clinicians, it is necessary to understand
sometimes associated with medication the importance of taking the patient's
and surgery. Further, hypnosis can ac psychological needs into consideration
celerate the psychological processes that when formulating a treatment plan.
must be activated in the effective man Behavioral techniques are significant
agement of chronic illness. For reasons concomitants when hypnosis is used to
not yet understood, the development of manage pain. The use of psychological
such an altered state of consciousness in techniques assumes, of course, that pa
conjunction with appropriate therapeutic tients are motivated and committed to
guidance can rapidly reduce obsessional, work on their own outside the therapeu
destructive thoughts, and can nourish a tic setting. It is important to formulate
patient's self-esteem by helping him or realistic goals for the therapist and pa
her to focus on personal capabilities and tient, and a specific time in which be
active participation in the therapy. This havioral assignments will be performed.
supports the patient's capacity to func For instance, one goal in managing can
tion and reduces the otherwise inevitable cer pain is to develop self-control over
sense of helplessness. Through hypnosis pain and its associated anxieties. It is
a patient may be freed from anxieties important that a patient spend a certain
associated with pain, disease, or death. amount of time daily to initiate and prac

@ VOL. 30, NO. 3 MAY/JUNE 1980 l@ 131


EHC8-15F-6ZAX ____
tice self-hypnosis. This strategy requires thinking developed, and she began to
that a patient participate in his or her accuse her husband of seeking lovers.
own care. Hypnosis was employed to help re
Involving family members is also im duce her escalating anxiety and depres
portant when hypnosis is used as a thera sion and to enable her to use her own
peutic modality, and it is helpful for capabilities to relieve discomfort and ob
them to actually learn how to participate sessional thinking. Additional psycho
in the patient's hypnosis. This not only therapy sessions in conjunction with hyp
diminishes the experience of helplessness nosis enabled Lynn to become aware that
on the part of the patient and family she was using pain as a means of securing
members, but also facilitates meaningful her husband's attention and maintaining
communication that otherwise is often her doctors' interest in her.
compromised as the disease progresses Two different techniques were used
and medical treatment becomes more in Lynn's case. First, structured guided
intrusive. imagery enabled her to focus on emo
Six hypnotic strategies may be used tional issues in an indirect manner by
to control cancer pain: creating mental images associated with

directly blocking awareness of pain a relaxed setting. Second, deeper hyp


through the suggestion of anesthesia notic inductions were employed to reduce
or analgesia; her pain and to begin the process of ac
substituting another feeling (such as cepting the terminal nature of her illness.
pressure) for the pain; The value of hypnosis was its positive

moving the perception of the pain to effect in increasing Lynn's sense of inner
a smaller or less vulnerable area of the strength and enhancing self-directed ef
body; forts at relaxation and pain reduction.

altering the meaning of the pain so it In addition, changes in her attitude de
becomes less important and less debili veloped that helped her to face her im
tating; pending death and separation from her

increasing tolerance for the pain; and husband.

in extreme cases, dissociating percep Case 2. Mark, a 42-year-old pharma
tion of the body from the patient's ceutical company representative, was di
awareness. agnosed with testicular cancer. He had
intense pain in his pelvic area and was
The following case reports describe fearful of becoming addicted to the nar
patients with pain secondary to malig cotics used to treat the pain. Mark was
nant disease who used clinical hypnosis: unable to face his physicians' reports that
Case 1. Lynn, a 47-year-old, recently his cancer was progressing rapidly and
married woman diagnosed with acute refused to accept the fact that his illness
myelogenous leukemia, complained of could not be cured. He insisted that there
pain in the pelvic and lower back areas. must be a drug to help him and began
Physical findings did not explain such to make plans to travel to Mexico for
discomfort. After six months of remis laetrile treatments.
sion, Lynn was rehospitalized to begin Mark presented doctors and nurses
an intensive course of chemotherapy. It with difficulties because he would not
was noted by her physicians and nurses comply with instructions and attempted
that she was becoming despondent and to plan his own treatment. Psychological
passive about her treatment, character consultation was requested because he
istics not evident during prior hospital was assessed as being depressed and de
izations. In addition, she was becoming fiant, showing inappropriate denial, and
increasingly dependent on her husband making unrealistic plans for marriage in
and physicians and reported a growing spite of the unfavorable prognosis.
sense of fear and helplessness when they Hypnosis was indicated at first as a
were not available. Paranoid obsessional means of helping Mark to relax and to

132 CA-A CANCER JOURNAL FOR CLINICIANS


reduce his anxiety. Resistance to this Pain control was maintained without
form of intervention was resolved when narcotics until two weeks prior to his
Mark was taught techniques to hypnotize death. Even then, narcotic dosages were
the therapist (as a means of increasing minimal, thus allowing cognitive func
his trust). Once he began to feel he was tioning during the reunion with his fam
not being used as a guinea pig,he be ily and the process of separation from his
came amenable to hypnotic inductions. girlfriend. Psychological distress was de
Suggestions to relax and develop better creased with self-hypnosis, and he was
communication with the hospital staff less anxious in the hospital than he had
helped relieve some of his feelings of
helplessness. With a growing sense of
ability to communicate his needs to the
hospital staff, Mark became less defen
Pain
control was maintained without
sive when presented with test results. narcotics until two weeks prior to
The treatment plan for hypnotherapy (the patient's) death.
had three components. Initial efforts
were focused on helping the patient relax
and interact cooperatively with the medi been prior to hypnotherapy. It was to the
cal and nursing staff. Relaxation sugges credit of the medical and nursing staff
tions were given, and the patient began that practical issues could be attended to:
to experience less anxiety. Second, the with their help, it was possible to avoid
patient learned self-hypnosis to help frequent interruptions and thus ensure
counteract pain in his pelvic area. time for the patient to engage in self
The third phase of treatment in hypnosis. This was made possible by ad
volved the patient working on psycho ministering medication at regular inter
logical issues relating to the progress of vals and posting signs on his door during
his disease and the inevitability of sepa prearranged 20-minute periods for self
ration from his loved ones. As a result of hypnosis.
the successful results of the previous two Case 3. Debra, a 27-year-old single
phases of treatment, Mark became in woman with breast cancer, suffered se
creasingly involved in assessing his re vere phantom pain following mastec
lationship with his girlfriend and gradu tomy. Although she was enrolled in
ally accepted the physicians' reports graduate school prior to her surgery, she
about his future. Using a hypnotic tech dropped out because pain interfered with
nique that allowed him to visually project her concentration. For seven years prior
himself and his girlfriend onto a halluci to her illness, she had lived alone or with
nated movie screen, he was able to dis her boyfriend, but during her recovery
tance himself from his own psychological from surgery she returned home to be
confficts about separation. Some resolu cared for by her parents. Debra's physi
tion was achieved in acknowledging the cians were optimistic about her chances
limitations of his treatment and the real for rehabilitation and a full life. How
ity that he would die within a few weeks. ever, she began to regress psychologi
As he became more willing to face cally, depending on her parents to help
death, Mark was determined to reconcile her with such tasks as dressing and cook
family differences. Age regression was em ing, which she realistically could perform
ployed when he felt ready to explore pain herself. She was referred for hypno
ful childhood memories. Mark requested therapy by her physicians when efforts
his parents and brother to fly from the at rehabilitation failed, causes and treat
East Coast to be with him while he was ment for prolonged pain remained un
still conscious. He was able to spend a clear, and she became despondent and
week before his death talking, laughing, prepared to die.
and crying with his family in a way that Debra presented as a passive, with
was impossible prior to hypnotherapy. drawn woman, reportedly different from

VOL.30, NO.3 MAY/JUNE1980 133


the woman she was prior to mastectomy. as an elementary school administrator and
She admitted feeling that she had lost her for the past 25 years had operated her
femininity and was no longer attractive own private school. She was angry about
to males. Recently, she had broken up developing cancer and frustrated that
with her boyfriend and felt she would not the pain was interfering with her ability
pursue relationships with other males. to work. She found narcotic analgesics
Hypnotherapy centered on relieving her ineffective. Hypnosis was suggested as a
anxiety and increasing her feelings of means to help her gain control over the
self-esteem. She was asked to visualize pain and to deal with her anger and sense
the woman she was prior to her diagnosis of helplessness. Although Lois seemed
and the woman she was after surgery. willing to engage in hypnotherapy, she
She made her own connections and asso was unable to significantly reduce the
ciations regarding the changes that had pain outside of the therapeutic setting.
occurred. In fact, she was surprised at Lois had been in a position of au
how much she had regressed and ac thority most of her adult life and had
knowledged that complaints of pain kept difficulty accepting suggestions to relax
her family and friends attentive to her and to alter her cognitions to develop a
because they felt sorry for her. sense of control over her pain. As she
Under hypnotic suggestion, Debra struggled against the awareness of her
had conversations with her former self poor prognosis, she may have generalized
and then with the dependent, pain-ridden her defenses to fight off all outside forces,
woman she had become. Suggestions including therapeutic ones. Lois experi
were made about her becoming increas enced frustration when progress was
ingly active and more oriented toward slow, and she prematurely terminated
living. Self-hypnosis was initiated as a therapy.
means to help Debra relax, to enjoy It is unfortunate that Lois left ther
physical contact with her boyfriend, and apy without the opportunity to explore
to become less aware of physical pain. psychological issues impinging on her
Her poor self-image and fear of rejection pain and illness (such as the issue of
were overcome as she slowly became de control by others), because it may be
sensitized to her surgical scar. In this that further therapy would have enabled
process she was able to tolerate the pain her to be open to pain relief that might
until it was significantly relieved. have lasted beyond the office sessions.
Within a year, Debra was attending In the three successful cases de
school full time and was no longer afraid scribed, hypnosis was used for immediate
to date. Although still involved with her relief, with suggestions to reduce anxiety
boyfriend, she expressed a desire to re and to promote analgesia and relaxation.
main single for a longer period of time This phase was followed by the teaching
to avoid rushing into marriage with the of self-hypnosis to significantly increase
first person who had accepted her as the patient's sense of self-control. And
somebody who had had a mastectomy. finally, therapy was broadened to deal
Continued use of self-hypnosis took the with the psychological issues related to
form of daily meditation. In addition, she pain, disease, separation, and death.
reported developing greater self-confi These cases illustrate that hypnosis is
dence, increasing relief from physical beneficial as part of the total treatment
discomfort, and an ability to distance plan in managing patients with cancer
herself from fears of dying. pain. Hypnosis is not always successful,
Case 4. This case is included to illus however, and should not be perceived as
trate that although hypnosis is often help either a panacea or a lastresort.
ful in the management of cancer pain, Although hypnotherapy has been
it is not always entirely successful. Lois successful in reducing pain and anxiety,
was a 73-year-old woman with pain from it is not magical. Patients must be in
bone cancer. She had had a full career formed about its nature, benefits, and

134 CA-A CANCER JOURNAL FOR CLINICIANS


limitations, and it is imperative that they ment for both therapist and patient, and
be receptive and motivated to accept the tend to result in abortive treatment. Pa
services of the clinician for psychother tients must be willing to actively engage
apy or hypnotherapy. To facilitate treat in therapy; they face treatment failure
ment success, the clinician must evaluate if they expect to be passive recipients.
the patient's needs and motivations and Short but structured periods of time,
apply this knowledge in choosing hypno especially in the initial phases of therapy,
sis and/or other psychological strategies. must be allotted, and an effort to practice
Expectations of instant improvements self-hypnosis must be part of the patient's
can lead to frustration and disappoint commitment to treatment.

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


Summary tients deal with death and separation.
In the treatment of cancer, particularly Ultimately, the value of hypnosis lies
when pain is a serious symptom, psycho in enabling an individual to potentiate
logical support of a patient is important inner capacities for creating psychologi
and can, in fact, facilitate ongoing onco cal quiescence and physical comfort. For
logic treatment. Hypnosis represents a a suffering cancer patient, relief that
psychological technique of great potency comes from within can provide a much
for reducing pain, increasing patients' needed experience of personal efficacy
life-enhancing attitudes, and helping pa and strength.

References
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1975, pp 86-103. 7. Sachs L: Construing hypnosis as modifi
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technique in the management of cancer The Psychology of Private Events. New
pain. Cancer Nurs J 11:361-363, 1978. York, Academic Press, 1971.
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gesia for dental pain in individuals of both indirect suggestions on success of posthyp
high and low hypnotic susceptibility. Un notic behavior. Paper presented at the meet
published doctoral dissertation, University ing of the American Society for Clinical
of Southern California, 1976. Hypnosis, San Francisco, California, 1978.
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@ presented at the meeting of the American and the context of therapy. mt Clin Exp
Psychological Association, Toronto, Can Hypn 26:143-153, 1978.
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S. Diamond M: Issues and methods for relevance of hypnosis susceptibility in the
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ify hypnotic susceptibility: some psycho lntegrated. New York, Vintage Books, 1973.

WAR AND PEACE


It is the greatest tragedy of the scientific community that so large a proportion of its
activity is devoted to the learning of war and so little to the learning of peace. It
could well be that because of this the overall long-run impact of science is to bring
closer 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. Copyright
1980 by the American Association for the Advancement of Science.

136 CA-A CANCER JOURNAL FOR CLINICIANS