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Blackwell Science, LtdOxford, UKEJCCEuropean Journal of Cancer Care0961-5423Blackwell Publishing Ltd, 200312137142Original ArticleHypnotherapy and cognitive-behaviour therapy in cancer careTAYLOR & INGLETON
Psychological interventions
Hypnotherapy and cognitive-behaviour therapy in cancer
care: the patients’ view
E. E . TA YL O R, bsc, mmedsci, ukcp, director of integrated health care, East Lancashire Integrated Health
Care Centre, Rossendale Hospital, Lancashire & C. IN GLET ON , ba, ma, phd, rgn, rnt, cert ed, senior
lecturer in nursing, University of Sheffield, School of Nursing and Midwifery, Sheffield, UK
TAYLOR E.E. & INGLETON C. (2003) European Journal of Cancer Care 12, 137–142
Hypnotherapy and cognitive-behaviour therapy in cancer care: the patients’ view
Psychological intervention is not widely available for emotionally distressed patients with cancer. The purpose
of this study is to investigate and report on the experiences of eight patients who participated in a programme
consisting of hypnotherapy and cognitive-behaviour therapy. Following the 12-session intervention, qualitative analysis of interview data demonstrated that patients had acquired the skills to enable them to cope, both
with invasive medical procedures and the psychological traumas they faced. The findings also indicated some
initial misconceptions about hypnotherapy and the need to provide a therapy setting sensitive to the needs
of cancer patients undergoing active medical treatment.
Keywords: cancer, hypnotherapy, cognitive-behaviour therapy, qualitative results.
INT RO D U C TIO N
Psychosocial distress and morbidity are frequently
reported following the diagnosis of cancer (Derogatis et al.
1983; Zabora et al. 1997), particularly at diagnosis and
during active treatment (Hughes 1982; Watson et al.
1992). Medical procedures have a significant impact on
quality of life (QOL), not least the side-effects of chemotherapy (Coates et al. 1983; Smith et al. 1991), and the
psychological cost can affect treatment compliance (Watson et al. 1992).
Adaptation to a cancer diagnosis and QOL are
improved when patients are given appropriate information and involved in treatment decisions to the extent
they wish (Fallowfield 1997) and the body of literature on
psychosocial interventions is extremely positive (cf.
Fawzy et al. 1995). However psychotherapy is not widely
available and many distressed cancer patients receive no
psychological help at all (Greer 1997). This is largely a
result of patients concerns not being appropriately identiCorrespondence address: Elizabeth Taylor, East Lancashire Integrated
Health Care Centre, Cribden House, Rossendale Hospital, Rossendale,
Lancashire, BB4 6NE, UK (e-mail [email protected])
European Journal of Cancer Care, 2003, 12, 137–142
© 2003 Blackwell Publishing Ltd
fied (Booth et al. 1996; Heaven & Maguire 1997) as well
as lack of available resources. These factors led one unit
in the north of England, East Lancashire Integrated
Health Care Centre (ELIHCC) to develop a psychotherapeutic intervention to help patients cope with the diagnosis and treatment of cancer. The intervention
combines cognitive-behaviour therapy (CBT) and hypnotherapy in a clinical package to meet individual need and
has become known locally as the ‘Hypno-Chemo
Programme’.
This paper presents findings from an evaluation of the
programme from the patients’ perspective. After describing the background literature, the paper explores the
experiences of participants based upon data gathered
from in-depth qualitative interviews conducted with
eight patients. The discussion will then locate some of
these issues in the wider literature on communication
skills, the therapeutic alliance, cognitive and behavioural
interventions and appropriate treatment location. The
aim of the study is to provide psychotherapists with
patients’ perceptions of the value of a combined cognitive-behavioural therapy/hypnotherapy programme for
cancer care, in order to inform service provision and
dissemination.
TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care
Background literature
Hypnotherapy and related procedures such as relaxation
training and guided imagery (GI) have been used to ameliorate the side-effects of chemotherapy, help patients
adjust to the disease, counteract pain and anxiety and alter
the mechanisms of immunity to hopefully improve prognosis. These interventions have been evaluated in a series
of studies including individual and group therapy. Extensive reviews of this literature (Morrow & Dobkin 1988;
Fawzy et al. 1995; Genuis 1995) have concluded consistently that hypnotherapy is effective in the above areas
with the possible exception of enhancing survival. The
randomized controlled trials relating to the latter have
produced conflicting results with some limited by methodological flaws (Fox 1995; 1998).
Influential in the development of the cognitivebehaviour intervention has been the work of Greer et al.
(1992) who randomly allocated 174 psychologically distressed, early stage cancer patients to an 8-week CBT programme specifically designed for cancer care or to a no
treatment control. The intervention included identification of concerns, cognitive restructuring, behavioural
assignments, progressive muscle relaxation and role play/
imagination to deal with imminent stressful procedures.
Significant advantages were found for the therapy group
on validated psychosocial measures immediately after the
intervention and at 4-month follow-up. At 12-month follow-up, patients who had received therapy still had less
anxiety and depression than controls (Moorey et al. 1994).
There is substantial evidence to demonstrate the efficacy of psychosocial interventions (cf. Fawzy et al. 1995).
However, studies reported from the quantitative perspective restrict understanding of the individual patient’s
interpretation of events, thus limiting the opportunity to
refine interventions more specifically to meet their needs.
The results of randomized controlled trials are infrequently implemented in clinical practice (Haines & Jones
1994) and yield results that do not differentiate between
patients who most need help and those who would have
done well without it (Watson 1983).
The hypno-chemo programme
The hypno-chemo programme, influenced by the work of
Greer et al. (1992) provides adjuvant CBT and hypnotherapy in a structured 12-session programme. Requirements
for inclusion are diagnosis of cancer at any stage and a reasonable command of English. Patients with organic brain
disease or psychotic illness are excluded. A medical and
psychosocial history is ascertained, the intervention
138
explained and treatment plan agreed before written consent is obtained. Hypnosis is induced by eye fixation, passive muscle relaxation and deepening procedures.
Treatment typically involves relaxation, confidence building and GI. Patients are taken verbally through the
sequence of events leading to, during and following chemotherapy infusions. Occurring anxiety, nausea or other
unpleasant sensations are cue controlled by hypnotic suggestion. For example, the patient is asked to visualize a
numerical dial representing nausea and practise turning
the dial up and down to obtain control. The latter is subsequently associated with a cue word, which is used to
reduce nausea in the chemotherapy environment and with
associated stimuli. Patients are asked to visualize their
white blood cells attacking and destroying cancer cells
using images/scenes of their choice. Pain management is
included if required. Hypnotic procedures are supported
by audiotaped instructions. These methods broadly conform to approaches described by Spiegal & Spiegal 1978;
Levitan 1987 and Redd et al. 1983). Cognitive-behaviour
therapy is used to identify and resolve cancer-related psychological problems and follows the procedures described
by Greer (1997). Participants are encouraged to disclose
and express the emotional impact of cancer on themselves
and significant others, taught to identify and challenge the
automatic dysfunctional thoughts underlying anxiety and
depression and replace them with more rational
responses. Task focused behavioural assignments are
encouraged to generate achievement and raise self-esteem.
An attitude of reasonable optimism, determination not to
give in, desire to understand/participate in treatment and
continue to live a normal life is encouraged.
PAT I ENT S AND MET HODS
The study was conducted at ELIHCC, which is adjacent to
a hospice in northern England. The centre provides complementary therapies and orthodox psychotherapy to
three local hospices and community patients and is
funded by a grant from the National Lottery Charities
Board.
Eight patients who had completed the hypno-chemo
programme were purposefully selected (Coyne 1997) for
inclusion in the study, all white females, aged between 32
and 60 years (average age 49). All presented with a first
diagnosis of carcinoma, seven breast and one colon at the
stage of local disease or local disease and regional spread.
All patients underwent surgery and chemotherapy and
seven received radiotherapy. Six patients commenced psychotherapy/hypnotherapy just before or after their first
session of chemotherapy. One patient joined the pro-
© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
European Journal of Cancer Care
Table 1. Interview schedule
1. Can you tell me how you felt when the hypno-chemo
programme was offered to you?
2. How do you feel about the therapy now?
3. If you were to go through the programme again or recommend
it to someone else with cancer, could you suggest any
improvements or changes you would like to make?
4. Is there anything else about the therapy you would like to
discuss?
gramme approximately halfway through chemotherapy
and another after the latter was completed.
Semi-structured interviews were conducted between 1
and 24 months (average 7 months) after the intervention.
Development of the interview schedule followed a procedure described by Bottomley (1998). This approach prepares the interviewer for topics likely to be raised by
participants. Lofland (1971) refers to these topics of interest as ‘puzzlements’, which were jotted down and read by
an independent health professional. This allowed a more
rigorous spread of the range of enquiry, enabling the
researcher to elicit what was ‘puzzling’ in the social context. Each puzzlement/question was written down on a
separate piece of paper and sorted into topically related
piles. Table 1 outlines the four main areas addressed
within the literature.
The tape-recorded interviews were conducted by the
first author in the patients’ homes, typically taking
between 30 min and one hour to complete. The interviews were fully transcribed verbatim for thematic analysis, which requires that the raw data is reorganized under
a series of headings reflecting emerging themes. Accordingly a 14-stage model described by Burnard (1991),
involving familiarization of the range and diversity of the
data, development of a thematic framework, judging the
meaning and significance of the data and applying it to the
framework and finally categorization was used.
FIN D IN G S
The primary themes identified from the data were: gaining help, treatment tailored to individual need, long-term
benefits and service satisfaction/patient information
needs.
Gaining help
Despite the widely publicised need for psychosocial support at all stages of cancer care and local publicity about
the services offered at ELIHCC, some patients had difficulties in accessing the hypno-chemo programme. This is
highlighted by the following quote:
I was halfway through my chemo before I heard about
it, nobody mentioned it before you know . . . If I
hadn’t been so poorly, I doubt that she would have
mentioned it . . .
Referral difficulties may be due to misconceptions
about hypnosis and the low priority given to psychosocial
concerns. There is substantial evidence to suggest that
health professionals are poor at eliciting the latter which
is cause for concern in the light of evidence that patients
with unresolved problems are at risk of later anxiety and
depression (Kornblith et al. 1992; Thomas et al. 1997).
Fear of chemotherapy was paramount in the present
study and this, coupled with feeling overwhelmed by their
diagnosis, led some patients to grasp the hypno-chemo
programme as a lifeline. The following extract encapsulates the views of many of the participants:
It was actually through my breast care nurse, ahmm
– I was doing very badly on my first chemo¢ so I rang
her out of desperation to see if she could put me in
touch with the Centre.
All the research participants received hypnotherapy,
though many had negative preconceived beliefs. For
example:
I could only picture the non-clinical hypnosis; the
stage stuff and I didn’t really know what it was.
Despite detailed explanation of what to expect in a hypnotic induction, patients assumed they would ‘go under’,
meaning lose consciousness or relinquish control to the
therapist.
These misconceptions may prevent patients who could
potentially benefit from hypnotherapy, from seeking reassurance about their concerns and subsequently not
obtaining help. Misunderstandings about hospice were
also apparent. Some patients were inhibited from attending the Centre because it was next door to a hospice, with
patients recommending a separate building off site.
Treatment tailored to individual need
This theme represents the identification of patients’ main
concerns and adopting appropriate therapies to aid their
resolution. That is, following the patient’s agenda rather
than the therapist’s. For example:
They obviously try to assess exactly what your personal needs are and try to work to them.
Not only was this appreciated but patients also valued
the therapists themselves. Given that the latter is recognized as an important variable in treatment outcome, it
© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
139
TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care
was noteworthy to discover that all patients considered
the therapists as skilful and important in their adaptation
to the cancer situation, exemplified by the following:
a lot more confident probably than I was before, a lot
more daring than I used to be and I’ll say what I think
to whom I think.
I couldn’t have managed without her . . . that was the
biggest part of it . . . actually being able to talk . . .
These findings support a substantial body of evidence
demonstrating the efficacy of behavioural approaches in
cancer care (Fawzy et al. 1995; Walker et al. 1999).
Understanding the cognitive model and utilizing the
techniques within it are considered essential to the efficacy of CBT. However, rather than demonstrating comprehension of the model and separating out the cognitive
and behavioural elements, patients tended to view the
intervention as a treatment package. A typical vignette
illustrates how participants amalgamated CBT aspects
with hypnotherapeutic techniques and GI in their understanding of altered thoughts and increased control:
I thought I was going to be as sick as anything for
6 months . . . that’s why I was so upset in the beginning because I felt that I’d no control over what was
happening . . . I wasn’t a relaxed person before it all
started, I was sort of a very busy person and found it
hard to switch off and I think it was good . . . it gave
me those techniques . . . the fact that I was given a
tool whereby I could switch off the nausea . . .
The exception to this was relaxation. Patients were very
clear on how relaxation helped them, particularly with
sleep disturbance and chemotherapy.
I had real problems sleeping all the way through my
treatment . . . and E gave me a sleep tape . . . which
really, really helped, erm – and the relaxation helped.
I took it down to my chemotherapy sessions and for
the couple of days afterwards when I felt particularly
bad, erm – I used to play the tape a few times a day
and they really, really did help.
Feeling in control, confidence building and the visualization of host defences destroying cancer cells complete
this theme and are closely interwoven. The need for control over what was happening to patients was an important finding with the ‘cancer cell attack’ considered a
principle tool:
I think it really helped me relax all the way through
and visualizing that I was actually helping my body
to get rid of the cancer and make myself better.
The combination of techniques was considered to
reduce helplessness and subsequent anxiety, leading to an
increase in confidence:
I definitely lost confidence in myself. I think in the
beginning . . . but I feel as though [laughs] I’ve become
140
Long-term benefits
The main purpose of the hypno-chemo programme is to
deal with cancer-related distress during active treatment.
However it became apparent in the early stages of data collection that patients had continued to benefit from the
techniques learned and still used their hypnotherapy
tapes. One patient, interviewed 8-months after completion of chemotherapy said:
I’m still using the techniques I was taught . . . I had
my kitchen replaced . . . and I got thoroughly stressed
out . . . I thought you’re going to give yourself cancer
back again because you’re just worrying so much so
I listened to the cancer cell attack . . . and it was a
great help because I got the kitchen . . . done all without having to feel totally stressed out.
Service satisfaction and patient information needs
This theme focuses on service satisfaction and identifies
deficits in information provision. Patients invariably
viewed their therapy positively. For example:
It was excellent, I can’t fault it.
The main critisicm was lack of information about the
existence of the service in appropriate clinics, closely followed by the need for health professionals to explain the
programme beforehand. The following extract illustrates
this:
I think that maybe the GPs need . . . more awareness
about the availability of this kind of service because
they’re the person who has contact . . . and I think it’s
very important for them to offer this kind of facility
and alternative to the conventional chemical medicines, erm – because I think if it’s worked in conjunction with that, erm – it can only be . . . helpful to the
patient.
Future availability was a major finding with most
patients suggesting follow-up sessions or later treatment
on request.
There was however, evidence of service dissatisfaction
related to medical procedures. Despite the widely publi-
© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
European Journal of Cancer Care
cised move from closed to open awareness, communication deficits were apparent. For example:
. . . and they sent me down for a scan and they found
my cancer, but they didn’t mention cancer . . . They
just said . . . we’ll have to operate on your
bowels . . . and somebody just . . . threw me a paper in
at the door and . . . she said, er – that’s to do with your
bag [colostomy]. Well . . . it never registered . . . and I
have to have a bag? . . . and she left me. I must be
honest, I was terrified then.
Some patients complained about hospital waiting
times, mechanical failure and human error.
Oh the, the waiting there was a nightmare . . . They’d
say, oh, there’s been a fault in the machine or I’m
sorry your prescription should have been ordered last
week and it hasn’t and . . . you were trapped there,
you couldn’t go home because you’d not had your
chemo, you know, you’d wait for your bloods, you’d
wait for the doctor, then you’d wait for your
treatment.
Collectively, the findings highlight the need for open
communication, identification of concerns and interventions tailored to individual need.
DI SC U SSIO N A ND CONCL US I ONS
The findings suggest that the combination of therapies
may provide advanced skills in coping/adapting to the
cancer situation. Patients were able to describe how having the opportunity to talk about their feelings had helped
them and how much they appreciated the therapists.
There is substantial evidence to suggest that intervention
outcome is determined by the therapeutic relationship
(Beck et al. 1987; Ellis 1994) and this study highlights the
importance of rapport, and comprehension of the problems facing cancer patients (cf. Faulkner & Maguire 1994).
It has been argued (Bottomley 1998) that understanding
the cognitive model is essential for patients to benefit
from the techniques within it. However, in this study
patients clearly expressed the value of CBT, that is their
ability to think and/or behave more adaptively, increase
confidence and reduce distress without necessarily isolating the underlying principles. Conversely, patients were
able to explain in detail how hypnotherapy had helped
them relax, sleep and cope more effectively. They were
also clear about the ways in which GI had assisted their
resolution of chemotherapy related fear and side-effects.
Guided imagery was highly valued in helping patients to
feel more in control of their situation with all patients
keen to visualize their host defences destroying malignant
cells. This approach, consistent with published research
(Fawzy et al. 1995; Walker et al. 1999), is never portrayed
as a cure for cancer but as a tool to encourage patients to
take an active role in their rehabilitation.
One important finding was that some patients experienced difficulties with referral, which may reflect communication deficits (Heaven & Maguire 1997) and/or
mistrust of hypnotherapy. The latter supports former
anecdotal reports of perceived witchcraft and involuntary
mind control (Redd & Hendler 1984). Such notions, perpetuated by the popular press (Hendler & Redd 1986) and
abuse by stage hypnotists (Finlay & Jones 1996) have led to
fearful and sceptical views. Despite their original concerns however, patients in this study were able to describe
in some detail how hypnotherapy had helped them, suggesting this may be a valuable intervention.
Another relevant finding was that some patients
objected to ELIHCC being adjacent to a hospice. Walker
et al. (1999) have demonstrated the benefits of a setting
sensitive to the needs of patients undergoing chemotherapy and it would appear that hospice-based community
care might be less sensitive to patient need in the active
stages of treatment than a hospital-based centre. Conversely, the analysis illustrated some dissatisfaction
with hospital-based procedures, in particular, inappropriate communication, long waiting periods, technical
breakdown and staff oversight. These findings mirror
those of previous research highlighting the superiority of
hospice care to that of hospital care, especially for psychosocial issues (cf. Wilkinson 1999). The evidence
therefore suggests that a hospital-based cancer unit
described by Walker et al. (1999) or a stand-alone centre
would be less inhibitory and more suited to the needs of
this particular client group. The latter were keen to recommend the service but were concerned about the lack
of availability.
CONCLUSI ON
The study supports the body of literature demonstrating
the value of psychosocial interventions in cancer care
while adding further insights to the patient experience
that is not always possible using more structured quantitative methods of enquiry. The findings from this study
will be used to refine provision in terms of providing a
more appropriate setting and easier access, as well as integrating the findings into teaching sessions. Further recommendations include an outcome study to assess the
efficacy of the combined intervention.
© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
141
TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care
ACKN O W L E D G E M E NT S
The study was sponsored by the National Lottery Charities Board. Approval for the study was granted from the
local Research Ethics Committee, Rossendale, Lancashire.
We are grateful to Helen Hills, East Lancashire Integrated
Heath Care Centre, for data accuracy checking and Dr Bill
Noble, Trent Palliative Care Centre, for supervision.
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