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HYPNOTHERAPY

How hypnosis is clinically utilized to address the spectrum of cancer's physical and psychological dimensions.
by Gérard V. Sunnen, M.D.


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Introduction

Medical hypnosis is a science increasingly recognized for its therapeutic applications. Applied to the comprehensive treatment of cancer, medical hypnosis offers unique possibilities due to its capacities for enhancing mind to body communication. This article describes how hypnosis is clinically utilized to address the spectrum of cancer's physical and psychological dimensions.

Abstract

Adjunctive hypnotic therapy in cancer may be directed to many levels of its manifestations. Physical symptoms of cancer, the most common of which are pain and fatigue, and the physical effects of its treatment may be alleviated to enhance quality of life. Hypnotherapy can significantly help patients through medical procedures and operations. Hypnosis may also be woven into psychotherapy to assist the uniquely personal adjustments facing each individual. Self hypnosis allows patients to actively contribute to their treatment. Finally, hypnosis and self-hypnosis may be recruited to stimulate healing spiritual discoveries.

Hypnotic and Self-Hypnotic Approaches to Comprehensive Cancer Care

Cancer is a multisystem condition, involving all levels of the organism, from the cellular to the psychological. While the baffling manifestations of its varieties continue to be elucidated, there is an ever-growing awareness of its complex psychological dimensions (Benjenke, 2000; Steggles, 1997). Of most humane concern are the intense travail and the spectrum of adjustments cancer patients are likely to face - adjustments to the condition itself, to its treatments, and to the poignant intrapsychic, family, and social changes it may induce (Kubler-Ross, 1969).

In hypnosis, an individual is guided from their usual state of consciousness to an experience marked by multi-level relaxation. In this special state of consciousness, novel perceptions may be experienced, such as feelings of enhanced communication with one's body, of the slowing down of the passage of time, and of shifts from analytic to synesthetic thinking, thus allowing the mind greater interaction with sensations and feelings (Sunnen, 1999).

In self-hypnosis the individual acts both as a guide and an experiencer. Through the use of self-oriented directives, progressive relaxation can bring about states of mind and body where, within the background of profound repose, mental images, healing emotions, and therapeutic affirmations can exert beneficent actions (Fromm and Kahn, 1990).

Hypnosis and self-hypnosis find applications at several levels of cancer care. Firstly, it is useful as a means of dealing directly with the symptoms of the condition: pain and symptoms referable to specific organ systems, and nonspecific symptoms such as fatigue, malaise, and insomnia. Secondly, hypnosis is useful in the management of the side effects of cancer treatments. Thirdly, cancer patients are faced with major psychological adjustments. Many pair their diagnosis with existential demands for the reframing of life priorities. Lastly, and somewhat controversially, hypnosis has been aimed at modifying the course of the disease process itself through the use of imagery, and via the therapeutic potential of special states of mind, which may be called meditative or transcendental.

Hypnosis in Management of Cancer Symptoms

Symptoms attributable to cancer vary according to its etiology. Pain is the most common symptom aside from fatigue. Hypnosis has been amply documented to be a potent pain modulator (Chaves, 1994; Hilgard and Hilgard, 1994; Holroyd, 1996; Lynch, 1999; Peter, 1996; Schafer, 1996). There is a synergistic relationship between pain and anxiety, and pain and depression. The following case history demonstrates the role of hypnotherapy in modifying symptoms associated with cancer.

A stockbroker with a diagnosis of colon carcinoma established two years previously was referred by his oncologist for hypnotic treatment of pelvic pain. A recent examination revealed metastatic liver nodules, and a solitary lesion in the pelvic bone. Ambivalent about plans for chemotherapy and radiation, he opted for more time to make a decision about these matters.

He achieved a hypnotic trance with an arm levitation technique. This technique, like many others, recruits the ability of the mind to experience imagined sensations. He raised his arm in front of him in the image of a piece of wood floating on a lake. Eyes closed he could imagine lightness and buoyancy filling his arm, as would a light gas lifting a balloon. "Let those buoyant feelings move your arm upward and gently toward your face." His hand gently touched his face, then rested on his thigh. In the same way that he was able to imagine lightness, he could conjure feelings of numbness in his hand. "Imagine a cold breeze from a snow-capped mountain coursing through your hand." A pinch of a thenar skinfold was eventually perceived by him as a faraway flicker of touch. "The numbness in your hand can travel into your thigh, as if touching the smooth surface of a pond; you may be able to visualize the concentric rings of numbness spreading within your body in all directions. This ability now becomes your own, and you will be able to use it in self-hypnosis."

The relief he obtained was incontrovertible. Sometimes he could banish the pain completely and could walk comfortably for an hour or so. At other times, especially when his mood was low, he could gain only partial relief. He felt significantly more relaxed, reported more energy, and clearly enjoyed his heightened capacity for pain-free activity.

States of mind reached in hypnosis often have the property of ushering a propitious milieu for experiencing insights. "Eyes closed, your body can contact its deepest rhythms and your mind can drift into the endless expanse of relaxation. Opening doors to the vast knowledge within you, you can let your unconscious mind offer you insights about how best to proceed with your medical treatment."

Through this exercise, he gained clear perception to undertake chemotherapy. He successfully applied self-hypnosis to modulate its side effects. He also recruited self-hypnosis to heighten energizing feelings of optimism and self-esteem, which robustly assisted him in his medical trajectory.

Techniques of Pain Relief in Cancer

When used adjunctively with analgesics, hypnosis can serve to reduce their dosage (Pinnell, 2000). The following approaches may be used singly or concomitantly in any patient, depending upon their hypnotic proficiencies (Edwin, 2001).

Hypnotic relaxation. Hypnosis may be described as the most potent non-pharmacological relaxant known to science. An important mechanism of hypnotic pain reduction centers upon its remarkable property for quelling anxiety in any one of its myriad expressions. Anticipatory anxiety - the anxious sensation that pain may ominously appear or worsen - may be so relentless that it creates its own anxiety. Relaxation can significant assist analgesia and enrich quality of life (Levitan, 1999).

Direct suggestions for pain removal. Some patients easily assimilate direct suggestions that the pain will diminish in intensity to the point of becoming unnoticeable. In spite of psychoanalytic assertions that symptom removal necessarily implies symptom substitution, it is often gratifying to observe patients responding unequivocally to such suggestions as: "Your mind has the capacity to let go of the discomforts and the pains you have been experiencing. With each breath, let discomforts give up their intensity to the point where they lose their power, and possibly even vanish."

Hand anesthesia with extension and diffusion. The hand is ideally suited as a starting point for hypnotic anesthesia because it is so richly endowed with sensory innervation and occupies such a prominent place in the cortical homunculus. Once the anesthetic experience is established in the hand, it is a relatively small step to transfer it to other parts of the body.

Altering the configuration of pain. The representation of pain in the mind - the pain's body image - may be reconfigured to occupy a smaller space in the mind's eye, therefore assuming less experiential presence. Neurophysiologically, this corresponds to a shrinking of cortical association networks. Suggestions are made for the pain to decrease in size as the patient is asked to visualize the pain as a progressively dwindling three-dimensional shape in mental space (Hammond, 1990).

Altering the qualitative aspects of pain. As pain fibers project from thalamic nuclei through diffuse thalamic radiations into cortical association networks, they gather complex nuances of experiencing. Pain is a multisensory dimension malleable by cortical influences. Hypnotic intervention, by the medium of recruitment of cortical overide, is thus able to change pain's qualitative expressions. Pain may be paired with coolness, warmth, heaviness, or other sensory modality, in order to soften the sharpness of its impact.

Imagery. With some individuals, hypnotic imagery is the most effective pathway to pain control. The type of imagery favored depends upon the patient's eidetic style. The imagery proclivities of the patient are noted in order to match imagery style with appropriate suggestions (Hammond, 1990). "Imagine a garden richly endowed with beautiful vegetation bathed in sunlight. The garden represents the forces in your mind. You notice some plants that do not appear to fit in this space. They represent your discomforts and your difficult symptoms. As you approach this unwanted vegetation you can begin to decide ways you want to deal with them."

Dissociation. Dissociation is an effective mechanism by which the pain may be experienced as moving away from the locus of awareness (Rainville et al., 1999). " The pain is not sticking to you. It begins to disconnect from your body, travelling outward, moving with each breath further and further into the distance; so far that it may even feel that it no longer belongs to you."

Hypnotic Treatment of Chemotherapy Side Effects

Particularly bothersome for some patients are certain side effects of chemotherapy. Sometimes a patient will become so sensitized by treatment after-effects that even the thought of subsequent sessions brings about great autonomic distress. Hypnosis has been well documented to have therapeutic potential for conditioned anticipatory emesis (Genuis, 1995; Marchioro, 2000). The following case illustrates some of the treatment principles in this condition.

A 26 year old graduate student with stage three Hodgkin's disease was receiving combination chemotherapy. Although physically tolerating this regimen, he became increasingly distressed by post-treatment nausea. During the third treatment, his nausea became so bothersome that he inquired about other treatment options. He complained of anticipatory anxiety and described how the mere picturing of the doctor's office had brought him waves of gastric turmoil.

Induction made use of the hypnotic technique of awareness of breath, an ancient discipline central to many practices of meditation. Eyes closed, he was asked to dispatch his feelings into his breathing and open his perception to the sensation of air touching the inside of his lungs. An ideomotor technique signaled degrees of internal discomfort. When nausea was experienced, his index finger moved sideways. When nausea was relieved, he moved it back. To counter nauseous feelings, sensations of hunger were elicited. Did he like the fresh taste of mint? What were his favorite foods and memorable gastronomical experiences? He imagined a typical treatment session gradually pairing treatment scenarios with intestinal comfort. Dissociation strategies were used to repel nausea further and further away in mind space. During the third session, he was able to visualize himself receiving treatment with no distress. In the actual treatment situation, he experienced only mild nausea but no vomiting, and he was able to gracefully finish his entire regimen protocol.

Hypnosis in preparing patients for medical procedures and operations

Cancer patients, in their medical trajectories, are likely to encounter a variety of diagnostic procedures and operative interventions. Confronted by an expanding array of medical tests and complex surgical options, the mind often reacts with perplexity and apprehension.

Hypnotic techniques are used to reduce anticipatory worry and to regulate sleep and other biological rhythms, thus saving the organism's energy reserves (Kessler, 1996; Montgomery, 2002). Post-hypnotic suggestions ñ affirmations designed to actualize themselves at a future time ñ can express themselves during the operative procedure so as to stabilize physiological parameters, even while anesthesia is administered (Eger, 1999). Postoperatively, hypnotic intervention aims to accelerate the physical and psychological task of convalescent healing (Holden Lund, 1988)

Hypnotic Approaches to Psychological Adjustments to Cancer.

A panoply of emotions is regularly encountered in the psychological response to cancer. Aside from anxiety, which is universal, there can be feelings of helplessness, anger, alienation, aloneness, guilt, low self-esteem, hopelessness, and loss. Hypnotherapy, to be maximally effective, relies heavily upon empathic emotional understanding between patient and hypnotherapist. The following hypnotic techniques can be helpful in achieving psychological harmony.

Learning relaxation, learning self-hypnosis. Relaxation, in its deeper realms, contains feelings of peacefulness, tranquility, and a profound sense of centeredness. Learning and practicing self-hypnosis to kindle these feelings can promote a satisfying sense of self-mastery.

Ego strengthening. "Please send your feelings into a place in your mind we may call your personal force. It contains strength, self-confidence and energy." Hypnotic ego strengthening encourages all the positive feelings that invigorate the personality ës adaptive functions (McNeal and Frederick, 1993).

Strengthening repression. A 28-year-old man with malignant melanoma complained that the oppressive thoughts about his cancer were constantly present. "There isn't five minutes that I'm not thinking about it. My mind is glued to my diagnosis to the point that it's hardly possible for me to live." Hypnosis was used to gradually expand minuscule "thought-free" periods from minutes to hours and to increase the ability of unconscious mechanisms to repress anxiogenic thought intrusions.

Imagery. The most effective images are usually the ones formulated by the patients themselves, and these are often best arrived at by the conjoint efforts of the hypnotherapist and the patient working as a dyad.

Recently, there has been an interest in imagery not only to guide cancer patients to better frames of mind, but also to influence the disease process itself. It is logical to assume ñ and it is well documented - that imagery, through its cortical connections with neurohumoral networks, has far-reaching influence on immune system function (Hannigan, 1999; Kalt, 2000; Miller et al., 2001; Ruzyla-Smith et al., 1995; Walker, 1998).

The following clinical story provides an example of this kind of imagery usage in cancer. The technique serves to illustrate an important therapeutic function, namely giving the patient the sense of playing an active role in the management of their condition.

A performing artist noted a small nodule in her armpit. Three months later she woke up during the night with pain in her axilla radiating to her breast. She received surgery and chemotherapy for breast carcinoma. Although there was no evidence of metastasis, she became increasingly worried about this possibility. She came for consultation for the specific reason of learning therapeutic imagery. She had previously attempted visualization exercises imagining white globules, symbolic of her healthy defenses, fighting off dark particles, symbolic of cancer cells. She reasoned that hypnosis could intensify imagery. This, in fact, was so. Her eidetic potential was stronger, more "real" in the context of trance.

In hypnosis, she realized that the exercise did not feel right for her - she did not like the idea of fighting, even though it only involved globules. " If so, allow your unconscious mind free reign to offer you images that symbolize your healing forces." After some time in hypnotic contemplation she described a gentle current imbued with a greenish glow coursing through her, intensifying with each respiration. With practice, she developed a solid conviction and solace that this life current could energize all her organ systems, including her immune functions.

Connections between hypnosis and spirituality.

The commonly observed psychological responses to end of life issues may be seen as adaptations of the ego to the possible end of the ego. Once the individual has traversed these psychological passages, what comes next? What lies beyond the ego's relationship to its own end?

The human psyche has the capacity to experience myriad states of consciousness (Austin, 2000; James, 1935; O'Brien, 1964). Some contain perceptions of oneself which, by the nature of their essence, may be called spiritual or transcendental. Still relatively unexplored, these may become manifested in the practice of disciplines such as hypnosis and self-hypnosis, and may be called upon, in the example of cancer patients, to the task of reaching new level of personal adjustment (Hornyak, 2000). Psychotherapy ñ including hypnotherapy ñ to be maximally effective, is best practiced when it touches upon the mind's highest functions (Karasu, 1999). The following history illustrates the spiritual dimensions of hypnotic intervention.

A librarian's gynecological symptoms prompted diagnostic tests revealing ovarian cancer. Within the space of a few months she had experienced chemotherapy and had weathered the travails of adjusting to her diagnosis. Knowledgeable about many subjects, she was intrigued by the health benefits of hypnosis. Interesting to her, was the potential of hypnosis to help her with her practice of meditation, a closely related discipline she had started some months before her diagnosis. Now, she felt compelled to explore it.

Her hypnotic induction centered on the creation of feelings of heaviness and warmth in one arm with subsequent extension to the rest of her body (Schultz, 1956). Pairing these sensations with breathing awareness, she knew she entered trance when she felt her body's internal configuration expand beyond its usual subjective boundaries.

"Please focus upon the thrust your mind seeks to pursue. Before the exercise, you had chosen the word "spiritual. In that case let that, or any other word of your choice, gently repeat itself in your mind. Allow your unconscious mind to give you the healing images it wants you to have"

Upon emerging from hypnosis, she struggled to put into words a most unusual experience. "I felt physically larger than life, as if I filled this room. At the same time I experienced the inside of my body as never before. My lungs, my heart, my stomach all felt so much closer to me. My enlarged body swayed like a feather in the wind all the while remaining in place. Hard as it is to put into words, I saw myself, the person with a name on one hand, and the energy of my spirit on the other, connected but so distinct from each other."

She pursued her spiritual practice. She learned to recapitulate the experiences of hypnosis via her own means, and eventually developed a personal technique which could best be described as a mixture of self hypnosis and meditation (Cardena, 2000; Gibbons, 1972; Meares, 1979).

Summary

Adjunctive hypnotic therapy in cancer may be directed to many levels of its manifestations. Physical symptoms of cancer, the most common of which are pain and fatigue, and the physical effects of its treatment may be alleviated to enhance quality of life. Hypnotherapy can significantly help patients through medical procedures and operations. Hypnosis may also be woven into psychotherapy to assist the uniquely personal adjustments facing each individual. Self hypnosis allows patients to actively contribute to their treatment. Finally, hypnosis and self-hypnosis may be recruited to stimulate healing spiritual discoveries.

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Gérard V. Sunnen M.D., Board Certified in Psychiatry and Neurology is an Associate Clinical Professor of Psychiatry at NYU-Bellevue Medical Center in New York.


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