Hypnosis and Suggestion in the Treatment of Pain

ANNA HAD BEEN treated for metastatic breast cancer with chemotherapy and radiation over the past two years. She was referred by her oncologist for treatment of isolation and depression, as well as assistance with managing her gut pain. At the time of the consult she was hospitalized for anorexia. She had been unable to eat, due to nausea and gut pain resulting from tumor infiltrates and possibly because of the effects of her radiation therapy. She had lost more than 30 pounds, but while this had taken much of her physical energy, she remained quick witted and acutely observant of her surroundings.

A retired army nurse, Anna, now 63, had always been a very independent person with few close friends. Her family lived across the country, she had only one friend available for some assistance, and she did not feel emotionally close to anyone. Anna no longer had the energy to seek interactions with others; yet, having become increasingly isolated since her diagnosis, she experienced acute loneliness.

In therapeutic interactions, she grieved for her losses and explored her feelings about dying alone. She grieved for what she had not had in her life, but also experienced a sense of comfort and competence from her recognition of the choices that she had made that she felt were best for her, such as her work in taking care of other people, even in difficult times such as combat.

This work was supported by National Cancer Institute grants CA57807 and CA63030.

More than any other disease, cancer and its treatment bring a multitude of pains and discomforts that rarely occur in isolation from other symptoms. A cancer diagnosis brings with it immediate concerns, which may become, in effect, internal suggestions to the patient. Foremost among these are loss of control over the physical body and uncertainty about the future, for which the patient almost certainly had other plans. The clinician who uses psychological approaches with cancer patients needs to understand this interplay of physical challenges and psychological demands. For optimal patient comfort, both phenomena must be integrated into suggestions for pain relief.

In this chapter, we discuss the context in which treatment for cancer pain exists. First, we provide a description of the types of pain reported by cancer patients. Next, we evaluate factors to consider in the integration of hypnosis with the medical management of the disease. Finally, we review some of the techniques that are effective in treating cancer pain.

Pain is one of the most common symptoms reported by people with cancer. Everyone with cancer will have pain from procedures, and many will have pain at some point from treatment. All cancer patients undergo painful procedures that can take between a few minutes to several hours—for example, blood draws, needle aspirations, and imaging. Many patients will have pain from their anti-cancer therapies. Radiation can cause skin burns or gastrointestinal distress; chemotherapies often cause diffuse aching or generalized discomfort or burning from neuropathies.

Although it is the pain of cancer itself that most frightens people, not all patients will have pain related to their disease. Prevalence of disease-related pain ranges from 30 percent to 40 percent for the entire cancer population, and from 60 percent to 90 percent for patients with advanced disease (Cleeland et al., 1994; Grond, Zech, Diefenbach, & Bischoff, 1994; Portenoy, 1989). It is normal for patients with advanced disease to have four to eleven symptoms concurrently. The most frequent symptoms are pain, fatigue, anorexia, nausea, and sleep disturbance (Donnelly, Walsh, & Rybicki, 1995; Portenoy et al., 1994). Gastrointestinal distress, which is particularly common, may include not only nausea and vomiting, but also diarrhea or constipation, difficulty swallowing, mouth and throat ulcers, and abdominal cramping. These symptoms make eating very difficult, contributing to weight loss and fatigue. When patients have pain from their disease, it is not unusual for multiple pains to occur simultaneously, in different locations.

An important distinction needs to be made between pain that is caused by damage to tissue, sometimes called physiologic pain or nociception, and pain that is caused by a disturbance in the neural transmission system, called neuropathic pain. Nociception can be highly variable, but it is often characterized by aching, heavy, or cramping sensations, while neuropathic pain is more characteristically felt as sensations of pins and needles, burning, electrical, shooting pain or numbness. Opioids and other medical treatments are more effective with nociception (Bonica, 1990; Saeger, 1992). Neuropathic pains tend to attack suddenly and unpredictably and, as a consequence, to overwhelm the patient’s ability to cope. During each occurrence, the pain tends to last a similar length of time. These are difficult but often rewarding symptoms to work with hypnotically, because patients often benefit from hypnotic treatment when it seems that nothing else is effective.

When treating neuropathic pain, suggestions need to begin with the reminder that the sensation is temporary. It is helpful to have a period of training during which the hypnotic experience can become familiar to the patient and images can be tested and refined to suit the patient. During neuropathic attacks, we use very brief images to transform the pain. These must be suggestions that the patient can use alone so that he or she has strategies available even when the clinician is not.

The cancer patient’s history must be considered when designing treatment—whether one considers brief procedures, postsurgical pain, treatment-related pain, or progressive disease-related pain. Past experience is one of the chief influencing factors in the patient’s fears and expectations and, therefore, in determining internalized suggestions. Identifying thoughts and emotions that occur with the pain can stimulate valuable metaphors and images to modify the patient’s experience.

Research with cancer patients clearly demonstrates an association between depression and pain (Ahles, Blanchard, & Ruckdeschel, 1983; Spiegel, Sands, & Koopman, 1994). Patients with greater distress, specific to their cancer situation or their pain, will also experience greater pain intensity (Syrjala & Chapko, 1995). Thus, treating distress is an important component of pain treatment, although of course it is never the only component.

To be effective in treating cancer pain, you need to understand the context in which most people experience cancer and the issues they face when managing this disease, as well as the types of pain that are caused by cancer and its treatments. With this understanding, hypnosis and suggestion can be immensely helpful, even to those patients who might have been reluctant to try such strategies prior to facing their disease.

As Table 6.1 illustrates, patients with cancer experience an assortment of pains with varying etiologies. They may have the briefest pain from a needle stick, or pain from treatment that continues for weeks but gradually resolves, or they may have pain that progressively worsens over months or years as a result of tumor invasion. Images and suggestions vary quite widely, depending on the circumstance of the pain and the concurrent issues a cancer patient is facing.

Acute procedural pain is brief and is treated as one would treat any brief pain situation. An important consideration in a patient with cancer is the repetitive nature of these procedures. A simple blood draw that may initially cause no distress can become wearing or even evoke phobic symptoms in patients whose treatment requires repeated needle sticks. Other procedures, such as bone marrow aspirations, can become so intolerable to patients that they refuse further life-promoting treatment rather than expose themselves to the excruciating pain of additional aspirations.

We emphasize procedures here because they tend to be ignored as sources of distress by a medical system focused on curing the disease. Patients, wishing to be cooperative and to be strong, often do not express their distress to health-care providers who are in a position to help them. As with most cancer pain, medical approaches can ease many of the procedural discomforts if staff recognize the level of patient discomfort and act to prevent or provide treatment for these symptoms. It has been demonstrated that hypnotic intervention is effective for treating pain from procedures (Genuis, 1995; Wall & Womack, 1989). Procedural discomforts are particularly responsive to hypnotic intervention, in part because they are temporary. Due to the repetitive aspect of procedures, we train the patient and/or a family member to use these methods without the presence of a clinician. Although most work on procedures has been done with children, we find these methods equally effective and immensely appreciated by adults.

Table 6.1

Types of Pain Common in Cancer Patients

Duration of Pain	Source of Pain	Examples

Brief	Procedures	Blood draws Needle aspirations (e.g., breast, bone marrow, liver) Angiographs and other imaging Bronchoscopies
	Unpredictable events	Neuropathies Gastrointestinal distress
	Incidental, movementrelated	Activity exacerbates a constant bone pain
Persistent treatment related	Post-surgical Oral mucositis	Mouth and throat ulcers with pain
	Radiation burns	Raw or burned skin, gastric distress
	Chemotherapy caused pain	Joint aching or burning pain in extremities
	Gastrointestinal distress	Chemotherapy induced gastric upset
Chronic, progressive disease related	Nociception	Bone pain
		Tumor invasion or obstruction of viscera
	Neuropathic	Nerve root invasion
Chronic, residual	Lymphedema	Massively swollen arms
	Fractures
	Phantom limb
	Post-herpetic neuralgia
Concurrent, non-disease related	Arthritis Low back pain Muscle aches

To illustrate these ideas, we will discuss a case that demonstrates the effectiveness of hypnotic management of procedural pain. Most patients tell us that bone marrow aspirations are the most painful procedures they endure. Other patients are very discomforted by magnetic resonance and other imaging procedures that require isolation in closed chambers and immobilization for long periods of time. In addition, some patients have needle phobias or other aversions that can make even blood draws or transfusions intolerable to them. These procedures are routine for medical staff whose focus is on “getting the job done.” For the most part, clinicians and patients share the same contradictory cultural beliefs about pain and suffering. These attitudes communicate, on the one hand, that no one should have to endure pain and suffering. On the other hand, society is permeated with messages that suffering is a virtue. This incongruity, in effect, leaves both patient and medical staff confused and wishing simply to escape from dealing with an insolvable quandary. In addition, no caring person wishes to cause another to suffer. Thus the medical staff may deny the importance of the pain to the patient or respond to a patient’s concern by suggesting that he or she is overreacting. For their part in this complex and difficult interaction, patients may wish to appear strong and thus win the respect of staff. As a result, they may not clearly communicate their distress.

When we are assisting with a procedure, our first step is always to assess the nature of the physical sensations that will be involved, the time each sensation normally lasts, and what sounds are commonly heard during the procedure. This helps us to incorporate references to these sounds and to suggest alternative sensations into our repertoire of suggestions.

Bone marrow aspiration procedures involve several intense physical stimuli: the cold liquid of the antiseptic wiping, stinging of the local anesthetic, very heavy pushing of the large needle into the bone, and a long, sharp pulling feeling throughout the hips and legs as the marrow is aspirated. (Samuel LeBaron and Lonnie Zeltzer describe this procedure fully in Chapter 11.) We consistently find that if we counter these intense sensations with either energetic physical activity or strong (but tolerable) sensations incorporated into our suggestions, patients are more likely to remain comfortably absorbed as the otherwise compelling procedure and the talking of staff continue around them.

The more invasive the procedure or the less absorbed a patient is likely to be, the more likely we are to have the patient talk to us, telling us what she sees and experiences.

Kristy was referred to me [KS] by her physician for treatment of acute anxiety. Her mother was also quite anxious, fearful of losing her only child, and unable to tolerate the distress she could see her daughter experiencing. This prevented her mother from being able to comfort Kristy and, in fact, left Kristy feeling that she needed to reassure and comfort her mother. Consequently, this left Kristy with no place where she could express her own fears and anger.

My primary therapeutic role was to provide Kristy with a safe place to experience and to explore her own feelings. This was helpful to her; fortunately, her mother was also relieved and grateful. (Sometimes parents who have not allowed their grown children to separate are resentful of a therapeutic relationship. In a cancer setting, where family is so essential in providing the emotional support and assistance a patient needs, meeting the therapeutic needs of a patient while not alienating a parent can be a difficult balance to achieve.)

When Kristy needed a bone marrow aspiration she asked me to be present. She said her mother could not tolerate being in the room, that she would “pass out” from seeing the blood and hearing Kristy yell. I rehearsed with Kristy a routine hypnotic induction leading to deep relaxation. I then suggested she imagine her favorite activity—exploring the farm where she grew up.

While Kristy had previously been able to be absorbed in the hypnotic experience, she was not as deeply absorbed during this procedure and was very vigilant about the people and sounds around her. To facilitate her absorption, I periodically asked her to tell me what she saw or felt in her imagination.

When the antiseptic was being wiped on her back, I asked her to “find some coolness, a breeze or perhaps even a stream that you might run your fingers through, or perhaps there is another coolness somewhere, but it really doesn’t matter, wherever it is just enjoy the coolness along with the warmth as you notice all of these sensations just making you that much more aware of how aware you can be, how sharp your vision is today as you enjoy seeing and smelling and hearing the sounds in the field.”

At the point of greatest physical pressure during the procedure, when the needle is punched into the bone and the marrow is aspirated, I raised my voice slightly, spoke more rapidly and suggested to Kristy that she begin to:

… Run through the field, down a slight hill and up the next, feeling your legs working, the strength and power in your legs as they move smoothly, landing firmly. Notice how your legs listen to the instructions from your mind and follow just where you tell them to go, how your mind moves your body where it needs to be, feeling the strength in your body as your legs carry you through the field, you feel the breeze in your face, and your mind knows just what your body needs in order to be strong and comfortable and confident. Feeling your lungs expand to take in the air you need, and just how good it feels to breathe out from deep inside. And now begin to slow down … coming to a stop … and resting. Enjoying the pleasure of feeling how well your body works with your mind, how good it feels to exert your body and then to rest, letting your whole body be quiet now … and once again, noticing the fields and hills around you.…

There is an additional element to this work that I find very helpful for coping with intense physical sensation, if it is appropriate for a particular patient. With Kristy, I stood near her head and shoulder and let her hold my hand while I put my hand on her shoulder. I let her know that she could squeeze my hand at any time and that I might squeeze her shoulder. At the moment of most intense physical stimulation, or when I felt her squeeze my hand, I squeezed harder on her shoulder. The physical pressure of my hand provided a neutral physical stimulus to compete with the sensations from the procedure; as important, I believe this acted as reassurance that I was there to support her through the experience.

Kristy endured this procedure three times, and after each time, she would turn to me, smile, and say, “That was the best one yet,” and then, fall asleep.

Treatment-related pain is now managed more effectively with opioids than was the case not long ago. Nonetheless, even aggressive opioid use does not eliminate all discomfort. Hypnotic intervention has significantly reduced suffering from painful procedures in cancer patients (Syrjala, Cummings, & Donaldson, 1992; Syrjala, Donaldson, Davis, Kippes, & Carr, 1995). However, effective hypnotic intervention needs to be started prior to the start of cancer treatment if at all possible, because cancer treatment often impairs cognitive function, causes extreme fatigue, and may cause complications other than pain. In any case, psychological strategies that are provided during treatment must often be brief, since most patients’ concentration and attention span are limited. When patients are in the midst of treatment, our typical intervention will last 10 to 30 minutes.

CASE EXAMPLE: PEARL, 61, SUFFERING FROM
TREATMENT-RELATED THROAT PAIN AND NAUSEA

Pearl’s physician asked that I [KS] provide hypnotic intervention for Pearl, who was being treated for lung cancer. Pearl needed to eat so that she could leave the hospital after her radiation therapy. But Pearl’s pain with swallowing and her continued nausea made it difficult for her to eat. Her physician could find no reason for Pearl’s pain or nausea; although he had tried all of the medical treatments he knew, Pearl still could not eat.

When I first saw Pearl, she was lying in bed with her curtains closed. In the initial evaluation, it quickly became clear that she was depressed. Pearl said that she had two personal goals: to get out of the hospital, so that she could return to her job at the burger stand where she enjoyed the companionship of her coworkers; and to return to smoking. Although her daughter came to visit about once a week and called daily, Pearl was otherwise alone. When I asked about her family, she said she had only her daughter and that her daughter was very mad at her because she was looking forward to smoking again. She explained that many people, including her doctor, had told her not to smoke, but smoking gave her great pleasure, and she was still looking forward to smoking. Pearl also had been a heavy drinker, but she had no intention of returning to alcohol. When we explored her difficulties with eating, she indicated that eating most food made her nauseated, and it was hard to swallow, but that ice cream and apple pie were OK to eat. Pearl did not eat only ice cream and apple pie, because “everyone tells me I have to eat more regular meals.”

It became clear to me that Pearl was fighting with most of her caregivers about what she should take in. She was a responsible adult who knew what other people thought was good for her and what she wanted for herself. Though I also knew what was and what was not good for her to take in, it seemed most helpful not to jump into this battle, but rather to focus on the healthy reasons Pearl wanted to leave the hospital—to return to her work and to make her own choices about the food she could eat. Often, the diets of cancer patients leave a lot to be desired, but calories become the most important factor, especially when trying to resume eating after a hiatus caused by the treatment. I recognized, too, that Pearl’s wish to smoke could be partly an attempt to hold onto some part of herself (even an unhealthy part), when she was losing so much else—including, probably, her life—whether or not she stopped smoking.

Despite her depression and the conflict she was experiencing, Pearl was eager to try hypnotic methods. When I asked for her thoughts on what might be causing her nausea and difficulty swallowing, she had no ideas. She did say, though, that her throat hurt, and that she was nauseated only when she tried to eat. Rather than exploring the etiology of this problem, which her physician had done in detail, I decided to begin by directly addressing the symptoms. She seemed to respond well to my induction and deepening suggestions. I next suggested:

As you enjoy these feelings of deep comfort and calmness, you may also become aware of feeling this same comfort in your throat and in your stomach. Notice just how comfortable and quiet you are right now. As you experience this comfort, imagine a smooth, protective coating beginning to line your throat, your stomach, all the way down. This can be any protective coating you wish. Perhaps it is like a steel lining coated with Teflon … hard and smooth and slick, so that anything that you swallow slides through easily, effortlessly, perhaps even without much awareness on your part … no need to even notice it any more than you wish.

You know, there are so many things that we do in a day that it’s not possible to remember them all … so you don’t. Some things just aren’t important to remember. Perhaps swallowing a few small bites of your next meal will be like that, just not important to remember. The food can just glide down over the protective coating, without any effort or awareness. So easily, you don’t even really need to pay attention, knowing the steel lining will protect you. And at any time, just before you are about to eat, or whenever you wish, you can just close your eyes, remember these feelings of calmness and comfort, you can remember this smooth slick protective coating, and allow the food or liquid to just pass through easily. How wonderful it is to know that you can be in control of your own comfort. You can choose what you take in, and you might be surprised how easy it can be to choose the best ways for you to be as healthy and as comfortable as can be, how natural and easy it is to choose what is best for you and your body now.

After the meeting with Pearl, I spoke with her physician and nurse, who confirmed that they had been telling Pearl that she could not just eat ice cream and apple pie but needed to take in more nutritious food. After our discussion, they agreed to let her eat whatever she liked and to merely praise her accomplishment in taking in calories.

I also spoke with May, Pearl’s daughter, who confirmed that she had had many fights with her mother, because her mother insisted that she wanted to continue smoking and May wanted her to stop. May also persisted in suggesting new foods that Pearl should try. As May and I discussed this struggle, I said I imagined this was difficult for both of them. May then expressed her fear that Pearl’s wish to smoke was really a sign that she was giving up and wanted to die. After further discussion, May agreed to assume that her mother knew well enough what she could eat and what she needed at the time; she further agreed not to struggle with Pearl about this.

I returned two days later to find that Pearl had begun eating, her affect was brighter, and she said, “The doctor says I can go home in two days if I keep on like this!” In that day’s hypnotic treatment, I used the suggestions for protective coating and described her ability to take care of herself and to choose what she eats and takes in so that she will feel as well as possible. Afterwards, she expressed some anxiety about returning home and being able to care for herself. She raised other concerns about being alone and expressed concern for her daughter as well. As a result, we scheduled a follow-up appointment for three days after she returned home.

When she came to see me as an outpatient, Pearl’s eating had continued to improve, her pain and nausea had completely resolved, and she seemed to be regaining her sense of competence.

After three additional follow-up meetings, Pearl had returned to work, was getting along better with May, and had not returned to smoking, although she did not say that she had stopped smoking altogether.

Hypnotic treatment for long-standing, disease-related pain has not been studied extensively, although there are indications that it can be effective (Spiegel & Bloom, 1983; Spira & Spiegel, 1992). Numerous factors interact in the treatment of this type of pain. Although 90 percent of cancer pain can be effectively treated with available medical methods, at least 42 percent of cancer patients with advanced disease do not receive adequate treatment (Cleeland et al., 1994). Clinicians considering hypnotic intervention for disease-related pain have an obligation to determine whether all available options for improved medical treatment have been used with these patients. Often, patients are unaware of medical options and physicians are unaware of the extent of the patients’ pain (Grossman, Sheidler, Swedeen, Mucenski, & Piantadosi, 1991). Patients may seek hypnotic treatment, rather than approaching their nurses or physicians for better treatment.

Even patients receiving excellent pain management are likely to have some residual pain or movement-related or incidental pain for which hypnosis and suggestion can be quite effective. Hypnotic intervention is an appropriate adjunct to medical treatment with these patients, not an alternative to medication.

A major issue in using hypnotic treatment with disease-related pain is determining how to maintain a durable effect for a pain condition that is likely to continue for months or even years. While hypnotic intervention can be extremely valuable, it needs to be repeated regularly, or patients need to be taught skills for using the methods on their own.

For a variety of reasons, many cancer patients who seek hypnotic treatment are not able to continue ongoing treatment. Most often, this is because patients have progressive disease, with progressive debility. Moreover, they have many medical appointments and demands; it takes tremendous energy just to meet these demands and endure. Tasks that may simply tire those of us who are healthy can thoroughly exhaust a cancer patient for several days. Since these patients do not want to be burdened by any appointments that are not essential, we find it extremely valuable to provide posthypnotic suggestions and training in brief, self-hypnotic methods that they can use on their own. We include these methods in the hypnotic treatment, and then we help patients to use the suggestions on their own whenever they need to feel better.

We find that hypnotic treatment eliminates most pain for patients during the time spent with us. Additionally, audiotapes can augment this help when the patients are on their own. However, sometimes patients say, “When I do hypnosis on my own, it helps while I’m doing it—but I hurt all the time, and the pain is tiring. I need something that helps when I can’t stop what I’m doing, like driving a car, or when I’m too exhausted and I can’t even concentrate enough to listen to the tape.” Sometimes, the impediment to self-treatment can be explained by just this kind of simple, practical objection. We need to be alert, however, for reasons that underlie these simple objections. (You may want to review this issue, discussed in Chapter 5.)

Frieda was a retired professional who had developed advanced breast cancer four years before she referred herself for hypnotic treatment. While there was no cure for her disease, she and her physician expected that she could live several more years. She was a very active person who enjoyed many friends and numerous sports, including biking and sailing.

Initially, Frieda had no pain, but in the past six months she had suffered progressively more bone pain. When she came to see me [KS], she had constant, diffuse, aching pain in her shoulders, ribs, and hips which she rated as “3” on a scale from 0 to 10 when she took her medication, “7” if she did not take her medication, and “8” if she moved in certain ways and when she stood after prolonged sitting. She complained that the pain was making her crabby; moreover, she was reluctant to see friends or commit to any activities because she did not know how she would feel at the time of the activity. She did not like her medication because she felt sleepy when she was on it and, as the sleepiness wore off, the pain returned. As a result, she rarely took her medication. She did not tell her doctor how much she hurt, because she expected he would only tell her to take more medication.

Such reluctance to take analgesic medication is very common in cancer patients. The “Just Say No” campaigns against drugs have worked very effectively on the population of people with cancer, the vast majority of whom have little risk for misusing drugs. The most frequent problem we see is people who are afraid that if they increase medication when the pain increases they will be come addicts. We also commonly see people who have side-effects such as nausea or sedation with an opioid medication like morphine and then assume that all analgesic medications will make them nauseated or sleepy. They stop taking the medication and do not tell their doctor because they do not know that the nausea can be treated, that the nausea or sleepiness may go away in a short time, or that there are many other drugs that may not make them nauseated.

Frieda was one of these people. Clear thinking and remaining active were very important to her, and she felt the medication hindered these aspects of her life. On the other hand, the pain hindered her ability to feel like herself. My first step was to offer her a brief education in analgesic medication. Instead of taking intermittent doses of medication, she tried a sustained release medication that kept her constant pain at a level of 2. She agreed to try the medication for two weeks to see if some of the sedation would wear off. Indeed, after about a week, she found she was not sleepy in the daytime and, because her pain was better controlled and her medication continued to work for eight hours, she was sleeping much better at night. However, she still had substantial increases in pain when she moved. She had immediate-release morphine that she could take when she anticipated movement or when her pain increased, but she also wanted to see if hypnotic methods could help her feel better when she moved.

Although Frieda had an analytical and practical style of thinking, she was also imaginative. She could easily imagine herself on her sailboat, feeling the wind and the waves. She was curious, but she was also skeptical about whether she could be hypnotized. I suggested that this was a very good attitude with which to begin.

You can stay as curious as you like, exploring all the ways to use your mind to find the ways that work best for you to be as comfortable as can be. And you know, when you’re sailing you can think of many things—the direction of the wind, the trim of the sails, the point of the boat. Your analytical mind continues to be very sharp and clear, but its focus is somewhere else, very much on the water, the sky, the wind, and the boat. Other concerns are far, far away. If they pass through your mind, they just don’t really matter any more, gone with the next wave.… And you can take your mind in this same way to another place, anyplace you like, anytime. Just take a deep breath, let your eyes roll up as if to the sky, and then, as you close your eyes and let out that breath, you can feel the light breeze on your face as you fully and completely imagine yourself on the boat, sailing. You know so well how it is when you’re sailing, and now you can experience it all again, and examine it as much as you like. Here, there is just the sound of the water, lapping against the sides of the boat, the feeling of the waves around you. And you might become aware of the other feelings here, on the boat. How many things you can feel … the boat as it moves slightly under you, your legs, as they adjust smoothly and easily to the shifting sensations, your hand, as it knows just where to rest lightly for the best balance, but mostly, just that feeling of breathing in life all around you in the air, feeling the refreshing and soothing steady breeze, as steady as the strength of the water beneath you. Just taking a few moments to breath in that life and energy, that feeling of renewal that you get from the water and the air. Always free to go in the direction you choose, finding the best direction for you now. And from this place of steady, calm, and easy movement, you can look back on yourself, perhaps from far away, but able to see what would help you to be comfortable as you move, watching as you do that, moving smoothly and easily, changing position, bending and standing, and knowing just how to do it as slowly or gently as needed but sure and steady. Just as you do here on the boat. Just taking a moment to experience this, so that, whenever you like, you can move with this same feeling, sure and calm and steady. And you might like sometimes to just get away on this sailboat to simply move away to where it is easy to look on the horizon and to move easily and comfortably. You can do this when you want to move. In just a few moments, you can take a deep breath, as if you are breathing in that fresh sea air, let your eyes roll up to the sky, let out that breath, and, from that place with steady balance, you can find it easy to move smoothly, from sitting to standing, one hand to balance as you steady, and then, when you’ve got that steadiness under you, it’s easy to just move on.

Afterward, I helped Frieda to practice the suggestions I had given her: She took a breath, looked up, imagined the sailboat and, from this place in her imagination, some distance away, she moved from sitting to standing. We met two more times, during which she said that she used the distancing/sailing suggestions on her own and that they were very helpful. She said she felt much more confident in getting together with friends and she was having an easier time changing positions. She still used medication if she found the pain continued after she moved, but she felt more comfortable using the medication and she was more confident that she could trust herself to be able to do what she wanted to do. And she was no longer afraid to move. She found herself using this distancing technique (a variation of what Barber describes as “dissociation” in Chapter 5) at other times when she was stressed or uncomfortable. She said she would just imagine herself on her sailboat, and then she would look at her troubles from far away and they just didn’t seem as big. Sometimes, she said, she was even able to see her problems differently; this helped her to find solutions to some difficult problems. The real joy for Frieda in this sailboat image was that, even though she was no longer actually able to sail because of her illness, she could once again enjoy the experience of sailing through her imagination. This intervention helped her with her pain and also restored one of her great joys in living.

Cancer treatment is changing rapidly and patients are living longer, receiving far lengthier courses of more aggressive treatment. When you treat the pain of cancer patients, you need to know not only the expected course of the disease but also the potential effects of various treatments. We consider it part of our standard clinical care to know what medications or treatment the patient is receiving. If the treatment is unfamiliar to us, we either find a colleague to inform us or search the literature to assure that we are aware, for example, of neurologic and somatic toxicities and their likely interaction with psychological intervention. For instance, a patient receiving ongoing interferon injections will have aches and pains as well as depressive CNS effects that can be relieved with pharmacologic treatment. If the patient understands that these symptoms result from treatment, rather than endogenously, his or her interpretation of the pain may be more benign, as we see in the following case.

Susan said, “I just can’t go on. I just want to die now. I hurt all over, I’m totally tired all the time and I just don’t care anymore, even about my kids. I feel very guilty because I don’t care about them, but I just can’t get interested.” She had been receiving interferon injections daily for three months and had at least three more months of injections. She knew that the injections gave her flu-like symptoms, but she did not know that interferon can also produce depressive symptoms.

Because she attributed her feelings of depression to her “self,” rather than to the effects of the interferon, Susan felt not only depressed but terribly guilty for being a “bad mother” and not caring about her children. I [KS] explained to her that depression is a very common side-effect of interferon and that her indifference to her life and those she loved was almost certainly a result of the medication, since this symptom did not predate the medication. We discussed pharmacologic and psychologic options for treating her depression.

As a result of this brief and respectful explanation, Susan felt tremendous relief and immediately stopped telling herself she was a bad mother; instead, she told herself, “I feel terrible, but it’s from this medication. As soon as it stops, I’ll feel better. Just because I feel bad, it doesn’t mean I don’t love my family.” She gave me permission to speak with her physician, and he began antidepressant treatment that relieved many of her depressive symptoms.

The most powerful suggestions offered to cancer patients, who almost always feel a loss of control over their body, are those that acknowledge the difficulty of the situation and reaffirm patients’ competence to manage these difficulties. Such a communication can be met with skepticism if expressed by a well-meaning family member or a clinician who has no knowledge of the disease or treatment. As we see from Susan’s example, however, this information can be empowering and gently supportive when it comes from a clinician who can normalize the patient’s experience and provide a context that includes the probable course of the symptoms. Often, as in Susan’s case, the patient can also be assured that the experience has a time limit.

An important role of any clinician involved in cancer pain treatment is to educate patients and their families about the available medical treatment options (Jacox, Carr, Payne et al., 1994; Syrjala, 1994; Syrjala, Williams, Niles, Rupert, & Abrams, 1993). For moderate to severe pain, patients should request hypnotic intervention as an adjunct to medical treatments but not as an alternative to these treatments. Fear of addiction, reluctance to depend on medication, and concern about side-effects of medications often result in cancer patients’ severely underutilizing life-enhancing medical treatments. Regrettably, healthcare providers themselves often share some of these misconceptions. They are often not aware of patients’ levels of discomfort and may not have adequate training in the treatment of cancer pain and its side-effects. Consequently, clinicians considering hypnotic treatment for pain related to cancer need to fully evaluate the pain, as well as the ability of the patient to advocate for his or her own needs with healthcare providers.

There is no more common question asked of a psychologist working in oncology than the one about how effective hypnosis, suggestions, or thoughts can be to cure the disease. As we will see, serious damage can be done by well-meaning relatives and patients who believe that cancer can be cured primarily by suggestion or by encouraging or discouraging certain thoughts. Such misconceptions require that we approach with care any expressions of the power of the mind in treating cancer, that we are clear about our own beliefs and how these beliefs may transmitted to our patients.

When we talk with a patient and his or her family, we try to be as clear as possible that hypnosis and suggestion are not known to cure cancer or even to directly affect its course. We further emphasize that, while we know that the mind and body are connected, and that the mind influences the body, no data demonstrate that the mind alone can cure cancer. It is as mistaken to think that the mind totally controls the body as it is to think that the mind has no influence on the body whatsoever. Since this belief in mind supremacy is a reflection of the basic human need for invincibility and immortality, we try to be sensitive to the patient’s and family’s struggle with mortality even as we discuss these scientific and clinical issues.

When these misconceptions are not confronted, patients who have difficulty with the guaranteed discomforts of medical treatment are naturally more likely to turn to a less painful treatment, such as hypnosis. Their wishes develop into beliefs that hypnosis will be the only treatment they will need, and they do not understand that hypnotic intervention is only one component of their cancer treatment. Other patients, discouraged when their medical treatment seems to be ineffective, may find it difficult to accept that currently available treatments are limited in their effectiveness. And so, they may believe that the failure to improve is their own fault—that their disease is not responding to treatment because of something lacking in their own attitude or personality. We strongly recommend that patients continue all medical care while integrating hypnotic treatment as a part of their active participation in their health. We try to support patients when they are discouraged and help them avoid blaming themselves when treatment is not effective. Because pain and other physical symptoms of cancer and its treatments respond very well to hypnosis and suggestion, we do encourage patients and their families to include these interventions in their overall care.

Communicating congruence with the patient’s beliefs is important to developing initial rapport, of course. So, if a patient believes in the “magic” of hypnosis, we do not discourage this belief. If a patient requests “visualization” or “guided imagery” rather than “hypnosis,” unless it is necessary to correct a misunderstanding, we simply respond by offering training in “visualization,” incorporating the use of suggestion as a potent component of this strategy.

Hypnotic responsivity is rarely an issue when treating cancer patients, although some knowledge of the patient’s capacity for imagination and absorption can be valuable. The data are mixed with respect to the issue of hypnotic responsivity and pain management. Some data indicate that highly responsive subjects reduce pain more than unresponsive subjects in laboratory studies (Spanos, Kennedy, & Gwynn, 1984; Spanos, Radtke-Bodorik, Ferguson, & Jones, 1979), while other data do not (Fricton & Roth, 1985; Price & Barber, 1987). Generally, clinicians do not believe that hypnotic responsivity is the best predictor of response to hypnotic treatment (Barber, 1980, 1982, 1991; Price & Barber, 1987). For cancer patients with strong motivation, response on standard measures seems even less useful than with non-cancer patients as a predictor of ability to benefit from these strategies (Barber, 1980; Frischholz, Spiegel, Spiegel, Balma, & Markell, 1981).

Our clinical experience suggests that almost anyone with sufficient motivation can benefit from individualized psychological treatment, although the patient with more responsivity will probably respond more readily to any approach. Rather than focusing on responsivity, we individualize our treatment approach by assessing the cognitive style of the patient and the beliefs or wishes that bring the patient to treatment. We find this assessment to be a useful guide to the development of treatment strategy.

With a skeptical patient who demonstrates little facility for imagination, or indicates some suspiciousness about hypnosis, we begin with phenomena that most patients find comfortable. For example, we may begin with tense-release muscle relaxation training, then move on to imagery, and after that incorporate suggestion. Since these patients often are not in touch with their bodies, they can gain confidence and a sense of personal control merely by becoming aware of the simple shift from tense to relaxed muscles.

It is often helpful to begin the first treatment with a description of what will happen. The concrete physical change and the experience of mental control over that physical change, as well as the patient’s greater comfort with feeling in control during the procedure, helps to eliminate his or her skepticism and engender probable success, which may not occur as readily with hypnotic suggestions initiated at this point.

Alternatively, we sometimes use an experiential exercise. For example, we may ask the patient to stand with arms extended and hands against our hands. Patients are instructed to raise their arms straight out in front of them and to continue to hold their arms straight while we press as hard as possible against them. Next, patients are instructed to imagine steel bars through their arms while the exercise is repeated. These demonstrations of the effects of the mind on the body are valuable first steps for patients who are inexperienced in using their imaginations.

Before we can responsibly develop a pain treatment plan incorporating hypnosis or suggestion, our patient needs to have a medical evaluation to determine appropriate medical treatments, as described in Chapter 2. While additional evaluation is valuable, the depth of this assessment depends in part on the duration of pain relief being sought. Very brief suggestions for procedural pain may require only a brief evaluation. However, designing a strategy for management of chronic cancer pain requires a more thorough evaluation. Medical and physical status can change suddenly. The evaluation needs to be updated as the patient’s needs change, depending, for instance, on the course of the illness and cognitive shifts, as well as input from others, such as the physician or family. Further details on assessment of pain in cancer are available from other sources (Cleeland & Syrjala, 1992). Let us review, now, the factors that need to be considered when we develop a pain treatment plan using hypnosis or suggestion.

A good description of the pain will help in developing hypnotic strategies and suggestions that can be tailored to the individual characteristics of the pain, as well as identifying other needs of the patient. Understanding the etiology and location of the pain is very important in developing an effective treatment plan. Is the pain a result of a procedure, surgery, chemotherapy, radiation, disease progression, muscle overuse, or is it of unknown origin? The answer to this question not only tells us about the targets and goals of treatment but also provides some information about the potential meaning of the pain to the patient and about secondary goals that might be achieved with hypnotic intervention. Is the pain a symbol to the patient of frustration, helplessness, or loss? Is it a cause for anxiety and questions about whether the disease is progressing?

Paradoxically, in a life-threatening illness, patients sometimes see the pain as an indicator of their health status—they are still alive—and may be reluctant to be completely relieved of the pain. We have had cancer patients tell us that they are reassured by staying in touch with the pain and saying to themselves, “The pain is the same today as yesterday so I’m not worse, the disease hasn’t spread.”

The intensity of the pain is easily measured with a VAS or numerical scale. A baseline assessment and reassessment after the use of suggestion can assist both you and the patient in evaluating the efficacy of treatment. In itself, this assessment can act as an important motivator, reminding the patient that the time spent using the technique has had a measurable effect, even if the pain does not disappear altogether (which, in itself, is probably an unrealistic goal). Continuous pain above “6” (out of 10) needs rapid attention from the medical team to assess options for improved treatment. Once we are assured that the treatment method is appropriate, it is usually best not to reassess pain immediately after each session, since assessment draws the patient’s attention back to the pain, perhaps undermining the effect of the suggestion. This can decrease comfort and make patients understandably irritated.

As clinicians we recognize the power of our suggestions in all of our conversations with patients and their families, whether or not hypnosis is a component of treatment. While suggested analgesia may be more powerful in the hypnotic state than without it (McGlashan, Evans, & Orne, 1969), suggestion is an extremely powerful tool in any state and may account in large measure for the placebo effect (Turner, Deyo, Loeser, VonKorff, & Fordyce, 1994). Increasingly, clinicians are recognizing that placebo effect should be maximized rather than eliminated. When you simply act as though pain relief will be accomplished with treatment, you effectively communicate the suggestion of success to your patient.

Additionally, you can suggest comfort and mastery over physical well-being. For example, you might say:

I’m sure that, as you see how easy this can be for you, you will find a way to use it that will make it automatically more comfortable. Perhaps at first you will think about it when you notice a sensation, just like when you learned to ride a bike. But pretty soon, just like riding a bike, you find yourself doing what it is that makes you feel more comfortable.

For many acute pain situations, analgesic or sensory transformation suggestions are not needed. Relief is obtained by actively moving the patient’s mind to comfort and pleasure that is unrelated to symptoms. The suggestion is implicit, since the patient knows that comfort is the goal.

We also recognize the powerful impact of self-suggestion. For patients with continuous pain or negative self-talk about procedures, we teach the skill of “refraining” to neutral or more positive self-suggestions. (This is related to what Barber describes as “reinterpretation” in Chapter 5.) We have identified four different ways to do this. A major clinical task, of course, is to help patients discover which of these ways best matches their own personal style.

1. Patients can focus on what they have accomplished, rather than on what remains to be done. For example, they might remind themselves what hurdles they have already passed, such as completing a course of chemotherapy or a marrow aspiration. They can then be encouraged to congratulate themselves for having gotten through it so well.

2. Patients can be assisted in finding something positive that can be gained from the situation and focusing on that. For example, he or she might say, “In coming through this, I have learned what a strong and capable person I am. I couldn’t have imagined two years ago that I would be able to do all this, but I’ve really done it, and done it well. Nothing can ever change that accomplishment.”

3. It can also be helpful to encourage patients to step out of the situation and observe it from a distance, saying to themselves something like, “When I take a step back and put this in perspective I can see that this is just a small part of my whole life.”

4. One of the most effective reinterpretations we can offer patients involves suggesting that they focus on the temporary nature of what is difficult or painful. For example, we might encourage a patient to say, “This is difficult, but I know that this will not last forever. In five minutes [or two days], I won’t have these feelings.”

One of our major goals in working with cancer patients is to identify aspects of their lives that they already can control. We then help them to gain greater control of their own comfort. Sometimes, with patients who feel very out of control, we initially take charge of the situation, and we introduce the seeming magic of the hypnotic experience. But, ultimately, we help the patient to “own” the accomplishment and abilities.

In the development of analgesic suggestions, it is essential to hear the patient’s description of the qualities of the pain and its pattern of occurrence. Is the pain brief, continuous, or intermittent? Is it expected to stabilize indefinitely or to progress in severity? For instance, with a pain that is brief, hypnotic suggestions can focus on active distraction. We can suggest that the patient imagine him or herself in a pleasant place and then suggest a particular physical activity to more fully engage the patient’s awareness for the duration of the procedure. For continuous or progressive pain, a sensory transformation method can help the patient to integrate the analgesic suggestion into his or her ongoing life.

Descriptions of the pain (e.g., stabbing, burning, cramping, shooting, aching, pressing) can be incorporated into the sensory transformation experience. For example, for a burning pain, we often use suggestions of freezing Arctic air blowing through the painful sensation:

Just take a deep full breath, and as you breathe out, breathe the cool air through that feeling. Imagine the air is freezing cold Arctic air and just breathe it through that hot burning place. That’s right … deep breath in, and breathe that icy cold air through it and watch as it changes, just notice the cooling as the feeling changes. Perhaps the shape changes, or the color might go from red to orange to yellow or even green. However it is, just notice as you feel more comfortable, more at ease. And continue to breathe that cool, comforting air through as long as you like. And whenever you like, or whenever you need, you can just take another cool, deep breath … whenever you would like to feel more comfortable.

Alternately, we may use information from the patient’s description to suggest that the patient imagine what the pain looks like, and then modify the image, sometimes in surprising ways.

Anna, whose story was introduced at the beginning of this chapter, was interested in doing all that she could to cope with her cancer and symptoms. When I [SR] raised the option of using hypnotic methods to help manage her pain, she was enthusiastic and eager to begin. While we worked on multiple facets of her emotional and physical discomfort, using a variety of techniques, here I focus on our sensory transformation work.

After the first induction, I asked Anna to focus on her gut and see if she was able to imagine the color of the pain she was experiencing. She did this quite easily, describing it as very dark and black. I then asked her if the “black” had a texture. She responded that the “black” had a “sticky” quality to it. I inquired whether the pain had a shape or form to it; if so, could she describe it for me? The sticky black became a hard, weighty, and sharp-edged geometric object, filling her gut and tearing at it with its sharp edges. As she described this, she expressed a tangible sense of anger and hostility toward the object. I encouraged her objectification of the pain and explored the specific sensations and emotions around it.

I then asked her to see what she could do to this object, using the descriptors she had used, to soften its impact. We began with a transformation of color. Anna imaged the object changing from black to red to orange to yellow, ending with cool blue. She remarked that the temperature of the object changed as she did this, from hot to warm and finally to comforting coolness. As the color and temperature changed, so did the form. The edges softened and the object became a sphere. With each change that occurred I gave suggestions for increased comfort and for her increased control over managing her own comfort.

In subsequent meetings with me, Anna experienced the pain-object as becoming more amorphous and fluid. In the third meeting, she was able to make the pain-object completely dissolve. With each transformation, and in each session, the pain in her gut diminished. By the third meeting, she reported a complete lack of discomfort. The tone of her emotions shifted. She reported actual joy, triumph, and pride in her own strength in conquering the pain.

We audiotaped the second and third meetings so that Anna could learn self-hypnosis. Her sense of control over this part of her cancer experience seemed energizing to her. She said, “I feel like now there is something I can do against the cancer. It’s not just the cancer eating at me and the doctors doing things to me, it’s also what I can do for myself.” Although the pain only rarely completely vanished, she was able to modify it enough to maintain eating and to be discharged from the hospital.

We most often use suggestions about patients’ “favorite places” as a part of the hypnotic intervention. For example, a patient may enjoy reliving a particular holiday at a particular beach, while another patient may enjoy remembering being with grandchildren, and still another may enjoy reliving the experience of hiking a favorite woodland trail. While such an experience is not necessary for analgesia, for patients with moderate to severe continuous pain the escape to a comfortable, safe place as a reprieve from the pain is as important as direct analgesic suggestions. We find that patients immensely enjoy this experience, and this pleasure further enhances their readiness to use these methods when needed.

In the pleasant place the patient chooses, we suggest that he or she walk, in order to feel his or her own body as strong, healthy, and whole, knowing how to move and take care of itself, even without conscious thought. To most effectively take the mind away from moderate to severe pain, we include suggestions for physical activity of some type within the images the patient uses. We find that when a physical activity such as dancing, swimming, or skiing is chosen, the patient’s affective absorption is much greater than if he or she is more passive (e.g., lying on the beach). Moreover, with a suggestion for activity, the patient is also required to focus on a variety of sensory experiences, including pleasant kinesthetic ones. This type of engaging suggestion is more easily maintained than a suggestion for relaxation by patients who have difficulty focusing on anything other than their severe pain.

Once patients have enjoyed being in their “special place,” we incorporate analgesic suggestions developed during our assessment of pain qualities. Often we use the suggestion of ice placed on the painful area. As it melts, we suggest, the cold is absorbed into the area of discomfort until that area is numb or just tingles. Ice works well as an analgesic agent for several reasons. It is familiar and can be brought into any image. In the mountains, snow can easily be found; at the beach, in a warm cozy house, or on the front porch, an ice cold, refreshing drink can be found—the patient imagines taking the ice out of the drink and placing where it helps the most. Remember that there is no limit to the use of suggestion, beyond what the clinician and patient can imagine and comprehend.

Here is an example incorporating suggestions that employ the experience of cold to relieve pain:

Enjoy being in this pleasant safe place, experiencing it fully. Noticing everything around you in this special place of yours.… And I wonder if you might be surprised by any of the sounds your hear around you, or any of the smells in the air … perhaps the smells of life or energy or freshness, just taking a moment to smell the air and feel the air against your face.… Notice if it is cool or warm or perhaps a bit of both … warmth from the sun or a slight cool breeze of fresh air. It doesn’t really matter what it is, whatever is there is just fine. And maybe you can enjoy this fresh air as it refreshes your face and body. Taking in a deep cleansing breath, feeling the comforting coolness.

And notice whether you can find something else cool nearby, something refreshing, icy cold. You may need to move around or look about you. It may be a refreshing drink with ice, a cool lake or stream, or perhaps even the cold of snow, or a different kind of cold. But wherever it is, however it is for you, just explore that feeling of cold in your hand. As you hold it, notice how the sensations change. First cold, then perhaps tingly or maybe numb, no feeling at all. You might even be curious to put that icy cold on a part of your body where you would like to feel more comfort and notice how the feelings change, gradually the coldness seeps in … layer by layer … a tingling feeling, perhaps … and then the feelings become less intense, perhaps even becoming numb, or no feeling at all.

However it is for you, just less noticeable or less bothersome, just cool sensations around the edges perhaps, but soothing cool. And you can hold this coolness there for as long as you like. And know that whenever you would like to come back to this comfort or numbness, you need only to close your eyes, take a deep breath, see this place in your mind, and bring back the feeling of fresh air in your face. Then you can bring this icy cool to any place on your body, as you allow the sensations to change and as you become more and more comfortable. How wonderful it feels to be in control of your own comfort. And you might even be surprised at how easy this becomes for you, when you take a deep breath and see this place and feel this coolness as it brings as much comfort as you need.

Many other analgesic options are available. Some are described in Table 6.2. In situations where pain is long-term, patients need methods for using individualized suggestions on their own.

We have at least two initial meetings with the patient to establish a trusting therapeutic rapport and to identify any problems and solutions that will facilitate the patient’s use of these methods on her own. Initially, we often provide an audiotape of the induction that was used and ask patients to practice creating the hypnotic experience between appointments. In the second appointment, problems are reviewed and addressed. For example, for the person who was unable to practice the skills between sessions, we inquire about the reasons and then problem-solve in order to facilitate future practice. We then offer a second induction. Again, patients are encouraged to practice on their own, both in a quiet place and, more briefly, during daily activities when discomfort is likely to occur.

From this point on, interventions are highly individualized. We tailor the number of meetings and the content of suggestions to the needs of the patient and his circumstances. Only a small percentage of patients continue using audiotapes regularly. In large measure this seems to be because the patients’ situations change so dramatically over time, and they do not think of the tapes in their new situations. Instead, patients take the points they recall as most helpful from the hypnotic experience and adapt the methods and images to their new situations. Most patients find suggestions that work for them and use tapes or more formal hypnotic inductions less for pain than for particularly tense or stressful periods or to facilitate restful sleep.

Table 6.2

Hypnotic Suggestions for Pain Control with Cancer Patients

Most Frequently Used

1. Escape or distraction by going to a favorite place:

(a) Include action for added intensity or involvement.

(b) Metaphors for dissociation may include flying above or away from the physical sensations.

Advantages

Most enjoyable.

Takes the least effort from an energy depleted patient.

Disadvantage

May provide shorter duration of pain relief.

2. Blocking pain through suggestions of anesthesia or analgesia:

(a) Often uses numbness via cold or anesthetic.

(b) Can use flipping switches in the brain or spinal cord to disconnect pain messages or changing channels.

Advantages

Patients can easily use the images on their own.

Has potential to extend pain relief past the duration of hypnosis.

Disadvantages

Takes more active participation and concentration ability from the patient.

May require more hypnotizability for full effect.

3. Sensory transformations:

(a) Go to the pain location and explore it; “open to the pain” rather than push it away; watch as the pain changes; usually it diminishes greatly.

(b) Take the pain description and introduce an image that can change as pain changes:

find the color of pain and change the color;

change the intensity of pain (e.g., reduce “8” to “3”);

blow cold Arctic air through a hot burning pain;

take a knotted, cramping pain and gather the knot into the fist and throw it away or unknot the pain, soften and smooth it.

Advantages

Takes less energy and goes with the patient’s focus of attention instead of fighting it.

Can be done quickly without lengthy induction, especially for fatigued patients or those with acute onset, severe pain. Can be very effective.

Disadvantages

Does not seem to “get rid of the pain.”

Pain may initially seem worse, scaring the patient.

Less Often Used

4. Increase tolerance of pain or decrease perceived intensity of pain (e.g., use metaphor of dessert: with each bite you are less aware of the taste, by the sixty-eighth taste it isn’t bad, you just don’t care about the flavor anymore, it’s just there, but you don’t notice).

5. Move pain to a smaller or less vulnerable area (e.g., hand).

6. Substitute another feeling for the pain (e.g., itch or pressure).

7. Alter the meaning of the pain to make it less fearful or debilitating (e.g., itch, pressure or burning are signs of treatment working, sensations are indications of healing).

8. Dissociate the body from the patient’s awareness or move the mind out and away from the body.

9. Distort time so it seems to go by very quickly.

10. Suggest amnesia to forget pain and reduce fear of painful recurrences.

With the uncertainty and constant changes patients experience during cancer treatment, the stability of our presence can be a great source of continued comfort and reliability. Many patients reach a point where they do not need further hypnotic intervention but wish to either stop by our office or have us stop by their hospital rooms, just to hear our voices or see a familiar, reassuring person who brings comfort and stability. Other patients will use their tapes in lieu of our presence to simply reexperience the comfort and sense of not being alone.

Often we invite someone else into the images that we suggest to patients. We ask patients if they can see someone else, someone coming toward them. We suggest that they listen to see if that person has something to say that can be helpful, something that they most need to hear right now. We may ask if the patients would like to reach out and touch that person,

… to feel the warmth and energy of the person and perhaps to absorb some of that life-giving energy, to feel the love and connection that flows with that energy. As you absorb that energy, you can feel it flow through your body, bringing strength and renewal.

This can be much more fully elaborated if the patient is pleased and comforted by the experience.

Isolation is one of the most common experiences of cancer patients. Patients tell us that inviting someone else into the image is a powerful support that they carry with them well beyond the induction to feel safe, loved, and less alone in what is often perceived as a lonely battle. The same suggestions that are used to bring someone else into the image can be used to suggest an image of the patient at a future point in recovery. Patients imagine themselves at some specified time in the future, usually at least one year ahead, strong, healthy, and pain-free.

At the time, these suggestions can be powerful motivators and sources of strength, regardless of the actual outcome of the disease. If we know a patient is not likely to live much longer, we emphasize an imagined place of peace where the person can enjoy seeing him or herself strong and healthy. For some people, this is a way to enjoy a health that is now lost in the “real world”; for others, this may bring a very soothing foreshadowing of death. We have not found it to be unsettling to people. As with all work with ill or dying patients, we need to be prepared to work with the issues that emerge and to explore the patient’s thoughts and images of death. We need also be prepared for strong feelings, perhaps fear, perhaps sadness, perhaps anger, both in the patient and in ourselves.

This entire process can be done out loud as a conversation between the patient and ourselves. We ask questions or elaborate patient responses, and the patient fills in the details. This keeps us aware of and able to respond immediately to the patient’s experience, while the patient is required to stay deeply involved in her imagination to be able to respond to our questions. We are most likely to use this conversational method with patients who have difficulty creating their own images or concentrating without fatigue or tangential thoughts disrupting their focus.

With cancer patients, as with many others, formal hypnotic inductions are often not necessary. It is possible simply to offer acutely distressed patients variations of the images found in Table 6.2. Brief, transforming images, such as seeing the pain as an object and watching as it changes color and shape or moves to a distant location, can be very effective and greatly enhance patient confidence when the pain is brief.

During occasions when concentration and attention are severely limited, helping the patient recall a “snapshot” of his or her pleasant place can take less energy, yet still provide relief. Metaphors and suggestions either with or without formal inductions are effective, particularly when you have established some therapeutic relationship with the patient. As an illustration, a patient who has said that her pain feels as if a metal band is squeezing her tighter and tighter with each new cramping sensation can be asked to describe what might be used to loosen and eventually remove such a metal band. Suggestions can then be developed based on her response. Or you might offer suggestions in the hypnotic context for cutting and gradually loosening the band. Using the patient’s own description of the pain is much easier, and is probably much more effective, than using a suggestion that is meaningful to us but perhaps not to the patient.

Several types of patients respond very well to active storytelling, especially when they are themselves involved in telling the story. This strategy is particularly effective when patients have difficulty concentrating because they have intrusive thoughts, short attention, or severe pain that intrudes into otherwise absorbing images. When using this strategy, it is important to elicit from the patient a story that evokes a pleasant or otherwise ego-enhancing time in his or her life. For example, we may ask a patient to describe the proudest moment in her life, the most joyous or the most at ease. We then encourage the patient to share as much detail as possible. Ordinarily, the patient becomes so engrossed in the reliving of that experience that she is unaware of pain for that moment.

Perhaps the greatest difficulty in using hypnosis for cancer pain is the requirement that clinicians work through their own fears about death and believe in their own capacity to assist a patient with managing sometimes terrible situations. This does not mean that clinicians do not have feelings. On the contrary, it is the awareness of our own feelings that so often guides us toward apt interventions with the patient. However, in the emotionally taxing environment of cancer care, there is a natural tendency either to take on too much of the feelings of our patients or to distance ourselves excessively from our own feelings. Taking either of these directions can lead to burnout or to sudden overwhelming feelings.

We have seen colleagues who try to overcome their painful feelings by suppressing unpleasant thoughts and emotions. These people often have to leave cancer work because eventually the suppressed pain begins to emerge, and it makes them feel unable to continue to shoulder the burden of this clinical work. Often, these feelings include great anger, partially at our own helplessness and at the unfairness of a world where good people suffer such terrible illness and pain. Not infrequently, the anger takes the form of blaming others. These emotions can be difficult to understand if we are not free to discuss and explore them in a trusting environment.

Many clinicians, of all specialties, are isolated with these feelings, just as patients may be. Understanding this aspect of our working environment enables us to work with other staff, as well as with the patient’s, effectively. As clinicians, we need to remain accessible to a patient’s feelings, yet not take on those feelings. We must stay in touch with our own feelings and know that these can be quite different from the patient’s feelings. We need to balance hope and yet plan for the worst. To continue working well with cancer patients, we must come to our own terms with physical deterioration and the intense emotional loss people experience when they are possibly dying of cancer. We realize that these things are not easily done. They take time; even more, they require that we find opportunities where we can safely express and explore our own thoughts and feelings.

One of the greatest difficulties in using hypnosis and suggestion for cancer pain is the requirement that, as clinicians, we need to work through our own fears about dying and about not being able to do enough to help. We need to believe in our own capacity to assist a patient with managing sometimes terrible situations, while knowing that there are limits to what we can do. We sometimes feel inadequate. Accepting these limits is extremely hard, and yet in some ways it reflects valuable growth. Really, this is essential if we are to be helpful to others who are also struggling to make sense of what can be done when one has cancer. Allowing these powerful feelings to go unexamined can interfere with the most basic aspect of patient care—the therapeutic relationship between clinician and patient.

For example, a clinician who is fearful about his own death or who has not come to terms with the death of a loved one is very likely to be drawn into the center of a patient’s own struggle when he is confronting his own mortality. As with any type of countertransference, if this issue is left unexplored the needs of the patient become hopelessly confounded with the needs of the clinician.

Once we are aware of and understand our own feelings, we are less likely to minimize the patient’s distress or to get caught up in believing that to help patients we must experience what they experience. It can be of immense help to the patient if we can convey the calm optimism that even the barely imaginable can be managed, that even the most intense feelings of the patient can be tolerated and accepted, and they will not harm the clinician.

Having said this, sometimes we must also assertively advocate for the patient to receive greater medical attention to symptom management needs when suffering should not be tolerated. Thorough pain assessment is crucial. For instance, a patient rating his or her usual pain level as greater than “4” (out of 10) is a candidate for more aggressive medical intervention.

Most of the other problems that occur when providing hypnotic treatment to cancer patients do not differ in type or solution from those problems seen in non-cancer patients. These include skeptical patients, religious prohibitions, patients with rigidly biological models for pain, etc. (See Syrjala & Abrams, 1996, for more detail.) In Table 6.3, we list difficulties that we see more often with cancer patients than with other populations, as well as some solutions that we have found.

The most common difficulty occurring when using hypnotic treatment with cancer patients is that patients are exceedingly fatigued or cognitive function is impaired such that concentration and complex processing are very limited. With these patients, we may need to reschedule an appointment or keep the content of the appointment very brief and simple. Otherwise, in the middle of an induction, a patient may say, “I can’t do this right now,” or she may simply fall asleep.

Table 6.3
Problems and Solutions Encountered with Cancer Patients

Problem	Solutions

Lack of concentration	Use brief images. If preoccupied, talk about preoccupations. Perhaps try at a later time. If medication effects are interfering, may try at a later time.
Unsupportive family	Talk to the family. Involve the family in helping the patient. Help the patient solve the problem.
Falling asleep	For patients in severe pain with sleep deprivation, encourage to continue with a deep restful sleep. Raise the tone of voice and incorporate suggestions for more active imagery. If patients complain of falling asleep during home use, suggest practice sitting up and at a time of day when more alert.
Intrusion of pain into trance	Use more active images to more fully engage patient. Use sensory transformation images that accept some pain. Have patient talk to you to more fully engage the patient’s cortical processes.
Fatigued or in severe pain First
	Use medications for better pain control. Consider medication options for fatigue/depression.
Then	Begin simply, do only what is possible, e.g., breathing with an image of pain description changing. Use brief images, little induction is needed. As appropriate, use touch on the hand, foot or shoulder to help the patient focus, to anchor the patient away from the location of the pain, and to provide a competing sensation to the pain.

Rarely, issues can occur that are more harmful to the patient or the family and require great care from clinicians. The most serious problems we have seen have occurred in families where the power of hypnosis or suggestion was embraced wholeheartedly—and unrealistically. In several situations, patients have taken their training in self-hypnosis and used the techniques to treat severe, post-chemotherapy nausea and vomiting, rather than using medication to relieve most of the symptoms. Because this “treatment” was ill-conceived, these patients have developed strong conditioned responses of nausea and vomiting to future hypnotic interventions and even, in one case, to the presence of the clinician who was associated with hypnosis.

Hypnotic treatment has proven effective in relieving conditioned effects of chemotherapy such as anticipatory nausea (Burish & Tope, 1992). However, in our experience hypnotic treatment will not always work as alternative to anti-emetic medication for treating nausea and vomiting caused directly by severely emetogenic chemotherapeutic agents (Syrjala et al., 1992, 1995). Knowledge of the literature is helpful in developing a realistic treatment plan.

If a patient is receiving chemotherapy and has vomiting, not just mild nausea, it is essential to advocate for early aggressive medication treatment of symptoms. Untreated vomiting greatly increases the risk of nausea and vomiting in future episodes of chemotherapy, as well as the risk of developing anticipatory symptoms (Andrykowski & Gregg, 1992). Furthermore, nausea and vomiting are the most difficult symptoms for patients to tolerate and can cause rapid exhaustion of internal resources.

On the other hand, if a cancer patient has mild nausea, which inhibits eating but permits activity, hypnotic intervention can be quite effective. For example, we might suggest the image of a protective coating, such as Teflon, lining esophagus and stomach, allowing pills and food to pass through easily, effortlessly and even unnoticed, as described in the case of Pearl.

Serious consequences of misusing hypnotic methods have also occurred when family members believe hypnosis will cure the patient when medical treatment has failed. In more than one situation, a family member has asked, after a patient died, whether the patient would have lived if he or she had only practiced hypnosis or suggestion more (or better), suggesting that “something” should have saved the patient’s life. Other times, this intervention becomes a method over which the patient has control when so much of the patient’s existence is beyond control. In these circumstances, family members may nag the patient to practice, the patient resists, and the resistance serves to divide the family as both sides struggle for an area of control when they are truly struggling with fear of loss. To avoid this possibility when the family is closely involved in a patient’s care, we discuss this common occurrence with patient and family. We make it a policy that the patient and family agree that the hypnotic methods belong to the patient. If the patient wishes help from a family member, he can request assistance. If a family member asks about the hypnotic intervention, and the patient does not wish to discuss the topic, we rehearse with the patient a response of simply “It’s fine, I don’t wish to discuss it.” If any further issues arise, the patient is encouraged to discuss them with us.

One additional situation deserves mention—a family looking desperately to hold onto a loved one, and misusing hypnosis in the attempt.

I [KS] received an emergency call to see Neal, a young man who was hallucinating, with tachycardia and hyperventilation. Neal was dying from multiple organ failure, including liver failure and fluid in his lungs, during aggressive chemotherapy to treat his advanced disease. When I arrived at his room, there were two physicians, a nurse, and his mother, all surrounding the bed. I had not seen Neal before, because he had been treated by another clinician who was now on vacation.

The staff reported to me that Neal had become very agitated, shouting, “The plane is going too fast, I can’t stop it, help me, help me!” The medical staff were trying to reassure him that he was not in a plane and that he was safe, but his distress continued to escalate. The situation apparently developed while the mother was suggesting the fantasy of sailing with Neal in an effort to calm him during a time when he had difficulty breathing and when his mentation was clouded from multiple medications and from the disease effects. Neal spontaneously began to hallucinate being in an airplane.

As I watched, Neal became increasingly agitated; suddenly he said he was no longer on a sailboat but now he was in a plane. I asked Neal if I could join him in the plane. Then I began to talk about the plane, describing it as strong and safe, able to hold us, and then I asked to hold the control column and the throttle, along with Neal. He agreed. I then began to guide the plane with him, gradually slowing the plane while looking for a safe place to land. When Neal said that he saw a safe, peaceful, grassy place to land, we landed the plane together. I then suggested, now that we had safely landed, that Neal could quiet his heart rate and ease his breathing to a nice steady pace, and he could then leave the plane. I suggested that there would be someone to meet him with whom he could be safe and at peace, so that he could rest for a bit.

During these suggestions, I asked for and received assurance from Neal that he was following the suggestions and that he was responding. He said that he met his aunt and uncle outside the plane, and they would go to a safe, comfortable spot to rest. At this point his heart rate had slowed and his breathing was easier, so the staff and I left him to rest. Outside the room, the mother said to me, “I know what you’re trying to do, you’re trying to help him die, to give him permission to die. He’s never met the aunt and uncle he was talking about. They’re dead. I won’t let him die. He has to fight!” I assured her that my only intent at the time had been to calm him by bringing him to a peaceful place where he could rest and feel safe from his agitated state. Unfortunately, at that point, I was called away by the staff (who needed guidance about coping with a possible recurrence of this situation). I said to the mother that I would return as soon as I had seen what the staff needed. Unfortunately, there was no more time to talk with her just then.

Ten minutes later, when I returned, Neal’s mother was once again encouraging him to imagine that he was sailing. But Neal was now very frightened, shouting, “I’m sinking, I’m going to drown, the boat is going down!” The mother responded with, “Climb the mast! You have to keep climbing! You can’t sink, don’t let go!” Meanwhile, Neal’s heart rate again soared, and his breathing became labored. He lost all consciousness. He was ventilated, but he never regained consciousness. Unfortunately, while his mother was trying everything she could to save her son, she lost the chance to say good-bye to him. She so desperately wanted to save him that she held to the belief that hypnosis and her love could keep her son alive.

When Neal’s clinician returned from vacation, I talked with him about this sad circumstance. He told me that he had trained Neal in using self-hypnotic methods prior to the cancer treatment. Neal had enjoyed and benefited from the treatment. As may be surmised, Neal’s mother was very close to him and wished to help him in using hypnotic methods, so she listened to his practice tapes, and sat in on some treatment sessions with the clinician in the hospital room. This treatment, along with his mother’s assistance, had greatly benefited Neal during earlier phases of his treatment. He and his mother had ably used the strategies for controlling pain. But, while hypnotic intervention could help him to be more comfortable, it could not keep his body functioning against a tide of organ failure.

These regrettable situations are rare, but they provide important reminders to us. Hypnosis is a powerful tool that, like any tool, can sometimes be misdirected out of good intentions by people who do not fully understand the problem they are working to resolve. Further, with cancer patients, the family is integral, and so it cannot be ignored. Increasingly, in today’s health-care climate of insufficiency, family members are required to be active caregivers. In many cases, a family member can learn hypnotic techniques along with the patient, in order to facilitate the patient’s use when he or she is fatigued or for other reasons prefers assistance when the clinician is not available.

For persistent pain or for multiple procedures, this strategy may be an excellent solution for some patients. It can also be inadvertently misused. Early consideration of the family’s role in the hypnotic treatment, as supporters, participants, or resistors, may enable us to anticipate and prevent unfortunate difficulties. In a situation like Neal’s, where we anticipate some issues with separation between a parent and particularly a young adult, we are likely to simply ask the parent to step out of the room when we provide hypnotic interventions. We talk with the parent separately to provide some support so she does not feel threatened, but we try to assist the patient in keeping the hypnotic treatment as his or her own domain.

Admittedly, the setting in which hypnosis takes place makes a difference to how it is used and often to its efficacy. The clinician who practices outside a medical environment faces a number of challenges not present for those of us who work within the hospital or clinic setting. Clinicians who work within the very setting in which their patients receive treatment have easier access to medical records and can be present for procedures. Practitioners who work outside the oncology setting can also gather the information they need, of course. It is essential to gain information about the medical management of the patient’s pain. This may mean obtaining the patient’s permission and calling the attending oncologist or oncology nurse to request the information. Regardless of the setting, clinicians who are able to communicate between psychological and medical caregivers will increase their success in controlling their patient’s discomforts.