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Blackwell Science, LtdOxford, UKEJCCEuropean Journal of Cancer Care0961-5423Blackwell Publishing Ltd, 200312137142Original ArticleHypnotherapy and cognitive-behaviour therapy in cancer

careTAYLOR & INGLETON

Psychological interventions

Hypnotherapy and cognitive-behaviour therapy in cancer


care: the patients’ view
E. E . TA YL O R, bsc, mmedsci, ukcp, director of integrated health care, East Lancashire Integrated Health
Care Centre, Rossendale Hospital, Lancashire & C. IN GLET ON , ba, ma, phd, rgn, rnt, cert ed, senior
lecturer in nursing, University of Sheffield, School of Nursing and Midwifery, Sheffield, UK

TAYLOR E.E. & INGLETON C. (2003) European Journal of Cancer Care 12, 137–142
Hypnotherapy and cognitive-behaviour therapy in cancer care: the patients’ view

Psychological intervention is not widely available for emotionally distressed patients with cancer. The purpose
of this study is to investigate and report on the experiences of eight patients who participated in a programme
consisting of hypnotherapy and cognitive-behaviour therapy. Following the 12-session intervention, qualita-
tive analysis of interview data demonstrated that patients had acquired the skills to enable them to cope, both
with invasive medical procedures and the psychological traumas they faced. The findings also indicated some
initial misconceptions about hypnotherapy and the need to provide a therapy setting sensitive to the needs
of cancer patients undergoing active medical treatment.

Keywords: cancer, hypnotherapy, cognitive-behaviour therapy, qualitative results.

INT RO D U C TIO N fied (Booth et al. 1996; Heaven & Maguire 1997) as well
as lack of available resources. These factors led one unit
Psychosocial distress and morbidity are frequently
in the north of England, East Lancashire Integrated
reported following the diagnosis of cancer (Derogatis et al.
Health Care Centre (ELIHCC) to develop a psychothera-
1983; Zabora et al. 1997), particularly at diagnosis and
peutic intervention to help patients cope with the diag-
during active treatment (Hughes 1982; Watson et al.
nosis and treatment of cancer. The intervention
1992). Medical procedures have a significant impact on
combines cognitive-behaviour therapy (CBT) and hypno-
quality of life (QOL), not least the side-effects of chemo-
therapy in a clinical package to meet individual need and
therapy (Coates et al. 1983; Smith et al. 1991), and the
has become known locally as the ‘Hypno-Chemo
psychological cost can affect treatment compliance (Wat-
Programme’.
son et al. 1992).
This paper presents findings from an evaluation of the
Adaptation to a cancer diagnosis and QOL are
programme from the patients’ perspective. After describ-
improved when patients are given appropriate informa-
ing the background literature, the paper explores the
tion and involved in treatment decisions to the extent
experiences of participants based upon data gathered
they wish (Fallowfield 1997) and the body of literature on
from in-depth qualitative interviews conducted with
psychosocial interventions is extremely positive (cf.
eight patients. The discussion will then locate some of
Fawzy et al. 1995). However psychotherapy is not widely
these issues in the wider literature on communication
available and many distressed cancer patients receive no
skills, the therapeutic alliance, cognitive and behavioural
psychological help at all (Greer 1997). This is largely a
interventions and appropriate treatment location. The
result of patients concerns not being appropriately identi-
aim of the study is to provide psychotherapists with
patients’ perceptions of the value of a combined cogni-
Correspondence address: Elizabeth Taylor, East Lancashire Integrated
Health Care Centre, Cribden House, Rossendale Hospital, Rossendale, tive-behavioural therapy/hypnotherapy programme for
Lancashire, BB4 6NE, UK (e-mail holisticresources@airtime.co.uk) cancer care, in order to inform service provision and
European Journal of Cancer Care, 2003, 12, 137–142 dissemination.

© 2003 Blackwell Publishing Ltd


TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care

Background literature explained and treatment plan agreed before written con-
sent is obtained. Hypnosis is induced by eye fixation, pas-
Hypnotherapy and related procedures such as relaxation
sive muscle relaxation and deepening procedures.
training and guided imagery (GI) have been used to ame-
Treatment typically involves relaxation, confidence build-
liorate the side-effects of chemotherapy, help patients
ing and GI. Patients are taken verbally through the
adjust to the disease, counteract pain and anxiety and alter
sequence of events leading to, during and following che-
the mechanisms of immunity to hopefully improve prog-
motherapy infusions. Occurring anxiety, nausea or other
nosis. These interventions have been evaluated in a series
unpleasant sensations are cue controlled by hypnotic sug-
of studies including individual and group therapy. Exten-
gestion. For example, the patient is asked to visualize a
sive reviews of this literature (Morrow & Dobkin 1988;
numerical dial representing nausea and practise turning
Fawzy et al. 1995; Genuis 1995) have concluded consis-
the dial up and down to obtain control. The latter is sub-
tently that hypnotherapy is effective in the above areas
sequently associated with a cue word, which is used to
with the possible exception of enhancing survival. The
reduce nausea in the chemotherapy environment and with
randomized controlled trials relating to the latter have
associated stimuli. Patients are asked to visualize their
produced conflicting results with some limited by meth-
white blood cells attacking and destroying cancer cells
odological flaws (Fox 1995; 1998).
using images/scenes of their choice. Pain management is
Influential in the development of the cognitive-
included if required. Hypnotic procedures are supported
behaviour intervention has been the work of Greer et al.
by audiotaped instructions. These methods broadly con-
(1992) who randomly allocated 174 psychologically dis-
form to approaches described by Spiegal & Spiegal 1978;
tressed, early stage cancer patients to an 8-week CBT pro-
Levitan 1987 and Redd et al. 1983). Cognitive-behaviour
gramme specifically designed for cancer care or to a no
therapy is used to identify and resolve cancer-related psy-
treatment control. The intervention included identifica-
chological problems and follows the procedures described
tion of concerns, cognitive restructuring, behavioural
by Greer (1997). Participants are encouraged to disclose
assignments, progressive muscle relaxation and role play/
and express the emotional impact of cancer on themselves
imagination to deal with imminent stressful procedures.
and significant others, taught to identify and challenge the
Significant advantages were found for the therapy group
automatic dysfunctional thoughts underlying anxiety and
on validated psychosocial measures immediately after the
depression and replace them with more rational
intervention and at 4-month follow-up. At 12-month fol-
responses. Task focused behavioural assignments are
low-up, patients who had received therapy still had less
encouraged to generate achievement and raise self-esteem.
anxiety and depression than controls (Moorey et al. 1994).
An attitude of reasonable optimism, determination not to
There is substantial evidence to demonstrate the effi-
give in, desire to understand/participate in treatment and
cacy of psychosocial interventions (cf. Fawzy et al. 1995).
continue to live a normal life is encouraged.
However, studies reported from the quantitative perspec-
tive restrict understanding of the individual patient’s
interpretation of events, thus limiting the opportunity to PAT I ENT S AND MET HODS
refine interventions more specifically to meet their needs.
The study was conducted at ELIHCC, which is adjacent to
The results of randomized controlled trials are infre-
a hospice in northern England. The centre provides com-
quently implemented in clinical practice (Haines & Jones
plementary therapies and orthodox psychotherapy to
1994) and yield results that do not differentiate between
three local hospices and community patients and is
patients who most need help and those who would have
funded by a grant from the National Lottery Charities
done well without it (Watson 1983).
Board.
Eight patients who had completed the hypno-chemo
programme were purposefully selected (Coyne 1997) for
The hypno-chemo programme
inclusion in the study, all white females, aged between 32
The hypno-chemo programme, influenced by the work of and 60 years (average age 49). All presented with a first
Greer et al. (1992) provides adjuvant CBT and hypnother- diagnosis of carcinoma, seven breast and one colon at the
apy in a structured 12-session programme. Requirements stage of local disease or local disease and regional spread.
for inclusion are diagnosis of cancer at any stage and a rea- All patients underwent surgery and chemotherapy and
sonable command of English. Patients with organic brain seven received radiotherapy. Six patients commenced psy-
disease or psychotic illness are excluded. A medical and chotherapy/hypnotherapy just before or after their first
psychosocial history is ascertained, the intervention session of chemotherapy. One patient joined the pro-

138 © 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
European Journal of Cancer Care

Table 1. Interview schedule I was halfway through my chemo before I heard about
1. Can you tell me how you felt when the hypno-chemo it, nobody mentioned it before you know . . . If I
programme was offered to you? hadn’t been so poorly, I doubt that she would have
2. How do you feel about the therapy now?
3. If you were to go through the programme again or recommend mentioned it . . .
it to someone else with cancer, could you suggest any
improvements or changes you would like to make?
Referral difficulties may be due to misconceptions
4. Is there anything else about the therapy you would like to about hypnosis and the low priority given to psychosocial
discuss? concerns. There is substantial evidence to suggest that
health professionals are poor at eliciting the latter which
is cause for concern in the light of evidence that patients
gramme approximately halfway through chemotherapy
with unresolved problems are at risk of later anxiety and
and another after the latter was completed.
depression (Kornblith et al. 1992; Thomas et al. 1997).
Semi-structured interviews were conducted between 1
Fear of chemotherapy was paramount in the present
and 24 months (average 7 months) after the intervention.
study and this, coupled with feeling overwhelmed by their
Development of the interview schedule followed a proce-
diagnosis, led some patients to grasp the hypno-chemo
dure described by Bottomley (1998). This approach pre-
programme as a lifeline. The following extract encapsu-
pares the interviewer for topics likely to be raised by
lates the views of many of the participants:
participants. Lofland (1971) refers to these topics of inter-
est as ‘puzzlements’, which were jotted down and read by It was actually through my breast care nurse, ahmm
an independent health professional. This allowed a more – I was doing very badly on my first chemo¢ so I rang
rigorous spread of the range of enquiry, enabling the her out of desperation to see if she could put me in
researcher to elicit what was ‘puzzling’ in the social con- touch with the Centre.
text. Each puzzlement/question was written down on a
All the research participants received hypnotherapy,
separate piece of paper and sorted into topically related
though many had negative preconceived beliefs. For
piles. Table 1 outlines the four main areas addressed
example:
within the literature.
The tape-recorded interviews were conducted by the I could only picture the non-clinical hypnosis; the
first author in the patients’ homes, typically taking stage stuff and I didn’t really know what it was.
between 30 min and one hour to complete. The inter-
Despite detailed explanation of what to expect in a hyp-
views were fully transcribed verbatim for thematic anal-
notic induction, patients assumed they would ‘go under’,
ysis, which requires that the raw data is reorganized under
meaning lose consciousness or relinquish control to the
a series of headings reflecting emerging themes. Accord-
therapist.
ingly a 14-stage model described by Burnard (1991),
These misconceptions may prevent patients who could
involving familiarization of the range and diversity of the
potentially benefit from hypnotherapy, from seeking reas-
data, development of a thematic framework, judging the
surance about their concerns and subsequently not
meaning and significance of the data and applying it to the
obtaining help. Misunderstandings about hospice were
framework and finally categorization was used.
also apparent. Some patients were inhibited from attend-
ing the Centre because it was next door to a hospice, with
FIN D IN G S patients recommending a separate building off site.

The primary themes identified from the data were: gain-


Treatment tailored to individual need
ing help, treatment tailored to individual need, long-term
benefits and service satisfaction/patient information This theme represents the identification of patients’ main
needs. concerns and adopting appropriate therapies to aid their
resolution. That is, following the patient’s agenda rather
than the therapist’s. For example:
Gaining help
They obviously try to assess exactly what your per-
Despite the widely publicised need for psychosocial sup-
sonal needs are and try to work to them.
port at all stages of cancer care and local publicity about
the services offered at ELIHCC, some patients had diffi- Not only was this appreciated but patients also valued
culties in accessing the hypno-chemo programme. This is the therapists themselves. Given that the latter is recog-
highlighted by the following quote: nized as an important variable in treatment outcome, it

© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142 139
TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care

was noteworthy to discover that all patients considered a lot more confident probably than I was before, a lot
the therapists as skilful and important in their adaptation more daring than I used to be and I’ll say what I think
to the cancer situation, exemplified by the following: to whom I think.

I couldn’t have managed without her . . . that was the These findings support a substantial body of evidence
biggest part of it . . . actually being able to talk . . . demonstrating the efficacy of behavioural approaches in
cancer care (Fawzy et al. 1995; Walker et al. 1999).
Understanding the cognitive model and utilizing the
techniques within it are considered essential to the effi-
cacy of CBT. However, rather than demonstrating com- Long-term benefits
prehension of the model and separating out the cognitive The main purpose of the hypno-chemo programme is to
and behavioural elements, patients tended to view the deal with cancer-related distress during active treatment.
intervention as a treatment package. A typical vignette However it became apparent in the early stages of data col-
illustrates how participants amalgamated CBT aspects lection that patients had continued to benefit from the
with hypnotherapeutic techniques and GI in their under- techniques learned and still used their hypnotherapy
standing of altered thoughts and increased control: tapes. One patient, interviewed 8-months after comple-
I thought I was going to be as sick as anything for tion of chemotherapy said:
6 months . . . that’s why I was so upset in the begin- I’m still using the techniques I was taught . . . I had
ning because I felt that I’d no control over what was my kitchen replaced . . . and I got thoroughly stressed
happening . . . I wasn’t a relaxed person before it all out . . . I thought you’re going to give yourself cancer
started, I was sort of a very busy person and found it back again because you’re just worrying so much so
hard to switch off and I think it was good . . . it gave I listened to the cancer cell attack . . . and it was a
me those techniques . . . the fact that I was given a great help because I got the kitchen . . . done all with-
tool whereby I could switch off the nausea . . . out having to feel totally stressed out.
The exception to this was relaxation. Patients were very
clear on how relaxation helped them, particularly with Service satisfaction and patient information needs
sleep disturbance and chemotherapy.
This theme focuses on service satisfaction and identifies
I had real problems sleeping all the way through my deficits in information provision. Patients invariably
treatment . . . and E gave me a sleep tape . . . which viewed their therapy positively. For example:
really, really helped, erm – and the relaxation helped.
It was excellent, I can’t fault it.
I took it down to my chemotherapy sessions and for
the couple of days afterwards when I felt particularly The main critisicm was lack of information about the
bad, erm – I used to play the tape a few times a day existence of the service in appropriate clinics, closely fol-
and they really, really did help. lowed by the need for health professionals to explain the
programme beforehand. The following extract illustrates
Feeling in control, confidence building and the visual-
this:
ization of host defences destroying cancer cells complete
this theme and are closely interwoven. The need for con- I think that maybe the GPs need . . . more awareness
trol over what was happening to patients was an impor- about the availability of this kind of service because
tant finding with the ‘cancer cell attack’ considered a they’re the person who has contact . . . and I think it’s
principle tool: very important for them to offer this kind of facility
and alternative to the conventional chemical medi-
I think it really helped me relax all the way through
cines, erm – because I think if it’s worked in conjunc-
and visualizing that I was actually helping my body
tion with that, erm – it can only be . . . helpful to the
to get rid of the cancer and make myself better.
patient.
The combination of techniques was considered to
Future availability was a major finding with most
reduce helplessness and subsequent anxiety, leading to an
patients suggesting follow-up sessions or later treatment
increase in confidence:
on request.
I definitely lost confidence in myself. I think in the There was however, evidence of service dissatisfaction
beginning . . . but I feel as though [laughs] I’ve become related to medical procedures. Despite the widely publi-

140 © 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142
European Journal of Cancer Care

cised move from closed to open awareness, communica- keen to visualize their host defences destroying malignant
tion deficits were apparent. For example: cells. This approach, consistent with published research
(Fawzy et al. 1995; Walker et al. 1999), is never portrayed
. . . and they sent me down for a scan and they found
as a cure for cancer but as a tool to encourage patients to
my cancer, but they didn’t mention cancer . . . They
take an active role in their rehabilitation.
just said . . . we’ll have to operate on your
One important finding was that some patients experi-
bowels . . . and somebody just . . . threw me a paper in
enced difficulties with referral, which may reflect com-
at the door and . . . she said, er – that’s to do with your
munication deficits (Heaven & Maguire 1997) and/or
bag [colostomy]. Well . . . it never registered . . . and I
mistrust of hypnotherapy. The latter supports former
have to have a bag? . . . and she left me. I must be
anecdotal reports of perceived witchcraft and involuntary
honest, I was terrified then.
mind control (Redd & Hendler 1984). Such notions, per-
Some patients complained about hospital waiting petuated by the popular press (Hendler & Redd 1986) and
times, mechanical failure and human error. abuse by stage hypnotists (Finlay & Jones 1996) have led to
fearful and sceptical views. Despite their original con-
Oh the, the waiting there was a nightmare . . . They’d
cerns however, patients in this study were able to describe
say, oh, there’s been a fault in the machine or I’m
in some detail how hypnotherapy had helped them, sug-
sorry your prescription should have been ordered last
gesting this may be a valuable intervention.
week and it hasn’t and . . . you were trapped there,
Another relevant finding was that some patients
you couldn’t go home because you’d not had your
objected to ELIHCC being adjacent to a hospice. Walker
chemo, you know, you’d wait for your bloods, you’d
et al. (1999) have demonstrated the benefits of a setting
wait for the doctor, then you’d wait for your
sensitive to the needs of patients undergoing chemother-
treatment.
apy and it would appear that hospice-based community
Collectively, the findings highlight the need for open care might be less sensitive to patient need in the active
communication, identification of concerns and interven- stages of treatment than a hospital-based centre. Con-
tions tailored to individual need. versely, the analysis illustrated some dissatisfaction
with hospital-based procedures, in particular, inappropri-
ate communication, long waiting periods, technical
DI SC U SSIO N A ND CONCL US I ONS
breakdown and staff oversight. These findings mirror
The findings suggest that the combination of therapies those of previous research highlighting the superiority of
may provide advanced skills in coping/adapting to the hospice care to that of hospital care, especially for psy-
cancer situation. Patients were able to describe how hav- chosocial issues (cf. Wilkinson 1999). The evidence
ing the opportunity to talk about their feelings had helped therefore suggests that a hospital-based cancer unit
them and how much they appreciated the therapists. described by Walker et al. (1999) or a stand-alone centre
There is substantial evidence to suggest that intervention would be less inhibitory and more suited to the needs of
outcome is determined by the therapeutic relationship this particular client group. The latter were keen to rec-
(Beck et al. 1987; Ellis 1994) and this study highlights the ommend the service but were concerned about the lack
importance of rapport, and comprehension of the prob- of availability.
lems facing cancer patients (cf. Faulkner & Maguire 1994).
It has been argued (Bottomley 1998) that understanding
the cognitive model is essential for patients to benefit
CONCLUSI ON
from the techniques within it. However, in this study
patients clearly expressed the value of CBT, that is their The study supports the body of literature demonstrating
ability to think and/or behave more adaptively, increase the value of psychosocial interventions in cancer care
confidence and reduce distress without necessarily isolat- while adding further insights to the patient experience
ing the underlying principles. Conversely, patients were that is not always possible using more structured quanti-
able to explain in detail how hypnotherapy had helped tative methods of enquiry. The findings from this study
them relax, sleep and cope more effectively. They were will be used to refine provision in terms of providing a
also clear about the ways in which GI had assisted their more appropriate setting and easier access, as well as inte-
resolution of chemotherapy related fear and side-effects. grating the findings into teaching sessions. Further recom-
Guided imagery was highly valued in helping patients to mendations include an outcome study to assess the
feel more in control of their situation with all patients efficacy of the combined intervention.

© 2003 Blackwell Publishing Ltd, European Journal of Cancer Care, 12, 137–142 141
TAYLOR & INGLETON Hypnotherapy and cognitive-behaviour therapy in cancer care

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