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