INTRODUCTION

The diagnosis and treatment of cancer carries a heavy emotional burden, with approximately half of all cancer patients experiencing anxiety and depression severe enough to reach clinical significance. The National Institute for Clinical Excellence (NICE) (2004) recommends that routine psychological support should be available to all cancer patients and there is a substantial body of evidence demonstrating the efficacy of hypnotherapy and psychotherapy in cancer care. Psychological distress and morbidity are frequently reported following a cancer diagnosis and during active treatment (c.f. Zabora et al 2001). The latter can be further compounded by chemotherapy side-effects which can have a direct influence on appetite/weight loss, muscular weakness, anxiety, depression and helplessness that, at worst, can affect treatment compliance (Walker et al 1999, Molassiotis et al 2002).

As nearly half of all cancer patients experience levels of anxiety and depression severe enough to affect their quality of life, NICE (2004) recommends that all patients should have access to psychological support. Historically this has been problematic, as health professionals were not trained to elicit patients’ psychosocial concerns and focussed exclusively on the physical aspects of the disease. Patients’ concerns therefore remained hidden and unresolved. The widespread training of senior health professionals in effective communication skills, however, has begun to redress the balance (Maguire & Pitceathley 2002, Fallowfield et al 2002, 2003, Wilkinson et al 2006). Even so, routine psychological support is not always available and some distressed cancer patients receive no psychological help at all (Greer et al 1997, Moorey & Greer 2002). These factors led REAL Wellbeing (a charitable organization in Northern England) to develop a psychotherapeutic intervention to help patients cope with the diagnosis and treatment of cancer. The intervention comprises effective elements of documented behavioural approaches in a clinical package to meet individual needs. Its official title is Psychological Support Services for Cancer Care but it is generally known as the ‘hypno-chemo programme’. The latter is misleading because it implies that patients need to be receiving chemotherapy in order to access it. This is not the case and the programme is suitable for patients at all stages of the disease trajectory. Nevertheless, hypno-chemo has ‘stuck’ and become more meaningful to both patients and health professionals than the official term. The programme was developed during the period 1996–2000 from experience within the team and from studies demonstrating the efficacy of the approaches used, up to and during the initial development period. As such, it has been necessary to include a number of older references or seminal papers.

This chapter will describe the hypno-chemo programme, outlining the therapeutic content of hypnotherapy, relaxation training and cognitive-behavioural therapy (CBT). Selected research demonstrating the efficacy of these therapies is outlined alongside studies indicating the importance of involving patients in decision-making and provision of a psychologically supportive setting in cancer care. These include hypnotherapy and relaxation training to ameliorate the side-effects of chemotherapy. Relaxation training is used as an alternative to hypnotherapy when misconceptions about the latter cannot be overcome or there is a risk of adverse reaction to hypnosis. Evidence relating to the provision of CBT to reduce cancer-related psychological distress is addressed, followed by behavioural approaches for pain control. CBT is a talking therapy which identifies dysfunctional thinking and behaviours. The patient works towards cognitive restructuring and behavioural change. The priority for the selection of papers was that they needed to be relatively recent outcome studies (at the time), comparing one or more experimental conditions with at least one control group. These studies, however, are reported from a quantitative perspective, which restricts understanding of the individual patient’s interpretation of events, and as a consequence, limits the opportunity to refine interventions more specifically to meet their needs. A post-intervention qualitative study was therefore conducted to separate out those elements of the hypno-chemo programme that most benefited participants, allowing their experiences to be fully assessed and viewed within the context of the situation (Taylor & Ingleton 2003). Patients’ experiences from this study are presented, highlighting service satisfaction and areas requiring attention. The chapter concludes with a dissemination study and clinical audit to assess the feasibility of multi-centre service provision and recommendations for education, training and development.

THE HYPNO-CHEMO PROGRAMME

The hypno-chemo programme aims to provide adjuvant psychological support and has borrowed effective components from appropriate psychosocial interventions to develop a 12-session structured approach consisting of hypnotherapy and CBT. Hypnotherapy is used to teach relaxation, manage pain, prepare for and treat the side-effects of chemotherapy and facilitate guided imagery (GI) to give the patient a perceived tool with which to fight malignant cells. CBT is used to elicit and treat the emotional problems associated with cancer and treatment.

Requirements for inclusion are diagnosis of cancer at any stage and sufficient command of English (or other language common to both parties) to be able to work with the therapist. Patients with unstable psychotic illnesses are excluded, as the combination of therapies described is inappropriate in active psychosis, and their psychological treatment/medication is available through the usual NHS resources. Patients with stable psychotic illness can be accepted at the discretion of the therapist and with the agreement of the patient’s psychiatrist. Hypnotherapy, however, is avoided with these patients and also in those diagnosed with malignant brain tumours to prevent any risk of adverse reaction.

ASSESSMENT

Patients are assessed and treated by the same psychotherapist. A medical history is taken, together with tumour histology, local/metastatic spread, medication and clinical treatment regimen. If pain management is required, a detailed sensory description of symptomatology is established. Psychosocial assessment aims to elicit patients’ physical, social, psychological and spiritual concerns. The biological effects of chemotherapy and how conditioning exacerbates these are explained and reactions to previous or current chemotherapy identified. A simple explanation of immunology is given. The cognitive-behavioural model and hypnotic intervention are explained, concerns about hypnotherapy identified and a treatment plan agreed before written consent is obtained. Partners/carers are present at the initial consultation according to the patient’s wishes.

HYPNOTHERAPY

Hypnosis is induced by eye fixation, passive muscle relaxation and appropriate deepening procedures (visualizing a peaceful scene, descending numbers, etc.). Treatment is tailored to individual need but typically involves relaxation, confidence-building suggestions and GI to deal with impending stressful procedures. Patients are taken verbally through the sequence of events leading to, during and following chemotherapy infusions. Occurring anxiety, nausea or other unpleasant sensations are cue-controlled by hypnotic suggestion. For example, the patient is asked to visualize a numerical dial representing nausea, and practise turning the dial up and down to obtain control. The latter is subsequently associated with a cue word, which is used to reduce nausea in the chemotherapy environment and with associated stimuli. Patients are asked to visualize their white blood cells attacking and destroying cancer cells using images/scenes of their choice. Pain modification is tailored to individual need. Imagery techniques are preferred for good hypnotic subjects (high hypnotizables), such as giving the pain a shape and colour and allowing it to float away. Distraction techniques are preferable for low hypnotizables, e.g. focussing on competing sensations elsewhere in the body such as rubbing the fingers together maintained by post-hypnotic suggestion. All procedures are supported by audio-taped instructions for daily practice and use during chemotherapy infusions if required.

Hypnotherapy is not always appropriate, as widespread misconceptions of involuntary mind control, perpetuated by the popular press and abuse by stage hypnotists, have led to fearful and sceptical beliefs. Most concerns are easily overcome by sensitive explanation and rapport but if patients cannot be reassured, progressive muscle relaxation (PMR) is used instead. This involves physical stretching and relaxing of consecutive muscles to induce relaxation, accompanied by visualization such as a peaceful scene and followed by cancer-related GI, as above. The need for PMR is minimal but unfortunately the active requirements of this technique can burden some already exhausted cancer patients.

CBT is used to identify and resolve cancer-related psychological problems and follows the procedures described by Greer et al (1992) and Greer (1997). This approach focuses on the personal meaning of cancer for the patient and the patient’s coping strategies. Patients are encouraged to disclose and express the emotional impact of cancer on themselves and significant others, taught to identify the automatic dysfunctional thoughts underlying anxiety and depression, challenge these thoughts and replace them with more rational responses. Task-focussed behavioural assignments are encouraged to generate a sense of achievement and raise self-esteem. An attitude of reasonable optimism, determination not to give in, desire to understand and participate in treatment and continue to live a normal life is encouraged. This attitude characterizes ‘fighting spirit’ recommended by Greer and colleagues (1992). At REAL Wellbeing, this term is replaced by realistic positive thinking as recent evidence suggests patients can become burdened with guilt when they fail to maintain their fighting spirit (Watson et al 1999).

The combination of these approaches, tailored to individual needs represents the hypno-chemo programme, a popular intervention with demand surpassing resources. The psychosocial literature influencing the development and content of the programme is outlined below.

RESEARCH INFLUENCING THE DEVELOPMENT OF THE HYPNO-CHEMO PROGRAMME

Hypnotherapy and related procedures such as relaxation training and GI have been used to ameliorate the side-effects of chemotherapy, help patients adjust to the disease, counteract pain and anxiety and alter the mechanisms of immunity to hopefully improve prognosis. These interventions have been evaluated in a series of studies. Extensive reviews of this literature (e.g. Fawzy et al 1995) have concluded consistently that hypnotherapy is effective in the above areas, with the possible exception of enhancing survival. The randomized controlled trials (RCTs) relating to the latter have produced conflicting results with some limited by methodological flaws (Walker 1992, Fox 1995, 1998). Blake-Mortimer et al (1999) and Coyne et al (2007) provide a more recent debate on psychotherapy and cancer survival rates. However, quality, rather than quantity of life is the concern of the hypno-chemo programme and, although the methodology of some studies utilizing hypnotherapy has been criticized (c.f. Rajasekaran et al 2005), there is consistent empirical evidence to support the use and evaluation of this approach.

THE TREATMENT OF CHEMOTHERAPY SIDE-EFFECTS

COGNITIVE-BEHAVIOUR THERAPY FOR CANCER-RELATED PSYCHOLOGICAL DISTRESS

The work of Greer et al (1992) has strongly influenced the hypno-chemo programme. These workers conducted a controlled trial to determine the efficacy of Adjuvant Psychological Therapy (APT), a CBT approach specifically designed for cancer care. Patients with primary diagnosis or first recurrence of mixed cancers were screened for psychological morbidity using the Hospital Anxiety and Depression (HAD) scale (Zigmond & Snaith 1983) and the Mental Adjustment to Cancer (MAC) scales (Greer & Watson 1987, Watson et al 1988). The latter measures four broad dimensions of adjustment: fighting spirit, helplessness, anxious preoccupation and fatalism. A total of 174 patients with scores above previously defined cut-off points were randomly assigned to experimental or control conditions. Experimental patients individually participated in the 8-week, problem-focussed APT programme, while controls received no therapy. Outcome measures included the HAD and MAC scales, Rotterdam Symptom Check List (RSC, De Haes et al 1990) and the Psychosocial Adjustment to Illness Scale (Derogatis 1983). The trial was completed by 90% of patients.

The intervention, which aimed to detect and treat the emotional problems associated with the disease included cognitive restructuring, behavioural assignments, PMR and role-play/imagination to deal with imminent stressful procedures. Immediately following the intervention, the therapy group had significantly lower scores on helplessness, anxious preoccupation and fatalism, anxiety, psychological symptoms and orientation to healthcare, and significantly higher scores on fighting spirit than controls. At the 4-month follow-up, experimental patients continued to have significantly lower scores on anxiety and psychological symptoms/distress. At the 12-month follow-up (Moorey et al 1994) patients who had received therapy still had less anxiety and depression than controls. The authors concluded that APT significantly reduces cancer-related psychological morbidity, thus enhancing the psychological dimension of QOL. However, one-third of eligible patients refused to take part and the author did not report any adverse therapy effects. No post-intervention qualitative assessment was conducted to indicate in detail which elements of the intervention the participants valued the most.