Collingwood BR, Elliott NJ.*
Australian Academy of Hypnosis and Advanced Mind Dynamics Pty Ltd, Perth, Australia.
Complimentary and alternative medicine (CAM) used by cancer patients is becoming much more prevalent the world over. Many beneficial outcomes have been seen from the addition of hypnosis to conventional protocols. As with all treatments, the focus of the hypnotherapy is to ameliorate the effects of pain and to restore a level of psychological and physical wellbeing and functioning Methods: The EORTC QOL-QC 30 core questionnaire was used to assess changes in perceived quality of life. Each patient received six hypnotherapy sessions; the sessions were conducted by the same hypnotherapist each time and questionnaires completed prior to induction of trance.
Results: Responses from the questionnaire were evaluated comparing the initial questionnaire with the final questionnaire. Statistically significant improvements were noted with Fatigue (fa) (35.75% to 12.38%; p<0.0044), Global health status (ql) (63.5% to 79.00%; p<0.0058), Insomnia (sl) (53.75% to 8.25%; p<0.008) and Physical functioning (pf) (75.75% to 87.25%; p<0.0395) All aspects of the questionnaire showed improvement following the six hypnosis sessions.
Conclusions: Overall patients experienced the benefit of hypnosis in reducing symptoms and increasing their overall quality of life. Many patients commented that commencing hypnosis at the time of diagnosis of cancer, and continuing throughout their treatment, would have been greatly beneficial. In this study, specific non-Ericksonian hypnosis techniques were beneficial for symptom control and in increasing the quality of life in patients with cancer.
Complimentary and alternative medicine (CAM) used by cancer patients is becoming much more prevalent around the world. Patients with all the tumour types and stages use CAM  in the hope of cure, disease control, longer survival, improved quality of life and palliation. Most CAM is the used in addition to current conventional medical treatment, therefore it does not reduce health costs and disclosure to physicians is usually incomplete. [1,2] Breast cancer patients who use CAM tend to have higher levels of psychosocial distress. CAM-CANCER is a retrospective literature analysis which hopes to generate statements on CAM in cancer. 
During the period surrounding the diagnosis of cancer people can experience anxiety, emotional and physical distress and mood disturbance. During treatment these symptoms are often compounded by treatment side-effects including nausea, vomiting, procedural and disease related physical pain and symptoms. Conventional medicine targets pain, distress and depression however conventional treatments do not always relieve these symptoms to patient satisfaction. Often these patients will opt for complementary and alternative medicine such as acupuncture, naturopathy, homoeopathy, mind-body techniques and a host of others in an attempt to reduce symptoms, emotional and physical distress, and even in the hope of a cure.
The National Institutes of Health (NIH) define mind-body therapies (MBT’s) as “interventions that use a variety of techniques designed to facilitate the mind's capacity to affect bodily functions and symptoms”. Many hospitals are seeing the benefit of these therapies in the conjunction with current treatments and establishing Mind-Body Cancer Research Programs or “Alternative Therapy Centres”. Hypnosis has been used to reduce side-effects with treatment and allow patients to function better emotionally and physically.[1-9] Many literature reviews describe beneficial outcomes from the addition of hypnosis to conventional protocols. Quality of life in cancer patients is one common measure for treatment success particularly in palliation. Symptoms relating to psychological distress and existential concerns are even more prevalent than pain and other physical symptoms among those with life-limiting conditions. Therefore there exists a need for a broad and inclusive model of integration of mind-body interventions for palliative care.
In previous studies “Existential Psychological Theory has [been] employed as a conceptual and theoretical foundation for the use of hypnotically facilitated therapy in the management of intractable pain, nausea, and vomiting in end-stage, terminally ill cancer patients.” Iglesias (2004) stated ”the existential principles of death anxiety, existential isolation, and existential meaninglessness were addressed with a combination of classic and Ericksonian techniques to allow medication to become effective in treating symptoms.” After 6 sessions patients previously unresponsive to medical management became responsive to treatment. In radiotherapy the patients wellbeing and own sense of mental health showed improvement without symptom improvement having statistical significance. Just as with psychotherapy and prescribing habits can vary greatly so too can hypnotherapy techniques. As with all treatments, the focus of the hypnotherapy is to ameliorate the effects of pain and to restore a level of psychological and physical wellbeing and functioning.[5-9] Specific non-Ericksonian hypnosis techniques were used in the following study designed to improve quality of life in a sample of cancer patients.
Patients and Methods
The study was conducted on nine patients (4 male and 5 female) with various cancers, one with prostate, two with bowel, three with breast, and two with oesophageal cancer. To participate patients obtained a referral from their treating doctor and were required to remain on current conventional medical treatment unless modified by their treating doctor. The EORTC QOL-QC 30 core questionnaire was used to assess changes in perceived quality of life. Questionnaires were completed at the initial interview and then prior to each hypnosis session. All patients were able to complete questionnaires unassisted and all questions were answered. Patients were also given a hypnosis CD to listen to once a day during the course of the study. Each patient received six hypnotherapy sessions, the sessions were conducted by the same hypnotherapist each time. Statistical analysis was performed using paired t-test analysis.
Of the nine patients commencing the study eight were able to complete all six sessions of hypnotherapy. One female patient withdrew after four sessions due to weakness following intensive radiotherapy. The average age of male patients was 63 years (range 50-76 years), and the average age of female patients was 56 years (range 47-64 years). All patients completing the study maintained regular contact with their doctor. Data was analysed from questionnaires for the initial session (pre-treatment) and final session.
Figure 1. Global health status/QOL (ql), the functional scales (rf, sf, pf, ef, cf), the symptom scales (nv, pa, fa) and a single items (di, co, dy, sl, ap, fi) for the study participants comparing pre-treatment with completion questionnaires.
Figure 1 demonstrates that the study patients have improved values on all functional scales and also have reduced average levels on symptom scales.
Responses from the questionnaire were evaluated comparing the initial questionnaire with the final questionnaire. Statistically significant improvements were noted with Fatigue (fa) (35.75% to 12.38%; p<0.0044), Global health status (ql) (63.5% to 79.00%; p<0.0058), Insomnia (sl) (53.75% to 8.25%; p<0.008) and Physical functioning (pf) (75.75% to 87.25%; p<0.0395)
Moderate significance was seen in Constipation (co) (20.63% to 4.13%; p<0.1036), Cognitive functioning (cf) (68.75% to 85.5%; p<0.138) and Nausea (nv) (20.88% to 0%; p<0.095).
Improvements were seen in Emotional functioning (ef) (66.88% to 82.25%; p<0.125), Pain (pa) improved (26.88% to 14.63%; p<0.171), Diarrhoea (di) (12.38% to 4.13%; p<0.171), Role functioning (rf) (29.13% to 54.25%; p<0.351) and Dyspnoea (dy) improved (8.25% to 4.13%; p<0.351)
Insomnia is a prevalent form of sleep difficulty which can affect all of the population reducing quality of life, decreasing work potential and increasing health care utilization.[10-11] The analysis showed that one of the most statistically significant improvements was in insomnia (p<0.008). The patient’s initial responses to insomnia were slightly higher than those suggested for the general population.  This would be expected as disease and mood factors influence insomnia. The response to the hypnosis was rapid with most patients reporting their insomnia was dramatically improved within the first three sessions of hypnosis. This improvement was then maintained for the remainder of the study. Figure 2 represents the initial and final assessments of patients in the study and their sleep patterns. Final responses indicate that the hypnosis treatments allowed the patients to enjoy a much better and longer sleep.
Figure 2. Patient responses to insomnia comparing initial responses with final treatment responses.
Figure 2 shows a graphical depiction of the four point scale which allows patients to describe with their lack of sleep over the past week. Sleep difficulty can also cause irritability, depression and fatigue. Anxiety and depression in patients can be a factor increasing insomnia and treating any underlying problem has been shown to help alleviate insomnia. Emotional functioning issues like irritability, tension, anxiety and depression all decreased during the study period which may have also added to the insomnia improvement.
Many symptoms that patients experience during cancer treatments are related either to their medication or directly to the cancer. Gastrointestinal symptoms like diarrhoea and constipation can lead to nausea and appetite loss. Throughout the study period the participants showed increased appetite and reduced nausea and vomiting. One patient was amazed by the return of normal taste sensation (instead of a metallic taste) and another began to put on weight whilst undergoing chemotherapy and radiotherapy. Figure 3 shows the reduction in the nausea and vomiting experienced by patients in the study.
Figure 3. Patient responses to nausea comparing initial responses with final treatment responses.
Other studies have demonstrated improvements in the efficacy of medication following hypnosis.  Over the study period patient’s reduced “when required“anti-nausea medication the hypnosis seemed to impact on overall nausea. This indicates that the reduction was not merely in their perception of the symptom or an increased effect of their current medication.
Fatigue has been seen as one of the most common symptoms experienced by cancer patients and is associated with significant impairment in functioning and overall quality of life.  Fatigue showed the greatest response statistically, with all patients describing increased energy levels, decreased time spent at rest and a greater ability to live their lives the way they wish. Although the precise pathophysiology of fatigue in cancer is not well known  figure 4 shows that hypnosis had a profound effect on participant’s experience of fatigue in this study.
Physical functioning; which consists of ability to take a long or short walk, the patients need to spend time in a bed or chair, their ability to carry out their own daily activities and ability to perform strenuous activity, improved as a result of the hypnosis sessions. During the study there were changes that occurred in patient’s perception of daily activities. Initially many patients described a long walk as being a distance of one kilometre, however, at the conclusion of the study many patients perceived a long walk to be four kilometres or more. The increase in energy described by patients and the change in their perception of a long walk may indicate that there were direct effects on the body’s energy levels from the hypnosis not just an increase in sleep reducing fatigue.
Figure 4. Constructed graphs showing patient responses to fatigue comparing initial responses with final treatment responses.
Global health status / QOL represents a patients feeling as to their overall wellbeing. It is based upon that individual’s beliefs and experiences. Psychiatric disorders, such as major depressive disease and post traumatic stress disorder, are significantly associated with lower functional scales ('emotional functioning', 'body image' and 'future perspective') and higher symptom scales ('appetite loss', 'diarrhoea', 'fatigue' and 'nausea-vomiting') in QOL. During the study some of the participant’s global health status measure dipped dramatically after the second session, even with improvements in all other aspects of their questionnaire. When participants were questioned about this decline they stated that they were previously comparing their QOL with when they were sick, now they compared it to how they felt before they had any symptoms. All patients in their subsequent questionnaires then showed improved global health status, this indicates the change in outlook of participants to their quality of life.
The hypnotic techniques used in this study showed improvements in all aspects of the patient’s quality of life. Patients had more energy and were more active after hypnosis more able to cope with the difficulties that they face in their every day lives. A clinically significant improvement was seen with insomnia, nausea, physical functioning, and global health status. Hypnosis can effect perception of symptoms however in this study the results seemed to point to a deeper change with energy and fatigue being modified positively. The experience of hypnosis was described as beneficial by all patients and reductions in symptoms and increased overall quality of life. Patients commented that they would have seen the best benefit if hypnosis was begun around the time of diagnosis of cancer and continuing throughout their treatment.
In this study, hypnosis has been beneficial for symptom control and in increasing the quality of life in patients with cancer. Further research into the use of specific non-Ericksonian hypnosis techniques for symptom control and improved quality of life involving a larger number of participants, are needed to support these results.