by Christina Liossi, Lecturer in Health Psychology
University of the West of England Bristol
Psychological approaches to symptom management are among the oldest and are an intrinsic part of medical practice in every culture. Hypnosis under various names has been used for as long as records have been kept. Suggestive therapy is probably the oldest of all therapeutic methods. Using hypnotic techniques with children also dates back to ancient times. This article gives a brief overview of the contemporary uses of hypnosis in paediatric oncology.
Given the contentiousness of the field, the following definition and description of hypnosis as prepared by the American Psychological Association, Division of Psychological Hypnosis (Division, 30) for the general public is provided:
“Hypnosis is a procedure during which a health professional or researcher suggests that a client, patient, or subject experience changes in sensation, perception, thought, or behaviour. The hypnotic context is generally established by an induction procedure. Although there are many different hypnotic inductions, most include suggestions for relaxation, calmness, and well being. Instruction to imagine or think about pleasant experiences are also commonly included in hypnotic inductions. People respond to hypnosis in different ways. Some describe their experiences as an altered state of consciousness. Others describe hypnosis as a normal state of focused attention, in which they feel very calm and relaxed. Regardless of how and to what degree they respond, most people describe the experience as very pleasant. Some people are very responsive to hypnotic suggestion and others are less responsive. A person’s ability to experience hypnotic suggestion can be inhibited by fears and concerns arising from some common misconceptions. Contrary to some depictions of hypnosis in books, movies or on television, people who have been hypnotized do not lose control over their behaviour. They typically remain aware of who they are and where they are, and unless amnesia has been specifically suggested, they usually remember what transpired during hypnosis. Hypnosis makes it easier for people to experience suggestions, but it does not force them to have those experiences …” (American Psychological Association, 1994).
Theories of hypnosis
From the observations on the uses to which hypnosis and hypnotic phenomena have been put, various theories concerning the fundamentals of hypnosis have been proposed. In the past, the majority of hypnosis researchers believed that there is an hypnotic state, which fundamentally differs from the waking state. Nowadays, instead of two opposing camps, there is a continuum of positions on the issue. At one end of this continuum are scholars who espouse the concept of hypnotic state in its strongest possible form, as a condition that is fundamentally different from normal waking consciousness and from other altered states such as daydreaming and relaxation.
At the other end of the continuum are theorists who use the term state to describe hypnotic phenomena but deny that it explains or causes those phenomena in any way and those who explicitly reject the hypnotic state construct as inaccurate and misleading. Most hypnosis researchers agree that the impressive effects of hypnosis stem from social influence and personal abilities, not from a trancelike state of altered consciousness (kirsch & Lynn, 1995). Similar to the state issue, the trait issue can most accurately be portrayed as a continuum, rather than a dichotomy. Most scholars recognize a role for stable individual differences and a role for contextual variables in determining hypnotic response. Furthermore, most stress the importance of considering the interaction between these variables (Kirsch & Lynn, 1995).
Clinical hypnosis for children with cancer
Hypnosis has established a successful record in the paediatric oncology setting mainly in the management of chemotherapy-related nausea and vomiting (NV) and procedure-related pain. Initial reports on the use of hypnosis to treat NV were in the form of case studies. Subsequently several controlled studies have assessed and supported the efficacy of hypnotherapy in alleviating chemotherapy-related NV. In the most recent study Hawkins et al (1995) demonstrated the effectiveness of hypnosis for the reduction of anticipatory NV in a randomized controlled-design study that aimed to assess the possible therapeutic gains that may be derived from hypnosis while controlling for gains that may be derived from non-specific therapeutic factors.
Children and adolescents in treatment for cancer undergo also numerous painful procedures including venepunctures, lumbar punctures, bone marrow aspirations and biopsies. A number of controlled studies have shown that hypnosis is effective in treating procedure-related cancer pain. Hypnosis interventions have been found to be of significant help in reducing pain and anxiety in all of the studies conducted so far. In the most recent one Liossi and Hatira (1999) reported a comparison of hypnosis versus cognitive behavioural (CB) skills training in alleviating the pain and distress of thirty paediatric cancer patients undergoing bone marrow aspirations.
Results indicated that both hypnosis and CB coping skills are effective in preparing patients for BMA with hypnosis being superior in minimizing anxiety and behavioural distress. The consistency of the findings among the studies contacted so far indicates the usefulness of hypnosis as an effective intervention for helping children and adolescents to control the pain and anxiety associated with medical procedures (Liossi, 1999). Additionally, there is possibility for hypnosis to be utilized for the management of other cancer-related symptoms such as chronic pain, phantom limb pain, needle phobia, generalized anxiety, dysphagia for pills, insomnia etc. It is important to remember that at any particular time, the young cancer patient may present a number of symptoms, one of which can be dominant at a single hypnotherapy session, but that does not mean that other symptoms need be ignored.
Hypnotisability and therapeutic outcome
Although the relationship between hypnotisability and symptom reduction is not perfect, there is a much increased probability of successful symptom reduction for those children highly responsive to hypnosis, at least with procedure-related cancer pain (Hilgard & Hilgard, 1994).
Children have long been regarded as good respondents to hypnosis and hypnotic interventions with hypnotic-like states common to their experience. Antecedent conditions are found in childhood play, fantasy, and imaginary playmates. Several studies have demonstrated that children are more hypnotically responsive than adults. The relationship between age and hypnotic responsivity is complex. Hypnotic ability is limited in children below the age of 3, achieves its apex during the middle childhood years of 7-14, and then decreases somewhat in adolescence, remaining stable through midlife before decreasing again in the older population.
There are no significant differences in hypnotic responsiveness between boys and girls at any age. Children’s natural desire for mastery of skills and for understanding of, and participation in, their environment is directly related to responsiveness to hypnosis (Olness & Gardner, 1988). Clinicians capitalize on these qualities when they introduce hypnosis to a child as ‘something new you can learn how to do – not everybody knows how to do it, just as not everybody knows how to ride a bike’ (Wester & O’Grady,1991).
Apart from specific correlates of hypnotic responsiveness in childhood, several variables not directly related to hypnotic talent may enhance or impede hypnotic responsiveness. Prior to conducting any hypnosis it is imperative to remove any misconceptions that may be held by patients, parents, or health care professionals. Most of these will stem from demonstrations of stage hypnosis or dramatizations on television or in films.
Overall plan of hypnotic interventions
The process of clinical hypnosis conceptually can be divided into six phases: (1) preparation, (2) induction, (3) deepening, (4) therapeutic suggestions, (5) post-hypnotic suggestions, and (6) termination (0’Grady & Hoffman, 1984). The hypnotist develops an overall plan of the hypnotic session by choosing tasks for each phase and arranging the suggestions for the task in a sequence.
Preparation usually includes discussion of the reasons for utilizing hypnosis, clarification of misconceptions, and full reply to questions. Details of the child’s likes and dislikes, significant experiences, fears, hopes, and comfort areas are discussed. Children respond to a large number of hypnotic induction techniques (e.g. visual imagery, auditory imagery, movement imagery, story-telling, ideomotor, progressive relaxation, eye fixation, distraction) each with countless variations. Any induction method may also be used as a deepening method, and methods may be combined in almost any order.
The choice of an appropriate induction for any given child depends on the needs and preferences of the child. One needs to know something about the social and cultural backgrounds of young patients, general likes and dislikes, and themes of interest related to storybooks, television programmes, and current films. Compared with adults, children are more likely to wriggle and move about, open their eyes or refuse to close them and make spontaneous comments during hypnotic inductions and treatment. Although these behaviours may indicate resistance, this is not necessarily the case. Most often the child is simply adapting hypnosis to their behavioural style. The induction techniques and the specific therapeutic suggestions used should emphasise children’s involvement and control, and encourage their active participation in the process of experiencing and utilising hypnosis. The purpose of therapy is always to increase the child’s control of desired feeling or behaviour, and any suggestion that emphasises loss of control can only inhibit therapeutic progress. The therapist can also teach the patient self-hypnosis as a way for them to participate actively (in a motivated and purposeful way) in the treatment process, and to reinforce self-mastery.
Hypnosis has several attractive features. It is safe and does not produce adverse effects or drug interactions. Children enjoy the hypnotic experience. They obtain relief without destructive or unpleasant effects. There is no reduction of normal function or mental capacity and no development of tolerance to the hypnotic effect. It is a skill which children can easily learn, that provides a personal sense of mastery and control over their problems and counters feelings of helplessness and powerlessness. A beneficial change in attitude towards cancer and hypnosis also fosters a sense of control.
An additional benefit is that hypnosis can be generalised to many distressing circumstances. The child who learns hypnosis for management of bone marrow aspiration may apply their skills to lessen the distress of lumbar punctures, venepuncture, or manage nausea and vomiting from chemotherapy, insomnia, anxiety etc. Moreover, hypnosis is an opportunity for the clinician to be inventive, spontaneous and playful, and to build a stronger therapeutic relationship with a child while providing symptom relief (Liossi, 1999).
It is clear that children with cancer would benefit tremendously from the wider application of hypnosis in paediatric oncology centres. In terms of clinical practice, the optimal control of children’s symptoms requires an integrated approach because many factors are responsible, however seemingly clear-cut the cause. Children might well receive hypnotic intervention in conjunction with pharmacological treatments. Hypnosis is a reasonably cost~efficient technique that may well enhance patient compliance, reduce time allocations of expensive medical personnel and equipment, and minimise the distress of children who must undergo invasive medical procedures, radiotherapy or chemotherapy.
Clinical hypnosis should be used only by properly trained and certificated health care professionals who have been trained in the clinical use of hypnosis and are working within the areas of their professional expertise.
It is therefore imperative that paediatric practitioners are well trained, properly supervised and that the provision of services is carefully planned, resourced and managed.
American Psychological Association (1994). APA definition and description of hypnosis. Defining hypnosis for the public. Contemporary Hypnosis, 11(3), 142-143.
Hawkins P. J., Liossi C., Ewart B. W., Hatira P., Kosmidis H., and Varvutsi M. (1995). Hypnotherapy for control of anticipatory nausea and vomiting in children with cancer: preliminary findings. PsychoOncology 4, 101-106.
Hilgard E. R. and Hilgard J.R. (1994). Hypnosis in the Relief of Pain (Rev. ed.). New York: Brunner/Mazel.
Liossi C. (1999). Management of paediatric procedure-related cancer pain. Pain Reviews, 6, 279-302.
Liossi C. and Hatira P. (1999). Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations. Intemational Journal of Clinical and Experimental Hypnosis, 47(2), 104-116.
Kirsch I., and Lynn S.J. (1995). The altered state of hypnosis. Changes in the theoretical landscape. American Psychologist, 50(10), 846-858.
Olness K., and Gardner G.G. (1988). Hypnosis and Hypnotherapy with Children (2nd Ed.), Philadelphia: Grune & Stratton.
0’Grady D.J., and Hoffmann C. (1984). Hypnosis with children and adolescents in the medical setting. In W. Wester and A. Smith (Eds.), Clinical Hypnosis: A Multidisciplinary Approach (181-209). Philadelphia: Lippincott.
Wester W.C. and O’Grady D. J. (1991). Clinical Hypnosis with Children. New York: Brunner/Mazel.
First published in March 2000 in the British Psychological Oncology Society’s Newsletter and reproduced here with their kind permission.