An Introduction to the Use of Hypnosis in Palliative Care

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1 An Introduction to the Use of Hypnosis in Palliative Care With Dr Sara Booth & Dr Ann Williamson from the British Society of Clinical & Academic Hypnosis (

2 What is Hypnosis? 2

3 Definitions of hypnosis "..A waking state of awareness, (or consciousness), in which a persons attention is detached from his or her immediate environment and is absorbed by inner experiences such as feelings, cognition and imagery. (M. Heap) Hypnosis involves the focusing of attention and imaginative involvement to the point where what is being imagined feels very real

4 HYPNOSIS ITSELF IS NOT A THERAPY IT IS A TOOL - LIKE A SYRINGE It can however, facilitate therapy Hypnosis does NOT make the IMPOSSIBLE POSSIBLE Suggestion does not consist in making an individual believe what is not true. Suggestion consists of making something come true by making a person believe in its possibility. J.D.Hadfield

5 When we have learned hypnosis we THINK about every word we say. By the use and acceptance of suggestions, the clinician and patient construct a hypnotic reality which enables them to fulfill their roles.

6 fmri studies Have demonstrated neural correlates of hypnosis Landry, M. et al., Brain correlates of hypnosis: A systematic review and meta-analytic exploration. Neurosci. Biobehav. Rev.(2017), Have demonstrated that using imagery in the hypnotic state triggers similar brain changes to the real experience

7 Kosslyn et al, groups, hypnosis or mental imagery Identical suggestions Mental imagery group didn t have hypnotic induction In hypnosis group only were colour areas of right & left hemispheres activated when asked to perceive colour HYPNOTIC VISUAL ILLUSION ALTERS COLOUR PROCESSING IN THE BRAIN. Kosslyn, S. M., Thompson, W. L., Constantin-Ferrando, M. F., Alpert, N. M & Spiegel, D. (2000) American Journal of Psychiatry, 157:

8 fmri studies Suggestion only Hypnosis + suggestion

9 Functional pain Physically-induced pain Hypnotically-induced pain Imagined pain 8 participants (>8 on Harvard scale) fmri Three conditions All in hypnosis All right hand 1. Heat probe pain (48.5oC) - physically-induced pain 2. Suggested heat probe pain - hypnotically-induced pain 3. Imagined heat probe pain - imagined pain

10 Physically-induced and hypnoticallyinduced pain BOTH accompanied by activations in areas associated with the classic pain matrix :- Thalamus; Anterior cingulate; Insula; Prefrontal cortex; Parietal cortex Imagined pain produced minimal activations in :- Insula; Secondary sensory cortex. CEREBRAL ACTIVATION DURING HYPNOTICALLY INDUCED AND IMAGINED PAIN. Derbyshire, S.W.G., Whalley, M.G., Stenger, V.A. & Oakley, D.A. (2004) NeuroImage, 23,

11 Trance States Running, dancing Driving Theatre, cinema Absorbed in an activity Prayer / meditation Either side of sleep or anaesthetic Transderivational search Shock, anxiety

12 Beware Spontaneous Trance Acute trauma Breaking bad news General anaesthesia Especially if high hypnotisable

13 Memory Intentional Communication Verbal L Logical Rational Abstract Critical R Emotions Feelings Instinctive Intuitive Memory Involuntary State dependent Communication Non-verbal Imagery

14 What is it like? You may feel relaxed You may feel alert Practice improves skills

15 Misconceptions Control issues Weakness of character Sleep Reveal information? Open to abuse Problems awakening

16 Memory Reconstructive U/C mind fills gaps Beware leading questions Hypnosis is not a truth drug!

17 Hypnosis A therapeutic day-dream A right brain state Effective communication An interactive process

18 Advantages Deals with emotions, not just cognition Treatment can be selfadministered Passes control to the client Can be done in groups

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20 HYPNOSIS IN PALLIATIVE CARE A personalised treatment Increases the impact of other treatment approaches Tool for self-management increasing self efficacy Portable, cheap, no adverse effects

21 OBJECTIVES OF PRESENTATION Brief review of applications of hypnosis in palliative care Brief review of psychoneuroimmunology Focus on patient case histories Hypnosis in context of wellbeing interventions Innovation and excellence in health and care

22 THE IMPACT OF CANCER Physical symptoms Psychological symptoms Psycho-social impacts Losses Problems with money Questions about mortality Longer term impact ( with and beyond )

23 LIMITATIONS OF PHARMACOLOGICAL APPROACHES FOR SYMPTOM CONTROL Pain, particularly neuropathic pain and incident pain Breathlessness Nausea Poor sleep Loss of meaning, regrets, distress

24 WHAT IS PNI? PSYCHO-NEUROIMMUNOLOGY

25 PSYCHONEUROIMMUNOLOGY : PNI, DARUNA 2012 The brain and CNS The endocrine system The immune system All work together and affect each other It is clear that disease begins within organismic microenvironments and that complexity is not diminished by progressively narrowing the focus of analysis.

26 GLASER AND GLASER 1999 These studies and others suggest that psychological or behavioral factors may influence the incidence or progression of cancer through psychosocial influences on immune function and other physiological pathways.

27 HOW CAN HYPNOSIS HELP IN PEOPLE WITH CANCER? During treatment with adverse effects During treatment with psychological distress During treatment with symptom control After treatment with long-term symptoms After treatment with symptom control Long term adjustment to living with and beyond (LWB)

28 TAWAKOLET AL, THE LANCET 2017;389: Relation between resting amygdalar activity and cardiovascular events: a longitudinal and cohort study 293 patients (median age 55 years [IQR ])..included in longitudinal study, 22 had a cardiovascular disease event during median follow-up of 3 7 years (IQR ). Amygdalar activity..associated with increased bone-marrow activity (r=0 47; p<0 0001) arterial inflammation (r=0 49; p<0 0001), and risk of cardiovascular disease events (standardised hazard ratio 1 59, 95% CI ; p<0 0001), a finding that remained significant after multivariate adjustments.

29 TAWAKOL ET AL, 2017 The association between amygdalar activity and cardiovascular disease events seemed to be mediated by increased bone-marrow activity and arterial inflammation

30 CANCER AND ITS SYMPTOMS Associated with an activated inflammatory response

31 HYPNOSIS IN CANCER CARE Hypnotherapeutic insights and interventions: a cancer odyssey. Contemporary Hypnosis, 21:35-45 These studies have provided evidence that relaxation therapy, guided imagery and hypnotherapy can be very beneficial in helping patients cope with the diagnosis and treatment. Intriguingly, there is some evidence that they may prolong life Walker LG (2004).

32 WHAT IS THE EVIDENCE? FEW RCTS In the area of cancer symptom management, auricular acupuncture, therapeutic touch, and hypnosis may help to manage cancer pain. Mansky & Wallerstedt 2006 Hypnosis for nausea and vomiting in cancer chemotherapy: a systematic review of the research evidence Richardson et al, 2007

33 WHAT IS THE EVIDENCE? Few RCTs Often simplified as a CAM (complementary and alternative medicine) rather than an adjunct Getting older; systematic review Rajasekaran et al, 2005 No currently available evidence from palliative care Rather more from oncology

34 HYPNOSIS MIND BODY APPROACH Hypnosis in Breast Cancer Care: A Systematic Review of Randomized Controlled Trials Cramer et al, 2015 Integrative Cancer Therapies 2015, Vol. 14(1) 5 15 Thirteen RCTs with 1397 participants Positive effects on pain, distress, nausea, fatigue, hot flushes Consider as an ancillary treatment

35 HYPNOSIS IN CANCER CARE Mrs AB Slow growing spinal cord tumour Sudden onset numbness/tingling/weakness Told you may not walk again post op

36 HYPNOSIS IN CANCER CARE Mrs A.B. Post-op Neuropathic pain: worst lower limbs Fear of marriage break up Fear of exercise, although helps Exhaustion

37 HYPNOSIS IN CANCER CARE Mrs AB Anxiety / distress reduction. Protection from emotional distress. Interrupting circuits for pain relief. Rehabilitation in mind leading to greater physical freedom. Pain relief.

38 HYPNOSIS IN PALLIATIVE CARE Visor to protect from pain. Metal gates within pain pathway. Snake representing pain; snake prevented from reaching spinal cord by gate. Psycho-social uses of hypnotic intervention to improve general health

39 HYPNOSIS IN HOT FLUSHES 35 year old woman Separating from husband Hot flushes very disabling Young daughter Imagery Ice Tap turned on and off at will Cool sheets Waterfall (most successful)

40 FOUND IMAGE WITH DAUGHTER

41 MAINTENANCE THERAPY Often only use when in trouble Rapid self hypnosis can become a habit Everyday pauses Everyday actions Post-hypnotic suggestions

42 Do I need to understand my patient s prognosis?

43 HYPNOSIS IN CANCER & PALLIATIVE CARE Dynamic Creative Energising Can relive activities now lost

44 HYPNOSIS RECORD MRS E.T. Dates seen: Special Place: Beach in Cornwall; nice day but not high summer. Husband there. Warm, roughish waves, suitable for surfing, walking on the beach on the rocks in a wet suit. Imagery to avoid: No swings, no lifts. Preferences: Breathe out black, breathe in white light. Images used: Beach walk, Starship Enterprise with person adjusting previous painful memories and pain circuitry. Clench fist for strength and purposefulness and confidence. Rucksack removing heavy unnecessary stones.

45 Hypnosis Trance plus Suggestion

46 Do I need to understand the treatment my patient is on?

47 NEUROPATHIC PAIN: CHRONICITY Mrs F. delay in diagnosis Slow growing spinal tumour that cannot be removed. Many intrusive sensory effects which shift & change Somatic symptoms with drugs an issue Long term adverse effects a concern Not sure about hypnosis

48 NEUROPATHIC PAIN

49 NEUROPATHIC PAIN: UMBRELLA TERM Up to 40% cancer patients Poorly managed Most evidence on agents comes from nonmalignant disease: PHN & diabetes How similar are these to cancer neuropathic pain? No robust classification system making large trials difficult

50 SUMMARY WHAT CAN BE DONE FOR NEUROPATHIC PAIN Listen Screen for neuropathic pain Assess & document severity Treat Reassess Titrate drug therapy subtly Explain & educate & support Self management strategies including hypnosis

51 Addressograph: Mrs Pink, dob 1975 Dates seen: Special Place: Beach hut, or lovely sea, blue sky, white sand, white fluffy clouds, lots of cushions, reading a book. James opposite reading a book. Feeling the warmth of the sun, feeling the soft cushions. Cold gin and tonic in hand. Hearing the sea crashing and the rustling of trees. Wearing a maxi dress. Imagery to avoid: Lifts Preferences: In: turquoise blue Out: dark green (representing nausea) Prefers stairs likes swings. Images used: A big knob, like on the car to turn down nausea. Some behaviour adjustments. Having the tidy before she leaves and comes home. Not having noise or upset in the house so the children going away for two days. Using the feeling of wellness a few days. Using the image of the chemo. Crushing the tumour and sending it to lots of pieces. Gave her a mindfulness CD. Talked through the ideas of mindfulness and hypnosis Breathing in and the breathing out were the same as last time (In blue, out green). Wanted to concentrate on short hypnosis. Use the ocean as a way of washing away bad things. Use the cumulative effect of breathing in the blue to give a reserve before her next chemo. Used a pebble as an object for her to use in the hospital to remind her of the seashore and therefore the calm and peace of the sea shore. Outcomes: Much calmer, much better feeling after the chemo. Virtually no nausea. Stopped using an extra anti-emetics. Feels much more in control. Using the CD regularly. Prompts: Washing hands, putting hand cream on to breathing in blue. When the chemo is attached up, breathing in blue and breathing out green.

52 IMAGERY IN SECOND SESSION Building up blue Common action: washing hands and hand cream, RSH linked to these Transitional object : pebble = beach Beach hut is best place to have chemo Film The Green Mile seeing tumour destroyed and leaking out of her

53 A NUMBER OF INTERVENTIONS Interventions CD Short hypnosis interventions for her to use RSH Long sessions hypnosis/rest/cd

54 HYPNOSIS POOR SLEEP Waking up in early hours and lying awake Feeling tired the next day Not managing work or missing pleasurable activtities Approach sleep hygiene Worries and concerns Imagery that suited her (mountains and rivers) Stones in back pack

55 HYPNOSIS POOR SLEEP Man aged 67 years Difficulty getting off to sleep Seemingly completely at rest Frustration Approach Difficulty with induction Good visual imagination What did I do?

56 HYPNOSIS : STAGED PROCEDURE First visit distress reduction Second visit more distress reduction, consolidation Third visit managing anger Fourth visit pain Fifth visit dealing with family issues Combined with other medical interventions

57 SYMPTOMS Peripheral generators Central processors Both offer approaches to amelioration Use person s interests and work to influence imagery Priors may act as triggers/exacerbators

58 HYPNOSIS - AFFECTS LEARNED ASSOCIATIONS???over perceptions priors pulmonary rehabilitation correlated with reductions in prior-related activity in the insula and anterior cingulate cortex (ACC) (breathlessness), increased activations in attention regulation and motor networks (breathlessness-anxiety) Pattinson et al, 2017

59 HYPNOSIS IN CONTEXT anxiety reduction nutrition exercise social contacts preventing or early treatment of depression caring for carers Innovation and excellence in health and care

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61 Why Hypnosis? Prevention is cheaper than cure! You can learn how working in a brief, solution oriented way, using hypnosis and imagery, can be fast and effective. Learn practical ways that a busy health professional can maximise the effectiveness of the time they have with a patient.

62 Learn how avoid the nocebo effect and how to teach patients tools that they can go away and use themselves. However we label techniques we can access a client s unconscious resources through their imagination and use imagery to connect in a very powerful way to their ability to heal themselves.

63 Learn how to Rapidly build rapport Help your patient relax Decrease patients anxiety and pain Use less medication and improve the patient experience Go to for more details

64 Why should you join BSCAH? Contact, support and network with like minded professionals Access to training in hypnosis with opportunity to gain Accreditation Access and opportunity to present at BSCAH educational meetings and annual conference Free access to the journal Contemporary Hypnosis and Integrated Therapies Access to Branch and audio libraries and the Society s newsletter Opportunity to access ESH and ISH via the Society s membership of same

65 Foundation Training Three two day modules Core curriculum Tailored to profession of course participants Small groups Talks, demonstrations and practical exercises Practically based teaching by experienced health professionals

66 City of Birmingham University Accredited Advanced Diploma in Clinical Hypnosis and Stress Management For more details refer to BSCAH Accreditation Further training and practise Five written case studies Viva by two Assessors

67 One day workshops for Health Professionals run by experienced doctors, nurses and psychologists from BSCAH on request On-site training with a tailor-made workshop for your department These introductory workshops are targeted to the specific speciality and needs of the participants, for example pain management for pain clinic teams, dental uses for dental teams, psycho-dermatology, primary care. This training will give participants some practical expertise, as well as an understanding of hypnosis and its uses within your specific field.

68 Thank you for your interest! Any questions? British Society of Clinical and Academic Hypnosis Telephone: