Imagery and Hypnosis in the Treatment of Cancer Patients

Spiegel and Moore draw an important distinction between the use of psychologicaltechniques to
promote quality of life and their use to promote quantity of life. On theone hand, a considerable body of research documents that hypnosis and otherpsychological techniques improve the quality of life of cancer patients.On the other hand, only limited empiric evidence supports the view thatimagery and other psychological techniques increase the quantity of lifeof cancer patients.

Moreover, in the few studies showing that the use of psychological techniquesby cancer patients is associated with increased survival,[1,2] the techniquesstudied were fairly traditional in nature and not of the "alternativemedicine" variety. For example, in the study by Spiegel et al,[1]the intervention consisted of supportive-expressive group therapy and instructionin self-hypnosis for pain control. The study of Fawzy et al[2] employedhealth education, training in problem solving and stress management, andsupportive group therapy. As noted in the article by Spiegel and Moore,both interventions were also found to improve the quality of life of cancerpatients. Taken together, these findings suggest that interventions thatimprove the quality of life of cancer patients may also confer a modestsurvival benefit.

Relaxation Training

In their review of psychological interventions, Spiegel and Moore focuson the use of hypnosis for cancer pain control. Clinicians and cancer patientsneed to be aware of other psychological techniques that can be used toenhance quality of life. A recent survey of comprehensive cancer centersindicated that, next to support groups, relaxation training was the mostwidely offered form of psychological care.[3]

The widespread use of relaxation training among cancer patients canbe attributed to several factors. First, training in relaxation techniquescan usually be accomplished in a brief period. Thus, it is well suitedfor use in oncology, in which rapid control of aversive symptoms and emotionaldistress is desirable.

Second, relaxation training is readily accepted by patients, who perceiveits potential benefits as including a greater sense of personal control.

Third, and perhaps most important, empiric research has repeatedly shownthat relaxation training enhances the quality of life of cancer patients.Results of controlled studies indicate that interventions incorporatingrelaxation training are effective in relieving pain,[4] nausea and vomiting,[5]and emotional distress.[6,7]

Relaxation training refers to a variety of mental and physical exercisesthat can be used to induce subjective and physiologic relaxation. Amongthe exercises typically included in relaxation training programs are tensingand releasing of muscles, abdominal breathing, distraction, suggestion,and the use of relaxing mental imagery.

In our institution, relaxation training is generally conducted by amental health professional (psychologist, social worker, or psychiatricnurse). The initial training can be accomplished in as little as 1 hour.The patient is given an audiotape of the training session, and thus, additionaltraining can be accomplished by practicing the exercises at home. In addition,the patient can subsequently listen to the audiotape whenever he or shewishes to induce relaxation to reduce stress or promote symptom control.

Increasing the Availability of Psychological Interventions

The cost and availability of psychological interventions are major barriersto their more widespread use in oncologic settings.[8] Many treatment centersdo not have either the economic or human resources required to provideprofessionally administered psychological interventions on a routine basis.

Several modifications have been devised to address this issue. One alternativeis to train oncology staff or paraprofessionals to deliver psychologicalinterventions. Along these lines, Morrow and colleagues[9] demonstratedthat an intervention that included relaxation training was equally effectivein reducing nausea and vomiting among chemotherapy patients when it wasprovided by oncologists, oncology nurses, or mental health professionals.In contrast, Carey and Burish[10] found that relaxation training was notas effective when provided by paraprofessional volunteers as when providedby professional therapists.

At Moffitt Cancer Center, we recently initiated a National Cancer Institute-fundedstudy to examine the effectiveness of a patient self-administered psychologicalintervention. Patients scheduled to begin chemotherapy receive speciallyprepared audiovisual materials (a videocasstte, an audiocassette, and abrochure) that provide information and instruction in relaxation trainingand other stress management techniques. This self-administered interventionis being compared to a professionally administered intervention and toa no-intervention control condition. Both the clinical efficacy and cost-effectivenessof the self-administered program in improving quality of life are beingassessed.

The development of an effective self-administered program that requiresminimal professional contact and costs little more than usual care hasthe potential to greatly increase patient access to psychological interventionsin oncologic settings. As a result, many more patients who would otherwisenever receive a psychological intervention could experience better qualityof life during cancer treatment.

References:

1. Spiegel D, Bloom JR, Kraemer HC, et al: Effect of psychosocial treatmenton survival of patients with metastatic breast cancer. Lancet 2:888-891,1989.

2. Fawzy FI, Fawzy NW, Hyun CS, et al: Malignant melanoma: Effects ofan early structured psychiatric intervention, coping, and affective stateon recurrence and survival 6 years later. Arch Gen Psychiatry 50:681-689,1993.

3. Coluzzi PH, Grant M, Doroshow JH, et al: Survey of the provisionof supportive care services at National Cancer Institute-designated cancercenters. J Clin Oncol 13:756-764, 1995.

4. Sloman R, Brown P, Aldana E, et al: The use of relaxation for thepromotion of comfort and pain relief in persons with advanced cancer. ContNurse 3:6-12, 1994.

5. Lyles JN, Burish TG, Krozely MG, et al: Efficacy of relaxation trainingand guided imagery in reducing the aversiveness of cancer chemotherapy.JConsult Clin Psychol 50:509-524, 1982.

6. Telch CF, Telch MJ: Group coping skills instruction and supportivegroup therapy for cancer patients: A comparison of strategies.
J Consult ClinPsychol 54:802-808, 1986.

7. Greer S, Moorey S, Baruch JD, et al: Adjuvant psychological therapyfor patients with cancer: A prospective randomized trial. Br Med J204:675-680, 1992.

8. Burish TG, Redd WH: Symptom control in psychosocial oncology.Cancer 74:1438-1444, 1994.

9. Morrow GR, Asbury R, Hammon S, et al: Comparing the effectivenessof behavioral treatment for chemotherapy-induced nausea and vomiting whenadministered by oncologists, oncology nurses, and clinical psychologists.Health
Psychol 11:250-256, 1992.

10. Carey MP, Burish TG: Providing relaxation training to cancer chemotherapypatients:
A comparison of three delivery techniques.
J Consult Clin Psychol 55:732-737, 1987.