Cancer is a multisystem illness, involving all levels of the organism, from the cellular to the psychological. While the baffling varieties of its manifestations continue to be elucidated, there is a growing awareness of its complex psychological dimensions. Of most humane concern is the intense travail and the varieties of pain cancer patients are likely to experience -- pain from the disease itself, from its treatments, and from the deep intrapsychic and social changes it induces. Recently, there has been an expanding appreciation for the varied needs of cancer patients: needs for support, openness of communication, and understanding; and for the sensitivity and professionalism with which issues of death and dying need to be approached.

Hypnosis finds applications at several levels of cancer care. First, it is useful as a means of dealing with the symptoms of the disease itself: pain and symptoms referable to specific organ systems, and nonspecific general symptoms, ie, fatigue, malaise, irritability, and insomnia. Secondly, hypnosis is useful in the management of the side effects of cancer treatments. This is very important because side effects of chemotherapy and radiation are often so uncomfortable that they may cause the patient to drop out of therapy. Thirdly, cancer patients are faced with major psychological adjustments. Many view their diagnosis as a death sentence and are forced to grapple with profound existential issues. Hypnosis has a place in helping with this difficult situation. Lastly and somewhat controversially, hypnosis has been aimed at modifying the course of the disease process itself through the use of imagery. While the first three applications are of proven clinical efficacy, the last has mostly anecdotal support. It will be briefly mentioned, however, because of its current interest and for the fact that it raises interesting issues for research.

Symptoms attributable to cancer are as varied as its subtypes. Pain, the most common symptom aside from fatigue, is highly variable. Some patients with advanced disease report no pain at all, while others suffer from it at the onset. Pain may be dull, constant, diffuse, and related to motion, or it may be sharp, localized, and lancinating. The hypnotherapist will want to know about the history of the pain, its distribution, quality, and evolution, in addition to details about its context in the patient. Is the patient anxious? Depressed? Are there associated symptoms producing concern or worry, ie, difficulty in breathing, swallowing, or walking?

There is a relationship between pain and anxiety. Usually, one will feed into the other, making both worse. If the patient is feeling despair, pain is experienced as more unbearable and hopelessly endless.

Paying attention to the contextual milieu of cancer pain may suggest adjunctive treatment strategies, such as evaluation for a trial of antidepressant therapy or for the addition of antianxiety medications.

In altering or removing pain, care must be taken not to block its warning function. In the early stages of the illness, a new discomfort may herald metastasis and may be important for purposes of changing therapeutic course. In more advanced cases, this is not as relevant. The following case history demonstrates some principles of hypnosis use in symptoms due to cancer.

A 55-year-old man, with a diagnosis of left colon carcinoma made two years previously was referred by his oncologist for hypnotic treatment of pelvic pain. A recent check-up had revealed metastatic liver nodules, and a bone scan showed a solitary lesion in the right pelvic bone. He had started taking aspirin, propoxyphene and, occasionally, codeine. This highly educated man was able to appraise the complexities of his situation with aplomb mixed with open-mindedness. He did not wish to discuss the issues of his death. Those, he said, were clear to him, and many of the feelings he had could not, in his estimation, be communicated adequately. He felt that to do so would be a squandering of his precious time. He stated succinctly, however, that he wanted to be with his family, have time to take care of certain business matters, and be as free as possible of discomfort. His intermittent pelvic pain interfered with walking and with the sexual aspects of his life. Very ambivalent about plans for chemotherapy and radiation, he opted for more time to make a decision about these matters.

He was successful in achieving a medium trance with the arm levitation technique. By gently and repeatedly touching his right hand with a finger and associating suggestions for numbness and coolness (some patients prefer warmth), glove anesthesia was induced. A prick of a thenar skinfold was perceived by him as a faraway flicker of touch. He was told that, by way of the same mechanisms that removed the sensations in his hand, he could induce numbness in any part of his body. His numb hand was brought to rest on his right pelvis. "Imagine the numbness and coolness in your hand, seeping through your skin, extending into your body with each breath, as if you've touched the smooth surface of a pond, and see the concentric rings spreading out in all directions. Please keep your hand there until the numbness is clearly all through your pelvis." His hand, after three minutes, lifted off. "Your ability to repeat this process will stay with you, and you will be able to use it on your own by learning self-hypnosis."

The relief he obtained was variable. Sometimes he could dispel the pain completely and could walk comfortably for up to half an hour. At other times, especially when his mood was low, he could obtain only partial relief. But overall, he felt more relaxed, consequently had more energy, and was more active. He later applied self-hypnosis to help himself cope with chemotherapy.

It is well documented that hypnosis has significant potential for alleviating cancer pain, and when used adjunctively with analgesics, serves to reduce their dosage. The following approaches may be used singly or concomitantly in any patient, depending on hypnotic aptitude.

Direct suggestions for pain removal Some patients respond adequately to direct suggestions that the pain will diminish in intensity to the point of becoming unnoticeable. There is some controversy as to whether the word "pain" should be used during hypnosis or be replaced by a euphemism such as "discomfort." There is no proof that either approach is superior.

Glove anesthesia with extension As in the case above, hypnotic focusing on a part of the body, ie, the hand, is sometimes helpful for the production of sensory alterations. Once the experience is established in the hand, it is only a small psychological step to transfer it to other parts of the body.

Altering the configuration of pain The representation of pain in the mind -- the pain "body image" -- may be compressed to occupy a "smaller space." Neurophysiologically, this corresponds to a shutting down of association networks. Suggestions are made for the pain to decrease in size as the patient is asked to visualize the pain as a three-dimensional shape in space, shrinking progressively.

Altering the qualitative aspects of pain As pain fibers project from thalamic nuclei through diffuse thalamic radiations to corrical areas, they become associated with the process of experiencing. The feelings within the experiential process are unique to each individual and are malleable by cortical influences. Hypnotic intervention may be able to change the quality of the pain, to associate it with coolness or warmth, or numbness, in order to make it less insistent and less immediate.

Control of anticipatory anxiety Anxiety acts synergistically with pain. Anticipatory anxiety -- the anxious sensation that pain may worsen -- heightens the dolorous experience. Helping the patient relax, both at the moment and for the future, can provide significant analgesia.

Imagery With some individuals, hypnotic absorption in imagery is the best antidote for pain. The type of imagery to be used with a particular patient will depend on their eidetic style (visual, auditory, somesthetic) and on their personal experience (happy, uplifting, "high" memories). The hypnotherapist obtains an impression of the imagery potential of the patient during the preinduction interview and feeds back appropriate images during the trance.

Dissociation Dissociation is a very important and effective mechanism by which the pain may be experienced as an event moving away from the locus of awareness. "It is there but it doesn't feel like it belongs to me," is a common comment from subjects adept at dissociation.

Particularly bothersome for some patients are certain side effects of chemotherapy. Sometimes, in a simple conditioning paradigm, a patient will become so sensitized by the aftereffects of the first treatments that subsequent sessions, or even the thought of them, bring about great autonomic distress. Typically, a nausea-vomiting response occurs one to two hours after the injection of antineoplastic drugs, and it is estimated that at least 25% of chemotherapy patients manifest such respondent conditioning.

Conditioned anticipatory emesis can make chemotherapy excruciatingly unpleasant and contributes directly to patients dropping out of treatment. Antiemetics are usually marginally effective and have side effects of their own.

Hypnosis has been well documented to have therapeutic potential for conditioned anticipatory emesis. The following case illustrates some of the treatment principles in this condition.

A man of 26 with stage three Hodgkins disease was receiving combination chemotherapy (doxorubicin, bleomycin, vinblastine). Although physically tolerating this regimen well, he became increasingly distressed by nausea following his treatments. Experienced for the first time less than one half hour after the first treatment, it had worsened each time. At the third treatment, he was reporting significant nausea as well as anticipatory anxiety several hours before treatment was started, and described how the mere picturing of the doctor's office had brought him waves of autonomic distress. At the fourth treatment, the feelings had brought on repeated vomiting. Antinausea drugs (prochlorperazine, trimethobenzamide) were unsuccessful, and he was referred for hypnotherapy.

Induction using a standard arm levitation method was followed by medium trance. An ideomotor technique was used to signal degrees of internal discomfort. Every time nausea was experienced, his right index finger moved sideways on the armchair cushion. When it was relieved, he moved it back towards his other fingers. To counter nauseous feelings, sensations of hunger were elicited. A history was obtained of his favorite foods, restaurants, and memorable gastronomical experiences; associated feelings of appetite and hunger were hypnotically rekindled. By small steps, he was asked to imagine the sequence of events characteristic of a typical treatment session, and feelings of hunger were repeatedly reinforced. When nausea appeared during the process, suggestions were given for total relaxation until it disappeared. During the third session, he was able to visualize himself receiving treatment with no comfort. In the actual treatment situation, he experienced only mild nausea but no vomiting, and he was able to finish his entire regimen protocol.

Relaxation Inducing deep feelings of relaxation is an effective antinausea treatment. Deep relaxation induces a slowing down of peristalsis and a toning down of autonomic hyperactivity. Many patients, by relaxation alone, will significantly decrease the intensity of their experience of nausea. Direct suggestions for the removal of nausea are often of marginal effectiveness. Because nausea stems from massive and extensive autonomic discharge, it tends to be difficult to dispel. Some individuals, however, will easily respond to simple suggestions for its dissolution.

Using hunger as an antidote Feelings of hunger and the physiological changes that they produce are neutralizing to nausea. Direct suggestions for hunger sensations are made, sometimes using the patient's favorite food, or foods served on special holidays. When the patient is actively nauseous, it is usually best at first to induce a deep state of relaxation, then to introduce hunger imagery.

Imagery For some subjects, imagery remains the most effective pathway for autonomic control. Images have the property of beckoning the subject's awareness away from negative experiential states to positive ones. Conjured images of significant positive experiences, or of fantasized idealized settings, may lead the patient into experiencing feelings that are incompatible with distress.

Systematic desensitization This is perhaps the longest method but it is the most consistently successful, especially in refractory cases. The patient needs to be motivated to participate in this, at times, somewhat tedious procedure. Relaxation, or relaxation with suggestions of hunger, gradually paired with a narrative of the treatment situation, from its most neutral to its most adverse conditions, until the latter can be experienced, in the imagination, in a more acceptable context.

Dissociation Some individuals are very adept at hypnotically pushing nausea away from direct experience. It can then be felt as distant, "barely touching me," or as a tolerable annoyance, thus defusing the gnawing immediacy which may lead to an emetic response.

Sensory alteration Suggestions may be given for the nausea to change in quality to make it less stressful. Having' the patient imagine drinking a tall glass of icy water, feeling the sensations of soothing cold seeping through the chest and abdomen, can take the edge off the burning sensation nauseous patients are apt to experience.

We have talked about the applications of hypnosis in the care of the outward manifestations of cancer: pain, fatigue, insomnia, and treatment side effects, among others. Beyond these surface symptoms lie deeply personal, intrapsychic issues. The cancer patient is usually experiencing great inner turmoil and is working with massive personal readjustments. While modern treatment procedures have lightened the ominous implications of a cancer diagnosis, many patients are directly thrown into difficult issues of dying and death.

The hypnotherapist needs to develop a personal philosophy of death, especially as it relates to dealing with patients, and needs to elicit, understand, empathize, and respond to the complex manifestations of death anxiety. Before hypnotherapy begins, especially if it is aimed at helping intrapsychic adjustments, illness and patient must be understood in their relationship to each other. Sometime during the first interview, several questions have to be examined. What is the reality of the patient's clinical situation? How does he fit into the social-familial milieu? To what extent has the patient incorporated the diagnosis and its implications? How much denial is being used? What are his strengths and adaptation potentials? What are the patient's philosophies, wishes, aspirations?

Kubler-Ross (1969) delineated five psychological stages of dying: denial, anger, bargaining, depression, and acceptance. It is well recognized that these stages, which may occur as sequelae of any poignant loss, are highly variable in each patient, may not happen in this sequence, and may often manifest themselves concurrently. Some dying individuals use denial until death; others accept, then deny; others spin into a catastrophic depression or mobilize themselves into a frenzied angry rebellion. The dying patient often experiences a multitude of feelings, many of which are poorly describable. The sensitive clinician should be alert to feelings of hope, bitterness, alienation, envy, self-blame, love for life, dependency, and existential despair, among many others. Rare is the individual who accepts death with wisdom.

Cancer patients are commonly prone to certain feelings and coping mechanisms. Besides anxiety, which is universal, there are feelings of helplessness and loss of control; feelings of alienation and aloneness; feelings of guilt -- that somehow their forbidden impulses have brought about this great misfortune; and feelings of loss of self-esteem -- that somehow they have proven to be supreme failures .

Before proceeding with hypnotherapy, one must have a clear idea of its goals. This will be influenced by the therapist's own approach to death. For some, it is to help the patient look straight on at reality and to map out a rational course of action. Some physicians indeed, in a counterphobic stance, like to "lay it on the line" with a clear breakdown of prognosis, sequence of probable events, and even approximate time of death. Other physicians, as a way of giving in to their own anxieties, are adept at skirting the issues even if confronted directly by their patients.

The goal of hypnotherapy is to maximize the quality of life, to bring comfort, sustenance, freedom from stress and pain, and to work out meaningful family communications. It is important for the therapist to respect denial and work with it, not against it; to acknowledge the legitimacy of the patient's angers; to identify the losses that are faced; to offer ongoing emotional support, yet not give false hopes; to discuss issues relating to personal meaning; to acknowledge the patient's wishes and rights to remain in control by providing choices about treatment; to identify misconceptions the patient may have; and to help set obtainable goals and maintain a hopeful attitude towards achieving them. It is important for the therapist to "be with" the patient at all times and to stay on the lookout for personal reactions which mitigate against the patient's welfare: anxiety, annoyance, withdrawal, or feelings of hopelessness.

Hypnotic approaches to treatment will necessarily be geared to these goals. Very often, hypnotic alleviation of pain and regulation of physiological functions (digestion, insomnia) will bring about marked psychological recovery. The following hypnotic techniques may be used in the context of total patient care.

Inducing relaxation and teaching self-hypnosis The patient's experiences of a state of mind (hypnosis) containing profound feelings of relaxation, peacefulness, tranquillity, and freedom from worry in the context of a positively altered state of consciousness can be very uplifting and inspirational. Practicing self-hypnosis to recapture these feelings of relaxation further adds to a sense of inner mastery.

Ego strengthening Feelings of guilt and self-blame, hopelessness, loss of self-esteem, alienation and aloneness, dejection and hurt, and helplessness, which are so commonly experienced by cancer patients, can be directly countered by suggestions reaffirming the integrity of the self-image.

Strengthening repression A 28-year-old man with malignant melanoma complained that the oppressive thoughts of the reality of his cancer were constantly with him. "Doctor, there isn't ten minutes that I'm not thinking about it. I can't enjoy myself, I can't live." Hypnosis was used to expand these "free" periods from ten minutes to hours, and to help him suppress and repress the constant insidious thoughts of finality. He was then much more able to enjoy each day for itself.

Imagery Imagery may be used to strengthen adaptation mechanisms, induce positive feeling states, brighten self-esteem, speed adjustments to stresses, foster acceptance of the illness, focus on realistic goals, decrease anticipatory anxieties, ease hurt, anger, and alienation, and to bolster feelings of self-control and hope. Visualizations of many different types are woven in with appropriate suggestions. Effective images are often created by the patient and the hypnotherapist, working as a dyad. The patient will usually communicate, verbally or nonverbally, his preferences for certain kinds of imagery. Through rapport and intuitive understanding as well as the exploration of different themes, imagery becomes fitted to the patient. Scenes of seashores, mountains, underwater places, or fantasized lands may be as absorbing as the personal memories of peak experiences. Through the medium of hypnotic imagery, the patient can learn to transcend many of the negative cognitions he may have built about his condition.

Recently, there has been an interest in imagery not only to guide cancer patients to better frames of mind, but to influence the disease process itself. It is postulated that imagery, through connections with neurohumoral mechanisms, has indirect influences on the immune system. Strengthening the immune system, in this holistic approach to the mind/body problem, could slow down the progress of cancer. Anecdotal case reports tend to support the beneficial influence of imagery. Longitudinal studies, however, have yet to be carefully designed.

The following case history provides an example of this kind of imagery usage in cancer. Although results cannot, of course, be held conclusive, the technique serves to illustrate an important therapeutic function: it can give the patient the sense of playing an active role in the treatment of his cancer and can be instrumental in developing a feeling of being in charge of the situation.

A 30-year-old woman studying the performing arts noted a small nodule in her left armpit. She preferred not to think much of it. Three months later she woke up in the middle of the night with pain in her axilla radiating to her breast. She received surgery as well as radiation and chemotherapy for carcinoma of the breast. She coped well with some nausea and hair loss and was stabilized. Although there was no evidence of metastasis, she became increasingly worried about this possibility. She came for consultation for the specific reason of learning imagery techniques and with strong motivations to do everything in her power to vanquish her cancer. She had attempted visualization exercises with the help of a therapist, which consisted of imagining white globules, symbolic of her healthy defenses, fighting off black particies, symbolic of cancer cells. She had the conviction, however, that with the help of hypnosis, she could create more effective imagery. This in fact happened. Her eidetic potential was stronger, more "real" in the context of trance.

In medium to deep hypnosis, she repeated the exercise but came to realize that it did not feel right for her -- she did not like the idea of fighting, even though it was only globules. Because of this philosophical penchant, it was suggested that she create an image of a glow, a light, or sunlike aura, to see and feel it enveloping her, growing in intensity with each breath until she could actually feel warmth throughout her body. The symbolism was clear but it was nevertheless discussed to make it more meaningful: light, she said, for her symbolized life, and had the property to outshine everything, including cancer. She felt comfortable with this imagery and has continued to use it daily in self-hypnotic practice. It gives her a feeling of self-control and inner peace because she is actively participating in her own health care.

The adjunctive hypnotic treatment of cancer may be directed to any level in the spectrum of its manifestations. Physical symptoms of cancer, the most common of which is pain, and the physical effects of its treatment (weakness, nausea, and vomiting) may be modified to render daily living more palatable. Hypnosis may also be woven into psychotherapy to assist in the uniquely personal adjustments each patient has to make to his illness.

Gérard Sunnen, M.D., received his medical degree from the State University of New York, Downstate Medical Center, and following an internship in surgery and medicine, he was appointed resident and chief resident at Bellevue Psychiatric Hospital, New York City. He practiced medicine and psychiatry in the Air Force, in forensic, acute care, and general hospital settings, and is currently in private practice and a consultant to several corporations and agencies.

Dr. Sunnen has for many years applied medical hypnosis to several dimensions of patient care. It was during his internship that he began to enlist hypnotic assistance to recuperation from illness, to toning of mind and body before operations, to anaesthesia, and to the soothing of discomfort and tension so commonly found in hospital situations. During his residency he applied the power of hypnotic mind states to the goals of psychotherapy, namely self discovery and personal transformation.

Both in the United States and his native France, Dr. Sunnen has lectured extensively on the theoretical and practical aspects of hypnotic aeatment, as well as on related topics including novel methods of psychotherapy, the promise of special states of consciousness, the nature of creative self-expression, and future directions in psychiatry As president for two terms of the International Association for Emergency Psychiatry, he has explored the application of medical hypnotherapy to traumatic stress reactions.

In his book "A Primer of Clinical Hypnosis," he explores a realm of special interest to him, namely the relationship between medical hypnosis and meditative states. For these insights, he expresses everlasting gratitude to his late parents who were both students of Paramahansa Yogananda.