Description
Hypnotherapy is a procedure with which behaviour, cognition and affective patterns are influenced by means of hypnosis and the shift in consciousness it induces. This makes it possible to restructure distressing events and perceptions while supporting the biological changes needed for healing processes.
Hypnosis has been suggested to be a useful adjunct for pain reduction in cancer patients. Hypnosedation is sometimes chosen by patients as an alternative to sedation/anaesthesia during cancer surgery. In addition, it is used for anxiety, insomnia, pain management and stress-related illnesses.
Efficacy
Hypnosedation during surgery: All evidence for hypnosedation is from nonrandomised studies in order to accommodate patient preference. Hypnosedation during surgery for breast cancer (n=2) may improve surgical outcomes and side effects of adjuvant treatments compared to general anaesthesia, and evidence suggests similar outcomes compared to conventional sedation for glioma (n=2).
Nausea and vomiting: Hypnosis does not appear to reduce nausea and vomiting in people with breast cancer (n=1 high-quality SR). It may improve nausea and vomiting in children with cancer (n=1 low-quality SR), but the evidence is outdated and subject to serious limitations. Evidence for other types of cancer/population is inconclusive and at high risk of bias.
Pain: There is some evidence from two SRs that hypnosis reduces cancer pain, but neither conducted a meta-analysis. A well-conducted SR found moderate evidence that hypnosis before general anaesthesia reduced postoperative pain in minor breast cancer surgery, confirmed by a subsequent RCT. Findings in other cancers are mixed and inconclusive.
Anxiety: Well-conducted SRs show that hypnosis significantly reduces anxiety compared to any control both for general anxiety in any cancer with immediate and sustained effects, and preoperative anxiety in breast cancer (3 SRs plus 3 RCTs, 2 CCTs).
Depression: There is limited and conflicting evidence from 2 RCTs and 2 CCTs for hypnosis improving depression in cancer patients.
Other mental health: There is no reliable evidence for other mental health outcomes.
Conventional treatment-related outcomes: There is some evidence that hypnosis does not reduce time spent in surgical procedures for breast cancer minor surgery (one SR), but no reliable evidence for other outcomes.
Heart rate: There is very limited good quality evidence that hypnosis increases heart rate variability (one RCT) but no evidence for an effect on heart rate.
Vasomotor symptoms, fatigue and sleep: There is no reliable evidence for vasomotor symptoms, sleep or fatigue outcomes.
Safety
Hypnotherapy is considered a safe treatment modality when administered by trained professionals. Acute psychoses, severe personality disorders and an inability to be hypnotized are considered contraindications.
Citation
Ava Lorenc, CAM Cancer Collaboration. Hypnotherapy , 21 Nov 2024.
Document history
Updated in July 2024 by Ava Lorenc. Revised in January 2016 by Markus Horneber. Updated in September 2014 and August 2012 by Katja Boehm. Summary first published in September 2009 authored by Katja Boehm.
Description
Hypnotherapy is a psychotherapeutic intervention using hypnosis, self-hypnosis or hypnosis therapy. Patients attempt to enter into a trance-like state in order to cope better with complaints such as anxiety and stress by actively diverting their attention towards relaxing thoughts (Stalpers 2005). When using hypnosis, subjects are guided by the hypnotist to respond to suggestions (Kihlstrom 1985). Hypnosis often takes the form of relaxation and imagery, incorporating suggestions which will increase comfort or transform physical sensations such as pain, cold or numbness (Syrjala 1992). The hypnotized person is often relaxed, but at the same time mentally alert.
Background
The term ‘hypnosis’ is derived from the Greek word ‘hypnos’, meaning ‘sleep’. The history of hypnotherapy indicates that spiritual leaders, priests, healers and philosophers were the practitioners of early forms of hypnosis.
Scottish surgeon James Braid (1795-1860) noticed that many of his patients experienced a trance-like state when they focused on one single spot for a longer period. He introduced the words ‘hypnosis’ and ‘hypnotism’ to the medical community. Some regard Austrian physician Franz Anton Mesmer (1734-1815) as the father of hypnotherapy. American psychiatrist Milton H. Erickson (1901-1980) is considered the founder of clinical hypnotherapy.
Clinical practice guidelines recommend hypnotherapy for needle procedures in children with cancer (Loeffen 2020). Healthcare practitioners appear generally positive towards hypnotherapy (Szmaglinska 2023)
Alleged indications
There is a wide variety of potential applications for hypnotherapy in a medical context, including pain management, psychosomatic conditions (e.g. irritable bowel syndrome, blood pressure), prenatal courses, physical rehabilitation (e.g. strokes), and use during medical examinations or treatments (Taylor 2003).
Hypnotherapy has been used in cancer care, together with other relaxation therapies, to ameliorate adverse effects resulting from cancer treatment or to help patients adjust to their disease. In some cases, hypnosis is also used to complement pain treatment (Elkins 2004).
Hypnosis attempts to change the negative state of mind cancer patients might experience and to give them a realistic but positive outlook. Patients value the emotional support from hypnosis (Szmaglinska 2023). By providing them with a tool to feel control over their emotional symptoms, patients may be better equipped to cope with the psychological and physical consequences of the disease.
Mechanisms of action
Current theories about hypnotherapy’s mechanisms of action are based upon newer concepts about learning and memory as well as on research about how stimuli are perceived and processed.
Hypnotherapy is intended to activate specific patterns which are critical to processes of learning and memory; it takes place in a way that facilitates people’s ability to modify their experiences and behaviours. Hypnotherapy circumvents the process of consciously addressing certain topics and content while concurrently stimulating implicit learning processes and making it easier to ignore disruptive stimuli (Halsband 2009). It is thought that cognitive, executive control, and sensorimotor processing are part of the control mechanisms of hypnosis (for respiration) (Liu 2018).
Application and dosage
Classic hypnotherapy attempts to induce a state of reduced concentration to make the patient more receptive to suggestion. Occasionally, techniques for muscle relaxation are used to reinforce the effect of the hypnotherapy (Jacobsen 1938). In addition, passive guided imagery may also be used to assist the hypnotized patient in envisioning pleasant auditory, visual and/ or kinaesthetic situations (Lankton 1983; Stalpers 2005).
Normally, there are three main stages of the depth of trance: light, medium and deep trance. Light trance is all that is needed for medical purposes. Nearly 90% of the population can enter such a trance-like state (Hartland 1998).
As a fundamental rule, people can only successfully be hypnotized if they wish to and cooperate. A willingness to cooperate and a desire to cope with complaints more effectively are prerequisites for efficacious hypnotherapy (Peynovska 2005).
Legal issues
In Europe, hypnotherapist is not listed as a regulated profession in the EU Commission’s database of Regulated Professions (with the exception of Latvia).
Hypnotherapy is subject to voluntary registration in several countries. Most hypnotherapists are licensed medical doctors, registered nurses, social workers or family counsellors who have received additional training in hypnotherapy. The practice of hypnotherapy, however, entails virtually no standards or requirements for minimum training, practical experience, or demonstrated competence.
Eight systematic reviews (SRs) on hypnotherapy and cancer have been published (Cramer 2015; Chen 2017; Franch 2023; Montgomery 2017; Richardson 2007; Sine 2022; Stefanopoulou 2017; Zeng 2022). However, two are not included here; one on end-of-life did not find any studies (Montgomery 2017) and another did not synthesise results (Cramer 2015), so they are not reported below. See Table 1 for details of the six included reviews.
A total of 17 controlled clinical trials (CCTs) reported in 20 articles have been published since or were not included in any of the systematic reviews: eight non-randomised studies reported in ten papers (Bankole 2023; Berliere 2018; Berlière 2021; Chapet 2018; Elyasi 2021; Hamdani 2020; Lacroix 2019; Pesce 2020; Téllez 2017; Téllez 2020) and nine RCTs reported in ten articles (Azam 2024; Barton 2019; Eaton 2022; Hawkins 1998; Hoslin 2019; Lemoine 2022; Moreno 2021; Rosenbloom 2024; Hockenberry-Eaton 1989; Oddby-Muhrbeck 1995). Five studies (six papers) reported on hypnosedation compared to anaesthesia during surgery, five studies (six papers) reported on hypnosis for cancer patients undergoing surgery, two reported on cancer survivors, two (three papers) on breast cancer, and two on children with various cancer types. See Table 2.
Hypnosedation during surgery
Five non-randomised studies (reported in six papers) reported on hypnosedation compared to anaesthesia during surgery (Bankole 2023; Berlière 2018; 2021; Chapet 2018; Lacroix 2019; Pesce 2020). All trials were non-randomised due to necessity, to account for patient preference. However, this means cause and effect cannot be determined.
Two of the studies were with breast cancer patients (Berlière 2018; 2021; Lacroix 2019), two with patients with glioma (Bankole 2023; Pesce 2020), and one with prostate cancer (Chapet 2018).
Berliere (2018) conducted an observational study of 300 breast cancer patients undergoing surgery (lumpectomy, mastectomy, dissection or biopsy) and found that the group who chose hypnosedation had improved surgical outcomes compared to those who chose general anaesthesia (shorter hospitalisation, fewer lymph punctures, less lymph removal). They also found some improvement in side effects from post-surgery treatment, including less frequent radiodermatitis and asthenia from radiotherapy, lower incidence of hot flashes, pain and asthenia for endocrine therapy and lower incidence of asthenia in chemotherapy. There was no difference in nausea and vomiting (N&V) for chemotherapy.
The subanalysis of those who received neoadjuvant chemotherapy reported in another paper (Berliere 2021) found improvements in polyneuropathy, musculoskeletal pain, postoperative pain and cancer-related fatigue in the hypnosedation group. However, as acknowledged by the authors, baseline differences in psychological measures may explain the group differences.
The other breast cancer study included patients undergoing mastectomy (n=42) and found lower incidence of postoperative chronic pain in the hypnosis group (Lacroix 2019). No hypnosedation patients requested a conversion to general anaesthesia. As well as being non-randomised, the study had a small sample.
The two (non-randomised) studies of patients with glioma found no significant difference between hypnosedation or standard sedation/spinal anaesthesia. Bankole (2023) included cancer patients undergoing awake surgery for glioma (n=61), hypothesising that hypnosis could modify the intra-operative patient performance - they found no difference in tumour volume or overall survival, but they did have a small sample and no information on dropouts. Pesce (2020) included patients with high grade gliomas undergoing awake surgery (n=15) and found surgery was significantly longer in the hypnosedation group, but they had a very small sample and no data on dropouts.
Chapet (2018) studied patients with prostate cancer undergoing brachytherapy (n=79) comparing hypnosedation with general and spinal anaesthesia. They found significantly less medication usage and shorter time in recovery for hypnosedation, but longer duration of surgery. However, full text of this paper was unavailable, so quality cannot be assessed.
Nausea and vomiting
Three systematic reviews included N&V outcomes. One SR in patients with any cancer type undergoing chemotherapy/radiotherapy or cancer survivors with ongoing symptoms included 22 RCTs (Franch 2023). One thereof measured nausea and reported lower levels of nausea, but reporting in the review is very limited.
Another systematic review included studies of breast cancer patients undergoing minor surgery (Zeng 2022). Of the eight included RCTs, four measured N&V. Meta-analysis showed hypnosis before general anaesthesia did not change postoperative N&V compared to any control. This is a well-conducted and reliable review.
Richardson (2007) included six RCTs, five of which were with children. Meta-analysis showed that hypnosis significantly improved anticipatory and chemotherapy-induced N&V in children compared to no treatment, and had a similar effect to cognitive behavioural therapy. However, this review is outdated, and the quality of the included studies does not appear to have been considered.
In addition, one RCT and one non-randomised trial reported on N&V in adults with cancer. The RCT included breast cancer patients (n=70) and found no difference in occurrence of N&V over 24 hours between self-hypnosis or placebo (background music) (Oddby-Muhrbeck 1995). However, only an abstract is available so the quality of this study is unknown. The non-randomised trial studied patients with head and neck cancer undergoing chemotherapy (n=64) and found significantly lower anticipatory nausea in the hypnosis group compared to control (Hamdani 2020). However, group allocation method is unclear, creating a major risk of bias.
Pain
Cancer pain: The review by Franch (2023) found that in ten of the twelve studies measuring pain hypnosis significantly reduced pain in patients with any type of cancer. Sine (2022) included 11 studies (10 RCTs, 1 controlled clinical trial, CCT) on any cancer. The review concluded that six studies out of the nine measuring pain reported significant reduction in pain. However, neither review conducted a meta-analysis, so conclusions are limited.
One RCT conducted since the systematic reviews studied 109 adult cancer survivors with chronic pain and found that hypnosis (recordings) improved pain and pain interference similarly to relaxation recording (Eaton 2022), but there was no non-treatment control, and a few patients left the study due to lack of effect.
Perioperative pain: A number of papers have explored hypnosis for post/peri operative pain. An SR of eight RCTs evaluated hypnosis for a range of peri/post operative outcomes in people with breast cancer, including postoperative pain (Zeng 2022). Their meta-analysis found that hypnosis before general anaesthesia reduced postoperative pain and the certainty of evidence is moderate. The review is well-conducted.
Six additional RCTs evaluated the effect of hypnosis on pain perioperatively. One RCT on any cancer surgery (n=92) was reported in two papers (Azam 2024; Rosenbloom 2024). They reported no effect of hypnosis (in person plus recordings) compared to control for pain, but a positive opioid sparing effect, and protection against increases in pain catastrophising two weeks after surgery (Azam 2024; Rosenbloom 2024). This RCT had no major risk of bias but there was a high attrition rate and higher dropout in the control than hypnosis group.
Two RCTs included people with breast cancer, one for mastectomy (Moreno 2021, n=40) and one preoperative wire placement (Lemoine 2022, n=167). Moreno (2021) compared hypnosis (recordings) to control, and found significant reduction in pain intensity, interference in daily activities due to pain, mood, social relationships, sleep and life enjoyment, but not interference in walking or work activities. However, their study was very poorly reported, had no sample size calculation and was not registered. Lemoine (2022) found no change in pain for hypnosis (conversational) compared to control and was well conducted with a powered sample size, but the trial was stopped early due to lack of improvement, which the authors feel is due to a change in communication between clinicians and patients in both groups.
Hawkins (1998) studied children with leukaemia and non-Hodgkin's lymphoma who were undergoing regular lumbar punctures (n=30) and found no difference between direct and indirect hypnosis for pain, but the study was small and had no non-treatment control.
Hoslin (2019) found no effect on perioperative pain for cancer patients scheduled for a subcutaneous central venous access port implantation (n=148) but the sample size does not appear to be powered and there is little detail on randomisation.
Anxiety
General anxiety: Three systematic reviews, three RCTs and two non-randomised studies included anxiety as an outcome.
One of the three systematic reviews was well-conducted, included 20 studies (13 RCTs, 7 single group pre-post) and conducted a meta-analysis, finding a significant reduction in anxiety for hypnosis compared to any control, both immediate and sustained (Chen 2017). The two other reviews (neither with a meta-analysis) reported that the majority of studies measuring anxiety reported significant differences (Franch 2023; Sine 2022)
The RCT for any cancer surgery patients (n=92) found no change in anxiety in the hypnosis group compared to control (Rosenbloom 2024). The RCT for cancer survivors with chronic pain (n=109) found similar reduction in anxiety for hypnosis compared to relaxation recordings (Eaton 2022).
Hawkins’ (1998) study on children with leukaemia and non-Hodgkin's lymphoma undergoing regular lumbar punctures (n=30) found no difference between direct and indirect hypnosis for pain-related anxiety.
Two non-randomised studies in breast cancer patients undergoing chemotherapy found reduced anxiety in hypnosis groups compared to control (Elyasi 2021; Tellez 2017). Elyasi (2021)(n=50) compared hypnosis (face to face) with cognitive behavioural therapy and no-treatment control. They claim randomisation was impossible due to patient preference; sample size was calculated but small. Confusingly, they seem to conflate ‘stress’ and ‘anxiety’ in their report. Téllez (2017) included breast cancer patients undergoing chemotherapy (n=40) and compared 24 sessions of group hypnosis with no treatment control. They found reduced anxiety after 1 month. This study gives no explanation for not being randomised.
Preoperative anxiety: The systematic review mentioned above (nausea and vomiting) also found that hypnosis before general anaesthesia reduced preoperative anxiety for breast cancer minor surgery compared to any control (Zeng 2022).
Three RCTs found no effect of hypnosis compared to control for either breast cancer patients scheduled to undergo preoperative wire placement (Lemoine 2022, n=167), any cancer patient undergoing surgery (Rosenbloom 2024) or cancer patients scheduled for a subcutaneous central venous access port implantation (Hoslin 2019, n=148).
Depression
Two RCTs measured depression/depressed mood. Eaton (2022) studied adult cancer survivors with chronic pain (n = 109) and Rosenbloom (2024) studied any cancer surgery (n=92), neither found a significant difference in depression scores between groups compared with relaxation recordings or no treatment control.
The same two non-randomised studies described above under anxiety also measured depression in breast cancer. One found reduced depression in hypnosis groups compared to control (Elyasi 2021) but the other found no difference for group hypnotherapy (Tellez 2017).
Other mental health
One SR found that the two RCTs that measured quality of life reported improvements with hypnosis and one reported lower confusion and improved wellbeing (Franch 2023). Elyasi (2021) found no difference in quality of life between hypnosis and control.
The RCT described above reported by Azam (2024, n=92) also measured subjective relaxation and found no difference between groups.
Two additional RCTs measured other mental health outcomes. Barton (2019) studied patients who have/have had breast or gynaecological cancer with a negative change in body image since diagnosis and a desire to improve (n=87), comparing hypnosis with progressive muscle relaxation (both face to face and home practice). They found body image improved in both groups with no difference between groups, and no difference in perception of sexual self, mood, sexual satisfaction or perceived change. However, this study was underpowered and had high dropout rates and no non-treatment group.
Hockenberry-Eaton (1989) studied children with various cancer types undergoing chemotherapy (n=22) and compared taught self-hypnosis with control. They found an increase in perceived self-competence scores in hypnosis group as opposed to a decrease in control group, however only the abstract is available, no p values are provided, and the sample is very small.
Three non-randomised studies included other mental health outcomes. The study described above comparing hypnosedation (in person during surgery) to general anaesthesia found no difference in distress (Lacroix 2019). Tellez (2017) found significant improvement compared to control in self-esteem and optimism at 1 month but no change in social support or stress.
Conventional treatment-related outcomes
Two SRs included outcomes related to conventional treatment. Franch (2023) and Zeng (2022) found no difference in time spent in surgical procedures for hypnosis, with Zeng performing a meta-analysis. Franch (2023) found one study reporting shorter recovery and hospitalization time (of three studies measuring it) and one reporting less medication use (of two studies measuring it) but the reporting of this review is very limited and there is no synthesis of results.
The RCT of cancer patients scheduled for a venous access port implantation (n=148) described above under preoperative anxiety found a significantly higher global index for perioperative experience (including comfort, pain, attention, information, waiting) (Hoslin 2019). The RCT of breast cancer wire insertion which closed early found no change in technician satisfaction with relationship or radiologist perceived ease of insertion of marker, but the trial was stopped early due to lack of improvement, which the authors feel is due to a change in communication between clinicians and patients in both groups (Lemoine 2022, n=167).
Heart rate
Two RCTs included heart rate outcomes. Azam (2024) found heart rate variability was significantly higher in the hypnosis group compared to control for cancer patients undergoing surgery (so prevents the deleterious effects of surgery), but no difference in respiration rate or heart rate. Hoslin (2019, n=148) also found no difference in heart rate.
Vasomotor symptoms
One systematic review explored vasomotor symptoms for breast cancer survivors or post/peri-menopausal women (Stefanopoulou 2017). They only found two RCTs, one of which found fewer hot flushes and night sweats in the hypnosis group compared to control, and the other fewer hot flushes. However, no synthesis was performed and there is little detail of the searching strategy, leaving this review open to bias. In addition, the quality of studies for hypnosis was not reported separately. Another SR found two studies that evaluated hot flashes (Franch 2023) and found that both reported improvements with hypnosis.
Fatigue and sleep
One systematic review included fatigue or sleep outcomes and reports that all seven studies that measured fatigue reported lower levels of fatigue in the hypnosis groups and one of two studies assessing sleep found improved insomnia (no synthesis) (Franch 2023).
Eaton found no difference for fatigue and sleep disturbance in adult cancer survivors with chronic pain for hypnosis compared to relaxation (Eaton 2022), and Rosenbloom (2024) found no difference in sleep for patients undergoing surgery.
Hypnosis that is conducted under the care of a trained therapist or health care professional is generally considered safe.
Adverse events
In clinical trials no serious adverse effects attributable to hypnosis have been reported. Other adverse effects are very uncommon (Bollinger 2018); most common adverse effects include anxiety, dizziness, drowsiness, headache, insomnia, and nausea (NatMed 2023). An analysis of systematic reviews found no signs of a higher rate of adverse effects in hypnotherapy groups than control groups (Hauser 2016).
Contraindications
Acute psychoses, severe personality disorders and an inability to be hypnotized are considered contraindications.
Interactions
None known.
Warnings
Special precautions must be taken with people who have experienced trauma or abuse to ensure that they retain control over the depth of their trance and the issues being processed.
Table 1: Systematic reviews of hypnotherapy for cancer
Table 2: Controlled clinical trials of hypnotherapy for cancer
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