Dr Robert London

Psychiatry and Medicine Working Together

Clinical Psychiatry News - Volume 33, Issue 6, Page 67 (June 2005)

A recent column I read in CLINICAL PSYCHIATRY NEWS (“Bouncing Back From Serious Illness,” April 2005, p. 98) took me back to therapy groups I ran for cancer patients in the 1970s with Dr. Edward Amorosi, a hematologist/oncologist at New York University Medical Center.

I remembered many of the issues members of those cancer groups had to face while they were receiving chemotherapy or had recently finished a course of it (“Concept Worth Another Try,” May 2003, p. 13). Sometimes, the patient's dignity was shattered. At other times, the patient felt hopeless and experienced decreased self-esteem, in addition to anger and a sense of despair.

The groups worked well. Dr. Amorosi participated in some sessions by adding an educational piece about cancer, and did so in a way that made patients feel comfortable: He didn't wear a white coat, and he loosened his tie.

We addressed some of the intellectual constructs surrounding the illness and explored ways in which patients could “bounce back.” The techniques used were wide ranging; no particular format of group therapy dominated.

Those groups ran almost weekly for about 5 years, not including holidays and summer breaks. As time passed, the patients' need to address specific problems of pain control emerged more and more, as did phobic responses that led to their avoiding, or wanting to avoid, chemotherapy. Learning to control nausea and vomiting during chemotherapy emerged as a major concern.

Over time, global questions—such as, Why did this happen to me?—lessened, as did some emotional expression. Among those patients who attended over a period of time, the group's focus shifted to discussions about specific ways to cope with some of the symptoms noted earlier.

In those early days of my career, I was in the process of developing my learning, philosophizing, and action (LPA) treatment of specific habits, anxieties, problems of pain control, and phobic responses through my work at NYU Medical Center/Bellevue Hospital, where I was directing the short-term psychotherapy program. We were using behavior modification and cognitive approaches, as well as hypnotic strategies, to address a myriad of psychiatric and medical problems.

At the time, I used several techniques with imagery to treat headaches. Migraine sufferers often report nausea as part of the symptom complex of their vascular headaches. So when chemotherapy patients in the group were concerned about nausea and vomiting, it was natural to offer a strategy similar to one I had used for the treatment of nausea related to migraine and vascular headache.

Using the Hypnotic Induction Profile as developed by Herbert Spiegel, M.D. (in “Trance and Treatment: Clinical Uses of Hypnosis” [New York: Basic Books, 1978] by Herbert Spiegel, M.D., and David Spiegel, M.D.), I measured the hypnotizability of the patient before I embarked on a strategy to help control nausea without—or with less—medication. Those who were in the mid to high range of hypnotizability were good candidates for the same strategy I had used in vascular headache sufferers. I did not offer this procedure to minimally hypnotizable patients who did not think they would benefit from this approach. Instead, I found other avenues of referral, such as biofeedback, for those patients.

The technique was straightforward. After teaching a patient how to induce relaxation using the hypnotic induction described earlier, the conceptual image of “cold” was used to cool, chill, and even freeze the air that the patient breathed.

The learning and philosophizing phases of this technique were explored in the group setting, but we entered into the action phase of LPA straightaway: The patient would sit comfortably in a chair, using a simple, rapid technique of relaxation/hypnosis.

When this state was achieved after 2–3 minutes, the patient was taught to imagine wearing an ice-cold helmet, or opening a freezer door and being hit with a blast of ice-cold air.

Then—to continue the imagery—I told the patient to breathe in that cold, cold air, thereby cooling and chilling the food pipe (esophagus) as the cold emanated from the imaginary helmet or freezer. The cooling and chilling would lead to a sense of numbness not only of the esophagus but also of the stomach.

These chilling and numbing sensations could then have the effect of controlling or stopping the nausea. I used a full hour to teach this method, allowing patients, of course, to make any modification that would improve the strategy. I always encouraged patients to practice this technique for a few minutes at least 10 times per day to ensure that they would know what to do if they became nauseated after chemotherapy.

For some patients, this hypnotic imagery method worked very well to help control nausea and the subsequent vomiting. Controlling vomiting once it had already begun was beyond the scope of our approach. Instead, our aim was for the patient to avoid vomiting in the first place or slow it down after it started, or even to reduce the patient's need for antiemetic medications. For some of the patients and for me, the results were pleasing.

As psychiatrists, we can offer these alternative mental processing techniques to help relieve some of the pain and suffering these cancer patients experience.

In future columns, I will discuss treatment strategies for pain and the phobic responses of this patient population. Let me know about your experiences treating the problems of cancer patients on chemotherapy, and I'll try to pass those ideas along to my readers.

PII: S0270-6644(05)70469-0


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