Butler, L.D., Koopman, C., Neri, E., Giese-Davis, J., Palesh, O., Thorne-Yocam, K.A., . . . Spiegel, D. (2009). Effects of supportive-expressive group therapy on pain in women with metastatic breast cancer. Health Psychology, 28, 579–587.

To examine the effect of supportive-expressive group therapy using hypnosis in patients with metastatic breast cancer experiencing pain and to explore the interaction between hypnotizability and pain experience in women trained to use hypnosis

Baseline pain, distress, coping, social support, physical activity, and immune and endocrine function were evaluated, and patients were randomized by the project director and a research nurse using an adaptive randomization biased coin-design method. Treatments were conducted at each of the three sites weekly for 90-minute sessions. Group size varied from 3–15 participants because of rolling recruitment and participants dying. Each supportive-expressive therapy session was co-led by two psychotherapists; among these were a psychiatrist, psychologists, and social workers. Themes emerging in these sessions were fears of dying and death, including dealing with the deaths of group members, reordering life priorities, improving support from and communication with family and friends, integrating a changed self and body image, and improving communication with physicians. A hypnosis exercise ended each session, and participants were instructed to practice this several times a day and any time the pain was noticeable or increased. The control group members were offered self-directed education and a year membership to a consumer health library in their community. Post-baseline assessments were every four months for the first year and then every six months after.

• N = 124   
• AGE: Education only group (control arm): mean = 53.1 years (SD = 10.8 years), range = 30–80 years; group therapy plus education group (intervention arm): mean = 52.7 years (SD = 2.7 years), range = 33–73 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Metastatic breast cancer, recurrent breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Participants had to be proficient in English, able to participate in a support group, living in the greater San Francisco Bay Area, and have a Karnofsky score of 70 or greater. They had to be able to care for themselves but unable to do active work or carry on normal activity. 
• EXCLUSION CRITERIA: Participants were excluded if they had positive supraclavicular lymph node as the only metastatic lesion at the time of initial diagnosis, active cancers within the past 10 years other than breast cancer, basal cell or squamous cell of the skin, in situ cancer of the cervix, melanoma with a Breslow depth below 0.76, or concurrent medical conditions likely to influence short-term survival.

• SITE: Mutli-site   
• SETTING TYPE: Outpatient setting   
• LOCATION: Stanford, San Francisco, and San Jose, CA. Patients were encouraged to use hypnosis training at home.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Late effects and survivorship, end-of-life and palliative care
   

• Randomized clinical trial

• Pain Rating Scale     
• Hypnotic Induction Profile
• Group feedback questionnaire

Analysis of covariance on change in intensity of current pain showed statistical significance (P = .001) in those in the treatment group versus the education only group. Those who received therapy and education showed a smaller increase in the intensity of current pain than the control (education alone) (P = .034). Those who had a greater intensity of current pain and suffering at baseline experience a great decrease in intensity (P = .001), whereas those for whom baseline pain was less experienced increases in intensity. No statistically significant relationships associated with hypnotizability were found across recruitment sites, and hypnotizability did not show an interaction with treatment. The treatment effect was not significant with the baseline level of pain but still predicted a greater decrease in pain (p = .008). Those who reported the most pain at baseline showed a decrease in frequency of pain, whereas those who reported least frequent pain at baseline showed an increase in frequency (p = .001). Constant pain at baseline showed the greatest reduction in constant pain, whereas those who did not report constant pain showed an increase in constant pain (p = .001). Treatment did not have an effect on constant pain. Highly hypnotizable women reported greater use of hypnosis exercises for controlling nausea and vomiting, for management of stress and anxiety, and for comfort versus low hypnotizable women.

Hypnosis and group sessions can be successful in reducing pain and suffering—more specifically for those with high hypnotizability—and potentially could be used to help control other symptoms in metastatic breast cancer or even other cancers. Patients without constant pain or with low current pain seemed to show an increase in constant pain and frequency. Low hypnotizability was also a less desirable trait in controlling symptoms; however, these individuals were found to have used hypnosis less frequently and may not have experienced maximum benefit. This method could be utilized as an adjunctive to treat symptoms other than pain; however, this study addressed pain only.

• Blinding was not possible because this was a psychotherapy trial.
• This study is limited to white, middle-to-upper class women with metastatic breast cancer.
• The benefits of hypnosis exercise cannot be determined from this study.
• This study relied on self-reported single measures of pain, potentially limiting the accuracy of pain assessments.
• This study also may be underpowered to determine relationships to treatment conditions.
• Unable to identify effects for participants throughout the intervention because of incomplete assessments, particularly related to illness and death 
• No attentional control was provided.

Nurses may want to become educated in hypnosis as an adjunctive therapy to educate patients to utilize this method in controlling pain. Additionally, nurses may want to refer those particularly having a difficult time with symptom management to a supportive-expressive therapy group rather than providing only educational material to patients with metastatic breast cancer. Nurses also must keep in mind that group intervention and hypnosis may not be successful or appealing to all patients and certain characteristics and hypnotizability impact the success of treatment.