Hypnosis with children and pain management

Kids Allowed

BY MARC SILVER

Integrative medicine isn't just for adult cancer patients.

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The 13-year-old girl has acute lymphoblastic leukemia. Her prognosis is good, with a 75 percent chance of cure. But side effects from chemotherapy have sunk her spirits. “She felt miserable,” says her doctor, Susan Sencer, MD, a pediatric oncologist.

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The child’s chemo is delivered into the spinal fluid via spinal tap to prevent the cancer cells from entering her spinal cord area and brain. But how do you protect the patient from the fear and pain the procedure can trigger? Anesthesia is one option. So is … hypnosis?

As medical director of hematology/oncology at the Children’s Hospitals and Clinics of Minnesota in Minneapolis, Sencer combines standard treatments with practices that a decade ago might have seemed offbeat, from hypnotherapy to energy healing. Such therapies are entering more hospitals and often have a growing amount of solid science behind them, though not every doctor is on board.

The question of what to call such therapies is up for debate. The adjectives “alternative” and “complementary” have been used. But “alternative”—meaning “instead of”—is problematic since no doctor would recommend an unproven treatment over a proven one. The word “complementary” also is used, but Sencer and many other doctors prefer the term “integrative medicine,” reflecting the idea that exercise, nutrition counseling, and stress reduction are vital parts of the anticancer package.

Whatever the label, skeptics want to know: Do these tactics really work? Let’s look at the case of the bummed-out 13-year-old.

Nitrous oxide, inhaled from a fruit-flavored mask, reduces the child’s agony index. Research shows the chemical compound known as “laughing gas” can diminish pain during chemotherapy and bring a bit of eupho ria.

The other tool is a hybrid of hypnosis and guided imagery. This is not sitcom hypnosis, where an unsuspecting subject ends up squawking like a chicken. Rather, Sencer aims to lessen distress by distracting the patient.

“Every person who hypnotizes has their own technique,” the doctor explains. Sencer puts her finger atop the girl’s head, tells her to look up, and speaks in a soft, reassuring voice: “I can see you relaxing. Your body is getting lighter.” Then she leads the child to an imaginary destination—that’s guided imagery.

“Generally, you take advantage of something the child gives you,” says Sencer, who knows the girl’s family has a cabin and boat on the Mississippi River. Sencer sends her floating out the window to the beloved getaway.

At one point during the 10-minute procedure, the patient shifts. Since sticking a needle into the spinal canal is tricky, Sencer prefers a motionless subject.

“Why did you move?” she asks.

“I’m fishing from my sailboat,” the child says.

When the chemo infusion is complete, Sencer shuts off the nitrous oxide and asks the patient to take three deep breaths. “Come back to me,” she says. “Open your eyes.”

“I was surprised you could fish on a sailboat,” Sencer remarks. The child replies, “It was the best boat in the world. I sailed into the hands of God, and God held me while you did this.”

Sencer is convinced the buzz of nitrous oxide and the joy of the pretend journey reduced the child’s pain. She sees long-term benefits as well: “I’m trying to teach the kids self-regulatory behaviors that will be helpful not just through their cancer journey but, hopefully, for the rest of their lives.”

Studies back up Sencer’s approach. Lonnie Zeltzer, MD, director of the pediatric pain program at Mattel Children’s Hospital UCLA, looked at hypnotherapy for pain relief in children with cancer versus distraction and support. “Distraction and relaxation were more effective than normal support,” Zeltzer says. “But hypnotherapy, involving children and their imagination, was even more effective.”

Doctors believe such mind games have a physical component. “If you’re anxious, your heart rate goes faster, your breathing gets faster, and your sympathetic nervous system is aroused,” explains Margaret Stuber, MD, a psychiatry professor at David Geffen School of Medicine at UCLA. A signal of danger—say, a needle prick—can be “emotionally amplified.” Conversely, slow deep breaths slow the heart rate, reduce arousal, and result in a less frightened patient. That could diminish pain.

Parents have long been fans of integrative techniques for their kids. Recent surveys report that 31 to 84 percent of children with cancer have tried the techniques. “It averages out to about 50 percent,” estimates pediatric oncologist Kara Kelly, MD, medical director of Columbia University’s integrative therapies program for children with cancer located at Morgan Stanley Children’s Hospital of New York-Presbyterian. For most parents, she says, it allows them to feel like they’re doing something on their own, without the physician, to help their children.

Kelly does point out two major caveats. First: “We haven’t found anything [in integrative medicine] that’s an effective anticancer therapy. Most of our approach is focusing on supportive care and symptom relief.” Second, parents should consult with the physician to ensure that an integrative treatment won’t harm the youngster or interfere with conventional treatments.

Killian died of cancer in August at age 16, but before his death he recorded Somewhere Else, an album to raise money for the cause. A gifted ukulele player, he made music with famous musicians like Dr. John and Levon Helm.

As for children, they’re usually happy to explore techniques that promise relief from pain and stress. But if they can’t do it emotionally, says Stewart Goldman, MD, medical director for neuro-oncology at Children’s Memorial Center for Cancer and Blood Disorders in Chicago, “I tell them not to and to revisit it later.”

Some hospitals that focus on childhood cancers have received grants or donations to offer integrative services for free. That’s a model Killian Mansfield and his family espouse. Diagnosed with a rare soft-tissue cancer at age 11 and treated at New York-Presbyterian, Mansfield found that acupuncture relieved anxiety, fatigue, and nausea. He and his family started the Killian Mansfield Foundationto help all young cancer patients gain access to integrative treatments.

Killian died of cancer in August at age 16, but before his death he recorded Somewhere Else, an album to raise money for the cause. A gifted ukulele player, he made music with famous musicians like Dr. John and Levon Helm. “Express Yourself” was a favorite song, says his mother, Barbara. Killian told her it sounded like a party that spilled over from a small room into a wider venue—just as his family hopes to bring integrative medicine into a bigger arena.

Insurance companies haven’t rushed to join the party, though. A few progressive insurers may reimburse for integrative therapies for kids, but many do not. CIGNA, for example, covers acupuncture for adults with cancer based on studies with that age group—but not for children.

There is a loophole of sorts. Insurance plans with a mental health benefit may cover visits to a therapist during cancer treatment, says psychiatrist James Gordon, MD, founder and director of The Center for Mind-Body Medicine ( 202-966-7338). Just as an insurer wouldn’t ask a therapist, “Did you talk about the patient’s mother?” there won’t be queries like, “Did you use guided imagery?”

The challenge for parents is to find a licensed therapist who uses integrative techniques. Gordon hopes the center’s website will soon offer a list of health care professionals, advocates, and survivors who have received the center’s “cancer guides” training, which includes integrative cancer for kids.

There is no guarantee integrative therapies will be a balm. Gabriella Casabianca, 7, has endured surgeries, chemotherapy, and radiation to treat her brain tumor, diagnosed in December 2008. “Acupuncture left a rash, and she didn’t really care for it,” says her mother, Frances. But foot massages—also known as reflexology—are a bright spot: “My daughter looks forward to it. She takes off her socks. She enjoys it.”

Energy healing appealed to Katrina Janik, whose daughter Carrie, now 5, was diagnosed with a brain tumor at 14 months. Energy healers use their hands to bring energy to a patient’s “unbalanced” energy system. Janik spent about $1,300 out of pocket to pay for 10 sessions with a practitioner. She had mixed feelings about the sessions, partly because the healer lacked the patience to work well with small children.

At Children’s Memorial Hospital in Chicago, Janik turned to touch therapy practitioner Suzanne O’Brien. After a five-minute session, Carrie will grow sleepy and say, “That feels good.” Carrie now meditates for hours, and Janik reports that a surgery went better than the doctor expected.

Doctors don’t quite know what to make of energy healing, in part because the biological basis of this practice is obscure.

Goldman of Children’s Memorial is overseeing a study that pits stretching and breathing exercises against energy healing to see how patients report the benefits. “I’m pleased we’re [examining it] in a more regimented way,” he says.

After a five-minute session, Carrie will grow sleepy and say, "That feels good." Carrie now meditates for hours.

At 5 years old, brain tumor survivor Carrie Janik has used medication and touch therapy to cope with the disease. Photo by Shauna Bittle.

Yet Goldman is willing to admit he can see a boon in the absence of evidence. “I’m skeptical about energy transferring from one body to another. I can’t comprehend how this works, but in a way, I don’t care as long as the kids come out feeling calm and comforted—that’s a benefit right there.”

From curetoday.com WINTER/2009