Hypnosis/Hypnotherapy

Hypnosis/Hypnotherapy

PEP Topic 
Acute Pain
Description 

A hypnotic state is a state between wakefulness and sleep, a state of heightened concentration and receptivity that results in suspension of peripheral cues. The effect of a hypnotic state results in alteration of perception and attention. Hypnosis has been tested for its effect on pain, anxiety, depression, chemotherapy-induced nausea and vomiting (CINV), hot flashes, and fatigue in patients with cancer. Hypnosis has been delivered in various formats, including individual in-person sessions, CD program, and self-hypnosis.

Likely to Be Effective

Research Evidence Summaries

Ebell, H. (2008). The therapist as a travelling companion to the chronically ill: Hypnosis and cancer related symptoms. Contemporary Hypnosis, 25, 46–56.

doi: 10.1002/ch.348
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Study Purpose:

To examine the effects of the combination of self-hypnosis and pharmacologic pain management

Intervention Characteristics/Basic Study Process:

Patients with cancer-related pain were randomly assigned to the order in which they received two different approaches—self-hypnosis with pain medications and pain medications alone. Patients used a daily log to record pain levels and the use of analgesics.

Sample Characteristics:

  • N = 39
  • AGE: No information reported
  • MALES, FEMALES: No information reported
  • KEY DISEASE CHARACTERISTICS: Not provided

Setting:

  • SITE: Single site
  • SETTING TYPE: Outpatient setting
  • LOCATION: United Kingdom

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Long-term follow-up, end-of-life and palliative care

Study Design:

  • Single group crossover design
    • Randomized

Measurement Instruments/Methods:

  • Visual analog scale
  • Stanford Hypnotic Clinical Scale for Adults (for response or non-response to self-hypnosis)

Results:

Eleven patients reported achieving pain control; 12 reported benefits in relaxation, rest, and sleep; and 9 reported no impact.

Conclusions:

The study report lacks full quantitative findings and, thus, very limited information about the efficacy of hypnosis.

Limitations:

  • Small sample of less than 100
  • No analysis of the differences between hypnosis and "control” condition
  • Those who added self-hypnosis first in the crossover sequence were likely to have contaminated results that occurred later in the control condition.
  • No disease-related or other demographic information about the sample is provided. 
  • Very limited reporting of results and analysis of findings

Nursing Implications:

This study provides little information and no clear support for the efficacy of hypnosis for chronic cancer-related pain.

Lew, M.W., Kravits, K., Garberoglio, C., & Williams, A.C. (2011). Use of preoperative hypnosis to reduce postoperative pain and anesthesia-related side effects. The International Journal of Clinical and Experimental Hypnosis, 59(4), 406–423.

doi:10.1080/00207144.2011.594737
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Study Purpose:

To test the feasibility of hypnosis as a preoperative intervention; to explore the effects of preoperative hypnosis on anxiety and pain

Intervention Characteristics/Basic Study Process:

Investigators gathered baseline assessments of pain, nausea, vomiting, distress, and anxiety. The hypnosis intervention was a 15-minute scripted hypnotic experience provided, within an hour before surgery, in the preoperative holding area of the operating suite. Investigators collected data and interviewed patients postsurgery. Data pertaining to historical controls were obtained from medical records matched for age, date, and type of procedure.

Sample Characteristics:

  • The sample was composed of 20 patients.
  • The age range of patients was 30–79 years. Authors did not report mean patient age.
  • All the patients were female.
  • All the patients had breast cancer and were undergoing surgical procedures. Authors do not cite specific procedures.
  • Of all patients, 65% were married or partnered and 65% were Caucasian.
  • Of all participants, 90% reported previous experience with mind-body techniques: 90% had used prayer, 45% had used deep breathing, and 40% had used relaxation.

Setting:

  • Single site
  • California, United States

Phase of Care and Clinical Applications:

Active treatment

Study Design:

Prospective pre- and postdesign with historical control comparisons; mixed method

Measurement Instruments/Methods:

  • MD Anderson Symptoms Inventory, condensed and modified
  • Measures of physical symptoms
  • Assessment of personal preference (Authors developed this assessment to allow a patient to show intervention preference, on a continuum of imagery-hypnosis and other preferences.)

Results:

Postintervention measures showed a decrease in anxiety, worry, and nervousness; however, authors did not report significant pre- and poststudy differences. The hypnosis group had a higher prevalence of postoperative pain and nausea than did the historical group.

Conclusions:

Providing a hypnosis intervention preoperatively appears to be feasible. Results reported do not provide substantial evidence of the efficacy of hypnosis in preventing postoperative pain and nausea.

Limitations:

  • The study had a small sample size, with fewer than 30 participants.
  • The study had a risk of bias due to no appropriate prospective control and no blinding.
  • Authors did not list the procedures that participants underwent.
  • Authors did not describe the timing of postintervention measurement or the method of extracting measurements from medical records.

Nursing Implications:

This study suggests that providing a hypnosis intervention preoperatively can be feasible. The impact of such an intervention cannot be determined from this study.

Liossi, C., White, P., & Hatira, P. (2009). A randomized clinical trial of a brief hypnosis intervention to control venepuncture-related pain of paediatric cancer patients. Pain, 142(3), 255–263.

doi:10.1016/j.pain.2009.01.017
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Study Purpose:

To compare the efficacy of EMLA cream to EMLA plus hypnosis in the relief of venipuncture-induced pain and anxiety; to determine whether the intervention has a beneficial effect on parents’ anxiety levels during their child’s venipuncture

Intervention Characteristics/Basic Study Process:

Patients arriving at the unit had 2.5 g EMLA cream 5% applied over a prominent vein. Those who agreed to the study were randomized to one of three groups: EMLA alone, EMLA plus hypnosis, or EMLA plus attention. Hypnosis included a 15-minute session with a therapist in a private room. The therapist provided analgesic suggestions and led the patient in relaxation. The attention group received a 15-minute session with the therapist and engaged in conversation unrelated to the procedure. Investigators collected measures of pain and anxiety immediately after the intervention and during two follow-up venipunctures. EMLA was removed after 60 minutes.

Sample Characteristics:

  • The sample was composed of 45 participants.
  • Mean patient age was 8.4 years (SD = 2.21 years). The age range was 6–14 years.
  • The sample consisted of 25 females and 20 males.
  • All patients were pediatric patients with cancer.

Setting:

  • Single site
  • Outpatient
  • Children’s hospital in Greece

Study Design:

Randomized blinded, controlled trial

Measurement Instruments/Methods:

  • Visual analog scale (VAS), 0–100 mm, to measure pain intensity
  • VAS, 0–100 mm, to measure the intensity of anxiety of children and parents
  • Procedure behavioral checklist, to document presence and intensity of 10 behaviors indicative of pain and anxiety (inter-rater reliability = 0.85), conducted on 22 procedures

Results:

  • The EMLA plus hypnosis group experienced less anticipatory anxiety, procedure-related pain, anxiety, behavioral distress, and parental anxiety than did the other two groups (p < 0.001).
  • The benefits that the EMLA plus hypnosis group enjoyed continued through the two consecutive venipunctures: significant change in mean self-reported pain over time (p < 0.001) and anxiety over time (p = 0.007).

Conclusions:

The study showed that hypnosis, used in conjunction with the local anesthetic EMLA, helped to decrease procedure-related pain anxiety, and distress in pediatric cancer patients. In addition, the intervention helped to decrease parental anxiety.

Limitations:

  • The study had a small sample, with fewer than 100 patients.
  • The study had a risk of bias due to lack of blinding.
  • The intervention must be implemented by a trained therapist. This fact could decrease the feasibility of the intervention.

 

Nursing Implications:

Oncology nurses in the pediatric setting may want to advocate for the use of hypnosis, along with local anesthetic, to decrease the pain and anxiety of venipuncture.

Snow, A., Dorfman, D., Warbet, R., Cammarata, M., Eisenman, S., Zilberfein, F., . . . Navada, S. (2012). A randomized trial of hypnosis for relief of pain and anxiety in adult cancer patients undergoing bone marrow procedures. Journal of Psychosocial Oncology, 30, 281–293.

doi: 10.1080/07347332.2012.664261
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Study Purpose:

To determine whether hypnosis, administered before and during a bone marrow procedure, can ameliorate pain and anxiety

Intervention Characteristics/Basic Study Process:

Patients were randomized to a group that received standard care or a group that received standard care plus hypnosis just prior to the procedure. Patients learned of their group assignment just before the procedure. In the hypnosis arm, after the local anesthetic was administered, the oncology nurse and physician left the room. A specially trained oncology social worker performed the hypnosis. After 15 minutes, the oncology nurse and physician returned to start the procedure. The social worker continued to deliver the scripted hypnosis until the procedure was completed. In the standard-care arm, the oncology social worker was not present during the procedure. Study outcome measures were obtained immediately before and after the procedure.

Sample Characteristics:

  • The study was composed of 80 patients with cancer who required bone marrow evaluation.
  • In the hypnosis group, mean patient age was 58 years (SD = 14 years); in the standard-care group, mean patient age was 61 years (SD = 14 years).
  • The entire sample was 52.5% male and 47.5% female.
  • Diagnoses included, among others, leukemia, lymphoma, plasma cell dyscrasias, myelodysplastic syndrome, myleoproliferative disorder, and aplastic anemia.
  • Patients were English-speaking, unpaid volunteers undergoing bone marrow aspiration or biopsy. Of all patients, 71% did not take analgesic or anxiolytic medications.

Setting:

  • Single
  • Outpatient
  • Cancer treatment center associated with Mount Sinai Medical Center, New York City

Phase of Care and Clinical Applications:

  • Phase of care: diagnostic
  • Clinical application: late effects and survivorship

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

  • Visual analog scales (VASs), to measure pain and anxiety.
    • For pain: Anchors were no pain at the biopsy site versus very severe pain at the biopsy site.
    • For anxiety: Anchors were no anxiety versus very severe anxiety.  
  • State-Trait Anxiety Inventory, Trait section, to assess whether the two groups were equivalent in terms of chronic levels of anxiety.
  • Blood pressure and heart rate before and after the procedure.
  • Patient satisfaction with the visit, assessed by means of a seven-step scale of verbal descriptors: very satisfied, pretty satisfied, somewhat satisfied, neutral, somewhat dissatisfied, pretty dissatisfied, or very dissatisfied.

Results:

The pain scores were slightly lower for the hypnosis group; however, the difference was not statistically significant (t(78) = 0.916, ns). The reduction in anxiety was substantially greater in the hypnosis group than in the standard-care group, with nonparametric tests showing that the difference was statistically significant (median test, p = 0.026).

Conclusions:

Pre-procedure hypnosis was effective in reducing procedure-related anxiety.

Limitations:

  • The study had a small sample, with fewer than 100 participants.
  • Assessment of pain experience should encompass sensory and affective components of the experience, differences in hypnotherapists, differences in physicians performing the procedure, and differences in cancer type.
  • Hypnosis induction was during the interval between administration of local anesthesia and start of the procedure, a period of 15 minutes. Some questioned whether induction was complete in some cases.
  • In-depth training is needed to implement this intervention; in this study, the intervention was implemented by a mental health expert.

Nursing Implications:

Hypnosis may be an effective intervention to reduce procedure-related anxiety. Although not demonstrated in this study, hypnosis has been shown to be effective in reducing procedure-related acute pain. Nurses can advocate for use of hypnosis to benefit appropriate patients. Provision of this intervention requires an appropriately trained and educated provider.

Systematic Review/Meta-Analysis

Landier, W., & Tse, A.M. (2010). Use of complementary and alternative medical interventions for the management of procedure-related pain, anxiety, and distress in pediatric oncology: An integrative review. Journal of Pediatric Nursing, 25, 566–579.

doi: 10.1016/j.pedn.2010.01.009
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Purpose:

To perform an integrative review of four electronic databases to determine the effectiveness of complementary and alternative medical (CAM) interventions, either alone or as an adjunct to pharmacologic therapy, in alleviating procedure-related pain, anxiety, and distress in children and adolescents with cancer

Search Strategy:

Databases searched were MEDLINE, CINAHL, PsycINFO, and Cochrane Database.

Search keywords were procedure, pain, anxiety, distress, childhood cancer, pediatric oncology, CAM, and complementary therapies.

Studies were included in the review if

  • The studies were case reports or reports of a clinical series or reports of clinical trials that included at least one CAM intervention aimed at reducing procedure-related pain, anxiety, or distress
  • The studies reported on a CAM intervention in one of the following: bone marrow aspiration or biopsy, lumbar puncture, injection, venipuncture for the purpose of blood sampling or starting an IV, or percutaneous access (excluding surgical procedure) to an implanted vascular device
  • The sample included at least some children and adolescents (that is, young people between the ages of 2 and 18 years) with cancer
  • The studies were published in English

Excluded from the review were studies that reported on surgical procedures (except percutaneous access to an implanted vascular device) and on the anxiety and distress of a parent.

Literature Evaluated:

  • Investigators retrieved a total of 195 references.
  • Reviewers read each paper and extracted information, including names of authors, publication year, study design, medical procedure performed, CAM modalities studied, description of study sample, level of evidence, and summary of  results.
  • Results were analyzed for themes.

Sample Characteristics:

  • Thirty-two studies—two meta-analyses, 18 experimental studies, 9 quasi-experimental studies, one nonexperimental study, and two case studies—were included in the review.
  • The total sample size was 1,760, with a range across studies of 3–514 participants.
  • Eleven studies included children with leukemia only; 13 included children with various cancer diagnoses other than leukemia; and 8 included children with a range of pediatric illnesses, including cancer.
  • Seven studies reported on children younger than 10 years, 3 studies reported on older children (10–17 years), and 22 studies included both age groups.

Phase of Care and Clinical Applications:

  • Phase of care: diagnostic
  • Clinical applications: pediatrics, procedure-related

Results:

Results suggest that mind-body intervention may be effective, alone or as an adjunct to pharmacologic interventions, in managing procedure-related pain, anxiety, and distress in pediatric patients with cancer. In this population the three most commonly studied mind-body modalities were distraction, hypnosis, and imagery.

Nursing Implications:

Although multiple studies demonstrated the value of CAM interventions, many of the studies were small and incorporated multiple CAM therapies as a single intervention. These types of interventions may be useful, particularly when used in combination with pharmacologic agents, but further research is needed to identify which interventions were valuable.

Montgomery, G.H., Weltz, C.R., Seltz, M., & Bovbjerg, D.H. (2002). Brief presurgery hypnosis reduces distress and pain in excisional breast biopsy patients. The International Journal of Clinical and Experimental Hypnosis, 50(1), 17–32.

doi:10.1080/00207140208410088
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Purpose:

To estimate the effectiveness of adjunctive presurgical hypnosis in the control of symptoms after surgery

Search Strategy:

  • Databases searched were MEDLINE and PsycLIT.
  • Search keywords were hypnosis or hypnotherapy and surgery or operation.
  • Studies were included in the review if they
    • Included administration of hypnosis to at least one group undergoing surgery
    • Included a control or usual-care group
    • Provided statistical data that allowed calculation of effect sizes

Literature Evaluated:

Authors did not report

  • Total literature evaluated
  • Quality rating of studies described or apparently used in the analysis

Sample Characteristics:

  • Authors analyzed 20 papers.
  • The studies the papers described included 1,624 patients. Overall, sample size was 20–339 participants.
  • Of the studies analyzed, two studies involved patients with cancer—one involved patients with head and neck cancer and the other involved women undergoing breast biopsy. These two studies involved a total of 52 patients.

Results:

Results demonstrated an effect size of D = 1.17 (95% CI 0.41–1.93) in favor of presurgical hypnosis as a means of decreasing pain severity. The effect size regarding impact on pain medication was D = 1.69 (95% CI 0.56–2.82). Results were similar whether hypnosis intervention was provided by tape or by means of a live session. Mean effect size, across several clinical outcome categories in studies involving cancer, was 0.63 in cases of head and neck cancer and 0.9 in cases of excisional breast biopsy.

Conclusions:

This analysis demonstrated that adjunctive presurgical hypnosis helped control postoperative pain in the majority of patients undergoing various types of surgery.

Limitations:

  • Only two of these studies related to patients with cancer. Both of these studies had small sample sizes.
  • The majority of studies did not provide an attentional control condition.
  • Authors provided no analysis of heterogeneity among the studies.

Nursing Implications:

Findings suggest a positive effect of presurgical hypnosis, delivered by tape or in a live session, for the management of the postoperative pain of surgical patients. This report and findings are limited by lack of information about how pain was measured, failure to examine heterogeneity in pooled data, and lack of information about the timing of outcome measures. Findings are also limited by the lack of attentional control conditions in the majority of studies and the lack of randomization in more than half the studies. The sample spans about 40 years. This meta-analysis does not provide strong evidence for the use of presurgical hypnosis as a way to decrease the postsurgical pain of patients with cancer.

Rheingans, J.I. (2007). A systematic review of nonpharmacologic adjunctive therapies for symptom management in children with cancer. Journal of Pediatric Oncology Nursing: Official Journal of the Association of Pediatric Oncology Nurses, 24(2), 81–94.

doi: 10.1177/1043454206298837
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Purpose:

To assist the health care practitioner by summarizing research studies that have examined the use of nonpharmacologic adjunctive therapies (NATs) for symptom management in pediatric oncology patients

Search Strategy:

  • Databases searched were Cochrane Library, PubMed, CINAHL, and PsycINFO.
  • Authors included an extensive list of search keywords. Of particular relevance to the pediatric oncology setting were pain, cancer, oncology, self-care, nausea, vomiting, fatigue, and coping.
  • Studies were included if they dealt with nonpharmacologic therapies to help alleviate symptoms associated with cancer treatment in children.

Literature Evaluated:

Investigators retrieved and reviewed 41 studies. Their review related to symptoms studied, modalities used, study design, sample size, and study results. The analysis included all 41 studies. The studies pertained to multiple modalities, including hypnosis, imagery, breathing, distraction, relaxation, cognitive behavioral therapy, art therapy, and music therapy.

Sample Characteristics:

  • Sample sizes ranged from N – 1 to 122 patients.
  • Across studies, participants included in the samples were pediatric patients receiving chemotherapy, needlesticks, radiation, lumbar punctures, bone marrow aspiration, IV insertion, MRI, or port placement for the treatment of unspecified disease.

Results:

Over all the studies, the results are mixed in regard to the effect of NATs on procedural pain. Some studies indicated that hypnosis produced promising results in reducing procedural pain. Cognitive behavioral therapy and distraction showed both an effect and no effect on pain. One study (based on observation and self-reporting) indicated that NATs had no effect on procedural pain. In a few studies, hypnosis (along with distraction and relaxation and cognitive behavioral therapy) produced significant pain reduction. Studies found that music therapy had little to no effect on the pain of bone marrow aspiration.

Conclusions:

This review of NATs produced mixed results.

Limitations:

  • The samples studied were inconsistent in regard to modality.
  • Some terms (e.g., anxiety and distress) were found to be interchangeable; on the other hand, hypnosis encompassed several definitions.
  • The sample size of some of the studies was small.
  • In the pediatric populations studied, the intervention provider (patient, professional, or parent) was unclear.

Nursing Implications:

More research needs to be done in this area. Health care practitioners, patients, and families need education about NATs and their application to pediatric oncology.

Richardson, J., Smith, J.E., McCall, G., & Pilkington, K. (2006). Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. Journal of Pain and Symptom Management, 31(1), 7084.

doi:10.1016/j.jpainsymman.2005.06.010
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Purpose:

To evaluate the evidence, from controlled clinical trials, relating to the effectiveness of hypnosis for reducing procedure-related pain and distress in pediatric cancer patients

Search Strategy:

  • Databases searched were MEDLINE, EMBASE, Allied and Complementary Medicine Database (AMED), Centralised Information Service for Complementary Medicine (CISCOM), CINAHL, PsycINFO, and the Cochrane Library.
  • Searched keywords were neoplasm, tumor, melanoma, cancer, chemotherapy, palliative care, terminal care, and hypnosis.
  • Studies were included in investigators' analysis if
    • They were relevant systematic reviews or controlled clinical trials that included outcome measures for pain.
    • They included pediatric patients, with a primary diagnosis of cancer, who were undergoing painful and invasive treatment-related procedures (lumbar puncture, venipuncture, bone marrow aspiration).
    • In the study, hypnosis was used as a specific intervention.
    • Patient- or observer-reported clinical measures of physical pain or anxiety or distress were recorded,
  • Studies were excluded if treatment included chemotherapy or if the studies did not include a control group.

Literature Evaluated:

  • Investigators retrieved nine studies. The studies comprised one systematic review, seven randomized controlled trials, and one nonrandomized controlled trial.
  • Authors analyzed eight studies, reviewing design, sample, inclusion criteria, complementary and alternative medicine treatment, control, outcome measure(s), results, methodology, comments, and clinical comments.

Sample Characteristics:

  • The sample was composed of 313 patients.
  • All patients had a diagnosis of cancer and were undergoing a painful procedure. Cancer diagnoses included lymphoblastic leukemia, acute myeloblastic leukemia, and nonmalignant blood disorder.
  • None of the studies identified cancer stage. Some studies did not report the percentages of male participants and female participants.
  • Authors did not identify the age range of patients.

Results:

Using rating scales in the pediatric population is a useful and valid procedure. Some studies included observations of procedure-related behavior, and these observations showed that the intervention yielded some benefit, although the observer's criteria are unspecified. Some studies showed that the level of hypnotizability, as  measured by the Stanford Hypnotic Clinical Scale for Children, was related to analgesic effect, but this finding was invalid. Studies that noted and stratified for the sex of the pediatric patient reported that the child's sex was related to level of distress. Self-hypnosis was not evaluated but has been shown to have an effect on management of symptoms.

Conclusions:

Studies reported that using hypnosis as specified had positive effects, resulting in statistically significant reductions in pain and anxiety or distress.

Limitations:

  • Most studies had a small sample size.
  • Few studies reported the method of randomization.
  • The studies did not provide enough information about the duration of the hypnosis session, whether parents were present, and who provided the information about intervention results.

 

Nursing Implications:

Work remains to be done in this area. Researchers should focus on age, developmental stage, and the association between the sex of the child and the effectiveness of the intervention.

Tomé-Pires, C., & Miró, J. (2012). Hypnosis for the management of chronic and cancer procedure-related pain in children. International Journal of Clinical and Experimental Hypnosis, 60, 432–457.

doi: 10.1080/00207144.2012.701092
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Purpose:

STUDY PURPOSE: To review published trials of hypnotic treatments for children with chronic and cancer-related pain

TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: MEDLINE, PsycINFO, Cochrane Collaboration

KEYWORDS: Children, hypnosis, pain

INCLUSION CRITERIA: RCT; patients 18 years old or younger; Catalan, English, French, Portuguese, or Spanish languages; included patients with chronic pain or cancer procedure-related pain

EXCLUSION CRITERIA: Abstracts only, not published in full in peer-reviewed journals

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 81

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: No study quality evaluation reported

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 12 (10 in cancer)
  • SAMPLE RANGE ACROSS STUDIES: 20–80
  • TOTAL PATIENTS INCLUDED IN REVIEW: Total in cancer studies = 394
  • KEY SAMPLE CHARACTERISTICS: Procedures involved were bone marrow aspiration, LP, or venipuncture

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Mutliple phases of care     
  • APPLICATIONS: Pediatrics

Results:

All studies in children with cancer were related to acute procedure-related pain and anxiety. Hypnotic interventions were better at reducing pain than no treatment, standard care, placebo, and attention control. Compared to other psychological treatments, hypnosis had about the same effectiveness as cognitive behavioral therapy. Comparison of hypnosis to distraction showed mixed results. Younger patients had significantly better responses to hypnosis. Parents of those receiving hypnosis had lower anxiety. Results of hypnosis on anxiety were mixed. One study showed similar effects between hypnosis and play. Calculated effect sizes with hypnosis showed decrease in pain of 20%–80%. In four studies that included follow up at 3–12 months, therapeutic effects appeared to be long-lasting.

Conclusions:

Hypnosis is effective in reducing acute procedure-related pain among children with cancer.

Limitations:

Studies tended to have small samples, and many of these studies were done by the same group of researchers.

Nursing Implications:

Findings of this systematic review support the use of hypnosis in children undergoing invasive procedures for reduction in pain. Nurses can advocate for availability of this intervention in pediatric settings.


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