INTRODUCTION

The diagnosis and treatment of cancer carries a heavy emotional burden, with approximately half of all cancer patients experiencing anxiety and depression severe enough to reach clinical significance. The National Institute for Clinical Excellence (NICE) (2004) recommends that routine psychological support should be available to all cancer patients and there is a substantial body of evidence demonstrating the efficacy of hypnotherapy and psychotherapy in cancer care. Psychological distress and morbidity are frequently reported following a cancer diagnosis and during active treatment (c.f. Zabora et al 2001). The latter can be further compounded by chemotherapy side-effects which can have a direct influence on appetite/weight loss, muscular weakness, anxiety, depression and helplessness that, at worst, can affect treatment compliance (Walker et al 1999, Molassiotis et al 2002).

As nearly half of all cancer patients experience levels of anxiety and depression severe enough to affect their quality of life, NICE (2004) recommends that all patients should have access to psychological support. Historically this has been problematic, as health professionals were not trained to elicit patients’ psychosocial concerns and focussed exclusively on the physical aspects of the disease. Patients’ concerns therefore remained hidden and unresolved. The widespread training of senior health professionals in effective communication skills, however, has begun to redress the balance (Maguire & Pitceathley 2002, Fallowfield et al 2002, 2003, Wilkinson et al 2006). Even so, routine psychological support is not always available and some distressed cancer patients receive no psychological help at all (Greer et al 1997, Moorey & Greer 2002). These factors led REAL Wellbeing (a charitable organization in Northern England) to develop a psychotherapeutic intervention to help patients cope with the diagnosis and treatment of cancer. The intervention comprises effective elements of documented behavioural approaches in a clinical package to meet individual needs. Its official title is Psychological Support Services for Cancer Care but it is generally known as the ‘hypno-chemo programme’. The latter is misleading because it implies that patients need to be receiving chemotherapy in order to access it. This is not the case and the programme is suitable for patients at all stages of the disease trajectory. Nevertheless, hypno-chemo has ‘stuck’ and become more meaningful to both patients and health professionals than the official term. The programme was developed during the period 1996–2000 from experience within the team and from studies demonstrating the efficacy of the approaches used, up to and during the initial development period. As such, it has been necessary to include a number of older references or seminal papers.

This chapter will describe the hypno-chemo programme, outlining the therapeutic content of hypnotherapy, relaxation training and cognitive-behavioural therapy (CBT). Selected research demonstrating the efficacy of these therapies is outlined alongside studies indicating the importance of involving patients in decision-making and provision of a psychologically supportive setting in cancer care. These include hypnotherapy and relaxation training to ameliorate the side-effects of chemotherapy. Relaxation training is used as an alternative to hypnotherapy when misconceptions about the latter cannot be overcome or there is a risk of adverse reaction to hypnosis. Evidence relating to the provision of CBT to reduce cancer-related psychological distress is addressed, followed by behavioural approaches for pain control. CBT is a talking therapy which identifies dysfunctional thinking and behaviours. The patient works towards cognitive restructuring and behavioural change. The priority for the selection of papers was that they needed to be relatively recent outcome studies (at the time), comparing one or more experimental conditions with at least one control group. These studies, however, are reported from a quantitative perspective, which restricts understanding of the individual patient’s interpretation of events, and as a consequence, limits the opportunity to refine interventions more specifically to meet their needs. A post-intervention qualitative study was therefore conducted to separate out those elements of the hypno-chemo programme that most benefited participants, allowing their experiences to be fully assessed and viewed within the context of the situation (Taylor & Ingleton 2003). Patients’ experiences from this study are presented, highlighting service satisfaction and areas requiring attention. The chapter concludes with a dissemination study and clinical audit to assess the feasibility of multi-centre service provision and recommendations for education, training and development.

THE HYPNO-CHEMO PROGRAMME

The hypno-chemo programme aims to provide adjuvant psychological support and has borrowed effective components from appropriate psychosocial interventions to develop a 12-session structured approach consisting of hypnotherapy and CBT. Hypnotherapy is used to teach relaxation, manage pain, prepare for and treat the side-effects of chemotherapy and facilitate guided imagery (GI) to give the patient a perceived tool with which to fight malignant cells. CBT is used to elicit and treat the emotional problems associated with cancer and treatment.

Requirements for inclusion are diagnosis of cancer at any stage and sufficient command of English (or other language common to both parties) to be able to work with the therapist. Patients with unstable psychotic illnesses are excluded, as the combination of therapies described is inappropriate in active psychosis, and their psychological treatment/medication is available through the usual NHS resources. Patients with stable psychotic illness can be accepted at the discretion of the therapist and with the agreement of the patient’s psychiatrist. Hypnotherapy, however, is avoided with these patients and also in those diagnosed with malignant brain tumours to prevent any risk of adverse reaction.

ASSESSMENT

Patients are assessed and treated by the same psychotherapist. A medical history is taken, together with tumour histology, local/metastatic spread, medication and clinical treatment regimen. If pain management is required, a detailed sensory description of symptomatology is established. Psychosocial assessment aims to elicit patients’ physical, social, psychological and spiritual concerns. The biological effects of chemotherapy and how conditioning exacerbates these are explained and reactions to previous or current chemotherapy identified. A simple explanation of immunology is given. The cognitive-behavioural model and hypnotic intervention are explained, concerns about hypnotherapy identified and a treatment plan agreed before written consent is obtained. Partners/carers are present at the initial consultation according to the patient’s wishes.

HYPNOTHERAPY

Hypnosis is induced by eye fixation, passive muscle relaxation and appropriate deepening procedures (visualizing a peaceful scene, descending numbers, etc.). Treatment is tailored to individual need but typically involves relaxation, confidence-building suggestions and GI to deal with impending stressful procedures. Patients are taken verbally through the sequence of events leading to, during and following chemotherapy infusions. Occurring anxiety, nausea or other unpleasant sensations are cue-controlled by hypnotic suggestion. For example, the patient is asked to visualize a numerical dial representing nausea, and practise turning the dial up and down to obtain control. The latter is subsequently associated with a cue word, which is used to reduce nausea in the chemotherapy environment and with associated stimuli. Patients are asked to visualize their white blood cells attacking and destroying cancer cells using images/scenes of their choice. Pain modification is tailored to individual need. Imagery techniques are preferred for good hypnotic subjects (high hypnotizables), such as giving the pain a shape and colour and allowing it to float away. Distraction techniques are preferable for low hypnotizables, e.g. focussing on competing sensations elsewhere in the body such as rubbing the fingers together maintained by post-hypnotic suggestion. All procedures are supported by audio-taped instructions for daily practice and use during chemotherapy infusions if required.

Hypnotherapy is not always appropriate, as widespread misconceptions of involuntary mind control, perpetuated by the popular press and abuse by stage hypnotists, have led to fearful and sceptical beliefs. Most concerns are easily overcome by sensitive explanation and rapport but if patients cannot be reassured, progressive muscle relaxation (PMR) is used instead. This involves physical stretching and relaxing of consecutive muscles to induce relaxation, accompanied by visualization such as a peaceful scene and followed by cancer-related GI, as above. The need for PMR is minimal but unfortunately the active requirements of this technique can burden some already exhausted cancer patients.

CBT is used to identify and resolve cancer-related psychological problems and follows the procedures described by Greer et al (1992) and Greer (1997). This approach focuses on the personal meaning of cancer for the patient and the patient’s coping strategies. Patients are encouraged to disclose and express the emotional impact of cancer on themselves and significant others, taught to identify the automatic dysfunctional thoughts underlying anxiety and depression, challenge these thoughts and replace them with more rational responses. Task-focussed behavioural assignments are encouraged to generate a sense of achievement and raise self-esteem. An attitude of reasonable optimism, determination not to give in, desire to understand and participate in treatment and continue to live a normal life is encouraged. This attitude characterizes ‘fighting spirit’ recommended by Greer and colleagues (1992). At REAL Wellbeing, this term is replaced by realistic positive thinking as recent evidence suggests patients can become burdened with guilt when they fail to maintain their fighting spirit (Watson et al 1999).

The combination of these approaches, tailored to individual needs represents the hypno-chemo programme, a popular intervention with demand surpassing resources. The psychosocial literature influencing the development and content of the programme is outlined below.

RESEARCH INFLUENCING THE DEVELOPMENT OF THE HYPNO-CHEMO PROGRAMME

Hypnotherapy and related procedures such as relaxation training and GI have been used to ameliorate the side-effects of chemotherapy, help patients adjust to the disease, counteract pain and anxiety and alter the mechanisms of immunity to hopefully improve prognosis. These interventions have been evaluated in a series of studies. Extensive reviews of this literature (e.g. Fawzy et al 1995) have concluded consistently that hypnotherapy is effective in the above areas, with the possible exception of enhancing survival. The randomized controlled trials (RCTs) relating to the latter have produced conflicting results with some limited by methodological flaws (Walker 1992, Fox 1995, 1998). Blake-Mortimer et al (1999) and Coyne et al (2007) provide a more recent debate on psychotherapy and cancer survival rates. However, quality, rather than quantity of life is the concern of the hypno-chemo programme and, although the methodology of some studies utilizing hypnotherapy has been criticized (c.f. Rajasekaran et al 2005), there is consistent empirical evidence to support the use and evaluation of this approach.

THE TREATMENT OF CHEMOTHERAPY SIDE-EFFECTS

COGNITIVE-BEHAVIOUR THERAPY FOR CANCER-RELATED PSYCHOLOGICAL DISTRESS

The work of Greer et al (1992) has strongly influenced the hypno-chemo programme. These workers conducted a controlled trial to determine the efficacy of Adjuvant Psychological Therapy (APT), a CBT approach specifically designed for cancer care. Patients with primary diagnosis or first recurrence of mixed cancers were screened for psychological morbidity using the Hospital Anxiety and Depression (HAD) scale (Zigmond & Snaith 1983) and the Mental Adjustment to Cancer (MAC) scales (Greer & Watson 1987, Watson et al 1988). The latter measures four broad dimensions of adjustment: fighting spirit, helplessness, anxious preoccupation and fatalism. A total of 174 patients with scores above previously defined cut-off points were randomly assigned to experimental or control conditions. Experimental patients individually participated in the 8-week, problem-focussed APT programme, while controls received no therapy. Outcome measures included the HAD and MAC scales, Rotterdam Symptom Check List (RSC, De Haes et al 1990) and the Psychosocial Adjustment to Illness Scale (Derogatis 1983). The trial was completed by 90% of patients.

The intervention, which aimed to detect and treat the emotional problems associated with the disease included cognitive restructuring, behavioural assignments, PMR and role-play/imagination to deal with imminent stressful procedures. Immediately following the intervention, the therapy group had significantly lower scores on helplessness, anxious preoccupation and fatalism, anxiety, psychological symptoms and orientation to healthcare, and significantly higher scores on fighting spirit than controls. At the 4-month follow-up, experimental patients continued to have significantly lower scores on anxiety and psychological symptoms/distress. At the 12-month follow-up (Moorey et al 1994) patients who had received therapy still had less anxiety and depression than controls. The authors concluded that APT significantly reduces cancer-related psychological morbidity, thus enhancing the psychological dimension of QOL. However, one-third of eligible patients refused to take part and the author did not report any adverse therapy effects. No post-intervention qualitative assessment was conducted to indicate in detail which elements of the intervention the participants valued the most.

BEHAVIOURAL APPROACHES IN THE MANAGEMENT OF PAIN

Adjuvant pain management is an important component in the hypno-chemo programme, which may be cancer, treatment-related, or general pain. There is substantial literature on the use of hypnotherapy in the management of pain but some workers suggest CBT is also effective in management. The manifestation of pain is predictable in bone marrow transplantation (BMT) providing an opportunity to test the efficacy of psychosocial interventions.

Syrjala et al (1992) postulated that both hypnosis and CBT would reduce treatment-related pain in this group of adults. Prior to their first transplantation, 67 BMT patients with haematological malignancies were randomized to one of four groups: hypnotherapy, CBT, therapist contact control or treatment as usual. Age, gender and a risk variable, based on diagnosis and relapse/remission rates, comprised biodemographic data. Physical functioning was assessed by the Sickness Impact Profile (SIP, Bergner et al 1976, 1981) with daily records of pain and nausea monitored on a visual analogue scale (VAS). Psychological symptoms were addressed by the Brief Symptom Inventory (BSI, Derogatis & Spencer 1982) and psychologist assessment. The SIP and BSI were used as covariates in the analysis. The intervention and therapist contact groups met with a clinical psychologist for 2 × 90 min sessions prior to transplant and 10 × 30 min reinforcement sessions after in-patient admission. Hypnotherapy consisted of relaxation and imagery targeted towards the reduction of pain and nausea and emotional reactions to the latter, together with suggestions of enhanced coping/control and well-being. Audio-taped instructions for daily practise were issued. CBT consisted of education about the mechanisms of pain and nausea with the benefits of reducing physiological arousal, together with cognitive restructuring, coping strategies, goal setting and PMR. The therapist contact condition included general discussion with no introduction of new coping skills. In the treatment as usual group, patients received standard medical care only. The remaining 45 patients provided covariate and time series data.

Results indicated that the hypnotic intervention only, was effective in reducing treatment-related pain. There were no significant differences in nausea, emesis and opioid use between the treatment groups and, contrary to expectations, CBT did not ameliorate the symptoms measured. The authors emphasize the importance of imagery in such interventions. This was not included in the CBT group and patients intermittently refused sessions with relaxation alone when treatment stress shortened attention span. During this stage, hypnotherapy patients also preferred shortened inductions/relaxation routines and more engaging imagery. Although the authors conducted no qualitative evaluation, they suggest the impact of both interventions on nausea and vomiting may be limited by inadequate training. Rather than a gradual onset, the first dose of chemotherapy produced severe emesis, which prevented the practise opportunities afforded to other cancer populations. This, coupled with cognitive side-effects of high-dose antiemetics and opioids, may have been too great a challenge to a newly learnt skill. The study only measured symptom intensity and the small sample size may have had inadequate power to demonstrate efficacy in all variables measured. Methods of pain and nausea control were not made clear, making replication difficult. Nevertheless, the study demonstrates the superiority of hypnotherapy and GI in pain management supporting a former large-scale RCT with 109 metastatic breast cancer patients. In their seminal paper, Spiegal and Bloom (1983) concluded that supportive group therapy coupled with hypnosis provided greater pain control than supportive therapy alone.

To obtain an in-depth insight and understanding of participant experience, a qualitative enquiry was conducted. Eight patients who had completed the hypno-chemo programme were purposefully selected. Seven had breast cancer and one had colon cancer at the stage of local disease or local disease and regional spread. All underwent surgery and chemotherapy and seven received radiotherapy. Six patients commenced therapy just before or after their first session of chemotherapy. One patient joined the programme approximately halfway through chemotherapy and another after the latter was completed. Semi-structured interviews were conducted between 1 and 24 months (average 7 months) after the intervention and transcribed verbatim for thematic analysis. Primary themes identified were: gaining help, treatment tailored to needs, long-term benefits and service satisfaction/information needs. The findings demonstrated that participants had acquired advanced skills to enable them to cope, both with invasive medical procedures and with the psychological traumas they faced. The study also indicated difficulties in accessing the service, initial misconceptions about hypnotherapy and the need to provide a therapy setting sensitive to the needs of cancer patients undergoing active medical treatment. Extracts from the study illustrate patients’ experiences.

GAINING HELP

There was an initial reluctance for health professionals to refer, possibly due to misconceptions about hypnosis and the low priority given to psychological concerns at that time (Taylor et al 2004). Typical quotations illustrate:

Fear of chemotherapy was paramount and this, coupled with feeling overwhelmed by their diagnosis, led some patients to grasp the hypno-chemo programme as a lifeline. Exemplified below:

All participants received hypnotherapy, however, many had negative preconceived beliefs and assumed they would lose consciousness or relinquish control to the therapist. For example:

Some patients were inhibited from attending the centre because it was next door to a hospice, illustrated below:

This ‘one way ticket’ was a common belief, with patients recommending a separate building off site.

All participants said they would recommend the service to others. For example:

This theme has implications for information giving, referral procedures and the provision of an appropriate environment, supporting the work of Walker and colleagues (1992).

TREATMENT TAILORED TO INDIVIDUAL NEEDS

This theme represents the identification of patients’ main concerns and adopting appropriate therapies to aid their resolution. Following the patient’s agenda rather than the therapist’s is illustrated by the following quote:

Not only was this appreciated but patients also valued the therapists themselves. Given that the latter is recognized as an important variable in treatment outcome, it was noteworthy to discover that all participants considered the therapist as skilful and important in their adjustment to their various situations. For example:

Sharing personal problems was important for many patients:

Understanding the cognitive model and utilizing the techniques within it are considered essential to the efficacy of CBT (Bottomley 1998). However, rather than demonstrating comprehension of the model and separating out the cognitive and behavioural elements, participants tended to view the intervention as a package. A typical vignette illustrates how patients amalgamated CBT with hypnotherapeutic aspects and GI in their understanding of altered thoughts and enhanced control.

Some patients commented on their improvement without reference to specific techniques. For example:

The exception to this was relaxation. Patients were very clear on how relaxation helped them particularly with sleep disturbance, chemotherapy and pain management. Typical vignettes illustrate:

The latter provides a good example of holistic pain management and the need for multidimensional assessment (Davies & McVicar 2000), in this case, the patient’s perception of pain. Jenny accurately described her chronic pain as a maladaptive fight, flight response, eloquently explained by Wall (1999). The body’s attention to pain is observed as a state of alertness, including muscle tension, stiffness, disturbed sleep, alert immune system and lethargic gut. The longer this state continues the more anxiety is felt, leading to reduced pain tolerance and increased pain intensity. As Jenny put it, ‘pain all over’. Jenny’s pain was successfully treated by hypnotherapy, which taught her how to relax tense muscles, distract her attention and promote sleep.

A technique referred to as vein enlargement is used at ELIHCC, simply conducted by hypnotherapy and GI. A typical script demonstrates the technique:

This approach was greatly appreciated, e.g.

No empirical research about this technique was revealed in the literature search. However, anecdotal reports support the use of this strategy in cancer care (Hammond 1990).

Feeling in control, confidence building and the visualization of host defences destroying cancer cells complete this theme and are closely interwoven. The need for control over what was happening to patients was an important finding with the ‘cancer cell attack’ considered a principal tool:

This attitude supports research recommending the controversial topic of fighting spirit (Greer et al 1992). Nevertheless, feeling part of the clinical team was necessary to patients, as illustrated below:

The combination of techniques was considered to reduce helplessness and subsequent anxiety leading to an increase in confidence. For example:

These findings support a substantial body of evidence demonstrating the efficacy of behavioural approaches in cancer care. For example, in a review of psychosocial interventions at varying stages of disease, specific and heterogeneous cancers and including some large-scale RCTs, Fawzy et al (1995) found psychological and physiological improvements together with enhanced immune functioning for studies utilizing behaviour/cognitive-behaviour therapy. The consistency of positive outcomes in this area (Greer et al 1992, Walker 1992) highlights the desirability of their transference into routine clinical provision.

LONG-TERM BENEFITS

Patients continued to benefit from the techniques learned after discharge. One patient, interviewed 8 months after completion of chemotherapy said:

Others used their learned skills to reduce tension and aid sleep. The use of cue-controlled GI is illustrated below:

Patients found they were able to relax at will:

Patients were able to express their feelings more openly. One patient interviewed after 2 years demonstrated this ability:

These findings again support outcome studies utilizing CBT and hypnotherapy. In Greer and colleagues’ study (1992), patients who had received APT continued to have significantly lower scores on anxiety and depression than controls at 12-month follow-up (Moorey et al 1994). Spiegal et al’s (1981) early controversial work on hypno-psychotherapy and survival, demonstrated superior psychological health in experimental patients compared to controls at 10-year follow-up. Similar benefits have been demonstrated in patients with malignant melanoma (Fawzy et al 1993) and Hodgkin’s/non-Hodgkin’s lymphoma (Ratcliffe et al 1995).

Both this and the previous theme clearly demonstrate that patients need to feel in control of their situation and enhance their immunology. This was true for all participants and, providing the cancer cell approach is offered honestly and ethically, that is without inappropriate reassurance or raising false hopes, it appears to be a valuable technique depending on disease stage and patient choice.

SERVICE IMPROVEMENTS

This theme focuses on service satisfaction and identifies areas for improvement. Patients invariably viewed their therapy positively. The main criticism was lack of information about the existence of the service in appropriate clinics, closely followed by the need for health professionals to explain the programme beforehand. For example:

Future availability was a major finding with most patients suggesting follow-up sessions or later treatment on request.

There was, however, evidence of service dissatisfaction related to medical procedures. Despite the widely publicized move from closed to open awareness, communication deficits were apparent.

Some patients complained about hospital waiting times, mechanical failure and human error, illustrated below:

Others were upset by the methods of breaking bad news and treatment delays, illustrated below:

Collectively, the findings highlight the need for open communication, identification of concerns, information provision, and interventions tailored to individual need. Effective communication is central to all these issues and much is currently being done to address deficits in the wider palliative care community by the requirement for widespread training in Advanced Communications in Cancer Care (National Cancer Action Team 2008).

The high level of service satisfaction with the hypno-chemo programme greatly increased referrals, and demand for the service highlighted the need for teaching and dissemination. Therefore, the feasibility of clinical provision in wider England was assessed by conducting an audit of the quality of training and service delivery, together with a cost analysis (Taylor et al 2006). Organizational approval was obtained from 36 palliative care centres.

A range of audit standards were monitored relating to the target population of patients, therapists, palliative care teams, tutors and supervisors. The method of data collection was the hard copy of audit tools and a range of analyses were conducted based on descriptive statistics.

All therapists attending the course met the pre-course requirements in relation to qualifications, insurance and membership of a professional organization. All prospective palliative care teams were sent the relevant information packs within the agreed time of 15 working days. The 36 therapists who completed the course in full all successfully met the training criteria. Response times for contacting the patient within 7 working days of receiving the referral was met 94% of the time and for making assessment appointments within 15 working days was met on 92% of occasions. All therapist records regarding patient appointments, supervision and pay claims were received in office each month with all essential documentation enclosed. Monthly, quarterly and twice-yearly supervision requirements were met by all therapists. Evaluation forms from the five key stakeholders (patients, therapists, palliative care teams, tutors and supervisors) showed positive attitudes towards the structure and running of the programme.

A total of 1244 patients were treated over the 2-year period with a large female majority. There was a wide age range of 18–89 years with an average age of 54. A total of 44 primary cancer sites were identified, with breast cancer accounting for approximately half of the sample. Patient outcomes indicated a high percentage of symptom relief pre- to post-treatment. The mean number of sessions for patients reporting elimination of their symptoms was 10, suggesting this is the optimal number of sessions required for patients receptive to techniques taught on the programme. Despite problems with integrating therapists in established workforces in some centres and a slow start in year 1 of the study, the success of the hypno-chemo programme was demonstrated as audit standards were consistently met and user views were for the most part positive.

Grant funding for service provision ceased in November 2005 and there was much concern from palliative care centres about the service ending. The programme supports one of the main aims of the NHS Cancer Plan (DoH 2000) to ensure that communication, information provision, psychological support, patient empowerment and palliative care are improved to reduce inequalities in service provision. Therefore, ways to sustain delivery remain important. Analysis of costs indicated value for money and every effort was made to assist participating centres to source continuation funding. This was problematic with the significant debt reported by the NHS at the time. However, 55% of centres were able to retain their therapist. The information obtained from the 3-year study was used to inform the purchasers and providers of cancer care and it was anticipated that the project might encourage primary care trusts to commission service provision.

SUMMARY

This chapter has outlined the development and clinical provision of combined hypnotherapy and cognitive-behavioural therapy in cancer care. Published work in areas of principal importance has been discussed. A qualitative investigation supporting these findings has added further insights to the patients’ experience, which is not always possible using quantitative methods of enquiry. Patients were able to describe how hypnotherapy and CBT had helped them to cope with the diagnosis and treatment of cancer, with learned skills considered valuable tools in rehabilitation or remission. Participants would have preferred to undergo therapy in a hospital-based cancer unit or standalone setting rather than adjacent to a hospice. Conversely, some dissatisfaction was expressed with the hospital-based procedure. Participants were keen to recommend the hypno-chemo programme but were concerned about lack of information about the service. Including health professionals in a multi-centre study, however, has done much to overcome their mistrust of hypnotherapy and initial reluctance to support the programme. Indeed, a substantial number retained their therapist on cessation of funding. One important finding from the multi-centre study was that 10, rather than 12 sessions, were sufficient for a successful outcome, which reduced costs.

RECOMMENDATIONS FOR TRAINING AND DEVELOPMENT

Although 55% of participating centres continued to fund the hypno-chemo programme on cessation of grant funding, demand for the service has generated waiting lists with some patients having completed chemotherapy before being seen. This unacceptable situation is incongruent with NICE (2004) guidance and, as there has been no financial support from Primary Care Trusts, ways need to be found to generate income for this popular intervention. Subject to funding, the programme is available for national dissemination. Alternatively, training could be provided for appropriately qualified personnel. A further suggestion is to provide a continuum of evidence by conducting a phase 2 and phase 3 RCT, thus enhancing the possibility of mainstream funding. This may be an appropriate course of action for an interested graduate working towards a higher degree.

AWARDS

The hypno-chemo programme has won two awards:

ACKNOWLEDGEMENTS

We are grateful to the BIG Lottery for supporting the multi-centre study and to the research participants.