A Thematic Analysis of Perceptions and Experiences Regarding Clinical Hypnosis from Palliative Care Health Professionals,Patients,and Their Relatives

Abstract

Background:

Clinical hypnosis appears to hold some promising effects for patients at end-of-life. Patients and health care professionals (HPs) are inclined to adopt the practice. Yet, the experience of hypnosis in this context remains under-researched.

Objectives:

To understand the process of integrating hypnosis into conventional care and the needs of palliative care patients and their relatives.

Design:

A qualitative study based on semi-structured interviews conducted between February 2022 and January 2023 in Switzerland. Interviews were transcribed verbatim and analyzed using thematic analysis.

Setting/Subjects:

The total sample was composed of 44 participants, including 30 service users who received hypnosis (20 palliative care patients and 10 relatives) and 14 palliative care HPs, among whom 5 were hypnosis practitioners.

Results:

Based on the feedback of HPs, we mapped various practices of offering and integrating hypnosis in palliative care. Then, we identified five sub-themes relating to the participants’ experience of hypnosis and self-hypnosis: (1) factors influencing the choice to engage in hypnosis; (2) reasons for not recommending hypnosis; (3) effects and meaning of hypnosis; (4) difficulties and drawbacks; and (5) the perception of the practice of self-hypnosis.

Conclusions:

The practice of hypnosis is very diverse and constrained by resources and limitations in institutional support. Patients and relatives identified that hypnosis had a positive impact to enable them to recognize and mobilize their personal resources toward greater self-empowerment. Our findings suggest that hypnosis might hold a real potential for patients and their relatives, thus warranting further study of its effects in palliative care.

Key Message

The practice of hypnosis for patients at end-of-life is diverse and constrained by institutional limitations. Our findings suggest that hypnosis might hold a real potential for patients and relatives, enabling them to recognize and mobilize their personal resources toward self-empowerment, thus warranting further study of its effects in palliative care.

Introduction

Palliative care is characterized by a holistic and interprofessional approach that integrates the physiological, psychological, social, existential, and spiritual dimensions of care throughout the trajectory of serious illness until death or survivorship.¹ Although conventional medicine is not always successful in alleviating the symptoms experienced by patients in palliative care, some complementary medicine (CM) approaches or interventions may address these gaps.²

CM refers to “a broad set of health care practices that are not part of that country’s own traditional or conventional medicine and are not fully integrated into the dominant health care system.”³ Integrative medicine is a holistic approach that proposes to include the best evidence of CM into conventional care through a patient-centered care framework.^2,4 Integrative and complementary health approaches (ICHA) remain the current denomination of the US National Institutes of Health for practices that were previously tagged as complementary and alternative (CAM).⁵ Integrative palliative care would offer the opportunity to expand the range of approaches available to relieve symptoms and suffering but it is still underdeveloped.^2,6

To address the challenges related to the quality of palliative care, there are a variety of CM interventions,³ among which clinical hypnosis (“hypnosis”), widely used in Western countries.^2,7,8 Hypnosis is defined as “a state of consciousness involving focused attention and reduced peripheral awareness characterized by an enhanced capacity for response to suggestion.”⁹ Hypnosis can be used in any care setting, has no adverse effects apart from a transient increase in the expression or experience of the symptom, and requires no equipment other than the skills of the hypnosis practitioner.¹⁰ Additionally, self-hypnosis can be taught quickly, enabling individuals to practice independently based on their needs. A hypnosis session starts with an assessment of the individual’s needs and resources by a trained health professional (HP). After the induction, suggestions are provided to help the person use their imagination and mental imagery to create a sense of safety and comfort or to alter their perception of a symptom.

Hypnosis and self-hypnosis have shown benefit for patients with advanced illness, including improvements in quality of life, reduction in pain, anxiety, symptom severity (for example, dyspnea), depression, sleep disturbance, reduction in analgesic treatments, and managing adverse effects or fears about treatment.^8,11–17 Other benefits have been highlighted, such as empowerment, focusing on the present moment, hope, positive memories, and the strengthening of the relationship with the therapist.¹⁸

Hypnosis is a valuable CM at the end of life, offering patients a different way to develop a sense of self-efficacy to improve their coping mechanisms.^14,19 However, the efficacy and effectiveness of hypnosis in palliative care remains under-researched.¹⁵ Barriers to its adoption and implementation include a lack of evidence, misconceptions about hypnosis, and its absence from clinicians’ training.⁸ More broadly, factors such as insufficient time, inadequate training of HPs, stigma, and misinformation hinder the integration of CM into conventional care.^20–22 Since no validated patient-reported outcome instrument exists for assessing CM experiences, qualitative research is essential.^18,23 Our objectives were to understand the process of integrating hypnosis into conventional palliative care and the needs of patients and their relatives in this respect.

Methods

Design

This qualitative study was based on semi-structured interviews conducted between February 2022 and January 2023 in Switzerland, with the approval of the local Human Research Ethics Committee (2021–02193).

The sample (n = 44) consisted of 20 patients, 10 relatives, and 14 palliative care HPs. Of these, 4 patients, 1 relative, and all 14 HPs were recruited from palliative care settings offering hypnosis as part of their routine care. The remaining 16 patients and 9 relatives were recruited as part of a feasibility study of a home-based hypnosis intervention for palliative care patients and their relatives. This study involved four individual hypnosis sessions lasting 15–20’ once a week for patients at the end of life and for one of their relatives, as well as recordings enabling them to practice self-hypnosis. Hypnosis sessions focused on symptom management for the patients and on developing a resource for their relative.

Patient inclusion criteria: (1) adult; (2) cared by a palliative care team; and (3) used CM in the past six months.

Patient exclusion criteria: (1) no French language fluency; (2) severe cognitive impairment; (3) severe hearing impairment without hearing aids; (4) severe psychiatric symptoms; and (5) acute decline in health status.

Relative inclusion criteria: (1) adult; and (2) relative of a patient who has used CM in the past six months.

Relative exclusion criteria: (1) no French language fluency; (2) severe hearing impairment without hearing aids; and (3) acute psychotic decompensation.

HP inclusion criteria: (1) caring for a palliative patient in an institutional context in which hypnosis was offered; or (2) being trained and practicing hypnosis with palliative patients.

Hypnosis sessions offered during the interventions were very similar, but not identical, to those that patients and relatives attended outside of the intervention (e.g. the number of sessions and the metaphors used by clinicians varied).

Methods

Between February 2022 and January 2023, ACS undertook semi-structured face to face interviews in French with participants. Interviews with patients and relatives explored the feasibility and impact of hypnosis, their experience and practice of hypnosis, self-hypnosis, and CM. Palliative performance status²⁴ was measured with a mean of 60 (range 40–90) but no cutoff was established. Participants were free to choose whether to take part in the interview alone or with their relative. Three interviews were conducted with the patient and relative as a dyad.

For HPs, the interview explored: the practice of hypnosis in their service, their perception of users’ experiences, and the integration of hypnosis into conventional care. Interview guides are available as Supplementary Data S1.

Analysis

Interview data were transcribed and analyzed thematically.²⁵ Initially, 10% of the data was parallel blind coded by A.C.S., a sociologist, and F.T.L., a palliative care nurse scientist and hypnosis practitioner. After comparing codes, discussing and resolving dissentions, A.C.S. created an initial codebook that was applied to the remaining data and enriched with new codes. Codes were developed into themes by A.C.S., and discussed with P.L., professor in palliative care nursing, and F.T.L. Coding development was deductive (following the interview guide) and inductive, looking at aspects related to participants’ experience not directly broached in the guide. The final analysis was confirmed with C.B. (professor in complementary and integrative medicine).

Results

Mean interview length was 30 minutes (range 7–76 minutes) for individual interviews and 42 minutes (range 39–45 minutes) for couple interviews. Information about participants is presented in Tables 1 and 2. We coded and explored two overarching themes (A and B):

Table 1.

Information on Patients and Relatives

	N (%); mean (SD)
Patients	20
Age	69.4 (13.7)
Gender
Women	16 (80%)
Men	4 (20%)
First diagnosis
Cancer	16 (80%)
Noncancer	44 (20%)
PPS	65 (30–90)
Setting
Receiving PC at home	16
Hospitalized in PC unit	4
Relatives	10
Age	62.4 (13.5)
Gender
Women	5
Men	5
Relationship with the patient
Spouse	7
Parent	2
Friend	1
Professional activity
Working	4
Retired	6

PC, palliative care; PPS, palliative performance scale.

Table 2.

Information on Health Professionals

	N (%)
Professionals profession	14
Nurse	4 (29%)
Physician	10 (71%)
Practice of hypnosis
Yes	5 (36%)
No	9 (64%)
Setting^a
PC hospital service	9 (60%)
PC home team	5 (33%)
Community nursing service	1 (7%)
Years of PC practice^b
Years	9 (69%)
≤10 years	4 (31%)
Years of practice of hypnosis
Years	2
≤3 years	3

One participant practiced in a PC hospital service and a home team.

One participant was from a community nursing service, involved in the care of palliative patients but not a palliative care practitioner herself.

Based on the feedback of HPs, we coded the practices of offering and integrating hypnosis in palliative care (A) regarding: (1) who practices hypnosis; (2) how the relevance of hypnosis is assessed; (3) who is responsible for referrals; (4) how patients are informed of hypnosis; (5) how hypnosis is explained; and (6) elements that can improve the integration of hypnosis (see Table 3).

Table 3.

Hypnosis Practices and Integration in Palliative Care

Practices	Results of the analysis (quotes are in brackets)
(1)Who practices hypnosis
Hypnosis only offered by inhouse practitioners	HPs are strongly encouraged to train in CM. It is important that “we have several strings to our bow” so that the same HP can accompany patients. The practice of hypnosis is recognized and accepted as part of the clinical activity, but there is no dedicated protected time for practice
Hypnosis only offered by external practitioners	HPs assess the relevance or the patient’s request of a CM intervention and relay the request to the hospital’s CIM center
Hypnosis offered by both external and inhouse practitioners	Some in-house HPs are practitioners and when these are not available, a request is relayed to the hospital’s CIM center
(2)How is the relevance of hypnosis assessed?
Systematic screening	Screening takes place at admission, during the nursing interview that makes an evaluation of patient’s needs (including a detailed history taking). The nurse establishes a course of action with various approaches that the patient confirms or not. A review is done after one moth to assess the approach
Nonsystematic screening	Identification and offer of hypnosis are triggered by certain aspects of the patient’s evaluation or history
Identified by patient	Patients are responsible for requesting hypnosis when they have the need and knowledge (either the patient has a prior experience that they want to reproduce, or information about all CM that are available are offered from the patient’s hospitalization, and the patient identifies which one is more relevant)
(3)Who is responsible for screening patients
Nonpractitioner HP	Nonpractitioner HPs document their assessed need for hypnosis and the symptom and transmit it directly to the practitioner or share it during the interdisciplinary colloquium.
Practitioner HP	Practitioner HP screen their own patients
(4)How are patients informed of the offer of hypnosis
Institutional information available for everyone	Information is available on the unit’s institutional website and on paper in each patient’s room
Offered by a nonpracticing HP	Some nonpractitioner HPs are trained by practitioner HPs to present hypnosis, others give information that they have acquired through their own resources
Offered by a practicing HP	Hypnosis is offered by the HP who will practice, after the identification or recommendation of a nonpracticing HP
(5)How is hypnosis explained
Explicitly	Practicing HP presents themselves as a practitioner of hypnosis; Practicing HP talks about clinical proof, explains the basic principles of hypnosis “to reassure them and to quickly understand how this can happen”
Nonexplicitly	“I don’t need to call it that, ‘we will have a little session of relaxation’ simply like that or ‘listen I suggest we tell a story’”
Not explained at all but done	“Sometimes it comes spontaneously, I say I’m a physician and I won’t make a presentation, but it just so happens that during my act of care hypnosis will take place a bit spontaneously, without me formally introducing it”
Variability	“I don’t always describe it in the same way, it depends actually on their state (…) I adapt my speech to that”
(6)Practices that can improve the integration of hypnosis in palliative care
Making training in hypnosis more available	“All professional should benefit from training in an approach that is relevant to them. And in their practice, they can use it as a supplementary tool, it’s a way of finding meaning in what we do and being equipped, it’s more rewarding”
Offer hypnosis at home	“In the patient’s setting, it allows them to feel more respected, to feel at home, and I think we can work on more aspects if a person is at home than if she comes to the hospital (…) the energy might be different, and all those people who are stuck at home, they need help”
Institutional support	Dedicated time would allow HPs to practice more often and in a more convenient way for themselves, the team and the patient. Training in hypnosis paid by the institution
Raise HP awareness	“Give as much information as possible and explain what we do, in a scientific way because physicians who practice traditional medicine are very cartesian thinkers and need to understand physiological aspects”
Raise patient awareness	Raise patient awareness by way of providing accurate, adapted information about hypnosis as soon as they are hospitalized, and details about the objective and steps of hypnosis
Offer hypnosis systematically	“Just like we take blood pressure and like we present the service, it should be offered and let patients think and talk again after 24 hours or 48 hours”
Offer hypnosis systematically to relatives	Relatives have important needs in relation to the dying and grief process, but are more difficult to track down than patients
Offer more resources to nonpracticing HPs	Facilitate the nonpracticing HPs mission to orient patients toward CM practitioners outside of the hospital
Information transfer	Ensure better information transfer from practitioner to HP with a written trace

CIM, complementary and integrative medicine; CM, complementary medicine; HP, health care professionals.

Based on the feedback of patients, relatives, and HPs, we coded for experience of CM, hypnosis, and self-hypnosis (B): (1) factors influencing acceptance; (2) reasons for not recommending hypnosis; (3) effects and meanings; (4) difficulties experienced; and (5) perceptions of the practice of self-hypnosis (Table 4).

Table 4.

Experience of Hypnosis and Self-Hypnosis

Theme	Sub-theme	Salience			Items / quotes
		Patient	Relative	HP
1. Factors influencing participation	(i) Expected benefit in terms of symptoms	✓	✓	✓	Pain, anxiety / stress / existential suffering, breathing difficulty / dyspnea, sleeping difficulty, sadness, tiredness fear of the unknown, as well as a positive resource: calmness / serenity / relaxation; comfort; concentration; force; taking a step back; unwinding; general “well-being”; social contacts
	(ii) How hypnosis is recommended
	• HP offering hypnosis overtly	✓	✓		“I didn’t know hypnosis, but since it was proposed by a health professional, I told myself, «yes it can have a positive effect»” (patient)
	• HP specifically recommending hypnosis for certain symptoms	✓	✓		“[The nurse] told me, ‘it’s to help you with your intense pai’, so I told myself «why not»” (patient)
	• Recommendation for hypnosis made by a recognized public health institution	✓	✓		“I thought that since it came from the [institution] it was a good idea” (patient)
	• Encouragement for hypnosis by relative	✓	✓		“She [wife] told me ‘do it, it will do you well’, I said ‘well then I’ll try it’” (patient)
	(iii) Previous exposure to hypnosis
	• Other relatives’ positive experience with hypnosis	✓	✓		“Recently, one of my goddaughters, she did hypnosis, we were talking about it maybe two months ago (…) she told me ‘It’s crazy, thanks to hypnosis, I fall asleep right away’. So now I thought, yes I need to try it” (relative)
	• Sources of information (TV, internet, YouTube)	✓			“I had heard lots of good things about hypnosis and even recently, I watched some shows on TV, they were talking about hypnosis, its merits, before operations, in the postsurgical, I thought it was awesome” (patient)
	• Prior experience of hypnosis	✓	✓	✓	“I wanted to find again the sensations I had had” (patient)
	(iv) Personal attitude
	• Openness to CIM and seeking complementary cures	✓	✓	✓	“I am sold to these complementary therapies, they have a big place for me within this medicine that will never be efficient if we don’t integrate a more general dimension of the person” (relative)
	• Experience to other CM similar to hypnosis	✓	✓	✓	“I was curious to see how hypnosis was compared to meditation” (patient)
	• Personality	✓		✓	“We first identify whether people like to be touched or not” (HP)
	• Tendency to rely on personal resources			✓	“I always ask the question of resources: what are your resources in life to which you turn to in difficult situations?”
	• Curiosity and openness	✓			“Why not try?”; “I’m open to anything”; “I’m naturally curious”; “I told myself it can’t hurt”
2. Reasons for which HPs refrain from recommending hypnosis	• Patient’s health status			✓	Psychotic or psychiatric problems; dissociative states and depression; severe symptoms; cognitive problems associated with dementia and delirium; having a very short life expectancy
	• Not establishing the therapeutic alliance			✓	“We always have particular affinities with certain patients and when I feel that this kind of synchronization isn’t there I won’t offer hypnosis because I know I wouldn’t be tending toward something that is useful for the patient”
	• Competences			✓	“We should practice hypnosis in the domain in which we are comfortable practicing without hypnosis. I know how to deal with pain in palliative settings without hypnosis so that’s where I can offer it, but I’m not a psychiatrist so I won’t offer hypnosis to a patient with psychiatric problems”
3. Experience
	(i) Positive effect on symptoms	✓	✓	✓	Pain, anxiety / stress / existential suffering, breathing difficulty / dyspnea, sleeping difficulty, sadness, tiredness
	(ii) Building positive resources	✓	✓	✓	Talking about illness; dealing with anxiety; achieving calm; not focusing on the illness; thinking good thoughts; recognizing one’s emotions; use of positive language
	(iii) Negative side effects	✓		✓	Stress; sadness; tiredness
	(iv) Modulate the effect of invasive procedures	✓	✓	✓	“When there are medical exams and such, how come the technicians and doctors and the other staff never told of of the possibility of doing them under hypnosis? Ask people to put up flyers, ‘if you dread, if you need support, hypnosis for examinations, for anxiety’ (…) in radiology, for IMR, for pain treatments, for surgery, for many things, it must be known” (relative)
	(v) Nonsymptom related effects
	• Being able to reproduce elements of hypnosis with someone in suffering		✓		“I applied what [clinician] did to [wife]. In a favorable moment and with my voice, that is deeper and that she knew well, and I managed to induce a deep relaxation”
	• Accepting the diagnosis	✓			“I had a tension here [indicates the mid-neck], because I had to accept (…) that I’m lost, because that’s the term (…) I know it they even told me. I had this ball here, I couldn’t swallow it and… it did me an enormous good (…) we talked and my tension, it went down and out through my feet”
	(vi) Relational dimension
	• Appreciation of the therapist as a person	✓	✓		Kindness; “an angel”; attentive; calm; benevolence; soothing; receptive
	• Appreciation of particular skills of the therapist	✓	✓		“The way she knew how to ask questions” (relative); “this soothing voice it really makes me let go” (patient)
	• Taking time to connect with the patient/relative	✓	✓		“She participates, she’s there in the discussion, there’s no constraint, there’s no joy, it’s in-between (…) she takes her time, she arrives, not in a rush. She takes her leave peacefully” (relative).
	• Establishment of a relation			✓	“Hypnosis is a pleasant tool to have for a nurse (…) there’s a different relationship between the hypnotherapist and the patient. It’s a privileged moment. There’s collusion, a knowledge, an exchange of information (…) I ask some information from the patient and I know much more from the medical file and I like to tell them a bit about myself so that there can be an exchange (…) Other than the fact that hypnosis is a tool for which there’s a diploma and a training, there are other stakes such as human relation, empathy, and respect, it’s inseparable”
	(vii) Adaptable to the needs
	• At home	✓	✓		“When we [patient and relative] first heard about hypnosis, we gave up, it was at the start of his [patient] diagnostic and my husband told me ‘in the beginning I will be able to get around but later I won’t be able to (…) if I start and then I have to go to a private practice, it won’t be possible” and when we heard that [the hypnotherapist] was coming home, we were reassured. And the fact of being in a setting that we know, it means we don’t get lost (…) we’re at ease to do the session and we can let go” (relative)
	• Identify objectives that are relevant	✓			“We would identify at each session on what we’d work, what I needed today (…) it was wonderful”
4. Difficulties
	(i) Approach of hypnosis
	• Needing to stay still	✓			“In my life, there was work. And this, doing nothing, I can’t just sit around. It’s a trap.”
	• Dealing with feelings	✓	✓		“The session when we talked about sadness was difficult, it was difficult just thinking where the sadness came from, there were unpleasant feelings, even though it helps to explore this, it’s a bit unpleasant. It heightens the sadness on the moment, then it’s better” (patient); “The most difficult, was the first time, when I was confronted to my childhood and lots of things came back” (relative)
	• Getting engaged/staying focused	✓	✓	✓	“Sometimes it wasn’t easy to find the target when we don’t have the experience. But it wasn’t her, it was me, I wasn’t clear with what I wanted to work on” (relative); “Very difficult, for me, because I always have an something [else] to think about” (patient)
	• Therapist’s volume of voice	✓	✓	✓	“Sometimes, I wouldn’t understand some things, she was talking very low” (relative)
	• Infectious disease protection measures			✓	“In geriatrics, with masks, people need to understand what we say, it was more complicated when you’re dressed like an astronaut”
	(ii) Organization
	• Finding an adequate place	✓		✓	“I have a dog; he was a bit disruptive in the beginning. Because he was happy to see the hypnotherapist, it’s a big dog so (…) it took some time. I should have imagined a more suitable place” (patient)
	• Limited availability of practitioners			✓	“Having sufficient personnel who is trained and can practice, people available. Having people available to go to the patient’s home and help rapidly, why miss this opportunity [of doing hypnosis at home]”
	• Juggling practice of hypnosis with clinical duties			✓	“As physician [practicing hypnosis] sometimes I’m caught up, I need to know, can I leave my phone, will my colleague answer, will it put the service in difficulty, it’s really a time problem”
					“It’s a mandate that is supplementary to our work time. So we stay later after work, our shift finishes at 4 pm, we stay one hour, one hour and half to do the hypnosis session. To transcribe the notes, to transmit the information to colleagues… or we come before our shift, but then it’s negotiations with the patient, will he be sleeping, will he be busy”
	• Bad identification			✓	“When professional community services invite us [hypnosis practitioners], sometimes they don’t know what to do anymore, so they say ‘Come do the hypnosis’ but the patient is not really willing, it’s difficult”
	(iii) Access to hypnosis
	• Lack of evaluation of the effect of hypnosis			✓	“It’s difficult to evaluate and track changes brought by hypnosis, to know how much it’s used here, the indications, to stimulate interest and support training”
	• Difficulty to direct patients			✓	“Home care nurses can’t just give therapist names randomly to patients, there should be an approved list of therapists and their domain of competence”
	(iv) Patient-centered factors
	• Limited availability of patients			✓	“They have so many consults, they are so often at the hospital, that it hypnosis was so just tiring for them”
	• Prior experience with hypnosis			✓	“Patients saying ‘it’s not the right time’, see, it was too early. They had already had a prior experience with hypnosis and weren’t convinced”
	• Overbearing symptom			✓	“The symptom is so strong, it’s impossible for the person to break away. Even if she’s doing efforts and she’s committed, the pain, often it’s the pain, stays”
	• Patient false and unrealistic representations			✓	“Another patient was oriented ‘I want to be cured’ when she is dying and ‘I want to gain muscle mass’ so she enjoyed the relaxation, she said it felt good, but that wasn’t her objective”
					“Patients saying ‘it’s not my thing’ or ‘I don’t believe in it’ or ‘it’s quack’ or ‘I’m too down to earth’”
	• Patient apprehensions
	o Being controlled	✓	✓	✓	“I think I was afraid in the beginning, that it would be something like when we are controlled by someone else, like in the shows”
	o Being in control	✓	✓		“I was a bit afraid that it would be too controlling. Like when you meditate, you have to control your respiration. And in moments of stress, wanting to control things makes it worse”
	o Fear of opening up too much	✓	✓		“Will I let out very very private things?” (patient); “I was suspicious (…) I didn’t want to open some doors where I had put all my suffering” (patient)
	o Fear of an unknown intervention	✓			“I was a bit stressed…a lot (…) it’s just the unknown, this is how I am in other situations, it’s just not knowing where I’m going”
5. Experience of self-hypnosis
	(i) Usefulness
	• Positive impact on symptoms and emotions	✓	✓	✓	Sleep, relaxation, pain, fear, negative thoughts
	• Autonomy	✓	✓	✓	“I do my own little session of hypnosis and I don’t think about bills anymore” (patient)
					“This patient, we trained her to do self-hypnosis because we [HPs] are not always there. So, we can’t guarantee to be here for wound dressing, so we worked on how patients can deal with it and self-hypnosis, and then it was her who was doing it. It worked well” (HP)
					“It allowed me to work on it on my own little time” (relative)
	(ii) Facilitators and enablers
	• Audio recordings	✓	✓		“With her voice it’s easier, it’s stronger” (relative)
					“I thought of downloading them to my phone, like this I can take them wherever. Soon I will be hospitalized again, I can take my phone, and listen to them” (patient)
	• Thinking back at hypnosis sessions		✓		“Listening to the recording, I close my eyes (…) and I think about when I did it with her [hypnotherapist]”
	• Being in a certain state (calm, having sufficient time)	✓	✓		“I need to be in a certain state… rather in the morning, sometimes I’m a bit stressed but if I have the time, I stay in bed, I put on my headphones, I do a session” (relative)
	• Practice of AH	✓			“The more we do it, the more we succeed”
	• Practice of similar CM	✓	✓		“She sent me the sessions, it’s difficult to say why it works (…) I’ve done a lot of ergotherapy, of psychology, reflexology” (patient)
	(iii) Difficulties and barriers
	• Lack of physical presence	✓	✓	✓	“The videos for self-hypnosis helped, it allows to do them by yourself, but it’s not the same thing, I would have wanted the presence of a physical presence, it reassures, somehow, it allows you to say “I have support, in front of me”. It’s not the same as a voice in the telephone” (relative);
					“If they do self-hypnosis they very well know that they will see less of me, so there is less will” (HP)
	• Feeling unwell and particular symptoms (dyspnea, tiredness)	✓		✓	“I always offer self-hypnosis to patients if they are willing, but with dyspnea (…) it’s difficult, it requires effort and it’s not easy to practice it” (HP)
	• Approach of AH		✓		“I’m just not capable of meditating. I would like to, but I just can’t”
	• Concentration and finding time	✓	✓		“I start and suddenly I think ‘Tomorrow I have to do this and that’ and I stray away” (patient)
					“Before, we didn’t have a minute to lose, now that we are retired, we don’t have a second” (relative)

CIM, complementary and integrative medicine; CM, complementary medicine; HP, health care professionals.

A. Practices of offering and integrating hypnosis in palliative care

Hypnosis was practiced by inhouse practitioners when staff were trained in hypnosis and had sufficient time for practice. When these resources were lacking, hypnosis was offered by external practitioners. The evaluation of patients who would benefit from hypnosis was generally not carried out systematically, or with clear criteria. Depending on the context, practitioner or nonpractitioner HPs could be responsible for screening and describing hypnosis to patients. To do so, nonpractitioner HPs could either be trained by their practitioner colleagues or rely on their own understanding of the indications/counterindications. To patients, hypnosis could be explained explicitly, with a definition, but also by alluding to related practices such relaxation, or by applying conversational hypnosis (using natural, informal dialogue to help a person enter a focused, hypnotic state). From a HP perspective, aspects that would improve the integration of hypnosis in palliative care were systematic screening for hypnosis and CM, and institutional support.

B. Experience of hypnosis and self-hypnosis

Theme 1. Factors influencing hypnosis acceptance

This theme concerns how patients and relatives justified their acceptance of CM, how HPs perceived these reasons, and reasons for which HPs recommended participation. Four sub-themes were identified: i) expected positive benefits; ii) how hypnosis is recommended; iii) previous exposure to hypnosis; iv) personal attitude.

The expected benefits mainly involved symptom relief and the development of positive resources such as serenity. One HP described offering hypnosis to patients who were isolated since it was seen as a resource for establishing social contacts. Among the ways in which hypnosis was recommended, overt recommendations by HPs had a major influence on its acceptance. Patients and relatives were particularly sensitive to the legitimacy of the recommendation coming from a recognized public health institution, specifically a university hospital. Sometimes it was the patient’s relative who promoted the practice of hypnosis. Participation was also encouraged by prior exposure to hypnosis, by self-practice or by having received positive information about it. Having a personal experience with and openness to complementary and integrative medicine was another reason for participation. This was met by HPs, who recognized identifying patients according to their personality and to their effort to find other options to alleviate symptoms. HPs also mentioned taking into consideration patients’ personal resources when faced with difficulties. Pragmatically, many patients seemed to have accepted CM based on the mere opportunity of it being offered. The importance of “curiosity” and “openness” was frequently mentioned.

Theme 2. Reasons for which HPs refrain from recommending hypnosis

Three sub-themes were identified: i) patient’s health status; ii) not establishing the therapeutic alliance; and iii) competencies. Reasons for which HPs didn’t offer hypnosis were mainly tied to the patient’s health status (e.g., cognitive or attentional limitations, short life expectancy, risk of overburdening them). Some professionals, who didn’t practice hypnosis, feared that this practice could worsen the patient’s condition in certain pathologies. More subjective factors concerned feeling that HPs had not yet developed a sufficiently close relationship with the patient to be able to offer hypnosis. One HP noted that hypnosis for palliative care patients should not be practiced by professionals who are not specialized in palliative care.

Theme 3. Effect and meaning of hypnosis

This theme regroups how patients and relatives experienced effects of hypnosis and the meaning it had for them, as well as for HPs. Seven sub-themes were identified: (i) positive effects on symptoms; ii) developing positive resources; iii) negative side-effects; iv) modulating pain and anxiety induced by invasive procedures; v) supporting a loved one at the end-of-life; vi) acceptance of one’s situation; vii) relational dimension of hypnosis; and viii) adaptability.

A relative recounted how his hypnosis practice had been invaluable in replicating it with his wife at the end of her life, helping her to calm down and fall asleep (subtheme v). Concerning the relationship component (subtheme vii), patients and relatives expressed a genuine appreciation toward the hypnosis practitioner as a person as well as for their skills (having a soothing voice, the way of asking questions, expressing empathy). The fact of taking the time to talk without the pressure of other activities was much appreciated. Given the importance of the relational dimension in this hypnosis practice, a patient shared his apprehension that “it would be difficult to replicate systematically.” The relational dimension was also relevant for several HPs. Adaptability (subtheme viii) was highlighted by participants in our intervention study, who appreciated the fact that hypnosis was offered at home, and that the practitioner could adapt the objectives of each session.

Theme 4. Difficulties

Theme 4 concerns difficulties in relation to hypnosis as experienced by patients and relatives, as well as difficulties that HPs perceive for their patients, or experience themselves in the practice of hypnosis. Four sub-themes were highlighted: i) the approach of hypnosis; ii) organization; iii) access; iv) patient-centered factors.

Some aspects were intrinsically related to the approach of hypnosis, and therefore, difficult to alter or adapt, such as the necessity to stay still, to deal with one’s feelings or to maintain focus. Organization concerned contextual (finding an adequate location) and institutional-related challenges such as limited availability for practice and the coordination between HPs that identify patients for hypnosis and hypnosis practitioners. Due to a lack of knowledge about hypnosis and the difficulties of its integration into clinical practice, hypnosis was rarely recommended by HPs. Lack of clear and reliable information prevented clinicians from directing patients to hypnosis practitioner. Patient-centered barriers concerned the limited availability of patients due to the burden of disease related appointments, an unsuccessful prior experiences with hypnosis, overwhelming symptoms, unrealistic expectations, and apprehensions.

Theme 5. Perceptions of the practice of self-hypnosis

Theme 5 concerned how users and HPs perceived the practice of self-hypnosis. Three sub-themes were identified: i) usefulness; ii) facilitators and enablers; iii) difficulties and barriers. Regarding usefulness, participants appreciated its positive impact and its effect on patient autonomy (being able to develop their own resources and apply them in a self-sufficient way adapted to their experience). Among facilitators, patients appreciated resources that allowed them to tie back with their prior hypnotic experience (e.g., using audio recordings with the therapist’s voice and thinking back to their sessions). Being in a relaxed state and practicing similar CM was conducive for self-hypnosis. Regarding difficulties, observations joined those made for hypnosis (theme 3), adding another dimension, lacking the presence of a therapist.

Discussion

The current study explored the integration of hypnosis into conventional palliative care through qualitative interviews with patients, relatives, and HPs. The findings highlight the potential of hypnosis to alleviate symptoms and enhance the overall quality of life for palliative care, while also identifying barriers to its broader adoption.

Integrating Hypnosis into Usual Palliative Care

Our findings highlight that offering hypnosis within a hospital context encourages participation, even if the intervention takes place at home¹⁷ and stresses that the endorsement of hypnosis by HPs is particularly persuasive. Therefore, it is crucial for all HPs, including those not specialized in hypnosis or working outside hospital environments, to discuss CM options with patients. This engagement can help demystify hypnosis and reduce resistance to unfamiliar interventions.^8,20,26

All interviewed HPs practicing hypnosis were also specialized in palliative care. For some, the practice of hypnosis enabled them to improve the quality of care they provided. However, in some palliative care units, CM practitioners are external consultants, without specific palliative care expertise. It is essential to ensure that professionals practicing hypnosis in this field of practice have the necessary background to address specific symptoms, such as death anxiety. Accurate assessment and appropriate referral to skilled professionals in both hypnosis and palliative care are crucial.

The Needs of Patients and Their Relatives

Participants’ expectations and reasons for seeking or accepting hypnosis revealed several needs. Consistent with prior studies, primary motivations included symptom relief and overall well-being.^27,28 Additionally, the relationship between the therapist and the patient was highly valued, emphasizing the importance of personal connection in enhancing the effectiveness of hypnosis. Since the early work of Milton Erickson, the importance of the relationship as a potentiator of hypnotic trance is well known.²⁹ The patients’ experience of our study is likely part of this dimension, which also favors greater mind-body communication in hypnosis.³⁰ The concept of “empathic hypnosis,” where the therapeutic relationship enhances the hypnotic experience, was particularly relevant in this palliative care setting. Participants noted that the lack of direct contact with a therapist was a significant barrier to self-hypnosis, highlighting the importance of resources that recreate the therapist’s presence.^23,31,32

Organizational and logistical needs, such as scheduling flexibility and the availability of HPs, were also identified as critical factors for successful hypnosis sessions. Addressing these needs can facilitate better integration of hypnosis into palliative care routines.³³

Strengths and Limitations

The richness of our findings stems from the diversity of our participants, including hypnosis practitioners, beneficiaries, relatives, and nonpracticing HPs interacting with beneficiaries of the intervention. This diversity enabled a comprehensive understanding of how hypnosis is offered and the associated challenges. However, our study has several limitations. We provide only indirect evidence regarding reasons for refusing hypnosis. Additionally, patients and relatives often did not distinguish between hypnosis and self-hypnosis, complicating post hoc differentiation. There may also be analysis bias since F.T.L., who conducted hypnosis sessions, participated in data analysis. Despite this, interviews were conducted by another researcher, and F.T.L. was blinded to participant identities during the analysis.

Conclusion

This study underscores the potential benefits of integrating hypnosis into palliative care, including symptom relief and enhanced well-being. Addressing the identified barriers and needs can lead to more widespread acceptance and utilization of hypnosis, ultimately improving the quality of care for patients and their relatives. Future studies should focus on larger, more diverse populations and assess the impacts of hypnosis on palliative care patients and their relatives using quantitative data. For effective implementation, it is necessary to follow the different steps for intervention implementation using a model such as the Medical Research Council Guidelines for Complex Interventions. Additionally, it will be necessary to educate all health care professionals about hypnosis, develop systematic screening processes, and ensure that hypnosis practitioners possess specialized skills in both hypnosis and palliative care.

Footnotes

Acknowledgment

The authors are grateful to the participants who talked about their experience, as well as to the HPs who helped with recruitment, and in particular to Lara Fillon.

Author Disclosure Statement

The authors declare no competing financial interests.

Funding Information

This study was funded by the Leenaards Foundation “Santé integrative.”

Supplementary Material

References

Kelley

, Morrison

. Palliative care for the seriously ill. N Engl J Med, 2015; 373(8):747–755; doi: 10.1056/NEJMra1404684

Bell

, Liu

, Cheng

, et al. Top ten tips palliative care clinicians should know about integrative palliative care. J Palliat Med, 2023; 26(12):1719–1727; doi: 10.1089/jpm.2023.0219

World Health Organization. WHO global report on traditional and complementary medicine 2019. World Health Organization: Geneva; 2019. Available from: https://search-ebscohost-com-443.web.bisu.edu.cn/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=2260110

Marchand

. Palliative and end of life care. In: Integrative Medicine. ( Rakel

, Minichiello

.Eds). 5th Edition. Elsevier, 2023, pp. 690–701.

Berna

, Goritz

, Mengin

, et al. Alternative or complementary attitudes toward alternative and complementary medicines. BMC Complement Altern Med, 2019; 19(1):83.

Chiaramonte

, Adler

. Integrative palliative care: A new transformative field to alleviate suffering. J Altern Complement Med, 2020; 26(9):761–765.

Facco

, Casiglia

, Zanette

, et al. On the way of liberation from suffering and pain: Role of hypnosis in palliative care. Ann Palliat Med, 2018; 7(1):63–74. https://hdl-handle-net-s.web.bisu.edu.cn/11577/3234136

Booth

. Hypnosis in a specialist palliative care setting–enhancing personalized care for difficult symptoms and situations. Palliat Care Soc Pract, 2020; 14:2632352420953436; doi: 10.1177/2632352420953436

Elkins

, Barabasz

, Council

, et al. Advancing research and practice: The revised APA division 30 definition of hypnosis. Int J Clin Exp Hypn, 2015; 63(1):1–9.

10.

Brann

, Owens

, Williamson

. The Handbook of Contemporary Clinical Hypnosis, Theory and Practice. John Wiley & Son: Chichester; 2015.

11.

Plaskota

, Lucas

, Evans

, et al. A hypnotherapy intervention for the treatment of anxiety in patients with cancer receiving palliative care. Int J Palliat Nurs, 2012; 18(2):69–75; doi: 10.12968/ijpn.2012.18.2.69

12.

Brugnoli

. Clinical hypnosis for palliative care in severe chronic diseases: A review and the procedures for relieving physical, psychological and spiritual symptoms. Ann Palliat Med, 2016; 5(4):280–297; doi: 10.21037/apm.2016.09.04

13.

Liossi

, White

. Efficacy of clinical hypnosis in the enhancement of quality of life of terminally ill cancer patients. Contemporary Hypnosis, 2001; 18(3):145–160; doi: 10.1002/ch.228

14.

Teike Luethi

, Currat

, Spencer

, et al. L’hypnose: Une ressource en soins palliatifs? Étude qualitative sur l’apport de l’hypnose chez des patients oncologiques. Rech Soins Infirm, 2012(3):78–89; doi: 10.3917/rsi.110.0078

15.

Bissonnette

, Dumont

, Pinard

, et al. Hypnosis and music interventions for anxiety, pain, sleep and well-being in palliative care: Systematic review and meta-analysis. BMJ Support Palliat Care, 2022; 13(e3):e503–e514; doi: 10.1136/bmjspcare-2022-003551

16.

Landry

, Stendel

, Landry

, et al. Hypnosis in palliative care: From clinical insights to the science of self-regulation. Ann Palliat Med, 2018; 7(1):125–135.

17.

Vayne-Bossert

. Hypnosis for symptom management in adult cancer patients: What is the evidence? Curr Treat Options Oncol, 2024; 25(3):364–375; doi: 10.1007/s11864-023-01168-y

18.

Armstrong

, Kupeli

, Flemming

, et al. Complementary therapy in palliative care: A synthesis of qualitative and quantitative systematic reviews. Palliat Med, 2020; 34(10):1332–1339; doi: 10.1177/0269216320942450

19.

Appel

. When hope is lost. Am J Clin Hypn, 2023; 1–12; doi: 10.1080/00029157.2023.2249058

20.

Szmaglinska

, Kirk

, Andrew

. Reporting and mapping research evidence on perceptions of clinical hypnosis among the general population and patients receiving health care including cancer care: A scoping review. Int J Clin Exp Hypn, 2024; 72(1):29–50; doi: 10.1080/00207144.2023.2276457

21.

Szmaglinska

, Andrew

, Massey

, et al. Exploring the underutilized potential of clinical hypnosis: A scoping review of healthcare professionals’ perceptions, knowledge, and attitudes. Int J Clin Exp Hypn, 2024; 72(2):109–138; doi: 10.1080/00207144.2023.2276451

22.

Kassis

, Papps

. Integrating complementary and alternative therapies into professional psychological practice: An exploration of practitioners’ perceptions of benefits and barriers. Complement Ther Clin Pract, 2020; 41:101238; doi: 10.1016/j.ctcp.2020.101238

23.

Mitchinson

, Chu

, Bruun

, et al. How best to capture the impact of complementary therapies in palliative care: A systematic review to identify and assess the appropriateness and validity of multi-domain tools. Palliat Med, 2022; 36(9):1320–1335; doi: 10.1177/026921632211229

24.

Anderson

, Downing

, Hill

, et al. Palliative Performance Scale (PPS): A new tool. J Palliat Care, 1996; 12(1):5–11.

25.

Clarke

, Braun

. Thematic analysis. The Journal of Positive Psychology, 2017; 12(3):297–298.

26.

Renold

, Berner

, Coen

. Hypnose médicale: Mythes et réalités. Rev Med Suisse, 2024; 20(858):167–169; doi: 10.53738/REVMED.2024.20.858.167

27.

Roth

, Highfield

, Cuccaro

, et al. Employing evidence in evaluating complementary therapies: Findings from an ethnography of integrative pain management at a large urban pediatric hospital. J Altern Complement Med, 2019; 25(S1):S95–S105; doi: 10.1089/acm.2018.0369

28.

Eliott

, Kealey

, Olver

. (Using) complementary and alternative medicine: The perceptions of palliative patients with cancer. J Palliat Med, 2008; 11(1):58–67; doi: 10.1089/jpm.2007.0102

29.

Short

. Conversational hypnosis: Conceptual and technical differences relative to traditional hypnosis. Am J Clin Hypn, 2018; 61(2):125–139; doi: 10.1080/00029157.2018.1441802

30.

Flemons

. Toward a relational theory of hypnosis. Am J Clin Hypn, 2020; 62(4):344–363; doi: 10.1080/00029157.2019.1666700

31.

Wickramasekera

. Mysteries of hypnosis and the self are revealed by the psychology and neuroscience of empathy. Am J Clin Hypn, 2015; 57(3):330–348; doi: 10.1080/00029157.2014.978495

32.

Güthlin

, Holmberg

, Klein

. Oncologists’ experiences of discussing complementary and alternative treatment options with their cancer patients. A qualitative analysis. Support Care Cancer, 2016; 24(9):3857–3862; doi: 10.1007/s00520-016-3205-3

33.

Greer

, Applebaum

, Jacobsen

, et al. Understanding and addressing the role of coping in palliative care for patients with advanced cancer. J Clin Oncol, 2020; 38(9):915–925; doi: 10.1200/JCO.19.00013

Supplementary Material

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