Cognitive Behavioral Therapy

Cognitive behavioral therapy or supportive counseling involves therapeutic techniques to help the patient obtain a sense of motivation, better acceptance, and improved self esteem. The initial task is to assess maladaptive conditions and consequent behavioral patterns. The therapist's role is one of support, acceptance, and facilitation of interaction; this interaction should be directive without being coercive. Referral to a skilled psychotherapist is recommended for optimal results.

Biofeedback

Biofeedback can be used to train the patient to relax specific tense muscles, to lessen autonomic arousal, and to promote general relaxation by providing biologic information (such as skin temperature) by means of a monitoring device. These devices are used in conjunction with other techniques such as relaxation exercises that achieve the desired effect. The role of biofeedback is limited in pain control, but it can be an adjunct to conventional pain therapy, contributing to helping the patient gain some control over the pain.

Self-Hypnosis

Another intervention that has been found useful in the treatment of cancer pain is self-hypnosis. However, not all pain responds to hypnosis. It appears that the depth of the hypnotic trance determines the quality of the response: the deeper the trance, the better the response. However, hypnosis as an adjuvant to other cancer pain treatment is helpful in a significant number of patients. It is a skill that should be taught by a qualified therapist.

Relaxation Training

Relaxation exercises can be useful in assisting the patient to promote muscle relaxation, improve blood flow to a painful part, as well as to reduce anxiety. Several techniques may be employed including progressive muscle relaxation, rhythmic breathing, and guided imagery. These can be used individually or in combination and should be individually tailored to the patientıs needs and preferences.

Progressive muscle relaxation involves focusing on individual body parts in an orderly succession (e.g. from toes to head.) The patient is asked to alternately tense and relax each area and to focus on the warmth and relaxation that ensues.

Rhythmic breathing involves focusing the patientıs attention on the breathing pattern and consciously increasing the depth and slowing the rate of breathing.

Guided imagery involves focusing concentration on a situation, feeling, or experience that is pleasant or soothing to the patient. Subject matter should be chosen that the patient has familiarity with and considers to be pleasant and/or soothing.

Any of these techniques can be enhanced through the use of music or recorded tapes that walk the patient through the process step by step. It is important to choose music or other recordings that the patient finds appealing for them to be successful.

Health care professionals are encouraged to try these exercises themselves to become familiar with the techniques and learn first hand of their potential benefits.


The "Therapeutic Milieu"

A recent and welcomed development in the care of cancer pain patients is the hospice. It has been observed that when patients enter a hospice, the control of pain improves significantly. One probable contributing factor is the high priority hospices give to psychosocial and spiritual issues. In a hospice, everyone gets involved in the treatment- patient, family, and health care providers - and all of them are considered to be subject to significant stress; therefore, support mechanisms are established for all. A hospice is able to provide multidimensional care that requires, of course, a multidisciplinary team approach. The family is not the patient's only source of support. However, involvement of family members in patient care is seen as preparing them for their period of bereavement. The reality and the imminence of death are not denied but rather dealt with directly. The atmosphere is relaxed in terms of regulations regarding visitors, food, and terms of daily living, in contrast to the more structured environment in a hospital. The establishment of hospices should be encouraged in all communities, and thought should be given to improvements that can be made in the "milieu" for the treatment of all pain, not reserving this approach for terminal patients alone. There is a growing emphasis on palliative care as a supportive approach involving pain and symptom management throughout the course of the patientıs experience with cancer, not just when the end of life is near and all tumor treatment options have been exhausted.