WHAT
EVERY PAIN THERAPIST
SHOULD KNOW ABOUT
GUIDED IMAGERY
by
David E. Bresler, Ph.D., L.Ac.,
Dipl.Ac.(NCCAOM)
President, Academy for Guided Imagery, Malibu, California
Former Founder and Executive Director, UCLA Pain Control
Unit
Former Associate Clinical Professor, UCLA School of
Medicine
Former White House Commissioner on Complementary
and Alternative Medicine Policy.
This article was previously published in:
Professional Pain Management
(September/October, 2005)
Mailing Address:
Academy for Guided Imagery
30765 Pacific Coast Hwy 355
Malibu, CA 90272
Tel: 800-726-2070
FAX:800-727-2070
www.AcadGI.com
Email: info@AcadGi.com
“Imagination is more important than knowledge, for
knowledge has its limits
”……. Albert Einstein
Mental images, formed long
before we learn to understand and use words, lie at the
core of who we think we are, what we believe the world is
like, what we feel we need and deserve, and how motivated
we are to take care of ourselves. They strongly influence
our beliefs and attitudes about how we fall ill, what might
help us get better, and whether or not any medical and/or
psychological interventions will be effective or even
helpful. For these reasons, learning how to guide our
patients’ imagery can be an enormously helpful tool for
modern pain therapists.
A mental image can be defined as a thought with sensory
qualities. It is something we mentally see, hear, taste,
smell, touch, or feel. The term “guided imagery” refers to
a wide variety of mind/body techniques, including simple
visualization and direct suggestion using imagery, metaphor
and story-telling, fantasy exploration, game playing, dream
interpretation, drawing, and “active imagination” where
elements of the unconscious are invited to appear as images
that can communicate with the conscious mind.
Once considered “mumbo-jumbo,” or at best, an “alternative”
or “complementary” approach, guided imagery is finding
widespread scientific[1] and public[2] acceptance, and
nearly ever bookstore now offers guided imagery self-help
CDs or tapes[3].
Guided imagery and other mind/body techniques are now being
taught to medical students and residents, and in a survey
of 53 medical schools conducted in 2000, 66% taught
meditation and relaxation, 37% taught guided imagery, and
34% taught biofeedback[4].
Because it is simple and highly cost effective to provide
imagery tapes or CDs, many health professionals have begun
recommending or using them to help relieve their patient’s
symptoms, teach stress management and psychophysiologic
relaxation, prepare patients for surgery, enhance tolerance
to procedures, alleviate anxiety and depression, improve
sleep, wean patients from medications, enhance treatment
compliance, promote rehabilitation, and accelerate healing
responses in the body.
Pain therapists utilize imagery in nearly every interaction
we have with patients (whether we are aware of it or not),
so below is my personal list of what every contemporary
pain therapist should know about guided imagery.
(1)
Historically, more people have been treated using guided
imagery than by any other therapeutic
intervention.
Despite guided imagery's recent emergence as a therapeutic
tool, its roots date as far back as the very first healing
prayers and rituals. Such ceremonies use imagery (either
overtly or covertly) to represent and evoke hopes, beliefs,
attitudes, and expectations, so in a sense, imagery can be
considered the oldest and most ubiquitous form of therapy.
The imagery-laden healing rituals of ancient cultures must
have had a certain level of efficacy or they wouldn’t have
persisted over time. Today, while we may dismiss the
therapeutic power of “faith healings” as a “placebo
effect,” the benefits are real and measurable with
important implications for our understanding of how healing
occurs.
Anton Mesmer’s ‘magnetic passes’ evoked remarkable and well
documented healings in early 19th century France. The
scientific basis underlying these healings was attributed
by the French Academy of Sciences to “the effects of the
imagination.” Later, Charcot and his student, Sigmund
Freud, further developed hypnosis and free association as a
way of exploring the subconscious mind.
Modern psychotherapists have since utilized a variety of
imagery techniques to tap the contents of the subconscious.
Hermann Rorschach, the Swiss psychiatrist, used
standardized ink-blot designs to examine the psychological
relevance of various non-descript images to his patients'
mental states. Carl Jung contended that the unconscious was
also the repository of our intuition, creativity,
compassion, and our deepest, most positive hopes for
fulfillment and self-actualization, and utilized attention
to spontaneous images as a way of connecting with it’s
wisdom. Roberto Assagioli, an Italian psychiatrist and
contemporary of Freud and Jung, developed Psychosynthesis,
which extensively utilizes sophisticated imagery
techniques.
(2) Patients
(and their doctors) use imagery all the time.
The most common way we use imagery is by worrying. Where
does worrying occur? Mainly in your imagination. The two
most common worries are regretting the past and fearing the
future. In the first case, we bring images from the past
into our imagination to analyze like an instant replay over
and over again. In the second case, we create fictional
future scenarios that only happen in our imagination. As
has been said, “yesterday is history, tomorrow’s a mystery.
Today’s a gift. That’s why it’s called “the present.”
We also use imagery whenever we mentally plan or prepare
for anything, If you’ve ever remodeled a room, or figured
out which would be the fastest way home, you’ve used mental
imagery to compare possible alternatives.
Between worrying and planning, a great deal of attention is
focused on the “movies” we write, produce, direct, and act
out in our imagination. It’s also helpful to remember that
whatever you give attention to grows, whether it’s your
garden, your children, or your worries and fears. Thus,
instead of promoting worrying by focusing our patients’
attention on what they can’t do (e.g., by listing
disabilities and limitations, writing restrictions, etc.),
perhaps we should be encouraging them to imagine all that
they might be able to do in time over time.
(3) Imagery has
powerful physiological consequences.
The body tends to respond to mental imagery exactly as it
would to a genuine external experience. Numerous studies
have shown that imagery can affect almost all major
physiologic control systems in the body, including
respiration, heart rate, blood pressure, metabolic rates in
cells, gastrointestinal motility and secretion, sexual
function, cortisol levels, blood lipids, and even immune
responsiveness[5].
To briefly experience this mind/body connection, take a
moment to imagine that you have a big, plump, fresh, juicy,
yellow lemon in your hand. Notice its heaviness and fresh
lemony smell. Now, imagine taking a knife and carefully
slicing into the lemon, cutting out a thick, plump, juicy
section.
Now imagine taking a deep bite of the lemon slice and
feeling the sudden burst of flavor as that sour, tart,
lemon juice touches your tongue, saturating every taste bud
in your mouth so fully that your lips pucker and your
tongue begins to curl. Imagine that sour, tart, lemon juice
swirling all around the back of your mouth, and down your
throat.
If you are able to imagine this vividly, you are probably
salivating right now, for your autonomic nervous system
understands and automatically responds to the language of
imagery. In the same way, an erotic thought can produce an
immediate and dramatic constellation of autonomic responses
throughout your entire body.
If imagining a lemon makes a person salivate, what happens
when they imagine themselves as helpless, hopeless victims
of intractable pain? Doesn’t that inform their healing
systems to simply surrender and give up? Isn't such
negative thinking likely to create neural and biochemical
signals appropriate to being defeated and depressed?
On the other hand, it’s well known that positive images
(such as those evoked by “placebo effects) can stimulate
healing in nearly all bodily systems.[6]
(4) Words can
evoke healing or hurting images.
When training medical students, interns, or residents in
pain medicine, I urge them to carefully select the words
they use in their interactions with patients. Even while
collecting “objective” data, such as a range of motion
measurement, a practitioner’s words can evoke negative
images and expectations that can greatly affect “objective”
findings.
For example, when maneuvering a patient’s upper extremity
to measure shoulder range of motion, students typically
say, “Tell me when it hurts” or “Is this painful?” When
palpating a traumatized muscle, they might ask “Is this
tender?” or “How much pain does this cause on a 1 to 10
scale?” The images that these words evoke cause the
expectation that even more pain is on the way, so patients
brace, contract their muscles, and tighten their joints in
preparation, limiting their range.
When I repeat the exact same examination but say “Does this
feel OK?” or “Is this comfortable?” or “Can you do this
easily?”, strikingly different “objective” findings are
obtained. These words evoke more positive images,
expectations, and intentions that encourage patients to
relax their muscles and unlock their joints, yielding
greater range of motion.
(5) Guided
imagery is a low risk, low cost alternative for helping
patients control symptoms.
When weaning patients from pain medications or performing
uncomfortable procedures, guided imagery and other
mind/body interventions are low risk, cost effective
alternatives for helping patients achieve acute symptomatic
pain relief.
A wide variety of guided imagery techniques can be used to
help alleviate painful symptoms[7-8]. These include symptom
suppression techniques such as "glove anesthesia,” a
two-step imagery exercise in which patients first are
taught to imagine developing feelings of numbness in their
hand, as if it were being placed into an imaginary
anesthetic glove. Next, they learn to transfer these
feelings of numbness to any part of the body that hurts,
simply by placing the "anesthetized" hand on it.
Glove anesthesia helps to "take the edge off" the pain
sensation, and it provides a dramatic illustration of the
power of self-control, for when patients realize that they
can produce feelings of numbness in their hands at will,
they recognize that they may be able to better control
their pain symptoms, too.
Symptom substitution, time distortion, and imagery dialogue
techniques can also be helpful, and researchers are now
reporting the benefits of guided imagery in treating
headaches[9-10], arthritis[11], burn patients[12],
post-surgical pain[13], pediatric pain[14], and a variety
of other chronic pain problems[15].
(6) Guided
imagery can greatly enhance symptom tolerance.
To me, there are three major goals of modern pain
management: (1) Decrease the pain signal; (2) Increase pain
tolerance, and (3) Teach self-management skills. Many pain
interventions attempt to interfere with transmission of the
pain signal by interrupting it (e.g., nerve blocks) or
competing with it (e.g., TENS units). Others (e.g.,
opiates) work by increasing a patient’s tolerance to the
pain they experience.
I’ve long believed that endorphins have little to do with
pain and much to do with suffering or a lack of pain
tolerance. When patients are given opiates (which mimic the
effect of endorphins), they often state that “it still
hurts, but it doesn’t bother me as much.” Opiates don’t
block the pain signal; they enhance the patient’s tolerance
to pain, and thus reduce suffering.
Tolerance can often be assessed by inviting patients to
draw a picture of their pain (see Figure One). When this
picture was discussed with the patient (who was diagnosed
with post-laminectomy syndrome), he discovered that it was
the pressure of family demands that was “tightening the
clamp” and making his pain unbearable. With the help of
family therapy, his pain tolerance was greatly improved and
his suffering alleviated.
Because of the intimate relationship between imagery and
state-dependent learning, the structured use of memory,
fantasy, and sensory recruitment can also help patients
move from affective states characterized by fear, anxiety,
confusion and hopelessness to those incorporating calmness,
clarity, strength and courage, all of which enhance pain
tolerance.
Guided imagery techniques represent a low risk,
cost-effective way to reduce the pain signal, enhance pain
tolerance, and teach patients relaxation, stress
management, emotional control, improved sleep habits, and
other important self-management skills, and more pain
therapists are beginning to use them.
(7) Guided
imagery can help better prepare patients for surgery or
invasive procedures.
It is well known that a person’s suggestibility is greatly
increased prior to surgery. When patients are asked to read
and sign an Informed Consent form, one must wonder if the
detailed list of potential risks that are so clearly
described might evoke negative images and expectations that
could affect the outcome of the procedure. That’s why it’s
a good idea after obtaining Informed Consent to tell
patients, “Now that we’ve reviewed everything that could
possibly happen, let’s discuss what’s most likely to happen
and how by working together we can get the results we both
want to achieve.”
Researchers have found that when patients were given
preoperative suggestions for early return of GI motility,
they were discharged 1.5 days sooner at a savings of $1,200
per patient compared to a control group given only
instructions and reassurance[16]. Similar benefits have
been reported for patients undergoing colorectal
surgery[17-18]. In addition, Blue Shield of California
reported an average savings of $654 per patient who
listened to a guided imagery tape for surgical preparation.
These patients also reported increased satisfaction with
their care, and over 80% would recommend this to a friend
or family member. Many pre-recorded surgical preparation
tapes and CDs are now commercially available.[3]
(8) Guided
imagery can enhance compliance with treatment
recommendations.
The lack of a patient’s compliance with their pain
therapist’s recommendations is often the result of an inner
conflict between one part of the patient who wants to
follow orders and get better, and another part that
believes that following orders will be uncomfortable, time
consuming, expensive, and/or unhelpful.
By inviting patients to “allow an image to form for some
part of you that doesn’t want to comply” and then
facilitating a dialogue with the image, you can often
quickly determine why resistance is present, and what is
needed to overcome it.
Patients can also be given an “Inner Advisor”, “Inner
Coach”, or “Inner Doctor” who lives in their imagination
and constantly supports their plans for getting better.
(9) Guiding
imagery can help motivate and track progress of patients in
rehabilitation.
It has been said that “you can lead a horse to water but
you can’t make him drink unless you make him thirsty.” When
patients in rehab process images of pain, discomfort,
helplessness, and a lack of progress, they often become
discouraged and lose motivation to complete rehabilitation
therapy. Helping patients replace these with positive
images of what they may be able to do upon completion of
rehab greatly stimulates their desire to achieve their full
potential.
Imagery can also be used to track a patient’s progress by
having them draw an image of their pain each time they are
seen for care.
(10) Guided
imagery is most effective when utilized
interactively.
Over the past 25 years, Martin Rossman and I have developed
a variety of ways to utilize imagery “interactively” to
teach patients how to draw on their own inner resources to
support healing, to make appropriate adaptations to change,
and to find creative solutions to challenges they
previously thought were insoluble. This Interactive Guided
Imagerysm approach is particularly useful in the
current era of managed care, where cost-effective mind/body
medicine, improved medical self-care, and briefer, yet
deeper, more empowering approaches to health care are much
welcomed and greatly valued by patients, providers, and
insurers alike.[19]
REFERENCES
[1]
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medicine: state of the science, implications for practice.
J Am Board Fam Pract. 2004:165(2):131-147.
[2] Eisenberg DM, Davis RB, Ettner SI, et al. Trends in
alternative medicine use in the United States, 1990-1997:
results of a follow-up national survey. JAMA.
1998:280(18):1569-1575
[3] An excellent selection of pre-recorded guided imagery
CDs can be found by visiting the Imagery Store at
www.AcadGI.com.
[4] Brokaw JJ, Tunnicliff G, Raess BU, Saxon DW. The
teaching of complementary and alternative medicine in U.S.
medical schools: a survey of course directors. Acad Med.
2002;77(9):876-881.
[5] Sheikh, A, Kunzendorf RG. Imagery, physiology, and
psychosomatic illness. In International Review of Mental
Imagery. New York: Human Sciences Press, 1984.
[6] Frank J. Persuasion and Healing. New York: Schocken
Books, 1974.
[7] Bresler D. Free Yourself From Pain. New York: Simon and
Schuster, 1979; Malibu, CA: Alphabooks, 1995.
[8] Bresler, D. Clinical applications of interactive guided
imagery(sm) for diagnosing and treating chronic pain, in:
Weiner’s Practical Pain Management. 7th Edition New York:
CRC Press, 2005.
[9] Brown JM. Imagery coping strategies in the treatment of
migraine. Pain. 1984 February; 18(2):157-67
[10] Mannix LK, Chandurkar RS, Rybicki LA, Tusek DL,
Solomon GD. Effect of guided imagery on quality of life for
patients with chronic tension-type headache. Headache.
1999; 39(5):326-34
[11] Rider MS. Treating arthritis and lupus patients with
music-mediated imagery and group psychotherapy. Arts in
Psychotherapy. 1990 Spr 17(1) 29-33.
[12] Achterberg J, et al. Severe burn injury: comparison of
relaxation, imagery and biofeedback for pain management. J
Mental Imagery, 1988 spr 12(1) 71-87.
[13] Daake DR. Imagery instruction and the control of
postsurgical pain. Applied Nursing. 1989 Aug 2(3) 114-120.
[14] Krueger LC. Pediatric pain and imagery. J Child
Adolescent Psychiatry, 1987 4(1) 32-41.
[15] Newshan G. Use of imagery in a chronic pain outpatient
group. Imagination, Cognition, and Personality, 1990-91
10(1) 25-38.
[16] Disbrow EA, Bennett HL, Owings JT. Effect of
preoperative suggestion on postoperative gastrointestinal
motility. West J of Med.. 1993 May; 158
[17] Tusek DL, Church JM, Strong SA, Grass JA, Fazio VW.
Guided imagery: a significant advance in the care of
patients undergoing elective colorectal surgery. Diseases
of the Colon and Rectum. 1997 February; 40(2):172-8.
[18] Renzi C, Peticca L, Pescatori M. The use of relaxation
techniques in the perioperative management of proctological
patients: preliminary results. International Journal of
Colorectal Diseases. 2000
[19] For additional information concerning training
programs, research projects, and imagery books, tapes, CDs,
and DVDs, contact the Academy for Guided Imagery, 30765
Pacific Coast Hwy #355, Malibu, CA 90265, Phone:
800-726-2070 info@acadgi.com
©Copyright 2005 by David E. Bresler, PhD,LAc. All rights
reserved. This article may be copied, reprinted, and/or
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