295DOI: 10.1089/act.2008.14604 • MARY ANN LIEBERT, INC. • VOL. 14 NO. 6DECEMBER 2008

Guided imagery is a mind–body therapy that has been used for decades by individuals and in clinical settings to influence health outcomes. Guided imagery is particularly helpful for pain management and for reducing symptoms related to anxi-ety, stress, and other mental health conditions in which intrud-ing thoughts play a role in the pathology.

Guided imagery can be an important adjunctive therapy to a conventional treatment approach for various conditions. In patients with chronic pain, for instance, medications and stan-dards of care may not be enough to reduce or eliminate the pain significantly. Complementary therapies, such as guided imagery, when practiced regularly, can decrease pain further and reduce the need for pain medications. Guided imagery can be practiced by individuals on their own, which leads to increased feelings of self-mastery and control, and at very low or no cost to persons, using the therapy. In addition, another benefit is that patients can practice the technique in virtually any location. Individuals may use an imagery practice during stressful medical testing such as getting magnetic resonance imaging (MRI), as well as at home, in the operating waiting room, or on a subway.

Guided imagery has been practiced, written about, and re-searched for decades and has been used in religious, secular, and diverse cultural settings. From shamanism to psychotherapeutic settings, guided imagery has become a well-known complemen-tary therapy. Increasingly, this imagery is utilized in clinical set-tings and is often encouraged and implemented by nurses. Blue Shield of California began offering guided imagery tapes to its presurgical patients due to increasing evidence that guided im-agery may decrease surgical complications and reduce postop-erative pain and pre- and postoperative anxiety.1

This article includes a description of guided imagery, a sam-pling of available research evidence on the topic, resources, and one woman’s experience with guided imagery.

Definition and Description

Guided imagery is a technique that utilizes stories or narra-tives to influence the images and patterns that the mind cre-ates. Often, these stories or narratives are combined with back-ground music. Merriam-Webster’s dictionary defines guided imagery as: “any of various techniques (as a series of verbal suggestions) used to guide another person or oneself in imag-ining sensations and especially in visualizing an image in the mind to bring about a desired physical response (as a reduction in stress, anxiety, or pain).”2 Basically, guided imagery is using the imagination to create images that bring about beneficial emotional and physical effects.

Noted guided imagery expert Belleruth Naparstek, L.I.S.W., wrote that imagery is “any perception that comes through any of the senses including sight, sound, smells and feel.”3 She also wrote about recalling the smell of the air dur-ing a first snowfall and how the recollection of such imagery evokes specific sensations and memories in a person although that event may not be happening in the present moment. Ms. Naparstek wrote that imagery can seem as real as actual events and, thus, therein lies its power. Guided imagery can evoke neurohormonal changes in the body that mimic the changes that occur when an actual event occurs, according to Ms. Naparstek. She wrote that people can intentionally cre-ate healthful imagery that has beneficial physical and emo-tional effects in the body and mind.

Guided imagery may be delivered by a practitioner, a video, or an audio recording, or conducted by an individual. A typi-cal guided-imagery session usually begins with relaxation in which the participant takes some deep breaths and releases tension in his or her mind and body. Then, the participant starts to visualize pleasant or effective imagery that may pro-mote healing.

Guided Imagery

Jane Hart, M.D.

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son who has cancer and visualizes cancer cells in his or her body being destroyed and killed, which can lead to increased feelings of power and control in that individual.4

In a review on the effects of guided imagery on outcomes, Van Kuiken described four types of guided imagery, which in-clude pleasant imagery (imagining a calm place), physiologi-cally focused imagery (focusing on the physiologic function that needs healing), mental rehearsal or reframing (imagining a specific task or performance before the event occurs or re-framing a prior event), and receptive imagery (scanning the body to direct healing).5

Guided imagery may be most effective in group settings, with the use of music, and when the imagery matches a person’s values and comfort level, according to Ms. Naparstek.3 She also wrote that guided imagery becomes increasingly effective with time and practice. She discriminates guided imagery from meditation and hypnosis, writing that the latter are broader categories under which guided imagery may apply. Hypnosis generally includes verbal suggestions without images, and meditation commonly focuses on one thing, such as the breath or a mantra. But guided imagery, according to Ms. Naparstek, for instance, can be con-sidered a form of meditation.

Weydert and colleagues commented that guided imagery is different than hypnosis in that a person creates individual-ized imagery rather than a therapist giving a specific sug-gestion for change.6 They stated that “guided imagery allows for communication with the subliminal part of the mind to create change.”

The exact mechanisms by which guided imagery works are not well-known, but theories include the fact that relaxation and positive imagery attenuate psychoneuroimmunologic and hormonal pathways that affect the stress response.5,6 One study suggested that the mechanism may be through the Gate Control Theory, which proposes that “only one impulse can travel up the spinal cord to the brain at a time” and “if this pathway is occupied with other thoughts, then the sensations of pain cannot be sent to the brain, and therefore the pain is re-duced.”7 Guided imagery may also release endorphins, which attenuate the pain response and may reduce pain or increase the pain threshold.7

Research on Guided Imagery

Evidence exists supporting the role of guided imagery for managing stress, anxiety, depression, side-effects related to chemotherapy, pain, and hypertension, preparation for medical procedures, stress during hospital stays, and other states and conditions, as well as for reducing length of hospital stays.8,9

Criticism about existing guided imagery research includes the fact that many studies have heterogenous populations, het-erogenous interventions and outcomes measures across studies, low methodological quality, and lack of knowledge about opti-mum timing and dose of treatment and individual differences, such as outcome expectancy, the ability to create imagery, and perceived credibility of the guided-imagery provider.8,10

The theory behind the use of guided imagery is that if a per-son can imagine negative or frightening images that increase pain or anxiety, then those images may be counteracted with positive or calming images, and the mind can be habitually trained to focus on healing imagery more often. And, if fright-ening or negative imagery has the ability to increase pain and other unwanted symptoms, then positive or calming imagery may lessen pain and unwanted symptoms, according to advo-cates of this approach.

An important point, however, is that guided imagery may include positive thinking but should not be limited to that construct when describing this therapy. For instance, guided imagery may utilize aggressive thinking as in the case of a per-

Boldly Going to Seek and Destroy Cancer CellsOne Woman’s Experience with Guided Imagery

During Chemotherapy

Elizabeth McKinley, M.D., M.P.H., was first diagnosed with breast cancer when she was 36 years old. Juggling a busy career in breast-cancer research and internal medicine, along with rais-ing children and going through treatments for her cancer, Dr. McKinley felt overwhelmed by her circumstances. She reached out to a number of different resources to help her get through this stressful time, including a support group at University Hos-pitals in Cleveland, Ohio, where the invited guest speaker was Belleruth Naparstek, L.I.S.W., a well-known leader in the field of guided imagery. During her presentation in Dr. McKinley’s group, Ms. Naparstek distributed tapes about the use of guided imagery during chemotherapy.

“I listened to the tape and found her voice soothing,” said Dr. McKinley. “There were affirmations on the other side of the tape with statements of fact like, ‘I’m feeling calm.’ She walked you through how you might think about an image that helps you feel more in control with what is happening.” For example, Ms. Naparstek shared how a person might create imagery around cancer cells being destroyed and gave examples in her talk that some people needed images that portrayed an aggressive approach. Dr. McKinley felt it was important for her imagery to be individualized in order to work and to be “hers.”

“After listening to the tapes, I had an image of Star Trek,” said Dr. McKinley. “The captain Jean-Luc Picard is portrayed as an infallible character who I thought I could trust, and so I created an image of him on the bridge of the Starship Enterprise. In my mind, I had him send out shuttle craft to gobble up the cancer cells in my body and ‘seek and destroy’ the cancer cells. Every time Picard sent a shuttlecraft out he would say: ‘Engage!’ The idea is that I was confident that he wouldn’t miss anything and that my cancer cells would be destroyed.” Dr. McKinley stated that, over time, she was able to conjure up that image more easily, and this would greatly calm her down during and after chemotherapy. “I felt a little bit more in control when the scary medicine was snaking through my veins,” said Dr. McKinley.

Dr. McKinley noted that her chemotherapy medicine was, in reality, a flame-red color and elaborately covered in materials to protect other people from its toxicity—all of which scared her. Guided imagery helped her move past the frightening aspects of chemotherapy and radiation treatments, which lasted for 8 months. She said the imagery also provided humor. “I would even be laughing during my chemotherapy and people would ask what I was laughing at,” she said. “This imagery helped me keep a sense of humor during something so difficult and scary. My body relaxed and, after I focused on the image a few times, I really felt like it was happening and it was meditative. Some-times I had to ask people to be quiet so that I could focus on my image.”

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The effectiveness of guided imagery is, in part, dependent on the observations of people who have found the therapy to be useful. Participants in this study14 reported that the guided-imagery intervention was a source of distraction, provided un-interrupted quiet time, and stimulated relaxation; anesthetic images were helpful; and the intervention did not require ac-tive physical involvement. The participants also reported that the pacing of the imagery was important and that they needed enough time under the guidance of the person leading the im-agery to create personal images. Certain imagery worked for certain individuals, and other imagery did not help. Some of the nonresponders in this study reported that the type or in-tensity of their pain prohibited them from being helped by the intervention and that the guided imagery, in fact, increased or reignited their pain or simply did not help.

In another study, 69 hospitalized patients with cancer-relat-ed pain used a 12-minute guided-imagery tape with analgesic imagery that offered suggestions to increase patient comfort and provided pleasant nature imagery, including walking along a river among wildflowers.10 Participants filled out pain ques-tionnaires pre- and postintervention. The average pain-intensi-ty score was lower than baseline for 90% of the participants and remained unchanged or increased for 10% of these patients. History of prior imaging use and imaging ability were signifi-cant predictors of outcome expectancy and pain outcomes such as pain intensity and control over pain.

Pain Syndromes

Guided imagery has been shown to help alleviate pain and reduce the need for pain medication for various conditions. Guided imagery can also help change the language a person uses to describe pain and the pain experience. One study found that, before using guided imagery, patients described pain in a variety of ways, including: never-ending, explainable, torment, restrictive, and changeable.15 But after randomization into one of two groups—a guided-imagery group or a control group that was simply monitored—the treatment group reported pain as changeable, and the idea of pain as “never ending” did not reemerge in the treatment group but persisted in the con-trol group.

One study evaluated the role of guided imagery in patients undergoing colorectal surgery.16 Patients who participated in this trial were randomly assigned to receive standard periop-erative care or standard care along with guided imagery. The imagery group listened to a guided-imagery tape 3 days preop-eratively; a music-only tape during induction, during surgery, and postoperatively in the recovery room; and a guided-imag-ery tape during each of the first 6 postoperative days. Guided imagery reduced pre- and postoperative anxiety, postoperative pain, and the need for opioid medications in treatment sub-jects, compared with controls.

Guided imagery can be particularly effective in children who tend to be more suggestible than adults and more open to their own creativity and imagination. One study examined

There is an abundance of research on the use of guided im-agery for treating various conditions.

Cancer

A patient who receives a diagnosis of cancer is faced with an array of physical and emotional symptoms. Typical emo-tional symptoms include fear of pain, suffering, treatments and side-effects, recurrence of disease, death, and other events. Guided imagery can be particularly useful in help-ing patients who have cancer cope with treatments such as chemotherapy and radiation. One study examined the effects

of chemotherapy and/or radiation and found that anxiety lev-els increase significantly at the beginning of, and continue throughout, treatments in some individuals and that higher levels of anxiety are correlated with poorer quality of life.11 As a result, interventions are needed to help reduce unpleas-ant symptoms in an already-difficult scenario.

One systematic review on using guided imagery during chemotherapy treatment found that, of six randomized trials, three showed that guided-imagery groups reported beneficial differences in anxiety, comfort, or emotional responses to che-motherapy compared with the responses in control groups.12

Another study explored the effect of guided imagery on comfort levels in patients with breast cancer who were begin-ning radiation therapy.13 Women who used guided imagery reported more comfort compared with the control group. The women in the treatment group listened to a guided-imagery audiotape once per day during the study. The researchers not-ed that the guided-imagery intervention increased comfort in patients with breast cancer, without an increase in personnel, costs, or time.

Admission to a hospital for pain relief is common among patients who have cancer. Researchers who studied the effects of guided imagery on cancer pain reported that the evidence for benefit is supportive but studies vary in reported outcomes from significant relief to no relief.14 In this study, 26 partici-pants with cancer pain were interviewed about a study in which they were previously enrolled. This study included two trials of progressive muscle relaxation and two trials of guided imagery as an intervention for their pain. Approximately one half of the participants were responders to guided imagery, meaning that their pain scores were improved by 30% or more. Partici-pants who practiced progressive muscle relaxation had similar response rates and scores for pain reduction.

Guided imagery can be particularly useful in helping patients who have cancer cope with treatments such as

chemotherapy and radiation.

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Interstitial Cystitis

A new study has evaluated the effects of guided imagery on interstitial cystitis (IC), a painful bladder syndrome marked by pain, urgency, and frequency.7 Often, people with IC do not gain adequate relief with medications. Other studies have suggested that complementary therapies, such as biofeedback and hypnosis, have been helpful, but no studies had previously examined the role of guided imagery on IC. For this study, researchers enrolled 30 women with IC and randomly as-signed them to either a guided-imagery group or to a control group. The guided-imagery group was instructed to listen to a 25-minute guided-imagery tape twice a day for 8 weeks. The tape emphasized healing the bladder, relaxing pelvic muscles, and calming nerves. The control group was instructed to rest by sitting or lying down for 25 minutes twice a day for 8 weeks. Both groups continued standard care for IC and kept pain and medication diaries.

The researchers found that 45.5% of the participants in the guided-imagery group reported moderate or marked improve-ment of IC symptoms, compared with 14.3% of women in the control group. Pain scores and urgency significantly decreased in the guided-imagery group as well. The guided-imagery

group had significant reductions in pain scores from 5.5 at baseline to 2.57 at the end of the study, compared with the control group, in which pain levels did not achieve significant statistical improvement—4.89 at baseline and 4.39 at the end of the study.

Conclusion

Thoughts are powerful. Experts in guided imagery and re-search findings suggest that people have the power to change their thoughts to promote health. Patients can move from thoughts of fear and anxiety to thoughts of peace and whole-ness. Guided imagery may be more than just positive think-ing. The images people conjure up in their minds have lasting physiologic effects on their brains and bodies.

The challenge for clinicians regarding guided imagery and other effective complementary therapies is to remember to recommend and utilize such therapies as adjunctive tools to manage and treat patients’ conditions. Clinicians should in-quire about the accessibility of learning such therapies within their own institutions. n

the effects of guided imagery on recurrent abdominal pain from functional gastrointestinal (GI) disorders in children.6 In this study, 22 children, ages 5–18, were randomly assigned to breathing exercises alone or to guided imagery with progressive muscle relaxation, for 4 weekly sessions. The imagery group had an initial 1-hour appointment, and then each subsequent ap-pointment was 20–30 minutes. In the first session, the children were guided in relaxation techniques and then asked to create images that represented their pain and then images that would relieve their pain. The children were then sent home with a tape of the guided imagery session. Subsequent appointments were for assessing competence and compliance only.6

At the 1-month follow-up, children in the guided-imagery group had significantly greater decreases in number of days with pain compared with the breathing exercises alone group. The children in the treatment group also had significantly greater decreases in days of missed activities due to pain. After 2 months of follow-up, more children met the desired outcome of 4 days or less per month of abdominal pain and no missed activities compared with children in the breathing exercises alone group.6

Another study evaluated the effects of guided imagery on pain, function, and self-efficacy in people with fibromyalgia.17 In this study, 48 people with fibromyalgia were randomly as-signed to receive guided imagery plus usual care or usual care alone. The guided-imagery group listened to one guided-im-agery tape a day for a total of 10 weeks. The participants used three tapes, which each lasted 20 minutes, and included relax-ation, pleasant imagery, and imagery of practicing and perform-ing behaviors in a way the patients would like to if they were free of pain. Functional status and self-efficacy for managing pain were significantly improved in the guided-imagery group, compared with the usual-care group. There were, however, no significant improvements or differences in pain between the two groups on pain scores.17

Interestingly, in Van Kuiken’s review, she noted another study conducted on fibromyalgia in which patients whose imagery fo-cused on physiology and pain reported increases in pain, compared with patients whose imagery focused on attention-distracting or pleasant imagery, and who reported decreases in pain.5

Recommended ReadingWebsites

Belleruth Naparstek’s Web site: www.healthjourneys.com/index.asp

Academy of Guided Imagery: www.academyforguidedimagery.com/

Martin Rossman’s Web site: www.thehealingmind.org/

Books for Your Patients

Staying Well with Guided Imagery By Belleruth Naparstek New York: Warner Books, 1994

Guided Imagery for Self-Healing By Martin L. Rossman Tiburon, CA: H.J. Kramer Inc, 2000

In a new study using guided imagery on interstitial cystitis, pain

scores and urgency significantly decreased in this group.

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11. Schreier AM, Williams SA. Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer. Oncol Nurs Forum 2004;31:127–130.12. Roffe L, Schmidt K, Ernst E. A systematic review of guided imagery as an adjuvant cancer therapy. Psychooncology 2005;14:607–617.13. Kolcaba K, Fox C. The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy Oncol Nurs Fo-rum 1999;26:67–72.14. Kwekkeboom KL, Hau H, Wanta B, Bumpus M. Patients’ perceptions of the effectiveness of guided imagery and progressive muscle relaxation interven-tions used for cancer pain. Complement Ther Clin Pract 2008;14:185–194.15. Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain Manage Nurs 2005;6:58–67.16. Tusek DL, Church JM, Strong SA, et al. Guided imagery: A significant advance in the care of patients undergoing elective colorectal surgery. Dis Co-lon Rectum 1997;40:172–178.17. Menzies V, Taylor AG, Bourguignon C. Effects of guided imagery on out-comes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia. J Altern Complement Med 2006;12:23–30.

Jane Hart, M.D., a board-certified internist, is a clinical instructor at Case Western Reserve University School of Medicine, Cleveland, Ohio, and is chair of the Committee on Integrative, Complementary and Alternative Medicine at Case Western Reserve University School of Medicine.

To order reprints of this article, e-mail Karen Ballen at: Kballen@liebertpub.com or call (914) 740-2100.

References

1. Anaya L, Bodtker T, Chaves M, et al. A study of efficacy and cost effective-ness of guided imagery as a portable, self-administered, presurgical interven-tion delivered by a health plan. Adv Mind–Body Med 2007;22:8–14.2. Guided Imagery. Definition. Merriam-Webster Online. Online document at: http://medical.merriam-webster.com/medical/guided%20imagery Accessed October 1, 2008.3. Naparstek B. Staying Well with Guided Imagery. New York: Warner Books, 1994.4. Simonton OC, Matthews-Simonton S, Creighton J. Getting Well Again: A Step-By-Step Self-Help Guide to Overcoming Cancer for Patients and Their Families. New York: J.P. Tarcher, 1978.5. Van Kuiken D. A meta-analysis of the effect of guided imagery practice on outcomes. J Holist Nurs 2004;22:164–179.6. Weydert JA, Shapiro D, Acra SA, et al. Evaluation of guided imagery as treatment for recurrent abdominal pain in children: A randomized controlled trial. BMC Pediatr 2006;6:29.7. Carrico DJ, Peters KM, Siokno AC. Guided imagery for women with in-terstitial cystitis: Results of a prospective, randomized controlled pilot study. J Altern Complement Med 2008:14:53–60.8. Eller LS. Guided imagery interventions for symptom management. Annu Rev Nurs Res 1999;17:57–84.9. Tusek DL, Cwynar RE. Strategies for implementing a guided imagery pro-gram to enhance patient experience. AACN Clin Issues 2000;11:68–76.10. Kwekkeboom KL, Kneip J, Pearson L. A pilot study to predict success with guided imagery for cancer pain. Pain Manage Nurs 2003;4:112–123.

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