At-Home Guided Imagery
Anesia Groves, NMD
Holism is fundamental to the practice of naturopathic medicine. At graduation from medical school, we take an oath to “heal the whole person through individualized treatment,” and many of us feel a comforting and energizing reminder of our passion for the ideals that led us to this profession in the first place. Then we are faced with the reality: the day-to-day responsibilities of being a primary care provider, the complicated web of complaints that our patients bring to the office, and the pressure to ease suffering in a timely manner so patients will stay around long enough for us to establish lasting relationships that will facilitate their achievement of lifelong optimal wellness.
While time and experience can alleviate these concerns to some degree, it can still be difficult to genuinely empower patients to reconnect more deeply with themselves. This challenge becomes all the more apparent when patients present with complaints involving some level of “mind-body disconnect.” How do we begin to address this disconnect? Guided imagery, an easy-to-use therapeutic technique, may provide a means for us to help patients shift from a state of being “disconnected” to a state of empowered awareness.
The Mind-Body Disconnect
For the purposes of this article, mind-body disconnect refers to a common situation in which:
1. The patient has physical symptoms that appear (after thorough history, physical, and workup) to relate either wholly or partly to mental/emotional problems such as poor stress-management skills and unresolved emotions.
2. The patient feels they have no or very little influence over the appearance and/or intensity of their symptoms.
3. The patient is either unconscious or only partially conscious that a connection exists between their mental/emotional state and the physical complaints.
4. The patient regularly has trouble recognizing their body’s subtle messages and needs, and finds it difficult to respond to symptoms with appreciation, compassion, and self-love. In severe cases this might manifest as catastrophizing pain.
It is important to note that mind-body disconnect differs from psychosomatic inasmuch as psychosomatic is sometimes still used to refer to illness that originates entirely in the mind and has no physical or organic cause. The conditions mentioned in this article are not generally considered strictly psychosomatic in nature by this definition, and often have identifiable physical etiological factors. The use of mind-body disconnect is also free of the negative connotations often associated with psychosomatic (ie, the insensitive attitude underlying the infamous diagnostic conclusion “it’s all in your head”).
Common Medical Conditions Involving a Mind-Body Disconnect
A number of conditions commonly seen in naturopathic practice involve a mind-body disconnect, and many of these have been noted in the literature as benefitting from guided imagery (GI). Three in particular warrant special attention: fibromyalgia (FM), interstitial cystitis (IC), and irritable bowel syndrome (IBS). Even though we generally recognize multifactorial biochemical and physical etiologies for these conditions, the mind-body disconnect might be considered a major perpetuating factor in many cases, and even perhaps a causative factor in some cases.1-7
Fibromyalgia in particular offers an illustration of the complicated way in which a mind-body disconnect can contribute to illness. It is well-accepted that the fibromyalgia syndrome is characterized by a number of psychological features, which vary from patient to patient but can include frank somatization, excessive focus on the slightest signs of physical distress (somatic hypervigilance), decreased self-efficacy, catastrophization, depression, and anxiety. In addition, some patients have a frustrating but wholly understandable tendency to reject any psychological explanation for their condition. These characteristics, which together comprise a mind-body disconnect as previously described, at the very least perpetuate the illness, and may sometimes be a causative factor.4
Interestingly, FM, IC, and IBS have in common at least one psychological characteristic—decreased self-efficacy combined with an external locus of control, ie, the patient attributes their circumstances to forces outside their control.1,4,8 This shared feature may be one reason GI can be helpful in these conditions, as will be discussed later.
Moreover, these 3 conditions have another theme in common – poor management by conventional care. Sufferers as a result often consult naturopathic offices for treatment, and thus it is important for NDs to have unique and effective treatment options. Indeed, an estimated 90% of FM patients use some form of complementary and alternative medicine.9
One of the challenges in treating conditions such as FM, IC, and IBS is that it can be difficult to address the mind-body disconnect without unintentionally giving the patient the impression that the physician thinks the problem is “all in his/her head.” Also challenging is effectively initiating an exploration of mind-body medicine with patients who may have little experience with such therapy, and may have little awareness of how their mental/emotional state is related to their condition. For these patients, the therapy needs to be simple, and it needs to fit into their worldview while simultaneously being able to facilitate a shift in awareness, especially in terms of locus of control. For patients with limited mobility due to pain, therapy also needs to be easy to perform physically.
Guided imagery provides a potential solution to each of these problems. In order to understand how it can be practical and effective for these conditions, it is important to have a basic understanding of guided imagery and how it works.
Guided imagery (GI), according to Merriam-Webster’s Medical Dictionary, is “any of various techniques (as a series of verbal suggestions) used to guide another person or oneself in imagining 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).10
The general principles and methods of GI probably have their roots in shamanistic and other indigenous healing practices. Over the past century, GI has developed as an increasingly well-recognized therapy and has been informed by various psychological theories including Gestalt therapy, cognitive behavioral therapy, Jungian psychology, hypnotherapy, and humanistic psychology.11
GI exists in various forms, including written scripts, recordings, and one-on-one or group sessions (which can be either listening only or interactive) led by a trained practitioner. The content is often characterized by elements of storytelling and metaphor, as well as direct references to bodily sensations. It is related to hypnosis and meditation, but is unique partly because of its specific focus on creating images.12
In general, several steps are usually involved:
1. Relaxation – induced through guided suggestions for breathing and awareness of bodily sensations.
2. Imagery – evoking all of the senses, sometimes with specific intent (eg, imagining the immune system functioning properly).
3. Integration – suggestions help secure the new awareness into easily accessible memory.
4. Closing – suggestions to help restore normal everyday alertness.
Principles of Guided Imagery
The mechanisms of action of GI are not entirely understood. However, experts point to several theories.
Based on the basic assumption that a mind-body connection exists that can influence illness, GI may work by re-establishing body awareness and helping patients learn to recognize and appropriately respond to the body’s subtle messages. GI’s positive effects may also be attributed to the fact that it encourages relaxation, which is assumed to be a state conducive to healing.
Another underlying assumption upon which GI is based is that the brain tends to interpret imagined stimuli as though they were real, and that the positive images experienced during a session exert similar effects as to what their real-life counterparts would. For example, if one imagines herself on vacation at the beach, she may get some of the same relaxation benefits she would get if she actually went on vacation.12
Perhaps most important in terms of the discussion of FM, IC, and IBS, is the idea that an internal locus of control may indicate better outcomes in these types of conditions. GI is thought to encourage a shift toward an internal locus of control, and may improve self-efficacy, which is important to recovery from these conditions.1-7,12
GI is also known to have significant physiological effects related to stress reduction, including reduction of cortisol,13 reduction in heart rate and blood pressure, and reduced pain perception.14 Gate control theory and mediation of endorphin release may be involved in how GI assists in pain management.12,15
Guided Imagery in the Literature
Guided imagery has been extensively studied in a variety of areas. Notable are its use in surgical procedures to reduce anxiety and the need for pain medications,16 its use in improving management of cancer pain and side effects of chemotherapy,17,18 and its possible enhancement of immune function.12,19,20
A few findings relevant to the discussion of FM, IC, and IBS are the following:
1. In a 2006 study on guided imagery treatment in FM, self-efficacy and functional status improved in the treatment group compared to the control group.3
2. In a 2008 study on guided imagery treatment in IC, 45.5% of patients treated with GI had moderate or marked improvement in IC symptoms, and the treatment group also reported significant reduction in pain scores and episodes of urgency as compared to controls.15
3. In a 2006 study on guided imagery and recurrent abdominal pain (which is very closely related to IBS and has similar pathophysiology) in children, 70% of patients were “healed” (4 or fewer days of pain and no missed activities each month) at the 2-month follow-up, as compared to only 14% of controls being “healed.”21
In addition, GI has also been studied with some encouraging results in anxiety and depression, bulimia nervosa, osteoarthritis, asthma, Parkinson’s disease, smoking cessation, and stroke rehabilitation.22-32
Practical Advantages of At-Home Guided Imagery
a. Most recordings/products are designed for the mainstream user
b. Free of specific religious, cultural or philosophical associations, unlike some forms of yoga or meditation
a. Recordings run $11.00–$15.00 vs cost of lengthy office visits
b. Reuseable indefinitely
3. Ease of use
a. Requires only comfortable setting and CD or MP3 player
b. Does not require intense concentration or any particular skill
c. Short duration—typically 10–20 minutes per session
d. Suitable for patients with physical limitations
Discussion and Summary
GI may help improve patients’ overall body awareness, self-efficacy, and coping skills in illnesses such as FM, IC, and IBS, as well as improve other specific outcomes in these conditions. In addition, it has important physiological effects, mainly related to stress-reduction and improved stress adaptation, which may be helpful in these conditions as well as in a variety of other common health problems. It also has significant practical advantages in terms of cost-effectiveness and accessibility. Because it is so easy to use and accessible, GI can be a practical means of introducing mind-body medicine to patients who may have little understanding of this type of therapy and/or may be resistant to the idea that their condition has a mental/emotional component. Therefore, GI can be a useful adjunct therapy in common illnesses involving a mind-body disconnect.
Other conditions not mentioned in this article in which GI could theoretically be beneficial (based on the idea that it is helpful for the mind-body disconnect) might include vulvodynia, irritable bowel disease, headache, and pain syndromes in general. Further research of GI’s many potential clinical applications is needed so that this cost-effective therapy might be used more widely in order to reduce the need for complicated and expensive workups and treatment for a number of common conditions.
Suggestions for Implementing Guided Imagery
Become familiar with sources and types of guided imagery products—many are tailored to specific health conditions.
1. Initiate a discussion of how GI could benefit your patient, citing research and avoiding any negatively framed suggestion that the patient’s condition is psychosomatic.
2. Select suitable product(s), with patient’s input as appropriate.
3. Prescribe a manageable, but regular, dose and frequency.
a. Studies generally point to 10–25 minutes once or twice daily.
b. Alternatively, treat as if it’s physical exercise—discuss realistic goals and increase use incrementally.
c. Have patient track symptoms and reassess at regular intervals
4. Address neuroendocrine, nutritional, lifestyle, environmental, and other contributing factors simultaneously, staggering start times of each therapy as necessary for easy monitoring.
5. Consider an alternative GI method (eg, in-person, interactive, or group) if the at-home method is ineffective.
6. GI should not be used while driving or while operating heavy machinery, as it can be deeply relaxing.
7. Complete thorough psychological screening and/or evaluation of patients where indicated in order to avoid inappropriate or inadequate treatment of serious mental illness.
Anesia Groves, NMD completed her naturopathic degree in 2005 as well as a family practice residency in 2006 at SCNM in Tempe, Ariz. She now has a diverse practice with Aletris Center of Integrative Medicine, with a focus on women’s health and neuroendocrine balancing. She also has a passion for teaching, and currently supervises a student rotation with SCNM. Dr. Groves aims to help individuals discover total wellness so they can share their vibrant, vital, and engaged selves with the world.
1. Keltikangas-Järvinen L, Auvinen L, Lehtonen T. Psychological factors related to interstitial cystitis. Eur Urol. 1988;15(1-2):69-72.
2. Link CL, Pulliam SJ, Hanno PM, et al. Prevalence and psychosocial correlates of symptoms suggestive of painful bladder syndrome: results from the Boston area community health survey. J Urol. 2008;180(2):599-606.
3. Menzies V, Taylor AG, Bourguignon C. Effects of guided imagery on outcomes of pain, functional status, and self-efficacy in persons diagnosed with fibromyalgia. J Altern Complement Med. 2006;12(1):23-30.
4. Van Houdenhove B, Luyten P. Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of perpetuating factors. Psychosomatics. 2008;49(6):470-477.
5. Shen L, Kong H, Hou X. Prevalence of irritable bowel syndrome and its relationship with psychological stress status in Chinese university students. J Gastroenterol Hepatol. 2009;24(12):1885-1890.
6. Pellissier S, Dantzer C, Canini F, Mathieu N, Bonaz B. Psychological adjustment and autonomic disturbances in inflammatory bowel diseases and irritable bowel syndrome. Psychoneuroendocrinology. 2010;35(5):653-662.
7. Jones MP, Wessinger S, Crowell MD. Coping strategies and interpersonal support in patients with irritable bowel syndrome and inflammatory bowel disease. Clin Gastroenterol Hepatol. 2006;4(4):474-481.
8. Gonsalkorale WM, Toner BB, Whorwell PJ. Cognitive change in patients undergoing hypnotherapy for irritable bowel syndrome. J Psychosom Res. 2004;56(3):271-278.
9. Fibromyalgia and CAM: At a Glance. National Center for Complementary and Alternative Medicine Web site. http://nccam.nih.gov/health/pain/fibromyalgia.htm. Published July 2008. Updated July 2009. Accessed March 7, 2010.
10. Definition of the phrase “guided imagery”. Merriam-Webster’s Medical Dictionary Web site. http://www.merriam-webster.com/medical/guided%20imagery. Accessed March 7, 2010.
11. What is Guided Imagery? Academy for Guided Imagery Web site. http://www.academyforguidedimagery.com/whatisguidedimagery/index.html. Accessed March 7, 2010.
12. Hart J. Guided Imagery. Alternative and Complementary Therapies. 2008;14(6):295-299.
13. Weigensberg MJ, Lane CJ, Winners O, et al. Acute effects of stress-reduction Interactive Guided Imagery(SM) on salivary cortisol in overweight Latino adolescents. J Altern Complement Med. 2009;15(3):297-303.
14. Eller LS. Guided imagery interventions for symptom management. Annu Rev Nurs Res. 1999;17:57-84
15. Carrico DJ, Peters KM, Diokno AC. Guided imagery for women with interstitial cystitis: results of a prospective, randomized controlled pilot study. J Altern Complement Med. 2008;14(1):53-60.
16. Manyande A, Berg S, Gettins D, et al. Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery. Psychosom Med. 1995;57(2):177-182.
17. Walker LG, Walker MB, Ogston K, et al. Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. Br J Cancer. 1999;80(1-2):262-268.
18. Kwekkeboom KL, Hau H, Wanta B, Bumpus M. Patients’ perceptions of the effectiveness of guided imagery and progressive muscle relaxation interventions used for cancer pain. Complement Ther Clin Pract. 2008;14(3):185-194.
19. Gruzelier JH. A review of the impact of hypnosis, relaxation, guided imagery and individual differences on aspects of immunity and health. Stress. 2002;5(2):147-163.
20. Lengacher CA, Bennett MP, Gonzalez L, et al. Immune responses to guided imagery during breast cancer treatment. Biol Res Nurs. 2008;9(3):205-214.
21. Weydert JA, Shapiro DE, Acra SA, Monheim CJ, Chambers AS, Ball TM. Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial. BMC Pediatr. 2006;6:29.
22. Esplen MJ, Garfinkel PE, Olmsted M, Gallop RM, Kennedy S. A randomized controlled trial of guided imagery in bulimia nervosa. Psychol Med. 1998;28(6):1347-1357.
23. Esplen MJ, Garfinkel PE. Guided imagery treatment to promote self-soothing in bulimia nervosa. A theoretical rationale. J Psychother Pract Res. 1998;7(2):102-118.
24. Toth M, Wolsko PM, Foreman J, et al. A pilot study for a randomized, controlled trial on the effect of guided imagery in hospitalized medical patients. J Altern Complement Med. 2007;13(2):194-197.
25. Utay J, Miller M. Guided imagery as an effective therapeutic technique: a brief review of its history and efficacy research. J Instr Psychol. 2006;33(1):40-44.
26. Page SJ, Levine P, Sisto S, Johnston MV. A randomized efficacy and feasibility study of imagery in acute stroke. Clin Rehabil. 2001;15(3):233-240.
27. Baird CL, Sands L. A pilot study of the effectiveness of guided imagery with progressive muscle relaxation to reduce chronic pain and mobility difficulties of osteoarthritis. Pain Manag Nurs. 2004;5(3):97-104.
28. Wynd CA. Guided health imagery for smoking cessation and long-term abstinence. J Nurs Scholarsh. 2005;37(3):245-250.
29. Lahmann C, Nickel M, Schuster T, et al. Functional relaxation and guided imagery as complementary therapy in asthma: a randomized controlled clinical trial. Psychother Psychosom. 2009;78(4):233-239.
30. Schlesinger I, Benyakov O, Erikh I, Suraiya S, Schiller Y. Parkinson’s disease tremor is diminished with relaxation guided imagery. Mov Disord. 2009;30;24(14):2059-2062.
31. Apóstolo JL, Kolcaba K. The effects of guided imagery on comfort, depression, anxiety, and stress of psychiatric inpatients with depressive disorders. Arch Psychiatr Nurs. 2009;23(6):403-411.
32. Lahmann C, Henningsen P, Schulz C, et al. Effects of functional relaxation and guided imagery on IgE in dust-mite allergic adult asthmatics: a randomized, controlled clinical trial. J Nerv Ment Dis. 2010;198(2):125-130.