Imagery
Maura Fitzgerald
Mary Langevin
Imagery is a mind-body intervention that uses the power of the imagination to bring about change in physical, emotional, or spiritual dimensions. Throughout our daily lives we constantly see images, feel sensations, and register impressions. A picture of lemonade makes our mouths water; a song makes us happy or sad; a smell takes us back to a past moment. Images evoke physical and emotional responses and help us understand the meaning of events.
Imagery is commonly used in health care—most often in the form of guided imagery, clinical hypnosis, or self-hypnosis. In the mid-1950s, the American Medical Association and the American Psychiatric Association recognized hypnosis as a therapeutic tool. Nurses, physicians, psychologists, and others use it with adults and children for treatment of acute and chronic illness, relief of symptoms, and enhancement of wellness. Imagery is a hallmark of stress-management programs and has become a standard therapy to alleviate anxiety, promote relaxation, improve coping and functional status, gain psychological insight, and even to make progress on a chosen spiritual path.
DEFINITION
Imagery is the formation of a mental representation of an object, place, event, or situation that is perceived through the senses. It is a cognitivebehavioral strategy that uses the individual’s own imagination and mental
processing and can be practiced as an independent activity or guided by a professional. Imagery employs all the senses—visual, aural, tactile, olfactory, proprioceptive, and kinesthetic. Although imagery is often referred to as visualization, it includes imagining through any sense and not just being able to see something in the mind’s eye.
processing and can be practiced as an independent activity or guided by a professional. Imagery employs all the senses—visual, aural, tactile, olfactory, proprioceptive, and kinesthetic. Although imagery is often referred to as visualization, it includes imagining through any sense and not just being able to see something in the mind’s eye.
Van Kuiken (2004) describes four types of guided imagery: pleasant, physiologically focused, mental rehearsal or reframing, and receptive imagery. While inducing imagery, the individual often imagines seeing, hearing, smelling, tasting, and/or touching something in the image. The image used can be active or passive (playing volley ball versus lying on the beach). Although for many participants physical and mental relaxation tend to facilitate imagery, this is not necessary—particularly for children, who often do not need to be in a relaxed state. Imagery may be receptive, with the individual perceiving messages from the body, or it may be active, with the individual evoking thoughts or ideas. Active imagery can be outcome- or end-state-oriented, in which the individual envisions a goal, such as being healthy and well; or it can be process-oriented, in which the mechanism of the desired effect is imagined, such as envisioning a strong immune system fighting a viral infection or tumor.
Imagery and clinical hypnosis are closely related. Clinical hypnosis is a strategy in which a professional guides the participant into an altered state of deep relaxation, and suggestions for changes in subjective experience and alterations in perception are made. Both hypnosis and guided imagery incorporate the use of relaxation techniques, such as diaphragmatic breathing or progressive muscle relaxation to assist the participant to focus the attention. In hypnosis, this is referred to as an induction. Guided imagery is often used within the context of hypnosis to further deepen the state of relaxation, and in both techniques suggestions for positive growth, change, or improvement are often made. Because of the close association between these two processes, selected studies on hypnosis are discussed in this chapter.
SCIENTIFIC BASIS
Imagery can be understood as an activity that generates physiologic and somatic responses. It is based on the cognitive process known as mental imagery, which is a central element of cognition that operates when mental representations are created in the absence of sensory input. Functional magnetic resonance imaging (fMRI) has demonstrated that the mental construction of an image activates the same neural pathways and central nervous system structures that are engaged when an individual is actually using one or more of the senses (Djordjevic, Zatorre, Petrides,
Boyle, & Jones-Gotaman, 2005; Formisano et al., 2002; Gulyas, 2001; Kosslyn, Ganis, & Thompson, 2001; Kraemer, Macrae, Green, & Kelley, 2005). For example, if an individual is imagining hearing a sound, the brain structures associated with hearing will become activated. Mental rehearsal of movements will activate motor areas and can be incorporated into stroke rehabilitation and sports improvement programs (Braun, Beurskens, Borm, Schack, & Wade, 2006; Lacourse, Turner, Randolph-Orr, Schandler, & Cohen, 2004).
Boyle, & Jones-Gotaman, 2005; Formisano et al., 2002; Gulyas, 2001; Kosslyn, Ganis, & Thompson, 2001; Kraemer, Macrae, Green, & Kelley, 2005). For example, if an individual is imagining hearing a sound, the brain structures associated with hearing will become activated. Mental rehearsal of movements will activate motor areas and can be incorporated into stroke rehabilitation and sports improvement programs (Braun, Beurskens, Borm, Schack, & Wade, 2006; Lacourse, Turner, Randolph-Orr, Schandler, & Cohen, 2004).
Andrasik and Rime (2007) postulated that cognitive tasks, such as mental imagery, can be conceptualized as neuromodulators. Neuromodulation is generally defined as the interaction between the nervous system and electrical or pharmacological agents that block or disrupt the perception of pain. By distraction, imagery alters processing in the central, peripheral, and autonomic nervous systems. The perception of a symptom such as pain or nausea is reduced or eliminated.
A key mechanism by which imagery modifies disease and reduces symptoms is thought to be by reducing the stress response, which is triggered when a situation or event (perceived or real) threatens physical or emotional well-being or when the demands of the situation exceed available resources. It activates complex interactions between the neuroendocrine system and the immune system. Emotional responses to situations trigger the limbic system and signal physiologic changes in the peripheral and autonomic nervous systems, resulting in the characteristic fight-or-flight stress response. Over time, chronic stress results in adrenal and immune suppression and may be most harmful to cellular immune function, impairing the ability to ward off viruses and tumor cells (Pert, Dreher, & Ruff, 1998).
The complexity of the human response to stress is best understood through psychoneuroimmunology (PNI), an interdisciplinary field of study that explains the mechanisms by which the brain and body communicate through cellular interactions. Early work was based on rat-model research by Robert Ader and Nicholas Cohen, which confirmed that the immune system could be conditioned by expectations and beliefs (Ader & Cohen, 1981; Ader, Felten, & Cohen, 1991; Fleshner & Laudenslager, 2004). Subsequent research focused on the mechanisms of brain and body communication through cellular interactions, and identified receptors for neuropeptides, neurohormones, and cytokines that reside on neural and immune cells and induce biochemical changes when activated by neurotransmitters.
A cascade of signaling events in response to perceived or actual stress results in the release of hormones from the hypothalamus, pituitary gland, adrenal medulla, adrenal cortex, and peripheral sympathetic nerve terminals. Psychosocial and physical stressors have the potential to upregulate this hypothalamic-pituitary-adrenal (HPA)
axis. Chronic hyperactivation of the HPA axis and sympathetic nervous system with the associated increased levels of cortisol and catecholamines can deregulate immune function, whereas moderate levels of circulating cortisol may enhance immune function (Langley, Fonseca, & Iphofen, 2006). Cytokines are secreted by cells participating in the immune response and act as messengers between the immune system and the brain (McCance & Huether, 2002). They also function as neurotransmitters crossing the blood-brain barrier or affecting sensory neurons. Through these channels, cytokines induce symptoms of fever, increased sensitivity to pain, anorexia, and fatigue, which are adaptive responses that may facilitate recovery and healing (Langley et al., 2006). These interactions between the brain and the immune system are bidirectional and changes in one system will influence the others. The stress response can therefore become a double-edged sword that can either enhance or suppress optimal immunity (Fleshner & Laudenslager, 2004).
axis. Chronic hyperactivation of the HPA axis and sympathetic nervous system with the associated increased levels of cortisol and catecholamines can deregulate immune function, whereas moderate levels of circulating cortisol may enhance immune function (Langley, Fonseca, & Iphofen, 2006). Cytokines are secreted by cells participating in the immune response and act as messengers between the immune system and the brain (McCance & Huether, 2002). They also function as neurotransmitters crossing the blood-brain barrier or affecting sensory neurons. Through these channels, cytokines induce symptoms of fever, increased sensitivity to pain, anorexia, and fatigue, which are adaptive responses that may facilitate recovery and healing (Langley et al., 2006). These interactions between the brain and the immune system are bidirectional and changes in one system will influence the others. The stress response can therefore become a double-edged sword that can either enhance or suppress optimal immunity (Fleshner & Laudenslager, 2004).
Although immune responses to emotional states are extremely complex, in general, acute stress activates cardiac sympathetic activity and increases plasma catecholamines and natural killer (NK) cell activity, whereas chronic stress (or inescapable or unpredictable stress) is associated with suppression of NK cells and interleukin-1-beta and other proinflammatory cytokines (Glaser et al., 2001). These effects appear to be mediated by the influence of stress hormones on T helper components (Th1 and Th2) (Segerstrom, 2010). Imagery, by inducing deep relaxation and reprocessing of stressful triggers, interrupts or alters the stress response and supports the immune system. In a review of guided-imagery studies examining immune system function, Trakhtenberg (2008) concluded that there is evidence to support a relationship between the immune system and stress or relaxation.
The degree of response to stress varies according to many factors, including the nature of the stressor, magnitude and duration, and degree of control over the stressor (Costa-Pinto & Palermo-Neto, 2010). Individuals who have great physiological responses to everyday stressors have high stress reactivity and are at greater risk for disease susceptibility, even when coping, performance, and perceived stress are comparable. One of the goals of imagery is to reduce stress reactivity by reframing stressful situations from negative responses of fear and anxiety to positive images of healing and well-being (Kosslyn et al., 2001). Donaldson (2000) proposed that thoughts produce physiological responses and activate appropriate neurons. Using imagery to increase emotional awareness and restructure the meaning of a remembered situation by changing negative responses to positive images and meaning alters the physiological response and improves outcomes.
INTERVENTION
Techniques and Guidelines
Imagery has been used extensively in children, adolescents, and adults. Children as young as 4 years old, who have language skills adequate to understand the suggestions, can benefit from imagery (Kohen & Olness, 2011). Young children often are better at imagery because of the natural, active use of their imaginations. Imagery may be practiced independently, with a coach or teacher, or with a videotape or audiotape. The most effective imagery intervention is one that is specific to individuals’ personalities, their preferences for relaxation and specific settings, their age or developmental stage, and the desired outcomes. The steps of a general imagery session are outlined in Exhibit 6.1.
Imagery sessions for adults and adolescents are usually 10 to 30 minutes in length, whereas most children tolerate 5 to 15 minutes. The session typically begins with a relaxation exercise that enables the participant to focus or “center.” A technique that works well both for children and for adults is to engage in slow and expansive breathing, which facilitates relaxation as the breath moves lower into the chest and the diaphragm, while the abdominal muscles begin to be used more than the upper chest muscles. Other techniques include progressive muscle relaxation or focusing on a word or object. Some children may use their bodies to demonstrate or respond to their image. Although most participants close their eyes, some, especially young children, will prefer to have eyes open.
Once the participant is in a relaxed or in an “altered” state, the practitioner suggests an image of a relaxing, peaceful, or comforting place or introduces an image suggested by the client. Scenes commonly used to induce relaxation include watching a sunset or clouds, sitting on a warm beach or by a fire, or floating through water or space. Some participants, particularly young children, may prefer active images that involve motion, such as flying or playing a sport. The scene used is one that the client finds relaxing or engaging. It is often introduced as a favorite place. Huth, VanKuiken, and Broome (2006) interviewed children who were participants in a guided-imagery research study, to determine the content of their imagery. The children reported their favorite images as the park, swimming at a beach, amusement parks, and vacationing. They also visualized a variety of familiar places, such as sports events and places that included pets and other animals.
Although mental relaxation is often accompanied by muscle relaxation, this is not always a goal. Participants of any age, but particularly preschool and school-age children, may imagine in an active state. For example, a group of 9- to 12-year-old boys with sickle cell disease were being taught guided imagery as a pain-control technique. When asked what special place they would like to go to, they requested a trip to a local amusement park and a ride on the roller coaster. During the imagery, many of them were physically and vocally active, swaying from side to side and moving their arms up and down. At the end of the visualization they all reported feeling like they had been in the park (absorption) and gave examples of things they felt, saw, heard, or smelled.
Exhibit 6.1. General Guided Imagery Technique
1. Achieving a relaxed state
A. Find a comfortable sitting or reclining position (not lying down).
B. Uncross any extremities.
C. Close your eyes or focus on one spot or object in the room.
D. Focus on breathing with abdominal muscles—being aware of the breath as it enters through your nose and leaves through your mouth. With your next breath let the exhalation be longer and notice how the inhalation that follows is deeper. And as you notice that, let your body become even more relaxed. Continue to breathe deeply, gradually letting the exhalation become twice as long as the inhalation.
E. Bring your mind back to thinking of your breathing and your relaxed body if your thoughts roam.
2. Specific suggestions for imagery
A. Picture a place you enjoy and where you feel good.
B. Notice what you see—hear—taste—smell—and feel.
C. Let yourself enjoy being in this place.
D. Imagine yourself the way you want to be—(describe the desired goal specifically).
E. Imagine what steps you will need to take to be the way you want to be.
F. Practice these steps now—in this place where you feel good.
G. What is the first thing you are doing to help you be the way you want to be?
H. What will you do next?
I. When you reach your goal of the way you want to be—notice how you feel.
3. Summarize process and reinforce practice
A. Remember that you can return to this place, this feeling, and this way of being anytime you want.
B. You can feel this way again by focusing on your breathing, relaxing, and imagining yourself in your special place.
C. Come back to this place and envision yourself the way you want to be every day.
4. Return to present
A. Be aware again of the favorite place.
B. Bring your focus back to your breathing.
C. Become aware of the room you are in (drawing attention to the temperature, sounds, or lights).
D. You will feel relaxed and refreshed and be ready to resume your activities.
E. You may open your eyes when you are ready.
For directed imagery, the practitioner guides the imagery, using positive suggestions to alleviate specific symptoms or conditions (outcome or end-state imagery) or to rehearse or walk through an event (process imagery). Images do not need to be anatomically correct or vivid. Symbolic images may be the most powerful healing images because they are drawn from individual beliefs, culture, and meaning. A cancer patient might imagine sweeping cancer cells away or an asthma patient might picture the lungs as an expanding tree.
The ability to use guided imagery is related to the individual’s hypnotic ability or the ability to enter an altered state of consciousness and to become involved or absorbed in the imagery (Kwekkeboom, Wanta, & Bumpus, 2008). Studies have demonstrated that responsiveness to hypnosis increases through early childhood, peaking somewhere between ages 7 and 14 and then leveling off into adolescence and adulthood. However, clinicians have argued that in clinical settings, in which techniques are adjusted to the child’s development, preschool children and younger can be quite responsive to hypnosis (Kohen & Olness, 2011).
Some individuals have naturally high hypnotic abilities: they recall pictures more accurately, generate more complex images, have higher dream-recall frequency in the waking state, and make fewer eye movements in imagery than poor visualizers. However, most individuals can use imagery if the experience is adjusted to their needs and preferences (Carli, Cavallaro, & Santarcangelo, 2007; Olness, 2008). Recognizing individual, cultural, and developmental preferences for settings, situations, and preference for either relaxation or stimulation can improve the effectiveness of the imagery and reduce time and frustration with learning it. Practicing imagery oneself is extremely helpful in guiding others.
Measurement of Outcomes
Evaluating and measuring outcomes are important in determining the effectiveness and value of imagery in clinical practice. The clinical outcomes of imagery are related to the context in which it is used and include: physical signs of relaxation; lower levels of anxiety and depression; alteration in symptoms; improved functional performance or quality of life; a sense of meaning, purpose, and/or competency; and positive changes in attitude or behavior. Health services benefits may include reduced costs, morbidity, and reduced length of stay.
The outcomes measured should reflect the client’s situation and the conceptual framework providing the rationale for the use of imagery. If imagery is used to facilitate rehabilitation or performance, outcomes would include functional measures such as improved gait or ability to perform a specific task. If imagery is used to control symptoms in clients undergoing chemotherapy for cancer, expected outcomes might include reduced nausea, vomiting, and fatigue; enhanced body image; positive mood states; and improved quality of life. When imagery is used to reduce the stress response and promote relaxation, outcomes may include increased oxygen saturation levels, lower blood pressure and heart rate, warmer extremities, reduced muscle tension, greater alpha waves on electroencephalography, and lower anxiety.
Factors that may influence imagery’s success include dose, client characteristics, and condition being treated. Great variability exists in how frequently imagery is recommended. In an attempt to quantify this effect, Van Kuiken (2004) conducted a meta-analysis of 16 published studies going back to 1996. Although the final sample of 10 studies was too small for statistical analysis, Van Kuiken concluded that imagery practice up to 18 weeks increases the effectiveness of the intervention. A minimum dose was not determined and further study is needed to explore a dose relationship with outcomes. To help with standardization of imagery interventions and generalizability, other documentation should include a detailed description of the specific interventions used, outcomes affected by the imagery, and factors influencing effectiveness.
Individual differences such as imaging ability, outcome expectancy, preferred coping style, relationship with the imagery practitioner, and disease state may all affect the outcome of an imagery experience. In a crossover-design pilot study comparing progressive muscle relaxation therapy (PMRT) and imagery to a control, the combined intervention groups demonstrated improved pain control (Kweekeboom et al., 2008). However, the individual responder analysis revealed that subjects did not respond equally to each therapy and only one half of the participants had reduced pain from each intervention. Imagery sessions were more likely to have positive results when participants had greater imaging ability, positive outcome expectancy, and fewer symptoms. A study of 323 adult medical patients who received six interactive guided-imagery sessions with a focus on gaining insight and self-awareness demonstrated that participants’ ability to engage in the guided-imagery process and the relationship with the practitioner were strong influences on outcome (Scherwitz, McHenry, & Herrero, 2005).
One of the most difficult determinations to make is whether the outcomes are the result solely of imagery or of a combination of factors. Learning and practicing imagery often change other healthrelated behaviors, such as getting more sleep, eating a healthier diet,
smoking cessation, or exercising regularly. The therapist’s presence, attention, and compassion also may constitute an intervention independent of the imagery process.
smoking cessation, or exercising regularly. The therapist’s presence, attention, and compassion also may constitute an intervention independent of the imagery process.
Precautions
Imagery is generally a safe intervention, as noted in a systematic review of guided imagery for cancer, in which there were no reports of adverse events or side effects (Roffe, Schmidt, & Ernst, 2005). However, occasionally a participant will react negatively to relaxation or to the imagery. Subjects may experience anxiety, particularly when using imagery to reduce stress. Huth, Broome, and Good (2004) reported that two children became distressed during guided-imagery practice sessions; hence, the authors encourage prescreening. Some individuals have anecdotally reported increased discomfort, airway constriction, or difficulty breathing when they focus on diaphragmatic breathing. This is most likely to occur if the participant is experiencing a symptom such as abdominal pain or dyspnea. Using another centering method, such as focusing on an object in the room or repeating a mantra, can reduce this distressing response and still induce relaxation. Some participants may report feeling out of control or “spacey” when deeply relaxed. The guide can help participants to become more grounded by focusing on an image such as a tree with strong roots or do more alert relaxation such as having eyes open and focusing on an object. Participants may report dizziness that is often related to mild hyperventilation and can be relieved by encouraging them to breathe slower and less deeply.
The expertise and training of the nurse should guide judgment in using imagery to achieve outcomes in practice. Imagery techniques can be easily applied to managing symptoms (pain, nausea, vomiting) and facilitating relaxation, sleep, or anxiety reduction. Advanced techniques often associated with hypnosis—such as age regression and management of depression, anxiety, or posttraumatic stress disorder—require further training.
USES
Imagery has been used therapeutically in a variety of conditions and populations (Exhibit 6.2). Pain and cancer are two conditions in which imagery has been helpful both in adults and in children.
Pain
Pain is a uniquely subjective experience, and proper management depends on individualizing interventions that recognize determinants affecting the pain response. Age, temperament, gender, ethnicity, and stage of
development are all considerations when developing a pain-management plan (Gerik, 2005; Young, 2005). Whether pain is from illness, side effects of treatment, injury, or physical stress on the body, emotional factors contribute to pain perception, and mind-body interventions such as imagery can help make pain more manageable (Reed, 2007). Stress, anxiety, and fatigue decrease the threshold for pain, making the perceived pain more intense. Imagery can break this cycle of pain-tension-anxietypain. Relaxation with imagery decreases pain directly by reducing muscle tension and related spasms and indirectly by lowering anxiety and improving sleep. Imagery also is a distraction strategy; vivid, detailed images using all senses tend to work best for pain control. In addition, cognitive reappraisal/restructuring used with imagery can increase a sense of control over the ability to reframe the meaning of pain.
development are all considerations when developing a pain-management plan (Gerik, 2005; Young, 2005). Whether pain is from illness, side effects of treatment, injury, or physical stress on the body, emotional factors contribute to pain perception, and mind-body interventions such as imagery can help make pain more manageable (Reed, 2007). Stress, anxiety, and fatigue decrease the threshold for pain, making the perceived pain more intense. Imagery can break this cycle of pain-tension-anxietypain. Relaxation with imagery decreases pain directly by reducing muscle tension and related spasms and indirectly by lowering anxiety and improving sleep. Imagery also is a distraction strategy; vivid, detailed images using all senses tend to work best for pain control. In addition, cognitive reappraisal/restructuring used with imagery can increase a sense of control over the ability to reframe the meaning of pain.
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