Several important psychology research findings about the ongoing imagery process, or “stream of consciousness,” have implications for the nursing care of patients and clients. Sensory deprivation research in the early 1960s spurred the study of the ongoing imagery process. Initially, the purpose of this research was to examine the functioning of the brain in the absence of sensory input. Much of this research resulted from the space program’s need to understand the impact on astronauts of the sensory deprivation, isolation, and confinement of space travel.²⁵ These studies indicated that an ongoing imagery process is a vital element in human mental experience, particularly when perceptual stimulation is reduced as it is in those who have a sensory impairment, those who are dealing with the monotony of hospitalization—particularly those in intensive care units—and those who work in monotonous environments.

Working with imagery has the potential to tap into memory at extremely deep levels. Wilder Penfield, a Canadian neurosurgeon working in the middle of the twentieth century, did extensive experimentation with direct electrical stimulation and mapping of the brain during surgery. In his research on locally anesthetized, conscious subjects, he identified an area of the brain he labeled the “interpretive cortex.” Upon electrostimulation of this region, he discovered that there is a brain mechanism “capable of bringing back a strip of past experience in complete detail without any of the fanciful elaborations that occur in a man’s dreaming … a record that has not faded but seems to remain as vivid as when the record was made.”²⁶ Penfield went on to indicate that, although the memories recalled in this manner were predominantly visual or auditory, the memory record included all the sensory information that had entered consciousness (e.g., smells, tastes, sounds, tactile sensations). In addition, there was a sense of familiarity
about the event. Simultaneous with the experience of these memory records, Penfield’s subjects retained an awareness of their present situation, namely, that they were on an operating table having their brain probed by a surgeon.

Penfield’s studies illustrate the capacity of consciousness to be absorbed in multiple activities at the same time. Penfield’s patients were conscious of complete sensory recall of memories, were conscious of being on an operating room table, and were able to verbalize their experiences to Penfield and his staff. Appreciating the potentials of human consciousness is a key element in imagery work.

A comprehensive survey of the research on the physiologic effects of imagery cites the following effects on a wide range of systems and symptoms.²⁷

Jacobson demonstrated imagery’s effect on motor responses in 1929, when he showed that subtle tensions of small muscles or sense organs result from imagining movement.²⁸ (See Chapter 15.) This aspect of imagery was applied in working with patients affected with parkinsonism. Mental images of movement were used to help in freeing movement in unmoving body parts.²⁹

Imagery has also been applied in poststroke rehabilitation.³⁰ Patients with chronic hemiparesis worked with imagined wrist movements and imagined movements of reaching and manipulating objects, resulting in significant improvement that remained stable for 3 months.

Simonton and associates explored the effect of imagery on immune function and the application of this information in the treatment of cancer,³¹ as did Achterberg and Lawlis.²²,³² Hall studied the effect of hypnosis and imagery on immune modulation, noting increases in the number of lymphocytes and general increased immune system responsiveness.¹,³³ Schneider and associates demonstrated enhanced immune responsiveness in subjects working with imagery of white blood cells attacking germs. Schneider and associates also successfully used imagery to increase adherence, or “stickiness,” of neutrophils.³⁴ Two factors affected the successful use of imagery in these studies. First, the biologic accuracy of the imagery appeared to be significant. Second, the ability to work with the imagery without straining at it played a part in significant outcomes.

One of the clearest reflections of the complex body-mind-spirit-environment interaction is in the chronic pain syndromes.³⁵ A study compared the effectiveness of two different types of imagery in the reduction of daily fibromyalgia pain. In the study, women were assigned to one of three groups: Group 1 received relaxation training and guided instruction in “pleasant imagery” to distract from the pain experience; group 2 received relaxation training and “attention imagery” instruction, encouraging the “active workings of the internal pain control systems”; group 3, the control group, received treatment as usual without any imagery. All the patients in the study were also randomly assigned to treatment with either 50 mg per day of amitriptyline or a placebo pill. The results showed a significant difference in the reduction of pain in the group receiving the pleasant imagery, but not in the attention imagery group when compared with the control group. In addition, it was found that amitriptyline had no significant advantage over the placebo in reducing fibromyalgia pain during the course of the study.³⁶

This information also reflects the fact that if an imagery intervention does not prove to be helpful for a particular patient, the practitioner should not be discouraged, but instead should use creativity and try other imagery approaches. The attention imagery may have worked for some, just as the pleasant imagery was not effective with everyone. Statistical significance is helpful and points to a general understanding of effects, but does not give us the final word on
what works for an individual. This information may even suggest what works for an individual under one set of conditions, but it may not apply in other circumstances.

Guided imagery with progressive muscle relaxation (PMR) (see Chapter 16) was demonstrated to be effective in the alleviation of pain and mobility difficulties in osteoarthritis (OA). Twenty-eight older women with OA took part in the study. The 14 participants in the treatment group listened to an audiotape of guided imagery and PMR twice a day for 12 weeks. The 14 women in the control group did not do any imagery or PMR. The treatment group reported a significant reduction in pain and increased mobility. This result confirms that this treatment is an effective, cost-effective self-management intervention.³⁷ Positive outcomes were also found in the introduction of imagery interventions to manage pain in an elderly orthopedic population.³⁸

Imagery has the ability to help alter the meaning that patients assign to their pain. This was observed in a study where pain patients learned and used a guided imagery audiotape over 4 consecutive days and the control group received their usual treatment for a 4-day period. At the end of the treatment those patients who used the imagery were able to perceive their pain as changeable as opposed to never ending. They also increased their sense of control, their ability to distract themselves from the pain, and other benefits.³⁹

The richness of imagery as an intervention in working with children has been described in many clinical settings. Children’s receptivity to imaginative play and interactions is an opening for the nurse’s creative use of imagery.⁴⁰ The effectiveness of imagery in the reduction of recurrent abdominal pain,⁴¹ in the reduction of postoperative pain,⁴² and in pediatric hospice pain management⁴³ are all areas for additional nursing research.

Our access to our imagination, our inner wisdom, and our inner healing resources are all elements of imagery work. Because anyone’s experience of imagery is deeply subjective, imagery is a challenge to quantify and objectify through a process of quantitative research. Although research is a vital element in gaining recognition of the clinical value of this exciting and effective tool, research necessitates, by its nature, reducing the questions asked into dichotomous frameworks. Do we even know if it is the image, per se, that is effecting the change? Or is it the focus, intentionality, and empowerment that we elicit in our patients when we provide them with education about inner skills and potentials that are ultimately creating the therapeutic effect? Imagery researcher Braud states: “Perhaps images are simply clothed intentions—specific intentions or focused intentions that have been dramatized or personified in imagery forms?”⁴⁴

One of the pioneers and influential innovators in the clinical application of imagery into body-mind-spirit medicine was Dr. Roberto Assagioli. He was an Italian psychiatrist who introduced these techniques beginning in 1909.⁴⁵,⁴⁶ His concept of the wholeness of human consciousness, called psychosynthesis, has been extensively applied in the helping professions since 1965. He was personally most interested in developing a science of the higher self, a term that he used to describe the aspect of each person that holds inner wisdom and connection with life purpose. He saw the higher self as a developmental step latent inside each person.

Assagioli used imagery in three forms:

Within his body-mind-spirit context, Assagioli developed a set of principles he referred to as “psychological laws,” which describe the interactive effects among images, ideas, emotions, physical responses, behaviors, attitudes, and impulses. According to one such law, “images or mental pictures tend to produce the physical conditions and the external acts that correspond to them.” According to a second law, “attitudes,
movements, and actions tend to evoke corresponding images and ideas; these, in turn, evoke or intensify corresponding emotions.”^46pp51-52 In these and other laws, Assagioli was seeking to outline the ability of the mind through imagery and intention to interact with, and positively affect, the body-mind for healing and psychospiritual growth.

In a recent study that follows the spirit of Assagioli’s work, researchers began with the observation that directing attention to the body is part of the effectiveness of techniques such as imagery and meditation in producing psychophysiologic harmonious states.⁴⁸ They wondered what the measurable effect would be of directing attention to particular body organs. Their studies focused specifically on the heart. When simultaneously measuring heart rhythm by electrocardiogram (ECG) and brain wave rhythm by EEG, they instructed subjects to focus attention on their heartbeat. In doing this, they discovered a state of heart-brain electrical wave synchronization. They then postulated that a linear process emerges as a result of the synchronization occurring from this focused direction of consciousness: self-attention to connection to self-regulation to order to ease. They proposed that this existed in contrast to a process of disattention to disconnection to disregulation to disorder to disease. It was also observed that the synchronization was more effective when participants practiced with eyes closed.

Imagery clearly taps a deep level of self-knowledge in the patient. One example of this occurs in relationship imagery. In one instance, when a patient was asked to describe his relationship with his father, he offered a few familiar comments. But when he was asked to get an image of his father, the patient suddenly got in touch with the feelings of sadness and hopelessness that his father stimulated in him. This deeper level of selfknowledge allowed the patient to appreciate why he struggled with hopelessness in himself.

Nurses are often working with patients and family members who are grieving past or immanent losses. (See Chapter 21.) Imagery is a valuable resource at this time because the connection with the loved one is alive in the imagination. People often feel strongly that they have communicated at an extremely deep, meaningful, and comforting way with internal imagery processes.⁴⁹,⁵⁰ These experiences may be helpful in making decisions, in rehearsing new behaviors, in understanding relationships, in making life choices, and in experiencing equanimity in the face of painful challenges.

Nurses often are caring for patients at a stage in their lives when values and spirituality have become a central concern. Illness, divorce, ethical dilemmas, deaths, or other life crises often cause people to slow down and ask basic questions about how they are going to conduct their lives. Changes in physical capacities, the need to find different employment, decisions about education and lifestyle, and retirement all call upon people to reassess their deepest values and their sense of spiritual purpose in life.

At these times, rational thought processes are not enough because they do not reveal the big picture. Imagery allows someone to imagine the actual results of a decision. For example, a nurse counseling a 59-year-old elementary school teacher struggling with a decision about retirement suggested that she close her eyes, focus on her breath, and imagine herself retired. After a few moments, the woman experienced an image of herself at home, looking bored and unhappy. She was frustrated with this image. She then tried to imagine her retirement as a time of new growth. She went back into the imagery, trying to imagine herself retiring and going back to school to study something new—she was unable to do so. Her imagination literally refused to see it. She then imagined herself doing service work in the community. Suddenly, during this imagery, she felt a peace and an ease settle into her experience.

Imagining pictures of the future helps a person to make specific behavioral and emotional changes. This information is invaluable for decision making because it provides a holistic level of information that is not available at the purely verbal level.

The transpersonal (beyond personality) level of human nature is a fact. Cultures throughout the world have used prayer, meditation, imagery, diet, physical training, contemplation and study, ritual, art, and many other methods to experience transpersonal states of consciousness. People seek these states because they tend to provide a subtler understanding of the universal patterns of reality and a more peaceful perspective on the “little self” living in the immensity of creation. Holistic nurses frequently cite their own transpersonal experiences as one of the reasons they became interested in introducing holistic methods into their work. Motivated by their own development through such experiences, they desire to pass the potential of transpersonal experiences on to others.

The role of imagery in transpersonal experience is a crucial one. Holistic nurses can use transpersonal imagery to introduce patients safely to the transpersonal level of consciousness.⁵¹,⁵²,⁵³ This imagery is referred to as transpersonal because it links and identifies the individual experience with universal processes. Transpersonal imagery taps into an expanded experience of the self, an experience that draws on human beings’ capacity to connect deeply with the flow of life energy and creation. This connection, and the imagery that emerges from it, can be interpreted as a connection with God, with all of humanity, with a higher power, with the wonder of the universe and nature, or a connection with the mysterious, nonverbal communication that occurs between people at the level of intuitive knowing and caring. (See Chapters 4 and 32.)

Visualization practice can be helpful for energizing and eliciting transpersonal experiences. Art images, photographs, and picture postcards are all sources for images that can be used in work with transpersonal symbols. The nurse can begin to collect art cards and other images that can be used to help patients. For example, one elderly woman hospitalized with advanced heart disease was feeling lonely, depressed, and fearful. She expressed fear that she was going to die. In sharing this with the nurse, she said she was
confused by spirituality and did not know what she believed. The nurse asked if she would like to explore these feelings with imagery, and the woman agreed. The nurse led her in a brief relaxation and then suggested that she experience herself in a place that she felt was sacred. The woman was silent for a long time. The nurse sat silently with her. After a while, the woman opened her eyes. She was surprised by her imagery. She felt herself in Florence, Italy, a place she had never visited. She imagined walking the streets, looking at the beauty of the churches, and feeling deeply connected to the sacredness of the art. She said she always imagined Florence as a sacred place. She deeply loved Renaissance art and imagined the magic of a place where so much beauty had been created. She realized that her love of art was the closest thing she could identify as a spiritual feeling. Recognizing the importance of this imagery for the patient, the nurse said she would bring her a postcard of Florence. This pleased the woman, and the nurse told her that it would be important to honor this inner experience by keeping a reminder of it where she could connect with it over the course of the day.