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8 Articles in Volume 5, Issue #6
Botox Treatment of Chronic Refractory Low Back Pain
DEA Enforcement versus Pain Practice
Group Psychotherapy for Chronic Pain Patients
How Expert Testimony Distorts the Standard of Care
Neurostimulation in Chronic Pain Patients
Physiological Consequences of Guided Imagery
The Role of Tertiary Gain in Pain Disability
Treating Muscular Dysfunction of Upper Limbs

Physiological Consequences of Guided Imagery

What every pain therapist should know about guided imagery.

“Imagination is more important than knowledge...”

- 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 scientific1 and public2 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 with patients (whether aware of it or not). Table 1 summarizes the author’s 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.
  2. Patients (and pain therapists) use imagery all the time.
  3. Imagery has powerful physiological consequences.
  4. Words can evoke healing or hurting images.
  5. Guided imagery is a low risk, low cost alternative for helping patients control painful symptoms.
  6. Guided imagery can greatly enhance pain tolerance.
  7. Guided imagery can help better prepare patients for surgery or invasive procedures.
  8. Guided imagery can enhance compliance with treatment recommendations.
  9. Guided imagery can help motivate and track progress of patients in rehabilitation.
  10. Guided imagery is most effective when utilized interactively.

Table 1. What every contemporary pain therapist should know about guided imagery.

Historical Perspective

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.

Patients and pain therapists 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 patients’ attention on what they can’t do (e.g., by listing disabilities and limitations, writing restrictions, etc.), perhaps they should be encouraged to imagine all that they might be able to do in time, over time.

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

Words can evoke healing or hurting images. When training medical students, interns, or residents in pain medicine, the author urges 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 the author has repeated the exact same examination while saying “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, and thereby yields a greater range of motion.

Low risk, low cost alternative for helping patients control painful 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 since, 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

Greatly enhance pain tolerance. The author suggests that 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.

The author has 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. When the resulting 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, with the result that more pain therapists are beginning to use these techniques.

Helping 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

Enhancing 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 those 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.

Helping 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 comparing a patient’s drawing of her radicular pain upon admission with her drawing following treatment, the practitioner can determine relative progress (the first drawing had heavy, sharp, jagged lines over large body areas as compared to the ‘after’ drawing showing smaller, lighter, less jagged lines over much smaller body areas).

Guided imagery is most effective when utilized interactively. Over the past 25 years, Martin Rossman, M.D., and the author 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

Last updated on: December 22, 2011
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