Clinical:Case Study: Guided Imagery Part I: Use in Medical Practice

Original materials created in July 1999 by Belleruth Naparstek, MA, LISW

History

Melissa, a 43-year-old married real estate agent with two adolescent kids, was told by her doctor at the Cleveland Clinic that her lifelong difficulties with her colon would almost certainly lead to colon cancer. Because her surgeon had invented a procedure that promised to bypass this eventuality by removing the colon, she was encouraged to sign up for the procedure as soon as possible. This would mean that she would have an ostomy bag for about a year, but that eventually her colon would return to normal functioning. Melissa was terrified, not of the procedure, nor of the disfigurement, nor of the prosthesis, but of the loss of control from the anesthesia during surgery. In fact, it was enough to keep her from signing up.

She knew this was irrational. She was wholeheartedly in favor of the surgery, grateful for the existence of such a procedure. She saw it as her chance to save her life. But she kept canceling, because the thought of the anesthesia filled her with terror.

By the time she came to see me, she had thwarted four successive dates, and the Cleveland Clinic, her doctors, and her husband were exasperated and worried.

I saw her twice. She was very tense when she entered my office. I asked her to attempt to get comfortable and to fold her hands over her belly and take a deep breath. Then I asked her to tell me about a moment in her life when she was filled with feelings of love and gratitude, feeling utterly safe and protected. She immediately went to a memory of a camping trip with her husband, several years earlier on Lake George. Her eyes became dreamy, her face softened, and she had a slight smile as she remembered.

At my prompting, she added more sensory detail, which got her deeper into the experience: the scent of pine needles in the crisp night air, the night sounds of crickets serenading them, feeling a fresh breeze on her face, and inhaling the richness of their combined body warmth, emanating from the sleeping bag...

Recalling these sensory memories and feelings sent the anxious Melissa into a relaxed trace in seconds. But she also wanted an image that would allow her to feel safe about being unconscious. She decided that she liked the idea that she was being watched over by trusted guardians while she slept. So she evoked the image of the O.R. filled with the faces of her grandmother, her husband, her father, a few special friends, her kids, two dearly loved pets, and a guardian angel or two. Her mother, usually a nervous wreck, was left to cool her heels outside in the waiting room.

Melissa played with these images several times a day, always positioning her hands the same way, folded over her belly, and breathing deeply as she began. This, of course, became a conditioning cue, what hypnotherapists call an “anchor.” Invariably, she would relax, smile, and feel safe, and the more she practiced, the more quickly she achieved this state.

She felt in control again. When it came time for her to get on the gurney to take that lonely ride up to the O.R., she was smiling and peaceful. After all, she was at Lake George, wrapped in her husband’s arms.

Melissa also used imagery to help her with postsurgical wound healing, pain, bowel control, and return to normal bowel function.

Discussion

Guided imagery leans heavily on sensory imagination and emotion as a way to create mental images that help to heal or relax the body. It is the power of visualization, the power of mind over matter - and it is nothing new.

For years, professional athletes have used it to see victory on the playing field, surgeons to envision successful procedures, stockbrokers to imagine a system of success in the midst of the chaotic trading floor.

Guided imagery is a way of creating images in the mind that direct the body to increase physical and emotional healing. Narratives that contain positive imagery are carefully designed to activate the nervous system to send neurohormones through the circulatory system to trigger healing activity at the cellular level. For example, Jeanne Achterberg, Ph.D., a psychologist who is also President of the Association for Transpersonal Psychology has published twelve “Bodymind” audiotapes for pain, disease, and stress-related disorders. Dr. Achterberg defines imagery as “a thought process that invokes and uses the senses: vision, audition, smell, taste, senses of movement, position, and touch. It is the communication mechanism between perception, emotion, and bodily change.

” Dr. Achterberg’s narratives are divided into “disease imagery, treatment imagery, and healing imagery.” On her cancer tape, for example, the disease imagery asks the listener to create an image from physiological and biological information. The narrative invokes a picture of the body as a marvelous machine with a surveillance system and built-in devices for protecting itself.

The treatment imagery asks patients to visualize the powerful white blood cells becoming active, guarding and protecting the patient, and attacking all abnormal cells and the tumor. The healing (or “end state”) imagery invites people to see themselves the way they want to be - whole and balanced, mentally, spiritually, and psychologically.

Psychological imagery works with the idea that the body is a metaphor for the psyche. If the body/psyche is not protecting itself properly, the patient can consciously concoct a metaphor to correct that situation. For example, a person can encircle him or herself with loving protection (in whatever form) to combat a sense of isolation and despair about being unprotected in the world.

Potent emotional imagery helps the listener to shift moods by generating feelings of love and gratitude, and “blue print” imagery reminds the patient how the body feels when it is functioning at full strength and engaged in what it loves to do.

A recent study on the use of guided imagery techniques in patients undergoing colorectal surgery was done at the Cleveland Clinic. This prospective randomized trial demonstrated the perioperative use of guided imagery decreased length of stay, use of pain medication, and perioperative anxiety in patients undergoing elective surgery for diverticulitis, Crohn’s disease, ulcerative colitis, familial polyposis, or colorectal cancer.

The 150 female and male patients were ages 18 to 75. Excluded were those with a history of substance abuse, chronic pain, major psychiatric disorder, or narcotic or benzodiazepine use for more than one month prior to surgery, and those unwilling to use IV patient-controlled anesthesia (PCA) or who were intolerant of morphine. Half of the patients received instructions on relaxation techniques along with standard perioperative instructions. For three days prior to surgery, they listened twice daily to audiocassettes that taught guided imagery techniques and promoted expectations of a positive outcome. On the day of surgery, they listened to tapes of soothing music in the preoperative holding area and in the OR. Postoperatively they listed to guided imagery tapes containing positive suggestions about outcomes for six days. The control group received only standard preoperative instructions. All patients received intravenous PCA.

Both study patients and controls were asked to rate anxiety and pain levels twice a day on a numerical ranging scale ranging from 0 to 100. In addition to IV PCA, narcotic use was tallied. In the patients using guided imagery, an average length of stay was reduced 1.5 days (from 7.9 to 6.4 days) and pain medication use was decreased by 50 percent. In addition, bowel function returned to normal 1.2 days sooner.

Self-reported perioperative anxiety levels were also significantly lower. Among guided imagery patients, the average perioperative anxiety level was 38, while the controls reported an average anxiety level of 73. Similarly, guided imagery patients reported steadily declining postoperative anxiety levels of 40, 30, 17, 10, and 3 on postoperative days 1 through 5 while controls’ anxiety level remained consistently 50-55 during that period.

Reference

Fazio, et al, Consult: 15, 1. Winter 1996