e4-08: Guided Imagery

According to the National Center for Complementary and Integrative Health, guided imagery is a practice used for healing or health maintenance that involves a series of relaxation techniques followed by the visualization of detailed images, usually calm and peaceful in nature. As is the case with psychotherapeutic techniques, guided imagery can be applied in a variety of ways. It may be directive, with the therapist providing specific images, or it may be more receptive, inviting patients to find their own images. It may be supportive, with the intention to create a relaxed, pleasant, or specifically positive feeling (eg, trust or patience), or it may intend to directly work with an area of active challenge (eg, anxiety or pain). If used for treatment, persons may visualize their bodies free of the specific problem or condition. Guided imagery can be conducted live with a therapist one-on-one, in a group setting (less common), or via audio recording.

Imagery has been used throughout history and can be found in the origins of all ancient healing systems still extant today. In contemporary Western medicine, the psychiatrist Dr. Carl Jung recognized the importance of imagery as an expression of the subconscious and in 1915 developed a psychotherapeutic technique called “active imagination.” With the similar intention to aid psychoanalytic exploration, the French psychotherapist Dr. Robert Desoille in the late 1930s created a method he called “directed daydreaming,” and in the 1950s, Dr. Hanscarl Leuner introduced “guided affective imagery.” Medical research on guided imagery began in the 1970s and increased greatly in the 1980s. In 1989, the physician Dr. Martin Rossman and the psychologist Dr. David Bresler founded the Academy for Guided Imagery, which began certifying health professionals. One modern application of guided imagery has been through technology and virtual reality. A recent pilot study of 34 patients with Parkinson disease found that treadmill training augmented by virtual reality (in which participants were presented obstacles and real-life challenges in a virtual environment) resulted in possibly improved function, perhaps reflecting increased brain efficiency. Another small pilot study of children with cerebral palsy in which they visualized themselves as an avatar, representing movement in real time, found clinically important improvements in measures of gait.

The mechanism of action of guided imagery is not well known, but some physiologic effects have been demonstrated. Three of five studies examining cortisol levels in relation to guided imagery have found that serum levels decreased after the intervention. Studies of the effect of guided imagery on immune function have shown mixed results. However, a 2009 randomized controlled trial of women with breast cancer showed improved NK cell cytotoxicity and increased IL-2-activated NK cell activity. One study documented reduced physiologic arousal around chemotherapy sessions, as measured by heart rate and systolic blood pressure. Some proposed psychological mechanisms postulated to explain the effects of guided imagery include cognitive restructuring, increased sense of control, increased adaptive coping, distraction, and relaxation.

The leading certifying organization, the Academy for Guided Imagery, generally limits certification to licensed health care professionals or health professional students, but exceptions are allowed. To obtain the certification known as “interactive guided imagery,” 150 total hours of training are required, including 52 hours of small group supervision. Applicants are also required to adhere to the American Psychological Association code of ethics. Another major certifying organization is Beyond Ordinary Nursing, which requires 110 total hours of training, including 10 documented imagery sessions.

The length of a typical guided imagery session with a therapist is 50 minutes, with 20–30 minutes spent in active imagery. The imagery portion of the appointment often begins with imagining a place of comfort and safety, then proceeding to the desired area of specific clinical attention. Polysensory recruitment is often used (ie, the patient is asked to imagine visual, auditory, tactile, and olfactory cues in the image scenario). Examples of specific clinical techniques used by the therapist might include dialoging with the symptom (“If your back pain had a voice, what would it say?”), consulting a wisdom figure or inner advisor (“What does your wisdom figure say about how to approach this cancer treatment?”), and visualizing a desired outcome (“Imagine yourself waking up after surgery feeling calm and comfortable.”). Interactive Guided Imagery is a type of imagery that more deliberately aims to enhance awareness of subconscious content.

Predictors of favorable outcome from guided imagery, based on three studies, are previous experience with guided imagery, imaging ability of the patient, perceived credibility of the therapist, and rapport of the patient with the therapist. Age, gender, and education level have not shown significant correlation with outcomes, suggesting that this technique can be applied widely.

Adverse events have not been reported with guided imagery. However, as is the case with any psychotherapeutic technique, distressing psychological content can arise.

There are no contraindications based on outcomes studies. However, due to the potential risk of reexperiencing original trauma, caution is advised in using guided imagery in patients with posttraumatic stress disorder or history of severe trauma or abuse.

A. Surgery

There are many studies examining the use of guided imagery on outcomes related to surgeries and procedures, including heart surgery, colorectal surgery, abdominal surgery, laparoscopic gynecologic surgery in adults, bone marrow aspiration, lumbar puncture, burn wound debridement, and administration of immunizations in children. Although many of the studies have methodologic limitations, reviews and meta-analyses have found overall benefit of small to moderate effect sizes for reducing psychological distress and reducing postoperative pain. A 2013 systematic review of the effect of mind-body therapies on postoperative outcomes concluded there was strong evidence that guided imagery improved psychological well-being measures and moderate evidence that it reduced analgesic intake. Two of the three randomized controlled trials assessing effect on average length of hospital stay found a significant decrease with guided imagery intervention. Other studies have shown significant decreases in total opioid use and average pharmacy costs. An interesting 2012 randomized controlled trial on guided imagery's effect on wound healing found that the intervention reduced perceived stress and increased hydroxyproline deposition in the surgical wound, a measure of the healing response. The most significant negative trial of the perioperative use of guided imagery was a randomized controlled trial of guided imagery for periprocedural pain and anxiety conducted with 170 women undergoing colposcopy, which did not show significant effect in the experimental group. In addition, a small 2016 three-arm randomized controlled trial of patients undergoing colorectal surgery did not find benefit from guided imagery or progressive muscle relaxation on quality of life after surgery.

B. Cancer-Related Symptoms

Most of the studies in patients with cancer that use guided imagery do so in combination with another modality, such as progressive muscle relaxation, meditation, hypnosis, biofeedback, or music therapy. These studies vary in methodologic quality. There are at least 20 randomized controlled trials in this category, and all show benefit for psychological outcomes, such as quality of life, anxiety, and depression. Studies that assessed the effect of guided imagery in combination with other modalities on nausea and vomiting also showed uniform benefit. For example, in a 2016 randomized controlled trial of 208 patients receiving a combination of guided imagery and progressive muscle relaxation once a week for 4 weeks while undergoing chemotherapy, the experimental group experienced significant improvements in fatigue, pain, and health-related quality of life when compared with usual-care control group. With respect to nonprocedural, cancer-related pain, there are at least six randomized controlled trials using guided imagery as part of a combination intervention. Three studies showed significant pain reduction with guided imagery intervention, two showed no pain reduction, and one showed significant benefit in patients' self-reported ability to decrease pain but not in measured pain intensity.

There are also several randomized controlled trials of guided imagery used alone, as a sole adjunctive treatment for patients with cancer. All of these studies again showed that guided imagery led to improvement in psychological outcomes, and in approximately half of the studies, the improvement was superior to other comparison interventions, such as progressive muscle relaxation or hypnosis. The evidence for guided imagery alone in preventing chemotherapy-related nausea and vomiting is mixed.

A single study examined the effect of guided imagery directly on cancer disease regression using clinical (Union for International Cancer Control criteria) and pathologic (biopsy) measures and found no effect.

C. Chronic Pain

There are several studies of guided imagery for various chronic pain conditions, such as phantom limb pain, osteoarthritis, headache, low back pain, fibromyalgia, and interstitial cystitis. Some of the studies are controlled, and all but one show benefit in either pain or psychological distress, or both. A rigorous systematic review found that eight of nine randomized controlled trials showed benefit of guided imagery for musculoskeletal pain, but due to variable quality of these studies, the review concludes that the evidence is encouraging but inconclusive. Similarly, a 2012 review of 15 randomized controlled trials on guided imagery for nonmusculoskeletal pain concluded that the evidence of benefit is encouraging but inconclusive. A 2017 systematic review and meta-analysis of studies on fibromyalgia concluded that guided imagery and hypnosis hold promise for this painful condition.

D. Stroke Rehabilitation

In at least two dozen trials, a variety of imagery techniques have been shown to be effective for stroke rehabilitation. These usually involve having patients practice imagining the movement or function they wish to execute, in a sense cognitively rehearsing. There are positive studies on hand function, upper extremity function, gait and lower extremity function, and balance.