IMAGERY: Using The Mind's Eye in Healing Toni Gilbert, RN, MA, HNC
The Pain RelationshipDavid E. Bresler, PhD, LAc
The Uses of Imagery in Self-Management Programs for Chronic Illness David Spero, RN, BSN
REVIEW......Joy of Cooking for the Psyche by Margo Adair
AUGUST 2001 VOLUME 1 number 1
IMAGERY: Using The Mind's Eye in Healing
Toni Gilbert, RN, MA, HNC
When he came to see me about his symptoms, fifty-year-old Martin was having trouble with headaches, stomach and intestinal upset (to the point of regularly spending the first part of his work morning in the bathroom). He also had a seizure disorder and was experiencing the dizziness he usually felt prior to each seizure. Needless to say, he was anxious. Martin told me that he was self-employed and was "stressed out" about his business. I listened to Martin's symptoms and suggested that he would benefit from work with "imagery."
What is imagery? It is a way that your mind stores, codes and expresses information. Imagery consists of thoughts that you can smell, hear, see and taste. It is an inner representation of your experience (or your fantasy). Imagery manifests as your dreams, daydreams, memories, plans or possibilities, and projections. It has been called the language of the arts, emotions, and the deeper self.
Guided imagery is a natural therapy. A therapist uses a hypnotic induction to place the client's mind in a state of relaxation. The therapist then verbally guides the client to access the unconscious mind for valuable information and insights on the nature of an illness. This information can then be used to assist in the client's healing.
Martin and I discussed the use and benefits of guided imagery. We decided to use a technique known as "dialogue with an inner healer."
The guided imagery session with Martin began with the induction of a state of relaxation and focused attention-like "dreaming" while awake. When Martin was ready, he was asked to picture, in his imagination, a scene where he felt safe and comfortable, and to describe the details of that scene. He described a forest scene with tall trees, ferns, small animals and the smells of the forest. When he had looked around and experienced the scene for a few minutes, he was asked to invite an inner healer to appear. In his mind's eye a wolf appeared on a ridge overlooking a valley. The wolf was friendly and communicated that he was there to help. Martin described the wolf as "very healthy, relaxed and calm." After a few moments spent getting to know the wolf, I asked Martin if he wanted to become the wolf (a technique known as evocative imagery). He thought that was OK since, in the imagination, anything can happen. So, in his mind he became the wolf and at once experienced the feeling of "being" the wolf. He said he could feel in his own body the calmness and confidence the wolf felt, how the wolf viewed the world as it truly was, not hurrying to make something happen in it. Martin gradually took on the persona of the wolf and could feel himself calming down.
Martin has continued to use the image of the wolf in his life. He resolved to check in with his wolf every day, by closing his eyes and imagining the wolf with him or himself as the wolf. Martin applied the experience of the wolf to himself, thus gaining the wolf's feelings of relaxation, confidence and calm. Over two years later, Martin is mostly symptom free and feels he has incorporated the essence of the wolf into his own personality. He still visits his wolf in his imagination nearly every day.
A Half Century of Imagery
As early as the 1950s, researchers and clinicians in China, Japan, Europe, and the United States began to explore the role of imagery as an important factor in health and illness, life and death. During the past thirty years, findings from basic stress research, biofeedback instrumentation, the clinical use of relaxation, and the emerging field of psychoneuroimmunology, have cumulatively built up a large body of knowledge indicating that psychological factors (the mind) can and do significantly affect the physiology of the body. Guided imagery is one modality that research has shown facilitates the mind-body connection in healing. No physical ailment is beyond this mind-body approach.
Simply put, your mind can affect the healthy functioning, or dis-functioning, of your body. When you imagine, or "image," scenes, you experience them in your mind, and your body responds as though it was actually happening. What you imagine can and does affect your hormonal secretions, the functioning of your various systems, your very heartbeat. For example, when you're hungry, you begin to salivate at the thought of food; you blush as you think about an embarrassing moment; your body responds to a sexual fantasy. In the same way, visualizing certain images (for example, Martin's wolf) can help you through some difficult emotional or stressful times.
Positive emotions, thoughts, and images have specific biochemical correlates that influence how the body works. Imagining the immune system functioning to perfection can counteract a life-threatening disease. By focusing attention on, and consciously directing imagination and emotions to different areas of the body, it is possible to actually alter the quality of blood flow, dilating or constricting blood vessels.
Guided imagery has proven especially useful for surgical patients: In a double-blind study of 130 patients at the Cleveland Clinic, subjects who listened to guided-imagery tapes for three days prior to, and six days following surgery, rated their anxiety levels as significantly lower than a control group. The first group described their pain to be half as severe, used 37 percent less pain medication, and were released from the hospital almost two days sooner than the control group.
A popular physician, Harvard educated Andrew Weil, lists guided imagery as one of the ten things you can do to have a successful surgery outcome. He advises anyone who is preparing for surgery to practice guided imagery regularly. He suggests it is best to work with a guided imagery therapist who can help you develop your own personal imagery. If this kind of help is not available, audio tapes, such as those cited in the above study, can be purchased.
The Power of Imagery
The images of our imagination are potent because they have been created from the depths of our emotions. These images come from the same place as our dreams and, because they are formed by feelings, they evoke feelings. These symbols represent emotional energy and the spirit of the figure represented (i.e. a wise person, mother, father, animal or plant, etc.). The images can calm and reassure us; they can give us emotional strength as well as affect our body processes.
The use of imagery may be the most ancient healing technique used by our primitive ancestors. The earliest records of such techniques are found in Babylonia and Summaria. These ancient people, and some Indian tribes such as the Canadian Eskimo and the Navahos of the American Southwest, held a common view that included a rich fabric of imaginary figures. In Egypt, the physician-priest would initiate healing ceremonies. He would perform rituals using herbs, healing symbols, and incantations consisting of both prayers and imagery.
Paracelsus, a physician of the Renaissance, said "The spirit is the master, imagination the tool, and the body the plastic material The power of the imagination is a great factor in medicine. It may produce disease in man and in animals, and it may cure them"
Our ancestors believed that our images come from our deepest self and that they have much to teach us. We may be wise to heed our ancestral teachings. In working with images, it is most important to do the things that help you understand and believe in your self, in your own power to heal.
SOURCES FOR PRACTITIONERS, AUDIO TAPES AND BOOKS
Beyond Ordinary Nursing: (650) 570-6157
Academy for Guided Imagery: (800) 726-2070
Dr. Andrew Weil: (800)523-3296
Toni Gilbert, RN, MA, HNC, is a certified holistic nurse with an education in psychology and transpersonal studies. Toni is a college instructor of psychology, and has a private practice in which she offers an array of healing arts techniques to enhance wellness and prevent illness. These techniques complement traditional medical treatment of disease and injury by adding a holistic psychological and spiritual component. She can be reached at (541) 327-7749; <mailto:tgilbert@dnc.net>tgilbert@dnc.net and a web site <http://www.tonigilbert.com/>www.tonigilbert.com
David E. Bresler, PhD, LAc
Associate Clinical Professor
UCLA School of Medicine
Executive Director,
The Bresler Center
White House Commissioner on
Complementary And Alternative Medicine
Originally Published in Practical Pain Management.
Guest Editorial. January, 2001
The Bresler Center
30765 Pacific Coast Hwy
Malibu, CA 90265
Bresler@aol.com
The Pain Relationship
Patients who live in chronic pain develop a long-term relationship with their pain, whether they choose to do so or not. In terms of interpersonal dynamics, this relationship is usually a negative one, characterized by feelings of fear, resentment, hostility, and mistrust.
Most therapists and counselors agree that developing and maintaining healthy, positive relationships is one of the most challenging of all human endeavors. There are two questions I like to ask that give a good sense of the health of any relationship: (1) "How do you feel when you're with ___?" and (2) "How does ___ make you feel about yourself?"
We generally feel good when we're with someone we love, and they usually make us feel good about ourselves. How do our patients feel when they're with pain, and how does pain make them feel about themselves? Not so good, which is why many of them start the relationship by looking for a "pain killer." How healthy is a relationship when one party starts it by attempting to "kill" the other?
As an alternative, I think it's better for people to first find out what pain may be trying to communicate before attempting to "kill" it. Using Interactive Guided Imagerysm techniques, I frequently invite my patients to close their eyes, allow an image of their pain to appear, and begin a dialogue with it. During this dialogue, I suggest they ask their pain why it's here, what it wants, what it needs, where it's going, and under what conditions it would be willing to leave.
After listening to thousands of these "inner conversations"
with pain, it's clear that most of the time, pain is not an enemy
to be "killed," but an overzealous, often misunderstood
ally who believes (sometimes mistakenly) that it is protecting
the patient from further harm.
For example, one patient complained that despite all attempts
at therapy, his back pain had ruined his life, destroyed his career,
and ended his marriage. As in most relationship disputes, the
other side (the image of his back pain) had a completely different
perspective. It told him, "When you first injured your back
by lifting a load that was too heavy, I gave you pain to let you
know that this was a problem. At first, you listened and stayed
in bed for a day, so I turned the pain down. The next day, though,
you returned to work, which I didn't understand at all since you
were still injured. So, I turned the pain back on and you responded
by taking pills and ignoring my message. I had no choice but to
turn the pain up even higher, and you responded by getting injections
so that you could get back to work. This made no sense at all
to me, and since you still didn't seem to get the message, I turned
the pain up even higher, and began running it down your leg. This
does seem to work because when you overexert, it's the one way
I can get you to lie down and stop hurting yourself. This works
for me, and I'm not going to turn the pain off since you can't
be trusted when I do." This mutual mistrust is a common scenario
when looking at the pain relationship. Patients don't trust their
pain, and their pain doesn't trust them. Perhaps we don't help
when we tell patients, "Tough it out. Don't listen to your
pain. Do it anyway. No pain, no gain."
How does one establish trust in a relationship? Only when both parties act with integrity over time. When someone is consistently honest, keeps agreements, and reliably does what they say they are going to do, we begin to trust them. It takes a lot of time to establish trust, but only a few seconds to destroy it.
>From this perspective, I encourage my patients to develop a new kind of relationship with pain, one that is characterized by open, honest communication, integrity, and a sense of mutual cooperation. Rather than remain embittered and resentful, I invite them to communicate with their pain, to take care of their pain, to give their pain random acts of kindness, and then to see what happens.
For example, if a patient in pain is on the fence about whether or not they are up to doing something, they typically complain, "If it weren't for that *$#&! Pain, I'd be able to do this easily." I recommend they try an attitude adjustment, and give their pain a gift by not doing it. I urge them to tell their pain, "This one's for you. I'm going to pass because I want to listen to you and take better of myself."
I'm not suggesting that people surrender to pain, or give in to it. It's not about fighting, winning, or losing. It's about having good communication, working together, mediating disputes, and watching out for each other's interests. It's about developing the best relationship you can have.
Patients ask me, "Does it really help to talk to my pain?" I tell them, "How successful have you been trying to fight with it your way? Have you 'conquered' it? Why not try it my way and see what happens? It's about 'rock turning.' When you turn over rocks, what do you see? Some dirt, maybe a few bugs, and once in awhile, a treasure. I can't promise you'll find a treasure if you turn over rocks, but I can promise that you won't find a treasure if you don't try it."
Like any other relationship, the pain relationship is always enhanced by clear, honest, direct communication. When patients are able to make their pain relationship a more positive one, their tolerance to pain, and subsequent functionality is often dramatically enhanced.
One patient visualized his lumbosacral pain as a swayback donkey with an aching back. During his dialogue, the donkey said he had been carrying too heavy a load for too long a time. The patient replied, "I can relate to that." This began an important dialogue that led the patient to a rehab program that embraced a different attitude of greater compassion for his back.
To learn more about Interactive Guided Imagerysm and how if can be used to facilitate inner dialogue, contact the Academy for Guided Imagery at 800-726-2070 or www.interactiveimagery.com. For further reading, I recommend my book, Free Yourself >From Pain (Awareness Press, 2000) and Guided Imagery for Self-Healing by Martin Rossman, M.D. (H.J. Kramer-New World Library, 2000).
The Uses of Imagery in Self-Management Programs for Chronic Illness
David Spero, RN, BSN
3 Grijalva Drive, San Francisco, CA 94132
November, 2000
This paper explains the self-management concept, describes the Stanford Chronic Disease Self-Management Program the author has trained to lead, highlights the role of imagery in the program, and makes suggestion for the better use of imagery to improve the program.
Chronic Disease Self-Management
The concept of self-management as a paradigm for helping people
with chronic illness was developed at Stanford University in the
1980's, under the leadership of Kate Lorig, RN, a doctor of public
health in the Stanford Health Education Department. Lorig et al
developed the Arthritis Self-Management Program (ASMP), and published
the first paper on the value of self-management in 1985. They
reported that ASMP graduates had better health outcomes, engaged
in more health behaviors, and required fewer medical services
than a control group. Stanford, with the help of Kaiser Permanente,
later generalized their program as the Chronic Disease Self-Management
Program (CDSMP,) which included patients with CHF, diabetes, COPD,
stroke, and other conditions.
Self-management has now become the ascendant, though by no means
the dominant, model for addressing the needs of the 60 - 70 million
Americans with chronic conditions. Devins (2000) states, "The
self-management approach represents a revolutionary new perspective
in which affected individuals take on much of the responsibility
for managing their disease....In so doing, the individual acquires
the requisite knowledge and skills to maintain a satisfying and
productive lifestyle."
Here is how two experts describe the self-management concept.
"Three principles are fundamental to the self-management
of chronic disease. First, the emphasis on self-management, implying
that the individual must accept responsibility for managing and
enhancing his or her condition to the extent that this is possible.Second,
self-management emphasizes a partnership between service providers
and recipients, meaning patient collaboration with health care
professionals rather than subservience to them.The third principle
maintains that information acquired through patient education
efforts must be implemented through effective coping skills and
behavior." (Devins and Binik 1996)
I would add that self-management programs aim at every step to
encourage self-efficacy, the belief that we can make desired changes.
Increased self-efficacy is now thought the major reason for patients'
improved status (Lorig, Sobel et al 1999.) Imagery plays a largely
underappreciated role in fostering self-efficacy.
Description of the Chronic Disease Self-Management Program (CDSMP)
CDSMP currently consists of six weekly sessions, of two and
a half hours each. Each session combines education with social
support. Groups are expected to include between 8 and 12 patients
with all types of chronic conditions, although some groups are
smaller or larger. Participants are encouraged to bring significant
others. Groups are led by lay people with chronic conditions of
their own, not by health professionals.
Written materials, including 25 flip charts and a leaders' manual,
have been created by Stanford and licensed to various providers
in the U.S., Canada, England, and Australia. The largest of these
providers are the Veterans' Administration and Kaiser Permanente.
CDSMP covers the nature and demands of chronic illness, our ability
and responsibility to manage our own conditions, the ability of
the mind to influence the body, and specific information on exercise,
medications, cognitive skills, nutrition, action planning, problem
solving, emotional coping, relaxation, breathing techniques, and
communication skills. Imagery is included in five of the six sessions,
as described below.
At the end of each session, participants create an action plan
for the following week, relating to some health behavior or life
improvement they wish to make. At the next session, people report
back and receive help from the class with problems they have encountered.
20-minute breaks are built into each session so that participants
can support and learn from each other. Lasting friendships and
supportive arrangements often result.
The use of imagery in the Self-Management program
Formal imagery exercises play a role in six activities in
the CDSMP, and are included in five of the six sessions. The first
activity in week one, after introductions, is the venerable image
of biting into a lemon. By demonstrating the salivary and puckering
response to the imagined lemon, leaders powerfully illustrate
the concept that the mind influences the body, increasing participants'
perceived ability to affect their bodies.
Session 3 includes the Jacobson Muscle Relaxation, starting with
focused breathing. At the end, the script instructs: "And
now, just enjoy this feeling of relaxation for a little while.
Remember this pleasant feeling. You can quiet your mind and body
in this way any time you do this exercise. With practice, you'll
be able to create this feeling just by taking a deep breath."
(Lorig, Gonzalez, Laurent 1997) This image encourages participants
to have more contact with their inner world as a place of safety,
relaxation, and comfort.
In week 4, leaders teach distraction as a technique for pain control.
Emphasis is on cognitive methods, - counting backwards, doing
alphabets, etc. -- but imagistic techniques - imagining playing
a baseball game in our head - are also mentioned, and could be
strengthened.
In week 5, leaders present the concept of changing our self-talk:
converting negative to positive thoughts, creating affirmations.
Students practice changing their self-talk along the lines Carl
Simonton suggests in unit 4A of the AGI home study program. Participants
are encouraged to rehearse their positive statements and to imagine
the positive ideas being expressed, as they say them.
Also in session 5, students go through a guided imagery exercise,
a "walk in the country." (Sometimes, we use an alternate
exercise, a "walk on the beach," especially for English
and Australian groups whose countryside looks far different.)
The script recruits five senses: touch, smell, sight, hearing,
and kinesthetic. It contains a suggestion that listeners find
a box by side of road, and "put into it any concerns, worries,
or pressures that you are carrying with you. You close the box
and fasten it securely knowing you can come back and deal with
those concerns whenever you are ready." (Lorig et al1997)
The box is never mentioned again! Leaders ask for show of hands
of those whose pain or tension decreased, or whose hands seem
warmer. We suggest that with practice these effects will increase.
In the final session, we sum up what we have learned and make
plans for the future. We lead a short evocative imagery exercise:
"Watch yourself now as you successfully complete the steps
you need to take to fulfill your future plans.Think about how
good you feel being able to do this." (Lorig 1997)
The importance of imagery in CDSMP
Descriptions of CDSMP by evaluators give surprisingly little
attention to the imagery components of the program, instead emphasizing
the educational aspects. The relative role of imagery would be
a fruitful direction for further research. The imagery exercises
each have the effect of demonstrating to participants their power
to control their bodies and their symptoms, the central concept
of the program. The use of evocative imagery in the final exercise
suggests the ability to influence the direction of our lives,
an even more powerful statement of self-efficacy. The pleasure
and relaxation students derive from imagery exercises may also
give them incentive to return for further sessions of the program.
Suggestions for improvements in the use of imagery in CDSMP
The initial lemon exercise could be strengthened with more
sensory recruitment ("roll the lemon around in your hands.cut
it into sections."). The self-efficacy potential could be
strengthened by adding at the end: "and since YOU were able
to do this, you will be able to do many of the cognitive self-help
techniques taught in this program.")
The self-talk section needs to be strengthened. Simonton's suggestions
- get in touch with the negative statements when you're feeling
badly, test them for reality and helpfulness - would help people
understand how to use the technique. One thing not in the leaders'
manual, which I always add, is that the positive statement has
to be something you can believe. I also stress that your body
does hear what you say to yourself, and that any belief, attitude,
or thought can be changed with practice.
The final exercise, imagining your next step for health, could
be strengthened with evocative techniques (locate the feeling,
turn it up, "let it fill your whole body," etc.)
Conclusions
Self-Management programs are still in their early childhood,
with a number of areas for improvement. The name, "Chronic
Disease Self-Management" turns off many people who could
benefit from the content. Kaiser has searched for a more attractive
name, and has currently settled on "Healthier Living with
Ongoing Conditions," which is not the final word. Concerns
about the cross-cultural relevance of the self-management program
have been raised. Cultures which value strong family and community
ties above other considerations may find self-management an inappropriate
concept. Others have asked whether the self-management focus may
appeal more to males than females. I have seen no evidence of
this disparity, but the program could be stronger in the areas
of relationships and communication. Among the most fruitful areas
for possible improvement will be strengthening the imagery components
of the program.
References
Devins, G., Cameron, J., Edworthy, S. 2000, Chronic Disabling
Disease, in Cognitive Behavioral Therapy for Persons with
Disabilities, C. Radnitz, Ed.
Devins, G. and Binik Y.M. 1996 Predialysis psychoeducational interventions: establishing collaborative relationships between health service providers and recipients. Seminars In Dialysis 9:51 -55
Holroyd, K.A., and Creer, T.L. 1986 Self-Management of Chronic Disease: Handbook of Clinical Interventions and Research, Academic Press
Lorig, K., Lubeck, D., Kraines, R.G. et al 1985 Outcomes of self-help education for patients with arthritis. Arthritis and Rheumatism 28:680-685.
Lorig, K., Gonzalez, V., and Laurent, D. 1997 The Chronic Disease Self-Management Course: Leaders' Manual. Stanford University
Lorig, K., Sobel, D., Stewart, A. et al, 1999 "Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial," 37 (1) 5 - 14
Joy of Cooking for the Psyche by Margo Adair
"Margo Adair has been a pioneer in consciousness for many years. She can show you how to free your imagination to carry you to and through the transformative opportunities that life offers you. Don't pass this one up." -Martin L. Rossman,
Imagine a reference book for the psyche that is as useful as
the Joy of Cooking has proved to be for the kitchen. I
wrote Meditations On Everything Under the Sun: The Dance of
Imagination, Intuition, and Mindfulness with this vision in
mind. It is a sourcebook that people can turn to time and again-whenever
one needs to bring the great healing powers of inner-consciousness
to bare on daily life. The book is designed to be easily accessible
and practical for both professionals and newcomers to guided imagery.
The book contains one hundred and seventy guided meditation scripts,
which have been designed to be mixed and matched. They are chock
full of ideas that can be used when leading a guided imagery
session. Utilizing repetition, rhythm, rhyme, memory, and metaphor
to open the imagination and evoke deep awareness, these meditations
address every issue people face in contemporary life. There is
a thousand word long Meditation Use Index which help people customize
their meditation to their current concern. For example, one can
look up relationship and choose meditations on friendship, loss
of self, finding a significant other, love, child rearing, family,
etc. Over twenty scripts are dedicated to physical healing and
another dozen to emotional healing; still others on meeting the
challenges of daily life whether inviting an insight, forgiveness,
care giving, test taking or decision making. Lastly, an extensive
section for use in group settings to help sustain community/ workplace
or family well-being are included. Truly there is a meditation
here for Everything Under the Sun.
The book begins with an exploration of the imagination and inner
consciousness. There is a nuanced description of the "Anatomy
of Consciousness" which people can use to navigate their
inner dimensions. It includes discussion on such topics as the
simultaneity, suggestibility and fluidity of inner awareness,
metaphor, intention, positive points of reference, belief structures,
ESP, the framing of questions to angle the light of awareness,
distinguishing between wishful thinking and expectation and emotional
versus intuitive information. These ideas about consciousness
will be help people develop a deeply intimate relationship with
their own inner process and come to trust their own awareness.
There is nothing more vital to the reclaiming of personal power
than to come to trust one's own awareness. Doing so leads to being
able to fully participate in one's own healing process.
Meditations' special contribution to understanding the
nature of consciousness is the exploration of what it means when
one cannot imagine something. This is not a limitation
of awareness; to the contrary it is a metaphoric representation
of exactly where blockage is present. In this section of the book,
one learns how to better interpret what is taking place, and how
to work with the story-making capacities of the imagination to
evoke intuitive knowledge so that one discovers what is needed
to bring balance about.
Meditation on Everything Under the Sun promises unleash
healing powers whether you are working on yourself or with others.
Margo Adair is the author of Working Inside Out Wingbow, 1985 (revised edition forthcoming with Sourcebooks 2003) as well as Meditations on Everything Under the Sun ( New Society Publishers 2001). She has been developing and teaching Applied Meditation for intuitive problem solving for over 25 years. It is a methodology, which is very complimentary to Interactive Guided Imagery. For more information about Adair's work go to www.toolsforchange.org