Guided Imagery as Supportive Therapy in Cancer Treatment
June 1999; Volume 2: 61-64
By Roberta Lee, MD
Many challenges face the clinician providing "supportive care" to cancer patients. Psychological problems and deterioration of quality of life caused by severe nausea, cachexia, and pain are just a few of the hurdles faced by those fighting this disease. Guided imagery, a cognitive intervention, has been implemented with increasing frequency as a therapeutic option for many encountering these difficulties.1,2
Achterberg has defined imagery as "the thought process that invokes and uses the senses: vision, audition, smell, taste, the senses of movement, position, and touch. It is the communication mechanism between perception, emotion, and bodily change."3 Guided imagery is a psychological and behavioral device that equips individuals to harness their ability to imagine and visualize all of the senses. Using self-selected images, patients can communicate with physiological processes of which they are not consciously aware.4
The practice of imagery in medicine has a long history. The ancient Greeks described trance experiences that were used as vehicles for treatment of mental or physical illness. In the 18th century, Franz Mesmer identified hypnosis, a cousin to guided imagery, as a formal phenomenon of psychotherapeutic interest.
In the mid-1950s, the American Medical Association and the American Psychiatric Association recognized hypnosis as a therapeutic tool. Approximately 10 years later, the technique of guided imagery was developed through the collective efforts of psychologists and physicians including Carl and Stephanie Simonton, Irving Oyle, Roberto Assagioli, Jean Achterberg, Frank Lawlis, and Martin Rossman.
Mechanism of Action
The potential therapeutic mechanisms for guided imagery have not been determined precisely. Green and Green, early pioneers in guided imagery research, proposed the first psychoneurological theories about the relation of imagery to healing. These researchers postulated that when the mind chooses and recreates an image of a desired physical, emotional, or mental behavior, a hierarchical self-regulating feedback mechanism takes over. This mechanism involves the cerebral cortex, the limbic system, and the hypothalamus, and affects the autonomic nervous system.4
The imagery sequence begins with the patient creating a mental image that, when stimulated in a deeply relaxed state, accesses the limbic system. The limbic system accepts the image as a course of action to be implemented. If the imagery includes changes in the involuntary autonomic nervous system, the limbic system "programs" the hypothalamus to bring about the physiological changes.4
Other mechanisms have been proposed for the use of imagery in controlling pain. In the gate control theory, pain stimuli are transmitted through the substantia gelatinosa in the dorsal horn of the spinal cord, which may act as a gating mechanism. Transmission of painful stimuli are blocked at the gate before reaching higher levels of conscious awareness. This theory acknowledges influences of cognitive control or higher CNS processing of pain control.5
Another theoretical perspective about imagery and pain control involves a model of stress and coping. The self-regulation model of pain control proposed by Leventhal and J. E. Johnson suggests that a person experiencing a stressful or noxious stimulus may initiate coping efforts that regulate responses to both sensory stimuli and emotional distress. Thus, a cognitive strategy such as guided imagery may decrease the anxiety response to stressful stimuli and to both sensory and emotional responses to pain.6
Guided imagery and hypnosis may be confused. Guided imagery is hypnotic, but involves interaction between the guide and the patient during the session. The patient is more "passive" in hypnosis, which does not require interaction.
The modern use of a therapeutic imaging session usually entails 20 to 30 minutes. The session begins with a relaxation exercise to help focus attention and "center" the mind. In the relaxation phase, the practitioner coaches the patient to relax "progressively" different parts of the body (e.g., first the feet, then the ankles, the knees, and so on). Once a state of total body relaxation is achieved, the practitioner suggests the introduction of an image of a serene, comforting environment.
For example, a typical dialogue might be: "Keep your eyes closed while you take a few deep, easy breaths, and imagine yourself in the most peaceful, beautiful serene place you can conjure up. Think of a time when you felt relaxed and peaceful—perhaps a walk in the park or a day on the beach. Focus on the sights, sounds, smells, and physical sensations associated with this time. Focus on this for about five minutes."
A number of options are possible after relaxation is established. Active imagery—the recruitment of the five senses—can be used to conjure up positive images designed to alleviate pain, relieve nausea, or even help patients become more in touch with their feelings about a chronic illness. In these examples, the image becomes a symbol that patients use to achieve a therapeutic response.
Imagery intervention and its clinical applications in oncology have focused on four areas: efficacy in pain control; ability to improve quality of life through psychological support; influences on immunity; and influences on surgical outcome.
Cancer pain involves complex physiologic and psychological mechanisms that often necessitate a combination of clinical interventions to achieve effective management. Hypnotic (imagery) intervention in pain control has demonstrated that imaging techniques may be helpful. A meta-analysis of all research articles published between 1960 and 1988 on the topic of cognitive strategies for pain modification showed that in more than 85% of the studies, cognitive interventions (such as hypnosis, guided imagery, and progressive relaxation) were significantly more effective in attenuating pain than no treatment.7
Even cancer patients in remission and those without need for chemotherapy or radiotherapy may have a poor quality of life. It is reported that even after years of complete remission, patients experience great apprehension about possible recurrence.8
Lyles et al reported that patients practicing "guided relaxation/imagery" felt less emotional distress, nausea, and physiological arousal following chemotherapy infusion than controls. In this study, 50 cancer patients receiving chemotherapy (25 by push injection and 25 by drip infusion) were assigned to one of three protocols for their chemotherapy treatments: progressive muscle relaxation plus guided imagery; therapist control, in which a therapist provided support and encouragement but not systematic relaxation training; and no treatment control. During the training sessions, patients who received relaxation training reported feeling significantly less anxious and nauseated during chemotherapy, showed less physiological arousal (as measured by pulse rate and systolic blood pressure), and experienced less anxiety and depression immediately after chemotherapy.9
Imagery and its effect on immunity have recently attracted the interest of researchers. A study by Kiecolt-Glaser et al examined the impact of imagery on natural killer cell function. Their treatment subjects were medical students with normal immune function. The students in the treatment arm were taught hypnosis and progressive relaxation. The controls were students with no relaxation training. Natural killer cell function and other cellular immune functions were measured after the students took their exams. Those who practiced the techniques routinely had significantly better immune function during exposure to the stress of exams.10
Gruber et al measured natural killer function and mixed lymphocyte responsiveness in patients with stage 1 breast cancer over an 18-month period. Subjects were provided with relaxation, guided imagery, and biofeedback training. The guided imagery tape provided a short segment on relaxation asking patients to place themselves in a relaxed setting where all things were possible. General guidelines were then given to patients regarding the immune system and the development of health promoting processes within their bodies. No specific imagery was suggested to the patients. The findings showed significant effects in natural killer cell activity (P < 0.017) and mixed lymphocyte responsiveness (P < 0.001). No significant psychological changes were detected. However, reductions were seen in psychological inventory scales measuring anxiety.11,12
Surgical outcome with the use of imagery has been another focus of clinical research. In one randomized controlled study, the value of a brief preoperative hypnosis experience was explored with a sample of 36 head and neck cancer surgery patients. Fifteen patients volunteered for hypnosis and 21 received the usual care (no hypnosis). Within the hypnotic intervention group, hypnotizability was negatively correlated with surgical complication and there was a trend toward negative blood loss during surgery and postoperative complications.13
Imagery techniques involve the skillful use of imagination which interplays in complex ways with the psyche. Not all cancer patients are ideally suited for this type of intervention. In some instances the use of guided imagery has had a significant destabilizing psychological effect or "abreaction."14
Psychotic patients have poor outcomes with imaging techniques. Those patients who have fundamental spiritual beliefs that prevent introspection seem to do poorly with this intervention.14 Patients who have experienced deep psychological, physical, or sexual trauma should not be casually introduced to this technique.
Learning guided imagery requires a time commitment and specific training. Currently, individuals who have been certified in guided imagery can be identified by contacting the Academy for Guided Imagery. This institution provides a structured curriculum and certification process involving guided imagery. The training involves up to 150 hours of observed instruction before qualifying for certification. Psychiatrists are not routinely trained in imagery, but may sometimes elect such training. Psychologists, physicians, social workers, and nurses among others may include imagery in their services.
Especially as an alternative to sedating medication in improving quality of life, guided imagery is of interest. The scientific data to support its use are not conclusive, but it may provide a means for patients to regain a sense of control over their lives in the face of crisis. After training, patients are able to evoke the imagery on their own (with audio or visual aids) at any time.
Guided imagery appears to be generally safe and potentially beneficial in providing symptomatic relief to some cancer patients. Guided imagery may allow some cancer patients to reduce anxiety and lessen symptoms of nausea and pain through use of their own sensory recruitment.
Dr. Lee is a Senior Fellow in the Program in Integrative Medicine at the University of Arizona in Tucson.
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14. Hammond D. Hypnotic Suggestions and Metaphor. New York, NY: WW Norton and Co.; 1990.
Guided imagery and hypnosis are psychological and behavioral techniques that both involve interaction between therapist and patient.