Vol. 25 • Issue 9
• Page 25
Guided imagery engages the power of imagination to assist patients in managing the stress and anxiety that can impede progress toward functional rehabilitation goals. This invaluable mind-body intervention can be applied with patients at all levels of ability/disability.
Guided imagery is widely used in pain management and sports psychology, and to treat a wide range of mental health concerns such as anxiety, PTSD and management of chronic illness.
An underlying principle of guided imagery is the understanding that feelings, thoughts and physiology are all connected. The images we carry with us affect our mood and behavior. Guided imagery employs intentional images to facilitate and affect behavior. This practice has more than emotional and practical benefits; research has demonstrated that engaging the mind in relaxation has direct physiological benefits and can elicit the relaxation response (See Feb: "Relaxation Response" article).
Guided imagery is used as a stress-management tool and as an anxiety-management tool to work through phobias or functional impasses.
Guided imagery is most commonly understood and used as a relaxation technique. The basic technique engages the mind in a soothing visualization in order to relieve stress. For this purpose, guided imagery facilitates relaxation and stimulates the release of soothing brain chemicals.
While anyone can benefit from learning how to relax and skillfully manage stress, people with disabilities have an even greater need for this skill. Individuals with chronic conditions are often negotiating states of chronic stress and hyper-arousal to pain as well as daily mobility challenges. These patients can especially benefit from learning to calm the mind and body with guided imagery.
There are innumerable books, tapes and CDs available in the guided imagery arsenal, in the popular press and in professional and spiritual literature (see Resources). It is important for OTs to explore a wide range of guided imagery references to design an appropriate toolkit for their populations.
There are several points to consider when implementing guided imagery for relaxation purposes. First, take the time to educate patients. Explain that the mind naturally produces images and that imagery can affect mood, behavior and physiology.
Next, when formulating guided imagery exercises for an individual patient, it is critical to explore the widest possible range of image options through a range of sensory modes in order to accommodate the particular disability. Images can be connected to sound, taste or sensation. When designing a prescriptive imagery exercise for a patient, it can help to write down a list of the patient's interests, likes and preferences. Ask the patient to bring in a visual cue-a picture from a favorite vacation or of a favorite pet-or ask about times or places that evoke positive feelings. Guided imagery works best when incorporating a patient's personality, temperament and interests.
Third, guided imagery can be structured or unstructured. I once observed a pain management group implementing a guided-imagery exercise with the earth as pain and outer space as the person, to help the participants connect to the fact that they are more than their pain and that their sense of self is vast. Half the group reported feeling emotional relief with this metaphor, while the other half found it to be anxiety-provoking. Be sensitive to what specific images evoke in patients; if one does not work, keep searching for new exercises.
Finally, when implementing guided imagery techniques, encourage patients to mentally let go and relax. To start, try a few breathing exercises; instruct the patient to get into a relaxed position or create the right climate in your office so the patient can relax and focus. It can be helpful to record the guided imagery sessions for patients to use at home so they can practice between sessions and ask any follow-up questions.
Using guided imagery to work through anxiety, trauma or phobias, both emotional and physical, is a more complex use of the technique.
Many patients with mobility impairments are prone to distress, relapses or falls. Guided imagery can be an excellent technique to work through fears and enhance coping by helping patients visualize alternative possibilities for situations they fear or in which they have been traumatized. In such cases it is crucial to first elicit the mental images that come up for the patient when they are working toward various functional tasks.
Judith Beck, PhD, a leading expert in cognitive-behavioral therapy, provides an excellent set of guided imagery strategies in her book, Cognitive Therapy: Basics and Beyond. While her clinical examples are primarily formulated in the mental health domain, I've adapted them in the following examples to the rehabilitation population.
One caveat: If the patient is suffering with more pronounced emotional or psychological trauma, such as PTSD, it is important to consult and work collaboratively with a mental health clinician.
Following an image to completion. This basic guided imagery technique helps a patient imagine working through an anxiety-producing situation step by step.
Example: A patient prone to falling fears ambulating on cold or icy days. He pictured himself walking the streets on a snowy day, assessing for risk as he ambulates, and asking for help when needed.
Imagine jumping ahead in time. Patients who have suffered life-altering, disabling accidents have to work through multiple stages of recovery to achieve a functional life. When the obstacles are numerous and the journey long, guiding patients to imagine themselves in the near future can alleviate the emotional demands of recovery.
Example: A patient is learning to function again after a car accident resulted in back, knee and hip injuries as well as mobility impairments. He imagined being back in his home environment, regaining his familiar routine and spending time with his children.
Imagine coping. In this strategy, patients imagine themselves coping through a difficult situation. It can be helpful to write out the plan on a coping card that outlines the self-instructional strategies the patient and practitioner develop.
Example: A patient who is a wheelchair user was planning her first plane trip alone without her family supports. Even though she traveled often with her family, the idea of traveling alone created tremendous anxiety. The patient mapped out the entire trip and imagined herself coping with various challenges should they arise.
In the event guided imagery techniques are too difficult, distraction techniques may be an effective pre-step. The basic point of distraction is to turn one's attention to another focal point. Patients may be empowered to know they have this set of tools, which requires little exertion and can be applied to a variety of situations.
Psychotherapist Bill O'Hanlon, in his book Do One Thing Different, provides some skillful guidelines for teaching patients attention-shifting/distraction techniques to manage distress. Again, it can be helpful to create a coping card listing these techniques. O'Hanlon notes patients can shift their attention in a number of ways; the following are examples of how this technique has been adapted in my own clinical work.
Shifting attention to a new sensory channel. Example: A patient who goes for blood work tends to faint at the sight of blood. She came prepared to her visit with an iPod; she shifted her attention to music, away from the lab tech obtaining a sample.
Shifting attention from past to present. Example: A patient who developed knee problems would ruminate about his running years and missed this as an athletic outlet. He learned to shift his attention to the present and focus on his new sport, swimming.
Shifting attention from present or past to the future. Example: A stroke patient was feeling emotionally stuck in the chasm between her past level of functioning and her current level. She learned to shift her attention to her future and began looking forward to returning to her apartment, where she would be able to go back to her daily routine.
Shifting from internal experience to external environment. Example: An elderly woman who used a walker was afraid to go out in her urban neighborhood after having several falls. She was taught to go out during less-crowded times so she would have more freedom to ambulate. She struggled with anxiety and fear of falling, but she also learned to shift her attention to her surroundings-the sunshine, the lack of crowds, the neighbors walking dogs-to decrease her internal anxiety.
Shifting from external environment to internal focus. Example: A young college student with cerebral palsy would suffer anxienty attacks on the subway during her daily commute to her university. She learned to shift her attention to her own thoughts and feelings when she felt over-stimulated.
Guided imagery techniques require patience and practice to master. Integrating these techniques in recovery and rehabilitation can alleviate the secondary stress of recovery, support functional recovery and, most importantly, teach patients how to maintain wellness on a tangible, applicable level in daily life.
Reji Mathew, PhD, is a psychotherapist/clinical instructor at the New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at firstname.lastname@example.org.
•The Benson-Henry Institute for Mind Body Medicine, Mind-Body Center Store (relaxation CDs, videos, DVDs), www.mbmi.org/shop/listproducts.asp?fam=3
•Cognitive Therapy: Basics and Beyond, By Judith Beck, PhD (The Guilford Press, 1995)
•Anxiety and Phobia Workbook, By Edmond J. Bourne (New Harbinger Publications, 2000)
•Do One Thing Different, By Bill O'Hanlon (William Morrow and Company, 1999)