Guided imagery as a psychotherapeutic mind-body intervention in health psychology: A brief review of efficacy research

In this article the guided imagery technique, which is a therapeutic tool in counseling and allied fields using mental images produced by appropriate scripts, suggestions or affirmations by videos/tape records and by the client himself/herself, will be discussed. Guided imagination is a mind-body intervention. Mind-body interventions focus on the interactions among the brain, mind, body, and behaviour, and on the powerful ways in which emotional, mental, social, spiritual and behavioural factors can directly affect health. The technique, used in health psychology and counseling psychology, can be classified by the modality of its content: visual, verbal, auditory, olfactory, tactile, gustatory, or kinesthetic. It is a flexible intervention whose efficacy has been indicated through a large body of research in the field over many decades. As such, it has earned the right to be considered a research-based technique. This article will give a brief outline of guided imagery techniques, and examples of selected research indicating its efficacy.

Imagery, as a mind-body intervention in counselling health psychology, is a general name given to a series of cognitive processes.The procedures used in these processes are psychotherapeutic tools that help professionals change people"s attitudes, behaviours, emotions and physiological reactions.The cognitive element in the techniques of imagery is "the whole of thoughts which represent and interpret the context of perception" (Crawford, 1992).A revival of interest in imagery was an important component of the so called cognitive revolution in psychology during the 1960s and early 1970s, a period when the behaviorist intellectual hegemony over the field was broken and the concept of mental representation was established as Europe's Journal of Psychology 228 central and vital to psychological theorizing (Kosslyn, 1980).Beginning in the 1960s, and perhaps stimulated by some of the research mentioned by Holt, there was also a growing interest in the application of imagery based techniques in psychotherapy and psychosomatic medicine (Assagioli, 1965, cited in Thomas, 2010).It is sometimes claimed or implied that these sort of techniques are based on ancient oriental, and particularly Indian, spiritual practices (e.g., Samuels & Samuels, 1975;Gawain, 1982, cited in Thomas, 2010), and it thus may not be coincidental that a prominent figure in the psychotherapeutic imagery movement is a Pakistani born psychologist, Akhter Ahsen, known mostly but not exclusively for his clinical and theoretical work (e.g.Ahsen, 1965, cited in Thomas, 2010).Today it is believed that mental imagery is based on a theory which assumes that personality and consciousness are composed of images and that, when required to make a change in a person"s consciousness level, the first thing to do is to "fix" his/her distorted images (Ahsen, 1968).This is allows the person to discover his/her inner "forms and symbols" and control his/her behaviors (Achterberg & Lawlis, 1982).Some of therapy models which use the tool of imagery are biofeedback, neurolinguistic programming (NLP), Rational Emotive Therapy (REBT), Gestalt Therapy and hypnosis; desensitization and counter-conditioning techniques also use imagery.
Moreover, recently performed meditative interventions that follow mantra and relaxation techniques by using systematic guidance are said to be located in the framework of imagery techniques (Crawford, 1992).

Using mind-body interaction in health psychology
Guided imagery, based on the philosophy of general imagery techniques, is a method of mind-body interaction that includes some specific interventions made by health professionals.Like other mind-body interventions, guided imagery is also based on the assumption that the mind affects how the brain functions.Mind-body interventions focus on the interactions among the brain, mind, body and behaviour, and on the powerful ways in which emotional, mental, social, spiritual and behavioural factors can directly affect health (Astin, Shapiro, Eisenberg et al., 2003).
Mind-body medicine typically focuses on intervention strategies that are thought to promote health, such as relaxation, hypnosis, visual imagery, meditation, yoga, biofeedback, tai chi, qi gong, cognitive-behavioral therapies, group support, autogenic training, and spirituality (Astin, Shapiro, Eisenberg et al., 2003)..The field views illness as an opportunity for personal growth and transformation and health care providers as catalysts and guides in this process (National Center for Complementary and Alternative Medicine Reports, 2007).Guided imagery aims at Guided imagery as a psychotherapeutic mind-body intervention in health psychology 229 making the mind go on a journey with the help of multiple senses (the containing function of the five senses), and not at making it focus on a stimulant (an image or a word) (Lynn & Rhue, 1988).According to Lynn and Rhue (1988), the main purpose of guided imagery is firstly to calm a person"s mind, secondly to enable him/her to face negative emotions like anxiety, fear or ambivalence and provide the person with an increased sense of consciousness with the help of the five senses.Lastly, this technique is teaching the patient to evoke his/her inner power, step by step, getting rid of the negative emotions that block behaviour and generate anxiety.With the help of guided imagery people can see, hear, feel, taste and smell "images".The reason why it is called "guided" imagery is that video, tape records or the professionals" instructions are used in the process.This way, the patient becomes able to use the interaction of mind-body-spirit for healing purposes.

The guided imagery process
Relaxation techniques are used in the initial phase of guided imagery as they help the mind be open to experiences and consciousness and as they make knowledge more easily to be processed.They not only decrease the tension of muscles, but also help the images in the subconscious to emerge.Arthur Reber (1985) in Dictionary of Psychology defines the term "subconscious" as follows: subconscious 1 n.In psychoanalytic theory, a level of mind through which material passes on the way toward full consciousness.Note that, in fact, most purists eschew the term as overly popularised and imprecise, preferring the term preconscious.2 n.In more general writings, an information store containing memories that are momentarily outside of awareness but which can easily be brought into consciousness.3 adj.Characterising information that is not part of one's momentary awareness but which can, given the proper circumstances, be made conscious.4 adj.Descriptive of information or stimuli that are at the margins of attention, events that one is only vaguely aware of.It should not, in any circumstance, be used as a synonym for unconscious.
In this context, guided imagery can be seen as "playing pictionary with your subconscious".The mind and the body, when relaxed, can process positive images more easily and this way physical and emotional healing is accelerated (Epstein, 2009).Using guided imagery after relaxation is recommended since this way the positive messages are more easily transmitted from mind to the body.In fact, guided imagery can be considered as a "small journey of the mind".

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As discussed in Martin & Rossman (2000), a typical guided imagery session begins with relaxation techniques; the person closes his/her eyes and focuses on breathing.
Secondly, some instructions are given by the therapist to the patient for helping him/her to be more relaxed and empty his/her mind.With these instructions, the patient is set on a journey to a place in which he or she can feel calm.During this journey the therapist gives other instructions to help the patient use all of the senses and help him/her face with the difficult issues in accordance with the treatment purposes, while also asking the patient what he/she feels and what comes to mind during these states (Horrigan, 2002).Consequently, the patient "migrates" to a different conscious level, uses his/her senses of the mind, feelings and body in interaction, gains the ability to see the problems he/she faces from a different perspective, and gains control over his/her body, mind and emotions by learning to heal himself or herself.In this process, videos and some other visual materials can be used alternative to the instructions of the therapist.The technique of guided imagery can sometimes be used as a mental rehearsal to balance emotional reactions which have been generated in an anxiety-provoking situation (Lascelles, Cunningham, McGrath & Sullivan, 1989) and also as a supporter of other therapeutic techniques that are used to increase patients" abilities in different domains (Morrison & Cometa, 1977).

Usage in hospitals
In studies researching the effectiveness of the guided imagery technique in mind and body health, it was found that it is used in hospitals and health centers for reduction of pain, anxiety and reducing the hospitalization time of the patients after surgeries; also for increasing patients" confidence of the medication for pain reduction and the level of benefit taken from the medication.Moreover, it is widely used in decreasing the level of anxiety before normal delivery by means of cognitive rehearsal (Oster, 1994;Manyende et all., 1995).
The technique, employed as a tool to reduce the level of anxiety, is also used in the relaxation of patients before surgeries, increasing concentration, body awareness, and decreasing the level of anxiety (Oster, 1994).It had been used to increase psychological adaptation before surgeries for a long time but it has proved its effectiveness as a relaxation technique in clinical situations mostly since the 1980s.
The usage of therapeutic communication and guided imagery interactively can be seen as a mechanism which changes people"s perceptions, emotions and body reactions.A mechanism like this accelerates patients" recovery processes, increases their physical and psychological control over pains and helps decrease patients" level of anxiety to an optimum level.In a study conducted by Norred (2000), a psychotherapy including guided imagery was given to a group of patients for 6 days before and after their colorectal surgeries.Results indicated that the level of anxiety of the patients who had attended the therapies before and after the surgeries was lower than that of the control group patients.Also, they had less pains after the surgeries.In another study made at California University (2000) results indicated that guided imagery sessions decreased surgery complications and the level of anxiety and pains before and after surgeries.For this reason the use of special videos and tape records of guided imagery in the hospital became more spread (Trump, 2004).
To conclude, there are indications that guided imagery techniques can be effective for pain control among patients (Deisch, Soukup, Adams & Wild, 2000;Dreher, 1998).
One of the reasons for his is that the technique increases the endorphin secretion of patients (Thomas, 1991).Moreover, the interaction of guided imagery and relaxation techniques with cognitive behavioral and biofeedback methods have been proven to be effective in increasing the general well being of hospitalized patients in several studies (Devine & Cook, 1986;Dreher, 1998).

Guided imagery in oncological studies
The guided imagery technique as a psychotherapeutic intervention is based on the idea that personal images affect physical and psychological health directly or indirectly (Lascelles et al., 1989).Because of this, the technique is widely used in integration with other mind and body techniques and Hypno-REBT, especially as fortification and improvement of bodily health.The usage of the technique in this field was accelerated by studies of oncologist Carl Simonton on cancer (Lemonick, 2001).A series of studies reported the efficacy of some psychotherapeutic techniques in decreasing, at least for a short time, the psychological disorders of cancer patients.Among these, guided imagery is the most popular one (Baider, Uziely & De-Nour, 1994).The results of a study made at the Hebrew University on 56 people with advanced cancer who were experiencing anxiety and depression was conducted by Sloman (2003).The study aimed at establishing the effectiveness of progressive relaxation and guided imagery techniques in decreasing the depression and anxiety levels of advanced cancer patients.Patients were randomly assigned to one of four treatment conditions: (1) progressive muscle relaxation training, (2) guided imagery training, (3) both of these treatments, and (4) the control group.
Results showed that progressive muscle training and guided imagery training together decreased the depression levels of the patients while they increased the patients" quality of life.In another study made by Hammond (2004a), which aimed at exploring which cancer patients benefited more from the use of the guided imagery technique as a strategy for controlling aches, 62 hospitalized cancer Europe's Journal of Psychology 232 patients who were complaining about pains were sampled.The results showed that the patients who had believed in the effectiveness of the techniques benefited more than the patients who did not believe in it.The results also showed that the ability of the patients to image predicted the level of pain, the perceived control over the pain and also positive emotions.Accordingly, the ability of the patient to image affected the level of benefit taken from using the technique.Results of Cassel"s (1991) longitudinal study, which sampled five year old cancer patients, showed that the 70% of the children"s complains about pains, nausea and anxiety were decreased after a year of systematic guided imagery process.As it is seen from this research, guided imagery can potentially impact on many aspects of your body.
During guided imagery patients are taught how to control their breathing and relax their muscles.They learn to focus on something specific -such as the therapist"s voice or the instructions given on a DVD or audio tape.They enter into a state of deep relaxation, success, and wholeness -similar to meditation.In guided imagery patients consciously imagine something -and that something depends on what the goal of the therpay is (Lynn & Rhue, 1988).If the goal has to do with healing from cancer, for instance, patients would be asked to visualise their cells and organs as strong, powerful, and healthy.If it is stress reduction before surgery, they would imagine the surgery from beginning to end -with a capable surgeon, caring nurses, and successful outcomes (Martin & Rossman (2000).

Guided imagery for stomach and migraine pains
Searching the literature it was also found that guided imagery is widely used in decreasing stomach and migraine pains for both children and adolescents.
Hammond"s (2004b) pilot study for example aimed at determining if guided imagery was effective for decreasing stomach pains in the case of children.The sample was made up of ten children who had been complaining about stomach pains.They attended guided imagery sessions for four weeks (50 min.every week).The results indicated that the interaction of the two techniques decreased about 67% of children"s pains.Migraines like headaches affect children"s daily functions negatively, and decrease their attendance to school.In the literature it is seen that relaxation and guided imagery techniques are effective for also decreasing migraine in children and adolescents (Penzien & Holroyd, 1994;Baumann, 2002).
Another field in which guided imagery has proved to be effective is that respiratory disorders, especially asthma, in the case of children and adolescents.The study of Castes, Hagel, Palenque, Canelones, Corao and Lynch (1999) focused on the usage of RGI (relaxation guided imagery technique) on children and adolescents complaining about asthma.The study indicated that the children who had attended RGI sessions had less complains and less need for medications than the ones who had not.Peck, Bray and Kehl"s (2003) study showed that the RGI techniques were also effective in increasing the self esteem of children and adolescents with asthma.This may result from the fact that two dimensions of temperament (negative reactivity and task persistence), as well as perceived coping efficacy and self-esteem, play a significant role in influencing the psychological adjustment of children with asthma (Lima, Guerra & de Lemos, 2010).
There are also authors who consider the importance of studying self-esteem in children with chronic illness, believing that it may act as protective factor or rather that children who have a "healthy" self-esteem are less likely to suffer as much from their illnesses and to adapt more easily (Barros, 1999, cited in Lima, Guerra & de Lemos, 2010).

Other fields of usage
The literature shows that guided imagery can also be used effectively in remembering and reconstructing traumatic memories (Loftus, 1993;Hyman & Pentland, 1996).But some don"t support these conclusions because with this technique people can remember false memories, memories of events that they had not lived before (Heaps & Nash, 1999;Paddock, 2001).
The studies that focused on the usage of the technique in anxious and depressed patients have showed that the technique can be used effectively in interaction with other psychotherapy techniques (Turner, Calhoun & Adams, 1992).At the same time it is well known that alternative psychotherapy techniques like guided imagery, meditation and yoga require people"s belief in the effectiveness of the techniques (Martin & Rossman, 2000).The literature that supports the effectiveness of these techniques in severe psychiatric disorders is still limited.A study conducted by Russinova and Wewiorski (2002) investigating 157 severe psychiatric patients showed that guided imagery techniques decreased these patients" emotional and cognitive distortions, and affected their social and spiritual development positively.But, the effectiveness of guided imagery in the case of psychotic patients is not supported yet widely supported by the literature.

Conclusion
Mind-body techniques have potential benefits and advantages in counseling and health psychology.Importantly, the physical and emotional risks of using these Evidence has shown so far that guided imagery, as a psychotherapeutic tool used in health psychology, can be effective in changing negative bodily reactions faced in somatic and psychosomatic disorders for more positive ones using the body-mind interaction.Major clinical chronic illnesses had increased by over 250% in the 1900sand cancer and cardiovascular disorders are first in the list (Cassel, 1991).The studies focusing on preventing and treating these disorders are more and more numerous.
From this perspective, guided imagery technique can continue to prove its effectiveness through its support for mind-body interaction and its focus on a holistic approach within counseling and health psychology research.
interventions are minimal.Moreover, once tested and standardized, most mind-body interventions can be taught easily.Finally, future research focusing on basic mindbody mechanisms and individual differences in responses is likely to yield new insights that may enhance the effectiveness and individual tailoring of mind-body interventions.In the meantime there is considerable evidence that mind-body interventions, even as they are being studied today, have positive effects on psychological functioning and quality of life (National Center for Complementary and Alternative Medicine, 2007) and may be particularly helpful for patients coping with chronic illness and in need of palliative care.