Cover Story: Imagine the Possibilities

An Introduction to Guided Imagery and Its Potential Benefits for Individuals with MS

Written by Susan Wells Courtney
Reviewed and Contributions by Miriam Franco, MSW, PsyD
Reviewed by Jack Burks, MD

Miriam Franco, MSW, PsyD (pictured in photo above), is a psychologist, social worker, and esteemed member of MSAA’s Healthcare Advisory Council. She is certified in Integrative Guided Imagery by Beyond Ordinary Nursing organization. Dr. Franco provides stress reduction and guided imagery interventions to MS patients in her psychology practice, and has conducted stress reduction and wellness workshops for the National Kidney Foundation, The Philadelphia Wellness Community, and Philadelphia Corporation for Aging. She is chair of the Sociology Department at Immaculata University and is a member of the Consortium of Multiple Sclerosis Centers.

We often hear about the mind-body connection in regard to our health and wellbeing. Many Western-trained physicians and researchers are discovering that the mind appears to have a powerful influence over one ‘s physical and emotional health, a concept long held by those who practice Eastern Medicine. In recent years, a technique known as guided imagery has been gaining much recognition by individuals, families, care partners, and health professionals. This is an exciting area of complementary and alternative medicine, offering benefits to almost anyone who practices this therapeutic exercise.

Dr. Miriam Franco is an experienced psychologist and social worker who is also certified to practice Integrative Guided Imagery. According to Dr. Franco, “Guided imagery may be described as specific mind-body techniques that first teach people to become deeply relaxed, and then to use sensory images to focus attention on positive and intuitive images. These images are from their own experience or their imagination, and are healing as well as helpful. In so doing, processes change in their body. By relaxing the body first, this promotes mental relaxation and allows worrisome thoughts to become less prominent.

“With practice, guided imagery can produce radical shifts in attitude, coping, and problem solving…which, in turn, can increase positive coping skills. Unlike some forms of meditation or hypnosis, guided imagery does not involve focusing your mind on a single word or image. Instead, guided imagery takes you on a journey through your own sensory experience in a relaxed state. It is based on the assumption that the mind can influence certain functions of the body.”

A well-known resource on this topic is the book, Staying Well with Guided Imagery, written by Belleruth Naparstek (Warner Books, 1994). While the copyright date is not recent, the information and guided imagery “scripts” are still considered to be an excellent foundation for learning about and practicing guided imagery. Belleruth (as she is referred to in all of her work) has since written and recorded a huge collection of books and CDs, while continuing to provide extensive information online at www.healthjourneys.com, all on the subject of improving emotional, mental, and physical wellbeing. These publications and recordings frequently appear under the series entitled, “Health Journeys.”

In her book, Staying Well with Guided Imagery, Belleruth refers to imagery as “any perception that comes through any of the senses.” She emphasizes that imagery is not strictly limited to visual images, but also to “images” that may be sensed through sounds, smells, tastes, or touch, as well. She defines guided imagery as “a kind of directed daydreaming, a way of using the imagination very specifically to help mind and body heal, stay strong, and even perform as needed.”

While guided imagery is more involved and more meaningful than simply daydreaming, for individuals who have no experience with any type of imagery – talking about daydreaming may be a good place to start. We are all familiar with daydreaming, which is a time when we are very relaxed and less focused on what is going on around us. We drift off into our imagination, often becoming totally immersed for a matter of seconds or possibly a few minutes, tapping into the creative and emotional right side of the brain. This is a shift from the left side of the brain, which uses logical reasoning and linear thinking to help us problem-solve throughout the day.

While daydreaming, we may lose ourselves in a pleasant, far-away time or place that may well cause us to smile or feel some other kind of emotion, almost as though we are actually experiencing whatever is going on in our mind. Sometimes we don’t even hear a person speaking to us when in this “altered state.” Mentally returning to the immediate surroundings can almost feel abrupt, and we may need a moment to collect our thoughts and return to the matter at hand.

Becoming fully immersed in something we imagine while in a very relaxed state, and feeling as though we are actually experiencing it, are the keys to imagery. The mind responds to an imagined situation in the same way as it would respond to a real experience, causing the mind to send the same signals through the body, prompting the same physiological changes.

For instance, imagining your favorite food – seeing its appearance, noting the steaminess of its warm recipe, smelling the aroma it gives off, hearing it sizzle in the pan, and of course, its delicious flavor – might cause you to feel hungry and your mouth to water. This is how your body responds to the messages sent by your brain, which is reacting to an imagined experience versus a real experience. While the brain’s response would have been more intense in a real situation, it still mimics the same behavior when imagining the same scenario.

With guided imagery, once relaxed, you may be given a topic to imagine, such as a favorite place to visit or a loved one you would like to see. One example is to remember when you were a child and the happiness of visiting your grandparents’ home.

Research is showing that through guided imagery, the mind can promote far more changes than just feeling hungry or having your mouth water. Biophysical and biochemical changes may take place within the body through the use of guided imagery, bringing about physical, emotional, and mental benefits. In general, these types of changes include:

• Mood may be improved, by calming, relaxing, inspiring, and motivating
• Depression and anxiety may be reduced
• Intuition, creativity, and performance may be increased
• Blood pressure may be lowered
• Blood sugar may be reduced
• Immune functioning may be improved
• Surgical wounds may heal more quickly
• Pain and headaches may be lessened
• Negative reactions to medications or treatments such as chemotherapy may be reduced
• Pre-surgery fears may be lessened

Guided imagery requires a state of deep relaxation, and adds the component of a gentle direction for your sensory images. A healthcare professional trained in the area of guided imagery may use a script to first help you to relax, and then he or she may give you a topic to imagine – such as a favorite place to visit, a loved one you would like to see, or possibly envisioning yourself accomplishing an important goal. In more advanced sessions of guided imagery, patients may learn to imagine specific cellular changes going on in their body to help fight disease, or they may return to a specific traumatic event to recall details and find closure.

Seeing a healthcare professional to participate in guided imagery is just one option; guided imagery dialogues are also available on CD, as well as in books. When using a book, individuals may record themselves reading a written script for their own guided imagery sessions. Some therapists may give guided imagery sessions over the phone or record an individualized CD for a client. Group sessions or workshops for guided imagery are additional options.

Guided imagery practitioners may obtain certification from two major training organizations in the United States. The Academy for Guided Imagery was founded by several psychiatrists and was initially the only center where healthcare professionals could obtain comprehensive training in Interactive Guided Imagery, a specific method in which the individual’s own imagery is solicited and scripts are not used. For more information about the Academy for Guided Imagery, visit their website at www.academyforguidedimagery.com.

Beyond Ordinary Nursing (online at www.integrativeimagery.com) is an organization founded in 1996 by two nurses who graduated from the Academy for Guided Imagery. Its mission is to provide registered nurses and licensed healthcare professionals with comprehensive, high quality training in relaxation and imagery skills. According to the organization’s website, “Guided imagery refers to using the power of the imagination to evoke positive mind/body responses…Guided imagery techniques are commonly scripted and directed by the practitioner or recorded on tape/CD. Typically, the recipient is guided to a peaceful scene or to concentrate on a theme in a guided visualization. And the widening field of therapeutic imagery is rapidly being accepted as an evidence-based holistic modality in many conventional healthcare settings.”

Different Conditions and Different Types of Guided Imagery

In her book, Belleruth notes that individuals seek help from a mental-health professional for different reasons. Some are suffering as a result of a traumatic event they have experienced or the heartbreaking losses they have had to endure. Others may have trouble with excessive worrying, loneliness, dysfunction in their relationships, or patterns of behavior that repeatedly cause problems.

Additionally, individuals who are chronically ill or suffer from a debilitating or possibly life-threatening medical condition may consult a mental-health professional. Such individuals may be looking for ways to get help with accepting their diagnosis and cope with any upcoming medical procedures. They may be seeking strategies for improving quality of life, reducing symptoms, and fighting their illness.

A tool for gaining more courage when facing difficult procedures and treatments (such as surgery, chemotherapy, dialysis, and frequent injections) can be of much help. People dealing with chronic illness or life-threatening conditions often feel helpless in their situation and would benefit greatly by becoming more proactive in the treatment of their condition. They are looking for something to help them gain more control, or a sense of mastery, over what is happening…providing new hope for the future.

A psychotherapist gives people the opportunity to speak with someone who is unbiased and outside of their group of family and friends. This enables patients to look at themselves in a more caring way, disconnected from their own suffering. The psychotherapist may give his or her clients the encouragement, input, and strategies they need to feel better and work toward their desired goals.

Fortunately, guided imagery can also help with all of the different types of physical and emotional conditions mentioned. While it is not a substitute for other treatment of these urgent issues – including psychotherapy, counseling, and possibly medication or other therapy as prescribed by one’s medical and mental-health professionals – guided imagery is a useful “therapeutic intervention” that can be of great help as an add-on to these other treatment plans.

Editor’s note: Anyone experiencing excessive anxiety, depression, worry, or other types of mental or emotional issues noted in this section, is strongly advised to seek professional help. Treatments are available and no one should suffer needlessly.

Different types of guided imagery may be used for different outcomes. Examples include: “Feeling-State Imagery,” aimed at improving your mood; “Final” or “End-State Imagery,” used to imagine yourself in an ideal condition or situation in your future; and “Physiological Imagery” or “Cellular Imagery,” which refer to imagining specific physical processes or cellular changes to fight disease and promote good health.

Belleruth’s book gives sample scripts for these and other types of guided imagery. She also offers several imagery exercises for general health, emotional resiliency, and common complaints, such as headaches, allergies, insomnia, and pain.

Dr. Franco explains that people can use guided imagery to imagine the healing properties of their bodies and/or their medicines or treatments. Noted earlier, these are referred to as Physiologic or Cellular Imagery. Once deeply relaxed, patients can picture and feel healing on a microscopic level.

For example, a person with cancer can picture how their body is increasing its number of white blood cells and imagine through their senses particular mechanisms in which they are destroying cancer cells in the body with elaborate detail. Or they may imagine the reduced swelling of a tumor or a boil on the skin many times a day.

Editor’s note: Guided imagery is not a cure for these types of conditions, but by practicing imagery, some individuals may feel more in control, and more actively involved in the treatment process. Researchers continue to look at the possible effects this type of guided imagery may have on different illnesses.

To practice this type of imagery, using anatomically-correct information is important. People have been found to connect more personally to their illness and healing process when engaged in this type of imagery work, and often love to practice imagining it throughout the day.

This is a particularly helpful technique to engage with medicine, medical treatments, or injections, enabling patients to embrace their treatments as healing allies. They can imagine, picture, and feel how these medicines or treatments are actually helping them to heal with specific sensory details.

“Final” or “End-State Imagery” is used to imagine oneself in an ideal condition in the future. Someone with weakness or other physical limitations might imagine a return of strength and function.

Patients soon discover that the medicine is not some ‘outside force or property,’ but rather one they can direct into their imagery and personal healing experience. This is a very empowering process and one that has been found to increase a person’s adherence to treatment – as treatment becomes unified with their own natural abilities to engage in their healing process and respond to it.

How Guided Imagery May Help Individuals with MS

Dr. Franco has conducted several workshops and has provided many guided imagery interventions to MS patients. Dr. Franco uses guided imagery to help individuals with MS to experience the following benefits:

• Become deeply relaxed, reducing stiffness and lowering muscle tension
• Reduce fatigue, renewing one’s energy and drive
• Lower anxiety, promoting adaptive and positive coping skills
• Cope more effectively with specific stresses associated with MS

Several studies have shown the effectiveness of relaxation and guided imagery in lowering blood pressure (Agras,1983; Henry & Sancore, 1987; Kaushik, Mahajan, & Rajes, 2006; Young, 2000; Yung, French, & Leung, 2001). Another study found that use of these [intervention] techniques, designed to enhance the coping process, were seen to improve adherence to therapies, including drug therapies (Mohr et al, 1997).

Studies have also been conducted with imagery and MS patients specifically. One study showed that the use of relaxation and Autogenic Imagery (using diaphragmatic breathing) led to significant reductions in state anxiety for individuals with MS (Maguire, 1996). Another study with MS patients found improvement in quality of life in regards to a significant increase in vigor and energy as compared to the control group (Sutherland, Andersen, Morris, 2005). The study also noted that since imagery does not require active effort, it is a suitable method for individuals across the range of physical disability, including individuals with significant mobility issues.

Lowering Injection Anxiety for Individuals with MS

Dr. Franco is especially enthusiastic about her most recent MS endeavor. She has created a guided imagery intervention to help reduce injection anxiety for individuals on an MS disease-modifying therapy (DMT). She will be conducting workshops for members of the MS community, and has produced a CD for MS patients to use at home.

As many of you already know, MSAA supports the American Academy of Neurology’s position that individuals with the most common types of MS (relapsing-remitting and other relapsing forms of MS) should be on a DMT. This helps to slow disease activity (as shown on magnetic resonance imaging) and reduces the severity and frequency of disease flare-ups.
Since the first lines of MS treatments are administered via self-injections at home, anxiety over these injections can play a major role in not adhering to the therapy. The frequency of these injections ranges from once daily to once weekly, depending on the specific medication prescribed, but these must be taken consistently to derive any benefit. This is the message that MSAA is advocating through its public education program, and Dr. Franco’s work toward reducing injection anxiety can do much to help MS patients to sustain treatment.

As part of her introduction to her CD, Relaxation and Guided Imagery for MS: Lowering Anxiety with MS and MS Injections, Dr. Franco states:

“Know that it is natural to be anxious or stressed about having MS and to learn how to use injected medications. As you learn to become deeply relaxed – a very healthy state of being – you can develop confidence in your ability to stay calm and focused while administering or receiving injections and you can learn to enhance the positive healing effects of the medicine as you create deeply restful, healing experiences…Your MS symptoms improve when you are less stressed. With practice, you can learn to be deeply relaxed, promote deep states of rest and healing and can even picture your healing process with your senses…This is a wonderful way to tune into your body’s intuitive healing mechanisms and to use state of the art medicine to reduce the frequency and severity of relapse symptoms, to forestall the development of new lesions, to alleviate stress, restore vitality and energy and to calm your inner world and body…to bring back the balance to your immune system and to your life.” (Excerpt from: Relaxation and Guided Imagery for MS: Lowering Anxiety with MS and MS Injections, copyright Franco, 2007.)

Dr. Franco is conducting educational workshops to determine the effectiveness of guided imagery in reducing anxiety associated with MS injections. MSAA is interested in the results of this project and was recently awarded a Bayer HealthCare Pharmaceuticals educational grant to fund the workshops. Dr. Franco will be teaching relaxation and guided imagery techniques to patients with relapsing-remitting MS, as well as to nurses and healthcare professionals. These workshops will help determine the potential of guided imagery to offer self-empowering skills for individuals with MS…to gain relief from anxiety and improve their ability to cope with MS and the disease-modifying therapies.

Initial feedback from participants in a similar workshop has been very positive. The six individuals who took part in the demonstration commented on how relaxed they have become while taking their injections. Many were surprised at the effectiveness of the guided imagery.

Practicing Guided Imagery

According to Dr. Franco, guided imagery is a specific mind-body intervention in which a person is guided to a deep state of relaxation by means of diaphragmatic breathing and images that invite stress reduction. Lower arousal in the body is first achieved before sensory images are introduced, related to a specific goal or end result the person wishes to experience and practice.

Under the right conditions of being deeply relaxed in a conscious state, our bodies don’t discriminate between sensory images in the mind and what we call reality. When we call upon a sensory image in our imaginations in a relaxed state, the emotions, mood, and physiological state associated with it appear very vivid, very immediate; and the imagined place, image, or event reverberates in the body.

When relaxed, you might imagine an ideal place of relaxation to be the beach. You may picture the blue sky, hear the sea gulls, feel the warm rays of the sun, and feel the sand beneath your toes.

Images in the mind are real events to the body, especially multi-sensory ones. So, for example, if when relaxed you are invited to an ideal place of relaxation, which may be the beach, you may picture the blue sky, hear the sea gulls, feel the warm rays of the sun on your back, or feel the sand beneath your toes, all sensory images of the beach. You may imagine a beach you know or have never visited, it does not matter – as in either event, your body starts to respond as if you are there, allowing you to experience the positive, soothing, or healing effects of being at the beach.

In this relaxed state, research demonstrates that your body is reliving this scene in a sensory way and is increasing the transmission of the restful properties of your parasympathetic nervous system. This system restores energy, rebuilds, relaxes, and opens one up to receptive processes.

Guided imagery is a method that allows us to deliberately introduce healthful images, even allow people to practice being relaxed during difficult medical procedures, and the body will respond positively. If you practice this, you can empower yourself to become more attuned to your natural healing abilities, more attuned to your body, and can use your deep states of relaxation and imagery to cope more effectively.

It also creates a locus of control within us – a way of letting go and relaxing that allows us to learn to feel better about ourselves because we can learn a sense of mastery in responding to what is happening to us. This provides positive ways in which we can rehearse and prepare for emotionally difficult or physically painful events. This lowers a sense of helplessness and increases our responsiveness. With relaxation and guided imagery, we have at our disposal a technique that gives us a sense of control, and this helps us to feel better and do better.

As you practice relaxation and guided imagery, you can learn to develop a relaxed focus, a kind of calm yet energized alertness – what athletes sometimes call “being in the zone” or “flow.” We’re in and out of these states all day long, we just don’t think about them nor use them in a specific, practiced, and directed way to increase healing, lower reactivity, and promote growth and change.

Historically, guided imagery was referred to as visualization techniques, but this term is no longer used, as guided imagery involves the use of multiple senses and is a whole-body experience. It is a well established form of complimentary medicine practiced by nurses who can use guided imagery to quickly and effectively teach patients to “befriend” a breathing tube, or lower anxiety associated with surgery, or reduce the nauseous effects of chemotherapy.

To follow is a brief description of a “safe place.” This is a very basic guided imagery intervention that is used right after one has become deeply relaxed, to center and anchor the self before he or she engages in a problem-solving or challenging task. It is an excerpt from Dr. Franco’s new CD: Relaxation and Guided Imagery to Relieve Caregiver Stress. This CD is customized to fit caregivers’ needs “to lower your stress, renew your energy and spirit, as well as restore the balance and meaning in your life, while actively responding to the needs of those you cherish. ” (Please note that dashes and dots indicate pauses and changes in inflection.)

“As your body remains relaxed and comfortable, imagine yourself in a special, safe place – – – – maybe some place you’ve visited or have never been …..some place you always wanted to see or perhaps some place most suited for you now…..a place of natural beauty and peace…..slowly survey this wonderful place with all of your senses — allowing it to become more vibrant and alive with all of its special properties………as you glance around you, notice its full range of colors and its vivid scenery…..your ears become fully attuned to its unique sounds: waves lapping the shore, logs crackling in the fire, perhaps birds chirping…….as you accustom your ears to the regular sounds and rhythms of this peaceful place, you settle yourself down, to take a fuller moment to capture its beauty and safety…….as you commit this vision to memory, you start to feel whatever you are sitting upon: the soft, freshly mowed grass…a sandy embankment…..or a stone wall you can dangle your feet over……..you can even feel the imprint of this site on your skin…a cool breeze that caresses your cheek, the refreshing mist of a waterfall that sprinkles your hair, sprinkles your face, or the warm glow of the sun on your back……the corners of your mouth may even curl into a smile as you recognize that this special place is always there, for you to return to at anytime you need it…..your blueprint for relaxation…a wellspring of hope to restore healing and coping…know that this is just the beginning, at any time, you can return to your special place and become secure, relaxed, and receptive to your next caregiver experience….or challenge …..” (copyright Franco, 2008)

When relaxed, you might imagine a place of natural beauty and peace, noticing its full range of colors and its vivid scenery. You may imagine the regular sounds and rhythms of this peaceful place, such as birds chirping and the rush of moving water from a nearby stream.

Tips for practicing guided imagery include:

• Finding a comfortable, quiet place to practice
• Practice the same program once or twice daily; listening to a guided imagery script while waking or falling asleep is a good time
• Guided imagery becomes easier and stronger with practice
• Don’t force yourself to relax and imagine certain imagery; allowing the mind to wander in and out is normal
• Guided imagery can help, even if you don’t believe it will work
• If you find that you become emotional, this just means that the imagery is working for you in a deep way; exhale slowly while breathing to stay responsive
• You can use your hands as a natural cue; holding them the same way each time you listen to a CD will eventually allow you to become more deeply relaxed through the position of your hands

Please note that certain types of music can also be of therapeutic value. Listening to music (with a slower beat) while practicing to relax with guided imagery can enhance your experience. Music with a quicker beat may be used when practicing guided imagery for motivational purposes. Children may also benefit from guided imagery. As always, consult a physician before starting any type of change to your lifestyle or medical care.

For More Information

Readers interested in purchasing guided imagery CDs, including those for reducing MS-injection anxiety and for relieving caregiver stress, may visit Dr. Franco’s website at www.imagerywork.net. For more information on these CDs or for weekend workshops in the Philadelphia area, readers may call Dr. Franco at (610) 935-8330.

To find local therapists who are certified as guided imagery practitioners, readers may visit Imagery International’s website at www.imageryinternational.com. Readers without internet access may call Imagery International at (707) 592-7667.

A great number of books, CDs, and other references on guided imagery are available through local and online suppliers, including www.healthjourneys.com and www.amazon.com.

Back