There is no question that diagnostic imaging—our ability to visualize the intimate internal details of the body—has improved dramatically in recent decades. The images we obtain from CT, PET, MRI and other technologies have honed our diagnostic acuity, in many cases saving lives.

But there is another realm of images related to health and illness that warrants just as much attention. I’m referring to the ways in which a patient visualizes or imagines his or her illness. The images a patient uses when talking about health problems can tell you a lot about what’s going on. Therapies based on working with imagery can be an extremely valuable set of healing tools.

As doctors, we are trained to diagnose and treat physically observable manifestations of disease and illness. In some instances, we can provide definitive, even life-saving interventions. Often, however, our attempts to help do not give such neat and acceptable results. In many cases, we are unable to identify the source of a patient’s condition—84% of the 15 most common symptoms presenting to a primary care doctor are never diagnosed as a clearly-defined disease.

Alternatively, we may give the symptom pattern a name, and perhaps provide some relief, but we can do little or nothing about much of the suffering that accompanies it. This is especially true in patients with the chronic illnesses that represent the most challenging and time-consuming aspects of our practices.

People with chronic illness need not only diligent medical care, but also attention to what we might call the invisible aspects of their conditions—the meaning aspects of the illness. These intangible, yet equally important facets are only accessible through their own awareness.

A physician that supports and encourages inquiry into this inner realm can help mobilize the patient’s internal resources to help them live better, whatever the specifics of the physical condition. At the same time, a patient that learns to work with mind/body skills becomes more of a partner in healing, more able to participate actively in their care.

As a physician working for over 30 years primarily with people who have chronic and life-threatening illnesses, I have found interactive guided imagery to be one of the most useful therapeutic tools I have ever encountered.

Intangible But Powerful

Imagery is a natural way the human nervous system stores, accesses and processes information. It is the coding system in which memories, dreams, daydreams, fantasies and expectations are stored. It is a way of thinking with sensory attributes. In the absence of competing sensory cues, the body tends to respond to imagery as it would to a genuine external sensory stimulus.

The most common and familiar example of this is sexual fantasy and its attendant physiologic responses. But there are many others. One could say that negative forms of imagery are the wraiths beneath the cowl of chronic stress physiology.

Imagery has been shown in dozens of studies to affect almost all major physiologic control systems, including respiration, heart rate, blood pressure, metabolic rates in cells, gastrointestinal mobility and secretion, sexual function, and even immune responsiveness.

From a clinical practice perspective, imagery is also a rapid way to access emotional and symbolic information that may affect physiology and the way a patient cares for him or herself.

For instance, a patient may talk at length about the nature of his back pain, but we get much more sense of what he’s experiencing when he uses imagery-laden language like, “It feels like a knife twisting in my back.”

Not only does this give us a graphic, sensory description of the symptom, it may also lead to important psychosocial information about the patient’s perception of the pain. In this case, perhaps, the comment could lead to respectful questioning about betrayals or related feelings that this patient might be holding.

Imagistic language is an essential part of the basic diagnostic process. Patients are often telling us far more about themselves than we realize. Too often, we as clinicians are focused on the physical aspects, and we fail to find out what the condition might mean in the patient’s inner world.

Forms of Imagery Interventions

“Guided imagery” is a term variously used to describe a range of techniques from simple visualization and direct imagery-based suggestion, through metaphor and story-telling. In clinical settings, guided imagery can be used to help teach psychophysiologic relaxation, to relieve symptoms, to stimulate healing responses, and to help people tolerate procedures and treatments more easily.

“Interactive Guided Imagery” (IGI) is a service-marked term coined by the Academy for Guided Imagery to designate a process in which imagery is used in a highly interactive format to evoke patient autonomy. This gives patients tools for drawing on their own inner resources to support healing, to make appropriate adaptations to changes in health, and to better understand what their symptoms may be signaling.

Here’s a clinical example: A 28-year-old woman with chronic mixed headaches came in with a severe migraine. We had worked together before, so I guided her through a simple progressive relaxation technique, asked her to focus directly on her pain, and invite an image to come to mind that could tell her something useful about the pain.

An image came of a large mynah bird, sitting on her head and pecking away in the area of her pain. “Why is he doing that?” she asked, and I suggested that she ask him, and imagine he could answer in a way she could understand. To her surprise, the bird answered, “Why not? You let everyone else pick on you!”

She started crying, and told me that the day before, she had accidentally overheard a fellow employee making fun of her in the coffee room. She started to get angry, but then got nauseous, and started to feel a migraine aura. She went home for the day and the migraine developed into the headache that brought her to my office.

In her imagery dialogue, the bird agreed to work with her to better understand and prevent her headaches. She left feeling 90% relieved without any other medical intervention.

Continuing dialogues with the mynah revealed a long-standing pattern of low self-esteem and non-assertiveness. The bird told her that this resulted in holding anger and that led to her headaches. I referred her to a good therapist and after 18 months she was not only relieved of headaches, but much happier and heading in a more successful direction in her life.

Applications in Clinical Practice

Imagery is essentially a way of teaching patients to utilize their own abilities to relax, learn more about themselves, and stimulate desired responses in their bodies. It is not a method of treating particular disease entities, per se, but because it deals with basic and ubiquitous psychological and physiological processes, it can be used in the context of treating many common conditions. It is especially effective in the following contexts:

• Relaxation training, and stress reduction
• Pain relief
• Managing chronic illness and preventing acute exacerbations
• Preparation for surgery and medical procedures
• Medication compliance and adherence issues
• Cancer treatment and life-threatening illnesses
• Terminal illnesses and end of life care
• Fertility, birthing and delivery
• Grief therapy
• Post-traumatic stress disorder
• Anxiety disorders
• Depression

How Can I Teach My Patients About Guided Imagery?

GI is an inexpensive and safe set of self-help tools, and many patients (and their physicians) can learn the fundamental skills using CDs and books listed in the resources below. Some patients may need personal instruction or guidance, which can either be provided by a physician who has studied the approach, or another health professional with appropriate training.

IGI includes techniques that are applicable in the course of brief medical office visits, or in longer counseling or psychotherapy formats. Physicians may practice it themselves or employ an ancillary health professional to offer the longer sessions.

IGI techniques are extremely safe practices, especially when used to augment healing in conjunction with other modalities. The primary danger is when they are used in lieu of appropriate medical diagnosis and/or treatment. We emphasize the necessity of an accurate diagnosis so that the patient can also be made aware of the medical options for treatment. When you recommend relaxation and GI or IGI after thoroughly evaluating a patient’s physical condition, this risk is eliminated.

Patients who are psychotic or who are on the verge of psychotic breaks, those with dissociative disorders, and those with borderline personality disorders must be handled with care. While these diagnoses do not represent absolute contraindications for imagery work, they are best handled by professionals who have expertise in working with them.

Imagery Resources

Self-Help Guides and CDs

The Healing Mind (www.thehealingmind.org): Research, information, expert opinion, books, CDs and self-study programs for consumers and professionals who want to learn to use relaxation and guided imagery for health-related purposes. Authors and experts include Rachel Remen, MD, Jeanne Achterberg, PhD, Marty Rossman, MD, Ken Pelletier, PhD, and Emmett Miller, MD.

DrMiller.com (www.drmiller.com): Books, CDs and programs by Emmett Miller, MD, a pioneer in teaching self-care mind/body skills through audio media.

Health Journey (www.imagepaths.com): Books, CDs, research and information about guided imagery from Social Worker Belleruth Naparstek and others.

Professional Referrals and Training

Academy for Guided Imagery (www.acadgi.com): A national professional organization, AGI offers a 150-hour certification program for licensed health professionals who want to practice IGI. Continuing Education credit is available for many professions. The Academy also maintains a referral database of AGI Certified professionals.

The Center for Mind Body Medicine (www.cmbm.org): Headed by Dr. James Gordon, CMBM provides training in a wide range of mind-body and stress-reduction techniques, including guided imagery. In addition to training US physicians, CMBM has also brought these techniques to a number of strife-stricken and war-torn parts of the world, including Israel/Palestine and Bosnia. In January, the Center will host its annual Practitioner Training Program in New Orleans. The program will include outreach to communities struggling to rebuild in the wake of Katrina.

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