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Guided imagery as an effective therapeutic technique: a brief review of its history and efficacy research.

Guided imagery is a flexible intervention whose efficacy has been indicated through a large body of research over many decades in counseling and allied fields. It has earned the right to be considered a research-based approach to helping. This article provides a brief introduction to the history of guided imagery and examples of selected research indicating its efficacy.

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Prepare to learn in an interesting way ... Some learning will be obvious and some may occur at a different level ... You are about to begin a journey back in time to meet researchers in the helping profession who will help you better understand the scientific validation for the use of guided imagery ... As you read this, you may or may not notice your rate of reading ... or rate of breathing ... As you continue feeling as relaxed and safe as you feel comfortable ... you might be curious about the topic, maybe excited, maybe you have healthy doubts too ... Whatever you are feeling about guided imagery is okay ... You are free at any time to pause to contemplate ... or move on to another article for any reason. Now better prepared, you can begin this brief primer on some history and selected research on therapeutic uses of guided imagery ...

Guided imagery was defined by Bresler and Rossman, co-founders of the Academy for Guided Imagery, as a, "range of techniques from simple visualization and direct imagery-based suggestion through metaphor and storytelling" (2003). It is not a new approach to helping but well established in Native American and other indigenous traditions; Hinduism, Judeo-Christian, and other religious traditions; and traditional Chinese medicine, to name a few historically-based uses. Though guided imagery is currently understood to be mainly an "alternative" or "complementary" therapeutic technique, it has been used in psychotherapy for over a century. So, though guided imagery has long been used in many religious and healing traditions, the focus of this review is limited to the past 100 years.

When writing on the history of guided imagery, Schoettle (1980) described many early 20th century examples of its use, starting with therapeutically working with daydreams. For example, Schoettle pointed out that Freud's psychoanalysis is based on the, "unraveling of the patient's fantasies, daydreams, and dreams" and, "continues to be a cornerstone in current analytical techniques" (p. 220). In the 1920s, Kretschmer and Desoille began using the daydream in therapy. Kretschmer referred to these inner visions as bildstreifendenken, or thinking in the form of a movie. Desoille referred to his therapeutic technique as the guided daydream (Schoettle, 1980).

Jacob Morena developed the therapeutic technique of psychodrama in the 1940s, in which trained participants, referred to as "auxiliary egos," playing key individuals in a person's life, re-enacted the patient's personal problems on stage. This can be now understood as a way of guiding the externalization of the client's internal imagery. In 1954, Hans Carl Leuner developed a technique he called experimentelles katathymes bilderleben, or experimentally introduced cathathymic imagery, and further developed psychodrama, which he called Symboldrama psychotherapy or guided affective imagery. William Swartley introduced Leuner's technique in the United States in 1965 as a diagnostic tool, calling it initiated symbol projection (Schoettle, 1980).

In the late 1960s, Joseph Wolpe introduced several imagery-related techniques in behavior-modification therapy: systematic desensitization, aversive-imagery methods, symbolic-modeling techniques and implosive therapy. Since that time there have been many advocates of guided imagery including the Simontons, Achterberg, Klapish, Lawlis, Oyle, Bresler, and Rossman (Schoettle, 1980).

Efficacy Research.

Not a lot is written on why guided imagery is often helpful. According to Nightningale (1998), guided imagery helps clients connect with their internal cognitive, affective, and somatic resources. The goal is not to provide new-and-improved images for the client, but to facilitate awareness of the imagery that already exists and guide clients to work with this imagery for their own needs (Nightingale, 1998). Regardless of explanation, it certainly has many champions in diverse areas. Guided imagery can be used to learn and rehearse skills, more effectively problem solve through visualizing possible outcomes of different alternatives, and increase creativity and imagination. It has also been shown to affect physiological processes. As described in the remainder of this section, in addition to its use in counseling, guided imagery has also been used with very positive results in sports training, rehabilitative medicine, and healthcare.

Guided imagery has been used increasingly by healthcare providers in the medical field with impressive results. This is particularly true with Cancer patients but also with patients who have other medical concerns such as stroke or recurrent abdominal pain. For example, Walker, Walker, Ogston, Heys, Ah-See, Miller, Hutcheon, Sarkar, and Eremin (1999) compared two groups of Cancer patients. One group received relaxation therapy and the other received relaxation therapy with peaceful imagery. Women in the peaceful imagery group were, "more relaxed and easy going, had fewer psychological symptoms and had a higher self-rated quality of life during chemotherapy" (p. 267). These women also had, "enhanced lymphokine-activated killer cytotoxicity, higher numbers of activated T-cells and reduced blood levels of tumour necrosis factor" (p. 267). In other words, they seemed to be healthier than the group without peaceful imagery.

In a 2001 article published in Clinical Rehabilitation, Page, Levine, Sisto, and Johnston discussed results of a study by the Kessler Medical Rehabilitation Research and Education Corporation which studied the efficacy of combining imagery and occupational therapy for stroke survivors. Participants in this study who received both therapy and guided imagery showed significantly more improvement in motor recovery than those who did not use imagery (2001). Also, in a pilot study by Ball, Shapiro, Monheim, and Weydert, children's recurrent abdominal pain was reduced 67 percent following the use of guided imagery (2003).

Guided imagery has also been used in sports, especially to improve motivation and performance as well as reducing pain during healing. For example, Thelwell and Greenless studied competitive endurance using mental skills training, including goal setting, relaxation, imagery and self-talk, for athletes preparing for a triathlon. This training enhanced competitive performance, increased motivation, and contributed to athletes' management of pain (2003).

Substantial research has suggested that imagining performing a specific sports skill improves the physical performance of that skill (for example, Eddy and Mellalieu. 2003). In a study by Eddy and Mellalieu (2003), of mental imagery in visually impaired athletes, the authors concluded that, "mental imagery ... [is] a useful psychological skill for athletes who are visually impaired" (p. 366) by improving both their motivation and performance. Imagery is not limited to sight, however. Hearing, smell, taste, and touch can also be incorporated into imagery or guided imagery.

The use of imagery in limiting strength loss in injured immobilized athletes was the focus of a study by Newsom, Knight and Balnave (2003). Participants in this study who used imagery experienced no significant change in wrist-flexion and extension during immobilization. Participants who did not use imagery showed a significant decrease in wrist-flexion and extension (2003).

Guided Imagery in Counseling

Guided imagery has been studied extensively as a therapeutic tool in counseling. For example, it has been applied to grief therapy (Melges & DeMaso, 1980) and decision-making and identity issues in individuals with eating disorders (Hill, 2001), to name just two of thousands. A recent Google search using the search terms, "guided imagery, counseling, and research" resulted in 108,000 hits. The following are brief examples to whet the appetite and encourage the reader to narrow readings to their specific area of interests, for certain populations, in particular settings.

Melges and DeMaso (1980) studied over 100 people with unresolved grief reactions. They employed three phases of treatment: "(1) cognitive structuring for the decision to re-grieve and for clarification of procedures, (2) guided imagery for reliving, revising, and revisiting scenes of the loss, and (3) future-oriented identity reconstruction" (p. 55). They found that reliving or re-imagining changed the client's view of reality concerning the grieving and therefore, the guided imagery part of the treatment was essential (Melges & DeMaso, 1980).

Hill (2001) used fairy tales, "as a vision-to-action treatment alternative for psychological dysfunctions focusing on eating disorders" (p. 584). She integrated guided imagery, cognitive refraining, and behavioral assignments in her treatment of individuals with bulimia nervosa. Hill concluded that, "fairy tales provide a paradigm that serves as a transitional structure in language, thoughts, and behaviors" (p. 587). She found that it, "helps the client assimilate new chapters analogous to her life transitions and develop necessary accommodations" (p. 587). Guided imagery was seen as a powerful tool in helping her clients overcome eating disorders.

Skovholt and Thoen (1987) used guided imagery scripts in parent group counseling. They concluded that, "understanding the dilemmas of others and the resolutions possible can be very instructive for someone who feels stuck and alone" and that, "guided imagery and daydreams are method[s] for discovering rich social comparison data" (p. 316).

Those are just a few of the many studies indicating the effectiveness of guided imagery for mental health and other helping professionals trained in its ethical use. Nightingale (1998) suggested three ways guided imagery can be used in counseling: 1) relaxation for stress reduction, 2) motivation by imagining a positive future, and 3) insight through exploration of possibilities and problem solving. A great advantage is that guided imagery is quite flexibly used by itself or in conjunction with other techniques, depending on the needs of the client and setting as well as the counselor's training, experience, and comfort with the approach.

Further research should reveal more information regarding the extent specific aspects of implementing guided imagery affects specific populations or issues. The nature of the mechanisms by which it is effective should also become increasingly clear through the growing body of research. In the meantime however, guided imagery is clearly already a versatile intervention whose efficacy has been indicated through much research over many decades in counseling and allied fields.

It has earned the right to be considered a research-based approach to helping. "Your journey is over, for now ... Some of what you read may have been new and interesting... Some may have been a useful review ... Perhaps you feel this is just the tip of the iceberg of research in guided imagery ... And you are correct ... You can feel thankful for this journal facilitating this learning experience ... And, you can congratulate yourself for your open mindedness to the potential usefulness of guided imagery ... You might be able right now to imagine learning more about guided imagery ... Or maybe using it with one of your clients ... Or yourself ... You can return to this article, this safe place of learning, any time you wish ... You can move on to another article now knowing there will be many opportunities for further learning about guided imagery in upcoming hours, days, weeks, months and years ..." (Utay & Kojsza, 2003).

References

Ball, T. M., Shapiro, D. E., Monheim, C. J., & Weydert, J. A. (2003, July/August). A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children. Clinical Pediatrics, 42, 527-532.

Bresler, D. E. & Rossman, M. L. (2003). History of guided imagery. Retrieved January 1, 2005, from http://www.healthyroads.com/ mylibrary/dala/ash_rel/htm/arl_historyofguidedimagery.asp

Eddy, K. A. T., & Mellalieu, S. D. (2003). Mental imagery in athletes with visual impairments. Adapted Physical Activity Quarterly, 20, 347-368.

Hill, L. (1992, May/June). Fairy tales: Visions for problem resolution in eating disorders. Journal of Counseling & Development, 70, 584-587.

Melges, F. T., & DeMaso, D. R. (1980, January). Grief-resolution therapy: Reliving, revising, and revisiting. American Journal of Psychotherapy, XXXIV, 1, 51-61.

Newsom, J., Knight, P., & Balnave, R. (2003). Use of mental imagery to limit strength loss alter immobilization. Sport Rehabilitation, 12, 249-258.

Nightingale, L. (1998). What is interactive guided imagery[SM]? Retrieved November 4, 2003, from http://www.nightingalecenter.com/guided. html.

Nightingale, L. (1998). What is interactive guided imagery[SM]? Retrieved January 1, 2005, from http://www.nightingalecenter.com/guided. html.

Page, S. J., Levine, R, Sisto, S., & Johnston, M. V. (2001). A randomized efficacy and feasibility study of imagery in acute stroke. Clinical Rehabilitation, 15, 233-240.

Schoettle, U. C. (1980). Guided imagery--A tool in child psychotherapy. American Journal of Psychotherapy, XXXIV, 2, 220-227.

Skovholt, T. M. & Thoen, G. A. (1987, February). Mental imagery and parenthood decision making. Journal of Counseling & Development, 65, 315-316.

Thelwell, R. C., & Greenless, I. A. (2003). Developing competitive endurance performance using mental skills training. The Sport Psychologist, 17, 318-337.

Utay, J., & Kojsza, M. Advanced guided imagery: A 20 step process explained and experienced. Adapted from an exercise presented at the 2003 Western Regional Pennsylvania School Counselors Association Conference at Slippery Rock University Friday, November 7, 2003.

Walker L.G., Walker, M.B., Ogston, K., Heys, S.D., Ah-See, A.K., & Miller, I.D. (1999). Pschological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. British Journal of Cancer, 80, 262-268.

Joe Utay, EdD, LPC, LMFT, AAMFT. NCC, Assistant Professor, Counselor Education, Indiana University of Pennsylvania, Director of Counseling and Evaluation Services, Total Learning Centers. Megan Miller, M.A. (in progress), Indiana University of Pennsylvania.

Correspondence concerning this article should be addressed to Joe@Totallearningcenter.com.
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Author:Miller, Megan
Publication:Journal of Instructional Psychology
Geographic Code:1USA
Date:Mar 1, 2006
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