You’re about to take a short, refreshing trip.

Close your eyes. Breathe out three times, turning your senses inward to the realm of the imagination. See, sense, and experience yourself standing on the bank of a river. You look down at the water, and you see that it is frozen solid — there’s no movement. Know that this frozen river is your fear, anger, and resentment.

Now you see yourself finding a pile of rocks on your right — hundreds of rocks weighing two, three, and four pounds a piece. You pick up one of the rocks and you throw it onto the frozen surface. You continue to throw one rock after another. Eventually, you see the ice begin to crack. You keep throwing one rock after another and the cracks begins to get larger until one of the cracks splits open. With additional rocks, more and more pieces of the ice break away. Eventually, all of the ice is washed away to the left. A free flow of water has returned.

Know that you have released yourself from the fear, anger, and resentment. Open your eyes. Return to the hear and now. You write out your experience and draw whatever images you desire.

This exercise, “The Frozen River,”¹ is an example of a mental imagery treatment for ridding oneself of resentment and fear. Adding an exercise such as this to patient care enlists the power of the ever-present unconscious mind to aid in the healing process. For example, besides monitoring a person’s adjustment process to a recent loss, providing bereavement referrals, strengthening nutrition and exercise (if indicated), and supporting psychotherapy and counseling programs, nurses can either perform or refer “stuck,” depressed, or sad and bereaved patients for guided imagery exercises.

Guided imagery has been integral to the success of many health care interventions. For instance, preeminent researcher-clinicians have long used this intervention in cancer care. And its application is far from exhausted. As one researcher puts it, “Much of what has been discovered will make a large-scale difference only if nurses apply it.”²

An inner experience

Guided imagery uses the power of imagination to evoke positive images to stimulate healing.³ It involves thinking in pictures to contact a person’s inner reality. Thinking in pictures invokes all of the senses — hearing, seeing, tasting, smelling, and touching — as well as sensing the body’s position and movement and even emotions.

Guided imagery is the term customarily reserved for exercises used for relaxation. Mental imagery is the term usually reserved for brief inner expeditions, lasting seconds to minutes, often used in the practice of psychotherapy. In practice, these names and other terminology, such as healing or creative visualization, active imagination, and interactive guided imagery, are often used interchangeably.

A guided history

Human beings have long sought contact with the deeper and higher realms of their psyche through the use of techniques involving mental imagery. The “vision quest” of certain American Indian nations uses isolation, fasting, prayer, and community support as the quester seeks contact with animals, spirits, and ancestors. People throughout the world have used hallucinogenic substances, drumming, and other methods of achieving an altered state of consciousness to enhance their inner lives and gain access to new realms of visionary experience to heal physically, emotionally, mentally, and spiritually. The people of ancient Greece, India, Egypt, and China used induced dreams and dream incubation to invoke the symbolic potential of the psyche. These practices even evolved in early Christian and Islamic traditions. And Celtic folk regularly interfaced with the “unseen” numinous world, that is, a higher spiritual or supernatural plane. Through seasonal rituals, dreams, landscapes, words, storytelling, music, and dance, they would align themselves with the inherent patterns of the natural world to promote healing.

The modern practice of guided imagery falls within the lineage of these ancient practices. In the past, a person invoked a state in which he or she could establish contact with a “god” or archetypal healing image that provided guidance about making an important decision or healing an illness. In much the same way, modern practices invoke numinous symbols and images through which a person may receive inner guidance and healing experiences. Modern practices follow the tradition that healing is accessible from within. The unconscious mind is capable of inducing more rapid and intense healing, emotional growth, learning, and performance. Activation of the unconscious mind through symbols, metaphors, or deep relaxation allows this altered state of consciousness to activate natural healing reserves. The body does not discern real from imagined.

Today’s practice of guided imagery flows from several psychotherapeutic traditions. For example, in the 1930s, Robert Desoille, a psychologist, founded a major French school of mental imagery that survives in psychotherapy today. His patients explored mental images through directed “waking dreams” that used images of a mountain, cave, or meadow.^4,5 The psychologist Carl Jung believed that patients could use active imagination without a therapist to expand beyond visualization to include painting, writing, sculpting, and dancing.⁶ To this day, counselors often suggest that patients concretize the powerful images generated by their unconscious mind during dreams or guided imagery by drawing them or making some kind of art project upon which to reflect. These mental imagery exercises are often used as supportive interventions for health promotion and disease prevention. Meanwhile, the general reading public has latched on to imagery exercises gleaned from such self-help authors as psychologist Francis X. Clifton;¹ oncologist Carl Simonton, MD;^7,8 Shakti Gawain;^9,10 Dean Ornish, MD, clinical professor of medicine, University of California–San Francisco;^11,12 and Jeffery Epstein, MD, clinical professor of psychiatry at Mt. Sinai Medical Center in New York City.^13,14

Categories of guided imagery

Many nurses are familiar with guided imagery used for relaxation and stress reduction, but they aren’t aware of other forms, such as the “The Frozen River” exercise.

In general, three categories of guided imagery exist.

Stress reduction and relaxation guided imagery combines a monotone-speaking voice, a smooth delivery, and relaxing images to induce a state of calm and well being. The initial setting of the images is usually a place in nature, such as a beach, a meadow, or a fragrant forest. The patient listens as the nurse guides him or her on a sensory and tactile journey of this place in nature. The nurse coaches the patient to vicariously see, hear, smell, taste, feel, sense, and/or experience in some way simple sensory phenomena in the imaginal scene. Phenomena include seeing wildflowers, hearing birdsong, sensing dappled sunlight, tasting fresh fruit, feeling a breeze, or smelling ocean air.

The length of the exercise can be modified to the realities of the clinical practice. The exercise can be very brief — a minute or two — to prepare a patient for a procedure or as long as 20 to 30 minutes for a hypertensive or anxious patient who is learning stress-reduction skills as part of a self-care program. An exercise also can be recorded on audiotapes for personal use. The nurse, too, can use prerecorded professional audiotapes.

This category of guided imagery is the most easily adaptable to nursing clinical practice. It is indicated for generalized anxiety, anxiety associated with surgery and other treatments, trauma, pain reduction, worry, nausea, insomnia, fear, and itchiness. Progressive muscle relaxation is an example of stress-reduction/relaxation guided imagery used in nursing practice to help people relax or go to sleep. Another example, a self-hypnosis for stress exercise, takes the patient through a vicarious sensory journey.

Directed-active guided imagery is most commonly called mental imagery. In this form of guided imagery, the patient makes an intention before visualizing. For instance, a patient might use the “The Frozen River” exercise, which is an example of this category, to harness the creative and healing powers of the imagination to relieve emotional pain and to stimulate healing responses.

Since the imagination speaks in pictures, symbols, and metaphors, the clinician creating mental-imagery exercises needs to understand the basic language of the unconscious mind. The crossing of a bridge can be a metaphor for leaving something behind, such as an addiction.¹⁴ The lighting of a torch in a dark room can be a metaphor for gaining clarity. Pinning clothes to a clothesline and then seeing one’s self using a big scissors to cut the line and watching the clothes drift off skyward can be a metaphor for letting go of obsessional worries and details. Counselors, psychotherapists, and psychiatric nurses are more familiar with this form of guided imagery and may have uninterrupted clinical time to use it with patients. Nonpsychiatric nurses may be more comfortable using simpler universal symbols. When a patient feels the need for support and guidance, the nurse can direct him or her to imagine sitting under an old tree. The patient may welcome an imaginal healing presence in the form of a shining sun. “Thinking in pictures” comes naturally and is related to intuition. This category of guided imagery can be applied to a vast array of physical and emotional problems, from depression to diabetes. The exercises are not simply coping skills; they connect the patient with the unconscious mind to generate new views and fresh associations, and they have physiological effects.

Insight-oriented guided imagery is a first cousin of hypnosis. This category contains longer induction and interactive visualizations in which the person gathers information about a symptom, problem, or possible solution. These exercises are more interactive as the patient interacts with imaginary “wise” figures and “helpers” as they appear from within the psyche. One example is the conscious reentering of a night dream for further exploration of its possible message. Another exercise involves inviting an image to form, after which the patient initiates a dialogue, interacting consciously by asking questions, such as, “What is your purpose?” and “What do I need to know to get healthier and how can I get healthier?” Like the second category of directed-active guided imagery, this form also mobilizes the latent, innate healing abilities of the unconscious mind. With mental imagery, imaginary figures might act or say something (e.g., the wise old tree talks to the patient), but they are usually directed by a nurse/guide/therapist; the images are not initially self-generated by the patient’s unconscious mind. In insight-oriented guided imagery, images are self-generated and more personal. Some religious or spiritual traditions employ this type of guided imagery as a form of prayer or consciousness-raising activity, where a person imagines himself or herself standing before a powerful spiritually advanced figure listening to his or her counsel.

In clinical practice, categories often overlap. The experience of the patient is affected by the imaging ability of the patient, the time allotted to the exercise, the acceptance of this modality by the patient, and the knowledge and skill of the healthcare or mental health professional. The categories can also be combined; for example, a brief guided relaxation may precede a directed visualization.

Nurses in medically oriented clinical practice are more apt to use the first category of guided imagery due to time constraints, educational preparation, and level of experience. A nurse can employ brief, yet powerful stress-reduction and relaxation exercises before medical procedures, diagnostic tests, and at bedtime or when a patient is in pain or uncomfortable.

Psychotherapists, counselors, psychiatrists, psychiatric nurses, other mental health professionals, and clergy are likely to have more training and experience in the use of methods to access the unconscious mind. These practitioners also have uninterrupted therapeutic time with patients and may therefore use all three categories of guided imagery. Nurses can assist their patients by making referrals and by supporting the use of this intervention.

The ability to image

Guided imagery is the use of one’s imagination to create healing mental images that involve all of the senses. Guided imagery does not work for everyone. Research into its effectiveness has produced mixed results. One important explanation is people’s varying ability to generate an image.¹⁵ The skill to imagine is called image generation. The ability to imagine may determine a person’s ability to use guided imagery.

Perhaps an even more important factor in the effectiveness of guided imagery is a person’s ability to become absorbed in the image.¹⁵ The personality trait of absorption is the disposition to become involved in sensory or imaginative experiences. It is correlated with hypnotic suggestibility. Consider people who have powerful imaginations and can completely immerse themselves in listening to music, watching movies, contemplating art, or enjoying a reverie. They can imagine the smells, the tactile sensations, the taste, and even hear from within the imagined scene. These are powerful absorption traits. To illustrate this personality trait further, consider the fairy-tale character, Cinderella, who could imagine and vicariously participate in life circumstances that were far different from her own lowly seat by the fireplace. The ability to generate an image is not as pivotal to the effectiveness of guided imagery as the ability to get absorbed in the image, using touch, taste, sense, feeling, smelling, and hearing. The patient senses or inhabits the images, not just visualizes them.

Therapists try to inspire and cultivate the image-generating ability of patients who are capable of full immersion. A nurse counselor might suggest that the patient imagine the aroma of spaghetti sauce emanating from the kitchen; or a red flag fluttering in the stiff wind; or a green balloon becoming untied from the back of a chair, lifting off slowly skyward and moving to and fro in the breeze. Nurses who teach health-promotion classes, lead stress-reduction groups, or teach individual patients can readily incorporate imaging-strengthening exercises into their patient-teaching sessions.

The components of guided imagery exercises

To use guided imagery effectively, nurses need to practice the induction (the lead-in), tempo, timing, rhythm, and eduction (lead-out), as well as the departure point (location or sense of place) and content of exercises. Perfecting the use of guided imagery as a nursing intervention will require most nurses to seek out continuing education on the subject and coaching by an expert practitioner, unless they have studied guided imagery in their basic nursing preparation. Using guided imagery is a skill that requires preparation, practice, and feedback.

Nurses should make sure they have adequate uninterrupted time before beginning a guided-imagery session with patients. Half-hearted or rushed guided-imagery teaching may negatively impact patients’ experiences and limit their interest in the use of this modality in the future.¹⁵ Also, it is important not to interrupt another professional who is engaged in leading a patient through a guided imagery exercise.

• The induction is the preparatory phase. Patients are invited to relax, to adjust their position to get comfortable, and to shut out the sounds of the room. Then they are asked to close their eyes and to begin to focus on their internal world.
• The tempo of the practitioner’s speaking voice needs to be regular, relaxed, and confident, employing a somewhat bland or monotone style.
• The timing should be regular, adjusted by mirroring the breathing of the patient. Typically, a phrase is stated in the time it takes a patient to take one full breath, including inhalation and exhalation.
• The rhythm needs to be even and uninterrupted.
• The eduction invites patients to move from the internal world back to normal, everyday reality by following their breathing, beginning to hear the sounds in the room, moving the body and stretching, and, when ready, to opening their eyes.

Easily recognizable places in nature make for good departure points. These places may include a beach, a meadow, a farm, or a forest. Frequently, patients have their own favorite place in nature. Patients will often spontaneously go to their own comforting inner landscape that may be based upon an actual physical location they have known. For new patients or for groups, the clinician chooses the departure point along with the content directing the patient’s visit to the place. Departure points are used in relaxation-guided imagery exercises but generally are not needed for the other two categories.

The content is determined by the indication and purpose. For example, the self-hypnosis for stress exercise is used for relaxation. It differs considerably from “The Frozen River,” which is a mental-imagery exercise used for being stuck in fear or resentment. A guided exercise to one’s future self, an extended interaction with a wise inner figure, or the reentry of a night dream are examples of content in the third category, the insight-oriented guided imagery. A partial list of clinical conditions and life situations for which guided imagery may be indicated is listed in the sidebar.

In addition to preparing the actual components of the exercise, nurses need to plan sufficient time; minimize environmental distractions; avoid interruptions; prepare themselves by getting into a calm, intuitive, and grounded inner space; explain the intervention to patients; and verify patients’ willingness to participate. Nurses must also be receptive to patients’ feedback and desire to discuss their inner experiences. Afterward, nurses or counselors need to document the intervention in the medical records.

Getting expert help

In addition to educational, holistic, psychiatric, and academic institutions, the Faran Center for Mental Imagery in New York, NY, (212/893-8740) offers training in mental imagery, a CD,¹ and a book — Guilt, Imagination and Freedom: The Foundation of Psychotherapy Within Imagination. The Academy for Guided Imagery in California (800/726-2070; ) offers training programs for nurses interested in learning guided and mental imagery.

Health Journeys offers a wide selection of guided imagery and meditation audiotapes, CDs, and books. Belleruth Naparstek, LISW, is the creator of the series and more information can be obtained by contacting Image Paths, Inc., 891 Moe Drive, Suite C, Akron, OH 44310-2538; (800) 800-8661.

The Oncology Nursing Society (866/247-4ONS) released a book in 2002, Voice Massage: Scripts for Guided Imagery, edited by D. Murray Edwards, an oncology nurse. Included with the book is a CD containing guided imagery scripts. Nurses can use the book and CD to assist patients trying to cope with the symptoms and side effects of cancer and its treatment.

Nurses can also ask the mental health provider on staff at their agency or facility to make audiotapes of guided imagery exercises for patient use. Many mental health and holistic professionals tape exercises for clients to use at home.

Guided imagery is a modern form of ancient healing practices. For patients possessing vivid imaginations with the ability to become fully immersed in their five senses, it may be especially beneficial. Guided imagery can be used in a host of clinical situations, disease states, and conditions. The list of clinical conditions in which guided imagery is used continues to evolve, and the research to support its application is growing.^16-27

The use of guided imagery and other cognitive and behavioral interventions in today’s modern health care system relies heavily upon its implementation by nurses.

Nurses are in an enviable position to help patients heal by accessing the enduring and ever-present power of the patient’s unconscious mind through a method that is noninvasive, relatively simple, and inexpensive. What are we waiting for?