Guided Imagery for Chronic Pain

The Use of Guided Imagery in Pain Management


According to recent statistics, treatment plans in the field of pain management that rely solely on pain suppression are inadequate.  Because the pain experience is multidimensional, it is important to address the psychological component in addition to the physiological mechanism of pain.  The use of guided imagery is proven to provide many benefits in a wide range of pain patients.  This includes decreased pain levels, enhanced psychological functioning, and a sense of control.  Guided imagery can easily be incorporated into various existing psychological techniques or used alone as an inexpensive adjunct to traditional treatment methods.  Because the efficacy of guided imagery techniques depends on having the flexibility to adapt to individual preferences, attempts at standardization can diminish results. 

            Keywords:  guided imagery, pain management, alternative medicine, visualization

            As the cost of pain management in healthcare continues to skyrocket, simple and inexpensive alternative methods of pain control prove to be a worthwhile tool to use in order to decrease the length of hospital stays and reduce medical costs.  Medical intervention, such as surgery or prescription medication, is heavily relied upon to treat pain patients.  However, according to recent statistics, drugs only reduce chronic pain by 30-40 percent in fewer than 50 percent of patients, and more than 40 percent of patients who are implanted with pain relieving devices will experience significant adverse effects (Turk, Swanson, & Tunks, 2008).  In addition to this, certain types of pain, such as chronic neuropathic and radicular pain, are of special importance because they are often unaffected by pharmaceutical methods of pain relief or anti-inflammatory drugs (DeLeo, 2006).  Patients afflicted by this category of pain are in dire need of functioning treatment programs to provide some sense of relief.

            The downfall of traditional medical techniques for treating pain is that they often focus solely on pain suppression (McCracken, 1999). Pain affects an individual on multiple levels, and cognition can play a large role in the experience of pain.  Any negative cognitions that become associated with pain, along with the individual's emotional state of mind, can contribute greatly to its overall effects (Turk et al., 2008). Often, psychological intervention is not part of the treatment plan until clinical levels of accompanying psychological dysfunction have been recorded or the pain has reached an elevated level of severity for extended periods of time.  Because the experience of pain is now commonly viewed as a multidimensional psychophysiological occurrence, this oversight makes little sense (Barber, 1996).  The failure of medical and pharmaceutical treatment in pain management suggests that a comprehensive treatment plan, which includes coping methods to deal with acute and chronic pain, should be included prior to the onset of severe dysfunction, instead of later.  The use of guided imagery (GI) is a simple, yet effective, technique which can be incorporated into any treatment program to assist in addressing many of these overlooked aspects of the pain experience.

            Guided Imagery in Pain Management

            Since the focus of traditional biomedicine remains grounded in treating the physiological symptoms of pain, while largely ignoring its social and psychological components, the experience of pain as a whole is often not addressed in Western medicine (Kleinman, Brodwin, Good, & DelVicchio-Good, 1992, as cited in Pincus & Sheikh, 2009).  Western culture and scientific study has firmly distanced itself from the traditional shamanic ways of seeing and evaluating the human experience.  According to Pincus and Sheikh, conceptual boundaries in the field of scientific study have been created which limit complementary dualities, such as body/mind, reality/imaginary, and spirituality/science in order to disconnect each pair into a distinctly separate category of its own.  Western models of thinking have been struggling to overcome this self-imposed restriction on conceptualization, and this limitation of thought also extends into the role of biomedical theory as it relates to the psychology of pain management.     

Historically, imagery and the imagination have always been a part of the healing process (Lewandowski, Good, & Draucker, 2005).  As science and medicine have evolved, ancient methods of folk healing have become abandoned and thought of as primitive quackery.  According to Eliade (1964), the shamanic healing system is based on techniques of entering into altered states of consciousness in order to engage and interpret the realm of the imagination (as cited in Achterberg, 1985).  The subconscious imagination, along with cultural beliefs and general expectations, helps to shape cognitions surrounding health and healing.  This becomes apparent upon examining the potent role of the placebo effect as a meaning response in healthcare (Moerman, 2002).  The powerful use of imagery that is the foundation of the shamanic tradition is now the inspiration of the modern use of imagination in some practices of psychology and healthcare today (Achterberg).  The use of guided imagery (GI) in pain management is one way to engage the creative psychological processes in order to create a substantial effect that has been proven to enhance medical and pharmaceutical treatment or can be used on its own.

            The terms guided imagery and hypnosis are often interchangeable and involve many similar and overlapping features.  They are generally defined as "states of highly focused attention during which alteration of sensations, awareness, and perceptions can occur" (Syrjala & Abrams, 1996, p. 231).  There are several other psychological techniques that fall into this categorical definition which also includes progressive muscle relaxation, breathing exercises, mindfulness training, and meditation.  Due to similarities between these treatments, protocols which involve guided imagery can often incorporate multiple methods (Syrjala & Abrams, 1996).  For example, most studies of progressive muscle relaxation (PMR) have incorporated some form of guided imagery (GI) into their protocols used (Baider et. al., 2001, as cited in Chen & Francis, 2010).  According to Syrjala and Abrams, "an individualized approach with labels and language that fit the patient's request and personal style" is the most effective in regards to pain management (p. 233).  An analysis of the efficacy of cognitive-behavioral methods for pain control reported that the most efficient component among the various techniques was the use of imagery (Fernandez & Turk, 1989, as cited in Syrjala & Abrams).  According to Eller's (1999) review of 46 guided imagery intervention studies, 87 percent of these studies found that guided imagery resulted in improvements in the psychological or physiological outcomes that were examined (as cited in Carrico, Peters, & Diokno, 2008). 

            The gate control theory of pain examines the role of the central nervous system and states that the pain experience consists of three dimensions that interact with one another to ultimately regulate the flow of sensory information between the body and the brain (Melzack & Wall, 1965, 1996, as cited in Pincus & Sheikh, 2009).  According to Pincus and Sheikh, the "sensory-discriminative dimension," which involves nerve receptors at the actual site of pain can be most affected by transformational or dissociation imagery.  The second dimension of the experience of pain is called the "motivational-affective dimension" and refers to the resulting feelings that motivate behavior as a result of the pain.  This dimension is most affected by scripts that involve pleasant environmental imagery to produce a relaxed and positive state of being.  The "cognitive-evaluative dimension" is the third dimension of the pain experience and refers to the attributions and meanings that are given by an individual.  This dimension can be most affected by any imagery that redefines the pain in a more positive light or a different context (Pincus & Sheikh).

            Melzack (2004) has continued his research into the gate control theory of pain which has now evolved into the neuromatrix theory of pain.  It is proposed that the patterns of nerve impulses which are generated within the brain's neural networks need not necessarily be triggered by actual sensory experience.  Because chronic pain involves cognitive aspects of the brain in addition to sensory input, the application of neuromatrix theory indicates that new approaches to treatment are necessary.  According to Melzack (2004):

            Pain is not injury; the quality of pain experiences must not be confused with the physical event of breaking skin or bone.  Warmth and cold are not "out there";      temperature changes occur "out there," but the qualities of experience must be        generated by the structures in the brain. (p. 87)

With this in mind, Melzack (2004) has illustrated how some forms of chronic pain with no apparent physical cause can be attributed to patterns that have become activated and engrained within the neuromatrix due to prolonged or repeated low level pain stimuli.  Pincus and Shiekh (2009) refer to this as a "body-memory" which can trigger the body's stress response and results in an increased level of stress hormones that have a negative effect over time (p. 15).  These neural patterns become increasingly emphasized as time passes and replay themselves, even in the absence of true somatic stimuli.  Melzack (1993) has also proposed that the limbic system, which is related to emotional response, plays a large contributing role to the neuromatrix.

            Benson and Friedman (1996) use the term, "remembered wellness" to refer to the placebo effect (as cited in Pincus & Sheikh, 2009).  This refers to the power of self-healing that resides within an individual to aid in recovery.  The use of imagery in pain management causes an inward shift in orientation that helps to direct the patient towards their own remembered wellness and unconscious healing abilities (Baer, Hoffman, & Sheikh, 2003, as cited in Pincus & Sheikh).  "Imagery allows for integration and adaptation in the flows of information within the consciousness of the body-mind" (Pincus & Sheikh, p. 81).  This allows an individual to tap into their own natural ability to heal and regain a sense of control in life.  This sense of control is paramount in pain management because previous research indicates that an expectation of uncontrollable pain often affects the perception of future pain stimuli and can result in an increased level of pain actually occurring (Turk, 1996). 

            The use of guided imagery is considered to be a part of cognitive behavioral therapy and can be used to alter the perception of pain because it is a "dynamic, psycho-physiological process" which helps to manipulate the experience of pain by shaping the inner reality of the subjective experience which is occurring (Menzies, Taylor, & Bourguignon, 2006, p. 24).   Techniques that teach self-management are an important means to regain a sense of self-control over pain (Turk et. al., 2008).  Often, when a pain patient experiences a loss of control, it can lead to catastrophic thinking, depression, and hopelessness (Vowles, McCracken, & Eccleston, 2008).  According to McCracken (1999), attitude is closely related to a person's ability to cope with chronic pain, and acceptance also plays a large role.  For example, a study on rheumatoid arthritis and chronic lower back pain revealed that feelings of uncontrollability and helplessness were more highly related to pain and disability than variables related to disease or pathology (Flor & Turk, 1988, as cited in Turk, 1996).  In addition to this, the degree of psychological flexibility which is possessed by the patient may have an even greater impact on the experience of pain.  It is proposed that this is an active process in which patients can adapt themselves to the pain experience (Vowles & McCracken, 2010).  The use of imagery in pain management has been shown to provide many benefits that decrease the patients subjective pain experience, increase life functioning, and provide a sense of control (Pincus & Sheikh, 2009). 

            According to the cognitive-behavioral approach to chronic pain, cognitive appraisal and interpretation of painful events affect the emotions and behavior surrounding the pain.  Pincus and Morley (2001) examined the role of cognitive bias in chronic pain by reviewing previous findings in regards to attention, interpretation, and memory biases in order to evaluate their effects on cognitive pain schemas.  It was proposed that there are three interrelated schemas (pain, illness, and self) that act together to produce these biases.  When a person's self related schema is interrupted by pain, the particular portion that is disturbed will direct the schema enmeshment and determine any cognitive and emotional biases that result (Pincus & Morley, 2001).  According to Pincus and Sheikh (2009), imagery can help to modulate emotional states, provide distraction, and direct attention in order to modify the pain related schemata.

Early Research on Imagery

            Early investigation into the therapeutic use of imagery revealed its ability to contribute to the regulation of the autonomic processes of the body including blood pressure, oxygen consumption, heart rate, and body temperature (Sheikh et al., 1979, as cited in Sheikh & Jordan, 1983).  Autogenic training, which emerged in the 1950s, was a method that was developed in order to induce a state of relaxation by using visual  imagery cues to engage the autonomic nervous system (Sheikh & Jordan).  This technique later began to be used effectively as a method of treatment in pain management (Pincus & Sheikh, 2009).  Imagery was often paired with meditation, biofeedback, and hypnosis in these early studies, and results were measured in terms of physiological changes that occurred as a result of somatic stimuli induced in a laboratory setting (Sheikh & Jordan, 1983).

            A more comprehensive technique that involves guided imagery, called stress inoculation training (SIT), became popular in the 1970s.  SIT is a therapeutic method that focuses on gaining control over a stressful situation by learning coping skills (Pincus & Sheikh, 2009).  Imagery, along with educational rationales and self-instruction, has been used in the field of psychology during SIT for controlling anger, anxiety, and pain (Worthington & Shumate, 1981).  Each component was incorporated specifically to treat each of the different components of the gate control theory of pain.  For instance, the sensory-discriminative pain component benefits from relaxation training, the motivational-affective component can be influenced by directing the subjects to use imagery to counteract the effects of pain, and the cognitive-evaluative aspect is influenced by restructuring the subjects’ cognitive processes.  Results from Worthington and Shumate's (1981) study suggest that imagery not only counteracts the sensation of pain but also leads to a greater sense of self control.  Thus, this finding shows that guided imagery can also be an important component to the cognitive-evaluative portion of gate control theory (Worthington & Shumate, 1981).

The Use of Recorded Scripts for Acute and Chronic Pain

            In recent years, research has indicated that GI scripts on CD can be used before surgery to reduce anxiety, postoperative pain, pain medication, overall hospital costs, and length of the hospital stay (Gonzales et al., 2010).  According to a new study,  even same-day use of guided imagery CD treatment for outpatient surgery still has the some of the same benefits as treatments involving the use of CD's for weeks prior to the surgery (Gonzales et al., 2010).  The main target in this study focuses on relieving pre-operative anxiety in patients who have been identified as highly susceptible to developing post-operative pain.  High levels of anxiety interfere with coping methods for pain control and contribute to a greater susceptibility toward pain because of the close relationship between pain and the emotions and the role of the limbic system in the pain experience (Gonzales et al.). 

            As an alternative to standardized guided imagery scripts on CD, it may be more effective to provide personalized recordings to patients for use at home.  Customized treatments have been proven most effective for guided imagery use in pain management (Syrjala & Abrams, 1996).  A recent study on patients with chronic pain that involved a combined use of guided imagery and progressive muscle relaxation used information gathered during each patient's initial session in order to personalize the imagery script used in the individualized recording (Chen & Francis, 2010).  In contrast to the Gonzales et al. (2010) study, results from this particular study indicated on the mental health scale that guided imagery may be more suitable for relieving depression than anxiety.  Chen and Francis (2010) also reported results that support other guided imagery studies showing a general upward trend in quality of life and decreased daily pain ratings.

Guided Imagery for Children

            There is an especially high need for non-pharmacological methods to use in conjunction with medication for the relief of post-surgical pain in children. 

Huth, Henson, Daraiseh, and McLeod (2009) evaluated the efficacy of a guided imagery CD for the use on post-operative pain in children seven to twelve years of age.  Results of the study showed a statistically significant reduction in pain scores after listening to the recording but non-significant changes in relaxation scores.  Upon further investigation, it was found that over 50 percent of the children in the study did not understand the term "relaxation" as used in the recording.  It was also noted that the small percentage of participants involved who reported the inability to imagine the particular scenarios also reported a general dislike for the particular dialogue used, calling it "annoying" or "weird."  These data support previous research that indicates how personalized imagery scripts have greater positive results (Syrjala & Abrams, 1996).  In addition, the results demonstrate that the use of words and terms contained in the imagery scripts must be carefully selected to suit the particular audience it is intended for.

            A similar study, performed in Finland, used a more generalized scripted CD which allowed for the child to create their own personalized images instead of directing them to imagine particular scenarios (Polkki et al., 2008).  Results showed that there was a decrease in self-reported pain measurements immediately after the intervention, but longer-term results were inconclusive.  Subjects in this particular study did not report the same confusion over the terms selected for use as in the Huth et al. (2008) study.  Interesting to note, was the large discrepancy between the measures of self-report as compared to the assessment, which was made by the nurses regarding the level of post-operative pain.  This is indicative of the fact that pain is often underestimated by health care providers when compared to patients’ subjective measurements (Polkki et al., 2008).

Guided Imagery for the Relief of Cancer Related Pain

            Previous GI research has been highly inconclusive for the treatment of cancer related pain (Kwekkeboom, Kneip, & Pearson, 2003).  Kwekkeboom et al. performed a study to evaluate possible methods to predict success with GI audio CD therapy for cancer patients.  The use of GI therapy decreased pain for 90 percent of the sample population in this study.  It was found that proficiency in imaging ability was directly related to the amount of decrease in pain intensity scores, an increased positive affect, and a heightened perception of control over the pain.  However, in contrast to previous research, outcome expectancy was not a significant predictor in this study.  It was suggested that patients be evaluated on their ability to focus on creating mental images and any previous positive experience with GI therapy before deciding to include imagery in the treatment plan. 

            A separate study by Kwekkeboom, Wanta, and Bumpus (2008) addressed how individual difference variables affect the outcome of GI therapy as part of a progressive muscle relaxation treatment for cancer pain and had similar results to the Kwekkeboom et al. (2003) study.  Results also revealed methodological problems related to the extremely diminished functioning of the sample population.  Many patients were too ill or exhausted to initially commit to the study, and a large portion of subjects became so sick that they could not complete their obligations regarding this study.  Even though previous research indicates that lengthy cognitive behavioral treatment works best for chronic cancer pain, this study implies that complicated and extensive therapeutic practice may not be suitable depending on the severity of co-occurring cancer symptoms (Kwekkeboom, Wanta, & Bumpus).  Secondary analysis on this data focused on evaluating the perceptions of the participants regarding the efficacy of the GI techniques (Kwekkeboom, Hau, Wanta, & Bumpus, 2008).  The most common response for perceived success was that the imagery provided some sort of distraction from the pain which helped to focus attention elsewhere.  The common response for those who reported that GI therapy was ineffective was that they preferred a different type of imagery than what was provided on the audio tape or that they had trouble visualizing the imagery used  (Kwekkeboom, Hau et al.).

Guided Imagery For Special Populations

            GI therapy has also been found to benefit patients who experience chronic pain due to fibromyalgia.  Although the participants' reported measures of pain did not show significant changes, other improvements were noted such as an improvement in overall functioning, a greater sense of control over the symptoms of pain, and an improvement in activity levels (Menzies et al., 2006).  In a study on interstitial cystitis, Carrico et. al. (2008) found that GI therapy reduced both pelvic pain and urinary frequency in over 45 percent of the sample population. 

            A small study was also conducted to test the efficacy of GI therapy on women with osteoarthritis pain which showed a clinically significant decrease in pain ratings for all 17 participants in the treatment group (Baird & Sands, 2004).  It was proposed by Baird and Sands (2004) that GI practice may create opportunities for the mental rehearsal of motor actions with an expectation of a more positive and less painful experience.  This expectation could then carry over into the actual experience itself. 

            However, a study conducted by Gustin et al. (2008) on the effect of motor imagery on sensations of neuropathic pain in patients with complete spinal cord injury showed just the opposite.  Although it was hypothesized that pain symptoms would diminish, this study showed that motor imagery involving regions without sensation actually caused an increase in neuropathic pain and other non-painful symptoms.  These results conflicted with findings from studies conducted on amputees with phantom limb pain.  Gustin, Wrigley, Henderson, and Siddall (2010) continued their exploration of motor imagery and spinal cord injury in order to demonstrate that motor imagery has the ability to activate the sensory and motor cortices in patients who lack any sensation at all in the area.

            Cupal and Brewer (2001) examined the efficacy of GI when used on subjects undergoing physical therapy after reconstruction of the anterior cruciate ligament of the knee.  Because previous research has indicated that there is a correlation between psychological factors and rehabilitation from injury and recovery time, it was proposed that GI could have substantial effects on the healing process, not limited to only the management of pain.  Not only did subjects report less pain at the end of the study, but they also demonstrated greater knee strength and less reinjury anxiety when compared to the control group.  This study further expands the usefulness of psychological treatments that include GI to include sports rehabilitation therapy (Cupal & Brewer).

Guided Imagery for Phantom Limb Pain in Amputees

            Phantom limb pain (PLP) is often attributed as a type of body memory that is shown to be accompanied by activity in the corresponding areas of the brain (Oakley, Whitman, & Halligan, 2002).  Previous research has proven that PLP is influenced by emotional states, suggestion, and expectation (Soloman & Schmidt, 1978, as cited in Oakley et al., 2002).  MacIver, Lloyd, Kelly, Roberts, and Nurmikko (2008) found that mental motor imagery provided significant pain relief for phantom limb pain.  It was proposed that these imaginary movements helped provide a sense of control over the phantom limb.  In Oakley et al’s (2002) review of various case studies, some cases reported using a combination of mental visualization and hypnosis while other cases used only proprioceptive imagery with no co-occurring visual images.  It was noted that both treatment protocols, as well as measures of pain, needed to be standardized in order to make comparisons accurate (Oakley et al.).

            Hugdahl et al. (2001) used functional magnetic resonance to demonstrate how motor imagery can activate the same motor areas in the brain as that of real movements.  This supports current trends in GI theory that show a connection between actual and perceived sensation and shows that imagined movements can have a real effect on the discomfort which is experienced in this population of patients.  It was also shown that pure motor imagery was able to engage areas of the brain related to motor activity while the somatosensory areas were activated by imagery of painful sensations in the associated area (Hugdahl et al.).

            In order to test earlier theories indicating that various therapies for pain management may have cumulative effects when used together, Bamford (2006) tested a four part approach to PLP which included self hypnosis, visualization of movement, psychological treatment, and hypnotic analgesia.  This approach to pain relief proved to be effective at both reducing pain and providing subjects a sense of control over the pain and self-efficacy in life.  However, this particular study did not account for whether or not any of the effects were cumulative with regard to the multifaceted approach in comparison to a single course of treatment because it neglected to include a control group (Bamford).

Additional Research

            It may be a general misconception that the analgesic effects caused by positive imagery are linked to its role as a method of distraction.  McCaul, Monson, and Maki (1992) found that as tasks of distraction got increasingly more difficult, they began to fail in their pain reducing efficacy.  Other research has indicated that distraction in pain management only works because of its use of positive emotions (McCaul et al.).  If this is true, then guided imagery is more beneficial because of its beneficial emotional aspect than its ability to merely distract from the situation at hand.  McCaul et al. proposed that distraction, as a technique in itself, actually fails to work, and it is the other involved therapeutic components that contribute to its perceived success.

            Alden, Dale, and DeGood (2001) performed a study to test the hypothesis that it is the qualitative component of the pain distracter that affects the analgesic outcome.  In this study, the effects of both positive and negative imagery were examined instead of only the typical positive imagery.  A second factor which was studied was whether or not the imagery had an internal or an external focus.  In addition to self-report measures, physiological measurements were also collected, such as skin potential frequency and heart rate.  It was found that positive imagery with an external focus had the greatest effects.  However, physiological measures did not correspond with any of the associated differences in pain measures between the experimental groups (Alden et al., 2001). 

Common Methodological Problems

            Due to both the subjective nature of pain and the ascribed personal meaning which is often a large portion of the pain experience, adequate measures for assessment are an important aspect of any research performed in this field (Turk & Melzack, 1992).  Even though substantial effort has been given towards providing a reliable and valid multidimensional measure for use in pain assessment, such as the McGill Pain Questionnaire, the benefits of having a descriptive diary giving an overview of all aspects of pain and its effect on psychological and life functioning cannot be denied (Melzack & Katz, 1992).  Many studies employed the use of various visual analogue scales for ease in comparing assessment scores (Jenson & Karoly, 1992).  However, the use of standardized scales limits the type of data which can be obtained from the research.  On the other hand, descriptive journals when used as a form of assessment can only be compared in terms of similar reoccurring themes.  At the very least, it is of utmost importance that assessment measures are comprehensive enough to cover the full experience of pain on a multidimensional level (Dworkin & Whitney, 1992).

            Another methodological problem lies in the fact that GI is most effective when its aspects of use are custom tailored to each individual.  Attempts at standardization of GI treatment must remain flexible enough to suit the needs of each individual.  The overall trend is that GI treatments which are most flexible are also more successful (Syrjala & Abrams, 1996).  In most GI studies, physiological measures are most widely used only during research which is performed in a laboratory setting.  Perhaps these measures could also be used in clinical research to add an additional psychophysiological dimension such as those employed in other areas of pain research (Flor, Miltner, & Birbaumer, 1992).  Although it should be noted that this effort can produce more questions than answers as reflected in past inconclusive results (Flor et al., 1992).


            Modern explorations into the effects of GI in pain management have shifted their focus towards actual clinical research and away from the analogue laboratory setting.  This has yielded results that are more relevant towards real life application.  Past research proves that GI is beneficial in the field of pain management as a valuable component of psychological treatment whether used alone or used as part of a more comprehensive healing program.  Because pain is affected by cognition, psychological state, and expectations, the use of GI can have positive effects that work on many levels of the multidimensional experience of pain.  Many patients who find that their current course of pain management treatment is insufficient may benefit from adding this technique.  Because of the rising costs of healthcare and the current state of the economy, future research should focus on implementing the use of GI as an effective low-cost way to augment current trends in pain management.  Although research has demonstrated that alternative methods, such as GI, should be implemented more often in the field of pain management, these techniques have still not gained sufficient popularity for widespread use.  Future attention should be directed at ways of implementing the use of GI in clinical practice.




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