SUCCESSFUL PAIN MANAGEMENT OFTEN INCORPORATES A MULTIMODAL TREATMENT APPROACH. WHILE MEDICATION IS AN IMPORTANT PART OF REDUCING PAIN, AN INCREASING NUMBER OF PEOPLE HAVE FOUND THAT COMPLEMENTARY THERAPIES ENHANCE THE EFFICACY OF THEIR PRESCRIPTIONS WITHOUT ADDING NEGATIVE SIDE EFFECTS.

One effective tool recommended by pain management specialists is guided imagery. A cognitive-behavioral therapy, guided imagery is a technique that redirects thoughts away from pain through visualizing a calming scene or relaxing situation.

WHO CAN BENEFIT
FROM GUIDED IMAGERY?

“In essence, guided imagery is one of several relaxation strategies to alleviate acute and chronic pain,” explains Gordon Asmundson, PhD, professor of psychology at the University of Regina in Saskatchewan, Canada. “The therapist, for example, may help the individual use narrative to visualize a comfortable, relaxing place, and this narrative can be as simple or as complicated as needed. With every breath, the individual is thinking of this wonderful place and working toward a state of relaxation.

“Most people soon realize that they can utilize guided imagery in ways they didn’t think they could and that it doesn’t have to take a lot of time,” Asmundson says. “If a person is motivated to try cognitive and behavioral techniques, it is a good tool to have in the treatment toolbox.”

Clinical studies suggest that guided imagery can be used effectively by a variety of patients. In addition to aiding relaxation therapies, guided imagery can help change or control emotions or responses to negative situations. The technique can also help individuals eliminate undesirable personal habits, adjust to new situations or control phobias, anxiety and/or pain.

“In sports, guided imagery is used a great deal,” says Jeffrey Feldman, PhD, assistant professor of neuro-psychology at Wake Forest University Medical Center. “You’ll see Olympic skaters, for example, with their eyes closed before they begin. They are often going through their entire routine, visualizing a positive performance. Some marathon runners imagine a successful race before a competition. It’s classic sports psychology,” he says.

GUIDED IMAGERY TO TREAT PAIN

Asmundson points out that numerous studies support the use of multimodal treatments for chronic pain. While standard care often includes medications, Asmundson adds that he has found guided imagery to be an important element of the overall pain management package for many patients.

“From my perspective, I want to be administering evidence-based strategies that have been shown to be effective in treating pain,” Asmundson explains. “In the case of guided imagery, the evidence is not yet conclusive, but there is definitely an advantage to adding this technique as a complementary pain management tool. All treatments are not necessarily about pain reduction; some are about teaching the patient to live productively in spite of the pain.

“One of the reasons guided imagery works well in treating pain is because people who have pain usually have stress and anxiety as well,” continues Asmundson. “With this technique, you are doing something that targets reducing the stress and anxiety and that, in return, often reduces pain. In general, it is the type of skill that works for almost everyone.”

Many health care professionals and patients state that treating pain is an ongoing and challenging process because pain is difficult to define in absolute terms. Consequently, each patient and his or her medical practitioner must find effective assessment methodologies and tools.

“Pain is impossible to describe to someone else,” Feldman says. “So with guided imagery, I will sometimes have the patient create an image of the pain. I ask them to consider the color, texture and shape of the pain and to think about how it looks when it gets worse. For example, is it more red or does it expand when it becomes worse? How does it look when it’s a seven on the pain scale compared to a four or a five?”

Feldman explains that pain triggers the “fight or flight” response in many patients. When this response occurs repeatedly, the patient’s “radar is turned way up,” says Feldman.

“It’s like a car alarm that is too sensitive,” he says. “The brain is working correctly to react this way, so we work to dial things down and change the channel. We work to slow the rate of breathing and then focus on relaxing the muscles. Finally, we attempt to ‘quiet’ the mind by activating memories associated with positive feelings.

“The more a patient is absorbed in guided imagery, the more he or she disassociates from pain,” Feldman says. “There are two affective components of pain. The principal component is the immediate negative emotional reaction to pain. The secondary component is the ‘what if ’ factor, anticipating the return of the pain. Guided imagery gets people out of their heads and into a place that evokes positive emotions.

WHAT TO EXPECT DURING
A GUIDED IMAGERY SESSION

Some individuals are uneasy or anxious about what they imagine will transpire during a guided imagery session. Feldman explains that the appointment usually begins with selecting something positive to focus on during therapy. After determining the focal point, Feldman asks clients to become aware of their breathing.

“Then I talk with them to discover the characteristic things that make them happy. Psychiatrist Milton Erickson referred to this as people’s “patterns of happiness,” Feldman says.

“This usually involves some form of absorption such as playing a musical instrument, being ‘in the zone’ while playing sports or being engaged with one’s grandchildren. It’s an effective tool in guided imagery.”

Says Asmundson, “When I practice guided imagery with someone, the office door is shut and their phone is off. We try to get to diaphragmatic breathing, and we’ll work on that a while with the goal of helping the individual determine how it feels. I perform pain assessments at the beginning and end of each session, and if a patient’s pain level goes from an eight to a six, we know we are making progress.”

THE FUTURE OF GUIDED IMAGERY

As traditional medical practitioners and patients continue to discover and embrace integrative therapies, guided imagery will likely be explored by an increasing number of individuals. Feldman and Asmundson think the therapy has many positive implications in the management of pain and other diagnoses.

“With guided imagery, the individual learns to use the neuroplasticity of the brain to make changes,” Feldman concludes. “The patient can usually learn how to do this within sic to eight with noticeable results, and practice often leads to considerable improvement in pain levels. Like acupuncture and some other complementary therapies, guided imagery can certainly enhance standard medical care.”

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Gordon Asmundson, PhD, RD Psych, FRSC, is a full professor of psychology at the University of Regina, an adjunct professor of psychiatry at the University of Saskatchewan and the leader of a CIHR New Emerging Team focusing on mechanisms and treatment of PTSD. In 2009 he was inducted as a fellow in the Royal Society of Canada. Dr. Asmundson holds several editorial posts, including North American editor of about his current research and practice, visit

Jeffrey Feldman, PhD, is director of Occupational Rehabilitation Programs, assistant professor of neuropsychology, associate director of the Center for Integrative Medicine and a member of the Translational Science Institute with a special interest in Team Science at Wake Forest University School of Medicine. Dr. Feldman teaches a course he developed for health care professionals to enhance self he has worked with the Center for Creative Leadership (articles and chapters on pain management, leadership of interdisciplinary teams and more.