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Becoming Your Own Advocate

Interactive Guided Imagery as a Way to Access Patient Strengths During Cancer Treatment

BY MARTIN L ROSSMAN, MD, DIPLAC (NCCAOM)

In cancer care, as in all medical care, there are two complementary goals of treatment. One, the usual medical goal, is to kill cancer cells and tumors, or reduce their numbers and ability to grow, reproduce, and metastasize. The other, perhaps best called the healing goal, is to support the well-being and resistance of the patient. Here I use "resistance" to stand for all the mechanisms, known and unknown, that protect us from the development and dissemination of cancer.

Conventional medical care for cancer has for too long concentrated on the first goal without paying appropriate attention to the second. The development of an integrated approach to treating the cancer patient is a much-needed response to that oversight and promises, at the very least, healthier people with cancer and, at most, an enhanced response to treatments and better cure rates in the people we treat.

Methods of supporting and enhancing resistance to cancer and tolerance of treatments generally fall into three categories that have received various amounts of research attention: (1) Nutritional support ranging from improvement of diet to generally acceptable levels to sophisticated individualized programs of nutritional supplementation with vitamins, minerals, herbs, essential fatty acids, and natural biological response modifiers; (2) Mind/body approaches consisting of psychological, psychosocial, and psychospiritual interventions ranging from support groups and counseling to meditation, stress reduction, and guided imagery practices; (3) Body/mind practices such as Yoga, Chi Gung, Tai Chi, Jin Shin Jyutsu and graded aerobic exercise; and (4) Systematic approaches from time-honored healing systems such as traditional Chinese medicine or Ayurvedic medicine.

In this brief article, I will focus on three case examples of the unexpected utility of guided imagery as a healing resource to the patient with cancer. Guided imagery in its various forms is becoming quickly and widely accepted as a useful adjunct in the treatment of people with cancer due largely to its ease of use, low cost, and rapid psychological benefits.1 It has also been shown to increase both the numbers and aggressiveness of natural killer cells when practiced over time,2,3 to reduce complications from surgery,4,5 relieve pain,6,7 and reduce adverse effects of chemotherapy,8,9 which in the terms of our conventional dualistic approach makes it not only a psychological intervention but a medical one as well.

A future article will more comprehensively review the range of guided imagery applications and techniques, but my purpose here is to share three brief examples of how an interactive use of imagery helped three people with cancer connect to inner strengths and resources that helped them through their challenges with cancer. These examples have been selected from hundreds of such examples in my practice to demonstrate the power of uniquely personal imagery to access the resilience and coping abilities of the patient.

Guided imagery is a term variously used to describe a range of techniques from simple visualization and direct imagery-based suggestion, through metaphor and storytelling. Guided imagery is used to help teach psychophysiologic relaxation, to relieve symptoms, to stimulate healing responses in the body, and to help people tolerate procedures and treatments more easily.

Interactive Guided Imagery (IGI) is a service-marked term registered by the Academy for Guided Imagery to represent a particular approach to using therapeutic imagery. In this approach, personal imagery relevant to the situation is evoked from the patient by a guide trained to do this without providing specific content. Thus the guide might prompt patients to imagine how their body might heal from or overcome their cancer, or how they might want to tell their children about their illness. Because the imagery comes from the patient, it is uniquely relevant and tells both patient and guide how the patient perceives the situation and creates an opportunity for them to work creatively with possible responses to it. The guide aims to create situations where patients can draw on their own inner resources to support healing, to make appropriate adaptations to changes in health behaviors, and to find creative solutions to challenges that they previously thought were insoluble. IGI encourages patients to access their own strengths and resources and tends to lead toward greater patient autonomy and self efficacy.

Battling cancer is frequently a complex journey involving some of the most difficult trials people are asked to cope with in normal life. There is growing recognition that cancer patients benefit from various types of support as they go through their journeys, ranging from informational to decision-making, physical, nutritional, psychological, social, and spiritual support. This article will present three brief cases showing how IGI can help people with cancer access what might be considered to be an "inner support system" at a time when it is most needed.

MAUREEN
Maureen Redl, creator of the "Voices of Healing" program, is a 65-year-old wise woman who was diagnosed with metastatic ovarian cancer 15 years ago. She was already familiar with guided imagery as a vehicle for insight and, in a meditative state, asked her unconscious mind for an image that could help guide her through what she imagined would be a terrible ordeal. She saw herself dressed in ski clothing and skis at the top of a very steep mountain. A lifelong skier, she immediately understood that she was about to push off on a run that would demand all her skill and determination. She also immediately saw that while the effort would challenge her to the extreme, it was clearly possible for her to make it all the way through if she gave it her full attention and focus. She also got the sense that if she did make it all the way down, she would be living life on a much deeper and more effective level than she ever had before.

This image was useful to her throughout many twists and turns of her journey with cancer, reminding her to stay focused on where she wanted to go and not let herself get lost in her fears. She not only "made it" herself, she has become an inspirational and effective guide to many others who are themselves struggling with life-threatening illness.

While this woman knew from previous experience that her imagination was a doorway to her inner life and could be helpful in this way, many people will not know that this is even possible, or their shock and anxiety may prevent them from being able to focus on strengths without professional support and guidance.

EMILY
"Emily" was a patient of mine, a nurse in her forties who had just been diagnosed with a recurrence of breast cancer. She could barely speak through her sobbing, but kept repeating "I just don't know if I can do this again... I don't know if I can do it." She had been free of cancer for four years and had changed her life in many healthy ways after her initial diagnosis. She had improved her diet, clarified her personal goals, cleaned up some personal baggage through therapy, and had been feeling better since her cancer treatment than she had for years beforehand. The recurrence was a shock and a cruel blow.

She was willing to do imagery, and I asked her what she felt she needed in order to be able to deal with the challenges that faced her. She was quiet and said, "Strength and courage... I don't know if I have the strength to go through this again." I asked her to go back in her memory to a time when she did have the strength and courage she was missing now, and in her imagination she went back to a time twenty years earlier when her mother had been diagnosed with breast cancer. By asking her to imagine that she was there again, and to notice what she saw, heard, and felt, she was able to recreate the experience fairly vividly. As she described her mother sobbing and being terrified, as Emily had been at the start of the session, I asked her to pay attention to how she felt as she experienced herself there with her mother. She said that she was calm, clear, and encouraging. She felt strength and confidence that they'd be able to take whatever steps they needed to take to deal with this. I invited Emily to notice where she felt these qualities of strength and confidence, of calmness and clarity, and over a few minutes, to imagine that she could feel them very strongly in her body, and she did. We took several minutes to let her feel these qualities even more strongly, feeling them in various parts of her body (chest, face, arms, legs, etc) I invited her to imagine she had a volume knob and could turn up the amplitude of the feeling as high as she liked, giving her time to experiment with it and find the "right level of strength for you right now." The imagery, being remembered in "present tense" allowed her to experience these qualities in herself, and when she opened her eyes, she said, "You know, I do have the strength I need, I just couldn't get to it."

Emily still had recurrent cancer and many decisions and treatments to face. She would get scared and feel like giving up periodically, but now had a tool that allowed her to reconnect with her strength and courage. After a few weeks, she remarked to me that "this is like emotional body-building" and she is right in that the more she practiced feeling those qualities, the more easily they became accessible and present in her daily life.

The shock, disorientation, and anxiety that often come with a serious cancer diagnosis often overwhelm people's sense of confidence and make it hard for them to feel effective or powerful at a time when they may need to feel this way even more than they normally do. Evocative imagery can help people to reconnect with their own resources and begin to use them effectively in their own behalf. Learning to shift from helplessness to hopefulness at will is an empowering experience for anyone, especially for anyone feeling overwhelmed with the fear of cancer.

People with a cancer diagnosis may not only face an on-going threat to life and well-being, they often need to do this in a situation characterized by uncertainty as to the best treatment, complicated by conflicting recommendations on the part of the best experts in the field. One use of IGI is to help people make good decisions once they have accumulated the information available but still cannot decide. We often invite people in this situation to imagine meeting with a figure that is both wise and caring, the kind of figure we all wish we had in our lives when times are difficult. We call this figure the "inner advisor," though many people have their own terms for it, ranging from "inner guide" and "inner voice" to "guardian angel" or "the wisdom within." The following case demonstrates how this technique was used effectively for this reason and provided an unexpected but much welcome bonus in addition.

HELENE
"Helene" was a handsome woman in her sixties who consulted me after being diagnosed with breast cancer. Because of the type of cancer, she had received a number of different treatment recommendations from top level oncologists and surgeons. These ranged from two different types of surgery with or without two other approaches to breast reconstruction followed by radiation and possibly adjunctive chemotherapy. She came to see me to do guided imagery to help her decide from a "deep level" what treatment course would be best for her. As I interviewed her, it became apparent that she was a warm, thoughtful, intelligent woman with a well-developed support system. She was happily married and had been for many years, had two loving grown children, and was a successful professional woman who loved her work. She had many good friends, and had participated regularly in a women's group for years, calling it the equivalent of another family.

We decided to use IGI to explore what decision might come from a place of wisdom and compassion, which we often do by asking the patient to imagine themselves in a beautiful safe place having a conversation with an image of an "inner advisor," a figure that has these two qualities of wisdom and compassion. In such an imagery dialogue process, the patient finds a relaxed yet aware position that allows them to explore ideas they imagine come from such a figure. The disidentification created, along with the focus on the desired qualities the figure embodies, often allows information to emerge that the patient may be having difficulty accessing.

Once Helene was feeling relaxed and comfortable in a beautiful imaginary glade, I prompted her to invite an inner advisor image to appear. An angel-like figure came to her mind, large, ethereal yet substantial, and winged. Helene felt a sense of love and wisdom from the angel figure and invited it to be comfortable with her. She discussed all the information she had gathered with the angel and asked it to help guide her to choose the best treatment for her. The angel seemed to respond in a way that made Helene feel that surgery followed by radiation was the best treatment for her—that it had the best evidence behind it and her own intuition had led her to think that was the course she wanted to choose. The angel confirmed that choice and Helene felt surer than she had to that point about that course of treatment. At the end of their dialogue, she thanked the angel for coming and asked if it would be all right to hug the figure in her imagery. The angel figure was receptive and Helene became very quiet for several minutes. She described the angel enfolding her in its large golden wings and surrounding her with a profound sense of warmth and love. She was very moved.

After the imagery part of the session was over, we discussed what had happened. Helene was clearly relieved to have reached what felt like a good decision for her, and I was pleased that the session had helped her achieve her purpose. Toward the very end of the session, I asked her a question I often ask people after an imagery session—"what was the most important thing about that experience for you?" I fully expected her to say that she had reached a decision she could live with, but instead she surprised me and said, "I found out that I am not alone." A tear fell from her eye as she said this. I was surprised for a moment because Helene was so deeply connected to her family and her friends, yet I knew instantly what she meant. This was about another kind of connection—a connection she later told me she felt with an aspect of life that ultimately went beyond life as we knew it.

The lesson here is that IGI can be used to access a perspective that includes both wisdom and compassion, and that perspective can not only help a patient make good treatment decisions but may also help them feel loved and connected to life, to the mystery, and to their spirituality in a very personal and tangible way. This sense of connection can help support a person through adversity in a way that can augment or even transcend external support.

The uses of guided imagery, especially when used in an IGI format that evokes personally meaningful and relevant imagery are protean in cancer care and range from relaxation and anxiety reduction through stimulation of healing responses in the body to mobilization of personal strengths and resources in the service of healing. Since imagery is a natural way that the human nervous system codes, stores, processes, and accesses information, its uses for someone with cancer are not limited to simple relaxation or immune system stimulation, but also include methods for decision-making, accessing and building emotional strength, and experiencing events in ways that are most functional for supporting the healing resources of the individual.

Martin Rossman is a graduate of the University of Michigan Medical School and, in addition to a busy practice emphasizing non-drug medicine and patient participation, has taught clinical guided imagery to over 10,000 health professionals since 1982. He can be reached through his website: www.thehealingmind.org

LISTEN ONLINE
To listen now to a guided imagery session led by the author, click here [MP3].

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References

1. Richardson MA, Post-White J, Grimm EA, Moye LA, Singletary SE, Justice B. Coping, life attitudes, and immune responses to imagery and group support after breast cancer treatment. Altern Ther Health Med. 1997;3(5):62-70.
2. Gruber BL, Hersh SP, Hall NR, et al. Immunological responses of breast cancer patients to behavioral interventions. Biofeedback and Self Regul. 1993;18(1):1-22.
3. Hall H, Minnes L, Olness K. The psychophysiology of voluntary immunomodulation. Int J Neurosci. 1993; 69(1-4):221-234.
4. Tusek, DL. Guided imagery; a significant advance in the care of patients undergoing elective colorectal surgery. Dis Colon Rectum. 1997;40(2):172-178.
5. Disbrow EA, Bennett HL, Owings JT. Preoperative suggestion hastens the return of gastrointestinal mobility. West J Med. 1993;158(5):488-492.
6. Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Pain. 1995;63:189-198.
7. NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches Into the Treatment of Chronic Pain and Insomnia. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA. 1996;276(4):313-318.
8. Troesch, LM, Rodehaver CB, Delaney EA, Yanes B. The influence of guided imagery on chemotherapy-related nausea and vomiting. Oncol Nurs For. 1993;20(8):1179-1185.
9. Burish TG, Carey MP, Krozely MG, Greco FA. Conditioned side effects induced by cancer chemotherapy: prevention through behavioral treatment. J Consult Clin Psych. 1987;55(1):42-48.

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