Lame Deer of the Oglala Sioux is credited with the statement, “What you see with your eyes shut is what counts.” Modern neuroscientists agree. The ability to “see” with the eyes shut, also known as imagery, guided imagery, creative visualization, or active imagination, has become widely accepted as a tool in medicine for managing stress, coping with emotions, and even alleviating physical symptoms.
Commonly offered to cancer patients to improve quality of life during chemotherapy, imagery is also known as a helpful adjunct therapy in preparation for surgery, childbirth, and other difficult situations. It has been shown to provide pain relief, shorten hospital stays, and lessen stress and anxiety. The link between stress and poor blood glucose control in people with diabetes is clearly established. And since much of the professional literature on diabetes calls for approaches to its management that consider the emotional and behavioral — not just physical — needs of the person, an easy-to-use stress buster that can also provide insight into behavior may prove to be very useful. This article provides a brief introduction to guided imagery and outlines three specific exercises that can be performed by individuals, clinicians who work with people with diabetes, or diabetes support groups.
Introductory exercise
Close your eyes for a moment and think of a lemon. Take a couple of deep breaths and relax as you allow the image of a lemon to appear in your mind’s eye. Imagine holding the lemon and feeling its texture, both bumpy and smooth. Use an imaginary magnifying glass to examine its subtleties and colors, even the way light glistens on its surface. Notice the fragrance. Take a knife and cut it open. Taste it if you like, touching it with the tip of your tongue. Is the lemon juicy? What does it smell like? What does it taste like?
Most people will quickly discover that as they become involved with the image, using all of their senses intensely to notice the look, smell, sound, feel, and taste of the lemon, the more engaged the body becomes, and wow, that’s a juicy lemon — sweet, sour, and tart! Feel your saliva flowing as your gums and tongue react to the mere idea of a lemon that isn’t even there. This is the mind–body connection at work, and such interactions between mind and body can become a basis of self-discovery.
Imagery in medicine
Imagery is practiced in an eclectic hodgepodge of forms, some validated by substantial bodies of research, and some not. An upsurge in interest in imagery came in the late 1960’s, when Carl Simonton, MD, developed the use of guided imagery with cancer patients. Evidence was later found that imagery could enhance immune system function and give patients hope and a greater sense of control while coping with a life-threatening disease.
For a 2004 report published in the journal Advances in Mind–Body Medicine, nurses Victoria Menzies and Ann Gill Taylor analyzed 128 clinical studies to form a definition of imagery as a basis for future research. They concluded that “Imagery, a mental function, is a lived experience that is a dynamic, quasi-real, psychophysiological process.” The word “dynamic” refers to the body’s interaction with the brain, which is no longer viewed as a separate, controlling blob that sits on top of the body. Instead, according to neuroscientist Candace Pert, the brain and body together form a psychosomatic network, in which chemical and electrical messages traveling through the bloodstream and nerves carry out several responses — physical, mental, and emotional — simultaneously. Exploring an image and allowing an intense sensory experience to unfold accesses the limbic system, the emotional center of the brain. The limbic system views the imaginary as a real experience, and the brain reacts by sending chemical messages throughout the body via the nervous system.
Allowing the mind to form images that represent calm, comfort, peace, happiness, spiritual awe, and deep relaxation activates the relaxation response, a phenomenon identified by Herbert Benson, MD, in which the nervous system deactivates the stress response. Brain waves, respiration, heart rate, muscle tension, and blood glucose all decrease, while immune function and feelings of well-being increase.
Many practitioners of imagery find that certain forms of it can help uncover causes of fear or anxiety that may be buried in the subconscious. Imagery can also be used to find ways to lessen the intensity of these feelings and solutions to the problems they cause. Thus, practitioners often speak of a cycle of healing and renewal, beyond the relaxation response, that can begin through imagery and lead to improved mental health and well-being.
While the professional literature on imagery refers to successful uses with a wide variety of medical and psychological conditions, there are only a handful of studies that have looked specifically at diabetes. In a 1999 study, nurses Harriet Wichowski and Sylvia Kubsch reported that people with diabetes who listened to an imagery script designed to increase adherence to recommendations for blood glucose monitoring, exercise, weight management, and diet showed improvement in these areas. In a 1990 study, doctors at the State University of New York encouraged a small group of adolescents with diabetes, all of whom had a history of poor compliance with treatment, to visualize achieving personally meaningful life goals despite diabetes. For example, one teen imagined his future as a firefighter in colorful detail, right down to the feeling of riding on the back of a speeding fire engine and noticing details like the buttons on his coat. After engaging in this imagery, dramatic drops in HbA1c levels were noted in the group, indicating improved blood glucose control.
Forms of imagery
Imagery happens in our minds all the time; it is inherent to how we think and feel and part of what makes us who we are. “No one owns imagery,” Marielle Fuller, a famous practitioner and teacher of imagery at UCLA, used to say in response to those who might claim authorship. Individuals can feel free to experiment with imagery for themselves, but those who would like to facilitate imagery for others need to seek appropriate training.
Researching imagery is problematic because of its varied forms; no one is exactly sure which one will work best in a given situation. Imagery is commonly used both in individual sessions and in groups, with or without an audiotape, and with or without a trained facilitator present.
And then there are different methods for the imagery itself. Each of the following methods requires that the participant relax in a comfortable position with the head supported, in a place free of interruptions. Ample time is required to get the maximum benefit from imagery, since this requires several integral phases, as noted by psychologist Jonathan C. Smith. These phases are withdrawal (from the physical world), release (from everyday burdens and analytical thinking), recovery (from fatigue and tension), and opening up (back to the physical world, renewed and refreshed). Half an hour is ideal for this process.
Evocative imagery. Evocative imagery allows images to arise spontaneously. Begin by identifying a desired state, close your eyes, and then allow an image to form that represents that state. You might search for an image that represents calm, relaxation, peace, joy, love, or — an important one for people with diabetes — acceptance. Remain open to whatever form the image takes. Sometimes images seem so ordinary that the journeyer (a common term for someone engaged in imagery) doubts the image is valid, but the subconscious always picks the “right” image. Ocean waves are a common image, but the family dog or the quiet of a bedroom are also common. The key to any image is to “entertain” it for a long time: to explore it with curiosity, engaging the image fully into the psychosomatic network by noticing smell, sound, movement, color, texture, and taste.
Archetypal imagery. Marielle Fuller used a form of archetypal imagery with roots going back to Swiss psychologist Carl Jung. Each journeyer met imaginary companions in the forms of an angel, a wizard, a jester, and a good witch. Personal relationships were developed with these figures, who were then consulted throughout every journey as guides. Therapy was complete when the individual could “travel” unassisted, beginning by meeting all of the guides in a clearing, and then following their directions.
The journeyer can benefit from a number of imaginary tools while engaging in evocative or archetypal imagery. These include a light to shine on images to see them better, a crystal to draw a circle of protection around oneself during moments of fear, and calling one of the imaginary guides for help when encountering an impasse.
Interactive guided imagery. Interactive guided imagery, developed by David Bresler, PhD, (President and Cofounder of the Academy for Guided Imagery in Los Angeles) and Martin Rossman, MD, combines evocative and archetypal imagery, allowing both the journeyer and the facilitator to interact and communicate with the images. Interactive guided imagery requires a trained, skilled, compassionate facilitator who encourages the individual to stay on track but allows the journey to take its own course.
Some facilitators will prescribe specific images and scenarios for the journeyer. This can be harmful if the individual associates any such image with past trauma. Even an image as seemingly harmless as a big, blue lake can be inappropriate if it brings to mind a boating accident and the person is not prepared to process intense feelings. Open-ended, evocative suggestions that invite journeyers to discover their own places of peace, safety, comfort, and beauty are usually more therapeutic and meaningful.
What to expect
The ability to benefit from any form of imagery depends on one’s belief system, personality style, and mental health status. For example, one study showed that imagery could produce changes in immune cell counts, but only in people who believed beforehand that this might be possible. Some people will cry tears of joy after a particularly moving imagery journey, while others will find a similar journey relaxing but remain emotionally unaffected by it. Depressed or anxious people may have difficulty developing internal imagery; for these individuals, other therapies or medication may be needed first.
Expect that becoming deeply relaxed will take practice and experimentation. Everyone experiences distracting thoughts — just notice them and let them pass while bringing your attention back to the internal image. People who are highly creative and open-minded may have wild, elaborate journeys with such spectacular imagery that they worry they’re nuts. Don’t worry; the world of imagery can indeed be fantastic. Just be sure to interpret the meaning of your inner journeys carefully when deciding how to apply what you’ve discovered to daily life.
Imagery is like a box of matches: Both are useful, but used to excess or carelessly, both can cause harm. For example, I have seen harm come when journeyers get overly enthusiastic about the possibilities of imagery and make unwise health choices (such as rejecting conventional medical treatment), and when facilitators use imagery in a domineering, instead of collaborative, manner. Always examine your feelings, use common sense, work only with facilitators who offer plenty of choices, and as Marielle Fuller used to say, “Never do anything in imagery that you don’t want to do.” However, try not to leave anything unfinished. Stay with images and explore them with curiosity until you know why your mind is showing them to you. Dismiss any overly intimidating images by just telling them to go away.
Marielle Fuller’s “Healing Pool”
Drawn from the work of Marielle Fuller, this script contains elements that help journeyers through the phases of withdrawal, release, recovery, and opening up. Give yourself plenty of time, and enjoy!
Walk in the woods until you hear the sound of water and come to a stream. Next to the stream sits a box that will float. This is a box where you can put away anything you’d like to be free of just for now. You can return to these things later if needed. After you have filled the box, close it, put it in the water, and watch as it disappears downstream.
Walk until the stream widens and forms a private healing pool. Let the water be the perfect color and temperature. There is a sandy place to rest your head. You can take off all your clothes or be in a bathing suit. A fluffy towel and robe lie ready for you.
Immerse yourself in the water and notice its special healing power. If you would like it to, allow it to penetrate under your skin, into your muscles, even into the cells. Feel the healing action of the water washing away tension. Bring awareness through your body starting with your feet, until every part is washed and refreshed. Include your internal organs, the stomach, the pancreas, the heart. Take your time. Release anything that you no longer need and let the stream carry it away.
While you relax, a little bird comes and looks at you a long while, then flies away. The bird comes back, bringing a message. When you understand the message and are
ready to get out of the pool, then dry off, dress, and go back through the woods the way you came before returning to full awareness.
“Listening to diabetes” exercise
A standard practice in interactive guided imagery is to allow an image representing a medical condition to form. This can be powerful for people with diabetes, as it can reveal anger, grief, sadness, fear — all of the most difficult feelings inherent to living with diabetes. If you try this, you should be aware that a disconcerting image may arise, but if this is the case, listening to what the image has to tell you can be especially valuable. Children commonly imagine their diabetes as a dog who wants care and attention, while adults may imagine diabetes as chains in which they are locked or as a potentially dangerous animal. To avoid excessive anxiety, draw the image on paper instead of closing your eyes. Be curious: Ask what it wants and needs, and let it “talk.” Make an agreement to give your diabetes what it needs. Interpret the experience afterward and decide if lifestyle changes are warranted.
Resources
If you decide to explore guided imagery, you will most likely want to find a facilitator. Check with your doctor or a local psychotherapist for a recommendation, or visit www.healthy.net to find facilitators trained in interactive guided imagery. Always ask facilitators about their training, experience, and philosophy to make sure they will be a good match. If you’d prefer not to have an actual facilitator just yet, you can find recordings of guided meditations meant to trigger the relaxation response at www.mbmi.org (click on “Store”). Or, for more imagery exercises, read the classic book Rituals of Healing: Using Imagery for Health and Wellness, by Jeanne Achterberg, PhD, Barbara Dossey, RN, MS, and Leslie Kolkmeier, RN, MEd.
A personal note
Years ago, when I was mired in a struggle with blood glucose control, a hypnotherapist suggested that I allow an image to form to represent acceptance. As I entertained my image of breezes blowing through an open window with fluttering curtains, I understood the meaning of acceptance for the first time and let go of my excessive fear of hypoglycemia. Later, when I was bothered by a nagging feeling that I wouldn’t live long enough to see my son graduate from high school, Marielle Fuller guided me to encounter a jester — representing lightness, wisdom, and humor — to take me to three places that would teach me about hope. I heard a clock ticking and found myself on a mountaintop with my son. Somehow, my fear of early death disappeared, and I intuitively knew that I had a long life ahead of me. I have since guided many others on their own imaginary journeys. I hope that you, too, will close your eyes, take some gentle breaths, and travel someplace that will teach you about hope.
