A Guided Imagery Handbook

Created for Child Life Specialists

By: Adam Herro

M.S. Child Life

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Introduction

The following handbook was written for child life specialists to

provide them with everything they may need to conduct a guided imagery

session with a pediatric patient. Inspired by a study that demonstrated the

overwhelming need for further education and training in this complimentary

form of therapy, this handbook hopes to both inspire child life specialists to

feel confident enough to provide guided imagery to their patients and

promote the usage and positive effects of this safe, non-pharmacological

pain management technique to patients in need. Please refer to the table of

contents on the following page to learn about all the information covered in

this handbook.

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Table of Contents What is Guided Imagery? ...................................................................................................4

Guided Imagery: When, Where, & How ...........................................................................8

Guided Imagery: A Developmental Perspective ...........................................................12

Developmentally Appropriate Pain Management Guided Imagery Techniques ....15

Complimentary Therapies ..................................................................................................19

Questionnaire for the Patient and Parent ...................................................................22

Frequently Asked Questions ...........................................................................................25

Sample Guided Imagery Scripts .....................................................................................29

Post-Guided Imagery Evaluation .....................................................................................39

References ...........................................................................................................................41

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What is Guided Imagery? Guided imagery is a form of mind-body therapy that falls under the

heading of complementary and alternative medicines, otherwise referred to

as CAMs (Landier & Tse, 2010). Minimally stated, guided imagery involves a

patient listening to guided or instructional information while they conjure

images in their mind as a therapeutic technique to help cope with a difficult

situation. Nevertheless, guided imagery is far too varied to define in a

simple sentence. Instead, guided imagery is often defined by describing its

variety of practiced forms and techniques as well as the benefits they

induce.

The Academy of Guided Imagery (2010) acknowledges techniques such

as “simple visualization and direct suggestion, and metaphor and storytelling”

as ways to elicit elements of the unconscious mind “to appear as images that

can communicate with the conscious mind” (para. 2). By establishing a link

between the unconscious and conscious mind, the patient can utilize internal

resources that they may not have been aware of to help him or her cope with

their current challenging situation (Rossman, 2004). The practice and

administration of guided imagery is equally as diverse as it can occur with

instruction or guidance from a psychologist or another trained professional,

a prerecorded video or audio tape, or completely on one’s own with no outside

guidance. The psycho-physiological benefits of guided imagery help people

cope with their current stressors while decreasing pain and promoting

relaxation and the arousal of the body’s internal healing mechanisms

(Rossman, 2004).

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One of the most commonly used forms of guided imagery is

Interactive Guided Imagery. A term coined by the Academy of Guided

Imagery, Interactive Guided Imagery is developed from the notion that

images should find their source in the mind of the patient, not from the

instruction of a professional audio recording. Personal imagery will help the

patient look deep into him or herself to find what is needed to get through

whatever obstacle he or she is facing. The guide’s job is simply to help the

patient get wherever he or she is going by encouraging the patient’s inner

self to be revealed (Rossman, 2004).

There are three forms of Interactive Guided Imagery that a child life

specialist should be aware of, which are imagery relaxation, healing imagery,

and ideal model imagery.

Imagery Relaxation • The most accessible form of guided imagery, imagery relaxation is a

simple technique that children as young as five years old may attempt.

• Imagery relaxation is a great introductory exercise into the world of

guided imagery because it does not demand the patient to partake in

difficult cognitive interactions or manipulations.

• During imagery relaxation the child life specialist will guide the

patient to a safe place of his or her liking. Sample destinations may

include the beach, home, or at a park.

• Once the patient has begun imagining his or her safe place, the child

life specialist will guide them to acknowledge what information they

are acquiring from their senses in response to their safe place. Such

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questions help the patient delve deeper into the imagery, thus making

the experience more realistic (Rossman, 2004).

Healing Imagery • Patients engaging in healing imagery are guided to imagine healing

occurring in their body.

• Healing imagery may be used with children from age seven on.

• Patients may imagine their healing in whichever way they choose.

Some may imagine their white blood cells fighting an infection while

others may imagine a more abstract healing response less grounded in

medical science.

• Once again, the patient is encouraged to incorporate all of their

senses into his or her healing process. The patient’s healing process

may take on a specific smell or even taste to it.

• Studies using MRIs have shown that if more senses are engaged

during imagery, more areas of the cerebral cortex are activated.

• Triggering the cerebral cortex by engaging all the senses during

imagery may trick the brain into experiencing a very realistic

occurrence of healing. This may in turn activate the body’s immune

responses (Rossman, 2004).

Ideal Model Imagery • Ideal model imagery encourages the patient to imagine doing an

activity or experiencing a positive life event without pain or when the

patient has completely recovered.

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• Ideal model imagery may be used with children from age seven on.

• Imagining a recovery or returning to a favorite activity without pain

allows the patient to experience the joy and the hope of one day being

able to accomplish the imagined activity in real life.

• Ideal model imagery may also allow a patient to acknowledge grief

related emotions and issues surrounding his or her newfound inability

to do an activity ever again or without pain.

• Child life specialists can use a variety of therapeutic activities to help

their patients cope with their grief and loss or their fears that they

may never recover (Rossman, 2004).

Source: http://www.traumaweb.org/content.asp?pageid=226

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Guided Imagery: When, Where, & How

Having defined guided imagery and its different forms, it is essential

to discuss when and where a child life specialist could conduct a guided

imagery session.

When: One of the most appealing aspects about guided imagery is that it

may be used to address or assist a multitude of emotions or situations. Child

life specialists may conduct a guided imagery session with a patient who is

feeling:

• Sad

• Anxious/Nervous

• Fearful

• Anger

• Frustration

• Homesick

• Lonely

• In Pain

Out of the above emotions or feelings, guided imagery is most often used

to address anxiety and pain. In fact, research shows that guided imagery

can be quite successful at reducing pain and anxiety, thus exposing a positive

correlation between the two (Huth et al., 2004). If the child life specialist

can address either the pain or the anxiety, it is quite likely that the other

will consequently improve as well. Using the previously discussed healing

imagery or ideal model imagery may help manage pain while using imagery

relaxation may help promote relaxation and diminish anxiety. Reducing

anxiety through the use of imagery relaxation may be quite effective before

the patient undergoes a procedure.

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Nevertheless, guided imagery may also be successful at treating the

other aforementioned emotions. Guided imagery allows children to mentally

escape the loneliness or sadness of the hospital environment by visually

engaging in a pleasant activity or spending time at a favorite place with their

favorite people or animals.

There is no firm answer on how often a patient should participate in

guided imagery (Rossman, 2004). It really depends on the child’s interest in,

and appreciation of, guided imagery. Child life specialists should never force

or make a child engage in guided imagery. Doing so would be a waste of both

the child life specialist’s and the child’s time because there is zero benefit

without the child’s full participation and engagement.

Where: Guided imagery requires little to no equipment; therefore, an

imagery session can take place anytime and anywhere the patient is

comfortable. Child life specialists will likely conduct guided imagery sessions

in the patient’s room. Here are some suggestions for creating an appropriate

environment:

• Turn off the TV in the room

• Close the door and draw the blinds, if available

• Make sure the child or teen is comfortable before beginning so

there are minimal distractions

• Dim the lights or turn them off completely if a enough sunlight

seeps through the blinds

• Speak with the nurses and hospital staff beforehand to designate a

time free of interruptions. This will help avoid a nurse interrupting

a session to change an IV or medicine.

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• Place a sign on the door notifying other staff that guided imagery is

in session.

• Plan the session at a time when little to no people are in the room.

Always ask the patient whom he or she wishes, if anyone, to remain

in the room. Generally, children from age seven on will voice their

preference for who is present in the room during a session (Pincus &

Sheikh, 2009).

• If the patient wishes, play instrumental music or nature sounds at a

low volume during the guided imagery session.

• For younger and school age children, child life specialists should try

to create a consistent routine and environment if guided imagery

sessions are regularly held. Since children respond well to routine,

consistency will help produce increasingly beneficial sessions (Pincus

& Sheikh, 2009). Setting up a specific time and date may also be

helpful for teens as well.

How: How a child life specialist provides guided imagery depends on the

developmental level of the patient and what he or she is trying to address

within the patient, such as pain, anxiety or loneliness. These two factors will

help determine how guided imagery is provided. Regardless, the child life

specialist should always assume the role of a nonjudgmental and patient

guide who expresses their support by reminding the patient that he or she

has the ability, strength, and qualities to effectively cope with whatever is

bothering them (Rossman, 2004).

When providing guided imagery to a child or teen, the child life

specialist should take the passenger’s seat and allow the patient to guide the

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interaction. The child life specialist should avoid suggesting a specific safe

place for the patient or any type of healing imagery, and instead encourage

the patient to discover his or her own. Whatever the patient discovers on

his or her own will always prove to be more effective than any suggested

image (Rossman, 2004). Child life specialists should guide the child along the

way of their imagery journey by initiating the session, encouraging a state of

relaxation, asking questions about their imagery, and promoting further

immersion into their imagery so it can become as realistic as possible for the

patient. Lastly, always make sure the patient is determining the pace of the

journey and that the guide is never getting ahead of or assuming the

patient’s progress (Pincus & Sheikh, 2009). Please refer to the sample

scripts within this handbook to learn about different phrases or questions a

child life specialist can ask to encourage a more detailed imagery experience.

If appropriate, guided imagery may employ the use of props to

promote sensory stimulation outside of the visual. For example, if the child

life specialist knows a patient loves the beach, he or she may prepare

additional beach related sensory stimulations. A bucket of warm sand for

the child to run their fingers through or a soundtrack of waves crashing may

help better enhance the child’s guided imagery journey. These additional

props are not always necessary and may detract from the patient’s

experience. The child life specialist is encouraged to try similar ideas with a

patient and receive feedback from him or her afterwards to learn whether

it is appropriate to continue such props.

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Guided Imagery: A Developmental Perspective

Although guided imagery is a safe form of therapy, it is not always

appropriate for all ages or all children. Depending on the child’s cognitive

development and level of comfort with this experience, guided imagery may

or may not be a suitable and effective treatment or activity. Children seven

years old and older are generally capable of participating in, and

consequently benefiting from, guided imagery. Depending on the child,

children as young as 5 may benefit from being introduced to simple forms of

guided imagery. The following section provides information on imagery and

its relation to a child’s cognitive development according to Piaget’s cognitive-

stage theory.

The Sensorimotor Period (Birth to 2) • Children are unable to store, recall, and manipulate images, which is

necessary to participate in guided imagery activities.

• Cognitive stimulation is very dependent on sensory information, which

is limited to the latest experiences.

• Children are likely to benefit more from simple distraction offered by

the parent or caregiver because it defers the sensory input of pain

(Pincus & Sheikh, 2009).

The Preoperational Period (2 to 7) • Children demonstrate improved capability of storing and recalling

mental images.

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• The child is not able to manipulate images. For example, the child may

be able to think of and imagine two distinct images as they were from

original sensory input, yet he or she is not able to have the two images

interact amongst each other and/or affect one another.

• Language is still developing at this age, so the use of metaphors and

similes must be used with caution along with easily misinterpreted

medically language.

• Although the imagination is engaged by this stage, children between

the ages of 2 to 5 often require props (e.g. dolls, figurines, costumes)

to interact with their imagination. The use of puppets, picture books,

and dolls may be the best route for pain management and expression.

• From age 5 on, children’s imagination becomes less and less dependent

on physical props as they begin to incorporate mental imagery (Pincus

& Sheikh, 2009).

The Concrete Operations Stage (7 to 12) • The ability to store and recall images continues to develop throughout

this stage while the newfound ability to manipulate images is

introduced.

• Abstract thoughts, as they relate to mental images and beyond, are

still not a particular strength for children in this stage.

• The combined improvement of both language and cognitive faculties

permits children in this stage to examine their emotions, ask

questions, and become more involved in their treatment (Pincus &

Sheikh, 2009).

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The Formal Operations Stage (13 to Adulthood) • This stage introduces the cognitive ability to incorporate and

manipulate abstract thought, thus being able to both attribute an

image to an intangible concept, such as pain, and manipulate it.

• Both healing imagery and imagery relaxation find a home during the

formal operations stage (Pincus & Sheikh, 2009).

Source: http://www.childrenwithexceptionalities.com/section-ii.html

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Developmentally Appropriate Pain Management

Guided Imagery Techniques As previously mentioned, guided imagery is most commonly used to

address pain. The following techniques are different forms of healing

imagery that may be used to help pediatric patients cope with pain. The

different techniques are divided into two sections based on development.

These techniques follow a specific plan or activity for the patient to comply

with. Although it is not an entirely free form of guided imagery, there is

still some freedom and control over one’s pain imagery and sensations.

Pain Management Techniques for the Concrete Operations Stage

Glove Anesthesia

The glove anesthesia technique is used to “numb” one’s pain site. To

begin, the patient is guided to imagine his or her hand becoming numb. The

patient may wish to achieve this sensation by simply imagining it or by

rubbing his or her hands against each other to create a “pins and needles”

like sensation. Once this is achieved the guide will acknowledge how the

patient was able to control the way his or her hands feel. This sense of

control will give the patient the confidence to continue to the next step of

the imagery journey. The patient is then guided to gently rub this numb

hand on their pain site. As the patient does this, the patient is to imagine

the numbness of the hand transferring from the hand to the pain site. The

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patient is now in direct control of his or her pain, free to rub any pain site

with their anesthetic glove (Pincus & Sheikh, 2009).

Displacement Imagery

Displacement imagery is quite simple, but can be effective at helping

children cope with pain. The guide encourages the child to both focus on his

or her pain and try to assemble or localize it into one small area. Once the

child has completed this task, he or she is guided to imagine moving the pain

to another area of the body where it will be more bearable and less painful.

The child should always choose the new pain site. Similar to the glove

anesthesia exercise, displacement imagery puts the child in control of their

pain by gathering it up and moving it to a more suitable spot on the body

(Pincus & Sheikh, 2009).

Dissociation Imagery

Dissociation imagery promotes the dissociation from one’s pain while

still maintaining a level of consciousness about it. This can be achieved in

one of two ways. The first way involves guiding the child to imagine that the

painful body area no longer exists. For example, a child may dissociate from

their left leg pain by engaging in imagery where he or she no longer has a

left leg. The language of the guide must comfort the child in acknowledging

that the leg is only missing for this moment and it is not a scary experience,

but a temporary relief from the pain.

The other way dissociation imagery may be achieved is by removing

one’s consciousness from the body entirely. The child’s mind will separate

from both their body and their pain experience as if their soul is leaving

their body. Again, the guide must use comforting imagery to avoid

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presenting a frightening journey instead of a peaceful respite. Children

should be reminded that this separation is temporary, safe, and comfortable.

Children should be encouraged to explore what it feels like to be free of the

bodily sensations that have brought them so much suffering as of recent

(Pincus & Sheikh, 2009).

Pain Management Techniques for the Formal Operations Stage

Ball of Pain

The “ball of pain” technique guides teens to focus on every ounce of

pain throughout their entire body. Next, they are to imagine all their pain

being rolled together into one ball within in their mind. With the ball of pain

in the mind’s control, the teen is encouraged to manipulate the ball of pain’s

qualities such as its size and its intensity (often represented by a color

chosen by the teen). The conscious manipulation of the pain allows the teen

to control their pain and how large and intense it can be and how small and

weak it can appear. This imagery exercise generally concludes with the ball

of pain moving from the mind to directly above the skin where the teen is to

imagine it floating away from the body and out into the world (Pincus &

Sheikh, 2009).

Emptying the Sandbag

This technique encourages teens to imagine their body as an empty

sandbag. Next, the guide tells them to imagine the bag slowly becoming full

of sand. Once the bag is full, the teen is told to acknowledge an area of pain

and focus on it. Finally, the guide instructs them to imagine cutting an

opening in the bag at the exact area of pain. The teen is to imagine the pain

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dissipating from their body as the sand

leaves the bag. Soon the teen will feel like

a light, empty sack that is free of pain.

The guide will encourage the teen to

relish in this peace as long as they wish.

The “emptying the sandbag” technique is

focused on releasing the pain instead of

attempting to control it (Pincus & Sheikh,

2009).

Spreading the Pain

This technique is an example of an “opening” technique, which is when

the pain is allowed to open up from its bodily constraints and be released

into the world. Teens are guided to acknowledge and focus on a specific pain

site in their body. The teen is then guided to imagine the pain expanding

from its focal point throughout the whole body. The pain dissipates as it

expands throughout the body becoming more and more tolerable. The pain

continues to travel as it moves outside of the body. The teen is to imagine

the pain filling the room, the building, the state, the country, and then the

world until the pain is spread so thin that the body can barely detect any

suffering (Pincus & Sheikh, 2009).

Source: http://swethagolla.blogspot.com/2010_07_01_archive.html

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Complimentary Therapies

Guided imagery sessions are often accompanied by another form of

complimentary therapy, such as deep breathing and progressive muscle

relaxation. Generally, these techniques precede guided imagery as a way to

help the child reach a relaxing state before beginning their session.

Deep Breathing

Deep breathing is a basic exercise that can serve as a precursor to

guided imagery. Deep breathing begins by placing the tongue on the ridge of

the mouth right behind the two front teeth. Next a deep exhale of old air is

followed by a deep inhale. Inhales should always come through the nose

while exhaling should always occur out of the mouth. Each inhale should take

about five seconds and should be held for seven seconds before exhaling

through the nose (Krane & Mitchell, 2005). A total of six deep breaths are

often recommended before beginning guided imagery to help improve the

focus necessary for guided imagery (Krane & Mitchell, 2005; Pincus &

Sheikh, 2009).

An additional way to engage in deep breathing requires the health and

proper functioning of the arms, chest, and shoulders. If the child has any

pain in these areas, please stick to the previous instructions. This form of

deep breathing requires the child to be sitting up right either in a chair or in

his or her bed. It begins by placing the interlaced knuckles under the chin.

The child will then inhale as his or her elbows rise to the ceiling as their

knuckles maintain their position under the chin. Inhaling as deep as he or

she can, the child should feel their spine lengthen. Once the inhale is

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complete, he or she will exhale through the mouth as they bring their elbows

together while their knuckles under their chin guide their head back. They

will then slowly return to a neutral position and repeat the exercise up to six

times. The coordination involved with this movement may make it more

accessible to teenagers.

Progressive Muscle Relaxation

Progressive muscle relaxation involves the tensing and releasing of the

muscles in order to create a full body sensation of relaxation and tension

release. This muscle engagement and release generally moves from the head

to feet or vice versa so the entire body is involved. Any injured muscles

that cause pain or discomfort should be avoided during this exercise.

Progressive muscle relaxation begins with the child lying comfortably on

their back with their hands by their side. The child will take a few deep

breaths before beginning the exercise (Krane & Mitchell, 2005).

Starting at the child’s feet, the child life specialist will instruct the

child to engage the muscles of the feet by curling in the toes for about 10

seconds. Breathing throughout, the child should exhale upon releasing the

tension as the child life specialist suggests imagining the pain and tension

leaving the body with the exhale. The same progression is done for every

other part of the body, including:

• The legs

• The abdomen

• The buttocks

• The hands, often engaged by making a fist

• The arms

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• The shoulders, often engaged by lifting the shoulders towards the

ears

• The facial muscles, often engaged by telling the child to pretend

that they ate a lemon

• The neck, often engaged by rolling it from side to side and bringing

the chin to the chest

• Progressive muscle relaxation often concludes with five deep

breathes through the nose and out the mouth (Krane & Mitchell,

2005).

Source: http://rhythmofthehome.com/archives/spring-2010/childrens-yoga/

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Questionnaire for the Patient and Parent

Guided imagery sessions can only be improved by knowing more about

the patient’s personality, past experiences, pain levels, and preferences.

Even though the guide should try to avoid suggesting imagery, sometimes

specific imagery must be used in pain management exercises such as the

ones in the preceding section (e.g. imagery of a sandbag, a glove, etc.).

Consequently, knowing more about the child will help the child life specialist

utilize an appropriate imagery activity and accurately analyze the session.

Additionally, asking the child such questions may help mentally prepare them

for his or her guided imagery session. Depending on the patient’s age, the

child life specialist may wish to discover the answers to these questions

through assessment by spending time with the child instead of directly

asking the child a sequence of questions.

Included are two separate questionnaires for the parent and the

patient. The patient questionnaire is more substantial than the parent

questionnaire because the parent is only questioned to discover any painful

past experiences the child may not be willing to talk about. It is not

necessary to have the child or parent answer all of these questions or only

these questions. These questionnaires are simply a guide for child life

specialists.

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Patient Questionnaire

Past Guided Imagery Experience

Have you ever participated in guided imagery before? _________________________

If so, did you enjoy it? What did you like about it? ___________________________

What didn’t you like about it? ___________________________________________

Personality Questions

What scares you? ___________________________________________________

What makes you happy? _______________________________________________

What’s your favorite color? ____________________________________________

What’s your least favorite color? ________________________________________

What’s your favorite place? ____________________________________________

What’s your least favorite place? ________________________________________

What’s your favorite activity or game? ____________________________________

What’s your least favorite activity or game? ________________________________

What’s your favorite animal? ___________________________________________

What’s your least favorite animal? _______________________________________

Pain Evaluation

Where do you currently feel pain or discomfort? ____________________________

Using the scale below, what is your current pain level?

Source: http://www.amputee-coalition.org/easyread/fact_sheets/painmgmt-ez.html

What does your pain feel like? __________________________________________

How does your pain make you feel? _______________________________________

Hospitalization

How does being in the hospital make you feel? _______________________________

What do you like the most about the hospital? ______________________________

What do you like the least about the hospital? ______________________________

What do you miss the most about being home? ______________________________

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Parent Questionnaire

The following questionnaire will provide the child life specialist with information to

cater your child’s guided imagery experience to his or her needs. If you have any

questions or concerns, please speak with your child life specialist.

Has the child had any traumatic past experiences, such as a car crash, near drowning,

or a loss in the family? Past medical issues or issues with pain?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Is there any environment the child would not feel safe in? If so, why?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Is there any activity the child would feel uncomfortable participating in? If so, why?

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

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Frequently Asked Questions Below is a list of frequently asked questions about guided imagery. It

may be beneficial to provide this list to a parent or caregiver who has

questions about guided imagery.

Question:

Is guided imagery safe?

Answer:

Guided imagery is a safe activity and an excellent complimentary treatment

to pain medications. The best part about guided imagery is that it is side

effect free.

Question:

How does guided imagery work?

Answer:

Guided imagery is conducted one on one between a guide and the patient.

Sometimes prerecorded guided imagery CDs are used as well. Sessions will

generally take place in the child’s hospital room. The guide will provide

general instructions to help the patient conjure up images that will help the

patient cope with their stressors and emotions, whether it is pain, anxiety,

or sadness. The imagery children activate in their mind can even help

trigger the body’s natural healing mechanisms (Rossman, 2004).

Question:

What are the benefits of guided imagery?

Answer:

Guided imagery can benefit a child in the hospital by reducing pain and

anxiety while increasing overall relaxation. Guided imagery may be used to

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help a child cope with their pain or hospitalization and it may also be used to

reduce anxiety and promote relaxation before a stressful procedure.

Question:

Are there any scientific research studies to back up the benefits of guided

imagery?

Answer:

Yes, there are numerous studies available that demonstrate the

effectiveness of guided imagery at reducing pain and anxiety while

promoting relaxation. For example, one study on young children with post-

operative pain found a decrease in pain levels and an increased sense of

relaxation after a guided imagery session (Huth, Henson, Daraiseh, &

McLeod, 2009). Some studies even show an improvement in symptoms. For

instance, a study found that using guided imagery in children with chronic

migraines helped promote relaxation enough to lower the level of an enzyme

that is released by a mast cell after activation. Activated mast cells are

considered to cause migraines; therefore, a lower level of the enzyme means

fewer migraines. This corresponded to the number of migraines in a month

falling from about 5 to less than one (Olness, Hall, Rozniecki, Schmidt, and

Theoharides, 1999).

Question:

How does guided imagery differ from hypnosis?

Answer:

Guided imagery is quite different from hypnosis because guided imagery is

led by the visualizations and imagination of the child, whereas hypnosis

creates a state of mind that is susceptible to the influence of the

hypnotherapist. Guided imagery allows children and adults to find their own

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sense of healing within themselves by using their visualizations to create a

positive effect on their body and mind. Hypnosis, on the other hand, creates

a mental environment where new thoughts, attitudes, or beliefs are more

easily assimilated and accommodated into the patient’s current mental

framework (Krane & Mitchell, 2005).

Question:

Do only children with specific diagnosis receive guided imagery?

Answer:

No, guided imagery is not limited to any level of pain, diagnosis, or

procedure.

Question:

My son is almost eighteen years old. Is he too old to benefit from guided

imagery?

Answer:

No. Guided imagery can be used on anyone from age 5 on. In fact, a study on

26 adult cancer patients found that 14 patients had greater than a 30%

improvement on their pain score after guided imagery (Kwekkeboom, Hau,

Wanta, & Bumpus, 2008). Even though older teens and adults’ imaginations

are not as active as children’s, they can still benefit from guided imagery

and may be even more able to cognitively engage.

Question:

Will my child have to imagine anything that is too scary or intense?

Answer:

No, the child is free to imagine whatever he or she wishes. The child life

specialist essentially guides the child to create the route and ultimate

destination of each session. There are some specific pain management

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exercises that have a little less creative freedom, but none which present

any frightening images or thoughts. The child is always free to approach all

of the exercises in any way he or she wishes. If you have any concerns over

specific pain management exercises, feel free to ask a child life specialist to

review the exercise with you before the guided imagery session begins.

Question:

Can I be in the room with my child during the guided imagery session?

Answer:

During hospitalization it is important to always provide the child with choices

whenever available. We would like to allow the child to determine if he or

she wishes to have anyone in the room during their guided imagery session.

Question:

Guided imagery seems to work well for my child. Can guided imagery ever be

prescribed in place of pain medications?

Answer:

Sometimes guided imagery can be so effective for children that they no

longer feel the need to take pain medications. Nevertheless, it is always the

doctor’s decision to discontinue a specific medication depending on each

individual case. Please free to address the doctor with this suggestion.

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Sample Guided Imagery Scripts This section contains five guided imagery scripts that may be used as

samples when working to create a specific script. Each script will begin

after any complimentary therapies are used to engage focus and promote

relaxation.

Imagery Relaxation Script

The following script is an example of creating a safe place through

imagery. The sample script presents many questions for the patient to

respond to. For simplicity, the majority of the questions are only asked in

this sample. During a real session it is important to pause so the child can

have an opportunity to respond to all the questions. Many of the questions

are asked to further engage the child’s senses so the experience appears to

be more realistic. In this sample, the child chooses to go to Disneyland and

ride his favorite ride. It is important to note that the child is choosing the

location and what he or she wishes to do in it. The guide simply follows the

patient’s lead, encouraging a more realistic experience throughout by using

descriptive words and questions.

Guide: Close your eyes and continue to breathe in and out of your nose as

you focus on each breath. Focus on the way your chest rises and falls with

each breath. Continue breathing as you become more and more relaxed with

each breath. Try to clear your mind of all your thoughts and worries until

there is nothing but blackness; just pure darkness. Once you have achieved

this total darkness, I want you to tell me where you would like to go. We can

go anywhere your imagination is capable of traveling to. It can be real place,

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a place that only exists in your imagination, or a place in the past that may no

longer exist. There is only one rule: this place must make you feel happy,

safe, and comforted. When you are ready, please tell me what this place is

called or where this place is?

Patient: Disneyland.

Guide: That sounds perfect. Today we will go to Disneyland. You are now

entering the gates at Disneyland. As you enter Disneyland, look around and

see everything there is to see. Notice the people, the rides, the colors, and

all the shapes around you. Next, notice who is with you at Disneyland. It

can be anyone you like. Can you tell me who you are at Disneyland with?

Patient: My mom, my dad, and my sister are there.

Guide: Okay, so you are at Disneyland with your mom, dad, and sister.

Notice what clothes they are wearing. Try to see if there is anything they

are holding in their hands. As you do this, continue to look around

Disneyland as you walk through the park. Is there anyone else that you

recognize in the park? Notice all the sounds of the park. What do you

hear? Next, notice all the smells of the park. What do you smell? How do

these sounds make you feel? What do these smells make you feel or think

of? As we are walking through Disneyland with your family you are thinking

about what you would like to do in the park. What would you like to do at

Disneyland?

Patient: I want to ride Splash Mountain.

Guide: Okay, you and your family are now boarding the ride. Imagine getting

inside of the log; notice the way your feet go on either side of the seat. As

you sit, feel the wetness on the seat from the last ride. Notice who is

sitting in front of you and behind you in the log. Now, slowly run your hands

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along the groves of the log. As you do this, you suddenly realize you are no

longer feeling any pain. You are calm and relaxed. You are at peace.

Suddenly, the log starts moving and you are gently gliding on the water

throughout the mountain. How does the ride make you feel? As you enter

the mountain, tell me what you see? The inside of the mountain can look any

way you like. Notice all the colors of the mountain. What are the smells of

the mountain? Take sometime to travel throughout the ride with your family

in whatever way you choose (pause for a minute or two).

Now, you are approaching the final drop before the ride is over. You

feel the log moving upwards. Feel the wind hit your face as you travel up the

mountain. Feel all your pain and worries wash away down the hill with the

water as you travel upwards. How does the water sound as it runs down the

hill? You now notice you can see the opening in side of the mountain that

your log is traveling towards. What does the sky look like? What new smells

are drifting inside the mountain? As you approach the drop, how do you

feel?

Patient: I feel excited.

Guide: Good. Suddenly, you begin to slide down the mountain. You are not

scared or afraid. Instead, you are safe and at peace. Your body feels

weightless. The log is travelling fast, but it feels as if time is moving slowly.

Take this moment to appreciate the joy and excitement you are feeling for

as long as you like. Take in all the sights, sounds, and smells as you continue

down the mountain. Let me know when your exciting journey down the

mountainside has ended.

Patient: Okay, we are now off of the ride.

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Guide: Okay, it is now time for you to leave Disneyland. As you begin

walking out of the park with your family, you start focusing on your

breathing again. Slowly the image of Disneyland fades away and it is once

again replaced with a calming darkness. As you watch Disneyland slowly fade

away, you remind yourself that you can come back here anytime you like and

go on any ride you like. You remember that feeling of happiness you

experienced when you went down the hill on Splash Mountain. You will try to

carry this feeling with you throughout the day. With each deep breath you

find yourself returning to your bed. When you are ready, open up your eyes

and fully return from your journey.

Ideal Model Imagery

The following sample imagery script concerns a teenage boy who is

recovering from a knee surgery. He injured his knee playing soccer, a sport

that he values greatly. This type of imagery will allow him to imagine

returning to the game he loved at full strength.

Guide: Please close your eyes and begin focusing on your breathing. Focus

on the rising and falling of your chest as the pain and your concerns drift

further and further away with each breath. Together we are going to leave

the present time and travel into the future. How far in the future would you

like to travel?

Patient: I want to travel 3 months into the future because the doctor said

my knee would feel better by then.

Guide: Okay, we will travel three months into the future. How would you

like to travel there? By car? Train?

Patient: Let’s travel by train.

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Guide: Okay, imagine yourself in a train car. How did you get on the train?

Did you use crutches or a wheelchair? Notice the people around you and the

sights outside of your window. What do you see as the time passes by?

Patient: I imagine the dates on the calendar being crossed out one by one.

Guide: Great. Please let me know when three months worth of dates have

been crossed out as you travel in your train car.

Patient: Okay, it’s now February.

Guide: Okay, it’s now February. You are about to leave the train car and

suddenly you realize your knee has fully recovered. There is little to no pain.

You are able to walk without crutches or a wheelchair. Tell me how you feel

about your knee? What does your knee look like? As you are walking off the

train car you realize you can do anything you’d like even if it involves your

knee. What would you like to do?

Patient: I want to play a

game of soccer with my

friends.

Guide: Great! Suddenly,

you are on a soccer field on

a February afternoon. Who

is there with you? Notice

the color of the jerseys and

the temperature of the air. Look around and see the scenery that surrounds

the soccer field. Listen to the sound of the ref blowing his whistle as the

game begins. Tell me how it feels to play. How does it feel to kick the ball?

Notice how your knee moves in a smooth, fluid motion with no resistance or

pain. You are as strong as ever. You are able to run and kick without pain.

Source: http://www.gettyimages.com/detail/photo/teenage-boys-

playing-soccer-in-san-diego-high-res-stock-photography/10116666

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Tell me what’s happening in the game. Stay here in the game for as long as

you wish. Please let me know when the game has ended and you are ready to

board the train again.

Patient: I am ready to board the train and return back to present time.

Guide: Okay you are now on the train returning to present time. As you sit

on the train, take some time to think about the game and how wonderful it

felt to play with no limitations. Resume your deep breathing, in and out of

your nose. As you breath, notice how strong your knee still feels even after

a long game. Relish in this feeling of strength and remind yourself that you

can return to this feeling anytime you wish. Take this feeling of strength

back to the present and hold onto as long as you can. When you are ready,

please open your eyes and return.

Emptying the Sandbag

The following imagery script may be used to address a pain sensation

occurring anywhere in the body. The following script is adapted from a

script by Pincus and Sheikh (2009).

Guide: Imagine your body as a paper bag, light and weightless. The bag is

fully expanded, free of any wrinkles or tears. Notice the color of the bag

and feel its texture. Notice the environment that surrounds the bag. Now,

imagine a consistent stream of sand falling from the sky like rain. As you

look around, you see the sand is falling nowhere else but in your bag. Notice

the color of the sand. What color is it? As you look at the sand, you begin

to realize that this is not any ordinary sand. This is special healing sand.

This brings you comfort to know this as the sand continues to fill your entire

bag. Please let me know when your bag is entirely filled.

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Patient: My bag is now filled.

Guide: Great. Now, acknowledge the weight of the bag. How does it feel?

Take a moment to scan the bag for any areas of pain or discomfort. Tell me

where it hurts, if anywhere.

Patient: I feel a pain in my stomach.

Guide: Okay, you feel a pain in your stomach. Tell me more about this pain.

Is it sharp or dull? Is it constant or does it come and go? What color is

your pain? Does it have a shape? What does your pain look like? Okay, now

that you are more familiar with the pain, you feel it is time to release it.

Would you like to release your pain? Great, let’s release your pain. Imagine

you have in your hand a nice, sharp knife. Acknowledge the knife and the

sharpness of its blade. Notice how it reflects in the light. Take this knife

and softly cut a tear at the site of your pain so the healing sand can wash

away your pain as it drains from the cut. Feel the smooth sand slide through

your pain site, delivering its healing qualities as it leaves. Feel your pain

slowly dissipate. You are about halfway empty now. Continue to feel the

comfort of the sand leaving your body. Listen to the sound it makes as it

leaves. Almost empty now. Listen to the sound of the sand. Listen. And

now you are empty. You are weightless. You are pain free. You are at peace

with your body. You are just an empty bag. Appreciate this feeling as long

as you’d like. There is no rush to return.

Glove Anesthesia

The following imagery script adapted from a script by Pincus and

Sheikh (2009) may also be used to address pain in a pediatric patient.

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Guide: Now that you are relaxed, I want you to imagine finding a very

powerful glove. This glove has the power to numb anything it touches. Tell

me what this glove looks like to you? Would you like to put it on? Great,

please tell me which hand you would like to put the glove on.

Patient: I am going to put it on my right hand.

Guide: Very good. Imagine yourself putting the glove on your right hand.

It fits perfectly as if it was made just for you. After a few seconds of

wearing the glove, you notice your hand starts feeling a little tingly. Focus on

your right hand. How does it feel? Imagine your hand is now completely

numb. You cannot feel any sensations at all in your right hand. The

numbness feels so nice and comforting that you begin to think about how

comforting this feeling would be on other places of your body. Is there

anywhere on your body that you would like to touch?

Patient: My head because I have a bad headache.

Guide: Okay, imagine slowly bringing your right hand to your head. Now,

begin softly rubbing your right hand against the part of your head that

hurts. Imagine the numbness of your hand traveling to your head. Tell me

how your head feels when you rub it with the glove? Keep rubbing your head

until you feel like it is time to stop. Once you have stopped, scan your body

for any other places you would like to rub with the glove. If there is no

where else you’d like to rub, imagine removing the glove from your right hand

and putting it somewhere safe so you can always use it again if you need to.

Feel free to stay in this place for as long as you like before returning to the

present.

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The Candles

The candles exercise is great to use with either children or teens who

are coping with pain or anxiety. The act of extinguishing the flame of a

candle can be a great representation for purging any feelings of pain or

anxiety (Pincus & Sheikh, 2009). The following example is adapted from a

script by Pincus and Sheikh (2009). This sample script applies the candles

exercise to procedural anxiety, which can be quite common for any child or

teen facing a stressful medical procedure.

Guide: Now that you are relaxed, I would like you to imagine a cake sitting

on a table in front of you. Notice the color of the frosting and the shape of

the cake. What type of cake is it? Go ahead and taste the cake. Pinch off a

piece from the side. What color is the cake? How does it taste? Notice

how the frosting has the perfect amount of sweetness. As you enjoy in the

deliciousness of the cake, you notice candles on top of the cake. How many

candles do you see?

Patient: I see three candles.

Guide: Great, there are three candles on the cake. Someone has already lit

them for you. Look deeply into the flames of each and every candle. Notice

the color of the flame. What are the colors? Notice how tall the flame is.

Even though it is not your birthday, you still feel compelled to blow these

three candles out. Before we begin blowing out candles, there is something

you must realize. These are not normal candles. These are special candles.

These candles carry the anxiety or nervousness you feel about having

surgery tomorrow. Yet, if these candles are extinguished, that anxiety will

go up in smoke and drift away. Let’s try blowing one candle out to see how it

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makes you feel. Pick one candle out of the three. Focus on its flame. On

the count of three, I would like you to breathe in deeply through your nose

and exhale through your mouth. Do this with your body. Ready. One, two,

three. Inhale through the nose and exhale through the mouth clearing out

all the air from your lungs. Watch as the flame goes out. Notice the smoke

billowing towards the ceiling as it takes a little of your anxiety and fears

with it. Move onto the next candle. Focus on one specific spot of the flame.

Ready. One, two three. Inhale through the nose and exhale through the

mouth clearing out all the air from your lungs. Again, watch the flame

extinguish as the smoke floats towards the ceiling as it takes even more of

your anxiety and fears with it. Ready for the last candle? One, two, three.

Inhale through the nose and exhale through the mouth clearing out all of the

air from your lungs. Watch as the final flame goes out. The smoke from

this flame is especially dark as it carries the rest of your anxiety and fear

away. As you look at each candle’s black wick, you feel calm and relaxed

knowing you have conquered your fears. All that’s left is the cake. You dip

your finger in the frosting and take one more taste. As you taste the

sweetness, you take one final deep breath. Your body and mind is completely

as peace. Stay here a moment, tasting your cake whenever you like.

Source: http://www.flickr.com/photos/sleepishly/2656467632/

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Post-Guided Imagery Evaluation After conducting a guided imagery session with a pediatric patient, it

is important to conduct a post-guided imagery evaluation. This evaluation is

especially important after the first few sessions because the child life

specialist needs to be aware of what is working and not working so he or she

can improve the guided imagery experience. Once all the issues have been

addressed, evaluations may be kept to a minimum mainly highlighting post-

pain levels.

Source: http://iridescentlearning.org/programs/family-science-2/

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Post-Guided Imagery Evaluation Questions

Where do you currently feel pain or discomfort? ____________________

Using the scale below, what is your current pain level?

Source: http://www.amputee-coalition.org/easyread/fact_sheets/painmgmt-ez.html

What was your favorite part of your guided imagery session?

_________________________________________________________

_________________________________________________________

What was your least favorite part of your guided imagery session?

_________________________________________________________

_________________________________________________________

If you could change anything about your guided imagery session, what would

it be? ____________________________________________________

_________________________________________________________

Was there anything hard or difficult about participating in guided imagery?

_________________________________________________________

_________________________________________________________

Would you like to do guided imagery again at another time?

_________________________________________________________

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http://acadgi.com/whatisguidedimagery/index.html

Huth, M. M., Broome, M. E., & Good, M. (2004). Imagery reduces children’s post-

operative pain. International Association for the Study of Pain, 110, 439-

448. doi: 10.1016/j.pain.2004.04.028

Huth, M. M., Daraiseh, N., Henson, M., & McLeod, S. (2009). Evaluation of the

Magic Island: Relaxation for Kids, compact disc. Pediatric Nursing, 35(5),

290-295. Retrieved from EBSCOhost.

Krane, E. J., & Mitchell, D. (2005). Relieve your child’s chronic pain. New York,

NY: Fireside.

Kwekkeboom, K. L., Hau, H. H., Wanta, B. B., & Bumpus, M. M. (2008). Patients'

perceptions of the effectiveness of guided imagery and progressive

muscle relaxation interventions used for cancer pain. Complementary

Therapies in Clinical Practice, 14(3), 185-194.

doi:10.1016/j.ctcp.2008.04.002

Landier, W., & Tse, A. (2010). Use of complementary and alternative medical

interventions for the management of procedure-related pain, anxiety, and

distress in pediatric oncology: An integrative review. Journal Of Pediatric

Nursing, 25(6), 566-579. doi: 10.1016/j.pedn.2010.01.009

Olness, K., Hall, H., Rozniecki, J. J., Schmidt, W., & Theoharides, T.C. (1999).

Mast cell activation in children before and after training in self-regulation.

Headache, 39, 101-107. doi: 10.1046/j.1526-4610.1999.3902101.x

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Pincus, D., & Sheikh, A. A. (2009). Imagery for pain relief: A scientifically

grounded guidebook for clinicians. New York, NY: Routledge.

Rossman, M. L. (2004). Guided imagery in cancer care. Seminars in Integrative

Medicine, 99-106. doi: 10.1016/j.sigm.2004.09.003