Relaxation with guided imagery: a useful technique MARILEE I. DONOVAN, B.S.N., M.N., Ph.D. assTRACT Relaxation techniques have been suggested as an ‘tfective intervention in the control of pain, nausea, and stress. This article describes one technique, relaxation with guided imagery. Preparation of the leamer, assessment prior to learning relaxation, and observations which aid in evaluation are cussed as well as the technique itselt. Introduction Stress is the response of increased activation of the body system which causes increased wear and tear on the human body. This response is a reaction to change, to the unknown, to frustration, or to threat. It is a response to anything that represents the novel and, therefore, calls the body to attention. The stress response begins when a stressor evokes an immediate reaction in an individual by stimulation of the sympathetic nervous system. This acts lke a telephone message. This message is reinforced by the secretion of hormones, primarily the adrenal hormones which act like follow-up memos to confirm the telephone message. The stress response can last for a few seconds, or it can last for days to months until the body exhausts its capacity to sustain a response or definite damage be- comes evident and some treatment intervenes. The difference between harmless life-enhancing stress and harmful stress is most likely related to the chronic nature of the response. If the initiating stimulus, or stressor, is pleasurable or harmless, the response is short-lived and repair of any resulting damage is rapid and Marilee |. Donovan is Coordinator, Graduate Program in Oncology Nuzsing, Rush-Presbyterian-St. Luke's Medical Center, Chicago, nos. ‘complete. However, when stimulus is distressing (frus- trating, threatening, painful, or recurring) one tends to recall and reconsider the situation, trying to attain some mastery. While one is involved in this problem-solving behavior, the feedback from within the body is largely ig- nored. The body becomes accustomed to functioning at this level of activation. When one does begin to relax, the amount of residual tension remains so great that it can take hours to resolve. It is quite likely that sometime during this ‘extended period of resolution of tension other stressors will arise. Eventually, the level of activation becomes so great that relaxation does not even occur when the indi- vidual is asleep.?:'' Repair is never complete and, ac- cording to Selye,"° a stage of physical and psychological exhausti which the diseases of stress occur becomes more likely.” ‘The results of this activation are apparent in almost ‘every organ of the body. Those which are most easily monitored include increased blood sugar, increased temperature, retention of sodium and water, excretion of potassium, urinary products of steroid metabolism, de- creased response to infection, increased blood pressure, increased heart rate, increased respirations, increased cholesterol, decreased gastric motility with increased acidity, and muscle tension.®:"! Because most have not been taught the importance of internal cues, individuals in Western cultures do not perceive or attend to the body's warning signs of stress ‘overload. As the individual engages in the problem-solving activities in response to stressors, he/she fails to notice ‘sensory input calling for “‘stop, too much muscle tension."" In addition, because the cortex is so engrossed in its mental task, it fails to send the appropriate inhibiting im- pulses to the muscles as it would do under circumstances of less intense focusing of attention. The result can be a ‘state of chronic muscle tension which can progress to a Cancer Nursing/February 1900 27MARILEE |. DONOVAN state of incapacitation by pain (as in a tension headache) without the person being aware that any muscles are tense. In the past the stressors of life were concrete and the problem-solving approach often led to appropriate flight or fight. The stressors of modern life are more often complex, interpersonal, with solutions which are elusive ‘and slow to elicit any change. Traditional fight or flight is inappropriate. One is left with taking a vacation, reading ‘a good book, or playing a few sets of tennis. Stress is the response of increased activation of the body system which causes increased wear and tear on the human body. Stressors can be arbitrarily divided into three cate- gories: those related to work tasks, those related to in- terpersonal relations, and those related to the person. Task-related stressors which are of relevance to nursing include rapid technological change, too much work for the time allotted, unrealistic expectations, and constant contact with people who themselves are experiencing major stress.° Stressors related to interpersonal rela- tionships include the lack of a stable and supportive work ‘group, complex system-related conflicts for which the individual is totally unprepared, and lack of trust in one’s supervisors. But ultimately itis the person who exists in these environments, relating to these people, that is the crucial variable. There may be a variety of family, social, ( personal stressors with which the individual copes using behaviors of varying effectiveness.° Studies have demonstrated that the use of a variety of techniques, which can collectively be termed relaxation Practices, produced changes in the body which were ex- actly opposite to those produced in response to stress.”® In Paul's studies, subjects practicing a systematic relax- ation technique in the laboratory showed significant changes in heart rate, respiration, and muscle tension when compared to subjects who were told to just sit and relax. Studies of the effects of transcendental meditation (TM) have repeatedly confirmed a response which is the opposite of the stress response and which can be elicited iques like TM. A recent study by the author suggests that for individuals who have insufficient effective coping skills at their disposal, relaxation with guided im- icantly reduce their response to the stressors inherent in their lives.° Interest in the use of relaxation techniques for pain control, nausea control, reduction of anxiety, as well as stress management is growing. Though specific tech- niques incorporated as part of childbirth education have 2B Cancer Nursing/February 1980 long been used and studied, the exten proaches to other types of pain is in its cs Relaxation techniques have long been employed in certain schools of psychology to alleviate anxiety, to en- hance self-esteem as part of behavior modification pro- ‘grams, or to enhance suggestibility or compliance. Carl and Stephanie Simonton have gained international rec- Cognition for their use of a guided imagery technique to help cancer patients enhance their immune response to their ‘cancers and hopefully contro! their disease. The technique discussed in this article was originally modified by Dr. Lawrence Pacoe, a clinical psychologist, from standard relaxation exercises to meet the needs of chronically il individuals; that is, it requires little physical strength and it provides a great deal of diversion both during muscle relaxation and during the period of guided imagery. The remainder of this article will discuss the prepa- ration for and procedure of this relaxation technique, re- laxation with guided imagery. Benson has stated that all relaxation and altered consciousness techniques have four factors in common: 1) quiet environment free from dis- tractions; 2) a comfortable position; 3) a point of con- centration; and 4) a passive attitude.’ Relaxation with ‘guided imagery meets these criteria. In addition, it is most Clearly a learned behavior—a skill ike walking or driving, AAs such, the learner needs to be prepared to practice and to be patient as the skill develops. Four phases are es- sential to the technique discussed in this article. They are the phases of preparation, assessment, implementation, and evaluation. The Phase of Preparation The goal is a realistic learner. The reason why the individual is interested in learning relaxation with guided imagery (RGI) needs to be explored. Though relaxation has been shown to be effective in controlling hypertension, reducing pain, and in minimizing or eliminating a variety of other symptoms, the benefits generally occur after extensive practice so that it is important to seek realisti interim goals. Some individuals may take four or five practice sessions before they note any effects related to learning RGI; others note changes immediately. This is a time for education regarding RGI. The learner needs to be ‘aware that sensory input changes as the muscles relax and that these sensory changes are the feedback which he/she needs to attend to, feedback that monitors the level of relaxation. This may include but is not limited to increase or decrease in temperature, heaviness, lightness, or mild paresthesias. ‘A common fear is that of loss of control. The sensory changes can feel like loss of control to an unprepared subject. It is helpful to approach the process from a‘rainer-trainee relationship. The trainee is learning a new skill and the trainer is guide and coach. Like learning to float, it is important to “let go" enough for the body to take ‘over: in the case of swimming, so that natural bouyancy will support the swimmer; in the case of relaxation, so that the subtle input from the relaxing muscles is recognized and accepted. In addition to preparation of the learner, this phase requires preparation of the environment. In most situations involving relaxation training, a totally quiet environment is impossible. Every effort, however, needs to be made to minimize distractions and to assure maximum comfort for the learner as suggested in Table |. The Phase of Assessment In practice these first two phases merge into a single pretraining period with assessment preceding the final preparation of the environment. For clarity, however, itis ‘easier to continue to discuss them as if they were distinct phases. Assessment of four areas of data is essential: reason for learning RGl, areas of tension, relaxing images, and medical or psychiatric contraindications. Table Il suggests a brief assessment which addresses these key points. Ian individual has previous successful experience with some other technique, it is important to determine TABLE | Phase of Teaching RG! Methods of Attainment | Realistic Discuss goals; set interim goals expectations Stress skill development Identify sensory cues Instruct significant others as well IL Enhancing environment A. Minimum Reduce glaring light distractions close curtains, position leaner so he/she Js not facing light, use low wattage light, Closing eyes may help. Decrease interruptions place sign on door, let everyone know, choose place wisely, use background ‘sound such as radio or tape to mask Intermittent noise, sit close enough to be hheard but not so close that intrusive. B. Comfort Recliner chair, bed or couch is best Be sure all body parts will be well supported a they relax (check head, arms, back, legs) A light blanket may be needed by those who feel cooler as they relax. Relaxation: a useful technique TABLE Il Pretraining Assessment 1, Reason for Why are you interested in learning a learning RG! systematic relaxation technique? What do you expect to gain from learning RGI? Have you ever used a similar technique (yoga, TM, prepared childbirth)? What is. the effect of that technique? When you are tense, worried, or upset, where do you feel it?” What areas of your body tell you that you are tense? What does it fee! like? If 0 represented ‘complete relaxation and 10 as tense as you could be, how tense are you right ‘Areas of tension now? 3. Medical/- ‘Are you currently taking any prescription psychiatric medications? What? Have you any history contra of heart irregularities, respiratory indications, problems, depression, psychosis? Do you have any joint or back problems? Do you wear contact lenses? 4, Relaxing image Describe for me a place you would really like to be that is extremely relaxing and refreshing. What would you see? Hear? Taste? Smell? Are you alone? Who else is. there? What are they doing? How do you fool? some details regarding that technique and why, if it was successful, the individual is learning a new technique. It is usually easier and less distressing for the learner if as- pects of their previous technique are incorporated in the teaching of RGI. For example, if the individual has used Lamaze childbirth techniques, concentration on breathing can be helpful; or if the individual practiced TM, a mo- rnotonous image like seeing the tension flow out of the body with each respiration may be superior to the usual de- soriptive scenes. ‘Approximately one-fourth of the individuals taught RGI by the author could not identify what tension felt like or what muscles became tense until after the first or second experience with RGI. Since this occurs, the teacher of RGI must be certain to reassess areas of ten- sion after the RGI experience to gain access to these data for future training sessions. Though the script presented in this article is the basis for all RG training, modifications in terminology and timing are based initially on the data obtained at this time regarding areas of concentrated tension. If an individual's “hands fee! like they are trying to make a fist,” then several fist-release cycles may be ‘employed. If the trainee, however, reports “my stomach gets tied in knots,” then the entire first part of the proce- ‘dure may be more quickly completed with more time spent imagining the knots coming untied. During the process of muscle relaxation, additional alterations in timing are made 29 Cancer Nursing/Pebrnary 1990