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Guided Imagery and Massage
Guided Imagery Finds Its Way Into the Spa

By Karrie Osborn

Originally published in Massage Bodywork magazine, May/June 2008. Copyright 2008. Associated Bodywork and Massage Professionals. All rights reserved.

For massage therapists, there is no mistaking the connection between body and mind. It's evident in each day's work--from the client who has an emotional release in the middle of a session, to the client who recalls vivid memories as you work his scar tissue from an old injury. Massage therapists know well that the mind is a powerful ally in maintaining health and wellness. The mind is so powerful, in fact, that it can produce its own medicine for the body, and, as with meditation, when we allow the mind to become quiet, true healing can take place.

"There's no area of our life that using our mind more effectively won't help," says Martin Rossman, MD, a pioneer in the field of guided imagery. That's especially so with massage and bodywork. Utilizing the body-mind connection during massage specifically through the use of guided imagery, can make the hands-on work that much more profound and healing for clients, he says.


From Ancient Roots To Today's Spas
Simply defined, guided imagery, or visualization, is a process incorporating verbal cues that teaches how to use your imagination to activate healing responses in your body.1 (For a quick demonstration of the physiological response guided imagery can create, close your eyes and imagine taking a bite out of a big, juicy lemon. See it, smell it, and taste its sourness. Do you feel your mouth watering in response to the thought?)

Massage practitioners and energy workers have incorporated guided imagery into their work for years, while psychotherapists have used the technique for more than a century. In fact, guided imagery has ancient roots. From Aristotle and Hippocrates to Freud, guided imagery has filled several roles in its long and varied history. It's well established in Native American and other indigenous traditions, as well as having roots in Hinduism and Judeo-Christian religions and traditional Chinese medicine.2

Guided imagery has been shown to produce a variety of health benefits, including fewer side effects from cancer treatments, better stress management, reduced frequency of headaches, as well as diminished levels of anxiety and fear before and after surgical procedures, a reduced need for pain medications, and faster recovery rates.3

It's because of those benefits that guided imagery is increasingly showing up in hospitals and clinics. For example, the Cleveland Clinic Heart Center offers a healing program to patients and families that focuses on positive emotions and expectations. Patients are encouraged to manage their pain through guided imagery, massage, and breathing exercises. Part of the center's protocol for surgical patients is to have them listen to a guided imagery CD twice a day, both before and after surgery. The North Mississippi Medical Center's Cancer Center began offering free guided imagery and massage to its cancer patients in 2004. And nurses from the Albert Einstein Medical Center in Philadelphia say that using guided imagery and massage therapy on their patients has been demonstrated to lower blood pressure, breathing rates, and heart rates.4

Known largely for its relaxation effects, guided imagery is now finding its way into the spa, as these facilities search for more treatment options that will marry well with their renewed focus on client wellness.


Guided Imagery's Role In Relaxation
So why does guided imagery lend itself so well to partnering with massage? Rossman, who partnered with Andrew Weil, MD, on the CD Self-Healing with Guided Imagery (Sounds True, 2004), explains that imagery is the natural way that we think and the way we put our world together on the inside. "The most common form of imagery is worry," he says. "But there's a function to worry. You can examine a problem from many different angles, like turning a ball of twine over and over. It's the same when we worry; we turn it over and over in our mind. That's the functional aspect of worry."

Function turns to dysfunction when worry turns into a habit. This habitual, worried stress is what Rossman believes is our Number 1 health problem, with excessive stress and/or poor coping skills showing up as part of every major or chronic illness. He explains that when this type of mental habit is formed, we are no longer conscious or aware of what we're holding onto in our mind. The body reacts with alarm all the time, similar to when it's under an actual threat, instead of gearing down into a reparative state. "When the mind is full of worries--whether about the economy, global warming, aging, health, war--and when you go over them day and night, your brain is constantly sending messages down through the autonomic nervous system to keep the body in an alarm state," Rossman says. "But you can use the same mind-body connections--the wiring--to send out all-clear images."

For those who become enmeshed in worry and a habitual stress state, guided imagery and other relaxation techniques can improve responses. "After 40 years of medical practice, I find guided imagery the easiest way for people to relax," Rossman says. "The simplest thing is to daydream yourself to a safe place of stresslessness.

"Imagery is a coding language of the brain. You have images about who you are, what the world is like, what your roles are, the people in your life. Most of the time you're not conscious of those images. For example, there are so many people who love massage and a large group of people who have a very distorted image of massage. They have a range of images--from 'it's holy' to 'it's prostitution.' That's true for a huge number of images in our life.

"What excites me so much about imagery is that it's a natural function--a birthright--but something that most of us have never really been educated in. Most of us have never been taught to use our imagination for healing. It's something we instinctively use for solving problems, for creating new approaches to old dilemmas, but there are specific ways to use the imagination that [have] real physiological and medical effects.

"Imagery is a powerful form of mental suggestion, because it relies on our senses," Rossman says. It can distract us from worry and allow us to slow down. It's not only understood in the medical world, but also in the world of advertising. Prescription drug commercials provide some of the best, albeit skewed, use of guided imagery, he says. Serene, beautiful visuals underscored with calming music can distract us from the underlying message, so when the laundry list of possible side effects for the drug is read aloud, Rossman says, we are less likely to notice that our leg might fall off as a result of taking it.

In trying to explain the power of guided imagery, Rossman says he asks people to recall the best experiences of their life. "They can do that in a fraction of a second. They can see what the day was like, what was said, the experience. It's multisensory. Imagery allows you to get that whole experience. It tells me it's a more efficient way of storing that info. It's much easier than trying to explain it in words."


A Trend Is Born
When Nob Hill spa director Jenean LaRoche first conceived bringing guided imagery to her San Francisco spa, Rossman was the expert she sought out. A fan of guided imagery since using it to work through her own back injury years before, LaRoche wanted to incorporate the technique into her spa's massage services. She knew it would complement Nob Hill's new focus on wellness and be a valuable offering for clients. "The spa world seems like the grassroots way to reach the people who are stressed out and could benefit from the guided imagery work," LaRoche explained to Rossman. She thought creating a guided imagery tool--a CD that incorporated music and guided imagery phrasing for massage therapists to use during their client sessions--would be the most efficient way to do that. Rossman agreed to sign on to the project, as did seven-time Emmy winning composer Gary Malkin. Nob Hill head therapist Julie Niegsch, along with other senior therapists from the spa, tested the Inner Spa CD throughout its creation, evaluating the pacing, words, music, and volume in a real-world massage session. "It was a real collaboration between doctor, composer, and our staff," LaRoche says.

With testing complete, Nob Hill began incorporating the guided imagery massage work in spring 2007. "It's included in all our types of massage, not just Swedish," LaRoche says. And it's not intrusive on the massage session. In fact, quite the contrary. "Massage therapists found the flow is really good; it's just a natural fit." Because it was created with Rossman's expertise, massage therapists need do nothing but listen for the various cues themselves. "It's not open for individual interpretation, yet it's not imposing on the treatment," LaRoche says. "Therapists can still be creative and find their own flow."

In this alliance between massage and guided imagery, LaRoche says, things get slowed way down to accommodate the process and to leave space for the massage work. For the first three and a half minutes of the Nob Hill guided imagery session, only piano music is played, allowing time for the therapist to get started with the client. Then, the first thing Rossman says on the CD is "breathe." LaRoche says the message does not need to be in the foreground. "It can be something that just goes to the back of the consciousness. The body picks that up. Even if you're not conscious of what he's saying, your subconscious is working all the time." LaRoche says it's not an accident that the messages in the CD are subtle. "We really did want it to be more in the background. We didn't want the mind to have to be very active in the process. We found the body didn't want that. So we tried to stay away from too many images."

Nob Hill clients are asked if they would like to add guided imagery to their massage session for a nominal additional fee. They can preview the CD in the spa waiting area before making a decision. LaRoche says it's still a fairly small percentage of clients utilizing the service, or buying the CD for a home guided imagery lesson, but the response is growing. Even though the spa is located in the upscale Huntington Hotel, approximately 85 percent of its clients are local, LaRoche explains. She thinks it might be these repeat clients--those ready and eager for the next step in their quest for health--who are asking for the guided imagery service.

As with most spas, LaRoche says Nob Hill has clients who come in for a variety of reasons. Many schedule appointments because they want their backs or necks to feel better. "They don't realize that the stress they're carrying is affecting their whole body," she says. "The majority of those going to spas are probably not at a place where they understand the effect this has on total well-being. It's the same as people who don't understand you are what you eat. As massage therapists, we need to do our best to educate our clients and give them [relaxation] tools they can use within their lifestyle."

The CD Nob Hill created for its clients is meant to be just that. "It gives them another tool to help them with their wellness," LaRoche says. Rossman says it's another way of bringing educational resources to both the spa and the therapist. "It extends the benefit of the massage and allows the therapist to be more of a wellness resource," he says.


Does It Work?
For Nob Hill client Pamela Westfall Bochte, combining guided imagery and massage has proven extremely beneficial. She's hooked. What she likes best is the fact that it's opened up a whole new level of healing for her. She explains it this way: "I think women are connectivity-oriented. When I go in for my massage, I feel like I need some connection with the therapist. The guided imagery massage takes that stress away, because the client and the therapist are both in the guided imagery experience. No one has to carry that burden. You immediately enter the same sort of space together without having to worry about how to get there."

Instead of feeling like she needs to be responsible for the massage experience, and a certain way to get what she needs from the massage (like being present or focused), Bochte says she is able to let go and "relax about relaxing." As a veteran consumer of both massage and guided imagery, Bochte says she would never have thought of blending them. "This is amazing. The guided imagery releases you into a space where the massage, breathing, and relaxation are deepened. It takes you to this blissful, deep experience." In the end, she says it's important to take time after a guided imagery massage to pull yourself together, "to come back."

Rossman says he's hoping for a new level of healing in the partnering of massage and guided imagery. "Part of the burden on the healthcare system and why we have such a crisis is that there's both a tendency and an encouragement, implicitly, for people to be passive recipients of care." He says one of the real pleasures of going to a spa for bodywork is you don't have to do anything but get yourself there on time. "You don't have to make decisions; you can just let go. That's a very valuable thing." It's in that state that the body is more readily able to receive significant healing opportunities. Rossman says massage consumers could benefit significantly if, in addition to incorporating massage as a regular part of their lifestyles, they would at some point also understand that the deep relaxation they experience can be explored from the inside out. By weaving together massage and guided imagery, Rossman says you can notice the relaxation response "not only in your body, but also in your mind."


Tangible Effects
For something somewhat ethereal (like using your mind and brain for healing), Rossman says guided imagery has very tangible effects, with a significant amount of research standing behind it. From insomnia to pain relief, Rossman says guided imagery is making a name for itself in the medical world. One of the most concrete areas of research is with pre- and post-surgery patients, where reduced complications and fewer adverse surgical effects have been proven outcomes of utilizing guided imagery. By reducing anxiety before and after surgery, Rossman says patients get out of the hospital faster, surgical procedures go quicker, and less medication is needed. Blue Shield of California is convinced by the results, he says, and is sending out guided imagery tapes/CDs to all its members scheduled for elective surgery.

Breast cancer patients are another population that have benefited from guided imagery. According to BreastCancer.org, the technique has been shown in several studies to relieve anxiety and depression, as well as boost the immune system for breast cancer patients.5 In a 2005 Korean study, breast cancer patients used guided imagery in combination with progressive muscle relaxation training during their chemotherapy regimens and were found to have less nausea and vomiting than the group receiving chemotherapy alone.6 Other outcomes have shown better quality of life for these patients and increased natural killer cells. And according to the Moores Cancer Center at the University of California Medical Center in San Diego, a review of nearly 50 studies conducted between 1966-1998 found that "guided imagery was successful in managing stress, anxiety, depression, pain, and the side effects of chemotherapy."7


Greatest Self-Care Tool
Our brain is potentially the greatest self-care tool there is, Rossman says, if you learn how to use it. "Through imagery, you can stimulate changes in your body which are usually considered inaccessible to conscious influence. I've spent my career learning about the mind-body connection. These things are inexpensive, they're quite safe, and they're complementary to every other form of healthcare. If guided imagery were in a pill, it would be prescribed."

Karrie Osborn is the contributing editor for Massage Bodywork magazine.

NOTES
1 Joe Utay and Megan Miller, "Guided Imagery as an Effective Therapeutic Technique: A Brief Review of its History and Efficacy Research," Journal of Instructional Psychology 33, no. 1 (2006).
2 "Guided Imagery for Renewal of Mind, Body and Spirit." Nob Hill Spa. www.huntingtonhotel.com/pdf/Guided_Imagery_Infocard_FINAL_3.30.07.pdf. (Accessed January 2008).
3 Mayo Clinic. "Enhance Healing Through Guided Imagery," ScienceDaily January 7, 2008. www.sciencedaily.com/releases/2008/01/080104123246.htm. (Accessed January 2008).
4 Mary Shaw Miller, "Complementary Care is Coming on Strong," Nursing Spectrum March 2002. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=6148 (Accessed January 2008).
5 "What is Guided Imagery?" BreastCancer.org, www.breastcancer.org/treatment/comp_med/types/imagery.jsp. (Accessed January 2008).
6 Hee J. Yoo, et al., "Efficacy of Progressive Muscle Relaxation Training and Guided Imagery in Reducing Chemotherapy Side Effects in Patients with Breast Cancer and in Improving their Quality of Life," Supportive Care in Cancer 13, no. 10 (2005).
7 "Complementary and Alternative Therapies for Cancer Patients," Moores Cancer Center, University of California. http://cancer.ucsd.edu/outreach/PublicEducation/CAMs/guidedimagery.asp. (Accessed January 2008).




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