New Zealand or—in the words of the indigenous Maori people—Aotearoa, includes Maori, as well as Pacific, Asian, New Zealand European, and other peoples. Our team set out to develop a computerized therapy to help extend the reach of psychological therapies to teenagers with unmet needs, particu- larly untreated depression and anxiety. We focused on computerized therapies because face-to-face services are limited, sometimes costly, inconvenient, or not preferred by adolescents. Computerized, or online, therapies have been tested and shown to be effective; however, often these have high dropout rates, many are very text heavy, and may not reflect the interests of diverse peoples.
Over several years we worked with young people, therapists, learning tech- nologists, researchers, and game developers to develop and test a computer program called SPARX (smart, positive, active, realistic, x-factor) thoughts.
This was shown to be effective in a large randomized controlled trial and is now freely available in New Zealand, funded through the Ministry of Health (https://
www.fmhs.auckland.ac.nz/assets/fmhs/faculty/ABOUT/ newsandevents/
docs/SPARX%20Fact%20sheet.pdf).
SPARX uses cognitive behavioral therapy techniques, storytelling, and meta- phor- and play-based learning. These strategies were selected based on evidence and on appeal to Maori and other youth. The program has seven levels or modules that young people can do on their own or with support. SPARX uses both explicit instructional learning and play-based, first-person experiential learning. Each level begins with “the guide,” a virtual therapist who welcomes the user, explains what the session is about, and discusses how it relates to real life (instructional learning).
The users then go into a game world, where they complete quests and challenges to “right the balance” and reduce negativity in the game world. In general, this is exploratory, play-based learning in the context of a rich visual environment. There is an overarching narrative. and metaphors are often used. At the end of each level, users come back to the guide, who invites them to reflect and develop strategies to use skills from the game in real life. For example, in the volcano province, users must negotiate with angry fire spirits and lift blocks from volcanic vents to prevent explosions. When they return to the guide, they consider what causes them to explode with anger and how to deal with these challenges in real life. In another example, users release the “Bird of Hope” from a chest where it has been trapped.
(continued)
98 II. MInd–Body–SpIrIt therapIeS
thyroid cancer incidence is also increasing worldwide. In Korea, thyroid cancer is the most common cancer. a group of nurse researchers observed significant stress in patients who were receiving radioactive iodine treatments post-thyroidectomy.
they provided guided-imagery Cds to the intervention group and had them view the Cd daily for 4 weeks. the control group received standard education about radioactive iodine therapy. there were significant decreases in stress and fatigue in the intervention group (Lee, Kim, & yu, 2013).
Cultures are broadly categorized as tending toward either individualism or collectivism. La roche, Batista, and d’angelo (2010) investigated guided-imagery scripts to determine their level of idiocentrism versus allocentrism. Idiocentrism is the tendency to define oneself in isolation from others and would be found in individualistic societies; allocentrism is the tendency to define oneself in relation to others and would be seen in cultures valuing collectivism. the authors reviewed 123 guided-imagery scripts and found that they tended to be more idiocentric.
this may indicate that guided imagery scripts may need to be adapted depending on the user’s cultural ethnicity.
When directing a guided-imagery experience, the practitioner should be aware of individual preferences and use images that are understandable and acceptable to the participant. as a rule, the most powerful and meaningful image is one that the participant creates rather than one that is supplied by the guide. participants are more likely to choose images that are congruent with their cultural, spiritual, and personal beliefs. the guide or therapist is there to help them use those images.
FUTURE RESEARCH
despite documented relationships between the mind and the body, there continues to be a lack of high-quality intervention trials testing the effectiveness of guided imagery and other mind–body interventions. although the body of evidence is
From there, the Bird of Hope follows them and helps them throughout the game;
again, this is explicitly linked to how one develops and maintains hope in real life.
The imagery in SPARX was created with input from youth, as well as cul- tural, learning, and computer game experts. The team included Maori and non- Maori health researchers, clinicians, and youth. The computer game company that developed the software was Maori-led, and cultural experts ensured that the content was appropriate and powerful. Evaluations have shown SPARX to be effective among young people seeking help for depression. There were no differences in its effectiveness between Maori and non-Maori or between males and females. This is exciting because many therapeutic interventions are more appealing to girls and/or majority-culture persons, which may inad- vertently increase disparities. Youth feedback has highlighted that the imagery and narrative helped increase the appeal of SPARX and made it easy to under- stand, remember, and use new skills:
“The Bird of Hope is encouraging, it’s like having someone next to you, by your side, it will be in my memory.”
“I learnt from the game. It was interesting and fun, you do learn from game stuff.”
“It felt personal, you know, like he [the guide] was talking to you, like you got to know him.”
6. IMaGery 99 SIDEBAR 6.3. COMPARISON OF THE USE OF GUIDED IMAGERY VERSUS MINDFUL ATTENTION WITH CHILDREN
IN THAILAND WITH CANCER Kesanee Boonyawatanangkool
In Thailand, as elsewhere, children with a life-threatening illness such as cancer experience multiple types of distress. These can range from disease symptoms, procedures, and treatments to the psychological discomfort of living with a potentially terminal illness. Indeed, there are numerous challenges inherent to the provision of holistic nursing care to these children throughout their illness trajectory. Guided imagery is an independent nursing interven- tion that uses psychoneuroimmunological principles to help manage distress symptoms such as pain, anxiety, and fear by directing attention away from difficult events. Conversely, mindfulness involves devoting attention to one’s experience in an accepting and nonjudgmental way; however, the effect of this instruction on distress symptoms—including pain and other outcomes—is unknown.
The objective we addressed in our clinical work was to examine whether mindful attention could help children focus on pain, anxiety, or fear without increasing their distress symptoms or decreasing their symptom tolerance.
In this clinical evaluation, we compared the effects of mindful attention to a well-established intervention for reduction of difficult symptoms (i.e., guided imagery/self-hypnosis)—an intervention that is designed to take attention away from uncomfortable events.
Anxiety and fear were monitored in children (n = 58) 5 to 18 years of age who were hospitalized and receiving chemotherapy. Each child attended and completed a session of guided imagery. Participants then received either mindful attention or guided-imagery instructions designed to direct attention to focus on or away from their pain, anxiety, and fear, respectively.
Our clinical evaluation revealed that children who received the mindful attention instructions demonstrated more awareness of the physical sensa- tions of pain, anxiety, and fear—including thoughts about those sensations—
without decreasing tolerance levels. Some of them said, “I am now feeling better; can you help me do this again please?” (e.g., a 14-year-old boy with palliation of rhabdomyosarcoma pain). There were no interactions observed between baseline characteristics of the children and the specific intervention used to address their symptoms.
Based on our clinical observations, we concluded that mindful (trance) attention—compared with guided imagery—was successful in helping the chil- dren focus attention on experiences of pain, anxiety, and fear without increased pain intensity or decreased symptom tolerance.
These conclusions were based solely on the clinical experience in my practice setting in Thailand. Factors that we know to be important to the imple- mentation of either intervention with children include the children’s knowledge, their developmental stage, trust and rapport, gender and age, pain and other uncomfortable experiences, coping strategies, disease status, religious and
(continued)
100 II. MInd–Body–SpIrIt therapIeS
growing, with many reports of clinical efficacy, more scientifically rigorous research testing outcomes are needed. For example, richardson et al. (2006) concluded that there is sufficient evidence for the efficacy of hypnosis to manage procedural pain in pediatric oncology but noted a number of methodological limitations. Small sample sizes, lack of standardized control groups, and inadequate reporting of research methods limit the generalizability of the findings of many imagery studies.
Key questions remain to be answered regarding specific physiological responses to imagery, the influence of imagery on clinical outcomes and quality of life, and the effect of individual factors. as a low-cost, noninvasive intervention, imagery has the potential to be effective in reducing symptoms and distress across several conditions. Questions to be pursued include:
●
● What is the role of imagery in maintaining health and wellness? Should imagery be a component of preventive medicine? over time, can imagery reduce stress, improve coping, enhance well-being, create healthier lifestyles, and reduce illness in individuals?
●
● What is the effect of imagery on clinical outcomes relevant to quality-of-life and health/illness states and does it have an impact on cost effectiveness and quality of care?
●
● What is the relationship between imagery and other relaxation strategies? are they more effective when paired or should they be used alone?
●
● does the type of imagery produce different outcomes? What imagery proto- cols or processes are most appropriate in specific conditions (use of recording/
app or session with a practitioner; duration and number of sessions)?
●
● Is it possible to predict the usefulness of an imagery intervention in spe- cific individuals? are there certain characteristics of individuals that deter- mine their ability to respond to imagery and produce desired outcomes?
are there certain individuals or conditions for which imagery should not be recommended?
●
● What are the long-term effects of imagery?
●
● What is the role of practitioner characteristics (type of training, practitioner style, number of different practitioners) in outcomes?
WEBSITES
the following websites contain additional information on guided imagery:
●
● academy for Guided Imagery (2017). Workshops and resources (www.acadgi.com)
●
● american holistic nurses association (2017) (www.ahna.org)
cultural beliefs, and family background. Both interventions appeared to be beneficial in reducing distress in children and included shared strategies such as eye-fixation techniques, deep breaths, and progressive muscle relaxation through guided instruction.
6. IMaGery 101
●
● american Society of Clinical hypnosis (2017). Certification, workshops, and resources (www.asch.net)
●
● association for Music and Imagery (2017). Bonny method of guided imagery and music therapy (www.ami-bonnymethod.org)
●
● Imagery International (2017) (www.imageryinternational.org)
●
● national Center for Complementary and Integrative health practices (2017). relaxation techniques for health (https://nccih.nih.gov/health/stress/
relaxation.htm)
●
● national pediatric hypnosis training Institute (2017). training in pediatric hypnosis (www.nphti.net)
REFERENCES
achtenberg, J. (1985). Imagery in healing: Shamanism and modern medicine. Boston, Ma:
Shambhala.
ader, r., & Cohen, n. (1981). Conditioned immunopharmacologic responses. In r. ader (ed.), Psychoneuroimmunology (pp. 281–319). new york, ny: academic press.
ader, r., Felten, d. L., & Cohen, n. (1991). Psychoneuroimmunology (2nd ed.). San diego, Ca:
academic press.
alam, M., roongpisuthipong, W., Kim, n., Goyal, a., Swary, J. h., Brindise, r.t., … yoo, S.
(2016). Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: a single-blinded ran- domized and controlled trial. Journal of the american academy dermatology, 75, 585–589.
alexander, M. (2012). Managing patient stress in pediatric radiology. Radiologic Technology, 83(6), 549–560.
american academy of pediatrics Section on Integrative Medicine. (2016). Mind-body therapies in children and youth. Pediatrics, 138(3), e20161896. doi:10.1542/peds.2016-1896
american pain Society. (2012). Assessment and management of children with chronic pain: A posi- tion statement from the American Pain Society. retrieved from http://americanpainsociety.org/
uploads/get-involved/pediatric-chronic-pain-statement.pdf
anbar, r. d. (2008). Subconscious guided therapy with hypnosis. American Journal of Clinical Hypnosis, 50(4), 323–334.
andrasik, F., & rime, C. (2007). Can behavioural therapy influence neuromodulation?
Neurological Sciences, 28(Suppl. 2), S124–S129.
armstrong, K., dixon, S., May, S., & patricolo, G. e. (2014). anxiety reduction in patients undergoing cardiac catheterization following massage and guided imagery. Complementary Therapies in Clinical Practice, 20(2014), 334–338.
Baird, C. L., & Sands, L. (2006). effect of guided imagery with relaxation on health-related quality of life in older women with osteoarthritis. Research in Nursing and Health, 29, 442–451.
Bakke, a. C., purtzer, M. Z., & newton, p. (2002). The effect of hypnotic-guided imagery on psychological well-being and immune function in patients with prior breast cancer. Journal of Psychosomatic Research, 53(6), 1131–1137.
Ball, t. M., Shapiro, d. e., Monheim, C. J., & Weydert, J. a. (2003). a pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children. Clinical Pediatrics, 42(6), 527–532.
Beaumont, G., Mercier, C., Michon p. e., Malouin, F., & Jackson, p. L. (2011). decreasing phan- tom limb pain through observation of action and imagery: a case series. Pain Medicine, 12, 289–299.
Beck, B. d., hansen, a. M., & Gold, C. (2015). Coping with work-related stress through guided imagery and music (GIM): randomized controlled trial. Journal of Music Therapy, 52(3), 323–352.
Boehm, L. B. & tse, a. M. (2013). application of guided imagery to facilitate the transition of new graduate registered nurses. Journal of Continuing Education in Nursing, 44(3), 113–119.
102 II. MInd–Body–SpIrIt therapIeS
Boltin, d., Sahar, n., Gil, e., aizic, S., hod, K., Levi-drummer, r., … dickman, r. (2015).
Gut-directed guided affective imagery as an adjunct to dietary modification in irritable bowel syndrome. Journal of Health Psychology, 20(6), 712–720.
Braun, S. M., Beurskens, a. J., Borm, p. J., Schack, t., & Wade, d. t. (2006). The effects of mental practice in stroke rehabilitation: a systematic review. Archives of Physical Medicine and Rehabilitation, 87, 842–852.
Braun, S. M., Wade, d. t., & Beurskens, a. J. (2011). Use of movement imagery in neurorehabil- itation: researching effects of a complex intervention. International Journal of Rehabilitation Research, 34, 203–208.
Brunelli, S., Giovanni, M., Iosa, M., Ciotti, C., de Giorgi, r., Foti, C., … traballesi, M. (2015).
efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized control trial. Archives of Physical Medicine and Rehabilitation, 96, 181–187.
Butler, L. d., Symons, B. K., henderson, S. L., Shortliffe, L. d., & Spiegel, d. (2005). hypnosis reduces distress and duration of an invasive medical procedure for children. Pediatrics, 115(1), e77–e85.
Calipel, S., Lucas-polomeni, M. M., Wodey, e., & ecoffey, C. (2005). premedication in children:
hypnosis versus midazolam. Pediatric Anesthesia, 15, 275–281.
Cardeña, e., Svensson, C., & hejdström, F. (2013). hypnotic tape intervention ameliorates stress:
a randomized control study. International Journal of Clinical and Experimental Hypnosis, 61(2), 125–145.
Carli, G., Cavallaro, F. I., & Santarcangelo, e. L. (2007). hypnotizability and imagery modality preference: do highs and lows live in the same world? Contemporary Hypnosis, 24(2), 64–75.
Carrico, d. J., peters, K. M., & diokno, a. C. (2008). Guided imagery for women with intersti- tial cystitis: results of a prospective, randomized controlled pilot study. Journal of Alternative and Complementary Medicine, 14(1), 53–60.
Casida, J. M., yaremchuk, K. L., Shpakoff, L., Marrocco, a., Babicz, G., & yarandi, h. (2012).
The effects of guided imagery on sleep and inflammatory response in cardiac surgery: a pilot randomized controlled trial. Journal of Cardiovascular Surgery, 53, 1–11.
Charalambous, a., Giannakopoulou, M., Bozas, e., & paikousis, L. (2015). a randomized controlled trial for the effectiveness of progressive muscle relaxation and guided imag- ery as anxiety reducing interventions in breast and prostate cancer patients undergoing chemotherapy. Evidenced-Based Complementary and Alternative Medicine, 2015, 270876.
doi:10.1155/2015/270876
Charalambous, a., Giannakopoulou, M., Bozas, e., Marcou, t., Kitslos, p., & paikousis, L.
(2016). Guided imagery and progressive muscle relaxation as a cluster of symptoms man- agement intervention in patients receiving chemotherapy: a randomized control trial. PLOS ONE, 11(6). doi:10.1371/journal.pone.0156911
Charette, S., Fiola, J. L., Charest, M. C., Villeneuve, e., Théroux, J., Joncas, J., … Le May, S.
(2015). Guided imagery for adolescent post-spinal fusion pain management: a pilot study.
Pain Management Nursing, 16(3), 211–220.
Chen, S., Wang, h., yang, h., & Chung, U. (2015). effect of relaxation and guided imagery on the physical and psychological symptoms of breast cancer patients undergoing chemotherapy.
Iran Red Crescent Medical Journal, 17(11), 1–8.
Chou, M. h., & Lin, M. F. (2006). exploring the listening experiences during guided imagery and music therapy of outpatients with depression. Journal of Nursing Research, 14(2), 93–102.
Chuang, L. L., Liu, S. C., Chen, y. h., & Lin, L. C. (2015). predictors of adherence to relaxation guided imagery during pregnancy in women with preterm labor. Journal of Alternative and Complementary Medicine, 21(9), 563–568.
Collins, M. p., & dunn, L. F. (2005). The effects of meditation and visual imagery on an immune system disorder: dermatomyositis. Journal of Alternative and Complementary Medicine, 11(2), 275–284.
Committee on psychosocial aspects of Children and Family health, task Force on pain in Infants, Children and adolescents. (2001). The assessment and management of acute pain in infants, children and adolescents. Pediatrics, 108(3), 793–797.
Costa-pinto, F., & palermo-neto, J. (2010). neuroimmune interactions in stress.
NeuroImmunoModulation, 17, 196–199.
6. IMaGery 103 Cotton, S., roberts, y. h., tsevat, J., Britto, M., Succop, p., McGrady, M. e., & yi, M. S. (2010).
Mind-body complementary alternative medicine use and quality of life in adolescents with inflammatory bowel disease. Inflammatory Bowel Disease, 16(3), 501–506.
Culbert, t., Friedrichsdorf, S., & Kuttner, L. (2008). Mind-body skills for children in pain. In h. Breivik, W. I. Campbell, & M. K. nicholas (eds.), Clinical pain management: Practice and procedures (2nd ed., pp. 478–495). London, england: hodder arnold.
Cyna, a. M., tomkins, d., Maddock, t., & Barker, d. (2007). Brief hypnosis of severe needle phobia using switch-wire imagery in a 5-year-old. Pediatric Anesthesia, 17, 800–804.
dipietro, J. a., Costigan, K. a., nelson, p., Gurewitsch, e. d., & Laudenslager, M. L. (2008).
Fetal responses to induced maternal relaxation during pregnancy. Biological Psychology, 77, 11–19.
djordjevic, J., Zatorre, r. J., petrides, M., Boyle, J. a., & Jones-Gotaman, M. (2005). Functional neuroimaging of odor imagery. Neuroimage, 24(3), 791–801.
dobson, C. (2015). outcome results of self-efficacy in children with sickle disease pain who were trained to use guided imagery. Applied Nursing Research, 28, 384–390.
dobson, C. e., & Byrne, M. W. (2014). Using guided imagery to manage pain in young children with sickle cell disease. American Journal of Nursing, 114(4), 27–36.
donaldson, V. W. (2000). a clinical study of visualization on depressed white blood cells in med- ical patients. Applied Psychophysiology and Biofeedback, 25(2), 230–235.
draucker, C. B., Jacobson, a. F, Umberger, W. a., Myerscough, r. p., & Sanata, J. d. (2015).
acceptability of a guided imagery intervention for persons undergoing a total knee replace- ment. Orthopedic Nursing, 34(6), 356–364.
driediger, M., hall, C., & Callow, n. (2006). Imagery use by injured athletes: a qualitative analysis. Journal of Sports Sciences, 24(3), 261–271.
dunsky, a., dickstein, r., Marcovitz, e., Levy, S., & deutsch, J. (2008). home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Archives in Physical Medicine and Rehabilitation, 89, 1580–1588.
elkins, G., Johnson, a., Fisher, W., & Sliwinski, J. (2013). a pilot investigation of guided self-hypnosis in the treatment of hot flashes among postmenopausal women. International Journal of Clinical and Experimental Hypnosis, 61(3), 342–350.
epstein, G. n., halper, J. p., Barrett, e. a., Birdsal, C., McGee, M., Baron, K. p., … Lowenstein, S.
(2004). a pilot study of mind–body changes in adults with asthma who practice mental imag- ery. Alternative Therapies, 10(4), 66–71.
Fichtel, a., & Larsson, B. (2004). relaxation treatment administered by school nurses to adoles- cents with recurrent headaches. Headache, 44, 545–554.
Fleshner, M., & Laudenslager, M. L. (2004). psychoneuroimmunology: Then and now. Behavioral and Cognitive Neuroscience Reviews, 3(2), 114–130.
Flory, n., Salazar, G. M. M., & Lang, e. V. (2007). hypnosis for acute distress management during medical procedures. International Journal of Clinical and Experimental Hypnosis, 55(3), 303–317.
Flynn, t. a., Jones, B. a., & ausderau, K. K. (2016). Guided imagery and stress in pregnant adolescents. American Journal of Occupational Therapy, 70(5), 700522002 1–7.
Forsner, M., norström, F., nordyke, K., Ivarsson, a., & Lindh, V. (2014). relaxation and guided imagery used with 12-year-olds during venipuncture in a school-based screening study.
Journal of Child Health Care, 18(3), 241–252.
Freeman, L., White, r., ratcliff, M., Sutton, S., Stewart, M., palmer, J., … Cohen, L. (2015).
a randomized trial comparing live and telemedicine delivery of an imagery-based behav- ioral intervention to breast cancer survivors: reducing symptoms and barriers to care. Psycho- Oncology, 24(8). 1–16.
Galili, o., Shaoul, r., & Mogilner, J. (2009). treatment of chronic recurrent abdominal pain:
Laparoscopy or hypnosis? Journal of Laparoendoscopic and Advanced Surgical Techniques, 19(1), 93–96.
Gerik, S. M. (2005). pain management in children: developmental considerations and mind–
body therapies. Southern Medical Journal, 98(3), 295–301.
Giacobbi, p. r., Stabler, M., Stewart, J., Jaeschke, a., Siebert, J. L., & Kelly, G. a. (2015). Pain Management Nursing, 16(5), 792–803.
Glaser, r., MacCallum, r. C., Laskowski, B. F., Malarkey, W. B., Sheridan, J. F., & Kiecolt- Glaser, J. K. (2001). evidence for a shift in the Th-1 to Th-2 cytokine response associated