Changes in the Meaning of Pain with the Use of Guided Imagery
Changes in the Meaning of Pain with the Use of Guided Imagery
Wendy Lewandowski, RN, PhD, CS; Marion Good, RN, PhD, FAAN; Claire Burke Draucker, RN, PhD, CS
Pain Manag Nurs. 2005;6(2):58-67. ©2005 W.B. Saunders
Posted 07/14/2005
Abstract and Introduction
Abstract
The purpose of this study is to determine how verbal descriptions of pain change with the use of a guided imagery technique. A mixed method, concurrent nested design was used. Participants in the treatment group used the guided imagery technique over a consecutive 4-day period, and those in the control group were monitored. Verbal descriptions of pain were obtained before randomization and at four daily intervals. A total of 210 pain descriptions were obtained across the five time points. Data were analyzed using content analysis. Six categories emerged from the data: pain is never-ending, pain is relative, pain is explainable, pain is torment, pain is restrictive, and pain is changeable. For participants in the treatment group, pain became changeable. The meaning of pain as never-ending was a prominent theme for participants before randomization to treatment and control groups. It remained a strong theme for participants in the control group throughout the 4-day study period; however, pain as never-ending did not resurface for participants in the treatment group.
Introduction
Imagery has been used in the healing arts since treatments for disease have been recorded, and it continues to be used for many purposes in health care today. Interest in the use of guided imagery for chronic pain has increased over the past two decades as the limits of traditional medicine have been recognized. Because pharmacologic and invasive procedures do not alleviate all pain, the efficacy of guided imagery with persons experiencing chronic pain is worthy of scientific inquiry. Although research findings indicate that guided imagery is effective in reducing the intensity pain, there has been no attempt to systematically describe how the overall experience, especially the meaning it holds for the person, changes with its use. An appreciation of how pain language changes with the use of guided imagery can help nurses understand how the meaning of pain is altered by the treatment. This understanding could provide a foundation for refining guided imagery techniques for this population so they can be implemented more effectively in a holistic approach to pain management.
Pain Language
More than 30 thirty years ago, a visionary nurse defined pain in a way that highlights its private, subjective nature: "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (McCaffery, 1968, p. 95). Pain is always subjective and can only be viewed in terms of the person's experience. Because pain is a private, internal event that cannot be directly observed, assessment of the pain experience is often built on a person's self-report. Pain expression is, therefore, inextricably linked to language, and the meaning of the language used is crucial to understand a person's pain experience. Using language to express pain not only states its existence and describes its nature but most often also becomes a part of the pain experience itself (Waddie, 1996).
In their seminal work, Melzack & Torgerson (1971) recognized that a focus on a single dimension to assess and understand a person's pain experience (e.g., a pain intensity score) failed to capture the complexity of pain, and suggested that the language of pain could provide a more meaningful way to assess the multidimensional nature of the pain experience. Starting with a list of words describing pain developed by Dallenbach (1939), Melzack and Torgerson obtained additional word descriptors from clinical literature and practice. A total of 102 words comprised the final list, and each word was placed into a category describing one of multiple aspects of pain. The McGill Pain Questionnaire (Melzack, 1975) was the direct result of this study, and today, it is the most frequently used instrument to measure pain in persons experiencing chronic pain. The McGill Pain Questionnaire includes 20 descriptor word groups measuring four dimensions of pain (sensory, affective, evaluative, and miscellaneous), along with a rating scale of present pain intensity.
Building on the work of Melzack and Torgerson (1971), Copp (1985) developed a pain coping model and typology linking pain language, self-image, and coping style. Rather than focusing on the pain stimulus itself, Copp indicated the importance of the subjective pain response. Consistent with the assumption that a person's self-image and coping style dictated his or her choice of pain language, Copp (1985) found that words used to describe pain could be categorized by the meaning that pain held for the person and the coping style that he or she brought to it. For instance, if the person experiencing pain had a self-image of being a passive victim, he or she will choose words that convey the pain as all powerful, such as killing, merciless, unrelenting, or crazy. The Copp typology consisted of five categories: the victim, the combatant, the responder, the reactor, and the interactor. Each category contained pain language commonly used and the coping style associated with pain descriptions.
Several researchers (Bowman, 1991; Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000) used qualitative methods to study and understand the experience of chronic, nonmalignant pain. Global themes from patients' descriptions were identified and clustered, producing a thematic structure of this phenomenon. Themes related to loss of the physical and psychological self were evident in all studies. Persons with chronic pain revealed that they experienced a continuous awareness of their bodies, in contrast with the relative lack of consciousness of the physical self that is found in healthy individuals. Their bodies became the primary focus of their existence (Thomas, 2000). Pain often overtook the mind, blocking all other sensation or thought, and patients believed that their personalities were greatly influenced by the pain. Patients experiencing pain described their pain as tiring, relentless, depressing, restrictive, and coloring most of their existence. Some participants expressed losing sight of what it was like to feel healthy. Persons with chronic pain viewed the body as an obstacle rather than an enabler to action, and they expressed sadness about the loss of physical abilities and power (Bowman, 1991; Seers & Friedli, 1996).
The experience of chronic pain was also associated with patterns of disengagement and isolation (Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000). Participants in these studies viewed pain as a physical problem that was invisible to people around them and believed it isolated them both physically and emotionally. They often hid their condition to avoid adverse reactions from other people. Many perceived others to hold disapproving views of the pain and expected skepticism and disinterest rather than support. Few participants mentioned a support person with whom they could freely talk about their pain. Pain closed up communication with family members, and patients experiencing pain were often very concerned over the effects it had on the family system. When efforts were made to engage others, this occurred most often in the context of appointments with physicians, whom they approached with both hope and mistrust. Overall, there was disparity between the expectations and perspectives of study participants and those of health professionals. It was common for participants to perceive that their pain was not believed. Being believed and having pain acknowledged as real, especially by the physician, was very important to participants.
Chronic pain imposed diverse restrictions on daily living and role performance (Bowman, 1991; Brown & Williams, 1995). It affected sleep, mobility, work, finances, travel, recreation, and simple activities such as cooking and cleaning. Participants searched for the cause and meaning of their pain. Not knowing the cause of their pain left them feeling helpless; many described how the pain controlled their lives. They indicated they were prepared to try anything that might help with pain relief. In this respect, participants spent a lot of time and money on alternative treatments. Most, however, did not give up hope for comfort and relief of their pain (Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996).
Guided Imagery
The effectiveness of imagery in reducing pain has been studied widely; however, most of the research was derived from pain induced in laboratory situations. A meta analysis of these studies showed that imagery was effective in decreasing pain (Fernandez & Turk, 1989). The comparatively smaller number of studies using chronic, clinical pain revealed mixed findings (Arathuzik, 1994; Ilacqua, 1994; Moran, 1989; Raft, Smith, & Warren, 1986; Sloman, 1995; Syrjala, Donaldson, Davis, Kippes, & Carr, 1995). The imagery techniques used in the majority of these studies were derived from a cognitive behavioral approach to pain management; they were designed to promote adaptation to pain by altering a person's images, attentional processes, and/or self-statements. Limitations of these studies were small sample size, lack of randomization, non-equality of treatment and control groups, and lack of control for opioid intake and imagery ability.
Martha Rogers' Science of Unitary Human Beings (Rogers, 1970, 1986, 1989, 1990a, 1990b, 1992) provides the framework for this study; it describes humans and their environments in a dynamic interplay in which each is continually affecting and being affected by the other. The usefulness of guided imagery with persons experiencing chronic pain is built on the premise that there is an underlying and enduring process that accounts for how pain is manifested in a person's life. It is proposed that guided imagery helps people experiencing chronic pain gain awareness of this underlying process and explore alternative ways of experiencing pain for greater consistency with well-being.
In Rogers' Science of Unitary Human Beings, the most important conceptual feature for nursing practice is the capacity of a person to participate knowingly in the process of change (Boguslawski, 1990; Cowling, 1990). Continuous change is inevitable. Assisting the person with chronic pain to knowingly participate in change as he or she evolves with the chronic pain experience leads to a greater sense of well-being. Chronic pain is not an isolated event. It is a manifestation of the whole; therefore, getting well entails resolving issues that are present in all aspects of one's life. First is awareness of these issues. Physical awareness (e.g., physical awareness of pain) is only a minute portion of the entirety of human awareness. With expanded awareness, the process of healing in relation to these issues begins. In this study, an innovative imagery modality was designed to enhance the capacity of the person experiencing chronic pain to participate knowingly in change by (1) stimulating increased awareness, (2) provoking creation of possibilities, and (3) encouraging the design of new ways of involving oneself in creating change.
Purpose
This study was part of a larger study that tested the effectiveness of a guided imagery technique to decrease pain in a sample of persons experiencing chronic pain (Lewandowski, 2004). The purpose of this study is to determine how verbal descriptions of pain changed with the use of the guided imagery technique. Research questions are the following:
1. Do persons with chronic pain, who use a guided imagery technique over the course of 4 days, describe their pain differently than persons who do not?
2. How do pain descriptions change over time with the use of a guided imagery technique?
Design
A mixed method (QUAN + qual), concurrent nested design (experimental + descriptive) was used. Participants were randomly assigned to a treatment or control group. Participants in the treatment group learned and used an audiotaped guided imagery technique over a consecutive 4-day period of time, whereas those in the control group received usual treatment and were monitored over the same period of time and taught the guided imagery technique at the end of the study. Qualitative descriptions of pain were obtained before randomization (T1) and at four consecutive daily intervals (T2, T3, T4, and T5).
Sample
Nonprobability, convenience sampling was used to obtain a sample of 44 participants (N = 44). Originally, the sampling frame included patients being treated for chronic pain at a large home health care agency. Because the availability of participants at the home care agency was low after 16 months of data collection (n = 25), the sampling frame was extended to include persons living in eight senior citizen apartment buildings in the same geographic area (n = 19). Of the 44 consenting participants, 2 subsequently withdrew from the study and were not included in data analysis. All participants reported having pain daily for 3 months or longer and indicated pain ratings of 4, 6, 8, or 10 on the Wong-Baker FACES scale (Wong, 1997) at the time of the screening interview. Persons who had evidence of psychosis or cognitive impairment, had pain related to cancer or autoimmune deficiency syndrome, had current involvement in pain-related litigation, or were beginning a new pain treatment were excluded from the study.
Random assignment to the treatment (n = 21) or control (n = 21) group was achieved using a computerized minimization program that controlled for age, antidepressant medication use, antianxiety medication use, long-acting opioid medication use, and length of pain. Because no statistically significant differences related to demographic or clinical variables were found between the two groups, scores were computed for the total sample. Participants' ages ranged from 34 to 90 years with a median age of 61 years. Most of the sample was female (83%), white (86%), married (36%), and disabled/unemployed (43%); all participants had a high school education or higher. Twelve participants (28%) identified using some kind of meditation technique before participation in the study.
Participants were asked to name all diagnoses responsible for their chronic pain ( Table 1 ). The most prevalent pain diagnosis was arthritis (69%). The second most common pain diagnosis was related to a spinal disorder, with 45% of the sample identifying herniated disc, fractured vertebra, scoliosis, sciatica, spinal stenosis, and/or degenerative disc disease as a basis for their chronic pain. Fibromyalgia was the most frequent (17%) single pain diagnosis. Participants experienced chronic pain for an average of 113.8 (SD = 102.5) months, with a median pain duration of 86 months ( Table 1 ). More than half (n = 24, 57%) of the participants in the sample were taking one or more forms of opioid analgesic, one third (n = 16, 38%) used nonsteroidal anti-inflammatory drugs, and one quarter (n = 11, 26%) used a non-opioid, nonsteroidal anti-inflammatory drug analgesic for pain relief.
Intervention
Guided imagery was operationalized as the participant's use of a 7-minute audiotape. In the audiotape, participants were first guided into a state of relaxed focus. Sensory images were then suggested, and personal images related to the participant's pain experience were evoked. Then, participants were guided to create personal change in their experience of pain ( Table 2 ). The guided imagery audiotape was made by the investigators for this study and did not contain music. Participants were asked to use the 7-minute guided imagery technique for a minimum of three times per day, over the 4-day study period.
Procedure
Participants at the home health care agency who met study inclusion and exclusion criteria were identified by their registered nurse case managers at the agency and informed about the study. Participants from the senior citizen apartment buildings responded to flyers describing the study by contacting the investigator and were interviewed by the investigator to determine whether each met criteria for inclusion in the study. Each participant was informed that the study would take place over a consecutive 4-day period of time, and that the investigator would schedule an initial visit and four subsequent visits in his or her home. The investigator requested that each participant choose a consistent time of day for each of the five visits, and that this time be 3 hours or more after his or her usual intake of analgesic medication.
During the initial visit, the purpose of the study and protocol were explained. After informed consent was obtained, each participant was asked, "Describe to me your pain right now," and responses were recorded on a tape recorder. Participants were then randomized to a treatment or control group. Participants in the treatment group were educated about the use of the guided imagery technique. It was practiced in the investigator's presence, and the following performance criteria were rated and recorded on a scale of 0 to 3 for each participant: eyes closed, face relaxed, and slow abdominal breathing. Participants were requested to use the 7-minute guided imagery technique for a minimum of three times per day, over the 4-day study period. Participants in the treatment group kept a 24-hour journal specifying the amount of time spent using the guided imagery intervention and the kind and amount of analgesic medication taken. Participants in the control group were told that the investigator would monitor their pain for 4 days, and at the conclusion of this period, they would learn and practice the guided imagery technique. Control group participants were also given a daily journal to record the kind and amount of analgesic medication used.
The investigator visited participants in both groups daily for the next 4 days (T2, T3, T4, and T5). Participants in the treatment group were assisted to practice the guided imagery technique during each visit in the investigator's presence, and performance criteria were evaluated. Immediately after practicing the technique, each participant was asked, "Describe to me your pain right now," and responses were recorded. Journals were collected daily. Participants in the control group were asked daily to describe their pain. Pain descriptions were recorded, and journals were collected.
At the conclusion of the study, participants in the control group were taught the guided imagery intervention and allowed to practice. Participants in the control group were asked if they used any type of meditation technique during the 4-day study period. Participants in both groups were given a copy of the guided imagery tape and a $25.00 incentive at the end of their participation in the study.
Analysis of Data
Audiotaped data obtained from participants' pain descriptions over the course of the 4-day study period were transcribed verbatim. There were 210 pain descriptions across the five time points. The content analysis procedure described by Lieblich, Tuval-Mashiach, & Zilber (1998) was used to answer the research questions. Analyses were performed on data without knowledge of which pain descriptions were from participants in the treatment group and which were from participants in the control group. It involved four stages.
First, on the basis of the research questions, all relevant sections of the 210 pain descriptions were highlighted and separated; this formed a subtext that was considered the "content universe of the area studied." The second stage involved defining the content categories. Categories emerged from carefully, but openly, reading the subtext. Sorting material was a circular process; it involved careful reading, suggesting categories, sorting subtext into categories, generating ideas of new categories, and refining the categories. Six categories were created and named from the 210 pain descriptions. During the next stage, all sentences in the subtext were assigned to a relevant category. Sentences in each category were labeled according to the time point (T1, T2, T3, T4, and T5) and the group (treatment, control) from which they came. Categories were separated by time point and group ( Table 3 ). Last, the contents of each category were described to give an understanding of the subtext. Category descriptions were compared at each time point for each group and used to answer the research questions.
Findings
Time Point 1
Six categories emerged from participants' pain descriptions for both treatment and control groups: (1) pain is never-ending, (2) pain is relative, (3) pain is explainable, (4) pain is torment, (5) pain is restrictive, and (6) pain is changeable.
Pain is Never-Ending. The theme of pain being never-ending is reflected in the first category, which consists of statements by 11 participants in the treatment group and 10 participants in the control group. Participants used words and phrases like "constant," "all the time," "the same every day," and "twenty-four seven." One participant with multiple pain diagnoses tearfully stated, "As far as describing the pain itself … it's hard to describe because it's been so many years that I've been without pain that it's almost impossible to actually describe. I can't. It's been too long." Presence of pain even during sleep was described by several participants, for example, "When I'm sleeping, I do have pain. I wake up and walk around a little bit."
Pain is Relative. The second category consists of statements by 11 participants in the treatment group and 9 participants in the control group. They described their pain by estimating how much pain they were currently experiencing in relation to no pain or a previous degree of pain experienced. Participants used words or phrases such as "severe," "moderate," "real bad," and "mild" to quantify their pain. Several assigned a numeric value to their pain, for example, "On a scale from 1 to 10, it would be 10."
Pain is Explainable. The third category, consisting of statements by 7 participants in the treatment group and 13 participants in the control group, reflects efforts by participants to specify a cause for their pain. Several participants attributed their pain to specific medical diagnoses, such as carpal tunnel, arthritis, and fibromyalgia. Others specified simple activities of daily living, for example, putting slippers on, washing the dishes, cleaning, working in the yard, as causing flare-ups in their pain. Several participants talked about the effect of the weather on their pain.
Pain is Torment. The fourth category consists of statements made by 7 participants in the treatment group and 6 participants in the control group describing their pain as tormenting. Participants used intense sensory images to describe their pain. Pain was also described as being inflicted on them. The most common image was a burning sensation. For instance, 1 participant who was diagnosed with reflex sympathetic dystrophy described his pain as "… a lot of aching and a lot of burning up in my thigh. It feels like somebody has taken a match and set my leg on fire. That's how bad it burns." Participants also described their pain using sharp sensory images. One participant stated that her pain "radiates out my spine like it is being cut with razors." Sensory images of tightness, for example, "It's like the skin is too tight on my wrist. It feels like the skin needs stretched out or something," and pinching, for example, "The pain in my left arm is just like a pinching pain. My fingers feel like I should pull them back into place," were also specified by several participants.
Pain is Restrictive. The fifth category reflects the theme of pain as restrictive; it is composed of statements by 8 participants in the treatment group and 5 participants in the control group. For most, pain interfered and limited their movement and mobility, for example, "I'm not able to do anything. I can't get out of bed, can't walk or nothing." Pain also restricted their ability to participate in household chores and activities of daily living. One participant stated, "Today, I couldn't do much … let the dishes and cleaning go. When I'm laying down like this, I'm okay, but if I go do anything in the house, it hurts."
Pain is Changeable. Descriptions of pain as changeable are reflected in the sixth category and are composed of statements by 4 participants in the treatment group and 5 participants in the control group. The use of analgesic medication was the primary way participants changed their pain, indicating that the analgesic medication "takes care of" the pain. One participant stated, "Without any medication I couldn't handle it."
Time Point 2
On day 2, participants in both groups continued to describe their pain by quantifying it and comparing it with other tormenting sensory images, for example, "searing," "dull toothache." Specific causes of pain, for example, "handling packages," "moving boxes," and "mopping," were also described by participants in both groups.
Two differences emerged between participants in the treatment group and those in the control group. First, whereas 11 participants in the control group continued to describe their pain as never-ending, for example, "I don't know how to describe it other than it is ever present," only 1 participant in the treatment group described the pain as never-ending, for example, "up all night with it." Another group difference surfaced within the category of pain as changeable. Five participants in the treatment group described using the imagery technique to "ease up the pain" or change their thoughts about pain. One participant stated, "I try to do everything to get away from it … I start out with black … That's the worse color, and then I go to white." Another participant stated, "So as I was listening to that, I was wonderin' … You know … We don't really understand pain … But as I was listening, I learned a few things … Sometimes if I get busy doin' something, you don't think about it as much, and it doesn't bother you. Sometimes things happen to you in life and you have to deal with it." Three participants in the control group described pain as changeable; all of these participants did so in relation to their use of analgesic medication.
Time Point 3
On day 3, only participants in the control group (n = 14) described themes of pain as never-ending, for example, "Another day of another dull ache. That's the only way I can describe it," "The pain just goes on and on." Descriptions of pain as restrictive remained prevalent for participants in the control group (n = 6), but only 1 participant in the treatment group described pain in this way. Participants in both groups gave descriptions of pain as changeable; however, participants in the treatment group described using the guided imagery technique to gain some control over the pain, whereas those in the control group again depicted pain as changeable only through the use of analgesic medication. In one case, a participant in the treatment group stated, "I picked up a white, fluffy cloud, and instead of … and I start with pain being little, and I keep it little, and I don't let it get unmanageable … like before." Another stated, "Now I try to skip the word pain, and I don't let it get any bigger than a pinpoint, a white pinpoint … and I don't let it get any bigger."
Time Point 4
On day 4, participants in both groups continued to describe their pain as relative. Many participants in the treatment group (n = 14) began to make statements such as "It's practically gone," "The pain is a lot better today," "The pain isn't bad … not bad at all," and "It's a little less than yesterday, but it is still hanging in there;" however, several (n = 4) also indicated little change in the intensity of their pain, for example, "Today, very bad … my hip, my arms, every inch of my body." Of the 13 participants in the control group describing pain relatively, 4 indicated an improvement in the intensity of their pain, for example, "Right now it's not too bad," "Mild … a little achin'." Participants in the control group continued to describe pain as never-ending, for example, "Just another day with pain. No change. Nothing ever changes," "Same old thing," "It's the same as it has been. I don't get any relief." Participants in the treatment group continued to describe pain as changeable. Several made statements reflecting a change in the way they thought about their pain, for example, "I think I can live with the pain. The pain is still there, but it is livable." One participant described how her pain changed with the use of the guided imagery technique, "This morning when I did the tape, it was just really relaxing. When I blow the pain out, I crinkle it up, and then I throw it away, and it flows out."
Time Point 5
On the final day of participation, the same trends continued. Both groups described their pain as being relative. Fifteen participants in the control group described their pain as never-ending; however, this theme again did not reoccur for participants in the treatment group. Pain as changeable continued to be a strong theme for participants in the treatment group. Similar to the preceding time points, participants described changing the way they thought about their pain and using the imagery technique to "throw the pain away," or "get it under control." Two participants in the control group described pain as changeable, but did so in relation to their use of pain medication. One participant in the treatment group and 4 participants in the control group described their pain as tormenting.
Discussion
People assign meaning to pain. Underlying pain description is the personal meaning that pain has for the person in his or her life. Pain may evoke feelings of frustration, helplessness, or loss. It can represent an unexplainable mystery or call to mind questions about whether a disease is progressing. Personal meaning of chronic pain may be recognized by the person or concealed from awareness. The meaning that a person attaches to the pain experience, whether it be known or hidden from awareness, influences perception of symptoms, processing of pain-related and other information, and ability to cope (Turk & Okifuji, 2002).
Six themes emerged from participants' descriptions of pain in this study: pain is never-ending, pain is relative, pain is explainable, pain is torment, pain is restrictive, and pain is changeable. Several of these themes support findings from other qualitative studies describing the nature of chronic pain. Descriptions of pain as never-ending have been a common theme (Bowman, 1991; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000). The "moment" has been described as an endless stopping of time, suggesting the possibility of never-ending pain. Another similarity is the tendency for persons, when describing pain, to make attempts to find a cause and/or relate how events in the past might have a bearing on current pain (Brown & Williams, 1995). Comparing pain with other sensory images, for example, pulling, stabbing, burning, shooting, has been commonly cited by persons experiencing chronic pain; in fact, many of the sensory images described by participants in this study are listed on the sensory scale of the McGill Pain Inventory (Melzack, 1975). In Copp's (1985) pain coping typology, persons who viewed themselves as victims also chose words reflecting pain as all-powerful and tormenting in nature. Last, pain has been widely described as restrictive, limiting a person's ability for and freedom of physical movement, participation in meaningful activities, and role performance (Seers & Friedli, 1996).
One major finding of this study is that, for some participants using the guided imagery technique, pain became changeable. This was manifested in several ways. First, participants described the guided imagery technique as relaxing. Relaxation has often been cited as a useful adjunct treatment for chronic pain because of its direct effects on muscle tension and for its ability to increase the person's sense of control and self-efficacy (Turk & Okifuji, 2002). Other participants used the guided imagery technique to transform their pain by mentally modifying the sensory images of pain to less aversive ones. Finally, several participants in the treatment group began to think about their pain in a different way. By thinking differently about pain, it became more tolerable. According to many pain experts (Gamsa, 1994; Turk & Okifuji, 2002), beliefs about pain play a major role in psychological functioning, disability, impairment, and treatment outcome.
Another major finding of this study is that participants using the guided imagery technique stopped describing pain as never-ending. The guided imagery technique may have allowed participants an escape or distraction from their pain. Time is a frequently cited example of a manifestation of field patterning in Rogers' framework (Rogers, 1992). Given Rogers' principles of homeodynamics and the postulated changes in patterning that emerge from the human-environmental energy field process, participants' use of the guided imagery technique to knowingly participate in change may be reflected in subjective changes in their experiences of time. This finding also provides support for anecdotal reports in the literature describing the "disappearance of time and space" during guided imagery (Epstein et al., 1997; Samuels & Samuels, 1990). Last, descriptions of pain as tormenting by participants in the treatment group changed during the 4-day study period. On the last study day, only 1 participant in the treatment group described pain as torment. The guided imagery technique may have allowed participants to experience less pain by replacing tormenting sensory images and/or bolstering feelings of control.
Although there have been randomized controlled clinical trials supporting the use of mental imaging strategies to assist persons with unrelieved pain (Arathuzik, 1994; Ilacqua, 1994; Moran, 1989; Raft, Smith, & Warren, 1986; Sloman, 1995; Syrjala et al., 1995), there are very little data to help guide nurses in selecting the types of suggestions that are most effective during the guided imagery exercise. The findings of this study show that relaxation was an important component of the guided imagery intervention. A state of relaxed focus not only reduces muscle tension and helps a person direct attention away from bodily sensation but also assists the person to form and become absorbed in sensory images. Helping the person go to the pain location, explore it, and then introduce sensory images that transform the pain was also described by participants in this study as effective in changing the pain experience. Guiding the person to move his or her mind out and away from the body, while substituting less punishing images of pain, may mitigate the tormenting nature of pain. Last, using suggestions to alter beliefs about pain, making it less fearful or debilitating and more tolerable, were specified by participants as useful in changing pain and can be easily included in a guided imagery intervention.
Chronic pain is associated with an array of health problems, and nurses care for persons experiencing pain in a variety of clinical settings. Complementary therapies are being used increasingly by persons experiencing chronic pain to help manage pain. The results of this study show that the use of a guided imagery technique over 4 days was effective in changing a person's pain experience. Participants used the guided imagery technique to relax, transform sensory images of pain, and change thinking about pain. The meaning of pain as never-ending and tormenting was also changed with the use of the guided imagery technique. Although the use of guided imagery should not be used in place of analgesic medication, it is useful as an adjunct to more traditional methods of pain treatment and can be offered to those persons who are unable or refuse to take analgesic medication. One goal of nursing is to enhance a person's ongoing, independent pursuit of health and well-being. Continuous change is inevitable as persons live with chronic pain. The use of guided imagery to assist persons experiencing pain as they evolve with the pain experience is an effective evidence-based nursing intervention.
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Table 1. Pain Diagnoses by Group
Diagnoses
Treatment n = 21
Control n = 21
n
%
n
%
Arthritic pain
14
67
15
71
Spinal disorder
12
57
8
38
Fibromyalgia
2
10
5
24
Hand paina
2
10
4
19
Shoulder paina
3
14
2
10
Vascular pain
2
10
1
5
Post-polio syndrome
2
10
0
0
Chronic leg wounds
1
5
0
0
Cluster headaches
0
0
1
5
Crohn's disease
1
5
0
0
Gout
0
0
1
5
Neuropathy
1
5
0
0
Reflex sympathetic dystrophy
1
5
0
0
Temporomandibular disorder
1
5
0
0
Note. Arthritic pain = arthritis, osteoarthritis, rheumatoid arthritis, degenerative arthritis, osteoporosis; pain related to spinal disorder = spinal stenosis, degenerative disc disease, herniated disc, fracture vertebrae, sciatica, scoliosis; shoulder pain = chronic rotator cuff tendonitis, torn rotator cuff, spurs in the shoulder; hand pain = carpal tunnel syndrome, shattered wrist; vascular pain = vascular insufficiency, vascular necrosis of the bone.aPain is not related to arthritis.
Table 2. Excerpts from Guided Imagery Technique
Components of Imagery Technique
Excerpts from Imagery Technique
Guided into a state of relaxed focus
"… Close your eyes. Begin by breathing in fully and deeply through your nose, blowing out fully and deeply through your mouth … Let yourself feel calm and revitalized by each breath … As you watch your breathing, you'll notice that you become calmer and more peaceful … that your inner space expands … and that you become alert but quiet … watchful yet detached …"
Sensory images related to pain are suggested and evoked
"… Begin to describe your pain in silence to yourself … Be present with the pain … Know that the pain may either be physical sensations … or worries and fears … the pain can be anything … whatever comes to your mind … Let your pain take on a shape … become aware of its dimensions … What is the height … the width … the depth … Give it color … a shape … feel the texture … Does it make a sound?"
Sensory images are used to create personal change
"… Now with your eyes still closed … let your hands come together with palms turned upward as if forming a cup … Put your pain object in your hands … How would you change the shape … the size … Now change the color … and its texture … Give it a different sound … decide what you would like to do with the pain … There is no right way to finish the experience … just accept what feels right to you … You can throw the pain away … or place it back where you found it … or move it somewhere else … Let yourself become aware … of how pain can be changed … By focusing with intention, the pain changes"
Table 3. Participants' Pain Descriptions Across Five Time Points
Categories
T1
T2
T3
T4
T5
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Pain is never-ending
11
10
1
11
-
14
1
9
-
15
Pain is relative
11
9
14
14
18
13
18
10
19
14
Pain is explainable
7
13
3
5
3
8
1
3
1
2
Pain is torment
7
6
6
3
2
4
2
5
1
4
Pain is restrictive
8
5
2
5
1
6
2
5
-
1
Pain is changeable
4
5
5
3
8
3
8
-
11
2
Note. T = time point; Tx = treatment group; C = control group.
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Funding Information
Support for this research was provided by American Nurses Foundation grant no. 99-71 (October 1, 1999 to October 1, 2001) and a Kent State University Summer Research Appointment (2003).
Reprint Address
Address correspondence and reprint requests to Wendy Lewandowski, College of Nursing, 113 Henderson Hall, Kent State University, Kent, Ohio 44242. Email address: wlewando@kent.edu
Wendy Lewandowski, RN, PhD, CS,* Marion Good, RN, PhD, FAAN,† Claire Burke Draucker, RN, PhD, CS**College of Nursing, Kent State University, Kent, Ohio and †Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
Wendy Lewandowski, RN, PhD, CS; Marion Good, RN, PhD, FAAN; Claire Burke Draucker, RN, PhD, CS
Pain Manag Nurs. 2005;6(2):58-67. ©2005 W.B. Saunders
Posted 07/14/2005
Abstract and Introduction
Abstract
The purpose of this study is to determine how verbal descriptions of pain change with the use of a guided imagery technique. A mixed method, concurrent nested design was used. Participants in the treatment group used the guided imagery technique over a consecutive 4-day period, and those in the control group were monitored. Verbal descriptions of pain were obtained before randomization and at four daily intervals. A total of 210 pain descriptions were obtained across the five time points. Data were analyzed using content analysis. Six categories emerged from the data: pain is never-ending, pain is relative, pain is explainable, pain is torment, pain is restrictive, and pain is changeable. For participants in the treatment group, pain became changeable. The meaning of pain as never-ending was a prominent theme for participants before randomization to treatment and control groups. It remained a strong theme for participants in the control group throughout the 4-day study period; however, pain as never-ending did not resurface for participants in the treatment group.
Introduction
Imagery has been used in the healing arts since treatments for disease have been recorded, and it continues to be used for many purposes in health care today. Interest in the use of guided imagery for chronic pain has increased over the past two decades as the limits of traditional medicine have been recognized. Because pharmacologic and invasive procedures do not alleviate all pain, the efficacy of guided imagery with persons experiencing chronic pain is worthy of scientific inquiry. Although research findings indicate that guided imagery is effective in reducing the intensity pain, there has been no attempt to systematically describe how the overall experience, especially the meaning it holds for the person, changes with its use. An appreciation of how pain language changes with the use of guided imagery can help nurses understand how the meaning of pain is altered by the treatment. This understanding could provide a foundation for refining guided imagery techniques for this population so they can be implemented more effectively in a holistic approach to pain management.
Pain Language
More than 30 thirty years ago, a visionary nurse defined pain in a way that highlights its private, subjective nature: "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (McCaffery, 1968, p. 95). Pain is always subjective and can only be viewed in terms of the person's experience. Because pain is a private, internal event that cannot be directly observed, assessment of the pain experience is often built on a person's self-report. Pain expression is, therefore, inextricably linked to language, and the meaning of the language used is crucial to understand a person's pain experience. Using language to express pain not only states its existence and describes its nature but most often also becomes a part of the pain experience itself (Waddie, 1996).
In their seminal work, Melzack & Torgerson (1971) recognized that a focus on a single dimension to assess and understand a person's pain experience (e.g., a pain intensity score) failed to capture the complexity of pain, and suggested that the language of pain could provide a more meaningful way to assess the multidimensional nature of the pain experience. Starting with a list of words describing pain developed by Dallenbach (1939), Melzack and Torgerson obtained additional word descriptors from clinical literature and practice. A total of 102 words comprised the final list, and each word was placed into a category describing one of multiple aspects of pain. The McGill Pain Questionnaire (Melzack, 1975) was the direct result of this study, and today, it is the most frequently used instrument to measure pain in persons experiencing chronic pain. The McGill Pain Questionnaire includes 20 descriptor word groups measuring four dimensions of pain (sensory, affective, evaluative, and miscellaneous), along with a rating scale of present pain intensity.
Building on the work of Melzack and Torgerson (1971), Copp (1985) developed a pain coping model and typology linking pain language, self-image, and coping style. Rather than focusing on the pain stimulus itself, Copp indicated the importance of the subjective pain response. Consistent with the assumption that a person's self-image and coping style dictated his or her choice of pain language, Copp (1985) found that words used to describe pain could be categorized by the meaning that pain held for the person and the coping style that he or she brought to it. For instance, if the person experiencing pain had a self-image of being a passive victim, he or she will choose words that convey the pain as all powerful, such as killing, merciless, unrelenting, or crazy. The Copp typology consisted of five categories: the victim, the combatant, the responder, the reactor, and the interactor. Each category contained pain language commonly used and the coping style associated with pain descriptions.
Several researchers (Bowman, 1991; Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000) used qualitative methods to study and understand the experience of chronic, nonmalignant pain. Global themes from patients' descriptions were identified and clustered, producing a thematic structure of this phenomenon. Themes related to loss of the physical and psychological self were evident in all studies. Persons with chronic pain revealed that they experienced a continuous awareness of their bodies, in contrast with the relative lack of consciousness of the physical self that is found in healthy individuals. Their bodies became the primary focus of their existence (Thomas, 2000). Pain often overtook the mind, blocking all other sensation or thought, and patients believed that their personalities were greatly influenced by the pain. Patients experiencing pain described their pain as tiring, relentless, depressing, restrictive, and coloring most of their existence. Some participants expressed losing sight of what it was like to feel healthy. Persons with chronic pain viewed the body as an obstacle rather than an enabler to action, and they expressed sadness about the loss of physical abilities and power (Bowman, 1991; Seers & Friedli, 1996).
The experience of chronic pain was also associated with patterns of disengagement and isolation (Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000). Participants in these studies viewed pain as a physical problem that was invisible to people around them and believed it isolated them both physically and emotionally. They often hid their condition to avoid adverse reactions from other people. Many perceived others to hold disapproving views of the pain and expected skepticism and disinterest rather than support. Few participants mentioned a support person with whom they could freely talk about their pain. Pain closed up communication with family members, and patients experiencing pain were often very concerned over the effects it had on the family system. When efforts were made to engage others, this occurred most often in the context of appointments with physicians, whom they approached with both hope and mistrust. Overall, there was disparity between the expectations and perspectives of study participants and those of health professionals. It was common for participants to perceive that their pain was not believed. Being believed and having pain acknowledged as real, especially by the physician, was very important to participants.
Chronic pain imposed diverse restrictions on daily living and role performance (Bowman, 1991; Brown & Williams, 1995). It affected sleep, mobility, work, finances, travel, recreation, and simple activities such as cooking and cleaning. Participants searched for the cause and meaning of their pain. Not knowing the cause of their pain left them feeling helpless; many described how the pain controlled their lives. They indicated they were prepared to try anything that might help with pain relief. In this respect, participants spent a lot of time and money on alternative treatments. Most, however, did not give up hope for comfort and relief of their pain (Brown & Williams, 1995; Carson & Mitchell, 1998; Seers & Friedli, 1996).
Guided Imagery
The effectiveness of imagery in reducing pain has been studied widely; however, most of the research was derived from pain induced in laboratory situations. A meta analysis of these studies showed that imagery was effective in decreasing pain (Fernandez & Turk, 1989). The comparatively smaller number of studies using chronic, clinical pain revealed mixed findings (Arathuzik, 1994; Ilacqua, 1994; Moran, 1989; Raft, Smith, & Warren, 1986; Sloman, 1995; Syrjala, Donaldson, Davis, Kippes, & Carr, 1995). The imagery techniques used in the majority of these studies were derived from a cognitive behavioral approach to pain management; they were designed to promote adaptation to pain by altering a person's images, attentional processes, and/or self-statements. Limitations of these studies were small sample size, lack of randomization, non-equality of treatment and control groups, and lack of control for opioid intake and imagery ability.
Martha Rogers' Science of Unitary Human Beings (Rogers, 1970, 1986, 1989, 1990a, 1990b, 1992) provides the framework for this study; it describes humans and their environments in a dynamic interplay in which each is continually affecting and being affected by the other. The usefulness of guided imagery with persons experiencing chronic pain is built on the premise that there is an underlying and enduring process that accounts for how pain is manifested in a person's life. It is proposed that guided imagery helps people experiencing chronic pain gain awareness of this underlying process and explore alternative ways of experiencing pain for greater consistency with well-being.
In Rogers' Science of Unitary Human Beings, the most important conceptual feature for nursing practice is the capacity of a person to participate knowingly in the process of change (Boguslawski, 1990; Cowling, 1990). Continuous change is inevitable. Assisting the person with chronic pain to knowingly participate in change as he or she evolves with the chronic pain experience leads to a greater sense of well-being. Chronic pain is not an isolated event. It is a manifestation of the whole; therefore, getting well entails resolving issues that are present in all aspects of one's life. First is awareness of these issues. Physical awareness (e.g., physical awareness of pain) is only a minute portion of the entirety of human awareness. With expanded awareness, the process of healing in relation to these issues begins. In this study, an innovative imagery modality was designed to enhance the capacity of the person experiencing chronic pain to participate knowingly in change by (1) stimulating increased awareness, (2) provoking creation of possibilities, and (3) encouraging the design of new ways of involving oneself in creating change.
Purpose
This study was part of a larger study that tested the effectiveness of a guided imagery technique to decrease pain in a sample of persons experiencing chronic pain (Lewandowski, 2004). The purpose of this study is to determine how verbal descriptions of pain changed with the use of the guided imagery technique. Research questions are the following:
1. Do persons with chronic pain, who use a guided imagery technique over the course of 4 days, describe their pain differently than persons who do not?
2. How do pain descriptions change over time with the use of a guided imagery technique?
Design
A mixed method (QUAN + qual), concurrent nested design (experimental + descriptive) was used. Participants were randomly assigned to a treatment or control group. Participants in the treatment group learned and used an audiotaped guided imagery technique over a consecutive 4-day period of time, whereas those in the control group received usual treatment and were monitored over the same period of time and taught the guided imagery technique at the end of the study. Qualitative descriptions of pain were obtained before randomization (T1) and at four consecutive daily intervals (T2, T3, T4, and T5).
Sample
Nonprobability, convenience sampling was used to obtain a sample of 44 participants (N = 44). Originally, the sampling frame included patients being treated for chronic pain at a large home health care agency. Because the availability of participants at the home care agency was low after 16 months of data collection (n = 25), the sampling frame was extended to include persons living in eight senior citizen apartment buildings in the same geographic area (n = 19). Of the 44 consenting participants, 2 subsequently withdrew from the study and were not included in data analysis. All participants reported having pain daily for 3 months or longer and indicated pain ratings of 4, 6, 8, or 10 on the Wong-Baker FACES scale (Wong, 1997) at the time of the screening interview. Persons who had evidence of psychosis or cognitive impairment, had pain related to cancer or autoimmune deficiency syndrome, had current involvement in pain-related litigation, or were beginning a new pain treatment were excluded from the study.
Random assignment to the treatment (n = 21) or control (n = 21) group was achieved using a computerized minimization program that controlled for age, antidepressant medication use, antianxiety medication use, long-acting opioid medication use, and length of pain. Because no statistically significant differences related to demographic or clinical variables were found between the two groups, scores were computed for the total sample. Participants' ages ranged from 34 to 90 years with a median age of 61 years. Most of the sample was female (83%), white (86%), married (36%), and disabled/unemployed (43%); all participants had a high school education or higher. Twelve participants (28%) identified using some kind of meditation technique before participation in the study.
Participants were asked to name all diagnoses responsible for their chronic pain ( Table 1 ). The most prevalent pain diagnosis was arthritis (69%). The second most common pain diagnosis was related to a spinal disorder, with 45% of the sample identifying herniated disc, fractured vertebra, scoliosis, sciatica, spinal stenosis, and/or degenerative disc disease as a basis for their chronic pain. Fibromyalgia was the most frequent (17%) single pain diagnosis. Participants experienced chronic pain for an average of 113.8 (SD = 102.5) months, with a median pain duration of 86 months ( Table 1 ). More than half (n = 24, 57%) of the participants in the sample were taking one or more forms of opioid analgesic, one third (n = 16, 38%) used nonsteroidal anti-inflammatory drugs, and one quarter (n = 11, 26%) used a non-opioid, nonsteroidal anti-inflammatory drug analgesic for pain relief.
Intervention
Guided imagery was operationalized as the participant's use of a 7-minute audiotape. In the audiotape, participants were first guided into a state of relaxed focus. Sensory images were then suggested, and personal images related to the participant's pain experience were evoked. Then, participants were guided to create personal change in their experience of pain ( Table 2 ). The guided imagery audiotape was made by the investigators for this study and did not contain music. Participants were asked to use the 7-minute guided imagery technique for a minimum of three times per day, over the 4-day study period.
Procedure
Participants at the home health care agency who met study inclusion and exclusion criteria were identified by their registered nurse case managers at the agency and informed about the study. Participants from the senior citizen apartment buildings responded to flyers describing the study by contacting the investigator and were interviewed by the investigator to determine whether each met criteria for inclusion in the study. Each participant was informed that the study would take place over a consecutive 4-day period of time, and that the investigator would schedule an initial visit and four subsequent visits in his or her home. The investigator requested that each participant choose a consistent time of day for each of the five visits, and that this time be 3 hours or more after his or her usual intake of analgesic medication.
During the initial visit, the purpose of the study and protocol were explained. After informed consent was obtained, each participant was asked, "Describe to me your pain right now," and responses were recorded on a tape recorder. Participants were then randomized to a treatment or control group. Participants in the treatment group were educated about the use of the guided imagery technique. It was practiced in the investigator's presence, and the following performance criteria were rated and recorded on a scale of 0 to 3 for each participant: eyes closed, face relaxed, and slow abdominal breathing. Participants were requested to use the 7-minute guided imagery technique for a minimum of three times per day, over the 4-day study period. Participants in the treatment group kept a 24-hour journal specifying the amount of time spent using the guided imagery intervention and the kind and amount of analgesic medication taken. Participants in the control group were told that the investigator would monitor their pain for 4 days, and at the conclusion of this period, they would learn and practice the guided imagery technique. Control group participants were also given a daily journal to record the kind and amount of analgesic medication used.
The investigator visited participants in both groups daily for the next 4 days (T2, T3, T4, and T5). Participants in the treatment group were assisted to practice the guided imagery technique during each visit in the investigator's presence, and performance criteria were evaluated. Immediately after practicing the technique, each participant was asked, "Describe to me your pain right now," and responses were recorded. Journals were collected daily. Participants in the control group were asked daily to describe their pain. Pain descriptions were recorded, and journals were collected.
At the conclusion of the study, participants in the control group were taught the guided imagery intervention and allowed to practice. Participants in the control group were asked if they used any type of meditation technique during the 4-day study period. Participants in both groups were given a copy of the guided imagery tape and a $25.00 incentive at the end of their participation in the study.
Analysis of Data
Audiotaped data obtained from participants' pain descriptions over the course of the 4-day study period were transcribed verbatim. There were 210 pain descriptions across the five time points. The content analysis procedure described by Lieblich, Tuval-Mashiach, & Zilber (1998) was used to answer the research questions. Analyses were performed on data without knowledge of which pain descriptions were from participants in the treatment group and which were from participants in the control group. It involved four stages.
First, on the basis of the research questions, all relevant sections of the 210 pain descriptions were highlighted and separated; this formed a subtext that was considered the "content universe of the area studied." The second stage involved defining the content categories. Categories emerged from carefully, but openly, reading the subtext. Sorting material was a circular process; it involved careful reading, suggesting categories, sorting subtext into categories, generating ideas of new categories, and refining the categories. Six categories were created and named from the 210 pain descriptions. During the next stage, all sentences in the subtext were assigned to a relevant category. Sentences in each category were labeled according to the time point (T1, T2, T3, T4, and T5) and the group (treatment, control) from which they came. Categories were separated by time point and group ( Table 3 ). Last, the contents of each category were described to give an understanding of the subtext. Category descriptions were compared at each time point for each group and used to answer the research questions.
Findings
Time Point 1
Six categories emerged from participants' pain descriptions for both treatment and control groups: (1) pain is never-ending, (2) pain is relative, (3) pain is explainable, (4) pain is torment, (5) pain is restrictive, and (6) pain is changeable.
Pain is Never-Ending. The theme of pain being never-ending is reflected in the first category, which consists of statements by 11 participants in the treatment group and 10 participants in the control group. Participants used words and phrases like "constant," "all the time," "the same every day," and "twenty-four seven." One participant with multiple pain diagnoses tearfully stated, "As far as describing the pain itself … it's hard to describe because it's been so many years that I've been without pain that it's almost impossible to actually describe. I can't. It's been too long." Presence of pain even during sleep was described by several participants, for example, "When I'm sleeping, I do have pain. I wake up and walk around a little bit."
Pain is Relative. The second category consists of statements by 11 participants in the treatment group and 9 participants in the control group. They described their pain by estimating how much pain they were currently experiencing in relation to no pain or a previous degree of pain experienced. Participants used words or phrases such as "severe," "moderate," "real bad," and "mild" to quantify their pain. Several assigned a numeric value to their pain, for example, "On a scale from 1 to 10, it would be 10."
Pain is Explainable. The third category, consisting of statements by 7 participants in the treatment group and 13 participants in the control group, reflects efforts by participants to specify a cause for their pain. Several participants attributed their pain to specific medical diagnoses, such as carpal tunnel, arthritis, and fibromyalgia. Others specified simple activities of daily living, for example, putting slippers on, washing the dishes, cleaning, working in the yard, as causing flare-ups in their pain. Several participants talked about the effect of the weather on their pain.
Pain is Torment. The fourth category consists of statements made by 7 participants in the treatment group and 6 participants in the control group describing their pain as tormenting. Participants used intense sensory images to describe their pain. Pain was also described as being inflicted on them. The most common image was a burning sensation. For instance, 1 participant who was diagnosed with reflex sympathetic dystrophy described his pain as "… a lot of aching and a lot of burning up in my thigh. It feels like somebody has taken a match and set my leg on fire. That's how bad it burns." Participants also described their pain using sharp sensory images. One participant stated that her pain "radiates out my spine like it is being cut with razors." Sensory images of tightness, for example, "It's like the skin is too tight on my wrist. It feels like the skin needs stretched out or something," and pinching, for example, "The pain in my left arm is just like a pinching pain. My fingers feel like I should pull them back into place," were also specified by several participants.
Pain is Restrictive. The fifth category reflects the theme of pain as restrictive; it is composed of statements by 8 participants in the treatment group and 5 participants in the control group. For most, pain interfered and limited their movement and mobility, for example, "I'm not able to do anything. I can't get out of bed, can't walk or nothing." Pain also restricted their ability to participate in household chores and activities of daily living. One participant stated, "Today, I couldn't do much … let the dishes and cleaning go. When I'm laying down like this, I'm okay, but if I go do anything in the house, it hurts."
Pain is Changeable. Descriptions of pain as changeable are reflected in the sixth category and are composed of statements by 4 participants in the treatment group and 5 participants in the control group. The use of analgesic medication was the primary way participants changed their pain, indicating that the analgesic medication "takes care of" the pain. One participant stated, "Without any medication I couldn't handle it."
Time Point 2
On day 2, participants in both groups continued to describe their pain by quantifying it and comparing it with other tormenting sensory images, for example, "searing," "dull toothache." Specific causes of pain, for example, "handling packages," "moving boxes," and "mopping," were also described by participants in both groups.
Two differences emerged between participants in the treatment group and those in the control group. First, whereas 11 participants in the control group continued to describe their pain as never-ending, for example, "I don't know how to describe it other than it is ever present," only 1 participant in the treatment group described the pain as never-ending, for example, "up all night with it." Another group difference surfaced within the category of pain as changeable. Five participants in the treatment group described using the imagery technique to "ease up the pain" or change their thoughts about pain. One participant stated, "I try to do everything to get away from it … I start out with black … That's the worse color, and then I go to white." Another participant stated, "So as I was listening to that, I was wonderin' … You know … We don't really understand pain … But as I was listening, I learned a few things … Sometimes if I get busy doin' something, you don't think about it as much, and it doesn't bother you. Sometimes things happen to you in life and you have to deal with it." Three participants in the control group described pain as changeable; all of these participants did so in relation to their use of analgesic medication.
Time Point 3
On day 3, only participants in the control group (n = 14) described themes of pain as never-ending, for example, "Another day of another dull ache. That's the only way I can describe it," "The pain just goes on and on." Descriptions of pain as restrictive remained prevalent for participants in the control group (n = 6), but only 1 participant in the treatment group described pain in this way. Participants in both groups gave descriptions of pain as changeable; however, participants in the treatment group described using the guided imagery technique to gain some control over the pain, whereas those in the control group again depicted pain as changeable only through the use of analgesic medication. In one case, a participant in the treatment group stated, "I picked up a white, fluffy cloud, and instead of … and I start with pain being little, and I keep it little, and I don't let it get unmanageable … like before." Another stated, "Now I try to skip the word pain, and I don't let it get any bigger than a pinpoint, a white pinpoint … and I don't let it get any bigger."
Time Point 4
On day 4, participants in both groups continued to describe their pain as relative. Many participants in the treatment group (n = 14) began to make statements such as "It's practically gone," "The pain is a lot better today," "The pain isn't bad … not bad at all," and "It's a little less than yesterday, but it is still hanging in there;" however, several (n = 4) also indicated little change in the intensity of their pain, for example, "Today, very bad … my hip, my arms, every inch of my body." Of the 13 participants in the control group describing pain relatively, 4 indicated an improvement in the intensity of their pain, for example, "Right now it's not too bad," "Mild … a little achin'." Participants in the control group continued to describe pain as never-ending, for example, "Just another day with pain. No change. Nothing ever changes," "Same old thing," "It's the same as it has been. I don't get any relief." Participants in the treatment group continued to describe pain as changeable. Several made statements reflecting a change in the way they thought about their pain, for example, "I think I can live with the pain. The pain is still there, but it is livable." One participant described how her pain changed with the use of the guided imagery technique, "This morning when I did the tape, it was just really relaxing. When I blow the pain out, I crinkle it up, and then I throw it away, and it flows out."
Time Point 5
On the final day of participation, the same trends continued. Both groups described their pain as being relative. Fifteen participants in the control group described their pain as never-ending; however, this theme again did not reoccur for participants in the treatment group. Pain as changeable continued to be a strong theme for participants in the treatment group. Similar to the preceding time points, participants described changing the way they thought about their pain and using the imagery technique to "throw the pain away," or "get it under control." Two participants in the control group described pain as changeable, but did so in relation to their use of pain medication. One participant in the treatment group and 4 participants in the control group described their pain as tormenting.
Discussion
People assign meaning to pain. Underlying pain description is the personal meaning that pain has for the person in his or her life. Pain may evoke feelings of frustration, helplessness, or loss. It can represent an unexplainable mystery or call to mind questions about whether a disease is progressing. Personal meaning of chronic pain may be recognized by the person or concealed from awareness. The meaning that a person attaches to the pain experience, whether it be known or hidden from awareness, influences perception of symptoms, processing of pain-related and other information, and ability to cope (Turk & Okifuji, 2002).
Six themes emerged from participants' descriptions of pain in this study: pain is never-ending, pain is relative, pain is explainable, pain is torment, pain is restrictive, and pain is changeable. Several of these themes support findings from other qualitative studies describing the nature of chronic pain. Descriptions of pain as never-ending have been a common theme (Bowman, 1991; Carson & Mitchell, 1998; Seers & Friedli, 1996; Thomas, 2000). The "moment" has been described as an endless stopping of time, suggesting the possibility of never-ending pain. Another similarity is the tendency for persons, when describing pain, to make attempts to find a cause and/or relate how events in the past might have a bearing on current pain (Brown & Williams, 1995). Comparing pain with other sensory images, for example, pulling, stabbing, burning, shooting, has been commonly cited by persons experiencing chronic pain; in fact, many of the sensory images described by participants in this study are listed on the sensory scale of the McGill Pain Inventory (Melzack, 1975). In Copp's (1985) pain coping typology, persons who viewed themselves as victims also chose words reflecting pain as all-powerful and tormenting in nature. Last, pain has been widely described as restrictive, limiting a person's ability for and freedom of physical movement, participation in meaningful activities, and role performance (Seers & Friedli, 1996).
One major finding of this study is that, for some participants using the guided imagery technique, pain became changeable. This was manifested in several ways. First, participants described the guided imagery technique as relaxing. Relaxation has often been cited as a useful adjunct treatment for chronic pain because of its direct effects on muscle tension and for its ability to increase the person's sense of control and self-efficacy (Turk & Okifuji, 2002). Other participants used the guided imagery technique to transform their pain by mentally modifying the sensory images of pain to less aversive ones. Finally, several participants in the treatment group began to think about their pain in a different way. By thinking differently about pain, it became more tolerable. According to many pain experts (Gamsa, 1994; Turk & Okifuji, 2002), beliefs about pain play a major role in psychological functioning, disability, impairment, and treatment outcome.
Another major finding of this study is that participants using the guided imagery technique stopped describing pain as never-ending. The guided imagery technique may have allowed participants an escape or distraction from their pain. Time is a frequently cited example of a manifestation of field patterning in Rogers' framework (Rogers, 1992). Given Rogers' principles of homeodynamics and the postulated changes in patterning that emerge from the human-environmental energy field process, participants' use of the guided imagery technique to knowingly participate in change may be reflected in subjective changes in their experiences of time. This finding also provides support for anecdotal reports in the literature describing the "disappearance of time and space" during guided imagery (Epstein et al., 1997; Samuels & Samuels, 1990). Last, descriptions of pain as tormenting by participants in the treatment group changed during the 4-day study period. On the last study day, only 1 participant in the treatment group described pain as torment. The guided imagery technique may have allowed participants to experience less pain by replacing tormenting sensory images and/or bolstering feelings of control.
Although there have been randomized controlled clinical trials supporting the use of mental imaging strategies to assist persons with unrelieved pain (Arathuzik, 1994; Ilacqua, 1994; Moran, 1989; Raft, Smith, & Warren, 1986; Sloman, 1995; Syrjala et al., 1995), there are very little data to help guide nurses in selecting the types of suggestions that are most effective during the guided imagery exercise. The findings of this study show that relaxation was an important component of the guided imagery intervention. A state of relaxed focus not only reduces muscle tension and helps a person direct attention away from bodily sensation but also assists the person to form and become absorbed in sensory images. Helping the person go to the pain location, explore it, and then introduce sensory images that transform the pain was also described by participants in this study as effective in changing the pain experience. Guiding the person to move his or her mind out and away from the body, while substituting less punishing images of pain, may mitigate the tormenting nature of pain. Last, using suggestions to alter beliefs about pain, making it less fearful or debilitating and more tolerable, were specified by participants as useful in changing pain and can be easily included in a guided imagery intervention.
Chronic pain is associated with an array of health problems, and nurses care for persons experiencing pain in a variety of clinical settings. Complementary therapies are being used increasingly by persons experiencing chronic pain to help manage pain. The results of this study show that the use of a guided imagery technique over 4 days was effective in changing a person's pain experience. Participants used the guided imagery technique to relax, transform sensory images of pain, and change thinking about pain. The meaning of pain as never-ending and tormenting was also changed with the use of the guided imagery technique. Although the use of guided imagery should not be used in place of analgesic medication, it is useful as an adjunct to more traditional methods of pain treatment and can be offered to those persons who are unable or refuse to take analgesic medication. One goal of nursing is to enhance a person's ongoing, independent pursuit of health and well-being. Continuous change is inevitable as persons live with chronic pain. The use of guided imagery to assist persons experiencing pain as they evolve with the pain experience is an effective evidence-based nursing intervention.
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Table 1. Pain Diagnoses by Group
Diagnoses
Treatment n = 21
Control n = 21
n
%
n
%
Arthritic pain
14
67
15
71
Spinal disorder
12
57
8
38
Fibromyalgia
2
10
5
24
Hand paina
2
10
4
19
Shoulder paina
3
14
2
10
Vascular pain
2
10
1
5
Post-polio syndrome
2
10
0
0
Chronic leg wounds
1
5
0
0
Cluster headaches
0
0
1
5
Crohn's disease
1
5
0
0
Gout
0
0
1
5
Neuropathy
1
5
0
0
Reflex sympathetic dystrophy
1
5
0
0
Temporomandibular disorder
1
5
0
0
Note. Arthritic pain = arthritis, osteoarthritis, rheumatoid arthritis, degenerative arthritis, osteoporosis; pain related to spinal disorder = spinal stenosis, degenerative disc disease, herniated disc, fracture vertebrae, sciatica, scoliosis; shoulder pain = chronic rotator cuff tendonitis, torn rotator cuff, spurs in the shoulder; hand pain = carpal tunnel syndrome, shattered wrist; vascular pain = vascular insufficiency, vascular necrosis of the bone.aPain is not related to arthritis.
Table 2. Excerpts from Guided Imagery Technique
Components of Imagery Technique
Excerpts from Imagery Technique
Guided into a state of relaxed focus
"… Close your eyes. Begin by breathing in fully and deeply through your nose, blowing out fully and deeply through your mouth … Let yourself feel calm and revitalized by each breath … As you watch your breathing, you'll notice that you become calmer and more peaceful … that your inner space expands … and that you become alert but quiet … watchful yet detached …"
Sensory images related to pain are suggested and evoked
"… Begin to describe your pain in silence to yourself … Be present with the pain … Know that the pain may either be physical sensations … or worries and fears … the pain can be anything … whatever comes to your mind … Let your pain take on a shape … become aware of its dimensions … What is the height … the width … the depth … Give it color … a shape … feel the texture … Does it make a sound?"
Sensory images are used to create personal change
"… Now with your eyes still closed … let your hands come together with palms turned upward as if forming a cup … Put your pain object in your hands … How would you change the shape … the size … Now change the color … and its texture … Give it a different sound … decide what you would like to do with the pain … There is no right way to finish the experience … just accept what feels right to you … You can throw the pain away … or place it back where you found it … or move it somewhere else … Let yourself become aware … of how pain can be changed … By focusing with intention, the pain changes"
Table 3. Participants' Pain Descriptions Across Five Time Points
Categories
T1
T2
T3
T4
T5
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Txn = 21
Cn = 21
Pain is never-ending
11
10
1
11
-
14
1
9
-
15
Pain is relative
11
9
14
14
18
13
18
10
19
14
Pain is explainable
7
13
3
5
3
8
1
3
1
2
Pain is torment
7
6
6
3
2
4
2
5
1
4
Pain is restrictive
8
5
2
5
1
6
2
5
-
1
Pain is changeable
4
5
5
3
8
3
8
-
11
2
Note. T = time point; Tx = treatment group; C = control group.
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Funding Information
Support for this research was provided by American Nurses Foundation grant no. 99-71 (October 1, 1999 to October 1, 2001) and a Kent State University Summer Research Appointment (2003).
Reprint Address
Address correspondence and reprint requests to Wendy Lewandowski, College of Nursing, 113 Henderson Hall, Kent State University, Kent, Ohio 44242. Email address: wlewando@kent.edu
Wendy Lewandowski, RN, PhD, CS,* Marion Good, RN, PhD, FAAN,† Claire Burke Draucker, RN, PhD, CS**College of Nursing, Kent State University, Kent, Ohio and †Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
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