‘You are braver than you believe,
stronger than you seem, and
smarter than you think.’
A.A. MILNE
Some studies have shown that visualization can reduce the severity of some side effects of cancer treatment and also reduce the risk of reoccurrence of cancer after treatment.
A 1999 randomized controlled study published in the British Journal of Cancer, for example, examined the daily use of guided imagery in which patients visualized their immune system destroying cancer cells. The study involved 96 women who’d been recently diagnosed with breast cancer that was large or locally advanced and who were receiving six cycles of chemotherapy.
As an aid to visualization and so they had a good mental representation, the women were shown coloured cartoons depicting how the immune system works. They also rated the vividness of their imagery. The main measurements in the study were mood and quality of life and these were assessed before each of the cycles of chemotherapy and again three weeks after the sixth cycle. The study also measured the patients’ clinical responses to chemotherapy after the six cycles.
Quality of life is often used as a measurement because it’s well known that it’s a prognostic factor for survival; that is, quality of life is correlated with the chance of recovery from a disease and also the chances of the disease reoccurring. Indeed, studies have shown that a higher quality-of-life rating is linked with survival of patients with early-stage breast cancer and also advanced disease.
Quality of life is also sometimes associated with a patient’s response to chemotherapy. A study of women with advanced breast cancer, for instance, found that quality of life was a predictor of their response to chemotherapy and also their survival rates. The higher the reported quality-of-life rating, the better the response to chemotherapy. In the same vein, stress is often associated with a poorer response to chemotherapy.
Cancer diagnosis and treatment also often leaves people with depressed mood, leading to clinically significant depression and anxiety. This can impact on their quality of life and can thus be related to their likelihood of survival.
The results of the 1999 visualization study showed that quality-of-life rating was much higher in the visualization group than in those who didn’t use visualization, which suggested that visualization might have increased their chances of survival, and also reduced the likelihood of cancer returning. And, just as in the studies of mental representation structure earlier in this book, the women’s clinical responses were correlated with the quality of their visualizations. Those who reported the most vivid visualizations had the greatest positive clinical response to the treatment.
Patients who used visualization also had higher numbers of T-cells (key components of the immune system) and enhanced levels of lymphokine-activated killer (LAK) cell cytotoxicity. Cytotoxicity refers to the ability of these ‘killer cells’ of the immune system to destroy cancer cells. Put simply, the immune system of patients who visualized their immune system seemed to be working more optimally than in patients who didn’t visualize.
The impact of visualization on the immune system during cancer treatment has been reported by other researchers, too. A randomized controlled trial (RCT) of 80 women with newly diagnosed large or locally advanced breast cancer also used imagery of the immune system destroying tumour cells, in addition to relaxation training. The women were shown cartoons describing the process and were also encouraged to make their own images. They also recorded the vividness of their visualizations on a 1–10 scale.
The women received chemotherapy, surgery, radiotherapy and then hormone therapy. Blood samples were taken 10 times over 37 weeks and several immune substances were measured. In the group who did visualization, immune activity and cytotoxicity were increased compared with the group who didn’t do the visualizations. Specifically, levels of CD25+ (activated T-cells), CD56+ (LAK cells) and CD3+ T lymphocyte cells were higher in the group who did the visualization. Activated T-cells are known to induce the death of tumour cells and also to inhibit the growth of tumours.
Furthermore, as with other studies, the vividness of the imagery seemed to have an effect. Women who reported vivid imagery had significantly higher levels of natural killer (NK) cell activity during and after treatment and again at followup. NK cells are a critical component of the immune system and are known to be naturally cytotoxic (as before, they kill cancer cells).
Indeed, part of these women’s immune systems showed high levels of cytotoxicity even after the fourth (and final) chemotherapy cycle. The researchers said that ‘relaxation training and guided imagery beneficially altered putative anticancer host defences during and after multimodality therapy’.
Another study, of women with breast cancer who were undergoing surgery, used the same kind of visualization of the immune system destroying cancer cells. It involved 28 women with stage 0, 1 or 2 breast cancer, and found the same kind of elevating effect on natural killer (NK) cell cytotoxicity.
The women’s visualization sessions varied in frequency, ranging from twice a week to twice a day over a period of four weeks. Measurements of NK cell activity were taken before surgery and again four weeks after it. As with the other studies, the women who did the visualizations had much higher NK cell activity than those who did not.
In an earlier (1988) US study, conducted at George Washington University hospital and lasting a whole year, increases in several components of the immune system were also measured in patients with metastatic cancer who visualized their immune system destroying cancer cells.
Monthly blood samples were taken regularly throughout the year and showed positive changes in NK cell activity, the responsiveness of lymphocytes, increased immunoglobulins (as in the Achterberg study described in the last chapter), and increased Interleukin-2 secretion. Interleukin-2 (IL-2) is a natural anticancer substance in the body that helps activate white blood cells. Again, visualization was having a positive impact on the immune system.
Some studies have shown that relaxation imagery, where imagery is of pleasant, relaxing images and scenes, also benefits cancer patients. In part, this is likely because relaxation reduces stress and therefore helps the immune system work more optimally.
A randomized controlled study of 208 patients, led by Andreas Charalambous of the Cyprus University of Technology, used this kind of guided imagery in an attempt to manage cluster symptoms in people undergoing chemotherapy or radiotherapy for breast or prostate cancer. Cluster symptoms are defined as two or more related symptoms that occur at the same time, and they’re quite common side effects in patients undergoing cancer treatment.
Approximately half the patients in the study did the guided imagery and relaxation sessions and were compared with a control group who didn’t visualize. Prior to the study, the patients were asked what they might like to visualize and most chose relaxing images such as floating on a cloud or a relaxing beach scene.
Imagery sessions were supervised once weekly and unsupervised (patients did them on their own) daily for four weeks. After four weekly sessions of guided imagery and progressive muscle relaxation, pain levels dropped in the intervention group, yet increased in the control group, who didn’t receive the imagery training. The imagery group also experienced a reduction in fatigue, anxiety and nausea, retching and vomiting, and depression, as well as in levels of the stress hormone cortisol. Overall quality of life increased in the imagery group but decreased in the control group.
In another study of 65 breast cancer patients undergoing chemotherapy, guided imagery and relaxation training was given to 32 patients in addition to their chemotherapy, while another 33 patients received chemotherapy alone. Both groups also received chemotherapy self-care instructions.
Imagery and relaxation was conducted prior to chemotherapy and then for the following seven days for 20 minutes each time. At the end of the seven days, the patients who did the imagery and relaxation sessions experienced significantly less insomnia, pain, anxiety and depression and numbness in physical symptoms (typical side effects) than the group who didn’t receive the imagery and relaxation.
I’ve learned of this kind of effect from a large number of people whom I come across in my work. I’ve taught the mind–body connection and imagery in a number of charitable cancer centres where people going through cancer treatments (chemotherapy, radiotherapy or surgery) also attend to receive some complementary and alternative therapies. Time and time again, people share stories of how they used visualization and had much-reduced side effects (you can read some of these later in the book).
Research into the use of visualization shows that it can be applied to a wide variety of medical conditions. I’ve summarized some of this research below.
A 2015 US study demonstrated the benefits of using guided imagery to help patients being weaned from mechanical ventilation (weaning is the gradual reduction in the use of a ventilator to assist breathing). In helping patients to breathe, mechanical ventilation thus helps oxygenate tissues and eliminate carbon dioxide. It’s a vital, and expensive, treatment and, as of 2015 (when the study was published), it cost an estimated $27 billion a year – 12 per cent of total hospital costs in the USA.
The study involved 42 patients – 21 from each of two hospitals. The patients in one of the hospitals received guided imagery sessions that focused on relaxation, while those in the other hospital didn’t practise imagery, to serve as a comparison.
The imagery patients received two sessions for 60 minutes at a time, during weaning trials, two days apart, and the imagery was greatly successful. Oxygen saturation levels significantly improved during the second imagery session, compared with the group who didn’t practise imagery. Imagery patients were also much calmer and their heart rate and respiratory rate were much lower than they were in the comparison group. The imagery group also required fewer sedatives and analgesics to manage pain.
Overall, the imagery group required an average of 4.88 fewer days of mechanical ventilation and an average reduction in hospital stay of 1.4 days. If the study was reflective of a larger population trend, this reduction in hospital stay, amounting to 6.7 per cent fewer days, could save the US$1.8 billion a year in hospital costs – from an entirely free therapy: the directed use of a patient’s mind.
Medics at Tai Po Hospital in Hong Kong used guided imagery relaxation to treat patients with COPD. Twenty-six patients were involved in the study. Thirteen of them had six sessions of guided imagery while the other 13 just rested during these times. At the end of the study, there was an increase in oxygen saturation in the blood of the group who did guided imagery.
Visualization has also been successfully used to help asthma sufferers breathe more easily. In an Alaskan study involving 70 asthma patients, participants either did what the researchers called ‘biologically targeted imagery’, where they imagined reduced bronchospasm and inflammation, or they simply received education in the management of asthma, as a comparison group.
After six weeks of twice-weekly two-hour sessions, both visualization and education had substantially improved the symptoms of asthma; but the greatest improvement was with the patients who’d used visualization.
The third most performed surgery in the USA is total knee replacement. One study involved 58 patients, half of whom did guided imagery sessions daily for two weeks before their surgery and for three weeks after surgery.
For this, they listened to a CD that guided them in visualizing their knee being strong and able to easily support their weight. It also guided them in visualizing themselves walking, turning a pain dial down and imagining their medication doing what it needed to do. In addition, affirmations were included to help the patients feel positive, to be motivated to do their physical therapy exercises and to have belief in their recovery.
At both three weeks and six months post-surgery, the guided imagery group had improved walking velocity, lower pain scores and lower stress hormone levels than the group who didn’t do the imagery sessions.
A 2006 study conducted at Purdue University School of Nursing in the USA showed that guided imagery benefited older women with osteoarthritis. Twenty-eight women were involved in the study: half used guided imagery for 12 weeks and half were in the control group for comparison. The study found that the women who used guided imagery had significantly improved quality of life than those who didn’t.
A 2008 US study at William Beaumont Hospital in Royal Oak, Michigan, used guided imagery in the treatment of interstitial cystitis. Twice daily for eight weeks, 15 women used images focusing on healing the bladder, relaxing the pelvic-floor muscles and quietening the nerves involved in the condition for 25 minutes at a time. Fifteen women in a control group rested during these times. The women who used guided imagery had significantly reduced symptoms and pain than those who didn’t.
Guided imagery even affects wound healing, as was shown by a 2007 study at Southeastern Louisiana University School of Nursing in the USA involving 24 patients undergoing surgery to remove their gallbladder. The study found that the guided imagery not only reduced levels of anxiety and stress hormones, but also that those who used it had much lower levels of surgical wound erythema – redness around a wound that’s usually associated with infection or inflammation. In effect, guided imagery speeded up the healing of the patients’ wounds.
A friend of mine told me that one of her weight-loss strategies is to drink water before she eats. The water, she says, suppresses her appetite a little and she then finds that she eats less. Researchers at Carnegie Mellon University in the USA found a novel way of using visualization to affect a person’s appetite.
In a study, 51 people were asked to imagine eating either three or 30 units of a particular food; the food used was M&M’s sweets. One set of volunteers had to imagine eating three M&M’s, and they also had to imagine putting 30 coins into a laundry machine. Another set of volunteers had to do it the other way around: they imagined eating 30 M&M’s but were to imagine placing only three coins into the machine. A third set of volunteers just imagined placing 33 coins into the machine.
You might wonder about the relevance of imagining putting coins into a machine. The reason was because the muscles used in doing so are similar to those used in lifting food into our mouth, and it was important that the volunteers all imagined the same number of hand movements.
After a distracting activity, the volunteers were invited to eat some M&M’s from a bowl in preparation for what they were told was going to be a ‘taste test’. But it wasn’t really a taste test: it was so that the experimenters could secretly record how many M&M’s they ate. Amazingly, the researchers found that those who’d imagined eating the most M&M’s (30) ate far fewer from the bowl than the other two groups.
The conclusion of the study was that imagining eating the M&M’s suppressed the appetite to eat more of them, just as if the volunteers had physically eaten them. It’s like the brain was saying, ‘OK, I’ve had enough M&M’s now. I’m full,’ even though the person hadn’t actually eaten anything at all.
The researchers did a similar experiment with cubes of cheese and found the same thing. However, imagining eating M&M’s only reduced the volunteers’ appetite for M&M’s, not for cubes of cheese, and vice versa. This is known as habituation. As we eat more of a particular food, after a point our appetite for that food reduces, otherwise we’d keep on eating it. It doesn’t necessarily reduce our desire for other foods. We all know what it’s like to be completely full after eating a meal, but somehow we have space for pudding. But importantly, habituation seemed to happen just by imagining eating.
As we’ve learned so far in the book, there’s a thin line between real and imaginary as far as the brain is concerned. And as far as the Carnegie Mellon University study was concerned, Carey Morewedge, who led it, said, ‘The difference between imagining and experiencing may be smaller than previously assumed.’
It seems that if a person actually imagines the full process of eating – i.e. repetitively chewing and swallowing the food – it produces a similar effect in the brain to actually eating the food. It might be that we can imagine eating a meal, bite for bite, before we eat and then find that we don’t feel like eating as much; therefore, weight loss is a natural side effect.
However, the research is still in its infancy and there’s no data yet on whether imagining eating affects any of the body’s other systems, like blood sugar, for instance, or even whether it causes us to eat so much less that the body lacks the nutrition it needs. But it’s interesting to see the same kind of effect in that the brain often doesn’t make much of a distinction between real and imaginary. It seems it’s true for movement, immune function and even eating. It’s likely to be a much wider phenomenon that further research will reveal in the future.
Instead of imagining the workings of their immune system or visualizing a state of repair taking place, or illness moving towards wellness, as I mentioned above, many people who are taking medication visualize their medication working: from chemo drugs to pain-killing medication and even antibiotics.
Some people derive great benefit from creating a mini-ritual around taking their medicines. It’s much better, they believe, than popping a couple of pills in a hurry, where they just take a gulp of water and rush on with whatever else they’re doing. Some people take medication just before or during a meditation, or they say a prayer as part of their ‘medication ritual’.
Many people I’ve spoken with who are undergoing treatment for cancer visualize their chemotherapy drugs acting like Pac-Men or piranha fish and eating the cancer cells or tumour(s). They imagine cancer cells or tumours then becoming smaller and smaller until they vanish. People undergoing radiotherapy do something similar: imagining the radiation as like bolts of lightning gradually burning the cancer cells or tumour away. People on antibiotics sometimes imagine the antibiotics as little vacuum cleaners clearing an infection away.
Given that we’ve learned how selectively the mind can affect the body – from placebo effects to visualizing different parts of the body and even to selective changes in immune function – the key is to be as clear and specific as you can.
Mental representation for illness and disease can be a little different from rehabilitation and sports in that, unlike in those, the exact physiology visualized doesn’t seem to be as important as having a representation that feels right to the person visualizing. A symbol does as well as an accurate picture, so long as it feels right (that is, it makes sense to the individual doing it). In other words, imagining an immune cell as a Pac-Man or piranha fish is just as good as imagining how it actually looks, so long as what you imagine makes sense to you and represents what you are intending.
In the cancer studies above where imagery vividness was assessed, the positive impact on the immune system and on quality of life was correlated with the clarity of imagery. The same kind of thing was shown with visualization for sports. In each case, the impact of visualization seemed to be stronger when there was a clear mental representation. As indicated earlier, mental representation – the clarity of our images – also affects success in healing. It can even affect our ability to relax.
In a 2006 study, scientists from the Department of Health Promotion and Human Behaviour at Kyoto University in Japan measured levels of stress hormones (salivary cortisol) and mood in 148 people who received two guided imagery relaxation sessions.
First, the study found that salivary cortisol levels were much less after the first and second sessions. The scientists wrote that, ‘Unpleasant information, a cause of mental stress, is replaced by a comfortable image, and this replacement affects a person’s salivary cortisol level.’ Second, those who had the more vivid images had the biggest reduction in salivary cortisol levels.
Sometimes, relaxation imagery can be better than targeted visualization, but clarity helps, regardless. The type of visualization a person chooses really depends on the condition and also on the person, in terms of whether they’re more interested in relaxation or distraction, or even find an active visualization enjoyable or stressful.
This could be seen in a guided imagery study used to treat fibromyalgia pain. Publishing in the Journal of Psychiatric Research in 2002, scientists at the Norwegian University of Science and Technology compared ‘pleasant imagery’ (which used pleasant images to distract the patients from their pain) with ‘attention imagery’ (visualizing the ‘active workings of the internal pain-control systems’).
Fifty-five women were involved in the study and their level of pain was monitored every day for a period of four weeks. The pain level in the ‘pleasant imagery’ group was significantly reduced, while it wasn’t in the ‘attention imagery’ group.
There’s no question that visualization has biological effects. It selectively impacts the immune system and has been shown to bring about positive effects on a number of medical conditions, including cancer. Previous chapters of this book have also shown that placing attention on a region of the body impacts that part of the body, as well as the region of the brain connected with it.
Don’t be concerned, however, if you think you’re not a good visualizer. For some people, visualization vividness can be more about the clarity of an idea rather than the formation of a physical image in their mind’s eye. Understanding how the immune system works and clearly and succinctly intending it to work for you (or even asking it to work for you, as some people do), without actually ‘seeing’ anything, might be just as effective as having a mental image in the mind’s eye.
Regardless, with practice, visualization gets easier. I know that from experience. The parts of your brain involved in visualizing will expand with practice and your ability will improve. It’s just like getting better at a sport. Few people can run a 10k on a first attempt; most will barely manage around the block. But with some training – trying out various shorter distances on a regular basis – it’s not long before the average person can run a 10k. It’s the same with learning to do visualization.
So, does visualization work exclusively through its impact upon the immune system? In many of the studies mentioned above, people targeted their visualizations towards their immune system, and in some of these they even imagined their immune system destroying cancer cells. But in other studies, visualization was more about visualizing the movement of muscles, or the relief of symptoms, or even the repair of a body system. And whether a person believes in visualization or not might even introduce placebo or nocebo effects.
Clearly, visualization works in different ways depending on the nature of the visualization used. The next chapter briefly explores some of the different ways that visualization might be having its effects.