Guided Imagery Treatment to

Promote Self-Soothing in
Bulimia Nervosa
A Theoretical Rationale

MARY JA N E E S P L E N , R.N., PH.D.

PAUL E. G A R F I N K E L , M.D., F.R.C.P.C.

Bulimia nervosa (BN) has been described as

involving impairment in affect regulation and B ulimia nervosa (BN) is characterized by a
loss of control over eating, in the form of
bingeing episodes and extreme attempts to
in self-soothing. Such a conceptualization
suggests the need to design treatments that control body shape and weight. It entails a set
specifically target these problems in order to of attitudes frequently described as a morbid
fear of becoming fat, or concerns regarding
assist individuals with BN in comforting
weight and shape that unduly influence the
themselves. A model of guided imagery evaluation of the self. Since the description of
therapy suggests that imagery therapy has B N in 1979,1 a number of treatment ap-
multiple levels of action and can assist these proaches have demonstrated efficacy, at least
individuals in the regulation of affect by in the short term.2–4 However, the treatments
providing an external source of soothing and shown to be helpful often address only the con-
also by enhancing self-soothing. The authors ceptual or cognitive and behavioral aspects of
illustrate the model with a case example and the disorder, and, moreover, a significant num-
report the results of a study in a clinical ber of patients do not respond to current treat-
sample of BN. ments.5–8 The difficulty that BN patients have
(The Journal of Psychotherapy Practice with affect regulation, feelings of emptiness,
and Research 1998; 7:102–118) and the experience of extreme aloneness is
often less amenable to standard treatments.
The theoretical literature has suggested
that at least a subgroup of individuals with BN
may have difficulty in modulating affects or in
self-soothing.9–12 This conceptualization sug-
gests the need to design treatments that specif-

Received August 6, 1996; revised September 18, 1997;

accepted October 21, 1997. From the Departments of
Psychiatry and Nursing, Mount Sinai Hospital, and the
Department of Psychiatry, University of Toronto, Clarke
Institute of Psychiatry, Toronto, Ontario, Canada. Ad-
dress correspondence to Dr. Esplen, Departments of Psy-
chiatry and Nursing, Mount Sinai Hospital, 600
University Avenue, Toronto, Ontario, Canada M5G 1X5.
Copyright © 1998 American Psychiatric Press, Inc.

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ESPLEN AND GARFINKEL 103

ically target the problem of affect regulation capacity, referred to as the ability for “transi-
and that help these patients comfort them- tional relatedness,” has been defined as “the
selves. In this article we review the literature person’s unique experience of an object
on self-soothing and propose a conceptual whether animate or inanimate, tangible or in-
model of guided imagery therapy to address tangible in a reliable soothing manner based
the difficulty of affect regulation. on the object’s association or symbolic connec-
tion with an abiding mainly maternal primary
T H E C A P A C I T Y F O R process presence” (Horton,13 p. 35).
S E L F - S O O T H I N G Although there is general agreement
among professionals that very young children
The ability to manage or regulate tension (affect) usually make healthy use of growth-facilitating
has been referred to in the psychodynamic soothers, the existence of soothing (solacing)
literature as the capacity for self-soothing.13–15 methods at later stages of development has yet
This capacity is believed to develop through to be sufficiently researched.13 Soothers in
the internalization of earlier soothing or com- early childhood or transitional objects, exem-
forting experiences. Later, as children mature, plified by the blanket, stuffed animal, and
they are able to soothe themselves with fanta- favorite tune, are normally replaced by in-
sies, images, and memories of interaction. In creasingly subtle and complex vehicles for
this regard, Winnicott16 described the notions growth and solace through a lifelong series of
of “good-enough mothering” and the “holding progressive psychological transformations.13
environment” and emphasized the empathic As Horton13 notes, “Maturation is accompa-
bond between mother and child; he also out- nied by increasing sensitiveness to the qualities
lined the broad limits of what might be “good of potential solacing objects” (p. 129).
enough.” He introduced the term transitional Typical intermediate objects include
phenomena, referring to various soothing expe- imaginary companions, tunes, fairy tales, po-
riences and behaviors such as the infant’s re- etry, religious figures, prayers, works of art,
petitive babbling sounds and the holding of a mentors, the church, spouses, lovers, and
soft blanket against the skin. It is believed that friends. It is the relationship with these objects
the infant, at the stage of recognition memory, that protects an individual from aloneness and
is able to keep in his awareness the soothing fear and serves to propel an individual to the
of the mother through the holding and feeling next stage of finding the highest good in self
of a familiar object that is reminiscent of her and others.13,17 This developmental process
touch. With the development of “evocative may result in considerable refinement to
memory,” the infant develops the ability to higher-order object relations as experienced in
produce a mental image of the object (mother) “oceanic,” “near-death,” and “creative” expe-
in her absence. riences.13,16
The internalization of earlier soothing ex- For individuals who lack the capacity
periences allows the progressive separation of for self-soothing, a particularly vulnerable
the child from the mother and becomes crucial time exists when they are alone, because the
in the development of the capacity to be alone. chief function of self-soothing has been linked
The child is able to leave the mother’s bosom to the development of the capacity to be
when he can find something of her nurturance alone.12,13,18–21 During these times the individual
in the external world. Therefore, the child no is left to his own resources for self-comforting
longer depends fully on the presence of actual and the maintenance of a calm state. An im-
people for comfort. The child is able to soothe pairment in this self-function may be indicated
himself with fantasies, images, and memories when emotional arousal of panic or fear is ex-
of earlier interactions with objects that resonate perienced, resulting in behaviors such as
with the soothing maternal presence. This bingeing or addictive behaviors coming into

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104 GUIDED I MAGERY

play as a response to the experienced discom- devoid of feeling and spontaneity.

fort and inner pain.22,23 Few studies have been conducted to sys-
tematically investigate these phenomena in
E M P I R I C A L L I T E R A T U R E adult clinical populations. A recent study by
Richman and Sokolove30 investigated the bor-
Conceptualizations of early development re- derline experience of extreme aloneness, sug-
lated to self-soothing have been used to under- gesting an incapacity for self-soothing. Adler22
stand addictive behaviors,13,24,25 B N,9–11,26 expanded on the “empty, desperate” alone-
anorexia nervosa,27,28 obesity,29 and borderline ness experienced by borderline patients, em-
personality disorder (BPD).14,18,22,30–32 Re- phasizing that these patients cannot rely on
searchers have found that eating-disorder pa- their own internal resources to hold and soothe
tients have difficulties identifying, verbally themselves when faced with separations, and
expressing, and regulating all forms of physical consequently they experience the panic of to-
tension.27,33–36 The literature has identified a tal aloneness and abandonment.
primitive inability among these patients to ver- Generally, studies thus far have focused
balize emotion, despite being articulate in on patients with BPD and have found that
other areas.27 This difficulty leads these pa- these individuals use more maladaptive sooth-
tients to a state that is “incommunicable” at ing behaviors39,40 and have fewer transitional
times and experienced as an “extreme state of objects, or show rigid or maladaptive use of
tension,” while at other times it is characterized their transitional objects throughout their de-
by feelings of emptiness that they cannot velopment.39,41 Studies investigating clinical
soothe.26,37 Researchers and theorists have sug- populations have found an association be-
gested that binge eating and vomiting, as well tween psychopathology and an incapacity for
as drug or alcohol abuse, represent an attempt self-soothing (Gunderson et al., 198541; R. Jam-
to artificially modulate negative affect and, in pel et al., unpublished, 1983).
a sense, to numb the pain.8,26,27 Bruch27 linked There have been no previous investiga-
the sense of loneliness, the feeling of not being tions to study the self-soothing capacity of BN
listened to or understood, and the pervasive patients. In clinical populations of BN, behav-
sense of emptiness to eating binges. A preoc- iors such as binge/purge episodes, theft, wrist-
cupation with food and bingeing and purging slashing, substance abuse, and sexual activity
behaviors can be thought of as filling a need are common.42–44 In addition, a distinct sub-
to relieve pain, and the individual may rely on group of “multi-impulsive” bulimics (those
these behaviors for this function. The psycho- who display more than one impulsive symp-
logical pain becomes a physical one, and emo- tom) has been identified and associated with
tional experience is concretized.38 poorer prognosis and the diagnostic overlap
Individuals with eating disorders have with BPD.45 There is some empirical evidence
been described as maintaining strong efforts to suggest that individuals with eating disor-
directed at avoiding any arising tension; this ders have difficulty identifying, verbally ex-
pattern can lead to a self-organization of ex- pressing, and regulating forms of physical
treme compliance and self-control, best exem- tension, including hunger and emotional
plified by Winnicott’s term false self.16 The false states.27,33,46 The construct of alexithymia, de-
self consists of an outer self that provides an fined as an inability to identify and express
appearance of compliance and high levels of emotions and to distinguish between emo-
functioning, control, and self-esteem; this false tional states and physical sensation, has been
self serves to protect the inner self from being described among eating-disordered pa-
revealed. This way of being in the world can tients.47,48 It has been suggested that this ego
result in feelings of deadness, numbness, and deficit has significant effects on the early rela-
emptiness and a state characterized as being tionship of self to body.26 It is not clear how

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ESPLEN AND GARFINKEL 105

this develops. Bruch27 identified a group of pa- the privilege of agreeing or disagreeing if
tients who believed that they had been physi- it appears relevant. Such a patient needs
cally or emotionally “insulted.” She believed help and encouragement in becoming
that they were particularly vulnerable to eating aware of impulses, thoughts and feelings
that originate within himself. (Bruch,27 p.
disorders. Recent community and clinical
338)
studies have demonstrated a significant num-
ber of women with eating disorders who have
been sexually abused.49,50 Bruch believed that this approach promoted
the development of patients’ untapped re-
I M P L I C A T I O N S F O R sources such as autonomy, initiative, and self-
T R E A T M E N T responsibility and would lead to a feeling of
aliveness as to what is going on within them-
Treatment approaches stemming from an ob- selves.
ject relations framework have focused on the More recently, self-psychological treat-
roles of empathy and the holding environment ment approaches have highlighted the role of
as they relate to people with deficits in the ca- validation of subjective experience. This role
pacity for self-comforting.13,15,19 These ap- involves assisting the patient in establishing
proaches propose that therapeutic work occurs an attitude of interest in, and a feeling of
in the transference relationship and that pa- acceptance of, her own emotional life.11,18,46
tients are provided with a new opportunity for These authors propose that such an approach
the internalization of self-regulatory structures strengthens tolerance of affect and the growth
that had failed to develop in early life. The and development of functional capacities to
repeated working-through of disruptions and assist in regulating affects and impulses, result-
events in therapy leads to a greater capacity to ing in a sense of mastery and enhanced self-
sustain empathic failures in relationships. In- esteem.
terpretations offered by the therapist assist in Adler and Buie18 suggest that individuals
providing meaning and coherence, as well as who lack sustained mental representations of
practice in naming affective experiences. others are prone to the experience of recurrent
Psychodynamic theorists have empha- fears and panicky reactionsparticularly
sized the value of interpretation, but others around the notion that the therapist does not
have cautioned against it. Winnicott16,51 noted exist in the intervals between therapeutic ses-
that therapist interpretation may pose a danger sions. These authors emphasize the impor-
in that it may serve to repeat experiences such tance of a sense of continuity and stability
as intrusiveness or lack of validation in early within the relationship to allow for the inter-
caregiving. He suggested that any accurate in- nalization of more stable soothing repre-
terpretation for which the patient is not ready sentations. For example, in the treatment of
can reach the innermost self and evoke the BPD, telephone contact with the patient “at
most primitive defenses. The most valuable in- the time of emergencies” between therapy ses-
terpretation has been described as one that is sions is a means of providing concerned atten-
“felt” and “created” by the patient.27,51 tion and fulfills the patient’s need to evoke
soothing object representations that can offset
the fear of being alone.18 Other techniques that
For effective treatment, it is decisive that
a patient experience himself as an active
may be useful for delaying interpersonal con-
participant in the therapeutic process. If tacts include encouraging reading or other dis-
there are things to be uncovered and in- tracting activities, tape-recorded therapy
terpreted, it is important that the patient sessions, and encouraging increased social ac-
makes the discovery on his own and has tivities. Such activities help patients learn adap-
a chance to say it first. The therapist has tive behavioral responses and lead to an

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106 GUIDED I MAGERY

increase in the tolerance for affects.18,52 or arouse an entire constellation of mean-

The literature on difficulty in affect regu- ings, which can then be explored” (p. 158).
lation (self-soothing) and the inability to toler- 6. Increased awareness and self-reflection
ate aloneness led us to the speculation that during guided imagery facilitate the expe-
guided imagery as a therapy may facilitate the rience, and the identification, of emotions
internalization of soothing experiences and the and themes that can be validated.
use of a therapist for self-soothing. 7. Self-experience is enhanced through vari-
Guided imagery therapy provides an ideal ous modes of expression of the imagery,
opportunity to address the difficulty of affect including verbal and written forms and
regulation in BN for a number of reasons: drawings.

1. Guided imagery occurs within the context A G U I D E D I M A G E R Y

of a therapeutic relationship, thereby fa- T R E A T M E N T A P P R O A C H
cilitating the role of empathy and the de-
velopment of a holding environment. Guided imagery has been used in a variety of
2. The efficacy of guided imagery for en- clinical areas, and empirical studies have sup-
hancing the relaxation response and a ported its wide-ranging applications. Imagery
calm affective state has been well docu- has been extensively used as a therapy in on-
mented.52–55 cology, particularly in symptom and stress
3. Guided imagery provided by the therapist management,55,57–59 and more actively as a
can act as an “external” source of soothing healing imagery focusing on the cancer.58,60,61
and comfort, and it therefore can assist in- A few well-controlled studies suggested signifi-
dividuals in managing painful affective cant improvement in performance by the use
states. The use of audiocassette tapes, writ- of mental rehearsal,62–66 in the promotion of
ten scripts, or recalled imagery exercises weight loss,67 for body-image disturbance,56,68
used in a therapeutic session provides a and in the production of physiological changes
portable “transitional object” that can be such as changes in cellular immune function69
used between therapeutic sessions. The and alterations in skin temperature.70,71 The use
imagery provided by a therapist (such as of guided imagery in the promotion of the re-
the therapist’s taped voice) facilitates the laxation response is well documented,72,73 and
connection between the patient and the relaxation imagery remains a frequently used
therapist and may promote a “therapist treatment, either alone or with subsequent im-
presence” outside of therapy. agery exercises.74,75
4. The specific words and phrases of imagery Imagery has been used in psychotherapy
are tailored within the context of the illness as a method for eliciting insight and feelings
and therefore can incorporate image de- associated with past experiences.76–79 A few
scriptions that are relevant for soothing. studies have made use of imagery as a treat-
5. Imagery is the language of the inner self. ment for depression.80–86 These studies provide
It produces personal images and meta- evidence that various types of directed im-
phorical themes and provides an active agery, either alone or in combination with
and “playful” approach that engages the other cognitive-behavioral approaches, can re-
individual in working with her imagina- duce both self-report and behavioral indices of
tion and in contemplating meaning in the depression.
experience. The subtle, nonintrusive sym- No controlled study has investigated the
bolic character of imagery is less apt to use of guided imagery in BN patients. How-
trigger defenses or resistance, and it fre- ever, bulimia patients have been found to be
quently evokes revelations. As Hutchin- significantly more hypnotizable than patients
son56 notes, “A single image can symbolize with anorexia nervosa and normal age-

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ESPLEN AND GARFINKEL 107

matched populations, and a trend was found therefore available about the specific mecha-
for purging subgroups of anorexic patients.87–90 nisms involved.
There are few controlled trials of hypno- In the literature on imagery, studies report
therapy in eating disorders. However, a num- greater success with the use of images that are
ber of case reports and anecdotal evidence characterized by close approximation to real-
suggest its usefulness as a component of a mul- life situations in that the person actually “feels”
tidimensional treatment program.90–92 A vari- the image (experiencing the sensations as if ac-
ety of approaches in using hypnosis/imagery tually performing the task in the imagery).53
have been presented. For example, its use as a Imagery exercises practiced through the use
relaxation/calming technique has been sug- of audiocassettes were found to be effective
gested (using nature imagery or progressive and superior to self-directed practice by newly
muscle relaxation).93,94 Other suggestions in trained subjects.101
the literature include exercises geared to-
ward increasing awareness of bodily sensa- A M O D E L O F G U I D E D
tions at mealtimes,90,95,96 age-regression I M A G E R Y T R E A T M E N T
techniques aimed at identifying precipitating T O E N H A N C E
events of the eating disorder,52,97 ego-state S E L F - S O O T H I N G
therapy,52 imagery to correct body image dis-
tortions,56,94,97,98 ego-strengthening hypnotic We have developed a conceptual model of
suggestions,51,99,100 cognitive restructuring,52 guided imagery therapy that is relevant for the
and future-oriented age-progressive hypno- treatment of an impairment in self-soothing.
sis involving imagining future goals or life Although we recognize the multidimensional
without an eating disorder and associated nature of BN, we have chosen to focus our
personal changes.96,97 The therapist, there- model on the role of self-soothing, for two pri-
fore, has a large variety of exercises/sugges- mary reasons: 1) treatments geared to affect
tions from which to draw in tailoring a regulation as a feature of the illness have not
hypnotherapeutic/imagery treatment pro- been extensively developed and tested in BN,
gram for any given patient. and 2) the literature on imagery, hypnosis, and
Despite the variety of hypnotic/imagery relaxation has demonstrated that such tech-
suggestions offered, a number of common ele- niques can decrease arousal and therefore
ments are apparent, including the following: suggests their relevance to helping these indi-
1) the identification of the need to decrease viduals build skill in managing affect.
arousal and promote comfort, 2) the recom- The proposed guided imagery treatment
mendation to incorporate audiocassette-taped approach is conceptualized as having “layers”
exercises (made by the therapist or patient) for of active ingredients, with the view that each
practice outside of therapy, and 3) the identi- added layer deepens the effect (Figure 1).
fication of use of metaphors or symbols as a Reading the model from left to right sug-
useful way to explore personal issues (particu- gests each individual layer promotes a psycho-
larly where difficulties with self-expression im- logical-soothing state. Reading downward
pede therapeutic progress).52,90,93,94,96,99 In indicates the additive and simultaneous nature
addition, it has been suggested that these types of the layers in facilitating psychological sooth-
of therapies enhance the development of the ing. It is not necessary to incorporate all of the
therapeutic alliance.94 layers in order to achieve a soothing experi-
In summary, most of the evidence on the ence; in fact, working with one or two levels
use of hypnotherapy, relaxation, or imagery in can achieve significant results. For example,
eating disorders is anecdotal and presents the an unknown soothing voice suggesting com-
described technique as one part of a multicom- forting images can result in the experience of
ponent approach to treatment. Few details are a calm state (as attested by the numerous audio-

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108 GUIDED I MAGERY

cassette relaxation/imagery tapes that are manent capacity for self-soothing.

commercially available). However, the addi- Two types of imagery can be incorporated
tion of a familiar therapist’s voice significantly in imagery exercises: directive, in which the
enhances the effect, and the imagery tape or image is specifically described (“imagine a
exercise may function as a transitional object. meadow”), and nondirective, in which less
Similarly, the further addition of soothing mu- specific description allows for the formation
sic (the therapeutic effects of which are well of more personalized and spontaneous im-
documented54,102) can complement the other agery (“imagine some natural environment”;
components, such as voice and images, in pro- “find some special place”). Some individuals
moting a calm state. experience ambivalence or difficulty with a
The specific words and phrases used in nondirective suggestion and prefer the more
guided imagery exercises are generally de- direct approach. It is important to note that
signed within the context of the illness. Within directive imagery is also personal, as demon-
a self-soothing model, one would use image strated by having different individuals de-
descriptions that are relevant for soothing and scribe the “meadow” experienced in their
ego strengthening. The soothing imagery pro- imaginations.
vided by the therapist’s voice can become in- Difficulties with the technique or the im-
ternalized for self-soothing during vulnerable agery are explored during therapeutic ses-
times, and therefore it can act as a transitional sions. Individuals who have difficulty with
object outside of therapy. Individuals are en- imagining a nondirective exercise can be en-
couraged to practice imagery between sessions couraged to try a more directive imagery ap-
(either with scripts or audiocassette tapes). This proach. Those who have experienced painful
practice assists the individual in becoming fa- emotions through the experience are encour-
miliar with the technique and enhances per- aged to express their feelings. They can be
sonal responsibility and self-efficacy in introduced to alternative, more soothing exer-
regulating emotional states. The guided im- cises, encouraged to build in greater safety in
agery can promote the development of inter- their imageryor, if they are willing, they can
nalized representations (e.g., of the therapist) be encouraged to contemplate and work with
that may provide a future and potentially per- the evoked images (for example, through

FIGURE 1. Guided imagery therapy model.

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ESPLEN AND GARFINKEL 109

dialogue with the imagery: “Is there anything private imagination. These images range from
you would like to say or do with the image?”). the concrete, such as objects or persons, to the
Images used during the early stages of more abstract, such as a color or metaphor.
treatment should suggest an inner atmosphere The therapist guides the individual to concen-
of safety, so as to establish a secure environ- trate and observe the experienced personal im-
ment and raise interest in the identification of ages as they are forming, and this promotes a
emotions and themes that will occur through feeling of being active and creative in the thera-
the more challenging self-exploration exer- peutic process. Such an approach results in a
cises. Imagery themes that may enhance safety kind of “playful” engagement between the
include soothing environments (outdoor water therapist and the individual as she imagines
and meadow scenes, warmth of the sun, a gold- and awaits the images and emotions that
en light, familiar places where the individual emerge during a given exercise. This aspect of
has felt safe), the construction of a protective guided imagery incorporates the elements of
structure, or the inclusion of a trusted individ- self-discovery and spontaneity that Bruch27
ual. The imagination is embedded in bodily and Winnicott51 emphasized as being particu-
experience, and therefore each image is larly important in the treatment of these indi-
accompanied by physical and emotional sen- viduals. The role of creative activities has been
sations.103,104 During the imagery therapy, per- linked to feelings of vitality and a sense of being
sonal images occur spontaneously and bring alive, feelings that appear to be lacking in the
forth reactions. Feelings of fear, surprise, and lives of many with BN.
recognition of earlier experiences are among Personal imagery is frequently abstract,
the reactions that may occur. During or after having metaphorical themes. At times, a pro-
the imagery exercise, the individual is encour- found sense of surprise or discovery is experi-
aged to identify and comment on her bodily enced with emerging images and themes. A
experience. The individual’s attention is di- particular image or metaphor may have sig-
rected by asking questions about these reac- nificant meaning for an individualby being
tions: “How do you feel here?” and “When you linked to an earlier memory or experience, for
observe this image, what feelings come for- example, or providing insight into some be-
ward?” The therapist assists in exploring any havioral pattern or emotion, or shedding light
arising themes or changes in affective states on an important goal. The individual is encour-
that occur. aged to “play” with personal imagery, verbally
According to this model, personal insight engage with the images, rehearse behaviors or
is promoted through soothing exercises in a interactions, and express any corresponding
relaxed state. A relaxed state is viewed as a feelings. Self-expression is encouraged in oral
necessary condition for self-reflection. The and written forms and, if the individual is will-
process of self-reflection occurs at the individ- ing, through more creative modes such as
ual’s level of readiness. It is important for the drawings of the images. These multiple forms
therapist to allow the individual to comment of expression promote communication and re-
on self-experience through several sessions, flection of the imagery experience at cognitive
rather than make interpretations. Personal im- and bodily levels. Encouraging drawings or
agery will be linked to experience, and fre- written expression provides the opportunity to
quently individuals are able to find their own observe and inspect aspects of the imagery and
meaning in the images. assists in identifying emotional reactions and
This process is congruent with Bruch’s27 personal insights.
therapeutic approach, which focused on self- Discussing an issue or feeling through a
experience and discovery. Imagery therapy is metaphor can be experienced as less threaten-
ideal in this regard. The imagery exercises pro- ing because the metaphor or image is viewed
duce personal images within the individual’s in this model as providing permission and

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110 GUIDED I MAGERY

safety for the expression of feeling. At times, Six Imagery Exercises

the individual may be unaware of what is being
revealed and gradually come to identify some 1. “Creation of an Inner Sanctuary”: This exer-
key insight. Further deepening of the process cise has been used in the literature to have
occurs when the identification of an important the individual create a special internal
metaphor is linked to some symbol. Once a place for relaxation and becoming aware
symbol is identified it can carry with it special of feelings.105
meaning, and the therapist explores with the 2. “Exploration of a Meadow”: This exercise
individual methods of integrating new discov- consists of directive imagery and has the
eries into daily living. The individual is encour- individual explore a meadow.106 Its func-
aged to bring this symbol into her life in some tions include promoting the use of all
way. Some individuals may choose to incorpo- senses during imagery, enhancing a re-
rate a real object that serves to remind them of laxation response, and demonstrating to
an important discovery, a goal, or a new skill the individual his ability in doing imagery.
that is being developed, while others may 3. “Creating a Mask”: This exercise has the
choose a color or a symbol in nature to repre- individual imagine discovering a box full
sent some important theme in their imagery. of creative supplies and making a special
This symbolic form of expression can be mask. It helps introduce the individual to
viewed as providing a space in the real world a self-exploration exercise and at the same
where meaning can be represented and stored. time involves participation in a creative
The symbol, in a sense, provides a type of act.
bridge between the individual’s internal world 4. “Color of Self”: This exercise involves hav-
and physical reality. Once based in reality, the ing the individual draw herself as a color
symbol can be used as a reminder of progress, or combination of colors, called a color-
personal strengths, and possibilities for the fu- form. The individual is asked to imagine
ture. This symbolic representation promotes the colorform on paper and to experiment
the integration of new meaning and insight into with a variety of colors of paint, including
experience. a special jar called the “color of aliveness.”
The individual is encouraged to experi-
G U I D E D I M A G E R Y ment with the colors and to note what she
E X E R C I S E S observes. This exercise is designed to be
soothing and to continue with the self-ex-
We have included six major imagery exercises ploration in a creative and playful manner
that can be used for soothing and that promote and frequently addresses body image
self-exploration of the individual’s inner expe- issues.
rience (recognizing that there are other possi- 5. “Theater Scene”: This exercise has the indi-
ble themes that can be used). The two early vidual imagine being in a theater and ob-
exercises familiarize the patient with guided serving his “colorform” in an interaction
imagery, focus on the relaxation response, and (past, current, or future) of his choice. Its
promote increased awareness of inner feelings. goal is to continue the self-exploration to
As the individual becomes familiar with im- the realm of interpersonal relationships.
agery and gains a sense of mastery with the 6. “Design of a Personal Quilt”: This exercise
technique, progress can be made to the more has the individual imagine making a per-
challenging self-exploration imagery exercises sonal quilt through a medium of choice
(exercises 3–6). We have chosen here to pro- and to observe the pattern that is develop-
vide the script for the first exercise, with a brief ing. The exercise is designed to be sooth-
description of the images and goals of the other ing, to continue with self-exploration, and
five. to promote themes of continued growth

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ESPLEN AND GARFINKEL 111

and change. The exercise is viewed as ing from your body. Let the painful feelings go.
creative, and we have found it to be useful . . . Go from your body. . . . They will go . . . and
near the end of therapy to promote an in- soon you will feel more in control . . . and
ternalized feeling of continued develop- more at ease. . . . Continue breathing slowly.
ment and growth, thereby facilitating Continue in . . . and out. . . . Breathing slowly.
termination. . . . Continue to listen to my voice.
Now, continue to focus on relaxing, and I
Example of Imagery Exercise: am going to describe some images. Just follow
“Creation of An Inner Sanctuary” my voice. Continue to breathe slowly and
deeply . . . and allow the images to soothe your
This is an exercise through which I will guide feelings. By continuing to breathe slowly and
you. Just follow my voice and the script, but deeply . . . you will allow any tension that you
remember that you have control over the ex- are experiencing to flow from your body . . .
ercise. Even if you are experiencing a build-up to leave your body. [Further breathing instruc-
of your emotions and feelings, you can use this tions repeated.]
exercise to help you feel relaxed . . . and safe Now, you are beginning to feel more re-
and to help you to gain control and to manage laxed and in control. . . . Continue to close
the feelings that you are experiencing. So, just your eyes and just follow my voice and the
follow my voice and allow the images to come. images that I describe. . . . Imagine yourself in
Try to acknowledge and recognize your feel- some beautiful natural environment. . . . It can
ings as they come forward and know that you be any comforting place that appeals to you
can learn to manage these feelings . . . to un- . . . in a meadow . . . on a mountain . . . in a for-
derstand them . . . and you can feel more re- est . . . or beside a lake or an ocean. It may be
laxed . . . and more in control . . . and some some special place where you have been be-
release from these emotions. . . . Remember, it fore . . . where you felt warm and safe . . . and
will be within your ability to follow these in- where you felt the beauty and strength of its
structions. . . . Just feel my voice and allow atmosphere. If you find difficulty in relating to
your senses and imagination to follow the a place where you have been before . . . imag-
voice. . . . You can feel safe during the exercise ine and create a beautiful, serene, and peaceful
. . . and although you may be feeling some dif- place. . . . It may be another planet if you like
ficulty or pain . . . you will soon feel more re- . . . or a place that you recall from a novel . . .
laxed and in control. Feel free to use all of your or a place in your imagination. . . . The special
senses. . . . Feel the images. . . . Imagine your- place is one of your choice . . . any place that
self experiencing these images. . . . appeals to you . . . one that you would like to
We’re going to begin by focusing on your return to . . . perhaps one that you have cre-
bodily feelings. Make yourself comfortable. . . ated in your own imagination . . . that would
Close your eyes and allow your body to feel have this special, wonderful atmosphere. . . .
loose and comfortable. Take a deep breath . . . Wherever it is . . . it should feel comfortable,
slowly . . . a deep breath. Concentrate on your pleasant, and peaceful to you.
breathing as you count silently to yourself. Feel this environment around you. Use all
Inhale, “In . . . one . . . two. . . . Out . . . one . . . of your senses . . . the beauty of it that you see
two . . . [repeated several times]. Feel yourself . . . the quiet and pleasant rhythmic sounds of
relax as you breathe. . . . Breathe out slowly the environment. . . . Feel the warmth on your
. . . . Concentrate on your breathing . . . slowly skin . . . the breeze feels so warm and gentle. . . .
and deeply . . . breathing deeply. . . . Feel the Notice the smells in this environment. . . . It
air going into your lungs . . . out of your lungs. feels familiar to you. . . . Your senses are open
As you breathe out, notice that you begin to to all of the atmosphere’s textures, smells,
feel more and more relaxed. Tension is drain- sounds . . . .and warmth. . . . Explore your en-

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112 GUIDED I MAGERY

vironment, noticing all of its details. . . . This about this place . . . and you do not have to
is your special place . . . and notice the feelings share it with anyone if you don’t want to. . . .
and impressions that you are beginning to ex- This place will become more and more famil-
perience. iar to you as you visit it repeatedly, over time
Now, continue exploring your surround- . . . and it will become more and more easy for
ings . . . and do anything that you would like you to recall this place as you continue to visit
to do to make it your special place and com- it when you are feeling frightened . . . or tense
fortable for you. . . . If you would like to build . . . or angry . . . for any reason. . . . You can
some type of shelter or house . . . begin to even visit it any time you want to feel that com-
imagine its structure. . . . Or perhaps you fort . . . and trust . . . or when you wish to ex-
would like to surround the whole area with a plore your own inner feelings . . . and thoughts
golden light of protection and safety. . . . Cre- . . . It is always open . . . any time . . . at night
ate and arrange things that are there for your . . . or during the day. . . . This place is to help
convenience . . . and enjoyment . . . in order you to explore . . . to heal . . . and to feel more
to establish it as your special place. in control and in touch with your experience
Create a kind of sanctuary . . . one that is of your mind and your body.
only yours . . . so that when you need to visit You may want to make changes and addi-
this sanctuary you can at will. . . . Every time tions to your sanctuary . . . from time to time
that you return you will feel these warm feel- . . . and you are free to add things to it . . . but
ings. . . . These feelings of safety . . . and in- it will always remain peaceful . . . and tranquil
creased understanding . . . and peace. . . . You . . . and you will always feel safe here. . . . It is
can come here to explore yourself. . . . To find comforting and has a soothing atmosphere. . . .
this calmness and to experience and enjoy it. Now, you may stay within your inner sanc-
. . . When you need to get away . . . from mo- tuary as long as you wish. . . . And when you
ments of tension. . . . are ready to leave . . . just count backwards
This can be your inner sanctuary. . . . It’s slowly from five . . . to . . . one . . . and you can
very personal . . . and you can explore your leave . . . by focusing again on your breathing
feelings . . . and your thoughts and come here and bodily feelings. . . . Notice how relaxed
to recognize your feelings . . . and understand you feel. . . . The tension that you felt before
why you are experiencing these feelings. . . . has left and you feel more in control . . . and
Allow the calmness here to help you . . . to feel more calm . . . and you feel more positive . . .
safe . . . to come in touch with your feelings . . . and trustworthy . . . that you can be in touch
and to learn new things about yourself and with your inner self . . . and feelings. . . . You
your feelings. . . . feel much more relaxed. . . . [Repeat of breath-
This calmness will always be in your per- ing exercises to end of exercise.]
sonal place. . . . It will be soothing and familiar,
and it can be reached when you need to feel
Case Example
comforted. You can return at any time to this
special place by closing your eyes and desiring
to be there. You will come to recognize and “Helen” is a 23-year-old woman, living with her
always feel these comforting feelings and in a boyfriend and attending university. She has a his-
sense your imagination can become a trusting tory of anorexia nervosa, which developed at age
15 following a move with her parents to Den-
friend that will help you to return to this place
mark from Canada. At the age of 19 and after
. . . when you need to . . . just by closing your reaching her “goal weight” of 108 pounds (she is
eyes . . . or by following my voice on the tape. 5 feet 4 inches tall), which followed an intensive
Sense this personal inner sanctuary as a treatment program, she began engaging in binge
healing and relaxing place. . . . It belongs only eating and self-induced vomiting on a regular ba-
to you. . . . You are the only one who knows sis. By the age of 23, she had returned to Canada

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ESPLEN AND GARFINKEL 113

and was able to eat regular meals daily and had university that she sought treatment for her binge-
somewhat accepted her body weight; however, ing/purging. At that time she continued to have
she had been unable to stop binge/purge epi- conflictual feelings and anger toward her parents,
sodes (reporting 3 to 6 episodes weekly), which and when beginning the imagery therapy she de-
prompted her to seek treatment. scribed intense negative feelings around her past
Helen was introduced to imagery through experiences in Denmark.
individual outpatient psychotherapy in a random- Helen was encouraged to explore “the
ized trial of guided imagery. In this trial, imagery stone house” that presented itself consistently
was the focal psychotherapeutic technique, with through many of the exercises described above
no concurrent therapy other than self-monitoring (for example, during the meadow scene, and
of eating symptoms. The therapist conducted the again when “making her mask,” she was in the
“inner sanctuary” exercise during an early ses- stone house). The therapist pointed out that the
sion. Helen’s visualized “place” where she felt stone house appeared to be a refuge and a place
comfort was a “stone house” that she imagined of calming (according to Helen’s verbalization on
being located in Denmark. When asked to ex- her imagery), and yet it was in an environment
plore what was so special about this place, Helen that she associated with strong and intense nega-
eloquently described feeling “safe,” “peaceful,” tive feelings. Helen, too, made this observation
and “protected” and in some way even “more se- and was encouraged over time to explore in de-
cure.” She was encouraged to practice this first tail what it was about the stone house that was so
scenario, daily, particularly around her bingeing meaningful for her and contributed to her feeling
and purging behaviors. Following her first week so secure. She described the house as not being
of therapy, she reported using the taped exercise particularly familiar to her (there are many in
on several occasions, and was able to discontinue Denmark), but as being “strong,” “old,” “natural,”
3 episodes of bingeing by listening to the taped and “very real”; as not being “brightly colored”
version of the inner sanctuary exercise. During or “perfect,” but as having “depth” and a comfort-
her sessions, she was encouraged to explore in de- ing solitude.
tail her experiences in Denmark and the image of As Helen progressed in therapy and ex-
the stone house (which became a central theme pressed her feelings about her imagery through
during her sessions). her drawings of images and verbally during thera-
Her history revealed that her parents had peutic discussions, it became evident to her that
moved from Canada to Denmark when Helen she saw herself as “not measuring up to others,”
was 14, following her completion of primary feeling inadequate, and wondered how her boy-
school. Helen recalled feeling “popular,” “confi- friend could care for her. When alone at home
dent,” having “numerous friends” (including a prior to his return in the evening, she would expe-
boyfriend), participating in athletics, excelling at rience strong urges to binge and purge. However,
school, and being healthy in Canada. After her ar- over time it became clearer through her descrip-
rival in Denmark she found herself having diffi- tions of the house that she admired the qualities
culty making friends. She felt uncomfortable in a of the “stone building” in contrast to personal
foreign country and began to strongly resent her qualities she described as being “superficial” and
parents for taking her away. She found solace uncomfortable for her. Her innermost yearnings
only in skating and became competitive in the seemed to be for self-qualities that she described
sport, participating in little else. It was at this time in terms of the house; for example, she revealed
that she began to severely restrict her food intake, that her chief goal was to engage in academics
developing anorexia nervosa. She also relayed and produce “meaningful” and “worthwhile”
feelings of fear in relation to dating male col- work that would be of enduring quality. How-
leagues, particularly around her feelings of sexual- ever, she felt she could never “permit” herself to
ity, as she perceived the students in Denmark to engage in courses that she desired, such as phi-
be permissive and “more mature.” She became losophy or historical literature. She believed that
so ill that she was hospitalized at that time, de- her family and friends did not see that she had
spite being successful in her competitive skating. such qualities within her. In addition, despite hav-
It was several years later (after Helen returned ing participated in athletics and “the glamour of
with her family to Canada and following her treat- performing,” she felt unfulfilled by these accom-
ment for anorexia) and while she was attending plishments and had never experienced a sense of

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

114 GUIDED I MAGERY

esteem (despite many hours of preparation to- focusing on her specific images during the
ward achieving goals in her skating). therapeutic sessions (and in her journal) she
As the imagery therapy progressed, Helen came to the conclusion that the stone house
was encouraged to visualize the “stone building”
represented some aspect within her that was
regularly in a sensory way and to explore her at-
tachment to this image and its meaning for her.
hidden from others and kept private. Perhaps
Her personal imagery became a vehicle through because it was her own personally evoked im-
which she could disclose (metaphorically at first) age (rather than one suggested by the thera-
her innermost feelings, express her pain associ- pist), it became particularly meaningful and
ated with being in Denmark and her feelings to- solacing for her, and she repeatedly called
ward her parents. Over time she was able to upon it for comforting and to inspect its mean-
grasp something more positive from her time ing. The therapist acted to guide the patient to
there, rather than to view it as “wasted and pain- explore the imagery, and as themes emerged
ful years of her life.” After her 6 weeks of im-
asked the patient to inspect them and to de-
agery therapy, she was able to describe her
experiences in Denmark as possibly contributing
scribe any associated feelings or interpreta-
to the development of personal qualities such as tions. This procedure is similar to Bruch’s27
“strength,” “endurance,” and “substance” that she “fact-finding” approach, which she believes to
was beginning to sense she possessed as she ex- be crucial for promoting self-discovery and
plored her imagery. The therapist encouraged autonomy.
her to remain in touch with these qualities (“to re- Helen, through her imagery, was able to
ally feel them”) and to allow them to fully de- further understand from a new perspective her
velop. She was encouraged to nurture the development of an eating disorder and to learn
qualities that she valued and to share them with
about personal issues that may be contributing
others over time as she felt comfortable. She also
came to recognize the house and its special quali-
to her need to binge/purge, despite having nor-
ties as representing her and her personal experi- malized eating and feeling fairly comfortable
ence in Denmarkand, interestingly, as being with her body weight. She frequently had com-
separate from the experience of her parents. This mented on the fact that she had gone through
was an important self-discovery for her to make, previous treatments and addressed other issues
given that she felt so “cheated” and “controlled” (such as her weight), and yet, could not under-
in being taken from a comforting safe environ- stand her lack of control at times over her eat-
ment to an unknown country, contrary to her ing and self-induced vomiting. Helen received
wishes to remain in Canada.
the guided imagery without any concurrent
By the end of the 6 weeks, Helen had only
occasional binge/purge episodes (1 or 2 every
therapies (other than maintaining self-moni-
few weeks) and reported a greater sense of con- toring of her eating symptoms as part of her
trol. She also reported an increase in her mood personal journal). However, the therapist re-
level and a renewed life interest. She continued frained from making comments/recommen-
to utilize the imagery for self-comforting in con- dations on her eating and kept a focus on her
nection with her exams and her eating urges, and experienced imagery, suggesting that her in-
she shared her personal experiences with her im- sights and behavioral changes appeared to
agery with her boyfriend. She had also discussed have occurred as a result of the imagery ther-
her feelings more openly during a visit to her
apy.
parents.
G U I D E D I M A G E R Y
This case example is useful in highlighting R A N D O M I Z E D T R I A L
the elements in the imagery model as well as
demonstrating the patient’s acceptance of the The guided imagery model described above
imagery therapy as a comforting device and has been applied in a recent study described
participatory experience. Helen took an active elsewhere.107 A randomized controlled trial
role, the imagery was “personal,” and through compared patients receiving 6 weeks of indi-

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ESPLEN AND GARFINKEL 115

vidual guided imagery therapy (with self- S U M M A R Y

monitoring of symptoms) with a control group
of untreated BN patients (which controlled for In summary, BN has been linked to a difficulty
therapist contact and self-monitoring of symp- in the ability to modulate affects or in self-
toms). Fifty participants who met DSM-III-R soothing. This conceptualization suggests the
criteria for BN completed the study. Scores on need to design treatments that specifically tar-
measures of eating disorder symptoms, psy- get the problem of affect regulation and that
chological functioning, and self-reports associ- assist these individuals in comforting them-
ated with the experience of guided imagery selves. A model of guided imagery therapy has
therapy were obtained. The guided imagery been described that can be used to provide an
treatment had substantial effects on the reduc- external source of soothing and to enhance
tion of bingeing and purging episodes; the im- self-soothing. The model suggests that imagery
agery group had a mean reduction of binges therapy has multiple levels of action that can
of 74% (P < 0.0001) and of vomiting of 73% (P assist these individuals in the regulation of af-
< 0.0001). The imagery treatment also demon- fect. A case report and preliminary evidence
strated improvement on measures of attitudes from a randomized trial have demonstrated its
concerning eating, dieting, and body weight in effectiveness in improving eating disorder
comparison to the control group. In addition, symptomatology and in promoting self-com-
the guided imagery group demonstrated im- forting at least in the short term, possibly by
provement on psychological measures of providing patients with a transitional object.
aloneness (P < 0.05) and the ability of self-
comforting (P < 0.001). Evidence from this
preliminary study suggests that guided im- The authors acknowledge the valuable suggestions of
agery is an effective treatment for BN, at least Dr. Ruth Gallop and the helpful comments con-
in the short term, and promotes psychological tained in the anonymous referees’ reports on the first
soothing. draft of this paper. This work was partially sup-
ported by the Ontario Mental Health Foundation.

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