Imaging and doing are not as different as they sound

So, why do we still dismiss things by saying, "Oh, it's all in your head?"   If visualization changes muscle strength and imagery lights up the brain in the same way as if we were seeing an object in the outer world, then the power of imagination could be immense.   We should probably spend as much time visualizing as doing.

When I used to teach medical students and residents emergency medicine, I taught intubation, the insertion of chest tubes, and the insertion of central lines in this way.   I taught the learners to sit quietly before proceeding and to take themselves through every step of the procedure in their mind's eye.   They visualized the relevant anatomy as it would appear in the patient.   They watched themselves calmly doing what was necessary to accomplish the procedure.   When they had completed it and felt pleased with their ability and skill, I would ask them to open their eyes and then repeat what they had just done on an actual patient.   Their success rate was much higher for their first try than it would have been had they not imagined first.   Indeed, I did this before every procedure, and I had the reputation even with the anesthesiologists of being able to intubate anyone (that means putting a tube into a person's trachea, through the vocal cords, so that we can breathe for them using a ventilator).

In an airport restaurant, I heard a pilot telling learners whom he was training to fly a new airplane that they should sit with their eyes closed and visualize every aspect of a perfect take-off before flying the airplane.   He recommended doing the same procedure before landing the plane.   He told them he understood that they might think he sounded crazy or silly, but he guaranteed them that this really worked and not to knock it until they tried it.   I got his attention as their group was breaking up and told him about my experience teaching emergency medicine.   He was grateful to hear that he was not the only person on earth who had discovered the power of visualization.   He had figured it out as a high precision fighter pilot in the Air Force.

When I was still doing obstetrics as a family physician, I would do birth visualizations with as many of my clients as would do so.   In this procedure, I would talk the woman through a relaxation process in which she would slow down her breathing, heart rate, reduce muscular tension, and enter into a light state of suspension of thinking.   Then I would ask her to imagine herself giving birth and to tell me about it.   I would pay close attention to how much her experience resembled the normal birth.   When she was finished, I would take her on a corrective guided imagery journey through giving birth in which I emphasized parts that she had left out and provided her with a more realistic rehearsal.   I often made a recording for the women to use later so that they could go through birth many times before actually giving birth.   I published a study on this approach in the American Journal of Clinical Hypnosis in 2004 in which I had actually randomly assigned 520 women to either imaginary rehearsals of birth or just talking to me about their stressors and problems.   The women in the rehearsal group had significantly fewer birth complications, shorter labor, used much less medication and/or anesthesia, and had fewer Cesareans than the women in the supportive psychotherapy group.   Perhaps I made a mistake in calling this hypnosis, for it's become too easy to dismiss hypnosis, even though it's an element of all that we do that uses words and persuasion.   Perhaps I should have published the study in a journal about guided imagery or visualization.   If I had access to a neuroimaging device, I could have perhaps shown that the brains of these women changed.

In a similar vein, neuroscientist Pascual-Leone taught two groups of people who had never studied the piano a sequence of notes, showing them which fingers to move and letting them hear the notes as they were played.   Then, the "mental practice group" imagined both playing the sequence and hearing it for 2 hours per day for 5 days.   A physical practice group played the music 2 hours per day for 5 days.   Both groups learned to play the sequence with remarkable similar brain changes.   The level of improvement in the mental practice group was not as great as those in the physical practice group, but one two hour physical practice session erased these differences, and, then, both groups performed equally well.  

What's important for us clinically, in medicine and psychology, is the realization that imagination of illness can be a powerful force to make people sick.   Last night I arrived to Hawaii for a conference, and, of course, this morning I was awake at 4 am thanks to the five hour time difference between Vermont and Hawaii.   I turned on the television and saw an old Dr. Kildare movie on Turner Classic Movies channel.   To my surprise, in the 1930s when these movies were made, people were aware that our minds could make us sick.   Dr. Kildare was trying to convince a young debutante that she was making herself sick with her thoughts.   As Jeffery Schwartz (my apologies to him for sometimes renaming him Jeremy) points out, if mind can change brain, mind is a powerful force.   This is the essence of how rehearsing a story over and over changes our physiology.   If we tell ourselves a downtrodden, sad story about how useless we are, and how we matter to nobody, our bodies will eventually respond to that story physiologically and will conform to that expectation.   If we tell ourselves happy stories about how many people love us and care about us and about how useful we are and helpful we are to others in the world, our bodies will eventually mold to embrace that reality.

In psychiatry and in mental health in general, we generally train our patients to tell themselves stories that keep them feeling defective and continue to isolate themselves.   We convince them that they will never change and will have to take medication for the rest of their lives.   We encourage them to be content living on disability and welfare.   We don't challenge them to do more.   So they tell these stories to themselves and that's what they become.   It seems too hard for many of my patients to imagine doing anything but watching television and playing videogames.   My challenge has been to encourage them to get out of their houses and apartments, to actually go into the public arena and mingle with other people, to attend events and groups, to rejoin the mass of humanity who is searching for meaning and purpose and for connection to each other, to imagine themselves well and happy.   I have found that when I ask my patients what they mean by "feeling normal" or "feeling happy" or "feeling myself again", which is what they say they want to feel, most cannot describe this.   They can't imagine what it would feel like.   If they can't imagine, they can't get there.

Similarly, if people with pain can't imagine being free from pain, how can they get there?   If people who have asthma can't imagine breathing freely and easily, how can they get there?   If people with mobility problems can't imagine walking, how can they get there?   There's no end to what we can imagine.   The typical biomedical response is to say that people will feel worse about themselves if they imagine walking and then don't.   However, I feel the opposite.   At least they had the joy of imaging movement again.   I think we need to be more playful about our imagination, and playfulness is an area of difficulty for conventional medicine and psychology.

Consider my friend, Elly, who had a dream about her mother.   In her dream, she was landing a plane in a field of golden flowers through a beautiful sunrise.   Here mother was standing at the end of the field.   The flowers made the perfect runway for the plane.   Elly exited the plane and told her mother everything she'd wanted to say to her mother before he mother died, but didn't.    Her mother received her communication very warmly and lovingly.   Elly felt embraced and supported by her mother.   Her mood was different upon awakening.   She had transformed through the imagination in a dream as if she had resolved matters with her mother.   In some indigenous beliefs, perhaps she had.   Nevertheless, we see the power of imagination, the power of "as if".

It's this power that makes placeboes so incredibly effective and that underlies much of what is healing, and, it's this power that we need to more intentionally address and mobilize in our health care efforts.