Guided Imagery Treatment to Promote Self-Soothing in Bulimia Nervosa: A Theoretical Rationale

Abstract

Bulimia nervosa (BN) has been described as involving impairment in affect regulation and in self-soothing. Such a conceptualization suggests the need to design treatments that specifically target these problems in order to assist individuals with BN in comforting themselves. A model of guided imagery therapy suggests that imagery therapy has multiple levels of action and can assist these individuals in the regulation of affect by providing an external source of soothing and also by enhancing self-soothing. The authors illustrate the model with a case example and report the results of a study in a clinical sample of BN.

Bulimia nervosa (BN) is characterized by a loss of control over eating, in the form of bingeing episodes and extreme attempts to control body shape and weight. It entails a set of attitudes frequently described as a morbid fear of becoming fat, or concerns regarding weight and shape that unduly influence the evaluation of the self. Since the description of BN in 1979, ¹ a number of treatment approaches have demonstrated efficacy, at least in the short term.^2–4 However, the treatments shown to be helpful often address only the conceptual or cognitive and behavioral aspects of the disorder, and, moreover, a significant number of patients do not respond to current treatments.^5–8 The difficulty that BN patients have with affect regulation, feelings of emptiness, 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 suggests the need to design treatments that specifically target the problem of affect regulation and that help these patients comfort themselves. In this article we review the literature on self-soothing and propose a conceptual model of guided imagery therapy to address the difficulty of affect regulation.

The Capacity for Self-Soothing

The ability to manage or regulate tension (affect) has been referred to in the psychodynamic literature as the capacity for self-soothing.^13–15 This capacity is believed to develop through the internalization of earlier soothing or comforting experiences. Later, as children mature, they are able to soothe themselves with fantasies, images, and memories of interaction. In this regard, Winnicott¹⁶ described the notions of “good-enough mothering” and the “holding environment” and emphasized the empathic bond between mother and child; he also outlined the broad limits of what might be “good enough.” He introduced the term transitional phenomena, referring to various soothing experiences and behaviors such as the infant's repetitive babbling sounds and the holding of a soft blanket against the skin. It is believed that the infant, at the stage of recognition memory, is able to keep in his awareness the soothing of the mother through the holding and feeling of a familiar object that is reminiscent of her touch. With the development of “evocative memory,” the infant develops the ability to produce a mental image of the object (mother) in her absence.

The internalization of earlier soothing experiences allows the progressive separation of the child from the mother and becomes crucial in the development of the capacity to be alone. The child is able to leave the mother's bosom when he can find something of her nurturance in the external world. Therefore, the child no longer depends fully on the presence of actual people for comfort. The child is able to soothe himself with fantasies, images, and memories of earlier interactions with objects that resonate with the soothing maternal presence. This capacity, referred to as the ability for “transitional relatedness,” has been defined as “the person's unique experience of an object whether animate or inanimate, tangible or intangible in a reliable soothing manner based on the object's association or symbolic connection with an abiding mainly maternal primary process presence” (Horton,¹³ p. 35).

Although there is general agreement among professionals that very young children usually make healthy use of growth-facilitating soothers, the existence of soothing (solacing) methods at later stages of development has yet to be sufficiently researched.¹³ Soothers in early childhood or transitional objects, exemplified by the blanket, stuffed animal, and favorite tune, are normally replaced by increasingly subtle and complex vehicles for growth and solace through a lifelong series of progressive psychological transformations.¹³ As Horton¹³ notes, “Maturation is accompanied by increasing sensitiveness to the qualities of potential solacing objects” (p. 129).

Typical intermediate objects include imaginary companions, tunes, fairy tales, poetry, religious figures, prayers, works of art, mentors, the church, spouses, lovers, and friends. It is the relationship with these objects that protects an individual from aloneness and fear and serves to propel an individual to the next stage of finding the highest good in self and others.^13,17 This developmental process may result in considerable refinement to higher-order object relations as experienced in “oceanic,” “near-death,” and “creative” experiences.^13,16

For individuals who lack the capacity for self-soothing, a particularly vulnerable time exists when they are alone, because the chief function of self-soothing has been linked to the development of the capacity to be alone.^{12,13,18–21} During these times the individual is left to his own resources for self-comforting and the maintenance of a calm state. An impairment in this self-function may be indicated when emotional arousal of panic or fear is experienced, resulting in behaviors such as bingeing or addictive behaviors coming into play as a response to the experienced discomfort and inner pain.^22,23

Empirical Literature

Conceptualizations of early development related to self-soothing have been used to understand addictive behaviors,^13,24,25 BN,^9–11,26 anorexia nervosa,^27,28 obesity,²⁹ and borderline personality disorder (BPD).^{14,18,22,30–32} Researchers have found that eating-disorder patients have difficulties identifying, verbally expressing, and regulating all forms of physical tension.^27,33–36 The literature has identified a primitive inability among these patients to verbalize emotion, despite being articulate in other areas.²⁷ This difficulty leads these patients to a state that is “incommunicable” at times and experienced as an “extreme state of tension,” while at other times it is characterized by feelings of emptiness that they cannot soothe.^26,37 Researchers and theorists have suggested that binge eating and vomiting, as well as drug or alcohol abuse, represent an attempt to artificially modulate negative affect and, in a sense, to numb the pain.^8,26,27 Bruch²⁷ linked the sense of loneliness, the feeling of not being listened to or understood, and the pervasive sense of emptiness to eating binges. A preoccupation with food and bingeing and purging behaviors can be thought of as filling a need to relieve pain, and the individual may rely on these behaviors for this function. The psychological pain becomes a physical one, and emotional experience is concretized.³⁸

Individuals with eating disorders have been described as maintaining strong efforts directed at avoiding any arising tension; this pattern can lead to a self-organization of extreme compliance and self-control, best exemplified by Winnicott's term false self.¹⁶ The false self consists of an outer self that provides an appearance of compliance and high levels of functioning, control, and self-esteem; this false self serves to protect the inner self from being revealed. This way of being in the world can result in feelings of deadness, numbness, and emptiness and a state characterized as being devoid of feeling and spontaneity.

Few studies have been conducted to systematically investigate these phenomena in adult clinical populations. A recent study by Richman and Sokolove³⁰ investigated the borderline experience of extreme aloneness, suggesting an incapacity for self-soothing. Adler²² expanded on the “empty, desperate” aloneness experienced by borderline patients, emphasizing that these patients cannot rely on their own internal resources to hold and soothe themselves when faced with separations, and consequently they experience the panic of total aloneness and abandonment.

Generally, studies thus far have focused on patients with BPD and have found that these individuals use more maladaptive soothing behaviors^39,40 and have fewer transitional objects, or show rigid or maladaptive use of their transitional objects throughout their development.^39,41 Studies investigating clinical populations have found an association between psychopathology and an incapacity for self-soothing (Gunderson et al., 1985⁴¹; R. Jampel et al., unpublished, 1983).

There have been no previous investigations to study the self-soothing capacity of BN patients. In clinical populations of BN, behaviors such as binge/purge episodes, theft, wrist-slashing, substance abuse, and sexual activity are common.^42–44 In addition, a distinct subgroup of “multi-impulsive” bulimics (those who display more than one impulsive symptom) has been identified and associated with poorer prognosis and the diagnostic overlap with BPD.⁴⁵ There is some empirical evidence to suggest that individuals with eating disorders have difficulty identifying, verbally expressing, and regulating forms of physical tension, including hunger and emotional states.^27,33,46 The construct of alexithymia, defined as an inability to identify and express emotions and to distinguish between emotional states and physical sensation, has been described among eating-disordered patients.^47,48 It has been suggested that this ego deficit has significant effects on the early relationship of self to body.²⁶ It is not clear how this develops. Bruch²⁷ identified a group of patients who believed that they had been physically or emotionally “insulted.” She believed that they were particularly vulnerable to eating disorders. Recent community and clinical studies have demonstrated a significant number of women with eating disorders who have been sexually abused.^49,50

Implications for Treatment

Treatment approaches stemming from an object relations framework have focused on the roles of empathy and the holding environment as they relate to people with deficits in the capacity for self-comforting.^13,15,19 These approaches propose that therapeutic work occurs in the transference relationship and that patients are provided with a new opportunity for the internalization of self-regulatory structures that had failed to develop in early life. The repeated working-through of disruptions and events in therapy leads to a greater capacity to sustain empathic failures in relationships. Interpretations offered by the therapist assist in providing meaning and coherence, as well as practice in naming affective experiences.

Psychodynamic theorists have emphasized the value of interpretation, but others have cautioned against it. Winnicott^16,51 noted that therapist interpretation may pose a danger in that it may serve to repeat experiences such as intrusiveness or lack of validation in early caregiving. He suggested that any accurate interpretation for which the patient is not ready can reach the innermost self and evoke the most primitive defenses. The most valuable interpretation has been described as one that is “felt” and “created” by the patient.^27,51

For effective treatment, it is decisive that a patient experience himself as an active participant in the therapeutic process. If there are things to be uncovered and interpreted, it is important that the patient makes the discovery on his own and has a chance to say it first. The therapist has the privilege of agreeing or disagreeing if it appears relevant. Such a patient needs help and encouragement in becoming aware of impulses, thoughts and feelings that originate within himself. (Bruch,²⁷ p. 338)

Bruch believed that this approach promoted the development of patients' untapped resources such as autonomy, initiative, and self-responsibility and would lead to a feeling of aliveness as to what is going on within themselves.

More recently, self-psychological treatment approaches have highlighted the role of validation of subjective experience. This role involves assisting the patient in establishing an attitude of interest in, and a feeling of acceptance of, her own emotional life.^11,18,46 These authors propose that such an approach strengthens tolerance of affect and the growth and development of functional capacities to assist in regulating affects and impulses, resulting in a sense of mastery and enhanced self-esteem.

Adler and Buie¹⁸ suggest that individuals who lack sustained mental representations of others are prone to the experience of recurrent fears and panicky reactions—particularly around the notion that the therapist does not exist in the intervals between therapeutic sessions. These authors emphasize the importance of a sense of continuity and stability within the relationship to allow for the internalization of more stable soothing representations. For example, in the treatment of BPD, telephone contact with the patient “at the time of emergencies” between therapy sessions is a means of providing concerned attention and fulfills the patient's need to evoke soothing object representations that can offset the fear of being alone.¹⁸ Other techniques that may be useful for delaying interpersonal contacts include encouraging reading or other distracting activities, tape-recorded therapy sessions, and encouraging increased social activities. Such activities help patients learn adaptive behavioral responses and lead to an increase in the tolerance for affects.^18,52

The literature on difficulty in affect regulation (self-soothing) and the inability to tolerate aloneness led us to the speculation that guided imagery as a therapy may facilitate the internalization of soothing experiences and the use of a therapist for self-soothing.

Guided imagery therapy provides an ideal opportunity to address the difficulty of affect regulation in BN for a number of reasons:

1. Guided imagery occurs within the context of a therapeutic relationship, thereby facilitating the role of empathy and the development of a holding environment.

2. The efficacy of guided imagery for enhancing the relaxation response and a calm affective state has been well documented.^52–55

3. Guided imagery provided by the therapist can act as an “external” source of soothing and comfort, and it therefore can assist individuals in managing painful affective states. The use of audiocassette tapes, written scripts, or recalled imagery exercises used in a therapeutic session provides a portable “transitional object” that can be used between therapeutic sessions. The imagery provided by a therapist (such as the therapist's taped voice) facilitates the connection between the patient and the therapist and may promote a “therapist presence” outside of therapy.

4. The specific words and phrases of imagery are tailored within the context of the illness and therefore can incorporate image descriptions that are relevant for soothing.

5. Imagery is the language of the inner self. It produces personal images and metaphorical themes and provides an active and “playful” approach that engages the individual in working with her imagination and in contemplating meaning in the experience. The subtle, nonintrusive symbolic character of imagery is less apt to trigger defenses or resistance, and it frequently evokes revelations. As Hutchinson⁵⁶ notes, “A single image can symbolize or arouse an entire constellation of meanings, which can then be explored” (p. 158).

6. Increased awareness and self-reflection during guided imagery facilitate the experience, and the identification, of emotions and themes that can be validated.

7. Self-experience is enhanced through various modes of expression of the imagery, including verbal and written forms and drawings.

A Guided Imagery Treatment Approach

Guided imagery has been used in a variety of clinical areas, and empirical studies have supported its wide-ranging applications. Imagery has been extensively used as a therapy in oncology, particularly in symptom and stress management,^55,57–59 and more actively as a healing imagery focusing on the cancer.^58,60,61 A few well-controlled studies suggested significant improvement in performance by the use of mental rehearsal,^62–66 in the promotion of weight loss,⁶⁷ for body-image disturbance,^56,68 and in the production of physiological changes such as changes in cellular immune function⁶⁹ and alterations in skin temperature.^70,71 The use of guided imagery in the promotion of the relaxation response is well documented,^72,73 and relaxation imagery remains a frequently used treatment, either alone or with subsequent imagery exercises.^74,75

Imagery has been used in psychotherapy as a method for eliciting insight and feelings associated with past experiences.^76–79 A few studies have made use of imagery as a treatment for depression.^80–86 These studies provide evidence that various types of directed imagery, either alone or in combination with other cognitive-behavioral approaches, can reduce both self-report and behavioral indices of depression.

No controlled study has investigated the use of guided imagery in BN patients. However, bulimia patients have been found to be significantly more hypnotizable than patients with anorexia nervosa and normal age-matched populations, and a trend was found for purging subgroups of anorexic patients.^87–90

There are few controlled trials of hypnotherapy in eating disorders. However, a number of case reports and anecdotal evidence suggest its usefulness as a component of a multidimensional treatment program.^90–92 A variety of approaches in using hypnosis/imagery have been presented. For example, its use as a relaxation/calming technique has been suggested (using nature imagery or progressive muscle relaxation).^93,94 Other suggestions in the literature include exercises geared toward increasing awareness of bodily sensations at mealtimes,^90,95,96 age-regression techniques aimed at identifying precipitating events of the eating disorder,^52,97 ego-state therapy,⁵² imagery to correct body image distortions,^56,94,97,98 ego-strengthening hypnotic suggestions,^51,99,100 cognitive restructuring,⁵² and future-oriented age-progressive hypnosis involving imagining future goals or life without an eating disorder and associated personal changes.^96,97 The therapist, therefore, has a large variety of exercises/suggestions from which to draw in tailoring a hypnotherapeutic/imagery treatment program for any given patient.

Despite the variety of hypnotic/imagery suggestions offered, a number of common elements are apparent, including the following: 1) the identification of the need to decrease arousal and promote comfort, 2) the recommendation to incorporate audiocassette-taped exercises (made by the therapist or patient) for practice outside of therapy, and 3) the identification of use of metaphors or symbols as a useful way to explore personal issues (particularly where difficulties with self-expression impede therapeutic progress).^{52,90,93,94,96,99} In addition, it has been suggested that these types of therapies enhance the development of the therapeutic alliance.⁹⁴

In summary, most of the evidence on the use of hypnotherapy, relaxation, or imagery in eating disorders is anecdotal and presents the described technique as one part of a multicomponent approach to treatment. Few details are therefore available about the specific mechanisms involved.

In the literature on imagery, studies report greater success with the use of images that are characterized by close approximation to real-life situations in that the person actually “feels” the image (experiencing the sensations as if actually performing the task in the imagery).⁵³ Imagery exercises practiced through the use of audiocassettes were found to be effective and superior to self-directed practice by newly trained subjects.¹⁰¹

A Model of Guided Imagery Treatment to Enhance Self-Soothing

We have developed a conceptual model of guided imagery therapy that is relevant for the treatment of an impairment in self-soothing. Although we recognize the multidimensional nature of BN, we have chosen to focus our model on the role of self-soothing, for two primary reasons: 1) treatments geared to affect regulation as a feature of the illness have not been extensively developed and tested in BN, and 2) the literature on imagery, hypnosis, and relaxation has demonstrated that such techniques can decrease arousal and therefore suggests their relevance to helping these individuals build skill in managing affect.

The proposed guided imagery treatment approach is conceptualized as having “layers” of active ingredients, with the view that each added layer deepens the effect (Figure 1).

FIGURE 1.

Reading the model from left to right suggests each individual layer promotes a psychological-soothing state. Reading downward indicates the additive and simultaneous nature of the layers in facilitating psychological soothing. It is not necessary to incorporate all of the layers in order to achieve a soothing experience; in fact, working with one or two levels can achieve significant results. For example, an unknown soothing voice suggesting comforting images can result in the experience of a calm state (as attested by the numerous audiocassette relaxation/imagery tapes that are commercially available). However, the addition of a familiar therapist's voice significantly enhances the effect, and the imagery tape or exercise may function as a transitional object. Similarly, the further addition of soothing music (the therapeutic effects of which are well documented^54,102) can complement the other components, such as voice and images, in promoting a calm state.

The specific words and phrases used in guided imagery exercises are generally designed within the context of the illness. Within a self-soothing model, one would use image descriptions that are relevant for soothing and ego strengthening. The soothing imagery provided by the therapist's voice can become internalized for self-soothing during vulnerable times, and therefore it can act as a transitional object outside of therapy. Individuals are encouraged to practice imagery between sessions (either with scripts or audiocassette tapes). This practice assists the individual in becoming familiar with the technique and enhances personal responsibility and self-efficacy in regulating emotional states. The guided imagery can promote the development of internalized representations (e.g., of the therapist) that may provide a future and potentially permanent capacity for self-soothing.

Two types of imagery can be incorporated in imagery exercises: directive, in which the image is specifically described (“imagine a meadow”), and nondirective, in which less specific description allows for the formation of more personalized and spontaneous imagery (“imagine some natural environment”; “find some special place”). Some individuals experience ambivalence or difficulty with a nondirective suggestion and prefer the more direct approach. It is important to note that directive imagery is also personal, as demonstrated by having different individuals describe the “meadow” experienced in their imaginations.

Difficulties with the technique or the imagery are explored during therapeutic sessions. Individuals who have difficulty with imagining a nondirective exercise can be encouraged to try a more directive imagery approach. Those who have experienced painful emotions through the experience are encouraged to express their feelings. They can be introduced to alternative, more soothing exercises, encouraged to build in greater safety in their imagery—or, if they are willing, they can be encouraged to contemplate and work with the evoked images (for example, through dialogue with the imagery: “Is there anything you would like to say or do with the image?”).

Images used during the early stages of treatment should suggest an inner atmosphere of safety, so as to establish a secure environment and raise interest in the identification of emotions and themes that will occur through the more challenging self-exploration exercises. Imagery themes that may enhance safety include soothing environments (outdoor water and meadow scenes, warmth of the sun, a golden light, familiar places where the individual has felt safe), the construction of a protective structure, or the inclusion of a trusted individual. The imagination is embedded in bodily experience, and therefore each image is accompanied by physical and emotional sensations.^103,104 During the imagery therapy, personal images occur spontaneously and bring forth reactions. Feelings of fear, surprise, and recognition of earlier experiences are among the reactions that may occur. During or after the imagery exercise, the individual is encouraged to identify and comment on her bodily experience. The individual's attention is directed by asking questions about these reactions: “How do you feel here?” and “When you observe this image, what feelings come forward?” The therapist assists in exploring any arising themes or changes in affective states that occur.

According to this model, personal insight is promoted through soothing exercises in a relaxed state. A relaxed state is viewed as a necessary condition for self-reflection. The process of self-reflection occurs at the individual's level of readiness. It is important for the therapist to allow the individual to comment on self-experience through several sessions, rather than make interpretations. Personal imagery will be linked to experience, and frequently individuals are able to find their own meaning in the images.

This process is congruent with Bruch's²⁷ therapeutic approach, which focused on self-experience and discovery. Imagery therapy is ideal in this regard. The imagery exercises produce personal images within the individual's private imagination. These images range from the concrete, such as objects or persons, to the more abstract, such as a color or metaphor. The therapist guides the individual to concentrate and observe the experienced personal images as they are forming, and this promotes a feeling of being active and creative in the therapeutic process. Such an approach results in a kind of “playful” engagement between the therapist and the individual as she imagines and awaits the images and emotions that emerge during a given exercise. This aspect of guided imagery incorporates the elements of self-discovery and spontaneity that Bruch²⁷ and Winnicott⁵¹ emphasized as being particularly important in the treatment of these individuals. The role of creative activities has been linked to feelings of vitality and a sense of being alive, feelings that appear to be lacking in the lives of many with BN.

Personal imagery is frequently abstract, having metaphorical themes. At times, a profound sense of surprise or discovery is experienced with emerging images and themes. A particular image or metaphor may have significant meaning for an individual—by being linked to an earlier memory or experience, for example, or providing insight into some behavioral pattern or emotion, or shedding light on an important goal. The individual is encouraged to “play” with personal imagery, verbally engage with the images, rehearse behaviors or interactions, and express any corresponding feelings. Self-expression is encouraged in oral and written forms and, if the individual is willing, through more creative modes such as drawings of the images. These multiple forms of expression promote communication and reflection of the imagery experience at cognitive and bodily levels. Encouraging drawings or written expression provides the opportunity to observe and inspect aspects of the imagery and assists in identifying emotional reactions and personal insights.

Discussing an issue or feeling through a metaphor can be experienced as less threatening because the metaphor or image is viewed in this model as providing permission and safety for the expression of feeling. At times, the individual may be unaware of what is being revealed and gradually come to identify some key insight. Further deepening of the process occurs when the identification of an important metaphor is linked to some symbol. Once a symbol is identified it can carry with it special meaning, and the therapist explores with the individual methods of integrating new discoveries into daily living. The individual is encouraged to bring this symbol into her life in some way. Some individuals may choose to incorporate a real object that serves to remind them of an important discovery, a goal, or a new skill that is being developed, while others may choose a color or a symbol in nature to represent some important theme in their imagery. This symbolic form of expression can be viewed as providing a space in the real world where meaning can be represented and stored. The symbol, in a sense, provides a type of bridge between the individual's internal world and physical reality. Once based in reality, the symbol can be used as a reminder of progress, personal strengths, and possibilities for the future. This symbolic representation promotes the integration of new meaning and insight into experience.

Guided Imagery Exercises

We have included six major imagery exercises that can be used for soothing and that promote self-exploration of the individual's inner experience (recognizing that there are other possible themes that can be used). The two early exercises familiarize the patient with guided imagery, focus on the relaxation response, and promote increased awareness of inner feelings. As the individual becomes familiar with imagery and gains a sense of mastery with the technique, progress can be made to the more challenging self-exploration imagery exercises (exercises 3–6). We have chosen here to provide the script for the first exercise, with a brief description of the images and goals of the other five.

Six Imagery Exercises

1. “Creation of an Inner Sanctuary”: This exercise has been used in the literature to have the individual create a special internal place for relaxation and becoming aware of feelings.¹⁰⁵

2. “Exploration of a Meadow”: This exercise consists of directive imagery and has the individual explore a meadow.¹⁰⁶ Its functions include promoting the use of all senses during imagery, enhancing a relaxation response, and demonstrating to the individual his ability in doing imagery.

3. “Creating a Mask”: This exercise has the individual imagine discovering a box full of creative supplies and making a special mask. It helps introduce the individual to a self-exploration exercise and at the same time involves participation in a creative act.

4. “Color of Self”: This exercise involves having the individual draw herself as a color or combination of colors, called a colorform. The individual is asked to imagine the colorform on paper and to experiment with a variety of colors of paint, including a special jar called the “color of aliveness.” The individual is encouraged to experiment with the colors and to note what she observes. This exercise is designed to be soothing and to continue with the self-exploration in a creative and playful manner and frequently addresses body image issues.

5. “Theater Scene”: This exercise has the individual imagine being in a theater and observing his “colorform” in an interaction (past, current, or future) of his choice. Its goal is to continue the self-exploration to the realm of interpersonal relationships.

6. “Design of a Personal Quilt”: This exercise has the individual imagine making a personal quilt through a medium of choice and to observe the pattern that is developing. The exercise is designed to be soothing, to continue with self-exploration, and to promote themes of continued growth and change. The exercise is viewed as creative, and we have found it to be useful near the end of therapy to promote an internalized feeling of continued development and growth, thereby facilitating termination.

Example of Imagery Exercise: “Creation of An Inner Sanctuary”

This is an exercise through which I will guide you. Just follow my voice and the script, but remember that you have control over the exercise. Even if you are experiencing a build-up of your emotions and feelings, you can use this exercise to help you feel relaxed . . . and safe and to help you to gain control and to manage the feelings that you are experiencing. So, just follow my voice and allow the images to come. Try to acknowledge and recognize your feelings as they come forward and know that you can learn to manage these feelings . . . to understand them . . . and you can feel more relaxed . . . and more in control . . . and some release from these emotions. . . . Remember, it will be within your ability to follow these instructions. . . . Just feel my voice and allow your senses and imagination to follow the voice. . . . You can feel safe during the exercise . . . and although you may be feeling some difficulty or pain . . . you will soon feel more relaxed and in control. Feel free to use all of your senses. . . . Feel the images. . . . Imagine yourself experiencing these images. . . .

We're going to begin by focusing on your bodily feelings. Make yourself comfortable. . . Close your eyes and allow your body to feel loose and comfortable. Take a deep breath . . . slowly . . . a deep breath. Concentrate on your breathing as you count silently to yourself. Inhale, “In . . . one . . . two. . . . Out . . . one . . . two . . . [repeated several times]. Feel yourself relax as you breathe. . . . Breathe out slowly . . . . Concentrate on your breathing . . . slowly and deeply . . . breathing deeply. . . . Feel the air going into your lungs . . . out of your lungs. As you breathe out, notice that you begin to feel more and more relaxed. Tension is draining from your body. Let the painful feelings go. . . . Go from your body. . . . They will go . . . and soon you will feel more in control . . . and more at ease. . . . Continue breathing slowly. Continue in . . . and out. . . . Breathing slowly. . . . Continue to listen to my voice.

Now, continue to focus on relaxing, and I am going to describe some images. Just follow my voice. Continue to breathe slowly and deeply . . . and allow the images to soothe your feelings. By continuing to breathe slowly and deeply . . . you will allow any tension that you are experiencing to flow from your body . . . to leave your body. [Further breathing instructions repeated.]

Now, you are beginning to feel more relaxed and in control. . . . Continue to close your eyes and just follow my voice and the images that I describe. . . . Imagine yourself in some beautiful natural environment. . . . It can be any comforting place that appeals to you . . . in a meadow . . . on a mountain . . . in a forest . . . or beside a lake or an ocean. It may be some special place where you have been before . . . where you felt warm and safe . . . and where you felt the beauty and strength of its atmosphere. If you find difficulty in relating to a place where you have been before . . . imagine and create a beautiful, serene, and peaceful place. . . . It may be another planet if you like . . . or a place that you recall from a novel . . . or a place in your imagination. . . . The special place is one of your choice . . . any place that appeals to you . . . one that you would like to return to . . . perhaps one that you have created in your own imagination . . . that would have this special, wonderful atmosphere. . . . Wherever it is . . . it should feel comfortable, pleasant, and peaceful to you.

Feel this environment around you. Use all of your senses . . . the beauty of it that you see . . . the quiet and pleasant rhythmic sounds of the environment. . . . Feel the warmth on your skin . . . the breeze feels so warm and gentle. . . . Notice the smells in this environment. . . . It feels familiar to you. . . . Your senses are open to all of the atmosphere's textures, smells, sounds . . . .and warmth. . . . Explore your environment, noticing all of its details. . . . This is your special place . . . and notice the feelings and impressions that you are beginning to experience.

Now, continue exploring your surroundings . . . and do anything that you would like to do to make it your special place and comfortable for you. . . . If you would like to build some type of shelter or house . . . begin to imagine its structure. . . . Or perhaps you would like to surround the whole area with a golden light of protection and safety. . . . Create and arrange things that are there for your convenience . . . and enjoyment . . . in order to establish it as your special place.

Create a kind of sanctuary . . . one that is only yours . . . so that when you need to visit this sanctuary you can at will. . . . Every time that you return you will feel these warm feelings. . . . These feelings of safety . . . and increased understanding . . . and peace. . . . You can come here to explore yourself. . . . To find this calmness and to experience and enjoy it. . . . When you need to get away . . . from moments of tension. . . .

This can be your inner sanctuary. . . . It's very personal . . . and you can explore your feelings . . . and your thoughts and come here to recognize your feelings . . . and understand why you are experiencing these feelings. . . . Allow the calmness here to help you . . . to feel safe . . . to come in touch with your feelings . . . and to learn new things about yourself and your feelings. . . .

This calmness will always be in your personal place. . . . It will be soothing and familiar, and it can be reached when you need to feel 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 always feel these comforting feelings and in a sense your imagination can become a trusting friend that will help you to return to this place . . . when you need to . . . just by closing your eyes . . . or by following my voice on the tape.

Sense this personal inner sanctuary as a healing and relaxing place. . . . It belongs only to you. . . . You are the only one who knows about this place . . . and you do not have to share it with anyone if you don't want to. . . . This place will become more and more familiar to you as you visit it repeatedly, over time . . . and it will become more and more easy for you to recall this place as you continue to visit it when you are feeling frightened . . . or tense . . . or angry . . . for any reason. . . . You can even visit it any time you want to feel that comfort . . . and trust . . . or when you wish to explore your own inner feelings . . . and thoughts . . . It is always open . . . any time . . . at night . . . or during the day. . . . This place is to help you to explore . . . to heal . . . and to feel more in control and in touch with your experience of your mind and your body.

You may want to make changes and additions to your sanctuary . . . from time to time . . . and you are free to add things to it . . . but it will always remain peaceful . . . and tranquil . . . and you will always feel safe here. . . . It is comforting and has a soothing atmosphere. . . .

Now, you may stay within your inner sanctuary as long as you wish. . . . And when you are ready to leave . . . just count backwards slowly from five . . . to . . . one . . . and you can leave . . . by focusing again on your breathing and bodily feelings. . . . Notice how relaxed you feel. . . . The tension that you felt before has left and you feel more in control . . . and more calm . . . and you feel more positive . . . and trustworthy . . . that you can be in touch with your inner self . . . and feelings. . . . You feel much more relaxed. . . . [Repeat of breathing exercises to end of exercise.]

Case Example

“Helen” is a 23-year-old woman, living with her boyfriend and attending university. She has a history of anorexia nervosa, which developed at age 15 following a move with her parents to Denmark from Canada. At the age of 19 and after reaching her “goal weight” of 108 pounds (she is 5 feet 4 inches tall), which followed an intensive treatment program, she began engaging in binge eating and self-induced vomiting on a regular basis. By the age of 23, she had returned to Canada and was able to eat regular meals daily and had somewhat accepted her body weight; however, she had been unable to stop binge/purge episodes (reporting 3 to 6 episodes weekly), which prompted her to seek treatment.

Helen was introduced to imagery through individual outpatient psychotherapy in a randomized trial of guided imagery. In this trial, imagery was the focal psychotherapeutic technique, with no concurrent therapy other than self-monitoring of eating symptoms. The therapist conducted the “inner sanctuary” exercise during an early session. Helen's visualized “place” where she felt comfort was a “stone house” that she imagined being located in Denmark. When asked to explore what was so special about this place, Helen eloquently described feeling “safe,” “peaceful,” and “protected” and in some way even “more secure.” She was encouraged to practice this first scenario, daily, particularly around her bingeing and purging behaviors. Following her first week of therapy, she reported using the taped exercise on several occasions, and was able to discontinue 3 episodes of bingeing by listening to the taped version of the inner sanctuary exercise. During her sessions, she was encouraged to explore in detail her experiences in Denmark and the image of the stone house (which became a central theme during her sessions).

Her history revealed that her parents had moved from Canada to Denmark when Helen was 14, following her completion of primary school. Helen recalled feeling “popular,” “confident,” having “numerous friends” (including a boyfriend), participating in athletics, excelling at school, and being healthy in Canada. After her arrival in Denmark she found herself having difficulty making friends. She felt uncomfortable in a foreign country and began to strongly resent her parents for taking her away. She found solace only in skating and became competitive in the sport, participating in little else. It was at this time that she began to severely restrict her food intake, developing anorexia nervosa. She also relayed feelings of fear in relation to dating male colleagues, particularly around her feelings of sexuality, as she perceived the students in Denmark to be permissive and “more mature.” She became so ill that she was hospitalized at that time, despite being successful in her competitive skating. It was several years later (after Helen returned with her family to Canada and following her treatment for anorexia) and while she was attending university that she sought treatment for her bingeing/purging. At that time she continued to have conflictual feelings and anger toward her parents, and when beginning the imagery therapy she described intense negative feelings around her past experiences in Denmark.

Helen was encouraged to explore “the stone house” that presented itself consistently through many of the exercises described above (for example, during the meadow scene, and again when “making her mask,” she was in the stone house). The therapist pointed out that the stone house appeared to be a refuge and a place of calming (according to Helen's verbalization on her imagery), and yet it was in an environment that she associated with strong and intense negative feelings. Helen, too, made this observation and was encouraged over time to explore in detail what it was about the stone house that was so meaningful for her and contributed to her feeling so secure. She described the house as not being particularly familiar to her (there are many in Denmark), but as being “strong,” “old,” “natural,” and “very real”; as not being “brightly colored” or “perfect,” but as having “depth” and a comforting solitude.

As Helen progressed in therapy and expressed her feelings about her imagery through her drawings of images and verbally during therapeutic discussions, it became evident to her that she saw herself as “not measuring up to others,” feeling inadequate, and wondered how her boyfriend could care for her. When alone at home prior to his return in the evening, she would experience strong urges to binge and purge. However, over time it became clearer through her descriptions of the house that she admired the qualities of the “stone building” in contrast to personal qualities she described as being “superficial” and uncomfortable for her. Her innermost yearnings seemed to be for self-qualities that she described in terms of the house; for example, she revealed that her chief goal was to engage in academics and produce “meaningful” and “worthwhile” work that would be of enduring quality. However, she felt she could never “permit” herself to engage in courses that she desired, such as philosophy or historical literature. She believed that her family and friends did not see that she had such qualities within her. In addition, despite having participated in athletics and “the glamour of performing,” she felt unfulfilled by these accomplishments and had never experienced a sense of esteem (despite many hours of preparation toward achieving goals in her skating).

As the imagery therapy progressed, Helen was encouraged to visualize the “stone building” regularly in a sensory way and to explore her attachment to this image and its meaning for her. Her personal imagery became a vehicle through which she could disclose (metaphorically at first) her innermost feelings, express her pain associated with being in Denmark and her feelings toward her parents. Over time she was able to grasp something more positive from her time there, rather than to view it as “wasted and painful years of her life.” After her 6 weeks of imagery therapy, she was able to describe her experiences in Denmark as possibly contributing to the development of personal qualities such as “strength,” “endurance,” and “substance” that she was beginning to sense she possessed as she explored her imagery. The therapist encouraged her to remain in touch with these qualities (“to really feel them”) and to allow them to fully develop. She was encouraged to nurture the qualities that she valued and to share them with others over time as she felt comfortable. She also came to recognize the house and its special qualities as representing her and her personal experience in Denmark—and, interestingly, as being separate from the experience of her parents. This was an important self-discovery for her to make, given that she felt so “cheated” and “controlled” in being taken from a comforting safe environment to an unknown country, contrary to her wishes to remain in Canada.

By the end of the 6 weeks, Helen had only occasional binge/purge episodes (1 or 2 every few weeks) and reported a greater sense of control. She also reported an increase in her mood level and a renewed life interest. She continued to utilize the imagery for self-comforting in connection with her exams and her eating urges, and she shared her personal experiences with her imagery with her boyfriend. She had also discussed her feelings more openly during a visit to her parents.

This case example is useful in highlighting the elements in the imagery model as well as demonstrating the patient's acceptance of the imagery therapy as a comforting device and participatory experience. Helen took an active role, the imagery was “personal,” and through focusing on her specific images during the therapeutic sessions (and in her journal) she came to the conclusion that the stone house represented some aspect within her that was hidden from others and kept private. Perhaps because it was her own personally evoked image (rather than one suggested by the therapist), it became particularly meaningful and solacing for her, and she repeatedly called upon it for comforting and to inspect its meaning. The therapist acted to guide the patient to explore the imagery, and as themes emerged asked the patient to inspect them and to describe any associated feelings or interpretations. This procedure is similar to Bruch's²⁷ “fact-finding” approach, which she believes to be crucial for promoting self-discovery and autonomy.

Helen, through her imagery, was able to further understand from a new perspective her development of an eating disorder and to learn about personal issues that may be contributing to her need to binge/purge, despite having normalized eating and feeling fairly comfortable with her body weight. She frequently had commented on the fact that she had gone through previous treatments and addressed other issues (such as her weight), and yet, could not understand her lack of control at times over her eating and self-induced vomiting. Helen received the guided imagery without any concurrent therapies (other than maintaining self-monitoring of her eating symptoms as part of her personal journal). However, the therapist refrained from making comments/recommendations on her eating and kept a focus on her experienced imagery, suggesting that her insights and behavioral changes appeared to have occurred as a result of the imagery therapy.

Guided Imagery Randomized Trial

The guided imagery model described above has been applied in a recent study described elsewhere.¹⁰⁷ A randomized controlled trial compared patients receiving 6 weeks of individual guided imagery therapy (with self-monitoring of symptoms) with a control group of untreated BN patients (which controlled for therapist contact and self-monitoring of symptoms). Fifty participants who met DSM-III-R criteria for BN completed the study. Scores on measures of eating disorder symptoms, psychological functioning, and self-reports associated with the experience of guided imagery therapy were obtained. The guided imagery treatment had substantial effects on the reduction of bingeing and purging episodes; the imagery group had a mean reduction of binges of 74% (P <0.0001) and of vomiting of 73% (P <0.0001). The imagery treatment also demonstrated improvement on measures of attitudes concerning eating, dieting, and body weight in comparison to the control group. In addition, the guided imagery group demonstrated improvement on psychological measures of aloneness (P <0.05) and the ability of self-comforting (P <0.001). Evidence from this preliminary study suggests that guided imagery is an effective treatment for BN, at least in the short term, and promotes psychological soothing.

Summary

In summary, BN has been linked to a difficulty in the ability to modulate affects or in self-soothing. This conceptualization suggests the need to design treatments that specifically target the problem of affect regulation and that assist these individuals in comforting themselves. A model of guided imagery therapy has been described that can be used to provide an external source of soothing and to enhance self-soothing. The model suggests that imagery therapy has multiple levels of action that can assist these individuals in the regulation of affect. A case report and preliminary evidence from a randomized trial have demonstrated its effectiveness in improving eating disorder symptomatology and in promoting self-comforting at least in the short term, possibly by providing patients with a transitional object.

Acknowledgments

The authors acknowledge the valuable suggestions of Dr. Ruth Gallop and the helpful comments contained in the anonymous referees' reports on the first draft of this paper. This work was partially supported by the Ontario Mental Health Foundation.