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The Effects of Guided Imagery onComfort, Depression, Anxiety, and Stress

of Psychiatric Inpatients withDepressive Disorders

João Luís Alves Apóstolo and Katharine Kolcaba

hives of Psyc

Thisarticledescribestheefficacyofaguided imagery intervention fordecreasingdepression, anxiety, and stress and increasing comfort in psychiatric inpatientswith depressive disorders. A quasi-experimental design sampled 60 short-termhospitalized depressivepatientsselectedconsecutively.Theexperimental grouplistened to aguided imagerycompactdisk onceaday for10 days.ThePsychiatricInpatients Comfort Scale and the Depression, Anxiety, and Stress Scales(DASS-21) were self-administered at two time points: prior to the intervention(T1)and10days later (T2).ComfortandDASS-21werealsoassessed in theusualcare group atT1andT2. Repeated measures revealed that the treatment grouphad significantly improved comfort and decreased depression, anxiety, andstressover time.© 2009 Published by Elsevier Inc.

From the Coimbra Nursing School, Research UnitNursing Domain, UiCiSa_dE, Coimbra, Portugal; andCollege of Nursing, The University of Akron, Akron, OH.

Corresponding Author: João Luís Alves Apóstolo, RN,PhD, Coimbra Nursing School, Research Unit NursingDomain, UiCiSa_dE, 3001-901 Coimbra, Portugal.

E-mail address: apostolo@esenfc.pt© 2009 Published by Elsevier Inc.0883-9417/1801-0005$34.00/0doi:10.1016/j.apnu.2008.12.003

D EPRESSION HAS A significant impact atfamily, social, and economic levels and could

become the first cause of morbidity in developedcountries in the near future (Coppen, 1994; WorldHealth Organization, 2001).

Psychiatric inpatients with mood disordersexperience their condition in a complex existentialcontext of generalized discomfort, which resultsfrom the illness and hospitalization itself. In somesituations hospitalization is repeated many timesuntil the person can overcome the illness state.Patients feel constrained, impotent, uncomfortable,imprisoned in illness, needing to (re)build them-selves to continue living, and believing that theycan only rebuild through hospitalization. Thehospital is perceived as a refuge, but it is also aplace where freedom is limited (Apóstolo, 2007).Within this setting, guided imagery (GI) may bebeneficial in reducing the many discomfortsassociated with mood disorders, including depres-sion, stress-related symptoms, anxiety, inability tohold a job, and relationship problems.

hiatric Nursing, Vol. 0, No. 0 (January), 2009

Throughout its history, the mission of nursinghas been focused on the discomfort of patients andinterventions to relieve it. Nursing should base itsinterventions in operable theories that support theprovision of comfort through assessment of thepatients' needs, implementation of care, andassessment of the results from those interventions.In this context, Comfort Theory has regained arelevant role in the philosophy of nursing care(Kolcaba, 2003) and subsequently has been thetarget of interest of several different authors(Apóstolo, 2007; Apóstolo, Batista, Macedo, &Pereira, 2006; Goodwin, Sener, & Steiner, 2007;

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Jenny & Logan, 1996; Koehn, 2000; Morse,Bottorff, & Hutchinson, 1994; Schoener & Krysa,1996; Schuiling & Sampselle, 1999; Walker, 2002).Therefore, the purpose of this study is to test theeffects of a GI intervention on patients' perceptionof comfort, depression, stress, and anxiety in asample of persons hospitalized for mood disorders.

It is hypothesized that after 10 days, patients withmood disorders who received the GI interventionon a compact disk (CD) once a day for 10 days willhave higher comfort and lower depression, stress,and anxiety than the comparison group.

BACKGROUND

Conceptual Framework of Comfort

The conceptual framework of comfort, derivedfrom the mid range theory by Kolcaba (1991, 2003)supports this study. Comfort is defined for nursingas the immediate experience of feeling strengthenedwhen basic human needs for relief, ease, andtranscendence are addressed in four contexts ofexperience (physical, psychospiritual, sociocul-tural, and environmental). In part, this definitionoriginates from its archaic definition “to strengthengreatly,” which is relevant for patients in stressfulhealth care situations and who must be strengthenedto meet their future challenges.

Relief is the state in which a specific comfortneed has been met, essential for the person toreestablish her or his normal functioning; ease is astate of calm or contentment and is needed foreffective performance. Relief presupposes theexistence of previous discomforts, and ease pre-supposes the attention to risk factors for specificdiscomforts. Transcendence is the state in whichpersons feel motivated or inspired to control theirfate, resolve their problems, and make constructiveplans for their futures.

Fig 1. Taxonomic str

These three types of comfort are experienced inthe following four contexts: physical, psychospiri-tual, sociocultural, and environmental. The physicalcontext pertains to bodily sensations; the psychos-piritual context pertains to the internal awareness ofself, including sexuality and meaning in one's life,and it can also encompass one's relationship to ahigher order or being. The sociocultural contextpertains to interpersonal, societal relationships, andfamily traditions. The environmental contextinvolves light, noise, equipment (furniture), color,temperature, and natural versus synthetic elementsin one's surroundings. The four contexts combinedwith the three types of comfort form a taxonomicstructure (TS) of 12 cells (Figure 1), whichrepresents the total gestalt of holistic patientcomfort from the perspective of patient's needsand the fulfillment of their needs (Kolcaba, 1991,2003). The TS guided the construction of thecomfort questionnaire, which was used to measurethe efficacy of the intervention in this study.Comfort Theory (Kolcaba, 2003) also states that acomforting intervention, given over time, enhancesthe comfort of patients in stressful health caresituations. The intervention in this study is GI.

When comfort is enhanced, patients are betterable to be successful in their health-seekingbehaviors (HSBs). Scholtfeldt (1975) includedinternal behaviors and external behaviors in herdefinition of HSBs, and both of these behaviors areincorporated into Comfort Theory. Therefore, it washypothesized that increased comfort would lead to areduction in anxiety, stress, and depression.

Guided Imagery

In the context of this study, GI is defined as theuse of the imagination to bring about positive mind/body responses (Rossman, 2000). It is a cognitiveprocess that evokes and uses many senses: sight,

ucture of comfort.

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sound, smell, taste, and touch and also the senses ofmovement. All of these senses together produceregenerative changes in the mind and body(Achterberg, 1985). GI is a program of instructionsmeant to help people acquire a state of psycholo-gical and physiological ease through muscularrelaxation and positive mental images, relievingthe discomforts provoked by symptoms associatedwith mood disorders (Apóstolo, 2007). Increasingadaptive responses in depressive individualsrequires replacing the negative processes of think-ing with a more positive cognitive style (Achter-berg, 1985; Rossman, 2000). GI is a complementarynursing intervention that can be implemented inaddition to other therapeutic approaches to mooddisorders. Studies show that focusing the imagina-tion in a positive way can result in a state of ease,encouragement, and mood regulation, all of whichallow the patient to reestablish a state of physicaland mental health (Rossman, 2000).

Guided Imagery and Depression

Currently, it is thought that good body function-ing is accompanied by positive thoughts, whereaspathological body functioning is accompanied bynegative and repetitive thoughts (Damásio, 2004).In the brain, a thought, idea, or mental image workas “emotionally competent stimuli.” These stimuli,whether prescribed by biologic evolution or learnedhave the capacity to produce certain patterns ofhomeostasis. The state of sadness is accompaniedby a reduced number of positive mental images andby more excessive attention to those images. Whenpersons have the experience of positive thoughts,their mind represents more than well-being; it alsorepresents well-thinking. On the contrary, feelingsadness is associated not only with sickliness butalso with an inefficient way of thinking, concen-trated around a limited number of ideas of loss(Damásio, 2004).

In GI, positive mental images and positiveaffective experiences can counteract the depressionrumination spiral (Folkman & Moskowitz, 2000).This process works as an adaptive alternative todecompensation, raising the mood, and relievingdepressive symptoms. Therefore, GI contributes toantirumination strategies that, as Nolen-Hoeksema(1991, 2000) states, are debilitating. Positive mentalimages have a relaxing effect and, consequently, apsychophysiologic and cognitive effect (Singer,2006). When depressed individuals have access to

positive mental images and to a state of bodyrelaxation, they are able to reorient their thoughtsaway from unpleasant stimuli. Thus, positivethoughts contribute to an improvement in feelingsabout oneself and the world.

Results from the empirical literature indicatedthat GI was effective in improving mood states inindividuals with a variety of illnesses. Sloman(2002) conducted a community-based nursingstudy in 56 people with advanced cancer. Progres-sive muscle relaxation and GI training revealedsignificant decreases in depression. Campbell-Gillies (2004) used a program including positivemental images and music with 45 women withbreast cancer. Her findings revealed that GIdecreased depression and anxiety over a six-cycleperiod of chemotherapy. McKinney, Antoni,Kumar, Times, and McCabe (1997) used GIcombined with music with 28 healthy adults andreported significant decreases in depression, fati-gue, and total mood disorders between pretest andpostsessions. Identical outcomes were revealed inthe study of Watanabe et al. (2006), with a sampleof 148 healthy adults, using relaxation and positivemental images. After two sessions, positive moodincreased, and negative mood decreased. Finally, inan experimental design, Kolcaba and Fox (1999)assessed the effects of GI for increasing comfortover time in patients with breast cancer goingthrough radiation therapy. However, no experi-mental studies have been conducted for patients in apsychiatric context to increase their comfort.

Methods

Design

This quasi-experimental design was used tomeasure the differences in comfort, depression,anxiety, and stress between a treatment group and ausual care group (comparison) of short-termpsychiatric inpatients diagnoses with depressivemood disorders.

Intervention

GI was recorded on a 21-minute-long CD for thisstudy by a collaborator, a clinical psychologist,chosen because of her pleasing voice and consider-able knowledge about mental health. In the audio-taped CD, patients were invited to (a) do deepdiaphragmatic breathing using the abdomen and

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diaphragm; (b) do progressive muscle relaxationexercises involving tension then full relaxation ofeach muscle group; (c) imagine relaxing naturalscenes like landscapes, paying attention to smellsand natural sounds to stimulate the senses; (d)imagine meeting somebody with whom they couldshare their life situation; and (e) create positive,comforting, and serene images of the hospitalcontext. The therapist intended that patients idealizea space where they could experience a sense of ease,safety, refuge, positive images and becoming free ofdisturbing thoughts.

The CD script was guided by the literature revueabout GI (Achterberg, 1985; Rossman, 2000),relaxation (Payne, 2003), comfort needs of patientsin stressful health care situations (Kolcaba, 2003),and a qualitative study about the lived experience ofcomfort/discomfort of psychiatric mental inpatients(Apóstolo, 2007). For example, the followingstatements addressed physical, social, environmental,and psychospiritual comfort by improving feelings ofpeace, freedom, and transcendence: “…imagine ameeting with somebody with whom you could shareyour life situation….What would you like to share…Feel this environment as a place of peace…where youfeel protected…where you can renew your energy andyour life….This is calm and safe environment wereyou feel free and in peace…”.

The CD was submitted to a validation processincluding experts and 25 patients and nursingstudents. Between 70% and 88% agreed or stronglyagreed about the relaxing quality of the CD, mentalimages, voice, music, and the volume. However,only 28% agreed or strongly agreed about the easeof breathing exercises. According to the partici-pants' suggestions, the time between inspirationand expiration was shortened. Soft and relaxingbackground music was added as a background forthe script (Apóstolo, 2007).

Measures

Psychiatric Inpatients Comfort Scale (PICS),Portuguese version, was developed by Apóstolo,Kolcaba, Mendes, and Antunes (2007) based onKolcaba's (1991, 2003) conceptual framework ofcomfort assessing the three types and the fourcontexts of comfort. In the questionnaire-developingprocess the authors of the PICS evaluated reliability,construct validity, and concurrent validity. Thepsychometric properties of the PICS were sufficientin pilot testing to allow its utilization as a comfort

assessment in a psychiatric clinical context. ThePICS is 5-point Likert type scale with 42 items forself-reporting ranging from 1, “It doesn't correspondto anything that happens with me” to 5, “It totallycorresponds to what happens with me.” Participantswere asked to mark the extent to which eachstatement applied to him/her during the last 10days. Consistent with its holistic perspective,Comfort was computed for the total scale. For thesample in this study, the Cronbach's alpha was 0.87(Time 1) to 0.93 (Time 2) and the PICS demonstrateda medium effect size. Portuguese and Englishversions of PICS are available on Kolcaba (on line).

Depression, Anxiety, and Stress Scales (DASS-21) by Lovibond and Lovibond (1995) wastranslated from English into Portuguese by Após-tolo, Mendes, and Azeredo (2006). In the transla-tion process, the authors assessed scale reliability,construct validity, and concurrent validity. TheDASS-21 contained a set of three 4-point Likert-type subscales for self-reporting. Each subscaleconsisted of seven items, aimed at assessingdepression, anxiety, and stress. Participants wereasked to mark the extent to which each statementapplied to him or her. There were four possibleanswers in terms of severity or frequency, organizedin a scale from 0 to 3. The result was obtained byadding the scores of the items for each of the threesubscales and total scale for the total DASS-21. Forthe sample in this study, the Cronbach's alpha was.93 (Time 1) and .95 (Time 2).

Anxiety was operationalized by elevated levels ofphysiological hyperarousal, whereas depressionwascharacterized by low levels of positive and negativeaffect. The stress concept included questions relatedto negative affective states or conditions and wasconsidered by the authors as an affective reactionstandard or state that has clear affinities with anxiety(Lovibond & Lovibond, 1995).

Ethical Considerations

The study was approved by the ethical commis-sions of the three psychiatric hospitals. The patientscompleted the questionnaires and began the inter-vention after signing informed consent forms. Theresearcher obtained the informed consent.

Sample

Power analysis was based on previous publishedstudies about GI and the relationship between GI,

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comfort, and depression. The power analysisindicated that 60 total patients were needed toachieve significance at an alpha of .05.

Sixty short-term hospitalized depressive patients(experimental group: 30, comparison group: 30)were selected from three psychiatric unities/facil-ities with identical characteristics from the Centreof Portugal by consecutive sampling. At T1, groupswere equivalent in demographics (Table 1).

Each participant submitted to a preparatoryinterview by the researchers who introduced thestudy and evaluated his or her clinical condition.Inclusion criteria were the following: adults;diagnosed as having clinical depression andclassified from moderate to extremely severedepression, according DASS-21 classification(Lovibond & Lovibond, 1995); able to read andunderstand Portuguese; and with the willingness toparticipate. Exclusion criteria were presence ofpsychotic symptoms and cardiac and breathingproblems (Payne, 2003).

To avoid contact and contamination betweenexperimental and usual care groups, the selectionprocess was as follows: The first 20 women and 10men hospitalized with depressive disorders betweenOctober 2005 and January 2006 were selected forthe experimental group, since their clinical situationtriggered the development of the protocol. Thereason for proportional sampling was that depres-sion affects 1.5 to 3 times more females then males

Table 1. Sample Characteristics and Group Compar

Variables

Experimental(n = 30)

n %

Gender Male 20 66.67Female 10 33.33χ2 = 0.00, P = 1.00

Marital status Married 18 60.00Unmarried couples 1 3.33Single 6 20.00Divorced 5 16.67Widowed – 0.00χ2 = 2.23, P = .69

Education 4 years 1 3.335–9 years 15 50.0010–12 years 6 20.00Higher 8 26.67χ2 = 0.123, P = .99

Age Min = 20, Max = 58M = 39.57, SD = 11.41t = −0.60, P = .65

(Dew, Lynn, & Hall, 2003), and in those psychiatricsettings, this proportion held true.

Procedures

After the individuals in the experimental groupwere selected and signed informed consent, theintervention was introduced. The audiotaped CDwas given to the patients at around 9 p.m. becauseat this time the environment was quiet and it wasthought that the CD would promote relaxation,leading to a good night's sleep.

The experimental group was to listen to the GIaudio CD once a day for 10 days. Self-reports ofadherence, success, and adverse manifestations ofeach CD session were monitored by the head nurseand recorded in the patient's intervention plan. Theinstruments (PICS and DASS-21) were administeredat two time points for the experimental group: priorto the introduction of intervention (T1) and 10 dayslater, which was the end of the intervention (T2).Four patients did not complete the 10 sessionsbecause they got discouragedwith the protocol. Theywere excluded from the study and were replaced bynew patients. No adverse effects were reported.

After the intervention group completed the study,the selection of individuals for the usual care groupwas initiated. Thus, this group included patientswho had been hospitalized between January andMarch 2006. The patients were matched with the

isons of Sociodemographic and Clinical Data

Comparison (n = 30) Total (n = 60)

n% n %

2066.67 20 33.331033.33 40 66.67

1756.67 35 58.33310.00 4 6.67516.67 11 18.33413.33 9 15.0013.33 1 1.67

13.33 2 3.331653.33 31 51.67516.67 11 18.33826.67 16 26.67

Min = 19, Max = 55 M = 40.38M = 41.20, SD = 9.68 SD = 10.53

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individuals in the experimental group by socio-demographic data (age, gender, marital status, andeducation). No changes in hospital staff or policyoccurred this period. The instruments (PICS andDASS-21) were administered in the comparisongroup at the same intervals but without theGI intervention.

Data Analysis

A significance level of .05 was established apriori for all statistical tests. Chi-square, Indepen-dent t tests, paired t tests, and repeated measuresanalysis of variance were used to examine the initialgroup's equivalence on demographic characteristicsdepression, anxiety, stress, and comfort and changesover time on comfort on the DASS and PICS.

RESULTS

Table 2 summarizes the groups' changes on theDASS-21: t tests for independent samples revealedgroups (intervention and comparison) were equiva-lent at T1 but different at T2. The treatment grouphad significantly lower levels of depression,anxiety, and stress (DASS-21; −0.96) than thecontrol group (−0.37) after 10 days of GI interven-tion (F = 11.76, P = .00). GI explains 17% of thevariance (η2 = 0.17), power = 0.92.

Changes in each of the DASS-21 subscalesrevealed that the treatment group had significantlylower depression, anxiety, and stress. Varianceexplained by the intervention was 10% for depres-sion, 13% for anxiety, and 17% for stress. Powerranged between 0.71 (depression) and 0.92 (stress).

Table 3 summarizes the groups' changes on totalcomfort: t tests for independent samples revealed

Table 2. Different Evolution of Experimental and Comparisons Psych

groups (intervention and comparison) were equiva-lent at T1 but different at T2. The treatment grouphad significantly higher comfort (+0.49) than thecomparison group (+0.20) after 10 days of GIintervention (F = 4.42, P = .04). GI explained 7% ofthe total variance (η2 = 0.07), power = 0.54.

Comfort scores were strongly predictive of whowould show decreased symptoms of depression,anxiety, and stress on the DASS-21. At time 2, thetotal score on the DASS-21 was negativelycorrelated with the total comfort score (r = −0.73,P = .00). The negative correlation meant thatpersons with higher comfort had lower depression,anxiety, and stress.

DISCUSSION

Power greater than 0.50 are traditional in socialsciences. As Cohen (1988) reported, a statistical testmust have a power of 0.80, and the probability of atype II error of 0.20. By these criteria, we lost one infive genuine effects. However, Murphy and Myors(1998) reported that in the social sciences, powerusually ranges from 20% to 50%. Therefore, theseinvestigators recommend using a power of 0.50 infuture similar research, where the intervention hasminimal known harmful effects.

In future research, data about medications andtheir dosages should be recorded for each patient ateach time point. These data would provideinformation about possible covariates, should base-line scores be significantly different at baselinebetween the two groups. It would be interesting todetermine if the complementary GI interventionwas correlated with a reduction in psychiatricmedications as well. Future research also should

iatric Inpatients on Depression, Anxiety, and Stress (DASS-21)

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Table 3. Different Evolution of Experimental and Comparisons Psychiatric Inpatients on Total Comfort

7EFFECTS OF GUIDED IMAGERY

include a third or fourth comparison group whoreceive, for example, only relaxation, breathingexercises, and/or music or neutral images. Genderdifferences should be compared for the effective-ness of GI on the same outcomes, and follow-upassessment should also be developed.

Results provide evidence that the GI interventiondecreased feelings of depression, anxiety, and stresswhile increasing personal perception of comfort. Inthe GI audio CD, relaxing and peaceful imageswere suggested, and individuals were asked toidealize a secure and peaceful therapeutic environ-ment where professional help and positive affectivechanges occur. Specifically, patients felt morerelieved of their depressive symptoms and experi-enced a state of greater ease, satisfaction, andharmony. These feelings allowed them to benefitmore from their other therapeutics, achieve moreefficient improvement, and attain or regain compe-tence to plan and control their destiny.

The results of this study can be compared withothers using GI programs. As referenced above,results of McKinney et al. (1997), Sloman (2002),Campbell-Gillies (2004), and Watanabe et al.(2006) showed the positive effects of GI in moodregulation, although comfort was not measured.The study using GI with women going throughradiation therapy showed positive effects of GI oncomfort (Kolcaba & Fox, 1999). The findings fromthis study are consistent with previous descriptiveones about the effectiveness of GI for psychiatricpatients. The study also demonstrated the sensitiv-ity of the comfort questionnaire to detect significant

changes in comfort over time given an effectiveintervention. Both the intervention and measure-ment strategies were consistent with a holistic andhumanistic approach to psychiatric care.

The intervention of GI has many advantagesincluding its effectiveness, its affordability, and itssimplicity. Therefore, nurses can include thisintervention as part of the health care plan to assistpatients to relieve their discomfort and reach a stateof homeostasis. This will enable patients totranscend their limitations and face the problemsof life. It is possible that GI, used as complementaryintervention, can contribute to the reduction ofantidepressive medication dosage and, conse-quently, to a diminution of related side effects andadherence to a more holistic therapy.

CONCLUSION

If the way people think influences the waypeople feel, positively or negatively, then positivethinking can relieve the depressive state and relateddiscomforts. GI can play a role in cognition, even ifpeople are not aware of that fact (Thomas, 1999).GI helps fight rigid, automatic, and desperatethoughts and, in this sense, helps to reinforce self-esteem and personal transcendence. Self-esteemand transcendence contribute to a more positiveexperience, which enhances positive affection(manifestations of anhedonia and the absence ofpositive emotional experiences with a lack ofpleasure energy and disinterest) and interfereswith negative affection (nervousness, tension and

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preoccupation, anger, guilt, dissatisfaction, sense ofrejection or sadness, among others).

Imagery creates a bridge between mind and body,linking perception, emotion, and psychological,physiological, and behavioral responses. Accordingto Gilbert, Baldwin, Irons, Baccus, and Palmer(2006), shifts of emotions associated with anxietyand depressive disorders are often related toimages. The ability to generate powerful, warm,and accepting images seems significantly protectiveof depression symptoms. It may be the inability togenerate warm images, as much as the ability toneutralize self-criticism that is central to somedepressions or other emotional difficulties.

This intervention is effective in enhancingpatients' comfort and decreasing symptoms whenthey have a depressive disorder. Interpretation ofthe results is to be made bearing in mind that thiswas a complementary intervention (in addition toother interventions that are part of the usualprotocols in these patients).

Because of its effectiveness and also because it isa relatively easy method for individuals to learn anduse, psychiatric nurses could include this interven-tion as part of their integrative treatment plans.

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