1. Mind, Body and Spirit Interventions in Recreation Therapy- A review of meditative
practices, empirical data and implications for utilizing guided imagery and mindfulness
/meditative techniques in therapeutic recreation practices.
Introduction
There was a time when the discussion of meditation conjured up notions of exotic mystics in far
off places. The very suggestion of utilizing some of the techniques developed in ancient times
for primarily spiritual practices to address very real modern day stressors, injuries and ability
challenges would have been met with disdain.
But times are changing and the mind/body/spirit connection has been welcomed into many
mainstream western medical practices and disciplines in recent decades. The fact that attitude
and belief has a very real impact on the probable prognoses of patients is not lost on a great
many health professionals.
We have all heard of the placebo effect, whereby an individual becomes 'better' by complying
with a medication regimen, even when that medication is a sugar pill. The theory is that it was
the patient's belief that he or she would be made well that brought about the improvement- and
not the pill that contained nothing but non-medicinal ingredients.
There will be those who adhere to the belief that the efficacy of meditation and other
mind/body/spirit practices might seem to fall into that same 'placebo effect' category. Research
studies in recent years have shown, however, that the mind/body/spirit connection yields
empirical data that cannot be denied.
For the field of Therapeutic Recreation, the implications are far reaching and indicate that guided
imagery, meditation, relaxation, motor imagery, creative visualization and similar methods and
techniques may prove to be valuable tools for working with clients or residents.
What are meditation, guided imagery, creative visualization guided relaxation, and
progressive relaxation therapy?
Meditation has been practiced almost since the beginning of time and has a variety of differing
methods and descriptions. It is sometimes done as a religious or spiritual practice. Even among
spiritual practitioners, there are differing methods, rituals and goals. Some individuals use
prayer beads, some use mantras or chants, some focus on breathing.
Meditative practices are commonly seen to be mind training. Meditation can be engaged in
while sitting, usually in lotus position, with legs crossed, but can also be done while sitting in a
wheelchair, standing, actively moving or while lying down on a bed or sofa. In other words- can
be done by anyone anywhere.

2. For many years, meditation has been used to clear the mind and has been implemented to help
with hypertension, depression, sleep disorders, anxiety and a myriad of other physical
complaints. Practitioners claim that its use is beneficial for self awareness, spiritual growth,
cardiac health and optimum well being. While there are many forms of meditation, for the
purposes of this paper, the entire group of meditation techniques, will simply be called
meditative practices. Independent meditation requires the ability to focus intently and is best
suited to those who are able to maintain a central thought or focus.
Guided Imagery, commonly used in sport psychology, is a technique that uses all of the senses
related to the outcome that is desired as if the end result had already happened. it is basically a
mental rehearsal of the result that the patient wishes to achieve. (Quinn, 2013, Using the Mind to
Heal the Body- Guided imagery and hypnosis may speed healing).
Guided imagery used as adjunct therapy for sports injury involves MI which is Motor Imaging
or Body Rehearsal. This mental imagery involves imagining the muscles, tendons, nerves, and
bones moving in the exact same way they would actually move - were there no injury - and
imagining the desired outcome.
Guided imagery has uses beyond sports injury rehabilitation, though and is often used for
"special place" imagination for children's meditation to aid in stress reduction and behavior
modification, helping people of all ages improve sleep, lose weight, end bad habits and form
good habits. Guided imagery that is designed for a specific purpose very often produces easily
identifiable results and is a good tool for use by health professionals who want to measure
outcomes.
Creative Visualization is a technique whereby an individual uses the imagination to visualize
specific desired events or behaviors in his or her life. The technique, to be effective, requires
imagining all of the senses as actively engaged in the scenario of the desired outcome. What will
that feel like? What would the person look like? What might the remarks of others sound like?
And so on. Creative Visualization has been used since the nineteenth century when it became
well known through the New Thought movement in the United States.
(http://en.wikipedia.org/wiki/Creative_visualization)
While it is similar to the guided imagery used in sport psychology, in that there is a visualization
of a desired outcome, guided imagery is often comprised of a script while creative visualization
is at the discretion of the individual doing the imagining.
Guided Relaxation can refer to any number of methods that utilize the voice of another to guide
one into a relaxed state of body and mind. Whereas guided imagery may be used for many
different reasons and with a multitude of different desired end results, the main objective with
guided relaxation exercises is for the listener/subject/client to become relaxed. The state of
relaxation is what is deemed the desired result and may be measured by biofeedback, self report
on questionnaires or simply by satisfaction of the client with the results achieved.

3. Progressive Relaxation is a term made well known by Dr. Herbert Benton in his work The
Relaxation Response. While he offers a number of well documented and useful methods of
eliciting the relaxation response, his instructions of systematically tensing and relaxing specific
body parts, moving from the feet, up the body, has been used with success as it was first
presented, some thirty nine years ago. (Benson, Dr. Herbert, The Relaxation Response (1rst Ed.)
1975. New York: Morrow).
The focusing of one particular part of the body, tensing those muscles , holding that tension, then
relaxing, while thinking or saying one word or mantra allow for might be referred to as being
present in the body or in the moment. For Recreation Therapy purposes, this method can be
scripted and put into a guided imagery or guided relaxation format.
Studies on the Effectiveness of Various Meditative, Relaxation and Imagery Techniques
In sports psychology , guided imagery has been used successfully for many years to aide in
recovery from in sports injuries. In one study discussed by Handegard, et al , participants
attributed 30 to 40% of their successful recovery from sports injury to the mental training
program- specifically guided imagery that utilized body rehearsal for rehabilitation. (Handegard,
Loretta A. , Joyner, A. Barry, Burke, Kevin L. and Reimann, Bryan. Relaxation and Guided
Imagery in the Sport Rehabilitation Context, 2006, Journal of Excellence, Issue No. 10. USA)
A study focusing on adolescents diagnosed with major depression utilized a 3x3 experimental
design around adolescent psychiatric patients playing a video game. Levels of verbal persuasion
were: a) persuasion to promote internal and stable attributions; b) ambiguous persuasion to bring
about external and unstable attributions and c) no persuasion.
The imagery variable involved a) imagery of successful experience; b) imagery of a failure
experience and c) no imagery experience. The effects of success imagery was evident in the
study results and those in the internal persuasion group had significantly higher scores on the
collection of dependent variables. ( Ellis, Gary. D., Maughan-Pritchett, Marianne and Ruddell,
Edward. Effects of Attribution Based Verbal Persuasion and Imagery on Self Efficacy of
Adolescents Diagnosed with Major Depression. (1993) Therapeutic Recreation Journal, Vol. 27,
No. 2)
Functional Abdominal Pain (chronic stomach pain with no known cause) is associated with
disability and decreased quality of life. (http://www.giresearch.org/site/iffigd-research-
awards/2007/guided-imagery) A study involving 34 children with FAP, between the ages of 6
and 15 years, had some of the children listen to guided imagery CD's over an eight week period
while some received only traditional medical care. 63.1 percent of the guided imagery group
experienced a significant decrease in stomach pain over just 26.7 percent in the control who
received traditional medical care only. (van Tilburg, Miranda A.L. et al Audio-Recorded
Guided imagery Treatment Reduces Functional Abdominal pain in Children: A Pilot Project.
Pediatrics. Vol. 124. No. 5 2009. pp. e890-3897)
A review of neuroelectric and imaging studies revealed that with practice, meditation changes
attentional allocation. Neuroimaging studies showed increased regional blood flow measures

4. during meditation. Meditation did in fact, according to the studies, facilitate changes to the
brain, specifically the anterior cingulate cortex and the dorsolateral prefrontal areas. (Cahn, B.
Rael; Polich, John. Meditation States and Traits: EEG, ERP and neuroimaging studies.
Psychological Bulletin, Vol. 132 (2) Mar. 2006, pp. 180-211.)
More than 200 research studies, conducted over the past thirty years, have produced evidence
that guided imagery can help in the following areas:
• pre-surgery anxiety reduction and post operative recovery
• counteracts loss of control, fear, panic, anxiety, feelings of helplessness and uncertainty
• overcoming stress, anger, pain, depression and other problems often associated with
illness, disability and medical or surgical procedures.
• reduce side effects of and complications of medical procedures
• reduce recovery time and shorten hospital stays
• increase self confidence and self control
• strengthen the immune system and enhance the ability to heal
• helps patients deal positively with chemotherapy, dialysis, and other treatment
procedures. ( http://myclevelandclinic.org/wellness/integrative-medicine/treatments-
services/guided-imagery.aspx)
While an earlier study conducted by Dror and Kosslyn in 1994 suggested that age related
changes caused a deterioration in the ability of older individuals to mentally generate and
manipulate images (Dror, I.E. and Kosslyn, S.M. 1994. Mental Imagery and Aging. Psychology
and Aging. 9, pp. 90-102), later studies have found that age alone was not a significant predictor
of imagery use but rather it was a combination of advanced age and low activity level. (Giacobbi,
P.R. (2007) Age and activity level differences in the use of exercise imagery. Journal of Applied
Sport Psychology, 19 pp. 487-493). This would suggest that, with practice and activity, older
individuals could learn and become better at using guided imagery and mindfulness techniques.
Benefits of meditation, guided imagery, guided relaxation and progressive relaxation
therapy.
Research also indicates that practicing guided imagery creates new neural pathways and can
reinforce positive behaviors. The human brain cannot distinguish between real or imagined
activities. (Guided Imagery- Encouraging Mindfulness in Children
http://www.themindfulword.org/2012/guided-imagery-scripts-children-anxiety-stress). As new
neural pathways are created and the therapy continues, the brain actually believes that the
positive outcomes are happening, resulting in positive mindset.

5. Meditation for stress reduction is now used in acute care medical settings to reduce
complications associated with increased stress that include depressed immune systems. There
are now several main stream health care programs in the U.S. offering MSBR or Mindfulness
Based Stress Reduction programs.
A 2003 meta-analysis found that MBSR may be extensively useful for both clinical and non-
clinical problems. MBSR was found to be helpful with patients with chronic pain, fibromyalgia,
cancer and coronary artery disease. (Grossman, P.; Niemann, L.; Schmidt, S.; Walach, H. (2004).
Mindfulness-based stress reduction and health benefits A meta-analysis Journal of
Psychosomatic Research 57 (1): 35–43.)
Patients suffering Bodily Distress Syndrome (BDS) which is a general definition covering
conditions such as fibromyalgia, chronic fatigue syndrome and somatization disorder were found
to benefit from Mindfulness Based Stress Reduction (MBSR) in a group program conducted in
Denmark. MBSR, utilizing mindfulness practice to reduce suffering associated with physical,
psychosomatic and psychiatric disorders, was found to be comparable to specialized treatment in
improving the function, quality of life and symptoms of the study patients at a 15 month follow-
up.(Fjorback, LO. Mindfulness and Bodily Distress. The Research Clinic for Functional
Disorders and Psychosomatics. Aarhus University Hospital, Aarhus, C. Denmark.
lonefjor@rm.dk. Danish Medical Journal.2012 Nov. 59 (11): B4547)
Research from Harvard Medical School also found that during meditation, there is a decrease in
respiration and increase in blood oxygen saturation levels. ( Marr, Arthur J. In the Zone: A
Biobehavioral Theory of the Flow Experience. Athletic Insight- The Online Journal of Sport
Psychology. 2001.Benecom Technologies, Inc. New Orleans, Louisiana. lanna@bellsouth.net
and drmezmer.com)
In a review of empirical data on the effects of mindfulness, Keng, Smoski, and Robins found that
mindfulness practices lead to various positive psychological effects, including subjective well
being, reduced psychological symptoms and reduced emotional reactivity. (Keng, S.L., Smoski,
M.J. and Robins, CJ. Effects of Mindfulness on Psychological Health: a review of empirical
studies. Clinical Psychology Review. 2011 Aug: 31 (6) pp. 1041-56)
Findings from a neuro-imaging study conducted at Massachusetts General Hospital found that
brain regions associated with attention, interoception and sensory processing were thicker in
older subjects who meditated than in the control group. The differences between the two groups
was most pronounced in the older study participants indicating that meditation might counteract
age related cortical thinning by slowing the rate of neural degeneration of these brain regions.
(Lazar, Sara W., et al. Meditation experience associated with increased cortical thickness.
Ageing NeuroReport.Lippincott Williams & Wilkins. Vol. 16 No. 17 November 2005)
Transcendental meditation and mindfulness appear to produce similar results in terms of
improved psychological well being, positive emotions and life satisfaction outcomes. And
studies have shown that the only real difference in outcomes is related not to the type of
meditative practice or mindfulness but to the number of times per week the activity is
conducted. (Zamarra, J/.W. et al Usefulness of the Transcendental Meditation program in the

6. treatments of patients with coronary artery disease. 1996. American journal of Cardiology, 78,
pp 77-80)
Walsh and Shapiro, in their discussion of meditative practices, cite one numerous studies
indicating the usefulness of mindfulness including reduced mortality among nursing home
patients who were taught Transcendental Meditation. Other studies referenced by Walsh and
Shapiro show findings that mindfulness activities help with :
• Type 2 diabetes , asthma, sleep disorders, atherosclerosis
• improved concentration, motor skills and reaction times, empathy, perceptual sensitivity
• improved processing speed, cognitive abilities, short and long term memory recall, and
some measures of creativity
• reduction of trait anxiety, improved self control and self reported increased self esteem
• reduced arousal, modified autonomic nervous system activity, stress immunization
• catharsis and learning to control emotional reactions
(Walsh, Roger and Shapiro, Shauna L. The Meeting of Meditative Disciplines and
Western Psychology : A Mutually Enriching Dialogue. American Psychologist, Vol. 61
(3), April 2006, pp227-239)
Guided imagery can stimulate changes in heart rate, blood pressure and respiratory patterns.
Studies have shown that chronic and persistent pain and/or anxiety can lower the immune
system. Guided imagery can help individuals achieve a state of mind and body that is the
optimum for healing, which is deep relaxation and positive focus.
(http://myclevelandclinic.org/wellness/integrative-medicine/treatments-services/guided-
imagery.aspx)
Implications for Use of Guided Imagery and other Mind/Body/Spirit Techniques as
Therapeutic Recreation Intervention Tools
Living in long term care, group home settings or even spending time in an acute care setting and
dealing with long term or short term challenges can be difficult and can make every stressor
seem larger and more insurmountable than it is. Such short term or long term stress and anxiety
can be ameliorated with meditative practices, progressive relaxation.
Recreation therapists in acute care settings can offer mindfulness activities post surgery or
pre/post other procedures to aid in healing. One method is to offer generalized post procedure
recordings that promote relaxation and healing. An alternative is to conduct an interview with
the patient and then provide a person -specific recording for use that includes procedural and
emotionally specific images as incentive to optimal healing and return to pre-procedure
functional, where possible.

7. Residents/clients in virtually any setting can benefit from individualized guided imagery
provided it is either generic, such as in generalized relaxation, mindfulness or positive thought
focused, or uniquely designed to address a specific resident concern or barrier to leisure
enjoyment.
For those with the ability to focus attention independently, a script can be followed with good
results. However, that same script can be recorded and, combined with soothing background
instrumental music or nature sounds, can then be used as a guided relaxation or guided imagery
exercise.
Newly admitted residents or clients who are experiencing sensory overload due to the sights,
sounds of the facility, in addition to having to share a room or even just dining with many others,
could benefit significantly in stress reduction, adaptation to a new environment, and acquisition
of effective self comforting strategies.
Residents or clients who are recovering from a new health challenge may benefit from guided
imagery or creative visualization in order to respond better to other healing modalities. Once in
a moderately relaxed state, where self talk is less likely to 'judge' the activity, the individual can
be guided through positive imagery to optimal healing.
There are, however, a select group of individuals for whom mind/body/spirit meditative or
guided imagery practices would not be advised. Such practices are contraindicated for those
living with schizophrenia or any other condition where hallucinations are possible or probable. In
place of the above mentioned modalities, other relaxation methods would be beneficial, but
would involve music and sounds without the visualization of images.
Guided imagery and creative visualization can be used as part of a well rounded spiritual care
program in that it is non-denominational in nature and be uniquely adapted to a participant if
required.
Guided imagery, meditative practices and creative visualization can and are often used by
healing professionals to increase confidence and self esteem, increase feelings of ability, to
provide a locus of control, to foster feelings of achievement and to increase independence.
Mindfulness techniques can also lead to increased participation in leisure activities both in-house
and in the community at large.
Mindfulness, guided imagery and meditative practices offer a multitude of benefits and are
supported by hundreds of studies demonstrating their benefits. Additionally, the cost of provision
is low, easily learned by residents/clients and portable.
When all factors are considered, there really are very few other strategies that are so universal,
cost effective and adaptable for use by therapeutic recreation professionals.

8. Submitted by:
Ava Jean (Jeannie) Lawler-Lunn, Rec.T.® B.G.S. (Psych) ACht
Jeannie is a Recreation Therapist in independent practice and she can be contacted through
recreationpotentials@shaw.ca or http://www.reCreationPotentials.ca
References
Benson, Dr. Herbert. The Relaxation Response (1975) (1rst Ed.) New York: Morrow pp.162-163
Cahn, B. Rael; Polich, John. Meditation States and Traits: EEG, ERP and neuroimaging studies.
Psychological Bulletin, Vol. 132 (2) Mar. 2006, pp. 180-211
Dror, I.E. and Kosslyn,S.M. 1994. Mental Imagery and Aging. psychology and Aging. 9,
pp. 90-102
Ellis, Gary. D., Maughan-Pritchett, Marianne and Ruddell, Edward. Effects of Attribution Based
Verbal Persuasion and Imagery on Self Efficacy of Adolescents Diagnosed with Major
Depression. (1993) Therapeutic Recreation Journal, Vol. 27, No. 2
Fjorback, LO. Mindfulness and Bodily Distress. The Research Clinic for Functional Disorders
and Psychosomatics. Aarhus University Hospital, Aahurs, C. Denmark. lonefjor@rm.dk.
Danish Medical Journal. 2012 Nov. 59 (11): B4547
Giacobbi, P.R. (2007) Age and activity level differences in the use of exercise imagery. Journal
of Applied Sport Psychology, 19 pp. 487-493
Gillespie-Lopes, Catherine. Guided Imagery- Encouraging Mindfulness in Children - Use these
scripts to help children cope with anxiety and stress.
Grossman, P.; Niemann, L.; Schmidt, S.; Walach, H. (2004). Mindfulness-based stress reduction
and health benefits A meta-analysis Journal of Psychosomatic Research 57 (1): 35–43.
Handegard, Loretta A. , Joyner, A. Barry, Burke, Kevin L. and Reimann, Bryan. Relaxation
and Guided Imagery in the Sport Rehabilitation Context, 2006, Journal of Excellence,
Issue No. 10. USA
http://en.wikipedia.org/wiki/Creative_visualization ( retrieved August 1, 2014)

9. Keng, S.L., Smoski, M.J. and Robins, CJ. Effects of Mindfulness on Psychological Health: a
review of empirical studies. Clinical Psychology Review. 2011 Aug: 31 (6) pp. 1041-56
Lazar, Sara W., et al. Meditation experience associated with increased cortical thickness. Ageing
NeuroReport.Lippincott Williams & Wilkins. Vol. 16 No. 17 November 2005
Marr, Arthur J. In the Zone: A Biobehavioral Theory of the Flow Experience. Athletic Insight-
The Online Journal of Sport Psychology. 2001.Benecom Technologies, Inc. New
Orleans, Louisiana. lanna@bellsouth.net and drmesmer.com
http://myclevelandclinic.org/wellness/integrative-medicine/treatments-services/guided-
imagery.aspx ( retrieved July 20, 2014)
http://www.themindfulword.org/2012/guided-imagery-scripts-children-anxiety-stress/ ( retrieved
August 1, 2014)
http://www.giresearch.org/site/iffigd-research-awards/2007/guided-imagery ( retrieved July 20,
2014)
van Tilburg, Miranda A.L. et al Audio-Recorded Guided imagery Treatment Reduces Functional
Abdominal pain in Children: A Pilot Project. Pediatrics. Vol. 124. No. 5 2009. pp. e890-
3897)
Walsh, Roger and Shapiro, Shauna L. The Meeting of Meditative Disciplines and Western
Psychology : A Mutually Enriching Dialogue. American Psychologist, Vol. 61 (3), April
2006, pp227-239
Zamarra, J/.W. et al. Usefulness of the Transcendental Meditation Program in the Treatment of
Patients with Coronary Artery Disease. 1996. American Journal of Cardiology, 78,77-80