Guided Imagery

Also known by these names

  • Active imagination
  • Creative visualization
  • Purposeful daydreaming
  • Visualization
  • Waking dream

Key Points 

  • All mind-body treatments and self-care approaches, such as guided imagery, self-hypnosis, auto-suggestion, relaxation techniques, and meditation, consist of either paying attention to or withdrawing attention from the outputs of your imagination. 
  • Guided imagery is a set of very useful mind-body skills for the person dealing with the challenges of cancer.
  • Certain imagery techniques and skills are particularly helpful in dealing with cancer-related issues. “Guided” imagery teaches you how to use your imagination for best effect in managing stress and anxiety, making good decisions, preparing for and tolerating diagnostic and therapeutic procedures, and maintaining  energy and attitude.
  • Guided imagery can reduce fatigue, nausea and pain in people undergoing chemotherapy, radiation therapy and other cancer treatments.
  • Guided imagery can reduce pre- and post-operative anxiety, complications and pain levels.
  • Guided imagery can improve quality of life. 
  • Guided imagery is beneficial to the person with cancer, helping to relax and empower them in their journey
  • Guided imagery includes a range of techniques from simple visualization and direct imagery-based suggestion to metaphor and story-telling.

Imagery is the natural language of the human subconscious, a rich, sensory-based and emotional coding language of the brain/mind that shows itself in human culture through art, poetry and drama. It is the language of dreams, visions, insights, intuitions and creativity.  Imagery allows us both to become aware of and change our perceptions of our external and internal environments. It is central to mind/body healing because the body both responds to imagery-based suggestions, and also communicates to the conscious mind through images and symbols.

One of the reasons mental imagery is so important in healing is that the body responds much more quickly to images than it does to verbal requests or suggestions. For instance, if I asked you to salivate right now, you might be able to produce a little saliva. But if I asked you to vividly imagine sucking on a lemon you will salivate much more. If I asked you to imagine sitting in front of your favorite meal, and imagine how it looks, and smells, and what it will taste like, your stomach and intestines will begin to secrete digestive juices and begin to move.  Sexual fantasy will get you physiologically aroused. And when you learn to use images as multi-sensory suggestions of healing responses in the body, your body will respond with changes in muscle tension, blood flow, immune activity, better sleep and better digestion.

Imagery is not only an effective form of suggestion to the body, it is also a symbolic language that can allow your unconscious to communicate to you what it may be feeling and how it perceives situations including your health. In a very real way, imagery is like the Rosetta Stone of body/mind/spirit communication.

When I work with patients in my practice, the focus is always on what the most important issues are to that patient at that time. In cancer care, if a patient has been recently diagnosed, the initial focus is on making sure they have the best oncological and support care, and on helping them learn ways to manage the fear and other strong emotions that almost always accompany a cancer diagnosis.  I invite them to create a simple image that represents the outcome they would have if it were up to them. This image serves as a touchstone and guiding light for them as they navigate the complex world of treatment decisions, tolerating treatments, and learning about supporting their innate abilities to heal.

A woman I once worked with was an advanced skier. When I invited her to allow an image to form that would help her through her cancer journey, she imagined herself at the top of a very challenging ski run. As she surveyed the imaginary slope in front of her, noticing the trees and rocks she would have to avoid, she said, “It’s important to know what to avoid, but once I push off, the only place to look is where I want to go, never where I don't want to go.”

Most people dealing with cancer can learn simple, straightforward imagery techniques to relax, reduce anxiety and fear, reduce or relieve side effects like nausea from chemotherapy, prepare for and recover from surgery, reduce pain and discomfort, and help themselves sleep. The easiest way to learn these skills is to listen to audios that guide you through the process, like the ones recommended in our More Information section.

If you are the kind of person to whom it’s important to explore the meaning of life events, or find the best you can make from them, imagery can allow you to explore your experience of cancer in this light. Usually it’s best to do this with an experienced and trusted therapist or guide familiar with imagery.

One other aspect of guided imagery I want to mention is that images may be unintentionally conveyed to you in your interactions with your doctors or other health professionals. The fact that both the patients’ and physicians’ expectations impact treat­ment effects is the reason that we go to the immense trouble and expense to do double-blind studies. Although researchers want to eliminate the effect that patient beliefs have on their experience and outcome, patients and clinicians want to maximize its benefit and use it to therapeutic advantage. An effective oncologist is someone who will treat cancer expertly but also treat you respectfully, encourage your participation in your healing efforts, and be mindful of what they are communicating through their words and expressions.

Martin Rossman, MD

People create or harbor internal imagery about their health, Illnesses, treatments and outcomes. Your internal images represent your fears, hopes, expectations and goals regarding your health, illness, treatments and outcomes. Unconscious expectations can significantly influence (or affect or impact) response to treatments, including treatment outcomes. Guided imagery can allow you to consciously become aware of and influence your unconscious imagery.

Guided imagery can allow you to consciously become aware of and influence your unconscious imagery.

Guided imagery can help teach psycho-physiologic relaxation, to relieve symptoms, to stimulate healing responses in the body, to access inner resources, and to help you tolerate procedures and treatments more easily. Mental imagery may include visual, auditory, olfactory or other sensory modes of thinking.

Guided imagery includes a range of techniques from simple visualization and direct imagery-based suggestion to metaphor and story-telling.

Guided imagery may be learned from books, classes, individual teachers or therapists, or from audio recordings available online or through apps.

Help from an Unlikely Inner Guide

by Laura Pole, RN, MSN, OCNS

Jane, near the end of her life, met her inner guide, Mr. Bluebird, who appeared on her shoulder as she imagined herself skiing down a pristine slope in the Virginia mountains. This momentous meeting came after days of being in the hospital as we tried to get her symptoms of advanced breast cancer under control. I noticed that she was having to call the nurses fairly frequently for them to give her IV morphine to control her pain. I asked her if she would consider a special pain pump that would allow her to press a button to deliver her pain medication—that way she wouldn’t have to wait so long for the nurse to prepare and give her the injection. Jane said, “If I have to press a button for my pain medicine, I want there to be a real person answering the button and not a machine.” “OK” I said, “I get it. . How would you like to learn a way to fill the wait time with something that would take your focus off the pain and direct it to something pleasant?” She was all in for that. 

Read more

Interactive Guided Imagery (IGI) is a specific way of using imagery that is particularly effective in helping patients use their own inner resources. Patients are guided to work with their own personal imagery and insights about their illness and healing, to clarify any issues that may be involved, and to learn to use the mind to support their own healing. IGI principles can be used in self-care approaches but often are best facilitated by a trained health professional, especially where highly emotional issues are involved, as they often are with cancer.

Guided imagery may be included in other mind-body therapies, such as cognitive-behavioral therapy. This summary focuses on the evidence behind the use of guided imagery either alone or specifically mentioned in conjunction with other therapies.

Clinical Practice Guidelines

The 2016 American Society of Clinical Oncology clinical practice guideline for managing chronic pain in adult cancer survivors concluded that benefits of guided imagery outweigh harms, with intermediate-quality evidence. The guidelines give a moderate recommendation for guided imagery to manage chronic pain.1

2014 clinical practice guidelines from the Society for Integrative Oncology (SIO) recommends relaxation with imagery for routine use for common conditions, including anxiety and mood disorders (Grade A, high certainty that the net benefit is substantial).2

Treating the Cancer

No evidence yet shows that a patient can directly affect the tumor or its microenvironment through guided imagery, such as by reducing blood flow to tumors or turning off oncogenes. However, these images serve as autosuggestions representing potential mechanisms of resisting or overcoming cancer. As long as they are not substituted for more definitive or effective treatment, clinically, BCCT concludes it is ethical and reasonable to encourage patients to imagine healing in a way that has meaning for them. 

Investigators have concluded that cancer patients should not be denied programs, including guided imagery, that improve quality of life and well-being simply because there is uncertainty about whether such programs might also lengthen lifespans.3

Managing Side Effects and Promoting Wellness

Randomized studies indicate that guided imagery and other mind-body therapies can reduce or eliminate emotional and physical side effects of surgery, radiation and chemotherapy treatments.

While medical treatments including surgery, chemotherapy, and radiation can be powerful weapons in fighting cancer, side effects including fatigue, pain, and nausea can be debilitating and even cause patients to forego or discontinue treatment. Randomized studies indicate that guided imagery and other mind-body therapies can reduce or eliminate emotional and physical side effects of surgery, radiation and chemotherapy treatments. 

Early Psychological and Emotional Issues with a Cancer Diagnosis 

Receiving a cancer diagnosis is almost always unnerving and often traumatic. A serious cancer diagnosis comes with a unique set of challenges for patients, their families and healthcare professionals. Patients newly diagnosed with cancer, and their support people, are frequently in shock, fearful, and emotionally regressed. During this difficult emotional time they are called on to evaluate complex information and opinions that are often in conflict. They also have to make difficult treatment decisions, all in an atmosphere of urgency. They can feel pressured to sort through an overwhelming amount of information and may feel torn between conventional, complementary and alternative treatment advice. Finally, cancer patients often are asked to choose treatments that can have difficult, disfiguring, and sometimes life-threatening effects of their own, which makes choices difficult, even with potential benefits. 

Almost everyone responds to the diagnosis of cancer with a period of shock, numbness, and disbelief. Approximately 40 to 60 percent of cancer patients are significantly fearful and distressed following their diagnosis.4

Guided Imagery and Mind-Body Approaches with Cancer 

Research supports the use of guided imagery (and other mind-body approaches) in six important aspects of living with cancer or cancer treatments: 

  1. Helping with the stress and emotions of being diagnosed with cancer
  2. Coping with and reducing adverse effects of cancer treatments
  3. Stimulating immunity, blood flow and other healing responses
  4. Reducing or relieving cancer-related pain
  5. Improving quality of life
  6. Influencing the progression or outcome of the diagnosis

Anxiety, Depression, Stress and Distress

Guided imagery may reduce anxiety and depression and improve mood and quality of life in cancer patients.

Reviews of the literature and meta-analyses have found that guided imagery may reduce anxiety and depression and improve mood and quality of life in cancer patients,5 although not all results show an effect.6

Relaxation with guided imagery and other mind-body techniques have been highly effective in reducing anxiety before, during and after surgery in both adults and children.7

In a 2019 study, interactive guided imagery (IGI) and progressive muscle relaxation alleviated pain-related distress in terminal cancer patients.8

A 1999 review suggested the effectiveness of guided imagery in the management of stress, anxiety and depression, and for the reduction of blood pressure.9 A clinical trial found that using a comprehensive coping strategy program (CCSP) including guided imagery significantly reduced psychological distress in patients with breast cancer who underwent autologous bone marrow/peripheral blood stem cell transplantation (ABMT).10 A 2008 study demonstrated well-maintained reductions of cortisol after a cognitive-behavioral stress management group intervention in cancer patients during and just after treatment.11

Effects with breast cancer:

  • A 2005 study assessed the effectiveness of progressive muscle relaxation training and guided imagery in a randomized study of patients with breast cancer. The treatment group had a better quality of life with significantly less anxiety, depression and hostility than the control group..12
  • A randomized comparison study of women undergoing radiation therapy for breast cancer found that those who learned muscular relaxation or relaxation and guided imagery from audiotapes had relief from depression. The group using imagery improved more than the relaxation group. The control group, in which women were encouraged to talk about their feelings, had worsened depression during the study.13

Pain, Fatigue and Sleep Disturbance

Imagine Dialing Down a Symptom

by Laura Pole, RN, MSN, OCNS

David had a blood cancer that required multiple bone marrow biopsies. For his first biopsy, the doctor told him the pain from the procedure, though temporary, would be intense, and so he was going to give him a medication to consciously sedate him. David doesn’t remember the procedure and thus doesn’t remember any pain. However, he didn’t want to continue to use analgesic or sedating drugs with the procedure if he could avoid it.

Read more

The prevalence of pain in patients with cancer has been reported to be between 50 percent and 70 percent during cancer treatment and 65 percent for those with advanced disease.14 Pain is both a physical sensation and an emotional experience. It is one of the most common, burdensome, and feared symptoms experienced by patients with cancer,15 and is often underreported, underdiagnosed, and undertreated.16 The way a patient manages stress, tension, and emotions can amplify or reduce the suffering associated with pain.

Guided imagery can significantly reduce pain and the need for pain medication post-operatively.

Guided imagery can significantly reduce pain and the need for pain medication post-operatively.17

One study found patients undergoing elective colorectal surgical procedures who used guided imagery experienced considerably less preoperative and postoperative anxiety and pain and used 50 percent fewer narcotics after surgery compared to patients receiving routine perioperative care.18 Another small study found that “patients who achieved a meaningful improvement in pain with analgesic imagery reported greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms than those who did not achieve a meaningful reduction in pain.”19

A 2001 review concluded that “hypnotic-like methods, involving relaxation, suggestion, and distracting imagery, hold the greatest promise for pain management” of behavioral interventions investigated.20 A 2019 review found “trends in reducing the severity of cancer pain” with guided imagery and other mind-body therapies.21

A 1999 review suggested the effectiveness of guided imagery for pain and other side effects of chemotherapy.22 Daily guided imagery audiotapes led to a significant overall increase in comfort in breast cancer patients undergoing radiation therapy and continuing after treatment.23

A clinical trial using a comprehensive coping strategy program (CCSP) including guided imagery significantly reduced pain and fatigue in patients with breast cancer who underwent autologous bone marrow/peripheral blood stem cell transplantation (ABMT).24

A 2009 review found that guided imagery and other mind-body interventions could improve a cluster of symptoms (pain, fatigue and sleep disturbance) in persons with cancer with a single treatment strategy.25 A 2014 review found evidence of reduced cancer treatment–related pain or distress, with small to moderate effect sizes.26

A 2015 review concluded that no evidence was available to determine the effectiveness of cognitive behavioural therapy techniques for pain in lung cancer patients.27

Nausea and Vomiting 

A clinical trial using a comprehensive coping strategy program (CCSP) including guided imagery significantly reduced nausea in patients with breast cancer who underwent autologous bone marrow/peripheral blood stem cell transplantation (ABMT).28 A 2003 review found that behavioral interventions for cancer treatment can effectively control anticipatory nausea and vomiting from chemotherapy.29 A 2005 study assessed the effectiveness of progressive muscle relaxation training and guided imagery in a randomized study of patients with breast cancer. The treatment group had less anticipatory and post-chemotherapy nausea and vomiting.30

Reviews of evidence-based interventions to prevent, manage and treat chemotherapy-induced nausea and vomiting found evidence of effect or recommended the use and effectiveness of guided imagery and other mind-body interventions.31

Quality of Life

Guided imagery and other mind-body techniques are effective in improving overall quality of life.

Along with people newly diagnosed or in treatment for cancer, an increasing number of people are living with a history of cancer. Attending to the quality of life and health of both groups is important. Interestingly, the most common treatment goal of research examining psychosocial interventions for cancer patients has been to improve quality of life.32

A 2017 review of guided imagery and other mind-body techniques concluded that they are effective in improving overall quality of life.33

A survey of 896 caregivers participating in the American Cancer Society Quality of Life Survey for Caregivers concluded that caregivers can benefit from interventions that enhance their ability to accept their situation and find meaning in their caregiving experience. This may improve their satisfaction with life and reduce their depressive symptoms.34 A related needs assessment of family caregivers of cancer survivors reported that interventions designed to help caregivers manage their own emotional distress, as well as the survivors’ distress, can help them find meaning in the cancer caregiving experience and foster supportive familial relationships that will benefit the caregivers quality of life, not only during the time of diagnosis and treatment, but for years afterward.35

Other Effects

Guided imagery and suggestion reduces the time for patients’ bowels to return to normal functioning,36 and may shorten hospital stays.37 Evidence from one small trial indicates that guided imagery may speed wound healing.38

Optimizing Your Terrain

In 1981, researchers Ader and Cohen discovered that the immune system could be classically conditioned, which demonstrated the link between the central nervous and immune systems.39 Ader coined the term “psychoneuroimmunology” (PNI) to describe the field that examines the basis and phenomena of this relationship.

Thus, a biochemical mechanism explains how depression, anxiety and related negative or positive emotional states can affect immunity. Stressful life events, grief and depression—all common in cancer—can significantly down-regulate immunity.40

Hypnosis and guided imagery can enhance both psychological well-being and immune function in patients treated for stage I or II breast cancer.41 When patients with breast cancer used guided imagery to increase an immune response, the numbers and aggressiveness of natural killer cells increased, an effect which increased with time.42

Studies confirm that relaxation training and guided imagery, with other mind-body approaches, can effect a significant immune response, including NK cell activity and lymphocyte proliferation in patients with breast cancer and those undergoing cancer treatment.43

Access

Guided imagery is widely available from practitioners, or as audiotapes, scripts or videos, many available at no cost on YouTube and on apps. See some resources in More Information below.

Cautions

If the following precautions are heeded, guided imagery and related mind-body therapies will have minimal risk:

  • Guided imagery shouldn't be offered as a stand-alone treatment for any cancer.
  • Caution should be used in patients with mental illness, especially psychosis or diffuse dissociative disorders. These patients, who have difficulty distinguishing between inner and outer reality, should work with a qualified mental health professional.
  • Patients with a tendency toward relaxation-induced anxiety will become more anxious. Those with a more severe case would be best served by a qualified mental health professional.
  • Patients may link their ability to help themselves via mind-body therapies to thinking they caused their cancer because of mind-body error or neglect. Offer these techniques as an "opportunity to participate in their efforts toward recovery or acceptance and not be construed as 'blaming the victim.'"

Integrative Programs, Protocols and Medical Systems

For more information about programs and protocols, see our Integrative Programs and Protocols page.

Written by Martin Rossman, MD, Nancy Hepp, MS, and Laura Pole, RN, MSN, OCNS; most recent update on February 12, 2020.

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More Information

Professional Training, Imagery Groups, and Referrals

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