Relaxation and Visual Imagery

Relaxation and Visual Imagery

PEP Topic 
Sleep-Wake Disturbances

Visual imagery involves the use of mental visualization and imagination to enhance relaxation and alter specific experiences and may or may not include direct suggestion. It may differ from guided imagery in that the process may not be highly specific nor aimed at imagining a relaxed setting or memory. Relaxation may involve breathing exercises but not the specific process of progressive muscle relaxation.

Effectiveness Not Established

Research Evidence Summaries

Freeman, L.W., White, R., Ratcliff, C.G., Sutton, S., Stewart, M., Palmer, J.L., . . . Cohen, L. (2014). A randomized trial comparing live and telemedicine deliveries of an imagery-based behavioral intervention for breast cancer survivors: Reducing symptoms and barriers to care. Psycho-Oncology. Advance online publication. 

doi: 10.1002/pon.3656

Study Purpose:

To determine the effects of guided imagery training on quality of life (QOL) for survivors of breast cancer

Intervention Characteristics/Basic Study Process:

Trained professionals facilitated five weekly live (LD) or teleconference (TD) group sessions. The initial four sessions each included four one-hour modules of training in guided imagery (i.e., four hours per week). Each module was divided equally between a didactic lesson and an interactive small group activity. Didactic lessons provided education on the mind-body connection, particularly the influence of mental imagery and corresponding sensory experiences on physiologic processes. Small group activities incorporated opportunities to process lessons and to practice active and targeted imagery aimed at improving QOL. Each week, participants were given a guided imagery CD to reinforce current lessons and to promote the practice of imagery techniques daily. The fifth week provided a final group check-in for individuals to share their future plans for incorporating imagery into daily life. Weekly calls were made to encourage daily practice during the intervention and for three months postintervention. Waitlist controls (WLs) received no intervention. Outcome measures were assessed before the behavioral intervention and at one and three months after the intervention.

Sample Characteristics:

  • N = 118    
  • MEAN AGE: 55.4 years (SD = 8.39 years) 
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors of all stages at least six weeks postcompletion of treatment
  • OTHER KEY SAMPLE CHARACTERISTICS: Sample was an average of 50.9 (44.45) months from diagnosis.


  • SITE: Multi-site    
  • SETTING TYPE: Multiple settings    
  • LOCATION: Anchorage and Seattle in community centers for group sessions and participants’ homes for daily practice of guided imagery

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship

Study Design:

Randomized, waitlist-controlled trial

Measurement Instruments/Methods:

  • Functional Assessment of Cancer Therapy, Cognitive Scale (FACT-Cog) version 2
  • Pittsburgh Sleep Quality Index (PSQI)
  • Functional Assessment of Chronic Illness Therapy Fatigue scale (FACIT-F) version 4
  • Medical Outcomes Study Short-Form survey (SF-36)
  • Functional Assessment of Cancer Therapy, Breast (FACT-B)
  • Functional Assessment of Chronic Illness Therapy, Spiritual Well-Being Expanded Scale (FACIT-Sp-Ex) version 4
  • Brief Symptom Inventory-Global Severity Index (BSI-SI)


Both intervention groups (LD and TD) reported better cognitive function, less fatigue, and less sleep disturbance than waitlist controls (p < .01 for both). The LD and TD groups did not differ in any outcomes. No group effects were found for the other QOL outcomes. No time or group-by-time effects were found for any outcomes. A smaller portion of LD and TD participants reported clinically meaningful sleep disturbances (p < .01 for both) and fatigue (p < .05 for both) at the follow-up assessments.


After five weeks, the group guided imagery course provided by a trained facilitator may improve patient-reported cognitive impairment, sleep disturbances, and fatigue in breast cancer survivors. The delivery of this intervention in person or via teleconference produced the same results, suggesting that the intervention may be appropriate for use in telemedicine.


  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Findings not generalizable
  • Intervention expensive, impractical, or training needs
  • Other limitations/explanation: Participants were not blinded, and it is unclear whether the research assistants who did the QOL assessments were blinded to group assignment. The nonspecific effects of social support or attention may have been responsible for the improvement of symptoms given the lack of an active control group. The sample was mostly white and well-educated, limiting generalizability. The TD group was half the size of the LD group, limiting the study's ability to demonstrate a difference between these modes of delivery. The intervention would require training for facilitators to maintain fidelity; feasibility may be an issue in practice because of the time commitment required from facilitators and participants. Cognitive function was measured only with self-report instruments. The duration of the intervention effect is unknown because of the lack of long-term follow-up assessments.


Nursing Implications:

A group guided imagery course, delivered live or via teleconference by a trained facilitator, may improve cognitive impairment, sleep disturbance, and fatigue for breast cancer survivors. However, more research with larger samples and a longer follow-up is warranted to determine whether the intervention is effective and practical.

Serra, D., Parris, C. R., Carper, E., Homel, P., Fleishman, S. B., Harrison, L. B., & Chadha, M. (2012). Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clinical Journal of Oncology Nursing, 16, 617–623. 

doi: 10.1188/12.CJON.617-623

Study Purpose:

To examine the effects of guided imagery on patient distress and symptoms during radiotherapy.

Intervention Characteristics/Basic Study Process:

Patients received instruction on guided imagery during the first few days of radiotherapy treatment and participated in sessions with a nurse immediately prior to radiotherapy treatments. Sessions lasted about 30 minutes and involved relaxation and breathing exercises with visualization of a calming experience and setting. Patients were provided with a CD for home practice. Study measures were performed at baseline and at the end of radiotherapy treatments. Pre- and postsession pulse, blood pressure, and thermal biofeedback measures were obtained.

Sample Characteristics:

  • The study reported a sample of 66 women; only 11 remained for the final measures.
  • Mean age was 57 years (range 28–77).
  • All patients had breast cancer and were undergoing active radiotherapy. Most were also receiving adjuvant chemotherapy and/or hormonal therapy.


  • Single site
  • Outpatient

Study Design:

A quasiexperimental design was used.

Measurement Instruments/Methods:

  • Distress thermometer and visual analog scale (VAS) subscales
  • EuroQol EQ-5D questionnaire
  • Thermal biofeedback


EQ-5D subscale scores for anxiety and depression declined from a mean of 1.42 to 1.26 by the end of treatment (p = 0.01). There was a decline in overall distress scores (p = 0.04), but no significant changes occurred in depression, sleep, or fatigue scores. Patients showed immediate postsession reduction in respiratory rate and blood pressure but no significant differences in thermal biofeedback findings.


The findings suggest that relaxation and imagery can be helpful to patients during radiotherapy.


  • The study had a small sample size, with less than 100 patients.
  • The study had risks of bias due no control group, no blinding, and no random assignment.
  • Patient withdrawals were 10% or greater.
  • It is not known whether patients used the intervention between sessions.

Nursing Implications:

Findings suggest that relaxation therapy and imagery can be helpful to patients during radiotherapy treatment; however, this study had substantial design limitations that limited the strength of the evidence. Relaxation and imagery, and particularly patients’ use of these techniques on their own, pose no patient risks and can be a practical intervention that is helpful to patients during active treatment.

Systematic Review/Meta-Analysis

Kwekkeboom, K. L., Cherwin, C. H., Lee, J. W., & Wanta, B. (2010). Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. Journal of Pain and Symptom Management, 39, 126–138.

doi: 10.1016/j.jpainsymman.2009.05.022


To identify and synthesize the evidence for mind-body interventions for which the evidence suggests benefit for at least two of the three cluster symptoms of pain, fatigue, and sleep disturbance.

Search Strategy:

Databases searched were CINAHL, MEDLINE, and PsycINFO through March 2009.

Search keywords were guided imagery, hypnosis, relaxation, biofeedback, cognitive behavioral therapy, coping skills training, meditation, virtual reality, music AND cancer AND fatigue, sleep disturbance, sleep difficulty, insomnia, and pain.

Studies were included in the review if they

  • Were limited to research
  • Included adults aged 18 years and older
  • Included mind-body activities that involved primarily mental activity that could be performed by almost all patients
  • Included pain, fatigue, or sleep among study dependent variables.

Studies were excluded if they

  • Involved the use of yoga
  • Involved patients in whom a diagnosis of cancer was not yet established
  • Had a sample that included people without cancer.

Literature Evaluated:

A total of 47 studies were identified. In four of those, all testing virtual reality, only the symptom of fatigue was measured, so these were eliminated.

Sample Characteristics:

The final sample included 43 studies. Study sample sizes and total patients involved across studies were not reported.



Six studies examined relaxation interventions in hospitalized patients, outpatients with chronic pain, and women with early-stage breast cancer.

  • Significantly greater pain relief was obtained with progressive muscle relaxation compared to massage, usual treatment, mood manipulation, distraction, and controls.
  • One study found no difference in pain between a daily relaxation exercise and distraction.
  • Training in muscle relaxation did not improve fatigue in one study compared to provision of information.
  • In one study, muscle relaxation improved sleep compared to usual treatment controls.

Imagery and Hypnosis

Six studies examined imagery and hypnosis.

  • In four studies, imagery was used in hospitalized patients with cancer pain, and beneficial effects were reported.
  • One study found no differences in pain or fatigue between patients with an imagery intervention and those receiving standard care.
  • Four studies used imagery in comparison to cognitive-behavioral therapy (CBT) and combined imagery with relaxation. Of those, one study reported no significant effect, two reported significant pain reduction, and one reported significant reduction in fatigue and sleep disturbance.

Cognitive Behavioral Therapy (CBT)/Coping Skills Training (CST)

Twenty-one studies tested CBT/CST.

  • In three studies, fatigue was the primary focus. Significantly more improvement in fatigue was reported with a six- to 12-week CBT/CST intervention compared to usual treatment and controls.
  • Three studies evaluated CST effects on the combination of pain and fatigue. In all of these, a one-session CST intervention resulted in no difference in symptoms compared to controls.
  • Seven studies evaluated the effects of CBT/CST on fatigue and sleep disturbance. One study reported a decreased incidence of fatigue and sleep disturbance using an audio recording for coping skills training prior to chemotherapy. Two studies reported improvement in sleep with a four- to eight-week CBT intervention, but only one of these also reported improvement in fatigue. One study reported improvement in sleep and fatigue with a five-session CBT intervention, two other studies showed improvement in sleep but no change in fatigue, and one study reported no improvement in either of these two symptoms.
  • Four studies reported effects of CBT/CST on all three symptoms concurrently. One showed improvement in fatigue and sleep but no impact on pain. One study reported less sleep disturbance but no difference in pain or fatigue. One reported lower ratings of worst pain immediately after the CBT program and greater reduction in pain and fatigue six months after the intervention compared to controls. One study found no differences in any of the three symptoms with a CST intervention.


Four studies were included.

  • Three of these studies used mindfulness-based interventions. One study reported significant improvements in both fatigue and sleep among outpatients who participated in an eight-week intervention.


  • Four studies looked at the effect of music on pain. Two studies found significant improvements in a pre-/posttest design using 30 minutes of preferred music among hospitalized patients. Two other studies found no difference in pain with listening to music compared to control groups.
  • Two studies tested a music intervention on fatigue. One found a significant effect, and one found no difference in fatigue between intervention and control groups.


Findings of this review were equivocal.


  • Although the authors stated a criterion for inclusion of examination of at least two of the three symptoms of interest, the review appeared to include studies in which only one of these symptoms was reported.
  • Few investigators used multisymptom interventions and evaluations.
  • Measures of symptom clusters were not been well identified.
  • Some instruments were stated to potentially be more sensitive; however, the scales and individual items that were most useful to measure this symptom cluster were not determined.
  • Timing, dosage, and frequency of interventions varied among studies, making it difficult to draw systematic conclusions. Most music interventions were very brief.
  • This review did not provide study details, such as clear sample descriptions, sample sizes, or actual statistical results, and no effect sizes were calculated, although some studies used the same outcome measures.

Nursing Implications:

Although the findings did not clearly demonstrate the effects of these interventions across studies, the authors concluded that these interventions hold promise. Although such interventions carry minimal risk to patients, some interventions would require substantial time and resource commitment to provide.