Guided Imagery

Our assessments of evidence for each medical benefit fall into one of these categories:

• Strong evidence: consistent, significant effects in several large (or at least one very large) well designed clinical studies or at least two meta-analysesa statistical analysis that combines the results of two or more research studies; the results of smaller research studies addressing the same or similar questions can be analyzed as though they are one bigger, more powerful study of clinical studies of moderate or better quality (or one large meta-analysis) finding similar results
• Good evidence: significant effects in one large or several mid-sized and well-designed clinical studies ( randomized controlled trialsa study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects with an appropriate placebo or other strong comparison control or observational studies that control for confounds)
• Modest evidence: significant effects in at least three small but well-designed randomized controlled trials (RCTs), or one or more well-designed, mid-sized clinical studies of reasonably good quality (RCTs or observationala type of study in which individuals are observed or certain outcomes are measured, but no attempt is made to affect the outcome (for example, no treatment is given); an example is a study that records people’s diets, but doesn’t try to alter their diets, and looks for patterns of disease or other outcomes related to different foods studies), or several small studies aggregated into a meta-analysis
• Preliminary evidence: significant effects in small or poorly designed clinical studies OR conflicting results in adequate studies but a preponderance of evidence of an effect
• Weak evidence: one or more case studies, supported by animal evidence OR small treatment effects of limited clinical significance OR studies with no controls OR weak trends of effects
• Insufficient evidence: preclinical evidence only OR clinical studies with such poor or unclear methodology that no conclusion can be drawn OR conflicting findings across clinical studies with no preponderance of evidence in one direction; conflicting evidence occurs when studies find conflicting effects (positive effect vs no effect or negative effect) with the same treatment and the same general study population (same cancer type, for example)

Learn more about how we research and rate therapies and practices in How We Rate Therapies ›

• Better symptom scores, including anxiety, depression, and somatization, among people with breast cancer who had completed cancer treatment 6 weeks to 1 year earlier participating in an 8-week imagery stress-reduction program compared to baseline in a small uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design¹²Freeman L, Cohen L et al. Imagery intervention for recovering breast cancer patients: clinical trial of safety and efficacy. Journal of the Society for Integrative Oncology. 2008 Spring;6(2):67-75.

During chemotherapy: preliminary evidence of less anxiety during chemotherapy among people treated with guided imagery

• Less anxiety during chemotherapy among people with cancer treated with guided imagery once a day for a week compared to controls in an RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects¹³Mahdizadeh MJ, Tirgari B, Abadi OSRR, Bahaadinbeigy K. Guided imagery: reducing anxiety, depression, and selected side effects associated with chemotherapy. Clinical Journal of Oncology Nursing. 2019 Oct 1;23(5):E87-E92.
• Less anxiety among non-hospitalized people with cancer who had recently received at least 1 cycle of chemotherapy and treated with guided imagery, whether with or without hypnosis, compared to standard care in a small RCT¹⁴Feldman CS, Salzberg HC. The role of imagery in the hypnotic treatment of adverse reactions to cancer therapy. Journal of the South Carolina Medical Association. 1990 May;86(5):303-6.

During surgery: no evidence of an effect on anxiety among people with cancer undergoing surgery treated with guided imagery in a preliminary trial

• No evidence of an effect on anxiety among people undergoing excisional surgery for basal and squamous cell carcinoma treated with guided imagery compared to relaxing music or controls in a mid-sized RCT¹⁵Alam M, Roongpisuthipong W et al. Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: a single-blinded randomized controlled trial. Journal of the American Academy of Dermatology. 2016 Sep;75(3):585-589.

• No evidence of an effect on lung function after conventional resection of colorectal carcinoma among elderly people treated with guided imagery compared to relaxation or controls in a small RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects¹⁶Haase O, Schwenk W, Hermann C, Müller JM. Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum. 2005 Oct;48(10):1955-63.

• Better appetite during chemotherapy among people with cancer treated with guided imagery once a day for a week compared to controls in an RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects¹⁷Mahdizadeh MJ, Tirgari B, Abadi OSRR, Bahaadinbeigy K. Guided imagery: reducing anxiety, depression, and selected side effects associated with chemotherapy. Clinical Journal of Oncology Nursing. 2019 Oct 1;23(5):E87-E92.

Without regard to treatment phase: weak evidence of less depression among people with breast cancer treated with guided imagery

• Less depression among people being treated for stage 1 or 2 breast cancer participating in an 8-week hypnotic-guided imagery intervention compared to baseline, but the effects did not continue once the intervention ended in an uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design¹⁸Bakke AC, Purtzer MZ, Newton P. The effect of hypnotic-guided imagery on psychological well-being and immune function in patients with prior breast cancer. Journal of Psychosomatic Research. 2002 Dec;53(6):1131-7.

During chemotherapy: preliminary evidence of less depression, better mood, or less negative emotions during chemotherapy among people with cancer treated with guided imagery

• Less depression during chemotherapy among people with cancer treated with guided imagery once a day for a week compared to controls in an RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects¹⁹Mahdizadeh MJ, Tirgari B, Abadi OSRR, Bahaadinbeigy K. Guided imagery: reducing anxiety, depression, and selected side effects associated with chemotherapy. Clinical Journal of Oncology Nursing. 2019 Oct 1;23(5):E87-E92.
• Less depression among non-hospitalized people with cancer who had recently received at least 1 cycle of chemotherapy treated with guided imagery, whether with or without hypnosis, compared to standard care in a small RCT²⁰Feldman CS, Salzberg HC. The role of imagery in the hypnotic treatment of adverse reactions to cancer therapy. Journal of the South Carolina Medical Association. 1990 May;86(5):303-6.

With surgery: no evidence of an effect on fatigue after surgery among elderly people treated with guided imagery in a preliminary study

• No evidence of an effect on reported fatigue after conventional resection of colorectal carcinoma among elderly people treated with guided imagery compared to relaxation or controls (no intervention) in a small RCT²¹Haase O, Schwenk W, Hermann C, Müller JM. Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum. 2005 Oct;48(10):1955-63.

During chemotherapy: insufficient (conflicting) evidence of an effect on nausea during chemotherapy among people with cancer treated with guided imagery in preliminary studies

• Less nausea during chemotherapy among people with cancer treated with guided imagery once a day for a week compared to controls in an RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects²²Mahdizadeh MJ, Tirgari B, Abadi OSRR, Bahaadinbeigy K. Guided imagery: reducing anxiety, depression, and selected side effects associated with chemotherapy. Clinical Journal of Oncology Nursing. 2019 Oct 1;23(5):E87-E92.
• No evidence of an effect on nausea and vomiting during cisplatin treatment among people newly diagnosed with cancer treated with guided imagery compared to standard care in a small RCT²³Troesch LM, Rodehaver CB, Delaney EA, Yanes B. The influence of guided imagery on chemotherapy-related nausea and vomiting. Oncology Nursing Forum. 1993 Sep;20(8):1179-85.

With surgery: no evidence of an effect on nausea, vomiting, or ileus from surgery among people with colorectal cancer treated with guided imagery in preliminary studies

• No evidence of an effect on duration of ileus after conventional resection of colorectal carcinoma among elderly people treated with guided imagery compared to relaxation or controls in a small RCT²⁴Haase O, Schwenk W, Hermann C, Müller JM. Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum. 2005 Oct;48(10):1955-63.

During chemotherapy: preliminary evidence of less pain during chemotherapy among people treated with guided imagery

• Less pain during chemotherapy among people treated with guided imagery once a day for a week compared to controls in an RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects²⁵Mahdizadeh MJ, Tirgari B, Abadi OSRR, Bahaadinbeigy K. Guided imagery: reducing anxiety, depression, and selected side effects associated with chemotherapy. Clinical Journal of Oncology Nursing. 2019 Oct 1;23(5):E87-E92.

With surgery: no evidence of an effect on pain from surgery among people with cancer treated with guided imagery in several trials

• No evidence of an effect on pain among people undergoing excisional surgery for basal and squamous cell carcinoma treated with guided imagery compared to relaxing music or controls in a mid-sized RCT²⁶Alam M, Roongpisuthipong W et al. Utility of recorded guided imagery and relaxing music in reducing patient pain and anxiety, and surgeon anxiety, during cutaneous surgical procedures: a single-blinded randomized controlled trial. Journal of the American Academy of Dermatology. 2016 Sep;75(3):585-589.
• No evidence of an effect on analgesic use or subjective pain intensity at rest or while coughing after conventional resection of colorectal carcinoma among elderly people treated with guided imagery compared to relaxation or controls (no intervention) in a small RCT²⁷Haase O, Schwenk W, Hermann C, Müller JM. Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum. 2005 Oct;48(10):1955-63.
• No evidence of an effect on pain scores among women undergoing surgery for breast or gynecologic cancers treated with standard care (analgesic medications) and guided imagery compared to standard care alone in a small RCT²⁸Kwekkeboom KL. 1999. The role of imaging ability in successful use of guided imagery for cancer related pain. PhD, The University of Wisconsin-Madison.

During hospitalization: preliminary evidence of less pain during hospitalization among people with cancer treated with analgesic imagery or virtual reality

• Less pain among hospitalized people with cancer and moderate-severe pain treated with 10 minutes of either 2-dimensional guided imagery distraction therapy delivered by handheld tablet or immersive virtual reality (VR) distraction therapy, with stronger effects from VR therapy which were sustained for 24 hours, compared to baseline in a mid-sized RCT²⁹Groninger H, Violanti D, Mete M. Virtual reality for pain management in hospitalized patients with cancer: a randomized controlled trial. Cancer. April 8, 2024.
• Lower pain intensity, less pain-related distress, and more perceived control over pain among hospitalized patients with cancer pain treated with either analgesic imagery compared to controls, mostly among people with greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms, in a small controlled triala study design in which people are assigned to either an experimental group or a control group to compare the outcomes from different treatment; assignment is not random, and so this is not as strong a study design as a randomized controlled trial, but still stronger than an uncontrolled trial³⁰Kwekkeboom KL, Wanta B, Bumpus M. Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. Journal of Pain and Symptom Management. 2008 Dec;36(6):604-15.

During chemotherapy: preliminary evidence of better quality of life and related measures during chemotherapy among people treated with guided imagery, sometimes with other mind-body therapies

• More positive experience with cisplatin chemotherapy among people newly diagnosed with cancer treated with guided imagery compared to standard care in a small RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects³¹Troesch LM, Rodehaver CB, Delaney EA, Yanes B. The influence of guided imagery on chemotherapy-related nausea and vomiting. Oncology Nursing Forum. 1993 Sep;20(8):1179-85.

During radiotherapy: preliminary evidence of more comfort during radiation therapy among women with early stage breast cancer treated with guided imagery

• Higher reported comfort during radiation therapy among women with early stage breast cancer treated with guided imagery compared to controls in a small RCT³²Kolcaba K, Fox C. The effects of guided imagery on comfort of women with early stage breast cancer undergoing radiation therapy. Oncology Nursing Forum. 1999 Jan-Feb;26(1):67-72.

After treatment: modest evidence of better quality of life and function after completing cancer treatment among people treated with guided imagery

• A weak trendan apparent change due to a therapy, close to but not achieving full statistical significance (this is the CancerChoices definition; other researchers and studies may define this differently toward increased vigor and improved functional and social quality of life after completing cancer treatment for primary breast cancer, excluding stage 4, among women treated with imagery compared to standard care in a small RCT³³Richardson MA, Post-White J et al. Coping, life attitudes, and immune responses to imagery and group support after breast cancer treatment. Alternative Therapies in Health and Medicine. 1997 Sep;3(5):62-70.
• Better quality of life after recent chemotherapy among non-hospitalized people with cancer treated with guided imagery and/or hypnosis compared to standard care in a small RCT³⁴Feldman CS, Salzberg HC. The role of imagery in the hypnotic treatment of adverse reactions to cancer therapy. Journal of the South Carolina Medical Association. 1990 May;86(5):303-6.
• Better quality of life related to physical, social/family, emotional, and function well-being, plus breast cancer and spiritual subscales, 6 weeks to 1 year after completing treatment among people with breast cancer participating in an 8-week imagery stress reduction program compared to baseline in a small uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design³⁵Freeman L, Cohen L et al. Imagery intervention for recovering breast cancer patients: clinical trial of safety and efficacy. Journal of the Society for Integrative Oncology. 2008 Spring;6(2):67-75.

During hospitalization: preliminary evidence of less pain-related distress among hospitalized people with cancer pain treated with analgesic imagery

• Less pain-related distress among hospitalized people with cancer pain treated with analgesic imagery compared to controls, mostly among people with greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms, in a small controlled triala study design in which people are assigned to either an experimental group or a control group to compare the outcomes from different treatment; assignment is not random, and so this is not as strong a study design as a randomized controlled trial, but still stronger than an uncontrolled trial³⁶Kwekkeboom KL, Wanta B, Bumpus M. Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. Journal of Pain and Symptom Management. 2008 Dec;36(6):604-15.

After treatment: preliminary evidence of less stress after cancer treatment among people treated with imagery

• Better coping skills (seeking support) and perceived social support and a weak trend toward better overall coping and death acceptance and less stress after treatment for primary breast cancer, excluding stage 4, among women treated with imagery compared to standard care in a small RCT³⁷Richardson MA, Post-White J et al. Coping, life attitudes, and immune responses to imagery and group support after breast cancer treatment. Alternative Therapies in Health and Medicine. 1997 Sep;3(5):62-70.
• Less stress 6 weeks to 1 year after completing treatment among people with breast cancer participating with an 8-week imagery stress-reduction program compared to baseline in a small uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design³⁸Freeman L, Cohen L et al. Imagery intervention for recovering breast cancer patients: clinical trial of safety and efficacy. Journal of the Society for Integrative Oncology. 2008 Spring;6(2):67-75.

Among caregivers: weak evidence of less distress among cancer caregivers participating in a guided imagery intervention

• Less psychological distress among caregivers of people with lung cancer participating in guided imagery in a telephone symptom management intervention compared to baseline in a mid-sized uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design³⁹Winger JG, Rand KL et al. Coping skills practice and symptom change: a secondary analysis of a pilot telephone symptom management intervention for lung cancer patients and their family caregivers. Journal of Pain and Symptom Management. 2018 May;55(5):1341-1349.e4.

Preliminary evidence of lower anxiety levels among people undergoing elective colorectal surgical procedures using guided imagery tapes

• Lower anxiety levels among people undergoing elective colorectal surgical procedures using guided imagery tapes from 3 days before until 6 days after the procedures compared to routine care in a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects⁴⁰Tusek D, Church JM, Fazio VW. Guided imagery as a coping strategy for perioperative patients. AORN Journal. 1997 Oct;66(4):644-9.

Preliminary evidence of less anxiety among hospitalized children or their parents receiving guided imagery

• Lower anxiety at the time of listening to imagery tapes, but not about 24 hours after discharge among children undergoing ambulatory tonsillectomy and/or adenoidectomy receiving taped guided imagery before and after surgery compared to standard care in a small RCT⁴¹Huth MM, Broome ME, Good M. Imagery reduces children’s post-operative pain. Pain. 2004 Jul;110(1-2):439-48.

Modest evidence of less pain and use of pain medications after surgery or during hospitalization among people treated with guided imagery, including virtual reality

• Lower pain among hospitalized people reporting pain treated with either standard virtual reality (VR or video capture VR compared to controls not receiving VT in a mid-sized RCT⁴²Powers MB, Carl E et al. Nonpharmacologic pain management among hospitalized inpatients: a randomized waitlist-controlled trial of standard virtual reality (CGI VR) versus video capture VR (360 degrees 3D/Stereoscopic Video Capture VR). Clinical Journal of Pain. 2021 Sep 1;37(9):678-687.
• Less pain and substantially less use of narcotics among people undergoing elective colorectal surgical procedures treated with guided imagery tapes from 3 days before until 6 days after the procedures compared to routine care in a mid-sized RCT⁴³Tusek D, Church JM, Fazio VW. Guided imagery as a coping strategy for perioperative patients. AORN Journal. 1997 Oct;66(4):644-9.
• Less pain and distress about pain and fewer requests for analgesia after abdominal surgery among people treated with guided imagery compared to controls who received background information about the hospital in a small RCT⁴⁴Manyande A, Berg S et al. Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery. Psychosomatic Medicine. 1995 Mar-Apr;57(2):177-82.
• Less pain at discharge from the post anesthesia care unit to home among people undergoing gynecologic laparoscopic surgery using guided imagery audiotapes compared to standard care in a small RCT⁴⁵Laurion S, Fetzer SJ. The effect of two nursing interventions on the postoperative outcomes of gynecologic laparoscopic patients. Journal of Perianesthesia Nursing. 2003 Aug;18(4):254-61.
• Lower pain at the time of listening to imagery tapes, but not about 24 hours after discharge, and no evidence of an effect on combined opioid and non-opioid use among children undergoing ambulatory tonsillectomy and/or adenoidectomy with taped guided imagery before and after surgery compared to standard care in a small RCT⁴⁶Huth MM, Broome ME, Good M. Imagery reduces children’s post-operative pain. Pain. 2004 Jul;110(1-2):439-48.
• Substantially less use of sedative and analgesic drugs among people undergoing interventional procedures treated with anodyne imagery compared to no imagery in a small controlled triala study design in which people are assigned to either an experimental group or a control group to compare the outcomes from different treatment; assignment is not random, and so this is not as strong a study design as a randomized controlled trial, but still stronger than an uncontrolled trial⁴⁷Lang EV, Hamilton D. Anodyne imagery: an alternative to IV sedation in interventional radiology. AJR American Journal of Roentgenology. 1994 May;162(5):1221-6.

Guided imagery with other therapies, not specific to cancer

Guided imagery with music: preliminary evidence of less anxiety or pain, better quality of sleep, and shorter time to first bowel movement, but no evidence of an effect on nausea or vomiting, complications, or itching among people undergoing colorectal or anorectal surgery treated with guided imagery (not specific to cancer)

• Less anxiety, less pain and use of opioids, and shorter time to first bowel movement, but no evidence of an effect on nausea or vomiting, complications, or itching among people undergoing their first elective colorectal surgery treated with guided imagery before and for 6 days after surgery, plus music during surgery and in the recovery room, compared to standard care in an RCT⁴⁸Tusek DL, Church JM, Strong SA, Grass JA, Fazio VW. Guided imagery: a significant advance in the care of patients undergoing elective colorectal surgery. Diseases of the Colon and Rectum. 1997 Feb;40(2):172-8.
• Less pain and less painful first urination, plus better quality of sleep scores among people undergoing surgery for anorectal diseases treated with a guided imagery tape with music and relaxing text before, during and after surgery compared to standard care in a small RCT⁴⁹Renzi C, Peticca L, Pescatori M. The use of relaxation techniques in the perioperative management of proctological patients: preliminary results. International Journal of Colorectal Disease. 2000 Nov;15(5-6):313-6.

Guided imagery combined with relaxation: preliminary evidence of less state anxiety among people undergoing gallbladder removal (cholecystectomy) treated with relaxation with guided imagery

• Less state anxiety and surgical wound redness (erythema) among people undergoing cholecystectomy treated with relaxation with guided imagery compared to controls given a quiet period in a small RCT⁵⁰Holden-Lund C. Effects of relaxation with guided imagery on surgical stress and wound healing. Research in Nursing & Health. 1988 Aug;11(4):235-44.

Guided imagery or visualization with relaxation techniques

Anxiety

Modest evidence of less anxiety among people with cancer treated with relaxation techniques and guided imagery

Preliminary evidence of less anxiety among parents of children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery

• Less anxiety among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized RCTrandomized controlled trial, a study design in which people are randomly assigned to either an experimental group or a control group to compare the outcomes from different treatments; an RCT is considered a strong design for determining a therapy’s effects⁵¹De Paolis G, Naccarato A et al. The effectiveness of progressive muscle relaxation and interactive guided imagery as a pain-reducing intervention in advanced cancer patients: a multicentre randomised controlled non-pharmacological trial. Complementary Therapies in Clinical Practice. 2019 Feb;34:280-287.
• A weak trend toward less anxiety (low to moderate effect size) among children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery compared to no intervention in a small RCT⁵²Tsitsi T, Charalambous A, Papastavrou E, Raftopoulos V. Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in Republic of Cyprus and Greece. European Journal of Oncology Nursing. 2017 Feb;26:9-18.
• Less anxiety during radiotherapy among people with breast cancer treated with relaxation and visualization therapy compared to radiotherapy alone in a small RCT⁵³Nunes DF, Rodriguez AL et al. Relaxation and guided imagery program in patients with breast cancer undergoing radiotherapy is not associated with neuroimmunomodulatory effects. Journal of Psychosomatic Research. 2007 Dec;63(6):647-55.
• Less anxiety during brachytherapy within hospitalization among people with gynecologic or breast cancer treated with relaxation and guided imagery compared to controls in a small RCT⁵⁴León-Pizarro C, Gich I et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-oncology. 2007 Nov;16(11):971-9.
• Less anxiety during first-time chemotherapy among people with breast cancer treated with progressive muscle relaxation training and guided imagery compared to controls in a small RCT⁵⁵Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer. 2005 Oct;13(10):826-33.
• Less anxiety among parents of children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery compared to no intervention in a small RCT⁵⁶Tsitsi T, Charalambous A, Papastavrou E, Raftopoulos V. Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in Republic of Cyprus and Greece. European Journal of Oncology Nursing. 2017 Feb;26:9-18.

Depression or sadness

Modest evidence of less depression among people with cancer treated with relaxation and visualization or guided imagery, including during cancer treatment

• Less depression during chemotherapy among people treated with guided imagery and progressive muscle relaxation compared to standard care in a mid-sized RCT⁵⁷Charalambous A, Giannakopoulou M et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.
• Lower depression during radiotherapy among people with breast cancer treated with relaxation and visualization therapy compared to radiotherapy alone in a small RCT⁵⁸Nunes DF, Rodriguez AL et al. Relaxation and guided imagery program in patients with breast cancer undergoing radiotherapy is not associated with neuroimmunomodulatory effects. Journal of Psychosomatic Research. 2007 Dec;63(6):647-55.
• Less depression during brachytherapy within hospitalization among people with gynecologic or breast cancer treated with relaxation and guided imagery compared to controls in a small RCT⁵⁹León-Pizarro C, Gich I et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-oncology. 2007 Nov;16(11):971-9.
• Less depression during initial chemotherapy among people with breast cancer treated with progressive muscle relaxation training and guided imagery compared to controls in a small RCT⁶⁰Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer. 2005 Oct;13(10):826-33.
• Better mood scores during 6 cycles of chemotherapy among women with newly diagnosed large or locally advanced breast cancer treated with standard care plus relaxation training and imagery compared to standard care in a small RCT⁶¹Walker LG, Walker MB et al. Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy. British Journal of Cancer. 1999 Apr;80(1-2):262-8.
• A weak trendan apparent change due to a therapy, close to but not achieving full statistical significance (this is the CancerChoices definition; other researchers and studies may define this differently) toward less negative emotions (affect) during chemotherapy among people with cancer treated with relaxation training with guided relaxation imagery compared to standard care in a small RCT⁶²Burish TG, Snyder SL, Jenkins RA. Preparing patients for cancer chemotherapy: effect of coping preparation and relaxation interventions. Journal of Consulting and Clinical Psychology. 1991 Aug;59(4):518-25.
• No evidence of an effect on mood among people with metastatic breast cancer experiencing physical pain treated with relaxation and visualization training, whether with or without cognitive coping skills training, compared to no intervention in a small RCT⁶³Arathuzik D. Effects of cognitive-behavioral strategies on pain in cancer patients. Cancer Nursing. 1994 Jun;17(3):207-14.
• Less mood disturbance among people with nasopharyngeal carcinoma treated with progressive muscle relaxation and guided imagery training compared to baseline in a mid-sized uncontrolled triala study in which a therapy is used, but without a comparison group against which to judge outcomes; an uncontrolled trial is considered a weak study design⁶⁴Yang XL, Li HH, Hong MH, Kao HS. The effects of Chinese calligraphy handwriting and relaxation training in Chinese nasopharyngeal carcinoma patients: a randomized controlled trial. International Journal of Nursing Studies. 2010 May;47(5):550-9.

Preliminary evidence of less depression among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation

• Less depression among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized RCT⁶⁵De Paolis G, Naccarato A et al. The effectiveness of progressive muscle relaxation and interactive guided imagery as a pain-reducing intervention in advanced cancer patients: a multicentre randomised controlled non-pharmacological trial. Complementary Therapies in Clinical Practice. 2019 Feb;34:280-287.

Preliminary evidence of less sadness among parents of hospitalized children treated with progressive muscle relaxation and guided imagery

• Less sadness among parents of children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery compared to no intervention in a small RCT⁶⁶Tsitsi T, Charalambous A, Papastavrou E, Raftopoulos V. Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in Republic of Cyprus and Greece. European Journal of Oncology Nursing. 2017 Feb;26:9-18.

Fatigue: preliminary evidence of less fatigue during chemotherapy among people treated with guided imagery and progressive muscle relaxation

• Substantially less fatigue (fatigue decreased with the intervention and increased without it) during chemotherapy among people treated with guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT⁶⁷Charalambous A, Giannakopoulou M et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.

Gastrointestinal symptoms: modest evidence of less nausea and/or vomiting during chemotherapy treatment among people with cancer treated with guided imagery and progressive muscle relaxation or another relaxation technique

• Less nausea, vomiting, and retching during chemotherapy among people treated with guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT⁶⁸Charalambous A, Giannakopoulou M et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.
• Less anticipatory and chemotherapy-induced nausea and vomiting in the 3 days following chemotherapy among people with breast cancer new to chemotherapy treated with progressive muscle relaxation training and guided imagery compared to controls in a small RCT⁶⁹Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer. 2005 Oct;13(10):826-33.
• Shorter duration of nausea and vomiting, with weak trends toward lower frequency of nausea and vomiting, but no evidence of an effect on intensity, during chemotherapy among people with breast cancer new to chemotherapy treated with progressive muscle relaxation training and imaging techniques 1 hour before and for 5 days following chemotherapy sessions compared to controls in a small RCT⁷⁰Molassiotis A, Yung HP, Yam BM, Chan FY, Mok TS. The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: a randomised controlled trial. Supportive Care in Cancer. 2002 Apr;10(3):237-46.
• A weak trend toward less vomiting during chemotherapy among people with cancer treated with relaxation training with guided relaxation imagery compared to standard care in a small RCT⁷¹Burish TG, Snyder SL, Jenkins RA. Preparing patients for cancer chemotherapy: effect of coping preparation and relaxation interventions. Journal of Consulting and Clinical Psychology. 1991 Aug;59(4):518-25.
• Less nausea, but no evidence of an effect on frequency of vomiting, among people who had developed negative conditioned responses to their chemotherapy and treated with progressive muscle relaxation training and guided relaxation imagery instructions immediately before and during their chemotherapy treatments compared to controls in an RCT⁷²Burish TG, Lyles JN. Effectiveness of relaxation training in reducing adverse reactions to cancer chemotherapy. Journal of Behavioral Medicine. 1981 Mar;4(1):65-78.

Pain or discomfort

Modest evidence of less pain during cancer treatment among people treated with relaxation and imagery

• Substantially less pain (pain decreased with the intervention and increased without it) during chemotherapy among people treated with guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT⁷³Charalambous A, Giannakopoulou M et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.
• Lower oral mucositis pain levels during bone marrow transplants among people with cancer treated with relaxation and imagery, whether with or without cognitive-behavioral coping skills, compared to usual care in a small RCT⁷⁴Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Pain. 1995 Nov;63(2):189-198.

Preliminary evidence of less pain among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation

• Less pain intensity among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized RCT⁷⁵De Paolis G, Naccarato A et al. The effectiveness of progressive muscle relaxation and interactive guided imagery as a pain-reducing intervention in advanced cancer patients: a multicentre randomised controlled non-pharmacological trial. Complementary Therapies in Clinical Practice. 2019 Feb;34:280-287.

Preliminary evidence of less body discomfort during brachytherapy among people with gynecologic or breast cancer treated with relaxation and guided imagery

• Less body discomfort during brachytherapy within hospitalization among people with gynecologic or breast cancer treated with relaxation and guided imagery compared to controls in a small RCT⁷⁶León-Pizarro C, Gich I et al. A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-oncology. 2007 Nov;16(11):971-9.

Quality of life: modest evidence of better health-related quality of life during chemotherapy among people with cancer treated with guided imagery and progressive muscle relaxation

• Substantially better health-related quality of life (quality increased with the intervention and decreased without it) during chemotherapy among people treated with guided imagery and progressive muscle relaxation compared to no intervention in a mid-sized RCT⁷⁷Charalambous A, Giannakopoulou M et al. Guided imagery and progressive muscle relaxation as a cluster of symptoms management intervention in patients receiving chemotherapy: a randomized control trial. PLoS One. 2016 Jun 24;11(6):e0156911.
• Better quality of life 6 months after chemotherapy among people with breast cancer new to chemotherapy participating in progressive muscle relaxation training and guided imagery compared to controls in a small RCT⁷⁸Yoo HJ, Ahn SH, Kim SB, Kim WK, Han OS. Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life. Supportive Care in Cancer. 2005 Oct;13(10):826-33.

Sleep disruption: weak evidence of less insomnia among people with nasopharyngeal carcinoma treated with progressive muscle relaxation and guided imagery

• Less insomnia among people with nasopharyngeal carcinoma treated with progressive muscle relaxation and guided imagery training compared to baseline in a mid-sized RCT with unstated comparisons to controls⁷⁹Yang XL, Li HH, Hong MH, Kao HS. The effects of Chinese calligraphy handwriting and relaxation training in Chinese nasopharyngeal carcinoma patients: a randomized controlled trial. International Journal of Nursing Studies. 2010 May;47(5):550-9.

Stress

Modest evidence of less psychological distress among people with cancer treated with progressive muscle relaxation with guided imagery

• Moderately less psychological distress among people recently diagnosed with localized cancer treated with progressive muscle relaxation with guided imagery compared to controls in a mid-sized RCT⁸⁰Baider L, Peretz T, Hadani PE, Koch U. Psychological intervention in cancer patients: a randomized study. General Hospital Psychiatry. 2001 Sep-Oct;23(5):272-7.
• Lower reported stress during radiotherapy among people with breast cancer treated with relaxation and visualization therapy compared to radiotherapy alone in a small RCT⁸¹Nunes DF, Rodriguez AL et al. Relaxation and guided imagery program in patients with breast cancer undergoing radiotherapy is not associated with neuroimmunomodulatory effects. Journal of Psychosomatic Research. 2007 Dec;63(6):647-55.

No evidence of an effect on distress among people with cancer and with pain participating in relaxation and visualization training in a preliminary study

• No evidence of an effect on distress among people with metastatic breast cancer who were experiencing physical pain treated with relaxation and visualization training, whether with or without cognitive coping skills training compared to no intervention in a small RCT⁸²Arathuzik D. Effects of cognitive-behavioral strategies on pain in cancer patients. Cancer Nursing. 1994 Jun;17(3):207-14.

Preliminary evidence of less tension among parents of children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery

• Less tension among parents of children hospitalized with a malignancy treated with progressive muscle relaxation and guided imagery compared to no intervention in a small RCT⁸³Tsitsi T, Charalambous A, Papastavrou E, Raftopoulos V. Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in Republic of Cyprus and Greece. European Journal of Oncology Nursing. 2017 Feb;26:9-18.

Weak evidence of less distress among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation

• Less distress among people with terminal cancer in hospice treated with interactive guided imagery and progressive muscle relaxation compared to baseline, and an apparently larger benefit than with usual care in a mid-sized RCT⁸⁴De Paolis G, Naccarato A et al. The effectiveness of progressive muscle relaxation and interactive guided imagery as a pain-reducing intervention in advanced cancer patients: a multicentre randomised controlled non-pharmacological trial. Complementary Therapies in Clinical Practice. 2019 Feb;34:280-287.

Guided imagery with relaxation techniques and biofeedback training

Weak evidence of less anxiety among women with breast cancer participating in relaxation, guided imagery, and biofeedback training

• A weak trend toward less anxiety among women with stage 1 breast cancer participating in relaxation, guided imagery, and biofeedback training compared to no intervention in a small RCT⁸⁵Gruber BL, Hersh SP et al. Immunological responses of breast cancer patients to behavioral interventions. Biofeedback and Self-Regulation. 1993 Mar;18(1):1-22.

Imagery with relaxation techniques, psychotherapy, and spirituality

Preliminary evidence of better perceived quality of life during treatment after mastectomy among women treated with brief psychotherapy and relaxation, mental images, and spirituality

• Better perceived quality of life during treatment after mastectomy among women treated with brief psychotherapy (average of 6 sessions) and relaxation techniques, mental images, and spirituality compared to brief psychotherapy alone in a small RCT⁸⁶Elias AC, Ricci MD et al. The biopsychosocial spiritual model applied to the treatment of women with breast cancer, through RIME intervention (relaxation, mental images, spirituality). Complementary Therapies in Clinical Practice. 2015 Feb;21(1):1-6.

Meditation, affirmation, imagery, and ritual

Weak evidence of less anxiety among people with breast cancer treated with meditation, affirmation, imagery, and ritual

• Less depression, comparable to cognitive-behavioral approaches combined with group sharing and support, and less anxiety among women with breast cancer treated with meditation, affirmation, imagery, and ritual compared to baseline and comparable to combined cognitive-behavioral approaches with group sharing and support in a mid-sized uncontrolled trial⁸⁷Targ EF, Levine EG. The efficacy of a mind-body-spirit group for women with breast cancer: a randomized controlled trial. General Hospital Psychiatry. 2002 Jul-Aug;24(4):238-48.

Guided imagery with psychotherapy and relaxation

Preliminary evidence of less nausea or nausea combined with fatigue after autologous bone marrow/peripheral blood stem cell transplantation among people with breast cancer receiving preparatory information, cognitive restructuring, and relaxation with guided imagery

• Less nausea or nausea combined with fatigue 7 days after autologous bone marrow/peripheral blood stem cell transplantation among people with breast cancer receiving preparatory information, cognitive restructuring, and relaxation with guided imagery compared to controls in a mid-sized RCT⁸⁸Gaston-Johansson F, Fall-Dickson JM et al. The effectiveness of the comprehensive coping strategy program on clinical outcomes in breast cancer autologous bone marrow transplantation. Cancer Nursing. 2000 Aug;23(4):277-85.

Guided imagery with discussion, breathing, and adaptive coping skills

Preliminary evidence of better mood scores among men undergoing surgery for prostate cancer participating in a stress-management intervention including discussing concerns about the surgery, diaphragmatic breathing, guided imagery, and adaptive coping skills

• Better mood scores among men undergoing surgery for prostate cancer participating in a stress-management intervention including discussing concerns about the surgery, diaphragmatic breathing, guided imagery, and adaptive coping skills compared to either 2 sessions of supportive attention or standard care in a mid-sized RCT⁸⁹Cohen L, Parker PA et al. Presurgical stress management improves postoperative immune function in men with prostate cancer undergoing radical prostatectomy. Psychosomatic Medicine. 2011 Apr;73(3):218-25.

Guided imagery with a therapist

Preliminary evidence of better health-related quality of life and less cognitive dysfunction, fatigue, or sleep disturbance after completing cancer treatment among people with breast cancer participating in an imagery-based group intervention with a therapist attending

• Better health-related quality of life and less cognitive dysfunction, fatigue, or sleep disturbance more than 6 weeks after completing cancer treatment among breast cancer survivors participating in 5 weekly 4-hour imagery-based group intervention sessions with a therapist present, or with a therapist streamed via telemedicine, compared to no intervention in a mid-sized RCT⁹⁰Freeman LW, White R et al. 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. 2015 Aug;24(8):910-8.

Guided imagery with neural mobilization

Weak evidence of less pain among hospitalized children with cancer treated with imagery and neural mobilization

• Less neuropathic pain among children with cancer with graded motor imagery and neural mobilization compared to baseline in a small uncontrolled study⁹¹Casanova-García C, Lerma Lara S, Pérez Ruiz M, Ruano Domínguez D, Santana Sosa E. Non-pharmacological treatment for neuropathic pain in children with cancer. Medical Hypotheses. 2015 Dec;85(6):791-7.

Guided imagery with education, cognitive restructuring, coping skills enhancement, and relaxation

Preliminary evidence of better quality of life, health, functioning, and psychological/spiritual well-being among people with breast cancer scheduled to receive high-dose chemotherapy and autologous hematopoietic stem cell transplantation and treated with a comprehensive coping strategy program of educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery

• Better quality of life, health, functioning, and psychological/spiritual well-being among people with stage 2–4 breast cancer scheduled to receive high-dose chemotherapy and autologous hematopoietic stem cell transplantation and treated with a comprehensive coping strategy program of educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery compared to no program in a mid-sized RCT⁹²Gaston-Johansson F, Fall-Dickson JM et al. Long-term effect of the self-management comprehensive coping strategy program on quality of life in patients with breast cancer treated with high-dose chemotherapy. Psycho-oncology. 2013 Mar;22(3):530-9.