Guided imagery is offered in hospitals but rarely tested on its own

If you’ve been offered guided imagery in a hospital, it probably arrived as one line on a list of services. It might be a recording to play before surgery, a session with a nurse during chemotherapy, or a home audio program for a child whose stomach pain has no medical explanation. In each version, a voice or a script steers your attention toward calming pictures and scenes.

Hospitals have listed it for years. In a 2010 survey run by an American Hospital Association subsidiary and the Samueli Institute, 42 percent of responding hospitals offered at least one complementary therapy, up from 27 percent about five years earlier, KFF Health News reported in 2011. Only 714 of the 5,858 hospitals surveyed answered, a 12 percent response rate, so the figure describes respondents rather than US hospitals as a whole. For outpatients, the most common offerings were massage, acupuncture and guided imagery. The Oncology Nursing Society’s news publication reported in January 2021 that many cancer centers, clinics and community centers offer it.

Here is what the service list leaves out. Researchers rarely test guided imagery by itself. A 2005 systematic review in Psycho-Oncology searched for trials that used imagery as the only add-on therapy in cancer care and found six, with detailed results for just four. Much of the remaining evidence comes from studies that pair imagery with muscle relaxation, file it under hypnosis, or count it as one ingredient in a relaxation package.

That bundling is the honest headline, and it shapes everything below: why guidelines rarely name imagery, why its certificates mean less than they sound, and why you should ask exactly what was tested before trusting a claim. This article treats imagery as a delivered intervention, the thing a hospital or practitioner provides. It does not teach the technique.

Why imagery’s evidence is so hard to isolate

Look at how the major reviewers file guided imagery and a pattern appears. Almost nobody gives it a category of its own.

• Cochrane, the international network that produces systematic reviews, published a 2017 review of psychological treatments for children’s recurrent abdominal pain. It sorted 18 trials into four types of therapy and placed the imagery studies inside the hypnotherapy group.
• The American academy of sleep medicine (AASM), in its 2021 insomnia guideline, defines relaxation therapy as structured exercises that reduce physical tension or mental arousal, and names guided imagery training as an example of the mental kind.
• The national center for complementary and integrative health (NCCIH), part of the National Institutes of Health, lists imagery on a relaxation page last updated in June 2021, beside progressive relaxation, autogenic training, biofeedback-assisted relaxation and self-hypnosis.
• A 2016 Cochrane review of psychological preparation for surgery, covering 105 studies and 10,302 adults, sorted interventions into seven techniques. Relaxation and hypnosis each made that list. Imagery did not.

The bundling reaches into individual trials, too. A 2006 randomized trial in BMC Pediatrics was titled as an evaluation of guided imagery for children’s recurrent abdominal pain. It enrolled 22 children. Those in the treatment arm learned imagery combined with progressive muscle relaxation over four weekly sessions with a therapist, and the comparison group learned breathing exercises. The imagery group also started with more days of pain per month, 23 against 14, which makes the result harder to interpret.

There is also an overlap in definitions, offered here as this article’s analysis rather than as anyone’s published finding. The American Psychological Association’s hypnosis division defines hypnosis partly by a heightened capacity to respond to suggestion, and an imagery script is a sequence of suggestions. When the boundary depends on what a clinician chooses to call the session, separating the two in trials will stay difficult. Clinical hypnosis is examined at length in the companion piece on that practice, while progressive muscle relaxation and the other manualized methods are taken up in our article on relaxation practices.

On this library’s evidence scale, most claims about imagery used alone land at insufficient evidence to assess. It matters which kind of insufficient. Imagery has not gone untested, because some imagery-only trials exist. The problem is that the intervention is so rarely separated from its companions that the evidence for it cannot be read on its own.

The cautions named bodies have put in writing

Imagery’s documented risks are modest next to many practices in this category. They are also specific, and they concentrate in identifiable groups of people.

NCCIH’s June 2021 relaxation page, which covers imagery, calls these techniques generally safe for healthy people and says most studies have reported no negative side effects. It also records that people occasionally describe increased anxiety, intrusive thoughts or a fear of losing control. It notes rare reports of symptoms being triggered or worsened in people with epilepsy or certain psychiatric conditions, and in people with a history of abuse or trauma.

The Oncology Nursing Society’s January 2021 evidence summary, published in ONS Voice, went further. Its authors called imagery a safe intervention but advised caution for patients with past trauma or abuse and for people with psychosis. Such patients, they wrote, may struggle to separate objective reality from subjective experience, or may encounter traumatic images that need professional support. That is a professional-society article, not a formal guideline, and it should be weighed that way.

A third concern applies when imagery is pointed at the past instead of at calm. A 2025 review in Frontiers in Psychology on hypnosis and false memory concluded that both hypnotic regression and guided imagery should be used with caution, because either can unintentionally produce recall of events that never happened. The legal history of that problem, including a 1987 Supreme Court case, belongs to the hypnosis coverage.

Two more points matter. The 2017 Cochrane review of children’s abdominal pain reported no adverse effects for any intervention, but small trials that report no harm are not proof of safety. And when the two oncology societies behind a 2022 cancer pain guideline graded imagery, they coded its balance of benefit and harm as uncertain. That coding comes from Guideline Central’s published summary of the guideline.

These are situations for a licensed clinician rather than a recording, an app or a coach. They include imagery that brings up intrusive or traumatic memories, panic or a sense of unreality during a session, a history of psychosis or dissociation, and a seizure disorder. So does any program that promises to help you recover forgotten events.

What the guidelines say

This is where careful reading matters most, because summaries tend to round up.

The only clinical guideline found that names guided imagery in a recommendation comes from two bodies working together. It is the 2022 guideline on integrative pain care in oncology issued by the Society for Integrative Oncology (SIO), written jointly with the American Society of Clinical Oncology (ASCO). Its Recommendation 1.7 says imagery combined with progressive muscle relaxation may be offered to patients with general pain from cancer treatment. Guideline Central, a publisher of guideline summaries, lists that recommendation with low-quality evidence, an uncertain benefit-harm balance and a weak strength rating. The guideline’s journal abstract is consistent: only acupuncture, reflexology or acupressure, hypnosis and massage reached moderate strength, and the evidence for other mind-body approaches was described as low or inconclusive.

So the accurate sentence is narrow. One cancer guideline weakly endorses imagery paired with muscle relaxation for general pain from cancer treatment. It does not endorse imagery by itself, and it says nothing about imagery for anxiety, nausea or survival.

The 2023 SIO-ASCO guideline on anxiety and depression in adults with cancer moves the other way. ASCO’s summary table of its recommendations does not contain the word imagery anywhere. It says relaxation therapies may be offered for anxiety during active treatment, on intermediate evidence with moderate strength, and for depression during treatment, on low evidence with weak strength, without defining which techniques count as relaxation.

An earlier SIO guideline on breast cancer care, published in 2017 and endorsed by ASCO in 2018, shows the bundle from the inside. Its key recommendations name music therapy, meditation, stress management and yoga for anxiety, and meditation, relaxation, yoga, massage and music therapy for depression. Imagery is not on either list. Yet the full document describes the usual relaxation program as progressive muscle relaxation paired with guided imagery, and it gives relaxation its highest grade, A, for depression and mood on the strength of six trials of relaxation programs with or without imagery. A common line in consumer health writing holds that cancer guidelines recommend guided imagery. As those guidelines are worded, that line is imprecise: imagery earns credit inside relaxation, or paired with muscle relaxation, not as a treatment in its own right.

Insomnia follows the same pattern. The AASM’s 2021 guideline gives relaxation therapy a conditional recommendation on low-quality evidence, and imagery appears only inside the definition. Writing that the AASM recommends guided imagery for insomnia would overstate the document.

Hospital accreditation tells the same story. The Joint Commission’s pain standard, effective January 1, 2018, requires accredited hospitals to provide nondrug pain treatments. The report explaining the standard lists relaxation therapy among its examples but names neither imagery nor hypnosis, and a Joint Commission FAQ last reviewed in November 2022 says its standards don’t require any specific complementary option.

On this library’s scale, imagery reaches the top tier, recommended by name in a clinical guideline, only in that one bundled and weak form.

What the trials measured, condition by condition

Children’s recurrent abdominal pain

This is the strongest signal. In the 2017 Cochrane review, the hypnotherapy group, which included the imagery studies, pooled four trials with 146 children. It showed more treatment success right after treatment, with an odds ratio of 6.78, along with lower pain intensity and frequency. The reviewers rated that evidence low quality because the trials were small and open to bias. A 2009 pilot trial in Pediatrics tested imagery delivered entirely by audio and video recordings at home. Among 34 children, 63.1 percent of those using the recordings responded, against 26.7 percent receiving standard medical care alone. The control group got no comparable attention, which tends to inflate differences like that one.

Surgery

A 2020 meta-analysis of imagery before surgery identified 21 trials but could pool only eight. It reported a small reduction in adults’ pain after surgery. It also reported an effect on children’s anxiety before surgery so large, 3.71 standard deviations, that it more likely reflects small, biased trials than a real effect of that size. The broader 2016 Cochrane review of psychological preparation found a small reduction in postoperative pain across all techniques, rated low quality, and concluded that the evidence could not support firm conclusions. For surgical pain, imagery sits at measured but small.

Cancer

The 2005 Psycho-Oncology review found that imagery alone may be psychologically supportive and increase comfort, with no compelling evidence of effects on physical symptoms such as nausea and vomiting. The 2021 ONS Voice summary read the record more warmly, saying data suggest imagery may help with nausea and vomiting from chemotherapy, while conceding that most studies were small, poorly designed and short. Those two readings have not been reconciled. A 2022 meta-analysis on cancer pain listed guided imagery with progressive muscle relaxation among the most effective approaches, bundled once again.

Chronic pain outside cancer

A 2024 systematic review in Medicina examined 26 trials of mindfulness or imagery for chronic pain not caused by cancer. Three imagery trials reported a significant drop in pain intensity, and most trials in the review carried moderate to high risk of bias.

Arthritis, fibromyalgia, sleep and headache

NCCIH’s June 2021 page summarizes several more reviews that touch imagery, and each comes with a limit. A 2015 review suggested imagery may help adults with arthritis and other rheumatic diseases; the imagery in that review was delivered through audio technology. Another 2015 review found that a single imagery session brought immediate relief of fibromyalgia pain, while results for longer programs conflicted. For sleep, a 2015 review found that autogenic training or imagery helped people fall asleep faster but did no better than a placebo, and its authors doubted the positive results because the studies were small and weak. And in a 2018 headache review, NCCIH notes, hypnosis was often paired with imagery, the bundle turning up yet again.

One related practice deserves a line of its own. The Bonny Method of Guided Imagery and Music is a music-centered approach delivered over a series of individual sessions. A 2017 review in the Journal of Music Therapy found nine studies with 275 adults reporting medium to large psychological effects, while none of the physiological effects were replicated from one study to the next. That method fits better with the library’s music therapy material.

What delivery looked like in the trials

Because this article treats imagery as a service someone provides, it helps to see what the trials provided. The formats vary far more than the label suggests.

• In the 2006 pediatric trial, a therapist met each child for four weekly sessions that combined imagery with progressive muscle relaxation.
• In the 2009 pilot, children used audio and video recordings at home for two months under a protocol designed to be home-based. The researchers reported a compliance rate of 98.5 percent.
• In the 2020 surgical meta-analysis, imagery was given before the operation and compared with conventional preoperative nursing care.
• In the Bonny Method review, only programs of at least six individual sessions were counted.

A recording, a nurse, a psychologist and a music-centered guide can all be described as providing guided imagery. They are not interchangeable, and a result from one format does not automatically carry over to another. If a hospital offers you imagery, the format it uses tells you which of these trials, if any, resembles what you would receive.

Who delivers it, and what a certificate means

This library sorts every credential into four buckets: defined in regulation, government certification, private certification, and undefined. Guided imagery sits in the bottom two.

• Defined in regulation: none found. This review found no state license for guided imagery practitioners.
• Government certification: none found.
• Private certification: the most prominent is the Academy for Guided Imagery’s professional certificate. The academy’s website lists a foundations course and eight advanced courses, self-study exams, and two three-day preceptorship workshops held live online. The foundations course is aimed at nurses, psychologists, psychotherapists, counselors and coaches, and no license or degree requirement is stated. The academy’s FAQ says it is working toward continuing-education approval but has no current standing.
• Undefined: everyone else. Anyone may call themselves a guided imagery practitioner.

One number circulates widely. Consumer health sites have said the academy’s certificate requires 150 hours of training. The academy’s current pages give no total, and the hours listed for its nine courses add up to 71.5, before the workshops. Treat the 150-hour figure as unconfirmed.

In practice, the credential that protects you is usually a different one. A nurse, psychologist or licensed counselor who uses imagery answers to a state licensing board for that underlying license. The ONS summary noted that people can learn imagery from a licensed practitioner or from books and recordings, and the 2009 pediatric pilot delivered imagery through recordings alone. The question that matters, then, is something other than whether a person holds an imagery certificate. It is which license, if any, stands behind the person delivering it. Certificates for practices that no state licenses are compared field by field in the library’s guide to practitioner training.

Questions that separate one program from another

These questions follow from the gaps described above. They are not drawn from any provider’s checklist.

1. Is this imagery alone, or imagery combined with muscle relaxation, breathing work or hypnosis? The answer tells you which body of evidence applies.
2. What license does the person delivering it hold, separate from any imagery certificate, and which board oversees it?
3. Is the goal comfort and calm during treatment, or a change in the disease itself? Nothing cited in this article supports the second.
4. What happens if distressing images or memories come up, and who follows up?
5. Will the sessions involve searching for forgotten events? That use carries the false-memory concern.
6. Is the rest of your care team aware of it? Hospital programs usually sit inside that team; a private session may not.

The takeaway: grade the package, not the label

When someone tells you guided imagery works, the useful follow-up is: which package? The best numbers in this field, for children’s abdominal pain and for pain from cancer treatment, come from trials where imagery traveled with relaxation training or sat inside a hypnosis category. The only guideline recommendation names imagery together with muscle relaxation, weakly, on low-quality evidence. Imagery tested alone has a thin record of small trials suggesting comfort benefits and no compelling effect on physical symptoms.

That does not make it worthless. It makes it a comfort-focused add-on whose evidence depends on what it was bundled with, and whose safety depends on the license of the person delivering it.

Sources

1. National Center for Complementary and Integrative Health, National Institutes of Health. “Relaxation Techniques: What You Need To Know (content Last Updated June 2021; list of techniques including guided imagery, safety statements, guided imagery evidence summaries).” nccih.nih.gov
2. Cochrane Database of Systematic Reviews. “Abbott RA, Martin AE, Newlove-Delgado TV, Bethel A, Thompson-Coon J, Whear R, Logan S. "Psychosocial interventions for recurrent abdominal pain in childhood." Cochrane Database Syst Rev, 2017. PubMed. DOI: 10.1002/14651858.CD010971.pub2.” pubmed.ncbi.nlm.nih.gov
3. Psycho-Oncology. “Roffe L, Schmidt K, Ernst E. "A systematic review of guided imagery as an adjuvant cancer therapy." Psychooncology, 2005. PubMed. DOI: 10.1002/pon.889.” pubmed.ncbi.nlm.nih.gov
4. Cochrane Database of Systematic Reviews. “Powell R, Scott NW, Manyande A, et al. "Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia." Cochrane Database Syst Rev, 2016. PubMed. DOI: 10.1002/14651858.CD008646.pub2.” pubmed.ncbi.nlm.nih.gov
5. American Academy of Sleep Medicine (Journal of Clinical Sleep Medicine). “Edinger JD, Arnedt JT, Bertisch SM, et al. "Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline." J Clin Sleep Med, 2021 (published February 1, 2021; Table 3 definition of relaxation therapy; Recommendation 5). DOI: 10.5664/jcsm.8986.” pmc.ncbi.nlm.nih.gov
6. Journal of Clinical Oncology (Society for Integrative Oncology and ASCO). “Mao JJ, Ismaila N, Bao T, et al. "Integrative Medicine for Pain Management in Oncology: Society for Integrative Oncology-ASCO Guideline." J Clin Oncol, 2022. PubMed. DOI: 10.1200/JCO.22.01357.” pubmed.ncbi.nlm.nih.gov
7. Guideline Central. “Integrative Medicine for Pain Management in Oncology (SIO-ASCO guideline summary; guideline published September 18, 2022; Recommendation 1.7 with quality and strength codes).” guidelinecentral.com
8. American Society of Clinical Oncology. “Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults with Cancer: SIO-ASCO Guideline (2023) Summary Table.”
9. The Joint Commission. “R3 Report Issue 11: Pain assessment and management standards for hospitals (August 29, 2017; LD.04.03.13 effective January 1, 2018).” jointcommission.org
10. The Joint Commission. “Standards FAQ: Acceptable non-pharmacologic pain treatment modalities (last reviewed November 17, 2022).” jointcommission.org
11. BMC Pediatrics. “Weydert JA, Shapiro DE, Acra SA, Monheim CJ, Chambers AS, Ball TM. "Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial." BMC Pediatr, 2006. PubMed. DOI: 10.1186/1471-2431-6-29.” pubmed.ncbi.nlm.nih.gov
12. Pediatrics (American Academy of Pediatrics). “van Tilburg MA, Chitkara DK, Palsson OS, et al. "Audio-recorded guided imagery treatment reduces functional abdominal pain in children: a pilot study." Pediatrics, 2009. PubMed. DOI: 10.1542/peds.2009-0028.” pubmed.ncbi.nlm.nih.gov
13. Journal of Clinical Oncology (American Society of Clinical Oncology). “Lyman GH, Greenlee H, Bohlke K, et al. "Integrative Therapies During and After Breast Cancer Treatment: ASCO Endorsement of the SIO Clinical Practice Guideline." J Clin Oncol, 2018. PubMed. DOI: 10.1200/JCO.2018.79.2721.” pubmed.ncbi.nlm.nih.gov
14. Complementary Therapies in Clinical Practice. “Álvarez-García C, Yaban ZŞ. "The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis." Complement Ther Clin Pract, 2020. PubMed. DOI: 10.1016/j.ctcp.2019.101077.” pubmed.ncbi.nlm.nih.gov
15. Journal of Pain and Symptom Management. “Ruano A, García-Torres F, Gálvez-Lara M, Moriana JA. "Psychological and Non-Pharmacologic Treatments for Pain in Cancer Patients: A Systematic Review and Meta-Analysis." J Pain Symptom Manage, 2022. PubMed. DOI: 10.1016/j.jpainsymman.2021.12.021.” pubmed.ncbi.nlm.nih.gov
16. Medicina. “Pinto BM, Tavares I, Pozza DH. "Enhancing Chronic Non-Cancer Pain Management: A Systematic Review of Mindfulness Therapies and Guided Imagery Interventions." Medicina (Kaunas), 2024. PubMed. DOI: 10.3390/medicina60050686.” pubmed.ncbi.nlm.nih.gov
17. Journal of Music Therapy. “McKinney CH, Honig TJ. "Health Outcomes of a Series of Bonny Method of Guided Imagery and Music Sessions: A Systematic Review." J Music Ther, 2017. PubMed. DOI: 10.1093/jmt/thw016.” pubmed.ncbi.nlm.nih.gov
18. Frontiers in Psychology. “Leo DG, Bruno D, Proietti R. "Remembering what did not happen: the role of hypnosis in memory recall and false memories formation." Front Psychol, 2025. PubMed. DOI: 10.3389/fpsyg.2025.1433762.” pubmed.ncbi.nlm.nih.gov
19. Oncology Nursing Society (ONS Voice). “Gubili J, Corcoran S, Bao T. What the Evidence Says About Guided Imagery in Oncologic Care (January 18, 2021).” ons.org
20. KFF Health News. “Andrews M. Hospitals Offering Complementary Medical Therapies (November 15, 2011; reports the 2010 American Hospital Association and Samueli Institute survey of 714 hospitals).” kffhealthnews.org
21. Academy for Guided Imagery. “Full Certification: professional certificate program (course list, CE hours, preceptorships, CE-standing FAQ; site footer 1988-2022).” acadgi.com
22. American Psychological Association, Monitor on Psychology. “Weir K. Uncovering the new science of clinical hypnosis (Vol. 55, No. 3, April 1, 2024; Division 30 definition of hypnosis).” apa.org
23. American Hospital Association. “Press release of 7 September 2011 on the 2010 Health Forum (an AHA subsidiary) and Samueli Institute survey of complementary and alternative medicine in hospitals (mailed to 5,858 hospitals; 714 responses, a 12 percent response rate).” aha.org
24. CA: A Cancer Journal for Clinicians (Society for Integrative Oncology guideline). “Greenlee H, DuPont-Reyes MJ, Balneaves LG, et al. "Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment." CA Cancer J Clin, 2017 (relaxation Grade A for depression/mood, based on six trials of relaxation with or without guided imagery). PubMed. DOI: 10.3322/caac.21397.” pubmed.ncbi.nlm.nih.gov