Visual Imagery Technique in Caring for Children “Imagination is more Powerful than Knowledge”-by Albert Einstein


S.  K. Mohanasundari1, Dr. A. Padmaja2

1PhD Scholar, Tutor/Clinical Instructor (Nursing), AIIMS, Jodhpur.

2Vice-Principal/Professor, College of Nursing, SVIMS, Tirupati. AP

*Corresponding Author E-mail:



Visual imagery technique (VIT) some time referred as Guided therapeutic imagery, a technique in which mental health professionals help individuals in therapy focus on mental images in order to evoke feelings of relaxation, is based on the concept of mind-body connection. Mind-body connection upholds the interaction between body and mind as one important factor in a person’s overall health and well-being. In guided therapeutic imagery, a person can call on mental images to improve both emotional and physical health. Nurses must learn about how to apply visual imagery technique in clinical practice for the management of physical and psychological (e.g. pain and anxiety) symptoms. Goal of VIT To manage pain, promote healing, promote relaxation and to reduce anxiety, improve mood, feel less nervous or upset, help to reach goals (such as losing weight or quitting smoking), help to prepare for an athletic event or academic achievement or for public speaking and provide a sense of empowerment or control. Types of VIT is Relaxation imagery, Healing imagery, Pain control imagery and Mental rehearsal. Steps of VIT is Phase-1: Image generation, Phase-2: Image maintenance, Phase-3: Image inspection and Phase-4: Image transformation. Two components of VIT is first components: a state of deep relaxation through breathing and muscle relaxation techniques, and Second component: Imagery or visualization component. It can be started once the person achieves the state of relaxation. Typically a therapist using this approach will provide verbal prompts to direct the focus of the imagery, often encouraging the participant to notice various sensory aspects of the scene. Some practitioners may use music as part of the technique. There are two distinct routes by which mental imagery can be generated/created within consciousness. Involuntary/Immediate perceptual information and Voluntary/Previously stored information. Child can react to VIT physiologically and psychologically. Conditions like Social phobia, Schizophrenia, Depression, Post-traumatic stress disorder, Stress, Anxiety, Grief, Relationship issues, Diminished self-care and Family and parenting issues can benefit from VIT. Present review was undertaken to know the origin of visual imagery technique, existing practices/situation/knowledge/attitude, existing problems/shortcoming, strategies to improve the situation/minimize or solve problems technique and nursing implications for visual imagery.


KEYWORDS: Visual imagery technique, guided imagery Relaxation imagery, mental imagery, rehearsal imagery etc




Visual imagery plays a critical role in children's creativity. The ability to think creatively in childhood is linked to the vividness of mental images, but not the ability to transform mental images, a skill that is linked instead to logical thinking. However, a particular mental transformation, synthesis (i.e., combination of images), seems to be related with creativity1.


Research conducted in 2005 by Dr. Elisha Goldstein demonstrated that study subjects who spent 5 minutes a day practicing a guided meditation exercise significantly reduced stress levels and enhanced feelings of well-being2.


Results of a study conducted at The Cleveland ClinicFoundation found that cardiac surgery patients who used a guided imagery tape prior to surgeryexperienced less pain and anxiety. These patients also left the hospital earlier following surgery than patients who used pain medication only.


Another study found that for more than 200 patients undergoinginvasive vascular or renal surgery, guided imagery controlled pain and anxiety more effectively than medication alone2.


A Review of the Effects of Guided Imagery on Cancer Patients with Pain (2010) reveled that Often, analgesic medications do not completely relieve the pain and alternative measures are sought out for relief. Mind-body techniques such as guided imagery (GI) have been thought to be helpful and used as an adjuvant to pain relief3.


A study reported (2012) that guided imagery significantly reduces chronic stomach pain in children. In this study, 30 children with chronic stomach pain listened to guided imagery CDs over an eight-week period; 63.1 percent experienced a significant decrease in their pain compared to just 26.7 percent in the control group who only received traditional medical care4.



Guided imagery techniques work to help people relax for several reasons. As is the case with many techniques, they involve an element of distraction which serves to redirect people's attention away from what is stressing them and towards an alternative focus. The techniques are in essence a non-verbal instruction or direct suggestion to the body and unconscious mind to act "as though" the peaceful, safe and beautiful (and thus relaxing) environment were real.


Finally, guided imagery can work through the associative process described above, where scenes become a learned cue or trigger that helps recall memories and sensations resulting from past relaxation practice.


2.1 Origin of visual imaginary technique or guided imaginary technique:

Various forms of guided imagery have been used for centuries, as far back as ancient Greek times, and the technique is an established approach in Chinese medicine and American Indian traditions as well as other healing and religious practices. Jacob Moreno’s technique of psychodrama, developed in the 1940s, can also be linked to guided imagery, as the enactment of the person in therapy’s unique concerns can be understood as a method of directing a person’s own imagery. In fact, Hans Leuner, who further developed psychodrama, called the approach guided affective imagery.


In the 1970s, Dr. David Bressler and Dr. Martin Rossman began establishing support for guided imagery as an effective approach for the treatment of chronic pain, cancer, and other serious illnesses. Their work led them to co-found the Academy for Guided Imagery in 1989.


Currently, guided imagery is an established approach in complementary and alternative medicine, and studies show it is frequently helpful when used as part of the therapeutic process5.


2.2.  Benefits of visual or guided imaginary technique:

One of the biggest benefits of using guided imagery as a therapeutic tool is its availability. Imagery can be used virtuallyanywhere, anytime. It is also an equal opportunity therapy. Although some initial training in the technique may berequired, guided imagery is accessible to virtually everyone regardless of economic status, education, or geographicallocation.


2.3.  Goals of visual or guided imaginary technique:

·        To manage pain

·        To promote healing

·        To promote relaxation and to reduce anxiety

·        To improve mood,

·        To feel less nervous or upset,

·        help to reach goals (such as losing weight or quitting smoking),

·        help to prepare for an athletic event or academic achievement or for public speaking

·        To provide a sense of empowerment or control5


2.4.  Types of visual or guided imagery technique:

Thereare a number of different types of guided imagery techniques, limited only by the imagination. Some commonly usedtypes include relaxation imagery, healing imagery, pain control imagery, and mental rehearsal.


a)      Relaxation imagery:

Relaxation imagery involves conjuring up pleasant, relaxing images that rest the mind and body. These may be experiences that have already happened, or new situations.


b)      Healing imagery:

Patients coping with diseases and injuries can imagine cancer cells dying, wounds healing, and the body mending itself.Or, patients may picture themselves healthy, happy, and symptom-free.6


c)      Pain control imagery:

Individuals can control pain through several imagery techniques. One method is to produce a mental image of the pain and then transform that image into something less frightening and more manageable.


Another is to imagine the pain disappearing, and the patient as completely pain free. Or, one may imagine the pain as something over which he hascomplete control. For example, patients with back problems may imagine their pain as a high voltage electric currents urging through their spine. As they use guided imagery techniques they can picture themselves reaching for an electrical switch and turning down the power on the current to alleviate the pain6.


d)      Mental rehearsal:

Mental rehearsal involves imagining a situation or scenario and its ideal outcome. It can be used to reduce anxiety aboutan upcoming situation, such as labor and delivery, surgery, or even a critical life event such as an important competition or a job interview. Individuals picture themselves going through each step of the anxiety-producing event and then successfully completeing6.


2.5.  Qualification and training for Guided Therapeutic Imagery:

The Academy for Guided Imagery offers professional certification in guided therapeutic imagery, or Interactive Guided Imagery. Training, which consists of three levels that must be completed within 24 months, is offered through home-study modules and online group study workshops. The practitioners must complete 150 hours of training, 33 hours of independent study, and be licensed to practice as a mental health professional.


2.6.  Stages of guided imagery:

According to the computational theory of imagery, which is derived from experimental psychology, guided imagery comprises four phases. Through this technique, a patient is assisted in reducing the tendency to evoke images indicative of the distressing, painful, or debilitative nature of a condition, and learns instead to evoke mental imagery of their identity, body, and circumstances that emphasizes the capacity for autonomy and self-determination, positive proactive activity, and the ability to cope, whilst managing their condition.

As a result, symptoms become less incapacitating, pain is to some degree decreased, while coping skills increase


a)      Phase-1: Image generation: Image generation involves generating mental imagery, either directly from sensory data and perceptual experience, or from memory, or from fantasy.


b)      Phase-2: Image maintenance: Image maintenance involves the volitional sustaining or maintaining of imagery, without which, a mental image is subject to rapid decay with an average duration of only 250ms.This is because volitionally created mental images usually fade rapidly once generated in order to avoid disrupting or confusing the process of ordinary sensory perception. The natural brief duration of mental imagery means that the active maintenance stage of guided imagery, which is necessary for the subsequent stages of inspection and transformation, requires cognitive concentration of attention by the participant


c)      Phase-3: Image inspection: Once generated and maintained, a mental image can be inspected to provide the basis for interpretation, and transformation.{For visual imagery, inspection often involves a scanning process, by which the participant directs attention across and around an image, simulating shifts in perceptual perspective


d)      Phase-4: Image transformation: Finally, with the assistance of verbal instruction from the guided imagery practitioner or teacher, the participant transforms, modifies, or alters the content of generated mental imagery, in such a way as to substitute images that provoke negative feelings, are indicative of suffering, or that reaffirm disability or debilitation for those that elicit positive emotion, and are suggestive of resourcefulness, ability to cope, and an increased degree of mental and physical capacity7-10.


2.7.  Visual/guided imaginary technique and children:

The world has become more complicated and it’s no longer just school and peer pressures that impact kids. Free play time has diminished as a plethora of extracurricular activities jump in to fill every spare moment. Children are exposed to live-coverage of natural disasters, wars and other negative media that may induce worry and stress in children. So it’s not surprising that anxiety-related disorders in children and teens are on the rise.


Children, especially younger ones, aren’t able to identify feelings of stress and anxiety as easily as adults. They may not connect their stomach aches, headaches, restlessness or irritability as being symptoms of anxiety. Depending on the child’s age and cognitive ability, emotions may be a difficult idea to grasp because they’re such abstract concepts. Feelings like sad and happy can be easily understood, but disappointment, frustration, grief and anxiousness are harder to conceptualize. Since feelings can be confusing and overwhelming, helping your child to identify and become mindful of their feelings will help them navigate difficult times. Mindfulness techniques can be introduced to children at an early age, which will help them to develop self-awareness and mastery over their feelings.


A natural way to introduce children to mindfulness is through guided imagery. Guided imagery is a meditative process that uses visualization and imagination to bring awareness to the mind-body connection. Children can easily access this healing process because they’re naturally imaginative. By relaxing into a vivid story they gain tools to deal with stress, pain or difficult feelings. It’s a wonderful way to connect with your child as they learn to listen to their inner wisdom and access their own power of healing.


Guided imagery can be beneficial for a variety of issues and the process can be tailored to suit your child’s specific needs. It can help reduce stress in all children, but it can also help with specific issues like sleep problems, test anxiety, back-to-school jitters or illness. It can enhance coping skills, encourage self-esteem, increase creativity and boost the immune system.


For more serious problems, guided imagery is recognized as a form of treatment for anxiety, depression, learning disabilities, Attention Deficit Disorder, and to help children prepare for surgery and procedures. Considered an alternative therapy for years, guided imagery is now gaining widespread acceptance in the medical and scientific world11-12.



While initially considered to be no more than an alternative or complementary approach, the approach's proven effectiveness has garnered support in recent years. Guided therapeutic imagery is now widely used and supported by research. The technique is commonly used for stress management, with the person in therapy encouraged to picture a place that instills a sense of relaxation.


3.1.  Conditions requires visual or guided imaginary techniques:

Research shows guided imagery to be helpful in the treatment of a number of concerns, including:

·        Social phobia,

·        Schizophrenia,

·        Depression,

·        Post-traumatic stress disorder.

·        Stress

·        Anxiety

·        Substance abuse

·        Grief

·        Relationship issues

·        Diminished self-care

·        Family and parenting issues


3.2.  Techniques or Component and steps of visual or guided imagery technique:

Guided imagery is simply the use of one's imagination to promote mental and physical health. It can be self directed, where the individual puts himself into a relaxed state and creates his own images, or directed by others. When directed byothers, an individual listens to a therapist, video, or audiotaped exercise that leads him through a relaxation and imagery exercise. In this way, guided therapeutic imagery expands beyond visualization because it involves all five senses.


Guided imagery is a two part process:

There is no single correct way to use visual imagery for stress relief. However, something similar to the following steps is often recommended.3


First components: A state of deep relaxation through breathing and muscle relaxation techniques


Step-1: Find a private calm space and make yourself comfortable.

Step-2: Close your eyes.

Step-3: Take a few slow and deep breaths to center your attention and calm yourself.

Step-4: Focuse on the slow, in and out sensation of breathing or focus on releasing the feelings of tension from muscle, starting with the toes and working up to the top of the head.


Relaxation tapes often feature soft music or tranquil, natural sounds such as rolling waves and chirping birds in order to promote feeling of relaxation.


Second component: Imagery or visualization component. It can be started once the person achieves the state of relaxation. Typically a therapist using this approach will provide verbal prompts to direct the focus of the imagery, often encouraging the participant to notice various sensory aspects of the scene. Some practitioners may use music as part of the technique.


Step-5: Imagine yourself in a beautiful location, where everything is as you would ideally have it. Some people visualize a beach, a mountain, a forest, or a being in a favorite room sitting on a favorite chair.


Step-6: Imagine yourself becoming calm and relaxed. Alternatively, imagine yourself smiling, feeling happy and having a good time.

Step-7: Focus on the different sensory attributes present in your scene so as to make it more vivid in your mind. For instance, if you are imagining the beach, spend some time vividly imagining the warmth of the sun on your skin, the smell of the ocean, seaweed and salt spray, and the sound of the waves, wind and seagulls. The more you can invoke your senses, the more vivid the entire image will become.

Step-8: Remain within your scene, touring its various sensory aspects for five to ten minutes or until you feel relaxed.

Step-9: While relaxed, assure yourself that you can return to this place whenever you want or need to relax.

Step-10: Open your eyes again and then rejoin your world.


3.3.  Implementation or generation of visual imagination:

There are two distinct routes by which mental imagery can be generated/created within consciousness.

a)      Involuntary/Immediate perceptual information: The generation of involuntary mental imagery is created directly from present sensory stimulation and perceptual information, For example, someone can look at a picture of a horse, create a mental image of the picture in their mind, and then maintain this mental image as they look away or close their eyes.

b)          Voluntary/Previously stored information: Second, an image can be created entirely from previously stored information held in long-term memory. For example, someone can hear the word “horse” and then create mental imagery based on their previous experience of what a horse looks like13.


3.4.  Duration and method of delivering visual or guided imaginary therapy:

For a successful guided imagery session, individuals should select a quiet, relaxing location where there is a comfortable place to sit or recline.


The session, which can last anywhere from a few minutes to an hour, should be uninterrupted. If the guided imagery session is to be prompted with an audiotape or videotape, a stereo, VCR, or portable tape player should be available. Some people find that quiet background music improves their imagery sessions.


Imagery combined with other relaxation techniques such as yoga, massage, or aroma therapy can greatly effects of these therapies. It can be done virtually anywhere14.



3.5.  Reaction to visual or guided imaginary technique:

Guided imagery can have many health-related physical, mental and emotional benefits.

a)      Physiologically: Imagery has a positive effect on heart rate, blood pressure, breathing and oxygen rates, brain waves, temperature, hormone balance, boost the immune system, and lower cholstrol and blood sugar level.

b)      Psychologically: Guided imagery can help relieve symptoms caused or made worse by stress, such as: chest pain (angina), high blood pressure, high blood glucose, headaches and digestive and breathing problems15.


3.6.  Functional Mechanism of mental imaginary:

The mind is a very powerful tool that can have a tremendous effect on the body. Our bodies react the same whether we are actuallyexperiencing something or just imagining something. For instance, if you think about lying on the beach in Hawaii, your body responds as if you are actually lying on the beach in Hawaii15.



·        Practicing imagery 15-20 minute daily will increase the success, therefore can be seen as a time consuming activity.

·        Limited time frames to evaluate effectiveness.

·        Although the use of guided therapeutic imagery is supported by research, some studies suggest it can lead to false memories. However, there are typically other factors contributing to the recovery of false memories, such as group pressure, personality factors, and personal experiences.

·        Guided imagery may not work for every individual, and some people may prefer to address their concerns with other approaches.

·         The resulting mental imagery is solely a product of the individual's imagination. Some individuals have difficulty in imagination. They may not get actual clear images but perhaps vague feelings about the guided journey.

·        Guided imagery can induce sleepiness, and some individuals may fall asleep during a session.

·        There is an under-explored field in clinical psychology research3.

·        There is currently a lack of a guiding framework from which clinicians may select the domains or associated measures most likely to be of appropriate use in mental imagery research16.



·        Because of the state of extreme relaxation involved in guided imagery, individuals should never attempt to use guidedimagery while driving or operating heavy machinery

·        Guided imagery is most effective when the person teaching it has training in guided imagery techniques.

·        This technique is generally considered to be safe for use by most people, No known risks are associated with it. The initial guidance of a therapist is encouraged, and when a person experiences a serious concern, the support of a mental health professional is always recommended17.



·        Nurses must learn about how to apply visual imagery technique in clinical practice for the management of physical and psychological (e.g. pain and anxiety) symptoms.

·        The client must have access to the relevant information about the risks, benefits and effects of the treatment, and other available options, to make an informed choice.

·        Nurses have the authority to perform procedures that fall within one of the controlled acts authorized to nursing, or procedures that are not considered controlled acts. When considering the appropriateness of performing an intervention, nurses should keep in mind the following factors:

-        Not all procedures that may cause harm are included in the controlled acts; and each nurse is accountable for her/his actions and for acting within the scope of nursing practice.

-        Consent from the client is required regardless if the therapy is requested by the client or proposed by a health care practitioner.

·        Nursing and administrative authorities would make this decision. If the complementary therapy is not a recognized intervention, nurses may wish to advocate for it to be recognized.

·        Nurses need the necessary assessment skills to carry out the ongoing assessment and evaluation of the effects of the therapy. The entire nursing process must be used as a basis for incorporating music therapy and visual imaginary technique into a plan of care.

·        Nurses must be able to evaluate the effect of the complementary therapy on the overall health status of the client, and to recognize when additional skill, knowledge and expertise are required18.



There is plenty of evidence to show that visual imaginary technique used in health care settings can help calm patients. And given there are no side effects associated to these therapy, it’s certainly a treatment worth trying. Visual imaginary technique when combined with other modalities may be more effective than when presented alone, and that both can reduce the amount of pharmacological agents needed to control other physiological and psychological symptoms (e.g. pain and anxiety.). Greater understandings of the role of these therapy in clinical disorders will help drive forward advances in both theory and treatment.



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Received on 29.03.2018        Modified on 27.06.2018

Accepted on 21.07.2018     ©AandV Publications All right reserved

Int. J. of Advances in Nur. Management. 2018; 6(3): 236-268.

DOI: 10.5958/2454-2652.2018.00059.8