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Guided Imagery

Library of Research Articles on Veterans and CIH Therapies

January 2021 Edition

Guided Imagery

Epstein DR, Babcock-Parziale JL, Herb CA, Goren K, Bushnell ML. Feasibility test of preference-based insomnia treatment for Iraq and Afghanistan war veterans. Rehabil Nurs. 2013 May-Jun;38(3):120-32.


The study determined the feasibility of implementing a brief, preference-based non-medication insomnia treatment for Iraq/Afghanistan war Veterans who experienced blast and/or other injuries resulting in an altered level of consciousness.


The study used a one-group pre-post design with a 3-month follow-up assessment. Forty-one veterans (two females, mean age 30.32 ± 7.73 years) with a mean insomnia duration of 3.90 years (± 2.03) received treatment that included one in-person and three telephone sessions of behavioral intervention and incorporated electronic delivery components. Feasibility indicators and preliminary treatment effectiveness were assessed.


Results indicate the preference-based treatment was acceptable to veterans and feasible to implement. Treatment components delivered in-person were used more than electronic methods. Insomnia decreased from moderate severity to the sub-threshold range. Pre- to post-treatment effect sizes were large for most sleep outcomes. Sleep improvement maintained at the 3-month follow-up assessment.


Further testing of a brief insomnia treatment model is needed.

Freeman M, Ayers C, Kondo K, Noonan K, O'Neil M, Morasco B, Kansagara D. Guided Imagery, Biofeedback, and Hypnosis: A Map of the Evidence.  Washington (DC): Department of Veterans Affairs (US); 2019 Feb.

The Veterans Health Administration (VHA) established the Integrative Health Coordinating Center (IHCC) with the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) to aid in development and implementation of complementary and integrative health (CIH) strategies across the VHA. This topic was nominated by Dr. Ben Kligler, National Director of the Coordinating Center for Integrative Health (IHCC) and Laura Krejci, Associate Director of the Office of Patient Centered Care and Cultural Transformation (OPCC&CT). The purpose of this report is to provide a broad overview of the effectiveness of guided imagery, biofeedback, and hypnosis, and the health conditions for which these interventions have been examined in systematic reviews, in the form of evidence maps. The evidence maps will be used to guide and support decision-making about these treatment modalities in the VHA.

Ralevski E, Southwick S, Jackson E, Jane JS, Russo M, Petrakis I. Trauma- and Stress-Induced Response in Veterans with Alcohol Dependence and Comorbid Post-Traumatic Stress Disorder. Alcohol Clin Exp Res. 2016 Aug;40(8):1752-60.

Alcohol dependence (AD) and post‐traumatic stress disorder (PTSD) commonly co‐occur, and the co‐occurrence is associated with worse prognosis than either disorder absent the other. Craving is an important construct related to relapse, but the relationship between PTSD symptoms, craving, and relapse is not well understood. Several studies have documented the relationship between stress and craving in individuals without comorbid PTSD, but the effect on those with comorbid PTSD is not well known. A small literature suggests that trauma imagery affects craving. This is the first study to explore the effects of trauma‐induced and stress‐induced scripts on alcohol craving, affect, cardiovascular, and cortisol responses in the laboratory.

Veterans (n = 25) diagnosed with AD and PTSD who were participating in a randomized clinical treatment trial took part in this laboratory study. Baseline assessment included PTSD symptoms and drinking quantity and frequency over 3 months before study initiation. In the laboratory, participants were exposed to neutral, stressful, and trauma scripts randomly assigned. Main outcomes included craving, anxiety, mood states, salivary cortisol, and cardiovascular responses.

Both stress and trauma scripts produced greater increases in craving, negative affect, and cardiovascular reactivity, compared to neutral scripts. Trauma scripts produced significantly stronger craving for alcohol and greater cardiovascular reactivity than stress scripts. Also, trauma‐induced but not stress‐induced craving was positively correlated with baseline levels of drinking. There were no changes in cortisol levels from pre‐ to postexposure of any scripts.

The results highlight that trauma cues are more salient in inducing alcohol craving than stress cues and higher reactivity is related to more baseline drinking. This finding is consistent with clinical observations that show an association between PTSD symptoms and alcohol relapse. It also underscores the importance of adequate treatment of PTSD as reactivity related to trauma cues and reminders may be an important factor in craving and relapse.

Stoerkel E, Bellanti D, Paat C, et al. Effectiveness of a Self-Care Toolkit for Surgical Breast Cancer Patients in a Military Treatment Facility. J Altern Complement Med. 2018;24(9-10):916‐925. doi:10.1089/acm.2018.0069


To assess whether a self-care toolkit (SCT) provided to breast cancer patients undergoing surgery could mitigate distress and lessen symptoms associated with surgery.


One hundred women with breast cancer, planning to undergo initial surgery, were randomly assigned to either one of two groups: treatment as usual (TAU; n = 49) or TAU with the addition of an SCT (n = 51). The SCT contained an MP3 player with audio-files of guided mind-body techniques (breathing, progressive muscle relaxation, meditation, guided imagery, and self-hypnosis) and acupressure antinausea wristbands. Anxiety, pain, nausea, sleep, fatigue, global health, and quality of life (QOL) were assessed using validated outcome measures. Two inflammatory blood markers (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) were measured serially. Data were collected at baseline (T1), immediately before surgery (T2), within 10 h postoperatively (T3), and ∼2 weeks postsurgery (T4).


Numerous studies have shown that psychological distress associated with a cancer diagnosis can affect pain perception and QOL.


Between T1 and T4, there were significant between-group differences in Patient-Reported Outcomes Measurement Information System (PROMIS)-57 scores of Pain Interference, Fatigue, and Satisfaction with Social Roles, favoring the SCT group compared with TAU (p = 0.005, p = 0.023, and p = 0.021, respectively). There was a significant mean change in Defense and Veterans Pain Rating Scale (DVPRS) scores from T2 to T3, with the SCT group having significantly smaller increases in postoperative pain (p = 0.008) and in postoperative ESR (p = 0.0197) compared with the TAU group. Clinically significant reductions in anxiety occurred in the SCT group during the main intervention period.


These results suggest that using the SCT in the perioperative period decreased pain perceptions, fatigue, and inflammatory cytokine secretion.

Story M, Beck B. Guided Imagery and Music with female military veterans: An intervention development study. The Arts in Psychotherapy Volume 55, September 2017, Pages 93-102.

Military Sexual Trauma (MST) is an issue among returning veterans that causes a significant amount of distress with a high occurrence of Post-Traumatic Stress Disorder (PTSD). There is a need to evaluate and develop treatment protocols for MST related PTSD.

Five veteran women participated in up to 10 music and imagery sessions and modified Guided Imagery and Music (GIM) and a post session focus group over the course of 3 months. Sessions were audio recorded and analysed through a process of meaning condensation to identify how female veterans experienced specific components of a continuum of Music Imagery and Guided Imagery and Music sessions. The PTSD checklist (PCL-5) was used to assess changes in symptom severity.

Participants reported using music and imagery to manage PTSD symptoms and several themes were identified related to the experience of GIM. Three out of four scored clinically significant reductions and one out of four scored a reliable reduction of PTSD symptoms.

Participants shared common themes in their experience of GIM sessions that led to development of a stronger protocol for a follow up study. This study adds to the understanding of female veterans with MST related PTSD and their experience with GIM as a treatment modality.