Anxiety, Stress, & Coping

An International Journal

ISSN: 1061-5806 (Print) 1477-2205 (Online) Journal homepage: https://www.tandfonline.com/loi/gasc20

Visual stimuli in narrative-based interventions for

adult anxiety: a systematic review

Serene Lin-Stephens

To cite this article: Serene Lin-Stephens (2020): Visual stimuli in narrative-based

interventions for adult anxiety: a systematic review, Anxiety, Stress, & Coping, DOI:
10.1080/10615806.2020.1734575

To link to this article: https://doi.org/10.1080/10615806.2020.1734575

Published online: 04 Mar 2020.

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ANXIETY, STRESS, & COPING
https://doi.org/10.1080/10615806.2020.1734575

REVIEW

Visual stimuli in narrative-based interventions for adult anxiety: a

systematic review
Serene Lin-Stephens
Faculty of Medicine and Health, Discipline of Rehabilitation Counselling, The University of Sydney, Sydney, Australia

ABSTRACT ARTICLE HISTORY

Background: Visual stimuli are frequently incorporated into interventions Received 14 April 2019
that use narratives to meet counseling, therapy, education, and clinical Revised 20 November 2019
needs. However, the treatment efficacy of visual stimuli is unclear. This Accepted 8 February 2020
systematic review synthesizes and evaluates visual narrative
KEYWORDS
interventions addressing anxiety. Narrative therapy; narrative
Methods: Databases (n = 9) and extended reference searches identified 13 counseling; narrative
original studies using visual artifacts in narrative interventions for adult intervention; visual stimuli;
anxiety. The visual stimulations were analyzed based on artifact origin, anxiety; image
user interactivity, and functions of the stimuli.
Results: Three types of visual artifacts- virtual reality (VR) (n = 4), videos (n
= 4), and drawings (n = 5) were found. Dichotomous patterns of artifact
origin (native vs. foreign) and interactivity (participatory vs. non-
participatory) characterized the applications. A hierarchy of functions-
engage, externalize, internalize, and rescript was observed. Most studies
confirmed the positive effects on the varied anxiety conditions; however,
unclear risk of bias and extraneous factors was present.
Conclusions: Future visual narrative studies addressing adult anxiety are
recommended to strengthen the current body of knowledge by using
double-blinded randomized control trials with robust anxiety measures,
incorporating artifact origin and user interactivity in intervention
designs, considering alternative stimuli with high accessibility, such as
images, and including employment-related anxiety conditions.

Introduction
Narrative-based interventions entered the therapeutic domains as an alternative yet critical paradigm
to re-conceive illnesses and problems (Biggs & Hinton-Bayre, 2008). Narrative practices facilitate the
recognition of multiple realities and possible storylines to meaning and identity constructions
(Gonçalves, Henriques, & Machado, 2011; McAdams, 1996; White, 1995; White & Epston, 1990). In
this paradigm, therapists, counselors, or clinicians work with clients to address wellbeing issues holi-
stically and flexibly. The therapeutic practitioner must exercise their critical, reflexive ability to absorb
information and form understanding. The rise of narrative medicine attests to the discipline required
of therapy and treatment providers to attentively listen to and act on client stories, which is using
narrative competence to maximize therapeutic outcomes (Charon, 2001). In effect, critical “history
taking” adopts a form of “story taking” by synthesizing seemingly isolated facts into a cohesive
account of health concerns and desired outcomes. The narrative approach calls for a critical eye to
see beyond statistical variables and caution against the ill concept of the “average man” (Schiff,
2017). Examining individuals through their unique stories merits open and robust development of
therapeutic possibilities.

CONTACT Serene Lin-Stephens slin9617@uni.sydney.edu.au

© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 S. LIN-STEPHENS

Visual stimuli have a strong presence in narrative interventions, eliciting thoughts, and under-
lying assumptions for open, rather than closed inquiries. Visual stimuli initiate information retrieval
to process conscious thoughts and subconscious feelings so that the situations clients experience
can be verbalized (Lang, 1977). The range of visual stimuli found in the therapeutic literature is
vast, including images such as photos, pictures, graphics, drawings, and paintings, as well as
videos and virtual reality (VR), to name a few. These visual stimuli have been used in health
care, social work, and education settings to promote wellbeing and treat disorders. Visual narra-
tives, including video stories and digital storytelling, have been used to promote medication
understanding (Appalasamy et al., 2018), disease prevention (Warriner et al., 2015; Wieland
et al., 2017; Willis et al., 2018), screening awareness and communication (Occa & Suggs, 2016),
self-help cognitive behavioral therapy (Gaudiano, Davis, Miller, & Uebelacker, 2019), and advanced
care planning (Hutson & Hankins, 2019). Patient-generated visual narratives and digital stories
have played a role in health assessments (Buchbinder et al., 2005), alcohol behavior studies
(Burnett, Walter, & Baller, 2016), and drug adherence and coping (Treffry-Goatley, Lessells, Molet-
sane, de Oliveira, & Gaede, 2018; Willis et al., 2014). Photo elicitations enrich data collection in
studies of obesity (Lachal et al., 2012), exercise psychology (Monforte, Pérez-Samaniego, &
Devís-Devís, 2018), and addiction treatment (Bailly, Taïeb, Moro, Baubet, & Reyre, 2018). Story-
books contribute to trauma treatment (Hanney & Kozlowska, 2002) and stress coping (Tunney &
Boore, 2013), especially for children. In a similar vein, trauma studies use drawing and storytelling
(Bassin, Wolfe, & Thier, 1983; Crenshaw, 2005), and emotion regulation (Ruppert & Eiroa-Orosa,
2018). A brief survey of the literature shows the frequent use of visual stimuli in mental health
research, with objectives of illness prevention, health promotion, and behavioral adjustment
and modification.
However, while the pursuit of innovative, subject-centered interventions has seen visual stimuli
flourish in narrative inquires of health, the efficacy of these applications needs further examination.
The value of narrative interventions should be established through evidence (Leopold, 2018), yet so
far in the extant literature, no synthesis or evaluation has been found to examine visual stimuli appli-
cations in narrative interventions. To inform the decision making of researchers and health prac-
titioners, a review and analysis of the evidence presented in relevant studies to date will be
necessary and critical to establish the validity and scientific value of visual stimulations. Considering
the heterogeneity of mental health conditions and its impact on different age groups, the scope of
this review will focus specifically on adults and the most prevalent mental health problem- anxiety
(The WHO World Mental Health Survey Consortium, 2007). Anxiety has a lifetime prevalence of up
to a third of the population (Bandelow & Michaelis, 2015). Given its direct impact on employment
outcomes (Himle et al., 2014; OECD, 2015), addressing anxiety can make a difference in personal well-
being, employability, and national productivity. The research aims of this systematic review are to
ascertain the types and functions of visual stimuli in narrative-based interventions of adult anxiety,
synthesize and evaluate these applications through bespoke analytical devices, and identify future
research directions.

Method
This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines (Liberati et al., 2009). Here, visual stimuli refer to methodical facili-
tation in which visual artifacts play a role as stimulants. These artifacts include images, photos, pic-
tures, drawings, graphics, videos, animations, and virtual reality, which can be observed visually by
the naked eye of both research participants and researchers. Therefore, mental images that can
only be “visualized” by research participants or subjects are not included. Both in vivo exposure
(Nixon, Bryant, & Moulds, 2006) and mental imagery (Fernandez & Allen, 1989; Pratt, Cooper, &
Hackmann, 2004) are not part of this review due to other significant mental and sensory extraneous
factors associated with the application process, which can render the actual visual stimulation
 ANXIETY, STRESS, & COPING 3

component a secondary stimulant. Narrative interventions refer to treatments, counseling, thera-

peutic inquiries, and health literacy or education programs that integrate story qualities or
elements (Petraglia, 2007). Stories embody a constructivist stance in knowledge acquisition and
understanding formation through accounts of experience, metaphors, themes, plots, characters
or actors, timelines, and contexts. Anxiety refers to all forms of anxiety characterized by excessive
worrying, tension, or apprehension, and covers a spectrum from state anxiety (aroused in face of
unpleasant, threatening, or challenging situations) and trait anxiety (a personal tendency to
respond to, or anticipate traumatic or stressful situations) (Spielberger, 2010), to the clinically diag-
nosed generalized anxiety disorder (Spitzer, Kroenke, Williams, & Löwe, 2006). Adult refers to
anyone over the age of 18. This review focuses on anxiety conditions in adult studies only, so
that it is the therapeutic effects of visual stimuli that are examined, not their mitigating effects
on compensating underdeveloped communication or language abilities, as are often achieved in
child studies (Atlay, Kilicarslan-Toruner, & Sari, 2017; Crenshaw, 2005).

Database search and article screening

A systematic search was conducted in nine research databases which offer varying data coverage:
Academic Search Ultimate (from 1975), Allied and Complementary Medicine (from 1985), CINAHL
(from 1982), Cochrane Library (from 1995), Embase (from 1974), Eric (from 1966), Medline (from
1966), PsycINFO (from 1986), and Scopus (from 1788). The search strategy was (visual OR image
OR photo OR picture OR drawing OR graphic OR video OR animation Or virtual) AND ((narrative
AND therap*) OR (narrative AND counsel?ing) OR (narrative AND intervention) OR (narrative AND
treatment) OR (narrative AND medicine) OR storytelling) AND (anxiety OR anxious), applied to
full text search including related words and all available articles across the nine databases up to
late March 2019. Since the related word search function was selected in the database search, it
was decided not to add anxiety-associated words manually. An attempt to exhaust all possible
terms was problematic because of the high comorbidity of anxiety with other mental health con-
ditions and association with emotions and personal traits. The search was limited to peer-review
journal articles, conference papers, human subjects, and English only. This generated 219
records, some of which were review papers. The review papers were excluded, but extended refer-
ence research on studies cited in these papers generated 44 articles, which were added to the
abstract screening. Duplicates, non-journal articles, child studies, and articles which were not nar-
rative interventions were excluded. These included articles which were narrative reviews, reports or
syntheses of irrelevant topics; literary analyses; film, media, political, cultural, or social studies and
commentaries; digital designs and media production with no patient or subject interactions;
aphasia treatment or therapy; language development; articles where the terms of “picture,”
“image,” “drawing on … ” did not mean an artifact; medical imaging, videoing and photography
for record-keeping purposes (not intervention), and content analyses of images not acting as stimu-
lants. This produced 33 articles eligible for full-text screening. Upon full-text screening, articles that
did not provide anxiety outcome descriptions or use eligible visual stimuli were excluded. In the
end, 15 articles from 13 studies were eligible for the final review. To minimize publication bias, a
Google search restricted to sites .org, .gov, and .edu, using the same search syntax, was conducted.
This generated 24 results; however, none of them fulfilled the criteria for inclusion. The search and
screening process is outlined in Figure 1.

Results
The search results are summarized in Table 1, with each study numbered in square brackets, in
approximate descending orders of levels of technology required to complete the intervention. Of
the 15 articles retrieved, two studies [2, 7] contained results published in separate articles; therefore,
the total number of studies analyzed was 13.
4 S. LIN-STEPHENS

Figure 1. PRISMA flow diagram (Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009).

Types of anxiety and outcome measures

A diverse range of presentations of anxiety was covered in these studies. These included
anxieties that are associated with exams, travel, commuting, nightmares, pre-release from
prisons, sense of loss from migration experience, social anxiety, Generalized Anxiety Disorder
(GAD), and other mental health disorders such as Borderline Personality Disorder (BPD)and
Post Traumatic Stress Disorder (PTSD). Consequently, different outcome measures were used.
Depression Anxiety Stress Scales (DASS-21), State-Trait Anxiety Inventory (STAI), Social Inter-
action Anxiety Scale (SIAS), Generalized Anxiety Disorder Scale (GAD-7), Symptom Checklist-
90-R (SC-90-R), Hamilton Anxiety Scale (HAS), Self-rating Anxiety Scale (SAS), and author-
devised or elective scales were used. These anxiety outcomes were measured by Likert-type
rating scales.

Types of study designs

Of the 13 studies, six incorporated qualitative data (verbatim transcripts, written accounts, and visual
analysis) [1, 7, 8, 10, 11, 12] for thematic analysis [1], grounded theory [7], and content analysis [8]. All
the studies used the quantitative data as the first analysis, and qualitative data, if there were any, as
the subsequent analysis. Four studies were randomized control trials, two of which used repeated
Table 1. Characteristics of reviewed studies that used visual stimuli in narrative interventions for adult anxiety.
Study Intervention
[1] Avatar in VR
Falconer et al. 4 avatar-MBT sessions 45–
(2017) 60 min each at weekly
intervals
At least 10 weeks into an 18
mth (2–3 days a week)
mentalization-based
treatment program
before participation
[2] Speech dialogues with
Morina, Brinkman, virtual human being
Hartanto, and High-quality head mounted
Emmelkamp (2014) display (HMD) vs. One
screen projection
[2] Speech dialogues with
Morina, Brinkman, virtual human being
Hartanto, 2 sessions exposure to VR in
Kampmann, and 1 week, <30 min each
Emmelkamp (2015). session
Control
Study design Participant group Outcomes Main findings
Mixed methods Convenience sample No Anxiety No significant changes for self-report
One group repeated 11 patients with BPD, 39% of DASS-21 anxiety, 4-point Likert measures across 4 sessions
measures a total pool of 28 aged 20– scale Advantages of Avatar-based MBT
Thematic analysis of 43. over standard MBT through
interviews 9 participants (8 females) in thematic analysis:
(8–24 min,
x = follow up phone interviews
15 min) . express and understand oneself
. keep track and participate
. take and understand other’s
perspective
. see the big picture
. give distance to think clearly
. group therapy or one-to-one
sessions
Randomly assigned Non-clinical sample, no No Social anxiety No difference found in level anxiety
two-group participants met criteria for Social Interactive Anxiety Scale during exposure between HMD
comparison (HMD social anxiety disorder (SIAS), 4-point Likert scale and One-screen projection groups
& One screen) University psychology Subject Unit of Discomfort (SUD),
Pretest-Posttests students 11-point Likert scale
HMD (n = 21)One screen
projection (control, n = 22)
Randomly assigned Non-clinical sample, no No Social anxiety High anxiety group reported
two group participants met criteria for SIAS, 4-point Likert scale lowered scores of social anxiety 3
comparison social anxiety disorder Self-efficacy for social situations months after exposure to virtual
Pretest-posttest University psychology (SESS) on a 10-point Likert scale social world as compared to pre-
ANXIETY, STRESS, & COPING
students aged 18–51, 32 treatment, t (15) = 2.99, p = .009,
females. Cohen’s d effect size = 0.62.
Low social anxiety group (n = Both high (t (15) = − 4.197, p = .001,
18) Cohen’s d effect size = 0.98) and
High social anxiety group (n low anxiety groups (t (17) = − 6.67,
= 16) p = <.001, Cohen’s d effect size =
1.77) reported higher levels of self-
efficacy 3 months after exposure
than pre-exposure.
(Continued )
5
 6
Table 1. Continued.

S. LIN-STEPHENS
Control
Study Intervention Study design Participant group Outcomes Main findings
[3] Imagery rehearsal and One group repeated Convenience sample of 19 No Anxiety associated with nightmare Anxiety levels declined t = 2.73, p
McNamara, Moore, rescripting in VR, 3 measures adults aged 19–65, 10 DASS = .014, two-tailed; Cohen’s d =
Papelis, Diallo, and images per session, 2 females, 9 males Linguistic Inquiry and Word Count 0.63
Wildman (2018) sessions per week over 4 (LIWC)
weeks Anxiety related words decreased
(1.43–0.47), p = .014
Action verbs increased (14.4–19.8), p
< .006
Cognitive process words increased
(9.64–11.7, p = .018)
[4] VR with narration video Two group Not real tourist Yes Travel anxiety VR with narration video provides
Ahn and Lee (2013) VR without narration video comparison 63 males and 37 females 91% Questionnaires of website ability more anxiety relief than without
Pretest-Posttest of age twenties in providing anxiety relief, narration video in ability (t = 3.817,
66 males and 34 females 94% benevolence, integrity, and risk p = .000) factor.
of age twenties in control acceptance, 5-point Likert scale
group
[5] Mobile narratives Randomized control 75 female university students Yes State anxiety related to exams Video/audio interventions on mobile
Grassi, Gaggioli, and Video and audio on mobile trial aged 20–23 State-Trait Anxiety Inventory phone decrease anxiety level (F(3,
Riva (2011) phone Repeated measures, 348) = 12.904, p < .001) and
Video and audio on DVD 5 levels with increase relaxation level (F(9, 348)
Audio on mp3 player pretests-posttests = 6.949, p < .001)
Audio on CD Visual stimuli and
Control group relaxation exercise,
8 weeks.
[6] Mobile narratives Randomized control 120 commuting college Yes State anxiety related to commuting Video and audio combined
Grassi, Gaggioli, and Video and audio trial students aged 20–25 State-Trait Anxiety intervention has higher efficacy in
Riva (2009) Video-only Repeated measures Inventory (STAI) reducing anxiety level
Audio-only Four levels Visual Analog Scale (VAS) anxiety STAI:
Control group item State: F (3, 348) = 6.194, p < .005.
Generalized Self-Efficacy Scale Trait: F (3, 116) = 5.072, p < .005
VAS: F (3, 348) = 12.904, p < .001
Increased relaxation, VAS: (F (9, 348)
= 6.949, p < . 001) and self-efficacy
(F (3, 116) = 10.404, p < .01) levels.
[7] Transmedia storytelling. 3
Heilemann, internet-accessible story-
Soderlund, Kehoe, based videos (14, 4,
and Brecht (2017) 4 min)
[7] Transmedia storytelling. 3
Heilemann, Martinez, internet-accessible story-
and Soderlund based videos (14, 4,
(2018) 4 min)
[8] 4 Digital Stories (each video
Kim et al. (2018) 3 min. long)
[9] 30 min art making activities
Sandmire, Gorham, (mandala design, painting
Rankin, and Grimm free form, collage making
(2012) or clay forms, and
drawing)
One group pretest- 28 Latinas aged 21–48 with No General anxiety disorder Significant reduction in anxiety (F₂,₄₅
posttests elevated symptoms of Depression PHQ-8 = 18.7, p < .001) and depression
Period of study: 6 depression or anxiety Anxiety Generalized Anxiety (F₂,₄₅ = 9.0, p < .001) across time
weeks Purposive sampling Disorder Scale (GAD-7), 4-point Higher levels of confidence
Likert scale associated with lower levels of
depression (Spearman ρ: −.399, p
= .04) and anxiety (Spearman ρ:
−.288, p = .14), 1 week after
intervention
Individual phone As above No General anxiety disorder Relating to the character’s
interviews How participants relate to the vulnerability: “All those feelings
(average 45 min) main character in the videos that she felt, I felt.”
Grounded theory Recognizing shared experiences: “I’m
not the only one going through
this.”
Needing the support others while
lacking self-support: “Handle it and
keep going.”
Imaging alternatives through the
character: If she could, “Why
wouldn’t anyone?”
One group pretest- 20 adults undergoing No Anxiety Anxiety decreased from 1.34 (SD .89)
posttest hematopoietic cell Profile of Mood States subscales to .63 (SD .65), p < .01
Content analysis of transplantation, 65% male Emotional Approach Coping Depression and Emotional approach
follow up coping no change
interviews (15 min) Quality of life increased from 22.63
ANXIETY, STRESS, & COPING
(SD 5.24) to 24.31 (SD 4.0), p < .001
Randomized control 57 undergraduate students in Yes State and Trait anxiety Following treatment, experimental
trial experimental group (n = State-Trait Anxiety Inventory, 4- group has decreased state anxiety
Pretest-posttest 29) and control (n = 28) point Likert scale (t = 3.98, p < .001), and trait
groups, 45 females, 12 anxiety (t = 4.20, p < .001) than the
males control group.
Students with anxiety
disorders excluded
(Continued )
7

Table 1. Continued.
Study Intervention
[10] 20-minute Mandala
Henderson, Rosen, drawing activity per day
and Mascaro (2007) over 3 consecutive days
[11] AT.9 test: Participants
Nguyen, include 9 named items in
Bellehumeur, and their drawing and write a
Malette (2018) story about the drawing
Length not reported
[12] 30 min House-Tree-Person
Yu, Cong, Ma, Jiang, drawing, followed by 40–
and Ling (2016) 60 min’ group interview
with the experimental
group
Control group has group
interview only, 10
sessions over 5 weeks
[13] Draw and paint as a starting
Gunnarsson and point of therapeutic
Björklund (2013) conversations
8
S. LIN-STEPHENS
Control
Study design Participant group Outcomes Main findings
Randomized control 36 undergraduate psychology Yes State and trait anxiety The only significant outcome for the
trial students aged 18–23, 8 State-Trait Anxiety Inventory intervention was decreased PTSE
Pretest-posttest male, 28 female, Posttraumatic Stress Diagnostic symptom severity. No difference
Written disclosure experimental group (n = Scale, Beck Depression for anxiety.
studies 19) and control group (n = Inventory, The Spiritual
Single-blind 17) Meaning Scale, The Pennebaker
Inventory of Limbic
Languidness
Non-experimental 129 Vietnamese migrants No Anxiety The higher the positive God image,
one group survey, aged 23–65 for initial Questionnaire on God Image, 5- the lower the level of anxiety, r = −
with survey, 58 males, 71 point Likert scale .176, p < .05, two-tailed
accompanying females Brief Symptom Inventory (BSI),
story 32 completed the drawing Davidson Trauma Scale (DTS),
and story writing activity AT.9 test
Two group 33 pre-release male prisoners Yes Pre-release anxiety Intervention decreased anxiety for
comparison in experiment group, 36 in Hamilton Anxiety Scale (HAM-A) the experimental group, HAM-A:
Pretest-posttest control group on 5-point Likert scale, p < .001, d = 0.69; SAS: p < .05,
Individual Interviews Self-rating Anxiety Scale (SAS), 4- d = 0.55
Single-blind point Likert scale Control group has higher anxiety in
the posttest than the pretest,
SAS: p < .05, d = − 0.39
One group pretest- 31 adults aged 18–60, 4 male, No Anxiety Decreased anxiety from 76.0–70.0,
posttest 27 females, with mental Anxiety: SCL-90-R symptom scale, p = 0.001
health conditions 5-point Likert scale
 ANXIETY, STRESS, & COPING 9

measures [5, 6], while the other two used pretests and posttests [9, 10]. The rest were one group
repeated measures [1, 3], one group pretest-posttest [7, 8, 13], two-group comparison pretest-postt-
est [2, 4, 12], and non-experimental one group survey [11]. Only two studies reported blinding pro-
cedures, both of which were single-blind [10, 12].

Participants
Some studies reported participants as having pre-existing mental health conditions, including
anxiety, PTSD, BPD, affective syndromes, obsession syndromes, eating disorders, and other personal-
ity disorders, according to DSM-IV Axis II and ICD-10 classifications [1, 7, 13]. However, varying levels
of precision were present in the disorder reporting. In the rest of the studies, mental health conditions
were not a necessary inclusion criterion for participant recruitment. One study excluded participants
with anxiety disorders or other mental illnesses or were taking medication known to influence the
central nervous system, giving the indication of targeting non-clinical participants [9]. Overall,
there were significantly more female participants across the studies. Two studies had female partici-
pants only [5, 7]. One study had male participants only [12]. One study reported using purposive
sampling [7], and two studies reported convenience sampling [1, 3].

Types of visual artifacts

The 13 studies identified used three types of visual stimuli: VR [1–4] (n = 4), videos [5–8] (n = 4), and
drawings [9–13] (n = 5). No use of images such as photos, pictures, or paintings was found, nor were
motion graphics, animations, or cartoons. The studies involved varying levels of technology set up
and administration requirements. Stimulation by VR requires sophisticated user interaction with
technology. One VR study found no difference between the level of anxiety relief provided by
high technology display and lower technology projection [2]. Next, stimulation by video narratives
requires mid-level user interaction with technology, one way or interactive. Two studies required the
participants to use different media, including the internet, mobile phones, DVDs, CD, and MP3
players [5, 6]. Some studies used additional audio-video combined content [4, 5, 6, 7]. Studies
using stimulation by drawing required low technology [9, 10, 11, 12, 13]. However, the studies
used drawing activities, not artifacts of drawing, as stimulation. These studies posed minimal restric-
tions on how to go about the drawing activities, although some provided instructions to include
selected elements in the drawings. Varying levels of intervention intensity existed, ranging from
intensive (4 weeks) [1, 3] to a single session less than an hour [9]. Not all studies reported exact
lengths of interventions [11, 13].

Functions of visual stimuli

Given that the review concerned the effect of visual stimuli, the role the stimuli play in the therapeutic
process was examined. The studies’ purposes and procedures of using the visual stimuli were coded
based on themes first. The themes were then regrouped repeatedly for re-examination until they
could be consolidated into distinct functions. As reported in Figure 2, a hierarchical structure encap-
sulates these functions, beginning with a broad base function (engage), followed by a single or dual
objective of inward or outward therapeutic facilitation (internalize, externalize), and ending at a point
of narrative production that extends into possible changes and future actions (rescript).

Engage
An important factor in successful therapeutic interventions is the engagement of patients and par-
ticipants (WHO, 2016). The studies reviewed had chosen visual stimuli interventions because of
the engaging factor deriving from novelty, realism, efficacy, and acceptability. Visual activities
were deemed as an effective medium to engage participants in free and creative expressions in
10 S. LIN-STEPHENS

therapies [9]. Value for “edutainment” is further highlighted in studies using video stories. Video nar-
ratives afford vicarious learning to engage and support participants through telenovela and webno-
vela, where enjoyable storytelling has a serious purpose [7]. Video and audio contents inform users of
coping strategies to manage anxiety and stress [7, 8]. Narrative content delivery via mobile phone
technology is deemed as highly viable for its accessibility and flexibility [5, 6].

Externalize
Externalization was the dominant function of the visual stimuli employed in the studies. Visual nar-
ratives generated visual representations of the self and others, by which participants made sense of
thoughts, emotions, and behaviors of themselves and others [1]. Participants related to the storyline
and characters; thus, materializing shared experiences [7]. Visual externalization also initiated verbal
externalization of symbolic, integrated self-expression, as well as disclosure of negative, traumatic
experiences [10, 12]. The visual artifacts gave insight into the client’s perceptions, induced free
expression and flow-like state for relaxation [9], and eased participants into therapeutic conversations
[13]. Verbal externalization also occurred by interacting with virtual human beings [2].

Internalize
In the other direction of externalization, visual artifacts were used to internalize desired emotions or
beliefs and to absorb the impact of adverse experience. Video narratives were used as a guided self-
help tool on emotion regulation and stress inoculation [5, 6, 8]. Desensitization of fear or phobia indu-
cing experience was achieved in VR, where challenging situations were simulated as part of exposure
therapy, via safe measures and controlled environments. Participants manipulated visual artifacts to
develop control over intrusive or frightening imagery, thus alleviating fear [2, 3]. Participants also
practiced handling social anxiety in challenging social interactions [2] and a sense of insecurity in
unfamiliar surroundings [4].

Rescript
Rescripting played a crucial role in the studies to generate alternative solutions for decision making
and action planning. Visual stimuli increased the number of action verbs and cognitive process words
while reducing anxiety-related words [3]. Participants synthesized the meaning of their personal
experience and shifted their focus from problem stories to action and reason, which enabled retro-
spection and new perspectives, even in the face of trauma and loss [10, 11, 12]. In video narratives, by
relating to the characters and brainstorming solutions, participants were prompted to evaluate situ-
ations and seek help [7].

Discussion
Quality of evidence
Despite the prevalence of visual methods in narrative-based inquiry, surprisingly few studies with
measurement outcomes have focused on the use of visual stimuli for adult anxiety. Given that sen-
sorial dimensions are a salient feature of narrative construction, such as in Cognitive Narrative Psy-
chotherapy (Gonçalves et al., 2011; Gonçalves & Machado, 1999), the results suggest possible
underreporting of visual stimuli and their effects on adult anxiety.
Of the 13 studies identified, high heterogeneity exists in the study designs, intervention types,
outcome measures, and participant characteristics. Where participants have been identified as
having mental health symptoms, inconsistency is present in the reporting of the exact mental
health conditions. There is also a lack of discussion on potential confounding effects of these con-
ditions on the results. Consequently, the assessment via a GRADE evidence profile was prohibited
(Ryan & Hill, 2016; The GRADE Working Group, 2013). Nevertheless, key quality of evidence indicators
across studies are addressed here. A primary limitation of the studies is the presence of risk of bias.
 ANXIETY, STRESS, & COPING 11

Only two of the studies reported a single-blind study design [10, 12]. Only four were randomized
control trials [5, 6, 9, 10]. Several studies acknowledged the indirectness of evidence, including
weak representativeness of the sample, such as not using real tourists to measure travel anxiety,
subject recruitment not capturing clinical samples, convenience sampling, non-equivalence in demo-
graphic attributes of gender and age, and small sample sizes. Due to the different study designs and
sampling procedures, the demographics of participants were not comparable. Indirectness, along
with differences in interventions, settings, and outcome measures, limits the applicability of the
studies.
Most studies reported significant effects on anxiety; three studies reported no significant results in
the main findings [1, 2, 10]. However, there is variability in the consistency of results across studies
using different visual artifacts and media. In VR studies, Avatar in VR was not associated with any sig-
nificant changes in anxiety across sessions in one study [1], nor did two different virtual displays affect
levels of anxiety during exposure [2]; however, positive effects were detected in a three-month
follow-up, with the high anxiety group reporting lowered social anxiety [2]. Two other VR studies
reported a decrease in anxiety levels following the interventions [3, 4]. Video narratives had more
consistent findings and a significant reduction in anxiety following interventions [5, 6, 7, 8]. The
drawing activities reported a decrease in anxiety, except for one study [10]. The lack of a control
group was a threat to the single group studies, as history, maturation, and other potential confound-
ing factors weakened the internal validity of the studies. Missing details such as confidence interval
reporting in the studies cast uncertainty on the precision of effect size. Publication bias was unclear.
Most studies reported significant results, with two insignificant results from the quantitative analyses
[1, 10], and one insignificant result at the initial intervention but a significant result at the follow-up
[2]. One study declared a potential conflict of interest with industry funding, although it did report
insignificant results [1].
Potential extraneous variables existed in the studies. The studies showed a preference for interac-
tivity but did not account for the effects of interactivity. It was unclear whether the effects of drawing
activities derive from the visual artifact themselves, or the act and process of drawing or interacting
with VR. Thus, art therapy is a confounding influence on the visual stimulation of drawing, so is
manual manipulation to the VR simulations. Also, some studies used relaxation exercises or menta-
lization-based therapy as part of the therapy [1, 5], so the relationship between the visual intervention
effects and other simultaneous stimulations was unclear.

Conceptualizing the use of visual stimuli in narrative interventions

Two dichotomous patterns of relationship were found in the use of visual stimuli in the studies.
The first concerned a continuum of origin of the visual artifacts- who generated or supplied the
materials, with subject-generated (native) artifacts on one end and non-subject-generated
(foreign) artifacts on the other. The second concerned the relationship between the subject and
the stimulation- what did the subjects do with the materials. Some visual stimuli were given in
a one-way, non-interactive format (non-participatory), while others required the subjects to interact
with the visual artifacts (participatory). The level of participation progressed in a continuum, with
passivity on one end and increasing levels of interactivity on the other. By mapping the studies
onto a conceptual framework (Figure 2), viewers can detect a tendency of the studies to use
more researcher-controlled (foreign) visual artifacts in the interventions. The foreign artifacts
were elaborate technologies and high-cost, whereas native artifacts were low technology and
low-cost.
Figure 3 shows that the visual stimulation designs in this review favored “doing” activities on the
part of participants. Although the engagement factor is appealing, it is problematic to separate the
effects of visual artifacts from those of the activities. This should be a consideration for researchers-
to identify whether it is the effects of the artifacts or what participants do that is the primary research
focus. The implications are manifold. If the research focus is on the effects of the artifact, study designs
12 S. LIN-STEPHENS

Figure 2. Functions of visual stimuli in narrative interventions for adult anxiety.

should not incorporate mixed activities, or should clarify the effects of the respective activities. If the
research interest is the activity, alternative visual stimuli that can achieve the same results should be
considered to minimize costs and participant burden. The consideration of budget and burden on par-
ticipants is crucial in the health care and education settings. The burden on participants can be tech-
nology glitches or side effects such as those noted in the VR exercises, which required monitoring [3].
The studies so far show neglect of images, which are low-cost, less technically demanding, and appli-
cable to most people and settings, compared to the high technology interventions.

The gap: image-based stimuli applications in narrative interventions

To take a step towards filling this gap, selective image-based interventions addressing broader health
concerns are presented here for the reference of future research. The examples are mapped in Figure 3,
according to artifact origin and user interactivity. The roles of the images to engage, externalize, inter-
nalize, and rescript evident in these studies are also discussed.
Plentiful examples of images-based patient engagement exist in narrative health
interventions (Figure 4). Images can be researcher supplied (foreign), with content ranging from
appealing colloquial pictorials for clinical education (Lubitz et al., 2007), aesthetic images of paintings
to construct life stories (Garwolińska, Oles, & Gricman, 2018), to intriguing and confronting pictorial

Figure 3. Mapping visual stimuli based on artifact origin and user interactivity- a review of current narrative interventions for adult
anxiety
 ANXIETY, STRESS, & COPING 13

Figure 4. Mapping visual stimuli according to artifact origin and user interactivity- selective examples from narrative interventions
in health inquiries

warning labels and aversive images in narrative exposure therapy (Adenauer et al., 2011; Thrasher et al.,
2012). More commonly, participants’ own images are the primary method of engagement in the
interventions (native). Novel clinical assessments have employed participant-generated images, as
in the case of magazine picture collage (Lerner, 1979; Sturgess, 1983). Photography dominates
image stimuli in narrative interventions as a reflexive means to generate health narratives. Photo eli-
citation, a photo interviewing or feedback method, makes participants’ otherwise hidden experience
visible in various studies (Balbale, Schwingel, Chodzko-Zajko, & Huhman, 2014; Lorenz, 2011). Further,
photo-elicitation studies can have explicit intents to share experience in public forums, such as via
social media (Haines-Saah, Kelly, Oliffe, & Bottorff, 2015) and public exhibition (Oliffe & Bottorff,
2007). Visual data collection of lived environments such as photo walkabouts enables participants
to share their experience to contribute to patient-inclusive care planning (Backman et al., 2012;
Backman, Stacey, Crick, Cho-Young, & Marck, 2018). Photovoice studies take a stance further in advo-
cacy and activism by using individual and shared narratives to inform and influence others (Her-
manns, Greer, & Cooper, 2015; Lewinson, 2015; St. John, Hladik, Romaniak, & Ausderau, 2018).
Making unique experiences visible is a valuable step towards facilitating changes that meet indi-
viduals’ needs. However, in a true narrative sense, externalization means more than making experi-
ences seen, but making experience separate from individuals (White, 2007). When experiences are
seen in images, they are objectified, and separated from individuals- a process observable in
image-based studies. Images enable individuals to untangle and detach themselves from problem-
centered narratives momentarily to create space for alternative stories, so new information and
insights can be accommodated and internalized (Taylor & Savickas, 2016). This higher level of exter-
nalization is exemplified by visual examples of evolving self-concepts such as photo-self-narratives
(Ziller, 2000), positive visual reframing (Ruppert & Eiroa-Orosa, 2018), and visual metaphors (Monforte
et al., 2018). Individuals distanced from their sufferings and reunite with their illnesses through trans-
formed, rescripted narratives of their health stories (Mizock, Russinova, & Shani, 2014; Sitvast, Abma, &
Widdershoven, 2010).

Conclusion
Modern health paradigms are increasingly critical of treating mental health conditions primarily via
medication (OECD, 2015). Health practitioners further therapeutic frontiers by using visual narrative
interventions to reconceive and re-evaluate treatment possibilities, as well as reflecting on therapeutic
14 S. LIN-STEPHENS

practice and health delivery (Amerson & Livingston, 2014; Burke & Evans, 2011; Michael, Della, Banner,
Duckworth, & Nilson, 2012; Padfield, Zakrzewska, & Williams, 2015; Ridgway, Mason-Whitehead, &
McIntosh-Scott, 2018). This study supports the theoretical and practical development of visual narra-
tive intervention by evaluating current research, synthesizing functions of visual stimuli, presenting a
conceptual framework for artifact analysis and intervention design, identifying gaps in the literature,
and providing future directions for researchers and practitioners. Specifically, when incorporating
visual stimuli in narrative interventions, researchers and practitioners can consider the types of artifact
input (native vs. foreign) and affordance of interactivity (participatory vs. non-participatory). Functions
of visual stimulation- engage, externalize, internalize, and rescript can also be considered in measuring
outcomes. This may operationalize and crystalize relationships between intervention inputs and
desired effects. Although results from the studies indicate positive effects of visual stimuli, to under-
stand why and how these effects occur will require further research through nomothetic and idiopathic
means to theorize the effect of visual narrative interventions on adult anxiety. There is potential to
develop and test hypotheses of narrative-based intervention facilitated with visual artifacts, which
could have implications for theories of perception, awareness, and meaning construction.
More rigorous study designs are necessary because of the risk of bias, indirectness of participant
recruitment, and inconsistent effect reporting contained in the studies. Future double-blind, random-
ized control trials involving participants with anxiety will be a starting point to confirm intervention
effects. Several other practical considerations must also be addressed. An intriguing one is that of the
ten different measures of anxiety found in the studies, not one of them used the Anxiety Scale in the
Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983)- HADS-A (Julian, 2011), which is a
common instrument with substantial validation literature in different languages and recommen-
dation by the National Institute for Health and Care Excellence (Stern, 2014). Another glaring omission
is the absence of image-based stimuli. Given that the studies showed that high technology appli-
cations did not necessarily produce superior results in alleviating anxiety, adopting image-based
stimuli in future research may be a viable option to increase intervention applicability and reducing
extraneous factors present in existing studies. Extending from this point, varying user ability and tech-
nology thresholds should be considered for future research and intervention design, especially when
engaging people with cognitive, sensory, and physical conditions or disabilities.
The breadth of adult anxiety conditions covered in the visual narrative interventions suggests the
nuances inherent in anxiety and anxiety-inducing situations. However, employment-related anxiety
was absent. Except in one study [2], in which attending a job interview was one of the social situations
tested, no employment or work-related anxiety was addressed by the visual narrative interventions.
Future visual narrative interventions need to fill this gap, given that decades of research have estab-
lished a strong association between employment, anxiety, and mental health (Himle et al., 2014; Linn,
Sandifer, & Stein, 1985; Montgomery, Cook, Bartley, & Wadsworth, 1999; Perreault, Touré, Perreault, &
Caron, 2017). Findings from future research may inform assisted, rehabilitation, employability, or edu-
cational technology designs.
This review is limited by the paucity of published results identified through the database and
extended reference searches and a language bias towards English. Although it has managed dupli-
cate publication bias by detecting study results disseminated through multiple publications and
including trial registers, there is still a risk of failure to cover insignificant and unpublished results
based on selective reporting and dissemination bias. In addition, the variability of the studies prohib-
ited a meta-analysis and a full GRADE assessment. Continual efforts in researching and reviewing the
evidence are necessary to ensure visual narrative interventions serve the purpose of invigorating and
liberating therapies that they were intended to, both theoretically and methodologically.

Acknowledgment
The author would like to thank Dr James Athanasou, the Chief Editor, and reviewers of the Journal for their thorough
review of and constructive feedback to the manuscript.
 ANXIETY, STRESS, & COPING 15

Disclosure statement
No potential conflict of interest was reported by the author.

ORCID
Serene Lin-Stephens http://orcid.org/0000-0002-8996-3780

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