stˈeɪdʒ fˈoːɹ ɪz ˈɪmɪdʒ tɹænsfoːɹmˈeɪʃən, ɪnwˌɪtʃ ðə pɑːɹtˈɪsɪpənt tɹænsfˈɔːɹmz, mˈɑːdᵻfˌaɪz, ɔːɹ ˈɔltɚz ðə kˈɑːntɛnt ʌv dʒˈɛnɚɹˌeɪɾᵻd mˈɛntəl ˈɪmɪdʒɹi, ˌɪntʊ sˈʌbstɪtˌuːt ˈɪmɪdʒᵻz ðæt pɹəvˈoʊk nˈɛɡətˌɪv fˈiːlɪŋz, ˈɪndᵻkˌeɪt sˈʌfɚɹɪŋ, ænd ɛɡzˈæsɚbˌeɪt saɪkəlˈɑːdʒɪkəl pˈeɪn—ɔːɹ ðæt ɹˌiːɐfˈɜːm dˌɪsɐbˈɪləɾi ɔːɹ dᵻbˌɪlɪtˈeɪʃən fɔːɹ ðoʊz ðæt ᵻlˈɪsᵻt pˈɑːzᵻtˌɪv ɪmˈoʊʃən, ænd ɑːɹ sədʒˈɛstɪv ʌv ɔːtˈɑːnəmi, ɐbˈɪləɾi tə kˈoʊp, ænd ɐn ɪŋkɹˈiːst dᵻɡɹˈiː ʌv mˈɛntəl ˈæptɪtˌuːd ænd fˈɪzɪkəl ɐbˈɪləɾi.
Stage 4 is image transformation, in which the participant transforms, modifies, or alters the content of generated mental imagery, into substitute images that provoke negative feelings, indicate suffering, and exacerbate psychological pain—or that reaffirm disability or debilitation for those that elicit positive emotion, and are suggestive of autonomy, ability to cope, and an increased degree of mental aptitude and physical ability.