In cognitive behavioral therapy (CBT), clinicians typically teach their clients to challenge irrational thoughts and beliefs. In some cases, it is useful to extend this intervention to the images that accompany these thoughts, so they may be replaced with new, adaptive images.
When we say “images”, we mean the pictures, sounds, smells, and other sensory information that run through our minds when we have a thought or feeling. Much like irrational thoughts, these images can be distorted depictions of reality that contribute to mental illness.
Also like irrational thoughts, imagery has the power to influence emotions and behavior. Positive images lead to positive emotions, and increase the likelihood of doing the imagined behavior (4). Imagining success at a task can actually improve performance.
Imagery can be used in the treatment of many mental health problems, including depression, mania, anxiety, trauma, and phobias (3, 6, 7, 8).
Imagery’s Role in CBT
Imagery interventions can be used in addition to standard thought interventions, such as thought logs and cognitive restructuring. In fact, although thought interventions are used more frequently, some research has found that imagery has a more powerful impact on emotion (2, 7). Using imagery also allows the clinician to gain a deeper understanding of the client’s problems (2).
For some people, distressing images contribute to mental illness. In these cases, imagery techniques can help stop or change the images and reduce negative emotions. In other cases, a person may understand that some of their thoughts are irrational, and manage to challenge them successfully, but they do not “feel” the changes emotionally. When a person has trouble internalizing cognitive changes, it is also helpful to use imagery (5).
The process for using an imagery intervention is as follows: (1) Provide education about imagery, (2) Help clients elicit their images, and (3) Change and replace unhelpful or distressing images.
Education About Imagery
Some clients will readily describe their internal imagery without prompting, while others will require assistance. Some people will be anxious about discussing imagery, fearing it is “weird” or “crazy”. It is helpful to normalize the experience of imagery and discuss its therapeutic benefits (1).
Imagery Education Script
Mental images are the pictures you see in your mind. Nearly everyone experiences some type of images. These images can also include any of the five senses. For example, you can "hear" sounds in your imagination. You might also smell, taste, or feel things in your imagination. Images may be clear or unclear, fleeting or long-lasting. When I refer to "mental images", this is what I’m referring to.
Discuss with your client why you would like to use imagery for their particular problem. There are a number of ways in which imagery can be beneficial:
- Internalize cognitive changes. Clients may understand on a cognitive level when thoughts are irrational, but not actually feel better because of it. Imagery can help a person accept new, adaptive thoughts on an emotional level.
- Decrease uncomfortable emotions. Distressing images may trigger or maintain uncomfortable emotions. Imagery techniques can lessen the intensity of the images and associated emotions.
- Decatastrophize. Many images involve worst-case scenarios. Imagery techniques can help clients imagine more likely outcomes.
- Increase adaptive behaviors. Imagery allows clients to visualize using adaptive behaviors, such as coping skills, to work through difficult emotions or situations. This increases the likelihood of using these behaviors.
- Respond appropriately to a situation. Imagery allows clients to “test out” different behaviors and identify better possible responses to a situation.
Once clients understand what imagery is and why it is beneficial, you can begin your work eliciting images.
Techniques for Eliciting Images
Watch for Spontaneous Imagery
Some people will describe their mental imagery without prompting. Pay attention when clients are descriptive about a particular scene, including details from any of their senses. When this happens, ask follow-up questions, such as “Can you tell me more about what you see?” or “Can you elaborate on that picture?”
Ask About Images Related to Thoughts or Feelings
When a client expresses a thought or feeling, ask about the images that accompany it. It may be helpful to first complete a thought log, to know where to begin. Below are questions for prompting discussion of imagery related to thoughts and feelings.
- When you had that thought, did you have a picture in your mind?
- When you thought _______, what did it look like?
- What can you see in your mind when you think about _____?
- Do you have any images connected to this situation?
- Do you have any images that accompany that feeling?
- When you feel _____, do you get a picture or image in your mind?
Practice with a Neutral Scene
If the client is struggling to grasp the concept of imagery, have them practice by describing a neutral scene in detail. For example, ask them to imagine taking their dog for a walk. Ask them what this scene would look like: “Where are you? What do you see around you? What is the weather like? Can you hear birds chirping?” Starting with a neutral scene may make it easier to describe more intense imagery (1).Caution: Imagery may evoke intense emotion. Ask for consent before exploring a potentially distressing image. If an image is related to a traumatic event, the clinician must be trained in working with trauma (5).
Techniques for Changing ImagesNote: Each technique listed below includes an example. For the sake of clarity, these examples are condensed to highlight the techniques. In practice, it would be appropriate to prompt clients for more detail in their imagery, and to offer more instruction when necessary.
See the Image Through
When imagining anxiety-filled situations, many people stop when the anxiety is at its worst. As a result, they may never “see” how the situation resolves. By following an image all the way to its conclusion, many will find that the situation improves.
When it’s useful: This technique can be helpful when a person is catastrophizing an anticipated situation, imagining it to be worse than it will likely be. It may also be beneficial for clients engaging in all-or-nothing thinking, only seeing the negative side of a situation.
Example: The client has shared anxiety-provoking images related to attending a party at a friend’s house. Because the client seems to be catastrophizing and ending the image early, the clinician decides to help her see the image through to the end.
Client: I see myself getting ready—I get dressed in something nice and put on make-up. I feel nervous about how I look, but I go anyway. I imagine myself parking my car in front of their house and slowly walking up to their door. I can hear people inside and this is when I start to get really nervous. I start to think “I won’t know anyone” and “This is going to be so awkward”. That’s where I stop the image, because at that point I decide: “I’m not going to the party”.
Clinician: It sounds like the anxiety hits you hard before you even get into the party. But I wonder what would happen if you tried taking the imagery even further? Let’s try, just to see. What would happen next?
Client: Well, I would knock on the door… and I would probably feel like I’m about to throw up.
Clinician: Oh, that sounds terrible. Do you think you would actually throw up?
Client: Well, no. My friend would answer the door, and I think she would be happy to see me. She would take me inside and introduce me to a bunch of strangers, which would make me nervous… but I’m sure they would be friendly.
Clinician: That sounds a bit better! What happens next?
Jump Ahead in Time
In the moment, a distressing situation can feel all-consuming. By imagining a time in the future, your client will see that they make it through. Depending on the situation, you may ask them to imagine how their life looks 1 month, 1 year, or even 5 years into the future.
When it’s useful: This technique is similar to “seeing an image through”, but is more appropriate when the situation will not be resolved as quickly. Jumping ahead in time allows a client to see that a situation, even if it is painful, will not last forever.
Example: The client has been discussing his recent breakup, which has been very painful. He has had difficulty looking toward the future.
Client: I just don’t know what I’m going to do. I was with my girlfriend for over a year, and I thought we were going to get married. I feel like I have to start all over.
Clinician: That must be difficult—I think anyone would feel hurt in your situation. But I wonder if we can try looking forward a bit, and imagining what might happen next. How do you think you will feel in a month?
Client: A month? Probably not much better. Maybe I’ll at least be leaving the house.
Clinician: Describe that for me. What’s happening when you leave the house?
Client: Well, I wasn’t spending much time with my friends during the relationship. I’ll probably reach out to them. Maybe I’ll get back into playing sports, or just visiting my friends.
Clinician: How about a year from now? Can you describe for me what your life could look like then?
Client: I mean, a year from now things might be better. I might meet someone new in that time. I’m sure by then I’ll be back in the swing of things, back into my old hobbies. I think I’ll still miss my ex, but it won’t feel like it does now. I see myself putting more time into other things, like my job and my friends.
Change the Image
In this technique, clients will review how they are currently dealing with a problem, or how they imagine they will deal with a problem. Then, with the help of the clinician, they will imagine different behaviors that may lead to better outcomes.
When it’s useful: Changing the image is helpful when a person’s behavior is contributing to an undesirable outcome, or when a change in their behavior could improve the outcome.
Example: The client has been lonely, reporting that he spends all his free time alone and at home. He would like to have reasons to get out of the house, but is not sure where to start.
Clinician: We’ve been discussing how you’re spending a lot of time alone at home, and you’re unhappy about that. If things were better, how do you imagine they’d look?
Client: I don’t know, I guess I’d have reasons to leave the house. Maybe I’d take a class, or I’d visit my kids. I would be more involved with everything. I imagine waking up and feeling like I have a sense of purpose.
Clinician: That sounds great! Can you describe this in even more detail? What sort of classes? What would your relationship be like with your kids?
Client: Well, the community center by my house has all sorts of art classes. I’ve always wanted to learn to paint, and maybe I would make some friends. As for my kids, I just want to have more contact with them. I’d be happy if we spoke on the phone once or twice a week.
Clinician: Great! What’s one step you could take tomorrow to start making this a reality?
Cope in the Image
Much like in “changing the image”, clients will imagine a new way to respond to a particular type of situation. However, in this technique, clients will use imagery to practice a coping skill.
When it’s useful: This technique is useful when a client has trouble coping with a particular type of situation due to anger, anxiety, or other emotions. This technique allows them to imagine what they need to do in order to get through the difficult situation.
Example: The client presents with anxiety about giving a class presentation. They are worried they’ll get tongue-tied or forget what to say.
Client: Before my presentation I’ll be sitting at my desk, and I’ll feel my heart racing. Then, when it’s my turn, I feel like I want to throw up. I can see myself stumbling over my words and getting tongue-tied in front of everyone. In my imagination, the classroom is so quiet. Everyone’s just watching me mess up.
Clinician: We’ve been practicing deep breathing the past few weeks. Try going through that same scenario again, just like you did, but this time imagine you use deep breathing while waiting your turn.
Client: Um… I guess I would be sitting there waiting, and I would start to feel my heart racing. So I would try to focus on my breathing, like we practiced. I would have enough time to practice for a few minutes. At least I would not be thinking about the presentation so much, and my heartbeat might go back to normal. But I’m sure I would still be nervous when my turn comes.
Clinician: That’s a great start. I wouldn’t expect deep breathing to instantly remove all of your anxiety. But it sounds like the situation would be a little more manageable.
Turn Down the Intensity
Sometimes, distressing images will not be rooted in reality. A client might fear an overwhelmingly negative outcome to a situation that is likely to be harmless. In this technique, the client will be instructed to progressively bring the image closer to reality.
When it’s useful: This technique is appropriate when clients imagine a perceived threat or situation to be far worse than it is likely to be. Phobias and anxieties that involve catastrophizing can be targeted with this technique.
Example: The client has a phobia of dogs, which has brought her to the point where she will not walk down the street in her neighborhood.
Client: Whenever I imagine walking down the sidewalk, I see a dog come out of nowhere. I imagine it running straight at me with these big, sharp teeth. It jumps at me and bites my leg.Clinician: That sounds horrible. I can’t imagine how terrifying that must feel. But right now, it sounds like you’re imagining the worst possible situation. If there was a scale of how badly things could go, this would be a 10 out of 10. What if you told me the story again, but it was just a 5 out of 10?
Client: Well, I don’t actually see loose dogs very often… I’m just afraid it could happen. I guess a 5 out of 10 would be a scary-looking dog on a leash. It would bark and lunge at me, but the owner would hold it back. That still sounds really bad!Clinician: I see how that would still be scary. That’s also more realistic, but I bet you can come up with something even more likely. Let’s try once more, even lower on the scale. What would things look like at a 2 out of 10?
Client: At a “2”… I guess one of my neighbors would walk by with a friendly dog. I would cross the street to avoid it, but I would be OK.
Imagery is useful in treating a number of mental health problems. If you would like to learn more, check out the book Cognitive Behavior Therapy: Basics and Beyond by Judith S. Beck:
1. Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond, Second edition. New York: The Guilford Press.
2. Hales, S., Blackwell, S. E., Di Simplicio, M., Iyadurai, L., Young, K., & Holmes, E. A. (2014). Imagery-based cognitive-behavioral assessment. Assessment in cognitive therapy, 69-93.
3. Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of behavior therapy and experimental psychiatry, 38(4), 297-305.
4. Holmes, E. A., Crane, C., Fennell, M. J., & Williams, J. M. G. (2007). Imagery about suicide in depression—“Flash-forwards”?. Journal of behavior therapy and experimental psychiatry, 38(4), 423-434.
5. Josefowitz, N. (2017). Incorporating imagery into thought records: Increasing engagement in balanced thoughts. Cognitive and Behavioral Practice, 24(1), 90-100.
6. Ng, R. M., Di Simplicio, M., & Holmes, E. A. (2016). Mental imagery and bipolar disorders: Introducing scope for psychological treatment development?.
7. Pictet, A. (2014). Looking on the bright side in social anxiety: the potential benefit of promoting positive mental imagery. Frontiers in human neuroscience, 8, 43.
8. Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S. (2007). “I’ll believe it when I can see it”: Imagery rescripting of intrusive sensory memories in depression. Journal of behavior therapy and experimental psychiatry, 38(4), 371-385.