Although many evidence-based practices emphasize addressing the cognitive aspects of mental health disorders, research suggests that we may be missing helpful interventions that do not fall under the  cognitive behavior therapy (CBT) model of “thoughts, feelings and behaviors.” Several predominant CBT models fail to emphasize mental imagery by continuing to equate thoughts only with verbal manifestations. This is best seen in the counseling techniques and interventions of self-talk, thought records and the ABC (activating events, beliefs, consequences) model.

While these techniques should be lauded for alleviating the symptoms of countless clients, there are other clients who are not served by these treatments. We propose that a lack of focus on imagery can either, at best, prolong the course of treatment for clients or, at worst, encourage clinicians to label clients as “resistant” because their images insulate negative affective responses.

Most clinicians in the field tend to neglect mental imagery despite research showing that disturbances in mood and the development of certain forms of psychopathology are often correlated with negative images that contribute to the strength and production of negative emotions. Historically, mental imagery has been difficult to research and measure, but we now have evidence suggesting that mood disturbances and psychopathology can be addressed through imagery work. As professional counselors, our role is to promote a holistic approach to counseling not only by addressing our clients’ symptoms but also by focusing on the prevention of those symptoms in the first place.

Mental imagery can be defined as the representation and experience of sensory inputs without a direct stimulus. Several theories have been proposed for the creation of mental images, but bio-informational theory is the one that we will be discussing. In this theory, there is a strong connection between imagery and emotion. This connection is attributed to physical and behavioral reactions to images. For instance, negative images, in comparison with neutral images alone, often produce more negative emotional reactions (e.g., imagining yourself stuttering as you give a future speech in public increases anxiety about future speech performance).

What does neuroscience say?

From a neuroscience perspective, mental imagery is consistently implicated in the propagation of certain emotion regulation patterns. Research shows that this may occur because there is overlap between different areas of the brain based on the type of perceived image. There appears to be brain activity that overlaps between the frontal (cognitive function and voluntary movement/activity) and parietal (sensory processing) areas of the brain regardless of imagery content, but there is also some overlap between the parietal and occipital (visual processing) areas of the brain. This suggests a top-down process when retrieving information from long-term memory.

Damage to the occipital lobe can make it difficult for people to produce images, especially when they try to recall past memories. Neuroimaging also suggests a correlation between visual cortex activation and a person’s subjective rating of the vividness of an image. This could explain why it is easier for someone to recall a memory that has an emotional component to it (sometimes called a flashbulb memory).

This seems to suggest a connection between episodic memories (i.e., two people who experience the same event can have a drastically different recollection of that event) and how a negative autobiographical memory can influence future behaviors. If I continue to imagine potential future situations negatively (imagining all future speeches going poorly, for example), the likelihood is that my present and future will align with those images. If I can create a positive future image (future speeches going smoothly), I am more likely to rewrite my present, negative autobiographical memory to be more positive and, therefore, influence both my past and future self toward positivity.

Benefits for clients

Working with mental imagery in counseling offers several benefits. First, it should be noted that imagery work integrates a person’s cognitive, emotional and somatic aspects, with primary focus placed on the emotional aspect. This is important to consider because although clients might rationally “know” that something is true for them, they can still remain “emotionally stuck” in their past maladaptive behaviors. Counselors who work with images may be able to get around the rational “knowing” and actually address clients’ emotional connections to their images.

Second, imagery is often taught as a skill or to reinforce other skills. Because mental imagery connects different aspects of the brain, imagery has been shown to increase imagination and memory capacity. Additionally, teaching imagery as a skill can help clients realize their power over their own images.

For instance, both of us have used a simple image of a cupcake with a raspberry on top of it with clients. We ask clients to look at the picture of the cupcake and then close their eyes (if comfortable doing so) and imagine the cupcake in all its detail. Then we ask them to change the cupcake in the image they are envisioning, removing the raspberry and replacing it with a blueberry. By being able to manipulate the cupcake image in this way, clients can work up to practicing changing more negative images that elicit negative emotions for them. For example, perhaps clients can imagine themselves providing an eloquent speech without stuttering. Or a speech in which they stutter but are able to remain calm and collected regardless of how well they speak. There are many different ways of teaching mental imagery skills to assist clients that are outside of the scope of this article.

Third, there are several specialized areas beyond mental disorders that seem to benefit from the application of imagery work. For instance, imagery can help clients cope with current problems by allowing them to explore all sides of the issue in vivo and visualize outcomes and other alternatives. Not only can clients effectively problem-solve in this manner, they can get to the heart of emotional components that are often connected with their decisions. Mental imagery encourages clients to take into consideration the temporal nature of situations by helping to reconstruct future beliefs about identity, which in turn increases goal setting and motivation. Connecting imagery to a plan or viewing goals with imagery can increase confidence and belief that one can accomplish them.

When applied to grief work, imagery can help clients work through their grief reactions by allowing them to revisit scenes that are connected with the loss in the past. In addition, positive imagery can be promoted to help clients confront impulses in cases of nonsuicidal self-injury or even to improve outcomes of sports training. Interestingly, mental imagery has also been implicated in healing from sports injuries by decreasing subjective pain responses.

Imagery and emotion regulation

Mental imagery also plays a pivotal role in a number of mental health disorders. For example, intrusive images are considered part of the diagnostic criteria for specific disorders such as posttraumatic stress disorder (PTSD) and often are hinted at in criteria discussing “thought” processes connected to anxiety, bipolar disorder and obsessive-compulsive disorder. Typically, these distressing images match the core concerns of the presenting issue and work to insulate the distressing emotions by acting in tandem with other symptoms. Examples of this might be clients who have obsessional thoughts about insects experiencing images of insects on their bodies, clients with test anxiety experiencing future-focused images of themselves failing a test, and military veterans with PTSD returning home from active duty and reexperiencing traumatic memories during fireworks displays.

The clinical significance of understanding mental imagery when treating clients with emotional dysregulation is of utmost importance. Recent research supports the notion that when compared with verbal content, imagery elicits stronger emotion and can even have an amplifying effect. For example, when an image promotes anxiety-provoking content, it can increase a person’s anxiety. Likewise, it can amplify positive messages, such as when imagining positive outcomes through imagery rehearsal for an upcoming public speech.

Given that the “realness” of images (or a lack of image production) can influence a person’s belief in said images, it is imperative for counselors to understand the content of client images to better provide intervention strategies. Client perceptions of the “realness” of their images appear to add to the power of the content, influencing not just emotions and behaviors but also beliefs.

A strategic clinical intervention

There are several ways to promote imagery as a clinical intervention. The five specific strategies that follow are summed up based on how they can be utilized in session. These interventions, although different from each other, also overlap at times.

1) Competition to imagery: When planning counseling interventions, it can be wise to follow the adage of “fighting fire with fire” to promote the greatest reduction of symptoms in the shortest amount of time. In this instance, “competing” with tasks that use similar cognitive resources can serve to reduce the distressing vividness of the images. This is due to “overloading” the brain. The competition strategy differs from distraction coping techniques because the imagery is being processed simultaneously.

This strategy is often one of the first steps in systematic desensitization for phobias because pairing mental imagery with relaxation often has a therapeutic effect of lowering distress to the said phobia. This is because a client cannot feel both anxious and calm at the same time physiologically. It is also theorized that this is why eye-movement desensitization and reprocessing works — the clinician’s use of bilateral stimulation while the client’s image is exposed overloads the brain and reprocesses the image.

2) Exposure to imagery: One of the most common and best practice techniques occurs by exposing clients to intrusive or distressing images. The reason exposure works is because it addresses images that cause increased emotional dysregulation, allowing clients to regulate themselves over time. Eventually, the client will see an image and not have a negative emotional reaction toward it. Exposure therapy continues to show documented evidence of lowering client distress toward the images during the therapeutic protocol.

3) Imagery retraining: Retraining or “rescripting” imagery seeks to train clients to produce positive images in response to neutral environmental cues or to adapt a distressing image into a more neutral form. This is especially helpful in cases of depression because a lack of positive future images appears to insulate depression symptoms. With either method — producing positive imagery or adapting a more neutral form — the critical process seems to promote alternatives to the client’s current image or lack thereof.

In some sense, producing positive imagery is a relatively new idea. The counselor seeks to encourage the production of positive images in response to ambiguous cues to in turn help clients produce more positive images to novel stimuli. One aspect of the computerized training known as cognitive bias modification is an example of this strategy. Research suggests that this strategy alleviates depression symptoms in clients through the promotion of positive images about the future.

4) Imagery questioning: While the “realness” of mental imagery seems to predict the quality and impact of the images, another strategy used to address imagery is to examine the mental representations themselves. This is similar to the verbal thought work of CBT. With the rise of mindfulness and third-wave behavior therapies such as acceptance and commitment therapy, counselors could take a metacognitive approach to their intervention strategy for images. The object of this type of imagery is to question the “truth” of the image being reported and to promote client functioning. A client would be encouraged to go back to the image and address its truth (i.e., did everyone really laugh at me during my speech? Did I really stutter the whole time I was talking?). Now remembering the image more realistically, the client has the capacity to recall the image as it actually occurred.

5) Transformational imagery: In this work, clients are encouraged to produce an image and modify, adapt or manipulate it (rotating spatially) to promote autonomy over the image and to decrease the occurrence of distressing images. Being able to control the image allows clients to provide a safe place for themselves within a distressing image, transform the image into something different (e.g., transforming a snake into a balloon) or otherwise manipulate the image (like what we did with the cupcake mentioned earlier in the article). This is similar to imagery questioning but also promotes client empowerment to control the image themselves. Guided imagery, as a technique, is an example of this strategy in which images are transformed as an outcome of the intervention.

Steps to integrating imagery into clinical work

When addressing mental imagery in counseling, counselors should weigh the benefits and risks of incorporating the tool in sessions. As professional counselors, it is imperative that we complete thorough assessments to help us determine whether clients are stable enough to address their images. If not, it may be appropriate to first provide them with some coping tools and techniques to increase safety. Second, for imagery work to be effective, clients must be able to produce images. This is also an important piece of assessment.

A simple way to do this is by asking clients to visualize an important family member or friend who produces positive feelings in them. Then invite clients to tell you what this person looks like from head to toe. If clients do not have someone who meets this criteria, find a picture of an object, ask clients to view the picture for one minute, talk to them afterward for a few minutes, and then come back to the picture and ask them to draw that image up in their heads and tell you what they see. If clients are unable to bring back the image, they may not be appropriate for imagery work and would need further assessment.

As with any intervention we use, we need to provide our clients with appropriate informed consent and discuss the potential benefits and detriments of doing imagery work. Clients need to be informed that imagery can produce intense emotions, but providing some information about why that is might help lessen their anxiety about the process. Additionally, the therapeutic relationship is still of the utmost importance; clients must trust in the relationship to be able to get the most benefit out of therapy. Counselors may want to seek additional training to address client imagery. This can help counselors feel better prepared to engage with mental imagery and to work with clients from a variety of backgrounds. 

Conclusion

Our hope is that all counselors have access to interventions that will assist their clients in getting better. As all counselors in the field know, some interventions work seamlessly with certain clients and just don’t work with others. The more competent we are with the interventions we have to address client concerns, the more we will be able to do great work. We believe mental imagery is one intervention that professional counselors can add to their toolboxes to increase the quality of care provided to clients.

 

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Katie Gamby is a licensed professional counselor and assistant professor at Malone University in Ohio. Her research and writing interests include client wellness, mental imagery, schema therapy, and spiritual bypassing. She enjoys serving the state of Ohio through multiple professional organizations. Contact her at kgamby@malone.edu.

Michael Desposito is a licensed professional counselor at a private practice in Ohio and president of an Ohio state counseling division. He has presented at national, state and local conferences on a number of topics, including emotion regulation and mood disorders, affirmative therapy and pedagogy practices for LGBTGEQIAP+ populations, and wellness. Contact him at wellifestylecounseling@gmail.com.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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