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Mental Imagery: From Basic Research to Clinical Practice

Article in Journal of Psychotherapy Integration · January 2018

DOI: 10.1037/int0000108

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MENTAL IMAGERY RESEARCH AND PRACTICE 1

Published article, Journal of Psychotherapy Integration:

Blackwell, S. E. (2018). Mental imagery: from basic research to clinical practice. Journal of
Psychotherapy Integration. doi: 10.1037/int0000108

©American Psychological Association, 2018. This paper is not the copy of record and may

not exactly replicate the authoritative document published in the APA journal. Please do not

copy or cite without author's permission. The final article is available, upon publication, at:

http://dx.doi.org/10.1037/int0000108
MENTAL IMAGERY RESEARCH AND PRACTICE 2

Mental Imagery: From Basic Research to Clinical Practice

Simon E. Blackwell

Ruhr-Universität Bochum

Simon E. Blackwell, Faculty of Psychology, Ruhr-Universität Bochum, Bochum,

Germany.

I would like to thank Marcella L. Woud for her comments and feedback on an earlier

draft of this article.

Correspondence concerning this article should be addressed to: Simon E. Blackwell,

Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität

Bochum, Massenbergstraße 9-13, 44787 Bochum, Germany. email: simon.blackwell@rub.de

MENTAL IMAGERY RESEARCH AND PRACTICE 3

Abstract

Mental imagery has long been used in psychological therapies, but only more recently has

research started to illuminate the relevant scientific basis. Research shows that mental

imagery is widely prevalent in everyday life, such as when remembering the past or thinking

about the future, and that it is a form of thought that can have a particularly strong impact on

emotion, cognition, and behavior. Investigations of mental imagery within clinical

populations reveal a range of imagery dysfunctions across many disorders. Research

highlights the importance of asking about mental imagery at assessment, and considering

mental imagery-based treatment techniques. Drawing on scientific research, mental imagery

may be used in therapy not only within the context of established techniques such as imagery

rescripting, but also more broadly to enhance emotional, cognitive, and behavioral change.

An awareness of this research can enhance practitioners’ confidence in the scientific basis for

the relevance of mental imagery in clinical practice.

Keywords: Mental imagery, imagery rescripting, memory, depression, PTSD

MENTAL IMAGERY RESEARCH AND PRACTICE 4

Mental Imagery: State of the Science

The study of mental imagery and its use in psychological therapies both have a long

history, dating back to Platonic philosophy (around 400 BC) and the late-nineteenth century,

respectively (for a review of this history, see Edwards, 2007; MacKisack et al., 2016). A

reciprocal relationship between scientific study and therapeutic application of mental imagery

is evident more recently, including in the development of behavior therapy approaches (e.g.,

Lang, 1977; Mathews, 1971; Wolpe, 1961). This article considers the implications of the

current state of scientific research into mental imagery for clinical practice in mental health,

and highlights some future directions for clinically-oriented mental imagery research. The

article is not intended to provide a comprehensive review of all mental imagery research, but

rather highlights empirical evidence with particular relevance for clinical practice with adults.

(For a review of mental imagery research amongst children or adolescents, see Burnett

Heyes, Lau, & Holmes 2013.)

What is Mental Imagery?

Mental imagery refers to “representations and the accompanying experience of

sensory information without a direct external stimulus” (Pearson, Naselaris, Holmes, &

Kosslyn, 2015, p. 590), often described as “‘seeing with the mind’s eye’, ‘hearing with the

mind’s ear’, and so on” (Kosslyn, Ganis, & Thompson, 2001, p. 635). For example, if you

were to stop reading for a moment and instead imagine yourself lying on a secluded tropical

beach, you may not only be able to picture the scene--the sand, blue sea, sun, perhaps palm

trees--but also imagine the sensations of the warmth on your skin, the smell of the sea air, and

the sounds of the waves. This image-based thought is distinct from symbolic forms of

cognition, such as verbal-based thought or semantic knowledge about the locations or names

of various beaches.
MENTAL IMAGERY RESEARCH AND PRACTICE 5

Accumulating evidence from neuro-imaging studies indicates that mental imagery is

encoded similarly to actual perception, even at basic low-level perceptual areas in the visual

cortex. A combination of neuroimaging and behavioral evidence has led to the suggestion

that mental imagery can be considered akin to a ‘weak’ form of perception (Pearson et al.,

2015). The overlap of representation of imagery and perception is believed to be responsible

for some of the particular properties of mental imagery-based cognition, to be considered

later on, as there is direct access to emotional and behavioral systems, and to episodic

representations in memory.

When do People Experience Mental Imagery and What are its Functions?

For many people, mental imagery is a common feature of their daily lives, and there

are many everyday situations in which mental imagery may be used or experienced. For

example, mental imagery may be helpful for certain kinds of decision-making or problem

solving, such as planning a route or mental rotation (e.g., Ghaem et al., 1997), and it can be

used to help emotion regulation (e.g., imagining positive scenes or recalling positive

memories; Werner-Seidler & Moulds, 2012).

Mental imagery may particularly occur in everyday life via recalling events from the

past or imagining potential events in the future, often referred to as ‘mental time travel’

(Berntsen & Jacobsen, 2008; D’Argembeau, Renaud, & Van der Linden, 2011). We can use

such mental imagery to, for example, simulate and pre-experience a potential event, perhaps

helping us to decide between various courses of action by ‘testing out’ in our mind their

likely consequences. It can also be used to re-play events, for example in recalling how

pleasurable a particular activity was or the course of a conversation.

Future projections and memories can be both voluntary or involuntary, with

involuntary imagery accompanied by greater emotional, physiological, and behavioral

reactions (Berntsen & Jacobsen, 2008). Involuntary mental imagery can, for example, remind
MENTAL IMAGERY RESEARCH AND PRACTICE 6

us of something we had planned to do, or warn us of upcoming potential danger, and thus

may have important consequences in guiding our thoughts and behavior. However, such

‘flashes’ of imagery may be very transient: in the absence of efforts to maintain an image in

mind, the average duration is only 250 milliseconds (Kosslyn, 1994). Thus, someone may

only be aware of the reaction to an image and not what triggered it. The famous examples

from Proust’s “In Search of Lost Time” illustrate this well: the narrator is first aware of

experiencing strong emotion, for example when eating a madeleine or stepping on some

uneven flagstones, and then has to consciously search to identify the image or memory that

aroused it.

What are the Properties of Mental Imagery?

Mental imagery and emotion. Mental imagery can have a strong impact on emotion.

Experimental studies with healthy volunteers have shown that processing emotionally-

valenced information via mental imagery has a greater impact on subjective emotion than

verbal processing. To illustrate, several studies have used a paradigm in which participants

listened to descriptions of situations that started ambiguous (i.e., could end positively or

negatively), but always ended in a consistently-valenced manner (e.g., always negatively or

always positively). For example: “Your boss wants to discuss your recent work. They tell you

that it has left them extremely impressed/disappointed” (possible positive/negative

resolutions in italics). Participants instructed to imagine themselves in the scenarios show

greater changes in state mood than participants instructed to think about them verbally (e.g.,

Holmes, Lang, & Shah, 2009).

Similar results have also been found using other experimental paradigms, in which

mental images were generated in response to word or picture cues (e.g., Görgen, Joormann,

Hiller, & Witthöft, 2015; Mathews, Ridgeway, & Holmes, 2013). Interestingly, Görgen et al.

(2015) did not find a greater effect of imagery compared to verbal processing on emotion in a
MENTAL IMAGERY RESEARCH AND PRACTICE 7

group of depressed participants. This may reflect difficulties in generating mental imagery in

depression, such that while people with depression can derive emotional benefit from positive

mental imagery (e.g., see Hitchcock, Werner-Seidler, Blackwell, & Dalgleish, 2017), they

may need more detailed instructions as to the content of the imagery, and more time to

generate a vivid image (Holmes, Blackwell, Burnett Heyes, Renner, & Raes, 2016).

Imagery-based processing may also enhance the emotional impact of memories.

Although not directly comparing imagery versus non-imagery processing as such, several

studies investigating positive memory recall have compared an experiential or ‘concrete’

processing style, focussing on reliving the experience via sensory-rich mental imagery, to an

analytical or abstract processing style. Results have indicated relatively greater positive

impact on mood of the imagery-rich processing style amongst both healthy (e.g., Gadeikis,

Bos, Schweizer, Murphy, & Dunn, 2017; Seebauer et al., 2016) and depressed (Werner-

Seidler & Moulds, 2012) participants. This research has particular clinical relevance because

people may sometimes find that recalling a positive memory makes them feel worse, such as

when they are depressed and the recall triggers rumination (Joormann, Siemer, & Gotlib,

2007). However, the enhancement effect of concrete or experiential processing is not always

found and may depend on factors like the type of memory being recalled. For example, if a

memory is of a particularly important event in someone’s life and has been frequently

rehearsed, there may be little impact of adopting a different processing mode during an

instance of recall (Werner-Seidler & Moulds, 2014).

Several factors may modulate the emotional impact of imagery, with the perspective

of the image having received particular attention. A scene can be imagined as if through

one’s own eyes, termed ‘field’ perspective, or from the outside, termed ‘observer’

perspective. In general, it has been found that field-perspective imagery tends to have a more

emotional impact than observer perspective imagery, albeit with some mixed results in the
MENTAL IMAGERY RESEARCH AND PRACTICE 8

literature (Wallace-Hadrill & Kamboj, 2016). The impact of imagery perspective may vary

according to the nature of the imagined or recalled event. For example, using observer

perspective may be more likely to dampen positive mood when imagining/ recalling positive

events that have the potential to trigger negative thoughts about oneself (Grol, Vingerhoets,

& De Raedt, 2017).

The emotional impact of mental imagery can also be modulated by factors that

interfere with the generation of an image, or how the image is stored in memory. Mental

imagery requires substantial cognitive resources, particularly in relation to visuospatial

working memory. Thus, engaging in tasks that also require use of visuo-spatial resources can

disrupt image-based processing. For example, engaging in directed eye-movements while

holding an emotional image in mind can reduce its vividness and emotional intensity (Van

den Hout & Engelhard, 2012). Further, experimental studies have found that engaging in

visuo-spatially demanding tasks, from tapping a complex pattern to playing the computer

game Tetris, during or after watching a film containing distressing scenes, leads to

participants experiencing fewer intrusive memories of the film scenes in the subsequent week

(e.g., James et al., 2016). This interference is not simply distraction, as similarly distracting

tasks that do not engage visuo-spatial working memory do not have the same effect.

Mental imagery and cognition. Mental imagery can have a powerful impact on other

aspects of cognition. One aspect of this is illustrated in the studies mentioned earlier (Holmes

et al., 2009), in which participants listened to ambiguous scenarios that are resolved

consistently positively or negatively. In these studies, participants also rated the valence

(‘pleasantness’) of another set of ambiguous scenarios. Participants who had imagined

ambiguous scenarios resolving positively showed a tendency to interpret subsequent

ambiguous scenarios more positively than participants who thought about the same scenarios

verbally.
MENTAL IMAGERY RESEARCH AND PRACTICE 9

Some research has investigated whether the imagery task used in studies such as that

by Holmes et al. (2009) could be used to train a more positive interpretation style amongst

people who are currently depressed. In most of these clinical studies, depressed participants

have been asked to complete one session of the imagery task each day from home over the

course of one week, such that by the end of the week the participants had listened to and

imagined themselves in hundreds of ambiguous scenarios ending positively. These studies

have often found reductions in the tendency to make negative interpretations of novel

ambiguous information after one week of training (Hitchcock et al., 2017; Pictet, Jermann, &

Ceschi, 2016), although in most cases did not directly compare imagery to non-imagery

processing. Evidence for an effect of imagery on subsequent interpretation of information

further comes from studies investigating perception of facial expressions. For example, one

study found that when participants imagined a face with only a mildly fearful facial

expression, this reduced how fearful they perceived the expression to be on a subsequently-

presented face showing a very fearful expression (Diekhof et al., 2011).

Mental imagery can seem very real to the extent that imagining an event can promote

confusion between what has been actually experienced versus what has been imagined. For

example, experimental studies have found that people may incorrectly report to have seen

pictures that they have in fact only imagined, compared to a verbal processing comparison

condition (Mathews et al., 2013), and may be more likely to think that a false event is real if

instructed to imagine it rather than just think about it (albeit without explicit instructions not

to use imagery; Hyman & Pentland, 1996). The ‘as if’ reality nature of mental imagery (cf. Ji,

Burnett Heyes, MacLeod, & Holmes, 2016) is also demonstrated by conditioning studies

showing that a mental image of a stimulus can be used in classical conditioning in place of an

actual stimulus. For example, in a study by Lewis, O’Reilly, Khuu, and Pearson (2013),

participants underwent a conditioning procedure in which the instruction to imagine a

MENTAL IMAGERY RESEARCH AND PRACTICE 10

particular visual pattern was always followed by either a pleasant or an aversive photograph.

Subsequent presentation of the previously-imagined visual patterns elicited the conditioned

emotional response, suggesting a generalization of learning from imagery to actual

perception.

The sense of realness of mental imagery may be increased via repeated rehearsal,

increasing how ‘plausible’ an imagined event seems (Szpunar & Schacter, 2013). In fact, this

could be one mechanism via which repeated rehearsal of mental imagery may have broader

impacts. For example, some research has found that repeatedly imagining a positive future

situation has led to changes in people’s appraisals of the future, specifically increasing how

optimistic they are (e.g., Meevissen, Peters, & Alberts, 2011).

Mental imagery and behavior. Imagery may also have a strong influence on

behavior. An early study examining this effect found that participants instructed to imagine

the benefits of having a new cable TV service were more likely to subscribe to the service

than participants instructed simply to read about the same benefits (Gregory, Cialdini, &

Carpenter, 1982). Several studies have examined the effects of imagery on health-related

behavior. In one such study, students who were assigned to practise imagining eating fruit in

various situations in which this would be a possible action subsequently ate more fruit than

students completing comparison tasks (Knäuper et al., 2011). Studies in other areas such as

physical exercise (Chan & Cameron, 2012) have investigated what kind of imagery may be

most useful for achieving behavior change. Their results suggest that imagining the process

of working towards a desired goal (i.e., the steps towards reaching the goal) in combination

with the desired goal itself may be optimal for using imagery to change behavior. The effect

of imagery perspective on behavior has also been investigated, but with sometimes

contradictory results (e.g., Libby, Shaeffer, Eibach, & Slemmer, 2007; Rennie, Harris, &

Webb, 2014). From a more clinical perspective, there is preliminary evidence that repeatedly
MENTAL IMAGERY RESEARCH AND PRACTICE 11

imagining engaging in everyday activities with positive resolutions can increase behavioral

activation amongst participants with depression (Renner, Ji, Pictet, Holmes, & Blackwell,

2017), albeit as a secondary analysis of data from a randomized controlled trial.

However, imagery can also have maladaptive or unwanted effects on behavior. For

example, imagining positive outcomes from events could in some circumstances act as a

‘substitute’ for the actual reward, reducing motivation (Kappes & Oettingen, 2011). Negative

imagery can lead to avoidance behavior, as when someone with PTSD avoids locations or

people that they know to trigger intrusive memories of trauma. Further, ‘positive’ (or perhaps

rather ‘appetitive’) imagery may sometimes encourage dysfunctional approach behavior, such

as in the context of addiction, where imagery of the desired substance (e.g., alcohol or a drug)

can drive craving and thus seeking out of the substance (Kavanagh, Andrade, & May, 2005).

Another example of dysfunctional ‘positive’ imagery comes from bipolar disorder, in which

people may experience positive images of future success at times of elevated mood. Such

images can be experienced as highly compelling and contribute to (hypo)manic mood

escalation, for example by driving excessive goal-directed behaviour aimed at reaching the

imagined success (Ivins, Di Simplicio, Close, Goodwin, & Holmes, 2014).

Mental Imagery in Psychopathology and Wellbeing

Dysfunctions in mental imagery have now been found across many areas of

psychopathology. Several disorders are associated with intrusive distressing mental imagery,

such as intrusive memories of trauma in posttraumatic stress disorder (Ehlers, Hackmann, &

Michael, 2004). Other disorders are associated with imagery that represents a distorted sense

of reality, but feels real, such as images of oneself sweating and blushing bright red in social

anxiety (Hirsch, Clark, Mathews, & Williams, 2003). People may also experience

dysfunctional ‘flashforwards’ that is, future-oriented imagery, such as suicidal plans in

depression (e.g., Hales, Deeprose, Goodwin, & Holmes, 2011), ‘manic’ positive events in
MENTAL IMAGERY RESEARCH AND PRACTICE 12

bipolar disorder (Ivins et al., 2014), or images of self-injury that are experienced as pleasant

and comforting (Weßlau, Cloos, Höfling, & Steil, 2015).

Other areas of psychopathology are associated with deficits in mental imagery. For

example, depression is associated with impoverished positive mental imagery, in particular

difficulty imagining positive events in the future (Holmes, Blackwell, et al., 2016). Of course,

thoughts generally do not take the form of being purely imaginal or purely verbal, but rather a

combination. It is common for thoughts to have a sensory (i.e., image-based) component and,

in fact, greater levels of sensory-based thoughts may be associated with higher levels of

symptoms of psychopathology (e.g., in the context of depression; Moritz et al., 2014).

Interestingly, the studies mentioned in the previous paragraphs generally relate to

emotionally-valenced imagery, suggesting that it is dysfunction in emotional imagery, such

as an excess of intrusive negative imagery or an absence of positive imagery, that is

associated with psychopathology. With some exceptions, studies generally find indices of

general (non-emotional) imagery use or ability to be unrelated to indices of psychopathology

or wellbeing (e.g., Di Simplicio et al., 2016; Ji, Holmes, & Blackwell, 2017).

Moving from a psychopathological to a more wellbeing-oriented perspective, the

ability to imagine possible positive events vividly in one’s future has been associated with

higher levels of optimism (e.g., Ji et al., 2017), and greater experience of positive affect when

viewing positive pictorial stimuli (Wilson, Schwannauer, McLaughlin, Ashworth, & Chan,

2017). This indicates a relation between imagery and important aspects of everyday

experience that is relevant not only for understanding psychopathology, but also positive

aspects of mental health.

Implications for Clinical Practice

Simply being aware of the scientific basis for considering mental imagery in treatment

can in itself be extremely helpful; for various reasons, both practitioners and patients may
MENTAL IMAGERY RESEARCH AND PRACTICE 13

misperceive mental imagery-based techniques as somehow pseudo-scientific or ‘dangerous’

(cf. Bell, Mackie, & Bennett-Levy, 2015), leading to avoidance or embarrassment. Feeling

secure in the scientific underpinning of the use of mental imagery, and being able to

communicate this to patients, can help overcome these potential barriers.

Mental Imagery in Assessment and Formulation

The research clearly indicates the need to include mental imagery in clinical

assessment, as mental imagery forms a substantial part of many people’s mental experience,

and can have powerful effects on emotion, cognition, and behavior. Not asking about it risks

missing an important maintaining factor, particularly given that dysfunctions in mental

imagery characterise so many areas of mental health. Assessment of mental imagery may be

particularly important in the context of potential suicidality or self-harm, given the link

between imagery and behavior and the high prevalence of suicidal and self-harm imagery

(Hales et al., 2011; Weßlau et al., 2015). Having ascertained the presence of imagery

dysfunction provides opportunities to make use of imagery’s powerful effects via a range of

imagery-focused treatment techniques.

Mental imagery may have to be explicitly assessed, as patients may not spontaneously

report it, even thinking it is not relevant, feeling embarrassed about it, or interpreting it as a

sign of ‘madness’ (see Beck, Rush, Shaw, & Emery, 1979; Hales et al., 2014). Further,

whereas for some people talking about mental imagery seems obvious and natural, others

may experience only vague or no imagery at all, need to have mental imagery defined for

them, or need to ‘relive’ a situation to identify transient flashes of emotional imagery.

An outline for assessment and formulation of mental imagery is described by Hales et

al. (2014; see also Hackmann et al., 2011). Assessment of imagery should include not only

details of content (including perspective, i.e., field versus observer), triggering situations, and

consequences (emotional, cognitive, physiological, and behavioral), but also the subjective
MENTAL IMAGERY RESEARCH AND PRACTICE 14

appraisals of the image (if any). This is particularly important, as the overt content of the

image may not match the affect experienced (e.g., suicidal imagery may be comforting, or

aversive and distressing).

Patients (and practitioners) may sometimes be at a loss to understand why an image

has such a dramatic impact, or why it is triggered so easily. Being aware of the scientific

literature, such as the basic links between imagery and emotion, and the overlap between

imagery and perceptual processing, can help explain to patients the impact of imagery, and

also help them to reduce secondary distress caused by a strong reaction to an image known

logically to be irrational. An image may just feel real or compelling; this is simply a property

of mental imagery, and in itself may be sufficient to explain the impact of the image on

subsequent emotions and behavioural responses.

The process of assessment can itself be helpful and demonstrate to patients the nature

of mental imagery and what it does or does not mean. For example, someone with a car travel

phobia experienced a recurrent intrusive mental image of the aftermath of a fatal accident,

which they appraised as a premonition. Asked for more detail, they described seeing their car

lying on its roof in a field at the side of the road. However, the process of describing the

image made them realize spontaneously that it was completely unrealistic: The car was lying

on its roof, but with no external damage, and no sign of disturbance to the rest of the

environment, such as skid marks or flattened grass. This helped reduce the power of the

image (i.e., its anxiety-arousing effect, cf. Hales et al., 2014), as they now saw it as simply a

symptom of their anxiety, and not a possible future event. Finally, as stated earlier, mental

imagery dysfunction can include not only the presence of distressing imagery, but also the

absence of positive imagery. Noticing the absence of imagery where it may normally have a

positive impact on mood or behavior (e.g., in recalling a positive memory or anticipating an

upcoming event) can therefore add useful information to a formulation.

MENTAL IMAGERY RESEARCH AND PRACTICE 15

Mental Imagery in Treatment

There are a number of established or emerging imagery-based treatment techniques,

such as imaginal exposure, imagery rescripting, compassionate imagery, or memory-focussed

imagery techniques. This section does not intend to review these detail, with comprehensive

descriptions available elsewhere (e.g., Hackmann et al., 2011; Hitchcock et al., 2017). Rather,

this section will focus on considering the implications of the scientific literature outlined in

the first section for the use of mental imagery in treatment.

As a starting point, it can be useful to explain to patients the nature of mental imagery,

as indicated by the scientific research, namely how it can have a powerful impact on emotion,

and feel particularly real and compelling. Explaining that these are simply results of how

image-based thought is processed in the brain can be help the patient make sense of their

strong reactions to imagery, and reassure them that this does not indicate ‘going mad’ or

some kind of weakness on their part. Understanding the nature of imagery can sometimes

help patients move towards a more metacognitive perspective, stepping back from a

distressing image and seeing it for what it is: just an image. Many images may simply be a

reflection of the individual’s current emotional state and concerns, in the same way as

sweating can simply be a symptom of anxiety, and seeing them as such can help patients start

to disengage.

Enhancing emotional and cognitive change. The scientific literature suggests that

imagery can be used to enhance the emotional and cognitive impact of information, including

enhancing the sense of realness and memorability. Imagery-focussed techniques, such as

imagery rescripting, illustrate one method that makes use of the impact of imagery on

emotion and cognition to effect change. A memory or image can be re-appraised in a less

distressing manner and the negative emotion reduced via incorporating the new appraisal into

an imagery-based ‘rescript.’ Incorporating this re-appraisal via imagery may have more
MENTAL IMAGERY RESEARCH AND PRACTICE 16

impact than simply developing and discussing it in verbal form. Whereas imagery rescripting

is most often associated with distressing memories, if viewed simply as an imagery-based re-

appraisal technique it can be applied more widely, such as via generation and rescripting of

metaphorical images (Butler, Fennell, & Hackmann, 2010). As an illustration, part-way

through therapy, a letter from his bank led to a man with recurrent depression to suddenly

feel overwhelmed by his financial situation, feeling hopeless and struggling to get out of bed.

He described a sense of feeling trapped and imprisoned. Focusing on this ‘felt sense’ (see

Butler et al., 2010), he generated an image of himself trapped in a jail cell, with the walls and

ceiling falling down on him. He rescripted this image, imagining pushing open the door and

walking out into a sunny and open meadow. The relief and reduction in acute anxiety from

this simple rescript allowed him to then engage in constructive problem-solving around his

current situation and make plans for steps forwards.

In addition to specific imagery-focussed techniques, the potential for imagery to

change emotion and cognition can be harnessed more broadly within therapy. For example,

Josefowitz (2017) describes how mental imagery could be used to enhance the impact of the

thought records commonly used within cognitive-behavior therapy. As one illustration of this

idea, once a positive or balanced alternative thought has been developed, this can be

represented as an image; not only may an image feel more real and have more emotional

impact than a verbal representation of the alternative thought, but it may also be more

memorable. For example, if someone came up with the alternative thought, “I’m competent,”

as an answer to the negative automatic thought, “I’m incompetent,” they could develop a

mental image that represented them being and feeling competent, perhaps drawing on

memories of competence used as evidence against the original negative thought (e.g., an

occasion when they received positive feedback about their work). If brought to mind in

situations where the person experienced the original negative thought, such an image may
MENTAL IMAGERY RESEARCH AND PRACTICE 17

have more impact than simply rehearsing the verbal statement “I’m competent.” Imagery

may also be used to relive or rehearse a distressing situation and test out or practice potential

cognitive coping strategies, as has been advocated in techniques such as rational restructuring

(Goldfried & Davison, 1976).

The scientific literature indicates that repeated rehearsal of an image can make it more

vivid and plausible, perhaps increasing the subjective sense of likelihood. This can be useful,

for example, if someone is keeping a positive log of events that constitute evidence for a

target positive belief (e.g. competence). Rehearsing these positive instances via imagery may

help them feel more real, enhance the emotional impact, and increase memorability (cf.

Fennell, 1999). Similarly, rehearsal of imagery or positive memories may be used to enhance

emotional impact, realness, and memorability if trying to develop a more positive self-

identity (cf. Padesky & Mooney, 2012). Imagery-based memory rehearsal may also be used

to increase accessibility of older adaptive memories, or to overcome the overgeneral memory

style that characterizes depression (Hitchcock et al., 2017; Holmes, Blackwell, et al., 2016).

The imagery-based memory strategy of method-of-loci may be used as a mnemonic

technique to help the retrieval of adaptive positive memories on a daily basis (Werner-Seidler

& Dalgleish, 2016). In this approach, the individual identifies a familiar route (e.g., to work)

and several loci (i.e., places) along the way. For each locus, they create a mental image

linking it to a specific positive helpful memory, ideally one that is bizarre and thus more

memorable (e.g., seeing a park bench and garbage bin suddenly transform into a cosy sofa

and fireplace as a reminder of an evening where the person felt particularly connected to a

close friend). The imagined route then becomes a repository for the storage and retrieval of

helpful positive memories, which can be used to reinforce a positive self of sense and to

repair negative mood (Werner-Seidler & Dalgleish, 2016).

MENTAL IMAGERY RESEARCH AND PRACTICE 18

However, at least in the case of using positive imagery, research also suggests that

this can sometimes backfire. For example, if someone recalling a positive memory, instead of

reliving the memory via imagery, starts ruminating and comparing the positive image to their

current situation, they may end up in a spiral of self-blame and worsening mood. If someone

is not experiencing the expected congruent emotion from imagining or recalling something

positive, it is worth exploring how they are imagining it and any other thought processes that

may be occurring.

Promoting behavior. The links between imagery and behavior indicate the potential

utility of incorporating imagery into interventions intended to encourage someone to engage

in particular behaviors. To increase the likelihood of someone actually carrying out the

desired behavior (e.g., physical activity), it may be beneficial to develop and rehearse an

imagery script incorporating both the process of working towards the desired outcome (step

by step) and the reward from the outcome.

As an illustration, someone may wish to try going for a brief walk as a response to

feeling down in the evening, instead of having an alcoholic drink or sitting and ruminating.

They could generate an imagery script that includes the context (being at home in the evening

and mood worsening, perhaps starting to ruminate), the sequence of actions necessary to get

out for a walk (getting up, putting on shoes and coat), the outcome (walking outside, paying

attention to the scenery, feeling themselves unwind and returning home in a relaxed state),

and perhaps the longer-term goals towards which this plan contributes. In fact, new

interventions are currently being developed that capitalise on the use of imagery in this way,

such as functional imagery training (Andrade, Khalil, Dickson, May, & Kavanagh, 2016);

these appear promising, but are in early stages of evaluation. However, care also needs to be

taken that someone does not simply spend time indulging in imagining positive activities or

outcomes, which may paradoxically reduce motivation (Kappes & Oettingen, 2011). Finally,
MENTAL IMAGERY RESEARCH AND PRACTICE 19

over-positive imagery should be avoided in the context of bipolar-disorder, in case it

contributes to manic mood-states (Ivins et al., 2014); instead, more balanced imagery should

be sought.

Reducing unwanted images. One emerging approach involves the use of imagery-

disrupting tasks to reduce the distress caused by distressing mental images. For example, eye

movements made while holding a memory in mind can reduce the vividness of the memory

and associated distress, and this is thought to be a possible working mechanism behind the

memory-processing part of eye-movement desensitization and reprocessing (EMDR) therapy

(Van den Hout & Engelhard, 2012). Further, initial clinical studies indicate that a simple

intervention including playing the visuo-spatially challenging computer game Tetris, which

involves mentally rotating and fitting together a series of geometric shapes that fall from the

top of the computer screen, can reduce occurrence of intrusive memories in the week after a

road traffic accident (Iyadurai et al., in press) or traumatic childbirth (Horsch et al., 2017).

Use of imagery-disrupting tasks has also been incorporated into an imagery-focused

cognitive therapy approach for bipolar disorder (Holmes, Bonsall, et al., 2016).

Summary. In addition to specific mental imagery techniques, such as imagery

rescripting, the basic properties of mental imagery described in the scientific literature can be

harnessed more broadly in treatment, to enhance emotional and cognitive impact, including

realness and memorability, promote adaptive behavior, or dampen the impact of recurrent

distressing images. An awareness of these basic properties of imagery may open many

opportunities to optimise commonly-used therapeutic techniques, from enhancing the

emotional impact and believability of an ‘alternative thought’ identified in a thought record

by representing it as an image, to increasing the chance that positive memories, plans, or

coping strategies can be retrieved from memory when needed.

MENTAL IMAGERY RESEARCH AND PRACTICE 20

Future Research Directions

Imagery to enhance positive affect

Current treatments often do not adequately address deficits in positive affect, such as

the symptoms of anhedonia that are a core part of depression (Craske, Meuret, Ritz, Treanor,

& Dour, 2016; Dunn, 2012). Positive imagery may provide one route to increase positive

affect and reduce anhedonia in the context of depression (cf. Blackwell et al., 2015; Pictet et

al., 2016), but the optimal imagery mechanisms to target (e.g., generation of positive affect,

imagery-based simulation of potential reward) and how best to achieve this need

investigation.

Imagery to promote desired Behavior

Behavioral change is a key part of many efforts to improve both mental and physical

health, and thus the possibility of using imagery to enhance this process holds particular

promise. However, the mechanisms by which imagery may influence behavior and the

parameters for using imagery in this way need to be further delineated. Potential imagery

parameters include not only content (e.g., process/outcome/goals), but also how much to

practice it and when, and how to enhance retrieval in everyday life (e.g., deliberate retrieval

or making use of cues to enhance involuntary retrieval).

Disrupting Distressing and Maladaptive Imagery

Initial clinical studies (Horsch et al., 2017; Iyadurai et al., in press) provide proof-of-

principle for using visuo-spatial tasks to reduce intrusive memories of traumatic events. How

best to optimize the interference effect and the extent or limitations of broader clinical

benefits require further investigation. It may be, for example, that repeated doses of the

intervention or longer period of game-play, or an alternative visuo-spatial task, may have a

stronger impact. Research should also investigate extending this approach to reduce the re-

occurrence of intrusive memories in the context of established PTSD.

MENTAL IMAGERY RESEARCH AND PRACTICE 21

Uncovering Unexamined Imagery

Whereas dysfunctional mental imagery has been observed across a wide range of

disorders, there are likely to be further areas where mental imagery dysfunction is present,

but has not yet been well characterized, potentially providing routes for treatment innovation.

Areas in which dysfunctional imagery has been described more recently include incontinence

phobia (Pajak, Langhoff, Watson, & Kamboj, 2013) and binge eating (Dugué, Keller,

Tuschen-Caffier, & Jacob, 2016), and it is likely that there are many further examples of as

yet uninvestigated mental imagery awaiting characterization.

Understanding Imagery-Related Mechanisms

Although recent decades have seen great advances in the understanding of mental

imagery at both cognitive and neural levels, continuing to develop our understanding of how

mental imagery is represented, how these representations are retrieved or updated, and the

connections with other neural systems, can contribute to refining mental imagery-focused

treatment approaches and broader science-driven treatment innovation.

Conclusions

The current scientific literature indicates the following main messages for clinical

practice:

 Given the broad range of imagery dysfunction across psychopathology, mental imagery

should be explicitly inquired about in assessment. Not asking about mental imagery risks

missing potentially important maintaining factors, and precludes the use of powerful

imagery-focussed treatment techniques.

 If indicated by the formulation, imagery-focused treatment techniques should be

considered. The powerful impact of imagery on emotion, cognition, and behavior means

that imagery can be used more broadly to enhance emotional, cognitive, and behavioral

change.
MENTAL IMAGERY RESEARCH AND PRACTICE 22

 An awareness of the scientific underpinnings of mental imagery can be extremely useful

in informing assessment, formulation, and treatment in clinical practice. Further, being

able to communicate the scientific basis for the impact of imagery to patients can be

helpful not only in helping making sense of their experience, but in overcoming potential

barriers to benefiting from powerful treatment techniques.

MENTAL IMAGERY RESEARCH AND PRACTICE 23

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