01 - 20. Imagery

20. Imagery

M any clients experience automatic thoughts not only as unspoken words in their minds but also in the form of mental pictures or images (Beck & Emery, 1985). As I’m sitting here now, I can recall several images I had today. As I read an email from a friend, I pictured her in my mind. As I planned a family dinner, I had a visual memory of the last time we all had a meal together. When my client reported an automatic thought (“[My husband] will blame me”), I envisioned her husband speaking to her with a mean look on his face. While most imagery is visual, images can be sensory (such as a tone of voice) or somatic (physiological sensations). Imagery affects how we feel (influencing both positive and negative emotions) more than verbal processes (Hackmann et al., 2011). I’ve found that many CBT therapists, even very experienced ones, don’t use techniques to induce positive images in their clients and/or fail to identify and address their clients’ important distressing images. This chapter answers the following questions: How can you help clients create positive images? How do you identify and educate clients about spontaneous negative images? How do you intervene therapeutically with distressing spontaneous images? IMAGERY

INDUCING POSITIVE IMAGES In previous chapters, we discussed positive imagery in several ways. For example, we ask clients to imagine achieving their aspirations and goals and living in accordance with their values—­along with the positive emotions they would experience if they were able to do so. We may ask clients to envision doing their Action Plans to strengthen their motivation, identify and resolve potential obstacles, and increase the likelihood that they will follow through. Below, you’ll find five additional interventions, each of which induces a positive image: focusing on positive memories, rehearsing adaptive coping techniques, distancing, substituting positive images, and focusing on positive aspects of an upcoming situation. Focusing on Positive Memories Creating vivid positive imagery can increase clients’ positive emotions, motivation, and self-­confidence. You can have clients recall memories, relevant to a current or upcoming situation, in which they solved problems, coped well with difficult situations, or experienced success (Hackmann et al., 2011). Judith: [summarizing] It sounds to me as if you’ve lost a lot of confidence in yourself. Do you think that’s right? Abe: (Thinks.) Yes. (pause) I keep thinking how hard things are. Judith: Things really are harder for you now because of the depression. But I remember you telling me about a really hard period in your life, when you worked for a contractor one summer during high school. Abe: Yeah, I didn’t really know what I was doing at first. Judith: What happened? Abe: I watched the other guys, saw what they were doing, and then I tried to do the same thing. Judith: Was it hard the whole summer? Abe: No, eventually I caught on. I mean the work was physically hard, but I did a good job. Judith: Can you imagine yourself back at that time? Maybe your last day of work? Can you see yourself? Abe: Yeah. Judith: What are you doing?

Imagery

Abe: Helping another guy putting in beams. Judith: Was it hot? Abe: It sure was. Judith: Can you see it in your mind’s eye? It’s hot, you’re doing this hard work. (pause) How are you feeling? Abe: Pretty good. Judith: Confident? Abe: Yes. Judith: Knowing you were doing something hard but doing it well? Abe: Yes. Judith: Can you see that you’re still the same person? Someone who can do hard things? You have depression, true, but you haven’t given up. You do hard things every day. And some things, like cleaning up around the house, doing errands, volunteering at the homeless shelter—­all of these things have gotten easier, haven’t they? Abe: Yeah, that’s true. Judith: Do you think it could help this week if you try to remember more about that summer in high school, where you were faced with a challenge, a hard challenge, and you succeeded? And then remind yourself that you’re still the same person and that some things have already become easier. Abe: Yeah, I could do that. Rehearsing Adaptive Coping Techniques You use this technique to help clients practice using coping strategies in imagination. Doing this usually boosts their confidence and their mood and motivates them to use these adaptive behaviors between sessions. Here’s how I help Abe at one of our booster sessions. Judith: Okay, you’re predicting that you’re going to have a rough time on your first day of work? Abe: Yeah. Judith: When will you first notice your anxiety going up? Abe: When I wake up. Judith: And what will be going through your mind? Abe: I’m going to mess up. Cognitive Behavior Therapy: Basics and Beyond

Judith: What does that look like? Abe: I’ll be sitting in a cubicle, just staring at the computer screen. Judith: Okay, what could you do to calm yourself before you leave for work? Abe: Remind myself it’s natural to feel nervous on your first day in a job. Judith: Can you see yourself doing that? Abe: Yeah. Judith: Okay, what else can you do? Abe: I could do my mindfulness practice. Judith: Can you see yourself doing that? Abe: Yeah. Judith: Then what? Abe: I feel a little better, but I’m still too nervous for breakfast. I just shower, get dressed, get ready to go. Judith: What’s going through your mind? Abe: What if I keep getting more and more nervous? Judith: How about imagining yourself reading those therapy notes we just composed before you leave your apartment? Can you imagine pulling them out and reading them? Abe: Yeah . . . I guess it helps some. Judith: As you get near the building, can you imagine jumping ahead in time. It’s lunch time, you’ve mostly been filling out papers, taking a tour, maybe setting up your email with the IT people . . . How do you feel now? Abe: Some relief. Still worried, but not as bad. Judith: Okay, now you’ve just come back from lunch. What happens next, and what do you do? Abe continues to imagine in detail realistically coping with the situation. Then he writes down the specific techniques he predicts will help. Distancing Distancing is another induced imagery technique to reduce distress and help clients view problems in greater perspective. In the following example, I help Abe see that his difficulties are likely to be time limited.

Imagery

Judith: Abe, I know you’re feeling kind of hopeless now, and you’re predicting that these problems will go on and on. Do you think it would help if you could envision getting through this rough period? Abe: I guess. But it’s hard to imagine. Judith: Well, let’s see. How about if you try to picture yourself a year from now? When you’ve gotten through this, and you’re feeling better? Abe: Okay. Judith: Any idea what life is like? Abe: I don’t know. It’s hard for me to think that far ahead. Judith: Well, let’s be concrete. When do you wake up? Where are you? Abe: Probably I wake up around 7 o’clock or 7:30. I guess I’m in my same apartment. Judith: Okay, can you see yourself waking up? What do you want to imagine you’re doing next? Helping Abe visualize a day in the future when his mood and functioning have improved creates hope and motivation. Substituting Positive Images Substituting a more pleasant image has been extensively described elsewhere (e.g., Beck & Emery, 1985). It, too, must be regularly practiced for the client to experience relief from distressing spontaneous images. It’s appropriate to use this technique only intermittently when clients experience negative images. If negative images are part of a dysfunctional thought process, then techniques like mindfulness are more suitable. Judith: Abe, another way of dealing with this kind of upsetting image is to substitute a different one. Some people like to imagine that the distressing image is a picture on a television set. Then they imagine changing the channel to a different scene, like lying on a beach, or walking through the woods, or recalling a pleasant memory. Would you like to try this technique? Abe: Yeah. Judith: First, you’ll picture the pleasant scene in as much detail as possible, using as many senses as possible; then I’ll have you practice switching from a distressing image to the pleasant one. Now, what pleasant scene would you like to imagine? Cognitive Behavior Therapy: Basics and Beyond

Focusing on Positive Aspects of a Situation Another type of induced image is designed to allow clients to view a situation more positively. One client, who feared undergoing a Cesarean section, envisioned the excited face of her partner, holding her hand; the kind and caring faces of the nurses and doctor; and then the wonderful image of holding her newborn child. IDENTIFYING NEGATIVE IMAGES Although many clients have automatic thoughts in the form of negative visual images, few are aware of them initially. These spontaneous images may last just for milliseconds. Merely asking about them, even repeatedly, is often insufficient. When clients do have distressing images, it’s useful to teach them imaginal techniques. Unaddressed images usually result in continued distress. Here’s how I identify one of Abe’s negative spontaneous image that involves his ex-wife. Judith: [summarizing] Did I get this right? You were thinking about this upcoming family dinner at your son’s house and you thought, “What if Rita criticizes me in front of the family?” Abe: Yes. Judith: Did you imagine what the scene would look like? Abe: I’m not sure. Judith: [helping Abe to think very specifically] Could you picture it now? Where would this come up? In the living room or kitchen? Or as you’re sitting around the dinner table? Abe: Around the dinner table. Judith: Okay, can you picture it now? It’s Saturday night, you’re all sitting around the dinner table . . . Can you see it in your mind? Abe: Yes. Judith: What’s happening? Abe: We’re talking about the Fourth of July holiday, and Rita says, “Abe, you know you’ll just drag everyone down.” Judith: When she says that, what does her face look like? Abe: Kind of mean. Judith: Do you think that image flashed through your mind when you were thinking about the family dinner?

Imagery

Abe: Yeah, I think so. Judith: Okay. [providing psychoeducation] That picture, what you were imagining, is what we call an image. It’s an automatic thought in another form. TEACHING CLIENTS ABOUT DISTRESSING IMAGES Clients may not grasp the concept of images if you only use that one term. Synonyms include mental picture, daydream, fantasy, imagining, movie in your mind, and memory. Had Abe failed to report an image, I might have tried using one of these different words. Or I might have reminded him that we created an image in our first therapy session when we identified his aspirations and goals. You must often be diligent in teaching clients to identify images until they “catch on.” Most clients simply are unaware of images initially, and many therapists, after a few tries, abandon the attempt. If you get a visual image yourself as the client is describing a situation, you can use it as a cue to probe further. “Abe, as you were just describing walking into the homeless shelter and feeling overwhelmed, I got a picture of it in my head, even though obviously I don’t know what the shelter looks like. (pause) Have you been imagining what happens as you walk in?” CLINICAL TIPS A few clients can identify images but don’t report them because their images are graphic and distressing. They may be reluctant to reexperience the distress or fear you will view them as disturbed. If you suspect either scenario, normalize the experience. “Lots of people have visual images either instead of or along with their other automatic thoughts. But usually we don’t realize it. Sometimes images seem pretty strange, but actually it’s common to have all kinds of images—­sad, scary, even violent ones. The only problem is if you think you’re strange for having an image.” MODIFYING SPONTANEOUS NEGATIVE IMAGES There are two kinds of spontaneous negative images you’ll address in treatment. The first kind occurs repeatedly and is experienced as intrusive. You can view them as an unhelpful thought process and Cognitive Behavior Therapy: Basics and Beyond

use mindfulness techniques (Chapter 16). When images aren’t part of a thought process, there are several strategies you can teach clients: changing the “movie,” following the image to completion, and reality testing the image. Advise clients that they’ll need to practice the techniques in and out of session to use them effectively when their distressing images spontaneously arise. Changing the “Movie” Abe reported a spontaneous image he had recently. He saw himself sitting alone in his apartment during the upcoming weekend, feeling sad and lonely. I educate him about images and help him create a new “movie.” Judith: Abe, you don’t have to be at the mercy of your images. You can change them, if you want. It’s as if you’re a movie director. You can decide how you want them to be instead. Abe: I’m not sure I understand how to do that. Judith: Well, okay, you said you saw yourself sitting on the couch, feeling really sad. What do you wish would happen next? Abe: Umm, maybe that my daughter calls and invites me over for dinner. Judith: Can you imagine picking up the phone? How do you feel when she invites you over? Abe: Better. Judith: Is there any other scenario you’d like to imagine? Abe: Maybe that I call my cousin and she wants to do something with me. Judith: That’s a better movie too. Abe: But how do I know they’ll come true? Judith: Well, first of all, neither of us really knows if you’ll actually end up sitting on the couch, all weekend. What we do know is that imagining it makes you feel really sad now. Second, maybe we could talk about how to make it more likely that there really is a better ending. What could you do to make it more likely that you’d get together with your daughter or your cousin? Following Images to Conclusion Three techniques help you and clients conceptualize a problem and do cognitive restructuring, to provide relief.

Imagery

1. Help clients imagine coping with a difficult situation until they’ve gotten through a crisis or resolved a problem.
2. Suggest that clients imagine the near future when they keep imagining one problem after another after another.
3. Ask clients to jump to the far future (and, when relevant, discuss the meaning of a catastrophe). Coping with Difficult Experiences Clients usually feel better and more self-­confident when they picture themselves getting through a stressful event. Judith: Okay, Abe, can you get that image in mind again about being interviewed for the job? Tell it to me aloud as you imagine it as vividly as you can. Abe: I’m sitting in an office. The interviewer is asking me what happened in my last job. My mind is going blank. I’m paralyzed. Judith: And you’re feeling . . . ? Abe: Really, really anxious. Judith: Anything else happen? Abe: No. Judith: Okay. [providing psychoeducation] This is typical. Your mind automatically stops the image at the very worst point. Now I’d like you to imagine what happens next. Abe: Hmm. I’m not sure. Judith: Well, do you stay that way for the whole interview? Abe: No, I guess not. Judith: Can you picture what happens next? . . . Do you begin to talk? Abe: I guess so. Judith: What do you see happening next? Abe: I kind of sputter. I tell him that I had done a really good job for over 20 years, but I got a new boss who changed my job and didn’t support me when I needed help. Judith: That’s really good! Then what happens? Can you see it in your mind’s eye? Abe: He asks me another question about how the job changed. Judith: Then what? Cognitive Behavior Therapy: Basics and Beyond

Abe: I answer it okay. Judith: Then what? Abe: I guess we keep talking until he runs out of questions. Judith: Then what? Abe: He thanks me for coming in and shakes my hand and I leave. Judith: And how are you feeling in the image now? Abe: A little shaky. But okay. Judith: Better than at the start when you were feeling blank and paralyzed? Abe: Yes. Much better. Jumping to the Near Future Following an image to the end can be ineffective when clients keep imagining more and more obstacles or distressing events with no end in sight. At this point, you might suggest that clients imagine themselves at some point in the near future, when they’re feeling somewhat better. Judith: [summarizing] Okay, Abe, when you imagine doing your taxes, you keep seeing how hard it is and how much effort it’s taking and how many problems you’re having with it. Realistically, do you think you’ll eventually finish them? Abe: Yeah, probably. I might have to work on them for days though. Judith: Could you imagine jumping ahead in time and finishing them? Can you picture that? What does it look like? Abe: Well, I guess I see myself looking them over one last time. Then I print them out and mail them. Judith: Could you slow it down a little, really imagine the details? When is it? Where are you? Abe: Okay. I’m sitting at the table. It’s Sunday, late afternoon. It’s hard, and my attention wanders, but I finally finish looking over the form for mistakes. Judith: So, you’re finished. How do you feel? Abe: (Sighs.) Relieved . . . like a weight has been taken off my chest. Lighter. Judith: Okay, let’s review what we did. You had an image of yourself starting to work on your taxes, and the more you imagined, the more problems you saw. Then you jumped ahead in time and saw yourself finishing them, which made you feel better. Can we write

Imagery

something down about this technique—­jumping ahead in time—so you’ll be able to practice it at home too? Jumping to the Far Future Sometimes when you guide clients to imagine what happens next, they visualize the scene worsening catastrophically. If so, question clients to determine the meaning of the catastrophe and intervene accordingly. Judith: Okay, Maria, so you see your friend in intensive care. What’s happening to her? Maria: They’re trying to help her, but she’s too weak from the cancer. She stops breathing. Judith: (gently) Then what? Maria: (crying) She’s dead. Judith: Then what happens? Maria: I don’t know. I can’t see past that. (still crying) Judith: Maria, I think it’ll help if we try to go a little further. What’s the worst part about your friend dying? What does it mean to you? Maria: I can’t survive without her! My life is ruined! In this example, following the image to completion leads to a catastrophe. I empathize with Maria. Then I gently ask her if she’s willing to imagine what she is doing and how she is feeling at her friend’s funeral, then a year later, then 5 years later, and finally 10 years later. She is able to see herself with a new best friend in 5 years’ time, and she’s feeling somewhat better. Jumping ahead in time allows her to see that while she will always feel sorrow, she will be able to continue on with her life and experience peace again. She then feels less desperate about losing this relationship. Reality Testing the Image Another technique is to teach clients to treat images as verbal automatic thoughts, using standard Socratic questioning. I teach Maria to compare a spontaneous image with what is really happening. Maria: I was out really late last night. When I got to the parking lot, I suddenly saw myself feeling really sick and passing out and having no one there to help me. Judith: Was that accurate? Was the parking lot deserted? Cognitive Behavior Therapy: Basics and Beyond

Maria: (Thinks.) No. There were a couple of other people there. Judith: Okay. With this kind of image, when you’re spontaneously imagining something happening right at the moment, you can do a reality check. You can ask yourself, “Is the parking lot actually deserted? Am I actually feeling really sick right now?” If you had known to do that last night, what do you think would have happened to your mood? Maria: I guess I might have felt a little less nervous. In general, it is preferable to use techniques in imagery form or combined with verbal techniques when dealing with images, rather than verbal techniques alone. However, clients who have many vivid, distressing images will benefit from a variety of techniques, and sometimes the verbal technique of a reality check is helpful. SUMMARY Imagery can be used in various ways to heighten positive emotion, increase confidence, rehearse the use of coping techniques, and change cognition. When clients experience negative images, you may need to use persistent (though gentle and nonintrusive) questioning to help clients recognize their images. Clients who have frequent, distressing images benefit from either regular practice of several imagery techniques or, if their images are intrusive, mindfulness techniques. Imagery can be used to modify negative core beliefs by reframing the meaning of significant adverse life events (see Appendix D). It can also be used more extensively to create and reinforce new ways of being (Hackmann et al., 2011; Padesky & Mooney, 2005). REFLECTION QUES TIONS Why might you induce a positive image with clients? How would you do that? How might you use imaginal techniques to help a client who has had a distressing negative image? PRACTICE EXERCISE Try to recall a distressing image you’ve had. For example, did you feel nervous before you saw your first client? Did you have a mental picture of him

Imagery

or her? Or maybe you had an upsetting image when you were thinking about an upcoming interpersonal interaction (a meeting, a confrontation, a large social gathering, or a presentation) that you thought might be stressful. Did you picture others’ faces? Body language? What emotion did you imagine they would be feeling? What did you imagine they would say? Get the image as clearly in mind as you can. Then use techniques in this chapter to respond to the image. Cognitive Behavior Therapy: Basics and Beyond