Photo by David Stuckman

The human capacity to picture things in the mind’s eye is an extremely powerful tool. Imagine for a moment your response when someone asks for directions to your favorite restaurant. Most people do not suddenly generate a line-by-line list of MapQuest steps. Instead, the map is generated in the form of a brief “video” run-through of the streets and landmarks you pass along the way.

What would your life be like without mental imagery? Not a pretty picture if you think about it. For every trip, you would need to carry a list of directions for all the places you had to frequent. So, a picture is worth a thousand words, yet this awesome and innate human skill is easily taken for granted in our culture where we are oversaturated with external imagery from every conceivable media, art, or entertainment source.

As providence had it, my sleep medicine career began in 1988 writing about and testing imagery treatments for chronic nightmares. Since then, mental imagery has proven to be the single most reliable cognitive tool for my patients. In addition to standard Imagery Rehearsal Therapy (IRT) provided through the Maimonides International Nightmare Treatment program, we routinely offer imagery training and coaching to our patients day and night to treat insomnia and enhance acclimation to PAP therapy.

The potency of the mind’s eye emerged in full view for me when our earliest nightmare patients reported routine use of imagery to treat insomnia, solve problems, and organize tasks. Some used an advanced intuitive form of imagery to resolve interpersonal conflicts. Remarkably, these patients evolved these tactics on their own. We instructed them on IRT only to treat nightmares without prompting their imagery use for other things.


To coach your patients on mental imagery, follow these two precepts to enhance your outcomes. First, you must use your own mind’s eye in various situations to gain confidence and competence prior to training your patients in the application. The second precept evolves from the first when you clearly perceive that mental imagery is primarily “guided daydreaming.” It is not meditation, hypnosis, or some futile attempt to generate or hold exact or photographic replicas of external images in your mind’s eye.

Human imagery in most situations reflects the capacity to appreciate a flux of ever-changing images parading across your mental landscape, which may or may not need any guidance and only rarely would they need to be painstakingly controlled. Consider the example of insomnia. I have written on the paradigm of “Thoughts, Feelings, and Images” (TFI System) and how insomniacs spend too much time stuck in the thinking mode of consciousness. Most insomniacs have the capacity to use mental imagery, but they rarely do so because they are too busy thinking about stuff, or in the more severe cases, they think that thinking is the only way to think!

With a bit of self-training and practice, you’ll be prepared to ask patients to reflect on their own daydreaming. Then, you can suggest they engage this same process at bedtime to supplant racing thoughts or ruminations. Our sleep techs provide these instructions to almost every patient studied in the sleep lab every time they undergo a polysomnogram, and we reinforce these instructions at clinic appointments and with educational materials.

Not every patient is a candidate for imagery exercises. Severe post-traumatic stress disorder (PTSD) patients or schizophrenics may have vulnerable imagery systems that decompensate when they attempt to access the mind’s eye on a regular basis. However, most patients report relaxing with mental imagery, and some insomniacs report imagery helps them fall asleep or return to sleep in the lab.


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As a pleasant surprise, we discovered mental imagery also helps patients acclimate to PAP therapy masks and pressurized airflow. Patients with covert or overt anxiety often respond to PAP by amplifying their tension and overfocusing on sensations created by a mask or pressurized air. They are usually stuck on some thought or feeling just like insomnia patients stuck on racing thoughts. Once this predictable yet relatively unhelpful response is triggered, patients move down the wrong path in which mask or airflow is sensed as unacceptably uncomfortable. Asking patients to “intervene” by moving their attention toward pleasant images often reduces this general tension, and most importantly, it often reduces specific complaints about mask discomfort or breathing out against pressurized airflow during expiration. Mental imagery works best when it effectively distracts the patient, which in turn de-escalates the sense of discomfort. These “guided daydreaming” instructions are offered during presleep desensitizations as well as through the night for those who awaken due to slower or gradual adaptations.

Originally, I was intrigued by the potency of IRT in eliminating disturbing dreams in patients who reported their problems for years or decades. Now we see a similar potency in helping insomnia patients and PAP therapy users in the sleep lab or clinic. Although I appreciate that research is limited in this field, I am increasingly persuaded that regular and comfortable use of the mind’s eye provides patients with an opportunity to attain greater self-reliance and mastery in their quest to overcome sleep problems.

Barry Krakow, MD, is the author of Sound Sleep, Sound Mind,i>, principal investigator at Sleep & Human Health Institute, and medical director at Maimonides Sleep Arts & Sciences Ltd (, and blogs at He can be reached at [email protected].