Mental images are part of every individual’s internal world. We remember the past and simulate the future through them (1). Imagery is therefore inextricably linked to emotion, and paintings allow artists to communicate their emotional experience evocatively but often ambiguously, as in the image above by Josephine McInerney.

Experiments have demonstrated that generating mental imagery elicits a greater emotional response than verbalizing the same material. This has been attributed to direct neural pathways connecting brain areas responsible for visual and emotional processing. The brain recruits the same regions when viewing either the real or the imagined world. So material that generates imagery can have an additional psychological impact, “as if” reality (2).

Historically, clinical training in psychiatry is biased toward eliciting patients’ verbalization of experience, rather than their mental imagery. Yet powerful and intrusive mental imagery, in the form of flashbacks, is a hallmark of posttraumatic stress disorder, and emotionally significant imagery is now recognized to be common in many other psychiatric disorders (3). Thus, intrusive images of the future, or flash-forwards, commonly accompany suicidality (4). Moreover, some diagnoses are more imagery-prone than others. Compelling mental imagery of the future is strongly associated with bipolar disorder and predicts interepisode mood instability (5). The extension of the bipolar diagnosis toward a spectrum disorder and its common comorbidity with anxiety, substance misuse, and impulse control problems (6) imply a much wider potential significance for imagery in psychopathology than is currently understood.

Images are often ambiguous: the same mental image can unfold to reveal a scenario of disaster or victory, and mood will follow the image’s changes. Using words explicitly to accompany mental images can disambiguate them in order to construct helpful meanings. Adopting this approach, Josephine McInerney transposes mental imagery in her drawings and at the same time helps illustrate how mental states can change. For example, if a blue circle represents sadness and a red shape represents excitement, an alternative image can be developed that alters the prominence of either raw emotion. Thus, the blue can be “caged” or the red image “shrunk” mentally: controlling the mental picture provides a functional tool to regulate mood, so that “the blue circle is remaining small and out of the way” (as shown in the figure). To “imagine positively” may be more effective for many individuals than trying to “think positively” by using words.

There are currently not enough “images in psychiatry,” in either clinical assessment or treatment. For example, checking the presence of suicidal flash-forwards, not just “suicidal ideation,” could aid the risk assessment of bipolar patients in crisis (4). If, as we believe, our clinical focus is too much on what can only be spoken, we disregard a crucial aspect of many individuals’ internal world and a cognitive process critically linked to dysfunctional emotions.

Opening our eyes to the mind’s eye could cast light on psychopathological mechanisms underlying emotional disorder and offer us new instruments for treatment.