Therapist Manual — Imagery-Focused Therapy for Visual Hallucinations
(Adaptable for psychosis, neurological causes, and visual deprivation conditions such as Charles Bonnet syndrome)
Below is a structured, session-by-session clinical protocol you can use in practice or publication.
Treatment Structure
• Format: Individual therapy
• Length: 8–10 sessions (45–60 min)
• Homework: Daily imagery practice + monitoring
• Primary goals:
o Reduce hallucination distress
o Increase perceived control
o Modify threatening imagery content
o Improve functional adaptation
Session-by-Session Protocol
Session 1 — Engagement, Assessment, and Normalisation
Goals
• Build therapeutic alliance
• Assess hallucination phenomenology
• Introduce imagery model
Therapist Tasks
• Obtain detailed hallucination description:
o Content
o Frequency
o Duration
o Triggers
o Emotional response
• Assess insight and beliefs
• Screen for risk / severe psychopathology
• Provide reassurance (especially important in CBS)
Psychoeducation Script (Example)
“Many visual hallucinations are influenced by the brain’s imagery systems. Therapy can help you change how these images appear and how you respond to them.”
Homework
• Begin Hallucination Monitoring Log
Session 2 — Individualised Imagery Formulation
Goals
• Map maintenance cycle
• Identify imagery triggers
Therapist Tasks
Develop formulation diagram including:
• Sensory deprivation / fatigue / stress
• Hypervigilance
• Threat imagery rehearsal
• Avoidance behaviours
• Emotional escalation
Technique
• Draw Imagery Feedback Loop
Homework
• Monitor imagery vividness (0–10 scale)
• Note behavioural responses
Session 3 — Imagery Awareness and Control Training
Goals
• Strengthen voluntary imagery generation
• Improve metacognitive observation
Exercises
• Visualise neutral objects (cup, tree, room)
• Manipulate:
o Size
o Distance
o Colour
o Motion
Therapist Coaching
Encourage slow, deliberate control.
Homework
• 10-minute daily imagery practice
• Continue monitoring hallucination episodes
Session 4 — Imagery Rescripting (Core Intervention)
Goals
• Reduce threat salience
Procedure
1. Patient recalls recent hallucination
2. Freeze scene
3. Therapist guides transformation:
o Shrink image
o Blur edges
o Change expression
o Turn figure away
o Replace scene
4. Replay new version
Processing
• Rate distress before / after
Homework
• Apply rescripting during real hallucinations
Session 5 — Competing Imagery Installation
Goals
• Develop “replacement imagery repertoire”
Techniques
• Safe-place imagery
• Positive autobiographical scenes
• Multi-sensory imagery (sound, touch)
CBS Adaptation
Encourage:
• Texture exploration
• Environmental scanning
• Lighting modification
Homework
• Practice rapid imagery switching
Session 6 — Behavioural / Perceptual Experiments
Goals
• Challenge beliefs about uncontrollability
Experiments
• Approach hallucination vs avoid
• Change gaze position
• Increase sensory input
• Perform cognitive task during episode
Record outcomes
Session 7 — Emotional Regulation Integration
Goals
• Reduce anxiety amplification
Techniques
• Slow breathing
• Attention shifting
• Cognitive distancing
• Label hallucination as imagery event
Homework
• Combine imagery + regulation techniques
Session 8 — Consolidation and Relapse Prevention
Goals
• Develop long-term coping plan
Therapist Tasks
Create:
• Early warning sign list
• Imagery response script
• Environmental strategies
• Practice schedule
Final Exercise
• Simulated hallucination rescripting rehearsal
Optional Extension Sessions
• Trauma-linked imagery processing
• Social confidence work
• Sleep regulation
• Vision rehabilitation integration
Mechanistic Targets
This protocol aims to:
• Reduce precision weighting of internally generated imagery
• Increase prefrontal inhibitory control
• Modify visual predictive templates
• Improve attentional flexibility
• Reduce fear conditioning to hallucinations
Expected Outcomes
• Reduced hallucination distress
• Increased sense of mastery
• Possible reduction in frequency/duration
• Improved functioning and sleep