When and for whom do psychodynamic therapists use guided imagery? Explicating practitioners’ tacit knowledge

Guided imagery psychotherapy (GIP) is an established therapeutic method using creative mental imagery within a psychodynamic frame of reference. Although there is evidence for the method’s general effectiveness, it is yet unclear under which conditions and for which patients it should be used. The aim of this study was therefore to empirically identify indication criteria for the use of guided affective imagery (GAI) as part of psychodynamic therapies. We conducted semi-structured interviews with N=15 psychodynamic therapists also qualified as GAI training therapists. We asked them to recollect cases in which they had decided either for or against the use of imagery. The therapists described a complex interplay of different factors. Using grounded theory coding supplemented by elements of Consensual Qualitative Research we reconstructed from their accounts a sequential model of their indicative decisions. First, there is a consideration of clear contraindications related to reality testing and destructiveness. Second, there are aspects requiring a modified application of GAI such as emotional instability and post-traumatic stress disorder symptoms. In a final step, there are a number of characteristics of the patient, the therapist, the therapeutic relationship, the patients’ initial imagery and different therapeutic goals and foci which are weighed relatively to each other in order for therapists to reach an indication decision. We end by discussing ways in which the indicative decision model may be used to improve GAI training as well as the method’s differential efficacy and effectiveness.