Novel therapy for psychosis tackles disturbing mental imagery

A pioneering therapy targeting distressing and disturbing mental images for people with psychosis could lead to a transformative intervention for a condition estimated to cost England almost £12 billion a year.

As many as 74 per cent of people with psychosis, a condition which causes people to hear voices, unfounded fears that others mean them harm, also see intrusive images in their mind's eye. These images can be the result of trauma, anxiety, fear of anticipated future events, and many other factors.

A recent survey of over 10,000 UK adults found that imagery was the third most strongly linked factor with mistrust and paranoia. These vivid images can often be multi-sensory and associated with distressing voices, as well as unfounded beliefs that others mean them harm.

Existing psychological therapies, such as Cognitive Behavioural Therapy (CBT), have demonstrated a robust but small effect in the treatment of psychotic experiences, such as hallucinations and delusions. Similarly, while antipsychotic medication can alleviate some psychosis symptoms, around 74 per cent of patients discontinue or switch medications within 18 months. This is largely due to debilitating side effects or a lack of reported benefit, highlighting a critical need for more effective therapies.

The University of Sheffield research team believes imagery-focused therapy could be a valuable intervention to complement existing treatments.

iMAPS therapy aims to directly address such 'mind's eye' imagery by helping the patient to understand, make sense of, and change the images, replacing them with more positive ones. It also targets negative beliefs about self and others (schemas) using imagery techniques. The National Institute for Health and Care Research (NIHR)-funded trial recruited 45 patients with psychosis who were seeking help with hallucinations and delusions, and had reported distressing and intrusive mental imagery linked to their symptoms.

The largest feasibility trial to date of imagery-focused therapy for people with psychosis with 45 patients, detailed in a University of Sheffield study published recently in the Schizophrenia Bulletin journal, demonstrated iMAPS safety and yielded promising results, leading to hopes for a multi-centre clinical trial to test the treatment's clinical and cost-effectiveness.

Imagine someone experiencing psychosis, who has the terrifying belief that their home will be invaded and they will be attacked. They might then vividly picture an intruder breaking in, triggering intense fear and worsening their distress."

Dr Christopher Taylor, Senior Lecturer and NIHR Fellow, School of Psychology, University of Sheffield

Dr. Taylor is also a Consultant Clinical Psychologist, Pennine Care NHS Foundation Trust.

He added, "This intrusive image can amplify their suspicion and paranoia, making them feel even more vulnerable. Our goal is to help them understand and eventually gain control over these powerful images. When you try to suppress distressing mental images, they often return more intensely - like a New Year's resolution to avoid chocolate biscuits leading to stronger cravings.

"In therapy, we address this by helping individuals understand these shared experiences. We gently introduce imagery work with 'safe place' exercises to foster feelings of safety, then practice altering the image's size, shape, and texture to build a sense of control. We also use imagery rescripting, a technique borrowed from trauma therapy, where we guide individuals to imagine a new, positive ending to a past negative event, engaging all of their senses. While we can't change the past, we can empower individuals to re-script their experiences and change the meaning."

In the trial, the talking therapy was administered over 12 weekly sessions; each patient had at least one distressing image linked with a hallucination or delusion. These might also include purely imagined images alongside those from a person's past or their future worries.

Thom Brandwood-Spencer, 28, a participant in the first iMAPS study, first began experiencing distressing symptoms when he was around nine years old.

"It initially manifested as a general fear, where I'd be walking home from school and jumping from lamp post to lamp post to avoid this abstract fear. When I was 12 or 13, I started hearing unsettling voices, and a year or so later, I began seeing things, which developed into sinister, featureless figures making strange noises.

"It was very distressing and difficult to understand. I'd often feel like I was in danger, as if the images and sounds were portents of things to come."

Thom was later referred to local mental health services and was ultimately diagnosed with paranoid schizophrenia with episodes of psychosis. Through support, his condition became easier to manage, and he went on to study computer science at university - but his visions continued to fill him with dread and paranoia, and eventually forced him to drop out.

It was at that point, while under the care of a first episode psychosis team, Thom became involved with iMAPS, and over eight weekly sessions, his therapist helped him to understand and change the narrative of the images he experiences.

"At that point, the condition was completely disrupting my life, and the prescribed medication I was taking wasn't working," he said.

"One of the most difficult aspects was the powerlessness - and the idea that what was happening to me was permanent and inescapable. iMAPS helped me to address this by changing this narrative of powerlessness and understanding that my life and my experiences are not pre-ordained. Therapy enabled me to shift my concentration away from what I was seeing in my mind and separate the images from those menacing feelings of threat.

"I came to see that the threat wasn't from the figures, but from my own feelings, and grasping that made a significant difference. We also used a technique to imagine putting the featureless figures in a suit of armour or a diving suit, and it helped me feel like they couldn't get me anymore."

Thom went on to successfully complete an undergraduate degree in Psychology and then continued on to pursue a Master's in the same field. He now works in a role supporting others with mental health problems, and even discussed his experiences with iMAPS at an international conference.

"As well as the benefits of the iMAPS therapy itself, I've been able to act as a consultant on the latest study and an advocate to help others going through similar experiences. I'm now able to give people what I needed when it all began.

"One of the most important messages I'd like to get across to others is that whatever you are going through, it doesn't have to be forever. It can change, and there is hope."

Dr Taylor from the University of Sheffield added: "We're greatly encouraged by feedback from patients like Thom, who serves as an excellent advocate not only for iMAPS but also for recovery and supporting others with similar experiences.

"A full clinical trial is the necessary next step to assess iMAPS's broader clinical and cost effectiveness, paving the way for it to potentially complement the offer of existing NICE recommended psychosis treatments."