iMAgery focused psychological therapy for persecutory delusions in PSychosis (iMAPS): a multiple baseline experimental case series

Trauma therapies for psychosis: A state-of-the-art review

BACKGROUND

Traumatic events, particularly childhood interpersonal victimisation, have been found to play a causal role in the occurrence of psychosis and shape the phenomenology of psychotic experiences. Higher rates of post-traumatic stress disorder (PTSD) and other trauma-related mental health problems are also found in people with psychosis diagnoses compared to the general population. It is, therefore, imperative that therapists are willing and able to address trauma and its consequences when supporting recovery from distressing psychosis.

METHOD

This paper will support this need by providing a state-of-the-art overview of the safety, acceptability and effects of trauma therapies for psychosis.

RESULTS

We will first introduce how seminal cognitive-behavioural models of psychosis shed light on the mechanisms by which trauma may give rise to psychotic experiences, including a putative role for trauma-related emotions, beliefs and episodic memories. The initial application of prolonged exposure and eye movement and desensitation and reprocessing therapy (EMDR) for treating PTSD in psychosis will be described, followed by consideration of integrative approaches. These integrative approaches aim to address the impact of trauma on both post-traumatic stress symptoms and trauma-related psychosis. Integrative approaches include EMDR for psychosis (EMDRp) and trauma-focused Cognitive-Behavioural Therapy for psychosis (tf-CBTp). Finally, emerging dialogic approaches for targeting trauma-related voice-hearing will be considered, demonstrating the potential value of adopting co-produced (Talking with Voices) and digitally augmented (AVATAR) therapies.

CONCLUSION

We will conclude by reflecting on current issues in the area, and implications for research and clinical practice.

Emotional and non-emotional mental imagery and auditory verbal hallucinations (hearing voices): A systematic review of imagery assessment tools

It is unknown to what extent mental imagery and auditory verbal hallucinations (AVHs) are related. Trials evaluating this issue used both emotional and non-emotional mental imagery tools, thereby complicating outcomes comparisons. Therefore, the present study aimed to systematically review the literature on mental imagery in individuals with AVHs to (1) inventory imagery assessment tools used in this population, (2) to collect information on the relation between emotional and non-emotional mental imagery in all sensory domains and AVHs and (3) to integrate the outcomes of this systematic review in a model of different mental imagery domains and related assessment tools. We conducted a systematic literature search in the PubMed Database. After full-text screening, 17 papers were included. Findings showed that a variety of assessment methods have been used to assess various aspects of mental imagery in people with AVHs, suggesting that there is a lack of agreed theoretical conceptualization of mental imagery and AVHs. In addition, the studies confirmed as was expected that non-emotional mental imagery seemed unrelated to AVHs whereas emotional mental imagery was related to AVHs. Lastly, we proposed a model of mental imagery domains and corresponding assessment methods distinguishing between emotional and non-emotional mental imagery.

Assessing the delivering of iMAgery-focused therapy for PSychosis (iMAPS) via telehealth

OBJECTIVES

To examine the feasibility and acceptability of a novel telehealth (video-conferencing software and telephone calls) imagery-based therapeutic intervention for people experiencing persecutory delusions. Utilising a multiple baseline case series design and exploring imagery-focused therapy for psychosis (iMAPS).

DESIGN

A non-concurrent A-B multiple baseline design was used.

METHODS

Participants experiencing persecutory delusions and self-reporting a psychosis or schizophrenia-spectrum diagnosis were recruited through online adverts. On completion of assessments, participants were randomly assigned to multiple baseline assessments, of between three and five sessions. Six therapy sessions followed, consisting of imagery formulation, safe-place imagery creation, compassionate imagery, imagery manipulation and rescripting. Participants completed pre- and post-measures and sessional measures via an online survey software or in semi-structured interviews. Two weeks post-intervention, a final measure was completed exploring any potential adverse effects of psychotherapy.

RESULTS

Five female participants completed all baseline and therapeutic sessions, suggesting the therapy was and mode of delivery was feasible and acceptable. Results indicate strong effect sizes across PANSS positive subscale and mood, as well as participants reporting a clinically significant change in at least one measure, for example, PSYRATS. All participants reported a reduction in the realness and compelling nature of distressing imagery.

CONCLUSIONS

Results suggest delivering a telehealth imagery-focused therapy is acceptable and feasibly delivered via telehealth. A control group and blinding of assessments would strengthen the methodological limitations present.

Enhancing future-directed thinking in people with first-episode psychosis using a guided imagery intervention

BACKGROUND AND OBJECTIVES

Future-directed thinking (FDT) is associated with goal directed behaviour and may differ in people with psychosis compared to non-clinical controls. This study investigated whether guided imagery could enhance positive FDT in people with psychosis.

METHOD

Participants were 44 people experiencing a first episode of psychosis. They were assessed for negative and positive symptoms, FDT on the Future Thinking Task (FTT), depression, anxiety, autobiographical memory, verbal fluency and spontaneous use of imagery. They were randomised to either a positive or neutral imagery condition, before being retested on the FTT. Outcomes on the FTT were number of events generated, anticipated likelihood, anticipated affect and a composite score.

RESULTS

Participants in the positive imagery condition generated significantly more positive events on the FTT compared with those in the neutral (F (1, 42) = 19.916, p < .001, η_p² = 0.322). In both imagery conditions, likelihood ratings of positive events increased post-intervention. Positive and negative events were both perceived as less likely to occur the further into the future they were, and positive events were anticipated to be more positive and negative events more negative, the further into the future they were.

LIMITATIONS

The participants in this study experienced relatively low levels of symptoms, and therefore caution should be used when applying these results to people with greater symptomatology.

CONCLUSIONS

Positive guided imagery shows promise for enhancing positive FDT in people with first-episode psychosis. This intervention may offer a simple and effective method of enhancing engagement with the future, with potential implications for goal-directed behaviour.

A randomised multiple baseline case series of a novel imagery rescripting protocol for intrusive trauma memories in people with psychosis

BACKGROUND AND OBJECTIVES

There has been limited investigation of therapies targeting trauma-related psychological mechanisms hypothesised to play a role in post-traumatic and psychosis symptoms. Imagery rescripting (ImRs) is a therapeutic technique which involves transforming images, such as episodic memories, to modify associated distressing beliefs. This study is the first ImRs study for psychosis to incorporate experimental controls. We used a novel ImRs protocol, targeting present-focused, self-referential distressing meanings associated with intrusive trauma memories. A multiple baseline case series design investigated whether the protocol was feasible, safe, acceptable and effective.

METHODS

12 participants with a psychosis diagnosis and intrusive trauma memories were assessed and randomised to a monitoring period (one, two or three weeks), followed by three ImRs sessions (over three weeks), a further two-week monitoring period with a post-therapy assessment a week after completing therapy. Memory phenomenology was assessed daily during monitoring. Post-traumatic stress symptoms and wellbeing were assessed pre and post therapy.

RESULTS

ImRs was feasible, safe and rated as highly acceptable. No participants dropped-out of the brief, targeted intervention. There were moderate effects on the frequency, distress, controllability and appraisals of trauma memories. Notably, ten participants showed reliable change, and seven clinically significant change, in post-traumatic stress symptoms.

LIMITATIONS

Assessments were not blinded and impact on psychosis was not examined.

CONCLUSIONS

The study indicates that a brief, novel ImRs protocol targeting present-focused, self-referential meanings is a promising intervention for intrusive trauma memories. Future research should investigate its integration into trauma-focused therapy for psychosis and impact on psychosis severity.

A compassionate imagery intervention for patients with persecutory delusions

BACKGROUND

Negative beliefs about the self, including low self-compassion, have been identified as a putative causal factor in the occurrence of paranoia. Therefore, improving self-compassion may be one route to reduce paranoia.

AIMS

To assess the feasibility, acceptability, and potential clinical effects of a brief compassionate imagery intervention for patients with persecutory delusions.

METHOD

Twelve patients with persecutory delusions received an individual four-session compassionate imagery intervention. Assessments of self-concept and paranoia were completed before treatment, immediately after treatment, and at 1-month follow-up. A qualitative study exploring participants' experiences of the treatment was also completed.

RESULTS

Twelve out of 14 eligible patients referred to the study agreed to take part. All participants completed all therapy sessions and assessments. Post-treatment, there were improvements in self-compassion (change score -0.64, 95% CI -1.04, -0.24, d = -1.78), negative beliefs about the self (change score 2.42, 95% CI -0.37, 5.20, d = 0.51), and paranoia (change score 10.08, 95% CI 3.47, 16.69, d = 0.61). There were no serious adverse events. Three themes emerged from the qualitative analysis: 'effortful learning', 'seeing change' and 'taking it forward'. Participants described a process of active and effortful engagement in therapy which was rewarded with positive changes, including feeling calmer, gaining clarity, and developing acceptance.

CONCLUSION

This uncontrolled feasibility study indicates that a brief compassionate imagery intervention for patients with persecutory delusions is feasible, acceptable, and may lead to clinical benefits.

Delivering Imagery Rescripting via Telehealth: Clinical Concerns, Benefits, and Recommendations

PURPOSE OF THE REVIEW

Delivery of psychological therapies via telehealth has increased with the emergence of the COVID-19 pandemic. Therapists may be hesitant in moving to telehealth when delivering therapies targeting memories of traumatic experiences. This paper collates the clinical experiences of clinicians and clients who have delivered or received imagery rescripting, respectively, via telehealth across a range of clinical presentations, and describes key clinical considerations and recommendations.

RECENT FINDINGS

It is important to consider perceived and real safety; practical and technological issues; therapeutic alliance; depth of emotional processing; and dissociation. There was support for the delivery of imagery rescripting via telehealth being no less effective than face-to-face delivery; however, telehealth delivery was not a viable option for many clients during COVID-19 lockdowns who were living in high density housing, old houses with thin walls, or with some complex disorders.