Mental Imagery in the Science and Practice of Cognitive Behaviour Therapy: Past, Present, and Future Perspectives

The effect of positive mental imagery versus positive verbal thoughts on anhedonia

Anhedonia, the loss of interest in and pleasure from previously enjoyable activities is a core symptom of depression and presents a major challenge to treatments. Interventions involving positive mental imagery generation have been suggested to reduce anhedonia. However, it is not clear whether the imagery component of such interventions is crucial for these effects. The current study aimed to test this by contrasting repeated generation of positive mental imagery versus positive verbal thoughts. Over a one-week period, 53 mildly anhedonic adults completed five sessions of a computerized training program involving the generation of either positive images or positive sentences. Compared to participants who generated sentences, participants who generated imagery showed greater improvements from pre- to post-training on an individualized multi-facetted measure of anhedonia (the Dimensional Anhedonia Rating Scale), but not on standardized measures of anticipated pleasure (the Snaith-Hamilton Pleasure Scale), depression symptoms, or positive affect. The present study supports the proposal that positive imagery could provide a route to improve anhedonia, with generation of imagery in particular (as opposed to positive thoughts in general) as an important driving mechanism for these effects. This has theoretical and clinical implications for understanding the role of imagery in anhedonia and its treatment.

Adding brief content-related information to sensitive-content screens does not exacerbate screen- or image-related distress

Content descriptions presented on sensitive-content screens reduce how often people view negative images. But does this reduction in exposure come at an emotional cost? Across two experiments, we investigated this possibility. In Experiment 1, we compared participants' change in state anxiety when exposed to sensitive-content screens with and without brief and detailed content descriptions. State anxiety was similar for participants who saw screens with and without brief content descriptions, but we found larger increases in state anxiety for detailed content descriptions. Therefore, detailed content descriptions negatively impact how people feel when they view sensitive-content screens. In Experiment 2, we presented participants with a single sensitive-content screen, either with or without a brief content description, and gave them the opportunity to uncover it. Participants who uncovered the screen viewed the negative image and then rated their distress. Most participants uncovered the screen and, irrespective of condition, reported similar image-related distress. Taken together, brief descriptions do not negatively impact how people feel when they view sensitive-content screens or the forewarned content. Therefore, brief content descriptions do not create an emotional cost. Social media platforms should move beyond merely warning about upcoming content and provide brief content descriptions indicating what the content depicts.

Effects of instructed visual imagining on emergent conditional discriminations

Visual imagining has been proposed to play a role in the emergence of derived stimulus relations. We examined whether test-relevant visual imagining during baseline training would, accordingly, facilitate emergent visual-visual conditional discriminations at test. Adult participants (n = 75) were randomly assigned to three groups. Baseline tact training established conditional discriminations among sets of image samples and textual comparisons (AC/BD), and baseline intraverbal training established conditional discriminations among pairs of textual stimuli (CD). Two groups received tact before intraverbal training, and one group received the reverse sequence. During intraverbal training, one of the former groups was instructed to visualize the images that went with the textual stimuli. These instructions did not affect participants' retrospective self-reports of test-relevant visual imagining during training. Nevertheless, they produced a large effect on correct responding in an image-matching test (AB/BA) that followed intraverbal training. This effect was independent of baseline retention.

Attenuating conditioned fear using imagery-based interventions: An overview

A growing literature has sought to include mental imagery in fear conditioning studies. Imaginal extinction and imagery rescripting are mental imagery-based interventions that reduce conditioned fear. In the current study, we reviewed the recent findings on the efficacy of imaginal extinction and imagery rescripting as interventions to attenuate conditioned fear responses among healthy individuals. In accordance with the PRISMA guidelines, we conducted a literature search in four databases, PubMed, Scopus, Science Direct, and Web of Science to find published original empirical articles involving imagery-based interventions using a fear conditioning paradigm. The inclusion criteria were (i) use of an imagery-based intervention (either imaginal extinction or imagery rescripting), and (ii) use of a differential fear conditioning paradigm. 13 original articles reporting 15 experimental studies were included in the review. The review revealed that imagery-based interventions are effective in reducing conditioned fear. Although studies have shown that imaginal extinction and standard extinction have comparable effects in fear extinction, many studies have not been conducted to confirm the findings, or explore the underlying mechanisms. We also found the need for a standardized intervention protocol to enhance experimental control in intervention-based fear conditioning studies.

Project Soothe: A pilot study evaluating the mood effects of soothing images collected using a citizen science approach

Background

Mentally-generated soothing imagery is a therapeutic technique to support mental wellbeing, but some individuals may require support using externally presented stimuli. Project Soothe was launched to collect soothing images using a citizen science approach. This online pilot study evaluated the first 575 soothing images collected, examining: 1) if the images were perceived to be soothing; 2) if viewing the images had a positive impact on mood; and 3) if mood effects were influenced by individual differences in age, gender and depressive symptoms.

Methods

We recruited 1152 participants (13 - 79 years, M = 35.62, SD = 14.60; 77% female). Participants were randomly allocated to one of 23 sets, each containing 25 images (n = 50 per set) and asked to rate their emotional response (soothed, excited, and anxious) to each image. Participants also reported their mood states pre- and post-viewing the images (using the International Positive and Negative Affect Schedule - Short Form).

Results

Project Soothe images were rated to be significantly more soothing than anxiety- or excitement-inducing. Further, viewing 25 images was significantly associated with an increase in positive affect and decrease in negative affect. These effects were associated with age and depressive symptoms, with older individuals and those with lower depressive symptoms being associated with more positive changes in mood.

Conclusions

This pilot study provides preliminary evidence that these soothing images can promote positive mood changes. Further work can now replicate these findings in larger-scale studies with comparison groups and extended outcome variables. The images and associated data have been made available in a data repository (OSF) as a free resource for researchers and practitioners. It is hoped that these images can be developed into useful therapeutic resources.

Positive mental imagery and mental health amongst university students in Pakistan

Mental health problems amongst university students pose a major public health challenge, and this is particularly the case in Pakistan. Alongside broader societal and cultural pressures, cognitive factors likely also play a role in the development of and resilience to mental health problems and may provide a feasible target for interventions. The current study built on previous research in primarily European samples investigating the relationship between one cognitive factor, positive future-oriented mental imagery, and mental health, extending this to a sample of university students in Pakistan (N = 1838). In a cross-sectional design, higher vividness of positive future-oriented mental imagery was associated with lower levels of depressive symptoms and higher levels of positive mental health amongst participants completing questionnaire measures on paper (N = 1430) or online (N = 408). In the sample completing the measures on paper, these relationships remained statistically significant even when controlling for socio-demographic and mental health-related variables. The results provide a foundation for further investigating positive mental imagery as a potential mechanism of mental health and intervention target amongst university students in Pakistan.

The validity of a therapeutic invigoration task in avolitional schizophrenia outpatients

BACKGROUND AND OBJECTIVES

Avolition is associated with much morbidity and functional impairment in schizophrenia patients. Vigor may be taken as, in part, the inverse of avolition, but it has not been investigated as a therapeutic pursuit before. To this end, a therapeutic invigoration task was developed drawing on cognitive-behavioral and guided imagery therapies. This study investigated the validity and reliability of a therapeutic invigoration task in avolitional residual phase schizophrenia outpatients.

METHODS

In a proof-of-concept quasi-experimental one-group sequentially repeated pretest/posttest study design, patients (n = 76) participated in a structured invigoration task that was repeated after 1 month (n = 70).

RESULTS

Patients' vigor during the preceding 7 days measured on the Vigor Assessment Scale increased highly significantly in anticipation of the subsequent 7 days on both occasions with respectively very large (Cohen's δ with Hedges' correction [δ] = 1.46) and large (δ = 1.04) effect sizes. The anticipated vigor after the first occasion was partially consummated during the subsequent month in that vigor during the 7 days preceding the second occasion was lower than participants had anticipated but still significantly higher than at baseline (p < 0.001; δ = 0.70). Repeating the task a month later, together with homework, had a cumulative effect as indicated by a very large effect size (δ = 1.61).

CONCLUSION

Results suggest that the invigoration task did what it was supposed do, and did so consistently, in patients with avolitional residual schizophrenia. These results warrant a subsequent randomized controlled trial to establish the efficacy of the invigoration task.

Can mental imagery boost the effect of the positive cognitive bias modification of interpretation (CBM-I) on interpretation bias and memory bias?

BACKGROUND AND OBJECTIVES

Cognitive bias modification of interpretation (CBM-I) has been widely used and yielded mixed results. This experiment explored the unique role of mental imagery in positive CBM-I.

METHODS

60 participants (M = 23.13, SD = 1.04) were randomly assigned to a imagery-based positive CBM-I group (imagery group) and a conventional verbal-based positive CBM-I group (control group). The imagery group received additional practice in generating mental imagery and were instructed to fully focus on the imagery during the formal training. The dependent variables included interpretation bias (probe latencies and similarity ratings for recognition task), memory bias, and intrusive memory.

RESULTS

(1) For the positive probe scenario, the reaction time of the two groups was shorter in the posterior five blocks than the anterior five blocks. However, the difference in latency between pre- and post- training for the imagery group was larger than that of the control group; (2) For the recognition task, the positive target statement score was significantly higher, while the negative one was significantly lower for the imagery group than that of the control group (3) The imagery group (vs. control); showed more beneficial effects on memory bias.

LIMITATIONS

The limitations consisted of the difference in time of the manipulation between the two groups, the richness of the imagery operationalization, generalizability, and the lack of pre-manipulation of interpretation bias assessments.

CONCLUSIONS

The imagery-based CBM-I led to more positive interpretation biases, less negative interpretations, and more positive memory biases, indicating that mental imagery can boost the effect of the positive CBM-I.

Eye movement desensitization and reprocessing (EMDR) therapy or supportive counseling prior to exposure therapy in patients with panic disorder: study protocol for a multicenter randomized controlled trial (IMPROVE)

BACKGROUND

Exposure-based therapy is the treatment of choice for anxiety disorders, but many patients do not benefit sufficiently from it. Distressing images of threat related to the future or past may maintain the anxiety symptomatology or impede exposure therapy. An intervention that targets threat-related imagery is eye movement desensitization and reprocessing (EMDR) therapy. The main goal of this multicenter randomized controlled trial is to investigate whether EMDR therapy plus exposure therapy, relative to supportive counseling plus exposure therapy, improves treatment efficacy, tolerability, and adherence in patients with panic disorder. In addition, we will examine potential predictors of optimal treatment allocation, mechanisms of change as well as the long term effects of treatment. Finally, we will assess cost-effectiveness.

METHODS

A multicenter randomized controlled trial mixed design will be conducted. Participants will be 50 patients, aged ≥ 18, diagnosed with a panic disorder. They will be randomly assigned to one of two conditions: EMDR therapy (i.e., flashforward strategy) or supportive counseling (each consisting of four weekly sessions of 90 min each) prior to exposure therapy (consisting of eight weekly sessions of 90 min each). Assessments will be made pre-treatment (T1), between-treatments (T2), post-treatment (T3), one month post-treatment (FU1) and six months post-treatment (FU2) by an assessor blind to treatment condition. The primary outcome measure is severity of panic-related symptoms. Secondary outcome measures are: tolerability of exposure therapy (initial avoidance, willingness to start exposure therapy, considered drop-out; no-show and drop-out), related symptomatology (generalized anxiety, depression), and functional impairment.

DISCUSSION

The primary goals of this research are to compare the efficacy, tolerability, and adherence of EMDR therapy plus exposure therapy and supportive counseling plus exposure therapy and to identify predictors, moderators, and mediators for treatment success. This multi-center research aims to make a significant contribution to our understanding as to how treatment for patients with anxiety disorders can be optimized, and elucidate who can benefit most from this novel approach.

TRIAL REGISTRATION

ISRCTN-ISRCTN29668369: Improving anxiety treatment by modifying emotional memories before real-life exposure. Registered 27 June 2022-retrospectively registered. ISRCTN-ISRCTN29668369.

Simulating the best and worst of times: the powers and perils of emotional simulation

We are remarkably capable of simulating events that we have never experienced. These simulated events often paint an emotional picture to behold, such as the best and worst possible outcomes that we might face. This review synthesises dispersed literature exploring the role of emotion in simulation. Drawing from work that suggests that simulations can influence our preferences, decision-making, and prosociality, we argue for a critical role of emotion in informing the consequences of simulation. We further unpack burgeoning evidence suggesting that the effects of emotional simulation transcend the laboratory. We propose avenues by which emotional simulation may be harnessed for both personal and collective good in applied contexts. We conclude by offering important future directions.

Imagine How Good That Feels: The Impact of Anticipated Positive Emotions on Motivation for Reward Activities

Background

Disease burden and unsatisfactory treatment outcomes call for innovation in treatments of depression. Prospective mental imagery, i.e. future-directed voluntary imagery-based thought, about potentially-rewarding activities may offer a mechanistically-informed intervention that targets deficits in reward processing, a core clinical feature of depression. We propose that the previously described impact of prospective mental imagery on motivation for everyday activities is facilitated by affective forecasting, i.e. predictions about an individual’s emotional response to the imagined activities.

Methods

Participants (N = 120) self-nominated six activities to engage in over the following week and were randomized to either: (1) an affective forecasting imagery condition (n = 40); (2) a neutral process imagery condition (n = 40); or (3) a no-imagery control condition (n = 40).

Results

As predicted, increases in motivation ratings from pre to post experimental manipulation were significantly higher following affective forecasting imagery compared to both neutral process imagery (d = 0.62) and no-imagery (d = 0.91). Contrary to predictions, the number of activities participants engaged in did not differ between conditions.

Conclusions

Results provide initial evidence for a potentially important role of affective forecasting in prospective mental imagery. We discuss how these findings can inform future research aiming to harness prospective mental imagery’s potential for clinical applications.

Cognitive Behavior Therapy at the Crossroads

The early development of cognitive behavior therapy (CBT) can be characterized by the coming together of behavioral and cognitive traditions. However, the past decades have arguably seen more divergences than convergences within the field. The 9th World Congress of Behavioural and Cognitive Therapies was held in Berlin in July 2019 with the congress theme "CBT at the Crossroads." This title reflected in part the coming together of people from all over the world, but also the fact that recent developments raise important questions about the future of CBT, including whether we can in fact treat it as a unified field. In this paper, we briefly trace the history of CBT, then introduce a special issue featuring a series of articles exploring different aspects of the past, present, and future of CBT. Finally, we reflect on the possible routes ahead.