The June BABCP Article of the Month is from the Cognitive Behaviour Therapist (tCBT) and is entitled “‘Knees being set on fire’: A qualitative study exploring the impact of intrusive mental imagery on chronic pain patients” by Rita DeNicola, Simon Blackwell, Edward Hirata and Jo Daniels.

Chronic pain, defined as persistent and recurrent pain lasting over three months, affects 100 million people in Europe alone (Breivik et al., 2006). The National Institute for Health and Care Excellence (2021) recommends cognitive behavioural therapy (CBT) within a collaborative care model to promote functional remission, reduce medication use, and lower healthcare utilisation (Gilliam et al., 2021).

Chronic pain often leads to psychological distress and functional disability, reducing quality of life of those affected (Dueñas et al., 2016). It also increases the risk of mental health conditions such as depression, anxiety, and post-traumatic stress disorder (McWilliams et al., 2003).

A hallmark of these disorders is intrusive mental imagery – unwanted, negative, and vivid memories that occur without deliberate or conscious effort (Brewin et al., 2010). These distressing intrusions often recall traumatic events, spontaneously triggered by both situational and internal cues (Çili & Stopa, 2015). Recognising their crucial role in psychological disorders, imagery-based interventions are now a key component of CBT interventions (Holmes et al., 2007).

Intrusive imagery may significantly impact chronic pain; yet, few studies to date have investigated this. Recent research reported rates of pain relevant imagery in chronic pain to be as high as 52%, further concluding that the role of interpretation of the imagery is pivotal to functional outcomes (Maxwell-Watts et al. 2024), consistent with the CBT literature.

In this paper, we aimed to provide deeper insights into how intrusive imagery affects the lived experience of people with chronic pain, and to seek a potential target for enhancing CBT for this group. We recruited ten individuals, conducting in-depth semi-structured interviews to investigate 1) the nature and characteristics of intrusive imagery, 2) the personal meaning attributed to pain and pain-related images, and 3) the perceived impact on emotions, cognition, and behaviours.

Through inductive thematic analysis (Braun & Clarke, 2006), we identified three key themes: descriptions of participants’ mental imagery; metaphors for pain; and the role of intrusive images in experiencing pain. Mental imagery was found to be intrusive, uncontrollable, clear, and vivid. We found that the imagery not only helps in better conceptualising the experience of pain but serves as a powerful communication tool to enhance mutual understanding. Participants also reported diminished sense of control and autonomy when reflecting on their pain, with imagery representing loss of control and identity. These distressing images often worsened the experience of pain, acting as an ‘emotional amplifier’ (Holmes et al., 2008) and leading to avoidance behaviours. These themes and concepts align with the cognitive behavioural approach to pain.

Whilst further work is needed in the area, this research contributes to our emerging understanding of mental imagery and its relevance in chronic pain. These results provide preliminary evidence suggesting that for those who experience pain-related imagery, targeting these images and the meaning of the content is likely to enhance understanding and treatment of chronic pain; imagery-based interventions are known to facilitate cognitive restructuring and promote affective and behavioural changes (Blackwell, 2019), the cornerstones of a gold standard approach to chronic pain, CBT.

References

Blackwell, S. E. (2019). Mental imagery: From basic research to clinical practice. Journal of Psychotherapy Integration, 29(3), 235-247. https://doi.org/10.1037/int0000108

Braun, V., & Clarke, V. (2006). Successful qualitative research: A practical guide for beginners (1st ed). Sage.

Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain (London, England), 10(4), 287-333. https://doi.org/10.1016/j.ejpain.2005.06.009

Çili, S., & Stopa, L. (2015). Intrusive Mental Imagery in Psychological Disorders: Is the Self the Key to Understanding Maintenance?. Frontiers in psychiatry, 6, 103. https://doi.org/10.3389/fpsyt.2015.00103

Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., & Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of pain research, 9, 457-467. https://doi.org/10.2147/JPR.S105892

Gilliam, W. P., Schumann, M. E., Cunningham, J. L., Evans, M. M., Luedtke, C. A., Morrison, E. J., Sperry, J. A., & Vowles, K. E. (2021). Pain catastrophizing as a treatment process variable in cognitive behavioral therapy for adults with chronic pain. European Journal of Pain, 25(2), 339-347. https://doi.org/10.1002/ejp.1671

Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive behaviour therapy: images, treatment techniques and outcomes. Journal of behavior therapy and experimental psychiatry, 38(4), 297–305. https://doi.org/10.1016/j.jbtep.2007.10.007  

Holmes, E. A., Geddes, J. R., Colom, F., & Goodwin, G. M. (2008). Mental imagery as an emotional amplifier: application to bipolar disorder. Behaviour research and therapy, 46(12), 1251-1258. https://doi.org/10.1016/j.brat.2008.09.005

Maxwell-Watts, J., Blackwell, S. E., & Daniels, J. (2024). Intrusive Mental Imagery in Chronic Pain: Prevalence and Associations with Common Comorbidities. Cognitive Therapy and Research. Advance online publication. https://doi.org/10.1007/s10608-024-10480-2

National Institute for Health and Care Excellence. (2021, April 07). Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE.  https://www.nice.org.uk/guidance/ng193

From Hayley Keeble, Associate Editor of tCBT: Why I chose this article

This article gives a helpful insight into individuals’ experiences of mental imagery related to their chronic pain, and helps readers to consider how imagery may affect individuals’ difficulties in living well with chronic pain. Given the significant number of people living with chronic pain, this article gives thought to important areas for future research as well as how CBT therapists may consider adapting their practice to include working with imagery to improve the quality of life for those living with chronic pain.

Author Bios:

Rita De Nicola, a postgraduate in Applied Clinical Psychology from the University of Bath (2022), engaged in a competitive Research Apprenticeship Scheme during her MSc studies. This opportunity led to her securing a position as a research assistant in the Psychologically Informed Policy and Practice (PiPP) project in January 2023, supervised by Dr Jo Daniels. Clinically, Rita is committed to applying her psychological expertise by providing emotional support for adults with learning disabilities, autism, and complex needs.

Simon Blackwell is a postdoctoral researcher and clinical psychologist based at the University of Göttingen, Germany. He has a broad interest in the process of developing and testing evidence-based psychological interventions, and how we can do this more efficiently. His research has a particular focus on positive mental imagery and its potential use within psychological interventions. Simon is also co-chair of the BABCP Scientific Committee.

Edward Hirata is an Assistant Psychologist under the Adult Psychology Service in Powys, NHS Wales. Edward was previously a postgraduate in Health Psychology, having completed both his dissertation and MSc placement under the supervision of Dr Jo Daniels.

Jo Daniels is a Senior Lecturer at the University of Bath and a practicing Clinical Psychologist, currently working with the Department for Health and Social Care on a UKRI/ESRC-funded Policy Fellowship. Her research and clinical interests focus on psychological distress and psychophysiology within medical contexts, particularly the role of pain and health related anxiety, and the role of CBT in improving quality of life and functioning in people with medical problems. Jo is also the co-chair of the BABCP Scientific Committee.