A new therapy reshapes the images that fuel psychosis

Summary: A new imagery-focused therapy called iMAPS may help people with psychosis control disturbing mental images that fuel paranoia, fear and hallucinations. In a 45-participant feasibility trial, the approach showed strong patient engagement and significant reductions in distress by teaching people to understand, transform, and rewrite intrusive images.

Unlike standard treatments, which often have limited impact or significant side effects, iMAPS directly targets mental images that generate distrust and threatening beliefs. Early results suggest the therapy could become a powerful complement to existing treatments for psychosis, and the next step is to conduct a larger multi-site trial.

Key facts

Images as a driver: Up to 74% of people with psychosis experience intrusive mental images that intensify paranoia and hallucinations. Targeted Intervention: iMAPS teaches patients to reshape frightening images, changing perceptions of threat and helplessness. Promising trial: Largest feasibility study showed safety, strong patient engagement, and significant symptom relief.

Source: University of Sheffield

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.

Up to 74 percent of people with psychosis, a condition that causes people to hear voices, unfounded fears that others want to harm them, also see intrusive images in their minds. These images can be the result of trauma, anxiety, fear of anticipated future events, and many other factors.

A recent survey of more than 10,000 UK adults found that images were the third most strongly linked factor to distrust and paranoia. These vivid images can often be multisensory and associated with distressing voices, as well as the unfounded belief that others want to harm them.

Existing psychological therapies, such as cognitive behavioral therapy (CBT), have shown a robust but small effect in treating psychotic experiences, such as hallucinations and delusions.

Similarly, while antipsychotic medications can relieve some symptoms of psychosis, about 74 percent of patients stop or change medications within 18 months. This is largely due to debilitating side effects or lack of reported benefits, highlighting the critical need for more effective therapies.

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

iMAPS therapy aims to directly address these “mind’s eye” images by helping the patient 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 images related to their symptoms.

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

Dr Christopher Taylor, Senior Lecturer and NIHR Fellow at the University of Sheffield’s School of Psychology and Consultant Clinical Psychologist at Pennine Care NHS Foundation Trust, said: “Imagine someone suffering from psychosis who has a terrifying belief that their home will be invaded and attacked. They could then vividly imagine an intruder breaking in, causing intense fear and worsening their distress.

“This intrusive image can amplify their suspicions 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 with greater intensity, like a New Year’s resolution to prevent chocolate cookies from triggering stronger cravings.

“In therapy, we address this by helping people understand these shared experiences. We gently introduce image work with ‘safe place’ exercises to foster feelings of safety, then practice altering the size, shape and texture of the image to create a sense of control.

“We also use imagery rewriting, a technique borrowed from trauma therapy, where we guide people to imagine a new, positive ending to a negative event from the past, engaging all of their senses. While we can’t change the past, we can empower people to rewrite their experiences and change meaning.”

In the trial, psychotherapy was administered over 12 weekly sessions and each patient had at least one distressing image related to a hallucination or delusion. These may also include purely imagined images along with those from a person’s past or future concerns.

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

“It initially manifested itself as a general fear, when I would walk home from school and jump from lamppost to lamppost to avoid this abstract fear. When I was 12 or 13 I started hearing disturbing voices and about a year later I started seeing things, which turned into sinister, featureless figures making strange noises.

“It was very distressing and difficult to understand. I often felt in danger, as if the sights and sounds were harbingers of things to come.”

Thom was subsequently referred to local mental health services and was eventually diagnosed with paranoid schizophrenia with episodes of psychosis. Thanks to the support, his condition became easier to manage and he began studying computer science at university, but his visions continued to fill him with fear and paranoia and eventually forced him to drop out.

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

“At the time, the condition was completely disrupting my life and the prescription medications I was taking were not working,” he said.

“One of the most difficult aspects was helplessness, and the idea that what was happening to me was permanent and inescapable. iMAPS helped me address this, changing this narrative of helplessness and understanding that my life and my experiences are not predetermined. Therapy allowed me to shift my focus away from what I was seeing in my mind and separate the images from those looming feelings of threat.

“I came to see that the threat came not from the figures, but from my own feelings, and understanding that made a significant difference. We also used a technique to imagine putting the featureless figures in armor or a diving suit, and it helped me feel like they could no longer trap me.”

Thom successfully completed a bachelor’s degree in Psychology and then continued with a master’s degree in the same field. She now works supporting other people with mental health problems and even spoke about her experiences with iMAPS at an international conference.

“In addition to the benefits of iMAPS therapy itself, I have been able to act as a consultant on the latest study and an advocate to help other people going through similar experiences. I can now give people what I needed when it all started.

“One of the most important messages I would like to convey to others is that whatever you are going through doesn’t have to last forever. It can change and there is hope.”

Dr Taylor from the University of Sheffield added: “We are very encouraged by the feedback from patients like Thom, who acts 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 the clinical and cost-effectiveness of iMAPS, paving the way for it to potentially complement the existing NICE-recommended psychosis treatment offering.”

Key questions answered:

About this psychosis research news.

Author: Amy Pullan
Source: University of Sheffield
Contact: Amy Pullan – University of Sheffield
Image: Image is credited to Neuroscience News.

Original research: Open access.
“iMAgery Targeted Therapy for Psychosis (iMAPS-2): An Evaluator-Blinded, Randomized, Controlled Clinical Trial” by Christopher Taylor et al. Schizophrenia Bulletin

Abstract

iMAgery Focused Therapy for Psychosis (iMAPS-2): an Evaluator-Blinded, Randomized, Controlled Clinical Trial

Background and hypotheses

Intrusive mental images and negative schematic beliefs have been identified as maintenance and possible causal factors of some psychotic experiences, with limited focus on existing therapies in psychosis. Our primary objective was to evaluate the feasibility and acceptability of conducting a randomized controlled trial (RCT) of a new psychological therapy for image-focused psychosis (iMAPS).

Study design

An assessor-blinded RCT (iMAPS-2). Participants seeking help; with hallucinations or delusions, who reported distressing intrusive mental images were eligible to participate. Participants were randomly assigned (2:1) to receive 12 sessions of iMAPS therapy plus standard care or treatment as usual (TAU). Evaluations were carried out at 0, 16 and 28 weeks. Primary feasibility outcomes were recruitment goal, retention at 16-week follow-up, and number of therapy sessions attended.

Study results

Trial recruitment was 100% of target (45 participants). The study had a high retention rate of 80% (36 participants) at the 16-week primary endpoint, a high rate of adherence to imagery-focused therapy (77%), and positive qualitative feedback. There were two serious adverse events in the iMAPS therapy group that were considered unrelated to treatment and none in the TAU group.

Conclusions

This is the largest trial to date of imagery-focused therapy for psychosis, showing it is safe. An adequately powered clinical and cost-effectiveness trial is warranted to provide an estimate of the effects of iMAPS therapy.