It has been found that distressing intrusive mental imagery is common, occurring in around 70% of people who live with psychosis (Morrison et al., 2002; Schulze at al., 2013). This can mean experiencing vivid, intrusive mental images related to peoples’ experiences, such as flashbacks or ‘pictures in their mind’s eye’. These aren’t just thoughts; they can be deeply distressing and feel incredibly real, triggering strong emotional and even physical reactions, much like a memory of a traumatic event might feel. Many individuals with psychosis have experienced stressful or traumatic life events, which is a topic we have covered in some depth in the past here, and such events have been associated with intrusive imagery and negative beliefs about the self and others.
Despite their frequency and the distress associated, intrusive mental imagery is not routinely addressed in psychological interventions, such as cognitive behaviour therapy for psychosis (CBTp) and there have been a limited number of trials of interventions targeting intrusive imagery in psychosis (Cairns et al., 2024).
iMAgery focused therapy for Psychosis (iMAPS) is a psychological therapy that targets mental imagery in psychosis and employs a variety of techniques including imagery manipulation, imagery rescripting (changing the associated meaning and narrative content) and positive imagery (Taylor et al.,2019).
This study, the largest trial to date of imagery focused therapy for psychosis, sought to investigate whether the iMAPS intervention would reduce imagery related distress in psychosis and improve other outcomes such as symptoms of psychosis, mood, and well-being. As a feasibility study it also sought to assess whether it would be feasible and acceptable to test this new approach on a larger scale.
Methods
This study employed a randomised controlled trial design where they allocated clients either to their usual treatment plus the imagery intervention or just their usual treatment at a two to one ratio. The assessors were blind to the treatment allocation to reduce the potential for bias in the outcome measures that were being completed.
Assessments were completed at baseline and then at 16 and 28 weeks. While this type of feasibility study provides useful indicators of the effect of interventions on outcomes for study participants, the primary aim is to assess whether a larger study is justified. Therefore, the primary outcomes were:
- Recruitment of participants into the trial,
- Levels of trial retention at 16-week follow up,
- Levels of engagement of participants in the iMAPS therapy.
A range of secondary variables were assessed, including measures of psychosis symptoms, recovery and core schema. These were included primarily to explore which might be candidate variables for a larger trial.
Results
This study included a total of 45 participants (31 receiving the imagery intervention plus treatment as usual and 14 receiving the treatment as usual). This study had a high retention rate of 80% (at 16 week follow up) but dropped to 67% (at 28 weeks follow up). Additionally, 77% of clients adhered to the imagery therapy, which received positive feedback. These findings suggest that this imagery focused intervention is acceptable, feasible, and safe to deliver to individuals with psychosis. Therefore, the authors hope to proceed to a larger randomised control trial to determine the effectiveness of the intervention.
Evidence for the acceptability of the approach was complemented through qualitative interviews where participants described how the approach had helped them make sense of intrusive imagery and had been easy to engage with. Some described aspects as distressing which the authors suggest is inevitable where remedial work is required. None of the 13 adverse events recorded, two of which were serious, were found to be related to the intervention.
Secondary outcomes related to the effectiveness of the intervention were also reported but given the small sample size these can only be taken as indicative and properly understand the effectiveness of the approach a full scale and properly powered study would be needed. That caveat aside, the authors found an effect in favour of the iMAPS intervention on images and positive belief of self and of others but no effect on symptom severity or recovery measures.
Findings suggest that this iMAPS mental imagery intervention is acceptable, feasible, and safe to deliver.
Conclusions
This is a novel psychological intervention explicitly focusing on distressing intrusive imagery, which has also been linked to negative beliefs about oneself and others. This study highlights the feasibility of delivering this imagery intervention to individuals with psychosis and the case for a larger trial, which would allow for the assessment of effectiveness, has been well supported.
The authors reflected that the lower retention rates at the 28 week follow up may be due to the large number of questionnaires to complete, highlighting the need for the authors to prioritise which measurements to use for any larger trial. Participants reported that the intervention helped them to make sense of their distressing imagery, reduce their frequency, and increased their sense of control over their images.
People reported that the intervention helped them to make sense of their distressing imagery, reduce its frequency, and increase their sense of control.
Strengths and limitations
This study is methodologically sound as it had a clear research question, clear inclusion and exclusion criteria, and included relevant references and a prisma flow diagram. They also clearly explained what the active intervention included, as well as acceptability and retention rates. There is a need to enhance and innovate psychological interventions for psychosis and this is an important contribution to the literature.
Imagery is an important clinical intervention target that is currently underutilised in psychosis, therefore research to further our understanding of its possible benefits is invaluable. This study employed a number of validated measures of core beliefs, emotions, and symptoms, which is a strength of the study, along with following the methodological criteria for randomised control trials. Assessors were blinded and any adverse events were also documented and assessed.
Even though imagery is a transdiagnostic psychological mechanism that can be a target of therapy, combining participants with early psychosis from early intervention services with more long-term psychosis presentations from community mental health teams might potentially dilute the findings. Additionally, for the early psychosis sample it may have been helpful to have collected data regarding the duration of untreated psychosis (DUP) in order to explore potential differences in the participants who may or may not benefit from or engage with this intervention. It would also be interesting to compare the feasibility and effectiveness of this intervention between participants from early intervention services versus community mental health services to see if there are any differences in how they responded. A further possible limitation was that the potential for medication related differences in intrusive imagery was not explored.
While this feasibility study had many strengths, some differences between groups of participants were not explored.
Implications for practice
Imagery has a powerful effect on the body and on our behaviours. For example, if we ask you to imagine a juicy hamburger with chunky fries, you might start to feel hungry, even if there’s no actual hamburger present. Your mind creates a vivid image that triggers a physical response. As long as you aren’t vegetarian, thinking of a hamburger is pleasant enough but distressing imagery is of course, by its very nature, upsetting and has the potential to negatively influence feelings and behaviours for people affected by psychosis.
A person experiencing paranoia might have a fleeting, vivid image of a shadowy figure following them, instantly triggering intense fear and a feeling of being unsafe, even when no one is physically present. Or someone hearing voices might see an image associated with those voices, intensifying their distress and conviction in what they are experiencing. These are the kinds of distressing images that iMAPS therapy aims to address and its where current interventions are extremely limited.
This study matters because intrusive imagery is an underexplored area of psychosis where there is real potential to intervene safely and therapeutically. Indeed, treatment option for all aspects of psychosis are limited so new evidence for even the feasibility of further research should be welcomed with a degree of therapeutic optimism, particularly where their feasibility is so clearly and rigorously demonstrated.
Feasibility studies are crucial in clinical research because they help determine whether a proposed larger clinical trial can be carried out successfully, ethically, and efficiently. They are a fundamental first step that can prevent significant waste of resources, protect participants, and ultimately increase the likelihood of a trial achieving its objectives.
Here, the authors are also commended for being true to the principles of feasibility research where the temptation may be to focus on emerging effectiveness outcomes rather than primary feasibility outcomes. While it may be some time before iMAPS becomes part of psychological practice we look forward to a fuller trial and the next stage in developing a new evidence-based treatment for an underserved group of people.
While it may be some time before iMAPS becomes part of routine practice, demonstrating its feasibility for further effectiveness research is an important step.
Links
Primary paper
Christopher D J Taylor, Ben Helliwell, Rebecca Coleman, Chris J Sutton, Paul Hutton, Yvonne Sylvestre, Leanne Bird, Gemma Shields, James A Kelly, Thomas Brandwood-Spencer, Alicia Boland, Emma Sharrock-Ingham, Bukunmi Babatunde, Amy Beech, Anvita Vikram, Serena Guillemard, Arnoud Arntz, Sean F Harper, Katherine Berry. (2025) iMAgery Focused Therapy for PSychosis (iMAPS-2): An Assessor-blind Feasibility Randomized Controlled Clinical Trial. Schizophrenia Bulletin, Volume 51, Issue Supplement_3, October 2025, Pages S317–S335, https://doi.org/10.1093/schbul/sbaf060
Other references
Cairns AJJ, Taylor CDJ, Kelly JA. (2024). The outcomes of imagery-focused interventions in relation to distress in people with delusions: a systematic literature review. Behavioural and Cognitive Psychotherapy, 52(6):596-615. https://doi.org/10.1017/s1352465824000237
Morrison, A. P., Beck, A. T., Glentworth, D., Dunn, H., Reid, G. S., Larkin, W., & Williams, S. (2002). Imagery and psychotic symptoms: a preliminary investigation. Behaviour Research and Therapy, 40(9), 1053-1062. https://doi.org/10.1016/s0005-7967(01)00128-0
Schulze, K., Freeman, D., Green, J., & Kuipers, E. (2013). Intrusive mental imagery in patients with persecutory delusions. Behaviour Research and Therapy, 51(1), 19-26. https://pubmed.ncbi.nlm.nih.gov/23178174/
Taylor CDJ, Bee PE, Kelly J, Haddock G. (2019). iMAgery focused therapy for persecutory delusions in PSychosis (iMAPS): A novel treatment approach. Cognitive and Behavioural Practice, 25:575-588. https://doi.org/10.1017/s1352465820000168