National guidance recommends that relatives of people with dementia receive support to develop coping strategies. STrAtegies for RelaTives (START) is an evidence-based manualised intervention for delivery on a one-to-one basis by trained graduate psychologists to family carers of people with dementia. However, implementation of START in standard National Health Service (NHS) provision has proved difficult. We describe collaboration between a Talking Therapies service and a Memory Service to co-facilitate and run START as a group. We consider implementation outcomes according to RE-AIM domains showing: the collaboration reached higher number of carers than other implementation initiatives (reach); there was significant reduction in caregiver anxiety and a trend towards significant reduction in depression (effectiveness); feedback from service users and clinicians on the service model has been positive (adoption); delivery has been supported by the written and audio materials (implementation); and the initiative has sustained over five years, despite the COVID-19 pandemic and staff turnover (maintenance). Finally, we discuss implications and potential future development.

1. (1) To develop knowledge about the content of the STrAtegies for RelaTives (START) coping intervention for family carers of people with dementia.

2. (2) To understand the similarities between low-intensity cognitive behavioural therapy for anxiety and depression, as provided by Psychological Wellbeing Practitioners (PWPs), and START psychoeducational content and skills exercises.

3. (3) To reflect on the rationale for group delivery of START.

4. (4) To consider the benefits of collaboration between Talking Therapies and Memory Services for implementing START.

Motor neuron disease (MND) is a progressive, fatal, neurodegenerative condition that affects motor neurons in the brain and spinal cord, resulting in loss of the ability to move, speak, swallow and breathe. Acceptance and commitment therapy (ACT) is an acceptance-based behavioural therapy that may be particularly beneficial for people living with MND (plwMND). This qualitative study aimed to explore plwMND’s experiences of receiving adapted ACT, tailored to their specific needs, and therapists’ experiences of delivering it.

Semi-structured qualitative interviews were conducted with plwMND who had received up to eight 1:1 sessions of adapted ACT and therapists who had delivered it within an uncontrolled feasibility study. Interviews explored experiences of ACT and how it could be optimised for plwMND. Interviews were audio recorded, transcribed and analysed using framework analysis.

Participants were 14 plwMND and 11 therapists. Data were coded into four over-arching themes: (i) an appropriate tool to navigate the disease course; (ii) the value of therapy outweighing the challenges; (iii) relevance to the individual; and (iv) involving others. These themes highlighted that ACT was perceived to be acceptable by plwMND and therapists, and many participants reported or anticipated beneficial outcomes in the future, despite some therapeutic challenges. They also highlighted how individual factors can influence experiences of ACT, and the potential benefit of involving others in therapy.

Qualitative data supported the acceptability of ACT for plwMND. Future research and clinical practice should address expectations and personal relevance of ACT to optimise its delivery to plwMND.

1. (1) To understand the views of people living with motor neuron disease (plwMND) and therapists on acceptance and commitment therapy (ACT) for people living with this condition.

2. (2) To understand the facilitators of and barriers to ACT for plwMND.

3. (3) To learn whether ACT that has been tailored to meet the specific needs of plwMND needs to be further adapted to potentially increase its acceptability to this population.

Climate distress describes a complex array of emotional responses to climate change, which may include anxiety, despair, anger and grief. This paper presents a conceptual analysis of how acceptance and commitment therapy (ACT) is relevant to supporting those with climate distress. ACT aims to increase psychological flexibility, consisting of an open and aware orientation to one’s experiences, and an engaged approach to living, guided by personal values. We discuss the pertinence of each of these processes for adapting to the challenging reality of climate change. By embracing climate distress as a natural human experience and promoting value-guided action, ACT offers a promising approach that brings co-benefits to individuals and wider society.

1. (1) To understand the concept of climate distress and its various emotional responses.

2. (2) To explore the relevance of acceptance and commitment therapy (ACT) in addressing climate distress and promoting psychological well-being.

3. (3) To examine the importance of psychological flexibility in coping with climate change.

4. (4) To analyse the role of ACT in embracing climate distress as a natural human experience.

5. (5) To investigate how ACT can encourage pro-environmental behaviours and climate change mitigation efforts.

As we face a future of rising global temperatures, and associated extreme weather events, distressing emotional responses are understandable. Climate scientists comprise a unique group, in that they must regularly confront the reality, and consequences, of climate change. In this paper, we explore how the principles of compassion-focused therapy (CFT) might be applied to comprehend the responses of climate scientists to climate change; by doing so, we aim to gain a deeper understanding of these responses in order to consider fruitful avenues for providing support and investigating this area further. We consider how flows of compassion, and blocks to compassion, might play a role in climate scientists’ experiences. Additionally, we conceptualise a role for compassion towards the wider world and humanity more broadly. Finally, by applying the CFT Three Systems model to current understanding of climate scientists’ emotional experiences, we seek to proffer a potential conceptualisation of them.

1. (1) To formulate the emotional experiences of climate scientists from a compassion-focused therapy perspective.

2. (2) To explore how blocks to flows of compassions serve to negatively impact and/or maintain difficult emotional experiences of climate scientists.

3. (3) To consider ways in which the field of psychological therapy can support climate scientists through a difficult emotional journey, and how future research might explore this further.

As humanity faces a future of rising global temperatures, and associated extreme weather events, distressing emotional responses are understandable, but often silenced. Climate Cafés are unique, dedicated spaces where such responses can be shared and validated with others. Semi-structured interviews were conducted with attendees of Climate Cafés facilitated by the Climate Psychology Alliance (CPA). An initial interview of 45 minutes was followed by a shorter follow-up interview 3 months later. Interpretative phenomenological analysis (IPA) methodology was used with seven female participants. Four superordinate themes were identified: (1) Having a keen awareness of threats to planetary health, (2) Action taken in the face of climate change, (3) Journeying from isolation to connection, and (4) Legacy of Climate Cafés. Participants described positive experiences both during and after the Climate Cafés, particularly having their concerns heard and validated, being with others who share their worldview, and feeling more connected. Attending Climate Cafés appears to offer important support to people experiencing distress related to the climate and ecological emergencies. Findings are discussed in light of the compassion-focused therapy (CFT) ‘Three Systems’ model, which offers a unifying theoretical conceptualisation that could support future development and research in this area.

1. (1) To understand the idiosyncratic experiences of seven UK women at Climate Cafés.

2. (2) To begin to conceptualise and apply psychological models to current Climate Café practices, especially compassion-focused modalities.

3. (3) To use the experiences reported here to add to the growing understanding of eco-emotions.

Young people are increasingly distressed by the climate and ecological crises (eco-distress). This has been associated with the failure of people in power to act appropriately, which may cause moral distress and moral injury. We examined this hypothesis by interviewing 13 young adults (19–25 years) in the UK about their climate concerns and perceptions of how State actors and authorities are responding to climate change. Using reflexive thematic analysis, four themes were developed: (1) Climate change is a wicked problem, (2) Moral distress is associated with witnessing acts of omission and commission, (3) Moral distress drives eco-distress, and (4) Opportunities for moral repair. Climate concerns extended to broader concerns about ecological degradation (eco-distress), linked to feelings of moral distress arising from repeatedly witnessing powerful people failing to act on climate change. Eco-distress was also exacerbated by (a) witnessing others in society failing to take appropriate responsibility, (b) realising the limitations of individual action, and (c) being embedded within a culture where personal contribution to climate change is inescapable. In contrast, eco-distress was lessened by seeing authorities engage with the issues morally, and further mitigated by collective, ethical, pro-environmental action. This adds empirical evidence to support the hypothesis that eco-distress involves moral distress and injury arising when State authorities and other powerful bodies engage in wrongful acts and omissions on climate change. We argue that this is affecting the wellbeing of young people and supports the argument that such wrongful (in)action infringes human rights. Clinical implications are discussed.

1. (1) To understand how and why moral distress and moral injury relate to the distress that young people feel about climate change (eco-distress).

2. (2) To consider the clinical implications of formulating eco-distress in a way that includes reference to the violation of core moral codes.

3. (3) To explore what opportunities exist that could reduce moral distress and support young people.

4. (4) To understand how research into moral distress and moral injury in relation to climate change can offer important insight into the relevance of eco-distress to human rights infringements and justice-oriented care.

5. (5) To discuss practical solutions that might support moral repair, both in psychotherapy settings and in broader social policy.

Both extreme weather and climate change have been linked to distress and at times mental health problems. Pro-environmental actions have often been related to higher distress. The uncertainty distress model (Freeston et al., 2020) proposes that in real-world situations, perceptions of threat and uncertainty contribute to distress. The aim of this study is to integrate variables from these two literatures and examine their relationships.

A community sample (n=327) was recruited and completed an online survey. Network analysis was used to analyse the relationships between the variables. Exposure to extreme weather, perceptions of climate change, climate change distress and pro-environmental action were measured along with symptoms of adjustment disorder and post-traumatic stress disorder, and uncertainty intolerance and behaviours.

There was variable exposure to extreme weather, but greater exposure was associated with more severe post-traumatic symptoms. Pro-environmental action was associated with greater severity of adjustment disorder symptoms. The perception that climate change was happening now was linked positively to pro-environmental action and negatively to perceptions of uncertainty about whether climate change was happening.

The results replicate several findings from the emerging climate change distress literature and are consistent with some predictions of the uncertainty distress model, but not others. Uncertainty as to whether climate change is happening now may be a less distressing position. Research that simultaneously considers extreme weather and climate change may help understanding the range of complex responses that may arise as the frequency of extreme weather increases and evidence for anthropogenic climate change strengthens.

1. (1) To consider why the uncertainty distress model may be an appropriate framework to understand responses to extreme weather and climate change.

2. (2) To consider how the perceived proximity of climate change may play a role in peoples’ emotional and behavioural responses to climate change.

3. (3) To consider some of the variables that are linked to pro-environmental action.

4. (4) To consider whether an uncertainty-based understanding of extreme weather and climate change has helpful implications for practice.

The dominant economic, political and sociocultural system is leading the Earth towards climate and ecological breakdown (IPCC, 2023) as well as causing adverse mental, physical and social health consequences (Eisenberg-Guyot and Prins, 2022). To address these inter-related crises there is an urgent need for cultural evolution to life-sustaining ways of living and organising human life (Brooks et al., 2018). This requires concurrent psychological and ideological shifts and psychological contexts of support, in which people can explore their relationship with, and response to, the planetary predicament and the roles they would like to play in its transformation. The Work That Reconnects (WTR) (Macy and Brown, 2014) is a groupwork methodology developed to address this need. It consists of a set of philosophical and psychological teachings and experiential practices drawn from deep ecology, living systems thinking, Buddhism, and indigenous, spiritual and other wisdom traditions. It originated outside the field of CBT and psychotherapy, within activist movements, within which it is an increasingly well-known methodology for psychological support. The WTR has many characteristics which align with cognitive behavioural approaches with regard to processes, techniques and mechanisms of change. The WTR has, as yet, received minimal scientific research attention. The aim of this paper is to raise awareness of the methodology within the cognitive behavioural field, introducing philosophies, concepts, and techniques that may be of utility to CBT practitioners and stimulate research and evaluation of a methodology with potential to address psychological needs at this time.

1. (1) To learn about a groupwork methodology, the Work That Reconnects (WTR), for developing adaptive resilience, motivation, agency and wellbeing when facing concerns about the world.

2. (2) To learn about the four stages of the spiral of practices of the Work That Reconnects: gratitude, honouring our pain for the world, seeing with new and ancient eyes, and going forth.

3. (3) To understand the key concepts of the model including cultural schemas such as ‘the three stories of our time’ and application of living systems thinking to create cognitive and behavioural shifts towards adaptive action.

4. (4) To explore the parallels with cognitive behavioural approaches, review the evidence base, highlight the need for further research, and outline areas for investigation.

5. (5) To suggest ways in which the WTR can inform individual therapy for climate and ecological concerns.

This paper describes an interdisciplinary integration of the concept of environmental identity into cognitive behavioural approaches to facilitate psychotherapy interventions for climate distress. Environmental identity encompasses one’s sense of self in relation to the natural world and other species, and is an important sub-identity analogous to gender, sexual and other forms of self and social identity recognized in psychotherapy. We provide a background on the construct of environmental identity as developed in social and environmental psychology and share culturally responsive methods for mental health practitioners and the public to evoke and explore their own environmental identity. We then discuss steps to create environmental identity-based therapy interventions using cognitive and behavioural approaches for climate distress. We highlight the potential for acceptance and commitment therapy to foster mindfulness and values-based action, dialectical behaviour therapy to support emotional regulation, and radically open dialectical behaviour therapy to mitigate perfectionism and over-controlled coping styles. We also describe a composite case study of environmental identity-based cognitive behavioural therapy for an LGBTQ+ client.

1. (1) The paper presents new opportunities and techniques for adapting cognitive behavioural interventions in a climate conscious manner, with insights and observations from the authors based on clinical practice, which informs research into psychotherapy best practices in the context of environmental and climate issues.

2. (2) Readers will become familiar with the empirical basis of environmental identity drawn from theory and research in social and environmental psychology; how environmental experiences and values intersect with other forms of personal and social identity addressed in mental health practice; and culturally responsive ways to elicit environmental identity on the part of practitioners and those they serve.

3. (3) Readers are guided through examples of environmental identity-based cognitive and behavioural interventions including (1) promoting values-based action using acceptance and commitment therapy, (2) addressing emotional dysregulation using dialectical behaviour therapy, and (3) modifying over-controlled or perfectionistic coping styles using radically open dialectical behaviour therapy.

4. (4) A composite case study provides an example of environmental identity-based cognitive behavioural therapy for a 20-year-old LGBTQ+ person experiencing climate distress.

Climate change distress is a challenge to people seeking help, and to those providing help. Those providing help are working in a new area of clinical practice where little is known, but they may also be experiencing climate change distress. The aim of this article is to highlight the personal and professional implications of the unfolding climate crisis and how we might better understand and support those with understandable, yet intense, emotional reactions to the climate crisis. This article consists of a first-person narrative by the first author, and a commentary on the narrative based on the psychology of climate change literature by the second author. We have worked independently on the narrative and commentary; each is responsible for their own contribution. The narrative highlights the first author’s personal experience of moving from denial to facing the truth of the climate crisis and the impact on professional practice. The commentary by the second author found that literature is scarce, but more familiar areas of practice may help to understand and respond to climate change distress. Practitioners face a situation where they may experience similar emotions to their clients, analogous to the shared threat of the pandemic. Awareness of the crisis is daunting, but therapy, self-reflection and action can help hold our emotions and support our clients. The evidence is limited but experience of the pandemic suggests that CBT can respond, adapt, innovate, and even revolutionise mental healthcare. These two perspectives suggest, despite the challenges, there may be reasons for hope.

1. (1) To increase familiarity with climate change distress and its multi-faceted presentations.

2. (2) To understand the importance of self-care for climate activists and the different forms this may take.

3. (3) To consider the implications of being a practitioner helping people with climate change distress, while also experiencing climate change distress.

4. (4) To reflect on the tensions between, and the potential integration of, the personal and the professional in the context of climate change.

The concept of Service Model Fidelity is considered as a parallel process to Treatment Fidelity in evidence-based psychological therapies. NHS Talking Therapies (formerly IAPT) aimed to increase access to an expanded, upskilled workforce on a national scale. This included systematic training, supervision and front-line service delivery, emphasising treatment fidelity to evidence-based interventions. A further feature of NHS Talking Therapies was modernising and restructuring of the health system that housed these trained practitioners. The term ‘service model fidelity’ (Cromarty, 2016) was coined to emphasise service modernisation aspects as a distinct entity. A definition of the latter is included. Examples of service model fidelity and of service model drift, are outlined to distinguish these from therapist drift. This links to past literature recommending changes in traditional mental health service design and emergent evidence from NHS Talking Therapies. The latter examines publicly available data identifying characteristics of service design, which appear to be predictors of enhanced clinical outcome. Challenges in modernising health systems are discussed and conclusions are made highlighting the crucial role of service model when delivering evidence-based therapies. Suggestions for further research into service configuration to improve experiences of service users are considered. This includes ongoing exploration of service design being more than a qualitative feature, and increasingly appearing as a key factor in enhanced clinical outcome.

1. (1) To identify service model fidelity as separate entity to treatment fidelity.

2. (2) To provide a clear definition of service model fidelity.

3. (3) To delineate therapist drift from service drift.

4. (4) To further examine the role of service model in delivering evidence-based interventions.

Psychological Wellbeing Practitioners (PWPs) are central to NHS Talking Therapies services for depression and anxiety (TTad; formerly ‘IAPT’). This workforce has been trained to deliver low-intensity treatments for mild to moderate depression and anxiety. In practice, PWPs routinely work with more complex clients, likely due to a combination of reasons. Over half of referrals experience concurrent personality difficulties, which are linked to poorer treatment outcomes, and PWPs describe feeling unskilled to work with these clients. This study aimed to develop and pilot a Continuing Professional Development workshop for PWPs about enhancing practice in the context of concurrent personality difficulties; and evaluate acceptability, feasibility and potential impacts on clinical skills and attitudes. This is an audit of routine feedback from a pilot of the workshop offered in a single TTad PWP workforce (n=139). The workshop was successfully developed and a series of five workshops were delivered to 74% of the PWP workforce. Feedback was overwhelmingly positive, and a majority of PWPs reported improved confidence in key skills covered during the workshop, and a positive attitude towards working with clients with personality difficulties after the workshop. PWPs described enhanced capability, opportunity and motivation to undertake work with this client group following the workshop. The workshop showed potential to improve PWP confidence and skill to support TTad clients in the context of personality difficulties, although it is not yet known if this translates to better treatment outcomes for clients. Implications for practice and future research are discussed.

1. (1) Understand the feasibility of gathering feedback and outcome data of a Continuing Professional Development (CPD) workshop delivered in routine practice for PWPs.

2. (2) Understand PWP perspectives on attending a CPD workshop to support tailoring PWP treatments for depression and anxiety in the context of personality difficulties.

3. (3) Reflect on potential opportunity to enhance PWP treatments in the context of personality difficulties via brief training workshops.

4. (4) Consider how COM-B can be used to explore barriers and enablers to PWPs implementing new learning to their practice.

People with Raynaud’s phenomenon (RP) experience poorer mental health and quality of life than the general population, and there is limited evidence for treatment options in RP. The Common Sense Model of illness representations (CSM) is a well-established theoretical model, which has not yet been robustly investigated in RP, but may provide potential avenues for psychological interventions with the ability to explore perceptions and beliefs, such as cognitive behavioural therapy (CBT). The study aims were to investigate illness perceptions and examine the relationship between illness perceptions and symptom severity and quality of life in RP to explore a theoretical basis for potential treatment avenues. A cross-sectional online questionnaire design was employed and 169 adults with RP (primary or secondary) were analysed. Illness perceptions significantly differed between primary and secondary RP types on all but one domain (p < .05). Hierarchical multiple regressions indicated that illness perception subscales made a significant unique contribution to the models explaining 65% variance in symptom severity (R2 = .65, p < .001) and 30% variance in quality of life (R2 = .30, p < .001). This novel study provides preliminary evidence regarding the applicability of the CSM to RP in a clinically meaningful way. CBT, which can specifically target illness perceptions within a wider psychological formulation, may be helpful for individuals with RP who are experiencing psychological distress in relation to symptom severity. Further work is needed to develop outcome measures specific to RP and tailor interventions to manage distress and impaired quality of life.

1. (1) The Common Sense Model is applicable and relevant to Raynaud’s phenomenon (RP) and there are important differences between illness perceptions in those with primary and secondary RP subtypes.

2. (2) Findings show that illness-specific cognitions make a significant contribution to the variance in symptom severity and quality of life in those with both subtypes of RP, which has notable implications for the assessment, formulation and treatment of psychological difficulties in RP.

3. (3) This offers a basis for further replication and development and adaptation of an intervention for this group, drawing on the evidence base for long-term conditions.

Only a few instruments can monitor the quality of individual supervision sessions. Therefore, the first objective was to develop a brief Quality of Supervision Questionnaire (QSQ). The second objective was to examine person and context variables associated with more effective supervision sessions. Two online samples of n=374 psychotherapy trainees and n=136 supervisors were used to develop the QSQ using exploratory factor analysis, validity and reliability analyses, and tests for measurement invariance. In addition, correlations between the QSQ and person and context variables were examined. The final QSQ included 12 items and three factors (Effectiveness, Procedural Knowledge, Relationship). The supervisee version had good reliability (α=.83 to .88) and correlated moderately to strongly with convergent measures (r=.37 to .68). The supervisor version was partially invariant to the supervisee version, displayed weak to good convergent validity (r=.27 to .51) and mixed reliabilities (α=.67 to .81). Regarding person variables, higher session quality was positively associated with supervisee self-efficacy (r=.16) and being a supervisor (vs supervisee, d=0.33 to 0.56). Regarding context variables, there were significant effects for supervisors in cognitive behaviour therapy (vs psychodynamic therapy; in terms of Procedural Knowledge, d=0.86) and for competence feedback (vs no feedback; d=0.47 to 0.68), but not for individual (vs group-based) sessions. Overall, the QSQ is a valid and reliable self-report questionnaire. We discuss the conceptual overlap between supervision scales.

As a result of reading this paper, readers will:

1. (1) Be aware of the Quality of Supervision Questionnaire (QSQ), which is a brief self-report scale assessing the quality of individual supervision sessions with 12 items and three subscales: Effectiveness, Procedural Knowledge, and Relationship.

2. (2) Learn that there are no significant differences in the quality of supervision between sessions in individual and group formats. Compared with psychodynamic supervisors, supervisors in cognitive behaviour therapy report more procedural knowledge (i.e. what exactly to do and how to do it) in their sessions.

3. (3) Understand that supervisees evaluate sessions that included competence feedback as qualitatively better than supervisees who did not receive competence feedback.

Little is known about dialectical behaviour therapists’ (DBT) own experiences of mental health issues or being experts by experience. Quantitative exploratory methodology surveyed DBT therapists about their own experiences of mental health issues. Questionnaires were varied and far-reaching including collection of data on demographics as well as mental health experiences and disclosures of difficulties, Adverse childhood experiences, quality of life, attitudes towards people with borderline personality disorder (BPD), and a measure of internalised stigma and stigma resistance for people who endorsed a formal mental health diagnosis. Ninety-four people responded, 92 of whom identified as a practising DBT; 80 endorsed a history of or current mental health difficulties. This exploratory research, based on responses from 94 DBT therapists, expands knowledge on the relevance of ‘wounded healer/impaired practitioner’ concepts for practitioners of DBT and raises issues related to consultation team and a duty of care towards DBT therapists. Low response rate makes it difficult to generalise these findings. Respondents were predominantly white, female, heterosexual therapists earning well above the median and mean incomes in the UK. Additionally, respondents were not asked to define the functions and modes of their DBT practice.

1. (1) Readers will learn about the treatment relationship within a DBT context.

2. (2) Readers will learn about the concepts of wounded healer and impaired practitioner as well as the related issue of stigma.

3. (3) Readers will learn about the experiences of mental health issues of 94 DBT therapists.

The prevalence of mental health conditions is high for autistic adults. Yet, the IAPT manual states that referral rates into NHS Talking Therapies Services (NHS-TTS) do not reflect this nationally. Non-adapted treatment has been identified as a key barrier to accessing these services. It is therefore imperative that clinicians adapt to the needs of autistic individuals to make treatment accessible and effective. However, there is limited research in the field, especially for low-intensity cognitive behavioural therapy (LICBT). This service evaluation explores adapted LICBT for autistic adults within Plymouth’s NHS-TTS and Autism Service. It investigated clinical outcomes of adapted group and one-to-one LICBT with 84 participants. It hypothesised that psychometric measures for anxiety and depression would be lowered on treatment completion, whilst exploring whether either intervention showed a greater reduction. Additionally, semi-structured interviews were conducted with six participants from the sample to gather perspectives on what aspects of treatment were favourable or require improvement. A factorial ANOVA revealed that psychometric measures reduced on completion across both interventions, with a greater decrease for one-to-one treatment and the anxiety measure. In addition, four themes and nine subthemes emerged following a thematic analysis, which focus on different aspects of treatment, such as content, structure, interaction, and barriers to engagement. Findings indicated that adapted LICBT was associated with lower anxiety and depression for autistic adults. This consequently has implications for improving the current LICBT provisions being offered to autistic adults within the NHS-TTS.

1. (1) To understand some of the barriers autistic people face accessing an NHS Talking Therapies Service (NHS-TTS) and cognitive behavioural therapy (CBT).

2. (2) To reflect on the importance of adapting practice and CBT for autistic people.

3. (3) To present potential adaptations to low-intensity CBT for autistic adults with anxiety and depression.

1. (1) To understand the process followed to establish a university-run cognitive behavioural therapy service for students and enable other institutions to replicate this model.

2. (2) To identify whether universities can deliver safe, effective mental health services that are fully evaluated and result in commensurate clinical outcomes to other service contexts.

3. (3) To reflect on key learning, challenges and ethical considerations in establishing such services.

Chronic pain is common and debilitating, and recommended treatments are only moderately effective for pain relief. Focus has shifted to refining targets for change within psychological therapy to improve pain management. Evidence has shown the role of intrusive images in many psychological disorders. However, only a few studies have advanced our knowledge of the presence and impact of mental imagery in chronic pain. This exploratory study aimed to increase our understanding of how people with chronic pain perceive intrusive visual images to influence their daily life. The study employed a qualitative design, using semi-structured interviews to explore the content, emotional valence, cognitive and behavioural impact of pain-related visual images of ten participants with self-reported diagnosis of chronic pain. Data analysis was conducted by performing an inductive thematic analysis. Three key themes were identified: (1) ‘I start to create images in my head’: pain-related mental images, which revolves around descriptions of participants’ most significant visual image; (2) metaphors for pain, related to the imagery as a means to conceptualise and give meaning to the pain; and (3) “With the pain comes the image”: a companion to pain, which focuses on the role of intrusive images in the experience of pain. Results show that pain-related mental imagery appeared to be an intrusive, uncontrollable, and vivid cognitive accompaniment for many pain sufferers. The findings suggest that mental images may serve as an additional target in cognitive behavioural therapy to enhance individuals’ cognitive, behavioural and emotional change.

1. (1) To understand the role of mental imagery in the daily life of individuals with chronic pain.

2. (2) To examine the impact of intrusive images on the emotions, cognitions, and behaviours of people with chronic pain.

3. (3) To consider clinical implications for CBT interventions targeting pain-related mental images to manage chronic pain.