In this episode of Research Matters, host Steph Curnow talks to Dr. Alex Lau-Zhu, lead author of the paper “Flashforward Mental Imagery in Adolescents: Exploring Developmental Differences and Associations with Mental Health,” published in Behavioural and Cognitive Psychotherapy.

Alex discusses his research into flashforward mental imagery—vivid mental pictures of future events that can be intrusive and emotionally powerful. We explore how these flashforwards relate to anxiety in adolescents, why mental imagery isn’t always a focus in CBT, and how young people may benefit from imagery-based interventions.

Guest Bio:

Dr. Alex Lau-Zhu is an MRC Clinician Scientist Fellow at the University of Oxford's Department of Experimental Psychology and a clinical psychologist supporting young people affected by trauma. His full list of publications and research areas can be found here: https://www.psy.ox.ac.uk/people/alex-lau-zhu

Links & Resources:

Read the paper: “Flashforward Mental Imagery in Adolescents: Exploring Developmental Differences and Associations with Mental Health” - https://bit.ly/3Eysxd0

Explore more from Behavioural and Cognitive Psychotherapy –https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy

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Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today, I'm talking to Dr. Alex Lau-Zhu, Alex is lead author on the paper “Flash Forward Mental Imagery in Adolescence: Exploring Developmental Differences and Associations with Mental Health” which has been published in Behavioural and Cognitive Psychotherapy. I really enjoyed this chat with Alex. We talked all about his paper, and we also talked about maybe why mental imagery isn't explored so much with adolescents, or even in CBT in general. It's a really interesting listen, so I hope you all enjoy.

Hi Alex. Welcome to the podcast.

Alex: Hi Steph, thank you for having me.

Steph: You’re welcome. So, before we get into talking about your paper, would you mind introducing yourself to the listeners and telling us a little bit about who you are and the areas you work in?

Alex: Yeah, of course. I'm currently an MRC clinician scientist fellow at the Department of Experimental Psychology at the University of Oxford, and I also work as a clinical psychologist in our local county in Oxfordshire, supporting young people who are affected by trauma.

Steph: Thank you. So we're talking today about the paper that was published in the last issue of Behavioural and Cognitive Psychotherapy, which is about flash forward mental imagery in adolescents. So could you tell us a bit about how this paper came about? Was there any particular motivation for the research?

Alex: Yeah so I work with a lot of young people in my clinical work and often find that they sometimes struggle with expressing themselves, sometimes around identifying what goes on in their minds in particular, which is really a key part of doing CBT, for example. And speaking to other clinicians, also working with young people, it seems like actually sometimes they do find thinking on mental images perhaps a bit easier to thinking about, for example, using visual mediums or drawings to express how they feel and what they think, but sometimes it goes to be around talking about mental images that they experience inside their mind, just describing what is it that they see, what is it that they hear, as a way to then better understand some of those thinking processes or what we might call as distortions in CBT.

And that led me to think kind of more broadly around how much do we know about these sorts of processes in young people. And actually, we know incredibly little. There's some really I think exciting work that has happened in the last 20 or 30 years in working with adults and doing CBT with adults around thinking about mental images, not just verbal thinking. But that knowledge somehow hasn't really trickled down to working with young people as much. So I'm really curious more generally in, in understanding mental imagery in young people and whether that can help us improve our treatments.

Steph: And would you mind just explaining what flash forwards are for anyone who might not be aware of the term?

Alex: Yeah, I think it's probably a term that if once I explain what it means, then you might realise it's something that you're familiar with, you just perhaps haven't used this term to describe that before. So, the simplest way to think about it is the opposite of what a flashback would be. So a flashback is, you know, often a mental picture, often very visual, of the past, of a stressful, traumatic past event that just popped back into mind. So we think of flashforward as the almost the opposite of that. So again, mental images that just pop back. They're depicting something stressful and threatening, but they are about the future rather than about the past. And so perhaps another term that have been used in the literature or in clinical practice is intrusive images that are specific around the future.

So one example would be, let's say, perhaps, last night before coming to the podcast, I had a flash forward of being on this podcast and perhaps, I don't know, my, my voice breaking, the technology not working, you know, something happens and maybe it's going live and I could kind of see your face or the laptop running out of battery. That's what I can see in my mind. And naturally that if someone has a very sticky image like that, then it's going to be very anxiety provoking. But if we take that to clinical case, let's say with young people that I work with, they might have flash forwards of having to do a school presentation later in the week and feeling like people are not really paying attention because they find that presentation boring, maybe laughing at them for not really knowing perfectly what they're talking about. So that's perhaps that, that brings about in terms of social anxiety, for example, and we can think about different types of flash forwards of different content for a range of anxiety presentations.

Steph: Yeah, it's interesting you saying that mental imagery hasn't been explored in adolescents so much because you would imagine the kind of flash forwards being quite prominent in clients with OCD, for example, you would imagine that they would often quite have flash forwards about what might happen if I don't do this or if I don't do that. So it's interesting that in adolescents has not been explored so much.

Alex: Yeah, and I don't really know why exactly that's been the case. I think there's something about imagery work that, that, well, you know, by now we know that imagery can be really emotionally powerful, in our therapies. I’ve been reading actually some very old work by Aaron Beck, who was still developing CBT in the early 70s. And actually, I didn't know, maybe other people do know, but he had a psychoanalytic sort of background right before breaking into CBT. But a lot of his clinical work in the early stages of CBT used loads of imagery. So, asking his patients about imagery, finding ways to interrupt those images and manipulate those images, changing the ending of a lot of images, like the way you would do that in imagery rescripting, for example, for those who are familiar with that technique. He was doing a lot of that sort of, not typical kind of CBT techniques and somehow then that got lost as CBT became more developed and disseminated and other researchers, you know, expanded on that thinking. I don't really know why. I wonder whether there's something about imagery that, that it kind of feels like it has too many links to psychoanalytic thinking, thinking about dreams and fantasies and CBT was perhaps trying to move away from that, but I think Beck always said that cognition is not just verbal thinking, it can also be imagery. Somehow the verbal thinking took over as CBT expanded, and actually, it would be great to be able to talk to Beck about what he was thinking.

But I think for young people in particular, imagery is helpful and powerful for all ages, I believe. But for young people, I think, particularly relevant because I think it could be really creative work, it could be really imaginative, it could be really playful and fun, and young people often like therapists that has that kind of greater sense of agency on what they can bring to therapy.

Steph: So I imagine imagery work as well must be really subjective too, and so that must be really helpful for adolescents to be able to sort of think, oh my therapist isn't just going to tell me what to do, they're going to ask me, you know, how to describe something, and if I can't, imagery might be a really helpful way to kind of get this out and to explain myself.

Alex: Yeah, exactly. I mean, how you might want to change the content of an image, you know, from a more negative to more positive ending, for example, that the young person can become the director of their own film and I think at an age where agency is quite important, to me, it feels like imagery techniques really lend themselves to that developmental sensibility.

Steph: Yeah, absolutely. Okay, so we'll get into talking about the paper a little bit then. You very helpfully laid out some very clear hypotheses in your paper, which were very helpful to talk about what you were going to be investigating. Would you mind just going through those and explaining what they were?

Alex: Yes. So we were interested in exploring flash forwards, this sort of different mental imagery about the future and whether that relates to anxiety in young people based on some work that has been done in adults showing that there is a link, but no, let's just do the kind of first step, because there's been so little done in the area. So, is there a relationship between flash forwards and anxiety in young people? But we're also, we're very clear on asking that question with a group of young people to perhaps it's more reflective of what we might see, in terms of presentations in everyday CAHMS and often some of the complexities that comes with working in CAHMS are often linked to things like neurodiversity, like diagnosis of autism, or a background of some people might call it like developmental trauma or an early history of maltreatment, such as abuse and neglect. Those are the sort of developmental differences that often make treatment a little bit trickier, makes engagement a little bit trickier. So we wanted our sample to kind of reflect that actually in terms of generalisability, and there is some interesting work in terms of memory. So understanding emotional memories in autistic kids and autistic adolescents, as well as those young people with trauma backgrounds that actually made that thought, Oh, maybe they might have a greater propensity to also experiencing flash forwards.

So let me break it down. In the context of autism, one of the challenges I often describe relates to executive functions. So, the harder that one is going to struggle with inhibiting information, perhaps that means that flash forwards are going to be more likely to keep popping up. Right? And in the context of trauma, there’s some suggestion that people across all ages with a trauma background might develop a tendency to cope by avoiding negative thoughts and negative feelings. But actually, we know that can be quite counterproductive. We know that the more you try to suppress something, the more it's going to bounce back. So if we apply that to flash forwards, if young people with trauma background have that tendency to try to avoid and suppress those flash forwards, perhaps that means they're going to bound back even more. So, in summary, we're thinking about two groups of young people where flash forwards might be more prevalent, but perhaps through different mechanisms.

Steph: So you were actually looking at quite a range of adolescents then, in this study. Would you mind telling me a bit about how you recruited them? Was it actually quite difficult to get people to take part in this study?

Alex: Well, the study actually happened in the middle of COVID. So it was planned before, then COVID happened, and our initial plan was actually a more kind of extensive interview based in person approach, but with COVID, you know, doing research and taking part in research was challenging for everyone which is why we then swiftly adapted to a more kind of simpler survey approach. But I think we still were able to capture some important findings.

Steph: That's probably answered my next question then, which was going to be, were there any challenges in conducting this study, especially as you had such a diverse group of adolescents? COVID would be one of the major challenges, I would imagine.

Alex: Yeah, I mean, as I mentioned before, we're really keen on, on thinking our diverse sample with a diverse background in terms of those developmental differences that meant that we had to engage with a range of services and develop partnerships, for example, with CAHMS services but also with social care, particularly for the young people that had that trauma background that I mentioned, schools, and also using online platforms. But we managed in the end.

Steph: Yeah, I've talked to Sandra Krause, who was on the podcast a while ago, and she highlighted the peril sometimes of trying to do online surveys, particularly through social media and how sometimes recruiting through Twitter doesn't always work.

Alex: No, and actually there are increasingly more problems around imposter participants, sort of fake participants, and that's the real issue but thankfully that was not an issue for my research at the time. The imposters were not as developed and included at the time. And I think it was a time where there was a lot of awareness around the importance of mental health around that time, actually. So, in some way, that also helped with the study.

Steph: Yeah, brilliant. So can you talk a little bit about what you did then? And then what did you find? And was there anything you found that was surprising?

Alex: Yeah. So, as I mentioned, we use a survey approach. So, a combination of asking questions to the young people directly. So these were adolescents age 10 to 16, but also asking questions to one of the carers or parents. Everything was done online because of the context. So they had the flexibility to, to complete those measures at their own time. And what we found mainly, well, first of all was that- so do you remember I mentioned those hypotheses that perhaps some young people will have an increased propensity, for example, to experience flash forwards. We actually did not find that was the case. So autistic young people or young people with the trauma background or typically developing ones, they all seem to have comparable levels of flash forwards. It was the flash where they describe were equally emotional, equally frequent, equally vivid. But what we did find was that across the whole sample, as the intensity of those flashboards increased, so the more emotionally intense they were, the more anxiety problems young people exhibited. Actually, both in terms of their own self report but also based on the description from the caregiver parent, which provides with converging evidence that there is a link between those two measures. And that fits with, of course, what we know so far from the adult literature, right? That flash forwards are particularly important for anxiety. And in some ways sounds quite intuitive, right? Like if you're going to be having mental images of threatening events, you know, things that are really important to you, but that you perhaps think in some way will go really wrong, and you have that frequently all the time. In the same way that a flashback makes you relive a past event, a flashforward can help you pre live a future event. And then over time that unsurprisingly can lead to more anxiety problems, right? Your body's much more gear and more on edge. You're worrying more. Perhaps you might start avoiding such a situation. So, as a result, you might start acting like that future threatening event. It's really real and it's going to happen because it keeps popping up in your head.

Steph: So it's very much like doing a safety behaviour when you have social anxiety, isn't it? Where you might start to avoid certain situations because you've already thought that this is what's going to happen.

Alex: Yeah. Yeah. So our sample was quite a broad sample, right? We didn't just have a sample from CAMHS. So it's very different from doing research that just focuses on young people with a diagnosis of anxiety disorder, for example. So we don't fully understand how do these flash forwards then lead to an anxiety disorder. We know that they lead to symptoms. But perhaps there might be other processes that are needed, to then turn symptoms into a disorder. So, of the sample that I presented, we didn't have diagnostic information. We only had symptom measures, so we can't really tell who would have better diagnosis, but, I imagine quite a few probably from those that came from a CAMHS setting, but we don't have that information.

Steph: And did you find any kind of similar themes that came up in the kind of imagery that people were describing and in their flash forwards?

Alex  Yeah, that was another interesting finding. It seems like a lot of the adolescents were thinking about events related to career, about education, about future professions, and that perhaps matches with being in secondary school. And I think a lot of the learning around what, why are you going to choose this special subject in GCSE? Why are you going to choose these A levels? So, I think, in that sense, it makes sense with the developmental preoccupation.

Steph: Yeah. And I think for young people as well, at the moment, the future feels very uncertain for them, doesn't it? You know, they're constantly being told that there's no hope, you know, the planet is burning, there's going to be no jobs. So it would make sense maybe that actually. There probably is quite a preoccupation about what my future is going to look like in terms of job and career and profession.

Alex: And the data was during Covid so I imagine that preoccupation was even more pronounced during that time. So, it'd be interesting to see whether doing that study now perhaps outside of Covid would be different. But as you mentioned there are all these big world scale problems and maybe some of those would feature in terms of content now.

Steph: So given these findings then, what do you think are the implications for clinical practice and future research? I always ask people, what impact do you think this paper will have on the world of CBT?

Alex: Yeah. I mean, I think it's very early stage. I think just developing that curiosity for asking about mental images and clinical practice. I think we don't ask enough, even when we work with adults, you know, often images for a lot of people, it's like mainly restricted to, I think, PTSD, maybe sometimes people think about it in social anxiety, but often it's not really used that much. And so I think just that curiosity on thinking about cognition and thought, not just as the sentences that we write down in words, but also in images. And I wonder whether the more we ask young people what they see in their mind that they might be able to more readily express and access those cognitions more, more so than verbal methods that we rely on. And I would say that there's so much more research we need to do in terms of how best we measure these things in young people, how do we adapt interventions in young people. But given that we know a lot of really good, imagery-based techniques could be used in adults, there's no reason to believe that they wouldn't be useful for young people. So I think if someone has gone on some training, for example, using some imagery techniques for adults, whatever condition that is, there's no reason to think that’s not going to be applicable to young people. And in fact, I would say, potentially even more applicable for young people.

And I think the findings about autism is quite important. So, in my experience, talking to other clinicians that have worked with autistic individuals, there’s a bit of a myth, I think, that at least for some autistic people, they can't really use mental imagery which I always found that kind of quite interesting, because in my experience working with autistic individuals, I can't think of one where imagery wasn't useful, and obviously that is just my anecdotal experience and that's something that my, in my research, I'm trying to explore a little bit more. And I suppose there is probably some that are amazing imagery and some that really struggle and therefore, I think just because someone has a diagnosis, I think we should not rule out the use of these techniques that might be particularly useful, particularly for those are really good at it.

Steph: Yeah, and maybe that goes back to what we touched on before as well, and maybe it's about having the really good therapist that will try that with them and try and bring that out and work with them to draw that out rather than just assume because they have a diagnosis that maybe that won't be applicable to them.

Alex: Yeah, exactly. And we know from lots of research now that people often don't spontaneously talk about imagery, but you actually really have to ask. There's lots of reasons why imagine I guess, I guess, as humans in our day to day life we don't really talk about our images, but we talk about our thoughts. And so that's kind of like the default and clinically in clinical conditions, some images might be linked to shame for example, and you might not want to share them unless the clinician normalises the experience. So, you asked me about the impact in the CBT world, I think just to begin to have that curiosity and asking about images routinely, we're doing our initial assessment, for example, we're just beginning our CBT work.

Steph: And I think that's really great advice for clinicians as well, it's about having the openness and that curiosity. I think it's something we should all try and bring to our work, isn't it?

Alex: Yep, I mean, I imagine that for some clinicians, they might be like, Oh, but what if they say they have images? What do I do with them? And obviously my paper doesn't talk about necessarily interventions, but there is. a really kind of rich set of techniques out there. Most of the writing is in adults, and I think that your journal actually has published quite a lot of work in mental imagery. Mostly in adults, I would say. I've seen recently papers on pain and other anxiety conditions and depression. And actually all of those techniques could be used for either dampening negative imagery or promoting positive imagery in young people.

Steph: So just going back to the paper then for a minute, is there anything you would have done differently if you could do this all over again?

Alex: Good question. I think it was a first step and our approach was very much let's ask the first question with the methods that we have available. But actually, I would say I would be rethinking the way we measure flash forwards in young people. We have relied so far on measures that have been proposed and used with adults, but actually we don't fully understand is the language used in those measures appropriate for young people? Is it really capturing the way they experience mental imagery and flash forwards in particular? Are there aspects of flash forwards that are not being captured that are unique to the adolescent period, for example. And actually, I'm doing some research now trying to develop a new measure that's more youth friendly in terms of language, but also more, can develop in consultation and collaboration with young people with lived experience of flashforwards and anxiety. Because otherwise I think we might be underestimating the impact if we're only measuring it based on an understanding of how things work in adults. And I think as most people who have some sort of psychology background would know that a correlation is not the same as a cause. I would have liked to, to do that study with longer follow ups, for example, so that we can understand what flash forwards at a given time really help us predict anxiety later. So, moving a little bit closer to think about causal links.

Steph: Brilliant. And as the journals managing editor, I'm always curious about this, how did you find the peer review process for this?

Alex: I think that as a whole with peer review processes, you know, you see the comments at the beginning and you're like “urgh I don't like this”. And then you cool down and it's often a really helpful conversation. It was definitely helpful. I'm trying to remember what are the specific points that, that really helped shaped the final writing. I think, it really made me think about, that we should be better at distinguishing intrusive images and flash forwards when they are quotation mark “normal”, you know, normal part of human experience. You know, we'll have images about things that we worry that just will pop up all the time, some people that work in cognitive psychology, in fact, have suggested that's just how, that's our default way of existing. We just have things popping up. We have images popping up that say something really important to us, right? That's how our minds work. Can we really differentiate those sort of images from the ones that we need to really pay attention to that are toxic and sticky? The ones that are then cause mental health problems. And do we have good measures that really distinguish those two? So, I think that's something that, that needs to be thought about a bit more. and that's why developing better measures, it's really important.

Steph: Yeah. Oh, brilliant. Thank you. And I'm really glad that they were helpful as well. I always think it's helpful to hear from other people's experiences about peer review process because it can be really daunting.

Alex: Yeah. I mean, I think of it as like, you know, whenever you might be giving a talk and then you have such a diverse range of people with different backgrounds in the audience and sometimes you kind of get bit of an odd question and a side question you've never thought of. I like to think of it's a bit like that in the sense that the review process will always be different depending on like, I think, who you get,

Steph: Absolutely.

Alex: And ultimately we need to be engaging in this sort of conversation with, like, all different types of research and different types of background. So I just see that as kind of part of that process if that makes sense?

Steph: Yeah, brilliant. And finally, I was just going to ask, what's next for you? Can you tell us what you're working on now? And is there anything we should be looking out for you from you in the future?

Alex: Yeah, so I've alluded to some of the things I've been thinking about already. So I think broadly describing two different streams. So the first stream is around continue to improve our understanding of flash forwards and mental images more generally and to do that, we are exploring using more rigorous design. So, as I mentioned, using longitudinal approaches. But also experimental approaches, studying this process is not just in kind of a laboratory type setting, but also naturalistically and understanding a little bit more, you know, why is it having mental images like flash forwards can then lead to anxiety problems in young people.

And the second stream is more around, thinking about how we can then change and modify these processes if they are relevant. So thinking are there interventions that not only be effective, but actually also appealing for young people that they actually want to use and do, and ideally also interventions that could be easily accessible, given the scale of, mental difficulties and the problem with access that are well known now.

Steph: Okay. Well, that sounds brilliant. Alex, thank you so much for coming on the podcast and talking to us about your paper. It's been really interesting to listen to you.

Alex: Thank you so much, Steph, for having me.