Transcript of interview with Dr. Emily Holmes

JP: Welcome. I am Jackie Persons. I am Director of the Cognitive Behavior Therapy and Science Center in Oakland, California. I'm also Clinical Professor in the Psychology Department at UC Berkeley. I am here today with Dr. Emily Holmes. Dr. Holmes is a Professor at the Karolinska Institute, Department of Clinical Neuroscience Psychology Division in Stockholm. She is also a Visiting Professor of Clinical Psychology at the University of Oxford and she holds an honorary Science appointment at the MRC and Brain Sciences Unit in Cambridge in the UK. The hallmark of Dr. Holmes' research career is the investigation of mental imagery and emotional biases across psychological disorders from flashbacks in PTSD to flash forwards in bipolar disorder, and as we'll discuss today, imagery anomalies in depression. Her research focuses on deriving a better understanding on cognitive and affective mechanisms underlying psychiatric disorder with the goal of using basic science findings to guide treatment innovation. Dr. Holmes is Associate Editor of Behaviour Research and Therapy, has received numerous honors and awards, most recently in 2014 the Distinguished Scientific Award in the area of psychopathology from the American Psychological Association. Welcome, Dr. Holmes, and thank you so much for giving us your time here today.

EH: Thank you so much for talking with me today.

JP: So let me say that I'm hosting this interview as part of a series called Translating Science to Practice hosted by the Society for a Science of Clinical Psychology. Our goal is to help clinicians access and use findings from basic science in their clinical work. And I'm delighted here today to talk with Dr. Holmes about her imagery research and in particular we're focused on this fabulous article entitled "Mental imagery in depression: Phenomenology, potential mechanisms, and treatment implications" authored by you, of course, Dr. Holmes and your co-authors are Simon Blackwell, Stephanie Heyes, Fritz Renner, and Filip Raes. Did I say them all correctly?

EH: That's perfect. Yes.

JP: So let me start by asking you if I could about this article. What would you see for clinicians who are reading this article, listening to this interview... what would you see as the three main take home messages you would like clinicians to get and use in their clinical work?

EH: That's such an interesting question. So this article, as you said, is about mental imagery and depression, and its possible treatment implications. The first take home message I would say is that it's actually really very early days. To me, makes it a really exciting area clinically to look about. Because all those clinical observations are incredibly important for building up the evidence base about what we can do about in imagery and depression.

JP: OK. So clinicians can offer input based on their observations about imagery that can contribute to the research direction itself.

EH: Ya. Because we've got some fascinating findings here. So if I could just talk about three. What we're starting to see is that in depression, some of the research we see is that there's almost as many negative images... that's memories, sensory memories that come to mind when you don't want them to- negative past events- that occurs in depression, and that may even be similar in frequency to post-traumatic stress disorder, but perhaps more depressive related events. So number one is that it's worth us asking about whether they have negative intrusive imagery.

JP: OK. And it's worth us asking the depressed patient. We're very aware about asking the person with PTSD. But you're saying the depressed patient is also having a lot of negative images that it would be worthwhile for the clinician to ask about.

EH: Ya. I think it really is worthwhile in assessment, asking, because when I think about depression I often think about rumination, which is a very verbal thing. And I ask them about their negative automatic thoughts potentially. But we know that imagery brings quite a different set of processes with it and a lot of affect. So even if they don't seem as frequent as the verbal thoughts. Even having a few of these strong negative images per week might make a difference to your patient. And really worth finding out about.

JP: OK. So I'm going to come back to that. But that's #1. The clinician would do well to assess imagery in the patient. That's one of the main take home messages.

EH: Ya, and I'm talking about negative images. Intrusive or unwanted images, for example, of the past.

JP: OK. So tell me two more take home messages.

EH: So I'm going to flip to the opposite. So we've talked about past negative imagery. Another that is less noticed in depression is the hypothesis that people with depression find it quite difficult to imagine positive future images. If we think about it, this is very important. Our ability to navigate towards a goal, to dream about a future, that's actually predicated on our mind's ability to imagine what that future looks like. And this might be a really simple thing like getting out of bed in the morning, imagining how one's going to navigate the day, something to look forward to, to really quite specific hopes and images of the future. So again a suggestion for assessment, and possibly to weave into the treatment would be to think about or focus on positive future, image based thinking to bring into our wonderful toolkit, alongside all the other things we're doing. To really think about that specifically.  

JP: Very interesting. OK. So also in addition to assessing past negative images that the depressed person may be having an excess of, the idea is to assess how able the depressed person is to generate positive images of the future. Beautiful. OK, I want to come back to both of those. And I want to hear the third first.

EH: The third one is... clinically we all know it's relevant in the depressed to assess for suicidal thinking. And one of the things that we've written about is that suicidal thinking can also take the form of images as well as words. And there's a few studies now that find that suicidal thinking can be associated with suicidal flash forwards, so simulations associated with suicidal acts or their aftermath. So I guess this is more a clinical part, again, just strengthening our toolkit, doing all good things we already do, all the protocols we have to follow, which is very, very important. But an additional form of information might be to ask a patient if they can see in their mind's eye and if they imagine suicidal acts or their aftermath because this is also an important source of information.

JP: Wow. As soon as you said that word... what did you say? Imaginal rehearsal? 

EH: Ya. Imaginal rehearsal. So we coined the term suicidal flash forwards because they can be so vivid, a bit like flashbacks in PTSD, but suicidal flash forwards to an event where people might repeat, might rehearse, what a plan might be, and what's in it. And from an imagery basic mechanisms point of view, that's quite important because we know that imagining can be associated with acting on something. That kind of information might be really useful.

JP: Yes. Indeed. I get a flash of fear when I hear you describe the patient whose actually imagining and rehearsing in his or her mind a visual image of carrying out an act of suicide or the aftermath, which another good thing to think about. That is a beautiful immediate implication for clinicians, something they can assess when they have a depressed patient, a suicidal patient in their office, they can assess imagery. What was that phrase you used?

EH: I guess we often say to people "Do you have any thoughts or plans?" but I guess one could say "If you do have plans, do you ever see in your mind's eye what that plan would look like? Can you tell me what it's like? Tell me what you see. If I were a film director, what would I see? What would I see in your head?" So not to ask leading questions ever. But simply to get more detail because if you don't ask about images, sometimes people don't tell you. When we ask about thoughts, the word "thoughts" just means language, like the way you and I are talking now, Jackie. It just gives an extra source of information that's important to weigh in in the choices you make with the patient about what to then do.

JP: Fascinating. Very helpful. Thank you, Emily. So you've given us those three take home messages. Now I want to go back to the first one, in which you're pointing out that the depressed patient may have - if the clinician asks about it, the clinician might learn that the patient is having a lot of negative images about the past. It would be useful to find out about that. If we find out, why would that be useful? And then what would we do with that information?

EH: OK. So would you mind if I started out defining mental imagery and the sort of thing I might mean?

JP: Perfect.

EH: What we find in our clinical work is that most people- when we talk, we talk in verbal language, we talk in words. Unless you're hanging out with artists, which are much more visual obviously. When we ask about thoughts, as we know with cognitive therapy, even though thoughts and images are brought in from the very beginning, unless we keep saying images and explain what they are, they're not necessarily instantaneously reported. But if we give people a sense of "Well we can think in two ways" We can think in verbal language, but we can also see in our mind's eye we can have images about the world, and then if you said to somebody "How do you think about yourself?" versus "Do you ever have images for how you appear?" immediately you start opening up a different way of thinking about the same topic. Coming back to the issue of negative past imagery, we might be interested in if someone said they had negative thoughts about themselves and they felt very small I might say "And do you have an image of that? What do you see?" They could say no. But they might report images of actually seeing that situation. A common example might be remembering an event that was very negative to them. For example, when they were bullied at school. And to still vividly see in their mind's eye what it was like to be in that school yard.

JP: And they have a mental image, a picture of themselves or a picture of the other people who were bullying?

EH: Ya, exactly. And that could be a single incident event. And there's lovely work by, going back now, all sorts of researchers looking at these. And it could be back to a childhood memory, or a young adult memory. Could be an imagined memory, but representations of the self that fit with the problematic core belief or belief, or whatever level you might working with for that patient at that time.

JP: And suppose I elicit that information. How can I use it therapeutically, would you suggest?

EH: That's a really interesting questions. There are different things we can do. So at the very least, by eliciting that information, it gives you as a clinician a richer source of information on which to build the same treatment you're going to build anyway because just by examining that information, so... What does it look like in that school yard? How are you looking? How old are you there?  What is running through your mind? All of these things give us essential information to move on and to bring in more adaptive information and build our work.

But beyond the assessment, there's also more things we can do. We can also use imagery in our technique toolkit. The sorts of techniques we might use with repetitive negative images that come again and again and again might include things like imagery rescripting.

JP: Ah. Right. Tell me about imagery rescripting. How does that work exactly?

EH: Imagery rescripting is a technique where we would, there are all sorts of rescripting, but in the case I'm talking about, we might take a negative repetitive image and rather than just verbally talking about that image try and work with the image itself to change it. Just like any good therapy, we're trying to bring about change i meaning and emotion. So if you'd like to, I can talk a little bit about when we work with it, how we do it.

JP: Please, yes.

EH: But there are lots of good ways to do it. So I would refer the listener to all sorts of great books by Arnoud Arntz on imagery rescripting.... So what we might do is something as simple as ...First what we always do is try to understand... we break it into 5 stages basically. We try to understand the image. What's in the image? Get a really good description of it? We try in a very structured way, we call this imagery micro formulation. So we do a micro formulation just around the image. We break down, as if I were analyzing a picture, find out what are the main emotions (plural) associated with that image, and what are the main meanings associated with those emotions and that image. We break that down nicely and clearly. This is part of the micro formulation, which then enables us to do the rescript. Because you can't just randomly change an image. We have to understand what the image means to that person, what that affect and meaning it's carrying. And what a good rescript does is move that affect, move that meaning so that image disappears or merges into a more adaptive way of being for that person, what they need right now. So that's why you have to be a little forensic and break it down.

So we work out the emotions and the meaning. And we'd also work out one final thing which is why does this image hold so much power? Because sometimes images pack a more powerful emotional punch than verbal thoughts do, and our research has shown that over a whole series of experiments. Think about the same information in images or words, images are more powerful emotionally. That means images have this powerful hold on you and part of it is that they just feel more real, like seeing is believing. So if your brain presents this information to you in the form of an image, it's much harder to dismiss that or discredit it. So we have to build that into our imagery rescript as well. For one person it might be that I see this means it's really going to happen. For another person, it might be that this means it's really true. We've built that extra level into the rescript. Something that just shakes.....might introduce a bit of information that this image is just an image. An image is a mental representation in my head. It does not mean it's a real thing in the real world. So once you've established all that with a person, and it can go smoothly and rapidly at times. We can then examine that together. And if we really agree this is what this image is saying, we could say "And how would we like it to be otherwise?" We would call this the antidote image, this is where the rescript is heading. The reason we call it an antidote is that for every poison there's an antidote that will unlock and detoxify what's happening. For example, Jackie, if we had an image with the feeling of shame and humiliation and sadness. The meanings might be "I've lost my hope for the future, I'm a terrible person, I don't deserve good things." The alternative is all the exact opposite that we'd normally do in cognitive therapy. We'd write those down. But what we're trying to do is to get to an image based version of that. So what would it be like to not feel sad? Perhaps it would be to feel hopeful. What would it be like to not feel shame? To feel a sense of positivity or even pride about oneself. What would it be like to not feel humiliated? To feel strong. And this piece is almost like a film script that we'll build up now. We can work together thinking, constructing the image that has all of these meanings within it. Really work with that person's creativity in coming up with that image. It can be incredibly idiosyncratic which is why I can't create or you can't create an image for your patient. They have to create it. But what we can help with is with the content with what that image needs to say.

JP: Right. Because you start with your micro formulation of what are the problematic meanings? What are the problematic emotions? And you use that as a guide to figure out where to focus the rescripting.

EH: That's exactly it. Did I explain that OK?

JP: Ya, you did perfectly....But now I think I didn't get to step 5. After the image is created and the antidote image, then what do we do with that? Does the person practice it? Or...?

EH: We would come up with that image, practice it so it's very clear, but then in the rescript what we do is introduce that image to make it stick in mind we create an affect bridge. When an emotion is hot, we go back to the negative image and all those emotions come on board-- a bit like with work with PTSD-- when those emotions are strong and vivid in mind then we invite them to bring in their new image, to bring that to mind, to make that very vivid. And that process...it usually doesn't take too many repetitions, but by doing that you create a bridge from the negative meanings to the more adaptive ones.

JP: Cool. Wow. Thank you, Emily. I can see there's a lot to learn here that could make a difference for my patients. I was sitting here thinking about one of my PTSD patients, one of my OCD patients, even one of my patients who has an eating disorder who has these terribly distorted images of what she looks like. I'm thinking I can work on these ideas with all of these patients. Does that make sense to you? I'm taking all these ideas.

EH: No, you can do it with any disorder. It's not really just depression. In fact OCD is delicious because they are often quite good at imagery so I can send you the micro formulation worksheet- just very simple- that we use. But only if you can give me... I can't believe I can teach you anything, Jackie, so you're just brilliant at all of this complex cases, formulations, all the rest of it, but if the interview is worth something... the worksheet...we're just happy to distribute them. They're just so practical, patients like them.  

JP: Beautiful.

EH: It's like how do I take your complicated image and let's work on understanding it. It's simple.

JP: Thank you. And can we post the worksheet on the webpage for the SSCP so all the people who are listening to interview can get it?

EH: Ya. I don't see why not actually. When I do clinical teaching, I do it with my colleague Carrie Young who I recommended to you... I'll ask Carrie but I'm sure she'd be fine with that. And also it may seem more practical for your listeners.

JP: Absolutely. Thank you so much. Ok so here we've been talking about imagery rescripting, an intervention the clinician can do after the assessment piece that many of us are not currently doing to assess... to identify and get details about their negative images. So then unless there's more you want to say about that, I was going to go to the piece you told us about a moment ago about the deficient recall of positive image.

EH: Can I say one more thing on the negative?

JP: Yes. Please do.

EH: So I think imagery rescripting a very interesting, and can be a powerful and structured technique. It's not the only thing you can do with a negative image. So lots of things in our toolkit we can use for negative images. Behavioral experiments are classic examples. So you might visualize something that will happen, so you can test that out. Like do people see me in this way? So just because you have a negative image what we need to be creative about, and the microformulation helps with, is you can break that image cycle in a variety of places. But that comes from your formulation of the image.

JP: So I'm having trouble understanding what a behavioral experiment related to a visual image would look like. Can you give me an example?

EH: Oh, my first example is not one of depression....

JP: It doesn't have to be depression.

EH: OK. Say for example, someone might say "I've never been able to go out in nature. Or go to the park. I'm terrified of birds. Every time I go there I just have these intrusive images. I've had them since I was a child.  I saw this horrible movie with them, and I just always see these birds." So you could do a rescript but actually a really practical thing would be to do a behavioral experiment. What do you think would happen? What is this image telling me. So if my micro-formulation said at this point OK so the picture is bird, the emotion is fear, the meaning is birds going to get me, the power of the image is this is super real, it's really going to happen if I go to the park....I could rescript it or I could break that vicious cycle by saying let's test it out. What's your prediction? So the power of the image is that it's real, so let's check if this really happens. And then go off and do your behavioral experiment like you would for anything. That's partly what I think about the creativity work of imagery, it's giving you extra ammunition to work with.

JP: OK. So is there more for negative images or is it ok if I shift to deficient positive images for the depressed person.

EH: Ya.

JP: So this is very interesting. You're saying the depressed person, you have some data showing that these patients are less likely than non depressed people to be able to recall or to bring to mind positive images what of the future in particular?
EH: Ya. So this is the hypothesis and there is some data to indicate this is the case. We know that from survey based work that it seems to be that optimism, the ability to be resilient and positive in a way about the future is associated with higher levels of vivid mental imagery. And by the flip one of the aspects that we're interested in in depression is anhedonia, so the inability to feel positive affect. So if we go back to our science premise, we know that imagery has a very powerful impact on emotion. It has a really powerful impact on negative emotion. But if we want to feel positive, imagery also has the more powerful impact on emotion.

So we might say to ourselves 50 times "I'm a nice person. I'm a nice person." But that's not as emotionally powerful as imagining oneself or imagining a reward or imagining the day brightening up and so

JP: Imagining a visual image of those things. 

EH: Ya. Imagining a visual image, a sensory image.

JP:  What's a sensory image? 

EH: A really interesting thing about mental imagery is that an image can be visual, but it can be in any sensory modality. So if I'm pre experiencing the world. Like if I'm imagining my holiday I'd love to come to California for holiday, for example. So if I'm imagining the wonderful weather you have over there compared to Stockholm, I might see a palm tree. I might feel the breeze on my cheek, the sun. I might smell the ocean. I'm encapsulating an as-if experience of the world. So another word for mental imagery can be mental simulation. When it's rich and intense and vivid, it's often multi-sensory.

JP: Wow.

EH: So does that makes sense why I was using the word sensory?

JP: Yes. Ok. So we're talking about the depressed person who has a limited ability to do this mental simulation of positive experiences.

EH: Exactly. So what research on simple measures like perspective imagery measures says that people are equally good at imagining negative past events, but perhaps less good when we're depressed at imagining positive future events.

And I think that's really interesting because it's not something someone will necessarily assess or pick up. But it might have a quite big impact. If you can't imagine it being worthwhile to do something, or ...the point of doing your homework with your therapist or the fact that

JP: Or getting up in the morning.

EH: Exactly. If you imagine doing an action, you're more likely to believe it's the case, and you're more likely to act on it. If you're imagining that things are going to get better, you're more likely to feel that positive affect and feel a sense of optimism. I think the word pre-experiencing is a really beautiful word. We're using it to pre-experience what it would be like for the world to be like that if we did that. Imagine that not being there. Like we're doing this all the time on a micro-basis. That must make one feel very empathic, like gosh it must be extra hard to motivate.

JP: Motivate, right, and to take action.

EH: And to plan for the future.

JP: And it would make sense then, that I would have anhedonia.

EH: Ya. Because you wouldn't get that pleasure out of those visualizations or whatever.

JP: So now imagine I do an assessment of that in my depressed person or imagine I hypothesize that might be the case for my depressed person... then how can I use that to intervene with that person would you suggest?

EH: There are a whole bunch of ways you might use it. So we explored the idea of just getting people to practice simulating events. Imagine imagery like a muscle. You can train it up. It's dormant. Through practice or guided instruction, people could do it if they weren't spontaneously doing it. We did that in the laboratory and also Elisa Williams has done some internet based work, training people to imagine a more positive future about small every day events again and again. And Simon Blackwell has done some beautiful work in that area. So you could just focus on that. And I think that in and of itself can be very useful. The kind of people that are not quite ready to tackle the big negative... it's part of our toolkit. But perhaps we can be even more precise that that, perhaps there are many small things we can use positive imagery for. Perhaps if someone has a problem remembering to do their homework, getting someone to visualize doing it, and visualize bringing it back.

JP: Or forgetting to take... one of my guys who forgets to take his medication, we could do a mental imagery of taking the medications.

EH: Ya. That's exactly what we use imagery for. For predicting the future, for remembering to do things, mentally navigating our world. But there may be other points in the session where people reply a bit glumly when you ask them if they enjoyed something. And one can practice shifting mental modes. Is it more ... do you get a better response, are you better able to savor something if you're doing that in an image based form than verbally? If that's the case, is it helpful?
JP: Ah. So they did do the homework and they did try to do something that we were hoping would give them some positive emotions or gratification. But they don't seem to be experiencing it. We could ask them to recruit a positive image of the experience. Is that what you're suggesting?

EH: Ya. And certainly if we think about remembering something. Does it become more positive if you're able to add the image based detail and bring it to life more richly?

JP: OK.

EH: So just for boosting positive affect within the session to summarize that bit. But also boosting positive affect with relation to the future and completing tasks. As you pointed out, remembering to do things. That could be super useful too.

JP: OK. So now in your paper you describe some data suggesting that helping depressed patient imagine or recall positive things wasn't always so helpful, and that it sometimes led to an increase in negative mood. Can you talk to us about that?

EH: Yes, Jutta Joormann and others have done some beautiful work looking at if people are simply asked to be positive it can lead to mood deterioration. So her paper had a lovely title like "The Blues." If we present people with stuff that's just positive, say verbally, and we all know this, it can have a negative effect when one is in a depressed mood. So all sorts of things start happening like 'it used to be positive then but it's not now' or 'it might be positive for them, but not for me.' So kicking off a ruminative chain of thinking. Now I suppose rumination and verbal processing invites that kind of comparative style. And this deterioration, in fact the opposite gaining from positive information can happen in imagery mode so if someone is able to visualize ... because we know that imagery can feel more real, if you present positive information instead in an image based format rather than "Did you have a nice time when you last went on holiday?" "Yes it was all very nice but it was awful now." "I'd like you to imagine your last holiday. Tell me about that time on the beach. What did it feel like? What did it look like?" In your mind's eye, vividly. It's giving people that bit that's always saying no and comparing verbally ... just putting that aside for a minute and a chance to go back into episodic memory, imagery based processes, and a more experiential form of memory rather than that sort of combative verbal ruminative memory.

JP: Ah. Let me tell you what I'm hearing. You're suggesting... there is some data that you present in your paper that ... summarizing work from Jutta Joormann that if we have depressed people... and I'm thinking of a patient I saw in my office yesterday... if she recalls her marriage which broke up then she'll say "Oh I was so happy then but look at my life now, it's horrible." And so it seems to trigger rumination and comparative thinking that pulls her mood down.

EH: Exactly, that's exactly it. Ya.

JP:  And you're suggesting that one way to work around that is to spend a little more time on actually eliciting a sensory visual memory of the happiness of the memory to make it more real, and try to interrupt that comparative thinking. Is that what you're saying?

EH: Well, I guess imagery doesn't invite comparative thinking in the same way. What our heads do with words. That's why philosophers or politicians have arguments or people argue in words. You can do a lot of combative things in words. An image based format doesn't do that. So it might be that if your goal in the session was to focus on enhancing positive mood in that moment, then focusing on that positive information in an image based form may be beneficial. And that here and now positive thinking and testing that out-- suddenly lessening the amount of verbal comparative thinking. I think it's hard. In the situation in the past... there's a truth value to it. Things are more difficult now. But a nice place to start might be even with smaller things. So I got some good news this morning in the post but it didn't even make me feel happy because I just knew it would all get bad again. Actually just allowing someone to savor a small positive in the here and now by imagining it, getting more involved, helps boost even tiny experiences of positive affect. Simon Blackwell used the term positive flashes in everyday life. We need just tiny moments where we savor positive things. Even though all these other cascades and processes also continue sometimes.

JP: So that idea about these small positive flashes in daily life that our depressed patients are not spontaneously having. These kinds of interventions can be very powerful I think to help the person... like I get out of bed I think about my coffee.

EH: Ya. Me too. [laughter]

JP: I don't know that I have a visual image of it, but maybe I do! And it's part of... being able to imagine these things helps motivate my behavior and move me forward. So helping our depressed patients get those flashes of every day positives. Part of what you're saying that I think is worth highlighting is the visual image is more tightly tied to emotional experiencing than verbal thoughts. And just that idea alone I think has huge therapeutic potential for clinicians to use.

Wow. Ok, so now we're coming to the end, Emily, but I want to ask you one other thing which is ... part of what I'm interested in and what the SSCP is interested in is the integration of science and practice. Part of what you said earlier reminded me that as you say this work is in the early days in terms of clinical applications. So imagine you're a really sharp talented clinician like many of our listeners, and you wanted to start doing some assessment in your clinical practice to guide your clinical work. Is there any areas where detailed assessment of images if the clinician was tracking some of those things and tracking mood and emotions and behavior across time where there's a place where a clinician could make a contribution to the research area. Where are the places where you could imagine that could happen? I know that's a tough question.

EH: I think it's a lovely question. So I think it's so important that we have a strong link between science and clinical practice. I think it's incredibly important that that link's bidirectional. If you look at history, the time it's really worked is when scientists are learning from clinicians and clinicians are communicating with scientists. And I suppose because work in imagery has been increasing in the last decade, but there's still so much to do. I would love to see more single case studies on different ways that people can think about either the existence of problematic imagery or the absence of adaptive imagery. How they can build that within their case and make a difference. Even as we're talking, we're bouncing ideas off each other all the time. Oh, where could we use it in the formulation? What part of the process.. is it the process of doing therapy well? Or is it in remembering to do homework? Is it tackling the core part of the disorder? So I think there are so many interesting ways of thinking how can we enrich our toolkit to get beyond the good successes we're having with therapy but still the 50% of improvement we need to reach more people. And the more we can formalize that, measure that, have ethics obviously, but to write it up and disseminate, I think that's how advances in clinical science is made. It's by noticing these details and trying to collect evidence so that we can all keep working together.
JP: I think one of the beauties of your work, Emily, is that it's very clear that you are a clinician and you're sitting with the patient and you understand the details of the clinical phenomenon and you're also a basic scientist and you bring those together. That's part of why your work is so powerful. To go back to what you just said... so I can imagine I'm a therapist. I've been working with a depressed patient for a long time. I'm doing these traditional verbal interventions. The patient is not responding. And maybe I'm collecting symptom measures at every session so I know the patient is not responding. I have a clinical record that shows I've been doing these typical interventions. And then I could add some of these imagery interventions and assessments of the sort you're describing. And then if I got a response, that would be a single case. And you're saying there are a lot of creative ways that the therapist could use these imagery ideas, which makes total sense to me. That would be a beautiful single case that would be publishable, attending to these ethical issues, getting the patient's permission. Does that sound right?

EH: Absolutely. Clinicians are incredibly creative. And so are our patients. And so it's working together. I hope imagery can offer many different ways to change emotions, meanings, and behaviors. We've just got so much to learn.

JP: Beautiful. Any final word you'd like to offer us based on your research?

EH: I guess that we need to keep thinking about the building blocks of what we're doing in terms of processes. I hope what we've talked about with depression today has some relevance transdiagnostically.

JP: Ah. Say something about that.

EH: Well, we get negative images with many disorders. Like your patient with OCD.

Across different diagnoses, the human brain didn't evolve to have different types of ...it evolved to have different processes going on like memory, emotion, language, etc. So these processes are things that we could keep learning about across disorders, which is actually often our clinical reality. So I think understanding processes and building them into our work is one thing. I suppose the other thing relevant to this society is just encouraging clinicians out there interested in doing science to do that, to think about that, and to be part of research, or to work with researchers. It's exciting times for clinical psychological science. If we all work on it, we can all make a difference.

JP: Thank you, Emily. It is so much fun to talk to you and hear about what you're doing and hear about what your research can contribute to our clinical work. I thank you for your time. And I'd like to remind the listeners to complete the feedback survey that's on the webpage where you accessed this interview. And let us know how we can improve what we're doing here to add to your clinical work. Thank you again, Emily, it has been a pleasure.

EH: Thank you very much. It's been a pleasure to take part. I will continue to imagine it for a long time. [chuckle]

JP: Thank you very much, Emily.