Emily Holmes: "A picture is worth a thousand words"

Combining insight with inexhaustible curiosity, Emily Holmes is trying to understand more about how our internal mental images are connected to our psyche. Her objective: To develop new psychological treatments that can reach sufferers of trauma including newly-arrived immigrants – without needless delay.

Text: Cecilia Odlind, first published in Swedish in Medicinsk Vetenskap no 1, 2017

A picture is worth a thousand words. This old adage is one of Emily Holmes’ favourites, and her research shows that a picture really can have a considerably stronger influence on our feelings than words that describe the equivalent situation. Without thinking about it, we regularly experience mental images – this could, for example, be a visual memory of something we’ve recently experienced, such as a disagreement with a colleague or a kiss from a new love.

“These mental images can have a powerful effect on our emotional state by throwing us backwards and forwards in time. The fact that they have such a strong emotional effect on us makes them particularly interesting to study – not least among people who suffer from various types of psychological problems”, says Emily Holmes, psychologist and newly-appointed professor at the Department of Clinical Neuroscience at Karolinska Institutet, and previously of the Medical Research Council at Cambridge and Oxford University in the United Kingdom.

Her interest in mental images and their connection to mental health began when, as a newly-qualified clinical psychologist, she started treating refugees suffering from post-traumatic stress disorder (PTSD). PTSD is a form of psychological disorder that can arise following a traumatic experience. It can occur a result of events where an individual has experienced a life-threatening situation. Anybody who is involved in a traumatic event – such as a serious car accident or a traumatic child birth, for example – can potentially be affected. People with PTSD often experience intrusive memories from the traumatic event (colloquially known as ‘flashbacks’), where images or sequences of images present themselves involuntarily (unbidden).

“What is typical for these intrusive memories is that they are image-based, they appear suddenly, and they are difficult to avert. Many people after trauma experience intrusive memories initially, and they can be important in helping us to avoid ending up in similar situations in the future. But when these intrusive memories impair functioning in our daily lives and become more permanent, then help is needed”, says Emily Holmes.

For people with fully-developed PTSD, effective treatments are now available in the form of trauma-focused cognitive-behavioural therapy and EMDR – eye-movement desensitization and reprocessing therapy. Such evidence-based treatments are both relatively time-consuming and resource-intensive. There is still a lack of effective preventative treatments which could be used directly after a trauma has been experienced.

“If we can find ways of reducing the magnitude of the problem at an early stage and preventing the build-up of symptoms, we would be in a much better position”, says Emily Holmes.

There has also been a lack of basic knowledge about why certain traumatic experiences result in intrusive memories and why some people, but not all, are affected. Neither gender, genetics nor age seem to have notably large effects on the risk. But one thing is apparent: if other people are involved in the trauma, there is a significant increase in the risk of developing PTSD.

“Of the people that have been caught up in natural catastrophes, such as an earthquake, relatively few go on to develop PTSD, whilst the risk is considerably greater following experiences such as rape, assault and torture”, says Emily Holmes.

In order to understand more about intrusive memories, she and her colleagues have studied the phenomenon in the laboratory using films featuring traumatic events – for example, a public safety film warning about the effects of drink-driving.

“This is an established method to create temporary intrusive memories that we will can then investigate to help understand and develop treatments”, says Emily Holmes.

“It is becoming possible to identify which images in the film – so-called hot spots – will later become for the particular person being studied. I find this incredibly fascinating”, says Emily Holmes.For many years, this method has enabled them to study the phenomenon of intrusive memories. Among other things, the researchers are able to register the participant’s brain activity before, while and after they watch the film. Some of the results have surprised Emily Holmes; for example, by observing the changes in the flow of blood to the brain, it is possible to predict which scene in the film will later appear in the form of an intrusive memories This can be predicted from data even before the person has actually experienced a flashback.

Her research group has also shown that it is possible to reduce the occurrence of intrusive memories by making the participant in a study perform a certain types of task shortly after they have watched the film. In order to achieve the desired effect, the task needs to involve using mental imagery, such as the computer game Tetris, for example.

“We are exploiting the fact that the brain is not able to hold in mind two images simultaneously”, says Emily Holmes.

Their studies show that, even some time after the experimental trauma, it is possible that, by making the participant play Tetris at the same time as they relive (in controlled conditions) their memories of the event, the occurrence of intrusive memories can be reduced.

“It is not so much a question of deleting the memories, but is more about making the memories less intrusive”, says Emily Holmes.

The research group has taken this further and tested the hypothesis in real-life situations – including with trauma patients at a hospital emergency-care clinic and, in a smaller study, with newly-arrived refugees.

“In recent years, many refugees have arrived in Sweden and a significant proportion of them have intrusive memories of traumatic events, which means that they can find it difficult to maintain concentration. At the same time, they are trying to learn a new language and are expected to make adjustments so that they can integrate into their new country. In coping with these challenges, many would benefit from advances in evidence-based psychological treatments”, says Emily Holmes.

She does not hesitate to meet the people that she ultimately hopes to help. When the flow of refugees to Stockholm was at its height in 2015, Emily and her colleagues were at the central station to recruit participants for their study. According to Emily Holmes, there was great interest among the refugees they encountered in taking part in the study. She believes that many of the younger people would be interested in participating in forms of treatment that involve mobile phones and computer games than only in conversational therapy.

“There is an extensive need for simple and accessible forms of treatment. This is where we hope to make a research contribution”, she says.

But Emily Holmes’ research is not only concerned with PTSD – it also includes other psychological conditions. Interestingly enough, our general capacity to conjure up mental images also applies to potential future events, in the form of her group has called ‘flashforwards’. Research shows imagining future events in the form of a picture – a flashforward – can increase the subjective probability of the event occurring and drive behaviour. In this way, flashforwards can serve to support us in the practical implementation of the plans that we have considered. But they can also cause problems.

“A person with bipolar disorder who is experiencing a manic period might see clear images of the future in his/her mind. This could, for example, be a picture of the person in a new sports car. If the person is in a depressed state, however, the image could be of their own suicide. The pictures are recurring and have a powerful emotionally impact and may even influence behaviour”, says Emily Holmes.

She believes that we underestimate the strength and effect of these internal pictures, and has long incorporated mental imagery into her cognitive behavioural therapy with patients as a complement to verbal therapy. One example is her work with depressed patients, where the objective is to get the patient to imagine positive pictures of future events. But it is not simply a matter of ‘thinking positively’.

“Thinking of positive statements in word form can actually have the opposite effect. But by using pictorial thinking, a more positive effects on emotion can be achieved”, she says.

According to Emily Holmes, a great deal of knowledge is still lacking from the overall research field of mental health. Worldwide, one in four individuals suffers from mental health problems and this figure looks set to increase. But, consideringthe scope of the problem, she believes that research in this field is scandalously underfunded.

“With increased resources, we would be able to both develop better and more accessible treatments and learn more about how the brain works. We are all at risk of experiencing trauma or suffering from mental illness, so we could all benefit from such investment – everybody from someone having a motor bike accident to a refugee who has fled a war”, says Emily Holmes.

Emily Holmes on...

… a role-model
The chemist Dorothy Hodgkin was the first – and, so far, only – British woman to be awarded the Nobel Prize. She mapped the crystal structure for, amongst other things, insulin and penicillin. Her strong interest in images and basic science resulted in practically useful knowledge.

… a good quote
“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less.” This is attributed to the French scientist Marie Curie – two times winner of the Nobel Prize and the first female winner.

… the importance of collaboration
I am passionate about increasing the dialogue between clinical and laboratory researchers, between psychologists and neuroscientists, and between people in general. I myself have worked together with various disciplines from mathematicians and philosophers to voluntary organisations and artists.

… being an academic citizen
A researcher should not only involve themselves with their own narrow field of interest. Research must be able to be used if it is to resolve important problems in society. In turn, this demands that researchers must communicate, inspire and become engaged beyond their own immediate sphere of interest