Acute impact of self‐guided mental imagery on craving in cocaine use disorder: a mixed‐methods analysis of a randomized controlled trial
Authors: Lowry Natalie , Marsden John , Clydesdale Bethany , Eastwood Brian , Havelka Eva Maria , Goetz Camille 
Published: January 2021

AbstractMental imagery manipulations are used to treat several psychological disorders, but their utility in treating cocaine use disorder (CUD) is unknown. Using prompted re‐experiences and simulations with contrasting valence, we assessed the acute impact of a deliberate mental imagery task on cocaine craving.DesignA quantitative–qualitative ‘mixed‐methods’ analysis of data collected for a randomized controlled trial that was stopped prematurely.SettingUK National Health Service addictions treatment clinic and outpatient clinical research facility (laboratory).ParticipantsAdults with CUD. The original target sample was 120. All participants enrolled at the point the original trial was stopped were included (38 enrolled, 31 completed study).InterventionsPersonalized (3‐minute) cue–exposure (handling cocaine paraphernalia and watching video of drug preparation), immediately followed by a single 5‐minute, audio‐recorded, self‐guided and verbally described imagery task with random assignment to one of four conditions: two mental imagery memory re‐experiences (positive image before initiation to cocaine use or a negative image of a ‘worst time’ adverse cocaine use episode) or two future simulations (positive theme of recovery from CUD or negative theme of worsened CUD).MeasurementsTask transcripts were rated for imagery detail using five dimensions using a six‐point scale of imagery detail (ID) (total score = 0–25) and thematically coded. The outcome measure was cocaine craving using the Craving Experiences Questionnaire—strengths version (CEQ–S11; score = 0–110) reported at baseline, arrival at the laboratory, and immediately after the cue–exposure and mental imagery tasks.FindingsA mixed‐effects, longitudinal, restricted linear regression, with the past‐positive imagery condition as referent, showed main effects of reduced craving after the imagery task (b = –29.2, 95% confidence interval (CI) = –45.3 to −13.1, P‐value < 0.001) and increased craving for the future‐negative task (b = 14.2, 95% CI = 0.1–28.4, P‐value 0.049). There was a future‐negative task by post‐imagery craving interaction (b = 28.1, 95% CI = 0.1–56.1, P‐value 0.049). A theory‐driven, deductive/inductive qualitative analysis of the transcripts revealed six major themes: sensory characteristics, CUD vicious cycle, self‐care, emotions and appraisals, social role and CUD recovery. Positively themed simulations included interpersonal connections and rewarding activity; negative images included personal adversity, with appraisals of self‐criticism and hopelessness. Transcripts with more imagery detail were not associated with significantly greater reductions in craving in the positive or negative imagery task (r = –0.32, 95% CI = –0.69 to 0.13 and r = 0.06, 95% CI = –0.58 to 0.53, respectively).ConclusionIn people with cocaine use disorder, after cue–exposure, a self‐guided imagery task with positive themes reduced craving, whereas mental imagery simulating worsened cocaine use disorder did not appear to.