Research Paper

British Journal of Occupational Therapy

2015, Vol. 78(7) 404–411

Using drawings of pain-related images to ! The Author(s) 2015

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understand the experience of chronic pain: A DOI: 10.1177/0308022614562791
bjo.sagepub.com
qualitative study

Joanna Phillips1, Jane Ogden2 and Claire Copland3

Abstract
Introduction: This study aimed to use drawing as a means to explore the content of pain-related images in a sample of people
with chronic pain.
Method: Adults (n ¼ 90) attending three United Kingdom National Health Service pain clinics were asked to bring to mind and
draw an image of their pain. Drawings were analysed using critical visual analysis methodology.
Results: Fifty-four participants drew a picture of their pain. Drawings were vivid, emotionally charged and included catastrophic
interpretations of pain. Image content was described using three main themes: pain as an attacker, the nature of pain (pain
sensations, timeline, pain location) and the impact of pain (pain as a barrier, being trapped by pain and the future with pain).
Drawings reflected different perspectives taken in the image, with images of the person themselves in pain (as if seen through the
eyes of an observer) evoking a sense of helplessness and isolation.
Conclusion: Pain-related images can provide a valuable insight into people’s pain worlds, with images reflecting pain cognitions
and barriers to recovery. Clinicians may find drawing a helpful tool in the assessment and management of chronic pain, enabling a
visual and shareable language for pain.

Keywords
Chronic pain, imagery, drawing, illness perceptions, cognitions

Received: 23 March 2014; accepted: 11 July 2014

(Biro, 2010: 15). As a consequence, pain is often portrayed

Introduction
Chronic pain can be a debilitating condition which is
often associated with a long journey of medical investi-
gations and treatments in search of an explanation and
cure. Some research indicates that patients may have
images of their pain and that these may form a useful
basis for communication, assessment and treatment. The
present study was carried out by psychologists and
aimed to explore whether patients with chronic pain
could spontaneously evoke and draw an image of their
pain and to use visual imagery analysis to describe and
evaluate these images.
Literature review
The complexity of chronic pain often makes it difficult
both to understand and describe to others. The largely
invisible nature of pain and the lack of objective measure-
ment tools poses challenges for pain assessment, and can
leave people feeling misunderstood or not believed (Clarke
and Iphofen, 2008). Pain has been described as an experi-
ence which challenges language like no other, leaving
people feeling ‘tongue-tied’, with an ‘absence not only of
words to describe it but also of ways to think about it’
as an isolating and lonely experience (Newton et al., 2010).
In light of these challenges, ways to enable clearer com-
munication about the complex pain experience warrants
exploration. For some people, visual imagery (or mental pic-
tures seen in the mind’s eye) may prove more helpful than
verbal description, as images encapsulate a valuable insight
into the person’s pain beliefs and perceptions of pain.
In line with self-regulatory approaches to health and
illness, people come to develop common-sense beliefs
and an understanding about their condition in an attempt
to cope with illness and respond to threat (Leventhal et al.,
1997). For example, beliefs a person holds about a condi-
tion’s cause, the symptoms, how long it will last, its con-
sequences and the extent to which it can be controlled are
likely to influence subsequent help seeking and behaviour.
1
Clinical Psychologist, University of Surrey, Guildford, UK
2
Professor in Health Psychology, University of Surrey, Guildford, UK
3
Consultant Clinical Psychologist, St George’s Healthcare NHS Trust, London,
UK
Corresponding author:
Jane Ogden, Professor in Health Psychology, University of Surrey, School of
Psychology, Faculty of Arts and Human Sciences, AD Building, Guildford,
Surrey, GU2 7XH, UK.
Email: J.Ogden@surrey.ac.uk
Phillips et al.
Therefore, accessing information about such beliefs has
important implications for tailoring treatment
interventions.
The cognitive process of imagery has been found to
feature across a range of presenting problems (Brewin
et al., 2010), and has received increasing attention within
anxiety disorder research and cognitive therapy advances
(Hackmann et al., 2000, 2011; Speckens et al., 2007).
Indeed, clinical observations and recent research in the
field of chronic pain indicate that a substantial number
of pain sufferers experience imagery related to their pain
(Gillanders et al., 2012; Jamani and Clyde, 2008; Philips,
2011; Wintercrowd et al., 2003). Clinical descriptions of
such images suggest four main image ‘types’ that typically
comprise images of the pain itself, the person in pain,
relationships with others (for example, being misunder-
stood) and, finally, images of a future with pain
(Wintercrowd et al., 2003). Early findings indicate a link
between pain-related images (PRI) and pain catastrophiz-
ing (thinking negatively about pain) (Gillanders et al.,
2012). Pain-related images may have a powerful role to
play in contributing to fear-avoidance cycles in chronic
pain (Jamani and Clyde, 2008), therefore impacting
upon subsequent adjustment and having valuable implica-
tions for pain management interventions. Accruing evi-
dence suggests people are able to pictorially represent
how they ‘see’ a specific health condition in their mind’s
eye, using methods such as drawing and photography.
Studies have included pictorial representation of heart
failure (Reynolds et al., 2007), cancer (Harrow et al.,
2008), headaches (Broadbent et al., 2009), myocardial
infarction (MI) (Broadbent et al., 2004) and chronic
pain (Henare et al., 2003; Padfield, 2003). Resulting pic-
torial representations have been found to be linked with
recovery; for example, the extent of heart damage drawn
was found to predict recovery better than medical indica-
tors in MI patients (Broadbent et al., 2004). Further find-
ings indicate that pictorial representations can be valuable
as a communication tool to enhance understanding
between the person and their health professional, and in
enabling the sufferer an opportunity to reflect upon and
make sense of their pain experience (Henare et al., 2003;
Maclean, 2009).
Recent research has therefore highlighted a potential
role for visual imagery across a number of chronic con-
ditions including chronic pain. Furthermore, studies sug-
gest that imagery may be related both to the patients’
experience of their condition and their subsequent recov-
ery. In addition, it has been argued that imagery may be
a useful communication aid for health professionals to
use during the consultation. To date, however, little is
known about the ways in which people with chronic
pain visualize their pain. Therefore, in line with this,
the present study aimed to explore whether people
with chronic pain can spontaneously generate pain-
related imagery when asked to draw an image of their
pain. Furthermore, using a qualitative approach and
critical visual analysis the study aimed to offer an in-
depth insight into the content and nature of such images
405
as a means to explore whether such drawings could con-
tain rich information about the pain experience, beyond
that accessible through verbal language.
Method
Design
This qualitative study was nested within a larger cross-
sectional study, with an overarching aim to explore the
role of pain related imagery in the experience of chronic
pain. This current paper focuses on the qualitative content
of the pain-related drawings.
Participants
Participants were recruited from three National Health
Service (NHS) pain management programme (PMP)
services in greater London. All eligible new referrals
and follow-up patients attending the PMP services
during the recruitment time frame (September 2010
to May 2011) were invited to participate. In line
with the services’ referral criteria all participants were
adults experiencing chronic pain, and had malignant
causes of pain excluded. Participants were excluded
from the study if they did not have sufficient
English to complete the questionnaire. Participants
were approached in the waiting room by either the
researcher or the receptionist and approximately (due
to some data not being recorded at one site) 200
people chose to take away a questionnaire pack and
90 completed questionnaires were returned. Of those
90 participants, 54 provided a drawing of their pain-
related image and comprise the study sample reported
here. The study was approved by the NHS Research
Ethics and the relevant Research and Development
committees.
Measures
Items were developed in collaboration with a pain man-
agement specialist and were piloted by four individuals
with chronic pain. Demographic information collected
included gender, age and ethnicity. Participants also com-
pleted quantitative measures of their pain experience.
They then took part in a drawing task to elicit their pain
related imagery.
Pain experience
Participants indicated the pain location (for example,
lower back, upper back and head) and if they had a diag-
nosis to explain their pain (Yes/No), with a yes response
prompting elaboration. Pain duration was described in
years and months. A Visual Analogue Scale (VAS) mea-
sured present pain intensity, a widely used, validated and
sensitive self-report measure (Jamison et al., 2002). The
VAS consisted of a 10 cm line anchored either end by
two descriptors no pain and worst possible pain, resulting
406
in a score from 0 to 100 with a higher score reflecting
greater pain.
The drawing task: Pain-related imagery
The drawing task was embedded in the longer question-
naire and began with a description of imagery: ‘In this
study we are interested in the mental images, pictures or
impressions that go through people’s minds when they
think about their pain’. It was further explained that
images might also include things the person can imagine
seeing, feeling or hearing and that images may be fleeting
or longer lasting, be pleasant or unpleasant and may relate
to the future, present or past. This information is based
upon findings from broader imagery research and practice,
and preliminary findings in the chronic pain domain
(Gosden, 2008; Hackmann et al., 2011). The questionnaire
instructions guided participants to bring an image of their
pain to mind, to make this as vivid as possible and draw
the image in the blank space provided. The space was half
an A4 page and participants completed their drawing at
home. No drawing pens or pencils were provided.
Participants were reassured that drawing ability was not
being considered. Instructions were adapted from previous
research using drawings (Broadbent et al., 2009). The
drawing item was followed by an open-ended question
(‘please add any comments if you feel it might help us to
understand what your drawing means to you’) to aid
analysis.
Data analysis
To generate insight into PRI content, the pain drawings
were described and interpreted using Rose’s critical
visual methodology framework (Rose, 2007) as recom-
mended by Guillemin (2004) for use in drawing analysis.
Rose (2007) proposes that meanings of a visual image
are made at three sites: image production (how an
image is made), the image itself (what it looks like)
and the site of audiencing (how it is seen). The analysis
focused on a compositional interpretation as a means of
exploring picture form and content; therefore, looking
mainly at the site of the picture itself. Where partici-
pants had annotated drawings or provided a written
description this was used to inform interpretation. The
researcher posed a series of questions to guide the ana-
lysis process. These included questions about image con-
tent, colour and light, organization and expressive
content. Themes generated from the picture interpret-
ation were also described. The findings were then dis-
cussed between the researchers and changes were made
when it was felt that alternative terms could be used to
best describe the images. The researchers all have a
background in psychology (academic and clinical)
which may well have influenced the analysis with our
emphasis on sense making, coping and pain as a per-
ception. It is felt, however, that such a perspective is
very much aligned with most health professionals work-
ing in the field of chronic pain management, particularly
British Journal of Occupational Therapy 78(7)
those which prioritize the patients’ experience and prefer
non-medical approaches where possible.
Results
Participant demographics and pain
characteristics
Fifty-four participants provided a drawing of their pain-
related image. The majority of participants were female
(80%, n ¼ 43), of white ethnicity (85%, n ¼ 46) and were
aged between 22 to 79 years old (M ¼ 53 years).
Participants indicated multiple pain locations, with the
most frequently reported site (70%, n ¼ 38) as lower limbs
(knees, legs and feet), lower back (70%, n ¼ 38) and neck
and shoulders (50%, n ¼ 27). Participants had suffered with
pain for a duration which ranged from 1 year 4 months to
30 years (M ¼ 10 years). Pain intensity as measured by the
VAS ranged from 6 to 100 (M ¼ 57).
The majority of participants (94%, n ¼ 51) indicated
they had a medical diagnosis or diagnoses to explain
their pain. A quarter of the participants reported more
than one diagnosis. The qualitative information partici-
pants provided was categorized for descriptive purposes
in liaison with a specialist chronic pain physiotherapist.
The most frequent diagnoses (40%) were classified as
degenerative changes (included osteoarthritis, disc
damage and spinal conditions). The second and third
most frequent diagnoses were described as neuropathic
(16%, for example, sciatica, nerve damage and complex
regional pain syndrome) or another classification (13%,
for example, bursitis, scar tissue and diabetes). Less fre-
quent diagnoses included conditions such as fibromyalgia
and chronic fatigue, rheumatoid arthritis, onset following
trauma and onset after spinal surgery. All participants
have been given pseudonyms.
Visual analysis of the pain pictures
The majority of participants did not use colour, provid-
ing black pen or pencil pictures. However, 15% used
colour including red, green and blue. Participants
tended to annotate their drawings. For some partici-
pants, annotations included reference to colour; for
example, ‘because it (the pain) is so hot, I imagine
that the colour is deep red’ (James). The highest pro-
portion of participants (41%) drew images of pain as
external to them; for example, a monster, weapon or
abstract shape. Some participants (28%) drew images
of themselves in pain, and a similar proportion drew
pain sensations as metaphors (for example, flames).
The remaining participants drew painful body parts.
Three main themes were generated from the visual ana-
lysis. These comprised pain as an attacker, the nature of
pain and the impact of pain. Some pictures were described
using more than one theme (for example, where partici-
pants had drawn multiple images in the space provided).
Overall, the expressive content of the images reflected a
sense of attack, helplessness, isolation and fear.
Phillips et al.
Theme 1: Pain as an attacker. Almost one-third of the pic-
tures primarily represented pain as an attacker. These
images were interpreted as having two different image per-
spectives. First, an image of pain as an externalized
threatening object or other, and second, images drawn
from an observer perspective, depicting the person being
attacked by pain (see Figure 1).
Pain as an externalized threatening object or
other. Pictures reflected pain as something external
to the person, and this was felt to be threatening.
Pictures represented pain as a dragon, a monster, as
spiky shapes, a vicious set of teeth, and a box with sharp
points tied with string. Weapons were portrayed in many
of the pain image drawings (for example, swords, arrows,
sharp objects, nails and knives). Verbal descriptor words
used to annotate drawings also included frequent reference
to weapons. The pictures were large, filling the page and
creating a sense of pain as an enemy and a dominating
force.
Figure 1. Pain as an attacker (externalized, being attacked).
407
The person being attacked by pain. Pictures drawn from
an observer perspective depicted the person themselves
being attacked in the image. Pictures included people
being stabbed, squeezed and shot with arrows; expressing
a fight with pain, of being beaten and of the person being
one of pain’s victims. One participant drew a series of four
images creating a powerful picture narrative. The story
reflects a metaphor of the person as a happy floating bal-
loon who becomes scared by threatening arrows of pain
and falls to the ground deflated and in agony having been
hit by the pain arrows. The participant annotated the story
with: ‘A balloon is floating happily then an arrow (pain)
comes and ruins everything! The balloon is me! And it
(pain) wins. I see it coming and I am (the balloon) left
feeling deflated and defeated’ (Sarah).
Theme 2: The nature of pain. Almost half of the pictures
were interpreted to represent the nature of pain, reflecting
participants’ beliefs relating to pain sensations, time line
and location (see Figure 2).
408
Pain sensations. Pictures contained metaphorical
images and used colour and texture to describe pain sen-
sations. For example, pictures included fireworks, flames,
lightning, pins and needles, hot and cold taps and broken
glass. Colour was used to communicate the felt sense of
intensity and heat, with red being used to create a vivid
drawing of flames, and a sun which was annotated to be
‘burning and throbbing’ (Amy). One participant wrote
‘the worse my pain is, the stronger the colours are in my
mind’ (Amy). Texture in the picture was reported by one
participant to relate to tension levels.
Time line. Pictures representing perceptions of the time
line of pain conveyed pain as constant, although varying
in intensity. One participant drew a series of graphical
representations of their pain levels over time, illustrating
high pain peaks. Another participant pictured pain as a
weather forecast, annotating their drawing with the
description ‘continuous bearable pain but more severe at
regular intervals’ (Sally). The pictures further expressed a
sense of pain as having no end, and of the person having
little control of their pain.
Pain location. Pictures represented pain location.
Participants either drew a person and indicated where
Figure 2. The nature of pain (sensation, timeline and location).
British Journal of Occupational Therapy 78(7)
the pain was or drew a painful body part. Isolated pictures
of body parts were felt to reflect attentional focus on that
area and their perceptions on cause and prognosis; for
example, one participant drew their shin bone and com-
mented ‘see pain as blackened and rotting bone as if gone
bad’ (Rachel). Another participant drew their back and
commented: ‘I only picture the damaged body parts and
how much worse they may get, also how anybody can put
them right again as they will continue to wear out when I
use them’ (Caroline).
Theme 3: The impact of pain. For a proportion of partici-
pants the PRI drawings reflected concerns and beliefs
about pain’s impact, with the pictures expressing the
sense of pain as a barrier, being trapped by pain and the
future with pain (see Figure 3).
Pain as a barrier. Pictures represented pain as an exter-
nal blocking object, such as a wall or a bolt through the
neck. The pictures expressed the consequences of pain
stopping the person from engaging with valued activities,
and reflecting pain as blocking the person communicating
emotional distress. The experience of having the image
was reported as intense, with one participant annotating
their picture of a grid like structure to say ‘it was not so
Phillips et al.
Figure 3. The impact of pain (as a barrier and feeling trapped).
much a vivid image as a feeling of the image that was
intense’ (Hannah).
Being trapped by pain. Participants reported images of
darkness, conveyed through pictures of black shapes),
black holes and dark clouds. One participant drew them-
selves stuck in a hole, and two participants described in
words images of pain being chained to them (for example,
image of a ball and chain and a tight metal shackle). The
pictures appeared to express fears of isolation and a sense
of helplessness and hopelessness.
The future with pain. A small number of PRI repre-
sented perceptions about a future with pain. The pictures
reflected threats to identity, a fear of being a burden, and
death (for example, drawing of a gravestone engraved with
RIP). One participant commented ‘I see a bed and me
almost unable to get out of it and then to be a burden
to my family’ (Maeve). However, images for this partici-
pant and one other expressed a sense of hope for their
future, with the above participant commenting ‘but I am
strong and I wish to fight this happening’ (Maeve).
Discussion and implications
The present study aimed to explore whether people with
chronic pain could spontaneously generate an image of
their pain and to offer an in-depth characterization of
the content and nature of such images using visual ana-
lysis. Primarily, the results demonstrated that a high pro-
portion of participants were able to deliberately evoke a
pain-related image in response to a questionnaire item,
and visually represent this image by drawing it.
Furthermore, as anticipated, the pain drawings generated
rich data, providing an idiosyncratic representation of
pain perceptions and an insightful journey into people’s
pain worlds.
The images paralleled clinical experience and reports of
images from people with chronic pain. Pictures were vivid,
emotionally charged, and reflected catastrophic interpret-
ations and beliefs about pain. Broadly speaking, images
409
were consistent with the four types suggested by
Wintercrowd et al. (2003) reflecting images of pain itself,
the person in pain and images of a future with pain.
Images relating to the fourth image type, ‘relationships
with others’, were reflected less so in the present study.
A small sample of the pictures reflected a sense of hope
for the future.
Three main themes emerged from the drawn pain
images: pain as an attacker, the nature of pain and the
impact of pain. Images largely painted a vivid picture of
pain as an enemy and as an isolating and hopeless experi-
ence. Frequent reference was made to weapons, both
through the use of drawing and annotation of the
images. Colour (and lack of colour), shading, size and
both literal and metaphorical images portrayed pain as a
threatening and dominating experience.
Many of the image drawings encompassed the nature of
pain, reflecting illness beliefs and perceptions as proposed
within the common-sense model of illness (Leventhal
et al., 1997). Images represented pain sensations or symp-
toms, and the timeline of pain. For some, pain was por-
trayed as uncontrollable and images also depicted the
consequences of pain. A number of images focused upon
painful body parts and conveyed the person’s beliefs about
the cause of their pain (for example, ‘blackened’ and ‘rot-
ting bone’), and the belief that pain was worsening due to
wear and tear.
Images which portrayed the impact of pain comprised
emotive content and illustrated a picture of pain as an
overpowering and dark force. Within these images, par-
ticipants saw themselves as being trapped and held back in
their lives by pain (sometimes as if a prisoner to pain).
With the exception of a couple of participants, these
images painted a bleak outlook on a future with pain.
What emerged of particular relevance was the perspec-
tive taken in the image. Participants pictured pain as an
externalized object or other (as if seen through their own
eyes) or pictured themselves in pain (as if seen through the
eyes of an observer). In accordance with the suggestion by
Hackmann et al. (2011) the perspective taken may have
clinical significance. Pain images drawn from an observer
410
perspective were felt to represent the person as a vulner-
able victim of pain, evoking a sense of helplessness, isola-
tion and of feeling ‘beaten’ by pain’s vicious and
unpredictable attack.
The study has its limitations, such as the process of
completing a PRI drawing task within the remit of a ques-
tionnaire, as participants did not then have an opportunity
to discuss it and its associated meaning with the
researcher. Therefore, the reported meaning encapsulated
within the pictures was informed by picture content and
annotations only. Furthermore, and in line with all quali-
tative methods, this approach is open to the specific per-
spective and disciplinary perspective of those carrying out
the analysis. All researchers are psychologists which may
well have influenced the meanings attached to the images
and the ways in which they were interpreted. Furthermore,
the use of colour features as important in the analysis of
visual material (Rose, 2007), yet, the questionnaire
instructions did not encourage the use of colour and
people were limited to whatever drawing materials were
available to them in their home setting.
Pain-related images have the potential to provide direct
access into the pain experience thereby communicating
information about pain cognitions, the person’s relation-
ship with pain and inherent emotions. This has implica-
tions for both research and clinical practice. In terms of
research, further studies are needed on a larger scale to
explore the representativeness of the current findings and
to enable an assessment of differences in imagery accord-
ing to factors such as age, gender, time since pain onset
and types of treatments attempted. In addition, research
could evaluate the usefulness of using imagery in practice
in terms of improving both communication between
health professional and patient and the patient’s own
experience of their pain. In terms of clinical practice,
there are implications for both assessment and treatment.
First, in terms of assessment, using imagery could enhance
information collected during an assessment process
increasing an understanding of the patient’s own beliefs
and sense-making processes. Furthermore, asking the
patient to draw their pain may be useful for those who
find it difficult or distressing to articulate their pain experi-
ence verbally, creating a visual tool to be used by both the
patient and clinician. Second, pain imagery may also be
useful for treatment. For example, a recent study has pion-
eered the way in evaluating direct image work in pain
sufferers using images as the basis for re-scripting. In par-
ticular, participants were asked how they would prefer
their pain image to be and then to generate a rescripted
image. The results showed reductions in negative emo-
tions, appraisals and pain during the recall of the
rescripted image (Philips, 2012).
In line with this, an example of how images could be
used in practice follows. First, a patient with pain could be
asked to evoke and draw an image of their pain. Using the
image from one participant in the current study as an
example, this might be of themselves as a balloon left
defeated and deflated by the arrows of pain. The clinician
could then encourage the person to try to generate a more
British Journal of Occupational Therapy 78(7)
positive narrative; for example, imagining themselves
taking control of pain by perhaps using pain management
tools to blunt pain’s arrows, throw water over the flames
or strengthen the outer layer of the balloon. This could
help to enhance the patient’s sense of agency and shift
them to a position of empowerment. The person may
then find it helpful to rehearse the new image. It is
hoped that this might exert an impact through increasing
confidence to manage when pain strikes and by reducing
the threatening image impact, therefore enabling the
person to feel less scared of pain and more likely to
return to previously avoided activities. In this way,
direct image interventions may enhance a person’s confi-
dence to take control of the pain, to reduce the impact of
pain in their lives and enable them to find their way out of
the darkness often created by pain by eliciting hope.
Conclusion
The present study’s key message can be summed up as
‘a picture paints a thousand words’. Images about pain
contain valuable information about the chronic pain
experience. Facilitating people with chronic pain to see,
paint and repaint their pictures of pain has exciting impli-
cations for clinical practice. Drawing provides a means to
access people’s pain imagery, providing a simple yet uni-
versal and powerful assessment tool. Such self-generated
pictures of pain have the potential to overcome communi-
cation and cultural barriers, and to identify unhelpful pain
beliefs. In this way, pain drawings defy the inability of
language to articulate the often abstract pain phenomena,
thus providing a visual and shareable language for pain.
Key findings
. Most chronic pain patients were able to evoke and
draw an image of their pain.
. The images provided insights into their pain experi-
ences above and beyond the use of words.
What the study has added
Asking patients to draw an image of pain may be a
useful forum for both the assessment and treatment
of chronic pain.
Acknowledgements
We would like to thank our participants for taking part in the study
and sharing their experiences. Thank you to the team members at the
pain services involved for their expertise and assistance with data
collection. We would also like to thank David Gillanders and Clare
Philips for sharing their early work in this field.
Research ethics
The study was approved by the NHS Research Ethics and the rele-
vant Research and Development committees (Rec No: 10/H0803/75).
Declaration of conflicting interests
None declared.
Phillips et al.
Funding
This work was supported as part of the clinical psychology doctoral
training programme for JP at The University of Surrey.
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