Imagery Rescripting as a Method to Change Emotional Memories & Schemata/Representations

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Imagery Rescripting

as a Method to Change

Emotional Memories

& Schemata/Representations

Arnoud Arntz

Maastricht University the Netherlands

Overview

• What is imagery rescripting?

• History

• Clinical effects

• Practice: adult trauma

• Practice: childhood trauma

What is Imagery Rescripting

• Imagine the experience of a traumatic/nasty

memory

• Imagine that somebody (yourself, another

person, a fantasy figure) intervenes and

changes the outcome

– Realize needs and wishes and meet them – Express inhibited responses (e.g. attack instead

of freeze)

– Change of meaning of the UCS/UCR representation

History

cf. Edwards (2007). BTEP, 38, 306-316

• Already used by ancient Egyptians & Greek • Hypnosis, dissociation theory:

– Janet (1889) “imagery substitution”

• Psychoanalytic: often more symbolic than autobiographic

– Jung (1918) “active imagination”

– Ferenczi (1929) “neocathartic method” (‘work with split-off child parts’)

– Leuner (1984) “guided affective imagery”

• Experiential therapies

– Gestalt (Perls, 1973): ‘unfinished business’ – Transactional Analysis (Erskine, 1980): ‘script cure’

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History

cf. Edwards (2007). BTEP, 38, 306-316

• Early CBT: imagery work, but little rescripting

– Wolpe (> 1950): systematic desensitization – Cautela (1977) & Lazarus (1984): covert rehearsal,

positive time projection

• Later CBT: more restructuring of the image

– Edwards, Smucker, Young: learned from Gestalt – A.T. Beck, D.M. Clark: integrated in CT for anxiety

• But, until approx. 2000, mostly viewed as unscientific

Why is Imagery Important?

• Imagery evokes emotions; emotions evoke images (Holmes, 2005, 2007)

• Restructuring ideas and interpretations is much more effective if imagery is involved (Holmes et al., 2009)

• Little difference in activated brain regions between imagery and real experience

– Even when the person realizes the image is not a real perception

• ImRs changes the memory representation (in meaning & emotions): different mechanism than exposure (which leads to learning when the US is not occurring).

Clinical Applications

• PTSD (Ehlers & Clark, 2000, 2003, 2005; Smucker et al., 2007; Arntz, Kindt & Tiesema, 2007) • Nightmares (Krakow et al., 2001; Davis & Wright,

2007)

• Simple Phobia (Hunt & Fenton, 2007)

• Social Phobia (Wild, Hackmann, & Clark, 2007) • Depression (Wheatley et al., 2007, 2008) • Eating Disorders (Cooper et al, 2007)

• Personality Disorders (Weertman & Arntz, 2007;

PTSD Treatment Study

• Imaginal Exposure vs. Imaginal Exposure

& Imagery Rescripting

• 10 sessions

• 67 participants

• All kinds of trauma; 1/3 multiple

• index trauma

– 1/3 sexual assault – 1/3 nonsexual assault

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Dropout % before session 8 (p < .05)

Arntz, Tiesema & Kindt (2007) JBTEP

PTSD treatment: PTSD symptoms

Treatment superior to Wait List

IE+ImRS equivalent to IE

(Arntz, Tiesema & Kindt, JBTEP, 2007)

***

PSS PSS-completers PSS-itt

PTSD treatment:

IE+ImRS superior to IE in non-fear emotions

(Arntz, Tiesema & Kindt, JBTEP, 2007)

Anger In Anger Control

*

*

PTSD treatment:

Anger In & Anger Control

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• 3 had no preference

• 4 preferred IE+RS

• None preferred IE (p = 0.052, permutation test)

• Therapists experience less distress with RS

Therapists’ preference

Three new studies into ImRs as

complete treatment

• Arntz, Sofi & van Breukelen (2013). PTSD. BRAT.

– Refugees with complicated war-related trauma – Treatment often with translator

– Case series design with control for time & trauma exploration.

– Could act out revenge fantasies in ImRs – Large effects on PSS (d= 2.87) and BDI (d=1.29)

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PSS observed and estimated means

from mixed regression

BDI observed and estimated means

from mixed regression

Recent studies

• Nillson et al. (2012): ImRs for social phobia.

Behav Ther & Exp Psychiatry, 44, 351-360.

– 1 session ImRs vs reading task

– Strong effects of ImRs (e.g., FNE d=1.18)

• Lee & Kwon (2013): ImRs for social phobia.

Behav Ther & Exp Psychiatry, 44, 351-360.

– 3 sessions ImRs (1 imagery interview, 2 ImRs)

vs. 3 sessions control (1 clinical interview, 2 supportive therapy).

– Stronger effects of ImRs (e.g., FNE d = 1.27)

Imagery Rescripting:

not necessarily a Complete Treatment

• Part of treatment package (e.g., of Schema

Therapy, cognitive therapy)

• But sometimes a complete treatment (e.g.,

for nightmares, PTSD)

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Rescripting of Recent Traumas

1. Start with imagining the (start of) the trauma (= Im Exp)

2. Ask for perceptions, emotions, needs, and impulses

1. What is happening? What do you see, hear, smell, etc.? 2. What do you feel?

3. What do you need? 4. What do you want to do?

3. Prompt the patient to act it out in the image 4. Return to 2 and repeat until patient is satisfied

Recent Trauma Rescripting - 2

1. Check anger expression (address

avoidance; push stronger expression)

2. Check needs after the trauma

sometimes other reactions after the trauma were more pathogenic than trauma itself

3. Helpers may be introduced or T may

intervene if P is too helpless (~ childhood

RS)

Recent Trauma Rescripting - 3

1. Imagining prevention of trauma might be

more effective than imagining changes

during or after the trauma.

– But trauma memory should be enough activated

– Ask patient to imagine to prevent the trauma

2. If the most problematic experience

happened after the trauma (e.g., treatment

by police, medical doctor, etc) address

Rescripting of childhood

memories

Basic protocol = 3 steps:

1. Imagine the memory

2. Patient imagines that (s)he sees the

child and intervenes

3. Patient imagines the intervention as a

child and may ask for other/extra

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Step 1:

Get a memory

(if possible, with eyes closed)

1. Start with present problem and use affect

(etc.) to get childhood memory

2. Get into known childhood situations

directly (e.g., known from anamnestic

interview; ask patient to look to face core

figure; etc.)

3. Patient imagines safe place and then gets

childhood memory; if this is a good

memory ask for opposite

Pathways to childhood memory

Present problem Safe place Childhood memory Instruction Instruction Instruction Spontaneous Spontaneous

Step 1:

Get a memory-2

1. Let experience the memory emotionally

Questions:

what do you see, hear, smell, experience; what is happening?

what do you feel (emotionally)? what do you think?

what do you need?

2. With trauma: not necessary to get whole trauma memory

3. Then go to step 2

Step 2:

Change perspective to adult

1. Ask patient to enter the scene as an adult 2. Ask the patient:

what do you see, hear etc. What is happening? (look to the child!)

what do you feel (emotionally)? what do you think?

what do you want to do?

3. Prompt the patient to do this in fantasy

o.k., do it!

4. Then go back to 2

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Step 3:

Change perspective to child

1. Ask patient to experience the rescripting by the adult-self as a child

2. Ask the patient:

what do you see, hear etc.; what is happening? what do you feel (emotionally)?

what do you think? what do you need? what do you want to happen?

3. Prompt the patient to ask the adult to do what he/she needs: o.k., ask it!

4. Then go back to 2

5. Until patient is satisfied (often after extra rescripting)

Variation - 1

• Patient does not dare to intervene

– Helpers are introduced

• Helpers can coach the patient or intervene together with the patient, or on instructions of the patient

– Therapist may help patient

• Therapist can coach the patient or intervene together with the patient, or on instructions of the patient

Variation - 2

especially for severe PDs (BPD)

• Patient is not able to do any rescripting

– Therapist takes the lead and does the rescripting, intervening him/herself – Patients stays in the child perspective

– Therapist must be able to push the intervention – Therapist may need helpers

– Therapist must be able to sooth the child – Therapist must be able to offer him/herself as a

Practical issues - 1

• What memory to chose?

– Early, emotional, central to schema’s, related to core figures

• Pt cannot find a memory

– Explore reasons, take time, reduce fear, do exercise by surprise

• Pt doesn’t close eyes

– Explore reasons, reduce fear, tolerate it

• Pt dissociates

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Practical issues - 2

• Loyalty to parents

– Explain difference between positive and negative loyalty; explain survival value of loyalty for children; explain that RS is directed to parts of parent’s behaviour; explain pt can chose later how to relate to parent

• Pt experiences guilt about intervention

– Try other RS; address excessive guilt with CT; explore double standard

• Pt experiences guilt about having not intervened as a child

– Explore reasons, explain this is not childrens’task; explain child is dependent

Practical issues - 3

• Pt resists (any) intervention as unrealistic

– Explain purpose is not that intervention could have been done in reality, but processing and therefore recovery; explore reasons underlying this resistance – Rewind and try out new rescripting more realistic for

patient (e.g., with perpetrator not made nice whilst that is unrealistic)

• Pt too fearful/powerless in the image to intervene

– Use any way (fantasy) to increase power and safety; therapist assists or rescripts

Practical issues - 4

• Pt cannot take child perspective

– take earlier memory; intervene as therapist, free the child from its responsibilities, and talk & behave to the child as a child

• Fear of future consequences

– Ask actively whether this fear is present; build in measures to deal with future dangers (e.g., put abuser in jail; take child to safe place; give child beeper)

Practical issues - 5

• Therapist fears acting out of anger

– so far opposite has happened (better anger

control, even after violent interventions in RS – with violent patients: first/also train anger

control

– intervene as therapist and model appropriate ways of expressing anger & support child in processing angry feelings

– agree to postpone actions

– look to vulnerable feelings underlying anger and focus on them

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Literature suggestions

Arntz, A. (2011). Imagery Rescripting for Personality Disorders. Cognitive and Behavioral Practice, 18, 466-481.

Arntz, A. (in press). Imagery Rescripting for PTSD. In Thoma, N. & McKay, D. (Eds.) Engaging Emotion in

CBT: Experiential Techniques for Promoting Lasting Change. New York: Guilford.

Arntz, A. (2012). Imagery Rescripting as a therapeutic technique: review of clinical trials, basic studies, and research agenda. Journal of Experimental Psychopathology,3,189-208.

Arntz, A., Sofi, D. & van Breukelen, G. (2013). Imagery Rescripting as treatment for complicated PTSD in refugees: A multiple baseline case series study. Behaviour Research and Therapy, 51, 274-283. Arntz, A., & van Genderen, H. (2009). Schema therapy for borderline personality disorder. Oxford:

Wiley-Blackwell.

Arntz, A. & Weertman, A. (1999). Treatment of childhood memories; theory and practice. Behaviour

Research and Therapy, 37, 715-740.

Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting. Journal of Behavior Therapy and Experimental Psychiatry, 38, 345-370.

Hackmann, A. (2011). Imagery Rescripting in Posttraumatic Stress Disorder. Cognitive and Behavioral

Practice, 18, 424–432.

Hackmann, A., Bennett-Levy, J. & Holmes, E. (2011), Oxford guide to imagery in cognitive therapy. Oxford: Oxford University Press.

Edwards, D. J. A. (1990). Cognitive therapy and the restructuring of early memories through guided imagery.

Journal of Cognitive Psychotherapy, 4, 33-51.

Edwards, D. J. A. (2007). Restructuring implicational meaning through memory based imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38, 306-316. Holmes, E.A. & Arntz, A. (2007). Special issue on imagery. Journal of Behavior Therapy and Experimental

Psychiatry, 38.

Holmes, E.A., Arntz, A., & Smucker, M.R. (2007). Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry,

38, 297-305.

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