Imagery and Imagery Rescripting

Although cognitive behavioral therapy (CBT) is portrayed as being concerned with thoughts, it has a long history of attending to client images and the meaning contained within them. There is evidence that imagery can produce more powerful emotional responses than verbal representations (Holmes et al., 2006). It is often claimed that imagery work can lead to changes in felt emotion, and that it can be especially useful when clients are stuck using cognitive techniques alone: ‘I hear what you’re saying, but I don’t feel it.’

Hackmann, Bennett-Levy, and Holmes (2011) identify a taxonomy of approaches for working with imagery:

Techniques for Using Imagery in Therapy

Imagery interventions commonly used in therapy include:

• Assessing metacognitive beliefs about having imagery that may be responsible for some of the distress clients feel about experiencing imagery, and the ways in which they react to having imagery (Wells, 2000).
• Cognitive restructuring within reliving (‘Enhanced reliving’) for PTSD where patients are helped to insert new and incompatible information into memories of peritraumatic ‘hotspots’ (Grey, Young, & Holmes, 2002).
• Compassionate imagery is commonly used within compassion-focused therapy (CFT) interventions to foster a sense of self-compassion and to help patients to access different social mentalities (‘mindsets’) (Gilbert, 2010).
• Exposure, relaxation, and rescripting therapy (ERRT) which is an intervention for post-trauma nightmares. ERRT involves psychoeducation about trauma and sleep hygiene, progressive muscle relaxation, symptom monitoring, writing about nightmares, identifying trauma themes, and altering the nightmare and rehearsing the new script (Davis & Wright, 2005).
• Eye movement desensitization and reprocessing (EMDR) where imagery of traumatic events is combined with bilateral stimulation to aid ‘processing’ of traumatic events (Shapiro, 2001).
• Imaginal desensitization in which a feared stimulus is held in imagination until the patient habituates (Wolpe, 1958).
• Imaginal flooding in which a feared stimulus is repeatedly presented in imagery at high intensity without reinforcement and without any counterconditioning process (Stampfl & Levis, 1967).
• Imagery rehearsal therapy (IRT) which is often used in the treatment of trauma-related nightmares (Krakow et al., 2001).
• Imagery rescripting which has been used in the treatment of Axis II disorders and is commonly used in the treatment of symptoms of PTSD including flashbacks and nightmares (Arntz & Weertman, 1999; Smucker, Dancu, Foa, & Niederee, 1995). There is also evidence that is can be used as a standalone intervention for depression (Wheatley et al., 2007).
• ‘Reliving’ of traumatic memories in PTSD where patients with PTSD are asked to ‘relive’ a traumatic event and to recall details as vividly as possible (e.g., Foa & Rothbaum, 1998).
• The rewind technique or visual-kinesthetic dissociation (VK Dissociation) is frequently used by practitioners of NLP and is often taught as a standalone treatment for trauma/PTSD (Koziey & McLeod, 1987).

References

Arntz, A. and Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37(8), 715–740.

Davis, J. L., & Wright, D. C. (2005). Case series utilizing exposure, relaxation, and rescripting therapy: Impact on nightmares, sleep quality, and psychological distress. Behavioral Sleep Medicine, 3(3), 151–157.

Edwards, D. (2007). Restructuring implicational meaning through memory-based imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 306–316.

Edwards, D. (2011). Invited essay: From ancient shamanic healing to twenty first century psychotherapy: The central role of imagery methods in effecting psychological change. In A. Hackmann, J, Bennett-Levy, & E. A. Holmes (Eds.), Oxford guide to imagery in cognitive therapy (pp. xxxiii–xlii). New York: Oxford University Press.

Foa, E. B., & Rothbaum, B. O. (1998). Treatment manuals for practitioners. Treating the trauma of rape: Cognitive-behavioral therapy for PTSD. New York, NY, US: Guilford Press.

Gilbert, P. (2010). Compassion focused therapy. CBT Distinctive Features Series. New York: Routledge.

Grey, N., Young, K., & Holmes, E. (2002). Cognitive restructuring within reliving: A treatment for peritraumatic emotional ‘hotspots’ in posttraumatic stress disorder. Behaviouraland Cognitive Psychotherapy, 30(1), 37–56.

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

Holmes, E. A., Mathews, A., Dalgleish, T., & Mackintosh, B. (2006). Positive interpretation training: Effects of mental imagery versus verbal training on positive mood. Behavior Therapy, 37(3), 237-247.

Koziey, P. W., & McLeod, G. L. (1987). Visual-kinesthetic dissociation in treatment of victims of rape. Professional Psychology: Research and Practice, 18(3), 276–282.

Krakow, B., Hollifield, M., Johnston, L., Koss, M., Schrader, R., Warner, T. D., … & Prince, H. (2001). Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA, 286(5), 537–545.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd ed.). New York: Guilford Press.

Smucker, M. R., Dancu, C., Foa, E. B., & Niederee, J. L. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from post-traumatic stress. Journal of Cognitive Psychotherapy: An International Quarterly, 9(1), 3–17.

Stampfl, T., & Levis, D. J. (1967). Essentials of implosive therapy: A learning-theory-based psychodynamic behavioral therapy. Journal of Abnormal Psychology, 72(6), 496–503.

Watkins, J. G. (1971). The affect bridge: A hypnoanalytic technique. The International Journal of Clinical and Experimental Hypnosis, 19(1), 21-27.

Wheatley, J., Brewin, C. R., Patel, T., Hackmann, A., Wells, A., Fisher, P., & Myers, S. (2007). I’ll believe it when I can see it: Imagery rescripting of intrusive sensory memories in depression. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 371–85.

Wells, A. (2000). Emotional Disorders and Metacognition: A practical manual and conceptual guide.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.