Working with Emotion in Cognitive Behavioral Therapy
Chapter 8
Imagery Rescripting for Personality Disorders: Healing early maladaptive schemas

Introduction

Patients with personality disorders (PDs) might be quite resistant to the kind of rational approach that is so prominent in most CBT.
This can be understood from schema theory. People form knowledge structures about the world that govern information processing, including the regulation of attention, information selection, and giving meaning to information.
A schema is not necessarily (fully) open to conscious inspection and its content is not necessarily restricted to verbal information.
Very early (preverbal) experiences are thought to play a role in personality development. Early attachment experiences contribute strongly to the development of schemas.

PDs are generally thought to develop as the result of an interplay between constitutional and environmental factors.

Two reasons to use imagery rescripting (ImRs) in the treatment of PDs

• The nonverbal (feeling) aspects of dysfunctional views call for techniques that can address the nonverbal content of underlying schemas directly
• The influences of early childhood experiences on the formation of dysfunctional schemas call for techniques that address these early experiences

Rationale for ImRs

Imagery evokes more emotions than just talking about issues. The experimental manipulation of interpretations is strongly enhanced by having participants imagine the situation.

In many respects, the brain does not differentiate between real and imagined experiences.
Imagined experiences have highly similar brain responses to real experiences, and imagining skills is the second best option after real practice.

Imagined stimuli can act as conditioned and unconditioned stimuli, similar to real stimuli.

The basic idea of ImRs in the treatment of PDs is to activate memories of childhood events that contributed to the formation of dysfunctional schemas, re-experience the event, and imagine a different ending that better matches the needs of the child.
Through this process a change of the meaning of the original event is created, which leads to a change in the schema.
Reprocessing of experiences from childhood is the central aim.

Several aspects of ImRs are probably important in explaining why it is such a powerful technique

• Reattribution
  Patients start to attribute what has happened to other causes than they did when they were a child
• Emotional processing
  Difficult experiences from childhood are usually not emotionally processed in patients with PD.
  ImRs helps them to feel more comfortable with emotions and to process them. This changes the basic dysfunctional views of patients about emotions.
  ImRs also teaches them how to deal with emotions so that their emotion regulation improves
• Receiving care
  In ImRs patients with PD experience, although in fantasy, somebody taking care of them as a child, often for the first time in their life
• Changing the meaning on the child level
  The use of corrective information at the adult level might have only limited impact on knowledge that was stored in memory during childhood. It is helpful to adjust the corrective information to levels on which children process information.
• Transforming the rule to the exception
  With ImRs, patients start to learn that their childhood environment was the exception

Empirical evidence

ImRs has not been tested extensively as an isolated technique for PDs.
But, combined it shows promising results.

Application with PDs

Imagery of a safe place

Imagery of a safe place is an option, not a necessity.
For patients who easily experience high anxiety, it is a helpful method to help them find safety.
One can start introducing imagery work by teaching the patient to imagine a safe place, so that the patient gets used to imagery.
With a powerful image of a safe place, patients can return to that safe place at any time if the other imagery exercises evoke too high levels of negative emotions.

In cases that the patient cannot find a safe place because the world is to dangerous, it is essential that the therapist develops a strong, safe therapeutic relationship, so that safety is brought in by the therapist.

Diagnostic imagery and imagery rescripting of memories from childhood

It is not clear yet what the best approach is to introduce ImRs in the treatment of PDs.

In ImRs, an image of a childhood memory is ‘rescripted’ by having an adult person enter the scene and intervene, thus changing the script.
In the early stages of treatment of patients with PD, it is advised that the therapist enters the image and rescripts.

• These patients usually don’t have a strong enough healthy part to intervene themselves
• Most patients with PD did not get adequate protection and care as a child, and they should learn, on the child level, to receive and accept this, as it is essential for healthy development.

The following approach is suggested

1. Start with a problem form the last week
2. Ask the patient to close his or her eyes and get an image of the recent problem.
   Let the patient describe in here-and-now terms, from his or her own perspective, what happens and what he or she experiences. Ask for emotions and needs
3. Instruct the patients to stick with the feeling but to let the image go, and to see whether an image from childhood appears
4. Ask the patient how old he or she is, where he or she is, with whom, and what happens.
   Let the patient talk in the present tense, from the persepective of the child
   After factual details are clear, ask for emotions, thoughts, and needs.
   If severe abuse is (nearly) happening, don’t wait but intervene.
   If it is not completely clear what is happening and what the emotional problem is, let the image continue
5. The rescripting begins.
   Tell the patient that you will now enter the scene and act on your own healthy views.
   When you intervene, describe to the patient what you are doing and what you are saying.
   Ask the patient what happens next in the image, how he or she feels now, and what he or she needs.
   Rescript further until the threat is under control. Then create a safe situation (this is also very important). Take care of the future needs of the patient.
6. When it is ok for the patient, ask him or her to slowly open his or her eyes and return to the therapy room.
   Discus the exercise.
7. If the patient is not satisfied, try another way of rescripting

General guidelines for ImRs for treating the childhood roots of PD problems

• The younger the child in the image is, the better the technique works
  Earlier experiences lie closer to the root of problems and it is more convincing for the patient that he or she is not guilty of the problems when the patient was very young.
• It is not essential whether the memory is correct or not for ImRs to be effective.
• When there was extreme trauma, it is not necessary, and even contra-indicated, to relive the whole trauma.
  Therapists should enter the scene when the trauma is going to happen, but before it takes place and stop it from happening.
• The therapist should know that imagery rescripting can bring about a period of mourning.
• In general we allow patients to have revenge acted out in the rescripting if they feel a need for it.
  But the therapist should feel free to refuse to execute it if he or she feels it as a moral transgression.

Later treatment phases: patient rescripts

Later in treatment, the therapist invites the patient to enter the scene as an adult to rescript.
First, the patient experiences the adverse event from the child’s perspective. When the moment for an intervention has come, the therapist asks the patient to step into the scene as an adult.
The therapist initially assists the patient.
After the maltreatment has stopped, the therapist asks the patient to look at the child and take care of it.
The cycle is repeated until the patient (as an adult) feels satisfied.

An important next step is to let the patient experience the whole intervention by the adult and the therapist again, but form the perspective of the child.
From the child perspective new needs may come up, and the therapist asks the patient to ask her adult self to fulfil them.

Frequency of application of ImRs

ImRs should be used repeatedly in its application to PDs.
Usually there are many childhood experiences that are related to the patients’ problems that should be addressed.

Imagery rescripting of present and future situations

ImRs can also be used to address current and anticipated problems.
This is usually in the alter phases of therapy.
ImRs can help to bring about behaviour change.

Difficulties with the application of ImRs

• The patient does not date to close his or her eyes
  The therapist should find out the reason for this and work out a solution.
• The patient does not get a memory of a young child
  The reason for this should first be clarified.
• The patient dissociates
  As soon as dissociative symptoms appear, the therapist should bring the patient back to reality
  Less frightening memories can be tried out and the therapist must bring safety into the image as soon as possible
  Patients should learn to detect early signs of the dissociative shifts and prevent if form happening
• The patient feels disloyal to his or her parent(s)
  Therapist can explain that if they address the parent in the image, they are not addressing the complete parent, but only his or her behaviour at the moment.
  They can also explain that there are two kinds of loyalty, positive and negative.
  Therapists can explain that it is ultimately up to patients to decide what they want to do in reality with their parents.

When and how to use ImRs in CBT of PDs

ImRs can be easily integrated in regular CBT, and it is a good idea to add it to the more verbal and rational CT work and to use it before the focus of treatment is on behavioural change.

Specific indications for using ImRs in the context of CBT treatment
- It is useful when patients have trouble emotionally integrating new beliefs
- There might be traumas or other adversities that the patient wants to process or that the therapist feels that processing would be helpful.
ImRs offers an excellent processing method.
- ImRs of childhood memories is most indicated in the earlier and mid-treatment phases, as the later phases of treatment should focus more on the present and future, and necessary behavioural change

There is no specific indication when ImRs work can be considered completed, although a good sign is when patients are capable of taking the lead as an adult in the rescripting and report that ImRs improves their functioning.