Working with Emotion in Cognitive Behavioral Therapy
Chapter 9
Imagery Rescripting for Posttraumatic Stress Disorder.

Introduction

Imagery resccripting (ImRs) is a powerful treatment with high acceptability that can be used for simple as well as complex PTSD.

Rationale for ImRs

The basic idea of ImRs in the treatment of PTSD is to activate the trauma memory and imagine a different ending that better matches the needs of the patient.

The facts of the original trauma memory are not forgotten or overwritten by rescripting.

The mechanism of ImRs seems to be a change in the meaning of the trauma memory, brought about by experiencing in fantasy what one needed in the situation and getting these lingering, unmet needs in fantasy. This is a change in meaning of the original unconditioned stimulus (the traumatic experience).
With US revaluation, new information is fed into the memory representation of the US. If this information is helpful, it will reduce the dysfunctional meaning of the trauma memory.
Independent of context, a trauma reminder will trigger the changed memory representation of the trauma and, if the meaning change was successful, this memory will no longer lead to dysfunctional responses.
The effects of treatment using this mechanism are not context-dependent.

Another possibility is that the expression of needs, feelings, and actions in ImRs, which were inhibited at the time, is a healing factor.

Empirical evidence

Studies of ImRs for PTSD show positive results, especially regarding dysfunctional interpretations and emotional problems.

Application with PTSD

Simple trauma

The therapist can start with gathering the usual information about the trauma.
Reliving symptoms might form a helpful focus for ImRs, as they are often central to the dysfunctional meaning the patient gave to the trauma and often represent signals of the feared catastrophe.
The meaning of the traumatic event for the patient should be explored, as well as emotions and action tendencies that were activated but could not be expressed.
In the next session, the therapist can either start ImRs directly, or do a cognitive preparation.

Important parts of the explanation of ImRs that therapist give to patients are:

• Imagery is a more powerful way than talking to change traumatic memories and the associated meaning and emotion
• During a traumatic event it is natural that all kinds of needs, emotions, and action tendencies are triggered, but they usually cannot be fully actualized.
  It is healthy and corrective to imagine emotions to be expressed, actions to be carried out, and needs to be met.
• The effect of ImRs is not that the original memory of the facts is replaced by a new memory.
  A cognitive and emotional processing of the event is brought about by ImRs, which leads to reduction of the vividness of the memory, a change in its meaning, a reduction of fear of the memory, and reduced intrusions and nightmares
• The patient can imagine all kinds of changes in the script that meet his or her needs.
  It is not important whether these changes are realistic, as long as they are experienced during ImRs as having a powerful impact and satisfying the patient’s needs.
• If the patient is not (completely) satisfied with the rescripting, there is no problem, as additions to the script, or completely different scripts can be tried out.
• It is helpful if the patient rehearses the ImRs several times during the week.

After the questions, the therapist invites the patient to sit comfortably, close his or her eyes, and start imagining and describing the sequence of events that led to the trauma.
While initially the focus is on perceptions, the next questions focus on emotions and on cognitions.
If it is clear that distress is getting high, the therapist asks what the patient needs.
When the needs are clear, the patient is invited to change the script so that his or her needs are better met by imagining the new script as vividly as possible.
The perspective remains the point of view of the patient.
The therapist helps the patient to imagine the rescripting as vividly as possibly by asking the same questions as before (first focusing on perceptions, then on emotions, cognitions and possible further needs).

ImRs does not require full exposure to all details of the trauma. In ImRs, the rescripting can start just before the trauma proper happens. It can also address only parts of the trauma.

It is not encouraged to start rescripting before a clear explectation of the trauma is built up, and associated emotions are triggered.
ImRs might be particularly effective as a method to change the meaning of the trauma memory because the rescripting brings an unexpected change into an expected sequence.
To capitalize on this mechanism, a clear expectation on both a cognitive and an emotional level should be activated.

Multiple traumas

With multiple traumas it might be necessary to make a list of the traumas that should be addressed and to decide what trauma to address first.
There is no need for a hierarchical order, and the therapist can leave the choice of which trauma to start with to the patient.

Complex PTSD

With complex PTSD there has usually been extended childhood abuse in a context of lack of safety, and this issue has considerably damaged interpersonal trust and self-views.
It is then indicated that the therapist initially leads the rescripting, preventing the abuse, crating safety, correcting the abusers, and taking care of the child after this has been done.
One of the reasons to do this is that these patients often are too frightened during the imagery to be able to fantasize any rescripting.
Another reason is that for this kind of early abuse it might be an extra healing factor for the patient t experience a healthy adult patient protecting the child and taking care of her or him.
During treatment, the patient can gradually take the lead in the rescripting.

Difficulties with the application of ImRs

• The patient does not dare to close his or her eyes
  The therapist should try to find out why.
• The patient dissociates
  As soon as dissociative symptoms appear, the therapist should bring the patient back to reality
  Dissociation suggests high fear levels, so perhaps less frightening memories should be tried out first
  It is important that the therapist brings safely into the image as soon as possible.
  Patients should also learn to detect early signs of the dissociative shift and prevent it from happening.
• The patient wants to take revenge in imagery
  Laboratory work has so far indicated that there is no indication of adverse effects by using revenge in ImRs.
  With specific populations, therapists might want to reach agreement about reducing risk factors before allowing them to act out revenge during ImRs.
• The patient goes into a mourning process
  In essence, this is a natural and healthy process, and the therapist should explain this process to the patient, validate the sadness, and support the patient.
  If the mourning process gets stuck, factors that prevent resolution should be explored.

When and how to use ImRs for PTSD

ImRs can be given as a full treatment for PTSD and will then usually take between five and twenty sessions.
An ImRs exercise takes about twenty minutes.