Psychotherapy
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Working with Emotion in Cognitive Behavioral Therapy
Chapter 9
Imagery Rescripting for Posttraumatic Stress Disorder.
Imagery resccripting (ImRs) is a powerful treatment with high acceptability that can be used for simple as well as complex PTSD.
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.
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:
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
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.
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This is a bundle about the ussage and efficacy of psychotherapy. This bundle contains the literature used in the course 'DSM-5 and psychotherapy' at the third year of psychology at the University of Amsterdam.
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