Psychotherapy
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Working with Emotion in Cognitive Behavioral Therapy
Chapter 8
Imagery Rescripting for Personality Disorders: Healing early maladaptive schemas
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
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
ImRs has not been tested extensively as an isolated technique for PDs.
But, combined it shows promising results.
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.
The following approach is suggested
General guidelines for ImRs for treating the childhood roots of PD problems
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
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.
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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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