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Arntz & Jacob's new book "Schema therapy in practice": rescripting traumatic memories

I have already written a series of blog posts - both on Arntz & Jacob's new book and on working with traumatic memories.  In today's post I want to explore imagery rescripting more fully.  The memorably named Mervin Smucker is an important figure in cognitive therapy's development of rescripting with the paper he & colleagues published in 2007 - "Imagery rescripting and reprocessing therapy after failed prolonged exposure for post-traumatic stress disorder following industrial injury" - with its abstract reading "Prolonged exposure (PE) has been reported to be effective for improving post-traumatic stress symptoms in 60-65% of trauma victims suffering from post-traumatic stress disorder (PTSD). This study examined the results of adding an imagery-based, cognitive restructuring component (imagery rescripting and reprocessing therapy, IRRT) to the treatment of 23 Type I trauma victims suffering from PTSD, all of whom failed to improve with PE alone. With the added treatment component, 18 of 23 clients showed a full recovery from their PTSD symptoms, and no longer met criteria for PTSD after 1-3 sessions of IRRT. It was noteworthy that non-FEAR emotions (e.g., guilt, shame, anger) were found to be predominant for all 23 PE failures examined in this study, suggesting that a simple habituation model (on which PE is based) is not sufficient to address non-FEAR emotions in PTSD. By contrast, IRRT, a cognitive restructuring treatment, was much more effective in PTSD symptom reduction for these clients. It was proposed that more detailed, individualized trauma assessments be conducted for each patient that focus on (1) identifying the predominant trauma-related emotions and cognitions that maintain the PTSD response, and (2) finding the best CBT "treatment fit" for the specific trauma characteristics of each patient."  This sounds pretty impressive, although we need to be a cautious with results from a case series rather than a randomized controlled trial, and cautious too with the pretty inevitable allegiance effects associated with results found by the originators of a new treatment. 

Arntz et al's 2007 paper is another in the sparse literature supporting rescripting over simple prolonged exposure.  I've quoted "Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting" already, noting the abstract's comments "We tested whether the effectiveness of imaginal exposure (IE) treatment for posttraumatic stress disorder (PTSD) was enhanced by combining IE with imagery rescripting (IE+IR). It was hypothesized that IE+IR would be more effective than IE by (1) providing more corrective information so that more trauma-related problems can be addressed, and (2) allowing patients to express emotions that they had been inhibiting, such as anger. In a controlled study 71 chronic PTSD patients were randomly assigned to IE or IE+IR. Data of 67 patients were available. Treatment consisted of 10 weekly individual therapy sessions and treatment evaluation was conducted post-treatment and at 1-month follow-up. Results show that when compared with wait-list, treatment reduced severity of PTSD symptoms. More patients dropped out of IE than out of IE+IR before the 8th sessions, 51% vs. 25%, p=.03. Completers and intention-to-treat analyses indicated that both conditions did not differ significantly in reduction of PTSD severity. IE+IR was more effective for anger control, externalization of anger, hostility and guilt, especially at follow-up. Less strong effects were found on shame and internalized anger. Therapists tended to favor IE+IR as it decreased their feelings of helplessness compared to IE. Results suggest that the addition of rescripting to IE makes the treatment more acceptable for both patients and therapists, and leads to better effects on non-fear problems like anger and guilt."   

Of course more standard (in UK terms) trauma-focused CBT may well involve some degree of rescripting as well, with its emphasis on "What do we know & understand now, that we didn't know & understand then (at the time of the trauma)?"  See earlier blog posts that describe this form of intervention in much more detail.  This cognitive restructuring explanation gives Ehlers & Clark's style of trauma-focused CBT an obvious and compelling therapeutic rationale.  Initially this may not seem so obviously the case with Arntz's approach to rescripting.  In his 2011 paper "Imagery rescripting for personality disorders", Arntz writes "Imagery rescripting is a powerful technique that can be successfully applied in the treatment of personality disorders. For personality disorders, imagery rescripting is not used to address intrusive images but to change the implicational meaning of schemas and childhood experiences that underlie the patient's problems. Various mechanisms that may be involved in the application of the technique when applied in the treatment of personality disorders are discussed. Next, the empirical evidence for the effectiveness of the technique is discussed. Then four practical applications are presented: diagnostic imagery; imagery of a safe place; imagery rescripting of childhood events; and imagery rescripting of present and future events. The paper ends with a general conclusion."  The text of the full article is freely available at http://tinyurl.com/cafmmcw. 

In their new book "Schema therapy in practice", Arntz & Jacob write (p.143) "The main emotion-focused technique in the treatment of vulnerable child modes is imagery rescripting.  In imagery rescripting exercises, the patient enters a traumatic memory in imagery related to their current negative feelings.  This image is then changed in such a way that the needs of the child (or the patient at another age) are fulfilled.  Negative feelings, such as threat, anxiety, shame, guilt, and disgust are reduced, and safety and safe attachment are increased."  Again (p.161), they write "When the patient feels the painful feelings related to the situation in question, the image is changed in such a way that negative emotions (guilt, shame, threat) are replaced by positive ones (attachment, safety, empowerment, joy).  Imagery rescripting is a very flexible and creative technique.  The exact content of an imagery exercise can never be completely predicted.  However the emotional process can be clearly defined and guides the actual content of the exercise.  Hackman et al ("Oxford guide to imagery in cognitive therapy") offer a thorough introduction to this treatment technique."  And they go on to present a table which provides an overview of their imagery rescripting sequence:

1.)  Provide relaxation instruction, optionally with a safe-place image.

2.)  Access the current stressful situation and related negative emotions in imagery.

3.)  Affect bridge: keep the feeling, but wipe out the image of the current situation: access instead an emotionally stressful memory image associated with the emotion (most often a childhood image).

4.)  Briefly explore the childhood situation ("Who's there?" "What's happening?"); focus on the feelings and needs of the child.

5.)  Introduce a helpful figure who cares for the child's needs and changes the situation in such a way that the child feels safe and that its needs are met.

6.).  Once the immediate threat has been taken away, deepen the feelings of safety and attachment.

7.)  Optional: transfer the emotional solution in the childhood picture to the original image/situation.

In the next post in this sequence on the use of imagery, I'll look more at mechanisms of action in this kind of "fantasy creation" type of rescripting - see "Imagery, associative networks, embodied cognition and the transformation of meaning."

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