Imagery Rescripting as a Method to Change Emotional Memories & Schemata/Representations Arnoud Arntz Overview What is imagery rescripting? History Clinical effects Practice: adult trauma Practice: childhood trauma Maastricht University the Netherlands What is Imagery Rescripting Imagine the experience of a traumatic/nasty memory Imagine that somebody (yourself, another person, a fantasy figure) intervenes and changes the outcome Realize needs and wishes and meet them Express inhibited responses (e.g. attack instead of freeze) Change of meaning of the UCS/UCR representation History cf. Edwards (2007). BTEP, 38, 306-316 Already used by ancient Egyptians & Greek Hypnosis, dissociation theory: Janet (1889) imagery substitution Psychoanalytic: often more symbolic than autobiographic Jung (1918) active imagination Ferenczi (1929) neocathartic method ( work with split-off child parts ) Leuner (1984) guided affective imagery Experiential therapies Gestalt (Perls, 1973): unfinished business Transactional Analysis (Erskine, 1980): script cure 1
History cf. Edwards (2007). BTEP, 38, 306-316 Early CBT: imagery work, but little rescripting Wolpe (> 1950): systematic desensitization Cautela (1977) & Lazarus (1984): covert rehearsal, positive time projection Later CBT: more restructuring of the image Edwards, Smucker, Young: learned from Gestalt A.T. Beck, D.M. Clark: integrated in CT for anxiety But, until approx. 2000, mostly viewed as unscientific Why is Imagery Important? Imagery evokes emotions; emotions evoke images (Holmes, 2005, 2007) Restructuring ideas and interpretations is much more effective if imagery is involved (Holmes et al., 2009) Little difference in activated brain regions between imagery and real experience Even when the person realizes the image is not a real perception ImRs changes the memory representation (in meaning & emotions): different mechanism than exposure (which leads to learning when the US is not occurring). Clinical Applications PTSD (Ehlers & Clark, 2000, 2003, 2005; Smucker et al., 2007; Arntz, Kindt & Tiesema, 2007) Nightmares (Krakow et al., 2001; Davis & Wright, 2007) Simple Phobia (Hunt & Fenton, 2007) Social Phobia (Wild, Hackmann, & Clark, 2007) Depression (Wheatley et al., 2007, 2008) Eating Disorders (Cooper et al, 2007) Personality Disorders (Weertman & Arntz, 2007; Arntz, 2011) PTSD Treatment Study Imaginal Exposure vs. Imaginal Exposure & Imagery Rescripting 10 sessions 67 participants All kinds of trauma; 1/3 multiple index trauma 1/3 sexual assault 1/3 nonsexual assault 1/3 others 2
Dropout % before session 8 (p <.05) PTSD treatment: PTSD symptoms Treatment superior to Wait List IE+ImRS equivalent to IE (Arntz, Tiesema & Kindt, JBTEP, 2007) PSS PSS-completers PSS-itt *** Arntz, Tiesema & Kindt (2007) JBTEP PTSD treatment: IE+ImRS superior to IE in non-fear emotions (Arntz, Tiesema & Kindt, JBTEP, 2007) PTSD treatment: Anger In & Anger Control Anger In Anger Control * * 3
Therapists preference 3 had no preference 4 preferred IE+RS None preferred IE (p = 0.052, permutation test) Therapists experience less distress with RS Three new studies into ImRs as complete treatment Arntz, Sofi & van Breukelen (2013). PTSD. BRAT. Refugees with complicated war-related trauma Treatment often with translator Case series design with control for time & trauma exploration. Could act out revenge fantasies in ImRs Large effects on PSS (d= 2.87) and BDI (d=1.29) 4
PSS observed and estimated means from mixed regression BDI observed and estimated means from mixed regression Recent studies Nillson et al. (2012): ImRs for social phobia. Behav Ther & Exp Psychiatry, 44, 351-360. 1 session ImRs vs reading task Strong effects of ImRs (e.g., FNE d=1.18) Lee & Kwon (2013): ImRs for social phobia. Behav Ther & Exp Psychiatry, 44, 351-360. 3 sessions ImRs (1 imagery interview, 2 ImRs) vs. 3 sessions control (1 clinical interview, 2 supportive therapy). Stronger effects of ImRs (e.g., FNE d = 1.27) Imagery Rescripting: not necessarily a Complete Treatment Part of treatment package (e.g., of Schema Therapy, cognitive therapy) But sometimes a complete treatment (e.g., for nightmares, PTSD) 5
Rescripting of Recent Traumas 1. Start with imagining the (start of) the trauma (= Im Exp) 2. Ask for perceptions, emotions, needs, and impulses 1. What is happening? What do you see, hear, smell, etc.? 2. What do you feel? 3. What do you need? 4. What do you want to do? 3. Prompt the patient to act it out in the image 4. Return to 2 and repeat until patient is satisfied Recent Trauma Rescripting - 2 1. Check anger expression (address avoidance; push stronger expression) 2. Check needs after the trauma sometimes other reactions after the trauma were more pathogenic than trauma itself 3. Helpers may be introduced or T may intervene if P is too helpless (~ childhood RS) Recent Trauma Rescripting - 3 1. Imagining prevention of trauma might be more effective than imagining changes during or after the trauma. But trauma memory should be enough activated Ask patient to imagine to prevent the trauma 2. If the most problematic experience happened after the trauma (e.g., treatment by police, medical doctor, etc) address prevention of that (e.g., assert yourself) Rescripting of childhood memories Basic protocol = 3 steps: 1. Imagine the memory 2. Patient imagines that (s)he sees the child and intervenes 3. Patient imagines the intervention as a child and may ask for other/extra interventions 6
Step 1: Get a memory (if possible, with eyes closed) Pathways to childhood memory 1. Start with present problem and use affect (etc.) to get childhood memory 2. Get into known childhood situations directly (e.g., known from anamnestic interview; ask patient to look to face core figure; etc.) 3. Patient imagines safe place and then gets childhood memory; if this is a good memory ask for opposite Instruction Present problem Spontaneous Instruction Safe place Instruction Childhood memory Spontaneous Step 1: Get a memory-2 1. Let experience the memory emotionally Questions: what do you see, hear, smell, experience; what is happening? what do you feel (emotionally)? what do you think? what do you need? 2. With trauma: not necessary to get whole trauma memory 3. Then go to step 2 Step 2: Change perspective to adult 1. Ask patient to enter the scene as an adult 2. Ask the patient: what do you see, hear etc. What is happening? (look to the child!) what do you feel (emotionally)? what do you think? what do you want to do? 3. Prompt the patient to do this in fantasy o.k., do it! 4. Then go back to 2 5. Just start again if patient is not satisfied 7
Step 3: Change perspective to child 1. Ask patient to experience the rescripting by the adultself as a child 2. Ask the patient: what do you see, hear etc.; what is happening? what do you feel (emotionally)? what do you think? what do you need? what do you want to happen? 3. Prompt the patient to ask the adult to do what he/she needs: o.k., ask it! 4. Then go back to 2 5. Until patient is satisfied (often after extra rescripting) Variation - 1 Patient does not dare to intervene Helpers are introduced Helpers can coach the patient or intervene together with the patient, or on instructions of the patient Therapist may help patient Therapist can coach the patient or intervene together with the patient, or on instructions of the patient Variation - 2 especially for severe PDs (BPD) Patient is not able to do any rescripting Therapist takes the lead and does the rescripting, intervening him/herself Patients stays in the child perspective Therapist must be able to push the intervention Therapist may need helpers Therapist must be able to sooth the child Therapist must be able to offer him/herself as a foster parent Practical issues - 1 What memory to chose? Early, emotional, central to schema s, related to core figures Pt cannot find a memory Explore reasons, take time, reduce fear, do exercise by surprise Pt doesn t close eyes Explore reasons, reduce fear, tolerate it Pt dissociates Give control, reduce fear, gradual approach, do not go deeply into trauma s 8
Practical issues - 2 Loyalty to parents Explain difference between positive and negative loyalty; explain survival value of loyalty for children; explain that RS is directed to parts of parent s behaviour; explain pt can chose later how to relate to parent Pt experiences guilt about intervention Try other RS; address excessive guilt with CT; explore double standard Pt experiences guilt about having not intervened as a child Explore reasons, explain this is not childrens task; explain child is dependent Practical issues - 3 Pt resists (any) intervention as unrealistic Explain purpose is not that intervention could have been done in reality, but processing and therefore recovery; explore reasons underlying this resistance Rewind and try out new rescripting more realistic for patient (e.g., with perpetrator not made nice whilst that is unrealistic) Pt too fearful/powerless in the image to intervene Use any way (fantasy) to increase power and safety; therapist assists or rescripts Practical issues - 4 Pt cannot take child perspective take earlier memory; intervene as therapist, free the child from its responsibilities, and talk & behave to the child as a child Fear of future consequences Ask actively whether this fear is present; build in measures to deal with future dangers (e.g., put abuser in jail; take child to safe place; give child beeper) Practical issues - 5 Therapist fears acting out of anger so far opposite has happened (better anger control, even after violent interventions in RS with violent patients: first/also train anger control intervene as therapist and model appropriate ways of expressing anger & support child in processing angry feelings agree to postpone actions look to vulnerable feelings underlying anger and focus on them 9
Literature suggestions Arntz, A. (2011). Imagery Rescripting for Personality Disorders. Cognitive and Behavioral Practice, 18, 466-481. Arntz, A. (in press). Imagery Rescripting for PTSD. In Thoma, N. & McKay, D. (Eds.) Engaging Emotion in CBT: Experiential Techniques for Promoting Lasting Change. New York: Guilford. Arntz, A. (2012). Imagery Rescripting as a therapeutic technique: review of clinical trials, basic studies, and research agenda. Journal of Experimental Psychopathology,3,189-208. Arntz, A., Sofi, D. & van Breukelen, G. (2013). Imagery Rescripting as treatment for complicated PTSD in refugees: A multiple baseline case series study. Behaviour Research and Therapy, 51, 274-283. Arntz, A., & van Genderen, H. (2009). Schema therapy for borderline personality disorder. Oxford: Wiley- Blackwell. Arntz, A. & Weertman, A. (1999). Treatment of childhood memories; theory and practice. Behaviour Research and Therapy, 37, 715-740. Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting. Journal of Behavior Therapy and Experimental Psychiatry, 38, 345-370. Hackmann, A. (2011). Imagery Rescripting in Posttraumatic Stress Disorder. Cognitive and Behavioral Practice, 18, 424 432. Hackmann, A., Bennett-Levy, J. & Holmes, E. (2011), Oxford guide to imagery in cognitive therapy. Oxford: Oxford University Press. Edwards, D. J. A. (1990). Cognitive therapy and the restructuring of early memories through guided imagery. Journal of Cognitive Psychotherapy, 4, 33-51. Edwards, D. J. A. (2007). Restructuring implicational meaning through memory based imagery: Some historical notes. Journal of Behavior Therapy and Experimental Psychiatry, 38, 306-316. Holmes, E.A. & Arntz, A. (2007). Special issue on imagery. Journal of Behavior Therapy and Experimental Psychiatry, 38. Holmes, E.A., Arntz, A., & Smucker, M.R. (2007). Imagery rescripting in cognitive behaviour therapy: Images, treatment techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38, 297-305. Stopa, L. (2011). Special issue on imagery rescripting. Cognitive and Behavioral Practice, 18. 10