What is imagery rescripting?
Imagery rescripting (IR) is a therapeutic technique that addresses the content of events in our lives that are stored in our memory, and cause difficulties. In short, during IR, an unpleasant or traumatic event (the mental representation of that event) is retrieved from our memory and, through imagery, the course of the event is changed in a more desired direction. A recent meta-analysis shows that strong therapeutic effects are achieved with this technique (Morina et al., 2017). Interest in and the application of IR has increased considerably since the 1990s (Arntz, 2012). The literature describes two different ways in which this change in the course of events can be realized.
Variant 1: imagery rescripting in combination with cognitive restructuring
In this variant, IR is preceded by a discussion in which the meaning of the image is examined and adjusted. During rescripting, the more realistic conclusions of that discussion are fed into the imagery with questions such as 'What do you now know about (the likelihood of this threat/what alternative interpretations could be)?' (Grey et al., 2002). The change in the course of events sometimes takes place on the basis of alternative scenarios discussed beforehand. IR can be a repeated exercise of the alternative scenario devised in advance (see e.g. Hackmann, 1998).
Variant 2: imagery rescripting without prior cognitive restructuring
In this variant of IR, the course of events is changed during the imagery without prior cognitive restructuring. Rescripting is then done on the basis of questions such as, 'What do you think of this situation?', and 'What do you need now?' (Arntz, 2015). In this variant, therefore, the course of the visualized events is not determined on the basis of a scenario discussed beforehand, but each IR intervention can each time lead to a different course of events.
In this book, imagery rescripting is described as a standalone intervention, without the addition of other treatment elements such as cognitive restructuring. Therefore, this book will mainly describe the second variant of IR (Arntz, 2015; Arntz & Van Genderen, 2010; Arntz & Weertman, 1999).
The possibilities for imaginal rescripting of the course of unpleasant experiences are endless: aggressors can be defeated; enemies humiliated; victims can be saved, comforted and treated with compassion; or there can be communication with the deceased. The rescripting regularly includes elements that are factually impossible, such as the deployment of superhuman forces or supernatural beings, or the execution of impossible changes of reality (see, for example, Arntz, 2015).
The superficial impression could emerge that the application of IR is merely a change from a negative image from the past to a positive image. The real purpose of imagery rescripting is to allow the client to develop a new view of past events, to generate new feelings that do not necessarily have to be positive (such as anger), learn to recognize non-validated basic needs again, or to face reality (e.g. experiences of abuse) so that a grieving process can begin (Holmes, 2007).
Which images are targeted using imagery rescripting?
With IR, intrusive and unpleasant images can be processed, such as traumatic memories (Arntz et al., 2007; Grunert et al., 2007), or fantasy images of negative events without clear autobiographical memories (for example, the image of stabbing someone for clients with obsessive-compulsive disorder or the image of a suicide in depression). However, IR can also focus on meaningful, but not necessarily traumatic, memories that guide underlying schematic beliefs such as borderline and other personality disorders (Arntz et al., 2007; Holmes et al., 2007; Weertman & Arntz, 2007). For example, this could be a reminder of a situation in which the client was not listened to, making her feel unimportant and lonely.
The history of imagery rescripting
Although interest in IR has grown strongly since the 1990s, the technique itself has been used much longer. As early as 1889, Pierre Janet described examples of guided imagery exercises, in which he had the client rewrite memories (see Van der Hart et al., 1989). However, his work was ignored in the century that followed, which was dominated by the Freudian and post-Freudian psychoanalytic approach (Edwards, 2007).
However, in 1970 Beck described the use of simple imagery techniques, and Freeman (1981) described how the use of dream images could make an important contribution to a client's cognitive case conceptualization. Structured imagery exercises were developed and became known within behavioural therapy in the 1970s and 1980s – for example, in the form of systematic desensitization, or counterconditioning (Arntz, 2012; Edwards, 2007).
However, in the 1980s there still seemed to be a strong separation between the more sceptical, academic approach to IR on the one hand, and clinical practice on the other, where various experiential techniques were already used frequently. For example, Erskine and Moursund (1988) described the use of what would now be called IR in the healing of ‘scripts’ (a term from transactional analysis that could be considered synonymous with core beliefs or schemas in Young’s model (Young et al., 2003)). Young began to integrate techniques from transactional analysis into schema-focused cognitive behavioural therapy (Young, 1990). In 1995, a first publication appeared on imagery rescripting as we know it today (Smucker et al., 1995).
Over the past few years, scientific interest in IR has increased enormously (Hackmann et al., 2011) and IR has been integrated into various well-tested treatment protocols, such as cognitive behavioural therapy for PTSD, social anxiety disorder (Clark et al., 2006; Ehlers & Clark, 2000; Ehlers et al., 2005), and nightmare disorder (Davis & Wright, 2007; Krakow et al., 2001) and cognitive therapy and schema therapy for personality disorders (Arntz & Van Genderen, 2009; Giesen-Bloo et al., 2006; Layden et al., 1993; Young et al., 2003).
The effectiveness of imagery rescripting
A recent meta-analysis by Morina and colleagues (2017) describes 19 studies on the effectiveness of IR in a total of 363 patients. IR proved effective for the treatment of unpleasant memories in various disorders, such as posttraumatic stress disorder, depressive disorder, social anxiety disorder, body dysmorphic disorder, bulimia nervosa, and obsessive-compulsive disorder. IR had a positive effect, and this effect was achieved within an average of 4.5 sessions (Morina et al., 2017).
Below is an overview of the various disorders in which IR appears to be a useful intervention. For each disorder, a summary of the evidence for the role of imagery in the disorder is provided. Next, results regarding the effectiveness of IR in treating the disorder are summarized. It is not our intention to provide an exhaustive overview of published studies. However, we did try to list the key results.
Post-traumatic stress disorder
Intrusive symptoms such as recurring re-experiences of, or dreams about, traumatic event(s) are characteristic of posttraumatic stress disorder (PTSD; APA, 2013). Research has shown that PTSD, regardless of the type of trauma, mainly involves visual images, followed by other sensory experiences, such as physical sensations, sounds, or taste sensations (Ehlers et al., 2004). The mental images are often meaningful fragments of the traumatic memory. However, these images do not always have to be a faithful representation of what happened during the traumatic event. The images can also be distorted and, above all, reflect the subjective meaning that the event had for the person at the time, or has had since (Hackmann, 2011).
For example, someone may have intrusive images relating to a car accident she had in the past. At the time of the accident, she thought she would not survive. This experience keeps coming back in the form of imagery in which she sees herself dying in the car accident. The images are experienced as something that happens now, rather than realising that it concerns a memory of something from the past. As a result, the images are often linked to a sense of imminent danger (Ehlers & Clark, 2000), despite information from the patient’s context that this is not the case. In addition to fear or helplessness, images can also induce anger, disgust, sadness, shame, or feelings of guilt (Hackmann, 2011).
Imagery rescripting for PTSD
Ehlers and Clark integrated IR in their cognitive therapy for PTSD in the 1990s and achieved strong effects with this combination therapy (Ehlers & Clark, 2000; Ehlers et al., 2005; Smucker & Niederee, 1995). However, the effect of IR has not been studied separately. The aforementioned meta-analysis by Morina and colleagues (2017) did examine the effectiveness of IR in various disorders. Out of 19 included studies, eight concerned the treatment of PTSD (Morina et al., 2017). In three of these studies, IR was compared with another condition, namely a waiting list condition (Jung & Steil, 2013), imaginal exposure (Øktedalen et al., 2015) or EMDR (Alliger-Horn et al., 2015).
IR demonstrated to be an effective treatment of PTSD symptoms in these three studies (Morina et al., 2017). Not only were treatments consisting of ten or more sessions effective (see, for example, Kindt et al., 2007), but two or three sessions appeared to reduce PTSD symptoms (Alliger-Horn et al., 2015; Jung & Steil, 2013; Steil et al., 2011). IR also seems to reduce difficulties other than anxiety, such as feelings of guilt, anger, or shame (Grunert et al., 2007; Øktedalen et al., 2015). Furthermore, the effect of IR was found to increase when the rescripting took place early in the traumatic image, preventing the actual traumatic event and providing early safety. Hence, it does not seem necessary to relive the trauma in detail during treatment (Arntz et al., 2013). Raabe and colleagues (2015) also found that, as with imaginal exposure, IR was also effective for the treatment of PTSD as a result of childhood abuse, even without a prior stabilization phase.
Social anxiety disorder
Research has shown that a distorted, negative self-image is a very common condition in social anxiety disorder (see, for example, Moscovitch et al., 2011; Reimer & Moscovitch, 2015; Stopa, 2009). For example, a patient described the image she had formed of an approaching job interview: she started to cough heavily, as a result of which she could no longer utter a meaningful word, she turned increasingly red, and eventually had to leave the scene in frustration.
In cognitive models of social anxiety disorder, such negative self-images are seen as a sustaining factor (Clark & Wells, 1995; Rapee & Heimberg, 1997). A negative self-image makes people more anxious, incites them to use more safety behaviours, and is related to the belief that they are less competent and that they are actually assessed as socially less competent by independent assessors (Wild et al., 2007). These images are often related to memories of unpleasant events underlying the onset or worsening of the disorder, such as being bullied, humiliated, or criticized (Hackmann et al., 2000; Moscovitch et al., 2011; Wild et al., 2007, 2008).
Imagery rescripting for social anxiety disorder
A first controlled study showed that one session of IR of unpleasant memories of social situations in the past led to a significant change in the meaning of the memories and the reported social anxiety difficulties, whereas in the control condition, in which memories were only verbally processed, no changes occurred (Wild et al., 2008). These effects sustained a week after the session. In this study, IR was combined with cognitive restructuring. In a later controlled study, this combination also proved to be superior to the placebo control condition in which the participant’s problems were listened to with understanding (Lee & Kwon, 2013). This effect was also maintained at three months follow-up. IR as a standalone treatment of social anxiety i.e. without cognitive restructuring, may also be effective (Nillson et al., 2012). Although this study involved a small number of participants, the importance of cognitive restructuring appears less important than initially thought by the authors.
Furthermore, a study by Reimer and Moscovitch (2015) showed that a single session of IR not only led to a reduction in social anxiety symptoms, but also to a reduction in the emotional intensity of the autobiographical memories related to the onset of the symptoms. Participants also reported a reduction in negative thoughts about themselves or others, and reduced feelings of shame. On the other hand, feelings of satisfaction and pride about their rescripted autobiographical memories increased. Perhaps the most intriguing fact from the studies mentioned above is that only one session of IR was sufficient to produce the effects. However, it should be noted that although many of the participants suffered from social anxiety, they did not suffer from this fear to the degree that they sought help themselves. Frets et al. (2014) did study patients who had signed up with a long-term, persistent social anxiety disorder, often also involving comorbidity (N=6). In this study, the treatment was not limited to a fixed number of sessions; it could last as long as the therapist and patient felt was necessary. This resulted in treatments ranging from 5 to 17 sessions, with an average of 11.2 sessions.
This study also showed that without prior cognitive restructuring, IR can be an effective intervention in the treatment of social anxiety disorder, with effects that were maintained for at least six months after treatment. Norton and Abbott (2016) studied the relative effect of both cognitive restructuring and IR compared to a non-intervention control condition. Their study, including 60 participants, showed that one IR session can be effective for the treatment of social anxiety disorder. IR and cognitive restructuring were both effective, but on different outcome measures. The authors indicated that several participants were so overwhelmed by fear, shame, or powerlessness during the imagery exercise, that they were unable to independently rescript the image. For these participants it might be necessary for the therapist to do the rescripting first, in preparation for the rescripting by the patients themselves. In conclusion, there is increasing evidence that IR can be a standalone and potentially effective treatment for social anxiety disorder. IR seems to reduce not only social anxiety difficulties, but also feelings of shame and the credibility of negative core beliefs about oneself or others. These effects seem to persist for at least three to six months after treatment.
Specific phobias
There is strong evidence that imagery and visual images play an important role in the maintenance and perhaps also in the development of specific phobias. For example, patients with arachnophobia created frightening and distorted images in which the spider suddenly became larger, or in which they were held by a spider larger than themselves (Arntz et al., 1993). Hunt et al. (2006) found that 78% of people with a specific phobia reported visual images that were fear-related. Some of these images were distorted and highly improbable (such as the image that a rat would bite into the foot of the patient and not let go, whatever they did (Hunt et al., 2006)). These findings suggest that imagery is an important part of specific phobia and that these mental images can contribute to the persistence of the phobic fear. Other research has shown that imagery can play a role in the onset of specific phobia. For example, children were able to develop new fears when they were shown images of non-existent beings, accompanied by a vivid, negative description of these beings (Field, 2006; Field & Lawson, 2003).
Imagery rescripting for a specific phobia
Hunt and colleagues (2006) examined the relative effectiveness of IR combined with cognitive restructuring (CR) in the treatment of 60 participants suffering from a fear of snakes. IR with CR turned out to be more effective than exposure in vivo for high-anxiety participants. Exposure in vivo, on the other hand, turned out to be more effective for the low-anxiety participants. An important finding was that participants found IR with CR less aversive than exposure in vivo. A second study showed that IR with CR is at least as effective as exposure in vivo for the treatment of a specific phobia (Hunt & Fenton, 2007). In conclusion, IR seems to be an effective treatment for specific phobias.
Obsessive-compulsive disorder
Obsessive-compulsive disorder, along with PTSD, is one of the disorders characterized by recurring, intrusive images (APA, 2013). Systematic studies showed that 81-95% of patients with obsessive-compulsive disorder reported vivid and disturbing images (Lipton et al., 2010; Speckens et al., 2007). The disorder is distinguished from other anxiety disorders by a higher frequency of images that are less related to autobiographical memories. The content of the images also differs and is more often about danger in the present (e.g. becoming infected with germs) or future danger (e.g. killing someone) (Lipton et al., 2010; Rachmann, 2007; Speckens et al., 2007). In the majority of cases, these images were experienced from the first-person perspective (Lipton et al., 2010).
Imagery rescripting for obsessive-compulsive disorder
Although the intrusive images are not a direct representation of autobiographical memories, they often appear to be thematically related to memories of unpleasant events that preceded the onset of the disorder (Veale et al., 2015). Processing these memories could therefore have a therapeutic effect on obsessive-compulsive symptoms. Veale and colleagues (2015) showed that a single session of IR resulted in clinically significant symptom reduction in seven out of 12 participants, and the authors suggest that multiple sessions of IR could be even more effective. Maloney and colleagues (2019) offered the opportunity to adjust the number of sessions of IR to what was necessary to produce a significant symptom improvement. This study included 13 patients who experienced insufficient effects from previous exposure with response prevention treatment. Six patients had significantly fewer difficulties after just one session of IR. For the other patients, on average two sessions were needed to achieve that result. These effects were largely retained after a period of three months. In summary, research on IR in obsessive-compulsive disorder is limited, but the first small studies show encouraging, although preliminary, results.
Depression
In groups of depressed patients, 44-96% reported having intrusive, negative images of unpleasant autobiographical memories (Brewin et al., 1996; Newby & Moulds, 2011; Patel et al., 2007). These images can relate, for example, to physical or sexual abuse in the past, humiliation during youth (for example, being bullied at school), experiences of failure (for example, being fired) or overwhelming grief (for example, the loss of a loved one) (see for a review: Weßlau & Steep, 2014). Not only are depressed patients characterized – compared to non-depressed people – by a higher number of negative images, but also by a lower number of positive images (Holmes et al, 2008; Morina et al., 2011; Moscovitch et al., 2011; Pile & Lau, 2018). Depressive patients, just like those with an anxiety disorder, also appear to have more intrusive images about negative events in the future, the so-called flash-forwards (Morina et al., 2011). Examples are images in which patients see themselves automutilating, committing suicide or seeing their own funeral, or the consequences of their death (Crane et al., 2012; Holmes et al., 2007).
Imagery rescripting for depression
Compared to the more verbal cognitive behavioural therapies, imagery has received less attention as part of the treatment of depression (Holmes et al., 2016). Hence, there are relatively few studies that have investigated the effect of IR in depression. Brewin and colleagues (2009) treated 10 patients suffering from depression, of whom some showed severe, chronic depressive symptoms, with an average of eight sessions of IR focused on intrusive memories. The majority of the patients showed a clinically significant improvement in symptoms and the average symptom decrease corresponded to that produced in a standard cognitive behavioural therapy of about 16 sessions. This effect was maintained for at least one year after completion of treatment.
Moritz and colleagues (2018) investigated whether IR can be effective as a self-help technique for the treatment of depression, using a comprehensive and less extensive patient manual explaining the intervention and exercises. Compared to a waiting list condition, patients in the IR condition where the extensive handbook was used had significantly fewer depressive symptoms. However, it turned out to be mainly patients with more serious difficulties, more confidence in the technique, and a greater willingness to change who benefitted from the treatment.
In addition to IR for autobiographical memories, one could also focus on future-oriented images of suicide or self-mutilation. These images may function as short-term emotion regulation (Selby et al., 2007). However, in the longer term these future-oriented images seem to increase the likelihood of actual suicidal behaviour (Crane et al., 2012). The effect of IR on these forward-looking images has not yet been investigated. In summary, there is preliminary evidence that IR might be a good alternative treatment strategy for depression. IR as a standalone treatment or as part of a cognitive behavioural therapy seems to reduce depressive symptoms (Brewin et al., 2009). However, more research is needed to determine whether IR is actually an effective treatment for depression.
Eating disorders
There are indications that mental images contribute to the persistence of eating disorders (e.g. Cooper, 2011). For example, patients with bulimia nervosa report more negative mental images than people without an eating disorder (Somerville et al., 2007). These negative images are related to food, body weight, and body shapes (Somerville et al., 2007), or – prior to vomiting – to social rejection (Hinrichsen et al., 2007). However, Dugué and colleagues (2016) found that patients with an eating disorder (81% binge eating disorder and 19% bulimia nervosa) did not report more images of body shape and weight than the control group containing healthy participants and patients suffering from non-eating disorders – although these images were associated with a greater urge to eat. Recurrent and vivid, negative self-images are also reported in anorexia nervosa (Cooper et al., 2007a).
However, patients with anorexia nervosa do not seem to experience more visual images of body shape and weight than people without this disorder. But they do report a larger number of images that are associated with specific auditory experiences, such as hearing negative comments (e.g. that they should become thinner, that they should vomit or that they are fat), with related feelings of shame, sadness, and fear (Cooper et al., 2007a). Images reported by patients suffering from eating disorders are frequently related to specific autobiographical memories. In bulimia nervosa, these are often reminders of negative comments about their weight, body shape, and appearance (Somerville et al., 2007) and to humiliation, abuse, or abandonment (Hinrichsen et al., 2007). The early recollections of these eating disorder-related experiences date from the period when one was on average about ten years old (Cooper et al., 2007a; Somerville et al., 2007). In anorexia nervosa, often memories related to rejection and worthlessness are reported (Cooper et al., 2007a).
Imagery rescripting for eating disorders
Only limited research has examined the effectiveness of IR in eating disorders. In 2007, Cooper and colleagues compared the effect of one session of IR with a control intervention session (verbal review of image related to eating disorder) in 24 patients with bulimia nervosa. IR led to less belief in eating disorder-related beliefs, a better mood, and a reduced urge to eat (Cooper et al., 2007b). Dugué and colleagues (2019) were the first to conduct a controlled study comparing IR with cognitive restructuring, in 36 patients with bulimia nervosa or binge eating disorder. IR was not superior to cognitive restructuring, although the effect of IR on core beliefs was larger at follow-up. However, the study was limited in scope and there was a large drop-out at one week follow-up, so future studies must reveal whether IR is a good alternative treatment of bulimia nervosa or binge eating disorder.
Another study compared the effect of IR with a cognitive intervention (cognitive dissonance) – both offered online – in women who were not satisfied with their bodies and were at risk of developing an eating disorder (Pennesi & Wade, 2018). The results give a first indication that this online variant of IR can lead to greater acceptance of one’s body image and to more self-compassion. In summary, mental images relating to body, body shape and eating seem relevant to the development and persistence of eating disorders. There is a clear relationship between such images and autobiographical memories that are associated with the onset or worsening of the eating disorder. However, research into the effect of IR in eating disorders is still in its infancy. The first, preliminary results are positive, but more research is needed.
Nightmares
A nightmare disorder is characterized by frequent nightmares about insecurity or threats to physical or emotional integrity. The nightmares are accompanied by a strong fear, anger, sadness, and disgust (APA, 2013). The nightmares are usually well remembered after waking up and cause great suffering (Lancee & Schrijnemaekers, 2013; Spoormaker et al., 2006). Nightmares are common: 83% of adults report one or more nightmares a year (Hublin et al., 1999; Schredl, 2016) and 2-5 % say they have one or more nightmares a week. The nightmare disorder is common in psychiatric populations (Nielsen & Levin, 2007; Schredl, 2016; Spoormaker et al., 2006). Patients with a nightmare disorder experience a high degree of powerlessness and uncontrollability with regard to their nightmares (Kunze et al., 2019). IR offers the possibility of changing the storyline in nightmares and this can lead to the experience of being able to do something about the content of the nightmares (Kunze et al., 2016). IR is an intervention par excellence for this disorder.
Imagery rescripting for nightmares
For many years, nightmares were treated using imagery rehearsal therapy. For a detailed description of this intervention, please see publications by Krakow and Zadra (2006, 2010). In short, this treatment is comprised of two components: a cognitive restructuring of thoughts about (having) the nightmares and a second component in which the storyline of the nightmare is rescripted, after which this new scenario is repeated daily in one’s mind.
Imagery rehearsal therapy was effective in reducing the frequency of nightmares and related suffering (Augedal et al., 2013; Hansen et al., 2013). In people who had PTSD in addition to the nightmare disorder, these post-traumatic stress symptoms also decreased (Casement & Swanson, 2012; Krakow et al., 2001). Kunze and colleagues (2017) compared IR – as a standalone treatment – and imaginal exposure to a waiting list control condition in a group of 104 patients suffering from nightmare disorder. IR and imaginal exposure each consisted of three weekly sessions.
The frequency of the nightmares and the associated anxiety decreased significantly more in both active conditions than in the waiting list control condition. No difference was found between IR and imaginal exposure – they were equally effective. In summary, imagery rehearsal therapy is effective for the treatment of nightmare disorder. However, this treatment consists of several components, including cognitive restructuring. As far as we know, there is only one study that examined IR as a standalone treatment, and this was compared to another proven effective intervention (imaginal exposure). This study provides a first indication that IR, although not superior, can also be effective for nightmares.
Psychosis
Approximately three-quarters of psychotic patients report having negative mental images associated with their psychotic symptoms (Morrison et al., 2002). These images are thematically related to autobiographical memories (Schulze et al., 2013). Ison and colleagues (2014) describe a patient who saw images of a dead man with a bullet hole in his forehead. The autobiographical memories associated with these images were a suicide of her uncle when she was fourteen years old, after which she dreamed of his face under water, and an experience later in her life witnessing dead people in a burnt-down house. In people with auditory hallucinations, the images are related to the origin of the voice, or to what the voice is saying. Ison and colleagues (2014) also describe a 45-year-old woman who heard voices on the street calling her a child abuser. She described a mental image in which she saw how she was abused as a child. This image turned out to be related to memories of the sexual abuse by her brother when she was eleven years old.
Imagery rescripting for psychosis
So far, there is very limited evidence that IR could be effective in the treatment of psychotic disorders, as little research has been done on the subject. There are two published case studies on the effectiveness of IR in delusions. IR was part of a more comprehensive treatment package including cognitive restructuring (Morrison, 2004; Serruya & Grant, 2009). Furthermore, two studies investigated the effect of IR in patients with auditory hallucinations. A single session of IR reduced the stressfulness of the intrusive images of memories associated with their auditory hallucinations for three out of four patients (Ison et al., 2014). Paulik and colleagues (2019) demonstrated that eight sessions of IR in 12 patients with auditory hallucinations drastically reduced both PTSD symptoms and auditory hallucinations. In summary, intrusive images seem to be common in people experiencing psychotic symptoms. Up to now, there has been only limited research into the possible effectiveness of IR for these difficulties. The available evidence does suggest that IR could have positive effects. However, far more research is needed.
Body dysmorphic disorder
Patients with a body dysmorphic disorder (BDD) are concerned about perceived bodily imperfections, such as wrinkles or the size or shape of the nose or eyes (APA, 2013). Although these imperfections are usually not visible to others, patients may spend hours a day checking their appearance, applying covering makeup or clothing, or regularly asking for reassurance. An increased self-centred attention, in which patients see themselves as an ‘aesthetic object’, seems to be a central feature of the disorder (Veale, 2004; Wilson et al., 2016). Cognitive-behavioural therapeutic models of the disorder emphasize the role of mental images as a sustaining factor (Veale, 2004; Veale & Neziroglu, 2010).
Patients with this disorder are more likely to have negative images of their appearance than subjects who do not. These images are often observed from the third-person perspective, where patients see themselves through the eyes of someone else (see Veale, 2004). Moreover, these images are more vivid, detailed and distorted, and are more often accompanied by physical sensations compared to those of a healthy control group (Osman et al., 2004). The content of the images is often related to memories of unpleasant events in childhood or adolescence. The most common memories concern bullying experiences or the physical changes that occurred during puberty (Buhlmann et al., 2007, 2011; Osman et al., 2004), or experiences of sexual and emotional abuse in the past (Neziroglu et al., 2006).
Imagery rescripting for body dysmorphic disorder
Given the central role that imagery seems to play in BDD and the strong association of the images with autobiographical memories, IR could be an effective intervention in this disorder. Although research into IR and BDD is limited, two studies with six patients each showed that one or two sessions of IR combined with cognitive restructuring led to a significant reduction in difficulties in most patients (Ritter & Stangier, 2016; Wilson et al., 2016), which sustained for (more than) half a year after the intervention. In summary, mental images seem to play a central role in BDD. These images appear to be strongly related to memories of meaningful experiences from the past. Research into the effectiveness of IR in BDD is very limited, but initial results seem favourable.
Personality disorders
Unlike PTSD, personality disorders are not particularly characterized by intrusive memories of specific traumatic events. People suffering from a personality disorder develop schemas in their youth that are based on meaningful, but not necessarily traumatic, youth experiences (Arntz 2011).
Imagery rescripting for personality disorders
IR can be used to process memories of meaningful childhood experiences. This application of IR is thought to be an effective way to treat personality disorders (Arntz & Van Genderen, 2009; Lobbestael et al., 2010; Young et al., 2003). However, due to the nature of the pathology, the treatment of personality disorders almost always consists of an extensive package of various methods and techniques. This makes it very difficult to investigate the isolated effect of IR. For example, IR is an important component of schema therapy, but it is certainly not the only one. Over the past fifteen years, schema therapy has been found to be highly effective for the treatment of personality disorders (e.g. Bamelis et al., 2014; Farrell et al., 2009; Giesen-Bloo et al., 2006; Nadort et al., 2009; Nordahl & Nysaeter, 2005; Van Asselt et al., 2008). It is likely that IR, as part of that treatment, has contributed to the effect. However, it is unclear whether this assumption is correct and to what extent IR was a primary component of the effectiveness of the therapy.
Other areas of application
IR is used in various other psychological problems. For example, IR was applied to a patient diagnosed with terminal cancer. The rescripting of childhood memories led to a reduction in anxiety and mood symptoms (Whitaker et al., 2010). Patients with agoraphobia appear to have images of agoraphobic situations that are associated with memories of unpleasant events in the past. Based on these findings, it is suggested that IR could be a possible part of the treatment of agoraphobia (Day et al., 2004). Furthermore, Reiss and colleagues (2018) found that cognitive behavioural therapy in combination with IR was an effective way to reduce subjective anxiety in students with test anxiety. The above studies illustrate the increasing interest in IR among people with various fear-related problems.
Summary
Most studies on the effectiveness of IR have been done in the field of PTSD and social anxiety disorder, and IR appears to be an effective treatment for these difficulties. Preliminary evidence suggests that IR could also be a good treatment strategy for depression. Moreover, the comorbid depressive symptoms were also found to decrease significantly when the intervention was applied to disorders other than depression (Morina et al. 2017). IR appears to be a promising, possibly complementary intervention in the treatment of obsessive-compulsive disorder, nightmares, psychoses, eating disorders, specific phobias and personality disorders. However, it is important to bear in mind that research into the effectiveness of IR in these disorders has to date been limited and IR has not been compared to any other effective technique. Hence, it is not yet possible to give a definite answer about the effectiveness of IR in these disorders.
The working mechanism
Although there are now many studies that have demonstrated the effectiveness of IR in, for example, PTSD, there is still relatively little knowledge on the working mechanism of the intervention i.e. how the intervention produces its effect. The most common hypotheses explain the effect of IR either by a changed meaning of the representation of the meaningful autobiographical memory (Arntz, 2012) or through the creation of an alternative memory that competes with the original memory (Brewin, 2006, 2010; Stopa, 2010; Stopa & Jenkins, 2007). These two hypotheses are discussed in more detail below.
Hypothesis one: Imagery rescripting changes the meaning of the representation of autobiographical memory (Arntz, 2012)
This theory is based on the assumption that the mental representation of an event that is meaningful to the person, termed highly simplified as the ‘original memory’, enters a ‘labile state’ when retrieved in working memory. This labile state makes it possible to add information (e.g. through IR) and thus to change the intrinsic meaning of this representation (Arntz, 2012; Nader 2003). IR yields a stronger impact than a more verbal way of processing information (see e.g. Blackwell, 2018; Holmes & Mathews, 2010), and could change core beliefs at both cognitive as well as non-verbal/emotional levels (Arntz, 2011, 2015). In this way, IR can strengthen a sense of mastery (i.e. that something can be done about it), as opposed to the feelings of powerlessness and helplessness that were linked to the original memory (Kunze et al., 2019). By changing this meaning, the memory is stored in long-term memory with a different, less negative valence, which in theory should lead to fewer negative cognitions, feelings, and intrusions regarding the memory. Various experiments partly support this hypothesis (e.g. Dibbets et al., 2012, 2018; Hagenaars, 2012; Hagenaars & Arntz, 2012; Rijkeboer et al., 2019). However, many questions remain unanswered, so more research is needed.
Hypothesis two: Imagery rescripting creates an alternative memory that competes with the original memory
This hypothesis states that in every situation, different relevant autobiographical memories compete for retrieval. In mental disorders, such as anxiety disorders, particularly negative, anxiety-confirming memories win the competition and are recalled in mind over memories that do not fit in that well to the experience of anxiety. Brewin (2006) argued that psychological treatments do not simply change negative memory representations. Rather, new, alternative representations are created that compete with the original, negative representations in terms of accessibility. From this point of view, the new representations need not so much be more realistic, but only need to be more easily accessible when patients are confronted with anxiety-inducing triggers (Brewin et al., 2010). According to this hypothesis, IR does not change the mental representation of a traumatic event, but instead a new, alternative representation is formed, which – hopefully – is often easier to retrieve than the negative variant (see also Arntz et al., 2013).
In conclusion, so far there seems to be little insight into the working mechanism of IR. The two most common hypotheses suggest a changing meaning of the original memory (Arntz 2012) or making an alternative mental representation more accessible (Brewin et al., 2010). But there may be other explanations for how IR works (see Arntz, 2012).
I also think bottom-up therapies are especially helpful for OPs, since they may lack the ability to achieve insight.
