Information for therapists

No. Although Imagery Rescripting is often used within schema therapy, it has also been researched as a stand-alone therapy. Initially, the approach was used to treat PTSD symptoms. However, it has since been shown to be effective in reducing various undesirable cognitions (including intrusive thoughts, beliefs, mental images, memories, nightmares and hearing voices) in various disorders. ImRs is a technique that is also often used in cognitive behavioural therapy. In schema therapy, ImRs is often used to address memories related to the development of schemas or modes that are being treated during the treatment, and to reduce associated post-traumatic stress symptoms.

In a recent randomized control study (IREM) that compared EMDR and ImRs in the treatment of complex PTSD (sexual abuse), it appeared that EMDR led to faster symptom changes. By the end of the treatment, the outcomes of both therapies were comparable, but in follow-up, ImRs showed better results than EMDR, with the symptoms continuing to improve for the ImRs group after treatment (Boterhoven de Haan KL, Lee CW, Fassbinder E, et al. 2020)). However, therapists often integrate elements of ImRs into their EMDR practice and use EMDR in combination with ImRs within schema therapy (see the podcast What’s The Schemata, episode ‘EMDR and Schema Therapy; a Power Couple? Schema, Trauma and PTSD with Dr Sarah Dominguez).

In imaginal exposure, the client relives a negative memory during therapy (usually with eyes closed, in the present tense and in the first person) with the aim of getting used to experiencing the emotions. ImRs contains an element of imaginal exposure, as the client relives the original memory in the first part of the rescripting. However, in ImRs, the memory is paused at the moment the client feels the original negative emotions (i.e. at or just before the ‘hot spot’ of the traumatic memory), and the ending is adjusted to help the client have their needs met.

ImRs can be safely applied to clients who are prone to dissociation, although there are several recommended ways to reduce or manage dissociation. Strategies to prevent dissociation include; a thorough analysis of dissociation; discussing ways to avoid/manage dissociation with the client before commencing ImRs; reducing uncertainty/anxiety by discussing the rescripting steps in advance; reducing anxiety before the rescripting (for example, by breathing more slowly); move more quickly through the original memory part of the re-enactment to lower the intensity of emotions; the therapist takes a more leading role in the re-enactment; use grounding techniques (such as sensory objects) during the re-enactment; client and therapist can each hold one end of a scarf, so the therapist can pull on it if the client does not respond. To manage dissociation when it occurs, the therapist can use grounding and calming techniques while continuing with the rescripting and reassuring the client (for example: ‘You are safe with me here in the therapy room, this image cannot harm you and there is no reason to dissociate. Come back to the image…”). See Paulik, G., Newman-Taylor, K., Steel, C., Arntz, A. (2020).

In the early years of Covid-19, therapists often had to offer therapy online. As a result, it allowed researchers to discover whether ImRs could be applied safely and effectively online. Although no RCTs were conducted, feedback from clients and therapists widely indicated that ImRs were equally effective and safe, but only if the client had sufficient privacy to conduct the online session and other issues, such as internet connection and post-therapy routines, could be resolved (see Paulik, G., Maloney, G., Arntz, A., Bachrach, N., Koppeschaar, A., & McEvoy, P. (2021)

There is no set number of ImRs sessions. The duration of the therapy depends on the mental health condition and the problem to be treated (with more sessions for more complex cases). It also depends on whether ImRs is given as a stand-alone intervention or integrated into schema therapy or CBT, with fewer sessions usually being devoted to ImRs when it is incorporated into a broader therapy approach. Studies have shown that even just one session of ImRs can be useful. For a meta-analysis, see Morina, N., Lancee, J., & Arntz, A. (2017).

There are various factors that must be taken into account when determining how much the therapist should intervene in the image versus the client, such as how early/late it is in ImRs therapy (often the therapist intervenes more in earlier sessions with rescripting, while the client does more on their own later), how well developed the client’s healthy adult mode is (clients with very complex childhood traumas and little experience with therapy often have a less developed healthy adult mode and therefore do not know what their unfulfilled needs as a child were or how these can be fulfilled); and whether the client is prone to dissociation (in clients prone to dissociation, it is often recommended that the therapist intervene more, especially in the initial stages of therapy). Where possible, it is important to strive for the client to lead the rescript themselves, as qualitative studies on ImRs have shown that clients experience phases 2 and 3 – in which they mainly lead the rescript themselves – as particularly empowering.

There is some debate about whether violence against an offender is acceptable within ImRs, which seems to depend largely on the preference of the client and the therapist. An important guideline in using violence is ‘What is the relevant emotional basic management need of the client?’. Suppose a client has experienced a lack of self-expression in the past. In that case, the use of violence can be a form of self-expression that offers the corrective emotional experience that is appropriate for this client. However, if a client has had a deficit in learning to tolerate realistic boundaries and safe connections with others in the past, then the use of violence may not be the necessary corrective experience, but rather, a more limited, safe way of expressing feelings would be appropriate. One study compared the absence versus the inclusion of violent/vindictive behaviour within ImRs (in a healthy sample) and found that although there was no additional value to the outcomes, it did not cause an increase in ‘aggressive emotions among the participants’ (Seebauer, L., Froß, S., Dubaschny, L., Schönberger, M., & Jacob, G. A. (2014)

ImRs is often carried out slightly (and sometimes very) differently for different client populations and with various problems. ImRs has been studied as a stand-alone therapy for some disorders, while for others it is studied as a technique that is added to a broader therapeutic approach (for example, CBT). For a discussion of the various applications, see Arntz, A. (2012). See Strachan, L.P., Hyett, M.P. & McEvoy, P.M. (2020) for a more recent review on anxiety disorders.

ImRs appears to be most effective when used at the most emotional moment of the memory (Dibbets et al., 2016). A practical guideline during the exercise is “You need to feel it to heal it”. It is typical for clinicians to be fearful of upsetting the cleint emotionally or worrying about re-retraumatizing the client. However, it is important to remember that the rescript happens before an abusive interaction. Once this image is accessed, the clinician meets the need and provides corrective emotional experiences for the client. The therapist is active and can use their influence in the image to give care and protection. At the same time, the client must remain able to process the experience and not become dissociated. So, during the exercise, check whether the client can still hear and respond to the interventions offered.

Most people are able to visualize. A small percentage (2-3%) are genuinely unable to summon up mental images. If your client indicates that they do not see any images, a form of (subconscious) avoidance may be at play. In such situations, start with a less emotionally charged memory so the client can have a successful experience with ImRs before moving on to the more emotional memories. It can also be useful to pay extra attention to explaining how the technique works, offer reassurance, and emphasize that the client is in control of the exercise and can stop at any time.

Clinicians can help or support the antagonist in the image to reassure the client (for example, offering help to the caregiver). Guilt often means that the client’s attention is focused on the other person’s feelings, so ask the client to pay particular attention to how it feels when someone stands up for their needs.