Imagery Rescripting: Theory and Practice 1914010574, 9781914010576

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Imagery Rescripting: Theory and Practice English translation of Imaginaire rescripting, theorie en praktijk © Pavilion Publishing & Media The author has asserted his rights in accordance with the Copyright, Designs and Patents Act (1988) to be identified as the author of this work. Published by: Pavilion Publishing and Media Ltd Blue Sky Offices, 25 Cecil Pashley Way Shoreham by Sea, West Sussex BN43 5FF Tel: 01273 434 943 Email: [email protected] Web: www.pavpub.com Published 2021 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission in writing of the publisher and the copyright owners. A catalogue record for this book is available from the British Library. ISBN: 978-1-914010-57-6

Pavilion Publishing and Media is a leading publisher of books, training materials and digital content in mental health, social care and allied fields. Pavilion and its imprints offer must-have knowledge and innovative learning solutions underpinned by sound research and professional values.

Imaginaire

First published in Dutch under the title by Remco van der Wijngaart, edition: 1

rescripting; theorie en praktijk

Copyright © Bohn Stafleu van Loghum is een imprint van Springer Media B.V., onderdeel van Springer Nature, 2020 This edition has been translated and published under licence from Springer Media B.V., part of Springer Nature. Springer Media B.V., part of Springer Nature takes no responsibility and shall not be made liable for the accuracy of the translation. Author: Remco van der Wijngaart Cover design: Anthony Pitt, Pavilion Publishing and Media Ltd Page layout and typesetting: Anthony Pitt, Pavilion Publishing and Media Ltd Printing: CMP (UK) Ltd

Contents Imprint Acknowledgements About the author Foreword

Chapter 1: Introduction Chapter 2: Diagnostic imagery Chapter 3: Imagery rescripting – the therapist rewrites Chapter 4: Imagery rescripting – the client rewrites Chapter 5: Future-oriented imagery rescripting to break negative patterns Chapter 6: Specialized fields of application and forms of imagery rescripting Chapter 7: Pitfalls for therapists Appendices Appendix 1: Roadmap for diagnostic imagery exercise Appendix 2: Roadmap for explaining imagery rescripting to clients

Appendix 3: Roadmap for imagery rescripting – the therapist rewrites Appendix 4: Roadmap for visualizing the healthy adult Appendix 5: Roadmap for imagery rescripting – the client rewrites Appendix 6: Roadmap for rescripting future scenarios

References

close my eyes and see trees part, a clearing soft light, hear birds above the silence here where colours dance land .

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Acknowledgements Now that the work is done, I would like to explicitly thank a few people for their role in the creation of this book. First of all, I would like to thank the publisher, Bohn Stafleu van Loghum, for the confidence they gave me to write this book. Yulma Perk: you really won me over with your confidence and enthusiasm, and I really want to thank you for that! Hester Presburg, you’ve been a pleasant, cheerful consultant who was always there very quickly when I needed you – very fine! Prof. Arnoud Arntz: Dear Arnoud, I really appreciate that you wanted, and were able, to free up space to provide this book with a wonderful preface! In particular, I want to thank Prof. MM Rijkeboer for her indispensable contribution to the realization of this book; Marleen, you are really great! I really value your coauthorship of the first chapter; what a gift that someone so skilled has ploughed through my writing – hours and hours of patient work that you have managed to fit into your extremely busy life, making it a beautiful chapter. I can't thank you enough for all that work! I also consider the feedback from Dr. Julie Krans on the book to be a gift. Dear Julie: I am very, very grateful for your astute, humorous and expert feedback on the manuscript! Marisol Voncken: I would like to thank you very much for the articles you sent me and the advice on scientific notations. Hélène Bögels: we’ve often talked about how busy our lives are, and that's why it's all the more true that you’ve been free to go through the manuscript. I would like to thank you for your positive feedback and active thinking! Daphne: as a graphic designer, how beautiful you make everything, including the cover of the Dutch edition of this

book! You are also very helpful and help me out every time a deadline is approaching. Thanks! I would also like to thank the many students and supervisors for their stimulating questions about imagery rescripting during training or supervision. In doing so, you have encouraged me to delve further into all facets of imagery rescripting, which, I think, has made the book richer and more complete. I would also like to thank my clients I have treated with imagery rescripting over the past twenty years for their willingness to allow me into their world of experience, to allow me to rewrite images, and for forgiving the inevitable mistakes I made in that process. I would like to end these acknowledgements by thanking Marion and my daughter and son, Robin and Arthur. You had to endure many hours of me sitting at the computer, and you often got up and went to bed with me there. I’m glad the book is now finished and life can resume again. You are the most beautiful thing that has happened to me in life. Thank you!

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About the author Remco van der Wijngaart is a psychotherapist and healthcare

psychologist. He has spent more than twenty years working in an academic department of an outpatient mental health institution where he participated as a therapist in numerous treatment studies for anxiety, somatoform and eating disorders and personality disorders. In a first treatment study into the effectiveness of schema therapy for borderline personality disorder, he was trained and supervised in imagery rescripting by Jeffrey Young, founder of schema therapy. Remco currently works in an independent psychotherapy practice in Maastricht. In collaboration with others, he has developed various audio-visual productions, such as Fine-Tuning Imagery Rescripting – 35 scenes showing imagery rescripting in all its facets.

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Foreword Imagery rescripting is becoming an increasingly popular therapeutic technique. Numerous applications have been studied worldwide, and fundamental laboratory research is helping to unravel the underlying mechanisms. The increasing popularity is probably due to several factors. For example, scientific research has helped to ensure that imagery rescripting is no longer seen as a dubious and unproven technique. Also, theoretical developments and brain imaging studies have enabled a better understanding of the effects of imagery rescripting than some thirty years ago. But also the broad field of application, the powerful therapeutic effects and the fact that imagery rescripting is well tolerated by clients (the drop-out rate is very low) contribute to the increasing interest. For many years, it was taboo in cognitive behavioural therapy to treat early experiences. That was seen as something psychoanalytical, and the prevailing view was to only assess and treat reinforcing factors. Although there is no good reason why the re-evaluation of representations of original unpleasant experiences that underlie many psychopathological problems would be the wrong approach – on the contrary, this fits in perfectly with modern learning theory – it was a predominant idea. This view changed with the finding that when treatments focusing solely on the here-and-now got stuck, they could often get back on track by processing memories of early experiences with imagery rescripting. It is also likely that new awareness of the harmful long-term effects of child abuse and neglect has increased the attention paid to early memories, as has the growing understanding that traumatic experiences need not only lead to post-traumatic stress disorder. Finally, the broad applicability: imagery rescripting is pre-eminently a trans-

diagnostic technique, and the possibility of offering it, either as a complete treatment or integrated into a broader treatment package, is attractive to many. The increased interest in imagery rescripting has led to demand for an overview of the scientific foundations and applications. There are protocols available for the application in specific disorders, but a book that provides a broad overview has been lacking. It is therefore very gratifying that Remco van der Wijngaart, with the support of Marleen Rijkeboer, has written this book. It provides an excellent and up-to-date overview of the state of science and clinical applications of imagery rescripting. Practical examples are given, and possible solutions to problems that the practitioner may encounter are discussed. This book therefore offers, as far as I know, the most extensive overview of imagery rescripting. In its pages, the clinician will find a wealth of clinical applications and tips based on the latest insights.

Arnoud Arntz

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Chapter 1: Introduction Written by Remco van der Wijngaart and Marleen Rijkeboer* * Prof. Marleen Rijkeboer is affiliated with Maastricht University and the University of Amsterdam. Her research focuses on schema therapy, EMDR and imagery rescripting, among other things. She is Chair of the Dutch Schema Therapy Society and heads the Governmental postmaster courses for Clinical Psychologist and Psychotherapist at RINO Amsterdam.

Chapter summary 1.1 Mental imagery 1.2 Imagery rescripting 1.3 The effectiveness of imagery rescripting 1.4 The working mechanism 1.5 Chapter summary 1.6 Introduction to running case studies: Nicky and Greg

1.1 Mental imagery 1.1.1 What is mental imagery? In scientific literature, mental imagery is described as ‘seeing with the mind’s eye, hearing with the mind’s ear, and so on’ (Kosslyn et al., 2001). Imagery is seen as ‘representations and the accompanying experience of sensory information without a direct external stimulus’ (Pearson et al., 2015). The experience during imagery can contain several sensory elements, not only visual but also auditory, olfactory, tactile, and motor elements (Kosslyn, 1994). For example, when we imagine a crepe stall, we not only see the

stall; we also hear the hiss of the batter, smell the gradually cooking crepes; and feel the warmth of them melting on our tongues. During imagery, autobiographical memory plays an essential role. Mental images are constructed from elements of what is stored in our memory. On the other hand, the recollection of autobiographical events is accompanied by mental images. In other words: when people remember, they imagine, and when they imagine, they use memory (Conway & Loveday, 2015). Mental images do not have to concern the past only – they can also be future-oriented, and can be evoked voluntarily (such as fantasizing about a planned holiday), but can also sometimes pop-up involuntary (such as the intrusive reliving of post-traumatic stress disorder (PTSD)). Imagery can therefore take various forms, such as daydreams, nightmares, and pleasant fantasies. All these forms of imagery can then be described on the basis of their content, vividness, brightness, colour, shapes, movement, foreground and background properties, and other spatial characteristics (Horowitz, 1970). Although imagery can encompass all the senses, visual images are the most frequently discussed in the literature. These images can be experienced as a faithful reconstruction of a real event, or as a complete hypothetical situation, or everything in between (Martin & Williams, 1990).

1.1.2 Imagery is part of healthy functioning Imagery seems to be an essential part of our psychological life, allowing us to remember the past, simulate or experience the future in advance, and make decisions (Schacter et al, 2012). Thus, imagery seems to be used in almost every behaviour that could benefit from sensory simulation, ranging from avoiding danger or seeking a reward,

to solving problems and completing tasks (Holmes et al., 2016). Almost everyone succeeds in imagining things vividly. Only two to three per cent of healthy adults seem incapable of generating mental images (Holmes, 2015; Isaac & Marks, 1994). This capacity is independent of gender or age, although there are some age-related differences in the degree of vividness of the visualized images. For example, a study with 547 participants aged seven to fifty years or older showed significantly increased vividness of images in girls of eight to nine years of age, compared to girls in other age groups. Boys aged ten to eleven also had an increased vividness of the images compared to boys in other age categories. In general, women seem to describe more vivid images than men, but that difference seems to have disappeared by the age of fifty (Isaac & Marks, 1994). Virtually everyone seems capable of imagery, but individual differences are reported on how well people can visualize. However, for the time being it is unclear what influence these differences have on the emotional experiences generated by the images (Ji et al., 2016).

1.1.3 The role of imagery in the processing of information There has been scientific interest in imagery since the 19th century. According to Galton (1880), mental images are the building blocks of dreams and hallucinations (for a more detailed description, see Holmes et al., 2016). Despite the scientific interest in this phenomenon, it took until 1987 before a first testable theory on emotion-inducing visualizations was developed.

Lang (1987) formulated his ‘bio-informational theory’ in which imagery plays a role in the processing of emotions. He assumed that imagining a situation or object (for example, the image of a large spider close to you) evokes virtually the same emotional reactions as an actual confrontation with a situation or object (a spider that is, in reality, close by). Thus, imagery appears to trigger a reaction ‘as if it is real, or really happening’. Lang also described the therapeutic implications that may result from this, such as learning new, more adaptive responses through imaginal exposure. His theory laid the foundation for forty years of experimental and clinical research into imagery. The knowledge and understanding of imagery and its impact on emotional and behavioural responses have increased enormously during that time (see Ji et al., 2016).

1.1.4 The impact of imagery on experienced emotions A series of experiments showed that the processing of emotionally charged information through imagery had a greater impact on the experienced emotions than a more verbal processing thereof. For example, depressed and socially anxious adults were asked to consciously generate mental images in response to emotionally charged triggers (e.g. stories or certain image-word combinations). Changes in their mood were seen in both positive and depressive or anxious directions, congruent with the emotional valence of the stimuli offered (Holmes et al., 2006, 2008; Pictet & Holmes, 2011; Stopa et al., 2012). On the other hand, verbal processing of the same information did not show comparable mood changes (Holmes & Mathews, 2005; Holmes et al., 2008). Although replication is necessary, these experiments give a

first indication that imagery acts as an amplifier of both positive and negative emotions (Holmes, 2010). So, there is a strong relationship between imagery and emotional experience. Holmes and Mathews (2010) describe three hypotheses that might explain this strong relationship: 1.

Imagery activates emotional systems in the brain that respond to specific sensory information, even when these are visualized. Imagery appears to activate the emotional parts of the brain, such as the amygdala, more than verbal information. This could have a survival function from an evolutionary point of view: seeing danger signals, also imaginal, leads directly to fight-or-flight behaviour.

2.

Imagery activates the same brain areas that are active in perception. Mental images are therefore interpreted as real emotional events. Imagery selectively activates those areas of the brain that also play a role in the processing of sensory information, such as visual perception (Ganis et al., 2004; Kosslyn & Thompson, 2003; Pearson et al., 2015; Sirigu & Duhamel, 2001). Hence, the same brain areas are active when imagining an emotional event as in the actual perception or experience of an emotional event (Holmes, 2010). Thus, imagery can be seen as a ‘weak’ form of perception (Pearson et al., 2015) with the accompanying emotional reactions. For example, people with PTSD experience their flashbacks as if the event is taking place again, with all the emotional reactions associated with it.

3.

In imagery, elements of autobiographical memories of emotional experiences are used. This hypothesis assumes that mental images are constructed using elements from autobiographical memory and the associated emotions. Indeed, there seems to be a relationship between imagery and the mechanisms of autobiographical memory. Mental images are reported for most forms of remembering. This is even more the case with regard to memories of personal events and almost everyone seems able to create mental images (Holmes & Mathews, 2010). So, if someone remembers something that is emotional, it is most likely in the form of a visual image.

A vivid visual image of a remembered personal event can be very convincing (‘seeing is believing’; Holmes & Mathews, 2010). However, this does not mean that this image is an exact representation of this experienced event and that it actually took place (in that way). It is not as if a video was made of the event and you can play it over and over again, with the same scenes every time. Memories (and the images one has of them) rather seem to be constructions of loosely stored elements (Conway & Pleydell-Pearce, 2000). These loose fragments would therefore be used in the construction of ‘memories’ that did not actually take place and in the formation of images of future events (Schacter et al., 2007). When memories are visualized, the same brain areas are active as when visualizing future events (D'Argembeau & Van der Linden, 2006). The above-mentioned hypotheses on the emotion-enhancing effect of imagery are not mutually exclusive and can be seen as part of a more complex, coherent whole (Holmes & Mathews, 2010).

1.1.5 The relationship between imagery and psychopathology Having intrusive images is a diagnostic criterion of posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), but is not mentioned among the criteria of other psychological disorders (APA 2013). Nevertheless, there is increasing evidence that intrusive images play an important role in many psychological disorders, such as social anxiety, depression, eating disorders, or psychotic problems (see, for example, Brewin et al., 2010; Hirsch & Holmes, 2007; Kadriu et al., 2019; Wesslau & Steep, 2014). People with psychopathology, compared to those who do not, have more intrusive images, and these are perceived as more stressful (Brewin et al., 2010). These intrusive images are also often associated with unpleasant events in the past. However, images need not only have a negative content. For example, in manic patients and people with a substance-use disorder, there are also positively coloured images that can further enhance the pathology. In summary, imagery appears to play an important role in various forms of psychopathology.

1.1.6 Imagery, real or not? Since there seems to be a certain overlap between actual perception and imaginal perception, it can be assumed that people can confuse images with memories of actual events. Indeed, a repeated imagining of events (or behaviours) that never took place appears to cause these to be remembered as if they really happened (Hyman & Pentland, 1996; Johnson & Raye, 1981; Thomas et al., 2007). The more vivid the image, the stronger the belief that it concerns a real memory (Gonsalves et al., 2004; Johnson,

2006). Emotional images are usually perceived as more vivid than neutral images (Bywaters et al., 2004), and the consequence could therefore be that particularly vivid, emotional images could be confused with real memories (Holmes & Mathews, 2010). In a related study (Hyman & Pentland, 1996), participants were presented with events from their youth to which one emotionally charged event had been added that had never taken place (for example, the knocking over of a glass at a wedding reception causing the drink to fall over the bride's parents). One group of participants was asked to mentally visualize the events repeatedly, while a second group of participants only had to think about the events. Participants who had visualized the events more often indicated that they actually remembered the made-up event (e.g. the knocking over of the drink). In other words, by repeatedly imagining a situation vividly, this situation becomes more real, making it seem as if it really happened. In fact, all of our ‘memories’ are constructions, which generally only moderately correspond to the actual situation experienced at the time (Conway & Loveday, 2015). The degree of similarity can be greater or lesser, but imagery can reinforce the idea of similarity (i.e. that it actually happened that way). Therefore, always be aware that it is not self-evident that something really happened (in that way) when someone reports an emotional and highly vivid image of an event such as a flashback (for more myths about trauma and memory, see McNally, 2005). The leading memory researcher Daniel Schacter (1997) described it as follows:

‘We often edit or entirely rewrite our previous experiences – unknowingly and unconsciously – in light of what we now know or believe. The result can be a skewed rendering of a specific incident, or even of an extended period in our lives, that says more about how we feel now than about what happened then.’ And this rewriting of events is what is used

– in a positive sense – in the technique that is the main subject of this book: imagery rescripting.

1.2 Imagery rescripting 1.2.1 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).

1.2.2 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 her1 feel unimportant and lonely. 1 The female form was chosen because many of the examples used stem from the treatment of borderline personality disorder and post-traumatic stress disorder, disorders that occur relatively more frequently in women than in men (RIVM 2020).

1.2.3 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).

1.3 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.

1.3.1 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 metaanalysis 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.

1.3.2 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.

1.3.3 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 fearrelated. 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.

1.3.4 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.

1.3.5 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 selfmutilation. 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.

1.3.6 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.

Examples of mental images in eating disorders (Dugué et al., 2016). Food: ‘I see myself sitting in the kitchen and eat and eat and eat; and I munch with my cheeks full [participant is demonstrating the munching]. I just gorge myself with everything.’ Body: ‘I see myself as a kind of Michelin Man, do you know that? …well it’s bulky, ugly, fat. I try to heave myself out of bed, but I can’t get up because I’m too fat.’ Social Rejection: ‘I am being criticized for something; which I can’t help; the whole team is being called to the office of our supervisor and then, “you’ve done this and that”, while he’s saying that the supervisor is looking only at me.’

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 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).

more

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.

1.3.7 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.

1.3.8 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.

1.3.9 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.

1.3.10 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.

1.3.11 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.

1.3.12 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 obsessivecompulsive 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.

1.4 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

how

intervention i.e. 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).

1.5 Applications of imagery rescripting 1.5.1 Indication criteria for imagery rescripting

Research suggests that the application of IR is suitable for various forms of psychopathology (see Morina et al., 2017). However, most research has been performed in trauma-related disorders, such as PTSD. Although there are indications that IR can also be applied to other forms of psychopathology, general treatment guidelines should be followed initially. If first-line treatments are not sufficiently effective for a particular patient, IR can be used as an alternative treatment or in addition to the first-line treatment. Moreover, during the diagnostic phase the use of imagery can be a welcome and useful addition to existing methods and techniques, as it provides access to meaningful symptom or problem-related memories. This technique of diagnostic imagery can also provide insights into the suitability and willingness of the specific patient to engage in IR.

1.5.2 Who can do imagery rescripting? Patients report that they find diagnostic imagery useful, but they also perceive it as intensive and emotional (Ten NapelSchutz et al., 2011). Therefore, a good preparation of the patient by means of education about imagery exercises is recommended. IR can also evoke strong emotional experiences. Hence, it is important that, prior to using IR, a practitioner has received specific training and supervision in the application of the technique.

1.5.3 Duration of treatment and frequency of sessions The duration of the IR strongly depends on the specific symptoms or problems the technique is used for. In studies with fixed protocols, the duration varies from three sessions in the treatment of a nightmare disorder (Kunze et al., 2016) to twelve 90 minutes sessions in the treatment of PTSD due to

early childhood trauma (Boterhoven de Haan et al., 2020). And in the treatment of borderline personality disorder, IR is frequently used next to other techniques for two to three years (Giesen-Bloo et al., 2006). In recent studies on the effectiveness of IR as a standalone treatment of PTSD, a frequency of two sessions a week was used (e.g. Boterhoven de Haan et al., 2020). This frequency proved to work well for both therapists and patients. So, IR as a standalone treatment might be better applied in a short and intensive way – for example, a double session twice a week, after which the treatment is completed.

1.5.4 Treatment plan and evaluation criteria Irrespective of the disorder for which IR is used, a treatment plan must be developed at the start of the treatment. It describes how long the therapy will last (including how many sessions) and on which criteria it will be evaluated. Examples of such evaluation criteria are: can the patient visualize meaningful images? is it possible to rescript these images, so that the rescripting leads to meaningful experiences? is the patient able to remember these meaningful experiences between sessions? is the patient able to independently rescript meaningful images? does the credibility of dysfunctional cognitions of memory/image change? does the technique lead to a change in symptoms/problems to some extent, as is evident from the questionnaires used and other forms of self-report?

1.5.5 Emotion regulation during imagery rescripting IR is an effective treatment method for various disorders that taps into the emotional intensity that imagery can generate. At the same time, various forms of psychopathology are characterized by poor emotional regulation, such as the characteristic avoidance response in anxiety disorders, or the strong mood swings in borderline personality disorder. Some patients may get too close to their problems and the associated emotions or too far away from them. If your patient gets too close to their problems, causing them to be overwhelmed by emotions, then you will have to help them take some distance from proceedings and calm down. However, if your patient is too far away from their problems, they will feel little and no corrective emotional experiences can be gained. In that case, you will have to intensify the IR. Whether a person gets too close to or remains too far away from their problems and associated emotions varies with the individual. Moreover, this may also vary over time due to situational circumstances. Therefore, as a therapist, you will have to constantly assess the strength of your patient’s emotional experience during the exercises. This is done by observing well, but also by regularly asking questions as: ‘How do you feel?’, ‘What do you feel when I say this/if you see this image?’ IR uses a lot of 'feeling related language'. With this language you try to assess whether your patient is overwhelmed by, or shut off from, her emotions. The following chapters describe various methods that enable you as a therapist to somewhat regulate these emotional experiences. One way to regulate the emotional intensity during IR can already be given: the use of the third person

perspective is a frequently reported phenomenon associated with a reduction in emotions (Brewin et al., 2010). This phenomenon fits well with the long history of clinical observations and the idea that dissociative reactions, such as seeing oneself from a distance, would have a protective effect against the emotional impact of extreme stress.

1.5.6 Critical note Although there are many indications that IR is an effective treatment method for disorders other than PTSD, relatively few randomized controlled studies have been conducted. This means that it is still largely unknown if and to what degree IR is effective in these disorders, when compared to other effective, more regular treatment methods such as exposure. For this reason, it is strongly recommended to follow the general treatment guidelines and to apply IR only if the guidelines or recent research give reason to do so, or in case the treatments of choice produce insufficient effects. This book describes the application of IR based on current, although still limited, insights into the working mechanism of the technique. Hence, the suggestions in this book should not be adopted as a binding guideline.

1.6 Chapter summary Virtually all of us have the capacity for imagery. We have images of autobiographical memories, or events that might take place in the future, or images that seem to have no connection whatsoever with reality. Images can be intrusive or voluntarily invoked and seem to play an important role in the processing of information. Imagery has a greater impact on emotions than the verbal processing of the same information, possibly because the same brain areas are active in imagery as in observing and remembering emotional

autobiographical events. A vivid image can therefore easily be confused with a memory of an event that actually took place. Although people with a mental health disorder do not necessarily report a larger number of negative, intrusive mental images than people without a mental health disorder, they do experience these images as more stressful. During IR, the course of events in a memory representation is changed in a more desired direction. This basic method was first described more than a century ago, but since the 1990s it has experienced major growth in both scientific and clinical applications. IR is an effective treatment for various disorders and this effect can be generated within a short period of time. However, few studies have compared IR with other effective treatments. Moreover, there is still little knowledge on how IR produces this effect. The most common hypothesis is that imagery rescripting alters the meaning of the original memory. In any case, IR turns out to be an effective intervention that can evoke strong emotional experiences. Therefore, it is important that therapists who apply this technique are properly trained to induce corrective emotional experiences. The following chapters describe how the technique is applied in practice.

1.7 Introduction to the running case studies: Nicky and Greg This book uses two cases as a guide, Nicky and Greg. Although these are fictional characters, their case histories are an amalgamation of different patients. Each described phase of IR is illustrated with an application to Nicky or Greg. The dialogues are literal transcripts of scenes that can be seen on the audiovisual production (Van der Wijngaart & Hayes, 2016).

Fine Tuning Imagery Rescripting

Nicky Nicky is a 28-year-old woman with borderline personality disorder and recurring depressive periods. She tends to avoid potential conflict situations with others, but because of accumulated tensions she can sometimes have outbursts of anger. These difficulties have existed for years and are related to a childhood in which she was a victim of violence and emotional neglect. She grew up as an only child in a family with an aggressive father who regularly beat and scolded her. Her mother drank a lot and was emotionally absent. Her self-image is very negative; she thinks she is stupid, whiny and hopeless. She mistrusts other people and often has the feeling that others don't like her and will abandon her. Just like in her childhood, she often feels anxious, lonely and sad. She tries to feel this pain as little as possible by deactivating her feelings, which makes her feel empty and tired.

Greg Greg is a 41-year-old male with PTSD and a persistent depressive disorder. He works as a policeman in a small town. Six months ago, he found two dead children in a car wreck when he arrived at a traffic accident. The motorist who caused the accident turned out to be the same one that Greg had fined for drink-driving three days earlier. In the period that followed, he was troubled by recurring memories of the accident and the image of the dead children. However, he is also increasingly suffering from feelings of loneliness and sadness associated with his past. He comes from a family with a cold, distant father who was not aggressive but was demanding, and indirectly conveyed to Greg that he was not interested in him. His mother was emotionally softer, but unable to compensate for his father’s dominant parenting.

As a child, Greg felt, saw and heard how unhappy his mother was after marrying his father. She would complain to him about his father, she was openly sad and gloomy around her son and said things like: ‘Nobody cares how I feel...’ Greg has always felt that he was failing and that he should perform better. He looks at the world around him as his father taught him: ‘In the end you're on your own in life. Don’t complain, just bear it.’ He internalized his mother’s messages as a self-image coloured by a feeling of not being strong enough and not supportive enough for others.

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Chapter 2: Diagnostic imagery Chapter Summary 2.1 Introduction 2.2 The process of diagnostic imagery 2.3 Chapter summary

2.1 Introduction This chapter discusses how to use the imagery exercise in the diagnostic phase of the therapy. After a brief overview of the different steps in this diagnostic imagery, each step is further explained with examples. At the end of each explanation, challenging, difficult situations that may arise in clinical practice will also be discussed. At the end of this chapter, you will have sufficient basis to use this visualization exercise in the diagnostic phase and have tools that enable you to deal with challenging situations that may occur in clinical practice. The initial phase of the application of imagery rescripting (IR) as a treatment intervention aims, together with the client, to learn to understand the problems in her current life from meaningful events in the past. The core of the diagnostic imagery is that the client visualizes current difficult and/or unpleasant situations, empathizes with those images and then pauses to reflect on the feelings that are evoked. By concentrating on those feelings, memories of experiences in other phases of life can be activated through this ‘affect bridge', usually from (early) childhood. In this way, therapist and client learn

more about the origin and persistence of the negative patterns in her life. There are different ways to perform diagnostic imagery, where the starting point is to acknowledge that the exercise is not a goal or intervention in itself, but more a tool to identify original memories that are related to the current symptoms. If you have no experience with this method as a therapist, a structured step-by-step plan can help.

Roadmap for diagnostic imagery exercise Step 1: Introduction Step 2: Safe place Step 3: Unpleasant situation in the present Step 4: Affect bridge to the past Step 5: Exploring a meaningful experience from the past Step 6: Back to the safe place Step 7: Review and discussion This step-by-step plan can provide guidance and structure in the phase of familiarising yourself with the method. With more experience of the imagery exercises, you can vary more with the different steps, depending on what happens in the session. For example, your client may tell you that she has been suffering from anxiety for days, which she feels especially in her chest and where she feels that something bad is going to happen all the time. In such a situation, the exercise can start with step 4: ‘Affect bridge to the past’ and you do not have to visualize a safe place first. Ask this

client to close her eyes, concentrate on that fearful feeling and let an image emerge from her childhood. A client can also explain that she has suffered in the past week from childhood memories of her father calling her names. In that case you can ask her to close her eyes and describe the images from her past that she apparently already has anyway. The diagnostic imagery then begins with step 5: ‘Exploration of a meaningful experience of the past’. In other words, the steps of diagnostic imagery are not a rigid script, but rather a suggestion to make use of active parts of the technique and, at the same time, become familiar with imaging exercises.

2.2 The process of diagnostic imagery Each step in the process of diagnostic imagery is explained in more detail below. Nicky’s case illustrates what each step can look like in practice. Problems or challenging situations that you may be confronted with in clinical practice are discussed for each step.

2.2.1 Step 1: Introduction to diagnostic imagery There are two ways to introduce an imagery exercise. The easiest way is by simply announcing it as: ‘I’d like to do an exercise now.’ In most cases, such an announcement is accepted by clients without resistance. For them, the proposed exercise is unknown, but they don’t usually protest against it. Therefore, any fear of doing an imagery exercise usually involves the therapist more than the client.

A second way to introduce the exercise is to make it more in line with what has just been discussed with the client. Nicky, for example, had just told us about an argument in the past week, which made her feel very bad during the following days. The introduction of the imagery exercise can then be: ‘That sounds like a challenging situation for you. I can imagine that this situation would be stressful for anyone. But it also sounds like you were really upset by what happened. Shall we do an exercise that might help us better understand what made you so upset?’ A variant of this is to draw your client's attention to the images that already seem to be visualized: ‘You describe the situation very vividly and I can almost see it happening in front of me. I can imagine you’ve got images of what happened, as well. Could you close your eyes and describe those images?’ The explanation of the imagery exercise that will take place is, in principle, limited to three points: 1.

Duration of the exercise A diagnostic imagery usually takes ten to fifteen minutes. Research has shown that clients find the imagery exercises valuable, but that they perceive them as stressful if the duration of the exercise is unknown or can vary greatly (Ten Napel-Schutz et al., 2011).

2.

Working method Some explanation of what is about to happen is desirable, but don't go into too much detail. The following could be a good explanation: ‘I'm about to ask you to close your eyes and keep them closed for ten to fifteen minutes. During that time, I’ll ask you to form images of meaningful situations from the

recent and distant past. I'll guide you through the exercise. We can then discuss what you’ve experienced and what we can learn about your difficulties.’ Due to unfamiliarity with the exercise, as a therapist you may want to describe very precisely what the different phases of the imagery exercise will be. However, although intended to reassure the client and ensure that he has a certain level of control, a comprehensive explanation may raise fears and questions. For more suggestible clients, it is advisable to give a little more explanation of the working mechanisms of the exercise (Health Council of the Netherlands 2004 Advisory Report). In this way, you can emphasize that, in the exercise, you reflect on meaningful experiences that aren’t automatically the same as actual memories. Maybe her father was often tired after work and therefore irritable, but the client perceived this as him being angry with her. In the case conceptualization we are trying to map the client's world of experience, so our primary goal is not to describe actual reality. 3.

Providing security Finally, it is advisable to emphasize that the client remains in control and that closing the eyes is only a way to better focus on what she is experiencing.

If your client is willing to do the exercise, ask her to sit down easily so that she is not too distracted by her posture during the exercise. For the exercise, it is good to sit upright, with both feet on the ground and the hands loosely in your lap. Then ask the client to close her eyes and the exercise begins.

Step 1: Introduction to diagnostic imagery – Nicky

The session has been going on for ten minutes, and Nicky has said that she has had an intense run-in with her boyfriend, Peter. She's about to talk about the impact of that on her week. However, the therapist still wants enough time to do a diagnostic imaging and interrupts her. >> Therapist: “I want to remember what you just said, Nicky. When you told sounds like you were situation like this, really deep. Is that

me about your fight with Peter, it upset. Now, anyone could be upset in a but you were really upset. It struck right?”

>> Nicky: “Yes...” (sounds sad) >> Therapist: “I wonder what struck you so deeply that it upset you all week long? We can do an imagery exercise to help us. Do you think that’s a good idea?”

>> Nicky: “Yes.” >> Therapist: “Great. This exercise can really help us

better understand what happens during these moments. Now, I’d like to ask you to close your eyes for the next ten to fifteen minutes. It isn’t hypnosis and you’ll stay in control. Closing your eyes is mainly a way to avoid distractions and properly concentrate on your feelings and your perception. How does that sound?”

>> Nicky: “Yes, that makes sense... but I don’t want to dwell on it too much. I’m just glad that things are okay now.”

>> Therapist: “I understand that and I think it’s quite

normal; of course it isn’t pleasant to think about things that make you feel bad. We’re not doing it to make you feel bad, but just to get a better understanding of why that unpleasant feeling is so overwhelming in those situations.

And I’m going to help you not get upset by that feeling again, okay?”

>> Nicky: “I don't know...” >> Therapist: “Let me assure you, Nicky, I don't want to

force you into anything! If don’t want to, then it doesn’t happen, you stay in control. I’m struggling a little with how we’re going to proceed now, so let me just think out loud so you can listen to what I have doubts about. On the one hand, I’m thinking: ‘Okay, she’s already had a hard time, so leave her alone for a while. So don’t do that exercise, she just got everything back under control.’ On the other hand, I’m thinking: ‘Well, if I leave her alone now, isn't that what's happened before? That after an intense experience, you didn’t think or speak about what happened? Maybe the exercise is a little tough for Nicky right now, but it would help us better understand what’s upsetting her each time. I’d really like to offer her better help...’ When I put it that way, I think that I'd rather do the exercise anyway. What do you think?”

>> Nicky: “Yeah, maybe... I know what you mean, but I’m just dreading it.”

>> Therapist: “Of course, I understand that completely!

Okay, let’s just try it for ten minutes, and agree that you can stop at any time if you feel that it's getting too intense. And I’ll help you keep it all manageable. What do you think?”

>> Nicky: “Okay, let's give it a try.” What if... …the client doesn’t want to do an imagery exercise due to fear of the unknown?

The client may be insecure and anxious about what the image is going to be. Despite the explanation and the reassurance of you as a therapist, the client is perhaps rejecting the exercise or feeling resistance from the proposal to do the exercise out of fear. A method to motivate your client for the exercise, is so-called ‘stealth imagery’ (Hayes, 2016). A detailed, vivid description of the exercise will allow your client to experience something of the effect of the exercise ‘under the radar’ and allow her to already feel more comfortable with the unknown exercise. …the client continues to ask about the usefulness of the imagery? Some clients tend to keep asking a lot of questions about the exercise before the exercise actually begins. The questions can sometimes be so critical that it seems more of a negotiation about the usefulness and importance of the exercise before the imagery actually begins. A possible explanation for this is the same unfamiliarity and uncertainty as described above. However, these clients have a somewhat more active, overcompensating way of dealing with that uncertainty than avoiding it. Their questions are an attempt to gain grip and control over something unknown and uncomfortable, and that may feel unsafe. It helps you as a therapist when you realize that there's uncertainty underlying this. You can view that (critically) inquisitive client as a suspicious gatekeeper who doesn’t want to grant you entry right away. Then try to negotiate with that gatekeeper, explaining, reassuring and giving control: ‘I'd best let you experience the usefulness by simply doing the exercise. Shall we just give it a try?’; ‘Would you try it for ten minutes and then we'll see if it was useful or not? Or maybe five minutes? You can stop anytime you want. You maintain the control.'

…the client doesn’t want to close their eyes? Closing one’s eyes is too threatening for some clients because they then feel like they are letting go of control. The essence of the imagery is not in closing one's eyes, but in pondering and visualizing meaningful experiences, and that can also be done with one’s eyes open. There is no evidence that there are consistent differences in the reported liveliness of the visualized images between the condition in which the eyes are open and that where the eyes are closed (Isaac & Marks, 1994). In order to ensure that clients don't have too much distraction from the space around them, you can ask them to look at a fixed point in front of them – for example, on the ground or the wall. …the client says that she can't visualize? Almost everyone succeeds in imagining things vividly. Only three per cent of healthy adults seem incapable of generating mental images (Isaac & Marks, 1994; Holmes, 2015). So, there's a chance that this particular client belongs to that three per cent, but not a big one. It is more likely to result from the perceived inability to visualize due to avoiding emotionally charged experiences. The lack of imaginary images is then a defensive reaction when the client is overwhelmed by emotions. In such cases, the client needs more security to distance herself a little more from her emotions. You can provide that security by starting the exercise with more neutral images and, for example, asking her to describe her parental home: ‘Was it a terraced house?’ ‘Did it have a garden?’ After having first discussed this in the past tense, the next step is describing the picture in the present, placing people into the image and then visualizing interactions with them. Thus, step by step, a neutral image becomes an image more

associated with meaningful, emotional experiences. If describing the parental home does not succeed (because the parental home is too connected with overly emotional memories that are avoided), you can, as a therapist, start asking questions about neutral or even positive life areas in the client’s present: ‘Where are your kids right now? What does that class look like? Do you know where they are in that class? What might they be doing right now? Can you close your eyes and describe to me the class you see?’ Conclude the exercise after your client has visualized such positive images, and in the follow-up discussion highlight that she does indeed appear to be able to see images.

…the client resists the exercise? Some clients say outright that they don’t feel like doing the exercise, or are even more active in their resistance to an exercise that could make them emotional. In addition to all the above strategies, one could also consider pointing out this resistance explicitly. Discuss the resistance in terms that ‘part of the client’ doesn’t feel like doing the exercise. It isn’t the client as a whole who doesn't want to do the exercise – part of her feels that resistance, but another part of her needs help. This form can help get past the resistance.

Problems with the introduction of diagnostic imagery – Greg

>> Therapist: “Okay, let’s do an imagery exercise.” >> Greg: “A what?” >> Therapist: “An imagery exercise. An exercise in which I ask you, for the next ten minutes, to close your eyes and

recall the memory of what happened. Not just to talk about it, but to really connect with the feelings you had then.

>> Greg: “And this is what you're doing... what we're doing here?”

>> Therapist: “Yes, this is the method we’ll employ here.”

>> Greg: “That sounds pathetic.” >> Therapist: “You feel like we wouldn’t be engaging seriously if we did an exercise like that?”

>> Greg: “Yeah, it sounds stupid and pathetic!” >> Therapist: “Well, I wouldn’t say that myself, because in my experience this exercise can help a lot. But I can imagine it sounds strange; you came here expecting to talk about things and this is a different method.”

>> Greg: “I just don't see how pretending is going to help me.”

>> Therapist: “Can we just give it a try? Of course, we can say we won’t do it, but shouldn't we just give it a try?”

>> Greg: “I just don't see the point! Why can’t we just talk like we have been so far?”

>> Therapist: “Okay, I understand. The way you’re sitting

there right now (points to space between them) you approach this with a sense of: ‘Hm, I don't like it, weird stuff! Is that right?”

>> Greg: “Yeah!”

>> Therapist: “But I know there’s another side (points to

client’s abdomen), an emotional Greg, who suffers, who feels guilty, who's upset. And if I only listened to your tough side (points again to the space between them) that says: ‘I’m not going to do that,’ and I didn’t do these exercises, then I’d be abandoning emotional Greg ( points to client’s abdomen again). I know there's that side that is suffering (points again to abdomen), who is having a hard time and who could really use my help and support. I’m really not going to force you to do this, but I do hesitate to let go of this idea now with that emotional Greg in mind.”

>> Greg: “I just don’t understand how it’s going to help me, turning into a puddle of misery.”

>> Therapist: “So, you’re afraid you would be overwhelmed if you made more contact with that emotional Greg?”

>> Greg: “I’d immediately turn into a pool of misery and trickle away.”

>> Therapist: “Then let me reassure you that I’ll do my

very best to make sure you feel okay at the end of the exercise. My expectation is that you’ll actually feel better. Because tough Greg helped you survive, but he couldn't get rid of that pain (pointing to abdomen) and I think these exercises will be able to do that. Shall we just agree to try it?”

>> Greg: “You’re going to open that cesspool and you can’t really solve all of it right now, can you?”

>> Therapist: “That's a fair question. Well, if someone

were to tell me: ‘That one step you take, you won’t finish the marathon with that!' I'd agree with him: one step isn’t a whole marathon. But I’ll need to take that step to get to the finish line. I get what you’re saying: this exercise

won’t get us to the finish line, but it's a first step. And I’ll do my best. I know that there’s a part of you that wants to try, even if it’s outside your comfort zone. I'd like to work with that side to make this work. Even if it seems a bit crazy. You know, I’d rather do something a little crazy that will help than leave something out just because it seems ‘weird’. I think you and your difficulties are too important not to do this.”

>> Greg: “Okay, let's try it then.” 2.2.2 Step 2: Safe place You then ask your client to come up with an image of a safe place: ‘Now, I’d like to ask you to evoke an image of a safe place, a place where you feel completely at ease. Don’t think too deeply about what that place should be, but let images come to mind when you think of a secure space...’ It’s not strictly necessary to start the exercise with a safe place. So far, research has been unable to demonstrate the added value of this step. However, there are a few reasons why you could choose to use it. Firstly, visualizing a safe place offers clients the opportunity to warm up their imagination. Closing one's eyes and visualizing meaningful events isn’t easy for all clients. They feel a little tense, the technique is still a bit awkward and the therapist isn’t yet completely familiar for them. The imagery exercise is therefore a partial abandonment of control and surrender to the imagination, and some clients still need to get that imagination going. The safe place is a first step in this process and gives the client the opportunity to get used to visualizing. Secondly, the use of a safe place also makes the image exercise safer for the client. The systematic starting and

finishing with the safe space makes the structure of exercise predictable and therefore safer. In addition, the safe place can also serve as a healthy emotion-regulating intervention when clients become very emotional. Incidentally, it would really have been better to speak of a ‘good place’ at this stage of the exercise, because that does not just emphasize the basic need for safety. After all, it's also fine if your client empathizes with an image in which she feels free, connected, powerful, or just cheerful and happy. The term ‘safe place’ probably came from a clinical practice with many clients with a background of unsafe attachments or traumatic experiences. For those clients, this phase of the exercise has a calming, emotionregulating effect. However, it may be more pleasant for another client, or at another time, to empathize with an image in which self-expression or competence is central. In view of the fact that ‘the safe place exercise' has become a well-known phenomenon among therapists, it was decided to keep this name in this book as well. Try to invite your client to visualize a nice place, not necessarily one where safety is central if it doesn't fit the relevant needs of your client at that moment. While visualizing the safe place, ask the client to empathize as much as possible, as if she really is there, and to describe what she sees, so that you know what the client sees and experiences. Asking for sensory information helps to intensify the experience: ‘Where are you now? ...Look around you; what do you see now? ...What sounds do you hear? ...What smells do you smell now?’ Ask your client to further concentrate on the pleasant feeling this place evokes. Let the client describe the emotional, cognitive and physiological aspects of the experience – for example: ‘I feel comfortable, relaxed... a feeling of warmth and peace in

my chest, a feeling that I don’t need anything, that I don’t need anything anymore.’ Then ask your client to let go of this safe place and let images emerge of a recent stressful situation: ‘Now let go of this image, let it fade or float away. I want you to make room for other images.’

Step 2: Safe place – Nicky

Nicky agreed to do the imagery exercise, but she didn't like it. So a visualization of a safe place is quietly started. >> Therapist: “All right, Nicky, I’d like to ask you to

sit down comfortably, with your feet on the ground and your hands in your lap. And you can close your eyes now... take a deep breath first... that’s right. First of all, I’d like to ask you to focus your attention on yourself; you travelled here through people, talking and bustle, but now it’s just you, with your feet on the ground... just be aware of the chair underneath you, your back against the backrest... and your breathing. You don't have to do anything with it, you just have to be aware of yourself, now, in this moment. Okay, I’d now like to ask you to first get an image of a safe place. It could be any place, from your present life or your past, or maybe something you've seen in a movie. As long as it’s a place where you feel comfortable. And if you have an image, can you tell me what you're seeing right now?”

>> Nicky: “I guess I’ll have to think about my room, just at home.”

>> Therapist: “That's fine. So, you're home, and where exactly are you now?”

>> Nicky: “In my bedroom, in bed…”

>> Therapist: “All right, look around you, and tell me what you see... “

>> Nicky: “I just see my room.” >> Therapist: “That’s fine, and what does your room look

like? What do you see now? Just describe it as you literally see it now, so I can watch with you.”

>> Nicky: “Well, I’ll be in bed and the TV’s right in front of me, right next to the door.”

>> Therapist: “And is the TV on now?” >> Nicky: “Yes.” >> Therapist: “What's on TV? What do you see?” >> Nicky: “Some cooking show... just, something easy.” >> Therapist: “Okay... so, you're in bed now, the TV is on... what else do you see? Is it light or dark in your room?”

>> Nicky: “Light, it’s daytime.” >> Therapist: “And what sounds do you hear?” >> Nicky: “There’s some traffic, sometimes a car driving by... and my cat is purring.” (smiles)

>> Therapist: “That sounds nice. Where's your cat now?” >> Nicky: “It’s lying stretched out on my lap, with its paws outstretched so that he can get some belly rubs.”

>> Therapist: “That’s so nice, just totally lazy...? (Nicky nods.) And how do you feel now, Nicky?”

>> Nicky: “Calm, relaxed... I don’t need anything right now.”

>> Therapist: “Nothing at all, calm, where do you feel that calm, relaxed feeling in your body?”

>> Nicky: “Here.” (points to her belly) >> Therapist: “In your belly... enjoy that nice, relaxed feeling there... the feeling that you don’t have to do anything.”

What if... …the client doesn't have a safe place? Some clients are so damaged by their background that they find it difficult to visualize a safe place. Emphasize that it doesn't have to be a realistic, existing place, but that it can also be a fantasy place, or a situation they have seen in a movie or read about in a book. In such situations, it can help to explore calmly and concretely, prior to the exercise, the moments in their lives when they have felt relaxed: Where was that? What helped them feel a little calmer? This preparatory exploration can help to visualize an image associated with a certain sense of security during imaging. Don’t forget that you can also suggest the therapy session as a safe place if there have already been moments during the conversations when the client has felt relaxed, connected, supported or heard. …the client experiences flashbacks?

For some clients, closing their eyes can mean that they are immediately overwhelmed by (traumatic) memories and the intense emotions that accompany them. At such a moment, your client can enter into a survival mode in which all feelings are blocked. That's an understandable reaction if she hasn't learned to deal with those memories and the associated emotions in a different way. Try to re-establish contact with the client by continuing to talk in a warm, supportive tone, and ask your client to focus on your voice. You can also ask your client to open her eyes for a moment to reconnect with reality, but then ask her to close her eyes again and visualize a safe place. The fact that your client has become emotional is not proof that the imagery exercise is a bad thing. It only indicates that, at that moment, a lot of old pain came to the surface, for which therapy, and therefore the methods and techniques that go with it, is necessary.

2.2.3 Step 3: Unpleasant situation in the present ‘Now evoke an image of an unpleasant situation you've been through recently. A situation in which you felt uncomfortable, angry, sad, guilty or something else. Don’t think too deeply about what it should be, just let the images come to mind.’ With this instruction, you try to let go of the conscious control of thinking and reasoning and let the client surrender to memories of a recent, meaningful and full experience, and the feelings associated with it. You want the client to relive the experience, not necessarily to talk about the experience. Therefore, be clear in your instruction, asking her to empathize as if she were in that situation right now. It helps to have the client describe the images in the present tense.

‘If you have an image in mind, I'd like to ask you to empathize with it, as if you're in that situation again. So, look around you. What do you see now? Just tell me so I can see where you are right now What do you hear now? What is happening now?’ As a therapist, it is also possible to propose a specific problematic situation that has been mentioned by the client during previous conversations, or prior to the exercise. Ask your client to fast-forward or rewind the visualized image until the emotional reaction is at its strongest. The information from previous conversations can help you think about this.

Step 3: Unpleasant situation in the present – Nicky

Nicky has just described an image of her safe place, in her bed, with her cat purring in her lap. She feels relaxed: ‘I don’t have to do anything right now.’ >> Therapist: “All right, Nicky, now I’d like to ask you to let go of this image of your room, of your cat and the TV. Let it drift away, so there’s room for other images. I’d like to ask you to think back to that fight with Peter you just talked about and form an image of it. Don’t think too much about what it should be, just let the images come up.”

>> Nicky: “I’m thinking about the moment he’s facing me and shouting at me.”

>> Therapist: “And where are you now?” >> Nicky: “I'm at home, in the kitchen.” >> Therapist: “And you're facing him?”

>> Nicky: “Yes.” >> Therapist: “Can you look at him? How is he looking at you now?”

>> Nicky: “He looks really angry, really angry... screaming.”

>> Therapist: “What's he saying?” >> Nicky: “He calls me stupid, a moron... it's all my fault.”

Make sure your client doesn’t automatically lapse into an old coping style of avoidance or overcompensation by, for example, talking about the situation in the past tense instead of experiencing it:

>> Therapist: “I can imagine that it isn’t nice to dwell

on this moment at all, and perhaps you feel an urge to stay away from it, for example, by not thinking about it or looking at other parts of the image. I can well imagine that, but I'd still like to ask you to dwell on this painful moment.”

What if… …the client describes an image, but doesn’t have a strong reaction to it? When describing a recent unpleasant situation, clients will tend to consider it rather than experience it. For example, the client explains in a rational way and in the past tense what happened. This can be a form of avoidance, while the aim of the exercise is to make contact with the feelings

associated with the situation. First of all, you can reformulate the client's words in the present tense:

>> Client: “I was at work and my boss came by.” >> Therapist: “So now you're at work, and you see your

boss coming in. What does she do now? Or what does she say now?” If that isn’t enough, you can repeat the instruction of the imaging:

>> Therapist: “I’d like to ask you to empathize, as if

you're reliving it now. So, what do you see now? What do you feel now?” If your client gets stuck in contemplative explanation, you can also say explicitly what you want to do differently:

>> Therapist: “I'd like to ask you to describe the image

in the present tense. We'll talk about what it all means later, but for now I want you to really experience the situation again. Try to be there again, and what do you feel now?”

…the client doesn’t form an image? If your client doesn’t form an image at all, or keeps describing an image in general terms and in the past tense, this can also be a signal that the experienced tension is too great. The stronger the coping mechanism, the greater the

emotional charge that is apparently experienced. You can therefore choose to explicitly mention this coping and the client’s defences. If you have explicitly discussed this defence mechanism with the client, you can look for ways together to get out of those old avoidance survival patterns. In doing so, you make the client, the healthy part of the client, co-responsible in your attempt to make contact with the underlying feelings and experiences.

2.2.4 Step 4: Affect bridge to the past The recent unpleasant situation and the associated emotional experiences can function as a gateway to (supposed) original meaningful experiences. Access to this early event is best obtained when the feelings in the current situation correspond as much as possible to the experiences of the past. Always ask your client about three different aspects of this emotional response: 1. Emotions: how does your client feel now? Anxious? Angry? Sad? 2. Physiological aspects: Where does your client feel this fear in her body? 3. Meaning aspects: what is your client afraid of, angry about, sad about, now? Now ask your client to focus on this feeling and let go of the image of the recent event. ‘Hold on to this feeling, no matter how unpleasant it is. It’s this feeling that’s important. This is what it’s all about, not this situation as such. So, concentrate on the feeling, and let the image fade away, let it drift away, so that there is room for other images related to this feeling. Do you recognize this feeling? Is this the first time you’ve had this feeling in your life, or is it familiar to you? What images or memories from the past emerge that somehow have to do with this

feeling? But don't think too much about what it should be, just focus on this feeling, and let the images come to you by themselves.’

Step 4: Affect bridge to the past – Nicky

Nicky has just described the image of her boyfriend, Peter, screaming angrily, facing her and calling her stupid. >> Therapist: “How do you feel now, when he says all that to you?”

>> Nicky: “Awful, sad, scared, guilty... it’s all my fault.”

>> Therapist: “So, you feel like he’s in the right here? That you did something wrong?”

>> Nicky: “Yes.” >> Therapist: “Where do you feel that sad, anxious, guilty

feeling in your body? The feeling you did something wrong?”

>> Nicky: “In my belly.” >> Therapist: “It sounds like a very unpleasant feeling,

but try to keep in touch with it over the coming minutes. Make it even stronger, that feeling that you’ve done something bad, that nasty feeling in your belly that scares you so much and makes you feel sad at the same time. Now let the image of Peter fade. And while you're keeping in touch with this feeling of sadness and guilt, I’d like to ask you to evoke images from your childhood, your younger years. What image from your childhood comes to mind? Don’t think about it, Nicky, let the images come up by themselves. And if you have an image, can you tell me what you see?”

What if… …the client doesn’t form an image? Again, this can mean that the emotional charge is so great that images are avoided. You’ll make it safer for your client to open up to images if you stay relaxed and provide space: ‘It doesn’t matter if you don’t form an image. Just wait a bit. All I'm asking you to do is keep in touch with the feelings you have right now. If you notice that they diminish a bit, then you can go back to that unpleasant moment last week, so that you can get a good feel of what was so unpleasant about that situation. Concentrate on this feeling, and just give yourself time.’ When waiting for images it is advisable not to let the silences become too long, because these silences can create an unspoken expectation that images should finally be formed. So, interrupt that silence now and then with a simple repetition of what the client felt in the trigger situation. …the client sees a lot of images? In that case, a lock seems to have been opened, making it difficult for your client to choose between the various images. In this case, it is advisable to reduce any pressure felt to ‘do the exercise well’ as much as possible. Emphasize, for example, that there is no 'right choice' for an image: ‘When there are lot of images, you just wait and see which of those images sticks out the most, comes to the fore the most. If that’s several images, you can just choose one; there’s no right or wrong choice, so choose one at random.’

2.2.5 Step 5: Exploring a meaningful experience from the past

When your client has an image in mind, ask her again if she is trying to empathize with that image, as if she is reliving the situation. Again, it helps to ask for sensory information: ‘What do you see now?’ ‘What do you hear now?’ ‘What do you smell?’ With these questions for sensory information, you generate the images that your client experiences from the first person more easily (Brewin, 2010). You can support this process of empathy by addressing your client directly as the child she describes, in a tone that fits the child's experience in the image. A mature tone of voice combined with a smooth pace of speech is more likely to keep your client in a mature state of mind. The risk here is that the event will not be experienced, but that it will mainly be thought about. ‘So, you’re seven years old now... you’re standing in the kitchen, and now your father comes up to you and looks angry. How do you feel when your father looks at you so angrily? Where do you feel that fear in your body? And what are you afraid he’ll do when he walks up like that?’ The aim of the exercise is to activate a meaningful experience, but not to relive all aspects of traumatic experiences. For example, it is not the intention to go through the whole event in which the father starts beating the client. At a time like this, it's better to stop the image: ‘Okay, I want you to stop the image right now – like you're pressing pause on a remote control. Can you do that now? Do you see that the image is paused and your father stops?’ Such interventions offer the opportunity to reflect a little longer on the client’s perception of their world, without causing them to have flashbacks of the traumatic moments.

The described image in itself offers a lot of information about the child’s circumstances and about the interaction patterns with important attachment figures. However, no matter how visual it is, the image does not automatically reflect the relevant basic needs. In order to gain insight into these relevant basic needs, you ask additional questions such as: ‘What do you need now?’ or ‘What else would you like?’ These questions are not intended to change the image, but rather to gain insight into your client's experience and needs. For instance, your client can describe an image in which her father was angry at her. On the basis of that image, you might think that your client mainly needed connectedness in the form of comfort. However, your client may also have felt the need to be angry with that parent (self-expression). Then ask the client to imagine that she is asking the other person (in this example, her father) for what she needs and pay particular attention to the reaction of the other person in the image. Once again, the aim is not to change the image, but to gain insight into how the attachment figures dealt with the basic needs expressed. ‘Okay, so you actually want to tell your Dad that you think it's stupid that he's so angry. Could you try saying that? And how does your father react to this?’ In this way, more insight can be gained into the relationship with parent and the interaction patterns.

Step 5: Exploring a meaningful experience from the past – Nicky

Nicky just described the fight with Peter that took place last week. She feels sad, anxious and guilty, a feeling she recognizes from her childhood.

>> Nicky: “I see myself sitting on my bed.” >> Therapist: “And how old are you?” >> Nicky: “Five.” >> Therapist: “So, you're five, and you're sitting there

on your bed. Now, if you look around you, what do you see?”

>> Nicky: “My stuff... I’m just sitting there, looking at the door.”

>> Therapist: “What do you feel now?” >> Nicky: “Guilty...” >> Therapist: “Why is that?” >> Nicky: “Because I did something wrong.” >> Therapist: “Because you did something wrong.”

(Therapist now speaks as you would to a five-year-old child…) “What did you do that would be so bad?”

>> Nicky: “I made Daddy angry...” >> Therapist: “And how did you do that?” >> Nicky: “I spilled some of my drink in the car on the way home, and he’s really angry about it.”

>> Therapist: “And what are you afraid of now?” >> Nicky: “I’m afraid he’ll come to my room and shout at me.”

>> Therapist: “Could you, just for a moment, put your father in the picture... do you see him?”

>> Nicky: “Yes.” >> Therapist: “What's it like having him there?” >> Nicky: “He's really angry.” (Nicky sounds scared) >> Therapist: “How can you tell?” >> Nicky: “He’s pointing at me, his face is red, he’s shouting.”

>> Therapist: “Okay... I'm with you Nicky, you're safe

here in the room with me, but hold on to that image. Like that five-year-old, what would you like to change about the picture?”

>> Nicky: “I wish he wouldn’t be so angry.” >> Therapist: “Can you fast-forward a bit, as if you’d just asked him if he could be a bit nicer. How does he react?”

>> Nicky: “He’s just standing there...” >> Therapist: “Okay, what expression do you see on his face?”

>> Nicky: “Strict.” What if… …the client can’t adopt the child's perspective? Some clients find it difficult to empathize with the child they see in the image. Clients mainly had to learn how to survive and that generally meant that they had to shut themselves off from the world of experience of the past. You can help your client to adopt this child’s perspective by

first of all, as a therapist, visualizing the child in the image as well as possible during the exercise. Think of the child you saw in the photos the client brought with him. By keeping this child in mind, the tone of your voice is likely to change automatically and you'll use different words than when you keep an adult in mind who you're talking to. There is a constant interaction between you and the client, so everything you do will affect what the client feels and experiences. If you talk to the child part of the client, it will help the client to make contact with that part of himself. …the client is overwhelmed by the intense feelings associated with the memory of the past? When your client becomes overwhelmed by the evoked emotions, this means that the experience has to be made less intense to keep doing the exercise. It is better to ask the client to take some distance from the image, to look at the image more like a picture, where she is no longer the child in that picture, but looks at that child from a distance. It will also help in this situation to talk more rationally, like talking to an adult instead of a hurt child. Finally, it may help to talk in the past tense, because if the event is discussed more, the emotional reaction may also diminish. …the client dissociates? This is another situation in which the client seems to be overwhelmed by the strong emotional experience. The dissociation can be seen as a coping style, a survival strategy to manage strong emotions. It is best to reestablish contact with the client using grounding techniques: keep talking, and ask the client to focus her attention on your voice, to open her eyes, look around, and describe what she is doing, what she sees, and to move her hands and feet

so she can feel her body. Experiencing sensory stimuli consciously is a way to bring the client back in touch with the reality around her. Most therapists, like the clients, will be so taken aback by this dissociation that they will not be inclined to resume the imagery. Still, it is advisable to do some safe place imagery before concluding the session. In this way, the imagery exercise can become a positive experience after the intense, and also unpleasant, experience before. …the client tries to understand the meaning of the images during the exercise? Some clients will recognize patterns and talk about them while the imagery is still going on. It is tempting for a therapist to go along with such an active processing of the experiences during the imagery. Sometimes, therapists themselves are inclined, even during the exercise, to make connections, or try to understand what is being experienced and why. However, this cognitive framing has an inhibiting influence on the emotional experiences, which are precisely the purpose of the imagery. Try to explicitly postpone talking about the experiences and making connections until after the exercise: ‘I hear the images seem to mean something to you. Let’s talk about that later, but, for now, I'm asking you to focus only on what you see, what you feel. Talking about what it means will come later.’

2.2.6 Step 6: Back to the safe place Ask the client to return to the safe place: ‘Okay, now I’m going to ask you to let go of the image. Let it drift away so there's more room to return to your safe place. Maybe it's hard to get back to a safe place now, so give yourself time, and focus on the details. Where are you now? Take a good look around you and tell me what you see now.’ Many clients will

find it difficult to make this transition to the safe place at the end of the exercise. Old memories have been activated and the feelings evoked make it difficult for your client to concentrate on a safe place again. As a therapist, you can help by describing the image of the safe place in detail as your client sketched it at the beginning of the exercise. The exercise is concluded by asking your client to let go of the image of the safe place and slowly return to the reality of that moment.

Step 6: Back to the safe place – Nicky

Nicky just described how she's being scolded by her father as a five-year-old girl, because she spilled a drink in the car. >> Therapist: “Let the image fade, Nicky. Let your father drift away and bring yourself back to your safe place.”

>> Nicky: “He’s just so angry... I just can’t do anything right by him.” (sounds sad and anxious)

>> Therapist: “Nicky... Nicky... concentrate on my voice, concentrate on my voice and try to get back to your safe place, with the TV on, the cooking show, your cat on your lap, lying there purring, stretched out. Do you see him?”

>> Nicky: “I don’t know... a bit, I guess.” >> Therapist: “That's fine, a little bit is a good start! What do you see now? Your cat?”

>> Nicky: “Yeah, so stretched out... and I’m rubbing his belly.”

>> Therapist: “And feel how soft his belly is, how you can almost feel the purring in your hand. Now listen to the

sounds of the cooking show. What are they cooking?”

>> Nicky: “Some kind of curry.” >> Therapist: “Yummy.” (Nicky smiles) “How do you feel now?”

>> Nicky: “A bit calmer.” What if... …the client can't retrieve the image of the safe place? The activation of emotional, meaningful events from the past makes the transition to a safe place particularly difficult for some clients. They are back in a past experience, and they are unable to release and store that memory. The instruction ‘try not to think about it’ won't really help, but it often works to ask the client to focus her attention on the sensory aspects of the safe place. As a therapist, you have an important supporting role in this – because you have written down or remembered the safe place well, you can now also provide the visual, auditory and emotional information that can help the client to return. Another option is to ask your client to let go of the image of the past and open her eyes, so that she makes more contact with reality, and then close her eyes and visualize the safe place.

2.2.7 Step 7: Review The debriefing of the exercise is an important final step in the application of diagnostic imaging. So far, powerful emotions have been experienced with the help of the imagery and the client may have experienced all kinds of things. Now that the exercise is over, it is important to understand what has been experienced and how this strong experience relates to the difficulties your client has in her current life.

First, give your client a chance to recover and switch from experience to contemplation. As a therapist, it is advisable not to discuss too soon after, but to first create some peace and quiet. Then start with a simple: ‘How do you feel now?’ A commonly used method of debriefing consists of explaining the strong emotional reaction in the present from the old pain that became visible in the memory of the past: ‘I understand much better now why you became so (anxious, sad, angry) this week. So, it wasn't just an unpleasant situation at the time, but it was also a situation that touched on old pain. It’s like you’ve been walking around with a bruise from what you went through as a child. And now, for the past week, you’ve actually been bumping into that bruise. Bumping into something is always painful, but that pain becomes even greater when a bruise gets hit right on the spot.’

Step 7: Review – Nicky

Nicky struggled to get her safe place back into her imagery, and the tension she felt with the images from her past has subsided somewhat. The exercise will now be concluded so there’s still plenty of time for the review. >> Therapist: “We’re going to end the exercise shortly,

but we’ll do it slowly and gradually. First, let the image of this safe place drift or fade away. Are you slowly regaining awareness of the now, of the room you’re in now, with the sounds that you hear here? Now move your hands and your feet so you can get back in touch with your body... and then when you’re ready, you can calmy open your eyes. Welcome back... take it easy. How are you feeling?”

>> Nicky: “I think... a little overwhelmed.” >> Therapist: “Overwhelmed by a sense of sadness? Or pain? Don’t try to analyse it, just tell me how it feels right

now.”

>> Nicky: “Yeah... I think mostly sad.” >> Therapist: “It was a very sad picture that you

described.” (Therapist speaks more and more in an adult tone to the client) “You as a five-year-old with such an angry father? Wow... it helps me understand why it’s so hard for you in situations like with Peter this week. What did you learn from this? What are you picking up from it?”

>> Nicky: “A lot of anger.” >> Therapist: “Yes, you’ve had a lot of anger to endure

in your life! And as a five-year-old... that really saddened me, the realization that as a five-year-old you had so much anger poured out at you.” (Nicky has tears in her eyes.) So you're right, it's about anger. What I also learned from it was that in both situations you did something perfectly normal: you spilled a drink, or got angry during the week. It happens to all of us, we all get angry occasionally in a relationship, and every child spills things. But each time you do something where you lose a little bit of control, it’s immediately linked to a feeling of guilt, a feeling as if you’ve done something terrible. Does that sound right?”

>> Nicky: “Yes... that’s how it feels.” >> Therapist: “It seems as if your father taught you to

feel that way. As a five-year-old, he literally made you feel like it’s awful if you do something that’s actually quite normal. But even now, now that he’s physically gone, he’s still in your mind. And if you do anything that comes out a little spontaneous, he’ll be right back: ‘You’re doing something terrible!’ How does that sound to you?”

>> Nicky: “Yes.”

>> Therapist: “So how does it feel that your father is still inside your head, criticizing and commenting that you’ve done something bad?”

>> Nicky: “Yes, that’s right...” >> Therapist: “Okay, so that’s something we could work on

in therapy, we could work on getting your father’s accusing voice out of you, so that you can just live your own life and enjoy it. How does that idea sound to you?

>> Nicky: “That would be such a relief!” Basic emotional needs With this follow-up discussion it has been made clear that the emotional reaction in a recent situation cannot only be explained by situational circumstances in the present, but that this emotional reaction is also related to meaningful experiences in the past. The way in which these emotional reactions are explained, the language used in the follow-up discussion, will depend on the theoretical model you use – for example, cognitive behavioural therapy, psychoanalysis or another approach. This book will frequently discuss ‘basic emotional needs’ or, more simply, ‘basic needs’ as an explanation for the emotional reactions of clients. This concept of ‘basic needs’ is a central principle within schema therapy. It is based on universal emotional needs that are embedded in our human DNA.

Basic needs Security Connectedness Self-expression Appreciation

Autonomy Realistic boundaries Spontaneity and play

Note: A recent development within schema therapy is an investigation of whether ‘self coherence' and ‘fairness' should be included among these universal needs (Arntz et al. 2020). A (chronic) lack of fulfilment of these basic needs leads to natural emotional responses such as grief, fear, anger and loneliness. It is these familiar experiences that can come to the fore during imagery exercises. In the review discussion, the emotional reactions can therefore be clarified from the basic needs in question that have not been validated.

What if... …the client says she doesn’t want to do the exercise in the future? When you have gone through all stages of the diagnostic imagery and overcome all the challenges, the client may still indicate afterwards that she perceived the exercise as unpleasant and does not feel like doing it again. In the first instance, you don’t have to worry about that; what the client indicates is that she perceived the exercise as very intense and, at this moment, she has had enough. That seems to be a perfectly normal emotional response after intensive work. On the other hand, there is a chance that emotional experiences will activate old, avoidant coping styles. The activated schemas and coping styles will disrupt the information processing. It’s like putting on a pair of coloured glasses, allowing your client to see and remember those aspects of the exercise that confirm her schemas and coping styles.

As a therapist, you can still exert some influence on the way in which the exercise is processed by focusing explicitly on the positive aspects of the exercise. In this way, you can recall that although the client was upset by the images from her youth, she also calmed down by returning to the safe place. You can focus her attention on the results of the exercise: although it was tough, you now understand better why she got so upset by the recent unpleasant event. That understanding not only feels good, but will also help to make the therapy more effective.

2.3 Chapter summary In this chapter, the different phases of diagnostic imagery are described: how to access meaningful past events from a safe place, via a recent trigger situation, by letting the client focus on the feeling. For the application of the technique, reference is made to the roadmap contained in Appendix 1. This can serve as a helpful tool when you want to do the diagnostic imagery exercise, but aren’t yet familiar with the different steps. With experience, the roadmap can serve as a guiding tool, without diagnostic imagery necessarily having to go through all the steps. It has been noted that reflection on and discussion of connections between current difficulties and the past should be postponed until after the exercise, so that the diagnostic image can remain an emotion-focused exercise. For you as a therapist, it helps if you close your eyes and visualize the described image. In this way, you can best keep in touch with the client’s experience and give her direction during the different steps of the exercise. However, don’t keep your eyes closed during the entire exercise as you’ll risk missing important non-verbal signals such as tears, the

clenching of fists or the client opening her eyes. The aim of the diagnostic imagery is to arrive at meaningful images that are related to your client's difficulties. The next chapter describes how to edit these images and the course of events within them to generate corrective emotional experiences.

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Chapter 3: Imagery rescripting – the therapist rewrites Chapter Summary 3.1 Introduction 3.2 Rescripting 3.3 Themes and topics 3.4 Chapter summary

3.1 Introduction The previous chapter described the steps of the diagnostic imagery exercise. In this chapter the emphasis is on rescripting, the phase in the exercise during which changing (the course of) the meaningful images can lead to new experiences. At the end of this chapter, you will have a good grasp of how to rewrite mental images. A step-by-step plan can help you learn to apply imagery rescripting (IR). The steps of IR are described below (based on Arntz, H. 8, in Thoma & McKay, 2014). Guidance for explaining IR to clients can be found in Appendix 2.

Roadmap for imagery rescripting – the therapist rewrites Step 1: Introduction to imagery rescripting Step 2: Safe place Step 3: Unpleasant situation in the present

Step 4: Affect bridge to the past Step 5: Exploring a meaningful experience from the past Step 6: Rescripting these meaningful images Step 7: If necessary, return to the safe place Step 8: Review As described earlier, such a step-by-step plan serves to provide guidance and structure during the phase in which you become familiar with the method. However, if you are more familiar with the technique, you can vary with the different steps, depending on what happens during the session. For example, you can propose to focus the imagery exercise on a specific memory that the client described during the case conceptualization. Or you can ask the client if she can close her eyes and visualize the event she was talking about at the beginning of the session, without first taking the step to the safe place. The steps mentioned are not a script that is cast in stone, but rather a suggestion to make use of active parts of the technique and, at the same time, become familiar with imagery exercises.

3.2 Rescripting 3.2.1 How does rescripting work? In Chapter 2 you learned how to help your client visualize meaningful images from the past. In that phase of the therapeutic process, the aim is to gain more insight into the experiences that underlie the client’s difficulties. However, the aim of therapy is not only to gain this insight, but above all to alleviate or remedy these issues. Experience

and research have taught us that changing (the outcome of) the visualized meaningful images will cause your client to feel differently and thus to behave differently. However, there is still much uncertainty about the operating mechanisms of IR. There are indications that it does not seem to make any difference to the brain whether an event is actually observed or ‘only’ vividly represented. The aim of the rescripting phase is for your client to make a vivid impression of another progression or another outcome of meaningful images.

3.2.2 Who does the rescripting? This chapter describes how the therapist enters the picture and changes the imaginary image. In the initial phase of the therapy, even with clients without personality problems, it is preferable for you as a therapist to do the rescripting, in order to be a role model for the client. In the next phase of the treatment, the client will learn to rewrite the images themselves. At which moment you switch to that next phase in the therapy depends on the problem and with that, the structure and phasing of the therapy. When applying IR as a treatment of twelve sessions for post-traumatic stress disorder (PTSD), for example, after the first six sessions the client can switch to rewriting the images themselves. If IR is part of a long-term treatment for personality problems, the phase in which the therapist does the rescripting may take months.

3.2.3 What is being rewritten? The purpose of the rescripting is, in this book, to validate the relevant needs of clients in the imaginary image. This can mean that justice is done to what has gone wrong by, for example, stopping antagonists, offering security and comfort,

allowing room for expressing anger or other needs, setting boundaries, and so on. Which intervention best suits your client will largely depend on the analysis of the case conceptualization. If the analysis phase has shown that the learning history of this client has mainly lacked security, then the rescripting should focus on providing security. However, if there is no room for self-expression and autonomy in the client's learning history, the rescripting should focus on this. Differences in basic needs therefore mean differences in how the rescripting is structured. For example, as a therapist, you will have to intervene directly and actively in the image in order to provide security. However, when it is more about stimulating self-expression and autonomy, you will more often ask what the client thinks, feels or wants to do.

Example 1 A client describes a violent image in which she is four years old and threatened with a beating. She’s terrified and can only crawl away. Relevant basic need: security Therapist’s action: “Pause for a moment, as if you were using the remote control; shut it down. I don’t think this is a safe situation for a lone child. I want to come and help you. Can you place me in the image?”

Example 2 A client with a dependent personality disorder describes an image in which she is again being ignored by somewhat absent parents.

Relevant basic needs: self-expression, connectedness Therapist’s action: “I think it’s important that you receive attention, that you’re listened to. What do you need now? I'd like to help you in this situation. Is that okay with you? What would you like me to do or say? What would you like to say yourself?”

3.2.4 Choosing the intervention The choice for an intervention depends not only on the case conceptualization, but also on your assessment as a therapist during the exercise. Try to empathize as if you were also present in the image presented. Then wonder: ‘If this really were to happen, and this were my foster child, what would I do or say?’ It generates a natural emotional and behavioural response. It is this natural emotional response that often best suits the client’s needs in the visualized event.

What do you need now? The leading question during the rescripting is: ‘What do you need now?’ You have to be aware of how you ask that question. If you want your client to empathize with the child’s perspective during the exercise, the question ‘What do you need now?’ easily appeals to a healthy, mature part of your client, especially if you pose it in a mature tone. If you want your client to continue to experience the rescripting from a child’s perspective, it is wise to ask the question in a tone that is in line with the child’s world of experience with which your client empathizes. Variants such as ‘What would you rather have now?’ or ‘What would you like to change in this situation?' are sometimes preferred.

3.2.5 When is the right time for rescripting? It is sometimes difficult to determine the right moment to step into the image in order to rewrite. Often the visualized memory consists of different moments, each of which is meaningful. For example, your client may have witnessed aggressive behaviour from her father towards her mother, but then the father also became angry with the client herself, the mother did not intervene and afterwards blamed the client for the quarrel. So how do you know when to intervene? Usually, a lot of information is already known from the case conceptualization, which can help you make a choice. Maybe your client was mainly affected by the quarrels between her parents, for example, or by the fact that she was blamed for those quarrels. At this stage of the exercise, you can actively ask your client if she can fast forward or rewind the image to the moment that seems most meaningful on the basis of the case conceptualization. Of course, during the exercise you can ask the client if she can focus on the specific moment she has been feeling. Another important clue for choosing the right moment for the intervention can be found in the study by Dibbets and Arntz (2016). In this study, the effects were compared between the early rewriting of induced traumatic intrusive images versus the inclusion of the most aversive scenes in the rescripting. This study showed that including the most aversive scenes during rescripting resulted in a greater reduction in the frequency and vivacity of trauma-related intrusive images than entering the image early (Dibbets & Arntz, 2016). Finally, for determining the right time for rewriting, it can also help to wonder: ‘When would I want to intervene if the child in this situation were my own?’ That natural parental response may be precisely what the client missed out on from

her own parents and what can be the corrective emotional experience for her in this imagery exercise.

Imagery rescripting – Nicky

>> Therapist: “Shall we do an exercise related to that

memory of your father coming to your room and getting very angry, which scared you so much. Would that be okay?”

>> Nicky: “Yeah... maybe.” >> Therapist: “Okay, let’s start with a safe place. Close

your eyes and take a deep breath. Now I want you to retrieve that image you described a few weeks ago: at the beach... what do you see now?”

>> Nicky: “The waves, they're blue and calm, and the sun is shining.”

>> Therapist: “And where do you see yourself?” >> Nicky: “I’m pretty close to the water, where the dry sand is just starting to get harder.”

>> Therapist: “What do you hear now?” >> Nicky: “That soft sound when the sea is very calm.

It’s not even waves breaking, just that soft lapping of water.”

>> Therapist: “And what smells do you smell?” >> Nicky: “Salty, a humid heat.” >> Therapist: “And how do you feel now?” >> Nicky: “Just very warm, my skin is wet from the water, and just nice and warm.”

>> Therapist: “And emotionally? How do you feel with the sea nearby, the sand beneath you?”

>> Nicky: “Very calm.” >> Therapist: “Remember that you can always return to this

place if you need to. And now I want you to quietly let go of this image... and I want you to retrieve the image from when you were five, in your room, that memory of your father yelling at you for spilling a drink in the car. He sent you to your room and stormed off, but he said he’d come back and teach you a lesson... and you’re in your room now. Try to be that little girl. What do you see now?”

>> Nicky: “I see myself, sitting on my bed, toys close to me, but I’m just staring at the door.”

>> Therapist: “Be that little girl, get into her skin. How do you feel now, sitting there in your room, on your bed?”

>> Nicky: “Very scared...” >> Therapist: “Can you feel that somewhere in your body?” >> Nicky: “Yes...” >> Therapist: “Where do you feel that in your body?” >> Nicky: “Just nauseous. I can’t breathe very well, just really scared.”

>> Therapist: “What’s going through your mind while you're sitting there right now?”

>> Nicky: “That I just did something really wrong. I made

Daddy very angry and I’m afraid of what he’ll do now.”

>> Therapist: “Ah, okay, so you're very afraid of what he might do. Maybe now you can fast forward the image a little... to the moment you hear your father coming up the hallway, heading for your room. Can you see it?”

>> Nicky: “Yes.” >> Therapist: “How do you feel now?” >> Nicky: “I’m feeling hotter... very scared and shaky.” >> Therapist: “Okay, I’m going to ask you to freeze the

image here, okay? And bring me into the picture now. So, I'm there now, at the door. Can you see me, over there in front of that door?”

>> Nicky: “Yes.” >> Therapist: “Between you and whoever comes through the door. How does that feel?”

>> Nicky: “A little safer, maybe.” >> Therapist: “Safer, okay. And can you put your father in the picture now? What’s he like?”

>> Nicky: “He’s just very angry, screaming...” >> Therapist: “What’s he saying?” >> Nicky: “He’s saying: ‘I just can't believe what you've done now. You do everything wrong!’”

>> Therapist: “Okay, put the image back on hold. I’m

there, I’m standing in front of the door, and I say:” (turns his head slightly, towards the imaginary father. This movement isn’t visible to the client, who has her eyes closed, but it is audible, so this sensory information increases the vividness of the rescripting) “I want you to stop hurting Nicky and talking to her like that! I won’t allow it. I decide what happens now, we decide what happens now, not you! I’m not scared of you. What’s wrong with you, treating your little girl like that?’ Okay, how are you feeling now?”

>> Nicky: “A little safer now that somebody’s around...” >> Therapist: “And what is your father doing now?” >> Nicky: “He’s still angry...” >> Therapist: “Would it feel better if I was taller? Can

you make me taller? So I can rise up and look down on him?”

>> Nicky: “Yes.”

>> Therapist: “And I say to him:” (turns his head away

slightly and speaks with a loud tone) “‘I'm not afraid of you! What kind of person does something like that? You have a great little girl and you treat her this way? I won’t allow it! You can’t hurt her anymore. And if you try anything, if you come any closer, I’ve got a Taser here and if you get any closer you'll find out what it feels like. Do you understand me?’” (Nicky chuckles and the therapist turns back to her with a soft tone) “How does he react?”

>> Nicky: “He’s stopped screaming...” >> Therapist: “I’m going to send him out of this room

now. Can you see how I’m getting him out of the room? ‘I want this to stop! What’s wrong with you? What kind of person would do something like that to a child? That’s enough!’ And now he’s out of the room. And it’s just us two. How do you feel now?”

>> Nicky: “That there’s someone there for me, I feel safer.”

>> Therapist: “Can you see me? I’m not super tall

anymore, I’m back to my normal height, and I say: ‘Little Nicky, you’re a great kid. Everybody spills something in the car sometimes. And your father is a very angry and punishing man, and I won’t let him treat you like that. I’m not afraid of him. I can handle him easily.’ How do you feel?”

>> Nicky: “Safe and warm... yes.”

So far, the rescripting involved fighting the punishing antagonist (in this case, a punishing father). Besides fighting the punishing messages, offering emotional care, compassion and understanding are equally important parts of the rescripting. Compassion has a soothing effect, like ointment when children accidentally burn their fingers. The rescripting is completed by bringing some relaxation and play into the picture. With this you teach your client an important emotion-regulating lesson – that it’s very healthy to seek some relaxation after intense tension.

Rescripting conclusion – Nicky

>> Therapist: “Your parents should be happy to have you as

their daughter. And to treat you like that, especially your father... you're a nice little girl. What would you like now? What would be nicer than being here right now? Maybe to go outside, into the garden?”

>> Nicky: “Yes...” >> Therapist: “Is there anything else you’d like to do in the garden?”

>> Nicky: “Skipping...” >> Therapist: “Skipping, very nice, okay. Can you imagine us two in the garden now, is it okay if I'm there too?”

>> Nicky: “Yes.” >> Therapist: “What are you doing now?”

>> Nicky: “I’m on the path now, where I always skip.” >> Therapist: “Okay, just enjoy skipping... and I’ll be there, just watching how you’re enjoying yourself, like every child enjoys playing. How do you feel?”

>> Nicky: “Nice… safe and warm.” What if… …there’s no antagonist present in the image? The presence or absence of an antagonist is not important for your ability to rewrite. First of all, the rescripting alone can mean that you step into the picture and comfort and help the child. In addition, you can also ask your client to put the antagonists in the picture and address them, even if they weren't there in the original situation. Indeed, the purpose of the IR is not to manipulate the actual, real aspects of memory, but to generate meaningful experiences based on meaningful events from the past. An alternative option is that you help the child in the situation she finds herself in and that, when she feels safe or comforted, you go to the place where the antagonist is located and then speak to her. As a therapist, for example, you can go to the café where the father is to talk to him and point out the child’s basic needs. …the client can't put the therapist in the picture? Sometimes a client struggles to place you as a therapist in an image of a past. This can have several causes. In the first place, your client may experience the memory in which

you were not present so vividly that it is simply difficult to visualize that you are there. Possibly the experience is so intense that your client is overwhelmed by emotions, making it difficult to process new information, such as visualizing you in the emotional image. Finally, a client may also have difficulty putting you in the picture due to an overcompensating, controlling coping style. A practical way to get into the picture is to let her focus more on you: ‘I want you to listen to my voice as I talk to you like that and try to remember what I look like. Try to retrieve the image of me and put me in the picture.’ You can also ask your client to open her eyes for a moment to incorporate the visual impression of you into the picture: ‘Open your eyes. and look at me. Look at me and listen to my voice. Now, I’d like to ask you to close your eyes again, but to include the image of me, talking to you, in the previous image.’ …the client doesn’t want the therapist to come into the picture, or wants to rewrite it herself out of a need for control? Some clients indicate that they prefer to address the antagonist themselves on the grounds that they know better what to say, that they know better how to get the message across to the antagonist. As a therapist, you may indeed have noticed that they know very well what works and what doesn't work for the antagonist. However, this does not automatically mean that you should leave the rescripting to your client. Perhaps this client, as a parentified child, has always had to be the smartest and strongest. The relevant basic need is then not so much that the antagonist is addressed, but who is doing it. The relevant need in that case is that the client feels connected and experiences support. In such situations you can say as a therapist: ‘I understand you want to do it yourself and you’re right, you know very well what to say and how to say it. My concern is not that you wouldn’t know what to say, or that you be strong enough to do

wouldn’t

that. My concern is much more that you had to be the strongest all your life, that you always had to have the strong shoulders to handle difficult situations. Now let me be the strong one and help you, instead of you having to do everything yourself again. I’d like to see you get some support instead of giving support.’ …the client feels guilty that the therapist appeals to the parent? Many clients struggle with feelings of loyalty to their parents when the therapist appeals to them during the imagery. Two forms of loyalty are distinguished: positively and negatively motivated loyalty (Cohen, 1984). Positively motivated loyalty yields something positive, but with the negatively motivated form something bad is likely to happen when parents’ expectations are not met (Cohen, 1984). Many clients feel negatively motivated to be loyal and therefore quickly feel guilty when their needs are met instead of meeting their parents’ expectations. For example, they feel bad that they have informed someone else (the therapist) about the situation at home, that they have allowed the therapist to witness the way in which parents treated the client and that they then also allow the therapist to address a parent about his or her behaviour. In such situations, it is first and foremost important that you see this as a compliment to your work: you have succeeded in getting the client to visualize a meaningful experience as if it were really being experienced anew. The fact that your client is now struggling with feelings of guilt means that the whole image is so lifelike that it is no longer an exercise but a real experience. You've brought an image to life and generated strong feelings with it. Of course, you don’t want your client to be overwhelmed by the emotional experiences you’ve managed to generate and only able to fall back on her old survival mechanisms of avoidance, surrender or overcompensation. There are two key ways to make the

experience less intense. First of all, you can try to offer more safety within the imagery exercise. For example, you can explain in the picture that a child doesn’t have to take care of a parent, but that a parent takes care of a child and that parents are adults who can find help themselves. Secondly, you can provide more security by reminding your client of reality. By emphasizing that it is an exercise, that there is no one else in the room but you and the client, you help the client to realize that an exercise in the privacy of the therapy session is not the same as actually accusing a parent. …the client still wants the parents to change? When replying to the question ‘What do you need now?’ or ‘What would you prefer now?’ many clients say that they would like the antagonist to treat them better. And your clients are quite right; of course it is the need of a child that a father and mother are friendly and give attention. However, this need contrasts sharply with the reality, in which these parents apparently could not offer these normal things. Thus, these clients have a long history of unfulfilled desire for good parenthood. It is then necessary that this hard reality is accepted and that the desire for good care is no longer directed at people who disappoint them in it. So, the acceptance of this raw reality also means mourning: letting go of the longing for an idealised parent. However, letting go of a desire for an improved version of the parent they had does not mean letting go of the need for care, support and appreciation, all that a parent who is doing ‘well enough’ should offer. As a therapist, you will have to explicitly explain this distinction between the rightly felt need on the one hand, and the reality of a parent who cannot meet it on the other:

>> Therapist: “What do you need now? >> Client: “I want my father to stop being so angry and criticizing me. I just want him to be nice to me...” (starts crying)

>> Therapist: “Of course you want that. That sounds like a

very normal and healthy need. Of course you want your father to be nice to you. So there’s nothing wrong with your need; you feel it very clearly. Sadly, your father has shown over and over again that he’s unable to offer you these normal things. I don’t want you to keep wanting him to give you something he never will. But I’m glad I’m here now and I can make sure you get what you need.” …the client becomes overwhelmed? Your attempts to make the IR a meaningful experience can result in the client being overwhelmed by the memories and associated emotions. Some clients are dragged into the experience and become so emotional that the rescripting is difficult or unsuccessful. Other clients become more closed off and emotionally flattened during such an intense experience. Both reactions are a sign that your client has been overwhelmed and is unable to incorporate new, corrective experiences into the overflowing emotions. In those situations, you will have to try to let your client distance herself a little more from her emotions. For example, you can ask for the image to be rewound to something slightly less intense. Another option is to reduce the emotional charge of the visual image by setting up a more neutral voice, or placing less emphasis on details but more on an overall description of the image, possibly formulated in the past tense. These are just some of the interventions that will

calm your client down and make them more receptive to the new experiences of rescripting.

3.3 Themes and topics During the imageries you, as a therapist, are confronted with different situations, and different types of antagonists that need to be addressed and fought. The way in which you will have to rewrite the visualized images depends very much on the meaning the images have for your client. In the diagnostic phase, you have already determined the meaning of the memories. After that, you have probably already chosen a strategy to reduce the influence of these memories on your client's emotional life. Below is a selection of common situations that you, as a therapist, can be confronted with during IR. These topics and themes are arranged according to basic needs. This arrangement is not an absolute way of framing, since it is not events themselves that determine which basic needs are relevant, but how your client experienced them and what meaning they had for him/her. In other words, one client, as a victim of war violence, may have mainly felt the need for security, while another client may have felt the need to express his anger about the injustice or take revenge (selfexpression).

Themes and topics suitable for imagery rescripting Lack of security natural disasters/accidents punishing/abusing/violent antagonists bullying unpredictability of the antagonists Lack of appreciation, spontaneity and play

demanding antagonists Lack of self-expression and autonomy guilt-inducing antagonists Lack of emotional attachment and care neglecting, absent antagonists Lack of realistic boundaries neglecting, pampering antagonists

3.3.1 Lack of security Natural disasters/accidents Some traumatic events are not primarily caused by other people, but concern catastrophes such as a fire, an accident or an earthquake. Other people are involved in the process leading up to that catastrophe. For example: someone has made a design error in the construction of the building, as a result of which it has now collapsed; or other people have been involved in an accident; or the fire brigade has not been able to extinguish the fire quickly enough. However, the other person did not directly and consciously inflict the trauma on the client – others made a contribution, but are not primarily guilty of the trauma. For your client, the trauma meant a confrontation with horrific images of death, mutilation or destruction. When you, as a therapist, are confronted with the description of these overwhelming events, this can quickly evoke a feeling of powerlessness in you. How can you use rescripting for such large disasters? Such powerlessness is further fuelled when you ask your client: ‘What do you need now?’ and the answer is: ‘That this never happened.’ At times like these you can wonder in despair what you can actually do; it is an actual event, which you cannot deny. It can’t be rewritten, can it? Realize then that rescripting does not mean that the event did not take place, just as the purpose of the exercise with

Nicky was not to deny that her father was a punishing man who could become aggressive. Observations in clinical practice have shown that merely imagining that the trauma did not occur is not effective (Dibbets & Arntz 2016). The purpose of the exercise is to, faced with the frightening stimulus, rewrite the image in such a way that a better feeling is linked to this original event. The goal is that the activated memory of that event is associated with other, healing emotional experiences. The disaster or accident is the given in the film, the ‘opening scene’. How that film goes on and with what feeling you leave the cinema? That's what IR focuses on. Which scenario you choose for the further progression of the film is highly dependent on the specific meaning of the trauma for this client. So, there is no unequivocal answer to the question of how to rewrite such images. For one client, the insecurity is particularly palpable because she is all alone during the traumatic event. In that case, the rescripting can mean that, as a therapist, you step into the picture and make your presence felt; make contact. For another client, it is not the loneliness but the intensity of the sensory stimuli that makes it a traumatic memory. In that case, you can rewrite the image by creating more distance from the sensory stimuli, such as sound or smell. In order to know which form of rescripting suits a specific client, a good case conceptualization is indispensable. In addition, it is important that during the exercise you also ask about the client's experience, so that you can fit in well with it: ‘What do you see now? How do you feel now? What scares you the most about what you’re experiencing right now? What does it mean to you when you see that... hear that...?’

Rescripting insecurity - Pamela

Pamela witnessed a gas explosion in an apartment building. In the image, she’s walking through the area just after the explosion. >> Therapist: “What do you see now?” >> Pamela: “I see debris, debris everywhere... body parts. I hear people screaming...” (sounds upset)

>> Therapist: “Okay, pause the picture for a moment, like

pressing the pause button on a remote control and everything stops. Do you see that?”

>> Pamela: “Yes.” >> Therapist: “How do you feel now?” >> Pamela: “Horrible...” >> Therapist: “Terribly frightened? Or sad? Or something else?”

>> Pamela: “Everything... sad, powerless... There’s nothing I can do.”

>> Therapist: “You stand there now, you see the debris,

the body parts. And you feel powerless. Of course you feel awful, because it’s a horrible situation. What do you need now?”

>> Pamela: “I want to get out of here.” >> Therapist: “That’s fine. Do whatever you need. What are you doing now?”

>> Pamela: “I’m starting to run, faster and faster. I’m running away.”

>> Therapist: “How do you feel now, while you’re running?”

>> Pamela: “Awful...” >> Therapist: “What do you see now?” >> Pamela: “I’m running down a street. Everything’s still in one piece, people are walking...”

>> Therapist: “How do you feel?” >> Pamela: “Lighter…” >> Therapist: “What else do you need?” >> Pamela: “I want to get out of town. I want to go into nature.”

>> Therapist: “Fine, let images of nature come up. Where are you now?”

>> Pamela: “In a forest, in a clearing…” >> Therapist: “Look around you. What do you see now?” >> Pamela: “Everything’s green, there’s no one... it’s quiet.”

>> Therapist: “How do you feel now?” >> Pamela: “Quiet, still a little tense, but relaxed in my belly.”

>> Therapist: “Enjoy it, that relaxed feeling in your

belly. Hold that feeling while now you let the image fade a little... let it drift away, and slowly bring yourself back to the space here with me. Move your hands and your feet to

feel your body the same way... and, when you’re ready, you can open your eyes. Welcome back.” The debriefing is an important phase of the IR. In this phase, the experience is cognitively framed. In this phase of the exercise, you emphasize the fact that a confrontation with the original event can be linked to another, better feeling by listening to their needs and rewriting the image according to what they need. This discussion is very important to motivate the client to do the exercise more often.

Review and discussion - Pamela

>> Therapist: “How do you feel?” >> Pamela: “A little shaky... but okay, I guess.” >> Therapist: “You did great! Do you mind looking back and discussing what happened? And why I like how you did it?”

>> Pamela: “Yeah, well, what do you think?” >> Therapist: “Well, when I think back to how you got

here, I see that you’re always trying not to think about what happened; the only way to deal with that powerless feeling is to think back to that day as little as possible. You’re looking for distraction all the time, so as not to dwell on those memories, the images. And now you’ve done something completely different in this exercise. You’ve allowed those images; you’ve dwelt on what happened. But not only that, you also changed something in those images, in that memory. You listened to what you needed and acted on it. And doing that made you feel calmer, didn’t it?”

>> Pamela: “Yes, it was better when I ran away, yes, but that didn’t change anything, did it?”

>> Therapist: “Sure it did! If you mean the explosion

still took place, that’s right. But what changed is that you didn’t push those images away; instead you were able to think about it and you did something that made you feel better! I’m very happy, because you’ve experienced that you can allow those memories and still do something to make you feel better. That’s what I explained to you about this treatment, but you’ve been able to experience it for yourself now. And that’s what I want: for you to experience more often that you can do something in those images that will make you feel different, better. It’s still a horrible event: but you’re not powerless; you can do something. Let’s do the exercise again. Then let’s go back to that image, that memory. It can take a whole other turn, it all depends on what you need at that moment. But it will be another exercise in listening to what you need and acting on it. Okay?”

>> Pamela: “All right then.” Punishing/abusive/violent antagonists The previous section dealt with clients who experienced insecurity due to situational circumstances, such as a natural disaster. However, insecurity can also be the result of forms of violence through which someone has been (consciously) harmed by others. You can think of different forms of physical, sexual or verbal violence in the nuclear family or in war situations, harassment at school and so on. In this paragraph, the rescripting focuses on addressing, stopping and/or correcting another person in the image: the antagonist. During the imagery exercise, a client is confronted with an antagonist who threatens to hurt or abuse,

or who makes the client feel unsafe in some other way. Providing safety in such situations means taking vigorous and immediate action; safety is paramount and immediate action is required. Although, as a therapist, you try to intervene immediately, the situation in the picture can escalate so quickly that your intervention is in danger of coming too late. A simple way to provide more time is to ask your client to pause the image and, if necessary, rewind to the point where you want to step into the image as a therapist. You ask your client to place you in the picture and you stop the perpetrator and speak to him/her powerfully. It is quite likely that your client will find it difficult to imagine that the perpetrator who could be so punishing, abusive or violent will immediately stand down when you address him/her. So, you have to be able to act more forcefully, if necessary, in order not only to emulate the antagonist but also to surpass him – for example, by raising your voice and getting angry. The rule is that you defeat the antagonist and fortunately that is always possible. The most important tool to use is your voice. To make it sound powerful and convincing, it is best to empathize with the image and imagine that it is your child who is the victim of the violence. In addition, you can make use of the endless possibilities offered by fantasy, by slowing down time, skipping forwards or backwards, calling in backup, making yourself bigger and whatever else is needed to create safety.

What if… …the antagonist is too strong? You are sometimes confronted with antagonists who are overwhelmingly strong, making it difficult, or sometimes

almost impossible, to provide security during rescripting. In the imagery, for example, you're facing a big, muscular and violent man who even the police are afraid of. Or you are facing a group of aggressive offenders. Bear in mind that the imagery offers limitless possibilities to cope with such situations. For example you can ask your client: to make you larger in the image; to make the antagonists smaller; to engage the police in the image; or to put up a thick, transparent wall between the client and therapist on one side and the antagonists on the other. In addition to these possibilities, as a therapist you should not underestimate the power of your voice. There have been several examples of a frail, feminine therapist who, simply because of the inner strength of her voice, was able to provide a corrective emotional perception of security even though the antagonists were physically stronger. Clients usually react mainly to the emotional message being communicated. The physical reality that is visualized can be an aid to this, without the corrective emotional experience being entirely dependent on these physical aspects. …the client is in a war zone? Some traumas that are maintained took place in combat situations or during internment in a concentration camp. In such situations, violence and insecurity are ubiquitous and often involve multiple perpetrators and antagonists. The massiveness of the described image can evoke feelings of powerlessness in you as a therapist. However, at its core the working mechanism of IR is no different in these situations: the film has a horrific setting, but its course can still be edited with rescripting. However, in these situations it can be important to be selective: which part of the image or which antagonist do you want to focus the rescripting on? In

doing so, choose the parts that are most meaningful for the development of the client’s difficulties. …the client is afraid the antagonist will come back when the therapist is gone? As discussed earlier, the client’s fear of reprisals from the antagonist after you leave is a great compliment for the work you have done so far. The purpose of the IR is to visualize meaningful experiences from the past as if they were really happening. Apparently, this has worked out so well that for your client that the boundary between imagery and reality has been blurred. However, this success of the exercise does mean that safety needs to be increased. For example, you can emphasize that this is just an exercise and that the father can't really do anything anymore. By emphasizing reality, you increase the perceived safety. An alternative is to try to solve it within the exercise. The advantage could be that the rescripting becomes a more meaningful experience due to the increased arousal during the exercise. In that case, you can imagine that there will be more physical distance between the client and the antagonist – for example, by locking up the antagonist, or taking the client to a place where the antagonist cannot enter. Unpredictability of the antagonists The examples so far described unambiguous forms of insecurity, such as mistreatment, abuse or bullying. Another form of insecurity may be the unpredictability of the antagonist e.g. a parent who was often nice, but could have an unexpected outburst of anger; or a parent who usually said positive things, but in a bad mood could make sarcastic, mean remarks. With such an antagonist, your client can wrestle with feelings of loyalty more quickly, because the other

person didn't just do nasty things, but also had a very healthy, sweet side. You will have to explain more about the fact that you do not reject the whole parent/other person, but only the unsafe behaviour or the punishing part of that other person. You can do this cognitive explanation prior to the IR, in preparation for the intervention. However, you can also give this explanation to the child in the picture during the intervention. No matter how kind or sweet the other person could be, the unsafe, hurtful behaviour of that other person will still need to be clearly addressed, allowing your client to experience the important message that her needs matter.

3.3.2 Lack of appreciation, spontaneity and play: demanding antagonist Some clients have not been victims of insecurity or violence, but have experienced a strong pressure that they had to perform better, that there was no time for relaxation, that work had to be done. These messages may have been communicated directly by parents who encourage better performance and at the same time forbid any form of entertainment. However, these messages may also have been communicated indirectly through the lifestyle of the parents themselves: parents who worked very hard are thus, perhaps unintentionally, a role model for these ruthless standards. The intentions of the parents can be very positive in both cases. They all want their child to succeed in life and believe that good performance is a prerequisite for that. However, in the end it is the messages experienced that are internalized. Fighting this demanding message requires a different approach to punishing messages. The therapist will adopt a more persuasive attitude, discussing and substantiating with arguments that relaxation, spontaneity and play are necessary basic needs.

Demanding antagonists – Ben Ben grew up with loving but hard-working parents who never had time for relaxation. However, they did take plenty of time to go over homework and discuss school performance. The pressure to perform better was therefore clearly perceptible to Ben, who developed a compulsive personality disorder. During the imagery exercise, the father stands behind a twelve-year-old Ben who is doing his homework. Ben has been working for an hour and wants to go outside for a while to play, but the father pushes him to keep working. The therapist speaks to the father in the image and on the one hand acknowledges his good intentions, but strongly argues the need for more relaxation:

>>Therapist: “I understand that you want what’s best for

your child, but the way you’re now caring for him is exhausting for Ben. Every battery needs to be recharged from time to time or it will run out. I think we both want Ben to later look back on his life as a good life, full of love, connectedness and joy. I don’t want him to look back on a life that was all about deadlines, performance and working hard.’

What if... …the client feels guilty for addressing the antagonist? Since the demanding antagonist had good intentions, appealing to that antagonist can create feelings of guilt in your client. Such a reaction is first and foremost a compliment that the exercise has become so lifelike that it could activate such feelings in your client. There are several ways to let your client distance herself from her emotions. You can emphasize reality by restating that this is an exercise and that you aren’t contradicting the antagonist in real

life. You can also ask the client to visualize the other side of the antagonist within the image. Maybe the father wasn’t only demanding, but also very sweet and funny. In that case, your client can also put that sweet, funny father in the picture, next to the demanding father. By addressing only the demanding father, you make it clear that you aren’t correcting the whole father. An alternative is to visualize the father in his vulnerability, using possible memories of a more vulnerable, emotional father, alongside the demanding father. This variant has an extra element in that it becomes apparent that the father himself also suffers from the same demanding messages, which is an extra reason to appeal to the demanding side. …the client believes the demanding messages so strongly that the rescripting has no impact? Some clients have heard the demanding messages so often that they fully believe them. The moment you, as a therapist, tell the antagonist that those messages are incorrect, it will provoke resistance from your client, because, from the child’s perspective, the antagonist is right. Therefore, empathizing with the child’s perspective now has a counterproductive effect on the intended rescripting. Then ask your client to visualize the child, rather than being the child. Ask your client to keep watching the child while the antagonist repeats the demanding messages. It is usually easier for clients to experience from this observational perspective that the demanding messages do not fit the needs of the small child at all.

3.3.2 Lack of self-expression and autonomy: guilt-inducing antagonist

Some clients grew up in a family in which self-expression and autonomy were punished in an indirect, guilt-inducing way. Attachment figures didn’t react with physical or verbal violence, but with disappointment, sadness, withdrawal or other forms of indirect communication. These antagonists may be perceived as very punishing, but their messages differ greatly from those of punishing antagonists as they didn’t literally say the client was bad or stupid. As a therapist, you need to address guilt-inducing antagonists in a different way. First of all, indirect, sometimes subtle, communication must be explicitly mentioned. For example, a parent wouldn't literally say that it was bad what the client had done or said, but the silence that followed, the tears in the eyes of the other person, and the single remark, ‘Okay, if you don’t want to stay here with me, then you should go...’ speak volumes. It’s as though this is being done with the underlying message: ‘I feel bad and it’s your fault.’ After these guilt-inducing messages have been made explicit, they will have to be clearly contradicted. However, the strength with which you do this will be less than when fighting punishing antagonists. When you become too angry with the hurt, sad, or disappointed antagonist, there is a high risk that your client’s attention and compassion will go out to the antagonist, and the rescripting will not become the corrective emotional experience you had planned. You can then encourage your client to stop focusing on the antagonist. Finally, psychological education should also be given to your client about the difference between healthy loyalty and excessive responsibility.

Fighting a guilt-inducing antagonist – Greg

>> Therapist: “Greg, while we’re talking about this

situation regarding your wife, I’d like to ask you to close

your eyes for the next ten minutes. And can you form a picture of that situation regarding your wife... what do you see now?”

>> Greg: “Um... she’s doing the dishes in the dishwasher now, and she’s mad at me, throwing the plates in the rack.”

>> Therapist: “And what does she say to you?” >> Greg: “She says... she says I don’t help her enough in the household.”

>> Therapist: “Explore your emotions now. How do you feel when you look at her like that and hear what she says?”

>> Greg: “It sucks all the energy out of me. My arms feel completely limp, and I feel tense in my neck and shoulders.”

>> Therapist: “And what emotions are going through you right now?”

>> Greg: “Well...I don’t know exactly what I’m feeling. It's just like everything’s draining... like I should be doing something, but I don’t know what.”

>> Therapist: “Okay, so it’s a very strong feeling, a

physical feeling, but also a strong emotional feeling, like you should do something else, without knowing what it is?”

>> Greg: “I have to do something, but I don’t know what.”

>> Therapist: “Keep in touch with that feeling, but let’s

blur the image of your wife and see what images emerge from your past, that are somehow connected to this. Keep in touch with that feeling that you should be doing something else as

you blur the image and let new images form. What do you see now?”

>> Greg: “Um... I’m seven years old, I’m in the living room, and my mother‘s on the couch.”

>> Therapist: “Can you describe her so I can see her too?”

>> Greg: “She’s sitting in the middle of the couch, but

she’s bent over and she’s... she’s just looking at me.”

>> Therapist: “How is she looking at you?” >> Greg: “She’s tense and she’s... she’s sad and upset.”

>> Therapist: “Be that seven-year-old boy. How do you feel?”

>> Greg: “I don’t know what to do. I don’t know why she’s looking at me like that.”

>> Therapist: “It sounds like a very bad feeling... like you want to do something, but you don’t know what.”

>> Greg: “Yeah... she wants me to fix it somehow.” >> Therapist: “That sounds like another situation that

shows how caring you are. But it’s also a situation in which you’re stuck, feeling the pressure to do something but not knowing what to do. And that doesn’t feel right. It makes me feel like I want to be there, with you, to help you. Is that okay? Can you put me in the picture?”

>> Greg: “She’s very vulnerable now. I don’t think

it’s... because if it goes wrong, she’ll just get more upset.”

>> Therapist: “And how would you feel if she got any more upset?”

>> Greg: “Well, that would be my fault, wouldn’t it? Because I let you in.”

>> Therapist: “Ah, okay, so you’d feel guilty that you’d done something to upset her even more?”

>> Greg: “Yes.” >> Therapist: “Of course I don’t want to make you feel

any worse, Greg, because I know you’re having a hard enough time. But I’m also thinking: ‘Hey, you’re just a sevenyear-old kid. Of course you don’t want your mother to feel bad, but you also feel bad yourself and don’t know what to do. And that’s not good either. It’s not right for a child to be left alone in a situation like this. A seven-year-old needs care, to be nurtured.’ So that’s why I’d still like to join you. I’ll do my best not to upset your mother anymore, but I’ll also do my best to help you. I think you’ve been abandoned too many times. I don’t want to be one of those people who leave you to your fate. So is it okay if I join you for a while?”

>> Greg: “Okay. >> Therapist: “Okay, I’ll be there now, a little to one side of you maybe.”

>> Greg: “You’re standing in front of the table to my right.”

>> Therapist: “What’s it like for you that I’m here now?”

>> Greg: “It’s...strange, because you’ve turned towards me, you’re closer to my mother.”

>> Therapist: “Actually, I'd like to be closer to you. I'd like to support you. But if it feels better for you if I’m closer to your mother, then that’s okay too.”

>> Greg: “Yes.” >> Therapist: “I’m going to talk to your mother. And I

want you to listen in and see how that feels to you, okay?”

>> Greg: “Okay...” >> Therapist: “Then I turn a little to look at your

mother, and I say: ‘It’s clear that you’re upset, and I can see that you’re suffering. I can tell by your attitude, the way you look at Greg. It’s obvious. And that’s what I want to say: it’s too overwhelming. Greg sees all that and he feels sad about how hard it is for you. He’s a sensitive child and he’s picking up on those signals. So, I want you to hide that pain and deal with it yourself instead of looking at Greg like he needs to find a solution to your problems. He’s just a kid, you shouldn’t do that to him.’ How does she react to this?”

>> Greg: “She finds it very difficult to look at you.” >> Therapist: “Okay, but I’m asking her to do it anyway.

‘I need you to look at me now, to stop looking at Greg and to look at me. This is for grown-ups. We’re both adults and we know there are ways to solve this kind of problem, and you can’t ask a child to do it.’” (to Greg:) “‘You're only seven years old... just look at me.’” (to the mother:) “‘I'll organize help. I’ll refer you to one of my colleagues or arrange for some other form of help, but I’m not going to leave Greg here alone.’” (to Greg:) “‘How do you feel?’”

>> Greg: “I feel good now. It was hard at first when you

spoke to her, but it’s better now because you said you were

going to help her.”

>> Therapist: “I’ll organize some kind of help. Others

will help her. I want you to stop looking at your mother and look at me. Because every time you look at her, every time you talk about her, your heart opens for her. And that only shows what a warm, sensitive boy you are, but when your heart is open, you also feel all her pain. And I want you to learn to close that gate once in a while. Life is complicated enough and it’s important that you stay healthy, that you learn to deal with challenges and that you enjoy life. So, look at me. I’m here for you. I’ll help you. It’s not your responsibility to take care of your mother. How do you feel when I say that?”

>> Greg: “Good... good.” >> Therapist: “Yeah? I’m glad, but I also notice that

this has been intense. I think it’s time now for us to do something lighter, more playful. I want you and me to get out of here and go somewhere more fun. Where do you want to go?”

>> Greg: (laughs)… “I want us to take the dog to the park.”

>> Therapist: “That sounds like a good idea. Let’s do that. So, we're in the park right now. What do we do?”

>> Greg: (laughs) “You let the dog off the leash and then you try to catch the dog again, and the dog loves to be chased. So, she keeps running past you and then running away. And she’s just running around.”

>> Therapist: (laughs) “I like it. I run after her and sometimes I jump to grab her?”

>> Greg: “Yeah... yeah.”

>> Therapist: “I like to see you smile, Greg. And how do you feel now?”

>> Greg: “Good.” >> Therapist: “And what kind of feeling is that?” >> Greg: “It’s free, and open and fun.” >> Therapist: “That sounds very good, that you’re freed

from all the pressure and stress and responsibility. So, look at the dog, see me fall, run to get her, and enjoy that good feeling.”

What if... …the client continues to feel guilty and worry about the antagonist? As previously noted, the internalized messages from the past are often so credible that clients have difficulty accepting the other perspective expressed by the therapist. A factor here is that the client is used to being sensitive to signals that the antagonist is disappointed or unhappy. As long as the client continues to focus her attention on the antagonist, there is a good chance that feelings of inadequacy will be triggered. Therefore, ask your client to focus her attention on you, draw her eyes away from the antagonist and instead look and listen to you: ‘I want you to stop looking at your mother now and listen to me. You’re a sensitive child and every time you look at her, you see her suffering and pain again. You’ll have to learn to close your eyes to her pain now and then. That’s not selfish, even though it might feel that way. On the contrary, you’ve learned too much to listen to her needs and, as a result, you have become a little less good at listening to your own needs. I want us to listen to your needs now.’ Then you can

offer to organize help and support for the antagonist, such as a therapist, social worker or friend. In this way, you can remove the responsibility for the care of your client.

3.3.4 Lack of emotional attachment and care: absent antagonist During the exercise, your client can describe an image in which she sits alone in her room as a small child, feeling lonely and sad. There is no one there, no parents or other relatives. Your client grew up in an atmosphere of emotional neglect and loneliness. Even though no punishing words have literally been said, your client may have internalized the absence of care figures as a punishing message: ‘Your needs don’t matter and you’re not important.’ When you enter this image as a therapist, you can first of all offer solidarity and care to the child you find there. In addition to compassion for the lonely child who sits alone, you can also appeal to the neglected antagonists in this image. In reality, the parents may not have been present; in the image, you can ask your client to put the parents in the image, after which you speak to them about their absence.

Absent antagonist – Patrick Patrick describes an image in which he sits alone in his room as a nine-year-old boy. His parents are gone, and he doesn’t know where they are or when they’ll be back. The therapist steps into the picture and comforts the sad and lonely child. Next, he asks to place the parents in the room:

>> Therapist: “Now, can you include your parents? I’d like to have them in the room with us right now.”

>> Patrick: “They’re gone... they never come to my room. I don’t know whether they’ll come... they have more important things to do...”

As a therapist, explain that this is exactly what you want to talk to them about. You’re asking whether he can visualize his parents in the image so that you can speak to them about their absence:

>> Therapist: “What kind of parents are you, to leave your little son alone without letting him know where you’re going? You can’t do that! I’m saying this because I want Patrick to hear that this isn’t normal, that there’s nothing wrong with him. You are the ones not doing this right.”

3.3.5 Lack of realistic limits: pampering/neglecting antagonist One of the basic needs of every child is to learn realistic boundaries, to learn that in life you don't get everything you want and that not everything works out the way you want. It is the task of parents to teach a child this and to tolerate the fact that the child is angry and sad when they’re not allowed to do something they want to do at that moment. By setting boundaries, a parent helps the child to build tolerance for the frustrations that they will inevitably experience in life. When no limits are set and a child is spoiled with all he or she wants, this is a form of neglect: this child will face an adult life in which she is not prepared for the frustrations and setbacks that will inevitably occur. For someone who is not used to it, it is not easy to set boundaries. IR is a helpful intervention precisely for this reason; you can teach your clients that there are boundaries, without having to tell him that face to

face. By addressing the parents responsible on their shortcomings during the rescripting process, you indirectly but meaningfully convey to the client the important message that she cannot get everything she wants.

Neglecting antagonist – Hans Hans grew up as the youngest in a family with two children. His parents were often absent; his father travelled a lot for work, and his mother was busy with her studies and work. The lack of emotional attention and connectedness was always offset by increasingly lavish gifts, becoming more and more expensive every year. During the imagery exercise, Hans describes the image that he is alone, frustrated in his room after his Dad said he couldn't get an air rifle. Hans is eleven years old at the time. Then Dad comes into the room and says he will buy an air rifle for Hans. The therapist asks if he can enter the image at that point and speak to the father: ‘I do understand that it bothers you that Hans is angry and sad in his room, but it’s not good that you’re giving him his way now. He’ll have to learn that there are limits and that what he wants is not always what he needs. He needs to learn that a “no” is not the end of the world. He can only learn that if you now tolerate him being angry. Of course he’s angry; he’s a child and it’s never nice not to get something that you want, but that'll pass. It’s not good that he’s getting an air rifle when he's only eleven years old.

3.4 Chapter summary This chapter is about rewriting meaningful images that are visualized during the imagery exercise: rescripting. The guideline for this rewriting is that the visualized change matches the basic needs of the client and that this change is

visualized as vividly as possible. In order for the rescripting to work, it helps that you empathize as a therapist, so that you see the image in front of you as vividly as possible and wonder: ‘What would I do now if the child/person in this image was my child?’ This question helps to generate natural emotional and behavioural responses that are well-suited to the needs of the client. Also important for the rescripting is the realization that the imagery knows no limits, and that as a therapist you are free to fast forward, rewind or stop the image and to use aids or call on support troops during the rescripting. Appendix 3 contains a summary of the steps described in this chapter that can help you when you want to apply IR to a client. The next chapter describes how you can coach clients to independently edit the mental images.

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Chapter 4: Imagery rescripting – the client rewrites Chapter summary 4.1 Introduction 4.2 When can the client begin to rewrite? 4.3 Visualizing the healthy adult 4.4 Imagery rescripting at the end of therapy: the client rewrites 4.5 Chapter summary

4.1 Introduction So far, as a therapist, you’ve stepped into the imaginary image and done the rescripting. This chapter describes how clients can learn to rewrite the meaningful images themselves. The clients learn to rewrite the images of the meaningful memories associated with fear, sadness, anger and so on as a now healthy adult. This makes rescripting technically more difficult in this phase, because the client has to visualize herself not only as a victim in the (traumatic) memory, but also as a healthy adult. In this phase of imagery rescripting (IR) there are therefore two client perspectives and your clients need to learn to switch between the two. This chapter consists of two parts. The first discusses how your client can learn to visualize her healthy adult. The second part describes how the client can learn to rewrite the

images during the IR itself from a healthy, mature perspective. At the end of the chapter, you as a therapist will have a good impression of the working method and you will have a theoretical basis at your disposal, which, supported by supervision and/or intervision, enables you to guide clients in rewriting their own images.

4.2 When can the client begin to rewrite? Before we go into the ‘how’, we must first consider the question of ‘when’ we should move into this new phase of treatment in which the client does the rewriting herself. That decision will be strongly determined by the pathology being treated and the therapy plan chosen for it. If IR is used as a standalone treatment for post-traumatic stress disorder (PTSD), you have already made a choice for the total number of sessions in the therapy plan – for example, twelve weekly appointments of ninety minutes each. The goal is then that, at the end of those twelve sessions, your client can rewrite the traumatic memories on her own and has experienced the healing effect of this, reducing her difficulties. In that case, it is necessary to switch to the phase in which you let the client do the rescripting herself, in time – for example, after the sixth session. There will be a different therapy plan with a corresponding time schedule when the treatment focuses on serious personality problems. In that case, you probably decided on a long-term trajectory of, for example, two years. In that case, the treatment must be structured and phased in such a way that at the end of those two years your client can rewrite images independently. However, in such a long-term

treatment process it is more difficult to monitor the structure and the phasing, and it is therefore best to incorporate fixed evaluation moments in advance – for example, after six months and a year. However, the actual transition to the new phase, in which the client takes the lead in rescripting, often remains a gradual process of trial and error. For example, you have worked well with the technique for a few months now and you notice that your client gets to know the rescripting better and better, and benefits from it more and more clearly. You can then try to see if the client can come into the picture as a healthy adult and repeat what you just said to the antagonist. In practice, for many clients this is a learning process with varying degrees of success; sometimes they get better and better for a while, after which they return to needing your active support because they're going through a tough period. In this book, we discuss these phases as distinct, consecutive steps in the therapy process, but in practice it will often be a gradual process in which you increasingly take on a coaching role on the sidelines. Supervision, intervision and clear, pre-determined evaluation moments are very important in monitoring the course of the therapy plan.

4.3 Visualizing the healthy adult In order to rewrite meaningful images themselves, clients need to place themselves in the image as a healthy adult, someone powerful enough to rewrite sometimes traumatic images. In the treatment of otherwise healthy clients requiring help with a specific issue, this visualization of a healthy adult does not require much explanation and attention and clients can usually put themselves in the picture as a healthy adult without too much effort. However, the situation is often very different in the treatment of personality disorders: the lives of these clients are marked by a

burdensome history, negative self-evaluations, emotional pain and attempts to feel that pain as little as possible. There has been little or no opportunity to develop a healthy selfimage and instead all the energy has gone into surviving difficult circumstances. These survival mechanisms were functional in those circumstances, but they cause persistent problems in their current lives. In order to learn to visualize themselves as a healthy adult, clients need explanation, practice and attention. With the step-by-step plan below, you can shape this phase of the treatment.

Roadmap for visualizing the healthy adult Step 1: Explain why clients need to learn to visualize the healthy adult Step 2: Give a personal example of your own healthy adult Step 3: Focus on specific aspects of this memory Step 4: Ask the client to visualize her healthy adult Step 5: Review, discussion and homework

4.3.1 Step 1: Explain why clients need to learn to visualize the healthy adult This new phase needs some explanation and a framework, so your client knows what the objectives and the way of working in this phase of the therapy are. You can start by explaining that the goal of the therapy is to strengthen the healthy side of the client, so that she no longer has to fall back on old survival mechanisms. So far, new, healthy experiences have been gained in the treatment by rewriting images from the past. Now you want the client to learn how to rewrite.

This requires that your client is able to evoke an image of her healthy adult. By visualizing the healthy adult, the client has the strength and self-assurance to change the emotionally charged images of the past.

Step 1: Explain why clients need to learn to visualize the healthy adult – Nicky

>> Therapist: “Okay, we’ve done a lot of work in therapy. And what you may have noticed is that I’ve talked a lot about your healthy side. The goal of this therapy is to strengthen your healthy side. Maybe today we can talk about exactly what we mean by that: your healthy side. Is that okay?”

>> Nicky: “Yes.” >> Therapist: “I want to make that healthy part of you

stronger. It’s already there – the fact that you came to therapy and stuck with it, despite the upset that it sometimes causes you, shows you have that healthy side. When faced with difficult situations, you need that healthy adult. You can activate that part of yourself by thinking back to past situations where you were that healthy adult. By seeing yourself as a healthy adult in awkward situations, you put yourself in touch with that side of yourself and you become more and more of a healthy adult.”

What if... …the client says she’s not ready for this new phase yet? Some clients feel so insecure that they tend to think they can't handle this new phase of therapy. First of all, it is important to know how we can understand this resistance: does the client actually still feel too vulnerable and insecure to enter this next phase, or is there an avoidance of doing

things independently, which fits within the pathology of the client? However, in both cases it is not a matter of course to adjust the treatment plan if your client is hesitant about the new phase. Part of the effectiveness of the method lies in the goal-oriented approach. Certainly, try to keep your client’s emotions tolerable, but don't try to avoid them.

4.3.2 Step 2: Give a personal example of your own healthy adult One way to teach your client to visualize her healthy adult is by telling her how you do it yourself. Through this personal approach, you give an important message that a healthy adult like you also struggles and is challenged in life. In this phase of the therapy, your client will practice, under your guidance, the healthy handling of these violent feelings. The goals of the therapy become more real by telling the client about your own struggles.

Step 2: Give a personal example of your own healthy adult – Nicky

>> Therapist: “For example, if I’m facing a tricky

situation, and I have to prepare for it, then sometimes I literally close my eyes to think back to a situation in which I was that healthy adult. And that helps me to feel stronger, to actually be that healthy adult and to better face the difficulties. If I had to do that now, I’d probably think back to a situation that took place a few weeks ago. You know I have children. My daughter is twelve now and she’s in high school. She had to finish a project, which she found tricky, so she’s delaying that project a little. And the situation I have to think about right now is the day she actually had to hand in the project while it was still unfinished. She was very stressed, nervous and angry at herself and at the school. But she was also sad, because

she felt very vulnerable at that moment. Can you imagine what that must have felt like for a twelve-year-old?”

>> Nicky: “Yes...” >> Therapist: “So I saw her, at the moment when she burst

into tears... and naturally felt a lot of love and the urge to help her at that moment; my father's heart opened up and wanted to embrace her. And so I did, because she needed that support. But I wasn’t just thinking of comforting her. Part of me realized that this is her life, her struggle, in which she has to find her own way. I can help her find that way, but I can’t travel it for her. I would have when she was a little girl. But she’s older now and she must learn to deal with situations like this. Thinking but also talking about that fact makes me feel more balanced. Part of me wants to comfort her, but by talking about the fact that she has to find her own way, I feel calmer, stronger in a way. I’m open to her, but I realize that you can’t do everything for someone.”

>> Nicky: “Yes...” >> Therapist: “And it’s a good feeling, I feel calm and

strong. And I realize that this is my healthy side. By thinking about that situation, I’m also looking at a father that I want to be more often. I look at my healthy adult there. You can view one of those memories as a gateway – thinking about that situation is, as it were, the gateway to opening up to that healthy adult.”

What if...

…you'd rather not share personal information with your client? First of all, you should only share what you want to share; no one can or should ask you to do things you don't want to do. So, find out what your needs and your own limits are. Having said that, it is also important to realize that we sometimes close ourselves off reflexively from clients who behave in a somewhat arrogant or aggressive manner. That’s a natural reflex, but a lot of people before you have had the same response to these clients. They may need to learn that vulnerability is not the same as being weak or defenceless. By showing that you also have your struggles and vulnerabilities, but that you are still a healthy, strong adult, you are offering these clients a corrective emotional experience, allowing them to learn to show more vulnerabilities and feelings for themselves.

4.3.3 Step 3: Focus on specific aspects of this memory Having a visual image of the healthy, mature part of the client is an important step for her to learn to do IR herself. However, during rescripting, your clients will be exposed to emotional memories that can easily cause them to feel old pain and slip back into the coping mechanisms they use for these. A visual image alone may not be enough to maintain their strength. During the visualization of the healthy adult, you ask about all the different aspects of this state of mind. For example, ask where they experience the positive feeling in their bodies, whether they can adopt a posture that fits that feeling, and whether they can think of a ‘motto’ that illustrates this positive experience. The explicit awareness of the emotional, cognitive, physiological and postural aspects can strengthen the healthy adult, which

in emotionally charged situations helps to make and maintain contact with the healthy adult side.

Step 3: Focus on specific aspects of this memory – Nicky

The therapist has just told Nicky about a memory in which he himself was a healthy adult. >> Therapist: “Now when I think about what I experience

when I’m that healthy adult, I notice that I feel that calm feeling all over my body, but especially in my belly... and I notice that I’m sitting up straight, with my shoulders straight. It’s different when I fall into my old ‘careworn’ role; then I seem to lean forward a little more; I don’t know if I really do this, but that’s how it feels to me. And when I sit up straight, I feel more balanced, more in touch with my daughter and reality. And the word ‘reality’ also helps, just that word already makes me more balanced, more that healthy adult. ‘The reality is...’ yes, I feel that that helps.”

What if... …your client can't describe specific aspects of her experience? Some clients have not learned to be aware of their feelings and are usually trying so hard to not feel them that they are unable to give words to experiences. They find open questions such as ‘What do you feel?’ and ‘Where do you feel that in your body?’ difficult to answer. You can help your client become more aware of the different aspects of the healthy adult by mirroring behaviour, attitude and emotions: ‘I see you’re sitting up a little straight now that we’re talking about this situation. Do you notice that?’ ‘I notice that you smile a bit when you tell me about your choice to go back

to your old hometown. You’re clearly less sad right now than you were before. Do you notice that too?’

4.3.4 Step 4: Ask the client to visualize her healthy adult Then ask your client to create an image of her own healthy adult. You explicitly do not ask for images in which the client only feels strong or good, because then there is a risk that memories will be visualized out of overcompensation or avoidance. A healthy, mature state of mind means that you are still in contact with all your uncertainties, doubts and irritations, and that you do not avoid or overcompensate for them. Healthy means that those feelings do not dominate you, but that you can handle them properly. In the instruction for your client, you ask about those memories in which your client had a hard time, but which she still looks back on with a certain pride, because she managed to handle the situation and everything she experienced. You then ask the client to become aware of all aspects of that healthy adult.

Step 4: Ask the client to visualize her healthy adult – Nicky

The therapist has just told Nicky about a memory of his own healthy adult and all the characteristics of that state of mind. >> Therapist: “Well, I want you to have a picture of your healthy adult, too. So, I want to work on that today. is that okay?”

>> Nicky: “Yes...” >> Therapist: “I’d like you to close your eyes... take a deep breath... okay, so let a memory of your healthy adult

come to mind. These are often memories of a situation that was awkward, but which you handled well... one that you can look back on with a certain pride. What memory comes to you?”

>> Nicky: “Um... I think, when I got my job last year.” >> Therapist: “That sounds like a good memory. What do you see now?”

>> Nicky: “I had to go for a job interview, just me and

the guy who was recruiting for that job. So I went to his office.”

>> Therapist: “So, you’re in his office now and what do you see?”

>> Nicky: “I’m sitting on the other side of a big desk and he’s asking me all kinds of questions.”

>> Therapist: “Just be in that office, with all these questions. How do you feel?”

>> Nicky: “Uh, I feel really nervous, scared, like I want to get out of here as fast as I can.”

>> Therapist: “And where do you feel that fear?” >> Nicky: “I can barely breathe, I feel nauseous. I don’t want to mess it up.”

>> Therapist: “Realize this is your vulnerable side; this

is little Nicky feeling scared again. But now I want you to focus on how you deal with this, how you handle this fear.”

>> Nicky: “I’m really thinking: ‘No, I’m going to do this! I know I can do this!’”

>> Therapist: “And how do you feel now?”

>> Nicky: “Stronger, I guess?” >> Therapist: “Focus on that strong feeling. where do you feel that in your body?”

>> Nicky: (points to her belly) “Here, I think.” >> Therapist: “Be that strong Nicky... and maybe you can find a posture to match. Sit as it suits this strong feeling.” (Nicky sits upright) “So, what’s happening now?”

>> Nicky: “I can see he’s smiling and I really feel it now: ‘I can do this!’”

>> Therapist: “And how does that feel?” >> Nicky: “Good, strong...” >> Therapist: “And which words fit that feeling?” >> Nicky: “‘I can do this.’” >> Therapist: “Say those words again?” >> Nicky: “‘I can do this!’” >> Therapist: “Maybe now you can take a step away from

that confident Nicky, so that you can look at her. What does she look like?”

>> Nicky: “She looks happy, with a look of ‘I can do this’. She knows what she’s doing. Relaxed, happy.”

>> Therapist: “Just take a mental picture of her; this is

your healthy adult, the captain of your ship. Just look at her: that’s what she looks like. Hold on to that feeling and just become more aware of the room, here with me... and

move your hands and your feet just for a moment so you reconnect with your body... and when it feels right, open your eyes.”

What if... …your client says she has no memory of a healthy adult? It is rare that clients do not have a memory of a healthy adult, but in case of serious personality problems, sometimes they don’t. For you as a therapist, it is sometimes hard to imagine that a severely traumatized client has had healthy experiences in her life history. However, experience shows that almost every client has had such experiences. They only have difficult accessing these because of highly internalized negative self-evaluations. Even severely traumatized borderline patients appeared to have made healthy choices in the past: leave a destructive relationship; resume studies; or go into therapy. These are some examples of experiences in which a healthy-adult part of the client was present and took the lead.

4.3.5 Step 5: Review, discussion and homework Now that your client has an image of her healthy adult, the homework for the coming period is to visualize that image on a regular basis. By practicing this regularly in situations where there is not so much emotional arousal, your client learns to switch to this healthy part of her more and more easily. This exercise is much-needed by some clients to teach them to make contact with their healthy adult when images of traumatic events from the past emerge. It's like learning to swim in calm, shallow water before entering the sea. The goal may be to swim in the sea, but this requires some preparatory exercise.

Step 5: Review, discussion and homework – Nicky

>> Therapist: “Welcome back, Nicky. How do you feel now?” >> Nicky: “Um... all right, relaxed.” >> Therapist: “Is that another part of the big, adult Nicky you’re feeling?”

>> Nicky: “Yeah, I guess so.” >> Therapist: “That sounds really good! What I like so

much is that Big Nicky knows what she’s worth. That’s exactly what Little Nicky missed: appreciation, trust. I’d like to ask you to practice recalling the image of Big Nicky in the coming week. Shall we characterize that image of her, with all her properties, describe them, so you can recall the image more easily? Or we could record the description on your phone so you can listen to it again? Or maybe you’d like to have a symbol, choose an object that can help you get that image back into your mind? Whatever you decide, it’s important to practice connecting with that mode regularly, learning to switch to Big Nicky if that’s what you want.

4.4 Imagery rescripting – the client rewrites Now that your client has an image of her healthy adult, you can coach her in rewriting meaningful images herself. It is recommended to follow the next step-by-step plan. These steps will be explained in more detail in the following sections.

Roadmap for imagery rescripting – the client rewrites

Step 1: Introduction Step 2: Visualizing the healthy adult instead of the safe place Step 3: Visualizing a traumatic event from a child/victim perspective Step 4: Rescripting the traumatic image from a healthy adult perspective Step 5: Rescripting the traumatic image from a child/victim perspective Step 6: Review and discussion

4.4.1 Step 1: Introduction The rewriting of images by the client marks a new phase in the treatment, which started with rescripting by the therapist. It is therefore advisable to be very explicit in explaining that your client is now going to step into the picture and change the course of events: ‘The goal of the therapy is that you, from your healthy adult, can keep in touch with your basic needs, can listen to what you need. In order to work towards this, I want to practice editing memories or images from your past with you.’

4.4.2 Step 2: Visualizing the healthy adult instead of the safe place So far, the IR has always started with visualizing a safe place. This is partly done to warm up the visualization, but partly also as an extra emotion-regulating tool. if your client becomes too tense during the exercise, you can always return to the safe place to reduce the pressure. In the next

phase of treatment your client will have to learn to activate her healthy adult in emotional images for the rescripting. By now starting the exercise with the visualization of that healthy adult, you are already priming it. Memory files regarding the healthy adult have already been activated, making it less difficult to reactivate them later in the exercise.

Step 2: Visualizing the healthy adult instead of the safe place – Nicky

>> Therapist: “Okay, now close your eyes... I want you to

conjure up the image of that powerful, healthy part of you... that side of you that we talked about a few sessions ago about you in the job interview? What do you see now?”

>> Nicky: “Um... I look really happy. I look like I know what I’m doing.”

>> Therapist: “Okay, now try to be that healthy adult. What’s going on around you?”

>> Nicky: “Um... the guy from the company says: ‘You got

the job. I’m looking forward to working with you.’ And I feel really strong and confident, a feeling that: ‘I can do this!’”

>> Therapist: “And can you feel that in your body?” >> Nicky: “Yes.” >> Therapist: “And where do you feel that in your body?” >> Nicky: “It’s really...” (waving her hands in front of her chest) “everywhere, really.”

>> Therapist: “Realize that this is your healthy adult,

okay? You’re powerful, self-assured: ‘I can do this!’ And

now I want you to let this image fade...”

4.4.3 Step 3: Visualizing a traumatic event from the child/victim perspective The IR in this phase actually starts in the same way as before: you ask your client to form a picture of a meaningful situation in the past and to empathize as if she were there again. You help your client by being clear in your instructions: ‘Now let’s see that twelve-year-old girl again. And look around you like that twelve-year-old girl. What do you see now?’ You let your client empathize with the perspective of the child, or, when the meaningful experience took place later in life, in her experience during that event. From that perspective, you explore the experience and ask for sensory information: ‘What’s going on?’ ‘What do you see/smell/hear?’ As with previous sessions of IR, you let the image stop at the moment intervention is required. As a therapist, you still have a leading role in this in the beginning, but over time your client needs to learn better and better when it is desirable to stop the image.

Step 3: Visualizing a traumatic event from the child/victim perspective – Nicky

Nicky just activated the image of her healthy adult. Now she visualizes meaningful memories from her past, which she can rewrite by drawing on her healthy adult. >> Therapist: “Can you now conjure up that picture of that situation where you’re alone in your room, very afraid of your father, of what he might do, of the punishment for spilling a drink in the car, okay...?”

>> Nicky: “Yes…” (nods)

>> Therapist: “Construct the image. What do you see?” >> Nicky: “That I’m sitting on my bed, very small, looking at my bedroom door, waiting for it to open...”

>> Therapist: “And how do you feel?” >> Nicky: “Very scared, nauseous and sad.” >> Therapist: “And what’s going through your head?” >> Nicky: “That I did something wrong again. That Dad is going to come in soon and be very angry.”

>> Therapist: “Okay, just fast forward the image a little bit, to the point where the door opens, and your Dad’s there. What do you see now?”

>> Nicky: “He just stands there. He’s very angry, and he’s red, and he’s screaming.”

>> Therapist: “And what does he say?” >> Nicky: “‘I can’t believe you did something so stupid again! You always do everything wrong! It’s always your fault!'”

>> Therapist: “Okay, what about the tone of his voice?” >> Nicky: “Very strict and disgusted... angry with me.” >> Therapist: “Okay, I want you to pause the image now.” In previous sessions with IR, you stepped into the image as a therapist. However, in this phase the next step is for your

client to visualize her own healthy adult in this image, in order to rewrite the course of the event from that healthy adult.

4.4.4 Step 4: Rescripting the traumatic image from a healthy adult perspective You now ask your client to visualize her healthy adult. Especially the first few times, it is necessary to help your client recall all the characteristics of the healthy adult that your client described at the beginning of the exercise. Your client needs to change perspective; from the perspective of the child, she now needs to change to the perspective of the healthy adult. You’re helping your client with different manoeuvres to make this switch. First of all, be clear in your instruction: ‘Now I want you to be that healthy adult. Now be that big (name client). So you stand here, and you see that little girl sitting there and feeling scared, while her father looks at her very angrily. What do you think of that?’ You also accompany this change of perspective by a change in your voice: so far you have addressed her during the presentation of the situation in the perspective of the child and you have intensified the experience by actually addressing a child, with the tone of speech that goes with it. However, now you want your client to be a healthy adult and there’s another way to address them: more maturely, more firmly. Then you coach her during the rescripting of the event. In this phase it becomes more and more important that your client learns to feel what she wants and act accordingly. Your role as a therapist in this phase changes from pretending to coaching. Instead of telling her what to do, you ask more about her feelings and needs, and encourage her to fulfil those needs. So, you’ll be asking increasingly

open questions, such as: ‘What do you think of that?’ and ‘What are you saying/doing?' Coaching also means encouraging and repeating those parts of the rescripting that are meaningful to your client. By speaking out loud and repeating her needs, your client increasingly becomes the owner of what she says. You pursue two goals when coaching the healthy adult. First of all, you strengthen the client’s sense of self-confidence and competence by letting her fight the antagonist as a healthy adult. And second, you ask the healthy adult to empathize and comfort the child, teaching the client to look at herself with more compassion. For clients who have difficulty feeling that compassion, or who don’t yet feel competent or strong enough to fight an antagonist, it may be advisable to first practice self-compassion for a while, without an antagonist in the picture. Once the antagonist has been removed and the child has been comforted, you stop the image and move on to the next step of the exercise.

Step 4: Rescripting the traumatic image from a healthy adult perspective – Nicky

Just now the image has been visualized in which the father angrily enters the room of Little Nicky, who is waiting there in fear for the punishment she expects from him. >> Therapist: “I want you to pause the image now. And now

bring in your healthy adult, the Nicky we were just talking about. So, there’s Little Nicky, there’s your father, and there’s you, okay? Can you place yourself in the image like this?”

>> Nicky: “Yes.” >> Therapist: “So where do you see yourself now?”

>> Nicky: “I’m right in front of him.” >> Therapist: “So, you’re facing him, between Little Nicky and your father?”

>> Nicky: “Yeah, she can still see him.” >> Therapist: “Okay, then I want you to be that Big Nicky. What do you think of what’s going on here?”

>> Nicky: “It’s just really bad! You can’t yell at a child like that!”

>> Therapist: “Do you feel like you can handle it this

way, or would you like to make yourself a little bigger?”

>> Nicky: “Yes, a little bigger...” >> Therapist: “Imagine standing over him. Do you need anything else?”

>> Nicky: “No, just that I’m bigger.” >> Therapist: “So, you stand there, bigger, and you look

down at him, at the door. What do you want to say to him?”

>> Nicky: “You’ve got to stop doing that! You can’t yell

at her like that, she’s just a little girl, and you’re making her very scared and very sad, and that’s very bad of you, can’t do that!”

>> Therapist: (softly) “‘I will not allow you to...’” >> Nicky: “I won’t let you do that to her!” >> Therapist: (softly) “Good.” >> Nicky: “Never again!”

>> Therapist: “All right, that’s it! How do you feel?” >> Nicky: “Um, well... ‘You have to go now! You must go away from here and never come back!’”

>> Therapist: “All right!” >> Nicky: “‘Leave her alone! Leave her alone!’” >> Therapist: “And how does he react?” >> Nicky: “He’s gone!” >> Therapist: “He is? That’s great! So he’s out of the picture.”

>> Nicky: “Yes.” (both chuckle) >> Therapist: “And how do you feel now?” >> Nicky: “Great!” >> Therapist: “And where do you feel that in your body?” (client points to her chest with a powerful movement) “That's great. And what happens to Little Nicky now?”

>> Nicky: (chuckles) “She’s lying on her bed...” >> Therapist: “Is she? And how do you feel about her?” >> Nicky: “I just want to give her a big hug...” >> Therapist: “Will you do that?” >> Nicky: “Yes...” >> Therapist: “Okay, you’re going to give her that big hug now?”

>> Nicky: “Yeah, and she’s just standing there jumping.” >> Therapist: “Yes. Is she jumping on her bed? And what do you say to her now?”

>> Nicky: “‘You’re a super, sweet girl, and you’re just doing your best, and he can never hurt you again. He can never yell at you like that again.’”

>> Therapist: “Great! And how does she react?” >> Nicky: “She just stands there cuddling and laughing, giggling...”

>> Therapist: “She enjoys having someone to protect her?” >> Nicky: “Yes...” What if... …the client can't do the rescripting independently yet? Although they have been shown several times how to rewrite an image and have already practiced a lot with visualizing their own healthy adult, in practice some clients appear to be poorly able to shape the rescripting themselves. For example, they can't answer your questions such as ‘What do you need now?’ or ‘What do you want to say?’ Apparently, during visualization they are too overwhelmed by emotions and thus fall back into old survival mechanisms. This does not mean that your client is not yet ready for this new phase of therapy. As a therapist in this situation, you will have to be more active in coaching the healthy adult. You can make suggestions for what your client might say or put yourself in the image without taking over the rescripting right away. If this problem occurs more often, you can also prepare the exercises in the future by formulating a healthy script that

your client can apply during the exercise in advance, describing your client’s needs and what she wants to say to the antagonist. …the client wants to use violence in rescripting? Sometimes, as a therapist, you are confronted with a client who wants to rewrite the image in a violent way. There are indications that it is healthy to fantasize about revenge, because then revenge fantasies become less frightening and the expression of revenge in fantasy can even lead to better anger regulation and a reduction in anger (Arntz et al., 2007). Moreover, there seems to be no short-term adverse effects of visualizing revenge fantasies in an IR (Seebauer et al., 2013). How best to deal with this depends very much on the relevant basic needs of this specific client. The IR aims to generate corrective emotional experiences. For a client who has never had the chance to express her needs and feelings, visualizing a violent rescripting may be the corrective emotional experience she needed: finally, she has the chance to express, in a safe way, all the pent-up anger about the injustice that has been done to her. However, for a client who is more often aggressive and uses violence as a problemsolving strategy, this violent rescripting is not a corrective emotional experience but rather a continuation of that behavioural pattern. It is more important for this client to learn to express her anger in a healthy, limited way, because this client needs realistic boundaries. If she says she feels the need to use force, you might react with: ‘I think it’s good that you feel how angry this makes you and that you want to show your anger. But I don’t want you to express that anger in such a way that you won’t be heard and it only leaves you with bigger problems. Violence has been in your life for too long. I want that to change now.

So, show that anger, but do it with words: speak about your anger so that you can really be heard.’

4.4.5 Step 5: Rescripting the traumatic image from a child/victim perspective Your client has now gained the skills to rewrite the image from the perspective of a healthy adult. From that perspective, she has been able to do justice, express her anger, send the antagonist away or any other intervention needed to validate her basic needs. Now you ask your client to rewind the image to the point where the healthy adult enters the image and visualizes the rescripting again, but this time from the child's/victim's perspective. There are two reasons for this repetition of the rescripting from the child’s perspective. First of all, the repetition of the rescripting is good for internalizing healthy experiences. Your client has a healthy experience for the second time, which will be remembered even better. In addition, the repeated rescripting will touch on other basic needs from a different perspective; the rescripting from the perspective of the healthy adult will strengthen a feeling of strength and self-confidence: ‘I can do something!’ Experiencing the rescripting from the perspective of the child/victim touches on the need to be seen, to matter: ‘Someone's standing up for me. I’m being taken care of!’ From a technical point of view, this extra step is challenging and certainly a bit tricky for the beginning therapist. However, for clients, this extra step often means gaining an even deeper healing experience. You can help your client change perspective by being clear in your instruction in the first place: ‘Now I want you to rewind to the point where you come into the picture as a healthy adult. But now I want you to be that girl of twelve again... so you’re

sitting there, with your angry father opposite you, but now there’s also the big (name client) Do you see her? What’s it like for you that she’s here now?’ For many therapists, it feels uncomfortable and awkward to give ‘commanding’ instructions, but for clients, these provide clarity and structure to the emotional experiences they undergo. A second way to support your client in this change of perspective is by again adjusting your voice and tone of speech; if you want your client to empathize with the child perspective, it helps if you address her as a child and no longer as a healthy adult. Then, from a child’s perspective, you ask her to tell you how the rescripting is going.

Step 5: Rescripting the traumatic image from a child/victim perspective – Nicky

Nicky just spoke to her father as a healthy adult and sent him away. Then she embraced the little girl and comforted her. >> Therapist: “And now I want you to rewind the image...

and I want you to be Little Nicky again, at the point where Big Nicky comes in. So now you’re Little Nicky and you see that big adult come in...” (soft voice) “How do you feel?”

>> Nicky: (softly) “I hope she can do something...” >> Therapist: (softly) “Yes? And what’s going through your mind?”

>> Nicky: (softly) “I hope she can stop Daddy...” >> Therapist: “So, what’s happening now?” >> Nicky: “Um, she’s yelling at him, poking her finger in his face, because she’s bigger than him!”

>> Therapist: “What’s she saying?” >> Nicky: “She says: ‘You leave her alone! You’re going to leave here, and you’re never going to yell at her like that again because she doesn’t deserve it. She’s just a sweet little girl!’”

>> Therapist: “That’s good – and how does it feel for you to hear that?”

>> Nicky: “I really feel like someone’s standing up for me.”

>> Therapist: “So, what’s happening now?” >> Nicky: “She just shows him the door and he leaves.” >> Therapist: “Very good... and how do you feel?” >> Nicky: (cheerfully) “Giggly... happy... like I want to jump up and down.”

>> Therapist: “A bit happier?” >> Nicky: “Yes.” >> Therapist: “A feeling of: there’s someone there for me?”

>> Nicky: (laughing) “I won!” >> Therapist: “And what do you need now?” >> Nicky: “I want her to give me a big hug.” >> Therapist: “Can you tell her that?” >> Nicky: “‘Could you please give me a big hug; I’d really like a hug.’”

>> Therapist: “And how does she react?” >> Nicky: “She gives me a really big hug.” >> Therapist: “Okay, so she’s giving you a big hug now? And how does that feel?”

>> Nicky: “Great!” >> Therapist: “And what does she say to you?” >> Nicky: “She says: ‘You’re a very sweet girl and

you’re just doing your best, and you shouldn’t be treated like this.’”

>> Therapist: “That’s it...” >> Nicky: “‘And I’ll give you hugs when you need hugs!’”

>> Therapist: “And how does that feel?” >> Nicky: “Very nice, warm and soft...” >> Therapist: “A warm soft feeling?” >> Nicky: “Yes...” 4.4.6 Step 6: Review and discussion The client has stood up for her needs from a healthy, adult perspective and has experienced from the child’s perspective what it's like when someone stands up for you. It is not strictly necessary to return to the safe place before the exercise can be completed. After all, in the exercise your client has already calmed down and her needs have already been validated. Often, time will be an important factor to

complete the exercise without the safe place. However, should that time still be there, the ritual return to the safe place can be a peaceful way to conclude the exercise. Once your client has opened her eyes, the best way to start the follow-up interview is to allow her to relax and then ask her how she feels. The debriefing is an important phase in which the generated emotional experiences now need to be cognitively understood and framed. At this stage, you want the client to look back on the exercise from her healthy adult part. So, first of all, ask the client to make contact with her healthy, adult part, and then start the follow-up interview. In this review, questions such as, 'What have you learned?' are discussed, but the healthy, healing experiences are also discussed in detail: ‘How did it feel to stand up for yourself like that?’ and ‘Where did you feel that? Can you still feel that a little bit?’ Through explicit and extensive attention, these healthy experiences will be better internalized and remembered in the future. Also, try to discuss with the client how she can hold on to these experiences and think of all the possibilities available to you: audio flashcards; written flash cards; repeating certain parts of the exercise at home; listening to (certain parts of) the recording of the session; and so on.

4.5 Chapter summary This chapter describes how to teach clients to do imagery rescripting themselves. A first step is to teach your client to visualize her healthy adult. Healthy memories from the past can serve as a gateway. These memories can make clients aware of the different aspects of such a healthy state of mind. In Appendix 4, you will find a summary of the steps to take in this phase of the exercise. When your client is able to do so, you can coach her in the rescripting of meaningful

images. The whole exercise is preceded by visualizing the healthy adult instead of the safe place. The IR has three different phases at this stage: a phase in which the client visualizes the original image from the perspective of the child/victim; a second phase in which the client rewrites the image from the perspective of the healthy adult; and a third phase in which the client undergoes this rescripting again from the perspective of the child/victim. A summary of these steps can be found in Appendix 5. In the next chapter, we describe how imagery rescripting can also be focused on future trigger situations.

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Chapter 5: Future-oriented imagery rescripting to break negative patterns Chapter summary 5.1 Introduction 5.2 Future-oriented imagery rescripting: preparation 5.3 Future-oriented imagery rescripting: practice 5.4 Chapter summary

5.1 Introduction This chapter describes how imagery rescripting (IR) can be used to generate and edit future-oriented images. Futureoriented images seem to play a role in various difficulties and disorders. For example, Morina and colleagues (2011) found that patients with an anxiety disorder and patients with a depressive disorder had more intrusive future-oriented images with negative content than control subjects who did not. It also appears that depressive patients have suiciderelated mental images in times of crisis (Holmes et al., 2007). Future events can seem to be ‘pre-experienced’ in a mental image, just as memories can be relived (Schacter et al., 2007, 2008). During these future-oriented mental images, the same brain areas seem to be active as during the visualization of past events (Byrne et al., 2007; Schacter et al., 2007). Moreover, future-oriented mental images seem to motivate people. For example, test subjects who visualized

that they were going to vote in approaching elections from a third-person perspective more often actually did so, compared to test subjects who created the image from a first-person perspective (Libby et al., 2007). Editing future-oriented images with IR could therefore lead to meaningful experiences, just as it does when editing memories from the past. Future-oriented IR could thus be an effective way to prepare clients for future events and allow them to practice a healthy way of reacting.

5.2 Future-oriented imagery rescripting: preparation So far, IR has mainly been used to edit the related autobiographical memories or images afterwards, in response to traumatic situations in the (recent) past. IR has been used to generate corrective emotional experiences. In a disorder-oriented IR, for example for specific intrusive images in post-traumatic stress disorder (PTSD), this is the core of an effective treatment (see, for example, Arntz et al., 2013; Øktedalen et al., 2014; Raabe et al., 2015). In such treatments, it is expected that these corrective emotional experiences will result in clients being less bothered by these images in future trigger situations. This is different in the case of personality disorders. By definition, personality disorders are persistent emotional disturbances and behavioural patterns that are difficult to change. The pattern is that a multitude of situations repeatedly activate underlying autobiographical memories and images, with all their related emotional and behavioural symptoms. Editing autobiographical memories is, in this case, often not enough to break these persistent patterns. IR can then be used to prepare clients for future trigger

situations. In this way, they can experience in advance how to handle their emotions and problem situations in a healthy way. First of all, the question then arises as to what this healthy way of handling challenging problem situations is. What is the new, healthy alternative to the dysfunctional behavioural patterns and years of emotional disruption? In a sense, this is the demand for characteristic elements of a healthy adult. Particularly in the literature on schematic therapy for personality disorders in recent years, increasing attention has been paid to the question of how the healthy, adult part of clients can be strengthened. A range of cognitive, emotional and behavioural methods, techniques and exercises have been described that could support this process (Claassen & Broersen, 2019; Claassen & Pol 2015; Roediger et al., 2018). Now that your client has to learn to rewrite the images in a healthy way, it is important to be able to transfer the mentioned cognitive, emotional and behavioural methods and techniques to your client. This range of methods and techniques can be compressed into three core elements – three steps of healthy, mature handling of problem situations: 1. Self-compassion 2. Cognitive restructuring 3. Behavioural change Explicitly explain these three steps of healthy problemmanagement to your client. This explanation is part of strengthening the healthy adult part of the client. These three steps are further elaborated below. It also explains why the above order is important and why self-compassion is

necessarily the first step before striving for behavioural change.

5.2.1 Self-compassion Many clients with a personality disorder have an internalized, self-critical part with which they look at themselves in a punishing, demanding or guilt-inducing way. For example: a client with a compulsive personality disorder feels that he should have done even better; a client with borderline personality disorder is plagued by self-hatred; and clients with an avoidant personality disorder feel guilty about their thoughts or behaviour. The background of these internalized, critical selfevaluations is often a difficult childhood in which the client has been criticized, bullied, abused and/or has experienced a lack of emotional support. Because they have never, or far too little, experienced gentle compassion from others, they have not learned to look at themselves with gentleness and compassion, whereas it is assumed that compassion activates those systems in the brain that calm a person down (see Gilbert 2009). There are different ways to build compassion. Below are some ways you can use while performing IR.

Self-compassion Visualizing the vulnerable, emotional part of your client. Naming emotions: ‘I can see you’re sad, scared, angry.’ Explicit understanding of situational circumstances: ‘Of course you feel that way, because this is a tricky situation, because...’

Explicit understanding of the autobiographical background of emotions: ‘Of course you feel so sad, scared, angry, because of what you have been through, it is even more difficult.’ Take the time for this explicit display of understanding. Adjust the tone of voice: warm, calm, understanding. The calming effect of self-compassion is a necessary condition for thinking about behavioural alternatives and problem-solving strategies in a healthy, realistic way. With a future-oriented IR, your client must first learn to look at herself and her emotional reactions with compassion. If your client is not calm, she probably has a (human) tendency to look for immediate solutions in case of unpleasant feelings and take action. Behavioural reactions that arise from strong, negative emotions are often old survival strategies. Old survival strategies are functional in the short term, but often do not meet your client’s needs in the longer term. Therefore, self-compassion should be the first step in learning to handle problem situations in a healthy way in the future. Many clients find it easier to have compassion for someone else than for themselves. For those clients, it is easier to practice compassion from the third-person perspective first, looking at themselves from a distance in a situation where they feel anxious, sad or alone. Subsequently, the emotional impact can be increased by practicing self-compassion from the first-person perspective.

Self-compassion – Nicky

Following an imaginary fight with her boyfriend, Nicky now has the image of herself as a little girl who is scared and

sad after her father has been angry and derogatory to her. >> Therapist: “Can you understand why she’s so scared and sad?”

>> Nicky: “Nicky: Yes.” >> Therapist: “Can you? Why is that?” >> Nicky: “Well… first of all, it’s not a nice situation, having a fight isn’t nice.”

>> Therapist: “Exactly, the situation itself just isn’t

nice. It’s only natural for you to be scared and sad. That feeling of fear and sadness, do you recognize it?”

>> Nicky: “That’s how I’ve always felt.” >> Therapist: “Exactly, that’s the same pain you’ve been experiencing all your life. And now you’re experiencing it again. Can you tell her that, that you understand why she feels that way?”

>> Nicky: “It’s okay to be sad and scared, that’s

normal. it’s not a physical situation and, especially with everything you’ve been through, it’s quite normal that you’re scared and sad right now.”

>> Therapist: “What does she need when she’s so scared, what do we all need when we’re scared and sad?”

>> Nicky: “I think she needs someone to understand her, she needs warmth...”

>> Therapist: “And how can you offer her warmth other than what you just said?”

>> Nicky: “Uh... know that you’re not alone and that I’m here for you.”

>> Therapist: “That sounds very good. Can you let that in and feel what you feel when you hear those words: it’s quite normal to feel that way, but you’re not alone'?”

>> Nicky: “It makes me feel calmer.” >> Therapist: “It has a calming effect?” >> Nicky: “Yes. What if... …the client is unable to look at herself with compassion? Firstly, you can actively coach clients in such cases in learning to look at themselves with compassion, just as you have offered compassion and understanding in previous sessions as a therapist. In addition, you can investigate which underlying experiences block self-compassion and then edit them, either by means of a cognitive restructuring prior to the exercise or by means of IR.

5.2.2 Cognitive restructuring After the first, soothing step of self-compassion, it is now important to correct negative beliefs. A strongly internalized negative self-image can make your client tend to fall back into negative, critical self-evaluations. In the preceding phases, in which memories were rewritten, this cognitive restructuring implicitly took place when battling antagonists. Future-oriented imagery rescripting prepares your client for situations that may trigger negative selfevaluations. In preparation for this future-oriented imagery rescripting, in which antagonists do not have to be directly visible in the image, an explicit cognitive restructuring of the

assumptions about oneself, the other, the world and the related behavioural patterns is desirable. Your client needs to learn to independently correct such negative selfassessments in the future with specific arguments. Those arguments were collected in the preliminary phase of the treatment. In previous sessions, clients have had a number of corrective emotional experiences due to IR. After each exercise, the meaning of these experiences was discussed and realistic conclusions were drawn, which often differed from the original meaning of the mental images or events. Your client must now learn to apply these realistic conclusions in future problem situations. Prior to the imagery exercise, these realistic conclusions can still be summarized. During the exercise you coach the client in becoming aware, remembering those realistic conclusions with questions like: ‘What’s another explanation for your father’s behaviour?’, ‘Why is it not true that you’re stupid?’

Cognitive restructuring – Nicky Nicky often thinks she can't do anything right and that she's stupid. During the imagery exercises, it has become clear that this self-image is related to negative, punishing messages from her father. In rescripting those experiences, she received healthy, more realistic messages from the therapist and from herself as a healthy adult. These messages included that nothing is wrong with her and that she's certainly not stupid. The debriefing of each exercise was aimed at making Nicky aware of this more realistic view of herself. Now that treatment is focusing more on the future, Nicky must learn to apply these realistic beliefs about herself, others and the world in these future problem situations. During the course of the sessions, more and more arguments have been collected that contradict her father's

negative messages. Prior to the imagery rescripting in the current session, those arguments were briefly repeated.

>> Therapist: “So, it’s actually quite understandable

that she feels so scared and sad – she doesn't think she’s good enough, because she’s heard it so many times.”

>> Nicky: “Yes...” >> Therapist: “What do you make of the idea that she’s

not good enough, that she’s stupid? And I’m now addressing you as that healthy, mature Big Nicky.”

>> Nicky: “Well it’s not true. I’m quite capable...” >> Therapist: “Can you explain that to Little Nicky?” >> Nicky: “Well: ‘You just finished school, and it went well, I... I mean, you just had normal grades.’”

>> Therapist: “Exactly, very good. And, what’s more, what would be other reasons that you’re not stupid?”

>> Nicky: “Well, people have said a number of times that you're smart.”

>> Therapist: “So, is her Dad right when he says she's stupid?”

>> Nicky: “No, not at all. He should never have said that. That’s a really bad thing to say to a child. If you say that to your child, then something’s really wrong with you as a parent.” The application of cognitive restructuring in IR is an important step in strengthening the healthy, mature part of your client. This combined approach (IR with cognitive

restructuring) has been described in detail in various protocols, manuals and articles (see, for example, Grey et al., 2002; Hackmann et al., 1998). For example, you can ask clients to keep a positive log of all experiences that support a more positive, realistic self-image. These experiences can then be repeated in imageries to increase their emotional impact (Fennell, 2016). There are indications that the effectiveness of imagery rescripting doesn’t necessarily increase due to separate pre-exercise cognitive restructuring (Voncken et al., 2019). Nevertheless, experience has shown that the credibility of these realistic arguments is enhanced by speaking out loud during the IR about the concrete reasons why the old negative self-assessment is not correct. For that reason, it is recommended to do this during rescripting.

What if... …your client is unable to look at herself or the problem situations in any other way? Although you have provided a number of arguments during previous IR, which show that the old assumptions are not realistic, it may be the case that your client is not yet able to apply these arguments herself. In that case, it may prove necessary to investigate the credibility of her views cognitively with your client explicitly. Techniques from cognitive therapy, such as role reversal, probability calculation, the pie wedge technique or the courtroom method can help to arrive at more credible, realistic conclusions. These conclusions can then be applied during future-oriented IR. For a detailed description of these cognitive techniques, one can refer to manuals such as Cognitive Therapy: Theory and Practice (Bögels & Van Oppen, 2011) or audiovisual productions such as Cognitive Therapy, Methods and Techniques (Van der Wijngaart, 2016).

5.2.3 Behavioural modification The third step in strengthening healthy, mature problem management is to learn new, healthier behaviours. Several studies have shown that imaginary representation of a behavioural change leads to an actual behavioural change – for example, in eating patterns (Knäuper et al., 2011), sports (Chan & Cameron, 2012), sleeping (Loft & Cameron, 2013) and gambling (Whiting & Dixon, 2013). Future behaviour is changed by imagining that behavioural change rather than by a cognitive, verbal approach (Renner et al., 2017). Visualizing future events or behaviours and their influence on emotions enables clients to experience them in advance (Moulton & Kosslyn, 2009; Schacter et al., 2008; Suddendorf & Corballis, 2007; Kavanagh et al., 2005). In such an image of a future situation, hypothetical scenarios for the future can be visualized along with the reactions that may occur. Prior to IR, you can discuss with your client what other, new behaviour could be more effective in the problem situations. Formulating specific scripts helps your client to visualize this new behaviour. Thus, visualizing specific steps in the pursuit of the goals set is more effective than just thinking about the reasons why those goals are desirable (Hackmann et al., 2011). In the imagery, not only the behavioural change should be visualized step by step, but also the reward or benefits of that behavioural change (Blackwell et al., 2018). Learning new skills is further enhanced when these scripts are repeated frequently (Cummings & Ramsey, 2008; Renner et al., 2017; Hackmann et al., 2011). However, the disadvantage of scripts is that they are not flexible enough for the erratic reality in which situations turn out slightly differently than expected. Therefore, a phased approach is preferable: first working with previously

discussed scripts and then practising a more spontaneous, unprepared handling of future problem situations.

Behavioural modification – Nicky

Nicky wants to learn how to deal with situations in which she feels let down by her boyfriend. She gets scared and angry and fights occur, especially when he goes out with friends without her. >> Nicky: “We're in the living room, and he suddenly puts

on his coat to leave and says that he’s going out with his friends. He just wants to go out with his friends, again...”

>> Therapist: “And how do you feel now?” >> Nicky: “Afraid. That means I’m going to be alone all night. He’s going to leave me behind all alone.”

>> Therapist: “Does that make you sad or angry?” >> Nicky: “Angrier.” >> Therapist: “Where do you feel that in your body?” >> Nicky: “In my throat. I want to scream.” >> Therapist: “And that’s the old pattern, that anger takes over. Do you recognize that?”

>> Nicky: “Yes.” >> Therapist: “Be aware of it, and now try to switch back to Big Nicky. Do whatever it takes, adopt her posture.”

>> Nicky: (sits up straight) “'I’m okay, and I can handle this!’”

>> Therapist: “Very good... and what do you want to say to Mark now as healthy Big Nicky?”

>> Nicky: “I don’t like you going out and wanting to do that without me. I think we should go out together.”

>> Therapist: “How do you feel now?” >> Nicky: “Well, a little nervous.” >> Therapist: “You’re doing very well, acknowledging what you feel but also talking about it. Can you say it again?”

>> Nicky: (a little louder) “I don’t like it that you

want to go out without me all the time, and only want to go out with your friends.”

>> Therapist: “‘That makes me feel alone.’” >> Nicky: “I feel alone.” >> Therapist: “‘And angry...’” >> Nicky: “And angry, and then I feel like you don’t want

to spend time with me. You’re my boyfriend and I want to go out too. I want us to go out together.”

>> Therapist: “‘I need us to spend time together.’ Can you say that?”

>> Nicky: “I need us to spend time together.” >> Therapist: “And now look at Mark. How does he react?” >> Nicky: “I really don’t know; it could be anything.” >> Therapist: “Okay, so now it’s getting a little foggy. We don’t know what he’ll say. But keep in touch with the

feeling you have right now. Where do you feel that in your body?”

>> Nicky: “That it’s more open here.” (indicates chest) >> Therapist: “Just keep in touch with that feeling and

let the image drift away now. Now bring yourself back to the room here, with me... and open your eyes. How do you feel now?”

>> Nicky: “Yeah, all right actually!” In summary, behavioural change through IR means visualizing realistic goals, applying concrete strategies to achieve those goals, and then repeatedly visualizing new skills (Hackmann et al., 2011). Below you will find an explanation of how the future-oriented IR is applied in practice.

What if... …your client is unable to visualize new, healthier behaviour? It is not the case that clients must go through the stages of IR step by step as described in these chapters. The reality is that this process will be much more chaotic. For example, if you have judged that your client is able to visualize previously discussed, new behaviour, it can then turn out that she is no longer able to do that during the exercise. In that case, you will have to coach more actively or, in some cases, go back into the image as a therapist to rewrite it in a healthy way. It is a learning process, which is often a matter of trial and error.

5.3 Future-oriented imagery rescripting: practice

Future-oriented IR integrates various elements from the earlier stages of treatment. In this way, the healthy, mature part of the client is visualized, negative images or scenarios are visualized in response to specific situations, and the course of these scenarios is changed by the client herself from her healthy, mature part. An important difference with the earlier phases is that the situations that are visualized have not yet occurred, but are likely to occur in the (near) future. Future-oriented IR is a way of preparing clients mentally to handle those moments in a healthy, realistic way. A step-by-step plan can also help with future-oriented application of IR.

Roadmap for rescripting future patterns Step 1: Preliminary discussion Step 2: Visualizing the healthy adult Step 3: Visualizing the feared scenario Step 4: Reconnecting with the healthy adult Step 5: Coaching in self-compassion, cognitive restructuring and behavioural modification Step 6: Review and homework

Note: These steps, spread over several sessions, can also be practiced separately. Since each step can take so much time that it is not possible to complete all the steps in one session, the steps can also be spread over multiple sessions. Because of the many steps, and the changes of perspective and the application of complex new skills, the exercise could

soon become confusing for both therapist and client. Therefore, it should be clear that the above steps can also be practiced separately and spread out over several sessions. For example, for some clients it can already be very difficult to make contact with their healthy, adult part when imagining themselves in a problematic situation. For those clients it is useful to practice this step a number of times, over several sessions. Each step is explained in more detail below.

5.3.1 Step 1: Preliminary discussion In this preparatory first step, you explain to your client why the IR should be focused on future problem situations, discuss together which problem situations are likely to occur in the future, and, finally, discuss how your client can best deal with that problem situation. Rationale for future-oriented imagery rescripting In principle, a rationale doesn’t have to be complicated or extensive. Explain to your client that the treatment is now entering a new phase and it is important to prepare for future problem situations. Future-oriented IR uses the power of the imagery to handle problem situations in a healthy, new way. If a short explanation is not enough, you can refer to research that shows that the same brain areas are active when retrieving a past memory and imagining a future situation. You can also explain that, for many years now, sportspeople have used future-oriented imageries to improve performance in the future (Cumming & Ramsey, 2008).

Step 1: Preliminary discussion: rationale for futureoriented imagery rescripting – Greg

>> Therapist: “You’re now ready to enter the past image as a healthy adult and address your father powerfully. Good.”

>> Greg: (smiles) >> Therapist: “We’re now entering a phase of therapy in

which we’ll pay more and more attention to the future. After all the work in which we’ve tried to heal past pain, we’ll now focus on how you’re going to do things differently in the future. Because if you don’t change your behaviour, those old patterns can take over again after a while. So, I want you to be prepared for difficult trigger situations in the future.”

>> Greg: “Okay.” Determine future problem situation You then discuss and determine with your client future situations in which the difficulties and patterns are most likely to be activated. On the basis of the image conceptualization and the treatment so far, you have now formed a good picture of these situations. It is advisable to let your client take the lead in this process, as typical situations from the past may no longer be relevant to her at this stage of therapy. Furthermore, in this phase it is important to transfer more and more control of the treatment to your client in preparation for the end of therapy. Which future trigger situation is most suitable to prepare your client for can be determined by a number of factors: How likely is it that this situation will occur? Is the situation significant for the difficulties? How concrete is the situation?

There is no right or wrong choice, but in order for the exercise to have as much impact as possible you should strive for a balance between these factors. An example of a meaningful event in the future is abandonment by a spouse. If that happens, it is very likely to reinforce your client’s negative self-image and make her feel gloomier. However, if the probability of abandonment is very small, future-oriented IR will have little practical value. So, it would be better to practice with more frequent situations, such as a quarrel with her husband or being criticized. Such situations are more likely to occur, are meaningful to her and can be made concrete. In Greg’s case, he chooses to prepare for Christmas at his mother’s house. While Christmas is an annual event, it is imminent in this case – thus it is concrete and of great significance to Greg.

Step 1: Preliminary discussion: determine future problem situation – Greg

The therapist has just explained to Greg why it can be useful to prepare using imagination for future trigger situations. >> Therapist: “What do you think a difficult situation would be?”

>> Greg: “Well, Christmas is almost here, and my mother

will be counting on us to stay both days. But my wife and I have already talked about the fact that we don’t want to do that.”

>> Therapist: “What you want is...” >> Greg: “What we want is just to have some time to celebrate Christmas as a family, by ourselves.”

>> Therapist: “So, you expect discussing how you want to manage Christmas to be difficult.”

>> Greg: “Yes, because she’s expecting us to spend both

days there. She’d prefer us to come for Christmas Eve too, but that’s not going to happen.”

>> Therapist: “Okay, I imagine that’s a tricky situation

and I think many people have trouble with it. It’s difficult to take account of the needs of others and, at the same time, stay in touch with your own needs. And that’s exactly what we need to work on: keeping you more in touch with your own needs and teaching you to close your eyes a little more to what your mother wants. But that’s difficult, so let’s work on that together today.”

Preliminary discussion of behavioural modification Discuss with your clients how they would like to deal with such problematic situations in a different way. Due to his background, Greg feels responsible for his mother’s wellbeing. Out of guilt, he tends to put his own needs aside and put his mother’s needs and wishes first. Now he wants to learn to hold on to the rational awareness that his own needs are just as important as his mother’s in problem situations, such as during Christmas. He must also learn not to automatically do what someone else wants, but to base his behaviour on his own needs.

Step 1: Preliminary discussion: behavioural modification – Greg

It has been discussed that Christmas is coming soon and Greg's mother will want him to come for a full two days, while Greg and his wife only want to come for a few hours.

>> Therapist: “What do you fear will happen if she insists you come all day?”

>> Greg: “Well, I’ll give in and not say we don’t want to.”

>> Therapist: “And why is that, that you do what the other person wants instead of what you want?”

>> Greg: “I don’t know. I just feel guilty; she's alone,

she doesn’t see us very often, and then I think: well, what difference does it make, those few days.”

>> Therapist: “Exactly, so you feel so guilty that you end up doing whatever she wants.”

>> Greg: “Yes...” >> Therapist: “And that’s exactly the old pattern we’ve been working on so far. But now we also know where that guilt comes from. How come you feel guilty again right away?”

>> Greg: “You mean those past situations, that used to make me feel responsible?”

>> Therapist: “Yes. And we’ve discussed why that isn’t

right. Why your feelings and needs are just as important as someone else’s, if not even more so.

>> Greg: “Yes, because it matters what I think, that I

matter... and I know that, but I just feel sorry for her when she’s so alone.”

>> Therapist: “That’s why we have to do this exercise,

Greg. I want you to try to apply all the insights you have now and find another way forward rather than just giving in

to the other person to get rid of your feelings of guilt. What other way would there be to respond to your mother?”

>> Greg: “That I don’t want that?” >> Therapist: “Sounds good, because you don’t want to

stay both days, just a couple of hours. Maybe you can say to her that you understand she would have wanted things to be different, but that’s just the way it is?”

>> Greg: (Remains silent) >> Therapist: “I understand that you find it difficult to

imagine that you’d react like that, but that’s why we do these exercises – so you can imagine yourself more and more saying that and build up to a point where you can really say it to her.”

>> Greg: “Okay...” >> Therapist: “In the meantime, I want you to stay kind to

yourself Greg. Remember, healthy and mature in the first place means that you have to stay kind to yourself. It’s quite understandable that these are difficult situations for you, but try to remember that your needs matter; you matter, and that means you can do what you need.”

>> Greg: “Yeah, okay, yeah…” >> Therapist: “Let's practice this, so you can feel and

experience what it's like. Now we’re just talking about it, but in the imagery exercise you can experience a little of what it would really be like.”

>> Greg: “Okay.”

5.3.2 Step 2: Visualizing the healthy adult Rescripting patterns in the future should be done from the healthy, mature part of clients. The exercise starts with visualizing the healthy adult. Try to let your client visualize this positive self-image as vividly as possible, paying attention to different sensory aspects, such as posture, physical sensations and so on. As in the previous phase of treatment, this step covers the client’s healthy, mature part with ‘primer’, so that the client will soon be better able to deal with strong emotional and behavioural reactions in trigger situations. The first exercises with future-oriented IR in particular help to recall the three steps of healthy problem management: compassion; cognitive restructuring; and behavioural change.

Step 2: Visualizing the healthy adult – Greg

The therapist and client have just discussed how Greg would like to deal with the situation in which he refuses to spend all of Christmas with his mother, which is what she wants. >> Therapist: “In situations like that, we really need the

healthy adult – the strong Greg, who can stay in touch with his own feelings but at the same time is able to deal with difficult, challenging situations. One way to prepare for situations like this is to close your eyes, right now. Just close your eyes... and I’ll ask if you can make contact with this healthy, mature part of yourself. The Greg who is strong, but not in a tough, enclosed way – the strong, healthy adult. I think of that Greg who is strong, but who also feels free, opens up, is in contact. Be that healthy, Big Greg; sit like that healthy Greg sits. Adopt a posture that suits him. How do you feel now you’re a healthy adult?”

>> Greg: “I feel balanced, strong, relaxed and I feel I can move freely.”

>> Therapist: “That sounds very good. It sounds like the healthy, mature part of you.”

5.3.3 Step 3: Visualizing the feared scenario The next step is to ask the client to create images of the feared future trigger scenario, and to recognize the old negative patterns of feelings and behaviour. Ask your client to describe these images as vividly as possible, so take your time. Invite your client to empathize from a first-person perspective, as if the situation were happening right now. If necessary, ask her to freely fantasize what such a situation looks like. Ask for sensory experiences: ‘What do you see now?' ‘How can you see that (the antagonist) is angry?’ ‘What does (the antagonist) say now?’ ‘How does his voice sound when (the antagonist) says that?’ The goal of future-oriented imagery is, first and foremost, to practice awareness. Awareness of automatic emotional and behavioural responses and their origins is the necessary first step for healthy emotion regulation and change of behavioural patterns. When imagining a future trigger situation, you ask the client to be alert to automatic emotional and behavioural responses. By slowing down, or sometimes pausing the image in the imagery, you can create possibilities for that awareness. Emotional awareness is stimulated by asking questions on a regular basis: ‘What do you feel now?’ ‘Where do you feel that (emotion) in your body?’ Awareness of behavioural patterns is stimulated with questions such as: ‘What would you like to do now?’ and ‘What are you inclined to do now?’ In the diagnostic phase of the treatment, insight was

gained into the original autobiographical memories of the events that led to these conditioned emotional and behavioural responses. This insight was further enhanced during treatment, when the same connections were made time and time again between the difficulties and the original memory. With future-oriented imagery, your client learns to make the connection between automatic responses and original memories as soon as possible when those difficulties arise. Your role as a therapist is to help your client see this connection: ‘Do you recognize this feeling? Where does it come from? So now you feel the child you once were, the child who also felt frightened and threatened?’

Step 3: Visualizing the feared scenario – Greg

Greg has prepared himself for the future problem situation, has activated his healthy adult and is now starting the actual exercise. >> Therapist: “Now, I’d like to ask you to focus on that Christmas situation. Get a picture of that situation where you talk to your mother about how you want to spend Christmas.”

>> Greg: “I’m in the kitchen, by the sink, on the phone with my mother.”

>> Therapist: “Do you see yourself, or are you standing there right now – as if you’re really there?”

>> Greg: “I have the phone in my hand.” >> Therapist: “All right, let’s play the movie then. Just

talk to your mother and let me listen in. What do you say to

your her?”

>> Greg: “Mum, we’ve been thinking about how we want to

spend Christmas this year, and we’ve decided not to stay with you both days. We’ll arrive at about ten o’clock and stay until about two o’clock in the afternoon.”

>> Therapist: “Now listen to her reaction. What’s she saying?”

>> Greg: “Uh, she makes that disappointed sound...” >> Therapist: “What kind of sound is that?” >> Greg: “A sound like ‘Oh...’ And then there’s a long silence, and then she says: ‘I thought you’d stay both days. You always stay both days.’”

>> Therapist: “How does her voice sound?” >> Greg: “She sounds hurt, like I ruined Christmas for her.”

>> Therapist: “Now find out how you feel, listening to

your mother make that disappointed sound, like you ruined her Christmas. How does that make you feel?”

>> Greg: “I expected her to react like that. It’s almost like I caught a ball that I have to throw back now.”

>> Therapist: “How exactly does that feel when you listen to the sound of her voice?”

>> Greg: “I can feel the tension rising from my neck all the way up to my jaw.”

>> Therapist: “What emotions do you feel?”

>> Greg: “The first feeling is I just have to give in and say: ‘Oh, we’ll stay all day.’ But I don’t want to, so I’ll keep going.”

5.3.4 Step 4: Reconnecting with the healthy adult Your client should now reconnect with the healthy adult, which was visualized prior to the exercise. Shifting the focus is an important part of this exercise; your client learns to make (or maintain) contact with a healthy, mature self-image, even when old emotional and behavioural patterns are activated. When the latter occurs, your client may find it difficult to connect with the healthy adult. That is why it is good to practice this step of the exercise a number of times first. In this way, you can ask clients who have made contact with their healthy adult to become aware of the old emotional responses that were activated by the imagery and then reconnect with the healthy adult. Sensory and cognitive aspects, and the posture of the healthy adult can now help to make the transition from activated old pain to a healthy adult response. For example, ask your client to adopt a posture that suits that healthy, mature state of mind. In this way, your client can shrink when old emotional pain is experienced and then sit up straight when contact has been made with the healthy adult part.

Step 4: Reconnecting with the healthy adult – Greg

Greg has just visualized how the interaction with his mother could take place, and how he then starts to feel guilty and tends to give in to her wishes instead of standing up for his own needs.

>> Therapist: “But I don’t want Little Greg to be

overwhelmed by this. I want the strong Greg to deal with this. So just take a moment to reconnect with Big Greg. Adopt the posture that fits, able to move freely, strong, in contact.”

>> Greg: (sighs and sits up straight) >> Therapist: “Be that Big Greg. How do you feel now?” >> Greg: “Calmer... more relaxed. I’m breathing more easily.”

>> Therapist: “Enjoy that, be aware of this feeling, this experience... realizing that this is your healthy, mature side. Do you feel that tension just now?”

>> Greg: “Yes... in my jaw.” >> Therapist: “Now focus your attention on that, feel that tension, like you’ve ruined your mother’s Christmas...”

>> Greg: (frowns) “Yes... like I have to make it up to her. She’s sad and it’s my fault.”

>> Therapist: “Be aware that you’re experiencing that old

feeling again, but that you can let go of it now. I want you to turn your attention back to yourself as Big Greg. Sit up... take that breath... try to look at that image of Big Greg.”

>> Greg: (sits up straight, sighs deeply, twists his head as if to relax a bit around his neck)

>> Therapist: “How do you feel now?” >> Greg: “Um... better. I’m breathing more easily.”

5.3.5 Step 5: Coaching in self-compassion, cognitive restructuring and behavioural modification In this phase, the three steps of the healthy adult are practiced: self-compassion, cognitive restructuring of beliefs related to the difficulties, and breaking through negative patterns by visualizing behavioural alternatives.

Self-compassion Your client should first learn to look at herself with gentleness and understanding, even at times when she tends to evaluate herself critically and falls back into old behavioural patterns. This gentleness soothes and slows down emotional reactions, which allows one to break through old patterns more easily.

Step 5a: Coaching in self-compassion – Greg

Greg has connected with his healthy adult and starts applying the skills of a healthy adult: compassion, cognitive restructuring and behavioural change. >> Therapist: “But before you go through with it, I want

you to take a moment to realize that this is a very normal reaction. Why is it so understandable that you feel this way now?”

>> Greg: “I just find it awkward when she’s like this.” >> Therapist: “Like what?” >> Greg: “When she’s so hurt.”

>> Therapist: “Exactly: you feel that sensitive, emotional

side of you, Little Greg, reacting to a situation that would make anyone tense. It’s not nice to hear you’re ruining her Christmas. This feeling you’re experiencing now comes from that little boy who has so often felt tense and guilty. Could you say that literally, to the little Greg you’re feeling right now?”

>> Greg: “Hm... ‘It’s okay, she feels hurt, and now it feels like it’s your fault.’”

>> Therapist: “‘Of course you feel bad, because it’s just hard when your mother feels so hurt.’ Can you say something like that?”

>> Greg: “Hmm... ‘Of course you feel so bad now, because everyone would feel that.’”

>> Therapist: “And especially with what she has accused you of in the past...”

>> Greg: “Yes... ‘She always made you feel like you

weren’t good enough, that what you did was never good enough.’”

>> Therapist: “I think we can understand why he’s feeling so inadequate again, right? Seems like a perfectly normal reaction to me.”

>> Greg: “Yeah... yeah, I guess so.” >> Therapist: “Can you say that to him?” >> Greg: “‘It’s quite normal for you to feel so bad right now.’”

>> Therapist: “‘There’s nothing wrong with your emotional system...’”

>> Greg: “‘They’re very normal reactions, there’s nothing wrong with you...’”

>> Therapist: “How do you feel about these words?” >> Greg: “Yeah, more relaxed.” Cognitive restructuring Now, all rational arguments from previous sessions that contradict the negative self-image must be recalled. In this phase, your role as a therapist is mainly to guide and coach. However, if you notice that your client is not able to remember these rational arguments during the IR, you can become a bit more active in supporting cognitive restructuring.

Step 5b: Coaching in cognitive restructuring – Greg

Now that Greg has calmed himself down a little with the help of self-compassion, there’s room for activating the realistic arguments that contradict the old beliefs. >> Therapist: “Why is it not true that you’re failing? That you’ve done something wrong?”

>> Greg: “It’s not weird to want to have some time for my own family over Christmas... and it’s not like I never visit her.”

>> Therapist: “And is it ever good enough for her, no matter what you do?”

>> Greg: “No, no, it doesn’t seem to matter what I do. She’s never satisfied anyway.”

>> Therapist: “What do you think of someone who expresses his own needs?”

>> Greg: “I’m just envious of that.” >> Therapist: “Can you explain these considerations directly to Little Greg?”

Behavioural modification The previously discussed script can now be visualized, or you can coach your client in devising behavioural alternatives on the spot. Focus on details: what exactly do you say, in what tone, with what posture? The more vivid and detailed the picture, the more impact it has and the more credible this future behaviour becomes for your client. A simple way to support this internalization is by repeating the visualized behaviour.

Step 5c: Coaching in behavioural modification – Greg

It has just been repeated why it isn’t at all wrong for Greg to have his own Christmas plans. Now is the time to visualize how he really wants to deal with this situation in a different way. >> Therapist: “Very good, be Big Greg. How would you like to respond to your mother now?”

>> Greg: “‘I'm sorry you feel that way. But that’s your problem and you’re going to have to learn to deal with it.’”

>> Therapist: “Wow, very good. Can you say it again?” >> Greg: (A little louder) “‘I’m sorry you feel that

way, but that’s your problem, and you’ll have to learn to

deal with it!’”

>> Therapist: “‘This is my life... and I have to take care of it myself.’ Can you say something like that?”

>> Greg: “Mm... ‘This is my life, and I have to take care of myself and my family. And yes, you’ll always be part of my family, but my family now starts with my wife and children.’”

>> Therapist: “How do you feel now?” >> Greg: “Well, it feels good to make my point.” >> Therapist: “It sounds very good. Where do you feel that in your body?”

>> Greg: (points to the middle of his chest) “Right here, in the middle.”

>> Therapist: “Wow, enjoy that good feeling. You’re doing

really, really well. And stay in touch with that feeling. Now I want you to end the conversation as Big Greg. So, what do you, Big Greg, want to say to your mother?”

>> Greg: “‘I’ll call you again in a week and hopefully

you’ll feel better when you’ve had a chance to get used to the idea.’” You can vary the exercise by adjusting the scenario a little. For example, you can make the practice more difficult if you notice that your client is quite capable of handling the problem situation in a healthy, mature way. By making the exercise a little more difficult, you prepare your client for a reality in which unexpected, challenging events sometimes occur that you have to deal with on the spot.

Step 5d: Coaching the healthy adult with harder variant – Greg

Greg turned out to be quite capable of dealing with this problematic situation from a healthy adult’s perspective. In an effort to further strengthen Greg’s healthy adult, the therapist suggests a few more difficult moments that could arise. >> Therapist: “And then your mother sighs, and she stays quiet for a few seconds. How do you react?”

>> Greg: “I say: ‘It’s going to be okay, Mum, you’re going to be okay.’”

>> Therapist: “And then she says: ‘Well, if this is what you want...’”

>> Greg: “Yes, ‘If this is what has to be done, so be

it,’ and I say: ‘Yes Mum, this is what will happen.’”

>> Therapist: “Good, very good. And now you hang up the phone.”

5.3.6 Step 6: Review, discussion and homework At the end of the imagery rescripting, not only will the exercise itself be discussed, but arrangements will also be made to repeat it at home. Repetition and practice are necessary to master the behavioural change and increase the chance that your client will be capable of putting this into practice in the real world and the problem relationship.

Step 6: Review, discussion and homework – Greg

>> Therapist: “How do you feel now?” >> Greg: “A bit tense, nervous, but all right, I’m glad I did it.”

>> Therapist: “You’ve done very well, and I understand

why you feel nervous as well as good. They’re both there: the emotional, vulnerable feeling and the strong, healthy side of you. And that’s the reality, that both sides exist. I want you to let go of the image now and come back to the room with me. And maybe you could move your hands and feet so you’re reconnecting with your body. And when it feels good for you, you can open your eyes. Wow, that was great, Greg! I’m really impressed.”

>> Greg: (smiles) >> Therapist: “I knew you could do it. You’ve worked so

hard these past sessions. Anyway, these are really tricky, challenging situations. It’s so hard to listen to your mother when she feels hurt, especially for you, with everything you’ve been through in your childhood. So I’m impressed. I also realize that this is just part of the work; in real life it might just be a little bit different. So, it will be good for you to prepare for that, by practising this a few times. You can be really proud of yourself now, but I’d like to continue working on it in the coming sessions. How does that sound?”

>> Greg: “All right, fine.” >> Therapist: “Let’s see when you’re going to practice

this. Are there any fixed moments in the day when you could take some time for this?”

>> Greg: “I think so... in the evening, after dinner should be okay.”

>> Therapist: “That’s fine. Then I think it might be

helpful to use the recording you made of this conversation to do the exercise. But if you notice that you’re doing okay, then I think it’s also okay to try to do it without the recording.”

What if... …you, or your client, find all these steps complicated and lose track? The above steps are designed to perform a future-oriented IR in such a way that your client can prepare in their imagery for trigger situations in which old patterns threaten to take over. However, there are many different steps, with different perspectives and different actions that need to be visualized. This can make it somewhat confusing for your client and perhaps also for you. Bear in mind that the steps are a guide and not a prescriptive protocol. So, feel free to simplify them by, for example, only visualizing the desired behaviour in a future trigger situation and not, in the first instance, asking your client to become aware of old patterns. Visualizing a healthy problem management alone makes the exercise easier and is still good preparation for the future. Another option is to split the entire future-oriented IR into separate steps, with a brief discussion in between each time. If you choose to follow that approach, you can also choose to spread the whole exercise over several sessions.

5.4 Chapter summary This chapter describes how IR can help your client prepare for future trigger situations in which she is at risk of falling into old patterns. Future-oriented IR seems to be good preparation for trigger situations, as it does not appear to make any difference to the brain whether someone

imagines a past or future situation – the same areas are activated. To prepare for this future-oriented rescripting, the client must learn to visualize a more positive, competent self-image: the healthy adult. She first practices visualizing a healthy, mature part of herself in neutral circumstances. When she is able to do this, she can prepare for challenging trigger situations that may occur in the future. During future-oriented IR, your client visualizes herself handling future problem situations in a healthier way by connecting with her healthy adult. The chapter describes how this healthy problem management can be reduced to three steps. The first step is self-compassion – to gently and comprehensively acknowledge that not only is the situation difficult in itself, but that learning experiences in the past also make it difficult to manage these problematic situations adequately. This self-compassion is a necessary condition for being able to think calmly and realistically about why old ideas are inadequate in the situation in question. This second step, the cognitive restructuring of old, dysfunctional assumptions, leads to the third step, that of behavioural change. In this, a new, healthier behaviour is tried out. A summary of the steps of a future-oriented IR can be found in Appendix 6. The next chapter describes how you can apply all the skills learned so far to specialist areas of treatment, such as addiction and nightmare disorder, or when editing flashforwards in the case of depression, obsessive-compulsive disorder or social anxiety disorder. Other forms of imagery will also be described, such as positive imagery.

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Chapter 6: Specialized fields of application and forms of imagery rescripting Chapter summary 6.1 Introduction 6.2 Specialist areas of application 6.3 Specialist forms of imagery rescripting: positive imagery 6.4 Chapter summary

6.1 Introduction In this chapter you will learn how to apply the imagery rescripting method to various issues such as addiction problems, nightmare disorder and flash-forwards in depression and obsessive compulsive disorder. IR for these disorders will in many ways not differ from what has already been presented in this book: meaningful images are visualized and changed in the same way. However, in this chapter you will learn to conceptualize the disorders in such a way that it becomes clear why you can also use IR with them. Finally, this chapter also describes other forms of imagery exercises, such as positive imagery and cognitive bias modification.

6.2 Specialist areas of application 6.2.1 Imagery rescripting in addiction problems

So far, we have mainly described mental images that are experienced by clients as negative and aversive. However, in some disorders, images appear with content that is less aversive, or even experienced positively. In addiction problems, for example, images of a drug’s use can evoke a desire for it (see May et al., 2004). Imagining behaviour increases the chance of performing that behaviour (Libby et al., 2007), and vivid, positively experienced images about using a drug can thus lead to its actual use. Because of the strong short-term effects of drug use, the client gets more positive images about using the drug and a vicious circle is created. Breaking this pattern using IR contains two core elements. Firstly, the underlying, meaningful experiences from the past that have contributed to the addiction problem can be edited. In addition, future-oriented imageries (see chapter 5) can contribute to breaking the behavioural patterns of drug use. These two key elements of the treatment are further elaborated below.

Processing the underlying reasons for the addiction problem The background to the addiction can vary greatly from client to client, but a common feature is that the use of the drug has served a function. For one client, the first use of the drug may have been a way to escape from loneliness or insecurity. For another, a way to feel connected to others, and for another a way to satisfy impulses from a lack of frustration tolerance. The diagnostic imaging identifies the meaningful experiences that have contributed to the use of the drug. IR then focuses on validating the underlying, frustrated, basic needs so that the use of the resource with that function becomes redundant. These healthy experiences can contribute to breaking the addiction. It is preferable

that the client is soberly present in the sessions and that the addiction has already been scaled back. The treatment of the addiction problem thus follows two tracks: on the one hand reducing the addiction and on the other hand starting up IR.

Identifying autobiographical memories associated with the addiction – Brian

>> Therapist: “How have you felt in the last week?” >> Brian: “It was okay... well, it was tough over the weekend, and it almost went wrong, but yeah, I held it together.”

>> Therapist: “So, the weekend was tough. in what way?” >> Brian: “Hm.... I had nothing to do, and then I called a friend, but he didn’t have time, and then... well, I just sat there thinking I wanted a drink.”

>> Therapist: “Okay, so you didn’t have anything to do

and felt unhappy about it, and then the thought of alcohol came to you, is that right?”

>> Brian: “Yes.” >> Therapist: “You explain it very clearly, and as you

describe it. It’s as if you see the situation in front of you again, as if images are coming up with the words. Do you recognize that?”

>> Brian: (nods approvingly) >> Therapist: “Then I’d like to ask you to close your

eyes and let those images appear, and then describe what you see. So, close your eyes, and think back to the weekend and

to the situation when you really wanted to meet up with that friend, but it didn’t happen. What do you see now?”

>> Brian: “I don’t know... it’s more like I’m hearing him say that again, that he had an appointment with his brother... he sounds... I don’t know.”

>> Therapist: “That’s okay, let it happen. What do you see now? You’re on the phone with him?”

>> Brian: “Yes... I’m sitting on the couch.” >> Therapist: “And he’s talking about the meeting with his brother.”

>> Brian: “Yes... and he’s happy, I can tell.” >> Therapist: “And how do you feel now?” >> Brian: “Just... bad... like I have to figure it out myself... something like that.”

>> Therapist: “It also sounds like you might feel a bit lonely, but I don’t know if I’m understanding that correctly?”

>> Brian: “Yes.” >> Therapist: “Where do you feel that in your body while

you’re sitting on the couch, your phone to your ear and you hear Harry talking so happily about his meeting?”

>> Brian: “Pressure... here.” (points to his chest) >> Therapist: “Concentrate on that and the feeling of

having to figure it out for yourself, that unpleasant feeling that you’re now feeling. Now let this image fade away, but hold on to that feeling of being alone and having

to work it all out for yourself. What images from your past come to you now?”

>> Brian: (Remains silent) >> Therapist: “The feeling of being on your own, having to

solve it yourself, and the other person is busy with other things, has no attention or support for you ... that feeling in your chest ... where do you recognize that feeling from?”

>> Brian: “I don’t know, I don’t get it... I see my Dad... but he’s just working.”

>> Therapist: “Describe what you see.” >> Brian: “He’s sitting at the table and he’s working on something... and I want him to come, I want him to help me. I’m working on something... something from school.”

>> Therapist: “And do you see yourself now?” >> Brian: “Yes... I’m standing there... waiting.” >> Therapist: “How old is that little boy you're seeing now?”

>> Brian: “Twelve... something like that.” >> Therapist: “Now try to put yourself in the shoes of

that little boy of twelve, be that twelve-year-old... and you’re standing there waiting, looking at your father. What does your father look like?”

>> Brian: “Absent... he’s just very busy.” >> Therapist: “And how do you feel now, looking at him like that?”

>> Brian: “That it doesn’t make any sense, whatever I want... he doesn’t have time.”

>> Therapist: “No time for you?” >> Brian: “No... as if it wasn’t important enough.” >> Therapist: “So, what’s happening now?” >> Brian: “I’m going to watch TV.” >> Therapist: “What are you watching?” >> Brian: “Doesn’t matter... anything, I’m just watching TV.”

In the review of this image, it becomes clear that there has been a lack of emotional care and connectedness in the client’s past, as a result of which he often felt unimportant, lonely and sad as a child. In the recent situation, in which he vainly wanted to make an appointment over the weekend, this old feeling of not being important enough and the associated feelings of sadness and loneliness seem to have been activated. As in the past, there is a strong tendency to alleviate this emotional pain through distractions. It used to be the TV and, later, alcohol became the remedy. In the rescripting exercise, connection, attention and care are offered as healing experiences for the losses that have been experienced in the past.

Rescripting the meaningful autobiographical memories – Brian

After the image from the past has been visualized, the therapist has just asked if the client can place the therapist in the picture.

>> Therapist: “What’s it like for you that I’m here?” >> Brian: “Strange... but okay.” >> Therapist: “Alright, I understand it feels a little

awkward, but I’m here to help you and I’m glad I’m standing next to you right now. I’m glad it feels okay for you. I want to say something to your father right now, and all you have to do is listen and feel what that’s like. Okay?”

>> Brian: “Okay.” >> Therapist: (with head slightly turned away, as if

talking to father) “‘Your son has been standing here for a while now waiting for you to help him, but it seems like all kinds of other things are more important to you than helping him. That’s not good. That makes him sad and makes him feel he’s not important.’ How does he react?”

>> Brian: “He shrugs his shoulders, like: ‘Yeah, so?’” >> Therapist: “Okay.” (to father) “‘No, that’s not

something you can just shrug your shoulders about! This is about your son, and he matters! If someone were to tell me that my child feels unimportant and sad because of what I’m doing, I would be scared to death. I would want to hold him and reassure him that he’s the most important thing in the whole world. And this is your reaction, shrugging your shoulders? You can’t do that!’” (to client) “How does he react?”

>> Brian: “He looks a little annoyed... he’s not used to being addressed like this by others and he gets angry.”

>> Therapist: “Just keep looking at me. Don’t mind your

Dad, I’ll make sure things stay safe. And how do you feel about what I’m saying?”

>> Brian: “That it’s nice that someone’s standing up for me.”

>> Therapist: “Very good, it’s good you feel that. Where do you feel that in your body?”

>> Brian: “Here.” (points to belly) >> Therapist: “Put your hand on your belly then, keep in touch with that feeling, let the image of and listen to my voice. You’re important matters. Of course you want some time and not crazy, that’s not a burden! There’s you. Do you understand?”

your father fade, and what you feel attention. That’s nothing wrong with

>> Brian: (nods) >> Therapist: “How do you feel now?” >> Brian: “Yeah, better... less tense.” Rescripting the memory has been a successful exercise. However, in addiction, the strong, positive short-term effects of using a drug make this a persistent problem that is often remedied simply by editing past experiences. Therefore, in addition to IR from past experiences, it is important to practice with future-oriented IR, which teaches your client to deal with the frustrations and desires aroused by abstinence from, or exposure to, drug-related situations. In these exercises, your client will have to learn to remain compassionate to herself when the urge to use the drug is activated, to keep in mind the arguments as to why the desire to use the drug is not the real unsatisfied need, and then also to visualize concretely how she can deal with these activating situations in a different way.

6.2.2 Imagery rescripting for nightmares In Chapter 1, it became clear that there are two different approaches to applying IR to nightmares. Imagery rehearsal therapy (IRT), developed and researched by Krakow and colleagues (2001, 2006, 2010), is the first choice for a nonmedicated treatment of nightmare disorders within mental health services. This therapy consists of two components: cognitive restructuring of thoughts about (having) nightmares; and rewriting the storyline of the nightmare. This new, rewritten scenario is then repeated in one’s mind every day. A second approach, relating more closely to the IR described in this book, was developed by Kunze and others (Kunze et al., 2016, 2017). They were the first to conduct a randomized, controlled study of the effect of IR compared to imaginary exposure and showed that IR can be an effective, standalone treatment for nightmare disorder. IR for this disorder is described below according to the protocol used in this study (Kunze et al., 2016, 2017). During the intake, a ‘core’ nightmare is identified that will be processed using IR. The core nightmare should be a common nightmare, emotionally charged, and an example of a recurring theme in the client’s troublesome nightmares (e.g. being chased, being killed or similar). Because of the short nature of the treatment, the focus is on this core nightmare.

Describing the nightmare – Jane

>> Therapist: “I want to ask you now if you can describe

to me the nightmare that’s most common, and that causes you the most tension. The nightmare you’d most like to reduce the frequency of. Can you describe that nightmare the way

you’re experiencing it, like you’re describing a movie, so I can see it as well?

>> Jane: “I’m very small, two or three years old, in a

crib at home. And I’m lying there alone, and then my Mum, Dad and my boyfriend come in, and they just stand there and watch me looking very angry, disappointed. And I’m asking them not to, but then they just leave the room, and I cry, really, really cry, but no-one comes back. And then I’m big and I can get out of the crib and go to the door, and when I open the door and walk down the hallway, the whole house is dark, there’s no one there. And then I go out into the street, but the whole street is dark too, the streetlights are out, and everything is dark, very quiet; no cars, no sounds, and I walk on and on and on... and there’s nobody, anywhere.” The effectiveness of the treatment of this disorder can partly be deduced from a reduction in the frequency of nightmares. So do not forget to ask during each session how often this core nightmare occurred in the past week, and how stressful it was, and record this information. Then you explain the thought behind IR, the rationale for the treatment. Try to keep the explanation of the IR as clear and simple as possible, and check whether your client has any questions or doubts after your explanation.

Explanation of the rationale for imagery rescripting – Jane

>> Therapist: “Today, I want to work with you on your

nightmare using the imagery exercise I told you about. I’m about to ask you close your eyes and evoke images of the nightmare you described. I want you to describe the nightmare as if you’re in it right now, and for that reason it may help to talk about it in the present tense, so ‘I’m

lying in the crib’. It also helps to pay attention to details. This allows the images to cause more tension, but it’s important that you allow yourself to experience all the feelings that come when you have this nightmare. To begin with, the exercise may be tough for you, but we’ll change the ending of the nightmare today to make it easier. You can do whatever you want; you can use your imagery, you can do it more realistically, whatever feels good for you. I’ll occasionally ask you how you feel and what else you need. Do you have any questions about what we’re going to do?”

>> Jane: “No, I don’t think so.” >> Therapist: “Okay, how anxious do you feel about this

nightmare right now? When you think about having to recall that nightmare in a moment?” The IR of the nightmares takes place in two phases. In the first phase, you ask the client to evoke the nightmares in the imagery. This phase is meant to activate the nightmare.

Activation of the nightmare – Jane

>> Therapist: “What do you see now?” >> Jane: “I’m in the crib, in the corner of my room. I’m still very small, two or three years old.”

>> Therapist: “What do you see when you look around you now?”

>> Jane: “There are no toys in the crib. I can look up, and it’s very dark.”

>> Therapist: “And now that you’re lying there. What do you smell?”

>> Jane: “I don’t really smell anything, maybe the sheet.”

>> Therapist: “Focus your attention on that smell, but also on what you hear now.”

>> Jane: “It’s really quiet. I can’t really hear

anything, it’s quiet as if I’m in a bubble... I don’t really hear anything.”

>> Therapist: “Just describe what’s happening.” >> Jane: “Mum and Dad and my boyfriend are all coming into

the room, and they’re all watching me, embarrassed, and angry, and disappointed. They look at me like: ‘She’s done everything wrong.’ They look really angry... yeah... that it’s all my fault.”

>> Therapist: “And how do you feel when you see the way they look at you?”

>> Jane: “I feel very sad... and as if they don’t love me at all.”

>> Therapist: “Can you feel that sadness in your body too?”

>> Jane: “Yes.” >> Therapist: “Where do you feel that?” >> Jane: (points to her chest) “I can feel it here.” In the second phase, your client changes the course of the nightmare in a way that she chooses.

Rescripting the nightmare – Jane

>> Therapist: “What else would you like to change?” >> Jane: “I want them to smile at me and look at me, like, it’s okay, we love you... just being nice.”

>> Therapist: “Just see that in front of your eyes, like

it’s happening right now... can you tell me what you see?”

>> Jane: “Mum comes to the crib, and the other two follow her, and they’re standing over me, and Mum bends over and picks me up.”

>> Therapist: “And is she smiling?” >> Jane: “Yeah, she gives me a kiss.” >> Therapist: “And how do you feel?” >> Jane: “Very happy and safe and warm, loved.” >> Therapist: “Is there a place in your body where you can feel that feeling?”

>> Jane: “In my chest.” >> Therapist: “Make contact with it, and enjoy it... let it flow through you.”

The exercise is followed by a follow-up discussion in which clients are asked again about the tension they experience when they think about the nightmare. These measurements give an indication of the effectiveness of the exercises. Then, in the remaining time, IR is done again, or even repeated several times, relating to the core nightmare, each time asking what your client would want to change, what she needs. This can mean practising three or four times in one session with a different rewritten course of the nightmare each time.

6.2.3 Imagery rescripting for flash-forwards The literature on mental images in psychopathology focuses on intrusive images from the past, such as the reliving of posttraumatic stress disorder (PTSD) (e.g. Ehlers et al., 2004; Grey & Holmes, 2008; Krans et al., 2009) and intrusive memories in depression (e.g. Newby & Moulds, 2011a; Patel et al., 2007). However, there is also an increasing interest in the troublesome imagining of future events (see, for example, Schacter et al., 2008). Future-oriented imageries can also be intrusive, unpleasant images. These are called flashforwards, in contrast to the obtrusive memories of past events, the flashbacks. A flash-forward is defined as ‘the experience of intrusive, undesirable and unpleasant mental images of events in the future’ (Deeprose & Holmes, 2010). Flash-forwards to unpleasant images of possible future situations occur with anxiety disorders (Engelhard et al., 2010a; Morina et al., 2011) and other disorders such as schizophrenia (Malcolm et al., 2015). In table 6.1, examples are given of flash-forwards for different disorders. Flashforwards in depression can be images in which patients see themselves committing suicide (Holmes et al., 2007). These obtrusive images can be accompanied by the fear and despair of a hopeless existence of unbearable suffering. However, for some depressed patients the images have a reassuring meaning, in which death is a way out of their suffering, or are experienced as a reflection of their strong feelings of worthlessness. In such cases, the flash-forwards are not entirely without risk: since mental images seem to influence future behaviour (Libby et al., 2007), a flash-forward about committing suicide could increase the likelihood of actual suicidal behaviour. Depressive patients who have attempted suicide report having had flash-forwards about suicide prior to that attempt (Holmes et al., 2007).

Table 6.1 Examples of flash-forwards for different disorders Disorder

Examples of flash-forwards

Obsessive-compulsive disorder

Seeing someone stabbed (Speckens et al., 2007).

Depression

Seeing oneself commit suicide (Holmes et al., 2007).

Social anxiety disorder

Seeing one’s face bright red in a social situation (Hackmann et al., 2000; Stopa & Bryant, 2004)

Holmes and colleagues (2007) described the possibility of using IR to change the outcome of the flash-forward, or the vividness of the image. Flash-forwards can then be rewritten, just as memories from the past can be edited. If flashforwards play a perpetuating role in several disorders, then IR of those flash-forwards could be an alternative treatment intervention. Thus far, the research into flash-forwards and the editing of those images is very limited. The following description of IR for flash-forwards should therefore only be seen as an additional, alternative option if insufficient results have been achieved with existing, proven interventions. The choice of how to rewrite a flash-forward will depend on its meaning, as rescripting will be interpreted differently by the clients depending on their specific underlying need.

For example, a depressed client who feels anxious about an image in which she sees herself taking an overdose of pills can visualize that she is flushing the pills down the toilet. It is also possible to rescript the despair in the image by stepping into it and offering understanding and comfort. However, rescripting could have a very different effect for a depressed client experiencing a flash-forward about suicide in part as a way out of their misery. Changing the outcome of this flash-forward could have the unintended consequence of removing a form of psychological support. In such cases, the purpose of IR is to generate images that are less harmful, but that still meet the underlying need for control, safety or reducing tension. Table 6.2 describes a number of ways in which flash-forwards can be rewritten.

Table 6.2 Examples of rescripting flash-forwards Basic need

Flash-forward

Rescripting

Security

Death (peace at last)

Aladdin’s magic lamp, providing endless safe ways to obtain peace

Death (not being Connectedness lonely)

Bringing friends and/or the therapist into the picture

Selfexpression

Expressing anger to others

Death (revealing private suffering publicly to others)

Autonomy

Death (demonstrating Visualizing changing tack the ability to in life e.g. quitting a achieve something) job

Death (deserved Being valued punishment for worthlessness)

Contradicting punishing antagonists and expressing appreciation

Realistic boundaries

Death (taking resistance to demands to extreme limit)

Freedom

Death (as a means of Holiday, lottery win escape)

Setting limits on others, demands, expectations

Example: Imagery rescripting of a flash-forward in a client with obsessive-compulsive disorder Below is an IR of a flash-forward in a client with an obsessive-compulsive disorder. Whenever he leaves home, the client checks the door up to seventy times for fear that the house will be broken into and that he will be blamed. This fear is triggered by a flash-forward in which he sees his house after it has been burgled. The rescripting starts with the vivid visualization of this flash-forward.

Visualizing the flash-forward – Greg

>> Therapist: “Okay, what I’d like is for you to close

your eyes and talk again about the image you have at that

moment, but as if it’s happening right now. You’re there and describing what you see.”

>> Greg: “You mean the moment I come home and find the house completely destroyed?”

>> Therapist: “Yes, the image you have in your head at

that moment. Your hand is on the doorknob and at that moment you have that image. Just close your eyes.”

>> Greg: “Okay…” >> Therapist: “Describe to me what you have in mind right now.”

>> Greg: “Um, the coffee table is knocked over and

smashed, and all the cushions are thrown off the sofa... but they’ve also been ripped open, and all the books have been thrown from the bookshelf... and all the things that were on the mantelpiece are knocked down. Further on in the kitchen, all the plates have been taken out of the cupboards and smashed, thrown on the ground. So you can’t walk, there's just no space.”

>> Therapist: “Where are you in the picture?” >> Greg: “Uhm... uhm... I feel like I’m standing in the living room.”

>> Therapist: “Okay, now be there, make contact with your

feelings, and look around you... look at the things you see, but also try to experience what you feel about them.”

>> Greg: “How do I feel? Like it’s my fault... that I... that I had to lock the house better so that...”

>> Therapist: “Okay, so now you’re standing in the living room, looking around, and you’re feeling guilty?”

>> Greg: “Hm...” >> Therapist: “Like you should’ve done it differently, you should’ve prevented this from happening?”

>> Greg: “Hmmm.” >> Therapist: “Concentrate on that guilt. Where do you feel that in your body?”

>> Greg: “Um... all around me, in my stomach area.” The key question during rescripting is: what does the client need to experience more security?

Rescripting the flash-forward – Greg

>> Therapist: “Okay, stay with that feeling. Don’t walk

away from it. Keep in touch with that feeling. And if you feel this way now, What else would you like? What do you need now? While you’re standing there right now in that ruined living room, but also experiencing that guilt, the feeling that this is your fault... what do you need now, to make you feel better?”

>> Greg: “Um... I want everything back in place, like it didn’t happen. I don’t want to feel that this is my fault.”

>> Therapist: “Okay, so what I’m hearing is that you need

all your guilt and responsibility to be taken away. If you could see it didn’t happen, it would make it all better? But you’re standing there, everything’s destroyed, that’s the reality you’re in now.”

>> Greg: “Yes.”

At this moment there are several options. The therapist could choose to edit aspects of the image, making it less threatening. Changing an unpleasant image into a positive image will generate positive feelings. In the current example, the image could be changed into a picture in an illustrated book, or presents lying on the floor instead of clutter in the room. The core of IR remains that images have an emotional impact, whether they are realistic or not. The option chosen below is to change the story line. The burglary and the clutter are seen as the starting scene of a film that may have started badly, but can end positively.

Rescripting the flash-forward (continued) – Greg

>> Therapist: “I’m thinking, can you put me in this picture? Can you see me over there next to you?”

>> Greg: “Hmm.” >> Therapist: “Next to you, right there in the living

room, and I’ll talk to you: Greg, I know you’re very upset because you believe this is all your fault, but it’s not. It isn’t your fault! This kind of thing happens. And if anyone’s to blame for this then it’s the burglar, the one who did it. You didn’t invite him into your house. You’ve done something normal that everybody else does; you’ve left the house and locked the door. So, it’s not your fault. Whatever you’d done, no matter how many times you’d checked, it wouldn't have made any difference. This isn’t something you have control over. And that may feel bad, and maybe it is, but it’s not something that you should feel guilty about. How do you feel listening to me?”

>> Greg: “Yeah, it's hard to listen. I just... it’s hard to listen, my attention keeps wandering off to the mess on the floor.”

>> Therapist: “Okay, it’s good that you’re saying that. So, in the picture, I want you to look at me.”

In this example, the therapist chooses to stay in the picture as the client has sketched it. Another option would have been to rewind the storyline a bit back in time and intervene at the moment the burglar is about to run away, or even earlier, when the burglar is just about to destroy everything. The current rescripting incorporates rational arguments that may have been discussed beforehand. Bringing them into the vivid image exploits the greater emotional impact an image has. However, the intrusive images that are part of the obsessivecompulsive disorder turn out to be so emotionally charged that the rescripting so far is not sufficient. The realistic information may gain in credibility if the realistic considerations are also shared by other important attachment figures. Therefore, the client may be asked to put important others, such as his wife, in the picture and let them express their guilty thoughts.

Rescripting the flash-forward (continued) – Greg

>> Therapist: “Look at me, but not just me. All those

people who are important to you, like your wife, can you put her in there?”

>> Greg: “Yes, but I don’t want her to have to see this mess.”

>> Therapist: “I get it, this is the same feeling of

responsibility again, where you’re mainly looking at what others need. Concentrate on your wife: what’s she saying to you now?”

>> Greg: “She says that... that there’s no way I could have known that this would happen. She says it’s not my

fault. She says these things, burglaries, are things that can happen. That no one can do anything about it.”

>> Therapist: “And how do you feel when she says all that?”

>> Greg: “Um...It’s hard, but I can hear her.” >> Therapist: “That’s good, concentrate on her voice... and I totally agree with her.” (Greg starts crying)

>> Therapist: “Greg, it isn’t your fault, we’re here

together, it’s not your responsibility. The burglar’s the one who’s guilty, it’s the burglar who should be punished for this, not you. You’ve done nothing wrong, nothing at all. We’ll fix this. We’ll make sure that things get fixed. How do you feel?”

>> Greg: “Better...” >> Therapist: “What better feeling is that?” >> Greg: “Um... I can... I can breathe more easily.” >> Therapist: “Okay, focus on that feeling, on the feeling

that it’s easier to breathe. Enjoy that that burden has been taken away from you... keep in touch with that feeling, and let the image fade a little and bring yourself back to the room here with me. Try to keep in touch with that feeling and, when you’re ready, you can open your eyes. Okay, how are you feeling?”

>> Greg: “Uhm... uhm... fine.” >> Therapist: “What needs to happen now is that you

practice this, that you retrieve this image, but also those other people who can tell you what’s right and wrong.”

The above is just one example of how the client’s flashforward can be rewritten. Other options would have been to clean up the mess in the image or to arrest the perpetrator, and for the court to rule that it was not the client but the perpetrator who was solely responsible for the problem and the mess. Using the boundless possibilities of the imagery, meaningful ways of rescripting can be sought that meet the needs of the client.

6.3 Specialist forms of imagery rescripting: positive imagery 6.3.1 Introduction With standard IR, negative images are visualized then rewritten to become more positive. However, in positive imagery positive images are formed from the start (Hackmann et al., 2011). The effectiveness of positive imagery has been known within sports for decades and, indeed, positive imagery is one of the most common interventions in sports psychology (Cummings & Ramsey, 2008). However, positive imagery can also be an effective intervention in the treatment of various forms of psychopathology, or can make an existing treatment more effective. For example, it is assumed that a lack of positive futureoriented mental images is a factor that perpetuates depression (Holmes et al., 2016). Positive imagery could be a direct response to this and could become part of the treatment of depression. Indeed, there appears to be evidence that positive imagery strengthens a positive mood and could protect against future instances of depression (Holmes et al., 2009).

An example of positive imagery can be found in a study by Meevissen and others (2011). They asked healthy subjects to do a daily imagery exercise in which they visualized themselves as ‘the best possible version of themselves’ (‘the best possible self (BPS)’). This meant that they visualized an imaginary future version of themselves, in which all the positive goals they were going to set for themselves were actually achieved. Compared to people who visualized the activities of the previous day, the positive, forward-looking image led to an increase in optimism about the future. Optimistic people appear to have less suicidal ideations (Carver & Scheier, 2014) and more hope (Tucker et al., 2013). Moreover, optimistic people are at lower risk of depression (Vickers & Vogeltanz, 2000; Korn et al., 2014).

6.3.2 Different forms of positive imagery So far, we have described positive imagery in general terms, with a single concrete example, such as visualizing the ‘best version of oneself’ (Meevissen et al., 2011). However, in practice, there are various forms of positive imagery. Each variant is based on a different theory about the mechanism of action of the methods and techniques used. What they have in common is the fact that positive images are generated directly, instead of rewriting negative images into more positive ones. Some forms of positive imagery are described below. For a detailed description, please refer to the listed articles and/or manuals.

Compassionate mind training Imagery exercises are used in compassionate mind training (Lee, 2005; Gilbert, 2009) to teach clients to calm themselves and generate a sense of security. In this approach, you encourage the client to create a personalized image symbolising compassion. This image of the perfect

nurturer can then act as a reminder, coach or guide who is always compassionate with your client. This image can be of a real person, a fictional person, or even an image from nature such as a tree full of blossoms. The form doesn’t matter; what is important is that the feelings and sufferings of the client are experienced as being understood in a gentle way. This image is then evoked in various circumstances, so that compassion is gradually internalized. This positive image generally has the following characteristics: It is formed by the client herself, so that it fits her experience and needs. The image symbolizes the client’s personal ideal of complete compassion. For one client it may be an image of another person who has compassion, for another client it may be an image of herself in which she is older, wiser and more compassionate. Compassion has several elements, such as wisdom, strength, gentleness and a non-condemning acceptance of the self. Compassion generates multiple sensory experiences, such as a warm feeling in the body and compassionate emotions, such as sympathy or empathy.

Competitive memory training The goal of competitive memory training (COMET) (Korrelboom et al., 2009a, b, 2011) is to make meaningful, positive selfimages more accessible than negative self-images. This approach is in line with Brewin’s theory (2006) that in memory, all kinds of concepts with multiple meanings are stored. For example, the concept of ‘I’ may be associated with several meanings, such as ‘perseverance’ or ‘humour’, but also with ‘uncertainty’ or ‘stupidity’.

Depending on the context, one meaning is activated at a time. There is a ‘retrieval hierarchy’, whereby different meanings ‘compete’ with each other to be activated in a particular context. COMET aims to promote the activation of the more positive self-image. Imagery, in combination with motor skills (posture and facial expression) and music, is one of the core elements of COMET that creates an emotionally lived positive self-image. This positive self-image, with more functional meanings of the ‘I’, is then regularly evoked, both in the session and during homework assignments.

Functional imagery training People are often inclined to place healthy goals further into the future, where they remain vague (for example: ‘I want to eat healthier food’). In contrast, intrusive images often relate to the present or the near future and are concrete and vivid (for example, for someone with eating problems, specific images of eating unhealthy food). Therefore, these near future images have more influence on feelings and behaviour than the vague long-term goals of eating less or healthier food (Trope & Liberman 2010). However, when people imagine that they are actually implementing what they have set themselves as a long-term goal, it becomes more likely that they are will actually take action to achieve that goal (Knäuper et al. 2009). Functional imagery training (FIT, Andrade et al., 2016) is a protocol-based intervention that trains clients to visualize positive goals. In FIT, people are encouraged to imagine the usefulness of a functional behavioural change and possible ways to achieve it. Clients practice this both in the sessions and with homework assignments. Through these imagery exercises, long-term goals are broken down into concrete, achievable goals that can be visualized more easily and vividly. The purposeful imageries are linked to everyday

activities so that the images are repeated frequently. Experiences in which they have successfully worked towards their goals are regularly recalled. FIT has proved to be effective as an intervention to delay snacking in people with self-reported eating problems (Andrade et al., 2016).

Imaginary cognitive bias modification Both anxiety and mood disorders are characterized by distortions in information processing demonstrated in attention, interpretation and memory processes (Mathews & MacLeod, 2005). Anxious people, for example, are more inclined to pay attention to fear-related information than non-anxious people. In addition, depressive people will tend to negatively interpret a situation that can be judged in multiple ways. It is assumed that these distortions in information processing cause or maintain these psychological disorders (Koster et al., 2009). The starting point of cognitive bias modification (CBM) (Blackwell et al., 2015; Torkan et al., 2014; Lang et al., 2012) is to edit these distortions. With the help of specific, structured tasks, participants are trained to have more attention, for example, for positive information, or to interpret unclear situations in a more positive way. In the treatment of depression, these CBM procedures have been adapted by adding imagery: CBM-I (Holmes et al., 2006; Holmes et al., 2008, 2009b). Participants must visualize a positive interpretation of situations that are open to multiple interpretations. For example, they are shown combinations of pictures (e.g. an image of a busy street) and words or short sentences with a positive meaning (e.g. the word ‘lively’ instead of ‘intimidating’). Participants are asked to visualize these images from a first-person perspective and in the present tense. One week of daily practice led to a reduction in depressive symptoms (Lang et

al., 2012). Despite the demonstrated positive effects of CBMI in depressive clients (Blackwell et al., 2013; Kom et al., 2014; Lang et al., 2012; Torkan et al., 2014), one study found CBM-I to be no more effective than a control condition that did not use explicit positive imaging (Blackwell et al., 2015).

6.4 Chapter summary This chapter describes how IR can be used for various psychological issues and disorders such as addiction problems, nightmares, and flash forwards that can occur with depression and obsessive-compulsive disorder. The working mechanisms and practical implementation of IR are no different, and the examples of IR in these disorders will have been largely recognizable. However, each disorder has its own specific characteristics, which makes the application of the technique feel different. Positive imagery has also been described as a specialist form of IR. Positive imagery has been known in sports psychology for decades, but now has several variants such as compassionate mind training, competitive memory training (COMET), functional imagery training (FIT) and imaginary cognitive bias modification (CBM-I). These forms of IR can be applied as standalone interventions or used as part of a more comprehensive IR treatment. For example, COMET, compassionate mind training and functional imagery training are all to some extent part of the future-oriented IR as described in Chapter 5. So far, we have described the different phases of IR, as well as the different specialist forms and fields of application. In the final chapter, we describe the pitfalls you can encounter as a therapist during the application of the intervention.

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Chapter 7: Pitfalls for therapists Chapter summary 7.1 Introduction 7.2 The therapist asks the client to rewrite too quickly 7.3 The rescripting is insufficiently powerful 7.4 The therapist speaks too rationally and too fast 7.5 The therapist is too detailed 7.6 Chapter summary

7.1 Introduction This chapter describes the most common pitfalls that we as therapists can encounter in imagery rescripting (IR). Applying IR is difficult, not only because, as therapists, we must deal with difficult and challenging situations, but also because of our own shortcomings and the fact that we do not always handle the challenging situations appropriately in clinical practice. Of course, nobody consciously chooses to deal inadequately with a challenging clinical situation. That it does happen is partly explained by inexperience and, with the aid of this book, you can become more familiar with the method. However, the activation of our own schemas and pitfalls is also a reason why we do not always apply the technique adequately. As a profession, we have specific common schemas or pitfalls in common. For example, a significant proportion of therapists report unpleasant experiences in their youth which, while enabling them to be empathetic to the suffering

of clients, also make them vulnerable to the activation of schemas and coping styles (Barnett et al., 2007). Among therapists, self-sacrifice and ruthless standards are the most common schemas (Kaeding et al., 2017; Simpson et al., 2018). Activation of schemas can lead to a coping style of avoidance, surrender or overcompensation (Young, 2003). These are not always the most helpful responses, with the result that we apply the technique of IR less effectively. This chapter describes how we can recognize the activation of our schemas during the application of IR. Practical advice is then given on how best to deal with these pitfalls and use IR as effectively as possible. The descriptions below of common pitfalls are based on years of training, supervision of a large number of therapists and, of course, a great deal of personal experience with my own schemas and pitfalls when applying IR.

7.2 The therapist asks the client to rewrite too quickly The purpose of IR is to provide clients with corrective emotional experiences that enable them to rewrite meaningful images themselves. However, the focus on the needs of clients, combined with the desire to heal them as quickly as possible, can lead us to ask too quickly whether a client is able to rewrite the image herself. We aim to address a healthy, mature part of the client who we believe would be able to recognize her needs and who should feel powerful enough to rewrite emotional images. However, the reality is that many clients do not have a healthy, mature part capable of doing this at the beginning of therapy. Questions such as ‘What do you need now?’ ‘What would you like to say to the other person?’ and ‘Can you

address the other person?’ unintentionally confront clients with their powerlessness in that initial phase. So, there is a risk that the exercise, which is intended to provide a corrective emotional experience, will instead reinforce the client’s feelings of incompetence and powerlessness.

The therapist asks the client to rewrite too quickly – Nicky

>> Therapist: “Okay, so your Dad gets angry in the image. Can you tell me what he's doing? What does he say?”

>> Nicky: “He’s just very angry. He yells, points at me and says: ‘It's all your fault, I can’t believe you did this. It’s your fault.’”

>> Therapist: “Okay, now I want you to freeze the image, and I want you to place your healthy adult in

the image. I want you to see your healthy adult, to be her, and that you’re between your father and Little Nicky. I want you to be that healthy adult who’s tired of how her father’s been treating Little Nicky. I want you to get in touch with those emotions. What do you feel when you see how he’s dealing with Little Nicky?”

>> Nicky: “Uh... I don’t know... I don’t really want to be there.”

>> Therapist: “Can you get angry now and really go against

him, and say you can’t allow him to treat Little Nicky like that anymore?”

>> Nicky: “He’d just get angrier at me, scream more at me.” (shakes her head, clearly anxious)

>> Therapist: “Well, I want you to be that healthy adult

who won’t take it anymore. I want you to stand up to him.”

>> Nicky: (opens her eyes, anxiously tense) “I don’t

think I can do that. He'd just yell at me more. I don’t want to.”

>> Therapist: “Okay, that’s okay. We’ll try again some other time.”

7.2.1 Awareness There may be several reasons why we try to speak to clients as a healthy adult too quickly. For some therapists, it stems from the conviction that it is respectful to address our clients on their strengths. Another reason may be that therapists feel uncomfortable with a more direct, controlling attitude in which they take the lead. This may involve feelings of shame (‘Who do I think I am when I say I want to step into the picture and rewrite it?’) and/or feelings of failure (‘If I do and I fail, the client may lose faith in the therapy’) or perhaps stricter standards about ‘how it should be done’ ('Surely you can’t decide for someone else what they need?’).

7.2.2 Self-compassion The intention to give your clients space for their own rescripting process is a good one, and it is understandable that it can feel a little strange or uncomfortable to take the lead in the initial phase of IR. Of course, those feelings are amplified and made more unpleasant when schemas of failure or shame/defectiveness are present. It is not only the situation in itself that makes it difficult to be

directive, it also brings into play a whole history that can make you to feel even more inhibited about taking the lead.

7.2.3 Cognitive restructuring The above does not mean that it is always wrong to let your client take the lead in the exercise. However, it is important that our actions meet the needs of our clients. In the early stages of therapy, the need for support and connectedness among our adult clients may be greater than we assume. Clients may also be quickly overwhelmed by emotional experiences and handling them can cost so much energy that they are unable to rewrite from a full-wash perspective. In those early stages, a directive attitude from you as a therapist may support a client who has difficulty regulating her emotions in an adequate way. You can then change your attitude over the course of therapy if your client has a greater need for competence and autonomy. If therapy proceeds successfully, your client will also become able to tolerate her emotions better and better, and to handle them in a healthy way.

7.2.4 Behavioural modification In conclusion, it is advisable not to ask your client to rewrite evoked images themselves too quickly. Even when clients appear to have a highly developed healthy adult, it is better to rewrite the images yourself or at least expect to do so during the first sessions as a therapist. In doing so, you not only validate the client’s needs for connectedness, support and care, you also act as a role model that shows how to fight antagonists and rewrite emotional images.

7.3 The rescripting is insufficiently powerful During IR we are sometimes confronted with the image of an offender who is bigger, stronger and angrier than we are, and who is also known to be boundless in their aggression. Or we are faced with multiple offenders behaving aggressively. The consequence of this overwhelming aggression can be that, as a therapist, you become insecure and feel powerless to change anything about the image. Many therapists will probably recognize this. Personal characteristics can make a therapist even more susceptible to such feelings. Maybe you're a physically smaller, slighter therapist and, in the imagery, you're confronted with a big, aggressive man. The physical contrast can evoke feelings of powerlessness or insecurity. But even for a large, strong therapist, many situations can arise that lead to an emotional reaction of powerlessness. This can make rescripting less powerful; when you feel uncomfortable, the actions you propose to make the situation safe tend to be cautious and hesitant, and you are also less creative in devising possibilities for rescripting. Because you are less decisive in the rescripting and sound less certain, your client may not have faith in your ability to handle the situation. This in turn may make you feel even more insecure and powerless.

The rescripting is insufficiently powerful – Nicky

>> Therapist: “So, you're on your bed, you’re five years old, and your Dad’s in the room too. What does he look like?”

>> Nicky: “Uh... he looks really mad, he’s mad at me.”

>> Therapist: “What’s he saying? Does he say anything?” >> Nicky: “He says: ‘I can't believe you did this. Why

did you do this? It’s all your fault. I have to clean it up now!’”

>> Therapist: “Hmm... anything else?” >> Nicky: “Just: ‘It’s all your fault! You’re always

doing everything wrong!’ And I know he’s going to hit me. I just feel that coming...” (sounds very scared)

>> Therapist: “Hmm... and can you put me in the picture

now? I’d like to be there with you, to help you... try to help you a little... to fight your father... something like that. Can you put me in?”

>> Nicky: “Yeah, but he’s really angry, he’s coming at you, and he’s really going to hurt you!”

>> Therapist: “Okay, so I’d say, for example, ‘That’s not how you talk to a child... that’s not good... um… that’s not the way to treat children.’ How does he react?”

>> Nicky: “He’s still standing there very angry... he still looks angry, really very angry.”

>> Therapist: “Would it help if I kind of stood between the two of you?”

>> Nicky: “Maybe.” >> Therapist: “Well, let’s try that another way. So, I’m standing there, and I’d say something like that to him: ‘You don’t say that to your daughter.’ Could that maybe help change something?”

>> Nicky: (disbelieving expression on her face) “Hmm, no, he’d just say: ‘It’s just wrong, it’s her fault!’”

>> Therapist: “And, um, how does he say that?” >> Nicky: “Raging! ‘She just shouldn’t have done that!’”

>> Therapist: “So, if I said ‘No!’ – what would your father's reaction be?”

>> Nicky: “He’d just say ‘No’ back.” (desperate disbelief on her face) “That doesn’t really change anything.”

>> Therapist: “Or we could try, um... that... we could put him sort of further away in the room, could that help, do you think?”

>> Nicky: “I don’t know.” (opens eyes) “It doesn’t

really work. I don’t want to go through with this... he’s just angry.”

>> Therapist: “Yeah, but let’s go ahead and see if I can stop him... and make sure it’s safe for you.”

>> Nicky: “No, I don’t want to go through with it.” >> Therapist: “No?” >> Nicky: “No...” >> Therapist: “Maybe next time?” >> Nicky: “I don’t know... I don’t know... this feels really bad.”

>> Therapist: “Of course, I don’t want to make you feel bad, it’s just... well, maybe it’s enough for today.

You’ve worked hard, that’s really good, you’ve done really well... and... maybe next time we can see if we can work on this?”

>> Nicky: “Yeah, maybe.” 7.3.1 Awareness First of all, it is important to understand what is happening. The above events will be perceived as overwhelming and discouraging by many therapists. It is not a problem in itself to have such feelings and sensitivities. In fact, to some extent, familiarity with feelings of insecurity can help to make a good therapist. Because you have experienced uncertainty yourself, you can better connect with the emotional experience of clients struggling with shame or fear of failure. However, this familiarity also has a drawback. When feelings such as fear of failure or inadequacy are strongly activated, as a therapist you may come across as less powerful or credible at those very moments when your client requires that to feel safe.

7.3.2 Self-compassion Be gentle and understanding with yourself. Of course you feel insecure when confronted with an antagonist who is big, strong and aggressive. That's a normal human reaction in such situations. Moreover, you have those feelings of shame or fear of failure that you carry with you in your life. There are reasons why you carry them with you: with your background and the things you have experienced, it is only logical that you have a certain vulnerability to feelings of insecurity. It is quite understandable then, that these feelings of anxiety are activated with overwhelming antagonists in this situation and you suffer from them.

7.3.3 Cognitive restructuring It is important that you mobilize your own healthy adult and actively counter the undermining thoughts that you’re failing or you aren’t good enough. So, think for a moment what arguments there are to show that those thoughts aren’t accurate. When you get to this point, there is probably more room to think about how best to deal with this situation.

7.3.4 Behavioural modification There is some advice that can help you with this. The credo applies: fake it till you make it! In other words, even if you feel insecure, try to stay strong in your attitude, voice and actions. By temporarily 'acting out' this powerful attitude, you increase the chance that your client will feel safe, which makes it easier for you to stay in control of the situation. A second piece of advice is to remember that the possibilities of imagery are limitless. So, make yourself bigger, silence the image, call in help – in all these ways and more you can strengthen a sense of competence and support for both your client and for yourself, reducing uncertainty and powerlessness.

7.4 The therapist speaks too rationally and too fast One of the most common pitfalls for therapists is being too rational. Instead of experiencing images, we talk about them. And when we do so, we express ourselves in a number of ways. In the past tense, for example, we often use calm, rational questions such as: ‘What happened then?’ ‘What did he say then?’ or ‘What would you have wanted to do then?’ Another form of expression is tone and tempo of speech. In the

reflective state in which you find yourself as a therapist, your voice will sometimes sound a bit too rational. This can be accompanied by a higher speaking rate. The intensity of the IR will decrease as a result, as rational rather than emotional responses will be used.

The therapist speaks too rationally and too fast – Greg

>> Therapist: “Okay Greg, I was thinking we could do an imagery exercise now. Is that okay?”

>> Greg: “Yeah, all right.” >> Therapist: “Okay, well, in this imagery exercise, I’m going to ask you to close your eyes. Well, maybe we can do that right away?”

>> Greg: “Okay...” >> Therapist: (sounding factual) “So close your eyes and

let’s start by recalling a safe place. So, you see yourself in a place where you feel relaxed, at ease, and you feel okay about where you are. Where are you?”

>> Greg: “In the park...” >> Therapist: “Okay, so you’re in the park, and you’re

feeling nice and relaxed, and now I want you to blur this image, or put it aside, and instead take an image of a situation that happened recently, maybe one that was a little stressful for you, a situation where you felt... uh... angry maybe, or guilty! Because that could have happened, too, maybe with your wife? Do you have that kind of image? Something stressful?”

>> Greg: “Uh...” >> Therapist: “Something that triggered you?”

>> Greg: “Uhh... yeah.” >> Therapist: “And what happened in that situation?” >> Greg: “I’m in the room...” >> Therapist: “In the room, and what happened?” >> Greg: “Well, I was watching TV, and my wife wanted me to empty the dishwasher and I hadn’t, and that wasn’t a big thing, but I was a little tense about it...”

>> Therapist: “Okay, now focus your attention on that

feeling of being tense, and at the same time I want you to blur the image. It’s not about the dishwasher or the TV, it’s about that tense feeling, stick with that feeling, and then I want you to bring up an image from your childhood, which is linked to that tense feeling. What do you see now?”

>> Greg: “Uh...uhm...uhm...my mother...” >> Therapist: “Hm... and what happened to your mother. What did she say?”

>> Greg: “Um... she was mad at me...” >> Therapist: “Okay, because you did something that made her angry? What happened?”

>> Greg: “Uh... I was playing with matches...” >> Therapist: “Okay, all right, well, focus on that

image... and now I want you to place me in the picture, with you and your mother, okay?”

>> Greg: “Um, okay?”

>> Therapist: (looks away, as if thinking for himself)

“And then I’d say, like: ‘I don’t want you to be angry at Greg, because that makes him feel bad, and I don’t want him to feel that way, he’s just a child.’ And maybe I'd tell you something about children’s needs, that they just play, that they do stuff like this, play with matches. I’ve played with matches. That’s not a bad thing. How do you think that made you feel?”

>> Greg: “Uh. Um, yeah, well...” >> Therapist: “Okay, is there anything else you need?” >> Greg: “Uhm... no?” >> Therapist: “Okay, then keep in touch with that feeling,

that good feeling... and let the image go now, and return to your safe place, try to be there, in the park where you’ll feel good, and safe... and hold on to that feeling, and when you’re ready, you can open your eyes.” (while Greg opens his eyes) “Okay, since we're a little short on time, Greg, let’s talk about what you can do with this.” This phenomenon of staying overly rational and reflective during IR can often occur when the exercise is still new and unfamiliar. The therapist’s attention is then naturally focused on the technical aspects of the exercise: ‘What is the next step I have to take?’ ’What comes after that?’ And so on. This understandable reaction can be reinforced by an unrelenting standards schema, one of the most common schemas among therapists (Simpson et al., 2019; Saddichha et al., 2012). These technical and/or schema-driven demands are felt as a pressure to ‘want to do it right’ – a pressure that increases the tendency to approach the exercise cognitively, with the effect that the client does not have the emotional experience that the therapist hoped for. The

absence of similar emotional reactions from the client can further increase the pressure of internalized high demands on the therapist. How can you break such a vicious circle?

7.4.1 Awareness First of all, it’s important to learn to recognize this pitfall of ‘talking rather than experiencing’. The sooner you realize that you’re in a somewhat rational mode, the sooner you can do something about it. You can recognize this pitfall in different ways. First of all, you may be aware that you tend to become somewhat cognitive when you find things difficult or exciting. Forewarned is forearmed, so you can be extra alert to this. A second way to recognize the pitfall is to pay attention to your client’s reactions. Sometimes it is easier to notice something in others than in yourself. So, when you notice that your client continues to sound rational or unemotional, it may be a sign that you yourself are in a rational mode as well.

7.4.2 Self-compassion Once you’ve noticed that you may be talking too much about an experience instead of helping your client experience it, it is important to remain compassionate and understanding towards yourself. It's hard to do something you haven't quite mastered yet. It may also be difficult for this particular client to get in touch with her feelings. And finally, you may feel a little uncomfortable if you have to talk in a way that you experience as dramatic or exaggerated.

7.4.3 Cognitive restructuring With the space that this gentle compassion offers, you can then consider whether it is really exaggerated or dramatic of

you to want to make the exercise more emotional. It may feel uncomfortable for you, and perhaps initially for your client, but by making the exercise more emotional, you increase your client’s chance of a corrective emotional experience. Feelings of discomfort do not mean that it is wrong to make an exercise more emotional.

7.4.4 Behavioural modification There are a number of ways to avoid being too rational and cognitive when performing IR: Close your eyes and try to visualize the situation your client describes. By considering the image yourself, you will be better able to focus on sensory information – aspects of the image that contribute to generating an emotional response. Speak in the present tense as if the experience were happening in real time. The word ‘now’ can help: ‘What do you see now?’ ‘What’s happening now?’ Paraphrase regularly – short summaries will lower the tempo of the exercise. Regularly ask how the client is feeling, in order to check that he or she has not become detached and is still in touch with the emotional experience.

7.5 The therapist is too detailed Sometimes, therapists are too eager to bring images to life and, on these occasions, it is easy to ask too much and too intensely about the sensory experiences. Detailed and specific questioning may be intended to provide your client with an emotional experience, but if you ask too much about it the focus will be so emphatically on those sensory aspects that the emotional charge of the image diminishes. The

delaying effect of detailed, lengthy questioning also reduces the emotional charge of the visualized situation. Another way in which this pitfall manifests itself is that the images become so realistic and lifelike that, as a therapist, you are hindered from validating basic needs for security and connectedness by physical laws of reality. For example, the client sketches the image of herself being attacked as a child in her bedroom by her father. You want to get into the picture to intervene, but instead of placing yourself directly in the bedroom, ask your client to imagine you ringing the doorbell, asking to come in and climbing the stairs.

The therapist is too detailed – Greg

>> Therapist: “Close your eyes and evoke the feeling that

you’re being criticized by your father. Can you do that?”

>> Greg: (sighs) “Okay.” >> Therapist: “Okay, and let that image appear before your eyes. What do you see now?”

>> Greg: “Um... that I’m sitting at my desk and Dad’s standing next to me.”

>> Therapist: “And what’s your father wearing?” >> Greg: “He’s wearing his uniform...” >> Therapist: “Is he? And the colour of the walls of the room?”

>> Greg: “Um, they were kind of light green.” >> Therapist: “And what’s the colour of the desk?”

>> Greg: “Um... it’s a dark, wood colour.” >> Therapist: “And can you see your father’s face?” >> Greg: “Uh, yes...” >> Therapist: “How does he look at you?” >> Greg: “He looks like... he looks angry.” >> Therapist: “And what do you hear?” >> Greg: “Uh... I can hear Dad shouting at me...” >> Therapist: “And what smells are in the room?” >> Greg: “Uh... the paper on the desk...” >> Therapist: “And how do you feel?” >> Greg: “Uh... I feel... a little scared, I guess?” >> Therapist: “Okay, you feel scared while you’re sitting

there at your desk, and your Dad’s angry at you... your Dad is giving you a hard time, you feel scared... and... what do you need?”

>> Greg: “Uh... I need Dad to stop shouting, I need some help?”

>> Therapist: “Okay, can you place me in the image now... can you see me?”

>> Greg: “Hmm...” >> Therapist: “And what do you see? How do I look?” >> Greg: “Uh... you’re wearing your dark trousers and your shirt.”

>> Therapist: “And where am I in the room?” >> Greg: “Um... there on the bed.” >> Therapist: “And what do you hear?” >> Greg: “Um... I can hear the air conditioning.” >> Therapist: “And how do you feel now that I’m here, in the picture with you and your father?”

>> Greg: (yawning) “I feel... um... I don’t know.” This pitfall may be the result of an urge for perfection. Perhaps in the back of the therapist’s mind a demanding standard is active, such as: ‘If you do something, you have to do it right.’ Such high standards are common in the care workers’ profession. The strength of these strict requirements is that we are driven to do our job well and thus provide good care to our clients. The downside of this is that we can become too detailed, too focused on form.

7.5.1 Awareness First of all, it is important to be aware of this pitfall. This awareness may make you more observant during the session when your IR becomes too detailed. A good signal is that you are still asking about facts while your client is emotional – so your attempt to make the image detailed and lifelike does not seem to fit in with your client’s emotional experience.

7.5.2 Self-compassion Stay gentle and compassionate toward yourself. Maybe you’ll catch yourself being a little too detailed, but that doesn't

have to be a problem. Carefulness has many advantages. If you’re too careful now, there are reasons for it. Maybe you were brought up to do everything right.

7.5.3 Cognitive restructuring Next, it’s important to realize that the exercise is not just about making the image as vivid as possible. The vividness of the image is not in itself the essence of the exercise, but merely a tool to arrive at meaningful experiences. If your client is emotional, you already have material that you can work with and you don't have to ask what colour the window frames are or whether the window is to the left or right of your client. So realize that it’s fine to be a bit looser when constructing the image sometimes, and that you don't have to abide by all the laws of physics. All these considerations can counterbalance the urge to do it perfectly.

7.5.4 Behavioural modification Give yourself the freedom to be spontaneous and creative; anything is allowed in order to arrive at that corrective emotional experience. So, you don’t have to ask questions such as: ‘How do I get in that bedroom?’ or ‘What do I say if Dad won’t listen?’ Instead of being paralysed by such overly realistic considerations, you can creatively and spontaneously place yourself in the room and you get to make yourself bigger. And if that doesn’t have enough effect on the father in the image, you just tell the client what it looks like when you get the father out of the door, which can allow the client to visualize it herself thanks to your description.

7.6 Chapter summary

This chapter has described pitfalls therapists can encounter when doing IR. The most common ones are that we do the exercise too cognitively and rationally, so that the imagery generates insufficient emotions, that we appeal too quickly to clients as the healthy adult they seem to be, that we are too hesitant in the rescripting, or that we are too perfectionist in the imagery. While these are all normal, human phenomena, these pitfalls can be further exacerbated by characteristics many therapists share. For example, therapists are often sensitive to the fear of failure, are inclined to conform to what clients say they want, and make high demands on themselves, sometimes focusing too much on technique and less on the purpose it serves. Finally, for each pitfall we have described how best to deal with it. The overall strategy is first to become aware of the pitfalls. Then we must continue to look at ourselves and our actions with gentleness and compassion, because we need peace and quiet to get out of the trap. Conscious attention to the cognitive restructuring of the old pitfalls is then a prelude to adjusting your actions so that the IR can become more effective.

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Appendices Appendix 1: Roadmap for diagnostic imagery exercise Appendix 2: Roadmap for explaining imagery rescripting to clients Appendix 3: Roadmap for imagery rescripting – the therapist rewrites Appendix 4: Roadmap for visualizing the healthy adult Appendix 5: Roadmap for imagery rescripting – the client rewrites Appendix 6: Roadmap for rescripting future scenarios

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Appendix 1: Roadmap for diagnostic imagery exercise Aim: To trace meaningful images from the past Roadmap for diagnostic imagery exercise Step 1: Introduction to diagnostic imagery Step 2: Safe place Step 3: Unpleasant situation in the present Step 4: Affect bridge to the past Step 5: Exploration of meaningful past experience Step 6: Back to the safe place Step 7: Review and discussion

Step 1: Introduction to diagnostic imagery I’m about to ask you to close your eyes and keep them closed for ten to fifteen minutes. In that time, I’ll ask you to bring up images of meaningful situations from the recent and more distant past. I’ll guide you through the exercise. We can then discuss what you’ve experienced and what we can learn from this with regard to your difficulties and their background. It’s not hypnosis and you will remain in control at all times. Closing your eyes is only meant to help you

concentrate on the images and make sure you aren’t too distracted by your surroundings. All right, then I’d like to ask you to sit down, feet on the ground, hands in your lap... and you can close your eyes now... take a deep breath... all right. First, I’d like to ask you to focus your attention on yourself for a moment. You travelled here, people were talking, there were crowds, but now it’s just about you... with your feet on the ground... just be aware of the chair underneath you, your back against the backrest... and your breathing. You don’t have to do anything with it, just be aware of you, right now, in this moment... okay...

Notes Specify duration of exercise Explain method briefly Offer security and control

Step 2: Safe place In this situation, I’d like to ask you to first evoke an image of a safe place... it can be any place, from your present life or your past, or maybe something you saw in a movie. As long as it’s just a place where you feel good... and when you have an image, can you tell me what you're seeing right now? When you have an image, try to move into that situation as if you were there right now. Take a good look around: Where are you now? What do you see? Are you alone? How do you feel now? What makes this place nice and safe for you? Where do you feel this nice feeling in your body? Concentrate on that feeling.

Step 3: Unpleasant situation in the present

Let go of this situation and the feeling, let it drift or fade away. Now let a picture emerge of a difficult situation you’ve been through recently. Don’t think too deeply about what it should be, just see what comes to mind. If you have an image, live it as if you’re there now. Take a good look around: Where are you now? Who are you with? What’s going on? How do you feel? What do you feel bad about now? Where do you feel that in your body? Focus on the feeling. Notes Always ask your client about three different aspects of emotional response: Emotions: How do you feel now? Anxious? Angry? Sad? Ashamed? Physiological aspects: Where do you feel this feeling in your body? Meaning: What are you afraid of now, angry about, sad about?

Step 4: Affect bridge to the past Do you recognize this feeling? Then hold on to it, but release the image, let it drift or fade away. Now let a situation from your childhood emerge that is somehow linked to this feeling. Don’t think about what it should be, just concentrate on the feeling and see what comes up. If nothing comes up, give it a little more time and, in the meantime, concentrate on the feeling you have now. Is it familiar to you? Where do you recognize it from? Don’t think about it

too deeply. If more than one childhood situation arises at a time, just pick one to focus on.

Step 5: Exploration of meaningful past experience If you have an image, live it as if you’re back there now. Take a good look around: How old are you now? Where are you? What’s going on? Who are you with? How do you feel now? Where do you feel that in your body? What does this mean to you? Is there anything you’d like to do, but might not dare? What’s stopping you? Is it impossible? Try something you might want to do. Or do you want someone to help? Imagine that, with or without a helper, you’ve just said or done something you’d like to have done differently. How do they respond to that now?

Notes Ask your questions in the present tense and encourage your client to speak in the present tense. Adjust the tone of your voice depending on whether you address an adult, a younger child or an older child in the image.

Step 6: Back to the safe place Now let go of your feelings and the situation and move back to the safe situation. Take a good look around you and concentrate on your pleasant feelings. Be back there in your mind. What’s good for you here? Just stay here for a while, and notice what’s good for you.

Step 7: Review and discussion

The client can open their eyes again. Discuss any connections between the current problem situations and feelings and the meaningful events of the past.

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Appendix 2: Roadmap for explaining imagery rescripting to clients (adapted from Arntz & van Genderen, 2020)

Aim: To identify and edit meaningful images from the past 1. What has happened to you in the past has been awful, and if you don’t receive help to deal with those events, symptoms such as feelings of fear, shame, low self-esteem and problems in relationships with others may develop later in life. 2. The memories of what happened to you haven’t yet been properly processed. You can still suffer a great deal from the meaning these experiences have had for you. For example, a child may conclude that what happened to her happened because she is evil; that no one can be trusted; that it is bad to get attached to someone; or she might feel guilty and ashamed of what happened and of herself. Even if you know rationally that those feelings are not justified, they can still feel as if they’re really true. 3. We can’t change what actually happened, and we can’t erase our memories of it. 4. But we can change the meaning a memory has for you. 5. We can try to change that meaning by talking about it or understanding why it is wrong, but we know from research that it is much more effective to use imagery exercises. 6. Neurological research has shown that the human brain reacts in the same way when we imagine an event vividly as when we actually experience it, even if someone knows it didn’t actually happen. This means that imagining

things vividly has a much greater impact on our brains than just talking about them. 7. With imagery rescripting, we’ll change how you view the terrible events that have happened to you. We can’t erase the memories, we just can’t, but we’ll help you to get a different sense of what happened and to experience it so strongly that it changes the meaning of the events. That means that painful feelings associated with those memories, such as shame, guilt, disgust, anger and panic, will diminish and you’ll be able to develop a more positive self-image and learn to trust others more. If so far you’ve tended to associate with people who actually aren’t good for you, you’ll find that the treatment helps you learn to choose people who treat you better. If you were afraid of the ferocity of your emotions, the treatment will help you to become less afraid of allowing those emotions in. Therefore, the treatment can have several positive effects. 8. Imagery rescripting also offers you the opportunity to express feelings, needs and behaviours that you had to suppress at the time. For example, if someone is attacked, he or she may feel the urge to fight back. However, if it is too dangerous to fight back, people often (automatically) suppress that impulse. Although that is a very sensible thing to do when you are powerless (because the consequences of fighting back can be even worse) suppressing that impulse can have unhealthy long-term consequences. That’s why we want to help you express those feelings, needs and behaviours in the imagery exercise, because it’s safe to do so now. 9. Children need protection from ill treatment and neglect. If they do experience it then they need to be supported, reassured and soothed, to hear a healthy view of what happened, and to hear who is really guilty and should be ashamed of themselves. This need for support and

explanation is very natural, but is often overlooked or ignored by people who have the same background as you. In imagery rescripting, we help you to experience those needs being listened to and, although this happens in imagery, the brain reacts to it as if it were a real-life healing experience. 10. The treatment will be able to evoke all kinds of feelings and insights. Some of those feelings and insights may seem hard to bear at first, but I’ll help you with that. For example, you can feel sadness about what happened and that can be very painful to feel. However, grief is a natural reaction and when that natural reaction is suppressed it can cause problems. It’s okay to feel sadness, or other emotions, that can be evoked by the therapy – they are part of a natural healing process. Therefore, such feelings are not proof that the therapy doesn’t work; they can actually be seen as a positive sign. 11. In imagery rescripting you’ll be asked to depict a meaningful event that is about to happen again. When it’s clear what's going to happen, I’ll ask you to imagine that I’m with you in that image. I’ll then intervene to prevent or stop what goes wrong. I’ll help you imagine that there is security and attention for all your needs with regard to this event. In the later stages of the therapy, I’ll help you imagine that you yourself provide this help and support by stopping the unpleasant events and taking care of your needs. 12. In imagery rescripting you don’t have to share all the details of what happened. This is not necessary for this treatment to be effective. So, if horrible things happened, you don’t have to tell me all the details. When it’s clear what’s going to happen, and your emotions are sufficiently activated, that’s when I’ll enter the image.

13. If you notice that a certain intervention doesn’t have enough effect for you, that’s not a problem. We can just rewind the course of events in time and try something else. The more you think about what else to do, the better. 14. We can make a list of all the unpleasant events that are relevant to your current difficulties. You can then choose which of these events we tackle first. We’ll also pay attention to the difficulties in your present life that are related to the events in your past, as those events make you vulnerable to problems now. If I have the impression that you may be inclined to avoid certain parts that could be important for your recovery, I’ll discuss it with you. I won’t force you to do anything you don’t want to do. 15. We’ve noticed that it is better to use earlier memories than later ones. So, if we have a choice, we’ll try to retrieve those memories in which you are young, as past memories are often at the root of the problems. 16. Usually, we work on one memory per session. It isn’t necessary to cover all the difficult memories you might have. Often multiple memories have the same meaning and when we’ve successfully started to change the meaning of one relevant memory, you’ll notice that the meaning of the others also changes. So, we’re free to choose the memory we want to work on – it depends on the relevance of that memory in that phase of therapy. 17. That was quite a long explanation. Do you have any immediate questions?

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Appendix 3: Roadmap for imagery rescripting – the therapist rewrites Aim: To change (the course and meaning of) meaningful images Roadmap for imagery rescripting – the therapist rewrites Step 1: Introduction to imagery rescripting Step 2: Safe place Step 3: Unpleasant situation in the present Step 4: Affect bridge to the past Step 5: Exploration of meaningful past experience Step 6: Rescripting these meaningful images Step 7: Back to the safe place Step 8: Review and discussion

Step 1: Introduction to imagery rescripting I’m about to ask you to close your eyes and keep them closed for ten to fifteen minutes. In that time, I’ll ask you to bring up images of meaningful situations from the recent and more distant past. I’ll guide you through the exercise. We can then discuss what you’ve experienced and what we can

learn from this with regard to your difficulties and their background. It’s not hypnosis, and you will remain in control at all times. Closing your eyes is only meant to help you concentrate on the images and make sure you aren’t too distracted by your surroundings.

Step 2: Safe place Close your eyes, and let an image emerge of your safe place. When you’ve evoked that image, really try to move into that situation as if you were there right now. Take a good look around: Where are you now? What do you see? Are you alone? How do you feel now? What makes this place nice and safe for you? Where do you feel this nice feeling in your body? Concentrate on that feeling.

Step 3: Unpleasant situation in the present

Let go of this situation and the feeling, let it drift or fade away. Now let’s form an image of the difficult situation you’ve been through recently. If you think about those events that upset you so much, what image comes to mind? If you have an image, live it as if you’re there now. Take a good look around: Where are you now? Who are you with? What’s going on? How do you feel? What do you feel bad about now? Where do you feel that in your body? Focus on the feeling. Step 4: Affect bridge to the past Do you recognize this feeling? Then hold on to it, but release the image, let it drift or fade away. Now let a situation from your childhood emerge that is somehow linked

to this feeling. Don’t think about what it should be, just concentrate on the feeling and see what comes up. If nothing comes up, give it a little more time and, in the meantime, concentrate on the feeling you have now. Is it familiar to you? Where do you recognize it from? Don’t think about it too deeply. If more than one childhood situation arises at a time, just pick one to focus on.

Step 5: Exploration of meaningful past experience If you have an image, live it as if you're back there now. Take a good look around: How old are you now? Where are you? What’s going on? Who are you with? How do you feel now? Where do you feel that in your body? What does this mean to you?

Step 6: Rescripting of meaningful image

6a: Step into the image

Okay, pause the image like you have a remote control. And now I want to ask if you can put me into the image. I’d like to join you, because Little [client’s name] needs help. Can you see me? I'm going to say something to [antagonist’s name] and listen.

6b: Fight the antagonist

Arguing/fighting with the antagonist until the basic needs of the client in that situation are met.

6c: Comfort the little child

Explicit recognition of feelings, soft tone of voice, quiet pace.

6d: Ending rescripting with a nice activity

Take the little child to a pleasant place for some relaxation/spontaneity and play.

Step 7: Back to the safe place

Now let go of your feelings and the situation and move back to the safe place. Take a good look around and concentrate on your positive, pleasant feelings. Be back there in your mind. What’s good for you here? Just stay here for a while, and notice what’s good for you. Note: If the client feels good after the rescripting, this step can be omitted.

Step 8: Review and discussion The client can open their eyes again. Discuss the corrective emotional experience.

How do you feel now? How did you feel when I stood up for you? Where did you feel that in your body? What did you like about me standing up for you? Listening to what you need and standing up for it feels good. Generating a lot of these experiences will make you feel better and better. Notes Explicitly discuss the changed assumptions about oneself or the other (e.g. I always thought I was a bad kid but…). As a therapist, you may also be able to share what you have experienced and what can be regarded as recognition

for the feelings and needs of the client. Homework: repeat this experience often using (audio) flashcards, listening to the recording of sessions, and remembering the effect of the rescripting.

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Appendix 4: Roadmap for visualizing the healthy adult Aim: To increase awareness of the healthy adult mode Roadmap for visualizing the healthy adult Step 1: Explain why clients need to learn to visualize the healthy adult Step 2: Give a personal example of your own healthy adult Step 3: Focus on specific aspects of this memory Step 4: Ask the client to visualize her healthy adult Step 5: Review, discussion and homework

Note: For less serious problems, steps 4 and 5 can be done on their own. Step 1: Explain why clients need to learn to visualize the healthy adult

Okay, we’ve done a lot of work in therapy. And what you may have noticed is that I’ve talked a lot about your healthy, mature side. The goal of this therapy is to strengthen your healthy side. Maybe today we can talk about exactly what that means, that healthy side of you. I want to make that healthy part of you stronger. When faced with difficult situations, you need that part, your healthy

adult. You can activate that part of yourself by remembering past situations in which you were that healthy adult. By seeing yourself as a healthy adult in challenging situations from the past, you bring yourself into contact with that side of yourself, and you become more and more of a healthy adult. Step 2: Give a personal example of your own healthy adult

For example, when I have to prepare for a difficult situation, I sometimes take a moment to literally close my eyes and think back to a time when I was that healthy adult. And that helps me to recapture that feeling, to feel stronger, to actually be that healthy adult and to be able to face the difficulties better. If I had to do that now, I’d probably think back to a situation that occurred a few days ago... [describe a personal situation in which you felt emotionally touched or challenged, but which you handled well, making you look back with a certain pride).

Step 3: Focus on specific aspects of this memory Describe the different modalities of the experience: emotional, cognitive, physiological and postural aspects. What I’m feeling right now is... I feel that in [place in body]. What am I feeling so proud/self-assured/powerful about? If I had to find a posture that fits this good feeling, I would... [describe the posture you are adopting].

If I were to take a mental picture of myself when I experience this, I would see... [describe visual aspects of the healthy adult].

Step 4: Ask the client to visualize her healthy adult

Well, I want you to form a picture of your healthy adult, too. I want to work on that, is that okay? I’d like you to close your eyes... take a deep breath... now let a memory of your healthy adult come to mind. These are often memories of a situation that was difficult, but which you handled well... which you can look back on with a certain pride. What memory comes to mind? What’s that healthy feeling? Where do you feel that in your body? What is the meaning of this feeling? (What are you feeling so proud/self-assured/powerful or something similar about?) Look for a posture that fits this good feeling. Why does this posture feel new? If you take a mental picture of yourself when you experience this, what does that adult look like in that picture? Recognize that this is your healthy, mature part, this is you at your best, the captain of your ship. Notes Ask for those memories in which your client had a hard time, but which she looks back on with a certain pride, because she managed to handle the situation and everything she experienced.

Step 5: Review, discussion and homework Discuss all the different aspects and modalities of the healthy, mature side that client has just visualized. The homework is to visualize that image regularly, and to write down the properties of the healthy adult and reread them.

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Appendix 5: Roadmap for imagery rescripting – the client rewrites Aim: To strengthen the client’s healthy adult Roadmap for imagery rescripting – the client rewrites Step 1: Introduction Step 2: Visualize the healthy adult instead of a safe place Step 3: Visualize the traumatic event from a child/victim perspective Step 4: Rescripting the traumatic image from a healthy adult perspective Step 5: Rescripting the traumatic image from a child/victim perspective Step 6: Review and discussion

Step 1: Introduction

You’ve already made a lot of progress; you’ve allowed me to gain new experiences by letting me rewrite images of your past. In addition, you’re now increasingly able to form an image of your own healthy adult. That’s really good! The goal of the therapy is that you and your healthy adult can keep in touch with your basic needs, that you can listen to

what you need. To work towards that, I want to practice editing memories or images from your past with you. Step 2: Visualize the healthy adult instead of a safe place

Okay, now close your eyes. I want you to conjure up the image of that powerful, healthy part of yourself... that side of you we talked about a few sessions ago. What do you see? Now try to be that healthy adult. What’s going on around you? How do you feel? Where do you feel that in your body? Adopt the posture of your healthy adult, sit down in a way that suits this feeling. Notes By now starting the exercise with the visualization of the healthy adult, you are already ‘priming’ it; memory files regarding the healthy adult have already been activated, making it easier to reactivate them later in the exercise.

Step 3: Visualize the traumatic event from a child/victim perspective. Possibly visualize a recent trigger situation followed by affect bridge to the past. Let your client empathize with the child’s perspective, or, when the meaningful experience has taken place later in life, with her experience during that event. From that perspective, you explore the experience and ask for sensory information: ‘What’s going on?’ ‘What do you see, smell or hear?’ Have your client pause the image at the time when intervention is required.

Step 4: Rescripting from a healthy adult perspective

I want you to pause the image now. Okay? Now, bring in your healthy adult. Be that healthy adult. Where are you? What do you think of what’s going on here? Do you feel like you can handle it the way you are, or would you like to make yourself a little bigger? What do you want to do or say? Say it out loud! How do you feel when you say or do this? And where do you feel that in your body? What happens to Little [client’s name]? How do you feel about her? Step 5: Rescripting from a child/victim perspective Now ask your client if she can rewind the image to the point where the healthy adult steps into the image. Once she has rewound and paused at the appropriate point, ask your client to empathize with the perspective of the little child/victim and visualize the rescripting again.

Now, I want you to rewind to the point where you come into the picture as a healthy adult. But now I want you to be the child/victim again – so you’re sitting there, in the same situation, but now there is also Big [client’s name]. Do you see her? What's it like for you, now that she’s here? How do you feel now? And now what happens? (Have the situation described again from the perspective of the child/victim) What does she say? What does she do now? How does it feel to you to hear or see that? What do you need now? What else would you like? Can you tell her that? How does she react? And how does that feel?

Notes

Be clear in your instruction. Use tone of voice and tempo of speech to support the change of perspective.

Step 6: Review and discussion Explore the healthy experiences explicitly and extensively: ‘What have you learned?’; ‘How did it feel to stand up for yourself like that?’ ‘Where did you feel that? Can you still feel that a little bit?’ Also, try to discuss with the client ways in which she can hold on to these experiences: audio flashcards, written flashcards, repeating certain parts of the exercise at home, listening to (certain parts of) the recording of the session.

Notes It may not be necessary to return to the safe place before completing the exercise.

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Appendix 6: Roadmap for rescripting future scenarios Aim: To prepare healthy adults for future triggers Roadmap for rescripting future scenarios Step 1: Preliminary discussion Step 2: Visualize the healthy adult Step 3: Visualize the feared scenario Step 4: Make contact with the healthy adult Step 5: Coaching in self-compassion, cognitive restructuring, behavioural change Step 6: Review, discussion and homework

Note: The individual steps can be practiced separately, spread out over several sessions. Step 1: Preliminary discussion Rational future-oriented imagery rescripting We’re now in a phase of therapy in which we focus more and more on the future. We’re going to use the power of imagery to prepare for problem situations that may arise in the future. By imagining how to deal with these problem situations now, it will become a

lot less difficult to deal with them later on in real life. Possibly: Research indicates that the same brain areas are active when you retrieve a memory from the past and when you imagine a situation in the future. For many years now, sport has been using futureoriented imagery to improve performance in the future. Determine which problem situations are likely to occur in the future: How likely is it that this situation will occur? Is the situation significant to the difficulties? How concrete is the situation? What are typical emotional and behavioural responses in such situations? Preliminary discussion of behavioural change How would your client want to deal with such a situation?

Step 2: Visualize the healthy adult

In these kinds of situations, we really need our healthy adult, the strong [client’s name] who can stay in touch with her own feelings, but at the same time can deal with difficult, challenging situations. One way to prepare for those situations is to close your eyes now. Just close your eyes. And I want to ask you if you can make contact with this healthy, mature part of yourself. The captain of the ship, who is strong, but not in a tough, closed way. Just be that healthy adult. Adopt an attitude that suits her. How do you feel now that you’re that healthy adult?

Step 3: Visualize the feared scenario Ask for images to emerge of the feared scenario and to recognize the old patterns of feelings and behaviour. Ask your client to describe these images as vividly as possible, and to be alert to automatic emotional and behavioural responses: ‘Do you recognize this feeling? Where do you recognize it from? So now you feel like the child you once were, the child who also felt scared and threatened?’

Step 4: Make contact with the healthy adult

You feel like that scared child again now, and your protector mode would like to take over and get rid of that feeling. But instead, I want you, as captain, to take the helm and set the course. Step 5: Coaching in self-compassion, cognitive restructuring and behavioural change In this phase the three steps of the healthy adult are practiced: Self-compassion You’re feeling... (feelings evoked by the client). Of course you feel that, because in this situation... (explicit understanding of situational aspects). Of course you feel that way, because with what you’ve been through... (explicit understanding of

emotionally charged history). Cognitive restructuring Recall all rational arguments from previous sessions that contradict the negative self-image. Why is that assumption wrong again? Behavioural change Ask your client to visualize the previously discussed script, or coach your client in coming up with behavioural alternatives on the spot. Focus on details: what exactly do you say; in what tone; with what posture?

Step 6: Review, discussion and homework Discuss the experience during the imagery, and provide concrete and specific homework to practice this futureoriented imagery rescripting at home.

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