Symposium presented at the 39th Annual Congress of the European Association for Behavioural & Cognitive Therapies, Dubrovnik, Croatia.
The use of imagery interventions in CBT has been an emerging topic among CBT theorists and clinicians in recent years. Clinicians are finding that intrusive, affect-laden images can contribute to significant distress in a variety of psychological disorders, and that using imagery interventions directly on upsetting images can be a powerful approach that leads to alleviation of emotional distress.
Research has found that emotional memory tends to be visual in nature, and conversely, mental imagery is generally more emotional than verbal processing of the same material. As such, directly challenging and modifying distressing images appears to be a powerful means of promoting emotional change.
The speakers in this symposium present different approaches that use imagery in CBT with both anxiety disorders and personality disorders. Case examples are used to illustrate the approaches.
Mervin Smucker Ph.D
The earliest use of “imagery rescripting” interventions is found in the work of:
- Pierre Janet (1880)
- Sigmund Freud (1898)
- Carl Jung (1930)
- Aaron Beck (1985)
Which of the following is not part of Beck’s Cognitive Therapy model?
- Cognitions consist of thoughts and images
- Repeated and prolonged exposure to distressing images leads to habituation
- Verbal techniques are generally used when the affective disturbance is encoded verbally
- Visual techniques are often more effective when the affective disturbance is embedded in imagery
Which of the following therapists used imagery interventions in their clinical work with “neurotic” patients?
- All of the above
Which of the following CBT treatments does not use imagery as a key component?
- Prolonged Exposure
- Imagery Rescripting
- Schema Therapy
- Client Centered Therapy
The only manualized imagery rescripting treatment to date is:
- Prolonged Exposure (PE)
- Imagery Rescripting & Reprocessing Therapy (IRRT)
- Schema Therapy
- Gestalt Imagery
IRRT was originally developed for:
- Victims of adult rape with PTSD
- Victims of industrial accidents with PTSD
- Adult survivors of childhood abuse with PTSD
- None of the above
Which of the following is not true of IRRT?
- Especially useful with DID clients
- Blends visual and verbal interventions
- A trauma-processing CBT treatment with stabilization components
- An extension of Beck’s model of cognitive therapy
Which of the following are exclusionary criteria for the three phases of IRRT?
- Significant substance or alcohol abuse
- Ongoing self-injurious or suicidal behaviours
- Involvement in current abusive relationship
- All of the above
Which of the following is not part of IRRT?
- Socratic imagery
- Imagery modification
- Guided imagery
- Schema modification
During the Mastery Phase of IRRT, the ADULT self today enters the trauma scene:
- Just before the worst happens (before the SUDS have peaked)
- While the worst is happening (while the SUDS are at their peak)
- After the worst has happened (after the SUDS have subsided some)
- None of the above
Dr, Mervin Smucker
The unique garb of the Amish symbolizes nonconformity and remains a distinctive feature of Amish society. Their clothing styles have changed little since regulations were first instituted under Jacob Amman’s leadership over 300 years ago. The women wear ankle-length, full-peasant dresses with aprons. Typical colors include black, blue, brown, and purple. The women also wear white organdy prayer caps at all times. The men wear front-fall pants, no neckties, and coats without lapels. Hats are customarily worn and serve to distinguish the age and status of the wearer. All men grow beards after they marry. The children’s clothing is patterned after that of adults. Hairstyle is specified for both sexes. Nothing of a non-utilitarian value is to be worn, including buttons or jewelry.
Many people carry around with them malaptive beliefs and assumptions that render them vulnerable to emotional disturbances, especially during times of stress. The first step in challenging our dysfunctional beliefs is to identify them. One technique for doing so is to write down an upsetting thought as it comes to you. Then pretend that the thought is true and ask yourself: „What does this mean to me, and why is it upsetting?“ Likely another negative thought will follow, which you also write down. Repeat the procedure by asking youself again: „If that thought is true, what does it mean to me?“ Continue to identify and write down related negative thoughts until you can no longer fill in the blanks. Then, infer from the themes that unite these thoughts what your underlying assumptions might be.
Dr. Mervin Smucker is an international trauma consultant and author of numerous articles and books on trauma and cognitive-behavioural therapy interventions.
The concurrent presence of chronic PTSD symptoms, maladaptive traumagenic beliefs and schemas in survivors of childhood trauma suggests the need for a therapeutic approach that simultaneously addresses these different levels of pathology. Imagery rescripting was developed as an expanded information-processing, schema-focused model in which the recurring, intrusive traumatic memories are conceptualized both within a PTSD framework and as part of one’s core schemata. An extension of Beck’s cognitive therapy model and Foa’s extinction model, the procedure employs imagery and verbal interventions to activate the entire trauma memory (visual, affective, sensory and cognitive components), as well as to identify, challenge, and modify the recurring traumatic imagery along with the trauma-related beliefs and schemas. The use of imagery enables the traumagenic schemas (e.g., powerlessness, unlovability, mistrust, abandonment) to be visually activated through the eyes of the traumatized child, and challenged, modified, and reprocessed through the eyes of the empowered adult.
Mervin R. Smucker
The nature of traumatic memories has implications for how trauma-related material is accessed, confronted, and processed in psychotherapy. Traumatic memories are generally encoded and accessed differently from non-traumatic or narrative memories. In contrast to narrative memories, traumatic memories are more likely to:
- lack in verbal narrative and context;
- involve primary sensory stimuli (visual, kinesthetic, auditory)
- be encoded in the form of vivid sensations and images that are not accessible by linguistic means alone;
- be state dependent;
- be difficult to integrate via assimilation or accommodation because they are stored differently
- dissociated from conscious control,
- “fixed” in their original form and remain unaltered by the passage of time.
Cognitive therapy has described underlying dysfunctional beliefs as schemas. Schemas are “cognitive structures” according to cognitive therapy founder Aaron T. Beck. Another way to approach a schema is to think of it as a story deeply embedded in a person’s mind and used as a way to interpret the world. Uncovering and challenging such stories, and helping a person to understand how these stories empower their decisions and values can be a transformative process. Through such a process a person who has absorbed and lives according to stories of helplessness or victimization can learn to tell new stories about themselves as the hero of their own journey.
Significant recovery from Panic Attacks occurs when you:
- learn to accurately re-interpret your bodily sensations
- apply variety of coping techniques when you begin to feel Panic-like symptoms
- controlled breathing
- focused breathing
- brown bag technique
- de-catastrophizing of symptoms
The Re-Learning Process
- Identify the feelings, body sensations, thoughts, and images that occur during a panic attack.
- Identify the terrifying thoughts/beliefs you have about panic attacks.
- Become educated about the nature of your panic symptoms so that you can learn to more accurately interpret your bodily sensations.
- Learn coping techniques (e.g., controlled breathing, distraction) that will reduce your symptoms to a more manageable level.
- Conduct experiments that test out the validity of your frightening thoughts and beliefs (e.g. using the Weekly Panic Log)
In his memoir, The Blessing, poet Gregory Orr notes that the French root of the word “blessing” is blesser, meaning “to wound.” Our wounds and our blessings are inextricably linked, Orr demonstrates, as he recalls a childhood trauma in which he accidentally shot and killed his younger brother when on a family hunting trip. The incident has haunted and shaped Orr’s journey as a writer and poet, in which he has produced such works as Poetry as Survival and How Beautiful the Beloved, as well as his memoir, The Blessing, which explores the dysfunctional family environment of his childhood from a hard-won perspective of compassion for self and others.
Mervin Smucker is an expert in trauma. Imagery rescripting and reprocessing therapy is an information-processing, schema-focused model in which the recurring traumatic abuse memories are treated with a combination of prolonged imaginal exposure and imaginal rescripting.
Haiku LMS was developed to bring teachers, students and parents together in a user-friendly and impeccably-designed online learning environment. Without HTML training, teachers can use drag-and-drop content positioning to create calendar and event scheduling, assignment listings, image galleries, documents, video, audio, blogs, discussion boards, and other classroom content on the web, choosing what they share with parents and students. Since 2006, Haiku LMS has combined an excellent product together with a well-executed marketing strategy to build online relationships with tens of thousands of teachers around the world, evolving into a company with nearly 50 employees and five million dollars in annual sales.
In the cognitive therapy model of emotional disorders, „automatic thoughts“ are viewed as highly subjective, „stream-of-consciousness“ cognitions that are directly linked to emotion. They appear to come out of nowhere and are not preceded by a process of deliberation or careful reasoning. As such, they are often twisted, distorted, and involve cognitive errors; yet they appear to the individual as plausible and are often accepted uncritically as reality-based and render the individual vulnerable to bouts of depression and anxiety.
The following is a technique for testing the validity of one’s automatic thoughts.
- What is the evidence to support this thought? Counter evidence?
- Are there any alternative interpretations of this event?
- Possible errors in my thinking? Cognitive distortions?
- What is the worst that could happen if my negative interpretation is true? What is the worst that could happen if my negative interpretation is true? What is the most realistic outcome?
- What is the most realistic outcome?
SUMMARIZED RATIONATIONAL RESPONSE…
In Western culture we are schooled for achievement, ranking, and competition as a path to success. The American Dream articulates the idea entertained by millions of immigrants and working class people that hard work and opportunity for all will lead to happiness in the form of life, liberty, and a house with a yard and white picket fence. Of course, American literature is full of critiques of this dream, too. For instance, in The Great Gatsby, Jay Gatsby achieves great wealth in pursuit of winning Daisy, the symbol of the class barrier he is unable to cross. The narrator, Nick Carraway, who witnesses Gatsby’s rise and fall, revises his own story as a result of what he’s witnessed. Recognizing one’s own underlying story is the first step in becoming aware of how such stories can unconsciously influence virtually every choice one makes.
„The world is dangerous“
- Calculating probabilities of specific events.
- Listing advantages/disadvantages of current worldview.
- Cost–benefit analysis of specific vigilance and avoidance behaviors.
- Identifying reasonable precautions.
„Events are unpredictable and uncontrollable.“
- Listing advantages/disadvantages of belief.
- Listing areas of life over which one has some control, and rating the degree of control for each.
- Doing a cost–benefit analysis of specific efforts at prediction/control.
- Keeping a daily log of behaviours that produce predicted outcomes.
- Engaging in behaviours with high probability of predictable outcome.
- Accepting that some events are unpredictable.
„I am incompetent.“
- Examining evidence for competence in daily life.
- Examining unreasonable expectation of competence in extreme an (unusual circumstances.
- Keeping a daily log of competent coping.
- Using graded task assignment.
„Other people cannot be trusted.“
- Listing known persons who are trustworthy, and listing specific ways in which each can be trusted.
- Rating people on a continuum of trustworthiness.
- Examining one’s history of relationship choices and if better alternatives are available?
- Conducting behavioral experiments involving trusting others in small ways.
- Keeping a daily log of people who honour commitments.
„Life is meaningless.“
- Listing activities that formerly were rewarding.
- Scheduling pleasurable/rewarding activities.
- Recognizing feelings of loss as a way of confirming meaning.
- Examining which goals and activities are longer useful/adaptive.
- Working toward an acceptance of death.
- Finding meaning in each day.
Tuning into your breath can be the first step to understanding how your physiological state affects your thoughts and feelings. In our hectic world with its multiple electronic communications systems, it is easy to live in the mind and get caught up with thoughts, pressures, and a sensation of being rushed. Simply taking a few minutes to be present with your breathing can do much to help you regain a sense of calm. At first, just notice, without judging, where you naturally inhale and exhale. Does your breath mostly reside in your upper chest, or do you tend to breath with your belly? As you pay attention to the breath, allow it to expand and take up more room in your body. Then, slowly exhale. You might try counting to three or four on the in-breath, then pause for a moment, and count to three or four on the out-breath, followed by a pause. Such even breathing, with slight rests between inhale and exhale, can help to reset your body’s sense of equilibrium and calm your mood.
A high percentage of traumatized individuals suffering from posttraumatic stress regularly engage in substance use and/or abuse (e.g. alcohol, drugs) in an attempt to numb themselves to their painful trauma-related thoughts/feelings and thereby to avoid the re-experiencing of trauma-related material (e.g. flashbacks, intrusions). These avoidance behaviors frequently pose a serious obstacle to, and interfere with, trauma treatment and serve to further reinforce their traumagenic beliefs that they are unable to cope. With these substance abuse clients a “stabilization phase” is generally an essential first-step of treatment, the primary purpose of which is for clients to learn to more adaptively manage/regulate their trauma-related emotions and dysfunctional coping strategies. If trauma-processing treatment interventions are attempted before a client has stabilized vis-à-vis his/her use of drugs or alcohol as a “coping” strategy, the trauma treatment will likely fail.
This randomized clinical outcome unpublished study examined the efficacy of two different trauma treatments for chronic posttraumatic stress disorder (PTSD) related to female adult survivors of childhood sexual abuse in an outpatient setting. Twelve adult females (mean age 35 years), who had been victims of severe childhood sexual abuse perpetrated by a male family, were randomly assigned to one of two treatment groups: (1) imagery rescripting, which combines visual reliving and rescripting of the traumatic imagery or (2) prolonged exposure plus stress inoculation training. At pre-treatment, all patients met DSM criteria for chronic PTSD. Each treatment consisted of an extensive pre-treatment evaluation session plus eight therapy sessions (1.5 to 2.0 hours each) with regular between-session homework. At post-treatment and 6-months follow-up, none of the patients in either treatment group met criteria for PTSD. In addition, all patients in both treatment groups showed significant reductions in PTSD-related symptoms, although the overall reduction of PTSD symptoms for patients in the imagery rescripting treatment group were noticeably greater than those in the prolonged exposure – stress inoculation group.