Smucker, Mervin, Langkaas, Tomas, Hoffart, Asle, McCullough, Leigh. Using Imagery to Promote Emotional Change. Symposium presented at the 37^th Annual Congress of the European Association for Behavioural & Cognitive therapies, Helsinki, Finland.

 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.

Clinicians and researchers have increasingly observed that mental imagery is generally more emotional than verbal processing of the same material and that emotional memory tends to be visual in nature.  As such, directly challenging and modifying distressing images can 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

When the Imagery Rescripting shifts to ADULT-CHILD imagery only (i.e., IRRT Phase 3 only), the PIQ-B is can be helpful in obtaining a quick and ongoing cognitive assessment of the individual’s schematic shift from maladaptive abuse-related beliefs (schemas) to more adaptive abuse-related beliefs and self-schemas in the following areas:

• from self-directed anger, self-hatred, and self-blame to self-acceptance,
• from feeling disconnected from others and “abandoned” to feeling a sense of “connectedness” and attachment, especially within oneself,
• from feeling untrusting and unsafe with oneself to feeling more trusting and safe with oneself,
• from perceived fragmentation of the ADULT and CHILD “parts” of self to a healthier accommodation and integration of the ADULT and CHILD.

The PIQ-B is administered by the clinician immediately following the completion of an ADULT-CHILD (Phase 3 only) imagery session. The clinician introduces the PIQ-B to the client as follows:

                  I would like to ask you a few questions about the imagery session we just completed. I will be asking you to rate your response to each item on a 0-100 scale. Do you need a few moments to get reoriented?    

Once the client indicates a readiness to begin, the clinician reads alouds the items of the PIQ-B beginning with Item A.

Mervin Smucker

A critical consideration in the treatment of posttraumatic stress disorder is whether the traumatic event producing the posttraumatic stress reaction is a Type-1 or Type-2 trauma.  In short, a Type-1 trauma is an unexpected, isolated traumatic event of relatively short duration (such as, a motor vehical accident, a single incident of physical or sexual assault, a natural disaster), that often involves fear of dying during the event itself.  Recovery from a Type-1 traumatic event is often relatively rapid, especially if the trauma victim does not suffer from any kind of permanent or lasting physical injury.  By contrast, a Type-2 trauma is more long-standing in nature and often involves a series of expected, repeated traumas, such as ongoing sexual or physical abuse or torture, that result in a negatively altered schematic view of oneself, others, and the world.  Type-2 traumas often develop into more complex and chronic posttraumatic stress responses that are linked to other psychological disorders, including higher rates of depression, anxiety and panic disorders, eating disorders, substance abuse, chronic relationship difficulties and long-standing personality disturbances evidenced by emotional lability, suicidality, and self-abusive behaviors.

Mervin Smucker

This randomized clinical outcome 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 escripting, 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.

Mervin Smucker

Why do some people in difficult circumstances survive well, while others who may appear to be thriving commit suicide? There is no easy answer to this question; however, the perception of hopelessness experienced by an individual in a given situation appears to be a critical factor. Prof. Beck at the University of Pennsylvania spent many years researching the topic of suicide, including the variables that best predict suicide intent and suicide itself. Somewhat surprising was the finding that neither severity of depression, nor depression per se, was found to be a significant predictor of suicide. Of all the various components of depression, the degree of perceived hopelessness was found to be the single best predictor of suicide (Beck et. al. 1985). Beck & colleagues developed the Hopelessness Scale, a self-report scale that measures an individual’s present degree of hopelessness (Beck et. al., 1974). The scale is widely used in inpatient and outpatient settings today.

Mervin Smucker Ph.D  is an international trauma consultant and author of numerous articles and books on trauma and cognitive-behavioural therapy interventions.

Core maladaptive schemata are deep-seated, stable and enduring beliefs about oneself that develop as a result of negative interactions with significant others in childhood (e.g., caregivers, family members, teachers, peers) and are elaborated throughout one’s lifetime. These core negative schemata are unconditional in nature, highly believable and resistant to modification, emotionally charged, overpowering and often overwhelming when activated. Confronting and modifying negative schemata, while possible, is generally a challenging and long-term endeavor, as schemata tend to self-perpetuate and self-reinforce via maintenance mechanisms that distort information in order to maintain the schemata (e.g., by magnifying data that confirm the schemata and screening out data that refute the schemata).

Dr. Mervin Smucker is an international trauma consultant and author of numerous articles and books on trauma and cognitive-behavioural therapy interventions.

1. Nature of trauma (e.g., physical or sexual assault, combat, occupational injury, vehicular accident, natural disaster)?
2. Type of trauma:  Type I vs. Type II trauma (single event vs. multiple,  repeated/prolonged events)?
3. Number and duration of traumatic events?
4. Age of trauma victim?
5. Human-perpetrated (intentional, unintentional) vs. non-human-perpetrated trauma?
6. Victim-perpetrator relationship?
7. Perceived severity of trauma (e.g. life threatening)?
8. Emotional state at time of trauma (e.g. degree of emotional upset, numbing, dissociation)?
9. Trauma coping responses (peri-trauma, post-trauma)?
10. PTSD symptoms (past, current)?
11. Predominant PTSD emotions and related cognitions?
12. Other trauma-related emotions and cognitions?
13. Previous trauma(s) experienced?

Mervin Smucker

Since Dr. Smucker first developed Imagery Rescripting as a CBT intervention in the early 1990s, the use of imagery as a primary therapeutic agent in fostering cognitive and emotional processing of traumatic material has been being employed by a growing number of CBT clinicians.  Since much of the cognitive-affective disturbance associated with intrusive memories is embedded in the traumatic images themselves, directly challenging and modifying the traumatic imagery becomes a powerful, if not preferred, means of processing trauma-related material.

Trauma victims suffering from PTSD can be effectively treated with Imagery Rescripting and Reprocessing Therapy (IRRT) – an imagery-based, trauma-processing CBT treatment (with stabilization components) that blends visual and verbal interventions to access, modify, and process traumatic memories.  Specifically, each IRRT session comprises three phases that involve: (1) visually activating and reliving the traumatic imagery, (2) transforming the trauma-related imagery into mastery/coping imagery, and (3) facilitating emotional self-regulation through self-calming, self-soothing, and self-nurturing imagery.  The goal of IRRT is to: (a) reduce or eliminate posttraumatic stress symptoms, (b) modify maladaptive trauma-related beliefs relating to guilt, shame, anger, and fear, (c) enhance one’s capacity to self-nurture and self-calm, and (d) promote the development of adaptive schemas. IRRT is a manualized CBT treatment for PTSD with empirical support.

Mervin Smucker Ph.D

Symposium presented at the 39^th 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:

1. Pierre Janet (1880)
2. Sigmund Freud (1898)
3. Carl Jung (1930)
4. Aaron Beck (1985)

Which of the following is not part of Beck’s Cognitive Therapy model?

1. Cognitions consist of thoughts and images
2. Repeated and prolonged exposure to distressing images leads to habituation
3. Verbal techniques are generally used when the affective disturbance is encoded verbally
4. 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?

1. Janet
2. Jung
3. Freud
4. All of the above

Which of the following CBT treatments does not use imagery as a key component?

1. Prolonged Exposure
2. Imagery Rescripting
3. Schema Therapy
4. Client Centered Therapy

The only manualized imagery rescripting treatment to date is:

1. Prolonged Exposure (PE)
2. Imagery Rescripting & Reprocessing Therapy (IRRT)
3. Schema Therapy
4. Gestalt Imagery

IRRT was originally developed for:

1. Victims of adult rape with PTSD
2. Victims of industrial accidents with PTSD
3. Adult survivors of childhood abuse with PTSD
4. None of the above

Which of the following is not true of IRRT?

1. Especially useful with DID clients
2. Blends visual and verbal interventions
3. A trauma-processing CBT treatment with stabilization components
4. An extension of Beck’s model of cognitive therapy

Which of the following are exclusionary criteria for the three phases of IRRT?

1. Significant substance or alcohol abuse
2. Ongoing self-injurious or suicidal behaviours
3. Involvement in current abusive relationship
4. All of the above

Which of the following is not part of IRRT?

1.  Socratic imagery
2. Imagery modification
3. Guided imagery
4. Schema modification

During the Mastery Phase of IRRT, the ADULT self today enters the trauma scene:

1. Just before the worst happens (before the SUDS have peaked)
2. While the worst is happening (while the SUDS are at their peak)
3. After the worst has happened (after the SUDS have subsided some)
4. 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.

Mervin Smucker

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.

Mervin Smucker

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.

Mervin Smucker

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
• distraction

The Re-Learning Process

1. Identify the feelings, body sensations, thoughts, and images that occur during a panic attack.
2. Identify the terrifying thoughts/beliefs you have about panic attacks.
3. Become educated about the nature of your panic symptoms so that you can learn to more accurately interpret your bodily sensations.
4. Learn coping techniques (e.g., controlled breathing, distraction) that will reduce your symptoms to a more manageable level.
5. Conduct experiments that test out the validity of your frightening thoughts and beliefs (e.g. using the Weekly Panic Log)

Mervin Smucker

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

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.

Mervin Smucker

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.

AUTOMATIC THOUGHT…

1.  What is the evidence to support this thought? Counter evidence?
2.  Are there any alternative interpretations of this event?
3.  Possible errors in my thinking? Cognitive distortions?
4. 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?
5. What is the most realistic outcome?

SUMMARIZED RATIONATIONAL RESPONSE…

Mervin Smucker