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Schema coaching, a recently developed approach, integrates a range of techniques from psychodynamic therapy, cognitive behavioural therapy, attachment theory and gestalt therapy. This provides the suitably trained and ethically adherent coaching psychologist with a wide range of powerful experiential techniques to deal with persistent and protracted client problems. In this article, the third in the series on schema coaching, the techniques of imagery rescripting and transformational chairwork are explored. Imagery rescripting is designed to help the client to get in touch with painful archaic emotions and to help to start to heal these distressing memories. The client cannot undo the past and cannot delete old memories that have been imprinted but new neural pathways that inhibit the old ones can be created with the help of the coaching psychologist. Rescripting does not change the memory but does enable the client to see it in a new way and find new meaning in it. By contrast transformational chairwork refers to a wide range of techniques in which chairs are used to help clients better gain an understanding of themselves in the present moment. The technique was first used in psychodrama, but it was Fritz Perls who popularised the approach in gestalt therapy. Chairwork can be used in a wide range of ways in schema coaching including to explore and help resolve painful historical events, to strengthen the healthy adult, to reduce the impact of the inner critic or to help deal with painful emotions such as sadness, guilt, anxiety or anger. Both techniques are powerful and highly experiential so are particularly useful for intelligent, articulate executives who have a strong tendency to intellectualise their problems while having a real desire to deal with the underlying drivers of their dysfunction. [ABSTRACT FROM AUTHOR]

The effectiveness of imagery rescripting (IR) in reducing psychological symptoms associated with aversive memories has been confirmed across various disorders. To better understand the neural mechanisms underlying IR, we assessed the immediate and lasting effects and their associations with imagery tendency by using unpleasant pictures depicting child maltreatment within a population with childhood maltreatment (CM) history. Participants (n = 68) were instructed to engage in two experimental phases while electroencephalogram was recorded. In the rescripting phase, participants viewed neutral or unpleasant pictures and then either imagined the same pictures or rescripted unpleasant ones to assess immediate effect. In the re‐exposure phase, participants passively viewed all pictures without instruction to assess lasting effect. Participants rated their subjective valence and imagery vividness in the rescripting phase or intensity of negative feelings in the re‐exposure phase. IR led to an attenuation of the late positive potential (LPP) amplitude in the late time window (2000–6000 ms at parietal‐occipital electrodes) and a decrease in self‐reported unpleasantness during the rescripting phase. After 5‐min interval, unpleasant pictures with rescripted history elicited smaller LPP (400–1500 ms at centro‐parietal electrodes) and negative feelings than those with imagery history in the re‐exposure phase. The higher habitual use of imagery was associated with a greater reduction in late LPP during the rescripting phase and full‐time range LPP during the re‐exposure phase. The current findings suggest that IR has an immediate effect and a lasting effect on subjective and neural response in the CM population. Individuals with higher imagery tendency are likely to profit more from IR. [ABSTRACT FROM AUTHOR]

Background: Intrusive re-experiencing of trauma is a core symptom of posttraumatic stress disorder. Intrusive re-experiencing could potentially be reduced by 'rewinding', a new treatment approach assumed to take advantage of reconsolidation-updating by mentally replaying trauma fast-backward. Methods: The present analogue study was the first to investigate 'rewinding' in a controlled laboratory setting. First, 115 healthy women watched a highly aversive film and were instructed to report film-related intrusions during the following week. Twenty-four hours after film-viewing, participants reporting at least one intrusion (N = 81) were randomly allocated to an intervention (fast-backward, or fast-forward as active control condition) or a passive control condition. Intervention groups reactivated their trauma memory, followed by mentally replaying the aversive film either fast-backward or fast-forward repeatedly. Results: Results indicate that replaying trauma fast-backward reduced intrusion load (intrusion frequency weighted for intrusion distress) compared to the passive group, whereas replaying fast-forward did not. No above-threshold differences between fast-backward and fast-forward emerged. Conclusion: Present findings strengthen the view that 'rewinding' could be a promising intervention to reduce intrusions. [ABSTRACT FROM AUTHOR]

Imagery rescripting (ImRs) is a prominent approach to help individuals alleviate the negative consequences following victimization. In two studies (total N = 641), participants experienced a victimization incident induced by a video. In subsequent audio‐guided (ImRs or control) interventions, we examined the impact of imagined (i) victims' active or passive role, (ii) punishment for the offender (yes/no), and (iii) offender moral change (yes/no) on both psychological states and behavioural intentions. Specifically, after the ImRs, participants reported their feelings of empowerment, justice‐related satisfaction, positive and negative affect, and intention to act after the intervention. Results revealed that ImRs significantly reduced negative consequences of victimization, with active ImRs surpassing passive ImRs in enhancing victims' empowerment and positive affect. Notably, neither imagined offender punishment nor moral change affected the efficacy of ImRs. We discuss these findings in light of ImRs as an intervention to address victims' threatened needs. [ABSTRACT FROM AUTHOR]

Imagery rescripting commonly seeks to target memories by imagining the intervention of a caregiver. In some cases, such as obsessive-compulsive disorder (OCD), the target imagery may also be episodic future imagery, and a sense of mastery may be more salient than an intervening caregiver. We aimed to compare how varying the target image and rescripting approaches influenced beliefs, emotions, or characteristics of idiopathic imagery relevant to OCD. We recruited 250 online participants high in OCD traits. Participants were randomly assigned to one of four conditions, reflecting variations in target image (memory/future) and rescripting approach (attachment/mastery). Self-administered audio-guided exercises were used to elicit the target image and facilitate rescripting. Participants completed a range of measures before and after rescripting. Participants in all groups tended to report changes in self-related beliefs, emotions, and imagery characteristics. In general, these results did not differ between target images or rescripting approaches. However, mastery-based rescripting reduced anxiety associated with episodic future imagery to a greater extent than attachment-based rescripting. These results suggest that the general benefit of modifying emotionally salient imagery tends to outweigh differential effects of varying the target image or rescripting approach. Standardised re-scripting protocols could be varied based on the individual's needs. [ABSTRACT FROM AUTHOR]

Objective: People who hear voices (auditory verbal hallucinations) often have post‐traumatic stress disorder (PTSD) symptoms. Cognitive behavioural therapies (CBT) have yielded inconsistent findings when treating voices and PTSD symptoms in voice hearers. Preliminary evidence suggests imagery rescripting (ImRs) is associated with large reductions in voice hearing and PTSD symptoms. This study replicated past studies using a larger sample to examine the effectiveness of ImRs in reducing such symptoms. Method: Participants (N = 49; 65.3% female; Mage = 35.86) were clients at an Australian transdiagnostic clinic for voice hearers. A one‐arm open trial design was used with three pre‐treatment baselines and a mid‐treatment, post‐treatment and 3‐month follow up assessments of PTSD symptoms (Posttraumatic Diagnostic Scale for DSM‐5), voices (Hamilton Program for Schizophrenia Voices Questionnaire) and emotional symptoms (Depression Anxiety and Stress Scales‐21). Five single‐item measures were administered weekly to explore the trajectories of change in trauma intrusions, voice‐related distress, voice frequency and positive and negative voice valance. Results: ImRs was associated with very large reductions in PTSD symptoms and voices (both emotional and physical characteristics of voices) and emotional symptoms at post‐treatment and follow‐up (η2p = 0.24–0.44). There were medium‐large to large reductions in weekly symptoms of intrusions, voice‐related distress, voice frequency and negative voices (η2p = 0.12–0.16) and a non‐significant increase in positive voices (η2p = 0.05). Conclusions: This study provides further evidence that ImRs is an effective treatment for voices and PTSD symptoms in voice hearers with a range of diagnoses. Randomised controlled trials are needed to compare the efficacy of ImRs to CBT protocols. [ABSTRACT FROM AUTHOR]

ABSTRACTBackground: Imagery rescripting (ImRs) has shown to be an effective treatment for posttraumatic stress disorders (PTSD) resulting from childhood-related trauma. The current theory is that the change of meaning of the trauma memory is central to the treatment. Several authors have suggested that the expression of needs, feelings and actions may act as potential healing factors, but little specific research aimed at (in)validating this hypothesis has been done so far.Objective: In this study we investigated to what extent the expression of inhibited action tendencies and the fulfilling of needs lead to the reduction of PTSD symptoms in clients with early childhood trauma.Method: Recordings of 249 therapy sessions of 24 ImRs treatments were rated with an observation instrument developed for this purpose, after which the scores were related to pre and posttreatment symptoms, assessed with the Impact of Events Scale-Revised (IES-R).Results: Scores on the IES-R decreased from pretreatment to posttreatment. The two subscales of the NATS (At-scale and N-scale)significantly predicted the posttreatment scores on the IES-R after controlling for the influence of pretreatment IES-R scores: the better the expression of inhibited action tendencies and the better the fulfilling of needs, the lower the symptoms after treatment.Conclusions: This pilot study on the underlying mechanisms of ImRs in PTSD treatment has shown that the expression of action tendencies and fulfilling basic needs during ImRs are associated with a decrease in PTSD symptoms after treatment, and that actions and basic needs cannot be viewed separately. Follow-up research could focus on which of the six domains of the Needs and Action tendencies Scale (NATS) has the greatest effect on the reduction of PTSD symptoms. With this information we can further improve the ImRs protocol.

Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment.Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs).Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12–18 sessions) or ImRs + GST (12–18 ImRs + 52–58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5.Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97–2.87; dImRs + GST = 2.44, 95%CI = 1.99–2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = −0.33–0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months.Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment.Trial registration: ClinicalTrials.gov identifier: NCT03833531

Background: The relationship between trauma-related negative cognitions and post-traumatic stress disorder (PTSD) symptoms has been studied frequently. Several studies found a mediating effect of trauma-related negative cognitions on symptom reduction in studies on different psychotherapeutic treatments, however, this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR).Objective: To analyse the role of trauma-related negative cognitions in the treatment of PTSD due to childhood trauma with EMDR and ImRs.Method: N = 155 patients with PTSD due to childhood trauma aged between 18 and 65 (M = 38.54) participated in a randomized clinical trial and were treated with either EMDR or ImRs in Australia, Germany, and the Netherlands between October 2014 and June 2019. We analysed the relationship between PTSD symptoms (Clinician-administered PTSD Scale for DSM-5, CAPS-5 and Impact of Event Scale revised; IES-R, completed twice for index trauma and for all other traumas) and trauma-related negative cognitions (Post-Traumatic Cognitions Inventory, PTCI) using Granger Causality analyses with linear mixed models on person-centered variables. Assessments were conducted pre-treatment, post-treatment (12 sessions in 6 weeks), eight weeks post-treatment, and one year after the pre-treatment assessment.Results: Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectional) as measured by the CAPS and the IES-R for index trauma. For the IES-R related to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. On the level of PTCI subscales only changes in cognitions about oneself preceeded changes in PTSD symptoms.Conclusions: The results support the idea of a general role of trauma-related negative cognitions in the treatment of PTSD. The analyses should be replicated with a higher frequency of assessments.

Schema coaching uses the methods of schema therapy, applying these with high-functioning individuals in the workforce. Imagery rescripting, a core schema technique, is an imagery-focused approach designed to reduce distressing memories and so change related beliefs and early maladaptive schemas. This qualitative study used an interpretative phenomenological approach to investigate the experience of clients undertaking imagery rescripting by employing semi-structured interviews. Overall, the experience of clients was that imagery rescripting was powerful but emotionally draining and had a positive long-term impact. There can be cautious optimism about suitably trained, supervised and ethically adherent coaches using this approach.

Introduction: Imagery rescripting (ImRs) is a psychotherapeutic intervention targeting aversive memories. During the three-phase intervention, patients reexperience their aversive memory (phase 1), observe the scene from their adult perspective, and intervene to help their former selves (phase 2), and reexperience it again with the positive changes (phase 3). Previous studies have rarely investigated emotional and regulatory processes taking place during the intervention. Objective: This randomized controlled trial investigated self-reported affective and physiological responses during ImRs. Methods: Seventy-seven patients with social anxiety disorder (SAD) were randomly assigned to a single session of ImRs or a control intervention (recall and discussion of the memory) targeting an aversive social memory. Heart rate (HR) and heart rate variability (HRV) were assessed during and post hoc ratings of positive and negative feelings after baseline and the intervention phases. Results: Relative to the control intervention, ImRs resulted in an initial increase in negative feelings from baseline to phase 1 and a following larger (phase 1 to phase 2) and more stable (phase 2 to phase 3) decrease in negative feelings/increase in positive feelings. On the physiological level, during ImRs compared to the control intervention, mean HR was significantly higher during phase 1 and HRV during phase 3, each compared to baseline. Conclusions: These results provide further information about the specific sequence of emotional responses on different response levels during ImRs, being consistent with known theories of emotional processing and supposed mechanisms of ImRs. [ABSTRACT FROM AUTHOR]

Imagery rescripting (ImRs) interventions have been found effective in improving sleep outcomes, although research has mostly focused on civilian, rather than military, samples. The aim of this review was to estimate the overall effectiveness of ImRs interventions for military veterans on primary outcomes of nightmare frequency and sleep quality. A systematic search was conducted in CINAHL, MEDLINE, PsycArticles, PsycINFO, Psychology and Behavioural Sciences Collection and the PTSDpubs database and was completed on 1 November 2021. Randomised controlled trials, nonrandomised trials and pre–post studies of ImRs interventions in veterans with sleep disturbances or nightmares were included. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool, and meta‐analysis was performed using Stata. Nineteen articles from 15 empirical studies were included in the review, and data from the 15 studies (involving 658 participants) were included in the meta‐analysis. Meta‐analysis findings indicated that ImRs interventions are associated with significant positive changes from pretreatment to posttreatment for nightmare and sleep quality. Significantly greater improvements were found in ImRs interventions compared to control groups for sleep quality (Hedges' g = −0.65, 95% CI [−1.20, −0.10]) but not for nightmare frequency (Hedges' g = −0.10, 95% CI [−0.34, 0.14]). Overall, the meta‐analysis included a relatively small number of studies with poor methodological quality and considerable heterogeneity; therefore, findings should be cautiously interpreted. Further research should focus on veteran participants with larger samples and from a broader range of sources to determine effectiveness more confidently. [ABSTRACT FROM AUTHOR]

A feared possible self refers to the unwanted characteristics that a person may possess or develop. We tested an experimental paradigm to target fear of possible self using imagery rescripting. A student sample (n = 91), with moderate obsessive–compulsive disorder symptoms, engaged in written and audio-guided exercises to evoke episodic future mental imagery that represented their feared possible self. Participants were then randomized between imagery rescripting or neutral imagery control tasks. The results revealed no difference between conditions in fear of self or general obsessional beliefs following the manipulation. State anxiety and the urge to neutralize the imagery reduced more in the control condition than in the rescripting condition. These findings suggest that the current paradigm is emotionally engaging but not effective at addressing fear of self as measured. Methodological improvements such as removing a written component of the rescripting task and idiosyncratic measuring of fear of self are proposed. [ABSTRACT FROM AUTHOR]

Imagery rescripting (ImR) has shown to reduce negative belief about the self, negative emotions and emotional dysregulation. However, the mechanisms through which this improvement in emotion regulation takes place is currently the object of investigation. An untested hypothesis is that ImR reduces the negative emotional response to primary emotions (i.e. the Meta-emotional problem) associated to difficulties in emotional regulation. In this study, the researchers aimed to investigate the impact of group ImR delivered via telehealth on dysfunctional personality beliefs, the Meta-emotional problem, difficulties in emotional regulation, and self-compassion in a non-clinical sample of participants. A total of 45 community sample participants received three sessions of group ImR delivered via telehealth. Personality dysfunctional beliefs, meta-emotions, self-compassion and emotional dysregulation were measured before ImR and in three follow-up sessions. Dysfunctional personality beliefs, specifically those associated with the dependent, obsessive–compulsive, antisocial, and histrionic personality disorders, were significantly reduced after the ImR intervention. Additionally, the Meta-emotional problem and difficulties in emotional regulation were also reduced. Moreover, negative self-compassion showed a significant decrease after ImR, but positive self-compassion remained unchanged. These findings suggest that group ImR delivered via telehealth can effectively reduce negative beliefs about oneself, negative emotions, and emotional dysregulation. However, it seems that this intervention does not increase a more benevolent attitude towards oneself, possibly due to the less direct intervention of the therapist in the group telehealth setting. The researchers discuss the implications of these findings for clinical practice in a group telehealth context. [ABSTRACT FROM AUTHOR]

Abstract Background This controlled pilot study investigates the effect of the combined use of cognitive restructuring (CR) and imagery rescripting (IR) compared to treatment as usual among inpatients with moderate and severe depression. Alongside expert ratings and self-report tools, fitness wristbands were used as an assessment tool. Methods In addition to the standard inpatient care (SIC) program, 33 inpatients with moderate and severe depression were randomly assigned to an intervention group (two sessions of IR and CR) or an active treatment-as-usual (TAU) control group (two sessions of problem-solving and build-up of positive activity). Depression severity was assessed by the Hamilton Depression Rating Scale-21 (HDRS-21), the Beck Depression Inventory-II (BDI-II), and as a diagnostic adjunct daily step count via the Fitbit Charge 3™. We applied for analyses of HDRS-21 and BDI-II, 2 × 2 repeated-measures analysis of variance (ANOVA), and an asymptotic Wilcoxon test for step count. Results The main effect of time on both treatments was η2 = .402. Based on the data from the HDRS-21, patients in the intervention group achieved significantly greater improvements over time than the TAU group (η2 = .34). The BDI-II data did not demonstrate a significant interaction effect by group (η2 = .067). The daily hourly step count for participants of the intervention group was significantly higher (r = .67) than the step count for the control group. Conclusions The findings support the utilization of imagery-based interventions for treating depression. They also provide insights into using fitness trackers as psychopathological assessment tools for depressed patients. Trial registration The trial is registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) under the registration number: DRKS00030809.

Introduction: Non-suicidal self-injury (NSSI), which refers to the deliberate act of causing harm to one's own body without the intent to commit suicide, occurs in 20% of youth. Interestingly, approximately 90% of individuals who engage in self-harm report intrusive mental imagery thereof shortly prior to the act of NSSI. Previous research has demonstrated that imagery rescripting (IR) is an effective technique to treat intrusive mental images and associated clinical symptoms, such as emotion dysregulation, in various psychiatric disorders. However, there is no research on IR for adolescents who self-harm. Therefore, the present study aims to investigate the efficacy and feasibility of a two-session short-intervention using IR to reduce NSSI and associated clinical symptoms in adolescents. The intervention was supported by an app-based digital health intervention (DHI). Methods: A single case series A-B design with three post-assessments (1 week, 1 month, and 3 months post-intervention) was implemented. Seven adolescents received two treatment sessions of IR, supported by a DHI between sessions. NSSI (SITBI), emotion regulation (ERQ), emotional distress (BDI-II, STAI-T), self-efficacy (WIRKALL_r), and treatment satisfaction (BIKEP) were evaluated. Results: There was an increase in adaptive emotion regulation strategies up to 3 months post-intervention. Furthermore, patients improved regarding their self-efficacy, depressiveness, anxiety, and NSSI symptomatology. The developed DHI was described as a helpful and supportive tool. Conclusion: The intervention has shown initial evidence to be feasible and beneficial for adolescents conducting NSSI. The DHI has demonstrated to be a valuable tool in the treatment of self-harming youth. [ABSTRACT FROM AUTHOR]

Psychological treatment for social anxiety disorder (SAD) has been found to be less effective than for other anxiety disorders. Targeting the vivid and distressing negative mental images typically experienced by individuals with social anxiety could possibly enhance treatment effectiveness. To provide both clinicians and researchers with an overview of current applications, this systematic review and meta‐analysis aimed to evaluate the possibilities and effects of imagery‐based interventions that explicitly target negative images in (sub)clinical social anxiety. Based on a prespecified literature search, we included 21 studies, of which 12 studies included individuals with a clinical diagnosis of SAD. Imagery interventions (k = 28 intervention groups; only in adults) generally lasted one or two sessions and mostly used imagery rescripting with negative memories. Others used eye movement desensitization and reprocessing and imagery exposure with diverse intrusive images. Noncontrolled effects on social anxiety, imagery distress and imagery vividness were mostly large or medium. Meta‐analyses with studies with control groups resulted in significant medium controlled effects on social anxiety (d = −0.50, k = 10) and imagery distress (d = −0.64, k = 8) and a nonsignificant effect on imagery vividness. Significant controlled effects were most evident in individuals with clinically diagnosed versus subclinical social anxiety. Overall, findings suggest promising effects of sessions targeting negative mental images. Limitations of the included studies and the analyses need to be considered. Future research should examine the addition to current SAD treatments and determine the relevance of specific imagery interventions. Studies involving children and adolescents are warranted. [ABSTRACT FROM AUTHOR]

Introduction: Visual hallucinations (VH) are more common than previously thought and are linked to higher levels of distress and disability in people with a psychotic illness. Despite this, scant attention has been given to VHs in the clinical literature, and the few therapy case series of cognitive behavioural therapy (CBT) published to date have not demonstrated reliable change. In other areas of clinical research, problematic mental imagery has been found to be more strongly related to negative affect in psychological disorders than negative linguistic thinking, and imagery focused techniques have commonly been found to improve the outcomes in CBT trials. Given VHs have many similarities with visual mental imagery and many of the distressing beliefs associated with VHs targeted in CBT are maintained by accompanying mental imagery (i.e., imaging a hallucinated figure attacking them), it seems plausible that an imagery‐focused approach to treating VHs may be most effective. Methods: The current study is a multiple baseline case series (N = 11) of a 10‐session imagery‐focused therapy for VH in a transdiagnostic sample. Results: The study had good attendance and feedback, no adverse events and only one [seemly unrelated] drop‐out, suggesting good feasibility, safety and acceptability. The majority of clients reported reduction on both full‐scale measures (administered at 3 baselines, midtherapy, posttherapy and 3‐month follow‐up) and weekly measures of VH severity and distress, ranging from medium to large effect sizes. Conclusions: The case series suggests that an imagery‐focused approach to treating VHs may be beneficial, with a recommendation for more rigorous clinical trials to follow. [ABSTRACT FROM AUTHOR]

Background: This controlled pilot study investigates the effect of the combined use of cognitive restructuring (CR) and imagery rescripting (IR) compared to treatment as usual among inpatients with moderate and severe depression. Alongside expert ratings and self-report tools, fitness wristbands were used as an assessment tool. Methods: In addition to the standard inpatient care (SIC) program, 33 inpatients with moderate and severe depression were randomly assigned to an intervention group (two sessions of IR and CR) or an active treatment-as-usual (TAU) control group (two sessions of problem-solving and build-up of positive activity). Depression severity was assessed by the Hamilton Depression Rating Scale-21 (HDRS-21), the Beck Depression Inventory-II (BDI-II), and as a diagnostic adjunct daily step count via the Fitbit Charge 3™. We applied for analyses of HDRS-21 and BDI-II, 2 × 2 repeated-measures analysis of variance (ANOVA), and an asymptotic Wilcoxon test for step count. Results: The main effect of time on both treatments was η2 =.402. Based on the data from the HDRS-21, patients in the intervention group achieved significantly greater improvements over time than the TAU group (η2 =.34). The BDI-II data did not demonstrate a significant interaction effect by group (η2 =.067). The daily hourly step count for participants of the intervention group was significantly higher (r =.67) than the step count for the control group. Conclusions: The findings support the utilization of imagery-based interventions for treating depression. They also provide insights into using fitness trackers as psychopathological assessment tools for depressed patients. Trial registration: The trial is registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien) under the registration number: DRKS00030809. [ABSTRACT FROM AUTHOR]

IntroductionNon-suicidal self-injury (NSSI), which refers to the deliberate act of causing harm to one’s own body without the intent to commit suicide, occurs in 20% of youth. Interestingly, approximately 90% of individuals who engage in self-harm report intrusive mental imagery thereof shortly prior to the act of NSSI. Previous research has demonstrated that imagery rescripting (IR) is an effective technique to treat intrusive mental images and associated clinical symptoms, such as emotion dysregulation, in various psychiatric disorders. However, there is no research on IR for adolescents who self-harm. Therefore, the present study aims to investigate the efficacy and feasibility of a two-session short-intervention using IR to reduce NSSI and associated clinical symptoms in adolescents. The intervention was supported by an app-based digital health intervention (DHI).MethodsA single case series A-B design with three post-assessments (1 week, 1 month, and 3 months post-intervention) was implemented. Seven adolescents received two treatment sessions of IR, supported by a DHI between sessions. NSSI (SITBI), emotion regulation (ERQ), emotional distress (BDI-II, STAI-T), self-efficacy (WIRKALL_r), and treatment satisfaction (BIKEP) were evaluated.ResultsThere was an increase in adaptive emotion regulation strategies up to 3 months post-intervention. Furthermore, patients improved regarding their self-efficacy, depressiveness, anxiety, and NSSI symptomatology. The developed DHI was described as a helpful and supportive tool.ConclusionThe intervention has shown initial evidence to be feasible and beneficial for adolescents conducting NSSI. The DHI has demonstrated to be a valuable tool in the treatment of self-harming youth.

Dysfunctional mental imagery is integral to the maintenance of many psychological disorders and is typically associated with stronger affective and behavioural responses than verbal cognitions. This finding extends itself to the high prevalence of suicidal mental imagery in disorders such as depression and bipolar disorder. Imagery Rescripting is a therapy approach which has been found to effectively reduce dysfunctional mental images across various mental health conditions. Thus, Imagery Rescripting of suicidal mental imagery may be effective at reducing such cognitions and ultimately associated risk. However, this remains an unexplored area within the treatment literature. This paper puts out an urgent call for clinical research to evaluate the effectiveness of such a treatment intervention, and to assist, we propose and describe a clinical approach to this to stimulate further thought and research. There are also many research questions of clinical relevance that must be explored in this field of work, which we put forward and consider in this commentary piece. What is already known about this topic: Mental imagery is a form of cognition that generates stronger emotional responses compared to verbal-linguistic thinking and is integral to the maintenance of most psychological disorders. Cognitive Behavioural Therapy (CBT) approaches are typically more effective when mental imagery techniques – such as Imagery Rescripting (ImRs) – are incorporated to target intrusive, distressing mental imagery. Mental images of suicide (comprised of both flash-back and/or flash-forward mental images) are more distressing, realistic and promote suicidal behaviours more than verbal thoughts, and are common in disorders such as depression and bipolar disorder. What this topic adds: Urgent clinical research is needed to evaluate the effectiveness of ImRs at reducing intrusive suicidal mental images, and thus related risk, and this paper proposes and describes an approach for researchers to use as a framework. There are several clinical research considerations to be made when examining ImRs of suicidal mental images, including around the delivery and safety of the intervention. More research is needed to clarify the above clinical considerations, and to further understand change mechanisms, to learn the most safe and effective ImRs approach. If ImRs is found to be effective at reducing suicidal images in upcoming clinical trials, it is strongly recommended clinicians receive adequate training and ongoing clinical supervision from an experienced practitioner given the complexities around this approach. [ABSTRACT FROM AUTHOR]

Background: Misophonia, a disorder of decreased sound tolerance, can cause significant distress and impairment. Cognitive behavioural therapy (CBT) may be helpful for improving symptoms of misophonia, but the key mechanisms of the disorder are not yet known. Aims: This case series aimed to evaluate individual, formulation-driven CBT for patients with misophonia in a UK psychology service. Method: A service evaluation of one-to-one therapy for patients with misophonia (n =19) was conducted in a specialist psychology service. Patients completed an average of 13 hours of therapy with a focus on the meaning applied to their reactions to sounds and associated behaviours. Primary outcome measures were the Misophonia Questionnaire (MQ) and the Amsterdam Misophonia Scale (A-MISO-S). Repeated measures t -tests were used to compare scores from pre-treatment to follow-up, and reliable and clinically significant change on the MQ was calculated. Results: Scores significantly improved on both misophonia measures, with an average of 38% change on the MQ and 40% change on the A-MISO-S. From pre-treatment to follow-up, 78% of patients showed reliable improvement on the MQ and 61% made clinically significant change. Conclusions: Limitations included a lack of control group, small sample size, and the use of an outcome measure that had not been thoroughly validated for a treatment-seeking sample. These results suggest that one-to-one, formulation-driven CBT for misophonia is worth exploring further using experimental design. Potential mechanisms to explore further include feared consequences of escalating reactions, the role of safety-seeking behaviours and the impact of early memories associated with reactions to sounds. [ABSTRACT FROM AUTHOR]

Imagery Rescripting & Reprocessing Therapy (IRRT) is the first psychotherapeutic treatment for posttraumatic stress disorders (PTSD) with imagery rescripting. An IRRT treatment session comprises three phases: In Phase 1 the patient relives, visualizes and verbalizes the traumatic scene; in Phase 2 the patient visualizes his/her Adult Self today entering the traumatic scene at the most upsetting moment to confront and disempower the perpetrator; in Phase 3 the Adult Self today interacts directly with the Child, the goal of which is to comfort and nurture the Child. Further adaptations of IRRT have led to the broadening of its application across a wide spectrum of mental disorders, e. g. prolonged grief disorders and, in particular, IRRT-Inner-Child Work with complex PTSD (c-PTSD). [ABSTRACT FROM AUTHOR]

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Objectives: Post‐traumatic stress is common among people who hear voices (auditory verbal hallucinations), many of whom hear trauma‐related voices, whereby voice content is related to past trauma. Preliminary evidence suggests that imagery rescripting (ImRs) may more effectively reduce post‐traumatic stress and voices compared to treatments that are based on existing models of PTSD or positive symptoms. No known studies have explored the potential maintaining factors of trauma‐related voices in relation to ImRs. We aimed to uncover insights into the factors that maintain trauma‐related voices and how ImRs may influence such factors by exploring voice hearers' explanations of voices and experiences of change throughout ImRs. Design: Thematic analytical methodology was used due to the study's critical epistemological framework. Methods: Semi‐structured interviews explored relationships between trauma and voices, and experiences of change and stability throughout ImRs in a transdiagnostic sample (N = 10) who underwent 10–18 weekly ImRs sessions. Thematic analysis was used to develop themes. Results: Two themes captured explanations of voices, which suggested voices may have counterproductive protective functions. Three themes captured psychological experiences during ImRs, which reflected concepts such as freedom to experience emotions, and experiences of justice, closure and grieving. Three themes described the outcomes of ImRs, reflecting concepts such as increased confidence, coping, perceived safety and voices becoming less powerful. Conclusions: Trauma‐related voices may have underlying protective functions and ImRs may support emotional expression, adaptive trauma re‐appraisals and improve self‐worth and coping self‐efficacy. These change processes may have clinical implications in ImRs and other treatments for trauma‐affected voice hearers. [ABSTRACT FROM AUTHOR]

BackgroundEarly childhood adversity plays an important role in the etiology of borderline personality disorder (BPD). Current evidence suggests that trauma treatment for patients with BPD can be performed safely and that early trauma treatment has a positive effect on the course of PD. However, there is a scarcity of RCTs comparing the effects of the timing of trauma treatment during schema therapy (ST) for BPD on BPD severity. Therefore, the LUCY trial investigates the effects of the timing of trauma treatment by comparing early trauma treatment using imagery rescripting (ImRs) on the course of BPD during ST to trauma treatment in the middle of the treatment course.MethodsIn this multicenter RCT, two conditions are compared among 73 individuals with BPD. The participants receive combined individual and group ST in both conditions. However, in condition (A), participants directly start ImRs in the individual sessions in months 2–4, and in condition (B), participants receive ST-as-Usual (STAU), in which ImRs is not allowed during months 2–4. The treatment follows ST treatment protocols, consists of a fixed combination of individual sessions and group sessions with a maximum of nine patients, and has a maximum duration of 25 months. The primary outcome is change in BPD severity, which is assessed using the Borderline Personality Disorder Severity Index-5 by independent raters blinded to the treatment. Secondary outcome measures include treatment retention, disconnection/rejection schemas, general functioning, posttraumatic stress disorder symptoms, general psychopathological complaints, quality of life, happiness, schemas, and schema modes. Multilevel analysis will be performed to analyze and compare changes in BPD severity between conditions and generalized linear mixed model analyses to test predictors and moderators.DiscussionThis study will increase the knowledge on whether trauma treatment early in therapy positively affects the course of BPD manifestations during ST. When the early application of ImRs leads to a faster decrease in BPD manifestations, the treatment of BPD patients might be shortened, leading to improved treatment outcomes and decreased healthcare expenses. Moreover, the planned sub-studies will expand our knowledge of how ST works and the factors that influence the outcome of treatment.

Introduction: Despite the positive outcomes observed in numerous individuals undergoing trauma-focused psychotherapy for PTSD, veterans with this condition experience notably diminished advantages from such therapeutic interventions in comparison to non-military populations. Methods: In a preliminary study we investigated the efficacy of an innovative treatment approach in a small sample of veterans (n = 7). Recognizing that accessing and targeting trauma memory in veterans with PTSD may be more challenging compared to other patient populations, we employed unique and personalized retrieval cues that engaged multiple senses and were connected to the context of their trauma. This was followed by a session focused on memory reconsolidation, which incorporated both psychological techniques (i.e., imagery rescripting) and a pharmacological component (i.e., 40 mg of propranolol). Results: The findings from this small-scale case series cautiously indicate that this brief intervention, typically consisting of only one or two treatment sessions, shows promise in producing significant effects on symptoms of PTSD, distress and quality of life.This is particularly noteworthy given the complex symptomatology experienced by the veterans in this study. Conclusion: To summarize, there are grounds for optimism regarding this brief treatment of combat-related PTSD. It appears that the potential for positive outcomes is far greater than commonly believed, as demonstrated by the encouraging results of this pilot study. [ABSTRACT FROM AUTHOR]

• Imagery Rescripting (ImRs) can be tailored to different cultural backgrounds. • The case study illustrates ImRs as a stand-alone treatment for PTSD in a refugee. • Symptoms of PTSD were reduced after rescripting multiple traumatic events. • Dissociation was managed with the use of antidissociative skills during ImRs. Posttraumatic stress disorder (PTSD) is among the most prevalent mental disorders in refugees. Imagery Rescripting (ImRs) has gained growing interest as an innovative and effective treatment for several disorders, including PTSD. The technique aims to change the meaning of traumatic memories by asking the patient to imagine a different outcome of a particular memory. As ImRs focuses on meeting individual needs, it can be tailored to patients with different cultural and religious backgrounds and may be a promising intervention for refugees. This case study therefore illustrates the application and challenges of ImRs as a stand-alone treatment for a refugee patient. The patient had experienced multiple traumatic events during flight and met full criteria for PTSD according to the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; total score of 32). The treatment was conducted with the assistance of an interpreter and consisted of 12 100-min sessions, during which the most distressing traumatic events were rescripted. Cognitive restructuring and imagery modification—another imagery-based intervention showing some similarities with ImRs—was applied as an additional intervention to address feelings of contamination. At the end of treatment, symptoms were reduced and the patient no longer met diagnostic criteria for PTSD (CAPS-5 total score of 25); however, only change in self-reported symptoms reached clinical significance. Challenges during treatment included frequent dissociative symptoms that were managed by instructing the patient to use antidissociative skills during ImRs. Findings corroborate ImRs as a feasible approach for the treatment of PTSD in patients with complex trauma histories. [ABSTRACT FROM AUTHOR]

There is an unmet need for effective short-term therapeutic techniques to reduce clinical symptoms associated with prospective-, as well as retrospective aversive mental images across mental disorders. We investigated the efficacy of imagery rescripting (IR) as a short-term intervention across clinical disorders, as the literature suggests that this technique could be a promising intervention to reduce psychopathology by altering intrusive mental images. A systematic literature review identified 23 trials including 805 adult patients, out of which 15 trials were designed as randomized controlled trials (RCT) including patients with the following diagnoses: Social anxiety disorder (SAD), Posttraumatic-Stress-Disorder (PTSD), Bulimia Nervosa, Borderline Personality Disorder, Obsessive-Compulsive Disorder, nightmare disorder, test anxiety, health anxiety, and Generalized Anxiety Disorder. Most studies (14) comprised of one treatment session. Effect size estimates indicate that IR is highly effective in reducing clinical symptoms associated with mental images from pre-, to post-treatment (g = 1.09, 95% CI = [0.64; 1.53]), as well as from pre-treatment to follow-up (g = 1.90, 95% CI = [1.02; 2.77]). Comparing the IR intervention to a passive control group showed large effect sizes at post-treatment (g = −0.99; 95% CI = [-1.79; −0.20]), however, comparing IR to an active control group resulted in a small effect (g = −0.05; 95% CI = [-0.43; 0.33]). Lastly, large effects of IR were found for the SAD and PTSD subgroups, for comorbid symptoms of depression. In summary, our results indicate that IR is a promising short-term therapeutic technique for clinical symptoms associated with aversive prospective-, and retrospective mental images. [ABSTRACT FROM AUTHOR]

Sudden gains, defined as large and stable improvements in symptom severity during psychological treatment, have consistently been found to be associated with better outcomes across treatments and diagnoses. Yet, insights on coherent predictors of sudden gains and on emotional changes around sudden gains in post‐traumatic stress disorder (PTSD) are lacking. We aimed at replicating a measure of intraindividual variability as a predictor for sudden gains and testing its independence from change during treatment. Furthermore, we expected changes in emotions of guilt, shame and disgust prior to sudden gains to predict sudden gains. Data from a pre‐registered randomized controlled trial (RCT) of eye‐movement desensitization and reprocessing (emdr) and Imagery Rescripting (ImRs) for PTSD in 155 adult survivors of childhood abuse were used. Intraindividual variability of PTSD symptoms in both treatments did not predict sudden gains status and was not independent of change during treatment. In the EMDR condition, levels of shame during treatment predicted sudden gains and shame decreased shortly before a sudden gain in both treatments. Reductions in all emotions during sudden gains were significantly higher for participants with sudden gains than for comparable intervals in non‐sudden gainers. Our findings do not support the predictive validity of intraindividual variability for sudden gains. The decrease of guilt, shame and disgust during sudden gains warrants further research on their role as a mechanism of treatment change for PTSD. [ABSTRACT FROM AUTHOR]

Abstract Background Major depressive disorder (MDD) is a common, recurrent mental disorder and a leading cause of disability worldwide. A large part of adult MDD patients report a history of childhood trauma (CT). Patients with MDD and CT are assumed to represent a clinically and neurobiologically distinct MDD subtype with an earlier onset, unfavorable disease course, stress systems’ dysregulations and brain alterations. Currently, there is no evidence-based treatment strategy for MDD that specifically targets CT. Given the central role of trauma in MDD patients with CT, trauma-focused therapy (TFT), adjunctive to treatment as usual (TAU), may be efficacious to alleviate depressive symptoms in this patient population. Methods The RESET-psychotherapy study is a 12-week, single-blind, randomized controlled trial testing the efficacy of TFT in 158 adults with moderate to severe MDD, as a ‘stand-alone’ depression diagnosis or superimposed on a persistent depressive disorder (PDD), and CT. TFT (6–10 sessions of Eye Movement Desensitization and Reprocessing and/or imagery rescripting) + TAU is compared to TAU only. Assessments, including a wide range of psychological/psychiatric and biological characteristics, take place before randomization (T0), during treatment (T1), at post-treatment (T2) and at 6-month follow-up (T3). Pre-post treatment stress-related biomarkers in hair (cortisol) and blood (epigenetics and inflammation) will be assessed to better understand working mechanisms of TFT. A subgroup of 60 participants will undergo structural and functional Magnetic Resonance Imaging (MRI) assessments to determine pre-post treatment brain activity. The primary outcome is self-reported depression symptom severity at post-treatment, measured with the 30-item Inventory of Depressive Symptomatology – Self Report (IDS-SR). Discussion If adjunctive TFT efficaciously alleviates depressive symptoms in MDD patients with CT, this novel treatment strategy could pave the way for a more personalized and targeted MDD treatment. Trial registration ClinicalTrials.gov, registered at 08–12-2021, number of identification: NCT05149352.

IntroductionDespite the positive outcomes observed in numerous individuals undergoing trauma-focused psychotherapy for PTSD, veterans with this condition experience notably diminished advantages from such therapeutic interventions in comparison to non-military populations.MethodsIn a preliminary study we investigated the efficacy of an innovative treatment approach in a small sample of veterans (n = 7). Recognizing that accessing and targeting trauma memory in veterans with PTSD may be more challenging compared to other patient populations, we employed unique and personalized retrieval cues that engaged multiple senses and were connected to the context of their trauma. This was followed by a session focused on memory reconsolidation, which incorporated both psychological techniques (i.e., imagery rescripting) and a pharmacological component (i.e., 40 mg of propranolol).ResultsThe findings from this small-scale case series cautiously indicate that this brief intervention, typically consisting of only one or two treatment sessions, shows promise in producing significant effects on symptoms of PTSD, distress and quality of life.This is particularly noteworthy given the complex symptomatology experienced by the veterans in this study.ConclusionTo summarize, there are grounds for optimism regarding this brief treatment of combat-related PTSD. It appears that the potential for positive outcomes is far greater than commonly believed, as demonstrated by the encouraging results of this pilot study.

Exposure and response prevention (ERP), a specific type of Cognitive and Behaviour Therapy, is well recognised as the first-line psychological treatment in obsessive-compulsive disorder (OCD), either alone or in combination with selective serotonin reuptake inhibitor pharmacotherapy. However, given that up to half of patients suffering from OCD do not experience a clinically significant reduction in symptoms following ERP, further treatment options for treatment-resistant OCD are needed. Initial research into using ImRs as a psychological adjunct for treatment-resistant OCD has been encouraging. We provide a detailed case study of a 61-year-old male who continued, following ERP treatment, to suffer debilitating OCD symptoms of compulsive checking to prevent making mistakes. Following ERP, the individual received two sessions of ImRs as a therapy adjunct, which resulted in a further reduction of 56% in OCD symptoms. The individual reported associated improvements in mood, life satisfaction, and occupational and interpersonal relationships. This case study describes how ImRs can be incorporated into ERP treatment for OCD. Details of the ERP and ImRs treatment are provided, along with transcript excerpts to highlight the ImRs process. Further research is needed to enhance understanding of mechanisms and optimal deployment of ImRs in treatment sequencing for OCD sufferers. [ABSTRACT FROM AUTHOR]

Background: Refugees and asylum seekers present with high levels of post-traumatic stress disorder (PTSD), whilst little research has been conducted to assess the effectiveness or acceptability of psychological interventions for this group. Imagery rescripting is effective in reducing distressing intrusive memories within a range of conditions. The current study evaluates this approach for the treatment of PTSD in refugees and asylum seekers within a UK NHS service. Aims: To evaluate the clinical outcomes of using imagery rescripting for the treatment of PTSD in UK-based refugees and asylum seekers. Method: Ten adult service-users from an NHS specialist service with a primary diagnosis of PTSD were recruited as part of routine service delivery. A multiple baseline design was used with participants randomly allocated to a baseline varying from 5 to 9 weeks. A baseline wait-period was followed by up to five sessions of psychoeducation and treatment preparation, in turn followed by up to 10 sessions of imagery rescripting. The Post-traumatic Symptom Scale (PSS) and Physical Health Questionnaire-9 (PHQ-9) were collected every week during baseline, at end of treatment and weekly for 5 weeks after treatment, and again at 12-week follow-up. Data were analysed with mixed regression. Results: Results indicate a significant improvement both in PTSD symptoms and mood, and that this was attributable to the imagery rescripting phase of the intervention, and not the passage of time or non-specific therapy factors. Conclusions: Evidence indicates imagery rescripting to be a safe and effective treatment choice for PTSD in refugees and asylum seekers. [ABSTRACT FROM AUTHOR]

This study piloted the efficacy and acceptability of Virtual Reality Imagery Rescripting (VR-ImRs) compared to conventional Imagery Rescripting (ImRs) for PTSD due to childhood sexual abuse (CSA). Eight adult patients with clinician-rated PTSD due to CSA as their primary diagnosis participated, of whom six completed the full treatment. A non-concurrent multiple baseline design with cross-over elements was used, with randomly assigned baseline lengths and treatment conditions. After baseline and a 5-session 'education and exploration' phase, six sessions of either ImRs or VRImRs were given, followed by another six sessions of the opposite treatment condition and a 5-week follow-up without treatment. The primary outcome was PTSD symptoms (PCL-5), and secondary outcomes were negative and positive emotions (added PCL-5 items), anxiety and depressive symptoms (HADS) and trauma-related cognitions (PTCI). Data were analyzed with mixed regression. Results showed a significant linear reduction of trauma symptoms and negative emotions only during ImRs. No significant treatment effects on positive emotion, anxiety and depressive symptoms were found for both treatment conditions. Both treatment conditions showed significant positive effects on trauma-related cognitions. This study does not support the efficacy of VR-ImRs in reducing PTSD symptoms. Possibly VR-ImRs keeps people from reprocessing their memories, making it less effective. [ABSTRACT FROM AUTHOR]

Plain English summary The present study was the first to investigate treatment of posttraumatic stress symptoms, such as re-experiences and flash backs, in underweight eating disorder patients. This research is important because these patients: Often do not receive treatment for trauma symptoms while they are underweight. Have worse eating disorder treatment results than patients without posttraumatic stress disorder. Patients and patient organisations have for years expressed the wish that posttraumatic stress disorder be treated during the weight gaining phase of eating disorder treatment. The results of this study are important because they show that treatment for trauma is possible for patients that are underweight. Ten patients received trauma treatment. Trauma and eating disorder symptoms were measured before, during and after treatment. We tested whether trauma symptoms were reduced during and after treatment. This research was done because patients requested posttraumatic stress disorder treatment while they were underweight. Previous patients were involved in the development of the interview and all participants were interviewed about their experiences. The findings will be published and presented at eating disorder conferences attended by patients.

• Imagery rescripting is effective for PTSD due to childhood trauma. • Caring for the child and speaking up to the perpetrator are important elements. • Rescripting by the therapist, as well as rescripting by the patient, is important. • Patients find a positive connection with the therapist helpful. Imagery rescripting (IR) has been proven effective in several studies applied to different disorders. It is unclear, however, what the elements of change are according to patients and therapists and whether they agree on this. In this study, we examined the perspectives of patients and therapists and their degree of agreement regarding the elements of change in IR for posttraumatic stress disorder due to childhood trauma. Patients who showed a substantial decrease in symptoms on the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) after a maximum of 12 sessions of IR, as well as their therapists, were approached. Ten patients and nine therapists provided in-depth interviews about the elements of change in the treatment they had received or conducted. A qualitative analysis of the results was used. One element of change was mentioned by all but one interviewee—namely, caring for the child by the therapist when the therapist rescripts the traumatic event. All except two interviewees mentioned that when the therapist rescripts, speaking up to the perpetrator was important. Both aspects were also important when patients did the rescripting themselves. All patients mentioned the positive connection they had with the therapist and the encouragement they received from him or her was important. There was only moderate agreement between patient and therapist regarding the most important element of change, although overall both patients and therapists believed the same elements were of importance. To our knowledge this is the first study in which the elements of change viewed by patients and therapists are investigated in relationship to one another. Despite the fact that this study does not provide definite answers of what works, the perspective of patients and therapists needs to be taken into account when IR for posttraumatic stress disorder is further developed. [ABSTRACT FROM AUTHOR]

Background: Major depressive disorder (MDD) is a common, recurrent mental disorder and a leading cause of disability worldwide. A large part of adult MDD patients report a history of childhood trauma (CT). Patients with MDD and CT are assumed to represent a clinically and neurobiologically distinct MDD subtype with an earlier onset, unfavorable disease course, stress systems' dysregulations and brain alterations. Currently, there is no evidence-based treatment strategy for MDD that specifically targets CT. Given the central role of trauma in MDD patients with CT, trauma-focused therapy (TFT), adjunctive to treatment as usual (TAU), may be efficacious to alleviate depressive symptoms in this patient population. Methods: The RESET-psychotherapy study is a 12-week, single-blind, randomized controlled trial testing the efficacy of TFT in 158 adults with moderate to severe MDD, as a 'stand-alone' depression diagnosis or superimposed on a persistent depressive disorder (PDD), and CT. TFT (6–10 sessions of Eye Movement Desensitization and Reprocessing and/or imagery rescripting) + TAU is compared to TAU only. Assessments, including a wide range of psychological/psychiatric and biological characteristics, take place before randomization (T0), during treatment (T1), at post-treatment (T2) and at 6-month follow-up (T3). Pre-post treatment stress-related biomarkers in hair (cortisol) and blood (epigenetics and inflammation) will be assessed to better understand working mechanisms of TFT. A subgroup of 60 participants will undergo structural and functional Magnetic Resonance Imaging (MRI) assessments to determine pre-post treatment brain activity. The primary outcome is self-reported depression symptom severity at post-treatment, measured with the 30-item Inventory of Depressive Symptomatology – Self Report (IDS-SR). Discussion: If adjunctive TFT efficaciously alleviates depressive symptoms in MDD patients with CT, this novel treatment strategy could pave the way for a more personalized and targeted MDD treatment. Trial registration: ClinicalTrials.gov, registered at 08–12-2021, number of identification: NCT05149352. [ABSTRACT FROM AUTHOR]

Imagery rescripting (ImRs) is a therapy technique that, unlike traditional re-living techniques, focuses less on exposure and verbal challenging of cognitions and instead encourages patients to directly transform the intrusive imagery to change the depicted course of events in a more desired direction. However, a comprehensive account of how and in what circumstances ImRs brings about therapeutic change is required if treatment is to be optimised, and this is yet to be developed. The present study reports on the development of a coding scheme of ImRs psychotherapy elements identified in the literature as potential ImRs mechanisms. The codes were assessed in relation to short-term outcomes of 27 individuals undergoing ImRs for post-traumatic stress disorder. The timing of the change in the image, degree of activation of the new image and associated cognitive, emotional and physiological processes, self-guided rescripting, rescript believability, narrative coherence and cognitive and emotional shift were identified as being related to symptom change and so are potentially important factors for the re-scripting process. [ABSTRACT FROM AUTHOR]

Background: From 1949 to 1990, about 500,000 children and adolescents in the former German Democratic Republic (GDR) were placed in institutional care. Many of these individuals experienced physical and sexual abuse as well as general maltreatment. While this population group is in great need of psychosocial support, few low-threshold interventions aimed at the needs of adult survivors of institutional childhood abuse exist. Objective: This pilot study examines the efficacy of an internet-based imagery rescripting intervention in reducing psychopathological symptoms, within a population of survivors of institutional abuse from state childcare institutions, in the former GDR. Additionally, a case study is presented, depicting the treatment of a woman suffering from PTSD after having been institutionalised in the former GDR. Method: Participants received 10 internet-based writing assignments, based on the principles of imagery rescripting, specifically tailored to the needs of survivors of institutional childhood abuse in the GDR. The participants received personalised feedback on their assignments. Symptoms of posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), depression, and anxiety were assessed at pre- and post-treatment. Results: A total of 15 participants completed the intervention (mean age 56.2 years; 66.7% female). Paired t-tests showed a significant reduction of PTSD, CPTSD, depression, and anxiety symptoms. Large effect sizes were found for PTSD (d = 1.26), CPTSD (d =.97), depression (d = 1.08) and anxiety (d = 1.20). Conclusion: The results of this pilot study provide preliminary evidence for the efficacy and feasibility of the intervention in treating psychopathological symptoms in survivors of institutional abuse in the GDR. The case study additionally demonstrates the applicability of the intervention. A randomised controlled trial should be applied to further evaluate the intervention and its effects. Trial registration: German Clinical Trials Register identifier: DRKS00020266.. Based on the principles of imagery rescripting, this pilot study investigates a newly developed internet-based writing intervention for adult survivors of GDR childcare institutions. Self-reported symptoms of PTSD, CPTSD, depression, and anxiety were significantly reduced at post-treatment. Although further research is needed, the writing intervention seems to be a promising intervention for survivors of institutional abuse in the GDR, suffering from PTSD and other psychopathological symptoms. [ABSTRACT FROM AUTHOR]

Recurrent, negative self-imagery is common in social anxiety disorder (SAD). Imagery rescripting (ImRs) is an effective therapeutic technique that aims to target past aversive memories to modify their associated meanings, and update the encapsulated negative schematic beliefs. The current study aimed to extend previous research by investigating the cognitive and affective shifts during each phase of ImRs delivered within a group cognitive behavioral therapy protocol. Participants (N = 32) retrieved an aversive memory associated with social anxiety and were guided through brief cognitive restructuring, prior to completing ImRs. Core beliefs associated with the memory (strength and valence) and fear of negative evaluation were assessed before and after ImRs and affect was assessed following each phase. Strength and affective valence of encapsulated core beliefs about the self, others, the world, and the image itself significantly reduced following ImRs, and core beliefs were updated to become more positive. Participants reported large affective shifts early in the process, with smaller shifts in the later stages. Fear of negative evaluation did not significantly reduce following ImRs. Outcomes provide some support for cognitive and affective changes during group ImRs for SAD and suggest future research directions to investigate longer-term impacts and to better understand the underlying mechanisms of the technique. [ABSTRACT FROM AUTHOR]

The account of Kelly's therapy (Edwards, 2022b), and the commentaries by Singer (2022) and Margolin (2022), each, in different ways, highlight the significance of multiplicity, and the importance of understanding it, for the practice of psychotherapy. For several decades, many approaches to therapy have recognized and provided guidelines working with this multiplicity (Hermans & DiMaggio, 2004; Kellogg & Young, 2006; Lazarus & Rafaeli, in press; Rowan & Cooper, 1999; Schwartz, 1997; Stiles, 2011; Teasdale, 1999; Watkins & Johnson, 1982). Schema therapy is an integrative therapy that draws freely on these historical traditions, while offering its own distinctive framework for using multiplicity in case conceptualization for a wide variety of clinical phenomena (Edwards, 2022a). Examination of processes within cases treated within this framework provides the opportunity to further develop and synthesise clinically grounded theory, and, as Edwards (2022b) argued, it is increasingly possible for that practice to be grounded in a scientific understanding of the systems of memory and learning that underlie the client's experience, drawing on the significant advances in our understanding of autobiographical memory systems. This article continues to explore this idea by responding to the commentaries on the case study of Kelly by Singer and Margolin. [ABSTRACT FROM AUTHOR]

David Edwards' case of Kelly is a vivid demonstration of the power of Schema Therapy to address the present day emotional difficulties of Kelly, an individual with a background of traumatic childhood experiences. The therapy drew on Kelly's imagination and emotional memories to elicit distinct child-parts (called child "modes" in Schema Theory) of herself emerging from that traumatic background. Specifically, Edwards' interventions involved entering Kelly's inner world and therapeutically interacting with her modes. While Kelly's problems were primarily limited to her inner experience rather than to her behavioral functioning, I have found that Edwards' approach with Kelly applies to the cases I see who are much more seriously disturbed than Kelly. Specifically, I see cases with Dissociative Identity Disorder (DID), who share the experience of childhood trauma with Kelly, but whose behavioral lives can be chaotic and highly disturbed, sometimes requiring hospitalization. In this commentary I will briefly describe Edwards' Schema therapy model exemplified in the case of Kelly and illustrate the value of the model as applied to two cases of DID, Susie and Anna, that I have seen. [ABSTRACT FROM AUTHOR]

This is a narrative case study of the psychotherapy of Kelly (pseudonym) that describes processes that took place within the last 17 sessions of a longer therapy of 67 sessions over a period of 26 months. A phenomenologically grounded and coherent account takes readers on an experiential journey that enables them to live through aspects of the process at least partially. These processes began in session 52 in which Kelly saw an image of a circle of caring people within which a series of child parts of herself were able to find a sense of safety and holding. Over the course of the sessions, eight different child parts approached and eventually entered the circle, each representing a different dissociated set of early schema patterns, each with its own related emotional distress. Through dialogue work and imagery rescripting, the predicament of each child and her unmet needs were brought into focus. This served as the basis for providing corrective emotional experiences that led to the child parts feeling able to voluntarily step into the circle. The material serves as the basis for theoretical-interpretative investigations with a focus on the phenomenology of memory and transformation in experiential psychotherapy. This is organized under several themes: (1) complexes, schemas, and internal working models; (2) autobiographical memory and the working self; (3) the "theater of consciousness" and the "theater of the imagination"; (4) understanding the figures that entered Kelly's healing circle; (5) how far back can we remember? (6) reparenting, corrective experiences, and imagery rescripting; and (7) coping decisions and demanding and punitive features in coping modes. A brief conclusion aims to contribute to our understanding of the phenomenology of corrective experiences and psychological transformation. [ABSTRACT FROM AUTHOR]

Abstract Background Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study’s aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated. Methods The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains. Discussion This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome. Trial registration Netherlands Trial Register NL6965, registered 25/04/2018.

Abstract Background Posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have high comorbidity. Although prior research indicated that PTSD can effectively be treated with Prolonged Exposure (PE) in these patients, reported effects are small and treatment dropout rates high. Eye Movement Desensitization and Reprocessing (EMDR) and Imagery Rescripting (ImRs) are other promising treatment options for PTSD, that have not yet been examined in this patient group. Furthermore, it is unclear whether PTSD treatment is most effective when offered simultaneous to or after SUD treatment. Methods In this article, the Treatment Of PTSD and Addiction (TOPA) study is described: a Dutch randomized controlled trial (RCT) that studies the effectiveness of PTSD treatment as an add-on to regular SUD treatment in patients with SUD and co-occurring PTSD. Effects of PE, EMDR, ImRs, and a 3-month SUD treatment only condition will be compared, as well as simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment. The primary outcome measure is PTSD symptoms. Secondary outcomes are: treatment completion, psychological distress, substance use, interpersonal problems, emotion dysregulation, and trauma-related emotions guilt, shame, and anger. Discussion This study is the first to compare effects of PE, EMDR, and ImRs in one study and to compare simultaneous SUD/PTSD treatment to sequential SUD/PTSD treatment as well. This RCT will provide more knowledge about the effectiveness of different treatment strategies for PTSD in patients with co-occurring SUD and will ultimately improve treatment outcomes for patients with this common co-morbidity worldwide. Trial registration Netherlands Trial Register (NTR), Identifier: NL7885 . Registered 22 July 2019.

[Background] Despite the growing evidence that trauma-focused treatments can be applied as first-line approaches for individuals with childhood trauma-related PTSD (Ch-PTSD), many therapists are still reluctant to provide trauma-focused treatments as a first-choice intervention for individuals with Ch-PTSD, especially by telehealth. The current manuscript will therefore give an overview of the evidence for the effectiveness of trauma-focused therapies for individuals with Ch-PTSD, the delivery of trauma-focused treatments via telehealth, and a case example on how a specific form of trauma focused therapy: Imagery Rescripting (ImRs) can be applied by telehealth. [Method] This article presents a clinical illustration of a blended telehealth trajectory of imagery rescripting (ImRs) Ch-PTSD delivered during the COVID-19 pandemic. [Results] The presented case shows that ImRs can be safely and effectively performed by telehealth for ch-PTSD, no stabilization phase was needed and only seven sessions were needed to drastically reduce Ch-PTSD and depressive symptoms, and to increase quality of life. [Conclusion] This case report shows the effectiveness of ImRs by telehealth for Ch-PTSD, which gives hope and additional possibilities to reach out to patients with ch-PTDS. Telehealth treatment might have some of advantages for specific patients, especially, but certainly not only, during the pandemic.