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1 Using Imagery Rescripting to Treat Major Depression: Theory and Practice

2 Jon Wheatley, Central and North West London NHS Foundation Trust and Royal Holloway University
3
4
Ann Hackmann, Warneford Hospital, Oxford
5
6 This paper considers the role that intrusive memories may play in maintaining depression and the rationale for using imagery
7 rescripting in order to target these memories. Potential mechanisms of change underlying imagery rescripting are discussed. The
8 relationship between depressive rumination and memories is considered, as well as potential links with mindfulness-based approaches.
9 The paper also discusses the practical applications of imagery rescripting with depressed patients, including basic principles and some
10 common problems, such as how to deal with multiple memories, avoidance, and suppression of memories. Finally, the relative merits of
11 different types of imagery rescripting that may utilize different affective systems are considered.
12

13 Why Use Imagery Rescripting to Treat Depression? reported to be very intrusive, ranging from daily to weekly 41
frequency. The wide variance here may be attributed to 42
14 Those unfamiliar with imagery rescripting might
methodological differences between studies, the high 43
15 wonder why we would want to use imagery in cognitive
rates of comorbidity with anxiety disorders, or possibly to 44
16 therapy with depressed patients when the cognitive
the tendency for depressed patients to try to avoid and 45
17 behavioral treatment of depression has traditionally
suppress their distressing memories. These studies indi- 46
18 involved either verbal restructuring of negative thoughts
cate that intrusive memories are almost as common in 47
19 and/or behavioral activation (Beck, Rush, Shaw, &
depression as in PTSD. The content of the memories is 48
20 Emery, 1979, Martell, Addis, & Jacobson, 2001).
somewhat different from that in PTSD, with more 49
21 However, we know from recent experimental work that
emphasis on loss of loved ones and interpersonal crisis 50
22 imagery has a greater impact on emotions than verbal
in the depressed population as opposed to personal 51
23 thought (Holmes & Mathews, 2005), and this raises the
assault or injury in PTSD. Frequent intrusive memories 52
24 possibility that imagery techniques might be more
may play an important role in maintaining depression 53
25 effective at eliciting and transforming emotions than
because they predict whether or not patients are still 54
26 verbal techniques such as thought records. This paper will
depressed at follow-up even when initial symptoms of 55
27 first explain why intrusive memories might be a potential
depression are controlled for (Brewin, Reynolds, & Tata, 56
28 treatment target in depression, and why imagery rescript-
1999). 57
29 ing (an approach originally developed to treat distressing
The reporting of intrusive memories in depression is 58
30 memories in other disorders) might be useful in the
perhaps unsurprising given that several studies have 59
31 treatment of this disorder. The bulk of the paper will then
found that depression is associated with distressing life 60
32 focus on practical considerations of how best to make use
events from childhood or later life (e.g. Brown & Harris, 61
33 of imagery rescripting when working with depressed
1978). Ma and Teasdale (2004) researched patients who 62
34 clients.
had a chronic relapsing history of depression and argued 63
that there might be two different populations of 64
35 Intrusive Memories and Life Events in Depression depressed patients: one with a history of childhood 65
adversity and another with later onset of depression 66
36 Distressing intrusive memories are common in depres-
associated with severe negative life events. In their 2004 67
37 sion. Previous studies have found that the percentage of
study, patients who had experienced three or more 68
38 depressed patients reporting intrusive memories has
depressive episodes reported more adverse early experi- 69
39 ranged from 44% to 87% (Brewin et al., 1996; Kuyken
ences (typically experiences of parental indifference and 70
40 & Brewin, 1994; Patel et al., 2007). These memories are
abuse) than patients who had only one or two previous 71
episodes. The latter group tended to have a later onset of 72
1077-7229/11/xxx–xxx$1.00/0
© 2011 Association for Behavioral and Cognitive Therapies. depression, which was preceded by negative life events. 73
Published by Elsevier Ltd. All rights reserved. Both groups may well be left with distressing memories of 74

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
2 Wheatley & Hackmann

75 these experiences. Whether the adverse events occurred challenges the toxic meaning of the original memory. 127
76 in childhood or in adult life, if patients continue This process allows the patient to construct a new 128
77 to experience frequent intrusive memories of these representation of the original memory that challenges 129
78 events, then they might potentially benefit from imagery its original meaning, and will hopefully be preferentially 130
79 rescripting. recalled over the toxic one. According to the retrieval 131
competition hypothesis (Brewin, 2006), our sense of self 132
consists of different representations, such as memories 133
80 Methods of Imagery Rescripting and Potential that compete with each other. These competing repre- 134
81 Underlying Mechanisms of Change sentations directly influence our beliefs and behavior. 135
82 There are theoretical mechanisms underlying imagery The implication of this hypothesis is that it might be 136
83 rescripting that may provide a rationale for its potential possible to create new representations of key memories 137
84 use in treating depression. Therapeutic procedures that using imagery techniques. If these new representations 138
85 are effective in reducing intrusive memories in personal- are memorable and meaningful, then they may be strong 139
86 ity disorders and posttraumatic stress disorder (PTSD) enough to compete with the original representation that 140
87 could potentially be applied to reduce intrusive memories had been stored with all its negative meanings. 141
88 in depression. Imagery rescripting is an effective treat-
89 ment for personality disorders (Arntz & Weertman, 1999;
Exploratory Study of Imagery Rescripting With 142
90 Weertman & Arntz, 2007). It has also been successfully
Depressed Patients 143
91 used to treat PTSD resulting from childhood sexual abuse
92 (Smucker & Dancu, 1999/2005) and from industrial An exploratory study was recently conducted to see 144
93 accidents (Grunert et al., 2007). It has also been used to whether imagery rescripting could be effective as a stand- 145
94 treat social anxiety disorder (Wild, Hackmann, & Clark, alone treatment for depression in patients with intrusive 146
95 2007). Rescripting aims to reduce the distress associated memories (Wheatley et al., 2009). This study included 10 147
96 with memories of past events that color the patient's patients with a long history of depression; in some cases 148
97 experience of the present. depression was associated with a history of childhood 149
98 Cognitive models of PTSD (Ehlers & Clark, 2000) adversity, and in others depression had been precipitated 150
99 suggest that traumatic memories are stored with the by severe life events in adult life. Several patients had 151
100 meanings that they had at the time of the event. The experienced distressing events in both childhood and 152
101 highly successful treatment approach (Ehlers, Clark, adulthood, and were troubled by a variety of intrusive 153
102 McManus, & Fennell, 2005) based on this model involves memories from key scenes throughout their lives. The 154
103 accessing the meanings of these memories though average age of patients was 41.3 (range: 30–56), the mean 155
104 imaginal exposure. These meanings are discussed with length of their current depressive episode was 2.3 years; 156
105 the therapist to discover new information that challenges all had experienced previous depressive episodes and 6 157
106 the toxic meanings of the memory. This new information also had comorbid anxiety disorders. Prior to treatment, 158
107 is then incorporated into the memory structure using half the patients scored in the severe range and the other 159
108 imagery techniques. The meaning of the memory is half scored on the moderate-severe range on the Beck 160
109 updated by asking the patient to imagine the event once Depression Inventory (Beck, Steer, & Garbin, 1988). 161
110 more, but this time inserting corrective information. This The exploratory study found that memories of 162
111 method of imaginal reliving usually involves updating the childhood and adult life events responded equally well 163
112 memory to include information about what actually to rescripting. For detailed case examples, see Wheatley 164
113 happened (e.g., that the patient did not die). In contrast, et al. (2007 and 2009). The average reduction in Beck 165
114 the method of imagery rescripting allows for more Depression Inventory scores was 16.60 (SD 13.47) after 166
115 “artistic license,” as the memory may be transformed in an average of 8.1 sessions of imagery rescripting and 167
116 ways that couldn't possibly have happened at the time. For gains were very well maintained at 1-year follow-up. 168
117 example, patients may imagine their adult “survivor” self Rescripting was most effective when intrusive memories 169
118 intervening to protect themselves as an abused child. were frequent and therefore more likely to be a 170
119 Imagery rescripting can be thought of as a kind of mental maintaining factor in the disorder (for further details, 171
120 time travel in which the patient imagines him- or herself see Brewin et al., 2009). 172
121 traveling back in time, revisiting key scenes from their One problem that potentially complicates treatment 173
122 past. This rescripting process must be closely related to is that intrusive memories may be associated with a 174
123 the key cognitions of the patient in order to be ruminative thinking style. Rumination itself has been 175
124 meaningful. Simply asking the patient to imagine some shown to predict depressive episodes and is associated 176
125 fantastical outcome that could never have happened will with more severe levels of depressive symptoms (Nolen- 177
126 not be helpful unless the imagery transformation Hoeksema, 2000). Studies have shown that intrusive 178

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
 Imagery Rescripting for Major Depression 3

179 memories may be experienced within processes of may also be a good idea for the patient to name the 232
180 ruminative thinking (Birrer, Michael, & Munsch, 2007; different parts of themselves that they are imagining (e.g., 233
181 Pearson et al., 2008). This echoes the findings of their child self, adult self, survivor self, etc.) in order to 234
182 Speckens et al. (2007), who found that in PTSD avoid confusion during the procedure. It is helpful for the 235
183 rumination can often trigger intrusive memories, and therapist to keep checking that the patient is visualizing a 236
184 vice versa. Brewin et al. (2009) found that depressed clear enough image and to inquire about associated 237
185 patients with intrusive memories also reported high levels emotions and sensations, but if the therapist prompts or 238
186 of rumination, and that their rumination decreased as inquires too much then this runs the risk of interfering 239
187 the frequency and distress of their intrusive memories with the patient's experience of reliving. Similarly, it is 240
188 decreased. This reflects the tendency for intrusive best for the emotional stance of the therapist to be 241
189 memories and rumination to occur together and perhaps relatively neutral during the imagery procedure; expres- 242
190 indicates that they are mutually self-supporting. For sions of empathy should be made both before and after. If 243
191 example, memory intrusions may provide powerful the therapist becomes too empathic during the proce- 244
192 reminders of specific meanings concerning the self and dure, this might bring the patient too far out of the 245
193 thus trigger depressive rumination. It is therefore difficult memory and back into the room. As high levels of affect 246
194 to separate memories from their meanings and from the may be experienced by the patient when using imagery, it 247
195 predominantly verbal process of rumination, as they are is advisable to begin the procedure early on in the session 248
196 all connected. In summary, there is evidence that both and to ensure that sufficient time is left for debriefing and 249
197 intrusive memories and rumination maintain and exac- discussion so that the patient returns to baseline levels of 250
198 erbate depression, and we have some promising initial emotion before leaving the room. 251
199 evidence that imagery rescripting may be effective in We have suggested the following procedure when 252
200 targeting both these processes. working with depressed patients (as described in Wheatley, 253
Brewin, & Hackmann, 2009), drawing on ideas from 254
201 How to Use Imagery Rescripting in the Treatment Brewin, Arntz, Smucker, Ehlers and Clark, Holmes, and 255
202 of Major Depression other colleagues. We summarize the steps in the process 256
203 This section describes the basic procedure of imagery below before addressing some common problems and 257
204 rescripting before addressing some of the common concerns that therapists might encounter. 258
205 clinical problems that may be encountered when attempt- Steps of the rescripting process: 259
206 ing this technique with depressed patients. There are 1. It is often helpful when introducing the rationale for 260
207 several protocols for imagery rescripting with different imagery rescripting to use the metaphor of the patient 261
208 disorders (e.g., Arntz & Weertman, 1999; Hackmann, being haunted by the distressing memory (or memories). 262
209 1998; Smucker & Dancu, 1999/2005; Wild et al., 2007). These ghosts from the past don't need to be banished, 263
210 These procedures nevertheless seem to share some because memories cannot be erased, but the patient 264
211 fundamental ideas about good practice. It is advised that needs to be able to see them as “normal” bad memories of 265
212 while reliving a distressing memory the patient should things that can no longer hurt them, and that do not have 266
213 have “one foot in the memory and one foot in the room.” implications for their present. 267
214 This means that they need to be reliving the memory in 2. The patient is asked to vividly imagine and describe 268
215 sufficient detail in order to be able to access the emotions the event represented in the distressing memory, bringing 269
216 and appraisals that are associated with it, but that they all the associated sensory detail, key associated emotions 270
217 should not become so absorbed in the memory that they and cognitions into awareness. This stage of the process 271
218 dissociate from the fact that they are in the therapy room can be described as “imaginal reliving.” 272
219 in the present day. In order to best access the memory it is 3. After this reliving, the meaning of the memory is 273
220 helpful for patients to close their eyes (if they feel explored through Socratic questioning, and affect and 274
221 comfortable doing so) and then visualize and verbalize belief ratings are taken. It is best to do this after, rather 275
222 the scenes that they see unfolding in their mind's eye, than during, the imagery exercise because taking such 276
223 using the first person present tense, as if it were ratings may bring the patient out of imaginal reliving. It 277
224 happening now. If the patient slips back into using the will, however, need to be done immediately after reliving 278
225 past tense, it is often helpful for the therapist to prompt so that affect is still “hot.” 279
226 them by simply repeating back to them what they have just 4. The next stage is to begin rescripting the memory. 280
227 said in the present tense. In order for the patient to access The patient is asked what needs to happen in the scene 281
228 the entire memory network, it may be helpful for the that they are imagining in order for their distress to be 282
229 therapist to inquire about the full range of sensory reduced. The patient may need to try imagining several 283
230 experience — what can the patient see, hear, taste, smell, different ways of transforming the image before they 284
231 or feel in their body when they hold the image in mind? It settle on one that successfully reduces their distressed 285

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
4 Wheatley & Hackmann

286 affect and introduces feelings of safety, soothing or control memories that are linked in terms of their meanings. It 338
287 (depending on what they may have needed at the time). may be helpful to think of thematically linked memories 339
288 5. Belief and affect ratings are then repeated once a as being located at the same “address in the mind.” It 340
289 satisfactory transformation of the affect has been therefore happens that if we change the meanings 341
290 achieved. This is vital to check that the transformation associated with just one or two key memories, then the 342
291 has been meaningful and has led to a reappraisal of the beliefs associated with other memories in the network 343
292 original memory. may also change. We suggest a pragmatic approach of 344
293 6. The patient rehearses and elaborates this alternative, beginning with either the most frequent or the most 345
294 more positive representation of the event from their past distressing intrusive memory reported by the patient 346
295 until the distressing affect and unhelpful beliefs associated (often the memory that intrudes the most is the most 347
296 with the original toxic memory are significantly reduced. distressing one). 348
297 7. Finally, the therapist asks whether any other similar Both therapist and patient will also be reassured that it 349
298 memories may have emerged either during the proce- does not seem to be necessary for the patient to relive the 350
299 dure, or in the days and weeks following the session. If events of their intrusive memory in their entirety before 351
300 new memories have emerged, then it is important to ask they start to rescript the memory. It seems to be sufficient 352
301 the patient whether the affect and meanings accompa- to ask the patient to visualize and verbalize the key 353
302 nying these memories are similar to or different from moments from the memory that elicit high affect and 354
303 those associated with the original memory that had been associated toxic meanings. This approach is comparable 355
304 targeted in therapy. Sometimes working on the original to working on the “warning signals” (Ehlers et al., 2002) 356
305 memory will be enough to change the meanings of other or “hot spots” (Grey, Holmes, & Brewin, 2001) of 357
306 memories also, but it is possible that patients may access traumatic events in PTSD. These might be moments 358
307 additional memories that they believe to be consistent when the meaning of an event changed for the worse. For 359
308 with deeply held negative beliefs about the self, and these example, one patient in the study cited above reported 360
309 may require rescripting in their own right until those that her distress was highest when she saw an image of her 361
310 beliefs begin to change. father, who had formerly been a boxer, collapse helplessly 362
onto the floor of the hospice where he was being cared 363
for. This was the moment when the patient realized that 364
311 How to Proceed if the Patient Reports More Than One her father was no longer the strong man that he had once 365
312 Distressing Memory? been and that she would soon be losing him. Another 366
313 The prospect of attempting to rescript distressing good place to start rescripting a memory might be at the 367
314 memories can be a daunting one for inexperienced moment in the memory that signaled that a distressing 368
315 therapists (or for experienced therapists who may not be experience was about to happen. To give an example 369
316 familiar with using imagery techniques). A common (again from the case series described by Brewin et al., 370
317 difficulty is that therapists are unsure which particular 2009), for one patient simply imagining the sound and 371
318 memory to work on and how many memories they might smell of an abuser as he approached her as a child was 372
319 need to address before they can hope to bring about enough to elicit the associated emotions and meanings (“I 373
320 emotional and cognitive change. As mentioned earlier in am powerless and a bad person”). It has also been 374
321 this article, imagery rescripting can be used to treat either observed in work with personality disorders that it is not 375
322 very recent memories of a distressing life event (Grunert, necessary for the patient to relive the whole distressing 376
323 Weis, Smucker, & Christianson, 2007), or memories of memory before rescipting it (Arntz & Weertman, 1999). 377
324 childhood events (Arntz, van Genderen, & Drost, 2009; How much of the original toxic memory needs to be 378
325 Arntz & Weertman, 1999; Weertman & Arntz, 2007). Our “relived” by the patient before the memory is rescripted 379
326 recent exploratory study used imagery rescripting suc- will be a judgment call that is more based on clinical art 380
327 cessfully with a single memory and with multiple than clinical science. 381
328 memories of events that had been experienced through- It is important that the therapist does not make any 382
329 out the life span. The good news (for both clinician and assumptions about what the most meaningful aspects of a 383
330 patient alike) is that we do not need to attempt to search distressing memory might be. For example, one patient 384
331 for all the toxic memories that the patient might have. from the Brewin et al. (2009) case series had experienced 385
332 Our task is to change the toxic affect and meanings that several terminations of pregnancy during her twenties 386
333 are associated with particularly distressing memories, and and was distressed by three different aspects of this 387
334 we have found that working on just one highly emotional experience: her perception that the medical staff had 388
335 memory may be enough to change important strongly morally condemned her, her experience of feeling lonely 389
336 held beliefs about the self. In clinical practice we have and rejected following the procedure, and images of the 390
337 often found that there is a network of self-defining tormented souls of her dead babies in the afterlife. Her 391

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
 Imagery Rescripting for Major Depression 5

392 intrusions were therefore a combination of memories PTSD developed by Ehlers and Clark (2000) suggests that 444
393 based on actual experience and her imagination of what such avoidance of emotional memories might be prob- 445
394 may have happened to the souls of her babies. Accessing lematic as it may mean that the distressing memories are 446
395 the meanings of a distressing experience might therefore not carefully considered or elaborated, so that they are 447
396 require some detective work from the therapist, similar to more likely to be stored with the meanings that they had 448
397 the process of eliciting hot spots when treating PTSD at the time of the event (even if these were distorted). The 449
398 (Grey, Young, & Holmes, 2002). past experiences of abandonment, loss, indifference, or 450
399 In summary, imagery rescripting can be used to treat abuse that are common in depression might therefore be 451
400 memories of distressing events from both childhood and appraised as having threatening implications for the 452
401 adulthood. Clinical experience suggests that there is often patient's experience of the here and now, and influence 453
402 a network of distressing memories that are similar in their predictions about likely future experiences. 454
403 terms of their associated meanings and emotions. Active suppression of distressing memories might also 455
404 Changing the meaning of one memory may transform have an unhelpful rebound effect. Dalgleish and Yiend 456
405 the meaning of other memories in the network. (2006) found that when subjects tried to suppress one 457
particular distressing memory, other upsetting past 458
memories intruded more frequently—for example, 459
406 Avoidance and Suppression of Distressing Memories when attempting to suppress a specific memory of failure, 460
407 Although depressed patients frequently experience other experiences of failure came into mind. This possible 461
408 intrusive memories, they may attempt to avoid experienc- rebound effect might go as follows: qI don't want to think 462
409 ing the emotional impact of these memories in various about that memory of failureq spreads to qI don't want to 463
410 ways. Some of the patients in the Brewin et al. (2009) case think of any failure memories,q leading to intrusions of 464
411 series used drugs and alcohol in order to block out several memories in attenuated form. 465
412 emotional memories. Fortunately, their substance misuse In our clinical work we have found that patients often 466
413 decreased as treatment progressed and their intrusions start to recall networks of associated memories when they 467
414 ceased. All patients in the series reported frequent and are accessing one particular memory in therapy. It may be 468
415 prolonged periods of rumination associated with their that rescripting helps people to bring memories that they 469
416 distressing memories prior to treatment. The functions of have previously avoided to mind, perhaps because their 470
417 rumination as escape and avoidance strategies in depres- metacognitive beliefs about the memories change (e.g., 471
418 sion have been suggested by Watkins (2004, 2005). “It's only a memory or a ghost from the past, therefore I 472
419 Potential functions of rumination may include cognitive don't have to suppress it”). We have found that patients 473
420 and emotional avoidance and anticipating negative often report an initial increase in the frequency and 474
421 responses from others or the environment in order to intensity of their intrusive memories at the start of 475
422 avoid criticism. Rumination about the implications of treatment and that this then fades as treatment pro- 476
423 intrusive memories may indicate an overly evaluative gresses. This might be the result of an initial change in the 477
424 thinking style. Imagery rescripting is an experiential metacognitive meanings of the memories (“I no longer 478
425 technique that aims to switch patients out of the have to avoid these memories”), followed by changes in 479
426 abstract-evaluative processing style of rumination into the meanings encapsulated by the memories that had 480
427 the actual experience of emotions, thoughts and sensa- previously been avoided. In summary, it seems that trying 481
428 tions. The technique of imagery rescripting brings to suppress a particularly distressing memory may have 482
429 emotional material that may have previously been avoided the paradoxical effect of bringing negative memories of 483
430 “on-line” and into the patient's awareness, so that it can similar experiences to mind, which may in turn fuel 484
431 be processed and transformed with guidance from the rumination. When patients are asked to bring a specific 485
432 therapist. distressing memory to mind during the rescripting 486
433 An important function of rumination may be to procedure, this will often result in recall of memories of 487
434 suppress the high affect that is associated with distressing similar distressing experiences. However, it is hoped that 488
435 memories. It has been suggested that the predominantly the meanings of these memories might change during the 489
436 verbal activity of worry suppresses emotional imagery and process of rescripting (e.g., “That was a painful experi- 490
437 its associated somatic sensations in patients with general- ence but it may not have the toxic meaning that I once 491
438 ized anxiety disorder (Borkovec & Inz, 1990). As the thought it did”). If a network of related memories are all 492
439 process of rumination in depression is similar to the to be found at the same address in the mind, then when 493
440 process of worry in GAD, rumination might function as the meaning of one memory changes it may also change 494
441 motivated avoidance of emotional imagery and may have the “post-code” of other associated memories. 495
442 the effect of inhibiting the full sensory and emotional There is a potential overlap here between imagery 496
443 recall of distressing images and memories. The model of rescripting and the practice of mindfulness-based cognitive 497

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
6 Wheatley & Hackmann

498 therapy (Segal, Williams, & Teasdale, 2002). Mindfulness- then reappraise beliefs. In cases where the patient is 550
499 based cognitive therapy (MBCT) encourages patients to anxious about engaging in imagery work, it may be 551
500 allow emotional material that may previously have been helpful for the therapist to frame the exercise to them as a 552
501 avoided or else endured with distress into their awareness. behavioral experiment and to ask them to make predic- 553
502 MBCT does not aim to change the content of patients' tions about the process: for example, how much distress 554
503 cognitions, but to help them learn a new relationship to do they think they will experience or to what extent do 555
504 their thoughts as simply “events in the mind.” Patients are they think they will be in control of what they imagine? 556
505 encouraged to experience the contents of cognition, It has been suggested that Socratic imagery is likely to 557
506 thoughts, images, memories and the emotions that be more powerful than therapist-directed imagery 558
507 accompany them without their habitual reactions of (Smucker & Dancu, 1999/2005), and our own clinical 559
508 aversion or judgment. Imagery rescripting has a similar experience would concur with this. Asking Socratic 560
509 rationale of allowing cognitive and emotional phenomena questions—such as, “How do you need to feel when you 561
510 that may previously have been avoided into awareness, so hold this memory in mind?” “What would need to happen 562
511 that patients can learn a new relationship to their (in the image) in order for you to feel okay?” “Can you 563
512 memories of these events (perhaps also coming to see imagine that happening?”—might help the patient to 564
513 them as simply mental events). This provides an arrive at a rescript that works for them (i.e., one that 565
514 opportunity for the meanings of the memories to be allows them to access more positive emotions and that 566
515 updated. Images rarely remain static and sometimes challenges the original toxic meaning of the memory). 567
516 simply encouraging the patient to hold an image in Just as when you are planning effective behavioral 568
517 awareness will lead to reflection and perhaps a new experiments, it is important to specify the key cognitions 569
518 understanding of the experience that is represented in and emotions associated with any memory before 570
519 memory, which may result in spontaneous emotional attempting to rescript it. Any changes in affect or belief 571
520 change. In addition, the therapist does not suggest ratings must be carefully tracked both before and after 572
521 imagery transformations to the patient; rather the the rescripting process. Tracking cognitive and affective 573
522 therapist Socratically helps the patient to envisage and change in this way serves as a manipulation check to see 574
523 elaborate their own rescript, based on their wider whether or not the rescript is reducing toxic affect and 575
524 experience of the world and their understanding of how changing the associated meanings. Taking belief and 576
525 they need to feel when holding the memory of mind. affect ratings before and after any rescripting is important 577
526 In summary, avoidance of distressing memories seems because sometimes powerful shifts in degree of belief can 578
527 to be common in depression. Imagery rescripting is an take place within a single session, and the belief ratings 579
528 experiential technique that aims to help patients to allow provide a marker of such shifts. For example, in cases of 580
529 this emotional material into awareness so that the childhood abuse, sometimes asking the adult patient to 581
530 meanings of key events from the past can be reappraised. vividly imagine themselves as they were when they were a 582
531 This process sometimes leads to spontaneous cognitive child can produce spontaneous feelings of compassion 583
532 change. towards themselves (“She's so little and defenseless”) and 584
reappraisals of the abuse (“It's not her fault, she's only a 585
little girl—it's him that's the bad one”). A further reason 586
533 How to Help a Patient to Effectively Rescript a why it is so important to take these ratings is that different 587
534 Distressing Memory memories in the associative network may be associated 588
535 One reason that therapists might avoid using the with similar emotions and beliefs. For example, one 589
536 technique of imagery rescripting is that they are unsure patient recalled three different memories from different 590
537 exactly how a rescript of a memory is supposed to unfold. ages that all had the same cognitive theme of being at the 591
538 The therapist cannot predict what the patient will be mercy of more powerful people and the same sensory 592
539 imagining or where the rescript might lead. There are qualities of being unable to stand up on her feet: an early 593
540 parallels here with the process of conducting behavioral memory of being placed on a donkey against her will 594
541 experiments (Bennett-Levy et al., 2004), another tech- during a seaside holiday as a little girl; a childhood 595
542 nique that generates high levels of affect. When engaging memory of being pushed down some steps by a gang of 596
543 in the experiential techniques of imagery rescripting or older children; and an adult memory of having her legs 597
544 behavioral experiments, neither therapist nor patient can held in stirrups during a termination of pregnancy. 598
545 predict exactly what the outcome will be. As Aaron Beck Taking affect and belief ratings helped the therapist to 599
546 has said, cognitive change takes place “within the fires of keep a check on the process of change in the key 600
547 affect” (cited by Edwards, 2009) and the high levels of cognitions and emotions associated with these memories. 601
548 affect that are generated by these techniques may partly A final reason to take belief and affect ratings before 602
549 explain why they can be powerful methods to activate and and after the rescripting procedure is to see whether any 603

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 Imagery Rescripting for Major Depression 7

604 positive emotions and meanings associated with a rescript competing representation of the experience and serve as 658
605 are retained by the patient once they leave the therapy a manipulation check of the techniques' effectiveness. 659
606 room. A significant shift in belief ratings might occur The therapist needs to ensure that any competing 660
607 immediately following an intensely emotional imagery representations of a memory will be memorable and 661
608 exercise within the session, but if the rescript is not meaningful enough to be able to compete with the 662
609 distinctive or meaningful enough, then the old represen- original intrusion. 663
610 tation and meaning of the memory may be retrieved in
611 response to environmental triggers when the patient
How to End a Rescript: Is Mastery or Compassion More 664
612 leaves the safety of the therapy room. As Brewin has
Important When Treating Depression? 665
613 suggested in his retrieval competition hypothesis (Brewin,
614 2006), our emotions and behavior are under the control The greater artistic license that therapists have when 666
615 of alternate memory representations that compete for using imagery rescripting as opposed to imaginal expo- 667
616 retrieval. This means that any new representation that is sure or reliving can cause some confusion. Imagery 668
617 created in therapy must be able to compete effectively rescripting allows the patient to give a distressing memory 669
618 with the old toxic representations of the memory. As the an alternative ending. This does not mean that we invite 670
619 intrusive negative memories are likely to have been well- patients to simply imagine that the distressing event never 671
620 rehearsed, any new representation will need to be happened (e.g., that they were not abused and that their 672
621 distinctive and meaningful if it is to effectively compete parent did protect them). The aim is to give the memory a 673
622 with them. The task in therapy is to help the patient different meaning by rescripting it according to what it 674
623 construct competing representations of the memory that might have been helpful for the patient to have known or 675
624 are similar enough to the old toxic representation to be experienced at the time of the event (e.g., to know that 676
625 retrieved by environmental reminders of the event, but the abuse wasn't their fault or to feel a sense of safeness). 677
626 different enough to access positive feelings and beliefs. It Imagery rescripting is essentially an experiential tech- 678
627 would therefore be ineffective for the patient to simply nique with a cognitive rationale; the aim is to change the 679
628 substitute a “good” memory for a “bad” one, or for a new key cognitions associated with a distressing memory by 680
629 representation to gloss over the distress associated with asking the patient to imagine altering events of the past in 681
630 the old memory. The new representation is not a ways that challenge their original appraisals of them. 682
631 replacement for the old memory, but rather an elabora- Whereas imaginal exposure would have a habituation 683
632 tion of it, taking into account information from a wider rationale, imagery rescripting aims to create an alterna- 684
633 context. During the rescripting process the patient holds tive representation of the memory that will give new 685
634 the distressing experience in working memory while meaning to the experience. 686
635 introducing positive visual and sensory content. Compet- When constructing a competing representation that is 687
636 ing representations of the memory are linked to the linked to positive affect, clinicians are often unsure about 688
637 imagination of positive states such as mastery over to what degree the rescript should involve elements of 689
638 adversity or compassionately relating to the distressed mastery imagery (during which the patient accesses 690
639 self. At the end of treatment the patient will still be able to feeling of power and resourcefulness) or compassionate 691
640 recall the negative experience, but with a new under- imagery (during which they access feelings of being 692
641 standing of the meaning of that experience; perhaps the soothed or nurtured). Depression is frequently associated 693
642 knowledge that they survived, that they coped with it as with feelings of helplessness (Abramson, Seligman, & 694
643 best they could, or that it wasn't their fault. One further Teasdale, 1978) and shame (Andrews, 1998). Further- 695
644 implication of the retrieval competition hypothesis is that more, depressed patients often have high levels of self- 696
645 any avoidance of distressing memories by the patient blame and self-attacking (Gilbert & Irons, 2005). Imagery 697
646 during treatment might make it difficult for them to rescripting for depression therefore needs to find ways to 698
647 construct a new representation of the memory that will be address these core cognitive and emotional problems. It 699
648 robust enough to compete with the old representation. has been suggested that when using imagery rescripting to 700
649 This might leave the patient vulnerable to relapse because treat anxiety disorders, elements of both mastery and 701
650 the old memory network may be easily triggered by compassion are necessary in order to reach positive 702
651 reminders and because key parts of the memory may not reappraisals (Hackmann, 2005). This has also been 703
652 have been updated. suggested when treating depression (Wheatley et al., 704
653 In summary, just as in standard cognitive therapy 2007) to address the common themes of helplessness, 705
654 methods, the therapist should take belief and affect shame, and self-blame. However, it is currently unclear 706
655 ratings associated with each intrusive memory before and how best to combine these two elements in a rescript, and 707
656 after rescripting them. These ratings will help the what their relative contributions might be towards 708
657 therapist and patient to Socratically create a meaningful change. How can we judge whether or not a rescript 709

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
8 Wheatley & Hackmann

710 contains the right proportion of mastery and compassion? therapy before she was able to generate a compassionate 764
711 This is an empirical question that we cannot currently representation that was could effectively compete with 765
712 answer and so our best guide will be the belief and affect her dominant intrusive memories. First, the patient chose 766
713 ratings made by patients as the process unfolds. If a key to bring photographs of herself as a child to the therapy 767
714 cognition or emotion is not changing, we may need to ask sessions to help her imagine the key scenes from the past. 768
715 whether this can this be linked to a theme of shame, She then brought a compassionate figure into the image 769
716 helplessness, anger, or some other emotion not yet (an aunt whom she had experienced as kind, but who had 770
717 addressed. We will then be able to consider various ways not known the full extent of the child's distress at the 771
718 in which the patient may need to try altering the events time). The patient was able to imagine this aunt 772
719 that they are imagining so that they will have a different intervening to protect her child-self. During the imagery 773
720 emotional experience of them. exercise the patient recalled new information that had 774
721 The distinction between mastery and compassionate previously been outside her awareness—that as a child 775
722 imagery can be important as different types of positive she had regularly taken her pocket money and put half of 776
723 affect may be experienced quite differently by the patient. it into each of her parent's coats in the hope that this 777
724 It has been suggested that positive affect associated with might stop them fighting. This memory helped the 778
725 affiliation might be very different to positive affect patient to feel some compassion for herself as a child 779
726 associated with mastery (Gilbert, 2008). In clinical and she now felt more inclined to intervene in the image 780
727 practice we have observed that patients might initially as her adult self. However, she was unsure how to respond 781
728 want to begin a rescript by increasing their sense of power compassionately to her child self, perhaps because she was 782
729 or control, for example, to banish an abuser or stand up to unable to access memories of this actually happening to 783
730 a critical figure. Following these mastery-based transfor- her. The patient was then asked to think of someone in 784
731 mations, patients may then express more of a need for the present whom she felt compassion towards. The 785
732 soothing or nurturing their distressed self. Paul Gilbert's patient thought of a cousin who had Down's syndrome 786
733 work would suggest that it might be best to end a rescript and imagined hugging him. Holding on to that feeling of 787
734 at a point when the patient is accessing and experiencing affiliation, she was then able to imagine her adult self 788
735 feelings of soothing and affiliation through imagery hugging her child self. Following this session, the patient 789
736 rather than feelings associated with mastery or “drive.” started to grieve that her parents had been so preoccu- 790
737 However, it may not be easy for some patients to generate pied with their problems that she had not received the 791
738 such compassionate representations. Patients who are care that she had needed as a child. This resulted in 792
739 highly self-critical may find it much harder to create feelings of sadness, then of anger, before the patient was 793
740 compassionate images, and may even find being asked to able to arrive at a more balanced and compassionate adult 794
741 do so aversive because of associative links to memories of perspective of her childhood experiences (for a more 795
742 neglect or abuse in previous attachment relationships detailed account of this work see Wheatley et al., 2009). 796
743 (Rockliff et al., 2008). If patients are able to access In summary, creating an alternative representation of a 797
744 emotional memories of affiliation, then the task of distressing memory is a creative process that often involves 798
745 therapy is simply to bring those feelings and experiences elements of both mastery and compassion. The alterna- 799
746 on-line. In such cases, simply asking the patient to tive representation is not a replacement for the original 800
747 imagine themselves as a child may lead to spontaneous memory, but the process of rescripting allows the patient 801
748 feelings of compassion. However, if patients do not have to bring in new perspectives that hopefully change the 802
749 sufficient access to memories of affiliation or nurturance, meaning of the original event. 803
750 then they may need some guidance from the therapist
751 before they can imagine these experiences. Creative Summary, Conclusions, and Further Questions 804

752 imagery techniques aimed at helping patients to construct Imagery rescripting can be a powerful way of first 805
753 an image of their “perfect nurturer” in order to access accessing and then transforming distressing memories 806
754 feelings of soothing and safeness have been described that might be maintaining depression. Our sense of self 807
755 elsewhere (Lee, 2005). and our memories are closely intertwined (Stopa, 2009), 808
756 One final example from the Brewin et al. (2009) case and so working on key memories may lead to reappraisals 809
757 series illustrates some ways in which patients may be of negative or traumatic experiences that can result in 810
758 helped to access ways of relating to themselves compas- fundamental shifts in how patients see themselves. As one 811
759 sionately during imagery rescripting. A severely depressed patient commented at the end of treatment (quoted in 812
760 patient in her mid-39′s had been emotionally neglected Brewin et al., 2009), “It's like I've salvaged my self, my soul.” 813
761 by her parents, whom she had experienced as being However, although the initial results that have been 814
762 either preoccupied with their marital difficulties or highly obtained using imagery rescripting to treat major 815
763 critical of her. We went through the following steps in depression seem promising, we should remain cautious 816

Please cite this article as: Jon Wheatley & Ann Hackmann, Using Imagery Rescripting to Treat Major Depression: Theory and Practice,
Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004
 Imagery Rescripting for Major Depression 9

817 as this evidence is thus far restricted to a small sample Brewin, C. R. (2006). Understanding cognitive behaviour therapy: A 875
retrieval competition account. Behaviour Research and Therapy, 44, 876
818 size. Imagery rescripting can currently only be said to be 765–784. 877
819 evidence-generating practice rather than evidence-based Brewin, C. R., Hunter, E., Carroll, F., & Tata, P. (1996). Intrusive 878
820 practice. In order for the results obtained in Brewin et al. memories in depression. Psychological Medicine, 26, 1271–1276. 879
Brewin, C. R., Reynolds, M., & Tata, P. (1999). Autobiographical 880
821 (2009) to be placed on a more secure footing, there memory processes and the course of depression. Journal of 881
822 would need to be a randomized controlled trial compar- Abnormal Psychology, 108, 511–517. 882
823 ing rescripting with standard cognitive restructuring Brewin, C. R., Wheatley, J., Patel, T., Fearon, R. M. P., Hackmann, A., 883
Wells, A., Fisher, P., & Myers, S. (2009). Imagery rescripting as a 884
824 procedures. brief stand-alone treatment for depressed patients with intrusive 885
825 There are also many unanswered questions about the memories. Behavior Research and Therapy, 47, 569–576. 886
826 possible mechanisms of change underlying imagery Brown, G. W., & Harris, T. (1978). Social origins of depression. London: 887
Tavistock. 888
827 rescripting. An explanatory framework may be offered Dalgleish, T., & Yiend, J. (2006). The effects of suppressing a negative 889
828 by cognitive models of posttraumatic stress disorder, or by autobiographical memory on concurrent intrusions and subse- 890
829 the retrieval competition hypothesis. One important quent autobiographical recall in dysphoria. Journal of Abnormal 891
Psychology, 115, 467–473. 892
830 question is whether rescripting works by creating more Edwards, D. (2009). Using imagery and chair dialogue to rescript early 893
831 functional self-representations during therapy, or by maladaptive cognitive patterns. Symposium conducted at the BABCP 894
832 improving access to positive representations that previ- Conference, Exeter, U.K. 895
Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic 896
833 ously existed, but that had been outside the patient's stress disorder. Behaviour Research and Therapy, 38, 319–345. 897
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836 the current limitations of our knowledge base and the Ehlers, A., Hackmann, A., Steil, R., Clohessy, S., Wenninger, K., & 901
837 high levels of affect that can be generated through Winter, H. (2002). The nature of intrusive memories after trauma: 902
838 imagery techniques, many therapists may feel cautious The warning signal hypothesis. Behaviour Research and Therapy, 40, 903
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1005

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Cognitive and Behavioral Practice (2011), doi:10.1016/j.cbpra.2010.06.004