J Contemp Psychother (2017) 47:23–30

DOI 10.1007/s10879-016-9329-4

ORIGINAL PAPER

Imagery Rescripting for PTSD and Personality Disorders: Theory

Published online: 2 March 2016

Abstract Imagery Rescripting is a psychotherapy tech- Keywords Imagery rescripting
Schema therapy

nique that has been integrated into Cognitive Behaviour Cognitive therapy
Personality disorders
PTSD
Therapy (CBT) interventions in the treatment of various
psychiatric populations including post-traumatic stress Imagery Rescripting is a psychotherapy technique that has
disorder (PTSD), personality disorders, specific phobias, been integrated into Cognitive Behaviour Therapy (CBT)
depression, obsessive–compulsive disorder, social phobia, interventions to treat various psychiatric populations
and suicide risk. Whilst empirical evidence for imagery including post-traumatic stress disorder (PTSD) (Arntz
rescripting is accumulating, the technical application and et al. 2013; Grunert et al. 2003, 2007; Hagenaars and Arntz
theoretical rationale for its use can differ markedly 2012; Long et al. 2011), personality disorders (Young et al.
depending on treatment protocol, treatment population, and 2003), specific phobias (Hunt and Fenton 2007), depression
research group. One such instance is in the case of PTSD (Brewin et al. 2009; Wheatley et al. 2007), obsessive–
and personality disorders where there is significant dis- compulsive disorder (Speckens et al. 2007; Veale et al.
parity in the rationale and application of imagery 2015), social phobia (Frets et al. 2014; Reimer and
rescripting for the two populations. This paper describes Moscovitch 2015; Wild et al. 2007), body dysmorphic
the theoretical and technical differences between protocols disorder (Willson et al. 2015) and suicide risk (Holmes
for the use of imagery rescripting with these two popula- et al. 2007b).
tions. It will be argued that the differences between these Imagery rescripting describes a set of related therapeutic
protocols may not necessarily represent meaningful disor- procedures that are aimed at changing the unfolding of
der-specific considerations. Instead, choosing between events in a distressing or traumatic memory. In this pro-
different protocols for the application of imagery rescript- cess, part or all of a distressing memory is evoked and the
ing may be better guided by considering the goals of the client is assisted to ‘rescript’ the memory by imagining a
intervention as well as the individual client’s readiness for more desirable outcome (Hackman et al. 2011). This can be
mastery in rescripting. Finally, current research limitations achieved in a number of ways, and may involve imagining
in this field are highlighted and the authors suggest future a different ending to a traumatic event, bringing a trusted
research directions for further clarity in clinical decision- adult-figure into the memory to protect the vulnerable
making regarding this intervention. individual, or punishing the perpetrator of the distressing
event (Stopa 2009). Recent experimental findings have
confirmed the special capacity of mental imagery to evoke
emotions (Holmes and Mathews 2005), suggesting that
techniques which make use of imagery may be a powerful
& Robert N. Brockman
[email protected]
tool for any therapy which aims to facilitate emotional
processing.
1
Graduate School of Health, University of Technology Although not a new technique amongst psychotherapists
Sydney, PO Box 123, Ultimo, NSW 2007, Australia (Edwards 2007), imagery rescripting has become the focus
2
University of Wollongong, Wollongong, NSW, Australia

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of serious academic endeavor to claim its place as a particularly in the case of type II, non-fear related emotions
technique used in the CBT tradition in the last decade such as guilt, powerlessness, self-blame, disgust and shame
(Holmes et al. 2007a). As will be reviewed in detail in this may contribute to the maintenance of PTSD (Holmes et al.
paper, the development of imagery rescripting followed 2005). Imagery rescripting has emerged as a potential
two parallel streams: (1) as an approach to treating PTSD, method of targeting these non-fear related emotions in
particularly type II traumas (Smucker et al. 1995); and (2) PTSD. The following section outlines the theoretical
as a method for modifying the schematic beliefs that often rationale and protocol for the use of imagery rescripting for
characterize personality disorder presentations (Arntz and individuals with PTSD with non-fear based emotions.
Weertman 1999). Separate protocols for the use of imagery
rescripting have emerged from these two streams. Imagery Rescripting for PTSD
This paper will endeavor to describe the theoretical and
technical differences in the application of imagery A description of imagery rescripting applied to PTSD
rescriping to PTSD as well as to personality disorders, as populations was first published by Smucker et al. (1995)
outlined by protocols within the literature. It will be argued who described the use of this technique for survivors of
that the differences between these protocols may not nec- childhood sexual abuse (type II trauma). Smucker et al.
essarily represent meaningful disorder-specific considera- identified the need for treatment approaches targeting the
tions. Instead, choosing between different protocols for the complex array of non-fear related emotions often experi-
application of imagery rescripting may be better guided by enced by these individuals, including powerlessness, self-
considering the goals of the intervention as well as the blame, disgust and shame. At this time, Prolonged Expo-
individual client’s readiness for mastery in rescripting. sure (Foa et al. 1989) had emerged as a popular treatment
Finally, current research limitations in this field are high- of PTSD in which the client recalls and relives traumatic
lighted and the authors suggest future research directions memories by telling their account out loud, in present tense
for further clarity in clinical decision-making regarding this and in first person narrative. Imaginal exposure to these
intervention. memories is repeated and corrective information is pro-
vided within a safe therapeutic environment. Through
modification of the meaning given to the memory, the
Rationale and Application of Imagery Rescripting reliving of the traumatic event becomes less distressing
for PTSD (Foa et al. 1989). Smucker et al. (1995) argued that despite
its success in guiding treatment for PTSD in general, the
Posttraumatic stress disorder (PTSD) is a psychological Foa et al. (1989) model of PTSD was too narrow to
condition that may develop in individuals who have been encompass the non-fear related meanings and emotions
exposed to one or more traumatic events. It involves the that are frequent in presentations of childhood sexual abuse
presence of intrusion symptoms such as recurrent flash- survivors. Furthermore, Prolonged Exposure was argued to
backs or nightmares as well as avoidance of stimuli asso- be too narrow to encompass and drive treatment for the
ciated with the traumatic event. Individuals diagnosed with pathogenic schemas which generally developed alongside
PTSD also display negative alterations in cognition, mood, such early maladaptive experiences. Smucker et al. (1995)
arousal and reactivity, related to the traumatic event argued that although prolonged exposure may successfully
(American Psychiatric Association 2013). In examining the decrease danger appraisals, it was limited in its ability to
nature of traumatic events that precede posttraumatic bring about change in the meanings of trauma events.
symptoms, Terr (1991) distinguished between ‘‘type I’’ Indeed, it is being made increasingly clear in the trauma
single-incident trauma (an unexpected event such as a literature that although fear is the most common emotional
traumatic accident, natural disaster or terrorist attack) and response to trauma, non-fear related emotions are often
‘‘type II’’ complex trauma (repetitive traumatic events such seen as primarily maintaining many PTSD cases (Holmes
as ongoing childhood sexual abuse, community violence, et al. 2005). While exposure treatments are known to be
or genocide). Type II trauma is associated with a much effective for fear-related disorders, there is no compelling
higher risk for the development of PTSD compared with evidence that non-fear related emotions habituate to
type I (Copeland et al. 2007). Type II trauma can also lead exposure alone (Grunert et al. 2007).
to negatively altered schematic views of oneself and others, To address this limitation, Smucker et al. (1995) intro-
particularly when occurring at developmentally critical duced imagery rescripting as a variation to Prolonged
periods. Further, an individual’s ability to form a healthy Exposure. They termed their protocol Imagery Rescripting
identity and coherent personality may be impacted as a and Reprocessing Therapy and articulated the following
result of exposure to type II trauma (Cook et al. 2005; Van aims: (a) decrease physiological arousal, (b) decrease
der Kolk et al. 2005). In both types of trauma, but PTSD intrusions, (c) facilitate cognitive change regarding

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the meaning of the event, and (d) modify maladaptive but instead prompts the client to think of their own way of
abuse-related beliefs and schemas. Unlike Prolonged obtaining mastery. A therapist may for example ask, ‘is
Exposure, the imagery rescripting protocol is not based there something or someone you would like to bring into
upon helping clients ‘habituate’ to PTSD memories. the scene so that you can help the child?’ Once a client has
Instead, imagery rescripting for PTSD aims to directly experienced success with stage 2 of imagery rescripting by
modify trauma images to give the client a sense of mastery demonstrating that they can overcome their powerlessness
over the distressing memory thus decreasing fear, as well and have mastery over the image, they progress to stage 3,
as modifying the maladaptive non-fear related meanings which involves adult-child interaction imagery. The pur-
that might be driving emotions such as disgust, shame, and pose of stage 3 imagery is for the ‘healthy adult’ within the
guilt. Theories of emotional processing (Foa and Kozak client to provide nurturance and support to the abused child
1986) and state-dependent recall (Bower 1981) suggest that in the image, something that was presumably missing in
the maladaptive meanings and schemas associated with the original narrative. Successful imagery rescripting ses-
childhood sexual abuse can most readily be accessed and sions where the client has a good mastery experience are
modified when the client is in an emotional state most audio-recorded and given to the client to repeat for
similar to that occurred during the abusive experience. That homework.
is, cognitive change is more likely to occur when the
greatest number of elements or cues that underpin the Empirical Evidence of Imagery Rescripting
traumatic experience is present, conditions that may be for PTSD
replicated with the use of imagery rescripting.
The application of imagery rescripting to PTSD is made Thus far, there is some empirical evidence for the use of
up of three discrete stages, beginning with an imaginal imagery rescripting in the treatment of PTSD. An initial
exposure stage (stage 1) (Smucker et al. 1995; Smucker paper by Smucker and Niederee (1995) describes a suc-
and Dancu 1999). In the imaginal exposure stage, the client cessful case study for a survivor of childhood sexual abuse
visually recalls and re-experiences the images, thoughts with PTSD, and the results of a small open trial comparing
and associated affect associated with the traumatic event in imagery rescripting to CBT with Prolonged Exposure for
much the same fashion as is done in a Prolonged Exposure survivors of childhood sexual abuse with type II trauma.
paradigm. The difference however, is that in imagery This trial reports that both treatments resulted in significant
rescripting, the exposure is not prolonged so as to bring reductions in PTSD symptoms, with imagery rescripting
about habituation but only lasts as long as it takes for the showing superior reductions on all but one outcome mea-
client to recall the memory script once, for the purpose of sure when compared to CBT with Prolonged Exposure.
fully activating the memory and associated affect cues. These findings suggest that imagery rescripting may be at
Next, an imaginal rescripting stage (stage 2) ensues where least as effective if not more effective in this population
the client begins to again recount the script up until the when compared to a gold standard treatment. However, the
height of the trauma (the client’s subjective units of distress lack of a control group in the study design weakens the
is frequently taken from which the clinician decides where strength of such conclusions.
the affect is most intense). At this point, the therapist Grunert et al. (2003) conducted the first case study of
encourages the client to imagine his or her adult-self imagery rescripting with work-accident related PTSD. Two
entering the scene and provides prompting so that the client clients who were considered non-responders to CBT with
may be able to change the abuse imagery and instead Prolonged Exposure were selected to participate. Both
produce a mastery imagery. The therapist uses what were assessed to be suffering prominent non-fear related
Smucker and Dancu (1999) refer to as Socratic imagery, emotions such as guilt and anger to varying degrees. The
analogous to the Socratic method of questioning to pro- research design combined Prolonged Exposure and ima-
mote guided discovery (Padesky 1993). In the Socratic gery rescripting components at different times in treatment
imagery method, the therapist assists the client to make his so as to aid in some comparison. The case study showed
or her own decisions about what to do next in the scene so that these two clients with a high loading of non-fear
as to maximise the mastery experience. With this in mind, related emotions did not habituate after 14 and 2 sessions
the therapist provides prompts for the client to engage in of Prolonged Exposure respectively (participant 2 dropped
the imagery but will not enforce a set direction or narrative. out after 2 sessions). However, both participants no longer
The therapist might ask ‘is there something you would like met criteria for PTSD after adding just one session of
to do or say in the scene as your adult self?’, encouraging imagery rescripting followed by several experiences of
the client to autonomously generate the imagery. Even at reliving the imagery rescripting session through use of a
times when the client clearly struggles to have power in the tape for homework over the following week. This case
image, the therapist does not intervene in a directive sense, study data suggests that adding an imagery rescripting

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component to Prolonged Exposure may be of benefit to Prolonged Exposure may be more effective for clients with
persons suffering PTSD with prominent non-fear related prominent fear-related PTSD, yet those suffering PTSD
emotions. However, these results must be interpreted with with prominent non-fear related emotions appear to better
caution due to the methodological limitations within this tolerate and benefit from imagery rescripting. They call for
design. The uncontrolled nature of the research design, individualised trauma assessments where care is taken to
minimal number of participants and potential participant- assess the prominent PTSD emotions thought to be main-
selection bias render the broad generalisability of the taining the disorder. From these assessments, clinical
findings questionable. Further, the mechanism through decisions can be made as to choice of approach, with
which imagery rescripting seemed to facilitate a strikingly presentations loading heavily on fear receiving Prolonged
rapid reduction in PTSD symptom warrants closer Exposure and presentations with prominent non-fear rela-
investigation. ted emotions receiving an imagery rescripting component.
Arntz et al. (2007) recently conducted a randomised In sum, imagery rescripting appears from a small
wait-list trial investigating the use of Prolonged Exposure number of case studies and open trials to be at least as
versus Prolonged Exposure ? imagery rescripting versus effective as CBT with Prolonged Exposure in the treatment
wait-list control in a group of 71 individuals suffering of both type I and type II trauma. However, the most
chronic PTSD. In total, 39 % of participants reporting interesting finding from these case studies and trials is the
multiple traumatic experiences and 24 % of participants trend that imagery rescripting appears to be more effective
reporting trauma that had taken place in childhood. Data and better tolerated than CBT with Prolonged Exposure in
from 67 participants were available at completion of the the treatment of PTSD with prominent non-fear related
study which showed that, at completion, both treatment emotions. These findings align with the notion that the
groups significantly reduced PTSD symptoms in compar- theoretical model of emotional processing and habituation
ison to the wait-list group. Interestingly, there were sig- underpinning Prolonged Exposure is not sufficiently
nificantly more drop-outs in the Prolonged Exposure group applicable in the treatment of PTSD with prominent non-
compared with the Prolonged Exposure ? imagery fear related emotions. Clearly however, further investiga-
rescripting group (51 vs. 25 %, p = .03). Intention to treat tion using more rigorous research designs including ran-
analyses showed that the two treatment groups did not domised controlled trials is required to provide more solid
differ from each other in terms of the effect on PTSD evidence for these assertions.
symptoms overall. However, participants in the Prolonged
Exposure ? imagery rescripting group reported greater
reductions in uncontrollability of anger, externalisation of Rationale and Application of Imagery Rescripting
anger, hostility, and guilt when compared to those who had for Personality Disorders
received Prolonged Exposure alone. Further, the results
showed a trend towards further improvement at follow-up. Although imagery rescripting first emerged as a treatment
These findings suggest that compared to Prolonged Expo- for the intrusive symptoms of PTSD, it is increasingly
sure alone, Prolonged Exposure ? imagery rescripting is at being seen as a viable treatment component for people with
least as effective in reducing the overall symptoms of personality disorders, particularly within Schema-Focused
PTSD, is better tolerated by clients, and has a greater effect Therapy (Young et al. 2003). In the context of Schema
on problematic non-fear related emotions such as anger and Therapy, imagery rescripting is applied to assist with
guilt. change in the early maladaptive schemas which are thought
These results were further supported in a study con- to maintain personality disorders (Arntz 2011), rather than
ducted by Grunert et al. (2007) where 23 Prolonged to reduce PTSD symptoms such as intrusions through the
Exposure treatment non-responders received 1-3 sessions facilitation of emotional processing (Foa et al. 1989;
of imagery rescripting. The findings of the study indicated Smucker et al. 1995). The main rationale for the use of
that 18 out of 23 participants no longer met criteria for imagery rescripting for personality disorders is that suc-
PTSD after this small course of imagery rescripting work. cessful change in the underlying early maladaptive sche-
Interestingly, this study also reported that all 23 partici- mas involves the use of cognitive-behavioural techniques
pants (sufferers of type I trauma who had had an unsuc- not only at a propositional knowledge level (i.e. cognitive
cessful trial of Prolonged Exposure) were assessed before challenging of cognitions and beliefs as is common in
treatment to be suffering predominant non-fear related Beckian cognitive therapy) but at an implicational knowl-
emotions. The interpretability of these results is also edge level where the client experiences the new perspective
somewhat limited by potential selection-bias issues and emotionally (Arntz 2011; Arntz and Weertman 1999).
lack of experimental control. However, situating this study From this perspective, deep cognitive change requires cli-
within other literature, Grunert et al. argue that CBT with ents to activate the meaning structures on an emotional

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level so that they can be accessed and modified with new the beginning. However, the cost of this may be that the
more adaptive perspectives (Holmes and Mathews 2005; imagery experience is less powerful for the client as it is
Teasdale 1993). Imagery rescripting is one such technique not self-generated as it is when applied to PTSD. In ima-
that allows clients to reprocess new, more adaptive gery rescripting for PTSD, clients retain control of the
meanings using both the implicational and propositional direction of the imagery and Smucker and Dancu (1999)
meaning systems because of the ability of mental imagery argue in principle that such Socratic processes may be
to evoke the strong emotions associated with the original more meaningful and powerful for the client. No empirical
meaning structures (Holmes et al. 2007a). It is thus clear studies to date have looked specifically at comparing the
that the rationale and goals of imagery rescripting with efficacy of these two variations of imagery rescripting to
personality disorders within Schema Therapy differs see whether either procedure is likely to be more or less
markedly from that used in imagery rescripting for PTSD. beneficial than the other in any population.
The focus on the use of imagery rescripting for personality
disorders is on cognitive and emotional change of early Empirical Evidence of Imagery Rescripting
maladaptive schemas rather than addressing PTSD symp- for Personality Disorders
toms including re-experiencing.
The technical application of imagery rescripting to Evidence for the efficacy of the entire schema therapy
personality disorders in Schema Therapy also has several package for personality disorders is quickly emerging. Two
important divergences when compared to its application to randomised trials have been published for the overall
PTSD populations (Arntz 2011). Young et al. (2003) Schema Therapy package including imagery rescripting for
describe imagery rescripting in full as it is applied in the treatment of Borderline Personality Disorder in indi-
Schema Therapy. The main discrepancy between imagery vidual (Giesen-Bloo et al. 2006) and group formats (Farrell
rescripting for personality disorders and PTSD relates to et al. 2009) with favorable results for schema therapy over
the degree to which the imagery is therapist-directed. transference-focused individual psychotherapy and generic
Whilst imagery rescripting for PTSD involves a Socratic group therapy respectively. These results have also now
endeavor in which the therapist facilitates client-driven been generalised to Cluster C, Narcissistic, and Histrionic
discovery, imagery rescripting protocols within Schema Personality Disorder in a large Randomised Controlled
Therapy for personality disorders assume that clients are Trial (Bamelis et al. 2014). However, no research to date
often unable to generate such imagery on their own. As has investigated the efficacy of any individual components
such, therapists using Schema Therapy with clients with of Schema Therapy for personality disorders, including
personality disorders are instructed to enter the imagery imagery rescripting.
and model the alternative perspective or healthy adult The closest direct evidence for the efficacy of imagery
response for the client. The imagery rescripting thus takes a rescripting for personality disorders comes from a decon-
different form with the client’s ‘adult self’ playing no part struction study conducted by Weertman and Arntz (2007)
in the exercise initially, either in interactions with an who compared the efficacy of past- versus present-focused
abuser/invalidating figure or in child-self soothing inter- CBT techniques for the treatment of personality disorders.
actions. The idea is that the therapist models the healthy The major aim of the present-focused CBT intervention
adult perspective in order for the client to process this was to change maladaptive schemas and beliefs by tech-
different perspective from some distance in a safe way, niques focusing on the present including continuum
without the risk of having a failure experience. Arntz methods, positive data logs, pie charts, Socratic question-
(2011) asserts that many clients with personality disorders ing, schema-dialogue, role plays in the present and use of
do not yet have a healthy side that is developed enough to the therapeutic relationship (empathic confrontation, giving
lead the imagery. These clients may lack accessible healthy direction, self-disclosure). Each session focused on sche-
views on the situation and may struggle to adaptively mas that were active in the present, with no use of methods
interact in the imagery with invalidating figures and their focusing on the past. The past-focused CBT intervention
child-selves in healthy ways. Furthermore, he argues that aimed to change the meaning of schematic representations
the process of initially having the therapist come in and act that have roots in childhood by use of historical role-plays
as an advocate for the child-self is an important part of the and imagery rescripting. The use of present techniques to
limited re-parenting process that is core to Schema Ther- challenge schemas was not allowed and real life current
apy. With time and multiple positive experiences with problems were related to historical roots of the activated
therapist-intervening imagery, the therapist may then schemas. The study utilised a cross-over design in which
encourage the client’s healthy adult to enter and take over participants experienced both past- and present-focused
this process. In this way, imagery rescripting for person- interventions with randomised order of treatment phases.
ality disorders is graded and less confronting for clients in This study found significant and large effect sizes for both

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past- and present-focused interventions compared with the the use of client-directed and Socratic rescripting as
‘exploration period’ for which no significant effects were opposed to the therapist-lead approach outlined within the
found. These outcomes were maintained at 12-month fol- personality disorder literature. However, the fact that two
low-up. There was no significant difference in outcomes distinct general protocols for the use of imagery
for the past- and present-focused interventions. The authors rescripting emerged from different diagnostic groups does
conclude that past-focused CBT interventions, for which not necessarily mean that the differences between the
imagery rescripting is the core technique, are as effective in approaches reflect meaningful disorder-specific consider-
the treatment of early maladaptive schemas in personality ations. Instead, choosing between different protocols for
disorders as present-focused techniques. Several limita- the application of imagery rescripting may be better
tions of this study should be noted when interpreting these guided by considering the goals of the intervention as
findings. Firstly, the results must be interpreted with cau- well as the individual client’s readiness for mastery in
tion and the generalisability of findings may be question- rescripting.
able due to the small sample size (n = 21). Further, the Firstly, the goals of the intervention may be a useful
crossover design utilised in this study meant that a direct consideration in choosing one application of imagery
comparison between CBT with and without treatment of rescripting over another. If the primary goals of the inter-
childhood memories was not possible. Thus, the research- vention are change in early maladaptive schemas for the
ers were not able to determine whether a combination of purpose of decrease in personality disorder symptoms, then
present- and past-techniques is more effective than CBT best evidence thus far indicates that a schema therapy
without treatment of childhood memories. In addition, the rationale and application is best supported. If on the other
experimental design meant that the researchers could only hand the primary goals of the intervention are to intervene
examine the long-term effects of the total therapy package in the PTSD syndrome, to bring about change in the core
but not of the past- and present-focused interventions symptoms of PTSD such as intrusive symptoms, then the
separately. Finally, the small sample of this study meant addition of imagery rescripting to CBT has some empirical
that no conclusions can be drawn regarding the influence of support.
treatment of childhood memories for different personality Perhaps more importantly, another core issue for con-
disorder diagnoses. It is therefore clear that more investi- sideration in deciding between imagery rescripting proto-
gations are needed to test the effectiveness of imagery cols is to assess whether or not the client is likely to be
rescripting on personality disorders more directly. capable of generating mastery imagery through Socratic
rescripting. Schema Therapy protocols suggest that the
more severe the client’s personality disorder features, the
Clinical Implications and Considerations more the therapist should guide the imagery initially to
assist in modeling a healthy view of the image. This would
This review has highlighted that imagery rescripting is a seem to also apply to cases where the primary goals of the
psychotherapy technique which appears to be an effective intervention are to reduce PTSD symptoms in persons with
addition to CBT treatments across a large number of co-morbid personality disorder diagnoses or features. It
populations, including PTSD. At present, less research is may also be that a client presenting with PTSD resulting
available to support its use with personality disorders. from type II trauma, particularly when exposed to trauma
However, evidence exists for the use of Schema Therapy in their early development, finds it difficult to lead an
for this population, with imagery rescripting being a core imagery rescripting intervention since type II trauma
component of this intervention. commonly leads to negatively altered schematic views and
Clinical protocols for the use of imagery rescripting can impede the formation of a healthy identity (Cook et al.
with clients with personality disorders and PTSD evolved 2005; Van der Kolk et al. 2005). These considerations must
separately and differ markedly in terms of both rationale be balanced in conjunction with the cognitive therapy
and technique. However, these two clinical subgroups principle that a more Socratic, client-guided imagery
have considerable diagnostic overlap and a presumed rescripting may ultimately be a more powerful intervention
shared etiology (Lobbestael and Arntz 2007), given the for clients due to increased mastery. A cautious clinical
longstanding recognition of the high frequency of abuse approach may be to initially use therapist-guided imagery
histories in personality disorders (Gunderson and Sabo rescripting when in doubt as to the above questions. This is
1993). As a result, appropriate rationale and application of less likely to lead to poor outcome for the client, can ease
imagery rescripting may present a point of confusion for the client into the process of imagery rescripting in a gra-
therapists, particularly when such diagnostic overlap is ded fashion, and may assist the therapist in providing fur-
present. These protocols differ markedly in the roles of ther assessment of a client’s readiness to engage in more
the therapist and client, with PTSD protocols calling for Socratic imagery rescripting.

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Current research on the effectiveness of imagery borderline personality disorder: A randomized controlled trial.
rescripting for PTSD and personality disorders is plagued Journal of Behavior Therapy and Experimental Psychiatry, 40,
317–328.
with limitations and design issues. Rigorous empirical Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear:
studies are required to more stringently test the above Exposure to corrective information. Psychological Bulletin, 99,
clinical considerations, which are put forward on the basis 20–35.
of the data available to date. In addressing the lack of Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/
cognitive conceptualizations of post-traumatic stress disorder.
clarity regarding clinical decision-making in the use of Behavior Therapy, 20, 155–176.
different imagery rescripting protocols, it is imperative that Frets, P. G., Kevenaar, C., & van der Heiden, C. (2014). Imagery
research is conducted to examine whether there is greater rescripting as a stand-alone treatment for patients with social
efficacy for any one protocol over another, and possibly phobia: A case series. Journal of Behavior Therapy and
Experimental Psychiatry, 45, 160–169.
more importantly, for whom. Clinical decision-making in Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W.,
the use of this intervention for clients with PTSD and Dirksen, C., Van Asselt, T., & Arntz, A. (2006). Outpatient
personality disorders could be improved through exami- psychotherapy for borderline personality disorder: Randomized
nation of relevant client (and possibly therapist) variables trial of schema-focused therapy vs transference-focused psy-
chotherapy. Archives of General Psychiatry, 63, 649–658.
in the effectiveness of imagery rescripting. Enhancing our Grunert, B. K., Smucker, M. R., Weis, J. M., & Rusch, M. D. (2003).
understanding of and ability to measure client readiness for When prolonged exposure fails: Adding an imagery-based
Socratic-based imagery rescripting is an important first step cognitive restructuring component in the treatment of industrial
in improving clinical decision-making regarding appropri- accident victims suffering from PTSD. Cognitive and Behavioral
Practice, 10, 333–346.
ate implementation of imagery rescripting. Grunert, B. K., Weis, J. M., Smucker, M. R., & Christianson, H. F.
(2007). Imagery rescripting and reprocessing therapy after failed
prolonged exposure for post-traumatic stress disorder following
industrial injury. Journal of Behavior Therapy and Experimental
Psychiatry, 38, 317–328.
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