Image Rewriting Therapy: characteristics and functioning.

Summary of the characteristics and functions of this therapy, and the disorders in which it is used.

There are many therapies proposed to treat disorders related to trauma and stressors, especially focused to treat PTSD, which has been shown to be a disorder with high prevalence in the general population.

Among the most recent proposals to treat both PTSD and other disorders related to the recall of traumatic events are Imagery Rewrite Therapya therapy that is little known in the Hispanic world but which seems likely to gain popularity in the next decade.

Next we will discover what this therapy consists of, for what disorders it has been used and what relation it has with imagination and exposure.

What is Imagery Rescript Therapy?

Imagery Rescript Therapy is an effective treatment for psychotherapeutically addressing trauma-related disorders. is an effective treatment for psychotherapeutically addressing trauma-related disorders and stressors, especially and stressors, especially Post Traumatic Stress Disorder (PTSD). The purpose of this technique is to change the memories or mental representations that are aversive to the subject, and which are the source of psychological discomfort.

The importance of the development of Imagery Rewriting Therapy lies in the main disorder to which it is directed. In recent decades, research directed towards PTSD has been increasing, motivated by the fact that this disorder has a high prevalence in the general population, close to 4%, and among people who have been exposed to a traumatic event, such as sexual abuse, terrorist attack or natural disaster, close to 6%.

PTSD has been associated with high levels of social, occupational and physical disability, implying a high economic and health care cost. For this reason, clinical psychology and psychiatry clinical psychology and psychiatry have invested a lot of effort in trying to find treatments to improve the quality of life of people with PTSD. to improve the quality of life of people diagnosed with this disorder, or any other disorder related to trauma and stress factors.

This technique is quite recent, having its methodological structuring in the 90's with several groups of researchers. with several groups of researchers. However, its origins are quite classical, and can be found in the figure of Pierre Janet (1919), an author who himself used what he called "imagery substitution" with hysterical patients. However, the current version has its origins in the work of Arntz and Weerman in 1999, in which this technique was already applied with traumatic memories, and Smucker, Dancu, Foa and Niederee (1995) who had used the technique with a population who had suffered abuse in childhood.

Disorders in which it is used

Although research has focused mainly on the application of this technique with patients diagnosed with PTSD, it has been shown to be useful with other psychological disorders. has been shown to be useful with other psychological disorders.

This therapy can be applied, both independently and in therapeutic packages, for the treatment of various disorders, among which we can find personality disorders, specific phobias, mood disorders, social phobia, suicide attempts and obsessive-compulsive disorder (OCD).

The therapeutic importance of imagination

The main characteristic of this therapy is is to rely on the use of imagination, understood in its English translation as "mental imagery".. That is, imagining images (although not necessarily only in its visual sense) in the mind. Imagination has been a widely used element in psychotherapy throughout its history, although it has not been until relatively recently that the focus has begun to be put on it to know its theoretical basis.

Imagination or "mental imagery" could be defined as mental representations accompanied by sensory experiences without a direct external stimulus that provokes them. That is to say, it is to feel something without the need to be perceiving it objectively. For example, if we imagine that we are eating a cake, it would be the action of seeing the cake with the mind's eyes, smelling it with the mind's nose, touching it with the mind's hands and tasting it with the mind's tongue. It is imagining and "living" the action in the mind.

Because imagination can be a truly powerful tool, leading us to experience situations that are not real but very vividly, it is not surprising that it has become important in the application of psychological therapies. It has been proven that imagination allows eliciting changes in the therapeutic process at emotional, cognitive and behavioral levels..

Within the techniques in which imagination is used, we could speak of two types. On the one hand we have those that seek to change a negative image for a more positive one, that is, to "repaint the situation in a more pleasant way", while, on the other hand, we would have those that seek to see a situation from another point of view. Image rewriting therapy could be included in both categories.

How is it applied?

During the application of Imagery Rewriting Therapy specific memories of past experiences associated with current problems in the patient's life are addressed. in the patient's life. The aim of this therapy is to make the patient bring to consciousness a memory or mental representation as vividly as possible, as if he/she were living it in the place and moment in which he/she is currently. The idea is to then modify the imagined sequence of events in the desired direction and change the outcome, as well as reduce the feeling of anxiety.

Imagery Rewriting Therapy is especially useful with PTSD. This is because this treatment emphasizes the modification of memory schemas, based on the idea that this disorder has an important basis in memory, in the sense that the focus of the discomfort is the reliving, in the form of flashbacks, of the traumatic event. It makes it possible to change the traumatic memories that reside in the patient's memory..

Although it may seem that imagining the traumatic situation is not technically an exposure, it can be considered as such. The individual must bring to mind the problematic memory, which is the closest to exposure to the stressful event, since it cannot be replicated in real life. To understand this, in arachnophobia, we can work on the patient's phobia of spiders by bringing him a spider and have him try to accept its presence. On the other hand, we cannot expose a rape victim to that event again, basically because it is unethical.

General structure of the therapy

The application of Image Rewriting Therapy is not homogeneous, since there are different protocols depending on the psychological problem to be treated. In its original conception, this therapy was proposed for the treatment of trauma, although nowadays protocols have been developed for the treatment of different psychopathologies, as we have already mentioned above. The protocol may also vary depending on the therapeutic objective to be achieved.

The fact that this therapy is so multifaceted is a great advantage.This is especially true in cases where the patient shows a high comorbidity, as is often the case in many anxiety and personality disorders. For example, if the therapeutic objective has to do with changing the patient's source of stress, this therapy can be applied following the same protocol used with PTSD patients. On the other hand, if the aim is to work on the patient's ingrained beliefs, the most convenient approach is to apply a protocol similar to that used in personality disorders.

In the particular case of PTSD, whatever the origin of the disorder (e.g., having been a victim of childhood sexual abuse is not the same as having lived through a natural disaster), Imagery Rewriting Therapy aims to achieve the following three objectives.

The first is to reelaborate and integrate the traumatic memories in the context in which they occurred.. The second is to work on the dysfunctional appraisals that continue to be made about the traumatic event. Finally, the aim is to eliminate dysfunctional coping strategies that perpetuate the problem. These strategies may include avoidance, self-harm, drug use, carrying out various risky behaviors...

Therapy begins with the exploration phase of the traumatic event. It is at this point that exposure to the traumatic event would begin, the objective of which is to bring the trauma to memory in order to work on it. The usual and most recommended approach at this point is to the patient to close his eyes, encouraging him to speak in the first person and in the present tense ("I am seeing who wants to do me harm"). ("I am seeing who wants to hurt me..."), expressing in as much detail as possible how he/she feels on an emotional and sensory level.

This phase of therapy can be quite time-consuming, as it is clearly very aversive for the patients. They are living in their mind what they experienced in their own flesh, what hurt them. It is for this reason that, if the psychotherapist considers it appropriate, some modifications can be incorporated to this part, such as having the patient reminisce with his eyes open. This prevents the patient from dissociating and ceasing to be aware that he/she is in a safe and protected place, such as the therapist's office.

It is essential that a solid therapeutic alliance has been established before this phase of the treatment. Although this therapy can be applied on its own, it is best to have established a good therapeutic foundation through exploration of the patient, knowing where he/she comes from, where he/she is going, what it is that has led him/her to come to therapy in the first place..

In some cases it is important that the imagination of the traumatic event is not carried out fully, i.e., the patient should not be made to remember the complete experience of the aversive event. This is especially recommended for cases in which the traumatic moment was particularly severe, such as a case of child sexual abuse. The patient must warn just the moment before the worst comes.

From then on, therapist and patient should reflect and discuss which are the hot spots of the traumatic memory. We understand by hot spot the moment of the traumatic event in which the individual suffered the most, the moment that "froze" in his memory the aversive memory. In addition to understanding and discovering which are those moments of special suffering, the associated meanings and interpretations must be explored.

Although Image Rewriting Therapy has only just begun at this point, the patient may begin to show spontaneous cognitive changes.. An example of this is that he may become aware that the only place where his memory is harmful is in his memory. It does not imply a physical damage or transport him to the moment when he suffered the traumatic event, but it is a damage that comes originally from his own mind.

Once the imagination of the traumatic event is achieved, the phase of rewriting itself arrives. In this phase, the aim is to introduce new information, to change the course of the event in the patient's imagination, in short, to make the mental material less harmful.

The patient will recall the event until the hot spots are reached, at which time the therapist will try to promote guided discovery of how he/she would like the event of how he/she would like the memory to be modified.

For example, the patient is given indications so that he/she can become involved in the memory, but does not impose a particular direction or narrative. However, there may be cases in which the therapist has to propose directly what would be the best direction for rewriting the story.

Once it has been verified that the proposed rewritings are helpful to the patient, they should be practiced until it is verified that the suffering decreases and the dysfunctional beliefs are corrected. At this point, it is useful to record successful rewriting sessions so that the patient can repeat the task. so that the patient can repeat the task at home.

Bibliographical references:

• Miguel-Alvaro, Alejandro, & Crespo, María. (2019). Imagery rewriting for the treatment of posttraumatic stress: analysis and review. Clinica y Salud, 30(3), 137-146. Epub October 21, 2019.https://dx.doi.org/10.5093/clysa2019a19.
• Arntz, A. (2012). Imagery rescripting as a therapeutic technique: Review of clinical trials, basic studies, and research agenda. Journal of Experimental Psychopathology, 3, 189-208. https://doi.org/10.5127/ jep.024211
• Janet, P. (1919). Les médications psychologiques: Études historiques, psychologiques et cliniques sur les methodes de la psychotherapie (Vol. 1-3). Paris, Francia: Alcan.
• Morina, N., Lancee, J. y Arntz, A. (2017). Imagery rescripting as a clinical intervention for aversive memories: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 55, 6-15. https://doi. org/10.1016/j.jbtep.2016.11.003
• Smucker, M. R., Dancu, C. V., Foa, E. B. y Niederee, J. L. (1995). Imagery rescripting: A new treatment for survivors of childhood sexual abuse suffering from post-traumatic stress. Journal of Cognitive Psychotherapy: An International Quarterly, 9, 3-17. https://doi. org/10.1891/0889-8391.9.1.3