In recent years, an increasing number of cognitive-behavioral oriented clinicians have elaborated on the clinical application of imagery as a means of modifying maladaptive cognitions/schemas and restructuring disturbing events and associated meanings. Within the CBT family, behaviorists were the first to report the clinical use of imagery in their work with phobias. As part of their systematic desensitization treatment, covert desensitization was employed as a means of deconditioning and extinguishing anxiety responses.
After learning progressive deep muscle relaxation in the presence of pleasant imagery, patients were assisted in going back and forth from a physiologically relaxed state to an anxiety state that was induced by imaginal exposure to a hierarchy of fear-evoking stimuli. Each imaginal exposure segment was followed by relaxation until no further anxiety was reported during exposure. Imaginal flooding was also employed by behaviorists with anxious patients, which involved repeated, prolonged imaginal exposure to the feared stimuli until the anxiety response was extinguished. Variations of covert desen-sitization and imaginal flooding continue to be employed by CBT clinicians today who work with anxious patients (e.g., specific phobias, GAD, OCD, and PTSD).
Beck et al. (1985) acknowledged the emotional and cognitive power of imagery in creating corrective experiences with anxious patients who have upsetting, catastrophic visual images of danger before and during bouts of anxiety. As with verbal cognitions, these visual cognitions often represent a distortion of reality whereby patients who visualize such upsetting scenes tend to react as though they were actually occurring. Beck and colleagues found it useful to have patients visually "relive" and "reexperience" their inaccurately constructed beliefs as a means of enhancing cognitive restructuring. They further observed that a patient's distressing visual images can be activated, challenged, and modified by an array of imagery modification interventions, e.g., induced imagery, modification of induced images, identifying cognitive distortions within the imagery, decatastro-phizing imagery, substituting positive imagery, substituting contrasting imagery, imagery rehearsal, and a variety of other types of coping imagery.
Dowd (1997) asserted that adding a hypnotherapy component to treatment may enhance CBT interventions by minimizing avoidance and thereby increasing the patient's capacity to confront and habituate to the experienced or anticipated noxious events. An array of guided imagery techniques have been used as part of cognitive hypnotherapy as a means of modifying dysfunctional behaviors, as well as negative automatic images, maladaptive beliefs, and core schemas. Such imagery techniques may include evocative imagery, replacement and coping imagery, age regression imagery, desensitization and flooding imagery, visual cognitive rehearsal, imaginary dialogues with significant others, and modification of distorted images relating to past memories.
The use of imagery as a primary therapeutic agent in fostering emotional processing of traumatic events has been emphasized by a growing number of CBT theorists and clinicians in recent years. Since traumatic memories and their associated meanings tend to be encoded as vivid images and sensations, they are not likely to be accessible through linguistic retrieval alone. The notion that traumatic imagery is not likely to change in the absence of corrective imagery was articulated by Beck, Freeman, and Associates (1990) in the following passage:
Simply talking about a traumatic event may give intellectual insight about why the patient has a negative self-image, but it does not actually change the image. In order to modify the image, it is necessary to go back in time, as it were, and re-create the situation. When the interactions are brought to life, the misconstruction is activated—along with the affect—and cognitive restructuring can occur. (p. 92)
It thus appears that directly identifying, challenging, and modifying the trauma victim's distressing imagery (e.g., recurring flashbacks, repetitive nightmares) can be a potent therapeutic means of providing "corrective" information and facilitating emotional processing with this population (Smucker & Dancu, 1999).
Although much attention has been given to the clinical application of imagery techniques within CBT circles, to date only two cognitive-behavioral treatments (with treatment manuals) have been developed that use imagery as a primary therapeutic agent: Prolonged Imaginal Exposure (PE; Foa, Rothbaum, Riggs, & Murdock, 1991) and Imagery Rescripting and Reprocessing Therapy (IRRT; Smucker & Dancu, 1999; Smucker et al., 1995). Both of these imagery-based treatments were designed to facilitate cognitive and emotional processing of traumatic events, and are especially geared to individuals suffering from symptoms of PTSD.
PE is a cognitive-behavioral treatment that relies predominantly on the processes of exposure, habituation, desensitization, and extinction to reduce trauma-related fear and anxiety. Essentially, patients are taught that their upsetting visual memories are tolerable and manageable and that the anxiety and fear associated with these memories will eventually subside during exposure. The PE sessions themselves involve the visual and sensory reliving of the distressing/traumatic material. Patients are asked to visualize and verbalize aloud, in detail, the entire upsetting experience using the first person and present tense, as though it were happening at the moment. Patients are asked to rate their discomfort level (SUDS: Subjective Units of Distress Scale) every 5-10 minutes as a means of conducting an ongoing assessment of their affective involvement and distress. The 60- to 90-minute imaginal exposure session is audiotaped and given to the patient for daily listening in order to enhance habituation and desensitization. Some discussion may take place before and after each PE session that addresses the patient's trauma-related emotions and beliefs (e.g., fear, guilt, shame), although this is not done in a structured or methodical manner. The standard PE treatment involves eight imaginal exposure sessions. In vivo exposure interventions may also be implemented during treatment to confront maladaptive avoidance outside the therapy sessions (Foa et al., 1991).
While there is considerable evidence supporting the use of PE with trauma victims (e.g., victims of rape) suffering from PTSD, preliminary outcome data from a study with over 800 occupation-related injuries (treated over a period of 20 years) indicated that PE was the treatment of choice with Type I victims when fear was the predominant trauma-related emotion and avoidance was the primary coping strategy, but that PE by itself was not a good treatment choice for trauma victims whose predominant emotions are other than fear, e.g., guilt, shame, anger, self-blame. In such instances, treatment effects were significantly enhanced when imaginal exposure was supplemented with an imagery-based cognitive restructuring intervention.
By contrast, IRRT (Smucker & Dancu, 1999) is a multi-faceted, imagery-based, cognitive-behavioral treatment designed to help trauma victims cope more effectively with recurring trauma-related images (e.g., flashbacks, nightmares) and related beliefs and schemas (e.g., powerlessness, unlov-ability, abandonment). A primary goal of IRRT is to transform victimization imagery into adaptive imagery, thereby enabling trauma survivors to "see" themselves responding to the trauma as empowered individuals no longer paralyzed in a powerless state of victimization.
The IRRT treatment itself combines imaginal exposure (activating the upsetting imagery and its associated affect) with imagery rescripting (replacing distressing imagery with coping/mastery imagery), self-calming/self-nurturing imagery (visualizing one's ADULT SELF today, or another compassionate adult, entering into the imagery in order to calm, sooth, nurture, and reassure the "traumatized" or "distressed" self), and emotional-linguistic processing (transforming the distressing imagery and accompanying emotions into narrative language, while challenging and modifying the underlying traumagenic beliefs/schemas). SUDS ratings are used throughout each imagery session as a means of assessing the patient's emotional state and identifying "hot spots" that may require further attention. An audiotape of each imagery session is given to the patient for daily listening and processing. The patient's subjective reactions to the imagery tape are recorded in a journal. Three SUDS levels (beginning SUDS, ending SUDS, and peak SUDS) are also recorded on a homework sheet immediately following each audiotape listening. Patients are asked to bring the SUDS sheets to each treatment session for review and additional processing. The homework SUDS sheets are also useful for ascertaining homework compliance as well as progress. The standard IRRT treatment consists of eight sessions ranging from 60 to 90 minutes each, although the length of treatment may be adapted according to the specific needs of a given patient.
A distinguishing feature of IRRT is its use of Socratic imagery, which is essentially guided discovery applied in the context of imagery modification. Patients are thus challenged to develop their own coping/mastery imagery as well as their own self-calming/self-soothing imagery. Socratic imagery emanates from the Beckian notion that it is more empowering for patients to create their own solutions (e.g., developing their own mastery imagery) than to have the therapist suggest, direct, or dictate solutions to them (Smucker & Dancu, 1999).
Another component of IRRT that is viewed as critical in the processing of emotionally upsetting material is the interplay of primary and secondary cognitive processing. A "primary cognitive process" involves nonverbal, nonlin-guistic mental activity that is essentially iconic and auditory in nature (e.g., visually reliving a traumatic event), whereas verbalizing (talking or writing) one's reactions to an event is viewed as a "secondary cognitive process." In IRRT, the cognitive processing of traumatic material occurs both at a primary level (reliving the traumatic imagery) and at a secondary level (talking about the imagery, putting the imagery into words). Periodically, during an IRRT session, the upsetting imagery is put "on pause"—especially during times of heightened affect—so that the patient's thoughts and feelings about the imagery and its symbolic meaning can be discussed and processed. While secondary cognitive processing involves the patient's immediate response to the imagery itself, it may also address core schemas that serve to reinforce and provide a cognitive template for the recurring, upsetting imagery. Immediately following an IRRT session, patients are asked to verbalize their reactions to the imagery session, which further promotes the processing of primary material at a secondary level of cognitive processing (Smucker, 1997).
While there is considerable empirical evidence supporting the efficacy of IRRT with both Type I and Type II trauma survivors (Smucker & Dancu, 1999), it appears to be especially effective with those whose predominant trauma-related emotions are other than fear, e.g., guilt, shame, anger, powerlessness, humiliation (Grunert, Smucker, Weis, & Rusch, 2003).
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