Mervin Smucker. Overview of imagery Rescripting

Imagery Rescripting is an imagery-focused treatment originally designed to alleviate posttraumatic stress symptomatology and alter trauma-related beliefs and schemas (e.g. powerlessness, unloveability, inherent badness, abandonment) of adults who experienced childhood trauma.  The therapy combines imaginal exposure (visually recalling and re-experiencing the traumatic images, thoughts, and associated affect) with imaginal rescripting (replacing traumatic imagery with mastery imagery), and self-nurturing imagery.  Through the rescripting process, the internalized victimization images are altered and the traumagenic beliefs and schemas can be identified and challenged.  The use of imagery allows these trauma-related schemas to be visually activated through the eyes of the “traumatized child” and challenged, modified, and reprocessed through the eyes of the empowered “adult self.”

The standard treatment program consists of eight sessions (plus two follow-up sessions) ranging in length from 1-2 hours each. Imagery Rescripting sessions are best held on a weekly or bi-weekly basis.  It is generally preferable to meet more often (e.g., once a week) in the beginning of treatment, and then meet less frequently in the latter part of treatment (e.g., once every two weeks).  Audio-recordings are made of each Imagery Rescripting session and given to the client as homework for daily listening.  A minimum of two follow-up sessions are recommended at one month and three months post-treatment.

Mervin Smucker

An Interview with Mervin Smucker, PH.D.

Dr. Mervin Smucker is an internationally renowned clinician, consultant, and trainer in the field of trauma. Dr. Mervin Smucker has conducted training seminars around the world on imagery rescripting, an application of cognitive behavior therapy, which has proven effective in cases of trauma and (PTSD).

Question: What is imagery rescripting?

Dr. Smucker: Imagery rescripting is an original treatment that I developed with colleagues in the early 1990s as an effective form of cognitive behavior therapy (CBT). Clients with PTSD often see repeated upsetting images of their original trauma in their minds. Such image-rich scenarios can play out vividly, engaging all of the senses and appearing as a scenario in the present rather than in the past. Imagery rescripting helps clients to move beyond these repeat multi-sensory experiences by providing a new script or modification that enables them to replace victimization images with mastery images, and to develop self-compassionate imagery by means of visualizing oneself as a competent, capable individual today calming, soothing, nurturing, and reassuring one’s “traumatized self” back then.

Question: Please describe the process.

Dr. Smucker: A session may last 60 to 90 minutes and includes three phases. In the first phase, we have the client visualize and describe the distressing imagery, including all of the sensations and emotions that accompany it. We call this imaginal reliving. In the second phase, the client develops mastery imagery by challenging, confronting, modifying, and replacing the distressing images with coping/empowering images. Finally, in phase three the client visualizes him-herself as a competent, empowered individual today calming, soothing, comforting the “traumatized self” back then.

Question: Can you give an example of this?

Dr. Smucker: Suppose a childhood abuse victim is reliving experience through repeated flashbacks. The client may see herself as an adult today entering the abuse scene and confronting (physically, verbally) and disempowering the perpetrator, and then visualizing taking the CHILD to safety where the ADULT can visually offer nurturance and reassurance to the CHILD.

Question: How long does the process take to work?

Dr. Smucker: The standard treatment is eight sessions. However, it may only take a few sessions, depending on the type of trauma. We encourage the client to listen to audio recordings of the session every day until their next session. This helps to reinforce the newly-created mastery images from the previous session.

Mervin Smucker

Mervin Smucker. Different types of flashbacks.

Though the term „flashback“ is typically referred to in a general sense as pertaining to the re-experiencing of a traumatic memory or event, there are several different types of „flashbacks“ that individuals may experience.

Replay Flashback – involves a complete re-living of a traumatic event in a film-like fashion;

Appraisal Flashback – a snapshot image at the peak of a trauma (the worst or most frightening moment), which is typically photographic in nature;

Projected Flashback – involves experiencing vivid images of traumatic „events“ that never occurred (a false memory)

Mervin Smucker

Mervin Smucker. When Change is not on Time – Troubleshooting Protocol-Based Treatment of PTSD

Smucker, Mervin, Borge, Finn-M., Nore, Gro, & Langkaas, Tomas. When Change is not on Time – Troubleshooting Protocol-Based Treatment of PTSD. Symposium presented at the 37th Annual Congress of the European Association for Behavioural & Cognitive Therapies, Helsinki, Finland.

Recurring and distressing thoughts and images of a traumatic event are key characteristics of posttraumatic stress disorder (PTSD). The disorder leads to significant distress and loss of functioning for those who suffer from it. Developing effective treatment for PTSD has received increased interest in the CBT field in recent years, and several protocol-based CBT approaches now exist.  However, employing a treatment protocol on a specific case does not always lead to the desired change and expected progress, and a significant proportion of PTSD clients in naturalistic settings fail to respond to our CBT treatments. The central theme for this symposium is “How to progress with protocol-based PTSD treatment when change does not happen as expected?”

The speakers of this symposium present case examples undergoing different protocol-based PTSD treatments that failed to progress as expected.  Various attempts to troubleshoot these cases are discussed.

Mervin Smucker

Mervin Smucker. Using Imagery Rescripting to Enhance Successful Emotional Processing of Trauma with Individuals experiencing Posttraumatic Stress Disorder (PTSD)

From an information-processing perspective, PTSD results from inadequate emotional processing of traumatic events, and PTSD will abate once adequate or successful emotional processing has occurred. As such, it is one’s response to trauma – and not the traumatic events themselves – that produces a PTSD syndrome.

Successful emotional processing is generally thought to have occurred when the trauma victim is able to talk about, see, listen to or be reminded of the traumatic events without experiencing distress.  However, many trauma victims use denial, numbing, amnesia, or other dissociative strategies as protection from information overload and the emotional distress associated with their trauma.  While the use of such avoidance responses may have been adaptive survival responses at the time of the traumatic events, and perhaps for a period of time thereafter, their continued, long-term post-trauma use is often a maladaptive avoidance strategy that thwarts or delays successful emotion processing.

In Imagery Rescripting, four conditions are essential for successful emotional processing of traumatic material to occur:  (1) visual and verbal activation of the trauma-related memory, including cognitive, affective, and primary sensory stimuli (visual, auditory, kinesthetic, tactile), (2) transformation of the traumatic imagery into coping/mastery imagery, (3) development of self-calming, self-soothing imagery, and (4) linguistic processing of the transformed imagery and its meaning.

Mervin Smucker

Mervin Smucker. Neuroscience Trauma Research Findings.

In a neuroscience research study conducted by Lanius et. al. (2004), traumatic imagery vs. neutral imagery was measured by fMRI functional connectivity analyses to determine if differences existed between patients with and without PTSD.

  • Scripti-Driven Imagery was used with 24 trauma patients
    – 11 had PTSD (6 sexual assault, 5 motor vehicle accidents)
    – 13 no PTSD (5 sexual assault, 8 motor vehicle accidents)
  • All subjects scanned the traumatic and neutral imagery 3 times while instructed to
    – (30 seconds) Lie still and focus on script of a traumatic or neutral event that they had experienced as the script of the event was being read to them;
    – (60 seconds) Remember olfactory, auditory, somato-sensory, visual sensations as soon as the script was heard;
    – (120 seconds) Lie still, breathe through nose, and let go of traumatic imagery
    – Above script was repeated two times

Results of fMRI analyses yielded the following differences between PTSD vs. non-PTSD patients.

  • PTSD Patients Experienced:
    – Trauma memories as affect-laden memories in flashback form (e.g., reported feeling „I was back at the scene of the trauma“
    – Increased heart rate during the script-driven imagery
    – Increased right hemispheric activity consistent with a non-verbal pattern of memory retrieval
  • Non-PTSD Patients Experienced:
    – Trauma memories recall as non-affect-laden, autobiographical memories (in narrative form)
    – Increased left-hemispheric activation consistent with verbal pattern of memory retrieval
    – No increase in heart rate during script-driven imagery

Mervin Smucker

Mervin Smucker: Panic Symptom Questionnaire

Below is a list of physiological symptoms that people sometimes experience when they are feeling anxious or panicky.  Please rate on the line next to each item how fearful you are of these symptoms using the numbers from 0 to 3 below.  Please rate each item.

  • N/A  –   Symptom not present
  • 0 – Not at all fearful
  • 1 – Somewhat fearful
  • 2 – Quite  fearful
  • 3 – Extremely fearful

____   1.  Lightheadedness / dizziness

_____ 2.  Shortness of breath

_____ 3.  Wobbliness in legs

____   4.  Nausea

____   5.  Blurred / distorted vision

____   6.  Tingling in fingertips

____   7.  Numbness in arms or legs

____   8.  Heart palpitations

____   9.  Pressure / heaviness in chest

____ 10.  Knot in stomach

____ 11.  Lump in throat

____ 12.  Dry throat

____ 13.  Sweating

____ 14.  Disorientation / confusion

____ 15.  Sense of disconnectedness from body

Mervin Smucker