08/01/14

AGENDA

• Imagery: WHAT? WHY? HOW?

• Two Minds Rationale
• Working with Images
• Imagery Training
Working with Imagery
• Safe Place Imagery
28.06.18 • Formulating Questions
Elliot Rose • Imagery Rescripting - Constructing Answers

© University of Reading 2008 www.reading.ac.uk/charliewaller 2

WHAT? - A Definition of Mental Imagery WHY….Is it important in CBT?

“Mental imagery occurs when perceptual information is accessed
from memory, giving rise to the experience of ‘seeing with the
mind’s eye’, ‘hearing with the mind’s ear’ and so on. By contrast,
perception occurs when information is directly registered from
the senses…”
Kosslyn et al., (2001)
"...a mental image occurs when a representation of the type
created during the initial phases of perception is present but the
stimulus is not actually being perceived; such representations
preserve the perceptible properties of the stimulus and ultimately
give rise to the subjective experience of perception“
Kosslyn et al., (2006)
• Intrusive imagery in many disorders e.g. PTSD,
agoraphobia, social phobia, depression, OCD, BDD,
psychosis…
• In therapy important - reliving, metaphors, “what do
you see/comes to mind?”, “What would you say to a
friend?” (Gestalt), Mindfulness, Insights, Senses (HA),
Memory, BDD, MCT
• Beck (1976) therapeutic focus needs to be on
meanings, can be accessed through verbal thoughts,
images, memories, dreams.

HOW? HOW? - What the research says…

• Cognitive neuroscience – fMRI similar brain regions
used in imagining and actually doing e.g. motor
control, sports psychology “…imagery appears to play a
special role in representing emotionally charged
material” (Kosslyn, 1994)
• Evidence from experimental studies on the relationship
between imagery & emotion – Holmes & Mathews
(2005) Emotion
• Recent advances in cognitive neuroscience, including functional brain-
imaging techniques, have shown that mental imagery makes use of much
the same neural substrates as perception in the same sensory modality.
• Visual mental imagery seems to use the same two pathways (ventral or
object processing, and dorsal or spatial processing) as perception. Defects
in one or other pathway often, but not always, produce parallel deficits in
both perception and imagery. Auditory and motor imagery also draw on
cortical areas involved in auditory perception and motor control,
respectively.
• Imagery of emotional events can activate the autonomic nervous system
and amygdala in a similar way to perception of the same events, leading
to physiological changes. For example, imagining threatening events can
increase heart rate, skin conductance and breathing rate.
Kosslyn et al., (2001)

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Let’s explore a quick example Let’s explore a quick example

Imagine an event for yourself that generates a sense

of threat, increased heart rate, change in
temperature, breathing

Rate it out of 10 for perceived level of arousal (SUD)

THE FREEZE RESPONSE

TIME FROZEN

Feedback Enactive Interaction

Enactive procedures - either in reality or imagination -
hold the key to changing cognition (Teasdale, 1997)
What were your experiences?
We create our own experience through how our actions
Has anything happened to your SUD? interact in the context of our perceived world

Organisms are not passive receivers of input from the

environment, but are actors in the environment such that
what they experience is shaped by how they act.“ (Hutchins
1996)

In Two Minds …
Rational/Reflective & Emotional/Experiential Working with Images
https://www.youtube.com/watch?v=JiTz2i4VHFw
Two purposes:
1. To gather information for the formulation
In small groups, consider, how this video is clinically relevant
2. As a treatment strategy
for:
• Cognitive biases
Imagery versus verbal processing – includes pictures, bodily
• Context sensations and sometimes sounds, tastes.
• External priming
• Perceptual (sensory) v Conceptual (verbal) information Images might include what has happened in the past, what is
happening now, what might happen in the future
Q How have people experienced this in the therapy room ?
Evidence for images and imagery work is increasing
Q What different approaches might be needed in formulation
and treatment? 11

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Intrusive memories v. Intrusive Images Examples of imagery techniques in Tx.

Images as memory or construction ??

Actual experience------------------------------------------Constructed experience • Reliving traumatic memories (e.g. PTSD)

Truth/Fact Symbolic representation
• Imaginal exposure for cognitive avoidance (e.g.GAD)
Intrusive memories = traumatic memories
Intrusive images = schemas/beliefs with a pictorial component • Safe place imagery
Intrusive mental imagery = autobiographical memory of an actual experience,
typically …material that is abstracted from or represents an imaginal extension • Rescripting Images (e.g. Social Phobia/PTSD)
of an actual experience

What matters..?
Imagery versus verbal processing – includes pictures, bodily sensations and
sometimes sounds, tastes. 13 14

Principles of imagery work

DEVELOPING VISUALISATION SKILLS
• We can’t assume that everyone can see
amazing 3D 4k Ultra HD visuals in their
• Ask about images! mind for minutes at a time.

• Normalise • We (i.e. you) have to be OK with people

not being good at it.

• Provide rationale • You’re having training now, and they

might need it too.
• Manage intensity
• People vary a great deal in how easily
and vividly they can see mental imagery
• Neutral stance but, like any skill, everyone can improve
their clarity and control by practising.
• Debrief
• We all have photographic memories, it’s
just that some people have better quality
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film in their cognitive cameras.

Bring thoughts/images into awareness Bring into awareness

Show them what you mean with an DEVELOPING VISUALISATION
example of imagery. • Close your eyes, relax your body and watch your mental screen. Describe what
you see to yourself. It will probably be shades of grey with splashes of white at
first. You may see a negative image of what you had just been looking at before.
When this settles down, imagine a small black speck in the centre of your visual
field
• Make it as black as you can
• Now imagine that speck growing link ink dropped into a pool of water so that it
slowly spreads out from the centre and starts to colour your entire mental
screen. The blacker you can get the screen, the better. Put your hand over your
eyes if it helps.

• Now open your eyes and look at a nearby object. Relax your eyes, don’t stare at
it or try to imprint it on your mind.
Recognise the types of brain/thinking • Gradually close your eyes. As you do, keep a picture of the object in your mental
Fast & Slow field of vision. It may help to look up to your left, even though your eyes are
closed. This eye position helps you to visualise.
(O’Connor, 2001)

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Bring into awareness Bring into awareness

DEVELOPING VISUALISATION DEVELOPING VISUALISATION
• Close your eyes and imagine the object in front of you exactly how it was. • Now move the object in your mind.
• What colour was the object? • Imagine turning it upside-down so you can see it from the bottom.
• See the colour as vividly as you can. • Then turn it around so you can see it from the back. If this is difficult, open your
• Now make your picture even brighter. eyes and do it to the physical object (if you can), then close your eyes and
• Imagine a spotlight on the object making it stand out more clearly. visualise what you have just seen.
• Imagine making the object smaller so it recedes into the distance. • Imagine turning the object inside-out and looking at it from the inside
• Now make it zoom up close. • Now imagine clambering inside it so you can look at it from the inside.

• Being able to imagine different perspectives is important. You need to be able

to control your picture by looking at it from different angles.
• Imagine yourself floating on the ceiling looking down on the object.
• Now imagine yourself on the floor looking up at the object.

(O’Connor, 2001) (O’Connor, 2001)

Assessing Images Working with Images

• What might be the advantages of assessing images as well as thoughts? Bring it into awareness and examine it
– More information Specific, detailed, first person present tense
– Forgotten details
– Stronger emotions
Images can be triggered by:
– Elaborates meaning (for you and the client)
In vivo exposure – in session/homework
• Accompany client to naturalistic anxiety-provoking situation and use
• What might you need to be aware of?
careful questioning
– ‘Weird’ Factor
• Add image/memory column into thought diary
– Heat

In small groups: for a few minutes - think of clients you have seen, did they have Imaginal exposure – in session/homework
images? Did you ask about images? What might they be imagining? • Symptom induction in session can also help with elicitation
• Behavioural experiments as information gathering
Feedback

Working with Images Safe Place Imagery

What does the image seem to mean about: A place that makes them feel safe and calm!!!!
• The client What can they see?
“What is around you?”, “What colours do you see?”, “Are you inside/outside?”, “Who is
• Other people with you?”
• The world
• The Future What can they feel?
“What are you doing?”, “What can you touch?”, “Can you feel the warmth of sun/breeze on
your face/skin?”, “Are you sitting/lying/walking/flying?”, “What is under your feet?”
• What is the main message?
• How is the sense of threat represented in the image? What can they hear?
Sea, breeze, music, voices, traffic, birds, crickets etc.
• Get belief ratings
- Help the client feel in harmony with their safe place.
• How can you change the sense of threat in the experience? - Bring online a feeling of safety and being wanted/belonging in that place
- Concentrate on that factors that reinforce those positive feelings

23 Take your time

Find the image, return to the image, feel the affect, rehearse the image

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Safe Place Imagery Safe Place Imagery

Some client’s need help – so help construct CLIENT or THERAPIST

“I can’t do imagery!” PRACTICE MAKES PERFECT

That’s OK – (It’s usually it’s a language/meaning thing….)

How do you think about what you are going to eat?

Can you remember/tell me about your earliest memory from
school, home?
What’s the most interesting thing about where you live?

Whatever you’re doing now……do that! - “Remembering”

Identifying Images

HAVE A GO – Safe Place Imagery

Practice in pairs – Find partner’s safe place
Bring it online
Rehearse, rehearse, rehearse – get good at bringing it online

Questions for identifying images Questions for examining images

What went through your mind then? Can you describe it as if it is happening now?

How do you picture that? What can you see, hear, feel in your body, taste or smell?

Do you have a mental image of that? What is happening in the image?

Was that a memory? What has led up to this?

Do you see it in your minds eye? What do you think will happen next?

How does it feel in your body? How does that make you feel?

What does that look like? (Hackman, Bennett-Levy & Holmes, 2011)

(Hackman, Bennett-Levy & Holmes, 2011) 29 30

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What is the client’s response to the image? Metacognitive beliefs about having the image
What you feel the impact of the image How do you interpret it?
Does it seem to reflect the past, present or future?
What do you feel like doing? Does it seem like a premonition/a warning?

Do you feel like avoiding anything? Are you afraid of what might happen if you hold that imagery in mind?
Are you afraid you might go mad, die, collapse, be overwhelmed if you allow this
What actions do you take? into your mind?
Does it seem like the image can change reality/affect other people?
Do you start to dwell on the content of the imagery?
Do you think that having +/- imagery could make it more(or less) likely to happen?
Do you ask anyone for reassurance about it? Do you think having imagery like that makes you a bad person?
Do you think holding negative imagery in mind helps you make better decisions
Do you try to supress the image/distract yourself? about what to do?
(Hackman, Bennett-Levy & Holmes, 2011) (Hackman, Bennett-Levy & Holmes, 2011)

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Micro-formulation Jane
(Hackman, Bennett-Levy & Holmes, 2011)
Source? Jane is 24 and trying to work towards her masters degree in
music. She has always been a quiet person in large groups and
reported preferring the company of one or two close friends
Image Description than the crowd. Amongst her family and close friends she
describes herself as animated, witty and a bit cheeky.

However, since starting her Masters degree Jane has realised

that she misses the comfort of her traditional peer group from
Consequence home and her undergraduate degree and has become more
reserved. She is conscious that she is quiet and withdrawn in
Meaning/appraisal social situations.
Emotion(s) Jane reports that recently she has stopped socialising at university and is contemplating leaving her
Maintaining factors course. When asked about what springs to mind during these thoughts of leaving Jane reports that
she is pre-occupied with images of herself at school orchestra sitting on her own and watching the
(cognitive/behavioural) other girls talking and laughing. Jane remembers thinking that they were talking about her, that she’s
strange because she isn’t as confident as the other students and this makes her experience feelings of
being humiliated and rejected.

Jane reported that she thought this meant that she was strange and not likeable. Jane spoke about
Impact in here-and-now many experiences at secondary school when she was singled out for ‘being quiet’ by her peers. She
identifies with being bullied while at school.

Jane Micro-formulate Jane

(Hackman, Bennett-Levy & Holmes, 2011)
Source?
At university Jane finds herself in a similar
professional/social situations. She has to attend orchestra
practice and is expected to liaise with the three other
clarinet players and also socialise with the orchestra a at
Image Description
music events. Jane does so but she’s either always thinking
about what they think about her, usually imagining that
they think she’s strange or has nothing interesting to say.
Consequence
Jane usually tries to avoid these situations, such as avoiding practice, getting there late so she
Meaning/appraisal
doesn’t have to engage in small-talk or completely avoiding, which means she’s behind in Emotion(s)
practice and also feels more out of touch with her peers.
Maintaining factors
When Jane does talk to the other musicians she’s frequently wondering what to say and
regretting the things she does say. Jane says she feels it’s too late, she’s believes that she has
(cognitive/behavioural)
missed out on the initial bonding, everyone is already in their social groups and she’ll always
be the outsider.

She has images of sitting alone on the stage while the other musicians are all getting on Impact in here-and-now
together without her. She experiences feelings of humiliation, rejection and also anger at
herself for being so stupid and weak.

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Exercise – Assessing/Formulating Images

Practice in pairs – Build one formulation each (ideally for yourself)
Bring a situation to mind when you experienced embarrassment
(or bring a client to mind and roleplay their problem)

Use question prompts to identify the image, examine its meaning

and response tendencies, then reflect upon the image
Micro-formulate the image

Exercise – Assessing/Formulating Images Further information on micro-formulating images can be found in:
Practice in pairs – Build a formulation each (ideally for yourself)
Bring a situation to mind that, thinking about it, makes you uncomfortable Chapter 7 of Hackman et al. (2011)
or bring a client to mind and roleplay their problem (or Jane)

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Imagery Rescripting - Disorders

What disorders can this be used in ..?

Health anxiety (Wells and Hackman, 1993)

IMAGERY RESCRIPTING Social phobia (Hackman et al., 1998)
Agoraphobia (Day, Holmes and Hackman, 2004)
Depression (Wheatley et al. 2007)*
OCD (Veale, et al., 2015)
PTSD etc….
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Imagery Rescripting Imagery Rescripting

The purpose of rescripting = new corrective information about the meaning
of the event for self and others…not exposure/extinction paradigm. Arntz and Weertman (1999) treatment of childhood memories:
theory and practice
Creating more adaptive schematic representations (Smucker et al., 1995)

Three phases:
Retrieval Competition (Brewin, 2006)
1. Patient as child = original scene as experienced as a child
“Imagery rescripting appears able to produce highly acceptable,
2. Patient as adult – observed from adult perspective and
memorable images that are effective competitors to the memories that
intervention from the adult perspective
previously maintained depressive mood”
3. Patient as child – intervention done by the adult but experienced
by the child
Focus – mastery and compassion
What might the different perspectives provide?
42 43

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Example Rationale (Wheatley et al., 2007)

Intrusive memories are very common. Sometimes these can be very pleasant, such a
images of a special day that we remember well. When we recall that day we might
recall sounds, smells and sensations as well as mental pictures. However when bad
things happen we may be left with distressing images and memories that haunt us and
colour our experience of the present. Sometimes these distressing memories are
stored with the meaning they had at the time of the event. We may believe that these RETURNING TO HOT SPOTS
distressing memories say a lot about the kind of person we are. When these memories
are very vivid it can feel almost as if the past is happening all over again, and it is not
unusual for us to feel emotions or even physical sensations that we had at the time.
Some of our beliefs about these events may be unhelpful, distorted, or out-of-date.
These memories need to be updated so that they find their proper place amongst your
other memories. The best way to do this is for us to access the memories by
Re-experiencing them in your imagination. We can then try to transform them using
creative imagery so that they become less distressing
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Hot Spots in PTSD Dealing with Shame

With respect to the diagnostic emotions for PTSD, 42% of emotions were of fear, helplessness
and horror. Eyeball inspection indicates the most common emotion theme is fear. However,
dissociation, anger and sadness all appear more frequently than both helplessness and horror.
Horror appears less frequently than all other negative emotion categories. Jane’s story links to feelings related to shame.
Holmes, Grey & Young (2005)

Shame: A sense of oneself as defeated, deficient, exposed,

worthless, inadequate (Gilbert, 1997)
58% NOT FEAR
Guilt, shame, anger, Hot Spots in PTSD - Fear was easy – Why?
sadness also present

How might we work with shame?

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Dealing with Shame Dealing with Shame

Ensure you are really displaying empathy Start contructing Compassionate Mind ideas
(Gilbert, 2010)
Recognise and let go of the ‘finger of shame’
and using Compassionate imagery (Lee, 2012)
Use you existing therapist skills:
Talk about it, find meaning, try to normalise the
situation and try to cognitively reconstruct the
situation, the client might need to be socially educated Recognising the self-critic and developing a more compassionate stance towards
about how other people might behave in similar situations – use self and problems
examples in session.
Imagery re-scripting – using the client’s own existing ability to imagine by taking
Responsibility – Are there feelings related to responsibility? Can the existing image and adding components that might alter the emotions
restructuring these thoughts help the client? generated by the image (e.g. go back in time as adult to emotionally nurture
younger self, enact facing abuser differently, be a self-mentor………essentially
Positive data logs to challenge negative self-concept and gather new construct anything that the client feels is shifting the feeling of shame)
current evidence
48 49

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Rescripting with Compassionate Imagery Compassionate Imagery

• Key approaches
• Gilbert (2010) – Emotional Regulation Systems - Imagine self with qualities of wisdom, authority & strength,
warmth, responsibility/ability to relieve suffering
- Imagine yourself at your best
- Develop a “Perfect Nurturer”

• Perfect Nurturer
- real/imagined person
- how they look, smell, sound, feel
- including perfect personal qualities of acceptance, warmth,
• Train self-soothing system
strength, wisdom, genuineness, hope, resilience
• More powerful when associated with smell

Exercise – 3 Stage Rescript Questions for rescripting phases 2 and 3

In Groups of 3 What happens?
Use a clinical example or your personal example from earlier formulation
What do you see?
Three phases: What are you feeling?
1. Patient as child = bring online original scene as experienced as a child
What are you inclined to do?
2. Patient as adult – observed from adult perspective and intervention
from the adult perspective
Ok do it……
3. Patient as child – intervention done by the adult but experienced by
the child )
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Rescripting Exercise – Feedback

Tips What did you notice as :
Return to your formulation – construct a more compassionate
response (whatever ‘feels right’ to them) • The Observer

Use same questions/prompts to identify the new version of image,

• The therapist
examine its meaning and TRY IT ON to see if it’s a good fit.

• The client
What are the new responses? Get them to repeat the image and
rehearse it.

(It can be updated further over time)

54 55

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Common problems (Arntz & Weertman, 1999) Learning Points….

“It may be helpful to think of mental imagery manipulation as a core
• What memory to choose cognitive therapy skill” (Wheatley et al., 2007)
• Cannot find a memory
• Patient does not close eyes
• Patient dissociates
• Loyalty to parents
• Guilt about chosen intervention (from adult self)
• Guilt about not having intervened as a child
• Intervention is discarded as being unrealistic
• Patient is too fearful to intervene
• Patient cannot take on the child perspective
• Fear of future consequences
56 57

References
• Arntz, A. and Weertman, A., 1999. Treatment of childhood memories: Theory and practice. Behaviour research and
therapy, 37(8), pp.715-740.
• Brewin, C.R., 2006. Understanding cognitive behaviour therapy: A retrieval competition account. Behaviour research
and therapy, 44(6), pp.765-784.
• D. M. Clark & C. G. Fairburn (Eds.), Oxford medical publications. Science and practice of cognitive behaviour therapy
(pp. 67-93). New York, NY, US: Oxford University Press.
• Edwin Hutchins (1996). Cognition in the Wild. MIT Press. p. 428.
• Hackmann, A., Bennett-Levy, J. and Holmes, E.A., 2011. Oxford guide to imagery in cognitive therapy. Oxford university
press.
• Kosslyn, S.M., Thompson, W.L. and Ganis, G., 2006. The case for mental imagery. Oxford University Press.
• Gilbert, P., 1997. The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy.
Psychology and Psychotherapy: Theory, Research and Practice, 70(2), pp.113-147.
• Gilbert, P., 2010. The compassionate mind: A new approach to life's challenges. New Harbinger Publications.
• Holmes, E.A., Grey, N. and Young, K.A., 2005. Intrusive images and “hotspots” of trauma memories in posttraumatic
stress disorder: An exploratory investigation of emotions and cognitive themes. Journal of behavior therapy and
experimental psychiatry, 36(1), pp.3-17.
• Lee, D. and James, S., 2012. The compassionate mind approach to recovering from trauma: Using compassion focused
therapy. Hachette UK.
• Smucker, M.R., Dancu, C., Foa, E.B. and Niederee, J.L., 1995. Imagery rescripting: A new treatment for survivors of
childhood sexual abuse suffering from posttraumatic stress. Journal of Cognitive Psychotherapy, 9, pp.3-3.
• Teasdale, J. D. (1997). The relationship between cognition and emotion: The mind-in-place in mood disorders. In
• Kosslyn, S.M., Ganis, G. and Thompson, W.L., 2001. Neural foundations of imagery. Nature Reviews Neuroscience,
2(9), p.635.

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