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Cognitive and Behavioral Practice 18 (2011) 424–432

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Imagery Rescripting in Posttraumatic Stress Disorder

Ann Hackmann, University of Oxford

This article provides an overview of methods of working with imagery to change meanings and ameliorate posttraumatic stress disorder
(PTSD). It opens with a description of phenomenology in this disorder, usually characterized by a small number of recurrent images of the
trauma, each representing a moment that warned of a threat to the physical or psychological integrity of the client. These intrusions are
vivid, distressing, sensory fragments, which appear to signal current threat. Theoretical models of maintenance of PTSD are discussed,
highlighting the importance of imagery as a target in therapy. Assessment and possible spontaneous cognitive change is then outlined,
followed by an account of methods of prompting for additional shifts in meanings associated with the “hot spots” in memory. These
include methods of updating the memories by incorporating corrective information, and also identifying and expressing trauma-related
emotions. Finally, there is a description of methods of working with childhood memories that have colored the experience of adult trauma.

I MAGERY rescripting is broadly defined in this article as a

collection of methods for working directly with
imagery in order to change meanings and ameliorate
distress. Imagery interventions have long been part of
cognitive behavior therapy (CBT) and indeed of psycho-
therapy in general (Edwards, 2007). The earliest recorded
form of imagery rescripting is attributed to Pierre Janet
(1889; described in L’Automatisme psychologique), who used
a form of imagery substitution, replacing one image with
another. In more recent research, there has been a surge
of interest on the topic, including a special issue on
imagery rescripting across disorders in the Journal of
Behavior Therapy and Experimental Psychiatry (edited by
Holmes, Arntz, & Smucker, 2007).
This article considers phenomenology in posttraumat-
ic stress disorder (PTSD) and discusses theoretical models
that indicate what maintains the problem and why
imagery may be a good target and an effective vehicle
for change. The main body of the article offers an account
of how imagery rescripting can be used in various ways to
bring about emotional processing.
Phenomenology in PTSD
PTSD is defined in DSM-IV as a disorder in which the
person has “experienced, witnessed or was confronted
with an event or events that involved actual or threatened
death or serious injury, or a threat to the physical integrity
of the self or others.” The response involves “intense fear,
helplessness or horror” (American Psychiatric Associa-
1077-7229/11/424–432$1.00/0
© 2011 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
tion, 2000). The three clusters of symptoms include
reexperiencing symptoms; avoidance of potential triggers
for reexperiencing; and hyperarousal, including hyper-
vigilance or startle responses to trauma reminders. Thus,
the definition points strongly to the role of memory for a
traumatic event (or events) in this disorder.
Memory in PTSD has two distinctive features: there is
involuntary retrieval of intrusive (negative, unwanted)
segments of memory from the trauma and its sequelae.
Deliberate retrieval of the memory may also be confused,
disorganized, and/or incomplete (Ehlers & Clark, 2000).
Several studies (e.g., Ehlers et al., 2002; Ehlers & Steil,
1995; Grey, Holmes, & Brewin, 2001; Hackmann, Ehlers,
Speckens, & Clark, 2004; Speckens, Ehlers, Hackmann,
Ruths, & Clark, 2007; van der Kolk & Fisler, 1995) have
investigated the nature of spontaneously triggered intrusive
memories in PTSD. Key findings include:
• Most intrusive memories involve sensory imagery,
visual material being most common, followed by
bodily sensations, sounds, tastes and smells, in
descending order.
• Most patients with single-event trauma have only a
small number of recurrent intrusive memories.
• Intrusive images tend to be of moments that are
“warning signals” of the onset or worsening of the
trauma.
• The intrusions map closely onto what are later
revealed as the “hot spots” in the memory (i.e.,
moments filled with the worst meanings and the
greatest emotional impact).
• When the imagery is triggered, it is often felt as
something happening now—it is experienced
 Imagery Rescripting in PTSD
without the normal “time-code.” At its most extreme
level, the client experiences a full dissociative
flashback, where all awareness of present reality is
lost and the trauma is fully reexperienced.
• Intrusions often carry the meaning they had at the
time of the event (e.g., “I am going to die, and I will
never see my children again”). Such thinking has
little or no connection with the individual's factual
knowledge that these outcomes did not occur.
• Not all the images are veridical: some are of
imagined events, recalled as happening at the time
of the traumatic event or at a subsequent moment.
• Some images are composite, with input from a
number of memories.
• Nightmares in PTSD may be replicative (i.e., the
material is identical to that in the memory of the
trauma) or they may be thematically linked.
On closer inspection, the content of intrusive memory
is equally interesting. The most distressing parts of the
trauma (often reflected in intrusions and hot spots)
include the expected reactions of fear, helplessness, or
horror, but other emotions such as guilt, anger, and
shame are also prominent (Grey & Holmes, 2008;
Holmes, Grey, & Young, 2005). In addition, particular
personal significance may be attributed to the moment,
often on the basis of the client’s previous experience,
assumptions, or beliefs (e.g., “This is happening to me
because I deserve it”; “I am weak to be responding like
this, how typical of me”; or “This is happening because I
attract bad luck”). It is clear from the content of intrusive
imagery that a traumatic event may cause not only a threat
to the physical integrity of the body, but also to the
person’s sense of self (Stopa, 2009).
Intrusive memory images are sometimes given idiosyn-
cratic significance in the present. For example, there may
be metacognitive appraisals, such as, “This image of the
car crash is a premonition that I will be involved in another
accident”; “The image is a portal to the other world: I will
travel back in time, experience the same trauma, and this
time I shall die”; or “The image is a warning that I can
expect further punishments for being bad.”
Clinically it has been observed that strenuous efforts
are often made to avoid triggers for the intrusions, or, if
they are triggered, clients use suppression, distraction, or
other safety behaviors to deal with them. Rumination may
also ensue, frequently triggering more intrusive images
(Speckens et al., 2007).
Emotional Processing
In 1980, Rachman wrote about emotional processing, a
concept that has subsequently been addressed by many
others. Rachman provided a pragmatic definition of the
desired outcome by suggesting that successful emotional
425
processing can be gauged by the person’s ability to talk
about, see, listen to, or be reminded of the emotional events
without experiencing distress or disruption (Rachman,
1980, p. 51). This is clearly our objective when treating
PTSD. Rachman returned to the topic in 2001, extending
the model by including a discussion of cognitive influences
on emotional processing, with particular reference to the
treatment of PTSD.
He focuses on the model suggested by Ehlers and
Clark (2000). This in turn draws upon the work of many
other theorists (Brewin, Dalgleish, & Joseph, 1996; Foa &
Rothbaum, 1998; Janoff-Bulman, 1992; Joseph, Williams,
& Yule, 1997; Resick & Schnicke, 1993; van der Kolk &
Fisler, 1995, among others) and is intended to provide a
new synthesis and framework for CBT. It also draws on the
theoretical framework concerning general autobiograph-
ical memory with applications to PTSD, advanced by
Conway and Pleydell-Pearce (2000). These authors have
observed that PTSD memories are not well integrated
with other long-term autobiographical knowledge. In-
stead, they are easily triggered because they threatened
the person’s sense of self. In order to become less
intrusive, these memories need to be integrated with
other, more positive memories, rather than being avoided
and hence remaining distorted and threatening in their
content (Conway, Meares, & Standart, 2004).
Ehlers and Clark’s (2000) model suggests that PTSD
becomes persistent when individuals process the trauma
in a way that leads to a sense of serious, current threat.
Such an emotion is thought to arise as a consequence of
excessively negative (i.e., distorted) appraisals of the
trauma and/or its consequences, and a disturbance of
autobiographical memory, characterized by poor elabo-
ration and contextualization of memories (and strong
associative memory and perceptual priming). This means
that intrusive memories carry distorted meanings, do not
connect with other knowledge the person has, and are
easily triggered. Three treatment targets are suggested:
• The trauma memories need to be elaborated and
integrated into the wider context of preceding and
subsequent experience, rather than persisting as
distressing fragments that do not connect with
anything else.
• Problematic appraisals of the trauma and/or its
consequences need to be modified. It is noted that
previous experience and beliefs may have played an
important role in coloring such appraisals, and need
attention in their own right.
• Dysfunctional strategies that maintain the problem
(e.g., suppression, avoidance, and rumination),
need to be relinquished.
As Ehlers and Clark point out, a wide range of
techniques have been used to bring about change in
426
these three areas (see, for example, Foa & Rothbaum,
1998; Joseph et al., 1997; Resick & Schnicke, 1993). This
present article focuses on techniques using imagery
rescripting to achieve these ends, in memories formed
as an adult or in childhood. However, imaginal exposure
(or reliving) is often introduced as a precursor to
rescripting imagery, as an aid to bringing as much of
the memory as possible to consciousness, in order to
investigate associated affect and meanings that have been
given to the event. Of course imaginal exposure has been
used extensively and effectively in the treatment of PTSD
(particularly in treatment trials by Foa’s group), and in
itself can bring about cognitive change (see Foa, Molnar,
& Cashman, 1995; Jaycox, 1998). Foa coined the term
“reliving.” Here we describe the way in which reliving is
presented and utilized in (some) imagery rescripting
sessions, largely as a method of assessing meanings and
associated affect in the hot spots.
Socialization and Assessment
Before imagery rescripting can be undertaken in a
CBT framework, a period of assessment takes place. First,
the client is asked to give a brief journalistic account of the
traumatic event (or events). A discussion follows on the
nature of trauma memories and on what strategies the
client uses to cope with reexperiencing symptoms.
Typically, clients speak of how easily the intrusive
memories can be triggered, and how they attempt to
use distraction, suppression, or avoidance of possible
triggers. Clients describe how they ruminate and dwell on
rather general miserable thoughts about the self, other
people, and the world once the memories are triggered.
Some psychoeducation is included here, to the effect that
although it is very understandable to deal with the
memories in this way, it never gives the client a real
chance to lay them to rest among all their other
memories. At this point metaphors can be used to explain
what might need to happen for emotional processing to
occur. For example, one could use:
• The cupboard metaphor: After an upsetting experience
is it tempting to push painful memories away. This is
like hastily stuffing everything back into a cupboard
after a burglary, which can result in the cupboard
frequently bursting open. Socratic questioning is
used to reach the conclusion that what is needed is
to get things out of the cupboard and sort through
them before neatly putting them away.
• Memories of events are normally like luggage on a
conveyor belt at an airport: they circle round before
being recognized and carried away. During a
traumatic event, such upsetting and vivid ideas
come to mind that one does not want to revisit
them. Therefore, like unclaimed luggage, traumatic
Hackmann
memories can cycle round and round. The solution
is to remove them from the conveyor belt, unpack
them, and store the contents in the right place in
memory: in this case, in the proper context—among
other memories/knowledge. As a memory loses its
upsetting meanings, it is less likely to intrude
inappropriately in the client's mind.
The assessment proceeds with the therapist inviting the
client to elaborate further on the trauma memory. Often,
but not always (see section below on precautions), it is
suggested that the client relive the traumatic memory,
with their eyes closed, speaking in the first person, present
tense, with as much detail as possible concerning all the
sensory and emotional aspects of the experience and the
thoughts that are passing through the mind as events
unfold. The main purpose of reliving at this stage is to
unpack the distressing meanings given to the event, and
to subsequent intrusions. This can be a distressing
experience, and plenty of time is required for the client
to access and relive the memory, reflect on the contents,
and then be gently regrounded in the present (see next
section). For some clients it may be preferable for them to
do this with their eyes open, particularly if they have trust
issues or if the affect is overwhelming.
Precautions When Reliving Memories
It is important to note that even an initial reliving session
may not always be part of the protocol when carrying out
imagery rescripting. It may be avoided in cases where there
has been multiple trauma, or where there is some
substantial ongoing threat, or when the affect threatens to
be totally overwhelming. In such cases a good relationship is
even more important than usual, and other forms of
treatment and social support may be utilized.
If any reliving is introduced it is essential to ensure in
advance that there will be enough time for the client to
approach the material, and then reflect and recover
before the end of the session, or the resumption of
normal activities. If the client is thought to be vulnerable
to dissociation, grounding techniques can be taught—for
example, opening their eyes and being asked to describe
features of the room; playing favorite music; lighting a
scented candle, or engaging in any other pleasant or
neutral activity which brings them back into the present.
This can be used, if required, after reliving in order to
ground the client in the present.
In treatment for adverse childhood memories, Arntz,
Tiesma, and Kindt (2007) recommend that, in some
cases, reliving be used only up to the point when the client
realizes that something terrible is about to happen:
rescripting commences from then on. In a similar vein,
Krakow and colleagues (for example, Krakow & Zadra,
2006) no longer recommend imaginal reliving of
 Imagery Rescripting in PTSD
distressing nightmares, but suggest that clients simply start
by rescripting new, more preferable dreams in imagery,
which are then repetitively practiced. It is an empirical
question for further research whether and when reliving
all or part of a traumatic memory or nightmare, at least
once, before attempting any rescripting, adds or subtracts
value to the client's treatment.
Spontaneous Cognitive Change as a Result of
Evoking Imagery
One great benefit of going through the reliving process
(if this is possible) in one or more sessions is that it provides
an opportunity for some spontaneous cognitive restructur-
ing to occur. As the memory is brought more fully into
consciousness, the following changes might occur:
• The client begins to put an appropriate “time-code”
on the memory, seeing that it is not happening in the
present.
• The client starts to appreciate that the image is only
input from memory, not a warning of future danger,
and so forth.
• A more coherent narrative may emerge, gaps may
be filled in, and the worst moments may begin to be
connected with the rescue and/or coping that came
later and softened the impact.
• The client may appraise his or her own behavior or
that of others on the basis of the fuller information
that emerges. This can lead to a reduction of guilt,
self-blame, or anger.
• The client may realize that avoidance is not as
important as was assumed, if the affect is less than
they imagined, or begins to decrease.
For further discussion on the nature of cognitive changes
following reliving, see Foa, Molnar, and Cashman (1995),
Jaycox (1998), and Butler, Fennell, and Hackmann (2008).
Unpacking the Meaning of “Hot Spots”
When treating PTSD in a cognitive therapy framework,
meaning is considered to be of central importance. After
discussing or reliving the whole memory, the client and
therapist may reflect on the hot spots in the trauma
memory (i.e., those where the affect was greatest; Holmes
et al., 2005). These hot spots become the focus of
subsequent treatment. As described earlier, hot spots
are the moments of greatest emotional impact, when the
meaning of the event changed, usually for the worse
(Ehlers et al., 2002). Janoff-Bulman (1992) has suggested
that traumatic events may shatter a person’s positive
assumptions and beliefs, or strengthen negative ones.
Several possible categories of images follow:
• At the simplest level, the client’s images are memory
images of shocking moments, depicting the state of
427
the world that they wish to avoid at all costs in the
future (Conway et al., 2004). An example would be
images of car headlights approaching fast, with the
sudden realization that one might be about to die,
or that one’s child was about to be seriously injured
or killed. Such appraisals associated with intrusions
can persist after the trauma, even though these
things did not occur.
• If the client was injured or disfigured, intrusive
images that may arise where the damage pictured in
the damaged parts of the body may be very
distorted. For example, the image may not have
been updated to include changes from treatment
and/or healing.
• Sometimes the client has an image of someone
suffering or dying that comes to them with a sense
of “nowness,” even though the suffering is long
over.
• The meaning given to the event at the time can be
erroneous. For example, someone in a car crash
may mistakenly believe they attracted the accident
because they are evil. A person who has been caught
in an explosion and temporarily unconscious might
“see” dust-covered people walking towards them as
“the living dead.” Here, the image could be of what
was experienced at the time, accompanied by the
erroneous appraisal.
• If the person has often encountered potentially
traumatic events (in the course of their work, for
example) a composite, even symbolic image may
emerge. A policeman might have an intrusive image
of “the archetypal damaged child,” representing all
the dead or damaged children encountered in his
work, and signifying his sense of the vulnerability of
children.
• The image may not be a veridical memory, but an
image constructed at the time. Examples might be
of the self seen from an observer perspective in
“out of the body” or a “near-death experience”
during the trauma. A similar change occurs when a
person experiences terror at what might happen
next, causing a catastrophic image, such as pictur-
ing their bones shattered, or even seeing their own
funeral.
• The image might be one from a previous trauma, if
there are similarities at a sensory or thematic level
between the previous and more recent traumas.
There is a substantial range of possible images along
the lines of those exemplified. A great variety of emotions
are attached to the imagery: fear, helplessness, horror,
sadness, guilt, anger, and/or shame. The content can
encapsulate meanings about the self, the world, other
people, the past, and/or the future.
428 Hackmann
Introducing Corrective Information Into the
Meanings of Distressing Adult Memories in PTSD
Once the process described above—of reliving the
memory, identifying the hot spots, and considering their
meanings and their metacognitive significance—is com-
plete, the task of prompting for further cognitive change
can begin. The goal is to introduce new information that
helps the client to view the material in a less toxic, more
realistic way. The new information is often arrived at using
guided discovery, and may subsequently be useful in a
process called “cognitive restructuring of hot spots within
reliving” (Grey, Young, & Holmes, 2002). To begin, the
client relives the hot spot with eyes closed. When the
client reaches a distorted appraisal, the therapist asks,
“And what do you know about that now?” The client
supplies information from the new perspective arrived at
by guided discovery.
If this process does not result in an adequate shift in
affect or beliefs, other imagery techniques may be
introduced to give a more vivid representation of the
wider perspective. The idea here is to bring in informa-
tion, often obtained through guided discovery in one or
more earlier sessions, which updates the meaning that the
person gave the event at the time. The distorted appraisal
is placed in the wider context of the client's previous and
subsequent experience. Some examples are given below.
Correcting a Distorted Image
During an actual trauma, clients may imagine a worst-
case scenario about to take place, although this does not
occur. Here the image needs to be replaced by an image
closer to what actually happened. A client involved in the
London bombings imagined all the stairways collapsing
after an explosion, so that she could not get out of the
building. She replaced this with a realistic image of the
stairways not collapsing, so she could in fact escape when
help arrived. Another client had an image of ending up in
a wheelchair as the result of a car crash. This was updated
by asking him to remember having that image, then
guiding him to “run the memory on” until he experi-
enced images of receiving the good news at the hospital
that his injuries were not critical.
Seeing Events From Another Perspective
A client who was involved in a car crash saw two nurses
walk straight past her car instead of asking if they could
help. She appraised this as meaning that no one cared
about her anymore and that she was just as alone as she
had been as a child. In reality, only moments after the
nurses walked past, several other people who had heard
the crash ran straight up to help her. Logic told her that
these other people had not neglected her, but the
emotional sense of neglect persisted. The distorted
appraisal was challenged by asking the client to view the
scene from the perspective of a bird in the sky. At once
she visualized both the off-duty nurses walking by, and the
helpful others who did come to her aid. This shifted her
affect and the false belief that nobody cared.
The Survivor Self Travels Back Through Time to
Reassure the Traumatized Self
A client had a persistent intrusion of a near-death
experience that occurred to her after a serious accident.
From an out-of-body perspective, she could see her badly
injured body, and had the sense that she was dying. She
imagined traveling back in time and being present to
reassure her traumatized self that she was not going to die:
further, she would not lose her arm or her eye as she had
feared after the accident. The client told her younger self
that she would be there to support her, even if her parents
were not.
The Survivor Self Travels Back to Explain to Others
What the Traumatized Self Is Experiencing
A client had a serious car accident during which his
legs were badly injured. When the ambulance arrived he
phoned his wife to ask her to meet him at the hospital,
reassuring her that he was fine. In truth, he was terrified
that his legs would have to be amputated. As he had
married just recently, it would be a disaster. In imagery, he
chose to travel back into the past to reassure his injured
self that he would not lose his legs, and to explain to his
wife how afraid he had been about becoming disabled. He
was able to explain to his wife how this fear had arisen: not
long before a friend’s father had lost a leg in a car crash
that happened very much like his own.
The Client Curtails the Sense of Interminable Suffering
by Imagining Being the Victim and Moving Beyond the
Point of Death or Serious Injury
Sometimes, examining a hot spot involving a dead person
reveals that the client is distressed by the sense that the
deceased is still somehow stuck and suffering inside their
dead body. It can be helpful to imagine moving the person
on. An elderly client, Jane, had been traveling across London
by Underground, when suddenly her train was bombed.
Uninjured herself, she had comforted a number of people
who had been hurt. She also saw a man who had died in her
carriage. The horror of this incident was softened by Jane
imagining actually being the dead man and having a “near-
death experience” during which his soul left his body, went
down a tunnel, and came out into the light.
Another client had witnessed someone being blown to
pieces in an explosion and needed to imagine that the
body parts had all been magically joined back together
again before the person was buried.
 Imagery Rescripting in PTSD
In each of these cases, the client’s distress arose as a
result of the sense that the dead person was somehow
“stuck” in their dead or shattered body. Upon corrective
imagining, both clients could experience the sense that
the dead were now at rest. Neither client believed at a
rational level that dead people continue to suffer, but the
intrusive image conveyed that emotional meaning before
the imagery rescripting took place.
Dialogues With Dead People
If consistent with the client’s wishes and beliefs, it may
be helpful to explore events from a wider perspective by
having a dialogue with someone who is no longer alive. A
client’s father committed suicide and left a note for his
daughter telling her where to find the body. When the
client found the corpse, she was shocked to see that her
father had hung himself. In this hot spot, the daughter had
concluded that her father could not have loved her if he
had left her to make this terrible discovery. However,
following some Socratic questioning and guided discovery,
a new perspective was explored. By imagining, from her
father's perspective, how much he had suffered during the
last weeks of his life, the client realized that (although
misguided) his father had meant to honor her rather than
cause her a great shock. Her father had thought that his
daughter was the only person who would be capable of
dealing calmly with the suicide. In imagery, the client went
on to explain to her father just what a blow this event had
been to her as a young woman. She felt she experienced
her father’s remorse about what had been forced on her.
Reducing the Sense of Current Threat From a Past Abuser
A client was troubled by recurrent intrusive images of
her ex-husband breaking in to her home and attacking
her, as he had often done in the past. This was despite the
fact that her ex-husband was serving a prison sentence,
and that she had moved to an address unknown to him. In
imagery she decided to make him smaller and smaller, to
the point where he was no bigger than a mouse, and then
to imagine that she swept him into a dustpan and threw
him into the dustbin. Another client (whose abuser was
actually dead) told him in imagery to go back into the
past, and reminded him that he could not hurt her any
more.
Imagining the perpetrator getting smaller, moving
further away, or going back into the past can remove the
sense that the abuser still represents a current threat to
the client, even though they know this is not true.
Imagining Actions the Client Regrets Not Taking, and
Testing the Likely Outcome
Often clients regret not acting differently at the time of
the trauma. Verbal discussion usually suggests that this
429
would not have been possible, or would probably not have
worked out well. However, as we have seen before, the
client remains unconvinced, ruminating about what
might have happened if they had tried to act differently.
In these situations, a thought experiment can be helpful.
The client is asked to close their eyes and vividly imagine
doing what they wish they had done, and experiencing for
themselves how it would have worked out. For example, a
client was a passenger in a car crash during which he
(erroneously) thought that his wife had died. He had
anticipated the crash, and thought he should have
shouted out to warn the driver. He was tormented with
guilt because he feared that his wife could easily have
been killed, and he had not intervened to prevent the
crash. Reliving the accident, and imagining that he did
actually shout to warn the driver made it clear to him that
this would have made no difference at all, as the driver
would not have had time to take evasive action. The client
continued with the image to the point where he realized
that his wife was not seriously hurt. These changes in the
imagery relieved his sense of guilt.
Such techniques for elaborating, contextualizing, and
updating fragments of trauma memories have been used as
part of a very effective range of strategies for treating PTSD
in several recent research trials (Ehlers et al., 2003; Ehlers
et al., 2005). The vividness and frequency of intrusive
imagery diminish over time (Hackmann et al., 2004), along
with decreases in nightmares and a corresponding increase
in the quality of sleep (Hackmann, 2005a).
Discovering and Expressing Any Trauma-Related Inhibited
Emotional Responses, With Particular Reference to the
Work of Smucker, Arntz, and Their Colleagues
Overlapping to some extent with the variety of
interventions described above are those that involve
opportunities to discover and express any trauma-related
inhibited emotional responses. This may be particularly
important with clients who have experienced a sense of
mental defeat, alienation, or permanent change in
response to the trauma (Ehlers, Maercker, & Boos,
2000). Mental defeat is defined as “the perceived loss of
all autonomy, a state of giving up in one’s own mind all
effort to retain one’s identity as a human being with a will
of one’s own’ and predicts later PTSD status in adult
assault victims” (Kleim, Ehlers, & Glucksman, 2007).
The techniques discussed below were originally devel-
oped to deal with traumatic childhood memories (Arntz
& Weertman, 1999; Smucker, Dancu, Foa, & Niederee,
1995), as described in the next section. However, these
techniques have also been used more recently to enhance
treatment for survivors of adult trauma who meet DSM-IV
criteria for PTSD. Arntz, Tiesma, and Kindt (2007) and
Grunert, Weis, Smucker, and Christianson (2007)
430 Hackmann
hypothesized that this may not only alleviate PTSD
symptoms, but also change trauma-related schemas and
beliefs (e.g., the sense of powerlessness, victimization, or
badness), despite the fact that there is less overt attention
to changing meanings. The method involves changing the
traumatic imagery to produce a more favorable outcome,
without denying the reality of the original traumatic
event. For example, clients are encouraged to experiment
in imagery with gaining control over situations by
expressing their needs and their feelings and imagining
behaving in different ways.
In their study, Arntz et al. (2007) contrasted eight
sessions of imaginal exposure (IE) with three sessions of
IE plus five sessions of imagery rescripting (IE + IR). Their
IE protocol was provided by Foa. In the IR sessions, the
therapist worked with the client to discover if there were
any reactions the client regretted not enacting. In
subsequent sessions the clients were exposed to the
most difficult moments, and asked to imagine reacting in
the way that they wished they had done. Overall, these
treatments were found to be equally effective, but there
were fewer dropouts in the IE + IR group. In addition, the
latter treatment also produced greater changes in anger
control, externalization of anger, hostility, and guilt (but
not shame). Therapists favored IE + IR because they felt
less helpless themselves.
The study by Grunert et al. (2007) also produced
interesting results. Imagery Reprocessing and Rescripting
Therapy (IRRT) was originally developed for adult
survivors of childhood sexual abuse (Smucker et al.,
1995) and has been adapted for use with survivors of
industrial accidents (Grunert, Smucker, & Weis, 2003).
Grunert et al. (2007) described the rationale as being one
in which traumatic images and associated beliefs are
transformed and placed in a newly created associative
framework that leads to the resolution of PTSD. IRRT was
offered to 23 clients who had failed to respond after
between 6 and 15 sessions of prolonged exposure
treatment, without any symptomatic change or decrease
in distress ratings during imaginal exposure. Grunert et
al. (2007) describe the IRRT protocol, which involves
reliving, developing adaptive positive imagery, and
updating the trauma memory by inserting positive
imagery after the original hot spots. The client imagines
their survivor self arriving at the scene of the traumatic
event and assisting the traumatized self in that past
situation, in a variety of ways. These include gaining a
sense of mastery and providing nurture to the trauma-
tized self. Socratic questioning is used to help the trauma
victim develop and imagine their own mastery, with
coping, self-calming and self-soothing strategies. After as
few as 1 to 3 sessions of IRRT, 18 of the 23 clients who had
failed to respond to prolonged exposure no longer met
diagnostic criteria for PTSD.
Making a Bridge to the Past
So far, only memories of adult trauma have been
addressed. A complicating factor is described by Ehlers
and Clark (2000): the way in which adult trauma is
processed may sometimes be heavily colored by past
experience. The adult trauma can be simply seen as yet
another example of the way life has generally treated the
person, reflecting their core beliefs. Where this is the case,
distorted appraisals of the latest trauma can be hard to
shift. One strategy is to investigate the possible origins of
such strongly held beliefs, using the “emotional bridge”
technique, borrowed from hypnotherapy literature
(Watkins, 1971). The client is asked to evoke the
troublesome hot spot, with all its sensory, emotional,
and meaning qualities—and to reflect on the moment in
the past when an experience reminiscent of the felt
sense in the hot spot first occurred. Where schemas are
involved, it is common for this inquiry to elicit one or
more key memories from much earlier in the client’s life,
carrying similar meanings. The therapist and client
choose an early memory that most strongly encapsulates
the schematic material and attempt imagery rescripting.
They test the effects of the rescripting by taking ratings
of beliefs associated with this early memory, and also
belief ratings of meanings given to the adult trauma. A
typical case of adult PTSD colored by childhood trauma
using this technique is provided by Hackmann (2005b).
Rescripting Childhood Memories in Cases of PTSD
Smucker and colleagues pioneered the first systematic
attempt to use imagery rescripting for adult survivors of
childhood sexual abuse presenting with PTSD (for a
protocol see Smucker & Niederee, 1995). In the first 4
sessions, imaginal exposure is used to capture all the content
and pathogenic meanings of the abuse memories. This is
followed in each of these sessions by mastery imagery, in
which the client visualizes herself rescuing her child self, and
driving out the perpetrator. On completion of the mastery
imagery, the client is encouraged to develop imagery of her
adult self nurturing the child. From Session 5 to Session
8 the imagery all centers on the adult self nurturing the
child. This process can be lengthy, as the adult self may
initially have a poor opinion of the child, even blaming her
for the abuse. The therapist endeavours to assist the client by
suggesting that she dialogues with the child to see how she is
feeling, and/or moves closer to her, looking carefully at her
facial expression, her small size, and pathetic appearance.
The authors conclude by describing how this kind of
imagery rescripting can help reduce abuse flashbacks,
identify and modify trauma-related beliefs, and facilitate a
shift in schematic representations of the self and others.
Arntz and Weertman (1999) describe their develop-
ment of this protocol for the treatment of childhood
 Imagery Rescripting in PTSD
memories in adults more generally. There are three
phases. First, there is a lively visualization of the original
scene, as experienced by the child. The authors stress that
there is no need for prolonged exposure, nor for
exposure to the whole memory (initially at least) in
severe cases. Second, the client is asked to imagine going
back in time and to experience the scene as an adult
bystander, with an awareness of what the child might be
feeling, thinking, and inclined to do. The client moves on
to imagine intervening. Often this involves the adult self
gaining some mastery over the situation, such as calling
the police or hitting the perpetrator. Finally, the scene is
imagined again from the child’s perspective, viewing the
adult self and their interventions, and asking for anything
else the child may need from the intervening adult. This
often involves the child requesting comfort, cuddling, or
more nurture of some other kind.
This procedure differs from the Smucker protocol, in
that the scene is ultimately viewed from the child’s own
perspective, rather than the adult perspective. This results
in high levels of affect with some different emotions, such
as sadness, and its resolution coming into play. Viewing
the rescripted events as the child may mean that the new
information is fed more directly, and from the same
developmental level, into the original schematic repre-
sentations. As in Smucker’s protocol, there is emphasis on
the possible “solutions” being offered by the client rather
than the therapist. A number of different approaches may
have to be tried by the client before any success or
resolution is achieved. The therapist would only make
suggestions if the client were stuck. The therapist may
offer to play a supportive role in the imagery, in the
absence of a kindly relative or friend who could be
incorporated into the imagery in a helpful way.
A controlled trial was recently published (Weertman &
Arntz, 2007) comparing 24 sessions of imagery rescripting
of early memories with 24 sessions of more present-
focused standard schema change work. The results
showed a significant change in both groups, but with no
difference in the magnitude of change. All clients had
both treatments and expressed a preference for working
on the early memories first, then moving into the present,
rather than working in a reverse order.
Summary
Imagery rescripting attempts to replace a traumatic
image with one that encapsulates a more realistic and/or
less toxic appraisal of the significance of the original
incident. The client moves to an appropriate sense of the
imagery as part of something that happened in the past,
without implications for the present. Using imagery can
be more effective than verbal discussion when it comes to
changing meanings and associated affect. This observa-
tion is supported by evidence from experimental work
431
that changes in imagery are accompanied by larger affect
shifts than changes in verbal thought (e.g., Holmes,
Mathews, Dalgleish, & Mackintosh, 2006). New memories
are formed of what might have happened; research
suggests that imagining things makes the client feel it is
more likely that they have actually occurred (e.g., Garry,
Manning, Loftus & Sherman, 1996). In Brewin’s (2006)
framework these new memories should potentially have a
retrieval advantage in the presence of cues that previously
triggered the old traumatic memories. Placing the
content of old distressing fragments in the wider context
of previous and subsequent knowledge could have the
effect of decreasing their intrusiveness (Conway &
Pleydell-Pearce, 2000; Ehlers & Clark, 2000).
It may seem strange to alter the previously imagined
outcome when rescripting trauma memories, but modern
learning theory suggests a way in which it may help. This
theory postulates that what is learned first in a totally new
situation forms the basis for a generalized rule, and that
each subsequent experience is likely to be seen as an
exception to the rule, rather than disproving it. Going
back and working on their memories may help a client to
realize that the original experience was so toxic and
atypical that it is better seen as the exception to how life
generally works, rather than as the basis for a general rule.
In this article, we have looked at a number of possible
ways to use imagery rescripting in cases of PTSD. The
outcome trials published so far indicate potential benefits,
but many empirical questions remain to be answered. For
example, we could look at how much reliving (if any) is
required during imagery rescripting, in various diagnostic
groups. We could also study the relative merits of verbal
and imagery rescripting.
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Address correspondence to Dr. Ann Hackmann, Department of
Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3
7JX; e-mail: ann.hackmann@psych.ox.ac.uk.
Received: November 7, 2009
Accepted: June 26, 2010
Available online 31 January 2011