Imagery Rescripting for PTSD

The natural instinct is to push these mental pictures away or to try to avoid anything that brings them to mind. Especially if they haunt your dreams and make it difficult to sleep.

However, there are therapies that create long term solutions, including imagery rescripting techniques (also called ImRs). Here, we explore this visualisation therapy for PTSD and C-PTSD and show how it can help manage upsetting images from the past and future. It’s thought to be particularly useful where emotions like anger, shame, or guilt are also felt as a result of your trauma.

What is imagery rescripting?

Image rescripting is a concept that has been around a long time, but there have been various modern interpretations of how it can be used. The person largely accredited with creating the standard application for PTSD and C-PTSD is international trauma specialist Mervin Smucker PhD.

It is a technique that is often used in therapy to deal with upsetting or significant images that occupy our mind, and play a part in keeping our mental health problems going. It helps people to dismantle the emotional context behind thoughts and perceptions that trouble them.

One of the hardest things about PTSD or C-PTSD recovery is controlling involuntary images that come to mind at all times of the day and night. During imagery rescripting, a therapist helps you to explore a memory or thought from your lived experience that you find troubling, including the way it makes you feel. This could mean mentally replaying a previous event or memory from your childhood. However, it could also be a contemporary image that causes you distress or concern, such as a ‘vision’ you regularly see of a danger that’s not yet happened.

Then, you are guided to find a new interpretation that makes it less problematic. In effect, you mentally rescript that aspect of your life, just as you might physically rewrite a description of a memory or future expectation. You would be guided to think about it from new angles. When that image comes into your mind, what do you wish had happened? How could it have a more comforting outcome? If it’s a memory, you could speak to yourself or get someone else involved as you explore it, to work to reduce your feelings of helplessness, distress or fear.

By ‘recrafting’ it in a new way, you can feel greater control and gain a new perspective.

Sometimes, it takes several attempts to find a successful ‘new version’, and defuse the traumatic association and ‘with very severe patients, where the patient is incapable of imagining a good outcome, the therapist rescripts the sequence, whilst the patient imagines this’, but it can be a very powerful therapy.

The aim of Imagery Rescripting

‘Particularly if you are using imagery rescripting to deal with a past memory of a true upsetting or traumatic event, you might be thinking, what’s the point of all this “playing pretend”? That’s not what happened in reality!

Imagery rescripting is not about pretending that a bad thing didn’t happen. It is awful when someone goes through something upsetting and traumatic, and unfortunately the event itself can’t be changed. However, what is also awful is when the memory of the bad thing continues to hurt the person over and over again. This is where imagery rescripting comes in.

The aim of imagery rescripting is to lay the memory to rest, by fully processing the image, rather than avoiding it, and when doing this to start seeing the image from new and different perspectives. Rewriting the image in new and wonderful ways, imagining things occurring that clearly didn’t happen in reality and often are so fanciful that they couldn’t happen in reality, seems to help with bringing new and different perspectives to the image. These new and different perspectives help to change what the image means to you. Changing the meaning of the image and hence the feelings attached to the image, is the main aim of imagery rescripting.

The new picture you come up with during imagery rescripting is in some ways irrelevant. It doesn’t matter how realistic or fanciful the picture is, what matters is what the picture means, what it represents and conveys. Capturing more helpful meaning in the new picture that is created during rescripting, can have a powerful and beneficial impact on how we feel about a past memory, current nightmare or future difficult situation.’

Using Imagery Rescripting instead of avoidance

‘You will notice that with all the different upsetting images that people might be dealing with, the common response is to try to avoid the image, to push it away, to rid of it from our minds. Whilst this is a very understandable reaction, unfortunately avoiding these images usually makes things worse, making us very fearful of the image itself, giving the image power over us, so the image becomes much more than “just an image”.

By working on these images using imagery rescripting, we are no longer avoiding them. Instead we are actively approaching them. That is, we close our eyes and run through the image in our mind, and then rewind the image and rewrite it – rewrite the story, in whatever way we choose. In essence, we are taking charge of the image on our own terms. Now, some rewrites might be somewhat realistic in nature, and others will be pure fantasy. There are no limits to how you can change the image when it comes to Imagery Rescripting. In this way it can be quite an empowering and creative process. You might rewrite the image one way, and decide you aren’t satisfied with that, and so you can just rewind the image and try something else on for size.

Some rescripting will involve simply considering how you would like the image to be different, what you would like to do to the image to make it less threatening or for you to feel safer, or what you are needing in the image and finding ways to rewrite the story to meet that need.

Some rescripting, particularly if it is a past memory of something that happened in your younger years, might involve you entering the image as your now older and compassionate-self, and intervening in whatever way you want to help and support your younger-self. If that is too difficult initially, then your therapist may take the lead with this, and come in to support your younger-self in whatever way is needed to feel safe.’

Advantages and disadvantages for imagery rescripting

Any therapy that focuses on traumatic experiences can be controversial, and it is certainly not the best treatment option for PTSD or C-PTSD if you find this type of activity worsens your symptoms.

However, there is growing evidence that some people find imagery rescripting a valuable tool for coping with everyday life and recovery from PTSD or C-PTSD. That’s because it can also address secondary imagery associated with trauma, as well as the core experience.

For example, if loud noises trigger strong images and feelings of fear, you can work on those images and rescript that contemporary experience to prove to yourself you are in control and safe, rather than reliving the original trauma that led to your PTSD or C-PTSD.

It can be used within cognitive behaviour therapy (CBT). One report suggested that imagery rescripting is particularly helpful for “patients who fail to respond to regular CBT, perhaps especially when earlier aversive (traumatic) events block these patients to profit from techniques focusing on the present.”

Does ImRs work?

Whilst everyone responds to treatment for PTSD or C-PTSD differently, there are many research projects which show ImRs is an effective treatment for both.

One ‘open trial investigated whether ImRs is a helpful treatment when imaginal exposure for accident- related PTSD fails. Twenty-three patients with PTSD as result from industrial accidents participated, all nonresponders to standard imaginal exposure. Eighteen of the 23 patients showed a full recovery from PTSD.’

Another study looked at people who had PTSD/C-PTSD as a result of a childhood trauma. People who showed a substantial decrease in symptoms after a maximum of 12 sessions of Imagery Rescripting were interviewed. One major ‘element of change was mentioned by all but one interviewee—namely, caring for the ‘child’ by the therapist when the therapist rescripts the traumatic event. All except two interviewees mentioned that when the therapist rescripts, speaking up to the perpetrator was important. Both aspects were also important when patients did the rescripting themselves.’ 

One further study looked at ImRs as a stand-alone treatment for PTSD related to childhood physical and/or sexual abuse. Participants (6 women and 2 men) had 16 twice-weekly ImRs sessions. ‘Participants showed improvement in both self-reported and clinician-rated PTSD symptoms. Gains were maintained at 3-month follow-up. At post-treatment, 50% of participants no longer met criteria for PTSD, and this number increased to 75% at 3 month follow-up.‘

Resilience, self-belief and PTSD

Though rescripting is something that can help to reduce the emotional impact of memories, it’s also a therapy option if your recovery is hindered by fears and uncertainties for the future. This includes something called negative self-representation.

For example, a traumatic experience in your past can make you imagine scenarios in which you won’t be able to cope, or someone will badly let you down. Perhaps a simple task or situation gives you a strong ‘vision’ of you being in danger or a loved one facing catastrophe.

Therapists who use imagery rescripting techniques help defuse these unwanted mental pictures.

There are also ways you can self-manage PTSD or C-PTSD symptoms by rescripting an image that you find deeply troubling.

Fundamentally, you paint a new mental picture in which you are in control, calm and coping well with that task or situation, to help you to move forward more confidently. This makes imagery rescripting a useful tool for helping with PTSD or C-PTSD symptoms such as social anxiety and lack of self-belief.

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To take part in Imagery Rescripting Therapy, please speak to your GP, therapist or mental health team.

NICE guidance updated in 2018 recommends the use of trauma focused psychological treatments for Post Traumatic Stress Disorder in adults, specifically the use of Eye Movement Desensitisation Reprocessing (EMDR) and trauma focused cognitive behavioural therapy (CBT).

Please remember, these aren’t meant to be medical recommendations, but they’re tactics that have worked for others and might work for you, too. Be sure to work with a professional to find the best methods for you.