How to defeat dementors (aka Is imagery rescripting magic?)
The authors of this study entitled their article “Is it magic”? Is this self-congratulatory hype? Or are we asleep at the wheel leaving a powerful approach to working with depression in the shed while trotting out less experientially intense, more familiar approaches like behavioural activation and cognitive restructuring? Perhaps the promise of psychology training programs finally becoming more like Hogwarts is blinding me to some fatal flaw in their research. Please read on and write and let me know if I’m getting too carried away!
This study comes from China. 41 clients with depression were randomly assigned to 3 weekly 60-90 min sessions of either: 1) cognitive restructuring; or 2) imagery rescripting (ImRS). The imagery rescripting procedure involved clients bringing to mind an image of the event associated with their most distressing recent mental intrusion. They gave a narrative description rich in sensory detail and the thoughts and meanings that went with it. They were then asked what needed to happen for them to be less distressed by the event and were then guided to visualize an outcome of the event that provided safety or comfort. Cognitive restructuring involved clients being taught to identify automatic thoughts and beliefs, examine evidence for and against them, identify cognitive errors and look at the pros and cons of their beliefs. Therapists used both guided discovery and coaching to facilitate clients completing their thought records.
The results were impressive. There was a time x group interaction effect for depressive symptoms (as measured by the BDI-II), whereby both groups reduced depression symptoms from pre- to post-treatment but only the ImRS group achieved further reductions in depression from post-treatment to 2-month follow-up. To reinforce the significance of this finding, the average pre-treatment BDI-II score for both groups was in the severe range; by post-treatment (and follow-up), the ImRS group mean scores were in the mild range while the mean scores for the cognitive restructuring group were in the moderate range. These are impressive results for 3 sessions!
Interestingly, the authors explored a number of other measures to better understand the potential mechanism of ImRS. A similar pattern of results (as for depression symptoms) was found for rumination, worry and experiential avoidance (AAQ-II) and a measure of intrusive imagery-related frequency, distress and impairment. When looking at associations with improvement adjusting for other measures, only worry was significantly associated with ImRS-associated reduction in depression. This was a novel finding so requires replication but it is intriguing – changing the significance of intrusions reduces worrying, leading to less depression.
To temper getting over-excited, the interventions were both provided by a single clinician. Perhaps the clinician was either particularly good at ImRS or not as good at cognitive restructuring? The authors cited use of only self-report measures although I personally don’t see this as a major limitation as most research shows that clinician or assessor-rated instruments are more responsive than self-report measures. The finding of worry as mechanism needs to be replicated and studied in the context of other possible measures. Importantly, participants in this study were recruited according to having experienced an intrusive negative event in the prior 2 weeks. It is unclear whether results would apply to individuals selected for diagnosis alone. As is fairly common, people with psychosis, organic brain disease, substance use disorders and at high risk of self-harm or suicide were excluded. Finally, the diagnostic status of participants was determined for some participants by clinical records and for others by structured interviews. Although it’s not clear whether this may have contributed to the pattern of results, a consistent assessment procedure is warranted to increase confidence in the results.
OK, but how amazing is that? I doubt I have overseen the reduction from severe to mild depression in 3 sessions by many clients in my career (that wasn’t attributable to some major external life event). Despite Arnold Lazarus’s early exhortations to routinely assess imagery and Wheatley's (e.g., Brewin et al., 2009) impressive results using ImRS for depression, ImRS is likely to be heavily underutilized in presentations of depression. Given that several comorbidities have also shown positive results with ImRS including PTSD, BDD, OCD, psychosis and personality disorders, it seems like a promising line of attack early in treatment, even for severe clients for whom repetitive distressing intrusive images constitute part of their symptom cluster.
Clinician implications
Ask your clients whether they experience frequent, intrusive, distressing images. If they do, consider imagery rescripting as an early intervention.
3 sessions of imagery rescripting should be enough to tell whether the procedure will help reduce depressive symptoms
For the original article, go to:
https://www.sciencedirect.com/science/article/pii/S0005791621000860
REFERENCES
Brewin, C., Wheatley, I., Patel, T., Fearon, P., Hackmann, A., Wells, A., Fisher, P. and Myers, S. (2009) Imagery rescripting as a brief stand-alone treatment for depressed patients with intrusive memories. Behaviour Research and Therapy, 47 (7). pp. 569-576.
Ma, O.Y.T., & Lo, B.C.Y. (2022). An exploratory randomized controlled trial comparing imagery rescripting and cognitive restructuring in the treatment of depression. Journal of Behavior Therapy and Experimental Psychiatry, 75. https://doi.org/10.1016/j.jbtep.2021.101721