The role of imagery-based techniques in cognitive–behavioural therapy for adults with eating disorders

Clinical Psychology Review 31 (2011) 1101–1109

Contents lists available at ScienceDirect

Clinical Psychology Review

The role of imagery-based techniques in cognitive–behavioural therapy for adults with eating disorders Madeleine Tatham ⁎ Vincent Square Eating Disorders Service, Central and North West London NHS Foundation Trust, London, UK University of Hertfordshire, Hatfield, Hertfordshire, UK

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Article history: Received 2 March 2011 Received in revised form 17 June 2011 Accepted 25 June 2011 Available online 19 July 2011 Keywords: Cognitive–behavioural therapy Eating disorders Core beliefs Imagery rescripting

a b s t r a c t Disorder-specific and transdiagnostic cognitive–behavioural models and treatments primarily target surfacelevel maintaining factors in order to effect symptom change. Despite this approach resulting in the most effective evidence-based approach for most eating disordered patients, a significant proportion of sufferers fail to benefit from such treatments. This conclusion suggests that deeper-level causal factors might also need to be addressed in some cases. Theoretical and empirical findings are considered in terms of the clinical applicability of imagerybased techniques and their ability to enhance cognitive–behavioural treatment of the eating disorders. Imagery techniques (particularly, but not only, imagery rescripting) are proposed as a means to enhance current treatments and improve existing outcomes. Potential treatment targets include core beliefs, emotional regulation difficulties and body image disturbance. The existing literature is limited but early indications suggest that imagery rescripting is effective in modifying core beliefs in this population, and that other imagery-based methods are potentially beneficial. Areas for further clinical application and investigation are identified. © 2011 Elsevier Ltd. All rights reserved.

Contents 1. 2. 3.

The current status of cognitive–behavioural models and treatment of the eating disorders . . . . . Gaps in cognitive–behavioural models of the eating disorders: a role for imagery-based techniques? Recent developments in the role and use of imagery in CBT . . . . . . . . . . . . . . . . . . . 3.1. Imagery and emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Negative self-imagery in axis I disorders . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Imagery, autobiographical memory and negative self-beliefs . . . . . . . . . . . . . . . . 3.4. Imagery in the eating disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Use of imagery as a treatment tool: imagery rescripting . . . . . . . . . . . . . . . . . . . . . 4.1. Proposed mechanisms of change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Outcomes from imagery rescripting . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. The use of imagery rescripting in the treatment of the eating disorders . . . . . . . . . . . . . . 5.1. Existing evidence supporting the use of imagery rescripting with the eating disorders . . . 5.2. The case for incorporating imagery techniques into CBT for the eating disorders . . . . . . 5.3. Research directions with imagery-based techniques in the eating disorders . . . . . . . . 5.3.1. Eating disorder ‘mindsets’/personality modes . . . . . . . . . . . . . . . . . . 5.3.2. Affect regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.3. Accessing emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.4. Image manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

⁎ Norfolk Community Eating Disorders Service, 13-15 Cathedral Street, Norwich NR1 1LU, UK. Tel.: + 44 300 300 0142. E-mail address: [email protected]. 0272-7358/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2011.06.008

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Cognitive–behavioural theory and research has taken a leading role in developing empirically supported disorder-specific models and treatments for the eating disorders. Such disorder-specific cognitive– behavioural treatments typically target ‘here and now’ maintaining processes, such as negative automatic thoughts, cognitive biases, and physiological and behavioural responses. Whilst cognitive–behavioural therapy (CBT) is undoubtedly effective for many people with eating disorders (Fairburn et al., 1995), it can be argued that the primary focus on current maintaining factors is inadequate for a significant proportion of such cases where deeper level beliefs have been shown to play a role (Leung, Thomas, & Waller, 2000). Within the wider field of CBT, advances have been made in addressing deeper beliefs through the use of imagery techniques. Initially developed to treat post traumatic stress disorder (PTSD; Foa & Kozak, 1986), those techniques have more recently been applied to a range of axis I disorders, including social phobia (e.g., Wild, Hackmann, & Clark, 2008) and depression (e.g., Wheatley et al., 2007), and axis 2 personality disorders (e.g., Giesen-Bloo et al., 2006). Preliminary results suggest that imagery is a more powerful tool than conventional verbal techniques for accessing and modifying beliefs at a deeper level. Consequently, it can be suggested that imagery rescripting might be incorporated into disorder-specific evidencebased treatments in order to enhance outcomes. Imagery has received little attention in the conceptualization or treatment of the eating disorders. Rather, models continue to stress the role of ‘here and now’ cognitions, behaviours, emotions and physiological states (e.g., Fairburn, 1997). Whilst those models have been recently extended to include consideration of the role of a wider range of beliefs and emotional states (e.g., Fairburn, Cooper, & Shafran, 2003), there remains a subgroup of eating disorder patients who remain resistant to this leading evidence-based approach (Fairburn & Dalle Grave, 2008). It has been suggested that such cases might be better addressed through the use of methods that address deeper level cognitions such as schema-level beliefs (e.g., Waller, Kennerley, & Ohanian, 2007) and metacognitive processes (e.g., Cooper, Todd, & Wells, 2009). This review examines the evidence as to whether imagery techniques – particularly imagery rescripting – might be useful in enhancing the effectiveness of CBT for the eating disorders. The key clinical question is whether imagery techniques are effective in targeting the core beliefs in this population that can hinder progress in treatment (e.g., Leung et al., 2000). 1. The current status of cognitive–behavioural models and treatment of the eating disorders Historically, there have been separate cognitive–behavioural conceptualizations of anorexia nervosa (Fairburn, Shafran, & Cooper, 1999) and bulimia nervosa (Fairburn, 1985), reflecting the diagnostic distinction between the two disorders. Whilst some of the cognitive aspects of the two models were similar (i.e. self-worth primarily evaluated in terms of weight, shape, eating and its control), treatment targets differed. For example, CBT for bulimia nervosa incorporated specific behavioural interventions for binge eating and compensatory behaviours, compared to an emphasis upon the use of cognitive strategies to address the need for self-control in CBT for anorexia nervosa. However, this disorder-specific approach has more recently been overtaken by a transdiagnostic formulation, which stresses the common maintaining features in the pathology and treatment of anorexic and bulimic disorders (Fairburn et al., 2003, 2008). Common factors include weight and shape concerns (as a way of maintaining self-esteem), strict dietary rules (serving to prevent feared weight gain), irregular or restricted eating behaviour (leading to starvation, semi-starvation and/or binge-eating), and the use of compensatory and non-compensatory weight control behaviours. Fairburn (2008) argues that: “the psychopathology of eating disorders may be likened

to a house of cards. If one wants to bring down the house, the key structural cards need to be identified and removed and then the house will fall down.” (p. 47). Consequently, treatments for the eating disorders are based on targeting these key maintaining mechanisms, using methods such as: regular eating (to reduce starvation effects and physiological triggers to overeating); modification of strict dietary rules (leading to reduced dietary restraint); and reduction in body checking behaviour (reducing shape concerns). There is evidence that this approach is effective for adults with eating disorders across diagnoses (Fairburn et al., 2009; Fairburn & Dalle Grave, 2008). In addition to the core eating pathology, the transdiagnostic model (Fairburn et al., 2003) has been expanded to address other factors that can maintain the eating disorders — core low self-esteem, interpersonal difficulties, clinical perfectionism and mood intolerance. However, whilst potentially playing a maintaining role, these factors can also be seen as deeper-level cognitive and emotional states that causally underpin the eating pathology. For example, the constructs of ‘core low self-esteem’, ‘clinical perfectionism’ and ‘mood intolerance’ can be seen as similar to Young's (1994) schema-level constructs (e.g., defectiveness/shame; unrelenting standards; emotional inhibition). Addressing these elements among adults with eating disorders adds to the effectiveness of treatment for more complex cases (Fairburn et al., 2009), stressing the importance of addressing deeper-level representations in some individuals with eating disorders. However, whilst both the core and the extended versions of CBT for the eating disorders have evidence to support their utility and their underlying models, there remain a substantial number of adult eating-disordered patients (49%) who do not fully benefit from CBT in its current incarnation (Fairburn et al., 2009; Fairburn & Dalle Grave, 2008). In the absence of superior therapeutic alternatives (National Institute for Clinical Excellence, 2004), it is important to consider novel approaches that might more effectively address the core beliefs and metacognitive processes that appear to underpin development of the eating disorders (Waller, 2009; Waller, Cordery, et al., 2007). 2. Gaps in cognitive–behavioural models of the eating disorders: a role for imagery-based techniques? Cognitive–behavioural models of the eating disorders have generated substantial evidence regarding the role of negative automatic thoughts and dysfunctional assumptions in maintaining the core pathology (e.g., Hinrichsen, Morrison, Waller, & Schmidt, 2007; Vitousek & Hollon, 1984). However, there is also evidence of a role for schema-level core beliefs in the aetiology of eating disorders, including defectiveness, worthlessness, failure to achieve and abandonment (Cooper, 2009a; Cooper, Cohen-Tovee, Todd, Wells, & Tovee, 1997; Cooper & Hunt, 1998; Cooper, Todd, & Wells, 1998; Cooper & Turner, 2000; Leung, Waller, & Thomas, 1999; Somerville & Cooper, 2007; Waller, 2003; Waller, Ohanian, Meyer, & Osman, 2000). In line with theoretical predictions, associations have been found between negative core beliefs and self-reported early environmental experiences (e.g., Brewerton, 2007; Cooper et al., 1998; Leung et al., 2000; Somerville, Cooper, & Hackmann, 2007). Using Fairburn's analogy, core beliefs might therefore also function as a “key structural card” in the pathology of some individuals with eating disorders. As such, additional strategies would seem to be required to target these beliefs over and above the eating disorderspecific cognitions. However, there has been little empirical investigation regarding the role and impact of core beliefs on treatment outcomes for the eating disorders. The only such study (Leung et al., 2000) found that higher levels of defectiveness/shame, social isolation and social undesirability beliefs predicted a poorer outcome following group CBT for bulimia nervosa, thus supporting the premise that core beliefs need also to be addressed in some cases. There are three domains where imagery-based techniques are potentially valuable

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additional techniques in the treatment of the eating disorders — schema-level cognitions (core beliefs), emotions and body image. Recent CBT models and approaches have indeed begun to address the role of core beliefs in maintaining the eating disorders, particularly if they present in the form of low self-esteem and perfectionism (e.g., Fairburn, 2008). However, such approaches advocate the use of existing CBT techniques (e.g., Fennell, 1997, 2006), which elsewhere, have been criticised as failing to account for or address the full nature of such problems (e.g., Cockerham, Stopa, Bell, & Gregg, 2009; Luke & Stopa, 2009). Indeed, the intensity of affect (e.g., shame) associated with the content of these core beliefs (e.g., defectiveness) has historically proven challenging for traditional CBT approaches (Arntz & Weertman, 1999; Rector, Bagby, Segal, Joffe, & Levitt, 2000). Somerville and Cooper (2007) argue that this is because negative core beliefs have stronger emotional than rational bases, thereby making them potentially more resistant to traditional CBT methods, such as cognitive restructuring. They propose the use of more emotion-focused techniques, such as compassion-focused imagery (Gilbert & Irons, 2005) as a more potent intervention. CBT models have also begun to stress the importance of understanding emotional regulation difficulties in maintaining the eating disorders, with eating and compensatory behaviours serving the function of reducing awareness of intolerable emotional states (e.g., Heatherton & Baumeister, 1991; Hinrichsen et al., 2007; Meyer, Waller, & Waters, 1998; Root & Fallon, 1989). This has led to a greater capacity of eating disorder CBT models to account for frequently occurring comorbid emotional states, such as anxiety, alexithymia and borderline personality disorder (e.g., Christie, Watkins, & Lask, 2000; Corstorphine, 2006; Fichter, Quadflieg, & Reif, 1994) and inclusion of techniques aimed to equip patients with the skills to manage their emotions more effectively. However, these emotional states have also been associated with core beliefs (e.g., Hinrichsen et al., 2007; Leung et al., 2000; Luck, Waller, Meyer, Ussher, & Lacey, 2005; Waller et al., 2000) with the suggestion that they might also benefit from treatment methods that are directed at the underlying core beliefs. As stated earlier, imagery rescripting has been cited as an additional and potentially potent method for addressing this level of emotion and cognition (Cooper, 2009a; Ohanian, 2002). The final domain where imagery-based techniques might play a role in enhancing existing cognitive–behavioural approaches is in the treatment of disturbed body image. Poor body image at the end of treatment for the eating disorders is a predictor of relapse (Keel, Dorer, Franko, Jackson, & Herzog, 2005), and therefore is a problem that needs particular attention. Body image is widely accepted as being a multifaceted, multi-sensory, and dynamic phenomenon (e.g., Kearney-Cooke, 1989). Indeed, one study exploring the experience of ‘feeling fat’ in a small anorexic population highlighted a combination of negative self-beliefs, negative emotion, a range of internal and external bodily sensations and auditory, olfactory and visual imagery (Cooper, Deepak, Grocutt, & Bailey, 2007). At present, in vivo exposure has been shown to be an effective element in the treatment of body image (e.g., Cash, 1995; Rosen, 1997; Rosen, Salzburg, & Srebnik, 1989), with suggestions that mindfulness-based methods might be effective in supplementing the treatment of body image (e.g., Stewart, 2004; Wilson, 2004). However, the interaction of core beliefs, visual, and other sensory modality experiences would suggest that imagery techniques might also be effective in targeting this aspect of eating disorder pathology. To summarise, there are suggestions that imagery rescripting might be relevant in addressing three elements of the eating disorders that have proven difficult to treat using traditional CBT for the eating disorders — core beliefs, emotional dysfunction and body image. It is noteworthy that all three of these phenomena have been associated with a history of traumatic experiences (Brewerton, 2007; Pitts & Waller, 1993; Waller, Hamilton, Rose, Sumra, & Baldwin, 1993). This link is in keeping with the development of imagery-based methods,

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which have a strong root in the treatment of post-traumatic psychopathology (e.g., Smucker & Niederee, 1995). The following section considers the potential role of imagery techniques to address the difficulties outlined above, including the role of negative imagery in maintaining psychological disorders and the use of imagery in modifying core beliefs. Preliminary findings within the wider CBT literature will be briefly reviewed before considering its application in the treatment of eating disorders. 3. Recent developments in the role and use of imagery in CBT Despite a long history within the psychotherapy field, there has only recently been substantial empirical investigation of the mechanisms and theoretical assumptions underlying the use of imagery as a therapeutic tool. Stopa (2009a) defines an image as “a mental representation that occurs without the need for external sensory input” (p. 1), which can be either deliberately self-generated or involuntary. Such mental representations take many different forms, including images of real objects or people (including the self) and of events (real or fantasy), either in the present or in an imagined future (Holmes & Hackmann, 2004). Thus, images might or might not reflect a historical event (i.e. might or might not be a memory), and might or might not be based on reality. Whilst such images are commonly visual representations, they are also often in other sensory modalities, including auditory, olfactory, cutaneous, kinaesthetic and tactile modalities (Kosslyn, Ganis, & Thompson, 2001). 3.1. Imagery and emotion Recent experimental studies have demonstrated the link between imagery and emotion, with imagery having a more powerful impact on emotion than thoughts and words (Holmes, Mathews, Mackintosh, & Dalgleish, 2008), and acting as an “emotional amplifier” for both positive and negative mood states (e.g., Holmes & Mathews, 2005; Holmes, Mathews, et al., 2008). Evolutionary theories suggest that the primacy of emotional systems over language systems makes the individual more responsive to sensory-perceptual stimuli than verbal stimuli (Holmes & Mathews, 2005). Cognitive neuroscience findings also indicate that “mental imagery draws on much of the same neural machinery as perception in the same modality and can engage mechanisms used in memory, emotion and motor control” (Kosslyn et al., 2001, p. 639). Working in imagery therefore is “like having a concrete experience” (Epstein, 1994), accessing physiological, emotional and behavioural responses similar to those activated in real scenarios (Holmes, Coughtrey, & Connor, 2008). 3.2. Negative self-imagery in axis I disorders Intrusive imagery has long been recognised as a key maintaining feature and focus of interest in certain anxiety disorders (e.g., PTSD). However, recent investigations have found that spontaneous intrusive negative imagery occurs across a range of psychological disorders including social phobia (Hackmann, Surawy, & Clark, 1998), health anxiety (Wells & Hackmann, 1993), agoraphobia (Day, Holmes, & Hackmann, 2004), obsessive compulsive disorder (Ottaviani & Beck, 1987), body dysmorphic disorder (Osman, Cooper, Hackmann, & Veale, 2004), and bulimia nervosa (Somerville et al., 2007). Clinical populations report significantly higher levels of negative imagery than control groups (except body dysmorphic disorder; Osman et al., 2004) with imagery rated as particularly likely to be recurrent, intrusive and distressing. Negative images tend to involve the self (Hackmann, Clark, & McManus, 2000), the content and nature of which tends to be disorder-specific in reflecting the way the self is represented (e.g., self seen as visibly anxious in social phobia; Hackmann et al., 1998). This specificity has led to the suggestion that “imagery and the processes

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interacting to create the experience of the self could represent both transdiagnostic and disorder-specific processes” (Stopa, 2009a, p. 7). Experimental studies have demonstrated that negative self-imagery can play an important role in maintaining psychological disorders (e.g., social phobia: Hirsch, Clark, Mathews, & Williams, 2003; depression: Newby & Moulds, 2010). Several pathways have been suggested through which this might occur. For example, in social phobia, self-images are commonly inaccurate or distorted past impressions of the self that are believed to be true (Wild et al., 2008). Associated increases in negative affect (i.e., increased anxiety) serve to promote the use of safety behaviours, thus impacting upon actual social performance and observer ratings of competence (Hirsch et al., 2003). Negative self-imagery also “hijacks attention” preventing access to potentially disconfirmatory information (Holmes, Arntz, & Smucker, 2007). In this way, it has been argued that the role of negative imagery may be akin to that of automatic thoughts, therefore making it a viable target for treatment in itself (Holmes, Lang, & Deeprose, 2009). 3.3. Imagery, autobiographical memory and negative self-beliefs In addition to its role in maintaining symptoms, negative imagery also reflects a means of carrying information and emotion about the self (Holmes & Hackmann, 2004). As self-concept is central to emotional disorders (Beck, 1995), negative self-images are likely to be particularly emotionally potent since they are “a direct threat to the integrity of the self” (Stopa, 2009b). Indeed, there is a: “triadic relationship between imagery, autobiographical memory and self… (and) the autobiographical memory base is the bedrock of the individual's identity and provokes a sense of stability and continuity” (Stopa, 2009a, p. 5). Numerous factors are involved in the formation and recall of autobiographical memories including: the positive or negative nature of an event; its typicality and relevance to current self-functioning (i.e., “self-defining memories”; Singer & Salovey, 1993); and frequency of rehearsal (Ritchie et al., 2006). Models of autobiographical memory propose that these types of memories are stored in the form of images with their associated emotional states (Conway & Pleydell-Pearce, 2000). As such, “images may thus be particularly effective cues for reactivating related episodes in memory, together with their prior associated emotion” (Holmes, Mathews, et al., 2008, p. 396). Indeed, Hackmann et al. (2000) found significant similarity between the sensory sensations experienced during negative imagery and the original memory.

tive, perhaps reflecting disorder-specific fears regarding negative appraisal by others (Osman et al., 2004). Both groups reported images as recurrent and related to the self, with specific reference to body size and shape: “I can see rolls of fat around the back. Flesh spilling out over my underwear. I hear myself saying “you are so disgusting”” (Somerville et al., 2007, p. 440). As with other axis 1 disorders, the link between self-imagery and bulimic symptomatology suggests the potential importance of identifying and investigating the content, idiosyncratic meaning and personal significance of intrusive imagery and its subsequent impact upon behaviour (Hackmann, 2009). For example, there might be a relationship between the content, frequency or inaccuracy of negative self-imagery and the degree of preoccupation, distress and overevaluation of weight and shape. Furthermore, negative imagery and its role in triggering eating symptomatology might not be limited to images of the self. Activation of other imagery (e.g., relating to the family) has also been found to increase urges to binge-eat (Villejo, Humphrey, & Kirschenbaum, 1997). Whilst no research specifically investigating imagery in anorexia nervosa has been undertaken, the common nature of the different levels of cognitions and body image issues across the eating disorders (e.g., Cooper, Deepak, et al., 2007; Fairburn et al., 2003) make it likely that imagery will have a similar role in anorexia nervosa sufferers. A significant proportion of clinical subjects with axis 1 disorders who report negative imagery relate it to memories of events occurring around the onset of the disorder (e.g., Osman et al., 2004; Wild et al., 2008). The same is true of the studies investigating imagery in bulimia nervosa. Somerville et al. (2007) found that two thirds of patients linked their images to early memories of negative comments about weight and shape, whilst Hinrichsen et al. (2007) showed that over a third described a link between images and childhood memories such as humiliation, abuse and abandonment. Such findings across disorders have been taken to suggest a role of early adverse events in the formation of “encapsulated” self-beliefs and recurrent “selfdefining memories” in the subsequent development of axis I pathology (Hackmann et al., 2000). Indeed, both eating disorder studies report associations between imagery, early memories and core beliefs of worthlessness, insufficient self control, defectiveness, shame and failure (Hinrichsen et al., 2007; Somerville et al., 2007). However, methodological issues preclude clear inferences regarding the causal role of recollected memories or associated imagery in determining subsequent pathology. 4. Use of imagery as a treatment tool: imagery rescripting

3.4. Imagery in the eating disorders Until recently, little interest had been shown in the presence or role of imagery in eating-disordered populations. To date, there have been no specific studies in anorexia nervosa, but two studies have investigated imagery in bulimia nervosa (Hinrichsen et al., 2007; Somerville et al., 2007). Patients were asked to bring to mind the image they experienced the last time they worried about their eating, weight or shape (Somerville et al., 2007) or before inducing vomiting (Hinrichsen et al., 2007). As in axis I disorders, Somerville et al. (2007) found higher levels of spontaneous imagery among patients (85%) than among dieting (56%) and non-dieting (50%) controls. Similarly, Hinrichsen et al. (2007) found that 57% of patients reported spontaneous imagery prior to vomiting. Those images were rated as more negative and distressing in content, as more vivid (involving more sensory modalities), and as being associated with significant feelings of anxiety and shame (Hinrichsen et al., 2007). As with social phobia and body dysmorphic disorder patients, bulimia nervosa sufferers reported self-imagery from an observer (vs. field) perspec-

As images derive their potency from the triadic relationship between self-imagery, memory and underlying core beliefs, they potentially function as a useful clinical tool in directly accessing and targeting representations at the core belief level. Techniques can involve working directly and indirectly with the image and/or addressing intrusive negative imagery to promote positive imagery (see Holmes et al., 2007). Imagery rescripting is a technique developed to modify the meanings ascribed to early events and the implications they continue to hold for the present (Holmes & Hackmann, 2004). Originally developed as a treatment approach for PTSD symptoms following childhood sexual abuse (e.g., Smucker, Dancu, Foa, & Niederee, 1995; Smucker & Niederee, 1995), it has since been extended to address a range of the “pathogenic early developed schemas” that underpin axis II pathologies (Arntz & Weertman, 1999; Giesen-Bloo et al., 2006) and to target core beliefs in axis I disorders. Such imagery-based approaches involve a combination of verbal restructuring (exploring alternative meanings), imaginal exposure (deliberately evoking the intrusive memory) and imagery

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rescripting (transforming the memory using imagery to challenge or modify the meaning and/or course of the event). This diverse set of tasks differentiates imagery rescripting from simple exposure-based techniques, which do not include restructuring meaning or achieving attributional shift (Edwards, 2007). Imagery rescripting varies somewhat between authors (e.g., Layden, Newman, Freeman, & Morse, 1993; Smucker & Niederee, 1995), with differences in foci (e.g., memories, fantasies, beliefs) and endings (e.g., transforming pre-existing memories into more benign memories; generating a new positive image to capture positive meanings to counterbalance the old negative ones) (Holmes et al., 2007). Stopa has argued that this variation is a positive asset: “a great strength of imagery is its plasticity: people can imagine different outcomes for their fears, rehearse behavioural sequences, transform ordinary and painful memories and create images that represent desired and feared parts of their selves” (Stopa, 2009a, p. 2). However, Arntz and Weertman's (1999) procedure is probably the most well developed, involving three phases: 1. Re-experiencing a memory in the present from the perspective of the age at which it occurred (e.g., as a child), in order to evoke associated sensory and affective experiences and to explore the meaning of an event. 2. Re-experiencing the same memory from the perspective of an adult, observing their younger self and intervening if necessary. 3. Re-experiencing the memory from the child's perspective, with the adult self intervening in a way that resolves the situation in a satisfactory way and that allows the identification and/or expression of needs that were previously unacknowledged or unmet. 4.1. Proposed mechanisms of change Explanations of the mechanisms underlying imagery rescripting draw upon multi-level information processing and memory models (e.g., dual representation theory — Brewin, Dalgliesh, & Joseph, 1996; interacting cognitive subsystems theory — Teasdale & Barnard, 1993; self-regulatory executive function model — Wells & Matthews, 1996). These models all delineate independent processing and memory systems for thoughts and images. It has been demonstrated that those systems can be independently manipulated (e.g., Hagenaars, Brewin, Minnen, Holmes, & Hoogduin, 2010; Holmes, Brewin, & Hennessy, 2004). For example, the interacting cognitive subsystems theory (Teasdale & Barnard, 1993) distinguishes types of knowledge involving propositional (explicit, “knowing” meaning) and implicational (implicit, “feeling” meaning) subsystems. Implicational coding is proposed to be directly linked to emotion, and shift in meaning is thought to occur when information is transferred from the propositional meaning system to the implicational meaning system (i.e., between “knowing” and “feeling”). It is proposed that imagery rescripting activates implicational meaning representations via the repeated evocation of the traumatic/ negative memory and associated emotion, using as many sensory channels as possible (Wild et al., 2008). The introduction of new information (i.e., rescripting of meaning and/or inviting a compassionate perspective) within the implicational system is thought to result in the re-appraisal of the original event and the development of more adaptive beliefs about the meaning of the event for the self and others. Whilst preliminary findings from animal behavioural studies provide some evidence to indicate that new information provided during reconsolidation could affect old memories when modifying them (Quirk & Milad, 2009; Schiller et al., 2009), theoretical assumptions regarding the shift from propositional to implicational subsystems have yet to be validated in humans (Stopa, 2009a).

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4.2. Outcomes from imagery rescripting Whilst the proposed mechanisms underlying imagery techniques are yet to be empirically validated, studies have been undertaken to investigate the clinical effect of imagery rescripting on core beliefs and symptomatology in a range of axis I and axis II disorders. Early case studies investigating the effectiveness of imagery rescripting reported positive improvements in modifying traumabased beliefs and decreasing PTSD symptoms in childhood sexual abuse (Smucker & Niederee, 1995) and borderline personality disorder (Giesen-Bloo et al., 2006). Later studies comparing traditional CBT disorder-specific evidence based treatments with those additionally enhanced with imagery rescripting reported greater symptomatic improvements across a range of axis I disorders, including depression (Wheatley et al., 2007), phobia (Hunt & Fenton, 2007), and social phobia (Clark et al., 2006). However, results were more mixed for PTSD. Imagery rescripting was found to be beneficial in cases of industrial accidents (Grunert, Weis, Smucker, & Christianson, 2007) but variable when combined with imaginal exposure (Arntz, Tiesema, & Kindt, 2007), suggesting it might be more appropriate for shame-based emotions as opposed to fear-based emotions in PTSD. Although such evidence supports use of imagery rescripting in clinical settings, methodological issues have largely prevented evaluation of the specific contribution of this therapy element. More recently, however, imagery rescripting has undergone more stringent analysis as a stand-alone intervention in the treatment of social phobia (Wild et al., 2008), depression (Brewin et al., 2009) and depressive symptomatology in cancer (Whitaker, Brewin, & Watson, 2010). For example, Wild et al. (2008) investigated the effects of a single session of imagery rescripting (e.g., Arntz & Weertman, 1999; Hackmann et al., 2000) of a trauma memory on negative self-belief ratings, imagery properties and axis I symptomatology in a small sample of socially phobic patients. In the control condition, memories were accessed and explored but no attempt was made to change their meaning. The imagery rescripting condition resulted in reductions in negative self-belief ratings, image and memory distress, image vividness, and axis I symptomatology. Further reductions were reported at 1-week follow-up, although no change in frequency had occurred, suggesting that it is the meaning associated with selfimagery that underlies distress, as opposed to the image per se (Wild et al., 2008). There was no impact in the control condition, suggesting that exposure alone was not effective in the same way as rescripting. Brewin et al. (2009) investigated the impact of a longer (eight session) stand-alone imagery rescripting treatment, targeting intrusive negative imagery in depression. They reported reductions in both negative belief ratings and depressive symptomatology (e.g., rumination). However in this study, intrusive imagery was targeted without verbal challenging, suggesting that verbal restructuring may not in fact be required in imagery rescripting. Similar reductions in the frequency of intrusive imagery, negative belief ratings and depression have been reported in a single-case design study assessing the impact of a seven-session stand alone imagery rescripting intervention for depressive symptomatology in a cancer patient (Whitaker et al., 2010). This impact was maintained at the six-month follow-up. These preliminary findings indicate that imagery rescripting is effective in targeting intrusive memories and associated negative selfbeliefs in axis I disorders, suggesting scope to enhance existing CBT treatments across a range of disorders (Wild et al., 2008). However as the literature currently stands, a number of theoretical, empirical and clinical questions remain unanswered: Given the various methodological designs and differences in the use of protocols and procedures within the literature, the active component and causal mechanism underlying imagery rescripting remain unclear. Repeated evocation of memory, verbal restructuring, insertion of new information and/or introduction of a compassionate perspective have all been suggested,

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although Brewin et al.'s (2009) study suggests verbal restructuring might not actually be necessary. Further research is clearly required, including rigorous component analyses (Wild et al., 2008). This approach will inevitably present challenges as how to conceptualise imagery rescripting (e.g., “either as a unit or as a collection of procedures each with its own mode of action” — Murphy, Cooper, Hollon, & Fairburn, 2009, p. 5) and how to operationalise procedures (e.g., foci of intervention; what is used as an endpoint to the procedure). The relationship between imagery rescripting and symptom reduction is also unclear. Theoretical assumptions that propose change in meaning underlies symptom reduction (e.g., core belief ratings) remain to be tested fully. For example, imagery rescripting encourages the: “imagined self to have control over the direct outcome of memory”, and thus might simultaneously serve to increase self-efficacy and self-esteem, which might then operate as the mechanism underlying symptom reduction (Stopa, 2009b). Further research also needs to include a broader range of measures of psychological functioning, to assess other possible mechanisms involved. 5. The use of imagery rescripting in the treatment of the eating disorders The literature outlined above suggests that imagery processes are relevant across diagnoses and that they have some disorder-specific characteristics. As a considerable proportion of patients with eating disorders have significant levels of negative core beliefs and/or report intrusive negative imagery linked to memories of adverse early experiences, it has been hypothesised that imagery rescripting might be relevant when working with the eating disorders. If that hypothesis is supported, with comparable effects to those found with other axis I disorders, then imagery rescripting might be a valuable addition to the cognitive–behavioural approach as applied to the eating disorders. As argued previously, its use may be particularly pertinent where the individual experiences marked levels of negative core beliefs, emotional distress and body image disturbance. 5.1. Existing evidence supporting the use of imagery rescripting with the eating disorders Two studies have addressed this possibility. Ohanian (2002) reported the effects of a single session of imagery rescripting on bulimic behaviours following eight sessions of conventional CBT for bulimia nervosa (Fairburn, 1995). Using the protocol outlined by Smucker and Niederee (1995), imagery rescripting was used to address an early memory and modify a core belief of defectiveness/incompetence that had remained unaddressed using standard CBT techniques. Whilst eight sessions of CBT had resulted in 50% reduction in binge–vomit frequency, a further 75% reduction in remaining binge–vomit behaviour was reported following the single imagery rescripting session, with complete abstinence 2 months later. This case study suggests the effectiveness of imagery rescripting in bringing about rapid change in bulimic behaviours compared to standard disorder-specific techniques (e.g., Hinrichsen et al., 2007). However, the study had significant limitations (e.g., being a single case; failure to measure the target core belief explicitly; not measuring other bulimic symptomatologies, including weight/shape concerns), reducing the conclusions that can be reached regarding the proposed underlying mechanism of change. Building on this foundation, Cooper, Todd, and Turner (2007) conducted a study of a small sample of patients with bulimia nervosa, assessing the impact of a single session of imagery rescripting on core beliefs. They used the protocol outlined by Layden et al. (1993), rating rational and emotional negative core beliefs (as measured by the Eating Disorder Belief Questionnaire — Cooper et al., 1997). The effects of imagery rescripting were compared with the impact of verbal

discussion of a distressing image and associated memory. Whilst both groups reported reductions in rationally held belief ratings, the single session of imagery rescripting resulted in significantly greater reductions in emotionally held belief ratings, negative mood and urges to binge-eat. Whilst this method and experimental design need further investigation to demonstrate the exact mechanism of change, the authors (Cooper, 2009b) have since developed a protocol designed to be embedded within evidence-based CBT, for use in cases of the eating disorders where emotional beliefs persist despite the use of traditional CBT techniques. 5.2. The case for incorporating imagery techniques into CBT for the eating disorders Holmes et al. (2009) argue that it is important to target the most ‘toxic’ cognitions in order to achieve the best treatment results in CBT. It has been argued here that current leading CBT treatments for the eating disorders do not directly incorporate specific techniques to address the deeper level ‘toxic’ cognitions that have been shown to be held by a significant subgroup of the ED population. Preliminary studies suggest that imagery rescripting is applicable and effective in targeting the core beliefs that appear to contribute to treatment failure in standard CBT for the eating disorders (e.g., Leung et al., 2000), with consequent effects for issues such as emotional dysregulation and body image disturbance. Given the link of such core beliefs with emotion and their potential role in maintaining symptomatology, imagery-based techniques might also usefully be employed to enhance work at the level of the maintenance cycle that is addressed using existing evidence-based CBT techniques. This approach might be particularly useful in targeting residual eating disorder symptomatology (e.g., emotionally triggered binge-eating, self-induced vomiting) once standard CBT has had its initial impact. Fig. 1 illustrates how these different levels of representation might be associated with different intervention strategies, with imagery rescripting used predominantly with the ‘toxic’ schema level cognitions, but other imagery techniques used with the more specific eating-disorder features (e.g., negative body image). 5.3. Research directions with imagery-based techniques in the eating disorders Existing research into the use of imagery techniques in eating disorder populations is limited and largely confined to imagery rescripting. Furthermore, that small research base is compromised by methodological shortcomings (e.g., small samples, reliance on selfreport), and is confined to patients with bulimia nervosa. Little is known about the role of imagery rescripting in anorexia nervosa and atypical cases, although a transdiagnostic approach (e.g., Fairburn et al., 2003) would suggest that the findings are likely to be comparable across eating disorder diagnoses. The key issues for further research into the use of imagery rescripting in the treatment of the eating disorders are similar to those that apply in other disorders, and future research would benefit from following the advances that have been made in those fields of psychological distress. For example, for whom and when might imagery be most effective? What clinical factors might impact on the utility of this approach (e.g., starvation-based cognitive inflexibility)? Is imagery rescripting effective for negative self-beliefs in the absence of negative imagery or adverse early memories? Finally, given the high incidence of defectiveness and unrelenting standards and core beliefs found in eating-disordered populations, would compassionfocused imagery be more appropriate or effective in targeting selfcriticism and shame (e.g., Gilbert & Irons, 2005; Lee, 2005)? Imagery work is not confined to imagery rescripting, and there are other domains of imagery work that merit investigation in the eating disorders.

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Enhanced CBT - Schema-focused CBT, including imagery rescripting

Early experiences

Schemas/core beliefs

Rules and assumptions

Cognitions

Emotions

Behavior

(e.g., anxiety)

(e.g., avoid food; overeat)

Physiology

(e.g., starvation; low serotonin)

Standard CBT techniques for eating disorders, including other imagery techniques

(e.g., "I will keep gaining weight")

Fig. 1. Illustration of the levels of cognition where imagery rescripting and other imagery-based techniques might be applied.

5.3.1. Eating disorder ‘mindsets’/personality modes Particularly in anorexia nervosa, poor outcomes have been hypothesised to be due to the “ingrained nature of the restrictive thinking pattern”, making such beliefs resistant to traditional CBT techniques (Mountford & Waller, 2006, p. 533). Recent work has employed imagery (directly and indirectly) to facilitate CBT techniques for working with this highly ego-syntonic disorder. For example, Fairburn (2008) uses the analogy of a DVD player to illustrate the metacognitive effects of an eating disorder mindset, which operates to maintain mechanisms and lock the eating disorder in place (Fairburn, 2008). Patients are encouraged to recognise the mindset, identify triggers for when it “slips back into place” and to learn how to “press the eject button” (Fairburn, 2008, p. 120). In a similar vein, Mountford and Waller (2006) have explicitly used imagery techniques to personify the “restrictive anorexic schema mode”, depicting the eating disorder as an element of the self that struggles for control with other personality modes, and illustrating its influence on thoughts, emotions and behaviours. This technique involves collaboratively constructing a visual image of the restrictive mode in a range of domains (i.e., appearance, personality, colour, size, etc.), and using a range of techniques to give a sense of control and distance over the eating disorder personality mode. This approach is designed to facilitate CBT on two levels simultaneously — addressing core beliefs regarding weight and shape, and working in the beliefs and behaviours relating to the anorexic mode's self-maintenance strategies (Mountford & Waller, 2006). The authors report positive symptom improvement in nine out of the ten patients with whom it was used, and this was maintained at six-month follow-up (Mountford & Waller, 2006). In the case where it was not effective,

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the patient had been unable to identify a distinct image. This suggests that the suitability and effectiveness of imagery techniques might be mediated by individual differences in ability to visualise. The authors conclude that this is a technique to increase the efficacy of CBT, rather than a stand-alone therapy, and that it can be used to address other aspects of eating disorder pathology (such as body image disturbance). However, whilst preliminary outcomes are promising, there are no further empirical investigations of this technique to date. 5.3.2. Affect regulation Given the demonstrated link between imagery and emotion, imagery techniques might be used to enhance existing CBT strategies in addressing the inherent emotion regulation difficulties in eatingdisordered populations (e.g., Fairburn et al., 2003). Such techniques include self-soothing, where guided imagery has previously been used with the eating disorders (e.g., Esplen & Garfinkel, 1998; Rabinor & Bilich, 2009). Indeed, in a study comparing guided imagery with CBT, Esplen, Garfinkel, Olmsted, Gallop, and Kennedy (1998) concluded that guided imagery is effective in reducing eating disorder symptoms in bulimia nervosa. Whilst CBT for bulimia nervosa (e.g., Fairburn, Marcus, & Wilson, 1993; Fairburn, Peveler, Jones, Hope, & Doll, 1993) achieved greater symptom reduction, dropout rates were lower in the guided imagery group, suggesting a high level of acceptability for this imagery-based technique. Explanations of the underlying mechanisms could include self-validation of subjective experience and an enhanced therapeutic alliance (Rabinor & Bilich, 2009), but self-soothing is clearly a technique that needs further evidence to demonstrate its uses and limitations. 5.3.3. Accessing emotion The eating disorders in general and starvation in particular are associated with limited ability to access affective states (Christie et al., 2000; Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950). Imagery has the potential to facilitate such access. Whilst no empirical studies have been undertaken to support this possibility, Mountford and Waller (2006) used imagery techniques with this population in tackling the restrictive schema mode and stress the potential of imagery to allow the underweight individual to process emotion safely and to bring it to conscious processing. 5.3.4. Image manipulation Whilst the techniques above have been discussed in relation to their potential to address core beliefs and affective issues, it has been hypothesised that imagery might be valuable in addressing treatment-resistant body image concerns in the eating disorders, and food and weight concerns. There has been little investigation of the role of food and eating imagery in the eating disorders, despite early documentation of food imagery reported by the semi-starved subjects in the Minnesota study (Keys et al., 1950). Given that images have been shown to produce physiological reactions akin to real behaviour (Kosslyn et al., 2001), it could be argued that shape, food and eating imagery are particularly relevant when exploring a patient's experience and beliefs regarding their body image and their food cravings. For example, bringing to mind an image of a desired or forbidden food may precipitate a physiological response (e.g., salivation) which is then interpreted as evidence of a lack of control and/or a sign of an impending loss of control over eating. Other manipulation techniques could be used to change the meaning of such images in order to reduce their potency (e.g., discrimination in relation to size and shape) or used to challenge beliefs about lack of control (e.g., introducing mastery of control over eating imagery). For example, guided imagery of eating favourite foods has been used to provide an imagined experience of eating in a controlled way in order to lessen anxiety about eating feared foods in experiential therapies (e.g., Esplen & Garfinkel, 1998). Techniques include reviewing a binge as though watching a movie, re-playing the

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binge in slow motion, observing emotional response and rewriting the “movie script” to eliminate the binge (e.g., Orbach, 1987; Rabinor & Bilich, 2009). It can also be hypothesised that imagery combined with mindfulness (Wilson, 2004) might be as effective as exposure techniques when addressing body image disturbance in the eating disorders. However, no empirical investigation has yet been undertaken as to the potential use of such techniques within the eatingdisordered population. 6. Conclusions Recent advances in the field of imagery research and practice suggest the potential to embrace increasingly innovative treatments to enhance existing evidence-based CBT approaches and improve outcomes. Preliminary research findings suggest that imagery techniques – specifically imagery rescripting – might be usefully incorporated into leading CBT models and treatments for the eating disorders. As a technique, imagery rescripting enables clinicians directly to address and work with deeply held negative self-beliefs and complex emotions that often interfere with a patient's response to standard CBT. Anecdotal reports suggest that patients also find imagery interventions personally meaningful, and therefore those techniques might also indirectly reduce attrition as well as improve outcomes. Given the demand for evidence-based practice, imagery-based clinical interventions will require greater evidence-generating research, theoretical elucidation and empirical investigation. The currently limited investigation within eating disorder populations suggests it is an area worthy of further attention and scope to consider more creative techniques when working with this patient group. Acknowledgements The author would like to thank Jane Evans for her helpful comments on an earlier draft of this paper. References Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting. Journal of Behaviour Therapy and Experimental Psychiatry, 38, 345–370. Arntz, A., & Weertman, A. (1999). Treatment of childhood memories: Theory and practice. Behaviour Research and Therapy, 37, 715–740. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press. Brewerton, T. D. (2007). Eating disorders, trauma and comorbidity: Focus on PTSD. Eating Disorders, 15, 285–304. Brewin, C., Dalgliesh, T., & Joseph, S. (1996). A dual representation theory of PTSD. Psychology Review, 103, 670–686. Brewin, C., Wheatley, J., Patel, T., Fearon, P., Hackmann, A., Wells, A., et al. (2009). Imagery rescripting as a brief standalone treatment for depressed patients with intrusive memories. Behaviour Research and Therapy, 47, 569–576. Cash, T. E. (1995). What do you see when you look in the mirror? Helping yourself to a positive body image. New York: Bantam Books. Christie, D., Watkins, B., & Lask, B. (2000). Assessment. In R. Bryant-Waugh, & B. Lask (Eds.), Anorexia nervosa and related eating disorders in childhood and adolescence (pp. 105–126). (2nd ed.). Hove: Psychology Press. Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., Grey, N., et al. (2006). Cognitive therapy vs. exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058–1067. Cockerham, E., Stopa, L., Bell, L., & Gregg, A. (2009). Implicit self esteem in bulimia nervosa. Journal of Behaviour Therapy and Experimental Psychiatry, 40, 265–273. Conway, M. A., & Pleydell-Pearce, C. W. (2000). The construction of autobiographical memories in the self-memory system. Psychology Review, 107, 261–288. Cooper, M. (2009a). Imagery and the negative self in eating disorders. In L. Stopa (Ed.), Imagery and the threatened self. Perspectives on mental imagery and the self in cognitive therapy (pp. 181–205). Hove: Routledge. Cooper, M. (2009b). Imagery modification in eating disorders: A three step protocol. Paper presented at the BABCP conference, Exeter, July. Cooper, M., Cohen-Tovee, E., Todd, G., Wells, A., & Tovee, M. (1997). The eating disorder belief questionnaire: Preliminary developments. Behaviour Research and Therapy, 35, 381–388. Cooper, M., Deepak, K., Grocutt, E., & Bailey, E. (2007). The experience of feeling fat in women with anorexia nervosa, dieting and non-dieting women. European Eating Disorders Review, 15, 366–372.

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