Imagery Rescripting: Exploratory Evaluation of a Short Intervention to Reduce Test Anxiety in University Students

Addressing self-criticism in depression using CBT-based emotion-focused chairwork: study protocol of a randomised controlled trial

INTRODUCTION

Self-criticism is a key feature in people diagnosed with depression, resulting in significant psychological distress. Despite the fact that cognitive-behavioural treatments are readily available, a significant number of patients report experiencing cognitive, but not emotional, change following therapy, resulting in the maintenance of psychological symptoms. Additionally, interventions targeting emotional experiencing, such as chairwork, are generally implemented within large-scale therapeutic treatments. Therefore, within the present study, we aim to evaluate the efficacy and safety of a short intervention using emotion-focused chairwork to target self-criticism in patients diagnosed with depression.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial with two parallel arms. 62 patients diagnosed with depression will be randomised to the intervention group or the waiting-list control group receiving treatment as usual. The intervention comprises of three treatment sessions using the chairwork technique over the course of 3 weeks. Outcome assessments will take place 1 week before the first treatment session, as well as 1 week and 3 months after the last treatment session. The primary outcomes are self-criticism and self-compassion. Secondary outcomes assess depressive symptoms, emotion regulation and overall self-esteem. Statistical analysis will be performed using intention-to-treat analysis, as well as per-protocol analysis implementing linear-mixed models.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the State Chamber of Physicians in Baden-Wuerttemberg, Germany (approval number: F-2023-12). Scientific findings shall be published in peer-reviewed journals to inform prospective clinical studies focusing on the implementation of chairwork within clinical practice.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00031307; https://drks.de/search/de/trial/DRKS00031307).

Imagery rescripting as a short intervention for symptoms associated with mental images in clinical disorders: A systematic review and meta-analysis

There is an unmet need for effective short-term therapeutic techniques to reduce clinical symptoms associated with prospective-, as well as retrospective aversive mental images across mental disorders. We investigated the efficacy of imagery rescripting (IR) as a short-term intervention across clinical disorders, as the literature suggests that this technique could be a promising intervention to reduce psychopathology by altering intrusive mental images. A systematic literature review identified 23 trials including 805 adult patients, out of which 15 trials were designed as randomized controlled trials (RCT) including patients with the following diagnoses: Social anxiety disorder (SAD), Posttraumatic-Stress-Disorder (PTSD), Bulimia Nervosa, Borderline Personality Disorder, Obsessive-Compulsive Disorder, nightmare disorder, test anxiety, health anxiety, and Generalized Anxiety Disorder. Most studies (14) comprised of one treatment session. Effect size estimates indicate that IR is highly effective in reducing clinical symptoms associated with mental images from pre-, to post-treatment (g = 1.09, 95% CI = [0.64; 1.53]), as well as from pre-treatment to follow-up (g = 1.90, 95% CI = [1.02; 2.77]). Comparing the IR intervention to a passive control group showed large effect sizes at post-treatment (g = -0.99; 95% CI = [-1.79; -0.20]), however, comparing IR to an active control group resulted in a small effect (g = -0.05; 95% CI = [-0.43; 0.33]). Lastly, large effects of IR were found for the SAD and PTSD subgroups, for comorbid symptoms of depression. In summary, our results indicate that IR is a promising short-term therapeutic technique for clinical symptoms associated with aversive prospective-, and retrospective mental images.

Harnessing emotional mental imagery to reduce anxiety and depression in young people: an integrative review of progress and promise

Emotional mental imagery is a powerful part of our mental landscape. Given its capacity to depict, process, and generate emotional events, mental imagery could have an important role in psychological therapies. This Series paper explores whether harnessing emotional mental imagery is meaningful to young people; ways in which interventions use emotional mental imagery; contextual and individual factors influencing intervention effectiveness; and mechanisms underpinning imagery techniques. We completed a systematic review of imagery interventions and consulted young people with lived experience (n=10) and leading international experts (n=7). The systematic search identified 86 papers covering a diverse range of imagery interventions. Across the seven categories of techniques reviewed, imagery rescripting for aversive memories, techniques targeting positive imagery, and imagery-enhanced protocols indicated the most potential. The report suggests that harnessing emotional mental imagery in psychological interventions could be a promising approach to reduce anxiety and depression and that mental health science could inform the development of new interventions and help to maximise intervention effectiveness.

Mental Imagery in the Science and Practice of Cognitive Behaviour Therapy: Past, Present, and Future Perspectives

Mental imagery has a long history in the science and practice of cognitive behaviour therapy (CBT), stemming from both behavioural and cognitive traditions. The past decade or so has seen a marked increase in both scientific and clinical interest in mental imagery, from basic questions about the processes underpinning mental imagery and its roles in everyday healthy functioning, to clinical questions about how dysfunctions in mental imagery can cause distress and impairment, and how mental imagery can be used within CBT to effect therapeutic change. This article reflects on the current state of mental imagery in the science and practice of CBT, in the context of past developments and with a view to future challenges and opportunities. An ongoing interplay between the various strands of imagery research and the many clinical innovations in this area is recommended in order to realise the full therapeutic potential of mental imagery in CBT.

Using Imagery Rescripting as an Early Intervention for Depression in Young People

Innovation is urgently needed for school-based early interventions for depression. Imagery rescripting for aversive memories has been shown to be a valuable therapeutic approach in adults. Yet it is rarely applied to young people or to depression. This is surprising given that intrusive images of aversive memories are implicated in the development and maintenance of depression. We review the literature and describe the co-development of an imagery rescripting protocol for young people (age 16-18) with high symptoms of depression. To contextualize and illustrate this approach, we identify three themes of negative images emerging from the 37 participants who completed imagery rescripting and provide a detailed case example for each theme. The identified themes are failure, interpersonal adversity, and family conflict or disruption. Given that there is some therapist concern about using imagery rescripting, we highlight any reported negative consequences of engaging in imagery rescripting. We propose that imagery rescripting is an acceptable and potentially effective tool for early intervention in depression, which is significantly underutilized in current practice.

The Association Between Test Anxiety, Self-Efficacy, and Mental Images Among University Students: Results From an Online Survey

Background and Objectives: A substantial portion of students report test anxiety, and those reporting low levels of self-efficacy seem to be especially affected. Previous research has indicated the relevance of mental images in the maintenance of anxiety disorders, however, no data are available with respect to test anxiety. In order to close this gap, the present study investigates the association between test anxiety, self-efficacy and mental images. Method: One hundred sixty-three university students completed an online survey. Test anxiety (PAF), general self-efficacy (WIRKALL-r), study-related self-efficacy (WIRK_STUD), intrusiveness of mental images (IFES), spontaneous use of imagery (SUIS) and vividness of imagery (VVIQ) were examined. Results: Test-related mental images were frequently reported among the surveyed students. Test anxiety showed a positive correlation with IFES and a negative correlation with self-efficacy. Mediation analyses showed that about one fifth of the influence of self-efficacy on test anxiety is mediated by IFES. Discussion: The present study gives first indication about an association between test anxiety, self-efficacy and mental images, even though the results are limited with respect to generalizability. Further investigations with respect to the impact of test-related mental images on the self-efficacy/test-anxiety linkage are needed.

Short Imagery Rescripting Intervention to Treat Emotionally Dysregulated Behavior in Borderline Personality Disorder: An Exploratory Study

BACKGROUND

Current research on borderline personality disorder report an association between emotionally dysregulated behaviors and intrusive mental imagery depicting similar scenes. Imagery rescripting techniques have proven effective in reducing intrusive mental imagery in numerous contexts. We developed a two session-short intervention in which intrusive mental images are identified, analyzed, and modified for daily rehearsal at home. This study aimed to reduce the negative emotions and cognitions associated with self-injurious behaviors by replacing unhealthy imagery with more adaptive content.

METHODS

Seven females diagnosed with borderline personality disorder who reported intrusive mental imagery of dysregulated behaviors were recruited for participation. Each participant engaged in two individualized treatment sessions and daily homework requiring the rehearsal of modified imagery. Emotion regulation strategies, borderline symptom severity, and depressiveness were assessed before and after treatment.

RESULTS

Acceptance was positive, as no patient dropped out from treatment. Symptom exacerbation was not observed. Borderline symptom reduction was noted and indicia of emotional dysregulation and negative affect declined.

LIMITATIONS

The generalizability of results is limited by the small sample size and the absence of a control group. Conclusions: This new two-session short intervention was shown to decrease the emotionally dysregulated behaviors that accompany negative feelings in females with borderline personality disorder.