ثبت مجدد تصاویر اولین خاطرات زندگی پس از ضربه در هراس اجتماعی

Negative self-images appear to play a role in the maintenance of social phobia and research suggests they are often linked to earlier memories of socially traumatic events. Imagery rescripting is a clinical intervention that aims to update such unpleasant or traumatic memories, and is increasingly being incorporated in cognitive behavioral therapy programs. In previous research, we have found that imagery rescripting was superior to a control condition in terms of its beneficial effects on negative beliefs, image and memory distress, fear of negative evaluation, and anxiety in social situations. In this article, we describe our imagery rescripting procedure. We consider the importance of updating negative imagery in social phobia, the theoretical basis for imagery rescripting, directions for future research, and how to conduct imagery rescripting, including potential problems and their solutions.

In social situations, patients with social phobia often experience distorted, negative images or impressions of how they fear they will come across to other people (i.e., Hackmann et al., 2000 and Hackmann et al., 1998). Research has reported that the negative images/impressions are often linked in meaning and content to early socially traumatic (embarrassing/humiliating) events clustered around the onset of the disorder (Hackmann et al., 2000). In the treatment of social phobia, it is necessary to update these negative images because they maintain social anxiety. They cause patients to feel more anxious and to perform less well than when they hold benign imagery in mind (e.g., Hirsch, Clark, Mathews, & Williams, 2003). Further, the negative imagery prevents patients from disconfirming their social fears, which can include, for example, a fear of running out of things to say or of blushing, of people noticing and then concluding that they are inadequate or incompetent. Negative imagery appears to maintain social fears for a number of reasons. First, patients believe their negative self-images are a true reflection of how they come across to other people. They therefore think they come across much worse than they actually do, which reinforces rather than disconfirms their perception of performing inadequately. Second, negative imagery motivates patients to use safety-seeking behaviors, which can interfere with their social performance and make them appear less interested in other people than they really are (Alden and Taylor, 2004, Clark and Wells, 1995, Hirsch et al., 2004 and Rapee and Heimberg, 1997). Third, negative self-imagery blocks positive interpretation bias (Hirsch, Mathews, Clark, Williams, & Morrison, 2003). This means when faced with an ambiguous social cue, such as a smile from a conversational partner, patients with social phobia are unlikely to make a positive interpretation about the smile and so miss opportunities to benefit from the very feedback that could help them to reevaluate their fears and reduce their anxiety. Fourth, negative imagery facilitates selective retrieval of negative memories (Stopa & Jenkins, 2007) and there is evidence that judgments about the future probability of an event are influenced by the accessibility in memory of past instances (Tversky & Kahneman, 1974). Several cognitive behavioral therapy (CBT) programs for social phobia include present-focused techniques to correct distorted self-images, such as videofeedback, surveys, and behavioral experiments. These techniques are employed almost immediately in cognitive therapy for social phobia (Clark, 1999) because of the pivotal role negative imagery has in maintaining patients’ social fears, avoidance, and anxiety. Given that the images are often linked in meaning and content to distressing memories, it also makes sense to treat the origins of the images, particularly if patients continue to experience negative imagery following intervention with these present-focused techniques. Imagery rescripting describes a set of related therapeutic procedures that focus on changing unpleasant memories (Stopa, 2009). The procedure is also known as imagery with rescripting (e.g., Arntz & Weertman, 1999), and throughout this paper, we use these terms interchangeably. Imagery rescripting techniques have been used as major components of CBT programs for borderline personality disorder (Giesen-Bloo et al., 2006), bulimia (Cooper, Todd, & Turner, 2007), and posttraumatic stress disorder arising from childhood sexual abuse (Smucker & Neiderdee, 1995). Turning to social phobia, Clark and colleagues have recently incorporated imagery rescripting techniques into their cognitive therapy program, particularly for patients who have made only modest improvements with present-focused techniques. A recent trial (Clark et al., 2006) found that this integrated cognitive therapy program was superior to exposure therapy, and the authors speculated that the overall beneficial effects of cognitive therapy for social phobia were partly due to the use of imagery rescripting. To formally test the role of imagery rescripting per se, Wild et al., 2007 and Wild et al., 2008 conducted two studies that assessed the effects of imagery rescripting alone in unselected populations of patients with social phobia. Wild et al. (2007) reported pre- and post-rescripting results in 14 patients with social phobia with whom they developed the approach. Imagery rescripting alone was associated with significant improvements in patients’ negative social beliefs, the vividness and distress of their image and early memory, and in self-report measures of social anxiety. Wild et al. (2008) then compared a session of imagery rescripting with a control session in which images and memories were explored without being updated. Measures were taken before each session and 1 week later. The imagery rescripting session was associated with significantly greater improvement in negative beliefs, image and memory distress and vividness, fear of negative evaluation, and anxiety in feared social situations. In this paper we describe in detail our procedure of imagery rescripting for social phobia, which includes a cognitive restructuring component, and which demonstrated effectiveness in Wild et al., 2007 and Wild et al., 2008. We first present the theoretical basis for the technique, then a description of how to conduct it, followed by clinical examples, how to address potential problems, and directions for future research.

Addressing negative self-imagery with present-focused techniques is a key component of many CBT programs for social phobia. However, the recurrent negative self-images that patients with social phobia report are often linked to earlier socially traumatic events. These events go beyond feeling as though a social performance situation has gone badly; rather, they include experiences of intense anxiety in which the patient perceives humiliation, ridicule, extreme criticism, or rejection—the very features that make them socially traumatic and indicate the potential utility of imagery rescripting for early memories in social phobia. Imagery rescripting may be useful for other disorders for which recurrent negative imagery has been linked to earlier unpleasant events, such as agoraphobia (e.g., Day, Holmes, & Hackmann, 2004), and health anxiety (e.g., Muse, McManus, Hackmann, Williams, & Williams, 2010). The imagery rescripting procedure we have described in this paper is one in which we have evaluated in former research (i.e., Wild et al., 2007 and Wild et al., 2008). It includes a phase of cognitive restructuring followed by three stages of imagery rescripting, drawing on the imagery rescripting procedure described by Arntz and Weertman (1999). Our procedure differs from Arntz and Weertman in that we include a component of cognitive restructuring followed by three stages of rescripting in which intervention usually only occurs in Stage 3. The aim of our procedure is to update the socially traumatic memory and the meaning linking the negative image and memory. It is indicated for patients who have made only modest improvement following standard present-focused techniques, such as videofeedback and surveys, in the CBT treatment of social phobia, and whose recurrent negative image links to an identifiable earlier event. Imagery rescripting for social phobia is intended to be offered as part of a CBT treatment package for the disorder. In our studies, the procedure was applied judiciously by therapists who had extensive prior experience with cognitive therapy. It is unclear how much prior general training in cognitive therapy is required for the effective delivery of the intervention, but this could be clarified with future research.