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Imagery is a relatively novel area of interest in eating disorders (EDs). Clinical experience and some research work indicate that rescripting of early memories may be a useful way to modify core beliefs in EDs. Relevant constructs, as applied in the current paper, are defined and described, including core beliefs, imagery rescripting, and early memories. Existing empirical research on the outcome of imagery rescripting of early memories is outlined, including in EDs. Relevant ED research on images and early memories in EDs is presented. A case is made for applying imagery rescripting to early memories in EDs. The origins and development of a clinical protocol are described. The aim of the protocol is to identify and rescript or modify early memories associated with the core beliefs characteristic of EDs. This process has also been applied in other disorders. Clinical examples illustrate the application of the protocol in EDs, including extracts of dialogue from a clinical case. The paper covers indications for use of the protocol, practical and ethical considerations, its suitability in individual cases, and some final practical tips. These include examples of useful questions to ask patients that facilitate successful rescripting of memories, and thus core belief modification. The paper concludes with some thoughts on future work.

Some preliminary attention has been paid to the use of imagery in relation to core beliefs1 in people with eating disorders (EDs; Cooper et al., 2007, Mountford and Waller, 2006 and Ohanian, 2002). Despite this, relatively little has yet been written on the topic. The current paper is concerned with the use of imagery rescripting of early memories in people with EDs. This approach, unlike that of Mountford and Waller, has the explicit aim of modifying the core beliefs of those with EDs. This article will begin with a short summary of ED outcome to set the scene. This will highlight the need for novel approaches to treatment in EDs. A brief overview of the advantages of using imagery strategies, versus more traditional verbal strategies, will be provided. What is meant by imagery rescripting (as well as imagery and early memories), and the effectiveness of imagery rescripting, in eating and other disorders will be discussed. Particular attention will be given to definitions used in the current paper. Relative to EDs, a much larger literature exists in other disorders. Reference to definitions and outcome in other disorders will, therefore, help contextualize those used here in EDs. With a similar aim, research on relevant constructs (core beliefs, imagery, early memories, and images of early memories) in EDs will then be discussed. A rationale for imagery rescripting of early memories in EDs will be briefly presented. This will be followed by some initial thoughts on how imagery rescripting might work theoretically (in relation to cognitive theory), including in eating, and other disorders. Given that relatively little has been written on exactly how to carry out imagery rescripting in people with EDs, the majority of the paper will then describe a practical protocol. This will describe how to modify core beliefs in EDs, using the technique of imagery rescripting. This involves working with early memories. The methodology is based on that termed “imagery rescripting” by other researchers and clinicians (e.g. Edwards, 2007). It will focus on the rescripting of early childhood memories identified as being associated with patients' core beliefs, as described, for example, by Arntz and Weertman (1999). A similar protocol has previously been described as part of a comprehensive, integrated metacognitive and cognitive therapy treatment for bulimia nervosa (BN) and binge eating (Cooper, Todd, & Wells, 2009). The current description and protocol, however, is designed to be a stand-alone strategy. As such, it might potentially be integrated with a range of different treatment approaches. Detailed clinical material, taken from the author's experience with patients with EDs, will be used to illustrate the application of the protocol. Information on expected response and outcome will also be included. EDs are often hard to treat successfully. Cognitive behavior therapy (CBT) has had some success, particularly for bulimia nervosa (BN; e.g., Agras, Walsh, Fairburn, Wilson, & Kraemer, 2000), but overall outcomes are less than optimal, especially when long-term outcome is considered (e.g., Fairburn & Harrison, 2003). Compared to BN, therapy for anorexia nervosa (AN), at least in systematic research trials, often results in poor outcome. This is true both in the short term, as well as over the longer term (e.g., Pike, Walsh, Vitousek, Wilson, & Bauer, 2003). One approach to improve outcome involves revision and elaboration of older cognitive-behavioral models of EDs (Jansen, 2001) and translation of these developments into clinical practice (e.g., Cooper, 2003, Cooper et al., 2004, Cooper et al., 2007 and Waller et al., 2007). An important aspect of this is now often considered to be the identification of core beliefs: their role in the development and maintenance of EDs, and the application of this understanding to clinical work. An integral part of these developments is incorporation of core beliefs into an overall formulation of EDs. Here they are assigned a role either in the development of EDs (Waller et al., 2007) or one in which they also play an important maintaining function (Cooper, in press). They also play a role as one significant module to be added to transdiagnostic treatment in some cases (Fairburn, Cooper, & Shafran, 2003). To date, much core belief work in EDs has drawn on well-established strategies devised for personality disorders (e.g., Beck et al., 1990), and other long-standing difficulties (e.g., Young, 1990). Padesky (1994) provides a useful overview of how schema (or core belief) change might be achieved, and some of these methods have been adapted for EDs (e.g., Cooper, Todd, & Wells, 2000). These include historical tests of core beliefs and continuum work. Importantly, in the current context, however, all these strategies rely primarily on verbal methods. Anecdotally, clinicians have found these useful in EDs, but have also identified some important limitations (e.g., Cooper et al., 2009). In particular, while considerable change can be made in “rational” beliefs (when one considers the belief logically, or rationally), this change does not always extend to “emotional” beliefs (when one considers how one feels, irrespective of what is logically believed). As a result, patients may report that although they know logically (i.e., when they think about it rationally), that a belief about the self is no longer true, they still feel and behave, and remain convinced deep inside, that it is true. Few traditional methods of modifying core beliefs, in eating or other disorders, employ imagery-based strategies. The potential advantages of imagery-based strategies, compared to verbal strategies, will be considered in more detail below. In a number of disorders, attention has turned to the therapeutic use of imagery (e.g., Holmes, Arntz, & Smucker's, 2007, special issue of the Journal of Behaviour Therapy and Experimental Psychiatry) as a nonverbal strategy for producing change. This applies to core beliefs as well as other cognitive behavioral constructs. It has been recognized for some time that imagery may have greater power than verbal representation (for example, in facilitating some forms of learning; Paivio, Smythe, & Yuille, 1968). Singer, 1974 and Singer, 2006) provides a useful history of mental imagery in relation to the development of modern psychotherapy. Edwards (2007) suggests that its origins go back to Janet (1889) and use of “imagery substitution,” the practice of which may involve (under hypnosis) visualization of early negative or traumatic early memories followed by their transformation into more positive images. A widely cited example from Janet (Marie) is not dissimilar in content to the current practice of imagery rescripting of early memories. Indeed, it is described as such by van der Hart and Friedman (1989). However, the theoretical mechanisms hypothesized to be responsible for change as outlined by Janet are not consistent with those that might be proposed by modern-day CBT. The role of imagery in assisting emotional change formed part of behavior therapy, notably in systematic desensitization ( Wolpe, 1958). Visualization is an important technique in Gestalt therapy ( Perls, 1970). However, the therapeutic use of imagery has only begun to be extensively explored in CBT. It has been proposed that imagery, compared to verbal representation, has a special relationship to emotion. Evidence is now rapidly accumulating in support of this notion (Holmes & Mathews, 2005). For example, research has demonstrated how use of mental imagery compared to use of a verbal sentence produced a greater emotional response, even though the material being processed was the same (Holmes, Mathews, Mackintosh, & Dalgleish, 2008). A number of different applications of imagery have been described historically in CBT. Beck, Emery, and Greenberg (1985), for example, used imaginal exposure of anxious images, imagining of worst scenarios, and substitution of positive imagery for feared situations. Of particular interest here, however, is the relatively recent application of imagery rescripting to treat childhood memories (with the aim of modifying core beliefs), for example, as part of cognitive therapy for personality disorders (e.g., Arntz & Weertman, 1999). As suggested above, imagery rescripting is not a completely new treatment strategy (Edwards, 2007). Edwards described its precursors, early origins, and subsequent integration into mainstream CBT. He noted that it is now prominent in a number of CBT approaches to a range of different disorders. Indeed, his article forms part of a special issue on imagery rescripting (see Holmes et al., 2007), where application to several different disorders is presented. Holmes et al. describe three types of imagery rescripting techniques in CBT. All address negative imagery, and are termed “direct techniques imagery interactive.” In other words, the therapist works directly with, and interacts with, the image in some way. The specific form of rescripting is partially dependent on the disorder or symptoms involved. For example, rescripting of fantasy images is particularly relevant to obsessive-compulsive disorder (OCD), where there may be no clear autobiographical memories that represent feared outcomes. Rescripting of “image-based memories” (Holmes et al.'s term) would appear to come closest to the approach that will be described here for EDs. In this approach, the therapeutic work is conducted in imagination with the individual's remembered early experiences. The work described by Weertman and Arntz (2007) seems to come closest to the protocol which is presented here. Like Weertman and Arntz, early memories are treated using imaginal strategies in order to effect change in disorder-related core beliefs and psychopathology. In discussing different versions and definitions of imagery rescripting, it is important to define what is meant by imagery and early memories, particularly in the current context. Hackmann (1998, p. 301) defines images as “contents of consciousness that possess sensory qualities, as opposed to those which are purely verbal or abstract.” While visual imagery appears most common (Horowitz, 1970), images can also contain other sensory qualities, including auditory, tactile, gustatory, and organic or body-based qualities. All aspects may be important in individual cases of imagery rescripting in EDs. The early memories treated in imagery rescripting may be likened to autobiographical memories, in that they concern events (general or specific) that have happened in an individual's personal history. Unlike work in PTSD on intrusive thoughts and flashbacks (e.g., Ehlers & Clark, 2000), the approach to be outlined here does not assume that the childhood memories recalled are intrusive or problematic in their own right. Neither does it assume that they are necessarily traumatic, or that they are accurate representations of the past. Bartlett (1932) referred to memories as imaginative reconstructions, and memories often come to awareness as mental contents or images. As Beck further noted in relation to CBT, it is the interpretation that is important (Beck, 1976). Theoretically, in imagery rescripting of early memories, it is assumed only that the memories, and their associated images (which will then be modified), are functionally linked to core beliefs. It is thus hypothesized that rescripting or modifying them will alter the schema or core beliefs associated with them (Arntz & Weertman, 1999). As noted below, this means that a good assessment of any links between current problems and core beliefs is crucial if rescripting is to be effective. Imagery rescripting of early memories has now been conducted in several disorders, albeit using slightly different approaches, and no one completely consistent protocol. A number of studies incorporate it into a more comprehensive treatment strategy (e.g., Farrell, Shaw, & Webber, 2009), thus its specific effectiveness can be difficult to assess. A number of studies, however, have evaluated it in isolation, with overall promising results. Weertman and Arntz (2007) compared focus on present versus past core belief change using a protocol-based imagery rescripting intervention for childhood memories in those with personality disorders. They found past-focused methods produced more change in schemas than present-focused methods. Treatment was relatively long, with 24 sessions allocated to each intervention in a crossover design. The protocol was a direct extension of Smucker, Dancu, Foa, and Niederee (1995), with the addition of historical role-plays developed by the authors. A single-session intervention rescripted early memories in a small group of people with social phobia, compared with a control session. This produced significant change in encapsulated belief (core belief linking recurrent intrusive images to early memory), image and memory distress (Wild, Hackmann, & Clark, (2008). The protocol used was based on that of Arntz and Weertman (1999), although also involved cognitive restructuring. Two papers have also described the treatment of images of childhood memories, with the aim of modifying core beliefs, in patients with depression (Brewin et al., 2009 and Wheatley et al., 2007). Two case studies (Wheatley et al.) showed reduced distress, belief and symptom change, as well as behavioral change. A case series showed similar changes that were maintained at 1-year follow-up (Brewin et al.). Both studies used protocol-based treatments, largely derived from that described by Arntz and Weertman, as well as Hackmann, 1998 and Smucker and Dancu, 2000. The average number of sessions in the case series was 8.1, and no verbal challenging of beliefs took place. In relation to EDs, two studies were found in the literature in which treatment of early memories using imagery rescripting was used. The first (Ohanian, 2002) describes imagery rescripting as part of additional CBT, based on Edwards, 1990, Layden et al., 1993 and Smucker et al., 1995. This is a single-case report with a good outcome in terms of decreased binge eating and vomiting when conventional CBT had failed. The second is an experimental study (Cooper, Todd, Turner, & Wells, 2007) in which imagery rescripting was used in a single session to modify early memories associated with idiosyncratic core beliefs in 12 women with BN. Compared to a matched control group that received an intervention that was not designed to rescript early memories, significant change in emotional core beliefs and associated mood and ED symptoms was achieved. Layden's work (Layden et al., 1993) formed the basis for a detailed protocol in this study.