Restructuring implicational meaning through memory-based imagery: Some historical notes

Abstract

This paper provides a historical perspective on the recent increase in the clinical application of imagery techniques to restructure systems of implicational meaning that drive emotional distress or self-defeating behaviors. Janet's early application of such techniques was largely ignored except by a few hypnotherapists. Current applications in cognitive therapy were adapted and extended in the early 1980s from Perls' Gestalt therapy methods. Some precursors to Perls are examined, as well as the work of some of those who developed and formulated the integration of his techniques into Beck's cognitive therapy. It is argued that this process amounted to a significant paradigm shift.

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Journal of Behavior Therapy
and Experimental Psychiatry 38 (2007) 306–316
Restructuring implicational meaning through
memory-based imagery: Some historical notes
David Edwards

Department of Psychology, Rhodes University, Grahamstown 6140, South Africa
Abstract
This paper provides a historical perspective on the recent increase in the clinical application of
imagery techniques to restructure systems of implicational meaning that drive emotional distress or
self-defeating behaviors. Janet’s early application of such techniques was largely ignored except by a
few hypnotherapists. Current applications in cognitive therapy were adapted and extended in the
early 1980s from Perls’ Gestalt therapy methods. Some precursors to Perls are examined, as well as
the work of some of those who developed and formulated the integration of his techniques into
Beck’s cognitive therapy. It is argued that this process amounted to a significant paradigm shift.
r2007 Elsevier Ltd. All rights reserved.
Keywords: Cognitive therapy; Guided imagery; History of psychology
What we now call imagery rescripting is not entirely new. In fact, the following vignette
describes very similar procedures reported well over a century ago.
Marie had serious psychological problems including psychogenic blindness in the left eye
since the age of 6, when she had shared a bed with another child disfigured by impetigo on
the left of her face. Her menstrual periods were preceded by depression, hostility, and
uncontrollable shivering. After 2 days, menstruation would stop abruptly and she would
again shiver, become delirious, and display disturbed behaviors including shouting out,
running about wildly, or behaving in a childlike manner. Using hypnotic regression, her
therapist uncovered the source of these symptoms. When her first period began at the age
of 13, she had felt profoundly shocked and deeply ashamed. After a day or so she had
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plunged into a bath of cold water to try to stop the flow. After that she did not menstruate
for 5 years, and when menstruation resumed it was accompanied by the symptoms already
described. The treatment was creative, but simple. Using hypnosis, her therapist suggested
she re-experience the time just before her first menstruation and visualize her menstrual
flow starting normally, her accepting it, making no attempt to stop it, and the period
taking its course and ending naturally. This procedure resolved the symptoms. In another
session, the therapist guided her to remember sharing the bed with the girl with the
disfigured face, to imagine her as a friendly person without impetigo and to visualize
caressing the girl’s face without fear. Her sight returned and there was no return of
symptoms over the next 5 months.
Pierre Janet described these examples of ‘‘imagery substitution’’ in 1889 in
L’automatisme psychologique (Ellenberger, 1970, pp. 361–364 reproduces an English
translation of this case; see also Van Der Hart, Brown, & Van Der Kolk, 1989). But in the
century that followed, Janet’s work was largely ignored (Van Der Hart & Friedman, 1989)
by the main Freudian and post-Freudian psychoanalytic approaches. There were
exceptions, mostly notably in Jung’s (1960)
1
active imagination, and later, Leuner’s
(1984) guided affective imagery, though in these there is considerable focus on symbolic
imagery, rather than biographical memories. Mary Cerney’s (1986) striking application of
guided imagery to bereavement is also documented on video (Cerney, 1989).
In early behavior and cognitive therapy, structured imagery interventions included
systematic desensitization, covert rehearsal, and even positive time projection (Cautela,
1977;Lazarus, 1984). However, emotional processing was not explicitly addressed, and
Ramsay (1977) and Stampfl (1976) explained the impact of flooding techniques in terms of
habituation or extinction.
Some hypnotherapists used methods similar to Janet’s throughout the 20th century (Van
Der Hart et al., 1989), although there was often a focus on precipitating a strong emotional
response (catharsis or abreaction) with little emphasis on active restructuring either during
or afterwards (Nichols & Zax, 1977). More recently, however, Watkins and Frankl
describe methods of restructuring meaning that have marked parallels to imagery
rescripting. A client of Frankl (1994) recalled being a happy toddler, but ‘‘when father
appeared, the atmosphere changed.’’ His mother changed too: ‘‘the warmth went out of
her’’ (p. 117). After processing the complex implications of this for the relationships
between himself, his father and his mother, he came to see his father as a man ‘‘with all
kinds of faults and many difficulties and no longer as an implacable, larger than life
authority.’’ Frankl also describes guiding a client to ‘‘see your mother as you really, deep
down, want her to be’’ (p. 134). Watkins’ (1992) hypnoanalysis, developed in 1945 to treat
post-war PTSD, evolved to include ‘‘ego-state therapy’’ featuring imagery dialogues
between different parts of the self.
However, cognitive and behavioral psychologists were often suspicious of hypnother-
apy. Hackmann (personal communication, 30 July 2007) recalls that at London
University, ‘‘we were forbidden to read about hypnotherapy, or experiment with it,’’
and Dowd (personal communication, 14 August 2007) recalls a colleague, years ago, telling
him not to use it because it was ‘‘powerful’’!
Today, by contrast, imagery-based methods for the transformation of meaning
associated with emotionally charged memories have become a significant component of
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1
This paper published in 1958 was a revision of one published 40 years earlier.
D. Edwards / J. Behav. Ther. & Exp. Psychiat. 38 (2007) 306–316 307

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cognitive therapy. This paper examines some precursors to these contemporary
applications and some personal accounts of how their integration into cognitive therapy
gradually gathered momentum.
1. Gestalt therapy and its precursors
It has been Fritz Perls’ (1893–1970) Gestalt therapy, rather than the hypnotherapy
literature, which mainly influenced cognitive therapists. Born in Germany, Perls had
rapidly become disillusioned with the Freudian circle. There were many influences on his
development from those who were diverging from Freud, including Reich, Ferenczi, and
Rank. Before leaving Germany in 1934, Perls had been in therapy with Wilhelm Reich
(1897–1957) who argued that unexpressed emotion gives rise to patterns of rigidity in the
skeletal muscles, which he called ‘‘character armour.’’ Reich used exercises to soften rigid
muscles and also physical manipulation to initiate emotional release, but, although these
often activated early traumatic memories, there was little focus on memory content, let
alone on active restructuring of meaning (Nichols & Zax, 1977).
Ferenczi’s (1873–1933) ‘‘neocathartic method’’ also involved reliving early memories of
emotionally painful events. At odds with Freud, Ferenczi concluded that these could not
be dismissed as instinctual fantasies. Trauma, he argued, led to a ‘‘splitting off of a part of
the personalityy[which] lives on hidden, ceaselessly endeavouring to make itself felt,
without finding any outlet except in neurotic symptoms’’ (Ferenczi, 1929, p. 121). Ferenczi
anticipated contemporary emphasis on the healing of the inner child and the therapist’s
reparenting role. He promoted restructuring by encouraging therapists to engage with the
split off child part and ‘‘persuade it to engage in what I might almost call an infantile
conversation’’ (Ferenczi, 1929, p. 122). Anna Freud commented that he worked with the
child part of adults much as she did with children themselves (Ferenczi, 1931).
Rank (1884–1939) emphasized exploration of the client’s emotional vulnerability in the
present. He recognized that focusing on experience in the here and now activated creative
healing processes and took the emphasis away from developmental analysis. In 1938, he
recommended that therapists attend to ‘‘the emotional experience rather than the
intellectual enlightenment of the patient’’ (Kramer, 1995, p. 79). These developments
directly influenced Gestalt therapy as well as a wide range of emerging approaches
including interpersonal, object-relations and existential psychotherapy. It was encounters
with Rank and those trained by him that contributed to Carl Rogers’ exploration of how a
focus on present experience in the relationship between client and therapist had the
potential to enable a creative process of healing (Kramer, 1995;Rogers, 1942, 1951).
There were numerous other influences on the evolution of Perls’ work. These included
his own interest in contemporary expressive art: in his biographical notes, for 1922 (he was
29 years old), Perls (1969) refers to ‘‘We: bohemians, off the beaten path. Actors, painters,
writers....’’ Nor was Reich the only mentor in the domain of somatically oriented therapies.
His wife Laura was involved with the expressive somatic practitioner Laura Gindler
(1885–1961) (Perls, 1969: entry for 1930) and after moving to New York in 1946, he and
his wife were both trained by Charlotte Selver (1901–2003), who had been trained by
Gindler (Weaver, 2006).
His first book, written in South Africa and first published there in 1942 (Perls, 1969), was
re-published on his arrival in the USA. In it, Perls (1947/1969), was already describing a
focus on moment to moment awareness in a way that prefigures contemporary
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cognitive–behavioral assessment. In what is perhaps a self-observation, he described a man
becoming agitated while waiting for a tram. An image of the tram arriving repeatedly
comes to mind and activates an impulse to approach and board the tram. Since the tram
has not arrived, the impulse is suppressed and the process produces a persistent feeling of
restlessness and irritation.
In New York, Perls was drawn to Paul Goodman, a controversial, Bohemian and
anarchist poet and novelist who had undergone Reichian therapy and who shared his
interest in the expressive arts (Stoehr, 1994). Perls was writing a more comprehensive
account of the significance of the focus on moment to moment awareness for the therapy
process, much of which Goodman extensively reworked (Perls, Hefferline, & Goodman,
1951). It was a landmark book in which Goodman, described Rank’s ideas on creativity
and the arts as ‘‘beyond praise’’ (p. 395).
By the time of his death in 1970, Perls’ ideas had consolidated into a coherent
psychological theory and his work with imagery and dialogues was elegant and telling.
Habitual processes of cognitive and emotional avoidance of distressing material leave
‘‘unfinished business,’’ Perls (1973) argued, which often presses into awareness and will
naturally emerge if avoidance mechanisms are relaxed. He would begin therapy sessions
with images from dreams or images that spontaneously arose in response to the suggestion
that clients close their eyes and focus on a feeling or event. They were encouraged to be
open to emotions or sensations and to articulate their meaning. They would also identify
with a figure that had been imaged and allow words to flow that articulated the
unexpressed meaning and, in particular, to express needs that were not previously
acknowledged or met, or attitudes or responses which were suppressed in anticipation of a
punitive response. Restructuring might occur spontaneously, or be promoted by
questioning and dialogue techniques. In his later years Perls would give workshop
demonstrations with individuals who would work intensively with him (the ‘‘hot seat’’)
while other participants observed. However, many professionals (including Gestalt
therapists themselves) were critical that the work was not systematically followed through
as would be expected in a therapy process.
2. A split between academics and experiential therapists
Nevertheless, so compelling was the simplicity and power of the techniques that they
came to be widely used in the 1970s within the humanistic therapy movement. I
encountered them in 1978 in England, during a year of in-service clinical training run by
the University of Surrey. However, there was a split between what was the focus of
academic and professional training on the one hand, and experiential approaches which
were having significant influence outside the Universities. It was not the Department of
Psychology, but the Department of Adult Education that disseminated these practices
through weekend workshops offered to health professionals and the general public, and
Heron’s (1977, 1978) manuals summarized the methods.
Back in my academic post in South Africa, I wondered how I would deal with this split.
The permission I needed came from a workshop at the University of Port Elizabeth by
Richard Erskine who was integrating Gestalt techniques with the cognitively focused
transactional analysis (TA). The TA literature was the source of the term ‘‘scripts’’ in the
sense of automatic and habitual patterns of cognition, emotion, and behavior. Erskine and
Zalcman (1975/1997) analysis of the way in which unmet needs and unexpressed feelings
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led to ‘‘script beliefs’’ and ‘‘script displays’’ anticipated what cognitive therapists would
later call core beliefs and early maladaptive schemas, and Erskine (1980/1997) used the
phrase ‘‘script cure’’ with a meaning similar to what Young, Klosko, and Weishaar (2003)
would call ‘‘schema healing.’’ Later, Erskine and Moursund (1988, p. 55) anticipated what
cognitive therapists now call imagery rescripting. ‘‘The client is allowed to go back in
fantasy to a time of script formation,’’ they wrote, ‘‘... and to use the superior resources of
the ‘now’ to assist his or her confused or fearful or angry child ‘then.’’’ The goal is to effect
cognitive and affective change, but also to change intent so that the client makes a
‘‘redecisionya clear and conscious choice to go a different route than before.’’
From 1979, I integrated experiential techniques with cognitive and behavioral methods
in my private practice and 4-day experiential learning workshops for students. Then, in
July 1984, I began a post-doctoral fellowship at Beck’s Center for Cognitive Therapy at the
University of Pennsylvania. David M. Clark was visiting; Merv Smucker had the office
next door; Jeff Young was one of the trainers. It was an extraordinary convergence,
facilitated by an intellectual climate which supported integration. Lazarus (1985) warned
against eclecticism in the sense of haphazardly selecting interventions from different
approaches to therapy, but encouraged ‘‘technical eclecticism,’’ the incorporation of
techniques from other traditions on the basis of a coherent formulation. ‘‘One need not
believe in Gestalt principles to use Gestalt techniques’’, Lazarus (1985, p. 3) observed and
described use of the Gestalt empty chair dialogue method within multimodal therapy.
3. Cognitive therapy as an integrative model
Beck and those associated with him shared this perspective. Freeman, one of my
supervisors, was co-editing a book (Mahoney & Freeman, 1985) which drew attention to
the parallels between cognitive therapy and several psychodynamic approaches. Guidano
and Liotti’s (1983) synthesis of the ideas of Beck, Piaget and Bowlby, described a
comprehensive conceptual and technical integration. Arnkoff (1981) recommended
integration of Gestalt methods into cognitive therapy. Furthermore, in terms of Beck’s
cognitive model, ‘‘cognition’’ did not just mean something verbally expressed. Thoughts
and assumptions often arose from schemas whose origins lay in childhood and infancy and
whose content might be emotionally charged and not easily accessible (Beck, 1985).
Theories on the relationship between cognition and emotion were already well
developed. In a seminal article in Cognitive Therapy and Research,Greenberg and Safran
(1984b) described different levels of processing, with different characteristics, including a
‘‘schematic emotional memory mechanism’’ (p. 566) and an ‘‘abstract conceptual system’’
(p. 567). Only the former was directly linked to emotional states. These authors challenged
as simplistic the idea that cognition could be separated from emotion. ‘‘In a sense,’’ they
observed, ‘‘there is no affect without cognition and no cognition without affect’’ (p. 569).
The term ‘‘hot cognitions’’ was already frequently used to refer to meanings which were
encoded in the schematic emotional system, and was included in the title of Greenberg and
Safran’s (1984a) response to critics in the same issue of the journal. Soon Foa and Kozak’s
(1986) seminal article would use the term ‘‘emotional processing’’ to refer to the activation
of emotional schemas and the modification of their encoded meaning through exposure to
corrective information.
Young (2007) recalls that at that time there was limited emphasis in cognitive therapy on
core beliefs and early development. However, the theoretical groundwork was in place.
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Understanding the historical origins of dysfunctional beliefs could aid clients in revising
them, argued Beck, Emery, and Greenberg (1985). The distinction was drawn between
prescriptive ‘‘technical’’ cognitive therapy and formulation-driven ‘‘conceptual’’ or
‘‘structural’’ cognitive therapy’’ particularly by Young and by Guidano and Liotti who
provided the basis for writing a cognitive developmental case formulation. In addition to
analysis of maintaining factors in the form of assumptions, thoughts and self-defeating
behaviors, clinicians began placing more emphasis on cognitive vulnerability due to the
impact of developmental experiences on the schematic emotional memory mechanism.
Here was fertile ground for the integration of TA/Gestalt imagery techniques into
cognitive therapy. Beck (1970) had observed the important contribution that imagined
scenes could play in generating personal distress and described some simple imagery
techniques. Another paper in 1971 was recently republished (Beck, 2002). Freeman (1981)
had described how dream images provided access to personal meanings which could be
significant for case formulation. A range of imagery-based techniques were described in
Beck et al.’s (1985) book on cognitive therapy for anxiety, that was soon to be published.
Judy Beck would sometimes drive me home (we lived in the same suburb) and ask me
detailed questions about imagery work. Young’s ideas on the integration of Gestalt
imagery methods into schema-focused cognitive therapy were being presented at seminars,
even though nothing would be available in published form for 5 years (Young, 1990).
In 1985, while still in Philadelphia, I began to write what turned into two papers, using
material from my own cases. Arthur Freeman made encouraging comments. The one,
which appeared as Edwards (1990a, p. 39), argued that activation of early memories
provided access to the ‘‘primitive cognitive system’’ in which distortions were encoded and
showed how guided imagery offered a vehicle for cognitive restructuring. It was illustrated
with session transcripts. The other began by showing how Perls’ technique, as applied in
one of his dreamwork sessions, provided a means for guided discovery and implicit
restructuring. It was followed by a systematic description of techniques for evoking and
transforming images, illustrated with case material (Edwards, 1989).
Back in South Africa I again had limited contact with the international research
community. Imagery restructuring techniques featured occasionally in the cognitive
therapy literature (Dowd, 1992). Mary Anne Layden, then at the Beck Institute, was also
promoting them and described their application (Layden, Newman, Freeman, & Morse,
1993) and Young described them extensively as soon as his publications began to appear
(Young, 1990;Young & Lindemann, 1992). These methods were all based on case
formulations that gave a significant focus to developmental factors. Leahy (1996, p. 197)
would be soon using the term ‘‘developmental analysis’’ and Dowd (1997) the term
‘‘cognitive–developmental therapy.’’
The theory of levels of processing was given further prominence by Teasdale’s (1993)
account of Interacting Cognitive Subsystems (ICS) theory, which included a distinction
between implicational and propositional cognitive systems. Teasdale argued that meaning
in the implicational system was holistic and often communicated by ‘‘poems, parables and
stories’’ and mentioned the role of ‘‘visual imagery elicited’’ (p. 345) by such expressive
methods. Later he explicitly argued that imagery offered ‘‘a very powerful way of
introducing new elements into a pattern of implicational code’’ (Teasdale, 1997, p. 150).
In South Africa, in 1995, I presented a case study in which restructuring of early
memories played an important role (Edwards, 1995) and shortly afterwards encountered
the first publication on imagery rescripting (Smucker, Dancu, Foa, & Niederee, 1995).
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Although Merv Smucker and I had adjacent offices for a year, we had never really
discussed imagery techniques! Like myself, Smucker had experienced a split between
University-based approaches to psychotherapy and experiential methods widely practiced
outside. I learned much later that he had a significant personal experience with a Gestalt
therapist a few years before but had not then seen how to integrate it into cognitive therapy
(Smucker, 2006).
Young (2007) recently described his experience of this same split. Following personal
sessions with Gestalt therapists from 1980, he immediately begun to experiment with
imagery techniques in the evolving framework of schema-focused cognitive therapy. ‘‘It
was my first realization that there was a viable method for accessing schemas other than
cognitive therapy. I’m quite confident that no one had introduced imagery of the Gestalt
kind into cognitive therapy before’’ (Young, personal communication, 24 July 2007).
The same was true for Ann Hackmann (personal communication, 30 July 2007) whose
keen interest in imagery and dreams (she had been recording her own) was not met in her
undergraduate courses at London University. Her clinical training, begun in 1967, seemed
similarly arid although one patient retrieved a traumatic memory during a procedure for
positive conditioning of sexual responses! Once in practice she ‘‘branched out and helped
with art therapy and psychodrama.’’ However, as in my own case, it was Beck’s model that
provided the framework for a meaningful integration. On a visit to the Beck Institute in
1986, she encountered Mary-Anne Layden who shared her passion for imagery and I
would learn much later that my 1989 chapter and 1990 paper had played a role in her
thinking and practice because, as she observed, they showed ‘‘how one might work with
dreams, images and memories within a cognitive therapy framework.’’
4. The restoration of restructuring applications of guided imagery
Today, imagery restructuring methods are prominent in many cognitive therapy
treatment approaches, including for posttraumatic stress disorder (Dowd, 2000;Ehlers,
Hackmann, & Michael, 2004;Fidaleo, Proano, & Friedberg, 1999;Grey, Young, &
Holmes, 2002;Hackmann, Ehlers, Speckens, & Clark, 2004;Karpelowsky & Edwards,
2005), the sequelae of child abuse (Dowd, 1997;Smucker & Dancu, 1999), and personality
disorders (Arntz & Weertman, 1999;Layden et al., 1993). In the treatment of personality
disorders, Weertman and Arntz (2007) provided an experimental comparison between
imagery rescripting on the one hand and cognitive restructuring and behavioral
experiments on the other. Using a cross-over design they provided evidence that both
are effective forms of intervention which complement each other. The value of imagery
rescripting is also increasingly recognized as having potential for social phobia (Hirsch &
Holmes, 2007;Wild, Hackmann, Clark, & Ehlers, 2005), agoraphobia (Day, Holmes, &
Hackmann, 2004;Hackmann, 1998), depression (Hackmann & Wheatley, 2007) and eating
disorders (Cooper, 2007;Ohanian, 2002). Finally, experimental studies with the
interpretation paradigm have provided evidence consistent with Teasdale’s ICS model,
showing that imagery offers a more direct connection than words to the implicational level
of encoding (Holmes & Mathews, 2005;Holmes, Mathews, Dalgliesh, & Mackintosh,
2006).
It has been a long journey of over a century from the work of Janet to the present
resurgence of imagery restructuring methods. Janet’s method is traditionally referred to as
‘‘imagery substitution.’’ However, the contemporary term ‘‘imagery rescripting’’ is a far
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better way of referring to the kinds of imagery methods discussed here and in this special
issue. There is a risk that simple techniques of substitution may only be a temporary
palliative as they may fail to identify and address the range of emotions involved and the
complexity of the associated meanings (Edwards, 1990b;Van der Hart et al., 1989).
A central feature of contemporary cognitive therapy approaches that work with traumatic
memories (recent or past) is a comprehensive assessment of the range of emotions and
associated meanings that underlie the client’s emotional distress and the systematic
application of methods appropriate for addressing them (Arntz & Weertman, 1999;
Edwards, 1990a, 1995, 2002;Hackmann, 2005;Smucker & Dancu, 1999;Young et al.,
2003). Viewed from this perspective, Janet’s interventions look more like rescripting than
mere substitution.
The inclusion of this kind of experiential work into cognitive therapy has required
something of a paradigm shift. Back in 1984, it seemed a distant possibility that schema-
focused cognitive therapy would evolve into a comprehensive, integrative treatment,
rooted in the cognitive model, and emphasizing imagery rescripting as a central
intervention that would prove its worth in a major randomized controlled trial of the
treatment of borderline personality disorder (Giesen-Bloo et al., 2006). The shift has
involved personal journeys of paradigm integration for several influential contributors.
Commenting on her current work on dreams and nightmares in posttraumatic stress
disorder, Hackmann (personal communication, 30 July 2007) remarked, ‘‘It has taken me
40 years to get to the point of studying the phenomenon that first attracted me to
psychology!’’.
‘‘The approaches you fight against, you may be using in five or ten years time,’’
confessed Young (2007) to a large audience at the World Congress of Behavioral and
Cognitive Therapies. It is often more effective to ignore the immediate verbal content of
thoughts and focus on here and now affective states, he argued, and recommended even
more emphasis on imagery and dialogue techniques. I like to imagine the spirit of Janet
sitting in the audience, smiling, and perhaps even shedding a tear.
Acknowledgments
Preparation of this paper was supported by a grant from the Rhodes University Joint
Research Committee.
The author wishes to thank Ann Hackmann and E. Thomas Dowd for helpful
comments on the draft.
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