Imaginative techniques have been used in therapeutic contexts, for several centuries and have now been extensively integrated into the Schema Therapy (ST) approach (1, 2). Imagery Rescripting (ImR) is a therapeutic technique that aims to reduce the distress associated with negative memories of early aversive experiences. It consists of prompting patients to rescript the autobiographical memory in order to satisfy their unmet needs. Although these basic needs are considered to be important in the genesis of maladaptive beliefs in Schema Therapy, studies specifically monitoring in which specific emotional needs are frustrated are scarce.

One of the salient features of ImR is its effectiveness in the treatment of different mental disorders. Over the past 10 years, abundant evidence proving efficacy has been collected, using ImR as both an integral part of broader clinical protocols and as a standalone technique (3, 4).

When considered as part of broader clinical protocols, ImR has proved to be effective in reducing the symptoms of posttraumatic stress disorder (PTSD) (5–7), social phobia (8, 9), and personality disorders (10). However, in these studies, ImR has not been experimentally isolated from cognitive restructuring.

The technique has proved to be effective also as a standalone technique in the treatment of PTSD (11–15), social phobia (16, 17), body dysmorphic disorder (18, 19), bulimia (20), depression (21, 22), and obsessive-compulsive disorder (OCD) (23–26). Recently, ImR has also been found to be effective at treating trauma-affected voice hearers (27).

The aforementioned studies delivered ImR individually, but ImR has also been successfully incorporated into Group Schema Therapy treatment of borderline personality disorder and eating disorder (28–32). The application of Group Schema Therapy has been described in the work by Farrel et al. (32).

However, to the best of our knowledge, the efficacy of group ImR on early childhood memories as a standalone technique has not yet been studied. Thus, in this study, we focused on ImR delivered in groups.

Initially, this research was conceived with the idea of delivering group ImR in person, but the spread of the COVID-19 pandemic forced the authors to perform the procedure via telehealth. A recent study supports the delivery of ImR via telehealth showing that, as long as privacy is granted, it is not less effective than face-to-face delivery (33). Group telehealth imagery setting might have the clear advantage of containing therapy costs. Moreover, it enables geographical distances to be reduced and thus allows access to population groups from more rural areas, which are often prevented from accessing clinical and research centers.

Notably, a growing body of literature has shown that the ability to become immersed in the autobiographical memory affects ImR outcome (34–37). Therefore, in this study, we assessed whether memory realism (level of vividness, ability to immerse, and participants’ distance from the images) was associated with a greater effectiveness of the group technique in meeting the subject’s core needs and in changing the dysfunctional belief attached to the memory.

Thus, the main purposes of this research were to verify the effectiveness of a group ImR intervention via telehealth. Specifically, we aimed to assess whether group ImR is effective in (i) responding to the basic emotional needs of participants as defined by ST, (ii) reducing dysfunctional beliefs and, and (iii) changing participants’ affective state.

In line with previous observations, we hypothesize that group ImR is effective in producing a cognitive and emotional improvement. In addition, we expect memory realism features to affect ImR effectiveness in meeting participants’ needs.

The aim of this study was to assess the effectiveness of a telehealth delivered ImR group intervention on childhood memories, in producing cognitive and emotional improvement. One of the first questions, we attempted to reply, was if ImR group intervention would be able to make participants retrieve memories. From the data, it is found that group ImR was effective in facilitating the retrieval of childhood memories. Monitoring the types of frustrated needs was not the main aim of this study but it is nevertheless interesting given their central role in the genesis of maladaptive beliefs in Schema Therapy. Specifically, memories were associated mostly with the frustration of secure attachment needs, than with the need for autonomy, competence, and sense of identity, and subsequently with the need to express one’s own needs and emotions, the need for spontaneity and play, and finally with the need for realistic limits. Group ImR was effective in facilitating needs’ satisfaction in almost the totality of our sample. This result is very important because in ImR individual delivery, patients’ need satisfaction is the ultimate goal of the intervention, which is concluded by the therapist only when participants report that they are emotionally satisfied (36). Along with the ability to satisfy the patient’s basic emotional needs, the technique seems to be effective in modifying maladaptive beliefs encapsulated into memory as already reported by Lee and Kwon (16), Wild et al. (8, 9), Cooper (20), in clinical samples, and by Otera et al. (49) in a non-clinical sample. The change in the maladaptive belief is observable particularly between the pre-test and the second and third sessions. This result is consistent with previous studies that show that the efficacy of the ImR interventions is notable a week after the first intervention (4, 50). As several studies have already proposed, three ImR sessions seem to be effective in modifying dysfunctional intakes or symptomatic conditions (16, 26).

Memories evoked through the group script were generally described as vivid and close, and participants stated to have been able to immerse themselves in the image. Importantly, this latter measure was strongly associated with the perception of having one’s own needs satisfied. This result is in line with a recent study by Looney et al. (37), who compared ImR features between high and low responders, in a sample of PTSD participants. The authors found that the new elements incorporated into the imagery are perceived as more vivid in high responders than in low responders. Therefore, considering the growing interest in the delivery of therapeutic techniques outside the classical therapeutic setting (51), helping the client to immerse themselves in memory seems to be important in the memory rehearsal and in satisfying the unmet emotional needs. This is in line with the study showing larger effects when app-based interventions are combined with therapist support (52).

Finally, our data show that the intervention brought about a change in the affective state. In the three sessions, there was a reduction in attention and activation levels. It would seem that ImR sessions reduced arousal bringing participants to a state of greater calm. This effect could be associated with progressively reduced fatigue in processing the emotional content related to target memories. This result is in line with previous studies indicating that ImRs reduce state stress symptoms (53).

Importantly, we also observed a general reduction in shame levels from the first to the third sessions. To the best of our knowledge, studies directly investigating the effect of group ImR on the affective state are very limited. However, previous studies reported a pre- and post-therapy reduction in shame and anxiety levels in participants with eating disorders and mixed personality disorders (29, 30). Our results suggest that increased positive emotionality might constitute a mechanism for the effectiveness of ImR, which is in line with the study by Dibbets et al. (54).

In conclusion, this study suggests that group ImR is a promising technique. However, it underlines the importance of monitoring the degree of immersion in the memory, which not only facilitates the memory rehearsal, but also makes the memory more vivid and affectively characterized. This provides evidence for which clinical experience has been suggested with respect to the technique in changing dysfunctional beliefs. When the client is not emotionally immersed in the memory, the technique is ineffective in meeting clients’ needs.

The sample is unbalanced with regard to gender and refers to a specific population. In this sample, participants were highly educated and almost half of the sample was constituted by psychologists. This limits the generalization of our results since psychologists are more familiar with the concept of “basic emotional need” and are probably more aware than the general population of their frustrated needs. However, none of the participants had previous experience with ImR, nor with group ImR. Future studies should include a more heterogeneous sample.

Ultimately, the absence of long-term follow-up does not allow us to monitor whether changes in beliefs have remained stable over time.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Guglielmo Marconi University Ethical Committee. The patients/participants provided their written informed consent to participate in this study.

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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