Imagery rescripting (ImRs) is a psychological intervention effective in treating intrusive images in PTSD. Studies have suggested factors in ImRs which may influence outcome; however, research is still in its infancy, with mechanisms of action still unknown and factors which make it successful unclear (Arntz, 2012). This study aimed to investigate therapists' experience of the process of delivering ImRs in PTSD and what they believe make it an effective intervention. The study used a Grounded Theory (GT) approach to investigate eight therapists' experience of using ImRs in PTSD, and their view of what makes it successful. A GT analysis produced a model illustrating the process of using ImRs, consisting of four theoretical themes: using ImRs in PTSD, facing obstacles in working with the imagination, identifying the mechanisms of action and moving from the unknown to the known. The main suggested mechanisms of action involved re-establishing power and enabling an emotional shift to occur. The model highlighted inter-relationships existing, with distinct themes feeding into each other. The GT model suggested more structure and research is required for an increased understanding in ImRs, allowing therapists to feel more confident and comfortable using the perceived anxiety-provoking technique. Future research could focus on interesting findings from this study allowing an already powerful therapeutic tool to develop and become a more widely-used and prioritised treatment technique in PTSD.

Intrusive images are a common phenomenon in post-traumatic stress disorder (PTSD; American Psychological Society, 2013). Imagery-Rescripting (ImRs; Arntz & Weertman, 1999) is an experiential technique for targeting intrusive images and is gaining popularity as a treatment for PTSD (Arntz, 2012). Although there is evidence to suggest that ImRs is an effective treatment of PTSD (see Arntz, 2012), it is currently unclear how ImRs works. The aims of the present study were 1) to develop a coding scheme that captured important factors of ImRs session, and 2) to apply this coding scheme prospectively to investigate how certain factors might relate to treatment outcome. The study used thematic analysis (Braun & Clarke, 2006) to develop an ImRs coding scheme. Next, a single case experimental design was employed to track six participants over the course of their ImRs therapy for PTSD. Session content captured by the coding scheme was compared to changes in weekly outcome measures to investigate whether the presence of certain codes related to a reduction in PTSD symptoms. Results suggested a number of factors might be important for determining treatment outcome. Specifically, Attitude towards ImRs, Activation of the image, Ability to follow ImRs, Activation of original internal processes and internal processes during the re-script, Believability and Attitude towards the outcome are suggested as potentially important factors for determining ImRs efficacy. Study strengths, limitations and clinical implications are discussed. Recommendations for future research, including in-depth investigation of individual factors are suggested.

The aim of the present thesis was to examine the effectiveness of the Illness Management and Recovery (IMR) program for teaching clients with schizophrenia or schizoaffective disorder to better manage their illness and to promote recovery. This was accomplished through an examination of the program’s effects on psychosocial functioning and psychopathology, the evaluation of general and specific impact of neurocognition on learning the fundamentals of illness self-management, and the impact of symptom severity on outcome of the IMR program. The utility of the illness management and recovery scale to evaluate illness self-management of clients with schizophrenia and schizoaffective disorder was also investigated. The effects of the IMR program were evaluated in a randomized controlled trial that compared participants in the program to participants receiving treatment as usual. 41 participants were recruited at six psychiatric outpatient rehabilitation centers in Uppsala, Sweden, and were randomly assigned to IMR groups for approximately 40 sessions or to a treatment as usual control condition. The IMR program participants demonstrated greater improvement compared to participants in treatment as usual in illness self-management, reduced psychiatric symptoms, improved coping skills, and decreases in suicidal ideation. The findings suggest that the IMR program is effective in improving the ability of individuals with schizophrenia and schizoaffective disorder to better manage their illness. Possible association between neurocognitive functioning and the acquisition of illness self-management skills was investigated in a total of 53 participants who completed the IMR program. Speed of processing was related to client reported illness self-management skills acquisition, before and after controlling for psychiatric symptoms and medication, but neurocognitive functioning did not predict improvement in clinician ratings of client illness self-management skills. The findings suggest that compromised neurocognitive functioning does not reduce response to training in illness self-management. The impact of symptom severity on outcome of the IMR program was explored in 52 participants who completed the program. The results suggest that significantly more participants met the severity criterion of remission at post-treatment, and it appears that participants not reaching the severity criterion at post-treatment, also benefited from the IMR program, as indicated by the similar effect sizes of the two subgroups (meeting versus not meeting the severity criterion at post-treatment). The psychometric properties of the Illness Management and Recovery Scale (IMRS) were evaluated in 107 participants with a diagnosis of schizophrenia or schizoaffective disorder. And an item-by-item investigation was conducted in order to establish their utility in monitoring the clients' progress in the IMR program. Both the client and clinician version of the IMRS demonstrated satisfactory internal consistency, large test-retest reliability, and convergent validity with conceptually related measures of psychiatric symptoms, quality of life, and perception of recovery. The findings support the utility of the IMRS as a measure of illness self-management and recovery in clients with schizophrenia and schizoaffective disorder. The general findings of this thesis support the IMR program to be effective in improving the ability of the participants to manage their disorder. The impact of neurocognitive dysfunction on the participants’ ability to learn the fundamentals of illness self-management seems to be limited, and symptom severity did not limit the benefits of the IMR program. Support for the utility of the IMRS to monitor the participants’ progress in the program was also found, providing a brief and economical method for assessing outcome of the IMR program. / Syftet med föreliggande avhandlingsarbete var att undersöka Illness Management and Recovery (IMR) programmets effekter av att lära klienter att bättre hantera negativa konsekvenser av schizofreni eller schizoaffektiv sjukdom och att främja återhämtning. Detta åstadkoms genom en utvärdering av IMR programmets inverkan på psykosocial funktion och psykopatologi, en undersökning av specifik och generell påverkan av neurokognition avseende deltagarnas möjligheter att lära in grundläggande sjukdomshanteringsfärdigheter (illness self-management), samt en undersökning av huruvida schizofrenisymtomens svårighetsgrad inverkar på programutfallet. Vidare undersöktes Illness Management and Recovery Skalans (IMRS) användbarhet för att utvärdera sjukdomshantering och återhämtning (illness self-management and recovery) hos personer med schizofreni eller schizoaffektiv sjukdom. IMR programmets effekter utvärderades genom en randomiserad kontrollerad studie i vilken 41 programdeltagare jämfördes med deltagare i kontrollgrupp vilka fick enbart sedvanlig psykiatrisk behandling. Deltagarna rekryterades vid sex subspecialiserade psykiatriska öppenvårdsmottagningar och slumpades till att antingen delta i IMR programmet eller kontrollgrupp. IMR programmets deltagare uppvisade i jämförelse med kontrollgruppen förbättring i sjukdomshantering, minskade psykiatriska symtom, förbättrade coping-färdigheter samt minskade självmordsbeteenden. Resultaten stöder antagandet att IMR programmet är effektivt vad gäller att förbättra deltagarnas förmåga att hantera negativa effekter av schizofreni och schizoaffektiv sjukdom. Möjliga associationer mellan neurokognitiv funktion och förmågan att tillägna sig färdigheter för sjukdomshantering undersöktes hos 53 deltagare som genomförde IMR programmet. Resultaten pekar på att neurokognitiva svårigheter inte inverkar på deltagarnas möjligheter att lära sig sjukdomshantering enligt IMR modellen. Processhastighet var relaterad till klientrapporterad sjukdomshantering men inte till klinikerrapporterad sjukdomshantering. Processhastighet tycks vara relevant för klientens upplevelse av hur väl han eller hon tillägnat sig programmets strategier och färdigheter, snarare än sjukdomshantering per se. Huruvida schizofrenisymtomens svårighetsgrad inverkar på utfallet av IMR programmet undersöktes hos 52 deltagare som genomförde IMR programmet. Resultaten pekar på att signifikant fler deltagare uppfyllde svårighetsgradskriteriet för remission av schizofrenisymtom efter genomfört IMR program. Även deltagare som inte uppfyllde svårighetsgradskriteriet har nytta av IMR programmet något som indikeras av de båda gruppernas (uppfyllde jämfört med uppfyllde inte svårighetsgradskriteriet) likartade effektstorlekar. Illness Management and Recovery Skalans (IMRS) psykometriska egenskaper undersöktes för 107 deltagare med en schizofreni eller schizoaffektiv diagnos. Skalans enskilda frågor analyserades för att undersöka skalans användbarhet för att utvärdera deltagares progress och utfall i IMR programmet. Både klient och kliniker versionen av skalan uppvisade tillfredsställande intern konsistens, stor test-retest reliabilitet och konvergent validitet med konceptuellt relaterade instrument för psykiatriska symtom, livskvalité och återhämtning. Resultaten stöder antagandet att IMRS är ett användbart instrument för att utvärdera sjukdomskontroll och återhämtning för personer med schizofreni eller schizoaffektiv sjukdom. Avhandlingsarbetets resultat stöder antagandet att IMR programmet är effektivt vad gäller att förbättra deltagarnas förmåga att hantera de negativa konsekvenserna av schizofreni och schizoaffektiv sjukdom. Neurokognitiva svårigheter inverkar i begränsad utsträckning på deltagarnas möjligheter att lära sig sjukdomshantering och schizofrenisymtom tycks ha begränsad inverkan på programutfallet. Resultaten stöder även antagandet att IMRS är ett användbart instrument för att utvärdera sjukdomskontroll och återhämtning för personer med schizofreni eller schizoaffektiv sjukdom, vilket erbjuder en kortfattad och ekonomisk metod att utvärdera effekterna av IMR.