Iain McCormick ✉
Schema coaching uses the methods of schema therapy, applying these with high-functioning individuals in the workforce. Imagery rescripting, a core schema technique, is an imagery-focused approach designed to reduce distressing memories and so change related beliefs and early maladaptive schemas. This qualitative study used an interpretative phenomenological approach to investigate the experience of clients undertaking imagery rescripting by employing semi-structured interviews. Overall, the experience of clients was that imagery rescripting was powerful but emotionally draining and had a positive long-term impact. There can be cautious optimism about suitably trained, supervised and ethically adherent coaches using this approach.
schema coaching, schema techniques, imagery rescripting, client experience, qualitative study
Accepted for publication: 10 July 2024 Published online: 01 August 2024
© the Author(s) Published by Oxford Brookes University
Schema coaching was developed by McCormick (2023a) who adapted the methods and techniques of schema therapy (Young et al., 2003; Farrell & Shaw 2012; Farrell, et al., 2014) and applied these to high-functioning individuals in the workforce. Schema therapy and coaching both have a clear integrated approach based on early maladaptive schema which are persistent organised patterns of thought and behaviour that are self-defeating and dysfunctional for the individual (Young et al., 2003). Schema coaching should only be undertaken by suitably trained and supervised coaches who remain within their competence limits (McCormick, 2022). Both schema therapy and schema coaching aim to assist clients to change their maladaptive schemas and have their core needs met (McCormick, 2016).
Imagery rescripting, a core schema technique (Jacob & Arntz, 2013; Arntz, 2012), is an imagery-focused approach designed to reduce distressing images or memories and to change related beliefs and schemas. Imagery rescripting has been successfully used with a range of disorders, such as posttraumatic stress disorder, social anxiety disorder, obsessive compulsive-disorder, major depression, bulimia nervosa, and body dysmorphic disorder (Morina et al., 2017).
The process of imagery rescripting involves the activation of core childhood memories that appear to underlie the presenting early maladaptive schemas and then assisting the client to reframe these. After an appropriate schema case conceptualisation and psychoeducation phase (McCormick, in press), the coach asks the client to imagine a core childhood event with its inherent painful emotions and unmet needs. The client is encouraged to tell their story in the first person present (‘I am now seven years old and at school …’) Shortly before the memory recall peaks in intensity, the coach asks the client if they can intervene in the story and change the painful circumstances so that it has a greatly improved ending and addresses the unmet client need. In the earlier stages of rescripting the intervening figure is typically the coach, however with time, this support can come from an imagined caring individual or a fantasy figure. With more practice the client can learn to be their own coach and use their healthy adult mode (the person’s mature executive functions) to intervene with effective coping behaviours, for example, self-compassion and acceptance.
The aim of this study is to evaluate the effectiveness of imagery rescripting from a qualitative and interpretative phenomenological perspective using semi-structured interviews. The study addresses a range of questions including: Do clients undertaking imagery rescripting understand the process and are they able to explain the purpose of the technique in a succinct and clear way? Also the study explores what the impact of imagery rescripting is for client in the short and long term. The interpretative phenomenological approach has been adopted because there is a wide range of quantitative studies evaluating the effectiveness of imagery rescripting, however, little work has been undertaken to assess the clients’ views on the approach.
There is currently very little literature on the effectiveness of schema coaching as the approach is very new, however there is an extensive literature in the closely related field of schema therapy. A range of relevant research is summarised below.
In an early meta-analysis, Jacob and Arntz (2013) examined five studies that involved patients with borderline personality disorder using schema therapy. They concluded that schema therapy demonstrated preliminary effectiveness in the treatment of these types of patients in both inpatient and outpatient environments and using either individual, group and combined therapy.
In a subsequent publication (Bakos et al., 2015) undertook a larger scale systematic review of schema therapy effectiveness. The authors identified 3,200 published research abstracts and then selected studies with participants over 18 years old, who had undertaken 10 or more sessions and studies had more than three subjects. This resulted in nine studies being reviewed and on this basis they concluded that there was preliminary evidence for the effectiveness of schema therapy.
Avramchuk and Hlyvanska (2018) undertook a review of the literature that compared dialectic behavioural therapy, mentalisation-based therapy and schema therapy methods with borderline personality disordered clients. They identified 33 studies that met their methodological criteria and concluded that all three therapeutic approaches could be beneficial. They noted that schema therapy produced the longest periods without symptom recurrence and had the lowest dropout rates.
In a meta-analysis Körük and Özabacı (2018) reviewed 35 studies that used schema therapy with depressed clients. The authors concluded that schema therapy was an effective treatment for depression and that the impact was independent of country or culture in which the work was undertaken, individual or group therapy format, session duration, the number of sessions per week or the type of depressive disorder.
Koppers et al. (2020) reviewed the impact of group schema cognitive behavioural therapy with clients who suffered from both personality disorders and depression. They concluded that this variant of schema therapy was effective for a broad range of these clients.
Peeters et al. (2020) in a systematic review examined 41 eligible studies on the effectiveness of schema therapy combined with systematic exposure to the feared source and found that it was a useful treatment for clients with chronic anxiety and co-morbid personality disorder.
Dostal and Pilkington (2023) conducted a systematic review and meta-analysis of early maladaptive schemas and obsessive-compulsive disorders. They reviewed 22 studies and found that early maladaptive schemas were positively correlated with obsessive-compulsive disorder. They concluded that these early maladaptive schemas relating to dysfunctional negative expectations and a belief about being unable to cope were most strongly associated with this disorder.
Zhang et al. (2023) undertook a systematic review and meta-analysis of schema therapy for the treatment of clients with personality disorders. They identified seven single-group trials with 163 participants and eight randomized controlled trials with 587 participants. Their work suggested that schema therapy produced a moderate effect size (g = 0.359) compared to control groups, for reducing symptoms. Schema therapy also improved the quality of life compared to control conditions and it reduced the impact of early maladaptive schema. They concluded that schema therapy can be effective in the treatment of clients with personality disorders with evidence that it improves quality of life and reduces symptoms.
Joshua et al. (2023) also undertook a systematic review of the impact of schema therapy in adults with eating disorders and found evidence to support its use particularly with clients experiencing more severe conditions.
Outside the clinical setting, Shahsavani et al. (2020) found schema therapy to be effective in migraine severity reduction at post-test and follow up. In the area of couples therapy, Roediger et al. (2020) used a random controlled trial with imagery re-scripting based on schema therapy and found that it had a positive impact on experienced closeness and the mood of the couple.
Based on the above studies, there is growing evidence of the effectiveness of schema therapy in a range of areas.
The research described above is primarily quantitative in nature and there are few qualitative studies examining the experiences of clients with schema therapy and its techniques. In one such study that explored clients’ and therapists’ general perspectives on schema therapy, De Klerk et al. (2016) found that the helpful elements of schema therapy were the powerful therapeutic relationship, the clear theoretical model, and the specific schema procedures. A study by Ten Napel-Schutz et al. (2011) showed that imagery techniques in schema therapy were considered a valuable method by personality disordered patients. Tan et al. (2018) used semi-structured interviews and indicated that schema therapy patients found the approach confrontational but valuable. Schaich et al. (2020) undertook a qualitative study on the impact of imagery rescripting used as part of schema therapy and found that patients reported it to be highly emotional and exhausting in the short term. However, in the long-term patients reported that they gained a better understanding of their early maladaptive schemas and enhanced both their emotional regulation and interpersonal relationships.
Imagery rescripting is a core technique in schema therapy that enables clients to reframe early maladaptive memories, so address their unmet needs and improve their quality of life (Young et al., 2003). Ramano et al. (2020) in a preliminary study had 33 individuals with social anxiety disorder randomly assigned to either a single session of imagery rescripting or to imaginal exposure or to supportive counselling. Outcomes were assessed one to two weeks after the intervention and at three-months. Their results demonstrated imagery rescripting increased positive and neutral memory details and supportive counselling produced no memory changes.
Fink-Lamotte et al. (2022) undertook a study to compare imagery rescripting with imagery self-compassion and passive positive imagery use to reduce pathological disgust. The study used 24 subjects with diagnosed contamination-related obsessive–compulsive disorder and 24 matched, healthy controls. There results indicated that all three imagery strategies equally impacted disgust.
Lloyd and Marczak (2022) undertook a systematic literature review of ten studies to evaluate the impact of imagery rescripting on negative self-image in social anxiety disorder. They found that imagery rescripting was associated with decreases in a range of variables such as image distress, memory distress, image vividness, memory vividness and associated beliefs.
Steel et al., (2022) studied the impact of imagery rescripting on refugees and asylum seekers with post-traumatic stress disorder. They used a multiple baseline design where clients were randomly allocated to a baseline waiting list or a treatment condition. Their results showed a significant improvement in symptoms and mood as a result of the imagery rescripting phase and not in the waitlist control. They concluded that imagery rescripting was a safe and potentially effective treatment for post-traumatic stress disorder in refugees and asylum seekers.
Kroener et al. (2023) studied the efficacy of imagery rescripting as a short-term intervention across a range of clinical disorders using a systematic literature review. They used 23 trials with 805 adult subjects. When they compared imagery rescripting to a passive control group they showed large post-treatment effect sizes. They also found large effects for the social anxiety disorder and post-traumatic stress disorder groups that had comorbid depression. They concluded that imagery rescripting is a promising short-term technique for a range of clinical disorders that have aversive mental images.
Kip et al. (2023) undertook a meta-analysis of studies using randomised controlled trials on the efficacy of imagery rescripting for disorders that involved aversive memories. They reviewed 17 trials with 908 participants who had either anxiety disorders, depression, posttraumatic stress disorder or eating disorders. They demonstrated an overall effect size of g = 0.68 compared to control conditions. The authors concluded that imagery rescripting can be effective in treating a range of psychological conditions.
Hicks (2023) undertook a study to assess how military veterans face mental health challenges caused by demanding working conditions, extended periods away from family, and making the transition from military service back to civilian life. The study examined the effectiveness of imagery rescripting, using a systematic review and meta-analysis, of nightmares and sleep disturbances for veterans. The author found that imagery rescripting had a positive impact on nightmare frequency, sleep quality and post-traumatic stress symptoms.
In summary, schema therapy is a potentially effective treatment for a range of psychological disorders and schema coaching is based on this foundation. One of the key techniques in schema therapy is imagery rescripting and there is indicative research on its effectiveness in a range of disorders. Most of the research discussed above is quantitative in nature and there is a very limited number of qualitative studies.
The present qualitative study used an interpretative phenomenological approach (Eatough & Smith, 2017) and aimed to investigate the experience of clients undertaking imagery rescripting as part of schema coaching (McCormick, 2023b) by employing semi-structured interviews based on the work of Schaich et al. (2020). The interpretative phenomenological approach is valuable as it can assist coaches to better understand the breadth and depth of clients’ experiences (Passmore & Fillery-Travis, 2011). This approach can be particularly relevant to highly emotive and engaging techniques such as imagery rescripting.
Participants in the study were clients who had completed schema coaching and were followed up to review progress and to assess their experiences of imagery rescripting. Both the schema coaching and the follow-up semi-structured interviews were conducted by the author. There were ten client participants, six male and four female. The mean age of the participants was 52 years. At the time of interview all participants had completed their schema coaching and none had dropped out before completion. All participants had graduate qualifications and eight had post-graduate qualifications. All participants were currently employed.
The interviews lasted between 30 and 60 minutes and the eight questions below were asked of all participants via telephone or in person. The author took notes during the interview and read these back to the clients to ensure their accuracy. If needed corrections to the notes were made at this stage.
The interview questions, based on the work of Schaich et al. (2020), included the following.
Detailed notes were taken during each interview and then a content analyses was generated to summarise the results.
The qualitative data were designed to address eight themes as set out below.
The results of the interviews are presented below, grouped using the eight themes above, however in some cases the quotes from clients have been altered slightly to preserve anonymity and improve clarity.
All clients were able to clearly articulate the nature of the imagery rescripting process. They saw it as a structured process that involves rewriting early painful memories with a new context and interpretation. It helped clients understand the impact of these memories and take back ownership of them.
Three verbatim examples are given below.
Client A: Imagery rescripting involves taking an image from your memory and working to give it a different context and interpretation. It is being able to see the bigger picture of the event and learning to be more compassionate with yourself and others.
Client C: It is working with deeply buried painful memories and understanding them and their impact. It is a structured process that enables you to analyse your past so it is not just memories but something you can learn to deal with.
Client G: Imagery rescripting is an opportunity to reflect on your early years and experiences and how these have influenced you and how you deal with things today.
Clients used imagery rescripting to deal with painful memories that made them feel out of control and immobilised. They undertook the approach to address a range of painful emotions, including a deep sense of failure and problematic reactions due to lack of support.
Client B: I used imagery rescripting because I was working on a powerful and unwanted sense of failure. It was very deep. I did not have support as a child and so I built very strong walls to protect myself. The technique helped me to make sense of all that.
Client E: The coach and I had already done a lot of more surface coaching work and we wanted to delve deeper into more impactful events that had shaped me.
Client J: I had this very difficult situation in my mind and I could not let go of it – so imagery rescripting was worth trying.
Clients typically found that the process was exhausting and sometimes shocking, but in the long term, it was positive. They found it challenging to revisit the past painful experience, but the coach's voice offered a supportive alternative explanation. Overall, the experience was valuable, allowing clients to think deeply about their challenging past.
Client F: It was hard to open up. Hard to find a specific story to work on. Once I told the story of the painful memory it was easy to see the situation very clearly in my own mind and to feel it in my gut. It is finding the early memory that is the difficulty. The later stage of being my own coach and using imagery rescripting was also challenging.
Client H: The hardest part was imagining the perpetrator doing something different as a result of the intervention. However, after a few moments it became easier to see and that was very helpful. The voice of the coach as re-scripter was very useful.
Client J: The hard part is delving deeper into the detail of the situation. I did not want to get into it - it was hard. On the positive side the experience was validating – both the coach’s voice and having the time to reflect. I got a very different perspective. I felt validated by going into it and then talking to myself about it. The experience allowed me to validate myself. That was healing.
Client D: Overall, it was helpful. The introduction enabled me to be at peace and feel safe starting the exercise. During the imagery rescripting I felt disconnected from the outside world. I was totally in the now. The debrief was particularly helpful, I loved it and found it extremely useful. We had an extended session, so the timing worked really well for me. The support from the coach was excellent and the private office space felt safe.
Client H: The introduction part of the technique was similar to other therapy that I have had so I could understand what was going on. The explanation of the technique was clear as was the guiding hand of the coach. I felt the expertise of the coach and I felt safe. The time used was good and I never felt time pressure. The debrief was very helpful and succinct while still allowing me time to process the experience. I felt very supported by the coach – very much.
Client I: The introduction was very clear and it fitted well with what happened in the experience. The debrief was useful as I came to understand what happened. I could connect the body experience with what I knew. Connecting the idea with what made sense and noting patterns. We had more than an hour in the session so the time felt luxurious. I felt huge support from the coach and this was essential. The intensity of the coaches voice in the technique was key. I was taken good care of.
All clients expressed the view that the short-term impact of imagery rescripting was significant, with most clients feeling exhausted and in one case pleased not to have to deal with domestic issues immediately after the session. For others the immediate impact was feeling more relaxed and less emotional. However, the long-term impact was substantial for all clients, with several feeling calmer, better able to cope with emotions, more able to deal with their inner critic and having a foundation for further schema work.
Client B; The impact has been huge. In the short term it really made me think. In the longer term I have really changed my lifestyle. I went to a weekend retreat some months after our session and started yoga. I walk the dogs a lot and my changes have had a very positive impact on my blood pressure. The long term impact is very clear.
Client D: In the short term I felt really centred and had a strong sense of self-compassion. I felt I understood the painful memory and why it was traumatic. In the long term the impact has been great. I have an ongoing frame of reference that is very helpful. I have a clear understanding of my inner adult and my inner child. I also understand the impact that the painful situation had on me for a long time. It has been really useful. I have been able to cope with my emotions much better and understand the power of the context on these.
Client E: The short term impact was confronting and upsetting but I settled down afterwards. In the longer term it brought important issues to the fore and emphasised how much I needed to work on my inner critic.
The clients all learned about managing memories, revisiting the past, understanding early childhood experiences, and the power of imagery rescripting. They also learned about self-awareness and the importance of emotional drive in personal growth. They realised that their perception of past events may not always be helpful or rounded. They also learned to reframe past events to help themselves and avoid repeating unhelpful patterns. They found that it was never too late to resolve distressing experiences and that listening to oneself from a healthy distance was more important than validation from others.
Client G: I learned how to reframe what happened in the past that was not helpful, so you can help yourself and not repeat past patterns.
Client H: It is never too late to resolve something that is distressing you. It does not have to be a traumatic experience to need work. If it is distressing to you, you should work on it.
Client I: I learned to listen to my own inner voice but from a healthy distance – somewhat removed. I love that perspective – its self-validating which is much more important than validation from another person.
The clients all recommend imagery rescripting as a powerful tool for individuals with troubled pasts, stresses, and deep challenges. It was seen as particularly beneficial for people who are less stable and easily triggered for no obvious reason. However, it is less suitable for those who are not visual, and the use of photos or timelines may help those who are not. Clients suggested that the technique could be dangerous in the wrong hands and should only be undertaken by a competent coach well trained in schema therapy or coaching. It was thought to be most effective for those who ruminate on the past, repeatedly revisit painful past scenes, or are victims of abuse or post-traumatic stress disorder.
Client C: Absolutely I would recommend it for others. However I would want to make a judgement about who would benefit from it, before thinking about making a recommendation.
Client D: Yes I would recommend it to others particularly for executives that are talented and able but less stable. It would be very useful for individuals who are easily triggered for no obvious reason. I am a very visual person so this worked well for me, perhaps if you are not, then it might not work so well. Perhaps the use of photos or a timeline relevant to the painful memory would be useful for those who are not so visual.
Client I: It would be hugely beneficial to many people. Anyone who ruminates on the past and wants to put something in perspective or cannot stop revisiting a scene. Any victim of abuse, post-traumatic stress disorder and so on. But it is a very powerful technique and could be dangerous in the wrong hands.
Clients felt that coaches using imagery rescripting needed to be well-trained and preferably with a background in clinical psychology because the technique requires a particularly strong sense of trust between client and coach. The coach must be experienced, clear about the individual's objectives, and practiced in delivery so they can exude confidence and create a safe environment for the client.
Client A: I can imagine that some clients would struggle with the technique – some people struggle to find and remember things. I am verbal and also able to imagine things so it was good for me .
Client C: Any coach using this technique would need to create a strong sense of trust with the client. A background in clinical psychology would be very useful. The coach would need experience and expertise. This is not a technique for someone with no psychology background and a simple on-line coaching course!
Client I: Other coaches using this approach need to be very practiced in the delivery, so they exude confidence, so the other person feels safe. Clear instruction and confidence are very important.
This study explored the experiences of clients with the technique imagery rescripting, as part of schema coaching. The paper aimed to examine the factors that clients saw as helpful or hindering when undertaking imagery rescripting as well as the short and long-term impacts on their everyday lives. The interpretative phenomenological approach revealed that clients found imagery rescripting both powerful but emotionally draining and that it had a positive long-term impact. The approach also produced a range of initial implications for coaching practice in the area of schema and imagery rescripting which are set out below.
Adequate training is vital for coach practitioners if they are to be able to assist clients and remain within their areas of competence. In the case of imagery rescripting this is particularly important due to the intense personal nature of the approach. Clients in this study suggest that imagery rescripting is a powerful technique and so great care needs to be taken to ensure the clients’ safety needs are met. Coaches must also be confident in order to intervene in the client’s imagery with power and impact. The technique can only be successful if the client’s ‘wrongs are righted’ and the coach’s performance will directly impact this. If the coach is uncertain in the rescripting process it would leave the client in a confused and uncertain state.
Supervision is critical for all coaches if they are to develop professionally. Coaching psychology practitioners undertaking schema work may require two types of specialist supervision, firstly from a clinical psychologist with expertise in schema therapy and secondly from an organisational psychologist with expertise in coaching in the workplace. This combination is more likely to be able to address their support and challenge needs during schema coaching.
Imagery rescripting is typically practiced by clinical psychologists with clients drawn from the forensic or clinical populations. By contrast, coaches generally engage with clients from the workplace and are not often trained to deal with individuals from the clinical population. So ensuring that the client is, in fact, high functioning and free from any form of dissociative dysfunction or other major psychological disturbance is essential. So, undertaking a risk analysis during case conceptualisation is vital for coaches. Where the coach suspects the client may be part of the clinical population, or could be suffering from a more severe form of psychological dysfunction, referral on to a clinical psychologist is critical.
The imagery rescripting technique can generate high levels of emotionality and coaches need to be able to handle these levels with confidence and competence. This not only requires adequate training and supervision, but also coaches participating in personal schema therapy to address their own issues and challenges. To demonstrate the needed levels of empathy for clients going through imagery rescripting, all coaches should have also undertaken this process as clients themselves and worked on their own personal development before offering these services to clients.
At the beginning of the imagery rescripting process, coaches need to give clients a full and clear introduction to the technique. This is especially important for executives and others in the workplace who have rarely had experiences of this nature. Helping the client to understand the potential discomfort and even pain that they may experience during imagery rescripting is necessary. This is particularly so because intense emotional experiences are often routinely avoided by successful business people and so the rationale, structure and process of the technique can help clients feel comfortable, safe and willing to undertake the work. Sticking to a protocol which closely follows the initial explanation of imagery rescripting can help clients feel comfortable and avoid unexpected changes.
Imagery rescripting needs to be undertaken in an uninterrupted manner to be most effective, so having an office environment that is quiet and reasonably sound proof, without outside distracting noise, is vital. Also having sufficient time to explain the procedure, undertake it and then debrief is a key to success. Experience in schema coating suggests that often two or even three hours are required to undertake this process in an unhurried way.
Imagery rescripting is a highly experiential technique and clients’ need to focus on their emotions and bodily sensations to get the most from it. To increase the opportunities for this experiential focus some clients’ find it helpful to start with a slow breathing or other relaxation exercise. This moves the client from the intellectual to the somatic and can be very helpful to enable the client to feel comfortable during the early stages of the work.
Giving clients sufficient time to think about the core childhood memory that they want to work on, in imagery rescripting, is vital. Allowing silences in relevant parts of the session can be very helpful in giving clients the opportunity to consider the best option. Some clients will benefit from the opportunity to write out the event, as this provides processing time for them. Also reassuring clients that there is no one right memory to work on can reduce pressure on the client and allow them to proceed more comfortably. Suggesting to the client that they can, if they feel comfortable, undertake additional rescripting sessions, either with the coach or by themselves is important.
Building a strong sense of safety and control is critical in imagery rescripting. The client must, at any time, be able to ask to stop the process if they feel uncomfortable. The usual confirmation of confidentiality in the session is essential.
Allowing time for the client to recover and compose themselves after the rescripting session is always necessary. Clients typically get deeply involved in the imagery process and explaining that they may not feel like going straight back into work or domestic duties can be helpful.
Homework in schema coaching involves agreeing with the client the actions or exercises that they will undertake between sessions. Clients often find it helpful to repeat the imagery rescripting exercise at home but with a different childhood memory compared to the one used in the coaching session. Care needs to be taken with imagery rescripting homework that the client is kept safe and that there is no possible re-traumatisation. Talking through the details of the imagery rescripting homework options can help the client to learn to always intervene before the emotional climax of the memory and so avoid any possible re-traumatisation.
In conclusion, the current phenomenological study suggests that there can be cautious optimism about suitably trained, supervised and ethically adherent coaches using this approach. The current paper suggests that imagery rescripting may have a positive long term impact, despite some clients being exhausted and fatigued by the process.
The current study has a range of limitations. Firstly the sample is small and drawn from one geographical region in New Zealand. Wider sample groups would be useful in understanding the generalisability of the findings. The current study contains no control condition and this type of methodology would ensure findings are more robust. The coach also collected the client data in the present study and having independent data collection would enhance the validity of the study. Data was collected from clients only once and clarity about the longevity of the findings would be improved with multiple data collection points over time.
Future research is required in the area of schema coaching as it is in its infancy. This research should include: more diverse client groups, longitudinal empirical designs, large sample sizes, independent data collection processes and randomised allocation to control and schema coaching groups. Replication of the study using different schema coaches would also be helpful to enhance the robustness of the findings.
Replicating the study with a large sample of more diverse clients and over a longer period of time or across work groups would also provide greater clarity about the efficacy of imagery rescripting as part of schema coaching in the workplace.
This study offers a new client-based perspective on imagery rescripting in schema coaching. It provides a detailed insight into the technique and sets out a range of practical implications for coaches wishing to consider using imagery rescripting with clients.
Iain McCormick PhD, an executive coach, trained initially in clinical psychology, then completing a PhD in work stress. His research and practice interests include reflective practice and schema coaching.