Martijn van Teffelen

Imagery-enhanced cognitive restructuring: Protocol 111 5 seated?” can be asked to help a participant relive the situation. When a participant is reliving a mental image, it is helpful to look for signs that reveal a participant is becoming emotional, such as sweating or changes in facial expression. By asking too many questions participants can also get distracted or feel that they need to do well and provide the ‘right’ answer. Then it is recommended to summarize the mental image and let the participant focus on it. A third problem that can arise is that a participant might start describing a mental image in past tense. Describing an image in past tense will potentially lower the vividness and emotionality of the image. When this occurs, a therapist can help a participant by for example by rephrasing “... So your daughter is looking at you. She is not telling the truth.” When a participant continues to describe the image in past tense, a therapist should mention this and encourage a participant to describe the image in present tense. A fourth relevant problem a participant might run into is giving multiple ‘scenes’, or examples in a situation. For instance, a participant described getting angry multiple times because she did not get a promised taxi ride. The situation described by this participant involved multiple scenes, e.g., being on the phone, waiting on the sidewalk, talking to the hotel clerk. The problem of multiple scenes can be tackled by having the participant select the most prominent scene that triggered the most anger. Fifth, a participant might hold a degree of loyalty to the ‘aggressor’, especially when close relationships are concerned. Participants might then not dare to express their anger, which in turn might trouble the identification of hostile beliefs. A potential solution to this problem is to ‘normalize’ anger through empathizing with the elicited anger. For example, when a participant is describing that she was not invited to a party with friends she normally hangs out with during the recall phase, a therapist might respond with: “No way, you have to be kidding me? Did (s) he really does that? Does (s)he not realizes what this means to you? I can imagine this must have really triggered your anger!”. A sixth problem that may occur is when a participant is not able to reexperience the momentary angry affect that was once associated to the situation as they already developed some helpful thoughts or due to shame rationalized the anger. In that case, extra attention should be paid to the imagery phase. During the last part of the imagery phase, a therapist could repeat to ‘focus on the bodily sensations, angry unjust feeling and all its details’ as much as possible and provide the participant enough time to do so. In some cases, participants may actively avoid difficult emotions. When a participant is actively avoiding emotions, potentially multiple sessions are required. Last, therapists sometimes had difficulties streaming the flood of words into a concise sentence and to include some form of ‘intention’ by the aggressor (e.g., (s)he did it on purpose). Therefore, we designed a format for the hostile beliefs which our therapists regarded as helpful. Last, therapists sometimes had difficulties streaming the flood of participants’ words into a concise sentence when formulating the hostile belief and to include some form of ‘intention’ by the aggressor (e.g., ‘(s)he did it on purpose’). Therefore, we designed a format for the hostile beliefs (i.e., ‘[AGGRESSOR] [VICTIM] [ACT] [HOSTILE INTENTION]’) that our therapists regarded as helpful. This is underlined by evidence indicating that hostile cognitions focusing on ‘blaming’ vary as a function of (among