Martijn van Teffelen

Imagery-enhanced cognitive restructuring: Protocol 113 5 over time. Last, some authors have proposed that anger can manifest itself as a primary but also as a secondary emotion (i.e., feeling angry in response to a primary emotion such as feeling hurt) (Pascual-Leone et al., 2013). In the present intervention, we approached anger as a primary affective state. Perhaps, focusing on anger as a secondary emotion or probing for co-existing non-angry affect could lead to other images. With regard to recommendations for further clinical implementation of this technique, we need to say that in our study therapists received 20 hours of extensive training. The training included feedback on role-playing, pilot-runs, and participant tapes by our research group, including a licensed clinical psychologist (E.M.) and cognitive behavioral therapist (M.V.) who have wide experience using imagery techniques in clinical practice. In day-to-day clinical settings, such training seems difficult to obtain. However, substantial time was spent on fine-tuning the protocol, moreover, our therapist were master-level students that had no experience yet with the CR technique ‘evidence-gathering’. A more important issue is that in our experience, the parts in which hostile and helpful beliefs are identified and when beliefs are transformed into images is challenging. That is, formulating clear challengeable beliefs and images that cover the affective load of a belief is essential to the intervention, but at the same time very delicate. Our therapists indicated they found it helpful to look for intentionality in formulating the beliefs, and to caricature-like images. Ultimately, we hope that when the technique is applied to multiple situations in which hostility plays a role, this benefits the generalizability to novel ‘real-life situations’, as for example is reflected by stable, long-term symptom reductions after CBT for other psychopathologies (Hofmann et al., 2012). For hostility however, this remains to be investigated. In developing the present intervention, we have employed a transdiagnostic approach to hostility. However, as we put forward in the introduction hostility consists of different dimensions (i.e., cognitive, affect and behavioral). Some people may score high on ‘affective’ aspects of hostility, whereas others score high on cognitive and behavioral aspects of hostility. In traditional diagnostic terms, hostility aspects are reflected differently across psychiatric diagnostic classifications. For example, Intermittent Explosive Disorder includes behavioral aspects of hostility. Post-traumatic stress disorder and borderline personality disorder include both affective and behavioral aspects of hostility. Paranoid personality disorder mainly includes cognitive aspects of hostility. Although I-CR showed efficacious reductions on all aspects of hostility, I-CR showed increased efficacy on cognitive and behavioral, but not affective aspects of hostility compared to traditional CR . For this reason, I-CR may have no added value over traditional CR for patients who primarily experience affective aspects of hostility. However, for patients with more cognitive and behavioral aspects of hostility (e.g., Intermitted Explosive Disorder, Post-traumatic disorder, and borderline and paranoid personality disorder) I-CR could be more suitable than traditional CR.