The imagery rescripting protocol for obsessive-compulsive disorder (ImRs-OCD): A decade of iterative refinement in treatment sequencing following ERP

Obsessive-Compulsive Disorder (OCD) remains a significant clinical challenge, with up to 40% of patients failing to achieve adequate symptom reduction through gold-standard treatments like Exposure and Response Prevention (ERP). This paper introduces a refined, 10-step Imagery Rescripting (ImRs-OCD) protocol developed over a decade of clinical practice. The intervention is designed to be used as an adjunct to ERP, specifically targeting the intrusive mental imagery that often underlies OCD symptoms.

Unlike traditional imaginal exposure, which focuses on habituation to distressing stimuli, imagery rescripting aims to modify the emotional meaning of aversive memories or images. The authors emphasize that applying this technique to OCD requires specific adaptations to ensure it does not inadvertently reinforce compulsive rituals or reassurance-seeking. The protocol integrates both therapist-led and client-led rescripting phases, allowing for a flexible transition that supports the client in meeting unmet emotional needs and modifying core maladaptive beliefs.

The protocol was refined through a decade of iterative development, guided by the Medical Research Council (MRC) framework and the ORBIT model for behavioral intervention. By collecting systematic feedback from clinicians and clients, the authors transitioned from the original three-phase model to a more structured 10-step approach. This final version includes standardized assessment tools, preparatory sessions, and clear guidelines for maintaining fidelity to core principles while addressing the unique, ego-dystonic nature of OCD obsessions.

This work provides clinicians with a roadmap for sequencing ImRs alongside ERP. The authors highlight that while ERP remains the first-line treatment, ImRs-OCD offers a valuable tool for those who remain symptomatic. The paper includes illustrative case examples and emphasizes the importance of professional training and supervision to ensure that the rescripting process remains therapeutic and does not become a site for compulsive engagement.