Building on recent work in the sociology of intellectual interventions, the study of cultural boundaries of science, and the role of ideas in politics, the article develops a theory of public epistemologies as argumentative tools people use to support or oppose political positions. Two prominent public epistemologies that have recently crystallized in Italian politics are taken as illustrations, with special attention paid to the role of two academics (an economist and an immunologist) turned public intellectuals. The article argues that the rise of populism in Italy has contributed to unusual alignments between political and epistemological positions, which has made questions about science and expert knowledge much more relevant in contesting and supporting political decisions. Science and expertise have become central political categories in contemporary democratic societies. Debates about fake news, post-truth, politicisation of research, technocracy, populist anti-intellectualism, and attacks on universities are a recurring feature of our political predicament. Instead of interpreting this either as the result of technocratic infiltration into all facets of social and political life, or as the consequences of an irrational assault on science, we should recognise that both processes are simultaneously taking place in Western democracies: an “unprecedented reliance on science and expertise” is coupled with “increase suspicion, scepticism, and dismissal of scientific findings, expert opinion, or even of whole branches of investigation” Eyal . In thesThis article deals with a kind of folk theorising of science that takes place in political debates. This is not limited to controversies in which the natural and medical sciences are mobilised. “Talks of science” are abound in any dispute involving sufficiently complex subjects, including economic, social, and cultural issues, as witnesses by the ubiquity of claims to expertise in debates about immigration law, economic policy, and crime control. By focusing on recent Italian politics, I argue that political debates involving complex and technical issues reveal competing public epistemologies that have a certain degree of internal consistency. Public epistemologies are recurring, complex, and relatively coherent but potentially unstable cultural schemes that define how one is to distinguish truth from falsity, what is the nature of science, what kind of people or institution can be trusted to provide reliable knowledge, and which describe in a sequential or plot-like form why ignorance and error exist in the world and what is to be done of them. Public epistemologies are systematised by intellectuals and scientists, who are increasingly engaged in highly publicised controversies. They are anchored in specific political communities and are used strategically to secure victory in deliberations over concrete policy decisions.Where do these public epistemologies come from? How do intellectuals and experts develop, use, and disseminate them? How are they related to party platforms and political ideologies? The paper offers an answer to these question in the following way. In the first section, I review several strands of literature and introduce the concept of public epistemology to capture the relatively coherent and stable theories that actors, and particularly intellectuals, produce when talking about science. In defining this concept, I untangle my theoretical assumptions to clarify the specificities of my approach in relation to similar endeavours, such as the literature on civic epistemologies. In the second section, I present my empirical illustration, first by describing the importance of appeals to science in the Italian political context at the beginning of the twenty-first century, then by focusing on the public epistemologies elaborated by two researchers who have achieved the status of public intellectuals: an immunologist strongly engaged against anti-vaccination groups and an economist strongly engaged in favour of Italy’s withdrawal from the eurozone. In the concluding section, I extrapolate the main features of the public epistemologies found in my empirical cases, and I advance some suggestions about their connection with broader social and political transformations.To think about public epistemologies, I draw on four main literatures: research on ideas in politics, and in particular on the role of “public philosophies” in shaping political debates Schmidt , researcSince the 1980s, political scientists and sociologists have increasingly focused their attention on the role of  ideas in shaping policy-making outcomes Campbell . Ideas aThis is a useful insight in the study of public epistemologies. It is problematic to assign beliefs to whole groups, institutions, or societies, especially when these are traversed by deep cleavages or function according to adversarial principles. A similar argument can be advanced against certain works in the “civic epistemology” tradition Jasanoff , accordi1Instead, the approach I want to defend sees public epistemologies as strategically construed and deployed in adversarial setting to influence other people and steer them toward certain decisions. As such, it owes much to the study of cultural boundaries of science as conceived in the work of Gieryn , with it2Moreover, like Gieryn and others, I suggest that we should give special attention to the discourse produced by powerful actors who have the instruments to produce a complex discourse, the capacity of being heard, and the symbolic power of transforming their words into realities, such as judges, politicians, high civil servants, journalists, and intellectuals, i.e. “those who deal professionally in making things explicit and producing discourses” Bourdieu , p. 37. In the last decade, science has become a deeply political issue in Italy. The concept was so politically connoted that the centre-left Partito Democratico (PD) urged to “Vote for science” by “choos[ing] the PD” in one of its advertisements for the 2018 general election . And that certain parties prize science more than others is also consistent with a vast literature on the politicisation of science. For example, in the USA, since the 1970s, conservatives have become more distrustful of science, while liberals’ trust remained stable Gauchat . HoweverConsider the debates that took place in the two chambers of the Italian parliament in September 2018 about the approval of a decree including a change in vaccination policy. According to the decree, parents registering their children for school could self-certify that their kids were vaccinated, as required by existing law, instead of providing official documents produced by medical institutions. For the opposition, mainly formed by centre-right and centre-left parties, this allowed parents who were hostile to vaccination to easily circumvent the obligation by lying on the self-certification, thus putting at risk the lives of children who cannot be vaccinated for medical reasons. Deputies opposing the decree called it an “attack on science” and “a declaration of war against science”. The government was accused of having chosen “superstition over science”, and of having written the decree under the advice “of shamans, not of scientists”. Members of the opposition claimed to be defending “the Italy of science, the Italy of modernity”. They said that the parliament should be united in “adopting decisions dictated by science, by good sense, which is prior to politics”, and that “on science, either you are for or against”, as “the scientific method is one and only one”. The names of several “great Italian scientists”, such as Giordano Bruno and Galileo Galilei, were invoked time after time. Members of the majority, formed by anti-establishment parties, reacted by accusing the opposition of “scientocracy”, others of transforming science into “an electoral instrument” or into an instrument to promote special interests instead of the welfare of all. A senator of the majority expressed concerns with the dichotomy that the opposition was drawing between science and politics, and claimed that it would be worrying if the latter “had no right in questioning certain absolute truths” posed by the former. He suggested that the diversity of policies that have been variably considered as scientific is proof that “science can become not the exercise of doubt and research, but the simple continuation of politics by other means”. In turn, the opposition argued that criticising the decree “did not mean that science is infallible, but simply that the fallibility of science can be ascertained only by science itself”. They added that “considering science itself as a power that is separate from the interest of the citizens” is “an obscurantist principle”. That these epistemological arguments did not apply only to vaccination policies was made clear in the speech given by a member of the opposition, a professor of economics. After having stated that the government was lingering with “the constituency of those who oppose scientific truths”, i.e. of those according to which statements are true “not because they are scientifically demonstrated, but because many people say that they are true”, he added that “this is true for vaccines but perhaps even more for economics, where in the last years prominent members of the government have championed economic theories that not only have no scientific validity, but no empirical evidence either”. Conversely, a senator of the majority, also a professor of economics, argued that one should not idolise the truths of science, offering as proof his belonging to “a scientific community that has defended austerity policies in the past and that has now changed its mind”, after having negatively affected the lives of many people.3science aversion narrative, and the second the science perversion narrative. What both narratives have in common is that they consider the place and role of science as something crucial to understand contemporary society.4In sum, the Italian parliament was deeply divided in September 2018 about how to define science and its role in society. These debates epitomise two broad public epistemologies that exist in contemporary Italian politics. I call the first the According to the first, Italy is a country characterised by a deep and irrational aversion to scientific and expert knowledge. Science aversion is at times framed as a betrayal and at other times as simple indifference, but the key theme is similar: the country regularly ends up being administered by people with low intellectual capacities, who disdain experts and intellectuals, believe in conspiracy theories and other pseudo-scientific ideas, and prize football, motors, and sex parties over knowledge and culture. The effects of this form of anti-intellectualism are catastrophic: measures are not taken to protect people from risks and uncertainties, to increase the efficiency of state services, or to discover new solutions to pressing social problems. Instead, politicians pass legislation that is based on emotions rather than reason, putting peoples’ lives at risk and creating deep injustices.fanalino di coda] in research and development spending”  in social media websites something enjoyable and fashionable. They have introduced a whole series of epithets to ridicule ignorant people, notably the sympathisers of the anti-establishment Five Star Movement (M5S), such as “webete”  or “la ggente” (a twisted version of “the people”). This narrative has also been enriched by concepts having a technical and scientific flavour, such as that of “functional illiteracy”  or “return illiteracy” , generally presented as the condition of a person who can read but cannot interpret new information. Accordingly, reports attributed to the UNESCO and the OECD are frequently cited in support of the claim that over 30% of the Italian population is illiterate in this sense. People raising awareness of the omnipresence of functional illiterates often assume that their cognitive deficiency would lead them to embrace false beliefs on a wide range of different topics. In every policy domain, be it the environment, migrations, or homosexual rights, there would then be an “illiterate” position based on bogus pseudo-scientific theories. In this perspective, many believe that the chemtrail conspiracy theory is to policies concerning air pollution what the opposition to Genetically Modified Organisms (GMOs) is to agricultural policy. Between 2010 and 2020, the science aversion narrative has been particularly common in mainstream media outlets such as the Corriere della Sera, La Stampa, and L’Espresso. Further, it has been politically championed by the PD and by other liberal, reformist, pro-European parties, such as +Europa, Scelta Civica, and sections of Silvio Berlusconi’s Forza Italia. In recent years, these parties have gathered votes from the most highly educated and wealthier strata of Italian society (De Sio People embracing this narrative have made the practice of “debunking” or “blasting” conspiracy theories and hoaxes (y De Sio .volere è potere”). Against the bureaucratic routinisation of science and its transformation in a hierarchical organisation, defenders of the science perversion narrative celebrate the self-educated citizen, the passionate activist, and the maverick genius. It resonates in sarcastic remarks addressed to academics, professionals, and higher civil servants to ridicule the emptiness behind official titles and qualifications. An example is Matteo Salvini, leader of the Lega, ironically addressing the former President of the Italian Constitutional Court as “Professor, Doctor, President, Emeritus”, and contrasting “the big professors” who pretend to criticise and explain everything with his government, formed by “humble, unexperienced, poor little boys who travel in the back seats”, but who can do more in a few months than they did in forty years (Stella il Fatto Quotidiano (representing the moderate side), and La Verità.According to the opposite narrative, the science perversion narrative, the problem is not the fact that science is ignored or distrusted, but the fact that scientific knowledge has been used in Italy and elsewhere to support special interests and has replaced the will of the people in determining what decisions are taken. At least since the 1990s, science has become an excuse to pass elitist legislation that benefits the few against the many. Arguments offered to support this claim are diverse, but often emphasise that Italy has been ruled by several so-called “technical governments”, notably from 1995 to 1996, when Lamberto Dini led a team of economists and jurists after the fall of the first Berlusconi cabinet, and, from 2011 to 2013, when economist Mario Monti led a cabinet composed by many independent experts. If the science aversion narrative labels its opponents as populist, the science perversion narrative labels its opponents as technocrats. This comes with the accusation of exploiting the allegedly neutral authority of expertise to pursue self-interested political choices, often closely associated with industrial, financial, and military powers. Against the fetishism of facts, this narrative proclaims that “where there’s a will there’s a way” , including “vaccines are safe” and “vaccines are not a conspiracy organised by multinational corporations”  and the Eurozone have become widespread in Italy since the depths of the European debt crisis. Italy is among the countries in which the attitude toward the EU has most deteriorated in the decade from 2008 and 2018  who supported EU targets of low inflation, deficit reduction, and liberalisation, and, on the other hand, amateurs with little or no academic standing who clumsily urged to burn EU institutions to the ground. Initially addressing people on the left, Bagnai argued that an anti-euro position required believing not in plots orchestrated by extravagant secret societies, but just in old-school class conflict and geopolitics. Although an entertaining and often sarcastic writer, Bagnai emphasised the importance of rigour and accuracy in making the case against the euro, citing academic sources and using datasets from trusted sources such as the IMF or national statistical agencies. Several of his blog posts are longer than many academic articles in economic journals. Bagnai’s standing as a serious thinker was also reinforced by a series of extra-academic assets: he is fluent in French, English and German, makes abundant use of Greek and Latin phrases, and plays harpsichord in several baroque ensembles.Sbilanciamoci, for a communist newspaper, il Manifesto, and for liberal magazines such as Lavoce.info. In November 2011, when the editorial staff of Lavoce.info refused to publish a paper in which he criticised Monti’s contractionary fiscal policies, arguing that Italy was facing a crisis of private debt due to trade imbalances rather than a crisis of public debt, Bagnai decided to create his own platform, a BlogSpot blog titled Goofynomics. In 2012, his book Il tramonto dell’euro. Come e perché la fine della moneta unica salverebbe democrazia e benessere in Europa [“The sunset of the euro: how and why the end of the single currency would save democracy and welfare in Europe”] was published by a then-recently created publisher, Imprimatur, which has since become a prolific actor in the dissemination of contrarian and Eurosceptic ideas  were represented as a “liberation”  as well as concrete individuals.Other perversions of expert knowledge Bagnai chastises include the supposed independence of bureaucracies in general and of central banks in particular, an idea he designates as a “fetish”, “an antidemocratic and ruinous dogma”, whose consequence is keeping governments under the duress of markets whenever they try to redress the hardships of the country through fiscal policy. He often uses the now popular acronym TINA to ridicule the ideology according to which there is no alternative other than staying in the Eurozone and adopt austerity policies Bagnai . JournalLascienza]. Thescience is for Bagnai and his followers a mockery of true science: non-democratic (as Burioni would say), dogmatic, siding with the powerful. By contrast, true science is democratic and constantly open to doubt. Thus, Bagnai can argue that his blog originated “in the desire to redeem science from her slutty cousin, Thescience”  which today is asymmetrical and based on the dominance of the market instead of a wider economic and social dimension”  and strategic calculations by Salvini and other leaders. A draft of the 2018 government deal between the Lega and the M5S contained a motion to “introduce specific technical procedures of a juridical and economic nature that will allow member states to withdraw from the monetary union, and thus to regain their monetary sovereignty”  political forces. Many observers believe that a new opposition, orthogonal to the classic left and right dimension, increasingly structures contemporary political debates across the world. Although the particulars vary sensibly, the diagnosis is similar: we are witnessing a rise of populist movements and parties, which appeal to a homogenous, authentic people rooted in a specific national culture in opposition to unelected administrative bodies, condescending intellectuals, powerful institutions, foreign powers, and elites of various sorts.We could then consider the science perversion narrative as the epistemological facet of Italian populism, and the science aversion narrative as the epistemological facet of Italian liberalism. Burioni nicely illustrates the anti-populist inclination of the science aversion narrative when he offers the analogy between talking about mandatory vaccination and commentating a football match: everyone knows that there are rules in football and that these must be known to be able to talk about it; whereas, when talking about compulsory vaccination, everyone thinks they have a say in the discussion even without knowing the “rules”, i.e. immunological scientific evidence. Thus Burioni, in classic anti-populist fashion, suggests that the gap between the mass of laypeople and highly specialised experts should be widened rather than narrowed: the popular will cannot translate directly into policy but must be mediated by independent scientific institutions. Conversely, Bagnai epitomizes the populist bent of the science perversion narrative when he claims that “a good 90%” of the research on the euro cannot be trusted because it is funded by pro-EU organisations, or when he chastises the “fetish” of central bank independence. This is what many scholars have identified as a key piece of the populist repertoire, and what Brubaker designates as “antagonistic repoliticization”, i.e. “the claim to reassert democratic political control over domains of life that are seen, plausibly enough, as having been depoliticized and de-democratized, that is, removed from the realm of democratic decision-making” , p. 364.Speaking of the science perversion narrative as one of the possible epistemologies of populism might sound strange to many. There is a long-lived and heterogeneous body of literature arguing that populism puts experience, what people see with their own eyes, over knowledge, i.e. facts and theories about the world  of the relations between science and society identified by Collins and Evans . AccordiFurthermore, Burioni and Bagnai have tried in their own way and to different degrees to synthetize different perspectives, integrate critiques and respond to counterarguments. Burioni admitted that individual scientists can be wrong, while Bagnai argued that a Nobel prize signals that an economist deserves to be heard. Each of the two might claim that his views are complex and well-rounded, while his opponent’s views are just the expression of one-sided fanaticism. In reality, what can be observed is just a conflict between two opposite positions, without anything really suggesting that one side is overcoming the tension between expert authority and democratic participation. As much as this can be considered a false dilemma, it is what recent Italian politics has produced in terms of public epistemologies.


Imagery Rescripting (IR) is a therapeutic technique that is used in a wide spectrum of therapeutic methods for various mental disorders. As an important component of Schema Therapy (ST), IR is frequently used in the treatment of patients with borderline personality disorder (BPD). However, little is known about how IR is experienced by individuals with BPD. The aim of this study was to explore BPD patients' experiences with receiving IR. Qualitative data were collected through semi-structured interviews with 21 individuals  with a primary diagnosis of BPD who received IR within their ST treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of IR including initial high emotionality and exhaustion. Long-term effects included a better understanding of schemas and an improvement regarding emotion regulation and interpersonal relationships. Participants reported factors hindering the successful implementation of IR, such as external noise, stress, and a fast pace during IR. Facilitating factors included adequate time for debriefing, a transparent structure, and preparation of IR as well as the therapist providing safety. Implications of the findings for optimizing IR in clinical practice are discussed. Imagery Rescripting (IR) is an imagery-focused treatment technique designed to alleviate involuntary and distressing images or memories and alter related beliefs and schemas. IR has been successfully applied to patients with various psychiatric disorders, such as posttraumatic stress disorder (PTBS), social anxiety disorder, obsessive compulsive disorder, major depression, bulimia nervosa, and body dysmorphic disorder .To date, there have been few studies investigating the effect of IR in patients with personality disorders (PDs). One study on patients with PD found techniques of cognitive behavior therapy that focuses on childhood memories (the dominant technique being IR) to be just as effective as techniques focusing on the present . FurtherIR in the context of ST for PDs is not primarily used to reduce intrusions, but to change the implicational meaning of schemas and childhood experiences that underlie patients' problems , 12. ThiTo date, there have been only few qualitative studies on the experiences of patients with PDs with ST and its techniques. De Klerk et al.  intervieTherefore, the present study used thematic analysis of qualitative interviews with BPD patients receiving IR to explore the following research questions:  what exp*BPD trial, an randomized controlled trial (RCT) comparing ST with Dialectical Behavior Therapy, conducted at the outpatient clinic of the Department of Psychiatry and Psychotherapy at Lübeck University, Germany . The mean age of the participants was 32.76 years (SD = 10.81). The mean symptom level measured by the Borderline Personality Disorder Symptom Inventory (BPDSI) at baseline was 35.69 (SD = 8.62). The mean number of comorbid axis I and II diagnoses was 4.14 (SD = 1.98) and 0.91 (SD =.83), respectively. For demographic and clinical characteristics, see Having broad experience in the research and treatment of BPD, three of the authors  developed a semi-structured interview. The interview addressed patients' experiences with different techniques of ST. The parts of the interview relevant to the research question of this study are shown in The interviews lasted between 52 and 126 min. Four questions were added later , who extracted meaningful passages and attributed codes to relevant text passages. With these interviews, a preliminary category system was established. Then, selection criteria were defined using the research questions. The five interviews were processed for each of the research questions separately, by extracting relevant passages that came across as meaningful. A coding frame was developed for transparence and traceability of this process. Subsequently, the extracted passages were paraphrased, and afterwards, generalization of the paraphrases took place across all of the five interviews by keeping a low abstraction level. In the next step of the data condensation, meaningless paraphrases were deleted, paraphrases with the same meaning were summarized, and paraphrases with similar meanings were expressed by a new statement . SimultaThe analysis resulted in three key domains: (1) engaging in and undergoing IR is difficult (including hindering factors), (2) there are factors that facilitate the successful implementation of IR, and (3) various effects occur after the implementation of IR. Fifteen participants reported experiencing problems when getting started with IR. These problems were linked to four subthemes:Five patients described some kind of resistance that hindered their engagement in IR without being able to specify what exactly caused this resistance: “[…] I can't access the pictures, access what, what happened, where, like a wall, what happened there, access the memory” (P8). One participant suspected a lack of acceptance of inner processes; others stated that the topic was “too painful” (P20), or that anxiety and resistance held them back: “[…] that I don't, not really, am able to really engage, because I have too much anxiety and too much resistance” (P13).Two participants stated that they had difficulties starting IR because of a lack of trust in their therapist: “[…] yes, I wouldn't try it with the new one yet, because the bond of trust isn't there yet.” (P18).Five participants reported daily hassles to be hindering factors for their engagement in IR: “[…] and to separate myself from my everyday thoughts, like, if I/you keep looking at the clock and you know ok, in half an hour, I have to get the dog and then I have to go grocery shopping real quick […]” (P10), “The more stress I have, the less likely it is that it works. Ehm, this can be emotional stress; this can be stress at work or anything else” (P20).Eleven participants mentioned specific difficulties at the start of the imagery. Two participants reported that they had difficulties talking about the distressing experience with another person: “[…] well, it cost some effort to talk about the distressing traumatic situation with someone […]” (P16). Especially, describing the situation in detail and re-experiencing it by doing so was reported to be unsettling. Four participants reported that they had difficulties with allowing and expressing emotions: “Yes, showing any emotions at all and to, at the beginning it was extremely difficult to do it” (P19). Six participants stated that they had trouble choosing an appropriate situation and imagining it: “At the beginning, it is really difficult to think of a situation on the spot” (P18). One participant reported that some important situations were too difficult to imagine. Another participant reported difficulties finding a situation when feeling low. Two participants expressed trouble to accept the technique initially, and one participant reported not to be able to take the technique seriously.While in theme A1 problems with the initial engagement and getting started with IR were reported, theme A2 focuses on the difficulties that 18 participants reported while receiving IR. These difficulties were linked to eight subthemes:Two participants reported having trouble recognizing and verbalizing needs during IR: “[…] I had trouble somehow, ehm, firstly to know what I would have needed and, ehm, then also to say it or receive it” (P12). Three participants expressed problems accepting support during the rescripting phase: “[…] how can I accept that now, that, ehm, I as a grown-up take my therapist back to the childhood, who then tries to fix something there” (P6).Some participants stated that distracting thoughts and emotions hindered the IR: “Well, hindering is, if your thoughts go in a totally different direction than they should. That happens really quickly. Takes only one word.” (P11), “Well, hindering is if sadness occurs. Sometimes anger” (P11). One participant reported having too many pictures in their mind, and another one described an emotional and cognitive confusion causing that “what the therapist actually wanted to achieve, didn't happen. The rescripting didn't work […]” (P6).Two participants reported having difficulties because the rescripting felt unreal: “And, ehm, there is always a certain point, well I was always really aware of the fact, that it is somehow, that it is not real, that it is just a game, somehow” (P13). Three participants described the way the rescripting was done either as ridiculous, unrealistic, or exaggerated: “For me all of the therapist's attempts in this situation that I was in, seemed ridiculous, that way” (P18).Seven participants reported hindering modes and coping strategies during the rescripting. Two participants noticed a dysfunctional parent mode: “And if I say okay, I have to stop I can't do it any more, the parent mode is like: ‘you loser!’” (P19). Five participants reported dysfunctional coping strategies hindering them and preventing the therapist to get close to them: “Well, I there have like a wall there and can't get past it, then the therapist can do whatever she wants” (P7).Four participants reported that they sometimes noticed that they and their therapists were not on the same page during the IR: “Very often, ehm, it is that with/was there a new insight and was I was going in a totally different direction as, ehm, the therapist actually wanted to go” (P6). This could happen because the participants had trouble “[…] to verbalize the content that actually happens inside of you in a way that the therapist can eventually follow” (P10) or because they were distracted by new insights.Two participants reported trouble recognizing, verbalizing, and paying attention to their own boundaries: “[…], that I sometimes don't recognize my boundaries and don't say ‘Okay, I am actually already beyond what I can endure’ or ‘Could we slow down a little?’” (P21).Five participants reported having trouble trusting the therapist during the IR. Two participants had problems with the therapist entering the situation. Also, some participants reported the presence and support of the therapist during the IR as too close emotionally: “[…] especially this situation of the rescripting where the therapist, yes, like, plays with you or, ehm, I don't know, does something nice and supporting. That, ehm, it is always a little, I always feel uncomfortable at this moment. Because then it is too close. Too close emotionally […]” (P21).Four participants reported being troubled by a fast pace both during the first implementation of IR: “I found it, I felt overrun […]”, “There was practically no explanation, but we just did it” (P21) and during subsequent IR sessions: “[…] she sometimes was too fast, yes, well, I wasn't actually ready yet” (P20).Thirteen patients described experiencing difficulties after the performance of IR that was linked to three subthemes:Six participants reported having trouble dealing with new insights, experiences, and emotions after IR: “[…] the anger increased and, ehm, also the sadness about it and also a question mark; what do I do with it, how do I cope?” (P6). Not knowing how to deal with those led to uncertainties about guilt, to dysfunctional coping strategies, or to a feeling of shame toward the therapist. Five participants reported feeling left alone with their emotions and thoughts after the IR: “And then you got to the emotion, then it is over and then you are sitting there, that's what I mean, you're sitting there alone” (P21).Four participants experienced a positive feeling right after the rescripting but reported having trouble with integrating it in the long run because they knew that the rescripting was different than the actual situation: “That just awakes needs that cannot be satisfied anymore today, and I am always asked to sugarcoat this situation […] Well, I can imagine it differently, but I know that it wasn't like that” (P9). One participant reported having trouble accepting “[…] that what I learned was just not right” (P15).Seven participants reported that the IR lasted until the end of the session leading to insufficient time for debriefing: “There was the problem again that the imagery worked at the end, then the session was over and it had to be interrupted and could not be processed afterwards. And the next time I was there, it was too long ago, one week later” (P15). Without debriefing, participants kept ruminating about the situation, often felt distressed, and the need to talk about it.Sixteen participants mentioned external conditions that made it harder for them to engage in IR. These difficulties could be linked to four subthemes:Two participants reported having trouble being videotaped during IR, another one with being videotaped with closed eyes, and one participant reported not wanting to talk about specific topics in front of a camera: “External conditions was the camera at the beginning, well, that took a long time until I was ready to talk in front of a camera” (P20).Six participants stated that 50 min was not enough time for a session including IR: “Time is pressing. 50 minutes are over quickly. First there is the introduction, how are you? What did you do? And then doing it during the last ten minutes that is, well, you are hyped, then. That is difficult” (P2). Participants reported that they needed time in order to get access to their feelings and also to debrief after the IR. One participant reported that the time of the day of their therapy session was unfavorable: “The timing of my therapy sessions is bad, both individual and group therapy at noon, I cannot do something useful before or after, and it is during lunchtime, that is stupid.” (P13).Twelve participants described external noises as hindering during the IR: “If there are sounds or noises from the outside. Then you can't concentrate […]” (P11). This could be noise due to a construction site, but also the ringing of a telephone or the siren of an ambulance. Some participants felt distracted by sounds, such as steps outside the therapy room or the ticking of a clock.Three participants stated that they had wished for more coziness in order to help them settle down and feel secure: “I personally would have liked it if there somehow was, if you had the possibility to make it more comfortable somehow” (P10), “Just a blanket (laughs). If you are really exhausted and very (sighs). If you already feel totally naked emotionally, then a blanket feels pretty good.” (P5).Twenty participants reported structural factors that they found helpful regarding the implementation of IR. These factors could be linked to five subthemes:Seven participants found it important to achieve some kind of distance to the rescripted situation before going home: “[…] enough time for debriefing at any rate, that the patient doesn't feel alone afterwards” (P18). Four participants appreciated a short conversation about what the participant's plan for the day was. One participant reported benefiting from a personal safe-place imagery that was imagined at the end of the IR. Five participants reported that it was helpful to receive or compile a written or auditory memo about the most important content of the IR to take home with them: “It was always helpful, when she wrote something down for me. Some helpful sentences or some words or/That was always very helpful. That I could take something with me” (P11).Three participants found a consistent sequence and rituals during the therapy sessions to be helpful: “[…] that we like, have our rituals about how the session goes and that this stays approximately the same. That you can rely on that” (P21). Four participants found it helpful that the IRs followed a transparent structure: “[…] there was always a clear structure, well you also knew how long it would take […] that was communicated well.” (P6).The possibility to learn about the technique in general prior to the implementation, for example, by receiving a handout, was perceived as helpful by three participants: “Ehm, yes, I found this handout actually pretty helpful. Well, to know what it is about and what is going to happen, hm” (P12). Two of them reported having appreciated talking about and choosing the situation that was to be rescripted in advance: “Mh, it was helpful if we already talked about it in the session before. Like, if I knew exactly, if I got there and knew exactly ‘ok, we will be doing a rescripting now’ […] that was nice, if you knew beforehand and could prepare yourself a little” (P15).Eight participants reported that they appreciated the therapist entering the imagery as an auxiliary person that made them feel supported and protected: “I did this a couple of times. And that was good. Because I suddenly, in these situations, when I felt alone and helpless, suddenly I had support. And that was a good thing” (P3), “[…] that she was there and, ehm, protected me and, ehm, told my parents that you can't treat children like that and such” (P13). Also, the therapist providing different advice and ideas was perceived as helpful.Four participants stated that they appreciated starting IR with easier situations: “[…] well, that was very helpful, that you started slowly and not with the hard ones” (P14). One participant reported being very anxious about IR, and a slow start with a stepwise increase of the difficulty reduced this anxiety: “Well, I was always afraid of, of these exercises […] she led me cautiously, starting with easier situations and then the situations became more difficult, like that” (P19).Twenty participants mentioned that certain therapist-related factors helped them to engage in IR. These factors were linked to three subthemes:Twelve participants appreciated the flexibility of their therapists regarding their needs: “I found it especially helpful that my therapist was very flexible” (P10). Eight participants reported that the therapists were paying attention and adjusting to their needs carefully while introducing IR: “[…] She gave me silence and time. Showed me a breathing technique. And told me ‘if you are ready, let me know’” (P7). Some participants needed a slow introduction with breaks; others appreciated a quick start.Four participants reported that they appreciated knowing they could stop the IR at any time: “[…] well, I found it helpful, ehm, that my therapist said, that I could say stop at any time, if it becomes too much” (P12). Six participants mentioned that it was helpful to know that they could get support if necessary: “[…] I knew, that I can come by or whatever/well, I found this helpful, somehow” (P16). Participants found it reassuring to know that they could call or come by the clinic at any time or leave a message, even if they would not reach their therapist in person.Thirteen participants reported that they felt they were in good hands with their therapist. Participants described their therapist as authentically expressing understanding, care, and compassion: “What he did really well was to express this empathy and, ehm, well, you could take it seriously, if he said ‘I understand how you feel’ and stuff […]” (P15). The therapists managed to express closeness, while, at the same time, keeping an adequate distance: “And, ehm, she manages exactly to keep the distance, that is a great skill, ehm, not to come too close but also not to be too far away. Ehm, and that works for me, I am absolutely happy there.” (P20). Three participants found it helpful that their therapist captured the essential topics quickly: “No, I think she is really good at it because she manages to[…] capture the essentials, always, ALWAYS get the principal point, that is what it's is about” (P20). Also, the therapist remembering details of the rescripted situations was appreciated by the participants.Thirteen participants stated that internal factors helped them to engage in and cope with IR. These internal factors were linked to two subthemes:Six participants experienced getting access to and feeling their emotions as helpful during the IR: “Also, with the emotions you dwell on that a little bit, because you know, oh, that gets to you. That now it gets down to business. But the thing is, this is healing, and if you let it get close to you” (P1), “Ehm, yes well when I just, ehm, could engage more, well, so emotionally and really be more in the feeling and in the situation, than it worked better somehow.” (P12).Nine participants mentioned that the IR worked better, and that they were better able to cope if they were in a good mood and feeling better in general: “Well, if I felt better in general and had a good day, then it was easier” (P17), “Ehm, I have to be pretty, yes say, in a good mood, that I am not totally down the drain then, ehm, because it takes a lot of strength.” (P21).Eighteen participants highly appreciated the possibility of experiencing emotions directly through IR. But even when the IR did not work, two patients reported having benefitted from the technique. Participants' statements on this topic could be linked to two subthemes:Two participants reported that they did not perceive it as a setback if the IR somehow did not work, but by working out which coping mechanisms prevented the successful implementation, this led to new insights: “[…] therefore it is actually a two-way model which in the end leads to the same goal. And it doesn't matter if I go left or right. Ehm, the result is correct and that, THAT you can feel clearly and I think that is really important, hmm.,” “[…] if I wasn't able to get into it or let it happen, ehm, you can conclude clearly, that the brain is working against it, somehow. Ehm, and if you approach the situation like this, you can get there another way, maybe not as close as if it works, but pretty close anyway” (P20).Fifteen participants reported that they perceived it as an advantage that IR passes by the cognitive level and goes directly to the emotional level, and that it lets the participant experience the situation intensely: “Yes for me it had a bigger effect, if I really imagined it. And really enter it, also in the emotion. Instead of just talking about it” (P17). One participant described not having captured the real problem until taking the role of the child. Another advantage of IR that was mentioned by five participants was the instant experience of change when they experienced that someone stood up for them and protected them during the IR: “Well, you have this instant success, say, together with the therapist and, ehm, you can instantly change something. But you change it yourself, well, I mean, ehm, as long as you don't imagine it, the therapist can talk as much as he like […]” (P21). Furthermore, participants appreciated that they had the possibility to actively change distressing feelings during IR.Eight participants mentioned improvements of their emotion regulation skills. These improvements were linked to two subthemes:Four participants stated that IR made it easier for them to accept and allow emotions: “[…] I can, ehm, better accept now, yeah, that, ehm, that I can be sad at times.” (P20), “[…] well, regarding emotions, that I allow them and that I had that experience, then, that I got better at this” (P8).Seven participants reported being able to cope with emotions more appropriately. Three participants could express and verbalize their feelings better: “[…] that I for some part somehow verbalize emotions and say ‘Somehow, I think this is sad right now or makes me mad’ or something” (P10). Some participants described recognizing emotion and reacting to them more appropriately: “Ehm, or I can counteract and I say ‘ok, now this happens and such and so, now you have to do this and that and that’ yes” (P20). One participant reported that having better control over emotions led to a reduction in self-injury and increased their ability to ask for help and support.Twenty participants reported that IR had an effect on their emotional state. These effects were linked to two subthemes:Seventeen participants reported experiencing adverse emotions during the IR: “It could end in crying fits, in fits of anger, ehm, well in intense emotions” (P18). Participants reported that they often felt worse initially after a session with IR, which a lot of participants found difficult and strenuous: “[…] that it really, ehm, overwhelms you, by falling back into this situation” (P21).Twelve participants reported long-term benefits including feeling more relaxed, serene, balanced, satisfied, positive, secure, and calm as well as less impulsive and anxious. Especially the reduction of tension and the feeling of calmness were emphasized by 10 participants: “That I was more relaxed, physically as well as mentally, let's say. The tension was almost gone completely and I could let go emotionally” (P8).Thirteen participants described that the IR lingered during the following days. Participants' statements were linked to two subthemes:Ten participants reported a great exhaustion after the IR: “Ehm, (…) and then I felt really exhausted and totally totally weak like smashed to the ground and that like went away during the day” (P20). Participants reported a physical exhaustion as if they were “physically overstrained” (P17): “Like I was running a marathon” (P17). This was described as a short-term effect.Another effect of IR described by eight participants was repetitive thoughts or rumination about the rescripted situation: “That you really couldn't think about anything else afterwards. Your thoughts were constantly with this scene” (P2). This mental occupation could last up to several days: “Ehm, yes it's regularly been on my mind al lot for some time. Well, yes sometimes only a couple of days or so and then I could put it aside pretty well, like, sometimes also longer” (P12).Sixteen participants mentioned that IR led to a broader understanding of their schemas, problems and needs. Participants' statements were linked to three subthemes:Five participants stated that they could recognize schemas better and were more aware of them: “I notice it soo/sooner now, so that I can say, okay, it's just not going so well right now and, ehm, but then I also know, that it is just, which part this is, like, and that it is not necessarily all of it, so that's pretty good in the long run” (P10). One participant noticed that, by being more aware of schemas, it was possible to actively decide whether acting according to it was reasonable or not: “Ehm, well, I noticed, well, with the schema somehow or was more aware of the schemas and, ehm, yes, I then knew that it is such a schema and I can pay closer attention to whether it is reasonable to act on it or not” (P12).Eleven participants reported being able to understand their problems and the origin of their problems better: “That I now understand, well that I better understood the origin of my problems better, because of the imagery.” (P7). One participant described it like puzzle pieces forming into a picture due to IR. Two participants stated that they realized that “[…] not everything that happened was right. That there are definitely things that you have learned or that were instilled in you that, ehm, can be clearly wrong” (P15). One participant reported that understanding their reaction to specific situations led to acting differently in these situations. Two participants reported that due to IR, they understood the origin of their, sometimes unsuitable, feelings.Eight patients observed that, due to IR, it was easier for them to become aware of and/or to take care of their needs: “Well, and with some topics I say ‘stop, please stop, because otherwise something will happen’. So, I'm more aware of it. I wasn't able to before, then I would go into dissociation and it would be over.” (P19). Two participants stated that they were better able to recognize and verbalize the needs of the child during the IR. Four participants were also able to recognize their needs and boundaries in present situations. Seven participants reported also to stand up for their needs by setting boundaries or leaving unfavorable situations as well as by asking for help or verbalizing problems: “I got more courageous by saying something about it, ehm, which wouldn't have been said otherwise. And this is also nice” (P3).Improvements in interpersonal relationships were experienced by eleven participants and were connected to three subthemes:Three participants reported noticing an improvement in their family life. One participant experienced an improvement in the relationship with their parents, and another reported being able to forgive a family member and therefore feeling better toward this person. The third participant noticed a reduction in arguments, an improvement in the relationship with family members, and the ability to allow closeness: “[…] well, to accept closeness, especially from my family, those are the closest people, that improved dramatically” (P20).Five participants reported a change regarding their attitude and behavior toward other people: “And I'm better with people” (P11). Participants reported being more open, friendly, and relaxed as well as less mistrusting and anxious toward others. One participant reported this change being also noticeable to others: “[…] I am told I am somehow more open and […] also, ehm, talked to some people about the situation, well, which I never did before, yes” (P16).Three participants reported that some relationships worsened due to IR: “Distance from my mother. Even a little further and that I let her words get to me less, yes that” (P18). This concerned especially dysfunctional relationships. These participants described an intensifying of anger toward and accusations against specific persons.Sixteen patients observed that they felt better in general, more stable, and that their quality of life had improved due to IR. Participants' statements were linked to six subthemes:Eight participants reported noticing positive changes in their self-perception. They were more forgiving of themselves and could accept themselves better: “Yes well, I became more understanding and I can put a lot of things in context more. Condemn myself less” (P17).Six participants mentioned treating themselves and their bodies better: “Like, I have a little more respect of my body” (P10). They reported eating enough without binging as well as reducing self-injury and excessive exercise. Also, participants stated that they were less self-blaming and self-critical: “Well, before it was like, that I, for as far as I am concerned, put more blame, blame myself, where maybe there is none at all, and, ehm, afterwards it was obvious ‘no, I'm not to blame, maybe it wasn't my fault’” (P8).Eight participants stated that they experienced relief right after the IR: “Ehm, the internal knot was loosened a little. Because I have such a restlessness and such a knot inside me. Ehm, this was loosened a little regarding this at that moment. Sensed relief.” (P7). Three participants explained this sense of relief with the fact that they had addressed the distressing situations, thoughts, and emotions for the first time: “Positive experience was, that there was, afterwards, usually an actual feeling of relief quite instantly […] the ghost of the past was gone a bit, so to say” (P10).Three participants stated that they could better cope with their past and have closure: “Ehm, and that I could retrospectively store the past experiences differently, ehm, emotionally. And cope with the bad things from the past differently” (P14). One participant mentioned to be better able to cope with schema modes. Three participants stated that they would deal better with situations they had trouble with in the past: “Well, even after the first application that I had then, that let's say got more to the bottom of it, I could deal with such situations better” (P8).Two participants reported a reduction of physical symptoms, such as dizziness, palpitations, and pain: “Physically, ehm, I don't have like, like imagined gouts any more. Well, I went to my physician pretty often and then this hurt and that hurt and I don't need that any more” (P20). One participant also reported noticing an improvement regarding concentration and attention.Four participants mentioned the experience of not being alone, of getting help, being safe, and being loved to have helped them stabilize: “I benefitted from it in so far as that I for the first time had the feeling, I get support. Yes, just to have this feeling: I am supported, I am not left alone the way I am used to. That was great. Well, I definitely got something out of that” (P3).Twelve participants noticed an influence on their motivation to continue working with IR. Participants' statements were linked to two subthemes:Two participants reported that they sometimes were unenthusiastic about the technique if they did not feel well that day. Two participants stated that they did not like the technique because it would get very emotional: “That I don't like it (laughs), because it just goes into the emotional level a lot” (P8). Two participants mentioned that they did not appreciate the technique and would not want to repeat it because they would feel especially bad afterwards: “Yes, because why? I don't see any sense in it. Well, that has just only brought up sadness somehow” (P9).Six participants reported that they initially found the technique strenuous and painful but would repeat it at any time again because of the various, partially immediate positive effects: “Ehm, in the long run it was great. Ehm, because there is noticeably a change, ehm, well a change. And I also think that any following imageries will be even more helpful, ehm, yes, in the long run I look at it all in a positive way.” (P14).When asked to weigh the costs and benefits of IR, four out of 21 participants (19%) estimated the costs of IR to be higher than the benefits, three (14%) thought that the costs and benefits were balanced, and 14 (67%) estimated the benefits to be higher than the costs.The aim of this study was to explore the experiences of patients with BPD with the technique of IR, to examine which factors patients perceived as helpful or hindering when receiving IR, and what effects on their everyday life were observed after receiving IR. A thematic analysis of participants' statements revealed that patients found engaging in and undergoing IR difficult and named several hindering factors. Furthermore, they also reported several factors that facilitate the successful implementation of IR and experienced various effects after the implementation of IR.The majority of the participants reported factors that hindered the successful implementation of IR. Hindering external factors included stress, noise, a sterile environment of the therapy room, and the session length being too short for IR, leaving little time for debriefing. This feeling of time pressure is in line with findings of de Klerk et al. .Regarding hindering internal factors, participants mentioned having trouble entering the imagery, a lack of trust, or getting access to and verbalizing emotions and needs. Some had trouble finding or choosing a situation, a problem which was also described by Arntz and Weertman . Some paFacilitating external factors included adequate debriefing, the use of the therapist as auxiliary person, and the possibility of stepwise increasing the level of difficulty. Ten Napel-Schutz et al.  found thParticipants mentioned various effects that occurred after the implementation of IR in the context of ST. Participants reported initial unpleasant effects to be high emotionality, exhaustion, and enhanced preoccupation with the targeted memory. Long-term effects were mainly positive and included a better understanding of the origins and interrelations of their problems and schemas as well as improvements of emotion regulation skills and a better understanding and verbalizing of their needs. Also, participants reported improvements regarding interpersonal relationships. Furthermore, participants described themselves as more stable, and some participants expressed relief. Other effects included an improvement in problem solving skills and physical well-being. In the study by Tan et al. , patientTo our knowledge, this is the first qualitative study specifically exploring BPD patients' experiences with IR. However, participants interviewed in this study received IR in the scope of ST in the same outpatient clinic. For this reason, generalizability is limited, and including patients with BPD receiving IR from other institutions is warranted. Also, in this study, more female than male participants were interviewed, and only one participant who dropped out of treatment could be motivated to participate in the qualitative interview. It should also be considered that due to the setting at a university clinic, participants in this study were complex BPD patients with high BPD symptom severity and comorbidity. Particularly, almost 40% of the participants suffered from a comorbid avoidant PD, which is likely to be associated with high experiential avoidance. These patients may show a higher resistance to such an emotionally intensive technique.Regarding the effects of IR reported in this study, it is important to keep in mind that participants received IR in the context of ST. Therefore, although the reported effects, such as improvements in interpersonal relationships and emotion regulation, were linked to IR by the participants, they could also be related to the combination of ST techniques the participants received. On the other hand, IR is a technique that might lead to an implicit change; therefore, it is possible that participants may not have linked important changes to IR. Generally, it is difficult to attribute specific effects to specific techniques delivered in a complex treatment program.As inclusion was based on convenience sampling and the recruitment of participants was challenging because of limited reachability and willingness to participate, selection bias is likely to have occurred. As the participants who dropped out of the treatment might have been less likely to answer the telephone and take part in the interview, it is also possible that participants who did not benefit from or those who were discontent with ST techniques were less likely to be interviewed.For this publication, the example quotes for the subthemes were translated into English, which might have caused some loss of meaning.A strength of this study was the consensual analysis of 25% of the interview material by two raters who were not involved in the treatment process, as well as the discussion of the category system within an expert group.Because of the subjective nature of qualitative findings, the present study can only raise tentative suggestions for clinical implications and hypotheses for testing in further research.Based on the statements of the participants of this study, therapists can keep in mind several points to optimize the frame conditions for IR when working with patients with BPD:Providing the patients with adequate information and preparation before the implementation of IR and following a clear structure and routine during the IR can help avoid feelings of insecurity. Also, a clear explanation of the rationale of the technique and its possible effects can enhance the commitment of patients; a handout for the patient to read as homework assignment and addressing the patient's questions during the next session is useful. However, extensive preparation and exploration might also have disadvantages for some patients as it might enhance anticipatory anxiety and avoidance. Indeed, in our study, some participants appreciated a quick start, whereas others preferred a slow introduction with a stepping up of the difficulty. Therefore, after the introduction of IR, a quick start with a first IR on an easily tolerable memory might help overcome anxiety and avoidance and lead to a positive first experience with IR. It is also important for therapists to explain that it is not possible to change what happened or to erase the memory, but that IR aims to change the meaning of adverse childhood events. For this reason, a different ending is imagined in which the perpetrator is stopped and the child's needs are fulfilled. This ending does not have to be realistic; it can also be fantastical.Therapists can try to minimize noise, or they can ask whether the patient is distracted by sounds. Therapists can try to reduce day-to-day stress by helping the patient to settle in  before starting the IR. They can also advise patients to come in early and do a relaxation exercise in the waiting room by themselves.Therapists can reduce time pressure by starting promptly with the IR or by scheduling longer sessions. For example, for treatments for PTSD with IR, the session length is up to 90 min to allow for enough time for emotional processing and debriefing . Also, tAgreeing to use a stop sign can give patients a sense of control and safety. A feeling of safety can be increased further by providing comfort, for example, by using blankets or by moving into a corner of the room. Also, paying close attention to the patients' reactions and staying in constant contact with them, checking at each step of the way what they experience, can prevent a drifting apart of the therapist and the patient and can help them to verbalize emotions, needs, and boundaries. By paying close attention to the patients' reactions and by debriefing elaborately, hindering modes and coping strategies can possibly be recognized and dealt with in the early stages of treatment.Besides the suggestions mentioned above, we would recommend that therapists inform patients that IR may evoke a wide range of feelings, and that it can lead to emotional pain and distress. This may trigger coping modes to ease that pain. However, therapists should explain that all these emotions are natural reactions that only lead to problems when they are suppressed. Having these emotions is not a sign that the treatment is not working, but that it is a natural part of the recovery process. Therapists should also assure the patients that they will help them to deal with these emotions. They should keep in mind the patients' “window of tolerance,” the range of optimal arousal states in which emotions can be experienced as tolerable and experiences can be integrated . TherapiInterestingly, only a few participants mentioned that a lack of trust in the therapist was a problem, although this patient population is known to have trust issues. This could be the case because all of the participants included in this study had already had five months of ST, and a reliable therapeutic relationship had already been established. Moreover, after five months of treatment, participants may have already shown a reduction in experiential avoidance and coping strategies that may have facilitated the performance of IR. Future research investigating IR as a stand-alone treatment for patients with BPD or IR implemented during the early stage of therapy could shed light on the question whether a stabilization phase is necessary to establish a reliable therapeutic relationship and to overcome experiential avoidance. Such a design would also help to identify effects that are directly linked to IR. Some participants in this study reported that knowing about the initially distressing emotions associated with IR would reduce their motivation to further engage in IR. Future research could investigate if there is a relationship with attrition rate or with a reduced application of IR and on how client individual differences can be taken into account in assessing how conditions for IR can be optimized.Some participants evaluated the costs of IR to be higher than the benefits. There was no indication that this was due to an earlier treatment stage or a lower frequency of IR exercises. Interestingly, these participants were more likely to state that IR felt unrealistic, or that they had trouble accepting the rescripting. Those participants only reported few positive effects of IR, and all but one stated that the distress experienced during IR led to a reduction in their motivation to continue IR exercises. Therefore, investigating discontent patients and drop-outs more thoroughly could help to identify and prevent hindering mechanisms.Patients with BPD experience IR as highly emotional and exhausting. Preparation, a consistent structure, and transparent communication, as well as an adequate debriefing and being particularly attentive to the patients' needs, can help to recognize difficulties early on and to satisfy the patients' need for safety and control. Hindering and facilitating factors that were identified in this study can help therapists to optimize the implementation of IR. If implemented successfully, IR can be a powerful technique that is valued by patients and can help to generate improvement in various areas of the patients' life.anja.schaich@uksh.de.The datasets presented in this article are not readily available because only individual patient data which do not allow any conclusion on patients' identity will be shared with researchers who provide a methodologically sound proposal. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by the ethics committee of Lübeck University, reference number 13-005. The patients/participants provided their written informed consent to participate in this study.AS: drafting main body of the manuscript, revising manuscript following feedback, involved in organization of logistics, data management, and recruitment of patients. DB: qualitative research counseling, involved in conception and design of the qualitative study, training of interviewers and coders in qualitative data assessment, and provided critical revision of the manuscript. AR: recruitment of participants, conduction of interviews, transcription, coding, and provided critical revision of the manuscript. CM: coding and provided critical revision of the manuscript. NA: involved in organization of logistics, data management, recruitment of patients, and provided critical revision of the manuscript. SK: involved in organization of logistics, data management and recruitment of patients, and provided critical revision of the manuscript. AA: external ST and IR expert, involved in the development of study protocol and development of the qualitative interview, and provided critical revision of the manuscript. US: involved in conception and design of the study, development of the study protocol, development of the qualitative interview, and provided critical revision of the manuscript. EF: coordinating investigator, initial conception and design of the study, development of the study protocol, development of the qualitative interview, implementation of the two treatment programs, and supervision. All authors read and approved the final manuscript.EF, AA, and US have provided trainings and/or published books on ST and IR. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In Ethiopia, high community-level exposure to consistent messages and the perceptions of community health workers and relationships with them drove newborn care behavior change. In Nigeria, exposure to messages was limited, community health workers were less trusted, and behavior change was reported less frequently. In Ethiopia, high community-level exposure to consistent messages and the perceptions of community health workers (CHWs) drove behav-ior change.In Nigeria, exposure to messages was limited, CHW were less trusted, and behavior change was reported less frequently.The role of saturation and trust in behavior change in Ethiopia suggests that CHW counseling interventions should not be assumed to work through didactic provision of messages that focus on the behavior benefits.In settings with low coverage of CHW visits, low levels of message reinforcement from other sources, and low trust in CHWs, achieving behavior change may be difficult, even among people who receive visits. Changing behaviors is usually a core component of the role of community health workers (CHWs), but little is known about the mechanisms through which they change behavior. We collected qualitative data from 8 sites in Ethiopia and northern Nigeria where CHWs were active to understand how they change newborn care behaviors. In each country, we conducted 12 narrative interviews and 12–13 in-depth interviews with recent mothers and 4 focus group discussions each with mothers, fathers, grandmothers, and CHWs. We identified 2 key mechanisms of behavior change. The first was linked to the frequency and consistency of hearing messages that led to a perception that change had occurred in community-wide behaviors, collective beliefs, and social expectations. The second was linked to trust in the CHW, obligation, and hierarchy. We found little evidence that constructs that often inform the design of counseling approaches, such as knowledge of causality and perceived risks and benefits, were mechanisms of change. Community health workers (CHWs) are central to efforts to reduce neonatal mortality in many low-income settings,,,,,–In many cases, CHWs facilitate behavior change through the use of counseling cards that include written instructions for the CHW and pictures to help families understand and remember the benefit of the behavior.,–,–,,,–,,,–,,–,,–,,,,Current evidence suggests that CHWs are much more than conduits of information. A common theme among studies exploring how CHWs effect change is that they can serve as brokers and connectors.Current evidence suggests that CHWs are much more than conduits of information.,,,,CHWs also differ from other community members due to their training, skills, and association with the health system, which places them as “outsiders.” As such, they can have increased acceptance, respect, and status.,,,Trust and credibility can be lost if CHWs do not meet community expectations, for example, if they lack supplies or demonstrate poor capabilities or when communities doubt their motives.In this article, we report data from both CHWs and the community, exploring how CHWs change newborn care behaviors in Ethiopia and northeast Nigeria. We use an approach informed by realist evaluation to identify the mechanisms and the contextual factors that influence change.,Data were collected between March and June 2015 in the Southern Nations, Nationalities, and Peoples Region and the Amhara region in Ethiopia and in Gombe state in Nigeria. –In both the Ethiopian and Nigerian sites, CHWs made prenatal and postnatal home visits, which included promoting neonatal care practices and service utilization. In Ethiopia, the HEWs also provided counseling during antenatal care at health posts, and all women were part of the HDA. The HDA members were meant to work in small groups with a leader whose role included helping families adopt the HEW messages by identifying pregnant women and linking them to services, holding monthly meetings, and running participatory learning and action cycles. The HDA leaders were selected by their group, were volunteers, and received an average of 15 days of training facilitated by the HEWs.kebeles (districts) that had no unusual characteristics such as being near an industrial center or a tertiary hospital. In Nigeria, we selected 4 local government areas (LGAs) (districts)—2 urban and 2 rural. Insurgents were active at the time of data collection, which meant that the study team needed to return to the state capital each day, and LGA selection was limited to sites that were within a few hours drive of the state capital. In Ethiopia, data collectors were able to access study sites that were more remote. With the assistance of L10K and SFH program staff, we identified 4 study sites in each country that had CHWs in place who were considered to be active. In Ethiopia, we selected 4 Interventions that have the greatest impact on neonatal mortality are those that improve care in labor, during birth, in the first week of life, and for small and sick babies.Interventions having the greatest impact on neonatal mortality are those that improve care in labor, during birth, in the first week of life, and for small and sick babies.–The interview guides included free-flowing questions, such as a description of labor, delivery, and newborn care, to allow unanticipated themes to emerge . These qNarrative and in-depth interviews (IDIs) were conducted with mothers at their houses. Focus group discussions (FGDs) were conducted with mothers, grandmothers, fathers, and CHWs in a neutral location, such as a school for community members and the health centers for CHWs. Having multiple respondent groups allowed us to capture different perspectives and to triangulate findings. We conducted narratives with mothers to understand their experiences and to see how events influenced each other and IDIs to capture perceptions. FGDs were conducted with 3–7 participants each to explore issues that would benefit from being discussed. We enhanced FGD interaction and reduced social desirability bias through activity-oriented exercises.kebele, all HEWs in the study kebele and those from neighboring kebeles were invited to participate in the FGDs. The SFH CHWs in Nigeria were identified with assistance from SFH and through snowball sampling. For mother interviews, we aimed to get a range of participants regarding age, educational level, parity, sex of newborn, and place of delivery.Community respondents were identified through community informants, such as women’s organization leaders, by the CHWs, at places of worship, and through snowball sampling. As we were interested in the mechanisms through which CHWs change behavior, we excluded respondents who had no contact with these cadres. In Ethiopia, due to the small numbers of HEWs in a Data were collected in local languages by 4–6 interviewers in each country. In Ethiopia, interpreters were occasionally needed to translate from Amharic into Silte. Interviewers were social science graduates with 2–17 years of qualitative research experience. They received 4 days of classroom training, which included a detailed review and discussion of the content of the guides, probing strategies, transcription, and ethics. This training was followed by a 2-day field pilot.Interviewers approached potential community respondents in their homes and CHWs at their homes or health posts, explained the study, obtained written informed consent, and arranged a convenient time for the interview. Three respondents declined to be interviewed, stating that they were too busy. Interviews and FGDs were audio recorded, transcribed, and translated into English by the interviewers during data collection with conceptual and, where possible, semantic equivalence.Data collection stopped when additional interviews and FGDs did not provide new information. This point was determined by frequent transcript reviews and through discussions with interviewers. The sample size, respondent groups, and the interview content are shown in Ethical approval was granted by the Ministry of Science and Technology in Ethiopia, the National Research Ethics Committee and the Gombe State Government in Nigeria, and the London School of Hygiene & Tropical Medicine in the United Kingdom.Analysis began during data collection through regular team meetings and 2 data analysis workshops to discuss emerging themes, receive feedback on transcripts, remove or add questions, and increase reflexivity. These initial themes and the theoretical framework were used to develop a deductive coding template in Nvivo. Interviews and FGDs were then coded inductively within these broad themes, with new themes added as they emerged. Coding and interpretation were done separately for each country by 4 of the senior researchers , who initially read through the transcripts to identify a first set of inductive themes and codes and to get an impression of the data as a whole. To enhance coding rigor and conceptual thinking, initial coding was done through consensus coding of the same transcripts, a code book was developed, and the team regularly met to discuss coding. Each analyst then took a set of transcripts to code. The study lead author (ZH) checked all coding using the coding stripe function of Nvivo. Coding discussions focused around merging conceptually similar codes and examining patterns, links, and contradictions in the data. We triangulated findings between respondent groups and data collection methods to check credibility. Due to logistical constraints and literacy issues, we were unable to return transcripts to participants for comment.The FGD participant mothers varied in age (range 20–40 years), parity (range 1–8 children), education (none to secondary level), and ethnicity. The FGD participant fathers were older (range 28–61 years of age), and the FGD participant grandmothers were almost all uneducated.Most families interviewed in Ethiopia reported that they adopted the practices that the HEWs and HDA leaders promoted, and they highlighted that it was a change from their past behaviors:In previous time, the baby was bathed immediately after birth, but now, based on the teaching of health post and health center, we wrap the baby immediately after birth. — Father, FGD Kebele C, EthiopiaThe previous and the current situations … . are like the earth and the sky. —Father, FGD Kebele C, EthiopiaMost families interviewed in Ethiopia reported adopting practices promoted by the HEWs and HDA leaders, which differed from past behaviors.Skin-to-skin care was the only thermal care practice that was reported as not being promoted, and this practice was new to most of the community respondents.saturation and trust theories. A third theory, facility behavior, was identified but applied only in the context of women who delivered in a facility.We identified 2 interlinked mid-range theories relating to how HEW interactions with families influenced the promoted practices in Ethiopia—The saturation theory describes a set of mechanisms that relate to families receiving consistent messages, reinforced by multiple sources  at multiple time points  and through multiple channels :We are told not to give anything until 6 months . … [By] [HDA leader] [HEW], and we are told in the health center or when we go to the health post for vaccination [antenatal care]. —Mother, IDI, Kebele D, EthiopiaI heard this advice before, but when they give me additional advice it strengthen the idea…the HEWs advised me that the baby should not be bathed immediately after birth, and it was the same thing that the health professionals advised me. —Mother, IDI, Kebele A, EthiopiaThis saturation of messages led to high levels of community-wide familiarity with the promoted behaviors, with social diffusion further reinforcing the messages:I didn’t hear that with my ears but I heard a rumor that if you delivered at health facility you have to bathe [the baby] after 3 days. —Mother, Narrative 1, Kebele D, EthiopiaSaturation of messages led to high levels of community-wide familiarity with promoted behaviors, with social diffusion further reinforcing the messages.This familiarity led to a perception that there had been a change in collective beliefs and practices and a social expectation that the new behaviors should be practiced:No one [in the family or community] suggested bathing the baby immediately … They all know that the baby should be bathed after spending a day. —Mother, Narrative, Kebele C, EthiopiaIt is the same [people’s behavior], it has no difference. They [others] have received the lesson . … They have received the same lesson as me. —Mother, Narrative, Kebele C, EthiopiaThe HEWs attributed message penetration to the formation of the HDA, whose members were able to have more frequent contacts with households. This attribution was confirmed by some community respondents.Having messages provided from multiple sources meant that even if a worker was less active, messages were still heard. For example, in 1 study site, HEWs were reported as being relatively inactive in making home visits, but most women still received messages from other sources.Grandmothers were also familiar with the promoted behaviors and, with the exception of delayed bathing, were generally supportive of them, recognizing that this was a new time:It is our children who advise us about what they know … Today’s mothers are wise. In previous time, there was no education. —Grandmother, FGD, Kebele D, EthiopiaGrandmothers were also familiar with the promoted behaviors and were generally supportive of them.As a result of being “educated” about the practices, mothers had increased maternal agency and felt more knowledgeable than their “outdated” elders and more able to reject their advice:These days, they [HEW] give us good education on how to take care of babies … my families are getting older … So even though they give us advice, we would not follow that … I follow my own way. —Mother, Narrative, Kebele B, EthiopiaOverall, fathers were less familiar with the details of the behaviors being promoted, but they were supportive of the CHWs and health worker advice, as illustrated in this conversation in one FGD:Previously … . our mothers decided. —Father A, FGD, Kebela A, EthiopiaNow I can decide that it [food] should not be given before 6 months. —Father B, FGD, Kebele A, EthiopiaBecause health professionals teach this. —Father A, FGD, Kebela A, EthiopiaFamiliarity with the messages was important, but knowledge of the benefit of the behavior was not a prerequisite for adoption. For example, although many respondents could report that delayed bathing helped maintain warmth, several did not know the reason for the practice but still reported that they carried it out. In these cases, the trust theory was the driver of change:I do what they told me to do; I waited the time and bathed the baby … I was thinking it could not be harmful; they said this because it is useful. —Mother, IDI, Kebele D, EthiopiaFamiliarity with the messages was important, but knowledge of the benefit of the behavior was not a prerequisite for adoption.The trust theory relates to a trust in the CHWs and health workers as a collective to act in the community’s interest, leading families to follow the advice given:They [mothers] listen to the HEW, even if they tell you that you have to walk naked. —Grandmother, FGD, Kebele C, EthiopiaTrust was related to CHWs’ high status in that they were “better” and “more educated” than community members:I was advised about it before delivery. I accept what they told me because they know better. —Mother, Narrative, Kebele C, EthiopiaWe just respect educated people. They are educated, and we are just farmers. —Mother, IDI, Kebele A, EthiopiaTrust was also related to CHWs being seen as connected to the government, as well as to their visibility, connectedness, and understanding of the community.Although the HEWs as a collective were trusted as acting in the community’s interest, this trust could be lost for individual HEWs, for example, if they provided inequitable services, had a poor work ethic, took bribes, or were unkind:They [HEWs] are not responsible enough to carry out their tasks … they want you to give them something as a bribe … . if she doesn’t give something as a bribe, the woman won’t get any service … they did not have good manner. —Mother, IDI 5, Kebele B, EthiopiaTrust could be lost for individual HEWs if they provided inequitable services, had a poor work ethic, took bribes, or were unkind.Trust in the HEWs and their status were combined with a hierarchical relationship that resulted in families feeling obligated to follow the advice of HEWs. This circumstance is illustrated by community respondents describing behaviors as “forbidden” or “not allowed” and reporting that the HEWs “commanded” them. This hierarchical relationship was compounded by a belief that the HEWs had the power to make life difficult if advice was not followed, either by being angry with families or denying them services.HDA leaders did not have the same status as HEW/health workers and were described as “villagers just like us.” They were viewed as conduits of information and were important drivers of the saturation mechanisms but were not drivers of the trust mechanisms:They give advice as local people, not different from advising as a neighbor. —Father, FGD, Kebele B, EthiopiaThe third theory, centered on facility behavior, relates to the recent increase in facility deliveries, which meant that some family practices had become health worker practices:When they deliver at the health center, they practice this [immediate breastfeeding] … they practice it mostly because they deliver at the health facility. —CHW, FGD, Kebele A EthiopiaAt a facility delivery, immediate drying and wrapping were done by the health workers, who also could insist on early breastfeeding and no bathing during the stay in the facility.The 3 theories described above were not triggered equally for all behaviors, with delayed bathing being the most difficult behavior to change. This was related to some families, and in particular grandmothers, having strong culturally entrenched beliefs against leaving the baby “dirty” after birth. This was especially the case if the baby was bloody or had an obvious vernix:We will bathe the baby anyway, how can we sit idle without bathing the baby. —Mother, IDI, Kebele D, EthiopiaAnother contextual factor that enhanced the uptake of behaviors was the value given to education and modernity:Do you think I want to do like in the past? I want it to be just like the modern time … Today’s mothers are young and modern. They easily accept new ideas. —Mother, Narrative Kebele C, EthiopiaIn the Nigerian sites, there were fewer reports of behaviors being changed, and the impact of saturation was less striking than in Ethiopia, as messages were received less often and from fewer sources. There was less evidence of a change in collective beliefs as well as more cultural barriers to behavior change, especially when mothers received conflicting advice:… I gave water on the third day … I am confused with the advice I am getting, some say give, some say do not give. —Mother, Narrative, LGA C, NigeriaIn the Nigerian sites, there were fewer reports of behaviors being changed, and the impact of saturation was less striking than in Ethiopia.As in Ethiopia, CHWs were generally trusted in the Nigeria sites, but fewer respondents reported that they carried out behaviors without knowing their benefits:I’ll follow the ways that I already know, I’ll follow the old ways until I hear more explanation on it. —Mother, Narrative, LGA C, NigeriaAs in Ethiopia being “educated” by a CHW allowed some mothers to challenge the advice of elders, and a theme in the grandmother FGDs emerged around times changing and their advice no longer being relevant:We the old grandmothers are in trouble. We have been swept into the dustbin. —Grandmother, FGD, LGA A, NigeriaBut in many households, elders remained key influencers of newborn care with a strong family hierarchy. For example, several mothers reported they followed or pretended to follow the advice of the elders to ensure harmonious relationships.In many households, elders remained key influencers of newborn care, with a strong family hierarchy.Unlike in Ethiopia, the facility behavior theory was not a key mechanism of change in Nigeria, as health staff did not practice the behaviors that CHWs were promoting as frequently as in Ethiopia:At hospital when you deliver, you will be allowed to rest for 1 hour … which in most cases, you will be sleeping. So, you see you don’t even have the time to breastfeed your baby. —Mother, IDI, LGA D, NigeriaHowever, a theme emerged around a facility delivery giving women more autonomy in decision making because they were viewed as having adopted and being exposed to modern practice:She [grandmother] used to say I should breastfeed them, and about water … I should give them … I tell her that in the hospital they told us not to give and she will not force me, she will respect what the hospital says. —Mother, Narrative, LGA A, NigeriaAs in Ethiopia, the mechanisms were not triggered for all behaviors in Nigeria, but in contrast to Ethiopia, delayed bathing was more amenable to behavior change than breastfeeding practices. This was because families had been convinced that the baby could be cleaned adequately by rubbing them with oil rather than bathing them, making delayed bathing culturally acceptable:They [health worker] clean the baby very well, so baby will not smell, if they leave the baby dirty … then, of course the baby will smell, my baby was very clean so, no problem. —Mother, Narrative, LGA B, Nigeria,,,,–The saturation and trust theories that we identified in our study sites are similar to findings from previous studies on how CHWs affect change,,,The saturation mechanism was linked to frequent and consistent information, which was provided more often in Ethiopia than in Nigeria. Where it occurred, saturation led to a perception that there had been a change in community-wide behaviors, collective beliefs, and social expectations of behaviors. CHW counseling interventions usually focus on changing the behavior of one individual at a time, with less emphasis given to message saturation or exposure.In the Ethiopian sites, high exposure to consistent information was achieved, but obtaining the same outcome may be difficult in many settings. Few countries have reached more than 10% coverage for postnatal home visits,,–16,–,,–The trust mechanism was related to trust in CHWs, status, obligation, and hierarchy but also to CHWs’ closeness to and understanding of the communities they serve. In Ethiopia, this mechanism was seemingly more important than individuals being convinced of the specific benefit of a behavior. Previous studies have highlighted the importance of relationships, trust, and power between CHWs and the community, and the impact that these factors can have on acceptability, motivation, and performance.,–In the Nigerian sites, respondents reported that messages were received less often and from fewer sources. In addition, the advice of CHWs was questioned more, and elders remained as key influencers. These findings could be attributed to a poorer functioning CHW system in Gombe, with lower coverage than in Ethiopia,We used multiple study sites, purposive sampling to saturation, reflexivity, triangulation of methods and respondent groups, consensus coding, and within and across case analysis to increase data quality and the transferability of findings.Our study did not aim to generalize about the effectiveness of the CHW programs but to uncover the mechanisms through which they may work when they are functioning. CHW programs face issues with inadequate training and support, high workloads, and poor motivation and performance,Inadequate training and support, high workloads, and poor motivation and performance can influence CHWs’ ability to deliver behavior change interventions.