Imagery Rescripting (ImRs) is one promising evidence-based intervention to address the unmet needs central to PAD. This experiential technique, originally developed within Schema Therapy (Arntz & Weertman, 1999), allows clients to revisit early aversive memories, fantasies, or nightmares and transform their emotional meaning (Müller-Engelmann & Steil, 2017; Nilsson et al., 2019). One of the hypothesized mechanisms of change in ImRs is the fulfillment of unmet needs (Koetsier et al., 2024). To our knowledge, however, no study has examined whether satisfying unmet needs from childhood and adulthood using guided imagery may be beneficial for survivors of IPV presenting with PAD (for a review, see Kip et al., 2023; Kroener et al., 2023). Specifically, it remains unclear whether, after these needs are addressed in imagination, survivors report reductions in PAD. Additionally, previous research on treatments for women IPV survivors has largely focused on PTSD, depression, anxiety, and self-esteem (Emirza & Uzun, 2024), often overlooking complex PTSD (ICD-11, 2018) symptoms—namely disturbances in self-organization, including affective dysregulation, negative self-concept, and relational difficulties—linked to ongoing trauma (Cloitre et al., 2018), as well as positive outcomes such as resilience and self-compassion. ImRs-PAD is expected to foster a more supportive and protective stance toward the vulnerable self, potentially increasing self-compassion. This is particularly relevant in survivors of IPV, who often experience high levels of self-criticism for not leaving the relationship earlier, despite recognizing its dysfunctional or abusive nature (Crapolicchio et al., 2021). Such self-criticism may be further reinforced by self-blame processes, as perpetrators frequently attribute responsibility for the violence to the victim (Naismith et al., 2024). This is consistent with the PAD construct, particularly the internal conflict dimension, which reflects the struggle between recognizing that the relationship is harmful and feeling unable to separate from the partner (Pugliese, Uvelli, et al., 2025). Moreover, despite substantial therapeutic and support efforts, many IPV survivors remain resistant to change within existing care systems (Paphitis et al., 2022). Existing evidence-based interventions for IPV survivors primarily target symptom reduction (e.g., PTSD, depression, anxiety) and may not directly address the underlying relational mechanisms that maintain dependence on abusive partners. These approaches may be less effective in modifying unmet relational needs and the associated internal conflict that characterizes PAD. The present study aims to address this gap by framing PAD as a relational pathway through which traumatic family and partner experiences may contribute to persistent difficulties in disengaging from abusive relationships. Addressing PAD may therefore represent a trauma-informed pathway to reduce re-exposure to violence, complementing symptom-focused PTSD treatments.

To address this gap, the present study explores the feasibility and preliminary effectiveness of an online imagery rescripting intervention (ImRs-PAD) tailored for female survivors of IPV with clinically meaningful PAD symptoms. Using an exploratory multiple case series design, the intervention specifically targets three core unmet needs—love, dignity, and safety—identified from participants’ autobiographical narratives and relational histories. In addition to evaluating the feasibility of online delivery, the study examines whether ImRs-PAD reduces PAD, complex post-traumatic stress, depression, anxiety, and somatic complaints while enhancing psychological well-being, self-compassion, and resilience. Online access is particularly relevant for IPV survivors who often face barriers to in-person care due to ongoing partner control or surveillance (van Gelder et al., 2023). The present study is an independent online multiple case series conducted in Italy, designed to provide a preliminary evaluation of the protocol prior to the implementation of a preregistered in-person multiple baseline study trial (ClinicalTrials.gov Identifier: NCT06670326). The preregistered trial is conducted in collaboration with several anti-violence centers and is currently ongoing in the Netherlands.

We formulated a set of hypotheses organized into primary and secondary outcomes, designed to capture the direct effects of the intervention at different stages of the protocol.

Three female participants were referred by a psychiatrist from a mental health center in Italy to participate in the current study. All presented with a history of abusive relationships with current or former partners and reported marked difficulties in achieving or maintaining separation despite recognizing the need to do so. The mean age was 31.3 years (SD = 2.08). All participants were unmarried at the time of treatment and reported recurrent difficulties in maintaining stable and autonomous romantic relationships. They also showed a marked inability to leave dysfunctional relationships and experienced exacerbations of depressive and anxiety symptoms during separation phases. All patients referred during the study period who met the inclusion criteria and provided informed consent were included. Inclusion criteria were sufficient fluency in Italian to complete the study procedures, age between 18 and 60 years, and clinically meaningful levels of PAD, as indicated by a score of 47 or higher on the Pathological Affective Dependence Scale – State and Trait versions (PADS-S, PADS-T; Pugliese, Uvelli, et al., 2025). Exclusion criteria were assessed through a comprehensive clinical interview by a licensed psychologist and psychotherapist with 10 years of clinical experience. These included the evaluation of current and past psychiatric conditions, substance use, medical history, and ongoing treatments. The assessment aimed to rule out the presence of psychotic disorders, severe substance use disorder, intellectual disability, debilitating chronic medical conditions, prior receipt of imagery rescripting–based therapy, and current psychopharmacological treatment. Detailed descriptions of individual cases included in this multiple case series are reported in Appendix A.

The intervention was conducted by two licensed clinical psychologists, both formally trained in cognitive-behavioral therapy (CBT) for PAD, and engaged in peer supervision throughout the treatment process. One therapist, with over 4 years of experience in both clinical practice and research, delivered the treatment to all three participants. The second therapist, with over 10 years of experience in both clinical practice and research, provided clinical supervision and administered the assessment measures. Three clients participated in a 5-month program consisting of weekly individual sessions (approximately 20 sessions each, including 4–6 assessment sessions, 13 treatment sessions, and the remaining sessions focused on follow-up).

All treatment sessions were conducted online via Google Meet using secure, individualized access links. For each session, a unique private link was generated and sent to the participant’s personal email address the day before the appointment. Access to the session was restricted to the invited participant, ensuring confidentiality and controlled access. A different link was used for each session and for each participant.

Before the intervention, all clients underwent a comprehensive psychological assessment. All self-report measures were completed independently by participants outside the therapy sessions. Therapists did not use questionnaire scores to guide the intervention and had no access to interim results during treatment. The treatment program started in March 2024 and concluded in August 2025. All participants provided informed consent, and the study was approved by the Ethics Committee of the Scuola di Psicoterapia Cognitiva (protocol number N. Pr 2/24).

The treatment component, ImRs-PAD, is a trauma-informed intervention based on Imagery Rescripting (ImRs), consisting of 13 weekly individual sessions (50 minutes each), including one psychoeducation session followed by 12 ImRs sessions. Grounded in PAD theory (Pugliese et al., 2023), ImRs-PAD aims to address chronic frustration of core relational needs for love, dignity, and safety across early family experiences, abusive intimate relationships, and anticipated future relational challenges. Across stages, responsibility for rescripting progressively shifts from the therapist to the client, fostering autonomy, affect regulation, and relational agency. ImRs-PAD is organized into three stages, each specifically targeting the reduction of PAD traits, PAD state, and relapse.

The Pathological Affective Dependence Scale (PADS; Pugliese, Uvelli, et al., 2025) is a 17-item self-report questionnaire available in two parallel forms that measure state (PADS-S) and trait (PADS-T) affective dependence, respectively. It assesses three dimensions of pathological dependence, including internal conflict (IC), inability to separate from the partner (IS), and partner abuse (PA). Items are rated on a 5-point Likert scale (1 = not at all, 5 = always). The total score ranges from 17 to 85, with higher scores indicating greater levels of affective dependence. In the original validation study (Pugliese, Uvelli, et al., 2025), Cronbach’s α was .89 for both the state and trait versions. Example items include “I am aware that I am suffering in this relationship, but at the same time, I cannot leave it” (IC); “I would do anything in order not to lose my importance in my partner’s sight” (IS); and “My partner devalues me” (PA). In this study, the PADS was administered at baseline (T0), after every session (T1-T12), and at follow-up.

The Self-Compassion Scale (SCS; Neff, 2003) is a 26-item questionnaire designed to measure six dimensions of self-compassion, including self-kindness, self-judgment, common humanity, isolation, mindfulness, and over-identification. Each item is rated on a 5-point Likert scale (1 = almost never, 5 = almost always). The total score ranges from 26 to 130, with higher scores reflecting greater self-compassion. To obtain the scores for the subscales, the mean of the items belonging to each subscale should be calculated. Cronbach’s α in the original study was .92 for the total score and between .75 and .81 for the subscales. Example items include “I try to be loving toward myself when I’m feeling emotional pain” and “I’m disapproving and judgmental about my own flaws and inadequacies.” In this study, the SCS was administered at baseline (T0), after 6 sessions (T6), after 12 sessions (T12), and at follow-up.

The Patient Health Questionnaire (PHQ; Kroenke et al., 2001, 2002; Spitzer et al., 2006) is a widely used self-report instrument that screens for somatic, anxiety, and depressive symptoms. It consists of 31 items across different modules, each rated on a 4-point Likert scale (0 = not at all, 3 = nearly every day). The score range differs for each module (e.g., PHQ-9 depression: 0–27; PHQ-15 somatic symptoms: 0–45; GAD-7 anxiety: 0–21). Higher scores indicate greater symptom severity. Cronbach’s α values in validation studies ranged from .86 to .89 (Kroenke et al., 2001, 2002; Spitzer et al., 2006). Example items include “Over the last 2 weeks, how often have you had little interest or pleasure in doing things?” and “Over the last 2 weeks, how often have you felt nervous, anxious, or on edge?” In this study, the PHQ was administered at T0, T6, T12, and follow-up.

The Ego-Resiliency Scale – Revised (ER89-R; Alessandri et al., 2007) is a 10-item self-report questionnaire designed to assess psychological resilience, particularly the ability to adapt to changing circumstances flexibly. Items are rated on a 4-point Likert scale (1 = does not apply at all, 4 = applies very strongly). The total score ranges from 10 to 40, with higher scores indicating greater ego-resiliency. Cronbach’s α in the Italian validation was .76 (Alessandri et al., 2007). Example items include: “I quickly get over and recover from being startled” and “I enjoy dealing with new and unusual situations.” The ER89-R was administered at T0, T6, T12, and follow-up.

The International Trauma Questionnaire (ITQ; Cloitre et al., 2018) is an 18-item measure assessing symptoms of post-traumatic stress disorder (PTSD) and complex PTSD (CPTSD) according to ICD-11 criteria. Each item is scored on a 5-point Likert scale (0 = not at all, 4 = extremely). The total score ranges from 0 to 72, with higher scores indicating greater symptom severity. Cronbach’s α in the original validation study (Cloitre et al., 2018) ranged from .88 to .94 across the different subscales. Example items include: “When I am reminded of the trauma, I get intense physical reactions (for example, sweating, heart beating fast, nausea)” and “I feel worthless because of the trauma.” In this study, the ITQ was administered at T0, T6, T12, and follow-up.

The Psychological General Well-Being Index – Short (PGWB-S; Grossi et al., 2006) is a 6-item self-report scale measuring overall subjective well-being. Each item is rated on a 6-point Likert scale (0 = none of the time, 5 = all of the time), with total scores ranging from 0 to 30. Higher scores indicate better psychological well-being. Cronbach’s α in validation studies (Grossi et al., 2006) ranged from .85 to .90. Example items include “Have you been bothered by nervousness or your ‘nerves’ during the past month?” and “How often have you felt cheerful and light-hearted?” The PGWB-SF was administered at T0, T6, T12, and follow-up.

The Young Schema Questionnaire – Short Form (YSQ-SF; Young & Brown, 2005) is a 90-item self-report questionnaire designed to assess 18 early maladaptive schemas. Items are rated on a 6-point Likert scale (1 = completely untrue of me, 6 = describes me perfectly). The total score ranges from 90 to 540, with higher scores reflecting stronger schema endorsement. Cronbach’s α for the subscales in the original validation study (Young & Brown, 2005) ranged from .83 to .96. Example items include: “I worry that people I feel close to will leave me or abandon me” and “I feel that people will take advantage of me.” In this study, the YSQ-SF was administered only at baseline (T0).

All self-report measures were administered using standardized procedures to minimize response bias and social desirability effects. Questionnaires were completed independently by participants online via a secure survey platform. Measures were administered and collected by a research team member not involved in therapy, and therapists had no access to questionnaire responses at any assessment point, ensuring a clear separation between clinical and research roles.

Data analysis was conducted in two steps. First, pre- (T0) and post-treatment (T12) scores were compared for each case using the Reliable Change Index (RCI; Jacobson & Truax, 1991), which expresses the ratio between the observed change and the standard error of Italian measurement. Values greater than 1.96 were considered statistically significant, indicating a reliable change. The RCI was selected because it allows the evaluation of clinically meaningful changes at the individual level, which is particularly appropriate for case-series designs in small samples. Second, differences were compared using the RCI across intermediate and follow-up phases (T0–T6, T6–T12, T12–FU, and T0–FU), to capture both short-term and long-term changes. All analyses were performed at the individual level, in line with the descriptive and exploratory nature of case-series designs.

The online delivery of ImRs-PAD appeared acceptable and manageable for all participants. No major technical difficulties, safety concerns, or treatment interruptions were reported during the intervention. The online format may have facilitated engagement by reducing practical and relational barriers to care (i.e., mobility constraints, partner surveillance, and privacy concerns), common among IPV survivors (van Gelder et al., 2023). Although these observations are preliminary and based on a small number of cases, they suggest that online delivery of ImRs-PAD may represent a viable option for trauma-informed care in this population.

Improvements in primary and secondary outcomes did not emerge uniformly across participants. This variability may be explained by a combination of relational factors (e.g., type of violence experienced: psychological and/or physical) and contextual factors (e.g., time since separation, ongoing contact with the abusive partner).

This study provides preliminary clinical indications that ImRs-PAD may be adapted to address IPV-related difficulties in survivors presenting with PAD. By targeting unmet relational needs for love, safety, and dignity, ImRs offers a therapeutic approach that goes beyond symptom reduction, aiming to modify dysfunctional relational schemas that maintain dependence on abusive partners. Clinically, ImRs-PAD may support disengagement from violent relationships and potentially reducing the likelihood of returning to abusive partners—a situation associated with adverse outcomes, including heightened risk of femicide (McFarlane et al., 2004). These implications must be interpreted cautiously, given the preliminary nature of the evidence, and clinical application should proceed with care until findings are replicated in larger, controlled studies.

This study has several limitations. First, it relied on a multiple-case series design, which limits the ability to draw causal inferences and generalize findings to broader populations. Second, the sample was relatively small and homogeneous, limiting applicability across different cultural, relational, or clinical contexts. Third, outcomes were primarily based on self-report measures, which may be subject to bias. Finally, online delivery may also present specific limitations in this population. For IPV survivors who are still living with a controlling or abusive partner, the home environment may not constitute a safe therapeutic space. Sessions may be subject to monitoring, interruption, or recording. These conditions may reduce the survivor’s perceived safety and interfere with therapeutic openness. For this reason, when delivering the intervention online, particular attention should be paid to safety conditions. Therapists should ensure that patients have access to a private and secure space for the session and can interrupt it at any time if they feel at risk. Moreover, given the potentially reparative role of the therapeutic relationship in trauma-related relational difficulties, the absence of physical co-presence may affect engagement and treatment outcomes. In this regard, the possibility of subsequent in-person treatment should be considered, when feasible, to further support the therapeutic process and enhance the reparative potential of the therapeutic relationship. Future research should directly compare online and in-person delivery modalities.

Despite these limitations, the findings are encouraging and highlight new directions for future research. Controlled studies with larger and more diverse samples are needed to further evaluate the effectiveness of ImRs-PAD and to identify predictors of early versus late treatment response. Once preliminary efficacy has been established, future studies may explore relational, contextual, and personality factors as potential moderators. For example, ongoing contact with the abusive partner, the type of violence (physical, sexual, psychological, or verbal), and/or specific schema may critically shape the pace and stability of improvements. Furthermore, dismantling studies could help clarify the relative contributions of early-life rescripting versus interventions targeting current and future partner-related dynamics. Longitudinal follow-up at three, six, and twelve months will be essential to determine whether the benefits of ImRs-PAD are sustained over time and translate into safer relational choices. In addition, incorporating behavioral outcomes—such as the intention to return to the abusive partner—and biological indicators, including cortisol, micro-RNAs, and inflammatory markers, could provide deeper insight into how ImRs-PAD supports survivors in breaking free from PAD and IPV. Finally, dedicated studies are needed to clarify the mechanisms of change in ImRs-PAD, showing how addressing unmet needs during rescripting translates into therapeutic gains.

This multiple case series provides preliminary support for the effectiveness of ImRs-PAD, a specific three-stage ImRs protocol grounded in PAD theory (Pugliese et al., 2023). According to this theory, PAD originates from the frustration of core needs—being loved, feeling safe, and experiencing self-worth—within childhood caregiving and adult intimate relationships. PAD may represent a relevant psychological risk pathway for IPV (Pugliese, Papa, et al., 2025; Pugliese, Uvelli, et al., 2025). After addressing these memories in guided imaginations and meeting the unmet relational needs during rescripting, we observed reductions in PAD symptoms, along with improvements in well-being, resilience, and self-compassion, as well as decreases in depression, anxiety, trauma-related, and somatic symptoms. These findings broaden the use of ImRs, showing its relevance for PAD and IPV survivors. They also contribute to a better understanding of the mechanisms of change in ImRs.