The topic-list questions produced five fixed themes. Close reading then produced a further 25 sub-themes. Through an iterative process, an additional theme with 3 sub-themes was added. The 28 sub-themes describe a total of 81 categories.

Below, the results are described on the basis of the six themes and 27 sub-themes. Additional file 1: Table S3 provides an overview of the themes, subthemes, categories and illustrative quotes. Additional file 1: Table S4 provides an overview of tips and suggestions from a participants' perspective.

Expectations

Overall, all participants had appreciated the opportunity to participate in this study, particularly because of the opportunity to address the symptoms of the ED and the PTSD simultaneously while they were underweight. Many had gone through a long search for adequate treatment. "I was very happy there was a clinic somewhere that was willing to offer trauma treatment even though I was underweight." Although three participants had had positive expectations of ImRs, the others had been coloured by earlier negative experiences of EMDR treatment, fearing disappointment, no longer dared to expect anything and had chosen to take the trauma treatment without expectations.

As well as indicating that it was difficult, a priori, to get a good idea of ImRs, two participants had also had doubts about its effectiveness: "Because the therapist explained that you can make up all sorts of things in your imagination, I wondered something like ‘is this going to work on my trauma…?’."

With regard to their preparation for the study, all participants indicated that they had received sufficient information. (See Tips and Suggestions Additional file 1: Table S4, point 4.1; Illustrative Quotes, Additional file 1: Table S3, points 1.1 and 1.2.)

Ability to participate in ImRs

In the interviews, participants talked about the ability to participate in ImRs in relation to their level of concentration, their ability to experience feelings, their ability to regulate emotions, gaining weight, their ability to imagine, their physical effects, their trauma topicality and openness about their trauma.

Ability to control attention and to concentrate during ImRs

With one exception, all participants indicated that their attention span had been sufficient to do the ImRs, even though they were underweight and had other co-morbid disorders (Attention Deficit Hyperactivity Disorder, Tourette Syndrome etc.). “Yes, I was generally able to concentrate sufficiently.” The exception indicated that, after a full day of therapy, she had been too tired for the ImRs treatment. Although she dropped out after three sessions of ImRs, she had experienced a positive result on her PTSD symptoms, but had been too tired the next day to follow the clinical treatment properly. “I managed, but it was such an effort that on the following day I could no longer concentrate on the therapy in the clinic.”

Ten participants reported adequate concentration. Of these, six participants indicated that three factors had made it difficult to maintain their concentration throughout the ImRs session (90 min): the time of day, the length of the ImRs session, and the many distractions caused by ambient noise. “You hear things in the hallway, so it’s difficult to maintain your concentration.” The therapists found solutions to these distractions: a quiet room, turning off the light, shortening the sessions, and finding a more suitable time for the ImRs. Despite the difficulties, three participants reported that well-coordinated individual person-oriented support had eventually made it possible for them to concentrate properly. (See Illustrative Quotes, Additional file 1: Table S3, point 2.1; Tips and Suggestions, Additional file 1: Table S4, point 4.2.)

Ability to feel

The interviews showed clearly that almost all (10) participants experienced enough emotions to do ImRs: "Yes, I’m still a bit overwhelmed: I could feel them very well." One person said she had tried to avoid her feelings, but her therapist saw from her body signals that the tension was building up. Especially at the end of the sessions, after ImRs, she had a lot of feelings.

In the period in which ImRs was provided, two participants experienced a change in their ability to feel, even when their body weight increased. "No, I don't really feel as if it changed very much." Although one participant indicated that she had been able to access her feelings better during the second six sessions, she attributed this to the method. "From the moment I started to intervene myself it became a bit easier." (Illustrative Quotes, Additional file 1: Table S3, point 2.2; Tips and Suggestions, Additional file 1: Table S4, point 4.2.)

Ability to regulate emotions

Seven participants indicated that they found it scary to feel emotions they had not felt for an extended period or had done their best to avoid. One participant said: "I feel everything again, and that's just what I wanted to get rid of." Another: "I'm not used to feeling emotions at all any more—I've always pushed them away, and it's scary when they’re there again."

During ImRs they were asked to start feeling these emotions. As this differed slightly from the ED treatment, in which they tried to let go of their old coping strategy of regulating emotions through ED behavior and thoughts, it evoked not only the fear of getting overwhelmed and lingering in the emotion, but also the experience of managing not to be flooded by emotions. "And then I was crying really hard and then it was okay too—not that I got stuck in it, because that was what I was really afraid of: getting stuck in it." They indicated that ImRs helped them more than previous methods to learn to regulate their emotions. They also reported that it helped that they could do ImRs in a safe clinical treatment environment where emotions were welcomed, and where they could cry, talk with peers and sociotherapists; or just go for a walk. (Illustrative Quotes, Additional file 1: Table S3, point 2.3; Tips and Suggestions, Additional file 1: Table S4, point 4.2.)

Ability to gain weight, and the role of weight and underweight

Participants had different experiences of being able to gain 700 g body weight per week during ImRs. While two participants said that the trauma treatment required too much energy for them to be able to continue the growth curve, all the others were able to manage both. However, as their trauma symptoms seemed to become worse or more noticeable when they gained weight, these participants were unanimous that help was needed to continue to put on weight while simultaneously handling the trauma symptoms. "Yes, [weight gain] did make me feel worse, and I really felt that you shouldn't wait to help me until I'm at a healthy weight, as that would make it very difficult for me actually to attain that weight.” For this reason, participants experienced the support they received at mealtimes during the ImRs period as essential to gaining or maintaining a stable weight during the ImRs treatment. "So, yeah: seeing I've previously had trauma treatment that gave no support to eating—where I actually went on hunger strike—yeah, I'm glad [ImRs] was done in a clinical setting." (Illustrative Quotes, Additional file 1: Table S3, point 2.4; Tips and Suggestions, Additional file 1: Table S4; 4.2.)

Ability to imagine

Many individual differences emerged regarding participants’ ability to work with imagination. Four could easily imagine situations and even marvelled at it. One participant noted that she was a visual thinker, so this technique suited her very well: "I was surprised how well I could imagine it." Two participants had to get used to it, after which it worked well. Two participants mentioned that, if you are an image thinker, the pictures really come into your mind, are extra vivid, and that if you think more rationally, it can be hard to imagine things that are not realistic or have not happened. For one person, imaging the therapist in the image did not work, as it was too far removed from reality. It had then helped her that she and her therapist decided to adapt the script and stay closer to reality. (Illustrative Quotes, Additional file 1: Table S3, point 2.5; Tips and Suggestions, Additional file 1: Table S4; 4.2.)

Ability to engage in ImRs: physical effects

Four participants found that ImRs caused many physical reactions, such as headaches, sweating, palpitations, fatigue, pain in the legs, paralysis of limbs, and an inability to move the legs. "I had a lot of physical reactions during and after ImRs—it was quite intense." Although one participant stopped ImRs due to fatigue, the physical reactions were not a reason for the other participants to discontinue it. Someone verbalized that the physical reactions decreased because they had learned to reassure themselves.

The participants with physical reactions indicated the importance of announcing in advance that multiple physical reactions could occur. As well as indicating the importance of the therapist remaining calm and looking for person-oriented entrances, they made several suggestions for making it possible for a participant to continue ImRs treatment despite the physical reactions; in the event of limb failure, for example, it helped to stand during the session. It also helped to have a wheelchair ready, not to schedule the ImRs sessions two days in a row, and to make it possible for participants to remain in the room after a session until they felt grounded again.

In summary, although participants experienced many physical reactions, these were a reason for hardly any of them to stop ImRs. (Illustrative Quotes, Additional file 1: Table S3, point 2.6; Tips and Suggestions, Additional file 1: Table S4, point 4.2).

Ability to engage in ImRs: trauma topicality and openness about trauma

Regarding the topicality of the trauma—in other words, the extent to which they were still troubled by it—it emerged that two participants were not yet fully in a safe environment outside the clinic (i.e. in their private lives). Three participants indicated that their traumas were no longer topical but that tensions could still be evoked, as they still had contacts with the perpetrator. For example, one perpetrator occasionally visited over the weekend; another continued to send messages; and as one group of perpetrators still lived in the same area, the participant occasionally ran into them.

Two participants indicated that, with a therapist they knew barely or not at all, they had difficulty being open about the trauma they had experienced. They sometimes found it difficult to share at all. One person indicated that she had started to write down her whole trauma story not only for the therapist to read, but also for any future therapists; this would make it unnecessary to tell her story again. Two participants indicated that they were unable to tell the whole story about the events, one reason being that they did not dare to complete certain memories in their mind. Another participant gradually increased her degree of openness, starting with the less difficult trauma images, and eventually discussing the more difficult images only in the final ImRs sessions.

Three participants indicated that the more often there was openness, the easier it went. If it was possible to be completely open, this was experienced as pleasant. But overall, all participants developed sufficient trust during the sessions to provide enough disclosure about their traumas. (Illustrative Quotes, Additional file 1: Table S3, point 2.7; Tips and Suggestions, Additional file 1: Table S4, point 4.2.)

In summary, participants indicated that, given well-coordinated person-oriented adjustments and a joint search for ways to maintain the treatment with the clinical treatment team and therapists, the following had been possible: to attend the treatment, to apply the imagining technique, to tolerate the physical effects, and to disclose their traumas sufficiently. They could do this with sufficient concentration, emotional experiences, and emotion regulation; and they were able to maintain or gain weight.

Perceived effect of ImRs

In the interviews, participants talked about their perceived effects of ImRs in terms of negative emotions, eating disorder symptoms, PTSD symptoms, self-compassion, internalization of ImRs and expected effects of ImRs in the future.

Perceived effect of ImRs on negative emotions

Although two participants found it difficult to feel anger, two participants noted that this improved during the ImRs sessions. Three participants indicated that they started to feel angrier about what had been done to them. Another participant noted that she succeeded in feeling less angry, and two participants in directing their anger less towards themselves but also towards the perpetrator or perpetrators. "First I was only angry at myself, and now I’m also angry at the people who did that to me." It emerged that six participants had been able to re-frame the trauma. (Illustrative Quotes, Additional file 1: Table S3, point 3.1.)

Different experiences emerged regarding the effect of ImRs on guilt. Four participants started to feel less guilty or were able to reframe the traumatic experience. "What happened really shouldn't have happened, and I was able to experience that it had not been my fault." Two participants noticed no difference in their feelings of guilt. However, there was also someone (who also experienced psychotic symptoms) who started to feel more guilty. "If only it had happened like that, if only I had made a different choice." (Illustrative Quotes, Additional file 1: Table S3, point 3.2).

With regard to the perceived effect of ImRs on shame, two participants reported that shame stayed out of the picture during treatment, and, even though the qualitative questionnaires had explicit questions on it, that the therapist had not asked about it directly. Typically, shame concerned questions of what the participants would have liked to do with the perpetrator or perpetrators, or shame about their own physical reactions to ImRs. "If you have so much shame, you’re not going to talk about it." It was suggested that the therapist should ask explicitly about feelings of shame. “If we’d been asked, I think it would have come up more often. Otherwise, if you’re so ashamed, you’re not going to tell them.” It also helped two participants that they could do whatever they wanted to do in their thoughts, and that they did not have to speak out loud. The therapist could support this process by taking a robust approach to it, by keeping calm, and by agreeing with participants what they should include in the imaging in order to reduce the feelings of shame. (Illustrative Quotes, Additional file 1: Table S3, point 3.7; Tips and Suggestions, Additional file 1: Table S4, point 4.3.)

Perceived effect of ImRs on ED symptoms

With regard to the effect of ImRs on eating, eight participants stated that, due to the emotions they had experienced through ImRs, it had been difficult to eat a meal after the session on the day of the ImRs. After ImRs, participants typically reported “feeling dirty”, having “too much tension”, having “too many sensory re-experiences”, and having “food triggers”; or “not being hungry when very emotional,” and “not being able to eat because of a lump in my throat." One participant reported difficulties also the day after ImRs. Four participants also indicated that they used "not eating" on the day of ImRs to avoid or distract themselves from emotions such as sadness and anger, and that the ED helped to push the emotions away. "ImRs makes it hard to get through the day. So, to suppress those feelings a bit again, I did tend to cut down on food." (Illustrative Quotes, Additional file 1: Table S3, point 3.3).

It is noteworthy that the topic of negative body perception was not addressed very much during the ImRs sessions. As one participant linked her negative body awareness to the ED and not to the trauma, she had no hope of change through ImRs. However, another participant who did discuss her negative body awareness during ImRs also experienced no effect of this on her body awareness: “My body still feels dirty and all that.” Two participants indicated the importance of explicitly discussing any negative body perceptions that may have originated from the traumatic event. (Illustrative Quotes, Additional file 1: Table S3, point 3.4; Tips and Suggestions, Additional file 1: Table S4, point 4.3).

Perceived effect of ImRs on PTSD symptoms

Participants reported variously that ImRs had had positive, neutral, and negative experiences on their PTSD symptoms.

With regard to its positive effect on PTSD symptoms, someone expressed surprise at how easily the brain could be changed. In her case, when she thought back to the unpleasant event, she now saw the therapist in the picture. Three participants stated that they had managed to stay in the here and now better by thinking about the rescripted situation. "Now I can also say to myself: it’s not now, it was then. And then I try to see a bit of the rescripted scene in front of me. So it will end well." Three participants also reported that their reactions to re-experiencing symptoms became less intense after a few ImRs sessions, and that their physical reactions, such as palpitations and sweating, and their nightmares, flashbacks, and emotional reactions to ImRs, had decreased. "No more crying all the time.”

One participant indicated that she had noticed little effect on her PTSD symptoms. She did not feel that she was thinking about her trauma less, or was less sensitive to stimuli, and still felt very vulnerable, unstable, and emotional. “No, I don't think anything has changed regarding the degree of those symptoms.”

Two participants reported a temporary aggravation of their PTSD symptoms, consisting of an increase in re-experiences, some of which became more intense during the period or on the day of the ImRs. During a re-experience they did not manage to go back to what had been done in the rescripting. They indicated that when a re-experience began, they consciously tried to call up the image from the session. They could then see this new image for a moment, after which the old image took over. " Sometimes, when images start coming up, I consciously try to call up an image from those sessions. But often I see it just for a moment and then it’s gone again—the other image, the real one, flies over and covers it." Three participants had a re-experience or dissociation during the ImRs sessions. "During ImRs I often found myself going into a kind of express train, so to speak, and the film started running for me, so I was actually in a re-experience I couldn’t escape from.” After the sessions, two participants suffered a lot from nightmares." And certainly, in the nights after the sessions I also had a lot of nightmares." (Illustrative Quotes, Additional file 1: Table S3, point 3.5).

Five participants indicated that ImRs initiated a grieving process whereby, through rescripting, they realized what protection or care they had missed at the time of the traumatic event. “[It’s a] process of mourning… and you think…'if only I’d had that.’” (Illustrative Quotes, Additional file 1: Table S3, point 3.6).

Perceived effect of ImRs on self-compassion, internalization and its expected future effect

The treatment was also found to influence the development of self-compassion. Self-compassion seemed to have increased in three participants, though a few (2) did not experience this. For example, while one participant did not at first know what to say to reassure herself, her ability to do so improved during the session. In contrast, two other participants indicated that they had not learned to look at themselves with more compassion. (Illustrative Quotes, Additional file 1: Table S3, point 3.10).

At the time of the interviews, it seemed that seven participants had not yet (fully) internalized the ImRs method, and were unsure whether they could expect any effect from it over time. However, two participants were already able to use it independently. (Illustrative Quotes Additional file 1: Table S3, point 3.5).

When asked if they expected any future effect from the ImRs treatment, participants had various ideas. Five participants indicated that they did not know: “I’ve no idea what to expect.” Two participants thought it would have not any further effect, while four participants thought the effect they had experienced would develop further: “I hope so, and definitely think it will do something.” They added that while it was the start of a nice change, it was not enough yet: “I don't know if this will get rid of it completely, but I do think it will do something.” (Illustrative Quotes, Additional file 1: Table S3, point 3.11).

Experiences with the ImRs technique

In the interviews, participants discussed their experience with the ImRs technique imagination with rescripting and their experiences with this technique in the first and second six ImRs sessions.

Imagination and rescripting

Seven participants reported that the imagining had gone well and were amazed how well they had been able to experience it. “Surprised how well I could imagine it and how it felt exactly like the time of the trauma.” Five of the participants also reported that they liked the fact that they could keep control. “I found it quite tough, but also a very nice treatment, as you get control and keep it.” One participant said that when she realized that she herself could determine the intensity of the tension she felt, she started to dread it less. “I was not looking forward to it, and after the first session I was dreading it even more. And after that it got less, because at a certain point I realized that I could determine how great I allowed the tension to become—to what extent I went back into that memory. I liked that.”

On the other hand, two participants indicated that the method made it possible to avoid unpleasant feelings or images. For example, one participant indicated that there were unfinished images to which she did not dare to go. During the rescripting, she did not have to finish these images. (Illustrative Quotes, Additional file 1: Table S3; 4.1, Tips and Suggestions, Additional file 1: Table S4; 4.1.)

The first six sessions

In the first six sessions, the therapist steps into the image and intervenes in coordination with the patient. Two participants reported that this was difficult in the beginning, as they had never shared certain events before. Seven participants indicated that it was nice that the therapist had intervened during the first six sessions, that they had not had to do it alone, and that there had been an example: "When X did it, I was pleased that she acted a bit more angrily than I could.” But at the same time, two people also found it confronting that no-one had helped in the past.

Five participants felt that rescripting with the use of fantasy felt unrealistic and rather crazy, which also could limit the imaging. They were aware during rescripting that the rewritten situation did not correspond with reality. One person became aware, especially after the rescripting, that if a rewritten and imagined situation was a bit bizarre, they sometimes experienced it as unrealistic. However, another participant found it impossible to let the therapist enter the picture because it was too unrealistic for her, which is why she imagined the help from her parents.

During rescripting, participants were asked what their needs were. Two participants experienced the question of need to be difficult or confronting, but two participants experienced the questions also as a question that was very nice. "I found it quite difficult, as I very often didn’t know what my need was. But I liked the fact that she had asked, because the question helped me realise much more strongly that I could think of something I actually wanted." However, two participants also stated that identifying the need became easier along the way. "As the sessions progressed, I was increasingly able to communicate what I needed.” (Illustrative Quotes, Additional file 1: Table S3, point 4.2; Tips and Suggestions, Additional file 1: Table S4, point 4.4.)

The last six sessions

In the last six sessions, the participant rescripts herself. Here the experience was mixed. Five participants found these sessions to be nicer than the ones guided by the therapist: they felt more empowered, were more in control, and could create their own narrative. "I liked the second part better because I could do it myself. And after that I felt more powerful.” On the other hand, three participants found it more difficult to take the lead. Sometimes, for example, the connection with the child in the image was completely broken. In two other cases, they did not dare to speak to the perpetrator out loud, failed in their attempts to comfort the child, or found it unpleasant to have to do it alone. " Having to step into the picture myself, as an adult—that took a lot of effort, especially because I noticed that I did not see my little self as myself. As if I were helping another child.” At the end of each ImRs sessions, the therapist asked participants to bring their attention back to the present. Two participants reported that this was not an easy process, and that they still felt “floaty” for a while. (Illustrative Quotes, Additional file 1: Table S3, point 4.3; Tips and Suggestions, Additional file 1: Table S4, point 4.4.)

Contextual conditions

The ImRs was offered at the time of inpatient admission for the ED treatment. In the interviews, the participants shared their experiences with the support in the clinical setting, with treating multiple participants at the same time, with beliefs about ImRs in a clinical setting, with the support during meals, about the combination of ImRs in a clinical setting and about the number, the timing and the scheduling of the ImRs sessions.

Clinical setting; support

Nine participants particularly appreciated ImRs treatment in the context of the ED facilities. They gave several reasons for this, such as the distraction, the structure, the relaxation, and the fact that it felt too heavy to return home after ImRs. The support after ImRs was particularly appreciated, as it had made it possible to talk to the sociotherapists, group members, or roommates; or to go for a walk, to avoid getting stuck in unpleasant feelings, or to prevent withdrawing. "And they [the sociotherapists] also helped me with re-experiences or dissociations, so to speak—they helped me through it. And after that they made sure I was completely here again and safe.” However, one person indicated that she needed more support, as she had mostly coped alone. She had found it difficult to ask for support. There were also two participants who just wanted to be alone for a while after ImRs and had no specific need for support. (Illustrative Quotes, Additional file 1: Table S3, point 5.1; Tips and Suggestions, Additional file 1: Table S4, point 4.5.)

Clinical setting; several participants at the same time

It happened twice during the study that two participants in the same ED treatment group received ImRs in the same period. One participant reported that a fellow patient’s re-experiences had triggered her own re-experiences. Two participants indicated that, at times, they felt guilty when they needed the sociotherapists’ support at the same time as someone else, as this prevented the rest of the clinical group from getting attention (Illustrative Quotes, Additional file 1: Table S3, point 5.1.2; Tips and Suggestions, Additional file 1: Table S4, point 4.5).

Clinical setting; belief about ImRs

Two participants indicated that at times it seemed that participants and clinic staff had the idea or belief that undergoing ImRs treatment was very intense. A participant who did not think it was so intense therefore became uncertain about whether she was entitled to ImRs because she did not experience it like that (Illustrative Quotes, Additional file 1: Table S3, point 5.1.3; Tips and Suggestions, Additional file 1: Table S4, point 4.5).

Clinical setting; mealtime support

By offering ImRs in the context of the ED facility, there was active support around meals. Almost everyone (9) found this to be supportive. "If I hadn't been in this environment, I think I would just have stopped eating." (Illustrative Quotes, Additional file 1: Table S3, point 5.1.4; Tips and Suggestions, Additional file 1: Table S4, point 4.5).

Clinical setting in combination with ImRs

Two participants found it difficult to undergo a six-week programme that combined two weekly 90-min ImRs sessions with the inpatient ED-treatment programme. "Found it quite tough to have one of those sessions twice a week in the inpatient programme—that really took a lot of energy out of me, so yes, I did find it tough." Five participants who had managed this full programme were positive about the fact there had been sufficient closure time after the rescripting. The participant who stopped after three ImRs sessions indicated that it had been too hard for her to attend ImRs as well as the clinical ED programme: "Unfortunately that was just a bit too much—I did benefit from it, but I was so tired that I no longer had the energy to continue.” (Illustrative Quotes, Additional file 1: Table S3, point 5.2.1; Tips and Suggestions, Additional file 1: Table S4, point 4.5.)

Number of ImRs sessions

Opinions about the number of ImRs sessions differed widely. While some participants thought that 12 sessions had not been enough, others thought 12 was enough or even too many. Three participants who had experienced multiple traumas, however, indicated that 12 sessions may have been too few: “I had quite a lot of memories I wanted to discuss, [and] didn't get to do them all. I needed more than 12 sessions.” (Illustrative Quotes, Additional file 1: Table S3, point 5.2.2; Tips and Suggestions, Additional file 1: Table S4, point 4.5.)

Timing of ImRs

A six-week naturalistic baseline had been followed by a random baseline period. Six participants felt that the start of ImRs had been well timed, because they needed some time to get used to the ED treatment. "Just a few weeks to get used to the programme in the group”. Two participants also indicated that if their weight had been lower than the weight specified in the study’s inclusion criteria, ImRs might not have been successful. "If my weight had been lower, ImRs probably wouldn’t have been possible. I was in a phase of not feeling. If I’d had to start feeling then, I don’t know if I could have, and I wouldn't have dared to make the step towards." One participant indicated that, for her, the onset of the ImRs treatment should have been earlier. She had taken a pause from the clinical programme two weeks before starting ImRs because the PTSD symptoms became too severe. "I didn't like it because the trauma symptoms had become so severe, and nothing was being done about them yet. The only thing being stressed [i.e., during the ED treatment] was eating. While eating had become extremely difficult because of all the re-experiences.” (Illustrative Quotes, Additional file 1: Table S3, point 5.2.3; Tips and Suggestions, Additional file 1: Table S4, point 4.5.)

Scheduling of ImRs

In principle, the ImRs sessions were scheduled for 3:15 pm, i.e. after the clinical therapy blocks. However, for scheduling reasons, it was sometimes necessary for a participant, and sometimes for the therapist, to move the session to the morning. While seven participants indicated that the time of the session did not greatly matter, they preferred it not to be planned immediately before a meal. "A meal after the session wasn’t doable—it invariably ended up in the bucket.” It had been intended to spread the two ImRs sessions over the week, but circumstances did not always allow this. On the one hand this was experienced as pleasant for one participant, as she was then “done with it.” But on the other hand, she experienced it as very heavy. (Illustrative Quotes, Additional file 1: Table S3, point 5.2.4; Tips and Suggestions, Additional file 1: Table S4, point 4.5.)

Themes emerged through the semi-structured interview

During the interviews, participants identified three other themes 1) hope/ perspective, 2) effect of ImRs on awareness, and 3) compassionate approach.

Hope/perspective

While five participants expressed they were feeling hopeless before the start of their trauma treatment (Additional file 1: Table S3; 1.1.3), they saw hope in the fact that research was being done into the possibility of treating trauma in underweight people. Three participants who had hoped that treatment might bring change were pleasantly surprised when their expectations were exceeded. “Yes, I thought it might suit me, but I didn't think it would be as good as it was.”

After the ImRs sessions, the five participants who had not dared to hope for a positive effect before the study seemed to have become more hopeful. They dared to look to the future: “Yes, I'm very glad I did this. I had been at a loss, and thought, “yes, this is the only chance I have to get the combination [of ED and PTSD],’” and "I'm very glad it went this way, because […] if I’d done ImRs in a non-clinical setting, it would have gone really wrong.” The participant who experienced no positive effects from the ImRs indicated that she was nonetheless glad she had been able to complete the 12 sessions. There had been no recurrence of the sense of failure that had followed her previous trauma treatment, when too many re-experiences had forced her to stop.

Afterwards, the three participants specified that it was helpful that the therapists had continued to hold out hope during this new treatment modality. In summary, it appears that everyone had been given hope by their experience of ImRs when underweight—some because they had succeeded in completing treatment, others because they noticed small changes, and others due to significant decreases in PTSD symptoms. (Illustrative Quotes, Additional file 1: Table S3, point 6.1; Tips and Suggestions, Additional file 1: Table S4, point 4.6).

Effect of ImRs on awareness

The interviews indicated that, in various areas, ImRs had initiated a process of awareness that had not previously been present. This had enabled six participants to re-frame the trauma: “I was able to give a different colouring to what had taken place.”

There are various examples of this awareness. One participant realized that she had PTSD. Others recognized the way things were connected, the severity of their trauma, the level of their tension, the lack of certain support figures, or their suppression of unpleasant memories. "That whole piece of becoming aware of something that I've tucked away for so long under a block of concrete and landmines. It's… I compare it to a pimple that has burst. And now it's burst, and the pus can come out.” In three participants, the awareness also triggered a grieving process. For two other participants, the awareness brought the hope of future improvement and insight. (Illustrative Quotes, Additional file 1: Table S3, point 6.2).

Compassionate approach

All the interviews testified to the importance the participants attached to a compassionate approach—something in which therapeutic attitude, group setting and ImRs method played a role.

One participant indicated that she had not had a good connect with her therapist, and thus changed therapists after two sessions. All other participants indicated that their therapeutic contact had been very compassionate. Comments included “Very nice,” “very pleasant,” “I felt taken seriously,” “she had expertise,” and “I felt she really listened to me.”

One participant indicated that therapists needed to realize that few such participants are securely attached individuals who have had only a single trauma. This makes it even more important for therapists to have a compassionate attitude. "I'm just not used to it [getting help]: I always told myself I didn't deserve it. Then suddenly it's very strange that someone does help [during ImRs].” Nine participants felt that the clinical group setting was also supportive, as compassionate support and understanding were both available. “The group was very helpful, and really supportive and wished me well when I went to ImRs.”

The ImRs method also contributed to not feeling alone. The therapist promoted this by stepping into the picture to help, which is experienced as both pleasant and compassionate. Because the therapist was constantly asking what someone needs, nine participants felt truly seen and understood, and saw the extent and reliability with which the therapist sympathized and helped. As a result, they saw this method as much less protocol-based than other, more standardized therapies such as EMDR. (Illustrative Quotes, Additional file 1: Table S3, point 6.3; Tips and Suggestions, Additional file 1: Table S4, point 4.5).