The European Network for Traumatic Stress Training

1
The European Network for Traumatic
StressTraining Practice

• www.tentsproject.eu

2
Brief Eclectic Psychotherapy for PTSD (BEPP)

• Academic Medical Centre
• University of Amsterdam
• Amsterdam
• The Netherlands

3
Brief Eclectic Psychotherapy (BEPP)
is efficacious

• BEP has been shown effective in three RCTs
• Gersons et al (2000) police officers
• Lindauer et al (2005) mixed civilian
• population
• Nijdam et al (in prep) civilian trauma survivors
  (vs EMDR)
• In reducing
• PTSD (all 3 symptom clusters)
• Depressive symptoms
• Biological measures

4
Brief Eclectic Psychotherapy (BEPP) is
efficacious

• NICE Guidelines (2005)
• Acknowledged as one of the effective treatments
  of PTSD
• Categorized under CBT

5
Brief Eclectic Psychotherapy (BEPP)

• a brief problem-focused psychotherapy
• 16 sessions
• 45-60 minutes
• each session is a well described step in
  different phases of the treatment

6
Why eclectic?

• Limitations of
• psychodynamic treatment
• pharmacological treatment
• prolonged exposure
• BEPP gathering of effective techniques of
  different psychotherapeutic views

7
Brief Eclectic Psychotherapy
8
Contra-indications

• Relative contra-indications
• major depressive disorder
• addiction dependency
• panic disorder
• agoraphobia
• Absolute contra-indications
• all psychotic disorders
• severe depression
• severe personality disorders
• severe substance abuse

9
Session 1

• Attendance of partner
• Psycho education
• Explanation of the treatment
• Recounting of the traumatic experience

10
Psycho-education

• Explain why partner is invited
• clarify the therapy (techniques, rationale)
• role of partner background support
• Explain goals of therapy
• integrate traumatic event into patients life
• get reduction of complaints
• Explain techniques to be used

11
Psycho-education

• Therapist describes
• how PTSD symptoms may result from a traumatic
  experience
• how these symptoms affect the functioning of the
  patient (this framing of symptoms is essential
  to understand the elements of the therapy)
• that patient not only experienced one or more
  traumatic events but still behaves as if such
  events will strike again
• that his psychobiological make-up is
  dysfunctional

12
Psycho-education

• Therapist further explains
• that symptoms still exist because extreme -
  frightening - emotions are not tolerated to be
  felt and still hinder the fading away of symptoms
• how relaxation and imaginal exposure are tools to
  bring back the experience and to feel and express
  the extreme emotions
• how writing and use of memorabilia are helpful

13
Psycho-education

• how after the experience of all emotions
• the patient will pay attention to how he sees
  the world and him- or herself now and how he will
  adapt to the world
• and that a key-problem of PTSD is to leave behind
  the traumatic event in one's own history
• ? farewell-ritual

14
Recounting of the traumatic event

• Pay attention to
• the details of the event
• salient cues that trigger emotions
• what happened just before?
• what happened afterwards?
• reactions patient, partner, others
• secondary victimization?
• ask about feelings but not too deeply

15
Session 2

1. Explanation of procedure
2. Relaxation
3. Imaginal exposure
4. Examination of memorabilia

16
Imaginal exposure

• The imaginal exposure is a technique to
• bring to the surface extreme emotions of
• - anger
• - guilt
• - sorrow
• - grief and sadness
• which are not fully, or not at all felt yet

17
Imaginal exposure

• The catharsis of yet unfelt emotions precedes
  psychodynamic insight ? domain of meaning
• Merely talking about feelings may suppress them

18
Imaginal exposure

• Aim to feel how fearful and terrible the
  experience was, by remembering the traumatic
  event in great detail
• No repetition of exposure to diminish fear at the
  end, as in most cognitive and/or behavioural
  therapies

19
Imaginal exposure

• Procedure
• short relaxation
• here-and-now approach
• start with memories of beginning of day of trauma
• find out moment of first vivid sensory memories

20
Imaginal exposure

• Therapist encourages patient to
• tell exactly what he sees, hears, feels,
  experiences in a sensory way
• vividly and sensorily remember the event
• focus on feelings of fear, embarrassment, pain,
  anger, sadness

21
Imaginal exposure

• Resulting in discovery of new memory details with
  hidden extreme fear or pain
• Very slowly, only 15-20 minutes per session
• Chronological order of event takes mostly 4-6
  sessions

22
Sessions 3 - 6

• Review of past week
• Imaginal exposure
• Review of emotions
• Assignment of writing task
• Memorabilia

23
Writing task

• Continuing letter (to be left behind in the
  farewell ritual)
• to express difficult aggressive feelings in a
  controlled form
• no censoring
• read and discuss in next session

24
Memorabilia

• Memorabilia things with concrete or symbolic
  relationship with traumatic event
• clothes worn during the event,
• newspaper articles and photos,
• certain objects (e.g. like a gun in police work),
  
• bag taken from an air crash,
• etc.

25
Sessions 7 - 12

• Discussion of written assignment
• Cognitive restructuring or integration of meaning
• Pay attention to real world issues

26
Domain of meaning

• Therapist starts with some psycho-education on
  how the traumatic experience changed life, view
  on the world, them self, family, work,
  environment, etc.
• Familiar old self will never come back
• Illusion of safety eroded
• Awareness of vulnerability of life

27
Domain of meaning

• Survival guilt ? need new sense of self worth
• More aware of risks and how to strengthen their
  security
• May feel detached from the world
• sadder but wiser
• Sometimes link with events in youth
• Patient starts to realize some basic existential
  questions
• The domain of meaning
• Going back to work

28
Domain of meaning

• after catharsis of emotions ?
• appreciate life and love more intense than
  before
• illusion of safety replaced by better
  anticipation
• practical consequences like resumption of work

29
Sessions 13-16

• Planning of farewell ritual
• Evaluation of the treatment

30
Farewell ritual

• Therapist explains
• aim ritual to leave behind the traumatic event,
  not to forget but to give it a place in ones own
  life
• behaviour of patient is still determined by
  events in the past
• It feels as if the patient 'lives with his back
  to the future'

31
Farewell ritual

• With the farewell ritual it is time to turn
  around and to actively take part in the future
• Turning passive into active (no longer victim)

32
Farewell ritual

• Patient decides on use of farewell ritual e.g.
• burning letters, clothes, drawings, etc. in their
  yard, nature or home
• throwing it away in the sea or river
• mementos can be used
• Patient (together with partner) chooses which
  approach is used
• Go through the plan in detail

33
Evaluation

• kind of psycho education
• how does patient look back on relation
  trauma-symptoms?
• symptoms may re-emerge
• what has pt learned?
• how to apply in future situation
• ending the therapeutic relationship

34
References

• Gersons, B.P.R., Carlier, I.V.E., Lamberts, R.D.,
  van der Kolk, B., A randomized clinical trial of
  brief eclectic psychotherapy in police officers
  with posttraumatic stress disorder, Journal of
  Traumatic Stress 13 (2)333-347,2000
• Lindauer, R.J.L, Booij J, Habraken JB, Uylings
  HB, Olff M, Carlier IV, den Heeten GJ, van
  Eck-Smit BL, Gersons BPR, Cerebral blood flow
  changes during script-driven imagery in police
  officers with posttraumatic stress disorder.
  Biological Psychiatry 565356-363, 2004
• Olff M, Lindauer RJL, Gersons BPR, The effect of
  psychotherapy on psychophysiological responses to
  trauma imagery in patients with posttraumatic
  stress disorder. International Journal of
  Psychophysiology 54 (1-2)176-177, 2004
• Gersons BP, Olff M. Coping with the aftermath of
  trauma, British Medical Journal 2005 May
  7330(7499)1038-9
• Lindauer, R.J.L, Vlieger, E.J., Jalink, M., Olff,
  M., Carlier, I.V.E., Majoie, C.B.M.L., den
  Heeten, G.J., Gersons, B.P.R., Effects of
  psychotherapy on hippocampal volume in
  out-patients with post-traumatic stress disorder
  a MRI investigation, Psychological Medicine 2005,
  35, 1-11
• Ramón J.L. Lindauer, Berthold P.R. Gersons, Els
  P.M. van Meijel, Karin Blom, Ingrid V.E. Carlier,
  Ineke Vrijlandt, Miranda Olff, Effects of Brief
  Eclectic Psychotherapy in patients with
  posttraumatic stress disorder randomized
  clinical trial, Journal of Traumatic Stress 2005
  18205-212
• Lindauer RT, van Meijel EP, Jalink M, Olff M,
  Carlier IV, Gersons BP. Heart rate responsivity
  to script-driven imagery in posttraumatic
  stressdisorder specificity of response and
  effects of psychotherapy. Psychosom Med. 2006
  Jan-Feb68(1)33-40.
• Olff M, de Vries GJ, Guzelcan Y, Assies J,
  Gersons BP.Changes in cortisol and DHEA plasma
  levels after psychotherapy for PTSD.
  Psychoneuroendocrinology 2007 Jul32(6)619-26
• Lindauer RJ, Booij J, Habraken JB, van Meijel EP,
  Uylings HB, Olff M, Carlier IV,den Heeten GJ, van
  Eck-Smit BL, Gersons BP. Effects of psychotherapy
  on regional cerebral blood flow during trauma
  imagery in patients with post-traumatic stress
  disorder a randomized clinical trial. Psychol
  Med. 2007 Sep 61-12

35
Fore more information please visit the BEPP
website

• www.traumatreatment.eu