Transcript Dia 1 - ESTSS

The European Network for Traumatic Stress
Training & Practice
www.tentsproject.eu
Brief Eclectic Psychotherapy for
PTSD (BEPP)
Academic Medical Centre
University of Amsterdam
Amsterdam
The Netherlands
Brief Eclectic Psychotherapy
(BEPP) is efficacious
BEP has been shown effective in three RCT’s:
• 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
Brief Eclectic Psychotherapy
(BEPP) is efficacious
• NICE Guidelines (2005)
– Acknowledged as one of the effective
treatments of PTSD
– Categorized under CBT
Brief Eclectic Psychotherapy
(BEPP)
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a brief problem-focused psychotherapy
16 sessions
45-60 minutes
each session is a well described step in
different phases of the treatment
Why eclectic?
• Limitations of:
– psychodynamic treatment
– pharmacological treatment
– prolonged exposure
• BEPP: gathering of effective techniques of
different psychotherapeutic views
Brief Eclectic Psychotherapy
Contra-indications
Relative contra-indications:
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major depressive disorder
addiction dependency
panic disorder
agoraphobia
Absolute contra-indications:
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all psychotic disorders
severe depression
severe personality disorders
severe substance abuse
Session 1
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Attendance of partner
Psycho education
Explanation of the treatment
Recounting of the traumatic experience
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
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
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
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
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
Session 2
1.
2.
3.
4.
Explanation of procedure
Relaxation
Imaginal exposure
Examination of memorabilia
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
Imaginal exposure
• The catharsis of yet unfelt emotions
precedes psychodynamic insight 
domain of meaning
• Merely talking about feelings may
suppress them
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
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
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
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
Sessions 3 - 6
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Review of past week
Imaginal exposure
Review of emotions
Assignment of writing task
Memorabilia
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
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.
Sessions 7 - 12
• Discussion of written assignment
• Cognitive restructuring or integration of
meaning
• Pay attention to real world issues
Domain of meaning
• Therapist starts with some psychoeducation 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
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
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
Sessions 13-16
• Planning of farewell ritual
• Evaluation of the treatment
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'
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)
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
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
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):333347,2000
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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 56:5;356-363, 2004
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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
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Gersons BP, Olff M. Coping with the aftermath of trauma, British Medical Journal 2005 May 7;330(7499):1038-9
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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; 18:205-212
•
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-Feb;68(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 Jul;32(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 6;:1-12
Fore more information please visit
the BEPP website:
www.traumatreatment.eu