The European Network for Traumatic Stress Training & Practice

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 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

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 • Explanation of procedure • Relaxation • Imaginal exposure • 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 56:5;356-363, 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 7;330(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; 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

35. Fore more information please visit the BEPP website: www.traumatreatment.eu