Home > Public Resources > Trauma Blog > 2015 - October > Clinician’s Corner: Brief Eclectic Psychotherapy for Post-Traumatic Stress Disorder: Intensive, Comp Clinician’s Corner: Brief Eclectic Psychotherapy for Post-Traumatic Stress Disorder: Intensive, Comprehensive and Effective Berthold P.R. Gersons, MD, PhD October 27, 2015 Traumatic events like war, being nearly killed, surviving a disaster, or being sexually abused for years are complex events with often long-lasting consequences. Brief Eclectic Psychotherapy for Posttraumatic Stress Disorder (BEPP) has been developed to encompass the complex consequences of traumatic events and subsequent PTSD in a comprehensive way. The roles of emotions and of meaning making of the event are central themes in BEPP. The aftermath of experiencing traumatic events may lead to overwhelming emotions, the longing for comfort from others, and acceptance. However, traumatized people are often afraid of these intense emotions. They even apologize for becoming sad or crying. Also they can feel lonely because of the traumatic experiences which made them lose faith in others, the world, and even belief in themselves. In BEPP fear is interpreted as being much afraid of the strong emotions associated with the trauma. The complexity of the aftermath of traumatic events together with PTSD makes a dual approach to diminish symptoms and to restore trust in oneself and the world necessary. In BEPP these two goals are encompassed in a logical sequence in 16 well-designed sessions. BEPP starts with psychoeducation with, if possible, a partner present. Here the therapist explains how the PTSD symptoms relate to the trauma. For instance remembering in every detail the traumatic event seems paradoxical to forgetting what one planned to buy at the supermarket. This makes clear danger is in the center of attention, essential for survival, but not useful in normal daily life. Psychoeducation helps to understand ones’ reactions. The next 4-6 sessions are devoted to imaginal exposure which entails recounting the traumatic event in great detail. The goal of the imaginal exposure is not to repeat the whole scene, but instead to go back and experience sadness for what happened. A short relaxation exercise precedes imaginal exposure to enhance a feeling of control and to increase focus. When the emotions of grief, sorrow, shame, disgust and anger are expressed, intrusions diminish, and the enduring tension and hypervigilance decreases. Other tools used for the expression of emotions are mementos and letter writing. Patients are asked to bring items connected to the traumatic event like photos or jewelry of deceased persons, and newspaper articles. The letter writing exercise is used to increase the survivors feeling of control and reduce powerlessness. Survivors are asked to write the letter to someone who is severely disappointed or blames them for the traumatic experience. The letter is not meant to be sent, but can be used in the farewell ritual at the end of the treatment. Letters written to loved ones who died help to express thoughts and memories important in the process of mourning. When emotions have been ventilated sufficiently, sleep often improves and sometimes people tell us as if they ‘awoke’. As they no longer need so much energy to be on guard for intrusions and uncontrolled intense emotions, they start to become interested in the world around them and feel the urge to get more insight in how their suffering relates to their past and related coping strategies, and how to prevent future risks. Major Tasks of BEPP: Session by Session During session 7 is when the meaning and integration part starts. The focus of this portion of the treatment is realizing how the events changed one’s view of him- or herself and of the world. The ‘old’, naive person will not return but will be replaced by a ‘sadder but wiser’ person who has learned from the terrible events. Experiences learned in childhood, previous relationships, and the work setting provides a larger context for which the survivor can understand the impact of the traumatic event. During the course of therapy, people regularly start to value life in a new way, no longer as self-evident but as a precious gift. The treatment is ended by a farewell ritual during which the patient and his/her significant other bury or burn the letters and mementos or find another purpose for items that are emotionally valuable. The goal of this exercise is twofold: it provides an opportunity for the survivor to experience sadness in the presence of loved ones once again and to leave the sadness behind. The second part of the farewell ritual is to celebrate the return in normal life and to go on with it in a much better shape. BEPP has proven to be as effective as some other trauma-focused treatments (Gersons et al., 2000; Lindauer et al., 2005; Schnyder et al, 2011; Nijdam et al., 2012; Nijdam et al., 2013; Gersons et al., 2013; Gersons et al., 2015). It is specifically indicated when people with PTSD want to learn from what happened to them, and how the impact of the trauma relates to other experiences in their life. Sometimes patients and therapists are afraid to pay attention to grotesque details of the traumatic experiences and to the strong expression of emotions of grief, anger and shame. When one endures this first phase, one will experience an impressive improvement and eagerness to live again. Much experience with BEPP has been acquired with police officers and outpatients with diverse traumatic events in the Netherlands. BEPP has also been applied for complex trauma in refugees and victims of childhood abuse. Experience with practicing BEPP has taken place in many different countries and places, from US, Chili, Australia, Africa, Italy, Lithuania, etc. with different cultures. Especially in cultures which are more narrative orientated or with a recent history of war BEPP seems to be like Narrative Exposure Therapy (NET) more appreciated compared to short and ultrashort trauma-focused treatments. Cultures in which public psychological knowledge is absent, the BEPP treatment needs more sessions especially the psychoeducation part. In addition, BEP for traumatic grief (BEP-TG) has been developed recently (Smid et al., 2015), and BEPP for children is on the way. Also, crossovers are sometimes used by therapists who apply Eye Movement Desensitization and Reprocessing instead of or in addition to imaginal exposure, and interventions of BEPP are integrated in NET. The BEPP-protocol is available free of charge in English, German, Spanish, Italian, Dutch, Polish, Lithuanian and Georgian language and it is applied in many European countries and on other continents. The website www.traumatreatment.eu informs patients and therapists about PTSD and BEPP (in English, German and Dutch). Four day courses are given by experienced trainers and Skype supervision is possible. An International BEPP Steering Group (IBSG) has been founded recently at the 2015 European Society for Traumatic Stress Studies (ESTSS) - conference in Lithuania. The chair is Dr. Vittoria Ardino from Italy and the secretary is Dr. Mirjam Mink-Nijdam from the Netherlands ([email protected] and [email protected]). Requests for the BEPP protocol and for BEPP workshops can be sent to the IBSG and to [email protected]. Acknowledgement: Dr. Gersons is grateful for comments and suggestions to improve this contribution by Dr. Geert Smid, Dr. Mariel Meewisse, Dr. Mirjam Mink-Nijdam and Dr. Vittoria Ardino. About the Author Berthold P.R. Gersons, MD, PhD, is emeritus chair and distinguished professor of psychiatry at the Academical Medical Center of the University of Amsterdam, the Netherlands and currently senior scientific advisor of Arq Psychotrauma Expert Group, the Netherlands. He developed the ‘Brief Eclectic Psychotherapy for PTSD’ (BEPP) protocol. He is an advisor for the police, the military, the National Coordinator for Counterterrorism and disasters like the recent MH17 disaster in the Ukraine. He has been member of the board of the Journal of Traumatic Stress, of the board of the International Society for Traumatic Stress Studies (ISTSS) and president of the European Society for Traumatic Stress Studies (ESTSS), from which he received the Wolter de Loos Lifetime Award. He has published over 200 papers in scientific journals and books and has lectured over 500 times in his home country and around the world. References Gersons, B.P.R., Carlier, I.V.E., Lamberts, R.D., & van der Kolk, B. (2000). A randomized clinical trial of brief eclectic psychotherapy in police officers with posttraumatic stress disorder, Journal of Traumatic Stress, 13, 333-347. Gersons, B. P.R., & Schnyder, U. (2013). Learning from traumatic experiences with brief eclectic psychotherapy for PTSD. European Journal of Psychotraumatology, 4, 21369. Gersons, B.P.R., Meewisse, M.L., & Nijdam, M.J. (2015). Brief eclectic psychotherapy for PTSD. In U. Schnyder & M. Cloitre (Ed.), Evidence based treatments for trauma-related psychological disorders. Heidelberg: Springer. Lindauer, R. J. L., Gersons, B. P. R., van Meijel, E.P.M., Blom, K., Carlier, I.V.E., Vrijlandt, I., & Olff, M., (2005). Effects of Brief Eclectic Psychotherapy in patients with posttraumatic stress disorder: Randomized clinical trial. Journal of Traumatic Stress, 18, 205-212. Nijdam, M. J., Gersons, B. P. R., Reitsma, J. B., de Jongh, A., Olff, M. (2012). Brief eclectic psychotherapy versus eye movement desensitization and reprocessing therapy in the treatment of posttraumatic stress disorder: Randomized controlled trial. British Journal of Psychiatry, 200, 224-231. Nijdam, M. J., Baas, M. A., Olff, M., & Gersons, B. P. (2013). Hotspots in trauma memories and their relationship to successful trauma-focused psychotherapy: A pilot study. Journal of Traumatic Stress, 26, 38-44. Schnyder, U., Müller, J., Maercker, J., & Wittmann, L. (2011). Brief eclectic psychotherapy for PTSD: A randomized controlled trial. Journal of Clinical Psychiatry, 72, 565-566. Smid, G. E., Kleber, R. J., de la Rie, S. M., Bos, J. B., Gersons, B. P., & Boelen, P. A. (2015). Brief Eclectic Psychotherapy for traumatic grief (BEP-TG): Toward integrated treatment of symptoms related to traumatic loss. European Journal of Psychotraumatology, 6, 27324.