protocol brief eclectic psychotherapy (bep) - IFP

PROTOCOL
BRIEF ECLECTIC PSYCHOTHERAPY (BEP)
FOR POSTTRAUMATIC STRESS DISORDER
English Version, June 2004
Copyright 1996, Revised 2004
Prof. Berthold P.R. Gersons, Dr Ingrid V.E. Carlier & Dr Miranda Olff
Center for Psychological Trauma, Psychiatry Section, AMC / de Meren

Center for Psychological Trauma
Psychiatry Section, AMC / de Meren
Tafelbergweg 25
1105 BC AMSTERDAM
Netherlands
tel.: +3120 - 566 2360
fax: +3120 - 697 8519
e-mail: b.p.gersons@amc.uva.nl
Note:
The authors can assume no responsibility for any application of this
therapeutic protocol if performed without proper training.
Previous versions:
1. (contained in) Carlier, I.V.E., Lamberts, R.D., Gersons, B.P.R. Ingrijpende gebeurtenissen in
politiewerk, Gouda Quint, Arnhem, 1994
2. Integral individual treatment protocol for posttraumatic stress disorder. Longitudinal research
project Critical Incidents in Police Work, Academic Medical Centre (AMC), Amsterdam, 1996
3. Protocol voor een geïntegreerde individuele behandeling van de posttraumatische stressstoornis,
based on the longitudinal research project Critical Incidents in Police Work,
Academic Medical Centre (AMC), Amsterdam, January 1997
4. Integratives individuelles Behandlungsprotokoll der posttraumatischen
Belastungsstörung: Ergebnisse einer Längsschnittstudie über kritische Zwischenfälle in
der Polizeiarbeit, Detailed Version, January 1997. Trans. Michaela Brückner and Doris
Denis, Berlin.
With thanks to:
Ineke Vrijlandt, Ramón Lindauer, Gré Westerveld and Renée Hutter of the Center for Psychological
Trauma, Psychiatry Section, AMC / de Meren, Amsterdam, for their advice and their contributions to
the revision.
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Contents
1. Introduction ...............................................................................................4
- Indications and contraindications ..............................................................5
- Medication.................................................................................................7
- Effectiveness.............................................................................................7
2. Protocol......................................................................................................8
- Content of the brief eclectic psychotherapy ..............................................8
1. Psychoeducation.................................................................................8
2. Imaginal exposure...............................................................................9
3. Writing tasks and mementos.............................................................10
4. Meaning and integration....................................................................10
5. Farewell ritual....................................................................................11
3. Description of the 16 sessions...............................................................12
- Psychoeducation.....................................................................................12
Session 1 ..............................................................................................12
- Imaginal exposure...................................................................................14
Session 2 ..............................................................................................14
Sessions 3 – 6.......................................................................................16
- Meaning and integration..........................................................................18
Sessions 7 – 12.....................................................................................18
Session 9 ..............................................................................................19
Sessions 10 – 12...................................................................................20
- Farewell ritual..........................................................................................20
Sessions 13 – 16...................................................................................20
Literature......................................................................................................22
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1. Introduction
A number of therapeutic protocols have been developed for posttraumatic stress
disorder, or PTSD (Gersons, 1999; Foa et al., 2000). These have drawn on the
various paradigms that inform very different schools of psychotherapy. Perhaps the
most widely known approach has been cognitive-behavioural therapy (CBT), based
on the ‘habituation of anxiety’ principle. The more recently developed eye movement
desensitisation and reprocessing therapy (EMDR) rather resembles CBT, but
achieves anxiety reduction through a different route. Our Brief Eclectic
Psychotherapy (BEP) protocol was originally developed in a psychodynamic
conceptual framework. The treatment consists of a short, problem-focused
psychotherapy consisting of sixteen 45- to 60-minute sessions. Each session forms a
carefully defined step in one of five therapeutic stages. The aims are to reduce PTSD
symptoms in clients and to help them integrate the traumatic event into their lives and
ultimately regain control.
We call our approach Brief Eclectic Psychotherapy because it is based on a
combination of theories drawn from psychodynamic, cognitive-behavioural and
directive psychotherapies. It was initially based on the pioneering work of Horowitz
(1986), who described the symptoms of PTSD as a biphasic alternation of the
reexperiencing and avoidance of traumatic memories. The phenomenon of
reexperiencing, or continuously reliving the trauma, bears a close resemblance to the
concept of repetition (Wiederholung) in anxiety neuroses, as known from
psychoanalytic theory. Repetition occurs when an anxiety theme is permanently
present in the conscious mind. Avoidance was interpreted by Horowitz as an attempt
to repress the memory of the traumatic event. He postulated that psychodynamic
psychotherapy would eliminate both the repetition and the avoidance by focusing on
the personal meanings clients give to a traumatic event and on how they perceive
and experience the associated emotions. This would give the event a place in their
personal life history.
The BEP protocol was developed further on this basis by Gersons in the 1980s and
1990s. He began by treating police officers according to the guidelines of
psychodynamic psychotherapy (Gersons, 1984, 1988, 1989, 1991, Gersons &
Carlier, 1994). Like Lindy’s (1988) psychoanalytic treatment of Vietnam veterans, the
Gersons approach produced very satisfying results. The police officers appreciated
their improved self-insight and clearer view of the world. Yet the PTSD symptoms still
persisted, both in the Gersons and in the Lindy approaches. Avoidance was reduced,
but the intrusive memories and hyperarousal still remained. The protocol was then
enhanced with a method concentrating more strongly on the catharsis of emotions
(Freud 1893), which had already been successfully applied in other areas such as
grief therapy. The faltering process of grief resolution was revived there by viewing
photographs of the deceased loved one and bringing emotions of anger and sorrow
to expression. In the BEP protocol, catharsis was achieved by using mementos –
objects or photographs reminiscent of the traumatic event – and by guiding the
client’s imagination back to the most vivid possible memory of the event. We
originally called this technique ‘imaginary guidance’.
Elements were added to these catharsis-focused parts of the therapy to help the
client retain continuous control during the therapy. This was motivated in part by
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Spiegel’s warnings that ‘passive patients’ could suffer further traumatisation under
the traditional psychodynamic approach. BEP enhances the client’s sense of control
by using limited relaxation exercises to accompany the imaginal exposure. Clients
learn to relax in ways that make it easier for them to concentrate on the guided
reexperiencing of the event, but to avoid going into trance. In addition, the therapy
begins with a highly detailed session of psychoeducation, in which the client, often
accompanied by a partner or other close companion, is given an explicitly cognitive
clarification of how PTSD symptoms are connected to the traumatic event. The
therapist also uses this context to explain the various components of the proposed
therapy and its anticipated outcome. A further element that draws on knowledge
generated by grief therapy is letter writing. In this case, the ‘running letter’ is not
normally directed at the deceased (except in some instances when that person forms
part of the traumatic experience), but to something or someone that the client is
extremely angry about. The letter helps the client to become aware of and express
this anger. The imaginal exposure concentrates primarily on the grief arising from the
traumatic experience.
This exposure component is followed by an effort to confer meaning to the traumatic
event, and a focus on self-insight and on the wider world. Because clients by now are
no longer burdened by the PTSD symptoms, they can effectively focus their attention
on these fundamental aspects. This meaning and integration component of BEP is
less explicitly present in the other therapy protocols for PTSD referred to above. A
further distinctive characteristic of BEP is that the therapy finishes off with a farewell
ritual (van der Hart 2003, Gersons 2003). In this component, the letter and any
mementos such as clothing, newspapers and photographs can be buried or burnt.
This revives the emotions one last time. The farewell ritual also serves as a
ceremony for ‘reunification’ with the world. It is followed by a celebration to mark the
leaving behind of the traumatic event in the client’s life history and the client’s return
to the world. The farewell ritual and the running letter are techniques borrowed from
directive therapy. Their purpose is to give clients more control over the therapeutic
process.
This brief therapy does not actively address any psychodynamic issues such as
transference or parent-child relationships. Developing such insights can be useful in
BEP only if clients themselves begin drawing connections between their traumatic
experience and other events or significant persons. Transference is used only
implicitly. Clients feel safe with the therapist because the course of treatment is
clearly delineated and structured. Limiting the therapy to 16 sessions also helps to
avoid dependence. Most clients experience the transference as positive because the
therapist understands and supports them. Negative feelings find outlets in the writing
tasks and the farewell ritual.
Indications
Before starting the therapy, clients undergo a comprehensive intake procedure which
includes assessment and diagnosis (Carlier et al., 1996, 1998). The therapy is
intended primarily for clients with chronic PTSD arising from traumas of type 1. The
distinction made by Terr (1991) between type 1 and type 2 traumas is important here.
Type 1 traumas are unanticipated traumatic events experienced by adults or young
adults. Many clients will have experienced more than one traumatic event of type 1.
Type 2 traumas involve repeated exposure to severe traumatic events during youth
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or childhood, such as continuous violence or abuse, which the child learns to
anticipate. Type 2 traumas are thought to interfere with brain and personality
development. BEP cannot resolve conditions like these. In most such cases, brief
intervention will not be sufficient, and more effort will have to be put into forging a
strong, stable therapeutic relationship and into stabilising the client if necessary. In
cases where type 2 traumas have resulted in PTSD, one can consider whether or not
BEP is suitable by weighing its possible effects on the client’s personality. Empirical
evidence is still lacking in this regard.
In cases where clients have experienced more than one traumatic event, one should
consider whether all such events need to receive attention. Sometimes a number of
traumatic events have occurred that did not previously result in PTSD, but which
gradually weakened a client’s resilience to the point where symptoms could emerge
after a relatively mild trauma. Usually, however, a single core trauma has preceded
the onset of the symptoms. This is often the point at which a wave of anxiety (an
adrenalin rush) sweeps through clients’ bodies, making them ‘lose their breath’. If the
vehement emotions they felt at that particular moment can be brought to expression
in the therapy, then ‘exposure’ to other traumatic experiences proves no longer
necessary. Other experiences do get addressed in the meaning and integration
stage. One illustration was a police officer who had had a shocking experience early
in his career when he was called to a railway station. Entering the platform, he saw a
woman lying on the rails. He suddenly realised that her head was severed from her
trunk. Her eyes were still open and they seemed to be looking at him. Although the
officer was certainly troubled by this macabre sight for several weeks, he did not
develop PTSD at that point. A year later, he had a second experience. During a brawl
in a dimly lit bar, he suddenly saw a knife gleaming right before his stomach.
Adrenalin rushed through his body. After he was threatened in the bar, he began
having intrusive memories of these events, but especially of the woman lying on the
railway tracks. During the meaning and integration stage, the question arose as to
why the woman had taken her life. That issue had gained significance for him once
he was threatened with death himself. In this case, then, the second event was the
right one to focus on in the exposure stage, but the first event was more appropriate
during the second part of the therapy. Hence, the existence of more than one
traumatic experience is by no means a contraindication for BEP.
Contraindications
Contraindications for BEP are comorbid conditions that overly interfere with the
execution of the protocol, or which could be exacerbated by the therapy. The
comorbid conditions are relative contraindications. Comorbidity of PTSD with
depression is quite common. The severity of the depression is the gauge of whether
BEP can be administered. Mild depression usually improves with BEP. In moderate
depression, antidepressants often need to be prescribed in conjunction with BEP.
Severe depression needs to be treated by itself before any decision on whether BEP
is appropriate. Similar criteria apply in cases of substance dependence or addiction.
The substance use needs to be brought under control, because the emotions
sparked by the therapy may throw the client out of balance and precipitate more
substance use. The same types of considerations pertain to clients who have other
kinds of anxiety disorders alongside PSTD. Personality disorders are a
contraindication for BEP, unless they are very mild. Psychotic disorders are absolute
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contraindications. Recently, however, positive results were achieved with a client
whose PTSD was comorbid with a well-controlled bipolar disorder.
Separate observations are needed about PTSD in combination with dissociative
disorders. Although dissociative symptoms often occur during traumatic experiences
(peritraumatic dissociation), they are transient in nature. Examples are perceiving the
event as extremely slow-moving, as a film, or as accompanied by complete silence.
The latter was the perception of a doctor called to treat youthful victims of a pub fire.
He experienced the scene outside the pub as ‘deathly quiet’. In cases where PTSD is
preceded by an acute stress disorder, dissociation has occurred by definition. Certain
aspects of the event have not been recorded in memory or can no longer be
retrieved. In some clients, dissociation takes place whenever they start to think back
to the event. This can be overcome by teaching them relaxation manoeuvres that
inhibit dissociation, and by taking care not to proceed too swiftly. Application of BEP
is not possible in clients who suffer from severe dissociative disorders.
Medication
Medication is not part of the BEP treatment. Some psychotropic drugs are known to
be wholly or partly effective in PTSD. As a rule, BEP is not administered in
combination with drugs, unless a client’s comorbidity or pathology necessitates.
Great restraint should be used in prescribing benzodiazepines or sleeping
medications that tend to cloud consciousness. Although these make clients feel more
tranquil, the effects on their experience of emotion may be so potent that it defeats
the purpose of BEP. Antidepressant medication, too, may induce a certain
‘indifference’ in clients which is incompatible with the desired catharsis.
Effectiveness
The protocol was developed by Gersons in the 1980s and 1990s to treat PTSD in
police officers. Randomised controlled studies have shown the therapy to be effective
both in police officers and in a general population of PTSD clients with a variety of
traumatic experiences (Gersons et al. 2000, Lindauer et al. submitted). Lindauer et
al. (2003) have also found significant improvement in terms of biological parameters.
Heart rate, in particular, which is elevated in PTSD, slowed significantly in BEP. The
frontal brain (‘the thought process’) was less inhibited after BEP, and it appeared to
gain more control over the limbic system (‘the emotions’).
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2. Protocol
Content of the Brief Eclectic Psychotherapy
This protocol is intended as a manual describing the overall psychotherapeutic
process and the various techniques employed in BEP. For each therapy session, the
protocol supplies information about content and procedure. The therapy consists of
five essential elements, to be discussed in chronological order:
(1) psychoeducation
(2) imaginal exposure
(3) writing tasks and mementos
(4) meaning and integration
(5) farewell ritual.
A good working relationship between the client and the therapist is essential to this
therapy. Many people who suffer from PTSD have grown highly distrustful of other
people – possibly including psychotherapists. An important thing to remember is that
individuals with traumatic experiences often tend to keep those experiences to
themselves, especially when it comes to the goriest details. They know such stories
will scare other people, but their reticence also facilitates their own avoidance. Shock
reactions like these are palpable in nonverbal cues, especially in clients’ faces.
Therapists will have to coax them into telling their stories. That will also require keen
concentration as well as self-preservation on the part of the therapist, who will have
to listen with empathy to the horrific stories and understand how intensely the client
suffered. Establishing a good therapeutic relationship is a prime focus in the initial
sessions. Therapists can smooth the process by showing empathy and
understanding and by having real knowledge of the worlds of trauma victims.
Examples of such ‘worlds’ are the experiences of tortured refugees, the
circumstances prevailing at specific disasters, the workings of sexual violence, and
certain professional settings such as police or military work.
1. Psychoeducation
At the start of the therapy, clients should be thoroughly instructed about the
connection between their own symptoms and the traumatic experience they have
undergone. Most clients have never heard of, nor thought about, the relationship
between such symptoms and the trauma. It is important to explain not only how
PTSD symptoms can arise out of traumatic experiences, but also how these
symptoms can affect and disrupt the clients’ personal functioning. Many symptoms
can be explained as useful, effective reactions of mental acuity in situations of
danger, but as disruptive forces if they continue after the danger has passed. The
normally vital and beneficial sense of fear has become oversensitised, causing it to
relay incorrect information. Clients feel jumpy. They are able to concentrate sharply
on ‘danger’, but worse and worse on ‘ordinary’ matters like shopping and daily
interactions. Many can no longer even read a book because they ‘unconsciously’
keep scanning the area for potential danger. Creating a systematic overview of the
symptoms (‘framing’) in the presence of the client (and partner or companion) is
essential for helping them understand the purpose of the therapy as well as the
elements and steps it contains.
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2. Imaginal exposure
An important principle to understand in this therapy is that psychodynamic insight
must always be preceded by a catharsis of yet unexperienced emotions. From
experience it has become abundantly clear that merely talking about feelings can
actually help to suppress them. Imaginal exposure is a technique that can bring
extreme emotions of grief, anger and guilt to the surface in clients who have not yet
perceived and experienced them fully, or perhaps not at all. Exposure techniques are
also essential components of behavioural therapy methods. In contrast to most
cognitive and behavioural therapies, however, our approach does not use repeated
exposure for the purpose of gradually reducing the anxiety. We use it to make clients
feel how terrifying and horrendous their experience really was by allowing them to
relive what happened in vivid detail. For this reason it is not the therapist that
describes the traumatic event, but the clients themselves. They are to recount, as
precisely and graphically as possible, what they are seeing, hearing, feeling and
experiencing during the guided reliving of the event. The exposure therefore
proceeds very slowly. Per session it occupies only 15 to 20 minutes.
The technique begins with short relaxation exercises (see below). Next, in a hereand-now
approach, the therapist elicits the client’s memories from the beginning of
the day on which the trauma was to occur, in order to pinpoint the moment at which
the first vivid, sensory, tangible memories begin to surface. The client is urged to
relive the event as graphically and true-to-life as possible. During the imaginal
exposure, the therapist zeroes in on feelings like fear, confusion, pain and grief.
Usually clients will then begin to recall new details that embody extreme fear or
anguish. They will discover feelings that now rise to the surface for the first time.
Even more important than their feelings at the time of the event are their emotions as
they look back on it in the here-and-now. Therapists should take great care to listen
closely to the clients, supporting them as they go through the difficult, frightening
emotions, but not restraining or suppressing these emotions in any way. No
psychodynamic interpretations should be offered during this stage of the therapy.
Since outbursts of extreme rage, grief or weeping can be frightening to therapists too,
they should allow time for a work break after every session.
Four to six sessions are generally sufficient to work through a client’s entire traumatic
experience chronologically from minute to minute. If a client turns out to feel nothing
right at the most terrifying moments, the image can be ‘frozen’ to concentrate on
releasing difficult feelings. Clients who have been through more than one traumatic
experience will probably choose the most significant of them, often the core trauma.
In most cases it will not be necessary to focus later on other traumatic experiences.
During the imaginal exposure, it is important for clients to be able to retake control of
their lives. They are therefore permitted to halt the exposure process at any time by
opening their eyes, walking round the room or whatever. To avoid dissociation during
the exposure, brief muscle (relaxation) exercises can be performed, or clients can
keep their eyes open. One common cause of dissociation is that therapists want to
move too swiftly, not allowing for a client’s own pace.
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3. Writing tasks and mementos
These two techniques are likewise designed to uncover the difficult feelings
connected to the traumatic experience. Mementos are objects that are tangibly or
symbolically linked to the traumatic event. Examples are clothes the client was
wearing at the time, newspaper clippings or photographs, objects such as weapons
(in police work) or a bag rescued from a plane crash. Such objects can help to revive
memories and feelings during the sessions. Some mementos can also be used later
in the farewell ritual.
Writing tasks are another tool for bringing extreme emotions to the surface, but the
tasks are not performed during the sessions or in the presence of the therapist. It is
good for clients to be actively involved in the therapy outside the sessions, feeling the
emotions without having the therapist nearby. The written assignments are not meant
to be accurate records of the traumatic experience, but they serve explicit purposes,
such as eliciting feelings of rage towards particular persons or organisations that the
client associates with the trauma.
4. Meaning and integration
After all the difficult feelings have been released, most PTSD symptoms will abate,
and clients will realise for the first time that their lives have been drastically changed
by the trauma. Even though many people are reasonably aware that traumas do
occur, those who have not experienced one themselves will often perceive their own
lives as rather stable and constant. The experience of trauma confronts people with
vulnerability, helplessness and the ferocious and terrifying sides of human behaviour.
The ‘illusion of safety’ vanishes, and victims may develop a deep distrust of
humanity. After experiencing the depth of awesome emotions like these, clients will
inevitably begin asking themselves certain fundamental, existential questions. They
will talk about their ‘view of the world’ – how they see the world, themselves, their
family, their job and other parts of their lives. It is important to realise that this is next
to impossible during a brief therapy. Yet what is crucial here is that clients now feel
better after experiencing the catharsis of emotions, and therefore begin to value life
and love more consciously. Their failing sense of security can now be replaced by an
adequate, focused anticipation of the future. Often this sets the stage for a new
beginning in occupational and other respects.
This brief therapy does not actively address any psychodynamic issues such as
transference or parent-child relationships. Developing such insights can be useful in
BEP only if clients themselves begin drawing connections between their traumatic
experience and other events or significant persons. Transference is used only
implicitly. Clients feel safe with the therapist because the course of treatment is
clearly delineated and structured. Limiting the therapy to 16 sessions also helps to
avoid dependence. Most clients experience the transference as positive because the
therapist understands and supports them. Negative feelings find outlets in the writing
tasks and the farewell ritual.
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5. Farewell ritual
The therapy finishes off with a ‘farewell ritual’. Therapists explain to clients (and their
companions) that the ritual serves to leave the traumatic experience behind. The
purpose is not to forget the experience, but to give it a place in their personal life
history. During the initial, psychoeducation stage of the therapy, the therapist has
already explained to clients that their behaviour is still being governed by events in
the past, and that they are ‘living with their back to the future’. The farewell ritual is
the moment when they turn around and actively direct their gaze to the future.
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3. Description of the 16 sessions
PSYCHOEDUCATION
Session 1
This is the first therapy session. That implies that assessment and diagnosis have
already taken place. Clients know that they have been diagnosed with PTSD, and
that they will be doing the BEP therapy for that reason. In this first session, the
client’s partner, or another close friend or relative, may take part if the client
consents.
Agenda:
1. Explanation of the purpose and content of the therapy
2. Psychoeducation
3. Reviewing the traumatic event (if necessary)
1. a. The purpose of the therapy is to reduce the symptoms of PTSD, to come to
terms with the traumatic experience and to give it a place in the client’s own life
history. The client’s partner, or other close companion, has been invited to attend.
One reason for this is to help that person better understand how the client’s
symptoms are related to the traumatic experience(s). The therapist explains how
the symptoms will be treated, and that most of them are expected to go away.
Attention is devoted to the fact that close relations often share in a client’s
suffering, both because they go out of their way to spare the client and because
they are affected by the client’s insomnia, irritability, concentration problems and
frequent social withdrawal. During this session, the companions can express their
own sorrow and grief. They are also to take part in the farewell ritual at the end of
the therapy.
b. The companions of clients also have the task of bringing and collecting the
client, if possible, during the first 4 to 6 sessions. The therapist explains that the
exposure procedure will evoke intense emotions that will persist after the session
and which may cause considerable apprehension beforehand. These may affect
the clients’ driving ability and even their ability to work that day. It is crucial to
explain that the anxiety will decrease and that symptoms like insomnia will
improve once these pent-up emotions have been released.
c. Clients are informed that the therapy comprises 16 sessions and that the focus
will be on the ‘core trauma’. The techniques will be to relive the traumatic event, to
express the intense emotions, to perform a writing task, to focus on mementos, to
seek meaning for the traumatic experience, and to finish off with a farewell ritual.
2. The psychoeducation consists of explaining the symptoms of PTSD. It is carried
out as follows (it may be useful to illustrate some aspects by making diagrams on
paper):
The client has been acting as if the traumatic event were about to happen
again. That is because the terrifying experience has been stored in the amygdala
(‘the alarm centre of our brain’) in such a way that we keep scanning around for
this newly found danger. This is an automatic reaction, as when people who have
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experienced a plane crash duck every time a plane flies over, ‘as if it’s going to
crash too’. If you ask them, they say they don’t really expect that to happen (‘No, I
don’t really think so’), but their rapid-reaction stress system always gets a jump on
their slower thinking processes. Edginess like this would be perfectly functional if
the traumatic event were to indeed take place again. However, such a
psychobiological state is extremely dysfunctional when danger is absent. ‘You just
can’t switch it off by yourself.’
This also explains the excruciating fatigue that clients often suffer, since they
are constantly on the lookout for danger that does not exist. ‘It’s like an engine
running too fast.’ This heightened vigilance explains why clients have trouble
falling asleep and why they wake up so soon afterwards (‘just take naps’). A
telling symptom is their inability to read a book. They lose track of the story after
two pages. They apparently just can’t shut themselves off to the ‘outside world’ of
impressions and noises, and so they can’t get absorbed in the book. This also
explains why they can acutely remember ‘danger information’, but may have
terrible trouble in remembering ‘unimportant’ things like ‘a tiny shopping list’. Their
brains select information too much in terms of the danger criterion. Their lack of
attention for ordinary matters can also cause them to get quickly irritated at
people around them, with whom they have ‘just don’t have any patience’.
The symptoms of experiencing everything over and over again, avoidance
behaviour and hyperarousal occur repeatedly because extreme, and hence
frightening, emotions linked to the life-threatening experience are suppressed.
They thereby stand in the way of a resolution of the symptoms. The assumption in
BEP is that this anxiety is actually in large part a petrifying fear of the violent
emotions ignited by the traumatic experience. The client therefore keeps trying to
suppress them.
Relaxation exercises make it easier for clients to concentrate on their
traumatic experience and to put themselves back into that terrifying situation. In
the imaginal exposure, they relive the experience in their imagination in order to
release and express the vehement emotions it caused. The most important
emotion to deal with is grief.
Mementos are employed to aid clients in retrieving the traumatic experience
into their memory down to its smallest details. The mementos also help to revive
the emotions. Later they can also play a part in the farewell ritual. Writing down
the traumatic experience, in the form of a ‘running letter’ to something or
somebody considered partly or wholly responsible for the traumatic occurrence,
can help clients perceive and express the anger they harbour.
After clients have experienced or relived the emotions associated with the
trauma, they are then asked to describe how they now look at the world and at
themselves, and how they think they can adjust back to the world. This is the part
of the therapy that concentrates on finding meaning in the trauma.
To allow clients to demonstrate that they will not forget the traumatic event but
now want to leave it behind them and focus their outlook on the future, the
therapy is finished off with a farewell ritual.
3. If they want to or need to, clients can now talk about the traumatic event again.
Therapists must be able to immerse themselves sufficiently in that situation to
ensure that clients will feel their empathy and that their partners will thoroughly
understand how devastating the experience has been for their loved one. One
should pay attention to (but not unduly encourage) the following matters:
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• details of the traumatic event, significant cues that trigger emotions
• things that happened just before the event
• reactions after the event by the client and others (the views of the partner or
companion are also useful here)
• whether ‘secondary victimisation’ occurred (the client also ‘got the blame’ for
the incident).
The therapist also inquires during this first session about the feelings aroused by
the traumatic event. The aim is not to delve deeply into such feelings at this point,
but mainly to identify them and get a better overall impression.
IMAGINAL EXPOSURE
Session 2
(Client alone)
Agenda:
1. Imaginal exposure
2. Discussion of the exposure
3. Explanation of mementos (‘linking objects’)
1. As always in this protocol, the therapist first explains the purpose of the session
(perhaps repeating certain elements of the psychoeducation). The session starts
by teaching relaxation exercises. They help clients to concentrate better on
awakening the most vivid possible memories of the event. The exercises should
confine themselves to particular muscle groups, and they are in no way intended
to put clients into trance. It is important for clients to retain their sense of control.
Clients sit down in a comfortable chair and relax as much as possible. Explain
that the purpose of the exercise is just to relax, and not to lapse into any kind
of semi-sleep or reduced state of consciousness. They are to stay in control
during the relaxation. Therapists first demonstrate the relaxation exercises
themselves. They start by clinching their own fists as tightly as possible and
releasing them 30 seconds later. Clients are to repeat this twice. They are
then asked to focus on a particular detail like their relaxed left middle finger.
This teaches them to distinguish between tension and self-induced relaxation.
Next, the foot muscles are tensed and then relaxed in a similar fashion. Often
this is a suitable moment to ask clients to close their eyes to help them
continue to concentrate on reaching the desired state of relaxation. They can
then become aware of another detail like a ‘heavy’, relaxed ankle (if they are
sitting with crossed legs). These tensing and relaxing exercises are then
repeated on the calves, shoulders and eyebrows. Some clients are so tense
and nervous, especially the first time, that contralateral contraction and
relaxation of the fists may help. They then clinch only one fist, leaving the
other unclenched. This enhances their sense of control. Clients with a
tendency to dissociation derive particular benefit from these exercises.
Focusing attention on breathing can also facilitate both relaxation and selfcontrol.
In cases where clients continue to be too fearful of going back to the
traumatic event, therapists can suggest getting accustomed to the imaginal
exposure by first retrieving a pleasant memory, like a holiday scene with the
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client sunning peacefully on a beach. This also teaches clients how they can
relive true-to-life scenes by evoking sensory perceptions like ‘warm air’, ‘cool
breeze’, ‘sea fragrance’, ‘the sound of breaking waves’ or ‘the cries of
seagulls’. New details often emerge in the process.
Once clients indicate that they are sufficiently relaxed, the imaginal
exposure can begin. The therapist makes several suggestions to bring the
client back to the day of the traumatic event. What day of the week was it
What month, what season Was it still dark, or already daylight Memories
about the hours immediately preceding the traumatic event are usually rather
vague, and sometimes have to be partially reconstructed. Only when they
arrive at the traumatic event itself will clients perceive a dramatic contrast in
the intensity of sensory recall and detail. ‘I can now feel that sock containing
those bones.’ ‘I now feel how strange and unreal I felt then.’ ‘I see him hanging
there. No, I don’t really see anything, but the smell is revolting. I feel sick to my
stomach, but I can’t move my feet.’ ‘I feel how the plane starts to shake and
how I grab the armrests. My hands are sweating and I think, "We’re not going
to make it." I feel the adrenalin rushing through my body.’ ‘I now see it’s not a
stick of wood protruding there, but a human bone with the flesh rotted away.’
These are examples of crucial moments in the trauma that the therapist wants
to reach. The process can be aided by asking questions like ‘What do you
feel, see, hear, smell’ ‘What’s the weather like’ ‘Do you feel wind blowing’
‘Is it light or dark’ In response to these sensory suggestions, clients
spontaneously begin telling about their experience. The therapist encourages
them to describe everything in the smallest possible detail, using the present
tense. ‘What colours do you see’ ‘Describe the clothes. What do they feel
like’
The therapist perceives at this point that clients are authentically viewing
the traumatic scene true-to-life before their eyes. Therapists will often start to
fantasise the scene themselves, and will also experience the excruciating
tension, and often horror, and even a degree of anxiety. They should at first be
cautious about intervening, so as not to disrupt the reliving of the trauma. But
then the time comes for the crucial intervention, even though clients may
already be weeping profusely or releasing their violent emotions in some other
way like screams or curses. The therapist now remarks, ‘Do you feel
miserable now’ or sometimes even ‘You must feel extremely miserable now.’
This brings about the catharsis. It can involve either the intense sorrow during
the event or the same feeling while looking back on the event now. This is an
important distinction, since some clients will have had no feelings at all during
the event, being totally numbed by the experience. They are now finally
experiencing the seemingly uncontrollable anguish, helplessness, revulsion
and other feelings connected with the event. At the very moment when clients
are feeling this grief, the therapist asks them to open their eyes. This is usually
after 15 to 20 minutes. Since BEP is not based on the ‘habituation of anxiety’
principle, the aim is decidedly not to have the whole traumatic scene played
out, but simply to release the emotions connected to it.
2. Discussion. The therapist now asks the clients how they feel about the session so
far. Usually they will be keen to talk about the experience they have just had,
which is new for many of them. They feel relieved about the discharge of
emotions, but they may also feel very tired or exhausted. Tell them they will
15

possibly relive the trauma more frequently in the week to come, and that their
sleeping problems may temporarily get worse after the session, but emphasise
that it will be worth the effort. One should also advise them to take some time to
‘recover’ from this session before going home. Ideally, a companion will bring
them and collect them.
3. In closing, clients are asked to bring some mementos to the next session –
objects that remind them of the traumatic event, such as clothes they were
wearing when they were raped, photographs of the disaster or newspaper
clippings. These will be used to stimulate emotions of grief and anger. They can
also be used later for the farewell ritual.
Sessions 3-6
Agenda:
1. Review of past week
2. Resumption of imaginal exposure
3. Focus on mementos
4. Discussion
5. Assignment of writing task
1. Both the client and the therapist will feel the need to review and discuss the first
exposure session. Did the client feel slightly relieved, or did the session have
many distressing after-effects If things go well, clients will often report that they
‘got rid of something’ or that they haven’t slept so well in ages. But it is also
possible that the reexperiencing symptoms, or even nightmares, have worsened.
That is usually a sign that the critical ‘hotspot’ of the traumatic event has not yet
been reached. Perhaps the exposure got no further last time than the deafening
vibrations of the aircraft, so that the actual crash on the runway will have to be
dealt with today. Clients will then be anxiously dreading the resumption of the
imaginal exposure. It is a good idea to promptly start the relaxation exercises and
then to immediately pick up where you left off the last time. One should be careful
here not to start delving into various issues that have been unleashed in clients,
such as recent problems with jobs, institutions or relationships, or problems from
their youth. However important such discussions may seem, they will usually just
be joint attempts by the client and the therapist to avoid returning to the horrifying
experiences. It is good to point this out explicitly.
2. The imaginal exposure of the traumatic event(s) continues in these sessions,
always preceded by the relaxation exercises, which most clients will now perform
without the aid of the therapist. The exposure usually starts where it left off the
previous time. New memory fragments will be released. ‘I had completely
forgotten about that woman that was sitting next to me. She died.’ ‘Suddenly I saw
the sun reflect off his machete.’ ‘I realise now I took my bag with me. How did I
ever manage that’ ‘Now I just hear another officer shouting, "Ha, your first
corpse, your first corpse!" I’m absolutely furious, and I can just feel my throat
constricting when I see the remains of that child’s head lying there.’ Because BEP
proceeds so slowly and moves ahead only slightly each time, new memories and
intense emotions are released. Fifteen to 20 minutes is enough each time. Some
clients may not succeed in getting in touch with their emotions, or may be inclined
to keep ‘rushing through’ the event. It is good to explain they should do this
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differently, because they will otherwise not get a chance to confront their
emotions. One approach is to ‘freeze the image’ at the most terrible moment and
then ask them what they are feeling. ‘Do you feel miserable now’ A firefighter
had given his oxygen cylinder to a small child. As his consciousness began to fail,
he saw the ‘film of his life’ flashing past. He saw his own little daughter before his
eyes; tears ran down his cheeks. This shows that the important thing here is not
so much the feeling at the time of the tragedy, but the feeling the client gets when
looking back in the here-and-now. The imaginal exposure is finished once a client
has experienced all the emotions. Everything has been confronted. The therapist
can ask clients about this. ‘Do you think we’ve been through everything now’
Clients now have a tremendous feeling of relief. Most of the PTSD symptoms
have gone away. If you have doubts about whether everything has been
sufficiently worked through, you should simply present arguments to explain why.
After all, the client and the therapist both share the responsibility for making the
therapy work.
3. Clients are then to show their mementos to the therapist. Examples are pictures
of the grotesquely maimed head of a person that was brutally kicked to death.
One middle-aged man brought a tiny red dress belonging to his three-year-old
sister, who had been caught and killed in a milking machine. Another man brought
a heavily battered camera, retrieved out of the plane wreckage. The therapist
should ask again here what the clients are feeling. Does this make them feel
grief The mementos help to bring the traumatic event closer and to experience
the emotions.
4. Discussions of the sessions always include a focus on the emotions that clients
have felt during the exposure. Usually clients will want to tell about new aspects of
the trauma that arose, which they were not yet aware of and which involve
extreme feelings such as powerlessness. Another point of discussion is whether
clients are satisfied with the procedure or whether they would like to change it in
some way.
5. The therapist then explains the writing task. The explicit aim of this technique is to
elicit feelings of anger that clients may be harbouring against certain persons or
organisations that they connect to the trauma. The writing task is therefore often
called a running letter. It is used to express difficult or aggressive feelings. It is
also a letter that will never be sent. Again, the purpose is to express virulent
emotions that need to be put into words uncensored. Some clients may also
prefer more ‘creative’ ways of doing this, such as painting, drawing or other
graphic ways to depict the feelings. The therapist should advise clients to obtain
special materials, such as a small notebook, for this purpose, and to write down
some thoughts for half an hour almost every day at the same quiet moment and in
the same place. Feelings of anger, sorrow and sometimes guilt often emerge
during this exercise. In the sessions to follow, the therapist will also read the
passages written by the client and discuss the emotions involved. The letter can
later be destroyed in the farewell ritual along with other mementos. This enables
the client to express aggressive emotions in a controlled manner.
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In principle, 2 to 6 sessions are sufficient for the imaginal exposure and for writing
and discussing the letter. This stage of the therapy is finished as soon as the
emotions have been fully, often exhaustively, worked through. Clients themselves will
notice that they are gradually becoming more active in daily life. At this point, the
effort to find meaning in the trauma often gets underway as a matter of course. For
the therapist, it is useful to evaluate this stage of the treatment by assessing whether
the emotional catharsis has been sufficiently achieved. Important points to focus on
are:
a. how realistically the trauma was relived
b. how much anxiety was felt
c. how much grief was felt
d. how much anger was felt
e. how much guilt was felt
MEANING and INTEGRATION
Sessions 7-12
Agenda:
1. Discussion of writing task
2. Finding meaning and achieving integration
3. Focus on topics from daily life
The writing task may have already been completed during previous sessions. If not,
attention should still be given to how the writing is proceeding. Are clients succeeding
in feeling their emotions, especially those of powerlessness and rage Does the
writing bring them a sense of relief Are new issues arising, such as guilt feelings
The therapist always reads what clients have written, or has them read important
passages aloud, in order to identify the points where the greatest anger was felt. As
noted above, the purpose of the writing task – much more than the imaginal
exposure – is to bring negative feelings to expression such as anger, hatred and
guilt. The therapist discusses with the client whether everything has been sufficiently
covered on paper.
The therapist now begins by repeating some points of psychoeducation. The
emphasis now is on how the traumatic event has also affected the way clients view
the world and themselves. Their familiar ‘old self’ will never come back, because they
cannot simply erase what happened. This also means that their illusion of safety has
been eroded. In other words, they will look differently at the world from now on. They
will take more heed of risks and of how they can strengthen their own sense of
security. More important still, in many cases, is that their tragic confrontation with
human misery has given them a keener awareness of the vulnerability of life – and
this can make them value life more dearly. Personal relationships, religion and other
such concerns may acquire more meaning. Another possibility is that they will decide
to part with certain people who have disappointed them.
One important issue here is that some clients will need to build a new sense of selfworth,
often because they are tormented by survival guilt. Two brothers had rescued
many passengers from the wreckage of a plane. They nonetheless felt guilty about
surviving the crash. Guilt feelings like these should not be ‘reasoned away’; one
18

should accept that such an awful experience ‘just feels that way’. After all, it really is
horrible to realise that those other people died. Non-clinicians are often inclined to
emphasise ‘how lucky’ the survivors are. In other words, ‘Stop harping.’ But the
feeling of a survivor is different. A police officer who had shot someone dead was
showered with praise and compliments from his colleagues when he arrived back at
the police station. However understandable such compliments might have been, the
man felt miserable. He had done something he had wanted never to do. He felt
guilty, and that was how it was.
During this stage of the therapy, elements from clients’ life histories often come into
focus. Clients may link the traumatic experience to the meanings of events that
happened long ago in their youth. Making such connections by themselves
strengthens the clients’ adaptation to their traumatic experience. It helps them
integrate the trauma into their personal life histories. An example is a police officer
that felt betrayed by the police department because he received no support or
attention from his superiors after being wounded in shooting incident. The officer
himself laid a link to his authoritarian father, from whom he had also never received
enough attention or support. Such links made by clients to earlier experiences with
f.i. their parents are useful in cases where these are the types of explanations they
are searching for.
As one part of this therapy, attention is turned to topics from daily life, such as going
to work or difficulties with insurance policies. This is also essential, because a great
deal of chronic stress arises from personal affairs that are seriously disrupted as a
consequence of traumatic events. The PTSD itself also tends to impair clients’ ability
to make sound judgments about personal matters and to adequately act on them.
Our experience with BEP has shown that a large number of clients are able to fully or
partially resume their work following the therapy.
Session 9
(Partner or other companion can attend this session if client wishes.)
Agenda:
Same as previous sessions, with the possible addition of:
4. How have the client and partner experienced the therapy so far
4. Obviously the client and the partner must both express willingness to carry out
this intermediate evaluation. It will also help the therapist get a clearer impression
of the results achieved up to now. Have the symptoms been reduced or
eliminated Is the client functioning better, for example by experiencing fewer
annoyances and having less trouble sleeping or concentrating What does the
partner think of the therapy so far Some partners feel they are able to give plenty
of support, but some can feel rather left out. This can be discussed here. Clients
often try to ‘spare’ their partners, not realising what consequences that can have.
The evaluation can also enable partners to express their own sorrow and
frustrations more openly to the clients. Attention can also be devoted in this
session to planning the farewell ritual.
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Sessions 10-12
In addition to the usual agenda items, these sessions are intended to focus more on
the consequences of the traumatic event for the clients’ lives. What have they learnt
from the event Has it made them wiser in any way Specific topics and emotions
pertinent to each particular client need to be highlighted. These may include feelings
of anger, grief and powerlessness, or perhaps a loss of faith in the goodness of
fellow human beings.
Opportunity needs to be given to clients to express negative emotions and learn to
better understand such feelings. They should be allowed plenty of room to do so.
After that, the therapist should also highlight the more positive sides of having gone
through the trauma (if the client can indeed perceive them as such). This is the
‘domain of meaning’.
These sessions also include room for guidance in clients’ reintegration process at
work.
FAREWELL RITUAL
Sessions 13-16
Agenda:
1. The farewell ritual
2. Evaluation and termination of the therapy
The technique of the farewell ritual is performed as follows. After an explanation of
the ritual, clients should decide whether they want to make use of it. The therapist
explains the ritual’s significance and different ways it might proceed. The purpose of
the ritual is to take leave, in a symbolic fashion, of the traumatic experience and the
negative effects it has had on the life of the client. Clients will never forget the
traumatic event(s), but they can leave such events behind them through the
therapeutic process. The farewell ritual thus also constitutes a ‘reunification ritual’,
marking their return to ordinary life. They will now move on, and they will celebrate
that with another person that is closely involved. It is a good idea to explain here how
the ritual normally works. Some people burn (under safe conditions) mementos such
as letters, clothing or drawings in their garden, somewhere out in nature or in their
home, or they throw them into the sea or other bodies of water. It is important for
clients to decide for themselves, together with their partner or another close person,
which approach will suit them best. Only when they feel that the traumatic event is
now truly a part of their past has the time arrived to openly exhibit this feeling in a
farewell ritual. This is the last time they will express the feelings of grief and
aggression – this time in the presence of someone very close to them. The technique
also serves as a return to normal life. The ritual is closed off by making a symbolic
parting gesture, such as taking a shower, or by celebrating the leaving behind of the
trauma with activities like a nice meal or a walk on the beach or in the woods,
together with the partner or companion.
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1. Clients are first asked whether they think the time is ripe for the farewell ritual
(which has already been explained to them). Ask them to discuss that with their
partner and to propose some plans in the next session. The plans are then
carefully reviewed to ensure that clients will not act too hastily or feel pressured to
do so to please the therapist. The therapist should therefore question clients
about why they have decided on this particular ritual (such as burning a letter out
in nature), what the chosen location and other details mean to them, and when
they want to perform the ritual. What effects do the client and partner expect the
ritual to have on them Does the partner approve of the ritual Most clients will
want the ritual to take place at the end of the therapy. Strictly speaking, the
farewell ritual indeed constitutes the end of the therapeutic process, but most
clients will also feel a need to report back on the ritual in the final session and
discuss the impact it had.
2. Psychoeducation is provided again during the evaluation and the rounding off of
the therapy. Clients are asked how they see the relationship between the trauma
and their symptoms in retrospect. They can report whether all the symptoms have
now gone away. They should also be informed that distressing experiences in the
future, or events elsewhere that remind them of their own traumatic experience,
may temporarily revive some of their symptoms, such as reexperiencing or bad
dreams. They will always retain a certain amount of vulnerability. The other side
of the coin is that most clients will feel ‘sadder and wiser now’. This also implies
that one needs to discuss the things each client has learned from the therapy and
how they think they can apply that knowledge in future situations. At the end, the
therapist and client carefully evaluate the therapy. What have we achieved, what
have we not achieved and what things have changed Have all the symptoms
disappeared A checklist might be used for this. Attention should also be devoted
to the emotional aspects that may arise when a client-therapist relationship is
coming to an end. For many clients, the therapist has been a very special person
who was willing to listen to all their horrific stories, to devote attention to them as
human beings and to understand their intense emotions. For the therapist, the
therapy has obviously been first and foremost a professional endeavour, but in
addition to that it is always a personal, and often a very emotional experience. If
the therapist and client deem it necessary, the possibilities for follow-up care may
be discussed here too.
21

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i Not all references are yet attached to the text of the protocol.
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