bob stahn, ed.m, lcpc, mac, icadc well spring counseling, llc idaho falls, id brief imagery...

Bob Stahn, Ed.M, LCPC, MAC, ICADC

Well Spring Counseling, LLCIdaho Falls, ID

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Imagery Rescripting and Reprocessing Therapy

Presented by

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Imagery Rescripting and Reprocessing Therapy (BIRRT)

One in five people who experience trauma

will develop PTSD

CBT works most effectively on PTSD Historically, CBT is effective up to 60% If the emotion is predominantly fear based, then

exposure therapy may be up to 90% effective Exposure therapy often takes10-12 90-minute

sessions

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In 1990

Aaron Beck Stated:

“Simply talking about a traumatic event may give intellectual insight about why the patient has a negative self-image, but it does not actually change the image....”

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Beck continued:

“In order to modify the image, it is necessary to go back in time, as it were, and recreate the situation. When the interactions are brought to life, the misconstruction is activated—along with the affect—and cognitive restructuring can occur.”

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Imagery Rescripting and Reprocessing Therapy(BIRRT)

In 1990 Mervin Smucker, Ph.D, from the Medical College of Wisconsin, created Imagery Rescripting and Reprocessing Therapy (IRRT) for the processing of traumatic experiences.

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Dr. Smucker found excellent success with IRRT (in approximately 10 sessions).

Especially with Type I (single incident, acute life threat and unexpected)

But found less success with Type II (repeated, prolonged and unpredictable course)

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Dr. Smucker's Therapeutic Goals of IRRT: Decrease physiological arousal Eliminate intrusive PTSD symptoms Transform traumatic imagery into mastery, self-

empowering imagery Modify trauma-related beliefs/schemas Enhance ability to self-calm, self-nurture and

affectively self-regulate Enhance linguistic processing by developing a

narrative about the traumatic event

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Dr. Smuckers' Inclusion Criteria Recalls or re-experiences at least one traumatic

memory (nightmares, flashbacks) Most or all of the traumatic memory is

visualized (and re-experienced) along with the painful affect

Non-fear emotions (e.g., guilt, shame, self blame) are predominant

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Dr. Smuckers' Exclusion Criteria

Client currently has: Involvement in an abusive relationship Alcohol/Substance Abuse or on heavy meds Dx of Acute psychosis, Dissociative Identity Disorder,

Schizophrenia or Severe Depression Overwhelming/traumatic daily stressors Vague/incomplete traumatic memories

Absence of visual trauma images

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3 Steps of Dr. Smucker's IRRT Imagery: Step 1—Imaginal Exposure (re-experience the

truamatic episode) Step 2—Mastery Imagery (episode starts the

same but onto it is spliced the perfect ending) Step 3—Adult-Child Imagery (nurturing,

comforting and educating the person who experienced the traumatic episode)

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Comparing IRRT and BIRRT

Same principles Same results But BIRRT is... well... brief!

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The Good News The technique is brief to administer. It generally is done in

one two-hour session per event. BIRRT is very effective. BIRRT breaks the trauma weld between the emotions

and the details of the traumatic event. There is no hypnosis, touching, specific eye movement or

holding of objects with BIRRT.

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The Good News (cont.) The technique uses imagery only. The results are immediate. Nearly all clients report a

feeling of relief, peace and relaxation. The results are enduring. PTSD symptoms are greatly

reduced or eliminated.

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The Bad News: BIRRT is event specific. Each dissimilar traumatic event

must be dealt with an individual 2-hour session. BIRRT is not supportive therapy. The process is not easy. It requires substantial trust by the client in the therapist, in

the process and in the client's own strengths.

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The Bad News (cont.) There is homework. It includes rehearsing the “new

ending” and spending time nurturing the younger client—twice a day for a week.

All told, the BIRRT process is not easy but it is very much worth the effort. Generally clients are not eager to GO through the BIRRT process, but are eager to BE through the process.

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THE STEPS

Preparation for Step 1: Summarize the process for the client Establish a Pre-BIRRT severity level (i.e., PTSD 30) Have client briefly outline the traumatic event Together determine who will be introduced into the

imagery during Step 2 Brief client on checking 1-100 level of discomfort

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THE STEPS

Preparation for Step 1 (cont): Encourage client to keep the recounting of the

event relatively short (latest in, earliest out) Describe event in first person, present tense Encourage client to push through all of Step 1

without giving up Client may invite a support person into session Reassure client about the likely outcome

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THE STEPS

Step 1: Client is invited to close eyes. Envisions & describes

the traumatic event, often via each of five senses After every few sentences spoken by the client, the

therapist summarizes Frequently check 1-100 level of discomfort Spend whatever time needed on any point in the event

to bring the client emotionally into the event

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THE STEPS

Step 1 (cont.): End by asking if there is anything else the client would

like to include in this imagery Invite client to open eyes and return to the present After Step 1 is completed, congratulate the client on a

difficult job successfully done Again reassure client about likely outcome

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THE STEPS

Step 2: Start the event again, just as in Step 1 Encourage the client to use all senses in

describing the event in order to be present in it Before the high point of discomfort, begin the

new ending

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THE STEPS

Step 2 (cont): The new ending consists of introduction of people who

will

1) empower and protect client 2) prevent trauma from happening 3) hold abuser, if any, accountable

The people may be anyone--real or fictional, historical, religious, superheroes or even the present-day client. Often includes law enforcement. Each is omniscient.

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THE STEPS

Step 2 (cont): Have intervening people also teach the client the truth

about: the client's value who is responsible for causing the trauma anything else that is true and pertinent

End Step 2 by asking if there is anything else the client would like to include in this imagery

Invite the client to open his/her eyes

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THE STEPS

Step 3: Have client close eyes and envision a “happy

place,” describing it via each of the five senses Invite client to picture the younger self (of the

traumatic event just reprocessed) Ask client to also envision the self of today with

the younger self

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THE STEPS

Step 3 (cont): Help today's client to nurture, encourage,

comfort and teach by speaking directly to the younger client

Invite today's client to commit to help, protect and be a companion to the younger client

Allow the younger client to respond and ask questions or make requests to meet needs

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THE STEPS

Step 3 (cont): Continue until the younger client feels nurtured,

comforted and guilt-free If done well, the younger client will feel grateful.

Encourage him/her to express gratitude (usually by physical contact, such as a hug) and allow the client of today to reciprocate

Close Step 3 when neither has more to say/do

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THE STEPS

After Step 3: Invite the client to express how he/she feels about

the results of the process Remind client of the likely outcome of the process Assign the homework of reviewing twice daily the

new ending and nurturing the younger client and call with a report the next day

At some point in the future (month, etc) again assess the PTSD symptom severity (i.e., PTSD 30)

BriefImagery Rescripting and Reprocessing Therapy

(BIRRT)

The Results

The Measuring Tool—The PTSD 30

- A 30-item questionnaire

- Based on DSM-IV Diagnostic Criteria

- A six-point severity scale (0=low, 5=high)


(BIRRT)

PTSD 30 ItemsYou have distressing dreams (nightmares).

You do not feel like being around anyone.

You feel as though you experience the trauma again (flashbacks).

You feel like you are not in control.

You go over the trauma again and again in your head.

You jump more than others when you get startled.

You do not remember parts of the traumatic event.

You make strong efforts to avoid things connected to the trauma.

You avoid thoughts, feelings and conversation connected to the trauma.

You feel numb or have very few emotions.


(BIRRT)

You feel less interested or participate less in previously enjoyed activities.

You feel like you have no future or that it’s hard to plan a future.

You often feel anxious.

You have difficulty staying or falling asleep.

You get scared easily.

You feel scared when reminded of the trauma.

You feel irritable.

You have outbursts of anger.

You have difficulty focusing, concentrating, or completing tasks.


(BIRRT)

You have urges to hurt yourself.

You act out all of a sudden without thinking, are impulsive.

You feel shame and guilt because you are partially responsible for the trauma.

You feel hopeless and in despair.

You feel permanently damaged.

You feel hostile.

You feel constantly on guard because you feel threatened.

You have a change in personality because of the trauma.

Your heart races and you sweat when reminded of the trauma.

You do not feel connected with others.

You are overly aware of everything around you.


(BIRRT)

The Results

The Population

- 57 Adult men and women who sought PTSD treatment at Well Spring Counseling

- They met PTSD criteria

- Information was collected starting AUG ‘11


(BIRRT)

The Results

The Process

- Pre-BIRRT measure taken (PTSD 30)

- BIRRT administered until all traumatic events were addressed

- At some point (weeks to years) a Post-BIRRT measure was taken


(BIRRT)

The Results

- Average Pre-BIRRT score 3.7 (on 0-5 scale)

- Average Post-BIRRT score 0.87 (no longer meet PTSD criteria)!

- Average benefit--nearly 3 points!


(BIRRT)


(BIRRT)

BIRRT Client Comments

“As a Vietnam veteran I had nightmares 2-3 times weekly and frequent flashbacks for over 40 years….One visit with Bob, however, and [the symptoms] were all gone for good. My depression is better. I felt more relaxed than I had in 40 years! Bob helped me more in one session than everything else I have done. I was skeptical before but a firm believer after.” -Gordon


(BIRRT)

BIRRT Client Comments

“I’m very different than I was a year ago…. The rescripting got out a tremendous amount of darkness. I don’t explode as I used to. I see life from a different perspective. I feel a lot of peace. It’s wonderful!” -Lisa

"I’m more relaxed….I’m much more hopeful than in the past. I have a more positive outlook at life. I’m very impressed with the effectiveness of the technique.” -Casey (Veteran)


(BIRRT)

“A weight or block that’s always been there is now gone! It’s amazing to me…. I don’t feel responsible even though I didn’t realize I was feeling that way before. I have carried anger for years but didn’t realize it. It’s night and day difference…. It is surprising where I am today.” -Teresa

“I’m happier and I feel more relaxed and good. It’s cool! I feel more confident; more peaceful. It’s almost like a memory now—a sense of serenity that I never knew I could have.” -Katie


(BIRRT)

“I met with Bob just once, but it made a world of difference—definitely great improvement…. I’m surely grateful. I highly recommend Bob and [Brief] IRRT!” -Pat

“The knot in middle of stomach is gone. I feel relieved and lighter…. I feel more freedom. I don’t feel the guilt and shame. It’s gone. I wasn’t sure this process was going to work but it did. It was excellent…. I haven’t wanted to use anymore…. I’m not afraid anymore after years of being afraid. I don’t feel powerless (especially about men) anymore…. BIRRT was absolutely worth it.” -Sandy


(BIRRT)

“I feel more relaxed than I’ve ever been! I can hardly stand this. I feel like I’m on a retreat and I never have to leave! This is just incredible! ….I now feel joy coming from within and it’s increasing. I’m feeling a lot of peace and happiness on a regular basis.” –Jo

“It’s completely different [since Brief IRRT]. Before I’d be curled up on the floor but now I’m dealing with it. It’s amazing!” -Billie


(BIRRT)

“I feel very happy--much better than I have in a long time….I can be myself without barriers! …Where I was and where I am now is night and day difference and I attribute it to [Brief] IRRT and to taking care of myself…I’m down to one medication from seven! And that one is going pretty soon. I’m more positive and not so depressed…. I am so very grateful.” -D'Arcy

“Life is quite joyful. I’m doing fantastic. [BIRRT] was very effective for me--extremely, extremely beneficial for me. I wish I’d known about this decades earlier.” -Kathy


(BIRRT)

“Wow! I feel better. I feel relief. I feel confident. I’m less anxious. Wow! This is the most confident I’ve felt in probably 10 years. I didn’t think this would work but wow! …Feeling this is really amazing. I haven’t felt this peaceful since I was a child. Wow! Thank you!” -T.M.

“After nearly two years I am still symptom free. I had no idea this kind of help was available. I have been through a lot of counseling before and had not found anything this beneficial.” -Kathy


(BIRRT)

“I’m freed from the [traumatic] moment. I’m shocked at the outcome…. Before doing it I thought ‘It ain’t going to work!’ But it did. I feel great…. Just one IRRT session--I didn’t think it would work but it did. All my symptoms are gone except a small amount of anxiety. I’m surprised it worked so well. I’m doing really good.” -Patricia

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THE RESULTS

Interesting phenomenon at Post-BIRRT scoring

Client comments

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Questions

and

Answers

bob stahn, ed.m, lcpc, mac, icadc well spring counseling, llc idaho falls, id brief imagery...

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